International
Activity
Report 2014www.msf.org

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

The country texts in this report provide descriptive overviews of MSF’s operational activities throughout theworld between January and December 2014. Staffing figures represent the total full-time equivalent positions
per country in 2014.
Country summaries are representational and, owing to space considerations, may not be comprehensive.
For more information on our activities in other languages, please visit one of the websites listed on p.92.
The place names and boundaries used in this report do not reflect any position by MSF on their legal status.
Some patients’ names have been changed for reasons of confidentiality.

contents

contents
2

MSF programmes Around The World

4	The Year in Review
Dr Joanne Liu, International President
Jérôme Oberreit, Secretary General4

The year in review

8	Overview Of activities
10	Glossary of Diseases and activities
14	Syria: For every patient we could see, there were
thousands we could not
16

Surviving Ebola

18	Over a decade of operational research in MSF:
from luxury to necessity?

14 S yria: For every patient we could see, there
were thousands we could not20	MSF’s Access Campaign in 201421

activities by country

88

Facts and figures

92	Contact Médecins Sans Frontières
16 Surviving Ebola

18 O
 ver a decade of operational researchin MSF: From luxury to necessity?

21 Activities by country

International Activity Report 2014 1

msf programmes around the world

msf programmes
around the world

UkraineserbiaItaly

Bulgaria

Georgia
Armenia
TurkeyGreecesyria
Lebanon
Palestine

Iraq
JordanLibya
EGYPT
MexicoMauritania

Haiti

Mali

Niger

Honduras

Sudan

Chad
guinea-buissau

GuineaSierra Leone
liberia
Colombia

Yemen

Burkinafaso
Côte
d’Ivoire

Nigeria

Cameroon

CentralAfricanRepublic

Ethiopia

south
Sudan
UgandaKenya
Democratic
Republic of
Congo

BurundiMalawi
Bolivia
Zimbabwe

Madagascar
Mozambique

SwazilandSouth
Africa2 Médecins Sans Frontières

Lesotho22	Afghanistan

54	Lebanon

24	Armenia

56	Kyrgyzstan

24

Bolivia

56	Lesotho

25

Bangladesh

57	Libya

26

Bulgaria

57	Madagascar

26

Burkina
Faso

58

27

Burundi27	Cambodia
28 	Cameroon
29	China
RussianFederation

Uzbekistan

Kyrgyzstan

Democratic People’s
Republic of Korea

Tajikistan

Iran29 	Côte
d’Ivoire

China
Afghanistan

Pakistan
India

Bangladesh
MyanmarCambodia

Philippines

60	Malawi
61	Mali
62	Mauritania
62	Mexico
63	Myanmar
64	Niger

30	Central
AfricanRepublic

66	Nigeria

32	Chad

70	Palestine

34	Colombia

71	Philippines

35	Democratic
People’sRepublicof Korea

72	Mozambique

35	Egypt

73	RussianFederation

36	Democratic
Republicof Congo

73	Serbia

38	Ethiopia

Papua
New Guinea

liberia

68	Pakistan

72	Papua New
Guinea74	Sierra Leone

40	Georgia

76	SouthAfrica40	Greece

77	Tajikistan

41	GuineaBuissau

77	Turkey

41	Honduras

78	SouthSudan

42	Guinea

80	Sudan

44	Haiti

81	Swaziland

46	India82	Syria

48	IRAQ

84 	Uganda

50	Iran84 	Uzbekistan

50	Italy

85	Ukraine

51

86	Yemen

Jordan52	Kenya87	Zimbabwe

the year in review

the yearin review
Dr Joanne Liu, International President
Jérôme Oberreit, Secretary General

In 2014, the largest Ebola
outbreak in history struck West
Africa, the number of displaced
people in the world exceeded
50 million and the war in Syria
entered its fourth year.

MSF and Ministry of Health staff were faced

elderly, people with disabilities and the sickwith the probability that at least 50 per

were often unable to escape to safety; and ascent of their patients would die from thehigh-income countries turned their attention

disease, and that there was no treatment

ever inward, people in desperate need foundthemselves largely forgotten.

Fighting Ebola in West Africa
When the Ebola outbreak was officiallydeclared on 22 March 2014 in Guinea, no
one could have foreseen the extent of thesuffering that would ensue. By the end ofavailable. They worked daily with the fearof contracting Ebola themselves. As thenumber of cases grew, the time available tospend with each patient became increasingly
limited and sometimes there were notenough staff members to care safely for the
sick. Impossible compromises had to be
made, such as turning people away at thegates. An MSF anthropologist in Liberia,

the year, the disease had claimed almost

Pierre Trbovic, told of turning away a father

8,000 lives in West Africa, including those

who had brought his sick daughter in theof 13 MSF employees.

boot of his car: “He was an educated man,
© Sylvain Cherkaoui/Cosmos

Médecins Sans Frontières (MSF) deployedteams to work in simultaneous emergency
situations across the globe, from Liberia
to South Sudan, from Ukraine to Iraq.
The common thread this year was one ofabandonment: the sheer number of Ebola
sufferers meant that at the height of theepidemic, many were left to die on their own,

stripped of their dignity; in conflict zones the

The relief is palpable as an MSF nurse removes her personal protective equipment (PPE) in the undressing area of an Ebola management
centre in Guinea.

4 Médecins Sans Frontières© MSFthe year in review

These civilians in the Sinjar mountains are escaping after days under siege. Tens of thousands of people crossed into Syria in August,heading for the relative safety of northern Iraq.

and he pleaded with me to take his teenage

remains unknown about the virus. Before

there are zero cases in a region for a perioddaughter, saying that whilst he knew wethis outbreak it had never been consideredof 42 days.

couldn’t save her life, at least we could savea priority for research by big pharmaceutical

the rest of his family from her.” People diedcompanies as it was perceived as affecting

The conflicts in Syria and Iraq

alone, in the rain, at the side of the road, in

only a limited number of economically

Another major challenge for MSF this year

front of the Ebola centre’s gates. The horror

disadvantaged patients in short-lived

was gaining access to people in need ofthat those living and working in West Africa

outbreaks in remote locations in Africa. In

have been through in the last year cannot be

August, MSF made the decision to partner

medical care. Due to bureaucratic, politicaladequately put into words.

with research institutions, the WHO,
ministries of health and pharmaceutical

The cross-border geographical spread ofcompanies to trial experimental treatments

this Ebola epidemic had never been seen

and vaccines during the outbreak. The first

before and, as the previous outbreaks had

trial began at MSF’s centre in Guéckédou inbeen much smaller, the number of people

Guinea on 17 December.

with experience of dealing with the diseaseor security issues – or a combination of all
three – in countries such as Libya, Nigeria,
Sudan, Mali and Myanmar, we were forced
to reduce or even in some cases end ourprogrammes. As a consequence, we are now
re-evaluating how we work in some contexts.
Syria is a good case in point. On 2 January,
five MSF staff members were taken hostage

was limited. The main problem, though,A practical plan to sustain research andwas that there was simply not enoughdevelopment for vaccines, treatments

political will to combat Ebola. It wasn’t untiland diagnostic tools must be developed.

8 August – months too late – that the WorldThe events of the past year have shown

Health Organization (WHO) at last declared

how the world is failing vulnerable people

the outbreak “a public health emergency of

in developing countries, many of whominternational concern” and that funding andwill never have the money to buy the

manpower were unlocked. However, themedicines they need. Effective research andaid provided was still insufficient and on

development that is not driven by economic

2 September, MSF appealed to the UN member

gain will be key to protecting people instates in New York for more help, including the

remote areas from resurgences and futurefrom the leaders that our teams will not be

deployment of civilian and military assets withoutbreaks of Ebola and other deadly diseases.

harmed. Furthermore, we still do not haveby ISIS (since renamed the Islamic State; IS)
in northern Syria, despite agreements withlocal commanders that we would be allowed
to work unhindered. Three staff members
were released in April and a further two inMay. The abduction led to MSF withdrawing
from IS-controlled areas, and although local
commanders have requested our return,
we are unable to do so without guarantees

the government’s permission to work in theexpertise in biohazard containment.
Late in 2014, the number of Ebola cases

areas that it controls, and we struggle to

Although MSF has learned a lot about thebegan to decline but the epidemic is notprovide substantial direct medical support

way Ebola behaves inside the body, much

yet behind us. An outbreak is not over until

to civilians countrywide. Nevertheless, MSF

International Activity Report 2014 5

© Michael Goldfarb/MSF

the year in review

The hospital in Leer, South Sudan, after the building had been ransacked and set alight. It was the only specialist healthcare facility inUnity state.

still runs some health facilities in the country

trying to escape conflict zones, and arerunning additional projects for Central

and supports networks of dedicated Syrian

searching for protection and a better life.

African refugees in neighbouring countries.

medical staff who often work in extremely

As safe channels become scarcer and land

However, staff and patient safety in CAR

hazardous conditions. This support, whileborders are sealed, asylum seekers, migrants

has remained an issue. On several occasions

valuable, is only possible in a few locations

and refugees have little option but to takearmed groups entered hospitals and MSF

and falls far short of meeting the massive

to the sea. It is estimated that at least 3,500

needs that medical teams inside Syria face.

staff had to physically protect patients,

people drowned close to European shores

shielding them from attack.

in 2014, many of them from Syria, Eritrea orMillions of people have fled the conflict in

sub-Saharan Africa. MSF has been working

Syria, many going to Jordan and Lebanon

This lack of respect for the medical mission

with asylum seekers, migrants and refugees

where MSF has projects which treat thein countries such as Greece, Bulgaria,

was not limited to CAR. In South Sudan, forwar-wounded and try to relieve some of

Italy, Serbia and Egypt, providing medical

the pressure on the host communities andconsultations and psychosocial support, andinfrastructure. A large number of Syrian

distributing relief kits.

refugees have also travelled to Iraq, which

example, patients were shot in their beds,
wards were burned to the ground, medical
equipment was looted and, in one case, anentire hospital – in Leer – was completely
destroyed. It will take months or even years

as the conflict between the Iraqi army andLack of respect for the
medical mission

armed opposition groups intensified. Over

Once again this year we have had to

Hundreds of thousands of people are

the course of the year nearly two million

consider the question of what to do wheneffectively being denied lifesaving assistancepeople left their homes in search of safety.

MSF employees, healthcare facilities andby acts such as these.

Shelling, air strikes and fighting prevented

patients are threatened or attacked. In thehumanitarian organisations from accessing

Central African Republic (CAR), 19 people,

Our Congolese colleague, Chantal, waspeople desperately in need of medical

including three Central African MSF staff

reunited with her family this year after being

supplies, food and water.

members, were killed in April during an

abducted by an armed group in July 2013,

armed robbery in the grounds of an MSF

but Philippe, Richard and Romy are still

At least half the people boarding

hospital in Boguila. MSF doubled its medical

missing and our thoughts go out to theirunseaworthy boats bound for Europe areassistance in CAR in 2014 and started

families and friends.

itself experienced an upsurge in violence

6 Médecins Sans Frontières

to rebuild what took only hours to destroy.

the year in review

Supporting hospitals in Palestineand Ukraine
When the conflict reignited between Israel
and Palestine in mid-2014, MSF supported
Al Shifa hospital with a full surgical team andemergency medical equipment, and madedonations from its emergency stocks to thecentral pharmacy. Normally teams work on a
fly-in/fly-out basis but a rise in the number ofcasualties led MSF to establish an emergency
surgical team in Gaza between July and
September to perform lifesaving operations.
A permanent reconstructive surgery team
was present until December.
Conflict also affected Europe this year, as
the political protests that started in Ukraine
in late 2013 gained momentum, leading
to violent clashes between police andprotestors, the removal of the president
from power, and, in May, fighting between
armed separatist groups and Ukrainian
government forces. Medical supply lines
were severely disrupted or cut completely,and health facilities’ budgets were soon

Tackling illnesses such as malaria,
tuberculosis (TB) and HIV
In addition to responding to emergencies
this year, MSF teams continued to tackle
diseases such as TB and HIV/AIDS in a
number of countries, including Uzbekistan,South Africa, Cambodia and India. Whencholera cases in Haiti spiked in October,
MSF set up treatment centres, distributed
disinfection kits and implemented awarenessand education activities. In Niger, incollaboration with other organisations, teams
worked to reduce under-five mortality, witha particular focus on children with severe
malnutrition and malaria. Our programmes
also looked at ways of improving treatment
protocols and models of care, for example
by supporting community adherence
clubs and expanding viral load testing.
From treating kala azar in South Sudan toproviding comprehensive care for victims ofsexual violence in Honduras, MSF worked insome of the most challenging environments
around the world in 2014.

Looking forward
The Ebola crisis highlighted global failuresin the humanitarian aid and health systems,
which had been present for years but had
never before been so evident. What struck
MSF most strongly this year, however,were the lack of global leadership and thereticence of those in power to engage inthe Ebola response. We were vocal about
this, but ultimately MSF is a patient-focusedorganisation and our attention remains
primarily on those in need of medical careand not on overhauling global systems.
MSF concentrates on individuals and weare constantly striving to provide assistanceto those who need it most. Our role is tosave patients’ lives, today, and we respondto crises with that at the forefront of ourminds. We could not work in this way
without our supporters and our teams
around the world. We want to take thisopportunity to thank you all.

© Felco Calderinexhausted. As the conflict spread andintensified, MSF dramatically increased its
support, and by the end of the year had
provided enough supplies to treat morethan 13,000 wounded patients in hospitals
on both sides of the frontline.

An MSF counsellor talks to a truck driver about HIV testing, as part of the new ‘corridor project’ rolled out in the high-transit cities ofTete and Beira, Mozambique.

International Activity Report 2014 7

overview of activities

Overview ofactivities
Largest country programmes
based on project expenditure

Project locations
Number of projects

1. South Sudan

6. Afghanistan

Africa240

Americas20

2. Democratic Republicof Congo

7. Niger

Asia*

55

Europe16

8. Liberia

Middle East

47

Pacific

6

3. Central African Republic

9. Ethiopia

4. Haiti

10. Iraq

Asia

5. Sierra Leone

AfricaThe total budget for our programmes in these 10 countries
is 380.5 million euros, 54 per cent of MSF’s operational budget.

14%

Middle East

63%

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

3,996

2. Democratic Republic of Congo

2,999

3. Central African Republic

2,593

4. Haiti

2,159

5. Niger

1,866

12%

Americas5%Europe4%

Pacific2%* Asia includes the Caucasus

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

Context of intervention
Number of projects

1. Democratic Republic of Congo

1,593,800

2. Central African Republic

1,401,800

3. South Sudan

936,200

4. Niger

508,300

5. Ethiopia

347,700

6. Kenya

333,400

7. Afghanistan

306,600

8. Pakistan

279,900

9. Chad257,200

10. Sudan

246,900

Stable157

Armed conflict

120

Internal instability

86

Post-conflict

21

41%
Stable8 Médecins Sans Frontières

31%
Armed
conflict

22%
Internal
instability

6%

Postconflictoverview of activities

2014 activity highlights
8,250,700

outpatient consultations

194,400

32,70081,70046,900

women delivered
babies, including
caesarean sections

group
counsellingor mental
health sessions

511,800

patients admitted

2,114,900
cases of malaria
treatedmajor surgicalinterventions,
including obstetricsurgery, under generalor spinal anaesthesia

people treatedfor cholera

ORAL
REHYDRATIONSOLUTION

1,513,700

people vaccinatedagainst measles in
response to an outbreak

217,900

severely malnourishedchildren admitted to
inpatient or outpatient
feeding programmes

229,900

HIV patients registeredunder care at the endof 2014

11,200patients medicallytreated for sexual
violence

33,70021,50075,100patients on
tuberculosis
first-line treatment

people treatedfor measles

people vaccinatedagainst meningitis in
response to an outbreak

7,400
218,400

patients on first-line
antiretroviral treatment
at the end of 2014

8,100

patients on second-line
antiretroviral treatment
at the end of 2014
(first-line treatment failure)

1,800

patients on MDR
tuberculosis
treatment, secondline drugs

185,700
individual
mental healthconsultations

peopleadmitted
to Ebola management centresin the three main West Africancountries, of which 4,700 wereconfirmed as having Ebola

2,200

peoplerecovered from
Ebola and discharged
from management centres

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

International Activity Report 2014 9

glossary of diseases and activities

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 transmitted by triatomine bugs,
which live in cracks in the walls and roofs
of mud and straw housing. It can also betransmitted through blood transfusions
or to the foetus during pregnancy, and,less frequently, through organ transplants.
Symptoms are rare in the first, acute stageof the disease and if they do appear they are
mild. Then the chronic stage is asymptomaticfor years. Ultimately, however, debilitatingcomplications develop in approximately
30 per cent of people infected, shortening
life expectancy by an average of 10 years.
Heart complications such as heart failure,arrhythmia and cardiomyopathy are themost common cause of death in adults.
Diagnosis is complicated, requiring laboratory
analysis of blood samples. There are currently
only two medicines available to treat thedisease: benznidazole and nifurtimox, whichwere both developed over 40 years ago.
The cure rate is almost 100 per cent in
newborns and infants and in acute cases,
but as the gap between the date of infection
and the beginning of treatment lengthens,
the cure rate declines.
The treatment currently used can be toxic
and can take longer than two months tocomplete. Despite the clear need for more
efficient and safer medication, there are few
new drugs in development.

CholeraCholera is a water-borne, acute gastrointestinal
infection caused by the Vibrio cholerae bacterium.
It is transmitted by contaminated water or food,or through direct contact with contaminatedsurfaces. In non-endemic areas, large outbreaks
can occur suddenly and the infection can spread
rapidly. Most people will not get sick or will suffer
only a mild infection, but the illness can be very
severe, causing profuse watery diarrhoea and

10 Médecins Sans Frontières

vomiting that can lead to severe dehydrationand death. Treatment consists of a rehydration
solution – administered orally or intravenously –which replaces fluids and salts. Cholera is mostcommon in densely populated settings where
sanitation is poor and water supplies are not safe.
As soon as an outbreak is suspected, patientsare treated in centres where infection control
precautions are taken to avoid furthertransmission of the disease. Strict hygiene
practices must be implemented and large
quantities of safe water must be available.
MSF treated 46,900 people for cholera
in 2014.

Ebola
Ebola is a virus that is transmitted through directcontact with blood, bodily secretions, organs
and infected people. Ebola first appeared in 1976
and, although its origins are unknown, bats are
considered the likely host. MSF has intervened inalmost all reported Ebola outbreaks in recent years,
but until 2014 these were usually geographicallycontained and involved more remote locations.
Ebola has a mortality rate of between 25 and 80
per cent, and as there is currently no vaccine ortreatment for the virus patient care is centred on
hydration and treating the symptoms such as feverand nausea. Ebola starts with flu-like symptoms,
followed by vomiting and diarrhoea and in somecases haemorrhaging and often death. Despite
being so deadly, it is a fragile virus that can be killedeasily with sunshine, heat, bleach, chlorine andeven soap and water.
Preventing transmission is essential: patients aretreated in Ebola management centres wherestrict infection control procedures are in force.
Identifying people the patient was in contact
with when they were ill becomes a priority, as dosafe burials. Community health promotion is also
undertaken to inform the community about thethreat and how to try and keep themselves safe
and what to do if they develop signs.
In 2014 MSF admitted 7,400 people toEbola management centres in the threemain West African countries, of which
4,700 were confirmed as having Ebola.

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

HIV/AIDS
The human immunodeficiency virus (HIV)is transmitted through blood and body
fluids and gradually breaks down the
immune system – usually over a threeto 15-year period – leading to acquired
immunodeficiency syndrome, or AIDS. As thevirus progresses, people begin to suffer from
opportunistic infections. The most common
opportunistic infection that (often) leads todeath is tuberculosis.
Simple blood tests can confirm HIV status, butmany people live for years without symptoms
and may not know they have been infected.
Combinations of drugs known as antiretrovirals(ARVs) help combat the virus and enablepeople to live longer, healthier lives without
their immune systems deteriorating rapidly.
ARVs also significantly reduce the likelihood of
the virus being transmitted.
As well as treatment, MSF’s comprehensive
HIV/AIDS programmes generally include
education and awareness activities, condom
distribution, HIV testing, counselling andprevention of mother-to-child transmission(PMTCT) services. PMTCT involves theadministration of ARV treatment to the motherduring and after pregnancy, labour andbreastfeeding, and to the infant just after birth.
MSF provided care for 229,900 people
living with HIV/AIDS and antiretroviraltreatment for 226,500 people in 2014.

© John Moore/Getty Images

glossary of diseases and activities

A health worker washes their hands in chlorinated water, whilst removing protective clothing after an hour-long shift in the high risk area of
MSF Ebola management centre in Paynesville, Liberia.

Kala azar (visceral leishmaniasis)
Largely unknown in high-income countries(although it is present in the Mediterraneanbasin), kala azar – Hindi for ‘black fever’ –is a tropical, parasitic disease transmitted
through bites from certain types of sandfly.
It is endemic in 76 countries, and of theestimated 200,000–400,000 annual cases,
90 per cent occur in Bangladesh, India,
Ethiopia, South Sudan, Sudan and Brazil. Kalaazar is characterised by fever, weight loss,
enlargement of the liver and spleen, anaemia
and immune-system deficiencies. Without
treatment, kala azar is almost always fatal.
In Asia, rapid diagnostic tests can be used todetect the disease. However, these tests are
not sensitive enough for use in Africa, where
diagnosis often requires microscopic examinationof samples taken from the spleen, bone marrowor lymph nodes. These are invasive and difficult
procedures requiring resources that are notreadily available in developing countries.
Treatment options for kala azar have evolved
during recent years. Liposomal amphotericin B
is becoming the primary treatment in Asia,
either alone or as part of a combination therapy.
This is safer and involves a shorter course oftreatment than previously used medication.
However, it requires intravenous administration,
which remains an obstacle to its use in local

clinics. In Africa, the best available treatment isstill a combination of pentavalent antimonials
and paromomycin, which is toxic and requires
a number of painful injections. Research into a
simpler treatment is underway and it is hoped
it will soon be available.
Co-infection of kala azar and HIV is a major
challenge, as the diseases influence each otherin a vicious spiral as they attack and weaken the
immune system.
MSF treated 9,500 patients for kala azar
in 2014.

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

Long-lasting insecticide-treated bed nets are
an important means of controlling malaria.
In endemic areas, MSF distributes nets topregnant women and children under the ageof five, who are the most vulnerable and havethe highest frequency of severe malaria. Staff
advise people on how to use the nets.
In 2012, MSF used a seasonal chemoprevention
strategy for the first time, in Chad andMali. Children up to five years old took oral
antimalarial treatment monthly over a period
or three to four months during the peakseason for the disease.
MSF treated 2,114,900 people for malaria
in 2014.

Malnutrition
A lack of food or essential nutrients causes
malnutrition: children’s growth falters andtheir susceptibility to common diseases
increases. The critical age for malnutrition isfrom 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.
continued overleaf

International Activity Report 2014 11

glossary of diseases and activities

Glossary of diseases and activities continued
Global malnutrition in children is usuallydiagnosed in two ways: it can be calculated
from measurements 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 stop theircondition from deteriorating further.
MSF admitted 217,900 malnourishedchildren to inpatient or outpatient feeding
programmes in 2014.

Measles
Measles is a highly contagious viral disease.
Symptoms appear between eight and 13 days
after exposure to the virus and include a runnynose, cough, eye infection, rash and high fever.
There is no specific treatment for measles –patients are isolated and treated with vitamin A,
and for any complications: these can include
eye-related problems, stomatitis (a viral mouth
infection), dehydration, protein deficiencies
and respiratory tract infections.
In high-income countries, most people infectedwith measles recover within two to three weeks,
and mortality rates are low. In developing
countries, however, the mortality rate can be
between 3 and 15 per cent, rising to 20 per
cent where people are more vulnerable. Death isusually due to complications such as diarrhoea,
dehydration, severe respiratory infection or
encephalitis (inflammation of the brain).
A safe and cost-effective vaccine against
measles exists, and large-scale vaccination
campaigns have significantly decreased
the number of cases and deaths. However,
coverage remains low in countries with weak
health systems and in areas where there islimited access to health services, leaving large
numbers of people susceptible to the disease.
MSF treated 33,700 patients for measles
and vaccinated 1,513,700 people inresponse to outbreaks in 2014.

Meningococcal meningitis
Meningococcal meningitis is a bacterial
infection of the thin membranes surrounding
the brain and spinal cord. It can cause

12 Médecins Sans Frontières

sudden and intense headaches, fever, nausea,
vomiting, sensitivity to light and stiffness ofthe neck. Death can follow within hours of
the onset of symptoms. Up to 50 per cent ofpeople infected will die without treatment.

as kits. For example, 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.

Six strains of the bacterium Neisseria
meningitidis (A, B, C, W135, X and Y) are
known to cause meningitis. People can be
carriers without showing symptoms andtransmit the bacteria when they cough orsneeze. Cases are diagnosed through theexamination of a sample of spinal fluid andtreatment consists of specific antibiotics.
However, even with treatment, 10 per centor more patients will die and as many as one
in five survivors may suffer from after effects,
including hearing loss and learning disabilities.

Where people are without shelter, andmaterials are not locally available, MSF
distributes emergency supplies – such as ropeand plastic sheeting or tents – with the aimof ensuring a shelter. In cold climates more
substantial tents are provided, or teams try
to find more permanent structures.

Meningitis occurs throughout the world,
but the majority of infections and deaths are
in Africa, particularly across the ‘meningitis
belt’, an east–west geographical strip from
Ethiopia to Senegal, where epidemics aremost likely to be caused by meningococcus A.
A new vaccine against this strain provides
protection for at least 10 years and evenprevents healthy carriers from transmitting
the infection. Large preventive vaccination
campaigns have now been carried out in
Benin, Burkina Faso, Cameroon, Chad,
Ghana, Mali, Niger, Nigeria, Senegal andSudan and have resulted in a decrease in
the number of new cases.
MSF vaccinated 75,100 people against
meningitis in response to outbreaks in 2014.

Mental healthcare
Traumatising events – such as suffering or
witnessing violence, the death of loved onesor the destruction of livelihoods – are likely
to affect a person’s mental wellbeing. MSF
provides psychosocial support to victims of
trauma in an effort to reduce the likelihoodof long-term psychological problems.
Psychosocial care focuses on supporting
patients to develop their own coping strategies
after trauma. Counsellors help people totalk about their experiences and process
their feelings so that general stress levels are
reduced. MSF also offers group counselling,which is a complementary approach.
MSF staff held 218,400 individual and groupmental health sessions in 2014.

Relief items distribution
MSF’s primary focus is on providing medicalcare but, in an emergency, teams often
organise the distribution of relief items thatare essential for survival. Such items include
clothing, blankets, bedding, shelter, cleaningmaterials, cooking utensils and fuel. In many
emergencies, relief items are distributed

MSF distributed 52,200 relief kits in 2014.

Reproductive healthcare
Comprehensive neonatal and obstetric careform part of MSF’s response to any emergency.
Medical staff assist births and perform
caesarean sections where necessary andfeasible, and sick newborns and babies with a
low birth weight receive medical care.
Many of MSF’s longer-term programmes
offer more extensive maternal healthcare.
Several antenatal visits are recommended
so that medical needs during pregnancy are
met and potentially complicated deliveries
can be identified. After delivery, postnatal
care includes medical treatment, counsellingon family planning and information andeducation on sexually transmitted infections.
Good antenatal and obstetric care canprevent obstetric fistulas. An obstetric fistulais a hole between the vagina and rectumor bladder that is most often a result of
prolonged, obstructed labour. It causes
incontinence, which can lead to social stigma.
Around two million women are estimated tohave untreated obstetric fistulas; there are
between 50,000 and 100,000 new cases eachyear. A number of MSF programmes carry out
specialist obstetric fistula repair surgery.
MSF held more than 665,400 antenatal
consultations in 2014.

Sexual violence
Sexual violence occurs in all societies and in allcontexts at any time. Destabilisation of contexts
often results in increased levels of violence,
including sexual violence. Sexual violence isparticularly complex and stigmatising and has
long-lasting consequences and can result in
important health risks.
MSF medical care for victims of sexual violence
covers preventive treatment against sexuallytransmitted infections (including HIV, syphilis
and gonorrhoea) and vaccinations for tetanus
and hepatitis B. Treatment of physical injuries,
psychological support and the prevention andmanagement of unwanted pregnancy are alsopart of the systematic care. MSF provides a
medical certificate to all victims of violence.

glossary of diseases and activities

used, but it is costly and still requires a phlegm
sample, as well as a reliable power supply.
A course of treatment for uncomplicated TB
takes a minimum of six months. When patientsare resistant to the two most powerful first-line
antibiotics (isoniazid and rifampicin), they are
considered to have multidrug-resistant TB(MDR-TB). MDR-TB is not impossible to treat,
but the drug regimen is arduous, taking up
to two years and causing many side effects.
Extensively drug-resistant tuberculosis (XDR-TB)
is identified when patients show resistance to thesecond-line drugs administered for MDR-TB. The
treatment options for XDR-TB are very limited.

© Sami Siva

In 2014, MSF treated 21,500 patients for TB,
of which 1,800 for MDR-TB.

A patient co-infected with HIV and XDR-TB has her routine check-up at the MSF clinic in
Mumbai, India.

Medical care is central to MSF’s response tosexual violence, but stigma and fear may prevent
many victims from coming forward. A proactive
approach is necessary to raise awareness about
the medical consequences of sexual violence andthe availability of care. Where MSF sees large
numbers of victims – especially in areas of conflict– advocacy action aims to raise awareness among
local authorities, as well as the armed forces when
they are involved in the assaults.
MSF medically treated 11,200 patients forsexual violence-related injuries in 2014.

Sleeping sickness(human African trypanosomiasis)
Generally known as sleeping sickness, human
African trypanosomiasis is a parasitic infection
transmitted by tsetse flies which occurs
in sub-Saharan Africa. In its latter stage, it
attacks the central nervous system, causing
severe neurological disorders and death if left
untreated. More than 95 per cent of reported
cases are caused by the parasite Trypanosoma
brucei gambiense, which is found in westernand central Africa. The other 5 per cent of cases
are caused by Trypanosoma brucei rhodesiense,
which is found in eastern and southern Africa.
During the first stage, the disease is relatively
easy to treat but difficult to diagnose, as
symptoms such as fever and weakness are
non-specific. The second stage begins when
the parasite invades the central nervous systemand the infected person begins to showneurological or psychiatric symptoms, such as
poor coordination, confusion, convulsions andsleep disturbance. Accurate diagnosis of theillness requires a sample of spinal fluid.
Nifurtimox-eflornithine combination
therapy (NECT), developed by MSF, Drugs

for Neglected Diseases initiative (DNDi)
and Epicentre, is now the World HealthOrganization (WHO) 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 and caneven kill the patient. It is hoped that the newmolecules currently under clinical trial willlead to the development of a safe, effective
treatment for both stages of the disease thatcan be administered orally.
MSF admitted 330 patients for sleeping
sickness treatment in 2014.

Tuberculosis (TB)
One-third of the world’s population iscurrently infected with the TB bacillus but
they have a latent form of the disease andso have no symptoms and cannot transmit
it. In some people, the latent TB infection
progresses to acute TB, often due to a weak
immune system. Every year, about ninemillion people develop active TB and1.5 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 in theirlives. The disease most often affects the lungs.
Symptoms include a persistent cough, fever,weight loss, chest pain and breathlessness in
the lead-up to death. TB incidence is muchhigher, and is a leading cause of death, amongpeople with HIV.
Diagnosis of TB depends on a sputum or gastricfluid sample, which can be difficult to obtainfrom children. A new molecular test that cangive results after just two hours and detect acertain level of drug resistance is now being

Vaccinations
Immunisation is one of the most cost-effective
medical interventions in public health.
However, it is estimated that approximately
two million people die every year from diseases
that are preventable by a series of vaccines
recommended for children by organisations
such as the WHO and MSF. Currently, these are
DTP (diphtheria, tetanus, pertussis), measles, polio,
hepatitis B, Haemophilius influenzae type b (Hib),
pneumococcal conjugate, rotavirus, BCG(against TB), rubella, yellow fever and humanpapillomavirus – although not all vaccines arerecommended everywhere.
In countries where vaccination coverage is
generally low, MSF strives to offer routine
vaccinations for children under five whenpossible as part of its basic healthcare
programme. Vaccination also forms a key partof MSF’s response to outbreaks of measles,
yellow fever and, less frequently, meningitis.
Large-scale vaccination campaigns involveawareness-raising activities regarding thebenefits of immunisation as well as the set-up
of vaccination posts in places where people
are likely to gather. A typical campaign lasts
between two and three weeks and can reachhundreds of thousands of people.
MSF undertook 376,100 routine vaccinationsin 2014.

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

International Activity Report 2014 13

syria: for every patient we could see, there were thousands we could not

syria: FOR EVERY PATIENTWE COULD SEE, THERE
WERE THOUSANDS WE
COULD NOTSam Taylor

Inspired by the Arab Spring demonstrations that swept
through North Africa and the Middle East, similar antigovernment protests started in southern Syria in March 2011.
The government responded to the protests with force and thesituation deteriorated rapidly. Over the four years since then,the conflict has grown more complex, entrenched and divisiveand the situation for those people living in Syria is critical.
With multiple, shifting fronts, besieged
populations cut off from essential aid anda myriad of armed groups, Syria was oneof the most difficult countries in which
Médecins Sans Frontières (MSF) tried to workin 2014. Several projects were forced toclose and international staff were withdrawn,
subsequently making it even more difficultfor MSF to reach patients. Syria has recently
been referred to as the world’s worst
humanitarian crisis.

in activities. Since security guarantees
from high-level IS group leaders were notforthcoming, MSF made the difficult decision
to stop all activities in IS-controlled areas,
but continued to operate facilities in nongovernment areas outside the control of IS.
MSF was unable to open any medical projects
in areas under government control in 2014,

but continued to operate three hospitals in
the north, a specialist burns unit in Idlib andtwo other hospitals in Aleppo, all staffed by
Syrians. In addition, MSF was able to run two
facilities in the northeast of Syria.

Aleppo under barrel bombs
Aleppo is Syria’s second-largest city but yearsof war have brought its health system to its
knees, and thousands of medical workers
have fled or been killed. Throughout 2014,
the facilities in the city run by Syrian staff andmanaged at a distance by MSF international
teams continued to provide a wide range of
medical services to the trapped population
amid a dramatically worsening humanitariansituation. These included treatment for thedevastating injuries caused by barrel bombs:
unguided high-explosive devices that are

Working in northern Syria

All this changed in January, however, when
13 of MSF’s staff were abducted by the group
who call themselves the Islamic State (IS). Thisoccurred despite written and verbal security
guarantees from local members. Eight Syrian
staff were released shortly after being taken,
but five international MSF colleagues were
held for up to five months. This significantly
altered the way MSF operated inside northern
Syria and led to a considerable reduction

14 Médecins Sans Frontières© MSF

By the start of 2014, MSF had a significant
and well-established presence in the northof the country in areas not controlled by
the government. It had not been easy to
set up these facilities, but by working with
networks of dedicated Syrians, MSF was able
to gradually expand its operations. With six
MSF-run hospitals, six clinics, several mobile
clinics and around 60 international staff
members working alongside hundreds ofSyrian colleagues, teams were able to treat
a substantial number of patients in Idlib andAleppo governorates.

In Idlib governorate, MSF runs the only burns unit in northern Syria where people canget the specialist care they need, such as wound cleaning (debridement) and dressingchanges that are performed under anaesthesia.

© MSFsyria: for every patient we could see, there were thousands we could not

A burn being tended to by an MSF staff member in a clinic in northern Syria.

filled with scrap metal and then dropped fromhelicopters or airplanes. As the bombs cannot
accurately target military installations, civilians
often fall victim to them.
The appalling toll on health is not just a resultof traumatic injuries caused by the fighting,however, but also of the lack of access tobasic healthcare and treatment for chronic
diseases such as diabetes. Women are forced
to give birth in deplorable conditions, andmany people are suffering the severe mental
health repercussions of living in a conflictzone for years.
As elsewhere in the country the needs ofthe population greatly outstripped what
was offered by MSF and other humanitarianorganisations working in the area. To makematters worse, in July, at least six hospitals in
Aleppo – including one run by MSF – werebombed and either destroyed or damaged.

Essential medical support
Since the beginning of the conflict, MSF
has donated equipment to support medical
networks which continue to operate inextremely difficult situations throughout Syria;
this can be as simple as gauze for wounds, oras complex as full kits of drugs and materials
for operating theatres, including devices
needed for orthopaedic surgery.

Over time this support work has expanded
and now provides supplies to more than
100 field hospitals, health posts and clinics– facilities that without MSF help would
struggle to offer essential medical services.
The support provided by MSF is particularly
valuable in areas that are besieged bygovernment forces – places where, for up
to two years, there has been a blockade on
certain goods. Although clearly useful this
support falls far short of the needs that MSF
knows exist.

security guarantees for staff and no accessto areas controlled by the government, thissimply was not possible. Increased and direct
hands-on assistance will only be viable whenthe many armed groups, both governmentand opposition, show the political willingness
to respect and allow independent medical
humanitarian action. This willingness was notforthcoming in 2014, resulting in intolerable
levels of suffering for the Syrian people.
For more on MSF's work in Syria in 2014,see pp.82–83.

Throughout 2014, MSF should have beenrunning major projects in Syria, but with no

STAFF STORYDr S – a young surgeon working in an MSF-supported hospital in the east of Damascus“ Three years of non-stop surgery under tough circumstances – I have maxed out. I’ve had
enough of scenes of misery. I was on the phone recently with my surgery professor and hesaid: ‘Regardless of the operating conditions, your work during these three years matches
my whole 30 years’ experience as a doctor. You have reached retirement in just three
years.’ And indeed, every moment of every day I feel I have had enough, but we have noother choice. People here need us. They are in desperate need of all kinds of medical care,from the most simple to the most complicated. We cannot add another reason for thedeterioration of this already disastrous situation. Today, I am almost certain that, when
the war is over, I will quit medicine. Any human being would make that decision after
living through what I have lived through. I look forward to the end of this war. It has tostop, one day. Then, I can choose what to do. Only then will we be truly alive again.”International Activity Report 2014 15

surviving ebola

SURVIVING
EBOLA
December2013
6 December
Death of alleged“patient zero”
of the epidemic,
a two-year-old
Guinean child

March
2014

May
2014

22 March
Ebola outbreak isdeclared by the
Guinean authorities
27 March
The first cases are
officially reported inConakry, Guinea’s
capital
31 March
Liberia reports two
confirmed cases

In 2014, the Ebola virus
coursed rapidly throughLiberia, Guinea and Sierra
Leone in a geographicalspread never seen before.
An Ebola epidemic was declared on 22 March,and it soon became the largest in history.
Médecins Sans Frontières (MSF) launched an
unprecedented response to this exceptional
outbreak, and deployed thousands of staff
who treated one-third of all confirmed casesin West Africa.

June
2014
2 May
Despite a decreasein the number of
new patients, MSF
declares that “theepidemic is not over
and we must remain
vigilant”
26 MayWorld HealthOrganization(WHO) reports
the first casesand deaths in
Sierra Leone

region, leading MSF to issue a rare call at
the United Nations (UN) in September forthe mobilisation of international civilian andmilitary medical assets with biohazard capacity.
No one knows exactly how many people
have died due to the epidemic: not only
from Ebola but also from all the otherdiseases and ailments for which they wereunable to obtain treatment due to thecollapse of the health system.

July
2014

3 JuneMSF raises the alarm
about a “resurgenceof the Ebola outbreakin West Africa”
17 JuneCases are reported
in Monrovia,
Liberia’s capital
23 JuneThe outbreak has
become the worst on
record and MSF says
it is “out of control”
and calls for massive
resources

20 JulyFirst confirmed
case in Nigeria.
The outbreak isdeclared overon 20 October.
28 JulyFirst case isreported in
Freetown, Sierra
Leone’s capital

By the end of the year, the number of casesin the region had begun to decline but the
epidemic is still far from over. MSF teams
continue to run Ebola management centres
and are turning their attention to gaps inoutreach activities, such as surveillance,
contact tracing and social mobilisation.
For more on the Ebola intervention, see
Guinea (p.42–43), Liberia (p.58–59) and
Sierra Leone (p.76–77).

MSF teams had never before responded to an
outbreak of viral haemorrhagic fever on sucha scale: the countries affected were Guinea,
Liberia, Sierra Leone, Mali, Nigeria and Senegal,
in addition to an unrelated Ebola outbreak in
the Democratic Republic of Congo.
Despite sounding the alarm early on andcalling for help, MSF teams battled Ebola
for months in the face of a “global coalitionof inaction”. The virus spread wildly in the

16 Médecins Sans Frontières© Sylvain Cherkaoui/Cosmos

The vulnerability of healthcare workers to
Ebola is a double tragedy; the virus takes the
lives of the very people meant to tackle it.
Nearly 500 healthcare workers have diedof Ebola while thousands of others haverisked their lives to support patients andhelp control the outbreak. The Ebola
epidemic took a heavy toll on MSF staff:
27 became infected and 13 tragicallypassed away in 2014.

A nurse gives medication to a suspected Ebola patient in the high-risk zone of the Kailahun
management centre, Sierra Leone.

surviving ebola

2–5 AugustTwo international staff
from Samaritan’s Purse are
infected and transferredto the US for treatment.
Both are declared cured
on 21 August.

2 September
MSF’s International President, Dr Joanne
Liu, gives a speech to the UN member
states. She warns that the world is “losing
the battle against Ebola”.

8 August
WHO declares Ebola an“international publichealth emergency”

17 September
MSF confirms that a French nurse isinfected with Ebola. After treatment in
Paris, she is declared cured on 4 October.

August2014
12 August
WHO gives its cautious
approval to the use ofexperimental drugs andvaccines to treat Ebola
24 August
Democratic Republic ofCongo declares an Ebola
outbreak, believed to be
separate from the West
African epidemic. It isover by 21 November.
29 AugustSenegal reports its first
confirmed case. The
country is declared Ebola
free on 17 October.

September
2014

3 October
MSF starts distributing family
protection and disinfection
kits in Monrovia, Liberia. The
kits are designed to protect
those who have been incontact with infected people
and who cannot immediately
be transferred to an Ebola
management centre. MSF
calls them “an imperfectresponse to an unprecedented
epidemic situation”.
October
2014

13 November
MSF announces that it
will host trials for Ebola
treatments in three of its
management centres inWest Africa

November
2014

December
2014

18 September
Dr KP Jackson Naimah, an MSF doctorfrom Liberia, tells the UN Security Council
that MSF has reached its limits andappeals for international aid. The council
unanimously adopts Resolution 2177.
The epidemic is declared “a threat tointernational peace and security”.

23 OctoberMSF doctor Craig Spencer
tests positive for Ebola.
He is declared virus freeon 10 November.

10 December
Time magazine
names “The
Ebola Fighters” its
Person of the Year he first case isT
confirmed in Mali

25 September
In a speech to the UN, Dr Liu calls upon
member states to take immediate action,
not “outsourcing” their response but
supplying the required human and logisticalresources needed to tackle the outbreak

25 October
In Monrovia, Liberia,
MSF starts distributing
anti-malarial treatments

17 December
Favipiravir
trial starts in
Guéckédou,GuineaBy the end of
December, WHOreports 20,206
confirmed casesof Ebola and7,905 deaths

30 September
The Centers for Disease Control andPrevention in the US confirms that Liberiannational Thomas Duncan has Ebola. He is
the first patient to be diagnosed with thedisease outside of West Africa. He dies on
8 October.

STAFF STORYPATIENT STORY

Patrick Trye – Medical Coordinator Assistant, Freetown, Sierra Leone

Benetta Coleman,“ I have been working with MSF since 2008, and when I felt ill in September 2014 I went straight tothe staff clinic assuming I had malaria. When I did not respond to malaria treatment after 48 hours,
the medical coordinator decided that I should be taken to the case management centre (CMC)in Bo for further tests. Within 24 hours I was told my viral status. Though it was a terrifying time,
the system in place meant that there was no delay in initiating treatment before I started showing
serious signs and symptoms of Ebola. It would have been worse if I had gone through the free-tollcall system (117), as it could have taken more than 48 hours for the response team to arrive.

25 year old Ebola survivor

At the CMC, I was terrified to see people dying from a disease that I had just been diagnosed
with but I helped those around me for as long as I could. Soon though my strength started togive in to the effects of the virus – vomiting, diarrhoea, sore throat and massive weakness – andI quickly realised I could no longer stand on my own. My first instinct was to think ‘my turn togo has come, I am going to die’. I thought of my family … my committed wife who had always
been by my side, my lovely children and my old mother.
I cannot overemphasise the terrible moments I went through at the centre, but what added tomy agony is the memory of a female MSF colleague who was very hopeful she would survive
the illness. She explained that she had recovered from Lassa fever some years back and thatshe knew she would recover from Ebola too. Unfortunately, she died two days after telling me
this. It left me with a bitter taste.
For seven days my temperature remained high and at some points I refused my medication. But theclinicians at the CMC were relentless and courageous; they did not allow me to have my own way
and coaxed me to comply. I was given antibiotics for my sore throat, and when I felt very weak anddehydrated intravenous fluids and oral anti-nausea drugs. My appetite was gone and I could noteat. Ten days after admission though, I started responding to the treatment, my throat improved
and the diarrhoea and vomiting ceased. My appetite gradually returned, my body temperaturenormalised and I slowly regained my strength. On 23 October, I was finally pronounced Ebola free.
After six weeks of absolute rest, I realised I had an unfinished battle. I had seen many people
die in agony and I knew that my contribution to the fight against Ebola was needed now
more than ever. Complying with the medical coordinator’s advice I started work on a half-day
basis. I am delighted to have resumed my normal life.”“ Ebola destroyed my future. I am lonely,
helpless and hopeless. But I am grateful that I
still have life despite the loss, grief, helplessness
and hopelessness. I lost my son and myhusband. I lost 22 other family members
including my parents, siblings, nieces andnephews. I survived along with four nieces
and nephews who I am now caring for.
My four year old niece caught the virus firstand it quickly spread to the rest of the family– living in neighbouring buildings. It’s still amystery to me how she contracted Ebola.
Before this I was a happy woman living witha happy family. But Ebola stole my happinessand rendered me homeless. Today, I ama widow, an orphan and a grief stricken
mother. I had not imagined that my life
would turn out this way but this is the sadreality that I must confront. I must put thehorrible past behind me. Recovering from
Ebola has not been without after effects
and I continue to feel pains in my legs.
Just before Ebola struck my family, I had
passed into the 12th grade. I am not sure if
I will return to school, as my husband andmy parents were my main sponsors. I do
not have the financial means to support
myself and also care for the children …
My dreams have been shattered.”International Activity Report 2014 17

Over a decade of operational research in MSF: from luxury to necessity?

Over a decade of operational research in MSF:

from luxury tonecessity?

Contributors: Rony Zachariah, Tony Reid, Nathan Ford, Eric Goemaere, Marc Biot, Tom Ellman,
Roger Teck, Wilma van den Boogaard, Engy Ali, Marcel Manzi, Rafael Van den Bergh, Petros Isaakidis,
Mohammed Khogali, Walter Kizito, Tom Decroo, Laura Bianchi, Paul Delaunois, Bertrand Draquez
How is operational research defined?
From a Médecins Sans Frontières (MSF)
perspective, a pragmatic definition ofoperational research is “the search forknowledge on interventions, strategies
and tools that can enhance the quality or
performance of programmes”. Broadly
speaking, operational research is the‘science of doing better’ and often it isabout showing ‘what works’ and ‘what
does not work’ in the contexts where wehave projects in order to advocate forchange in a scientifically credible manner.

What can operational research achieve?
There are many stories illustrating the start ofoperational research in MSF, but perhaps themost powerful are linked to our early struggles in
sub-Saharan Africa with malaria and HIV/AIDS.
Malaria

MSF and one of its research arms – Epicentre– undertook efficacy studies in collaboration
with health ministries in the early 2000s
to evaluate national protocols. The patient
was proved correct – chloroquine treatment
had a failure rate of up to 91 per cent for
Plasmodium falciparum malaria, which is oneof the most common and the most deadly
form of the disease. Now guidelines could bechanged and alternatives implemented.
By giving this example, we are not seeking
to blame clinicians, who do the best they
can with limited resources. The story simply
illustrates why operational research is a vital
component in evaluating a programme, and© Marco Longari/AFP

In a hospital outpatient clinic in Mali in the
1990s, doctors treating malaria patients gavea prescription for chloroquine to a man who
complained that he had already taken the drug
several times in the past and it had not worked.

He asked for an alternative. At the time though,MSF was applying national protocols basedon WHO recommendations and chloroquine
was the only medicine available. National andinternational authorities considered the available
evidence of chloroquine resistance to be
insufficient to justify the economic consequencesof changing to more effective but costlier
treatments. Evidence needed to be gathered toprove that chloroquine was not working.

An HIV-positive patient is given a month’s supply of ARVs at the Thyolo district hospital, Malawi.

18 Médecins Sans Frontières

why it should be a routine part of any project
cycle. A culture of inquiry, combined with theapplication of scientific methods and peerreviewed publications, is essential for advocacy,
to show ‘what works’ and ‘what does notwork’, and to find practical solutions.
HIV/AIDS
In the late 1990s and early 2000s, MSF
witnessed first hand the toll HIV and AIDS
was taking on communities in lower-income
countries, and there was much internal debate
about whether or not MSF should get involved
with potentially lifesaving antiretroviral (ARV)
treatment provision. Western governments
considered that ARVs were too complex and too
expensive (US$10,000–15,000 per patient per
year at the time) and that Africa should focus onother health priorities. This was at a time whenmore than 25 million people in sub-SaharanAfrica were infected with HIV/AIDS, over 17
million had already died and many countries in
the region had been brought to their knees due
to HIV/AIDS-related illnesses and deaths.
The real problem for some, however, wasperception. To give an extreme example,
Andrew Natsios, the head of the UnitedStates Agency for International Development
during the George W. Bush administration,argued against funding ARVs in Africa in
an interview with the Boston Globe in June
2001. He said: “The problems extend to theAfricans themselves. They do not know what
watches and clocks are … they don’t knowwhat Western time is. You have to take thesedrugs at certain hours each day, or they
don’t work. And if you say, one o’clock in
the afternoon, they don’t know what you aretalking about.” Needless to say, his argument
was roundly rejected and some called for
his immediate resignation. The role ofoperational research in all this was to provide
proof to people who thought as he didthat they were wrong. Research conductedby MSF in Uganda, Kenya, South Africa,
Malawi and Thailand played a historicalrole in demonstrating the feasibility andeffectiveness of HIV treatment in resourcelimited settings. It also showed that access to
ARVs could transform HIV/AIDS from a death
sentence into a manageable chronic disease.

Over a decade of operational research in MSF: from luxury to necessity?

To what extent has the MSF Movement
embraced this science?

Context
in Monrovia, three clinics
offer care for survivors of
sexual violence

obServatIon on the fIeLd
Package of care is designed
for adult women, but manysurvivors are children and men
ImpaCt on the fIeLd• Development of guidelines for
managing minors affected bysexual violence• new terminology introduced
related to acts of sexual
violence• Discussion with partners:
how to access male survivors?

Original rese ar ch
Sexual violence inpost-conflict Liberia:
survivors and their care

QueStIon
how appropriate is the MsF
approach to sexual violencein this context?
Objective
to describe characteristics ofsurvivors and the pattern, themedical consequences andmanagement of sex violence
anSwerthe package of care is not
adapted to children and misses
out minors and male adults

dISSemInatIon• Publish in peer-reviewed journal• Present at conferences• available atwww.fieldresearch.msf.org
reCommendatIonS• adapt the current approach tobetter meet survivors’ needs• expand awareness andadvocacy programs• adapt terminology anddefinitions linked to sexual
violence

MSF advocacy, in close collaboration withactivist organisations for ARV price reductions(the price is now close to US$70 per patient
per year), spearheaded by operational
research, made pivotal contributions insteering the political momentum towards a
global increase in ARV provision.

Why is operational research
relevant for MSF?
Operational research allows MSF to improve
programme performance, help patients,
assess the feasibility of new strategies and/orinterventions and advocate policy change.

It also makes MSF accountable to its patients,
its donors and itself, and consequently
challenges the ‘business as usual’ approach.
Furthermore, operational research leads toimproved medical/scientific visibility andcredibility, raises awareness of the scientific
literature among field staff and facilitates
networking and partnerships with otherorganisations. It also brings synergistic
improvements to data collection, monitoring
and feedback, which is vital for credible medical
témoignage. Operational research using project
data acts thus as a scientific ‘witness’.

MSF has become an important international
contributor to health research through the
expansion of its research activities. This isreflected in the number of peer-reviewed
publications in which MSF work has featured,
which has increased from barely five, mainly
focused on HIV/AIDS, in 2000, to more than150 covering a range of subjects in 2014.
Since 2010, the MSF Field Research website(www.fieldresearch.msf.org), which archives
MSF-authored publications and makes themavailable for free, has had 430,000 downloads
from around the world. The world seems to be
increasingly interested in the operational research
work done by MSF and we are clearly providing
information that people are actively seeking.
MSF has created operational research
fellowships, participated in international
scientific conferences, established an Ethics
Review Board, developed an institutional
position on supporting open (free) access topublications, launched an innovation fundand set up research registries. MSF has also
been a pioneering partner in developinga WHO-accredited course that is seen as a
blueprint for increasing operational researchin 70 low- and middle-income countries. This
intervention should result in more relevant
operational research being conducted, better
implementation of health programmes andultimately, more lives saved.
Integrating operational research into its
operations has helped MSF to improve
programme effectiveness, provided evidence
for advocating on behalf of patients at risk
and contributed to the growth of research
capacity worldwide. Rather than a luxury,
operational research undertaken by MSF units
such as LuxOR (Luxembourg), SAMU (South
Africa), the Manson Unit (United Kingdom),
Epicentre (France) and BRAMU (Brazil) is avital component of effective humanitarian aid.

Three examples of operational research studies published by MSF and their contributions to policy and practice:Operational research study'Improving performance of medical interventions'
Tayler-Smith K, Zachariah R, Hinderaker SG, Manzi M,
De Plecker E, Van Wolvelaer P, et al. Sexual violence inpost-conflict Liberia: survivors and their care. Trop Med
Int Health. 2012; 17(11): 1356-60.

Main findings

Effect on policy and practice

The care package focused only on
women and was not adapted to thecontext where sexual violence also
affected minors and men

Liberia’s national guidelines andMSF’s were revised

Integrated ARV treatment can beoffered in a conflict setting withgood outcomes

Provided knowledge on how to
implement an integrated HIV/AIDS programme in a rural conflictsetting. Led to revision of the SPHERE
guidelines* for displaced populations.

High levels of drug resistance infalciparum malaria and ineffective
national regimens in 18 countries

Led to a shift in national andinternational policy on use of more
effective antimalarial treatment'Assessing feasibility of interventions in specific populations'
O'Brien DP, Sauvageot D, Zachariah R, Humblet P. In
resource-limited settings good early outcomes can beachieved in children using adult fixed-dose combination
antiretroviral therapy. AIDS. 2006; 20(15): 1955-60.
'Advocating for policy change'
Guthmann JP, Checchi F, van den Broek I, Balkan S, van Herp
M, Comte E, et al. Assessing antimalarial efficacy in a time ofchange to artemisinin-based combination therapies: the roleof Médecins Sans Frontières. PLoS Med. 2008; 5(8): e169.

*Benchmark guidelines for offering health services for refugees and displaced populations.

International Activity Report 2014 19

msf's access campaign in 2014

MSF’s AccessCampaign in 2014
In 1999, Médecins Sans Frontières (MSF) launched the Access Campaign with thesole purpose of advocating for the accessibility and development of life-saving andlife-prolonging medicines, diagnostics and vaccines for patients in MSF projects andbeyond. Here are just some of the areas the Access Campaign worked on in 2014:
Vaccines

Hepatitis C

The Access Campaign drew attention to
the challenges of delivering life-saving
vaccines to children in developing countries,
advocating for companies to reduce prices
and to improve thermostability to enable
the vaccines to be transported further into
remote areas without the need forconstant refrigeration.

As MSF was preparing to scale up
treatment programmes for hepatitis C, adisease which affects 150 million people
worldwide, the Access Campaign calledon pharmaceutical firms to reduce theexorbitant prices of the drugs used to treat
the disease. Highlighting the enormous
gap between the prices being charged andthe actual cost of production, MSF urged
countries and companies to takeall necessary measures to ensure affordable
access to these life-saving drugs.

Tuberculosis
Having survived extensively drug-resistant tuberculosis(XDR-TB) – the deadliest form of the disease –Phumeza Tisile, with her MSF doctor Jenny
Hughes, wrote the ‘Test Me, Treat Me’
drug-resistant tuberculosis (DR-TB) manifesto
to urge countries, companies, donors andresearchers to support better DR-TB diagnosis
and treatment. More than 55,000 people
from around the world signed the petition,
which was presented to global leaders at the
UN’s World Health Assembly in Geneva in May.

Protecting the ‘pharmacyof the developing world’
India’s vital role in providing affordable medicines todeveloping countries, as well as MSF programmes,
is under threat from moves to roll back publichealth 'safeguards' in India’s patent law,which protect against frivolous patent
abuse and allow generic competition
to flourish in the interest of accessto affordable medicines. MSF urged
the Indian government to standfirm in the face of pressure fromthe US government and multinational
pharmaceutical companies.

Ebola
An unprecedented outbreakof the deadly Ebola virus inWest Africa prompted MSF tocall on donors, researchers andpharmaceutical firms to collaborate
to fast-track trials of new vaccines andtreatments for the disease, and to runsome trials at MSF treatment centres inWest Africa. Affordable access to promising products
should be prioritised for those in the most affected countries.

Trade agreements
Trade agreements currently being negotiated between
developed and developing countries, including
the Trans-Pacific Partnership Agreement, posea serious threat to affordable medicines.
MSF has urged countries not to accept
harmful intellectual property provisions
that extend monopoly periods forhigh-priced medicines while blocking
price-lowering generic competition.

Priorities for 2015

Stay Connected

In 2015, a major campaign on vaccines will be launched, advocating
for a reduction in prices and for an increase in transparency regarding
pricing. The Access Campaign will continue to push for affordable
hepatitis C drugs, and for wider availability of new drugs to treat DR-TB.

If you’d like to keep up-to-date with the work of
MSF’s Access Campaign, visit www.msfaccess.org andsign up to receive newsletter updates, and follow us
on Twitter @MSF_Access.

ILLUSTRATIONS © Vivien Peng

20 Médecins Sans Frontières© Corentin Fohlen

Ismael (aged 4) has severe cholera and has been hospitalised in the MSF centre in the Delmas neighbourhood of Port-au-Prince, Haiti.

Activities by country
22	Afghanistan

35	Egypt

56	Kyrgyzstan

24	Armenia

36	Democratic Republicof Congo

56	Lesotho

73	RussianFederation

57	Libya

73

38	Ethiopia

57	Madagascar

74	Sierra Leone

40	Georgia

58

76	South Africa

40	Greece

60	Malawi

41	Guinea-Buissau

77	Tajikistan

61	Mali

41	Honduras

77	Turkey

62	Mauritania

42	Guinea

62	Mexico

44	Haiti

63	Myanmar

46	India

64	Niger

48	IRAQ

66	Nigeria

50	Iran

68	Pakistan

32	Chad50	Italy

70	Palestine

84 	Uzbekistan

34	Colombia

51

71	Philippines

85	Ukraine

35	Democratic People’s
Republic of Korea

52	Kenya

72	Mozambique

86	Yemen

54	Lebanon

72	Papua New Guinea

87	Zimbabwe

24
25

Bolivia
Bangladesh

26	bulgaria
26

Burkina Faso

27

Burundi27	Cambodia
28

cameroon

29 	China
29 	Côte d’Ivoire
30	Central African
Republic

Jordanliberia

serbia78	South Sudan
80	Sudan81	Swaziland
82	Syria
84 	Uganda

afghanistan

afghanistan

No. staff in 2014: 1,738 | Expenditure: d24.8 million | Year MSF first worked in the country: 1980 | msf.org/afghanistan | blogs.msf.org/afghanistan
Key medical figures:

306,600 outpatient consultations
39,600 births assisted
7,800 surgical interventions

Cities, towns or villages with MSF activities

After more than a decadeof international aid andinvestment, access to basic
and emergency medical care in
Afghanistan remains severely
limited and ill-adapted to meetthe growing needs created by
the ongoing conflict.
In February 2014, Médecins Sans Frontières(MSF) published a report entitled Between
Rhetoric and Reality: The Ongoing Struggle toAccess Healthcare in Afghanistan, which revealed
the serious and often deadly risks that people
are forced to take to access medical care. It
found that the majority of the 800 patients
interviewed could not reach critical medical
assistance due to insecurity, distance and cost.
Of those who reached MSF hospitals, 40 per
cent told us they had faced fighting, landmines,
checkpoints or harassment on their journey.
Their testimonies exposed a wide gap between
what exists on paper in terms of healthcare andwhat is actually available.

care for women presenting with complicationsin pregnancy or labour, and for seriously ill
newborns. Just over a month after opening,the department was already functioning at
maximum capacity, and there had been
627 deliveries by the end of December,including 33 caesarean sections.
The 46-bed facility includes a delivery room,
an intensive care unit for women and newborns,
an inpatient department and an operating
theatre. Vaccinations, laboratory services anda blood bank are also available. There is evena ‘kangaroo room’, where mothers carry
their newborns on their chest, skin to skin, sothat their warmth acts as a natural incubator,
regulating the baby’s temperature.

Ahmad Shah Baba hospital, Kabul
In eastern Kabul, MSF continued to upgrade
Ahmad Sha Baba hospital, by increasing bed
capacity and training staff. Providing free andhigh-quality medical care, with a particularfocus on emergency and maternity services, thehospital is now the most important maternal
health facility in Bagrami and surrounding
districts, with operating theatres and surgeonsavailable at all times. This year, the teamassisted 14,968 deliveries, performed 949
surgical procedures and carried out 10,094
antenatal consultations.

Trauma centre, Kunduz
In the northern province of Kunduz, the MSF
trauma centre provides free surgical care to those

Dasht-e-Barchi hospital, Kabul

Over the past decade, Kabul has become oneof the world’s fastest-growing cities but services
have not kept pace with the rapid increasein population. The area of Dasht-e-Barchi hasover one million inhabitants but only one public
hospital and three public health centres. In a
bid to reduce maternal and neonatal mortality,
MSF opened a new obstetric department within
the hospital, providing free, around-the-clock

22 Médecins Sans Frontières© Celine Leto/MSF

At the end of November, MSF opened amaternity department in the district hospitalof Dasht-e-Barchi, western Kabul.

The Gulan camp in Khost province, eastern Afghanistan, is the temporary home ofthousands of people who have crossed the border from Pakistan.

© Andrea Bruce/Noor Images

afghanistan

Midwives at the Khost maternity hospital monitor newborn twins. MSF staff assisted in the delivery of 15,204 babies here in 2014.

with conflict-related injuries, as well as to victims
of general trauma such as traffic accidents, andpeople with moderate and severe head injuries.
Construction and refurbishment work continued
in 2014: the intensive care unit was expanded
and the total bed capacity in the hospital wasincreased to 70.
The number of patients visiting the centre rosein 2014. Staff treated a total of 22,193 people
and performed 5,962 surgical procedures.
About 54 per cent of the patients admitted
for more prolonged treatment had conflictrelated injuries – from explosions, gunshots orrocket attacks. As it is the only trauma centre
in the northern region, patients come fromsurrounding provinces such as Baghlan, Takhar
and Badakhshan. During intense periodsof fighting, people travelling to the trauma
centre are at risk of being caught in crossfire
and they are also delayed at checkpoints. For
some patients, arriving within an hour of theincident can save their limbs or even their lives.
MSF’s study published in February showed thatin Kunduz more than one in five people had
waited over 12 hours before going to hospital,
either because they could not travel at night for
security reasons, or because there was fighting
or they simply could not find transport.

Khost maternity hospital
The hospital in Khost is the only specialisedmaternity hospital in the area, and it aims toprovide a safe environment for women to givebirth. It focuses on assisting with complicateddeliveries and reducing the high numberof maternal deaths in the province. Manypatients travel long distances to access thefree, high-quality care on offer. Staff assisted in
the delivery of 15,204 babies; approximately
one in three children born in Khost province
was delivered in the MSF hospital this year.

Emergency assistance in Gulan refugee camp
At the beginning of the summer, tens of
thousands of people fleeing a military offensive in
the Pakistani region of North Waziristan crossed
the border into Afghanistan, seeking refuge in
Khost, Paktia and Paktika provinces. From July to
September, MSF teams provided assistance withmedical care and water and sanitation in Gulan
refugee camp, 18 kilometres from Khost city. Inview of the low vaccination coverage in North
Waziristan, teams focused on measles vaccinations
for children aged six months to 15 years – morethan 2,900 were vaccinated. A clinic was also set
up in the camp, where a medical team treatedon average 100 patients per day. Once the basic
services were up and running, MSF handed overthe medical and sanitation activities to otherhumanitarian organisations who could provide
longer-term support to the refugees.

Boost hospital, Lashkargah,
Helmand province
An MSF team continued to support Boosthospital with surgery, internal medicine,
emergency services and maternal, paediatricand intensive care. The 285-bed facility admitted
around 2,480 patients and performed 300
surgical procedures each month. The maternity
ward’s capacity was expanded from 40 to 60
beds and 9,207 babies were delivered in 2014.

Helmand is one of the provinces most
severely affected by the ongoing conflict.
People have to deal with landmines, bombs
and outbreaks of fighting on an almost daily
basis. MSF’s February report revealed thatas a result of insecurity, some patients had
waited more than a week before seeking
medical help. These delays are particularly
dangerous for children, many of whomare very sick by the time they arrive at thehospital. Malnutrition remains one of themain causes of child mortality in Helmand
province and the hospital’s therapeutic
feeding centre treated 2,200 severely
malnourished children this year.

PATIENT STORY
Fatima, 30 years old,
Dasht-e-Barchi“ I feel very tired but so happy. It’s my firstbaby. I have been pregnant four times
before but never had a baby. I lost each ofthem, after three months, four months andfive months. The last one after six months… When I got pregnant again, I went toa small private clinic for antenatal care.
I never did before because we don’t havemoney to spend for that. But this time,
we really thought it was important and I
went three times … My husband had towork a lot to pay for the medical care. Ourneighbours told us to come [to the MSF
clinic] once the baby came. They said I
would be taken care of.”International Activity Report 2014 23

armenia | bolivia

armeniaNo. staff in 2014: 91 | Expenditure: d2.2 million | Year MSF first worked in the country: 1988 | msf.org/armenia
TB remains a significant public healthconcern in Armenia, as the country has
one of the highest rates of the multidrugresistant (MDR-TB) form of the disease in theworld. According to the National Reference
Laboratory, in 2012 MDR-TB was detected in
38 per cent of patients being re-treated andin 14 per cent of all new TB cases.
Regions where MSF has projects
Cities, towns or villages where MSF works

Key medical figures:

120 patients under treatment
for MDR-TB

Médecins Sans Frontières (MSF)
supports the Armenian healthministry in improving drugresistant tuberculosis (DR-TB)
control activities in the country.

Since 2005, MSF has been working inArmenia to improve diagnosis and treatment
of DR-TB, and to support patients tocomplete the arduous regimen. This has
been achieved through patient education,
counselling and social support. MSF has also
helped implement infection control measuresand practices.
Bedaquiline, a new TB drug, has been
available to patients with MDR-TB andextensively drug-resistant tuberculosis(XDR-TB) since April 2013. Between April
2013 and September 2014, MSF and thehealth ministry provided bedaquiline to46 patients. MSF supports the supply ofthe drug, as well as the day-to-day careand follow-up of patients taking it. Other
antibiotics that are efficient in treating resistantforms of the disease are also made available.
Current treatments for MDR-TB and XDR-TB
are long, taking up to two years. They are also
painful and can have serious side effects, such as
loss of hearing. Furthermore, they are not that
effective: fewer than 50 per cent of patients are
cured. Seasonal economic migration and thesocial stigma surrounding the disease further
complicate the task of keeping patients under
treatment. MSF works with the health ministry
to offer support adapted to the individual
patient, for example home-based care whenneeded and counselling.
The MSF team aims to enhance the national
programme’s capacity to implement DRTB response plans in preparation for thehandover of DR-TB management, whichshould happen in 2016.

boliviaNo. staff in 2014: 12 | Expenditure: d0.5 million | Year MSF first worked in the country: 1986 | msf.org/bolivia

Regions where MSF has projects

As many as one million people
are estimated to be infectedwith Chagas disease in Bolivia.
People can live with this parasitic diseasefor years without symptoms. Complications
develop in about a third of cases and can

24 Médecins Sans Frontières

lead to death without treatment. Chagas is
endemic across 60 per cent of Bolivia and iscommonly transmitted by the vinchuca bug(Triatoma infestans), which lives in the cracks
and roofs of rural adobe houses. Only four per
cent of those people infected get treatment,
owing to a lack of access to care. The
government recognises this as a major healthissue and has been working to address it;
however, Chagas treatment is not guaranteed
or integrated into basic healthcare.
Médecins Sans Frontières (MSF) has set
up Chagas treatment programmes over
the years it has been working in Bolivia,
particularly in Narciso Campero province in
Cochabamba department, where the disease
is especially prevalent. The health ministry
has managed that programme since 2013.

In 2014, MSF teams focused on anotherpriority area: Chuquisaca department,
Monteagudo municipality, in Hernando Siles
province. Hardly any of the 61,900 residentsof this region have access to treatment. In
partnership with the health ministry, MSF
is working on a model of prevention andtreatment to be integrated into the basic
healthcare system.
MSF also collaborated with the healthministry in partnership with Johns Hopkins
University this year to prepare the launchof EMOCHA, an e-mobile surveillance
application. Upon detection of a vinchuca
infestation, a community volunteer will send afree SMS to a central information system, anda vector control team will be deployed.

bangladesh

bangladesh

No. staff in 2014: 324 | Expenditure: d3.1 million | Year MSF first worked in the country: 1985 | msf.org/bangladesh

Poor living conditions in slums
In Kamrangirchar and Hazaribagh, teams
visited factories and tanneries and conducted
more than 4,450 outpatient consultations.
MSF is looking for ways to increase accessto healthcare for workers in these industries,
many of whom work in hazardous conditions
for long hours.
Regions where MSF has projects

Key medical figures:

96,900 outpatient consultations
4,200 individual and group mental
health consultations

Médecins Sans Frontières(MSF) continued to provide
essential care to vulnerable
groups in Bangladesh:
undocumented refugees, young
women, and people living inremote areas and urban slums.
Many of the undocumented Rohingya who
fled violence and persecution in Myanmar
have been living in makeshift camps close
to the Bangladeshi border for decades, yetthey continue to suffer from discriminationand healthcare exclusion. In the Kutupalong
makeshift camp in Cox’s Bazar, MSF runs aclinic providing comprehensive basic andemergency healthcare to refugees and thehost community, as well as inpatient andlaboratory services and tuberculosis (TB)
treatment. Some 80,000 outpatient andover 1,200 inpatient consultations werecarried out during the year. More than
3,000 mental health consultations were
undertaken. Approximately 6,000 womenattended an initial antenatal consultation.

Teams also continued a sexual andreproductive health programme foradolescent girls aged 10 to 19 years. Morethan 7,700 consultations were carried out,
460 births assisted and 1,070 mental healthconsultations were conducted for social
problems such as intimate partner violence.
In addition, over 670 victims of sexual anddomestic violence received medical care andshort-term psychological assistance; almost
80 per cent of these attended further mental
healthcare consultations.

Malaria emergency
MSF supported the health ministry’s response
to a major outbreak of malaria in the remotearea of Bandabaran, Chittagong Hill Tracts,
in August 2014. Teams travelled in boats andhiked through forests to reach communities inneed of medical assistance. More than 2,280
people received treatment during the threemonth intervention.

Kala azar research
In Fulbaria, Mymensingh district, MSF
continued researching a treatment for postkala azar dermal leishmaniasis. Results are
expected in late 2015.

© Shafique Uddin/MSF

Cities, towns or villages where MSF works

MSF also monitored the vaccination status ofchildren and administered more than 3,560
measles and 3,050 polio vaccines supplied by
the health ministry.

An MSF nurse and two local health workers travel by boat to reach a remote village in the
Chittagong Hill Tracts and provide malaria treatment to the population.

International Activity Report 2014 25

bulgaria | burkina fasobulgaria

No. staff in 2014: 16 | Expenditure: d0.5 million | Year MSF first worked in the country: 1981 | msf.org/bulgaria

Bulgaria saw a large increase in
the number of Syrians arriving
via Turkey this year.

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

Key medical figures:

6,600 outpatient consultations
800 relief kits distributed

The Bulgarian government was underprepared
for the surge of new arrivals and although
makeshift camps were set up, the provision offood, shelter, and medical and psychologicalcare was inadequate. People were sleeping in
unheated tents, and up to 50 individuals weresharing one toilet.
During the 2013–14 winter, after seeing theterrible living conditions in reception centres,
Médecins Sans Frontières (MSF) started
working in those worst affected: Vrezdevna
and Voenna Rampa centres in Sofia, and also

in the Harmanli camp close to the Turkish
and Greek borders. MSF teams provided
medical, antenatal and psychological care,
distributed aid and made improvements
to buildings and facilities. Over 5,500
outpatient consultations were carried out.
In May, after the authorities had increased
their capacity and conditions had improved,
MSF handed over the provision of medical
and psychological healthcare services to the
Bulgarian State Agency for Refugees andother humanitarian organisations.
For more on refugees and migrants arriving
in Europe, see Italy (p.50), Greece (p. 40) andSerbia (p.73).

burkina faso

No. staff in 2014: 63 | Expenditure: d1.3 million | Year MSF first worked in the country: 1995 | msf.org/burkinafaso

In September, Médecins
Sans Frontières (MSF)
closed its project providing
healthcare to Malianrefugees in Burkina Faso.
Regions where MSF has projects

Malians began crossing the border into

Cities, towns or villages where MSF works

Oudalan province, fleeing violence andunrest in their home country, in February

Key medical figures:

10,900 outpatient consultations
430 patients treated for malaria
370 births assisted

26 Médecins Sans Frontières

2012. The following month, MSF openeda project providing basic healthcare tosome 8,000 people in informal settlements
around Gandafabou.
When the authorities moved the refugees to
official camps in July 2013, MSF reoriented
activities to assist those who had settled at

Déou and Dibissi (2,000 and 4,000 people
respectively). Staff ran mobile clinics threetimes per week offering medical care.
Basic healthcare was also provided tochildren up to the age of five in Déouhealth district. MSF screened children formalnutrition and ensured that those aged
between six months and five years hadreceived vaccinations.
Following a decrease in the number ofMalian refugees in Oudalan province,
MSF closed the project in September after
having made donations to medical facilities
in the region.

burundi | cambodia

burundiNo. staff in 2014: 122 | Expenditure: d2.3 million | Year MSF first worked in the country: 1992 | msf.org/burundi

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

Key medical figures:

2,700 patients treated for malaria
The use of injectableartesunate for severe malaria
is now well integrated into the
Burundian Ministry of Health’smalaria treatment policy.

As a consequence, the Médecins Sans
Frontières (MSF) programme focusing on
reducing severe malaria-related mortality is
being gradually handed over to the Ministryof Health. In July 2014, the Kirundo malaria
project, which was supporting 34 clinics
with diagnosis and treatment, was handed
over and the project in Mukenke district isdue to follow suit in early 2015. Injectableartesunate is easy to administer and thetreatment is shorter and more effective thanquinine, with fewer side effects.

Providing fistula care
An MSF team continued to provide obstetricfistula treatment at Urumuri health centre
in Gitega, alongside health promotion, staff
training and case-finding activities. MSF offers
reconstructive surgery, physiotherapy andpsychosocial support, and runs a hotline forthose seeking help. Fistulas, a consequenceof birth complications, cause not only pain
but incontinence, which in turn often leads

to social exclusion and sometimes rejection
by family and friends.
The number of new obstetric fistula cases
has declined over the last few years, as muchof the backlog that existed in the country
when the project opened in 2010 has now
been cleared. The project will be handed
over to the Ministry of Health at the end of
September 2015. The remaining cases will
be managed by the Ministry of Health, asMSF has trained three Burundian doctors infistula surgery.

Leaving Burundi
MSF has drawn up a preparedness plan incase of emergencies, but if no major MSF
intervention is needed in the next year all
programmes should close before the endof 2015.

cambodia

No. staff in 2014: 155 | Expenditure: d2.3 million | Year MSF first worked in the country: 1979 | msf.org/cambodia

Cities, towns or villages where MSF works

Key medical figures:

1,300 patients under treatment for TB
Médecins Sans Frontières (MSF)
continues to provide treatment
for malaria and tuberculosis(TB), two of the major healthconcerns in Cambodia.
Artemisinin-based medicines are currently
the most effective antimalarial treatment
and, in conjunction with other measures

such as mosquito nets, have reduced thesuffering and death caused by malaria.
However, areas of artemisinin drug
resistance have been identified, potentiallycreating a parasite pool that is more difficult
to treat and eliminate. The areas thatare most at risk of developing resistanceare located in underdeveloped andremote border regions, where population
movement and a lack of healthcaremake this disease difficult to control. In
September and October, MSF undertooka baseline survey of people with drugresistant malaria in 23 villages in Chey Saen
district, Preah Vihear province. In 2015, a
project with a specific treatment protocol
aiming to eliminate this strain of the disease
will be developed. Active case detection
was started in 2014, and health promotion
teams were engaged to increase awarenessin their communities.
The prevalence of TB in Cambodia remains
among the highest in the world. An MSF
programme of comprehensive TB care
continued in Kampong Cham, the mostpopulated province. The priority is early andactive detection and testing of people at highrisk of contracting the disease. In March,
MSF completed the first phase of active casefinding in Tboung Khmum district. All people
older than 55 – a high-risk group – werescreened, and 138 out of a total of 4,903
were found to have TB. Another round ofactive case finding began in October.

PATIENT STORY
Thea, 76 years old – was identified
through case-finding activities inKien Romiet village and admitted
for treatment“ MSF came to see the village chief, who
asked the people to go to see the MSF
team about the screening. An MSF
minivan came and took those whowanted to be screened to the hospital.
When I arrived at the hospital the doctor
saw me and after the process told me I
had TB … I did not know I had TB, but
MSF knew it.”International Activity Report 2014 27

cameroon

cameroon

No. staff in 2014: 277 | Expenditure: d8.7 million | Year MSF first worked in the country: 1984 | msf.org/cameroon

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

Key medical figures:

110,200 outpatient consultations
25,600 patients treated for malaria
10,500 patients treated in
feeding centres
3,300 patients admitted to hospital
Médecins Sans Frontières(MSF) opened an emergency
programme in east Cameroon
in response to an influx ofrefugees from Central African
Republic (CAR).

In Garoua-Boulaï, a small border citywhere many refugees crossed into Cameroon,
MSF teams conducted medical consultations,distributed relief items and worked on sanitation
and water supply at the Pont Bascule transit site.
The water and sanitation activities were handed
over to the NGO Solidarité Internationale in
October. Another team continued to work at
the district hospital and provided about 1,000
outpatient consultations per week last year.
At the Protestant hospital, MSF supported atherapeutic feeding centre and in 2014 increased
the bed capacity to 100 to accommodate morechildren with severe malnutrition.
From February to October, MSF ran ahealth centre at Gado-Badzéré camp, about
25 kilometres from Garoua-Boulaï. There
was an outpatient feeding centre and aspace designated for individual and grouppsychosocial counselling sessions. MSF also
carried out water and sanitation activities
in the camp, undertook epidemiologicalsurveillance and implemented an early
response to a cholera outbreak.
In March, MSF began working in Gbiti,
another border town where more than
20,000 refugees have been registered.

MSF conducted more than 1,000 medical
consultations per week, supplied water, andbuilt latrines and showers at a makeshift
camp. Two mobile teams provided medicalcare to small pockets of refugees in the area.
Patients requiring more intensive care werereferred by MSF to hospitals in Batouri or
Bertoua. MSF also supported Batouri district
hospital in the management of patientswith severe, complicated malnutrition, andincreased capacity to 150 beds.

Buruli ulcer project ends after 12 years
In June, MSF handed over the Buruli ulcer
pavilion in Akonolinga to the Ministry of
Health. This project had opened in response to
the high number of people in the area affectedby Buruli, a chronic and destructive infectionthat affects people’s skin and tissue. Laboratory
diagnosis, antibiotics, wound dressing, surgery
and physiotherapy were provided. Some 1,400
patients have been treated since the project
began in 2002, and around 43,000 people
have benefited from awareness activities. The
University Hospital of Geneva, Switzerland,
will continue training Cameroonian medical
students in chronic wound treatment and care,including for Buruli ulcer.

In January, MSF began to support the
Ministry of Public Health by providing
medical, nutritional and psychologicalsupport to refugees at sites in GarouaBoulaï, Gado-Badzéré, Gbiti and Batouri.
The majority of patients were sufferingfrom malnutrition, malaria and respiratory
infections. Medical care, primarily maternity
services and healthcare for children up
to the age of 15, was also offered tohost communities and MSF helped withvaccination campaigns.

28 Médecins Sans Frontières© Daniel Barney

Intercommunal conflict in CAR caused
hundreds of thousands of people to seek
refuge in Cameroon and other countries
in 2014. Some 9,000 arrived in Cameroon
during a 10-day period in February alone,
and by the end of the year, an estimated
135,000 were in the country.

Refugees living in Gbiti camp, on the border with the Central African Republic.

china | cote d'ivoirechina

No. staff in 2014: 2 | Expenditure: d0.2 million | Year MSF first worked in the country: 1989 | msf.org/china

YunnanRegions where MSF has projects

Médecins Sans Frontières(MSF) stopped working in
China in 2014.
Although the prevalence of HIV/AIDS
in China is low, people living with thedisease face difficulties accessing thenecessary care, and there is still widespread
discrimination and stigma. China initiatedthe ‘Four Frees and One Care’ policy inDecember 2003, providing HIV counselling
and testing, antiretroviral treatment,
prevention of mother-to-child transmission
and schooling for children orphaned by
AIDS, all free of charge. However, many
people with the disease have not benefited
from these measures.
A Chinese NGO, Aids Care China (ACC), isdeveloping high-quality care and treatment
through private clinics, hoping to show the
impact this can have on people’s healthand influence reforms that will make caremore widely available. In October 2011, at
the request of ACC, MSF started supportinga clinic near the border with Myanmar, in

Jiegao, Yunnan province, where there arehigh numbers of Chinese and Burmese
injecting drug users with HIV or HIV–TB and
HIV–hepatitis C co-infection. In September
2013, an MSF team began providing
technical assistance to ACC to improve theclinical management of HIV/AIDS patients.
The aim was to demonstrate that a newmodel of comprehensive care, incorporating
patient counselling, could deliver better
treatment outcomes. MSF also supported
the development of ACC by reinforcing its
medical expertise in HIV/AIDS management.
This collaboration came to an end in April
2014 due to a number of reasons, includingchanges in ACC’s objectives and the factthat the health ministry started treating HIV
patients suffering from hepatitis C.

cote d'ivoire

No. staff in 2014: 152 | Expenditure: d2.3 million | Year MSF first worked in the country: 1990 | msf.org/cotedivoire

Cities, towns or villages where MSF works

This year Katiola hospital’smaternity unit started
providing care for complicateddeliveries and ante- andneonatal emergencies.

Mother and pre- and antenatal care is a priority
for the Ministry of Health in Côte d’Ivoire, as
maternal mortality has been increasing since2005. Women generally deliver their babies
at home with traditional birth attendants andwithout effective emergency obstetric carewhen there are complications.

and sewage network in the hospital, andorganised training for midwives. As a result,emergency obstetric care and complicateddeliveries are now being managed by MSF, andbetween July and December over 1,000 births,
more than 100 of them requiring caesarean
sections, were assisted.

With the Ministry of Health, Médecins Sans
Frontières (MSF) opened a mother and childhealth programme in Katiola hospital in
2014. The 90-bed facility serves as the solereferral hospital for the whole region but
until recently had very limited capacity toprovide emergency obstetric and neonatalcare. Only women who could afford to betransported by ambulance were referredto the larger Bouaké hospital to get thenecessary medical assistance.

Ebola in neighbouring countries

MSF renovated Katiola’s maternity unit and thetwo operating theatres, built a water supply

As a consequence of the Ebola outbreak, theborders with Liberia and Guinea were closed
in August. No suspected cases were reported
in 2014, but an MSF team visited the area
bordering Liberia to assess the preparednessof local staff and the authorities, as well as
community awareness. MSF collaborated
with the health authorities to build an Ebola
management centre in Yopougon hospitalin Abidjan (the country’s largest city), asa contingency plan. MSF also supported
the training of health staff and rapid
investigation teams.

International Activity Report 2014 29

central african republic

central african
republic

No. staff in 2014: 2,593 | Expenditure: d53 million | Year MSF first worked in the country: 1997 | msf.org/car | blogs.msf.org/car

Regions where MSF has projects
Cities, towns or villages where MSF works© Andre Quillien/MSF

Key medical figures:

1,401,800 outpatient consultations
749,100 patients treated for malaria
13,400 surgical interventions

MSF staff working in the surgical emergency project at Bangui general hospital.

The health situation in Central
African Republic (CAR) is
catastrophic, and conflict anddisplacement prevent people
from obtaining the medical
services they desperately need.

and expensive, and drug supplies are frequently
interrupted. MSF remains the main healthcare
provider in CAR, with many longstanding
programmes offering comprehensive services,
as well as emergency projects that are set up
as needed. Malaria is rampant, and appalling
living conditions are causing health issues such asintestinal infections and diarrhoeal or skin diseases.

At the beginning of 2014, most of the Muslim
population in the western half of CAR left thecountry in the space of a few months to escapeattacks. Several thousand people remained living
in enclaves, fearful for their lives. Intercommunal
violence and attacks by armed groups were notlimited to the Muslim population though, and allcommunities in CAR were affected.

Providing healthcare in Bangui

By December 2014, some 430,000 people wereinternally displaced in the country and hundredsof thousands of others had crossed the border
into Chad and Cameroon. Although a transitional
government was formed in January (elections are
anticipated in 2015), many areas remain unsafe
and people do not want to return home. Banditry
and security incidents are common, and Médecins
Sans Frontières (MSF) has been directly affectedby armed attacks, harassment and robberies. On
26 April, 19 unarmed civilians, including three
MSF national staff members, were killed by armed
men at the MSF hospital in Boguila.
There is a severe shortage of skilled staff, and of
vaccines in the country. Access to care is limited

30 Médecins Sans Frontières

In Bangui, the capital city, MSF provides
emergency surgery at the general hospital for
victims of violence and trauma such as roadaccidents. From December 2013 to March 2014,
MSF supported maternal health activities andsurgery in the Castor health centre until thesituation improved and people could access other
health centres in the city. In June, some activities
resumed and MSF started to carry out obstetricand other emergency surgery. A programme
offering medical and psychological care for victimsof sexual violence was opened in July.
Basic healthcare for children under 15 isavailable at Mamadou M’Baiki health centre
in the city’s PK5 district, and MSF ambulancestransport emergency patients of all ages tohospital. Mobile clinics also began visiting
displaced people several times a week at
the Grand Mosque, Fatima’s Church and
St Joseph’s Parish Centre this year. Morethan 39,900 consultations were carried out in
PK5, nearly a third of them malaria-related.

There were approximately 100,000 displaced
people living in and around M’poko airport inmakeshift camps at the peak of the violence in2014, but by the end of the year this number
had dropped to 20,000. Two-thirds of patients
travelled from Bangui to access the healthcare
offered by MSF at the camps, as services
were lacking in the city. People were treatedfor malaria, births were assisted and over
80 victims of sexual violence were helped.
When MSF started working in the general
hospital in February, the emergency surgery
activities at community hospital in the capitalwere handed over to the International Committeeof the Red Cross. The project assisting displaced
people at the Don Bosco centre closed in Marchonce their number had significantly decreased.

Caring for the displaced
In January, MSF began activities at Berbérati
regional university hospital, responding to theneeds of displaced people, victims of violence,
pregnant women and children. Weekly mobile
clinics visited some 350 people living in the
Berbérati area. In July, teams started outreachactivities to support seven health centres
providing healthcare in surrounding villages.
Malnutrition, malaria, diarrhoea, respiratory
tract infections and measles were the main
health concerns. More than 41,900 outpatient
consultations and 3,000 surgical interventions
were performed. MSF also launched ancentral african republic

intervention from Berbérati to Nola, SanghaMbaéré prefecture, and 23,000 children were
vaccinated there against measles.
From January to April, MSF responded to thehealth consequences of a spike in violenceagainst enclaves of displaced people and the
local population in Bouar, Nana-Mambéré, withmobile clinics and by supporting the emergency
room and surgical activities at Bouar hospital.
Following the attack in Boguila, Ouham
prefecture, in April, MSF’s comprehensive
healthcare services were reduced to a healthcentre with an outpatient unit, four healthposts, maintenance of malaria testing andtreatment sites (‘palu points’) and HIV
treatment. The palu points were handed overto the NGO MENTOR Initiative in November.
Another long-running project provided basic
and specialist healthcare in Kabo. A seriesof security incidents resulted in a partial
evacuation of the MSF team in February but
the situation stabilised in the second halfof the year. Staff treated more than 46,000
patients, most of whom had malaria.

In Kémo, MSF started supporting Dekoua parish
clinic in May, following clashes that displaced
civilians. Activities focused on outpatient
consultations, assisting births and treating
malnutrition. MSF also conducted mobile clinics.
More than 5,500 consultations were undertaken,
mostly for young children. The project closed inAugust when people left the area.
Teams offered a comprehensive packageof healthcare in Carnot, Mambéré-Kadéï,in a longstanding project, carrying out
over 49,000 consultations during the year.
Approximately 500 Muslims from Carnot
have taken refuge in a church in the city;
more than 4,470 consultations were provided
to them through a regular mobile clinic.

Access to general healthcare
MSF opened a hospital-based project inBozoum, Ouham-Pendé, in January but closed
it in March, as people felt safer visiting thenearer health centres. In Bocaranga, MSF ran a
project between May and September to treat
children under five during the annual malaria
peak, and mobile clinics visited the northwestof the country. The comprehensive healthcare
project in Paoua has been operating for many
years and the team carried out some 71,400
consultations there in 2014.
In late February, MSF started working at the
80-bed referral hospital in Bangassou, the capitalof Mbomou prefecture, where services had been
severely disrupted. Basic and specialist healthcare,including internal medicine, maternity, paediatricand surgical services, were available. From May,MSF supported the 30-bed hospital in Ouango
and rehabilitated its maternity, paediatric, internal
medicine and surgery wards, as well as theoperating theatre and the laboratory. The Ouango
hospital was supported by MSF temporarily
between May and October.
MSF also provided comprehensive healthcare
to children under 15 in the refurbished hospitalin Bria, Haute-Kotto, where there are high rates
of malaria and malnutrition. More than 48,000
consultations were undertaken, and an average of
80 children were admitted to hospital each week.
A programme of basic and specialist
healthcare at Ndele hospital, BaminguiBangoran, and four nearby health centres
continued. Staff saw a significant increase inpatients with violence-related injuries.
MSF remained the main healthcare provider
for those living in the east of the country in
Haut Mbomou. Health facilities are scarce inthis prefecture and people travel up to
200 kilometres to reach the main healthcentre in Zémio and four outlying health posts.

© Yann Libessart/MSF

MSF also supported the 165-bed Batangafo
hospital and five local health centres. The
village became part of the frontline in 2014
and there were security incidents during
the year. More than 96,000 outpatient
consultations were carried out and almost
5,000 patients were admitted. The emergency
programme that had started in Bossangoa in2013 for displaced people continued, although
activities in the camps ceased in April whenpeople were able to return home.

Following outbreaks of violence andpopulation displacement in Ouaka prefecture,
MSF opened projects in Bambari and Grimari
in April. Mobile clinics travelled to villages andfound many people still living in fear in thebush. MSF supported palu points and healthcentres and vaccinated 4,000 children in theprefecture against polio and measles in August.
The Grimari project closed in October, and thefocus was concentrated on Bambari.

Muslims who have fled their homes for fear of violence are seen here sheltering in the Catholic church in Carnot.
International Activity Report 2014 31

chad

chad

No. staff in 2014: 1,032 | Expenditure: d19.5 million | Year MSF first worked in the country: 1981 | msf.org/chadKey medical figures:

257,200 outpatient consultations
158,200 measles vaccinations(outbreak)

156,700 patients treated for malaria
15,500 patients treated in
feeding centres

Regions where MSF has projects

Access to basic healthcare
is limited in Chad, where
malnutrition, malaria andoutbreaks of disease arecommon. An influx of refugees
from Central African Republic(CAR) in 2014 increased theneed for medical aid.
Although improvements are being madeto the health system, there are still criticalgaps, which Médecins Sans Frontières(MSF) continues to address. These include
implementing preventive measures andproviding free medical care to children
suffering from acute malnutrition and malaria,
responding to disease outbreaks – including amajor measles outbreak – with treatment andvaccinations, and meeting the acute healthcare
needs of people displaced by conflict. Chad ishome to the third largest number of refugees
in Africa, and with ongoing violence inneighbouring Nigeria, CAR and Sudan, therefugee population is likely to increase.

Refugees from CAR
Since December 2013, more than 200,000
people fleeing violence in CAR have sought
refuge in southern Chad. In January, MSF
started providing health assistance, withprojects in Bitoye until April, Goré until
October and in Sido, which hosted the largest
concentration of refugees (17,000). Altogether,teams carried out more than 35,000
consultations, mainly for malaria. Teams also
supported the health ministry with a measles
vaccination campaign for children aged six
months to 10 years in Goré and surrounding
areas, immunising around 7,000 children.

32 Médecins Sans Frontières

From May to October, MSF ran mobile clinics inthree villages near Goré on the CAR border andprovided seasonal malaria chemoprevention(SMC) for children under five, as 60 per cent ofconsultations were for malaria. More than 1,300
children were protected by this strategy ofadministering antimalarials as a prophylactic.

Responding to violence in Darfur
Since 2013, MSF has provided basic andspecialist healthcare to the community in andaround Tissi, a remote town that becomesinaccessible during the rainy season. Violencein neighbouring Darfur, Sudan, has caused
large numbers of Sudanese refugees andChadian returnees to cross the border. MSF
ran a fixed clinic in Tissi, mobile clinics inBiere and Amsisi, and health posts at Um
Doukhum and Ab Gadam. More than 47,300
general outpatient consultations were carriedout in the Tissi programme overall. Increased
stability in the region and the ensuing
decrease in patient numbers as people
travelled back to Darfur meant that MSF
was able to hand over the Ab Gadam healthpost to the NGO Agence de Développement
Economique et Social in June.

Malaria and malnutrition
Malaria is the main cause of death for children
under five, especially during the peak seasonfrom July to October. MSF teams focus on thetreatment of the most severely affected children
in Moissala hospital’s malaria unit in Mandoul
region and provide support to health centres
and community health workers in the districtsof Moissala and Bouna. SMC was given tochildren under five and pregnant women to
reduce the risk of severe malaria during thehigh season. Through these activities, 68,000
children were treated for malaria. In addition,

standard vaccinations were administered tomore than 27,200 children.
MSF also provides emergency paediatriccare to children up to the age of 15 andspecialised treatment for child malnutrition at
the hospital in Massakory, the capital of Hadjer
Lamis region, as well as basic healthcare infour surrounding health centres and a referral
system for complicated cases. In 2014, there
were more than 2,800 hospital admissions
and 55,300 outpatient consultations. Over23,900 children were treated during the peakmalaria season. Between June and December,
MSF ran an emergency care programme for
acutely malnourished children in Bokoro,
Hadjer Lamis. More than 4,760 children underfive were enrolled on an MSF therapeutic
feeding programme, and 574 were admitted
to hospital for treatment.

Salamat region
MSF continued to support the government
hospital in Am Timan and health centres in
Salamat region. The focus was on specialist
care for children up to the age of 15,
including treatment for severe malnutrition,and reproductive healthcare for women –more than 5,200 antenatal consultations
were carried out and 1,900 deliveries assisted.
The team also offered treatment for HIV andtuberculosis and implemented an emergency
malaria response for the general population.
More than 20,600 outpatient consultations
were carried out and 2,900 patients wereadmitted to hospital. In addition, MSF
supported the hospital infrastructure by
upgrading water and sanitation services.

Ouddaï region
MSF started supporting emergency services at
Abeché hospital in Ouddaï region in June.

© Mathieu Fortoul/MSF

chad

Since December 2013, more than 200,000 people fleeing violence in the Central African Republic have sought refuge in southern Chad.

Teams provided lifesaving care to all
emergency surgical cases coming from Abechéor referred from Tissi. The main causes oftrauma were road and domestic accidents.
More than 900 major surgical procedures werecarried out; one in five was related to violence.

Measles outbreakIn response to a measles outbreak early in theyear, MSF collaborated with the health ministry
at Liberty and Union hospitals in N’Djamena
and seven basic health centres. More than
4,500 patients were treated in March and April.
Teams also vaccinated over 69,600 children formeasles in Massakory during the outbreak.

BLOG

Kim Comer, logistician

canoe kiss“ Today we did a canoe kiss. It sounds a lot more romantic than it is.
A kiss movement is a movement between two projects or locations where one vehicle
from each project meets the other halfway to exchange cargo or passengers. It cuts downon the driver’s time behind the wheel and the vehicle’s time away from the field. It’s calleda kiss because the two Land Cruisers touch noses, like a kiss. In reality, they hardly evertouch noses. One, it’s dangerous. Two, it’s hard to load and unload when the cargo doors
are on opposite sides, rather than the cars being side by side in some shady spot. But still
the name remains, kiss.”
To read more, visit blogs.msf.org/kim

International Activity Report 2014 33

colombia

colombia

No. staff in 2014: 139 | Expenditure: d3.9 million | Year MSF first worked in the country: 1985 | msf.org/colombia

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

Key medical figures:© Anna Surinyach/MSF

12,300 outpatient consultations
6,800 individual and group mental
health consultations

People living in rural areas ofColombia and regions affectedby conflict continue to facebarriers to healthcare.
Up until recently, armed conflict was confined
to rural areas; now, new armed groups areconsolidating in urban centres and their
peripheries and insecurity is exacerbatingproblems of access to medical services.
Médecins Sans Frontières (MSF) continued its
programme in Cauca, Nariño and Caquetá,
where poverty, social exclusion and violence
have led to a high prevalence of preventablediseases and mental health problems. The
health authorities have not guaranteed
medical services in these areas. MSF teams
run mobile clinics and offer services athealth posts including basic, mental, sexualand reproductive healthcare, prenatal care,immunisations and a referral system for
emergencies. A similar programme continued
in Cauca Pacífico and a programme focusedon mental health support for victims ofviolence, including sexual violence, operates
in Cauca Cordillera.
People affected by conflict, sexual violenceand psychiatric illnesses benefit when mental

34 Médecins Sans Frontières

Decades of insecurity in Colombia have inflicted a devastating toll on people’s mental
health. Here an MSF psychologist is seen conducting a consultation with a patient.

health services are integrated into basic
healthcare. MSF is urging the government
to recognise sexual violence as a medical
emergency so victims can access thecomprehensive care they need. The team
opened a new programme offering mental
health services to victims of violence, as wellas comprehensive care (mental health andmedical) to victims of sexual violence in Tumaco
municipality in Nariño, and in Buenaventura.

Buenaventura tuberculosis (TB)
project closed
MSF’s TB programme in the port city of
Buenaventura closed at the end of the year.
Since its launch in 2010, a total of 147
patients were treated for drug-sensitive anddrug-resistant TB in MSF-supported facilities.
MSF also supported the national TB strategy.
Some aspects of the programme have beentransferred to the Municipal Program of TB
Control and the Social Company of the State.
The programme in Caquetá was also closed at
the end of the year.

PATIENT STORYAngela Patricia –Angela's brother and her sons’father were found murdered anddismembered in 2008“ My sons … still ask me what happened
to their father. I tell them you need toforgive to feel good. But they are angry
and ask why they did that to theirfather and uncle. The older one wasvery sad and missed him a lot. The MSF
psychologist has helped us overcome
the pain and she has guided me a lot
because there are times when you don´tknow how to explain things to children.
With her you can open up.”

Democratic people's republic of korea | egypt

democratic people's
republic of korea
No. staff in 2014: 3 | Expenditure: d0.5 million | Year MSF first worked in the country: 1995 | msf.org/dprk
Health facilities are not regularly maintainedin DPRK and they lack medical equipment andsupplies. The population is also affected byfood shortages. Only a handful of internationalNGOs are permitted to work in the country,
and their activities are closely controlled.

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

Negotiations are underway toestablish new medical projects
in the Democratic People’s
Republic of Korea (DPRK).

In June 2014, Médecins Sans Frontières (MSF)
completed a project in Anju district, South
Pyongan province, aimed at increasing thecapacity of medical services for the local
population, primarily through staff training
and donations of drugs and supplies. MSF’s
modular approach focused on mother andchild healthcare, including specific training
on management of diarrhoea, respiratory andneurological diseases, malnutrition amongchildren, and life-saving obstetric procedures.
As well as training medical personnel, theMSF team visited the paediatric and maternity
wards of the local hospital, examining
patients and assessing the implementationof training modules. MSF also supplied the
medical equipment and drugs related totraining topics, along with food for patients,
caregivers and staff. Through the project MSF
provided direct care for 250 patients andindirect support for 3,000 people.
At the end of October MSF began exploring
the feasibility of activities in other locations. The
team visited the county hospital in Sukchonin South Pyongan and Kim Man Yu hospitalin Pyongyang and was negotiating with thegovernment at year end to launch further
programmes. In December, two Ministry of
Health staff were invited by MSF to attend an
Ebola training session offered in Geneva.

egypt

No. staff in 2014: 104 | Expenditure: d2.6 million | Year MSF first worked in the country: 2010 | msf.org/egpyt

A key transit and destination country for African and Middle
Eastern refugees and migrants, Egypt has recorded a massive
increase in arrivals and departures since 2011.

Cities, towns or villages where MSF works

Key medical figures:

8,400 outpatient consultations
7,600 individual and group mental
health consultations

430 people treated after incidents ofsexual violence

Regional instability continues to encourage
the flow of refugees and migrants. In 2014,
177,000 people crossed the Mediterranean
to Italy, most having set off from Libya andEgypt. At least half a million migrants arethought to reside in Egypt (of which 193,000
are recognised refugees), where they have few
work opportunities, receive limited assistanceand frequently suffer harassment. Many of
those assisted have been victims of violencein their home country or during their journey.
Médecins Sans Frontières (MSF) teams provide
them with psychological support, and offer
specialised medical assistance to those whohave suffered sexual violence or torture.
In 2014, MSF expanded its services by opening
a second clinic in Cairo. The new clinic in
Maadi district and the existing one in Nasr
City district carried out a total of 11,030
consultations. An MSF team also assisted 1,690
vulnerable individuals on the northern coast,

providing over 1,000 medical consultations
and distributing 1,435 hygiene kits.

Viral hepatitis
MSF is collaborating with the health ministry
to respond to hepatitis C in Egypt: an
estimated 14 per cent of the population is
infected which is the highest prevalence inthe world. Access to treatment is limited
by both cost and the centralised nature ofcare. A decentralised model of care is being
developed, and a clinic integrated into an
existing healthcare structure is expected tolaunch in rural Fayoum governorate in 2015.
The Abu Elian mother and child healthclinic was closed in June, and patients weredirected to existing health facilities nearby
where the relevant services were available andaccessible. About 40,000 consultations had
been provided since 2012.

International Activity Report 2014 35

democratic republic of congo

democratic
republic of congo
No. staff in 2014: 2,999 | Expenditure: d70.1 million | Year MSF first worked in the country: 1981 | msf.org/drc

Key medical figures:

1,593,800 outpatient consultations
499,400 patients treated for malaria
116,300 patients admitted

to hospital

Regions where MSF has projects

DRC’s successive wars have had a severe
impact on the health infrastructure andgovernment-funded services. Violence, fearand displacement have not abated in theeastern provinces, despite a discourse ofstability linked to the large peacekeeping
force. MSF works closely with the healthministry to provide comprehensive
healthcare in some of the country’s mostremote areas, where people cannot obtainor afford the medical care they need. MSF’s
basic and specialist services typically coveroutpatient and inpatient consultations,
surgery, reproductive and mental healthcare,paediatric care including vaccinations,
treatment for malnutrition, HIV andtuberculosis, and aftercare for victims ofviolence – notably sexual violence. Teams
continually work at preventing and limiting
the frequent, life-threatening outbreaks ofmalaria, cholera and measles.
Four Congolese MSF staff members wereabducted in 2013 in North Kivu. This year,
one of them, Chantal, was reunited with

36 Médecins Sans Frontières

her family and she decided to start working
with MSF again. Efforts are ongoing to locate
Philippe, Richard and Romy.

North Kivu
The MSF-supported 300-bed generalreference hospital in Rutshuru remains
the only place where the host populationand displaced people can obtain specialist
healthcare in Rutshuru territory. More than
28,800 patients were admitted this year, a
31 per cent increase over 2013. Teams also

work in Masisi hospital, an outpatient centre
in Masisi town, and Nyabiondo health centre,
west of Masisi. Mobile clinics visit camps fordisplaced people and remote villages in thearea. A vaccination campaign in an extremely
remote mountainous area south of Masisi
immunised over 4,000 children and pregnant
women against a wide range of diseases.
MSF provides basic and specialist healthcare
in Mweso and Walikale hospitals andassociated health centres, and runs malaria-© Jeroen Oerlemans

In 2014, Médecins Sans
Frontières (MSF) continued torespond to the humanitarianconsequences of conflict inthe eastern provinces of the
Democratic Republic of Congo(DRC), as well as to outbreaksof disease across the country.

A mother and child in the paediatric ward of Baraka hospital, South Kivu.

democratic republic of congo

More than 37,000 people were treatedfor malaria during a 14-week emergency
intervention in Kinkondja.

© Phil Moore

Orientale

An MSF team en route to the village of Lukweti in Masisi, in the east of the DRC, to conduct
a mobile clinic – the route is inaccessible by car.

focused mobile clinics in Walikale health zone,
where the disease is rife. Over 16,200 patientswere treated for malaria in 2014.
As mortality rates had decreased, MSF
withdrew from Mugunga III camp, Goma,
after providing 21,100 consultations in2014. Activities in Bulengo were handed
over to other organisations in December.
A small cholera treatment centre on theoutskirts of Goma and its surrounding camps
continued to treat a small but steady streamof patients. In Birambizo health zone, MSF
supported paediatric care in Kabizo healthcentre until May and a cholera outbreak was
brought under control in July in Kibirizi.

infections, care for victims of sexual violence,and family planning services.

Katanga

MSF continues to support Shabunda general
hospital, the smaller Matili hospital, andseven health centres. Basic and specialist
care was also provided to displaced people
and host communities in Minova andKalonge through the local hospitals andhealth centres. The Kalonge project washanded over to the health ministry in April.

MSF continued to develop preventive
measures with other partners to combat
the recurrent outbreaks of cholera in
Kalemie town. These included improving
water supply, distributing residential water
filters in Kataki health area and vaccinating
51,400 people against the disease in July.
Some 700 people received treatment from
MSF during a cholera outbreak in July andAugust. In Kongolo, MSF treated more than
12,300 children under five for malaria andadmitted over 1,350 children with severeor complicated malaria to Kongolo hospital
between March and June. Teams also worked
at six health centres, treating respiratory andparasitic infections and diarrhoeal diseases.
In the provincial capital Lubumbashi, MSF
responded to a spike in measles cases by
providing clinical care in two health facilities.
Following a cholera outbreak in the city, MSF
distributed water, disinfected family homes
and rehabilitated wells.

In Fizi territory, MSF treated more than
101,200 patients for malaria in its Baraka
project, assisted 8,500 births and caredfor 2,035 cholera patients. A full range ofhealthcare was available at Lulimba hospitalin Kimbi Lulenge health zone. MSF saw anincrease in patient numbers in 2014, asother aid organisations providing healthcare
left the region – staff conducted more than
76,100 outpatient consultations and treated
42,800 patients for malaria. A sexual andreproductive health clinic was opened in
October in Misisi, offering ante- and postnatalcare, treatment for sexually transmitted

MSF supported Shamwana hospital andsix health centres in the conflict- anddisplacement-affected health zones of
Kiambi, Mitwaba and Kilwa with basic
and specialist healthcare. Some 67,000
outpatient consultations were carried out. A
community-based malaria programme withnine fixed sites along the Mpiana–Kishale
axis was set up, providing treatment for
simple malaria in villages in the area. A
motorbike referral system was expanded
to transport patients to hospital and roadrehabilitation work was undertaken to
improve access to healthcare.

South Kivu

Violent clashes between the Congolese army
and armed opposition groups continued totake a toll on people in Gety health zone. An
MSF programme here focuses on healthcare
for women and children under five. MSF
also manages Gety hospital’s emergency
and intensive care wards, paediatric andmaternity services, blood transfusions andlaboratory. A neonatal ward was opened
in September. To relieve pressure on
health centres in the area, MSF donatedmedicines and treated more than 96,800
patients. When large numbers of people
were displaced by extreme violence in Nia
Nia, Mambassa and Bafwasende healthzones, MSF provided medical care, including
urgently needed support for victims ofsexual violence, from June to November. In
October, teams offered health consultations
in Ituri district following an influx of 25,000
people escaping conflict in North Kivu.
The project screening and treating patientswith sleeping sickness (human African
trypanosomiasis) in Ganga-Dingila, Ango
and Zobia was closed due to low prevalence
but activities were ongoing in Doruma. MSF
continued to manage Dingila hospital’s
intensive care and emergency wards until
December when the project was closed.

Kinshasa
For many years now HIV treatment has been
increasingly decentralised in Kinshasa and acommunity-based programme manages the
distribution of antiretroviral medication tostabilised patients. The MSF HIV programme
is now focused on providing comprehensive
and high-quality care to people living in the
Massina neighbourhood and this includes
proactive testing, especially for high-risk
groups, the introduction of community
ARV groups and the implementation ofviral load monitoring.

Ensuring rapid response to emergencies
MSF’s emergency response teams monitor,
investigate and respond to disease across
DRC as needed, and interventions werelaunched following outbreaks of measles,
typhoid, Ebola and suspected yellow fever.
MSF’s emergency teams also responded to
the needs of displaced people and victimsof violence. When the first Ebola cases
were confirmed in August, MSF set up twotreatment centres and worked with thehealth ministry to manage and control theoutbreak. Of 25 Ebola patients treated atthese centres, 13 recovered. The outbreak
was over by November.

International Activity Report 2014 37

ethiopia

ethiopia

No. staff in 2014: 1,416 | Expenditure: d21.3 million | Year MSF first worked in the country: 1984 | msf.org/ethiopia
Key medical figures:

347,700 outpatient consultations
6,800 routine vaccinations
2,800 births assisted

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

Some 200,000 refugees from thecivil war in South Sudan arrived
in Gambella region, western
Ethiopia, between December
2013 and October 2014.
The long journey on foot, with inadequate
food and water, had taken a toll on people’s
health and many arrived in Ethiopia sick andmalnourished. From February, Médecins Sans
Frontières (MSF) provided medical consultations
and care at entry points close to the border.
Teams worked at a health post in Pagak andTiergol, ran mobile clinics in Pamdong and
Burbiey, and conducted outpatient consultations
at a health post in the Matar transit camps.

end of the year, 541 people with suspected
hepatitis E received medical care.
To address the lack of clean water and sanitation
facilities in Kule and Tierkidi camps, MSF set up awater treatment plant that produced 56.4 million
litres of safe water before it was handed overto Oxfam in July. Teams also constructed
more than 2,500 showers, 1,200 latrines and180 hand-washing points in the camps.
MSF launched a preventative vaccination
campaign against cholera in Gambella region in
July, targeting 155,000 refugees and membersof the host community who each received
two doses of the vaccine. In November, some

23,000 children aged six weeks to five years
were immunised against pneumococcus andcommon childhood diseases.

Southern Nations, Nationalities andPeople’s Region (SNNPR)
A programme focused on health services formothers and children under five continued
in the Aroressa and Chire woredas (districts)of Sidama, SNNPR. Teams worked in healthcentres in Mejo and Chire and conducted
outreach activities in 13 locations. During
the course of the project, which was handed
over to the Ministry of Health in October, twomaternity waiting houses were constructed

MSF ran inpatient and outpatient services forrefugees and the host population at a 118-bed
health centre in Itang, close to Kule and Tierkidi
camps, where more than 100,000 people had
settled by April. When the Itang health centre
flooded in August, MSF moved activities to thestaff compound and had to reduce the numberof beds. MSF provided decentralised medicalcare through two health posts in Tierkidi camp
and three in Kule, and ran a 120-bed hospitalin Kule. The hospital has an isolation unit for
hepatitis E patients and between July and the

38 Médecins Sans Frontières© MSF

MSF also started a programme in Leitchuor
camp. The 100-bed hospital offered outpatient
consultations, emergency services, maternal
healthcare and treatment for malnutrition.
Outreach workers engaged in health promotion
activities and identified people needing medical
attention. The camp is located in an area prone
to flooding and was inundated during the rainyseason, causing the eventual relocation of the
refugees to other camps in nearby villages andon higher ground.

A vaccination campaign underway in one of the refugee camps in Gambella region.

© Matthias Steinbach

ethiopia

A child being examined in Chire health centre, Sidama, where MSF runs a programme focused on the health of mothers and children under five.

to enable women with high-risk pregnancies
who lived far from health facilities to deliversafely. MSF also supported referrals of paediatricemergencies and women presenting withcomplications during labour to hospitals in
Hawassa, Yirga Alem or Addis Ababa.
MSF started a new project in SNNPR in October,
together with the Regional Health Bureau.
Its purpose is to strengthen the emergency
preparedness, surveillance system and response
capacity of the public health management teamin six selected zones of the SNNPR. These zones
are Sidama, Wollayta, Gamogofa, Segen, SouthOmo and Bench Maji.

Somali region
Underdevelopment and conflict between thegovernment and armed opposition groupspose barriers to healthcare in Somali region,and 200–500 refugees from Somalia arrive inthe Liben zone each month. The population of
Buramino and Hiloweyn refugee camps, Libenzone, has reached 77,000. MSF continued toassist with the provision of basic healthcare
at the reception centre and in the camps. A
team also provided medical care for Somali
refugees and the host community in Dolo Ado,
Liben zone. In the hospital, MSF supported thepaediatric inpatient department, stabilisation
centre, emergency room and laboratory,
as well as emergency obstetric surgery andmaternity services. Between January and Marchteams vaccinated 12,100 children against
measles and carried out several rounds of polio
vaccinations in collaboration with the Regional
Bureau of Health.

MSF supported the regional hospital in
Degehabur, providing inpatient care forchildren under five, tuberculosis (TB) treatment,
nutritional support, and emergency room
and intensive care services. It also supported
three health centres and nine health posts in
Degehabur, Ararso and Birqod woredas, andconducted outreach activities. The focus in2014 was on mother and infant health – there
were 2,578 antenatal consultations – as well as
nutrition and vaccination activities.
In September, MSF started supporting Fiq
hospital, Nogob zone, and provided an
emergency referral system, outpatient services,nutritional support, paediatric inpatient care,obstetrics and gynaecology, and pharmacy andlaboratory services. A network of community
health workers was also established.
In Danod, MSF offered basic healthcare in the
24-hour health centre and ran weekly mobile
clinics in four villages in the district. The teamconducted more than 12,000 consultationsin 2014. In addition, MSF helped build local
healthcare capacity by donating medical
supplies, and coaching and supervising staff.
Maternity services and treatment for malnutrition
are a focus of this programme. MSF continued
to address gaps in healthcare provision around
Wardher, running mobile clinics in five villages
in the district, and visiting Yucub health centre
three times a week to support and supervise
the staff and to donate medical supplies. An
ambulance service also operated, covering
18 villages in Wardher and Danod districts,
transferring patients with life-threatening

conditions to Wardher hospital. MSF supported
the hospital’s paediatric, TB and maternity
departments, as well as a stabilisation unit forseverely malnourished children and was involvedin the set-up of an operating theatre run by the
Ministry of Health, which provides emergency
obstetric surgery. A measles vaccination
campaign was carried out in collaboration withlocal health authorities in March, reaching 4,300
children, and eight rounds of polio vaccinations
were completed in Wardher and the surroundingarea. In September, MSF handed over routine
vaccinations, care for chronic conditions andtriage to national health authorities.

Kala azar and malnutrition in Amhara
The parasitic disease kala azar (visceralleishmaniasis), endemic in this area, is usuallyfatal if left untreated. MSF continued its
programme for patients with kala azar in
Abdurafi, Amhara region, including those coinfected with HIV/AIDS or TB. Nutritional support
is available to patients in the programme. Morethan 1,200 people were screened for kala azar in
2014. MSF also filled gaps in emergency services,
provided inpatient care for children under fivewith malnutrition and transported patients to
hospitals in Humera and Gondar.

Project closures
In Raad, Gambella region, an emergency
project that started in July 2013 came to an
end in January following the closure of thetransit camp for South Sudanese refugees.
Another project providing assistance torefugees in the western region of BenishangulGumuz, also came to an end in May.

International Activity Report 2014 39

georgia | greece

georgiaNo. staff in 2014: 28 | Expenditure: d0.8 million | Year MSF first worked in the country: 1993 | msf.org/georgia

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

Key medical figures:

18 patients under treatment for MDR-TB
Médecins Sans Frontières (MSF)
handed over its multidrug-resistanttuberculosis (MDR-TB) activities
in Abkhazia in August 2014,
and focused on patients withextensively drug-resistant forms ofthe disease in the capital Tbilisi.

Despite a very significant decrease in thenumber of TB cases in Georgia over thelast 20 years, prevalence remains high.
Every year around 500 patients are foundto have MDR-TB and are offered treatment;
approximately 10 per cent of these proveto have the extensively drug-resistantform of the disease (XDR-TB). Treatment
is not successful in more than 60 per centof patients diagnosed with XDR-TB and asignificant number of them subsequently
die. These statistics from the Georgia
Ministry of Health clearly show the needfor improved treatment regimens. Two new
drugs – bedaquiline and delamanid – haverecently become available to some patients
who have no other treatment options left.
These are authorised by the manufacturers
on a case-by-case basis.
In September 2014, MSF started supporting
the National Center for Tuberculosis andLung Diseases in Tbilisi. Training andtechnical support were provided to hospital
staff to improve detection and clinical careof XDR-TB patients, and to facilitate theirearly access to new drugs. As of December,
18 XDR-TB patients were benefiting frombedaquiline. Clinical trials for new andimproved treatments for MDR-TB should
start taking place at the hospital in 2016.
The trials will aim to identify new treatment
plans combining old and new TB drugs, andwill include assessments of their toxicity andeffectiveness. A grant for activities in Tbilisi
was under discussion with UNITAID at theend of 2014.

Handing over activities in Abkhazia
In August, MSF handed over its access tocare programme for elderly and vulnerable
people, as well as its TB and MDR-TB
activities in Abkhazia, to a local NGO set up
by former MSF staff. Support for patientswith chronic diseases included home-basedcare, ophthalmologic consultations andprovision of equipment such as wheelchairs.
MSF continues to facilitate the transportationof sputum samples from Abkhazia to theculture laboratory in Tbilisi.

greeceNo. staff in 2014: 10 | Expenditure: d0.5 million | Year MSF first worked in the country: 1991 | msf.org/greece

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

Key medical figures:

2,500 outpatient consultations
490 individual and group mental
health consultations

Thousands of migrants andasylum seekers arrived in
Greece in 2014, many on their
way to northern Europe.
40 Médecins Sans Frontières

Undocumented migrants and asylum seekers
continued to be detained with limitedaccess to healthcare or basic services. Living
conditions in detention centres remained
extremely poor. Overcrowding, substandard
hygiene, and inadequate heating, hot waterand ventilation led to the outbreak andspread of respiratory, gastrointestinal anddermatological diseases. In April, Médecins
Sans Frontières (MSF) released a report,
Invisible Suffering, documenting the massive
impact of detention on the physical andmental health of migrants and asylum seekers.
Many of those detained have no or limitedaccess to the outdoors. The report also
highlighted the gaps in healthcare provisionand the absence of medical assessments, aswell as the detrimental effects of prolonged
detention on the health of migrants andasylum seekers due to lack of necessary careor interruption of treatment.
In Evros region, MSF provided medical
consultations and psychosocial support topeople being held at detention centres in
Komotini and Filakio, and in the police stationsof Feres and Soufli. Nearly 600 relief kits were
distributed to help people maintain a basic
level of hygiene, health and dignity. In March,these activities were handed over to EKEPI.
In 2014, more than 42,000 people – almost
80 per cent of them from Syria – crossed the
Aegean Sea from Turkey to the DodecaneseIslands. Many were forced to sleep outside
or in overcrowded police cells while waiting
to be transferred to the Greek mainland,as there were not enough suitable facilities
to host them. Towards the end of the year,
MSF launched two emergency interventions,providing medical care and distributing morethan 2,000 kits containing sleeping bags andhygiene items such as soap.
In September, in collaboration with two Greek
organisations, MSF opened a project in Athens
offering medical rehabilitation, including
physiotherapy, for asylum seekers and migrants
who have been victims of torture.
For more on refugees and migrants arriving inEurope, see Bulgaria (p.26), Italy (p.50) andSerbia (p.73).

Guinea-Buissau | honduras

Guinea-Buissau

No. staff in 2014: 8 | Expenditure: d0.9 million | Year MSF first worked in the country: 1998 | msf.org/guineabuissau

There is a shortage of good-quality healthcare in Guinea-Bissau,
particularly in rural areas.
A rudimentary health system is in place,but its poorly functioning facilities lackresources and a referral system, and accessto them is unequal.
Regions where MSF has projects

Key medical figures:

1,000 outpatient consultations

In the central Bafatá region, publichealthcare is limited, the population isscattered and distances to the nearest
health facilities are considerable. Mortality
rates are therefore very high, and theaverage life expectancy is 48 years. Childand maternal mortality rates are particularly
concerning. As an initial response to
the high incidence of illness and deathamong young children, Médecins Sans

Frontières (MSF) opened a project inBafatá in November. Free basic paediatriccare is offered at the health centres in therural area of Tantan Cossé, Contuboel,
and a team provides basic and specialist
healthcare for children in the paediatricoutpatient area and the paediatric wardof the regional hospital. Furthermore, theproject aims to develop decentralised,community-based healthcare for young
children, involving community healthworkers. This would help to address theidentified barriers to access, and implement
simpler diagnostic algorithms for children
presenting with fever.

honduras

No. staff in 2014: 44 | Expenditure: d1.2 million | Year MSF first worked in the country: 1974 | msf.org/honduras
one of the world’s most violent cities, andmurder, abduction and rape are day-to-day
realities for many inhabitants.

Cities, towns or villages where MSF works

Key medical figures:

1,800 individual and group mental
health consultations

560 people treated after incidents ofsexual violence

Médecins Sans Frontières(MSF) provides treatment topeople affected by violence,with a particular focus on
victims of sexual violence.
Honduras has experienced years of political,
economic and social instability and as aconsequence has become overrun withcriminal activity. Tegucigalpa, the capital, is

MSF developed a servicio prioritario or
priority service in collaboration with thehealth ministry in Tegucigalpa, offering
emergency medical and psychologicalattention to victims of violence, including
sexual violence. Comprehensive healthcare
services are lacking for those who are able
to overcome fear of retaliation and seek
help. The priority service, where everythingis provided in one place and is confidential
and free, is offered at two health centres
and in Tegucigalpa’s main hospital. As
many people, especially young womenand girls, do not know that this help exists,
MSF’s health promotion teams focus onsensitisation and outreach activities to spreadthe word, and consequently the number ofvictims of sexual violence seeking assistancewithin 72 hours increased this year.
In 2014, MSF treated 700 victims ofviolence, including 560 victims of sexual
violence, and carried out 1,770 mental
health consultations. Medical treatment
for rape includes post-exposure
prophylaxis to prevent HIV infection andprovide protection against other sexuallytransmitted infections, hepatitis B and tetanus.

The mental healthcare includes counsellingand psychological first aid. The emergency
contraceptive pill, however, has beenbanned in Honduras since 2009. A debate
was initiated in 2014 in the HonduranCongress to change the policy on emergency
contraception, and it continues today. MSF
has taken part in the discussions and has
highlighted the psychological and medical
consequences of pregnancy as a result of
sexual assault.
As there are currently no guidelines in place
for the treatment of victims of sexual violencein Honduras, MSF is pushing for the healthministry to implement a national protocol.

PATIENT STORY
Aurelia* – an MSF patient in
Tegucigalpa, who was raped at
gunpoint by strangers“ Before the (MSF) doctors took care of me,
I wanted to die … I felt dirty; I felt as if
I had lost a part of my life; I didn’t want
to exist anymore. But I had therapy andcounselling and, thanks to this, I’ve beenable to overcome a lot. It has changed
my life. “* Name has been changed

International Activity Report 2014 41

guineaguineaNo. staff in 2014: 545 | Expenditure: d18.7 million | Year MSF first worked in the country: 1984 | msf.org/guinea | blogs.msf.org/ebola

On 22 March, what was to become the largest recorded
outbreak of Ebola was officially declared in Guinea.

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

Key medical figures:

3,100 patients admitted toEbola management centres, of which

1,700 were confirmed as having Ebola
800 patients recovered from Ebola

Médecins Sans Frontières (MSF) wascollaborating with the Guinean healthministry on a malaria-focused project in thehospital in Guéckédou and 20 community

locations in Guinée Forestière when Ebola
was suspected. On 18 March a reinforcement
team with viral haemorrhagic fever
specialists arrived in Guéckédou and started
an exploratory intervention, supporting
the health ministry in collecting samples
for analysis. Once the Ebola epidemic wasdeclared, the malaria programme was put
on hold as staff were reassigned to help the
MSF emergency team build the first Ebola
management centre (EMC) in Guéckédou.
The malaria programme closed in August.
The EMC in Guéckédou opened on 23 Marchand served as the main centre for Ebola casesin the region, caring for patients, carrying
out health promotion and outreach activities,
and training medical and sanitation staff. A
psychosocial team also worked at the EMC
to support patients, and spent time with© Sylvain Cherkaoui/Cosmos

and discharged

It is believed that the outbreak originated in
the Guinée Forestière region in December
2013. Previous outbreaks of Ebola had mostly
erupted in remote villages in central andeastern Africa, where they could be moreeasily contained. This time, however, Ebola
broke out at the junction of Guinea, Liberia
and Sierra Leone, where people regularly
move across the porous borders. The
deficiencies of the public health system in
Guinea and the fact that early symptoms ofEbola are similar to malaria – a salient healththreat in the country – led to misdiagnosis ofinfections early in the epidemic and allowed
for the spread of the disease.

An MSF staff member wearing personal protective equipment (PPE), which includes a protective suit, goggles, a face mask, gloves, an apron
and rubber boots. No skin should be exposed.

42 Médecins Sans Frontières© Sylvain Cherkaoui/Cosmos

guineaSia Bintou, pictured here being discharged, spent more than 10 days in the Guéckédou management centre before successfully beating Ebola.

families and communities, helping address
their fears and cope with the loss of family
and community members. By the end of theyear, 1,076 Ebola cases had been confirmed,
and 430 patients had recovered and beendischarged from the facility.
To reinforce the activities of the EMC,MSF opened a transit centre in Macenta,
Nzérékoré region, facilitating detection,
triage and referral of patients coming fromthe southeast of Guinea. Psychologicalsupport was also provided. Between
March and November, 520 patients weretransferred to Guéckédou EMC. At the endof the year, the transit centre was converted
into an EMC and handed over to the French
Red Cross.
On 25 March, MSF opened an EMC within
Donka hospital in Conakry, Guinea’s capitalcity. The team conducted health promotion,
educational and outreach activities,
including identification of possible patientswith Ebola, provided psychosocial support
and trained medical and sanitation staff. By
the end of the year, 1,463 patients had been
admitted; 594 of these were confirmed tohave Ebola and 290 recovered.

Telimele district, 270 kilometres north ofConakry, was relatively far from the country’s
Ebola epicentre in the southeastern forest
region, but Ebola cases were reported inMay. MSF teams were quick to respond,transforming one of the local health centre’swings into an isolation area and building an
EMC nearby which opened within days. By theend of July, Telimele was declared Ebola free.

Researching Ebola treatment
In the absence of specific human treatments
for Ebola, MSF partnered with the French
National Institute of Health and Medical
Research (INSERM) to trial an experimental
treatment in the midst of an outbreak. The
drug tested in Guéckédou for efficacy against
Ebola was favipiravir, an antiviral used inJapan to combat resistant flu in adults. Soonother sites, not managed by MSF, were also
included in the favipiravir trial. More trials fortreatments, vaccines and diagnostic tools wereplanned to start in the region early in 2015.

tracing, community mobilisation andinfection control protocols – needed to bestrengthened, and MSF continually asked
for more support in 2014. Many Guineansremain reticent to accept messages about
Ebola, as the general level of knowledge
about it is low. Health workers, patients,
contacts and survivors are often stigmatised
and this prevents people from seeking
medical help – such as those suffering frommalaria, which has not receded as a healthissue during the Ebola crisis.

Measles vaccinations in Conakry
In February 2014, MSF vaccinated more than
370,000 children aged between six months
and 10 years against measles in the Conakry
neighbourhoods of Matam, Ratoma andMatoto. At the end of the intervention thevaccination coverage was just over 87 percent. Staff treated 2,948 cases of measles,
241 of which were severe.

Ongoing challenges
In order to bring the Ebola outbreakunder control, critical components of the
response – such as surveillance, contact

International Activity Report 2014 43

haitihaiti

No. staff in 2014: 2,159 | Expenditure: d35.2 million | Year MSF first worked in the country: 1991 | msf.org/haiti

Emergency services in Port-au-Prince

Cities, towns or villages where MSF works

Key medical figures:

14,600 surgical interventions
9,500 births assisted
Five years after Haiti’s
massive earthquake, thehealth system is only
partially reconstructed andspecialist services remainout of reach for many people.
Médecins Sans Frontières (MSF) has
continued to fill gaps in the Haitian
healthcare system (gaps it has been fillingsince before the catastrophic earthquake in2010) and has been helping to build local
capacity by training national staff. Haitians
need better access to emergency services,
including obstetrics, neonatology, surgery
and trauma care. Cholera is an ongoinghealth threat but there is a lack of available
finances to tackle it and no effective
response plan in place. MSF is regularly
stepping in to treat patients and prevent
major cholera outbreaks and loss of life.

Responding to more than 45,000
emergencies in 2014, the Martissant
emergency and stabilisation centre is afree, around-the-clock resource for people
experiencing any kind of medical emergency,
caused by violence, accidents, burns orobstetric complications. There are eight beds
where patients can remain under observation
and an ambulance service for referrals toappropriate hospitals. MSF’s specialists
provide care in paediatrics and internal
medicine. Staff treated more than 25,000
patients with accidental trauma, 13,250 withviolent trauma and more than 3,700 people
with cholera.
MSF provides emergency services including
surgery and trauma-related care around theclock at the 121-bed Nap Kenbe centre in
Tabarre, eastern Port-au-Prince. The centre
has three operating theatres, an intensive careunit and an outpatient department that isopen six days a week. Since mid-2014, MSF
has been running an orthopaedic surgery
training programme at the centre.
To ensure a high standard of care, MSF
has installed onsite technical services,
including an X-ray machine, a laboratory
and a blood bank, sterilisation facilities
and a pharmacy. Social and mental healthsupport and rehabilitation through post-

operative care and physiotherapy are allavailable to patients to maximise theirrecovery after emergency treatment. Teams
responded to more than 9,880 emergencies
and performed more than 4,200 surgicalprocedures in 2014.

Specialist care for obstetric emergencies
Located in the central Delmas 33
neighbourhood of Port-au-Prince,
MSF’s 140-bed Centre de Référence en
Urgence Obstétricale (CRUO) continued
to provide 24-hour, free obstetric care topregnant women experiencing serious
and life-threatening complications suchas pre-eclampsia, eclampsia, obstetrichaemorrhage, prolonged and obstructedlabour and uterine rupture. CRUO offers a
range of reproductive healthcare services,
including ante- and postnatal care, familyplanning and prevention of mother-to-childtransmission of HIV, as well as neonatal careand mental health support. There is also
a 10-bed ‘Cholernity’ ward for pregnant
women with cholera. There was an averageof 17 births a day in the CRUO in 2014.
Some 10,400 patients were admitted to
the facility.

Chatuley hospital
Following the January 2010 earthquake,
MSF constructed a temporary container

Domestic accidents and poor living conditions
are the main causes of burns in Haiti, andvictims are predominantly women andchildren. MSF continued to run the only
facility treating burns patients in the country,
in Drouillard hospital, close to the Cité Soleil
slum in Port-au-Prince. Equipped with threeoperating theatres, the hospital increased
capacity from 30 to 35 beds. To focus on thetreatment of burns patients, MSF closed thetrauma unit it was running inside the hospital.
There were 481 patients hospitalised forburns in 2014.

44 Médecins Sans Frontières© Clara Nordon/MSF

Drouillard burns unit

A mother and child in the Drouillard burns unit are seen here talking to an MSF staff member.

© Corentin Fohlen

haiti

The number of people contracting cholera spiked in October. In response, MSF set up cholera treatment centres in Port-au-Prince neighbourhoods
such as Martissant. Cholera is transmitted by contaminated water or food, or through direct contact with contaminated surfaces.

hospital to conduct surgery in Léôgane,an area that was 80 per cent destroyed by
the disaster. The programme has evolved
to handle emergencies, focusing mainly
on complications in pregnancy and roadaccident victims. Basic medical care is also
provided to pregnant women as well as
children under five.
In keeping with the plan to shut the hospitalin 2015, MSF has been progressively
reducing activities at Chatuley since 2013.
In February, a cholera treatment unit that
had been running since 2010 was closed.
As of November, only emergency services
for pregnant women, newborn babies andchildren under five were being provided.
There will be no formal handover of thehospital to the Haitian authorities, and soteams have been reinforcing the capacityof other medical facilities in the area in
preparation for the closure.
In 2014, MSF admitted 6,782 patients
to Chatuley hospital, carried out 2,617
consultations for children under five,provided 6,162 antenatal consultations
and assisted 3,298 births.

Cholera response
Four years after cholera’s first appearance inthe country, the Haitian health system is stillfacing a shortage of funds, human resourcesand drugs. Many Haitians continue to lackaccess to clean water and adequate latrines,
resulting in regular outbreaks of cholera, apotentially deadly communicable disease.
Outbreaks today can mostly be predicted, yet
the authorities remain unprepared. There areinsufficient public cholera treatment centres(CTCs) in Haiti and reduced international

funding has limited the delivery of medicalcare and the provision of clean water andsanitation services. When the number ofpeople contracting cholera spiked in October,
MSF set up CTCs in the Martissant, Delmas
and Carrefour neighbourhoods of the capital.
Teams also focused on preventive measures,
including distribution of disinfection kits
(chlorine, buckets, etc), and awareness andeducation activities. More than 224,600
people were reached via these activities and1,640 disinfection kits were distributed.
Overall, more than 5,600 people received
MSF-supported cholera treatment.

International Activity Report 2014 45

indiaindia

No. staff in 2014: 657 | Expenditure: d10 million | Year MSF first worked in the country: 1999 | msf.org/india
Key medical figures:

92,200 outpatient consultations
4,400 patients treated in
feeding centres

2,700 individual and group mental
health consultations

1,500 patients on first-line
ARV treatment

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

Many people in India cannot
access medical care becauseof poverty, social exclusion
and an under-resourced
healthcare system.

malnourished children up to five years ofage with serious medical complications,and admitted more than 250 patientsover the course of the year. MSF continues
to work with the health authorities tointegrate nutritional care within the publichealth system.

High-quality services are available for thosewith means, but a significant portion of
the population cannot obtain even basic
healthcare. Treatment for diseases such as
HIV, tuberculosis (TB) and kala azar (visceralleishmaniasis) is not universal. Médecins Sans
Frontières (MSF) aims to fill some of thesegaps and build capacity so more people canget the medical care they need.

Kala azar
Kala azar is endemic in the Vaishali district ofBihar. Transmitted by the bite of an infected
sandfly, this parasitic disease is almost always
fatal if left untreated. Although MSF’s kalaazar programme saw more than 1,000
patients in 2014, the number of recorded

cases has decreased across India in the last
four years.
In order to achieve the goal of eliminatingkala azar in India by 2015, the government
adopted single-dose liposomal amphotericin B
as the first-line treatment in October.
This policy change was made following
sustained advocacy by MSF, which included
a presentation of the data collected from apilot project, aimed at demonstrating thesafety and effectiveness of new treatment
models. MSF also supported the authorities
by training doctors and nurses in areas
where kala azar is widespread.

Child malnutrition is an underreported
health emergency and MSF has beenworking with health authorities to increase
access to treatment for malnourishedchildren in Darbhanga district, Bihar state.
Most children are from impoverishedfamilies and live in villages where healthservices are often inadequate. The MSF
programme provides weekly outpatient
treatment for severely malnourishedchildren aged six months to five years,
through 12 basic health centres. Morethan 3,500 patients were enrolled for
outpatient treatment and over 300 children
with minor complications were referred to
MSF’s stabilisation centre for inpatient carein 2014.
The malnutrition intensive care unit, built
inside Darbhanga Medical College Hospitaland run by MSF, is the first of its kind in
India. It opened in March to treat severely

46 Médecins Sans Frontières© Sami Siva

Malnutrition

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

© Sami Siva

india

An MSF nurse takes a blood sample to check for malaria; one of the services offered at the mobile clinic in Chhattisgarh.

Mobile clinics
Ongoing, low-intensity conflict between thegovernment and Maoist groups makes it
difficult for people in Chhattisgarh, Andhra
Pradesh and Telangana to obtain medicalcare. MSF continued to offer healthcare
through weekly mobile clinics in villages insouthern Chhattisgarh, and to displaced
people in Andhra Pradesh and Telangana.
In Chhattisgarh, the MSF health centre in
Bijapur district focused on mother and childhealth, providing obstetric, neonatal andpaediatric care. Teams also ran mobile clinics
to bring basic and specialist medical services
to the surrounding population. More than
63,200 consultations were carried out, and14,657 patients were treated for malaria.

Extending care for HIV and TB
In Mumbai, MSF runs a clinic that provides
psychosocial and medical care to patientswith drug-resistant TB, HIV and hepatitis
B or C, and those who are co-infectedwith any of these diseases. These patientsrequire specialised diagnostics, care andtreatment which are not available throughthe public health system. Teams actively
share knowledge with local organisations
and professionals to build capacity.

MSF continued to run clinics providing
HIV and TB diagnosis and treatment in
Churanchandpur and Chandel districts inthe northeastern state of Manipur, which
has some of the highest rates of HIV in the
country. MSF started cooperating with a local
NGO to offer inpatient care for HIV patients,and offered additional support for opioid
substitution therapy for intravenous drug
users. After screening patients for hepatitis C,
MSF confirmed that more than 25 per cent of
HIV patients were co-infected.

Mental healthcare in Kashmir
MSF has been running mental healthprogrammes in Kashmir since 2001. There are
currently programmes in Srinagar, Baramulla,
Pattan and Sopore, and normally patientscome to the projects to see counsellors andclinical psychologists after referrals from
hospital psychiatrists. To increase local
awareness and the visibility of mental healthissues, MSF worked with a Kashmiri production
company to produce a 13-episode TV soap
opera, Aalav Baya Aalav. The first episode wasbroadcast on 18 December, and immediately
triggered 80 phone calls to the MSF clinic
information line with questions and reactions.
People subsequently visited the MSF clinics formore information and for counselling.

Floods in the Kashmir valley in September
forced MSF to close mental health clinics
in Kashmir for more than a month, but
counselling services were later extended withthe opening of clinics in Pulwama, Kakapora
and Bandipora. In the immediate aftermathof the flooding, teams distributed relief items
including water, food, blankets and wash kits.

Malaria emergency
By mid-year, more than 50,000 cases ofmalaria had been recorded in a four-month
period in different areas of Tripura state. MSF
trained community health workers to detectand treat simple malaria and refer complicatedcases for intensive care. More than 5,200 rapid
diagnostic tests were carried out and MSF
treated over 2,300 patients in some of thehardest-to-reach areas of the state.

Nagaland project handover
MSF played a key role in revitalising the
Mon district hospital in the northeasternstate of Nagaland with equipment upgrades
and staff training. The four-year project was
successfully handed back to the Ministry of
Health by mid-year, once the hospital was
fully functional.

International Activity Report 2014 47

iraq

iraq

No. staff in 2014: 627 | Expenditure: d20.4 million | Year MSF first worked in the country: 2003 | msf.org/iraq
construction of latrines and showers in Dabinto help maintain a basic standard of hygiene.

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

Key medical figures:

219,800 outpatient consultations
17,700 individual and groupmental health consultations
7,300 relief kits distributed
A rapid escalation in conflict in
Iraq caused massive internal
displacement in 2014. Nearly
two million people have fled
their homes in search of safety.
Continual fighting hampered the delivery ofhumanitarian assistance to displaced people
in northern and central Iraq. Médecins
Sans Frontières (MSF) launched emergency
interventions and found that most of thehealth problems were related to poor
sanitary conditions, particularly the lackof latrines and clean water. Staff routinely
treated people with respiratory and urinary
tract infections, gastrointestinal problems,and skin and chronic diseases.

In Kirkuk city and the surrounding areas,
two teams ran mobile clinics in fivelocations providing basic healthcare,focusing on chronic diseases, maternal andpaediatric care. More than 20,000 blankets
and 2,200 wash kits were given to displaced
families. Mobile clinics reached displaced
people in several locations between Mosul
and Erbil from June to August and MSF was
the first healthcare provider to arrive andset up a basic health clinic at Bharka camp,where displaced people were gathering. The
clinic was handed over to the International
Medical Corps several weeks later.
In October, MSF began offering basic
healthcare in a clinic in Diyala governorate,focusing on the needs of people displacedby the conflict in the region. Teams
conducted more than 4,700 medical
consultations. As winter was approaching,
they distributed relief items, including
blankets, tents and shelter construction
kits to more than 400 families living in
makeshift camps and informal settlements
in northern Diyala.
Between November 2014 and January 2015,
MSF assisted displaced people coming fromthe north of the country and from Najaf,
Karbala, Babil, Wassit and Al-Qadisiyyah

governorates, by running mobile clinics
and health promotion activities, and byproviding relief supplies. More than 14,000
kits containing blankets, cooking utensils
and hygiene items were distributed, and
1,387 consultations took place.
As fighting intensified in Anbar, Ninewa,
Salah ad-Din, Diyala and Kirkuk governorates
towards the end of the year, people trying toleave unsafe areas were finding themselvestrapped. MSF has repeatedly asserted that
protection, access to humanitarian aid
and the right to reach safer areas must be
guaranteed for all communities.

The consequences of conflict
In June, the day after MSF had completed
its basic healthcare clinic in Tikrit, thestructure was destroyed by an explosion,and international and Iraqi medical staff
were evacuated from the area. The IS group
took control of the city and MSF has notbeen able to return since.
Teams had been working in the general
hospital of Hawijah, supporting the
emergency services, since 2010. In August,MSF offices in the hospital compound wereseverely damaged during fighting and thisprompted the closure of the project. Also inAugust, staff had to flee the Sinjar hospitalwhen IS forces seized the town; some staff
members later joined the MSF teams in

Emergency relief for displaced people

In June, four mobile clinics started to operate
across Dohuk governorate, providing basic
medical care and distributing relief items todisplaced people. Teams supplied over 1,000
wash kits (soap, shampoo) and undertook
water and sanitation activities, including the48 Médecins Sans Frontières© Gabrielle Klein/MSF

The Islamic State (IS) group and allies
launched major offensives in Samarra andMosul in June, and around Sinjar, near
the border with Syria, in August. During
this period people fled for safety, mainly
into Iraqi Kurdistan. MSF responded bylaunching emergency interventions toprovide basic medical care and relief fordisplaced families in several locations.

Displaced people from Sinjar are living in Dohuk governorate, in unfinished buildings
and informal settlements.

© Gabrielle Klein/MSF

iraq

Patients are seen here at an MSF mobile clinic in Dohuk governorate, collecting medication after their consultation.

Dohuk and are still working to provide
medical services to their communities.
In December, MSF withdrew from Heet
hospital after the IS group took the city.
Most of the members of the medical team
left, and thousands of people from Al-Anbar
who had already fled their homes wereforced to move on once again.

Assisting Syrian refugees in
Iraqi Kurdistan
In addition to the newly displaced Iraqis
needing assistance in the region, morethan 200,000 Syrian refugees have been
living in Iraqi Kurdistan, many in Erbilgovernorate, and have ongoing healthcare
needs. MSF was the main provider of basic
healthcare to Syrians in Darashakran and
Kawargosk refugee camps, until activities
could be handed over to the International
Medical Corps in November and December,respectively. MSF had carried out morethan 64,000 outpatient consultations.
There is still a great need for psychologicalsupport among camp residents who havefled violence and are living with fear anduncertainty. MSF has continued to provide
a programme of mental health support inthese camps and the team carried out morethan 1,100 consultations during the year.
MSF remains the main healthcare provider
in Domiz camp, Dohuk governorate, home
to some 60,000 Syrian refugees. Services
include sexual and reproductive healthcare,management of chronic diseases andmental health support. MSF also ensuresemergency services and referrals to Dohukhospital around the clock. In August, MSF
opened a maternity unit and had assisted
571 deliveries by the end of the year.

liaison officers refers patients, and more than
150 Iraqi victims of violence needing these
specialist services were referred in 2014.

Programme closures
In February, MSF ended its support of theneonatal unit in Kirkuk general hospital.
MSF also completed a programme oftraining and support in Al-Zahra hospital,
Najaf governorate, in October.

Reconstructive surgery in Jordan
Many victims of war are unable to accessreconstructive surgery in Iraq because of
the cost and the security situation, andpost-operative care such as physiotherapy
is lacking. MSF offers wounded Iraqis
reconstructive surgery, psychosocial support
and physiotherapy through its project inAmman, Jordan. A network of eight medical

International Activity Report 2014 49

iran | italy

iran

No. staff in 2014: 31 | Expenditure: d0.7 million | Year MSF first worked in the country: 1990 | msf.org/iranDrug users, sex workers and impoverished refugees fromAfghanistan are among the vulnerable groups in Iran who facebarriers when seeking medical care.

Cities, towns or villages where MSF works

Key medical figures:

5,000 outpatient consultations
1,900 individual and group mental
health consultations

Despite improvements in the health system
and greater recognition of addictions andstigmatised diseases such as HIV, healthcare
gaps remain. A Médecins Sans Frontières(MSF) team continued to provide medical
and psychological care, as well as voluntary
counselling, social support and testing for
HIV and hepatitis, to some of Iran’s mostvulnerable residents in Darvazeh Ghar,southern Tehran. A team of community
workers and peer educators also worked
with MSF to reach those in need.
The health clinic, which opened in 2012,
offers care to drug addicts and those
excluded from regular medical services,primarily women, including sex workers,
and children under 15.
Specific attention is given to the most-atrisk populations for sexually transmitted
infections and infectious diseases such as
HIV, hepatitis C and tuberculosis. Patients
include drug users (including children)and their family members, sex workers andchild labourers.
In 2015, MSF will develop a specificapproach to the management of hepatitis C
and HIV, will undertake activities to try andreduce the risks of infection and hopes tostart working with male drug users.

italy

No. staff in 2014: 22 | Expenditure: d0.9 million | Year MSF first worked in the country: 1999 | msf.org/italy
Arriving via the Mediterranean remains
the main option for many migrants andasylum seekers trying to reach Europe andclaim international protection. Exploitation,
violence and the risks of the crossing are
not deterrents for people already facing
life-threatening situations.
Regions where MSF has projects
Cities, towns or villages where MSF works

Key medical figures:

42,100 outpatient consultations
136 patients admitted to hospital
An unprecedented number of
migrants, refugees and asylum
seekers landed on Italian shores
in 2014, many of them fleeing
wars in their home countries.

50 Médecins Sans Frontières

Médecins Sans Frontières (MSF) teams saw anincrease in the number of vulnerable people
disembarking in Italy, including victims ofviolence and torture, those with disabilities,
children and pregnant women. Figures fromthe UN’s Refugee Agency showed the mostcommon nationalities of arrivals were Syrian
and Eritrean. Collaborating with the healthministry, teams conducted health screenings
in Pozzallo, Sicily, and provided psychologicalcare to people living in reception centres in
Ragusa province. Many patients presented
with scabies, respiratory tract infections,suspected tuberculosis and psychologicalsuffering. A temporary tented clinic was also
set up in the port of Augusta to offer medicalcare to new arrivals and make urgent referrals
to hospital. The Augusta project was handed

over to the health ministry and the Italian Red
Cross in December, once the number of new
arrivals had decreased.
Between March and September, an MSF
team managed a 23-bed inpatient service
in Milan to provide medical care tohomeless people discharged from hospital.
The project was located in a shelter witha capacity for 150 people, and was run
in cooperation with local organisations,offering free inpatient and outpatient care,including nursing. Many patients sufferedfrom chronic diseases or illnesses resulting
from the harsh living conditions, such as
respiratory tract infections. The project
was handed over to the health ministryin September.
The MSF Chagas disease project, which
included education and screening, ended
in June.
For more on refugees and migrants arriving
in Europe, see Bulgaria (p.26), Greece (p.40)
and Serbia (p.73).

jordanjordanNo. staff in 2014: 209 | Expenditure: d8.4 million | Year MSF first worked in the country: 2006 | msf.org/jordan

More than 600,000 Syrians
fleeing war have sought safety
in Jordan, mainly in urban
areas. As a result, the needfor basic services such as
healthcare has vastly increased.

Cities, towns or villages where MSF works

Key medical figures:

1,500 individual and group mental
health consultations

1,500 patients treated afterincidents of violence© Kai Wiedenhoefer

1,300 surgical interventions

Rayya is a Syrian refugee from Daraa
governorate, where in January 2012 she
was injured by a grenade. The shrapnel
shattered her lower arm. She has since
undergone a number of operations in
Jordan, conducted by MSF staff.

The majority of refugees are living outsideof camps, where they share space, resources
and services with their Jordanian hosts.
This has stretched the capacity of all public
services – from health and education towaste collection and disposal. In November,
the Jordanian authorities announced that
Syrian refugees would have to pay for healthservices at public facilities.
Médecins Sans Frontières (MSF) runs amaternity hospital in Irbid, northern Jordan,
providing free healthcare to help meet theneeds of a large number of Syrian refugees
and vulnerable Jordanians. Ante- andpostnatal outpatient consultations andbasic emergency obstetric and neonatal
care are available. Over 2,000 births wereassisted in 2014. MSF extended services by
opening a paediatric outpatient department
in January, which conducted nearly 14,000
consultations throughout the year. In
October, MSF launched a mental healthprogramme for children showing signs of
distress from war and displacement andthere were 351 consultations by the end of
the year. A team also started a pilot projectin mid-December, offering free medicalcare to Syrian refugees and underprivileged
Jordanians with chronic diseases, mostly
diabetes and hypertension, at a government
clinic in Irbid. The aim is to ease thedemand on local medical resources.

Trauma surgery in Ar Ramtha
Just a few kilometres from the border with
Syria’s Daraa governorate, MSF provides
emergency surgery for wounded Syriansin Ar Ramtha hospital. More than 1,300
major surgical interventions, many of themlifesaving, were performed on 538 patients.
General inpatient care and physical therapy

were also available, and more than 1,160
mental health consultations took place.
In March, MSF opened a post-operative
care facility in Zaatari refugee camp. This
40-bed facility is for war-wounded patientstransferred from Ar Ramtha and otherhospitals in Jordan. Among the more than
460 patients admitted were 244 patientsneeding follow-up care for pain management
and wound treatment. Mental health support
and physical therapy are also offered.

Reconstructive surgery in Amman
MSF’s reconstructive surgery programmein Amman provides a critical service forvictims – many of them children – of conflictin Syria, Iraq and Yemen. Patients arereferred through a network of doctors in theregion and surgeons carry out orthopaedic,
maxillofacial and plastic reconstructive surgery
free of charge to help patients recover fromdevastating injuries. The team performed
1,369 surgical procedures in 2014, and Syrians
accounted for 45 per cent of all admissions.
An outpatient department also provides
consultations for Syrians who have undergone
operations elsewhere and need post-operativecare. Mental health professionals ran a total of
8,000 sessions with patients in this project.

PATIENT STORY
Ahmed – Ahmed’s nine year old
son and a friend were injured while
playing with something they found:unexploded ordnance. Ahmed
brought his son to Ar Ramtha for
emergency treatment.
“ In Daraa they told me they could not treat
the kind of injuries my son had. They did
not have the right kind of equipment,
and there was only one doctor. We were
lucky. It only took 15 minutes to get tothe border and we managed to get tothe hospital within 25 minutes. His wholebody was full of shrapnel; the largest
injuries were on his leg. So far he has hadseven surgeries, and we hope that histreatment is nearly finished. “International Activity Report 2014 51

kenyakenya

No. staff in 2014: 603 | Expenditure: d17.4 million | Year MSF first worked in the country: 1987 | msf.org/kenya
Key medical figures:

333,400 outpatient consultations
10,500 patients on first-line
ARV treatment
2,800 patients treated afterincidents of sexual violence

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

Over 350,000 people, mostly Somalis,
live in precarious conditions in Dadaab,the world’s largest long-term refugeesettlement. Following a tripartite agreementon voluntary return (signed by the UN
Refugee Agency and the governments of
Kenya and Somalia in 2014), the refugees
can either go back to a war-torn country
or stay in closed camps where theyreceive minimal assistance. The threatof kidnappings, robberies and sexualassault puts significant pressure on thepeople living in the camps and insecurity
severely limits the capacity of humanitarianorganisations to provide services.
MSF has not had a permanent international
staff presence in Dagahaley camp,
80 kilometres from the border with Somalia,
since 2011 due to increased insecurity, but
continues to manage a 100-bed hospitaland an inpatient feeding centre throughthe work of national staff and remotemanagement. Outpatient and inpatient
services for children and adults are provided,
including maternity care, emergency
surgery and treatment for HIV/AIDS and
TB. Four health posts in Dagahaley offer

52 Médecins Sans Frontières

basic healthcare consultations and outreachactivities including mental health support.
Each month, teams carried out around
15,000 outpatient consultations and 1,000
antenatal consultations, and admitted anaverage of 1,000 patients to hospital. MSF
issued a briefing paper in March 2014,
drawing attention to the inadequate andinsecure conditions in Dagahaley and callingfor more government and donor support for
the Dadaab camps.

HIV/AIDS
MSF’s programme in Homa Bay has provided
antiretroviral (ARV) treatment to people

living with HIV since 2001. Homa Bay was
the first public hospital in Kenya to offer
it free of charge. The programme is in theprocess of being handed over to the healthministry. More than 7,400 people wereon ARVs in 2014. A new programme wasstarted in Ndhiwa, where MSF has foundadult HIV prevalence as high as 24 per centand a worrying rate of new infections at
two per cent per year. In order to reduce
this, an integrated and simplified model ofcare will be introduced in health ministry
facilities and in the communities in order todiagnose and care for people living with HIV© Matthias Steinbach

Médecins Sans Frontières(MSF) continues to respondto the medical needs of someof Kenya’s most vulnerable
people: inhabitants of slum
settlements and refugee
camps, patients with HIV/AIDS
and tuberculosis (TB), andvictims of sexual violence.

Patients with TB wait to be seen at the Green House clinic in Mathare, Nairobi.

© Phil Moore

kenya

MSF midwives talk to a new mother in the Kibera South clinic in Nairobi, and examine baby John.

and decrease their viral load. Support will
be given to health authorities to improveaccess to HIV testing, voluntary medical malecircumcision, and prevention of mother-tochild transmission of the virus. MSF will also
focus on follow-up and treatment adherence,and on improving the quality of care in
Ndhiwa and Homa Bay hospitals’ inpatient
wards where mortality rates among HIV
patients remain high.

Healthcare in Nairobi slum settlements
In the Eastlands slums, poverty, drug use,crime and impunity contribute to highlevels of violence, including sexual assaults.
Victims, however, have very limited accessto emergency medical care in this part ofthe city. MSF has been working to fill thisgap with its programme at the LavenderHouse clinic in Mathare, which offers
comprehensive care to victims of sexual andgender-based violence, including access to a
24-hour hotline and pick-up by ambulance.
Patients receive medical consultations,
treatment to prevent transmission of HIV andsexually transmitted infections, a pregnancy
test when relevant, swabs for legal purposes,
psychological counselling, and referrals forsocial and legal support. In 2014, more than

200 patients received aftercare each month;half of these were minors, and a quarter
were under the age of 12. A trauma roomat Lavender House was also established to
manage ambulant medical emergencies, andstabilise and refer patients to other facilities
when needed. Some 300 patients received
care in the trauma room each month, themajority for physical assault.
After evaluating the health needs in the area,
MSF decided to address the population’slack of access to hospitals and specialist
healthcare. A dispatch centre was set up andtwo ambulances were made available to theresidents of Mathare and Eastleigh. During
the first six weeks of the project, 141 calls
were received. MSF also started supporting
the accident and emergency departmentof Mama Lucy Kibaki hospital – the only
hospital accessible for Eastlands’s two million
residents – with additional staff, equipment,
training and supervision. A programme
focusing on detection and treatment ofpeople with drug-resistant TB continued at
Green House, Mathare, and MSF started thefirst patient diagnosed with extremely drugresistant TB on a regimen that includes the
new anti-TB drug bedaquiline.

The only free basic healthcare for people
in the Kibera slum is provided through two
MSF clinics. Treatment for HIV/AIDS, TB andchronic diseases is available, and the teamruns a comprehensive aftercare programme
for victims of sexual violence. MSF openeda new clinic in Kibera South, offering basic
healthcare and maternity services. Thereis an inpatient maternity ward and an
ambulance service for obstetric and otheremergencies. Integrated management for
diseases such as HIV, diabetes and asthma
make it a one-stop service, improving patient
access to medical care and facilitating
early diagnosis, treatment and follow-up.
Health education sessions, counselling andsocial support are also available. More than
60 per cent of all consultations at MSF’s
Kibera clinics were for respiratory infections
and diarrhoeal or skin diseases, a result ofovercrowding, as well as poor hygiene andsanitation in the slum.

International Activity Report 2014 53

lebanon

lebanonNo. staff in 2014: 284 | Expenditure: d15.6 million | Year MSF first worked in the country: 1976 | msf.org/lebanon
Key medical figures:

245,200 outpatient consultations
7,200 individual and group mental
health consultations

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

An estimated 1.2 million
Syrian refugees, Palestinian
refugees from Syria, andLebanese returnees havesought refuge in Lebanon
since the Syrian conflictbegan in 2011. Lebanon, a tiny
country with a population of
only four million, is struggling
to cope.

Médecins Sans Frontières (MSF) continues to
respond with free medical care for people inneed, regardless of nationality and refugee
registration status.

Bekaa Valley
Many people who have crossed into Lebanon
have stayed close to the border, in areas suchas Bekaa Valley, where there is insufficient
healthcare infrastructure to meet the current
needs. MSF provides basic and reproductive
healthcare, treatment for chronic diseases,
counselling, and health promotion activities
to Syrian refugees and vulnerable Lebanese.

Teams work at clinics in the towns of Baalbek
and Majdal Anjar (West Bekaa), Aarsal (North
Bekaa), and in Hermel. Across the Bekaa
Valley, 113,000 consultations were carriedout during the year.

BeirutMSF continues to work in Shatila campin southern Beirut, a Palestinian refugeesettlement dating back to 1949, wheremore recent Palestinian refugees from
Syria and Syrian refugees are also living.
The focus is on unregistered refugees who
are not eligible for official assistance and

The lack of healthcare is one of the main
problems. Thousands of people who
had previously received regular medical
treatment in Syria for chronic diseases
such as hypertension, asthma and diabetes
have had to interrupt their treatment– sometimes with severe consequences –because they cannot access or afford it.
Many women receive no monitoring during
their pregnancies and specialised care iscompletely out of reach for most people.

54 Médecins Sans Frontières© Ghazal Sotoudeh/MSF

With few employment opportunities
and dwindling financial resources, therefugees and returnees are largely reliant
on humanitarian assistance for survival.
As no official refugee camps have been
established in response to the Syrian
conflict, a very large number of people live
in informal settlements, collective shelters,
farms, garages, unfinished buildings andold schools, with inadequate access toshelter, food and water. Overcrowding andexposure to extreme weather conditions
have a negative impact on their health.

A Syrian refugee with diabetes is shown by an MSF nurse how to exercise daily in order tostimulate his blood circulation.

© Diego Ibarra Sánchez

lebanon

An MSF midwife assisting a delivery in Shatila camp, southern Beirut.

registered refugees with medical needs
falling outside the UN Refugee Agency’s
eligibility criteria. Basic healthcare forchildren under 15, treatment for chronic
diseases and mental health support services
are available. A referral system is in place
for patients requiring specialist medical
intervention, such as caesarean sections
for women with high-risk pregnancies
and birth complications.

TripoliIn the coastal city of Tripoli in northern
Lebanon a team works in Dar al Zahraa
hospital in the Abou Samra neighbourhood.
Medical services, including treatment for
acute and chronic illnesses, reproductive
healthcare, counselling and routine
vaccinations, are provided to vulnerable
Lebanese and Syrian refugees, regardlessof their status. Similar services have beenoffered in Abdie since April. MSF also offers
reproductive healthcare, counselling andcare for acute diseases in Jabal Mohsen and
Bab el Tabbaneh dispensaries.

Southern Lebanon
A small team based in southern Lebanonoffers basic healthcare to refugees. MSF
supports three health centres, withactivities focused on children under 15,
chronic diseases, mental healthcare andreproductive and maternal health services.
There is also a referral system for patientsin need of specialist healthcare. In 2014,
MSF extended its healthcare programmefrom Ein-el-Hilweh camp to assist thePalestinian refugee community, Syrian
refugees and vulnerable residents acrossthe Sidon area. More than 4,800 mental
health consultations were conducted; nearly
double the number that took place in 2013.

staff STORYSAMAR ISMAIL – MSF counsellor,
Shatila camp, Beirut“ Many of the people I see come fromparts of Syria that have been bombed.
Some have lost children or other family
members ... The first thing I try to do isunderstand what happened to them andwhere the negative feelings are coming
from. We work on stress management,
after we understand the problems. Most
people have difficulty understanding
why people have treated them the way
they have.”International Activity Report 2014 55

kyrgyzstan | lesotho

kyrgyzstan

No. staff in 2014: 108 | Expenditure: d2.1 million | Year MSF first worked in the country: 2005 | msf.org/kyrgyzstan

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

Key medical figures:

620 patients under treatment for TB
One in four patients newly
diagnosed with tuberculosis (TB)
in Kyrgyzstan has a multidrugresistant strain of the disease.
This means they do not respond to standard firstline drugs and need longer, more complex andmore intensive treatment. In addition, medical
services for TB have been centralised and arelargely focused on treatment in hospitals only.
Consequently people have difficulty accessing
medical care, particularly in rural areas.

Médecins Sans Frontières (MSF) is the onlyinternational organisation actively engaged
in the direct clinical implementation of
drug-resistant TB (DR-TB) programmes in
Kyrgyzstan. In Kara-Suu district, Osh province,
where TB rates are among the highest in the
country, MSF focuses on outpatient care tolimit the amount of time a patient spends in
hospital and to improve their adherence totreatment. The programme aims to influence
health policy and has succeeded in introducing
this decentralised approach to DR-TB
treatment as a key strategy for the Kyrgyzstan
Ministry of Health in the coming years.
For patients with severe TB, MSF continued
to diagnose and treat patients in Kara-Suu
hospital, which has 80 beds, including an
isolation ward for those with multidrug-resistant
TB (MDR-TB). MSF provides support in thepharmacy and laboratory, and also assists withthe management of the hospital’s waste, waterand infection control.
Many patients have received prior treatment
for TB, and more than two-thirds of them
have developed drug resistance because
treatment has been interrupted or they have
had difficulty in adhering to it. As part of its
comprehensive package of care, MSF provides

psychosocial support to help people sustain
and complete their arduous drug regimens.

Prison project handoverIn 2006, MSF began to develop a programme
providing TB diagnosis and treatment for
inmates at a prison in Bishkek due to the highprevalence of the disease. The project washanded over to the International Committeeof the Red Cross, the health ministry andprison authorities in 2014. MSF had enrolled
and treated more than 3,000 patients overthe eight years.

PATIENT STORY
Shakir – suffering from MDR-TB“ While on treatment, I had no idea that I
would need psychological help. But when
you take the drugs, you get side effects.
I became nervous and apathetic. The
psychosocial support that I received from
MSF during my entire treatment was
tremendously helpful. After six months ofoutpatient treatment, the doctor cameto my house with the results of my last
sputum tests: ‘Shakirake, I have goodnews for you, the test results are great.
You have been cured!’ “

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

Women in Lesotho face numerous obstacles to obtaining
maternal care, and this poses severe risks to their health.

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

Key medical figures:

6,600 family planning consultations
5,900 patients received first-line
ARV treatment 

1,900 births assisted

56 Médecins Sans Frontières

The country is mountainous and has
few roads. Many people in remote ruralcommunities cannot afford transportation
costs to health facilities. There is also
a shortage of skilled health workers.
Consequently, about 50 per cent of womendeliver their babies at home. Anotherchallenge is the high prevalence of HIV in
Lesotho – it is 27 per cent among pregnant
women. HIV, along with tuberculosis (TB)
co-infection, contributes to high rates ofmaternal death. Médecins Sans Frontières(MSF) continues to focus on improving accessto maternal medical care and family planning,as well as to treatment for people with HIV.
Family planning services, ante- and postnatal
care and emergency services are offered at the
MSF-supported St Joseph’s district hospital inRoma, six health clinics in the lowlands andthree clinics in remote Semonkong. An averageof 133 babies were delivered each month at
St Joseph’s and more than 230 women wereaccommodated at the nearby maternity lodge,
where they can come to give birth. MSF also
has an ambulance to transport patients to thehospital for emergency treatment.
MSF trains and mentors local staff at thesefacilities to provide integrated care for patients
co-infected with HIV and TB. Local counsellors
and community health workers initiate andfollow up antiretroviral (ARV) treatment. Morethan 1,550 people were started on ARVs in2014. Viral load monitoring – an importantlaboratory measure of HIV in the blood that
can indicate treatment success or failure – wasalso expanded.

libya | madagascar

libya

No. staff in 2014: 71 | Expenditure: d2.2 million | Year MSF first worked in the country: 2011 | msf.org/libya

Renewed fighting erupted in the spring of 2014, forcing thousandsof people from their homes. Chaos and insecurity severely hampered
assessments and the delivery of aid throughout the year.

Cities, towns or villages where MSF works

Key medical figures:

390 outpatient consultations

Médecins Sans Frontières (MSF) opened amental health centre in Tripoli in 2013 toprovide medical and psychological support
to people suffering from physical and mental
health problems related to previous conflicts.
MSF’s team in Tripoli was temporarily
evacuated in July due to the volatile situationin the city. Staff returned in October but due
to the deterioration of the security situation,
MSF was unable to continue the project andit was closed in December.
Violence and unrest were still widespread at
the end of the year. Many health workers fledand health facilities experienced shortagesof supplies and drugs. Insecurity prevented
access to many areas, particularly in the east,
where there were high numbers of casualties.

MSF provided assistance to Tripoli, Zawiyah,
Yefren, Zuwara and Jaddu through donationsof drugs and medical materials, including kits
to treat war-wounded.
The crisis in Libya has funnelled thousandsof people through to Europe, with 90
per cent departing from its coast. People
working in Libya or using its coastline asa jumping-off point to reach Europe areespecially vulnerable to its instability. In
Zuwara and the surrounding area on thenorthern coast, where the majority of boats
heading for Europe leave from, MSF donatedhygiene materials such as chlorine, masks
and protective gloves to the local crisis
committee to help cope with the numberof bodies washing up on the shore.

madagascar

No. staff in 2014: 40 | Expenditure: d0.4 million | Year MSF first worked in the country: 1987 | msf.org/madagascar

In June, Médecins Sans
Frontières (MSF) handed overits project in the south ofMadagascar to the Ministryof Health.

on medical care for women experiencing

Regions where MSF has projects

Following the political crisis of 2009,

Over the course of the project, 20,000

Cities, towns or villages where MSF works

people in Madagascar faced a deteriorating

patients received emergency consultations,

economic and health situation and MSF

42 per cent of them were children aged fiveconducted several needs assessments

or under. One in four patients suffered frombefore opening a project in Bekily, Androy

malaria. Teams carried out 12,000 antenatal

region, in 2011. Based at Bekily hospital,

consultations and admitted 1,460 children

and providing support at two healthto hospital. A total of 130 TB patients were

centres, the project’s activities focuseddiagnosed and treated.

Key medical figures:

670 patients treated for malaria
290 births assistedcomplications and emergencies inpregnancy, malnourished children,and patients with tuberculosis (TB),
schistosomiasis (a curable parasitic disease)and malaria.

International Activity Report 2014 57

liberia

liberiaNo. staff in 2014: 373 | Expenditure: d23 million | Year MSF first worked in the country: 1990 | msf.org/liberia | blogs.msf.org/ebola

Cities, towns or villages where MSF works

Key medical figures:

2,500 patients admitted toEbola management centres, of which

1,600 were confirmed as having Ebola© Caitlin Ryan/MSF

670 patients recovered from Ebola
and discharged

On 31 March, the first cases ofEbola were confirmed in Liberia.
By the end of July, the number ofsick had risen to overwhelming
numbers and people were dyingin the streets.
Liberia’s healthcare infrastructure had suffered
as a result of the long civil war, and when the
Ebola outbreak occurred there were alreadysignificant gaps in care. As there were few
confirmed Ebola patients in March and April,and none between the end of April and the
beginning of June, the country and the aidorganisations present were lulled into a false
sense of security. The national health system
was unprepared to cope with the explosion ofcases when the situation rapidly worsened at
the end of July. In the space of two months,
the number of cases went from fewer than
10 in June to more than 1,000. The epidemic
peaked between August and October.

Margibi and Lofa counties
In April, following reports of suspected casesof Ebola in Liberia, MSF sent a small team to
Lofa and Margibi counties. In Margibi, east of
Monrovia, a small isolation unit was built bya local company and MSF supported it withtechnical expertise and organised training for
local health staff.
In Foya, close to the Guinean and Sierra
Leonean borders, MSF built an Ebola
management centre (EMC), and also trained
local health staff and made sure that alert

58 Médecins Sans Frontières

Construction teams building what will become one of the wards at ELWA 3, MSF’s EMC
on the outskirts of Monrovia.

systems were in place to refer suspectedcases. After the NGO Samaritan’s Purse
suspended operations in Liberia when two of
its international staff became infected, MSF
took over the management of the centre
and increased the bed capacity to 100. It
soon became clear that a comprehensive
approach to tackling Ebola was essential if
the virus was to be contained in this area. A
package of medical care, outreach activities,
psychosocial support, health promotion andcontact tracing was put into place. Nearly
700 patients were admitted to the centre,
394 of whom were confirmed as having
Ebola. There were 154 survivors. The centre
was closed in December.

Monrovia
In the capital Monrovia, MSF started by
supporting the authorities and training
medical staff in JFK and Elwa hospitals.
An isolation unit was also constructed in
JFK hospital. In August, the Elwa 3 EMC
opened with a capacity of 120 beds, but
this gradually increased as the outbreakworsened. The centre had 250 beds by theend of September, making it the largest
EMC ever built. At this point, teams wereadmitting on average 152 patients per week
and were being forced to turn away up to
30 people per day because there simply
wasn’t enough space.

An MSF rapid response team ran mobile
clinics and trained local health staff in triage
and infection control. To mitigate the risk ofcontagion and restore public confidence inthe health system, MSF supported 13 healthcentres with infection prevention and control– this later increased to 22 facilities, as newcases presented in different areas. MSF alsobegan constructing a new free-of-charge
paediatric hospital in the city. An ambulanceservice was also set up in December totransport suspected Ebola cases to an EMC.
Redemption hospital, the only facility inthe capital providing free medical care to a
population of approximately 90,000, closed
entirely in October. To enable the hospitalto start offering inpatient services again,
MSF opened a 10-bed transit centre for thetriage of those suspected of having Ebola.
Psychosocial support was also offered to thefamilies of Ebola sufferers.

River Cess county
Following a visit to River Cess county by
the Liberian county health team, the World
Health Organization and the Centers
for Disease Control and Prevention in
November, MSF was asked to establish atransit centre in Gozohn. This centre tested
people suspected of having Ebola andreferred patients to Monrovia for care.

liberia

By 8 December, the transit centre was empty
but contact tracing and health promotion
activities, as well as the construction of
triage areas and training of health workers
on infection control procedures, continued
in six health centres in the region. On
15 December, the organisation Partners in
Health and the county health team took
over the activities.

five districts (New Kru Town, Clara Town,
Gardnersville, West Point and Logan Town)
between late October and December.

Looking forward
The number of Ebola cases declined
sharply towards the end of the year, andby December Liberia was reporting thelowest incidence of the three main affected
countries. However, contact tracing andcross-border communication remain essential
in identifying and dealing with any newcases. Now that the peak of the Ebola crisis
looks to be over in Liberia, non-Ebola healthneeds must be addressed as an urgent
priority to ensure people do not continue to
die of treatable diseases such as malaria anddiarrhoea. Many hospitals have shut, healthworkers have died or fled, and few people
have access to the level of care they need.

Grand Bassa county

Distribution of antimalarials

Alexander Kollie – his son was
MSF’s 1,000th Ebola survivor“ I noticed my son looking more tired than usual.
I was worried about him. He didn’t have any
symptoms like vomiting or diarrhoea, but he justlooked tired. I called the Ebola hotline and MSF
brought him to their Ebola care centre here in Foya
to be tested … When the test came back positive, it
was a night of agony for me … After some time, myson started doing much better. He was moving around. I prayed that he would be free ofEbola and test negative, but I was worried that his eyes were still red. I just wanted us to
be together again. Then something amazing happened, something I could not actually
believe until I saw it. Until that moment I saw him coming outside, I could not truly believethat it would happen. I’ve seen people with Ebola start to look strong and then the nextday, they’re just gone. So I was also thinking, maybe Kollie will be one of those who will
be gone the next day. When finally I saw him come out, I felt so very, very happy. I looked
at him and he said to me, “Pa, I am well. “© Martin Zinggl/MSF

MSF distributed antimalarials to 522,000
people in Monrovia not only to protect
them from the disease but also to reduce
the number of patients presenting at
EMCs wrongly thinking they had Ebola.
Two rounds of distribution took place in

PATIENT STORY© Katy Athersuch/MSF

On 22 November, one case was confirmed
in Grand Bassa county but just eight days
later there were nine severely ill people.
MSF deployed a team of 16 to establish abase in Quewein. At the end of December,the charity Concern Worldwide and theLiberian county health team took over the
epidemiological surveillance and contact
tracing. The decommissioning of the EMC
and departure of the MSF team was plannedfor early January 2015.

Deddeh, who had recovered from Ebola, stayed in the confirmed area to take care of three-month-old Elijah. He had tested positive for thevirus, which killed his mother.

International Activity Report 2014 59

malawimalawiNo. staff in 2014: 586 | Expenditure: d7.1 million | Year MSF first worked in the country: 1986 | msf.org/malawi

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

Key medical figures:

43,300 patients on first-line
ARV treatment

A major limitation to
healthcare provision in Malawi
is the shortage of skilled
healthcare workers – thevacancy rate for clinical staff
is around 60 per cent.
For many years Médecins Sans Frontières(MSF) has been supporting the national
health system to strengthen its HIV response
through staff training and technical support
and trying out innovative treatment models
to reach more people with the virus.
In August, MSF and the health authorities
in Chiradzulu district began a four-year
handover process of a programme that
opened in 1997. MSF continues to simplify
HIV treatment: since September almost 50 per
cent of people taking antiretrovirals (ARVs)
in Chiradzulu have been on a six-monthappointment schedule, which reduces thepatient load and waiting times in the healthcentres. In addition, MSF is implementing a
UNITAID-funded project using point-of-care
tests to measure CD4 count (the CD4 countis an indicator of an HIV patient’s immunity
level) and viral loads (rather than sending
samples away to be tested) in Chiradzulu. By
the end of the year, five health centres were
testing for CD4 and four for viral load.
In Nsanje, MSF is supervising theimplementation of a policy to put all HIV-

60 Médecins Sans Frontières© Marco Longari/AFP Photo

400 patients under treatment for TB

A man being examined by a doctor at Thyolo health centre, a three-hour walk from his village.

positive pregnant and breastfeeding womenon ARVs, regardless of their clinical status,
to prevent transmission of the virus totheir babies. The team is also developing a
programme to treat tuberculosis (TB) in 14
health centres as a step towards integrated
HIV–TB treatment. In addition, MSF is
working to improve counselling, testing andtreatment services for sex workers, couples inwhich only one person has HIV, adolescents,
and people with advanced HIV.
The handover to the Ministry of Healthof first-line HIV treatment in Thyolo wascompleted in December 2013, but MSF
teams continue to mentor local staff who
provide second-line treatments and viralload testing to patients. It is planned for the
project to be handed over completely in2015. During 2014, the combined MSF andMinistry of Health community team enrolled
4,200 people into community ARV groups,
whereby people living with HIV take it inturns to collect medication on behalf of thegroup. More than 22,864 laboratory tests
for viral load were carried out for patients in
Nsanje and Thyolo.
Twelve students graduated from MSF’s Rural
Human Resources for Health Scholarship

Programme in 2014. They will work in theunderstaffed and hard-to-reach areas ofThyolo, Nsanje and Chikhawa.

Prison project
MSF started a new project in two prisons:
Maula in Lilongwe and Chichiri in Blantyre.
Some 4,400 inmates and staff werescreened for HIV, TB, hepatitis B and sexuallytransmitted infections (STIs). Treatment
was provided for HIV, TB and the STIs, andpeople were vaccinated against hepatitis B.
MSF undertook other activities to improveand expand prison health services, including
providing training scholarships to four prison
staff, constructing consultation rooms,
pharmacies and laboratories, as well as
supporting general outpatient services.
In 2014, a project offering testing for HIV
and STIs to truck drivers and commercial sex
workers began in Mwanza and Zalewa, near
the border with Mozambique. More than 300
sex workers and 50 truck drivers were tested.

mali

mali

No. staff in 2014: 883 | Expenditure: d9.5. million | Year MSF first worked in the country: 1992 | msf.org/mali

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

Key medical figures:

173,500 outpatient consultations
75,700 patients treated for malaria
15,000 routine vaccinations
Access to basic healthcare
was severely restricted inparts of northern Mali in
2014, as the security situation
deteriorated. Jihadist attacks
continued against military
targets and peace talks did
not lead to an agreement.
Northern Mali

MSF collaborated with other organisations toensure screening for child malnutrition andseasonal malaria chemoprevention (SMC)in Gao region. More than 40,000 children
between the ages of three months and five
years received antimalarials to guard against
the disease through its seasonal four-monthpeak. Teams managed to reach a scatteredpopulation in a very insecure environment.
MSF supported the 65-bed Timbuktu
regional hospital, focusing on medical andsurgical emergencies. There were on average
700 inpatient admissions and 150 assisteddeliveries every month. Teams also provided
consultations for patients with chronic
illnesses at the Centre de Santé de Référence(CSREF), to treat diseases such as diabetes or
hypertension and combat complications.
In the Timbuktu region, over 40 per centof people live more than 15 kilometresfrom the nearest health centre. Mobile
teams continued to support staff in five
peripheral health centres offering basic care,vaccinations and malnutrition screening, but
insecurity severely hampered supervision ofthese facilities in 2014 and danger on theroads hindered patient travel to Timbuktu
for referrals and hospitalisation.

Southern Mali
In the relatively peaceful south of thecountry, MSF focused on children’s health,primarily treating malaria (37,400 children
were treated) – the main cause of childmortality – and severe acute malnutritionin Koutiala, Sikasso region. MSF supports
the paediatric unit within Koutiala healthcentre, and basic healthcare in five district
health areas. MSF doubled the number ofbeds to 400 in the paediatric unit during
the seasonal malaria peak. MSF has beenrunning an SMC programme in thisarea for three years, and in 2014 treated
183,970 children. Teams also trained local
paramedics and medical students. A pilot
preventive paediatric care project, including
vaccinations and bed net distribution,
continued in the Konséguéla health area.

Ebola response
Following confirmed cases of Ebola in
October, two emergency teams weredispatched to Kayes and Bamako to set
up and run Ebola management centres(EMCs). MSF reinforced the health ministry’s
capacity to detect and respond to alerts,
trained rapid response teams, participatedin the elaboration of country protocols, andtreated patients in the EMCs to prevent
further infections. In addition, MSF set up
an early warning system on 1 December forsuspected cases in Sikasso. A team provided
comprehensive Ebola training to 95 healthworkers in Sélingué and Yanfolila.

The MSF programme supporting several
health centres in Gao region carried out
more than 47,750 consultations in 2014.
Some areas near the town of Ansongo,
south of Gao, were difficult to access. A
team continued to provide free healthcare
and medicine to patients in Ansongo
reference hospital, where there are currently
insufficient government health staff tocover the needs of the population. MSF
also supported the health ministry during
a measles outbreak at the beginning of theyear, and transferred 124 patients to Gao
hospital for treatment.

© Miguel Cuenca/MSF

Civilians were unable to seek medical
assistance in areas controlled by certain
factions or where there were violent clashes
between armed groups. Meanwhile, there
is still a shortage of health workers and theauthorities lack the means to respond tohealth crises such as epidemics. Médecins
Sans Frontières (MSF) programmes aimed tofill critical gaps between needs and available
medical services.

A young girl receives her antimalarials from a community leader as part of the SMC
campaign in Gao region.

International Activity Report 2014 61

mauritania | mexico

mauritania

No. staff in 2014: 346 | Expenditure: d4.4 million | Year MSF first worked in the country: 1994 | msf.org/mauritania

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

Key medical figures:

175,800 outpatient consultations
1,800 births assisted
260 surgical interventions

More than 51,000 Malianrefugees in Mauritania’s
Mbera refugee camp arealmost entirely dependent oninternational aid for survival
and many don’t have adequate
food or shelter.
The political and security crisis in Mali in2013 forced thousands of Malians to flee
across the border to Mauritania. Despite
the initiation of a peace process in 2014,
northern Mali remained so insecure thatgovernment services were largely absent
from the region. Armed groups splintered
while violent attacks and banditry dissuaded
refugees from returning home.

Médecins Sans Frontières (MSF) provides
basic and emergency healthcare, andgynaecological and obstetric services for the
refugees in Mbera camp and for the hostcommunities in nearby Bassikounou andFassala. By supporting the government clinics
and hospitals, MSF has ensured that everyonein the economically marginalised area hasaccess to free medical care for the first time.
In 2014, the majority of the life-saving
surgical procedures were caesarean sectionsand visceral and orthopaedic surgery.

mexicoNo. staff in 2014: 84 | Expenditure: d2.9 million | Year MSF first worked in the country: 1985 | msf.org/mexico

Cities, towns or villages where MSF works

Key medical figures:

21,200 outpatient consultations

In 2014, Médecins Sans Frontières (MSF)
continued to provide migrants with basic
and mental healthcare, hospital referrals andfollow-up of emergency cases. Many people
have experienced violence at some point on
their journey, but there are few resources
available for victims of sexual violence, andno mental health services. Teams carried out
more than 10,000 medical consultations and
1,000 mental health consultations in Ixtepec,
Apaxco, Lechería, Huehuetoca, Bojay andTierra Blanca.

health consultations 

MSF also started offering mental healthsupport to people subjected to extreme
violence in Colonia Jardín, Acapulco; the citywith the highest homicide rate in Mexico.

200 patients treated after incidents

Improving emergency care in
Tamaulipas state

The urban population, andmigrants passing throughMexico en route to theUnited States, are at risk ofkidnapping, extortion, physicaland mental abuse, and death.

People living in Tamaulipas state have been
exposed to extreme, drug-related violence
for more than a decade. The general hospitalin Nuevo Laredo – the only place in the citywhere free, good-quality medical care isavailable to the vulnerable population – isoverwhelmed by the number of patients. MSF
worked with health authorities to improve
emergency care by implementing 24-hour
triage, expanding the emergency room,

2,000 individual and group mentalof sexual violence

62 Médecins Sans Frontières

training staff, donating equipment and drugs,
and standardising treatments. There weresignificant improvements in patient care and in
October MSF replicated the project in Reynosa,
Río Bravo and Valle Hermoso. Mental healthand sexual violence care were introduced in
Nuevo Laredo and Reynosa in late 2014.

Integrating Chagas treatment
This year MSF collaborated with healthauthorities to implement a comprehensive
response to Chagas disease – a parasitic
disease that is prevalent but neglected in
Mexico – in the healthcare facility in San
Pedro de Pochutla municipality, Oaxaca
state. Education, preventive measures(including 3,145 rapid diagnostic tests),
and treatment were all available, with MSF
providing technical support and training.
Five health centres in the area have been
trained to provide treatment for Chagas
disease, which can be asymptomaticfor years but may cause debilitatingcomplications and death if left untreated.

The missing in Guerrero state
Since October, MSF has been offering
psychosocial and therapeutic support to nearly
400 relatives and classmates of the 43 students
who went missing in Iguala on 26 September.

myanmarmyanmar© Yasmin Rabiyan/MSF

No. staff in 2014: 1,146 | Expenditure: d14 million | Year MSF first worked in the country: 1992 | msf.org/myanmar

Regions where MSF has projects

Key medical figures:

51,600 outpatient consultations
34,700 patients on first-line
ARV treatment
1,300 patients under treatment for TB
The Médecins Sans Frontières(MSF) project in Myanmar’s
Rakhine state was suspended
for most of 2014, but by theend of the year it was again
providing essential healthcare to
thousands of people caught up
in a medical humanitarian crisis.
A long-established MSF project providing
basic healthcare to highly vulnerable
communities in northern and eastern
Rakhine state was suspended by theauthorities in February and resumed onlyin mid-December. Prior to the suspension,
MSF provided medical services in 24 camps
for displaced people and in isolated villages
across Rakhine.
From June, MSF was able to provide medical
staff to facilities managed by the Ministry of
Health in Rakhine, and supplied resources
such as vehicles and medical equipment
to the Ministry of Health Rapid Response
Teams in Sittwe and Pauktaw townships. HIV
patients previously under MSF care were also
supported. After the official resumption ofactivities, MSF teams carried out more than
3,400 consultations in less than a month,mainly for people with skin diseases andrespiratory tract infections; 550 were forpregnant women.
Not all of MSF’s project activities had
restarted by the end of 2014.

A patient who is undergoing treatment for MDR-TB at MSF’s clinic in Insein Township,
Yangon. It is the largest HIV/AIDS and TB clinic in Myanmar.

HIV and tuberculosis (TB)
Working in collaboration with the Ministryof Health, MSF remains a key provider of
HIV/AIDS and TB care in Myanmar, supplying
antiretrovirals (ARVs) to more than half ofthe 70,000 people undergoing treatment.
MSF treats patients co-infected with TB
and HIV through integrated programmes in
Shan and Kachin states, as well as in Yangon
and Dawei in Tanintharyi region. These
programmes also offer treatment for sexuallytransmitted infections, health education,
psychological and social support andprevention of mother-to-child transmissionof HIV. In November, MSF inaugurated its
newly renovated clinic in Insein Townshipin Yangon. The largest HIV/AIDS and TB
clinic in Myanmar, it is currently treating
approximately 10,000 HIV/TB patients.
In late 2014, MSF also started supporting
three HIV testing and counselling centres
in Dawei and the surrounding area,
focusing particularly on harder-to-reachgroups, such as sex workers, migrant
workers and men who have sex with men.
MSF counsellors also conduct support
groups within these communities.
A landmark development occurred in2014 for the treatment of cytomegalovirus(CMV) retinitis, an HIV-related infection thatcauses blindness. Approximately one in four
severely ill HIV/AIDs patients in Myanmar
develops CMV. Following many years ofprice negotiations with a pharmaceuticalcompany, MSF began providing its patientsin Dawei with valganciclovir, a single daily
pill taken orally. Although it has been
available in high-income countries since2001, this is the first time MSF has been able
to use the drug; patients previously had toendure uncomfortable injections directly into
the eye.

Emergency mobile clinics
When active fighting resumed in northern
Shan and Kachin states in April, MSF began
to operate mobile clinics to bring healthcare
to displaced people.

PATIENT STORY
ma* – diagnosed with advanced

HIV and CMV and was the first MSF
patient to take valganciclovir“ If I had not [attended] the clinic in Dawei,
I would probably be dead. For the CMV,
the doctor said that when he looked into
my eyes, he could see a lot of lesions in
my retina through the lens. But after fourmonths of treatment, that has improved.
I have not felt any side effects and I am
feeling better now. Before, it was not like
that, and I had to lie down all the time.
Now I can go everywhere by myself. I
even got my vision back and can read thetext messages on my mobile phone.
If I hadn’t got the treatment on time, I
might have lost my vision within threemonths. I feel very lucky that I got the
chance to take this oral treatment.”* Name has been changed

International Activity Report 2014 63

nigerniger

No. staff in 2014: 1,866 | Expenditure: d23.5 million | Year MSF first worked in the country: 1985 | msf.org/niger
Key medical figures:

508,300 outpatient consultations
185,100 patients treated for malaria
85,700 patients treated in
feeding centres

Regions where MSF has projects

Médecins Sans Frontières(MSF) continued to improveand expand integrated healthprogrammes to reduce childsuffering and death in Niger.
Niger is affected by child malnutrition of
epidemic proportions which peaks during the‘hunger gap’, a period between harvests in May
and September when household food stocks
become depleted and are insufficient to meet
nutritional needs. The hunger gap coincides
with the rainy season and a proliferationof malaria-transmitting mosquitoes, alethal combination for young children: amalnourished child is more vulnerable todiseases such as malaria and a sick child ismore likely to become malnourished.

as nets and has been proven to significantly
reduce the incidence of malaria in children
under the age of five.

Zinder region
In 2014, MSF continued a programme of
medical and nutritional care for children
under the age of five in Magaria, Zinder. The
programme focused on the paediatric unitof Magaria hospital, as well as seven healthcentres and 21 health posts during the peakin malnutrition. In 2014, more than 65,000
children were targeted for Plumpy’Doz(supplementary food) distributions.

Maradi region
In Madarounfa, MSF runs two outpatient and
one inpatient feeding centre to treat children
with severe acute malnutrition and supervises
four outpatient facilities managed by thenational NGO Niger Health Forum (FORSANI).
Over 137,000 children were screened formalnutrition and 14,500 were admitted fortreatment. MSF also supports the Ministry of
Health in Madarounfa hospital’s paediatricunit and provided additional support to 11
health centres during the annual malaria peakin 2014. Preventive activities included SMC,
providing 54,400 vaccinations and distributing

Aiming to complement treatment withprevention, MSF also conducted a seasonalmalaria chemoprevention (SMC) campaign
in the Sahel region (Tahoua, Zinder andMaradi) for the second year running,
reaching a total of 447,500 people. SMC
involves the administration of antimalarial
treatment. It is used alongside common
methods of mosquito bite prevention such

64 Médecins Sans Frontières© MSF

MSF collaborates with national authorities
and NGOs (FORSANI, Befem/Alima) to
reduce under-five mortality in several
regions of the country, with a particularfocus on the management of children withsevere malnutrition and malaria. In 2014,
MSF supported six inpatient and several
outpatient centres in Madarounfa andGuidan Roumdjii (Maradi region), Bouzaand Madaoua (Tahoua region), and Magaria(Zinder region).

Thousands of people fled their homes in the Lake Chad region, as a result of violence by
Boko Haram. Many sought refuge in the Diffa region of southeast Niger.

© Juan Carlos Tomasi/MSF

niger

A child is checked for malnutrition during a SMC campaign, which involves the administration of antimalarial treatment.

7,850 mosquito nets. A temporary respite careunit in Dan Issa relieves the pressure on the
Madarounfa centres during the malnutrition
peak and cares for the most severely ill children.
MSF supports five health centres in Guidan
Roumdji, where outpatient consultationsand vaccinations are available for children
up to the age of five. Those that are severely
malnourished are screened and treated inambulatory therapeutic feeding centres,
and the ones with medical complications
or associated diseases are admitted to the
paediatric ward of the MSF-supported district
hospital. In 2014, over 125,800 children
were treated in the outpatient facilities andapproximately 10,000 were hospitalised.
During the period of high malaria transmission
from June to December, MSF supports six
additional health centres by providing drugs,
training staff and supervising medical activities.
Nearly 9,300 paediatric cases of malaria weretreated and SMC was provided to over 67,000
children aged between three and 59 months.

Tahoua region
In Madaoua district, MSF supports six
integrated health centres to provide
treatment of childhood illnesses and severe
acute malnutrition throughout the year. Morethan 4,800 children with acute malnutrition
were admitted to inpatient programmes andover 13,660 received treatment as outpatientsin 2014. Psychosocial activities are also being

implemented to ensure healthy development
and recovery from malnutrition. A visiting
MSF psychologist carried out more than
2,000 consultations, supporting mothers
and children by introducing developmental
activities to help with psychosocial andpsychomotor (the relationship between
cognitive function and physical movement)
development, and conducting group andindividual counselling sessions.
In Bouza district, MSF provides paediatricand nutritional care for children under fivein the hospital in Bouza town and the area’s
six health centres. There is also a programmethat decentralises essential healthcare inthree of the project’s health areas; children
and pregnant women can be treated at thehealth posts and only need to attend thehospital if referred.
MSF is also beginning to work with children
with HIV and tuberculosis in Madaoua andBouza. In Bouza, basic training of hospital
staff on HIV was undertaken with the aim of
reducing stigmatisation.
MSF expanded its SMC campaign in the two
districts, covering all the health areas andtreating 237,000 children aged between
three and 59 months.

Aiding refugees from Nigeria
The violent activity of Boko Haram in Borno
state, Nigeria, caused people to flee theirvillages and cross into neighbouring countries,
including the Diffa region of southeast Niger.
Responding to the influx of refugees, mainly
women, children and elderly people, MSF
began supporting health centres in N’Garwa
and Gueskerou at the beginning of December,providing free access to healthcare anddistributing relief kits to new arrivals. MSF
also responded to a cholera outbreak among
refugees and the host population in Diffa,
after cases were recognised in Diffa city andChatimari. Teams set up cholera treatmentsites and oral rehydration points. MSF also
trained local health centre staff to chlorinate
water at the rehydration points.

Cholera outbreak
In September, MSF worked with the Ministryof Health to respond to an outbreak of cholera
affecting Tamaske, Madaoua, Bouza, Tahoua,
Maradi and Madarounfa. Emergency teams
treated some 1,000 patients within a few
weeks. This was one of the interventions
carried by EMUSa, an MSF emergency medical
response team for the Sahel, which is basedin Niger and aims to create better surveillance
and respond more rapidly to emergencies.

Tillabéri project handover
The healthcare programme for Malianrefugees and the host community in Abala,
Tillabéri region, was handed over to the
Qatari Red Crescent in June. A total of
20,777 consultations had been provided.

International Activity Report 2014 65

nigeria

nigeriaNo. staff in 2014: 508 | Expenditure: d9.8 million | Year MSF first worked in the country: 1971 | msf.org/nigeria

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

Key medical figures:

28,300 outpatient consultations
26,800 patients treated for cholera
13,000 patients admitted to hospital
10,000 patients treated for malaria
The security situation
deteriorated in many areas ofNigeria in 2014. Violence anddisplacement took their toll on
people’s health and reduced
their access to medical services.
© Florence Uzury/MSF

Médecins Sans Frontières (MSF) continued totry and provide healthcare to communities
in need, but some clinics experienced
temporary closures due to insecurity.

Healthcare for the displaced
Political instability, numerous attacks by
Boko Haram and security operations by the
Nigerian army forced thousands of people
to flee their homes. Up to 400,000 internallydisplaced people settled in and around
Maiduguri, the capital city of Borno state,with host families or in camps that were set
up in July. Medical supplies and physicians
remain extremely limited.
In August, MSF began providing care todisplaced people in two of the largest camps.
Weekly mobile clinics screened for malnutritionand offered antenatal care to pregnant women.
By the end of the year, 10,000 consultations
had been carried out across the camps. A
health surveillance system was also established
to respond to disease outbreaks and launchvaccination campaigns, if necessary.

66 Médecins Sans Frontières

Water being treated with chlorine during a cholera outbreak in northeastern Nigeria.

There was a cholera outbreak at the endof September and in the space of a month
4,500 cases and 70 deaths from cholera
were reported in Maiduguri. MSF set upa cholera treatment centre with 120 beds
and five posts for oral rehydration. By
December, MSF had supported the care of
6,833 patients, 40 per cent of whom weredisplaced people living in camps.

Focus on obstetrics
At Jahun hospital, Jigawa state, wherematernal mortality rates have been among
the highest in the country, MSF continued
to support the emergency obstetrics

programme, which admitted a total of
7,980 women, an 11 per cent increaseover 2013. More than 5,700 births wereassisted. ‘Kangaroo care’, a technique inwhich women spend time holding theirbabies skin to skin, was implemented after
more space was created in the new neonatal
unit. Kangaroo care was originally used in
low-resource settings that had no incubators
for premature babies and has been shown tosupport infant development and wellbeing.
Jahun hospital also treats fistula, with MSF
support. Obstetric fistulas are injuries to thebirth canal, usually caused by complicatednigeria

or prolonged labour resulting in pain,incontinence and often social stigma.
MSF offers reparative surgery, as well as
psychosocial support, helping women
to reintegrate into their communities.
A total of 264 women benefited from
fistula surgery in 2014.

Paediatric care

Teams also continued to treat children withlead poisoning in eight villages in Zamfara
state. Lead poisoning can cause brain
damage, kidney problems and even death.
As patient numbers decreased over theyear, MSF closed three outreach clinics but
continued to lobby the Nigerian government
to assist local villagers. Staff also screened
children for measles, meningitis and yellow
fever, treated over 3,560 for malaria andcarried out more than 7,680 outpatient
consultations.

Responding to disease outbreaks
The MSF-run Nigeria Emergency Response
Unit (NERU) provides early warning andrapid response to seasonal outbreaks ofinfectious diseases in the northwestern statesof Zamfara, Kebbi, Sokoto and Niger. From
June to December, NERU treated over 6,000
people for cholera in Goronyo (Sokoto state),

Aliero (Kebbi state), and Mada, Anka andShagari (Zamfara state). Some 330 people
were also treated for meningitis in Aliero.
Banditry and attacks on villages, mostly
in Zamfara, limited the movement of theemergency team for short periods from time
to time.

Ebola containment
MSF provided Ebola-related technical support
to health authorities in Lagos and Port
Harcourt from July to October, assisting withisolation and contact tracing, and providing
training and public education. There were 20
confirmed cases in Lagos and Port Harcourt
and eight patients died. The outbreak in
Nigeria was declared over by 20 October.
‘Visor flap for total upper and lower lip reconstruction:a case report’, Peter Nthumba and Louis Carter, Journalof Medical Case Reports 2009, 3:7312

1

© Abubakr Bakri/MSF

From the Noma children's hospital in
Sokoto, MSF provided care to children
suffering from noma, a rapid-onset gangrene
infection that causes facial disfigurement.
It is most common in children under theage of six. The exact cause of the disease isunknown but malnutrition, poor hygiene
and unsafe drinking water are among
the risk factors. Psychosocial counsellors
carried out 90 group sessions and 12
individual consultations, and 50 children
were admitted to hospital for treatment.
Nutritional and psychological support wasoffered and corrective surgery is plannedfor 2015. Without medical treatment, noma
has a mortality rate of around 90 per cent.

Approximately 140,000 new cases arereported each year, predominantly from
sub-Saharan Africa.1

Patients in an MSF cholera treatment centre. Severe cases require hospitalisation for intravenous rehydration.

International Activity Report 2014 67

pakistanpakistan

No. staff in 2014: 1,558 | Expenditure: d17.8 million | Year MSF first worked in the country: 1986 | msf.org/pakistan | blogs.msf.org/pakistan
Key medical figures:

279,900 outpatient consultations
25,200 births assisted
10,900 individual and group mental
health consultations
3,600 surgical interventions

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

Women and children inparticular suffer from thelack of access to healthcare
in Pakistan and there is an
overwhelming need for neonatalcare. Mother and child healthremains a focus for Médecins
Sans Frontières (MSF).
Teams also respond to the medical needsof vulnerable communities largely excluded
from medical care, including people
displaced by conflict, and marginalised,
low-income groups.

and additional psychosocial support services,such as children’s play groups, were available.
Teams also admitted 697 people sufferingfrom cutaneous leishmaniasis, a parasitic
disease prevalent in this region, and provided
treatment and supportive care. The disease istransmitted by the bite of a sandfly and cancause debilitating skin lesions.
Overall, MSF conducted almost 59,690
consultations and assisted 3,598 births in
Quetta and Kuchlak.
North of Quetta, at Chaman district hospital,
MSF supports medical services for women andchildren, including reproductive healthcare

and specialist neonatal and paediatric care.
There are also inpatient and outpatient
feeding programmes, and treatment andsupport services for trauma patients. Teams
carried out 6,978 outpatient consultations
and assisted 4,048 births. Over 5,795
women attended a prenatal consultation.
MSF also supervises the women’s outpatient
department, which is mainly run by healthministry staff using MSF protocols.
In eastern Balochistan, MSF works closelywith the health ministry and focuses on
malnutrition and on providing specialist
care to newborns, infants and children
suffering from acute medical complications

Government restrictions, bureaucratic
processes and a climate of insecurity andsporadic violence pose operational challenges
in Pakistan. The presence of armed militantgroups and ongoing counter-terrorism
operations hamper humanitarian access andthere is a general distrust of aid workers.
MSF’s activities in Pakistan are funded solely
by donations from individuals, with noinstitutional or government contributions.

MSF continued to provide basic healthcarewith a focus on women and children in
Quetta and Kuchlak, Balochistan – Pakistan’s
most underdeveloped province and home tothousands of Afghan refugees. Staff regularly
see malnourished patients and provide
nutritional support to severely underweight
infants, young children, pregnant women andlactating mothers. A total of 3,361 individualand group psychosocial sessions were
undertaken with both women and men in 2014

68 Médecins Sans Frontières© Noor Muhammad/MSF

Balochistan

An MSF doctor examines a malnourished child in Dera Murad Jamali district, eastern Balochistan.

pakistan© Sa'adia Khan

emergency room (where 114,957 patientswere triaged), resuscitation room (where
27,576 patients were seen and treated) andin the observation room. Comprehensive
obstetric care is available, including surgery
for complicated deliveries, and 7,369
deliveries were assisted in 2014. In May,MSF opened a neonatal unit for prematureand low birth weight babies. In addition,
MSF supports the hospital’s blood bank,sterilisation and waste management systems.

Aminah is being reassured by the MSF doctor that her baby is safe and well.

at the District Headquarters Hospital in Dera
Murad Jamali district. There are high rates
of malnutrition throughout this region,
which worsen during the May to October‘hunger gap’ between harvests. An outpatient
feeding programme, which runs all year, wasincreased during these months to cover eightlocations in Jaffarabad and Nasirabad districts,
in which more than 8,800 people received
nutritional support.
The obstetric and maternity components
in Nasirabad and Jaffarabad were handedback to the Ministry of Health at the end of
October. MSF also handed over Sohbat Pur
and Mir Hassan Basic Health Units to theministry at the end of May and the sexual andreproductive health components in October.

Federally Administered Tribal Areas (FATA)
MSF provides medical care to displaced andvulnerable communities in Bajaur Agency,
the northernmost tribal agency. Medical
staff support two basic health centres in Talai
and Bilot, and are improving services in theoutpatient departments and antenatal careunits. Children are screened for malnutrition
and receive vaccinations. MSF teams also workat Nawagai civil hospital, in the outpatient
department, emergency room, and motherand child health department. Paediatricservices include vaccinations and therapeutic
feeding for malnourished children. For
complicated cases, MSF ensures timely referralof patients to Khar, Timurgara or Peshawar.
In the Sunni enclave of Sadda, Kurram
Agency, MSF runs a paediatric outpatient

department for children up to the age of five,inside Tehsil Headquarters Hospital. There isalso a therapeutic feeding programme for thisage group. Newborns and children under 12
needing hospitalisation are treated on the
MSF-supported paediatric ward, and referrrals
are organised. MSF staff also assisted theante- and postnatal departments. In addition,some 160 patients received treatment for
cutaneous leishmaniasis at a general healthcentre established by MSF.
In Alizai, a Shia community in Kurram, MSF
operates a paediatric outpatient department
for children under 12 years of age. More thanhalf (59 per cent) of patients in 2014 were
under the age of five.

Khyber Pakhtunkhwa
In Peshawar, the province’s capital, MSF runs
a 35-bed maternity hospital receiving patientsfrom health units, government-run hospitals
and other health partners in the district and
FATA. Over 3,700 patients were admitted and3,268 babies were delivered.
Mother and child health is the focus at the
government-operated Hangu hospital too,
where MSF runs a round-the-clock emergency
room, an operating theatre and surgicalwards, and provides technical and referral
support to the delivery room. MSF also
supports the health ministry’s blood bank andX-ray departments.
MSF continues to work in the District
Headquarters Hospital in Timurgara, Lower
Dir, providing medical expertise in the

Isolation wards were established in Timurgara
following outbreaks of acute watery diarrhoea
and measles. MSF also ran dengue fever
prevention and awareness activities incommunities and schools in the area. Morethan 8,000 students and teachers attended
health promotion sessions.

Karachi
The Machar Colony slum is situated on
the edge of Karachi’s Fish Harbour; it is
crowded and polluted and has no proper
sanitation. MSF opened a clinic in 2012
with local partner SINA Health, Educationand Welfare Trust, providing basic andemergency healthcare, including outpatient
consultations, triage, stabilisation andreferrals for emergencies. Labour and delivery
support for pregnant women is also available.
Health promotion teams run health andhygiene education sessions for parents andchildren, and staff conduct mental healthconsultations. Demand continues to increaseas the community learns about the clinic’s
services from the health promotion teams andMSF’s commitment to provide free, highquality care.

PATIENT STORY
Gul Bibi * – brought her eightmonth-old granddaughter to the
MSF-supported hospital in Sadda fortreatment. Gul Bibi and her family
fled their village after militants took
control and destroyed their homes
and way of life. They now live in acamp for displaced people.
“ We lived in peace. We lived good lives …
then three years ago everything changed.
They came to the area and nothing
was the same again … There was fear
everywhere. We went from living in a
happy and peaceful place where everyone
knew everyone to not knowing whom we
could trust or who was living among us …
I still see our village burning when I close
my eyes and try to sleep.“* Name has been changed

International Activity Report 2014 69

palestine

palestine

No. staff in 2014: 121 | Expenditure: d4.3 million | Year MSF first worked in the country: 1989 | msf.org/palestine

Regions where MSF has projects
Cities, towns or villages where MSF works© Samantha Maurin/MSF

Key medical figures:

9,100 individual and group mental
health consultations

3,400 outpatient consultations
1,600 patients treated afterincidents of violence

400 surgical interventions
Violence increased across the
Occupied Palestinian Territory in
2014, and the year was marked
by a 50-day war with Israel.
Médecins Sans Frontières (MSF)
doubled its capacity to help meet
medical and psychological needs.
Tensions mounted between Israel and Palestinein June, and Operation Protective Edge waslaunched in the Gaza Strip on 8 July, leaving 2,286
Palestinians dead (25 per cent of which werechildren), over 11,000 injured and 3,000 withpermanent disabilities. A ceasefire was declared on
26 August, but of the 500,000 people displaced,54,000 have still not been able to return home.
Access to healthcare across the occupied territories
remains severely limited by the West Bank wall,
the Gaza blockade and other measures. There isa shortage of technical equipment and training
for specialist care, including surgery and mental
healthcare, in Gaza. Living conditions continue
to deteriorate and people’s coping mechanisms
are stretched. In the West Bank, including East
Jerusalem, daily violence, collective punishment,
and humiliation at checkpoints are common andhave taken a psychological toll.

West Bank
A mental health programme was started by MSF
in Hebron, Nablus and Qalqilya governorates
in the West Bank in 2000, extending to east
Jerusalem in 2011. The programme focuses on

70 Médecins Sans Frontières

An MSF anaesthetist in a hospital in Gaza is seen here caring for a child who suffered
severe burns after a missile fell on his family’s house.
adults and children who have experienced orwitnessed violence (Israeli–Palestinian or interPalestinian), and whose psychological suffering
impedes their normal life. It aims mostly to help
those served evacuation orders, whose homes
are demolished, and those under regular attackfrom settlers and Israel Defense Forces search
and arrest operations. More than 5,500 patients
received psychological support during the year.

Gaza Strip
The demand for reconstructive surgery in Gaza
dramatically increased because of the acuteconflict. Normally teams work on a fly-in/flyout basis to perform hand surgery, post-burnsurgery and correct defects, but a rise in thenumber of casualties led MSF to establish an
emergency surgical team in Gaza between
July and September to perform lifesaving
operations. A permanent reconstructive surgery
team was present until December. Over 320
surgical procedures were carried out in 2014.

BLOG

Two MSF clinics, in Gaza City and in an
inflatable tent at Nasser hospital, provided
post-operative care, including wound dressings(12,700), physiotherapy (11,800 sessions) andoccupational therapy. More than 1,000 patients
received rehabilitative care and 350 patientswere being treated at the close of the year.
After one and a half years, MSF’s support to
the intensive care unit at Nasser hospital was
suspended after results were not as good as
expected. Training sessions with doctors andnurses are now planned.
A Gaza mental health programme suspended
in 2011 by local authorities resumed in
October, responding to a rise in needs following
Operation Protective Edge. Mental healthconsultations were integrated into post-operativecare. MSF plans to launch a dedicated paediatricmental health programme within Ministry of
Health structures in the coming months.

 Hazem Abu Malouh, doctor“ It's very hard because we have no news from patients who used to come regularly for care.
Or we see patients that tell us terrible stories like this little girl of seven who has burns to her
face, caused by an explosion. She came for treatment. But when I asked her where her father
and mother were, she said they died. There is also this 32-year-old woman who was slightly
injured by shrapnel and was pretty good physically. But she was very shaken by the loss ofher four brothers. Two of them just got married and all died in recent weeks. We listen topatients, they need to talk but they do not understand what happened to them.
We really go through a lot of emotions. Sometimes incredible things happen also. A patient
we follow up for a while is in a wheelchair … When I learned that the city of Shujahia where
he lives was under heavy shelling and that everybody was fleeing, I wondered how he would
do. How to escape in a wheelchair? And then one night I was watching television that showed
refugee families in a school and I saw him on TV! He was alive. It was great.”
To read more, visit blogs.msf.org/hazem

philippines

philippines

No. staff in 2014: 114 | Expenditure: d6.9 million | Year MSF first worked in the country: 1987 | msf.org/philippines | blogs.msf.org/philippines
Key medical figures:

5,900 outpatient consultations
2,700 births assisted
840 surgical interventions

Regions where MSF has projects

Médecins Sans Frontières(MSF) continued to support
communities in the Philippines
affected by Typhoon Haiyan withresponse and recovery activities.
On Leyte island, local services are now
capable of meeting medical needs and MSF
therefore closed the 25-bed tented hospitalin Tanauan in Palo district in March andthe inflatable 60-bed hospital in the city of
Tacloban in April. Overall these facilities hadprovided over 45,600 consultations andhad facilitated 475 major and 5,400 minor
surgical procedures.

in Eastern Samar province: Albino Duranmemorial hospital in Balangiga and General
MacArthur municipal hospital in General
MacArthur. All renovation activities are
expected to be completed in 2015.
In Guiuan, Samar island, where the typhoon
had essentially destroyed Felipe Abrigo
Memorial hospital, MSF continued to treat
patients in a tent hospital until constructionof a permanent hospital was completed
in June. Around 80 consultations werecarried out daily, mostly for respiratory tract
infections and diseases such as dengue fever.
The volume and nature of medical needs
have returned to their pre-typhoon levels.

MSF facilitated the movement of patients into
the new structure and handed it over to theprovincial health office. Hospital equipment
and a six-month supply of drugs and medical
supplies were donated to make sure there
were adequate stocks. A small number of
MSF staff stayed until the end of October toensure that the hospital services were runningsmoothly before completing the handover.
The new hospital withstood the December
2014 typhoon Hagupit. It is made out ofinnovative durable and recyclable composite
materials adapted to the hot, humid
conditions in the Philippines.

A mental health programme that began
immediately after the typhoon continued
with individual and group sessions in
Tacloban, and in schools in Palo andTanauan, where teams helped identify
children who were still suffering from trauma
as a result of the typhoon. More than 7,400
patients took advantage of these services.

MSF worked on rehabilitating Abuyog
general hospital on Leyte, and two facilities© Nacho Hernandez

An MSF assessment showed, however, that
gaps persisted between needs and available
obstetric services in Palo. In May, MSF begansupporting the maternity ward and surgicalteam at Leyte provincial hospital. The
project focused on human resources support
in surgery, maternity and neonatology,
renovation of the wards, and ensuring anadequate supply of drugs and medical
supplies. Teams also repaired the damaged
sections of the hospital, installed new
facilities and donated equipment.
Patients wait to be seen at the outpatient department of the hospital in Guiuan, where
there are around 80 consultations a day.

International Activity Report 2014 71

mozambique | papua new guinea

mozambique

No. staff in 2014: 370 | Expenditure: d7.8 million | Year MSF first worked in the country: 1984 | msf.org/mozambique

Médecins Sans Frontières (MSF)
continues to fill some of themost critical gaps in treatment
for HIV/AIDS and tuberculosis(TB) in Mozambique.
Regions where MSF has projects
Cities, towns or villages where MSF works

Key medical figures:

38,300 antenatal consultations
31,400 patients on first-line
ARV treatment
3,600 women screened for
cervical cancer

The national response has made progressin recent years, but HIV remains the leading
cause of adult death in Mozambique, andthe Ministry of Health estimates that 1.6
million people are infected. The country also
has the world’s fifth-highest rate of HIV–TB
co-infection, which is resulting in an emerging
multidrug-resistant TB (MDR-TB) problem.
Since 2001, MSF has supported the Ministryof Health to ensure access to comprehensive
healthcare for HIV/AIDS and TB patientsin the health districts of Kampfumo andNlhamankulo (both formerly Chamanculo).
The aim for the next few years is to provide
specialised care for complicated cases andaddress emerging problems such as patients

presenting late with HIV, those with HIV who
fail first-line antiretroviral (ARV) treatment andthose co-infected with opportunistic infections
such as MDR-TB and Kaposi’s sarcoma, acancer that causes patches of abnormal tissue
to grow under the skin. In Primeiro de Maio
health centre the MSF project focuses primarilyon the needs of adolescents, and supports
urban community ARV groups.
Viral load testing was rolled out in the publichealth centres of Maputo city and Changara
district, as part of a pilot project aiming to
improve patient monitoring. In Tete province,
MSF works with community ARV groups,
whose members meet regularly to support
each other and take turns to pick up medicinesfrom health centres. By the end of 2014, over
10,500 people had joined groups. A new‘corridor project’ has started in the high-transit
cities of Tete and Beira, targeting hard-to-reach
populations such as sex workers, truck drivers
and seasonal workers. More than 2,000 people
were tested and treated for HIV and othersexually transmitted infections.

papua new guinea
No. staff in 2014: 219 | Expenditure: d5.3 million | Year MSF first worked in the country: 1992 | msf.org/png

Cities, towns or villages where MSF works

Key medical figures:

21,900 outpatient consultations
Médecins Sans Frontières (MSF)
opened a project for the diagnosis
and treatment of tuberculosis(TB) in July in Gulf province.
MSF started supporting Kerema general
hospital this year to improve detection rates
for TB. The hospital, including the laboratory,
was renovated and a consultation room for

72 Médecins Sans Frontières

suspected TB cases was set up. Over 290
people were diagnosed and treated, andpatient education and counselling activities
were organised. Teams also began to offer
diagnosis and treatment to people living
in remote areas, some only accessible byboat. MSF and the US technology company
Matternet successfully trialled the use of
unmanned aerial vehicles for the transportationof sputum samples and results between distanthealth centres and Kerema hospital.

Sexual, domestic, social and tribal violence
Domestic and sexual violence remains a
medical humanitarian emergency in Papua
New Guinea, with consequences at individual,family and national level. MSF is working withthe health authorities to provide access to
free, good-quality, confidential and integrated
medical care for victims.
At the Port Moresby Regional Treatment andTraining project, 50,000 people attended
awareness sessions outlining the care available
to the victims of sexual violence. Over 900
people were seen as outpatients, and there

were 265 first consultations for rape. In
Southern Highlands province, the MSF team at
Tari hospital performed 1,190 major surgicalinterventions, and also continued to provide
medical and psychosocial care for victimsof violence. In June, MSF handed over its
maternal and child health project in Buin to
the provincial health authorities.

Emergency intervention in the
Solomon Islands
In April, the Solomon Islands were hit by flash
floods and landslides. Approximately 10,000
people in the capital Honiara were madehomeless, and bridges, roads and some healthcentres were destroyed. MSF set up mobile
clinics in the temporary shelters, and carriedout 1,443 medical consultations. The teams
also offered mental health sessions, training
in psychological first aid and monitored
potential disease outbreaks. MSF implemented
a programme raising awareness of sexual
violence, which had been planned before thefloods occurred. The provision of relevant
services in Honiara and Guadalcanal province
were also increased.

russian federation | serbia

russian federation
No. staff in 2014: 132 | Expenditure: d4.9 million | Year MSF first worked in the country: 1992 | msf.org/russianfederation

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

Key medical figures:

5,300 individual and group mental
health consultations

300 patients under treatment for TB
Médecins Sans Frontières(MSF) continues to address
gaps in cardiac care,tuberculosis (TB) and mental
healthcare in Chechnya.

The rate of heart disease in Chechnya is high, but
the quality and scale of medical services do notmeet the needs of people with coronary syndromes
and cardiovascular emergencies. In Grozny, MSF
continued to improve patient services at the cardioresuscitation unit of the Republican Emergency
Hospital, donating medicines and medical
equipment and training staff on coronarography(an imaging technique to visualise the inside ofcoronary arteries) and angioplasty (an endovascular
procedure to widen narrowed or obstructedcoronary arteries). Training for ambulance staff
who administer first aid was also initiated.
Drug-resistant TB is a life-threatening issue
in Chechnya, resulting from years of poor
TB diagnosis and interrupted treatment.
A comprehensive programme, including
diagnosis, treatment and counselling for TB andmultidrug-resistant TB (MDR-TB), is integrated
in health ministry facilities. Extensively drugresistant TB (XDR-TB), a form of the disease
that does not respond to second-line drugs
administered for MDR-TB, is also on the rise.
MSF procured appropriate medicines to provide
treatment for people with XDR-TB. The TB
programme also includes laboratory support,
health promotion and psychosocial assistancefor patients and their families.

MSF runs a mental healthcare programme in
Grozny and the mountainous districts of Chechnya
still affected by violent clashes. People’s symptomsof trauma and anxiety are related to direct orindirect violence or abuse experienced in detention.
In August, an MSF project started in Moscow andprovided over 700 outpatient consultations tomigrants from former Soviet Union countries withlimited or no other access to healthcare services.
A limited number of referrals were also arranged
for specialist care in state medical facilities.

PATIENT STORY
Aslambek, 54 year oldheart patient“ When I was admitted to the hospital for
myocardial infarction [heart attack], I had
an injection of a thrombolytic to restart
my heart. But after being discharged, I
still had pain. Then I was offered a new
operation with [MSF] doctors who werecoming soon. I accepted. The operationconsisted of placing two stents. Since[the operation] I feel different, I can walkwithout any problem.”serbiaYear MSF first worked in the country: 1991 | msf.org/serbia
seekers were not being adequately registeredand assisted due to their high numbers. Working
with the authorities, MSF repaired, renovated andbuilt toilet and shower facilities at two temporary
asylum centres located in Sjenica and Tutin.

Cities, towns or villages where MSF works

In late 2014, a Médecins
Sans Frontiéres (MSF) teamarrived in Serbia aware thatthousands of migrants andasylum seekers were travellingthrough the country on their
way to northern Europe.
The cold winter months posed a great risk to
those people forced to sleep outside. MSF foundthat the undocumented migrants and asylum

In December 2014, teams also began toprovide medical assistance to migrants andasylum seekers in the village of Bogovadja,
which is about 80 kilometres from the capital
Belgrade, as well as in Subotica near the
Hungarian border. An MSF team ran mobile
clinics and distributed specially designed transit
kits containing essential relief items to hundredsof people. The kits contained hygiene, foodand survival items ranging from toothpaste tocooking pots and were designed to address theneeds of people in transit. The most common
health problems encountered by the team were
respiratory and skin diseases – mostly due tothe cold weather and poor sanitary conditions– and musculoskeletal injuries. There were alsopatients suffering from chronic illnesses such as
hypertension and diabetes who were without

the necessary medication; MSF gave them asupply to tide them over until they reachedtheir next destination.
For more on refugees and migrants arriving inEurope, see Bulgaria (p.26), Italy (p.50) andGreece (p.40).

PATIENT STORY
Afghan man, 27 years old“ I had to cross many countries to comehere: first Iran, then Turkey and finally
Bulgaria. The border between Iran and
Afghanistan was the most dangerous …
I was also detained for two and a halfmonths in Bulgaria. I have been here
[Subotica] for four days, and every day I
try to cross the border [to Hungary] but
so far I have not succeeded. Each time
I fail I have no choice but to come back
here, there is nowhere else to go. It is very
cold and I can barely sleep at night.”

International Activity Report 2014 73

sierra leone

sierra leone

No. staff in 2014: 959 | Expenditure: d26 million | Year MSF first worked in the country: 1986 | msf.org/sierraleone | blogs.msf.org/ebola

Cities, towns or villages where MSF works

Key medical figures:

1,800 people admitted to Ebola
management centres, of which

1,400 were confirmed as having Ebola
770 people recovered from Ebola
and discharged

When the first cases of Ebola were confirmed in
Sierra Leone, the Ministry of Health asked MSF tointervene. Teams opened an Ebola management
centre (EMC) on the outskirts of Kailahun town on
26 June, where testing and care was available forthose people suspected of having the virus. MSF
teams also launched outreach, health promotion
and disease surveillance activities, and trained
local health staff. Community health workers
were trained to deliver messages about how
people could protect themselves from Ebola andwhat to do if they showed signs or symptomsof the disease. An MSF psychologist provided
support to patients and to families who had lost
loved ones. As the virus quickly spread acrossthe country, patients arrived by ambulance fromlocations up to 10 hours away. The EMC had amaximum capacity of 100 beds. In addition, MSF
constructed a small maternity unit in Octoberwhere pregnant Ebola patients could receive
specialised care within the high-risk zone.

Bo, Southern Province
In September, MSF opened a second EMC fivekilometres outside Bo, which was more easily
accessible from most parts of the country.
The centre was extended to accommodate
104 beds. MSF teams carried out outreach,health promotion and surveillance activities,
trained local health staff and offered support
to the Ministry of Health’s activities.
Also in Bo, MSF launched a third Ebola projectfocused on offering specific, structured andtargeted training for other organisations toenable them to run EMCs safely. The training
sessions took place in MSF facilities or in thoseof the other NGOs to help them start activities.
In total six other organisations were trained.

Freetown
In early December, as health facilities in
the country’s capital, Freetown, became
overwhelmed, MSF opened an EMC in the© Anna Surinyach/MSF

Cases of Ebola were first
confirmed in the east of Sierra
Leone, near the border with
Guinea, at the end of May.

Even before the Ebola outbreak, people in Sierra
Leone had limited access to medical care andthe health system was both under-resourced andoverburdened. Médecins Sans Frontières (MSF)
was working in the country at Gondama, near
the city of Bo, running an emergency paediatricand maternity hospital as well as a midwifery
clinic in response to the devastating levels ofmaternal and infant mortality in the country.

A member of MSF's hygiene team hangs disinfected scrubs and goggles on a clothesline at the Ebola management centre in Freetown.

74 Médecins Sans Frontières© Anna Surinyachsierra leone

A clinical health officer hands medication for a patient to an MSF staff member who is already inside the high-risk zone.

centrally located Prince of Wales secondary
school. There were 30 individual rooms for
suspected Ebola cases and 70 beds. A new
design was used which meant that the intensive
care ward could be viewed through Plexiglas andpatients could therefore be better monitored bystaff who did not have to wear protective gear.
MSF started conducting outreach, healthpromotion and surveillance activities in nine
sub-districts of Freetown to support the
government coordination body, National
Ebola Response Centre (NERC), in mappingand following up on Ebola contacts.
Epidemiologists visited the areas and had
daily meetings with staff from the World
Health Organization, the Ministry of Healthand the NERC to support the response systemand help where possible. Teams also provided
training on disinfecting houses.

Magburaka, Northern Province
On 15 December, MSF opened a fourth EMC
in Magburaka, Tonkolili district, again, withcritical complementary activities including
outreach, health promotion, surveillance
and training of local health staff. A rapid
response team was established in Magburaka
to be deployed quickly wherever new cases
appeared in the country.

Infection control issues,
and antimalarial distributions
Many Sierra Leonean health staff on thefrontline of the outbreak were infected as aresult of caring for patients, because they
lacked the necessary protective gear andknowledge about the transmission of thedisease. Up to 10 per cent of local healthworkers are estimated to have died, leaving
government health facilities with even fewer
staff than before the epidemic and unable
to cope.
In October, MSF suspended its obstetricand paediatric projects in Gondama. Dueto the strain on resources as a result of
responding to the Ebola outbreak, MSF could
not guarantee the extremely high quality of
medical care needed to treat patients or theprotection of its staff from Ebola infection.

BLOG

Meanwhile, women suffering complications
in childbirth and people sick with malaria andother diseases were reluctant to seek care atgovernment hospitals for fear of contracting
Ebola, and untold numbers of people arethought to have died from non-Ebola-relateddiseases in 2014. In December, to address thethreat of malaria and to avoid confusion with
Ebola due the similarity of initial symptoms,
MSF recruited and trained some 6,000
volunteers to carry out a four-day, door-todoor distribution of antimalarial treatments inpartnership with the Ministry of Health. Some
1.5 million people in the Freetown area werereached. Another distribution campaign was
carried out in January 2015.

 Patricia Carrick, nurse“ The woman’s upper body was curved around one middle bed leg, her legs wedged aroundthe opposite middle bed leg, her lower legs and feet protruding from under one side of thebed, her face from the other, staring up into a blank nothing, her mouth stretched wide,
the desperate death-mask I am coming to recognise. She was still breathing but could not
respond, even to moan.
Despite training in Brussels, briefing in Freetown and Bo and Kailahun, an ever-increasing pileof tales of misery, and my own past experience, I admit I was dumbfounded. I began to reachtoward her and realised there was nothing, nothing to be done. I turned to Konneh stupidly
and, bless him, even from within the depths of my PPE (personal protective equipment)
and his, he had the compassion to say it to me in words – ‘We cannot do anything for her,
Patricia.’ We could not move her, lift her – we could not even wrest her from under the bed.
We had no proper equipment, we had limited time and energy; we had come for other tasks,
the discharge of survivors.”
To read more, visit blogs.msf.org/patricia

International Activity Report 2014 75

south africa

south africa

No. staff in 2014: 198 | Expenditure: d6.7 million | Year MSF first worked in the country: 1999 | msf.org/southafrica

Regions where MSF has projects
Cities, towns or villages where MSF works© Gianluigi Guercia/AFP Photo

Key medical figures:

15,600 patients on first-line
ARV treatment
1,400 patients under treatment for TB

Despite a tremendous increase in testing andtreatment and improved prognosis for people
with HIV, there are still many new infectionsand HIV-related deaths each year. Rates ofco-infection with tuberculosis (TB) are alsohigh. More needs to be done to reduce HIVtransmission and initiate and keep people on ARVtreatment, such as carrying out interventions
tailored to children and adolescents, and forhard-to-reach communities.
Médecins Sans Frontières (MSF) continues topilot new strategies to scale up testing andaccess to treatment for HIV and TB.

Khayelitsha, Cape Town
Each month some 1,000 people learn thatthey are HIV positive in Khayelitsha township,on the outskirts of Cape Town, where ratesof HIV and TB co-infection have reached 70
per cent. MSF provides testing and treatment
for HIV and TB, including drug-resistant TB,
which requires a longer, more intensive, toxic
and less effective drug regimen. Adherence
clubs are a key element in the HIV programme:
instead of monthly one-to-one appointments
at the health centre, club members attend bimonthly meetings where, as well as receivinga check-up and a drug refill, they can ask
questions and offer mutual support.
The programme also addresses the needsof children and adolescents. A pilot projectproviding diagnosis and treatment for

76 Médecins Sans Frontières

A mobile HIV-testing clinic on the outskirts of Eshowe, KwaZulu-Natal. The programmealso focuses on prevention activities such as promoting safe sex.

newborns began in 2014. Children are involvedin family clubs and there are now nine clubsthat are youth-focused, for those aged between
12 and 25 years. Overall the project supports
18 community adherence clubs.
An MSF-initiated pilot project at community‘wellness hubs’, offering family planning andtesting for pregnancy and sexually transmitted
infections, significantly improved access to
HIV screening for young women. More than
15,000 patients attended two wellness hubs
before the facilities were handed over to theWestern Cape Department of Health. MSF
also supported two human papillomavirus
vaccination campaigns in Khayelitsha,
vaccinating more than 3,800 girls.

KwaZulu-NatalMSF continued an HIV–TB programme covering
Mbongolwane Health Service Area and Eshowe
municipality in KwaZulu-Natal. In 2014, morethan 50,000 people underwent HIV testing,and three times as many viral load tests werecarried out compared to 2013. This enabled
staff to identify patients who could benefit
from a change in their drug regimen. The
programme also focuses on prevention activities
such as promoting safe sex. A million condoms
were distributed and more than 3,000 men
underwent voluntary circumcision, which isshown to decrease the risk of HIV transmission.

Stop Stock Outs project
Drug stock outs cause a major bottleneckin South Africa’s HIV–TB programming andthreaten the health of patients. MSF andseveral partners launched the Stop Stock
Outs project in 2013, asking patients andhealthcare workers to become 'sentinel
surveyors': to anonymously gather reports
on stock levels in the facilities they attend or
work at, map reported cases and track specificissues. The overall goal is to understand thecauses of shortages and stock outs and draw
attention to a struggling health system.

PATIENT STORY
Thulile, 29 years old“ I first heard about MSF early last year, and joined my first club
towards the end of 2013. Before clubs, you would first have toqueue to get your file, then queue to get your blood pressure
and weight measured, and then queue to see your nurse to getyour treatment. If the clinic was full, you could be there from
7am to 1pm. When your month’s supply of ARVs came to anend, you started dreading the clinic visit. You put it off. But withclubs, you actually look forward to the visit! It only takes anhour and we get two months’ supply of ARVs.”© Kate Ribet/MSF

South Africa runs the world’s
largest programme ofantiretroviral (ARV) treatment
for HIV.

tajikistan | turkey

tajikistan

No. staff in 2014: 67 | Expenditure: d1.4 million | Year MSF first worked in the country: 1997 | msf.org/tajikistan

Cities, towns or villages where MSF works

Key medical figures:

160 patients under treatment for TB,
of which 30 for MDR-TB
The first patient ever treatedfor extensively drug-resistanttuberculosis (XDR-TB) in
Tajikistan was declared cured
in December.

The 17-year-old received treatment throughthe paediatric TB programme supported by
Médecins Sans Frontières (MSF) at Dushanbe
hospital. The programme provides TB
diagnosis and treatment for young people
aged 18 or under. Before MSF began the
project, children undergoing standard TB
treatment had to withstand long, isolated
periods in hospital, while those withmultidrug-resistant TB (MDR-TB) or XDR-TB(for whom first- and second-line antibiotics,
respectively, have failed) went untreated.
Children with TB now receive appropriate
treatment on an outpatient basis
whenever possible, with nutritional andpsychosocial support to help them adhere
to their arduous regimens. In 2014, drug
compounding (combining drugs to create
a formulation particular to a patient’s
needs) was introduced to make paediatricformulations of drugs for MDR-TB.

The health ministry, in partnership with MSF,
diagnoses and treats patients’ family members
and MSF searches for individual solutions forpeople who live far from the hospital. MSF
is also working to eliminate the stigma of TB
and to facilitate children’s return to school.
Until now, only MSF was providing XDR-TB
treatment in Tajikistan, but discussions with
the Global Fund and the United Nations
Development Programme have been successful
and treatment provision is beginning to expand.
The Paediatric TB Protocol developed by MSF
has been adopted as the national guideline.

Kala azar
In May, MSF completed a response to
the 2013 outbreak of kala azar (visceralleishmaniasis) in Tajikistan. MSF trained healthministry professionals including doctors,
nurses, epidemiologists and laboratory
technicians in seven locations, and worked onnational guidelines for disease management.

turkeyNo. staff in 2014: 8 | Expenditure: d0.8 million | Year MSF first worked in the country: 1999 | msf.org/turkey
The poor living conditions and limitedaccess to medical care endured by many
predominantly urban and unregisteredrefugees in Turkey remain concerning.
This year Médecins Sans Frontières (MSF)
launched several interventions to support
Turkish Civil Society Organisations (CSOs)
in delivering assistance to those in need.
C ities, towns or villages where MSF supports projects

Over 1.8 million Syrian war
refugees were living in Turkey
at the end of 2014.

A number of Syrians have settled in thesouthern provinces of Kilis and Sanliurfa,
along the Syrian–Turkish border. MSF isproviding financial and technical support
to a number of organisations, including theHelsinki Citizens’ Assembly (hCa) which isrunning a clinic in Kilis aimed at offeringhigh-quality basic healthcare, such as mental
health services, to this vulnerable population.
The main goal of the mental health activities
in Kilis is to help refugees cope and adjust
to their new situation, regardless of whether
they live inside or outside the camps.

MSF also offers financial and technical support
to the humanitarian agency Support to Lifeand the International Blue Crescent Relief
and Development Foundation in Sanliurfa,
where there is a mental health intervention
for refugees and activities are underway to
improve water supply, hygiene and sanitation
conditions – something that is much neededin the temporary refugee settlements in thegovernorate. The CSOs supported by MSF
responded immediately to influxes of Syrian
refugees by distributing shelter materials andnon-food aid items such as soap, blankets andplastic sheeting.
If MSF’s request for legal registration is
granted by the Turkish authorities, activities
directly supporting the growing number ofrefugees may be increased.

International Activity Report 2014 77

south sudan

south sudan

No. staff in 2014: 3,996 | Expenditure: d83.3 million | Year MSF first worked in the country: 1983 | msf.org/southsudan | blogs.msf.org/southsudan
Key medical figures:

936,200 outpatient consultations
22,700 patients treated in
feeding centres
6,900 surgical interventions
6,800 patients treated for kala azar
6,800 patients treated for cholera
Regions where MSF has projects
Cities, towns or villages where MSF works

Throughout 2014, Médecins
Sans Frontiéres (MSF)
responded to emergency
medical needs arising fromconflict while striving tomaintain its pre-existing,essential healthcare
programmes in South Sudan.
When fighting broke out in the capital
Juba at the end of 2013 and rapidly spreadthroughout the country, MSF started
dispatching medical supplies and staff tocritically affected locations. The number ofprojects had soon increased from 13 to morethan 20 across nine states. Many people fled
their homes and thousands hid in the bush.
An estimated 1.5 million people remainedinternally displaced by the end of 2014.

lifesaving assistance because of these acts.
MSF staff witnessed the gruesome aftermathof armed attacks and clashes in Malakal
in Upper Nile state, when they discovered
patients murdered inside the town’s teaching
hospital. After fighting in Bentiu in April,people who had been seeking shelter inside
the hospital were killed on the grounds.

Juba
To escape the violence in Juba, tens of
thousands of people sought refuge in UN
compounds, where Protection of Civilians(PoC) sites were designated. MSF set up
medical facilities in the Tomping and Juba
House PoC sites, but spoke out about the
deplorable living conditions there, and inother PoC sites in the country, throughout theyear. With the gradual stabilisation of medical
needs, and as other organisations increased
their activities, MSF’s medical projects in
the Juba PoC sites were handed over to theInternational Medical Corps, South Sudan Red
Cross and Health Link South Sudan in August.

Unity state
The rapidly worsening security situation in
January forced the evacuation of international
staff from Bentiu. In April MSF was forced tostop providing TB and HIV care in the hospital
because of increased violence. The town’s
residents fled to the nearby UN compound,
where the population swelled from 6,000 people
to more than 22,000 in a matter of days.

Medical care has come under attack timeand again in South Sudan, with patients shotin their beds, wards burned to the groundand medical equipment stolen. Hundredsof thousands of people have been denied

78 Médecins Sans Frontières© Ian Atkinson/MSF

Since the beginning of the crisis in South
Sudan, MSF has called on all parties torespect the integrity of medical facilities, andto allow aid organisations to access affected
communities. In January 2014, there washeavy fighting in the town of Leer, southern
Unity state, and the MSF-supported hospital
was looted and set alight. The provision of
outpatient and inpatient care for children andadults, surgery, maternity services, treatment
for HIV and tuberculosis (TB) and intensive
care was interrupted for several months.

Bentiu’s residents sought shelter from violence in a UN compound; by the end of theyear 40,000 people were living there in a makeshift camp. In July, when the first rains
came, much of the camp was flooded.

south sudan

In Leer, the international MSF team wasevacuated in January due to increased
insecurity. Shortly afterwards, 240 South
Sudanese MSF hospital staff were forced toescape into the bush with their families andsome of the most severely injured patients.
By mid-April, the local population had begun
to return to the town and in May medical
activities resumed. By this time malnutritionin the area had reached crisis levels, andduring May and June MSF treated morepatients for malnutrition than in all of 2013.

Jonglei state
Some 70,000 people fled the town of Bor
as a result of violence and the state hospital
was ransacked. In April, an MSF team helped
the health ministry repair the hospital andresume basic medical activities. A team also
treated people wounded during an attack at
Bor airport. MSF had long supported Lankien
hospital, and in 2014 began emergency surgery
to treat the increasing number of war wounded.
Of the 910 major surgical interventions
performed at the hospital, 76 per cent were
violence-related. There was also a massive
outbreak of kala azar (visceral leishmaniasis)and more than 6,000 patients were treated.
Insecurity in Pibor in 2013 caused MSF towithdraw from a fixed health centre andoperate instead through mobile clinics. By July
2014, the situation had stabilised and MSF
resumed activities in Pibor town, including basic
health consultations, inpatient services andmaternity care. Teams also offered healthcare in
nearby Gumuruk, Lekwongole and Old Fangak,
areas regularly affected by the war.

Upper Nile state
In a pre-existing project at Nasir hospital,a monthly average of 4,100 consultations
were carried out until heavy fighting brokeout nearby. The town’s population fled andthe hospital was evacuated in May. MSF staff
visiting in June found the hospital completelylooted and the town deserted. They had© Valérie Batselaere/MSF

By the end of the year, the number had
increased to 40,000. At the PoC site, MSF
maintained a 24-hour emergency roomand provided more than 10,000 outpatient
consultations, treated nearly 1,000 children
for severe malnutrition and performed 300
emergency surgical interventions, 83 per centof which were conflict-related – mostly gunshot
wounds. Tens of thousands of children were
vaccinated against measles inside and outside
the PoC. MSF ran mobile clinics and set up botha general and an antenatal clinic for people
outside the site. Another team maintained
a programme of comprehensive medical
services for some 70,000 Sudanese refugees
at Yida camp, and undertook a pneumococcal
vaccination campaign – the first ever in a
refugee setting. Some 10,000 children under
the age of two were vaccinated.
In the hospital in Agok, an MSF surgeon and his team change the dressing and remove
damaged tissue from a child’s gunshot wound.

no way of knowing the whereabouts or thehealth status of those who had fled.
Due to mounting insecurity, MSF had tostop working in the Malakal public hospitalin April and rapidly opened a clinic in the
PoC where 20,000 people were sheltering.
In Melut, teams provided medical care to
those people displaced by violence, which
included treating them for kala azar and TB.
As the health situation in the refugee camps
stabilised over the year, MSF reduced its
number of outpatient clinics.

Lakes state
MSF provided basic and specialist healthcare,including vaccinations, in Minkamman
camp, Awerial.
Around 95,000 displaced people live inthe camp, and more have settled in thesurrounding areas. Teams carried out morethan 52,000 outpatient consultations and2,700 mental health consultations and also
launched vaccination campaigns against
measles, polio, cholera and meningitis.

high-risk and emergency obstetric care –more than 7,100 women were admitted
to the maternity ward and over 1,500
complicated deliveries were assisted during
the year. In addition, MSF treated more than
30,000 people for malaria in 2014 – threetimes as many as the previous year.
MSF has also supported Yambio state hospitalin Western Equatoria state since 2008, withspecialist paediatric and antenatal care,surgery and treatment for HIV. There are
more than 3,000 patients in the treatment
programme. In Warrap state, MSF runs asmall hospital in Gogrial town providing basic
and specialist care, including an operating
theatre for emergency surgery.

Agok

Following a measles outbreak in Cueibet county
in late March, MSF provided support to thehealth ministry and organised a vaccination
campaign against measles and polio whichreached 32,700 children under five.

MSF continued to work in Agok, 40 kilometres
south of Abyei, an area contested by Sudan andSouth Sudan. In the only hospital providing
specialist services in the region, teams offeredinpatient care, emergency surgery, maternity
services and an inpatient therapeutic feeding
centre. Early in the year a triage area andemergency room were also opened. Over 1,550
deliveries were assisted and 6,600 people wereadmitted to hospital. In February, the mobile
clinics run by MSF ceased due to security
concerns, and in March outpatient services
were handed over to the NGO GOAL.

Northern Bahr El Ghazal state

Cholera emergency response

In Pamat, close to the border with Sudan,
MSF continued to offer basic and specialist
medical care to people displaced by conflict.
Staff distributed relief items and provided
health consultations to new arrivals in
December. Since 2008, MSF has supported
Aweil civil hospital, with around-the-clock
paediatric and maternity services, including

On 15 May, the health ministry declareda cholera outbreak in Juba. MSF opened
and ran five cholera treatment centres andthree oral rehydration points, and provided
technical assistance at Juba teaching hospital.
MSF also responded to small outbreaks inTorit, Eastern Equatoria state, and in Malakal
and Wau Shilluk, Upper Nile state.

International Activity Report 2014 79

sudansudan

No. staff in 2014: 589 | Expenditure: d11.8 million | Year MSF first worked in the country: 1979 | msf.org/sudan

Regions where MSF has projects

Key medical figures:

246,900 outpatient consultations

Conflict continues to inflicta heavy toll on the health ofpeople in Sudan’s Darfur, South
Kordofan and Blue Nile states.
Médecins Sans Frontières (MSF) aims to
respond to emergency health needs in the
country, but in 2014 various restrictions
hindered its access to conflict-affected areas.
An MSF-operated hospital in South Kordofan
was bombed in January. Thousands of people
are cut off from humanitarian assistance andare in dire need of medical care.

North Darfur
Clashes took place between resident Zaghawa
and nomadic Arab tribes in Tawila, where an
MSF hospital-based project offers outpatientand inpatient care, focusing on the needs ofmothers and children. The team carried out
more than 34,900 outpatient consultations
and 5,400 antenatal consultations, andtreated 1,300 children for malnutrition.
Another MSF team, again concentrating on
basic medical care for mothers and children,
works in four health centres in Dar Zaghawa.
Postnatal care is available at three peripheral
health posts. More than 46,800 outpatient
consultations were conducted in 2014.
MSF continued to assist displaced people in
El Sireaf, providing water and sanitation, relief
items and medical care, including surgery.
More than 17,700 outpatient consultations
were carried out and 1,100 people weretreated for malaria.

80 Médecins Sans Frontières© MSF

400 patients treated for kala azar

A health clinic was opened in February in White Nile state to provide basic healthcare tosome 30,000 South Sudanese refugees, many of them women, children and elderly people.

North Darfur Emergency Response (NDER),a project with the North Darfur healthministry, conducts rapid health assessments
and interventions. Activities included relief
item distribution in Tawisha, Usban andEl Fasher; a hepatitis E intervention in Um
Kadada; malnutrition screening in Shangil
Tobaya; supporting the campaign against
dengue fever in El Fasher with such things ascase management, vector control and active
surveillance; and emergency response training.

South Darfur
In March and April, there were 4,000 new
arrivals at El Sereif displaced people camp near
Nyala. Their villages southwest of the city had
been destroyed and they had fled in fear. MSF
was already working in the camp, improving
the water supply (which was far short ofemergency standards) and treating residents
whose health was suffering due to the poor
living conditions.

West Darfur
Towards the end of 2014, MSF began tosupport four health centres in Kerenek
locality, West Darfur, offering basic medicalcare. A team also worked with the healthministry on Ebola preparedness, training morethan 100 staff and strengthening surveillance.

Assisting South Sudanese refugees
A health clinic was opened in February inWhite Nile state to provide basic healthcare tosome 30,000 South Sudanese refugees, manyof them women, children and elderly people
who had walked long distances to safety. An
average of 4,300 consultations were carriedout each month.

Neglected diseases
MSF conducted training on kala azar (visceralleishmaniasis) for 590 health professionals
in Sennar state and treated 400 kala azar
patients in Tabarak Allah hospital, Al Gedaref
state. MSF also supported reproductive
healthcare services in the hospital.
MSF supported tuberculosis diagnosis andtreatment in five health centres in Jebel
Awila, a large slum area on the outskirts ofKhartoum, where crowded living conditions
increase the risk of contracting the disease.

swaziland

swaziland

No. staff in 2014: 406 | Expenditure: d8.4 million | Year MSF first worked in the country: 2007 | msf.org/swaziland

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

Key medical figures:© Giorgos Moutafis

16,500 patients on first-line
ARV treatment
1,700 patients under treatment for TB
Decentralised care andinnovative treatments are
helping people with HIV live
longer, healthier lives.
The co-infection rates of HIV and tuberculosis(TB), including drug-resistant TB (DR-TB),
are extremely concerning, and 10 per centof people with TB are diagnosed with adrug-resistant form of the disease. Médecins
Sans Frontières (MSF) began collaboratingwith the health ministry to address the HIV–TB epidemic in Shiselweni in 2007 and in
Manzini in 2010.

Shiselweni region
MSF continued to support integrated HIV
and TB care in Shiselweni region this year,with projects in Nhlangano, Hlatikulu andMatsanjeni. Since 2010, the programme
has trained local workers and community
members living with HIV, and has helped
expand diagnosis and treatment of HIV and
TB in this rural southern region. Patientsare now able to access treatment andpsychosocial support through 22 healthclinics and three specialised facilities. A fiveyear evaluation on the decentralisation of caredemonstrated that simplifying it and bringing
it closer to home is sustainable, leads toincreased access to antiretrovirals (ARVs) andhelps patients adhere to their drug regimens.
Central to the programme are the HIVpositive community members trained by
MSF and the health ministry, Expert Clients,

A mother and child attending a clinic in Shiselweni region.

who carried out more than 3,200 healtheducation sessions in 2014. Through these,some 137,100 people in Shiselweni weremade aware of HIV-related issues. Door-todoor HIV testing has also been integrated
into the programme, increasing the detectionof HIV-positive people. Additionally, routine
viral load measuring has been implemented
to monitor health status, which allows forthe identification of patients whose viral load
is “undetectable”, meaning that the virus isunder control and that the risk of transmission
is markedly lower.
The first phase of the Treatment as Prevention
strategy targeted pregnant women. It was
implemented as a national strategy in 2014
after proving effective in a pilot project inNhlangano. The second phase, Early Accessto Antiretrovirals for All (EAAA), was launchedin Nhlangano in October, providing all HIVpositive patients with ARV treatment whatever
their clinical or immunological status.

Manzini region
The migrant workers and residents of
Matsapha can be tested and treated for HIV
and TB at MSF’s one-stop comprehensive
family health clinic. Basic healthcare services,
including maternity care, immunisations
for children under five, family planning,home-based care services, and medical andpsychosocial treatment for victims of sexual
violence are available.

Comprehensive care is also offered for people
co-infected with HIV and TB at Mankayane
hospital and community-based clinics.
Whenever possible, patients with DR-TB are
treated as outpatients, which helps minimise
the isolation and discomfort of long hospital
stays and increases adherence to treatment.
When standard first-line TB drugs do notwork, the patient is said to have multidrugresistant TB (MDR-TB). As the conventional
treatment for this form of the disease takes aminimum of 20 months and has many painfulside effects, MSF began an observational trial
to study the effectiveness and safety of a ninemonth MDR-TB regimen in Matsapha andMankayane in 2014.

PATIENT STORY
Sphiwe – started on ARVs at
Mashobeni clinic as part of the
EEAA strategy“ I am a rural health motivator (RHM); oneof the people who has been trained by
the Ministry of Health to conduct healthpromotion and home-based care atcommunity level. As an RHM I talk about
these things. Even at our support group
we talk about it and encourage people
to know their status and adhere to their
medication. Being a part of these groups
has helped me to accept my status anduse my story to encourage other people in
my community.”

International Activity Report 2014 81

syriasyria

No. staff in 2014: 729 | Expenditure: d16.6 million | Year MSF first worked in the country: 2009 | msf.org/syria | blogs.msf.org/syria
Key medical figures:

135,600 outpatient consultations
4,900 relief kits distributed
4,400 surgical interventions
1,400 births assisted
Regions where MSF has projectsA pproximate locations where MSF runs
medical facilities
MSF provides technical and material
support to Syrian medics runningfield hospitals and health clinics in thegovernorates of Aleppo, Daraa, Dimashq,
Hama, Homs, Idlib, Latakia and Tartus.

With millions of people in needof assistance, Médecins Sans
Frontières (MSF) should berunning some of the largest
medical programmes in its
44-year history, but it isprevented from doing so.
Violence and insecurity, attacks on health facilities
and medical workers, the absence of government
authorisation and the reneging by armed groups
on guarantees of safety for our teams have beensome of the main obstacles to a more extensive
programme of medical humanitarian aid.

west of Syria’s Idlib governorate, as well as thetwo health centres it was running nearby.

Aleppo governorate
MSF runs three health facilities within Aleppo
governorate, which has seen some of the mostintense fighting, and is one of the main corridors
for Syrians attempting to flee the country. One of
the hospitals has 28 beds, and offers emergency,
maternity and outpatient care. Vaccinations,orthopaedic services and treatment for somechronic diseases are also provided. The teamstabilises patients at this hospital before
transferring them to other facilities whennecessary. From this base, MSF donated drugs
and medical supplies to 10 field hospitals, nine
first-aid points and three health centres.

A second MSF hospital in the Aleppo area had
to be closed in August for security reasons. It
provided access to healthcare for adults andchildren, including surgery for war wounded,trauma cases and burns patients, as well as
emergency services, maternity, ante-and
postnatal care and outpatient consultations.
On the outskirts of Aleppo, a third MSF hospital
has a capacity of 12 beds. At this location teams
carried out some 22,000 outpatient consultations,more than 12,300 emergency room
consultations, over 500 surgical interventions,and admitted 1,200 patients. Vaccinations,antenatal care and mental health support wereavailable and the hospital has a referral system inplace for people who need additional services.

On 2 January 2014, ISIS (later renamed IslamicState; IS) abducted 13 MSF staff members.
Among them were eight Syrian colleagues who
were released after a few hours. The remaining
five international staff members were held
captive for up to five months. The abduction
led to the withdrawal of MSF’s international
teams and the closure of health facilities in ISheld areas. MSF closed its field hospital in themountainous region of Jabal Al-Akrad, in the

82 Médecins Sans Frontières© MSF

The war entered its fourth year in 2014, andcontinued to be defined by brutal violence
that does not distinguish between civilians andcombatants. An estimated 200,000 people havebeen killed, and half the population is displaced
either within Syria or in neighbouring countries.
Entire communities are besieged and cut off
from any outside assistance and people aretrapped between the ever-shifting frontlines.
Thousands of doctors, nurses, pharmacists andparamedics have been killed, kidnapped, or
displaced by violence, leaving a massive gap
in medical expertise and experience.

A young girl having a medical consultation at a mobile clinic in Al Hasakah governorate.

© Chris Huby

syria

Bab Al Hawa camp, where some of the Syrian people forced from their homes by the violence are now living in terrible conditions.

Idlib governorate
There are extreme shortages due to the war, andthe poor-quality fuel that families have to use forstoves and heaters frequently causes explosions,
resulting in severe burns. In Idlib governorate
MSF runs the only burns unit in northern
Syria where people can get the specialist
care they need, such as wound cleaning(debridement), dressing changes performed in
the operating theatre under anaesthesia, skingrafts and physiotherapy. The 15-bed hospital
has an emergency room, and a team offers
psychological support to patients. More than
1,800 burns patients came to the facility in 2014
and over 5,800 patients were treated in theemergency room. The team performed morethan 3,800 surgical interventions.
In response to reports of several measles cases
in a community of some 100,000 internallydisplaced people along the border with Turkey,
MSF conducted a vaccination campaign. Morethan 11,000 children were vaccinated against
measles in camps and villages in August. MSF
is continuing routine vaccinations for children
under three years old. The absence of routine
vaccination schedules as a result of the war has
led to a rise in preventable childhood illnesses.

Ar-Raqqah governorate
The health centres and hospitals that are still
operational in Ar-Raqqah governorate arestruggling to maintain supplies, staff numbers
and to ensure drugs are stored at the correcttemperatures. It is estimated that up to
40,000 people across the governorate havebeen forced to leave their homes, and this has

put additional pressure on local communities
who are sheltering them in their houses,
in schools and in former health centres.
MSF continued to run a basic healthcare
clinic in the Tal Abyad referral hospital, andsupported a paediatric ward in the facility.
Mobile teams provided emergency assistanceto the displaced in multiple locations,and also supported routine vaccination
activities by health workers in the region.
More than 5,200 outpatient consultations
were conducted, and 7,000 children were
vaccinated against measles before these
activities were handed over to the Ministryof Health and the local authorities in May.

Al Hasakah governorate
In northeast Syria, acute shortages of drugs,
medical supplies and skilled personnel arehaving a devastating impact on healthcare.
MSF provided staff and supplies to support
pre- and post-operative care in a hospital’s
trauma ward. A team also assisted in thematernity ward, which MSF rehabilitated
and furnished with new equipment. MSF
started to run two clinics offering outpatient
consultations and mother and child healthcare.
MSF has been running mobile clinics inthe region bordering Iraq since 2013. Basichealthcare, with a focus on the health needs ofmothers and children, is provided to displaced
people and to the host communities on the
Syrian side of the border. MSF also conducts
routine polio vaccinations campaigns in thearea – in October 2013, the first case of polio
in Syria in 14 years was reported.

The border with Iraq, which had been closed
since September 2013, reopened in one
direction in June – allowing people to travelfrom Iraq to Syria. In August, tens of thousandsof Iraqis crossed the border, fleeing violencein Iraq’s Ninewa governorate. MSF teams
working on both sides of the border responded
to the increase in needs by running mobile
clinics and setting up health facilities in transit
camps and in camps for displaced people.

Support programmes for Syrian doctors
Despite the increasing access restrictions, MSF
doctor-to-doctor networks continued to provide
clandestine support to medical facilities run
by Syrian doctors in both government- andopposition-controlled areas. These support
programmes allow dedicated Syrian medical
staff to work, often in extremely hazardous
conditions, and bring a minimum level ofhealthcare to people trapped by the conflict.
MSF has developed a programme of largescale support to over 100 undergroundand improvised healthcare facilities at two
locations along Syria’s borders and acrosssix governorates, almost half of which are
dedicated to besieged areas in the Damascus
governorate. The facilities are in bothgovernment-held areas and oppositioncontrolled zones – all locations where it is notpossible for MSF teams to be physically present.
These programmes are increasingly focusedon areas under siege, and supply essential
drugs and medical items, distance training andtechnical support, as well as tailored support
such as ambulances in some areas.

International Activity Report 2014 83

uganda | uzbekistan

ugandaNo. staff in 2014: 568 | Expenditure: d6 million | Year MSF first worked in the country: 1986 | msf.org/uganda

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

Key medical figures:

129,300 outpatient consultations
4,000 patients admitted to hospitalMore than 128,000 South Sudanesepeople fleeing violence had crossed
into Uganda by the end of October.
The majority of the refugees, some 81,000 ofthem, settled in northern Uganda’s Adjumani
district. After being registered through Numanzitransit centre, they were dispersed to camps.
Médecins Sans Frontières (MSF) launched

an emergency programme to provide basic
healthcare for refugees at the transit centre andin the four camps. Teams screened children formalnutrition, and set up outpatient and inpatient
departments, maternity wards and an intensive
therapeutic feeding centre. Water and sanitation
activities were also undertaken to ensure
minimum hygiene standards were being met.
As the number of arrivals dropped and otheragencies began to cover some of the needs, MSF
shifted it’s focus to the two largest camps in thesouth, Ayilo 1 and Ayilo 2, and health screening
and consultations at the transit centre. Morethan 124,000 consultations were carried out andover 4,000 patients were admitted to hospital.
A significant number of refugee children seen
by MSF had respiratory infections, which canspread quickly in crowded environments.
From July to September, MSF conducted threerounds of vaccination against pneumococcal
disease and Haemophilus influenzae type B,
the two main causes of respiratory infections
in children. More than 2,700 children undertwo, living in the refugee camps or in thesurrounding villages, were fully immunised
against pneumococcus. This was the first
vaccination campaign using the pneumococcal
conjugate vaccine ever run in Uganda, andone of the first in a refugee setting.

Arua HIV/tuberculosis (TB) programme closes
The HIV/TB programme that MSF started in
2001, based at Arua regional referral hospital,
was handed over to the Ministry of Health and
SUSTAIN (Strengthening Uganda’s Systems for
Treating AIDS Nationally), a Ugandan–American
NGO, in July. The project included clinical care,the management of a laboratory for HIV, TB
and drug-resistant TB testing and the provisionof antiretrovirals. MSF also handed over the
management centre for multidrug-resistant TB
that it built and had been running.
MSF is continuing to work on improving
access to viral load testing, including for
infants, with the UNITAID-funded Treatment
Success Project. An MSF team is also
assessing specific medical needs related to
HIV in particularly vulnerable groups, such as
children, adolescents and mobile populations.

Marburg emergency preparedness
In October, one case of Marburg haemorrhagic
fever was confirmed in Kampala, triggering a joint
response by the Ministry of Health, MSF and the
US Centers for Disease Control and Prevention.
MSF set up five transit centres and one Ebola
treatment centre within Kampala hospitals andtrained staff working at these sites and in otherprovinces. No further cases were reported.

uzbekistan

No. staff in 2014: 246 | Expenditure: d5.9 million | Year MSF first worked in the country: 1997 | msf.org/uzbekistan

Médecins Sans Frontières (MSF) continues to work to improve thequality and availability of treatment for tuberculosis (TB).

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

Key medical figures:

2,000 patients under treatment for TB
570 patients on first-line ARV treatment

Uzbekistan is one of many countries in Central
Asia with high levels of drug-resistant TB (DRTB), a form of the disease that does not respondto the standard first-line drug regimen. Accessto diagnosis and good-quality care is still limited
and the vast majority of people with DR-TB
remain undiagnosed and untreated.
MSF believes that introducing new approaches
to diagnosis and treatment of TB – such as
ambulatory care, rapid diagnostic tests and acomprehensive patient support programme
including education, psychological support,
transportation, food packages and financial
aid – will help increase adherence to treatment
and control the spread of the disease.

TB programme in Karakalpakstan
In the Autonomous Republic of Karakalpakstan,
MSF runs a TB programme in collaboration with
the Ministry of Health, helping patients manage

84 Médecins Sans Frontières

the side effects of their drugs and providing
psychosocial support to improve treatment
adherence. In 2014, over 2,000 patients wereenrolled for first-line TB treatment and 607 for
DR-TB. Many patients underwent treatment on
an outpatient basis, so they avoided the additional
stress of hospitalisation. During 2014, MSF
continued to enrol multidrug-resistant TB patientson a shorter, nine-month regimen instead of theusual two years. The first people who started theregimen in 2013 finished their treatment, andMSF will continue to monitor them for 12 months
to check that the TB does not return.

Treating HIV in Tashkent
MSF is also seeking to address the developing
HIV epidemic in Tashkent, Uzbekistan’s capitalcity. Teams continued to work at the Tashkent
City AIDS Centre, and a total of 671 people werestarted on antiretroviral treatment. Psychosocial
activities such as counselling were also provided.

ukraineukraineNo. staff in 2014: 71 | Expenditure: d5.5 million | Year MSF first worked in the country: 1999 | msf.org/ukraine
Medical supply lines were severely disrupted
or cut completely, and health facilities’
budgets for the year were quickly exhausted.
While local doctors were able to cope withtreating the wounded, they faced an acuteshortage of medical supplies, so MSF donatedmedicines and materials for treating warwounded patients to hospitals in Donetsk andLuhansk regions.

Regions where MSF has projects

Key medical figures:

1,200 individual and group mental
health consultations

280 patients under treatment for TB
Over 600,000 people weredisplaced and 10,000 wounded
during the intense conflict ineastern Ukraine in 2014.

© MSF

The political protests that started in late2013 gained momentum in 2014, leading toviolent clashes between police and protestors
and the removal of the Ukrainian president
from power in February. Médecins Sans
Frontières (MSF) provided medicines andsupplies to health facilities receiving the
injured in the capital Kiev. Following protests
in the east of the country, fighting broke out
in May between armed separatist groups andUkrainian government forces.

As the conflict spread and intensified,
MSF dramatically increased this support,
and by the end of the year had provided
enough supplies to treat more than 13,000
wounded patients in hospitals on both sidesof the frontline.
Throughout the conflict, hospitals weredamaged by shelling, depriving people ofmedical care just when they needed it themost. This demonstrated a lack of respect
for the health staff who continued to offercare at great risk to themselves, even thoughmany of them had not been paid for months
on end.
Despite a ceasefire in September, thefighting dragged on and medicines became
increasingly difficult to obtain. Following a
Ukrainian government decision to withdraw
all support for state services from rebelcontrolled areas, pension payments were cut,leaving disabled and elderly people particularly
vulnerable, and all banking services were
blocked. People began to delay going to see
a doctor simply because they could not affordtransport or medication. In response to thedifficulties people were facing to access basic
healthcare, MSF started to expand its medical
support to include those patients with chronic
diseases such as diabetes.

MSF teams also distributed more than
2,600 hygiene kits, including soap, dental
supplies and towels, to people in Donetsk
region who had fled their homes. In
preparation for the harsh winter, MSF
donated 15,000 blankets to hospitals
and displaced people around Donetsk
and Luhansk.

Treating the psychological effects of war
In March, MSF began to work with Ukrainian
psychologists in Kiev, conducting training
sessions and workshops on psychologicalproblems such as depression and posttraumatic stress, and treating patients on
both sides of the conflict. From August,
MSF psychologists started to run individual,group and family mental health sessions inseveral cities on both sides of the frontline in
the east, educating people about emotional
reactions following traumatic events, andteaching them practical tools to help
cope with fear, anxiety and nightmares. In
addition, MSF psychologists trained local
medical and mental health staff to improvetheir skills and avoid burnout.

Tuberculosis (TB) programme
MSF has been running a programme forpeople with drug-resistant TB within theregional penitentiary system in Donetsk since2011. Throughout the conflict, MSF has
made every effort to keep this project runningand support patients to avoid treatment
interruption. When heavy shelling made it
too dangerous for the teams to reach the
penitentiaries, they ensured the drugs werestill available by delivering them to a safer
location to be picked up by prison staff.

PATIENT STORY
Svetlana – a patient receiving“ I was in the yard with my husband when theshelling came. We had heard shelling before, butnever this close. An artillery shell hit very close
by. My husband was very badly wounded. Someshrapnel went into my legs and my chest. I still
have a piece of metal lodged between my ribs.
I called for an ambulance, but they said it was
too dangerous … My husband died in the yard.

MSF teams delivering medical supplies toa hospital just outside Donetsk.

© Julie Remy/MSF

counselling from an MSF psychologist

I’ve been staying at this hospital in Svitlodarsk for two months with my five-year-old daughter
because we have nowhere else to go. I’m too afraid to go back to Debaltsevo ... Now I hear
explosions when there aren’t any. When my daughter hears an explosion, she asks ‘Is that agrad or a shell?’ Is that normal for a five-year-old?”International Activity Report 2014 85

yemenyemen

No. staff in 2014: 562 | Expenditure: d9.9 million | Year MSF first worked in the country: 1994 | msf.org/yemen | blogs.msf.org/yemen

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

Key medical figures:

91,000 outpatient consultations© Malak Shaher/MSF

4,300 surgical interventions
720 patients on first-line ARV treatment
High levels of poverty andunemployment combinedwith continuous insecurity
make it difficult for Yemenis
to access healthcare.
Basic healthcare and lifesaving surgical careis provided by Médecins Sans Frontières(MSF) in Al Azaraq and Qataba’a districts of
Ad Dhale governorate. More than 47,000
outpatient consultations took place in 2014.
Emergency surgery for victims of violenceis available in Al Naser general hospital, Ad
Dhale city. The team performed around
300 surgical procedures here between Juneand September, when they were evacuatedbecause of insecurity.

Amran
MSF teams in Amran continued to support
Al-Salam hospital, providing emergency,
maternity, inpatient and outpatient services
and assisting in the laboratory and bloodbank. More than 2,300 surgical interventions
and 25,300 emergency consultations werecarried out, 5,200 patients were admitted tohospital and over 2,500 babies were delivered
during the year. To assist the communities
in the remote Osman and Akhraf valleys,
MSF supported the reopening of Heithah
health unit in April, but insecurity caused thesuspension and then complete cessation ofactivity in November.

86 Médecins Sans Frontières

Hundreds of thousands of Yemenis were forced to leave their homes due to conflict in 2014.

Aden

Reducing HIV stigma

MSF’s emergency surgical unit in Aden
re-established networks of medical referrals
from Abyan, Ad Dhale, Lahj and Shabwah –places frequently affected by violence andincreased surgical needs. More than 2,000
emergency consultations, 1,600 surgicalprocedures and 5,600 physiotherapy sessions
were completed. A weekly clinic in Aden
central prison recorded more than 1,600
consultations. Support to Lawdar and Jaar
hospitals in Abyan was stopped because
MSF was seeing fewer victims of violencefrom these areas, and the networks werere-established and strengthened so patients
could be referred to the MSF emergency
hospital in Aden.

Lack of knowledge about HIV/AIDS among
healthcare providers has been the main causeof stigma and discrimination in Yemen. MSF
trained staff in seven hospitals as part of its
work with the National AIDS Programme andits advocacy resulted in a dramatic increasein the number of people getting tested forHIV, including pregnant women, and in thenumber of HIV-positive patients admitted to
Al Gumhuri hospital in Sana’a.

Rapid emergency response
MSF set up a team to provide rapid medical
aid following violence and other emergencies.
Medical supplies were donated to clinics
and hospitals, relief items were distributed
to people forced to leave their homes by
conflict and direct care was offered to victimsof violence and the displaced. Medical items
were donated to 38 health facilities in fivegovernorates, including the capital Sana’a,and hundreds of displaced people received
direct emergency support.

MSF closed the mental health programme
for migrants in detention that had openedin 2013. The number of new arrivals hadstabilised, and there were organisations readyto take over running the project.

zimbabwezimbabwe

No. staff in 2014: 362 | Expenditure: d13.6 million | Year MSF first worked in the country: 2000 | msf.org/zimbabwe
Key medical figures:

6,000 patients on first-line
ARV treatment

1,400 patients under treatment for TB

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

Children with HIV have particular difficulty inobtaining appropriate care. Staff shortages,
restricted clinic hours, high fees and long
distances to facilities are some of the barriers
that patients face. Médecins Sans Frontières(MSF) has worked with the health authorities
to develop integrated care in government
health facilities, decentralising diagnosis andtreatment to help meet people’s needs close
to home.
In Epworth, Harare, MSF focuses on paediatricand adolescent HIV and tuberculosis (TB), andon providing treatment to patients whose
standard HIV or TB treatment has failed. Morethan 2,660 patients under 20 were tested
for HIV and more than 200 were started ontreatment. Routine HIV and TB management
was handed over to the health ministry in2014 after more than a year of building up thenecessary staff capacity.
MSF’s HIV–TB programmes in Buhera, Gutu
and Chikomba concentrated on staff training
and mentoring, and provided technical andmaterial support to local health centres toimplement new World Health Organization
guidelines and increase access to routine viralload monitoring. Testing and antiretroviral(ARV) treatment is now available to everyone
and has been decentralised to all clinics inthe three supported districts. MSF continued
to implement patient-friendly models of careto relieve the pressure on health centres. By
the end of the year there were 72 community

ARV groups in Gutu, with a total of 477
members, who take turns in picking up drug
refills for each other. New strategies werealso tried in Gutu to increase the numberof people taking HIV tests, including weeklynight clinics and testing and counselling
campaigns directed at young people or linked
with sporting events.
MSF also continued to support viral load
testing at the central hospital in Harare,
which enables the monitoring of patients on
ARVs. UNITAID financed the viral load testingmachine and covered its running costs, whilst
MSF piloted the implementation. A total of
35,439 tests were conducted in 2014.
In Nyanga district, HIV and TB care wasdecentralised to 18 out of a total of 21 clinics
in 2014.
Psychiatric care in prisons
MSF provides diagnosis and treatment of maleand female inmates with mental illness at
Chikurubi maximum security prison, Harare.
Staff in 10 prisons are also receiving training
on the appropriate diagnosis and managementof mental illness. MSF ensures that diagnosis
and treatment for HIV and TB is available in theprisons via the Ministry of Health.

sexual violence through two hospitals and 18
healthcare facilities. After three years, during
which time 12 facilities obtained accreditation
as ARV initiation sites and another six as ARV
follow-up sites, the project was handed overto the Ministry of Health and Child Care, as
the initial objectives had been achieved. In
Harare, MSF has also supported the ministry
to decentralise these services, which are now
available at six health centres. The team’s
recent focus had been on improving care forchildren with HIV and more complicated casesof HIV and TB. The project was handed overto the ministry in October, as they had thecapacity to offer the necessary medical care.
After more than nine years working on HIV in
Tsholotsho, the HIV project was handed overto local health authorities in November. The
programme had achieved its overall goal oftreating HIV/AIDS and reducing transmission
and related morbidity and mortality. By theend of August, more than 10,400 people
were on ARVs, 85 per cent of all people inneed of HIV treatment in the district.

Sexual violence programme
Sexual violence is a critical issue in Zimbabwe,
which MSF continues to address. In
Mbare, Harare, MSF’s clinic for victims ofsexual violence offers free medical care,and counselling and referrals for further
psychological, social and legal support.
Programme handovers
MSF’s project in the rural district of Gokwe
North decentralised and improved medicalcare for people with HIV and TB and victims of© Munyaradzi Makari/MSF

Access to treatment for
HIV/AIDS in Zimbabwe has
improved in recent years, but
remains limited for certain
vulnerable groups.

Before the introduction of community
ARV groups, Bej Murevi had a monthly
20-kilometre round-trip to pick up her
medication.

International Activity Report 2014 87

facts and figures

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

activities such as humanitarian relief supplies,
epidemiological and medical research, andresearch on humanitarian and social action.
These satellites, considered as related parties
to the national offices, include: MSF-Supply,
MSF-Logistique, Epicentre, Fondation MSF,

It comprises 21 main national offices in

Fondation MSF Belgique, Etat d'Urgence

Australia, Austria, Belgium, Brazil, Canada,

Production, MSF Assistance, SCI MSF, SCI

Denmark, France, Germany, Greece, Holland,

Sabin, Ärzte Ohne Grenzen Foundation

Hong Kong, Italy, Japan, Luxembourg,and MSF Enterprises Limited. As these

Norway, South Africa, Spain, Sweden,

organisations are controlled by MSF, they are

Switzerland, the United Kingdom and theincluded in the scope of the MSF Financial

United States. There are also offices in

Report and the figures presented here.

Argentina, the Czech Republic and Ireland.
MSF International is based in Geneva.

These figures describe MSF’s finances

The search for efficiency has led MSF to2014 combined international figures havecreate 10 specialised organisations, called

been prepared in accordance with MSF‘satellites’, which take charge of specificinternational accounting standards, whichon a combined international level. The

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 2014 Financial Report may
be obtained at www.msf.org. In addition,
each national office of MSF publishes annual,audited Financial Statements according to its
national accounting policies, legislation andauditing rules. Copies of these reports may berequested from the national offices.
The figures presented here are for the 2014
calendar year. All amounts are presented inmillions of euros.
Note: Figures in these tables are rounded, which may
result in apparent inconsistencies in totals.

Where did the money go?
Programme expenses by nature
Locally hired staff

31%

International staff

21%

Medical and nutrition

18%

Transport, freight, storage

14%

Logistics and sanitation

7%

Operational running expenses

6%

Consultants and field support

2%

Training and local support

1%

The biggest category of expenses isdedicated to staff working in the field:
about 52 per cent of expenditurecomprises all costs related to locally hired
and international staff (including planetickets, insurance, accommodation, etc).
The medical and nutrition category
includes drugs and medical equipment,
vaccines, hospitalisation fees andtherapeutic 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 and sanitationand logistical supplies.

88 Médecins Sans Frontières

Programme expenses by continent
Africa

66%

Asia

24%

Americas6%Europe2%

Oceania1%

Unallocated1%

facts and figures

Countries where we spent the mostCountries where MSF expenditure is more than 10 million euros

in millions of euros

100
80
60
40
20

a
di
In

n
da
Su

bw

nm

ba
m
Zi

M

ya

ba
Le

e

ar

n
no

ria
Sy

a
ny
Ke

an
st
ki

ne

a
Pa

ui
G

ad
Ch

q
Ira

ia
Et

hi

be

op

ria

er
ig

Li

an

ist

on
gh

Le

Af

ra
er
Si

N

an

e

ti
ai
H

ic
bl
pu

ra

lA

fri

ca

So

n

ut

h

Re

Su

D

da

RC

n

0

Ce

nt

2014

AFRICA

83.3

ASIA AND
THE MIDDLE EAST

Democratic Republic of Congo

70.1

Afghanistan

Central80 African Republic

53.0

Sierra Leone

South Sudan

100

in millions of E

THE AMERICAS

2013

in millions of E

Haiti

35.2

24.8

Colombia

3.9

Iraq

20.4

Mexico2.9

in millions of E

26.0

Pakistan

17.8

Honduras

60
Niger

23.5

Syria

16.6

Other countries

Liberia

23.0

Lebanon

15.6

Ethiopia

21.3

Myanmar

14.0

Chad
20

19.5

India

10.0

Guinea

18.7

Yemen

9.9

17.4

Jordan8.4

Zimbabwe

13.6

Philippines

6.9

Sudan

11.8

Uzbekistan

5.9

Nigeria

9.8

Palestine

4.3

Mali

9.5

Bangladesh

3.1

Cameroon

8.7

Cambodia

2.3

Swaziland

8.4

Armenia

2.2

Mozambique

7.8

Kyrgyzstan

2.1

OCEANIA

Malawi

7.1

Tajikistan

1.4

Papua New Guinea

5.3South Africa

6.7

Other countries *3.1

Uganda

6.0

Total

5.3

Mauritania

4.4

Egypt

2.6

Côte d’Ivoire

2.3

Burundi

2.3

Libya

2.2

Other countries *

1.9

40

0
Kenya

Total Africa

462.2

Total Asia

1.2
*

0.5

Total America

43.7

EUROPE

in millions of E

Ukraine

5.5

Russian Federation

4.9

Other countries *2.1

Total Europe

12.5

in millions of E

168.7

UNALLOCATED

in millions of E

Other

3.2

Transversal activities

3.5

Total unallocated

6.6

Total programme expenses

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

International Activity Report 2014 89

facts and figures

WHERE DID THE MONEYCOME FROM?
Private

2014

2013

in millions of e

percentage

in millions of e

percentage

1,141.7

89%

899.7

89%

Public institutional

114.7

9%

93.0

9%

Other

24.0

2%

15.9

2%

1,280.3

100%

1,008.5

100%in millions of e

percentage

in millions of e

percentage

Income

HOW WAS THE MONEY SPENT?

2014

2013

Programmes

699.1

66%

615.4

65%

Headquarters programme support

113.9

11%

108.8

11%

Témoignage/awareness-raising

31.1

3%

30.2

3%

Other humanitarian activities

14.1

1%

9.3

1%

Social mission

858.1

80%

763.7

80%

Fundraising

147.2

14%

131.6

14%

Management and general administration

60.2

6%

57.1

6%

Income tax

0.6

–

0

–

207.9

20%

188.8

20%

1,066.1

100%

952.5

100%

Other expenses

Expenditure
Net exchange gains/losses
Surplus/deficit

9.7

-7.9

223.9

48.1

YEAR-END FINANCIAL
POSITION

2014
in millions of e

2013

percentage

in millions of e

percentage

Cash and cash equivalents

857.8

82%

616.3

81%

Other current assets

106.2

10%

87.3

11%

Non-current assets

88.3

8%

61.7

8%

1,052.3

100%

765.3

100%

3.2

0%

3.1

0%

AssetsPermanently restricted funds
Unrestricted funds

851.6

81%

627.7

83%

Other retained earnings and equities

24.5

2%

3.4

0%

Retained earnings and equities

879.3

83%

634.2

83%

173

16%

131.1

17%

1,052.3

100%

765.3

100%

Current liabilities
Liabilities and retained earnings

Private income
Public institutional income
Other income

89 %
9%
2%

Programmes
Headquarters programme
supportTémoignage/awareness-raising
Other humanitarian activities
Fundraising
Management and generaladministration

66 %
11 %
3%
1%
14 %
6%

5.7
millionprivate donors

90 Médecins Sans Frontières

facts and figures

HR STATISTICS

2014

2013

Medical pool

1,836

26%

1,593

26%

Nurses and other paramedical pool

2,298

32%

1,892

30%

Non-medical pool

2,952

42%

2,714

44%

International departures (full year)

7,086

100%

6,199

100%

no. staff

percentage

no. staff

percentage

Locally hired staff

31,052

85%

29,91085%

International staff

2,769

8%

2,629

8%

Field positions

33,821

93%

32,539

93%

2,661

7%

2,493

7%

36,482

100%

35,032100%

Positions at headquarters
Staff

Locally hired staff
International staff
Headquarters staff

85%
8%
7%

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

Sources of income
As part of MSF’s effort to guarantee its independence and strengthen
the organisation’s link with society, we strive to maintain a highlevel of private income. In 2014, 89 per cent of MSF’s income camefrom private sources. More than 5.7 million individual donors andprivate foundations worldwide made this possible. Public institutional
agencies providing funding to MSF included, among others, theEuropean Commission’s Humanitarian Aid Department (ECHO) andthe governments of Belgium, Canada, Czech Republic, Denmark,France, Germany, Ireland, Luxembourg, Norway, Spain, Sweden,
Switzerland and the UK.
Expenditure is allocated in line with the main activities performed
by MSF according to the full cost method. Therefore all expense
categories include salaries, direct costs and allocated overheads(e.g. building costs and depreciation).
Programme expenses represent expenses incurred in the field or byheadquarters on behalf of the field.
Social mission includes all costs related to operations in the field aswell as all the medical and operational support from the headquarters
directly allocated to the field and “témoignage/awareness-raising”
activities. Social mission costs represent 80 per cent of the total costs
for 2014.
Other expenses comprises costs associated with raising funds fromall possible sources, the expenditures incurred in the management
and administration of the organisation, as well as income tax paid oncommercial activities.

Permanently restricted funds may be capital funds, where donors
require the assets to be invested or retained for long-term use rather
than expended; or the minimum compulsory level of retained
earnings to be maintained in some countries.
Unrestricted funds are unspent, non-designated donor funds
expendable at the discretion of MSF’s trustees in furtherance of oursocial mission.
Other retained earnings are foundations' capital and translation
adjustments arising from the translation of entities’ financial
statements into euros. Unspent donor-designated/restricted funds are
not included as retained earnings, but are treated as deferred income.
MSF’s retained earnings have been built up over the years bysurpluses of income over expenses. At the end of 2014, the available
portion (excluding permanently restricted funds and capital forfoundations) represented 9.8 months of the preceding year’s
activity. The purpose of maintaining retained earnings is to meet thefollowing needs: working capital needs over the course of the year,
as fundraising traditionally has seasonal peaks while expenditure isrelatively constant; swift operational response to humanitarian needs
that will be funded by forthcoming public fundraising campaigns
and/or by public institutional funding; future major humanitarian
emergencies for which sufficient funding cannot be obtained;
the sustainability of long-term programmes (e.g. antiretroviraltreatment programmes); and a sudden drop in private and/or public
institutional funding that cannot be matched in the short term by areduction in expenditure.
The complete Financial Report is available at www.msf.org

International Activity Report 2014 91

contact msf

contact msf
International Médecins Sans Frontières
78 rue de Lausanne Case Postale 116
1211 Geneva 21 Switzerland
T +41 22 849 84 84 F +41 22 849 84 04
msf.org
Humanitarian Advocacy and
Representation team(UN, African Union, ASEAN, EU, Middle East)
T +41 22 849 84 84 F +41 22 849 84 04
MSF Access Campaign
78 rue de Lausanne Case Postale 116
1211 Geneva 21 Switzerland
T +41 22 849 8405 msfaccess.org
Australia Médecins Sans Frontières /Doctors Without Borders
Level 4 1–9 Glebe Point Road
Glebe NSW 2037 Australia
T +61 28 570 2600 F +61 28 570 2699
office@sydney.msf.org msf.org.au
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Taborstraße 10 A-1020 Vienna Austria
T +43 1 409 7276 F +43 1 409 7276/40
office@aerzte-ohne-grenzen.at
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Rue de l'Arbre Bénit 46
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T +32 2 474 74 74 F +32 2 474 75 75
msf-azg.beBrazil Médecins Sans Frontières /Médicos Sem Fronteiras
Rua do Catete, 84 Catete Rio de Janeiro RJ
CEP 22220-000 Brazil
T +55 21 3527 3636 F +55 21 3527 3641
info@msf.org.br msf.org.br
Canada Médecins Sans Frontières /Doctors Without Borders
720 Spadina Avenue, Suite 402 Toronto
Ontario M5S 2T9 Canada
T +1 416 964 0619 F +1 416 963 8707
msfcan@msf.ca msf.ca
Denmark Médecins Sans Frontières /Læger uden Grænser
Dronningensgade 68, 3. DK-1420 København K
Denmark
T +45 39 77 56 00 F +45 39 77 56 01
info@msf.dk msf.dk
France Médecins Sans Frontières
8, rue Saint Sabin 75011 Paris France
T +33 1 40 21 29 29 F +33 1 48 06 68 68
office@paris.msf.org msf.fr
Germany Médecins Sans Frontières /Ärzte Ohne Grenzen
Am Köllnischen Park 1 10179 Berlin Germany
T +49 30 700 13 00 F +49 30 700 13 03 40
office@berlin.msf.org
aerzte-ohne-grenzen.de
92 Médecins Sans Frontières

Greece Médecins Sans Frontières /15 Xenias St. 115 27 Athens GreeceT + 30 210 5 200 500 F + 30 210 5 200 503
info@msf.gr msf.gr
Holland Médecins Sans Frontières /Artsen zonder Grenzen
Plantage Middenlaan 14 1018 DD Amsterdam
Netherlands
T +31 20 520 8700 F +31 20 620 5170
info@amsterdam.msf.org
artsenzondergrenzen.nl
Hong Kong Médecins Sans Frontières
無國界醫生 / 无国界医生
22/F Pacific Plaza
410– 418 Des Voeux Road West
Sai Wan Hong Kong
T +852 2959 4229 F +852 2337 5442
office@msf.org.hk msf.org.hk
Italy Médecins Sans Frontières /Medici Senza Frontiere
Via Magenta 5 00185 Rome Italy
T +39 06 88 80 60 00 F +39 06 88 80 60 20
msf@msf.it medicisenzafrontiere.it
Japan Médecins Sans Frontières /国境なき医師団日本
Waseda SIA Bldg 3F 1-1 Babashita-cho
Shinjuku-ku Tokyo 162-0045 Japan
T +81 3 5286 6123 F +81 3 5286 6124
office@tokyo.msf.org msf.or.jp

Switzerland Médecins Sans Frontières /Ärzte Ohne Grenzen
78 rue de Lausanne Case Postale 116
CH-1211 Geneva 21 Switzerland
T +41 22 849 84 84 F +41 22 849 84 88
office-gva@geneva.msf.org msf.ch
UK Médecins Sans Frontières /Doctors Without Borders
Lower Ground Floor Chancery Exchange
10 Furnival Street London EC4A 1AB UK
T +44 20 7404 6600 F +44 20 7404 4466
office-ldn@london.msf.org msf.org.uk
USA Médecins Sans Frontières /Doctors Without Borders
333 7th Avenue 2nd Floor New YorkNY 10001-5004 USA
T +1 212 679 6800 F +1 212 679 7016
info@doctorswithoutborders.org
doctorswithoutborders.org

Branch Offices
Argentina
Carlos Pellegrini 587 11th floor C1009ABK
Ciudad de Buenos Aires Argentina
T +54 11 5290 9991
info@msf.org.ar msf.org.ar

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

Czech Republic
Lékari bez hranic, o.p.s Seifertova 555/47
130 00 Praha 3 – Žižkov Czech Republic
T +420 257 090 150
office@lekari-bez-hranic.cz
lekari-bez-hranic.cz

Norway Médecins Sans Frontières /Leger Uten Grenser
Hausmannsgate 6 0186 Oslo Norway
T +47 23 31 66 00 F +47 23 31 66 01
epost@legerutengrenser.nolegerutengrenser.no

India
AISF Building 1st & 2nd Floor Amar Colony,
Lajpat Nagar IV New Delhi 110024 India
T +91 11 490 10 000 F +91 11 465 08 020
india.office.hrm@new-delhi.msf.org
msfindia.in

Spain Médecins Sans Frontières /Médicos Sin Fronteras
Nou de la Rambla 26 08001 Barcelona
Spain
T +34 93 304 6100 F +34 93 304 6102
oficina@barcelona.msf.org msf.es
South Africa Médecins Sans Frontières /Doctors Without Borders
Orion Building 3rd floor 49 Jorissen Street
Braamfontein 2017 Johannesburg
South Africa
T +27 11 403 44 40 F +27 11 403 44 43
office-joburg@joburg.msf.org msf.org.za
Sweden Médecins Sans Frontières /Läkare Utan Gränser
Fredsborgsgatan 24 4 trappor Box 47021
100 74 Stockholm Sweden
T +46 10 199 33 00 F +46 10 199 32 01
info.sweden@msf.org
lakareutangranser.se

Ireland
9–11 Upper Baggot Street Dublin 4 Ireland
T +353 1 660 3337 F + 353 1 660 6623
office.dublin@dublin.msf.org msf.ie
MexicoCuauhtémoc #16 Terraza Col. Doctores
CP 06720 Mexico
T +52 55 5256 4139 F +52 55 5264 2557
msfch-mexico@geneva.msf.org msf.mx
South Korea
5 Floor Joy Tower B/D 7 Teheran Road 37-gil
Gangnam-gu Seoul 135-915 South Korea
T +82 2 3703 3500 F +82 2-3703 3502
office@seoul.msf.org msf.or.kr
United Arab Emirates
P.O. Box 65650 Dubai UAE
T +971 4457 9255 F +971 4457 9155
office-dubai@msf.org msf-me.org

About this report
Contributors
Halimatou Amadou, Corinne Baker, Talia Bouchouareb, Brigitte Breuillac, Andrea Bussotti,
Giorgio Contessi, Silvia Fernández, Mathieu Fortoul, Diala Ghassan, Sarah-Eve Hammond,
Solenn Honorine, Karem Issa, Aurélie Lachant, Vivian Lee, Johan Martens, Sally McMillan,
Robin Meldrum, Isabelle Merny, Pau Miranda, Agustin Morales, Susana Oñoro, Heather Pagano,
Victoria Russell, Caitlin Ryan, Faith Schwieker-Miyandazi, Martin Searle, Alessandro Siclari,
Shumpei Tachi, Clara Tarrero, Sam Taylor, Rony Zachariah.

Special thanks to
Valérie Babize, Lali Cambra, Kate de Rivero, François Dumont, Marc Gastellu Etchegorry,
Jean-Marc Jacobs, Nicole Johnston, Jérôme Oberreit, Emmanuel Tronc.
We would also like to thank all the field, operations and communications staff who
provided and reviewed material for this report.

English Edition
Managing Editor Sara Chare
Writer Caroline Veldhuis
Photo Editor Bruno De Cock
Copyeditor Kristina Blagojevitch
Proofreader Nicola Gibbs

French Edition
Editor Laure Bonnevie, Histoire de mots
Translator Translate 4 U sarl (Aliette Chaput, Emmanuel Pons)

Spanish Edition
Coordinator Lali Cambra
Translator Nova Language Services
Editor Cecilia Furió

Arabic Edition
Coordinator Simon Staifo
Translator Aziz Rami and Bruno Barmaki
Editor Simon Staifo

Designed and produced by
ACW, London, UK
www.acw.uk.com

Médecins Sans Frontières (MSF) is an international, independent,
medical humanitarian organisation that delivers emergency aid
to people affected by armed conflict, epidemics, exclusion fromhealthcare and natural disasters. MSF offers assistance to people
based on need and irrespective of race, religion, gender orpolitical affiliation.
MSF is a non-profit organisation. It was founded in Paris, France
in 1971. Today, MSF is a worldwide movement of 23 associations.
Thousands of health professionals, logistical and administrative
staff manage projects in 67 countries worldwide.
MSF International is based in Geneva, Switzerland.

MSF International
78 rue de Lausanne, CP 116, CH-1211, Geneva 21, Switzerland
Tel: +41 (0)22 849 8400, Fax: +41 (0)22 849 8404
COVER PHOTO
A nurse entering the high-risk zone of an Ebola management centre in Kailahun, Sierra Leone.
© Sylvain Cherkaoui/Cosmos