International
Activity Report2013
www.msf.org

The MÉdecins Sans
Frontières Charter
Médecins Sans Frontières is a private international association. The association is made up
mainly of doctors and health sector workers and is also open to all other professions whichmight help in achieving its aims. All of its members agree to honour the following principles:Médecins Sans Frontières provides assistance to populations in distress, to victims of natural or
man-made disasters and to victims of armed conflict. They do so irrespective of race, religion,
creed or political convictions.
Médecins Sans Frontières observes neutrality and impartiality in the name of universal medical
ethics and the right to humanitarian assistance and claims full and unhindered freedom in theexercise of its functions.
Members undertake to respect their professional code of ethics and to maintain complete
independence from all political, economic or religious powers.
As volunteers, members understand the risks and dangers of the missions they carry out andmake no claim for themselves or their assigns for any form of compensation other than thatwhich the association might be able to afford them.

The country texts in this report provide descriptive overviews of MSF’s operational activities throughout theworld between January and December 2013. Staffing figures represent the total full-time equivalent positions
per country at the end of 2013.
Country summaries are representational and, owing to space considerations, may not be comprehensive.
For more information on our activities in other languages, please visit one of the websites listed on p.100.
The place names and boundaries used in this report do not reflect any position by MSF on their legal status.
Some patients’ names have been changed for reasons of confidentiality.

Contents
2

MSF programmes Around The World

4	The Year in Review
Dr Joanne Liu, International President
Jérôme Oberreit, Secretary General

8	Overview Of activities
10

Glossary of Diseases and activities

14

South Sudan: A country gripped by violence4

The year in review

16	
A ddressing Women’s Health Needs
18

CENTRAL AFRICAN REPUBLIC: DESCENT INTO CHAOS

22

A Day in the Life: médecins Sans Frontières(MSF) clinic at Dera Murad Jamali,
Balochistan, Pakistan

24

Overcoming challenges to meet
MSF’s vaccination ambitions27

activities by country

95

special reports 2013

96

Facts and figures

14 South Sudan: A country gripped by violence

16 Addressing women’s health needs

100	Contact MSF

18 CAR: Descent into chaos

27 Activities by country

Contents 1

MSF programmes
around the world

2

MSF programmes around the world

28	Afghanistan

58	Kenya

30	Armenia

60	Lebanon

30	Bolivia

62	Lesotho

31	Bangladesh

63	Libya

32	Bulgaria

63

Madagascar

32	Burkina Faso

64

Malawi

33	Burundi

65

Mali

33 	Cameroon

66

Mauritania

34	Cambodia

66

Morocco34	China

67

Mexico35	Colombia

68

Mozambique

36	Central
AfricanRepublic

69

Myanmar38	Chad72	Nigeria

40	Congo

73	Palestine40

73	Papua New
GuineaCôte d’Ivoire

41	Democratic
People’sRepublicof Korea
41	Egypt42	Democratic
Republicof Congo

70	Niger

74	Pakistan
76	Philippines
78	Paraguay
78	RussianFederation
79	South Africa

44	Ethiopia

80	Somalia

46

82	South Sudan

France46	Georgia

84	Sudan47	Greece

85	Swaziland

47	Guinea

86	Syria

48	Haiti

88	Sierra Leone

50	Honduras

88	Tajikistan

50

Iran

89	Turkey

51

Italy

89	Ukraine

51	LAOS90

Uganda

52

India

91

Uzbekistan

54

IRAQ

91	Zambia

56

Jordan92	Zimbabwe

57	Kyrgyzstan

94	Yemen

MSF programmes around the world 3

Médecins Sans Frontières

The Yearin Review
Dr Joanne Liu, International President
Jérôme Oberreit, Secretary General

In August 2013, Médecins
Sans Frontières (MSF) pulled
out of Somalia after working
in the country continuously
for 22 years.

Since its founding, MSF has faced different
forms of violence against its patients, staff,
health facilities and medical vehicles, andhas also witnessed targeting of healthsystems in general. The situation in Somalia,
however, became untenable in 2013 as thebalance could no longer be found between
the risks involved, the compromises we
had to make – such as hiring armed guards
and implementing remote management tosupport national staff – and our ability toprovide medical care to the Somali people.
Staff members had been threatened,attacked, kidnapped and even killed during

our time in Somalia, but it was when it
became apparent that the parties withwhom we were negotiating were in somecases actively involved in, or complacent
towards, violent actions directed against
MSF that we had no choice but to draw
the line. A lack of respect and deliberateviolations of medical humanitarianism forpolitical and financial profit were putting
the lives of our patients and staff at risk.
We withdrew with heavy hearts.
In Syria, the civil war continued into its thirdyear and it is estimated at present that ninemillion people are internally displaced in the
country or have fled abroad as a result of© Giulio Di Sturco

The last year has been one of exceptional
circumstances, decisions and compromises,
particularly with regards to Somalia and
Syria. We have again seen profiteering fromhumanitarian organisations, in the formof robberies and the looting of medical
structures, but the most striking thing wehave witnessed is the failure of the global
humanitarian aid system in countries suchas Central African Republic (CAR) andSouth Sudan.

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

4

The Year in Review

© Jodi Hilton

International Activity Report 2013

A young Syrian refugee is examined by an MSF paediatrician at the mobile clinic in Voenna Rampa camp in Sofia. Thousands of Syrians
have fled to neighbouring countries to escape the conflict.

the violence. This means that over 40 per
cent of Syrians have been forced from theirhomes. Those remaining in Syria have had
to endure ongoing and incessant violence,and entire cities have been decimated.
The healthcare system has collapsed,
resulting in outbreaks of preventablediseases such as measles and polio.
Countless Syrians are desperate to accessmedical treatment, and are without services
for everyday requirements like antenatalcare, immunisations and the managementof infections or chronic diseases. MSF
operated aid programmes where working
agreements could be negotiated, namely in
opposition-held areas where instability wasa constant challenge, and support was given
to Syrian medical networks. Inpatient wards,
outpatient consultations, surgery, andmaternal and obstetric care were provided
by MSF and vaccinations were undertaken.
However, in a country where we shouldhave been running some of our largest
medical programmes, the opportunities toreach people and to respond in a timely
manner to the enormous needs remained
extremely limited; a forceful reminder of
how access to medical care was by and large
not respected and in many cases directly
targeted by those involved in the conflictand used for political purposes. In Lebanon,
Iraq, Turkey and Jordan, MSF continued toprovide healthcare for Syrians inside andoutside the refugee camps.
The year was punctuated by numerous acutecrises that left entire communities vulnerable,with little skilled medical help. In some cases,
external assistance was their only lifeline andyet MSF often found itself alone tackling
not just the medical but also the otherhumanitarian needs of the people affected.
Political events marked a descent into
instability and brutal violence in both South
Sudan and CAR, displacing thousands. In
CAR, there was a presidential coup in Marchand subsequent political clashes spreadthroughout the country and inflamed
religious divisions. By January 2014, it wasestimated that over one million people hadfled their homes, 245,000 of them crossing
the border into neighbouring countries
such as Chad and Cameroon. Hundredsof thousands of people were shelteringin the bush and others were living in
displacement sites. By the end of 2013, nine
MSF emergency projects were delivering
healthcare in CAR alongside seven ongoingprogrammes, and over 800,000 medical
consultations had been provided to people
throughout the country.

In South Sudan, where people have cometo rely in large part on MSF for healthcare,violence in Jonglei early in the year caused
displacement, and in December, fighting
between different factions of the army
quickly spread throughout five states,
causing people to flee their homes anddestroying hopes of stability for the nascentcountry. More than 3,000 MSF staff
continued to operate 16 programmes innine states, and three emergency projects
were opened to care for the displaced
and war-wounded; further emergency
programmes opened in neighbouring
countries such as Uganda to provide aid
to the refugees. December was only the
beginning of what was to become a gravecrisis of violence, civil war and humansuffering in South Sudan.
Once again this year, MSF’s largest
programme expenditure was a responseto the repeated displacement of people
and the appalling lack of healthcare in
Democratic Republic of Congo (DRC).
While there is a large aid community in
DRC, much of it is focused in Goma andareas of the country considered stable, themore remote areas of eastern DRC, where
people are subjected to increasing conflict,banditry, widespread abuse and sexual
violence, are largely neglected. In 2013,

The Year in Review 5

Médecins Sans Frontières
heavy fighting caused massive displacement
and inadequate living conditions meantdiseases such as malaria, cholera andmeasles were rampant. MSF undertooka number of emergency projects andvaccination campaigns in the country andin total, more than 1.2 million children
aged between six months and 15 years
were vaccinated against measles.
Responding in the Philippines

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

On 12 December, MSF published an open
letter to Valerie Amos, UN Under-SecretaryGeneral, about the situation in CAR andthe UN humanitarian system’s failure to
respond adequately to the emergency
or ensure minimum requirements forhuman life. MSF’s deployment of staff
and delivery of aid had shown that withprincipled humanitarianism, it was possible
to provide widespread assistance. Less thana week later, MSF sent an open letter tomember states of the ‘High Level Groupon Syria’ meeting in Geneva, urging themto take action so that people blocked fromreceiving Damascus-controlled aid could
obtain the assistance they needed throughcross-border efforts.
Witnessing steady refugee flows fromconflicts in Africa and the Middle East,
MSF also spoke out about the restrictive
and repressive migration policies in EU
states. Teams have treated migrants
in several overcrowded, ill-equipped
detention centres that are contributing
to deterioration in residents’ physical andmental health. A December press releasecalling for the closure and refurbishment of
the Lampedusa centre in Italy was heeded
and MSF continued to provide healthcare
for undocumented migrants in Italy, Greeceand Bulgaria, all the while urging those
responsible to provide living conditions that
respect human dignity.

© Mikhail Galustov

This year we were shown once againthat public sympathy for the plight ofothers is never as strong as in the wakeof a natural disaster. While fundraisers
continue to struggle to raise financial
support for victims of war, individuals
worldwide quickly dug into their pockets
to assist survivors of the Philippines’
Typhoon Haiyan in November. The great
force of the storm, and the storm surgethat followed, destroyed public healthfacilities, but due to the experience of
local health workers and the preparednessof the Department of Health, medical
needs were much smaller than feared.
MSF sought to assist the Filipinos byproviding medical care and relief supplies,
while also rebuilding healthcare capacity.
Numerous logistical challenges wereencountered within the first days;
even so, by the two-week mark MSF had
a fast-growing team of international andlocal staff in four hospitals and eight healthcentres, and was running mobile clinics in
37 locations.

MSF doctors at Kunduz trauma centre in Afghanistan perform surgery on a man hit by a stray bullet.

6

The Year in Review

© Yann Libessart / MSF

International Activity Report 2013Children under two were vaccinated with the pneumococcal conjugate vaccine (PCV) in Yida refugee camp in South Sudan this year. It was the first time
PCV was used in the country.

MSF’s Access Campaign also worked
tirelessly, advocating for patients in lightof the Transpacific Partnership Agreement(TPP) being negotiated between the USA
and 11 Pacific Rim nations, as well as
the India–European Commission trade
agreement, continuing the Hands Off ourMedicine campaign launched in 2010. Boththese trade agreements include aggressive
standards for intellectual property,
extending drug patents and effectively
blocking access to generic medicines fordiseases including HIV – drugs that MSF
purchases for millions of patients and thatpeople in the developing world depend on
for their treatment and survival.
Tackling malaria, tuberculosis (TB) and HIV
Seasonal Malaria Chemoprevention (SMC),
a WHO-recommended preventive measure
which has proven effective in Chad and Mali,
was used in Niger for the first time in 2013.
For four months during the rainy season,children received a course of antimalarial
treatment and while usual methods ofmosquito bite prevention, including the useof nets and sprays remain the basis of the
programmes, SMC is proving useful to protect
the health of children at risk from severe
malaria in areas of high seasonal transmission.

In collaboration with the health authorities,
MSF continued to respond to drug-resistant
TB in the southern Caucasus. In KwaZuluNatal, South Africa, the Bending the Curves
project was introduced to tackle the highco-incidence of HIV and TB. Viral load
technology, which monitors the amountof HIV virus in a patient, was introduced
in areas of Mozambique this year, and in
Swaziland the ‘test early and treat early’
effort continued.
Medical Care under FireThe year’s events were a harsh reminderthat some choose to make medical aid
a target for their own benefit. Teams
withstood localised security incidents
in places such as Afghanistan, Nigeria,
Pakistan, South Sudan, Syria and Yemen.
In DRC, four Congolese MSF staff, Chantal,
Philippe, Richard and Romy, were abductedby an armed group while on an evaluation
mission in July. At the time of writing, a
dedicated team is still actively searchingfor them. On a more positive note, ourcolleagues Montserrat Serra and Blanca
Thiebaut were released after having been
held in captivity for 21 months. They
had been abducted from Kenya’s Dadaab
refugee camp in 2011. The issue of incidents

targeting MSF and other humanitarianorganisations is of significant concern, notonly for security, but also for the ultimate
impact these events and their consequences– temporary suspension or revocation of
medical services – have on the health andsurvival of the people we aim to help.
In 2013, MSF began researching such
incidents, their impact and our responsein the Medical Care under Fire project. We
hope to identify ways to improve patients’safe access to healthcare and the security ofhealthcare structures and international andnational medical teams.
MSF’s work in 2013 felt at times like an
uphill struggle. Despite the challenges,
however, and the sheer number ofpeople caught in crises this year – many
traumatised by the violence, losses anduncertainty of conflict – our supporters andteams around the world delivered medicalcare to more than eight million people intheir hour of need. We would like to takethis opportunity to thank everyone who hasmade our work possible over the last year.

The Year in Review 7

Médecins Sans Frontières

Overview ofactivities
Largest country programmes
based on project expenditure
1. D emocratic Republicof Congo
2. South Sudan

Programme locations
Number of programmes

6. Niger
7. Somalia
8. Iraq

3. Haiti

9. Chad

4. Syria

10. Zimbabwe

Africa240

Americas

24

A
 sia

108

Europe11

Pacific

4** A sia includes the Middle Eastand the Caucasus

5. Central African Republic
The total budget for our programmes in these 10 countries
is 323 million euros, 53 per cent of MSF’s operational budget.

62 %

1%
2.8 %

Percentage ofprogramme
portfolio

6.2 %Staff numbers
Largest country programmes based on the number of MSF staff
in the field. Staff numbers measured in full-time equivalent units.
1. Democratic Republic of Congo

3,604

2. South Sudan

2,854

3. Haiti

2,324

4. Niger

1,879

5. Central African Republic

1,631

28 %

Context of intervention
Number of programmes

Outpatient consultations

Stable161

Internal instability

88

Armed conflict117

P ost-conflict

21

Largest country programmes according to the number of outpatient
consultations. This does not include specialist consultations.
1. Democratic Republic of Congo

8

1,654,100

2. South Sudan

981,500

3. Niger

916,000

4. Central African Republic

816,300

5. Myanmar

519,100

6. Kenya415,700

7. Afghanistan

370,000

8. Somalia

318,400

9. Mali

308,100

10. Swaziland

287,800

Overview of activities

30 %
42 %

Percentage ofprogramme
portfolio

5%
23 %
28 %

International Activity Report 20132013 activity highlights
9,029,100

18,50014,200Outpatient

PMTCT – mother

Mental health (group)

Number of HIV-positive pregnant
women who received preventionof mother-to-child transmission(PMTCT) treatment

Number of group counselling or mental
health sessions

Number of outpatient consultations

477,700
Inpatient
Number of admitted patients

1,871,200
Malaria

16,800PMTCT – baby
Number of eligible babies born in 2013
who received post-exposure treatment

Total number of cases treated

233,800
Therapeutic
feeding centres
Number of severely malnourishedchildren admitted to inpatient or
outpatient feeding programmes

17,100
Supplementary
feeding centres

182,200
BirthsNumber of women who delivered
babies, including caesarean sections

77,350Surgical interventions
Number of major surgical interventions,
including obstetric surgery, undergeneral or spinal anaesthesia

Number of moderately malnourishedchildren admitted to supplementary
feeding centres

11,100341,600

Number of patients medically treatedfor sexual violenceHIV
Number of HIV patients registeredunder care at end 2013

325,500
Antiretroviral treatment(first-line)
Number of patients on first-line
antiretroviral treatment at end 2013

5,500
Antiretroviral treatment(second-line)
Number of patients on second-line
antiretroviral treatment at end 2013
(first-line treatment failure)

Sexual violence

29,90027,900CholeraNumber of people treated for cholera

2,497,250
Measles vaccinations
Number of people vaccinated against
measles in response to an outbreak

129,900
Measles treatment
Number of people treated for measles

162,400
Meningitis vaccinations
Number of people vaccinated against
meningitis in response to an outbreak

1,750
Meningitis treatment
Total number of people treatedfor meningitis

Tuberculosis (first-line)
Number of new admissions totuberculosis first-line treatment

1,950
Tuberculosis (second-line)
Number of new admissions to MDR
tuberculosis treatment, second-line drugs

141,100
Mental health (individual)
Number of individual mental healthconsultations

This data groups together direct, remote support
and coordination activities. Note: these highlights
give an overview of most MSF activities but cannot
be considered exhaustive.

Overview of activities 9

Médecins Sans Frontières

Glossary of
diseases andactivities
Chagas disease
Chagas disease is found almost exclusivelyin Latin America, although increased
global travel and migration have led
to more cases being reported in North
America, Europe, Australia and Japan.
Chagas is a parasitic disease transmittedby triatomine bugs, which live in cracks
in the walls and roofs of mud and straw
housing. It can also be transmitted throughblood transfusions or to the foetus during
pregnancy, and, less frequently, throughorgan transplants. A person with Chagas
often feels no symptoms in the first, acutestage of the disease. Then the chronic
stage is asymptomatic for years. Ultimately,
however, debilitating complications develop
in approximately 30 per cent of people
infected, shortening life expectancy by anaverage of 10 years. Heart complications
such as heart failure, arrhythmia andcardiomyopathy are the most common
cause of death for adults.
Diagnosis is complicated, requiring
laboratory analysis of blood samples. Thereare currently only two medicines available
to treat the disease: benznidazole andnifurtimox, which were both developed
over 40 years ago. The cure rate is almost
100 per cent in newborns and infants, but
as the gap between the date of infection
and the beginning of treatment lengthens,
the cure rate declines.
The treatment currently used can be toxic
and can take longer than two months tocomplete. Despite the clear need for more
efficient and safer medication, there are few
new drugs in development.
MSF treated 4,500 patients for Chagas diseasein 2013.

CholeraCholera is a water-borne, acutegastrointestinal infection caused by the

10 Glossary of diseases and activities

Vibrio cholerae bacterium. It is transmitted
by contaminated water or food, or directcontact with contaminated surfaces. In
non-endemic areas, large outbreaks canoccur suddenly and the infection can spread
rapidly. Most people will suffer only amild infection, but the illness can be very
severe, causing profuse watery diarrhoea
and vomiting that can lead to severe
dehydration and death. Treatment consistsof a rehydration solution – administeredorally or intravenously – which replaces
fluids and salts. Cholera is most common indensely populated settings where sanitationis poor and water supplies are not safe.
As soon as an outbreak is suspected,
patients are treated in centres where
infection control precautions are taken
to avoid further transmission of thedisease. Strict hygiene practices must be
implemented and large quantities of safe
water must be available.
MSF treated 27,900 people for cholera in 2013.

Health promotion
Health promotion activities aim to improvehealth and encourage the effective use ofhealth services. Health promotion is a twoway process: understanding the culture andpractices of a community is as important asproviding information.
During outbreaks of disease or epidemics,
MSF provides people with information on
how the disease is transmitted and how
to prevent it, what signs to look for, andwhat to do if someone becomes ill. If MSF
is responding to an outbreak of cholera,
for example, teams work to explain theimportance of good hygiene practices,because the disease is transmitted throughcontaminated water or food, or directcontact with contaminated surfaces.

HIV/AIDS
The human immunodeficiency virus (HIV) is
transmitted through blood and body fluids
and gradually breaks down the immune
system – usually over a three- to 15-year
period, although 10 years is more usual– leading to acquired immunodeficiency
syndrome, or AIDS. As the virus progresses,
people begin to suffer from opportunistic
infections. The most common opportunistic
infection that leads to death is tuberculosis.
Simple blood tests can confirm HIV status, butmany people live for years without symptoms
and may not know they have been infectedwith HIV. Combinations of drugs known asantiretrovirals (ARVs) help combat the virus
and enable people to live longer, healthier lives
without their immune systems deteriorating
rapidly. ARVs also significantly reduce thelikelihood of the virus being transmitted.
As well as treatment, MSF’s comprehensive
HIV/AIDS programmes generally include
education and awareness activities, condom
distribution, HIV testing, counselling andprevention of mother-to-child transmission(PMTCT) services. PMTCT involves theadministration of ARV treatment to the motherduring and after pregnancy, during labour andbreastfeeding, and to the infant just after birth.
MSF provided care for 341,600 people livingwith HIV/AIDS and antiretroviral treatment for
331,000 people in 2013.

Kala azar (visceral leishmaniasis)
Largely unknown in high-income countries(although it is present in the Mediterraneanbasin), kala azar – Hindi for ‘black fever’ –is a tropical, parasitic disease transmitted
through bites from certain types of sandfly.
It is endemic in 76 countries, and of theestimated 200,000–400,000 annual cases,
90 per cent occur in Bangladesh, India,
Ethiopia, South Sudan, Sudan and Brazil. Kalaazar is characterised by fever, weight loss,

International Activity Report 2013enlargement of the liver and spleen, anaemia
and immune-system deficiencies. Without
treatment, kala azar is almost always fatal.

Treatment options for kala azar have evolved
during recent years. Liposomal amphotericin B
is becoming the primary treatment in Asia,
either alone or as part of a combination
therapy. This is safer and involves a shorter
course of treatment than previously used
medication. However, it requires intravenous
administration, which remains an obstacle
to its use in local clinics. In Africa, the best
available treatment is still a combination ofpentavalent antimonials and paromomycin,
which requires a number of painful injections.
Research into a simpler treatment is underway
and it is hoped it will soon be available.
Co-infection of kala azar and HIV is a major
challenge, as the diseases influence each otherin a vicious spiral as they attack and weaken
the immune system.
MSF treated 5,300 patients for kala azar in 2013.

Malaria
Malaria is transmitted by infected mosquitoes.
Symptoms include fever, pain in the joints,
headaches, repeated vomiting, convulsions
and coma. Severe malaria, nearly always
caused by the Plasmodium falciparum parasite,causes organ damage and leads to death if
left untreated. MSF field research has helped
prove that artemisinin-based combination
therapy (ACT) is currently the most effective
treatment for malaria caused by Plasmodium
falciparum. In 2010, World Health Organization
guidelines were altered to recommend the useof artesunate over artemether injections for thetreatment of severe malaria in children.
Long-lasting insecticide-treated bed nets are
one important means of controlling malaria.
In endemic areas, MSF distributes nets topregnant women and children under the ageof five, who are most vulnerable and havethe highest frequency of severe malaria. Staff
advise people on how to use the nets.
In 2012, MSF used a seasonal chemoprevention
strategy for the first time, in Chad andMali. Children up to five years old took oral
antimalarial treatment monthly over a period or
three to four months during the peak season forthe disease. In 2013, this was introduced in Niger.

© Seamus Murphy/ VII

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

The triatomine bug, also known as the ‘kissing bug’, carries the parasite that causes
Chagas. The disease can be asymptomatic for years but can be fatal if left untreated.

Malnutrition

MeaslesA lack of food or essential nutrients causes
malnutrition: children’s growth falters andtheir susceptibility to common diseases
increases. The critical age for malnutritionis from six months – when mothers
generally start supplementing breast
milk – to 24 months. However, children
under five, adolescents, pregnant orbreastfeeding women, the elderly andthe chronically ill are also vulnerable.

Measles is a highly contagious viraldisease. Symptoms appear between
eight and 13 days after exposure to thevirus and include a runny nose, cough,eye infection, rash and high fever.
There is no specific treatment for measles– patients are isolated and treated withvitamin A, and for any complications:these can include eye-related problems,
stomatitis (a viral mouth infection),
dehydration, protein deficiencies andrespiratory tract infections.

Malnutrition in children can be diagnosed
in two ways: it can be calculated frommeasurements of weight and height,
or by measurement of the mid-upperarm circumference. According to thesemeasurements, undernourished children
are diagnosed with moderate or severe
acute malnutrition.
MSF uses ready-to-use food (RUF) to treat
malnutrition. RUF contains fortified milk
powder and delivers all the nutrients thata malnourished child needs to reverse
deficiencies and gain weight. With a longshelf-life and requiring no preparation,these nutritional products can be usedin all kinds of settings and allow patientsto be treated at home, unless they are
suffering severe complications. In situations
where malnutrition is likely to become
severe, MSF takes a preventive approach,
distributing nutritional supplements to
at-risk children to prevent their condition
from deteriorating further.
MSF admitted 250,900 malnourished patientsto nutrition programmes in 2013.

Most people infected with measles recover
within two to three weeks, and mortality
rates in high-income countries are low.
In developing countries, however, themortality rate can be between 3 and 15 per
cent, rising to 20 per cent where people
are more vulnerable. Death is usually
due to complications such as diarrhoea,
dehydration, encephalitis (inflammation of
the brain) or severe respiratory infection.
A safe and cost-effective vaccine against
measles exists, and large-scale vaccination
campaigns have significantly decreased
the number of cases and deaths. However,
coverage remains low in countries withweak health systems and in areas where
there is limited access to health services,leaving large numbers of people susceptible
to the disease.
MSF treated 129,900 patients for measles
and vaccinated 495,250 people in response
to outbreaks in 2013.

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

Glossary of diseases and activities   11

Médecins Sans Frontièrescontinued Glossary of diseases and activities

Meningococcal meningitis
Meningococcal meningitis is a bacterial
infection of the thin membranes surrounding
the brain and spinal cord. It can cause
sudden and intense headaches, fever, nausea,
vomiting, sensitivity to light and stiffness ofthe neck. Death can follow within hours of
the onset of symptoms. Up to 50 per cent ofpeople infected will die without treatment.
Six strains of the bacterium Neisseria
meningitidis (A, B, C, W135, X and Y) are
known to cause meningitis. People can be
carriers without showing symptoms andtransmit the bacteria when they cough orsneeze. Cases are diagnosed through theexamination of a sample of spinal fluid andtreatment consists of specific antibiotics.
However, even with treatment, 10 per centor more patients will die and as many as one
in five survivors may suffer from after effects,
including hearing loss and learning disabilities.
Meningitis occurs throughout the world,
but the majority of infections and deaths are
in Africa, particularly across the ‘meningitis
belt’, an east–west geographical strip from
Ethiopia to Senegal, where epidemics aremost likely to be caused by meningococcus A.
A new vaccine against this strain provides
protection for at least 10 years and evenprevents healthy carriers from transmitting
the infection. Large preventive vaccination
campaigns have now been carried out in
Benin, Burkina Faso, Cameroon, Chad,
Ghana, Mali, Niger, Nigeria, Senegal andSudan and have resulted in a decrease in thenumber of new cases.
MSF treated 1,750 patients for meningitis andvaccinated 162,400 people against the disease
in response to outbreaks in 2013.

Mental healthcare
Traumatising events – such as suffering or
witnessing violence, the death of loved onesor the destruction of livelihoods – are likely
to affect a person’s mental wellbeing. MSF
provides psychosocial support to victims of
trauma in an effort to reduce the likelihoodof long-term psychological problems.
Psychosocial care focuses on supporting
patients to develop their own coping strategies
after trauma. Counsellors help people totalk about their experiences and process
their feelings so that general stress levels are
reduced. MSF also offers group counselling,
as a complementary approach.
MSF staff held 155,300 individual and group
counselling sessions in 2013.

12 Glossary of diseases and activities

Relief items distribution
MSF’s primary focus is on providing
medical care, but in an emergency teams
often distribute relief items that contributeto physical and psychological survival. Suchitems include clothing, blankets, bedding,shelter, cleaning materials, cooking utensils
and fuel. In many emergencies, relief
items are distributed as kits – cooking kits
contain a stove, pots, plates, cups, cutlery
and a jerrycan so that people can prepare
meals, while a washing kit includes soap,
shampoo, toothbrushes, toothpaste andlaundry soap.
Where people are without shelter, andmaterials are not locally available, MSF
distributes emergency supplies – rope andplastic sheeting or tents – with the aim of
ensuring a shelter. In cold climates more
substantial tents are provided, or teams try
to find more permanent structures.
MSF distributed 146,650 relief kits in 2013.

Reproductive healthcare
Comprehensive neonatal and obstetriccare form part of MSF’s response to any
emergency. Medical staff assist births
and perform caesarean sections where
necessary and feasible, and sick newborns
and babies with a low birth weight receive
medical care.
Many of MSF’s longer-term programmes
offer more extensive maternal healthcare.
Several antenatal visits are recommended
so that medical needs during pregnancy
are met and potentially complicateddeliveries can be identified. After delivery,
postnatal care includes medical treatment,
counselling on family planning andinformation and education on sexuallytransmitted infections.
Good antenatal and obstetric care canprevent obstetric fistulas. An obstetricfistula is a hole between the vagina andrectum or bladder that is most often aresult of prolonged, obstructed labour.
It causes incontinence, which can lead tosocial stigma. Around two million womenare estimated to have untreated obstetricfistulas; there are between 50,000 and
100,000 new cases each year. A numberof MSF programmes carry out specialist
obstetric fistula repair surgery.
MSF held more than 703,900 antenatal
consultations in 2013.

Sexual violence
Sexual violence occurs in all societies and in allcontexts at any time. Destabilisation of contexts

often results in increased levels of violence,
including sexual violence. Sexual violence isparticularly complex and stigmatising and has
long-lasting consequences and can result in
important health risks.
MSF medical care for victims of sexual violence
covers preventive treatment against sexuallytransmitted infections, including HIV, syphilis
and gonorrhoea, and vaccinations for tetanus
and hepatitis B. Treatment of physical injuries,
psychological support and the prevention andmanagement of unwanted pregnancy are alsopart of the systematic care. MSF provides a
medical certificate to all victims of violence.
Medical care is central to MSF’s response
to sexual violence, but stigma and fear may
prevent many victims from coming forward.
A proactive approach is necessary to raiseawareness about the medical consequencesof sexual violence and the availability of care.
Where MSF sees large numbers of victims– especially in areas of conflict – advocacy
action aims to raise awareness among local
authorities, as well as the armed forces when
they are involved in the assaults.
MSF medically treated 11,100 patients forsexual violence-related injuries in 2013.

Sleeping sickness(human African
trypanosomiasis)
Generally known as sleeping sickness, human
African trypanosomiasis is a parasitic infection
transmitted by tsetse flies that occurs in
sub-Saharan Africa. In its latter stage, it attacks
the central nervous system, causing severe
neurological disorders and frequently death.
More than 95 per cent of reported cases arecaused by the parasite Trypanosoma brucei
gambiense, which is found in western andcentral Africa. The other 5 per cent of cases
are caused by Trypanosoma brucei rhodesiense,
which is found in eastern and southern Africa.
During the first stage, the disease is relatively
easy to treat but difficult to diagnose, as
symptoms such as fever and weakness are
non-specific. The second stage begins when
the parasite invades the central nervous systemand the infected person begins to showneurological or psychiatric symptoms, such as
poor coordination, confusion, convulsions andsleep disturbance. Accurate diagnosis of theillness requires a sample of spinal fluid.
Nifurtimox-eflornithine combination
therapy or NECT, developed by MSF, Drugs
for Neglected Diseases initiative (DNDi)
and Epicentre, is now the World HealthOrganization recommended protocol. NECT
is much safer than melarsoprol, the drug thatwas previously used to treat the disease, andwhich is a derivative of arsenic. Melarsoprol© Francois Dumont / MSF

International Activity Report 2013

Supplies are unloaded at MSF’s tent hospital in Guiuan in the aftermath of Typhoon Haiyan in the Philippines.

causes many side effects and can evenkill the patient. It is hoped that the newmolecules currently under clinical trial willlead to the development of a safe, effective
treatment for both stages of the disease thatcan be administered orally.
MSF admitted 1,800 patients for sleeping
sickness treatment in 2013.

Tuberculosis
One-third of the world’s population iscurrently infected with the tuberculosis (TB)
bacillus. Every year, about nine million people
develop active TB and 1.5 million die from it.
TB is spread through the air when infected
people cough or sneeze. Not everyone
infected with TB becomes ill, but 10 per
cent will develop active TB at some point intheir lives. The disease most often affects
the lungs. Symptoms include a persistent
cough, fever, weight loss, chest pain andbreathlessness in the lead-up to death. TB
incidence is much higher, and is a leading
cause of death, among people with HIV.
Diagnosis of TB depends on a sputum or
gastric fluid sample, which can be difficult
to obtain from children. A new molecular
test that can give results after just two hours
and detect a certain level of drug resistanceis now being used, but it is costly and stillrequires a phlegm sample, as well as areliable power supply.

yellow fever – although not all vaccines arerecommended everywhere.

A course of treatment for uncomplicated
TB takes a minimum of six months. Whenpatients are resistant to the two mostpowerful first-line antibiotics, they are
considered to have multidrug-resistant TB(MDR-TB). MDR-TB is not impossible totreat, but the drug regimen is arduous,
taking up to two years and causing manyside effects. Extensively drug-resistanttuberculosis (XDR-TB) is identified when
patients show resistance to the secondline drugs administered for MDR-TB. The
treatment options for XDR-TB are limited.

In countries where vaccination coverage is
generally low, MSF strives to offer routine
vaccinations for children under five whenpossible as part of its basic healthcare
programme. Vaccination also forms a
key part of MSF’s response to outbreaksof measles, yellow fever and meningitis.
Large-scale vaccination campaigns involveawareness-raising activities regarding thebenefits of immunisation as well as the set-up
of vaccination posts in places where people
are likely to gather. A typical campaign lasts
between two and three weeks and can reachhundreds of thousands of people.

MSF treated 29,900 patients for TB and 1,950
for MDR-TB in 2013.

Water and sanitation
Vaccinations
Immunisation is one of the most cost-effective
medical interventions in public health.
However, it is estimated that approximately
two million people die every year from
diseases that are preventable by a series ofvaccines recommended for children by theWorld Health Organization. Currently, theseare DTP (diphtheria, tetanus, pertussis),hepatitis B, Haemophilius influenzae type b(Hib), BCG (against tuberculosis), humanpapillomavirus, measles, pneumococcal
conjugate, polio, rotavirus, rubella and

Safe water and good sanitation are essential
to medical activities. MSF teams makesure there is a clean water supply and awaste management system in all the healthfacilities where it works.
In emergencies, MSF assists in the provisionof safe water and adequate sanitation.
Drinking water and waste disposal areamong the first priorities. Where a safe water
source cannot be found close by, waterin containers is trucked in. Staff conduct
information campaigns to promote the use of
facilities and ensure good hygiene practices.

Glossary of diseases and activities   13

Médecins Sans Frontières

South Sudan:

A country gripped by violence
South Sudan gained independence from Sudan in July
2011, becoming Africa’s first new country since Eritrea in
1993. Since then, however, hopes for the future of the youngstate have slowly crumbled and in 2013, as the government
collapsed and intercommunal violence reached explosive
levels, South Sudan edged towards civil war.
South Sudan, and what takes a matter ofhours to destroy can take months or evenyears to reconstruct, leaving many thousandsof people without adequate healthcare.
As the fighting in Jonglei state intensified,almost the entire population of Pibor county
sought refuge in the bush. People were
too afraid to leave their hiding places toseek medical attention, and so MSF went
to them: a small clinic was set up in Boma
town, staff continued to run a health post in
Gumuruk, and mobile clinics – some carriedout by helicopter – conducted hundreds ofconsultations in the bush in southern Pibor.
Before MSF could deliver assistance to those

December violence
In Juba, amid a power struggle inside theruling Sudan People’s Liberation Movement(SPLM), South Sudan’s president, Salva Kiir,
sacked his cabinet in July and so rid himself
of his main political rival, vice-president
Riek Machar. What started as a politicaldispute exacerbated ethnic tensions in an
already divided country. On 15 December,fighting broke out between battalions of
the Sudan People’s Liberation Army (SPLA),
spilled onto the streets of the capital andresulted in Kiir accusing Machar of an
attempted coup d’état. Conflict subsequently
spread throughout the country, between
those loyal to the government and those
supporting the former vice-president.
Civilians sought shelter in UN bases andin the bush, and many others crossed intoneighbouring countries such as Uganda,
Ethiopia and Kenya.

© Corinne Baker / MSF

Jonglei state has seen some of the worst
violence since independence, a result ofconflicts that are rooted in cattle raiding.
In March, however, the situation became
even more unstable as the army launched an
offensive against a rebel group led by DavidYau Yau. In April, Médecins Sans Frontières(MSF) was forced to suspend activities inPibor because of threats against staff andpatients and was preparing to return in May,
having secured the necessary assurances,when the hospital in Pibor was looted andrendered unusable. This was the sixth time
an MSF medical facility had been looted ordamaged in Jonglei state in two years. It isdifficult and expensive to build hospitals inin hiding though, requests for government
permission to travel to opposition-held
territory were repeatedly denied.

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

14 south Sudan: A country gripped by violencE© MSF

International Activity Report 2013

The MSF hospital in Pibor after it had been purposefully damaged to render it inoperable.

Bor, the once bustling capital of Jonglei
state, had become a ghost town by theend of the year as government troops and
SPLM-in-Opposition (SPLM-IO) battled forcontrol. It was the first major area to fallto the rebels after the December violence.
Thousands of civilians fled to the town of
Awerial, on the banks of the Nile in Lakes
state, and MSF’s emergency team supported
two Ministry of Health clinics by providing
consultations and obstetric care anddonating medicines. Clean drinking waterand measles vaccinations for children werea priority. With very little infrastructure inplace, and an already weakened population,
the risk of disease in makeshift camps suchas Awerial and Minkamman loomed large
and the situation will only be exacerbatedonce the rainy season starts and settlements
begin to flood.
Sudanese refugees
Amid the mass internal displacement andinstability that took hold of the nascentcountry in 2013, it could be forgotten that
South Sudan is also home to hundreds ofthousands of Sudanese refugees, the majorityof who fled conflict in Sudan’s South Kordofan© Jean-Pierre Amigo / MSF

Following the eruption of vicious fighting in
Juba on 15 December, people fled for theirlives and sheltered in two UN compounds.
MSF set up clinics in both camps, and also
provided Juba Teaching Hospital with drugs
and medical supplies. As the situation inSouth Sudan deteriorated, MSF suspended
activities for two days at the hospital in
Malakal, Upper Nile state, because staff wereunable to gain safe access due to outbreaksof violence. In the same month, staff had tobe evacuated from Leer hospital owing tosafety concerns.

The conflict in South Sudan has displaced hundreds of thousands of people.
and Blue Nile states in 2011 and 2012.
In refugee camps in Unity and Upper Nilestates, cholera, malaria and measles are alla threat, and hepatitis E outbreaks have had
a major impact on mortality in camps near
the border with Sudan. MSF ran a numberof vaccination campaigns in 2013. In April,more than 105,000 Sudanese refugees and27,500 residents of Maban county were
immunised against cholera; this was thefirst time MSF had used the two-dose oralvaccine as a preventive measure on such alarge scale, in such a remote location.
The pneumococcal conjugate vaccine wasused for the first time in South Sudan in
Yida camp, Unity state, in August.

this latest conflict access to healthcare waslimited and providing it was a challenge.
This is a barren region, with rivers, swamps,
and barely any roads. By the end of theyear, MSF’s priority became identifying
where needs were greatest, and responding
accordingly even if it meant staff leaving
ongoing, long-running projects focused onacute needs.

MSF has been working in what is now
South Sudan for 30 years and even before

For more details of MSF’s response in South
Sudan, see the country report, pp.82 – 83.

With interethnic tensions increasing, people’s
needs growing ever-greater and resources
scarcer due to the departure of internationalorganisations in December, as 2013 drew
to a close the situation in South Sudan waspoised to become dramatically worse.

South Sudan: A country gripped by violencE 15

Médecins Sans Frontières

Addressing women’s
health needs

Over the last 20 years, aid organisations
have learned that the specific needs ofwomen have to be addressed as part of an
emergency response. Trends in maternalmortality1 reveal a 47 per cent reduction in
the number of maternal deaths worldwide
between 1990 and 2010. This data is
encouraging, but the reality of girls andwomen in many parts of the world haschanged little. Differences between areas of
the world are huge: in developed regions
one in every 3,800 women risks dying
from pregnancy- or childbirth-related
complications, while in developing regions,
it is one in 180 women, and in sub-SaharanAfrica, one in 39 women.
In many situations where Médecins Sans
Frontières (MSF) works, obstetric care isin a constant state of emergency; national
health systems are disrupted, there arestaff shortages, low salaries and little orno supplies. Conflict and crises further
exacerbate the situation.
MSF’s work with regards women’s healthfocuses primarily on action that directly
impacts mortality and suffering: obstetricand newborn care, postnatal care andsafe abortion. MSF also offers a rangeof preventive actions that are known tocontribute significantly to the reduction ofmaternal morbidity and mortality: antenatalcare, the provision of contraceptives,
prevention of mother-to-child transmission(PMTCT) of HIV/AIDS, and cervical cancer
screening and treatment in pilot projects.
In some programmes, MSF provides
obstetric fistula repair.

16 Addressing Women’s Health Needs

Sexual violence occurs everywhere,
but it tends to be more prevalent incrisis situations. The majority of people
presenting after incidents of sexual violencein MSF projects are women and children,
but men are also coming forward. All MSF
operations are prepared to provide medical
and psychological care to victims of sexual
violence, as well as medico-legal certificates.
Complications during and after birth
Most maternal deaths occur during or
immediately after birth, and MSF’s primarycommitment, therefore, is the provisionof skilled obstetric and neonatal care.
In 2013, over one-third of MSF projects
offered obstetric care, and half of them had
the surgical capacity to perform a caesarean
section when needed. Maternal mortality
in the maternity wards supported by MSF islow, which shows that even in remote areasof Afghanistan, for example, obstetric andneonatal care can and should be provided.
MSF also treats women who have given
birth at home and who arrive with postnatal
complications such as a retained placenta,
severe bleeding or infection.
Most post-partum complications for bothmothers and newborns occur in the first
24 hours, and for this reason MSF encourages
women to stay in the maternity unit for
one day after delivery. This allows for early
diagnosis and treatment of complications,and also supports the breastfeeding mother.
At least one follow-up visit in the first week

after birth is recommended, either at thematernity unit or in the community.
Consequences of unwanted pregnancy
and unsafe abortion
Of the four main causes of maternalmortality, unsafe abortion is the one that is
entirely preventable. Worldwide, it accounts
for approximately 13 per cent of all maternal
deaths; the figures are much higher insome regions such as Latin America andin areas where the population is living in
displacement camps.
Girls and women with complications resulting
from unsafe abortion frequently arrive in theemergency rooms of MSF facilities. Some comein bleeding and distressed, rather than in any
real danger, and counselling and support
will be all that they need. Others arrive withlife-threatening complications and may require
antibiotics, surgery, blood transfusions or timein intensive care, or all of the above.
Experience shows that many women andgirls will seek unsafe abortion to terminate
an unwanted pregnancy if no safe abortion
care is available. They will do so risking
their life, sometimes knowingly, because thealternative is unbearable. MSF provides safe
abortion care to women and girls in need,whenever this is feasible.
MSF also makes a choice of contraceptives
available and provides information andcounselling to girls and women who want to© Laurence Geai

Pregnancy and birth do notstop because of a conflictor crisis, and neither do anyof the associated medical
complications. Pregnant
women make up five per centof a general population at
any given time but among
refugees and displaced
people, the percentage isoften higher. In general, there
are more women in displaced
populations because often themen are fighting or have stayedbehind to protect property.

Sonia is resting with her newborn baby, after delivering in the MSF hospital in M’Poko camp,
Central African Republic.

International Activity Report 2013
plan their pregnancies, and are in a position
to do so. Contraception is the best methodof preventing unwanted pregnancies. It
allows young women to delay their firstpregnancy and enables women who alreadyhave children to plan the timing of theirnext one. Women who have experienced
life-threatening complications can alsodecide whether or not they are willing torisk carrying another child.

Antenatal care (1st visit)

340,306

Vaginal deliveries

164,553

Caesarean sections

17,681

Contraception (consultations)

138,069

Postnatal care

114,356

Sexual violence care

11,062

PMTCT

18,489Safe abortion care (provided or

The role of antenatal carereferred to a quality provider)683

Antenatal care alone does not prevent
maternal death, but it is an important way
for health staff to connect with expectant
mothers. Some women may only attend one
antenatal consultation at an MSF clinic, latein their pregnancy. MSF uses this opportunity
to diagnose, manage and treat medical
conditions that affect the mother and baby,
to discuss birth preparation and to encourage
women to deliver at the maternity unit.

Obstetric fistula repair804© Mikhael De Souza / MSF

In areas with a high rate of HIV, MSF offers
testing to all pregnant women, primarily as
part of their antenatal care, but also during or
after birth. The transmission of the HIV virus
from mother to baby – during pregnancy andbirth and through breastfeeding – is the main
source of HIV infection in infants. PMTCT
is possible, and MSF provides appropriate
treatment to women who have tested positive
and treats their babies immediately after
birth. Wherever possible, MSF also refers
women for continuous HIV care after they
have finished breastfeeding and arranges
follow-up care for their babies.
Cervical cancer
After breast cancer, cervical cancer isthe main cause of cancer-related deathin women worldwide. The majority ofwomen who die from cervical cancer live indeveloping countries, and those with HIV/AIDS are particularly vulnerable. 2 In someprojects, MSF has started screening andtreating cervical cancer in its early stages.3
Abnormal cells are made visible to the eye
through a simple colouring method 4 andcan be removed in the same visit, without
the need for hospitalisation.

Having successfully undergone obstetric fistula surgery, Nafissa recuperates in the village desfemmes in Abéché, Chad.

The challenge of societal roles

MSF recognises that women and girls havevery specific medical needs, and provides
the necessary care whenever possible.
Today, a third of all MSF interventions, bethey longer term or emergency projects,
offer obstetric care.

© Yann Libessart / MSF

Many of the major challenges in the drive
to prevent maternal death are a result of
the roles that societies and communities
attribute to girls and women. Early marriage,
female genital mutilation, teenage pregnancy,
multiple pregnancies, sexual violence:these are all factors that contribute to highmaternal mortality, especially where there isno access to quality healthcare.

A baby boy delivered by caesarean section at Bethany hospital, Tacloban, in the Philippines.
After the typhoon, his mother walked for several days to reach medical help.
1 HO, UNICEF, UNFPA and The World Bank estimates – WHO 2012. 2 In HIV-infected women, cervical cancer isWmore frequent and develops much faster. 3 Pre-cancerous lesions. 4 VILI/VIA diagnosis

Addressing Women’s Health Needs 17

CENTRAL AFRICAN REPUBLIC:DESCENT INTO CHAOS
Central African Republic (CAR) has known decades of violence, displacement and lack of
medical access, and Médecins Sans Frontières (MSF) has been working there since 1996.
This year, however, the country was confronted with a massive humanitarian crisis to which
many in the international community, and the world in general, remained largely indifferent.
Towards the end of 2012, the Séléka –a coalition of rebel groups mainly from thenorth and east of the country – made their
way towards the capital, Bangui. En route
they took control of numerous towns andvillages, forcing residents to flee into thebush to escape the violence. The presence of
the Séléka exacerbated the ongoing conflict
between farmers and pastoralists, and CAR’s
armed forces, FACA, withdrew from areas
where they had been integral to keeping
the situation under control. The anti-balaka(anti-machete) traditional self-defence
groups started fighting the Séléka whomthey perceived as pro-Muslim for favouring
the pastoralists from the north.

Djotodia announced in September that hehad officially disbanded the Séléka coalition,
but many fighters refused to put down their
weapons. They committed atrocities against
civilians, and the anti-balaka – its ranks swelledwith former soldiers, gangs and other selfdefence groups – reciprocated with attacks onmembers of the Muslim community.
Displaced people found themselves living
without access to safe water, facing foodshortages and malnutrition, and with anincreased threat of malaria. Despite thehuge rise in people’s needs, however,
the humanitarian presence in the country
reached an almost record low. Many UNagencies and NGOs withdrew to the capital
due to the lack of security, leaving muchof the country without aid. In light of thesituation on the ground MSF felt compelled
to publish an open letter to Valerie Amos,
UN Under-Secretary-General, on
12 December, citing the ‘unacceptableperformance of the United Nations
humanitarian system in the Central African
Republic over the last year’ and Arjan
Hehenkamp, General Director of MSF
in the Netherlands, wrote a piece for
The Guardian newspaper stating that
‘The aid world has failed the people of
the Central African Republic’.

© Camille Lepage / Polaris

Despite signing a peace deal with thegovernment in January, the Séléka marchedon Bangui in March and seized powerclaiming unfulfilled promises. President Bozizé

left for Cameroon (he himself had taken
power by force in 2003), state security forceswere disbanded, and rebel Michel Djotodia
proclaimed himself president, suspended
the constitution and dissolved parliament.
In August he was officially sworn in.
The coup left the country in chaos, andwidespread violence and looting ensued as
CAR remained at the mercy of armed groups.

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

18 CENTRAL AFRICAN REPUBLIC: DESCENT INTO CHAOS

© Juan Carlos Tomasi / MSF

On 9 September, theanti-balaka targeted
the town of Bouca
and buildings wereburned to the ground.
Séléka fighters
were executed, andcivilians fled into
the bush or sought
shelter in the Catholic
mission compound.
Once the violence had
subsided, MSF helped
400 families who had
lost their homes.

Since the start of the conflict, tens of thousands of people have fled theirhomes to escape vigilantes armed with machetes and guns. In September in
Bossangoa, 30,000 people sought refuge in the grounds of the Catholic mission,and 8,000 people from the Muslim community sheltered in a mosque.

© Camille Lepage / Polaris

CENTRAL AFRICAN REPUBLIC: DESCENT INTO CHAOS  19

© Marcus Bleasdale / VII

The woman pictured above is being rushed from a camp at the church in Bossangoa
to the MSF-supported hospital for treatment. People are sheltering in large groups forsafety, in the Catholic mission compound, in the hospital, in a school and next to theairstrip. Those in the bush are particularly at risk of contracting malaria – CAR’s number
one killer – but all are living in precarious conditions with little access to sanitation
facilities. In a country of over 4.5 million people, which already has some of the worst
health indicators in the world, the crisis has heavily impacted the healthcare of civilians,
as routine vaccinations have not taken place, HIV treatment regimens have beeninterrupted and levels of malnutrition and malaria have increased.

© Camille Lepage / Polaris

On 5 December, a wave of violence swept
through Bangui as armed groups launched
an offensive after the arrival of French
troops to disarm the ex-Séléka. Attacks on
Christians followed by revenge killings against
Muslims took place around the country as
the ex-Séléka withdrew. The anti-balaka
increased the number of attacks against
Muslim communities in the north and westof the country, as they saw these areas aspotential political bases for the ex-Séléka.
MSF treated hundreds of wounded people.
At the Community Hospital, MSF teams weretreating 15 to 20 wounded a day during
early December, predominantly for gunshot
and machete wounds. Patients who had
been tortured and beaten were seen at thehospital, and many people presented with
defensive injuries to their heads, hands andarms. Amitié Hospital, Bangui’s main hospital,
was attacked and looted, and health staff
fled amid threats. Ten days after the unrest
began, the UN Office for the Coordinationof Humanitarian Affairs estimated that one infour residents of Bangui had been displaced.

Josianne
Displaced person who took refuge inthe bush, Bria
“Since this all started, we flee, we sleep in thebush, we don’t eat well, we are bitten bymosquitoes. There are too many illnesses.
We are always running. You can see foryourself what state we are in. We want peace.”20 CENTRAL AFRICAN REPUBLIC: DESCENT INTO CHAOS

© Juan Carlos Tomasi / MSF

This patient in the Community
Hospital in Bangui has
received a gunshot wound
to the leg. Despite repeatedcalls for those engaged in thefighting to respect medical
structures, ambulances,medical personnel and theill and wounded, attacks
on healthcare facilities andworkers continued and on
more than one occasion,
armed men entered thehospital. On 29 December
they threatened to lynch
some of the patients.
All humanitarian organisations
working in CAR have been
victims of looting androbberies, and staff havebeen threatened.

The beginning of 2014 brought no respite for CAR. When Djotodia left power in January, Christian militias began attacking Muslim civilians
and many were forced to flee to neighbouring countries such as Chad or Cameroon. MSF continues to treat the wounded and respond tothe massive displacement of people; at the time of writing MSF has more than 300 international staff and 2,500 Central African staff working
in the country. MSF and a handful of other organisations have shown that it is possible to keep working in CAR throughout the crisis, and evento expand operations. However, more international intervention is needed. The violence continues and the population of CAR live in fear.

© Marcus Bleasdale

For more details on MSF’s response in CAR, see the country report, pp. 36–37.

Dr Sabine Roquefort
MSF doctor at theCommunity Hospital, Bangui“We are accustomed toworking in very violent
environments, but thisorganised, wilful intent tomutilate, wound and killshocked me. The level ofviolence and suffering has
struck me more powerfully
than in any other conflictsetting where I have worked.”

CENTRAL AFRICAN REPUBLIC: DESCENT INTO CHAOS  21

Médecins Sans Frontières

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

There are few options for quality healthcare
in the area, with the nearest major centre of
Jacobabad about 40 kilometres away, andprivate clinics – of which there are only asmall number – charging tens of thousandsof rupees for caesarean sections, for example,
an impossible cost for most families. As well
as being excluded from medical care, thepeople here have been displaced by internal
conflicts and affected by social violence.
As Australian nurse David McGuinness says,
there are many challenges when working
for MSF in a location like Dera Murad Jamali:“Stories of loss, tales of terror, another bomb
blast, another kidnapping, and children
literally starving to death [but] the work
being done here is invaluable and theimpact it has on people is undeniable.”
Dr Raj Batra was working for a public
hospital before he joined MSF. “There
were poor people who couldn’t accesshealthcare and were being denied the proper
treatment,” he said. “When I read about
MSF’s independence and impartiality, I said I
wanted to join.” As the medical focal person
in MSF’s Dera Murad Jamali clinic, Dr Batra
supports all the departments, including
maternal and child health, the feeding
programme for malnourished children andthe mobile clinics. He explains: “The biggest
challenge is that people in this area are noteducated about health issues and often
depend on home remedies. For example,
with breastfeeding, women often avoid
using the first milk from the mother. But weknow how important that first milk is – withnutrition and antibodies for the baby.”© Sheeba Hanbi

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

Mohammad Aslam
Before MSF, I was working as a receptionist for an organisation that supported educationin Nasirabad and Jaffarabad. The organisation also provided some voluntary support tothe basic health units in the region.
I joined MSF in April 2009, for the professional experience and to help people in need.
I was still getting to know the job and the organisation when MSF launched its responseto the 2010 flood emergency. We had around 45 international and around 350 Pakistanistaff working in Dera Murad Jamali. I realised the international staff and national staff
had the same objective: to help those people affected by the floods.
A typical day
We start our working day at 8am with a meeting. I then spend time each day working
on the project’s medical supplies, receiving requests, organising quotations and making
the purchases.
Once a month, I receive the medical orders from the teams in Dera Murad Jamali andsend them supplies from our store. Once every three months, we send a big order forboth medical and non-medical items to the capital, Islamabad. The medical team leader
will talk to the logistics team about what’s needed, and then logistics will talk to me
about how we can arrange the supplies.
When we receive cargo from Islamabad, we enter it into the system and make sure thatanything needing to be refrigerated is placed in the cold chain. Sometimes I’ll also fill inas the assistant to the project coordinator.

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

International Activity Report 2013
In charge of the maternal and child healthdepartments at the clinic is midwife
Gaudesia Waitherero Kimani from Kenya.
She is responsible for the birthing unit,
antenatal and postnatal care, and thenursery. She draws on her experience
working as a midwife with MSF in South
Sudan to advise co-workers on the best
medical treatment.
“We have many cases of pre-eclampsia
and mothers haemorrhaging, which islife-threatening. In the nursery, it takes timeand you have to be patient. The prognosisof the babies is very poor, due partly to lackof hygiene in the community and because
many parents don’t come to the antenatal
clinic for vaccinations, which would protect
the baby.”

Gaudesia Waitherero KimaniThis is my third mission with MSF.
I have also worked as a midwife inSouth Sudan, first for six months in thetownship of Raga and then for a year
at a huge MSF project working withrefugees in Maban. In South Sudan,
MSF provides maternal and reproductive
health services, including looking after
mothers with complicated births andmothers with hepatitis E, which is aserious health issue there. In between
my MSF missions, I work at a private
hospital in Nairobi, Kenya.

Dr Raj Batra
Dr Raj Batra grew up in Jacobabad, where he completed his pre-medical studies. He was oneof just 31 candidates (out of 1,650 applicants) from his district chosen to complete a Bachelorof Medicine at Chandka Medical College in 2001. After further training in Karachi, he began
working as an ambulance paramedic with a Pakistani NGO (the Aman Foundation).
After he was injured in a road traffic accident, he began working as a doctor in telehealthand began an MBA in Health Management. He oversaw a project mapping all healthcare
facilities in Karachi and neighbouring districts – the first of its kind in Pakistan – to make iteasier for people to access health services.
Next he took a job looking after the health of workers in the textile industry in Karachi, andthen in December 2013 joined MSF as the medical focal point in Dera Murad Jamali.
A typical day
A normal day starts with a meeting, where we share security updates such as any bombing
incidents overnight or other incidences of violence. From the project side, we also discusseach team’s plans for the day. After that, I usually go to my office and might need to makea supply order, prepare a report or arrange reimbursements for staff. These jobs are really
important to help with the smooth running of the project.
I’ll then join the staff doing the morning medical round of the hospital and take theopportunity to ask patients for feedback on our services. I might need to prepare shortreports for the relevant staff to pass on any comments from patients.
I’m also responsible for the weekly medical meeting, where we gather and review cases, discuss
medical issues and try to reach a consensus. If we can’t reach agreement on a medical issue,
we might involve the project coordinator. I will work with the medical team leader to respond tohealth, operational, management and supply issues. I make sure that every protocol and policy
is being followed in the project. I’m also responsible for the health of our Pakistani staff. If they
are sick, I might need to refer them to the best facility for treatment. Basically I’m the person
who works to coordinate all the medical teams. Coordination is the thing that holds us together.

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

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

A Day in the Life: médecins Sans Frontières (MSF) clinic at Dera Murad Jamali, Balochistan, Pakistan 23

Médecins Sans Frontières

Overcoming challenges to meet

MSF’s vaccination
ambitions
Today, 10-month-old Roni will
be vaccinated against one of
the world’s biggest killers ofchildren his age: pneumonia.
He waits patiently, perched on
his mother’s hip, as she gives
his name and date of birth to
the Médecins Sans Frontières(MSF) team working in Yida
refugee camp in South Sudan.
While immunisation has always been a majorpart of MSF operations – with more than two
million people protected against measles in2013 alone, for example – the organisation
recently upped its vaccination ambitions. This
involves, in part, using the newest vaccines
more systematically in MSF operations,
including in emergencies, where children
are at their most vulnerable. For example,
Roni was one of several thousand children
vaccinated by MSF in the Yida camp between
July and September 2013 with two new
vaccines that were not yet available in South

Sudan: pentavalent and the pneumococcal
conjugate vaccine (PCV). MSF projects arealso rolling out innovative strategies, seeking
to show in Guinea, for instance, that a neworal cholera vaccine is effective in responding
to outbreaks and even works as a usefulpreventive tool where cholera is endemic.
MSF’s renewed commitment to vaccination
as a medical priority centres on the ambition
to strengthen routine immunisation, thatis to say, the vaccines the World HealthOrganization (WHO) recommends all children
should receive. Four priority countries havebeen chosen: Central African Republic (CAR),
Chad, Democratic Republic of Congo (DRC)and South Sudan. There are many aspects
to this work, and one is reducing ‘missed
opportunities’ in MSF projects by screening
eligible children for their vaccination statusduring clinic visits. Another is integrating
immunisation into other paediatricprogrammes. MSF projects in Niger, Mali andChad, for example, are already combining
routine vaccination activities with other healthmeasures such as seasonal malaria prevention.
A third strategy is pursuing opportunities

to find those children over the age of one
who haven’t completed the recommended
immunisation series and need to ‘catch up’.
However, these new vaccination plans are indanger of being thwarted by the issue of price,and by the very nature of the vaccine productitself. MSF, through specific campaigning
and advocacy, needs to address these issues,
while also focusing on innovative operational
activities and research.
When price curtails ambitions
The GAVI Alliance – the foundation thatprocures vaccines on behalf of many
developing countries – has been instrumental
in negotiating substantially lower vaccine
prices for the world’s poorest countries.
This has helped to improve availability of thenewest vaccines in countries hardest hit bydiseases like pneumonia.
These lower prices are, however, only available
through specific purchasing channels, andMSF has not been able to systematicallyaccess the ‘GAVI price’. Nor does GAVI havepolicy provisions that cater to emergency

WE NEED EASIER-TO-USE VACCINES

E

TIM

NO MO
N

SE V E

A
T RE

KA

IN

A

S
EROU T ERR A

I LY

6 WEEKS

AW

CH

FA M

OUR WALKRAFOR T NSPOM
Y F RO WOR

ND

BIRTH

LH

EY

RT

RA

Five Vaccination Visits are Required Before a Baby’s First Birthday.
This can be Difficult for Caregivers in Developing Countries

10 WEEKS

14 WEEKS

9 MONTHS

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

24 Overcoming challenges to meet MSF’s vaccination ambitions

© Ikram N’gadi / MSF

International Activity Report 2013

Ice packs are prepared for the vaccinations that need to be kept in the cold chain. Vaccinations must be kept cold but not too cold,
ideally between 2 and 8°C.
situations, as it is a development organisation
focusing on the WHO’s Expanded Programmeon Immunization (EPI). WHO released new
guidelines last year which recommend
vaccinating in humanitarian emergencies,
yet accessing vaccines at an affordable priceand in a timely manner remains a hurdle.
With the escalation of the humanitariancrisis in South Sudan, MSF sought tovaccinate vulnerable children in Yida campagainst pneumonia. It took 11 months toorganise the campaign because of problems
accessing the vaccines, an untenable
timeline for an emergency response.
So why did it take so long? The reasons
were complicated price negotiations withpharmaceutical companies GSK and Pfizer,
and with the GAVI Alliance, and lengthy
procurement processes. With the growing
refugee crisis and MSF’s frustration at theinability to purchase PCV at the GAVI price,
the MSF Access Campaign went public in April
2013 with its Dear GAVI social media campaign,urging the alliance to open up its discounted
prices to MSF and other humanitarianorganisations. Ultimately, MSF was able toaccess PCV at a price of US$7 per dose – still
double the lowest global price paid by GAVI.

The Dear GAVI campaign brought mixed
results, and while GAVI has publicly
committed to making its prices available
to humanitarian organisations if they use
its procurement channels, MSF will still
push to purchase vaccines at the lowest
global price directly from pharmaceuticalcompanies. These companies – who areultimately responsible for pricing decisions– refuse to sell their vaccines to MSF at
the cheapest possible price, so the AccessCampaign continues to advocate for greateraffordability and access.
Vaccines on ice
More than 22 million children each year
go without the basic package of vaccines
recommended by WHO, largely becausedelivering these products to remote areas isremarkably challenging. Vaccines are usuallydeveloped with wealthy-country conditions
in mind: reliable and constant electricity
to keep vaccines refrigerated; qualified
health workers able to deliver injections;the means to safely dispose of syringes;
and the relative ease for most caregivers toreach a vaccination point, meaning that themultiple visits needed to complete a complex
immunisation schedule – a minimum of five
– are feasible.

Little of this applies to many developing
countries where the most vulnerable children
live. MSF field logisticians say that the need for
vaccines to be kept at the right temperatures,in a constant ‘cold chain’, is one of the biggest
barriers to expanding the reach of vaccinations.
For an MSF measles vaccination campaign
in Chad, for example, 21,500 ice packs wererequired, and this involved 18 freezers andthree freezer rooms. Then there is the addedcomplexity that vaccines need to be kept cold,
but not too cold – vaccines can accidentally
freeze when they’re stored against ice packs
while on their way to vaccination points.
MSF is therefore campaigning for easier-touse products, particularly vaccines that are
more tolerant of heat for the very last stagesof their journey from a health centre to thepatient. This is being achieved in part throughoperational and clinical research: in 2013,
MSF and its research arm Epicentre carriedout a study to determine the stability andcontinued efficacy of a tetanus toxoid vaccinethat was kept in a ‘controlled temperature
chain’ at ambient temperatures of up to
40°C for up to 30 days. The results so far
are promising, and once the data has beenreleased it should be possible to use it to push
for the vaccine to be re-labelled, allowing it

Overcoming challenges to meet MSF’s vaccination ambitions 25

Médecins Sans Frontières
to be kept for a certain period of time outside
the cold chain. Pushing pharmaceuticalcompanies to re-label their vaccines foruse outside the cold chain for even several
days would be helpful for campaign andoutreach programme vaccines.
This, however, is just the beginning as ultimately
we need pharmaceutical companies to develop
future products that prioritise thermostability,
so that vaccines can be left out of the cold
chain for at least a month.

Two New Vaccines Account For 74% of the Cost to Vaccinate a Child

Total cost of vaccine package
in a developing country:$38.75
BCG (TB) $ 0.09
Hepatitis B $ 0.29

26%

Oral Polio $ 0.55
Measles-Rubella $1.09
Pentavalent (5 in one) $7.98

74%

Rotavirus $7.75 20%
Pneumococcal $21.00 54%

UNICEF Vaccine Price Data: http://uni.cf/mti97E
All Measurements in US Dollars
Price per vaccine is based upon the WHO-recommended number of doses
Pentavalent vaccine protects against five diseases: Diphtheria, Tetanus, Pertussis, Hep B, Hib© Ikram N’gadi / MSF

The cost of fully vaccinating a child has
increased by 2,700 per cent since 2001,
and humanitarian organisations and many
countries are therefore finding it increasingly
difficult to afford these essential health tools,
and then there are the added problems ofvaccines that require cold chain, and thecomplex logistics of a vaccination programme
in remote areas. What MSF is witnessing in thefield – children dying from vaccine-preventablediseases – is spurring us on to improve ourprogrammes and to speak out about whatchanges the vaccine community needs tomake. If we want to reach the 22 million
children that go unvaccinated every year,
GAVI, pharmaceutical companies and donors
must work together. We need products thatare better suited to the places where we workand to those who require them most, and weneed access to them at the lowest prices.

WE NEED MORE AFFORDABLE VACCINES

A number of vaccination campaigns took place this year, and nearly two and a half million people were vaccinated against measles in response
to outbreaks.

26 Overcoming challenges to meet MSF’s vaccination ambitions

© Yasuhiko Okuno

An MSF Community Testing Counsellor in Swaziland explains what HIV is, how it is transmitted and how it can be prevented.

Activities
by country
28	Afghanistan

41	Egypt

60	Lebanon

30	Armenia

62	Lesotho

78	RussianFederation

30	Bolivia

42	Democratic Republicof Congo

63	Libya

79	South Africa

31	Bangladesh

44	Ethiopia

63

Madagascar

80	Somalia

32	Bulgaria

46

France64

Malawi82	South Sudan

32	Burkina Faso

46	Georgia

65

Mali

84	Sudan

33	Burundi

47	Greece

66

Mauritania

85	Swaziland

33 	Cameroon

47	Guinea

66

Morocco86	Syria

34	Cambodia

48	Haiti

67

Mexico88	Sierra Leone

34	China

50	Honduras

68

Mozambique

88	Tajikistan

35	Colombia

50

Iran

69

Myanmar36	Central African
Republic

51

Italy

38	Chad52

India

40	Congo

54

IRAQ

40

56

JordanCôte d’Ivoire

41	Democratic People’s
Republic of Korea

51	LAOS89	Turkey

70	Niger89	Ukraine

72	Nigeria

90

Uganda73	Palestine

91

Uzbekistan

73	Papua New Guinea

91	Zambia

74	Pakistan

92	Zimbabwe

57	Kyrgyzstan

76	Philippines

94	Yemen

58	Kenya

78	Paraguay

Médecins Sans Frontières

afghanistan
The number of people
receiving critical medical careat Médecins Sans Frontières(MSF) hospitals has nearly
doubled over the last two
years, a clear indication of the
medical needs in the country.
In 2013, the ongoing war and its
consequences continued to restrict
people’s access to quality medical services –in particular to specialist healthcare.

Cities, towns or villages with MSF activities

Ahmad Shah Baba hospital, Kabul
The number of people in Kabul has
increased significantly as a result of
migration, displacement and repatriation.
In eastern Kabul, MSF has been upgrading
Ahmad Shah Baba hospital to become areliable district hospital, and has trained
Afghan staff from the Ministry of HealthKey medical figures:• 370,000 outpatient consultations• 48,000 patients admitted to hospital• 32,800 births assisted

and MSF so that they can provide emergency
and maternity services around the clock.
Major work completed in 2013 included a
new waiting area, the relocation of the female
outpatient department and the opening ofa new maternity ward with 21 beds offeringlabour, delivery and post-delivery care. This year,© Andrea Bruce / Noor Images

Private clinics are unaffordable for most Afghans
and many public hospitals are understaffedand overburdened. Many rural health clinics
are dysfunctional, as qualified health staff
have left the insecure areas, and the supplyof reliable drugs and medical materials is
irregular or non-existent. Insecurity can also
prevent entire communities from travelling tohospitals. Afghanistan has some of the worst
health indicators in the world according to theWorld Health Organization, and is still one of
the riskiest places to be a pregnant woman ora young child. MSF focuses on ensuring people
have better access to free, quality healthcare insome of the most conflict affected areas.

A woman delivers a baby via emergency caesarean section at the Ahmad Shah Baba hospital, Kabul.
28 afghanistan© Robert Nickelsberg / Getty

International Activity Report 2013

At a clinic on the eastern outskirts of Kabul, Afghan men get their drug prescriptions filled.

staff assisted approximately 1,000 births every
month. The hospital also provided treatment for
malnourished children, admitting 500 children
to the therapeutic feeding programme.

were also moved into the building, facilitating
access for patients returning for follow-up
visits. More than 12,000 physiotherapy
sessions were conducted during the year.

in Afghanistan and many qualified specialists
prefer to live and work in the big cities. MSF
international staff help fill the gap and also
provide training.

In January, MSF launched a mobile clinic toassist displaced people suffering as a result of
Kabul’s harsh winter. The team worked in six
camps and conducted 2,000 consultations
over a three-month period. From April, MSF
operated mobile clinics in the Ahmad ShahBaba area to carry out antenatal and postnatal
consultations, and vaccinations for children.

A mental health programme was launchedin 2013 to provide psychological support topatients and families coping with traumatic
events and bereavement. MSF also started
health promotion activities in the hospitalfor patients and their caregivers.

Boost hospital, Lashkargah,
Helmand province

Trauma centre, Kunduz
In the northern province of Kunduz, theMSF trauma centre which opened in 2011
continued to provide free surgical care to
victims of general trauma such as traffic
accidents, as well as conflict-related injuries
like gunshot wounds. As of this year, thehospital also admitted patients with moderateand severe head injuries. It was equipped in
January with internal fixation facilities, andstaff members were trained in the relevant
medical protocols and techniques.
Extensive construction continued, andrefurbishment of the old hospital building
allowed the emergency room and operating
theatres to be accommodated under one
roof. More space was made available enabling
better triage and treatment, and a third
operating theatre was also completed. The
outpatient and physiotherapy departments

The number of patients visiting the centre
continued to increase. Staff treated a totalof 17,000 people, about 10 per cent ofwhom were suffering from conflict-related
injuries, and performed 4,500 surgicalprocedures, three times more than in 2012.
Khost maternity hospital
The 83-bed hospital in Khost is the only
specialised maternity hospital in the area,
and it aims to provide a safe and healthy
environment for women to give birth. It focusesin particular on assisting with complicateddeliveries and on reducing the high number ofmaternal and neonatal deaths in the province.
Many patients travel long distances to accessthe free, high-quality care on offer. Staff
assisted in the delivery of 12,000 babies andhelped more than 2,000 women who hadcomplications during pregnancy or labour.
The recruitment of qualified female medical
staff in Khost has been a challenge. There isa general lack of skilled female medical staff

An MSF team continued to support Boosthospital, one of only two functioning referral
hospitals in southern Afghanistan, with surgery,internal medicine, and maternal, paediatric,
intensive care and emergency services. The
250-bed hospital admitted an average of 1,300
patients monthly. A total of 66,000 patientswere treated in the emergency room and
5,600 surgical procedures were performed.
Malnutrition remains one of the main causesof child mortality in Helmand province.
The hospital’s therapeutic feeding centre
treated 3,200 malnourished children in 2013.
Despite extensions in 2010 and 2011, the90-bed paediatric ward overflowed withpatients and approximately 200 children wereadmitted monthly. Following an evaluation ofhealthcare resources in the Lashkargah area,
MSF decided to close the hospital’s general
outpatient department at the end of 2013, as
basic health services were now available.
In February 2014, MSF published a report
entitled Between Rhetoric and Reality: The
Ongoing Struggle to Access Healthcare in
Afghanistan, based on information collected
in locations where teams operated in 2013.

No. staff end 2013: 1,526 | Year MSF first worked in the country: 1981 | msf.org/afghanistan

afghanistan 29

Médecins Sans Frontièresarmenia

MSF worked with the Ministry of Health’s
programmes for DR-TB and nontuberculous
mycobacterium infection (the same
bacteria family but not classic TB) in
Yerevan, Armavir, Ararat, Shirak, Lori,
Kotayk and Gegharkunik. A team also
assisted the programme in Karabagh.

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

Key medical figures:• 119 patients under treatment for MDR-TB

Armenia has one of thehighest rates of drug-resistanttuberculosis (DR-TB) in the world.
TB has become a significant public healthconcern in Armenia. Since 2005, Médecins
Sans Frontières (MSF) has been working
in the country to improve diagnosis
and treatment of DR-TB, and to support
patients so that they can complete the

The National Tuberculosis Programme’s‘compassionate use treatment’ for patientswith extensively drug-resistant TB (XDRTB) was supported by MSF in 2013. As of
December, 26 patients were receiving thetreatment. Also this year, in a collaborative
undertaking, a team of MSF and Ministry of
Health TB pulmonary surgeons successfully
operated on seven patients.
The MSF team aims to enhance thenational programme’s capacity to
implement DR-TB response plans andenable the gradual handover of existing
MSF activities in Armenia.

© MSF

arduous treatment. MSF has also helped
implement infection control policies,
measures and practices.

A member of the MSF flying TB surgery
team examines a patient.

Tatev
17-year-old MDR-TB patient from Yerevan
At first, I had difficulty accepting that I
needed to go to hospital, or that I had
the disease even. I think most of all I wasscared of taking the drugs. Maybe that’s
why I reacted as I did.
The first two days I took the drugs
normally, but it got harder when I realised
I would be taking them long term. It wasa difficult period but I forced myself tobelieve the treatment would work, and that
I would get rid of TB. That’s my dream.

No. staff end 2013: 98 | Year MSF first worked in the country: 1988 | msf.org/armenia

bOLIVIA
Médecins Sans Frontières(MSF) handed over its Chagas
programme in Aiquile after
successfully establishing an
integrated prevention, diagnosis
and treatment strategy.
Regions where MSF has projects© Juan Renau

Chagas, a parasitic disease endemicin Latin America, is most commonlytransmitted through the bites of infectedvinchuca bugs, which are often found incracks in the walls and roofs of rural adobe
houses. The disease can be asymptomaticfor many years, but if left untreated it may
affect internal organs and can lead to heart
failure and even death.

In Bolivia, significant efforts are made toraise awareness of Chagas.

Treatment for Chagas in Narciso Campero
province, where disease prevalence isestimated to be as high as 40 per cent, has
always been difficult both geographicallyand financially. The majority of inhabitants

live in remote areas far from the urban
hospitals and health centres that offer
treatment, and which often charge a fee.
In 2009, MSF began an integrated Chagas
programme in the communities of Aiquile,
Omereque and Pasorapa. Working throughcommunity clinics and health centres,
teams diagnosed and treated people aged
one to 60 for Chagas, and trained local
health staff. Significant efforts were madeto raise awareness and the communities
were involved in surveillance and control
of Chagas through educational workshops,
weekly meetings and a radio show.
In September 2013, the project was handed
over as planned to the Departmental
Chagas Programme of the Ministry of
Health and the province’s Health Network
Management. MSF is planning a new
project in Aiquile, which will implement asustainable treatment model that can be
replicated in other locations.

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

30 armenia | bOLIVIA

International Activity Report 2013

bangladesh
Cities, towns or villages where MSF works

People of the Rohingya
ethnic and religious minority
continued to cross into
Bangladesh in 2013, fleeing
severe discrimination andsporadic violence in Myanmar.
More than 200,000 Rohingya haveescaped to Bangladesh from Myanmar
over the past four decades and are losing
hope of ever returning home. They suffer
widespread discrimination, and as the
majority are undocumented they are
excluded from healthcare. At Cox’s Bazar,
Médecins Sans Frontières (MSF) continues
to provide comprehensive medical
assistance, including basic healthcare andmaternal and mental health services, forboth the host community and the 30,000
unregistered Rohingya in the makeshiftcamp at Kutupalong. The clinic also has astabilisation unit for severely malnourishedchildren, a small inpatient department anda diarrhoea treatment centre. MSF has anambulance to transport severely ill patients
to hospital for specialised treatment.
More than 74,300 patients were treatedat the clinic in 2013.
Dhaka, the capital city, has a populationof 15 million. In Kamrangirchar, the city’s
largest slum, half a million people live on
the bank of the Buriganga River, withvery little access to the city’s overstretchedhealthcare system. An MSF team runs ahealth centre in the slum, providing free,basic healthcare, and sexual and reproductive
health services to young women.

© Alfons Rodriguez

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

Mothers and children waiting to be seen at the clinic in Kamrangirchar.

Many people living in the slum suffer fromdiarrhoea and skin conditions resulting
from poor water quality and unhygienic
living conditions. The MSF programme istherefore also developing a stronger focus
on environmental health.
The project in Fulbaria treating primarykala azar began in 2010, and successfully
introduced a treatment with liposomal
amphotericin B. The project was handed
over to the Ministry of Health in March thisyear, as they were in a position to manage
it. MSF is currently awaiting permission
from the ministry to start treating post-kalaazar dermal leishmaniasis.
Emergency interventions
On 24 April, an eight-storey building
housing garment factories that employed
thousands of people collapsed in Savar,
a subdistrict of Dhaka. Many of those
who survived experienced symptomsof psychological trauma. An MSF teamprovided mental health support to 413
survivors and rescuers. MSF also gave
psychological first aid to 28 people who
had suffered burns from fire bombs thrownon public transport during pre-election
violence in Dhaka on 12 December.

Noor
30 years old, brought her children to
the MSF clinic in Kutupalong
I live with my husband and my fivechildren in a house in the camp.
We arrived five years ago from
Myanmar because the situation was
not good there. My three youngest
children were all born here in thecamp. The youngest was born in the
MSF clinic nine months ago. Both mineand my husband’s parents live in
Myanmar so we are all alone and haveto fend for ourselves. My husband cansometimes find work as a day labourer,
as a rickshaw puller or carrying things,
but sometimes this is difficult and thenwe do not have anything.

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

bangladesh 31

Médecins Sans Frontières

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

Key medical figures:• 2,200 outpatient consultations

The sudden increase inrefugee numbers in Bulgaria
in 2013 led to overcrowdingin accommodation centres,
and a shortage of adequate
healthcare.

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

Year MSF first worked in the country: 1981 | msf.org/bulgaria

burkina faso
The relocation of Malian refugees within Burkina Faso
resulted in a reduction in Médecins Sans Frontières (MSF)
activities in 2013.

Regions where MSF has projects

Key medical figures:• 18,800 outpatient consultations• 7,000 patients treated for malaria• 1,300 antenatal consultations

The stream of Malians fleeing violence
and attacks in their home country began
in February 2012, and an emergency
programme was opened by MSF to help
meet their healthcare needs. Initially,
most refugees gathered in camps near
the Malian border, within the provinceof Oudalan. Later that year though, theBurkina government moved the camps
further inland to ensure increased safety
for the refugees.

working – Ferrerio, Dibissi and Ngatourou-

At the beginning of 2013, due to deteriorating
security in the Sahel zone, the authorities
once again decided to relocate refugees.
Within six months, 11,300 people who had
been living in the camps where MSF was

measles – and referrals to the hospital in Dori.

Niénié – had been moved to the inland
camps of Goudoubo and Mentao. As aconsequence, MSF scaled down its activities.
In April, MSF began a twice-weekly mobile
clinic for people who remained in Dibissi
camp, as well as the 6,200 residents
in Gandafabou health district. The teamprovided basic healthcare consultations,vaccinations – primarily for tetanus andAn estimated 43,000 refugees from
Mali were present in Burkina Faso at
the end of 2013.

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

32 bULGARIA | Burkina Faso

International Activity Report 2013burundiRegions where MSF has projects
Cities, towns or villages where MSF works

Key medical figures:• 3,500 patients treated for malaria• 380 fistula repair operations

Improved access toemergency medical carein Burundi’s rural Kabezi
district has markedly
reduced maternal deaths.

Women with obstetric complications in
Kabezi had little access to appropriate
healthcare until Médecins Sans Frontières(MSF) launched an emergency programme,
the Centre for Obstetric Emergencies(CURGO), in 2006. Located in Kabezi
hospital, the project offered free,high-quality emergency and surgicalobstetric services. Referrals and ambulanceswere also provided so that women from24 health centres were able to reach the
CURGO, which admitted an average of
250 women per month in 2013.
After an MSF study in 2012 entitled Safe
Delivery: Reducing Maternal Mortality in
Sierra Leone and Burundi showed these
efforts had reduced maternal deaths by
74 per cent, the team trained and coached
Burundian medical staff, and handed theprogramme over to local authorities in 2013.
Providing fistula care
An MSF team continued to provide
obstetric fistula treatment this year at the

Urumuri health centre in Gitega. Fistulas, aconsequence of birth complications, cause
not only pain but incontinence, which inturn often leads to social exclusion andsometimes rejection by friends and family.
The package of care at Urumuri includes
surgery, physiotherapy and social support,
and is offered around the clock.
Malaria
In 2013, MSF staff at the Kirundo malaria
project continued to support 44 healthcentres and two hospitals with diagnosis
and treatment of severe malaria.

Séverine
an obstetric fistula patient
The MSF team welcomed me to thewomen’s village. I feel good here; wedance together often. All the women here
suffer from the same thing, and that helps
us cope. I’m having the surgery in a week.
I hope it will go well; I’m confident it will.

No. staff end 2013: 233 | Year MSF first worked in the country: 1992 | msf.org/burundi

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

Key medical figures:• 2,800 patients on first-line ARV treatment

The centralised system andtreatment costs pose barriers
to healthcare for many people
in Cameroon. Those withneglected diseases such as
Buruli ulcer, seen mostly inrural areas, are particularly
disadvantaged.

Buruli ulcer is a tropical disease that
destroys skin and soft tissue, usuallyon a person’s arms and legs. This cancause secondary infections, restrict their
movement and cause permanent disability
and scarring if left untreated. If the diseaseis detected early enough, the majority ofpatients can be cured with antibiotics,
although surgery may also be necessary. It
is still not known exactly how Buruli ulcer
is transmitted. About half of those in Africa
suffering from the disease are children.
People with suspected Buruli ulcer in
Cameroon are examined and laboratory
tests are performed. When positively
diagnosed, they receive antibiotics, wounddressing, surgery and physiotherapy at the
Buruli ulcer ‘pavilion’ run by Médecins Sans
Frontières (MSF) in Akonolinga hospital.
HIV testing is routinely offered to all
patients; 12.5 per cent of people entering
the programme during the year were foundto have HIV, nearly triple the estimatedpopulation prevalence. Those who test
positive receive comprehensive care forboth diseases. In total, the team treated
188 people with chronic wounds resulting
from Buruli ulcer, applied more than 15,800
surgical dressings, admitted 48 new patientsand carried out 78 surgical procedures.
Since November 2011, research has been
underway to facilitate diagnosis of Buruli
ulcer in those resource-limited countries
where it has a high prevalence. The aim is
to provide health professionals with aneasy-to-follow diagnostic grid for
identifying cases. The first phase of thestudy was completed this year, and in
total 370 patients have been enrolled.
The HIV programme in Douala was handed
over to the Ministry of Health in April,with tenofovir having been adopted as
the first-line treatment.

No. staff end 2013: 79 | Year MSF first worked in the country: 1984 | msf.org/cameroon

burundi | cameroon 33

Médecins Sans Frontières

Cities, towns or villages where MSF works

Key medical figures:• 1,150 patients under treatment for TB

are very high. It is therefore essential to find
new methods for better and earlier detection.
In 2013, the TB department of Kampong
Cham provincial hospital became fully
operational, and offered detection, diagnosis
and comprehensive care for TB patientsand those suspected of having the disease,
whether it was drug-sensitive, complicated or
drug-resistant (DR-TB). People from aroundthe province come to the hospital for testing.
MSF also supports the diagnosis and follow-up
of TB patients in Choeung Prey district. In
Tboung Khmum district, MSF is aiming toscreen all inhabitants aged over 55.

The prevalence of tuberculosis(TB) in Cambodia is one of
the highest in the world, withmore than 0.8 per cent of the
population already infected
and more than 60,000 people
newly infected every year.

In Phnom Penh and Kandal provinces,
MSF worked with a local organisation,
the Cambodia Health Committee, and thenational programme CENAT to treat
20 DR-TB patients and will continue toprovide follow-up until they finish theirtreatment. Thanks to this collaboration,
MSF monitored almost half of the diagnosed
DR-TB patients in Cambodia in 2013.

Fewer than 20 per cent of the people in
Cambodia infected with TB are diagnosed
each year, and as a result of this morality rates

MSF carried out a baseline survey this year,
looking at the percentage of inhabitants inthe district with the Plasmodium falciparum

Malaria in Preah Vihear district© Philippe Bosman / MSF

cambodiaParticipants of the PCR Detection Rate
Study being registered.
strain of malaria in their blood and more
specifically at artemisinin resistance. In
2014, a project with a specific treatment
protocol will be developed with the aim ofdemonstrating that artemisinin-resistantmalaria can be eliminated.
Handover of prison project
MSF started working in two Phnom Penhprisons in 2006, in response to high HIV
mortality rates. At the end of June 2013, theTB and HIV projects were handed over to twonational programmes and other local partners
as a result of improvements in care and theimplementation of a long-term approach.

No. staff end 2013: 159 | Year MSF first worked in the country: 1979 | msf.org/cambodia

china
Regions where MSF has projects

People living with HIV/AIDS
in China face difficulties
accessing the necessary care.

Although the prevalence of HIV in China
is low, providing an adequate responseto people needing treatment remains achallenge. China initiated the ‘Four Frees
and One Care’ policy in December 2003,
providing HIV counselling and testing,antiretroviral treatment, prevention of
mother-to-child transmission and schoolingfor children orphaned by AIDS, all free ofcharge, but many people with the disease
have not benefited from these measures.
According to the Ministry of Health, someregions and departments are not sufficiently
concerned with HIV, and there is stillwidespread discrimination and stigma.
A Chinese NGO, Aids Care China (ACC),
is developing quality care and treatment
through private clinics, hoping to show the
impact this can have on people’s healthand influence reforms that will make caremore widely available. In October 2011,at the request of ACC, Médecins Sans
Frontières (MSF) started supporting a clinic
near the China–Myanmar border in Jiegao,
Yunnan province, where there are highnumbers of Chinese and Burmese injecting
drug users with HIV or HIV–TB and
HIV–hepatitis C co-infection. In September,a four-person MSF team began providing
medical expertise and staff management
under a one-year agreement.
Flooding in Guangxi
In August, more than 127,000 people wereaffected by flooding and a landslide in
Guiping, Guangxi province. MSF distributed
hygiene kits, buckets, plastic sheeting andmosquito nets to 950 households.

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

34 cambodia | china

International Activity Report 2013

COLOMBIA
Cauca
NariñoBuenaventura
CaquetáColombia
Regions where MSF
has projects

Cities, towns or villages where MSF works

The testimonies of 4,400
Médecins Sans Frontières(MSF) patients revealed
that 67 per cent of people
in Colombia seeking
mental health support had
experienced at least one
violence-related event.
The Colombian armed conflict has
inflicted a heavy toll on people’s health.
In addition to the historic confrontation
between the military and FARC and ELN
guerrillas, new paramilitary groups anddrug-trafficking cartels have appeared inrecent years, creating different dynamics
of violence. Most armed activity isregistered in the southern departments ofCaquetá, Cauca, Putumayo and Nariño,
where civilians witness massacres andare subjected to threats, extortion,
displacement, injuries caused by mines,
torture, sexual violence, forced recruitment
and other human rights violations.
Medical and psychological support is criticalin such a context, yet healthcare access inthese geographically remote areas is limited.
MSF has a long-standing programme ofmobile clinics and health posts to provide
healthcare and mental health consultations
to people in need. Basic medical care,a referral system for emergencies,
sexual and reproductive health services
including family planning, antenatal care,immunisations and check-ups for children
and all available.

© Aurelie Baumel / MSF

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

As part of MSF’s support of the national TB programme in Buenaventura, a couple receive
health education in their home.
In July, MSF published The Less Visible
Wounds: Mental health, violence and conflictin southern Colombia, a report based on
the testimonies of patients treated in themental health component of the above
programmes in 2012. The report drewattention to the debilitating effects of theviolence and the fact that people caught
up in armed conflict and other formsof brutality lack critical state support toaddress their psychological needs.
Focus on tuberculosis (TB)
TB has emerged as a major public healthconcern, particularly in the crowded seaportof Buenaventura, where 9.5 per cent of newcases are found to be drug-resistant.
MSF works in two health facilities, andteams oversee an additional 15 medical
stations. In 2013, 218 drug-sensitive TB
patients began treatment, and 47 patientswere included in the programme for drugand multidrug-resistant TB.
In addition to providing support tothe national strategy for TB detection
and treatment, MSF started advocacy
initiatives and discussions with partners
and authorities to introduce bedaquiline
as a treatment for patients with extremely
resistant forms of the disease. Workshops
and negotiations are ongoing.

Programme closures
In February, given improvements to thehealth system in the area, MSF closed a
project focused on reproductive healthcare
in Buenaventura. In December, activities
in rural Nariño were handed over to local
health institutions due to better availabilityof healthcare.

A 50-year-old displaced woman from
Cauca describes how her family haschanged as a result of violence.
I haven’t been able to sleep in several
nights; I have dreams where I see thefaces of my neighbours. I see them crying,pleading, asking for mercy. I wake up
crying. I start thinking about our farm,about my plants in the garden, about
my hens, and the cattle, and my dogs
that wanted to come with us but that we
had to scare away with stones so thatthey wouldn’t follow us. I have never felt
like this. I have never seen my husband
so quiet; I have never seen him mournin silence. And what can I say about myson? The boy is not the same as he was.
Now there is no tenderness in his eyes;
there is only anger and hatred.

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

COLOMBIA 35

Médecins Sans Frontières

CENTRAL AFRICAN
REPUBLIC
Regions where MSF has projects

Key medical figures:• 816,300 outpatient consultations• 3,300 surgical interventions• 24,300 measles vaccinations

Escalating and extreme
violence in the Central
African Republic (CAR)
over the year resulted in a
massive, acute humanitariancrisis in addition to an
existing chronic medical one.

In response to this chronic medical crisis,
Médecins Sans Frontières (MSF) was
providing basic healthcare through sevencomprehensive projects – at Batangafo,
Boguila, Carnot, Kabo, Ndélé, Paoua and
Zémio – when the current emergency
began to unfold. Despite some interruptions
due to insecurity, these projects haveadapted and continue to provide medicalcare to people in the communities, and torespond to localised emergencies caused bypopulation displacement. Teams offer basic
and specialist healthcare, mental healthconsultations, maternity, paediatric andnutritional services, surgery and HIV andtuberculosis (TB) care.

When 2013 began, the rebel group Séléka
had recently seized several strategic towns,
and in March they took the capital Bangui,
leading to a presidential coup and thegradual destabilisation of the country overthe course of the year. Increased tensions
and violence, including assaults on civilians,
spread into previously peaceful areas.
In early September, armed self-defence
groups, the ‘anti-balakas’, started to attack
Séléka forces and civilian populations in
the northwest.
Throughout this period, MSF provided free
medical care to people wounded in attacks
or displaced by violence. Mobile clinics werelaunched and teams supported government
healthcare facilities, providing emergency
aid to people wounded in attacks or in needof medical attention. Additional activities
were started to ensure access to clean
drinking water and improve hygiene forthe displaced population.

© Juan Carlos Tomasi / MSF

For over 20 years, the small landlocked
country of CAR has witnessed many politicaland military crises. Continual population
displacement caused by pockets of armed
conflict, combined with a poorly resourced,

dysfunctional healthcare system, prevents
people from obtaining the treatment theyneed. Many die from easily preventable
and treatable illnesses such as malaria,
respiratory infections and diarrhoeal
diseases. Prior to the current conflict,mortality rates in some regions were up
to five times the emergency threshold.

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

36 CENTRAL AFRICAN REPUBLIC

© Juan Carlos Tomasi / MSF

International Activity Report 2013

Thousands of Bangui residents took refuge in M’poko airport in 2013, setting up a makeshift camp.

Short-term emergency projects opened andclosed in the first half of the year in Damara
and Sibut, supporting outpatient services at
local hospitals. The Damara team also offeredtreatment to people who had temporarily fled
into the bush. More than 12,800 consultations
were carried out through these projects.
Emergency projects also opened in 2013 in
Bangui, Bouca, Bossangoa, Bria, Sibut, Damara
and Gadzi, and emergency medical teams
visited Yaloke and Bouar. Emergency surgery
and basic healthcare were available for the
wounded, and teams regularly treated patientsfor malaria, respiratory and skin infections,diarrhoeal diseases and malnutrition.
Beginning in December, violence and chaos
took hold in Bangui. Despite the arrival ofinternational forces in the capital, there weredaily clashes, attacks, lynchings and reprisals.
In the first two weeks of that month alone,
the UN estimated that some 214,000 people
were displaced by the conflict. Hundreds ofthousands of people fled their homes andgathered in camps including Bangui airport(100,000 people), the monastery of Boy-Rabé(15,000) and the Don Bosco Centre (15,000).

Living conditions were, and still are,deplorable. With hardly any otherorganisations providing emergency
assistance, MSF undertook extensive
work to ensure a clean water supply,
basic standards of hygiene and humanwaste disposal: at the Don Bosco site,a team dug 20 emergency trench latrinesand provided 30 cubic metres of watera day. They later built 150 latrines there,
and a further 350 latrines in M’Poko
airport camp. In addition, MSF ran awater treatment plant that produced
600,000 litres of clean drinking water
per day and also distributed relief
supplies to the displaced population of
Bangui. MSF medical staff provided
trauma surgery and basic healthconsultations. However, the basic
needs of the displaced people in CAR
remained unmet as there was insufficientmobilisation by other humanitarianorganisations. At Castor health centre
in Bangui, surgeons responded to 465
trauma cases in just three weeks.
MSF also supported a Ministry of Healthmeasles vaccination programme.

MSF repeatedly spoke out, asking that all
parties involved in the conflict allow accessto medical care for the sick and wounded
and calling for an end to the violenceagainst civilians, and patients and staff inhealthcare facilities. MSF also denounced
the lack of mobilisation of UN humanitarianagencies and called for the deployment of
more means and resources – from the UN
and other aid organisations – to provide
an appropriate response to the extensive
human needs. Towards the end of the year,
MSF had more than 250 international and
2,500 Central African staff providing free
medical care to approximately 600,000
people in seven hospitals, two healthcentres and 40 health posts. At the time ofwriting, MSF is the largest employer in CAR.
By year’s end it was estimated that over
700,000 Central Africans were displaced
inside CAR and that a further 75,000 had
crossed into neighbouring countries.

No. staff end 2013: 1,631 | Year MSF first worked in the country: 1996 | msf.org/car

CENTRAL AFRICAN REPUBLIC 37

Médecins Sans Frontières

cHAD

Regions where MSF has projects
Cities, towns or villages with MSF activities

Although the Chadiangovernment has promised
to increase investment inhealthcare, the quality ofcare and health indicators
are still poor, particularly forrural communities, children
and refugees.
The mortality rate for children under fiveis high, and routine vaccination coverage
is low. People often die from malnutritionand preventable diseases such as malaria
and cholera, and disease epidemics arerecurrent. Instability in the surrounding
countries also means Chad is host to a highnumber of refugees. In 2013, some 60,000
new refugees arrived in the country, withurgent needs for basic and specialist
medical care.

At Massakory hospital, Hadjer Lamis region,
where MSF provided support in paediatriccare, teams treated 36,600 patients during
an acute peak in malaria cases between
July and December. Children also received
treatment for malnutrition in the hospitaland surrounding health zones. A large water
sanitation campaign for people’s homes
was launched to help prevent outbreaks ofdiarrhoea. This activity currently reaches
900 families in 20 villages.

Key medical figures:• 183,350 outpatient consultations• 113,900 patients treated for malaria• 20,850 patients treated in feeding centres

malaria unit. MSF also supported healthcentres and community health workers inrural areas with drug supplies and staff.
Seasonal Malaria Chemoprevention – thedistribution of antimalarials as a prevention
strategy – was organised for children
under five and pregnant women during
the high season (July to October). The
strategy had previously proven effective in
reducing the number of people developing
severe malaria. In 2013, prophylaxis was
distributed to 53,000 children and teams
recorded an overall reduction in malaria of
60 per cent in Moissala when compared tothe previous year.

From August to October there was an
emergency intervention in response to highlevels of malaria in the Salamat region. Basedat Am Timan hospital, outreach activities
expanded to ensure people in remote areasof the district could get the medical carethey needed. An MSF team in Am Timan
hospital also continued to provide basic
and specialist care with a focus on womenand children. Reproductive healthcare,emergency obstetric care and treatment for
tuberculosis and HIV, including preventionof mother-to-child transmission of thevirus, was offered. Teams carried out 5,280
outpatient consultations, assisted 1,895
births and tested 2,050 people for HIV.
A paediatric nutrition programme basedat the hospital and in nine outreach sites
admitted 9,990 children for treatment. Six ofthese outreach sites were handed over to the
Ministry of Health at the end of the year.
Providing assistance to Sudanese refugees
Renewed clashes in Darfur, Sudan, led to an
influx of refugees in the Tissi area of Chadearly in the year. MSF launched activities inTissi town, establishing an emergency room
to treat victims of violence, a health centre

Focusing on malaria

For the past few years, teams from
Médecins Sans Frontières (MSF) haveworked on preventing and treating malaria
in the Moissala and Bouna districts,
Mandoul region. Teams focused onchildren with severe and complicatedcases of the illness in Moissala hospital‘s

38 cHAD© Samantha Maurin / MSF

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

A child being vaccinated as part of expanding coverage for displaced people.

© Ritu Gambhir / MSF

International Activity Report 2013

An MSF nurse stabilises a patient in Tissi hospital prior to his evacuation to Abéché. Renewed clashes in Darfur early in the year resulted in an influxof Sudanese refugees.

in Ab Gadam camp, and a health post in
Um Doukhum. People were suffering mainly
from malaria, respiratory tract infections,diarrhoeal and skin diseases, and malnutrition.
The team carried out 52,820 outpatient
consultations and treated 10,400 people formalaria. MSF provided clean drinking waterand built latrines to improve basic hygiene in
Ab Gadam camp. In Goz Beida, a team carriedout basic healthcare consultations, provided
access to drinking water and distributed relief
supplies such as blankets and washing kits toimprove living conditions.
Extensive vaccination campaigns
Without routine vaccinations, children
are at greater risk of infection, and theconsequences can be fatal if they are also
malnourished. MSF has been involved in
expanding routine vaccination coverage incollaboration with the Ministry of Health,and organises vaccination campaigns

for displaced people and in response tooutbreaks of disease. There were threemeasles vaccination campaigns in 2013,reaching 257,000 children in Ouaddai regionin May, and 102,000 children in Guéréda and68,100 children in Iriba in September.
Beginning in February, a vaccination
campaign was carried out in Goz Beida for an
outbreak of yellow fever, a mosquito-borne
viral disease that can cause severe liver disease
and death. A total of 161,300 people were
vaccinated. In Salamat region, outbreaks
led MSF to vaccinate 12,250 people against
measles and 26,800 against meningitis.
Responding to emergencies
Following flooding in Maro, Moyen-Chariregion, MSF provided assistance to refugees
from Central African Republic living inYaroungou and Moula camps, carryingout 12,200 basic health consultations, andoffering nutritional support to 2,630 children,

as well as immunisations. In August,assistance was also provided to refugees
in Koldaga and Moissala.
Programme handovers
An MSF programme started in 2008 in
Abéché provided medical, rehabilitative andpsychosocial care to women with obstetricfistulas. Fistulas, a consequence of birthcomplications, cause not only pain but
incontinence, which in turn often leads tosocial exclusion and sometimes rejection byfriends and family. The programme handover
to the Ministry of Health began at the endof 2013. The 45-bed village des femmes had
welcomed around 850 women in total, andpatients had benefited from rehabilitative
surgery and post-operative care.
An emergency nutrition programme in
Bokoro, Hadjer Lamis, was handed over tothe health ministry in February.

No. staff end 2013: 1,039 | Year MSF first worked in the country: 1981 | msf.org/chadcHAD 39

Médecins Sans Frontières

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

Key medical figures:• 18,000 outpatient consultations

More than 36,000 refugees were repatriated from Congo totheir home province of Équateur, Democratic Republic ofCongo (DRC), in April.
In 2009, Médecins Sans Frontières (MSF)
opened an emergency programme to meetthe medical needs of refugees and the hostcommunity in Bétou district, Likouala, byexpanding and strengthening services in
Bétou hospital and health centres in thearea. Some 450 patients were admitted
to the hospital per month, and between
November 2012 and May 2013, 9,800
people were treated for malaria alone.
As many children were suffering frompreventable diseases such as tetanus, polio
and measles, 13 teams carried out a districtwide, door-to-door vaccination campaign
between December 2012 and May 2013,providing 97,500 vaccinations. With the
improvement of the security situation in
DRC and subsequent repatriation, MSF
closed the Bétou project in June. The team
had also worked with health authorities

to improve national control programmes
against tuberculosis, HIV, leprosy and yaws.
Yaws treatment
Yaws is a contagious but treatable bacterial
infection that causes skin lesions and can leadto disfigurement and disability. In the rainforestof northern Congo and in Bétou district, where
yaws is endemic, MSF carried out a second
round of treatment in April and May, targeting
Aka pygmies in remote areas who had notreceived treatment in the first round.
Cholera emergency response
The cholera emergency response that began
in Pointe-Noire in November 2012 wascompleted in May. In addition to opening
a cholera treatment centre in Loandjili
hospital and five rehydration centres, MSF
trained medical staff and helped authorities
implement preventive measures.

Year MSF first worked in the country: 1997 | msf.org/congo

Côte d’ivoire

Médecins Sans Frontières (MSF) has closed the last of its
emergency programmes launched to meet healthcare needs
during the Ivorian post-electoral crisis of 2010–2011.

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

Overall, the security situation has stabilised
and 2013 was declared ‘the year of health’.
However, although there has been an
increase in investment in healthcare, gaps
persist, due to a lack of qualified staff andoutdated technologies.
Teams from MSF gradually ceased activities
that were originally set up to address theneeds of people displaced during the 2011
armed conflict. Only the programme inTaï, along the border with Liberia, which
consisted of support to the Ministry of
Health teams in outpatient, paediatric andmaternity services in a 20-bed hospital,
continued until the end of March. A total of
27,338 consultations were carried out.

Work undertaken by teams in Duékoué
and Abobo during the crisis resulted in aneed for lifesaving maternal healthcare
being identified. Women generally deliver
their babies at home with traditional birthattendants and without effective emergency
obstetric care when there are complications.
This results in unnecessary suffering and thedeath of mothers and babies.
MSF is preparing to open a mother andchild health programme with the Ministryof Health in Hambol region in 2014. Carewill be provided for complicated deliveries,
and antenatal and neonatal emergencies at
the hospital in Katiola.

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

40 congo | Côte d’ivoire

International Activity Report 2013

DPR KOrea

After developing an agreementwith the government in May,
Médecins Sans Frontières(MSF) opened a programmein the Democratic People’s
Republic of Korea (DPRK).

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

Medical assistance is not considered a toppriority in DPRK and most help is steered
towards self-sufficient food production,
food aid and disease prevention strategies.
Only a few international aid organisations
are present in the country, and these facerestrictions on their movements and on freeaccess to patients.
In this context, MSF has employed anadapted approach. After a long absence,
MSF started working in the country again
in 2012, and from the beginning of 2013,
made visits on a regular basis to upgrade
some medical practices related to motherand child health in the district hospitalof Anju, South Pyongan province. A
memorandum of understanding was signed
in May, outlining the framework of thecollaboration between the government and
MSF, and MSF’s activities in the country.
In February, a team travelled to DPRK tostart updating the medical knowledge ofstaff through training. The first module
covered was ‘Management of dehydrationand shock among children’, and then in
June the team returned to complete thesecond training module, ‘Life support inobstetric services’. In October, the third
module, ‘Management of malnutrition,
respiratory and neurological diseases amongchildren’, was completed. The drugs andmedical materials related to the modules
were provided during each visit, as well
as food for the hospitalised patients, theircaregivers and the hospital staff. Follow-up
monitoring and supervision was carried out
during field visits.

No. staff end 2013: 5 | Year MSF first worked in the country: 1995 | msf.org/dprk

egypt
Cities, towns or villages where MSF works

Key medical figures:• 18,750 outpatient consultations• 3,300 individual and group mental
health consultations

Migrants and people living
in remote areas of Egypt
have difficulty accessing
medical services.
At Abu Elian clinic, on the outskirts of
Cairo, Médecins Sans Frontières (MSF)
offers healthcare to mothers and children
under five. In 2013, an average of 1,700

consultations were carried out eachmonth; 70 per cent of patients were young
children suffering from respiratory tract
infections, intestinal parasites, skin diseases
and diarrhoea. MSF also provides transportand covers hospital costs for pregnant
women in the clinic’s 24-hour emergency
referral system.

hepatitis C project aiming to improve
patient adherence to treatment bydecentralising their medical care. In rural
areas in particular, overcoming cost anddistance could markedly improve patients’cure rates. Approval was received in early2014 to launch the first phase of the projectin Fayoum governorate, south of Cairo.

Assistance for vulnerable groups

Winter relief and medical training

Many migrants and refugees living in
Egypt are victims of violence. In 2013,
MSF continued to offer mental healthcare(742 new patients, 2,530 follow-up sessions)and treatment to victims of sexual violence(305 new cases, 960 follow-up sessions) at
the Nasr City mental health clinic in Cairo.

During the especially harsh 2013–2014
winter, MSF teams in Cairo and Alexandria
supported vulnerable families who had
been identified by local health partners,
providing medical and psychiatricconsultations and distributing washingkits and blankets.

Expanding treatment for hepatitis C

MSF also trained a number of volunteer
Egyptian doctors in Cairo, including some
Egyptian Ministry of Health personnel,
so that they could respond quickly andeffectively to medical needs on the spot
during demonstrations. Training included
how to deal with large numbers of wounded.

There is a very high prevalence of hepatitis
C in Egypt; it is estimated that around
12 per cent of the general population
are infected. For the last two years, MSF
has been in discussions with the National
Committee for Viral Hepatitis about aNo. staff end 2013: 85 | Year MSF first worked in the country: 2010 | msf.org/egypt

DPR Korea | egypt 41

Médecins Sans Frontières

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

Owing to a dysfunctional healthsystem, people in Democratic
Republic of Congo (DRC) lackbasic healthcare, and in 2013
suffered numerous, preventable
outbreaks of cholera, malaria
and measles. The conflicts inthe eastern provinces were also
ongoing, displacing thousands.
Decades of conflict, lack of investment in
the healthcare system and ongoing violencecause extreme hardship. Humanitarian
aid is concentrated around big cities andplaces that are considered secure, but there
is a need for a rapid, flexible humanitarian
response to acute needs throughout theeast of the country. Teams from Médecins
Sans Frontières (MSF) are working toincrease the availability of healthcare andrespond to health emergencies.
While on an exploratory mission in July,
Chantal, Philippe, Richard and Romy, fourCongolese MSF staff, were abducted by anarmed group during an attack on Kamango,
North Kivu. At the time of writing, a dedicatedteam is still actively searching for them.
In 2013, measles epidemics continued
to proliferate. Some health zones were
overwhelmed by the number of cases,
and MSF launched emergency campaigns,
vaccinating more than 1.2 million children
aged between six months and 15 years.
North Kivu
A health centre in Mugunga III camp for
displaced people provided basic healthcare,dressings and aftercare for victims of sexual
violence, carrying out more than 41,800
consultations and treating some 840 people
for injuries resulting from sexual violence.
A team focused on cholera prevention andtreatment in Goma treated 1,660 patients.
Displaced people at spontaneous sites around
Bulengo also received healthcare from MSF,
including psychosocial support for victims ofsexual violence wanting to take legal action.

42 Democratic republic of congo

Regions where MSF has projects

In the hospital in Rutshuru territory – aregion controlled by M23 rebels until
they were forced to pull out in October– MSF continued to offer comprehensive
healthcare, including surgery, intensive andemergency care, and treatment for victimsof sexual violence. More than 7,600 surgicalprocedures were performed during the year.

and integrated psychosocial care were
provided in Pinga. A security threat caused
the suspension of the project there in
July and activities had not resumed by
year’s end. More than 34,389 outpatient
consultations, 5,100 consultations formalaria and over 900 mental healthsessions had been conducted in Pinga.

In Masisi, MSF provides full support to thegeneral hospital (internal medicine, surgery,gynaecology, maternity services, paediatrics
and neonatology) and to two health centres
in Masisi and Nyabiondo. There is a 76-bed
maternity village for women in their third
trimester of high-risk pregnancies. MSF
also works with community advisors tocounsel victims of sexual violence. Until
June, healthcare was provided to people in
Rubaya camp and to the host population.

In March, an emergency measles
vaccination campaign in Vuhovi reachedmore than 51,000 children.

Comprehensive healthcare is provided at
Mweso hospital, with psychiatric services
integrated into the basic healthcare
programme. The nearby Kitchanga project
closed mid-year. The mental health andsexual violence programmes were absorbed
into the Mweso-based project, which also
took over activities in Mpati and Bibwe.
Other activities were handed over to Merlin.
Security incidents caused the suspension of
the Mweso project twice in 2013, but theteams at Mweso hospital provided morethan 140,000 consultations, carried out
more than 1,300 surgeries and assisted
more than 4,500 deliveries.
Basic healthcare, including the preventionof, and response to, epidemic outbreaks,

South Kivu
South Kivu hosted more than 800,000
displaced people in 2013, most of them in
the Kalehe and Shabunda territories, where
MSF provides basic and specialist healthcare
in Kalonge, Shabunda and Matili hospitals
and in 15 health centres in the surrounding
areas. MSF supports a hospital and threehealth centres in Minova, an area regularly
affected by conflict and influxes of displaced
people, and conducts mobile clinics to assist
victims of violence.
In Fizi territory, MSF provides
comprehensive basic and specialist
healthcare, including surgery, reproductive
health services, neonatal treatment,
prevention of mother-to-child transmissionof HIV, tuberculosis and cholera treatment,
vaccinations, nutritional support and sexual
violence aftercare at Baraka and Lulimba
hospitals and six health centres. In addition,
MSF supports two permanent cholera
treatment centres (CTCs). A new 100-bed
hospital was also built in Lulimba.

© Colin Delfosse

International Activity Report 2013

A resident of Rubaya camp in Masisi, North Kivu, looks out over the makeshift tents.

MSF emergency teams responded to a numberof outbreaks of malaria, measles, rabies andcholera in South Kivu. Six cholera interventions
were carried out in the province, more than160,000 children were vaccinated against
measles, and in Lemera over 100 people were
vaccinated against rabies. During the malaria
outbreak, 64,000 patients were treated in Fiziand 43,000 in the isolated Shabunda area.
More than 565,000 outpatient consultations
were completed in South Kivu in 2013.
KatangaThose in Katanga province receive very little
humanitarian aid and suffer from a lack ofquality health services and fees they cannot
afford. MSF treats children in the paediatricunit of Kabalo hospital and 15 peripheral
health centres, mainly for malaria. As aresult of a measles outbreak in Kabalo, MSF
provided hospital treatment and undertooka targeted vaccination campaign. Whena nutritional survey indicated extensive
malnourishment, one inpatient and three
outpatient feeding centres were opened.
In April, MSF completed a cholera intervention
in Lubumbashi that had begun the previous
November. The team built an 80-bed CTC andtreated a total of 5,904 patients.
Comprehensive health services continued in
Shamwana and the surrounding area. Teams
responded to cholera outbreaks in Kaisengand Lukanzola and vaccinated over 150,300
children against measles in Moba.

A project in Kalemie aimed at reducing
cholera was suspended in November after
two consecutive attacks on MSF. A cholera
vaccination campaign was also cancelled.
Orientale
In Geti, South Irumu, MSF continued tosupport the health centre and provided
59,567 consultations, an increase of 41 per centon the previous year. Violent clashes between
government and rebel forces in August caused
massive population displacement in the area,and from September, MSF supported thematernity unit and operating theatre of Geti
hospital to guarantee adequate healthcare
for an increasing number of patients.
During this time, teams assisted 726 births
and operated on 106 trauma patients withconflict-related injuries. MSF also ran two
mobile clinics, improved water and hygiene
for displaced people, distributed 10,000 relief
kits and conducted two measles vaccination
campaigns, reaching a total of 42,567 children
under 15.
MSF continued to work in the emergency
department at Dingila hospital, and with
Ministry of Health staff, screened and treatedpeople for sleeping sickness at Ganga-Dingila
and Ango, Bas-Uélé. Some 73,336 people
were screened and 1,358 received treatment.
During an outbreak of measles in Bas-Uélé,
MSF treated 30,200 patients in the healthzones of Ganga-Dingila, Buta, Aketi, Bondo,
Likati, Titule and Poko, and vaccinated

189,000 children in the health zones ofGanga-Dingila, Buta, Aketi, Bondo and Likati.
Kinshasa
The HIV programme based at Kabinda
hospital has been increasingly decentralised
and a community-based programmemanages the distribution of antiretroviral(ARV) medication to stabilised patients.
More than 5,500 patients are on treatment.

Popol
52 years old
I did not want to tell anyone about my HIV
status. After the screening, I had to start
treatment, US$200 treatment. But I had nomoney, not even US$10. A doctor referred me[to MSF] for free care.
I am a salesman in a store; this is how
I feed my wife, my daughter and my son.
I was already working in this shop
before, but I was sick all the time, I was
no longer useful. So I was fired. I stayedat home. When I started ARVs, gradually
I regained my health. But I had nothing
to eat. A friend advised me to go to my
ex-boss and explain. I told him that I was
sick with HIV, but that I was taking thefree drugs and had regained strength.
The boss thought it brave that I cameto talk to him like that, and gave me
my job back.

No. staff end 2013: 3,604 | Year MSF first worked in the country: 1981 | msf.org/drc

Democratic republic of congo 43

Médecins Sans Frontières

ethiopia
Nomadic people, refugees,
people in conflict-affectedareas and those located in the
remotest parts of Ethiopia lackaccess to health services.

Regions where MSF has projects

Key medical figures:• 120,800 outpatient consultations• 9,900 patients treated in feeding centres• 600 patients under treatment for TB© Faith Schwieker-Miyandazi / MSF

Responding to the lack of medical services
for pregnant women and young children,
Médecins Sans Frontières (MSF) runs a
programme focused on maternal andchild health in Sidama, Southern Nations,
Nationalities and People’s Region (SNNPR).
People are seen at Mejo and Chire healthcentres, and through outreach activitiesin 15 locations. A maternity waiting
home offers women with high risk births
a place to stay for one to two weeks
before delivery, so that they are close to
emergency obstetric services. In 2013, theteam provided 10,460 ante- and postnatal
consultations, assisted 800 deliveries andvaccinated 19,260 children. The inpatient
department saw 3,000 patients.

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

44 ethiopia

International Activity Report 2013
Visceral leishmaniasis, or kala azar, a parasitic
disease transmitted by the bite of an infected
sandfly, is endemic and sometimes epidemic
in Ethiopia. In Abdurafi, Amhara region, MSF
provides treatment for people with kala azarand HIV/AIDS, and for those co-infectedwith tuberculosis (TB). MSF completed thehandover of patients with simple HIV to
the Bureau of Health in 2013. The Abdurafi
programme also offers nutritional support
for patients and treatment for malnourishedchildren under five.

Underdevelopment, a shortage of
qualified senior health workers and conflict
between government forces and armed
anti-government groups all pose barriers
to healthcare in the Somali region. In
Degehabur, MSF supported the regional
hospital with emergency obstetric services,mental healthcare, assistance for victimsof violence including sexual violence,treatment for malnutrition and TB. Basichealthcare was provided through mobile
clinics in Birqod, Ararso and Degehaburworedas. Teams carried out 3,460 antenatal
consultations and enrolled 960 children
in nutrition programmes. Mental healthactivities, including counselling and therapy
groups, were attended by 890 people,
and 430 patients began TB treatment. A
fully equipped 35-bed ward was built toprovide better care for children requiring
hospitalisation. Drugs and materials forthe management of health activities werealso provided. Improvements were made inwater quality and supply in MSF-supported
health facilities and a team completed ameasles vaccination campaign with the
Bureau of Health.
In the Wardher area, MSF supported
Wardher hospital, focusing on specialist
care for severely ill or malnourishedchildren, maternity services and TB
treatment. Basic healthcare was offered at
Yucub health post, and two health centres
in Danod and Yucub received support
in the form of staff, medical supplies
and training to provide quality healthservices to the surrounding population.
Additionally, regular mobile clinics travelled
to nine outlying locations and provided
antenatal care, therapeutic feeding
and immunisations. A free ambulance
served another 12 villages. Teams treated
1,467 children for malnutrition, provided
2,242 women with antenatal care andassisted 325 deliveries.
Critical refugee assistanceTeams continued to provide specialist
healthcare for Somali refugees and thehost population in Dolo Ado, Liben zone,
Somali region. Services include an inpatient© Francois Servranckx / MSF

Filling healthcare gaps in Somali region

An arrival site in Gambella region for refugees from South Sudan.

department, emergency obstetric surgery
and a therapeutic feeding centre forchildren. Teams vaccinated 12,180 children
against measles and, in collaboration with
the Regional Bureau of Health, also carriedout several rounds of polio vaccination.
In the western region of BenishangulGumuz, a team provided aid to South
Sudanese refugees. An evaluation of theemergency nutrition programme thatstarted in 2012 in Bambasi camp showedthat people’s nutritional status had greatly
improved. MSF continued to work withlocal authorities to improve healthcare andnutritional services in Bambasi, Tongo andat the new Ashura camp. Teams undertook
23,170 consultations and admitted 21,025
children to supplementary feeding
programmes across all three camps.
In July, following an outbreak of violencein South Sudan, MSF started providing
assistance to an estimated 3,000 refugees
and 3,000 people in the host communityof Raad, Gambella region. By the end of
the year, teams had carried out 5,500
consultations, and vaccinated 1,280 children
against measles and 1,980 against meningitis.
Responding to drought and deportation
The worst drought recorded in recent
years in Afar region had a severe impact
on people’s health and nutrition. In April,
MSF responded by sending a team to Teru
Woreda, a harsh and difficult to reach areathat lacks development support. Staff set up
a supplementary feeding programme andan inpatient unit, and carried out mobile

treatment activities. More than 1,880
children received medical care.
In November, the government of Saudi
Arabia began deporting ‘illegal’ foreign
workers, resulting in the arrival of 154,837
Ethiopian men, women and children atBole airport by the end of December.
MSF provided psychosocial support to15,673 people. One-fifth of those receiving
individual consultations were found to havea mental illness and 40 were referred tothe psychiatric hospital in Addis Ababa forfurther treatment.
Programme closures
TB is the second-most common cause ofdeath in Ethiopia after malaria, and there
are indications that drug-resistant formsof the disease are on the rise. MSF assisted
the Bureau of Health in establishing an
innovative programme for TB treatment
in Dire Dawa. The team handed over the
project after donating diagnostic equipment,
fine-tuning medical protocols and making
modifications to the TB ward and people’s
homes so that they could undergo treatment
without a lengthy hospital stay.
The clinic in East Imey, Somali region, washanded over to the Bureau of Health inMarch, and the therapeutic feeding centre in
Buramino refugee camp was closed in April.
MSF also handed over the project providing
inpatient, maternity and nutrition care at ahealth centre in Mattar, north of Gambella
city, in June. In the first half of the year, teams
carried out 33,140 health and 650 antenatal
consultations, and assisted 170 births.

No. staff end 2013: 1,226 | Year MSF first worked in the country: 1984 | msf.org/ethiopia

ethiopia 45

Médecins Sans Frontières

FranceMédecins Sans Frontières (MSF) closed its programme forasylum seekers in Paris this year.

Cities, towns or villages where MSF works

Since 2007, MSF has been providing medical
and psychological care as well as social
support to asylum seekers in Paris. Many havefled conflict zones or political persecution
at home and find themselves living on
the streets in France. Most have no healthinsurance and it is very hard for them toaccess any kind of medical care. Furthermore,
many of them cannot speak French.
In 2013, an MSF team of nurses, doctors,
psychologists and social workers continued
to treat and support asylum seekers who
had suffered repeated traumatic experiences

both at home and in exile. A particularemphasis was put on providing
psychological care to those who did not
speak French and could not access thenecessary help elsewhere.
MSF, after assessing the limitations, decided
to close its programme in France at theend of May 2013. The most pressing issues
encountered by migrants in France are thoselinked to administrative and social problems,
and these are currently beyond the remit of a
medical humanitarian organisation.

Year MSF first worked in the country: 1987 | msf.org/france

georgia
Key medical figures:• 169 patients under treatment for TB

Lack of access as well as poor adherence
to TB treatment were at the origin of
the emergence of multidrug-resistant TB(MDR-TB), a form of the disease that does
not respond to standard first-line drugs
as the bacteria is resistant to two main
antibiotics. Today, MDR-TB also spreads
from one patient to another. Treatment for
MDR-TB is available, but it takes up to two
years on a course of several drugs to be
cured. People must also tolerate difficult
side effects, such as depression, loss ofhearing, nausea and vomiting.

Tuberculosis (TB) remains amajor challenge in Georgia,
with many people sufferingfrom multidrug-resistantstrains of the disease.

Médecins Sans Frontières (MSF) treatspatients with MDR-TB in the autonomous
republic of Abkhazia, and is also assistingwith the development of the Abkhaziannational programme. Activities include
training, writing medical care protocols,laboratory support and the supply ofequipment and drugs.

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

The Georgian national TB programme iswell organised, and MSF is currently in
discussions with the Georgian Ministryof Health regarding clinical trials for two
new MDR-TB drugs which will shorten thelength of treatment and should result in
fewer side effects.
Care for the elderly
An MSF team continued to provide medical
assistance to vulnerable people in an accessto care programme that started in 1993.
Most of the 50 patients are now aged 70
or older, and live in Sukhumi, Abkhazia
and Tbilisi. They are bedridden andisolated, and suffer from serious chronic
diseases. MSF offers eye care, as well as
material support such as wheelchairs, andan MSF doctor carries out home visits.

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

46 France | georgia

International Activity Report 2013

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

Key medical figures:• 2,900 outpatient consultations• 200 individual and group mental
health consultations

Undocumented migrants andasylum seekers in Greece facelong periods of detention incentres with limited access tobasic services and healthcare.

Migrants and asylum seekers of all ages
can find themselves summarily arrested
and confined in detention centres for
up to 18 months. They have little or no
opportunity to communicate with theirfamilies, and their physical and mental
health often deteriorates.
Médecins Sans Frontières (MSF) has
responded to the situation by providing
medical consultations and psychosocial
support to people being held at detention
centres in Komotini, Filakio and Drama, andin the police stations of Feres, Soufli, Tycheroand North Iasmos. Items including clothes,sleeping bags, towels and soap have also
been distributed in centres to help people
maintain a basic level of hygiene, health anddignity. These activities were handed over tothe Hellenic Center for Disease Control andPrevention in April. Five months later, MSF
resumed assistance at Filakio and Komotini,and Feres, Soufli and North Iasmos as no
medical or humanitarian assistance wasbeing provided by the authorities. The teamalso responded to two outbreaks of scabies– a parasitic skin infestation that spreads

rapidly in crowded conditions – in thedetention facilities. More than 2,000 people
were treated between January and April and
September and December.
Healthcare out of reach
The financial crisis in Greece has led tothe country’s health budget being cut by
almost 40 per cent, and state funds for
medication have also been almost halved.
As a consequence there is limited availabilityof medicine, not only for vulnerable groups
like the unemployed and the uninsured, butalso for the general population. In October,an MSF team began assisting people in needof healthcare at food distribution centres
in Athens. On-the-spot care, including
medical consultations, hospital referrals andpsychosocial referrals for shelter and legal
assistance were provided. Many patientswere unemployed or elderly.
Freezing temperatures in early 2013 led
authorities to open temporary emergency
shelters to accommodate homeless people
in Athens, and MSF launched an emergency
intervention in January.

No. staff end 2013: 12 | Year MSF first worked in the country: 1991 | msf.org/greece

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

Key medical figures:• 179,400 outpatient consultations• 94,400 patients treated for malaria• 13,600 patients on first-line ARV treatment

The healthcare system in
Guinea is currently unable
to meet all the needs of its
people. Malaria remains aparticular concern.

Malaria is a preventable and treatable illnesstransmitted by infected mosquitoes, and isa leading cause of illness and death in the
country. Médecins Sans Frontières (MSF)
has continued to work with the Ministry of
Health on malaria prevention and treatment
in Guéckédou, and the programme now
supports the district hospital, seven healthcentres and 12 health posts. The MSF teamhas also trained 53 community healthworkers so that they can screen and treat
people with uncomplicated malaria.
HIV
Although the prevalence of HIV is relatively
low in Guinea, people who have theillness often cannot afford to pay thefees that are charged for antiretroviraldrugs. Many HIV-positive people also fear
disclosing their status due to the social
stigma, and this creates another barrier totreatment. The HIV programme based in
the capital Conakry, comprising one MSF
ambulatory treatment centre and five

health centres supported by MSF, offers afree, comprehensive health package that
includes psychosocial care, tuberculosis
treatment for co-infected patients andprevention of mother-to-child transmissionof the virus.
The HIV programme in Guéckédou washanded over to the Ministry of Health in2013, as was the Matam maternal healthprogramme.
Responding to cholera andmeningitis outbreaks
During an outbreak of meningitis in May,an MSF team treated 132 patients, provided
drugs to medical facilities and trained
local staff. In June, an emergency cholera
treatment centre was set up on Memgbe
Island, Conakry. Eighty people who had
contracted the water-borne disease weretreated. There were no new cases or deaths
after assistance had been provided.

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

greece | guinea 47

Médecins Sans Frontières

haiti
Cities, towns or villages where MSF works

Key medical figures:• 6 ,550 births assisted• 13,600 surgical interventions• 7,400 patients treated for cholera

Cholera, a water-borne infection that canlead to rapid dehydration and sometimes
death, remains a health threat where there
is poorly managed water and sanitation.
Overall, living conditions in Haiti have
improved over recent years, but in camps
hygiene standards remain extremely poorand some people are without access toaffordable drinking water.
The cholera crisis that began within monthsof the 2010 earthquake persists, particularly
during the rainy season, when the numberof patients reaches epidemic levels. Since
October 2010, more than 700,000 people
have been infected with cholera. Onethird of these have been treated by MSF.
Teams continued to run cholera treatment
centres (CTCs) in Delmas and Carrefour,in Port-au-Prince. Preventive measures
included distribution of hygiene kits,water chlorination points and educational
activities. In 2013, more than 85,000 people
learned about cholera prevention and 5,240
disinfection kits were distributed.
Historically there has been little emergency
care available for people in Haiti unlessthey can afford to pay for it. MSF runs
the Centre de Référence en Urgence
Obstétricale (CRUO), a 130-bed hospitalin Port-au-Prince providing free, 24-hourobstetric care for pregnant women sufferingfrom complications such as pre-eclampsia,
eclampsia, obstetric haemorrhage anduterine rupture. A full range of reproductive
health services, including family planning,
postnatal care and prevention of
mother-to-child transmission of HIV is alsooffered. A 10-bed unit, the ‘Cholernity’,is available for pregnant mothers withcholera within the CRUO. Teams assisted
5,450 births during the year.
Decentralising care
MSF continued to manage the 160-bed
temporary container hospital in the cityof Léogâne, which had originally been set
up to provide emergency services after© Diana Zeyneb Alhindawi

More than three years
after Haiti’s devastating
earthquake, the few public
medical facilities in the
country do not have theresources to meet theneeds of most Haitians.
Emergency services are
particularly lacking.

Healthcare in Haiti remains largely
privatised and most people do not havethe financial means to pay for it. In 2013,
Médecins Sans Frontières (MSF) continued
to provide urgently needed free services tohelp fill some of the gaps.

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

48 haiti© Yann Libessart

International Activity Report 2013

The specialist burns unit in Port-au-Price’s Drouillard hospital is the only one in Haiti.

the earthquake. Aware of the fragility of
the healthcare system after the disaster,
MSF decided to extend its programme
in order to support the Ministry of
Health’s aim of restoring services tothe pre-earthquake level in the region.
The hospital continued to provide basic
healthcare for women and children
this year, as well as specialist services,primarily for obstetric emergencies, andto run a cholera treatment unit. MSF
has begun to reduce its activities in thehospital, and straightforward deliveries
and antenatal care for uncomplicatedpregnancies can already be managed inlocal health facilities. MSF has started
to identify potential partners to handle
complicated cases.
Drouillard hospitalA team provides trauma care to victims ofaccidents, burns and violence, including
sexual violence, at the 130-bed Drouillard
hospital in Port-au-Prince, close to Cité Soleil
slum. Surgery, intensive care, orthopaedic
and burn care, and physiotherapy are
offered. Some 13,200 people were treated in
2013. More than one-third had been in roadaccidents, one-fifth were victims of violence(around 50 patients with bullet wounds

and 100 with knife wounds were admittedmonthly) and one-quarter were injured indomestic accidents. A large percentage ofpatients who suffered burns in domestic
accidents were children under five. Drouillard
hospital is the only facility with a specialist
burns unit in the country. MSF also maintains
a unit in the hospital that can quickly betransformed into a 130-bed CTC, if required.
Martissant emergency andstabilisation centre
MSF provides paediatric care, internal
medicine and maternity services, as well
as psychological support for patients andcaregivers at the Martissant emergency
and stabilisation centre. The centre is open
around the clock, offering free care topeople in any kind of emergency medical
situation. An ambulance service transports
patients to appropriate hospitals fortreatment. More than 100 patients wereseen daily in 2013.
TabarreManise19 years old
I was living in Canaan camp with mycousin after the earthquake. I stayed in thetent and prepared food, while my cousin
went out to work. One night, I went tocollect some water. Two men arrived anddragged me into an empty tent.
I shouted so loudly one of them left. The
other held on to me tightly and hit me
many times. It was around 8pm and there
were a number of passersby. No one cameto help me.
I had no problems in my pregnancy until
my feet began to swell. My health worsened
and one day I lost consciousness and woke
up in an MSF hospital. I saw the baby next
to me but could not remember the birth …
I am worried I won’t be able to feed myson once he is too old for breast milk. I am
going to offer to do washing for people.

The Nap Kenbe surgical centre in Tabarre
continued to provide free emergency
and trauma services, orthopaedics,
physiotherapy and post-operative carefor people in eastern Port-au-Prince.

No. staff end 2013: 2,324 | Year MSF first worked in the country: 1991 | msf.org/haiti

haiti 49

Médecins Sans Frontières

honduras

The public healthcare system in Honduras cannot keep pace withvictims of violence, leaving the most vulnerable people deprivedof much-needed services.
Survivors of criminal violence in Honduras
rarely seek medical or psychological help,
fearful of their aggressors and deterred by
the many barriers to healthcare. There are
frequent shortages of skilled personnel andsupplies at public hospitals and clinics, andhealth staff are reluctant to treat victims ofviolence for fear of repercussions.
Aiming to improve access to emergency
medical care, Médecins Sans Frontières(MSF) continued to run a comprehensive
programme offering quality treatment
and follow-up to victims of violence in thecapital city of Tegucigalpa. Teams worked
to increase vulnerable people’s access toemergency healthcare for trauma, medical
emergencies, sexual violence and mental
healthcare for victims of violence.
The emergency room of the university
hospital Escuela, the main public hospital in
the country, is always extremely busy, seeingsome 260 patients per day. MSF helped

reorganise services and is working on
improving emergency management
to better deal with large influxes ofpatients and to reduce chances of deathor permanent disability arising frominadequate trauma care.
A large street-based population, consistingof homeless people and people who work
informally, such as street sellers and sex
workers, are hyper-exposed to violence
and are excluded from the health system.
Mobile teams consisting of a social worker,
a psychologist and a clinician visited
25 sites around the city each week in
2013, identifying inhabitants’ medical,
psychological and social needs. The teams
provided on-the-spot first aid, preventive
care and mental health support. More than
1,040 victims of violence, including 725
victims of sexual violence, were identified
and treated across four MSF-supported
health clinics.

Cities, towns or villages where MSF works

Key medical figures:• 1,500 individual and group mental
health consultations• 720 people treated after incidents ofsexual violence

There is no national protocol for the treatmentof victims of sexual violence in Honduras andthis means that victims do not have accessto adequate medical care. MSF is part of a
Ministry of Health committee working todevelop national health guidelines for thetreatment and care of victims.
Dengue emergency
In San Pedro Sula, the country’s second city,
MSF responded to an epidemic of dengue
haemorrhagic fever and treated more than
600 children in the paediatric ward of Mario
Catarino hospital between August andNovember 2013. MSF also donated drugs
and medical supplies to the hospital for thetreatment of adults affected by dengue.

No. staff end 2013: 57 | Year MSF first worked in the country: 1974 | msf.org/honduras

IRAN
Rates of drug addiction in Iranremain high, yet many addicts
have difficulty accessing the
medical and psychologicalcare they need.
The Iranian authorities have recognisedthat drug addiction and HIV infection area growing public health concern, and havetaken significant steps to initiate harm
reduction and HIV/AIDS prevention among
injected-drug users. However, the broad
medical needs of high-risk groups remain
acute, especially in Tehran, where drug
users, sex workers and street children are
stigmatised and are therefore unable toaccess the general health system.
In Darvazeh Ghar, one of the poorest
neighbourhoods in Tehran, Médecins

Sans Frontières (MSF) continued to run
a health centre dedicated to women andchildren under five who are excluded
from healthcare, including undocumented
refugees. Together with Iranian authorities
and local organisations, MSF offered
free, basic healthcare, including medical
consultations for women and children,
gynaecological care, family planningand postnatal care. A mental healthprogramme started in September, withtreatment and support provided by apsychiatrist and a psychologist.
Iran’s Bureau for Aliens and Foreign
Immigrants’ Affairs estimates that thecountry hosts 850,000 refugees, most ofthem Afghans. While registered refugees
are granted private health insurance,
those who are undocumented have
limited access to healthcare.

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

50 honduras | IRAN

Cities, towns or villages where MSF works

Key medical figures:• 5,800 outpatient consultations• 1,200 antenatal consultations• 6 0 individual and group mental
health consultations

International Activity Report 2013

italy

Migrants and asylum seekers
face many health challenges
upon arrival in Italy, in both
reception and detention centres.

Victims of torture, human trafficking, sexual
violence and people with mental health issues
are particularly vulnerable on first arrival in
Italy, but there are insufficient services tomeet their needs. Crowded reception centres
and poor living conditions in facilities for
migrants pose further health risks.
Teams from Médecins Sans Frontières (MSF)
provide medical and mental healthcare tomigrants and asylum seekers in reception
centres on Sicily and in Calabria. Basichealthcare is offered to undocumented
migrants in Ragusa province, Sicily. In
Pozzallo, MSF supports the local healthauthorities with medical triage of migrants
on arrival. In December, MSF called forthe temporary closure of the Lampedusa
reception centre so that it could be
refurbished to ensure minimum reception

standards and respect for human dignity.
The authorities closed the centre and began
making upgrades.
MSF continued a pilot project for the early
diagnosis and treatment of tuberculosis
among migrants hosted in reception anddetention centres.
MSF teams also worked in Milan, Trapani,
Caltanissetta and Rome, in collaboration
with the Ministry of Health, the Ministryof Foreign Affairs and private companies
responsible for managing reception anddetention centres. In Lombardy, an MSF
team worked with the NGO OIKOS in the
Latin American migrant communities toensure access to diagnosis and treatment of
Chagas disease, which is endemic in theirhome countries.
A team also completed a three-monthassessment of the ongoing healthcare
needs of homeless patients discharged
from hospitals in Milan, Rome and Palermo.
A project will be launched in Milan in 2014.

Cities, towns or villages where MSF works

Key medical figures:• 6 ,750 outpatient consultations

A Syrian refugee whose family had
escaped a chemical weapons attack
and had travelled through Lebanon,
Egypt and Libya before arriving in
Pozzallo, Italy.
The trip was organised by armed men …
on board we had no water or food.
Thirsty, we drank the used engine water.
We stayed three days at sea before wewere rescued near the Sicilian coast. All I
want is a safe place for my family. Many
Syrians are stuck in hell: caught between
the battles, without doctors and food.

No. staff end 2013: 11 | Year MSF first worked in the country: 1999 | msf.org/italy

Regions where MSF has projects

Médecins Sans Frontières(MSF) stopped working in
Laos in December 2013.
In 2011, MSF decided to launch a programme
to provide obstetric and neonatal support
and paediatric care for children under five,in five district hospitals and 10 health postsin Huaphan province, northeastern Laos.
The aim was to reduce infant mortality, as wellas the number of deaths during pregnancy
and childbirth, and an MSF team worked
with the hospitals and health centresof XiengKhor, Sop Bao, Ett, Xamtai andKuan districts. Mobile medical clinics
reached some of the most remote anddisadvantaged communities in theprovince, and MSF worked to improvelaboratory and pharmacy facilities in
the area, as well as water, electricity andsanitation infrastructure.
The team found that low patient attendance
rates, the scattered nature of the healthfacilities in the province, and the difficulties
in recruiting qualified Lao staff andimporting the necessary drugs meant that
goals were not met and expected outcomes
for training medical staff and treating
patients were not reached. The decision
was made not to continue the programme
beyond the end of the year.

© Takuro Matsumoto / MSF

Laos

A midwife examines a patient, in thepresence of her family.

No. staff end 2013: 46 | Year MSF first worked in the country: 1989 | msf.org/laositaly | Laos 51

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

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

Healthcare in Nagaland
Until recently there had been few healthservices available in remote Nagalandstate, where the years of insurgency had
stunted the area’s development. Since
2010, MSF has supported Mon district
hospital by refurbishing the buildings andupgrading key services including pharmacy
and medical waste management, thelaboratory, infection control measures,and water and sanitation. MSF has also
provided staff training to improve medical
management, with special focus on sexualand reproductive health and TB. The teamcarried out 30,365 outpatient consultations,assisted more than 680 deliveries andtreated 15 patients for drug-resistant TB(DR-TB) in 2013. The project has beenrecognised by the government and local
community for the significant impact it
has had on people’s access to healthcare
in Mon district.

Regions where MSF has projects
Cities, towns or villages where MSF works
The maps and place names used do not reflect
any position by MSF on their legal status.

co-infections who have been excluded
from government health services. In 2013,
however, the focus shifted to responding
to the public health crisis posed by DR-TB
in the city. MSF treated patients with themost severe forms of DR-TB. The strategy
is to treat a small but acute group ofpatients who cannot access the government
healthcare system, and to use evidence
from operational research to encourage
the government to find ways and means
to provide treatment for these people.
MSF runs a clinic offering outpatient carethat provides third-line antiretroviral (ARV)
therapy for patients with second-line ARV
failure and treats patients co-infectedwith HIV and hepatitis B or C, or DR-TB.
In addition, MSF supports a government

Improving access to HIV and TB care
In Mumbai, MSF continued to provide
treatment for patients with HIV and

52 india

TB hospital with infection control andcounselling services. Approximately
300 patients received treatment in2013, including nearly 160 patients on
second-line and third-line HIV regimens,
approximately 50 patients with HIV and
DR-TB co-infection, and about 80 patientswith DR-TB.
In the northeastern state of Manipur, where
the prevalence of adult HIV infections is thehighest in the country, MSF offers HIV and
TB care in three clinics in Churanchandpur
and Chandel districts. One of the clinics
is situated in the town of Moreh, right on
the border with Myanmar. More than 560
patients started treatment for HIV this year
(a total of 1,244 patients were receiving
treatment by the end of 2013), 299 people© Azzurra D’inca / MSF

Longstanding, low-intensity conflict in
Chhattisgarh and Andhra Pradesh has
led to population displacement andreduced access to healthcare. Médecins
Sans Frontières (MSF) teams continued
to bring basic healthcare to people invillages through weekly mobile clinics insouthern Chhattisgarh, and those living in
displacement camps on the Andhra Pradesh
side of the border. Patients suffered mainly
from skin infections, general body pain,
respiratory tract infections and malaria.
A mother and child health programme
offered antenatal care, immunisations andnutritional support for pregnant women andchildren in Bijapur, Chhattisgarh. Screening,
diagnosis and treatment for tuberculosis(TB) were also available. In November,a clinic providing basic healthcare was
opened in Mallampeta, a remote village
on the border of Andhra Pradesh andChhattisgarh. In 2013, MSF carried out
nearly 52,600 consultations and treatedapproximately 8,465 people with malaria
in the region.

An MSF mobile clinic in a Chhattisgarh village.

International Activity Report 2013

began treatment for TB and 30 for
multidrug-resistant TB (MDR-TB).
Mental healthcare
Decades of conflict in Kashmir have takena toll on people’s mental health, and needs
persist for psychological support. A wellestablished MSF mental health programme
continued at five fixed locations in Srinagar
and Baramulla districts. Teams also visited
victims of violence in Srinagar hospitals andprovided psychological first aid – ensuring
basic psychological, social and material
needs were being met. Counselling services
were launched in Pattan in June. A total of
2,530 individual mental health consultations
were provided across the programme.
Heavy rains and landslides in Uttarakhand
state in mid-June caused significant
flash flooding in Uttarkashi, Chamoli,
Rudraprayag and Pithogarh districts. The
state is home to many holy Hindu sites andthe majority of the estimated 10,000 people
who lost their lives were pilgrims from allover India and the local population working

with them. MSF set up a three-monthprogramme to support those suffering fromacute distress in Rudraprayag district. Morethan 440 individual sessions and 37 groupsessions were provided.
Treating kala azar and malnutritionin BiharPeople in Vaishali district, Bihar, live in anarea where kala azar (visceral leishmaniasis),a parasitic disease transmitted by thebite of an infected sandfly, is endemic.
The infection is almost always fatal if left
untreated. MSF began responding to kalaazar in 2007, introducing L-AmB 20mg/kg(liposomal amphotericin B) as a first-line
treatment at Sadar district hospital andfive health clinics. More than 10,000
patients were treated, with an initial curerate of 98 per cent. Since 2012, MSF has
collaborated with the Drugs for Neglected
Diseases initiative (DNDi), implementing
a pilot project examining the safety andeffectiveness of two combination therapies,
as well as an alternative, single-shot dosageof L-AmB. Initial outcomes were encouraging
and the pilot programme will expand
to additional districts. If these new drug
regimens are proven effective and safe, theresearch could potentially change national
treatment protocols for the disease.
In the Darbhanga district of Bihar, childmalnutrition is a chronic and under-reported
health crisis. MSF teams provide weekly
treatment for children with severe acutemalnutrition through a community-based
programme in Biraul block. In 2013,
the programme expanded to cover an
additional four blocks. MSF also beganbuilding a malnutrition intensive care unit
inside a teaching hospital in Darbhanga totreat the most severe cases. MSF continues towork with health authorities to define amodel of care for children with severe acutemalnutrition that can be implemented within
the public health system. Over 13,000
children under the age of five have beentreated in Darbhanga since 2009.

© Angel Navarrete

No. staff end 2013: 672 | Year MSF first worked in the country: 1999 | msf.org/india

There are high levels of malnutrition in children aged between six months and five years in Bihar. Malnutrition bracelets like this one measure
the circumference of a child’s upper arm.

india 53

Médecins Sans Frontières

iraq

There was a dramatic increase in violence in
Iraq in 2013, and this further underminedthe capacity of health facilities to respondadequately to medical needs. Médecins
Sans Frontières (MSF) is focusing on fillingsome of the gaps in care, training staff andsharing knowledge at several hospitals.
Child and maternal healthRegions where MSF has projects
Cities, towns or villages where MSF works

Key medical figures:• 193,800 outpatient consultations• 10,800 individual and group mental
health consultations

The Al-Zahra hospital is the main referral
hospital for obstetrics, gynaecology andpaediatrics in Najaf governorate. An
MSF team trained doctors and nurses,
implemented treatment protocols andintroduced documentation and analysis
methods. Support was also provided in
hospital management, infection control,
structure rehabilitation and maintenance. MSF
trained hospital staff in case management

Hawijah hospitalMore than 300 emergency surgicalprocedures were performed each monthat the hospital in Hawijah, the only facility
offering specialist services in the entire
district. In addition to providing hands-on
emergency surgical services around theclock, an MSF team conducted training in
the management of emergency cases andinfection control intervention. MSF also
carried out assessments of health centres
in Hawijah district to ascertain whether
basic healthcare was available for the ruralcommunities, and this information will be
used as a reference to develop new activities.

© Diala Ghassan / MSF

Thousands of Iraqis endure
a lack of basic healthcare
services, and access is further
hampered by chronic insecurity.
War has affected medical
infrastructure in some areas.

In January, MSF began working with
the neonatal care unit at Kirkuk general
hospital, providing training and supervision
to ensure basic standards of care fornewborns and their mothers.

in order to try and reduce the number ofneonatal deaths. Along with training andsupervision, MSF placed an emphasis on
infection control, pharmacy standardisation,sterilisation procedures and data collection.
In 2013, 23,627 deliveries were registered at
the hospital, with more than 6,000 infants
requiring intensive care.

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

54 iraq© Diala Ghassan / MSF

International Activity Report 2013

A sick baby with his mother and siblings in the paediatric ward of Hawijah hospital.

Caring for Syrians in refugee camps
The Syrian crisis has resulted in a massive
flow of refugees into Iraq. According to the
UN refugee agency, more than 200,000
Syrians had crossed into the Kurdish regionof Iraq by the latter half of 2013. Borders
are opened only intermittently and morethan 50,000 refugees arrived within justa few days in mid-August. MSF openeda health clinic offering basic and mental
healthcare in September at the Kawargosk
camp in Erbil province, which hosts 12,500
refugees. A mobile clinic that ran from late
September in the smaller Qushtapa camp
(3,000 refugees), also in Erbil province, washanded over to the Department of Health inDecember 2013.
More than 18,900 consultations wereconducted with refugees, and 30 per
cent of these were for children under five.
Respiratory infections were the main cause
for consultations across all age groups.
MSF is also the main healthcare provider
in Domiz camp. Initially designed to host
1,000 families, the camp population
has swollen to 45,000 people. Despite
the efforts of the local authorities, campservices cannot keep pace with needs

and overcrowding and poor living
conditions have led to a deterioration inpeople’s health. Each week MSF carries out
some 2,400 medical consultations. Manypatients suffer from upper respiratory tract
infections and acute watery diarrhoea, but
MSF also provides treatment for chronic
diseases, reproductive health and mental
health. Targeted distributions of washingkits and water and sanitation activities toensure minimum standards of hygiene
were completed in the first half of the year.
Referring victims of violence forreconstructive surgery
Many patients suffering from burns andother traumatic injuries cannot accessthe specialised care they need within
the country. MSF runs a network of
medical liaison officers (MLOs) locatedin Baghdad, Najaf, Kirkuk, Ninewa, Erbil,
Al-Qadissiyah, Al-Anbar, Salah ad-Din, AlBasrah and Diyala. They identify and referpatients to MSF’s reconstructive surgery
programme in Amman, Jordan. Patients
receive orthopaedic, maxillofacial andplastic reconstructive surgery, along withphysiotherapy and psychosocial support.
The MLOs, together with administrative
support based in Baghdad, managed theadmission and discharge of 185 patients,
and provided follow-up for almost 400
patients in Iraq in 2013.
Reducing the stigma of mental illness
Mental illness is not openly discussed ortreated in Iraq. MSF had been providing
mental healthcare in Baghdad and Fallujah
since 2009, responding to needs and aiming
to reduce stigma. Individual counselling anda telephone helpline were offered. In 2013,
psychologists treated 775 people in 2,027
counselling sessions, before the programme
was handed over to the Ministry of Healthin June.
Sharing expertise in health services
MSF supported the national Poisoning
Control Center (PCC) in Baghdad throughthe donations of antidotes and theexchange of scientific knowledge. MSF
also responded to a request from thehealth ministry’s Department of Medical
Rehabilitation for a possible collaboration
concerning physiotherapy. Visits weremade to various rehabilitative departments
in Baghdad, and training for inpatientphysiotherapy is being organised.

No. staff end 2013: 526 | Year MSF first worked in the country: 2003 | msf.org/iraq

iraq 55

Médecins Sans Frontières

JORDAN
Médecins Sans Frontières(MSF) continued areconstructive surgery
programme in Jordan forvictims of conflict, opened a
trauma programme for war
wounded from Syria, andexpanded activities to help
meet the needs of Syrian
refugees and ease pressure
on host communities.

In addition, MSF conducted around
300 medical and surgical consultations
per month for Syrian refugees at a special
health clinic within the hospital compound.
Physiotherapy services were also offered
and a team provided physiotherapy andspecialist referrals.
In August, MSF opened an emergency
trauma project in the Ministry of Healthhospital in Ar Ramtha, less than fivekilometres from the border with Daraa
governorate in Syria, an area which has
seen some of the heaviest fighting in theconflict. Severely wounded patients crossing
the border here are taken to Ar Ramtha
hospital. They are the victims of bombingsand shellings, and are caught in the middleof the violence and left with limited accessto medical care. Since the project opened,
the team has admitted 181 patients andperformed 336 major surgical procedures.
The facility also offers individual and groupmental health and physiotherapy sessions.

Cities, towns or villages where MSF works

Key medical figures:• 320 individual and group mental
health consultations

Maternal and child health in Irbid
Irbid has one of the highest concentrationsof Syrian refugees outside of the camps –there were over 120,000 in the governorateby the end of 2013. An assessment of theirhealth situation conducted by MSF in May
and June showed that mothers and children
were not getting adequate healthcare. MSF
opened a programme in October offering
consultations and inpatient care for refugees
and people in need in host communities.
Filling a gap in paediatric care at Zaatarirefugee camp, an MSF team ran a 24-hour
hospital for children aged one to 10 from March
to November. The project was closed whenother health providers were able to meet thechildren’s needs. More than 17,500 patientswere treated over the course of the programme.

No. staff end 2013: 72 | Year MSF first worked in the country: 2006 | msf.org/jordan© MSF

In Amman, MSF runs a regional
reconstructive surgery programme forpatients suffering from severe injuries
that require a level of integrated andspecialised care that is difficult for themto access anywhere else. Many people
initially receive treatment for wounds atother hospitals, and a network of doctors
refers them to the reconstructive surgery
hospital. Orthopaedic, maxillofacial andplastic reconstructive surgery is offeredwith essential complementary care that
includes physiotherapy and psychosocial
support. Patients are also provided withtransportation and are accommodated at

an MSF rehabilitation centre. Surgeons
performed 1,370 operations on patientsfrom Syria, Iraq, Yemen and Gaza in 2013.

MSF runs a regional reconstructive surgery programme in Amman.
56 JORDAN

International Activity Report 2013

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

Médecins Sans Frontières(MSF) estimates the incidenceof tuberculosis (TB) among
prisoners in Kyrgyzstan to be
20 to 30 times higher than in
the general population, withmortality rates as much as
60 times higher.
MSF continued to offer TB care to prisoners
in the penitentiary system in Bishkek,
the country’s capital, which holds up to
9,000 inmates. In the institutions where
prisoners are detained until sentencing,teams provided full health screening andput identified TB patients on treatment
straightaway. Staff also diagnosed andtreated inmates with multidrug-resistant
TB (MDR-TB).
Using a comprehensive approach to TB
patient management, MSF also supported
treatment for co-occurring illnesses, andoffered screening and vaccination forhepatitis B. Uninterrupted completion oftreatment is crucial in order for it to be
successful, and the team ensured followups once individuals were released fromprison. Having helped establish protocols,
increased infection control and improved
access to care, MSF plans to hand over the
penitentiary project by the end of 2014.
MSF has also actively supported thedevelopment of a newly constructednational reference laboratory in Bishkek.

© Vincent Tremeau

Key medical figures:• 3 00 patients under treatment for TB

A doctor explains a lung x-ray to an XDR-TB patient in Kara-Suu hospital.

Promoting ambulatory care for TB
In Kara-Suu district, Osh province, whererates of TB are among the highest in the
country, MSF supported the Kara-Suu
hospital, which has 80 beds for TB and
DR-TB patients. This project aims to becomea model for effective walk-in treatment.
Whenever possible, patients receive carethrough the community-based healthcare
system, with ambulatory or home-based
treatment, rather than being hospitalised.
Psychosocial counselling for patientsand their families, and social packages(nutritional support, hygiene kits andtransport money) are provided to help
patients adhere to treatment.
Rehabilitation of the hospital and basic
health facilities was supported by MSF
to ensure optimal infection control andbetter sanitary conditions for the patients.
Teams also worked with health centre
staff to improve clinical case management,
and the detection of people sufferingfrom TB, DR-TB and HIV–TB co-infectionin the district. Comprehensive care wasprovided to people with drug-resistantforms of TB, and those with certain
co-occurring illnesses.

MukhtarI still remember the day in the TB centre
when my MSF doctors told me that I
was cured and could stop the treatment.
I had a strange feeling of happiness,
which I really cannot find any words
to describe. I still can’t believe that thetreatment has finished. I have conquered
death. I want to thank you all and to saythat good people can save the world.

Advocacy work has resulted in policychange and acceptance of the communitybased treatment model by the Ministry of
Health as the future strategy for TB care in
the country.

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

KYRGYZSTAN 57

Médecins Sans Frontières

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

Médecins Sans Frontières(MSF) continued to fight HIV
and tuberculosis (TB), and in
the camps growing insecurity
affected healthcare accessfor refugees.
In the Dadaab refugee camps, home to over
340,000 Somalis, the general level of security
has steadily deteriorated since the end of
2011. This has reduced access for aid workers,
and MSF is unable to maintain a permanent
presence of international staff in its hospitalin Dagahaley. Many aid organisations haveexperienced a decrease in funding, leading toan overall reduction in assistance for refugees
in Dadaab. The impact is visible: there is alack of maintenance and investment in camp
hygiene and shelter, which raises major healthconcerns and increases the risk of epidemics.
MSF manages a 100-bed hospital in
Dagahaley, providing adult and paediatriccare, maternity services, emergency
surgery and treatment for HIV/AIDS and
TB. Antenatal care, surgical dressingsand mental health support are available
through four health posts. Each monthin 2013, on average, 18,000 outpatient
consultations were carried out and over
700 people were admitted to hospital.
More than 2,580 babies were delivered andsome 4,100 children received treatment
through outpatient and inpatient feeding
programmes. Over 10,800 mental healthconsultations were also conducted.

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

non-communicable diseases. More than 330
people sought assistance at MSF’s 24-hourclinic for victims of sexual violence. Services
included post-exposure prophylaxis,
psychological support and medical
treatment. In 2013, teams working in Kibera
completed more than 142,000 outpatient
consultations, and provided antiretroviral(ARV) treatment to over 4,300 HIV patients.
In February, MSF opened a new clinic in
Kibera South that has been set up with theaim of gradually handing over management
to the Ministry of Health over a period offive years. It is equipped to provide residents
with basic healthcare and maternity services.
There is an inpatient maternity ward, and an
ambulance service for obstetric and otheremergencies. Integrated management ofchronic diseases such as HIV, and any otherillnesses, makes it a one-stop service, thus
easing patients’ access to medical careand facilitating early diagnosis, treatment
and follow-up. Health education sessions,counselling and social support are alsooffered to empower patients to manage
their own health.
More than 60 per cent of all consultations
at MSF’s Kibera clinics were for respiratory
infections and diarrhoeal or skin diseases, aresult of the poor hygiene and sanitation.
The Eastlands area of Nairobi, composed ofpoor suburbs and informal settlements, ishome to a population of about two million.
An average of 150 people who had been
the victims of sexual violence came to the© Phil Moore

In November, a Tripartite Agreement was
signed by the UN refugee agency and the
Kenyan and Somali governments, outlining
practical and legal procedures for thevoluntary return of hundreds of thousandsof refugees to Somalia. An assessment
conducted by MSF among patients in its
medical facilities in Dagahaley camp in
August found that four out of five people
would choose not to return to Somalia given
the current climate of insecurity.
Free healthcare in slum settlements
Three MSF clinics continued to provide
free basic healthcare in the Kibera slumin Nairobi, as well as integrated
treatment of HIV/AIDS, TB and chronic

58 kenyaResidents of the Kibera slum in Nairobi wait to be seen at an MSF clinic.

International Activity Report 2013

MSF clinic each month for medical andpsychological aftercare. A team also treatedaround 476 patients with TB and 40 withdrug-resistant TB. An MSF team carriedout a health assessment in Eastlands toevaluate other needs and to explore theextent of sexual violence in the area. A
proposal to expand the programme will becompleted in 2014. The Blue House clinic,
where MSF has been providing HIV caresince 2001, was handed over to the AIDS
Healthcare Foundation.

to this epidemic. It will open in the first halfof 2014.
Emergency interventions

MSF continued the handover of the HIVprogramme at Homa Bay to the Ministryof Health and its partners, and expects
to complete the process by 2015. Some
25,000 people have received care in the
programme since 2001.

An MSF emergency intervention had been
underway in the Tana River delta region
since the beginning of the year assisting
victims of intercommunal violence, but
the response was expanded when thearea was subject to heavy flooding in April
and many communities were displaced.
Teams provided medical and mental healthsupport to people from both the Orma andPokomo communities. More than 4,900
health consultations and 160 individualand family mental health consultations
were carried out. Staff also organised morethan 830 community activities within thecamps for displaced people, such as latrine
construction, distribution of relief items,
water treatment and sanitation services.

However, as a result of MSF’s HIV impact inpopulation survey in Ndhiwa, Homa Bay –which found one of the highest incidencesof HIV in the world – MSF set up a newprogramme in 2013 to increase the response

There was sporadic violence throughout
the year in the Rahmu area of Mandera
county, and during intense clashes between
local armed militias in May, houses weredestroyed and looted. An MSF team

Addressing the HIV epidemic in
Homa Bay

distributed relief items to the people
affected and donated drugs and medical
material to Rahmu hospital, where several
wounded were treated. MSF facilitatedreferrals and also conducted training for
Ministry of Health staff. This emergency aid
was completed in August.

Charles
43 years old
I felt hopeless after having been diagnosed
with HIV in 2003. This was when stigma
and discrimination was very high. Before
MSF came, all I thought I could do
was hide and wait to die just like I had
witnessed my friends and neighbours
fade away. I am now a family man with
one wife and a pretty five-year-old girl.
ARV treatment gave hope to the hopelessand I am now a beneficiary of the good
free health services offered by MSF. As
an activist, I continue to lobby for better
policies to ensure that all Kenyans whoneed treatment can access it.

© Francis Eiton / MSF

No. staff end 2013: 789 | Year MSF first worked in the country: 1987 | msf.org/kenya

An MSF team assisting flood victims in the Tana River region.
kenya 59

Médecins Sans Frontières

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

An estimated one million
Syrian refugees have madetheir way to Lebanon, acountry with a population of
only four million.
Despite tremendous efforts by the
Lebanese authorities and the provision ofinternational aid, the various structures andschemes put in place to assist refugees areunable to cope with their numbers.

In 2013, MSF was present in Tripoli, theBekaa Valley, Beirut and Sidon (Saïda),delivering medical care to people directly
or indirectly affected by the Syrian crisis,
including Syrian refugees, irrespective ofregistration status, vulnerable Lebanese,
Palestinian refugees, and Lebanese
returnees from Syria.
The majority of Palestinian refugees from
Syria have gathered in Sidon at the vastly
overcrowded Ein-el-Hilweh refugee camp,where there are regular security incidents
and clashes between political factions.
The camp has existed since 1948 and is
the largest Palestinian refugee camp in
Lebanon, with an estimated population of
75,000. As many people are experiencing
symptoms of trauma and distress, an
MSF mental health programme at Human
Call hospital and two clinics in the campprovide psychological support. They alsooffer medical and psychological carefor victims of sexual violence. In June, ateam began to carry out consultations forpeople with chronic diseases at Human
Call hospital. Outside the camp, MSF
offers mental healthcare to Palestinian and
Syrian refugees, as well as local residents,
at the Saïda governmental hospital and thePalestinian Red Crescent hospital. A team

60 LEBANON

implemented psychosocial activities
for Syrian refugees living in unfinishedbuildings in the area.
In Tripoli, Lebanon’s second largest cityand home to most of the Syrian refugees,
MSF provided medical care for acute andchronic diseases, reproductive healthcare
and routine vaccinations at Dar al Zahraa
hospital in Abou Samra district. Clinicians,
staff training, emergency managementand donations of medical supplies were
provided to the Tripoli government
hospital. A mental health programme
run out of the government hospital was
handed over to the International Medical

Corps in September. Treatment for acutediseases, reproductive healthcare androutine vaccinations were available at the
Jabal Mohsen and the Bab el Tabbaneh
dispensaries.
Bekaa Valley
A large number of Syrians crossing into
Lebanon enter through the Bekaa Valley.
Many people arriving here have suffered
as a result of disrupted treatment forchronic diseases such as hypertension,
asthma and diabetes. Those who stay in theregion live in overcrowded conditions withhost families or in scattered settlements
in unheated abandoned or unfinished© Nagham Awada / MSF

As a consequence of the huge increase in
new arrivals, tensions grew in 2013 andrefugees were living in dire conditions withvery little assistance. According to Médecins
Sans Frontières (MSF) assessments, access to
hospital care and free medicines for Syrian
refugees were severely limited, and obstetriccare was not available. It was difficult
for them to benefit from health services
because of the charges they had to pay –most had left everything behind and were
struggling to support themselves.

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

An MSF staff member visits a Palestinian family living in Ein-el-Hilweh refugee camp.

International Activity Report 2013

buildings, courtyards and tents. MSF worked
in Baalbek, Majdel Anjar (West Bekaa), andAarsal and Hermel (North Bekaa), providing
treatment for acute and chronic diseases,
as well as reproductive healthcare. Patients
included Syrian and Palestinian refugees,
and Lebanese returnees.
As winter approached, MSF began distributing
blankets, fuel vouchers, washing kits andstoves to the most vulnerable new arrivals.
Teams also helped refurbish public buildingsin Aarsal in order to accommodate newarrivals. Five buildings were finished by theend of the year, two of which were alreadysheltering Syrian families.
Beirut
MSF works in the Shatila camp in Beirut,
where many Palestinians from Syria havesought refuge, focusing on the basic andmental healthcare needs of children,
pregnant women and patients suffering fromchronic diseases. The team set up a system
for supporting patients with emergency
surgical needs, and refers them to two
hospitals with which MSF has agreements.

© Baozhu Wei / MSF

A small team based itself in Southern Lebanon
in February to provide basic healthcare forrefugees. This project is ready to expand if
there is another influx of refugees.

Malak
23 years old, Syrian refugee
My mother came yesterday with my two
younger brothers from Qara. She had avery difficult journey because there wasconstant shelling on the way. It took them
18 days to get here. They moved from
one neighbourhood to another until it
was safe for them to cross the border. My
husband and I took a van with our twochildren (four and two years old) 10 daysago. People were calling on each other inall Qara to leave. The situation was going
to be very dangerous. The first coupleof days we didn’t move; we thought
they were after young men for the army
service. But then we understood that even
women and children would be targeted.
So we left.

A young Lebanese girl has her temperature taken at Bab el Tabbaneh dispensary in Tripoli.

© Alla Karpenko / MSF

No. staff end 2013: 127
Year MSF first worked in the country: 1976
msf.org/lebanon

These two Syrian families live in an unfinished building in the suburbs of Arsal.
LEBANON 61

Médecins Sans Frontières

lesothoThere is also a shortage of skilled
healthcare workers.

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

Key medical figures:• 1,300 patients on first-line ARV treatment• 1,400 births assisted

More than half of allmaternal deaths in Lesotho
are attributed to HIV andtuberculosis (TB).
Although basic healthcare is free, accessing
it is not easy in this mountainous country,
where many people live far from facilities.

Médecins Sans Frontières (MSF) aims
to close some of the gaps in care byproviding integrated HIV and TB care ina programme focused on maternal andchild health. Antenatal, postnatal andemergency obstetric care are offered at St
Joseph’s district hospital in Roma, six basic
healthcare clinics in the lowland area andthree clinics in the more remote Semonkong
area. An ambulance and maternity lodge
provided by MSF, where women cancome to give birth, have also improved
emergency care.
Increased decentralisation of the HIV and TB
component of the programme is providing
people with the specialised care they needcloser to their homes. In order to meetstaffing needs, nurses have been trained toinitiate and follow up HIV and TB treatment
with the supervision of doctors, and village
health workers and lay counsellors havebeen trained in key support roles.

Several advances in the programme weremade during 2013. Beginning in April, allwomen who tested positive for HIV wereput on antiretroviral treatment to preventthe transmission of HIV to their babies.
A community adherence group was also
piloted in one health centre. Here, patients
get together to discuss concerns and pool
resources so that only one of them, on arotating basis, has to collect the medicines
for the entire group. Technologicalimprovements were made with the
installation of CD4 testing machines(the CD4 count is an indicator of an HIV
patient’s immunity level) in nine healthcentres, and the introduction of a rapid TB
test (GeneXpert).
MSF was also granted permission to
expand viral load monitoring within its
programme ahead of changes in thenational protocol. Measuring the amountof HIV virus in the blood is used toascertain when first-line HIV treatment has
failed and a patient needs an alternative
drug regimen.

© Peter Casaer / MSF

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

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

62 lesothoInternational Activity Report 2013

LIBYA

Libya’s health system isgradually recovering from the2011 conflict, but the violence
has had a lasting effect on
many people’s mental health.
The World Health Organization estimatesthat more than a third of Libyans weredirectly and/or indirectly exposed to theconflict. The prevalence of severe posttraumatic stress disorder was estimatedat 12.4 per cent and severe depression
at 19.8 per cent in 2012.
In August 2013, Médecins Sans Frontières(MSF) opened a mental health centre in
Tripoli, the country’s capital, to help people
suffering from physical and mental healthproblems related to violence. The centre
treats people who have been affectedby any form of violence, be it physical,
psychological, sexual or conflict-related.

Designed to provide comprehensive care
for a broad spectrum of mental disorders,the centre takes a multi-disciplinary
approach across psychiatry, psychology
and medical services. The team also trains
doctors from the Ministry of Health andhas established a referral system from basic
healthcare facilities and from Libyan andinternational NGOs.
Emergency support
An outbreak of methanol poisoning inMarch killed approximately 90 people in
Tripoli and resulted in the hospitalisation ofaround 1,000. MSF sent toxicology experts
from Norway to offer technical assistance tothe Libyan Ministry of Health and provided
supplies of the antidote fomepizole, whichacts by blocking the toxin produced bymethanol poisoning. MSF toxicologists also
carried out training for medical staff at
Tripoli Medical Center and Tripoli Central
Hospital to improve diagnosis and treatment
in case of future outbreaks.

Cities, towns or villages where MSF works

Key medical figures:• 3 00 individual and group mental
health consultations

A team provided support to the Sebha
Medical Center in the south of the country
in September, when the facility treated anumber of migrants suffering from burns
as a result of a traffic accident. Medical
supplies and materials needed for burnmanagement were delivered, and staff
received training in the appropriate clinicalmanagement of burn patients.

No. staff end 2013: 35 | Year MSF first worked in the country: 2011 | msf.org/libya

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

Key medical figures:• 9 00 births assisted• 4,800 patients treated for malaria

Tropical cyclone Haruna
struck the southwest
coast of Madagascar on 22
February, causing extensive
flooding and resulting in thedisplacement of more than
10,000 people.

People in the cities of Tuléar and Morombewere particularly affected by the cyclone.
Several aid agencies responded, including
a team from Médecins Sans Frontières(MSF) that ran mobile clinics and donateddrugs to facilities in the cities and to healthcentres in the surrounding areas until
mid-April. From February to May, a teamalso helped health authorities respondto a spike in malarial infections in Tuléar,
Morombe and Betioky. A total of 5,761
consultations were carried out.
Governmental budget cuts to social
services following the 2009 presidential
coup have severely affected the country’s
health sector. A policy of free healthcare
access for those in need was officiallyabolished in 2012. International donors
also remain reluctant to release funds for
non-emergency situations. Meanwhile,
people in remote regions are unable toaccess the services they need because of
the distances to health facilities.

Improving healthcare in Androy region
Since 2011, an MSF team has been
improving patient care in the remote
Androy region. Clinical care and drugs
are dispensed through Bekily hospital’s
emergency room, inpatient department,
and antenatal and maternity unit.
Medicines, staff training and consultations
are also provided in two health centres.
Patients receive treatment for a rangeof health concerns such as malaria andtuberculosis, as well as for schistosomiasis(bilharzia), a curable parasitic disease
endemic in Madagascar. In addition, MSF
works with the Centre for the Testing andTreatment of Tuberculosis, testing, raisingawareness and carrying out consultations.
During 2013, 70 new patients wereadmitted for treatment.

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

LIBYA | MADAGASCAR 63

Médecins Sans Frontières

malawiRegions where MSF has projects

Malawi is largely dependent oninternational aid for healthcare.
Seventy per cent of general
health services and 99 per centof antiretroviral (ARV) coverageare donor-funded.
Malawi’s HIV rates are among the 10 highest
in the world: more than one in 10 people
are estimated to be infected. The healthcare
system is chronically underfunded and there isa severe shortage of skilled workers – a 61 percent vacancy rate for clinical staff. Médecins
Sans Frontières (MSF) has therefore been
supporting the HIV response, improving carefor patients, and also aiming to strengthen
the existing health system through staff
training and technical support, innovativeand progressive treatment models, and byimplementing operational research.
Chiradzulu programme
The HIV programme based in Chiradzulu
district, and decentralised via 10 healthcentres, had more than 28,000 patients
receiving ARV treatment this year. In
mid-2013, the first point-of-care viralload test was installed in a rural healthcentre, thanks to a UNITAID grant. This
test measures the amount of HIV virus in
the blood, which increases when first-line
treatment fails, so patients can be switched
to a different drug regimen.
An MSF study in Chiradzulu showed that 65.8
per cent of people needing ARV treatment werereceiving it, and a population-based survey
revealed that there was also a very low levelof new infections (0.4 per cent), suggestingthat the large distribution of HIV treatment
has played a role in reducing transmission.

© Sydelle WIllow Smith

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

Marita Saga’s HIV status is classed as undetectable after she successfully adhered to her ARV
treatment regimen.

Nsanje project
MSF started providing mentorship andimproving health services in Nsanje andChikhwawa districts in the far south of thecountry in 2010. In 2013, MSF withdrew
from Chikhwawa and expanded its workin Nsanje, focusing on the needs ofspecific vulnerable groups. Early treatment
through a ‘test and treat approach’ was
implemented for sex workers, couples
where only one partner had HIV, and HIVpositive breastfeeding women. Preventionof mother-to-child transmission of HIV was
also fully integrated in all 14 health clinics.
A total of 50 health workers were mentored
in 14 sites and 88 per cent of themcompleted the mentorship programme.
Thyolo programme handover
The scheduled handover of first-line HIVtreatment in Thyolo was completed, withthe bulk of the HIV services now being
delivered by the Ministry of Health. MSF
remains in Thyolo to conduct operational
research, to help expand community ARVtreatment groups, and to provide technicaland clinical services for people in need ofadvanced or specialised HIV care.
Developing capacity for hard-to-reachrural areas
By the end of 2013, 49 students hadenrolled in MSF’s Rural Human Resources

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

64 malawifor Heath (HRH) Scholarship Programme.
With this programme, MSF addresses
the shortage of health workers in theunderstaffed, hard-to-reach areas ofThyolo, Nsanje and Chikhwawa districts
by recruiting local students and paying fortheir training as mid-level health workers.
In turn, the students agree to work for thehealth ministry in their home areas for atleast five years.

David
Chiradzulu
I have been on antiretroviral treatment
since February 2002. Two months ago
was the first time I got my viral load
measured. Before, I only had my CD4
cells counted. So after more than 11
years, I am happy to know that myviral load is undetectable and that mytreatment is working. I am also only
taking one drug a day now and I feelvery good!

International Activity Report 2013

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

Key medical figures:• 3 08,100 outpatient consultations• 2,400 births assisted

Although the situation
stabilised somewhat in Maliin the second half of the year,
many people are still afraid toreturn home. The 2012 crisis
has furthered weakened
the healthcare system,
particularly in the north.
Many health workers have fled the country
and access to adequate medical care remains
a significant issue throughout Mali, evenin the south. Malnutrition and malaria are
persistent health concerns.
Early in the year, sporadic attacks andfighting around Gao caused people to fleein fear of air strikes and reprisals. Somefamilies left the country while others foundshelter in small villages or withstood harshliving conditions in the bush. Médecins Sans
Frontières (MSF) provided basic healthcare
at several health clinics in the region. At the
beginning of the year, teams were working
in Chabaria, Wabaria and Sossokoira andservices began at Bazi Haoussa health clinic
in June. All these activities had been handed
over to other NGOs and development
agencies by the end of the year.

health situation. It is difficult for people toreach health facilities, particularly when
they have to travel along roads targeted byarmed gangs. MSF works in all departmentsof the 60-bed Timbuktu hospital, Niafunké
hospital and five outlying health centres.
A total of 91,975 consultations wereconducted for patients mainly sufferingfrom malaria, pregnancy complications,
respiratory infections and chronic diseases.
Paediatric care
In the south, MSF continued acomprehensive paediatric programme in
Koutiala, Sikasso state, in conjunction with
the Ministry of Health. A free healthcare
package is aimed at ensuring children’s
growth and development and reducing
hospitalisation. MSF manages the paediatricunit in Koutiala hospital, where over
5,300 patients were admitted, including
more than 5,000 children with severeor complicated malnutrition. Teams also
provide basic healthcare in five peripheral
health centres, where some 82,000 medical
consultations were undertaken, more than athird involving malaria, and 3,460 children
with severe malnutrition received treatment.
Preventive and curative paediatric careis also offered in the Konseguela healtharea, where children receive healthcare
and preventive measures, including afull package of vaccinations. Teams haveobserved a reduction in acute severe
malnutrition and stunting in the children
participating in the programme.
MSF implemented Seasonal Malaria
Chemoprevention during the hightransmission period between July andOctober. On average, around 163,000
children were given treatment at eachof the four rounds and it is estimatedthat approximately 87 per cent ofchildren received at least three of thefour distributions. The number ofchildren suffering from uncomplicatedmalaria in 2013 was 31 per cent lesswhen compared to the previous year.
Severely malnourished children received
medical care from MSF in Mopti region.
The project, which had opened in 2012,was handed over to Save the Children in
March. Before, during and after thefighting erupted in northern Mali, MSF
worked in Mopti and Douentza districts,
where the focus was on maternal andchild health, basic healthcare and surgery.
Teams worked in a referral centre in
Douentza and in five basic healthcare
centres: Konna, Boré, Douentza, Hombori
and Boni. These activities had all been
handed over to the Ministry of Healthby late November.

No. staff end 2013: 610 | Year MSF first worked in the country: 1992 | msf.org/mali© Paolo Marchetti

A team also worked in the 39-bed Ansongo
hospital, south of Gao, vaccinating children
and providing outpatient and inpatient
services, reproductive healthcare andemergency surgery. More than 8,500
children were vaccinated against measles.
Healthcare in Timbuktu
Insecurity in and around Timbuktu
contributed to a deteriorating food andWaiting to be seen at the MSF-supported health centre in Konna.

MALI 65

Médecins Sans Frontières

mauritania
In January, another 15,000 refugees escaping violence inMali crossed into Mauritania, joining those already settled
in precarious conditions at Mbera camp.
The presence of armed groups in Mali has
instilled fear and pushed thousands ofrefugees into Mauritania. By early 2014,
over 59,000 people had settled in the
middle of the desert, and ethnic tensions
in northern Mali have quashed any hopesof a swift return home.

a report calling on aid organisations to

Refugees receive healthcare through ahealth post at the border in Fassala –which also screens children aged from six
months to five years for malnutrition – andthrough three health centres in Mbera
camp, all supported by Médecins Sans
Frontières (MSF). Teams carried out some
1,800 consultations each week in 2013.

to eight weeks in the camp, and an average

The living conditions in the camp are very
difficult and people rely on aid to survive.
In April, MSF released Stranded in the Desert,

for referral to the hospital in Néma. MSF

meet the basic needs of refugees in Mbera.
The majority of the diseases treated inside
the camp are preventable, and are primarily

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

Key medical figures:• 168,600 outpatient consultations• 3,900 people treated in feeding centres

caused by a lack of clean water and food.
A comparative data analysis revealed thatchildren developed malnutrition after sixof 300 severely malnourished children weretreated there every month.
MSF also supports Bassikounou health centre,
where an operating theatre was set up toprovide emergency surgery for refugees andthe host population, and to stabilise patients
carried out 160 interventions this year, themajority of them emergency responses.

Azarra*40 years old, from Timbuktu
It took us two days to arrive in Fassala; wewere tired but we were alive and safe. That
was the most important thing. Now, wehave to adapt to life in Mbera camp but it
is very difficult for us … I was poor in Mali
but here it is even worse, I have absolutely
nothing and I feel like a complete stranger,
far from my own country. I want peace toreturn to the north so that I can finally goback home.
*

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

MOROCCOhowever, has meant that the country has
become an unexpected and sometimes
difficult final destination for many of them.

Cities, towns or villages where MSF works

MSF handed over its migrant
health projects in Morocco.
There is a steady flow of migrants fromAfrica – many of them coming fromwar-torn countries – making their way
to European countries through Morocco.
The reinforcement of European borders,Médecins Sans Frontières (MSF) openeda programme in 2002 to address thepoor access to healthcare and inhumane
treatment that migrants experience, andhas spoken out about their plight on several
occasions, including in a report publishedin 2013, Violence Vulnerability and Migration:
Trapped at the Gates of Europe.
In 2012, MSF started winding down a projectin Rabat which supported trafficked people– mainly women, and many the victimsof sexual violence – and the programmes
facilitating access to healthcare for migrants
in Oujda and Nador. The handover process tolocal health and human rights organisations
was completed in February 2013. The decision

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

66 MAuritania | morocco

to close the Morocco programme was basedon the fact that access to healthcare for
sub-Saharan migrants has improved, andthat local organisations have emerged to help
ensure that migrants get the healthcare theyneed and that their rights are respected.

Beatrice
52 years old
They sent us to Médecins Sans Frontières,who told us we should do the tests forHIV. It’s me who is a victim; my children
are in good health. When I started tocry the doctor encouraged me. She told
me that it’s good to know, because now
that we know they can help me with thetreatment.

International Activity Report 2013

mexicoCities, towns or villages where MSF works

Ongoing violence,
mainly linked to criminalorganisations involved in
the drug trade, has serious
health consequences forvulnerable populations,
including economic migrants
and people fleeing threats
and attacks in their homecountries.
The estimated1 91,000 migrants fromCentral America who journey across
Mexico by freight train each year, hoping
to reach the United States, are at particularrisk. Many become victims of assault,
abduction, torture, sexual violence and/or
murder. People living in areas affected byviolence also suffer from a lack of access to
medical care, due in part to overwhelmed
emergency services. Healthcare resources
are generally scarce for victims of violence,
particularly of sexual violence, and theirmental health needs go largely unmet.
Teams from Médecins Sans Frontières(MSF) are addressing the medical andpsychological needs of victims of direct
and indirect violence. Programmes
continued this year in Ixtepec (Oaxaca
state), Bojay (Hidalgo state), and Apaxco
and Tultitlán (México state). The activities
included basic healthcare, reproductive
and sexual health services, and mental
healthcare – during the year there were1,389 trauma consultations. Staff also madehospital referrals and ensured emergency
cases were followed up. The programme in© MSF

Key medical figures:• 12,700 outpatient consultations• 1,600 individual and group mental
health consultations• 2 2 patients treated after incidents ofsexual violence

Migrants from Central America travel across Mexico by train in a bid to reach the US.

Arriaga, Chiapas state, was closed in April,
as healthcare services for migrants werehanded over to the government.
Dengue emergency
Early in the year, the state of Guerrero andparticularly the city of Acapulco saw a peakin the number of dengue cases, a viral
infection spread by mosquitoes. Healthprogrammes were put in place to combat
the illness but were later suspended insome of the most vulnerable areas of
Acapulco because of security incidents.
In October, MSF worked with local
institutions such as the church to promote
dengue prevention and education, hiring
and training 140 people from the area andfumigating 7,200 houses.
Chagas disease

A Guatemalan transmigrant*
I was kidnapped for 16 days near
Tenosique … They talked with mybrother-in-law, as they forced us togive them the phone numbers of ourfamily. They asked for US$5,000 inorder to let us go. Once the ransom
was paid, they dumped us in Boca delCerro without clothes and with bruises
all over our bodies. I was on the hill all
day and then I had to walk all night toreach a town. Some people helped me
and took me to the nearest hospital …
I returned to Guatemala and, 15 days
later, I was again crossing into Mexico.
* For security reasons, the person’sname has been withheld.

Chagas, a parasitic disease that can beasymptomatic for years but may cause
debilitating complications and death if left
untreated, is now recognised as a healthcare
priority by the government. An MSF Chagas
project, designed in coordination withhealth authorities and integrated into the
public healthcare network of San Pedro dePochutla, Oaxaca state, was being set up at
the end of the year.
1 igrantes en su paso por México: nuevas problemáticas,
Mrutas, estrategias y redes. Ana María Chávez Galindo
and Antonio Landa Guevara.

No. staff end 2013: 62 | Year MSF first worked in the country: 1985 | msf.org/mexico

mexico 67

Médecins Sans Frontières

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

Médecins Sans Frontières(MSF) has been supporting
the Ministry of Health toincrease the number ofpeople on antiretroviral(ARV) treatment for HIV.
Despite progress in Mozambique’s national
response to HIV/AIDS, the virus stillaccounts for 40 per cent of adult deaths and
14 per cent of child deaths in the country.
One significant barrier to people getting
appropriate healthcare is a lack of skilled
medical professionals. MSF has developed
innovative solutions in the managementof HIV to overcome this obstacle, by
empowering patients as well as lower level
healthcare workers.
Comprehensive treatment for HIV
patients co-infected with tuberculosis(TB) was provided through programmes
in Chamanculo and Mavalane districtsin the capital city, Maputo, and in Tete.
Specialised care was given to people withmore complex conditions, such as drugresistant TB (DR-TB), and those who had
not responded to first-line ARV treatment,or had Kaposi’s sarcoma or cervical cancer.
Treatment for children was also includedin the programmes. MSF is supporting
implementation of a policy to provide all
HIV-positive pregnant women, and children
under five, with ARVs.

© MSF

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

There was extensive flooding at the beginning of the year in Gaza province and health facilities
were disrupted. MSF supported the Ministry of Health with extra staff and medical supplies.

In Chamanculo, MSF worked in five healthcentres and in one referral centre forcomplex HIV/AIDS cases, all run by the
Ministry of Health. MSF also supported theMavalane project which registered patientson ARV treatment in four health centres andone health post; six per cent of the patients
who registered were under 15. MSF has
another team supporting the Primeiro de
Maio health centre, which provides services
specifically for adolescents. More than 600
young people were offered counselling,peer education, testing and linkage to careeach month.

affected, and health facilities, including
the main hospital, were disrupted. MSF
deployed an emergency team to support
the health ministry with extra staff
and medical supplies. During the twomonth emergency programme the teamcarried out more than 23,000 medical
consultations. Almost half of these related
to HIV/AIDS and TB. The rest of the patientswere mainly suffering from respiratory
infections, diarrhoea and malaria.

Viral load technology, considered the ‘gold
standard’ for monitoring the amount of HIV
virus in a patient’s blood, was introduced in
Maputo and Changara district in 2013. An
MSF team provided staff training in supportof the Ministry of Health’s Acceleration Plan
to make ARV treatment available to more
people in need.

Cured of multidrug-resistant TB in Maputo

Flooding in Chokwe
At the beginning of the year, heavy rainscaused extensive flooding. Gaza province
and the city of Chokwe were particularlyCarla
I feel like I was born again. It was morethan two years of treatment, which finallyhas ended. I thought about giving up
the treatment and I even thought aboutsuicide. Today I have hearing problems andI am forced to use a hearing aid to be able
to listen. Besides that, my vision problem
got worse. It was a big challenge for me,
but now I am cured of drug-resistant TB
and I can proceed with my dreams.

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

68 MOZAMBIQUE

International Activity Report 2013

MYANMAR
Regions where MSF has projects

There is an ongoing medical
humanitarian crisis in
Rakhine state, and there
are concerns about theincreasing challenges facedby those assisting people inneed of healthcare.
While violence and segregation continue
in Rakhine state, more than 100,000
people remain displaced, living in appalling
conditions in camps, and almost entirely cut
off from healthcare and other basic services
including clean water. Communities living
in isolated villages and townships, mostin Northern Rakhine state, also face great
difficulty in accessing medical services. As
the minority Rohingya remain extremely
vulnerable, Médecins Sans Frontières (MSF)
is striving to overcome significant challenges
and obstacles and provide free, high-quality
medical assistance to those most in need.
Working closely with local communities,
the team has offered basic healthcare,obstetric services, mental healthcare,treatment for HIV/AIDS and tuberculosis(TB), and supported emergency referrals.
MSF also treated 10,816 malaria patients,
84 per cent of the nationwide total. Staff
worked in 10 townships across the state,in fixed and mobile clinics in 24 camps
for displaced people and in a number ofisolated villages.
Throughout 2013, MSF continued to urge
the government and the communities of
Rakhine to work together with international© Eddy McCall / MSF

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

A drug-resistant TB patient receives treatment at MSF’s clinic in Lashio, Shan state.

organisations to ensure that all patients inneed of emergency medical services could
access the necessary care, regardless of theirbackground or ethnicity.
HIV and TB programmes
MSF is the largest provider of HIV/AIDS carein Myanmar, treating over 33,000 patientsin a country where fewer than one in threepeople who need antiretrovirals receive
them. People with HIV are more likely tohave active TB, and multidrug-resistant TB(MDR-TB), which is harder to diagnose andrequires two years of arduous treatment, isalso an emerging health problem.
MSF runs projects treating HIV and TB
patients in Kachin, Shan and Rakhine
states, as well as in Yangon and in Dawei
in Tanintharyi region. After three years ofcollaboration with the prison department
in Yangon, MSF officially closed its HIV
project in Insein prison in December. MSF
had provided counselling and testing to
1,400 prisoners and conducted more than
15,000 outpatient consultations since theprogramme began in 2010.
In 2012, MSF started a programme in
Yangon in conjunction with the Ministry of
Health, which continued this year, treating
58 patients with MDR-TB.

Ko Min Naing Oo
37 years old, Yangon.
TB first came into my life in June 2000
and kept coming back over the next 13
years, getting harder and harder for the
doctors to treat it. I took many different
kinds of pills and injections over the years
but nothing seemed to get the diseaseout of my body for good.
Before I started, I was able to carry out
normal physical activities, but after I felt
tired and exhausted. The side effects fromthe treatment were strong and it was
really difficult to manage. I felt dizziness,
pain in my buttocks from all the injections
and had problems with my hearing. I felt
nauseous when I smelled cooking, foundmyself easily getting angry, constantly
weak and tired, always having diarrhoea,
and experiencing hallucinations.
I tried to forget my emotional pain by realisingthat there are other people who were moresocially, economically disadvantaged and withworse health than I was. I often reminded
myself that I needed to get back my good
health in order to save my family from amiserable situation.
From the MSF blog, ‘TB & Me’

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

MYANMAR 69

Médecins Sans Frontières

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

Seasonal Malaria
Chemoprevention (SMC)
was used for the first timein Niger in 2013. Combinedwith malnutrition screening
and treatment, this strategy
aims to reduce sufferingand child mortality.

Regions where MSF has projects

Aiming to shift from malaria treatment toprevention as much as possible, teams from
Médecins Sans Frontières (MSF) widened
the scope of prevention activities in 2013.
SMC, a new strategy which has proveneffective in Chad and Mali, was used in
Niger for the first time. For four months
during the rainy season, children received
a course of antimalarial medicine in the
districts of Guidan Roumdji and Madarounfa(Maradi region), Bouza and Madaoua(Tahoua region) and Magaria (Zinder
region). On average, around 225,000
children received treatment at each of thefour rounds and dependant on location
coverage has been estimated at between
94 and 99 per cent.
While the usual methods of mosquito biteprevention, including the use of nets andsprays remain the basis of the programmes,
SMC is proving useful to protect the healthof children at risk from severe malaria where
there is limited access to care.

70 niger© Narcisse Wega / MSF

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

Children waiting with their mothers for a course of antimalarial medication.

Teams involved in the SMC campaign
undertook it alongside activities forchildren with malnutrition. MSF has
ongoing nutrition programmes providing
mobile screening and treatment, as well as
hospitalisation for severely malnourishedchildren, in all these regions.
Delivering essential healthcare closer tohome is the goal of all MSF’s malaria andnutrition programmes, a strategy known
as PECADOM (Prise en Charge à Domicile).
In Bouza and Madaoua districts, Tahoua
region, MSF provided home-based malaria

diagnosis and treatment for pregnant
women and children through community
health workers based at 111 health posts.
These staff are trained by doctors to detectand diagnose malaria, treat simple cases andrefer complicated ones. They also examine
children’s nutritional and vaccination status.
Following a measles outbreak in March in
Madaoua and Sabon Guida, MSF launched avaccination campaign in May which reached
84,460 children under the age of 14.
A new approach is also being adopted tohelp prevent severe acute malnutrition inInternational Activity Report 2013

some villages in Tahoua region. The mamans
lumières receive training from MSF teams on
how to prepare food for maximal nutrition.
The mothers, in turn, share what they learn
with peers in their villages.
In Madarounfa district, Maradi region, where
MSF provides paediatric care in conjunction
with the Nigerien organisation FORSANI(Forum Santé Niger), a team also ran amalaria prevention programme for children
under two years old in three of the five
health areas. Nutritional supplements were
provided, mosquito nets were distributed,
and children received routine immunisations.
Following heavy rains that destroyed homes
and crops in Madarounfa in July, MSF
distributed kits with mosquito nets, water
cans, soap and blankets to 6,630 people.
In Magaria, Zinder region, MSF continued
to focus on decentralising points of care,thus making treatment for malnourishedchildren more accessible. Consultations
were held at ‘health huts’ and in people’s
homes, eliminating their need to travel tolarger facilities and allowing some of themost vulnerable people to obtain care in
their own communities. The developmentof intermediate treatment and observation
at health centres in Magaria, Dungass andBangaza enabled staff to improve triage andreduced the number of referrals to hospital.
MSF has also supported an inpatient feeding
centre at Zinder hospital for many years,
and this was handed over to the Ministryof Health at the end of 2013. Teams remain
ready to open an additional 450-bed
treatment centre during peak periods ofmalnutrition.
Caring for Malian refugees
Armed conflict in Mali since 2012 has led
to massive population displacement as
people cross national borders in searchof safety. MSF teams provided basic andspecialist care, maternal healthcare andimmunisations to Malian refugees and thehost community in Tillabéri region. A totalof 57,500 consultations were carried out.
The team responded to a cholera outbreakin May, treating 1,500 patients. Refugee
healthcare was handed over to the Qatar
Red Cross/UNHCR in September. MSF
also worked in the Abala camp, about 250
kilometres north of Niamey, Niger’s capital.
Basic and specialist care was provided to
14,000 Malian refugees in the camp andsome 33,000 local residents. Obstetric andsurgical emergencies were referred to the
district hospital.

Mariana Assoumane
26 years old, Tounfafi village, Madaoua
MSF community workers told us to comehere for the malaria prevention medicine.
We have now realised how important
this treatment is and this is why so many
people come here to take it. My children
usually have malaria. Then their bodies
burn with fever, causing seizures, vomiting
and diarrhoea. This year … there arefewer malaria cases.

© Ramón Pereiro / MSF

No. staff end 2013: 1,879 | Year MSF first worked in the country: 1985 | msf.org/niger

In Bouza district, MSF is working to improve healthcare for children under five and pregnant women, focusing on early treatment andprevention, particularly in malnutrition and malaria.

niger 71

Médecins Sans Frontières

NIGERIAremaining villages – for example remove
lead-contaminated soil and mining wastefrom villages, wells and ponds – and treat
the children affected by lead poisoning
who live there.
Providing maternity care andfistula surgery

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

Key medical figures:• 18,600 outpatient consultations• 6,400 births assisted• 1,500 surgical interventions

Health indicators for people
living in northern Nigeria
remain poor and there are
frequent outbreaks of measles,
meningitis and cholera.
An upsurge in violence in 2013 added to thedifficulty of obtaining adequate healthcare.
Threats posed by Ansaru and Boko Haram
are affecting security for Nigerians as wellas aid organisations.

Pregnant women in Jigawa state have
limited access to maternity services, anddeaths due to pregnancy and childbirth
are high. It is also estimated that between
400,000 and one million Nigerian women
live with obstetric fistula, a consequenceof birth complications that causes not only
pain but incontinence, which in turn often
results in social stigma. MSF’s programme
in Jahun hospital cares for women withobstetric emergencies and offers surgicalrepair of fistulas. More than 8,390 women
were admitted to the obstetrics unit and
370 women underwent surgery for fistulas.
A maternal and child health programme
continued in Goronyo, Sokoto state, where
many people suffer from malaria. The
project closed in June due to insecurity.

Emergency care in Borno
The ongoing violence in the northeastcaused population displacement to otherstates, including Abuja, and people also fled
to countries such as Niger and Cameroon.
MSF provided medical care to 3,750 people
in Baga and Chibok. The team ended theintervention, which lasted for 10 weeks, in
October because of insecurity.
Measles and cholera
A measles outbreak spread through Katsinastate in January and MSF donated medicine
to 300 public health clinics, thus providing
treatment for 14,290 people. More than
217,490 children were vaccinated against
measles in Bakori, Sabuwa, Funtua,
Dandume and Faskari.
Between March and July a team responded
to a measles outbreak in Kebbi, Sokoto andZamfara states, treating 47,585 people anddonating 3,600 treatment kits. Over 2,000
people received cholera treatment in Riniand Gusau between September and the endof December.

No. staff end 2013: 649 | Year MSF first worked in the country: 1971 | msf.org/nigeria

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

The rising price of gold has led to renewedinterest in mining in Zamfara state, where
unsafe practices have resulted in a numberof villages being contaminated with lead.
The gold deposits contain unusuallyhigh concentrations of the metal, andas the rocks are ground into sand highly
contaminated dust fills the air. Lead canenter the body through the lungs ordigestive tract and is particularly harmful
to children, potentially causing brain
damage, kidney problems and death. MSF
teams screened more than 1,570 children
in 2013 and provided some 10,800 basic
health consultations for children underfive. Since the beginning of the project,
4,804 children have been screened and4,306 treated. MSF continues to lobby atfederal government level to remediate the72 NIGERIA© Ruth Grace / MSF

Lead poisoning in Zamfara

Obstetric fistula patients holding up their art projects on the grounds of Jahun hospital, where
women with obstetric emergencies are cared for and surgical repair of fistulas is available.

International Activity Report 2013

PALESTINEThe Israel–Palestine conflict andinter-Palestinian violence has increased
people’s need for medical and psychologicalcare, and has reduced the availability ofdrugs, medical equipment and services totreat them. Médecins Sans Frontières (MSF)
runs programmes in the Occupied Palestinian
Territory aimed at meeting the needs notcovered by the Palestinian health system.

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

Key medical figures:• 160 surgical interventions• 7,200 individual and group mental
health consultations

Unrelenting violence in Gaza
and the West Bank continues
to have medical, psychologicaland social consequences
for Palestinians.

In Gaza, MSF focuses on plastic surgery,reconstructive surgery and hand surgery forpatients suffering from serious burns, trauma
and other debilitating injuries. MSF specialist
surgeons, anaesthetists and operating
theatre nurses work alongside Palestiniancolleagues in the two main public hospitals.
Most patients are children with burns injuriescaused by domestic accidents, as electricity
shortages force people to find alternativemeans of cooking and heating their homes.
MSF runs a clinic in Gaza City offering postoperative care, including physiotherapy anddressings, to help patients rehabilitate fromtheir surgery.
In 2013, MSF started supporting the
Ministry of Health on intensive care,by implementing training programmes
for medical and paramedical staff. An
MSF medical team is working in close
partnership with Nasser hospital medical
staff, providing bedside clinical instruction,
mentoring and technical support.
Mental health support
Exposure to conflict violence has a severe
impact on people’s mental health. In Nablus,
Hebron and East Jerusalem, MSF teams
continue to provide psychological andsocial support to direct and indirect victimsof violence. Almost half of the patientsare under 18, and most are suffering fromanxiety-related conditions. Depression,
behavioural issues and post-traumatic stressdisorder are common.

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

Papua New Guinea

Domestic and sexual violence is a medical-humanitarian
emergency in Papua New Guinea (PNG), with consequences
at individual, family and national level.

There are very high levels of sexual,
domestic, social and tribal violence
throughout PNG, and yet care for victims
remains inadequate and, in many places,
nonexistent. A durable model for prevention
or treatment has yet to be identified, andsurvivors need access to free, quality,
confidential and integrated medical care.

Cities, towns or villages where MSF works© Kate Geraghty / Fairfax

Key medical figures:• 3 4,700 outpatient consultations• 3,600 individual and group mental
health consultations

This patient at Tari hospital was attacked
by her husband.

In June, MSF handed its project treating
people suffering from high levels of intimate
partner violence and sexual violence backto Angau Memorial General Hospital in Lae,but continued to provide technical support.
The MSF team at Tari hospital in the southernhighlands performed 830 major surgicalprocedures this year, and also continued
to run a family support centre where 1,231
consultations were conducted. March marked
the launch of the Port Moresby Regional
Treatment and Training project, where staff
were trained to provide the integrated careavailable in Lae. Five essential services arecovered during one appointment: emergency
medical care for wounds, psychological firstaid, preventative drugs for HIV and othersexually transmitted infections, emergency
contraception and vaccinations to prevent
hepatitis B and tetanus. The aim of the projectis to help more people experiencing domestic
and sexual violence to access the care theyneed through health centres and family
support centres throughout the country.
Buin Health Centre
Access to healthcare in Buin district has
improved significantly in recent years,
and this combined with increased support
from the provincial health services and
AusAID (Australian Agency for International
Development) means that MSF is starting toplan the closure of its project there. Teams
carried out 3,894 antenatal consultations,979 family planning consultations and assisted
870 births at the Buin Health Centre this year.

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

PALESTINE | Papua New Guinea 73

Médecins Sans Frontières

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

Providing comprehensive
emergency healthcare topeople in remote regionsof Pakistan is a priority, yetaccessibility and security
are a constraint for both
Médecins Sans Frontières(MSF) and the patients.
In addition to the general gaps in thehealthcare system, people living in remoteareas and those displaced or directly
affected by conflict suffer from a criticallack of medical services, in particularemergency treatment and maternal andchild care. MSF runs programmes to try
to address these needs.
Khyber Pakhtunkhwa province
Hangu district borders three tribal agencies,
North Waziristan, Orakzai and Kurram.
These areas are among those most exposed
to violence since military operations werelaunched by the government in responseto an aggressive campaign by the Pakistani
Taliban, which started in 2007. There arealso sporadic clashes between the Sunniand Shia communities in the district. MSF
teams manage the emergency and surgicalservices in the Hangu Tehsil Headquarters
hospital. They admitted more than 25,000
patients to the emergency room andperformed 1,407 surgical procedures in
2013. Within the hospital’s maternity unit,
MSF midwives support Ministry of Healthstaff, assisting with complicated deliveries,
and providing training on obstetric
procedures and hygiene protocols.
MSF runs a 32-bed private women’s hospitalin Peshawar, which opened in 2011. It offers
free, emergency obstetric care, including
surgery. A third of the 3,717 admissions
this year were displaced or refugee women.
A referral network has been developed
among the district’s rural health centres,
communities and camps for displaced
people or refugees, and is expanding to
the neighbouring tribal agencies. A fivebed newborn unit opened, and a further
10 beds will be added in 2014.

74 pakistan

Regions where MSF has projects
The maps and place names used do not reflect
any position by MSF on their legal status.

In Lower Dir, there was a dramatic increasein patient numbers in the emergency andresuscitation rooms at Timurgara district
hospital. More than 100,000 patients cameto the emergency room, an increase of 33
per cent over 2012, and more than 22,000
patients were treated in the resuscitation
room. MSF provides obstetric care witha focus on complicated deliveries, andassisted around 7,000 births in 2013. Teamsalso support the blood bank, improvesterilisation and waste management, andorganise health education activities – some
56,000 health and hygiene education
sessions were carried out. In addition,
MSF conducted more than 5,300 mental
health consultations and 26,900 motherand child sessions.
Federally Administered Tribal Areas (FATA)
Conflict in Kurram Agency has led to theisolation of local communities, closure of
supply routes and the near-collapse of thestate-sponsored healthcare system. Measles
is very common in Kurram, highlighting
gaps in basic health services such as
vaccination. The area is hardly accessible tointernational staff, and local MSF personnel
provide paediatric services at hospitals in
the Sunni enclave of Sadda and the Shia
community of Alizai. In 2013, a military
offensive launched against the Tirah Valley
in the neighbouring Khyber Agency led tothe displacement of thousands of families
to New Durrani camp, and around Sadda.
In Bajaur Agency, years of violence have left
the population with limited access to basic
healthcare. In March, a team of local MSF
personnel began running mobile clinics
to facilities in Talai, Kotkay and Derakai,providing basic healthcare and monitoringfor cases of infectious illnesses such as
measles and diarrhoeal diseases.
Balochistan
Pakistan’s largest province is remote andrural, and hosts many Afghan refugees.
Healthcare indicators are among thecountry’s worst, as delays in obtaining
medical help are common and are accounted
for by geography, insecurity in the region
and a low density of medical services.
In Quetta, the paediatric inpatient medicalcare provided by government and private
hospitals is insufficient to meet the
population’s needs and many people cannot
afford the fees charged. MSF offers medicalcare in Quetta paediatric hospital, and treatsmalnourished children in ambulatory andinpatient feeding programmes. Neonatology
services, and family and individual
counselling sessions are also available.
An MSF team runs a mother and childhealth centre in nearby Kuchlak, offering
outpatient treatment, including nutritional
support, for children under five. Thereis a birthing unit, and a system to refercomplicated emergency obstetric cases to
Quetta. Other services include psychosocial
support and counselling, and screening andtreatment for cutaneous leishmaniasis.
Comprehensive emergency obstetric,
neonatal and emergency care is provided
at the Chaman District Headquarters
hospital, where 17 per cent of patientstreated in the emergency room in 2013
were victims of conflict. More than 2,500
measles vaccinations were given, in close
collaboration with the Ministry of Health.

International Activity Report 2013

In the eastern districts of Jaffarabad andNasirabad, MSF continued to focus onmaternal and child health in programmes
in Dera Murad Jamali hospital andfour health centres. Conflict-related
displacement has exacerbated malnutrition,and vaccination coverage is low. The teamconducted a measles vaccination campaign
with the Ministry of Health and reached7,500 children. More than 9,600 children
were treated in the therapeutic feeding
programme at the Dera Murad Jamali
hospital, and 6,000 antenatal consultations
were carried out.

around the clock. Mental health support
is also available. More than 35,000 basic
healthcare consultations were conducted
in 2013, 7,600 children were screened
for malnutrition and over 80,000 people
participated in health education sessions.

Healthcare in Karachi

Between August and November, teams
responded to outbreaks of both dengue
fever and acute watery diarrhoea in
Timurgara and Swat, a measles outbreakin Upper Dir in June and July, and anearthquake in the Mashkel district of
Balochistan in April. MSF was ready to

On the outskirts of Karachi, the Machar
Colony slum is home to many undocumented
migrants who cannot access medical care.
MSF runs a basic healthcare clinic with SINA
Health Education and Welfare Trust, providing
free basic, emergency and obstetric services

provide assistance following the Awaran
earthquake in September, in the sameprovince, but the Pakistani government did
not think it necessary for MSF to intervene.

Emergency responses
Together with Ministry of Health staff, MSF
treated 110 people for bomb blast injuries
resulting from election-related violence in
Khyber Pahktunkhwa and FATA over fourdays in May. Non-combatants were theprimary victims of the violence.

Faiz Bibi
Kirani village, west of Quetta
My one-month-old baby boy has beensick with pneumonia. He had a high fever
for two days and was wheezing and thenbecame lethargic. My house is far away
and when the baby was unwell during thenight, in the morning I told my husband
I would take the child somewhere –anywhere – for medical treatment. I asked
a tuk-tuk [small taxi] driver and he said
that at the MSF Quetta hospital, I could
have the best treatment for my baby.

© Haroon Khan / MSF

No. staff end 2013: 1,528 | Year MSF first worked in the country: 1986 | msf.org/pakistan

This unhappy patient is being treated in a clinic on the outskirts of Karachi.

pakistan 75

Médecins Sans Frontières

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

The strongest typhoon everrecorded at landfall struck
the storm-prone Philippines on
8 November, killing over 6,000
people and displacing morethan four million others.
A massive local response had already begun
as international aid flowed into the country,
including a team from Médecins Sans
Frontières (MSF) who arrived in Cebu on
9 November. Typhoon Haiyan destroyed
hospitals and clinics and disrupted the publichealth system. Assistance was needed totreat the wounded and provide relief over awide area. It was decided that MSF would fillgaps in emergency care and help rehabilitate
hospitals and clinics so services would beavailable for ongoing healthcare needs.

the hard-hit Eastern Visayas, which still had apartially functioning airport and one partiallyfunctioning hospital. Damaged and blocked
roads, fuel shortages and congested airports
in the country posed logistical constraints
and there were delays in getting supplies topeople in need, particularly during the first
10 days. As many aid organisations were
present around the city, MSF used trucks,
boats, planes and helicopters to reachoutlying areas and assess people’s needs.
Teams set up medical activities and delivered
relief supplies to typhoon survivors on theprincipal islands of Leyte, Samar and Panay,
as well as smaller outlying islands, adapting
aid to fill emerging healthcare gaps as thesituation evolved.
Immediately after the typhoon, MSF
provided surgery and wound dressings,© Laurence Hoenig / MSF

Initially most aid activity was centred around
Tacloban, on Leyte island, the main city in

Regions where MSF has projects

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

© Julie Remy

International Activity Report 2013

Typhoon Haiyan resulted in the death of thousands of people, displaced more than four million survivors and destroyed hospitals and homes.

and also treated patients presenting with
infected wounds several weeks after the
event. Healthcare for people undergoingtreatment for chronic diseases such as
diabetes, hypertension and kidney failure
was also crucial. The psychological impactof the storm itself and of the loss of loved
ones and homes meant that there were
substantial needs for mental health support.
Leyte island
In the city of Tacloban, MSF erected a 60-bed
inflatable hospital with an emergency
room and outpatient department, andprovided surgical, maternal and mental
health services. Teams took mobile clinics
around the city to reach people who could
not visit the health centres. In Palo district,teams worked in the town of Tanauan,
south of Tacloban and in Talosa, distributing
essential relief items to 3,000 families
In the Burauen area of Leyte, a teamsupported the district hospital with staff
and supplies and ensured that water andwaste disposal were in place and meeting
health standards. Staff distributed relief
supplies such as tents, washing kits andmosquito nets, supplied clean drinking
water and offered mental healthcare topeople experiencing severe distress. Morethan 25,200 people received healthcare,

48,500 obtained relief supplies and11,470 accessed mental health support.
Panay and offshore islands
Teams were based in Carles, Estancia and
San Dionisio municipalities on Panay island
and also delivered aid to people residing
on 21 offshore islands. MSF rehabilitated
13 health facilities along the coastal areasof the Panay mainland and on the offshoreislands, to render them functional andable to provide medical services to thosein need. On the offshore islands, MSF
vaccinated 4,650 children against polio, and14,990 against measles. Staff distributed
more than 11,000 relief kits and food for
11,000 families, as well as over 1.2 million
litres of chlorinated water.
The typhoon caused an oil spill in the
Estancia harbour and a team provided
medical care, relief items and some 1,500
tents to people relocated to an evacuation
centre, and also assisted vulnerable families
in the surrounding area.
The Ministry of Health was able to takeover Panay activities from MSF in January
2014. Teams had carried out 12,675 medical
consultations and given mental healthsupport to 3,290 people.

Eastern Samar
The Felipe Abrigo Memorial hospital in
Guiuan, Samar island, was damaged beyond
repair by the typhoon and so MSF set up
a 60-bed tent hospital as a temporary
replacement, equipped with an operating
theatre, delivery room, maternity unit andisolation room. Teams carried out medical
consultations in rural health centres on Samarand ran regular mobile clinics on the smaller
islands south of Guiuan. Many people were
suffering mental health distress and MSF
teams offered psychosocial support to adults
and children through group and individual
therapy sessions. MSF’s water and sanitation
experts ensured that there was proper waste
disposal, and supplied clean water for up
to 20,000 people each day. Tents, cooking
equipment and washing and shelter kits were
distributed among isolated communities
on the four nearby islands of Manicani,
Homonhon, Sulangan and Victory, so people
could begin to reconstruct their homes.
Many acute emergency activities werecompleted by January 2014, yet teams
maintained a strong presence in areas where
health services were severely diminishedand not yet completely rehabilitated. MSF
continued to work out of inflatable medical
hospitals providing surgery, inpatient careand psychological support.

No. staff end 2013: 89 | Year MSF first worked in the country: 1987 | msf.org/philippines

PHILIPPINES 77

Médecins Sans Frontières

paraguay

Medical services for the potentially fatal
Chagas disease, caused by a parasitic
infection transmitted by the triatominebug, are particularly lacking in remote,rural areas such as the Paraguayan Chaco.

Regions where MSF has projects

In December, a three-year
project helping to develop
better awareness, diagnosis
and treatment of Chagas
disease came to an end.

In Boquerón, Médecins Sans Frontières(MSF), in collaboration with the Ministryof Health, piloted an intervention strategy
to bring diagnosis and treatment closer
to Chaco’s most isolated communities.
Activities were integrated into Boquerón
regional hospital, two smaller hospitals, and15 health centres and health posts. Mobile
teams also visited 120 remote communities
that lacked a local health infrastructure.
The project was complemented bycommunity education activities throughout
the country and the training of medical

staff (through workshops and academic
meetings) and those undertaking
entomological surveillance of the bug.
A Chagas School Guide was created incollaboration with groups of teachers, and
196 people were trained to use it as a toolin health education.
In total, over the course of the project,
15,330 people were tested for Chagas
and 1,632 received treatment.
MSF continues to support Paraguayan
health authorities from a distance in thedevelopment of a national protocol for
Chagas diagnosis and treatment. MSF
advocates the delivery of Chagas care within
the basic healthcare system, integrated with
community education and entomologicalsurveillance and control.

No. staff end 2013: 55 | Year MSF first worked in the country: 2010 | msf.org/paraguay

Russian Federation
Years of conflict in the North Caucasus
have left gaps in many areas of thehealth system, resulting in a resurgenceof TB, especially DR-TB. Poor diagnosis,
interrupted treatment and the questionable
quality of the TB drugs available on the
open market are some of the factors
contributing to high drug-resistance levels.
Regions where MSF has projects
Cities, towns or villages where MSF works

Key medical figures:• 6 ,100 individual and group mental
health consultations• 430 patients under treatment for TB

Médecins Sans Frontières(MSF) is working with
Russian health authorities
to address tuberculosis (TB)
and drug-resistant TB (DR-TB)
in Chechnya.

In 2013, MSF, together with the Chechen
Ministry of Health, continued to implement
a comprehensive TB diagnosis andtreatment programme for patients withboth TB and DR-TB. The programme
promotes a patient-centred approach,and as the treatment is arduous and the
management of side effects an importantcomponent, MSF health educators andadherence counsellors provide psychosocial
support to all TB patients and their families.

medical services do not meet the needsof those with acute coronary syndromes
and other cardiovascular emergencies.
In Grozny, Chechnya’s capital, MSF is
improving the cardiac unit in the Republican
Emergency Hospital through staff training
and the purchase of medical equipment
and medicines for specialised treatment.
During 2013, the team conducted further
training on fibrinolysis (the breakdown offibrin, or clots) and improved laboratory
procedures, as well as the quality of
consultations pre- and post-admission.
Providing mental health support
An MSF team continued to offer counsellingto patients in Grozny and communities in
the mountainous districts of Chechnya,
who are still experiencing the psychologicaleffects of exposure to violence and death.

Expanding cardiac care
There is a high rate of heart disease in
Chechnya, but the scale and quality of

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

78 paraguay | Russian Federation

International Activity Report 2013

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

South Africa remains at thecentre of the worldwide
HIV/AIDS epidemic. Morethan six million people inthe country live with HIV.

© Peter Casaer / MSF

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

These Community Health Agents are doing door-to-door HIV testing.

Innovative models of care have been
introduced over the past decade and90 per cent of patients with HIV now
receive treatment through the public
sector. The projects run by Médecins
Sans Frontières (MSF) in 2013 continued
to support the empowerment of people
living with HIV, by giving them more
flexibility in treatment approaches andenabling them to obtain drugs andsupport in their home communities.

January 2011 and September 2013, 231 ARVclubs were established at 10 health facilities in
Khayelitsha, enrolling a total of 7,733 patients.

Khayelitsha

In September, the clubs were handed overto local health authorities and are being
scaled up, thanks to a US$15 million Global
Fund grant. Community-based clubs are
currently undergoing trials.

Khayelitsha, a poor township on the outskirtsof Cape Town, was the site of the firstprimary-level antiretroviral (ARV) treatment
programme in South Africa in 1999, andsubsequent innovations include the ARV
adherence clubs, introduced by MSF in 2011.
One-to-one appointments at the healthcentre are time consuming for patients
who may not have the time to queue forhours to pick up their drugs, and are an
added workload for health professionals
in a country where medical facilities arechronically understaffed. As an alternative,
MSF pioneered adherence clubs that offer
people living with HIV the opportunity to
combine peer support with check-ups anddrug refills at bi-monthly meetings. The
model quickly became popular and between

Research by MSF has found that 97 per centof adherence club members continued theirtreatment, compared with 85 per cent forpatients who qualified for membership but
remained in mainstream clinic care. Club
patients were also 67 per cent less likely toexperience treatment failure.

KwaZulu-Natal
KwaZulu-Natal has the highest tuberculosis(TB) incidence of all the provinces inSouth Africa and TB remains the leading
cause of death for people with HIV. It isalso the epicentre of the HIV epidemic
in the country, with one in four adults
infected. The Bending the Curves projectthat was introduced in 2013 seeks to
implement multiple strategies to address
the high co-incidence of HIV and TB, andreduce the number of incidences in linewith the South Africa National Strategicplan. These strategies include: the rapid
expansion of community-based testing,greater continuity of ARV and TB treatment,
faster TB diagnosis and treatment, andthe aggressive promotion of prevention
methods, including voluntary malecircumcision and earlier treatment of HIV.
Integral to these goals are mobile one-stop
shops, where people get rapid HIV testing
and treatment in a single location, at theheart of the community. In 2013, teams
started an outreach programme of testingand health promotion targeted at mobile
populations on farms around Eshowe andMbongolwane. A stronger focus was also
placed on measuring patients’ HIV viral load
to monitor the effectiveness of ARV treatment,
nurse-initiated management of ARV and thepromotion of ARV adherence clubs.
Improving access to generic drugs
MSF is actively involved in the Fix the Patent
Laws campaign in South Africa, which aims
to tighten the law so that it only grants
patents to drugs that are truly innovative.
This in turn would facilitate the production
and/or importation of generic drugs, thus
making them more affordable to people
seeking treatment.

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

south africa 79

Médecins Sans Frontières

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

In August, Médecins Sans
Frontières (MSF) closed allof its projects in Somalia
after 22 years of continuous
operations.
Leaving Somalia was an extremely difficult
decision to make. A series of violent attacks
on MSF personnel took place with thetacit acceptance – or active complicity –of armed groups and civilian authorities.
The minimal conditions necessary for
operations were not respected, and hence
MSF ceased supporting health facilities inSomalia by mid-September 2013, handing
them over to government entities andhumanitarian organisations where possible.
Although the humanitarian situation has
improved since the nutritional crisis of 2011,
the ongoing conflict in the south-central
regions, together with natural disasters andseasonal outbreaks of disease, put hugestrains on the weak healthcare system. In
many parts of Somalia, access to healthcare
is extremely limited and mortality rates for
pregnant women and young children areamong the highest in the world. Hundredsof thousands of Somalis remain displaced
inside the country and in refugee camps
across Somalia’s borders, living a precarious
existence exposed to many forms ofviolence and extortion.

Regions where MSF has programmes

To improve access to quality basic andspecialist healthcare for children, MSF ran
the only paediatric hospital in Mogadishu,
in Hamar Weyne. The hospital had isolation
wards for children suffering from measles
or acute watery diarrhoea and a nutrition
centre that treated 3,800 children between
January and August.
MSF also ran health clinics for displaced
populations and residents in the Wadajir,
Dharkenley and Yaaqshiid districts. These
focused on maternal and child health andwere able to respond to sudden outbreaksof disease such as cholera, treat peaks ofmalnutrition through feeding programmes,and participate in mass vaccinations against
polio, which had made a resurgence in the
country. Over 100,000 consultations werecarried out at these health facilities priorto MSF’s departure. All drugs and supplies

from these clinics were donated to otheraid organisations in Mogadishu, and the
Dharkenley clinic has continued operations.
Bay region
MSF began supporting Dinsor hospital in
Bay region in 2002. It is the main referral
hospital for the entire region, and is
especially active in providing maternity
services and treating malnutrition,
tuberculosis (TB) and kala azar (visceralleishmaniasis). In 2013, the team at the
60-bed hospital performed 16,208
outpatient consultations, around 1,458
antenatal consultations, and treatedmore than 680 malnourished children.
Lower Shabelle region
The Afgooye district hospital servesdisplaced people and residents of the
Afgooye Corridor with an outpatient© Muhammad Daoud / MSF

MSF did not want to leave Somalia but
was left with little choice, and continues
to support Somali refugees in Ethiopia,
Kenya and Yemen.
In and around Mogadishu
Nine kilometres northwest of Mogadishu,
in Dayniile, MSF supported a 60-bed
hospital with an emergency room,
operating theatre, intensive care unit,
paediatric unit, feeding centre andmaternity facilities. The team performed
646 surgical procedures and over 8,272
consultations in 2013.
MSF’s 40-bed hospital in the Jaziira districtof Mogadishu, which mostly catered todisplaced populations, carried out some
25,700 consultations and 2,200 hospital
admissions this year, and treated over 330
severely malnourished children.

80 somalia

In many parts of Somalia, access to healthcare is extremely limited and mortality rates for
pregnant women and young children are among the highest in the world.

© Muhammad Daoud / MSF

International Activity Report 2013

A child being tested for malnutrition in Hamar Weyne district.

and 30-bed inpatient department, emergency
room, maternity facility and an outpatient
feeding programme. Between January
and September, the hospital conducted
11,408 medical consultations, admitted
738 patients to its wards and assisted thedelivery of 953 babies. The Qatar Red
Crescent Society assumed support of thehospital following MSF’s withdrawal.
Middle Shabelle region
MSF provided outpatient care, maternaland child health services, vaccinations andnutritional support at the Jowhar maternity
hospital and health centres in Kulmis, Bulo
Sheik, Gololey, Balcad and Mahaday. The
Mahaday and Gololey facilities also treated
TB. Mahaday clinic closed in March 2013
due to insecurity and the other clinics werehanded over to the International Medical
Corps (IMC) in September. More than
60,000 consultations were performed,
1,040 deliveries assisted, and 8,447 womenand children received vaccinations.
Mudug region
MSF ran projects in two referral hospitals inthe divided city of Galkayo. In the Ministryof Health’s referral hospital in Galkayo
North, MSF offered paediatric outpatientand inpatient care, maternity services,feeding programmes and TB treatment.
MSF teams carried out 33,824 consultationsin 2013. In addition, MSF ran a satellite

programme for TB treatment in Burtinle in
Nugal region.

were carried out through this programme
between January and August.

In the hospital in Galkayo South, MSF
provided surgery and paediatric care,maternity services, nutrition programmes,
TB treatment and immunisations. Two
mobile clinics also provided primary
healthcare in Galmudug region. Some
44,071 people received assistance throughthe hospital and the clinics between
January and September. Management of
the hospital was passed to the Mudug
Development Organisation, which now
works in partnership with two international
medical organisations to continue thesevital services.

Lower Juba

Middle Juba
MSF’s hospital in the small rural townof Marere served as the referral hospitalfor the whole of Middle and Lower Juba
and Gedo regions, providing basic andspecialist healthcare, TB treatment,
nutritional services and emergency obstetriccare to a huge catchment population. In
addition, mobile teams covered the towns
of Ketoy and Osman Moto and delivered
basic healthcare to children under 12 andnutritional care to malnourished children
under five. A small fixed clinic in Jilib had
facilities to treat malnutrition, measles andcholera. Over 68,000 medical interventions

In the port city of Kismayo, MSF ran an
inpatient nutrition programme for children
under five, with special wards for those
suffering from measles and cholera. Thisfacility opened during the nutritional
crisis of 2011 and saw a steady streamof children thereafter: 5,183 received
treatment between January and September
2013. The International Committee of the
Red Cross opened a similar structure at
Kismayo hospital in October to compensate
for MSF’s withdrawal.
Somaliland
MSF had been supporting the inpatient,maternity and surgical facilities of the
160-bed Burao hospital in the Togdheer
region of Somaliland since 2011. Prior to its
withdrawal, MSF conducted 775 surgicalinterventions, admitted 1,602 people tothe inpatient department and assisted in
the birth of 720 babies.
MSF also intervened in three prisonsin Somaliland, carrying out medical
consultations, improving water and sanitation
facilities and distributing relief supplies.

No. staff end 2013: 1,188 | Year MSF first worked in the country: 1979 | msf.org/somalia

somalia 81

Médecins Sans Frontières

south sudanpeople, mostly women and children, fled
the capital of Jonglei state, Bor, for Awerial,
Lakes state.
Refugee assistanceRegions where MSF has projects
Cities, towns or villages where MSF works

Escalating violence in South
Sudan increased the need for
emergency medical aid as theyear progressed.
During clashes between the government
and militia in Jonglei state in April, staff andpatients at Pibor hospital were subjectedto threats and intimidation and Médecins
Sans Frontières (MSF) was forced to suspend
activities. In May, the hospital was looted
and severely damaged, and fighting in thearea caused Pibor residents to flee into thebush or hide in malaria-infested swamps
without access to safe water or food. As
the MSF hospital was the only one in the
county, 100,000 people were deprived ofhealthcare. Thousands of people emerged
40 kilometres away to attend MSF’s small
clinic in Gumuruk village, where teams
carried out over 100 consultations per day
for patients suffering from pneumonia,
respiratory diseases, malaria, diarrhoea andmalnutrition. During the first few weeks,a team set up a surgical unit at Gumurukand performed 49 surgical procedures. To
address the needs of the displaced people,
a second clinic was opened in Dorein, southof Pibor town, and a helicopter was used
to run mobile clinics in the bush in Piborcounty. More than 26,500 consultations
were provided across Pibor county over a
six-month period. The team also conducted1,468 antenatal consultations and offeredmental health support through individualand group sessions.

82 south sudan• 50,000 patients admitted to hospital• 2,750 patients treated for kala azar

On 15 December, fighting broke out inJuba between different army factions andviolence spilled onto the streets. Some
40,000 people fearing for their lives sought
refuge in two UN compounds, where MSF
set up clinics and provided 1,890 healthconsultations. A high number of people
were treated for acute diarrhoea, a direct
result of poor water and sanitation. MSF
also provided drugs and medical supplies
to the Juba Teaching Hospital.
Fighting spread quickly through several
states causing displacement, and 70,000

Teams began providing Sudanese refugees
from South Kordofan with basic andspecialist healthcare in Pamat, northern
Bahr El Ghazal, in February. In October,staff in Upper Nile state offered medical
and nutritional assistance to around 5,000
refugees in Fashoda, and carried out
surgery and post-operative care at thehospital in Malakal.
Basic and specialist health services
MSF teams continued to offer a fullrange of services at clinics and hospitals
throughout the country, including
surgery, maternal and child healthcare,vaccinations, emergency obstetric services
and treatment for malnutrition, kala azar,
HIV and tuberculosis (TB). They also
responded to outbreaks of disease.

© Isabel Corthier / MSF

Key medical figures:• 981,500 outpatient consultations• 4,700 surgical interventions

In Yida camp, Unity state, MSF provided
basic and specialist healthcare, ran nutrition
centres and helped ensure adequate waterand sanitation for 70,000 Sudanese
refugees. Teams delivered the same services
to more than 110,000 refugees acrossfour camps in Maban county, Upper Nilestate. In cooperation with the Ministryof Health, MSF staff vaccinated 132,500
people against cholera in the camps andthe surrounding area.

In Gogrial town, Warrap state, MSF runs a small hospital that provides a full range of basic
healthcare services.

International Activity Report 2013

In Jonglei state, more than 71,000
outpatient consultations were provided
among a full spectrum of services at the
Lankien hospital and an outreach clinic in
Yuai. Further south, in Bor, 177 patients
received emergency care from MSF at
the Ministry of Health hospital during theviolence that broke out in July and August.
The Nasir hospital, Upper Nile state,provided a full range of basic and specialist
services including HIV and TB treatment, andcared for patients referred from surrounding
counties and the border areas of Ethiopia.
In Bentiu, Unity state, MSF handed over anutrition programme to the health ministryin February and opened a project to treat
people with TB and HIV in the town andthe surrounding area. In Leer, also in Unity
state, MSF offered basic and specialist
healthcare. More than 68,000 outpatient
consultations took place; 13,394 of thesewere for patients with malaria. MSF also
performed 336 surgical interventions.

assisted more than 6,100 births and admitted
over 4,600 children to hospital this year.

Health services are offered to residents,
internally displaced people and nomads
in Agok, 40 kilometres from the city of
Abyei. MSF runs the only hospital in thearea, providing comprehensive services
including HIV and TB care. MSF constructed
a new maternity ward in September toaccommodate the high number of prematureand low birth weight babies. Staff operated
mobile clinics to ensure people in remoteregions could access basic and maternal
healthcare and referrals.

In November and December, MSF provided
fistula surgery to 55 women. Fistulas, aconsequence of birth complications, cause
not only pain but incontinence, which inturn often leads to social exclusion andsometimes rejection by friends and family.
The team also ran mobile clinics, treatinglarge numbers of people with malaria,
respiratory tract infections and diarrhoea.

Around-the-clock care is available forchildren up to the age of 15 at Aweil civil
hospital, Northern Bahr El Ghazal. Services
include intensive care, surgery, treatmentof burn victims, and neonatal, tetanus
and isolation units. The hospital also has
an inpatient maternity department. Staff

At Yambio hospital, Western Equatoria state,
MSF reinforced its support to the Ministryof Health’s HIV programme by recruiting,training and deploying key technical staff
to deliver comprehensive HIV care forHIV-exposed children and adults, including
pregnant women.
In November and December, more than
41,000 children were vaccinated against
measles in Lakes state.

© Yann Libessart

No. staff end 2013: 2,854 | Year MSF first worked in the country: 1983 | msf.org/southsudanThis mother in Yida refugee camp has just had her daughter vaccinated. Infectious diseases related to the camp’s poor hygiene conditions are further
exacerbated once the rainy season starts.
south sudan 83

Médecins Sans Frontières

sudan
Regions where MSF has projects

In Sudan, Médecins Sans
Frontières (MSF) focuses onproviding medical assistancein remote regions with poor
access to healthcare, and topeople affected by conflict,outbreaks of disease andnatural disasters.
In July, an MSF team started supporting thehealth centre in El Serif displaced personcamp near Nyala in South Darfur.
In North Darfur, MSF continued working
in Tawila but due to insecurity the project
was limited to basic healthcare activities
within the town and the implementationof a referral system to hospitals in El Fashirfor specialist treatment. The focus in Dar
Zaghawa was also on basic healthcare.
Teams supported two health centres
and two health posts, and carried out
postnatal home visits. Projects in Kaguro,
including vaccination campaigns, were
under remote management, as no access
was available to international staff. An
emergency intervention in El Sireaf started
in 2013 after tribal clashes displaced an
estimated 65,000 people. Two mobile
clinics provided outpatient consultations,
therapeutic feeding programmes andreproductive healthcare. Referrals weremade to the MSF-supported El Sireaf
hospital. In July, two mobile clinics
started providing care to people intwo displacement camps in El Serif.
Aiming to improve access to emergency
healthcare, MSF launched the North Darfur
Emergency Response (NDER) programme© Sharafeldin Magzoub

Key medical figures:• 130,000 outpatient consultations• 470 patients treated for kala azar
• 319,200 measles vaccinations (outbreak)In Al-Gedaref state in eastern Sudan, an MSF doctor explains to a group of schoolchildren
why they should be vaccinated against measles.

in 2013 in collaboration with the Ministryof Health.
Treating tuberculosis in Jebel Awlia
In February, MSF started diagnosing andtreating tuberculosis (TB) in five healthcentres in Jebel Awlia, a large slum on
the outskirts of the capital, Khartoum,
where crowded living conditions increase
people’s risk of contracting the disease.
The team is training Ministry of Healthstaff and working with patient groups inthe community to develop counselling andsupport systems that will help patientsadhere to treatment.
Reproductive healthcare in Tabarak Allah,
Al-Gedaref state
MSF began supporting the Ministry of
Health’s reproductive health activities in
July. The main objectives are to reducematernal and neonatal mortality, and toensure patients who need fistula repair andreconstructive surgery are appropriately
referred. Comprehensive emergency
obstetric services are offered, and women
also receive follow-up services including
postnatal consultations and family planningsupport. MSF renovated and equipped
the maternity wing and refurbished theoperating theatre in Quresha hospital.
Children were also referred for vaccinations.

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

84 sudanVaccination campaigns
In January, MSF assisted the Sudanese
health authorities in preventing a yellow
fever epidemic. Over 750,000 adults andchildren were vaccinated over nine months
in four localities in Central Darfur state.
In West and Central Darfur, 256 patientssuspected of having yellow fever weretreated. From early March to May, MSF
emergency teams carried out a measles
vaccination campaign in five locations in
Al-Gedaref state. A total of 306,400 people
were vaccinated.
Emergency flood response
Heavy rains in August caused flooding
which affected 150,000 people. Khartoum
state was particularly hard hit, and MSF
launched an emergency intervention,
providing 228,600 litres of clean waterand carrying out 654 mobile clinic
consultations in the Sharag Alniel locality.
Most patients had respiratory tract
infections, gastritis or diarrhoea.
Kala azar
MSF continued its kala azar work in Tabarak
Allah, Al Gedaref state, and treated 470
people in 2013. The Shangyl Tobaya basic
healthcare programme was handed over tothe Ministry of Health.

International Activity Report 2013

swaziland
Regions where MSF has projects

The decentralisation of
medical services in Swaziland
is helping people with
HIV, tuberculosis (TB) andmultidrug-resistant TB (MDRTB) get the care they need.
Swaziland has high rates of HIV–TB
co-infection and the number of people
with drug-resistant forms of TB (DR-TB) isrising. Médecins Sans Frontières (MSF), in
collaboration with the Ministry of Health,has been integrating HIV and TB services atbasic health clinics and in the community.
Further strategies have included advocating
for the introduction of shorter, moretolerable treatment regimens for DR-TB
and the promotion and implementation of
outpatient DR-TB care.
One-stop, comprehensive care for HIV
and TB is provided in Matsapha, Manzini
region, an industrial town that attracts
migrant workers. The clinic here offers
HIV counselling and testing, diagnosis
and treatment of TB, and sexual andreproductive healthcare services, including
ante- and postnatal care. The clinic
provides victims of violence with medical
and psychosocial care, and consultations
and treatment for common illnesses,
as well as immunisations for children,
are also available.
In Mankayane, MSF works closely with
the Ministry of Health’s HIV and TB
department to improve diagnosis andtreatment of patients suffering from
HIV–DR-TB co-infection. Antiretroviral(ARV) treatment has been integrated
with that for TB and DR-TB.

© Sven Torfinn

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

Treatment for drug-resistant TB involves swallowing 20 pills a day and receiving a painful
daily injection that makes it difficult to sit or even lie down.

In 2013, the MSF team continued to
improve infection control and provided
psychosocial support for patients in
Mankayane hospital and in communitybased clinics. They also trained staff at
the TB National Reference Laboratory
in Mbabane, where MSF assists with
TB cultures and drug-sensitivity testing.
Patient-centred HIV and TB carein Shiselweni
After five years of increasing the numberof HIV and TB services, Shiselweni,
formerly the most disadvantaged region
for healthcare, now has multiple HIV and
TB service points. MSF provides treatment
and psychosocial support for HIV and TB
patients in 22 basic health clinics andthree specialist facilities. Teams also workon infection control and improving
adherence to treatment.

community treatment supporters (CTS).
This is a new approach and an analysis of
the effectiveness of the CTS programme iscurrently underway.
A ‘test early and treat early’ effort began
last year as a preventive measure against
the transmission of HIV. It ultimately aims
to put everyone testing positive for HIV on
ARV treatment, regardless of how far thevirus has progressed. The first phase, whichstarted in January 2013, involved putting
all HIV-positive women on treatment, andthis work continues, along with routine viralload testing.
A voluntary door-to-door HIV-testing
campaign was also conducted inAugust, which resulted in 6,452 people
being screened.

In 2013, there was a strong focus on
improving access to DR-TB diagnosis andcare. Locating laboratories at points ofcare was an important component, andrapid diagnostic technology (GeneXpert)
was distributed throughout the region;
20 primary clinics now have their own
mini-labs. Furthermore, patients who
cannot come to their nearest facility
for daily injections during the intensive
treatment phase are now visited by

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

swaziland 85

Médecins Sans Frontières

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

Against a backdrop of
relentless violence, theSyrian people endured foodshortages, disrupted power
and water supplies, and thecollapse of the healthcare
system in 2013.

In Idlib governorate, MSF continued to run
a trauma surgical unit set up in a house,
where patients suffering from shrapnel
wounds, bullet wounds and burns weretreated. Physiotherapy and post-operative
care were provided. Given the many people
exhibiting psychological distress, mental
health services were added in February.
More than 60,000 people have settled indisplacement camps in the area around thehospital. MSF staff built 60 latrines and
40 showers to improve hygiene, anddistributed supplies such as tents, blankets
and plastic sheeting. The conflict has
disrupted essential preventive care andbetween February and May, teams vaccinatedchildren in the camps, immunising 3,137
against measles and more than 3,300 against
polio. Routine childhood vaccinations started
in November in partnership with two local
NGOs, with an average of 1,000 children
immunised per month. Seventy community
health workers undertook outbreaksurveillance and health education activities
in the camps. Two outpatient clinics werealso opened in November.

Regions where MSF has projects

In late 2012, a field hospital in a cave
was relocated to a converted farm in themountainous region of Jabal Al-Akrad.
More than 520 surgical procedures and15,550 emergency consultations were
performed there in 2013. When security
allowed, MSF ran mobile clinics in the area,
provided medical facilities with essential
drugs and equipment, and distributed basic
relief items. Over 30,600 consultations werecarried out at mobile clinics and the hospital.
Two additional basic healthcare clinics wereopened in the area in June.

acute and chronic diseases. Mental healthservices were launched in July.

Aleppo governorate

In July, MSF opened a third hospital on
the outskirts of Aleppo city, providing careto patients with conflict-related injuries
and those indirectly affected by the war.
There is an emergency room, an outpatient
department and a 12-bed ward.

The hospital MSF opened in 2012 in Aleppo
governorate continued to treat children andthe wounded. The team also performed
surgical procedures, provided maternity andobstetric care, and treated patients with

With needs steadily rising, MSF opened
another hospital in the governorate inMay. Services include surgery for trauma,including burns, and obstetric care.
Consultations are provided for adult andpaediatric outpatients and there is also an
inpatient department. Between May andDecember, staff performed more than 1,300
surgical procedures and carried out 14,300
consultations.

© Anna Surinyach / MSF

The conflict in Syria has decimated what
was previously a well-functioning healthcare
system. With regions of the country
inaccessible to humanitarian organisations,the huge medical needs that are indirectconsequences of the conflict remain largely
unreported and unseen. The initial focus for
Médecins Sans Frontières (MSF) was providing
emergency and trauma surgical care in
the north of the country. As the situation
deteriorated, activities were extended toinclude basic and mental healthcare, maternal
health services and measles vaccination
campaigns. MSF also donated medical
supplies and drugs to treat communicablediseases such as typhoid, chronic conditions
such as asthma and diabetes, as well as
cardiovascular and kidney diseases.

A transit camp in Aleppo governorate, home to thousands of people.
86 SYRIA© Robin Meldrum / MSF

International Activity Report 2013

In what used to be a chicken farm, MSF set up a makeshift hospital with an inflatable operating theatre – an efficient way to maintain asterile environment.

Tens of thousands of displaced people
live in camps in the Al Safira area andin October, MSF donated tents andmedicines. When people fled north after
violent attacks, a team supported Syrian
volunteers treating displaced people at ahealth centre in Manbij. MSF also helped
conduct a vaccination campaign anddistributed winter tents and plastic sheeting
to displaced people. Further support wasprovided to reopen the paediatric ward at
Al-Bab hospital in Aleppo governorate.
Ar-Raqqah governorate
In May, a team opened a basic healthcare
clinic in the Ministry of Health hospital in
Tal Abyad, and since July there has been
an MSF-supported paediatric ward in thefacility. Donations were made to cover
the treatment of dialysis patients, so thatwhen the supply chain broke there was nointerruption in care. Mobile teams provided
emergency assistance to people living in
empty school buildings, conducted morethan 12,600 outpatient consultations andvaccinated 27,000 children against measles
through several health centres. Non-medical
items such as blankets, stoves and hygienekits were distributed to vulnerable families.

Al Hasakah governorate
In July, MSF started to support the trauma
ward in a hospital in Al Hasakah withskilled staff and drugs. The border with
Iraq reopened in August and MSF set up ahealth post to assist those waiting to leave
Syria. The border closed again at the end of
September, leaving people in nearby villages,
but the number of arrivals decreased.
Approximately 3,110 consultations had
been conducted by the end of the year in
Al Hasakah. MSF also prepared for a possible
large influx of casualties.
Donations and remote support
Restrictions on access and concerns about
security are major obstacles to delivering
medical-humanitarian assistance in Syria.
Where MSF cannot send its own teams
because of insecurity or being denied
access by the government, drugs, medical
equipment, and technical advice andsupport are offered. Throughout 2013, anaverage of three tons of medical and nonmedical material were donated daily to a
network of 40 hospitals and 60 health posts
across seven governorates.
By the end of the year it was estimatedthat more than four million Syrians weredisplaced inside the country, and two million
had crossed into neighbouring countries.
MSF also provided emergency medical aid to
Syrians in Lebanon, Iraq, Jordan and Turkey.

A man who brought his sister to an
MSF field hospital
We heard the sound of explosions … I told
my sister to move and find shelter, as it
was close. She was behind me, about fivemetres. A bomb landed near her. She wascovered in rubble. I shouted: “Are you
hurt, sister?” She replied: “Yes, I am!” I
ran towards her and saw that shrapnel
had hit her face. Blood was coming outof her neck … We shouted for a car.
Thankfully there was one nearby. We took
her to the hospital, where they stopped
the bleeding. Her situation is stable now.
If there were no hospital, she’d havedied. We need medical care. In my sister’scase, she needs doctors, care, drugs. As
you know, we have nothing here. We
need support in medication, doctors,
ambulances capable of transporting
patients immediately, everything.

No. staff end 2013: 621 | Year MSF first worked in the country: 2009 | msf.org/syria

SYRIA 87

Médecins Sans Frontières

Regions where MSF has projects

Key medical figures:• 73,300 outpatient consultations• 2,200 births assisted

Médecins Sans Frontières(MSF) has begun reorienting
its work to focus on improving
medical care for children andits capacity for diagnosing
Lassa fever.

More than a decade has passed since theend of the civil war, but Sierra Leone isstill recovering. Healthcare gaps are
systemic and nationwide, and accessto quality healthcare remains a major
challenge for the population. Although
the government initiative offering freehealthcare to pregnant women and children
is improving access, many people still die
from treatable diseases such as malaria,
measles, acute respiratory infection and
Lassa fever, a viral haemorrhagic fever
endemic in the country.
In Bo district, MSF runs the Gondamareferral centre, a 220-bed hospital offering
emergency paediatric and obstetricservices. In 2013, ambulances transported
patients from nine community healthcentres to the hospital, and an additional
ambulance service took patients with
Lassa fever to Kenema hospital fortreatment. MSF also supports Gondama
health centre, a nearby clinic run by the

Ministry of Health, with staff, medicinesand medical materials.
MSF plans to build a 160-bed hospital
closer to Bo town that will provide better
access for patients, staff and supplies.
The new, more spacious facility will also
allow for better infection control protocols,
and will include a proper isolation ward
and a modern laboratory.

© Aisha Dodwell / MSF

sierra leone

A Clinical Health Officer examining a childat Gondama referral centre in Bo.

No. staff end 2013: 619 | Year MSF first worked in the country: 1986 | msf.org/sierraleone

tajikistan
Cities, towns or villages where MSF works

Key medical figures:• 2 20 patients under treatment for TB,
of which 28 for MDR-TB

Improving children’s accessto tuberculosis (TB) treatment
continued to be the main focus
of Médecins Sans Frontières(MSF) in Tajikistan in 2013.

In 2011, MSF started a paediatric TB
programme to improve access and qualityof care for children with drug-sensitive TB,
drug-resistant TB (DR-TB) and multidrugresistant TB (MDR-TB). The team continued
to support the paediatric TB hospital in
Dushanbe in 2013, offering diagnosis andcomprehensive care to children who wereadmitted. Their family members were also
tested and treated, and MSF worked with
the Ministry of Health to diagnose and treat
those who had come into close contact withthe children.
MSF provided outpatient care for children
and their families wherever possible,
along with nutritional and psychosocial
support to help them adhere to thedifficult treatment. Hospitalised children
took part in MSF-organised activities to
aid their development, and teams also
conducted activities to decrease the stigma
surrounding the disease.

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

88 sierra leone | tajikistan

The diagnostic tools and treatment
currently used are not adapted for children.
MSF is hoping to find ways to better
diagnose DR-TB and MDR-TB and produce
paediatric formulations of the drugs, forexample syrups.
Kala azar
Following an outbreak of kala azar (visceralleishmaniasis), MSF trained 200 Ministryof Health staff and introduced a rapid
test. Kala azar is a parasitic disease that is
almost always fatal if left untreated, and thespecialist facilities and expertise required
for reliable diagnosis are often missing inareas where it is prevalent. At the request of
the Tajik Ministry of Health, MSF developed
treatment guidelines for the national kalaazar programme.

International Activity Report 2013

TURKEYThe poor living conditions and lack ofaccess to medical care endured by manyof the predominantly Syrian refugees in
Turkey remain concerning, and this year
Médecins Sans Frontières (MSF) launchedseveral humanitarian interventions todeliver assistance to those in need.

 ities, towns or villages where MSF
Csupports projects

Key medical figures:• 2 9,000 outpatient consultations• 6 ,800 individual and group mental
health consultations

Over half a million Syrian war
refugees were living in Turkey
by the end of 2013.

Many Syrians have settled in the southern
province of Kilis, along the Syrian–Turkish
border. The NGO Helsinki Citizens’
Assembly (HCA), in collaboration with
MSF, is running a clinic in Kilis aimed atproviding quality healthcare, including
mental health services, to this vulnerable
population. The main goal of the mental
health activities in Kilis is to help refugees
cope and adjust to their new situation,
regardless of whether they live inside oroutside the camps. Unregistered refugees
are a priority for MSF since they live

outside of the camps and may not haveaccess to services or aid distribution.
A health needs assessment conducted by
MSF among migrants revealed no accessto healthcare, as well as financial barriers
and poor living conditions. The responseby humanitarian organisations was foundto be inadequate. MSF provided support
to an HCA psychosocial project assisting
mixed migrant communities in Istanbul.
Turkish psychologists, community healthworkers and interpreters supported referral
activities in 10 municipalities. The project
was closed at the end of the year, as MSF
decided to focus its interventions on Syrian
refugees in Turkey.

No. staff end 2013: 29 | Year MSF first worked in the country: 1999 | msf.org/turkey

UKRAINE
Key medical figures:• 2 50 patients under treatment for MDR-TB• 43 patients on first-line ARV treatment

The dual drug-resistanttuberculosis (DR-TB) and HIV
epidemics in the Ukrainian
penitentiary system are an
urgent public health issue.
Overcrowded prison environments and theinadequate healthcare provided to inmates
exacerbate the spread of DR-TB. The diagnosis

Some have psychological disorders, and many
suffer from drug and alcohol addictions.

Since 2012, Médecins Sans Frontières (MSF)
has provided DR-TB treatment to prisoners
and ex-prisoners in eastern Ukraine’s Donetsk
region. DOTS (directly observed treatment,
short course), the treatment recommended
by the World Health Organization, is
provided in a special prison TB hospitaland in three pre-trial detention centres.
Antiretroviral (ARV) therapy is given to DRTB patients co-infected with HIV. After theprisoners are released, MSF works to ensurethat they complete their DR-TB treatment.

MSF provides laboratory services for rapid,
accurate TB diagnosis, adverse effects
diagnosis and management, and guarantees
an uninterrupted quality-assured drugs
supply is available. MSF also lobbies theState Penitentiary Service of Ukraine and theMinistry of Health, at regional and national
levels, for the integration of TB and HIV
services and multidisciplinary, patient-oriented
TB case management in penal facilities.

The course of treatment for DR-TB takes up
to two years and can result in a number ofside effects, some of them severe, including
vomiting, nausea, depression and loss ofhearing. Counselling is an important partof the patient-centred programme, to help
people cope with their diagnosis and adhere totreatment. Inmates often come from deprived
environments, with difficult family histories
and experiences of social marginalisation.

© Niklas Bergstrand / MSF

Regions where MSF has projects

and treatment of the disease in Ukrainian
prisons is limited.

MSF provides drug-resistant TB treatment
to prisoners in Donetsk region.

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

TURKEY | UKRAINE 89

Médecins Sans Frontières

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

Key medical figures:• 52,900 outpatient consultations• 6,500 patients on first-line ARV treatment• 570 patients under treatment for TB

In Uganda, the rate of HIV
infection is on the rise again,
after decreasing for many
years. The country has also
had to host large numbersof refugees arriving from
Democratic Republic of Congo(DRC) and South Sudan.

After several years of progress in the fightagainst HIV, and large increases in thenumber of people being tested and treated
for the virus, the rate of new infections has
risen since 2010. Test kits and condoms
are difficult to obtain in several areas of
the country; meanwhile it is estimated that
one-third of women and half of men withHIV are not aware of their status. Specialisedcare, such as prevention of mother-to-childtransmission (PMTCT) and the combined
treatment of tuberculosis (TB) and severe
malnutrition, is often unavailable.
In West Nile region, the prevalence of HIV
among adults aged 15 to 49 is about five percent and has almost doubled since 2005.
Médecins Sans Frontières (MSF) has beenworking in the region to help improve accessto care and reduce HIV-related mortality.
For several years, MSF teams have treatedpeople with HIV and TB through a
programme based at the Arua regionalreferral hospital. Care is provided to people
living in the district as well as to a significant
number of patients from neighbouring
DRC. Activities include PMTCT and ensuring
people infected with both HIV and TB receive
the necessary integrated care.

After a 12-year presence in Arua, MSF has
started to hand over medical activities to local
authorities and their partner SUSTAIN, andwill close the project in July 2014. This follows
both an increase in the local ability to provide
medical care for people with HIV and TB anda reorientation of MSF’s work in the country.
Emergency care for refugees
The conflict in North Kivu province, DRC,
caused between 40,000 and 50,000 refugees
to cross into western Uganda between May
and the end of July. An estimated 22,000
people reached the Bubukwanga transit
camp, near Bundibugyo. Originally designed
for 12,500 people, the camp lacked sufficient
shelters, latrines and drinking water for theincreased numbers. MSF began providing
medical care in July. Patients were suffering
mainly from respiratory infections, malaria
and diarrhoea. Teams also built latrines andtrucked in water. Some refugees have since
been transferred by the Ugandan authorities
to the Kyangwali camp to ease pressure on
resources. MSF provided healthcare to the
33,000 people in Kyangwali camp from
September to the end of November. A totalof 25,000 consultations were conducted and1,500 people were admitted to hospital.

© Fulvio Bugani

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

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

International Activity Report 2013

UZBEKISTAN

Uzbekistan is one of many countries inCentral Asia with high levels of drugresistant TB (DR-TB), a form of the disease
that does not respond to the standard
first-line drug regimen. Access to proper
diagnosis and care is still limited and thevast majority of people with DR-TB remain
undiagnosed and untreated.

Key medical figures:• 2,200 patients under treatment for TB,
of which 516 for MDR-TB• 200 patients on first-line ARV treatment

A pilot project to shorten
treatment time for people
with multidrug-resistanttuberculosis (MDR-TB)
was launched in 2013.

In the Autonomous Republic of
Karakalpakstan, Médecins Sans Frontières(MSF) has been running a TB programmein collaboration with the Ministry of Healthsince 1997. In 2013, 1,212 patients wereenrolled for first-line TB treatment, as well
as 677 for DR-TB. Many patients underwent
treatment on an outpatient basis, so they
avoided the additional stress of hospitalisationand could remain at home close to theirfamilies and social support network. Overall,

Key medical figures:• 4,000 antenatal consultations• 770 births assisted• 380 postnatal consultations

In September, a three-year
project aimed at improving
access to reproductive healthservices in Luwingu districtcame to an end.
Luwingu, a remote and rural area, wasunderserviced in terms of health facilities
when Médecins Sans Frontières (MSF) first

In Tashkent, Uzbekistan’s capital city, an MSF
team continued to work at the Republican
AIDS Centre, and activities began at the
Tashkent City AIDS Centre in September.
Psychosocial activities such as counsellingwere also provided as an additional support
for people living with HIV.

No. staff end 2013: 184 | Year MSF first worked in the country: 1997
msf.org/uzbekistan

ZAMBIA
Regions where MSF has projects

The DR-TB project expanded this year into
the districts of Chimbay, Shumanay and
Kanlikul, while activities in the districts ofKhodjeily, Takhiatash and Nukus region werehanded over to local health authorities.

opened its programme in 2010. Residents
had to travel long distances for appropriate
health services and there were reports ofhigh maternal mortality because of thepoor availability of care. Although the
HIV rate among pregnant women was low
in the district, it was difficult for thosewith the disease to obtain antiretroviraltreatment because of a lack of resourcesat the district hospital.
In close collaboration with Zambian healthauthorities, MSF established comprehensive
sexual and reproductive health services inthe Luwingu district hospital and several
rural health centres. These included
family planning, ante- and postnatal care,prevention of mother-to-child transmissionof HIV and assisted births. Emergency
obstetric referrals were also made fromrural centres to the district hospital, and56 women with obstetric fistulas wereidentified and referred to Chilonga district
hospital for surgery.
Over the course of the project, MSF
improved facilities, trained local staff anddonated medicines, medical equipment andan ambulance. More than 400 pregnant
women referred from villages to healthcentres travelled by Zambulance, a covered
trailer pulled by a bicycle – a viable meansof transportation in this setting.
The decision to close the programme wasbased on the improvement of medical
processes and came after a gradualhandover to the Zambian Ministry of
Health. Medical activities ended in June
2013, the project closed in mid-September
and MSF withdrew from Zambia in October.

© Sophia Apostolia / MSF

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

nearly two-thirds of the DR-TB patientsbegan ambulatory care. In September 2013,16 MDR-TB patients were enrolled in a pilot
project in which the often arduous treatmentthat usually takes up to two years was
shortened to nine months.

Patients waiting at Luwingu district hospital.

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

UZBEKISTAN | ZAMBIA  91

Médecins Sans Frontières

ZIMBABWE
Key medical figures:• 6 4,500 patients on first-line ARV treatment• 3,200 patients under treatment for TB,
of which 63 for MDR-TB

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

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

MSF supported HIV and TB projects
throughout the country in 2013: in Harare(Epworth and Caledonia Farm), Gokwe
North, Tsholotsho, Beitbridge, Buhera, Gutu
and Chikomba. A new project also openedin Nyanga district, after an assessment
revealed that only five per cent of people
were getting the antiretroviral (ARV)
treatment they needed for HIV.
The emphasis in Nyanga is on paediatricARV care. The strategy used aims to increase
patient access to treatment by providing
quality HIV and TB care using existing
healthcare facilities and human resources.
Services in Nyanga are being integrated
into the district hospital and nine healthclinics, with nurses undergoing training toinitiate treatment. MSF supports the healthteam with the organisation of services,patient records and patient flow, so facilities
can manage the additional workload.
Community ARV treatment refill groups andthe provision of a three-month drug supply
for healthy patients reduce the number ofvisits to busy clinics.

92 ZIMBABWEThe Gokwe North project made progresswith its approach in 2013, increasing
decentralisation of services through training
and mentorship. Treatment for HIV and TB
and for victims of sexual violence is being
integrated into two rural hospitals and
16 rural health centres. Eleven facilities
currently provide care for people with
HIV, and four are treatment initiationsites. The Gutu/Chikomba programme has
decentralised care to 28 facilities in Gutu
and 31 in Chikomba. Support groups havealso been established.
MSF pushed for seven health facilities within
high-density suburbs in Harare, including theCaledonia Farm clinic, to be accredited as
ARV treatment and follow-up sites. HIV and

TB training was provided for 16 nurses
from Harare, thereby preparing fornurse-led treatment to be implemented
in these facilities. The HIV and TB
programme in Epworth was integrated
into the Epworth polyclinic at the end of
the year, with clinical responsibilities
handed over to ministry of health staff.
The Tsholotsho project is also in the processof being handed over, having achieved 98.7
per cent coverage of all people in need of HIV
treatment in the district. Provision of ARVs,
treatment of opportunistic infections andprevention of mother-to-child transmission(PMTCT) of HIV continued at Nyamandhlovu
hospital as part of the decentralisation of
the project. The standard implementation of© Julie Remy

Treatment for HIV is reportedly widely
available but there are still areas where
coverage is extremely low. The mainbarriers include a lack of human resources,
treatment fees, clinic hours and the long
distances people must travel to reachfacilities. Patients with multidrug-resistant
TB (MDR-TB), where standard first-line
drugs have failed, lack access to the best
available treatment. Integration of TB andHIV care, ensuring treatment is available
at a more local level, and moving tasks
over from doctors to nurses are all key
strategies being undertaken by Médecins
Sans Frontières (MSF) in collaboration with
the Ministry of Health. This streamlining
enables more people to obtain the medicalcare they require.

A 14-year-old patient being shown his x-ray.

International Activity Report 2013

PMTCT is a key strategy in achieving an
HIV-free generation in Zimbabwe.
At the end of December, MSF was forced
to abruptly close the project in Beitbridge,
on the border with South Africa, after theauthorities decided not to allow the team
to continue activities. Before leaving, MSF
arranged a three-month drug buffer forpatients to postpone interruption of theirtreatment, but remains concerned for the
future healthcare of HIV patients in thearea. Over the course of the project, 7,590
patients started ARV treatment. In 2013,853 patients started TB treatment, five of
these for DR-TB. Mental health specialists
saw 16,300 people for counselling sessions
over the course of the year.
Implementing newer technology
MSF is striving to implement modern
technology that will improve HIV patientcare in Zimbabwe. Routine yearly viralload (VL) monitoring – the gold standard
for monitoring HIV patients – was alreadybeing used in Buhera and Gutu, and it

was introduced in January in Chikomba.
Laboratory technicians and scientists weretrained at three hospitals in Harare (Hararehospital, Parirenyatwa and Chitungwiza),
and these were included as potential sites tosend VL results. New diagnostic technology(GeneXpert) was introduced to improve thespeed of diagnosis for TB and MDR-TB in
most MSF-supported health facilities.
In May, MSF installed the NUCLISENSE
platform at the National Microbiology
Reference Laboratory (NMRL) in Hararehospital. This project, funded by UNITAID
and run in close collaboration with NMRL
and the health ministry, aims to provide VL
analysis throughout the country. Between
September and December 11,500 samples
were processed, paving the way for more
to be dealt with in the country instead ofbeing sent to a laboratory in South Africa.

maximum security prison, where 250 maleand 30 female inmates receive care in a
psychiatric wing. Occupational therapy
was also available. The team treated 1,880
patients in individual and group counsellingsessions.
Care for victims of sexual violenceFree medical care, counselling and referrals
for psychological, psychosocial and legal
support were provided for victims ofsexual violence in the high-density suburb
of Mbare in Harare. Health promotion
activities were conducted to raise awarenessof sexual violence in the community, andthe importance of seeking immediate
medical care. A total of 1,220 new patientscame to the centre in 2013 and the teamsaw more than 920 people for follow-up.
A new building is under construction toaccommodate the growing programme.

Prison psychiatric care
A team of MSF mental health professionals
continued to provide psychiatric support
to inmates in 10 prisons, including Harare© Julie Remy

No. staff end 2013: 604 | Year MSF first worked in the country: 2000 | msf.org/zimbabwe

An MSF TB nurse injecting an MDR-TB patient in their home.

ZIMBABWE 93

Médecins Sans Frontières

YEMEN
Amran
hajjahAd-Dali
Lahj

Sana’aAbyan
ADEN

Regions where MSF has projects

Yemen
Key medical figures:• 102,600 outpatient consultations• 4,100 surgical interventions• 3,400 births assisted

There was a significant
deterioration in living
conditions in parts of Yemen in2013, and insecurity towards
the end of the year affectedavailability and accessibilityof healthcare.
Insecurity affected programmes supported
by Médecins Sans Frontières (MSF), further
cutting people off from healthcare, andactivities had to be suspended twice inAmran and once in Aden.
Over 150 Yemeni patients were sent from
Yemen to MSF’s reconstructive surgery
programme in Amman, Jordan, which
provides orthopaedic, maxillofacial andreconstructive plastic surgery (for moredetails, see the Jordan country report, p.56).
Ad-Dali
MSF continued to work in Ad-Daligovernorate, but problems with security
caused significant disruptions to theprovision of healthcare there at the end of
the year. Food shortages and maternal andchild health are of great concern in the area.
Teams worked with local communities,
both rural and urban, providing care forvictims of violence and trauma. Emergency
services, including surgery, were available atthe Al Naser general hospital, Ad-Dali city,and patients received basic healthcare andlifesaving surgery in Al Azaraq and Qataba’a
districts. More than 41,704 consultations
were carried out.
Aden and the south
In Aden, more than 2,500 surgeries were
performed and 860 patients received
post-surgery follow-up and physiotherapy

94 yemen© Anna Surinyach / MSF

Cities, towns or villages where MSF works

An MSF staff member talking to migrants living in the Sana’a detention centre.
at MSF’s emergency surgical unit, which
treated victims of violence from Aden as wellas the nearby governorates of Lahj, Abyan,
Shabwah and Ad-Dali. A weekly clinic was
run for inmates at Aden central prison, and80 patients were seen each month.
Staff support and supplies were provided
to hospitals in Lawdar and Jaar in Abyan
governorate. Teams also trained emergency
room staff and sterilisation technicians.
Amran governorate
Access to healthcare decreases progressively
in the rural areas of Amran governate
and ceases to exist for communities inthe valleys. At Al-Salam hospital, Khamir,
MSF is involved in the emergency,
surgery, maternity, paediatric, inpatientand intensive care departments, andcollaborates closely with the Ministry of
Health to improve medical services. Support
is also provided for the blood bank andlaboratory. There was a dramatic rise insurgery patients towards the end of the year
after violence intensified in the governorate.
More than 1,940 surgical procedures
were performed, and 4,080 people wereadmitted to hospital. Teams carried out
21,980 emergency consultations.
MSF resumed its support of the Huth
health centre in March, after six months’
suspension for security reasons. A teamprovided emergency, maternity andinpatient care. In September, Huth became

a stabilisation centre for managing large
influxes of wounded people, providing
emergency care and a referral system.
To assist the communities in remote areas
with very limited access to healthcare, teams
ran mobile clinics in the Osman and Akhraf
valleys, carrying out 5,350 consultations andtreating 427 patients for malaria.
Caring for migrants in Sana’a
MSF began providing HIV care to people in
Sana’a in 2013. A mental health programme
for migrants in detention also started in April.
Programme handovers
In February, MSF handed over activities
at the Radfan hospital, Lahj governorate,
to the Ministry of Health. A programme
offering healthcare at Haradh, Hajjah
governorate was closed in August.

MohamedShabwah
My nephew was shot during gunfire
in Shabwah. There was no hospital …
nothing in the area. The only place we
could bring him was here [MSF hospitalin Aden]. We sincerely thank MSF for theunconditional medical care they offeredto him and to everybody in this hospital.

No. staff end 2013: 459 | Year MSF first worked in the country: 1994 | msf.org/yemenspecial reports 2013
Hear my voice:Somalis on living in ahumanitarian crisis

FEBRUARY
Misery beyond the war
zone: Life for Syrian
refugees and displaced
populations in Lebanon

Violence, vulnerability
and migration: Trappedat the gates of Europe

MARCH
Syria two years on:
the failure ofinternational aid so far
Stranded in the Desert

APRIL
Healing Iraqis:
The challenges of providing
mental health care in Iraq

Untangling the Webof Antiretroviral Price
Reductions: 16th Edition

Putting HIV Treatment
to the TestJULY

DR-TB Drugs Under theMicroscope:3rd Edition

OCTOBERThe illness of migration

Central African Republic:
abandoned to its fate?

Hepatitis C:
The Hidden Epidemic

NOVEMBER
Improving paediatric TB
care in Tajikistan

HIV status? Undetectable

DECEMBER
How low can we go?
All these reports are available atwww.msf.org/reports

special reports 2013 95

Médecins Sans Frontières

Facts andFiguresMédecins Sans Frontières(MSF) is an international,
independent, private andnon-profit organisation.
It is made up of 23 associations (2013):
Australia, Austria, Belgium, Brazil,
Canada, Denmark, East Africa, France,
Germany, Greece, Holland, Hong Kong,
Italy, Japan, Latin America, Luxembourg,
Norway, Southern Africa, Spain, Sweden,
Switzerland, UK and the USA. MSF’s
day-to-day activities are managed by 19
national offices and nine branch offices(see page 100 for contact details).
The search for efficiency has led MSF
to create 10 specialised organisations,called ‘satellites’, which take charge of
specific activities such as humanitarianrelief supplies, epidemiological andmedical research, and research on
humanitarian and social action. Thesesatellites, considered as related parties tothe national offices, include: MSF-Supply,
MSF-Logistique, Epicentre, Fondation MSF,
Etat d’Urgence Production, MSF Assistance,
SCI MSF, SCI Sabin, Ärzte Ohne Grenzen
Foundation and MSF Enterprises Limited.
As these organisations are controlled by
MSF, they are included in the scope ofthe MSF Financial Report and the figures
presented here.
These figures describe MSF’s finances on
a combined international level. The 2013combined international figures havebeen prepared in accordance with MSF
international accounting standards, which
comply with most of the requirementsof the International Financial ReportingStandards (IFRS). The figures have been

jointly audited by the accounting firmsof KPMG and Ernst & Young, in accordancewith International Auditing Standards.
A copy of the full 2013 Financial Report
may be obtained at www.msf.org.
In addition, each national office of MSF
publishes annual, audited Financial
Statements according to its national
accounting policies, legislation andauditing rules. Copies of these reports
may be requested from the national offices.
The figures presented here are for the 2013
calendar year. All amounts are presented inmillions of euros.
Note: Figures in these tables are rounded,
which may result in apparent inconsistencies
in totals.

Where did the money go?
Programme expenses by nature
Locally hired staff
International staff
Medical and nutrition
Transport, freight and storage
Logistics and sanitation
Operational running expenses
Consultants and field support
Training and local support

Programme expenses by continent
33 %
23 %
18 %
12 %
6%
5%
2%
1%

The biggest category of expenses
is dedicated to staff working in thefield: about 56 per cent of expenditurecomprises all costs related to
locally hired and international staff(including plane tickets, insurance,
accommodation, etc).
The medical and nutrition category
includes drugs and medical
equipment, vaccines, hospitalisation
fees and therapeutic food. The
delivery of these supplies is includedin the category of transport, freightand storage.
Logistics and sanitation comprisebuilding materials and equipment
for health centres, water andsanitation and logistical supplies.

96 Facts and Figures

AfricaAsia
Americas
EuropeOceania
Unallocated

62 %
28 %
7%
2%
1%
1%

International Activity Report 2013
Countries where we spent the mostCountries where MSF expenditure is more than 10 million euros

in millions of euros

80
60
40
20

en
Ye
m

ia
er

i

ig

al
M

N

Et

hi

ki

st

op

ia

an

es
Pa

pp
ili

nm

Ph

ya
M

in

ar

a
ny
Ke

n
da

ist

Su

an

e
gh

an

ba

Af

m
Zi

n
Ce

nt

ra

lA

fri

ca

So

bw

ad
Ch

q
Ira

So

m

al

ia

er
ig
N

bl

Re

pu

Sy

ic

ria

ti
ai
H

ut

h

Su

D

da

n

RC

0

2013

2012

80
AFRICA70
Democratic Republic of Congo
60
South Sudan
50
Central African Republic
40
Niger
30
Somalia20
Chad
10
Zimbabwe
0
Sudan

2011

78.3

ASIA AND
THE MIDDLE EAST

Haiti

33.3

51.1

Syria

29.5

Colombia

5.5

26.0

Iraq

20.4

Mexico2.0

24.4

Afghanistan

18.7

Paraguay

1.6

21.2

Myanmar16.4

Honduras

20.0

Philippines

15.8

Other countries

19.9

Pakistan

14.2

17.1

Yemen

10.5

Kenya

16.9

India

9.1

Ethiopia

12.0

Lebanon

6.3

Mali

10.6

Uzbekistan

6.3

Nigeria

10.5

Palestine

3.5

Swaziland

9.9

Bangladesh

3.2

Malawi

8.5

Kyrgyzstan

3.0

Mozambique

7.8

Jordan2.8South Africa

7.3

Cambodia

2.5

Sierra Leone

6.6

Turkey2.3

Guinea5.8

Armenia

2.2

OCEANIA

Uganda5.0

Tajikistan

1.7

Papua New Guinea

4.4

Mauritania

4.1

Laos

1.0

Burundi

3.7

Iran

1.0

Total

4.4

Cameroon

2.0

Other countries *

1.8

Egypt

2.0

Madagascar

1.5

Libya

1.5

Other

3.2

Congo

1.4

Transversal activities

3.1

Côte d’Ivoire

1.2

Zambia

1.0

Total

6.3

Other countries *

1.8

Total

in millions of E

379.1

Total

THE AMERICAS
in millions of E

172.4

in millions of E

1.4
*

Total

0.2
44.1

EUROPE

in millions of E

Russian Federation

4.8

Ukraine

3.3

Other countries

*

Total

UNALLOCATED

1.6
9.8

in millions of E

in millions of E

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

Facts and Figures 97

Médecins Sans Frontières

WHERE DID THE MONEYCOME FROM?

2013

2012

in millions of e

percentage

in millions of e

percentage

Private

899.7

89%

838.9

89%

Public institutional

93.0

9%

82.7

9%

Other

15.9

2%

16.1

2%

1,008.5

100%

937.7

100%

in millions of e

percentage

in millions of e

percentage

Programmes

615.4

65%

619.4

66%

Income

HOW WAS THE MONEY SPENT?

2013

2012

Headquarters programme support

108.8

11%

103.9

11%

Témoignage/awareness-raising

30.2

3%

31.7

3%

Other humanitarian activities

9.3

1%

7.4

1%

Social mission

763.7

80%

762.4

81%

Fundraising

131.6

14%

124.8

13%

Management and general administration

57.1

6%

56.6

6%

0

–

0.1

–

Other expenses

188.8

20%

181.5

19%

Expenditure

952.5

100%

943.9

100%

Income tax

Net exchange gains/losses

-7.9

-4.8

Surplus/deficit

48.1

-11.1

YEAR-END FINANCIAL
POSITION

2013
percentage

in millions of e

percentage

616.3

81%

551.4

79%

Other current assets

87.3

11%

91.1

13%

Non-current assets

61.7

8%

57.4

8%

765.3

100%

699.9

100%

AssetsPermanently restricted funds

3.1

0%

3.4

–

627.7

83%

580.2

83%

Other retained earnings and equities

3.4

0%

15.0

2%

Retained earnings and equities

634.2

83%

598.6

85%

Current liabilities

131.1

17%

101.3

15%

Liabilities and retained earnings

765.3

100%

699.9

100%

Unrestricted funds

98 Facts and Figures

89 %
9%
2%

5
millionprivate donors

2012

in millions of e

Cash and cash equivalents

Private income
Public institutional income
Other income

IncomeExpenditure
Surplus1008.5952.5
48.1

International Activity Report 2013

HR STATISTICS

2013

2012

Medical pool

1,593

26%

1,548

26%

Nurses and other paramedical pool

1,892

30%

1,785

30%

Non-medical pool

2,714

44%

2,622

44%

International departures (full year)

6,199

100%

5,955

100%

no. staff

percentage

no. staff

percentage

Locally hired staff

29,91085%

29,22886%International staff

2,629

8%

2,592

7%

Field positions

32,53993%

31,820

93%

2,493

7%

2,326

7%

35,032

100%

34,146100%

Positions at headquarters
Staff

Locally hired staff
International staff
Headquarters staff

85%
8%
7%

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

Sources of income
As part of MSF’s effort to guarantee its independence andstrengthen the organisation’s link with society, we strive to maintaina high level of private income. In 2013, 89 per cent of MSF’s income
came from private sources. More than 5 million individual donors
and private foundations worldwide made this possible. Public
institutional agencies providing funding to MSF included, among
others, the European Commission’s Humanitarian Aid Department(ECHO) and the governments of Belgium, Canada, Denmark, France,
Germany, Italy, Ireland, Luxembourg, Norway, Spain, Sweden,
Switzerland and the UK.
Expenditure is allocated according to the main activities performed
by MSF. All programme expenditure categories include salaries,
direct costs and allocated overheads.
Social mission includes all costs related to operations in the field(direct costs) as well as all the medical and operational support fromthe headquarters directly allocated to the field (indirect costs). Social
mission costs represent 80 per cent of the total costs for 2013.

Permanently restricted funds may be capital funds, where donors
require the assets to be invested; funds retained for actual use,rather than expended; or the minimum level of retained earnings
that is compulsory for certain sections of MSF.
Unrestricted funds are unspent, non-designated donor funds
expendable at the discretion of MSF’s trustees in furtherance of oursocial mission.
Other retained earnings represent foundations’ capital as well as
technical accounts related to the combination process.
MSF’s retained earnings have been built up over the years bysurpluses of income over expenses. At the end of 2013, the available
portion (excluding permanently restricted funds and capital forfoundations) represented 7.9 months of the preceding year’s
activity. The purpose of maintaining retained earnings is to meetthe following needs: future major emergencies for which sufficientfunding cannot be obtained, a sudden drop in private and/or public
institutional funding, the sustainability of long-term programmes(e.g. antiretroviral treatment programmes), and the pre-financingof operations to be funded by forthcoming public fundraising
campaigns and/or public institutional funding.
The complete Financial Report is available at www.msf.org

Facts and Figures 99

Médecins Sans Frontières

Contact MSF
International Médecins Sans Frontières
78 rue de Lausanne Case Postale 116
1211 Geneva 21 Switzerland
T +41 22 849 84 84 F +41 22 849 84 04
www.msf.org

Humanitarian Advocacy and
Representation team(UN, African Union, ASEAN, EU, Middle East)
T +41 22 849 84 84 F +41 22 849 84 04
MSF Access Campaign
78 rue de Lausanne Case Postale 116
1211 Geneva 21 Switzerland
T +41 22 849 8405 www.msfaccess.org

Australia Médecins Sans Frontières /Doctors Without Borders
Level 4 1–9 Glebe Point Road
Glebe NSW 2037 Australia
T +61 28 570 2600 F +61 28 570 2699
office@sydney.msf.org www.msf.org.au
Austria Médecins Sans Frontières /Ärzte Ohne Grenzen
Taborstraße 10 1020 Vienna Austria
T +43 1 409 7276 F +43 1 409 7276/40
office@aerzte-ohne-grenzen.at
www.aerzte-ohne-grenzen.at
Belgium Médecins Sans Frontières /Artsen Zonder Grenzen
Rue Dupré 94 Dupréstraat 94
1090 Brussels Belgium
T +32 2 474 74 74 F +32 2 474 75 75
www.msf-azg.be
Canada Médecins Sans Frontières /Doctors Without Borders
720 Spadina Avenue, Suite 402 Toronto
Ontario M5S 2T9 Canada
T +1 416 964 0619 F +1 416 963 8707
msfcan@msf.ca www.msf.ca
Denmark Médecins Sans Frontières /Læger uden Grænser
Dronningensgade 68, 3. DK-1420 København K
Denmark
T +45 39 77 56 00 F +45 39 77 56 01
info@msf.dk http://msf.dk
France Médecins Sans Frontières
8 rue Saint Sabin 75011 Paris France
T +33 1 40 21 29 29 F +33 1 48 06 68 68
office@paris.msf.org www.msf.fr
Germany Médecins Sans Frontières /Ärzte Ohne Grenzen
Am Köllnischen Park 1 10179 Berlin
Germany
T +49 30 700 13 00 F +49 30 700 13 03 40
office@berlin.msf.org
www.aerzte-ohne-grenzen.de

100 Contact MSF

15 Xenias St. 115 27 Athens GreeceT + 30 210 5 200 500 F + 30 210 5 200 503
info@msf.gr www.msf.gr

UK Médecins Sans Frontières /Doctors Without Borders
67–74 Saffron Hill London EC1N 8QX UK
T +44 20 7404 6600 F +44 20 7404 4466
office-ldn@london.msf.org www.msf.org.uk

Holland Médecins Sans Frontières /Artsen zonder Grenzen
Plantage Middenlaan 14 1018 DD Amsterdam
Netherlands
T +31 20 520 8700 F +31 20 620 5170
office@amsterdam.msf.org
www.artsenzondergrenzen.nl

USA Médecins Sans Frontières /Doctors Without Borders
333 7th Avenue 2nd Floor New YorkNY 10001-5004 USA
T +1 212 679 6800 F +1 212 679 7016
info@doctorswithoutborders.org
www.doctorswithoutborders.org

Hong Kong Médecins Sans Frontières
無國界醫生 / 无国界医生
22/F Pacific Plaza 410– 418 Des Voeux
Road West Sai Wan Hong Kong
T +852 2959 4229 F +852 2337 5442
office@msf.org.hk www.msf.org.hk

Branch Offices

Greece Médecins Sans Frontières /Italy Médecins Sans Frontières /Medici Senza Frontiere
Via Magenta 5 00185 Rome Italy
T +39 06 88 80 60 00 F +39 06 88 80 60 20
msf@msf.it www.medicisenzafrontiere.it
Japan Médecins Sans Frontières /国境なき医師団日本
Waseda SIA Bldg 3F 1-1 Babashita-cho
Shinjuku-ku Tokyo 162-0045 Japan
T +81 3 5286 6123 F +81 3 5286 6124
office@tokyo.msf.org www.msf.or.jp
Luxembourg Médecins Sans Frontières
68, rue de Gasperich L-1617 Luxembourg
Luxembourg
T +352 33 25 15 F +352 33 51 33
info@msf.lu www.msf.lu
Norway Médecins Sans Frontières /Leger Uten Grenser
Hausmannsgate 6 0186 Oslo Norway
T +47 23 31 66 00 F +47 23 31 66 01
epost@legerutengrenser.nowww.legerutengrenser.no
Spain Médecins Sans Frontières /Médicos Sin Fronteras
Nou de la Rambla 26 08001 Barcelona Spain
T +34 93 304 6100 F +34 93 304 6102
oficina@barcelona.msf.org www.msf.es
Sweden Médecins Sans Frontières /Läkare Utan Gränser
Fredsborgsgatan 24 4 trappor Box 47021
100 74 Stockholm Sweden
T +46 10 199 33 00 F +46 10 199 32 01
info.sweden@msf.org
www.lakareutangranser.se
Switzerland Médecins Sans Frontières /Ärzte Ohne Grenzen
78 rue de Lausanne Case Postale 116
1211 Geneva 21 Switzerland
T +41 22 849 84 84 F +41 22 849 84 88
office-gva@geneva.msf.org www.msf.ch

Argentina
Carlos Pellegrini 587 11th floor C1009ABK
Ciudad de Buenos Aires Argentina
T +54 11 5290 9991 www.msf.org.ar
BrazilRua do Catete, 84 Catete Rio de Janeiro
CEP 22220-000 Brazil
T +55 21 3527 3636 F +55 21 3527 3641
www.msf.org.br
Czech Republic
Lékari bez hranic, o.p.s Seifertova 555/47
130 00 Praha 3 – Žižkov Czech Republic
T +420 257 090 150 www.lekaribezhranic.cz
India
AISF Building 1st & 2nd Floor Amar Colony,
Lajpat Nagar IV New Delhi 110024 India
T +91 11 490 10 000 F +91 11 465 08 020
www.msfindia.in
Ireland
9–11 Upper Baggot Street Dublin 4
Ireland
T +353 1 660 3337 F + 353 1 660 6623
www.msf.ie
MexicoChampotón #11 Col. Roma Sur
CP 06760 Ciudad de México Mexico
T +52 55 5256 4139 F +52 55 5264 2557
www.msf.mx
South Africa
Orion Building 3rd floor 49 Jorissen Street
Braamfontein 2017 Johannesburg South Africa
T +27 11 403 44 40 F +27 11 403 44 43
www.msf.org.za
South Korea
5 Floor Joy Tower B/D 7 Teheran Road 37-gil
Gangnam-gu Seoul 135-915 South Korea
T +82 2 3703 3500 F +82 2-3703 3502
www.msf.or.kr
United Arab Emirates
P.O. Box 65650 Dubai UAE
T +971 4457 9255 F +971 4457 9155
www.msf-me.org

About this report
Contributors
Corinne Baker, Igor G. Barbero, Aurélie Baumel, Niklas Bergstrand, Pierre Borelle,
Talia Bouchouareb, Andrea Bussotti, Brigitte Breuillac, Amandine Colin, Lali Cambra,
Giorgio Contessi, Stefan Dold, Silvia Fernández, Isabelle Ferry, Sarah-Eve Hammond,
Solenn Honorine, Karem Issa, Nicole Johnston, Joanna Keenan, Aurélie Lachant,
Sophie-Jane Madden, Samantha Maurin, Sally McMillan, Robin Meldrum, Isabelle Merny,
Agustin Morales, Rebecca Murray, Heather Pagano, Nondas Paschos, Catrin Schulte-Hillen,
Faith Schwieker-Miyandazi, François Servranckx, Sandra Smiley, Shumpei Tachi, Clara Tarrero,
Fiona Terry, Frank Theunissen, Ann-Marie Wilcock, Pascale Zintzen.
Special thanks to
Valérie Babize, Kate de Rivero, François Dumont, Marc Gastellu Etchegorry, Silvia Fernandez,
Nicole Johnston, Erwin van ’t Land, Caroline Livio, Jérôme Oberreit, Emmanuel Tronc.
We would also like to thank all the field, operations and communications staff who
provided and reviewed material for this report.
English Edition
Managing Editor Sara Chare and Linda Nagy
Editor and Writer Caroline Veldhuis
Editorial Support Robert Bartram
Photo Editor Bruno De Cock
Copyeditor Kristina Blagojevitch
French Edition
Editor Laure Bonnevie, Histoire de mots
Translator Translate 4 U sarl (Aliette Chaput, Emmanuel Pons)
Spanish Edition
Coordinator Silvia Fernández
Translator Pilar Petit
Editor Cecilia Furió
Arabic Edition
Coordinator Jessica Moussan-Zaki
Translator Bruno Barmaki
Editor Jessica Moussan-Zaki
Designed and produced by
ACW, London, UK
www.acw.uk.com

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

Médecins Sans Frontières (MSF) is an international,
independent, medical humanitarian organisation that delivers
emergency aid to people affected by armed conflict, epidemics,
exclusion from healthcare and natural disasters. MSF offers
assistance to people based on need and irrespective of race,
religion, gender or political affiliation.
MSF is a non-profit organisation. It was founded in Paris, France
in 1971. Today, MSF is a worldwide movement of 23 associations.
Thousands of health professionals, logistical and administrative
staff manage projects in 67 countries worldwide.
MSF International is based in Geneva, Switzerland.
MSF International
78 rue de Lausanne, CP 116, CH-1211, Geneva 21, Switzerland
Tel: +41 (0)22 849 8400, Fax: +41 (0)22 849 8404
COVER PHOTO
Critically ill child being cared for by MSF at M’poko camp, Bangui airport.
© Pierre Terdjman / Cosmos