MSF Activity Report

MSF Activity Report July 2005 – July 2006

Médecins Sans Frontières (MSF) was founded
in 1971 by a small group of doctors and journalists
who believed that all people should have accessto emergency relief. MSF was one of the first
nongovernmental organisations to provide urgently
needed medical assistance and to publicly bear
witness to the plight of the people it helps.
Today MSF is an international medical humanitarian
movement with branch offices in 19 countries.
In 2005, over 2225 MSF volunteer doctors, nurses,
other medical professionals, logistical experts,
water and sanitation engineers and administrators
joined approximately 25,850 locally hired staff
to provide medical aid in over 70 countries.
MSF was awarded the 1999 Nobel Peace Prize.

2005/06

MSF International Office Rue de Lausanne 78, Case Postale 116, CH-1211 Geneva 21, Switzerland
T (+41-22) 8498 400, F (+41-22) 8498 404, E office-intl@bi.msf.org, 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

About this publication
FE AT U R E W R I T ER S
Nathalie Borremans, Leopold Buhendwa, Dieudonné Bwirire, Fabien Dubuet, Margaret Fitzgerald,
C. Foncha, Moses Massaquoi, Marilyn McHarg, Dalitso Minsinde, Rodrick Nalingukgwi, Fasineh Samura,
Milton Tectonidis, Emmanuel Tronc

sector workers and is also open to all other professions whichmight help in achieving its aims.
All of its members agree to hounor the following principles:Médecins Sans Frontières provides assistance to populations
in distress, to victims of natural or man-made disasters andto victims of armed conflict. They do so irrespective of race
religion, creed or political convictions.
Médecins Sans Frontières observes neutrality and impartiality

CO U N T RY T E X T A N D S I D EBA R M AT ER I A L W R I T T EN BY
Emma Bell, Claude Briade, Lucy Clayton, Gabi Faber-Weiner, Petrana Ford, Stephan Grosserueschkamp,
Lisa Hayes, Jean-Marc Jacobs, Anthony Jacopucci, James Lorenz, Alessandra Oglino, Susan Sandars,
Diderik van Halsema, Erwin van ‘t Land
S PE CI A L T H A N K S TO
Anne Ameye, Laure Bonnevie, Marine Buissonnière, Anouk Delafortrie, Rowan Gillies, Tory Godsal,
Olivier Guillerminet, Lisa Hayes, Myriam Henkens, Florence Licci, Miquel Maldonado, Barry Sandland,
Miriam Schlick, Nicolas de Torrente, Emmanuel Tronc, and all the field, operations and communications
staff who reviewed material for this report.
ED I TO R Caroline Veldhuis
PH OTO ED I TO R S Bruno de Cock, Sofie Stevens
CO PY ED I TO R Melissa Francoin the name of universal medical ethics and the right to humanitarian assistance and claims full and unhindered freedom inthe exercise of its functions.
Members undertake to respect their professional code of ethics
and to maintain complete independence from all political,
economic or religious powers.
As volunteers, members understand the risks and dangers ofthe missions they carry out and make no claim for themselves

A R A B I C ED I T I O N
CO O R D I N ATO R Mohamed Naji
T R A N S L ATO R Brahim El-Khazrouni
ED I TO R Mohamed NajiFR EN CH ED I T I O N
CO O R D I N ATO R Corinne Cecilia
T R A N S L ATO R Emmanuel Pons
ED I TO R Corinne Cecilia
I TA L I A N ED I T I O N
CO O R D I N ATO R Barbara Galmuzzi
T R A N S L ATO R Selig S.a.S.
ED I TO R Barbara Galmuzzi

or their assigns for any form of compensation other than thatwhich the association might be able to afford them.

S PA N I S H ED I T I O N
CO O R D I N ATO R Mar Padilla
T R A N S L ATO R Pilar Petit
ED I TO R Eulalia Sanabra
G R A PH I C D E S I G N Studio Roozen, Amsterdam, The Netherlands
PR I N T I N G Drukkerij Mercurius, Wormerveer, The Netherlands

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

COVER PHOTO
Patients in the post-operation ward at the MSF Bon Marché Hospital, Bunia,
Democratic Republic of Congo, May 2005.
© Gary Knight (VII)2005/06

Contents
MSF Missions around the World

2

The Year in Review

4Rowan Gillies, President, MSF International Council
and Marine Buissonnière, MSF Secretary General

The Challenge of an Emergency in a World in Flux

7

Marilyn McHarg, General Director, MSF Canada

Acute Malnutrition: A Highly Prevalent, Frequently Fatal,
Imminently Treatable, Neglected Disease10

Milton Tectonidis, MSF nutrition expert

Doing More by Doing Less:
Decentralising HIV/AIDS Care in Rural Malawi

13

MSF Team in Thyolo, Malawi: Fasineh Samura, Rodrick Nalingukgwi,
C. Foncha, Dieudonné Bwirire, Leopold Buhendwa, Margaret Fitzgerald,
Dalitso Minsinde, Moses Massaquoi, Nathalie Borremans

United Nations: Deceptive Humanitarian Reforms?

16

Fabien Dubuet, UN Liaison Officer and Emmanuel Tronc,
Policy and Advocacy Coordinator, MSF International

Democratic Republic of Congo: Forgotten War

18

Photo Essay

Medical Conditions Frequently Treated by MSF

25

MSF Projects around the World

27

AfricaAsia and the Caucasus

53

The Americas

67

Europe and the Middle East

75

Project Handovers

83

Overview of MSF Operations

84

Audited Facts and Figures

85

Contact MSF

88

MSF Missions
around the WorldPOLAND P.80

BELGIUM P.76
LUXEMBOURG P.78
SWITZERLAND P.80
FRANCE P.76
ITALY P.77
LEBANON P.81
PALESTINIAN TERRITORIES P.82
MOROCCO P.42
NIGER P.44
MALI P.42

BURKINA FASO P.30
GUINEA P.37
GUINEA-BISSAU P.38
SIERRA LEONE P.46
LIBERIA P.40

GUATEMALA P.73
HONDURAS P.69
HAITI P.72
ECUADOR P.68
COLOMBIA P.70
PERU P.74
BOLIVIA P.68

IVORY COAST P.38
BENIN P.29
NIGERIA P.44
CAMEROON P.32
REPUBLIC OF CONGO P.34
DEMOCRATIC REPUBLIC OF CONGO P.34
ANGOLA P.28
SOUTH AFRICA P.50

2005/2
2 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006

RUSSIAN FEDERATION P.78

IRAN P.59
ARMENIA P.54
GEORGIA P.54

TURKMENISTAN P.65
UZBEKISTAN P.66
KYRGYZSTAN P.61
PAKISTAN P.63

JAPAN P.59
SOUTH KOREA P.66

CHINA P.56
CHAD P.32

LAOS P.61

SUDAN P.48

NEPAL P.62

E THIOPIA P.36

INDIA P.58

MALAYSIA P.61

CENTRAL AFRICAN REPUBLIC P.31
SOMALIA P.47
KENYA P.39
UGANDA P.50
R WANDA P.45
BURUNDI P.30

BANGLADESH P.55
MYANMAR P.60
THAILAND P.64
CAMBODIA P.56
INDONESIA P.57

TANZANIA P.46
MALAWI P.41
MOZAMBIQUE P.43
ZAMBIA P.52
ZIMBABWE P.52
LESOTHO P.40

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 3

The Year in Review

In July 2006, amid intensifying armed conflict
between Israeli Defense Forces (IDF) and LebaneseHezbollah fighters, MSF launched an emergency© Zohra Bensemra/REUTERS

intervention to help address medical-humanitarianneeds. Assistance was offered on the Israeli side
dealing with civilian deaths and injured from rocket
attacks; however the nature of the conflict was suchthat there were greater needs and less available
assistance in Lebanon.

With a high intensity bombardment cutting
major roads and bridges throughout thecountry, transportation was difficult anddangerous, compelling MSF to make publicstatements reminding those engaged in theconf lict that they had a responsibility toallow assistance to reach civilians caught in
the fighting. Though vociferous in suchdemands, MSF retained its neutrality byrefraining from commenting on specificmilitary decisions of either side. This independent and impartial approach to the provision of aid allowed us to move and assist
in a context where almost all movement wasprevented.

4 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006

The difficulties reaching people in need in
Lebanon are illustrative of a growing problem of access that MSF has confronted overthe past year. Despite the relative simplicity
of our mission – to provide impartial medical-humanitarian assistance to those inneed and prevent loss of life – our ability toobtain access to patients can rarely beMany of the people we help are trapped within highly
charged and complex social and political contexts thatcreate significant barriers to the provision of aid.

diminishing and underfunded aid madeavailable to them. Outside the camps, especially in West and North Darfur, violenceagainst civilians continues, accompanied bya significant increase in targeted attacks
against aid workers including MSF staff,
making land travel and logistical assistanceclose to impossible.
MSF has been working in Darfur since early
2004 and intends to stay as long as we areable to be effective, although the situation
is becoming increasingly precarious.
Serious security incidents have forced us toreduce activities in the Jebel Marra region,
despite an ongoing cholera outbreak, andwe can no longer send surgical referrals byroad for emergency care. This reduction in
the ability to provide basic assistance islikely to have a critical impact on an alreadyfragile health situation.
Likewise in Sri Lanka, a country where we
worked for many years during the conf lict,seventeen aid workers from the NGO Action
Contre la Faim were executed in July 2006.
The perpetrators of this outrage have notbeen identified. With such attacks on clearly identified aid workers, there is a grave
concern for the future of assistance in thiscountry. MSF is struggling to get access toareas where there is no humanitarianassistance at all in this brutal civil war.

An unhealthy mix

An MSF convoy transporting emergency medical supplies and fuel remained stuck north of the Litani
River after an airstrike destroyed the last bridge. Four tonnes of supplies were carried by hand over 500
metres using a human chain. A tree trunk spanning the river was used as a makeshift bridge.

assumed. Many of the people we help aretrapped within highly charged and complex
social and political contexts that create significant barriers to the provision of aid.

Security concerns
At the time of writing, humanitarianorganisations have been reducing activities

or pulling out of Darfur, Sudan. Over a
million people have been living a survival
existence with ‘adequate’ health parameters for over two years in camps in Sudan
and Chad, disguising an utter lack of hopeand despair that pervades these islands ofassistance. These are the lucky ones who
manage to have sustained contact with theOver the past year, there has been a mounting distrust toward aid organisations by
those who have the power to grant us
access. This mistrust is not always misplaced. The practice of some nongovernmental organisations (NGOs), private contractors and many governments doing‘humanitarian’ work with a specific political aim causes confusion, and reduces theacceptance of the universal nature ofhumanitarian assistance. This contributes
to a climate where groups opposed to any
underlying political aim use confusion as
an excuse to attack aid workers.
This mounting distrust is just one of theongoing challenges of providing emergency
assistance discussed in an article in thesepages by Marilyn McHarg, who underscores
our need to adapt to and anticipate not only
a changing humanitarian landscape, butalso dynamic social, political and even geographical environments in order to identify

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 5

Numbers mean little without reflecting on therelevance of the assistance and the quality of
our work.

where and how we can best provide effective assistance. Addressing the problem ofaccess, she proposes that new strategies
must necessarily be developed to carry out
our work. As this report goes to press, weare launching a new project to provide
reconstructive surgery for wounded Iraqis
in Jordan and working with Iraqi medicalgroups to assist them in responding to theeffects of daily violence in that country.

26,000 people with cholera in Angola in thespring of 2006, the largest outbreak of thisdisease in that country in over a decade.
But these numbers mean little without
ref lecting on the relevance of the assistanceand the quality of our work: each patient ismuch more than a statistic and we must be
sure that if we treat someone for malaria,
for example, that they get a humane consultation, the right diagnosis and treatment.

Coordination: not a panacea

Particularly when we have access to fieldappropriate medical and logistical tools, weare able to adopt new methods of treatment
to provide relevant and quality care. A novel approach to an old problem of treating
malnourished children, mobile feeding centres and the availability of an effective,
portable nutritional rehabilitation producthelped MSF carry out its largest and mostsuccessful response to child malnutritionin Niger in 2005. 63,000 severely malnourished children were admitted to programmes, where record cure rates wereachieved. Dr. Milton Tectonidis explains
this intervention and its importance in an
essay within this report – an undertaking
that allowed us to demonstrate that deathby malnutrition is not necessarily inevitable
and can more and more be equated withdeath by neglect.

With an ever-growing number of aid organisations, there are now increasing attempts
to coordinate humanitarian assistance tocontrol and direct this assistance in a certain direction. Superficially coordination
can have positive results allowing various
agencies to use their strengths within acomprehensive response; however, “lack of
coordination” is currently used as a blanket
excuse for every failing of aid assistance. In
some cases, it is not a failure of aid but
rather a deliberate and politically motivatedlack of access to aid for people in need. The
intricacies and potential dangers of coordination being provided as a sole response to
the failures of aid in the past is discussed inthis report by Fabien Dubuet andEmmanuel Tronc, who outline MSF’s position whilst the UN implements changes in
its system of aid assessment and delivery.
MSF remains careful to separate itself fromthese processes, instead relying on independence of assessment and action to
respond to specific needs of specific populations, rather than contributing to a global
framework of dubious origins and effectiveness. Independent and impartial assessment
is not only a principled, but also a practical
approach that allows us safe and rapid
access to people in need.

Effective responses
Despite our concerns around these issues,
our records over the past year show a massive volume of medical care to individuals
and families around the world: thisincludes doing more life-saving surgery,treating more malaria, and offering mental
health support to more people than everbefore. MSF in 2005 provided medicalhumanitarian assistance to over 10 million
people, including assistance in major emergency responses following an Octoberearthquake in Asia, and treatment for

Similarly, as we continue to provide a full
package of HIV/AIDS prevention and treatment to people and communities in 32
countries, our developing strategy is todecentralise care and increase the numberof sites where treatment is available – anapproach described in this report by ourteam in Thyolo, Malawi. The size of scaleup that is truly needed, however, continues
to be limited by a shortage of humanresources and the state of health systems inmany countries. It is unrealistic to believethat these issues will be solved sufficiently
to treat everyone with HIV/AIDS. A comprehensive response to this epidemic is precluded by a disgraceful lack of drugs, diagnostics and monitoring tools developed forresource-poor countries, who instead must
make do with the detritus of westernfocused research. More appropriate tools
are urgently needed to address this crisis
head-on, to treat many more people despite
the human resources and structural crises.
While we are buoyed by the outcomes of

6 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006

our interventions in 2005/2006, we also
recognise that MSF can only offer immediate and time-limited solutions. It must be
clear that the modest improvements we canmake should be viewed neither as an opportunity for governments and internationalorganisations to abdicate their responsibilities, nor an alibi for political inaction.
Speaking out and raising awareness of thisneglect is how we avoid covering up the
problem. This year, we include in thisreport a selection of photos of people fromthe Democratic Republic of Congo – where
human needs have largely been ignored by
the international community.
Self-criticism is an essential element of MSF
and the 19 sections of MSF went through aninternal process this past year aimed at
improving our operations and governancestructure. Developing from this is a commitment to maintain the transparency of
our actions and concretely increase theaccountability we display to those we assist
and the donors that generously assist ourwork, for it is reliance on individual donors
that allows us to act quickly and independently and in response to human needs.
We see this accountability as a potent tool
to ref lect openly on our operations andimprove them significantly as we meet new
challenges and obstacles. MSF will continue
to look for new ways to manoeuvre past
whatever barriers may arise, logistical,
security or political and assist those whoare being neglected – firmly grounded in
our identity, and our intention to provide
quality medical care for people who would
otherwise have none.
Rowan Gillies, M.B.B.S.
President, MSF International Council
Marine Buissonnière
MSF Secretary General© Bruno Stevens/Cosmos

BY M AR I LY N M CHA R G , G EN ER A L D I R EC TO R , MSF C ANADA© Didier Lefevre / imagesandco.com

The Challenge of an
Emergency in a World in Flux
As the world has changed, so has our response to emergencies. In thepast, a typical MSF emergency intervention saw us responding to refugees
within defined camps bordering war zones, to malnourished children
located in geographic pockets, to communities suffering from cholera outbreaks or meningitis epidemics, and other emergency situations such as
periodic floods, droughts or earthquakes.

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 7

With the effects of the tsunami, malnutrition in Niger andcholera in DRC, among many others, MSF has continued
to focus on responding to those most in need.

As a medical-humanitarian organisation, emergencies within crisis
situations have always been at the heart of our action, and our
response has focused on medical interventions. With time andexperience, our technical capacity to respond to urgent medical
needs has improved. Our inf latable hospital in Mansehra, Pakistan,an earthquake setting where pre-existing infrastructure had collapsed, is but one example of the evolution of emergency medical
action and resulting capacity to implement highly developed medical, surgical, and intensive care services.
Although these types of emergencies continue, the character andcomplexity of our contexts places new demands on us. To a large
extent, more conventional wars between states have been replaced
by internationally inf luenced guerrilla wars fought within countries. Underlying these conf licts, ideological motivations or territorial gains are more the exception, with economic motivations
becoming more the rule. Civilians, normally seen as those to beprotected in conf licts, are often used as commodities of war andbecome trapped or targeted as a result. The violence against civilians is frequently used as a means of diminishing opposing elements, meanwhile abduction or looting of civilians – sometimes
children, as in Uganda, where up to 20,000 children have been kidnapped and inducted into the Lord’s Resistance Army – havebecome standard strategies in gaining strength against an enemy.

Changing perceptions
With this degradation, there has been a weakening of respect for aid
and humanitarian interventions. Increasingly, belligerents of war
perceive us as either feeding into or aggravating warring agendas,much the same way they view the civilians we aim to support. With
many warring actors fragmented along various lines, it has become
increasingly difficult to negotiate our presence and also to maintainthe security of MSF staff in areas where access is accomplished.

identification and response more difficult. In Colombia, for example, ongoing conf lict has caused the displacement of over two million people and many are in need of medical and psychological care;however, these people are scattered and sometimes hidden within
urban centres, requiring us to seek out those needing assistance andlaunch multiple projects to reach a more diffuse population.
More recent global developments have also impacted on needs andour capacity to respond. As polarisation between various fundamentalist western elements and extremist Islamic groups intensifies, the capacity for organisations such as MSF to independently
respond to any humanitarian needs, free from any falsely based
accusations of political alliances, becomes increasingly limited andposes greater security risks. Aid workers are not in these contexts
to choose sides or to die, rather they are there to save others’ lives,and as global polarisation becomes more entrenched, overcoming
these barriers in order to respond to emergencies becomes increasingly difficult.

Assisting in middle-income countries
As major humanitarian crises occur more in middle-income countries, the type of our emergency response has required adaptation.
Historically, MSF has mostly responded to situations in subSaharan Africa, where infrastructure collapse has meant few staff
were available and disease patterns typically included tropical illnesses such as malaria, diarrhoea and many other infectious diseases. Within middle-income countries such as Lebanon and Iraq,
our classic emergency response has been tested with the presence ofsufficient numbers of capable staff and epidemiological patterns
that are more typical of western countries, with chronic diseases
being among the most urgent. Our medical policies, supplies andprotocols need to encompass chronic diseases such as cardiac disease, diabetes, asthma and epilepsy, among others.

Added to this, there are more and more aid organisations and agencies involved in the business of aid. Many have different values,
goals and strategies that confuse the perception of MSF. We havealways believed that our reliance on principles such as impartiality
and independence secures our capacity to safely intervene whereneeds are greatest. However, the multiplicity of actors has blurred
our distinction and with it, increased the risk of being erroneously
seen as part of political or even military agendas. This limits ourcapacity to engage in unhindered action for those most in need.

These middle-income contexts have also challenged MSF to develop new strategies and play a more secondary role whilst engaging in
more partnerships. In the summer of 2006 our medical activities in
Lebanon were in some ways unusual for MSF, conducted alongside
well-developed medical resources and included helping provide
supplies and treatment for chronic diseases, kidney disease in particular. It is likely we will be called upon to assist in this manner inthe future.

Displaced within borders

MSF has responded to a number of natural disasters through theyears, but these emergencies have not been seen as one of our maininterventions. Usually, MSF has struggled to find a role, as the mosturgent needs tend to be related to rescue, followed by logistical support. Most needs are answered by armies, national actors, andthrough local solidarities. The incredible local response of Sri
Lankans to the 2004 tsunami limited our need to intervene there.
Similarly, the Pakistani army was highly effective in its activities following the October 2005 earthquake in southern Asia.

Accessing populations also becomes more difficult with the changes
in population movements. In the past, populations facing war would
displace themselves to safer areas beyond their borders and cluster
into camps. The classic situation was characterised by groupings ofpeople in distinct locations where health risks were increased
because of the stress of displacement and crowding under austereconditions. We have increased our capacity to clearly identify thosein need and quickly provide needs-based responses in these situations. But today, more and more people displace themselves within
their borders, integrating into cities, smaller communities or otheropen settings so their locations are not as evident, making needs

8 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006

Learning from natural disasters

The needs for medical response in these situations, although present,
do not always amount to substantial medical interventions. Pakistan© Bruno Stevens/Cosmos

was an exception. With destruction of small buildings in remote areas, there were relatively more injured demanding a medical response,and fewer deaths. But usually this is not the case – survivors ofearthquakes and other natural disasters usually present limited injuries, whilst their major needs include shelter, water, sanitation, andfood. All interventions MSF can do, but usually on a small scale andin support of medical interventions.
In the future, however, factors including increasing environmental
degradation and climate change may well contribute to changes in
epidemiological patterns and a greater number of natural disasters
such as droughts and f loods. Although these events are highly
unpredictable in nature, we should be aware of what exactly we areable to provide to people in distress and be ready to respond with thestrengths we have developed.
By accepting our limits, but continuing to develop our corestrengths, we can advance our response. It is clear there are others
better able to respond in the first phase of natural disasters andintervening in the very first hours of a rescue phase requires anexpertise and logistical capacity that MSF does not have. We are
better placed to direct our efforts in the survival phase – this work
has synergies with interventions in other settings and facilitates thedevelopment of our specialities instead of potentially diluting themby broadening our scope. Emergency surgery is a particular activity
we have identified as a focus area. We are increasing our capacity for
emergency surgery and other specialised medical services – forexample we now routinely send nephrologists to the field to treat
crush syndrome, a condition characterised by renal (kidney) failure
and often seen in people who have survived a building collapse precipitated by earthquakes or bombings. Mental health, nutrition andmonitoring for epidemics amongst displaced persons in crowded
living spaces are also areas that overlap with our medical interventions elsewhere. These are aspects we need to further build up andadapt to evolving situations.

Treating emerging diseases

orrhagic diseases such as Ebola in parts of Africa have demanded
highly specialised and culturally adapted responses, which so far
have been limited in success due to the complexity resulting fromthe interplay between cultural orientations and needed medical
interventions. In Angola in 2005, an outbreak of Marburg haemorrhagic fever required us to wear bio-safety gear, which frightened
local community members. Further, people with the illness had tobe isolated to prevent the spread of this highly infectious disease.
Many of these patients died, so it was perceived that people separated out by MSF were meant to die, and community members
became reluctant to seek help for those who were sick. Such misunderstandings underscore the need for cultural sensitivity in situations where we cannot anticipate how our tools and approaches
may be received.
Likewise, a recent MSF intervention in a plague outbreak in Ituri,
Democratic Republic of Congo (DRC) highlighted the need for
MSF to continue in its pursuit of understanding such diseases,
their spread, and necessary treatment within various contexts – inthis case, an isolated war setting. Emerging diseases such as avian
f lu also demand highly specialised responses. But like any intervention by MSF, choices must be made and an avian f lu outbreakhighlights this dilemma more than ever. Our capacity to take onsuch a pandemic will be limited, though it should not inhibit our
preparedness to do what is possible, where it is possible.
2005 has been a demanding year for MSF in terms of emergency
response. With the effects of the tsunami, malnutrition in Niger
and cholera in DRC, among many others, MSF has continued tofocus on responding to those most in need. Although these
responses in their own right were of value and laid further foundation to whatever emergency responses are required in the future,
the challenges ahead in this changing world will place further
demands on us. Ours is a challenge of continued adaptation andevolution in order to ensure we are assisting those most in need ona medical basis and to the best of our abilities.

Changes in epidemiological patterns are among the greatest challenges ahead for MSF. Recent increases in frequency of viral haem-

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 9BY D R . M I LTO N T EC TO N I D IS , MSF N U T R I T I O N E XPER T

Acute Malnutrition: A highly prevalent,“…‘regular’ starvation has to be distinguishedfrom violent outbursts of famines…
Problems of: (i) existence of much regular
starvation, (ii) worsening trend of regular
starvation, and (iii) sudden outbreak of acutestarvation, are quite distinct…”(Amartya Sen, Poverty and Famines 1981)

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

10 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006

frequently fatal, imminently treatable, neglected disease

Niger is a country with chronically highlevels of what Nobel Prize winning economist Amartya Sen calls “regular starvation”. Other terms used are chronic hunger or under-nutrition. The Food &Agricultural Organization estimates
there are over 800 million undernourished, having access to less than their
daily requirement in food energy to benormally active. Economists view chronic food shortage in such large populations as a failure of development. Many
public health advocates actually playdown the link between food scarcity andchildhood malnutrition in poor countries, insisting instead on “inadequate
infant and young child feeding practices”, or, to a lesser extent, on poor accessto health services or clean water. Outsideof major crises, the usual proposed package of preventive and curative childhealth interventions rarely includes thetreatment of even the severest cases ofacute malnutrition.1
Severe acute malnutrition defines a formof malnutrition that bears a particularlyhigh risk of death but which neverthelessresponds rapidly to treatment. Individual
cases are diagnosed either on the basis of
the degree of emaciation or “wasting,” asmeasured by the weight to height ratio,or by the circumference of the mid-upperarm (marasmus); or by the presence of“water in the tissues” (oedematous malnutrition or Kwashiorkor). Moderate cases of acute malnutrition are those with aslightly less abnormal weight to heightratio. Unicef estimates there are over 60
million children suffering from acutemalnutrition (wasting) at any given
moment. Thirteen million of them areseverely wasted, whilst many others areaffected by Kwashiorkor. Acute malnutrition is implicated in over five million
preventable deaths yearly amongst young
children. 2
The Maradi region alone accounted for
39,353 admissions for severe malnutrition to MSF therapeutic feeding programmes in Niger in 2005. Over 95% ofcases occurred amongst children lessthan 30 months old, and the majority(over 60%) were admitted during athree-month period between mid-Julyand mid-October corresponding to theclassic hunger gap (over 80% between
June and November). Yearly admissionsin Maradi were four times higher than
the number admitted into the MSF programme in 2004. In some southern, ruralcantons of Maradi in 2005, almost half
the children between six and 24 monthsof age developed severe acute malnutrition during the year and were admitted
to an MSF therapeutic feeding programme.
It is inconceivable that infant and childfeeding practices can account for suchlarge seasonal and yearly variations inadmissions for severe acute malnutritionin Niger. Nor can this variation be
explained by increased exposure to disease and poor access to healthcare or
clean water. Such variations are largely
due to nutritional stress in the hunger
gap period, particularly in years following poor harvests. At these times, thequality and limited diversity of the diet isoften even more limiting than the caloric
and protein content of available food.
Over the past 20 years, clinical nutrition
research has increasingly concentrated

on the role played by micronutrient dietary deficiencies, typically associatedwith the monotonous, cereal-based dietsof rural-poor populations, in growth failure and malnutrition. Deficiencies intrace metals, sulphur, phosphorus, certain vitamins and other micronutrients
have particularly deleterious effects on
young children in the first two, critical
years of life. 3 Many easy-to-use, fortified,nutrient-rich products specificallydesigned for this age group to help prevent deficiency exist on the market indeveloped countries for those with themeans to purchase them. Any attempt toreverse the high rates of malnutrition incountries such as Niger has to address thedifficulty poor, rural populations face inproviding a sufficiently nutrient-rich dietfor their young, rapidly growing children.

Stepping up the treatment of
acute malnutrition
Results obtained in Niger in 2005 inrehabilitating large numbers of severely
malnourished children are exceptional.
Over 91% of severely malnourishedpatients from Maradi region (34,247 children) exited the programme cured, thatis, no longer acutely malnourished.
Providing individualised, therapeutic
treatment to such large numbers ofpatients had never been accomplished in
the large famines of the recent past in
Ethiopia, Somalia and Sudan. What haschanged? Until recently the World HealthOrganization (WHO) recommended that
all cases of severe acute malnutrition betreated with therapeutic (high energy,
nutrient fortified) milks, in therapeutic
feeding centres or inpatient wards of hospitals.4 Although high cure rates are
obtained by humanitarian agencies using
therapeutic milks in feeding centres during major crises, such specialised centres
represent a significant investment in staff
and infrastructure, are costly, and have
limited capacity at any one time. 5
Moreover, demands on a patient’s family
posed by prolonged inpatient feeding(generally several weeks) discourages
participation, lowers programme coverage and increases the number of children
who default before cure.
It is not completely surprising then, thatoutside large emergencies, the treatment© Didier Lefevre / imagesandco.com

Debate ensued over the nature of the
Niger crisis in 2005 and the appropriateness of the response, as internationalrelief efforts were finally stepped up in
July. There were objections to the use of
the term famine to describe the emergency, and resistance to providing free foodaid as a response until late into the hunger gap period, when food reserves fromthe previous year’s harvest were exhausted, and the steep price of staple fooditems on the market had broken all previous records.

© Henk Braam

Regular starvation in Niger andbeyondACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 11

of severe acute malnutrition has not been
seen as a priority by international publichealth consultants, and that few countries
with limited resources have made attempts
to integrate the treatment of acute malnutrition into their healthcare services. In thecase of Niger, a country where there are,depending on the season and year, between
250,000 and 500,000 acutely malnourishedchildren at any given time, no effective
nutritional rehabilitation programmes forseverely malnourished patients existed outside the MSF Maradi programme until July
2005.
The introduction of Ready to Use
Therapeutic Foods (RUTF) over five years
ago is changing perceptions and practices. 6
These nutrient-rich products designed for
rapid weight gain do not require preparation or the addition of water, and the energy-dense paste is impossible to contaminate. They are tailored for malnourishedchildren with poor appetites and small
stomachs who need to consume high quantities of calories. Small, severely malnourished children can gain one to two kilograms in a few weeks.
These factors make such products ideal for
outpatient use, and mothers quickly grasp
the therapeutic nature of the product. The
MSF experience in Niger in 2005 shows thatmost cases of severe, acute malnutrition canbe cured through attendance at outpatient
centres at regular, weekly intervals. Over
65% of severely malnourished children
were admitted directly into outpatient care,and the majority never required hospitalisation during the entire course of theirtreatment. Almost 85% of all admissions
finished their treatment as outpatients. The
average time to cure was less than a month.
Inpatient units are needed to handle referrals for complications such as anorexia,
weight loss, severe infection or anaemia.
There were almost 1000 deaths amongst
patients admitted to MSF inpatient centres
in Maradi in 2005; however, over 6200 others were discharged cured or referred backto an outpatient programme after having
spent less than two weeks on average as
inpatients.
The availability of a simple to use and effective therapeutic product permitted MSF toadmit record numbers of patients into its
feeding programmes in Niger in 2005. Such
new products and strategies open new possibilities for nutritional intervention in large
emergencies, and in situations with highlevels of childhood malnutrition. In Maradi
in 2006, MSF is treating all malnourished,severe and moderate, with the same therapeutic treatment regimen. The severely malnourished have higher rates of mortality,
but most malnutrition-related deaths occur
amongst the far more numerous, moderately
malnourished group. On an individual level,
all are at increased risk of death and disease,and most can be quickly cured when thebest available therapeutic, nutritional product is given to them. MSF is looking at ways
to further simplify outpatient managementof acute malnutrition. By reducing the frequency of follow-up visits, it is possible tofurther increase capacity and efficiency,
helping mothers who have to travel significant distances to attend scheduled consultations. It may be possible to bypass the time

1. Jones G et al. How many child deaths can we prevent this year?
Lancet 2003; 362: 65-71.
2. Black RE et al. Where and why are 10 million children dying every year?
Lancet 2003; 361: 2226-2234.
3. Shrimpton R et al. Worldwide timing of growth faltering: Implications fornutritional interventions. Pediatrics 2001; 107: e75.

12 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006

Clearly, efforts to address the underlying
causes of malnutrition are critical and mustbe supported. However, new therapeutic
products and outpatient treatment strategies make it possible to offer curative treatment now, to much larger numbers ofpatients, including in situations of chronic
hunger, where most cases of acute malnutrition and excess death are occurring. This
will be all the more true if RUTF products
can be made less costly and more widely
available. There is no reason why this can’t
be done. As treatment of acute malnutrition
becomes simpler and cheaper, it may nolonger be perceived exclusively as a tragic
dilemma requiring sustained, long-term
efforts and solutions, but also as a highly
prevalent, frequently lethal, neglected andimminently treatable disease, calling for
immediate and effective medical care.

4. Golden MH, Briend A. Treatment of malnutrition in refugee camps.
Lancet 1993; 342:360.
5. Collins S. Changing the way we address severe malnutrition during famine.
Lancet 2001; 358: 498-501.
6. Briend A et al. Ready-to-use therapeutic food for treatment of marasmus.
Lancet 1999; 353: 1767-1768© Paul Grover© Vincent Maure
Blanket Feeding, Tanout, Niger, October 2005. Food assistance ( enriched wheat and oil) is provided forfamilies identified with malnourished children.

consuming procedure of taking each child’sheight and rely on the measurement of the
mid-upper arm circumference (MUAC) andweight alone. Some of these new ideas are
currently being implemented in northern
Kenya, where three years of drought have
led to high malnutrition rates amongst pastoral populations.

BY MSF T E A M I N T H YO LO, M A L AW I : FA SI N EH SA M U R A , R O D R I CK NAL I N G U KG W I , C . FO N CHA , D I EU D O N N É BW I R I R E ,L EO P O L D B U H EN DWA , M A R G A R E T FI T ZG ER A L D, DAL I T S O M I NSI N D E , M OSE S M A SSAQ U O I , NAT HAL I E B O R R E M ANS

Doing Moreby Doing Less
Decentralising HIV/AIDS care in rural Malawi
The Thyolo region of southern Malawi is a
verdant area of tea estates. Bright green tea
fields are cut through by reddish tracks, linking
the many communities spread out in small
villages. One of 28 districts in the country, it isalso the area that is perhaps hardest hit by HIV/
AIDS, with 20% of people now testing positive
for the HIV virus.

Despite this grim statistic, concerted efforts are being madeto provide treatment in this district of 575,000 residents. The
Malawian Ministry of Health (MOH) has a national programme to address HIV/AIDS, there is currently a supply of
drugs for patients, and MSF has been present in the Thyolo
health district since 1997, helping to organise and provide
effective care for those suffering from the disease.
Whilst have had many successes, establishing an efficient system of treatment delivery has been challenging, particularly
given the rising number of people presenting themselves fortreatment. HIV/AIDS education, testing, and successfultreatment of opportunistic infections – conditions such as
pneumonia that can claim the lives of people with HIV –have led to more people surviving the virus and there are now
over 10,000 people without access to antiretroviral treatment(ART) who urgently need these life-prolonging drugs.

© Julie Rémy

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

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 13

© Julie Rémy

© Julie Rémy

One patient living in Namileme, 25 kilometres from the nearest
hospital, describes her experience:“I left at 3:30 am on foot to Thyolo hospital to try to get antiretroviral medicine (ARVs), arriving at 9:30 am after four hours of hardwalking. I waited in the group counselling room until 12:00 pm
and as I was very hungry and thirsty, left to the market to findsomething small to eat. When I returned, I was told the session was
already over and I must return one week later. I now had to walkback home for another four hours without anything! Now I must
walk back twice to Thyolo hospital, once for a group counsellingsession and then again for an individual counselling session before
I can get ARVs. The nurse says this is to make sure I will be committed to taking ARVs, but I already know very well that I reallyneed the ARVs and I am ready to take the medicines. It’s just so
hard to get them.”
The usual process for obtaining antiretrovirals involves educational group counselling, followed by a one-week period so patients canconsider making the commitment to treatment. Patients thenreturn for individual counselling to understand how to take their
ARVs properly. With such activities based at the hospitals, many
people lose valuable hours they need to earn a living. On children’s
clinic days, both mothers and children were exhausted upon arrival, practically falling asleep during counselling sessions! Motorised
transportation is a quicker way to get to the hospitals, but costs areprohibitive for most, and during the heavy rainy season, transportation is also difficult as the dirt tracks turn to mud, often doubling travelling time or stopping service altogether.

When less is more
Having set a goal of providing ART to 10,000 people by the end of
2007, it became clear we needed a new approach. Our mottobecame “do more by doing less.” We needed to get drugs to many
more people before their disease progressed to the point where theyrequired more intensive medical care. We also needed a faster, lesscumbersome and more patient friendly system.

“I always used to go to Thyolo hospital with myguardian, a relative who helps me comply withmy treatment, and it was expensive to pay for
two transport fees. Now I get exactly the same
service at my local health centre”.
Patient at Konjeni health centre, a decentralised site.

14 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006

Offering patient-centred care
Our solution was to decentralise antiretroviral treatment, moving
follow-up for stabilised patients on ART out of the hospitals andinto nine local heath centres.
To maintain quality care, we developed criteria to define eligible
patients and to identify the necessary characteristics for the selection of health centres. All staff who would be providing ART werealso required to undergo training. These workers are supported bya mobile MSF team that travels to the health centres for supervisionof treatment and counselling and dispensing ARV drugs. The
health centre teams continue the regular follow-up activities with
continuous support from MSF.
This approach is helping to “demedicalise” HIV, empowering individuals and community members to be more involved in caring for
those who have the virus. Communities are embracing this wholeheartedly, developing networks that engage in a range of supportiveand innovative activities, such as checking in with peers at community meetings to make sure pills are being taken properly, and documenting life-affirming “before and after” photographs of people
on treatment and living with HIV, which helps to reduce the stigma
of the disease.
Today there are over 2000 people who have formed an association
linked to the National Association of People Living with AIDS(NAPWA). Members are identifying ways they can help each other,undertaking projects such as organising vegetable, maize and fish
farms to help feed people who are poor and unwell, and creating
vocational training and income generation activities for HIV/AIDS
orphans. This community involvement has been a positive force inour efforts at decentralisation.

A dearth of human resources
The numbers show that decentralisation is working – in one village
alone we rapidly went from 20 to 150 patients on ART. But this new
approach also comes with its own challenges, the most serious
impediment being the lack of adequate and well-trained medical
personnel. As in many other African countries, there is a chronic
shortage of human resources here. Malawi graduated only 16 new
doctors in 2005, and only one remains in the country. The government is permitting us to train medical assistants to provide ART at
the health centre level because there simply are not enough medical
doctors or clinical officers to do so.
The pre-existing health centre staff who are now involved in decentralised HIV activities are understandably feeling overstretched.
HIV care is an added activity when they have many other responsi-

bilities and administration duties. Other priorities – primary
healthcare, vaccination programmes, training workshops or providing relief for colleagues on annual leave – compete with HIV
care and sometimes result in health centre clinics not opening
when they are supposed to. Absenteeism amongst medical staff isalso a problem and can be attributed, in part, to low salaries.
Although we have topped-up health staff salaries as a compensation
for the increased workload, there is a limit to how much work one
can do in one day. The lack of human resources is the most crucial
obstacle to our decentralisation effort.

those who need to change drugs will really help us leap forward.
But despite our limitations and multiple constraints on resources,
this is proving to be a good approach for getting treatment into thehands of more people who, quite literally, will not live without it.
Our staff sees a visible difference in the health and vibrancy of thepatients we treat, as a result of being able to access the care theyneed. From one of our patients at a decentralised site in Milongwe:“I have spent a lot of money trying to access ARVs at Thyolo but I
did not succeed. The first two weeks of taking ARVs are wonderful. I felt the difference. I actually can feel life coming back.”

These difficulties are compounded by a poor health infrastructure.
Operating ART clinics and general outpatient consultation simultaneously in the same room with a lot of staff and patient movement
can compromise confidentiality, and some patients have complained about sitting with other patients from the same areas intheir health centre. We have tried to put up partitions to split
rooms in two, but this does not always work because rooms are
small to begin with. We now need to refurbish and rehabilitate
some of the nine public health centres and in some cases, build
extensions to accommodate clinic rooms. For now, we are simply
doing the best we can with what we have.

Simplified treatments are key

Other avenues exist for simplification. In Malawi, laboratory services to do a CD4 count (an index of immune system function) are arare commodity and are usually not available in decentralised sites.
We have found that with treatment provided far away from labs,
blood specimens sometimes “spoil” before they can get to the lab tobe analysed. Sometimes blood must be collected twice for a single
analysis.
Though a baseline CD4 count is normally required as a pre-condition to start antiretroviral treatment, most patients we see are inadvanced stages of the illness (WHO stages III & IV) and exhibit
clinical symptoms that can lead to a decision to initiate ART without a blood analysis. In this environment, a thorough medical history and physical examination are a reliable way to select patientsneeding ARV treatment.

Reaching more patients, saving more lives
Scaling up ART to treat more people is a challenge, especially as thecaseload increases. Decentralisation is not an easy process and it is
not a cheap venture to provide patients with treatment. Researchand development into paediatric diagnostic tools and drugs, simplified treatment protocols, and affordable secondline medications for© Julie Rémy

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

To participate in decentralisation in Thyolo,
patients must:• have been on standard firstline ART for a minimumof 3 months• demonstrate good treatment adherence• be stable on ART without opportunistic infections• not have any specific psychosocial considerations• live at least 10 km or more from the main Thyolo ART
Clinic, but close to the approved health centre

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 15BY FA B I EN D U B U E T, U N L IA IS O N O FFI CER A N D
E M M A N U EL T R O N C , P O L I C Y A N D A DVO C AC Y
CO O R D I NATO R , MSF I N T ER NAT I O NA L

United Nations: deceptive
humanitarian reforms?
Responding to many of the same crises and often working alongside United Nations relief efforts within the field, Médecins Sans
Frontières has given much consideration to the nature of humanitarian aid offered under the UN relief system. Increasingly, there
has been a feeling of a great discrepancy between the needs to becovered quickly and the effectiveness of the UN response.
The past two years have raised many questions regarding the operational engagement of the United Nation’s agencies: there have been
inappropriate or slow UN responses to emergencies in Niger, theEastern Democratic Republic of Congo, Sudan and Somalia; difficulty understanding strategies and agendas, such as in Northern
Uganda, the Caucasus and in Colombia; poor coordination of theirdelivery partners in Indonesia following the tsunami or more
recently the earthquake in Pakistan, and the virtual absence of UN
aid in very fragile regions such as the Central African Republic.
Spurred on by increasingly public failures to adequately respond to
the needs of displaced persons in various contexts – Darfur being
the most egregious example, the UN, on occasion of its sixtiethanniversary, initiated a series of reforms intended to improve its
response to humanitarian crises. Marked by the modification of its
emergency fund to establish the Central Emergency Response Fund(CERF) in December 2005, these changes fall within the scope of awider process of organisational reform proposed by the UN
Secretary General under pressure from many Member States.1

MSF and current reforms: independence and pragmatism
Officially, reform aims to increase the role and authority ofhumanitarian coordinators in the field to better defend humanitarian space and principles. Everything rests on two pillars. The firstis financial resources that are more predictable and more readily
available in emergency situations through the new CERF. The second is a mechanism (“cluster system”) allowing the humanitarian
coordinator in a given country to clearly identify and quickly
mobilise the agency responsible for overseeing a response to particular needs, with the aim of eliminating any gaps between sectors. This “cluster lead” then relies on the other members of its
cluster to carry out a response: the UN operational agencies andNGOs it will mobilise to address an identified need.

humanitarian coordinators nor be accountable to them. In the faceof the challenges to be met, however, we can only welcome the willingness of the United Nations to improve their humanitarian
response.
We must also take a critical look at the possible effects of thereforms on the effectiveness of aid. While it is doubtless too soon to
fully evaluate the impact of proposed changes, the slowness of the
UN response to the recent cholera outbreak in Angola, including at
the peak of the crisis in May 2006, or in the face of the latest population displacements in Katanga province, Democratic Republic ofCongo (DRC) makes one wonder whether the reform will deliver
better assistance for those most in need. In DRC, the military operations launched in November 2005 by the Congolese armed forces
against certain Mai-Mai groups resulted in the displacement of several tens of thousands of people, yet the World Food Programmeneeded several months to become fully operational. In Northern
Uganda, chosen as a pilot country for the implementation ofreforms, the needs for water and latrines were not always met inmost districts more than six months after the reforms came into
effect.
Placed respectively in charge of the nutrition and health clusters,Unicef and the World Health Organization (WHO) have a chance
to play a leading role promoting and adopting new strategies for thetreatment of malnutrition, following the discovery of a new therapeutic product (in the form of an enriched ready-to-use paste).
Given this possibility, their position and operational decisions surrounding this issue will also constitute a full-scale test to see if the
new coordinated cluster structure results in any real improvements
in meeting human needs.
Whilst determined to retain its independence in the face of current
reforms, MSF will continue a dialogue with the UN operational
agencies and also accepts the need for context-related, operationoriented coordination between the head offices as well as in thefield. MSF will maintain its independence of analysis and action
and resources so as not to jeopardise the strictly humanitarian andimpartial nature of our organisation, particularly in conf lict situations, where it is critical to keep the trust of the belligerents to beable to reach those who require our assistance.

MSF continues to follow this process of reform with attention to its
potential implications for the organisation of emergency relief andthe response to humanitarian needs in the field. We have abstained
from publicly taking position on the current reforms, as we considered it did not fall within the competence of a medical-humanitarian organisation to comment on, or make proposals regarding theinternal workings of the UN. The current reforms are also a UN
process: clearly stated, we will not be a member of the clusters andthe action of MSF will not be placed under the responsibility of UN

Coordination: to what end?

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

16 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006

Coordination cannot be an end in itself; it must be useful, guided
by the reality of the situation on the ground and directed toward
concrete action. The limits of the mechanisms of coordinationmust be recognised: faced with political interference in humanitarian aid, the solution resides not in multiplication or strengtheningof technical measures, but rather in the need for humanitarianorganisations and the international community to highlight political constraints and ascribe responsibilities. The setting up of coor-

Nine different clusters have been validated by themembers of the Inter-Agency Standing Committee (IASC)
in the UN’s cluster system. These clusters are:dination structures at national (Joint Monitoring Committee) anddecentralised (District Disaster Management Committees) levels
did not, for example, help to improve the quality of assistance provided in Northern Uganda.
It is also crucial not to maintain the illusion that a unified aid system steered by the UN Office for the Coordination of Humanitarian
Affairs (OCHA) or any other agency would lead to an automatic significant improvement in the efficiency of relief efforts. Presented asa model of coordination, the international response to the tsunami
at the end of 2004 was nonetheless severely criticised by an international evaluation mission. 2 According to the conclusions of thatinvestigation, the international relief effort did respond to the actual
needs of the affected populations, but was driven more by politicaland media considerations. Faced with the scale of the public
response, the humanitarian organisations spent the money “quickly
and ostentatiously” and “to find something to do”.
The humanitarian landscape is currently made up of a large
number of actors with widely differing aims, resources and modus
operandi. It is not only impossible and unrealistic to believe that allthese actors can work in perfect synergy under a single banner, but
it can also be at times perilous, as some actors operate with mixed
agendas, the humanitarian goals falling second to political, security
or developmental objectives and resulting in unmet needs. The
existence of a diversity of approaches is what helped save the lives of
thousands of children in Niger in 2005, illustrating that independent actors may well offer people in need the best chance at effective
assistance. Further, diverse approaches to humanitarian aid help
assure that if one strategy fails, all do not fail, with deadly consequences. We have already seen this to be the case in contexts such
as East Timor and Angola.

The increasing politicisation of humanitarian action
According to United Nations official line, the reforms initiated in2005 should better defend the humanitarian space and principles
and improve the efficiency of the UN’s crisis response. This can be
doubted, however, in light of the UN Secretary General’s note on
integrated missions, adopted on 17 January 2006. 3 This document
reaffirms the central role of integration for the mounting of UN
peacekeeping missions. It is not only a matter of achieving “a moreconsistent UN system” in the field, but also of “ensuring efficient
coordination between the peacekeeping mission, the UN’s operational agencies and non-UN partners.” The note also specifies that
the UN presence must be based on a clear and shared understanding of the priorities and the willingness of all actors to contributeto the achievement of shared objectives – subject to reorientation
based on the global objective of the UN mission.
This document clearly shows that in the UN’s view, humanitarian
action remains subordinate to the UN’s political arm and thathumanitarian aid comes second to the political objectives pursued

mechanisms. Within the UN system, this dynamic led to the implementation of “integrated missions” consisting in placing all UN activities in the field under the authority of the
UN Secretary General’s Special Representative. See in particular “Renewing the United
Nations-A Programme for reform”, A/51/950 and “Report of the Panel on United Nations
Peace Operations” (the Brahimi report), A/55/305-S/2000/809.

• Nutrition• Water and hygiene• Health• Coordination and camp management for displaced people• Emergency shelters• Protection• Logistics• Means of communication• Re-launch of the economy in the post-conflict stage
This organisation applies mainly to relief efforts in favourof internally displaced populations.
by the peacekeeping missions. The DRC provides a perfect illustration of this: the weakness of the international assistance given to
Katanga and the slow response of the UN’s operational agencies tothe renewed displacements of populations that occurred at the endof 2005/ beginning of 2006 were linked to the reticence of the
Security Council and donors to examine the situation in this“Presidential province”, for highly diplomatic reasons.
MSF has on a number of occasions publicly stressed the risks of thepoliticisation and the militarisation of the system of aid brought
about by the “coherence agenda”4 and integrated missions, in particular in conf lict situations. This approach has notably led in thepast to certain groups in need being excluded from immediate
assistance in Angola, Sierra Leone and Burundi 5. In Sierra Leone,
for example, the UN in 1997 withdrew staff and cut off emergency
assistance to support its political aim of weakening the AFRC/
RUF, the result of which was deliberate and unnecessary sufferingand starvation of the population. This year, Darfur and the occupied Palestinian Territories served once again to remind us thathumanitarian action constitutes a crisis management instrument.
In April 2006, the World Food Programme (WFP) announced ahalving of food rations to the people displaced by fighting in
Darfur because of a lack of finance. This was brought aboutbecause the donor countries had decided to make assistance topopulations conditional upon the signing of a peace agreement.
Following the victory of Hamas in the January 2006 parliamentaryelection, several countries including the United States and theEuropean Union decided to suspend their bilateral financial aid to
the Palestinian Authority whilst proposing to redistribute thesefunds towards international relief organisations. Humanitarian
action thus became a palliative for a retaliatory measure and was
effectively asked to act as a substitute for the Palestinian Authority.
Improving the effectiveness of relief actions depends mainly on
upholding and implementing humanitarian principles by the operational agencies of the UN (WFP, Unicef, HCR) and by the NGOs,
in other words, strengthening the impartiality and independenceof humanitarian action. The increasing politicisation of the international system of aid over the past few years does little to inspire
optimism, particularly as the majority of humanitarian relief
actors are actively contributing to the process – or do not have themeans to escape from it.

5. For more information, see in particular “Angolans left to die: abandoning the humanitarian
imperative”, MSF report, 30 October 2003 and Nicolas de Torrenté, “Humanitarianism
Sacrificed: Integration’s False Promise”, in Ethics and International Affairs, volume 18, 2004.

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 17

Democratic Republic of Cong

As a medical-humanitarian organisation, MSF seeks tohelp people most in need, and for years the DRC has
been at, or near, the top of our list. The longstanding
war and the collapse of the public health system haveresulted in widespread acute medical needs. MSF teams,
composed of international and Congolese aid workers,
are active in all corners of this huge country striving toreach those most at risk.
It is a struggle to do anything other than respond to themost serious emergencies. The complex and diverse
nature of the violence, neglect, and discrimination in the
DRC challenges any notion of simple, blanket solutions
to redress even the immediate causes of so much deathand suffering. Whilst MSF does not purport to provide asolution, we want to draw attention to what theCongolese people are enduring.
More than 3.8 million people have died in the Congo
conflict since 1998. The majority of people die from disease and malnutrition.
Bon Marché Hospital, Bunia, May, 2005

18 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006

© Ron Haviv

o: Forgotten War

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 19© James Nachtwey/VII© Ron Haviv/VII

Internally displaced peopleof the Hema tribe at the Tche
camp, Ituri District. In
January 2003, renewed fighting forced tens of thousandsof people to f lee for theirlives into the surrounding
forests and abandon their
few possessions to local militias, with some 80,000 finding precarious refuge in
Djugu territory north of
Bunia. MSF carried out anemergency intervention infour displacement camps in
Gina and Tche, in the highlands, and Tchomia andKakwa, on the shores of
Lake Albert.

At a hospital in Bunia, a mother tries to soothe her two young children suffering from malaria and dysentery.
20 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006

© Joachim Ladefoged/VII

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 21

© Joachim Ladefoged/VII

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

© Antonin Kratochvil/VII

An AIDS patient being cared
for by MSF doctors at a hospital in the eastern town of
Bukavu, Congo, June 2005.
Throughout the country an
estimated 1.1 million
Congolese are living with
HIV/AIDS and many people
have little or no access tocomprehensive healthcare.

22 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006

© Gary Knight/VII© Antonin Kratochvil/VII

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

A guard at the entrance of an AIDS clinic run by MSF in Bukavu, June 2005.
ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 23

© Gary Knight/VII

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

Pictures can help.
Their essential quality is
to go behind the headlines
to offer glimpses of ordinary people’s lives –reminding us, andthe world at large,
that we must refuse to let
the unacceptablebecome© Ron Haviv/VII

normal.

Bon Marché Hospital, Bunia
24 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006

Photos are part of a touring exhibition by the world-renowned VII
Photo Agency photographers, who travelled with MSF in the
Democratic Republic of Congo in 2005. The exhibit has visited
Australia, Austria, Canada, DRC, Denmark, Hong Kong, Japan,
Macau, Switzerland and the USA.

Medical conditions
Chagas Disease
First described by the Brazilian doctor
Carlos Chagas, this parasitic disease isfound almost exclusively on the American
continent, though increased global travel
has led to cases being reported in the US
and Europe. This potentially fatal condition
damages the heart, nervous and digestivesystems.
The disease is transmitted by blood sucking
insects (Trypanosoma cruzi) that live incracks in the walls and roofs of mud andstraw housing, common in rural areas andpoor urban slums in Latin America. People
can be infected but show no symptoms foryears. Developing over time, chronic
Chagas causes irreversible damage to theheart, oesophagus and colon, shortening
life expectancy by an average of ten years.
Heart failure is a common cause of death
for adults with Chagas.
Treatment must occur in early stages of theinfection, and drugs are only effective in
the acute and asymptomatic stage of thedisease in children. Diagnosis is complicated, with doctors needing to perform two or
three blood tests to determine whether apatient is infected with the parasite. There
are few drugs developed to treat the disease
and the current line of treatment can betoxic, taking one to two months to complete. Apart from managing symptoms,
there is no treatment for chronic Chagas inadults.
MSF Chagas programmes in Bolivia andGuatemala focus on education, preventive
measures and screening and treatment forchildren. MSF is also urging for more
research and development on Chagas
through its Access to Essential MedicinesCampaign.

Cholera
The Greek word for diarrhoea, cholera is awater-borne, acute gastrointestinal infection caused by the Vibrio cholerae bacterium and spread by contaminated water orfood. The infection can spread rapidly andmay cause sudden large outbreaks.
Although most people infected with cholera
will have only a mild infection, the illness
can also be very severe, causing profuse
watery diarrhoea and vomiting and leading

to severe dehydration and death without
rapid treatment. Required treatment is theimmediate replacement of f luid and salts
with a rehydration solution administeredorally or intravenously.
MSF has developed cholera treatment kits
to provide rapid assistance and sets up cholera treatment centres (CTCs) in areas where
there are outbreaks. Control and prevention
measures include ensuring an adequate
supply of safe drinking water and implementing strict hygiene practices.
In 2005/2006, MSF conducted major cholera interventions in countries including
Angola, Democratic Republic of Congo,
Guinea, Guinea-B and Ethiopia.

HIV/AIDS
The human immunodeficiency virus (HIV)is transmitted through blood and body f luids and gradually weakens the immune system – usually over a three to ten year period– leading to acquired immunodeficiency
syndrome or AIDS. A number of opportunistic infections (OIs) such as candidiasis,pneumonia, and various kinds of tumours
are able to f lourish as the immune system
weakens. Some OIs can be treated, whilst
others are life-threatening. The most common opportunistic infection leading todeath is tuberculosis (TB).
Many people live for years without symptoms and may not know they have been
infected with HIV. A simple blood test canconfirm HIV status.
Combinations of drugs known as antiretrovirals help combat the virus and enable people to live longer, healthier lives without
rapid degradation of their immune systems.
It is simplest and easiest to take these drugs
properly when they are combined into single
pills (fixed-dose combination or FDC).
MSF comprehensive HIV/AIDS programmes
generally include education and awarenessactivities so people understand how to prevent the spread of the virus; condom distribution; HIV testing along with pre andpost-test counselling; treatment and prevention of opportunistic infections; preventionof mother-to-child transmission; and provision of antiretroviral treatment for patientsin advanced clinical stages of the disease.

In 2005/2006 MSF provided care for over
100,000 people living with HIV/AIDS andantiretroviral therapy for more than 60,000
people across 65 projects in 32 countries.

Human African Trypanosomiasis(Sleeping Sickness)
Frequently known as sleeping sickness, thisparasitic infection is seen in sub-SaharanAfrica and is transmitted through the biteof certain types of the tropical tsetse f ly.
More than 90 per cent of reported cases of
sleeping sickness are caused by the parasite
Trypanosoma brucei gambiense (T.b.g) The
parasite attacks the central nervous system,
causing severe neurological disorders andleading to death if untreated.
During the first stage of the illness, people
have non-specific symptoms such as fever
and weakness. This stage of the disease isdifficult to diagnose but relatively easy totreat. The second stage occurs once the parasite invades the central nervous system.
The infected person begins to show neurological or psychiatric symptoms, such as
poor coordination, confusion, or convulsions. People may also have difficulty sleeping during the night but are overcome withsleep during the day.
Accurate diagnosis of the second stage ofthe illness requires taking a sample of spinal f luid and treatment is painful, requiring daily injections. The most common
drug used to treat trypanosomiasis, melarsoprol, was developed in 1949 and has manyside effects. A derivative of arsenic, it ishighly toxic and fails to cure up to 30 per
cent of patients in some areas of Africa. It
also kills up to 5 per cent of people who
receive it. Ef lornithine, though somewhat
difficult to administer because it requires
an IV and a complicated treatment schedule, is a safer, more recent alternative being
used by MSF in its projects. MSF throughits Access to Essential Medicines Campaign
works to ensure the production and supplyof ef lornithine and urges for research anddevelopment aimed at new, easy-to-use
drugs and accurate diagnostic tests.
MSF admitted 5204 new patients for treatment for human african trypanosomiasis in
2005.

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 25

Leishmaniasis (Kala Azar)
Largely unknown in the developed world,leishmaniasis is a tropical, parasitic diseasecaused by one of over 20 varieties ofLeishmania and transmitted by bites fromcertain types of sandf lies. The most severe
form, visceral leishmaniasis, is also known
as kala azar, Hindi for black fever. Over 90
per cent of cases occur in Bangladesh,
Brazil, India, Nepal and Sudan. Without
treatment, this form of leishmaniasis isfatal in almost 100 per cent of cases.
Kala azar attacks the immune system, causing fever, weight loss, anaemia and an
enlarged spleen. There are considerable
problems with existing diagnostic tests,
which are either invasive or potentially
dangerous and require lab facilities andspecialists not readily available in resourcepoor settings. Treatment requires painful,
daily injections of drugs for 30 days. The
drug most widely used to treat kala azar,
sodium stibogluconate (SSG) was developed in the 1930s, is relatively expensive
and causes a toxic reaction in somepatients.
Co-infection of leishmaniasis and HIV isemerging as a growing threat, as both diseases attack and weaken the immune system. Infection with one of these diseases
makes a person less resistant to the otherand treatment becomes less effective.
MSF through its Access to Essential
Medicines campaign is urging for more
research into suitable diagnostic techniques
and affordable drugs to treat this neglecteddisease.
MSF treated over 7000 people for leishmaniasis in 2005.

Malaria
Caused by four species of the parasite
Plasmodium, malaria is transmitted by
infected mosquitoes, particularly during
rainy seasons, and mainly strikes poor andrural communities, slum dwellers and refugees. Symptoms include fever, pain in the
joints, headaches, repeated vomiting, convulsions and coma. Malaria caused by plasmodium falciparum, if untreated, may
progress to death.

Malaria is commonly diagnosed on a basisof clinical symptoms alone, such as feverand headaches. Around half the people who
present with fever and are treated for
malaria in Africa may not actually be
infected with the parasite. An accurate
diagnosis can be made through a count ofparasites by microscope or a rapid dipstick
test. Both methods are currently used by
MSF in its projects.
Antimalarial drugs are used to treat the illness. Chloroquine was once the ideal treatment for malaria caused by plasmodium
falciparum because of its price, effectiveness and few side effects; however, its effectiveness has decreased dramatically in thepast few decades. MSF field research has
helped prove that artemisinin-based combination therapy (ACT) is currently the mosteffective against this type of malaria andhas urged governments in Africa to change
their drug protocols to use ACT. Althoughmany governments have made the change inwriting, in many cases the drug is still notavailable for their patients.
MSF treated over 2.2 million people formalaria in 2005.

Meningitis
Meningococcal meningitis is caused by
Neisseria meningitidis and is a contagious
and potentially fatal bacterial infection of
the meninges, the thin lining surrounding
the brain and spinal cord. People can be
infected and carry the disease without
showing symptoms, spreading the bacteria
to others through droplets of respiratory or
throat secretions, for example when they
cough or sneeze. The infection can also
cause sudden and intense headaches, fever,nausea, vomiting, sensitivity to light andstiffness of the neck. Death can follow
within hours of the onset of symptoms.
Without proper treatment, bacterial meningitis kills up to half of those infected.
Suspected cases are properly diagnosed
through examination of a sample of spinal
f luid and treated with a range of antibiotics. Even when given appropriate antibiotic
treatment, five to ten per cent of people
with meningitis will die and as many as oneout of five survivors may suffer from aftereffects ranging from hearing loss to partial
paralysis.

26 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006

Meningitis occurs sporadically throughout
the world, but the majority of cases anddeaths are in Africa, particularly across aneast-west geographical strip from Senegal toEthiopia, the “meningitis belt” where outbreaks occur regularly. Vaccination is therecognised way to protect people from thedisease.
MSF vaccinated over 100,000 people against
meningitis in 2005.

Tuberculosis
One-third of the world’s population is currently infected with the tuberculosis (TB)
bacilli. Every year, nine million people
develop active TB and two million die fromit. Ninety-five per cent of these people livein poor countries.
This contagious disease affects the lungs
and is spread through the air when infectious people cough, sneeze or talk. Not everyone will become ill, but ten percent of(HIV negative) infected people will develop
active TB at some point in their lifetime,
suffering from a persistent cough, fever,weight loss, chest pain and breathlessness
in the lead up to death. TB is also a common opportunistic infection and leading
cause of death amongst people with HIV.
Drugs used to treat TB are from the 1950s
and a course of treatment takes six months.
Poor treatment management and adherence
has led to new strains of bacilla that areresistant to the drugs commonly used. Drug
resistant TB is not impossible to treat, but
the required regimen causes many side
effects and takes up to two years.
In 2005, MSF treated over 20,000 people
with TB in more than 20 countries worldwide.

© Paolo Pellegrin/Magnum Photos

MSF Projects
around the World
AfricaA child with cholera and his mother in an MSF-run cholera treatment centre in Malenje, Angola, May 2006.

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 27

AfricaI N T ER NAT I O NA L S TA FF 10 0
NAT I O NA L S TA FF 9 62

AngolaAfter three decades of civil war, reconstruction of Angola’s health infrastructure is starting to take the place of medical emergency assistance.
The country’s current health system, however, remains woefully inadequate and in February 2006 was challenged by the worst cholera out-

MSF, already present with numerous projects throughout the country, responded by
setting up 10 cholera treatment centres(CTCs) in Luanda, receiving up to 400
admissions daily at the height of the outbreak. Another 15-20 treatment centres
were set up to deal with the spread of thebacterial illness in other provinces.
Treatment efforts were complemented bywater and sanitation activities.
The required medical care for cholera
includes the immediate replacement of fluids and electrolytes. MSF organized 40 “oralrehydration salt points” in Luanda, where
patients could receive rehydration andmore severe cases could be immediately
referred to the closest CTC. This also
helped reduce pressure on CTCs by offering effective treatment for those not needing hospitalisation, whilst reducing time
between cholera detection and necessaryreferrals.
An educational component was part of theemergency response, including a cholera
song broadcast by national and local radio
networks. The number of cholera cases
began to decline by mid-May and MSF
started handing over the treatment centres
to the Ministry of Health (MOH).
More than 53,000 people were infected
and an estimated 2100 people diedbetween mid-February and early
September 2006. During its intervention,
MSF treated more than 26,000 people andsent more than 400 tonnes of medical andlogistical supplies to affected areas.

Treating people with HIV/AIDS,
tuberculosis and malaria
In the provinces of Malanje, Lunda Norteand Bié, MSF in 2005/2006 continued toassist thousands of people with HIV/AIDS,
tuberculosis (TB) and malaria. MSF has also

introduced new malaria treatment protocols using highly effective artemisininbased combination therapy (ACT) and isurging the government, who has adopted
ACT as its new treatment protocol, to makethe drugs available across the country.
MSF also supports the health centre in
Cuemba, Bié province, which provides
medical care for approximately 84,000 local
residents and Angolan refugees returningfrom other countries. In 2005, more than
40 patients were treated for TB at this location. MSF also supports the TB programme
at the provincial hospital in Kuito, which
serves approximately 500 patients receiving directly observed tuberculosis treatment.
In Luau, Moxico province, MSF supports
the 53-bed hospital, which conducted
more than 20,000 outpatient consultationsin 2005 and admitted approximately 125
patients monthly. MSF also provides assistance at five area health posts, using
mobile medical teams in this sparsely populated area. During 2005, teams performed
over 30,000 medical consultations.

Numerous projects close
The country’s stabilising situation has led
MSF to hand over many of its activities,
including projects in Mussende, Kwanza
Sul province (March 2006); Kuvango and
Vikungo, Huila province (March 2006);
Cangola, Uige province (July 2006);
Macocola and Buengas municipalities, Uige
province (December 2006); Caxito, Bengoprovince (January 2006); Mavinga, Cuando
Cubango (September 2006) and the Luautransit centre (September 2005).
MSF has worked in Angola since 1983.

28 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006© Paolo Pellegrin/Magnum Photos

break ever recorded in the capital city of Luanda.

Inside a Cholera Tr
The atmosphere inside the cholera treatment centre (CTC) is somewhat chaotic.
All the beds are full and some patients
have to share a bed. Both medical andlogistical staff are working f lat out, thelogisticians hastily putting up anothertent to house twenty more beds, but thetruth is they are running out of space.
The CTC itself is quite basic: at theentrance there is a disinfection area where
everyone is sprayed with chlorine, to kill
the bacteria that cause cholera. Cholera ishighly contagious so it’s crucial that
infected people are isolated and anyone
who comes into contact with them is disinfected. There is also a triage area for
newly arrived patients, a pharmacy, water
points, latrines, and several large tents
with rows upon rows of beds. Each bed
has a hole in the middle and two buckets
underneath, one labelled ‘vómito’ theother ‘excremento’.
It would be easy to be shocked by theindignity of it all, but the only way totreat cholera is to allow patients to f lush
the bacteria out of their bodies and to
rehydrate them as quickly as possible. For
those who reach a centre in time, recovery
is fast.

AfricaI N T ER NAT I O NA L S TA FF 11
NAT I O NA L S TA FF 9 4

Benin
Benin is one of the more stable countries In
Africa, though a poor one, with few natural
resources and where over 33 per cent of its
inhabitants subsist on less than a dollar perday. Malaria is a common cause of death,and HIV/AIDS is also a health concern.
MSF has developed a comprehensive HIV/AIDS project in the department of MonoCouﬀo, a rural area where HIV prevalence,at 3.4 per cent, is reported to be the highest
in the country. Activities Include counselling, testing, treatment and an educational
programme mounted in collaboration withlocal associations. MSF conducts an averageof 620 medical consultations and initiates
antiretrovirals (ARVs) for 35 new patientsmonthly. By the end of 2006, 900 patients
will be taking ARVs.

eatment Centre Luanda, Angola, March, 2006
Most patients at the centre are put on intravenous drips containing Ringer’s lactate
f luid to rehydrate them. MSF staff workaround the clock putting people on thesedrips, a doctor might do up to fifty IVs in
one morning. Once patients are on thedrips they must be constantly monitored. If
too much is given to a young child, there is
the risk of f looding their lungs. If it is not
given quickly enough to an adult, they
could die from dehydration.
When a cholera outbreak is first suspected,stool samples are used to diagnose the illness. By the time that a CTC is set up, suchtests are hardly necessary. The majority ofpeople coming to the centre will be infected, with the most severely affected easily
identifiable by what one nurse describes as‘cholera eyes’ – sunken eyes that show norecognition of the people around them, or
their surroundings.
Most patients in this centre are from Boa
Vista, one of Luanda’s biggest slum areas
where the cholera outbreak has been most
severe. Yet parents such as Florinda Mateus,
whose five-year old son is receiving treatment, find that with limited public transport, getting to the CTCs is not always easy:“I saw the notices on TV about cholera so I
knew to bring Nelo here, but the normal
buses wouldn’t take us so I had to call ataxi. They charged me 1500 kwanza, much
more than usual, because they knew my son
was ill.” Other patients reported they were
too scared of being robbed to come to thecentre at night, so each morning the CTC
sees a surge in patient numbers. Often this
delay means patients are so dehydrated
when they arrive at the centre that little canbe done for them.
Public education is integrated into a cholera
response, to help prevent the spread of theillness, but unfortunately cholera prevention is not just a question of knowledge. As
Julia Parker, who helped organise such education in Angola says “The people we’vebeen talking to in Luanda know they shouldwash their hands and treat their water but
the conditions here just don’t favour goodhygiene.”Now that the project is well established,
MSF is preparing its transfer to local healthauthorities and partners, whilst it continues to advocate for authorities to provide
free treatment for all illnesses linked to
HIV/AIDS.

Caring for Togolese refugees
Since June 2005, MSF has run a project toensure medical care for up to 10,000
Togolese refugees in a camp at Agamé, inthe south of Benin. In February 2006, violent confrontations between refugees andlocal residents resulted in the destructionof the camp and the medical outposts of
MSF were looted. Refugees made a massive departure towards Lokassa, 12 kilometres from Agamé. One week later, many
returned to the area and MSF was able tore-establish its activities, performing
approximately 2000 consultations monthly
for a population of 6690 refugees.

Diagnosing and treating patientswith malaria
In September 2005, in the refugee camp of
Agamé, 45 per cent of patients with fever
were diagnosed as being affected bymalaria. MSF intervened to provide moreaccurate diagnoses using a rapid qualitative test for malaria. MSF tested 3388 people with fever and treated the 1028 people
requiring treatment with artemisinin-based
combination therapy (ACT), currently themost effective antimalarial in this area.
MSF has worked in Benin since 1997.

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 29

I N T ER NAT I O NAL S TAFF 58
NAT I O NAL S TAFF 787

Burkina Faso

BurundiPeople living in the poor West African nation of Burkina Faso have an
average life expectancy of approximately 48 years. About 90 per centof people earn their livelihood through subsistence agriculture, mostly
cotton, in a country vulnerable to drought and desertification. Lack ofaccess to safe and clean water is a problem for much of the populationand the risk of infectious diseases is high.
MSF regularly intervenes to provide medical care during health emergencies. In
2005 there was a cholera outbreak frommid-August to November in the capital cityof Ouagadougou. MSF worked in a cholera
treatment centre, where it was involved in
the treatment of 1050 people who had
contracted the water-borne disease.

consultations are provided each month.
Antiretroviral treatment (ART) has been
supplied to patients since April 2003, andapproximately 85 new patients start treatment monthly. Approximately 3500
patients will be on ART by the end of 2006.

Meningitis is endemic in Burkina Faso andepidemics tend to break out during the
major dry season, from January to March.
In March 2006, the situation was particularly worrying, with the number of meningitis cases climbing to over 2000 persons injust seven weeks. MSF worked with the
Ministry of Health to carry out a vaccination campaign and provided supervisorypersonnel, vaccine supplies and logisticalsupport. In the districts of Banfora andSindou, MSF teams managed the vaccination campaign and helped safeguard
400,000 people against this disease
through immunisation.

Ouagadougou has a thriving sex trade and
MSF has been offering health educationand healthcare for teenage street girls
since 2005. Services include treatment forsexually transmitted infections (STIs),
obstetrical care and psychological support
for survivors of sexual violence. There arealso efforts to improve the legal protection
available to these teenagers. MSF trains
local health workers so they are able totreat girls with STIs. By July 2006, the project had reached 300 teenagers.

Supplying patients with HIV
treatment

MSF also provided medical care and psychological assistance to 700 of the capital’s
street children over the past seven years. A
local organisation took on this project inApril 2006.
MSF has worked in Burkina Faso since 1995.

© Anthony Jacopucci

In Ouagadougou, MSF has an established
HIV/AIDS project in the Pissy health district, where an average of 1600 medical

Health support for teenage street
girls

30 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006© Markus Marcetic/MOMENT

AfricaI N T ER NAT I O NA L S TA FF 27
NAT I O NA L S TA FF 214

An average family in Burundi has to work for two weeks to acare for those who would otherwise do without, using mobile

A country with a long history of ethnic
conflict, Burundi in 2005 continued alonga road of relative peace, seeing the democratic election of a new, power-sharing
government headed by Pierre Nkurunziza.
The country’s war-shattered economy andinfrastructure are high on the government’s development agenda, but a costrecovery system of healthcare means thatmany Burundians still lack access to basic
medical services, despite a May 2006
announcement of free medical care forpregnant women and children under five
years of age.

Offering low cost primary healthcare
MSF supports a number of hospitals
throughout the country, where health services are provided for very low fees, withfree access for the most vulnerable.
Malaria, a treatable but otherwise potentially fatal disease, represents up to 50 per
cent of MSF medical consultations at
health centres countrywide.
In Karuzi province, MSF works in the newly rebuilt, 180-bed Buhiga Hospital, offering surgery, maternity and paediatric care.
MSF also supports 12 primary healthcare
centres in the province (450,000 consultations in 2005), and runs a therapeutic
feeding centre that treated 10,669 children in 2005.
In Ruyigi district, MSF provides primary
healthcare in seven health centres(180,000 consultations in 2005, with
93,000 cases of malaria treated) and provides support to a hospital in Kininya.
Medical services include tuberculosis
treatment, ante and post-natal care, surgery and physical and psychological carefor women survivors of sexual violence.
There is also testing and treatment for HIV.
A similar project is running in Kazanza
province, where MSF works out of a 100bed hospital in Musema and four healthAfricaI N T ER NAT I O NAL S TAFF 13
NAT I O NA L S TAFF 95

Central African Republic“ There were 400 people attending aclinic in one village. Suddenly one ofthem thought they heard a vehicle
approaching from a distance. All 400
rose and fled into the bush within
seconds, leaving the MSF workers
standing alone and stunned.”

centres that conducted 96,500 consultations in 2005.

Responding to women’s healthcareneeds
MSF runs a specialised health centre forwomen survivors of sexual violence in
Burundi’s capital city, Bujumbura. The “centre des femmes” provides medical and psychological care as well as services for family planning and sexually transmitted
infections. The team also focuses on education and raising awareness about sexual
violence. On average 123 women weretreated monthly in 2005.
There is little capacity to deal with emergency obstetric cases in Bujumbura. In
2006, MSF began construction of a 30-bed
gynaecologic-obstetric reference hospitalwith a surgical unit in Kabezi, 20 minutes
outside the city centre, to provide emergency care for women throughout theprovince.

Helping Rwandan asylum seekers
In 2005/2006, some 20,000 Rwandans
streamed across the border, citing harassment by Rwandan authorities and fear ofneighbourhood tribunals established toprosecute genocide suspects. MSF established a clinic in Musasa and offered basic
healthcare to asylum seekers in the Musasa
and Songore camps. MSF also extended its
services to Burundians, some of whom
walk up to six hours to receive free andquality medical care. In the first sevenmonths of 2006, MSF performed 63,675
medical consultations here, seeing mainly
respiratory tract infections and malaria.

MSF closes the Centre de Blessés
The scaling down of fighting in and around
Bujumbura led MSF to close its ‘war
wounded’ health centre in March 2006. The
project ran for ten years and recorded 1101
new admissions in 2005.
MSF has worked in Burundi since 1992.

© Ton Koene

afford a medical consultation. MSF provides free healthe clinics to reach remote villages.

Simon Collins, MSF doctor

The civilian population in the north of theCentral African Republic (CAR) is bearing
the brunt of an ongoing conflict between
rebel and government forces. Violence
between armed groups has led to thetorching of entire villages and attacks on
civilians, causing many people to flee tothe bush, where they attempt to survive
the most primitive living conditions. The
fighting has caused a total collapse of thehealthcare system.
MSF runs ten mobile clinics near
Markounda, along the border with Chad,assisting thousands of people, many ofwhom suffer from malaria, worm infestation or acute respiratory infections – conditions often caused by living in the open. By
May 2006, teams were conducting over
8000 medical consultations monthly. MSF
vaccinates adults and children against
measles and other common infectious diseases as a preventive measure. Plastic
sheeting, blankets and soap are also distributed.
To care for patients requiring more intensive treatment, MSF set up a 16-bed hospital in Markounda. Each week up to 15 people are admitted to the facility and several
hundred patients receive care through thehospital’s outpatient department. In May
2006, MSF also began working in the 40bed regional referral hospital in the city of
Boguila Kota, southwest of Markounda.
In March 2006, MSF started providing medical care in the northwestern town ofPaoua. In April, the team began conducting
mobile medical consultations along roads
near deserted villages. On average, 400
consultations are carried out each week,with approximately 60 per cent of patients
under the age of five. Malaria is the main

illness seen here, affecting more than onethird of patients. Others suffer from maladies including respiratory infections,bloody diarrhoea or snakebites.
Patients needing more care are referred toPaoua Hospital, where another MSF teamworks after having rehabilitated the facility.
Approximately 500 people receive medical
consultations and 50 patients are hospitalised weekly.

Handing over sleeping sickness
activities
From 2001 to mid-2006, MSF ran a Human
African Trypanosomiasis (sleeping sickness)
programme in the Zemio, Mboki and Obo
areas of the southeastern province HautMbomou. The project was handed over tothe Ministry of Health and national sleeping sickness programme in April 2006,
once disease levels had dropped significantly. During its project, MSF screened
more than 76,000 people and treated 1509
individuals.
MSF continues to screen and treat people
with malaria in the area. The team trains
laboratory staff and supervises five healthcentres in the Haut-Mbomou. A mobile
health clinic operates close to Mboki town,
performing approximately 1400 outpatient
consultations monthly, many for people
with malaria. Another 200 people are hospitalised each month for more intensive
treatment.
In November 2005, MSF also responded toa measles outbreak in Mboki and vaccinated a total of 4500 children.
MSF has worked in the Central African
Republic since 1997.

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 31

AfricaI N T ER NAT I O NA L S TA FF 89
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I N T ER NAT I O NAL S TAFF 9
NAT I O NAL S TAFF 72

Chad

Cameroon
Buruli Ulcer is a largely neglected
health problem for the people of
Cameroon. Untreated, this disease
destroys the skin and underlying© Ton Koene

tissues, causing large ulcerations,
possible infection of the bone,and deformities, usually of the
A child receives an oral polio vaccine in one of the camps housing refugees from Central African Republic.

arms and legs. Buruli affects
mostly children under the age of

Chad experienced bouts of instability in
2005/2006. Several attempted coups on
the government culminated in a largescale rebel attack on N’Djamena in April
2006, resulting in hundreds of civilian andmilitary casualties. Earlier, in December
2005, clashes between government forces
and Chadian rebel groups broke out in andaround Adré, located at the Sudanese border. Since then, rebels or armed fighters
have undertaken regular violent attacks atvillages on both sides of the border.

Helping the wounded and displaced
Surgical capacity is necessary to treat people affected by violence. In the Adré hospital, MSF provides basic healthcare andbasic and emergency surgery to residents
and Sudanese persons who have fled
Darfur and are now living in refugee camps
in Chad. Healthcare and surgery are provided in the 50-bed hospital of Iriba, further north, and basic healthcare is available in a health centre at the border townof Tiné.
MSF has improved surgical facilities in thehospital of the provincial capital of Abéché
and has readied medical materials such as
kits and dressings to treat any war-wounds
resulting from flaring violence in the area.
The sustained instability in eastern Chadhas led to further population displacement
along the border stretch. South of Adré,
MSF operates fixed and mobile clinics toprovide healthcare, non-food items anddrinkable water to thousands of villagers
and displaced people in and around thevillages of Borota, Alacha, Adé, Koloy andDogdoré. In June 2006, more than 5000
children were vaccinated against measlesin this area.

Refugees from Darfur and Central
African Republic
MSF provides medical care – including paediatric and maternal care – and psychosocial support to approximately 80,000
Sudanese refugees in four refugee camps.
MSF also treats the surrounding Chadian
population. Teams are involved in addressing the consequences of sexual violence,
malnutrition, providing health educationand controlling communicable diseases.
Since June 2005, increasing violence in theneighbouring Central African Republic
prompted some 15,000 villagers to flee
into southern Chad. MSF teams assist
Central Africans on both sides of the border. In Goré, Chad, MSF supports the 50bed hospital and two health posts in the
Amboko extension and Gondje.

15, some of whom may lose theirlimbs or face permanent disability
without early medical care.
MSF runs a Buruli Ulcer project in the
Akonolinga district of Cameroon, where itis estimated that more than 400 persons
are suffering from Buruli in a rural population of close to 100,000. MSF works together with the local health authorities, healthcare staff and school and community
representatives to increase awarenessabout the disease and offer wound care,
medical treatment, surgery and physiotherapy. Treatment is organised in the district hospital at the “Pavillion Buruli” andcan last up to several months. MSF also
supplies medical materials, training, support and supervision and maintains andrehabilitates infrastructure and equipment.

Malaria, measles and meningitis
MSF runs a malaria project in Bongor district, bordering Cameroon. During theendemic season in 2005, almost 40,000
people were tested and treated with artemisinin-based combination therapy (ACT).
In Bongor’s district hospital, MSF provides
surgical training for local doctors andanaesthetist training for nurses. In April
2006 the mobile surgical team relocated to
N’Djamena to provide care for 49 persons
seriously injured by violence.
Throughout the year, MSF regularly
responds to emergencies such as measles,
meningitis and cholera epidemics throughout the country. In May 2006, MSF vaccinated over 50,000 people against meningitis.
MSF has worked in Chad since 1981.

32 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006

Case detection is steadily increasing
because of growing awareness and credibility of the treatment services in the
Akonolinga district hospital, where 145
persons were successfully treated in 2005.
Between January and the end of July 2006,
98 new cases were diagnosed and admitted for treatment.

Helping develop a national HIV/AIDS
programme
MSF’s HIV/AIDS work continues to focus onaccess to HIV counselling and testing andcare and antiretroviral (ARV) treatment
with gradual involvement of local andnational actors. The MSF HIV/AIDS projects
in Cameroon have been serving as “pilot”
projects both for MSF and the HIV/AIDS
National Programme of Cameroon.

Africa© Michael Goldfarb
MSF nurse Pat Murphy manages the Buruli clinic, giving medicine and emotional support to patients receiving treatment. Patients are often stigmatised and face
profound psychological and social hardships. Many with Buruli, especially children, find themselves alone and isolated from their families and communities.

Buruli Ulcer: A Mystifying Disease
By the end of July 2006, MSF was involvedin the support, care and treatment for morethan 4000 people with HIV/AIDS – 1300 on
ARV treatment – in the districts of Nylon
and New Bell in the city of Douala. In
Yaoundé, MSF supported the care andtreatment of more than 2200 people with
HIV/AIDS (1300 on ARVs), through its longterm support to the Military Hospital and a
new project at the Presbyterian district
hospital of Djoungolo.
The system of financial participation by
patients for HIV testing, care and treatment
continues to be a major obstacle forincreasing access to testing and treatment
in Cameroon, despite several governmental
decisions in the last three years on cost
reduction and fee waivers for indigents andchildren. MSF aims to work closely withlocal associations, activists and actors tolobby for the removal of barriers to HIV prevention, care and treatment.
MSF has worked in Cameroon since 2000.

Tania, a young Cameroonese athlete, was a
100-metre track champion when she foundout she had Buruli. “It all started with a little spot on my left ankle. It was in the middle of a competition and I did not want toget distracted or stressed. But weeks passed
and the spot became bigger and purulent. I
decided to go see a “mother”, a traditional
healer. She informed me it was onwondo or
Buruli Ulcer.
I was shocked. It was a terrible blow to myfamily, my coach and me. After two years of
being treated by traditional medicine andthe local nurse, and after another nodule
appeared on my left elbow, I found out
about MSF and decided to go visit them at
the Buruli department of the Akonolinga
hospital. I had to have an operation and thenurses looked after me day after day, cleaning and changing the dressing. Today, morethan five years later, I am smiling again. I
know I will be able to have a normal lifeand I’m so thankful to those who helped
me. But I want to tell those affected by theulcer: please do not wait, go and visit the
Buruli ward at Akonolinga as early as possible.”
Lack of awareness of Buruli by health workers and affected communities means thatthe disease is usually detected at a latestage. Other factors for not seeking medical
advice are financial constraints, beliefs thatthe treatment does not work, fear of surgery
and anaesthesia or superstition and stigma.

“The delayed recourse to surgery – themain treatment for the ulcer – is much
more traumatic than if carried out early,
when it is highly effective. At a later stage,
wide excisions or removal of the affectedskin area, including healthy tissues, are recommended to stop the infection and prevent recurrence or relapse at the same site.
It requires skin grafting and means a longstay in hospital,” explains a former coordinator of the Akonolinga project.
Patients suffering from Buruli Ulcer currently receive eight weeks of antibiotics aswell as wound dressing and surgery.
Although initial results of the antibiotic
treatment seem to reduce the need for surgery, more evidence is needed before concluding its effectiveness.
Named after a county in Uganda, Buruli iscaused by mycobacterium ulcerans, a bacteria related to tuberculosis and leprosy.
Scientists do not yet know how the disease
is transmitted, but it does not appear to becontagious. Currently diagnosed primarily
by clinical symptoms, Buruli needs more
research for rapid and accurate diagnosis
and effective treatment.
The World Health Organization estimatesthat 100,000 people are suffering from thistropical disease, which has been reported inover 30 countries worldwide, particularly inWest Africa, Central and South America,
Southeast Asia and parts of Australia.

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 33

AfricaI N T ER NAT I O NA L S TA FF 27
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NAT I O NAL S TAFF 1933

Republic of Congo(Congo-Brazzaville)

Democratic
Republic of Congo

Renewed fighting between government forces and Ninja rebels inregion today cannot obtain basic medical care.

Millions of people continue to live in crisis throughout Democratic Republic ofCongo (DRC) and the medical situation
remains grave. Five surveys conducted by
MSF in different parts of the country in2005 showed excess mortality – morethan double the commonly accepted
emergency threshold – and the absenceof or exclusion from medical care forlarge parts of the population.

In Pool’s Kindamba district, MSF performs
more than 2400 consultations monthly, atregional referral hospitals and throughmobile clinics. The team offers in and outpatient care, emergency surgery, andmaternal and childcare, including immunisations. In Mindouli district, another 2400
patients are seen monthly at mobile clinics
and in the district hospital. Mental healthservices are also offered through local
counsellors and social workers, who help
people overcome trauma related to theregion’s violent past.

Fighting continued to affect regions in
the eastern provinces of North Kivu,
South Kivu and Katanga as well as Ituri
district, causing the displacement of tensof thousands of people. Many live in thebush without adequate shelter, water,
medical care or food and under the continuous threat of insecurity. Others havefled to villages and are hosted by local
populations or live in camps. Against thisbackdrop of violence, 2006 witnessed thefirst and relatively peaceful presidential
and parliamentary elections in the DRC in
40 years.

Congo’s southern Pool region has caused increased hardship for
civilians living in this war-torn country. The recent violence follows
years of bloody conflict that destroyed the region’s infrastructure
including its healthcare system. The fighting also caused many
healthcare workers to flee. As a result, most people living in the Pool

HIV/AIDS care
MSF assists HIV-positive patients at a newprogramme in Mindouli. Counselling services and a patient support group havestarted and the first patient with advanced
AIDS began receiving antiretrovirals (ARVs)
in February 2006. HIV-positive patients areoften co-infected with tuberculosis (TB)
and MSF provides integrated care for coinfected patients in Kindamba andMindouli. MSF is urging the Ministry of
Health (MOH) to integrate TB and HIV/AIDS
care into its basic healthcare services.

Endemic diseases
Malaria accounts for a large proportion ofillness and death in this country. Advocacy
work by MSF and others has led to achange in the malaria protocol from chloroquine and fansidar to more effective
artemisinin-based combination therapy(ACT). Close to 1000 people were treatedfor malaria in the first two months of 2006
alone.

Sleeping sickness (Human African
Trypanosomiasis), a parasitic disease
spread through bites of the tsetse fly, isalso endemic here. After 20 years of screening and treatment, MSF closed its last project because of sharply reduced rates of theillness, but has urged the MOH to integrate
such activities into its healthcare services.

Handover of Kinkala project
In May 2006, after performing 90,000 consultations and rehabilitating health structures, MSF handed over a basic healthcare
project in Kinkala, Pool’s provincial capital,
to the MOH. MSF had also begun providing
HIV/AIDS treatment in Kinkala; thesepatients will continue to receive carethrough the programme in Mindouli.
Prior to the project handover, MSF sent asurgeon and anaesthetist to Kinkala to perform vesico-vaginal fistula surgery on 20
women. Caused by prolonged labour andother obstetric complications, fistulas
result in chronic incontinence, leading tosocial isolation. The surgery helps women
to function normally and, it is hoped, will
facilitate a return to their homes and families.
MSF has worked in the Republic of Congo
since 1997.

Katanga province
Fighting between local militias and theCongolese National Army (FARDC) flared
up in late 2005, and in northern Katanga,thousands of people were once again
forced from their homes.
For most people in central and northern
Katanga, upheavals and displacements
have become commonplace since thewar began in 1996. Malnutrition is one
result of ongoing violence, which prevents people from farming their lands forfear of being attacked by armed groups.
In November 2005, the small town of
Dubie was overwhelmed when over
18,000 displaced persons arrived in amatter of weeks. Already running a makeshift hospital and a network of five healthcentres, MSF rapidly erected three emergency camps. In the first three weeks ofJanuary, MSF carried out 1224 medical
consultations and began a mass vaccination campaign against measles.
Responding to urgent needs for the displaced, in early 2006 MSF started a programme around Lake Upemba, in thecentre of the province. With people living

34 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006

Africa“Hundreds of thousands of people are suffering multiple displacements, direct violenceby a variety of armed groups, malnutrition and outbreaks of preventable diseases.
This reality has become so commonplace in many areas that it goes virtually unnoticed.”
Excerpt from a speech delivered by MSF staff Helen O’Neill at the United Nations Security Council Arria Formulameeting, January 24, 2006.

MSF also worked in Nyunzu, Pweto,
Mitwaba, Shamwana, Ankoro and Mukubu,
providing primary and secondary health services to displaced and resident populations
and responding to emergencies caused by
epidemics and displacement.

North Kivu
Bordering Rwanda and Uganda to the eastof the DRC, North Kivu has been a theatreof fighting between various local and foreign militia as well as the Congolese army
and UN blue helmets. Militias, as well as
poor and unpaid soldiers, exert enormouspressure on civilians, who are subject tolooting, extortion, rape and other violenceon an almost daily basis. In Rutshuru hospital in 2005, 26 per cent of monthly surgicalinterventions were for war-related trauma.
In 2005, 1292 survivors of rape were treatedby MSF in Beni, Kayna and Rutshuru.
In early 2006, at least 40,000 people fled
their homes around Rutshuru, reaching thevillages of Kanyabayonga, Kayna andKirumba. Many others remained in the“People arriving in Dubie were ina really bad state as they had
walked hundreds of kilometresto get here, half-naked, withbarely any food.
Many mothers had given birthen route and some people did
not survive. You just wouldn’t
believe such a situation exists
unless you actually see it.”bush, subject to violence and looting. MSF
opened two health posts in Kanyabayonga,
where most of the displaced persons were
hosted, and MSF teams continue to work in
Rutshuru and Kayna hospitals, providing
medical and surgical care. A therapeutic
feeding centre is also running in Kayna.

Ituri
In Bunia, capital of Ituri district, MSF continues to run the ‘Bon Marché’, a comprehensive hospital that includes a focus on providing care to survivors of sexual violence.
More than 4500 people aged between
eight months and 80 years were treatedhere between April 2003 and December
2005. In June 2006, MSF teams also beganproviding clinical treatment and monitoring when a pneumonic plague outbreakoccurred several hundred kilometres northof Bunia town in the area of Rety. Two isolation centres for the treatment of patientswere set up in Kwandroma and in Vedza
and 376 patients were treated.

Treating HIV/AIDS and Sexually
Transmitted Infections (STIs)
HIV/AIDS is a major focus for MSF in the
DRC. In Bukavu, South Kivu, MSF provides
comprehensive HIV/AIDS care with counselling, testing and treatment of opportunistic infections, as well as antiretroviraltreatment (ART). The objective is to treat
1500 patients with ART by the end of 2006.
Two Karibu clinics opened in the northeastern town of Kisangani, in June 2005
and May 2006, and provide a combined
total of 3000 medical consultations month-ly. Medical care is complemented by targeted health education concerning thetransmission and prevention of sexuallytransmitted infections, HIV and issues surrounding sexual violence.
In addition to a long-running project inKinshasa, which treats about 1900 patientswith ART, a new HIV/AIDS programme
opened in Dungu in Oriental Province inJuly 2005. Following rehabilitation of thehospital, which was destroyed during fighting, MSF began providing essential medicine and training Congolese staff. One
aspect of the training focuses on treatmentof the deadly Human African
Trypanosomiasis (sleeping sickness), which
MSF treats in a separate project in Isangi,
Oriental Province.

Multiple emergency interventions in
2005/2006
The eruption of violence and disease is frequent in DRC and MSF teams are required
to be mobile and react at short notice,often on a large scale. To help facilitate this,quick-reaction teams known by the Frenchacronym PUC (Pool d’Urgence Congo) havebeen established in three major towns.
Major interventions in 2005 and 2006
included a typhoid fever outbreak in Kikwit
and a major measles campaign in Mbuji
Mayi, during which 380,000 children under
5 years of age were vaccinated.
MSF has worked in Democratic Republic ofCongo since 1981.

© Marcus Bleasdalein squalid conditions on the lake banks, instraw huts or on floating islets, MSF
opened a healthcare centre, launched ameasles vaccination campaign and distributed supplies such as plastic sheeting,blankets and cooking utensils for displaced
families. A cholera epidemic also struck theregion around Upemba and Kikondja, leading MSF to open an emergency programme, treating 1742 cholera patientsover 20 weeks.

Megan Craven, MSF nurse
An MSF nurse covers evening clinic in the hospital makeshift tent in Dubie, Katanga. Malnutrition, malaria,
cholera and tuberculosis make up the largest percentage of diseases that kill in the DRC.

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 35

AfricaI N T ER NAT I O NA L S TA FF 62
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Ethiopia© Åke Ericson/WorldPictureNews

lenge in Ethiopia. There is still a very limited
availability of the necessary drugs, even inareas where the disease is endemic.
Transmitted by the sand-ﬂy, the diseaseattacks the immune system causing fever,
wasting, an enlarged spleen, anaemia anddeath if left untreated. Today, kala azar is stillwidespread in many parts of the country.
In the district of Libokemkem in the northeastern Amhara Region, MSF treated 1150
patients for kala azar in the last eightmonths of 2005. In Humera, a town on theborder with Sudan and Eritrea, MSF focuseson patients co-infected with HIV and kalaazar and treated 1823 patients in 2005. A
third project is based in nearby Abdurafi.
A colour-coded measuring tape is used to examine the arm of young boy in an MSF feeding centre. If the tapeshows red, the child will receive treatment. El Kere, Ethiopia, June 2006.

Ethiopia remains one of Africa’s poorest countries, with a very low
income per capita and a population that is almost two-thirds illiterate.
Its economy is highly dependent on agriculture, which in turn is largely
dependent on rainfall.
Many Ethiopians rely on food aid fromabroad – in 2005, the UN reported between
five and seven million people dependent
on food aid out of a total population of 77
million. In years of poor harvest, as many as
14 million people risk lack of food, therefore the drought of the past year was ofparticular concern to MSF teams located in
the southeast of the country.
In Cherratti and Barre in the Ogaden, also
known as the ‘Somali Region’ of Ethiopia,
MSF started a therapeutic feeding programme for severely malnourished children in March 2006. Because of the nomadic nature of much of the population here,
the project was adapted to become ambulatory, with MSF teams moving around theregion rather than operating out of a fixedlocation. Nutritional assessment missions
were also carried out in the Afder andGode Regions in January and February andmonitoring continued throughout 2006.
MSF is supporting primary healthcare
activities in Cheratti district, performing up
to 100 consultations per day at the healthcentre, and offering emergency, inpatientand birth delivery capacity as well as antenatal care and therapeutic feeding. In

August 2005, the project expanded toinclude tuberculosis (TB) treatment and by
the end of May 2006, 191 patients had
been enrolled.
A second tuberculosis project is based in
Galaha in the arid and remote Afar Region,
situated in the east of the country. Like thepopulation of the Somali Region, the Afars
are nomadic, moving every three or fourmonths in search of grazing areas andwater for their livestock. Given that a full TB
course of treatment takes six to sevenmonths, with drugs administered daily,
MSF has had to find an adapted approachfor treatment. The solution was to create avillage of 400 huts centred around a healthcentre. Patients are required to live in thevillage under close medical supervision for
four months and are then provided with afurther three months of medication they
can take on their own. Since the project
began in 2001, more than 2400 patients
have been treated and the project enrols
approximately 40 new patients per month.

Treating patients with kala azar
Whilst national treatment guidelines forkala azar (visceral leishmaniasis) are being
reviewed, the disease remains a huge chal-

36 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006

Because much of the country lacks even themost rudimentary care, MSF runs primary
health facilities in a number of locations.
Malaria remains a big concern despite arecent change in Ministry of Health (MOH)
protocol to more effective drugs. In Amhara
and Tigray, MSF treated approximately
76,000 patients and then withdrew frommost projects in 2006 with improved
response capacity from the government. In
Foguera district, Amhara, MSF continues torun a programme that has supported thetreatment of 49,448 patients with malaria.

Emergency interventions formeningitis and cholera
In January 2006, cases of meningitis werereported in the Welayita region of southern
Ethiopia. MSF worked with the MOH to
respond to this epidemic, providing medicines and treatment training to medical
personnel at health centres. MSF also
launched a vaccination campaign, reaching
25,000 persons before handing over activities to the MOH.
In the western region of Gambella, where
up to 70,000 displaced persons in camps
are in urgent need of medical assistance,
MSF has established a fixed health centre
just outside the main town of Itang. A
mobile team is ensuring the most vulnerable communities are receiving basic
healthcare and referral for treatment. In
May 2006, the team conducted an emergency intervention, treating about 2000
cases of cholera.
MSF has worked in Ethiopia since 1984.

AfricaI N T ER NAT I O NA L S TA FF 27
NAT I O NA L S TA FF 367© Benjamin Béchet / Dolce Vita

GuineaThe people of Guinea live in a country with significant poverty andperiodic instability, leading to a lack of healthcare. Even when patientscan get to a health centre and afford to pay for medical services, shortages of medicines and supplies means they may have to go without
effective treatment.
This is frequently the case for those withmalaria, which accounts for about 30 per
cent of hospitalisations country-wide.
Through its projects in Dabola, MSF has
confirmed that artemisinin derivatives(ACT) are the most effective drugs for theillness. MSF continues to offer rapid testingand ACT for malaria at Dabola hospital andthe nine health centres of Dabola prefecture, where 4537 people were treated for
malaria in the first half of 2006. Although
the government now intends to use ACT, it
has been unable to provide the drugs
because of a lack of funding.

Helping large numbers of refugees
Over the past decade, Guinea has become
host to tens of thousands of refugees fromneighbouring Liberia and Sierra Leone.
Whilst the majority of refugees have been
repatriated, some remain in camps, where
MSF provides healthcare to them and thesurrounding Guinean host population.
In Forest Guinea, MSF works in the Lainéthree cholera treatment centres (CTC) in
Conakry and treating more than 3000
patients. In Boké, MSF provided medical
supplies. A second cholera emergency
began in February 2006 in the Forest
Guinea region, where MSF treated 1171
suspected cases.

camp near N’zérékoré, home to approximately 19,000 Liberians. In addition to primary healthcare, voluntary HIV/AIDS counselling and testing was introduced in
January 2006, and in mid-April the first
patient was put on antiretroviral medications (ARVs).

In early January 2006, MSF conducted athree-week long vaccination campaign following an outbreak of yellow fever in the
Boké area, and immunised 369,000 people.
In May, following a meningitis outbreak in
the prefecture of Mandiana, MSF immunised 175,000 people.

MSF also runs a comprehensive HIV/AIDS
programme of counselling, testing andtreatment in Conakry and Guéckédou.
Drugs and medical material are provided toenable treatment of severe opportunistic
infections. MSF has also trained counsellors
and lab technicians and supplied healthcentres with HIV test kits. By the end ofJune 2006, 850 patients were receiving lifeextending ARVs.

Handover of tuberculosis project

Responding to infectious disease
outbreaks
MSF assisted the Ministry of Health (MOH)in August 2005 to address a cholera outbreak in Boké and Conakry, by setting up

Actively involved in Guinea’s National
Programme for the Fight Against
Tuberculosis since 1988, MSF has trained
doctors and health workers to better manage TB, supplied drugs and laboratory
equipment, and increased awareness ofthe disease. In 2005, MSF handed over its
last activities in the Conakry region to the
Ministry of Health. MSF is now focusing
only on TB patients co-infected with HIV/AIDS.
MSF has worked in Guinea since 1984.

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 37

AfricaI N T ER NAT I O NA L S TA FF 5
NAT I O NA L S TA FF 16

I N T ER NAT I O NAL S TAFF 51
NAT I O NA L S TAFF 9 4 0

Guinea-Bissau

Ivory Coast

The West African country ofGuinea-Bissau has a precarious
water and electricity supply evenin its capital, Bissau. In addition
to common diseases such as
malaria and TB, there have been

© Espen Rasmussen

infrastructure, lacking a generalrecent epidemics of cholera,
measles and meningitis – theSporadic violence and instability continue in the Ivory Coast,most recent taking place in 2005.

despite a peace agreement signed between the government andrebel forces in 2003.
The country has effectively been cut in two
and the healthcare system was decimatedthrough the conflict that began in 2002.
Ministry of Health (MOH) staff are slowly
returning and medical services are resuming, but there remains little or no healthcare for most of the population.

© MSF

As well as providing basic healthcare inboth the north and south, MSF is pioneering new ways of delivering HIV care in thewest of the country, proving that this ispossible in a place where fighting canbreak out at any time.

The first cases of cholera emerged onJune 11, 2005 in Bissau, the capital. The
disease spread quickly to other regions
and by the end of August, the entire
country was affected. MSF responded to agovernment appeal for help, sending
teams into Oio province, Bissau city, Sao
Domingos and Bijagos. By the end of theintervention, MSF had treated 5242
patients of the more than 23,000 recordedin the country.
MSF worked continuously in GuineaBissau from 1998 until 2000. MSF keeps inregular contact with the authorities tohelp with any health emergencies thatarise.

HIV prevalence is estimated up to 15 percent in some areas. Previously, HIV/AIDS
care was administered by doctors in hospitals, but for many people with HIV this is
not viable for a host of reasons, including
distance and the difficulty in accessing
hospital care because of conflict. As analternative, MSF is training nurses and clinical officers to provide care in health clinics.
Education and communications activities
encourage people to come forward for voluntary counselling and testing, with free
antiretroviral therapy (ART) and treatmentof opportunistic infections provided for
those in need.
In Danané, MSF in 2005 built a new hospital
unit for pregnant women with HIV, dedicated to providing treatment that will prevent these women from passing the virus
on to their babies. In its first four months,
five per cent of the 922 women tested were
found to be HIV positive. In Bin Houye, MSF
is supporting Ministry of Health HIV/AIDS
treatment programmes in three health cen-

38 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006

tres and has started voluntary counselling
and testing services. MSF also supports thegovernment’s HIV/AIDS programme in Man.

Providing essential healthcare
At hospitals in Danané, Bouaké and Man,MSF continues to provide essential medicalcare, including paediatric consultations,emergency medicine, obstetric and gynaecological care and surgery. In 2005, MSF
teams in Bouaké provided approximately
4500 consultations monthly and in Man
more than 8000. Mobile clinics are used toprovide basic healthcare in more isolatedareas and in the “zone of confidence”, thebuffer area between the north and south,
where MSF runs a hospital in Bangolo anda health centre in Kouibly.
In January 2006, whilst many organisations
were forced to evacuate amidst riots anddemonstrations against internationalorganisations – labelled occupying forcesby certain groups – MSF teams in Guiglo
were able to continue their work, providing
primary healthcare for up to 6000 displaced persons and the local population(3200 consultations per month) and treating severely malnourished children in atherapeutic feeding centre.

Handover of prison project
After eight years working in MACA prison,
formally the Maison d’Arrêt et deCorrection d’Abidjan, MSF successfully
handed this project to the MOH at the endof 2005.
MSF has worked in the Ivory Coast since
1990.

Kenya“ When we opened the office in El Wak, people would
turn up at the door literally begging for water”

AfricaI N T ER NAT I O NA L S TA FF 42
NAT I O NA L S TA FF 39 9

MSF emergency co-ordinator Ibrahim Younis

Across the north of Kenya, the drought had
a devastating impact on livestock. In El
Wak, the bleached white earth became littered with carcasses of goats, cows, donkeys and camels – a crippling blow to thepeople of this neglected region. In this partof Kenya, animals are the lifeblood, serving
as wealth as well as the primary source ofnutrition.
An MSF nutritional survey in March showed
30 per cent of children to be severely malnourished and many more teetering on theedge. When torrential rains eventuallybegan in April, children already weakened
by malnutrition developd diarrhoea andrespiratory infections. Their nutritional status also worsened. During the month ofMay, the admission rate in El Wak increased
by 50 per cent over previous monthly averages, and MSF began to see children suffering from kwashiorkor, the form of severe
malnutrition that creates swelling and iscaused by insufficient protein and acuteinfections, all a result of insufficient foodintake.
In May, a second intervention was started
400 km west, in three of the most arid
regions in Marsabit District. MSF adopted asimplified strategy and ensured maximum
mobility of the team to effectively reachthe scattered, pastoral population displaced by ongoing inter-clan conflict andwidespread loss of livestock. Two mobile
teams provided biweekly medico-nutritional assistance in 35 sites in villages orperipheral settlements. By the end of June,
700 children at risk of death were enrolled
in the treatment programme and somesevere cases were referred to health structures including the district hospital, where
MSF set up a therapeutic facility.

© Dieter Telemans

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

Improving HIV/AIDS care

Handover to local authorities

For the past decade, the primary focus of
MSF’s work in Kenya has been HIV/AIDS.
MSF provides a comprehensive package ofcare, from testing through to treatment, inthe slums of the capital, Nairobi, as well as
Homa Bay and Busia in the west of thecountry. By March 2006, over 8500 people
were receiving antiretroviral treatment(ART) from MSF sites and over 17,000 wereenrolled in the projects.

After building an HIV/AIDS clinic on the
grounds of Mbagathi District Hospital,
Dagoretti district, Nairobi, MSF has been
providing comprehensive HIV/AIDS carealongside health authorities. MSF is now
supporting the Ministry of Health to takeover this project.

In Homa Bay and the Kibera and Mathareslums of Nairobi, MSF has specialised in thetreatment of HIV/AIDS and tuberculosis(TB) co-infection. Immune systems weakened by AIDS help to fuel tuberculosis andone of the objectives of the projects is todevelop an optimum treatment strategy.
MSF is piloting the field application ofhigh-tech diagnostic methods to increase
TB case detection amongst patients whoare co-infected with TB and HIV. In the
sprawling Kibera slum, MSF runs three clinics, two including HIV/AIDS as one part of afull primary healthcare package, with aparticular focus on mother-to-child healthcare. Early diagnosis of children born to
HIV-positive mothers is now accessible at
all these sites and there has been a significant increase in treatment of infected
infants below 18 months of age.

The goal of increasing access to treatment
is showing the need to decentralise, andmake care available at a greater number ofsites – not only through peripheral healthstructures but also directly through thecommunity, which is increasingly committed to participating in the follow-up of
newly tested patients and supporting people new to treatment.
In Kenya as a whole, only about 75,000 of
the more than 200,000 HIV/AIDS patients
who urgently need antiretroviral therapy
now receive the drugs, according to thehealth ministry. In June 2006, the government made the positive step of providing
free HIV/AIDS care in all public health facilities: a vital move given more than 60 per
cent of Kenya’s 33 million people live on
less than one dollar a day and about 1.2
million Kenyans are HIV-positive.
MSF has worked in Kenya since 1987.

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LesothoLiberia
In July 2006, electricity was partially restored to Monrovia, thecapital of Liberia, following afourteen-year blackout. Standpipe water also became available in parts of the city for the
first time in years. Rehabilitation
efforts are starting to bear fruitin this country, now rebuilding© Wayne Conradie

after a 14-year civil war, but
Liberia still lacks operational
health facilities and personnel.
In 2005, about 90 per cent of allhealthcare services were providPatients waiting outside one of the 14 health centres in the Scott Health Service Area.

ed by faith based-organisations

Lesotho, a small mountain kingdom landlocked by South Africa, hasor international NGOs such as

the third highest HIV prevalence in the world. With 28.9 per cent of

MSF.

adults infected, it comes after only Botswana and Swaziland, and is thepoorest of the three.
MSF arrived in Lesotho in January 2006
with the goal of launching a decentralised
approach to HIV/AIDS care and treatment.
Whilst HIV/AIDS care is typically only available at major centres in resource-poor
countries, here the programme would offer
access beyond hospitals and urban areas,
providing HIV care and antiretroviral therapy (ART) at 14 clinics in Scott HealthService Area (HSA), a rural health district
with a population of 220,000.
The team has benefited from the many
years of experience MSF has accumulated
operating AIDS treatment programmes
elsewhere, particularly in Khayelitsha andLusikisiki in nearby South Africa. Key factors were built into the programme fromthe start, such as provision of free HIV/AIDS
care and treatment; delegation of tasks tolower levels of health workers; simplification of treatment guidelines; and protocols
and empowerment for persons living with
HIV/AIDS (PLWHAs).
In less than six months, the MSF teamtrained more than 100 nurses, village
health workers, peer educators, and

PLWHAs; enrolled more than 1000 people
into HIV care; and initiated ART for nearly
300 people. Mobile medical teams visit
each health centre on a weekly basis, manyin remote, mountainous areas, to provide
direct clinical care for patients and offer
on-the-spot supervision and training fornurses. Intensive support is also provided
in the outpatient department, wards, laboratory, and pharmacy at Scott Hospital.
Essential to the project has been the development of strong partnerships with thehealth staff and management and PLWHAs
in Scott HSA (one of the many health districts managed by the Christian Health
Association of Lesotho), as well as the
Ministry of Health and Social Welfare,which provides all antiretrovirals for the
programme through a grant from the
Global Fund. Through these partnerships,
MSF aims to reduce AIDS-related deaths
whilst strengthening the capacity of healthworkers and communities to cope over thelong term with Lesotho’s truly overwhelming HIV/AIDS emergency.
MSF began working in Lesotho in 2006.

40 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006

In 2005/2006 many Liberians who fled
the fighting during the war returned
home from temporary camps and MSF
began closing camp-based health andsanitation programmes and established
new ones in the capital and around thecountry.

Providing healthcare in the capital
MSF has provided full support to hospitals in Monrovia since 1999. MSF runs a
150-bed hospital in the Mamba Point
area and provides specialist paediatricand obstetrics inpatient services at Island
and Benson hospitals. After six years of
supporting Redemption Hospital, MSF
handed over its management to Liberian
health authorities in November 2005.
MSF also supports two primary care clinics in Monrovia, providing over 10,000
consultations monthly.
Cholera thrives in the crowded conditions of Monrovia, with disease outbreaks
occurring regularly. In August 2005, atthe height of an outbreak, MSF teams
intervened and treated 350 suspectedcholera patients per week. Later in theyear, the MSF-supported cholera treatment unit was handed back to Liberian
health authorities.

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Malawi© Julie Rémy

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

Helping survivors of sexual violence
Since 2003, MSF has provided medical
treatment and psychological support tosurvivors of sexual violence. MSF staff also
conduct outreach activities and information sessions in markets, schools, churches,mosques and clinics to raise awarenessabout sexual violence and to encourage
survivors to seek care. In 2005, over 1400
persons were seen through MSF-supported
structures. Half of them were under theage of 18.

A pregnant woman receives antimalarial drugs and iron from an MSF clinical officer at the Thyolo District Hospital.

HIV/AIDS has dramatically reduced average life expectancy in Malawi to
below the age of 40. It has left 700,000 orphans and vulnerable children.
Close to a million people in the country are now HIV-positive. The disease has contributed to a huge shortage of qualified health staff, which
complicates efforts to address the disease, whilst approximately 170,000
people are in desperate need of antiretroviral (ARV) treatment.

Medical care around the country
In Saclepea, Nimba county, MSF runs ahealth clinic next to a camp housing about1000 Ivorian refugees. In 2005/2006,
approximately 3000 outpatient medical
consultations were conducted here monthly. A new women’s health unit was also created, offering family planning services andtreatment for sexually transmitted infections.
MSF also runs several health clinics andprovides care to survivors of sexual violence in Grand Bassa and River Cess counties, and runs a hospital providing freecare. A community-based programme inGrand Bassa treated 271 malnourishedchildren from January to July 2006.

© Chris Hondros/Getty

MSF has worked in Liberia since 1990.

The government has been increasing thenumber of treatment sites to provide
greater access to life-extending care. MSF
is closely involved in this decentralisationin the southern district of Thyolo, where
the number of treatment sites has risen
from one to seven and close to 6000
patients were using ARVs by July 2006. MSF
also conducts a programme at the district
hospital, started in 2002, to prevent mother-to-child transmission of the disease. By
mid-2006, over 2000 women had made useof this programme.
MSF provides a comprehensive HIV/AIDS
programme in the country’s central Dowa
district, with teams at district hospitals andseveral health centres. Aside from the local
residents, care is provided for refugees
coming from a number of African countries
and now living in a camp in Dzaleka. By theend of April 2006, 424 patients, including
22 children, were receiving ARVs from MSF
in Dowa. A support group has also beencreated for HIV-positive children aged six
and over, with high attendance.

2005, including 1300 patients who havebeen on ARVs for two years and more than
200 patients who have successfully used
this therapy for more than three years.
Another 250 new patients begin treatment
monthly. MSF also treats medically complicated cases including patients on secondline treatment (for whom firstline drugs
have failed), patients with Kaposi’s
Sarcoma – an AIDS related cancer – andchildren. MSF also cooperates with theregional hospital providing care in theadult medical and paediatric wards, whereapproximately 700 patients are admittedmonthly.

Distributing food
Malawians in 2005 experienced food shortages resulting from the worst drought inover a decade, and MSF provided nutritional support to help HIV-positive patientsand other vulnerable groups. In September
2005, MSF started feeding malnourishedpatients, and had distributed approximately 80 tonnes of food by the end of the year.
MSF has worked in Malawi since 1986.

In the Chiradzulu district, MSF was providing ARVs to 6491 patients by the end of

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Mali

MoroccoPeople living in Mali, a country located in the middle of Africa’s
meningitis belt, suffer from recurrent epidemics of meningitis, cholera,
measles and yellow fever. In 2005/2006, MSF responded to a numberof health emergencies in this country where the majority of its
13.8 million inhabitants are without access to basic healthcare.
Mali was then confronted with a number ofmeningitis cases in March 2006. Working in
conjunction with the MOH, MSF supervised
vaccinations, furnished free treatment forpatients and organised transportation,necessary refrigeration for vaccines andother logistics for the districts of Koutiala
and Sélingué. In total, 179,539 people were
vaccinated.

© Mickael Therer

Increasing access to healthcare

In the northwest part of the country, acholera epidemic broke out in Kayes andNara between June 2005 and January 2006.
MSF teams backed up the Ministry of
Health (MOH) by taking charge of patientcare, controlling hygiene measures andeducating the population about the disease. A total of 914 people were affected.
From September to November 2005, anintervention to identify and treat malnutrition was carried out in Goundam, an hour’s
travel from Timbuktu. Out of 5000 children
evaluated for malnutrition, 54 were hospitalised and 228 were treated as outpatients. National personnel at health centres
are now familiar with the techniques ofnutritional surveillance and will continue
to monitor for child malnutrition.

Malaria is the leading cause of death in the
country. Although the government has
updated its malaria drug protocol to use
artemisinin derivatives (ACT), insufficientquantities and high prices preclude thisprotocol from being used throughout thecountry. In July 2005, MSF began a projectaddressing malaria in Kangaba, offering
ACT to those diagnosed with rapid malaria
tests at community healthcare centres.
MSF has also been developing a programme, in cooperation with five otherNGOs, to reduce maternal-infant mortality
in the northern regions of Gao, Timbuktu
and Kidal. Equipping health centres,increasing community education related tomaternal health and performing obstetricsurgeries (such as fistula surgery) are theprincipal components of this programme.

An MSF team provides assistance to sub-Saharan immigrants
made with plastics and other materials supplied by MSF and

In October 2005, approximately 3000 subSaharan immigrants were rounded up
from the coastal Spanish villes autonome
of Ceuta and Melilla, and the cities ofRabat and Casablanca.
They were put in buses by Moroccan
police forces and driven to the Sahara
region of the country, near borders with
Mauritania and Algeria. Here more than
1000 people were dumped in the desert
without any food, water, or access tohealthcare.
MSF immediately intervened, providing
emergency medical care, distributing
food, water and blankets and denouncing
this inhumane treatment. Over 100 people were treated for wounds and bruises,some caused by failed attempts to jumpover fences into the Spanish territories
before being expelled to the desert. Manyother contusions were caused by rubberbullets and beatings, claimed by victims
to have resulted from violent force usedby Spanish and Moroccan authorities.
In total, more than 4000 people, someasylum seekers, were involved in a massive expulsion. Eventually more than 3500
persons were repatriated to Mali and
Senegal, whilst others were relocated ordispersed on their own.

Withdrawal from training project
After five years of MSF support, the nursing
school “Sahel Formation” has provided
regions in the north with more than 300
qualified nurses and lab assistants in azone that previously suffered from a complete lack of health personnel. The school
remains open, and MSF has now withdrawn
from the project.
MSF has worked in Mali since 1992.

42 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006

These were some of the thousands of illegal immigrants that arrive in Morocco
every year, en route to Spain and theEuropean Union. Increasingly tight bordercontrols find many of these people stuckin an inhospitable situation with difficulties accessing food, water or healthcare.
Only weeks earlier, in September, MSF
released a two-year report of medical data
and testimonials from its healthcare projects in Tangier, Nador and Oujda. Violenceand Immigration, a Report on Irregular SubSaharan Immigrants in Morocco, showed an
alarming 25 per cent of medical consulta-AfricaI N T ER NAT I O NAL S TAFF 59
NAT I O NA L S TAFF 853

in the “Kilometre Six”, next to Tangier. Their shacks areliving conditions are precarious.

tions between April 2003 and May 2005
were for violence-related injuries, 62 percent of the most severe cases claimed tohave been inﬂicted by Moroccan andSpanish security forces.
MSF has worked with the sub-Saharanimmigrant population in Morocco since2003, providing medical care to immigrants with the support of the Moroccan
health facilities. Vaccinations, ante-natal
care and family planning are necessary forthis vulnerable population and MSF runs
mobile clinics and monitors the community for disease outbreaks. MSF provided
4245 medical consultations in the past
year, caring for approximately 2500 people
in Tangier, Nador and Oujda. MSF also provides shelter, blankets and relief materials
to improve hygiene and help immigrants
attain minimum standards of living.
In early 2006, following continuous pressure from security forces and the deaths of
15 people, the majority of immigrants inthe north of the country moved to urban
areas, whilst a few hundred remained inbad conditions in the forests. MSF continues to provide assistance to the forest
dwellers through mobile clinics.
The Spanish government has now raised
the height of border fences separating
Spain from Morocco in Ceuta and Melilla,
resulting in fewer concentrations of immigrants in these areas and fewer MSF interventions. However, MSF continues to advocate for more humane treatment of
sub-Saharan immigrants based on theseinterventions, and monitors the health situation of potentially vulnerable populationsin the Moroccan Sahara region as well as
Algeria and north Mauritania – the departure point for immigrants heading to the
Canary Islands, and an area to which few
international organisations have access.
MSF has worked in Morocco since 1997.

An estimated 16 per cent of Mozambique’s population is affected by
AIDS, creating an urgent need for effective, accessible HIV/AIDS care ina country where the majority of the population lives in rural areas andbelow the poverty threshold. MSF is helping to address the epidemic
through comprehensive HIV/AIDS projects throughout the country.
In the capital city of Maputo, MSF wastreating over 5600 patients with antiretrovirals (ARVs) by the spring of 2006. MSF is
working with the Ministry of Health (MOH)
to make care available beyond main hospitals and at the primary healthcare level –decentralising care for asymptomatic casesthat do not require such intense medical
supervision, and patients who have recovered immunity through their treatment.
Training local staff is a significant part ofthis effort, as is field research aimed at simplifying the treatment for patients suffering from HIV/AIDS and tuberculosis.

1639 people by the spring of 2006, as partof another comprehensive HIV/AIDS programme that includes education, voluntary
counselling, testing and treatment. In all
MSF sites, activities were developed to prevent HIV transmission from mother tochild. These have been well integrated into
the public health system.

Preventing the spread of cholera

In Niassa province, MSF has an ongoingproject in Lichinga district. Here, 650
patients were treated in the spring of 2006,
with 400 of them undergoing treatment
with ARVs. MSF is looking at decentralising
comprehensive HIV/AIDS care, aiming for
its programme to be integrated into the
public health system.

In January 2006, torrential rain fell in Sofala
province, creating ideal conditions forcholera, the potentially deadly, waterborne disease that can spread rapidly without adequate sanitation. When the firstcases of cholera appeared, MSF teams from
Tete helped local authorities treat patientsand stop the spread of the disease by providing equipment and logistical expertise.
MSF also organised training in logistics andhygiene so local health workes are better
able to deal with future outbreaks of cholera.

Midway through the country, in Tete province, MSF was providing ARVs to more than

MSF has worked in Mozambique since1984.

© Francis de Beir

© Juan Carlos Tomasi

Mozambique

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Niger

Nigeria

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

In mid-2005, MSF opened seven new inpatient centres in Maradi province, two in
Tahoua province, and 27 ambulatory centres. When malnutrition levels began to fall,
most of these centres were closed or handed over to other nongovernmental organisations (NGO). Staff then concentrated on
helping children in southern Maradi, where
there continued to be a high rate of malnutrition. In August, MSF started working in
the Tanout area of northern Zinder province, setting up a therapeutic feeding centre (TFC) and 11 outpatient feeding centres. The TFC was closed in January 2006
after treating more than 3500 children.
MSF also provided care in the Ouallam district of the Tilaberi region during 2005,
treating 501 severely malnourished and2355 moderately malnourished children in
the last four months of the year. The programme was handed over to another NGO
in late December 2005.
In 2006, MSF teams continued working in
the regions of Zinder, Maradi, and Tahoua
treating both severe and moderate cases ofmalnutrition. By June 2006, more than
25,000 children were receiving malnutrition-related medical care from MSF teams.
About 2000 children were being admitted
to its nutritional programmes each week.
Because a sick child is at greater risk ofdeveloping acute malnutrition, MSF is
working with the Ministry of Health to offer
free care to children under five in most of
the health centres in the Maradi region.
MSF opened two paediatric units in Maradi
in July 2005 to handle cases of severe
malaria, acute respiratory infection andacute diarrhoea. More than 50,000 consultations and 2000 hospitalisations were carried out in these two hospitals during
2005. From January through May 2006,
MSF carried out 30,000 consultations and
900 hospitalisations.

Distributing foodIn October 2005, the Niger government,
backed by the UN’s World Food
Programme, called for food distributions toend. This was done two weeks after the
harvest so as not to destabilise the market.
MSF called for these distributions to be
redirected towards the areas where families were suffering from acute malnutrition.
MSF teams began to distribute a proportion of the UN aid to the most affected villages to the south of Zinder in late October.
In southern Maradi, MSF distributed
130,000 food rations for moderately malnourished children.

Meningitis outbreak
In February 2006, a meningitis outbreakoccurred in the southern districts of Maradi
province. MSF started a vaccination campaign, immunising more than 800,000 people during February and March. Staff alsocared for some of the patients alreadydiagnosed with the life-threatening disease.

© Henk Braam

MSF has worked in Niger intermittently
since 1985.

44 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006© David Levene

more than 90 per cent in Niger in 2005.

HIV/AIDS is a massive problem in Africa’s
most populous country. Many people inurgent need of treatment for AIDS andrelated illnesses find that the medical
attention they need is unaffordable orunavailable.
In Lagos, MSF has established a comprehensive HIV/AIDS programme, providing
care to more than 1500 people infectedwith HIV. Over 1000 patients are receiving
the antiretroviral (ARV) medicines theyneed at General Hospital Lagos.
MSF and civil society groups advocate foraccess to free treatment and actively promote the use of lower cost, generic ARVs
to help expand this treatment. Whilst
progress has been made to increase theavailability of first-generation ARV medicines, access to newer, field-adapted AIDS
drugs is an ongoing challenge. Researchin the Lagos project has shown an acuteand growing need for affordable secondline medications – the newer AIDS drug
formulations for patients who develop
resistance to a first combination of medicines and must change their treatment. In
2005/2006, MSF, treatment advocates andcivil society groups publicly urged pharmaceutical companies to make these AIDS
drug formulations immediately available
to patients in Nigeria and other developing countries, achieving some successwith initial shipments of the heat-stable,secondline drug lopinavir/ritonavir toNigeria in July 2006.

Multiple health emergencies
In response to a nutritional crisis in several areas of northern Nigeria, MSF in mid-AfricaI N T ER NAT I O NAL S TAFF 14
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2005 conducted emergency interventions
in Borno, Katsina and Sokoto states andtreated more than 15,000 severely malnourished children at three stabilisation
centres and dozens of outpatient therapeutic feeding sites. Mobile teams travelled
to remote communities to provide nutritional education, healthcare and highcaloric food supplements for children not
requiring hospitalisation. MSF also conducted over 14,000 paediatric consultations, and treated many of these children
for malaria. By the end of the year, fewer
and fewer children were admitted for treatment, and MSF closed down or handed
over projects to local health authorities
between January and March 2006.
When a cholera outbreak occurred innorthern Borno state in October 2005, MSF
set up a treatment site and cared for morethan 1300 patients within two months.
MSF also responded to a meningitis outbreak in Jigawa state from April to June
2006. MSF strengthened case managementin three hospitals, directly treated 527
patients, and conducted a vaccination
campaign in four local governmental areasfrom May to mid-June, vaccinating nearly
150,000 people.
The southern oil-rich Niger Delta region is
the site of regular, violent clashes between
various groups struggling for oil and in
October 2005, MSF opened a surgical programme for trauma victims in Port
Harcourt. From January to May 2006, MSF
staff performed 471 operations and admitted 561 emergency patients. More than aquarter of the emergencies treated in May
were for violence-related injuries such as
gunshot wounds, stabbings, beatings, rape,and domestic violence.

Malaria project closed
In November 2005, MSF ended its malaria
project in Bayelsa state, also located in the
Delta region. Local authorities were notwilling to improve health facilities andmedical staffing, making it difficult for MSF
to implement artemisinin-based combination therapy (ACT) in this malaria-prone
region. While quinine is still of use, MSF hasproven that ACT is the most effective treatment for malaria.
MSF has worked in Nigeria since 1996.

© Jennifer Warren

RwandaRwandans are confronting numerous consequences of the genocidethat began in 1994 and killed approximately 800,000 of the country’s
eight million people. Many people lost family members and the horrific events that took place are having a lasting impact on many aspectsof their lives. As a result of the genocide, there is now a gender imbalance within the country, a large number of widows heading households, and a lack of trained professionals such as judges, technicians,
administrators and doctors. MSF is operating projects to provide
maternal healthcare services and help people cope with HIV/AIDS.
Some of Africa’s highest maternal mortality
rates are found in Rwanda, with approximately 1071 women dying for every
100,000 live births. MSF is improving
reproductive health in Northern Province –formerly Ruhengeri Province – a region
with inadequate access to both basic
healthcare and reproductive healthservices.
MSF works in the maternity ward of theprovincial hospital and six health centresin the Burera district. Working closely with
community actors, this programme has
three main areas of intervention: obstetrical emergencies; implementation of familyplanning; and maintenance of all general
reproductive health services including
ante-natal, delivery and post-natal care.
Assistance for women survivors of sexual
abuse, including psychological support,
was also integrated in 2006.

previous fee system. Free services are also
ensured for the poorest sections of society.

HIV/AIDS programmes
In Kigali, MSF operates a comprehensive
HIV/AIDS project aimed at preventing the
spread of HIV and providing treatment tothose who are infected, offering care at
two health centres for some 7600 people
living with HIV/AIDS. Of those patients,
2200 people are receiving antiretroviral
medicines, including 260 children. MSF is
also helping implement the national AIDS
protocol and promoting access to genericantiretrovirals, the less expensive alternative to patented brands.
MSF has worked in Rwanda since 1991.

Admissions have risen steeply since MSF
implemented very low flat fees aimed at
improving access to care. Some 1464
admissions were recorded the first quarterof 2006 in the maternity ward alone, doubling the number of admissions over the

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Sierra Leone

Tanzania

Sierra Leone is still recovering from years of civil war, which shattered
its healthcare system and left most civilians unable to obtain basic
medical care. With the government and many donor countries focusing
on development projects, medical emergencies remain unaddressed inmany districts. MSF is providing medical care to some of the country’s
most vulnerable inhabitants: children, pregnant women and refugees.

Many women in Sierra Leone die from complications during pregnancy or delivery,
and close to one out of five babies dies
during or just after birth. MSF is helping
mothers and babies by reducing medicalrisks and making needed medical caremore available. Women often live far from
hospitals, so in Kambia and Tonkolili districts, MSF has established “maternity
houses” where women in their final weeks
of pregnancy can stay until they deliver. In
these facilities, MSF treats HIV-positive
pregnant women to prevent mother-tochild transmission of the virus. MSF staff isalso integrating HIV and tuberculosis (TB)
care in MSF-supported public health units,
and in the maternal and paediatric wardsof secondary health facilities. Teams train
and supervise staff and supply medicinesand other medical materials. MSF clinics
see approximately 2000 patients permonth in each district.

Helping refugees
By the end of 2005, an estimated 20,000
Liberians were living in refugee camps in
Sierra Leone, having fled their own country
during its civil war. In 2005, MSF provided

medical care in eight camps within Bo,
Moyamba, and Kenema districts. With
increasing repatriation and camp populations decreasing in some areas, MSF handed over activities in three camps in April
2006 but continued to provide healthcare
to refugees and the local population inclinics located beside five other camps.
Approximately 20,000 patients are seen
every month in Southern province, including 10,000 patients for malaria. An outbreak of measles occurred in the Tobanda
camp and nearby villages in November
2005, and MSF immunised 3363 children.
MSF has worked closely with the Ministryof Health (MOH) to change the nationalmalaria treatment protocol from chloroquine to the more effective artemisininbased combination therapy (ACT). Today
ACT is available in the health facilities supported by MSF, but not in other healthstructures. MSF continues to work with the
MOH to have ACT more widely available
and to prepare health staff and communities to use it correctly.
MSF has worked in Sierra Leone since 1986.

Tanzania has not escaped the African
AIDS epidemic. An estimated 120,000
people die each year from HIV/AIDSrelated illnesses here – many never having received a diagnosis or appropriatecare.
MSF runs a project to treat HIV/AIDS
patients in the remote, southwestern
Makete district. The team provides comprehensive care including antiretroviral(ARV) treatment. By mid-2006, 1216
patients were receiving care through the
project, including 583 people taking
ARVs. The team is also training community members and healthcare workers
and providing needed medical supplies.

Providing care in emergencies
Between September and December 2005,
political violence surrounding presidential elections in Zanzibar, a semi-autonomous island off the coast, led to many
injuries among civilians. MSF provided
care to some of the wounded, caring for
approximately 275 people.
In February 2006, MSF travelled north tothe Kibondo area in northern Kigoma,
when approximately 7000 Burundian refugees, “fleeing hunger”, entered thecountry. Thousands of refugees gatheredin transit camps set up to accommodate
only 100 people, so many slept out in the
open. As only a few international NGOs
were providing assistance, MSF began
working in the Nyakimonomono way station in March. The team ran an outpatient
clinic conducting about 180 medical consultations daily, distributed water, built
shelters and monitored the group’s nutritional situation. By mid-2006, most of the
refugees had left the area and MSF ended
its intervention.

Malaria project closes in Zanzibar© Dominick Tyler

A malaria project based on the island of
Zanzibar was closed in December 2005
after the project had achieved its goal ofincreasing access to ACT malaria treatment – the most effective treatment formalaria – in the districts of Unguja andPemba.

46 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006

MSF has worked in Tanzania since 1993.

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

In February 2006, the new government of Somalia met for the firsttime. Even agreeing on a regular location to convene proved arduous.
With the old capital Mogadishu imploding into all-out war in April, thetemporary solution for the transitional federal government was a converted food warehouse in the southern town of Baidoa.
Following a fourteen-year period without afunctioning government, Somalia’s newpolitical leaders are faced with the job of
rehabilitating a country ripped apart byrival warlords and with some of the worst
health indicators in the world.
Complicating their task is the rise of theIslamic Courts, which took control of large
swathes of south and central Somalia by
July 2006.
The country has virtually no health infrastructure. People rely on the occasional private pharmacy or clinic for care, but theseare out of financial reach for most. The only
free healthcare is provided by organisations such as MSF. Yet with unpredictable
and regular outbreaks of violence, international agencies are scarce in south andcentral Somalia, and MSF also temporarily
evacuates its missions on a regular basis.
MSF operates projects in seven locations
across south and central Somalia, including
the capital Mogadishu. A clinic in the
Yaqshid quarter stands as one the few public health facilities in the north of the city,
absorbing many patients from the neighbouring districts. The number of consultations here are far beyond what a single
facility can adequately absorb. In 2005,

109,000 outpatient and 7900 ante andpost-natal care consultations were provided at this clinic. Direct beneficiaries are the150,000 people of Yaqshid North district,although the catchment population isclose to a quarter of a million people. In
addition to seeing high numbers of people
with medical concerns such as respiratory
infections and intestinal parasites, MSF is
the only organisation in the area treating
epilepsy, asthma and other chronic healthconditions.
In Middle Shabelle, MSF attends to primary
healthcare in two districts – Jowhar and
Mahady – through six outpatient dispensaries, seeing many patients with respiratory
infections and skin diseases. In 2006, MSF
ran a measles vaccination campaign inthese districts, reaching 36,340 children
aged 6 months to 15 years. In Yaqshid
North area, 54,897 children were vaccinated.
The situation in Somalia worsened in
2005/2006 with a severe drought that decimated livestock and left many southernparts of the country with dwindlingreserves of food and water. In early 2006,
the MSF-run hospital in the town of Dinsor
bolstered its team to provide mobile out-

reach activities, whilst the therapeutic
feeding centre treated more than 600 children for severe malnutrition between
January and June, a figure almost ten times
higher than the previous year. Even in a‘normal’ year, malnutrition is a chronic
problem in many parts of Somalia. MSF
projects in Galkayo, Marare, Bakool,
Galgaduud and Dinsor contain nutritional
components that treat children year round.
Whilst news of the drought reached the
public in 2006, most gaps in healthcare go
unnoticed. Diseases such as kala azar andtuberculosis are rampant in the country –in Bakool alone there were 543 admissionsfor kala azar in the first half of 2006, mostof these children under age five.
MSF opened new projects in the towns of
Dhusa Mareb and Guri El in the Galgaduud
region in early 2006. In Dhusa Mareb, theregional capital of Galgaduud, the town’s
hospital had not functioned since the last
government collapsed in 1991. In the
Istarlin Hospital in Guri El town, all but themost rudimentary medicines and equipment were unavailable and the few remaining staff were unpaid and lacked training.
With MSF support, the two hospitals werealready treating a combined total of nearly
3000 patients per month by mid-2006.
Patients present at the clinic for injuries
resulting from car accidents and gunshots
and trauma as an indirect result of violent
conflict, including injuries sustained bychildren playing with grenades.
MSF has worked in Somalia since 1991.

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 47

Africa“ The health situation hasn’t improved and there are still only a
few organisations that are offering medical assistance.
For many Sudanese living in the areas where MSF works, life isjust as difficult now as it was before the peace accord.”

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Sudan

Christoph Hippchen, MSF coordinator, southern Sudan

Sudan is the site of MSF’s largest operations, with hundredsof international and thousands of national staff working inover 30 separate locations.
At the end of 2005, whilst a much-heralded
January peace agreement between the
Khartoum government in the north andthe SPLA/M rebel group in the south had
held, sporadic fighting and a slow pace ofchange heightened fears that stability will
not last the six-year period before thesouth votes in a referendum on self-determination. Armed conflicts continued tosimmer in the south, east, and in the Darfur
region to the west, where fighting and violence against the population has raged forover three years, driving over two million
people from their homes.

Violence continues in parts ofsouthern Sudan
By July 2006, the expected increase in aid
following the signing of peace accords was
slow in arriving. Hundreds of thousands of
Sudanese returning from the north or fromcamps in surrounding countries found acountry ill-prepared for their homecoming,with no transportation system, hardly any
health infrastructure, and occasional outbreaks of violence.
On 10 April, armed militia attacked the village of Ulang, where MSF operates a clinicthat treated 11,000 outpatients in 2005.
Most of the patients and villagers, alongwith MSF staff, fled in search of safety.
Thirty-one people were reported killed anddozens injured; 15 were treated in the MSF
hospital in the nearby town of Nasir.
Subsequent outbreaks and threats of violence forced MSF international staff toevacuate from Nasir and from clinics inWudier, Lankien and Pieri. In Pieri, most of
the patients in the MSF clinic, including
120 patients being treated for tuberculosis(TB), were forced to flee. Medical equipment, drugs and food for the patients werelooted, leaving the clinic effectively
destroyed.
In November 2005, MSF was also forced toevacuate its sleeping sickness project in
Tambura in the Western Equatoria region
because of fighting.

the Bentiu hospital, where a total of 17,125
consultations were provided in 2005.

Responding to staggering needs in
DarfurWithin this climate of violence, lack ofhealthcare continues to be the biggest
threat to the people of southern Sudan.
Health facilities are rare and despite areas
opening up with the end of war, theabsence of a transport system is a hugebarrier to access. This also represents achallenge for humanitarian work, sincemuch of the country is only accessible byair – an option limited during a rainy season that reduces much of the Upper Nileregion to swamp.
MSF offers primary healthcare in multiple
locations including Marial Lou and Akuem
in the Bahr El Ghazal province and Ler and
Wudier in the Upper Nile. In the Upper Nile
province alone, MSF treated 250,000 outpatients at six locations in 2005.
MSF also operates a 200-bed hospital in
Kajo Keji in Equatoria, where 200 patientswere treated for sleeping sickness in thefirst half of 2006. This is the only hospital insouthern Sudan providing HIV treatment,with 50 patients taking antiretrovirals as ofJuly.
A new project was opened in April 2006 in
Bor in Jonglei Province. The town of Bor has
become host to thousands of people whohave returned to the south following theend of the war. With only a dilapidated hospital and few medical facilities, the town is
ill-equipped to deal with any influx. MSF iscurrently upgrading the hospital to be areferral structure with a fully functional surgical unit and capacity for 100 inpatients.
In the town of Pibor, several hundred kilometres to the east, MSF teams have carriedout over 5000 consultations monthly,working out of tents during the construction of a new primary health centre. This
number includes outreach consultations inthe smaller health units of Lekuanguole
and Gumuruk, difficult to reach overlandand obliging MSF to use boats if the riverswells enough during the rainy season.
In Unity State, an area still disputed
between north and south, MSF works in

48 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006

In 2004, MSF launched the biggest humanitarian operation in the organisation’s history to provide assistance for the people in
Darfur. Two years later, MSF still had 170
international and over 2600 Sudanese staff
working in 18 locations, where healthneeds remained staggering. In North
Darfur State in December 2005 alone, MSF
carried out just under 20,000 medical consultations.
Numerous attacks against humanitarian
workers have drastically reduced the ability to deploy aid and reach people in need.
Despite ceasefires and peace agreements,
over a million remain in camps, totally reliant on humanitarian aid for their survival,
whilst violence still rages around them.
Examples are manifold. On May 8, 2006, a
truck arrived at the MSF clinic in the townof Muhajariya, northeast of the South
Darfur capital of Nyala. “The truck backed
up towards the clinic,” described MSF nurse
Lisa Blaker. “When the doors of the truck
opened and the tarp billowed up, I saw
injured people piled on top of each other.”Of the 46 patients, 30 were civilians, manyrequiring urgent surgery because of gunshot wounds to their abdomens, shoulders,arms, legs and chests. Two patients died asa result of their injuries. Some patients
described how their husbands, children
and other family members were shot down
and killed in front of them.
The team in Muhajariya admitted 127
patients with violent trauma in April 2006
alone. The 35-bed hospital is regularly
overstretched with the volume of patientsrequiring care.
A number of new projects were opened inJebel Marra, a mountainous area in thecentre of Darfur, in the spring of 2006. MSF
began working in two health posts in Lugo
and Bouley, with a referral system to an
expanded health centre in Kaguoro. Clinics
also opened in Killin and Gorni. By July,
security constraints required evacuations

Africa© Sven Torfinn

and prevented adequate access in thisregion. MSF was unable to respond to acholera outbreak in Jebel Marra because ofa lack of security, and the level of malnutrition in the area began increasing, as people were trapped in the mountains and difficult to get to.
MSF also runs a hospital in Niertiti, a town
of around 3000 residents and as many as
ten times that number of displaced in thefoothills of Jebel Marra. This hospital admitted 1128 patients in the first half of 2006.
Since 2004, MSF has worked in Mornay, acamp for displaced persons housing about
80,000 people. An MSF-constructed healthcentre and hospital conduct an average of4900 medical consultations monthly.
Healthcare services are also provided by
MSF for displaced living in the Shangil andShadat camps and Shangil Tobaya village,
though this project was evacuated on July
23 after a security incident.
Kalma is one of the largest displacement
camps in the world, where MSF runs a primary health clinic with almost 1000 consultations weekly and a women’s health centre that includes treatment for sexual andgender based violence. The project is com-plemented by community outreach and amental health programme to help people
cope with the profound psychosocial stressthey are experiencing.
MSF also provides primary and emergency
healthcare and nutritional support to morethan 100,000 persons, more than half ofthem displaced, in the more stable government areas of Kabakabiya and Serif Umra.

Assisting marginalised populationsin the east
Sporadic fighting also continued over the
past year in Sudan’s eastern Red Sea andKassala states. On the outskirts of Port
Sudan, MSF runs the Tagadom Hospital,
which treats a marginalised population
coming mainly from nearby shantytowns.
The hospital includes a home visitor network, set up to care for displaced persons
in the area, and a focus on maternal healthcare. By mid 2006, 5000 consultations were
performed here each month.

and providing psychological, medical andnutritional care to these children, the mortality average within the orphanage was
reduced to 2.9 per cent. MSF will hand the
project to local partners by the end of2006.

MSF calls for more humanitarian
support in Darfur
The situation in the camps in Darfur continues to be precarious, with a reported 2.1
million people completely dependent on
external aid. In May 2006, MSF issued analert highlighting the dwindling donorinterest in the crisis. With the World Food
Programme forced to reduce food rations
because of a lack of financing, a serious
nutritional crisis also threatened displaced
persons, whilst other vital services such as
drinking water supplies and hospital support were also affected by budget cuts.
As of July 2006, ongoing security incidents
caused MSF to continue to evacuate projects intermittently.

Handover of Mygoma orphanage
Since 2003, MSF has been working in
Mygoma orphanage, Khartoum, where themortality rate of children was a staggering
80 per cent. After collaborating with local
authorities, rehabilitating the institution

MSF has worked in Sudan since 1979.

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 49

I N T ER NAT I O NAL S TAFF 73
NAT I O NAL S TAFF 9 4 8South Africa

Uganda© Wayne Conradie

AfricaI N T ER NAT I O NA L S TA FF 9
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For nearly 20 years, people innorthern Uganda have suffered

South Africa has the largest number of people with HIV in the world,from brutal conflict between

with about six million infected. Since 1999, MSF has provided care andgovernment forces and rebel

treatment for people with HIV in poor areas of the country. In 2001, thegroups including the Lord’s

first patients were enrolled into antiretroviral (ARV) therapy inResistance Army (LRA).

Khayelitsha, the largest township near Cape Town and eventually the
first site in the country to provide ARVs at the primary care level.
By July 2006, the Khayelitsha HIV/AIDS clinics – run in partnership with the Western
Cape Department of Health – were providing care to 8000 patients and ARV therapy
to 4000 people, enrolling more than 200
new patients monthly. With plans to scaleup ARV treatment to 15,000 people by2010 and a high demand for services, themodel is being further decentralised.
Intense efforts of clinics’ organisation, triage of patients, redefinition of staff roles
and referrals are being implemented.
Given the extremely high incidence oftuberculosis (TB) in the township and thehigh level of TB-HIV co-infection (about 60
per cent), an integrated response to the TB
and HIV epidemic has been developed at
the Ubuntu clinic in Khayelitsha, now thebusiest primary care clinic in the province.
Central to the Khayelitsha programme in2005/2006 has been the transfer of clinicalresponsibilities from MSF staff to humanresources recruited by the provincial government. Drugs, including ARVs, are fully
procured by the government whilst MSF
continues to provide managerial and technical support.
In Khayelitsha, MSF has also catalysed theestablishment of services dedicated to vulnerable groups. The Simelela rape survivors
centre is a response to the high degree of

sexual violence against women and children in South African townships. Simelela
provides medical care and psychosocial
support and has integrated with other service providers to offer forensic examinationand police assistance to rape survivors in asingle location.
After four years of presence in Lusikisiki,
one of the poorest areas in the Eastern
Cape, the handover of MSF’s HIV/AIDS programme to the Eastern Cape Department
of Health is expected to be finalised by theend of 2006. This highly decentralised,nurse-based model is a good example of
how to provide HIV/AIDS care to a scattered rural population with a high prevalence of infection. Currently 2100 patients
receive ARV treatment through a central
hospital and 12 feeder clinics.
Coupled to all MSF’s clinical interventions
is a strong community component implemented in partnership with the Treatment
Action Campaign (TAC). TAC volunteers
provide intense community education
about HIV/AIDS, developing treatment literacy and generating greater awarenessabout available support and the rights ofpersons living with HIV.
MSF first worked in South Africa in the mid
1980s and returned in 1999 to respond to
the needs of people affected by HIV/AIDS.

50 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006

Large-scale displacements mandated by
the government have added to the misery. By mid-2006, almost two million people – nearly 90 per cent of the populationof the north – had been uprooted to 200
camps. Unable to work or farm, thesepeople are completely reliant on external
assistance.
Whilst direct violence began to subside
in 2005/2006, many people continued todie from preventable diseases including
malaria, respiratory tract infections anddiarrhoea. Most of the displaced living in
the northern districts of Gulu, Lira, Paderand Kitgum barely manage to survive
their deplorable living conditions.

Providing basic healthcare in thecamps
In Lira district, MSF provides healthcare in
six camps and runs a therapeutic feeding
centre in Lira town with a capacity for 360
children. The feeding centre also offers
tuberculosis (TB) treatment and in
January 2006, MSF started counselling
and testing children suspected to have
HIV/AIDS. In February, 78 of 158 children
tested were found to be HIV-positive. The
team treats the children’s opportunistic
infections and is exploring ways to set up
antiretroviral (ARV) treatment.
In Kitgum district, MSF offers basic
healthcare in five camps. The team also
provides mental health support, care forsurvivors of sexual violence and makes

Africa
MSF staff Amaia Esparzareferrals to secondary facilities. In Kitgum
town, MSF has established a clinic for children under the age of five, where up to1500 patients were treated in one month of2006 alone, 356 with malaria.
MSF cooperated with the NGO Interplast
Holland in December 2005 and April 2006
to provide reconstructive surgery in Kitgum
town for civilians mutilated during the conflict. Six patients with war-related injuries
were treated as well as 18 with cleft lip andpalate conditions or burns.

© Jean-Marc Giboux“It is no exaggeration to say that over the
past two decades, the fabric of society
has been torn apart. The effect of livingin the camps has crushed the life out ofmany people. Alcoholism is rife and violence, especially domestic violence, iscommon. What we treat is only the tip of
the iceberg…people are not living in thecamps, they are surviving. Nothing more.”

Over the years, the LRA is reputed to havekidnapped more than 20,000 children to fillits fighting ranks, although it is thought tohave only one-tenth that number of soldiers today. Every night as many as 4000
children stream into shelters including theLacor shelter, near Gulu town. Walking as
far as 10 kilometres, these “night commuters” are a vivid symbol of the violence inthe region. MSF provides basic healthcare
and mental health counselling for many ofthese children.

Focusing on HIV/AIDS
In neighbouring Pader district, MSF works
in the Atanga and Pader Town Council
camps. In the village of Patongo, where asingle camp houses close to 40,000 people,
MSF provides up to 1000 weekly medical
consultations at a health centre managedin tandem with Uganda’s Ministry of Health.
Malaria, respiratory infections and diarrhoea are the most common ailments treated. MSF has built an 8-bed structure –including an isolation ward for patients
suffering from bloody diarrhoea, meningitis
and measles – to complement the existing
15-bed inpatient ward, which was insufficient to meet the area’s needs.
In camps in Gulu, MSF oﬀers basic healthcare, giving special attention to young children and pregnant women and those suﬀering from malaria. The team carries out waterand sanitation work and health and hygiene
promotion among the local population.

In the northwestern Arua district, MSF provides comprehensive HIV/AIDS care to
thousands of people, with 2500 receiving
ARVs. Between 100 and 150 new patientsare admitted to the programme every
month, including patients from neighbouring Sudan and the Democratic Republic ofCongo (DRC). TB is the most common killerof persons living with HIV/AIDS, and MSF Is
working to integrate care for persons withboth diseases, completing construction of
a 40-bed isolation ward in Arua in
2005/2006.

Malaria and meningitis
In Nakapiripirit, along the border with
Kenya, MSF sees increasing numbers ofpatients suffering from kala azar andmalaria at Amudat Hospital and three
peripheral health centres. In July 2006, 300
malaria patients and 60 patients with kalaazar were receiving treatment. An outbreakof meningitis at the end of 2005 caused
MSF to launch a mass vaccination campaign that reached 40,000 children.

Improving water supply and sanitation
The growing population in rural camps has
stretched the water supply, such that people began collecting contaminated rainwater from the street or from surrounding rivers and springs, leading to an increase inwater-related illnesses. MSF has started
improving the water supply and sanitation
facilities in a number of locations.
Almost a quarter of the population has noaccess to latrines and those who do must
share one with at least 60 other people.
Waste management is virtually nonexistentand the burning of waste poses fire hazards to grass-roofed huts during theregion’s dry season. MSF is drilling boreholes, repairing hand pumps, rehabilitating
springs, constructing waste pumps andbuilding latrines to increase the availabilityof safe drinking water and sanitation facilities.

Increased insecurity
Violent ambushes against civilian andhumanitarian vehicles in the final monthsof 2005 led to the suspension of MSF international staff travelling to the camps innorthern Uganda for almost three months.
Killings of aid workers and civilians compelled MSF in November to call on allarmed groups to respect the safety of civilians and their freedom of movement, as
well as the independence and safety ofhumanitarian aid workers. Throughout thenorth, MSF continued to provide emergency medical relief through the efforts ofnational staff, and by February 2006, withimprovements in the security situation,
most international staff had returned.

Helping refugees from DRC
In February 2006, MSF in Kisoro district distributed blankets, soap and fresh wateramongst 10,000 refugees who had fled anattack on Rutshuru, DRC. Shortly thereafter,
half the refugees were moved to the Naki
Valley camp under pressure from national
authorities. The rest returned to DRC.
MSF has worked in Uganda since 1980.

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 51

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ZambiaZimbabwe© Juan Carlos Tomasi

Grinding poverty, political violence andHIV/AIDS are wreaking havoc on thehealth of many Zimbabweans. Dramatic
inflation rates in recent years have mademedical care out of reach for most people, who bear the costs for most consultations, inpatient care, laboratory services and transportation.

In the second half of 2005, the first cases of what became a massive
cholera outbreak were reported in the Lukanga swamps, 250 kilometres north of Zambia’s capital city, Lusaka. A perpetual problem during
Zambia’s November to April rainy season, this water-borne disease has
the potential to accelerate rapidly in impoverished areas with inadequate sanitation.
MSF immediately began an emergency
intervention, taking over management ofemergency medical activities in Lusaka in
December, when the number of cases roseto 200 per week.
MSF set up two cholera treatment centresin the city with a total of 500 beds. By late
January 2006, MSF had developed thecapacity to treat more than 475 people
weekly. MSF trucked chlorinated water tohard-hit neighborhoods, distributing
70,000 liters of water each week at theheight of the outbreak. The team also
implemented disinfection measures andhygienic burial activities. MSF staff fannedout in the community to promote strict
hygiene measures and distributed information on ways to control the disease’s spreadthrough pamphlets, drama performancesin schools and markets and on radio andtelevision.
In March, the number of cholera cases
started to decline and MSF was able toclose its intervention at the end of themonth, having treated 3028 patients. In

total, 5557 cholera cases were reported
and 151 people died.

Expanding AIDS care
Approximately 1.6 million of the country’s
11 million people are estimated to be HIVpositive and more than 100,000 people dieeach year from the disease. In response tothis crisis, MSF works in two districts of thecountry to provide comprehensive HIV/AIDS care to some of the most vulnerable.
MSF runs projects in the poor and rural
northeastern Nchelenge district in Luapula
province and in the Kapiri M’Poshi districtof Central province, where MSF recently
built a specialised antiretroviral (ARV) clinic
inside Kapiri District Hospital. Testing activities are finding between 30 and 40 per
cent of people infected with HIV in theselocations. By mid-2006, approximately
6000 people were receiving HIV/AIDS related care from MSF at these locations, and an
estimated 2000 were receiving ARV treatment.

Between May and July 2005, an estimated 700,000 people were made homelessas the Zimbabwean government demolished illegal settlements and marketplaces in a number of cities. MSF assisted displaced persons near Harare, conducting
over 20,000 medical consultations fromJanuary to April 2006 at projects in the
Epworth, Hopely Farm and Bellapaise
Farm settlements. The team also distributed blankets and plastic sheeting.
In early February 2006, heavy rains
spread cholera to urban and rural areasof the country. MSF assisted the Ministryof Health by setting up cholera treatment
centres in the provinces of Manicaland,
Mashonaland East and the Epworth section of Harare. Teams also provided medical and logistical supplies, transported
patients and trained health workers. MSF
installed and repaired water systems inhealth centres and organised health promotion activities. By July 2006, over 900
cases of cholera had been treated.

HIV/AIDS care
Almost one-quarter of the adult population of Zimbabwe is infected with HIV
and more than 3200 people die from HIV/
AIDS-related illnesses each week. In thesouthern city of Bulawayo, Matabelelandprovince, Gweru in Midlands province,
the Tsholotsho district of Matabeleland,
North province and Buhera district ofManicaland province, MSF provides HIV/
AIDS-related care to thousands and treats
almost 3000 with antiretroviral (ARV)
medicines. Malnourished children admitted at projects are tested for HIV/AIDS
and given care as needed. MSF is improving laboratory testing facilities and supporting efforts to decentralise treatment
to rural clinics, making HIV/AIDS caremore accessible for those living in isolated areas.

MSF has worked in Zambia since 1999.

52 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006

MSF has worked in Zimbabwe since 2000.

© Paolo Pellegrin/Magnum Photos

Asia and theCaucasus

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

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 53

The Caucasus

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Armenia

Georgia

Following the collapse of the Soviet Union, tuberculosis (TB) has risen
rent system does not offer treatment for the drug-resistant form of TB
because of its complexity: treatment is long and costly, causes severeside effects, and essential medicines are not readily available.
ed. Over 5000 consultations on STI/HIV
have taken place since the project’s inception.
© Alexander Glyadyelov

Alternative treatments for mental illness

In September 2005 MSF, in collaboration
with the Ministry of Health (MOH) and theCity Hall Mayor, established a TB programme in Yerevan and began treating
patients in two pilot districts – MalatiaSebastia and Shengavit. By May 2006, 65
persons were being treated for standard TB
and 25 patients for the multi-drug resistantstrain of the disease. MSF renovated two TB
dispensaries in Yerevan, where patients are
hospitalised. Once the intensive phase oftreatment (up to a year) is over, patientsare followed for several months through asystem of TB “cabinets” that include facilities for collection of sputum samples,
directly observed treatment rooms and abasic laboratory. A dedicated drug-resistant unit at the Republican TB hospital in
Abovian is also undergoing renovation.

Addressing sexually transmitted
infections
In the Shirak region of northwestern
Armenia, MSF runs a sexually transmitted
infections (STIs) management and prevention project. MSF is present in six local
health polyclinics, where it focuses on confidential testing and treatment of STIs,
ensuring access to care is free for all.
Awareness and education about STIs and
HIV/AIDS are important components of thisproject. MSF actively lobbies the MOH toadjust the national protocols for STI care –a primary goal is to obtain inclusion of
antiretroviral drugs on the Republic’s
essential drugs list, so they can be import-

In Armenia, psychiatric institutionalisation
has been the frequent solution for persons
with mental illness and there is a strong
stigma surrounding mental health issues inmuch of the country. Since 2004, MSF has
been supporting and developing outpatient mental health services in an attempt
to provide alternative means of care.
MSF has developed a programme emphasising a multidisciplinary approach to mental illness in the deprived province ofGegharkunik Marz. Between June 2005 andMay 2006, 6488 psychiatric consultations,434 psychological consultations and 1724
social worker interventions were recorded.
The programme includes a strong information and education component, addressing
and challenging the stigma of mental illness. Day centres, offering a range of therapeutic activities and skills workshops forthe mentally ill, have now been handed to
local partner Mission Armenia, and MSF
plans to hand its mental health projects to
the MOH by the end of 2006.
MSF also provides assistance to the primary healthcare system in this region, renovating ailing health structures in
Kharchaghbyur, Tsjambarak, Vardenis,
Geghamasar and Daprabak; and providing
training and medical supplies to local staff.
From June 2005 to May 2006, 14,292 primary care consultations were conductedby MSF-supervised doctors. International
donor presence and funds for healthcare
infrastructure and support have increased
significantly over the past year and MSF
will be phasing out its primary healthcare
support in this region by the end of 2006.
MSF has worked in Armenia since 1988.

54 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006© Alexander Glyadyelov

steadily in Armenia within an inadequate healthcare system. The cur-Georgia, a former Soviet state, has highlevels of poverty and in recent years has
seen only marginal improvements in thestandard of living. Economic stagnationand ongoing territorial disputes overSouth Ossetia and Abkhazia continue tothreaten destabilisation of the country.

Tuberculosis in Abkhazia
The bitter secessionist war fought by the
Abkhaz against Georgia in the early
1990s resulted in a political stalemate:
Abkhazia has created its own government and institutions, but these are notinternationally recognised and it is therefore not entitled to external donor support. MSF remains one of the few international humanitarian organisations
operating in this isolated region.
MSF’s Health Access Programme, whichtargets the vulnerable and elderly, operates through the City hospital in
Sukhumi, Abkhazia’s capital, and supports a network of eleven dispensaries in
the region. Doctors working in thesefacilities are given incentives by MSF toensure they provide free drugs and consultations to the most vulnerable. An
average of 2200 consultations were performed monthly in 2005. A mobile medical team in Sukhumi also visits people
who are house-bound, and provides palliative care to cancer patients who haveno other way of accessing pain relief.
In a region adjacent to Sukhumi, MSF
runs a tuberculosis (TB) and multi-drug–
resistant tuberculosis (MDR-TB) programme in Gulripsh hospital. Since 1999,
over 1500 patients have been treated forstandard TB, and innovations in 2005
included the introduction of ‘self-administered treatment’ where patients areallowed to leave the hospital after initialAsia

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Bangladesh
In April 2006, an MSF survey revealed high mortality rates and increased
malnourishment of small children in a makeshift camp near the town of
Teknaf, in the southeastern tip of Bangladesh. The camp is home tomore than 5000 Rohingya refugees – ethnic Muslims who fled neighbouring Myanmar, where they are subjected to widespread repression.
The camp is a squalid and crowded stretch of land where people live
packed into shelters constructed from wood and small pieces of plastic.
treatment and can continue taking medication with minimal supervision.
The MSF team also attempts to help
patients with MDR-TB deal with a complicated drug regimen and unpleasant side
effects from treatment. When patients test
negative for TB, they can go home, butmust attend an ambulatory facility daily toreceive medication and make monthly visits to the doctor. In 2005, a psychologist
joined the programme to help support
individuals who have had treatment setbacks and have been hospitalised forextended periods. Working with a team of
health educators, the psychologist also
holds group sessions to support those in
the ambulatory treatment phase. MSF has
admitted 100 patients to the programme
since 2001.

Surgical care
In Georgia, MSF provides surgical assistance to the population of the Pankisi valley, some of whom are Chechens displacedby the war. The surgical department of
Akhmeta hospital and the Douisi surgicalpost receive drugs and materials and 30
operations per month are performed in
Akhmeta. An average of 150 consultations
and 50 minor surgeries are done per monthin the Pankisi valley.

MSF has set up a small clinic and provides
basic health and maternal care to the population in the camp and surrounding area.
Malnourished children are enrolled in an
ambulatory nutrition programme. An MSF
technician improves the water quality andhygiene conditions in the camp; plastic
sheeting and much-needed mosquito nets
are also distributed.
On the border with India and Myanmar(Burma), MSF continues to work in the
Chittagong Hill Tracts. This mountainous
region is difficult to access and for decades
was ravaged by conflict and forced displacement. Until a peace accord was
signed between the government and themain rebel party in 1997, this area wascharacterised by internal strife and violence against the tribal population. Today,
ethnic fighting flares up sporadically, but
the area is relatively stable overall and has
seen an increase in local efforts for development.

Reducing the impact of malaria
As all of Bangladesh, the southeast regionis characterised by general poverty and alack of education in remote areas. The population in this particular area also suffers
badly from malaria. Although this tropicaldisease can be treated, in the Chittagong
Hill Tracts many people die from malaria,
especially children. MSF is running threeclinics and a dozen mobile clinics andtreatment sites in the districts ofKhagrachari and Rangamati, where basic
healthcare is provided with a special focus
on tackling malaria. Mobile teams take thefast-acting malaria combination therapy toremote villages, seeing more than 80,000
patients every year. Health educators alsoteach villagers about malaria prevention,
basic hygiene and pre-natal care. Midwives,
together with a team of birth attendants,
look after pregnant women and newborns
and ensure that patients are referred to a
hospital when any complications arise.
MSF has worked in Bangladesh since 1985.

MSF has worked in Georgia since 1993.

© Greg Constantine

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

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 55

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Cambodia

China

Asia

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In Cambodia, where approximately 180,000 people are estimated to be
HIV-positive, MSF is currently focusing its work on treating people with
HIV/AIDS. Government and NGO efforts, including those of MSF, haveincreased treatment access and by the end of 2005, Cambodia had 30
treatment centres. Over half of the 12,335 patients receiving antiretrovi-© Juan Carlos Tomasi

ral treatment (ART) were being treated at seven MSF-supported centres.

In the nation’s capital, Phnom Penh, MSF
works in Norodom Sihanouk hospital,
where over 2300 people are now followinga regimen of ARVs. In 2005, an average of
63 patients per month was added to theprogramme. Tuberculosis is the most common opportunistic infection for persons
who are HIV-positive and MSF offers integrated treatment for those co-infectedwith TB and HIV at all its treatment centres.
On the grounds of Siem Reap Hospital, MSF
runs a Chronic Diseases Clinic (CDC) where
over 2500 HIV/AIDS consultations were
provided per month in 2005. Consultations
and care are also provided for people withother chronic illnesses such as diabetes
and hypertension. MSF treated approximately 40 diabetics monthly in 2005.
MSF runs CDCs to the west of Siem Reap in
Sotnikum, and at Takeo Provincial Hospitalin the south of the country. Combined,
these centres currently have over 1200 HIV/AIDS patients on a regimen of ARVs, 176 ofthem children.
Together with the Ministry of Health (MOH)and other NGOs, MSF is supporting decentralisation of treatment from CDCs to provide more localised access to treatment. In
the towns of Kampong Trach and Poipet,
over 500 patients were receiving treatment
in decentralised sites by July 2006.

An HIV/AIDS clinic at the provincial hospital in Kompong Cham is the only one available to see patients, not only from its own
province, but also from the neighbouringprovinces of Kompong Thom, Kratie andStung Treng. By the end of 2006 it isexpected that 1600 patients will be receiving treatment at this location.

Treating tuberculosis
MSF runs a tuberculosis (TB) project in
Sotnikum and in 2005 introduced a community TB programme in 180 remote villages, providing community-based TB
treatment with the goal of increasing treatment access whilst ensuring adherence.
Village volunteers are assigned patientsand help ensure that medication is taken.
This programme is supported by bi-weekly
visits from a medical home care team.

Malaria projects
MSF has run a malaria project in the
Sotnikum area over the past five years,
which will be handed over to the MOH by
the end of 2006.
MSF has also operated a malaria outreachproject in the isolated Pailin area, utilisingvillage malaria workers to screen people,
and providing effective artemisinin-based
combination therapy (ACT) for this increasingly drug-resistant illness. In 2005 over7000 people were treated, and the activities will be handed over to the MOH at theend of 2006. MSF is currently assessing theeffectiveness of a recently developed andeffective antimalarial drug, Artekin, in thissetting.
MSF has worked in Cambodia since 1989.

56 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006

According to UNAIDS, up to 650,000 people in China are infected with HIV.
Although the healthcare system generally
operates on a market-oriented, fee-forservice approach, the Chinese government has launched a comprehensive AIDS
response and has begun providing free
antiretroviral treatment to AIDS patientsusing a combination of Chinese andimported antiretroviral medicines. MSF
continues to operate a model for HIV/AIDS programmes within the country.
Since December 2003, MSF has beentreating AIDS patients in a small clinic
located on the premises of the Guangxi
Centre for Disease Control in Nanning
City. Here, an average of 315 consultations are performed monthly and 276
patients receive free antiretroviral (ARV)
treatment. MSF was initially the only provider of free ARVs in the province of
Guanxi; now, several government-run
sites have also opened. The MSF project
has been distinctive because of its strongemphasis on confidentiality and counselling.
In central China, the spread of HIV/AIDS is
atypical. Most people here contracted HIVfrom unhygienic blood collection andtransfusion practices when selling theirblood plasma, a common practice undertaken by villagers to supplement theirincomes. In Xiangfan, Hubei province,
MSF manages a treatment clinic in collaboration with the Xiangfan Centre for
Disease Control. More than 360 patientsare registered in the clinic and 140
patients receive free ARVs. Care includes
home visits and a strong educational
component. All MSF projects in China arehighly community-oriented, with MSF
facilitating patient support groups andproviding information to patients’ families, health workers and the wider community.

Asia

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Indonesia
The December 2004 tsunami continued to define MSF action in

Blocked from Henan
MSF has been trying since 2002 to work in
Xiangfan’s neighbouring province ofHenan, where an estimated 300,000 or
more people are in need of HIV/AIDS treatment, many infected with HIV from selling
their blood. One-fifth of the patients in the
Xiangfan project come from Henan, andthe demand from people in that province
to be enrolled in treatment increased significantly in 2006. Despite repeatedattempts to establish a Henan programme,
provincial authorities continue to refuse
MSF access to the province.

Advocating for drug access
MSF is advocating at the national level for
China to facilitate access to AIDS medicines, particularly for fixed dose combination pills (FDCs) that can simplify treatment. Intellectual property protection andother factors currently block the use ofFDCs, resulting in restrictions in drug
choice, lack of availability of needed drugs,
and high prices for some medicines.
Production capacity exists for many drugs
that are either not available or too expensive in China, but patent barriers often
block generic manufacturing. A team of apharmacist, campaigner and lawyer work
full-time to document, raise awareness ofand overcome various barriers to accessing
medicines.

Handover of children’s shelter
Since 2000, MSF had been running a
project for street children in Baoji, Shaanxi
province. This crisis centre and shelter was
established to provide medical, psychological and social care for street children. In
2005, 109 children were taken into theshelter. After helping create a local NGO to
take over the management of this project,
MSF withdrew from Baoji in March 2006.
MSF has worked in China since 1988.

centred mainly, but not exclusively, in Aceh.
MSF was one of the first international aid
organisations to reach Aceh after the tsunami and at its peak was running projects
in eight districts. These addressed a wide
range of emergency medical needs withvaccinations, mobile clinics, mental healthprogrammes, surgery and the distributionof non-food items.
By the end of the year, the health situationin Aceh had returned to pre-tsunami levels
and MSF programmes decreased accordingly. By this stage, MSF had rehabilitated
27 health structures, a hospital and almost
300 wells; conducted over 40,000 medical
consultations and provided over 2000 individual counselling sessions. Over thecourse of the year, MSF had been reorienting its programmes, placing more emphasis on reaching out to inland communities
whose access to healthcare had been
restricted by years of civil war and reinforcing its mental health care for these, as well
as victims of the tsunami. Today, MSF maintains a more streamlined but just as committed team in Aceh, focusing on mental
health in three districts with a particularfocus on working with people affected byconflict. The team performs surgery in Sigli
hospital and provides primary healthcare
to a population of approximately 475,000
through clinics, training, drug donationand health promotion.

Asmat area, where MSF vaccinated over
13,500 children for measles. Here MSF isoffering measles follow-up care andaddressing other health needs.
MSF was just closing its cholera programme in Papua when the June 2006
earthquake hit Java’s cultural capital,
Yogyakarta. Emergency team members
flew straight from Papua to Yogyakarta,
with the first members arriving on thesame day as the earthquake and trucks
filled with emergency supplies soon to follow. Although the majority of needs were
swiftly covered by Indonesian emergency
services, hospitals were overwhelmed. An
MSF surgical team worked alongside otherIndonesian and international teams to help
clear the backlog of patients waiting forsurgery, and a tented 100-bed, post-operative ward was assembled to ease overcrowding in the hospitals and provide
quality post-operative care to patientsfrom all over the city. Psychologists offering training to Indonesian medical staff
and counselling those traumatised by theearthquake continue to work in the region.
MSF has worked in Indonesia since 1995.

Across the rest of Indonesia, MSF continued to respond to outbreaks of disease,including malaria in Alor and measles in
Sumba, and further developed its tuberculosis project in Ambon. In 2006 MSF’s emergency capacity in Indonesia was stretchedas teams used boat, plane and foot toreach people affected by simultaneous epidemics of cholera and measles in the
remote island of Papua. This island hassome of the worst health indicators for thewhole of Indonesia, with a high burden of
infectious disease and communities living
out of reach of even basic healthcare.
Mobile teams were still operating in the© Jodi Bieber© Chien Min Chung

Indonesia throughout the second half of 2005, with medical activities

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 57

Asia

I N T ER NAT I O NA L S TA FF 39
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© Henk Braam

India

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

Indian authorities estimated that approximately 1500 people inIndian-controlled Kashmir lost their lives and 6000 were injured in the
powerful earthquake that struck northeast Afghanistan, the north ofPakistan, and northwest India on October 8, 2005.
MSF launched an emergency aid operation
to assist those in need in both India andPakistan, where the epicentre of the earthquake was located. In India, MSF aid comprised the distribution of thousands ofblankets, tents, sets of clothes and bottles
of water, two tonnes of food and a tonne of
medical supplies to help the injured andthe 140,000 people rendered homeless.

These activities were carried out in addition to the mental healthcare MSF offers
people living in Jammu-Kashmir state, aconflict-prone region claimed by both
India and Pakistan. Working from various
locations in and near Srinagar, in 2005 MSF
aided approximately 1500 people withmental health problems related to thearea’s tensions and conflict.

MSF offered significant mental health support to earthquake victims who werebrought to the provincial capital, Srinagar,
for medical treatment. Team members conducted mental health counselling at fourarea hospitals where people received medical care. MSF later extended its mental
health programme, offering both individual and group therapeutic activities for people in the districts of Tangdhar andBaramulla, areas strongly affected by thequake. A mobile medical clinic waslaunched in the Kupwara district, treating
approximately 40 patients daily. MSF also
trained community counsellors to provide
mental health support for villagers during
the winter months, when snow cut off
remote areas from outside assistance.

Providing care to the internally displaced
In the Karbi Anglong region of Assam state,ethnic violence forced 40,000 persons toflee to camps or shelters in towns and MSF
began providing urgently needed assistance in October 2005. Malaria is an illnessof concern in Assam and teams usedartemisinin-based combination therapy(ACT) to treat approximately 10,000 malaria patients a month. Mobile clinics are used
to reach people in more than 50 camps,
where MSF sees many children with respiratory infections, diarrhoea and malnourishment. In early 2006, MSF carried out ameasles vaccination campaign in thecamps, trucked in clean water and installed
taps on water tanks.

MSF is also active in neighbouring Manipur
state, operating four primary healthcare
clinics in the district of Churachanpur anda clinic to treat people with sexually transmitted infections. Because of the state’s
high rate of HIV infection, in March 2006,
MSF began integrating HIV/AIDS care into
the state’s existing health programme. By
mid-year, 200 patients were receiving carefrom MSF, including antiretroviral (ARV)
treatment. Another HIV/AIDS project
opened in Mumbai to help patients excluded from the national care programme andthose co-infected with TB. As of June 2006,
124 patients were receiving comprehensive
care including 47 using ARVs.
Following the 2004 tsunami, MSF provided
aid to survivors in the southern region of
Tamil Nadu. Working in 28 coastal villages,
the team provided psychological counselling to a total of 770 people (5600 sessions), handing these activities over to a
local partner organisation in December
2005. Prior to this handover, MSF assisted
people affected by flooding in the regionin November, distributing 3000 blankets
and providing 1300 consultations to theaffected population.
In June 2005, MSF handed over a six-yearlong tuberculosis (TB) programme in
Mumbai to local health authorities andredirected its attention to the care of TB
patients co-infected with HIV/AIDS.
MSF has worked in India since 1999.

58 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006

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Iran

Japan

Asia

I N T ER NAT I O NA L S TA FF 6
NAT I O NA L S TA FF 107© Sibylle Gerstl

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

Iran has become home to hundreds of thousands of Afghan refugees
over the past decades. Since 2002, the Iranian government has put
intermittent pressure on its Afghan population to repatriate and nearly
two million people have left Iran.
Still, an estimated one million Afghansremain, many intending to stay. No longer
considered refugees by the authorities, andsince 2004 without rights to private healthcare, they face barriers in access to medical
services.
MSF has been providing care to the Afghan
population through both fixed and mobile
clinics in Mashhad and Zahedan. In 2005,
MSF conducted a total of 130,000 medical
consultations in these projects – seeing
primarily upper respiratory infections anddiarrhoea – and made 2280 hospital referrals, many for emergency care or surgery.
In the economically deprived Zahedan,
MSF has seen an increasing number of consultations and hospital referrals over the
past two years. Approximately 55 per centof the population in this area relies on MSF
for access to medical consultation. In its
two clinics providing primary care, 72, 349
consultations were performed in 2005, and1168 families were visited monthly in theirhomes.
Mashhad is Iran’s second largest city. In
2005, MSF ceased activity of three mobile
clinics travelling to surrounding villages,
and added a second fixed clinic in

Mashhad to improve access to care. A totalof 56,884 consultations were performed in
2005, and 635 families were visited permonth in their homes.
Toward the end of 2005, MSF conducted acommunity based epidemiological survey
to better understand the beneficiary population, which has changed since 2002. The
survey showed that over 80 per cent of the
population has been present in Iran for
more than 10 years, and many had accessto jobs and primary healthcare, particularly
in Mashhad. MSF will therefore be closing
its Mashhad programme in 2006 and focusing its efforts on improving primary andsecondary healthcare access for the more
vulnerable population of Zahedan.

Providing post-earthquake assistance
In March of 2006, MSF distributed hygienekits and food to 1000 families in two villages following an earthquake in Lorestan,
approximately 400 km southwest of
Tehran. Medical assistance was also provided to people in isolated areas.

Nishinari Socio-Medical Centre in theheart of Kamagasaki, the city traditionallyconsidered the core for daily workers andthe homeless of Osaka, remains the only
response to the medical needs of thehomeless, but the structure is well beyond
its capacity. Without healthcare or social
services, people have scattered into riversides, parks and train terminals.
MSF has made several attempts to establish a fixed health centre in the area torestore healthcare for the homeless, but
discrimination against this population is
fierce and widespread and has prevented
the establishment of a fixed clinic. MSF
has met with continual opposition fromsome of the local communities andauthorities.
In 2005, MSF mobile clinics visited fourparks on alternating weeks and conducted 1268 medical consultations, following
270 patients on file. The team treatedchronic conditions including hypertension, diabetes, joint pain and gastritis andreferred those requiring hospitalisation or
specialised care to health facilities in thearea. Patient histories were also collected
in 2005, enabling the MSF team to better
understand the mechanisms of sociomedical exclusion.
MSF has worked in Japan since 2004.

MSF provided aid in Iran following the1990 earthquake and has worked there
continuously since 1995.

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 59Asia

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© Claude Mahoudeau

Myanmar

Under military rule since 1962, Myanmar (Burma) is largely cut-off from the outside world. Much of the population is poor and many lack access to healthcare, including numerous minority groups, who remain undercontinuous pressure and regular violent attacks from the junta. MSF has worked in the country since 1992,
providing primary care and attempting to reach the most vulnerable in order to reduce their suffering.
Particular attention is given to those with malaria, tuberculosis (TB) and sexually transmitted infections(STIs). Gaining access to carry out independent humanitarian action has been challenging, and MSF continues to press the military authorities to gain access to people in need.
In 2005, more than 460,131 medical consultations were conducted in MSF-supported clinics in the capital of Yangon as well as
Rakhine, Kachin and Shan states. In theselocations, MSF conducted over 6000 consultations for those with HIV and by July
2006, had approximately 1888 patients following antiretroviral treatment (ART). Over400,000 people were screened for malaria,
with 175,000 treated. Required treatment
was started by 4310 of the close to 14,000
people that were screened for TB.
Health education – mostly concerning sexually transmitted infections – is a large partof MSF’s work, and half a million people inthese areas were reached in 2005. Morethan 40,000 medical consultations wereconducted for people with sexually transmitted infections (STI) and over two million
condoms were distributed.
In western Rakhine state, MSF provides
basic healthcare, seeing many patientswith malaria, malnutrition and HIV/AIDS,
including a large proportion of Rakhine
Muslims (Rohingya) who are denied citizenship and access to healthcare. In 2005,
MSF tested 350,000 people for malaria andtreated 150,000 with the disease.
Approximately 3000 severely and moderately malnourished children were treated.

Southern Myanmar
In Dawei and Myeik districts, MSF aims to
improve diagnosis and treatment formalaria, tuberculosis, HIV/AIDS and STIs,
with specific attention to the vulnerable
populations: ethnic minorities, community
sex workers and migrant populations – via
fixed and mobile clinics.
In Kayah state, at the border with Thailand,a place of continuing conflict between thejunta’s army and ethnic groups, MSF is also
assisting the population, mostly of the
Karenni people, through two fixed clinics
and two mobile teams. Through all these60 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006

projects in southern Myanmar, MSF in 2005
treated over 100,000 patients including
over 22,000 for malaria. Approximately 370
persons with HIV are following antiretroviral treatment.

Problems of access
Projects focusing mainly on malaria treatment for vulnerable ethnic minorities in
Mon and Karen states were closed in March
2006, as teams could not secure adequate
humanitarian space to operate its programmes independently and without making unacceptable compromises to theauthorities.
MSF has worked in Myanmar since 1992.

I N T ER NAT I O NAL S TAFF 5
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Kyrgyzstan

Laos

Malaysia

Within the prison system in

National authorities and many international organisations do not perceive HIV/AIDS
to be a major health problem in Laos. The
prevalence is low, with an estimated 600 to
3600 people living with HIV/AIDS. Becauseof the low prevalence and limited investment in prevention, there is little awareness of the disease and risk of a rapid
spread among vulnerable groups. With thecurrent HIV response in Laos, UNAIDS estimates there could be more than 18,000
people living with the virus by the year
2015.

With its prosperous economy, Malaysia
attracts high numbers of labourers frompoorer countries in Southeast Asia. Manyof them come from Indonesia and thePhilippines and a large number stay in
Malaysia without legal status.
A specific group within this population isthose who have fled violence and persecution in Aceh, Indonesia and Myanmar.
They cannot be granted refugee status in
the country, as Malaysia is not a signatory
to the international refugee convention.
This has major consequences for theiracceptance in society and for obtaining
essential services, including medical care.
Accessing healthcare is problematic for all
migrants, who find it difficult to pay thehigher fees required of foreigners, even in
the public health system. Refugees haveeven more difficulty, as health staff inpublic and private facilities have a legal
obligation to report undocumented
patients to the authorities.

Asia

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tuberculosis (TB) is up to 25 times
higher than in the civilian sector,
where the contagious disease ispresent at already alarmingly
high rates. Crowded prison conditions provide an ideal environment for the tuberculosis bacilli
to spread into the air quickly andeasily through coughing, sneezing, or even talking.
In 2005, MSF saw a role in helping
Kyrgyzstan confront its growing TB problem and opened a tuberculosis programme
in September. The project is focused on
two detention centres, one in Bishkek anda second in a nearby prison colony. Highquality TB drugs were imported into thecountry and MSF initiated medical training,
the preparation of health education material and started seeing patients.
By May 2006, 242 patients had been treated for TB. Early in May, MSF also began torehabilitate the laboratory in one of 11 colonies for sentenced detainees and somecells in SIZO 1, a pre-trial detention centre
in Bishkek, in order to provide better TB
care. The rehabilitation focuses on the separation of infected patients and the provision of a safe environment for sputum collection.
As more data are collected, it is becoming
apparent that many people in Kyrgyzstan
are multi-drug-resistant (MDR-TB), exhibiting a strain of the disease that renders thetwo best anti-tuberculosis treatments,
rifampicin and isoniazid, largely ineffective.
Treatment is possible, but it is extremely
rigorous and difficult for the patients, taking up to two years and normally requiring
lengthy hospitalisation. MSF will be assessing the prevalence of MDR-TB in the prison
system throughout 2006.
MSF has worked in Kyrgyzstan since 2005
and previously operated an HIV/AIDS andSTI prevention project from 1996 to 2001.

Laotians have had only one place where
they can access HIV/AIDS treatment: theMSF-supported care and treatment centre
in the hospital of Savannakhet, a city in thesouth of the country. By July 2006, MSF
was providing antiretrovirals (ARVs) for
more than 400 people in this location. The
service provides a full range of care for thepatients in Savannakhet, including counselling, testing, treatment of opportunistic
infections and access to ARVs.
Many patients treated in Savannakhet comefrom Vientiane, the country’s capital, oreven further north. Some people must travel up to 24 hours to get their treatment,
which adds an extra burden and causes a
range of problems including diﬃculties getting to the hospital or adhering properly totheir care and drug regimens. MSF has convinced the authorities to open a second
treatment centre in the country, in one ofVientiane’s leading hospitals, Settatirat,
where MSF will provide technical support,
training and a temporary supply of ARVs.
MSF has demonstrated that HIV patientscan be cared for within public health structures, and is continuing to advocate for anational strategy so that testing and treatment will be part of the Lao health structures, carried out by Lao health authorities.
MSF has worked in Laos since 1989.

© Gabi Faber-Wiener

Kyrgyzstan, the incidence of

MSF started working in Malaysia in 2004,
supporting a Malaysian non-governmental organisation (NGO) in providing mobile
clinics for refugees in and around Kuala
Lumpur, setting up a system for referral tohospitals, and introducing mental healthactivities for the often traumatised refugees. Depression, anxiety-related disorders, thoughts of suicide and post-traumatic stress disorder are widespread.
The work has expanded to support thisNGO in its medical work in detention centres, where arrested undocumented
migrants are held, and at improvised settlements in the forests near major construction sites. The main disorders seen
are upper respiratory tract infections, skininfections and gastritis, related to poor living conditions and psychological stress.
MSF has supported the national NGO in
medical and mental health services,offered weekly in three locations, tomigrants living among the general population of Kuala Lumpur. The number ofdaily consultations averages between 80
and 100 per location.
MSF is also establishing a network of
Malaysian doctors and psychologists who
volunteer some of their time to provide
care to undocumented migrants.
MSF has worked in Malaysia since 2004.

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 61

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Nepal

PakistanAsia

I N T ER NAT I O NA L S TA FF 12
NAT I O NA L S TA FF 97

On October 8, 2005 an earthquake measuring 7.6 on the
Richter scale hit northeast
Afghanistan, the north ofPakistan and northwest India.
The epicentre was approximately 100 kilometres north of the
Pakistani capital Islamabad,causing massive destruction in© Florian Larguier

surrounding regions and killing

The team returns to the village of Radidjula. Equipment is frequently transported by donkeys on theseremote mountain trails.

Nepal’s civilians remain caught in a violent struggle between government forces and Maoist rebels. The fighting has caused mostly civilian
casualties – more than 13,000 people are estimated to have died in the
bloodshed since 1996. Hundreds of thousands of people have now
been displaced in a country where nearly half the population alreadylives below the poverty line.
Fighting has limited access to healthcare
and worsened health conditions for mostof the country’s inhabitants. Many healthworkers have left their positions and movement between Maoist and governmentcontrolled areas is difficult, making referrals and distribution of medical materials
extremely problematic.
To provide assistance, MSF runs the 15-bed
Salle Hospital in the capital of the Rukum
district. MSF staff treat patients, supply
medicines and clean water and manage
waste disposal and hygiene. Each month,
the team carries out approximately 2000
medical consultations, including 100 hospitalisations. MSF also supports outlying
health posts in the same district, which
conduct approximately 3000 medical consultations a month.

MSF is also active in the western Kalikot
district. Starting in June 2005, MSF began
rehabilitating the 15-bed district hospitalso it could offer basic and secondary healthcare, reproductive healthcare, TB treatment, and emergency services. MSF also
improved the power and water supply systems. MSF sees approximately 1600
patients per month in the outpatient
department and admits patients to thehospital when required.
MSF expanded its activities with a new
project in February 2006 in the Khotang
district. MSF offers 24-hour healthcare to
local residents including inpatient care andemergency obstetric care. The team is also
rehabilitating Khotang’s Diktel District
Hospital and is recruiting badly needed
health staff.
MSF has worked in Nepal since 2002.

62 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006

an estimated 76,000 people.
The largest impact was in the northof Pakistan, where almost 80,000 people
were wounded and another three
million people were affected, many ofwhom instantly became homeless. The
earthquake triggered a massive emergency relief operation by MSF, operating
in both Pakistan and India.
In the immediate aftermath of the earthquake many victims were cut off from
help, as mountain roads had been
destroyed or blocked by landslides.
Thousands of critically wounded had tobe evacuated by helicopter, and others
were not able to reach hospitals until
several weeks later. The local population
began to rescue injured people, and local
health structures were the first to provide
medical care. National health authorities
deployed medical personnel from acrossthe country whilst the Pakistani army
mobilised helicopters, carried out evacuations, and loosened restrictions allowing
a massive influx of international support.
The number of wounded put enormous
strain on the heavily damaged healthinfrastructure. In the Azad Kashmir andthe North Western Frontier Province ofPakistan only 199 out of 564 health facilities remained fully functional after theearthquake. Patients were often treatedin makeshift hospitals and clinics, oralong the road.
MSF, already present on both sides of theLine of Control between Pakistan andIndia-administered Kashmir, immediately
switched to emergency mode. Within six

Asiamonths, MSF undertook over 116,000 outpatient consultations to treat minor
wounds and general pathologies and to
identify more severe cases for referral toinpatient facilities. Over 30,000 people
were vaccinated against diseases such as
measles. Three hospitals were also set up
to provide surgery and post-operative carefor earthquake victims in Mansehra, Baghand Hattian. Mental health treatment was
integrated from the start of the MSF intervention, with over 11,000 consultations
taking place in the first few months alone.

One of the main worries was the approaching winter and its potential impact on
those whose homes had been destroyed. A
medical and logistical race took place totreat as many wounded people as possible
and to deliver tents, blankets and othernon-food items before winter. MSF sent
almost 2000 tonnes of medical and relief
items to the affected area, benefiting
approximately 83,000 families.
A fleet of helicopters from various armies,
UN agencies and private contractors were
deployed to distribute basic relief material
and evacuate the wounded, and MSF hired
two helicopters to lessen its logisticaldependency on others and set its own priorities in visiting the various project areas.
Although conditions were harsh in someareas, no new medical emergencies arose
during the winter, despite the presence ofsome 20,000 people from the destroyed
cities of Muzaffarabad, Bagh and Mansehra
dependent on medical, shelter, water andsanitation assistance. MSF continued tohelp those in the displaced camps around
Muzaffarabad and Bagh by running a hospital and clinics, trucking in water and constructing permanent latrines.

© Bruno Stevens/Cosmos

Though many actors were involved in providing aid, relief efforts were hampered by
the remoteness of many locations, thedamage to the infrastructure and deteriorating weather conditions. On 119 sites
MSF conducted water and sanitation activities – constructing just over 1400 latrinesand distributing around 30,000 hygienekits from October to April. Still, water andsanitation remained a major problem forthose who could not yet return home.

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

Ongoing programmes throughout
PakistanDespite the intense activity required in theaftermath of the earthquake, MSF’s regularprogrammes in Pakistan continued
throughout 2005/2006.
MSF handed over its primary healthcare
projects to the local Taraqee Foundation in
the Mohammed Kheil Afghan refugee
camp in western Baluchistan province inApril 2006 after performing approximately
40,000 consultations. At the same time
MSF started a project in Kuchlak, a slum atthe outskirts of Quetta, where tens of thousands of Pashtuns from Afghanistan resideafter having fled their country. Here MSF
conducts about 130 mother and child consultations a day and screens for malnutrition.

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

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 63

Asia

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NAT I O NA L S TA FF 6 4 0© Antoine de Changy

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

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

Establishing non-discriminatory carefor HIV/AIDSMSF began its first-ever antiretroviral programme in Bang Kruai district hospital in2000 using generic antiretroviral (ARV)drugs. Since then, MSF has worked closelywith the Access to Essential Medicines
campaign, local partners and the Thai government to establish localised HIV/AIDS
programmes and MSF continues to advocate for large-scale generic production of
ARVs in the country.
In Chiang Rai province, MSF is supportingtwo public hospitals that offer HIV/AIDS
care to unregistered migrants from Laosand Myanmar. At the Mai Sai hospital, MSF
provides free ARVs to unregistered minorities who lack access to healthcare. An MSF
doctor works alongside hospital staff and
MSF ensures drug supply, pays for lab tests
and hospital referrals. At Chiang Saen district hospital, MSF offers HIV treatment andcare to unregistered minorities and to people who cross into Thailand seeking carespecifically for HIV/AIDS.

In Kuchinarai, Kalasin province, the district
hospital in 2005 assumed responsibility for
160 MSF patients receiving firstline antiretrovirals. MSF is now focusing on a pilot
programme to introduce secondline treatment, an alternative drug regimen for people who are not responding to the drugs
they were initially prescribed. This involves
understanding why initial drug regimens
failed and ensuring that hospitals and hospital staff have the correct training, accessto facilities and drug supply necessary tooffer effective secondline treatment.

Treating patients in Bangkok prisons
MSF provides clinical support for HIV in
two prisons in Bangkok: the medium security Minburi Remand Prison, and
Bangkwang, a maximum security male prison where inmates are incarcerated for life.
MSF provides medicines, training, covers
lab costs and sends medical staff to work in
the clinics several times a month. As of July
2006, 44 patients were taking ARVs.

64 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006

Providing basic medical care to
undocumented migrant workers
There are thought to be over two million
migrant workers in Thailand, with more
recent arrivals contributing to the post-tsunami reconstruction of hotels and tourist
resorts in areas such as Phuket. Many ofthese workers remain undocumented andlack access to healthcare. MSF is using
mobile clinics and a newly opened healthcentre in Phang Nha to provide basic medical care focusing on mother and childhealth, treatment of sexually transmitted
infections and ensuring clean water andsanitation.
In 2005/2006, MSF also added 518 patients
to its tuberculosis programme treating
undocumented migrants in Mae Sot, Itakprovince. HIV testing and treatment is now
systematically offered to tuberculosis
patients because of high rates of HIV/TB
co-infection, and treatment is now alsoavailable for persons with multi-drugresistant tuberculosis.

Asia

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Turkmenistan
Assisting Laotian refugees
In July 2005, with sanitation activities
addressed by other actors, MSF began providing healthcare and a water supply to6000 Laotian Hmong people who had taken refuge in Phetchabun in northern
Thailand. The Hmong are an ethnic minority who largely aligned with the Americans
during the Vietnam War, and cite marginalisation and persecution as reasons for fleeing their country even today. By October,6094 medical consultations had been conducted in the camp, mostly for respiratory
infections and diarrhoea. Other nongovernmental organisations (NGOs)
departed in October and MSF was the only
remaining NGO, left in complete charge ofthe camp. MSF lobbied the United Nations
High Commissioner for Refugees, NGOs
and the Ministry of the Interior to takeresponsibility for this refugee population,with no results. As of July 2006, MSF continued to carry out 500 medical consultations weekly.

Handover of projects to the Thaigovernment
In December 2005 MSF closed an HIV/AIDS
project in Surin province, where 752
patients were receiving ARVs. All patientson firstline treatment were integrated into
the national HIV/AIDS programme and MSF
will provide drugs to the 33 patients on
secondline treatment until December 2006.
In Phetburi, central Thailand, MSF has supported an HIV treatment programme byproviding drugs, medical staff, technicalsupport and training at Ban Laem District
Hospital and the paediatric department of
the Phetburi Provincial Hospital. Now the
responsibility for approximately 120 adults
and 70 children on ARVs has been handed
over to the Ministry of Health and the
project will close in 2006.
MSF has worked in Thailand since 1983.

Turkmenistan, one of the former Soviet republics, has been ruled byPresident Niyazov since it gained independence in 1991. Althoughaccurate data on the prevalence of disease and the population’s healthstatus is very hard to obtain, it is clear the regime’s national healthcare
policies and practices are resulting in unmet health needs for a large
number of people throughout the country.
Magdanly, close to the border ofAfghanistan and Uzbekistan, is the focal
point of MSF’s work. The area is home toabout 40,000 people, mostly of Uzbek ethnic origin, and some immigrants (former
refugees) from neighbouring Tajikistan.
MSF works in collaboration with the
Ministry of Health (MOH) in Magdanly
Town Hospital and four primary healthposts in Magdanly District.
In 2005, MSF saw more than 38,000 ambulatory patients and 2000 hospitalised
patients. MSF provides free consultations
and drugs and supports the efforts of thehospital’s local health workers throughtraining, equipment and the direct involvement of MSF staff. MSF teams participate in
the management of infectious diseases,
respiratory illnesses, neo-natal complications and conditions related to poor nutrition of babies and infants. MSF also provides materials, training and technicalsupport to the hospital laboratory, ensuring proper medical waste management
and the creation of hygienic and patientfriendly facilities. Safe blood transfusion
practices are also promoted.

gynaecological conditions and obstetriccomplications.
Through its reproductive health activities,
MSF increased efforts to raise awarenessabout the prevention, recognition andmanagement of a variety of sexually transmitted infections (STIs). HIV/AIDS – theexistence of which Turkmen health authorities have difficulty acknowledging – also
has MSF’s specific attention.
In September 2005, after four months ofdenied access, MSF successfully negotiatedwith national health authorities for permission to continue its work in primary healthposts of Magdanly district. Teams are once
again able to provide child, maternal andreproductive health services to the area’s
rural communities.
MSF has worked in Turkmenistan since
1999.

Ensuring reproductive healthcare
Extensive rehabilitation, especially of thewater and sanitation systems, was carriedout in the maternity ward and intensive
care areas of the hospital in 2005. MSF
devoted much attention to lifesaving
efforts in the maternity ward, where an
average of 75 babies are born every month.
Many premature babies are now saved as aresult of the MSF-initiated Intensive Care
Baby Room.
The Magdanly project was expanded in
2005/2006 to include maternal healthcare:ante-natal, delivery, and post-natal care,
and assistance to hospital staff in the management of prevalent female pathologies,

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 65

I N T ER NAT I O NAL S TAFF 14
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South Korea

Uzbekistan

Asia

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The present conditions in North
Korea make it impossible to provide independent and impartial
humanitarian assistance directly
inside the country and reachthose that need it most. In
North Korean refugees throughprojects operating out of South
Korea.
In Seoul, MSF has been the only foreignorganisation present in the transit governmental centre of Hanawon, where North
Korean refugees are placed for their first
three months upon arrival in the country.
MSF has developed mental healthcare
activities in Hanawon to help refugees
cope with symptoms of trauma – over 200
patients received MSF psychological support in 2005.
Following strong lobbying by MSF, positive
measures have been undertaken by South
Korean authorities to provide much-needed psychological support for North
Koreans both within and after they leave
the transit centre. In April 2006, 150 mental health professionals attended a conference mounted in collaboration with the
University of Psychiatry, Seoul, to discuss
therapeutic approaches to care and review
the three years of the MSF mental healthproject. Responsibility for the provision of
psychological assistance to refugees wasthen handed over to local authorities.
MSF worked in North Korea from 1995 to1998 and has worked with North Korean
refugees since 1998.

© Alessandro Cosmelli/Contrasto

2005/2006, MSF provided care to

MSF is one of the few humanitarian organisations present in Uzbekistan,where a combination of increasing economic hardship and deteriorationof tuberculosis services in the 1990s has led to an increased incidence oftuberculosis (TB). This is most evident in the region of Karakalpakstan,which is also confronting economic problems caused by massive environmental degradation in the Aral Sea area.
In 2001/2002, MSF conducted a drug resistance survey in Karakalpakstan, showing
levels of multi-drug-resistant TB (MDR-TB)
that are among the highest in the world.
Thirteen per cent of people never before
treated for TB were infected with MDR-TB,
and 40 per cent of re-treatment cases were
infected with this strain. MDR-TB is defined
as resistance to the two most powerfulanti-TB drugs, isoniazid and rifampicin. It isa man-made phenomenon caused by poor
patient management, poor adherence toprescribed regimens, poor programmemanagement, or a combination of thesefactors.
MSF began its MDR-TB programme in
Uzbekistan 2003, focusing its activities in
Nukus City and Chimbay District in theautonomous republic of Karakalpakstan. By
May 2006, a total of 246 MDR-TB patients
had been enrolled in the programme.
MDR-TB is a very difficult disease.
Treatment has very unpleasant side effects
and involves hospitalisation for six to 12

66 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006

months. Afterwards, patients have to betreated in the ambulatory phase for abouta year. The MSF team continues to try to
improve the quality of life for patients byoffering psychosocial assistance to themand their families, placing much emphasis
in 2005/2006 on the supervision ofpatients who are living in the community,
but who must still take medication six days
per week.
In collaboration with the Ministry of
Health, MSF recently opened an additional
inpatient TB ward in the TB 1 hospital of
Nukus City. The ward has 30 inpatient beds
designated for patients with PDR-TB (polydrug resistant tuberculosis), yet anotherform of tuberculosis that shows resistanceto certain drug protocols.
MSF has worked in Uzbekistan since 1997.

© Stephan Vanfleteren

The Americas

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 67

The Americas

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Bolivia

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

© Amanda Sans

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

Bolivia is home to a large indigenous population, many of whom arepoor, geographically isolated and have little access to healthcare. Up
to 40 per cent of people are affected by Chagas disease in some rural
areas, the highest prevalence in Latin America. Diseases preventablewith vaccines also continue to be an unresolved health problem.
MSF has focused on helping Bolivians with
Chagas, the deadly parasitic disease thatcan be transmitted through a “bug bite”
and eventually attacks the heart and digestive system. MSF currently operates projects in semi-urban areas and in the city of
Sucre, Chuquisaca department. As Chagas
cannot be effectively treated in adults,emphasis is on diagnosis and treatment for
Chagas in youth under 18, and by July
2006, 193 patients had been treated withgood results. MSF continues to support the
Ministry of Health’s Chagas prevention
activities, trains medical and community
health staff, and conducts community education. Lobbying and advocacy to improveaccess to diagnosis and treatment for
Chagas is also ongoing.
In O’Connor province, Tarija department,
MSF is testing and treating youth under 15
for Chagas, attempting to reduce its
impact. By July 2006, MSF had screened atotal of 7083 youths and treated over 1200
in this rural area. Strategies to diagnose
congenital Chagas in unborn babies havealso been implemented. MSF is now integrating these activities into public healthstructures, aiming to hand over the project

to local authorities at the end of 2006.
Awareness and advocacy efforts have also
been robust with MSF participating in
national and international Chagas forums
and media activities, lobbying at the
department level and contributing to the
Chagas department network.

Flooding in Bolivia
Unrelenting rains caused flooding in
Bolivia’s highlands and the Amazon basin
in January 2006, drawing extensive humanitarian aid. After assessing the health situation, MSF provided safe drinking water toapproximately 600 families in Gualberto
Villaroel province, La Paz department.

Neglected diseases project closes
In April 2006, MSF closed a neglected diseases project aimed at the diagnosis andtreatment of tuberculosis, malaria, leprosy
and leishmaniasis in Pando, because epidemiological surveillance showed these diseases were not as prevalent as expected.
After training local health staff, MSF handed over diagnosis activities to the Ministryof Health.
MSF has worked in Bolivia since 1986.

68 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006

The disease carries a strong stigma and in
2005/2006, MSF worked on breaking down
myths and stigmas attached to HIV – particularly amongst health staff – througheducational workshops and sensitivity
training and contributed to forums on HIV
in different areas of the country.

Advocating for drugs to expand
treatment
Generic medicines, the cheaper alternative
to branded drugs, are key to expanding
treatment for HIV/AIDS. Registering drugs
in Ecuador is a complicated process, andthe use of qualified generic medicines isbeing introduced slowly given strong pressure from pharmaceutical companies to use
branded drugs. MSF has been defending
registration of generics with the goal ofincluding them in the national HIV/AIDS
protocol, and the National AIDS Plan is now
giving greater consideration to generics
because of their lower cost.
MSF has also been lobbying for fixed-dose
treatment (whereby different drugs are
combined into single pills) to become partof the national protocol. Fixed doses makeit simpler and easier for patients to taketheir medicines and helps improve treatment adherence.
MSF is working on a progressive handoverof the Guayaquil HIV/AIDS project to the
Ministry of Health, which should be completed in 2008.
MSF has worked in Ecuador since 1996.

The Americas

I N T ER NAT I O NA L S TA FF 6
NAT I O NA L S TA FF 33© David Pretre / Strates

Honduras

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

Every year, about 20,000 to 30,000 Hondurans migrate from the countryside to the capital, many establishing themselves in squat slums within the centre of Tegucigalpa. With high rates of divorce, alcoholand drug abuse, family structure is fast-disappearing and many young children prefer to live on thestreets. Easy prey for druglords and prostitution, these young people engage in high-risk behaviours
and live amidst a climate of violence – yet they are routinely denied access to state healthcare.
Since April 2005 MSF, in cooperation withlocal organisations, has operated a therapeutic day centre for street children andyouth in the heart of Tegucigalpa. The project offers medical, psychosocial and socialeducational assistance to street children
and youth up to age 24 in an effort to
reduce high-risk behaviour and provide
healthcare. Almost 400 youths are now registered at the centre, which receives
approximately 35 visits per day.
Medical consultations number approximately 180 per month, most frequently for
respiratory infections, skin diseases andtrauma caused by violence. Sexual andreproductive health care are emphasised in
response to the needs of girls and adolescents exposed to the risk of pregnancy,
sexual exploitation, violence and sexuallytransmitted infections. Psychological careis an important part of the services offered,with the centre’s psychologist seeing
approximately 35 clients per month for
symptoms of depression and anxiety alone.
In 2005, the centre piloted psycho-educational group work. One group was createdfor young pregnant women and mothers to
exchange experiences and learn about sexual, reproductive and natal care. The second group, “Los Listos” (quick witted) was
aimed at male members and brings up
issues of violence and drug abuse.
Facilitated by a psychologist and education
specialist, members discuss topics including problems of substance abuse and difficulties living on the street. Girls soon lobbied for a similar group of their own, and in
December 2005, a female “Las Listas” wascreated. In a separate endeavour, a number
of well-attended informational HIV prevention sessions were also held in 2005/2006.

Lending antiretroviral medicines to
the government
After transferring an HIV/AIDS project inTela to national authorities in September
2005, MSF intervened in November 2005
and January 2006, lending antiretrovirals
to prevent impending interruption of treatment not only for its former patients, but
for all 3000 patients enrolled in the national antiretroviral programme. At both times,
drug stocks were about to run out becauseof untimely ordering of drugs by the
Honduran government. MSF expressed
public concern for these patients, and todate no further difficulties obtaining thesedrugs, financed by the Global Fund, havebeen reported.
MSF has worked in Honduras since 1998.

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 69

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Colombia
Now in its fifth decade, ongoing violent conflict in Colombia hascaused the displacement of over two million people. Whilst many people in remote villages find themselves cut off from basic healthcare
services, including immunisation programmes, those who have fled tourban shantytowns are subject to poverty, disease and rampant violence. Many people throughout the country are also suffering frommental disorders including acute trauma caused by witnessing or
being victims of violent events, but areas affected by violence are© Stephan Vanfleteren

often isolated and rarely benefit from visits by healthcare workers.

Expanding care through fixed andmobile clinics
In 2005/2006 MSF continued to provide
essential medical services in numerous
urban and rural areas of the country, using
both fixed health posts and mobile clinics.
In addition to basic healthcare, many programmes include vaccinations, reproductive healthcare, dentistry and psychosocial
support.
In the northeastern department of Nortede Santander, MSF conducted medical outreach activities in isolated rural areas within the El Catatumbo region. Approximately
750 patients were seen each month at two
fixed sites and through mobile activities.
In the provinces of Córdoba, Chocó andAntioquía, MSF in 2005/2006 expanded its
activities, establishing a fixed clinic forpeople who had returned to Saiza,
Córdoba, and starting a second one in Ríos
Sucio, Chocó. Mobile clinics were used toprovide healthcare to people living in outlying villages, treating approximately 900
patients monthly.
MSF also established a clinic for displaced
persons living in the urban slums ofSincelejo. An average of 1250 patients wastreated per month, the most common ailments being respiratory infections, diarrhoeal diseases and acute viral infections.
Near Bogotá, MSF assists the newly displaced in Soacha district, conducting medical consultations and providing mental
health support for approximately 1000 displaced persons monthly. The team also
informs displaced families about their rightto healthcare and provides information on
how they can gain access to the complicated government-run health system.
Psychosocial care is provided for people
living in Florencia, Caquetá. Here approximately 700 are seen monthly, largely for
depression and post-traumatic stress.
In addition to providing healthcare via
mobile brigades, MSF supports health facilities in the Barbacoas region of Nariño
province, by training health staff, providing
support to rehabilitate rural health structures and implementing water-sanitation
and waste management systems.
MSF is also providing medical and psychological assistance to victims of conflict inTolima and northern Huila departments, anarea of fighting, massacres and displacement. In 2005, MSF visited more than 20
different sites and conducted over 14,000
medical and over 4400 psychological consultations in this area.
When an evaluation carried out in Ibagué,
the capital of Tolima department, revealed
that displaced persons had to wait on average three months before obtaining assistance or medical coverage from government agencies, MSF opened a healthcentre in January 2006 to provide medical
and psychological assistance to new arrivals. More than 1000 consultations were

70 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006

conducted in the first four months, nearly
30 percent of them psychological consultations.

Offering medical assistance to survivors of sexual violence
In Chocó department, MSF is working in
the jungle city of Quibdó, population
120,000. There are two roads connecting
Quibdó to the rest of the country, but bothare extremely unsafe because of the ongoing conflict.
Here MSF provides a package of sexual andreproductive healthcare services, targetingsurvivors of sexual violence in particular.
MSF works in the maternity wards of San
Francisco Regional and Ismael Roldan hospitals and also supports the city’s five
health centres, providing them with familyplanning methods, emergency contraception and drugs. Using mobile clinics, MSF
also provides medical and psychologicalassistance in areas surrounding Quibdó. In
its first three months of activities, MSF performed a total of over 3000 medical, familyplanning and psychological consultations
through this project.

Providing help after violence and anatural disaster
In November 2005, fighting between army
and guerilla forces escalated in the town of
San Juancito and hundreds fled this part ofNorte de Santander. Heavy rains caused
flooding and landslides in the same region
days later. In coordination with local
authorities and the Colombian Red Cross,
MSF provided two truckloads of emergency medical material, food, shelter andhygiene kits to approximately 300 displaced persons.

MSF staff held
On 3 February 2006, a local armed group in
Norte de Santander detained five MSF staff
members. Three team members, all
Colombian staff, were released the following day. On 9 February, the final two international staff members were allowed toleave the village where they were being
held. After extensive analysis and evaluation of the security situation in its projects
in Colombia, MSF decided to cautiously
continue its activities, with the exclusion of
one area in Norte de Santander.
MSF has worked in Colombia since 1985.

“All families have suffered. Once I asked thepupils in my class, 11-year-old children, howmany of them had lost a family member
while the paramilitary were here. Out of 28
children, 20 told me they had at least one
family member killed by the armed groups.”

The Americas

The Human Cost of Colombian Conflict© Stephan Vanfleteren

teacher from a rural community

Colombia is a thriving country with a lively culture and growing
level of progress. It has modern cities and f lourishing scientific andeducation centres. But behind this upbeat image, an extremely violent, internal conflict has carried on unabated for decades. Fuelled bydrug trafficking and foreign military assistance, the struggle by guerillas, paramilitary groups and government forces to control territory
and resources continues to take a high toll on the civilian population.
People who live in conflict zones in rural Colombia are often perceived as resources for the armed actors who operate locally.
“We were taken somewhere and they started to threaten us and talkabout chainsaws. After awhile, they let us go. I grabbed my kids andwe left immediately for another town. We left only with the clothes
we were wearing; we walked all night and part of the day, and thekids kept asking for food…”
mother from a rural community
Violence is the leading cause of death in Colombia. During the last
decade, the homicide rate has been approximately 60 per 100,000
inhabitants, one of the highest rates in the world. For every person
who dies as a result of violence, many more struggle to survive it,
often burdened by a range of physical and mental problems.

“ The man was found wandering around town. He said he was feelingbad, but he could not explain what was wrong. He kept talking andcrying…tears went down his cheeks and when we asked him why he
was crying, he said “Am I crying?” and he cleaned his face, started
crying again and kept repeating he did not feel well. He was disoriented, confused, with mental blackouts, he could not remember what
had happened.”community leader, rural area
“My mother cannot sleep…if she hears a motorbike out in the streets
she wakes up and cannot fall asleep again…the thing is that last
week we had to pick up our brother-in-law. He was almost unrecognizable. They had beaten him up, and his head was chopped off. I
can’t get that image out of my head.”young man living in an urban slum
From Living in Fear, Colombia’s Cycle of Violence, a 64-page reportcompiled by MSF to raise awareness of the human cost of the conf lict by giving a voice to those who must bear its harsh consequences.

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 71

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Haiti
Although increasing violence before Haiti’s national elections in
February 2006 briefly focused world attention on this poor island
nation, violence has ravaged the capital, Port-au-Prince, in waves since
President Jean-Bertrand Aristide was forced to leave the country inearly 2004. Civilians suffer from clashes amongst armed factions andbetween armed groups and UN soldiers. Fear, lack of infrastructure andhigh healthcare costs prevent more than half of the country’s population from accessing basic medical services.
MSF provides free emergency medical andsurgical care to people at the 56-bed trauma centre at St. Joseph’s Hospital in theTurgeau neighborhood. During 2005, morethan 7000 people received emergency
medical assistance, almost 2500 of them
direct victims of violence. Half of thosetreated for such injuries were women, children or elderly. MSF also treated more than
100 survivors of rape during 2005 and gavereferrals for further psychological care andlegal assistance.
The enormous civilian cost of Haiti’s violence caused MSF to speak out in January
2006, calling on all parties to respect thesafety of civilians and allow immediate
access to emergency medical care. MSF
also called on all armed actors to respect
the safety of national and international aid
workers after a wave of kidnappings.

Responding to specialised needs
Specialised care for patients in need ofphysical rehabilitation or mental healthcare is provided by MSF in the capital’s
Pacot neighborhood. This includes postsurgical rehabilitation for patients withfractures from car accidents, paralysis fromgunshot wounds, amputated limbs or
those with serious burns. More than 256
patients were admitted for treatment in2005 and an additional 613 people
received outpatient physical therapy.
Eighty-seven patients received psychological support.
In one of the city’s most violent areas, Cité
Soleil, MSF operates the 75-bed Choscal
Hospital and primary healthcare centre in
Chapi. More than 3000 consultations arecarried out monthly, including maternaland child healthcare and surgical consultations.

MSF also works in the communes of Petite
Rivière, supporting health structures andproviding basic healthcare with a special
focus on maternal and child health.
Haiti has the highest level of maternal mortality in the Americas, with 523 deaths per
100,000 births. In March 2006, MSF opened
the 60-bed Jude Anne Hospital in the capital’s Delmas area. The project specificallytargets women living in the most violent
parts of the city, who have difficulty
accessing appropriate care, in part,
because of poverty and violence. Medicalcare is provided for women with pregnancies presenting dangers to the mother andchild, as well as treatment to help prevent
mother-to-child transmission of HIV.
Emergency obstetric care services are available around the clock. Between March andJune 2006, the team performed more than
1200 deliveries and 450 surgical interventions, including 250 caesarean sections.

Project handover
In June 2006, MSF handed over the activities of its primary healthcare project in the
Decayette area to a local NGO. The project
had focused on maternal and child healthincluding pregnancy care, treatment ofsexually transmitted infections and child
immunisations.
MSF has worked in Haiti since 1991.

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

Dr. James Smith, MSF surgeon

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GuatemalaIn October 2005, tens of thousands of people throughout
Central America lost their homes,
livelihoods and access to cleanwater when tropical storm Stan

© Kenneth Tong

struck the region, causing landslides, flooding lowlands, contaminating drinking wells anddisplacing an estimated 30,000
people. Around 1.5 million people
were directly affected. Although
the Guatemalan government
responded rapidly, help wasneeded to reach all of the areas
hit by the storm.
MSF was one of the first internationalorganisations to arrive, bringing 11.5
tonnes of relief materials to the Atitlán
Lake area, including basic emergency medical materials, blankets, mattresses anddrinkable water. Within one week, MSF had
provided 60,000 litres of drinking waterand first aid for people living in shelters indozens of communities in Atitlán,
Chiquimulilla, Coatepeque, San Marcos andEscuintla municipalities.

Providing post-emergency
assistanceOnce the initial emergency phase was over,
MSF focused on rehabilitating water systems, fixing infrastructure and resettlingfamilies. MSF also offered mental healthsupport to people traumatised by thedisaster in a number of locations and provided medical consultations in cooperation
with local doctors.
A large part of the intervention involved
the distribution of items such as hygienekits to help reduce the possibility of waterborne diseases. Overall, MSF distributed
5000 kits to nearly 25,000 people in one
month and gave out more than 15,000
mosquito nets to prevent malaria. MSF also
set up an epidemiological surveillance system, based on a network of health centres,
to monitor for outbreaks of Hepatitis A,
malaria, dengue fever and diarrhoea. In the

A blood sample is taken to test a child for Chagas disease, Olopa, Chiquimula.

months following the storm, there was no
significant increase justifying a medical
intervention.

Helping those with HIV/AIDS
Approximately 61,000 Guatemalans are living with HIV/AIDS. Despite external support, national HIV/AIDS programmes havebeen slow in starting and national healthinstitutions have done little to address the
AIDS pandemic. There is a lack of specialist
centres and staff, and HIV/AIDS care has
been highly centralised, available only in
Guatemala City.
MSF provides HIV/AIDS care in the city’s
Yaloc clinic, where 4000 medical consultations were performed and 803 patientswere receiving life-extending antiretrovirals (ARVs) by the end of 2005. MSF is also
advocating for planned treatment protocols for patients co-infected with HIV and
TB.

Halting the spread of a deadly
influenza

During 2005, MSF made significant progress integrating all aspects of care (counselling, diagnosis, treatment for opportunistic infections, ARV treatment andfollow-up) at all levels of healthcare delivery. This project will be handed over to the
Ministry of Health (MOH) and the national
AIDS programme in 2006.
Collaborating with local organisations, MSF
has been providing comprehensive HIV/AIDS care in the town of Coatepeque andhas begun the process of handing over the
project (2000 patients, 500 on ARVs) to the
MOH.
In the remote town of Olopa, MSF has been
testing and treating people with Chagas
disease, which can be fatal without early
treatment. MSF in 2005/2006 screened
almost 8000 children aged 15 and under,
and treated the 104 children found to havethe disease. Local staff have been trained
to take on these activities and MSF willclose this project in December 2006.

In March 2006, MSF responded to an outbreak of influenza A in Roosevelt Hospital,
which affected immuno-compromised HIV
patients and killed more than 20 people.
MSF provided vaccines for hospital staff
and patients who were able to provide agood immune response. Vaccinations werealso sent for hospital staff in Coatepequeand Puerto Barrios.

MSF’s project for street children in
Guatemala City’s Tzité clinic performed
2702 medical and 719 psychological consultations in 2005. In mid-2006, MSF organised a regional symposium to share theteam’s seven-year experience with academics and practitioners, and plans to withdraw from this project at the end of theyear.

Handing over projects for HIV/AIDS,
Chagas and street kids

After reaching a total of 11,000 students in
14 schools in Coatepeque, a sexual education programme was handed over to the
Ministry of Education in February 2006.

MSF has been promoting decentralisationof HIV/AIDS services to provide better
access to people in remote areas such as
Puerto Barrios, on the Caribbean coast.

MSF has worked in Guatemala since 1984.

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Peru
Lurigancho is one of the most populated prisons in Latin America.
Located in Lima, the prison houses more than 8500 inmates in a spacedesigned for 1500 and up to 4000 visitors are received daily. In
Lurigancho, the risk of contracting HIV is five to seven times higher
than outside the prison.
Starting in 2001, MSF, together with the
National Penitentiary Authority, developed
a multidisciplinary project addressing sexually transmitted infections (STIs) and HIV/AIDS within the prison. The goals were to
improve the quality of medical care andtreatment of STIs, provide care for people
with HIV/AIDS and to train and involve
health professionals from disciplines suchas psychology and education, who could
then provide support to this vulnerable
population.

from 8.2 per cent to 4.7 per cent in parallelwith increased counselling.
In February 2006, after five years of developing the programme, MSF published
Lessons Learned: a multidisciplinary work
experience in STI and HIV/AIDS in Lurigancho
prison in Lima, Peru and began handing
over the project to local authorities. MSF
will continue to support health workers
inside Lurigancho throughout 2006.

A new model of HIV/AIDS care
In the Lima slum of Villa El Salvador, MSF
runs a comprehensive HIV/AIDS project at
the Centro Materno Infantil San José healthclinic. Working closely with the Ministry of

By mid-2006, MSF had built a new clinicand 250 patients were being followed,
including 181 patients receiving antiretroviral treatment. Providing communitybased medical care and publicly addressing the issue of HIV/AIDS has been abreakthrough in an area where HIV is little
understood and remains a stigma.
MSF has worked in Peru since 1985.

© Paco Arevalo

From 2000 to 2005, over 1800 persons weretreated for sexually transmitted infections.
Voluntary HIV tests were taken by 5673
inmates and HIV prevalence decreased

Health, MSF has developed a programmeof simplified testing, streamlined drug regimens and decentralised care. The project
includes free and voluntary rapid testingclose to patients’ homes and the option ofhome-based care for those who cannot
come to the clinic. Social and psychologicalsupport are provided and MSF is creating a
range of educational tools to help patientsand their families understand what is needed for successful HIV/AIDS care – not aneasy task given the high level of illiteracy inVilla El Salvador.

74 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006

© Swen Connrad/YumeVision

Europeand theMiddle East

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

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 75

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Belgium

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

In addition to offering treatment, MSF
strives to redirect patients toward the institutions that should take care of them, getting local and national authorities and welfare agencies to face up to their
responsibilities and ensure care for themost vulnerable groups, care they are entitled to by law.
In July 2005, lobbying efforts reached apromising conclusion when MSF was able
to stop its medical consultations in Liègeafter reaching an agreement with the local
welfare agency. The agreement included
the creation of a Relais Santé, aimed at
guiding the patients through the adminis-

trative maze and at facilitating contacts
with service providers and agencies incharge of paying the bills. While this is amajor achievement, more structural changes are needed to facilitate easier access.

Handing-over of HIV testing activities
For the last 15 years, MSF’s Elisa Centre has
provided free and anonymous HIV testingin Brussels. On Jan. 1, 2006, after a huge
media and lobby push, this service was
finally taken over by the authorities and is
now available in Brussels and Antwerp.
Until then, Belgium was one of the only
countries in Europe not offering free andanonymous HIV testing, despite recommendations from the World HealthOrganization.
The data collected by MSF during the project proves that vulnerable groups are more
likely to come and get tested if it is bothanonymous and free: in its last year ofactivity, 2000 tests were undertaken at the
Elisa Centre, with 1.6 percent of people
testing positive for HIV.

© Layla Aerts

MSF has worked in Belgium since 1987.

76 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006© Julien Leveque

MSF has responded by providing healthcare to these people facing obstacles tohealth services in the regular system. In
2005, MSF conducted 140 medical and psychosocial consultations in clinics inBrussels and Antwerp. Seventy-four percent of these were undocumented
migrants, whilst most of the others were
asylum seekers waiting for a decision on
their applications.

Whilst healthcare and legal solutions do exist, undocumented
migrants in France experience
many difficulties in obtaining
the information and documents
necessary to access state medical aid.
In 2005, MSF conducted 7100 medical
consultations with migrants in ongoingprogrammes through medical/social clinics in Paris (4700) and Marseille (2400).
Eighty-eight percent of those who
received MSF care did not have medical
coverage, although most were potentially entitled. MSF social workers conducted
more than 2500 consultations to help
patients obtain their rights to health coverage through social security andreferred them to agencies for help withbasic needs such as accommodation,
meals, clothing, and legal information.
Although referral to specialists has been
easy to manage, this was not the case forpeople suffering with mental disorders.
New arrivals experience isolation andmany have gone through a violent journey whilst trying to migrate, often fromwar-torn countries. In 2006 MSF intends
to focus its medical activity toward thoseEuropeI N T ER NAT I O NA L S TA FF 2
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Italy
Italy receives thousands of migrants arriving by boat from Africa eachyear. Upon arrival, many of these people are weakened and in need offood, water and medical attention. In 2005/2006, MSF provided medical care for over 20,000 recent arrivals and migrant workers andopened new projects to reach more people in need.
Since 2003, MSF has opened health clinics
for migrants lacking legal status in various
regions of the country including Rome,
Sicily and Campania. The clinics operate aspart of the national healthcare service anduse anonymous codes to protect patient
identity. The clinics’ goals are to treat thesevulnerable people, inform them of theirlegal and healthcare rights and gradually
hand over activities to local health authorities.

Offering cold-weather assistancein Calais
From November 2005 to March 2006, MSF
was present in Calais to provide assistanceto migrants intending to cross the channel
towards England. Sleeping outdoors for an
average of 20 days before leaving France,these migrants – mostly from conflictzones in the Horn of Africa and the Middle
East – faced harsh winter weather andstrict barriers to healthcare. Apart fromemergency hospitalisation, they could notaccess any other due state medical aid.
Using a mobile clinic, an MSF physician saw
an average of 20 patients per day and coordinated any necessary referrals. The majority of patients sought help for infections ororthopaedic conditions related to theirjourney. MSF also complemented food distributions with weather protection kits. By
the end of March, MSF closed the project
after ensuring that state agencies would
improve their system and that anotheractor, Médecins Du Monde, was in place tocontinue primary care.
MSF has worked in France since 1987.

At the end of 2005, a new project with clinics for undocumented immigrants was
opened in the Sicilian town of Agrigento.
One of the main problems detected by MSF
in this area concerns mother and childcare,and barriers to accessing abortion.

Lampedusa, a small island south of Sicily, isa landing spot for more than 12,000 immigrants per year. MSF offers initial medical
screening at the harbour where boat people land after hazardous trips through theMediterranean Sea, and follows up on any
urgent medical referrals. Similar assistanceis provided on Sicily’s southern coast.

Seasonal farm workers’ project
In southern Italy, where agriculture is themain economic activity, thousands of asylum seekers and undocumented immigrants work as day labourers on farms. In
2005/2006, MSF provided medical care toseasonal farm workers in Sicily, Puglia andCalabria. Main pathologies detected wererelated to harsh living and working conditions, such as gastrointestinal disorders,dermatological and respiratory diseases ormusculoskeletal pathologies.
MSF has worked in Italy since 1999.

© Chris Maluszynski/Momentseeking asylum. Having come from countries with armed conflicts, many of these
individuals suffer mental disorders directly
or indirectly related to violence.

In mid-2005, MSF started a new project inNaples, providing healthcare for undocumented immigrants living in one of themost difficult, violent and complex Italiansocial-economic environments. Here immigrants live in ghettos completely excluded
from the rest of Italian society.

Assistance at landings in the SouthMSF staff examine newly arrived migrants at the harbour landing of Lampedusa. MSF has not been given
access to the overpopulated temporary migrant centre on the island.

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 77

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Luxembourg

Russian Federation

Luxembourg is one of the mostdeveloped and richest countries
in the world, where the inhabitants enjoy high health standards.
But hidden problems remain, oneof them being the rapidly growing
use of illegal and psychotropic
drugs.
With approximately 50 per cent of youths
under age 18 having already used illegal
substances, Luxembourg has the highest
prevalence of drug use by minors in
Europe.
MSF has created the Solidarité Jeunes project to help these youths, working withthem, their families and relevant institutions – including most secondary schools,
several educational centres, and outreachprogrammes in the country. A special
emphasis is put on collaboration with thejuvenile justice system, where the MSF programme constitutes an alternative to theclassic repression response. The programme provides psycho-medical, socialand psychotherapeutic care for youngusers and their families. From mid-2005 toearly 2006, efforts were geared toward
expanding the services of Solidarité Jeunes
by developing a concept of peer-intervention (called CHOICE) for first-time arrested
drug users. From June 2005 to May 2006,
MSF worked with a total of 263 adolescentsand families.

Exploring the needs of immigrants
MSF continues to participate in a working
group with other NGOs and the government, monitoring the medical and psychological situation of immigrants and asylum
seekers entering the country. After launching guidelines describing access to thehealth system in Luxembourg for these vulnerable populations, the MSF-led working
group began to scrutinise government procedures and practices concerning theexpulsion of sick migrant people. The working group has submitted a proposition to
the Ministries of Health and Immigration toclarify the criteria for such expulsions.
MSF has worked in Luxembourg since 1996.

Eleven years after the start of the first
Chechen conflict and despite official rhetoric claiming the situation has ‘normalised’,
the majority of Chechens still struggle
through lives burdened by fear, uncertainty
and poverty. Thousands of Chechen refugees have been forced by Russian andIngush authorities to repatriate fromneighbouring Ingushetia. Their homes
destroyed and lacking basic needs such as
clean water and healthcare, many
Chechens face grim conditions in overcrowded, temporary accommodation centres (TACs). Access to the republic remains
a pressing problem.
In Grozny, the republic’s capital, a mobile
team provides primary healthcare to six
TACs, and general, gynaecological and paediatric consultations in four polyclinics.
These clinics see a total of 5600 patients
per month.
MSF continues to distribute medicine andmedical material to Grozny Maternity,
which is the central maternity and referral
hospital for all of Chechnya. In 2005, MSF
provided drugs in support of 125,740 medical consultations in health structures in
Shatoi, Sharoi and Itum Kale. In the rural
region around Grozny – Grozny Selsky –MSF primary care mobile teams offer
healthcare in 10 different village settlements. A primary healthcare clinic was also
opened in May 2006 in Shelkovksy districtin the northeast, offering gynaecological,
paediatric and general services.

High rates of psychological distress
Mental health problems are widespreadamong the long-suffering population andmental health services are a large component of MSF’s programmes. A survey conducted by MSF in September 2005 in six
Grozny TACs showed that 77 per cent ofrespondents were suffering from discernible symptoms of psychological distress.
Fifteen MSF counsellors work closely withthe mobile medical teams, and also offer24-hour services for patients and staff in
the republic’s main trauma hospital – No. 9.

ment area of 300,000 – indicating that
rates of TB are very high. The programme
supports the existing TB dispensary systemwith drugs and necessary equipment, andalso provides specialist lab services. The
directly observed treatment system (DOTS)
has been adapted to the conflict setting
and MSF provides food to boost the nutritional status of patients. MSF health educators hold individual sessions, group workand public information campaigns on TB.
To improve the living conditions of the displaced, MSF organised distributions of
non-food items such as mattresses, blankets, stoves and building material. In 2006,
MSF is constructing sanitary facilities(water tanks, showers, latrines) for around200 families in some of the most precarious
settlements of the Chechen capital.
MSF is also expanding and developing its
surgical programmes in Grozny, providing
training support and equipment to theneurosurgery and trauma wards of Hospital
No. 9. A plastic and reconstructive surgery
programme for patients suffering disabilities from violence or accident related trauma, including gunshot wounds, mine injuries and burns began in July 2006.

Providing ongoing care in Ingushetia
In neighbouring Ingushetia, which saw anincrease in violent incidents in 2005, MSF
continues to provide mobile general,maternal and paediatric clinics in Nazran,Sunzha and Malgobek districts. A medical
clinic also opened in July 2005 in the
Angusht IDP settlement. The clinics conduct about 2700 consultations per month.
Winterisation works were carried out inseveral of the spontaneous settlements,
which still house about 9000 Chechens.
Mental health services are a critical component of the programme, with a team ofcounsellors working in 25-30 spontaneous
settlements. In close collaboration with a
network of local volunteers, they identify
people who could benefit from individual
therapy and organise group sessions andcommunity activities.

Expanding treatment for tuberculosis
MSF’s tuberculosis (TB) programme
expanded in 2005 to include a 4th dispensary, Karagalinkskaya. By June 2006 it had
enrolled over 750 patients from a catch-

78 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006

MSF worked in the North Caucasus from1993 to 1997 and resumed activity in theregion in 1999.

Europe“ We’ve been living in a constantstate of alarm in Chechnya for solong that it ages and exhausts us
and our physical health suffers”© Jorge Dirkx

Chechen doctor

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

Taking healthcare to the streets of Moscow

The homeless youth that MSF works with in Moscow generally live
in and around trains, subway stations or markets, developing compromising survival strategies to cope with the hostile environmenton the street. Some kids beg or work with street vendors, most are
exploited and controlled by criminal groups, and others become
involved in prostitution. In winter, living conditions make themprey to f lu and pneumonia. Sniffing glue, drinking or injecting
drugs are ways to cope with hunger, weather and loneliness.

The official system of police – hospital-priut (temporary orphanage) is more focused on coercion than rehabilitation, and does notfacilitate access to appropriate healthcare, or include street work.
At the core of MSF’s approach is outreach: every day and night, several teams of MSF medical and psychosocial staff walk the streetsand visit the areas where street youth gather, treating kids on the
spot if possible, and advising and accompanying kids to get more
specialised services for treatment. MSF also runs a day centre
where kids can participate in a range of therapeutic and educational activities and also shower, wash their clothes and take meals. The
MSF multidisciplinary team supports each individual to make asustained decision to leave the street, encouraging youths to cometo terms with the difficulties of their past and take control of their
future decisions.

Healthy growth is often interrupted through lack of adequate diet.
Sexually transmitted infections, dermatological and gastric problems, as well as the high risk of HIV/AIDS and other infections are
but a few of the many health challenges faced by this vulnerable
population. MSF provides primary care and first aid, referring
patients on to secondary care for more complex issues.

The MSF street children and teenagers project focused much effort
in 2005/2006 on developing networks with local organisations,establishing a partnership with a drug and alcohol rehabilitation
clinic called NAN. In June 2006 a photo exhibition documenting
the lives of the street kids, taken by the kids themselves, was also
mounted in Moscow.

Over the past ten years, official bodies responsible for the care ofminors have attempted to respond to the multifaceted needs ofhomeless and neglected children, but teenagers living on Moscow’s
streets are invariably excluded from society. Their access to a fullrange of health services is fraught with obstacles.

MSF believes there are, on any given day, 250 to 500 children livingon the streets of Russia’s capital. MSF works with an average of 80
kids each month, mostly boys of 15-16 years old.

“ We were sniffing not to be frozen over. When you
sniff you feel warmer. You are doped and you don’tcare about the cold.”

MSF has worked in the Russian Federation since 1988.

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 79

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PolandSwitzerland
Switzerland boasts one of the highest
standards of living in the world, andmany residents benefit from excellent
healthcare. With substantial fees and/or
health insurance required to see a doctor,
however, barriers in accessing medical
services exist for a sector of the population. Even at the primary care level, many
people face difficulties getting even themost basic and necessary healthcare.

© Swen Connrad/YumeVision

MSF has begun to address some of these
unmet healthcare needs. In January 2006,
after conducting a six-month study, MSF
opened a project in the canton of Zurich
to provide healthcare to marginalised
populations. The health meeting point,called Meditrina, is located in the city district Kreis 4 and provides free medical
consultations and very basic drugs forpatients who remain anonymous. Free
consultations are provided for all peopleof Swiss or other origin who are neither
medically insured nor in possession of
the necessary financial means to pay forthe treatment they need. When necessary, Meditrina refers patients through its
network of physicians, specialists, medical institutions and social organisations.
If it turns out a public institution is
responsible for an individual, the patientis referred.

Poland is hosting thousands of Chechen refugees seeking asylum inWestern Europe. Following two wars and continuing violence and insecurity, thousands of Chechens thinking they no longer had a future in
their own land have fled their country. At the start of November 2005,
over 3500 people were held in 16 separate camps in Poland.
When asylum seekers cross the borders of
the European Union via Poland, they are
registered and sent to transit camps where
they wait to receive refugee status. Only
eight per cent of the Chechen asylum seekers actually receive this status, whilst manyothers obtain a temporary status to residein Poland. According to the ‘Dublin 2’ rule,
the first country of entry into the European
Union must decide whether to give refugee status to an asylum seeker. If asylum
seekers who entered the EU via Poland
make their way to another EU country, they
are sent back to Poland. However, for many
Chechen refugees, Poland is only a transit
point to go west, and not a host country.
Many never intended to live in Poland andfeel is still too close to home to feel safe.

consultation suffer from post-traumaticstress and experience recurring memories,
nightmares and sleep problems. In thetransit centers the Polish authorities provide shelter, food, medical care and social
support, whilst MSF provides psychologicalcare.

MSF publicised the clinic through media,
direct community contacts and social
service organisations, and by the end ofJune 2006, 108 consultations had been
carried out and the average number ofpatients visiting the centre continues torise each week.

MSF began providing psychological support in August 2005 in seven transit camps,
and now works in all 16 transit camps in
Warsaw, Bialystok and Lublin. Psychologists
provide individual consultations to help
asylum seekers deal with trauma that has
been building up over the past decade.
Between August 2005 and April 2006, MSF
carried out a total of 1336 individual consultations for 425 patients.

MSF previously operated a similar projectin Fribourg, Switzerland. In 2004, this was
handed over to a local organisation, FriSanté.

Worn down by 10 years of violence andrepeated trauma, the asylum seekers areunable to find the conditions necessary for
their recovery. Intake records show that
forty per cent of patients coming in for

MSF began working in Poland in 2005.

80 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006© Tangi Zahn

MSF has worked in Switzerland since 2003.

Middle East

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

In July 2006, civilians in Lebanon were trapped by an intensifying war
between Lebanese Hezbollah fighters and the Israeli Defense Forces(IDF). Ongoing fighting, including bombings, caused hundreds ofthousands of people to flee their homes and left many civilians with alimited capacity to meet basic needs including healthcare.

extremely difficult and dangerous, andMSF spoke out about the lack of accesscaused by the imposition on any movement. MSF publicly refused to accept theparalysis of humanitarian assistance andreiterated its intention to use every possible means to reach those in need.

Ceasefire
The first MSF team arrived one week afterfighting began. MSF focused on providing
emergency aid including medical care,fresh water and sanitation facilities to hundreds of thousands of displaced persons
seeking refuge in Beirut, Saïda, Sour,
Jezzine, Nabatiye and the Aley region.
Assistance was also given to Lebanese refugees who had crossed into Syria. MSF supplied more than 60,000 displaced persons
in Lebanon and 3500 refugees in Syria withrelief items such as cooking and hygienekits, mattresses, blankets, baby formula,and tents. Mental health support was also
provided to help people cope with thetrauma experienced by the war.
Whilst Lebanese medical staff were able tocope with the crisis, medical supplies
began to diminish, especially stocks for thetreatment of chronic diseases such as kidney disease. MSF helped replenish needed
supplies, sending over 300 tonnes of material to Lebanon including relief items, med-

ical supplies and medicines, surgical kits,
and logistical materials such as sanitationequipment and water bladders. Teams also
worked with local medical teams to set up
mobile clinics.

Hard to reach
The IDF imposed an air and sea blockade
and carried out airstrikes on several bridges and important roads. MSF obtained safe
passage by sea and worked with
Greenpeace to transport 75 tonnes of
essential supplies from Cyprus to Beirut
aboard the Rainbow Warrior.
Ongoing airstrikes made it difficult toobtain access to people in need, particularly in the south. When the last functioning bridge across the Litani River in southern Lebanon was destroyed, a human chain
was the only practical means for transporting four tonnes of supplies. Trucks, vans,ambulances and cars were targeted several
times, making land transportation

When a ceasefire came into effect on 14
August, the majority of the displaced people returned home within a few days.
During this phase, MSF assessed needs inareas that had previously been cut off by
the fighting. It also brought medical andnon-medical care primarily to the south
and in the Bekaa Valley.
Throughout and following the conflict,
Lebanese health staff and facilities
addressed the majority of the medical
needs and MSF provided a supportive role.
Once the acute phase of the emergency
ended, organisations began to arrive tohelp reconstruction efforts and MSF ended
its activities. MSF continues to monitor thesituation closely.
MSF has worked intermittently in Lebanon
since the 1980s.

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Palestinian Territories
Many people living in the Palestinian Territories experience direct violence, isolation, restrictions on movement, and difficulties accessing
healthcare. The living conditions have psychological consequences formany individuals, manifesting as depression, anxiety, post-traumaticstress disorder or psychosomatic illness. MSF teams provide psychological and medical care and social work assistance to help.
In mid-2005, MSF readied for possible consequences of the Israeli government’s plan
to dismantle Israeli settlements in Gaza,
preparing an emergency programme
before the August withdrawal of nearly
8000 settlers. Ultimately, the army’s action
was carried out without major clashes.
In 2005, MSF undertook a large water andsanitation project in a disadvantaged areaof Gaza known as Al Fara Towers, located in
the Tuffah neighborhood of Khan Younis.
MSF carried out a scabies eradication program in coordination with the local municipality, while logisticians fixed leaking
indoor plumbing, constructed septic tanks,and distributed food kits and household
items such as mattresses and blankets.

In the West Bank district of Hebron,
approximately 70 per cent of MSF’s
patients experienced a traumatic episodein the past year. MSF gives home-based
treatment and support for individuals orfamilies using a team including a psychologist, a social worker and a doctor. MSF is
also trying to improve access to health services by making regular visits to the
Bedouin communities living in the south ofthe district, and to populations residing inareas where movement restrictions make itnearly impossible for them to reach healthservices.

© Alan MeierThroughout the year, MSF worked in thecity of Nablus in the West Bank, diversifying its referral network. Through these
efforts, the team is now well known in thiscity of about 150,000 people.

Approximately 35 per cent of MSF’s
patients in Nablus live in one of the three
refugee camps, the majority live in the oldcity. Here the medical aspect of the programme supports work done by the team’s
psychologists. A social worker also plays a
key role, referring patients to agencies forsocioeconomic assistance.

82 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006

When the January 2006 legislative elections brought Hamas to power, the US,
Canada, European Union and Japan decided to suspend their bilateral financial aid
to the Palestinian Authority. However, they
promised to continue to help the population meet its basic needs by reallocating
part of those funds to the UN and otherinternational aid organisations working in
the territories. On 13 April 2006, MSF publicly denounced this plan.
MSF emphasised that although it was agovernment’s choice to suspend aid,
humanitarian actors could not be used in
an attempt to veil retaliatory measures thatwould impact the entire population. It also
pointed out that humanitarian aid groups
lacked the competence, means andresponsibility to act as a substitute for thePalestinian Authority. Instead, MSF said,
meeting the basic needs of civilians livingin the occupied territories was the responsibility of the state of Israel, as set out in
the Geneva Conventions. MSF feared that
this “instrumentalisation” of NGOs and confusion of roles and responsibilities would
jeopardise NGOs’ independence and could
put them in danger in an already unstable
context.
MSF has worked in the Palestinian
Territories since 1988.

Closed projects

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

Brazil

Fully functioning health centre handed
over to local groups
The consequences of Brazilian inequality are dramatically clear in
the populous slums of Rio de Janeiro, which has over 500 such
communities. MSF started working here in 1997, and began a
project in 2003 in Marcilio Dias, a slum where residents experiencesome of the highest levels of social exclusion and violence, resulting in a diminished access to healthcare.
MSF established the Marcilio Dias Health Centre, providing integrated primary healthcare, psychosocial services, and linkages forcommunity support around issues such as domestic violence,teenage pregnancy and drug abuse. MSF has now handed over afunctional and fully equipped health unit to local authorities and
MOGEC, a nongovernmental community organisation createdunder the auspices of MSF in 1997. Over 43,000 consultations were
provided during the 32-month duration of the project, and thecentre provided access to healthcare for 14,776 people in 2005.

general awareness around the issue and a recent change in thepolitical climate. Previously a sensitive political issue rarely spoken
about, now four out of six political parties stand behind changing
the legislation concerning healthcare for asylum seekers and othergroups. In March 2006, the Swedish Red Cross committed to continue the medical programme for one year, whilst the government
reviews legislation.
MSF worked in Sweden from 2004 to 2005.

UkraineMinistry of Health and NGOs continuecare for patients with HIV/AIDS
HIV/AIDS knowledge is poor and stigma is high in Ukraine. MSF
began to address HIV/AIDS here in 1999, launching a national education campaign in conjunction with the Ministry of Health andnational NGOS; and setting up a continuum of care model that
focused on ongoing care from awareness raising and pre HIV-test
counselling, to psychosocial support designed to help patientscope with their illness and adhere to treatment.

MSF worked in Brazil from 1991 to 2005.

SwedenSwedish Red Cross takes on programme
for undocumented migrants
Sweden is one of the few countries in the EU to charge full costs
for emergency healthcare for undocumented migrants, the vast
majority of whom cannot afford these costs. In 2004, MSF started a
programme in Stockholm to provide medical assistance to thispopulation.

Programmes were established in Odessa, Mykolayiv andSimferopol. Increased international financial commitment to HIV/AIDS in Ukraine allowed MSF to withdraw from the project, as
ongoing care for patients is now ensured for the near future. The
programme handover was marked by a press conference and theopening of a photo exhibition in Kiev in late 2005. The exhibit
showed the lives of people living with HIV, testimony to the factthat people can cope with its effects, given affordable medicalcare and psychosocial support.
MSF worked in Ukraine from 1999 to 2005.

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

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 83

Overview of
MSF Operations
Largest Interventions

Based on project expenditures (excluding coordination)

In 2005, the largest countries of intervention remained Sudan, where
MSF continued to provide assistance to hundreds of thousands displaced; Niger, where MSF mounted a large nutritional intervention andtreated 63,000 severely malnourished children; and Democratic Republicof Congo, where violence affecting civilians continued throughout theyear. MSF responses to the Tsunami and Central Asia earthquake arealso ref lected, with large relief operations deployed in Indonesia andPakistan.

1.
2.
3.
4.
5.

SUDAN NORTHNIGER
DEMOCRATIC REPUBLIC OF CONGOPAKISTANINDONESIA

6. SUDAN SOUTH
7. LIBERIA
8. ANGOLA
9. IVORY COAST
10. CHAD

Activity Highlights(non-exhaustive)

Definition

Total (in thousands)

OUTPATIENTINPATIENTTOTAL NUMBER OF OUTPATIENT CONSULTATIONSTOTAL NUMBER OF ADMITTED PATIENTSMALARIATF
DELIVERIESSEXUAL VIOLENCE
SURGERY
WAR TRAUMA
HIV
ARV
TB
MENTAL HEALTHMEASLES VACCINATIONSYELLOW FEVER VACCINATIONSTOTAL NUMBER OF CONFIRMED CASES TREATEDNUMBER OF CHILDREN TREATED WITH THERAPEUTIC FEEDING IN 2005
TOTAL NUMBER OF WOMEN WHO DELIVERED BABIESTOTAL NUMBER OF CASES FOR ANY TYPE OF SEXUAL VIOLENCE TREATEDTOTAL NUMBER OF MAJOR SURGICAL INTERVENTIONSTOTAL NUMBER OF CONFLICT TRAUMA SURGERIESTOTAL NUMBER OF HIV PATIENTS REGISTERED UNDER CARE AT END 2005
TOTAL NUMBER OF PATIENTS ON ANTIRETROVIRAL TREATMENT AT END 2005
TOTAL NUMBER OF NEW ADMISSIONS TO TUBERCULOSIS TREATMENT IN 2005
TOTAL NUMBER OF INDIVIDUAL PARTICIPANTS IN INDIVIDUAL OR GROUP MENTAL HEALTH ACTIVITIESTOTAL NUMBER VACCINATED FOR MEASLESTOTAL NUMBER VACCINATED FOR YELLOW FEVER

10,000
382
2249
130
91
12
75
8
161
60
22
149
806
361

In 2005, MSF aggressively developed its activities in the field of malnutrition and more than doubled the number of children treated with therapeutic feeding. MSF also continued its investment in HIV/AIDS, more thandoubling the number of patients under ARV between 2004 and 2005, andfurthered its commitment to treating patients with tuberculosis.

MSF pursued its commitment to assisting victims of violence, with 76% of
its surgeries, 88% of its assistance to victims of sexual violence and 95% of
war-trauma activities taking place in unstable contexts.
Large-scale immunisation campaigns were also conducted against measles,
yellow fever, and meningitis.

Project Locations

Context of Interventions
Africa63%

Stable

53%

Asia

23%

Armed conflict

18%

America

7%Internal instability 16%

Europe7%

Post conflict

In 2005, 63% of all MSF projects were located in Africa, followed by 23% ofprojects in Asia, an increase over 2004 ref lecting MSF deployment in natural disasters affecting Central and Southeast Asia in 2005. MSF closed andopened more than 25% of its projects during the year, attesting to MSF’s
dynamism and capacity to react to crises and develop operations according
to context evolution.
84 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006

13%

In 2005, 47% of MSF projects took place in unstable settings – armed conf licts, internal instability and post-conf lict. A full 20% of MSF assistance
was targeted at displaced populations.

Audited
Facts and Figures
Médecins Sans Frontières (MSF) is an international, medical
humanitarian organisation that is also private and not-for-profit.
MSF comprises 19 national branches in Australia, Austria,
Belgium, Canada, Denmark, France, Germany, Greece, Holland,Hong Kong, Italy, Japan, Luxembourg, Norway, Spain, Sweden,
Switzerland, the United Kingdom, the United States, and with aninternational office in Geneva.
The search for efficiency has led MSF to create specialised organisations – called satellites – in charge of specific activities such as
humanitarian relief supplies, epidemiological and medical researchstudies, and research on humanitarian and social action. They
include: Epicentre, Etat d’Urgence Production, Fondation MSF,
MSF Assistance, MSF Enterprises Limited, Médecins Sans
Frontières – Etablissement d’Utilité Publique, MSF Foundation
Kikin, MSF-Logistique, SCI MSF, SCI Sabin, MSF Supply andUrgence Développement Alimentaires. As these organisations arecontrolled by MSF, they are included in the scope of the financial
statements presented here.

Owing to the fact that the Greek office rejoined the international
movement in 2005, Greece is not included in the 2004 comparative
figures presented here. However, for information purposes, its total
expenditures in 2004 were 5.3 million euros. Its total income was
4.5 million euros and its total balance sheet amounted to 5.3 million euros.
The figures presented here are for the 2005 calendar year. The
Activity Report itself covers the period mid-2005 to mid-2006.
All amounts are in millions of euros.
NB: Figures in these tables are rounded off and this may result inslight addition differences.

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

Where did the money go?
Programme expenses* by continent

Programme expenses* by nature
International staff 24.6%

Africa 68%

National staff 23.2%

Asia 21.8%

Medical & nutrition 19%

America 5.6%

Transport, freight, storage 17.3%

Europe 3.7%

Operational running expenses 8.4%

Non-allocated 0.9%

Logistics & sanitation 5.6%
Other expenses 1%
Training & local support 0.9%

* project and coordination team expenses in country

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 85

Programme expenses by country/region (including coordination)
Countries/Regions

In M€

Countries/Regions

In M€

AfricaSUDANCountries/Regions

In M€

Asia/Middle East
46.3

DEMOCRATIC REPUBLICCountries/Regions

In M€

Americas

SIERRA LEONE

5.0

PAKISTAN

20.4

HAITI

5.5

ZIMBABWE

3.8

INDONESIA

19.7

COLOMBIA

4.8

OF CONGO

29.4

REPUBLIC OF THE CONGO

3.2

MYANMAR

5.6

GUATEMALA

4.1

NIGER

23.4

GUINEA

3.1

CAMBODIA

4.5

ECUADOR

1.5

ANGOLA

14.3

ZAMBIA

2.9

INDIA

4.1

BOLIVIA

1.2

LIBERIA

13.6

BURKINA FASO

2.6

SRI LANKA

3.3

OTHER COUNTRIES*

2.4

CHAD

9.2

RWANDA

2.5

THAILAND

3.1

TOTAL

IVORY COAST

8.3

SOUTH AFRICA

2.3

ARMENIA

2.5

NIGERIA

8.0

MALI

1.6

CHINA

2.2

EuropeBURUNDI

7.7

CENTRAL AFRICAN REPUBLIC 1.6

GEORGIA

1.7

CHECHNYA / INGUSHETIA /UGANDA

7.7

CAMEROON

1.3

UZBEKISTAN

1.6

DAGESTAN

4.3

KENYA

7.4

TANZANIA

1.3

PALESTINIAN TERRITORIES

1.4

RUSSIA

2.2

SOMALIA

7.3

MAURITANIA

1.3

BANGLADESH

1.3

FRANCE

1.4

ETHIOPIA

7.2

GUINEA-BISSAU

1.1

IRAN

1.1

BELGIUM

1.1

MOZAMBIQUE

6.3

OTHER COUNTRIES*

1.5

OTHER COUNTRIES*

3.2

OTHER COUNTRIES*

3.6

MALAWI

5.3

TOTAL

236.5

TOTAL

75.7

TOTAL

19.5

12.6

* “Other countries” combines all of the countries for which program expenses were below 1 million euros.

Sources of income
As part of MSF’s effort to guarantee its independence and strengthen theorganisation’s link with society, we strive to maintain a high level of private
income. In 2005, 86.1% of MSF’s income came from private sources. Morethan 3.4 million individual donors and private funders worldwide madethis possible. Additional public institutional agencies providing funding to
MSF include among others, the governments of Belgium, Canada, Ireland,
Luxembourg, The Netherlands, Norway, Spain, Sweden, Switzerland, andthe United Kingdom.

represents 9.1 months of activity. The purpose of maintaining retained
earnings is to meet the following needs: future major emergencies forwhich sufficient funding cannot be obtained, and/or a sudden drop of private and/or public institutional funding, and the sustainability of longterm programmes (e.g. ARV treatment programmes), as well as the prefinancing of operations to be funded by upcoming public funding
campaigns and/or by public institutional funding.

Unspent temporarily restricted funds are unspent donor-designatedExpenditures
Expenditures are allocated according to the main activities performed by
MSF. Operations gather programme-related expenses as well as the headquarters’ support costs devoted to operations. All expenditure categories
include salaries, direct costs and allocated overheads.

Permanently restricted funds may be capital funds, where the assets
are required by the donors to be invested, or retained for actual use, rather
than expended, or they may be the minimum compulsory level of retained
earnings to be maintained by some of the sections.

Unrestricted funds are unspent non-designated donor funds expendable at the discretion of MSF’s trustees in furtherance of our social mission.

Other retained earnings represent foundations’ capital as well as technical accounts related to the combination process, including the conversion difference. MSF’s retained earnings have been built up over the years
by surpluses of income over expenses. As of the end of 2005, their available part (the unrestricted funds decreased by the conversion difference)

86 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2005/2006

funds, which will be strictly spent by MSF in accordance with the donors’
desires (e.g. specific countries or types of interventions) as needs arise.

Additional disclosures: Tsunami disaster
Public donations received in response to the December 2004 tsunami disaster resulted in contributions totalling 111 million euros, of which 36.4
million euros were received in 2004, and the balance in 2005. The funds
received were used for tsunami-relief operations or “derestricted” with theconsent of donors and spent where they are most needed within MSF’s
ongoing work. MSF spent a total of 24.5 million euros in 2004 and 2005 on
operations in the regions affected by the tsunami – 1.7 million in 2004 andthe remainder in 2005. In total 19.7 million euros were spent in Indonesia,
4.0m in Sri Lanka and 0.8m in India and Thailand. An amount of 2.3 million
euros of restricted tsunami funds remains unspent at the end of 2005 andare carried in the balance sheet within liabilities as “unspent restrictedfunds”. The remainder of the donations received were “derestricted” or “redirected” with the consent of the donors – approximately 30 million euros
of which were used to fund two other big emergencies that occurred in2005 – the malnutrition crisis in Niger and the earthquake in Pakistan.

2005

2004

Income

In M€

In %

In M€

In %

Private Income
Public Institutional ECHO*, EU & DFID**
Public Institutional Other
Other Income

543.0
44.8
45.5
15.7

83.7%
6.9%
7.0%
2.4%

342.8
55.9
47.0
12.4

74.8%
12.2%
10.3%
2.7%

Total Income

649.0

100.0%

458.1

100.0%

Operations
Témoignage
Other humanitarian activities

397.4
15.9
8.0

78.0%
3.1%
1.6%

321.5
14.5
7.9

76.3%
3.4%
1.9%

Total Social Mission

421.3

82.7%

343.9

81.7%

Fundraising
Management, general & administration

59.8
28.2

11.8%
5.5%

49.2
28.0

11.7%
6.6%

Total Expenditure

509.3

100.0%

421.1

100.0%Net exchange gains & losses(realised and unrealised)Surplus/(deficit)

4.1
143.7

How was the money spent?

-2.8
34.2

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

Balance sheet

In M€

In M€

(year-end financial position):
Non-current assets
Current assets
Cash & equivalents

35.5
66.6
352.1

31.7
91.2
201.8

Total assets

454.2

324.7

Permanently restricted funds
Unrestricted funds
Other retained earnings
Total retained earnings and equities
Non-current liabilities
Current liabilities
Unspent temporarily restricted funds

2.8
384.6
1.5

Total liabilities and retained earnings

2.8
236.6
-3.7
388.9
8.5
49.9
6.8

235.8
7.6
43.3
38.0

65.2

324.7

HR Statistics
International departures (full year):

4,768

100%

3,803

100%

Medical pool
Nurses & other paramedical pool
Non-medical pool

1,276
1,558
1,934

27%
33%
40%

1,034
1,257
1,512

27%
33%
40%

First time departures (full year):(*) in % of the international departures

1,466(*) 31%

1,340(*) 35%

Field positions:

28,083100%

24,666100%

International staff
National staff

2,227
25,855

8%
92%

2,026
22,6408%
92%* unaudited figures

ACTIVITY REPORT 2005/2006 MEDECINS SANS FRONTIERES 87

Contact MSF
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About this publication
FE AT U R E W R I T ER S
Nathalie Borremans, Leopold Buhendwa, Dieudonné Bwirire, Fabien Dubuet, Margaret Fitzgerald,
C. Foncha, Moses Massaquoi, Marilyn McHarg, Dalitso Minsinde, Rodrick Nalingukgwi, Fasineh Samura,
Milton Tectonidis, Emmanuel Tronc

sector workers and is also open to all other professions whichmight help in achieving its aims.
All of its members agree to hounor the following principles:Médecins Sans Frontières provides assistance to populations
in distress, to victims of natural or man-made disasters andto victims of armed conflict. They do so irrespective of race
religion, creed or political convictions.
Médecins Sans Frontières observes neutrality and impartiality

CO U N T RY T E X T A N D S I D EBA R M AT ER I A L W R I T T EN BY
Emma Bell, Claude Briade, Lucy Clayton, Gabi Faber-Weiner, Petrana Ford, Stephan Grosserueschkamp,
Lisa Hayes, Jean-Marc Jacobs, Anthony Jacopucci, James Lorenz, Alessandra Oglino, Susan Sandars,
Diderik van Halsema, Erwin van ‘t Land
S PE CI A L T H A N K S TO
Anne Ameye, Laure Bonnevie, Marine Buissonnière, Anouk Delafortrie, Rowan Gillies, Tory Godsal,
Olivier Guillerminet, Lisa Hayes, Myriam Henkens, Florence Licci, Miquel Maldonado, Barry Sandland,
Miriam Schlick, Nicolas de Torrente, Emmanuel Tronc, and all the field, operations and communications
staff who reviewed material for this report.
ED I TO R Caroline Veldhuis
PH OTO ED I TO R S Bruno de Cock, Sofie Stevens
CO PY ED I TO R Melissa Francoin the name of universal medical ethics and the right to humanitarian assistance and claims full and unhindered freedom inthe exercise of its functions.
Members undertake to respect their professional code of ethics
and to maintain complete independence from all political,
economic or religious powers.
As volunteers, members understand the risks and dangers ofthe missions they carry out and make no claim for themselves

A R A B I C ED I T I O N
CO O R D I N ATO R Mohamed Naji
T R A N S L ATO R Brahim El-Khazrouni
ED I TO R Mohamed NajiFR EN CH ED I T I O N
CO O R D I N ATO R Corinne Cecilia
T R A N S L ATO R Emmanuel Pons
ED I TO R Corinne Cecilia
I TA L I A N ED I T I O N
CO O R D I N ATO R Barbara Galmuzzi
T R A N S L ATO R Selig S.a.S.
ED I TO R Barbara Galmuzzi

or their assigns for any form of compensation other than thatwhich the association might be able to afford them.

S PA N I S H ED I T I O N
CO O R D I N ATO R Mar Padilla
T R A N S L ATO R Pilar Petit
ED I TO R Eulalia Sanabra
G R A PH I C D E S I G N Studio Roozen, Amsterdam, The Netherlands
PR I N T I N G Drukkerij Mercurius, Wormerveer, The Netherlands

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

COVER PHOTO
Patients in the post-operation ward at the MSF Bon Marché Hospital, Bunia,
Democratic Republic of Congo, May 2005.
© Gary Knight (VII)MSF Activity Report

MSF Activity Report July 2005 – July 2006

Médecins Sans Frontières (MSF) was founded
in 1971 by a small group of doctors and journalists
who believed that all people should have accessto emergency relief. MSF was one of the first
nongovernmental organisations to provide urgently
needed medical assistance and to publicly bear
witness to the plight of the people it helps.
Today MSF is an international medical humanitarian
movement with branch offices in 19 countries.
In 2005, over 2225 MSF volunteer doctors, nurses,
other medical professionals, logistical experts,
water and sanitation engineers and administrators
joined approximately 25,850 locally hired staff
to provide medical aid in over 70 countries.
MSF was awarded the 1999 Nobel Peace Prize.

2005/06

MSF International Office Rue de Lausanne 78, Case Postale 116, CH-1211 Geneva 21, Switzerland
T (+41-22) 8498 400, F (+41-22) 8498 404, E office-intl@bi.msf.org, www.msf.org