International
Activity
Report 2012www.msf.org

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

The country texts in this report provide descriptive overviews of MSF’s operational activities throughout theworld between January and December 2012. Staffing figures represent the total full-time equivalent positions
per country at the end of 2012.
Country summaries are representational and, owing to space considerations, may not be comprehensive.
For more information on our activities in other languages, please visit one of the websites listed on p.100.
The place names and boundaries used in this report do not reflect any position by MSF on their legal status.
Some patients’ names have been changed for reasons of confidentiality.

Contents
2

MSF programmes Around The World

4	The Year in Review
Dr Unni Karunakara, International President
Jérôme Oberreit, Secretary General4

The year in review

8	Overview Of activities
10

Glossary of Diseases and activities

14Adaptation and Innovation:
keywords for MSF’s medical action16	
Af ghans trapped as war rages on
14 Adaptation and innovation18

F inding refuge?

22‘ Test me, treat me’: The burden of
drug-resistant tuberculosis andthe push for better treatment

25

activities by country

95

special reports 2012

96

Facts and figures

16 Afghans trapped as war rages on

100	Contact MSF

18 Finding refuge?

25 Activities by country

Contents 1

MSF programmes
around the world

UkraineFranceItaly

Georgia
Armenia

United States

TurkeyGreeceSyria
LebanonIraq
Occupied
JordanPalestinian
Territory

Morocco
Libya

EGYPT
MexicoMauritania

Haiti

Mali

Guatemala

Niger

Honduras

Sudan

Chad
Guinea-Bissau

GuineaSierra Leone
Liberia
Colombia

Burkinafaso
Côte
d’Ivoire

Djibouti
Nigeria

Cameroon

CentralAfricanRepublic

Ethiopia

south
Sudan
Uganda

Kenya

Congo
Democratic
Republic of
Congo

Somalia

BurundiMalawi
ZambiaBolivia
Zimbabwe

Madagascar
Mozambique

PARAGUAY

SwazilandSouth
Africa2

MSF programmes around the world

Lesotho26	Afghanistan

60	Lesotho

28	Armenia

61	Liberia

28 	Bahrain

61	Libya

29	Bangladesh

65

Madagascar

30	Bolivia

62

Malawi30	Burkina Faso

63

Mali

64

Mauritania

65

Mexico66

Morocco67

Mozambique

68

Myanmar31	Burundi
31 	Cambodia
32	Cameroon
33	Central
AfricanRepublic
34	ChadRussianFederation

32	China
36	Colombia
37	Congo
37

Uzbekistan

Kyrgyzstan

Iran

38	Democratic
People’sRepublicof Korea

Democratic People’s
Republic of Korea

Tajikistan
China
Afghanistan

40	Democratic
Republicof Congo

PakistanBahrainIndia

Côte d’Ivoire

Bangladesh

38	Djibouti

Myanmar39	Egypt

Yemen
Cambodia42	Ethiopia

Philippines

44

Sri Lanka

France44	Georgia
45	Greece
Papua
New Guinea

46	Guatemala
47	Guinea
50	Guinea-Bissau
48	Haiti
51	Honduras

70	Niger
72	Nigeria
69	Occupied
Palestinian
Territory
74	Pakistan
76	Papua New
Guinea77	Paraguay
77	Philippines
78	RussianFederation
79	Sierra Leone
80	Somalia
82	South Africa
84	South Sudan
79	Sri Lanka
83	Sudan
86	Swaziland
87	Syria
88	Tajikistan
88	Turkey

52

India

54

Iran

55

Iraq

90

54

Italy

90	United States

58	Jordan

91	Uzbekistan

56	Kenya

94	Yemen

58	Kyrgyzstan

91	Zambia

59	Lebanon

92	Zimbabwe

89	Uganda
UkraineMSF programmes around the world 3

Médecins Sans Frontières

The Yearin Review
Dr Unni Karunakara, International President
Jérôme Oberreit, Secretary General

At the end of 2012 our colleagues
Montserrat Serra and Blanca
Thiebaut were still being held
hostage after their abduction
from a refugee camp in Dadaab,Kenya on 13 October 2011. Thisis one of the longest-running
kidnappings in the history of
Médecins Sans Frontières (MSF).

Challenges to delivering healthcare in
conflict zones
In Syria, conflict intensified. Extreme
violence, the collapse of the healthinfrastructure and the displacement of
millions of people led to massive needs, but
MSF has been frustrated at serious blockages
to providing care. According to authorities,
by early 2013, 57 per cent of public
hospitals in Syria had been damaged, butlack of authorisation from the government,
limited cross-border access and the severe
constraints caused by insecurity have all
restricted the provision of humanitarianassistance. Beginning with donations ofdrugs and medical supplies, our teams
managed to expand activities over the year,
setting up hospitals in Aleppo and Idlib
governorates. But we have been forced tolimit operations to opposition-controlled© Nicole Tung

Insecurity has had a significant impact on
our activities this year, and many teams
continued to work in unpredictable andunstable situations. Seven MSF staff weredetained in Myanmar in June, and two ofthem remain in detention. Two membersof staff were kidnapped in North Kivu, inthe Democratic Republic of Congo (DRC) in
April. Several hours later, they were released
unharmed. Armed men entered Huth
health centre, in Yemen, and threatened
MSF staff. Daynile hospital, on the outskirtsof Mogadishu, Somalia, was damaged byshellfire. We have not always been able torespond to people’s needs as we intended.

A man is examined by an anaesthetist at the MSF clinic in northern Syria before undergoing surgery to remove a bullet lodged in his abdomen.

4

The Year in Review

© Sven Torfinn

International Activity Report 2012

This nine-year-old boy’s legs were injured when a grenade exploded in his house. He received surgery at Virunga hospital in Goma,the Democratic Republic of Congo.
areas of the country and neighbouring
countries. We are concerned about what theconstraints on humanitarian assistance will
mean for the people of Syria in the future.

Several months of talks and assurances of
support resulted in the reopening of thehospital at the end of the year (see pages 16 –17
for more on healthcare in Afghanistan).

In eastern DRC, MSF continued working
in hospitals, health centres and clinics
across North and South Kivu, Orientale
and Katanga provinces, despite escalating
violence. In this country where health needs
are extreme even where the context is stable,
our programmes include basic as well as
specialist medical services, mental healthcare
and assistance to victims of sexual violence.
We carried out 1.6 million outpatient
consultations, adapting activities as people
were forced to move in search of safety.

Attacks on health workers and healthfacilities and the lack of respect for medical
action are having consequences that reachfar beyond the direct victims. At MSF, weare collecting data on these attacks in order
to assess their impact. This analysis will
increase awareness of the need to respect
medical activity and, it is hoped, help us
to develop effective responses.
Inadequate response to the needsof the displaced

Conflict in northern Mali and the warring
parties’ restrictions on movement madeit very difficult for people to get to healthfacilities. In an effort to improve access totreatment, MSF supported hospitals andhealth centres in remote locations as well asurban areas such as the city of Timbuktu.

In 2012, MSF saw huge growth in the needfor support for people forced to leave theirhomes. Unfortunately, we also saw a slow
and piecemeal response to that need. The
crises of the past year have revealed that
we must get the balance of assistance right:
between the delivery of humanitarian relief
and more specialised medical services.

In March, MSF opened a maternity hospitalin Khost, Afghanistan, a province thatborders Pakistan and the highly volatile tribal
areas. Some 100 births were being assisted
per week, but then in April the hospital was
targeted in a bomb attack, and seven people
were wounded. We suspended activities.

Fighting in Sudan led to a serious refugee
crisis in South Sudan, with 170,000 people
fleeing across the border. MSF set up field
hospitals, clinics and feeding centres, carryingout more than 8,000 consultations each week.
But the impact of healthcare is limited in theabsence of essentials such as water, food andshelter, and in view of the needs and lack of
broader response we realise that we shouldhave done more to meet basic needs.
Syrians who had fled to neighbouring
countries also lacked access to the basics.
As winter approached, refugees were still in
shelters without heating. Fuel was hard to
obtain. Half the refugees in Lebanon were
not receiving the healthcare they needed.
MSF ran assistance programmes in Lebanon,
Turkey, Jordan and Iraq, but had grave
concerns about the conditions for the
2.5 million people estimated to be displaced
within Syria, to whom access was restricted.
Even in Dadaab, Kenya, where the refugee
population is the size of a big city and there
are adults who have lived their entire lives in
the camps, agencies and organisations havenot been able to adapt to a rapidly changing
situation, and this has consequences formorbidity and mortality rates. We have taken
lessons from the challenges of this year, as
we do from every new setting in which we
work, to improve our response. (See pages
18 – 21 for more on refugee response.)
Flooding affects hundredsof thousands worldwide
Typhoons in the Philippines caused flooding
on several different occasions over the year,
and MSF delivered emergency assistance,

The Year in Review 5

Médecins Sans Frontières
supplying relief items and providing
medical care. Similar activities were carriedout when major flooding hit northern
Cameroon and eastern Nigeria. Teams set
up mobile clinics, built latrines and provided
safe drinking water when the Pakistaniprovince of Balochistan and southeasternparts of Sudan were severely flooded.
Improving how we deliver care
We need to constantly consider whether ourcare results in the best outcomes for people,
whatever the setting.
Take maternal health: most maternal deaths
occur just before, during or after delivery,
and are caused by complications that often
cannot be predicted. But skilled birthattendants can prevent some 80 per cent ofmaternal deaths. High-quality emergency
obstetric services, postnatal services andaftercare for unsafe abortions are all criticalto bringing down maternal mortality.
Concerned at the lack of recognition of
the importance of such services, MSF has
engaged more in the provision of emergency
obstetric care. Our teams assisted some
185,000 births in 2012, and around one inten of these were by caesarean section.

Despite progress in reducing mortality
from malaria, 660,000 people still die
from the disease every year, most ofthem African children. In Koutiala, Mali,
and Moissala, Chad, areas where thedisease is hyperendemic, MSF introduced
chemoprevention during the peak malaria
season. Teams systematically administeredantimalarial treatment to children between
three months and five years of age. The
number of simple malaria cases treated in thefollowing weeks fell sharply: by 66 per centin Koutiala and 78 per cent in Moissala.

This is a positive step, but the lethal impact
of malaria means that it must remain apriority. Strains of malaria that are resistantto current medication are already a concern
in southeast Asia, and there are to date noreal alternative treatment options. MSF islooking at how new programmes can tackle
drug-resistant malaria.
Drug-resistant tuberculosis:
a health emergency
Drug resistance has already reached crisis
point for tuberculosis (TB). Data on theprevalence of drug-resistant TB (DR-TB)
have shocked doctors tackling the disease:in Uzbekistan, 65 per cent of MSF’s TB
patients were found to have DR-TB. But
since only a minority of patients haveaccess to testing for resistance, this is justthe tip of the iceberg. The introduction ofa test that can detect resistance has nearlyquadrupled diagnoses of DR-TB in just one
MSF programme in Zimbabwe.
For the 20 per cent of people with DR-TB
who have access to treatment, what follows
is two gruelling years of taking pills andinjections, with severe side effects. Treatment
is so harsh that some choose to stop, accepting
what they know will be a death sentence.
This is an emergency. Hundreds ofthousands of people urgently need better© Michael Goldfarb

Our approach to HIV is changing too.
In KwaZulu-Natal, South Africa, we arefocusing on getting more people tested,

initiating treatment earlier and making surepatients can access treatment and careclose to home. The aim of models such as
the decentralisation of treatment and care(including diagnostics) is to maximise theimpact on patients’ health, as well as reduce
the spread of the virus, since treatment
significantly lowers the risk of transmission.
Our team in Swaziland is improving lab
facilities and capacity in local clinics inpreparation for the implementation of asimilar ‘test and treat’ approach, but there
are many more challenges for us to address.
Paediatric HIV, co-infection with other diseases,
opportunistic infections, the abandonment ofpeople with HIV in places where prevalence
is considered ‘not so high’: these issues areinvisible in wealthy countries, but require
urgent attention in the places where we work.

A Syrian refugee cradles her baby in a room in a ramshackle home on a cattle ground in Tripoli, Lebanon.

6

The Year in Review

© Ron Haviv/ VIIInternational Activity Report 2012

A 16-year-old girl who has MDR-TB undergoes treatment at home in Tajikistan. Her treatment involves taking up to 20 pills a day.

diagnostics. They need treatment regimensthat are effective, take less time and are nottoxic (see pages 22 – 24 for more).
Not-so-routine vaccination
The ‘Decade of Vaccines’ – a collaboration
including the WHO, UNICEF and private
foundations – was launched in 2010, but

Vaccine funding must be invested in
making vaccine programmes work: indeveloping new technologies and simpler
tools, adapting delivery and cutting costs.
Ultimately, our objective is, as always, to enable
access to medical attention to everyone who
needs it, no matter who or where they are.

every year.

Our frustrations with the limitations of
the medicines and tools available, and thelimitations of access and response, do notstop us. Thanks to the ongoing support ofmillions of people around the world, our
independence and impartiality have allowed
us to bring important assistance to people
in crisis. We continue to strive to improvethat assistance.

Children living where roads are poor,

Thank you.

two years later the number of children
who have not received the basic packageof immunisations has actually grown, from19 to 22.4 million. Large sums are being
invested in vaccines, yet the impact is not
obvious. Hundreds of thousands of children
are still dying from preventable diseases

where there is no electricity or where there
is insecurity, are all at risk of missing out on
immunisation. This is because most vaccinesmust be kept refrigerated from production toadministration, need more than one dose, andrequire a skilled health worker to administer
those doses. These constraints make it very
difficult to reach remote populations.

The Year in Review 7

Médecins Sans Frontières

Overview ofactivities
Largest country programmes
based on project expenditure
1. D emocratic Republic ofCongo

6. Kenya

2. South Sudan

8. ChadProgramme locations
Number of programmes
Africa

7. Sudan

3. Haiti

9. Ethiopia

4. Niger

10. Zimbabwe

247

Europe8A sia*

94

Americas

23

6.2 %

5. Somalia* A sia includes the Middle Eastand the Caucasus

The total budget for our programmes in these 10 countries
is 324 million euros, 52 per cent of MSF’s operational budget.

25.3 %
Percentage ofprogramme
portfolio

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

2,782

2. Haiti

2,582

3. South Sudan

2,415

4. Somalia

1,990

5. Niger

1,593

66.4 %

2.1 %Context of intervention
Number of programmes

Outpatient consultations

Unstable

205

Stable167

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

8

1,674,000

2. Niger

878,000

3. South Sudan

869,300

4. Somalia

624,200

5. Central African Republic

590,400

6. Myanmar

406,800

7. Kenya335,900

8. Afghanistan

332,300

9. Pakistan

298,000

10. Guinea

210,200

Overview of activities

45 %Percentage ofprogramme
portfolio

55 %International Activity Report 20122012 activity highlights
8,316,000
Outpatient

Number of outpatient consultations

472,900
Inpatient

Number of admitted patients

1,642,800
Malaria

Total number of cases treated276,300

13,100169,600

PMTCT – mother

Mental health (individual)

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

Number of individual mental healthconsultations

11,900PMTCT – baby
Number of eligible babies born in 2012
who received post-exposure treatment

185,400
Births

Therapeutic
feeding

Number of women who delivered
babies, including caesarean sections

Number of severely malnourishedchildren admitted to inpatient or
outpatient feeding programmes

78,50071,500
Supplementary
feeding
Number of moderately malnourishedchildren admitted to supplementary
feeding centres

Surgical procedures
Number of major surgical procedures,
including obstetric surgery, undergeneral or spinal anaesthesia

36,400Violent trauma

21,700Mental health (group)
Number of group counselling or mental
health sessions

57,400CholeraNumber of people admitted to cholera
treatment centres or treated with oral
rehydration solution

690,700
Measles vaccinations
Number of people vaccinated against
measles in response to an outbreak

26,200Measles treatment
Number of people treated for measles

Number of medical and surgicalinterventions in response to direct
violence

496,000

Number of HIV patients registeredunder care at end 2012

10,600

Number of people vaccinated against
meningitis in response to an outbreak

279,600

Number of patients medically treatedfor sexual violence

310,500
HIV

Antiretroviral treatment(first-line)
Number of patients on first-line
antiretroviral treatment at end 2012

4,670
Antiretroviral treatment(second-line)
Number of patients on second-line
antiretroviral treatment at end 2012
(first-line treatment failure)

Sexual violence

29,000Meningitis vaccinations

3,430
Meningitis treatment
Total number of people treated formeningitis

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

1,780
Tuberculosis (second-line)
Number of new admissions totuberculosis second-line treatment

These highlights do not give a complete overview
of activities and are limited to where MSF staff had
direct access to patients.

Overview of activities 9

Médecins Sans Frontières

Glossary of
diseases andactivities
Chagas disease
Chagas disease is found almost exclusivelyin Latin America, although increased
global travel and migration have led
to more cases being reported in North
America, Europe, Australia and Japan.
Chagas is a parasitic disease transmittedby triatomine bugs, which live in cracks
in the walls and roofs of mud and straw
housing. It can also be transmitted throughblood transfusions or to the foetus during
pregnancy and, less frequently, throughorgan transplants. A person with Chagas
often feels no symptoms in the first, acutestage of the disease. Then the chronic
stage is asymptomatic for years. Ultimately,
however, debilitating complications develop
in approximately 30 per cent of people
infected, shortening life expectancy by anaverage of 10 years. Heart failure is the mostcommon cause of death for adults.
Diagnosis is complicated, requiring
laboratory analysis of blood samples. Thereare currently only two medicines available
to treat the disease: benznidazole andnifurtimox, which were both developed
over 40 years ago. The cure rate is almost
100 per cent in newborns and infants, but
as the gap between the date of infection
and the beginning of treatment lengthens,
the cure rate declines.
The treatment currently used can be toxic
and can take longer than two months tocomplete. Despite the clear need for more
efficient and safer medication, there are few
new drugs in development.
MSF admitted 1,440 new patients to Chagas
treatment programmes in 2012.

CholeraCholera is a water-borne, acutegastrointestinal infection caused by theVibrio cholerae bacterium. It is transmitted
by contaminated water or food, or direct

10 Glossary of diseases and activities

contact with contaminated faeces. In nonendemic areas, large outbreaks can occur
suddenly and the infection can spread
rapidly. Most people will suffer only amild infection, but the illness can be very
severe, causing profuse watery diarrhoea
and vomiting that can lead to severe
dehydration and death. Treatment consistsof a rehydration solution – administeredorally or intravenously – which replaces
fluids and salts. Cholera is most common indensely populated settings where sanitationis poor and water supplies are not safe.
As soon as an outbreak is suspected,
patients are treated in centres where
infection control precautions are taken
to avoid further transmission of thedisease. Strict hygiene practices must be
implemented and large quantities of safe
water must be available.
This year, MSF has for the first time
successfully used oral cholera vaccines in
the context of an outbreak, in addition to
the usual outbreak response measures.
MSF treated 57,400 people for cholera in 2012.

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

HIV/AIDS
The human immunodeficiency virus (HIV) is
transmitted through blood and body fluids andgradually breaks down the immune system– usually over a three- to ten-year period– leading to acquired immunodeficiency
syndrome, or AIDS. As the virus progresses,
people begin to suffer from opportunistic
infections. The most common opportunistic
infection that leads to death is tuberculosis.
A simple blood test can confirm HIV status, butmany people live for years without symptoms
and may not know they have been infectedwith HIV. Combinations of drugs known asantiretrovirals (ARVs) help combat the virus
and enable people to live longer, healthier lives
without their immune systems deteriorating
rapidly. ARVs also significantly reduce thelikelihood of the virus being transmitted.
As well as treatment, MSF’s comprehensive
HIV/AIDS programmes generally include
education and awareness activities, condom
distribution, HIV testing, counselling andprevention of mother-to-child transmission(PMTCT) services. PMTCT involves theadministration of ARV treatment to the motherduring pregnancy, labour and breastfeeding,and to the infant just after birth.
MSF provided care for 310,500 people livingwith HIV/AIDS and antiretroviral treatment for
284,300 people in 2012.

Kala azar(visceral leishmaniasis)
Largely unknown in the developed world,kala azar – Hindi for ‘black fever’ – is atropical, parasitic disease transmitted
through bites from certain types of sandfly.
It is endemic in 76 countries, and of theestimated 200,000 – 400,000 annual cases,
90 per cent occur in Bangladesh, India,
Ethiopia, South Sudan, Sudan and Brazil.
Kala azar is characterised by fever, weight loss,
enlargement of the liver and spleen, anaemia

© Lynsey Addario / VIIInternational Activity Report 2012

This baby has just been delivered by caesarean section at the Gondama referral centre, Sierra Leone.

and immune-system deficiencies. Without
treatment, kala azar is almost always fatal.
In Asia, rapid diagnostic tests can be used
for diagnosis of the disease. However,these tests are not sensitive enough for use
in Africa, where diagnosis often requires
microscopic examination of samples takenfrom the spleen, bone marrow or lymph
nodes. These are invasive procedures
requiring resources that are not readily
available in developing countries.
Treatment options for kala azar have evolved
during recent years. Liposomal amphotericin B
is becoming the primary treatment in Asia,
either alone or as part of a combination
therapy. This is safer and involves a shorter
course of treatment than previously used
medication. However, it requires intravenous
administration, which remains an obstacle
to its use in local clinics. In Africa, the best
available treatment is a combination ofpentavalent antimonials and paromomycin,
which requires a number of painful injections.

Malaria

Malnutrition

Malaria is transmitted by infected mosquitoes.
Symptoms include fever, pain in the joints,
headaches, repeated vomiting, convulsions
and coma. Severe malaria, most often causedby the Plasmodium falciparum parasite,causes organ damage and leads to death if left
untreated. MSF field research has helped provethat artemisinin-based combination therapy(ACT) is currently the most effective treatment
for malaria caused by Plasmodium falciparum.
In 2010, World Health Organization guidelines
were altered to recommend the use ofartesunate over artemether injections forthe treatment of severe malaria in children.

A lack of essential nutrients causes malnutrition:
children’s growth falters and their susceptibility
to common diseases increases. The critical age
for malnutrition is from six months – whenmothers generally start supplementing breast
milk – to 24 months. However, children under
five, adolescents, pregnant or breastfeeding
women, the elderly and the chronically ill
are also vulnerable.

Long-lasting insecticide-treated bed nets
are one important means of controlling
malaria. In endemic areas, MSF systematically
distributes nets to pregnant women andchildren under the age of five, who are mostvulnerable to severe malaria, and staff advise
people on how to use the nets.

Co-infection of kala azar and HIV is a major
challenge, as the diseases influence eachother in a vicious spiral as they attack andweaken the immune system.

In 2012, MSF also used a seasonalchemoprevention strategy for the first time,in Chad and Mali. Children up to five years ofage took oral antimalarial treatment monthly
during the peak season for the disease.

MSF registered 5,860 new patients for kalaazar treatment in 2012.

MSF treated 1,642,800 people for malaria
in 2012.

Malnutrition in children can be diagnosed in two
ways: it can be calculated from measurementsof weight and height, or by measurement of
the mid-upper arm circumference. According
to these measurements, undernourishedchildren are diagnosed with moderate orsevere acute malnutrition.
MSF uses ready-to-use food (RUF) to treat
malnutrition. RUF contains fortified milk
powder and delivers all the nutrients thata malnourished child needs to reverse
deficiencies and gain weight. With a longshelf-life and requiring no preparation,these nutritional products can be used in
all kinds of settings and allow patients to betreated at home, unless they are suffering
severe complications.

continued overleaf

Glossary of diseases and activities   11

Médecins Sans Frontièrescontinued Glossary of diseases and activities

In situations where malnutrition is likely
to become severe, MSF takes a preventive
approach, distributing nutritional
supplements to at-risk children to prevent
their condition from deteriorating further.
MSF admitted 276,300 malnourished patientsto nutrition programmes in 2012.

Measles
Measles is a highly contagious viral disease.
Symptoms appear between 10 and 14 days
after exposure to the virus and include arunny nose, cough, eye infection, rash andhigh fever. There is no specific treatment formeasles – patients are isolated and treatedwith vitamin A, and for any complications:these can include eye-related problems,
stomatitis (a viral mouth infection),
dehydration, protein deficiencies andrespiratory tract infections.
While most people infected with measles
recover within two to three weeks,
between 5 and 20 per cent die, usually
due to complications such as diarrhoea,
dehydration, encephalitis (inflammation of
the brain) or severe respiratory infection.
A safe and cost-effective vaccine against
measles exists, and large-scale vaccination
campaigns have significantly decreased
the number of cases and deaths. However,
coverage remains low in countries with weak
health systems and in areas where there islimited access to health services, leaving large
numbers of people susceptible to the disease.
MSF treated 26,200 patients for measles andvaccinated more than 690,700 people against
the disease in 2012.

Meningococcal meningitis
Meningococcal meningitis is an infection of
the thin membranes surrounding the brain
and spinal cord. It can cause sudden andintense headaches, fever, nausea, vomiting,sensitivity to light and stiffness of the neck.
Death can follow within hours of the onsetof symptoms. Up to 50 per cent of people
infected will die without treatment.
Six strains of the bacterium Neisseria
meningitidis (A, B, C, W135, X and Y) are
known to cause meningitis. People can be
infected without showing symptoms andtransmit the bacteria when they coughor sneeze. Suspected cases are diagnosed
through the examination of a sampleof spinal fluid and treatment consists of

12 Glossary of diseases and activities

specific antibiotics. However, even withtreatment, 5 to 10 per cent of patients will
die and as many as one in five survivors may
suffer from after effects, including hearing
loss and learning disabilities.
Meningitis occurs throughout the world,
but the majority of infections and deaths are
in Africa, particularly across the ‘meningitis
belt’, an east–west geographical strip from
Ethiopia to Senegal, where epidemics aremost likely to be caused by meningitis A.
A new vaccine against this strain provides
protection for 10 years and even prevents
healthy carriers from transmitting theinfection. Large preventive vaccination
campaigns have now been carried out in
Benin, Burkina Faso, Cameroon, Chad, Ghana,
Mali, Niger, Nigeria, Senegal and Sudan.
MSF treated 3,430 patients for meningitis andvaccinated 496,000 people against the diseasein 2012.

Mental healthcare
Traumatising events – suffering or
witnessing violence, the death of loved onesor the destruction of livelihoods – are likely
to affect a person’s mental wellbeing. MSF
provides psychosocial support to victims of
trauma in an effort to reduce the likelihoodof long-term psychological problems.
Psychosocial care focuses on supportinga community to develop its own coping
strategies after trauma. Counsellors help
groups to talk about their experiences andprocess their feelings so that general stresslevels are reduced. This approach fosters
mutual support and allows a community torebuild itself according to its own culturalbeliefs, taking back control of the situation
as soon as it is able. MSF complements
psychosocial care with individual counsellingand psychiatric care for those who need it.
MSF staff held 191,300 individual and group
counselling sessions in 2012.

Relief items distribution
MSF’s primary focus is on providing medicalcare, but in an emergency teams often
distribute relief items that contribute to
psychological and physical survival. Suchitems include clothing, blankets, bedding,shelter, cleaning materials, cooking utensils
and fuel. In many emergencies, relief items
are distributed as kits – cooking kits containa stove, pots, plates, cups, cutlery and awater container so that people can prepare
meals, while a washing kit includes soap,
shampoo, toothbrushes, toothpaste andlaundry soap.

Where people are without shelter, andmaterials are not locally available, MSF
distributes emergency supplies – rope andplastic sheeting or tents – with the aim of
ensuring a roof, and some level of security
and protection. In cold climates more
substantial tents are provided, or teams
try to find more permanent structures.
MSF distributed 61,000 relief kits in 2012.

Reproductive healthcare
Comprehensive neonatal and obstetriccare form part of MSF’s response to any
emergency. Medical staff assist births andperform caesarean sections where necessary,and sick newborns and babies with a lowbirth weight receive medical care.
Many of MSF’s longer-term programmes
offer more extensive maternal healthcare.
Several antenatal visits are recommended
so that medical needs during pregnancy are
met and potentially complicated deliveries
can be identified. After delivery, postnatal
care includes counselling on family planningand information and education on sexuallytransmitted infections.
Good antenatal and obstetric care canprevent obstetric fistulas. Obstetric fistulas
are injuries to the birth canal, and are mostoften a result of prolonged, obstructedlabour. They cause incontinence, which canlead to social stigma. Around two million
women are estimated to have untreatedobstetric fistulas; there are between 50,000
and 100,000 new cases each year. A numberof MSF programmes carry out specialist
obstetric fistula repair surgery.
MSF held more than 784,500 antenatal
consultations in 2012.

Sexual violence
MSF offers patients who have sufferedsexual violence medical care, treatment
to prevent the development of sexuallytransmitted infections, emergency
contraception if needed, and psychological,
social and legal support. In settings
where the rate of sexual violence is high,such as in conflict zones and refugee ordisplaced persons camps, dedicated teams
provide assistance. Staff also work withthe community to raise awareness, provide
information about the care that MSF
provides and offer social and legal support.
MSF treated more than 10,600 patients forsexual violence-related injuries in 2012.

International Activity Report 2012
Sleeping sickness(human African
trypanosomiasis)

During the first stage, the disease is relatively
easy to treat but difficult to diagnose, as
symptoms such as fever and weakness are
non-specific. The second stage begins when
the parasite invades the central nervous
system and the infected person begins toshow neurological or psychiatric symptoms,
such as poor coordination, confusion,
convulsions and sleep disturbance. At thisstage, accurate diagnosis of the illness
requires a sample of spinal fluid.

© Olga Overbeek

Generally known as sleeping sickness, human
African trypanosomiasis is a parasitic infection
transmitted by tsetse flies that occurs in
sub-Saharan Africa. It attacks the central
nervous system, causing severe neurologicaldisorders or even death. More than 95 per centof reported cases are caused by the parasite
Trypanosoma brucei gambiense, which isfound in western and central Africa. The
other 5 per cent of cases are caused by
Trypanosoma brucei rhodesiense, which
is found in eastern and southern Africa.

Blood samples at the MSF lab at Anka hospital, Nigeria.

of drug resistance is now being used, but it
is costly and still requires a phlegm sample,
as well as a reliable power supply.

Nifurtimox-eflornithine combination
therapy, or NECT, is now the World HealthOrganization recommended protocol.
NECT is much safer than melarsoprol, thedrug that was previously used to treat thedisease, and which is a derivative of arsenic.
Melarsoprol causes many side effects andcan even kill the patient. It is hoped thatthe new molecules currently under clinical
trial will lead to the development of a safe,
effective treatment for both stages of thedisease that can be administered orally.

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

MSF admitted 2,000 new patients for sleeping
sickness treatment in 2012.

MSF treated 29,000 patients for TB and 1,780
for MDR-TB in 2012.

Tuberculosis

Vaccinations

One-third of the world’s population is currently
infected with the tuberculosis (TB) bacillus.
Every year, about nine million people
develop active TB and 1.5 million die from it.
TB is spread through the air when infected
people cough or sneeze. Not everyone
infected with TB becomes ill, but 10 per centwill develop active TB at some point intheir lives. The disease most often affects
the lungs. Symptoms include a persistent
cough, fever, weight loss, chest pain andbreathlessness in the lead-up to death. TB
incidence is much higher, and is a leading
cause of death, among people with HIV.

Immunisation is one of the most costeffective medical interventions in publichealth. However, it is estimated thatapproximately two million people die every
year from diseases that are preventable
by a series of vaccines recommended forchildren by the World Health Organization.
Currently, these are DTP (diphtheria,
tetanus, pertussis), hepatitis B, Haemophilius
influenzae type b (Hib), BCG (against
tuberculosis), human papillomavirus,
measles, pneumococcal conjugate, polio,
rotavirus, rubella and yellow fever – although
not all vaccines are recommended everywhere.

Diagnosis of TB depends on a phlegm sample,
which can be difficult to obtain from children.
A new molecular test that can give results
after just two hours and detect a certain level

In countries where vaccination coverage is
generally low, MSF strives to offer routine
vaccinations for all children under five aspart of its basic healthcare programme.

Vaccination also forms a key part of MSF’s
response to outbreaks of measles, yellow
fever and meningitis. Large-scale vaccination
campaigns involve awareness-raising activities
regarding the benefits of immunisation as wellas the set-up of vaccination posts in places
where a community is likely to gather.
A typical campaign lasts between two andthree weeks and can reach hundreds ofthousands of people.

Water and sanitation
Safe water and good sanitation are essential
to medical activities. MSF teams makesure there is a clean water supply and awaste management system in all the healthfacilities where it works.
In emergencies, MSF assists in the provisionof safe water and adequate sanitation.
Drinking water and waste disposal are the firstpriorities. Latrines are built at a convenient
distance from camps. Where a safe water
source cannot be found close by, waterin containers is trucked in. Staff conduct
information campaigns to promote the use of
facilities and ensure good hygiene practices.
MSF distributed more than 197,000,000 litresof safe water in 2012.

Glossary of diseases and activities   13

Médecins Sans Frontières

Adaptation andInnovation :keywords for MSF’s
medical action
Dr Marc Gastellu Etchegorry took up the position ofInternational Medical Secretary at Médecins Sans Frontières(MSF) in September 2012. He shares his views on the current
challenges to MSF’s humanitarian medical action.
The objective of MSF’s medical teams is to bringemergency aid to people affected by armed
conflict, epidemics, healthcare exclusion andman-made or natural disasters. Delivering
healthcare in such contexts is often a challenge
and requires adaptation and innovation.
Making choices in conflict situations
In armed conflict, the situation is neverstatic: as it evolves, front lines move, entire
populations are displaced, medical teams andinfrastructures shift. If we are to make a usefulassessment of medical needs and priorities,
these transformations must all be taken into
account – and when possible, anticipated.

medical conditions do not get treated or
prevented; maternal health programmes,
immunisation and treatment for infectious
as well as non-communicable diseases
are all essential services that save lives(even if not immediately). However, theirimplementation requires different resources,
equipment, tools, skills and networks.
Making choices is an essential part ofadaptation. We must choose our activities sothat we cover vital needs, take into accountoperational and medical constraints, and keep
in mind that the aim of our presence and ouraction is to address gaps in access to healthservices, and show where there is deliberate
willingness by armed forces to harass ordeprive people of essential healthcare.
Camp settings: ensuring the basics
are in place
Massive displacement of a population poses
different challenges. People fleeing fighting
or abuse take few belongings with them.
They rapidly – if not immediately – become
destitute and dependent on national orinternational assistance. As the delivery of

The difficulties of providing medical
assistance are particularly acute when
medical teams are harassed by armed
authorities or groups that deny assistanceto anyone they consider to be an enemy,
as well as to the people they believe would
help the ‘enemy’ – including women,children and the sick and injured.

But war injuries are not the sole medical
emergencies during conflict. When ahealth system collapses, many diseases and

14 Adaptation and Innovation© Trevor Snapp

In a context like Syria today, where
humanitarian assistance and humanitarian
workers are targeted by fighters, and where
the risks of deploying staff are high, medical
activities cannot always be fully implemented;
action must be hidden and minimal, and it isa challenge to maintain the quality of medicalcare. Because of the risks to patients andmedical teams, our work is mainly oriented
towards lifesaving acts such as war surgery
and acute medical emergencies.
High blood pressure is a common condition among the patients at Timbuktu hospital,
where MSF began working after conflict broke out in northern Mali.

© Corinne Baker/MSF

International Activity Report 2012

A doctor accompanies a pregnant woman to the car that will take her to the MSF field hospital in Jamam refugee camp, South Sudan.

aid tends to be slow and insufficient, living
conditions deteriorate, often very quickly.
The absence or scarcity of essentials suchas water, food or shelter leads to high rates
of illness and death, which healthcare
providers struggle to contain.
The benefit of healthcare is very limited if
these basic needs are not met. Consider thecrisis in South Sudan in 2012, when tens of
thousands of Sudanese refugees arrived at
makeshift camps with limited water supplies.
In such cases, MSF must widen the scope of
its activities, delivering safe water, providing
shelter and blankets and preventing
malnutrition. Once basic needs are met,
medical care can resume its full value;
programmes can be developed that meet
more sophisticated medical needs and adapt
to the health priorities of the population.
The thousands of people who fled recent
conflicts in North Africa and the Middle
East revealed new epidemiological profiles,
with a particularly high prevalence of noncommunicable diseases such as diabetes,
hypertension and epilepsy. Before conflict,patients had access to sophisticated diagnosis
and treatment through well-developed
medical systems, but now these same patientsare desperately seeking treatment.

Again, we must adapt our medical activities:
to the resources available, to the maincauses of illness and mortality, to a potential
deterioration in living conditions andto potential increases in the number ofrefugees or displaced people. Continuous
observation and assessment are essential,
as such situations nearly always remain
volatile. The immediate response to basic
needs must be balanced with a longer-term
approach to non-communicable diseases.
Healthcare where resources are scarce
In stable situations, adaptation may beslower, but it is no less necessary. Our
medical teams regularly have to diagnose
illnesses and treat patients with resourcesthat are inadequate for the conditions inwhich they operate. Access to health services
is restricted, resulting in late diagnosis anddifficulties in follow-up. Poor transportoften makes supplies unreliable. Electricity
can be intermittent or non-existent. Skilled
personnel are usually scarce.
In some domains, significant progress has
been made. Today the treatment options formalaria are effective and diagnostic tests areeasy to use in remote health posts (although
we have to anticipate the developmentof drug-resistant strains of the disease).
Elsewhere, progress is far from sufficient.

Tuberculosis, HIV, hepatitis, meningitis andthe vast majority of non-communicablediseases are difficult to diagnose at the pointof care and treatment regimens are often
long and complex, with many side effects.
Innovation is crucial. Diagnostic toolsthat are easier to use, treatment regimensthat are simpler and more effective, andnew, less complex models of care are allindispensable if we are to improve thequality and relevance of our medical action.
Our technical knowledge and innovationmust influence our programmes andour care, and so must epidemiologicalsurveillance and study. Dynamic analysis
and interpretation of the medical andpolitical environments are also essential inorder to adapt our projects to needs andensure the relevance of our response.
MSF treats individuals, not diseases, and it ishard to define priorities beyond the patient.
We do know that when healthcare is hard toreach, patients often visit medical facilities
late and are unlikely to come back soon. We
have learned that if we miss an opportunity
for diagnosis and treatment, we may havelost the chance to cure someone. Accessto quality health services is essential. To
improve access, innovation and adaptation
are crucial.

Adaptation and Innovation 15

Médecins Sans Frontières

Afghans trapped
as war rages on
After over 10 years of military intervention in Afghanistan,
the focus of the media is increasingly on the timeline of NATO
troop withdrawal and transition. Lost in the headlines is theharsh reality for Afghans trapped in a war that is still raging.
The continuing insecurity in Afghanistan
has many serious consequences for people’s
lives and livelihoods, not least the negative
impact on the availability and accessibilityof critical health services.

supplies and prevents entire communities
from travelling freely to reach secondary
health facilities. There is a private healthsector, but private clinics are too expensive
for most people.

People are trapped, unable to access thehealthcare they need. Many rural healthclinics are dysfunctional. The number ofpublic hospitals has increased, but many still
do not operate well and are overburdenedwith patients. Qualified health staff have left
insecure areas and there is an overall lackof highly trained personnel, in particular
women doctors and nurses. Insecurity
impedes the delivery of drugs and medical

Health indicators in Afghanistan are among
the worst in the world, and the breakdown ofessential health services is bound to grow more
pronounced the longer the conflict goes on.

Meeting health needs?
A major challenge facing MSF today is that
our four programmes are offering secondary
level surgical care in a setting where accessto basic health services is missing. Whatis more, the four projects are all locatedin provincial capitals – where we havemanaged to negotiate our security withall parties – when we know that there arealso pressing needs outside the main cities
and the walls of our hospitals, in rural areas
where the war is very present.

© Camille Gillardeau

Médecins Sans Frontières (MSF) first worked
in Afghanistan in 1981, but withdrew in 2004,
when five members of its team were killed. Afteran absence of five years, MSF returned to thecountry in mid-2009. Between 2009 and 2010,

it started supporting all services at a district
hospital in the east of Kabul, and working in theprovincial hospital in Lashkargah, Helmand. By
the end of 2011, MSF had opened a private
trauma centre in Kunduz, providing surgicalcare to victims of conflict as well as patients withinjuries from other causes. A private maternity
hospital was opened in Khost in early 2012.

As well as surgery and other specialist services, MSF staff at Boost hospital, Lashkargah, run a nutrition programme for children.

16 Afghans trapped as war rages on© Travaini Mario

International Activity Report 2012

MSF staff meet to prepare for the reopening of the maternity hospital in Khost, which was closed after an explosion inside the hospital.
However, we have to make choices on where
we can work. Being impartial means that
we base these choices on the needs of thepatients – a principle that is enshrined in bothinternational humanitarian law and medical
ethics. Our choices follow independent needs
assessments and are always driven by theimperative to provide good-quality healthcare
free of charge for a population that has
lived through 30 years of war. But they arealso defined by our own resources, security
constraints and access issues.

In Afghanistan, warring parties include theAfghan army and police, the American army,
the British army in Helmand, the Germanarmy in Kunduz and various oppositiongroups such as the Taliban. It is crucial toensure MSF interacts with all these armed
groups in exactly the same way. MSF isable to do so because of its independence –especially its financial independence – whichputs it in the position of being able to refusemoney from any government and thereby
ensure that its neutrality is accepted.

Strict neutrality must be observed in order forpatients to trust that the care they receive isdetermined only by their medical needs, without
any underlying political or military agenda.

However, this pragmatic approach still has
its limitations. One place that illustrates
the difficulties of working in Afghanistan
and the limits of negotiated access andcommunity acceptance is Khost province.

Negotiating access
For MSF, the only way to work in conflictsettings is through directly negotiatedaccess with all armed groups and with theacceptance of the community: this is alsoachieved through the provision of quality
healthcare and respect for culture and tradition.
All warring parties must agree not tointerfere with the medical choices of MSF
or with the patients MSF treats, and not
to target health facilities. In return, MSF
promises that its resources will be used for
medical purposes only, and not to benefit
the military effort of any warring party.

Activities were suspended and extensive
discussions and negotiations were reinitiatedwith all parties. Through this process, there
was a strong demonstration of support for
MSF as well as reassurances by the local
community and all relevant parties thatenabled the hospital to be reopened at theend of December, despite an increasingly
complex security environment.
In spite of the reassurances of acceptanceby the government, the opposition andthe community, in such a fluid context zerorisk is an illusion. The strengthening of ourinternal security measures, such as bodysearch for all patients, caretakers and staff,
has been a necessary step.

Considered the homeland of the Haqqani
network opposition group, and locatedat the border with the volatile Pakistani
tribal areas, maternal and neonatal healthindicators for Khost province are consideredamong the worst in the country. Qualified
Afghan medical staff from other provinces
are reluctant to work there and few
international organisations are present.

We still face difficult choices in terms ofbalancing the risks we run and the medical
impact we can have. As long as the safety
and security of patients, medical staff
and facilities is maintained, MSF remains
committed not only to continuing but also
to expanding its activities in Afghanistan,in order to meet the increasing medical
humanitarian needs in an uncertain future.

In March 2012, MSF opened a maternity
hospital in Khost. However, after six
weeks, during which time 600 babies weredelivered, a bomb exploded inside thehospital, injuring seven people.

In 2012, MSF carried out more than 332,000
consultations, assisted 16,500 births andconducted 7,200 surgical procedures at its
programmes in Kabul, Khost, Kunduz andHelmand, Afghanistan (see pages 26 – 27).

Afghans trapped as war rages on 17

Finding refuge?
Millions of people fled their homes in 2012. The contexts
differed – people escaping violence or natural disaster,gathering in makeshift camps, disused buildings, in the desert,
the bush or the city – but most have had one thing in common.
The assistance they received was minimal.
Even worse, in all too many cases, the response has been conditional. People who havefled their homes empty-handed have had to wait for formal registration as refugees before
receiving aid, and this can take time.
Displacement seems to force the acceptance of inhuman, degrading conditions, in whichsurvival is all people can hope for. Shortages of water, shelter, food and healthcare arecommonplace, and it is not standard practice to adapt assistance to changing contexts
and changing needs.
In 2012, MSF teams provided humanitarian medical assistance to refugees and displaced
people in more than 30 countries. They set up hospitals, health centres, mobile clinics,
nutrition programmes, safe water distribution and sanitation systems. At times, ourassistance was not adapted to needs; frequently, it was limited by external constraints;
and in all cases it was able to meet only a fraction of the total need. (For more on MSF’s
response to refugees and the displaced see the individual country reports, pages 26 – 94.)

© Kaung Htet

As well as increased risk of disease, restricted access to cleanwater means that refugees do not have the dignity of bathing
in privacy (camp near Sittwe, Rakhine state, Myanmar).

© Lynsey Addario/ VII

Many refugee camps are in places where even the fittest would struggle tosurvive. Yet people who arrive empty-handed, exhausted and under extreme
stress, are obliged to do what they can with a bare minimum of assistance,or nothing at all. Assistance often arrives late and poorly adapted to needs.
Extreme overcrowding at the refugee camps in Dadaab, Kenya, has meant thatthousands of new arrivals from Somalia have had to set up makeshift shelters.

Syrian man© Michael Goldfarb

Deir Zenoun camp, Lebanon“The sanitary conditions in
the camp are very bad. We
have no sewage system so
we dig ditches. When it rains,
the sewage runs between
the tents. It can come insideor get very close to where
people are living. The smell
is affecting us. The children
have rashes on their skin andthey feel nauseous. When it
rains, the tents are flooded.
There are no stoves for heat,and most people don’t have
any wood, so they burn plastic
to warm themselves. The
situation is extremely dire.”

Temporary, emergency solutions must be revisited when it proves impossible to return home soon. Public structures used as shelters
must be modified for their new purpose, and preparations made for seasonal changes. For Syrian refugees facing a harsh winter in 2012,
however, there was little to protect them from the cold. These two boys are tending a fire in their new home in Lebanon.
A family of 20 rent two rooms on a cattle ground. Water must be drawn from a nearby well.

Finding refuge? 19

© Lynsey Addario / VII

Both the quantity and qualityof water are a problem in manycamps. It is mainly womenand children who fetch water,
and they are often expected
to travel long distances todeserted sites and then carryback huge containers. These
Malian refugees are collecting
water at a point set up at
Mbera camp in Mauritania.

Sudanese woman© Florian Lems

El Fuj, South Sudan“When we arrived in El Fuj[border crossing-point between
Sudan and South Sudan], we
stayed there for one week.
We were very tired from walking
and not eating. We were given
a little bit of food and thencame here 12 days ago. We
have not been given anything
here. We have no plastic
sheeting, no food. We areeating leaves from the trees,
but it is not enough. People
are getting sick. There is notenough water. There was afood distribution today, but wehave not received anything.
I have seven children and no
food to give them.”

Refugees are often hungry when they arrive, if not malnourished. But food supplies have been inadequate in places supposed to offer
safety. MSF surveys in Batil camp, South Sudan, found child mortality rates in July to be double the emergency threshold, with morethan 10 per cent suffering from severe malnutrition. These children are receiving therapeutic food at MSF’s nutrition programme in
Doro camp, South Sudan.

20 Finding refuge?

This patient is receiving care at MSF’s field hospital in Yida camp, South Sudan,
having been found unconscious in the bush outside the camp.

© Camille Lepage

Without adequate water,
sanitation, shelter or food,diarrhoea, respiratory
infections, skin diseases
and malnutrition become
more common and there
is a heightened risk of
epidemics. Healthy people
become far more vulnerable
to disease, while theyoung, old and injured
need special assistance.
Medical services inrefugee camps tend
to focus on immediate
emergencies like these,
but if other conditions,
including those requiring
secondary or tertiary care,or chronic diseases likediabetes or hypertension,
are not treated, they can
become life-threatening.

© Robin Hammond

Somali refugees have been living in the camps
around Dadaab since 1991, yet providing
adequate assistance remains a major challenge.
Originally designed to accommodate 90,000
refugees, close to half a million people are now
living in and around the Dadaab camps.

A swift and comprehensive approach is vital if displaced people are to receive the assistance they need. Water, sanitation, shelter, food andmedical services must all be available and of adequate quality. As MSF nurse Chiara Burzio said while working in Jamam camp, South Sudan:“There are solutions for all these problems. It’s just that more needs to be done – fast.”

Finding refuge? 21

Médecins Sans Frontières‘Test me, treat me’:The burden of drug-resistanttuberculosis and the push
for better treatment
Baby Shirinmo crawls busily across thewaiting room of Dushanbe’s paediatrictuberculosis (TB) hospital, in Tajikistan, but
she breathes in gasps, with a rattling sound.
Shirinmo is just nine months old and has
been diagnosed with multidrug-resistanttuberculosis (MDR-TB).
“Shirinmo is not the youngest child wehave seen with TB, but she is the youngest
patient we have diagnosed with MDR-TB,”
says Dr Christoph Hoehn, who works for
the Médecins Sans Frontières (MSF) TB
programme in Tajikistan, where 30 children
and adolescents are currently receiving
treatment for MDR-TB.
Globally, our TB programmes are seeing
alarming numbers of people arriving at
the clinic with drug-resistant forms ofthe disease, including people who have
not had TB before. This is grave cause forconcern, as it means that the strains that areconsiderably tougher to treat – including
MDR-TB and extensively drug-resistant TB(XDR-TB) – are being directly transmitted
from person to person.

as well as eight months of daily painful
injections. In total, a person will need toswallow nearly 15,000 pills before theyfinish their treatment.
Furthermore, the side effects are severe andincapacitating: often people feel constantly
nauseous, suffer hallucinations, become
depressed or psychotic, and can even go
deaf. After all this, only 53 per cent ofpatients in MSF’s care are cured. Globally,
the figure is much the same – around48 per cent. It is unacceptable that thetreatment is so ineffective.
New hope
Some MSF centres – including one in
Swaziland – are looking at implementing a
new regimen in an attempt to make today’s
treatment less arduous for both patientsand caregivers. It reduces treatment timeto just nine months; but this is not enough.
More needs to be done.

At the end of 2012, the US Food and Drug
Administration approved a new drug called
bedaquiline. This is a major milestone: itis the first new drug for TB to be approvedin 50 years. Another drug will soon follow:
delamanid, which is also active against
resistant forms of TB, is expected to beapproved in 2013.
For the first time in decades, there are anumber of TB drugs in development. This
brings an unprecedented opportunity – andresponsibility – to improve and scale up
MDR-TB care. MSF has committed resources
to tackle the disease and find ways toovercome barriers to scale-up. But what
exactly needs to be done? And what role
can MSF play?
Research new treatment regimens
With two brand-new drugs to work with,there is an urgent need for research todevelop treatment regimens that are

Improved diagnosis, but inadequate
treatment
The ability to diagnose MDR-TB is improving.
A new test called Xpert MTB/Rif has reduced
the time it takes to detect drug-resistantforms of TB from two weeks to just twohours. This test is being rolled out across
MSF programmes: 46 devices are now being
used across 41 sites in 23 countries.
But what about treatment? Without it,
MDR-TB kills, yet fewer than one in fivepeople with the disease have access to care.
So few people are diagnosed and put ontreatment that there is no lucrative market
to entice multiple manufacturers to produce
the drugs and ensure both a steady supply
of medicines and the competition that willbring prices down. A full course of treatment
costs at least US$ 4,000 per person, anddrug stockouts are not uncommon.
Crucially, the treatment regimen itself isa major barrier to scale-up. Patients mustendure two years of up to 20 pills a day,© George Butler

Illustrator George Butler visited MSF’s MDR-TB project in Mumbai and drew a series of
intimate drawings of the patients. Here, a 12-year-old girl and her mother, who both have
MDR-TB, are talking to a doctor. The young girl had to drop out of school because of her
illness, but after two months of treatment is now back in class.

22 ‘Test me, treat me’: The burden of drug-resistant tuberculosis

International Activity Report 2012shorter, less toxic and, most importantly,
much more effective. MSF is advocating for
drug manufacturers to make the new drugs
accessible to researchers and affordable
for all countries with a high burden of TB.
MSF is also pushing for governments andresearchers to start working together inearnest to determine the most effective
way of introducing these new drugs so thattreatment can be dramatically improved forpeople with MDR-TB.
Test all TB cases for drug resistanceCountries with a high burden of MDRTB must ensure that all people with TB
undergo testing to determine exactly whichdrugs will work for them, so that those withdrug-resistant forms of the disease can starttaking the correct treatment much sooner.
This will prevent further drug resistancefrom developing, and reduce the spreadof resistant strains.
Meanwhile, research and development foran easy-to-use test that can detect both
drug-sensitive and drug-resistant strains
of TB on the spot is still urgently needed.
For such a test to work in high-burdencountries, it should be affordable, andnot require electricity.

© George Butler

Patients at MSF’s clinic in Mumbai see a doctor, nurse and counsellor on each visit.
A psychologist and psychiatrist are available for patients suffering from the side
effects of treatment, which can include severe depression and psychosis.

Scale up and fund MDR-TB treatment now
With better, shorter treatment regimens in
the pipeline, countries must prepare now
for increased numbers of patients receiving
MDR-TB care. Scaling up now will save
lives, and will set up the infrastructureand systems necessary to handle greaternumbers of patients in the future. To
achieve this, MSF is advocating for donors
and the Global Fund to Fight AIDS, TB and
Malaria to commit the funds needed fortreatment scale-up, and to ensure funding
for TB becomes a priority.
Develop better diagnostics and treatment
for children© George Butler

For patients already weakened by the disease, treatment for MDR-TB is excruciating. The side
effects of the drugs include nausea, body aches, rashes and even permanent deafness. Patientscan become depressed or psychotic. Only half of patients who start treatment are cured.

The needs of children continue to beneglected. Current methods to diagnose
children – who have difficulty producing
the samples of sputum (phlegm) needed
to conduct tests – are invasive, and still
end up missing nine in ten cases. Research
into methods that use samples that areeasier to collect, like urine, blood or stools,
is urgently required. So, too, are better
treatment regimens; with no paediatricformulations available for MDR-TB
drugs, children must take crushed adultformulations, which carries a risk of underor over-dosing. More effort needs to be put
into pushing for the development of better
paediatric drug formulations.

‘Test me, treat me’: The burden of drug-resistant tuberculosis 23

Médecins Sans Frontières
Listen to people with MDR-TB
It is the people with MDR-TB who are mostable to provide information and insight into
what is needed to improve treatment. Until
now, opportunities for them to speak up
about their needs, and to call on donors,
funding bodies and policy-makers to make
improved diagnosis and treatment a priority
have been extremely limited.
But MSF is working to change this. The ‘Test
Me, Treat Me’ manifesto has been written
and signed by people with MDR-TB andtheir treatment providers. The manifesto
demands better treatment, immediate
scale-up of treatment, and the funding thatwill help achieve this. People with MDR-TB
are also making themselves heard through‘TB&Me’, a series of blogs.
We have an historic opportunity for change.
If we can secure the political will, funding
and research, the ability to tackle this epidemic
successfully will finally be within reach.
In 2012, MSF provided treatment to 1,780
people with DR-TB in countries across theworld, such as Armenia, Swaziland, Uganda,
Kyrgyzstan, Myanmar and Colombia. MSF is alarge provider of DR-TB care, but the number
we reach is a small fraction of the estimated630,000 cases globally of DR-TB.

© George Butler

Gopal lost his job after he was diagnosed with
MDR-TB. After 14 months of treatment, which
involved a combination of painful injections
and taking up to 20 pills a day, he is back atwork and happy to be able to cook again.

First patient cured of MDR-TB in Zimbabwe
In her home on the outskirts of Zimbabwe’s
capital city, Harare, 48-year-old Mary Marizani
says that, having conquered MDR-TB, she now
faces another challenge: “I have my appetiteback and now I am eating everything in sight.”
Mary first showed symptoms of TB in 2006,
after caring for four members of her family
who had the disease. After eight monthsof treatment, and without screening toconfirm whether it had been successful,she was taken off TB medication by her doctor,
who declared she “looked much better”.
Over the following months, Mary was inand out of hospital with fever and a dry
cough that would not shift. She grewthinner and thinner, her condition got
worse and – having already lost half her
body weight – she took the advice of aneighbour and went to a clinic where MSF
was treating patients with TB.

She was diagnosed with a drug-resistantstrain of TB, but no treatment was available
at the time. When MSF launched its MDR-TB
programme in Epworth, near Harare, in 2010,
Mary was the first patient.
Treatment came just in time. “Just two days
before the MSF doctors came to tell us thegood news – that she would go on a new
course of drugs – my mother had coughed
up half a bucket of blood. It was terrible,
I thought she was going to die,” says Mary’s
daughter, Shorai.
In Zimbabwe, there is massive stigma around
TB. Mary says, “Most of my family deserted mefor two years while I was on MDR-TB treatment.
My own relatives didn’t come to visit me when
I was on death’s doorstep. The only family
I had left was MSF and my two children.

© MSF“I felt like I had bugs crawling on theinside of my head,” says Mary about thetreatment, which made her vomit, lose herappetite and hallucinate. “I had to passthrough hell to get to heaven.”

24 ‘Test me, treat me’: The burden of drug-resistant tuberculosis

But Mary was able to see the treatment
through to the end, with the support of
MSF staff. At the end of 2012, MSF wastreating 40 MDR-TB patients in Zimbabwe,
and Mary provides inspiration for the other
patients at Epworth.

© Isabel Corthier

A patient at MSF’s three-week fistula surgery camp in Warrap state, South Sudan. Obstetric fistulas are debilitating injuries to the birth canal thatcause incontinence and often lead to social stigma.

Activities
by country

40	Democratic Republicof Congo

61	Liberia

79	Sierra Leone

28	Armenia

61	Libya

42	Ethiopia

79	Sri Lanka

28 	Bahrain

62

Malawi

29	Bangladesh

44

France63

Mali

30	Bolivia

44	Georgia

64

Mauritania

65

Madagascar

65

Mexico84	South Sudan

66

Morocco86	Swaziland

67

Mozambique

87	Syria

68

Myanmar88	Tajikistan

26	Afghanistan

30	Burkina Faso
31	Burundi
31 	Cambodia
32	Cameroon
32	China

45	Greece
46	Guatemala
47	Guinea
48	Haiti
50	Guinea-Bissau
51	Honduras

80	Somalia
82	South Africa
83	Sudan

52

India

69	Occupied Palestinian
Territory

34	Chad54

Iran70	Niger89	Uganda

36	Colombia

54

Italy

72	Nigeria

9037	Congo

55

Iraq

74	Pakistan

56	Kenya90	United States

37

76	Papua New Guinea

38	Djibouti

58	Jordan

77	Paraguay

38	Democratic People’s
Republic of Korea

58	Kyrgyzstan

77	Philippines

59	Lebanon

39	Egypt

60	Lesotho

78	RussianFederation

33	Central African
Republic

Côte d’Ivoire

88	Turkey

Ukraine91	Uzbekistan
91	Zambia
92	Zimbabwe
94	YemenMédecins Sans Frontières

afghanistan
Conflict in Afghanistan
continues to limit access toquality healthcare services.

People in need of healthcare must often travel
long distances, across insecure areas, to reachpublic medical facilities. A lack of trained
medical staff, particularly female doctors
and nurses, further restricts access for many.
Médecins Sans Frontières (MSF) is expanding
its work at several hospitals, aiming to meetsome of the most urgent needs. (For more on
access to healthcare in Afghanistan, and thechallenges to delivery, see pages 16 – 17.)
Trauma care in Kunduz
The trauma centre run by MSF in Kunduz is
unique in northern Afghanistan, providing
free, high-quality surgical care to victims
of general trauma such as those resulting
from traffic accidents, as well as people withconflict-related injuries. Before the hospital
opened, most people with life-threatening
injuries had to travel to the capital, Kabul,or to Pakistan for treatment.
MSF developed the trauma centre in 2012
with a new emergency room, including more
beds for resuscitation and observation. The
centre now has a new, larger outpatient clinic,
better physiotherapy services and improved
infection control and sterilisation procedures,in preparation for the introduction of internal
fixation in orthopaedic procedures. Staff in
the intensive care unit also implemented
new protocols.

KunduzLashkargah

Kabul
khost

Cities, towns or villages with MSF activities

Key medical figures:• 332,300 outpatient consultations• 16,580 births assisted• 7,240 surgical procedures

When multiple patients arrive at a healthfacility at the same time, emergency
medical staff use triage so that those with themost critical needs get immediate attention.
This type of ‘mass casualty response’ is asignificant part of MSF’s work in Afghanistan,and took place on average once per monthin 2012 in Kunduz, sometimes involving large
numbers of people with life-threatening
injuries. During civil unrest in February,
50 patients were brought to the hospital:
more than 15 were severe, urgent cases.
In August, 20 people were seriously
injured in an explosion in the north of theprovince, and in September staff tended

to 33 casualties from a bus collision. Overthe year, 10,000 patients were treated in
the emergency department and surgeonscarried out 1,500 operations.
Ahmad Shah Baba hospital, Kabul
The population of Kabul has swelled
to more than three million as people
migrate or are displaced due to conflict,and refugees return from Pakistan. MSF
began working in Ahmad Shah Baba clinic
in eastern Kabul in 2009, upgrading it
to a district hospital with an emergency
department, operating theatre, outpatient
clinic, maternity ward and tuberculosis

Abdullah *40 years old, Helmand province© Francois Dumont/MSF

Our houses are destroyed. Our children
are hurt. Even our wounded are helpless.
One is putting bombs under our feet.
The other is dropping them on our heads.
Where can we go?

Mohammad, 70, was sitting in front of his shop in Lashkargah when a bomb exploded.
He has various wounds and is still in shock.

26 afghanistan

Vaccination is needed everywhere, butthere is a war in Afghanistan. There is nopeace. Sometimes it’s quiet, but then thefighting starts again. What we need is aproper clinic in a safe place.
We had to leave our homes. It’s been one
year since we’ve been to our village.
Two months ago we arrived in this newplace. Still there is fighting. This is ourreality – still there is war.
*

The patient’s name has been changed.

© Francois Dumont/MSF

International Activity Report 2012

A three-year-old boy and his younger sister in the emergency room of Boost hospital. The children sustained head injuries when a bombin Lashkargah caused the wall of their house to collapse.

clinic. In 2012, emergency obstetric care,including surgery, was extended to offer
services round the clock. Staff developed
mental health and health promotion
services to complement medical care at
the hospital, particularly in maternity,
nutrition, emergency and outpatient
services. A system was put in place toregister complaints, in order to increasetransparency and improve communication
with patients.
Boost hospital, Lashkargah
MSF continued to support one of the
only two functioning referral hospitals insouthern Afghanistan, Boost hospital in
Lashkargah. It provides surgery, internal
medicine, and maternity, paediatric andemergency services. Staff in the outpatient
clinic saw over 7,000 patients per month,
many of whom had travelled long distances
to obtain medical assistance.
The number of patients has grown as
people have learned about the hospitaland its services. The total number ofsurgical procedures increased to more than

3,000, over a third of them trauma-related
orthopaedic operations.
The hospital also has an inpatient
unit specialising in care for severely
malnourished children, where some
900 children were treated.
By the end of the year, the hospital was
equipped with 250 beds, and an extension to
the paediatric and neonatology departments
was completed with MSF support. About
2,000 people were admitted to the hospitaleach month, a 15-fold increase in patients
since MSF started work in this hospital in 2009.
Ensuring safety at Khost maternity hospitalthe hospital has the capacity to assist morethan 1,000 women to give birth every monthand to deal with obstetric emergencies.
Just six weeks after it opened, the hospital
was targeted in a bomb attack. The explosion
wounded seven people and MSF suspended
activities because of the security risks tostaff and patients. After several months ofextensive talks with community leaders andother relevant parties, MSF was assured ofsupport and safety for its medical activities
and reopened the hospital at the end of
December. Before the incident, the teamassisted over 600 births. MSF continues toenforce a strict no-weapons policy at all
locations where it works.

Khost, near the border with Pakistan, is a very
insecure province, with minimal medical services.
The one general hospital, located outside thecity of Khost, is understaffed. As a significant
proportion of the surgical staff is male,
women are deterred from seeking healthcare.
In March, MSF opened a maternity hospitalin the city centre, staffed only by female
doctors and nurses. Equipped with 56 beds,

No. staff end 2012: 1,111 | Year MSF first worked in the country: 1981 | msf.org/afghanistan

afghanistan 27

Médecins Sans Frontièresarmenia
In the capital Yerevan, as
well as in more remote areasof the country, Médecins
Sans Frontières (MSF) teams
are committed to improving
access to treatment for drugresistant tuberculosis (DR-TB).
Treatment is not universally available, andthose who can access it have to adhere
to a gruelling regimen, which can involve
painful side effects, for up to two years.
DR-TB is much harder to cure than drugsensitive TB, and without appropriate
support, many patients find it impossible
to complete the treatment.
The MSF DR-TB programme in Yerevan,Armavir, Kotayk, Ararat, Lori and Shirakprovides not only medication but also
counselling and social support to help
patients adhere to treatment.
Renovation and new facilities
In 2012, MSF signed an agreement withhealth authorities to begin improving
ventilation in the DR-TB ward of Armenia’s
main TB hospital, Abovyan, in Yerevan.
Improved ventilation and infection control

ShirakLoriMariama student from Yerevan

Kotayk
YerevanArmavir
AraratRegions where MSF has projects
Cities, towns or villages where MSF works

Key medical figures:• 216 patients started DR-TB treatment

will help reduce retransmission of the disease
among patients. It was also agreed that apalliative care unit will be set up, so thatpeople for whom treatment is failing canstill receive care to alleviate their suffering.
Focus on children with DR-TB
Detection of DR-TB in children is difficult, as
they find it hard to cough up enough sputum
for laboratory diagnosis. In 2012, MSF began
to focus specifically on this issue, and inJune launched a three-year study to improveunderstanding of infection patterns amongchildren with DR-TB. The study has alreadyyielded results: 23 children were diagnosed
and began treatment in 2012.

When I was diagnosed with DR-TB,
alarming thoughts began to swirl in myhead. How could I accept the fact that
I couldn’t go back to my husband? That
I couldn’t have a baby for many years?
I had to take about 15–20 tablets, aswell as injections. I had hardly started
treatment when I began to feel terribly
bad. I was vomiting, losing my appetite.
I couldn’t see or hear properly, had strange
noises in my ears, felt a heaviness on myback. It was difficult to breathe.
The doctors said I had to get used tothese feelings if I wanted to be cured.
I was thinking this kind of experience
couldn’t possibly be ‘treatment’.
I wanted to escape from the hospital.
Mariam did leave hospital, but she
returned and finally completed treatment in
September 2012. You can read the rest ofher story at blogs.msf.org/tb

No. staff end 2012: 93 | Year MSF first worked in the country: 1988 | msf.org/armenia

bahrain

Despite authorities’ efforts at reforms, recommended by the Bahrain
Independent Commission of Inquiry after the violence of 2011, many
people are still not seeking medical care in public hospitals.
The healthcare system in Bahrain is ofexcellent quality, but it is still grapplingwith the consequences of being caught up
in political unrest. Médecins Sans Frontières(MSF) had sought to assist people unable
to access medical attention, but its first aid
post was closed in July 2011.
An MSF team remained in the country until
March 2012, aware that hundreds of people
were still not going to public hospitals fortreatment. In March, staff were refusedentry to the country, and activities had tobe suspended.
No. staff end 2012: 1 | Year MSF first worked in the country: 2011 | msf.org/bahrain

28 armenia | bahrain

Hoping to return to Bahrain, MSF staff worked
from Dubai, in the United Arab Emirates,
submitting proposals for activities to the
Bahraini Ministry of Health. These included
providing technical support in emergency
preparedness and mental healthcare, as wellas accompanying patients to health facilities
to ensure that they and staff act in compliancewith universally recognised medical ethics.
In May, MSF held a mental health workshop
in Dubai, attended by medical professionals
from the Bahraini government andopposition. MSF personnel were allowed
into the country from June 2012, but
negotiations to launch activities failed. MSF’s
principal concerns are comprehensive mental
healthcare and patients’ access to services.

International Activity Report 2012bangladesh

The vast majority of the estimated 300,000 Rohingya refugees in
Bangladesh are unregistered and living in deplorable conditions.
In 2012, there were around 30,000
registered refugees living in Kutupalongcamp, in Cox’s Bazaar. Some were fleeing
renewed violence in Myanmar, whileothers sought protection from exploitationelsewhere in Bangladesh. Many have been
struggling to survive in the area for years.
Médecins Sans Frontières (MSF) runs aclinic for local Bangladeshis and refugees
just outside the makeshift camp, although
MSF’s presence has been challenged
by the government. Staff provide basic
healthcare, including maternal and mental
health services. The clinic also has a small
inpatient unit, a stabilisation unit for severely
malnourished children, a diarrhoea treatment
centre and an ambulance for hospital referrals.
MSF continues to advocate for improved
living conditions for the Rohingya.
Assisting children and women in Dhaka
In the Dhaka slum of Kamrangirchar, MSF
teams run two health centres offering basic

medical care and child and maternal healthservices. More than 40,000 paediatricconsultations were carried out over the year.
It is not uncommon for girls between
the ages of 10 and 15 in Kamrangirchar
to marry and become pregnant soonafterwards. However, information about
the elevated health risks for this age groupduring pregnancy and childbirth is seriously
lacking. Staff at both centres have begun
providing specialist services to adolescent
girls and young women.
Kala azar programme
Kala azar, also known as visceral leishmaniasis,
is a deadly tropical disease transmitted bysandflies. It is the second-biggest parasitic
killer worldwide, after malaria. Some 90 per
cent of cases occur in just seven countries,
and Bangladesh is one of them.

Fulbaria
Dhaka

Kutupalong
Cities, towns or villages where MSF works

Key medical figures:• 134,770 outpatient consultations• 570 patients treated for kala azar
• 1,900 births assisted

to treat the disease since 2010. This is safer
and more effective than previous treatments,
and takes just one day. In 2013 the Ministryof Health approved treatment with liposomal
amphotericin B nationwide and is in theprocess of changing its national protocol.

At MSF’s kala azar programme in Fulbaria, theteam has been using liposomal amphotericin B© Alfons Rodriguez

No. staff end 2012: 354 | Year MSF first worked in the country: 1985 | msf.org/bangladesh

An MSF staff member gives food rations to a family in Kamrangirchar.

bangladesh 29

Médecins Sans Frontières

bolivia
The prevalence of Chagas
disease in Narciso Campero
province, Bolivia, is morethan 40 per cent in the general
population, but doubles to 80 per
cent for people aged over 45.
Access to treatment, however, is difficult:most health facilities charge fees, andpeople tend to live a long distance from
centres offering diagnosis and treatment.
Screening is vital because Chagas canbe deadly. Although people may live foryears without symptoms, the disease canultimately cause debilitating complications.
Heart failure is the most common cause ofdeath for adults.
These complications require complex clinicaltreatment, which is not usually available
locally. New, simpler models of care areneeded so that patients can get the treatment
they need at their local health centre.

Médecins Sans Frontières (MSF) staff carryout screening and treatment for Chagas in
the communities of Aiquile, Omereque andPasorapa, in Narciso Campero province,and offer training to health staff. In 2012,
MSF signed an agreement with the Bolivian
organisation Puente de Solidaridad andthe local hospital, which allows patientswith heart and intestinal complications to
be referred to the hospital for specialist
treatment free of charge.
Production of medication guaranteed
In 2011, benznidazole, the most commonlyused medicine for Chagas, became unavailable
when the world’s sole manufacturer of thedrug, based in Brazil, ceased production.
After intensive lobbying, production of
the medicine resumed and delivery has
been guaranteed for 2013. In November,
MSF introduced a paediatric formulationof benznidazole for younger patients,
developed by the non-profit research anddevelopment organisation, the Drugs for
Neglected Diseases initiative (DNDi).

No. staff end 2012: 67 people worked in Bolivia and Paraguay, which is run as a
joint programme | Year MSF first worked in the country: 1986 | msf.org/bolivia

Narciso Campero

Regions where MSF has projects

Key medical figures:• 785 patients began treatment for
Chagas diseaseAngel

55 years old, lives in Chujllas,a small rural community in
Cochabamba department.
I wasn’t feeling well. I had some palpitations
when I was sleeping. I went to the hospitalin the town of Aiquile for a diagnosis. The
results were that I had Chagas. But it was
impossible for me to keep going to Aiquile
for treatment. Six months went by and afriend told me that MSF was coming to
Chujllas. “This is very important,” I said,“we mustn’t miss this opportunity.”
The whole community met with the doctors.
By that time I didn’t feel like working oreven eating. I started treatment. I recovered.
I hope others follow the treatment, as I am
feeling very well now.

burkina faso
By the end of 2012, an estimated 38,000 Malians had fled
to Burkina Faso to escape conflict.

Soum

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

Key medical figures:•2 2,440 outpatient consultations• 5,000 patients treated for severe malnutrition

The region at the border with Mali is arid,
and resources are scarce. Médecins Sans
Frontières (MSF) started offering emergency
assistance to refugees in Mentao camp,
Soum province, in February. The teamthen moved on to set up activities in four

We are a population who fled war, who
fled insecurity in northern Mali. We havebeen chased away by the army; a lot of
people have died. We fled, abandoning
everything. I am with my children. We havenothing. We are living in the open air here.

Closure of malnutrition programme
In 2012, the Titao nutrition programme
closed, following a consistent decrease inadmissions over the past few years. Openedin 2007, the programme offered treatment
for malnutrition at 11 outpatient feeding
centres and Titao hospital. In the hospital,
MSF treated patients for malaria andprovided basic healthcare to children under
14 years of age. More than 4,500 patientswere treated for malnutrition in 2012, and830 were treated for malaria.

No. staff end 2012: 178 | Year MSF first worked in the country: 1995
msf.org/burkinafaso

30 bolivia | Burkina Faso

from Mali© Aurelie Baumel/MSF

Titao

Oudalancamps near Deou, Oudalan province, as
more refugees arrived there and otherorganisations took care of services in Mentao
camp. Staff at Deou supported a healthpost and conducted mobile clinics, offering
basic healthcare, including antenatal care,treatment for malnutrition and vaccinations.
Patients were mainly suffering from malaria
and respiratory infections.

FatimaMSF provides health consultations to Malianrefugees at camps in Oudalan province.

International Activity Report 2012burundiKabezikirundoGitegaRegions where MSF has projects
Cities, towns or villages where MSF works

Key medical figures:• 2,170 births assisted• 190 patients treated for severe malaria• 4 85 fistula repair operations

Obstetric services havebeen provided free of charge
in Burundi since 2006, but
equipment, referral systems
and skilled staff are all lacking.

These gaps in services result in many
maternal deaths. In Kabezi, Bujumbura Rural
province, Médecins Sans Frontières (MSF)
runs the Centre for Obstetric Emergencies,
or CURGO, which provides free 24-hourcare. Three ambulances transport womenin need of emergency services from 24
health centres: on average, 250 women permonth were admitted in 2012. According to
MSF figures, this model of care – a referral
system and emergency obstetric services –has resulted in 74 per cent fewer maternal
deaths in Kabezi district compared with thenational average.
Obstetric fistula care
Obstetric fistulas are injuries to the birthcanal, most often a result of prolonged,
obstructed labour. They cause incontinence,
which can lead to social stigma. At the
Urumuri health centre in Gitega, MSF offers
fistula repair surgery, physiotherapy andpsychosocial support. The team also works
to raise awareness of the condition within

the country through medical staff training
and a telephone information line, among
other measures.
Severe malaria
National health statistics show that malaria
accounts for over half of all medical
consultations in Burundi, and it is the causeof more than a third of deaths in children
under the age of five. In September MSF
opened a severe malaria programme in
Kirundo province, where over 300,000
people suffered from the disease in 2011.
Staff in Kirundo hospital and 34 healthcentres in the province focus on diagnosis
and introducing artesunate injections as
the first choice of treatment at facilities.
Artesunate is more effective, requires ashorter period of treatment, is easier toadminister and has fewer side effects thanother drugs.

No. staff end 2012: 282 | Year MSF first worked in the country: 1992 | msf.org/burundi

cambodia

Tuberculosis (TB) is one of the most serious public healthchallenges facing Cambodia.
TB is spread through the air by an infected
person coughing or sneezing. It is an
opportunistic infection that takes advantage
of weakened immune systems.

may have TB. The team carries out regularawareness-raising activities to help increaseknowledge and understanding of TB andreduce the stigma surrounding the disease.

Searching for TB

These activities, as well as the completionof a new laboratory, have all contributed
to a significant growth in patient numbers.
Each month MSF staff now conduct around
1,000 consultations inside Kampong Cham
hospital’s TB ward. The team also makes
home visits to DR-TB patients who havedifficulty getting to the hospital, and atelephone hotline is available for anyone
with an urgent enquiry. The overall numberof patients is expected to double in 2013.

In Kampong Cham hospital, MSF offers
treatment for both drug-sensitive anddrug-resistant TB (DR-TB). DR-TB is muchharder to treat because it is a form of
the disease against which first-line drug
regimens have failed.
A priority is to improve detection of thedisease, and actively look for and test
people who may have it. MSF invites
individuals patients have had contact with,such as family members, to be tested, andworks with hospital staff, particularly in thepaediatric ward, to identify patients who

Handover of services in Phnom Penh prisonsKampong Cham

Phnom Penh
Cities, towns or villages where MSF works

Key medical figures:• 3,500 patients screened for TB• 770 patients started TB treatment• 18 patients started DR-TB treatment

Teams provide care and treatment for HIV
and TB. The programme is in the process of
being handed over to a number of nationalorganisations. Most support will stop by July
2013, although staff will remain to care forpatients with HIV.

Since February 2010, MSF has been working
in three prisons in the capital Phnom Penh.

No. staff end 2012: 129 | Year MSF first worked in the country: 1979 | msf.org/cambodia

burundi | cambodia 31

Médecins Sans Frontières

cameroon

The north of Cameroon was affected by a measles epidemic
at the beginning of the year and severe flooding at the end.
The people in the north are especiallyvulnerable to outbreaks of disease as thehealth infrastructure is so poor. After
measles broke out, Médecins Sans Frontières(MSF) set up a dedicated unit in the hospitalin Garoua, capital of North region. Most
patients were under five years of age, andsuffering from malnutrition and respiratorycomplications. At the end of April the unit
was handed over to the Ministry of Health.

The MSF team at the Buruli Pavilion insidethe district hospital of Akonolinga carries
out testing, treatment (with antibiotics
and dressings), surgery and physiotherapy
for patients suffering from this neglecteddisease. The staff also treat other chronic
wounds and HIV in patients who areco-infected with Buruli and HIV, caring
for around 100 people every year.

Between March and April, MSF also delivered
training to staff in 102 health facilities in
22 districts of North and Extreme Northregions and donated measles treatment
kits for some 1,835 patients.

In Nylon district hospital and Soboum healthcentre in the city of Douala, MSF trained
hospital staff and provided medicinesand other supplies for the treatment of

In September, flooding displaced thousandsof families in the Extreme North. MSF set
up a health centre and mobile clinic in
the camp of Kousseri, and improved theprovision of sanitation and safe water.
Buruli ulcer
People infected with Buruli ulcer develop
sores that can cause irreversible deformities,
which can restrict movement, and lead tosecondary infections and long-term disability.
The bacteria causing Buruli is related toleprosy but very little – not even the mode oftransmission – is known about the disease.

HIVextreme northnorth
Akonolinga
DoualaRegions where MSF has projects
Cities, towns or villages where MSF works

Key medical figures:• 5,160 patients on first-line antiretroviraltreatment• 3,380 patients treated for measles

5,000 HIV patients. MSF is increasing accessto viral load testing – which is used todetermine how patients are responding
to treatment – by subsidising the test. MSF
also continues to advocate for more patientsto receive the improved first-line treatment
for HIV, based on the drug tenofovir.

Natasha24 years old, was admitted to the Buruli programme in 2007. Five years later,
she talks about her experience.
In 2000, I noticed I had a little spot on myleft ankle. I thought it was a mosquito bite.
Several days later, a wound formed. My
parents put a dressing on it and it healed.
But months later the same wound
reappeared, and it didn’t heal. In fact it
got bigger. I spent four long months with a
traditional healer. My wound did not heal.
In the meantime, MSF arrived in
Akonolinga. A nurse persuaded us to cometo the hospital. The first operation wentsmoothly, but when I went to have thedressing changed, I nearly fainted. The sore
was even bigger. I was certain it wouldn’t
heal. I was convinced I would never walkagain despite everything the nurses said.
But I continued my treatment and after
a bit more than a year I was discharged.
One year after leaving hospital I was evenable to run again. Not as fast as before,
admittedly, but I could run.

No. staff end 2012: 96 | Year MSF first worked in the country: 1984 | msf.org/cameroon

china

In 2012, Médecins Sans
Frontières (MSF) provided
assistance after southernparts of China were flooded.
China is frequently hit by flooding,landslides, typhoons and earthquakes. While
the authorities’ response to such natural
disasters is improving, there are sometimes
gaps in emergency assistance, especially inthe delivery of adequate food and materials
for the survival of those affected.
In 2012, an MSF team delivered relief items
such as blankets and food, plastic sheeting andcooking kits to several thousand households
in Yunnan, Guizhou and Sichuan provinces.

Innovative HIV care
Although treatment for HIV and AIDS
is being scaled up in China, available
resources do not meet the increasing
demand, which has led to problems inaccessing quality treatment and care.
It was agreed in 2012 that MSF would support
the implementation of comprehensive
antiretroviral (ARV) treatment services for HIV
patients in five pilot clinics in three provincesof the country.
Local organisation AIDS Care China (ACC)
will lead the programmes, and MSF will
provide technical assistance in the clinicalmanagement of HIV patients. The aim
is to demonstrate that a new model ofNo. staff end 2012: 12 | Year MSF first worked in the country: 1986 | msf.org/china
32 cameroon | china

Sichuan

YunnanGuizhou

Regions where MSF has projects

Key medical figures:• 1,050 relief kits distributed• 4,000 mosquito nets distributed• Food distributed to 3,300 households

comprehensive treatment, incorporating
counselling, can result in better outcomesfor patients. MSF will also supply ARV drugs.

International Activity Report 2012

central african
republic
Ouham-Pendé
Ouham

BaminguiBangoranHaut-Mbomou
OMBELLA M’POKO
Mambéré-Kadéï
Regions where MSF has projects

Conflict across large areas of
the Central African Republic at
the end of 2012 increased healthneeds and further destabilised
the fragile health system.

© Corentin Fohlen / Divergence

Key medical figures:•5 90,400 outpatient consultations•3 34,200 patients treated for malaria•1
 ,700 patients on first-line antiretroviraltreatment•3
 40 patients treated for sleeping sickness

Tens of thousands of people come to MSF’s Paoua hospital, Ouham-Pendé, each year.
Basic healthcare is difficult to access and mortality rates in parts of the country are up
to five times the emergency threshold.

A military campaign by an alliance of rebel
forces, Séléka, took a number of major
towns and territory in eastern and central
regions. By early 2013, Séléka forces had
reached the gates of the capital Bangui.

to pay the fees required for treatment.
In short, a large proportion of the population
does not have access even to the most basic
healthcare, and mortality rates are above
emergency levels.

Thousands of people fled into the bush, andhospitals and health posts were abandoned.
Médecins Sans Frontières (MSF) teams,
already working in five regions across thecountry, continued activities and launched
extra mobile clinics to attend to the medical
needs of the displaced. An emergency
surgical team began work in Kaga-Bandoro,in the north, and donations were made tohospitals and clinics in locations affectedby violence.

MSF teams work with the Ministry of Healthin seven hospitals and more than 30 healthposts, providing a wide range of services:
basic and specialist healthcare, maternity
and paediatric services, surgery, HIV and TB
care, and treatment for neglected diseases,
including sleeping sickness (human African
trypanosomiasis).

Urgent health crisis
The conflict only exacerbated medical
needs, which were already huge even instable areas of the country. The healthsystem suffers from a lack of qualified staff
and there are few public facilities outside
the capital. Shortages of essential medicines
are frequent and many people cannot afford

Malaria is one of the main causes of deathin the country, and is a major priority
for MSF programmes. The goal is toboost prevention and offer diagnosis andtreatment in more locations.

is deadly if untreated, but both diagnosis
and treatment are complex and difficult toadminister. In Batangafo, in Ouham, MSF
is using a new rapid diagnostic test for the
disease and participating in clinical trials ofa new oral treatment for last-stage sleeping
sickness developed by the not-for-profit
research and development organisation, theDrugs for Neglected Diseases initiative (DNDi).
The mobile sleeping sickness team screened
more than 4,500 people for the disease in
the southeast of the country. Access to theregion has been difficult for some years due
to attacks by the Lord’s Resistance Army, but
in 2012 MSF was able to reach more people
as many left Zémio, in Haut-Mbomou, andreturned to their home villages to start
farming again.

Testing new tools for sleeping sickness
The Central African Republic is one of the
few countries where sleeping sickness
remains a problem. Sleeping sickness
attacks the central nervous system andNo. staff end 2012: 1,300 | Year MSF first worked in the country: 1996 | msf.org/car

central african republic 33

Médecins Sans Frontières

cHAD

Malnutrition, meningitis andmalaria were among therecurring health emergencies
faced in Chad in 2012.
Internal strife has diminished since 2010,
and the main public health problem for
Chadians today is a lack of quality healthservices or, in most cases, an absence of
health services altogether.
Médecins Sans Frontières (MSF) teams
continued programmes designed to meetthe neglected medical needs of women andchildren, and responded to malnutritionand other emergencies.
Widespread child malnutrition
Immunisation rates are very low and thecountry is regularly affected by outbreaksof preventable disease, which increase theexposure of young children to malnutrition.
In 2012, MSF treated more than 23,000
children for severe malnutrition in different
areas of the Sahel strip, which runs
across the middle of Chad. Two regularprogrammes run nutrition activities,
and four additional short-term nutrition
programmes were opened in places where
the existing capacity to tackle malnutrition
was overwhelmed. MSF handed overthese emergency programmes to otherassociations and the Ministry of Healthat the end of the peak of the crisis.

LAC

Batha

Wadi Fira
Abéché

Hadjer Lamis
N’Djamena

Salamat

Chari Baguirmi
Moyen-Chari

Mayo Kebbi Ouest
Logoné Oriental

MandoulRegions where MSF has projects

Key medical figures:• 71,380 outpatient consultations• 495,950 meningitis vaccinations• 28,930 patients treated for severe malnutrition

Cities, towns or villages with MSF activities

In Biltine, Wadi Fira region and Aboudeia,
Salamat region, 5,180 children were treatedfor malnutrition at two inpatient feeding
centres and 20 outpatient feeding centres. In
and around Yao, Fitri district, Batha region,
MSF ran an emergency nutrition programmefrom April to September. Staff at the hospitalin N’Djamena Bilala in Fitri ran a 30-bed
paediatric ward for children suffering severe
malnutrition and other diseases, and teams
screened for and treated malnutrition in
27 surrounding villages. Staff also carried out
1,330 paediatric consultations and ensured

routine immunisation for 6,300 children.
In June, MSF opened one inpatient and
10 outpatient feeding centres in Bokoro,
Hadjer Lamis, which treated 3,800 children.
An MSF team has worked at Massakory
hospital, Hadjer Lamis region, since 2010.
Staff offer emergency medical care forchildren up to 15 years old and provide
treatment for children under five with severe
malnutrition with complications. In 2012,
8,530 patients were treated for malnutritionand over 1,000 for malaria. A nutrition
programme operated in six health zones,
where teams also monitored for common
diseases. More than 17,000 children werealso vaccinated against measles and182 patients were treated for meningitis.
Meningitis outbreaks© Florian Lems/MSF

Chad lies in a swathe of countries across
Africa that see recurrent outbreaks ofmeningitis, an infection of the thinmembranes surrounding the brain
and spinal cord. Meningitis can cause
headaches, fever, nausea, sensitivity tolight and can lead to disability or death.

A nurse treats a severely dehydrated child at MSF’s mobile feeding centre in Angara
village, Biltine district.

34 cHAD

When meningitis epidemic thresholds
were passed in early 2012, MSF launchedvaccination campaigns in districts in theregions of Batha, Salamat, Mayo Kebbi
Ouest, Mandoul and Hadjer Lamis. Someteams were able to use a newer vaccine,which offers 10 years of protection against
the disease.
Teams treated hundreds of patients for the
disease in Am Timan and Aboudeia, Salamat© Florian Lems/MSF

International Activity Report 2012

A nurse carries out a consultation at MSF’s outpatient therapeutic feeding centre in Angara, Biltine district.

region and Moissala, in Mandoul. In April,
MSF responded to a meningitis outbreakin Léré, Mayo Kebbi Ouest. Medical supplies
were donated and a team worked withhospital staff to provide patient care andstaff training. More than 700 treatment kits
were donated to health centres and staff
led awareness sessions in the villages andthrough local radio broadcasts.
Malaria prevention and treatment
A quarter of all deaths in Chad are
attributed to malaria and it is the mostcommon cause of death for children. Casesof the mosquito-borne disease peak from
July to November.
In Moissala, Mandoul region, MSF has
trained healthcare workers to diagnose andrespond to simple malaria. They treated
39,500 people for the disease, while staff
in clinics treated another 20,000. MSF
donated drugs and medical supplies and ran
an inpatient malaria ward for children in the
district hospital, treating 2,100 children.
A new preventive strategy was also
implemented. Between July and October,teams distributed antimalarial medicine
to children once per month in two healthzones of Moissala district. In the eightweeks following the first distribution of
the medicine, staff in the health centres
recorded a 78 per cent reduction in thenumber of patients with simple malaria.
Specialist services for women and children
In Am Timan, Salamat region, MSF
supports the district hospital with anemphasis on emergency services for womenand children. On top of treatment formalnutrition, the team offers reproductive
healthcare and emergency obstetric care,including an HIV–TB programme andprevention of mother-to-child transmissionof HIV. Ante- and postnatal consultations
are held in six health zones and therapeutic
feeding programmes in nine health zones.
In 2012, teams conducted 20,790 antenatal
consultations and assisted 1,870 births.

and counselling. Surgery and post-operative
care is carried out at the regional hospital,
in collaboration with the Ministry of Health.
In 2012, 166 women received this surgery.
Assisting refugees from the Central
African Republic
Some 20,000 refugees from the Central
African Republic have lived for several years
in camps in the Moyen-Chari region ofChad. Heavy rains caused flooding in thecamps in October and the refugees had
to be relocated. MSF carried out 8,000
medical consultations, built 100 latrinesand provided clean water and blankets,
mosquito nets, water containers and soap
to some 4,000 families.

Women who have sustained an obstetricfistula, damage to the birth canal mostoften caused by obstructed and prolonged
labour, suffer physical pain, incontinence
and rejection by their families andcommunities. MSF runs a women’s healthvillage in Abéché, Ouaddai region, where
patients can stay for their weeks-longtreatment and receive nutritional support

No. staff end 2012: 997 | Year MSF first worked in the country: 1981 | msf.org/chadcHAD 35

Médecins Sans Frontières

colombia
Riosucio
Cauca
NariñoNorte deSantander

Buenaventura
CaquetáPutUmayo

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

Key medical figures:• 9 0,470 outpatient consultations• 10,750 group and individual mental healthconsultations• 335 patients started TB treatment

Colombians living in conflictzones have to contend not onlywith chronic violence but alsowith geographical, cultural,administrative and financial
barriers to healthcare.
In the southern departments of Cauca,
Nariño, Caquetá and Putumayo, Médecins
Sans Frontières (MSF) operated mobile clinics
and fixed health posts throughout the year,
offering basic healthcare and vaccinations,sexual and reproductive healthcare,including family planning and antenatal care,and referrals for emergencies.

People traumatised by regular exposure toviolence rarely have access to public mental
health services. MSF provides psychologicalassistance through clinical consultations,counselling sessions and community work.
Staff saw a steady growth in the numberof patients using services, carrying out
5,400 mental health consultations andproviding medical and psychological care tonearly 200 victims of sexual violence. Group
activities to promote good health and raiseawareness of mental health issues reached
38,400 people.
Violent attacks by armed groups forced
people to leave their homes in seven separate
incidents. MSF distributed medical supplies
and relief items to local health facilities andprovided direct medical and psychologicalcare to a total of 16,000 people.
Meeting health needs in Buenaventura
Thousands of people live in slum conditionsin the Pacific seaport of Buenaventura.
Tuberculosis (TB) is one of several publichealth concerns. MSF supports the National
TB Control Programme in the detection
and treatment of the disease, including themore difficult to treat drug-resistant TB. By
the end of the year, 285 new patients had
begun treatment, and 60 were undergoingtreatment for drug-resistant TB.
An MSF health facility also offers treatment
for victims of sexual violence, sexual andreproductive healthcare for teenagers

and medical care for children. More than
13,000 consultations were held. As thisfacility is more easily accessible for patients,
activities were concentrated here and asecond clinic in the island part of the city
was closed in February.
Work to ensure a safe water supply andprevent disease in the areas of Los Angeles
and Pampalinda was completed at the endof the year.
Programme closures
The Chagas programme in Norte deSantander was closed in September, after
10 years of activity. Patient numbers had
fallen: of 2,250 screened for Chagas in2012, 43 were diagnosed with the disease
and received treatment. Patient care washanded over to the Ministry of Health, while
the Pan American Health Organization took
over the monitoring of the programme.
In July, MSF handed over the River Atrato
programme, based in Riosucio, to the
Ministry of Health. The team had been
providing basic and mental healthcare,
reproductive healthcare and assistance tovictims of sexual violence through a clinic, as
well as mobile outreach to four communities.
MSF continues to advocate around threemain issues of concern in Colombia:
healthcare access, the effects of conflicton mental health and the urgent need formental health support, and awareness ofand treatment for sexual violence.

Alicia *received mental health support from
MSF in Cauca department.

© Karine Bodart/MSF

Look, this is all so hard … The day you
least think about it, there are combats
or explosions in our town. All the time
there has been this anxiety. That iswhat produces my poor health. Before,
I didn’t feel the pain that I now feel.
Now, every day I feel bad. I can’t
sleep … One feels bad, and one thinks:
until when do you have to live in thissituation? If I had somewhere to go,
I would go, but regrettably I don’t.

Drug-sensitive and drug-resistant tuberculosis are public health concerns in Colombia.
No. staff end 2012: 284 | Year MSF first worked in the country: 1985 | msf.org/colombia

36 colombia*

The patient’s name has been changed.

International Activity Report 2012

congo
Likouala

Bétou

Brazzaville
Pointe-Noire
Regions where MSF has projects
Cities, towns or villages where MSF works

Key medical figures:•1
 14,110 outpatient consultations•3
 7,220 patients treated for malaria•3
 ,030 births assisted

At the beginning of the year,
according to the UN refugee
agency, an estimated 59,000
refugees from the Democratic
Republic of Congo (DRC)
remained in Bétou district, inLikouala, afraid to go home.

At Bétou hospital, Médecins Sans Frontières(MSF) has strengthened capacity to meetthe needs of refugees and local residents.
The team has opened new services
including obstetrics, a nutrition programme
and a laboratory, and reorganised hospital
departments for surgery, outpatientsand emergency medicine. The majorityof roughly 2,600 outpatient visits permonth were children, most of whom
had respiratory infections or malaria. In
addition, staff provide emergency assistanceto refugees along the Ubangi River.
MSF also works with national control
programmes for tuberculosis (TB) and HIV. In
2012, 77 HIV patients and 97 TB patients wereregistered for treatment supported by MSF.
Explosions in BrazzavilleOn 4 March, explosions in a munitions depot
in Congo’s capital Brazzaville caused serious
damage. Two hundred people died, over 1,000
were injured and 15,000 became homeless.
MSF treated wounded at two public
hospitals, setting up triage tents at the
University Hospital to prioritise patientsin need of urgent treatment and donating
medical equipment for surgery.

Over 1,000 displaced people in two camps
received medical and psychological care.
MSF also managed safe water provisionand sanitation and monitored for cholera
and measles at five other locations. The
emergency response ended in June.
New treatment for yaws
The indigenous Aka pygmies in northern
Congo have scant access to healthcare.
These remote communities are stillaffected by yaws, a contagious but curable
skin infection that, untreated, can cause
permanent disfigurement and disability.
The World Health Organization has a newrecommended treatment protocol foryaws, which requires just a single oral doseof azithromycin. The MSF team in Congo
was the first to implement this protocol,
travelling to Aka communities in the forest
and treating 17,500 people.
Cholera in Pointe-Noire
Following torrential rains in November,cholera broke out in December in the city ofPointe-Noire. MSF set up a cholera treatment
centre in Loandjili hospital and helped healthauthorities put preventive measures in place.
A draft response plan was presented to local
and national authorities.

No. staff end 2012: 220 | Year MSF first worked in the country: 1997 | msf.org/congo

Côte d’ivoire

As the conflict following the disputed presidential election
subsided and the humanitarian situation improved, Médecins
Sans Frontières (MSF) gradually handed activities back toreturning Ministry of Health staff.

GuigloDuékouéTaï

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

Key medical figures:•5 2,380 outpatient consultations•2
 5,320 patients treated for malaria•1
 ,790 surgical procedures

A team remained at the hospital in thewestern town of Duékoué throughout 2012.
They took care of surgical emergencies,
internal medicine, and maternal and paediatricservices. In July, staff in the emergency
department treated 56 casualties from anattack on a camp for displaced people.
MSF started working in Taï, to the south of
Duékoué, at the end of 2011. Staff support
Ministry of Health teams in the outpatient,maternal and paediatric services of a 20-bed
facility, which sees more than 2,000 outpatients
every month.

Handover of medical activities
MSF support for health services in andaround the town of Guiglo came to an
end. The team at Bloléquin hospital left
in January. MSF left the Nikla dispensary,
where staff ran a feeding programme that
accommodated 20 inpatients, at the endof March. Activities at the health centre in
Guinkin, where the team was holding up
to 1,200 consultations each month, werehanded over to the Ministry of Health afew months later.

No. staff end 2012: 369 | Year MSF first worked in the country: 1990 | msf.org/cotedivoire

congo | Côte d’ivoire 37

Médecins Sans Frontières

djibouti
Djibouti city

Cities, towns or villages where MSF works

Key medical figures:• 235 patients treated for severe malnutrition© Marcus Bleasdale / VII

The nutrition programme in
Djibouti was handed over tothe Ministry of Health in 2012.
With an extremely hot and dry climate
and poor crop capacity, inadequate foodsupply is a chronic issue for the vast
majority of Djiboutians. Children needessential nutrients for normal growth anddevelopment and are most vulnerable tothe effects of malnutrition. For this reason,
Médecins Sans Frontières (MSF) opened
an emergency inpatient feeding centre forchildren in Djibouti in 2008.

ready-to-use supplementary food. This
high-protein formulation contains all thenutrients children need and is proveneffective in preventing malnutrition.

MSF’s lobbying for the implementation ofa preventive approach to malnutrition has
resulted in the health ministry distributing

The team also gave technical support to
the Ministry of Health so they could develop
their own specialised nutrition programme.

A child is screened for malnutrition using a MUAC (mid-upper arm circumference) band
during a visit by an MSF outreach team.
Staff training, medicines and medical
equipment were provided. The ministry
constructed a nutrition treatment centre
and MSF handed over its programme in
April. In four years, MSF teams treated
10,600 children for severe malnutrition.

No. staff end 2012: 31 | Year MSF first worked in the country: 2008 | msf.org/djibouti

DPR KOrea

Torrential rains led to devastating floods in the Democratic
People’s Republic of Korea in mid-2012, which displaced
thousands of people.

South Pyongan
Regions where MSF has projects

Key medical figures:• 1,000 relief kits distributed

Médecins Sans Frontières (MSF) assisted
in the response. A team undertook an
assessment of 13 health facilities in theflood-affected area, including a local
hospital, pharmacy and both urban andrural health centres.
Staff delivered medical kits to help healthworkers in South Pyongan province care forsome of the thousands of people caught

No. staff end 2012: 2 | Year MSF first worked in the country: 1995 | msf.org/dprk

38 djibouti | DPR KOrea

up in the emergency. These kits containeverything needed to meet medical needsin the weeks following a natural disaster.
In addition, teams distributed relief items
to some of the communities affected,
including blankets, water containers andplastic sheeting to provide temporary
shelter. Tons of rice and more than a million
water purification tables were also donated.

International Activity Report 2012

egypt
Cairo

Cities, towns or villages where MSF works

Key medical figures:•8
 ,950 outpatient consultations

Mothers and children in some isolated
settlements and rural areas lack access tothe specialist services they need. In August,
Médecins Sans Frontières (MSF) openeda mother and child clinic in Abu Elian, arural settlement in El Marg district, on
the outskirts of Cairo. Until then, it had
been more than an hour’s journey to theclosest medical facility, and transport andtreatment costs posed barriers to care.
Staff in Abu Elian carried out nearly 9,000
consultations. Most of the children they
saw were suffering from respiratory tract
infections, intestinal parasites, skin diseases
or diarrhoea. A 24-hour emergency referral
system is in place for pregnant women,with MSF providing transport and covering
hospital costs.
Many of the refugees and migrants living in
Cairo and throughout Egypt have experienced
violence and have almost no access to healthservices. MSF opened a clinic for womenin Nasr City, in Cairo, offering mental
healthcare and treatment for victims ofviolence, and treated more than 430 people.
Strengthening capacity fortuberculosis care
In September, MSF staff in Qalyubia
governorate trained 20 doctors and 20 nurses
from the Ministry of Health in tuberculosis(TB) care, focusing on infection control of thiscommunicable and potentially deadly disease.

© MSF

Vulnerable groups in Egypt,
including migrants and people
in poor, remote areas, do
not have access to critical
health services.

A paediatrician examines a young patient at the newly opened mother and child clinic
in Abu Elian.

Emergency assistance in Gazaand southern Sinai
When the ‘Pillar of Defence’ military
operation was launched on Gaza in
November, MSF donated close to five tonsof medicines and medical supplies to the
Gaza Ministry of Health and to El-Arishhospital, the Egyptian referral hospital thatreceived some of the wounded.
Expanding treatment for hepatitis C
According to government data, there is analarming prevalence of hepatitis C in the
country, with a national average of one inevery five people infected. In rural areas,
prevalence for certain age groups reaches
up to 55 per cent and 38 per cent for men
and women, respectively, and public healthfacilities are having difficulty meeting
medical needs. Passed primarily throughcontact with infected blood, hepatitis C is achronic disease affecting the liver that cancause serious health problems, including
cirrhosis and liver failure. MSF is awaiting
approval for a new model of care that canbe implemented with the Ministry of Healthin remote areas.

Mona *
brought her daughter to the motherand child clinic at Abu Elian.
My two-year-old daughter suffered froma lung infection for months. I sought
help in other healthcare facilities, but
the infection persisted. Now I tell all thepeople I know that since I brought mydaughter to the MSF clinic, she received
proper healthcare and I haven’t needed
to bring her again.
Earlier, when a child would get a fever,
the mother would wait for a week before
seeking medical care at a healthcare facility.
More mothers in the area are now bringing
their children to this clinic; they know it iseasily accessible for them and free.
*

Name has been changed.

No. staff end 2012: 63 | Year MSF first worked in the country: 2010 | msf.org/egypt

egypt   39

Médecins Sans Frontières

Democratic
republic of congo
Key medical figures:• 1,674,000 outpatient consultations• 4 07,600 measles vaccinations• 434,300 patients treated for malaria• 9 0,470 patients admitted to hospital• 4,040 patients treated after incidents
of sexual violence

Orientale
Équateur

NORth Kivu

Most people in the Democratic
Republic of Congo (DRC)
are suffering a desperatelack of healthcare: many
health facilities are barely
operational. Escalating
violence in the east has
increased the already highlevel of medical need.
In 2012, a newly formed armed group, M23,
attacked Rutshuru in North Kivu province
before occupying the provincial capitalof Goma for several days. Hundreds were
injured and thousands were forced to flee,
again: they abandoned Kanyaruchinya
displaced persons camp, heading toneighbouring camps or further south.
Médecins Sans Frontières (MSF) continued
to run services at Rutshuru hospitalthroughout the violence, although witha reduced team. From July to December,staff provided basic healthcare, nutritionalcare, maternity services and assistance tovictims of sexual violence at Kanyaruchinya
health centre, and set up a cholera
treatment centre. In November MSF started
work in Mugunga III camp, offering basic
healthcare, nutritional support, measles
vaccinations and treatment for victims ofsexual violence. Surgical staff operated on
60 war-wounded in Virunga hospital, Goma.
Comprehensive healthcare in Northand South Kivu
MSF fully resumed activities in Masisi
hospital in North Kivu in 2012: services had
been reduced after a member of staff was
injured in a security incident in 2011. The
team supports all services at the 160-bed
hospital, and provides basic healthcare
at two health centres and mobile clinics.
Comprehensive services are also provided
in Mweso, Kitchanga and Pinga.

40 Democratic republic of congo

Kinshasa

South Kivu
ManiemaBandundu

Katanga

Kasai-Occidental
Regions where MSF has projects
Cities, towns or villages where MSF works

In South Kivu, MSF supports basic andspecialist services in hospitals and healthcentres in Kalonge, Minova, Shabunda,
Kimbi Lulenge and Baraka.

medicines. When the MSF compound in Baraka
was robbed and staff intimidated, services
continued, though with fewer personnel.

In Lubutu, Maniema province, MSF’s
hospital programme has reduced mortality
significantly. In March MSF handed overto the Ministry of Health after the teamdemonstrated that high-quality, easily
accessible health services can be offeredat almost the same cost as that definedby the Ministry of Health.

Until August, a team in Kalémie in Katanga
province provided basic healthcare,maternity services, nutritional support andwater in two camps for people who had fled
conflict in South Kivu.

Insecurity limits medical activities
In April, two staff members were abducted in
Nyanzale, near Rutshuru. They were returned
unharmed after several hours but medical
activities – including both basic and specialist
services, and assistance to victims of sexual
violence – in Nyanzale were closed, and thenumber of staff at Rutshuru was reduced.
Pinga, also in North Kivu, was repeatedly thescene of armed conflict, and when residents,
including MSF staff, had to flee, MSF services
were interrupted. Heavy fighting between
the army and a Mai-Mai group, which
expanded its influence in the region over
the year, meant that an emergency response
to high rates of malaria in Walikale wassuspended for several weeks.
In South Kivu, staff who had been working
in six health facilities and running mobile
clinics in Hauts Plateaux, Uvira were evacuatedin February due to armed conflict, though
MSF continued to supply the facilities with

Assisting the displaced in Katanga

Fighting flared up in Katanga itself between
the army and Mai-Mai militias. MSF provided
basic and specialist health services to thedisplaced in Mitwaba between April andAugust, and in Dubie from March. Longerterm programmes providing comprehensive
health services in Shamwana saw a decrease
in inpatients as fighting hindered access to thehospital. Displacement prevented follow-up
for many patients.
Assisting victims of conflictin Orientale province
In Geti, Ituri district, MSF provides basic
and specialist services, paying particularattention to maternal and child health,although insecurity hampers activities.
More than 820 patients, two-thirds ofwhom were under five years of age, wereadmitted for emergency treatment.
In Bunia, MSF provides financial, humanand logistical resources to two Congolese
organisations (SOFEPADI and EPVI, or Hopefor Life) offering women’s health services,family planning and HIV treatment.

© Sven Torfinn

International Activity Report 2012

An AK47 bullet, removed from a young woman by surgeons at Virunga hospital, Goma.
MSF also supports the emergency
department of Dingila hospital in Bas-Uélé.
In 2012, 1,070 patients were admitted, morethan half of whom were suffering frommalaria. In Niangara in Haut-Uélé, a teamcontinued to support the general hospital aswell as three health centres, where activities
were expanded to offer mental healthservices and routine vaccinations. The
programme in Dungu was handed over tohealth authorities in December, following an
improvement in the security situation and areduction in the number of trauma patients.
Sleeping sickness
Three-quarters of all reported cases of sleeping
sickness (human African trypanosomiasis) are
in DRC, yet testing for the disease has declined
significantly. In Ganga-Dingila and Ango,
Bas-Uélé, MSF worked with Ministry of Healthstaff in the hospital and in mobile teams,
screening some 60,000 people and treating
1,070 for the disease. A further 100 patientsin Bandundu and Kasai-Occidental provinces
received treatment through a mobile
programme, which closed in December.
MSF’s programme in Doruma in Haut-Uélé
was handed over to the Ministry of Healthas the number of cases had fallen below the
emergency threshold.
HIV careOnly 15 per cent of people living with HIV
in DRC have access to the antiretroviral(ARV) treatment they need, one of thelowest coverage rates in the world.
In Kinshasa, staff at MSF’s Centre Hospitalierde Kabinda have treated a large numberof patients arriving in later stages of thedisease with serious complications. Some
4,700 patients are receiving ARV treatment
in Kinshasa, and many people attend MSF’s
other HIV programmes across the country.
Malaria
Malaria is the leading cause of illness anddeath in DRC. In 2012, an outbreak struck
several regions of Orientale, Équateurand Maniema provinces. Unusually highnumbers of cases of serious malaria required
hospitalisation. MSF teams set up treatment
and intensive care units, supplied drugs tohealth facilities and organised the transfer ofseriously ill patients to hospital. Between Juneand September, MSF treated tens of thousandsof patients, the majority children under five
years of age. A team also brought short-term
support following malaria outbreaks inNorth Kivu and Katanga.

to measles in Katanga, South Kivu, Bandundu
and Équateur provinces.
CholeraMSF responded to outbreaks of cholera in
DRC throughout the year, treating a totalof 1,160 patients in Ituri district, Orientale;
1,550 in and around Goma, North Kivu, where
the team also organised patient transfers
to MSF-supported hospitals and donatedmedicines to other health facilities; and300 in Lubumbashi, Katanga. Staff also
managed a treatment centre in Kalémie
hospital and assisted in responding to outbreaks
in Bandundu and South Kivu provinces.
Ebola outbreak in Haut-Uélé
Ebola, a haemorrhagic fever transmitted
through bodily fluids, broke out in Isiro in
Haut-Uélé in August. There is no known
cure for Ebola and the mortality rate
fluctuates from 30 to 90 per cent. MSF
assisted the response, treating 18 patientsand providing psychosocial support.

MeaslesAt the beginning of the year, there was ameasles epidemic in the areas of Dungu andFaraje, Orientale province. MSF vaccinated37,400 children and treated 61 patients.
When another massive epidemic brokeout in October, MSF carried out a major
vaccination campaign. Teams also responded

No. staff end 2012: 2,782 | Year MSF first worked in the country: 1981 | msf.org/drc

Democratic republic of congo 41

Médecins Sans Frontières

ethiopia
Tens of thousands of refugees are also inneed of health services. By the end of 2012,
an estimated 170,000 Somali refugees had
arrived in southern and eastern parts ofEthiopia, escaping conflict and the effectsof 2011’s severe drought. People fleeing
violence in Sudan and South Sudan haveentered Ethiopia from the west. Médecins
Sans Frontières (MSF) continued toprovide medical assistance to refugees andcommunities around the camps, as well as
to other people without access to healthservices, throughout the year.
Refugee assistance© Yann Libessart/MSF

Despite significant economic
progress in the country,
medical care remains beyond
reach for many Ethiopians,
particularly in remote andconflict-affected areas.

MSF teams at the Bambasi camp vaccinated children against measles and opened
a treatment centre for malnutrition.

Refugees are medically screened and receive
measles vaccinations upon arrival at thereception site at the southern border townof Dolo Ado in Liben zone, Somali region.
Further medical care, including outpatient
consultations, surgery, ante- and postnatal
services, vaccinations and treatment for
tuberculosis (TB), is available at the MSFsupported health centre.

To assist the many refugees with symptomsof mental distress, MSF carried out 1,090
individual counselling consultations and morethan 400 follow-up sessions. Outreach teams
conducted 14,840 education sessions to raiseawareness of the psychological suffering
among the refugees and suggest ways tostrengthen resilience in their communities.

For part of 2012, MSF also ran basic
healthcare and nutrition programmes in fiverefugee camps in Liben zone. Approximately
30,000 children per month were screened
for malnutrition. Children were also
diagnosed and treated for pertussis(whooping cough), kala azar and diarrhoeal
diseases. Staff handed activities over to the
Ethiopian authorities.

In the far west of Ethiopia, MSF supported
the Regional Health Bureau to meet theincreased needs for basic and specialist
medical care following the arrival of
refugees from South Sudan. Staff carriedout more than 60,000 consultations at
Mattar health centre and at mobile clinics,
which are run by car or boat, dependingon the season.

AmharaBenishangulGumuz

Gambella

In March, a mobile medical team conductedconsultations in and around the border
town of Moyale, which is partly in Oromia
region. for Kenyans fleeing intercommunal
clashes. MSF also supported healthfacilities with additional medical staff, drug
donations and training in management ofcommon illnesses. The programme wasclosed in May, when most of the refugees
had returned to Kenya and it was clear that
local authorities could manage the basic
needs of those remaining.

Somali Region

SNNPR

OromiaRegions where MSF has projects

42 ethiopia

When Ethiopian authorities transferred
12,000 Sudanese refugees from the AdDamazin camp, near the Sudan–Ethiopia
border, 80 kilometres east to Bambasi,
in Benishangul-Gumuz region, roughly
one out of four children was found to bemalnourished. MSF teams treated
500 people for malnutrition, immunised
3,500 children against measles anddistributed food rations to 4,000 people.
MSF has been providing emergency
healthcare to Sudanese refugees in
Benishangul-Gumuz since 2011, but directaccess to camps has proven difficult toobtain and MSF continues to negotiate withthe authorities.

Key medical figures:• 203,250 outpatient consultations• 1,400 patients began TB treatment• 2,160 births assisted

International Activity Report 2012

Basic and specialist health services
in Somali region

In an area known as Ogaden, in thenortheast of Somali region, MSF continues
to assist at the hospital in the town ofDegehabur with emergency obstetriccare, antenatal consultations, treatment
for malnutrition, and medical andpsychological care for victims of violence.
MSF staff also support Wardher hospital,
particularly in treatment for TB andmalnutrition, reproductive healthcare –including assistance for victims of sexual
violence – and vaccinations. Another teamworks in Danod health centre. Since January
2011, MSF has conducted mobile clinics in
Ogaden, providing basic healthcare, butthese activities were limited in the second
part of the year due to security restrictions
imposed by authorities.
Sidama mother and child healthcare
Responding to a lack of access to healthcare
in parts of Sidama, a zone in the Southern
Nations, Nationalities and Peoples Region(SNNPR), MSF opened a programme in2010 focused on the health of mothers andchildren under five years of age. Activities
include ante- and postnatal consultations,a 24-hour emergency service, medical andpsychological care for victims of violence,
surgery and treatment for obstetric fistulaand referrals. Obstetric fistulas are injuries
to the birth canal, and are most often aresult of prolonged, obstructed labour.
They cause incontinence, which can leadto social stigma.
A maternity waiting home was also opened
to accommodate women with obstetriccomplications so that they have rapid
access to skilled emergency care. Morethan 50,000 women and 34,000 children
received care in the Sidama programme in2012. The team is also training Ministry of
Health staff.

© Yann Libessart/MSF

The provision of healthcare in Somali region
is limited, owing to lack of development,a dearth of trained medical personnel andconflict between government forces andarmed anti-government groups. MSF runsa health clinic in West Imey and anotherin East Imey, providing basic and maternal
healthcare, an inpatient clinic, treatment for
TB and kala azar, as well as mobile clinics.
With health services for the largely nomadic
population now more firmly established,
activities will be handed over to the
Regional Health Bureau in early 2013.

Nearly 40,000 Sudanese people who fled fighting in Blue Nile state now live in camps
in Ethiopia.

Decentralising care for TB
TB is the second-most common cause ofdeath in Ethiopia, after malaria. There areindications that cases of drug-resistant
TB (DR-TB) – which requires two years ofgruelling treatment that can cause severeside effects – are on the rise.
MSF is assisting the federal Bureau of Healthin the launch of a decentralised DR-TB
treatment model in the eastern city of Dire
Dawa, which will offer care on an outpatientbasis. MSF has provided medical advice,donated specialised diagnostic equipment
and designed modifications for thehospital as well as patients’ homes. These
refurbishments will significantly reduce therisk of patients passing on the disease tofamily members and allow them to live athome during their treatment.
Kala azar and HIV
Kala azar, or visceral leishmaniasis, is aparasitic disease transmitted by the biteof a sandfly, and is almost always fatal if
not treated. It receives very little attention
from the medical community, however. In
Abdurafi, Amhara region, MSF works with
the Ministry of Health to treat patients withkala azar, including those co-infected with
HIV. MSF pays particular attention to groups
most vulnerable to these diseases, such as
migrants and sex workers.

Badoo
40 years old
I had my baby in the bush where I live,
as I’ve done with all my previous children.
A traditional birth attendant delivered
my baby girl but soon after I becamevery sick. I had a very high fever and was
shaking uncontrollably. I felt like all theenergy was leaving my body. I had been
cut very badly and became infected.
I found it painful to pass urine and thepain made me want to be sick. My family
put me on a donkey cart and it took
two hours to get here.
I have been in the hospital two days andthe staff check my blood pressure, havegiven me medicine and put me on an
oxygen machine. The doctor says I lookbetter now and I feel like I’m getting alittle more energy.
I feel like now I am here I will be OK. I wasin a lot of pain but every day I feel a little
bit better. If I had stayed in the bush andnot come to hospital, I don’t know what
would have happened to me.

No. staff end 2012: 1,564 | Year MSF first worked in the country: 1984 | msf.org/ethiopia

ethiopia 43

Médecins Sans Frontières

franceThe vast majority of patients seen by the staff at the Médecins
Sans Frontières (MSF) programme in Paris are asylum seekers
who live on the streets or in temporary accommodation.

Most have no health insurance, and it isextremely hard for them to access any kind of
medical care. The difficulties are compounded
for people who cannot speak French, andwho do not have a residence permit.
MSF’s health centre offers medical,
psychological and social care through amultidisciplinary staff of nurses, doctors,
psychologists and social workers. Manypatients – particularly those receiving
psychological care – have suffered repeatedtraumatic experiences both at home andin exile. In 2012, the team saw around
100 new patients. As well as medical
consultations, staff carried out more than
2,100 psychological consultations. Nearly
900 patients received social assistance.
In addition to providing direct medical andsocial assistance to those in need, MSF’s
goal is to ensure that barriers are removed,
so that vulnerable people can access carein the public system.

Paris

Cities, towns or villages where MSF works

Key medical figures:• 3,960 outpatient consultations

No. staff end 2012: 13 | Year MSF first worked in the country: 1987 | msf.org/france

georgia
Abkhazia

Tbilisi

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

Key medical figures:• 130 patients treated for kala azar
• 27 patients began DR-TB treatment

People in Georgia who
contract kala azar, or visceralleishmaniasis, now havegreater access to quality
care and shorter, moretolerable treatment.

Kala azar is a parasitic disease that is
almost always fatal without treatment.
It is transmitted through bites from infected
sandflies. Symptoms include fever, weight
loss, enlargement of the liver and spleen,
anaemia and immune-system deficiencies.
It is a neglected disease, and treatment until
recently has been painful, requiring multiple
injections which caused toxic side effects.
The disease is mainly found in Bangladesh,
India, Ethiopia, Sudan, South Sudan andBrazil. However, incidence of kala azar has
steadily risen in Georgia. Around 180 people
are diagnosed with the disease each year,
many of them children.
In 2011, Médecins Sans Frontières (MSF) began
working with Tbilisi’s Parasitological Hospital
to improve detection of kala azar with rapid
diagnostic tests, and to introduce a better
drug, liposomal amphotericin B, to treat it. This
treatment regimen is far easier for patients:
they receive the drug for four days and need
only remain in hospital for a maximum of
10 days rather than the month that was
required with the previous medication.

No. staff end 2012: 44 | Year MSF first worked in the country: 1993 | msf.org/georgia

44 france | georgia

After completing staff training, the MSF
team handed over the kala azar programme
to the national authorities in 2012, with afinal donation of liposomal amphotericin B.
Tuberculosis programme handoverSince 2010 MSF has run a TB programme
focusing on the treatment of patients withmultidrug-resistant TB (MDR-TB) in theautonomous republic of Abkhazia.
MDR-TB is a strain of the disease that
does not respond to standard TB drugs.
Treatment takes up to two years and oftencauses painful side effects. MSF continues
to treat patients while it assists with thedevelopment of the Abkhazian National TB
Programme, which will manage all activities
in future.
Access to care in Sukhumi
In 1993, during the civil conflict in Abkhazia,
MSF began a programme delivering medical
services to a community in Sukhumi whowere without access to healthcare. During
2012, MSF continued to provide medicalcare, including surgery and eye care, to
64 patients.

International Activity Report 2012

greeceEvros

the eastern Aegean islands (Agathonisi,
Lesvos, Leros, Samos, Simi), as well as topeople in detention centres.

AEGEAN ISLANDSLAKONIA

Regions where MSF has projects

Key medical figures:•2
 ,840 outpatient consultations•1
 5 patients treated for malaria•3
 ,330 relief kits distributed

Migrants arriving in Greece,
including asylum seekers,
face prolonged detention of
up to 18 months.
Access to medical care is limited to emergencies,and new migration policies have resulted inmass arrests of migrants and their detention
in sub-standard ‘pre-removal centres’.
During 2012 Médecins Sans Frontières(MSF) provided medical assistance tomigrants and refugees arriving at the landborder with Turkey (Evros region) and on

Most people came from countries affectedby conflict, and their medical complaints
were mainly a consequence of the gruelling
journeys and poor conditions they had
endured. MSF medical staff treated injuries,
skin and respiratory infections, gastrointestinal
problems, frostbite and exhaustion. They also
provided treatment for chronic conditions suchas diabetes and heart disease.
Basic relief items such as hygiene kits andsleeping bags were regularly distributed
to people on arrival and in the detention
centres of Evros, and necessities such as dry
clothes provided to those who needed them.
In December, teams extended medical
services throughout the region of Eastern
Macedonia and Thrace, making regular
visits to detention centres as state medical
teams had withdrawn. Migrants’ health
had been affected by the length of theirdetention in sub-standard and overcrowded
conditions. Staff treated patients for medical
problems such as scabies, skin infections
and gastrointestinal complaints.

Reappearance of malaria
Malaria has reappeared in Greece after almost
40 years. MSF supported the Hellenic Centre
for Disease Control and Prevention team andlocal health facilities for seven months, working
in the municipality of Evrotas, in Lakonia,
contributing to prevention, epidemiologicalsurveillance, clinical management, laboratory
diagnosis and vector control.

Samira *17 years old, Lesvos
In the Ghazni region of Afghanistan where
we used to live, my father was killed, andmy mother and two sisters were raped. I
was the only one spared, so we decided
to flee. We walked for months throughmountains in the dark and the cold.
We reached Lesvos island in extreme
exhaustion. Here we feel safe; we received
help from MSF and the local population.
At the border with Iran they separated
us from one of our sisters: they put her inanother truck and since then we’ve lost trackof her. We want to go and live in a peacefulplace, where our lives won’t be at risk.
*

Name has been changed.

© Juan-Carlos Tomasi

No. staff end 2012: 16 | Year MSF first worked in the country: 1991 | msf.org/greece

Detained migrants in southern Greece are registered in Poros (Evros), where MSF provided medical care.
greece 45

Médecins Sans Frontières

guatemalaIn four years, the percentage
of female patients seeking
assistance at the Médecins
Sans Frontières (MSF) sexual
violence treatment programmewithin 72 hours of being
assaulted has increased
from 17 to 64 per cent.
Timely treatment means patients canreceive prophylactic medication to preventthe transmission of sexually transmitted
diseases, including HIV.
For years, victims of sexual violence havereceived very little support in Guatemala,and have rarely known where to look forhelp. Recently, some positive changes
have been introduced: survivors of sexual
violence are now able to receive medical
attention before a crime is reported, andmedical staff in public health facilities havebegun to offer treatment.
MSF completed the handover of its
programme to the Ministry of Health in2012, having provided 24-hour services
to victims of sexual violence since 2008.
Teams had worked in five locations: a healthcentre and two clinics on the outskirts ofGuatemala City, the emergency departmentof the city’s general hospital, and in the

Public Ministry, where assaults are reported.
The provision of services in the Public
Ministry means that victims of assault who
seek justice can access medical care directly.
The teams provided medical, psychologicaland social care to nearly 4,000 patientsover the course of the programme, andcarried out more than 11,000 follow-up
consultations. MSF also worked to influence
policies and practices, including advocating
the availability of 24-hour healthcare.
In 2010, the Ministry of Health adopted
a national protocol on the treatment for
victims of sexual violence, facilitating accessto healthcare, and in 2011 asked MSF totrain its staff to implement this protocol.
MSF provided training for 450 healthprofessionals in 28 healthcare facilities.
Earthquake response
A 7.2 magnitude earthquake hit Guatemala’s
Pacific coast on 7 November, destroying
hundreds of homes.
MSF donated medicines to health centres
in affected districts of the departmentof San Marcos. The team also provided
psychological first aid – initial support andcounselling in the immediate aftermath ofa traumatic event – to survivors suffering
panic attacks. In the district of San Juan
Ostuncalco, in Quetzaltenango department,
more than 300 displaced families received
hygiene kits.

san marcos

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

Key medical figures:• 780 patients treated after incidents
of sexual violence• 1,510 individual mental health consultations

Claudia
17 years old
I was on my way to class, I was going to
do my practical work, when they mademe get into the car. They abducted andattacked me. They left me with only mytrousers and shirt.
My mother’s friend told us about ahospital we could go to. We went there
and spoke with a woman. That’s how we
got in contact with MSF for the first time.
I think the hardest time of all was themoment I discovered I was pregnant. I
remember the first day I put on maternity
trousers and I cried so hard. I was
ashamed to be seen outside. Some people
helped me, but lots of people blamed meand said bad things about me. So I got
angry … angry with them … angry with
God who let this happen to me.

© Natacha Buhler/MSF

This has been a long, difficult and often
bitter journey. I don’t think the governmentis paying the attention it should to sexual
abuse. It’s not because it isn’t happening– it’s because they pay more attention tokillers, as their crimes are more visible andeveryone knows it’s happening.

A member of staff leads a patient to her consultation in the Zona 1 health centre, Guatemala City.

No. staff end 2012: 23 | Year MSF first worked in the country: 1984 | msf.org/guatemala

46 guatemala

For more on MSF’s inner-city
programmes, including Guatemala City,
visit the Urban Survivors website:www.urbansurvivors.org

International Activity Report 2012

guineaAlthough the prevalence of HIV in Guinea is relatively low
compared with other countries in west Africa, many people
cannot access treatment early and this impacts on their health.

The team also conducted preventive water,
sanitation and educational activities to help
control the spread of this water-borne disease.

Teams also provide basic health services
to pregnant and breastfeeding womenand children under five at three centres inMatam. In 2012, staff carried out 57,000
consultations for children under five andassisted 7,000 births.

Malaria is a leading cause of illness and deathin Guinea. In Guéckédou, MSF supports
malaria prevention and treatment activities in
the local district hospital, six health centres
and nine health posts, and trains medical
staff. In 2012, 77,000 people received malaria
treatment, almost a third of them cared forby MSF-trained community health workers.

Boké

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

Key medical figures:•2 10,170 outpatient consultations•9 2,940 patients treated for malaria•1 40,000 cholera vaccinations

Supporting 5,800 patients on antiretroviral(ARV) treatment in the capital, Conakry,
Médecins Sans Frontières (MSF) has
become a significant provider of HIV/AIDS
care in the country. Staff offer diagnosis,
treatment and psychosocial support at five
health centres across the city, as well as
at an outpatient clinic in Matam district.

MSF handed over the HIV programme in
Guéckédou after activities had been integrated
into the district hospital. MSF will supply ARVdrugs for 1,670 patients until the end of March2013 and the Ministry of Health has committed
to ensuring continuity of treatment from then.
Responding to cholera emergencies
In response to a cholera outbreak in Boffa
prefecture, in Boké region, MSF vaccinatedover 140,000 people between April andJune. This was the first time an oral vaccine
was used as a preventive measure againstcholera before an outbreak turned into afully fledged epidemic. Staff responded
to another cholera outbreak in Conakry inJune, treating more than 50,000 people
across four temporary treatment centres.

Malaria

David *
25 years old, from Matam
I’ve been very sick for more than eightmonths. I went to a lot of health centres
and hospitals here in Conakry. I tried
everything, even traditional medical
treatments. No one ever suggested an HIV
test. Coming here, I was tested, and thentold the news. Nobody knows in my family
except my uncle, who accompanies andsupports me. These last months have been
physically and emotionally exhausting.
*

The patient’s name has been changed.

© Holly Pickett

No. staff end 2012: 366 | Year MSF first worked in the country: 1984 | msf.org/guinea

Rehydrating fluids are administered to patients at Donka cholera treatment centre, Conakry.
guinea 47

Médecins Sans Frontières

haiti
LéogânePort-au-Prince

Cities, towns or villages where MSF works

Key medical figures:• 24,980 patients treated for cholera• 16,820 surgical procedures• 14,890 births assisted

Reconstruction has been slow
since the 2010 earthquake,and many Haitians continue
to rely on humanitarian aid
for emergency medical care.

Maternal healthcare
Pregnant women in Haiti often findthemselves in a precarious situation in
emergencies. MSF runs a 130-bed obstetricand neonatal emergency hospital in theDelmas 33 neighbourhood of Port-au-Prince,
offering free, round-the-clock emergency
care for women experiencing complications,
including common hypertensive disorders
such as pre-eclampsia. In 2012, 7,980 patientswere admitted to the hospital and teams
assisted 6,360 births.
In addition, the hospital provides a full
package of reproductive healthcare services
including family planning, prevention of
mother-to-child transmission of HIV, neonatal

and postnatal care and mental healthcounselling. A 10-bed cholera centre has also
been set up inside the hospital for pregnant
women who have contracted the disease.
Emergency surgery in the capital
In February, MSF opened the Nap Kenbe– Creole for ‘staying well’ – surgical centre
in Tabarre, eastern Port-au-Prince. Teams
provide emergency trauma, orthopaedic andabdominal surgery for victims of gun crimeand domestic violence as well as people injured
in road accidents. Of almost 1,200 patients in
2012, 18 per cent had suffered violent trauma
and 72 per cent were victims of accidents.
MSF continued to work out of the 130-bed
Drouillard trauma hospital close to the Cité
Soleil slum in the north of the city. This facility
is equipped with an emergency department,
operating theatres and intensive care andburns units, and provides physiotherapy andmental health services. In 2012, hospital
staff cared for 19,700 emergency patientsand carried out 8,000 surgical procedures,
treated 480 people with burns and provided
medical and psychological support to150 victims of sexual violence.

© Yann Libessart/MSF

Delays in disbursements and in therealisation of planned projects mean thereconstruction of the health system is far
from complete. Access to healthcare was a
problem for vast numbers of people even

before the disaster: fees were unaffordable
and there were few adequately equippedpublic hospitals. Médecins Sans Frontières(MSF) continues to fill gaps in emergency
care with more than 500 beds in four
hospitals. Teams also provide treatment
for cholera, a potentially deadly waterborne disease, which according to Haitianauthorities had affected 638,000 people
and killed almost 8,000 by the end of 2012.

Many of the patients at MSF’s burns unit in Drouillard hospital, Cité Soleil, are young children injured in domestic accidents.

48 haiti© Emilie RégnierInternational Activity Report 2012

Mothers bring their sick children for diagnosis and treatment at Chatuley, Léogâne. Originally a tent hospital treating earthquake survivors,
MSF has since built a 160-bed container hospital.

Martissant emergency andstabilisation centre
The only MSF facility that remained intact
after the earthquake was the 35-bed
Martissant clinic for paediatric care, maternity
services and internal medicine. A 100-bed
cholera treatment centre remained open
until June. MSF closed its mental healthprogramme at Martissant at the end of theyear. In total, more than 61,200 patients
received treatment at the facility in 2012.
Chatuley hospital, Léogâne
The 160-bed container hospital run by
MSF in the city of Léogâne, close to theearthquake’s epicentre, is the only facility
in the region offering free 24-hour care for
medical and surgical emergencies. Somepeople travel from Port-au-Prince for medical
attention there. Facilities include a laboratory,
radiology, physiotherapy and mental healthservices and a special outpatient department
for pregnant women and children under five.
In 2012, staff assisted 6,600 births and carriedout 3,600 surgical procedures – most of thesewere for women requiring caesarean sectionsand victims of road accidents. The cholera
treatment unit is the only facility treating
patients suffering from cholera-associatedmedical complications.

measures, including distribution of hygienekits, water chlorination and education andawareness activities. MSF was still treating
more than 500 people for the disease per
week at the end of the year.

Cholera response

Completion of anaesthesia training

Cholera can cause rapid dehydration anddeath if untreated and is commonly found inareas with unsafe water and poor sanitation
control. Unhygienic living conditions anda lack of healthcare have exacerbated thecholera crisis that began in the country
in 2010. Public cholera treatment centres
remain inadequate throughout Haiti andthe overall response to the crisis is limited
because of reduced international funding.
In 2012, MSF treated close to 25,000 people
with cholera in Port-au-Prince and Léogâne.
Patient numbers increased after hurricanes
Isaac and Sandy, when rains caused open
sewers to overflow and led to the spreadof contaminated water, but the peak
period was in April and May, during therainy season. Teams continued preventive

In September, MSF completed the trainingof nurses in anaesthesia. In the absence ofother educational institutions providing suchtraining, this course equips nurses with thecritical skills they need in the managementof obstetric and surgical emergencies.

No. staff end 2012: 2,582 | Year MSF first worked in the country: 1991 | msf.org/haiti

haiti 49

Médecins Sans Frontières© Holly Pickett/Redux

guinea-bissau

A young woman, five months pregnant with her first child, recovers from cholera at the MSF treatment centre in Bissau.

Oio

CACHEUBIOMBOBISSAU

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

Key medical figures:• 1,960 patients treated for cholera

An outbreak of cholera
gradually escalated to a healthemergency in Guinea-Bissau.

Cholera, a communicable, water-borne
disease that can cause rapid dehydrationand sometimes death, is a recurring healthissue in Guinea-Bissau. Outbreaks can betriggered by heavy rainfall and flooding
in areas with inadequate water andwaste management.
A team from Médecins Sans Frontières(MSF) worked with the Ministry of Health toestablish a national programme on cholera
preparedness in 1999. Since then, emergency
teams have provided support during majorcholera outbreaks in 2005 and 2008.
At the end of August, the Ministry of Healthbegan to record an increase in the numberof cases of cholera. MSF started assisting an
emergency response in the capital Bissau
and affected areas of Biombo, Oio andCacheu regions in October.

Teams set up a 60-bed cholera treatment
centre in Bissau and treatment units in theother areas. MSF also supported healthcentres in the management of patientswith cholera by opening isolation units,providing treatment and medical supplies,
improving hygiene and sanitation insidefacilities, training health staff and raisingawareness among the population of thedisease and how it is transmitted.
MSF proposed using a new, two-dose oralcholera vaccine, which had recently been used.
in other countries. As cholera vaccinations had
never been carried out in the country before,
the proposal had to pass through a complex
approval system, and approval was given toolate for vaccination to have an impact on theepidemic in 2012. However, the government
has agreed to implement a preventive cholera
vaccination campaign in 2013.

No. staff end 2012: 3 | Year MSF first worked in the country: 1998 | msf.org/guineabissau

50 guinea-bissau

International Activity Report 2012honduras
Tegucigalpa

Cities, towns or villages where MSF works

Key medical figures:• 4,020 outpatient consultations• 140 patients treated after incidents
of sexual violence

Violence is widespreadin the Honduran capital of
Tegucigalpa, but very few
victims seek medical attention,
fearful of their aggressors anddeterred by the many barriers
to accessing healthcare.

Each week, Médecins Sans Frontières(MSF) teams visit more than 20 sites in thecapital’s most violent neighbourhoods,
offering assistance to people who would
otherwise be unlikely to receive medical
attention. Social workers, medical staff andpsychologists provide preventive care, firstaid and psychological support. Patients inneed of further medical and psychologicalattention are referred to four health centres
supported by MSF, where staff ensure thatcomprehensive treatment is available.
Tegucigalpa University Hospital is the only
public hospital in the city with the capacity
to treat victims of trauma, and violencerelated admissions have doubled over the
past five years. The overwhelming numberof people in need of urgent care due toviolence poses an enormous burden on
an already overstretched medical system,
particularly emergency departments. MSF
staff hope that treating and documenting
the needs of the people they see willencourage the Honduran authorities torecognise the need for a firm commitment
to address this issue and implement anappropriate response.

Marco
30 years old
I left home when I was around 11 years
old. I have always lived on the street.
One takes refuge on the streets when
there’s no other option.
I got into a fight. Both of us were armed,
and we exchanged gunfire. We both got
injured. And that’s how my foot got injured.
The truth is that there is so much meanness
here on the streets that one person doesn’t
hesitate to harm another. I have seen a lotof my friends die on the streets.
I was taken to the hospital. Many homelesspeople die at the hospital, because they
don’t receive the attention they deserveor aren’t treated in time. After hours of
waiting, I called MSF because they always
help you out. They took care of me at thehospital. I’m getting better now.
For more on MSF’s inner-city
programmes, including Tegucigalpa,
visit the Urban Survivors website:www.urbansurvivors.org© Spencer Platt/Getty Images

No. staff end 2012: 34 | Year MSF first worked in the country: 1974 | msf.org/honduras

A homeless man in Tegucigalpa receives an eye examination from an MSF health worker. Teams go into city streets daily to assess medical needs.

honduras 51

Médecins Sans Frontièresindia
Key medical figures:• 119,500 outpatient consultations• 6 40 patients began TB treatment• 1,990 patients treated for kala azar

Many people in India stillcannot access the medical
services they need, despite
significant economic
development within the country.
Drug-resistant tuberculosis (TB) is a major
health problem. Drug-resistant forms of TB
are much more difficult to treat, requiring
at least two years of medication, which cancause serious side effects. Although growing
public awareness of the issue has led
authorities to increase access to treatment,
the national health system’s response
remains underdeveloped.

Bihar

Chhattisgarh

nagalandManipur

MumbaiRegions where MSF has projects

Andhra Pradesh

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

A long history of insurgency, poor
infrastructure and a scarcity of staff mean
specialist health services are almost nonexistent in the far northeastern regionsof the country. MSF supports basic andspecialist healthcare, including TB services,in Mon district hospital in Nagaland.

care they need through the public system.

In Mumbai, an MSF team specialises in HIV
treatment for people who cannot access theoptions and models of care is an important

Staff offer medical and psychosocial care
to people with HIV who need second- or
third-line treatment or alternative first-line
treatment, and people who are co-infectedwith MDR-TB or extensively drug-resistant TBor hepatitis B or C. Research into treatment
component of the Mumbai project.

© Sami Siva

Médecins Sans Frontières (MSF) has HIV and
TB clinics in Manipur, where 17 new patientsbegan treatment for multidrug-resistant TB(MDR-TB) in 2012. Patient numbers increased
significantly when a fourth clinic was opened
near the border with Myanmar in April.

India-administered Kashmir

A patient undergoing treatment for MDR-TB, photographed outside his home near Churchandpur, Manipur.

52 indiaInternational Activity Report 2012

Supporting victims of conflict
In southern Chhattisgarh state, MSF
provides comprehensive basic healthcare
through weekly mobile clinics to peoplecaught in the long-running conflict between
the government and Maoist oppositiongroups. Patients requiring specialist careare referred to facilities in Andhra Pradesh.
In the town of Bijapur, MSF’s mother andchild health centre offers immunisations
and basic healthcare, and staff work withthe district hospital to perform emergency
obstetric surgery and diagnose TB.
In the disputed region of Kashmir, mental
healthcare continues to be the main
medical need. MSF staff focused services oncounselling in five urban areas, while basic
healthcare and mental health activities in therural areas of Kupwara district came to an end
in April. The team carried out two emergency
mental health programmes, offeringcounselling, after violence in Srinagar in 2012.
Researching better treatment
options in Bihar
Bihar state has one of the highest incidencesof kala azar (visceral leishmaniasis) in theworld. Kala azar is transmitted by infected
sandflies and without treatment it is almost
always fatal.

In Biraul subdistrict of Darbhanga, Bihar,
MSF has managed five feeding centres
since 2009. Negotiations with the state
government in 2012 will lead to the
expansion of MSF’s model for communitybased management of malnutrition
throughout Darbhanga in 2013: for the firsttime in India, treatment for children withsevere malnutrition will be integrated into
the state’s public health system, from thecommunity level and basic health facilities
up to the intensive care unit that MSF willbuild at the district hospital.

© Sami Siva

In 2007, MSF introduced liposomal
amphotericin B treatment to the kala azar
programme in Vaishali district, which
covers five health centres and Sadar district
hospital. This treatment is more effective
and more rapid than previous regimens,
but also more expensive. In August, theteam began a three-year project with thenot-for-profit research and development
organisation Drugs for Neglected Diseases
initiative (DNDi) to examine the safety andeffectiveness of more affordable treatment
options based on liposomal amphotericin B.
MSF helped Saliet, a patient receiving treatment for HIV and MDR-TB in Churchandpur,
Manipur, build a room of his own outside his brother’s home.

Gopal *
MumbaiI was working as a cook when I was first diagnosed with drug-resistant TB. The treatment
involved six months of injections every day. It was very difficult – every day there was pain.
After that I had to take 15 to 17 different tablets every day. I used to just stay at home.
It has been six months now since I finished my treatment. Now I am free of tension and I
want to earn money and live life properly. My family are happy because I’ve got my job
back and I’m able to support them.
* The patient’s name has been changed. Gopal is one of the patients featured in the article
on TB, pages 22 – 24.

No. staff end 2012: 733 | Year MSF first worked in the country: 1999 | msf.org/india

india 53

Médecins Sans Frontières

iran

Authorities in Iran have been improving social and medical
services in the capital Tehran, but many people living in thepoorest neighbourhoods remain unable to access them.
In April, Médecins Sans Frontières (MSF)
opened a health centre for women andchildren under five years of age in Darvazeh
Ghar, a district where many do not havethe identity papers they need to use thecountry’s healthcare system.
Social stigma is another obstacle toaccessing healthcare. Drug users, womenwith sexually transmitted diseases andnewborns who are suffering withdrawal
symptoms because their mothers were drug

users are often not welcome in medical
centres. Many are particularly susceptible toHIV, hepatitis C and tuberculosis, diseases
which pose a serious public health concern.
Since the health centre opened, staff havebeen seeing around 1,000 patients permonth. The team offers general medical
and gynaecological consultations, as well as
ante- and postnatal care. Patients requiring
emergency treatment are referred to the
Ministry of Health hospital.

TehranCities, towns or villages where MSF works

Key medical figures:• 12,970 outpatient consultations

No. staff end 2012: 84 | Year MSF first worked in the country: 1990 | msf.org/iranitaly
Bergamo
MILAN

ROME

TRAPANICALTANISSETTA
Cities, towns or villages where MSF works

Key medical figures:• 820 outpatient consultations• 28 patients began treatment for
Chagas disease

Screening and treating Chagas disease
Some migrants have been diagnosed with
Chagas, a parasitic disease transmitted by thebite of an insect most prevalent in Latin America
and almost unknown in Italy. MSF shared its
knowledge of the disease with the Ministry of
Health and other parties involved in migrant
health. In the northern city of Bergamo, in
collaboration with Verona hospital and Italianassociation OIKOS, MSF teams met with Latin
American migrants to screen for Chagas andarrange treatment. MSF is helping develop

standard procedures in Italy for the prevention,
detection and treatment of the disease.
Caring for the homeless in MilanIn December, MSF opened a programme
to provide medical care to homeless people
discharged from hospital, most of whom
have chronic diseases like diabetes andhypertension, and require follow-up. Somepatients were also suffering from conditions
exacerbated by the cold, such as bronchitis
and respiratory tract infections.

No. staff end 2012: 5 | Year MSF first worked in the country: 1999 | msf.org/italy

Gaps in healthcare persist for
migrants and asylum seekers
arriving in Italy.

In the centres in Caltanissetta, Milan, Romeand Trapani, Médecins Sans Frontières (MSF)
worked with the Ministry of Health, theMinistry of Foreign Affairs and private entities
managing the centres to improve the qualityof care. A mobile medical team advised andtrained medical personnel working at thecentres to detect and treat TB.

54 iran | italy© Halimatou Amadou/MSF

Migrants without papers are detained for up
to 18 months in Centres for Identificationand Expulsion. Health services, which havebeen subcontracted to private firms, lackcoordination. Tuberculosis (TB) and otherneglected diseases are poorly diagnosed
and treated, despite national protocols.

A woman takes a blood test for Chagas disease in Bergamo. Symptoms of the disease may
not show for years.

International Activity Report 2012

iraq
Domiz

KirkukHawijahfallujahbaghdad

Najaf

Cities, towns or villages where MSF works

Key medical figures:• 2 9,900 outpatient consultations• 4,530 surgical procedures• 16,810 individual and group mental healthconsultations

Activities in Iraq wereexpanded in 2012 to provide
assistance to Syrian refugees.
Tens of thousands of Syrians settled in thenorth of the country over the course of theyear. Since April, Médecins Sans Frontières(MSF) has been the main healthcare provider
in Domiz refugee camp. The team delivers
basic medical services and mental healthcare.

Emergencies are referred to the nearest
hospital. Staff also distribute relief items suchas hygiene kits, and ensure access to safe
water and adequate sanitation in the camp.
Emergency surgery in Hawijah
MSF’s surgical team continued to support the
emergency department of Hawijah general
hospital, keeping the operating theatre open
round the clock and performing more than
300 emergency procedures a month.

Kidney dialysis programme handed over
Having increased the capacity of Kirkuk
general hospital’s dialysis unit from
22 patients in 2010 to 100 in 2012, MSF
handed services over to the Ministry of
Health. During 2012, the surgical teamcarried out 26 operations on patientswith kidney disease. Staff also provided
training and worked with the hospital moregenerally to improve sterilisation, infection
control and pharmacy management.

Mental health services growing

New approaches in obstetric andneonatal care

Through its mental health services in
Baghdad and Fallujah hospitals, MSF aims
not only to provide care to people suffering
psychologically from violence and insecurity,
but also to reduce the stigma attached tomental health issues more broadly in society.
Some 3,800 people received treatment in
10,700 counselling sessions, and the Ministryof Health is rolling out services based on
the MSF model to other health facilities. In
addition, a telephone helpline has been set
up so that people can contact mental healthstaff more easily.

Half of all babies in Najaf governorate
are born in Al-Zahra hospital, the mainreferral centre for obstetrics, gynaecology
and paediatrics. The MSF team works
closely with hospital staff to build capacity,
offering bedside training to bring neonatal
mortality rates down. New infection control
measures are being implemented to reducethe incidence of sepsis – a severe response
to bacterial infection – which is a primarycause of death. Specialists in obstetrics andneonatology set up meetings to introduce
improved practices, and worked to build
partnerships between medical institutes.

© Michael Goldfarb/MSF

No. staff end 2012: 304 | Year MSF first worked in the country: 2003 | msf.org/iraq

A Syrian refugee speaks with a doctor about her child’s health at the clinic in Domiz camp.

iraq 55

Médecins Sans Frontières

kenya
Key medical figures:•3 35,900 outpatient consultations•1
 2,930 patients on first-line antiretroviraltreatment•1
 ,500 patients began TB treatment•3
 50 patients treated after incidents
of sexual violence

Healthcare needs are greatin Kenya’s urban slums andrefugee settlements, where poor
living conditions put people atincreased risk of contracting
communicable diseases.
Refugee camps and urban slums are
overcrowded and characterised by a lack ofbasic services such as water and sanitation.
Accessing healthcare is a challenge, particularly
for people with chronic or neglected diseases
such as HIV and tuberculosis (TB).
Healthcare in Dadaab
Located on a desert plain in northeastern
Kenya, Dadaab is the largest refugeecomplex in the world. The population,
mainly Somalis fleeing conflict and droughtin their country, is approaching half amillion. In addition to the original camps ofDagahaley, Hagadera and Ifo, there are two
new camps – Ifo extension and Kambios– which were set up to accommodate thegrowing numbers of refugees who started
to arrive in 2011. In December 2012,
the Kenyan government announced thecessation of refugee reception, registrationand documentation in urban centres in

DadaabKacheliba

Homa Bay
Nairobi
Ijara
Tana River
Regions where MSF has projects
Cities, towns or villages where MSF works

an effort to relocate refugees and asylum
seekers to the camps. Yet the camps are
ill-equipped to meet people’s basic needs.
Médecins Sans Frontières (MSF) has
been the sole provider of healthcare in
Dagahaley camp since 2009, working out
of a 200-bed hospital and at four healthcentres, where medical services include
vaccinations, antenatal consultations andmental healthcare. Staff carried out anaverage of 14,000 consultations and admitted
1,000 patients from the refugee and hostcommunities to the hospital each month.
High rates of acute malnutrition were recorded
in children over five years old in the camps in2012. MSF included children up to 10 years ofage in its feeding programme and lobbied forother healthcare providers to include this age
group in their annual nutritional surveys. Morethan 2,200 severely malnourished children
were admitted for inpatient treatment over theyear. There is also concern about the quality ofshelter and sanitation. Poor sanitation has led
to outbreaks of disease that otherwise could
have been controlled: in September, MSF
responded to hepatitis E and cholera outbreaks
in the camps. Both diseases are transmitted
mainly through contaminated water.
Since July 2012, following several security
incidents in which aid workers weretargeted, it has not been possible for MSF
international staff to work on a permanent
basis in Dadaab.
Response to violence in the Tana River area
Clashes between the two major communities
in the Tana River district, the Orma andthe Pokomo, caused dozens of casualties
and significant displacement in August and
September. MSF provided psychosocial
support to more than 900 people affected by
the violence, as well as medical and logisticalassistance to health facilities and in thecamps for displaced people.

© Andre Francois

HIV and TB

A laboratory test is used to diagnose TB and strains resistant to the primary TB drug,
rifampicin, at Kibera South health centre.

56 kenya

In Homa Bay, Nyanza province, MSF isproviding care to over 10,500 people livingwith HIV/AIDS. Roughly one in four of the
4,500 people tested in 2012 were foundto be HIV positive and more than 1,000
joined the HIV programme. An additional
345 patients were registered in the TB
programme.
In Nairobi, MSF continues to run the Blue
House clinic in the slum area of Mathare andthree clinics in Kibera. A new TB diagnostic
test introduced in 2011 has led to an increase© Andre Francois

International Activity Report 2012

Kizito (r), 49, started showing symptoms of diabetes in 2006 with frequent thirst and weight loss. By 2008 he weighed only 30 kg.
He now receives free, ongoing care at the medical clinic in Kibera.
in the number of people identified withdrug-sensitive and drug-resistant TB.
MSF provides a range of services in Kibera,
including HIV diagnosis and treatment,maternal and paediatric care, and treatment
for chronic diseases such as diabetes andhypertension. In 2012, cervical cancer
screening was introduced for women with
HIV. In total, the teams in Nairobi saw morethan 10,000 patients per month.
A large health centre incorporating a 24-hourmaternity unit was completed on the edgeof Kibera in 2012. It will be run jointly by
MSF and the Ministry of Health from the
beginning of 2013.
Sexual violence
Sexual violence is a major social and medical
issue in Mathare, and MSF has provided
medical care and psychological support
there since 2008. Each month, dozens ofpeople, more than half of them children,
come to the centre for help.
A new 24-hour sexual violence clinic was
opened on the outskirts of Kibera in 2012.
Each week it provides 20 to 30 victims ofrape with treatment to reduce the risk ofcontracting sexually transmitted infections,
psychological support and medical care.

Kala azar
Kala azar, a parasitic disease transmitted
by sandflies, is almost always fatal without
treatment. In 2012, 500 patients weretreated for kala azar in Kacheliba hospitalin West Pokot district, where MSF has run aprogramme since 2006, with a 98 per centcure rate. In December, the programme
was handed over to the Ministry of Health,which is implementing a national kala azar
control programme, supported by the
not-for-profit research and development
organisation the Drugs for Neglected Diseases
initiative (DNDi). Before the handover, MSF
trained health workers and raised awarenessof kala azar among the population througha photo exhibition in Pokot, Turkana, Merti,
Wajir and Habaswein.
Handover of Ijara programme
In October, a basic healthcare programmewith a focus on women and children in the
Ijara district of North Eastern province washanded over to the Ministry of Health andAtlantic Global Aid, a local organisation.
MSF provided reproductive healthcare andtreatment for 4,800 people in 2012, andoffered vaccinations and supported TB care.

Dickens
34 years old, is undergoing treatment for
HIV and multidrug-resistant TB (MDR-TB).
I discovered that I had TB in 2008, when
I was working in Tanzania. I wasn’t getting
better and in February 2010 I came backhome. I was put on first-line medication –three tablets. I started losing weight very
rapidly. It was scary. I weighed 58 kg, andwithin two weeks I dropped to 51. They
realised that I was probably resistant.
So they sent my sputum to Nairobi andthe result came back that I had MDR-TB.
I was referred to Homa Bay, and luckily
I got into the programme and started
treatment in October 2010.
I also have HIV. I take 19 tablets for MDR-TB
and four tablets for HIV every day. I’ve
not undergone many other treatments,
but I don’t think that there is any worse
than this. We [the patients] support eachother. It’s important, because sometimes
people feel like running away. When I got
here I was very weak, I could walk only
short distances. Now I weigh 60 kg, I am
walking, and I am already halfway
through treatment.

No. staff end 2012: 851 | Year MSF first worked in the country: 1987
msf.org/kenya

kenya 57

Médecins Sans Frontières

jordanJordan has become a placeof refuge for hundreds ofthousands of Syrians fleeing
conflict in their country.

offer them surgery. As a result, the numberof orthopaedic operations increased by77 per cent over 2011. There was also an
increase in Yemeni patients, with more than
100 admitted in 2012.

Médecins Sans Frontières (MSF) has been
operating a specialist surgical programme in
Amman for victims of conflict since 2006. The
programme was initially established to offer
surgery for severely injured Iraqis – adults
and children burned and wounded by bombsand explosions, many requiring reconstructive
and orthopaedic surgery they could not get intheir home country. With increased conflict in
the region, patients now come from Yemen,
Syria, Libya, Gaza and Egypt.

Expanding medical activities

From March, MSF visited transit camps
and health facilities, in an effort to identify
Syrian refugees in need of operations andMany Syrians are in need of medical careand mental health support. MSF opened
an outpatient department in Amman’s
Jordanian Red Crescent hospital compound.
Patients receive treatment for acute needs
and chronic conditions such as diabetes andhypertension. More than 350 medical andsurgical consultations were conducted monthly.
Physiotherapy has also been crucial for people
with conflict-related injuries that could not beproperly treated within Syria, and staff provide
psychosocial support to help people cope withsymptoms of mental health distress as well.

AMMAN

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

Key medical figures:• 16,330 outpatient consultations• 1,170 surgical procedures• 580 individual and group mental healthconsultations

To provide effective care, referrals for
additional expertise and services are
sometimes required. MSF has therefore
developed partnerships with Handicap
International, the Center for Victims of
Torture, the Jordan Health Aid Society, UN
agencies and specialist hospitals in Jordan.

MSF staff working in Jordan are accounted for through programmes in Iraq | Year MSF first worked in the country: 2006
msf.org/jordan

kyrgyzstan

Bishkek

Kyrgyzstan has one of the highest burdens of drug-resistanttuberculosis (DR-TB) in the world, but treatment is hard to obtain.

Severe budget constraints over past decades
have resulted in a deterioration of healthservices in general. DR-TB treatment takes
up to two years and often causes severe side
effects. It is expensive, and in Kyrgyzstan
it is prescribed selectively, according
to criteria set by the country’s DR-TB
Consilium, because of a chronic shortage ofdrugs. In October 2011, a further decreasein supply led to the suspension of theinitiation of DR-TB treatment.
Decentralised model of care for DR-TBIn February, Médecins Sans Frontières (MSF)
began offering comprehensive, free medicalcare for people with DR-TB and people coinfected with both HIV and TB in the districtof Kara Suu, Osh province. The rate of DR-TB
is particularly high in this region, as is thenumber of patients waiting for treatment.
The programme is a model for decentralisation:
staff screen for TB, DR-TB and HIV throughout
the district. Those who are diagnosed thenreceive the drugs and medical care they need,as well as psychosocial support to encourageadherence. Most people are treated as

outpatients and only the most seriously ill areadmitted to hospital. MSF helped renovate
the TB facilities in Kara Suu to improve
infection control.
High DR-TB prevalence in prisons
An MSF team is working across the capital
Bishkek’s detention system, screening inmatesfor TB. Those diagnosed with the disease
are referred to the TB centre for detainees,
where MSF provides treatment, counsellingand social support. The team also offers
nutritional support, and when patients are
released – some 30 per cent are released whilestill on treatment – makes sure they receive
psychosocial support and can continue
treatment in public medical facilities.
Infection control is vital to reducing TB
rates. MSF conducts awareness-raising
activities and advocates for improved
ventilation and living conditions, as well as
early detection of TB, among prisoners.
MSF also supports the national referencelaboratory with technical capacity, supplies
and staff supervision and training.

No. staff end 2012: 117 | Year MSF first worked in the country: 2005
msf.org/kyrgyzstan
58 jordan | kyrgyzstan

Osh province

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

Key medical figures:• 2 50 patients began TB treatment• 70 patients began DR-TB treatment

Mukhtar
44 years old
In February 2011, I felt bad, exhausted, had
fever, dizziness. After many tests the doctors
discovered TB. I was on treatment for six
months, then they told me to go to Bishkek
for treatment. I didn’t have the financial
means. Nobody was working at home;
we were living on my mother’s pension.
I had other tests, and was told that
I needed nine more months of treatment.
But there was no free place, so I was told
to go home.
One day someone told me about the
MSF project in Kara Suu. I decided to go.
On 29 June I was hospitalised. Before
hospitalisation I weighed 67 kg, but
in hospital I reached 82 kg. I did moretests and the results were very good.
On 14 September I moved to outpatient
treatment, and I have since gained
another 6 kg.

International Activity Report 2012lebanonWadi Khaled
TRIPOLICENTRAL &NORTH BEKAA

beirutSidon

treatment for chronic diseases and mental
health services. In April, a mental healthteam started work at Tripoli government
hospital, and in June MSF began to support
the hospital’s emergency department bytraining medical staff. Since November, MSF
has been offering basic health services forvulnerable people in the poorest and mostvolatile neighbourhoods of the city.

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

Key medical figures:•2
 2,640 outpatient consultations•2
 1,640 individual and group mental healthconsultations

Many of the 200,000 Syrians
who had sought refuge in
Lebanon by the end of 2012were unable to access thehealthcare they needed.
Some 63 per cent of unregistered refugees
had received no assistance whatsoever,according to the Médecins Sans Frontières(MSF) study Misery Beyond the War Zone,
conducted at the end of 2012.
The survey revealed a marked deteriorationin the humanitarian situation for refugees
and other displaced people in Lebanon, inlarge part due to very lengthy registration
delays. Refugees in Lebanon are not entitled
to formal assistance if they are not registeredor at least enrolled in the registration
process. Many live in overcrowded,
substandard structures and cannot afford
medical care. Local organisations andindividuals within the Lebanese community
have made a tremendous effort to help, butthey are reaching the limits of their capacity.

MSF had been running a mental healthprogramme in Wadi Khaled, but since many
refugees left the town and moved to Tripoli,
it was closed in September.
Assisting Palestinian refugees
Hundreds of thousands of Palestinian
refugees are living long-term in overcrowded
camps in Lebanon. Ein el-Hilweh, in Sidon(Saïda), is the most crowded, and the
population has grown with the arrival ofPalestinian refugees from Syria.
MSF provided mental health services in
two UN clinics and in Al-Nidaa Al-Insani
hospital. Since March, services have also
been available outside the Palestinian campin Sidon, in the Palestinian Red CrescentSociety hospital and in Sidon government
hospital, primarily to vulnerable Lebaneseand Palestinian refugees living in unofficial
gatherings outside the camp.
Mental health services at Burj el-Barajneh,in the suburbs of Beirut, which included
psychiatric and psychological care, werehanded over to the municipality and to theIslamic Health Society in December. Staff
had worked at the MSF community mental
health centre, the UN clinic, the Palestinian

Red Crescent hospital, and carried out
home visits since 2009. More than 17,500
consultations were held over four years.
MSF also coordinated a primary trauma carecourse for emergency doctors and nurses
throughout the country. More than 150 doctors
were trained in various regions.

Sami *
31-year-old Syrian man, Bekaa valley
We fled Syria under shelling, with only
the clothes we were wearing. My twonephews were both killed, and mysister-in-law was wounded.
We are now renting a flat in Baalbeck.
We have only a mat and a few mattresses.
It’s cold, we need fuel for heating, andwe don’t have money to pay the rent.
I cannot find work.
It is the first time I have come to the MSF
clinic. My wife is six months pregnant.
She is feeling some pain, but the doctor
has reassured us that everything is goingwell. He also examined my mother andgave her the drugs she needs for her
hypertension and ulcer.
My wife was refused a consultation at a local
clinic because we are not yet registeredas refugees. We were told to go to Al-Marj,
50 kilometres from Baalbeck. We are
10 people – can you imagine me taking
all of them so far for registration, in thecold, in their state of health?
*The man’s name has been changed.

The situation worsened in July, when the
Lebanese government announced that alack of funds was forcing it to stop financing
refugees’ medical care.
Assisting refugees in the Bekaa valley© Michael Goldfarb/MSF

MSF offered basic healthcare and mental
health services in the north and east of thecountry. Teams worked at six health facilities
in the Bekaa valley. In November, as needs
grew and winter loomed, MSF distributed
blankets and heating fuel as well as hygieneand cooking kits, and baby milk and nappies
to thousands of refugees in the Bekaa valley.
In Aarsal, staff provided mental healthsupport until the end of December.
Expanding activities in Tripoli
An MSF team began working in Tripoli in
February. Staff at Dar Al-Zahra hospitalprovided basic healthcare, as well as

An elderly Syrian man with Parkinson’s disease lives with 19 family members in two rooms
in Tripoli, Lebanon.

No. staff end 2012: 81 | Year MSF first worked in the country: 1976 | msf.org/lebanon
lebanon 59

Médecins Sans Frontières© Andre Francois

lesotho

When a blizzard closed roads, and people could not travel to Semonkong, MSF staff delivered antiretroviral drugs to patients in their villages.

Roma

Semonkong

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

Key medical figures:•2
 3,030 people tested for HIV•1 ,050 patients on first-line antiretroviraltreatment•1
 ,100 births assisted

More than half of all maternal,
infant and under-five deaths inLesotho can be attributed to HIV.
It is not only HIV treatment that is hard toaccess, but healthcare in general. Only asmall number of the health facilities in the
country are adequately staffed.

To address the huge gaps in access to
medical care, Médecins Sans Frontières(MSF) runs a programme focused onmaternal and child health, integrating
HIV and TB care at the same clinics.
Capacity has been increased through thedecentralisation of medical services to more
health facilities and the shifting of some
responsibilities from doctors to nurses.
MSF provides support to St Joseph’s district
hospital in Roma, six health clinics in thelowlands and three clinics in the remote
Semonkong area, where an ambulance
was supplied to transport patients to St
Joseph’s in emergencies. MSF also trained
counsellors and village health workers, who
help link patients to the services they need.
Lobbying for counsellors
In 2012, withdrawal and delays in funding
from international organisations, including
the Global Fund to Fight AIDS, Tuberculosis
and Malaria, resulted in a decrease in thenumbers of lay counsellors at facilities.
Counsellors are trained to provide one-to-one
support through HIV and TB testing and tohelp ensure patients adhere to treatment.

No. staff end 2012: 28 | Year MSF first worked in the country: 2006 | msf.org/lesotho

60 lesotho

They perform a critical role: without them,
the workload for nurses increases andpatient care is compromised. MSF lobbied
strongly to ensure funding for counsellors
and began working on a longer-term
solution with the Ministry of Health andother partners.
Faster access to second-line treatment
An HIV patient’s CD4 count is measured todetermine when to initiate antiretroviral(ARV) treatment. The viral load of HIV –the amount of the virus in the blood – ismeasured to ascertain whether first-line ARV
treatment has failed. If it has, the patientneeds to be switched to a second-line drug
regimen. In Lesotho, viral load tests had
to be carried out abroad, and switching tosecond-line treatment required approval bycommittee at the Ministry of Health. The
time taken by this process often meant thepatient died before approval was obtained.
In 2012, MSF received a grant from thefinancing initiative UNITAID to develop
and implement viral load testing, as wellas point-of-care CD4 testing, in eight HIV
programmes in Africa, including Lesotho.

International Activity Report 2012liberia
Monrovia

Cities, towns or villages where MSF works

Key medical figures:•6
 40 patients treated after incidents
of sexual violence

After more than two decades in Liberia, in 2012 Médecins
Sans Frontières (MSF) handed over the last of its programmes
to the Ministry of Health.
The final programme provided treatment
and counselling for victims of sexual violencein Monrovia. Since this project began in
2010, major emphasis was placed on training
Ministry of Health staff to carry out services.
Between January and July, 644 patients
received treatment: 12 per cent of themwere under four years of age, 38 per centwere aged between five and 12 years and41 per cent between 13 and 18 years.
Only nine per cent were adults. After agradual handover of responsibilities,
MSF withdrew in July.

MSF ran emergency operations in responseto the 14 years of civil conflict that raged
until 2004. Teams also provided emergency
healthcare for refugees from conflicts inneighbouring countries and improved accessto health services more generally throughthe set-up and management of hospitalprojects in the capital Monrovia, as well as inremote areas. As the emergency phase has
passed, one by one these projects have been
handed over to the Ministry of Health or toorganisations that can take the work forwardwith a long-term development approach.

No. staff end 2012: 11 | Year MSF first worked in the country: 1990 | msf.org/liberia

libya
Tripoli

Misrata© Sebastien Van Malleghem

Cities, towns or villages where MSF works

Key medical figures:•4
 30 individual and group mental healthconsultations

In 2012, the people of Libya
were still suffering the effectsof the violent conflict of theprevious year.

About 2,500 people from Tawergha, a pro-Gaddafi stronghold during the Libyan civil war,
live at the Janzour Marine Academy displacement camp.

A Médecins Sans Frontières (MSF) team began
medical activities in detention centres in thecity of Misrata in August 2011. Staff treated
war wounds, carried out surgery and provided
follow-up care such as physiotherapy.

Mental health support for residents of
Misrata continued until March. More than
150 group counselling sessions were held toassist people’s recovery from the conflict.

However, doctors had been increasingly
confronted with patients whose injuries
had been caused by torture. After reporting
115 such cases, and with no concrete response
from the authorities, in January MSF took thedecision to suspend activities in the centres.

As the conflict in Libya came to an end,
particular groups faced persecution.
Gaddafi had recruited mercenaries from
sub-Saharan Africa, and Tawergha had
been used as a base for Gaddafi’s forces.
Sub-Saharan Africans and members of theAssisting the displaced in Tripoli

Tawergha ethnic minority began to seek
refuge in camps in the capital Tripoli. MSF
carried out basic health services and offeredmental health support via mobile clinics inthe camps until August.
MSF is negotiating with the new authorities
to provide assistance in mental healthcare andhelp fill other gaps in health services in 2013.

No. staff end 2012: 23 | Year MSF first worked in the country: 2011 | msf.org/libya

liberia | libya 61

Médecins Sans Frontières

malawi

HIV/AIDS is the main cause of death among young adults in
Malawi – those who should normally be the most productive
age group in the country – according to national surveys.

Chikhwawa

Chiradzulu
ThyoloNsanjeRegions where MSF has projects

Key medical figures:• 67,520 patients on first-line antiretroviraltreatment• 2,640 women enrolled on PMTCT treatment

Médecins Sans Frontières (MSF) has been
adopting a range of approaches to improveaccess to treatment for people with thedisease and one programme has expanded,
while another is on track for handover tothe Ministry of Health.
Patient numbers increasing in Chiradzulu

Such large numbers mean models of caremust be simplified, but without sacrificing
quality. Some tasks have been transferredfrom doctors to nurses, so that services canbe decentralised to health centres. At the
10 centres where MSF works, teams offer
antenatal care to pregnant women, including
PMTCT, counselling and also integrated carefor people co-infected with tuberculosis (TB),
so that patients can obtain all their treatment
at one facility. Furthermore, people whoare in a stable condition need only attend
appointments every six months: this has
reduced the burden on both the patientsand medical staff.
Preparing for handover in Thyolo
Around 48,000 patients have begun ARVtreatment at the HIV programme in Thyolo
during its 15-year history. All 24 sites in the
district currently offer comprehensive HIV
care, including PMTCT option B+, which puts
pregnant women with HIV on lifelong ARVtreatment. The objective now is to hand overall basic services to the Ministry of Health by
the end of 2013 so that MSF can focus moreon technical support in specialist areas such as
diagnostics, including early infant diagnosis,
and integrated HIV and TB care.

© Miguel Cuenca/MSF

Antiretroviral (ARV) treatment was introducedin the HIV programme in Chiradzulu in 2001.
Implementation of the recommendations forcare that the World Health Organization set
out in 2009, including starting ARV treatment
earlier, has meant that the number of patientshas grown: in 2012, MSF had about 33,860
HIV patients, 80 per cent of whom were on
ARV treatment. Some 2,600 pregnant women
received prevention of mother-to-childtransmission (PMTCT) services.

At the World AIDS Day parade in Thyolo, a girl holds a sign saying ‘If you get tested for
HIV you will benefit from ARVs’.
With MSF’s support, 30 students were enrolled
in the Malamulo scholarship programme,
which trains young people from rural areas inhealth professions, on the condition that when
they qualify they return to work in rural
areas of Thyolo district for five years.
Supporting HIV care in Nsanje
and Chikhwawa
An MSF team has been supporting an
innovative nationwide mentoring programmein Nsanje and Chikhwawa. Mentoring staff asthey implement new clinical guidelines should
help improve patient care. MSF also assisted in
infection control and pharmacy management.

No. staff end 2012: 770 | Year MSF first worked in the country: 1986 | msf.org/malawi
62 malawi

Kingston
25 years old and studying for a diploma innursing and midwifery, sponsored by MSF.
When I was 15, my sister fell sick and
we took her to Thekerani hospital. The
queue was long and there was only one
clinician. We arrived at 7 am and mysister died right there in the queue at
2 pm. It was very difficult to understand.
The death of my sister was due to theshortage of healthcare workers, andI decided to become one.

International Activity Report 2012

mali
Kidal
Timbuktu
MOPTI

gao
Koutiala

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

Conflict erupted in thenorth of Mali in January.
Security forces fought Tuareg
opponents, who were later
supported by Islamist groups.
In March, a coup d’état took
place in the capital Bamako.
By April the country had virtually split
into two, with Tuareg and Islamist groups
controlling the north and an interim
government in the south. At the end of
2012, the UN estimated that 340,000
people had been displaced, while some
145,000 people, including many healthworkers, sought refuge in neighbouring
countries. Access to healthcare, alreadyprecarious due to lack of resources andinfrastructure, was reduced further.
Healthcare in conflict zones
Médecins Sans Frontières (MSF) beganproviding basic medical services at threehealth posts in remote areas of Kidal
region. An MSF team then progressively
took over the 65-bed Timbuktu hospital:
emergency department, paediatric ward,
general medicine, surgery, maternity
services, pharmacy and laboratory. Staff
also supported 10 health centres in the
Timbuktu region, carrying out a total of
50,000 medical consultations.
In Gao region, east of Timbuktu, MSF
provided basic services at two health centres
from September. Staff conducted some
65 consultations each day and ran mobile
clinics in rural areas. A team also took overthe management of a 40-bed hospital in
Ansongo, south of the city of Gao.

© Simon Rolin/MSF

Key medical figures:• 150,370 outpatient consultations• 57,960 people treated for malaria• 11,250 patients treated for severe malnutrition• 410 surgical procedures

A boy receives antimalarial medicine as part of a new malaria prevention strategy in Koutiala.

At the end of October, MSF begansupporting the referral hospital and a healthcentre in Douentza, central Mali, providing
outpatient, inpatient and maternity careand surgery, and conducting around 500
consultations each week.

referrals for medical consultations. All
children aged six months to two years
received supplementary food to prevent
malnutrition, mosquito nets to prevent
malaria, and routine vaccinations, withfollow-up consultations.

Teams also assisted Malian refugees in theneighbouring countries of Burkina Faso,
Mauritania and Niger.

New malaria prevention campaign

Medical care for children in the south
Mali lies in the Sahel region of Africa, wherechildren suffer from seasonal malnutrition
as families’ food stocks run out and prices
rise. In Mopti region, MSF started working
at four outpatient and two inpatienttherapeutic feeding centres in June,
treating hundreds of children.
Staff continued to provide nutritional
support and paediatric care at Koutiala
hospital, Sikasso region. More than 4,800
children, most of whom had malaria, weretreated at the hospital, and 4,400 withmalnutrition were admitted to the inpatient
feeding centre. Another 3,000 were treatedat six outpatient feeding centres.

Between August and October, MSF ran
a seasonal malaria chemoprevention
campaign newly recommended by theWorld Health Organization, reaching morethan 165,000 children in Koutiala district.
Children took antimalarial medicine once
per month for three months during themalaria season, with encouraging results:
a 66.5 per cent reduction in consultations
for simple malaria within the first weeks of
distribution, and a 70 per cent reduction inchildren hospitalised with severe malaria.

MSF supported four outlying health centresin the region with staff, supervision,
drugs and logistics. A complete packageof preventive and curative care wasprovided for children at a fifth healthcentre in Konseguela. More than80,000 consultations were conductedin the five centres. Community healthworkers in 19 surrounding villages also
detected and treated malaria, and madeNo. staff end 2012: 496 | Year MSF first worked in the country: 1992 | msf.org/mali

mali 63Médecins Sans Frontières

mauritania
BraknaAssabaHodh Ech Chargui

Regions where MSF has projects

Key medical figures:• 91,860 outpatient consultations• 7,350 patients treated for severe malnutrition• 836 births assisted

Tens of thousands of refugees
arrived in Mauritania’s Mbera
camp in 2012, escaping
conflict in northern Mali.

Refugees must all enter through the villageof Fassala, where they are registered before
being transferred to Mbera, in the region of
Hodh Ech Chargui. Conditions in the campare poor and the assistance provided has
not met people’s basic needs consistently.

In the confines of the camp, an outbreakof measles among children suffering frommalnutrition could be devastating, so protecting
them against the disease is a priority.
MSF therefore carried out a vaccination
campaign, reaching thousands of children.

In late February, soon after the first refugees
began to arrive, Médecins Sans Frontières(MSF) set up medical and nutritional
activities in the area of Bassikounou. A teamprovided free basic and specialist healthcare,including antenatal care, for refugees andthe local community. Medical teams ran two
health posts in Mbera camp and supported
two health centres: one in Mbera village andone at the border post of Fassala.

Staff carried out more than 60,000
consultations, assisted 200 births
and treated some 3,880 severely
malnourished children at the camp.

In November, an MSF nutritional andretrospective mortality survey in Mbera
camp showed that nearly 17 per cent ofchildren were malnourished, and 4.6 percent were suffering from the most severe
form of malnutrition.

Nutrition programmes
A particularly severe nutritional crisis was
expected in the south of the country
in 2012, and in April MSF teams begansupporting both outpatient and inpatient
feeding programmes in Boghé and Magtaa
Lahjar districts of Brakna region, andin Assaba region. Needs in Brakna andAssaba turned out to be less extreme
than anticipated, and staff were able toclose programmes in the two regions in
September and December, respectively.

© Lynsey Addario/VII

No. staff end 2012: 198 | Year MSF first worked in the country: 1994
msf.org/mauritania

In July, 1,200 Malian refugees arrived at the border town of Fassala in just one day.

64 mauritania

International Activity Report 2012

madagascar
Amid political uncertainty and financial difficulties, thenational health budget in Madagascar was halved in 2012,
exacerbating gaps in healthcare.
In the remote Androy region, up to 180,000
people have difficulty accessing medical carebecause of the distance to the nearest hospital.
In 2011, Médecins Sans Frontières (MSF) began
working with the Ministry of Health to improveand expand medical services.
Basic medical care and maternal and childhealth services are supported through a
programme at the hospital in the townof Bekily. MSF has assisted renovations,delivery of medical supplies and staff
training, and has increased hospital capacityfrom 20 to 38 beds. The team also provides
clinical care for adults and children andconducts joint consultations with Ministryof Health staff in three health centres.

The number of women attending antenatal
services has increased fivefold since June, thanks
in part to activities to improve awareness of theimportance of medical care during pregnancy.
Approximately 500 women now visit thehospital each month for antenatal care andteams assist more than 50 births per month.

BekilyRegions where MSF has projects

Key medical figures:• 4,860 outpatient consultations• 1,610 patients admitted to hospital• 610 births assisted

Treatment for schistosomiasis
Schistosomiasis, a curable disease caused byparasitic worms, is endemic in Madagascar.
People become infected through contact
with contaminated water when bathing or
swimming. Left untreated, the parasite caneventually damage internal organs suchas the spleen and liver. MSF treated429 patients for schistosomiasis in 2012.

No. staff end 2012: 75 | Year MSF first worked in the country: 1987 | msf.org/madagascar

mexicoMigrants travelling through Mexico on their way to the UnitedStates are exposed to serious risks and dangers to their health.
Many migrants enter Mexico from
Guatemala and Belize. From there, theyembark on a perilous rail journey, during
which they are at significant risk of assault,
kidnapping, rape or murder.

Migrants are rarely able to seek healthcare,so MSF has pursued a ‘proactive’ searchfor patients, especially among vulnerable
groups: women, children, unaccompanied
minors, and victims of violence, kidnappingand human trafficking.

Aiming to fill the gaps in medical services
and mental health support and improveconditions, Médecins Sans Frontières (MSF)
launched a new programme in the southern
Mexican states of Oaxaca (at Ixtepec) inFebruary and Chiapas (at Arriaga) in June.

Teams see patients with conditions related
to their journey: respiratory infections,skin diseases, dehydration, gastrointestinal
disorders, and the physical and mental
consequences of violence and sexual violence.

Early on, the teams made improvements towater and sanitation facilities and kitchens,
so that living conditions in migrant shelters
were raised to acceptable health standards.
Facilities for the provision of medical andpsychological services were also constructed.

Spike in needs in Lechería
A total of 1,200 migrants passed throughthe local shelter in Lechería, Mexico state,during the first week of June – where only
70 people are normally accommodated.
MSF provided healthcare and worked to
improve living conditions. Conflict with

Lechería
Arriaga
Ixtepec
Cities, towns or villages where MSF works

Key medical figures:• 7,680 outpatient consultations• 1,040 individual and group mental healthconsultations

local residents forced closure of the shelterin July and the migrants moved to makeshift
camps. Government agencies then offered
basic healthcare and MSF teams focusedon more complex health issues. MSF teams
also distributed more than 6,500 hygienekits, took care of water and sanitation andimproved the electricity system in the camp.

No. staff end 2012: 31 | Year MSF first worked in the country: 1985 | msf.org/mexico

madagascar | mexico 65

Médecins Sans Frontières

morocco

Rabat

There was an increase in violence against sub-Saharanmigrants in Morocco in 2012, with Moroccan security forces
making daily raids in the cities of Oujda and Nador.
As it has become increasingly difficult toreach Europe, Morocco has become the finaldestination for many sub-Saharan Africans.
Without permission to work or access tobasic social services, they are forced to livein unstable and insecure conditions.
Access to basic healthcare is granted by law,however, and more migrants are getting
medical care in Oujda, although the situationin Nador is less positive. Médecins Sans
Frontières (MSF) teams in both cities helped
2,300 migrants access services in 2012.
Increased violence by Moroccan and Spanish
security forces also led MSF to resume direct
medical consultations. Staff treated
1,100 people for violence-related injuries.
In Nador, near the Spanish territory of
Melilla, MSF ran monthly mobile clinics
throughout 2012, after a year of being

denied access to the city. The team also
distributed relief items, including hygienekits, blankets, plastic sheeting and clothing,
to migrants living in forests on the outskirtsof Nador and Oujda.
Activities in Nador were handed over to the
Migration Division of the Archbishopric of
Tangier at the end of the year.
Assisting victims of sexual violence
Migrants in Morocco have experienced
alarming levels of sexual violence. MSF
works with a local association, Fondation
Orient Occident, assisting victims. Morethan 60 people received medical assistanceat the centre in Oujda.
In the capital city of Rabat, MSF completed
the handover of its programme to treat
victims of sexual violence to the Association
de Lutte contre le SIDA.

Nador

Oujda

Cities, towns or villages where MSF works

Key medical figures:• 6 ,010 outpatient consultations• 330 patients treated after incidents
of sexual violence• 4,630 relief kits distributed

Sidy *
22 years old, from Mali, is living in
Oujda forest
They hit me with batons. I wanted to run,but they hit me and I fell down. They
started hitting me again. I tried to protect
my head and they broke my arms.
I’ve tried to cross [into Melilla] 10 times.
I’ve been beaten three times, but thistime it was very serious.
*

The man’s name has been changed.

© Anna Surinyach

No. staff end 2012: 35 | Year MSF first worked in the country: 1997 | msf.org/morocco

Migrants in Morocco have difficulties meeting their essential needs: shelter, food and water.

66 moroccoInternational Activity Report 2012

© Andre Francois

mozambique

An ARV treatment group meeting in Maputo. Peer groups provide social support and help people adhere to their drug regimens.

There has been progress in Mozambique’s response to HIV
over recent years, but still only 45 per cent of patients whoneed antiretroviral (ARV) treatment have access to it.

Tete
MaputoRegions where MSF has projects
Cities, towns or villages where MSF works

Key medical figures:•3
 9,300 patients on first-line antiretroviraltreatment

All three Médecins Sans Frontières (MSF)
programmes in Mozambique provide HIV
care. The teams are beginning to focus on
the integration and simplification of care for
specific groups of patients like children andadolescents, and gradually handing over
responsibility for first-line ARV treatment in
the Chamanculo and Mavalane districts ofthe capital Maputo to the Ministry of Health.

At the Primeiro de Maio health centre in
Mavalane, children and adolescents canaccess tailor-made services, and pregnant
women with HIV and people co-infectedwith HIV and tuberculosis (TB) can obtainall the medical attention they need at one
point. Patients with complex conditions
are referred to specialist services.
MSF is working with the Ministry of Healthat one of these specialist facilities in
Chamanculo, the Centro de Referencia deAlto Mae (CRAM). Here, patients sufferingfrom the cancer Kaposi’s sarcoma (anopportunistic infection of advanced stageHIV) and those in need of second- or
third-line treatment receive care.
In Tete, MSF is helping local health staff topromote community and patient involvement
in HIV treatment. Patients get together tooffer mutual support and take turns to pickup drug refills from the health centre, andstaff engage the community in improving thedetection, diagnosis and treatment of TB.

Ivanilda
15 years old
My mother and brothers are HIV
negative, but I have been living with HIV
for five years. I was sick a few years ago,and had many blood transfusions in thehospital. My mother believes that thesetransfusions are the cause of my infection.
Because my health was not showing
any improvement, my mother decided
to accompany me to take an HIV test.
I started ARV treatment in 2007. Now I go
to the health facility on my own. The ARV
drugs are my daily bread. If I do not takethem, I feel bad.
I have always had the support of mymother and uncle. Both know about
my HIV status, but they have neverdiscriminated against me. I also findrefuge and support at teenagers’ monthly
meetings. In these meetings I see that
HIV is not only my problem, but also
the problem of many children my age.

No. staff end 2012: 410 | Year MSF first worked in the country: 1984 | msf.org/mozambique

mozambique 67

Médecins Sans Frontières

myanmarKachinShan

In June, deadly intercommunal clashes in Rakhine state,
Myanmar, triggered an official state of emergency.
An estimated 75,000 people were displaced
and many houses were burned down.
Another outbreak of violence in Octoberworsened the crisis, forcing 40,000 more
people from their homes. Many ended up
living in makeshift camps without sufficient
shelter, sanitation, food or healthcare.
Emergency teams from Médecins Sans
Frontières (MSF) were able to provide basic
medical care in 15 of the largest camps. They
treated people suffering from skin infections,worms, chronic coughs and diarrhoea,
and made sure those with life-threatening
conditions were referred to hospitals.
MSF has long experience – nearly 20 years –of working in remote and neglected Rakhine
state, offering basic and maternal healthcare
and treatment for HIV and tuberculosis (TB).
Malaria is endemic in the region and teams
have treated hundreds of thousands ofpeople from all ethnic groups, including the
Rakhine community and the Muslim minority
population known as the Rohingya.
Insecurity, delayed authorisation and repeatedthreats and intimidation by a small and

RakhineYangonvocal group of the Rakhine community havehindered MSF’s work in 2012. With accesscurtailed, MSF was able to treat only 50,000
people between June and December, manyof whom were living in camps in Maung
Daw, Sittwe and Pauk Taw townships. Many
thousands more suffered without being able
to obtain the treatment they urgently needed.

Tanintharyi

Regions where MSF has projects

Key medical figures:• 4 06,800 outpatient consultations• 32,220 patients treated for malaria• 27,530 patients on first-line antiretroviraltreatment

Treating HIV and tuberculosis
Despite efforts to increase the healthcare
budget, thousands of people throughout
Myanmar have no access to medical
services. Coverage for antiretroviral (ARV)
treatment for people with HIV is very low:barely one in three of those needing it
receives it. MSF, the leading provider of
ARV medication in the country, has to makedifficult choices about whom to treat.

The number of patients with drug-resistant
TB (DR-TB), which is harder to diagnose andrequires two years of arduous treatment, isgrowing at an alarming rate. An estimated9,300 people contract DR-TB in Myanmar
each year, but only a few hundred havereceived treatment. In 2012, in a pilot
programme in conjunction with the Ministryof Health, MSF enrolled 82 DR-TB patients.

People with HIV are more likely than thegeneral population to have active TB.
MSF runs HIV and TB programmes in thecapital Yangon, in Kachin and Shan statesand in Tanintharyi region. There is also a
programme at Insein prison, Yangon, where
160 patients started ARV treatment and
79 started TB treatment in 2012.

In February, MSF released the report Livesin the Balance. It highlighted the devastating
impact that cancellation of Round 11 funding
from the Global Fund to Fight AIDS,
Tuberculosis and Malaria would have on
the efforts to scale up the provision oftreatment to people with HIV and TB
in Myanmar.

© Kaung Htet

No. staff end 2012: 1,247 | Year MSF first worked in the country: 1992 | msf.org/myanmar

A doctor examines a child suffering from diarrhoea at an MSF clinic in a refugee camp, Pauk Taw township, Rakhine state.
68 myanmar

International Activity Report 2012

© Isabelle Merny/MSF

Occupied Palestinian
Territory

A three-year-old boy awaits a pre-op consultation in the specialist reconstructive surgery programme in Khan Yunis.

Gaza STRIP

East
Jerusalem
HebronRegions where MSF has projects
Cities, towns or villages where MSF works

Key medical figures:•2
 ,530 outpatient consultations•6
 ,740 individual and group mental healthconsultations

Exposure to violence resulting from intraPalestinian and Israeli–Palestinian conflicthas medical, psychological and social
consequences, but people have difficulty
accessing the care they need. Médecins Sans
Frontières (MSF) programmes aim to address
the gaps in the Palestinian health system.

The Israeli embargo, the financial crisis and the chronic lack ofcooperation between Palestinian authorities have all contributed
to a deterioration in the public health system in Occupied
Palestinian Territory.
Surgery in GazaIn the city of Khan Yunis, MSF surgicalteams make regular visits to Nasser hospitalto carry out specialist procedures not
usually available to people living in Gaza.
Most patients are children with burns.
The post-operative care programme, set
up to reduce the level of disability after
injury, focuses on wound dressing andphysiotherapy. In 2012 the team began
to offer specialist hand rehabilitation, andprovided training in cardiac physiotherapy.
Emergency response to operation‘Pillar of Defence’
MSF’s post-operative care clinic remained
open throughout Israel’s military operationin November. The mobile field hospital

within the Nasser hospital compound
was converted to receive the injured andconduct minor surgery, and an emergency
medical team was sent to Gaza. Drugs
and medical supplies were donated to thecentral pharmacy, and medical kits to treat
the wounded were distributed to hospitals.
Mental health support
In Nablus, Hebron, MSF offers medical,
psychological and social support to people
affected by conflict. In 2012, the numberof psychological consultations increased by
50 per cent. In East Jerusalem, where MSF
provides psychological and social services,patient numbers tripled, and almost halfof patients were under 18 years of age.
Anxiety-related conditions, depression,
behavioural issues and post-traumaticstress were all common.

No. staff end 2012: 96 | Year MSF first worked in the country: 1989 | msf.org/opt

Occupied Palestinian Territory 69

Médecins Sans Frontières

niger
Key medical figures:• 878,000 outpatient consultations• 324,100 patients treated for malaria• 8 4,950 patients treated for severe malnutrition
AgadezIncluding prevention andtreatment of malnutrition aspart of basic health services
in Niger will allow many lives
to be saved.
Food insecurity and nutrition crises area chronic problem in Niger, but childmortality was reduced by 45 per centbetween 1998 and 2009, according to a
study in the Lancet. Health authorities haveshown the will to make changes. They haverecruited more medical personnel, andmeasures such as the decentralisation ofnutrition programmes and the provision of
supplementary treatment to prevent thoseat risk of developing severe malnutrition
have brought improvements.

ZinderTillabéri

MaradiRegions where MSF has projects

free services for children under five andpregnant women formally introduced five
years ago have yet to be made available.
Médecins Sans Frontières (MSF) activities
in Niger are mainly aimed at improving
healthcare for children under five andpregnant women, focusing on early
treatment and prevention, particularly of
malnutrition. Teams in the regions of Zinder,
Maradi and Tahoua run outpatient feeding

programmes in some 38 health centres.
Patients in need of hospitalisation are cared
for at inpatient feeding centres in Zinder,
Magaria, Madarounfa, Dakoro, Guidan
Roumdji, Madoua and Bouza hospitals.
The staff in Zinder and Magaria are in theprocess of handing over activities to the
Ministry of Health, and in 2013 expect
to provide support only during the peakseason for malnutrition.

© Juan-Carlos Tomasi

However, malnutrition rates remain high,with overall levels close to the World HealthOrganization’s emergency threshold in
2012. There are still chronic shortagesof drugs and medical supplies, and the

TahouaEach year, hundreds of thousands of children suffer from severe malnutrition in Niger. MSF runs outpatient feeding centres at some 38 locations.
70 nigerInternational Activity Report 2012

MSF handed over the inpatient feeding
centre it built at Dakoro hospital in Maradi
to the Ministry of Health, while the feeding
programme at the centre and at eight otheroutpatient centres have been handed overto the organisation ALIMA/BEFEN. MSF willcontinue to provide paediatric and maternalcare – including obstetric surgery – at
Dakoro hospital, where the team assisted
13,200 births in 2012. Paediatric services
also continued at the other hospitals, andMSF still supports maternity services, as wellas laboratory and sterilisation departments
at several of them.
Alarming rise in malaria
An extremely high incidence of malaria
was reported in nearly all regions in 2012.
Malnutrition and malaria peak at the sametime of year (July – September) and createa vicious cycle in children: malnutrition
weakens the immune system, while malaria
causes anaemia, diarrhoea and vomiting,aggravating malnutrition.
Guidan Roumdji’s intensive care andpaediatric units, in Maradi, were
overwhelmed, with an occupancy rate of
200 per cent in July. Dedicated units to treat
severe malaria were set up in Dan Issa andMadarounfa, Maradi region and Madoua,
Tahoua region. In Madarounfa, MSF worked
with local organisation FORSANI, focusing
on treatment for children under five.

© Tanya Bindra

When cholera struck Tahoua, the team set
up treatment units in Galmi, Koumassa andMadoua, and treated 350 patients.
Improving health closer to home
The positive results of moving healthcare
closer to people’s homes can be seen not
only in the outpatient feeding centres but
also in the community health programmesthat MSF runs in Niger.
When children in remote villages catch
malaria, they often arrive for treatment toolate, owing to a lack of access to adequate
healthcare in their villages.
In Madarounfa and Madoua, MSF implemented
a new strategy to improve early diagnosis andtreatment of malaria for children and pregnant
women: staff now provide diagnosis andtreatment in rural villages.
In Zinder region, community health workers
have been recruited to promote practices
that will help reduce child mortality,
such as improving hygiene, carrying out
vaccinations and encouraging people tovisit clinics. In village ‘health huts’, healthworkers screen and treat children formalnutrition, and diagnose and provide

A mother and her child peek into the health centre as they wait in line for their medical
consultation, Guidan Roumdji, Maradi region.
treatment for the three main childhood
killers: respiratory infections, diarrhoea andmalaria. Patients in a more serious condition
are referred to a health centre.
Assisting Malian refugees
Violence in Mali drove thousands of people
across the border to Niger’s Tillabéri region
over the course of the year. MSF provided
basic and specialist healthcare for the
refugees and the host population, including
vaccinations, maternal care and referrals.
Staff carried out more than 334,000
outpatient consultations, admitted nearly
19,000 people to hospital and vaccinatedover 22,000 children against measles. Whencholera broke out, teams set up treatment

centres and rehydration points, and treated
2,730 patients for the disease.
In August, MSF donated basic relief kits topeople affected by flooding in the region’s
Ouallam department.
Closure of programme in Agadez
Agadez is located on one of the main
migration routes from sub-Saharan Africa
to the north. MSF has been providing
maternal and paediatric services in Dirkou
and at eight health centres in rural areas
for migrants and local communities who
have difficulty accessing healthcare. The
programme was closed at the end of 2012as MSF focused its activities on the wider
humanitarian needs in the country.

No. staff end 2012: 1,593 | Year MSF first worked in the country: 1985 | msf.org/niger
niger 71

Médecins Sans Frontières

nigeria
Insecurity in northern Nigeria
is growing, and with it comesthe likelihood of increased
violence, displacement anddeteriorating health services.
Health services are already inadequate inthis region. The response to outbreaks of
disease is insufficient, nutritional crises are
frequent, and many women continue togive birth without any medical assistance.
In Jigawa state, Médecins Sans Frontières(MSF) has been providing obstetric services
at Jahun hospital since 2008, and close to
6,800 women gave birth there in 2012.
Another 284 women underwent fistula
repair surgery. Obstetric fistulas are injuries
to the birth canal, and are most often aresult of prolonged, obstructed labour.
They cause incontinence, which can leadto stigma and social exclusion.

SokotoJigawa

Kebbi
Niger

TarabaLagos
RiversRegions where MSF has projects
Cities, towns or villages where MSF works

Key medical figures:• 145,100 outpatient consultations• 6 ,780 births assisted• 4,470 surgical procedures

70,000 paediatric consultations and 28,500
antenatal consultations over the year.

Villages destroyed by flooding

The emergency team covering thenorthwest of the country responded tooutbreaks of malaria, measles and cholera,treating tens of thousands of patients.

Heavy rains, and the opening of the damon Lake Lagdo in neighbouring Cameroon,
led to major flooding in eastern Nigeria in
August. MSF set up mobile clinics to provide
basic and emergency healthcare to people
affected by the disaster, particularly young© Olga Overbeek

Further west, a team supports healthcentres in and around the town ofGoronyo, Sokoto state. Staff offer basic
healthcare, maternal care, paediatricservices, vaccinations and treatment formalnutrition. They carried out more thanZamfaraA woman is measured during an antenatal consultation at Goronyo hospital.
72 nigeria© Olga Overbeek

International Activity Report 2012

Born seven weeks premature, Carlos is now five weeks and doing well in Goronyo hospital. His 15-year-old mother, suffering from malaria anda bowel perforation, died after referral elsewhere, as she was awaiting emergency care.

children and pregnant women. Hygiene kits
were distributed to the displaced. As malaria
rates rose, MSF also donated mosquito nets.

not be fully resolved without a complete
clean-up and the implementation of safer
mining practices.

Lead poisoning response

Trauma programme closed

A team has been treating children for leadpoisoning in Zamfara state since 2010.
Unsafe gold mining and ore processing
practices have led to the contamination of
a number of villages, and an estimated400 children have died. MSF has treated
2,500 children for poisoning so far, butpatients will need long-term follow-up.

Political tensions in the oil-rich Niger Delta
region have eased and MSF therefore closed
the trauma programme it had been runningin a private hospital in Port Harcourt,
Rivers state, since 2005. The last patient wasadmitted in October. The team carried out
9,000 emergency consultations and treated
500 victims of sexual violence during the year.

Without environmental clean-up, treatment
is ineffective, because the children will
only become sick again when they returnhome. MSF hosted a conference on thecrisis in May, but six months later, none of
the key action points agreed upon at theconference had been put into effect. In
early 2013, following sustained advocacy
by MSF and other organisations, funds were
finally released to allow for remediation of
one of the contaminated villages, which will
mean that medical treatment can begin for
affected residents. However, the crisis will

Clinics in Lagos
Health facilities are scarce in the slums ofLagos. Since 2010, MSF’s clinics in Badia
and Makoko have been providing freeemergency care, as well as basic healthservices and maternal care. The floating
clinic in Riverine, on the lagoon, was thefirst place to offer free medical services
in the area. More than 19,200 people
attended medical consultations throughthe programme. MSF withdrew at the endof 2012, and the Ministry of Health has
agreed to maintain essential services.

Rabi
17 years old, celebrates her discharge
from the Jahun hospital fistula repair
programme.
And what of that sick woman who arrived
here many days ago? What of she who
suffered many days with labour pains,only to see a stillborn baby, and after her
wrapper cloth always wet? What of theway that her husband turned from her,
repulsed by the leaking urine, what of her
family who would no longer touch thefood that she cooked? What of that chair,
the one everyone avoided, the one shealone would sit on?
That chair is no longer for me, becausethat woman is no longer me. I am now
cured from my injury. With dry clotharound my hips, I am ready to return
to my family. I sing because I am happy,
I sing because I am free.

No. staff end 2012: 971 | Year MSF first worked in the country: 1971 | msf.org/nigeria

nigeria 73

Médecins Sans Frontières

pakistan
Key medical figures:• 2 98,000 outpatient consultations• 2 2,160 births assisted• 3,730 surgical procedures

Khyber Pakhtunkhwa
FATA

Health services in Pakistan areoften unaffordable and in many
regions, conflict and insecurity
further restrict access.
In many parts of Pakistan sectarian
violence is rife. Government forces are also
engaged in military operations against
armed opposition groups. Médecins
Sans Frontières (MSF) programmes focus
mainly on meeting urgent needs amongcommunities affected by insecurity.

Sindh

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

Khyber Pakhtunkhwa and FATA
building was constructed at the centre toaccommodate growth in patient numbers.
MSF operated treatment centres in Hangu
and Timergara from July until October to
respond to an increase in cases of acutewatery diarrhoea. After more than five
years supporting emergency, maternal andchild healthcare in Dargai hospital, services
were handed over to the Ministry of Healthin August.

In Peshawar, MSF runs a 30-bed hospital
specialising in obstetrics and gynaecology,
and also conducts antenatal and postnatal
consultations in 11 health centres in the
district. Staff at the health centres were able
to identify and refer high-risk pregnancies
or obstetric emergencies to the hospital.
MSF programmes in Kurram Agency in theFederally Administered Tribal Areas (FATA)© Sam Phelps

In Hangu, Khyber Pakhtunkhwa, where
many Afghan refugees and displaced people
have settled, MSF works in the hospital’s
emergency department and operating
theatre, and a midwife supports maternity
services. The team also organises patientreferral to facilities in the provincial capital
Peshawar. In Timergara, MSF provides full
support to the emergency department andmother and child health centre, and a new

Members of a mobile medical team bandage a boy’s infected cut at a camp for people displaced by flooding in Sindh province.
74 pakistan© Sam Phelps

International Activity Report 2012

A nurse listens to Soghran’s breathing in Ranga Pur, Sindh province. The four-year-old and her mother may have tuberculosis. They will beprescribed antibiotics and return for another consultation.

are staffed by Pakistani personnel, while
management is based in Peshawar, withregular visits. The team provides paediatricservices at hospitals in both the Shia communityof Alizai and the Sunni enclave of Sadda.

produces ulcers on the body, which cancause serious disability as well as social
stigma. Mental health teams provide
psychological and counselling services
in both Quetta and Kuchlak.

Improving access to healthcare
in Balochistan

Clinic opened in Karachi

Balochistan has some of the worst healthindicators in Pakistan. It is frequently
affected by sectarian and interethnic
violence and natural disasters. MSF is mainly
focused on the needs of pregnant womenand children, and carries out nutrition andhealth promotion activities.
MSF provides neonatal, obstetric andpaediatric care in Chaman and Dera Murad
Jamali hospitals. A team also supports
the emergency department in Chaman.
In Quetta, MSF runs a 60-bed paediatrichospital and is opening a network of basic
health units across the city. Not far from
Quetta, in Kuchlak, a team runs a motherand child health clinic that has a birthingunit. Patients also receive treatment for
cutaneous leishmaniasis, a disease thatAmina’s* son
was brought to the MSF nursery when
he was 10 days old, weighing only
2.36 kg. He was diagnosed with tetanus.
A few days after my son was born,he started having fits and had atemperature. I delivered him under amakeshift tent near the Pat Feeder Canal.

In October, in partnership with localorganisation SINA Health, Education andWelfare Trust, MSF opened a new clinic in
Machar Colony, a settlement in Pakistan’slargest city, Karachi. The clinic provides
basic healthcare and emergency services,
including maternal healthcare, mental
health services and stabilisation for patientsin a critical condition.

My husband used to work on ourlandlord’s land. But the water came andwe lost everything. We have no shade,no home or land. We live on the side of
the road. Thousands of families who losttheir homes are now living there too.
When my son got sick, I pawned myearrings because we had nothing left to
pay the doctors. However, when we cameto the MSF hospital here, we were told
the treatment is free, so I used the moneyfrom the earrings to buy food instead.
It’s been a month since I sold myearrings. Now even the food is gone.

Response to flooding
In September, eastern Balochistan wasaffected by severe flooding for the third
consecutive year. MSF teams set up mobile
clinics providing basic health services topeople who were living on the roadside or incamps, and a treatment centre for diarrhoea.
Safe drinking water was provided, latrines
were constructed and relief items such as
washing kits were distributed.

My son has been here for 25 days now.
We had thought about taking him fromthe hospital and going home because wedidn’t see an immediate change in his
health. Now, though, he opens his eyes,and can slowly start to feed.

No. staff end 2012: 1,404 | Year MSF first worked in the country: 1986
msf.org/pakistan*

The patient’s name has been changed.

pakistan 75

Médecins Sans Frontières

Papua New Guinea
There are high levels of domestic, sexual, social and tribal
violence in Papua New Guinea, yet medical care remains
inadequate. In some places it is not available at all.

MSF runs a second centre in Tari, inSouthern Highlands region. As there is anenormous need for emergency medical care
– often after assault – the team also offers
emergency surgery at Tari hospital.

Tari
LAE

Buin

Cities, towns or villages where MSF works

Key medical figures:• 21,200 outpatient consultations• 2,990 births assisted• 1,190 surgical procedures

Médecins Sans Frontières (MSF) is providing
comprehensive treatment and psychosocial
care, with a particular emphasis on victimsof domestic and sexual violence.
Local people are becoming more aware that
MSF’s family support centre in the Angau
Memorial Hospital in Lae offers a confidential
and safe space, and the team provided free,comprehensive medical and counselling
services to some 6,500 patients in 2012.

Violence is viewed as a police issue and the
medical condition of victims is frequently
overlooked in Papua New Guinea. Advocacy
and training are critical aspects of MSF’s
activities. Teams conducted training on
responding to the physical and mental healthneeds of victims of domestic and sexual
violence at hospitals and health centres inall but two of the country’s 22 provinces.
Improving access to healthcare
in Bougainville
Decades of conflict have weakened thehealth system in the Autonomous Regionof Bougainville and MSF is helping refurbish
several facilities. Construction of a six-bed
tuberculosis ward and accommodation
for caregivers at Buin health centre werecompleted in 2012. MSF also carried out
significant renovations and upgrades tothe health centre’s water and sanitation,
laboratory and pharmacy infrastructure.

Staff support clinical care, including
maternal healthcare, at Buin health centre
and five health facilities in the area. Patientnumbers increased following an awarenesscampaign conducted in local communities
and improvements to the referral system.

RachelLae
He can bash me up badly. He can use iron,knives to threaten me. How can I fight him? He
is a man and he has more strength than me.
He called me one time and was threateningme, saying, “I’ll break your arms, I’ll breakyour legs.” That evening he came andsurprised me and was chasing me aroundmy big sister’s house. He went to myworkplace and my boss told me, “You’re
new here, and seems like you are facing thisproblem. You are not going to work.”
So I lost my job.
When I share my problems with thecounsellors, I feel free. If I can stand in
public and tell everyone, it’s good forme. They know I’ve gone through it
and it can help them too.

© Basia Asztabska

No. staff end 2012: 201 | Year MSF first worked in the country: 1992 | msf.org/png

A maternity waiting home in Buin provides
accommodation for women in their final
weeks of pregnancy, so they are close to thehealth centre when they go into labour anddo not have to travel for long periods onpoor roads during an emergency.

A woman at MSF’s clinic in Lae has been beaten by her husband. She has several knife cuts on her legs and back, and bruises on her face and chest.
76 Papua New Guinea

International Activity Report 2012

paraguay

Chagas disease is endemic in Paraguay, yet diagnosis is still
not integrated into basic health services.
In many cases, this is because healthfacilities do not have the necessary
equipment or staff to carry out testing.
Chagas is a parasitic disease transmitted
by the vinchuca beetle. Awareness andtesting are crucial because Chagas canbe deadly. Although people may live foryears without symptoms, the disease canultimately cause serious, even fatal, heart

and intestinal problems. Since 2010,
a Médecins Sans Frontières (MSF) team has
been diagnosing and treating Chagas in
Boquerón, one of the three departmentsthat make up the Paraguayan Chaco. Healthservices are limited in the semi-arid Chaco
region, where the climate is harsh and many
communities are completely isolated when
it rains.

Boquerón

Regions where MSF has projects

Key medical figures:• 590 patients began treatment
for Chagas disease

MSF is based in Mariscal Estigarribia, a small
town of just 5,000 inhabitants, and works in
the regional hospital as well as at health postsin the towns of Teniente Martínez, Pedro
P. Peña, Pirizal, La Patria and Laguna Negra.

© Anna Surinyach/ MSF

Mobile teams travel to remote communities
to inform people how Chagas is transmitted
and explain the symptoms and the treatmentthat is available, returning later to carry out
testing and diagnosis.
Chagas drug production assured
Following intensive lobbying, productionof benznidazole, the most commonlyused medicine for Chagas, which is only
produced by one manufacturer in Brazil,
resumed after coming to a halt in 2011.
Delivery has been guaranteed for 2013.

Children learn about the vinchuca beetle during Chagas awareness activities in Boquerón.
No. staff end 2012: 67 people worked in Paraguay and Bolivia, which is run as a joint programmeYear MSF first worked in the country: 2010 | msf.org/paraguay

philippines
Typhoons wreaked havoc in
different parts of the Philippines
on three occasions in 2012.

Typhoon Washi hit the northeast coast of
the island of Mindanao in December 2011,
killing nearly 1,400 people and injuring
thousands more.
Around 10,000 homes were destroyed.
Between 9 January and 24 February, Médecins
Sans Frontières (MSF) mobile teams carriedout 5,400 medical consultations in the
Mindanao cities of Iligan and Cagayan deOro and treated some 240 children forsevere malnutrition.

In August, typhoons Kai Tak and Saola caused
severe flooding. Between 13 August and
18 September, MSF carried out 1,900
consultations and distributed 2,600 hygienekits to families in the municipalities ofHagonoy and Calumpit in Bulacan province,
north of the capital Manila. In collaboration
with local authorities, MSF also distributed
water purification tablets and watercontainers, and assisted in the removalof 6,400 tons of debris.
Typhoon Bopha, which hit the southern
Philippines on 4 December, was by far themost powerful of the year. In some areas,
all the health posts were destroyed andregional hospitals badly damaged.

BulacanMindanao

Regions where MSF has projects

Key medical figures:• 7,330 outpatient consultations• 240 patients treated for severe malnutrition

MSF launched mobile clinics in some of themost affected coastal areas, such as Cateel andBaganga on Mindanao island. The medical
team began consultations in December,and assistance continued into 2013.

No. staff end 2012: 1 | Year MSF first worked in the country: 1987 | msf.org/philippinesparaguay | philippines 77

Médecins Sans Frontières

Russian Federation
A health crisis persists in the north Caucasus region,
exacerbated by devastating illnesses such as tuberculosis (TB).
Years of war, the destruction of the healthsystem and social stigma associated with TB
have contributed to a lack of diagnosis andtreatment in the north Caucasus, especiallyfor drug-resistant TB (DR-TB).
Médecins Sans Frontières (MSF) has worked
with the Chechen Ministry of Health to
implement a comprehensive TB programmein the republic, including rapid diagnosis
and treatment for people with DR-TB, those
not responding to standard first-line drugs
for TB. Patients receive counselling andpractical support to help them complete
their lengthy, isolating and often arduous
treatment. The MSF team is developinga special focus on children, as well as on
HIV–TB co-infection.

unit in the Republican Emergency Hospitalthrough staff training and the purchase of
medical equipment and essential medicines
for carrying out specialist treatment. The
number of patients receiving emergency
care rose to almost 750 in 2012, as the unit
increased its capacity.
Attention to mothers and children
MSF has provided medical care for womenand children through three outpatient
clinics in Grozny and rural areas in northernand southern Chechnya since 2007. After a
total of 15,700 paediatric consultations and
8,800 gynaecological consultations, MSF
closed the programme at the end of 2012,
because of decreasing patient numbers andlow levels of disease.

Improving cardiac care

Mental health support in Ingushetia ends

One in six people in Chechnya has heartdisease but the scale and quality of medical
services do not meet the needs for acutecoronary syndromes and other cardiovascularemergencies. In Grozny, Chechnya’s capital,
MSF is working to improve the cardiac

Since 2002, MSF teams have provided
psychological support to communities
in the remote, mountainous regions ofChechnya and Ingushetia, where violent
conflict has had a serious impact on people’s
mental health. Counsellors have worked

Ingushetia

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

Key medical figures:• 3 00 patients began TB treatment• 750 patients admitted to the cardiac unit
• 8 ,990 individual and group mental healthconsultations

with individuals suffering from anxiety,mood-related problems and grief caused bypsychological and physical violence, abuse
and the deaths of loved ones.
The programme in Chechnya continues.
Services in Ingushetia, however, ended in
September. Following extensive discussions withthe government of the republic, senior officials
in Ingushetia thanked MSF for its efforts but
indicated that further assistance throughthis programme was no longer required.

© Lana Abramova

No. staff end 2012: 189 | Year MSF first worked in the country: 1992 | msf.org/russianfederation

An MSF doctor and his Ministry of Health counterpart examine a patient at the Grozny Republican TB hospital.
78 Russian Federation

International Activity Report 2012sierra leone
Freetown

Bo

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

Key medical figures:•9
 5,700 outpatient consultations•5
 ,030 patients treated for cholera•2 ,740 births assisted

An ambulance referral system
and access to 24-hour emergency
obstetric care has drasticallyreduced maternal deaths in
Bo district, Sierra Leone.

The government introduced a policy of
free healthcare for children under five andpregnant and breastfeeding women in2010, but real improvements in access forthese groups have not yet been achieved.
Many health facilities are understaffed,
underequipped and lack medical expertise,and high numbers of preventable maternaland child deaths in the country are a resultof a lack of access to healthcare.

Cholera emergency

In Bo, Médecins Sans Frontières (MSF)
runs a 220-bed obstetric and paediatrichospital, the Gondama referral centre. Fiveambulances transport pregnant womenand children from nine community healthcentres. Another ambulance refers patientswith complications from Gondama to thecapital Freetown. Yet another is a specialised
ambulance that brings patients to the Lassa
fever unit at Kenema hospital. Lassa fever
is a viral haemorrhagic fever that affects
several organs in the body.

26 years old

A study published by MSF in November
showed that the rate of maternal deaths
in Bo district is now 61 per cent lower
than in the rest of the country.

Between July and September, MSF
responded to a cholera outbreak that wasconcentrated in Freetown, and provided
treatment for 5,000 patients across four
treatment centres. MSF also supported theMinistry of Health to treat 427 patients at
Bo government hospital.

JennebaThis is my third pregnancy. I have had
two miscarriages before. Last night I felt
pain, so an ambulance picked me up
from the health centre and took me to
Gondama. The nurse in the ambulance
held my hand and talked to me nicely
during the ride. The nurses at the hospital
examined me and said that I wasn’t inlabour yet. I am still in pain and very
worried about what is happening. If I lose
this baby, I am worried that my husband
will leave me.
Jenneba’s son was born by caesarean
section 10 days later.

No. staff end 2012: 556 | Year MSF first worked in the country: 1986 | msf.org/sierraleone

sri lanka

Three years after the devastating civil war ended, Médecins
Sans Frontières (MSF) has handed over its last remaining
activities in Sri Lanka.

In Mullaitivu hospital, a team had been
assisting in the provision of emergency
care, surgery and gynaecological andobstetric services. Staff also held weekly
mobile clinics at five sites, providing accessto health services for isolated communities.
These activities came to an end in June.
Mental health services handed overPhysical scars may have healed, but themental health of those traumatised by war
and distressed by resettlement still needs
to be addressed. MSF mental health staff
worked at the main district hospitals in
Mullaitivu and Kilinochchi as well as at othersites in the districts. Mobile teams travelled
to more distant villages to offer care topeople unable to travel.

Mullaitivu

MSF also developed community-based
psychosocial services in schools. Before
leaving Kilinochchi, staff provided training
to 10 psychological support officers and
10 field assistants.

Kilinochchi

The Ministry of Health has committed tocontinuing the development of communitybased psychosocial services. In late 2011,
the ministry and the Sri Lanka College of
Psychiatrists launched a media campaign toraise awareness of mental health issues and toincrease access to expert medical care. MSF’s
programme in Mullaitivu has been handed
over to international non-governmentalorganisation World Vision, which has along-term operational plan for the north ofthe country, while a local organisation has
taken on activities in Kilinochchi.

Key medical figures:• 1,390 outpatient consultations• 120 individual and group mental healthconsultations• 210 patients admitted to hospital

Cities, towns or villages where MSF works

No. staff end 2012: 73 | Year MSF first worked in the country: 1986 | msf.org/srilanka

sierra leone | sri lanka 79

Médecins Sans Frontières

somalia
Key medical figures:• 624,200 outpatient consultations• 41,100 patients admitted to hospital• 3 0,090 patients treated for severe
malnutrition• 58,620 routine vaccinations• 2,750 surgical procedures

Burao

ceerigabo

hargeisa

Despite some improvements
in security during 2012, themajority of people in Somalia
are still living in crisis.

Guri-elGalkayo North

Belet Weyne

Galkayo South

AfgooyeDinsorLower Juba

Two decades of civil war have inflictedviolence, displacement and loss of livelihoodon the people of Somalia. Médecins Sans
Frontières (MSF) continues to work in areas
controlled by the government as well as
areas held by opposition groups.

Galguduud
Middle Shabelle
Mogadishu

Regions where MSF has programmesCities, towns or villages with MSF activities

Most of the country’s healthcare
infrastructure has been destroyed, leaving
only one doctor in the country for every
quarter of a million people. The nutritional
crisis of 2011 in south and central Somalia
further damaged coping mechanisms andcaused massive internal displacement as
people searched for food and security.

On the outskirts of the city, MSF manages
60 beds in Daynile hospital. Medical
services include an emergency department,
surgery, intensive care and paediatricinpatient units, a nutrition programme andmaternity services. At the end of March,fighting between pro-government forces
and Al-Shabaab drove MSF to close thehospital. It was reopened in September.

March and April, respectively. In July andAugust, the clinics in Rajo, Refinery and
Howlwadaag were closed. A 40-bed hospitalnear Jasiira camp admitted 2,000 inpatientsover the year.

At the beginning of the year, MSF decided
to put on hold any opening of new nonemergency projects in Somalia until thesafe release of its two colleagues, Blanca
Thiebaut and Montserrat Serra, abductedfrom the Dadaab refugee camps in Kenya
on 13 October 2011 and held against theirwill in Somalia.

Three health clinics located in Mogadishu’s
Wadajir, Dharkenley and Yaaqshiid districts
provide medical consultations and carefor pregnant women and children to help
meet the increase in need since displaced
people have arrived in the areas. A mobile
nutrition programme visited six camps forthe displaced in Wadajir.

Malnutrition in the Afgooye corridor

Basic healthcare in the capital

Teams also ran medical clinics in the city’s
Rajo, Refinery and Jasiira camps and opened
two more in Howlwadaag and Xadaar inChildren are suffering particularly and there
is an urgent need for preventive activities
such as vaccination, as well as lifesaving
emergency care. MSF supports a children’s
hospital in the city, running a generalward, inpatient feeding programme andisolation units for measles and acute waterydiarrhoea. Two mobile teams travelledfurther afield to carry out consultations,referrals and routine vaccinations. Some
6,300 children received nutritional support,
945 were admitted for inpatient treatment
and 2,480 were vaccinated against measles.

The Afgooye corridor, linking Mogadishu
and the town of Afgooye, is an increasingly
dense settlement of displaced people. MSF
supports the 30-bed community hospitalin Afgooye, the only health facility covering
the needs of 180 villages. The hospitaloffers outpatient consultations, emergency
services, maternity care and an outpatient
feeding programme. In 2012, staff carriedout consultations with 25,640 people.

© Muhammad Daoud/MSF

Access to food, water, sanitation, healthservices and shelter is irregular andinsufficient in Mogadishu, where an
estimated 369,000 displaced people areliving. Although the number of attacks,
bombs and targeted assassinations has
decreased, they remain frequent.

During a cholera outbreak in Mogadishu
between May and August, teams treated
350 people for the disease.

An outreach team gives a health promotion talk to a group of women in Hamarweyne,
near Mogadishu.

80 somalia© Mike Woodman/MSF

International Activity Report 2012

A health worker carries out nutrition screening at the Warshadaha outpatient feeding centre, Mogadishu.
In November, MSF medical staff visited
34 camps, which host some 18,000 people.
The team screened 1,530 children andtreated more than 400 for malnutrition.
They vaccinated against polio, diphtheria,
tetanus, measles and pertussis (whooping
cough), and all children under five yearsof age were given albendazole, to treat
worms, as well as vitamin A. Staff returnedin December for follow-up.
Comprehensive care in Dinsor
In Bay region, MSF facilities in Dinsor offer
inpatient care, a nutrition programme,maternity services, treatment for kala azar,
a TB programme and outpatient services.
Mother and child programmes in
Middle Shabelle
During the second half of 2012, Jowhar andBalcad were on the front line of conflict andaccess became a challenge for the deliveryof supplies and supervision visits. MSF staff
support the maternity hospital in Jowhar,and offer mother and child healthcare,including nutrition and vaccinations, throughfour clinics in Kulmis, Bulo Sheik, Gololey and
Mahadaay. Tuberculosis (TB) is also treated in
Mahadaay and Gololey. MSF runs a motherand child programme at the clinic in Balcad.

Galkayo North and SouthMSF has worked in the divided city ofGalkayo, capital of Mudug province, forover a decade. Teams support paediatricand TB services in a clinic in Galkayo
North, which is located in Puntland, aself-declared independent republic. A newmaternity ward was opened in the clinic in
December. In Galkayo South, administeredby the state of Galmudug, a hospital teamreceives patients from both sides of theregional armed conflict. Comprehensive
services include emergency, maternity andpaediatric care, TB treatment and surgery.
Lower Juba
MSF continues to run essential healthprogrammes throughout Lower Juba region.
In Marere, a hospital offers outpatient services,
reproductive health and emergency obstetrics,
surgery and TB treatment. Mobile teams
travelled to sites where displaced people had
recently settled, offering basic healthcare andtreatment for malnutrition. In Jilib, a healthcentre housing a measles isolation unit andproviding cholera treatment offers services
around the clock. MSF also runs an inpatient
nutrition programme for children under fivein the port town of Kismayo, the capital of

the region. The team opened emergency
treatment units in response to outbreaks ofmeasles and cholera during the year.
Programme closures
In May, due to worsening security conditions,
MSF made the difficult decision to close its
basic healthcare programmes in Dhusa Mareband Hinder, Galguduud. The 108-bed hospitalin Belet Weyne, Hiraan region, was closed
at the end of the year. Activities in Guri-El
hospital, Galguduud region, will be handedback to the community in January 2013.
Healthcare in Somaliland
In the self-declared republic of Somaliland,
staff are ensuring better access to healthcare
and improving water and sanitation systems
in Hargeisa, Mandheera and Burao (Burco)
prisons. Support is also given to psychiatricpatients in the Berbera mental health clinic.
An MSF team works with the Ministry of
Health at Burao general hospital in the
Togdheer region of Somaliland, focusing
on inpatient care. In 2012, emergency staff
dealt with more than 10 incidents involving
the arrival of numerous casualties. When
flash floods affected the region, MSF madedonations to health facilities in Buhoodle.

No. staff end 2012: 1,990 | Year MSF first worked in the country: 1979 | msf.org/somalia
somalia 81

Médecins Sans Frontières

south africa
MusinaJohannesburg

KwaZulu-Natal
Khayelitsha
Regions where MSF has projects
Cities, towns or villages where MSF works

Key medical figures:•3
 1,800 patients tested for HIV• 21,320 patients on first-line antiretroviraltreatment• 210 patients began DR-TB treatment

An estimated 5.6 million people
are living with HIV in South
Africa, the highest numberof people in any country in
the world.
KwaZulu-Natal province has the highest HIV
prevalence in the country, and Médecins
Sans Frontières (MSF) has a programmein KwaZulu-Natal with ambitious aims toincrease testing and treatment coverageand initiate treatment earlier.
The team tested more than 23,000 people
through its mobile one-stop shop in 2012,
almost triple the number for 2011. This wasin part a result of work with community leaders
and traditional healers to gain acceptance fortesting and treatment. The vast majority of
the 2,000 patients enrolled in HIV care werestarted on antiretroviral (ARV) treatment.

Instead of attending one-to-one appointments
at the health centre, adherence club members
go to meetings every two months for acheck-up and drug refill, and to talk to other
patients. MSF’s analysis found that 97 percent of club members stayed in care, while
the figure was 85 per cent for patients who
qualified for club membership but remainedin mainstream clinic care. By the end of theyear, there were 180 clubs, with more than
4,500 members, at nine health facilities in
Khayelitsha. The Western Cape Department
of Health has also set up more than 400 clubs.

Incidence of drug-resistant tuberculosis(DR-TB), a form of TB that demands two yearsof treatment, which can have painful side
effects, is particularly high in Khayelitsha.
Close to 200 patients, including those withmultidrug-resistant TB and extensively
drug-resistant TB, were started on treatment
at their local clinic in 2012. This pilot
project has contributed to changing South
African health policy towards decentralised
management of DR-TB, which is critical toaddressing the DR-TB epidemic.
Assisting migrants
Many of the estimated one and half million
Zimbabweans living in South Africa cannot
access the services they need. In Musina, on
the Zimbabwe border, MSF mobile clinics
offer basic healthcare, and testing andtreatment for HIV and TB, at night sheltersand outside the offices of the Departmentof Home Affairs. The teams have developed
a model of care for TB and HIV that is
adapted to the lives of the migrant farmworkers, who frequently move from place
to place.
In Johannesburg, the MSF team assisting
migrants living in slum buildings in the city
centre shifted attention to focus on improving
living conditions. Staff helped residents
clean up buildings and facilitated improved
sanitation and access to clean water.

Bongiwe Vutuza
Not anyone can join the club. In orderto join a club you must be taking yourtreatment and not miss any dates.
I wanted to join the club because in a club
everything becomes easy. Everything goesquickly. It’s not like at the clinic where you
arrive at seven in the morning and thengo home at four. When you arrive at theclub your treatment is always ready foryou. The people we work with, Sis Ntosh
and Sis Fanelwa, are friendly. If you havea problem you can go to them. If I’m not
feeling well, I can ask the facilitator andthey refer me to a doctor. And if we havea problem we can talk about it in thegroup. I only take 45 minutes, from 8:00
to 8:45. Neighbours don’t see that I go to
the clinic. At the club they try and assist
with the privacy of patients.

In 2012, the South African Department
of Health announced that it was shifting
gradually to a single daily pill for HIV
patients. It also announced that it willoffer this same fixed-dose combination
ARV treatment to all pregnant women
throughout pregnancy and breastfeeding toprevent mother-to-child transmission of HIV.
These two moves will make treatment easierfor patients and simplify care.

In the township of Khayelitsha, near CapeTown, MSF continued to provide support
through mentoring and operational
research on HIV and tuberculosis (TB)
treatment, and created more adherence
clubs in community sites outside healthfacilities and patients’ homes.

© Samantha Reinders

Expansion of adherence clubs in Cape Town

Hundreds of adherence clubs are helping HIV patients stick to treatment in South Africa.

No. staff end 2012: 207 | Year MSF first worked in the country: 1999 | msf.org/southafrica

82 south africa

International Activity Report 2012

sudan

Armed groups have extended their presence across Sudan’s
regions of North and South Darfur, and peace agreements do
not seem to have had a noticeable effect on people’s lives.
Conflict has also affected tens of thousandsof people living in South Kordofan and Blue
Nile states.
Health services are scarce across much of
the country – they are even more limited
for people living in conflict zones – and thegovernment does not allow humanitarianorganisations access to areas controlled by
opposition groups.
The Shaeria area in South Darfur experiencesintermittent unrest. Médecins Sans Frontières(MSF) provides services at the Ministry of
Health hospital, particularly maternal careand nutrition, as well as in three clinics,
offering a lifeline to people living in remotevillages. However, medical activities faced
more obstacles during 2012 as South Darfur
was divided into two states, South Darfur
and East Darfur, resulting in fewer resourcesin each state, and making administrative
procedures more complex.
In North Darfur, teams continued to provide
comprehensive health services at facilities in
Tawila and basic healthcare in five centres in
Dar Zaghawa. In Kaguro, there were problems
in the delivery of medical supplies, and MSF
continued to negotiate for improved access tohealthcare for residents and displaced people.

North Darfur
WEST
DarfurAs the situation stabilised in Shangil Tobaya,
where MSF had been providing basic healthservices since 2004, the programme washanded over to the Ministry of Health.
Assistance in 2012 focused on the provisionof healthcare in the displaced persons camp.
Yellow fever response
The Sudanese health authorities began
responding to an outbreak of yellow fever
in Darfur at the end of the year, and MSF
offered medical and logistical assistance.
Yellow fever is a viral haemorrhagic fever,named for the jaundice suffered by many
people with the disease. Although mostpeople who contract the disease recover
within days, up to 50 per cent will develop
more serious symptoms, which can befatal. MSF teams in Al-Geneina and Zalingei
treated patients and donated drugs andmedical supplies. Staff in five localities ofNorth and Central Darfur also took part ina vaccination campaign that reached a totalof 750,000 people.

Al-Gedaref
SennarCENTRAL
Darfur

EAST Darfur
South Darfur

Regions where MSF has projects

Key medical figures:• 170,600 outpatient consultations• 10,000 patients treated for malaria• 630 patients began treatment for kala azar

timely diagnosis and treatment nearly
always bring a cure.
In January, MSF trained medical staff in
Azaza Damoos, Sennar state, in kala azar
diagnosis and treatment, and mobile teams
visited the surrounding area to screen
people for the disease. MSF has supported
the hospital in Tabarak Allah, Al-Gedaref
state, since 2010, focusing on screening andtreatment of the disease. Additional support
is given for the treatment of patients withkala azar who also have tuberculosis or HIV.

Kala azar programme extended

Thousands displaced by flooding

Sudan has one of the highest rates of kalaazar (visceral leishmaniasis) in the world.
Transmitted by female sandflies, the diseaseis almost always fatal if left untreated, but

Heavy rains in August led to flooding. Teamsin Al-Gedaref and Sennar distributed relief
kits and plastic sheeting to people madehomeless by the rising waters. In Al-Mafaza,
Al-Gedaref, MSF delivered drinking water,
built latrines and showers, and trained
health staff in the diagnosis and treatmentof acute watery diarrhoea. In Al-Dinder,
Sennar, staff conducted mobile clinics
and vaccinated children against measles.
Measles vaccination was also carried out,
alongside nutritional screening in Mazmun,
where MSF supported the hospital’s
nutrition programme.

© Asia Kambal

No. staff end 2012: 1,031 | Year MSF first worked in the country: 1979 | msf.org/sudan

The MSF hospital in Kaguro, North Darfur, serves a population of some 100,000 people.

sudan 83

Médecins Sans Frontières

south sudan
The massive influx ofrefugees into South Sudancaused Médecins Sans
Frontières (MSF) to launch
one of its biggest emergency
programmes of 2012.

Conflict in Sudan’s Blue Nile and South
Kordofan states led to the arrival of
thousands of refugees in Unity and Upper
Nile states during the first half of theyear. But the land is inhospitable: in thedry season water is scarce and the baked
clay is extremely hard to drill, while in therainy season it is a flood plain and only
accessible by air. There is virtually no scopefor agriculture or grazing animals. In Maban
county, Upper Nile state, an estimated
110,000 refugees in four camps became
entirely dependent on humanitarianorganisations. However, their response
failed to meet refugees’ basic needs, and insome camps mortality levels had reacheddouble the emergency threshold by July.
MSF called for more humanitarian assistanceas teams ran three field hospitals and sevenoutreach clinics across the camps, carrying
out up to 8,000 medical consultations
per week and caring for people sufferingfrom the effects of lack of food and waterand long journeys on foot. Staff provided
treatment for malnutrition, skin andrespiratory infections and diarrhoea. MSF
also addressed the issue of water supply,
managing boreholes and hand pumps.

Northern
Bahr elGhazalWestern Bahrel ghazal

Agok

Unity
Upper Nile

J o n gl e iwarrapWestern
Equatoria

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

Key medical figures:• 8 69,300 outpatient consultations• 204,800 measles vaccinations• 148,700 patients treated for malaria

In central Jonglei, MSF runs a hospital in
Pibor town and two outreach clinics inthe villages of Lekwongole and Gumuruk.
The repercussions of an exceptionally
bloody attack on Lekwongole and Piborin December 2011, in which hundreds ofmen, women and children were killed orwounded and two MSF medical facilities
were damaged and looted, persisted into
2012. People were coming from the bushweeks after the attack, seeking treatment
for badly infected wounds.

• 4 6,780 patients admitted to hospital• 1,320 patients began kala azar treatment

Further attacks resulted in severe damage to
MSF facilities in Lekwongole and Gumuruk
in August and September. Again, tens of
thousands of people fled and staff ran amakeshift clinic in the bush, providing
basic and emergency healthcare. In total,
MSF carried out more than 32,000 medical
consultations across the three facilities in2012. The resurgence of a rebel militia inthis part of Jonglei state led to an increased
military presence and almost daily clashes
in the area by the end of the year.

A team worked in Yida refugee camp in Unity
state, where the population quadrupled to
60,000 people between January and July.
MSF offered inpatient and outpatient care,and operated four feeding centres.
By September, death rates had been brought
under the emergency threshold. However,the camps were soon faced with an outbreakof hepatitis E – a potentially fatal virustransmitted through contaminated water.

Violence and displacement
in Jonglei state
Brutal intercommunal clashes continued tocause widespread displacement in Jonglei.
People escaped deep into the bush, only
to become vulnerable to malaria, diarrhoea
and respiratory diseases.

84 south sudan© Nichole Sobecki

The refugees remain entirely dependent on
humanitarian assistance.

A clinician examines a young patient at the field hospital in Doro refugee camp, Upper Nile state.

International Activity Report 2012

In northern Jonglei, MSF runs a hospitalin Lankien and an outreach clinic in Yuai.
After Pieri village was burned down, theresidents never returned. MSF therefore
handed over the clinic, focusing insteadon mobile medical assistance. Staff carriedout 100,000 consultations and also treated
30,000 patients for malaria and 1,000 patientsfor kala azar (visceral leishmaniasis) during
outbreaks in 2012.
Abyei

In April, casualties from an air raid in
Abiemnom in Unity state were brought toAgok hospital, where staff carried out lifesaving
surgery. MSF also distributed relief items topeople displaced by the attack, vaccinatedchildren and conducted medical consultations.
A team ran mobile clinics in nine locations
that are only accessible during the dry
season. In November, they began mobile
medical activities for the nomadic Misseriya
population in the northern Abyei area.
This was the first time MSF had been able
to reach the area since July 2010.
The Abyei teams conducted a total of
29,200 consultations, helped deliver
860 babies and treated more than
3,500 children for malnutrition.
Basic and specialist health services
In Unity state capital Bentiu, MSF runs afeeding programme. Staff also supported thehospital personnel to treat people woundedin cross-border fighting. Towards the end of
the year, the team started to offer TB careso that patients do not have to travel to theprogramme in Leer for treatment.
In 2012, the number of cases of kala azar
in Unity state was far higher than in recent
years: 740 patients with the disease weretreated by MSF at Leer hospital. The team also
treated 5,200 people for malnutrition, enrolled
630 patients on TB treatment, and provided
support for TB care at the clinic in Koch.
In Nasir, Upper Nile state, MSF runs a hospitalproviding a full range of medical services,
including surgery. The team regularly
responded to violent trauma incurred
during cattle raids and tribal clashes.

© Nichole Sobecki

A region contested by Sudan and South
Sudan, Abyei is prone to conflict andpopulation displacement. MSF runs a hospitalin Agok, 40 kilometres south of Abyei,
providing a wide range of services, including
reproductive healthcare and treatment forsevere malnutrition, as well as a tuberculosis(TB) ward and emergency surgery.

Refugees wade through mud to reach a water distribution point in Batil camp,
Upper Nile state.
At Yambio hospital, Western Equatoria state,
MSF offers paediatric, outpatient, inpatientand maternity services. Staff carried out
more than 23,100 consultations and treated
13,970 children for malaria. Ten health posts
were supported with staff training and drug
supplies. When the area was hit by flooding,
the Yambio team distributed relief kits toover 1,000 families.
In Northern Bahr El Ghazal, MSF runs
the 250-bed Aweil civil hospital, focusing
on maternal healthcare and paediatrics,
including malnutrition. From July to
December, MSF mobile clinics responded
to a malaria outbreak and treated nearly
12,000 people. The paediatric mortality ratein the hospital decreased from 20 per centat the beginning of 2009 to 5 per cent by
the end of 2012.
A small MSF hospital in Gogrial town,
Warrap state, provides basic healthcare andemergency surgery. In 2012 staff carriedout 37,000 outpatient consultations andlaunched emergency responses to a measles
outbreak and a spike in malnutrition. In
December, 47 women received fistula repair
surgery. Obstetric fistulas are injuries to thebirth canal most often caused by prolonged
or obstructed labour. They cause pain andincontinence, which can lead to social stigma.

Rumbek town, Rumbek North, Ciubeit andYirol. Teams supported health facilities by
donating 30,000 rapid diagnostic tests
and providing 20,000 mosquito nets andmedicine to treat 7,350 patients.

Priscilla*
was among the first wave of refugees toarrive in Maban county from Sudan.
There is hunger here because there is notenough food. It’s even worse if children aresick because they are malnourished. Thereis water, but just not enough for all thesepeople. Surviving in this camp is not easy.
We fled the first fighting, still in the rainyseason. Along the way, we were moving,
but we could not race. It took us over two
weeks to escape. We drank water fromrivers. Many people got sick along theway, especially from malaria. As we fled,
we passed through villages that were half
empty. Some had already left, but otherscame with us when they saw us running.
Once we arrived at the border crossingpoint, we felt safe. We stayed there twoor three weeks. For the first time, people
started to feel the pains they had not felt
so far because they were so concentrated
on running and saving their lives.
*

The patient’s name has been changed.

Malaria response in Lakes state
In Lakes state, MSF launched a malaria
response from October to December in

No. staff end 2012: 2,415 | Year MSF first worked in the country: 1983 | msf.org/southsudan

south sudan 85

Médecins Sans Frontières

swaziland
Manzini

Shiselweni
Regions where MSF has projects

Swaziland is at the epicentre
of a dual HIV and tuberculosis(TB) epidemic, and isregistering a disproportionately
high number of deaths.
A key strategy taken by Médecins Sans
Frontières (MSF) and the Ministry of Healthis the decentralisation of HIV and TB care.
Testing and treating patients at local
health posts relieves them of the burden of
travelling and helps ensure better adherence
to treatment. It also leads to more patients
being tested and treated.
Given that 80 per cent of people with TB are
also co-infected with HIV, the integration oftreatment for these diseases, so people need
only visit one health facility, is critical.
Despite some successes in scaling up care,field results across the world still showthat limited impact has been made on
the drug-resistant TB (DR-TB) epidemic.
MSF in Swaziland is looking to identify
new approaches for multidrug-resistant
TB and extensively drug-resistant TB thatare shorter, more tolerable, effective andfeasible to scale up.
Treatment as prevention in Shiselweni
Research has shown that starting people
with HIV on antiretroviral (ARV) medication
as a matter of course not only helps protect
their health, but also decreases transmissionof the virus. However, most patients do not
begin ARV treatment until their CD4 count(a measure of immune system functioning)
drops to a certain threshold.
MSF and the Ministry of Health will
implement a pilot ‘treatment as prevention’programme in Shiselweni, a region
particularly hard hit by the epidemic. The
pilot will start with the ‘test and treat’ of
all pregnant women in the district, putting© Giorgos Moutafis

Key medical figures:• 17,040 patients on first-line antiretroviraltreatment• 1,370 women enrolled in PMTCT treatment• 190 patients began DR-TB treatment

An MSF staff member carried out an HIV test during a community testing campaign
in Nhletsheni, Shiselweni.
patients who test positive for HIV on ARVtreatment straightaway, before working with
all HIV-positive adults. Preparations for thisambitious programme were completed in2012, with care decentralised to 22 clinics andthree specialist health facilities in Shiselweni.
Collaborating with healers
Traditional healers are commonly consulted
in Swaziland, but many people visit healers
who cannot provide effective care for
HIV or TB. MSF has collaborated with 170
traditional healers in Shiselweni, sharing
medical knowledge and best practices fortreatment. As a result, the healers – manyof whom have now been tested for HIV andscreened for TB themselves – are identifying
and referring more patients to clinics.
Improving TB treatment accessin Mankayane
Renovation of Mankayane hospital’s TB
ward and outpatient department wascompleted and inaugurated by the Ministerof Health and the Queen of Swaziland. MSF
also decentralised treatment for TB and DR-TB
to four health facilities in the Manzini region.
The success rate for treatment improved from
62 per cent in 2010 to 75 per cent in 2012
and the first multidrug-resistant TB patients
successfully completed their drug regimens.
Expanding care in Matsapha
In Swaziland’s bustling industrial centre,
Matsapha, in Manzini region, MSF provides
comprehensive and integrated services
so patients do not need to go to separate
clinics for HIV, TB and general medical

No. staff end 2012: 307 | Year MSF first worked in the country: 2007 | msf.org/swaziland
86 swaziland

needs (including ante- and postnatal careand immunisations for children). The
addition of rapid testing and treatment for
DR-TB and treatment for victims of sexual
violence has made the centre a complete
one-stop facility.

Albert Zondo
is a traditional healer from Mnyatsi,
in Shiselweni.
I can cure illnesses that I recognise.
If I don’t understand the illness, I do nothesitate to refer them to Western medical
facilities. For me the main objective isensuring that the patient recovers.
I am not too concerned about how.
So when a patient presents any of thevital symptoms of HIV or TB I connect
them to the local MSF expert client, whothen links the patients with a clinic.
I got very sick in 2004. After resisting fora long time, I eventually agreed to testfor HIV and try western medication.
I was diagnosed with HIV and initiatedon ARVs at Mankayane hospital.
My counsellor strongly advised me neverto mix my medication with traditional
medication. How could I turn my backagainst my own medicine? This felt like
disloyalty to who I was. But I took thetreatment as instructed and I soon saw
the improvement in my health.
ARVs have worked for me. I will not keeppeople on treatment that will not help them.
That would be wrong. My fellow traditional
healers have never questioned what I do.

International Activity Report 2012

syria

Conflict intensified across Syria in 2012: an increasing numberof casualties was reported, while access to medical care was
reduced and the aid provided fell far short of what was needed.

Medical attention for the direct victims ofviolence is not the only problem: prevailinginsecurity, the targeted destruction of healthfacilities and the collapse of the health systemmean that many people cannot access theroutine or emergency healthcare they need.
As the year went on, the humanitariansituation in the country deteriorated.
Caring for the victims of conflict
Despite not receiving government authorisation
to deliver medical assistance, Médecins
Sans Frontières (MSF) decided to work in
the country, in opposition-held areas. Two
hospitals were set up in Idlib governorate
and a third was opened in Aleppo.
A 15-bed trauma surgery unit was set up
in a house in Idlib in June. It includes anoperating theatre, emergency department andresuscitation room. In November, the teambegan to provide post-operative physiotherapy.
By the end of the year, 665 surgical procedures
had taken place and 2,230 patients hadreceived emergency treatment.
The hospital team in the region of Jabal
Al-Akrad, also in Idlib, first worked in a
cave, and then in a converted farm, where

they set up an outpatient department,
emergency department and operating
theatre. The team had seen more than
7,200 patients by the end of the year.
Staff also distributed basic relief items topeople displaced by conflict.
The hospital in Aleppo governorate not
only treats the war-wounded but also offers
obstetric and all other kinds of emergency
care, as well as basic health services. Staff
performed on average 70 surgical procedureseach month.
Expanding medical services
As access to health services worsened,
MSF extended activities to basic healthcare,vaccinations and maternal care. In the Deir
Ezzor area, a number of patients who faced
interruptions in treatment for chronic illnesses
such as asthma, diabetes and cardiovasculardisease received the medication they needed.
In addition, MSF donated tons of medicinesand medical supplies to health facilities
in Aleppo, Homs, Idlib, Hama, Deraa andDamascus governorates. In September,a large donation of medical supplies andrelief items was made to the Syrian Arab

AleppoIDLIB

Regions where MSF has projects

Key medical figures:• 12,450 outpatient consultations• 1,020 surgical procedures• 180 births assisted

Red Crescent in Damascus. Teams also
distributed relief items – including hygieneand cooking kits, and food and blankets –to the displaced and to local residents.
At the end of the year, despite repeatedrequests, MSF still had not received
government permission to work in the country.
Refugee assistance
By the end of 2012, hundreds of thousandsof Syrian refugees were living in neighbouring
countries. MSF programmes provided medical
assistance and relief in Iraq, Jordan, Lebanon
and Turkey (see reports on these countries
for more details).

© Nicole Tung

No. staff end 2012: 123 | Year MSF first worked in the country: 2009 | msf.org/syria

A baby just delivered by caesarean section at a hospital in northern Syria is cleaned and wrapped by the head nurse.
syria 87

Médecins Sans Frontières

tajikistan
Dushanbe

KULOB
Cities, towns or villages where MSF works

Key medical figures:• 18 patients began DR-TB treatment

A new programme for children
with tuberculosis (TB) has
been launched in Tajikistan.
General poverty and gaps in the healthcare
system mean there is no access to treatment
for TB for certain groups in Tajikistan,
despite high rates of the disease in the
country. Until recently, children with drugresistant tuberculosis (DR-TB) – those forwhom first-line treatment fails – did notreceive the more intensive, potentiallylifesaving treatment needed for this formof the disease.

A Médecins Sans Frontières (MSF) teamhas begun working on a paediatric TB
programme in the capital Dushanbe and thecity of Kulob. The goal is to improve bothaccess to and the quality of treatment forchildren with drug-sensitive TB and DR-TB,
and demonstrate that comprehensive careis feasible. TB is highly contagious, so family
members of paediatric patients are also
tested and treated.
Whenever possible, MSF treats children
and their family members as outpatients.
The team provides children with nutritional
and psychological support and organises
educational and developmental activities for
those who have to be admitted to hospital.
When patients are no longer infectious,
staff encourage schools to allow them toreturn to the classroom. Stigmatisation is
an issue, and MSF is working to increase TB

awareness and public support for the needsof children with TB, while advocating for
wider access to quality treatment.

Rukshona
11 years old, is the first patient to start
treatment for MDR-TB at the paediatric
TB hospital in Dushanbe.
I was diagnosed with MDR-TB in
November, five months after I started
showing signs of being ill. When I arrived
at hospital, I had severe malnutrition
too, and I have HIV.
It’s my grandfather who convinces me totake the treatment; I am being treatedat home – a local doctor visits me everyday. But the hospital staff say I need tospend several months in hospital if I am
to make a full recovery. We are nervousof returning to the hospital, because weare gypsies, and we don’t always gettreated in the same way as other people.

No. staff end 2012: 38 | Year MSF first worked in the country: 1997 | msf.org/tajikistan

turkeyThe number of Syrian refugees in camps in Turkey hadreached an estimated 143,000 at the end of 2012.

Istanbul

Kilis

Cities, towns or villages where MSF works

Key medical figures:• 1,690 outpatient consultations• 5,640 individual and group mental healthconsultations

According to national estimates, another
60,000 were living in urban areas. Authorities
were reaching the limits of their capacity.

accounted for in any relief distributions
or provision of services.

In the southern province of Kilis, Médecins
Sans Frontières (MSF), working with localorganisation Helsinki Citizens’ Assembly,
provides humanitarian relief and medical
services to people living in the camps andthe surrounding area, focusing mainly on
mental healthcare.

Hundreds of thousands of undocumented
migrants are thought to be living in
Istanbul. Many live and work in crowded
and unsafe conditions, suffer from stigma
or experience violence. MSF provides
mental healthcare to people with elevatedrisks to their health and mental wellbeing
who would otherwise not have access tosuch services. A team of psychologists,
community health workers and translators
offers psychosocial support and facilitates
patients’ referral to other services.

People in an ‘irregular administrative
situation’ are particularly vulnerable,
because they either do not hold a passportor have not been officially registered as
refugees, and are not therefore immediately

Assisting migrants in Istanbul

No. staff end 2012: 35 | Year MSF first worked in the country: 1999 | msf.org/turkey

88 tajikistan | turkey

International Activity Report 2012

ugandaOutbreaks of cholera, Ebola and Marburg haemorrhagic fever
all occurred in Uganda over the course of the year.
Arua
nebbi

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

Key medical figures:•6
 ,635 patients on first-line antiretroviraltreatment•1
 ,030 patients began TB treatment

From March to May, Médecins Sans
Frontières (MSF) responded to a cholera
outbreak in several locations across the
Nebbi district of Northern region, treating
600 patients for the disease, which causes
profuse diarrhoea and can lead to severe
dehydration and death.

Between July and October, teams provided
medical care to refugees from the conflict inNorth Kivu, Democratic Republic of Congo(DRC). Staff provided technical expertisefor the management of severe malnutrition,
treating 500 children at the Nyakabande
and Rwamwanja camps in Western region.
Teams also provided technical expertisefor the management of Ebola and Marburg
haemorrhagic fever in August and October,
respectively. There is no specific treatment
for either of these diseases, and fatality rates
vary significantly. MSF was in charge of
the Ebola ward in Kagadi hospital, Kibaale
district, after the outbreak was declaredin July. Teams managed patient care andworked in collaboration with Ministry of
Health staff to stop the epidemic.
HIV and TB programme
Arua regional referral hospital is the basefor a long-standing MSF HIV and TB
programme, though HIV treatment is now

available in 42 centres in Northern region.
A significant proportion of patients arefrom DRC, where access to antiretroviral(ARV) treatment is very limited. By the endof 2012, more than 6,600 people werereceiving ARV medication from MSF andnearly 900 patients co-infected with TB were
undergoing treatment for both diseases.

Fifi
27 years old
I came from Bunia in DRC, 200 miles
from here. I come here to get ARV drugs
but transport is too expensive, so I’ve
stayed with my sister in Arua for the past
six months. Every two months I comehere to collect my free treatment from
MSF. My six-year-old daughter tested HIV
positive first – that’s how I found out I
was sick too. She stays with me; we areboth under treatment. In the community,
there are people that accept us andothers that stigmatise. In Bunia there
is no free treatment and I cannot workat the moment.

© MSF

No. staff end 2012: 456 | Year MSF first worked in the country: 1986 | msf.org/uganda

Health workers responding to the Ebola outbreak prepare to start work at Kagadi hospital.
uganda 89

Médecins Sans Frontières

ukraine

The prevalence of all forms of TB anddrug-resistant TB (DR-TB), as well as
HIV, is far higher in prisons than among
the general population.

DonetskRegions where MSF has projects

Key medical figures:• 190 patients began DR-TB treatment• 4 8 patients on first-line antiretroviraltreatment

Drug-resistant forms oftuberculosis (TB) pose a serious
public health threat in Ukraine,
yet a comprehensive response
is not yet being implemented.

After overcoming difficulties importing thenecessary medicines for the programme, inJune 2012 Médecins Sans Frontières (MSF)
began treating patients at the hospital for
prisoners with TB and three pre-trial detention
centres in the eastern region of Donetsk.
The team provides treatment, as well as
psychological support, to patients with
DR-TB, and those co-infected with HIV. It canbe difficult for patients to adhere to theirregimen, as it lasts at least two years, and the
medication often causes severe side effects.
Counselling is therefore an important part ofthe programme. When patients are released
from prison, MSF staff make sure that they
have access to services and drugs so thatthey can continue treatment.

Andriy *31 years old
I grew up in Artyomovsk, a small town
outside Donetsk, in eastern Ukraine.
Unfortunately, I am infected with drugresistant tuberculosis. I was studying tobecome a builder, but I got into a drunken
fight one night and ended up in jail.
Inside prison, MSF started to provide mewith DR-TB treatment. When I got outof prison, my mother had died and mysister had sold my flat. I had nowhere togo. MSF will provide me with treatment
until I am cured, and has also arranged
for me to stay at the Artyomovsk TB
dispensary until I can find a place to live.
*

The patient’s name has been changed.

Staff have also been working to improve lab
facilities, infection control and drug supply
at the detention centres.

No. staff end 2012: 52 | Year MSF first worked in the country: 1999 | msf.org/ukraine

united states

Hurricane Sandy thrashed the United States’ east coast on
29 October, causing massive destruction and displacing
many residents.

hoboken

NEW YORK CITY

Cities, towns or villages where MSF works

Key medical figures:• 1,000 people received emergency medical
and mental healthcare

Despite the government’s comprehensive
emergency response, Médecins Sans
Frontières (MSF) found that medical services
were lacking in two key areas: evacuation
centres and apartment blocks in New Yorkand New Jersey. Many elderly, disabled or
chronically sick people were confined inhigh-rise blocks without electricity, wateror access to their medicines.
Teams of returned field workers and staff from
MSF’s New York office offered medical andmental healthcare at the FDR High School in
Brooklyn, the Susan E. Wagner High Schoolin Staten Island, and the Wallace Public
School, St Matthew’s Church and Saints Peterand Paul Church in Hoboken, New Jersey.
Working with information provided by local
community groups and other organisations,
MSF staff also visited people in their homes
to address their health needs.
The main goal was continuity in medicalcare, as the vast majority of patients had
chronic conditions such as diabetes, heartdisease, hypertension and upper respiratory
tract infections. Pharmacies were damaged
and closed, so teams identified pharmacies
in neighbouring communities that could
provide the necessary medicines. MSF
handed over activities to government
agencies and other organisations.

Staff responded to the emergency on a volunteer basis and are therefore notaccounted for | Year MSF first worked in the country: 2012 | msf.org/unitedstates

90 ukraine | united states

International Activity Report 2012uzbekistan

Despite high rates of drug-resistant tuberculosis (DR-TB)
in Uzbekistan, most people who have the disease are
undiagnosed and go without medical care.

In the Autonomous Republic of Karakalpakstan,
Médecins Sans Frontières (MSF) is helping
address gaps in TB diagnosis and treatment,
focusing on the provision of quality medicalcare for patients with DR-TB, who do notrespond to the standard first-line regimenof drugs that can cure drug-sensitive TB.
MSF is also introducing new approaches,such as using rapid diagnostic tests andtreating people as outpatients so they do
not always have to be hospitalised.
TB medication can have powerful side
effects such as headaches and nausea,

which can cause patients to interrupt ordiscontinue their regimens. MSF helps
patients medically manage side effects andprovides counselling to see them throughtreatment. The programme also supports
patients with education, transportation,
food packages and financial aid.
In 2012, MSF expanded its programme ofcomprehensive TB care to the districts of
Kegeily and Nukus Town, while TB care in
the districts of Takhtakupir and Karauzyak
was handed over to the Ministry of Healthin June.

Karauzyak
KEGEILY
Nukus
regionKhodjeily

Takhtakupir
Nukus Town
Takhiatash

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

Key medical figures:• 1,380 patients began TB treatment• 550 patients began DR-TB treatment

No. staff end 2012: 160 | Year MSF first worked in the country: 1997 | msf.org/uzbekistanzambiaOnly four out of ten women giving birth at healthcare facilities
in Zambia’s Northern province have a skilled health worker
present, according to national health authorities.

The situation is worst in rural areas. Luwingu
district, Northern province, is a remote andisolated place, where many deaths related topregnancy and childbirth are preventable.
Delays in referrals, long distances to healthcentres and a lack of qualified staff allcontribute to loss of life.
A maternal health programme was started by
Médecins Sans Frontières (MSF) in Luwingu
in 2010. Teams provide family planning,ante- and postnatal care and assist births
at Luwingu district hospital and seven rural
health centres. Emergency obstetric referrals
are made from clinics to the hospital, where
163 caesarean sections were performed

in 2012. A surgical team also offers fistula
repair. Obstetric fistulas are injuries tothe birth canal most often resulting fromprolonged, obstructed labour. They cause
pain and incontinence, which can lead tostigma and social exclusion.
Included in comprehensive sexual andreproductive health services is theprevention of mother-to-child transmissionof HIV (PMTCT). The MSF team also
conducts awareness and educational
activities to reduce stigma regarding HIV –which often prevents people from seeking
assistance – and encourages them to cometo the centres for testing and treatment.

Luwingu

Regions where MSF has projects

Key medical figures:• 2,430 births assisted• 8 ,500 antenatal consultations

No. staff end 2012: 76 | Year MSF first worked in the country: 1999 | msf.org/zambia

uzbekistan | zambia 91

Médecins Sans Frontières

zimbabwe
Key medical figures:• 6 4,780 patients on first-line antiretroviraltreatment• 4,410 patients began TB treatment• 1,300 patients treated after incidents
of sexual violence

The health system in Zimbabwe
continues to struggle withthe dual epidemic of HIV andtuberculosis (TB). Babies,
children and young adults
often do not have access toadequate care.
At several locations, Médecins Sans Frontières(MSF) provides comprehensive HIV and TB
care. The package of services includes rapid
testing, treatment, counselling, prevention of
mother-to-child transmission (PMTCT) andmedical and psychological support for victimsof sexual violence. In 2012, programmes
were further decentralised and integrated
into Ministry of Health facilities to improve
patients’ access to services.
In Tsholotsho, MSF staff work in thehospital and 14 rural health facilities, witha special focus on PMTCT, adolescents andchildren. As 40 per cent of patients camefrom neighbouring Umguza district, theteam trained nurses in Umguza to initiate
antiretroviral (ARV) treatment. A family
support clinic was also opened at Tsholotsho
district hospital, where MSF provided
medical and psychological support to
100 victims of sexual violence.

Gokwe North

Tsholotsho

HarareChikomba

Gweru

EpworthBuheraGutu

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

Focus on TB
A specific focus in Epworth, a southeastern
suburb of Harare, has been TB diagnosis
and care. A new testing machine has
enabled staff to obtain more reliable
results, more quickly: the machine gives
results – including for resistance to the drug
rifampicin – in less than two hours. A totalof 2,798 samples were tested in 2012. Of
these samples, traditional microscopy had
identified 15 per cent of results as positive,
whereas the machine found 22 per cent, thus
indicating significantly improved diagnosis.
Additionally, nine new patients were enrolled
in the multidrug-resistant TB (MDR-TB)

programme. Treatment for MDR-TB takes
up to two years and can cause severe side
effects. At the end of the year, forty morepatients were under MDR-TB treatment in
MSF programmes in the country.
Mentorship and handovers
In the district of Buhera, teams mentored
Ministry of Health staff in 26 clinics inpreparation for the handover of services,as 100 per cent coverage of people in needof ARV treatment had been reached. A new
TB testing machine was added to the lab,
and approximately 320 tests were carriedout per month.

In Beitbridge, on the border with South
Africa, MSF supported the Ministry of
Health to ensure effective HIV and TB
prevention, treatment and care. Staff
worked in six rural health facilities toincrease access to services. MSF also
supported the district hospital’s outpatient
service to integrate the treatment ofopportunistic infections. Since the project
opened, more than 6,100 patients havestarted HIV treatment, a third of thenumber estimated to be in need of it.

92 zimbabwe© Julie Remy

A new programme was launched in January
in the district of Gokwe North. Staff in the
district’s two rural hospitals and 16 healthcentres tested 13,900 people for HIV andregistered 2,200 patients for care. A totalof 325 people began treatment for TB. Heretoo, the teams provide care and treatment
for victims of sexual violence.

A TB nurse visits to prepare the daily drug regimen for a 44-year-old MDR-TB patient in
Buhera district.

© Julie Remy

International Activity Report 2012

A group of people living with HIV meet at Gombe clinic, Buhera district, where they sing, dramatise, draw and discuss their illness.

Teams in Gutu and Chikomba districts
continued to train and mentor staff in
23 clinics and provide technical support,
preparing for a rapid scale-up of HIV
treatment. A new TB testing machine wasalso installed in Gutu Mission hospital. The
last remaining patients in the HIV and TB
programme in Gweru were successfullytransferred to the Ministry of Health at theend of April.
Treating young victims of sexual violence
In Mbare, Harare, a programme for victimsof sexual violence offers free medical care,counselling and referrals for psychological,
psychosocial and legal support. Working inclose collaboration with local partners, MSF
teams cared for 900 new and 925 followup patients. More than half of them were
under 16 years of age.
Psychiatric care in prisons
An assessment at Harare maximum security
prison indicated that many inmates

were suffering from undiagnosed anduntreated mental illness. MSF opened a newprogramme in May to fill gaps in psychiatriccare, providing patients from Harare andeight other prisons with psychiatric services,
psychological consultations and occupational
therapy.
Typhoid emergency
Between October 2011 and April 2012
and then from November 2012, MSF assisted
Harare city authorities in responding topeaks in a typhoid outbreak. Typhoid
fever is a bacterial disease spread throughcontaminated food and water, with symptoms
appearing only one to three weeks after
exposure. Patients are treated with antibiotics,
although some people remain carriers ofthe disease even after they have recovered
themselves. As well as offering treatment andcare, MSF assisted in the provision of safe
water, the improvement of sanitation anddisease prevention activities.

Sikhethklle
received PMTCT treatment in Tsholotsho.
Thanks to the prevention programme,
my daughter was born HIV-free. I was so
surprised that I called her Surprise! A nurse
gave me the medicine I had to take before,
during and after giving birth, and she told
me what I had to do on the day of delivery.
I did everything as the nurse told me, andwhen I went into labour, I took the twopills that I had been given at the hospital.
I remember that day very well!
I am so happy to see her; especially after
all the time I suffered while I was sick. At
that time I never imagined I could havea baby, but thanks to the prevention
programme I managed to have mydaughter free of HIV. Soon she will bea year old, and she has already begun
to take her first steps.

No. staff end 2012: 680 | Year MSF first worked in the country: 2000 | msf.org/zimbabwe

zimbabwe 93

Médecins Sans Frontières

yemen
Amran
hajjahAd-Dali
Abyan
Lahj

ADEN

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

Key medical figures:• 104,900 outpatient consultations• 3,400 surgical procedures• 3,160 births assisted

Violence and politicalinstability are preventing
access to healthcare in a
number of regions in Yemen.
Security incidents within health facilities
further restrict access. In 2012, Médecins
Sans Frontières (MSF) was forced to suspend
activities on several occasions in some areas.
MSF continues to promote the importanceof weapon-free health facilities andprotecting patients and staff.

Surgical centre opened in AdenIn April, MSF opened a 40-bed emergency
surgical centre inside Al-Wahda hospitalcompound, in the city of Aden. The centre
receives patients from within Aden as well
as from MSF-supported facilities in Abyan
and Ad-Dali. Patients needing specialist
reconstructive surgery are referred fromhere and Sana’a to Amman, Jordan(see page 58).
By the end of the year, most people
displaced by the civil unrest had returned
home, lessening the demand on healthfacilities in Aden, and the team withdrew
from three clinics in the city.
Supporting emergency services
In Ad-Dali governorate, MSF worked in theemergency department of Al-Naser hospitaland managed surgical referrals to Aden.
The team also improved sterilisation andwaste management, and donated drugs andmedical supplies for the operating theatre.
In Abyan governorate, staff provided
emergency, surgical and maternity services
at the Post Office medical post in Jaar, until
public health authorities reopened Al-Razi

hospital in June. The hospital had beenclosed in September 2011 after an attackon the facility killed seven people. MSF also
supports Lawdar hospital and other healthfacilities in Abyan with donations of drugs
and medical supplies.
Measles broke out in Amran and Ad-Daliat the beginning the year. MSF staff treated395 patients. In Abyan, 83 people weretreated for dengue, a virus transmitted
by infected mosquitoes, which causes
flu-like symptoms.
Mental health programme opened
An MSF team started to provide mental
health assistance to migrants in Haradh,
Hajjah governorate, which is on one of themain routes from the Horn of Africa to theGulf states.
Activities reduced in Hajjah and Lahj
Activities in the hospital near Al-Mazraq,
in Hajjah, and in Radfan district hospital,
Lahj governorate, were scaled down, as
the situation for the displaced stabilised.
In December, MSF withdrew from Al-Hosn
health centre.

No. staff end 2012: 576 | Year MSF first worked in the country: 1994 | msf.org/yemen

Huth health centre closed due
to security incident
Huth health centre, in Amran governorate,
was closed by the Ministry of Health after
armed men entered and threatened MSF
staff in September. Emergency, outpatient,maternal, paediatric and inpatient services
were halted.

Joint mobile teams of national and MSF
staff carried out regular clinics in the remote
Osman and Akhraf valleys to screen for andtreat malaria and malnutrition. Mosquito
nets were distributed and the number ofcases of malaria fell to zero in the Osman
valley towards the end of the year. More than
300 patients received treatment in total.

94 yemen© Jacob Zocherman

In contrast, the team at Al-Salam hospital in
Khamir increased activities, opening a newnursery, a paediatric ward and an intensive
care unit, and expanding maternity services.
The outpatient feeding programme washanded over to the Ministry of Health sothat MSF could focus attention on patients
suffering from more complex conditions.

A new paediatric ward was opened at Al-Salam hospital, Khamir, as part of an overall
increase in activities.

special reports 2012
Dadaab Refugee Camps:
Back to Square One

FEBRUARY
Lives in the Balance: The
Urgent Need for HIV and
TB Treatment in Myanmar

Syria: Medicine as a Weaponof Persecution

Urgent Delivery: Maternal
Death – The Avoidable Crisis

MARCH

Somebody Help: The Forgotten
Population of North Darfur
The Right Shot: Extending theReach of Affordable
and Adapted Vaccines

Losing Ground: How Funding Shortfalls
and the Cancellation of the Global Fund’sRound 11 Are Jeopardising the Fightagainst HIV and TB
From the Ground Up: Building a
Drug-Resistant TB Program in Uganda

MAY
Untangling the Webof Antiretroviral Price
Reductions: 15th Edition

Speed Up Scale Up: Strategies,
Tools and Policies to Get theBest HIV treatment to More
People, Sooner

Assisting the Somali
Population Affected by the
Humanitarian Crisis of 2011:
Overview of MSF Activities inSomalia, Kenya and Ethiopia

Fighting Neglect: Finding
Ways to Manage and Control
Visceral Leishmaniasis, Human
African Trypanosomiasis andChagas Disease

Dadaab: Shadows of Lives

JUNE

Undetectable: How Viral LoadMonitoring Can Improve HIV
Treatment in Developing
Countries

Time is Running Out: Zamfara
State Lead Poisoning Crisis

JULY
Closer to Home: Delivering
Antiretroviral Therapy in theCommunity

Safe Delivery: Reducing Maternal Mortality
in Sierra Leone and Burundi
South Sudan’s Hidden Crisis

Progress under Threat: Perspectives
on the HIV Treatment Gap

SEPTEMBER
DR-TB Drugs under theMicroscope: 2nd Edition

Fleeing the Violence in Syria:
Syrian Refugees in Lebanon

NOVEMBER

Out of the Dark: Meeting the
Needs of Children with TB

All these reports are available atwww.msf.org/2012-reports

special reports 2012 95

Médecins Sans Frontières

Facts andFiguresMédecins Sans Frontières(MSF) is an international,
independent, private andnon-profit organisation.
It is made up of 23 associations: Australia,
Austria, Belgium, Brazil, Canada, Denmark,East Africa, France, Germany, Greece, Holland,Hong Kong, Italy, Japan, Latin America,
Luxembourg, Norway, Southern Africa, Spain,
Sweden, Switzerland, UK, USA. MSF’s
day-to-day activities are managed by
19 national offices and nine branch offices(see page 100 for contact details).
The search for efficiency has led MSF
to create 10 specialised organisations,called ‘satellites’, which take charge of
specific activities such as humanitarianrelief supplies, epidemiological andmedical research, and research on
humanitarian and social action. Thesesatellites, considered as related parties tothe national offices, include: MSF-Supply,
MSF-Logistique, Epicentre, Fondation MSF,
Etat d’Urgence Production, MSF Assistance,
SCI MSF, SCI Sabin, Ärzte Ohne Grenzen
Foundation and MSF Enterprises Limited.
As these organisations are controlled by
MSF, they are included in the scope ofthe MSF Financial Report and the figures
presented here.
These figures describe MSF’s finances
on a combined international level. The
2012 combined international figures havebeen prepared in accordance with MSF
international accounting standards, which
comply with most of the requirementsof the International Financial ReportingStandards (IFRS). The figures have been
jointly audited by the accounting firms of

KPMG and Ernst & Young, in accordancewith International Auditing Standards.
A copy of the full 2012 Financial Report may
be obtained at www.msf.org. In addition,
each national office of MSF publishes
annual, audited Financial Statements
according to its national accounting
policies, legislation and auditing rules.
Copies of these reports may be requested
from the national offices.
The figures presented here are for the 2012
calendar year. All amounts are presented inmillions of euros.
Note: Figures in these tables are rounded,
which may result in apparent inconsistencies
in totals.

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

Programme expenses by continent
34 %
23 %
17 %
12 %
6%
5%
2%
1%

The biggest category of expenses
is dedicated to staff working in thefield: about 57 per cent of expenditurecomprises all costs related to
locally hired and international staff(including plane tickets, insurance,
accommodation, etc.).
The medical and nutrition category
includes drugs and medical
equipment, vaccines, hospitalisation
fees and therapeutic food. The
delivery of these supplies is includedin the category of transport, freightand storage.
Logistics and sanitation comprisebuilding materials and equipment
for health centres, water andsanitation and logistical supplies.

96 Facts and Figures

AfricaAsia
Americas
EuropeOceania
Unallocated

68 %
20 %
8%
2%
1%
1%

International Activity Report 2012
Countries where we spent the mostCountries where MSF expenditure is more than 10 million euros

in millions of euros

120
100
80
60
40
20

nd

a

ila
az

Sw

G

ui

ne

a
di
In

q
Ira

ar
nm

en

ya
M

Ye
m

ki

st

an

an
Pa

an
Af

gh

pu
Re
n

ra

lA

fri

ca

So

ist

bl

er

ic

ia

e

ig

Zi

m

N

ba

hi
Et

bw

ia
op

ad
Ch

da

n

a
Su

ny
Ke

ut

h

So

m

al

ia

er
ig
N

ti
ai
H

Su

D

da

n

RC

0

Ce

nt

In 2010, South Sudan and Sudan were one
country: total programme expenditure was
38.9 million euros.

2012

2011

2010

72.8

ASIA AND
THE MIDDLE EAST

Haiti

37.9

South120
Sudan

61.2

Afghanistan

16.5

Colombia

8.7

Niger100

26.2

Pakistan

14.5

Bolivia and Paraguay * *2.0Somalia

25.2

Yemen

13.3

Mexico

1.1

Kenya

22.6

Myanmar13.0

Other countries *2.0

Sudan 60

20.2

Iraq

12.9

Chad

20.0

India

10.9

Ethiopia

19.2

Syria

9.6

19.0

Uzbekistan

5.9

Nigeria 0

18.8

Lebanon

4.9

Central African Republic

18.5

Bangladesh

3.7

Guinea

10.5

Occupied Palestinian Territory

3.6

Swaziland

10.4

Kyrgyzstan

3.1

Malawi

9.8

Armenia

2.0

Mali

9.1

Cambodia

1.8South Africa

8.1

Tajikistan

1.3

Mozambique

7.6

TurkeySierra Leone

7.3

Other countries

Uganda6.4

Côte d’Ivoire

4.1

AFRICA

in millions of E

Democratic Republic of Congo

80
40

20
Zimbabwe

Total

THE AMERICAS
in millions of E

Total

in millions of E

51.7

EUROPE

in millions of E

Russian Federation

6.3

Ukraine2.4

FranceOther countries

1.2
*

Total

1.2
11.1

1.2
*

4.9

OCEANIA

in millions of E

Papua New Guinea

5.0

Total

5.0

123.1

Burundi4.1

Mauritania

4.0

Cameroon

3.3

Congo

3.1

UNALLOCATED

Burkina Faso

2.4

Transversal activities

1.2

Zambia

2.0

Other

5.1

Egypt

1.5

Madagascar

1.2

Total

6.3

MoroccoOther countries
Total

1.0
*

2.6
422.2

in millions of E

* ‘Other countries’ combines all the countries
for which programme expenses were below
one million euros.
** Bolivia and Paraguay are operated as a joint
programme.

Facts and Figures 97

Médecins Sans Frontières

WHERE DID THE MONEY COME
FROM?

2012

2011

in millions of e

percentage

in millions of e

percentage

Private

838.9

89%

791.6

89%

Public institutional

82.7

9%

75.2

9%

Other

16.1

2%

18.7

2%

Income

937.7

100%

885.5

100%

in millions of e

percentage

in millions of e

percentage

Programmes

619.4

66%

609.8

68%

Headquarters programme support

103.9

11%

92.3

10%

Témoignage/awareness-raising

31.7

3%

27.5

3%

Other humanitarian activities

7.4

1%

7.0

1%

Social mission

762.4

81%

736.6

82%

Fundraising

124.8

13%

110.9

12%

Management and general administration

56.6

6%

52.4

6%

Income tax

0.1

–

–

–

Other expenses

181.5

19%

163.3

18%

Expenditure

943.9

100%

899.9

100%

HOW WAS THE MONEY SPENT?

2012

2011

Net exchange gains/losses

-4.8

-1.6

Surplus/deficit

-11.1

-16.0

YEAR-END FINANCIAL
POSITION

2012
percentage

in millions of e

percentage

Cash and cash equivalents

551.4

79%

572.9

81%

Other current assets

91.1

13%

84.4

12%

Non-current assets

57.4

8%

49.6

7%

699.9

100%

706.9

100%

Permanently restricted funds

3.4

–

2.5

–

580.2

83%

592.3

84%

Other retained earnings and equities

15.0

2%

16.1

2%

Retained earnings and equities

598.6

85%

610.9

86%

Current liabilities

101.3

15%

96.0

14%

Liabilities and retained earnings

699.9

100%

706.9

100%

Unrestricted funds

98 Facts and Figures

89 %
9%
2%

4.6
millionprivate donors

2011

in millions of e

AssetsPrivate income
Public institutional income
Other income

IncomeExpenditure
Deficit

937.7
943.9
-11.1

International Activity Report 2012

HR STATISTICS

2012

2011

Medical pool

1,548

26%

1,734

27%

Nurses and other paramedical pool

1,785

30%

1,935

30%

Non-medical pool

2,622

44%

2,707

43%

International departures (full year)

5,955

100%

6,376

100%

no. staff

percentage

no. staff

percentage

Locally hired staff

29,22886%

29,302

86%

International staff

2,592

7%

2,580

8%

Field positions

31,82093%

31,882

94%

2,326

7%

2,062

6%

34,146100%

33,944100%

Positions at headquarters
Staff

Locally hired staff
International staff
Headquarters staff

86%
7%
7%

The majority of MSF staff (86 per cent) are hired locally in the countries of intervention.
Headquarters staff represent 7 per cent of total staff.

Sources of income
As part of MSF’s effort to guarantee its independence andstrengthen the organisation’s link with society, we strive to maintaina high level of private income. In 2012, 89 per cent of MSF’s income
came from private sources. More than 4.6 million individual donors
and private foundations worldwide made this possible. Public
institutional agencies providing funding to MSF included, among
others, the European Commission’s Humanitarian Aid Department(ECHO) and the governments of Belgium, Canada, Denmark, France,
Germany, Italy, Ireland, Luxembourg, Norway, Spain, Sweden,
Switzerland and the UK.
Expenditure is allocated according to the main activities performed
by MSF. All programme expenditure categories include salaries,
direct costs and allocated overheads.
Social mission includes all costs related to operations in the field(direct costs) as well as all the medical and operational support fromthe headquarters directly allocated to the field (indirect costs). Social
mission costs represent 81 per cent of the total costs for 2012.

Permanently restricted funds may be capital funds, where donors
require the assets to be invested; funds retained for actual use,rather than expended; or the minimum level of retained earnings
that is compulsory for certain sections of MSF.
Unrestricted funds are unspent, non-designated donor funds
expendable at the discretion of MSF’s trustees in furtherance of oursocial mission.
Other retained earnings represent foundations’ capital as well as
technical accounts related to the combination process.
MSF’s retained earnings have been built up over the years bysurpluses of income over expenses. At the end of 2012, the available
portion (excluding permanently restricted funds and capital forfoundations) represented 7.6 months of the preceding year’s
activity. The purpose of maintaining retained earnings is to meetthe following needs: future major emergencies for which sufficientfunding cannot be obtained, a sudden drop in private and/or public
institutional funding, the sustainability of long-term programmes(e.g. antiretroviral treatment programmes), and the pre-financingof operations to be funded by forthcoming public fundraising
campaigns and/or public institutional funding.
The complete Financial Report is available at www.msf.org

Facts and Figures 99

Médecins Sans Frontières

Contact MSF
International Médecins Sans Frontières
78 rue de Lausanne Case Postale 116
1211 Geneva 21 Switzerland
T +41 22 849 84 00 F +41 22 849 84 04
www.msf.org

Humanitarian Advocacy and
Representation team(UN, African Union, ASEAN, EU, Middle East)
T +41 22 849 84 00 F +41 22 849 84 04
MSF Access Campaign
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1211 Geneva 21 Switzerland
T +41 22 849 8405 www.msfaccess.org

Australia Médecins Sans Frontières
Level 4 | 1-9 Glebe Point Road | Glebe NSW 2037
PO BOX 847 | Broadway NSW 2007 | Australia
T +61 28 570 2600 F +61 28 570 2699
office@sydney.msf.org www.msf.org.au
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Taborstraße 10 1020 Vienna Austria
T +43 1 409 7276 F +43 1 409 7276/40
office@aerzte-ohne-grenzen.at
www.aerzte-ohne-grenzen.at

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

UK Médecins Sans Frontières /Doctors Without Borders
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T +44 20 7404 6600 F +44 20 7404 4466
office-ldn@london.msf.org www.msf.org.uk

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

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

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

Branch Offices

Italy Médecins Sans Frontières/Medici Senza Frontiere
Via Magenta 5 00185 Rome Italy
T +39 06 88 80 6000 F +39 06 88 80 6027
msf@msf.it www.medicisenzafrontiere.it
Japan Médecins Sans Frontières /国境なき医師団
3F Waseda SIA Bldg 1-1 Babashitacho
Shinjuku-ku Tokyo 162-0045 Japan
T +81 3 5286 6123 F +81 3 5286 6124
office@tokyo.msf.org www.msf.or.jp

Belgium Médecins Sans Frontières /Artsen Zonder Grenzen
Rue Dupré 94 Dupréstraat 94
1090 Brussels Belgium
T +32 2 474 74 74 F +32 2 474 75 75
www.msf.be or www.azg.be

Luxembourg Médecins Sans Frontières
68, rue de Gasperich 1617 Luxembourg
Luxembourg
T +352 33 25 15 F +352 33 51 33
info@msf.lu www.msf.lu

Canada Médecins Sans Frontières /Doctors Without Borders
720 Spadina Avenue, Suite 402 Toronto
Ontario M5S 2T9 Canada
T +1 416 964 0619 F +1 416 963 8707
msfcan@msf.ca www.msf.ca

Norway Médecins Sans Frontières /Leger Uten Grenser
Hausmannsgate 6 0186 Oslo Norway
T +47 23 31 66 00 F +47 23 31 66 01
epost@legerutengrenser.nowww.legerutengrenser.noDenmark Médecins Sans Frontières /Læger uden Grænser
Dronningensgade 68, 3. 1420 København K
Denmark
T +45 39 77 56 00 F +45 39 77 56 01
info@msf.dk www.msf.dk

Spain Médecins Sans Frontières /Médicos Sin Fronteras
Nou de la Rambla 26 08001 Barcelona Spain
T +34 93 304 6100 F +34 93 304 6102
oficina@barcelona.msf.org www.msf.es

France Médecins Sans Frontières
8 rue Saint Sabin 75011 Paris France
T +33 1 40 21 29 29 F +33 1 48 06 68 68
office@paris.msf.org www.msf.fr
Germany Médecins Sans Frontières /Ärzte Ohne Grenzen
Am Köllnischen Park 1 10179 Berlin
Germany
T +49 30 700 13 00 F +49 30 700 13 03 40
office@berlin.msf.org
www.aerzte-ohne-grenzen.de

100 Contact MSF

Sweden Médecins Sans Frontières /Läkare Utan Gränser
Gjörwellsgatan 28, 4 trappor Box 34048
100 26 Stockholm Sweden
T +46 10 199 32 00 F +46 8 55 60 98 01
info.sweden@msf.org
www.lakareutangranser.se
Switzerland Médecins Sans Frontières /Ärzte Ohne Grenzen
78 rue de Lausanne Case Postale 116
1211 Geneva 21 Switzerland
T +41 22 849 84 84 F +41 22 849 84 88
office-gva@geneva.msf.org www.msf.ch

Argentina
Carlos Pellegrini 587 11th floor C1009ABK
Ciudad de Buenos Aires Argentina
T +54 11 5290 9991 www.msf.org.ar
BrazilRua do Catete, 84 Catete Rio de Janeiro
CEP 22220-000 Brazil
T +55 21 3527 3636 www.msf.org.br
Czech Republic
Seifertova 555/47 130 00 Praha 3 Žižkov
Czech Republic
T +420 257 090 150 www.lekaribezhranic.cz
India
C-106 Defence Colony
New Delhi-110024 India
T +91 11 465 80 216 www.msfindia.in
Ireland
9-11 Upper Baggot Street Dublin 4
T +353 1 660 3337 www.msf.ie

Ireland

MexicoChampotón 11 Col. Roma Sur
CP 06760 Ciudad de México Mexico
T +52 55 5256 4139 www.msf.mx
Republic of Korea
9F Hosoo Bldg. 68-1 Susong-dong
Jongno-gu Seoul 110-140 Republic of Korea
T +82 2 3703 3500 www.msf.or.kr
South Africa
Orion Building 3rd floor 49 Jorissen Street
Braamfontein 2017 Johannesburg South Africa
T +27 11 403 44 40 www.msf.org.za
United Arab Emirates
P.O. Box 47226 Abu Dhabi UAE
T +971 2631 7645 www.msf-me.org

About this report
Contributors
Caroline Abu-Sada, Ali Al-Mawlawi, Halimatou Amadou, Louise Annaud, James Arkinstall,
Shaista Aziz, Aurélie Baumel, Niklas Bergstrand, Pierre Borelle, Andrea Bussotti, Jehan Bseiso,
Brigitte Breuillac, Talia Bouchouareb, Lali Cambra, Françoise Duroch, Silvia Fernández,
Isabelle Ferry, Mathieu Fortoul, Marisol Gajardo, Sarah-Eve Hammond, Carolina Heidenhain,
Joanna Keenan, Jo Kuper, Aurélie Lachant, Yann Libessart, Samantha Maurin, Eddy McCall,
Robin Meldrum, Isabelle Merny, Agustin Morales, Jessica Neerkorn, Elias Primoff, Yasmin Rabiyan,
Catherine Robinson, Javier Sancho, Faith Schwieker-Miyandazi, Victoria Russell,
Gregory Vandendaelen, Jonathan Whittall.
Special thanks to
Valérie Babize, François Dumont, Marc Gastellu Etchegorry, Myriam Henkens, Nicolette Jackson,
Unni Karunakara, Erwin van ’t Land, Caroline Livio, Jérôme Oberreit, Emmanuel Tronc.
We would also like to thank all the field, operations and communications staff who provided
and reviewed material for this report.
English Edition
Managing Editor Jane Linekar
Editorial Support Caroline Veldhuis and Yi Ling Hwong
Photo Editor Bruno De Cock
Proof Reader Kristina Blagojevitch
French Edition
Editor Laure Bonnevie, Histoire de mots
Translator Translate 4 U sarl (Aliette Chaput, Emmanuel Pons)
Spanish Edition
Coordinator Javier Sancho
Translator Pilar Petit
Editor Mar Padilla
Arabic Edition
Coordinator Jessica Moussan-Zaki
Translator Mouine Imam (Commanine)
Editor Jessica Moussan-Zaki
Designed and produced by
ACW, London, UK
www.acw.uk.com

Médecins Sans Frontières (MSF) is an international,
independent, medical humanitarian organisation that delivers
emergency aid to people affected by armed conflict, epidemics,
exclusion from healthcare and natural disasters. MSF offers
assistance to people based on need and irrespective of race,
religion, gender or political affiliation.
MSF is a non-profit organisation. It was founded in Paris, France
in 1971. Today, MSF is a worldwide movement of 23 associations.
Thousands of health professionals, logistical and administrative
staff manage projects in some 70 countries worldwide.
MSF International is based in Geneva, Switzerland.
MSF International
78 rue de Lausanne, CP 116, CH-1211, Geneva 21, Switzerland
Tel.: +41 (0)22 849 8400, Fax: +41 (0)22 849 8404
COVER PHOTO
A surgical team carries out an operation to remove a bullet from a patient, northern Syria.
© Nicole Tung