Activity
Report 2011www.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 and makeno claim for themselves or their assigns for any form of compensation other than that which theassociation might be able to afford them.

The country texts in this report provide descriptive overviews of MSF’s operational activities throughout the world between
January and December 2011. Staffing figures represent the total full-time equivalent positions per country in 2011.
Country summaries are representational and, owing to space considerations, may not be comprehensive. Some patients’names have been changed for reasons of confidentiality.
The place names and boundaries used in this report do not reflect any position by MSF on their legal status.

Contents
2

MSF programmes Around The World

4	The Year in Review
Dr Unni Karunakara, International President
Kris Torgeson, Secretary General4

The year in review

8	Overview Of Operations
10

Glossary of Diseases and ACTIVITIES

14

humanitarian action: at any price?

16

somalia: extreme needs, extreme choices

18

Thailand: Médecins Sans Frontières closes
its longest mission

22

Scaling up HIV treatment:
Getting ahead of the wave of new infections

25

activities by country

111

special reports 2011112

Facts and figures

14 Humanitarian action: at any price?

18 Thailand: MSF’s longest mission

116	Contact Médecins Sans Frontières

22 Scaling up HIV treatment

25 Activities by country

Contents

1

MSF programmes
around the world

FranceItaly

Georgia
Armenia

TurkeyGreeceLebanonTunisia

Syria

Iran

Iraq

Occupied
Palestinian
Territory

Morocco
Libya

EGYPT

Bahrain

Haiti
Mali

Guatemala

Niger
Sudan

Chad

Honduras
GuineaSierra Leone
Liberia
Colombia

Yemen

Burkinafaso

Djibouti
Nigeria

Ivory
Coast
Cameroon

CentralAfricanRepublic

Ethiopia

south
Sudan

Somalia

UgandaKenya

Congo
Democratic
Republic of
THE Congo

BurundiBrazilMalawi
ZambiaBolivia
Zimbabwe

Madagascar
Mozambique

PARAGUAY
SwazilandSouth
Africa2

MSF programmes around the world

LesothoRussian
Federation

Uzbekistan

Kyrgyzstan

Japan

China
Afghanistan

Pakistan
India

Bangladesh

26

Afghanistan

69	Lebanon

28

Armenia70	Lesotho

29 	Bahrain

71	Liberia

30	Bangladesh

72	Libya

31	Bolivia

74

Madagascar

32	Brazil

75

Malawi

33	Burkina Faso

76

Mali

34	Burundi

77

Morocco35 	Cambodia

78

Mozambique

36	Cameroon

80

Myanmar37	Central
AfricanRepublic

84	Niger

38	Chad40	China

85	Occupied
Palestinian
Territory

42	Colombia

86	Pakistan

41	Congo

87	Papua New
Guinea44	Democratic
Republic of the
Congo

MyanmarThailandCambodia46	Djibouti
Philippines

47	Egypt

Sri Lanka

Papua
New Guinea

82	Nigeria

88	Paraguay
89	Philippines
90

RussianFederation

48	Ethiopia

91	Sierra Leone

50

92	Somalia

France51	Georgia

94	South Africa

52	Greece

96	South Sudan

53	Guatemala

95	Sri Lanka

54	Guinea

98	Sudan

56	Haiti

99	Swaziland

55	Honduras

100	Syria

58	India

101	Thailand

60	Iran

102	Tunisia

61	Iraq

103	Turkey

64	Italy

104	Uganda

62	Ivory Coast

105	Uzbekistan

65	Japan

106	Yemen

66	Kenya110	Zambia

68	Kyrgyzstan

108	Zimbabwe

MSF programmes around the world3

Médecins Sans Frontières

The Yearin Review
Dr Unni Karunakara, International President
Kris Torgeson, Secretary General2011 was a year of multiple,
complex, humanitarian
emergencies, and almost
all challenged our capacity
to respond.
Protracted war, drought and restricted
access to medical assistance or relief allcontributed to a worsening of the crisis
across south-central Somalia. From May
to December, Médecins Sans Frontières(MSF) treated more than 95,000 people formalnutrition and over 6,000 for measles
in south-central Somalia and in refugee
camps in Ethiopia and Kenya. We vaccinatedalmost 235,000 children against measles
and held more than 450,000 consultations.
Yet we still had enormous difficulties
reaching the people we suspected to bein the greatest need. For the most part,we were limited to scaling up existing
operations. In many places, we were blockedfrom opening new programmes, whilein others, insecurity prevented us fromexpanding. On 13 October 2011, two of ourcolleagues, Blanca Thiebaut and Montserrat
Serra, were abducted from one of the Somali
refugee camps in Dadaab, Kenya. At thevery end of the year, our colleagues Philippe
Havet and Dr Andrias Karel Keiluhu wereboth killed while working in Mogadishu.
Dedicated humanitarians, Philippe andAndrias had each worked for MSF for morethan a decade. (For more on the challenges
of working in Somalia, see pages 16–17.)

MSF teams provided healthcare throughhospitals and fixed and mobile clinics
across western Ivory Coast and in the cityof Abidjan. They also brought medical
assistance to Ivorian refugees in Liberia.

continued to bring medical assistance topeople caught up in violence, focusing on
emergency medical care and surgery, as well as
maternal and paediatric services.

In the Democratic Republic of the Congo(DRC), violence and insecurity persisted
throughout the year. Our medical staff
tended to hundreds of thousands of people
who had no other access to healthcare.

In Bahrain, MSF staff brought basic healthcare
to the homes of some 200 people, who were
unwilling to run the risk of seeking assistancein public health facilities. But our movements
were restricted. We spoke out against thearrest of patients and staff in hospitals andclinics, and called on the Bahraini authorities
to respect their obligations regarding theprovision of healthcare to the sick and injured.

The DRC gained a new neighbour in 2011,
as South Sudan achieved independence,but it too was afflicted by insecurity andan inadequate health system. MSF teams
worked in seven of the country’s 10 states.
When conflict erupted in Libya, MSF supported
health facilities in a number of towns withsurgery, basic healthcare and psychologicalsupport. Teams also assisted some of thethousands of people who fled to Italy andTunisia. However, it was weeks before wewere able to work on both sides of the frontline. In Pakistan and Afghanistan, MSF teams

New contexts

The situation in Bahrain represented a newkind of context for our work: emergencies
in middle-income, even wealthy, countries,
which have good health systems. We
adapted our response accordingly, providing
short-term emergency assistance and filling
specific gaps. In Egypt, MSF supported
national health workers by donating supplies
and training staff in emergency preparedness
and response.

When the presidential election led to fullscale military conflict in Ivory Coast, clinics
and hospitals were abandoned as people
fled violence. “Many of the medical facilities
in the western part of the country are notfunctioning because health staff have not
returned to work and because they lack
medicine,” said Xavier Simon, MSF’s headof mission, at the time.

4

The Year in Review© Martina Bacigalupo

Conflict and insecurity

Displaced Somalis await food distribution in Mogadishu.

© Ben Milpas

Activity Report 2011

A patient receives treatment for a gunshot wound at Dungu hospital, Democratic Republic of the Congo.

Responding to natural disasters
An earthquake and tsunami wreaked havoc
in northeastern Japan in March. Again,
MSF adapted its response to a new context.
“The set-up with these very flexible mobile
teams is responding to the needs”, said
Eric Ouannes, general director of MSF Japan.
“Most urgent needs are covered… there
are some gaps, and we are here to try tofill those gaps”. Our teams targeted theirsupport, helping to build a temporary clinic,
conducting medical consultations andproviding counselling.
In Latin America, MSF brought assistanceto people displaced by flooding in Brazil,
Guatemala and Honduras, donating relief
supplies and operating mobile clinics. We also
supplied aid in southeast Asia, after a typhoonin the Philippines and floods in Thailand. When
Van province in Turkey was hit by earthquakes,
we offered relief and mental healthcare.
Neglected needs, protracted crises
MSF responded to many emergencies, butalso continued to work in places where
people endure situations of chronic crisis.
In both Haiti and South Sudan, MSF is
responding to a pressing need for specialist

healthcare by investing in hospitals, in orderto improve access to surgical care and otherlifesaving secondary health services.
Basic healthcare still remains a priority.
In the Central African Republic, we aresupporting nine hospitals as well as 36 healthcentres. But both government and donor
funding for health in the country is declining,although studies in 2011 revealed excess
mortality rates in the town of Carnot – which
has not suffered any particular crisis – to be
three times the emergency threshold.
The high rates of mortality in the Central
African Republic are caused by a highprevalence of diseases that can beprevented, and treated. Indeed, globally,outbreaks of some of the more common,
treatable, infectious diseases, like measles
and cholera, are increasing. However, ourapproaches to prevention and treatment
have changed little in decades. MSF
vaccinated over five million people against
measles in 2011, and treated nearly 139,000
for cholera. But our response is inadequate:
three million measles vaccinations in the
Democratic Republic of the Congo could
not prevent 129,000 people falling ill,and 1,500 dying.

We are advocating for a system that effectively
anticipates and prevents outbreaks, and for
improved treatment options, in order to beable to provide effective, good-quality care.
Assuring quality
Our standards of care reflect the respect inwhich we hold our patients, but assuring
these standards can be a challenge.
In Paraguay, our team temporarily had
to stop screening for Chagas disease, as
production of the drug used to treat it was
halted. Chagas disease affects some 14 million
people and kills 50,000 every year. Yet only
one company, based in Brazil, produces
benznidazole, the most commonly used
medicine for Chagas. An international
outcry prompted the Brazilian Ministryof Health to ensure production restarted.
However, at the end of the year, there werestill interruptions in supply.
As governments raise more regulatory
barriers to imports, and ministries ofhealth or other organisations frequently
have their own sources of supply, quality
assurance is becoming more of an issue
in relation to the medicines we use. The
increased risk was brought home to us

The Year in Review

5© Niklas Bergstrand

Médecins Sans Frontières

Surgical consultation at Ben Ashour clinic, Tripoli, Libya.

when falsified antiretroviral (ARV) drugs,
which had been purchased from one of themost reputable distributors in Kenya, oneof the most highly regulated countries in
East Africa, were found at an MSF clinic.
MSF introduced a drug quality assurance
system in 2002, but cooperation at a global
level, with governments and other medicalorganisations, is required if we are to ensurethat patients receive the quality medicines
they need.
Progress in jeopardy
We also need the unprecedented
international solidarity, which has resulted
in improved treatment for millions of HIV,malaria and tuberculosis (TB) patients,
to continue. With adequate funding, we
can halt the spread of these diseases.
But funding is declining. Just as we arepoised to win the battle against some of
the biggest problems in global health,obstacles are being thrown in our way.
Safeguards in India’s patent law, which
permit the production of affordable
generic medicines, which in turn haveenabled India to become the supplierof 80 per cent of ARV drugs, are being
challenged in the courts. In addition,

6

The Year in Review

the EU is trying to negotiate a free trade
agreement that protects intellectual
property at the expense of public health.
An alternative means of producing adapted,
affordable medicines – voluntary licensing– is not proving to be the breakthroughwe had hoped for. The first pharmaceuticalcompany has joined the Medicines Patent
Pool for ARV drugs, but so far every licencegranting the right to produce generic
medicines includes restrictions that prevent
prices from being pushed as low as they
could be. (For more on HIV care in 2011,see pages 22–24.)
Forty years of medical assistance2011 saw the closure of our longest-runningmission: MSF left Thailand after 35 years in the
country, as our team was unable to provide
medical assistance to the undocumented
migrants who needed it most. Since 1976, ourprogrammes in Thailand have been the sceneof innovations and developments that have
improved our emergency response worldwide(see pages 18–21).
2011 was also MSF’s 40th anniversary.
Over the past four decades, MSF hasgrown to include some 30,000 people
working in more than 60 countries.
At our International General Assemblyin December, we welcomed four new
associations to our Movement: MSF Brazil,
MSF East Africa, MSF Latin America and
MSF South Africa. MSF now numbers
23 associations worldwide. Expansion has
made us change the way we work. We havereformed our governance structure in orderto improve our decision-making.
Our intention is to make sure that MSF
remains both true to its founding principles
and fit to respond to the humanitarian
emergencies of the 21st century. The corevalues of humanitarianism, independence,neutrality and impartiality, first affirmed
in 1971, continue to drive and inspire us
to work for what ultimately matters: being
there in the field, reaching that one person
in crisis, and assisting their survival.
Thank you.

© P.K. Lee / MSF

Consultation at the inpatient feeding centre in Dera Murad Jamali district headquarter hospital, eastern Balochistan, Pakistan.

Médecins Sans Frontières

Overview ofOperations
Largest country programmes
based on project expenditure

Programme locations

1. D emocratic Republicof the Congo

6. Niger

2. Haiti

8. Zimbabwe

Africa

7. Kenya

3. South Sudan

9. Nigeria

4. Somalia

10. Chad

10.8 %

Number of Programmes
271

Europe5

A sia*113

Americas4725.9 %

Percentage ofprogramme
portfolio

62.2 %

5. Ethiopia
1.1 %The total budget for our programmes in these 10 countries is
329 million euros, 54 per cent of MSF’s operational budget.

* A sia includes the Middle Eastand the Caucasus

Staff numbers

Context of interventions

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

Number of programmes

1. Haiti

3,872

2. D emocratic Republic of the Congo

2,919

3. South Sudan

2,169

4. Somalia

1,729

Armed conflict

119

Post-conflict

14

27.3 %

Internal instability 132
Stable17139.2 %

Percentage ofprogramme
portfolio

3. 2 %

5. Niger	 1,705
30.3 %

Outpatient consultations
Largest country programmes according to the number of outpatient
consultations. This does not include specialist consultations.

Event triggeringintervention
39.4 %
Number of programmes

1. D emocratic Republic of the Congo

1,346,245

2. M yanmar	     669,948
3. Central African Republic	     557,947
4. Somalia	     551,321
5. Ivory Coast

8

Overview of Operations   531,298

Armed conflict

172

Epidemic

163

Health exclusion

81

Natural disaster

20

4.6%

Percentage ofprogramme
portfolio

18.6 %

37.4 %

Activity Report 2011

2011 activity highlights
These highlights do not give a complete overview of activities
and are limited to where MSF staff have direct access to patients.

Activity

Definition

Total

Outpatient

Number of outpatient consultations

8,300,000

Inpatient

Number of admitted patients

Malaria

Malaria: total number of cases treated

Therapeutic
feeding centres

Number of severely malnourished children admitted to inpatientor outpatient feeding programmes

348,000

Supplementary
feeding centres

Number of moderately malnourished children admitted to supplementary
feeding centres

60,000HIV

Number of HIV patients registered under care at end 2011

228,700

Antiretroviral treatment(first-line)

Number of patients on first-line antiretroviral treatment at end 2011

201,600

Antiretroviral treatment(second-line)

Number of patients on second-line antiretroviral treatment at end 2011
(first-line treatment failure)

3,200

PMTCT – mother

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

10,500PMTCT – baby

Number of eligible babies born in 2011 who received post-exposure treatment

10,100

Deliveries

Number of women who delivered babies, including by caesarean section

192,000

Surgical procedures

Number of major surgical procedures, including obstetric surgery,under general or spinal anaesthesia

73,100Violent trauma

Number of medical and surgical interventions in response to direct violence

54,300

Sexual violence

Number of patients medically treated for sexual violence

14,900Tuberculosis (first-line)

Number of new admissions to tuberculosis first-line treatment

30,700Tuberculosis (second-line)

Number of new admissions to tuberculosis treatment, second-line drugs

1,060

Mental health (individual)

Number of individual mental health consultations

169,700

Mental health (group)

Number of group counselling or mental health sessions

19,200CholeraNumber of people admitted to cholera treatment centres
or treated with oral rehydration solution

130,800

Measles vaccinations

Number of people vaccinated against measles in reponse to an outbreakMeasles treatment

Number of people treated for measles

126,500

Meningitis vaccinations

Number of people vaccinated against meningitis in response to an outbreak

952,600

Meningitis treatment

Number of people treated for meningitis

445,000
1,422,800

5,034,000

5,900

Overview of Operations

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, to the foetus during
pregnancy and, less frequently, throughorgan transplants. A person with Chagas
often feels no symptoms in the first, acute,stage 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 byan average of 10 years. Heart failure is themost common cause of death for adults.
Diagnosis is complicated, requiring laboratory
analysis of blood samples. There are currently
only two medicines available to treat thedisease: benznidazole and nifurtimox,
which were both developed over 35 years
ago. The cure rate is almost 100 per centin newborns and infants, but as the gap
between the date of infection and the
beginning of treatment lengthens, thecure 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 2,500 new patients to Chagas
treatment programmes in 2011.

10

water or food, or direct contact withcontaminated faeces. Large outbreaks
can occur suddenly and the infection canspread rapidly. Most people will suffer only
a mild infection, but the illness can be very
severe, causing profuse watery diarrhoea
and vomiting that can lead to severe
dehydration and death. Treatment consists ofa rehydration solution – administered orally or
intravenously – which replaces fluids and salts.
As soon as an outbreak is suspected, patientsare isolated in specialised treatment centres
to prevent the transmission of the disease.
Outside the centres, strict hygiene practices
must be implemented and a safe water supply
must be assured. Cholera is most common indensely populated settings where sanitationis poor and water supplies are not safe.
MSF treated 130,800 people for cholera in 2011.

Health promotion
Health promotion activities aim to improvehealth and encourage the effective useof health services. Health promotion isa two-way process: understanding theculture and practices of a community is
as important as providing information.
During serious outbreaks of diseaseor epidemics, MSF provides people
with information on how the disease istransmitted and how to prevent it, whatsigns to look for, and what to do if someone
becomes ill. If MSF is responding to an
outbreak of cholera, for example, teams
work to explain the importance of goodhygiene practices, because the disease istransmitted through contaminated water.

Cholera

HIV/AIDS

Cholera is a water-borne, acute gastrointestinal
infection caused by the Vibrio cholerae
bacterium. It is transmitted by contaminated

The human immunodeficiency virus (HIV) is
transmitted through blood and body fluids andgradually breaks down the immune system

Glossary of diseases and activities– 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,
but many people live for years without
symptoms and may not know they havebeen infected with HIV. Combinations ofdrugs known as antiretrovirals (ARVs) help
combat the virus, and enable people to live
longer, healthier lives without their immune
systems deteriorating rapidly. ARVs alsosignificantly reduce the likelihood of thevirus 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 themother during pregnancy and labour,and to the infant just after birth.
MSF provided care for 228,700 people livingwith HIV/AIDS, and antiretroviral treatment
for 205,000 people in 2011.

Kala azar(visceral leishmaniasis)
Largely unknown in wealthy countries,
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 250,000–300,000 annual cases,
90 per cent occur in Bangladesh, India,
Nepal, South Sudan, Sudan and Brazil.
Kala azar is characterised by fever, weight
loss, enlargement of the liver and spleen,
anaemia and immune-system deficiencies.
Without treatment, kala azar is almost
always fatal.

© Michael Tsegaye

Activity Report 2011

A lab technician carries out blood tests at MSF’s programme in Abdurafi, Ethiopia.
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
over recent years. Liposomal amphotericin B
is in the process of becoming the primary
treatment used 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 inlocal clinics. In Africa, the best available
treatment is a combination of pentavalent
antimonials and paromomycin, which
requires a number of painful injections.
Co-infection of kala azar and HIV is a major
challenge, as both diseases influence eachother in a vicious spiral as they attack andweaken the immune system.
MSF registered 7,600 new patients for kala azar
treatment in 2011.

Malaria
Malaria is transmitted by infectedmosquitoes. Symptoms include fever, painin the joints, headaches, repeated vomiting,convulsions and coma. Severe malaria, mostoften caused by the Plasmodium falciparum
parasite, causes organ damage and leads todeath if left untreated. MSF field research
has helped prove that artemisinin-based
combination therapy (ACT) is currently
the most effective treatment for malaria
caused by Plasmodium falciparum. In 2010,
World Health Organization guidelines werealtered to recommend the use of artesunate
over artemether for the treatment of severe
malaria in children.
Longlasting 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 aremost vulnerable to severe malaria, and staff
advise people on how to use the nets.
MSF treated 1,422,800 people for malaria in 2011.

Malnutrition
A lack of essential nutrients causes
malnutrition: growth will falter and a child’s
susceptibility to common diseases increases.

The critical age for malnutrition is from six
months – when mothers 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.
Malnutrition in children can be diagnosed
in two ways: it can be calculated frommeasurements of weight and height,
or by measurement of the mid-upperarm circumference. According to thesemeasurements, undernourished children
are diagnosed with moderate or severe
acute malnutrition.
MSF uses ready-to-use food (RUF) to treat
malnutrition. RUF contains fortified milk
powder and delivers all the nutrients thata malnourished child needs to reverse
deficiencies and gain weight. With a longshelf-life and requiring no preparation, thesenutritional products can be used in all kindsof settings and allow patients to be treatedat home, unless they are suffering severe
complications. In situations where malnutritionis likely to become severe, MSF takes apreventive approach, distributing nutritional
supplements to at-risk children to prevent theircondition from further deteriorating.
MSF admitted 348,000 malnourished patientsto nutrition programmes in 2011.

Glossary of diseases and activities

11Médecins Sans Frontières
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 drastically decreased thenumber of cases and deaths. However,
coverage remains low in countries withweak health systems, or among people withlimited access to health services, leaving large
numbers of people susceptible to the disease.
MSF treated 126,500 people for measles andvaccinated more than 5,000,000 people in 2011.

Meningococcal meningitis
Meningococcal meningitis is an infectionof the thin membranes surrounding thebrain and spinal cord. Meningitis can cause
sudden and intense headaches, fever,nausea, vomiting, sensitivity to light andstiffness of the neck. Death can follow
within hours of the onset of symptoms.
Six strains of the bacteria Neisseria
meningitidis are known (A, B, C, W135,
Y and X), but only two (A and W135) are
the cause of most epidemics. People canbe infected without showing symptoms
and transmit the bacteria when they coughor sneeze. Suspected cases are diagnosed
through the examination of a sampleof spinal fluid and treatment consists ofspecific antibiotics. However, even withtreatment, five to ten 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. Preventive vaccination campaigns

12

Glossary of diseases and activities

have now been implemented in Burkina
Faso, Mali and Niger and are planned tocover the entire meningitis belt.

perform caesarean sections where necessary,and sick newborns and babies with a low birthweight receive medical care.

MSF treated 5,900 patients for meningitis
and vaccinated 952,600 people against
he disease in 2011.

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 family planning counselling,
and information and education on sexuallytransmitted infections.

Mental healthcare
Traumatising events – suffering or witnessing
violence, the death of loved ones or thedestruction of livelihoods – are likely toaffect a person’s mental wellbeing. MSF
provides psychosocial support to victims of
trauma in an effort to reduce the likelihoodof long-term psychological problems.
Psychosocial care focuses on supporting acommunity in developing 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 189,000 individual and group
counselling sessions in 2011.

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 ajerrycan so that people can prepare meals,
while a washing kit includes soap, shampoo,
toothbrushes, toothpaste and laundry 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 225,500 relief kits in 2011.

Reproductive healthcare
Comprehensive emergency obstetric andneonatal care form part of MSF’s response to
any emergency. Medical staff assist births andGood antenatal and obstetric care can prevent
obstetric fistulas. Obstetric fistulas are injuries
to the birth canal, and are most often a resultof prolonged, obstructed labour. They causeincontinence, which can lead to social stigma.
Around two million women are estimated tohave obstetric fistulas, and a number of MSF
programmes carry out specialist obstetricfistula repair surgery.
MSF held more than 821,800 antenatal
consultations in 2011.

Sexual violence
MSF offers patients who have suffered sexual
violence medical care, treatment to preventthe development of sexually transmitted
infections, and psychological, social andlegal support. In settings where the rate ofsexual violence is high, such as in conflictzones or refugee camps, dedicated teams
provide assistance, and staff work with thecommunity to raise awareness of the problem
of sexual violence, provide information about
the care that MSF provides, and promotesocial and legal support.
MSF treated more than 14,900 patientsfor sexual violence-related injuries in 2011.

Sleeping sickness (human
African trypanosomiasis)
Generally known as sleeping sickness, human
African trypanosomiasis is a parasitic infectionthat occurs in sub-Saharan Africa and istransmitted by tsetse flies. It attacks the central
nervous system, causing severe neurologicaldisorders or even death. More than 90 per centof reported cases are caused by the parasite
Trypanosoma brucei gambiense, which isfound in western and central Africa.
The other 10 per cent of cases are causedby Trypanosoma brucei rhodesiense, which
is found in eastern and southern Africa.
During the first stage, the disease is relatively
easy to treat but difficult to diagnose, as
symptoms such as fever and weakness are
non-specific. The second stage begins when
the parasite invades the central nervous

Activity Report 2011
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.
Nifurtimox-eflornithine combination
therapy, or NECT, is now the World HealthOrganization’s 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. New molecules
are currently under clinical trial in the hopeof developing a safe, effective treatment
for both stages of the disease that can beadministered orally.
MSF admitted 1,400 new patients for sleeping
sickness treatment in 2011.

Tuberculosis

Vaccinations
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 and rubella – although not all
vaccines are recommended everywhere.
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 or meningitis. Large-scale vaccination
campaigns involve awareness-raising activities
regarding the benefits of immunisation andthe 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 MSF 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, water
will be trucked in containers. Staff conduct
information campaigns to promote the use of
facilities and ensure good hygiene practices.
In 2011, MSF distributed more than
96,000,000 litres of safe water.

One-third of the world’s population iscurrently infected with the tuberculosis (TB)
bacillus. Every year, 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.
Diagnosis of TB depends on a phlegm
sample, which can be difficult to obtainfrom children. There is a new molecular test
that can give results after just two hours,
and detect a certain level of drug resistance,
but it is costly, depends on a reliable power
supply, and still requires a phlegm sample.

© Bithin Das

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
to treat, but the drug regime is arduous,
taking up to two years and causing manyside effects. Extensively drug-resistanttuberculosis (XDR-TB) is identified when
resistance to second-line drugs develops on
top of MDR-TB. The treatment options for
XDR-TB are limited.
MSF treated 30,700 people for tuberculosis,
and 1,060 for MDR-TB, in 2011.
A health worker prepares medication to treat drug-resistant tuberculosis.

Glossary of diseases and activities

13

Médecins Sans Frontières

Humanitarian action :at any price?
Between 2004 and 2011, thirteen Médecins Sans Frontières (MSF)
staff members were killed in the course of their work in Afghanistan,
the Central African Republic, Pakistan and Somalia.
In 2008 and 2009, several sections of MSF had
to leave Niger and the north of Sudan because
the authorities had either suspended theiractivities or issued them with a deportation
order. In 2009, under threat of expulsion from
Sri Lanka, MSF signed a Memorandum ofUnderstanding obliging it to remain silent
in an – ultimately unsuccessful – attempt
to gain access to combat zones. In 2010 in
Yemen, MSF withdrew public statementsthat the government deemed inaccurate andinsulting in order to keep its activities running.

Making humanitarian space
MSF seeks to provide impartial assistance tovictims of conflict or natural disasters, to respondto neglected public health problems, and tocare for people excluded from healthcare.
In many cases, MSF is seeking to alleviate
suffering that has been decreed – or is at thevery least tolerated – by the established order.
MSF’s ambitions therefore come up against
a range of interests: perhaps an armed groupusing humanitarian aid as a means of legitimacy,or states seeking to isolate a regime, or forces

The space for humanitarian action must
be carved by negotiation with these otherinterests, by repeated transactions with local
and international political and military forces.
The scope of the space will depend largely on
the organisation’s objectives, the diplomaticand political support it can garner, and theinterest taken in its activities by those in power.
An acceptable compromise?
Acknowledging that humanitarian aid isonly possible when it coincides with theinterests of political powers does not meanthat MSF has to give way to political forces.
But how can it avoid doing so? How can
MSF ensure that its negotiations will resultin an agreement it can live with? How do wejudge whether a compromise is acceptable?
From past experience, we know that everythingis open to negotiation – the safety of staff, the© MSF

Since the 1990s, the revival of western
military interventionism, the development ofinternational criminal justice and the integrationof aid and politics in the United Nations haveall contributed to a blurring of distinctions
between what is military and political, and what
is humanitarian. Over recent years, MSF has
been vehemently denouncing the harmcaused by this blurring of lines.

Yet there are no legitimate perimeters tohumanitarian action. There is no clearly
defined legal and moral ‘humanitarian
space’ that, if proclaimed, will automaticallybe acknowledged and respected, allowing
humanitarian organisations to go about
their work of assistance and relief. What
there is, however, is a space for negotiation.

who do not make any distinction between
combatants and non-combatants. Authorities
may be more concerned about the politicalconsequences of an epidemic than its effects on
health, or they may want health workers to help
them manage a discriminatory health system.

In Myanmar, MSF is treating some 23,000 patients for HIV.
14

Humanitarian action: at any price?

© H.J. Burkard

Activity Report 2011

Negotiations in Angola, 1999.
activities undertaken, the quality of assistance,
control over resources – and we can draw on
this experience to work out how to negotiate
an acceptable outcome.

staff’s access to patients and on its freedomof expression. But it achieved results. MSF’s
HIV programme has saved the lives of morethan 23,000 people in Myanmar.

Judging for ourselves

It is important for MSF to be able to judge foritself, and to justify the compromises it makes
according to its own principles. Its justificationmust be based in an ethics of action founded
on a principle of medical effectiveness, and its
refusal to collude with policies of domination.
If, by its actions in a given context, MSF cannot
hope “to reduce the number of deaths, thesuffering, and the frequency of incapacitating
handicaps within groups of people who
are usually poorly served by public healthsystems”, 2 then the compromises it agrees
to are neither justifiable nor acceptable.

A key objective for MSF is to keep a distancefrom “that blurry, but very real, line beyond
which assistance for victims imperceptibly
turns into support for their tormentors”.1
That line is never clear. In Sri Lanka, whendesperately trying to gain access to peoplecaught up in fighting in Northern province,
it was very difficult for MSF to be confident
about its decisions. MSF had been a powerless
witness to the brutal all-out offensive launchedby the government against the Tamil rebellion,
which killed tens of thousands of people who
had been used by the insurgents as humanshields. When MSF was finally authorised to
set up a hospital outside the camps where
the government had placed survivors of theoffensive, it had legitimate doubts about
the proposal. Staff had only an approximate
idea of the health situation of the displaced,since the government was not allowing
non-governmental organisations to conduct
independent epidemiological surveys. How
could MSF be sure that it was treating thepeople most in need of medical attention, if it
had no control over who came from the camps?
MSF asked many such questions as it became
the regime’s de facto public health auxiliary.
In Myanmar, MSF also accepted restrictions:on where it could work, on its international

Seizing the moment
The crux of the matter is not so muchachieving total freedom of action – only in
exceptional and temporary circumstances
does MSF ever have total freedom – but rather
being able to choose alliances in accordancewith its own objectives, with no concern for
allegiances or loyalty to any particular partyor faction. In this respect, MSF is an unreliable
and unfaithful partner. It justifies this by theneed to identify auspicious openings in thepolitical space and seize opportunities.
MSF left Afghanistan in 2004, when
five members of staff were assassinated,cruelly driving home the fact that, despite
having worked in the country for 20 years,
MSF could no longer secure respect for ahumanitarian exception in the country.
The context had changed, and MSF wasincreasingly at odds with the agendas ofthe main political parties, military factions
and aid organisations on the scene.
Five years later, however, MSF returned.
The situation was no less polarised, andit was without doubt far more violent.
The key change for MSF was that medical
activities in conflict areas were being
seen by the competing warring parties ascontributing, in varying degrees, to theirclaims to legitimacy. MSF was able to returnto Afghanistan by playing along with thesechanging perceptions, demonstrating that its
medical assistance could appeal to each side.
Ultimately, rather than trying to gauge theextent of an imagined humanitarian space, it
may be more pertinent – and more useful – forhumanitarian workers to maintain negotiations
with all parties, while evaluating the constantly
evolving opportunities and risks, so they canthen seize the humanitarian moment.
1 

Rony Brauman, President’s Report, 1987, MSF France.

2

S ee Jean-Hervé Bradol, “Caring for Health”,
Humanitarian Negotiations Revealed, p. 216.

This is an edited extract fromMarie-Pierre Allié’s introduction
to C. Magone, M. Neuman and
F. Weissman (eds), Humanitarian
Negotiations Revealed: The MSF
Experience, 2011, Hurst & Co.

Humanitarian action: at any price?

15

Médecins Sans Frontières

Somalia:

Extreme needs,
extreme choices
Among the terms used to describe the situation in Somalia– hopeless, chaotic, miserable, disastrous – many talk of ‘donor
fatigue’, another way of saying that people are tired of hearing
and caring about this part of the world. However, Somalia
requires that the world overcomes its short attention span;because this is a place where so many people are strippedof their humanity.

place only exceptionally, prevented by
insecurity or because local authorities are
hostile to such interventions, on cultural orideological grounds. Many of the children
who died in MSF’s nutrition centres in
Mogadishu were infected with measles.
A persistent state of war has contributed tothe development of a culture of impunityand lawlessness. Kidnapping and piracy
have become industries, and humanitarians
are not exempt. At the time of writing, two
MSF colleagues are still held captive, having
been abducted from the Dadaab refugee
camp in Kenya, close to the border with
Somalia, in October 2011. In December, along-time employee of MSF shot and killed
two MSF colleagues in a pre-meditated act
inside the MSF compound in Mogadishu.

© Peter Casaer / MSF

Between a rock and a hard place

Insecurity in Somalia is such that MSF employs armed guards.
In south-central Somalia, civilians andcombatants fall to wounds from bullets andbombs, and conflict has displaced hundredsof thousands of people from their homes.
Malnutrition is rampant due to drought anddisplacement, and simple, curable diseases
such as measles go untreated in the absenceof any healthcare system.
How Somalia finds itself in such a situationis complex and contentious. Environmental
conditions have frequently been cited
as a factor, especially in the past year,
when poor rainfall caused a drought, andthousands of lives were lost. While weather

16

somalia: extreme needs, extreme choices

patterns played a role, they were not theroot cause of the 2011 emergency. Had
they been, malnutrition and mortality rates
would have been similar in the populationof the wider region, where rains had been
similarly poor. They were not.
Twenty years of conflict
The main difference in south-central Somalia is
20 years of factionalised, fragmented civil war,in which not only Somalis, but also external
parties, have sought to influence the situation.
In Somalia, simple vaccination campaigns
for measles, tetanus or diphtheria take

Despite these obstacles, MSF remains one of
the few organisations that have been able towork across Somalia continuously over the
past 20 years, and believes it has brought
valuable assistance to the population. But
at what cost?
Operational security in Somalia, andespecially in Mogadishu, is first andforemost a balancing act, which requires
juggling the allocation of the benefits andresources that a relief operation brings– such as salaries, car rental fees andprocurement of local supplies – among all
the clans and political, military and businessinterests. On top of this fragile managementof local power structures, Mogadishu is also
the centre of a broader conflict in Somalia,
involving other powers. This, too, requires
clear lines of communication with all
warring parties to ensure that their military
strategies do not target medical facilities.
Negotiation, communication and juggling
the distribution of resources, then, are key
to security. They are just as important asarmed protection – the iconic image of
security in Somalia.

Activity Report 2011
Dangerous oversimplifications
Of course, the medical crisis in Somalia
and the emergency response it requires
do not occur in a political vacuum. But thecurrent portrayal of the situation carries
two dangerous oversimplifications: the firstis that Al-Shabaab is solely to blame forthe conflict and underlying humanitariancrisis; the second is that the response to
the crisis can only occur in areas under
the control of the African Union Missionin Somalia (AMISOM), the Ethiopian army,
the Kenyan army or the Transitional Federal
Government (TFG) and pro-TFG forces.

Complex choices
It was only after a visit to Mogadishu
in July that MSF decided to expand
emergency assistance programmes in 2011.
From a distance, expanding operations,and taking the risk of being seen as anagency supporting AMISOM and the TFG
in creating a ‘safe haven’ for displaced
Somalis was considered a significant
political risk, and the large number of relief
organisations present seemed to be able
to cover people’s needs. Once in the city,
however, the team saw that the medical
and living conditions of the new arrivals
were so bad that the enormous needs
outweighed the political risk.

The people in Mogadishu, and much of therest of Somalia, are experiencing one of theworst humanitarian crises in the world.
Complex choices remain before us. We havesaid a sad, final farewell to two of our workers,
and our thoughts are with two others that areheld against their will (at the time of writing).
Somalia is still a place where we must makeextreme choices if we are to provide aid forpeople in extreme need.

In 2011, MSF was working in 11 regionsof Somalia. In many places, MSF hospital
programmes represented the only specialist
healthcare available. MSF provided treatment
for malnutrition, measles and cholera. In total,
MSF treated 864,000 patients in Somalia,
nearly double the assistance provided in
the previous year. For more information on
activities in Somalia in 2011, see pages 92–93.

Since that brief period of world attention
in the middle of 2011, the need forhumanitarian assistance has not vanished.

© Martina Bacigalupo

In such a complex and highly volatileenvironment, the last thing humanitarianorganisations need is for politicians tosuggest that aid personnel are working
on their behalf. As soon as humanitarianassistance is perceived to be part ofthe political agenda of any side, thepainstaking efforts made to reach an
agreement on security risk being brought
to naught. Indeed, many aid efforts in
Somalia are restricted today precisely
because states involved in the conflicthave successfully portrayed humanitarianassistance as a part of their military policy.

To be perceived as an ‘implementing
partner’ of one of the many parties
involved in military action, or of theirsponsors, because of warring parties’
rhetoric, risks the closure of aid
programmes. And it is the Somali people
who will pay the price, as they will not get
the assistance they desperately need.

People line up for vaccinations in Mogadishu.
somalia: extreme needs, extreme choices

17

Thailand
Médecins Sans Frontières
closes its longest mission

1976: Still in its infancy,
Médecins Sans Frontières(MSF) brings aid to
Cambodian refugees.

© MSF

In October 1976, an MSF medical teamarrived at the border with Cambodia,
where camps had been set up to shelter
Cambodians who had sought refuge
when the communist Khmer Rouge
forces swept into power in mid-1975.
Three years later, tens of thousands ofCambodians fleeing starvation and theadvancing Vietnamese army crossed
into Thailand, in need of assistance.
Thailand became the setting for thedevelopment of new techniques andideas in emergency assistance. It was in
the refugee camps in the northeast of
the country that MSF designed its firstemergency kits and mobile hospitals.

Medical staff provide emergency care to Cambodian refugees in Sakeo camp, November 1979.

© Virginie Tallio / MSF

MSF collaborates in thedevelopment of a newtreatment for malaria.

More than 35,000 refugees are still living in Mae La camp, near the border town of Mae Sot.

18

Thailand: MSF closes its longest mission

In 1984, fighting between the Burmese
military and the Karen Liberation Armydrove an estimated 10,000 Karenfrom their villages across the borderto Thailand. MSF began what was tobecome 20 years of assistance in thecamps along the border. In Mae Sot,
MSF’s collaboration with the Shoklo
Malaria Research Unit, of the Mahidol
University of Bangkok, led to a critical
medical breakthrough in the battle
against malaria: the developmentof artemisinin-based combination
therapy, which almost completely
eradicated malaria from the camps.

© Stefan Pleger

A doctor examines an HIV patient receiving ARV treatment, Surin province, 2004.

In 2000, MSF offers antiretroviral (ARV) treatment to HIV patients for the very first time.
At the end of 2000, MSF offered ARV treatment in Thailand, at a time when it was rarely available in government hospitals. The following
year, working closely with the Ministry of Health, MSF launched several HIV programmes across the country, and introduced ARVs in
Mae La refugee camp. MSF also collaborated with Thai civil society in major disputes with pharmaceutical companies over patents, andin campaigns for the local production of generic ARVs. The consequent reduction in the cost of generic medicines enabled the national
ARV programme to be extended to thousands more patients, and MSF could therefore focus on high-risk groups of people who were still
excluded from treatment, such as drug users and sex workers. MSF also developed a successful model of care for prisons in Bangkok.

Tuberculosis (TB) treatment
programmes for migrants andrefugees show that a more
inclusive policy can work.

© Espen Rasmussen

A team in Mae La camp began treatingrefugees for TB in 1985. MSF laterset up a TB programme for migrant
workers, opening a chest clinic in Mae
Sot in 1999 and then a pilot crossborder treatment programme. These
projects contributed to changes ininternational policy towards TB.

A consultation with a TB patient in Mae La refugee camp, 2007.

Thailand: MSF closes its longest mission

19© Michael Heine

More than half of migrants from Myanmar have no official status in Thailand. Many work as fishermen.

MSF extends health services to migrant workers.
Thousands of migrant workers came to Thailand to seek employment in reconstruction and other sectors after the 2004 tsunami. Without
documentation, migrants have very limited access to healthcare in Thailand, and they are often too scared and too poor to seek assistance.
MSF’s programme in the southern province of Phang Nga delivered basic health services, as well as HIV and TB treatment. At the same time,
MSF lobbied the Ministry of Public Health on the need to provide all workers with access to healthcare.

© Greg Constantine

Hmong refugees are excluded
from healthcare and at risk offorced repatriation.

Children at the MSF clinic in Huay Nam Khao refugee camp, Phetchabun province, 2007.

20

Thailand: MSF closes its longest mission

From 2005 to May 2009, MSF was the
only non-governmental organisation
providing medical care, watersupplies and sanitation in the campin Phetchabun, northern Thailand,
where Hmong refugees from Laos
were living. During this time, MSF
repeatedly denounced the Thai andLao policy of forced repatriation,
calling on the UN refugee agency,
UNHCR, to oversee a process to ensure
the refugees’ safety upon their returnto Laos. In May 2009, MSF ended its
activities in Phetchabun in protest at
the increased restrictions imposed by
the Thai military on the programmeand on access to patients.

© Veronique Terrasse

A health worker carries out a consultation in Mon state, Myanmar, 2008.

Medical teams are given training and supplies so that they can work across the border in Myanmar.
Many people living in semi-autonomous Mon state in Myanmar have very limited access to medical services. Based across the borderin Sangkhla Buri in Thailand, MSF provided malaria training and essential drugs to Mon medical workers, who then travelled to remotevillages in Myanmar to deliver basic healthcare and diagnose and treat malaria. Drawing from this experience, an MSF team in
Mae Hong Son also began training ‘backpackers’ to carry out similar activities in the border area.

2011: After offering emergency
assistance to flood victims,
MSF leaves Thailand© Véronique Terrasse / MSF

December 2011 marked the end of
MSF’s 35 years of medical assistancein Thailand. After failing to get
official authorisation from the Thaigovernment to work, MSF wasforced to close its projects providing
healthcare to undocumented migrants
in Three Pagodas Pass and Samut
Sakhon and suspend its activities withbackpackers working in the borderarea between Myanmar and Thailand.
However, a medical team responded
to the floods that hit the country in
October and November, distributing
emergency relief and carrying out
medical consultations.

MSF assists people affected by flooding in central Thailand in 2011.

Thailand: MSF closes its longest mission21

Médecins Sans Frontières

Scaling up HIV treatment:

Getting aheadof the wave of
new infections© Sven Torfinn

In 2000, Médecins Sans Frontières (MSF) began to provide HIV treatment to a small number ofpeople in Thailand, South Africa and Cameroon, at a time when very few had access to treatment
in developing countries. Sceptics said it couldn’t be done, claiming that antiretroviral
medicines were too expensive, and fragile health systems would not be able to cope.

Charles Sako, from Nairobi, Kenya, shows an image of himself in 2005, when he began antiretroviral treatment.
22

Scaling up HIV Treatment

Activity Report 2011
Today, MSF provides treatment to 220,000
people in 23 countries. In total, eight million
people in developing countries are on treatment.
While that is still less than half the number ofpeople who need treatment, it is a testament
to the huge progress made in the past decade.
In that time, MSF has learned how to reachmore people with better care. Ensuring people
have access to treatment early on, and before
they get ill, helps people stay healthy in thelong run. Providing medicines with fewer side
effects makes adhering to treatment easier.
Entrusting treatment to nurses working inclinics not only brings care closer to where
people live, but also helps overcome medical
staff shortages. Making sure people can receive
HIV and tuberculosis (TB) care in one clinic,
from the same health worker, at the same time,is one way to rein in the dual epidemic.
Two further ingredients have been vital togetting treatment to more people: lowering theprice of drugs, and raising the funding needed
to pay for them. But both are under threat.
Progress under threat
The price of HIV treatment has come down
dramatically since 2000 – by close to 99 per cent.
This has been possible because of competition
among manufacturers of generic medicines,
primarily in India, where there were nopatents to block the production of more
affordable versions of proprietary drugs.
But with international trade rules now forcing
India to grant patents, the production ofaffordable versions of the newer generation of
HIV medicines – which many people will need as
their illness progresses – looks increasingly bleak.
MSF will continue to support efforts to keep
the door open for the production of generic
medicines, particularly in India, which are so
crucial to keeping down the cost of treatment.
On the funding side, HIV treatment has also
hit major roadblocks. Even before the global
economic downturn, donors had begun toturn their back on financing global health.
In late 2011, because of insufficient funds, theGlobal Fund to Fight AIDS, Tuberculosis andMalaria—created in 2002 as a ‘war chest’ tofight the pandemics—had to cancel a funding
round for the first time ever. While the Global
Fund has since announced that it is back open
for business, this crisis is just part of a wider
trend of cuts to health financing. Much moresustained funding will be required to begin
turning the epidemic around.
Opportunity amid the challenge
Yet, while the challenges grow, the opportunities
at this moment could not be more promising.
In 2011, news from the scientific community
confirmed what people living with HIV
had long assumed: getting people ontreatment early reduces the likelihoodof transmitting the virus by 96 per cent.
This breakthrough has forever changed thediscourse surrounding HIV/AIDS, putting
an end to old debates of whether tackling

the epidemic through treatment or throughprevention is the best approach. Treatment
itself is a form of prevention.
In several of our programmes, MSF has been
looking at ways to make use of the latest
scientific findings. In South Africa, our teamis piloting an innovative approach, not only
scaling up treatment dramatically in orderto save lives, but also using treatment as
a way to reduce new HIV infections in thecommunity. The pilot project in Uthungulu
district, in KwaZulu-Natal, the province
hardest hit by HIV, seeks to demonstrate thefeasibility of scaling up testing, providing
treatment to people in an earlier stage ofthe disease’s progression, and increasing
uptake of prevention methods. The aim is to
reduce HIV and TB-related illness, as well as
to cut the number of new HIV infections.
Policy-makers seem to be recognising theopportunity to get ahead of the wave of new
infections. At the United Nations in June 2011,
all governments committed to ensuring
15 million people are reached with treatment
by 2015 – this means nearly doubling thenumber who have access today. But thesesame governments have failed to comethrough with their financial commitments
to turn these targets into reality.
MSF continues to focus on working in countries
most affected by HIV, and in those countries
that struggle the most to offer appropriatecare, like the Democratic Republic of theCongo and Myanmar, where the proportionof people on treatment is abysmally low.
By documenting both the progress and thethreats we see on the ground, we are pushingfor renewed political commitment to HIV
treatment, backed up by predictable financingof global health, and for access to the affordable
medicines needed to keep people alive in thelong run. MSF is still grappling with the HIV/AIDS
epidemic, and is committed to ensuring more
people can get better treatment, sooner.
MSF’s Access Campaign works to help our medical
teams give quality care to our patients throughpromoting the development of new vaccines,
medicines and tests, and challenging existing barriers
to treatment – such as cost – for patients in poorer
countries. To learn more, visit www.msfaccess.org
or follow @MSF_access on Twitter.

Grace’s story
Homa Bay, Kenya
Grace works as a peer educator at the
Homa Bay clinic in Kenya: she gives
health talks and assists patients before
they attend consultations. Her story
demonstrates the impact that scale-upof ARV treatment can have.
In 2003, after falling pregnant,Grace decided to take an HIV test.
She tested positive:“I was given PMTCT [prevention of
mother-to-child transmission of HIV], andI was very happy to give birth to a healthy
child. She is now seven-and-a-half, andhealthy and active. She is in class two
at school and doing very well.
“I have six children. Three of them are
HIV positive and are receiving care. And
I have six grandchildren. I encouraged
their mothers to use the PMTCT services
and only one is HIV-positive.
“Even though they are on treatment, you
wouldn’t suspect that my children were
sick. They are healthy and active and cando their work. I too live a normal life. I am
happy that I can see my grandchildren.”

Keeping HIV medicines

affordable
More than 80 per cent of the medicines
used by MSF to treat HIV are Indian
generics, and MSF relies on producers inIndia for drugs to treat other diseases andconditions as well. India is the ‘pharmacyof the developing world’: millions
of people rely on affordable, quality
generics produced in India to stay alive.
But the source of affordable medicines
is under threat of drying up. Patent
protection in India already means thatgeneric versions of newer HIV medicines
will be blocked from production, andwe cannot expect to see any dramatic
price drops unless urgent action is taken

to overcome barriers. India’s patentlaw has pro-health flexibilities to limit
some of the negative impact, but eventhis is under attack. As we write, theEuropean Union is pursuing a free trade
agreement with India that could further
harm generic production, and large
pharmaceutical companies like Novartis
are attacking the pro-health measures inIndia’s patent laws through the courts.
The struggle for lifelong access toaffordable medicines will continue, andMSF will be at the forefront of this effort toensure people in our projects and beyond
have the medicines they need to stay alive.

Scaling up HIV Treatment

23

Médecins Sans Frontières

Care in the community“I was here in 2001, when we were first starting patients on
ARVs, and the ones that were coming were very sick, mostwere in wheelchairs. But today most of our patients look well,and most walk to the clinic.”

Nicholas Oucho is a clinical officer with
MSF at Homa Bay district hospital, in Kenya.
Between appointments, he talks about thepositive impact MSF’s HIV programme has
had on the lives of people living here, on the
shores of Lake Victoria, in western Kenya.

© Sven Torfinn

More than 10,000 patients now regularly
make their way up the hill to MSF’s HIV clinic.
As Oucho says, “The programme has done a
lot to help the lives of patients. But we needto build capacity and improve the quality ofcare in local sites. By building capacity, we
will encourage patients to go to the facility
nearest them.”

Charles Sako, an HIV patient in Kenya, takes a dose of ARV treatment.

It is estimated that anywhere between
13,000 and 29,000 people living in Homa Bay
and neighbouring Ndhiwa district are notaccessing the care they need. From the hills
above Homa Bay, one of the obstacles toaccess becomes clear – houses sprawl acrossthe countryside, and it is hard to see where
one village ends and another begins. This isa rural, but densely populated region,and the distance to the nearest HIV clinic
can be prohibitive. Many do not get toa clinic until they are already very ill,
prejudicing their chances of survival.

Bringing treatment closer to people© Julie Damond / MSF

The Kenyan government has set a national objective for 80 per centof HIV patients to be able to access treatment at their nearest
medical facility. An MSF team supports HIV services in eight
health centres in the area with regular visits.

MSF clinicians who work at Homa Bay hospital also support local health centres.

24

Scaling up HIV Treatment

The team provides mentoring to thepermanent staff, offers counselling topatients and traces patients who havemissed appointments.
MSF has decided to focus more on building
the capacity of these local sites. “We want
to try and make each centre independent of
the main hospital,” says Catherine Moody,
MSF head of mission in Kenya.
By investing in staff, laboratory services
and counselling, MSF hopes to support theprovision of quality care, get more people
onto treatment, and improve patients’adherence to treatment throughout thetwo districts. These kinds of strategies, andothers, such as community drug distribution
programmes, offer the possibility of meetingthe medical need and allowing us to expand
treatment, not only saving the lives of thoseindividuals already infected with HIV, but also,
as we now know, preventing the virus fromspreading – effectively offering protection
from HIV to the whole community.

© P.K. Lee

Consultation at a mobile clinic in a displaced persons’ camp in Sindh province, Pakistan.

Activities
by country
26

Afghanistan

28

Armenia44	Democratic
Republic of
the Congo

64	Italy

29 	Bahrain

46	Djibouti

66	Kenya

30	Bangladesh

47	Egypt

68	Kyrgyzstan

31	Bolivia

48	Ethiopia

69	Lebanon

87	Papua
New Guinea

32	Brazil

50

France70	Lesotho

88	Paraguay

105 	Uzbekistan

33	Burkina Faso

51 	Georgia

71	Liberia

89	Philippines

106	Yemen

34	Burundi

52	Greece

72	Libya

90

108	Zimbabwe

35 	Cambodia

53	Guatemala

74

65	Japan

Madagascar

85	Occupied
Palestinian
Territory
86	Pakistan

RussianFederation

91	Sierra Leone

54	Guinea

75

Malawi55	Honduras

76

Mali

56	Haiti

77

Morocco94	South Africa

38	Chad58	India78

Mozambique

95	Sri Lanka

40	China

60	Iran80

Myanmar

96	South Sudan

41	Congo

61	Iraq82	Nigeria

98	Sudan

42	Colombia

62	Ivory Coast

84	Niger

99	Swaziland

36	Cameroon
37	Central African
Republic

92	Somalia

100	Syria
101	Thailand
102 	Tunisia
103	Turkey
104 	Uganda

110	Zambia

Médecins Sans Frontières

Afghanistan
Decades of conflict in
Afghanistan have taken a hugetoll on the quality of medical
services available, and Afghans’ability to access them.
Many people face long and dangerous
journeys to reach hospitals. Private clinics areoften the only option, but they are expensive,
unaffordable for much of the population, andthe quality of care is not guaranteed.
In 2011, Médecins Sans Frontières (MSF)
significantly expanded its activities. A new
hospital opened in Kunduz, providing
lifesaving surgical care to the people ofnorthern Afghanistan, and a new maternity
hospital in Khost is due to open in early 2012.
Ahmad Shah Baba, Kabul
The number of people living in Kabul has
tripled over the past decade, with tens of
thousands of displaced people fleeing more
insecure areas of the country, and refugees
returning from Pakistan. This has put asevere strain on health services. Ahmad
Shah Baba, in eastern Kabul, has a growing
population of between 200,000 and 300,000
inhabitants. MSF started working in Ahmad
Shah Baba district hospital in 2009.
MSF staff work in all departments of thehospital. Their focus has been to improve
the quality of, and access to, free medicalcare, with a particular emphasis on
maternity and emergency services.
MSF donates medicines and equipment to
the hospital. In 2011, new women’s andpaediatric outpatient departments werebuilt. Some 550 babies are now born at thehospital every month, compared with 330 in2010, while the outpatient department seesan average of 9,000 patients per month.

KunduzLashkargah

Kabul

Regions where MSF has programmes

admitted an average of 1,500 patients
per month – ten times the monthly figureof 120–160 in 2009.
In 2011, MSF opened a new outpatient service,
which now sees over 6,000 patients every
month, many of whom have travelled fromareas far outside Lashkargah. An extension
to the hospital, allowing for more bedsin the paediatric department, was also
completed during the year. Malnutrition
continues to be a chronic problem inHelmand, in particular among children,
and MSF has set up a therapeutic feeding
centre to provide specialised care.

Cities, towns or villages with MSF activities

KunduzIn August, MSF opened a new surgical
hospital in the northern province of Kunduz.
This is the only hospital of its kind in northern
Afghanistan. The staff provide surgical carefor victims of conflict as well as patients withinjuries from other causes. Before the hospital
opened, the main option for treatment wasa long, expensive journey across the border.
The hospital has 58 beds, which will be
increased to 70 during 2012. It is equippedwith an emergency department, two
operating theatres and an intensive care unit,
as well as X-ray and laboratory facilities.

Helmand

The team at Boost has improved theprovision of medical care across thevarious departments, including maternity,
paediatrics, internal medicine, surgery
and emergencies. By the end of 2011, thehospital was equipped with 180 beds and26

Afghanistan© MSF

Helmand continues to be one of Afghanistan’s
most volatile provinces, and its one million
inhabitants are among those most affectedby conflict. MSF started working in Boosthospital, in Helmand’s capital Lashkargah, in2009. It is one of only two functioning referral
hospitals in southern Afghanistan.

A doctor tends to a malnourished child in Boost hospital, Lashkargah, Helmand province.

© Peter Casaer

Activity Report 2011

Women collect prescriptions from the dispensary of the outpatient service at Boost hospital, Lashkargah, Helmand province.

There are separate surgical wards for maleand female patients. A full-time physiotherapist
follows up patients and helps with theirrehabilitation after surgery. Staff at thehospital are trained and equipped to respondquickly to serious incidents involving several
severely injured patients.
Since it opened, an average of 350 patients
have come to Kunduz hospital every
month. Most are from Kunduz, but as word
has spread, MSF has also seen patientsfrom neighbouring provinces, even fromclose to the Iranian border.
Khost
The conflict’s impact on the country’s
healthcare services has given rise to some ofthe highest maternal and child mortality rates
in the world. The availability of decent and freematernal healthcare is very limited, and most
women still give birth without assistance inunhealthy and dangerous conditions. In March
2012, MSF will open a maternity hospital in
Khost province, eastern Afghanistan. The
56-bed hospital will provide quality ante- andpostnatal care to women in the region, andwill be equipped with an operating theatre forsurgery during complicated births.

Afghan family Boost hospital, Lashkargah
Reda * :Reda:“I live with my sons, their wives andchildren. We all live together in the same
house. All morning we could hear bullets
flying past really close to the house.
Suddenly the shooting stopped and there
was complete silence. The women stayed
inside, and the men and children started
to move outside.”“Three of my grandchildren were killed: twoboys, five and six years old, and one girl,Haifa, who was 11. The mothers were safe
because they stayed inside. Nine othermembers of the family were wounded.”

Abdul * :“I was sitting on the window sill outside,and my father was lying down. My little
nephew, Zabiullah, was sitting next to me.
I only saw an aeroplane flying over andthen suddenly, this thing – they call it
hawan here – exploded in our garden in
front of us. I remember seeing a piece ofshell fly into Zabi’s head. He died instantly.”

Abdul:“We heard that our house wasn’t totally
destroyed, but we haven’t been back yet.
Every day people tell us there’s shooting,more trouble in our village. We can’t
go back but we can’t stay here in Boosthospital for ever either.“Ali * :
“L andmines and fighting control our lives.
My brother wasn’t able to take his son to
the doctor that day because of landmines;
they had to come back home. Then they
were both killed at home.”
All the patients’ names have been changed.

*

At the end of 2011, MSF had 496 staff in Afghanistan. MSF first worked in the country in 1980.

Afghanistan27

Médecins Sans Frontières

Armenia
ShirakLori
Kotayk
YerevanArmavir
AraratRegions where MSF has programmesCities, towns or villages with MSF activities

In Armenia, Médecins Sans
Frontières (MSF) is supporting
the treatment of patients
suffering from drug-resistanttuberculosis (DR-TB).
DR-TB can be caught from someone alreadysuffering from the disease, or it can develop
when a patient with drug-sensitive TB
becomes resistant to medication, which canhappen if their treatment regime is disrupted.

In 2011, MSF expanded its programme forchildren with DR-TB, and helped improve
facilities at several medical laboratories.
At the end of the year, 290 patients were
undergoing treatment for DR-TB in Armenia.
Treatment challenges
A patient with drug-sensitive TB has totake medication daily for between six andnine months, while a complete course oftreatment for drug-resistant TB can take up
to two years, is much more costly, and is
not always readily available.
Patients are usually admitted to hospital at first,
where they are closely monitored, and evenwhen they return home they must continue
a gruelling treatment regime. Many of thedrugs are toxic and side effects can include
headaches, vomiting and dizziness. For somepatients, the treatment is unbearable.
MSF uses a range of methods to help patientscope with side effects and to encourageadherence to treatment. In addition to regularcheck-ups with medical staff, counsellors offer
support in individual or group sessions.
Staff also make home visits to patients andprovide food if necessary.

Shortages affecting care
Regular staff shortages in the national TB
programme, in particular a lack of nurses,
prompted MSF to allocate more staff topatient care and counselling in 2011.
Then, in July, a global shortage of one of the
key DR-TB drugs, capreomycin, resulted in
an increase in the number of people put on
waiting lists for treatment. MSF introduced
specific counselling sessions for patients
who had been on waiting lists for more than
one month to explain why they couldn’t get
treatment, offer advice on infection control
measures and provide basic TB education.
Widening scope
In 2010, MSF began collaborating with thenational tuberculosis programme in thenorthern provinces of Armenia, and thisinitiative was expanded in 2011. The aim isto enable geographically isolated patientsin the rural areas of Kotayk, Ararat and Lorito complete their treatment at home, withthe support of local clinics. MSF increased
cooperation with national partners during 2011,
including the further handover of home-basedcare activities to the Armenian Red Cross.
At the end of 2011, MSF had 85 staff in Armenia.
MSF has been working in the country since 1988.

© Eddy McCall

MSF began working with Armenian authorities
to improve the detection, diagnosis andtreatment of DR-TB in 2005. Supporting
people who have fallen through gaps in thenational programme – often those with social
or psychological difficulties that may put themat risk of stopping treatment – is a key partof MSF’s activities.

A patient with drug-resistant tuberculosis receives a home visit.
28

Armenia

Activity Report 2011

© REUTERS/Hamad I Mohammed, courtesy of Alertnet.

Bahrain

Staff at Salmaniya hospital wait for the arrival of people injured during riots.
into the centre of the conflict. In its report,
Health Services Paralysed by Bahrain’s Military
Crackdown on Patients, published in April,
MSF raised concerns about the loss ofneutrality of Bahrain’s medical facilities,
and the related deprivation of care fornumerous sick and wounded people.
Regions where MSF has programmes

Protests began on 14 February
2011 in Bahrain. Within twodays, a Médecins Sans
Frontières (MSF) team wasin the country to conduct anassessment of medical needs.
In March, MSF was invited to give training
to about 40 health professionals from boththe public and private sectors on managing
care for large numbers of injured people.
Good-quality healthcare is available in
Bahrain, but MSF noted at that time thataccess to services was hampered. Healthfacilities and personnel had been drawn

While engaging with the government andawaiting a response to its proposal to assist, MSF
continued to provide basic first aid to the sick andinjured. Between March and July, staff brought
assistance to almost 200 patients who did notseek care in public health facilities because theyfeared being arrested for involvement in theprotests or affiliation with protesters. In July,
MSF’s premises in Bahrain were raided, and alocal staff member was arrested and detained.
He was released in early August.
Since then, MSF has been pursuingnegotiations with the authorities to register
formally in the country. MSF has proposed the
set-up of mental health activities for healthworkers and people in distress, and offered tosupport emergency preparedness at hospitals
and to help restore trust in the health system.
At the end of 2011, MSF had 3 staff in
Bahrain. MSF started working in the country
in 2011.

Abdul *
29 years old“I stayed in Salmaniya for five days
after I was wounded in the protests.
The police used to come into the ward
regularly to prevent us from sleeping.
They would come in with masks andsticks. It was scary. They would come at
1am and hit us. I begged the doctor todischarge me. I wanted to leave. It was
not safe for me in the hospital. When I
tried to run away, I was arrested by thepolice. I was taken to a police station
where I was blindfolded and beaten.
They finally let me go at 3am. I founda nurse to treat me at home. If I go
back to the hospital now to get moretreatment they will ask me how I got
these wounds and then beat me more.”
When the MSF team examined Abdul
during a medical assessment, he wassuffering from pain in his chest andhad difficulty using his right hand,which had been bound.
The patient’s name has been changed.

*

Bahrain29

Médecins Sans Frontières

Bangladesh
Fulbaria
Dhaka

Cox’s Bazar
Regions where MSF has programmes

There are acute medical
needs in Bangladesh, and
Médecins Sans Frontières(MSF) is working in a range ofcontexts, treating people who
would not otherwise haveaccess to medical services.
In Fulbaria, north of the capital Dhaka,
MSF runs a kala azar treatment centre with
the Ministry of Health.
Kala azar (visceral leishmaniasis) is transmitted
by a sandfly that lives in the cracks of mudhouses. After malaria, it is the second-biggest
parasitic killer worldwide. Women andchildren are particularly vulnerable to thedisease, which, if left untreated, is fatal.
In 2011, MSF treated more than 1,700
patients for kala azar and related illnesses
in Fulbaria using liposomal amphotericin B,
the treatment it introduced in 2010.
This drug is safer and more effective thanearlier drugs, which were highly toxic andneeded to be taken for longer. Treatment
time has been reduced to just three days
over a five-day period, and patients nolonger have to be hospitalised. In 2011,
over 99 per cent of patients treated forkala azar by MSF were cured.
Despite a high prevalence of the diseasein the area, not many people are aware ofkala azar. An outreach team works in thecommunity to identify patients with thedisease and refer them for treatment.
The team teaches people about the symptomsof the disease and how it is transmitted,
informs them about treatment options
and carries out health education activities.
MSF also provides an extra level of quality
control and supervision within the Ministryof Health vector control programme,
reporting findings to the head of thekala azar elimination programme.

30

Bangladesh© Stanley Greene/NOOR

Cities, towns or villages with MSF activities

A mother attends MSF’s day centre in Kamrangirchar, near Dhaka, with her baby.
Healthcare in the capital
Dhaka, Bangladesh’s capital, is one of
the most densely populated cities in theworld. Thousands of informal settlements
have sprung up as socioeconomic andenvironmental pressures bring people
from rural areas to the city.
Most residents of these settlements lackaccess to good-quality health services.
In Kamrangirchar, home to nearly 400,000
people, MSF runs two basic health centres
offering free maternal and paediatric care,and focusing particularly on treating severe
malnutrition. Staff conducted approximately
28,000 consultations and admitted more than
900 children and 580 pregnant or breastfeeding
women to the nutrition programme. Manypatients were suffering from diarrhoea
and skin infections, often a direct result ofpoor water quality and unhygienic living
conditions. MSF also responded toa measles outbreak in Kamrangirchar.
Improving access to healthcare
In Cox’s Bazar, one of the poorest districts of
Bangladesh, thousands of Rohingya who havefled Myanmar remain unregistered and areconsidered illegal immigrants. Many are living inand around the makeshift camp of Kutupalong.
In Kutupalong clinic, MSF treated over
55,000 patients in 2011, both Rohingya
from the camp and local Bangladeshis.
Staff provided basic outpatient and inpatientcare, maternity services, family planning,
vaccinations and mental healthcare.

The team carried out a nutritional survey
and found high rates of malnutrition among
the Rohingya. From January to September,staff admitted 440 malnourished children
suffering from medical complications tothe clinic. In addition to medical activities,
MSF lobbied for improved living conditions
for the stateless Rohingya people.
At the end of 2011, MSF had 323 staff in
Bangladesh. MSF has been working in the
country since 1985.

Salma“My name is Salma. I live in
Kamrangirchar together with my motherand my two small daughters. I have towork to support them all, because myhusband left me for another woman.
I work on a building site, where I carrybricks, bags of cement, climb stairs.
The men there swear and threaten tohit me if I don’t work hard. It is very
difficult for me, but I have to do it –where else will the money come from?
“Every few days, I suffer from pains,
feel feverish, catch colds, and I also
get sores and ulcers on my limbs.
I was unable to produce breastmilk,
and therefore my youngest baby
became very thin and sick. Now MSF
is looking after her in many ways, andmakes sure she is properly nourished.
They come and check up on the baby
and also give me advice on how to cook
good food. I am very happy for this.”Activity Report 2011

Bolivia
Eliseo© Vania Alves

55 years old

A Chagas disease patient receives a medical examination, Aiquile, Cochabamba.

Narciso Campero
La PazCochabamba City
Regions where MSF has programmesCities, towns or villages with MSF activities

Chagas disease is widespreadin Bolivia, and it can be deadly.
People living in poor housing
are most at risk, but they arealso less likely to be able toaccess care.
Chagas is a parasitic disease, transmitted mainlyby the vinchuca beetle, which lives in cracks inthe walls and roofs of mud and straw housing.
Consequently, people living in this type ofbuilding are more vulnerable to the disease.
Although Chagas can cause serious, evenfatal, heart and intestinal problems, people
infected with the disease can live without
symptoms for many years. Screeningis therefore a particularly importantcomponent in tackling Chagas. But healthservices often have to be paid for directly
in Bolivia, and many people likely to havethe disease are unable to access care.
Cochabamba
In April 2011, Médecins Sans Frontières(MSF) handed over its Chagas programmein Cochabamba City to the Bolivian Ministryof Health. Staff had been working in someof the most deprived parts of the city forthree years. During this time, of more than
20,000 people screened for the disease,some 3,000 tested positive and more than
1,900 people received treatment.
A team continued to work in the departmentof Cochabamba, running a programmein the rural province of Narciso Campero.
Prevalence of Chagas in this province is among
the highest in the country. MSF was the first
to offer diagnostic and treatment services,bringing healthcare to patients who had not yet
developed cardiac or intestinal complications.
MSF staff work directly with patients, butalso with the staff from local clinics andhealth centres. MSF offers training, andcollaborates with the authorities to improve
Chagas drug supply chains and treatment.
The aim is for Chagas prevention, diagnosis
and treatment services to be integrated into
local health facilities. The teams also engage
with the community to raise awarenessof the disease and how vector control –controlling the vinchuca beetle – can help
reduce transmission. They hold educational
workshops with teachers, students, community
leaders and patient groups, and take part ina regular radio show.
In 2011, 3,270 people were screened for
Chagas in Narciso Campero: 1,270 tested
positive and 716 started treatment. In therural health centres supported by MSF, an
additional 1,833 people were screened, andof these 399 started treatment.

Fifteen years ago, Eliseo was tested for
Chagas, and the results came backpositive. But at the time, there wasno treatment available. In 2010 Eliseo
started working with MSF. At first hedidn’t dare to tell his colleagues of his
diagnosis, but then he decided to takepart in an MSF screening, and again hetested positive for Chagas. He started
treatment in April 2011. Side effects,
such as abdominal pain, almost madeEliseo quit, but with the support of his
family and co-workers, he completed
treatment in July.
“I am happy that I had the screening
and medication,” says Eliseo. “I feel
my quality of life has improved. Now
I always help other people so that they
can be treated for Chagas too.”

There is currently no reliable test of cure
for Chagas. MSF is involved in a study with
the Drugs for Neglected Diseases initiative(DNDi), which could lead to just such a test.
Researchers are testing patients in Bolivia
to see whether polymerase chain reaction,a technique that amplifies pieces of DNA,can help to measure accurately patients’
response to treatment.
Shortage of medication
Benznidazole is the most commonly usedtreatment for Chagas. But in October,shortages of the drug affected treatment
programmes in several Latin Americancountries. MSF was forced to suspend
new projects it had planned in Bolivia.
Among other factors, the shortages werecaused by a lack of planning by Brazil’s
state-owned laboratory, where the drug
is manufactured. MSF urged the Brazilian
Ministry of Health to commit to speed up
benznidazole production, but at the endof 2011 there were still supply shortages.
Emergency in La Paz
A landslide in Callapa, a neighbourhoodin the city of La Paz, left 5,000 people
homeless in February. MSF contributed
to the emergency response by helping
to provide water and sanitation in sevenof the temporary shelters to which thehomeless were relocated.
At the end of 2011, MSF had 32 staff in Bolivia.
MSF has been working in the country since 1986.

Bolivia31

Médecins Sans Frontières

BrazilTabatinga

Rio de Janeiro

Cities, towns or villages with MSF activities

Haitians first began arrivingin Tabatinga, a small town
located at the border between
Brazil, Colombia and Peru,
in March 2010.

Living in such conditions can have a serious
impact on health. Stomach infections andpsychological disorders were common. In
mid-November, Médecins Sans Frontières(MSF) began offering psychological supportand distributed washing kits. Staff acted
as mediators and interpreters for Haitians
attending Brazilian health centres, andlobbied local and provincial authorities toimprove access to healthcare.
On 11 January 2012, the Brazilian Ministry ofJustice announced that some 4,000 Haitians
who had arrived in the country since theearthquake would be granted residence andwork visas. The federal government also
adopted a clear policy aimed at regularising
the situation of the Haitians in Brazil, andopened up legal migration opportunities

from Haiti. As a result, the number of Haitians
arriving in Tabatinga dramatically decreased.
With the improvement in the situation, theprogramme was closed in February 2012.
Many Haitians left Tabatinga for the city of
Manaus. MSF lobbying of the city authorities
helped ensure that they took responsibility forthe people’s health needs. An MSF team also
supported the response by giving training inmental healthcare and health promotion to
health staff and social workers in Manaus.
Flooding
In January, heavy floods and landslides
affected an area north of Rio de Janeiro,leaving thousands homeless. After carryingout an assessment and indentifying gaps inmental healthcare, MSF provided training tomore than 150 psychologists in four towns on
how to support survivors of natural disasters.
MSF also lobbied for mental healthcare to be
included in the overall disaster response.
At the end of 2011, MSF had 4 field staff in Brazil.
MSF first worked in the country in 1991.

© Alessandra Vilas Boas / MSF

More than 1,200 Haitians, who had fled
the devastation of the earthquake ofJanuary 2010 and sought asylum in Brazil,
were stranded. They were not allowed towork or leave Tabatinga until they received
authorisation, and this was taking months.

Many were living in extremely poor conditions,having spent all their savings on the journey
to Brazil. In some cases, one latrine was being
shared by up to 40 people. In one residence,as many as five people were living in each tiny
room without proper light or ventilation.

More than 1,200 Haitians were stranded in the Brazilian border town of Tabatinga.

32

BrazilActivity Report 2011

© Yann Libessart / MSF

Burkina Faso

An inpatient at the feeding centre for severely malnourished children in Yako.

Titao

YAKO

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

A hostile climate and fluctuating
prices both limit the availabilityof food for many people in
Burkina Faso. Médecins Sans
Frontières (MSF) works in thenorth of the country, operating
free nutrition programmes forchildren under five.

Teams in Loroum province treat children
for malnutrition and also provide basic
healthcare at 11 outpatient programmes
and one inpatient centre at the hospital in
the provincial capital Titao. Activities in five
health centres in Yako were gradually handed
over to the United Nations Children’s Fund
as it became more involved in child healthin the town.
MSF cared for children with a range ofconditions, the most common being diarrhoea,
malaria and respiratory infections. Patientswere also offered routine vaccination.
Malaria is the main cause of sickness
and death in Burkina Faso, especiallyamong under-fives, and between July andDecember the number of cases spikes.
In collaboration with the Ministry of
Health, MSF treated malaria patients in
Titao hospital year-round, and extended

treatment activities to outlying healthcentres during the malaria season.
Staff tended to some 820 patients.
In total, almost 4,500 children received
treatment in 2011. Since 2007, when the
programme began, staff have tended tomore than 55,400 children.
MSF has begun exploring possibilities
for new programmes in the country:
the malaria epidemic in the south ofthe country, increasing political unrest,
growing insecurity close to the border due
to fighting in neighbouring Mali and fears
of a particularly acute malnutrition crisis
were all cause for concern as 2012 began.
At the end of 2011, MSF had 215 staff
in Burkina Faso. MSF has been working
in the country since 1995.

Burkina Faso

33

Médecins Sans Frontières

BurundiIn Burundi, Médecins Sans Frontières (MSF) focuses onmaternal health, providing emergency obstetric care andobstetric fistula repair.

Kabezi

GitegaCities, towns or villages with MSF activities

Women are particularly affected by thelimited access to healthcare in Burundi.
According to the World Health Organization,
4,000 women die in childbirth and 1,200
develop an obstetric fistula every year.
Obstetric fistulas are injuries to the birthcanal, and are most often caused byprolonged or obstructed labour. These
fistulas cause incontinence, and women
have to live not only with the debilitating
physical consequences, but also, in manycases, with shame and social exclusion.
However, most fistulas can be repaired, andwomen who have successful fistula repair
surgery are usually able to return to theirnormal lives and integrate back into society.
The Urumuri health centre

Kabezi
Skilled medical assistance during labour
can prevent obstetric fistulas. In the townof Kabezi, in Bujumbura Rural province,
MSF is managing an emergency centre forgynaecological and obstetric care (CURGO).
The CURGO also offers neonatal services.
An ambulance service transports women inneed of emergency attention from 24 different
health centres in the surrounding area to the
CURGO in Kabezi. Almost 2,200 babies wereborn at the centre in 2011, and 446 of themwere admitted for intensive neonatal care.
Responding to emergencies
Through regular contact with an extended
network of medical authorities andorganisations across the country, MSF’s
emergency response unit makes sure it
has the latest information regarding therisk of emergencies in Burundi.

The team also assisted health authorities
during an outbreak of cholera, providing
treatment and follow-up for 1,072 patients,
and treated over 6,100 people for malaria.
At the end of 2011, MSF had 239 staff in
Burundi. MSF has been working in the country
since 1992.

291,000

measles
vaccinations

When measles broke out, the unit
participated in an immunisation campaign,vaccinating more than 291,000 people.

At the Urumuri health centre, in the city ofGitega, central Burundi, MSF offers free,around-the-clock treatment to women
suffering from obstetric fistulas. Surgeons
performed more than 370 fistula repair
operations in 2011 and began training
two Burundian doctors in the technique.
MSF is planning to increase the capacityof the centre and expects the number ofoperations to rise to 450 in 2012.

Many women do not know that it is possible
to treat or repair obstetric fistulas. To promoteawareness of the options available, MSF has
set up an information line, which people cancall with any questions about the condition.

34

Burundi© Gwenola Francois / MSF

If women are treated for fistula early, surgery
can be avoided, and in 2011, MSF piloted
a programme to do just that. For women
who have developed fistulas within theprevious six weeks, doctors in Gitega insert
a catheter to drain the bladder of urine.
This decompresses the bladder walls andallows the wounded edges to meet and join
together, so that the fistula heals naturally.

Patients wait for treatment at a mobile clinic.

Activity Report 2011

Cambodia
Kampong Cham

Phnom PenhRegions where MSF has programmes

Overcrowding, lack ofventilation and generally
poor living conditions all
contribute to the high risk ofcontracting tuberculosis (TB)
in Cambodian prisons.
Cambodia is on the World HealthOrganization’s list of 22 countries witha high burden of TB. TB is spread throughthe air by an infected person coughing.
It is an opportunistic infection that takes
advantage of weakened immune systems,
which are all too common among people
living in poverty in Cambodia. Malnutrition,
poor hygiene and living conditions and HIV
infection are all key contributing factors to
the spread of the disease.
Healthcare in the capital’s prisonsMédecins Sans Frontières (MSF) has beenworking in three prisons in Phnom Penh,
where 25 per cent of all Cambodia’s
prisoners are held, since February 2010.
Teams provide care and treatment for HIV
and TB, and have introduced measures
to improve infection control, such as aquarantine area in one of the prisons.
Staff carried out a comprehensive HIV and TB
screening programme for all prison inmates.
Mobile teams then conducted daily visits,
carrying out an average of 100 consultations
per month. At the end of the year, 94 HIV
patients were on antiretroviral treatment.
More than 3,600 people had been screened
for TB and 32 were receiving treatment forthe disease, bringing the number treatedsince 2010 to approximately 200.
Being able to keep up with treatment is crucial
if patients are to avoid developing drug
resistance. So, when they are transferred orreleased, MSF staff provide follow-up. They
help make sure patients have access to thedrugs they need, as well as to medical services.

© Eddy McCall

Cities, towns or villages with MSF activities

Villagers in Kampong Cham province meet to learn more about tuberculosis.
Inside the prisons, the teams are extending
their activities to provide basic healthcare,including the treatment of skin diseases andsexually transmitted infections. Staff also
engage in health promotion activities, suchas improvements to sanitation.
Kampong Cham TB programme
In Kampong Cham hospital, MSF offers
treatment for TB and drug-resistant TB(DR-TB). In the paediatric ward, staff workwith the hospital’s doctors to identify
children who may have TB.
Follow-up is key to the strategy. If patientsare unable to come to the hospital, staff
make home visits. A telephone hotline has
been set up for patients to call in case of
emergencies. Over the year, MSF conducted
over 6,000 consultations at the hospital andregistered more than 600 new TB patients.
The team is working to get more people
tested for TB earlier. Counsellors havebegun asking new patients whom they
have been in contact with, so that people
at risk can be invited to take a free TB test.
Testing and detection have improved with
the introduction of a new testing machinethat reduces the time it takes for diagnosis.

such outreach activities is to increase
understanding of the disease and reduce
stigma. MSF also advocates at a national
level for improvements to Cambodia’snational TB response.
At the end of 2011, MSF had 136 staff inCambodia. MSF has been working in the
country since 1979.

Srey *“In the beginning of my DR-TB
treatment I suffered bad side effects
like fever, dizziness, headaches andabdominal pain – it was very hard.
I wanted to stop the treatment but,when I saw the other patients trying,
I wanted to continue, even though it
was so difficult. MSF people come tomy house often to talk with me andcheck how my four children are.
They also bring me food sometimes –if I don’t have enough food to eat,
I get really unwell and the side effects
are worse. The village nurse comes
every day to give me drugs and see
how I am doing.”
The patient’s name has been changed.

*

Twice a month, an MSF doctor andcounsellor participate in a radio programme
about TB. Awareness-raising events are
regularly held at pagodas, universities,
high schools and mosques. The aim ofCambodia35

Médecins Sans Frontières

Cameroon

forms of HIV need to move on to second-line
treatment, which is far more expensive forboth the government and patients.

movement and lead to secondary infections
and long-term disability. Skin lesions can also
result in social stigma and exclusion.

Addressing HIV drug resistance
In Nylon district hospital, in the economic
capital Douala, Médecins Sans Frontières(MSF) medical teams have introduced
an improved first-line treatment, which
includes the medicine tenofovir (TDF), formore than 1,500 HIV patients. TDF has
fewer side effects, and staff are hoping thatthe new medication, together with better
patient follow-up, will encourage adherence
and reduce the risk of developing resistance.

Early treatment is crucial – the later someone
seeks medical attention, the longer treatment
and recovery take – but it is not easy to
implement. The disease is prevalent mainly
among poor, rural communities, in places
where health services are not able to provide
the complex and expensive treatment Buruli
ulcer requires. Investment in research isnecessary so that prevention, diagnosis andtreatment can be improved. The mode oftransmission of the disease is still not known.

MSF successfully lobbied the Ministry of Healthand international donors to follow suit andchange the national standard first-line medical
protocol from a combination of drugs including
stavudine (d4T) – which often causes side effects– to TDF-based combinations. The TDF-based
regime has been validated for first-line treatment
and the drugs are available in pharmacies.

CholeraYaoundéAkonolinga
DoualaCities, towns or villages with MSF activities

In Cameroon, there are
significant obstacles to providing
high-quality treatment forpatients with HIV, particularly
those who are developing
resistance to medication.
Tens of thousands of people living with HIV in
Cameroon are on antiretroviral (ARV) drugs
thanks to the government’s commitment topromote universal access to ARV treatment
and the support of the Global Fund to Fight
AIDS, Tuberculosis and Malaria.

Buruli ulcer
In the town of Akonolinga, central Cameroon,
MSF treated 160 patients with Buruli ulcer.
Although not normally life-threatening,
Buruli ulcer is extremely incapacitating andpainful. Related to leprosy, it can cause
irreversible deformities, which can restrict

Douala was hit by cholera in November.
MSF staff set up and operated a 130-bed
CTC next to the central hospital of Laquintiniefor nine weeks. On the first day alone, 56
patients were admitted. In total, more than
1,000 patients were treated for the disease.
At the end of 2011, MSF had 83 staff in Cameroon.
MSF has been working in the country since 1984.

© Alberto Masias

However, close to 10 per cent of patientsdevelop resistance to first-line drugs, usually
after several years of treatment, sometimes
because of problems with adhering to the
medication. Drug-resistant strains of thevirus can also be transmitted from person
to person. Patients with drug-resistantFifty-four HIV patients in Douala were
switched to second-line treatment.

An MSF team helped the Ministry of Healthtackle two cholera epidemics. The main
symptom of cholera is profuse, waterydiarrhoea, which can quickly lead to severe
dehydration. An outbreak was declared in
Yaoundé, the capital city, on 20 March. MSF set
up a 300-bed cholera treatment centre (CTC),
where some 1,350 patients received treatment.

A doctor conducts a medical examination at the ‘Buruli pavilion’ in Akonolinga.
36

Cameroon

Activity Report 2011

CentralAfrican Republic
Ouham-Pendé
Ouham

BaminguiBangoranHaut-Mbomou

Mambéré-Kadei
Regions where MSF has programmesCities, towns or villages with MSF activities

In the Central African Republic,
mortality rates are consistently
above the emergency thresholdcountrywide, indicating anurgent need for large-scale
medical assistance.
Recorded death rates were particularly highin 2011, caused by a high prevalence ofpreventable, and treatable, diseases, a failed
health system and years of conflict. Despite
this, funding for health is declining. In thereport State of Silent Crisis, published in2011, Médecins Sans Frontières (MSF)
called for greater medical assistance in
the Central African Republic.
MSF works in five of the country’s 17 prefectures,supporting nine hospitals and 36 healthcentres, mainly in the more unstable borderareas, where it can be very difficult forpeople to access healthcare.
Emergency programmes
In 2010, MSF’s team in Mambéré-Kadeï
opened a new programme in the district ofCarnot, providing paediatric healthcare andintegrated tuberculosis (TB) and HIV treatmentin the district hospital and four health posts.
In 2011, MSF registered almost 520 new HIV
patients and conducted 5,500 consultations.

consultations. Towards the end of the year,
MSF started offering antiretroviral (ARV)
treatment to people with HIV.

consultations, before closing some health posts
and handing management of Maitikoulou
hospital over to the Ministry of Health.

Supporting basic and specialist
health services

In Ndele, the capital of Bamingui-Bangoranprefecture, an MSF team is providing medical
assistance to both displaced people and local
residents. Surgeons performed an averageof 14 operations per month at the hospital.
Teams also ran mobile clinics and worked
in five health centres.

In the town of Paoua, in Ouham-Pendé, anarea recovering from conflict, an MSF teamprovides paediatric, surgical, maternal,
emergency and outpatient services. As well as
conducting 18,900 outpatient consultations
and admitting more than 2,700 patients tothe hospital, staff carried out consultations atseven health centres in the surrounding area.
Teams provide similar services in places
still beset by insecurity and violence. In
the neighbouring prefecture of Ouham,at Batangafo, Boguila and Kabo hospitals,
staff carried out some 16,700 consultations,admitted 940 inpatients and assisted morethan 180 births every month. At Boguila,
MSF regularly organises ‘surgical camps’,
in which a team visits for a limited period
to perform specialist surgery that would nototherwise be available in the area. Staff also
work in 14 health posts around the hospitals.
MSF confirmed that sleeping sickness (human
African trypanosomiasis) has been brought
under control in the Maitikoulou area. Sleeping
sickness is a parasitic infection transmitted by
the tsetse fly, and it is usually fatal without
treatment. MSF showed that prevalence
had fallen to below 0.5 per cent. The teamcarried out more than 56,000 general
medical consultations and 35,000 antenatal

Combating three killers: malaria, HIV and TB
Malaria remains a major threat to publichealth and the principal cause of death andillness among children in the Central African
Republic. In total, MSF treated more than
212,000 patients for the disease in 2011.
By July 2011, 998 HIV patients were receiving
ARV treatment at MSF clinics, a large increaseover the previous year. However, the National
Centre for the Struggle against AIDS has
estimated that 45,000 people, including
14,000 children, currently need ARV treatment.
At present, only one-third, or some 15,000
people, have started treatment.
The prevalence of TB has increased
significantly among both HIV-positive andHIV-negative people, and is estimated tohave at least doubled between 1990 and2009. MSF provides TB diagnosis and care atits hospitals in Batangafo, Kabo and Ndele.
At the end of 2011, MSF had 1,341 staff in theCentral African Republic. MSF has worked in
the country since 1996.

Although Carnot is neither affected by conflict
nor host to large numbers of displaced people,
mortality surveys carried out in 2011 revealed
death rates to be at least three times above theemergency threshold.
© Talia Bouchouareb / MSF

The emergency assistance programmein the town of Gadzi was handed over toauthorities in October.
In Zémio, on the border with the Democratic
Republic of the Congo (DRC), MSF continued
to assist people fleeing violence in the
DRC, carrying out close to 31,000 medical
A pregnant woman is referred to Paoua hospital, Ouham-Pendé.

Central African Republic37

Médecins Sans Frontières

Chad

Chad bears the grim distinctionof having the highest under-five
mortality rate in the world.
Médecins Sans Frontières(MSF) teams in the country
focus on maternal andpaediatric services, andrespond to emergencies.

Kanem

TandjiléAbéché

Massakory
N’Djamena

Kerfi

Chari-Baguirmi

In Am Timan, MSF supports a Ministry of
Health district hospital and seven healthcentres. Staff cared for more than 3,700
children on the paediatric ward, held some
7,300 antenatal consultations and assisted
1,795 births. More than 5,300 children underfive were treated for malnutrition.
In the southeast, in Kerfi health centre, MSF
provided comprehensive healthcare including
nutritional support, blood transfusions andhospital referral both to Chadians displacedby conflict and the local community. Staff alsooffered reproductive healthcare and assistancefor victims of sexual violence. The team treatedmore than 27,800 patients. Maternity staff
held 3,500 antenatal consultations andassisted 188 births. As the displaced left
the area, reducing pressure on health services,
MSF withdrew from the health centre.
In Massakory, western Chad, MSF is mainly
involved in treating malnutrition in underfives and delivering emergency medical careto under-15s. During the time of year known
as the ‘hunger gap’, when food scarcity is anacute problem, more than 170 beds in
Massakory hospital are reserved for children
in need of nutritional support or other vital
medical care. In total, about 1,200 children
were admitted for malnutrition in 2011.
Another 750 children were admittedwith malaria, meningitis, diarrhoea or
respiratory infections. Around 3,200 severely
malnourished children were treated in MSF’s
outpatient feeding programme, and morethan 6,400 children under three received
supplementary food to prevent malnutrition.

SalamatMayo Kebbi Est

Am TimanMayo Kebbi Ouest

Moyen-Chari

Logoné Occidental
Logoné Oriental

MandoulRegions where MSF has programmes

or obstructed labour and they generally
result in incontinence, which in turn canlead to women being rejected by theirfamilies and communities. In Abéché’s
regional hospital, where MSF supports
gynaecological and obstetric services,
specially trained medical staff performed
fistula repair surgery on 222 women,
and assisted more than 2,980 births.
Skilled obstetric care can prevent fistulas.
Malaria
The malaria programme in Moissala,
Mandoul region, includes treatment andprevention activities, and focuses on

Cities, towns or villages with MSF activities

children under five and pregnant women,
for whom malaria is particularly dangerous.
In a region where every child may have an
average of two bouts of malaria per year,
and where some villages are a three-hour
walk from the nearest health centre,
bringing healthcare to the communities
can make a crucial difference. MSF trains
workers to go to villages to perform rapid
diagnostic tests for malaria and provide
treatment for simple cases. Children
suffering complications are sent to thenearest health centre or transferred toa ward built by MSF at Moissala district
hospital. More than 2,100 people were

© Alfons Rodriguez

Further north, in Nokou district, in Kanem,
MSF extended its response to the nutrition
crisis, treating 3,600 children.
Obstetric fistula
An estimated two million women live withobstetric fistulas worldwide, most of themin Africa, in poor and remote areas withlimited or no access to maternal healthcare.
Obstetric fistulas are injuries to the birthcanal that are mostly caused by prolonged

38

Chad

A child receives an identity label before a consultation at a mobile clinic in Molobou,
Kanem region.

© Natacha Buhler

Activity Report 2011

Meningitis vaccination in Kelo district, Tandjilé.

treated at Moissala hospital in 2011, and
17,000 mosquito nets were given to young
children and pregnant women.
CholeraDespite efforts to contain the cholera
outbreak that began in 2009, it continued
through much of 2011. Inadequate sanitation
was the main reason for the persistence ofthe disease: cholera is an infection spread bycontaminated water or food. It causes profuse
watery diarrhoea and vomiting that can leadto severe dehydration and death if not treatedearly. Treatment consists of administering
rehydration solutions to replace fluids andsalts. Some 325 MSF staff worked in 23 healthcentres throughout the country, caring for
more than 12,700 patients.
Measles
MSF vaccinated approximately 575,000 people
against measles, the majority of themchildren, in districts in the southern andsoutheastern regions of Logoné Occidental,
Logoné Oriental, Moyen-Chari and Salamat.
More than 2,800 people were treated forthe disease, and the team donated drugs to
the Ministry of Health to treat an additional
3,500. Measles is a contributing cause of
malnutrition, and MSF staff treated almost
3,000 children in nutrition programmes in
Logoné Occidental.

Meningitis
Southern Chad falls within the so-called
meningitis belt, a huge strip across sub-SaharanAfrica where the disease is particularly
prevalent. Meningitis causes inflammationof the membranes surrounding the brain.
In 2011, MSF staff vaccinated more than
900,000 people in campaigns that covered
five regions. They treated close to 3,500 people
for the disease and provided drugs to treat anadditional 3,000. In Mandélia, Chari-Baguirmi
region, the team introduced a new vaccine,used for the first time in Chad, which offers
protection for 10 years – four times theprotection of the old vaccine.

Moussa *12 years old”When I got to school I didn’t feel well.
I had a backache. I had to take an
exam that morning, but I lay on thebench. The teacher told me to get up,
but I couldn’t.”
At home, Moussa’s pain worsened:
his joints ached, especially his ankles,
wrists and neck. He had a fever. His
mother took him to the hospital, where
he was diagnosed with meningitis.
Meningitis is treated with antibiotics.
When treated early, the chances ofcure are high. Without treatment,
however, only 50 per cent of people
survive the disease, often with serious
after effects such as deafness or aphysical disability.

Regional instability
War in neighbouring Libya aggravatedinstability in Chad. In the eastern provinces,road ambushes, car jackings, robberies
and the risk of kidnapping persisted. As aconsequence of the heightened security
risk, some MSF teams had to reduce theiractivities. Despite these constraints, staff
provided medical assistance to 1,850 Chadians
fleeing political violence in Libya andvaccinated 3,000 against measles.
At the end of 2011, MSF had 977 staff in
Chad. MSF has been working in the country
since 1981.

Moussa said the injections were quite
painful but that the doctors were niceand careful. He stayed in hospitalfor the injections and treatment
for dehydration, and to have histemperature monitored. A few days
later, he returned home with his family.
*

The patient’s name has been changed.

Chad

39

Médecins Sans Frontières© Heidi Spillane / MSF

China

An MSF doctor consults with an HIV patient in Guangxi province.

Baiyi

WangmoXincheng

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

Floods caused damage anddisplaced thousands of people
in various regions of China,
and Médecins Sans Frontières(MSF) teams assisted theemergency response.
In China, emergencies caused by extreme
weather events are frequent. The country is
hit several times a year by severe flooding,landslides, typhoons or earthquakes.
Over the past 10 years, China has improved
its responses to natural disasters; however,significant gaps remain, particularly interms of providing adequate food andrelief to those most in need.

40

China

In 2011, MSF sent teams to assist after major
floods struck central and southern parts ofthe country. They supplied relief items suchas tents, plastic sheeting and cooking kits
to 3,860 families in Xincheng county and
Gaosui in Guangxi province, Wangmo county
in Guizhou, and Baiyi in Sichuan province.
Unequal access to healthcare
With the transition to a market economy,
the healthcare system has been undergoingsignificant changes. Market incentives anddecreased government funding have affected
the quality of care. Fewer people are using
public services, and this has resulted in further
decreases in funding. The overall effectof these changes has been to increase
out-of-pocket expenditure for healthcare
to the extent that, for many, it is no longer
affordable – particularly in impoverished rural
areas where annual household income isless than US$ 475.
People from poor rural areas are therefore
flocking to wealthy cities to find work, buthere they also have problems accessing
health services, due to a complex resident
registration system and social discrimination.

Even when access is available, the quality ofcare varies dramatically, depending on thesocioeconomic status of the patient.
Medical challenges
Migrants comprise 43 per cent of the
population of Guangzhou city, Guangdong
province. Guangzhou has also drawn hundredsof thousands of immigrants from across Africa
in the last decade. Migrants from rural areas
are not granted social security in cities andtheir access to vital public services such as
education and medical care is restricted.
Many migrant women make a living ascommercial sex workers, and the lack ofhealthcare combined with the rapidly
growing commercial sex trade has led toa huge increase in sexually transmitted
infections (STIs) in the city. In 2010, theGuangzhou Center for Disease Control andPrevention found that one in five female sex
workers had an STI. In 2012, MSF plans to set
up a programme offering basic healthcare in
Guangzhou, focusing particularly on STIs.
At the end of 2011, MSF had 15 field staff in
China. MSF has been working in the country
since 1988.

Activity Report 2011

Congo
Likouala

Bétou

Pointe-Noire
Regions where MSF has programmesCities, towns or villages with MSF activities

Thousands of refugees who
fled violence in the Democratic
Republic of the Congo in 2009
remain across the border inCongo-Brazzaville, afraid toreturn home.

In order to ensure access to healthcare
for people living along the Ubangi River,MSF supported two health centres in
Ipenkbele, to the north, and Boyele, to thesouth, and operated mobile clinics in more
remote areas. Staff offered basic medical
and antenatal care, and treated people forsevere malnutrition, carrying out more than
8,900 consultations per month. People inneed of urgent, more specialised medical
attention were transferred by boat to Bétou.

Polio outbreak in Pointe-NoireAt the beginning of December 2010, polio
broke out in southwest Congo, and theMinistry of Health asked MSF to assist in
responding to the epidemic. A team started
work in the intensive care unit in Adolphe
Cissé hospital, in the city of Pointe-Noire.
Polio is an incurable viral disease that attacks
the nervous system and can cause paralysis.
Staff treated patients for symptoms andoffered physiotherapy sessions, crucial tolimiting long-term damage from the disease.
More than 140 patients received care.
In March, as the number of cases declined,
MSF withdrew, handing physiotherapy
services and mobility assistance over to
Handicap International.
At the end of 2011, MSF had 280 staff in theCongo. MSF has been working in the country
since 1997.

© Isabelle Ferry

Médecins Sans Frontières (MSF) is assistingwith the provision of medical care in Bétou
district, in the department of Likouala.
An average of 400 people were admitted tothe 89-bed Bétou hospital every month:around half of these were women requiring
maternity care and one-third were children.
Staff assisted more than 2,600 births.
MSF also worked with the staff of theCongolese HIV and tuberculosis (TB)
programmes. Since January 2010, MSF hastreated 80 people for TB, and 60 people
with HIV have started antiretroviraltreatment. More than 2,600 outpatient
consultations were held at the hospitalper month, mostly with children, and mainly
for respiratory infections and malaria.

Mobile clinics are conducted by boat in order to reach people living in remote areas along the Ubangi River.
Congo

41

Médecins Sans Frontières

Colombia
Conflict in Colombia hastaken a severe toll on the
population, and medical
assistance is often scarcefor people living in zones
affected by fighting.

TurbacoTierralta

Buenaventura
Cauca
CaquetáNariñoPutUmayo

Assisting rural communities

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

are offered prevention of mother-to-childtransmission services.
More than 54,200 patients attended
consultations at rural clinics in 53 locations
across the four departments. Over 1,600 people
traumatised by conflict also received mental
healthcare at MSF programmes in municipal
hospitals in Cauca and Caquetá.
Over the course of the year, MSF provided
medical and psychological assistance,
as well as water and sanitation services,
to 4,800 people during 19 emergency
interventions. Most of them were sufferingfrom conditions caused by conflict andforced displacement. When widespread© Aurelie Baumel / MSF

As part of its antenatal programme, MSF
began offering counselling and testingfor HIV. There is still significant stigma
attached to HIV, but the testing service has
been well received by pregnant women.
Those women who test positive for the virus

AraucaRiosucio

Guerrilla groups continue to fight government
forces, while paramilitary groups havere-emerged in many areas. The strife
has displaced an estimated three million
people, many of whom live in poverty on
the outskirts of the bigger cities, while large
parts of the countryside remain unsafe.

In the southern departments of Caquetá,
Nariño, Putumayo and Cauca, Médecins Sans
Frontières (MSF) set up additional permanentor semi-permanent clinics in order to improve
the quality of care available to people living
in conflict areas. Teams provided basic healthservices, reproductive healthcare, check-ups
and vaccinations for children, an emergency
referral system and dentistry. Dentists
perform essential work – such as extractions –which has a considerable impact on patients’
health and wellbeing.

Norte deSantander

A child receives treatment at a clinic in Buenaventura.

42

Colombia

flooding hit Cauca, MSF delivered washingkits, blankets and mosquito nets to 4,430
people. However, MSF teams were still
unable to reach 16 locations because of
security problems.
In Turbaco, Bolívar, and Tierralta, Córdoba,
MSF offered basic healthcare andpsychological assistance to people also
suffering the direct consequences of conflict.
Teams conducted more than 780 individual
mental health consultations and 53 group
counselling sessions. Mobile teams conducted
another 9,000 medical consultations.
In November, the programme was closed
due to a relatively low number of patients.
Through its report Access to Health is Accessto Life: 977 Voices, MSF gave medical
evidence of the barriers that Colombians
have to overcome in order to access decent
healthcare. People living in rural zones
have greater difficulty obtaining medical
assistance than people living elsewherein the country. The report exposed thenecessity of extending health services,
both qualitatively and quantitatively,
making them free of charge for more
people, and increasing the availabilityof essential medicines in health facilities.
It also highlighted the intrinsic relationshipbetween conflict and the lack of access to
medical care.
MSF was invited to present this report andits 2010 report Three Times Victims: Victimsof Violence, Silence and Neglect, Armed Conflictand Mental Health in the Department ofCaquetá to the Colombian parliament.

© Caroline Fernandez

Activity Report 2011

A young child is tested for Chagas disease at an MSF clinic.

Assistance to victims of sexual violence
At its clinic in the town of Riosucio, in
Chocó department, MSF provides mental
and reproductive healthcare, and assists
victims of sexual violence. Staff carriedout more than 3,900 consultations over
the year, as well as training and outreachactivities with teachers, health staff andprimary school students to raise awarenessabout sexual abuse and sexual violence.
Healthcare in Buenaventura
A great many people displaced by violencein the Pacific coast area seek shelter inthe city of Buenaventura. But the ratio of
health workers in Buenaventura is threetimes below the national average. In 2011,
MSF opened a second clinic in the city andconducted more than 33,200 consultations.
Staff provided a range of services, including
emergency assistance, medical andpsychological care for victims of sexual
violence, basic healthcare, ante- andpostnatal care, family planning, vaccinationand treatment for acute malnutrition.
Some 360 tuberculosis (TB) patients,
including 42 with multidrug-resistant
TB, began treatment.

Teams also carried out health promotion
activities and vaccinations in around
15 neighbourhoods. In several areas, MSF
helped residents to set up safe water supplies.

Cristóbal *9 years old
Cristóbal arrived in Florencia * twoyears ago and is still trying to adapt.
He misses the river that ran near his
old house. He misses riding his horsethrough the woods. He misses themilk, cheese and good food. He misses
his teacher and his friends and thegames he used to play with them in
the afternoon. He weeps when he talks
about the armed group that killed
his father two years ago a few steps
from his house, after accusing him
of supporting another armed group.

Offering treatment for Chagas disease
Chagas disease is an endemic parasitic
disease that causes chronic health problems
over many years, and if untreated, usuallyleads to fatal heart disease. It goes largely
untreated in Colombia. In collaboration
with the Ministry of Health, MSF hasdeveloped treatment protocols for Chagas.
Mobile teams in Norte de Santander and in
the Tame municipality of Arauca provided
screening and treatment, reaching morethan 2,000 children aged between ninemonths and 18 years in 2011: 41 patientsin Tame began treatment and the twochildren in Norte de Santander who tested
positive will start treatment in 2012.
The programme was closed in November,given the relatively low number of patientsfound to have Chagas.
At the end of 2011, MSF had 361 staff in
Colombia. MSF has been working in the
country since 1985.

Cristóbal is receiving care in an MSF
psychological programme, but, likemany other boys and girls from
Caquetá and other parts of Colombia,
he is in unfamiliar surroundings andtraumatised, trying to recover fromunspeakable tragedy.
* he patient’s name, and place names,T
have been changed.

Colombia43

Médecins Sans Frontières

Democratic
republic of
the congo
Accessing even basic
healthcare in the Democratic
Republic of the Congo (DRC)
is difficult.

In the eastern part of the country, violent
incidents occur daily, as a result of shifting
alliances between armed groups, and banditry.
Medical needs are great in eastern DRC
and the infant mortality rate is one of thehighest in the world, but general insecurity
and crime in the region have at times forced
Médecins Sans Frontières (MSF) to suspend
medical activities.

Orientale
Équateur

NORth Kivu
Kinshasa

South Kivu
ManiemaBandundu

Katanga

Kasai-Occidental

Responding to epidemics
MSF has a network of emergency teams
ready to respond to outbreaks of diseaseacross the country. In 2011, in response to ameasles epidemic, MSF staff vaccinated overthree million children, and treated morethan 13,700 for the disease.
Malaria accounts for approximately 40 per centof child deaths in DRC. MSF saw a 250 per centRegions where MSF has programmesCities, towns or villages with MSF activities

increase in the number of patients with malaria in
its hospitals in the east of the country comparedwith 2009, and treated more than 158,000
people in North Kivu, South Kivu, Katanga,
Équateur, Orientale and Maniema provinces.

Teams also responded to outbreaks ofcholera in the provinces of North Kivu,
South Kivu, Orientale, Bandundu, Équateur,and the capital Kinshasa, setting up treatment
centres and treating thousands of patients.
HIV careMore than one million people are estimatedto be living with HIV in DRC, yet antiretroviral(ARV) treatment coverage is among thelowest in the world: some 350,000 are inneed of treatment, but do not receive it.
Donors are withdrawing funding from HIV
programmes, and MSF is seeing the numberof people in urgent need of treatment grow.
An MSF team in Kinshasa runs a hospital
dedicated to HIV treatment, and MSF
programmes at hospitals and healthcentres across the country also offer HIV
care: in total, more than 5,000 patientsare registered for HIV treatment with MSF.

© Ben Milpas

Sleeping sickness programme

A surgeon operates on a woman injured in a motorcycle accident, Dungu hospital.

44

Democratic republic of the congo

The prevalence of sleeping sickness (human
African trypanosomiasis) in the districts ofHaut-Uélé and Bas-Uélé, Orientale province, isconsidered to be one of the highest in the world.
A parasitic disease transmitted by the tsetse fly,sleeping sickness is deadly if not treated. In 2011,© Robin Meldrum / MSF

Activity Report 2011

A nurse examines a 16-month-old child at the malnutrition clinic in Niangara hospital.
MSF staff screened tens of thousands of people
through a mobile clinic and in programmes in
Dingila, Haut-Uélé, and Doruma, Bas-Uélé, andtreated around 1,500 patients for the disease.
Providing healthcare to victims of conflict
At the end of 2011, more than 500,000
people in North Kivu were registered as
displaced, while another 630,000 in
South Kivu had fled their homes.
MSF runs a number of programmes, working
from hospitals and health centres across theprovinces, to provide healthcare to people
trapped by conflict. In North Kivu, teams in
Masisi, Mweso, Pinga, Birambizo, Rutshuru,
Nyanzale, and in and around Goma andButembo towns provide basic and specialist
healthcare. Last year, some services at
Rutshuru hospital were handed over to the
Ministry of Health. In total, staff carriedout more than 404,000 consultations in theprovince. In South Kivu, similar services areoffered in Kalonge – where the programme
was extended to three more health centres –Lulingu, Hauts Plateaux and Shabunda, andin a second hospital in Matili. In addition,
staff operate mobile clinics for people living
in more remote areas – some locations can bereached only by long journeys on foot – andin camps. There is also an MSF team in South
Kivu dedicated to emergency response.
At five camps on the border between
South Kivu and Katanga, MSF provided

basic healthcare, including vaccinations,and nutritional support. The team also
ensured access to safe water. In September,staff began assisting people in two camps
in the north of Kalemie town, in Katanga,providing basic healthcare and food aid.
In Katanga and North Kivu, teams ofsurgeons spent several weeks performing
fistula repair operations in MSF programmesin Manono, Shamwana and Masisi. Obstetricfistulas are injuries to the birth canal thatusually occur as a result of prolonged or
obstructed labour. They cause incontinence,
which often leads to social exclusion. In
2011, more than 110 women underwent
fistula repair surgery.
In Orientale province, MSF handed oversome of its activities in Bunia to a localorganisation, Sofepadi, which offers
treatment for sexually transmitted diseases,
family planning services and assistance tovictims of sexual violence. MSF provides
medical, technical and financial support
to Sofepadi, and now focuses its work on
emergency response and HIV treatment forchildren under 15. In Gety, a team provides
basic and emergency health services andruns a 24-hour therapeutic feeding centre.
In South Kivu in April, armed and uniformed
men opened fire on an MSF car travelling toMarungu, near Hauts Plateaux, robbed thedriver and stole everything.

Later, gunmen attacked another MSF car on
the road between Bukavu and Uvira: two
staff members were wounded. In November,a number of armed men forced their way
into the MSF residence in Masisi, North Kivu,
and opened fire. One member of the teamreceived a gunshot wound to the shoulder.
MSF suspended mobile medical activities
in the area, but continued to provide aminimum level of emergency support at
Masisi general referral hospital. There were
108 attacks involving humanitarian workers
in North Kivu in 2011.
Hospital care in Maniema
MSF took over Lubutu hospital in 2006.
By the end of 2011, the capacity of thehospital – which serves 100,000 people –had grown to 160 beds, and mortality inthe area had dropped fivefold since 2005.
In 2012, MSF plans to hand over activities
to another non-governmental organisation.
Sexual violence
As well as assisting victims of sexual
violence in many of its regular healthcare
programmes, MSF responded to around ten
incidents of mass rape around Fizi, South
Kivu, and Pinga, North Kivu. Altogether,more than 2,300 people received medical
and psychological assistance.
At the end of 2011, MSF had 2,919 staff in the
Democratic Republic of the Congo. MSF has
been working in the country since 1981.

Democratic republic of the congo

45

Médecins Sans Frontières

Djibouti

In Djibouti, screening by Médecins Sans Frontières (MSF)
teams in the first half of 2011 revealed a rise in the numberof children suffering from moderate levels of malnutrition.

Djibouti city

Cities, towns or villages with MSF activities

Over the course of the year, staff saw a
60 per cent increase in the number of children
admitted to the inpatient therapeutic feeding
centre: from 1,029 in 2010 to 1,735 in 2011.
Teams also treated more than 2,200 children
for malnutrition in six health centres on theoutskirts of Djibouti City.
A situation of chronic malnutrition

Lobbying for change
A hot, dry climate means there is little
capacity for crop cultivation in Djibouti, andthis has recently been further diminished bya regional drought. In Djibouti City, wheresome 60 per cent of the country’s population
live, food supplies are under strain. A ‘floating
population’ of migrants passing through thecountry adds to the pressure.
MSF petitioned the UN and the government
to take steps towards preventing further
deterioration of the situation, and advocatedthe use of nutritious ready-to-use food.

This ready-to-use food has an animal proteinbase and contains all the nutrients that arevital for a growing child, unlike the corn-soy
blend of fortified flour that is more commonlyused to supplement children’s diets.
The Ministry of Health is in the processof revising the national protocol for thetreatment of malnourished children underfive to include nutritious ready-to-use foods.
Responding to cholera
Cholera – a water-borne bacterial disease
that causes profuse, watery diarrhoea –broke out in July and August, and MSF
supported the health authorities’ responseby treating 190 patients. When a smaller
outbreak occurred in October, MSF again
provided assistance.
At the end of 2011, MSF had 134 staff inDjibouti. MSF has been working in the country
since 2008.

© Claude Mahoudeau

The nutritional situation in Djibouti is critical,
but it is unchanging. In order to focus on
emergency activities, MSF is handing over its
services in Djibouti. In August, the outpatient
programme was transferred to the
Ministry of Health and other longer-term,
non-governmental organisations.

Staff continued to see a large number ofchildren in the programme who were also
suffering from tuberculosis (TB): 81 tested
positive, and after completing treatmentin the feeding centre, were referred to thenational TB programme. The inpatient
feeding programme will be handed overto national authorities in April 2012.

Paediatric consultation at a clinic in Djibouti City.
46

Djibouti

Activity Report 2011

© MSF

Egypt

Children are seen by a nurse before the consultation with the doctor.

Cairo

Cities, towns or villages with MSF activities

Egypt has a competent medical sector andnumerous qualified doctors and healthprofessionals, but medical needs during thepolitical crisis of January and February 2011
exceeded what even a strong health system
could prepare for.
MSF teams delivered medical supplies tothree hospitals in Cairo. They also helped
provide care in an improvised clinic in amosque close to Tahrir Square, the focal
point of unrest. MSF staff with experienceof working in conflict settings gave training

During Egypt’s revolution, Médecins Sans Frontières (MSF)
gave assistance and supplies to support local medical staff
treating the wounded.
in responding to the medical needs oflarge numbers of people in a short periodof time, and set up additional emergency
preparedness systems.

eastern Libya by procuring and shipping
medical supplies, and supporting medical
and logistical teams.

When new clashes between protesters andsecurity forces broke out in November,
MSF donated essential drugs and medical
and surgical supplies to four hospitals in
Cairo and one in Suez.

In 2011, MSF was officially registeredin Egypt, allowing the development of
new programmes. Teams are considering
assisting residents of some of the mostdeprived districts in Cairo, and supporting
treatment for multidrug-resistanttuberculosis and hepatitis C.

As a result of MSF’s collaboration with Egyptian
volunteer doctors during the revolution, there is
now a group of medical staff ready to respondto any future emergency in the country.
MSF plans to offer training in the future.

Future health programmes

At the end of 2011, MSF had 7 staff in Egypt.
MSF has been working in the country since 2010.

Emergency response in Libya
In February, MSF staff in Egypt supported
the medical response to the conflict in

Egypt

47

Médecins Sans Frontières

Ethiopia
In 2011, responding to thenutritional crisis in the Hornof Africa, and providing
people living in remote areas
with access to healthcare,
were the focus of Medécins
Sans Frontières (MSF)
activities in Ethiopia.

In the border areas close to Somalia, MSF
massively scaled up its activities in responseto the dire nutritional situation. Drought,a collapsed health system and violent
conflict in Somalia saw more than 120,000
refugees arrive in camps in Ethiopia’s Libenzone. Services in two existing camps wereexpanded and three new camps were
established to meet the huge needs. At thepeak of the crisis in July, 3,000 refugees
were crossing the border at Dolo Ado everyday. MSF set up a medical screening unit at
the refugee reception point. When refugees
reached the camps, the team provided basic
healthcare and nutritional support. For those
who could not make it on their own, staff
used all means, including donkey carts, to getpeople to medical facilities. Over the courseof the year, tens of thousands of children wereenrolled in nutrition programmes, which wererun in partnership with the governmentof Ethiopia, the UN refugee agency UNHCR
and other organisations.
Overall, MSF admitted more than 31,600
children to nutrition programmes in the camps,
vaccinated over 53,000 people against measles

AmharaBenishangulGumuz

Gambella

Somali region

SNNPR

OromiaRegions where MSF has programmes

and held more than 61,000 consultations.
By the end of the year, the mortality rate
had returned to normal levels, althoughtens of thousands of refugees remained incamps, requiring humanitarian assistance.
Assisting marginalised populations
In Somali region, MSF continued working
with people affected by the Ogaden
conflict, in places where even the mostbasic services are lacking.
In Degehabur, where fighting between
government forces and insurgents has
hindered access to healthcare, MSF has been
supporting the regional hospital for four years,
providing a host of services, including
outpatient and inpatient care, nutrition

programmes, sexual and reproductive
healthcare, as well as treatment for malaria
and tuberculosis (TB) and assistance forvictims of violence. MSF conducted nearly
4,000 antenatal consultations and delivered
519 babies in Degehabur. Our staff also
attended to over 230 wounded and carriedout 270 surgical interventions.
In the town of Wardher, MSF expanded its
services, creating new ‘satellite’ sites andmobile clinics, and conducting 136 field
trips to ten different locations. The teamcarried out more than 67,000 consultations
with people living in remote communities.
Over 1,250 people were admitted to theregional referral hospital, where MSF
provides maternal healthcare as wellas treatment for malaria and TB.
Further southwest, in East and West Imey
districts, MSF conducted an average of
3,000 medical consultations per month,offering maternal healthcare, nutritional
support and vaccination. More than
300 patients also received treatment for TB.
In total, staff tended to more than 35,000
patients in East and West Imey.

© Michael Tsegaye

Nutritional support in Oromia
and SNNPR

A Somali refugee is vaccinated against polio at a reception centre in Liben zone.

48

Ethiopia

In Oromia region, 300 kilometres east of
the capital, where bad harvests can put asevere strain on local people, MSF supported
54 mobile feeding clinics operated by the
Health Bureau – 30 in Arsi and 24 in Anchar –ensuring the appropriate medical treatment
for malnourished children and womenand the supply of drugs and therapeutic
food. In total, more than 4,000 patientswere enrolled in MSF’s therapeutic andsupplementary nutrition programmes in
Oromia. As levels of malnutrition decreased,© Michael Tsegaye

Activity Report 2011

Somali refugees arriving at the reception centre in Liben zone are offered health screening.

MSF started handing over its programmes tothe Health Bureau. This process was formallycompleted in February 2012.
In September, MSF started nutritional activities
in Bensa and Aroressa districts, in the Sidama
zone of the Southern Nations, Nationalities
and People’s Region (SNNPR). As in Oromia,
the teams supported mobile feeding clinics
and treated severely malnourished children
in intensive feeding centres.
Focus on neglected diseases
In the northern town of Abdurafi, in
Amhara region, MSF focuses on treatingkala azar (visceral leishmaniasis), a chronic
and potentially fatal parasitic disease.
Many patients in this project are co-infectedwith HIV. With around 600 people on
antiretroviral treatment, some 1,100 inother HIV-related programmes and an
average of 600 on medication for kala azar
per year, MSF continued to show how
treatment can effectively be implemented
in resource-poor settings.
More than 11,000 people attended MSF
photo exhibitions about kala azar in
Gondar, Bahir Dar and Addis Ababa, whichhighlighted in particular migrant workers’
vulnerability to the disease. In 2012, MSF
plans to continue treating kala azar patientsin northwest Amhara region, while also
investigating better treatment options.

An outbreak of measles, potentially deadly topeople who have not been vaccinated, occurredin central Amhara region in the middle of 2011.
Between September and October, MSF treatedmore than 5,000 patients and conducteda vaccination campaign that covered some
34,400 children aged between nine months
and five years of age.
Caught between two worlds
The Nuer population of Gambella region, in
the far west of Ethiopia, grew as people fled
local and regional fighting across the borderin South Sudan. Intercommunal feuds, which
generate regular, violent cross-border cattle
raids, have been increasing in intensity for the
past few years. In 2011, MSF staff conducted
over 35,000 consultations in the Mattar healthcentre and a further 17,000 through mobile
clinics. Around 1,200 patients were admitted
to hospital, and maternity staff assisted anaverage of 17 deliveries per month.
In November 2011, fighting that brokeout between the Sudanese army and the
SPLM-North militias in the Blue Nile state of
Sudan forced a large number of people toescape to the Benishangul-Gumuz region of
Ethiopia. Approximately 25,000 registered
Sudanese refugees live in three camps:
Sherkole, Tongo and Adamazin. Thousands
more are hosted within local communities.
MSF teams ran health centres and managed
outreach activities as well as hospital referral

at two sites. However, direct access to thecamps in Benishangul remains difficult toobtain from the Administration for Refugee
and Returnee Affairs. MSF developed
medical programmes outside of the camps
in order to assist the refugees.
At the end of 2011, MSF had 1,396 staff
in Ethiopia. MSF has been working in
the country since 1984.

Aden Abdi
28 years old, father of four children,
Boqolmayo refugee camp.
“I came from Wajid, Somalia, a few daysago. It took us 10 days to reach Ethiopia
on foot. We didn’t have any money to
get transport. I am in the health centre
because my daughter is sick and she isin a very bad condition. She is getting
treatment now from MSF. I left Somalia
because of drought and conflict. I wasa farmer but, because of the lack of rain
for the last two years, I couldn’t feed
my family and I was forced to flee. My
camels, goats and sheep died becauseof the drought. I hope to go back to mycountry when it rains again. But I don’t
think this will change in the near future.”

Ethiopia49

Médecins Sans Frontières© Yoanis Menge

France

The centre in Paris offers medical and psychological support for people who have difficulty accessing heathcare.

ParisCities, towns or villages with MSF activities

The economic problems in
France are making accessto healthcare more difficult
for migrants. The rights of
migrants, asylum seekers,
and foreigners in ill healthare increasingly being
called into question.

50

FranceAt their medical and psychological centre
in Paris, a Médecins Sans Frontières (MSF)
team takes care of people who have sought
refuge in France. Most have fled war zones
in Afghanistan, Chechnya or Sri Lanka
and are suffering from a range of healthproblems. Many of the people who cometo the centre have had extremely difficult
lives and have suffered numerous traumatic
experiences, including that of exile.
The main aim of the staff is to help themost marginalised people – those who do
not speak French and who do not havedocumentation permitting them to stayin France. Psychologists, social workers,
doctors and nurses all work at the centre,
so patients have access to a range of
support. In total, staff carried out 6,300
consultations, and mental health staff
saw 200 new patients.

The vast majority of the 1,000 patients who
received medical assistance in 2011 from
MSF doctors and nurses sleep on the streets
or in temporary accommodation, and haveno health insurance.
During the course of the year, in orderto further improve access to healthcare,
MSF nurses started holding weekly clinics
at three emergency hostels run by thenon-governmental organisation Emmaüs.
At the end of 2011, MSF had 30 field staff
in France. MSF has been providing medical
assistance in the country since 1987.

Activity Report 2011

Georgia

The incidence of kala azar (visceral leishmaniasis)
is increasing in Georgia, and most cases are being
reported in urban areas, such as the capital Tbilisi.

Abkhazia

Tbilisi

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

Kala azar is a parasitic disease transmitted
to humans and animals through the biteof a certain kind of sandfly. It is not known
for certain why the incidence in Georgia
has risen, but deforestation and large-scalemigration from rural to urban areas havebeen suggested as possible explanations.
Symptoms of kala azar include fever, weight
loss, anaemia and enlargement of the spleen
and liver. If left untreated, the disease is fatal.

MSF has introduced rapid testing, whichis less expensive and far less complex andinvasive than previous screening methods,
which required bone marrow samples.
A new treatment regime has also been
implemented, using the drug liposomal
amphotericin B. Treatment now takes just
10 days, rather than 30.
Tuberculosis
Mortality rates for people with tuberculosis(TB) have declined in Georgia, but the
number of deaths remains high. Multidrugresistant tuberculosis (MDR-TB) is one of
the main reasons for this. MSF is treating
patients with drug-resistant forms of TB in
the autonomous republic of Abkhazia.

MDR-TB is contagious, and can be transmitted
through the air when an infected personsneezes or coughs, or it can develop whena patient becomes resistant to at least twoof the standard TB drugs, either throughmismanagement or misuse of medication.
Treatment is difficult: it can take up to two
years and causes severe side effects.
In June 2010, after 11 years of treating patientsfor TB, MSF decided to hand over the
programme to local medical authorities. In 2011,
the team worked to support the restructuring
and strengthening of the Abkhazian TB
programme, in preparation for the handover.
MSF also continued to offer health education andcounselling to help patients adhere to treatment.
Since January 2010, 208 patients have started
treatment for TB.
At the end of 2011, MSF had 72 staff in Georgia.
MSF has been working in the country since 1993.

© Julie Damond / MSF

In Tbilisi, Médecins Sans Frontières (MSF)
has launched a kala azar programme incollaboration with the city’s Parasitological
Hospital. MSF staff provide initial training
in diagnosis and care, and hospital staff

then take on programme management andpatient treatment. More than 130 people wereadmitted to the programme in 2011, some70 to 80 per cent of whom were children.

Laboratory testing at the tuberculosis programme in Georgia.
Georgia51

Médecins Sans Frontières

GreeceEvros

Regions where MSF has programmes

The Evros River, on the Greek–Turkish
border, is the main entry point in Europe for
undocumented migrants. In 2011, bordercontrols were tightened: a fence was built
along the northern border, and a team from
Frontex, the EU border security agency, wasdeployed in the northeast. Consequently,
the number of people arriving in northEvros fell by almost one half comparedwith 2010. However, there was a threefold
increase in arrivals in south Evros.
On entering the country, migrants arearrested by the police. They are registeredand given an expulsion order. Many
voluntarily give themselves up to the police,
because without an expulsion order theycannot buy a bus or train ticket to continue
their journey.
Critical conditions in detention
Médecins Sans Frontières (MSF) beganproviding relief items and healthcare at
the border police stations of Feres, Soufli
and Tychero in 2010, and reported on thecritical situation for migrants and asylum
seekers in detention.
In 2011, hygiene and sanitation remained
poor. Throughout the year, the number ofpeople having to share a latrine exceeded
the emergency standard by almost fourtimes. Detainees were not provided withany basic necessities, such as cooking
utensils, soap or blankets, nor with any legal
information or counselling. The Ministry of
Health irregularly provided only basic healthservices. There was no medical surveillanceor follow-up in the detention centres.
MSF systematically reported these problems.

52

Greece© MSF

During the first nine monthsof 2011, some 1,000 migrants
were arriving at the Greek
border every day, many inneed of medical attention.
A migrant receives medical treatment at a police station in Evros.

In March, the Ministry of Health began
to address direct medical needs, and MSF
handed over its activities. However, in August,the ministry suspended its work due to lackof funds, and MSF again provided medical
assistance and water and sanitation services
in five detention centres. In October, theMinistry of Health resumed its operations,and a second MSF handover was finalised.
Between January and April, and August and
September, MSF teams held nearly 2,700
medical consultations, as well as more than
170 mental health sessions. At Filakio, MSF
distributed basic essentials, such as sleeping
bags, washing kits, towels, toothbrushes
and clothing. The teams also repaired
blocked toilets and broken windows,
disinfected cells and distributed materials
so that detainees could keep their living
quarters clean.
Vulnerable people left without shelter
In an effort to ease overcrowding, theGreek authorities made a decision not todetain people for longer than one or twodays. However, without the means to moveon or find shelter, many people, including
pregnant women and young children,
ended up sleeping outside the detention
centres and police stations in harsh weather
conditions. MSF teams regularly distributed
sleeping bags, warm clothes and soap.
At the end of 2011, MSF had 3 field staff
in Greece. MSF has been providing medical
assistance in the country since 2008.

Charles *27 years old“I come from Ivory Coast. My father
arranged for me and my two brothers
to leave the country. If we did notleave, we were in danger of being
killed. I lost my brothers in Turkey.
I don’t know where they are now.
“I crossed the river in a small boat.
My friend was rowing when a tree
branch hit him. He fell in the water anddrowned. We took his dead body out of
the water, we left him there at the riverbank and left.
“T hen they arrested us and brought us
to this border police station. I havebeen here for 45 days. I heard thatthey have registered me as Nigerian.
I don’t know why they did that. I havetalked with the policemen many times,
also with the police commander, but
nobody explains to me why. I don’tknow where my brothers are. I tried
to call my father twice, but he did not
answer. He might be dead. I cannot
stay here any more. Please help me.”*

The patient’s name has been changed.

Activity Report 2011

Guatemala© Natacha Buhler / MSF

Daniela * 17 years old,and Maria *, her mother

The health centre in Zone 7 of Guatemala City offers treatment and support for
victims of sexual violence.

Daniela: “It’s been very difficult
for me to get over the rape. I got
pregnant so young and had to leave
my studies and many other things
behind. Each psychotherapy session
helps me find relief and consolation.
I try to see life differently and to move
forward... People don’t understand or
see the magnitude of sexual violencein Guatemala, or when they do see it,they judge us, the victims.”
Maria: “Psychotherapy has greatly
helped Daniela. I was also able toparticipate in a group therapy session.
Before, I didn’t even know how toreact. It has helped our whole family,
as Daniela’s rape has affected every
one of us.”The names of the patient and hermother have been changed.

* 

GuatemalaCity

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

Working alongside the
Ministry of Health in
Guatemala City, Medécins
Sans Frontières (MSF) offers
24-hour emergency care to
victims of sexual violence.
Between January and November 2011,close to 4,000 cases of sexual violence
were recorded in Guatemala, although
the real number is likely to be far higher,
as so many incidents go unreported.
MSF has been working in Guatemala City since2007, improving access to medical and mental
health services for victims of sexual violence.
Teams work in the emergency departmentof the general hospital and in clinics inneighbourhoods where violence is particularlycommon. A team also offers medical assistanceat the Ministry of Justice, where incidents ofsexual violence are reported.

In 2011, nearly 780 new patients received
medical and psychosocial support, and MSF
staff carried out more than 1,270 medical
consultations. Some 1,500 follow-up
psychological consultations were conductedwith patients suffering acute post-traumaticstress, anxiety and other symptoms arisingfrom their experiences.
As part of its care, MSF offers medication
that, if taken within 72 hours of an assault,
significantly reduces the likelihood ofcontracting HIV or other sexually transmitted
infections. In 2011, around 61 per cent ofpatients sought assistance early enough forthis treatment to be effective.
But many people in Guatemala are unawarethat the physical and mental effects of sexual
violence can be treated. Victims generally
receive little support. As well as providing
medical services, MSF teams organise eventsand carry out activities to raise awarenessand demonstrate to the authorities, themedical community and the public thatsexual violence is a medical emergency, andthat medical attention must be sought as amatter of urgency after an attack.

of sexual violence. In June 2011, MSF was
asked to participate in the promotion of the
protocol in various health facilities.
MSF began handing over services in twocity clinics to the Ministry of Health in early
2011, while continuing to monitor the carethat is given to victims of sexual violence.
In 2012, MSF will pursue the handover ofactivities and follow up implementationof the protocol on the provision of care
to victims of sexual violence.
Torrential rains and flooding
The risk of natural disaster in Guatemala ishigh, and aggravated by climate change.
In mid-October, a tropical depression caused
flooding and damage in departments on
the Pacific coast. MSF distributed blankets,
mattresses and washing kits to 1,000 families
living in the department of Escuintla.
At the end of 2011, MSF had 40 staff in
Guatemala. MSF has been working in the
country since 1984.

Advocating policy change
There have been some positive developments
in national policy and practice regarding
the treatment of victims of sexual violence
recently. In September 2010, the Ministryof Health adopted a national protocol thatfacilitates access to healthcare for victims

Guatemala53

Médecins Sans Frontières© Sarah-Eve Hammond

GuineaThe Guéckédou youth basketball club passes on messages about malaria transmission and prevention.

An inefficient drug supply system, unevenly distributed
facilities and a shortage of medicines and equipment are major
challenges currently facing Guinea’s national health service.
Conakry
Guéckédou
Regions where MSF has programmesCities, towns or villages with MSF activities

Guinea’s national HIV programme is unable
to secure sufficient funding and is barely
functional. The government’s decision in2007 to supply free antiretroviral (ARV)
treatment has not been implemented.
Patients are still asked to pay for drugs,
laboratory tests and medical follow-up.
As many patients cannot afford to pay,they cannot get the care they need.
Although the prevalence of HIV is low incomparison with many other countries in
sub-Saharan Africa, the lack of investment incare and the stigmatisation and discriminationthat patients with the disease encounter meanthat HIV is a significant problem in Guinea.
At the end of 2011, Médecins Sans Frontières(MSF) was providing ARV treatment to7,440 people in Conakry, the capital, and54

GuineaGuéckédou, in the south. MSF supports HIV
care in five health centres in the Matam districtof Conakry, with an emphasis on paediatric
HIV and prevention of mother-to-childtransmission.
Mother and child health
Since 2009, MSF has been operating amother and child programme in Matam,in collaboration with the national healthauthorities. The district is home to 242,000
people, including an estimated 43,600
children under five. The objective is toimprove the quality of healthcare and to
make it more accessible, particularly for
those most vulnerable to illness.
Sixty-five health workers raise awarenessabout health issues within the community,
encouraging pregnant women to visit ahealth centre for antenatal care and to
make sure their youngest children get the
medical assistance they need. In 2011, MSF
carried out more than 47,000 paediatricand maternal health consultations in threehealth centres.

Malaria
Malaria is hyperendemic in Guinea, meaningthat incidence is high and continuous
throughout the year. It is the main reason
for hospital admissions in the country, andtransmission peaks during the rainy season,
between April and November.
In June 2010, MSF launched a malaria
programme with the aim of decreasingtransmission and improving treatment forpeople in Guéckédou. An MSF team offers
expertise to 16 public health facilities(one hospital, six health centres and nineclinics), and in addition, trains Ministryof Health medical staff. The team has also
trained some 45 community health workers
from the region to diagnose and treat
simple cases of malaria in their villages.
In 2011, MSF treated more than 55,000
patients for the disease.
At the end of 2011, MSF had 283 staff in
Guinea. MSF has been working in the country
since 1984.

Activity Report 2011

Honduras
Tegucigalpa

Cities, towns or villages with MSF activities

In Honduras’s capital
Tegucigalpa, Médecins Sans
Frontières (MSF) is developing
a programme to improvemedical assistance for people
affected by violence.

Working on the streets of Tegucigalpa
MSF has set up mobile teams, made up ofa social worker, psychologist, doctor andnurse, who visit 20 sites around the city eachweek – perhaps a public square or street
corner – providing on-the-spot healthcare
where they can, or referring people in needof more advanced or complex treatment toMinistry of Health facilities.
The team conducted 1,860 consultationsin 2011. As the year progressed, there weresigns that the programme was beginning
to influence behaviour and encouraging
more people to seek medical treatment.
In March, 19 per cent of street-based
patients referred to a health centre by

MSF actually went. By December, thenumber had risen to nearly 26 per cent.
Introducing treatment for victimsof sexual violence
MSF also assists victims of sexual violencein four health centres in some of the mostviolent areas of Tegucigalpa. A team of
one nurse and one psychologist provides
psychological and medical care to patientsand trains Ministry of Health staff.
Since February, MSF has been actively
participating in the elaboration of anational protocol for the treatment ofvictims of sexual violence, helping to
draw up the medical content. MSF is
also advocating that sexual violence beconsidered a public health emergency.
At the end of 2011, MSF had 22 staff in
Honduras. MSF has been working in the
country since 1974.

© Aurélie Lachant / MSF

Drug trafficking, clashes between gangs
and legal access to guns have madeviolence commonplace in Honduras.

An MSF survey carried out at the endof 2010 found that nearly 59 per centof under-18s living on the streets of
Tegucigalpa had experienced physicalviolence within the past year, while
45 per cent reported that they had
been victims of sexual violence.

Staff working on the streets of Tegucigalpa provide on-the-spot medical care as well as referrals.
Honduras55

Médecins Sans Frontières

Haiti

At the end of 2011, almost two
years after the earthquake,nearly half a million Haitians
were still homeless and living
in unhealthy conditions.
The health system requires
a huge amount of investment
in reconstruction.

Nord

Artibonite
Baradères

LéogânePort-au-Prince

Médecins Sans Frontières (MSF) continued
to respond to the cholera epidemic andprovide specialist medical care inPort-au-Prince and nearby Léogâne.

JacmelCholera epidemic
The cholera epidemic, which broke out in
October 2010, had infected 520,000 people
by the end of 2011, killing more than 7,000.
MSF treated around 170,000 patients forcholera symptoms during this time, working
in 50 facilities across the country.
In Nord department, MSF opened 19 treatment
centres and 90 oral rehydration points.
Staff treated more than 31,700 patients in
Nord department alone. In the first monthsof the year, when the number of newpatients started to stabilise, MSF began
to hand over activities. Staff provided
six months of training and logistical support
to Ministry of Health workers in Nord
department before withdrawing in October.
MSF continued to provide treatment forcholera elsewhere in Haiti, particularly

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

for people suffering complications due topregnancy or existing chronic diseases.
In May, the rainy season began and the rate of
infection rose again. Staff reopened emergency
treatment centres in Port-au-Prince, bringing
capacity up to 1,000 beds in eight sites.
At the end of the year, cholera was still
not under control, and unexpected rises
in infection continued to occur. As long as
people are obliged to live in conditions thatexacerbate the spread of infectious diseases– half the population of Haiti does not haveaccess to safe drinking water – the resurgenceof cholera will be a risk. MSF spoke out
about the need to strengthen the national
surveillance and response systems.

Maternal healthcare
Before the earthquake, MSF’s work in Haiti
concentrated on maternal healthcare.
A large proportion of maternal deaths are
due to pregnancy-related hypertension
disorders, such as pre-eclampsia, which aretreatable, but many women do not haveaccess to emergency obstetric care.
The earthquake destroyed MSF’s emergency
obstetric hospital in Port-au-Prince. In
March 2011, a new referral centre forobstetric emergencies (CRUO) was openedin the neighbourhood of Delmas 33. This
80-bed hospital offers free 24-hour care to
women experiencing serious complicationsin their pregnancies. Staff at the centre
also provide postnatal and neonatal care,family planning, mental healthcare anda programme to prevent mother-to-childtransmission of HIV. In 2011, MSF assisted
over 4,000 births at the centre, most ofwhich were emergency deliveries.

© Yann Libessart

Hospital care in the capital

Emergency treatment at MSF’s hospital in Tabarre, Port-au-Prince.

56

Haiti

At hospitals across the capital, MSF has
switched its focus from emergency response
to more routine specialist medical services.
Bicentenaire hospital, which had been
set up in a former dental clinic just after
the quake, was closed in July. It offeredemergency care and surgery, paediatriccare and mental health services, as well as
ambulance referral. In the hospital and two
mobile clinics, Bicentenaire staff saw around
4,000 patients a month in 2011.
In the impoverished neighbourhood of
Cité Soleil, MSF staff at the Ministry of
Health’s Choscal hospital worked in thetwo operating theatres, the emergency

© Jon Lowenstein / NOOR

Activity Report 2011

A patient receives treatment following an incident of sexual violence, Port-au-Prince.

department and the paediatric andmaternity wards. They also provided
medical and psychosocial care to victimsof sexual violence.
MSF’s 40-bed emergency and stabilisation
centre in Martissant withstood theearthquake. In addition to emergency
assistance, the hospital continues to offer
maternity care, internal medicine andmental health services. In Sarthe, MSF
runs a centre offering wound care andorthopaedic and reconstructive surgery.
Handicap International physiotherapists
work with MSF to rehabilitate patientsand help them adapt to mobility aids.
In May, MSF’s inflatable hospital, set up on
school playing fields in the days after theearthquake, was replaced by a new 200-bed
hospital in Drouillard district. Drouillard
hospital offers a wide range of services
and has a specialised burns unit. Surgeons
performed around 20 operations a day,and 29,000 patients were admitted for
emergency treatment over the courseof the year.
Access to care outside the capital
Léogâne, a city just west of Port-au-Prince,
was almost completely destroyed by theearthquake. In October 2010, MSF replaced
the tent hospital it had set up in thecity immediately after the earthquakewith a semi-permanent container hospital.
Chatuley hospital has 160 beds andmainly focuses on trauma and obstetricemergencies. The outpatient department
offers basic healthcare to women andchildren under the age of five.
In Jacmel, in the southeast of the country,
MSF began supporting Ministry of Healthstaff at the Saint Michel hospital directly
after the earthquake. Staff provided
emergency care, surgery, paediatric andmaternal care, as well as mental healthservices. In February 2011, as emergency
needs had abated, MSF withdrew.
At the end of 2011, MSF had 3,872 staff
in Haiti. MSF has been working in the
country since 1991.

170,000Moïse
33 years old“I’m from Bogbanique. The illness began
when I was in my garden. I was working.
It began all of a sudden. I didn’t knowwhat was happening to me. I lost
consciousness. Some people took me
to the clinic. They put me on a drip.
I remember that, because that waswhen I came to. But the medical centre
there didn’t have the right treatment
for me, so they put me on a motorbike
and we came to Thomassique. I fainted
again. I don’t remember arriving here.
But now I am conscious again, andI feel better.
“I’ve seen others with cholera. I don’t
think I’m any worse off than them, but
I’m no luckier either. When this disease
gets you, it’s life or death.”patients
treated for cholera
since October 2010

Haiti

57

Médecins Sans Frontières

India
Quality healthcare remains
out of reach for millions ofpeople living in India.

Médecins Sans Frontières (MSF) provides
free health services to people living inthe states of Bihar and Chhattisgarh, thedisputed region of Kashmir, remote villages
on the border with Myanmar, as well as theenormous city of Mumbai.

India-administered Kashmir

BiharnagalandManipur

Chhattisgarh

Mumbai

Chhattisgarh: caught up in conflict
Villagers living in the forests of Chhattisgarh
state are caught up in the long-running conflict
between government forces and the Naxalites(a Maoist group). Medical facilities are scarce.
MSF runs mobile clinics in 16 locations,providing healthcare and hospital referrals torural communities in southern Chhattisgarhand to displaced people in camps in theneighbouring state of Andhra Pradesh.
In 2011, MSF expanded its activities in thearea, conducting almost 68,000 consultations,covering antenatal care, nutritional support
to children and pregnant women, treatment
for malaria and tuberculosis (TB) and healthpromotion activities.

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

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

health centre in Konta with TB counsellingand health promotion activities.
Health needs in the disputed regionof Kashmir

Countering neglect in the northeast
Nagaland, in northeastern India, near
the border with Myanmar, is an isolated
and neglected state, partly due to its
geographical location, but also as a resultof cultural differences and a long-running,
low-level conflict between separatists
and state security forces. The healthinfrastructure and supply system are poor,and there are few specialist medical staff.

Mental health needs are great in Kashmir, due
to the history of conflict, and MSF provides

During 2011, MSF rehabilitated thebuildings of Mon district hospital,
constructed a zone for waste management,
improved basic healthcare services andtrained hospital staff. The team held morethan 30,000 outpatient consultations, and3,044 people were admitted as inpatients.

In Vaishali district, more than 1,900 patients received treatment for kala azar.

58

India

psychosocial services and counselling totraumatised people. In 2011, mental healthstaff saw almost 4,000 patients.

In Kashmir, more than 20 years of instability
and violence have taken a toll on people’s
health and on the availability of medical
services, particularly in the areas along themilitarised Line of Control. At clinics near
the Line of Control, MSF delivers ante- andpostnatal care, vaccinations and TB screening
services. Female doctors are available forreproductive health consultations.

© Anna Surinyach / MSF

MSF carried out nearly 20,000 consultationsin the mother and child centre it runs in
the town of Bijapur. The team administered
more than 11,000 vaccinations and treatedapproximately 5,000 people for malaria.
In the district hospital, staff screened for
TB and performed emergency obstetricsurgery. MSF also supports a community

Andhra Pradesh

The neighbouring state of Manipur has also
suffered from years of internal conflict.
MSF continues to offer medical assistance at its
clinics in rural areas, including reproductive
health services and measles vaccinations.
The team runs an HIV programme, providing
both first-line antiretroviral (ARV) treatment
and second-line, for patients who develop
resistance to first-line drugs. In addition, staff
test, treat and counsel people with TB andmultidrug-resistant TB (MDR-TB), and haveintroduced an innovative home-based modelof care. Approximately 30,000 consultations
were carried out in 2011.
Mumbai: HIV care for marginalised groups
HIV care in India is improving, but somepeople remain unable to access treatment

© Anna Surinyach / MSF

Activity Report 2011

Members of the kala azar team in Vaishali district, Bihar.
in the public health system. These include
individuals co-infected with HIV-2, a lesscommon strain of HIV, hepatitis B, hepatitis C
and MDR-TB, as well as those requiring
alternative first-line drug regimes, andthose whose second-line treatment fails.

those suffering complications are admitted
to Sadar hospital. More than 1,900 people
received treatment with liposomal
amphotericin B in 2011. MSF is investigating
potential alternative treatments, including
single-dose and combined therapies.

Since 2006, MSF’s ARV treatment centre in
the Khar area of Mumbai has been providing
medical and psychosocial care to thesemarginalised groups. The team also conducts
outreach activities in the community andcarries out operational research in an effort
to improve HIV care countrywide.

Bihar is one of the poorest states in India andthere are high levels of malnutrition in children
aged between six months and five years. In
Darbhanga district, MSF operates a 20-bed
inpatient therapeutic feeding centre for children
in a critical condition, and five outpatient
centres, where those with severe malnutritioncome for weekly medical check-ups and receive
therapeutic food. More than 2,900 children
were admitted to the programme in 2011.

India has the second-highest number of
MDR-TB patients in the world, and in 2011
MSF increased the number of patients ittreated for the disease at its Mumbai clinic.
At the end of the year, 295 patients were on
ARV treatment, 29 of whom were co-infectedwith MDR-TB. In addition, MSF initiatedthird-line HIV treatment for seven patients.
Kala azar and malnutrition in Bihar
Kala azar (visceral leishmaniasis) is endemicin Bihar state in eastern India. People living inpoor conditions are most susceptible to thedisease, which frequently goes undiagnosed
and is fatal if left untreated. MSF has been
diagnosing and treating kala azar in five local
health centres in Vaishali district since 2007.
Most people are treated as outpatients; only

Local communities were also educatedabout the causes, symptoms and treatmentof malnutrition, while an art exhibition
helped raise public awareness of thisneglected issue.
At the end of 2011, MSF had 736 staff in
India. MSF has been working in the country
since 1999.

Rama
Chhattisgarh
Rama lives in a village in the forestsof Chhattisgarh. She has TB, butdefaulted from treatment last year,
due to social pressure in her village,
but also because she found it difficult
to travel the long distance to the clinic
in a conflict zone.
Rama’s husband has now been trainedby MSF teams to administer her
injections and make sure that she
takes her medication every day.
“ I’m more committed and motivatedto stick to the treatment. This time
I will not fail. I’m very happy that I
can work again, because the wholefamily needs this income. If MSF
were not here I would not have anyother place to receive treatment forthe disease. There are more people
in my village with the same disease,but they are still afraid to come so
far to get treatment. If they see my
improvement, they may get motivated
to come.”

India

59

Médecins Sans Frontières

Iran
ZahedanSistan-Baluchestan
Regions where MSF has programmesCities, towns or villages with MSF activities

Since 2001, Médecins Sans Frontières (MSF)
has provided basic and specialised healthcare
to both Afghans and Iranians who would
otherwise have difficulty accessing medical
services in three health clinics and one
specialised mother and child clinic in thecity of Zahedan, in Sistan-Baluchestan.

Sistan-Baluchestan has been closed tointernational humanitarian workers since2007. In mid-2011, security concerns led
to the closure of two of the clinics andthe end of home visits. The team focused
its activities on medical emergencies andwomen’s health instead. However, after
three years of tension between the Iranian
Bureau for Aliens and Foreign Immigrants’
Affairs and MSF, a decision was finally madein September to stop medical activities,
and MSF closed the Zahedan programme.

This year, for the first time since the 1979
revolution, authorities acknowledgedthat prostitution, child labour and childhomelessness were national concerns.
The Ministry of Health and some municipalities
are setting up medical and social centres inseveral areas of Tehran, offering services suchas social protection, methadone maintenancetherapy and health education to sex workers
and drug users. Nevertheless, many people still
have no access to medical or social support.

Health services for women andchildren in south Tehran
In the south of the capital Tehran, theneighbourhoods of Darvazeh Ghar, Khazaneh
Molavi and Shush are home to vulnerable
people such as sex workers and drug users.

MSF is collaborating with a network of
associations working mainly in childprotection or harm reduction, and inearly 2012 plans to open a newprogramme, providing healthcare tochildren under five and women livingin the Darvazeh Ghar area.

The Iranian authorities have recently started totalk about some social issues more openly.

At the end of 2011, MSF had 62 staff in Iran.
MSF has been working in the country since 1996.

© Marit Helgerud / MSF

Between January and September 2011,
MSF carried out more than 26,500
consultations, 38 per cent of which were
for children under five. Staff referredpatients requiring emergency medical
attention to a Ministry of Health hospital,
and then provided medical follow-up.
A team of 20 home visitors distributed
relief items, such as food, blankets andcleaning materials, to 820 families.

In 2011, Afghan and Iraqi refugees registered in Iran received
some good news: they were at last eligible for medical
insurance. However, undocumented Afghans and Pakistanisin the country face increasingly restrictive rules and policies,
and they continue to be deported.

Staff worked in four clinics in Zahedan and also made home visits to patients.
60

Iran

Activity Report 2011

Iraq
Hawijahfallujah
Najaf

KirkukbaghdadBasra

Regions where MSF has programmes

Years of economic sanctions,neglect, war and violence
have resulted in an overall
deterioration in national
health facilities and services
in Iraq. There are gaps inemergency services andobstetric care, and a striking
absence of mental healthcare.
In parts of the country, violence persists.
Health workers have to carry out their work in
insecure conditions, and with fewer resources.
Despite insecurity, Médecins Sans Frontières(MSF) was able to scale up its activities.
Obstetric and neonatal support in Najaf
Al-Zahra district hospital is the main referral
centre for obstetric, gynaecological andpaediatric care in Najaf governorate.
Some 24,000 babies are born in the hospital
every year. MSF works in close collaboration
with hospital staff, helping to build capacity
in specialised units such as intensive careand the maternal and neonatal departments.
MSF specialists in obstetrics and emergency
paediatrics held a conference with hospital
staff, advocating improved obstetric
practices in an effort to reduce neonatal
deaths. The team also provides training
and works with the hospital to improvesterilisation and infection control. Facilities
in the maternity ward were renovated.
Emergency care and surgery
Every month, as many as 20,000 people
seek emergency medical care at Basra
general hospital in the far south of thecountry. In 2011, an MSF team trained staff
in the management of emergency arrivals
and situations involving large numbers of
injured people. MSF also offered training
in post-operative and neonatal care,and renovated the operating theatre in
the emergency department, improving
conditions for the 300 or so operations that

© MSF

Cities, towns or villages with MSF activities

Surgery at Hawijah general hospital.
are performed each month. The programme
was handed over to the Ministry of Healthin June 2011.
Another team continues to offer surgery andobstetric care in Hawijah hospital. Between
January and June, surgeons carried out
212 operations.
Treating kidney failure

wounded Iraqis in Amman, Jordan.
Over the years, the programme has
expanded to admit patients from elsewherein the region, including Gaza, Yemen,
Libya and Syria. MSF provides specialists
in plastic, orthopaedic and maxillofacial
surgery. In 2011, they performed a totalof 913 operations. The team also offers
psychosocial support and physiotherapy.

In Kirkuk general hospital, some 200 kilometres
north of Baghdad, MSF offers treatment topeople with non-communicable diseases.
The team mainly cares for patients withsevere kidney failure. The capacity of thedialysis unit was improved and the numberof patients tripled: 88 were receiving
dialysis at the end of 2011.

Around 50 new patients are admitted to theprogramme each month. They may stay inthe centre for several weeks or as long as
two years, depending on their injuries.

Psychosocial care

At the end of 2011, MSF had 264 staff in Iraq.
MSF first worked in the country in 2003.

MSF staff conducted more than 10,700
counselling sessions with some 3,800 patientsin three hospitals in Baghdad and Fallujah.
Since 2009, staff have been working to reduce
the stigmatisation around mental healthissues in Iraq by organising awareness-raising
activities in the community. In conjunction
with the Ministry of Health, MSF produced
a film exposing the types of mental healthproblems that are common in the country
and explaining that help is available.

By the end of 2011, more than 1,700 patients
had received advanced surgical care since
the programme began.

Reconstructive surgery in Jordan
Since August 2006, MSF has been runninga reconstructive surgery programme for

Iraq

61

Médecins Sans Frontières

Ivory Coast
The dispute over Ivory Coast’spresidential election in
November 2010 provokedviolence that had escalated tofull-scale war by February 2011.

Dix-Huit Montagnes
Haut-Sassandra

Many of the country’s health facilities
closed due to the conflict. Médecins Sans
Frontières (MSF) set up mobile clinics andsupported hospitals and health centres in
Abidjan and western Ivory Coast, where
the heaviest fighting took place.
Western regions
In the western regions of Moyen-Cavallyand Dix-huit Montagnes, medical facilities
that had not been destroyed were shortof supplies and staff. Many people who
had been displaced by violence had noaccess to medical services. MSF began tooffer emergency medical assistance inthe town of Duékoué in early January.
Staff provided emergency treatment forsome 4,600 patients and assisted more than
1,480 births. Close to 100,000 consultations
were held at mobile clinics and a healthcentre in the area.
From March, teams began to support thehospital and operate mobile clinics inthe department of Guiglo, carrying out
more than 77,000 consultations. New
programmes were opened in Bloléquin,to the west, and Taï, further south,in September and December, respectively.
In total, almost 1,000 patients wereadmitted to hospital.
MSF also set up mobile clinics and carriedout more than 33,000 consultations in andaround the towns of Man, Zouan-Hounien
and Toulépleu. Over 300 malnourishedchildren were admitted to a nutrition
programme in Man between July and
September. The 15-bed health centre in
Bin Houye, just north of Toulépleu, wasreopened, and staff provided emergency
care for 175 patients.
In March alone, a surgical team in Bangolo
performed 147 operations, more than70 per cent of which were for gunshot
wounds. Some 470 patients received

62

Ivory Coast

Moyen-Cavally

Bas-Sassandra

AbidjanRegions where MSF has programmes

psychological support. Staff also ran mobile
clinics in the surrounding area, seeing over
5,000 patients.
In May, medical programmes were opened
further east, in the towns of Tabou andDaloa, and staff carried out more than80,000 consultations in total.
Abidjan
On 28 February, MSF opened Abobo Sud
hospital, on the front line of the conflict inAbidjan. Surgical teams worked around theclock. Between mid-April and the end of
August, they performed more than 2,200
operations. Some 3,890 patients wereadmitted to the emergency department,

Cities, towns or villages with MSF activities

and in other departments, MSF staff assisted
IVORY COAST
over 4,100 births and conducted around
20,250 consultations. As the violencecalmed, more people came to the hospital,and queues started to form from 4am.
To reduce the pressure on Abobo Sud,
MSF began working in eight health centres
and in two other hospitals in the north ofthe city – Anyama and Houphouët-Boigny.
In the south, Koumassi hospital was the first
health facility to resume activities and offer
free healthcare to a population of 600,000.
MSF health workers provided support tohospital staff, holding more than 19,800
consultations between April and May. In
June, MSF set up a cholera treatment unit

© Peter DiCampo

According to the UN, more than 1,000
people were killed. Hundreds of thousandsof people fled their homes, as villages wereburned. While some gathered in camps orcrossed the border into Liberia, others hid
in the bush, afraid to seek assistance.

A patient with bullet wounds has his dressing changed, Bangolo hospital, Dix-huit Montagnes.

© Peter DiCampo

Activity Report 2011

At Nanan Yamousso clinic, Abidjan, staff carried out wound dressing and surgery.

in the hospital to respond to an increasein the number of people with the disease.
The team also set up a unit in the campwhere the majority of cholera patients camefrom, and organised the decontaminationof areas where cholera was found.
In Treichville, MSF donated essential drugs
and medical supplies to the hospital andopened a trauma centre in Nanan Yamousso
clinic. Gynaecological and obstetric services
started shortly afterwards, and staff treatedmore than 750 emergency patients,
performing over 470 operations. In June,as the number of patients grew, the teams
transferred activities to the larger Port-Bouët
general hospital, just east of Treichville.
At Port-Bouët, MSF renovated two operating
theatres and the inpatient department,
increasing the number of beds to 120. Staff
carried out more than 4,000 emergency
consultations and 1,300 surgical procedures,
and assisted 1,250 births. Handicap
International worked with MSF, rehabilitating
patients after surgery. In addition, MSF
supported six health centres located around thehospital between May and July, carrying out
over 17,700 consultations. The team set up acholera treatment unit and treated 84 patients.

In the west of the city, in Yopougan,
MSF began handling emergency admissions
at Attié general hospital in April, when fighting
in the immediate surroundings had severely
restricted access to the hospital. Some 22,270
consultations were held in just over a month.
Close to 950 patients were admitted for surgery,including 169 who had been wounded bybullets or shrapnel. A team also set up amobile clinic at a nearby church, where morethan 1,000 people had taken refuge.
As the violence subsided and people returnedto their homes, access to healthcare slowly
improved across Ivory Coast, and MSF beganhanding activities back to the Ministry of
Health and non-governmental organisations.
At the end of 2011, MSF had 646 staff in
Ivory Coast. MSF first worked in the country
in 1990.

Charles *72 years old“ O n Monday 28 March I was at home,because I am old and retired. Armedpeople came and took me to the big
road. They laid me down on it, doused
me with gasoline and set me on fire.
My foot and my clothes were burnt.
Somebody took me to the hospitalon his moped the next day.
“ T hen the rest of my family followed me
here. Our home was destroyed, burned
down. We don’t have anything left.
The harvest has gone. Everything has
been ransacked.
“ I need to heal my foot. But when I getout of hospital where am I going togo and where am I going to put myfamily? I’m panicking just thinking
about going back to my village. I
don’t really care who the president is,whether it is Paul or Joe, I just want to
be in peace.”*T he patient’s name has been changed.

Ivory Coast63

Médecins Sans Frontières

Italy
RosarnoLampedusa
Mineo
Cities, towns or villages with MSF activities

Tens of thousands of people
undertook dangerous journeys
across the sea to seek refuge
in Italy in 2011.
Most people were fleeing violence andconflict in Libya or Tunisia. Many were
sub-Saharan Africans who had come toTunisia or Libya in search of a better life.
When conflict then broke out in these countries,
thousands of people risked their lives toreach Italy, crossing the Mediterranean Sea inovercrowded, unseaworthy boats. Most headed
for the small island of Lampedusa, which is lessthan 150 kilometres from Tunisia. More than
2,000 men, women and children never arrived,drowning at sea when their boats sank.
Many of those who survived arrived in a stateof extreme fatigue and shock. Médecins Sans
Frontières (MSF) offered assistance to people
as they arrived on shore, giving out blankets
and determining who needed priority
medical treatment. More than 200 people
were referred to hospital by ambulance,
while over 1,900 people received medical
attention upon landing.

torture and sexual violence, among others– were systematically detained in closed
centres while the authorities assessed theirstatus. In late June, MSF staff witnessedthat some refugees and asylum seekers had
already been kept in transit and reception
centres for as long as 40 days. In severalof these centres, services were practically
non-existent – with limited access to basic
healthcare, no information, no interpreters,
no legal advice and no telephones.
Detainees, including pregnant womenand people with medical problems, were
sleeping on mattresses on the floor, andthere was rarely separate accommodation
for single women or families.
In the absence of appropriate facilities,
unaccompanied minors were also detained, inblatant violation of European and international
standards. In June, MSF found that more than
300 under-18s had been locked in transit
centres on Lampedusa for weeks, 80 of themfor more than 30 days. MSF also counted
450 unaccompanied minors in transit andreception centres in Sicily (Pozzallo,
Porto Empedocle, Mineo, Caltanissetta).
Closure of Lampedusa holding centre
In September, the overcrowded holding
centre in Lampedusa was set on firein protest at Italy’s policy of forced
repatriation. Then riot police clashed withhundreds of migrants and asylum seekers
during a protest about living conditions.
The Lampedusa centre was closed and, atthe end of the month, the port was declaredunsafe for rescue-at-sea operations, putting
even more lives at risk.
Calling for protection
MSF repeatedly drew attention to theappalling living conditions in the reception
centres and their impact on detainees’
physical and mental health.
In May, MSF sent an open letter to themember states of the European Union, calling
especially on those directly involved in theconflict in Libya to protect victims of war
there and in Europe. MSF asked for decent
reception conditions for all those escaping
violence, access to asylum procedures for
those who requested it, and recalled the rightof refugees to protection against forcible
return. MSF reminded the EU and its member
states of their responsibility for the fate ofthese victims of war and their obligation toensure that refugees’ rights are respected.
Migrant workers in need of assistance
Hundreds of sub-Saharan migrants headfor Rosarno, in the south of mainland Italy,
in search of seasonal work. Housing andliving conditions for seasonal workers in
Rosarno are very poor, and bad weather
in 2011 made them worse. In November,
MSF distributed washing kits and blankets
to hundreds of people in need of assistance.
At the end of 2011, MSF had 8 field staff in
Italy. MSF first provided medical assistancein the country in 1999.

At the peak of new arrivals in March, 3,000
people spent several days and nights on thedocks, sharing 16 latrines and surviving on
1.5 litres of water each per day. MSF teams
provided medical assistance to nearly 2,000
people, and distributed thousands of relief
items such as blankets and washing kits.

© Mattia Insolera

When migrants, asylum seekers andrefugees had been transferred to detention
centres, MSF medical staff provided follow-up.
The most common complaints were
gastrointestinal, pulmonary and respiratory
infections. The team also treated patients
who had suffered violence, and in centres
in Mineo, on the island of Sicily, they gave
mental health support to 400 asylum seekers.
Assisting detained migrants
The most vulnerable migrants and asylum
seekers – pregnant women, and victims of

64

Italy

A team carries out medical triage and delivers relief to migrants arriving in Lampedusa.

Activity Report 2011

Japan
Ha Young Lee
Coordinator of the MSF psychological team

© Jun Saito“ Although some people have their own
coping mechanisms and can deal
with the situation in which they findthemselves, others find it very difficult.
People can have intrusive memoriesof the event, flashbacks, nightmares.
They can withdraw and not want tocommunicate. Some will not be able tosleep or eat. And all of these things canmake them very different than they used
to be and can cause significant suffering.

A consultation at an evacuation centre for earthquake survivors in Minami Sanriku.

Ensuring access to medical care
TaroMinamiSanrikuBaba-Nakayama

Cities, towns or villages with MSF activities

The earthquake and tsunamithat struck Japan on 11 Marchdevastated the northeastern
coast of Honshu Island.
Approximately 15,000 people were killed
and 6,000 were injured. At the end of theyear, some 5,000 people were still missing.
Japanese emergency teams were largely
able to respond to the needs of survivors,
and Médecins Sans Frontières (MSF) offeredspecialist assistance. The day after thequake and tsunami, staff made their way
to affected areas by helicopter and beganproviding survivors with medical care anddistributing relief items.
In the weeks that followed, MSF distributed
4,030 blankets, 6,500 litres of water, a generator
for a temporary shelter in Baba-Nakayama
village and 10,000 hygiene kits containing soap,
toothbrushes, toothpaste and towels. MSF also
provided kits containing batteries, candles andmatches to some 4,000 people and donated110,000 euros’ worth of medicines, medical
equipment and supplies.

MSF worked principally in the northern coastal
towns of Minami Sanriku and Taro, where
the main healthcare facilities were totally
destroyed. From March to June, medical teams
conducted some 4,840 consultations. Patients’
main complaints were hypertension and upper
respiratory tract infections.
MSF delivered two 30-seater buses toauthorities in Minami Sanriku to helptransport patients from evacuation centres
and temporary housing to medical facilities.
At the request of people staying in a centre
in Baba-Nakayama, MSF designed andhelped construct a semi-permanent shelter
close by. The team supervised 25 evacuees,
who built a private space for approximately
30 women and children, which reduced
overcrowding in the existing centre.
In Taro, MSF designed and built a temporary
clinic, for use until a more permanent structure
is completed. This was handed over to local
health authorities in December.
MSF also delivered a vehicle specificallydesigned to transport disabled patientsliving in and around Taro.
Invisible scars
After the initial emergency response, theteam shifted focus to the mental healthneeds of survivors, offering psychologicalsupport, especially for people living inevacuation centres.

“ Children are particularly vulnerable –it can be difficult for them to understandwhat is going on. They have limited
space where they can freely express theiremotions. They have lost the space tolearn and play.”

Staff conducted interviews with the media,
including a local radio station set up by
survivors of the disaster. They discussed
how to identify potential problems andmanage stress, how parents can help
their children, and where to seek support.
MSF staff accompanied nurses on visits
to temporary shelters and provided
direct training in mental health duringconsultations with patients. They also
visited schools to advise teachers on
supporting children post-trauma.
In April, a café was set up near the Bayside
Arena of Minami Sanriku. Here, people could
talk in an informal setting, with a teamof MSF psychologists on hand to provide
counselling. For those in need of extra
support, staff offered one-to-one sessions.
The main problems reported by people at thecafé related to stress management, difficulties
with memory and concentration, and sleeping
disorders due to crowded conditions in
temporary housing. Older people were
often concerned about dementia.
At the end of June, MSF handed over its
activities at the café to a local association.
More than 4,100 people had used the space,and 646 people had received psychologicalassistance. Over 970 individual support
sessions and 295 group sessions were
held in Minami Sanriku and Taro.
During 2011, MSF had 4 field staff in Japan.
This was the first time MSF had provided
medical assistance in the country.

MSF psychologists carried out activities
to raise awareness of mental health issues
and the support that was available.

Japan

65

Médecins Sans Frontières

Kenya
For more than two decades,
Médecins Sans Frontières(MSF) has been providing
medical care in Kenya. In
2011, MSF assisted both local
people and the large Somali
refugee population.

Drought in the Horn of Africa aggravatedthe already dire situation for refugees in
the overcrowded camps around Dadaab,in eastern Kenya. A surge of people
fleeing Somalia in search of safety, food,healthcare and shelter in the three campsof Ifo, Dagahaley and Hagadera resulted
in a humanitarian emergency. The camps,
which had been built for 90,000, swelled toa total population of nearly half a million,
making the Dadaab area the third-largest
city in Kenya. At the height of the crisis in
July, malnutrition levels were well above
the emergency threshold. Aid agencies
struggled to cope.
Two new camps were opened – Ifo 2 andKambioos. However, at the end of the year,
some 5,000 refugees were living outside
Dagahaley, unable to find a place to stayin any of the camps. Inside Dagahaley,
MSF was the main provider of healthcare
for nearly 125,000 registered refugees,
and also catered for the needs of refugees
referred to its hospital from other camps.
The team tripled capacity, setting up an
emergency nutrition centre with more than
200 beds, while maintaining a 100-bed
hospital for maternal care, paediatrics,
emergencies and general medical assistance.

Turkana
ManderaKacheliba

Dadaab

Liboi

Homa Bay
NairobiIjaaraRegions where MSF has programmes

As insecurity grew, refugee registration
was closed. Refugees were no longer
being transported to Dadaab or relocatedelsewhere. There was a general reduction in
non-lifesaving activities, which threatened
to reverse the gains achieved during the year.
Liboi, 80 kilometres from Dadaab, is oneof the primary crossing points between
Somalia and Kenya. When the flow of new
arrivals was at its peak, MSF worked ina health centre there, providing care forboth Kenyans and Somalis. Further south,in Ijaara district, MSF assisted Ministry of
Health staff in the provision of maternaland child healthcare. In March, fighting
in the Somali town of Bula Hawa drove

Cities, towns or villages with MSF activities

approximately 15,000 refugees and 5,000
displaced people to the Kenyan border
town of Mandera. MSF supported the
district hospital and conducted over
1,500 outpatient consultations.
The drought in the Horn of Africa also
affected other parts of Kenya. In April,
MSF organised mobile clinics and ensured
access to water for nomadic pastoralists inIjaara district. In addition, the team offeredreproductive healthcare and saw an increasein the number of women seeking medical
assistance during childbirth. In June, MSF
launched an emergency nutrition programmein the Lapur and Kibish subdistricts ofTurkana, in northwestern Kenya.

After protracted negotiations with thegovernment of Kenya and local communities,
MSF began working in Ifo 2 camp in July.
However, just three months later, in October,two staff members were abducted by a groupof armed men, forcing MSF to reduce healthactivities in the camp.

66

Kenya

© Lynsey Addario/VII

MSF conducted more than 170,000
consultations in its hospital and health posts
in Dagahaley camp, over 4,000 more permonth than planned. Admissions for nutritional
support averaged at 350 per month.
Over 11,500 patients were admitted to the
outpatient nutrition programme during theyear. As most of the refugees from Somalia
had had little or no access to healthcare
for two decades, outbreak of disease was amajor concern, and MSF launched a measles
vaccination campaign.

Children attend an MSF nutrition programme in Mayan, Turkana.

© Brendan Bannon

Activity Report 2011

A severely malnourished child is examined at Dagahaley camp, Dadaab.
Breaking ground in addressing
neglected diseases
In 2011, the Kenyan government, withthe help of MSF, launched the first evernational strategic plan to control neglected
tropical diseases, including kala azar
(visceral leishmaniasis). Kala azar, which
is transmitted by the bite of a sandfly,
is almost always fatal if not treated.
MSF has worked with kala azar patients in
Kacheliba, western Kenya since 2006, andin 2011 concluded a validation study of
rapid diagnostic tests (RDTs) for the disease.
The results of this study contributed to thegovernment’s decision to approve the tests
as a first-line diagnostic tool. An RDT is ideal
for use in resource-poor settings, and allows
a greater number of people to be screened
for the disease, thereby improving accessto treatment.
A new combination treatment for kala azar,
which takes just 17 instead of 30 days,
was introduced, and MSF also gave training
to local medical staff working in districts
where kala azar is endemic.
HIV and tuberculosis (TB) careAround 1.3 million people are livingwith HIV in Kenya, but only an estimated550,000 are receiving antiretroviral (ARV)
treatment. MSF has been providing HIV

and tuberculosis (TB) treatment for over a
decade, and is currently treating more than
17,000 people living with HIV/AIDS and TB
in urban areas and rural communities in
Nairobi and Nyanza provinces.
In September, MSF detected quality problems
with one ARV medicine, Zidolam-N.
The drugs were confirmed to be falsified
versions of World Health Organization
quality-assured medicines that werepurchased via a distributor certified by the
Kenya Pharmacy and Poisons Board. MSF
took immediate measures to trace andinform patients, replace the affected drugs
and provide medical follow-up.
In 2011, MSF completed the switch fromd4T-based first-line treatment to a TDF/AZTregime, which has fewer side effects. All
new patients are put on TDF/AZT.

outskirts of Kibera slum. It will at first be run
jointly by MSF and the Ministry of Health,then gradually handed over to the ministry.
Addressing sexual violence
In the slums of Kibera and Mathare, MSF
continues to focus on treating victims ofsexual violence. In both areas, the numberof child victims is very high – 65 per centof patients in Mathare are under 18.
MSF provided medical assistance to over
1,000 new patients, offering post-exposure
prophylaxis – treatment to reduce the riskof infection with HIV and other sexuallytransmitted diseases – as well as counsellingand social support.
At the end of 2011, MSF had 798 staff in
Kenya. MSF has been working in the country
since 1987.

New TB diagnostic machines have been
introduced in Nairobi, which are faster andmore sensitive . MSF also expanded its TB
programme in Mathare, Nairobi, to thepredominantly Somali neighbourhood ofEastleigh, where only limited TB treatment
services were available. Some 900 patientswith chronic diseases other than HIV also
received treatment at MSF health centres
in Nairobi. Due to be completed in 2012,
MSF is building a new health centre on the

Kenya

67

Médecins Sans Frontières

Kyrgyzstan
Bishkek

Osh

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

The underfunding of prisons in
Kyrgyzstan is affecting medical
services: many prisoners
with tuberculosis (TB) are notreceiving the care they need.
The incidence of TB among prisoners in
Kyrgyzstan is estimated to be 20 to 30 times
higher than among the general population,and mortality rates can be 60 times higher.
Poor conditions make inmates more susceptible
to the disease and encourage its spread.

Multidrug-resistant TB (MDR-TB)
In one detention facility, MSF installed a newmachine that tests for TB, which facilitates
better and more rapid detection of
drug-resistant TB, and enables patientsto start treatment earlier.
MDR-TB is either transmitted directly fromanother person with the disease, or develops
when a patient with drug-sensitive TB,
either through mismanagement or misuse of
medication, becomes resistant to at least twoof the standard TB drugs. Treatment for
MDR-TB is much harsher than for TB: it takes
up to two years and causes severe side effects.
Kyrgyzstan is one of 27 countries listed by
the WHO as having a high level of MDR-TB.
MDR-TB is even more prevalent in prisonsbecause close proximity makes it difficult toimplement infection control measures, andbecause high-risk behaviour such as drug or
alcohol addiction is more common among
prisoners, making adherence to medical
treatment more difficult. As a result, around
two-thirds of TB patients in Kyrgyzstan’s prisons
have drug-resistant forms of the disease.

MSF has set up a support system for patients
who are released before finishing theirtreatment for TB or MDR-TB, to help themkeep taking their medication. Volunteers living
close to the patients visit them regularly andoffer support until the treatment programme
is successfully completed. A hotline is alsoavailable, so that patients can call if they need
help. Between January and October, a networkof 20 volunteers helped 192 TB and MDR-TB
patients to complete their treatment.
After the 2010 riots

Political unrest and interethnic violence in2010 aggravated conditions of poverty formany people in Kyrgyzstan. During the unrest,
MSF donated drugs and medical supplies,
and facilitated access to health services for
those who were afraid to travel to healthcentres. Between December 2010 and April
2011, teams continued to offer assistance topeople in Osh, the second largest city in the
country. Staff held more than 1,000 medical
consultations, some 1,800 mental healthconsultations, and distributed 5,900 washingkits, 11,900 blankets and 800 cooking kits.
In July, the team started to develop a new TB
programme in Kara Suu district, Osh province.
At the end of 2011, MSF had 94 staff in Kyrgyzstan.
MSF has been working in the country since 2005.

© MSF

Working in collaboration with the Ministry of
Health and prison authorities, Médecins Sans
Frontières (MSF) began providing TB carein detention centres in 2006. Teams work in
two centres (Sizo 1 and Colony 31) near thecapital Bishkek, and treated 370 patients in
2011. They also worked to improve infection
control standards and living conditions, andrenovated the TB wards.

Staff work in two detention centres near Bishkek, treating patients for tuberculosis.
68

Kyrgyzstan

Activity Report 2011

© Dina Debbas

LebanonA social worker meets a recently bereaved family in Burj el-Barajneh refugee camp, Beirut.

Wadi KhaledbeirutSidon

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

Following the arrival of
thousands of Syrians fleeing
violence in their country,
Médecins Sans Frontières(MSF) extended its activities
in Lebanon.
MSF began by donating emergency
supplies to health centres near the borderwith Syria. In November, a team set up amental health programme in Wadi Khaled,a region in northeastern Lebanon, serving
a local population of more than 20,000

people as well as Syrians seeking refuge in
Lebanon. Staff carried out psychologicaland psychiatric consultations.
Mental healthcare in Palestinian
refugee camps
Life in the overcrowded Palestinian refugee
camps is arduous, and this has a significant
impact on mental wellbeing, particularly for
those who have already suffered traumatic
experiences. MSF offers community-based
mental health services – counselling,treatment and social support – in two refugee
camps and the area surrounding them.
Staff make home visits and work to raiseawareness of mental health services in aneffort to reduce the stigmatisation of mental
illness. On World Mental Health Day,
10 October, the MSF-produced documentary
film Where Do I Begin? directed by LebanesePalestinian filmmaker Carol Mansour, had its
premiere screening in Beirut.
Both Palestinian refugees and local people who
would otherwise be unable to afford mental
healthcare can go to the MSF community
mental health centre outside Burj el-Barajneh

camp in Beirut, as well as to MSF services at
the United Nations Relief and Works Agency(UNRWA) clinic and the Palestinian Red
Crescent hospital inside the camp.
In April, MSF extended its services to
Ein el-Hilweh refugee camp, in the cityof Sidon (Saïda), south of Beirut, wheresome 75,000 people live within just one
square kilometre. There are regular security
incidents and clashes between politicalfactions. MSF’s team works in the two
UNRWA clinics and in Al-Nidaa Al-Insani
hospital. Close to 380 patients in Sidon,
mostly aged between 18 and 40, received
psychological or psychiatric care in 2011.
In total, staff saw more than 1,000 new
patients and carried out more than
7,500 mental health consultations in Lebanon.
Patients were mainly suffering from depression,anxiety, psychosis and personality disorders.
At the end of 2011, MSF had 34 staff in
Lebanon. MSF first worked in the country
in 1976.

Lebanon69

Médecins Sans Frontières

LesothoRoma

Semonkong

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

Life expectancy for women in
Lesotho is less than 47 years,
and one in 32 women die frompregnancy- and childbirthrelated conditions.
HIV and tuberculosis (TB) epidemics havecontributed to this situation, and nearly
60 per cent of maternal deaths are HIV-related.
In May 2011, Médecins Sans Frontières(MSF) opened a new programme that aims
to help reduce the number of maternal
and infant deaths.
Roma and Semonkong are small towns in remoteparts of the country. About 170,000 people livein the area, and some 23,500 have HIV/AIDS.
MSF supports St Joseph’s district hospitalin Roma, six basic healthcare clinics in thesurrounding lowlands and three clinics
in Semonkong. All these facilities provide
comprehensive, integrated HIV and TB care,so patients with both HIV and TB only needto go to one place for treatment. As part oftheir maternal health services, the clinics
and hospital also work with patients toprevent mother-to-child transmission of HIV.
Between July and December 2011,
staff assisted more than 550 births.

Six health centres now have a CD4 testing
platform. By measuring a patient’s CD4
count, medical staff are able to determine
more accurately how far HIV has progressed,
and what treatment each patient requires.
Antiretroviral (ARV) treatment can bestarted earlier, reducing the patient’s risk ofdeveloping a number of HIV-related illnesses.
In 2011, MSF enrolled 8,025 people in HIV
care, and more than 5,300 patients started
ARV treatment. Between July and December,more than 8,220 people were tested for HIV.
Introducing a new automated test for TB
to the laboratory at St Joseph’s hospitalhas significantly speeded up diagnosis, inparticular for some forms of drug-resistant TB,
meaning people can start treatment earlier.
Encouraging more people to seek care
By bringing services closer to the patient,
MSF teams are hoping to encourage more
people to actively seek medical attention.
But if HIV and TB services are to be available
in more places, additional staff are needed
to deliver them. MSF wants to introduce
task-shifting in the health centres, which
will mean that nurses as well as doctors will
be able to initiate and follow up treatment
for HIV and TB, and non-medical staff
will be able to offer health education andcounselling for patients on ARV treatment.

Mobile MSF medical and counsellingteams have already begun mentoring andproviding training to health staff.
It is hoped that the community will also
get involved, with village health workers
supporting HIV and TB patients. MSF
provides guidance to enable members of thecommunity to refer their neighbours to healthfacilities, carry out health education activities
and conduct workshops. These workshops
provide training for lay counsellors and help
develop an awareness and understanding ofissues related to HIV. Village health workers
also help patients stick to treatment byenquiring after and offering support topeople who miss appointments at the clinic,
or who do not pick up their drug refills.
Limited access to healthcare
Accessing healthcare facilities is not easy foranyone living in this mountainous country,
and it is especially problematic for people
living in remote areas. Many have to walkfor up to 12 hours to reach a health centre.
In 2012, MSF will buy an ambulance forthe emergency transport of patients from
Semonkong to St Joseph’s hospital. The teamis also assessing new technological toolsthat could help improve communications
between patients and hospital staff, including
SMS reminders for patient appointments
and equipment to enable community healthworkers to collect data electronically.
At the end of 2011, MSF had 27 staff in Lesotho.
MSF has been working in the country since 2006.

8,025

patients© Zethu Mlobeli

enrolled in

People living in remote areas of Lesotho have great difficulty accessing health services.

70

Lesotho

HIV careActivity Report 2011

Liberia
Nimba

Grand Gedeh

Monrovia

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

The vast majority of Ivorian refugees were
hosted in local people’s homes, mainly inthe counties of Grand Gedeh and Nimba.
Others found shelter in refugee camps.
In January, MSF launched an emergency
programme in Nimba, delivering freehealthcare to both refugees and local residents.
The teams primarily treated respiratory andskin infections, watery diarrhoea and malaria
in mobile clinics and in a health post at the
Bahn refugee camp. MSF also vaccinatedchildren under 15 years old against measles
and provided local health centres with freedrugs and technical support. Staff conducted
more than 45,800 consultations; over 2,700 ofthese were antenatal, and some 14,500 were
for malaria.
In March, MSF started operating mobile
clinics in villages hosting refugees in Grand
Gedeh, to the south of Nimba. The teamconducted more than 38,300 consultations,admitted 226 children to a nutrition
programme, and carried out more than
1,900 mental health sessions. Water andsanitation staff constructed wells and latrinesand ensured the supply of safe water. Later,
MSF extended its services to camps in thearea, where some refugees had settled.
Despite the political resolution of the conflictin Ivory Coast in April, the situation initiallyremained insecure. Many refugees did not
return home, afraid of rape, torture andintimidation. Many had no source of income
as they had lost the land they had beenworking on, or had missed the planting
season. Nonetheless, the situation hadstabilised sufficiently by the end of theyear for MSF to hand over activities in© Gaël Turin / VU

More than 150,000 people fled
Ivory Coast and sought shelterin Liberia, where Médecins
Sans Frontières (MSF) provided
emergency assistancethroughout the year.
People living at the transit camp in Saclepea, Nimba county, receive medical screening.
Grand Gedeh to the Liberian Ministry of Healthand non-governmental organisations. Teams
continued to work in Nimba into early 2012.
Sexual violence in Monrovia
In Liberia’s capital Monrovia, MSF offers
comprehensive medical and psychosocial
care to victims of sexual violence. Teams
work with specialist Ministry of Health staff
in two hospitals to provide a walk-in service
seven days a week, with medical staff ora social worker on call 24 hours a day.
The teams conduct medical examinations
and treat patients for injury and sexuallytransmitted infections (STIs). Patientsarriving within 72 hours of an assault receive
post-exposure prophylaxis to reduce therisk of HIV and STIs. Trained mental healthworkers offer counselling and emotional
support to victims and their families.
Staff can provide medico-legal certificatesand put patients who fear for their safety
in touch with a network of safe houses.
MSF also works with a local non-governmentalorganisation, Mer-League, which is raisingawareness in the community about sexual
violence and the medical care that is available.
In 2011, 993 new patients received careafter a sexual assault, 92 per cent of whomwere under 18 years old, and 1,115 follow-up
consultations were also arranged for patientsrequiring further support.

Fred *
from Toulépleu, Ivory Coast“ When they attacked Toulépleu, we allran away together to a ‘campement’[a small shelter next to a plantation] near
my mother’s house. We were not there
long when fighters came and started
shooting at us. We ran and hid again.
“ We stayed for two months in the bush,moving from place to place whenever
we heard fighters moving. We wereattacked many times. In one attack,several children were shot. They took
my wife away with them.
“ In the bush there was no medicine
so we had to treat the children withtraditional medicine for their gunshot
wounds. Only weeks later did we makeit to Liberia, where MSF took them tothe hospital.
“ M y wife was gone for almost twomonths and we found each otheragain here in Liberia. While she was
kidnapped the fighters raped her. She
is still very anxious and disturbed anddoesn’t eat well. At night she jumps up,
remembering what happened to her.”*

The patient’s name has been changed.

At the end of 2011, MSF had 101 staff in
Liberia. MSF has been working in the country
since 1990.

Liberia71

Médecins Sans Frontières

Libya

A few days after violent clashes
broke out on 17 February 2011,a Médecins Sans Frontières(MSF) medical team crossed theborder from Egypt into eastern
Libya to provide medical
assistance to health facilities
trying to tend to large numbersof injured people.

In the country’s second city, Benghazi,
MSF donated much-needed medicines andsupplies, such as anaesthetics, antibiotics
and external fixators to help mend fractures.
But in several conflict zones, such as Zawiyah
and Misrata, thousands of people were cut
off from any external assistance, and critical
medical needs and shortages of medicinesand materials were reported. Some MSF staff
were able to provide logistical support for thedelivery of medical supplies to areas undersiege, but other teams were blocked fromentering the country. MSF repeatedly called
for urgent, unhindered access to medical
assistance for people caught up in the conflict.
In Benghazi and Ajdabiya, MSF provided
psychological support to health personnel
and patients, and trained medical staff in
psychological first aid for victims of violence.

TripoliZawiyahMisrata

Benghazi

ZintanYefrenAjdabiya
Sirte

Regions where MSF has programmes

Assisting people trapped in Misrata
Part of Misrata’s main hospital had been
bombarded, while the remaining functioning
clinics were overflowing with severely injured
patients. On 21 March, MSF managed toget a first shipment of surgical kits to thehospital. An additional six tons of medical
supplies reached the hospital in April.
Also in April, MSF organised two medical
evacuations by boat of a total of 135 patientsfrom Misrata. Medical teams provided
urgent assistance while the boat was heading

Cities, towns or villages with MSF activities

to Tunisia. Upon arrival, patients weretransferred to medical facilities for treatment.
In the same month, an MSF team from
Benghazi succeeded in reaching Misrata byboat and started supporting four medical
facilities, working alongside Libyan healthworkers in surgical wards and obstetrics
departments, and providing training on
war surgery, hygiene, sterilisation andwaste management. Teams carried out
137 surgical operations in Qasr Ahmed and
Abbad hospitals. In Qasr Ahmed hospital,
MSF also carried out 780 physiotherapy
sessions with patients who had undergone
surgery. Twelve patients in need ofreconstructive surgery were transferredto the MSF programme in Amman, Jordan.
In Ras Tubah medical centre, staff supported
the paediatric and emergency obstetricsurgery department, assisting 1,914 births,
312 of which were by caesarean section.

© Niklas Bergstrand

MSF donated several tons of drugs and medical
supplies to health facilities and provided
training, materials and ambulance equipment
to the health posts near the main front line.

A patient is prepared for orthopaedic surgery at Ben Ashour clinic, Tripoli.

72

Libya

In May, MSF launched a mental healthprogramme in Misrata, and by the endof the year, more than 3,000 patients
had received psychological support
through 200 group and 455 individual
consultations. In addition, staff gave
training to 20 Libyan psychologists.
MSF also provided medical assistance in four
detention centres, carrying out a total of 2,600
consultations, including 311 for violent trauma.
Doctors working in the centres repeatedly
came across patients with injuries caused by
torture during interrogation – they treated© Benoit Finck / MSF

Activity Report 2011

A physiotherapy session at a detention centre in Misrata.

115 people with such wounds. MSF reported
all cases to the relevant authorities in Misrata,
but medical staff continued to receive new
victims of torture, and some detainees weredenied any medical care. In January 2012,
MSF publicly denounced the situation andsuspended its activities in detention centres.
Following the line of battle

When fighting reached Colonel Gaddafi’s
home town of Sirte, MSF provided surgicalsupplies and 150,000 litres of water, andorganised the resumption of surgery in
Ibn Sina hospital. After the hospital cameunder fire and armed fighters started checking
patients inside the hospital, MSF called on thewarring parties to immediately halt all attacks
on and intrusions into medical facilities.

MSF teams supported health facilities inthe towns of Zintan and Yefren, in western
Libya, by performing surgery, donating
medical equipment and supplies and training
medical staff in responding to large numbersof casualties. Between April and October,
MSF treated more than 2,200 war-wounded
patients and conducted over 270 surgicalinterventions in the two towns. The mental
health team carried out 470 individual
consultations and over 1,000 group sessions
between July and October.

From August, MSF provided medicalcare in four camps in and around Tripoli,
where some 4,000 migrants and internallydisplaced people belonging to the Tawargha
minority had settled. Residents in thesecamps had been subjected to intimidation,
theft and assaults. Teams carried out morethan 5,100 medical consultations and offeredpsychological support in over 200 individualand 33 group sessions.

As heavy fighting moved towards the capital
Tripoli, an MSF surgical team went to Zawiyah,
to the west of the city. On the first day
alone, they treated over 70 casualties in thegeneral hospital. In Tripoli, MSF worked
in medical facilities, donating lifesaving
medication and supplies, and transferring
patients in need of urgent medical assistance.

Many people fled Libya during the fighting.
MSF teams in neighbouring countries, such as
Italy and Tunisia, provided them with medical
assistance and reminded governments,
particularly members of the European Union,of their responsibility under international law tokeep their borders open to people fleeing Libya,
and to ensure proper reception conditions.

Assisting displaced minorities andundocumented migrants

At the end of 2011, MSF had 64 staff in Libya.
This is the first time that MSF has worked in
the country.

Abdul
13 years old
Abdul suffered second-degree burns after abottle of benzene caught fire when bombs
hit the house next to his. Three days after
receiving care in a Misrata clinic, he was
evacuated to a Tunisian hospital. Ten days
later, he could open his eyes again.

Ali
45 years old
Ali had been diabetic for many years.
During the fighting, he was unable
to receive his treatment as Misrata
hospital was overwhelmed with so many
seriously injured patients that it could
no longer care for the chronically ill.
The interruption to Ali’s treatment caused
skin lesions to appear on his feet. After
his evacuation from Misrata, Ali had two
toes and the front of one foot amputated.

Libya

73

Médecins Sans Frontières

Madagascar
and half of all medical personnel now working
will retire within the next ten years.

BekilyRegions where MSF has programmes

In 2011, Médecins Sans
Frontières (MSF) opened a
programme in a remote areain the south of Madagascar,
where many people havedifficulty accessing healthcare
because of the long distances
to regional hospitals.

In April, MSF started to work in the hospitalin the small town of Bekily, in Androy district.
The hospital has 20 beds and offers general
medical, maternal and paediatric services.
There is no operating theatre, so surgicaland obstetric emergencies are transferredin four-wheel-drive vehicles to Ejeda or
Isoanala hospitals, which are four and twohours’ drive away, respectively.
MSF staff work in all three departments of Bekily
hospital. They assist around 25 births a month.
More than 450 patients were admitted to thehospital between April and the end of the year.
The teams also assisted three health centres
and mobile clinics in the surrounding area.
Paying particular attention to maternal care,they renovated clinics, donated supplies,
offered training and conducted joint
consultations with local health staff.
Work was suspended at the end of December,
however, following disagreements between

Towards the end of the year, MSF started
working with the Centre for Tuberculosis
Testing and Treatment. Staff in Bekily carryout TB awareness-raising activities andscreen and treat patients for the disease.
Risk of natural disaster
Madagascar is affected by on average
one natural disaster a year, and the risk ofemergencies is therefore high. Cyclones andfloods are a particular threat and tend to hit
the island between November and March.
MSF is in close contact with the National
Office for Disaster and Risk Management– sharing information and carrying out
evaluations – in order to be able to react
quickly to such emergencies.
At the end of 2011, MSF had 33 staff in
Madagascar. MSF first worked in the country
in 1987.

© Isabelle Ferry / MSF

Madagascar’s health system is facing a numberof serious problems, which are compoundedby the current financial crisis. The healthbudget was recently cut by 50 per cent,Strengthening medical care in
an isolated area

MSF and Ministry of Health staff over ethicalissues concerning the management of patientcare, such as deciding when patients could
be discharged from hospital. Since then,conditions have been agreed and activities
have resumed in the hospital.

Children are vaccinated at a mobile clinic in Bekily.
74

Madagascar

Activity Report 2011

Malawi
Chikhwawa

Chiradzulu
ThyoloNsanjeRegions where MSF has programmesMore than 10 per cent of Malawians aged
between 15 and 49 are living with HIV. In
the southern district of Chiradzulu, home toaround 310,000 people, the prevalence of
HIV is even higher, at over 17 per cent.
Médecins Sans Frontières (MSF) beganproviding antiretroviral (ARV) treatment
and follow-up at Chiradzulu district hospitalin 2001. The programme was designed
to demonstrate that ARV treatment was
effective in resource-poor rural contexts.
Ten years later, more than 55 per cent of thepatients who started treatment in 2001 arestill alive and healthy. At the end of 2011,
22,000 patients were on ARV treatment in
Chiradzulu, including 2,700 children.
New approaches to treatment
The scale of health needs in Malawi, andthe shortage of medical staff – there are justtwo doctors in Chiradzulu district – haveprompted MSF, in collaboration with the
Ministry of Health, to adopt new approaches
that enable more people to access care.
For example, certain medical tasks havebeen delegated from doctors to nurses –an approach known as task-shifting. Thanks
to this, MSF has been able to extend HIV
treatment activities from the hospital to
10 health centres across Chiradzulu.
As the programme has developed, the‘six month appointment system’ has been
introduced. Stable patients, who have no
special health issues other than their HIV
infection, need see medical staff only every
six months. This system reduces the workloadof health staff and saves patients both timeand money as they make fewer trips to healthfacilities. Some 3,500 people were on thesix-month programme at the end of the year,
representing 7,000 fewer consultations.

© Isabelle Merny

The HIV epidemic in Malawi
has reduced life expectancy
to just 43 years.
Antenatal consultation at Namitembo health centre, Chiradzulu district.

Scaling up treatment elsewhere
MSF began offering ARV treatment inThyolo district in 2003, implementing thesame models as in Chiradzulu, and is now
able to provide treatment to everyone who
needs it. At the end of 2011, more than
24,420 patients were receiving care. As thenational treatment programme has grown
and strengthened, MSF has started handing
over responsibility for HIV services to the
Ministry of Health.

six weeks old. Option B+ was introduced in
Malawi in October 2011 and is now part of
the national treatment programme.
MSF fully supports this decision.
By December, more than 1,650 pregnant
women in Chiradzulu and 1,500 in Thyolo
had enrolled in the PMTCT B+ programme.
Overall, in 2011, MSF assisted the births ofnearly 3,400 babies.
Circumcision of adult men

Staff will now share lessons learned fromthe successful programme in Thyolo withmedical personnel in the neighbouring
districts of Nsanje and Chikhwawa. In
an effort to boost HIV services, MSF will
mentor staff, support the scaling-up oftreatment and work to improve both theaccessibility and quality of care.

Evidence from several recent studies has shownthat male circumcision reduces the risk of HIV
being sexually transmitted from women tomen by approximately 60 per cent. MSF hasdeveloped a programme to offer circumcision
to adult male patients in Chiradzulu.
The service will be available from April 2012.

Preventing mother-to-child transmission(PMTCT)

More than 80 per cent of tuberculosis(TB) patients who register for treatment
at Chiradzulu district hospital are HIV
positive. TB and HIV care have therefore
been integrated, and patients need only
go to one appointment to receive all thetreatment they need for both diseases.

Without appropriate treatment, the rate ofmother-to-child transmission of HIV is close
to 40 per cent. For those who have access toprevention services, this figure falls to justthree per cent.
There are two recommended treatment
options for pregnant women. ‘Option B’
involves administering ARV medication
during pregnancy and breastfeeding,
stopping only when the baby has been
weaned. Under ‘option B+’, pregnant andbreastfeeding women start ARV treatment
and continue taking it for life. In both cases,
the baby receives ARV medication until it isTuberculosis

At the end of 2011, MSF had 819 staff in
Malawi. MSF has been working in the country
since 1986.

Malawi75

Médecins Sans Frontières

Mali
Kangaba
Koutiala
Konseguela
Regions where MSF has programmesCities, towns or villages with MSF activities

Malnutrition and malaria are the causeof at least half of all these deaths, andmalaria is the leading cause of illness anddeath throughout the country. In southernMali, Médecins Sans Frontières (MSF) runs
two paediatric programmes, focusing inparticular on these two deadly conditions.

Although significant progress has been made in reducing
child mortality in Mali, 178 of every thousand children bornin the country still die before they reach the age of five.
under five has dropped by 50 per cent.
Eight times as many people are attending healthfacilities. In April, MSF handed the project over
to a Malian association, the Medical Allianceagainst Malaria, which is continuing some of theactivities in partnership with an international
non-governmental organisation, Alliance forInternational Medical Action (ALIMA).
Basic healthcare in Koutiala

The number of people who die from malaria isespecially high in Kangaba, Koulikoro region,and MSF has been providing treatment for the
disease since 2005. In 2011, MSF supported
11 health centres in the province, delivering
free basic healthcare to 6,500 people, about
half of whom were children under five.

In Koutiala district, Sikasso region, MSF
has worked in five health centres and thepaediatric ward of the district hospital since2009. In four of the centres, MSF assists
Ministry of Health and community healthcentre (CSCOM) health workers, providing
additional staff, supervision, donations ofdrugs and logistical support in carrying out
outpatient consultations and vaccinations,as well as screening and treatment formalnutrition. Staff treated 53,000 children– 30,000 of them for malaria.

To improve access to care, a team of 66 malaria
experts, elected by local communities, hasbeen trained and equipped to screen andtreat people living in villages more than
five kilometres away from a health centre.
In five years, the mortality rate among children

In the fifth, Konseguela, MSF offers
comprehensive health services for children.
Healthy children aged between six months
and two years receive supplementarymilk-based food, routine vaccinations andmosquito nets, and are seen every three

In Koutiala hospital’s paediatric ward, MSF
has also set up a therapeutic feeding centre
and a paediatric intensive care unit. During
the annual malaria peak, between August andNovember, the hospital is able to receive up to
five times the normal number of admissions, as
total capacity is increased to 350 beds. In 2011,
more than 6,600 children were admitted tothe paediatric ward, and another 4,800 wereadmitted to the therapeutic feeding centre.
In 2012, MSF plans to start offering antimalarial
drugs to all under-fives as a preventive measureduring the annual malaria season, since thisage group is most at risk of developing
severe malaria.
At the end of 2011, MSF had 360 staff in Mali.
MSF has been working in the country since 1992.

© Marianne Viot / MSF

Malaria treatment in Kangaba

to six months. In 19 villages in the healtharea, community health workers test for andtreat malaria. They also refer people withother conditions, such as malnutrition, to thecentre. The community health workers treated
7,500 people for malaria in 2011. MSF carriedout 20,000 paediatric consultations at
Konseguela health centre, and provided
1,700 children with supplementary food.

Villagers from Konseguela, where MSF has a clinic, take part in research into health-seeking behaviour.
76

Mali

Activity Report 2011

Morocco
Rabat

Nador

Oujda

Cities, towns or villages with MSF activities
Morocco© Anna Surinyach

Sub-Saharan migrants
trying to enter Europe often
get stuck in Morocco, in
precarious conditions.
Médecins Sans Frontières(MSF) helps migrants toaccess health services.
Growing numbers of migrants are living in extremely poor conditions in Morocco.
Restrictive EU migration and asylum policies,
including increased and more rigorous controls
at the EU’s external borders, are having serious
consequences on the physical and mental
health of migrants and asylum seekers.
According to the Ministry of the Interior,
there are between 10,000 and 20,000
irregular migrants in Morocco. Police raids
in areas where migrants live are frequent,
as are deportations to the desert borderarea between Algeria and Morocco, where
temperatures are extreme and living
conditions are particularly hard.
Women, children and unaccompanied minors
are direct victims of smuggling networks, andmost are victims of human trafficking: they
are particularly vulnerable to kidnapping,rape, sexual exploitation and violence.
MSF works in the northern towns of Oujda
and Nador, which are close to the border,
and in the Moroccan capital Rabat, where
many migrants tend to gather. In 2011, nearly
half of those who sought medical care from
MSF had symptoms relating to poor living
and hygiene conditions, such as skin andrespiratory infections and digestive problems.
Medical and mental health services
in Oujda and Nador
Although local health authorities haveofficially set up support systems for womenand children who have been victims ofviolence, the systems lack funding and staff.
In Nador, close to the Spanish enclave ofMelilla, many people in need of medicalcare are afraid even to visit health facilities
for fear of being deported.

In January, MSF opened a centre in Oujda,
providing emergency medical assistance,and medical and mental healthcare tomigrant women. Staff carried out 1,110
outpatient medical consultations andresponded to 135 medical emergencies.
More than 40 victims of sexual violence
received specialised medical and mental
health support.
Unaccompanied minors do not receive
special attention from the authorities.
MSF staff have developed a register of young,unaccompanied migrants, and offer themmental healthcare and social support.
A Moroccan association, Fondation Orient
Occident, has begun conducting psychosocial
activities with women and under-18s.
In total, MSF staff provided psychosocial support
to more than 1,000 migrants, holding a totalof 290 individual mental health consultations
and 115 group sessions in Oujda and Nador.
As well as carrying out medical activities,
MSF distributed approximately 3,900
washing kits, 3,750 blankets, 2,250 plastic
sheets, 1,130 winter kits and 1,120 coats tomigrants in need. Teams also ensured accessto safe water for people living in forests on
the outskirts of Oujda and Nador.
Caring for victims of sexual violencein Rabat
MSF opened a new programme in Rabat for
migrant women who have been subjected
to sexual violence. The team worked in close
collaboration with the Ministry of Health andnon-governmental organisations to coordinate
a response to the needs of victims of sexual

violence, offering medical and mental healthservices and facilitating patients’ referral tosocial and legal services. The programme
moved to a new shared centre, in partnershipwith Moroccan organisation Oum El Banine,
where staff assisted 175 victims of sexual violenceand provided antenatal care to 188 women
who fell pregnant after being raped. A totalof 106 mental health consultations were held,
including the provision of psychosocial support
to 70 victims of sexual violence.
MSF staff also work as intermediaries
between patients and health staff in
Moroccan health centres and hospitals,
and helped 1,400 migrants in this way.
At the end of 2011, MSF had 32 staff in Morocco.
MSF has been working in the country since 1997.

Claudine*from Cameroon“When we arrived in Morocco we all went
to the university campus in Oujda, where
many migrants live. I was feeling very
sick and I was afraid I was going to die,so I asked the chief to seek medical help
for me. Two days later he called the MSF
medical team – they came the same day
and transferred me to the hospital.
“I have been here now for almost a week.
I am still hoping that I will manage to
get better and continue my life in Europe.
I dream that one day I will be healthy andI will be together with my daughter again.”*

The patient’s name has been changed.

Morocco77

Médecins Sans Frontières

Mozambique
In Mavalane, the biggest andmost populated district ofMozambique’s capital Maputo,
more than 80 per cent ofHIV-positive people now haveaccess to the antiretroviral(ARV) treatment they need.

Médecins Sans Frontières (MSF) has been
continuously pushing the HIV treatment
agenda in Mozambique for the past 10 years,
supporting the Ministry of Health in scaling up
ARV treatment across the national health system.
MSF supports five of the 11 health facilities
that provide HIV care in Mavalane, as well asfive of the seven health centres in a second
district, Chamanculo. In November, the teamcompleted the handover of the HIV programmes
in Angonia, in Tete province, and in Lichinga,
Niassa province, to the Ministry of Health.

Tete

MaputoRegions where MSF has programmes

and non-medical staff are trained to do jobs
once carried out exclusively by nurses), and thedecentralisation of services from large hospitals
to local clinics have been key to bringing HIV
and tuberculosis (TB) care to more people
in Maputo, Angonia and Lichinga. The
integration of HIV and TB care also means thatpatients with both diseases have access to all
the treatment they need in one place.

Cities, towns or villages with MSF activities

Overall, in 2011, MSF teams provided treatment
and care to 28,320 HIV patients, of whom morethan 1,600 were children. They also supported
a referral centre for patients who need special
attention. Staff assist in caring for patients withcomplicated conditions, such as HIV patients
who are on second-line treatment, who havethe cancer Kaposi’s sarcoma, who areco-infected with TB, or who are suffering© Brendan Bannon

By exploring innovative methods of HIV care,
MSF has demonstrated that providing andscaling up ARV treatment in low-resource
settings is feasible. Staff training, task-shifting(where nurses are able to provide treatmentthat was once the sole responsibility of doctors,

NiassaCarmen, who is on antiretroviral treatment, lives in Tete province with her husband and two children (see box).
78

Mozambique© Niklas Bergstrand

Activity Report 2011

Patients at Lifidzi, one of the health centres supported by MSF in Angonia, Tete province.
severe side effects of medication, andpeople with other chronic diseases.
Community ARV groups
Piloted by MSF in 2008, community ARVgroups are made up of about six HIV patients
who come together to support each other intaking treatment, and who take turns to visit
the health centre. Each month, one member
goes to the health centre to get a check-up
and pick up drugs for the whole group. The
system is a practical solution to the difficulties
of getting to the clinic – such as transport
costs and the time the visit takes – while italso reduces the pressures on medical staff
and the number of patients having to queue
for treatment. Moreover, the mutual support
provided by group members helps them toadhere to treatment and overcome the stigma
associated with HIV.
This approach has been so successful that thenational authorities have adopted the concept
and, with the support of MSF, will work on
rolling it out across the country in 2012.
Besides assisting this national roll-out, MSF will
also focus on developing a strategy for building
up community ARV groups in seven districts ofTete province and on adapting the model for
Maputo, to make it suitable for urban slums
where HIV prevalence is high. The teams will
pilot specific community groups for patients

co-infected with HIV and TB, patients not yeton ARV treatment, children, adolescents andsex workers, with the goal of actively involving
patients in managing their own treatment.
Staff will also start developing communitybased counselling and testing services.
A mobile team will travel to clinics with a CD4
machine, so that patients’ CD4 counts can bemeasured closer to their homes. By monitoringa patient’s CD4 count, medical staff candetermine more accurately how far HIV has
progressed, and what treatment each patient
requires. In 2011, MSF enrolled 10,720 people
in HIV care, and some 5,420 patients started
ARV treatment. Between July and December,
8,220 people were tested for HIV.
Reduced funding for healthcare
Despite significant advances in HIV care,many challenges remain. About 500,000,
or roughly two-thirds, of all Mozambicans
in need of ARVs do not have access to thislifesaving treatment.
Low government spending on healthcare
and a reduction in international support haveslowed the response considerably. In 2001, thegovernment pledged to raise health spending
to 15 per cent of the budget. But it still falls far
short of this level, at only seven per cent, andthe country is heavily reliant on donor funding.
MSF will continue pushing for the scaling-up ofquality treatment, despite funding constraints
and administrative challenges.
At the end of 2011, MSF had 444 staff inMozambique. MSF has been working in the
country since 1984.

Carmen32 years old, Tete“ I cried when I came back from thehospital on the day I found out I
was HIV positive, and I had no idea
what to do. It was my sister who
encouraged me to follow what thedoctor said. And I am glad I did
because without the medication,
I expect I would be dead by now.
Now I take my pills two times a day.
And right from the start, I began tofeel better. Before, my husband would
come back from work and find me
bedridden. But now the medicines
have really changed my life – now
I cook every day, and I am running asmall business right here at my place.
We also want to build a house ona piece of land that we have, downby the river, where we can have agarden. There is so much to live for.”Mozambique79

Médecins Sans Frontières

MyanmarMore than two-thirds ofthe 120,000 people livingwith HIV in Myanmar do
not have access to thelifesaving antiretroviral (ARV)
medication they need.

While there have been encouraging efforts toincrease the health budget, the state healthsystem remains underfunded. Furthermore,
although Myanmar is one of the least developed
countries in Southeast Asia, with a highincidence of HIV and tuberculosis (TB),
it receives very low levels of aid.

KachinShan

RakhineYangonTanintharyi

HIV care: needs not being met
Regions where MSF has programmes

and in some areas staff have been forced torestrict ARV treatment to the sickest patients.

Tanintharyi and Yangon regions. Staff also

At the end of 2011, MSF was the largest ARV
treatment provider in the country, with justover 23,000 HIV patients enrolled at its clinics
in Kachin, Rakhine and Shan states, andsuch as intravenous drug users, sex workers andoffered health education to high-risk groups
men who have sex with men, and provided
testing and counselling, and prevention of
mother-to-child transmission services.

© Greg Constantine

Médecins Sans Frontières (MSF) is working
in close collaboration with the Ministry of
Health and other agencies to build up thetechnical capacities and resources of thevarious HIV care programmes in the country.
Overwhelming numbers of people are inneed of treatment, but there are only a few
sources supplying medicines. MSF has had
to make tough choices about whom to treat,

This 34-year-old man tested positive for HIV in November 2011, and started antiretroviral treatment one month later.
80

Myanmar© Greg Constantine

Activity Report 2011

A patient collects medication from the pharmacy at the clinic in Insein, Yangon.

In Insein prison, Yangon, MSF started
150 prisoners on ARV medication andtreated 66 patients for TB.
TB and multidrug-resistant TB
TB can remain in an inactive state for decades
without causing symptoms or spreading toother people. The body’s immune system canfight off the infection and stop the bacteria
from spreading by forming scar tissue aroundthe bacteria and isolating it from the rest of
the body. However, when the immune systemof a patient with dormant TB is weakened,
the TB can become active, and without
treatment, be fatal.
Because HIV attacks the immune system,
the body becomes more susceptible toinfections, including TB. In many developing
countries, TB is one of the first opportunistic
infections to take hold in people with HIV,and is the main cause of death.
TB prevalence in Myanmar is nearly threetimes the global average. MSF provides
TB treatment, diagnosis and counsellingas part of its HIV programmes. Staff also
conduct outreach activities in the districts
surrounding the clinics, offering testing
and following up on patients. In 2011,
MSF enrolled approximately 3,000 TB
patients across its programmes in Myanmar.

The World Health Organization estimates that
9,300 people develop multidrug-resistant TB(MDR-TB) in Myanmar each year. MDR-TB
can be transmitted in the same way as
drug-sensitive TB, through sneezing or
coughing, but can also develop when apatient, either through mismanagement or
misuse of medication, develops resistanceto two or more of the standard TB drugs.
Treatment for MDR-TB takes up to two years
and has numerous side effects.
In a pilot project set up by MSF with the
Ministry of Health in Yangon, 72 patients
have begun MDR-TB treatment, and there
are plans to add MDR-TB treatment to HIV
and TB services already being offered in
Dawei, in the southern region of Tanintharyi.
MSF will continue to scale up treatment for
HIV/AIDS and MDR-TB while urging donors
to keep their pledges.
Exclusion from healthcare in Rakhine
MSF continued to provide medical care toa stateless Muslim minority in Rakhine, who
are marginalised in many ways and often
excluded from accessing the most basic
medical services. Activities focus on basic
healthcare, with a specific emphasis on
reproductive health and malaria.

Treatment for malaria
Malaria is one of the leading causes of deathin Myanmar. MSF clinics provide diagnosis,
treatment and prevention measures in areas
where the disease is particularly common.
Staff treated some 93,900 people in total.
At the end of 2011, MSF had 1,290 staff
in Myanmar. MSF has been working in the
country since 1992.

93,900peopletreated for
malaria

Myanmar81

Médecins Sans Frontières

Nigeria
Growing insecurity, combinedwith frequent outbreaks of
disease and a weak healthsystem, especially in the north,make access to healthcaredifficult for many Nigerians.

ZamfaraKatsina

SokotoBorno

JigawaKebbi
Niger
BauchiLack of access to basic medical services is aserious problem in much of northern Nigeria.
The armed group Boko Haram carried out
several deadly attacks in 2011, as inter-religious
tensions increased. Growing insecurity posesa potential threat to the future of Médecins
Sans Frontières (MSF) programmes in this partof the country, which would restrict access tohealthcare even further.
In Sokoto state, MSF supports health centres
in Goronyo town and the surrounding area.
Staff conducted just over 70,300 consultations
with children under five, and more than
28,700 antenatal consultations.

TarabaLagos

Plateau
RiversRegions where MSF has programmes

the birth canal, mainly caused by a long,obstructed labour. They result in incontinence
and infertility, and can lead to stigma andsocial exclusion. With good obstetric care,fistulas can be prevented. MSF responded toobstetric emergencies, and assisted more than
5,800 births at Jahun hospital in 2011.

Cities, towns or villages with MSF activities

Malnutrition is endemic in Kazaure, adensely populated region at the edge of the
Sahel, near the border with Niger. In 2011,
MSF carried out nutritional surveillance
and treated more than 16,000 children
for severe malnutrition. More than 4,000
children had to be admitted to hospital.

© Penny Bradfield

At Jahun hospital, in Jigawa state, a surgicalteam carried out 390 operations to repair
obstetric fistulas, which are injuries to

KadunaStaff and patients at Jahun hospital in Jigawa state, which offers obstetric care and fistula surgery.

82

Nigeria

Activity Report 2011

MSF was first alerted to a high number offatalities in villages in Zamfara in March2010 and has since treated more than
2,500 children for lead poisoning. Local,
small-scale gold-mining practices using
lead have contaminated the environmentof several villages in Zamfara. MSF has
been working with Nigerian agencies andinternational organisations to encourage
villagers to adopt safe mining practices andclean up the environment. In 2012, MSF will
host a conference, bringing together a rangeof experts to find sustainable solutions to
the problem.
Trauma hospital in the Niger Delta
In Port Harcourt, capital of Rivers state,
MSF runs an emergency trauma facility tobolster local capacity. With 75 beds, thehospital provides free emergency surgery
and healthcare. Staff held more than
12,000 emergency consultations in 2011.
Three-quarters were related to violence orroad traffic accidents. Surgeons carried out
an average of 340 operations a month.
The hospital also assisted more than
750 victims of sexual violence.
Emergency response
Outbreaks of diseases are frequent,particularly in northern Nigeria, and MSF
retains a dedicated emergency response
team in the country. When measles brokeout in northwestern Nigeria, MSF treatedmore than 7,900 patients. Staff also treatedalmost 4,800 people when cholera hit
the region. After receiving reports of highnumbers of children dying from malaria
in two villages, staff gave antimalarial
treatment to 277 people and distributed
more than 1,400 mosquito nets.
MSF also treated 15,700 people in measles
outbreaks in Bauchi and Katsina states
between January and March. Staff assisted
the Ministry of Health in a vaccination
campaign, immunising almost 190,000
children against measles in the south of thecountry, and more than 300,000 against
polio in Plateau and Kaduna states.
In addition, MSF treated more than 3,200
people during a cholera outbreak in Taraba
and Jigawa states and vaccinated 260 people
against diphtheria in Borno.
Concerned about potential politically motivatedviolence, MSF medical staff also worked in two
health centres in the volatile area of Jos North
during the presidential elections.

© Yann Libessart / MSF

Lead poisoning in Zamfara state

A young patient at the trauma facility in Port Harcourt.

Accessing healthcare in a megacity
Providing adequate healthcare for a city thesize of Lagos is challenging. The populationis around 18 million, and growing. MSF has
been striving to ensure that some of themost deprived inhabitants have access to
medical services. The Aiyetoro health centre
was set up to serve people living in theslum area of Makoko, but its location on amain road has attracted people in need ofhealthcare from much further afield. To copewith the extra patients, staff have introduced
an appointment system and begun referring
people to other facilities.
As in Makoko, the homes in Riverine havebeen mainly built on stilts on Lagos lagoon, by
newcomers to the city who cannot afford to live
elsewhere. Building has extended so far into thewater that some residents have never set footon dry land, and are unable to access healthfacilities on shore. MSF opened a floating healthclinic in Makoko in January, and a health post in
Badia, near the railway line. MSF provides the
only free medical services available in the area.
In October, MSF handed over the basic healthservices it was running in the Otto area of Lagos
to the Ministry of Health, to focus activities on
sexual and reproductive healthcare.
In total, more than 18,100 patients came to
MSF clinics in Lagos for consultations. Staff
administered more than 18,000 vaccinations,assisted some 1,200 births and admitted
900 patients for 24-hour care.

Amina
At the age of 16, Amina went into
labour. She was at home, and she
was alone. In accordance with her
culture, she made no noise and had no
assistance. But when the baby had still
not come after four days, she was taken
to a hospital by her neighbour, where
she delivered a stillborn baby.
The baby could not pass throughAmina’s underdeveloped pelvis.
Without skilled medical assistance,
the soft tissues of Amina’s pelvis werecompressed for days during the labour.
The tissue died and she was left with anobstetric fistula.
For four years, Amina was incontinent.
Her husband divorced her. Her stepmotherthought she was unclean. At last, shefound her way to Jahun hospital, where
she received surgery to repair her fistula,and aftercare to help regain continence
and get her life back.

At the end of 2011, MSF had 1,051 staff in
Nigeria. MSF has been working in the country
since 1996.

Nigeria83

Médecins Sans Frontières

Niger
TahouaAgadezZinderMaradiRegions where MSF has programmesCities, towns or villages with MSF activities

Despite major improvements
in its response to malnutrition,
Niger struggles with chronic
nutrition crises and high rates
of child mortality.
Every year, Niger is affected by a nutrition
crisis that peaks during the ‘hunger gap’,
which normally falls between May and
September. Although there were good
harvests in 2010, the acute malnutrition
rate among children in Niger was constantly
around the 10 per cent alert threshold.
Most of the emergency nutrition programmes
launched to respond to the 2010 crisis
continued in 2011. The Ministry of Healthcollaborated with national and internationalorganisations to treat some 300,000 children
for severe acute malnutrition, and enrolled
more than 650,000 at-risk children on
supplementary feeding programmes.
Insecurity and the risk of kidnapping
affected relief organisations’ ability to reachsome communities. However, Médecins
Sans Frontières (MSF) improved accessibility

to treatment by decentralising care anddelivering it at more sites. Working withlocal partners, MSF treated a total of
104,000 acutely malnourished children.
Maradi region
Since 2008, MSF and FORSANI (Forum Santé
Niger), a medical association in Niger, haverun a joint nutrition and paediatric programme
in Madarounfa, in the southern Maradi region.
In 2011, the programme provided outpatient
treatment for severe malnutrition in five healthcentres. Severely malnourished children who
were suffering medical complications, such as
severe anaemia or pneumonia, were admitted
to a therapeutic feeding centre.
MSF and FORSANI also began offering
supplementary rations of milk-based
food at all five centres to prevent severe
malnutrition. A 2010 study by Epicentre,
MSF’s epidemiological research unit, indicatesthat appropriate supplementary feeding
could lower child mortality by 50 per cent.
From May, MSF and FORSANI supported
the paediatric unit of Madarounfa district
hospital, and staff had tended to more than
900 children by the end of the year. During
the annual malaria season, MSF and FORSANI
treated 750 children for the disease at a
20-bed centre in Dan Issa, south of Madarounfa.
When measles broke out early in the year,
14,000 children in the area were vaccinated.
In the departments of Dakoro and Guidan
Roumdji, MSF carried out similar work,
supporting the departmental hospitals.
In Dakoro, staff worked in the maternity andpaediatric departments, delivered sterilisationand laboratory services and managed an

emergency ambulance referral system. In
Guidan Roumdji, MSF provided medical supplies
and drugs, as well as water and sanitation
support. Staff worked in the paediatric ward
and operated an intensive therapeutic feeding
centre. Teams also ran nutrition programmes
at five health centres in Dakoro.
In all, 76,500 consultations were conductedin Maradi, more than 44,000 of which were
for malaria.
ZinderIn the neighbouring region of Zinder,
MSF focused on children under five living
in Zinder city – Niger’s second-largest city –and the surrounding areas. The teams havedecentralised treatment, making medical careavailable via community health workers. They
also carry out preventive and outreach activities,
such as vaccinations and health screening, andprovide information on health issues.
Staff worked in nutrition programmes in
18 community health centres. Following
a measles outbreak, 26,700 people were
vaccinated against the disease. Staff also
ran nutrition programmes and carried out
paediatric consultations in the city of Magaria,
on the border with Nigeria. Outside the city,
MSF worked to strengthen services in healthposts in Dan Tchao and Dungass. Altogether,
MSF treated about 13,000 children formalaria, 11,000 for diarrhoea and 9,000
for respiratory infections.
Tahoua and Agadez regions
In Tahoua, there were very high rates of malaria
compared with previous years, and MSF treatedmore than 43,000 people for the disease.
At the height of the epidemic, over 300 people
suffering from both malnutrition and malaria
were being registered each week. MSF ran
two nutrition programmes in the Madoua andBouza districts of south-central Tahoua.
Agadez is located on a primary migrationroute for people trying to reach Europe.
Vulnerable individuals in need of medical
assistance regularly pass through the region.
MSF focused on reproductive and paediatrichealthcare for temporary residents andconducted nearly 4,500 consultations.

© Julie Remy

CholeraA child is examined at the intensive therapeutic feeding centre in Guidan Roumdji,
Maradi region.
84

Niger

Between June and September, MSF helped
to respond to a cholera outbreak in thecapital Niamey. The team set up treatment
centres, rehydration points and waste
treatment systems. They also donatedmedicines and other supplies and trained
Ministry of Health staff.
At the end of 2011, MSF had 1,705 staff in Niger.
MSF has been working in the country since 1985.

Activity Report 2011

Occupied
Palestinian
Territory
NablusQalqilya
Gaza City

Tubas
East
Jerusalem

HebronKhan Yunis
Regions where MSF has programmes

Residents of Occupied
Palestinian Territory continued
to suffer the consequences ofviolence and conflict in 2011.
In 2011, the number of attacks, shootings,
detentions, demolitions, evictions, raids,night incursions and violent incidents
increased alarmingly. In the West Bank, morethan 700 Palestinian civilians were displacedby force. Conflict between Palestinianfactions also caused injury and trauma.
Care for patients traumatised by violence
Médecins Sans Frontières (MSF) teams
provide medical care, short-term
psychotherapy and social assistance andreferral to people affected by violence andconflict in the West Bank districts of Hebron,
Qalqilya, Nablus and Tubas. The teams
focus on people who show signs of acutestress, anxiety, post-traumatic syndromes ordepression. In total, staff carried out morethan 1,600 medical consultations and over
4,000 mental health consultations.
The programme is being extended topeople in East Jerusalem who are sufferingfrom psychological distress and have noaccess to such healthcare: in 2011, staff held
223 consultations with residents of Shu’fat
refugee camp and the neighbourhoodof Silwan.
Similar programmes are operating in
the Gaza Strip, but a decision by healthauthorities forced their suspension in© Chris Huby / Le Desk

Cities, towns or villages with MSF activities

A family from Iraq Burin, near Nablus, is given psychological support.
August. Between January and August,staff carried out 870 medical consultations
and more than 2,000 mental healthconsultations. Most patients were children.
Shortages of medical supplies
The continuing Israeli embargo of the Gaza Strip,
years of financial crisis within the Palestinian
National Authority in Ramallah and thechronic lack of cooperation between
the Palestinian National Authority andGaza authorities have all contributed to a
deterioration in the capacity of the publichealth sector. Since mid-2011, health facilities
have been facing a serious shortage of
medicines and other supplies. MSF donatedessential medicines to the cardiology
department of Al-Shifa hospital, and madeother periodic donations as needs arose.

patients referred from the burns units
of Al-Shifa and Nasser hospitals.
MSF also operates a specialised surgery
programme in Nasser hospital, which is in
Khan Yunis, in the south of the Gaza Strip.
Several times a year, teams of surgeons,operating theatre nurses and anaesthetists
carry out complex surgical operations thatare not otherwise available. Most of those
who undergo surgery are children, andmost suffer from burns.
At the end of 2011, MSF had 136 staff in
Occupied Palestinian Territory. MSF has
been working there since 1989.

Assisting burns victims
Since 2007, MSF has been runninga rehabilitation programme for burns
victims in the Gaza Strip. The team provides
physiotherapy and wound dressing to

Occupied Palestinian Territory85

Médecins Sans Frontières

Pakistan
FATA

Khyber Pakhtunkhwa

Sindh
Karachi
Balochistan
Regions where MSF has programmesCities, towns or villages with MSF activities
The maps and place names used do not reflect any
position by MSF on their legal status.

Insecurity and natural disasters
have reduced access toessential healthcare in Pakistan.
At the beginning of 2011, some six months
after the floods first hit Pakistan, many people
started returning to their homes. Médecins
Sans Frontières (MSF) teams providing
medical care and safe water scaled down theiractivities. In Sindh and Balochistan provinces,where the water was slowest to retreat, theroad to recovery remained daunting, andpeople still lacked food and shelter. For
this reason, teams in Dera Murad Jamali,
Balochistan province, and Johi and Karachi,
Sindh province, continued their activities,
running nutrition programmes and providing
relief and temporary shelters. With the onsetof winter in Johi and Jamshoro districts, around2,000 temporary shelters made of bamboo
and plastic sheeting were distributed.
On the outskirts of the city of Karachi, morethan 20,000 people were living in camps inunhealthy conditions. To prevent the spreadof disease, MSF started running mobile clinics
and distributing safe water and emergency
relief. After conducting around 21,000 medical
consultations, the team handed over medical

and water and sanitation services to the
Karachi health authorities at the end of May.
In August, weeks of rain once again led tosevere flooding, and Sindh was particularly
badly hit. In the subdistrict of Tando Bago,land on both sides of the elevated main
roads was still under water two months
later. From September until November,
MSF provided medical care through mobile
clinics to displaced families living in camps
or on the roadside in Badin and Tharparkar
districts. Staff extended the same support topeople affected by floods in Moro district.
During the monsoon season, to copewith the increasing number of patientswith acute watery diarrhoea, MSF opened
temporary diarrhoea treatment centresin several areas of Khyber Pakhtunkhwa
province, and in Kurram Agency in theFederally Administered Tribal Areas (FATA).
A total of 9,774 patients were treated.
Emergency care
Although there were periods of respite, thesituation in the northern regions of Khyber
Pakhtunkhwa and FATA remained tense
due to longstanding sectarian violence andfighting between government forces andarmed opposition groups.
In this context, emergency medical
assistance continued to be a key componentof MSF’s work. In Khyber Pakhtunkhwa,
staff treated thousands of patients in theemergency departments and operating
theatres of hospitals in Dargai andTimergara. More than 18,800 patientswere treated in the resuscitation room inTimergara, and surgeons performed over
2,000 operations. Around 70 kilometresfrom the Afghan border, in Hangu, teams
provided lifesaving care in the emergency

department of the Tehsil headquarter
hospital, where they saw an average of
1,500 patients each month.
In the towns of Alizai and Sadda in Kurram
Agency, MSF supported local hospitals,
providing paediatric care and managing
incidents involving large numbers of casualties.
MSF also operated an ambulance service,
which transferred patients from Kurram and
Hangu to Peshawar for further treatment.
In October, after working in the casualty
department of the main hospital in Mingora,
Swat district, for 18 months, MSF boosted
its capacity and handed activities over to the
Ministry of Health.
MSF also provided emergency care in the
district hospital of Chaman, Balochistan
province. Chaman lies on the border with
Afghanistan, and Afghans often come insearch of medical assistance. MSF treatednearly 9,300 patients in 2011.
In all the hospitals where MSF works, ano-weapons policy is implemented, for thesafety of both patients and medical staff.
Each hospital is set up to cope with the arrivalof a large number of wounded, for example
after a traffic accident or bomb blast.
Maternal and child health
Limited access to good-quality emergency
obstetric care means women in Pakistan
face significant risks during childbirth.
In insecure areas, travel restrictions makeaccess even more difficult.
In Khyber Pakhtunkhwa province, MSF staff
delivered more than 7,000 babies in Dargai
and Timergara hospitals. In May, MSF
opened a women’s hospital in Peshawar
district. The 30-bed hospital focuseson providing care during complicatedpregnancies and births. MSF also supports
ante- and postnatal care at clinics run by
the local authorities.

© P.K. Lee

In Balochistan, staff deliver comprehensive
obstetric care in the district hospitals of Dera
Murad Jamali and Chaman. MSF has openeda paediatric hospital in Quetta, the provincial
capital. The 50-bed hospital provides freeneonatal and paediatric care, and has an
inpatient therapeutic feeding centre.

A mobile clinic is set up in an abandoned public building, where hundreds of families
have taken refuge from flooding.
86

PakistanIn the town of Kuchlak, home to many
Afghan migrants and refugees, as well as
nomads and a local settled population,
MSF runs a mother and child clinic that also
contains a birthing unit. Women who requirecaesarean sections or other specialist medicalcare are transferred to Quetta hospital.
At the end of 2011, MSF had 1,295 staff inPakistan. MSF has been working in the country
since 1986.

Activity Report 2011

Papua New
Guinea
Tari

LAE

Buin

Cities, towns or villages with MSF activities

Rates of domestic and sexual violence inPapua New Guinea are high. Most victims are
women and children. Poverty, unemployment
and drug and alcohol abuse are contributing
factors to the violence, which is often
not reported. Although the problem iswidespread, care remains inadequate and,in many places, there is none available.
In the city of Lae, Médecins Sans Frontières(MSF) runs the family support centre at Angau
Memorial general hospital. This is a confidential
and safe space that provides medical andpsychosocial care to victims of family and sexual
violence. In 2011, staff at the centre offeredcomprehensive, free care to approximately
2,200 people. A team also runs a family support
centre in Tari, in Southern Highlands province,
and assisted approximately 900 people. MSF
offered guidance to health staff in facilities
around the country, to help them establish theirown family support centres.
At Tari hospital, MSF provides emergency
surgical services in addition to managing
the family support centre. The surgicalteam performed more than 800 operations
and carried out over 10,000 outpatient
consultations. More than one-third ofcases were violence-related.
Healthcare in southern Bougainville
The Autonomous Region of Bougainville has
been the scene of recurrent conflict, especially inthe 1980s and 1990s, and the healthcare system
has been neglected for some years. Low-level
conflict persists, and access to healthcare is poor.

© Fiona Morris

Victims of domestic andsexual violence face problems
accessing health services
in Papua New Guinea.

Members of the team working at the Family Support Centre in Angau Memorial
general hospital, Lae.
MSF first supported Buin health centre,
in the south of Bougainville Island, after
the ceasefire of 1998. In April 2011, MSF
returned to Buin to improve access to care.
Staff carried out some 6,820 outpatient
consultations and cared for more than
570 inpatients.

At the end of 2011, MSF had 164 staff in
Papua New Guinea. MSF first worked in the
country in 1992.

Many women in Bougainville have to travel
enormous distances if they wish to givebirth in a health facility. MSF and Papua
New Guinea’s Division of Health haveopened a maternity waiting home in Buin,
where women can stay in the last weeks
of pregnancy, so that they are not far frommedical services when they go into labour.
More than 210 women gave birth in thehealth centre and 28 complicated cases
were referred to Buka hospital.

“ I am eight months pregnant and I am
here because I lost the babies of myfirst two pregnancies, when I tried togive birth at home. I want this baby somuch. I will wait here until I am due,and I know that I can deliver my baby
safely here at the health centre.”

The health centre is also being renovated.
Laboratory services are being updated,
and this will improve MSF’s support in thetreatment and follow-up of tuberculosis(TB) patients. In 2011, staff cared for
44 TB patients.
When Bougainville experienced its firstrecorded cholera outbreak, in Buka, in April
and May, MSF treated 521 patients.

Mona
23 years old, Buin health centre

1,540

birthsassisted

Papua New Guinea

87Médecins Sans Frontières

Paraguay
Boquerón

Regions where MSF has programmes

At first, a person with Chagas may nothave any symptoms, but up to one-third
will develop serious health problems
later in life, such as heart and intestinal
complications, which can be fatal.
The disease is primarily transmitted by
the bite of the vinchuca beetle, which
often lives in the cracks in mud and strawbuildings. People living in poor housing
are therefore most at risk of infection.
Drug supplies interrupted
In recent years, the response to Chagas
disease has improved. Medical evidence
has shown the benefits of using
benznidazole more widely, including withadults in the chronic – non-symptomatic –stage of the disease, and this has resulted
in an increase in demand.
But problems with planning at Brazil’s
state-owned laboratory – the only
laboratory manufacturing benznidazole– brought production to a halt in 2011.
MSF urged the Brazilian Ministry of Healthto take immediate measures to make thedrug available. Despite the ministry’s
commitment to speed up manufacturing
and regulatory approval, supplies were stillinterrupted at the end of the year.
Gran Chaco
Paraguay’s approach to Chagas has been
to focus on prevention through vector
control, targeting the vinchuca beetle.
In some regions, this has led to the successful
eradication of Chagas transmission.
MSF is focusing on treatment and raisingawareness among health staff – especiallystaff working in local facilities – about theoptions for treatment.

88

Paraguay© Anna Surinyach / MSF

A shortage of medication in
October forced Médecins
Sans Frontières (MSF) to
reduce screening activities
for Chagas disease in
Paraguay’s Boquerón district.
People from the village of Campo Loa are screened for Chagas disease.
The Gran Chaco is an extensive but isolatedarea in northwestern Paraguay. The climate
is harsh, towns are small and remote fromone another, and public transport is limited.
Health centres are few and far between.
In Boquerón department, MSF supports
the regional hospital in Mariscal Estigarribia.
Having furnished it with new laboratory
equipment, teams began screening people
for Chagas in 2010. In May 2011, the firstgroup of patients completed their treatment.
MSF and national authorities worked
together to train staff in 10 health facilities
in Boquerón. MSF staff also supported
rural health centres in the towns ofDoctor Pedro P. Peña and Pirizal, andmobile teams visited more remotecommunities, informing them about
Chagas and offering screening andtreatment. They encouraged people toreport the presence of vinchuca beetles
to the authorities, so that fumigation could
be carried out.
In 2011, more than 3,100 people werescreened for Chagas, and of these,
416 were diagnosed with the disease.
More than half – 218 people – started
treatment. Of the rest, some chose not tostart treatment, while others were unable
to because of their age, or because they
were pregnant or breastfeeding.
Chagas bus
An MSF team continued to travel aroundthe country in the ‘Chagas bus’. This bus
takes MSF staff to schools and hospitals

around Paraguay, where they stop andoffer information about Chagas, how it
is spread and how to seek testing andtreatment. In 2011, the bus visited thecapital Asunción, and the departments of
Paraguarí, Cordillera and Central.
With the support of the Ministry of Healthand the Pan American Health Organization,
MSF organised a scientific symposium on
Chagas at the University of Asunción.
More than 200 people, most of them
medical professionals, attended the event.
At the end of 2011, MSF had 35 staff in
Paraguay. MSF has been working in the
country since 2010.

3,100

peoplescreened for

ChagasdiseasE

Activity Report 2011

Philippines
BulacanRegions where MSF has programmes

A Médecins Sans Frontières (MSF)
emergency team of doctors, nurses andlogisticians found that six low-lying areasin the hard-hit central province of Bulacan
were in need of healthcare. The team set
up mobile clinics and conducted more than
2,600 consultations with people affected by
the floods in Bulusan, Meyto, Panducot,
San Jose, Santa Lucia and Sapang Bayan.

people suffering from acute respiratory
infections and children with malnutrition.
They were also able to monitor for outbreaksof acute watery diarrhoea and leptospirosis,
a severe bacterial infection that is transmitted
through contaminated water.
In addition, the team tended to patients
suffering from chronic diseases, suchas diabetes and hypertension, whose
treatment had been interrupted. Patientsrequiring lifesaving medical attention weretransferred to the provincial hospital in
Ministry of Health ambulances.

damaged by the flooding. MSF helped the
local health authorities to rehabilitate thehospital and donated drugs and equipment.
The team also distributed 20,000 litres ofdrinking water and 2,450 jerry cans in three
districts. To prevent the spread of disease,staff assisted in waste collection. After
two weeks, and a vast improvement in thesituation, MSF withdrew from Bulacan.
At the end of 2011, MSF had 2 staff in thePhilippines. MSF first worked in the country
in 1987.

In the town of Calumpit, in the southwest of
the province, the district hospital had been

© Nathalie Roberts

Travelling by boat and car to reach thosein greatest need of assistance, staff treated

In late September, typhoons Nesat and Nelgae hit the northernpart of the Philippines, causing severe flooding and damageon the country’s main island of Luzon.

Staff provide medical assistance to people whose homes were destroyed by flooding.
Philippines89

Médecins Sans Frontières

RussianFederation
Ingushetia

GroznyChechnyadagestan

Regions where MSF has programmes

Médecins Sans Frontières (MSF) works
to fill some of these gaps in Chechnya
and Ingushetia.

© Lana Abramova

Years of conflict in the north
Caucasus region of theRussian Federation have left
gaps in many areas of thehealth system.

A doctor examines a patient during a ward round at Grozny’s Republican TB Dispensary.

Resurgence of tuberculosis (TB)
The destruction and displacement resulting
from years of conflict – primarily between
Russian state authorities and Chechen
separatists – have stimulated a resurgenceof TB in the north Caucasus, particularly
drug-resistant TB.
MSF continued its TB programme in
Chechnya, improving access to treatment andfacilities. There was a shift in focus towards
decentralising treatment and offering patients
direct care at home. Patients take their
medication under observation, to help makesure they take the right dosage regularly, inorder to prevent the development of drug
resistance. Between January and December,approximately 500 patients were admitted
to the TB programme.
Supporting people caught up in violence
In 2011, MSF closed its assistanceprogramme in the city of Khasavyurt,
Dagestan, where it had provided healthcare
and counselling to migrants, and instead
focused on programmes in Chechnya andIngushetia, in particular the mountainous
areas most affected by violence and thegovernment’s counter-insurgency measures.
The psychological effects of conflict have been
far-reaching. The teams held approximately
8,000 individual and 1,700 group counselling

90

Russian Federation

sessions in Chechnya, as well as almost
5,100 individual and 1,020 group
counselling sessions in Ingushetia.
Healthcare for women and children
In Grozny, the capital of Chechnya, MSF
offered outpatient gynaecological andpaediatric care. Staff also ran mobile clinics
offering similar services in Shelkovskoy andNaursky districts, north Chechnya, andShatoy, south Chechnya.
An average of 1,500 women visited clinics eachmonth, 60 per cent of whom were diagnosed
and treated for sexually transmitted infections.
Teams held 1,620 paediatric consultations
per month, 62 per cent with children
under five years of age.
Cardiac emergency response
Cardiovascular disease is the cause of around
two-thirds of deaths in Chechnya. In the firstsix months of 2011, MSF teams worked onrenovating the cardiac emergency programmein Grozny’s Republican Emergency Hospital.
By mid-2011, the clinical laboratory was
functional, and staff were able to start assisting
patients. By the end of the year, there had
been more than 800 admissions, 72 per centfor acute coronary syndrome, which can leadto a heart attack.

In July, MSF carried out thrombolysis, thefirst cardiac emergency intervention in
the organisation’s history. By the end of
the year, this procedure, which involves
breaking down blood clots, had beensuccessfully performed on 17 patients.
At the end of 2011, MSF had 179 staff in the
Russian Federation. MSF has been working in
the Russian Federation since 1988, and in thenorth Caucasus since 1995.

Malika28 years old, Grozny“Since I was a child I have been afraidof TB. I heard stories of people dying
from the disease, and then I got sickmyself.” When Malika was diagnosed
with TB, her condition was serious, andshe had to spend four months in a TB
hospital, followed by more treatment
afterwards. “I never missed a tablet,
I took all the medicines,” Malika says.
“Elisa, from the TB adherence team,called me every day and supported
me emotionally.” After six months oftreatment, the results of the tests weregood, and Malika was free of TB.

Activity Report 2011

Sierra Leone

A decade after the end of the civil war, Sierra Leone is still
recovering. Médecins Sans Frontières (MSF) is working to
improve maternal and child health.

Bo

Regions where MSF has programmes

At the Gondama referral centre, a 200-bed
hospital outside Bo, the second-largest cityin the country, MSF offers specialist obstetricand paediatric care. Staff at the centre
tended to more than 8,700 children in 2011,
and assisted over 1,300 births, 723 of whichwere by caesarean section.

hospital more quickly. Three ambulances areon standby 24 hours a day at health centres
around the district to transport people freeof charge to Gondama. People with more
complicated conditions are referred to thecapital Freetown.

Healthcare in local health centres

Lassa fever is a viral haemorrhagic feverthat occurs in west Africa. It is an acuteillness that affects several organs in thebody, including the liver, spleen andkidneys. Sierra Leone has a specialist ward
for Lassa patients at Kenema hospital,
300 kilometres east of Freetown. MSF
operates an ambulance to transport people
with Lassa fever to Kenema.

An outreach team supports five community
health centres in Bo district. Staff offer basic
healthcare, antenatal care and treatment
for malnutrition and malaria, and carry out
health promotion activities.
A lack of qualified health staff and inadequate
health facilities mean that people in need of
specialist medical assistance often do not get
hospital treatment until the very late stagesof their illness or pregnancy. MSF operates anambulance service to help people reach the

Lassa fever

At the end of 2011, MSF had 484 staff in
Sierra Leone. MSF first worked in the country
in 1985.

© Niklas Bergstrand / MSF

MSF also treated more than 1,600 children withsevere malnutrition at its nutrition programme
at Gondama. Severely malnourished children
with medical complications were referred to
Bo government hospital, where an MSF nurse
supports the centre’s staff.

The network of community malaria volunteers,
who diagnose and treat simple cases of malaria
among their neighbours, was not as large asin previous years. The MSF team continues
to support the network, while refocusing its
malaria activities towards the provision of
specialist treatment at Gondama.

A ward round at Gondama referral centre, in Bo district.
Sierra Leone91

Médecins Sans Frontières

Somalia
A devastating drought,
protracted war, a collapsed
health system and restricted
access for relief organisations
worsened the humanitariancrisis in Somalia in 2011.

Burao

ceerigabo

hargeisa
Guri-elNorth Galkayo

Belet Weyne

Hundreds of thousands of Somalis fled tothe capital Mogadishu, or across the borderto Kenya or Ethiopia, in search of help.
Weakened and malnourished, many were
living in unsanitary, crowded conditions,with little access to safe water.

South Galkayo

AfgooyeJowharDinsorMarereJilib

Mogadishu
Wadajir
KismayoNutrition crisis
As victims of the conflict and drought
flocked to Mogadishu, Médecins Sans
Frontières (MSF) scaled up its activities,
opening health facilities in 12 new locations.
Staff provided a full range of healthservices, from basic healthcare to surgery,
nutritional support, cholera and measles
treatment, vaccinations and maternal care.
They also distributed relief items to both
displaced and local people. At the peak of
its activities, MSF was running programmes
in 22 places across the country.
Given the scale of medical needs, MSF took
the decision to send international staff to takeup permanent posts in south-central Somalia
for the first time since 2009. Tragically,on 29 December 2011, two long-serving
MSF staff members, Philippe Havet and
Dr Andrias Karel Keiluhu, were shot deadRegions where MSF has programmesCities, towns or villages with MSF activities

in their Mogadishu compound. This forced
MSF to close down two programmes, which
had been serving a population of 200,000
displaced people and local residents,
halving the medical assistance provided
by MSF in Mogadishu.
A paediatric inpatient department andmaternity ward were opened in the townof North Galkayo, Mudug region. Staff
managed tuberculosis (TB) programmes
in Galkayo, and in Mahadaay and Gololey
in Jowhar, Middle Shabelle region. In total,
MSF treated more than 864,000 patientsin Somalia, nearly double the assistanceprovided in 2010.

Measles and cholera
Malnourished children are more vulnerable
to measles infection, which in turnaggravates malnutrition. Between May
and December, MSF vaccinated 102,000
children against measles. However, insome parts of the country, permission toundertake vaccination campaigns was notgranted by local authorities.
Unhygienic living conditions provide a
breeding-ground for water-borne diseases
like cholera. When the rainy season beganin November, teams struggled to contain acholera epidemic. Treatment sites were set
up in five districts, and in Hodan, over
100 patients per week were admitted to
MSF’s 120-bed treatment centre.
Access blocked© Martina Bacigalupo

Limited or no access at all for relief
organisations to vast swathes of the country
meant that hundreds of thousands of Somalis
remained in desperate need, despite the aidthat was being sent to the country.

Thousands of severely malnourished children received treatment at clinics in Mogadishu.

92

Somalia

The fighting, restrictions on supply flights
and international support staff, as well as
administrative hurdles, all hindered thedelivery of assistance. In areas controlled
by Al-Shabaab, gaining access for medical
supplies and personnel to provide vital
medical aid was a major challenge. It proved
extremely difficult for MSF to work beyond
the gates of established health facilities.
Even in existing programmes, MSF faced
obstacles. Attempts to open new emergency
operations in south-central Somalia failed.
One of the few exceptions was the port cityof Kismayo, where MSF was granted accessin December after lengthy negotiations.
Within a few weeks of opening, MSF hadtreated 200 children for malnutrition.

© Yann Libessart / MSF

Activity Report 2011

Food distribution in Rajo camp for displaced people, Mogadishu.
High security risks
Access problems were compounded
by insecurity. In March, MSF suffered
two consecutive grenade attacks on its
compound in Wadajir district, west of
Mogadishu, in less than a week. MSF wasforced to suspend activities temporarily,
putting at risk the lives of 414 children
enrolled in the nutrition programme.
In North and South Galkayo, MSF treatedpatients wounded in separate incidents,
and in Daynile, nine kilometres northwestof Mogadishu, of the more than 3,500 patients
admitted to the emergency room, 44 per centhad war-related injuries.
Thousands of Somalis were trapped
between battle lines. In the Afgooye
corridor, where close to half a million
people have sought refuge, MSF supported
the district hospital, covering the needs of
180 surrounding villages. Staff conducted
more that 27,000 consultations and treatedover 3,300 malnourished children in Afgooye.
In October, two MSF staff members wereabducted from a refugee camp in Kenya,
where thousands of Somalis had fled.
Insecurity in Somalia increased after the
Kenyan army’s intervention that month.
In Marere, dozens of injured civilians wererushed to the MSF hospital following anaerial bombardment that hit a nearby

camp for the displaced in Jilib. Five people
were killed and 45 wounded, including
31 children.
Overcoming obstacles to access
MSF is increasingly using telemedicine tobring specialised care to Somalis in areas
where the risk is too high to fly doctors in.
Via an audiovisual link, specialist doctors
based in Kenya support medical staff inSomalia during consultations. More than
500 new patients received medical attention
through this technological innovation in 2011.
Healthcare in Somaliland
In the self-declared republic of Somaliland,
MSF expanded operations, providing
support in Burao (Burco) general hospital,
the only public health facility in the
Togdheer region. Admissions have tripled
and mortality rates have dropped in thematernity ward since MSF started operating
there. In Ceerigabo, MSF continued toprovide full support to the district hospital,
while in Somaliland’s capital Hargeisa, MSF
closed its basic health services in camps
in June, as the needs could be covered by
the Ministry of Health and another agency
working in the area. In total, more than
4,000 children under five were seen at
outpatient consultations. Staff assisted morethan 2,700 births and carried out
671 surgical procedures.

At the end of 2011, MSF had 1,729 staff inSomalia. MSF has been working in the country
since 1991.
For more on the challenges faced by MSF’s teams
working in Somalia, see pages 16–17.

Ali Ahmed *7 years old, and his mother, Burao hospital“ My boy was very sick and was swollen allover his body.
“ He was a very healthy boy before. Whenit started, it started with a fever and theboy complained about his hands. I live in
Talahabed. It is very far from here. It usuallytakes one day to get to the hospital.
“ I have been here for a long time; it is too
far to travel home. Where I come fromthere isn’t even a network to call from.
I was told by the villagers that thehospital might be able to help me.
I took public transportation to get tothe hospital – I had to pay to get here.
As soon as I arrived the doctors wereready to help me. They took Ali straightto surgery. They put him on medication.
Slowly, slowly, after the surgery, he was
improving every day. We carried him
here. Now he can walk, he is beautiful.”*

The patient’s name has been changed.

Somalia93

Médecins Sans Frontières

South Africa
MusinaJohannesburg

EshoweKhayelitsha
Cities, towns or villages with MSF activities

In 2011, the Médecins Sans
Frontières (MSF) programme
in Khayelitsha celebrated its
10th anniversary. More than
20,000 people have started
antiretroviral (ARV) treatment
since 2001.
The HIV treatment programme in
Khayelitsha, a township on the outskirts ofCape Town, was the first to provide ARV
treatment in South Africa’s public sector.
MSF is now focusing on new models of care,including decentralising treatment for drugresistant tuberculosis (DR-TB) to local clinics
and bringing HIV treatment even closer topatients by offering services in community
halls, libraries and private homes, in what
are referred to as adherence clubs.
In 2011, the provincial government began
piloting adherence groups – a concept
initiated by MSF in 2007 – across thetownship, setting up 218 clubs in 16 facilities.
Adherence clubs make living with HIV,and sticking to treatment, easier. Instead ofa one-to-one appointment at the healthcentre every month, club members go to‘meetings’ every two months, where they
are screened for symptoms and receive
drug refills, and can also ask questions andshare experiences, providing each otherwith mutual support. Club members are
two-thirds less likely to experience treatment
failure. More than 5,000 patients joined
an adherence club in 2011.

Over the course of the year, some 50,000
people were tested for HIV, and more than
450 began ARV treatment each month,bringing the total on treatment in
Khayelitsha to more than 21,800.
A new TB test
As HIV weakens the immune system, thebody is more susceptible to opportunistic
infections, including TB. South Africa has
seen a 400 per cent increase in TB cases overthe past 15 years, and more than 70 per centof patients are co-infected with HIV.
In 2011, the South African government
approved the use of a new automated test for
TB, which can provide results far more rapidly,
thus enabling people to start treatment
earlier. The test can also detect TB muchbetter than tests previously used and detect
resistance to rifampicin, one of the mostpotent drugs used in the treatment of thedisease. Following the introduction of this testin MSF’s project in rural Eshowe, KwaZuluNatal province, MSF has seen TB diagnoses
increase from 13 to 40 patients a month.
About 13 per cent of the patients diagnosed
with TB were resistant to rifampicin.

Treatment for DR-TB is far more complex,
expensive and arduous than drug-sensitive
TB. In 2010, there were 7,386 confirmed
multidrug-resistant TB (MDR-TB) patientsin South Africa. More than 700 patients had
confirmed extensively drug-resistant TB(XDR-TB), which is even more difficult to treat.

Screening for HIV and TB in KwaZulu-Natal
The eastern province of KwaZulu-Natal has
the highest prevalence of HIV in the country.
At the end of 2011, MSF launched a mobile‘one-stop-shop’, which travels around theprovince offering testing for TB and HIV.
In its first month of operation, more than
1,000 people were tested for HIV, and
50 were screened for TB. Future activities
will include promoting prevention, such as
through condom use and supporting malecircumcision. The aim is to reduce HIV and TB
incidence by 50 per cent, in line with South
Africa’s national strategic plan for 2011–2016.
Assisting migrants and asylum seekers
One-fifth of all applications for asylum
worldwide are made in South Africa.
The vast majority of people claiming asylumin South Africa come from Zimbabwe.
In Musina, at the Zimbabwean border,
MSF offered medical assistance to
new arrivals outside the offices of the
Department of Home Affairs and visited
migrant workers on farms in the area during
the day and at shelters in Musina town
at night. Staff provided basic healthcare,treatment for HIV and TB – testing justunder 1,900 people for HIV – and assistancefor 120 victims of sexual violence, manyof whom had been attacked on theirjourney to Musina.
Health screening in Johannesburg© Jose Cendon

Having observed that most patients attending
MSF’s clinic near a church in Johannesburg
came from nearby slums, in 2011 the teamtransferred activities from the clinic to mobile
screening trucks, which visited some of themost deprived areas of the city.

A peer counsellor helps fit a mask to prevent tuberculosis infection, Khayelitsha township,near Cape Town.
94

South Africa

Before closing the clinic in August, staff
conducted more than 1,100 consultations,mainly treating upper respiratory tract
infections, skin diseases and sexuallytransmitted infections (STIs). Mobile
activities began in May, and by the endof the year, some 11,100 people had been
screened for conditions such as HIV, TB and
STIs, and had either received treatment or
been referred to public health facilities.
At the end of 2011, MSF had 149 field staff
in South Africa. MSF has been working in
the country since 1999.

Activity Report 2011

Sri Lanka
Point Pedro
Mullaitivu
Kilinochchi
Vavuniya

Cities, towns or villages with MSF activities

In 2011, Médecins Sans
Frontières (MSF) continued tosupport people affected by thecivil war in Sri Lanka’s Northern
province, which ended in 2009.
National health authorities worked to restore
the health system in places damaged in theconflict, and by September, MSF found thatgeneral health services, though suffering
shortages, were managing to meet basic
needs. The team therefore focused on specialist
medical care and mental health services.
Reconstructive surgery and rehabilitation

People with spinal injuries received care
at MSF’s rehabilitation programme inPampaimadhu hospital, in Vavuniya.
Rehabilitation has a positive impact, not only
on people’s quality of life, but also on their life
expectancy. The team at the hospital provided
medical treatment, physiotherapy and mental
healthcare. Physiotherapy increases patients’mobility, and coaching helps prepare them forlife outside the unit. Staff also helped patients
to find training or work when they left the unit.
In October, when 90 patients had completed
their treatment and left the programme, MSF
withdrew, handing all facilities and equipment
over to the Ministry of Health.
Surgery and emergency care
At the hospitals in Point Pedro, in the far north,and Mullaitivu, on the northeast coast, MSF
staff assisted in the provision of emergency
care, surgery and gynaecological andobstetric services.
Surgeons performed 1,720 major operations
and 1,600 minor procedures. Medical staff
held over 6,900 emergency consultations.
Approximately 5,300 women received

antenatal care, and 929 births were assisted.
At Point Pedro, MSF also offered training
to hospital staff in laboratory hygiene,
sterilisation and infection control, before
withdrawing at the end of the year.
The team in Mullaitivu continues its activities,
which include improving local people’s accessto healthcare by operating mobile clinics
at five different sites around the district.
Staff carried out more than 11,500
consultations over the course of the year.
Mental healthcare
MSF expanded its psychological support
services in Mullaitivu district substantiallyduring 2011. Most patients were women
who had been living in the displaced
people’s camps after the war. Staff worked
at eight different sites in the district andconducted almost 3,600 individual and group
counselling sessions. A psychiatrist treatedpatients diagnosed with post-traumatic stressdisorder, depression, epilepsy and psychosis.
Staff also offered mental healthcare in
Kilinochchi. More than 433 patients, manyof whose relatives had died during theconflict, attended counselling sessions.
At the end of 2011, MSF had 310 staff in
Sri Lanka. MSF first worked in the country
in 1986.

© Pete Masters

In 2009, a specialist team began performing
reconstructive orthopaedic surgery in
Vavuniya general hospital. In 2011, the team
operated on 150 people with complicatedwar-related injuries. The programme wasclosed in December, and medical equipment,
drugs and surgical supplies were handed
over to the Ministry of Health.

Surgical consultation at Point Pedro Base hospital, Northern province.
Sri Lanka

95

Médecins Sans Frontières

South Sudan
The Republic of South Sudan
only came into existence on
9 July 2011, but the country has
already faced multiple crises.

Northern
Bahr elGhazalWestern Bahrel ghazal

According to the UN, some 350,000 people
returned home to South Sudan between
November 2010 and the end of 2011, while
violence displaced around 300,000 people.
Médecins Sans Frontières (MSF) continued
to focus on emergency response.

Conflict and emergency response
in Jonglei
Since 2009, violent, intercommunal
cattle-raiding has become more intensein the eastern state of Jonglei, and entire
villages have been destroyed.
In the last week of December 2011, the MSF
hospital in the town of Pibor was looted andUnity
Upper Nile

Jonglei
warrapWestern
Equatoria

MSF works in South Sudan as well as in thetransitional area of Abyei, providing a rangeof medical services, from maternal healthcare
and nutrition programmes, to surgery andtreatment for tuberculosis (TB), malaria andkala azar.
In September, MSF started negotiations
with the authorities to construct a hospitalin Juba, the capital city. The intention is toprovide paediatric and surgical care andemergency obstetric services.

AGOK

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

ransacked, and MSF’s clinic in Lekwongole
was burned, with only the walls and roof
left standing. Among the many people
killed were an MSF watchman and his wife.
MSF treated 108 people for violence-related
wounds in the first weeks after the attack.
Many frightened people hid in the bush forweeks on end and MSF consequently saw anincrease in the number of patients sufferingfrom malnutrition and malaria.
MSF is the only provider of healthcare forthe 160,000 people who live in Pibor county,
as the nearest alternative health services areover 150 kilometres away. In 2011, the teamcarried out around 12,500 consultations in
Pibor, and more than 11,800 in the villagesof Lekwongole and Gumuruk. Staff treatedapproximately 2,500 patients for malaria,
1,000 children with severe malnutrition, and
500 people with violence-related injuries.
Further north, the MSF clinic in Lankien serves
around 127,000 people. With outreach sites
in Pieri and Yuai, teams provide all kinds of
medical care, from treatment for respiratory
tract infections to spear wounds. In 2011,
they treated more than 74,600 outpatients.
In August, there was a raid on Pieri and12 surrounding villages; MSF treated over
100 people for injuries and referred another57 to hospitals in Leer and Nasir. The majorityof the victims were women and children withgunshot wounds. One MSF staff member
was killed, along with her entire household.
The raiders looted MSF’s compound andclinic in Pieri and burned down parts of it.
In early December, teams expanded theiroutreach activities in Lankien, Pieri and Yuai
in response to an increase in the number ofpeople suffering from malaria. Staff treated
3,160 patients for malaria in just one month,when the average is usually 300 to 400
cases a month.

© Avril Benoit / MSF

Emergency response in Abyei and thesurrounding area

A child is vaccinated against measles in Abathok.

96

South Sudan

The area of Abyei, contested by Sudan
and South Sudan, was the scene of violent
clashes in May. The MSF hospital in Agok,
40 kilometres south of Abyei, received
42 wounded in less than 48 hours andtreated at least 2,300 patients in the firsttwo weeks of the fighting. As most people
had fled with just the few belongings© Corentin Fohlen

Activity Report 2011

Refugees who fled fighting in the disputed Abyei area receive relief items.
they could carry, MSF distributed medical
supplies and basic relief items such as
shelters, plastic sheeting, mosquito nets
and soap. Staff also set up a rehydration
point in Agok hospital. Mobile teams
attended to the wounded and displaced
in several small villages outside Agok.
In 2011, MSF carried out a total of 26,000
outpatient consultations at the hospital.
A nutrition assessment in November
prompted MSF to start offering
supplementary food for all children underfive years old. The first batch was distributed
to 10,200 children in December.
Refugees from Sudan
In late November, MSF launched an emergency
response when thousands of refugees fled fromBlue Nile state in Sudan to several locations in
Maban county, Upper Nile.
By the end of 2011, around 35,000 refugees
had arrived in Doro and Jamam camps, andthe number would swell to over 90,000
by April 2012. As well as setting up a field
hospital in Doro camp, MSF teams provided
urgently needed healthcare for refugees
arriving at the border-crossing point at El-Fuj,
carried out measles vaccination campaigns
and distributed emergency supplies of food.

MSF water specialists also took steps toensure a minimum amount of safe water wasavailable and lobbied water organisations to
implement more permanent solutions.
In December, MSF began providing medical
assistance to some 20,000 refugees who
had arrived in Yida, Unity state, just southof the border with the extremely volatile
Sudanese state of South Kordofan.
Maternal healthcare in Aweil
Despite the eruption of violence along thenorthern border with Sudan, Northern
Bahr El Ghazal remained relatively stable. In
2011, MSF handed over its basic healthcare
activities and paediatric outpatient services
at its hospital in Aweil to the Ministry of
Health so that staff could focus resourcesand expertise on specialist maternity andpaediatric care and nutrition. In 2011,
over 1,200 children were enrolled on the
nutrition programme and almost 3,800
children were admitted to the paediatricward. Staff assisted more than 3,400 births
in the hospital.
In Western Bahr El Ghazal, staff supported
the maternity, paediatric and surgery
departments of Raja civil hospital, carryingout more than 12,000 paediatric consultations

and admitting over 1,600 children to thehospital for treatment. In Western Equatoria
state, MSF tended to some 24,000 patientsin Yambio state hospital – working in thematernity and paediatric departments as wellas treating malaria and malnutrition – andconducted outreach activities among people
displaced by violence.
At the end of 2011, MSF had 1,872 staff in
South Sudan. MSF has been working in the
country since 1983.

Wathoudisplaced from Lekwongole“T hey started shooting and I tried to run
away, but I fell over and hurt my back.
It is still not OK now. When I sleep,
I have no blankets or things to coverme; I just sleep in these clothes I’mwearing. And I am hungry; I have had
no food, nothing to eat. My mother is
old and cannot walk, so she has to be
carried. But she is still alive. There ismalaria attacking children and there
are very few mosquito nets here. Whenchildren get malaria, we take them tothe MSF hospital.”South Sudan

97

Médecins Sans Frontières

Sudan
North Darfur

Red Sea StateAl Gedaref
South Darfur
Regions where MSF has programmes

Bureaucratic constraints, however,continue to hamper the provision ofhigh-quality healthcare in some areas.
MSF has made repeated offers to set up
medical services in the states of Blue Nileand South Kordofan, where violence is rife,
but these have been declined.
Kala azar
Since 2010, MSF has been running a
programme in collaboration with the
Ministry of Health to treat kala azar, anunder-researched disease that is fatal if left
untreated. Kala azar is endemic around theAtbara river area in Al Gedaref state, eastern
Sudan. Last year, 3,090 people were screened
for the disease and 729 patients who tested
positive were treated in Tabarak Allah hospital.

providing free treatment to more than 19,600
patients with other conditions. At the end of
the year, a decision was made to expand theprogramme to nearby Sennar state, and a
new programme was opened in November.
DarfurSporadic fighting and banditry continue
in Darfur, making it difficult to reach thosein need of medical care. Many people whohave fled violence are still unable to return totheir home villages. In 2011, MSF maintained
five medical programmes, despite insecurity
and bureaucratic difficulties that forced
international staff to limit their presence toshort ‘flash visits’ to train, assist and ensure
standards of medical care.
In South Darfur, after an assessment in
the Shaeria area, a nutrition programme
was opened in March and 469 children
received treatment. Against a background ofintercommunal tensions, it quickly became
apparent that there were wider needs forsupport to the hospital and surrounding
abandoned rural clinics. MSF set up acomprehensive programme to support the
Ministry of Health in Shaeria. The teamstarted treating patients in early 2012.
Across North Darfur state, MSF carried out
more than 150,000 outpatient consultations.
MSF’s hospital in Shangil Tobaya provides© Juan-Carlos Tomasi

As Tabarak Allah hospital treats so many kalaazar patients, it is one of the few locations
where operational research into this neglecteddisease can be conducted. In July, the team
introduced a new regime, developed by
the Drugs for Neglected Diseases initiative(DNDi) and Sudanese scientists, which
reduced the duration of treatment from 30 to
17 days. MSF also supported hospital staff in

In Sudan, Médecins Sans Frontières (MSF) concentrates onproviding medical assistance for people living in conflictzones and in remote regions with poor access to healthcare,and on treating kala azar (visceral leishmaniasis).

Displaced people line up for medical assistance, North Darfur.

98

Sudan

both basic and specialist healthcare, including
paediatric, reproductive and counselling
services, and operates a mobile clinic bydonkey to neighbouring villages that do nothave access to medical care. The team in
Tawila works with the local health facilities
to provide comprehensive healthcare,including 24-hour emergency services, forthe local community and the inhabitantsof three camps for displaced people. In
Abushok and Al Salam camps, near the state
capital of Al Fashir, MSF ran a therapeutic
feeding programme, treating more than
1,000 children on an outpatient basis and afurther 239 inpatients between January andJuly, when the project was transferred to the
Ministry of Health. In Dar Zaghawa, near the
Sudan–Chad border, the team supports five
health centres and responds to emergencies
arising from outbreaks of violence.
MSF provided specialist healthcare andsurgery in the hospital in Kaguro, an area
held by opposition forces, as well as basic
health services in five rural clinics. The teamconducted more than 39,000 consultations
and performed 119 major surgical procedures.
However, difficulties in obtaining authorisation
to supply the programme with drugs and otheressentials are jeopardising activities.
Response to other emergencies
Between November 2010 and March 2011,
MSF supported the Ministry of Health’s
response to extensive flooding in Marafit
and surrounding areas in Red Sea state, close
to the border with Eritrea. Staff distributed
relief kits to 200 households and one tonof special nutritious food to approximately
1,500 children at risk of malnutrition.
In June, after MSF had recorded highnumbers of patients with measles, theteam in Tabarak Allah hospital conducteda measles vaccination campaign with
the national authorities. In total, 44,800
children were vaccinated and 620 weretreated for measles.
At the end of 2011, MSF had 853 staff in
Sudan. MSF has been working in the country
since 1979.

Activity Report 2011

Swaziland
Mankayane

NhlanganoMatsapha

Shiselweni

Regions where MSF has programmesCities, towns or villages with MSF activities© Sarah-Eve Hammond / MSF

Swaziland is struggling witha dual epidemic of HIV/AIDS
and tuberculosis (TB). The
scale-up of treatment has
been made even more difficult
by a national financial crisis.
A community treatment supporter prepares an injection for an MDR-TB patient.

Throughout 2011, there were strikes anddemonstrations, and the government had
difficulties securing funds to buy drugs andsupplies to respond to the national HIV
emergency. Thousands of lives are affected.
Almost 26 per cent of adults aged between
15 and 49 have HIV. At any one time, four in
10 pregnant women are HIV positive. Some
80 per cent of TB patients are co-infectedwith HIV.

to local workers – holding consultations
outside of working hours so that textile
workers can see medical staff. In Mankayane,
not far away, the MSF team assisted Ministryof Health staff in improving the diagnosis andtreatment of 664 patients co-infected withHIV and TB, and treated 60 patients withdrug-resistant tuberculosis (DR-TB).

HIV and TB care in Shiselweni

New DR-TB facilities

Swaziland is a rural country with many small,isolated villages. Health centres are often far
from people’s homes, making journeys for
medical attention long and expensive.
Shiselweni, in the south, is the poorest andmost remote region. Since 2007, Médecins
Sans Frontières (MSF) teams have been
focusing on facilitating free access to HIV
and TB services at the closest point of care.
Today, 22 rural clinics in Shiselweni offer HIV
and TB care. This means that people withboth diseases can receive all their treatment
at their local health centre. More than 2,000
patients are treated for TB every year, andat the end of 2011, 18,000 patients werereceiving antiretroviral (ARV) treatment.
In 2011, MSF introduced new staff, basedin the community, who offer testing andcounselling. They now work in every clinic,
and since the scheme started, the numberof people tested has more than tripled,to over 2,300 per month.
In addition, MSF works in a health centre in
the town of Matsapha, in central Swaziland,
where 378 people received treatment for
TB and 705 patients are on ARV treatment.
Staff also offer comprehensive healthcare

The management of DR-TB is a growing
challenge in Swaziland. DR-TB can be caught
from someone with the disease, but can also
develop when a person with TB grows resistant
to standard treatment. The treatment regime
for DR-TB is very difficult, and causes a rangeof side effects. Patients receive daily injections
for at least six months, and have to take as
many as 18 pills a day for up to two years.
Almost eight per cent of new TB cases are
drug-resistant. MSF supported the National
Reference Laboratory for Tuberculosis in
carrying out diagnoses. At the end of 2011,172 people were being treated for DR-TB
in the region of Shiselweni alone.
In September, a new DR-TB ward, built by
MSF, was inaugurated in Nhlangano, in thepresence of King Mswati III. Nhlangano isa large town in the south of the country.
The ward complements the communitybased approach to treatment by offering
inpatient care to those who are very sickcloser to home. It is run by the Ministryof Health and MSF teams together.
Eleven rural clinics were also rehabilitated.
They were fitted out with new, wellventilated waiting areas and additional
consultation rooms. In Matsapha andMankayane, MSF introduced a new TB
testing machine, which significantly reduces
the time it takes for diagnosis, and which
can test for some forms of drug resistance.
Task-shifting to go national
Very few Swazi medical doctors are working inpublic health outside of the capital Mbabane,
and many who train in the country leave forplaces where employment conditions are better.
A lack of medical human resources isrecognised as the main obstacle to expanding
health service capacity. MSF uses task-shifting
in its programmes to enable more people toreceive care. Nurses, rather than doctors,
are trained to initiate ARV treatment,or administer drugs for uncomplicated,
non-resistant TB, while counsellors are taught
how to test people for HIV, thus freeing up
nurses for other work. In 2011, the Ministry of
Health began developing a national framework
for task-shifting, which should significantly
increase staff capacity across the country.
Shortages of medicines
Although the HIV and TB epidemics havebeen declared emergencies in Swaziland,
MSF contingency stocks of ARV drugs had
to be used by thousands of patients in 2011
due to shortages in national stocks.
MSF appealed to King Mswati III to makesure all measures are taken to guarantee
the timely procurement, supply anddistribution of drugs and laboratory
supplies to health facilities and patients.
At the end of 2011, MSF had 246 staff in
Swaziland. MSF has been working in the
country since 2007.

Swaziland99

Médecins Sans Frontières

Syria
Damascus

Cities, towns or villages with MSF activities

In April, as unrest and violence increased,teams started to provide Syrian doctors withmedicines and other medical supplies. In June,
the MSF surgical team in Amman, Jordan,
received their first Syrian patient. In November,teams began offering mental healthcare to
Syrians who had fled to Lebanon.
Unregistered migrants in needof healthcare

In August 2009, MSF launched a healthcare
project in the capital Damascus, in partnershipwith a local organisation, known as the
Migrant’s Office. Based in a clinic, a teamconsisting of doctors, gynaecologists and a
psychologist provided free basic healthcare,antenatal care and mental health services forunregistered refugees and migrants, focusing
specifically on the most vulnerable, including
women and children.
Between January and March 2011, 1,965
patients received medical attention. Staff
held more than 220 antenatal consultations
and over 140 patients received mental
healthcare through individual consultations
and group sessions.
Withdrawal amid growing unrest
The widespread unrest in the country, whichbegan in March 2011, made it very difficultfor MSF to continue its work inside Syria, andthe team had to suspend collaboration with
the Migrant’s Office. MSF continued to try

to gain access to Syria in order to respond tothe humanitarian and medical needs resulting
from the violence.
From neighbouring countries, MSF
supported Syrian doctors’ work by providingthem with medical supplies and essential
drugs. In Amman, Jordan, where MSF has areconstructive surgery programme, surgeons
operated on 23 wounded Syrians who hadmanaged to cross the border.
In Lebanon, MSF donated emergency supplies
to health centres near the border with Syria.
In November, a team set up a mental healthprogramme in the northeastern region of
Wadi Khaled, where staff conducted individual
consultations and group sessions with Syrians
who had fled their country.
At the end of 2011, MSF had 48 staff in Syria.
MSF has had operational activities in Syria
since 2009.

© J.B. Russell

Syria is host to hundreds of thousands of
migrants and refugees, many of whom havefled poverty or conflict in Afghanistan, Egypt,
Iraq, Lebanon, Somalia and Sudan. A large
proportion of them are living in the country
unregistered, in precarious conditions, withlimited access to medical care.

From early 2011, Médecins Sans Frontières (MSF) was unable
to operate in Syria, and was therefore obliged to suspend its
work with migrants and refugees in the capital Damascus.

Orthopaedic surgery at MSF’s centre in Amman, where 23 wounded Syrians received treatment in 2011.
100 Syria

Activity Report 2011

© MSF

ThailandStaff distribute relief items to people affected by flooding.

Mae Hong Son

Phitsanulok

SukhothaiKamphaengPhet
Three
Pagodas Pass

PhichitSamut Sakhon

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

After working in Thailand
for 35 years, Médecins Sans
Frontières (MSF) has reluctantly
closed its final remaining
project in the country.
It has proved impossible to obtain permission
to offer medical attention to undocumented
migrants and vulnerable people who are notentitled to basic healthcare. In September,
MSF came to the conclusion that there wasno choice but to close its longest-runningmission, which started with the provision ofassistance to Cambodian refugees fleeing
the Khmer regime in 1976.

In the 1980s, MSF supported refugees from
Myanmar, and since the mid-1990s, it has
played a key role in providing and advocating
comprehensive care and treatment for people
living with HIV. Thailand was one of the first
countries to introduce free antiretroviraltreatment for HIV patients. In the past
decade, MSF has responded mainly toemergencies and offered healthcare to
Hmong refugees from Laos. For more on
MSF’s history in Thailand, see pages 18–21.
Assistance to migrants halted
Early in 2011, MSF was forced to close its
programmes in the central industrial zone of
Samut Sakhon and in the Three Pagodas Pass,on the border with Myanmar, depriving 55,000
vulnerable people of access to healthcare.
In the Three Pagodas Pass area, MSF had been
operating a mobile clinic, providing basic
medical services. Staff carried out 795 antenatal
consultations, referring pregnant women to
Ministry of Health hospitals for delivery. Some
4,200 people received general health education.
At the MSF clinic in Samut Sakhon province,
where thousands of undocumented migrants
live and work, staff conducted more than
1,380 medical consultations. Over 4,200
people attended health education sessions.

Mae Hong Son
In Mae Hong Son, in the north of Thailand,
MSF staff trained ‘backpackers’ to work as
mobile medical teams in the Myanmar–
Thailand border area. In 2011, more than
48,470 medical consultations and almost 1,590
antenatal care consultations were carried out
by these mobile teams. In the same period,
staff assisted some 420 births and distributed
more than 6,750 mosquito nets.
Flood response
The monsoon season began at the end of
July and caused severe flooding in northern,
northeastern and central Thailand. In October,floodwaters reached the mouth of the
Chao Phraya river, and inundated parts ofthe capital city, Bangkok. Of Thailand’s
77 provinces, 65 were declared flood
disaster zones. Approximately 800 people
died and 13.6 million were affected.
MSF teams supplied 66,000 people withrelief items – mainly food, water andmosquito nets – and carried out more than
1,400 medical consultations in the mostaffected areas of Sukhothai, Phitsanulok,
Phichit and Kamphaeng-Phet provinces.
At the end of 2011, MSF had 42 staff in Thailand.
MSF has been working in the country since 1976.

Thailand 101

Médecins Sans Frontières

Tunisia

Healthcare for third-country nationals

Tataouine

Ras Ajdir

RemedaDehibaCities, towns or villages with MSF activities

Violent clashes in Libya inearly 2011 forced hundreds ofthousands of people to leave
the country, many across theTunisian border.
Médecins Sans Frontières (MSF) staff in
Ras Ajdir, a small coastal town on theborder, were blocked from crossing into
Libya to assist the victims of the conflict,
and witnessed thousands of people arriving
in Tunisia in search of safety.
Assisting Libyan refugees
Health centres in towns and villages
bordering Libya were under enormouspressure. In the town of Dehiba, just a few
kilometres from the border, MSF set up astabilisation centre, caring for people who
had been injured in the conflict. The teamtreated nearly 60 emergency patients in
March and April. Other teams set up mobile
clinics in Dehiba, Remada and Tataouine,
offering medical care as well as psychologicalsupport to refugees.

In late February, the health authorities andlocal non-governmental organisations wereable to cover most of the people’s medical
needs. MSF identified a gap in mental
healthcare, and a team began offering
mental health services in Shousha refugee
camp, close to Ras Ajdir, in March, later
extending assistance to people staying in
two other transit camps in the area.
By June, more than 600,000 migrants,
refugees and asylum seekers had left Libya,
and although many were rapidly repatriatedto their country of origin, thousands remained
stranded in Egypt, Italy, Niger or Tunisia,with great uncertainty for their future.
For many, this stress, added to the traumatic
experiences they had been through or witnessed
while fleeing the conflict in Libya, and thepersecution and ill-treatment some of them had
survived prior to the conflict, was too much.
In Shousha, the largest camp, some 4,000
people, mainly sub-Saharan Africans, had still
not been repatriated, months after arriving,
mainly because of dangerous situations in theircountries of origin. Poor living conditions in
the camp, inadequate for a long-term stay, andgrowing security issues, led to violent clashes
in May. MSF expanded its activities, to provide
medical care, and distribute food, water andrelief items, as well as offer mental healthcare.
The violence exacerbated feelings of despair
among people living in the camp. Some
refugees chose to risk their lives by attempting
to cross the Mediterranean Sea, in the hope offinding a better reception in Europe.

MSF called on the countries engaged in the
war to better receive, assist and protect its
victims. In From a Rock to a Hard Place: The
Neglected Victims of the Conflict in Libya, MSF
reminded all warring parties and neighbouring
countries of their responsibility, underinternational law, to keep their borders open
and offer protection to those fleeing Libya.
Handover of activities
By August, the majority of Libyan refugees
had returned home, and MSF began to scale
down activities, stopping them completely
in September. Thousands of third-country
nationals remained stranded in Shousha,
but there were enough organisations
working in the camp to cover medical
needs. MSF therefore handed its activities
over to these organisations.
Between March and September, staff
carried out 10,500 medical consultations
and 21,000 mental health consultations.
Before leaving, medical supplies andequipment were donated to health facilities
in the towns of Tataouine and Medenine.
Medical evacuation by boat
In April, the Libyan city of Misrata was thescene of heavy fighting: residents were cut
off from external assistance and hospitals
and clinics were overwhelmed withcasualties. MSF carried out two medical
evacuations from Misrata to Tunisia. A teamremoved 135 patients by boat, with medical
staff providing urgent assistance on board.
Upon arrival, the Tunisian health authorities
and the Tunisian Red Crescent transferred
the patients to medical facilities in Sfax
and Zarzis, and on the island of Djerba.
At the end of 2011, MSF had 6 staff in Tunisia.
MSF started working in the country in 2011.

Mouhaydin
27 years old, from Somalia© Mattia Insolera“ I left Somalia in 1994 because of thewar. When my father was killed, myfamily fled to Ethiopia. They still live there.
I am the eldest child and need to support
my family. I decided to go to Libya andbeyond, to find work and build a future.

A health promoter talks to people in Shousha camp about mental health services.

102 Tunisia“ I arrived in Libya eight years ago. I wasworking as a labourer and a cleaner andlife was difficult. We were treated like slaves.
When the war broke out, the situation
became very frightening for foreigners.
I had to flee this country too, and I arrived
in Shousha camp on 6 March.”

Activity Report 2011

© MSF

TurkeyVictims of the earthquakes that struck eastern Turkey in October and November.

Istanbul

Van

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

In 2011, Médecins Sans
Frontières (MSF) teamsin Turkey provided mental
health support to migrants
in Istanbul and survivorsof the earthquakes in Van.

Undocumented migrants have no accessto health services in Turkey. In June 2011,
MSF signed a partnership agreement witha Turkish non-governmental organisation(NGO), the Helsinki Citizens’ Assembly,
to provide assistance to undocumented
migrants living in Istanbul. Teams provide
aid to the most vulnerable, including
women, children and the elderly, in 10 ofIstanbul’s municipalities. The majority ofpatients have been through traumatic
events and are now facing problems relating
to integrating in a new environment.
Psychologists provided mental healthsupport, while community health workers
and interpreters assisted the clinical teamand conducted outreach with the migrantcommunities, community organisations andTurkish health facilities. Almost 940 group
counselling sessions were held in 2011.

Earthquake response
The two earthquakes that struck eastern
Turkey in October and November killed atleast 500 people and injured 2,500. An MSF
team in Van worked with local authorities
and two Turkish NGOs, Hayata Destek andthe Helsinki Citizens’ Assembly, distributing
2,000 winter tents and 2,000 cooking kits
to 12,000 people in 37 villages in Van.
MSF started a two-month psychologicalsupport programme in 31 villages in
December. By the end of the programme,
3,470 women and 1,850 men had benefited
from group sessions, and 53 people received
individual counselling. Patients in a more
serious condition were referred to Van hospital.
At the end of 2011, MSF had 8 staff in Turkey.
MSF first worked in the country in 1999.

Turkey 103

Médecins Sans Frontières

UgandaArua

kitgumLamwo
LuweroKaramoja

Regions where MSF has programmes

MSF supports hospitals and health centres inthe districts of Kitgum and Lamwo and thesubregion of Karamoja in northern Uganda. In
2011, staff conducted close to 17,000 outpatient
consultations and 3,365 antenatal consultations,and admitted 506 people to hospital.
Since the conflict ended, the general
health situation has improved, and thishas prompted MSF to switch the focus
of its activities in Kitgum and Lamwo to
supporting victims of sexual violence: there
are now 18 centres in the two districts thatcan care for survivors of sexual violence.
In Karamoja, fighting persists, and a numberof patients needed treatment for injuries.
When yellow fever and hepatitis E broke out inthe region, MSF assisted the health authorities,
and also supported the response to an outbreakof Ebola in Luwero, central Uganda.
MSF continued to run its TB programme, andmore than 500 new patients started treatment
in 2011. In December, the first patient to start
treatment for multidrug-resistant TB (MDR-TB)

In Uganda, Médecins Sans Frontières (MSF) operates HIV andtuberculosis (TB) programmes and assists people recoveringfrom years of conflict in the north of the country.
in the programme was declared cured.
MSF has been lobbying for other organisations
to provide treatment for MDR-TB.
HIV care in Arua
The Ugandan Ministry of Health decided that
it would start implementing nationwide MSF’s
treatment protocol for preventing mother-tochild transmission (PMTCT) of HIV in 2012.

MSF continued to provide treatment at Arua
regional referral hospital, in the northwest of thecountry. Each month, an average of 25 womengave birth through the PMTCT programme.
Nearly 2,000 new patients were registered at
MSF’s HIV programme and more than 6,400
received antiretroviral (ARV) treatment.
Being close to the border with the Democratic
Republic of the Congo (DRC), where accessto ARV treatment is very limited, a significant
proportion of the people living with HIV in
the Arua area come from the DRC. MSF has
been supporting an HIV clinic at a healthcentre in Oli, on the outskirts of Arua. At theend of 2011, more than 780 patients werereceiving care in Oli. This programme will behanded over to the Ministry of Health in 2012.
The Oli and Arua programmes both offer
integrated care for HIV patients sufferingfrom other conditions associated with theinfection, including TB and malnutrition.
More than 700 patients co-infected with TB
and over 550 children suffering from severe
malnutrition received treatment in 2011.
Sleeping sickness
Sleeping sickness (human African
trypanosomiasis) is endemic in Uganda.
MSF had been supporting Ministry of Healthprogrammes, but in the middle of the year,
after an assessment revealed prevalence tobe less significant than suspected, the team
decided to focus instead on lobbying for the
opening of treatment centres and on providing
training to national and regional programmes.
Research to improve testing and treatment
A number of research projects werecarried out in Uganda in 2011. With theLondon School of Hygiene and Tropical
Medicine, MSF undertook operational fieldresearch into TB and drug-resistant TB
patients’ acceptance of home-based carethrough village health teams. In Karamoja,
researchers embarked on a study of how
children’s recovery from malaria, diarrhoea
or respiratory infections is affected by theirnutrient intake. MSF also started a study on
rapid diagnostic testing methods for HIV.
At the end of 2011, MSF had 613 staff in Uganda.
MSF has been working in the country since 1986.

Opira
34 years old, has MDR-TB© Maimouna Jallow“F or quite some time now, I have been
taking 18 tablets a day … Sometimes
when I take the drugs, I feel weakbecause the drug starts working on me
immediately and I cannot go anywhere;
I have to take some time. Sometimes,
I can take the drugs and, when I haveeaten well, I may not feel like vomiting.
Sometimes, I might feel like vomiting
but I can still walk around. But most of
the time when I take the drug, I feel likeI should first have a rest in bed because
I cannot walk.

Patients wait outside a clinic in Kaabong district, Karamoja region.

104 Uganda“In the end I will go back to Gulu. That is
my plan. I lived there during the conflictand didn’t leave until last year, 16 May.
That is the day I came to Kitgum, becauseof my illness.”
Opira writes a blog as part of MSF’s
TB&ME project. See his and others’
accounts of what it means to livewith TB at blogs.msf.org/tb/

Activity Report 2011

Uzbekistan
Chimbay
Nukus
Khodjeyli
Takhiatash

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

DR-TB can be transmitted from person toperson just like drug-sensitive tuberculosis,
but it can also develop when a TB patient,either through mismanagement or misuseof medication, becomes resistant to thestandard TB drugs. DR-TB treatment isarduous – side effects are common, andinclude nausea, headaches and sleep
disturbances – and takes up to two years.
Understandably, it can be very difficult forpatients to complete the course of treatment.
Implementing comprehensive TB care
In the Autonomous Republic of
Karakalpakstan, northwest Uzbekistan,
MSF expanded its programme from two
to five of 16 districts: Chimbay, Khodjeyli,
Takhiatash town, Nukus town and Nukus
region, and tripled the number of patients.
By the end of the year, some 780 patientswere receiving treatment for DR-TB, andalmost 200 were receiving treatment for
drug-sensitive TB.
MSF’s programme includes a range ofapproaches, which all contribute toimproving adherence. Treating people
as outpatients from day one, instead of
imposing a stay in hospital, can maketreatment more bearable. Educating
patients about DR-TB, the medication andthe side effects enables them to better
understand and manage their disease.
Psychological assistance, in the form ofindividual, group and family counsellingsessions, supports patients in coping© Natalia Sheletova / MSF

Drug-resistant tuberculosis(DR-TB) is widespread in
Uzbekistan. Médecins Sans
Frontières (MSF) is introducing
a comprehensive treatment
and support programme.
A daily dose of drugs for a patient with MDR-TB, including TB antibiotics and drugs tocounter the side effects of treatment.

with the physical and social effects bothof having TB and being on treatment.
More practical social support, such as help
with transport and food, is also provided.
Amid signs that Uzbekistan’s commitment
to tackling TB is strengthening, MSF plans
to expand its programme to three more
districts in 2012.
At the end of 2011, MSF had 157 staff in
Uzbekistan. MSF has been working in the
country since 1997.

MSF treated780
patients
for DR-TB

Rakhatay
Multidrug resistant TB patient“ I had been treated for TB in our local
hospital for over a year. There wasno effect. Then I was lying at home.
I guess God had pity on me, for you[MSF doctor] came to my house andtold me that treatment is available.
At that time I couldn’t even talk toyou, I could only listen.
“ It’s my daughter Kunduz, it’s thanks
to her I started my treatment anew.
She convinced me; she told me that
I should go for this treatment. Now
I am taking drugs. Before, I could noteat: I could only drink black tea froma spoon. I couldn’t even raise my head.
Thanks to God, now I can sit and evenmove around.
“ I never miss even one day of drugs.
There are nurses – Amangul, Umyt,
Muhabbat – they bring me medicines.
They are all such nice people; they coax
me like a child, and make up different
tricks so I don’t even notice how I haveswallowed the medicine. I am sothankful to them; I have reached sucha good state of health now.”

Uzbekistan 105

Médecins Sans Frontières

Yemen
In 2011, protests in Yemen’s
main cities regularly ended
in violent clashes.

On the whole, national health facilities wereable to care for the increased number ofpatients. Médecins Sans Frontières (MSF)
supported medical staff, filling gaps in
supplies and offering ad hoc support.

hajjahSaada
AmranSana’aViolence in the south
Fighting between opposing Islamic militantgroups and government forces in Abyan
governorate, southern Yemen, began to escalate
in May. Healthcare facilities were severely
damaged in the violence, and MSF staff
were prevented from reaching some places.
At a health post in Jaar, MSF provided basic
medical and emergency assistance andset up stabilisation and ambulance referral
systems. Some 2,000 people received
emergency care and more than 200 werereferred to a private hospital in Aden,
70 kilometres away.

Lahj

Aden

Regions where MSF has programmes

department, carrying out some 4,400
consultations and referring 120 patients
to facilities in Aden.
MSF continued the activities it had begun
in July 2010 in Radfan district hospital, Lahj
governorate. More than 9,500 patients wereadmitted for emergency care and surgeons

performed over 1,160 operations. MSF also
assisted in the pharmacy and laboratory.
Around 100,000 people were displaced byviolence. Some found shelter with residents
in the town of Al-Hosn, where MSF staff
supported a clinic. Most people, however,headed towards the city of Aden. In the© MSF

In Ad-Dali hospital, northwest of Aden,
MSF supported staff in the emergency

Abyan

Taez

An emergency consultation at Huth hospital, Amran governorate.
106 Yemen© MSF

Activity Report 2011

A doctor examines a young patient, Huth hospital, Amran governorate.

second half of the year, MSF conducted
outpatient consultations in three city clinics,
donated drugs and trained medical staff.
In the capital Sana’a, MSF donated drugs
and medical supplies to public and private
health facilities, and provided additional
training for the management of incidents
involving large numbers of injured patients.
Staff also ran an ambulance service and, for
two months, carried out surgery at a private
health centre.
Working conditions compromise
activities in the north
Civil conflict in Saada persisted, despite
a ceasefire agreement in 2010. Conditions
became increasingly difficult for relief
organisations, and MSF had to reduce
its activities.
In September, the Executive Council in chargeof humanitarian affairs in Saada announced
new conditions for all humanitarian andnon-governmental organisations working
in the governorate. Among these were thetermination of all independent assessments ofmedical needs and the obligation to replace
all Ministry of Health staff working with MSF
with staff proposed by the Executive Council.

Having considered the consequences ofthese new conditions on the quality andeffectiveness of its work, MSF suspended
activities in Al Talh and Razeh hospitals,
as well as in five health centres in the area.
Al Talh and Razeh are the only facilities
outside Saada city providing specialist care.
MSF staff in Al Talh held 48,000 outpatient
consultations, performed 459 surgicalinterventions and admitted 1,900 inpatientsduring the first nine months of the year.
In March and April, MSF also provided
support to Al Jamouri hospital in Saada city,
concentrating on strengthening paediatricand nutrition services.
Violence was still rife in the neighbouring
governorate of Amran in 2011. MSF worked
in Khameer and Huth hospitals and ran
mobile clinics in the surrounding area. Staff
carried out more than 40,000 consultations,
treated some 1,250 children for severe
malnutrition and assisted 500 births.
Due to growing insecurity, surgeons wereable to work for only three months of theyear. Nonetheless, they performed around
325 operations, and MSF teams cared formore than 800 inpatients.

Many Yemenis fleeing violence in Saada
made their way south to Al Mazraq,
Hajjah governorate. MSF provides general
healthcare to people living in the camps
around Al Mazraq, focusing particularly on
treating children for malnutrition, assisting
victims of sexual violence and supporting
people in need of mental healthcare.
MSF also manages the only hospital in
Al Mazraq, which was built by the Organizationof the Islamic Conference and the Qatar Red
Crescent Society. There is an emergency
department and an operating theatre, andstaff offer basic and specialist healthcare fordisplaced people and the local community.
In 2011, staff carried out more than 30,000
consultations, treated over 4,200 patientsfor emergencies and provided sexual andreproductive healthcare to 3,900 people.
Some 270 surgical procedures were
performed, and 2,700 children weretreated for severe malnutrition.
At the end of 2011, MSF had 574 staff
in Yemen. MSF first worked in the country
in 1994.

Yemen 107

Médecins Sans Frontières

Zimbabwe
Plans to further improve
HIV care in Zimbabwe werefrustrated in 2011, when the
Global Fund to Fight AIDS,
Tuberculosis and Malaria – oneof the major donors supportingthe country’s fight against
HIV and tuberculosis (TB) –announced the cancellationof its next funding round.

HarareGokwe North

EpworthTsholotsho

Chikomba
BuheraGweru

Gutu

Bulawayo

beitbridge

According to the Zimbabwean
government, 63 per cent of people inneed of antiretroviral (ARV) medication
are currently receiving treatment.
Médecins Sans Frontières (MSF) works withinpublic facilities, mainly delivering HIV and
TB – including drug-resistant TB – care.
The programme covers the testing, diagnosis,
treatment and counselling of patients withHIV and/or TB, and for pregnant women,
antenatal care and prevention of mother-tochild transmission (PMTCT) of HIV. In 2011,
MSF was supporting about 48,430 peopleon ARV treatment. Laboratory services,
health promotion activities and assistance forvictims of sexual violence were also available.
Scaling up treatment
Teams have been providing care for people
with HIV and TB in Buhera district, in the

Regions where MSF has programmes

eastern province of Manicaland, since 2004.
Today, 86 per cent of the people who need
ARV treatment are receiving it. Scale-up has
been possible thanks to new models of care.
MSF has implemented task-shifting, so thattrained nurses, instead of doctors, initiate
ARV treatment and follow-up. Staff havealso been working in rural health centres sothat people living far from urban areas havebetter access to HIV care: 75 per cent of
the 18,590 patients who have started ARVtreatment since the programme began
live in rural areas.
In an effort to rapidly extend services
elsewhere in the country, MSF trained

Cities, towns or villages with MSF activities

26 Ministry of Health staff to provide
support in HIV care to clinics in Gutu
district, Masvingo province, and Chikomba
district, Mashonaland East province.
In Tsholotsho, in the west of the country, teams
focused on treating adolescents and children
and pregnant women with HIV, and providing
PMTCT. By the end of the year, more than
9,000 patients were on ARV treatment.
Successful and sustainable handovers
Being integrated into public health facilities
has enabled MSF to offer training and transfer
expertise, including PMTCT services, andtherapeutic feeding for children. In 2011,© Brendan Bannon

Guide

An 18-month-old and his mother wait for a consultation at Overspill clinic, Epworth, near Harare.

108 Zimbabwe“I was first diagnosed with TB, but both
first- and second-line treatment failed.
My cough and weight loss continued,
I couldn’t walk any more and wassoon bedridden. In December 2010,
I was put on treatment for multidrugresistant TB (MDR-TB) and have sincemuch improved. Unfortunately, my wife
contracted the bacteria from me andis now also suffering from MDR-TB –it is difficult to keep a couple separate!
Now she is also being treated, andis staying overnight in a separate
room. Our kids are staying with their
grandparents down the road until it
is safe enough for them to moveback home.”© Brendan Bannon

Activity Report 2011

An HIV patient plays with her siblings outside her home in Epworth, near Harare.

nearly 4,000 patients were transferredfrom Domboramwari clinic in Epworth to a
new clinic built by MSF in Overspill, on theoutskirts of Epworth. The Overspill clinic washanded over to the Ministry of Health, whose
staff now run most services there.

Working with local non-governmentalorganisations, clinics and national health staff,
MSF provides medical and psychological care.
By the end of the year, the programme hadalready assisted 125 people.

MSF continues to work at the Domboramwari
clinic. In total, more than 26,600 people were
tested for HIV in Epworth, of whom 7,116 tested
positive. At the end of the year, MSF was treating
14,220 patients for HIV, with just over 10,500
receiving ARV medication. MSF also treated
1,353 patients for TB, including 11 for DR-TB.

In January, the MSF project in Beitbridge,
close to the South African border, which
had been offering basic healthcare, changed
its focus to provide local people withHIV and TB treatment, targeting those atparticular risk of infection. By the end of theyear, staff had seen around 2,500 patientsin Beitbridge district hospital, a clinic within
the town and four rural clinics in the area.

Another 11,000 HIV patients from MSF
programmes in Gweru and Bulawayo were also
fully integrated into the national health system.

Emergencies

Reaching vulnerable groups
MSF opened a new clinic in Caledonia Farm,a settlement on the outskirts of Harare thatsprang up following the clearance of urban‘squatters’ several years ago. The clinic
provides basic healthcare, counselling and HIV
testing, ARV treatment and treatment for TB.
In Mbare, a densely populated suburb of thecity, MSF set up a new programme in October,offering support to victims of sexual violence.

MSF continued to assist in responding
to emergencies and outbreaks of disease.
When cholera broke out in Buhera, andtyphoid in Harare, teams supported thenational health services, treating morethan 950 people for typhoid and nearly
70 for cholera. Staff also carried out rapid
assessments and response following thedeclaration of an anthrax outbreak anda measles alert in Tsholotsho.

More than

48,000patients
on ARV treatment

In 2011, MSF had 886 staff in Zimbabwe.
MSF has been working in the country since 2000.

Zimbabwe 109

Médecins Sans Frontières

ZambiaLuapalaLuwingu

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

The number of people being
treated for HIV in Zambia has
increased and, according
to the latest UNAIDS report,
between 70 and 80 per cent of
those who need antiretroviraltreatment are receiving it.
However, prevention is still an issue,
especially outside the big cities. A key
component of the Médecins Sans Frontières(MSF) programme in Luwingu district, in
the isolated and hard-to-reach Northern
province, is the prevention of mother-to-childtransmission (PMTCT) of HIV.

Simply offering counselling and testing is
not enough, however. The stigmatisationof HIV-positive people is still strong in rural
areas, and there is a reluctance to use testing
services. In response, an MSF team travels
regularly to villages in the district to raiseawareness and increase understanding of
HIV and its treatment. The objectives are
to encourage people to come for testing,so that if they do have HIV, they can seek
treatment, and pregnant women can prevent
their children being born with the virus.
Maternal care
In seven rural health centres in Luwingu, MSF
also supports general maternal health services.
Staff offer family planning, ante- and postnatalcare, and assist births. In 2011, they assisted
an average of 110 births and held some 700
antenatal consultations every month. As partof the antenatal care package, the team test
women for sexually transmitted infections,anaemia, HIV and malaria. If infected whenpregnant, malaria can put a woman’s life atrisk, and increases the chances of prematuredelivery, low birth weight or stillbirth.

Measles vaccination campaign
At the beginning of May, MSF launched
an emergency response to a measles
epidemic that had affected thousands ofZambian children, especially in the northof the country. Teams worked with thehealth authorities to carry out a vaccination
campaign targeting some 558,800 children
aged between six months and 15 years in
Luapula and Northern provinces. MSF also
treated people suffering complications such as
pneumonia, dehydration and malnutrition.
Cholera preparedness and prevention
MSF carried out a cholera prevention
programme in Lusaka over the rainy season,
when incidence is highest. This involved
chlorinating water at distribution points,
delivering soap door to door, and organising
activities to inform people about how tohelp prevent transmission, how to spot
signs of the disease and where to seek help.
Following this model, international agencies
and non-governmental organisations havecarried out further prevention activities
in the country.
At the end of 2011, MSF had 87 staff inZambia. MSF has been working in the
country since 1999.

MSF also provided training to Ministry of
Health staff and donated medical supplies
and vaccines.

© Serene Assir

In collaboration with the Ministry of Health,the MSF team offers counselling and testing
to pregnant women, and close to 4,800
were tested in 2011. Women diagnosed

with HIV are then referred to the district
hospital in Luwingu for treatment, where
MSF supports the PMTCT programme.

Health workers conduct measles vaccinations in northern Zambia.
110 Zambia

MSF special reports 2011
Haiti One Year After
January 2011

2011
JANUARYFEBRUARY

DR-TB Drugs under the Microscope
March 2011
Scaling up Diagnosis andTreatment of Drug-resistant
Tuberculosis in Khayelitsha,
South Africa
March 2011
Getting Ahead of the Wave: Lessons for the
Next Decade of the AIDS Response
May 2011

MARCH

APRIL

MAY

Reducing Childhood Mortality in Niger:
The Role of Nutritious Foods
May 2011
From North Africa to Italy:
Seeking Refuge, Finding Suffering
May 2011
Untangling the Webof AntiretroviralPrice Reductions
14th Edition, July 2011

Towards Lab-Free Tuberculosis Diagnosis
August 2011
Central African Republic: A State ofSilent Crisis December 2011
Sweet Sixty: The Status of
Refugees Today, Sixty Years
after a Landmark Convention
December 2011

JUNE

JULY

AUGUSTSEPTEMBEROCTOBER ealth Services Paralysed: Bahrain’s
H
Military Crackdown on Patients
April 2011
Nowhere Else to Go:
Survival Migrants inSouth Africa
June 2011

From a Rock to a Hard Place: The Neglected
Victims of the Conflict in Libya June 2011
Khayelitsha, South Africa,
Activity Report 2001-2011:
10 Years of HIV/TB Care atPrimary Health Care Level
June 2011
Humanitarian Negotiations
Revealed: The MSF Experience
October 2011

Out of the Dark: Meeting the
Needs of Children with TB
October 2011

Five Lives: How a Financial
Transaction Tax Could Support
Global Health October 2011

NOVEMBER
Urban Survivors: Humanitarian
Challenges of a Rising Slum Population
November 2011

In the Eyes of Others: How
People in Crises Perceive
Humanitarian Aid
December 2011
Access to Essential Medicines:
Ten Stories that Matteredin 2011 December 2011

Making the Switch: Ensuring
Access to Improved Treatment
for Severe Malaria in Africa
April 2011

Dadaab: No Way In June 2011

Positive Generation. Voices for an HIV-free
Future (CD and book) December 2011
Assisting the Somali
Population Affected by the
Humanitarian Crisis of 2011
December 2011

Pakistan: Six Months after the Floods
February 2011

10 Years of Antiretrovirals:
Treatment in Malawi by MSF
November 2011

DECEMBER
To read and download these reports,
go to www.msf.org/reports

MSF special reports 2011 111

Médecins Sans Frontières

Facts andFiguresMédecins Sans Frontières(MSF) is an international,
independent, private andnon-profit organisation.

research on humanitarian and social action.
These satellites, considered as related parties
to the 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.

It comprises 19 main national offices
in Australia, Austria, Belgium, Canada,
Denmark, France, Germany, Greece,
Holland, Hong Kong, Italy, Japan,
Luxembourg, Norway, Spain, Sweden,
Switzerland, the United Kingdom and theUnited States. There are also offices in the
Czech Republic, Ireland and South Africa.
MSF International is based in Geneva.
The search for efficiency has led MSF tocreate 10 specialised organisations, called‘satellites’, which take charge of specificactivities such as humanitarian relief supplies,
epidemiological and medical research, andThese figures describe MSF’s finances
on a combined international level.
The 2011 combined international figures
have been 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 2011 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 2011
calendar year. All amounts are presented
in millions 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
31 %
22 %
21 %
13 %
6%
5%
1%
1%

The biggest category of expenses
is dedicated to staff working in
the field: about 53 per cent ofexpenditure comprises 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 included in the category oftransport, freight and storage.
Logistics and sanitation comprisebuilding materials and equipment
for health centres, water andsanitation and logistical supplies.

112 FACTS AND FIGURES

AfricaAsia
Americas
EuropeOceania
Unallocated

66 %
18 %
13 %
1%
1%
1%

Activity Report 2011
Countries where we spent the mostCountries where MSF expenditure was more than 10 million euros
120

Millions of euros

100
80
60
40
20

Li
by
a

Ira
q

bi
a

Co
lo
m

al
aw
i
M

In
di
a

Ye
m

en

nm
ar
Af
gh
an
ist
an

ya

M

ki
st
an

bl
ic

Pa

pu

fri
ca
n

lA
tra
Ce
n

da
n
Su

2011

AFRICA

Re

Co
as
t

Ch
ad

Iv
or
y

ba
bw
e
N
ig
er
ia

ny
a

Zi
m

Ke

ig
er
N

ia
Et
hi
op

al
ia
So
m

da
n
Su

an
d

So
ut
h

Ha

iti

D
RC

0

in millions of E

Democratic Republicof the Congo

67.4

South Sudan

ASIA AND
THE MIDDLE EAST

2010

2009

THE AMERICAS

in millions of E

Haiti

62.3

Pakistan

15.0

Colombia

10.4

35.7

Myanmar13.9

Bolivia and Paraguay * *1.6

Somalia

35.1

Afghanistan

11.5

Guatemala

1.0

Ethiopia

24.8

Yemen

11.0

Other countries *

1.7

Niger

24.2

India

10.9

Kenya

22.9

Iraq

10.1

Zimbabwe

20.3

Uzbekistan

5.1

Nigeria

18.0

Palestinian territories

4.1

Chad

17.9

Bangladesh

4.0

in millions of E

Ivory Coast

17.4

Sri Lanka

3.6

Central African Republic

17.0

Japan

2.5

Total

EUROPE
Russian Federation

77.0

in millions of E

5.5

Ukraine2.1

France1.2

Other countries *

0.9

Total

9.7

Malawi

10.5

Iran

2.1

Libya

10.0

Kyrgyzstan

2.1

Swaziland

9.6

Armenia

2.0

Sudan

9.2

Syria

2.0

Guinea8.4

Thailand

1.4

Mozambique

8.0

Cambodia

1.4

OCEANIA

Uganda7.5

Lebanon

1.3

Papua New Guinea

3.8South Africa

6.9

Turkey1.3

Sierra Leone

6.2

Georgia

1.2

Total

3.8

Mali

4.6

Other countries *2.7

Burundi3.8

Zambia3.6

Liberia

3.2

Transversal activities

1.4

Cameroon

3.1

Other

1.8

Congo

3.0

Burkina Faso

2.7

Total

3.2

Egypt

2.2

Djibouti

1.5

Madagascar

1.0

Other countries *

1.2

Total

Total

109.2

UNALLOCATED

in millions of E

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.

406.9
FACTS AND FIGURES 113

Médecins Sans Frontières

WHERE DID THE MONEY COME
FROM?

2011

2010

In millions of E

Percentage

In millions of E

Percentage

Private

791.6

89%

858.9

91%

Public institutional

75.2

9%

69.3

7%

Other

18.7

2%

15.1

2%

Income

885.5

100%

943.3

100%

In millions of E

Percentage

In millions of E

Percentage

Programmes

609.8

68%

555.3

68%

Headquarters programme support

92.3

10%

78.7

10%

Témoignage/awareness-raising

27.5

3%

26.4

3%

Other humanitarian activities

7.0

1%

5.7

1%

Social mission

736.6

82%

666.1

82%

Fundraising

110.9

12%

103.7

13%

General management and administration

52.4

6%

43.1

5%

Other expenses

163.3

18%

146.8

18%

Expenditure

899.9

100%

812.9

100%

HOW WAS THE MONEY SPENT?

Net exchange gains/losses
Surplus/deficit

2011

2010

-1.6

2.1

-16.0

132.5

YEAR-END FINANCIAL
POSITION

2011
In millions of E

Percentage

Cash and cash equivalents

572.9

81%

600.9

84%

Other current assets

84.4

12%

71.1

10%

Non-current assets

49.6

7%

43.2

6%

706.9

100%

715.2

100%

2.5

0%

2.5

0%

Unrestricted funds

592.3

84%

608.1

85%

Other retained earnings and equities

16.1

2%

8.7

1%

Retained earnings and equities

610.9

86%

619.3

86%

96.0

14%

95.9

14%

706.9

100%

715.2

100%

Current liabilities
Liabilities and retained earnings

114 FACTS AND FIGURES

4.5
million2010

Percentage

Permanently restricted funds

89 %
9%
2%

private donors

In millions of E

AssetsPrivate income
Public institutional income
Other income

IncomeExpenditure
Deficit

885.5
899.9
-16.0

Activity Report 2011

HR STATISTICS
Medical pool

2011
1,734

27%

2010
1,672

25%

Nurses and other paramedical pool

1,935

30%

2,002

31%

Non-medical pool

2,707

43%

2,887

44%

International departures (full year)

6,376

100%

6,561

100%

No. staff

Percentage

No. staff

Percentage

Locally hired staff

29,302

86%

25,18585%

International staff

2,580

8%

2,465

8%

Field positions

31,882

94%

27,650

93%

2,062

6%

1,907

7%

33,944100%

29,557100%

Positions at headquarters
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 2011, 89 per cent of MSF’s income
came from private sources. More than 4.5 million individual donors
and private foundations worldwide made this possible. Public
institutional agencies providing funding to MSF included, among
others, the European Commission’s Humanitarian Aid Department(ECHO) and the governments of Belgium, Canada, Denmark,Germany, 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
from headquarters directly allocated to the field (indirect costs).
Social mission costs represent 82 per cent of total costs for 2011.

Locally hired staff
International staff
Headquarters staff

86%
8%
6%

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 iscompulsory for certain sections of MSF.
Unrestricted funds are unspent, non-designated donor funds
expendable at the discretion of MSF’s trustees in furtherance of
our social mission.
Other retained earnings represent foundations’ capital as well as
technical accounts related to the combination process.
MSF’s retained earnings have been built up over the years bysurpluses of income over expenses. At the end of 2011, theavailable portion (excluding permanently restricted funds andcapital for foundations) represented 8.1 months of the preceding
year’s activity. The purpose of maintaining retained earnings is
to meet the following needs: future major emergencies for which
sufficient funding 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 thepre-financing of operations to be funded by forthcoming publicfundraising campaigns and/or public institutional funding.
The complete Financial Report is available at www.msf.org

FACTS AND FIGURES 115

Médecins Sans Frontières

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116 Contact MSF

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About this report
Contributors
Halimatou Amadou, Louise Annaud, Nagham Awada, Valérie Babize, Aurélie Baumel,
Niklas Bergstrand, Andrea Bussotti, Jehan Bseiso, Brigitte Breuillac, Talia Bouchouareb,
Natacha Bühler, Lali Cambra, Lorna Chiu, Silvia Fernández, Isabelle Ferry, Marisol Gajardo,
Diderik van Halsema, Sarah-Eve Hammond, Carolina Heidenhain, Maimouna Jallow,
Julia Kourafa, Jo Kuper, Aurélie Lachant, Yann Libessart, Eddy McCall, Scotti McLaren,
Sally McMillan, Robin Meldrum, Isabelle Merny, Simon Petite, Yasmin Rabiyan,
Catherine Robinson, Ricardo Rubio, Nihal Shafik, Ewald Stals, Clara Tarrero,
Véronique Terrasse, Victoria Russell, Gregory Vandendaelen, Wyger Wentholt.
Special thanks to
François Dumont, Myriam Henkens, Aloïs Hug, Unni Karunakara, Erwin van ’t Land,
Caroline Livio, Kris Torgeson, 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 Rachel McKee
Photo Editor Bruno De Cock
Proof Reader Kristina Blagojevitch
French Edition
Translator Translate 4 U sàrl ( Aliette Chaput, Emmanuel Pons )Editor Laure Bonnevie
Italian Edition
Coordinator Marina Berdini
Translator Selig S.a.S.
Editor Marina Berdini
Spanish Edition
Coordinator Aloïs Hug
Translator Pilar Petit
Editor Eulàlia Sanabra
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 affectedby armed conflict, epidemics, exclusion from healthcare and natural
disasters. MSF offers assistance to people based on need and irrespectiveof 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 ofhealth professionals, logistical and administrative staff manage projects
in more than 60 countries worldwide. MSF International is basedin 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, Email: info@msf.org
COVER PHOTO
Doctors examine a young boy at Guiglo hospital, Ivory Coast.
© Panos Pictures