MSF Activity
Report 2009

The Medecins Sans
Frontieres Charter
Médecins Sans Frontières is a private international association. The
association is made up mainly of doctors and health sector workers andis also open to all other professions which might help in achieving its
aims. All of its members agree to honour the following principles:Médecins Sans Frontières provides assistance to populations in distress, tovictims 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 ofuniversal medical ethics and the right to humanitarian assistance and claims
full and unhindered freedom in the exercise of its functions.
Members undertake to respect their professional code of ethics and to maintaincomplete independence from all political, economic or religious powers.
As volunteers, members understand the risks and dangers of the missions
they carry out and make no claim for themselves or their assigns for any
form of compensation other than that which the association might be able
to afford them.

The country texts in this report provide descriptive overviews of MSF work throughout the world
between January and December 2009. Staffing figures represent the total of full-time equivalent
positions per country in 2009.
Reasons for Intervention classify the initial event(s) triggering an MSF medical-humanitarian
response as documented in the 2009 International Typology study. Country summaries are
representational and, owing to space considerations, may not be entirely comprehensive.

Contents
2 MSF Missions Around The World
4 The Year in Review
Kris Torgeson, Secretary General, MSF International
Dr. Christophe Fournier, President, MSF International Council

11

MSF Missions Around The World

11

Africa39

Asia and the Caucasus

57

The Americas

65

Europe and the Middle East

8 Overview Of MSF Operations
10 Glossary of Diseases
MSF Projects Around the world
11
39
57
65

AfricaAsia and the Caucasus
The Americas
Europe and the Middle East

ARTICLES
32 Punishing Success? Risks of faltering AIDS funding
63 Haiti Earthquake

77 MSF Country Programme Closures
78 Facts and Figures
80 Contact MSF

CONTENTSMSF Missions
around theworld
UkraineFranceMoldova

Switzerland

Georgia

Italy

Armenia

GreeceLebanon Syria
Palestinian
Iraq
Territories

Malta
Morocco

Mali

Haiti
GuatemalaHonduras
GuineaConakry

Niger

Colombia

Yemen

Sudan

Burkinafaso

Djibouti
Nigeria

Sierra Leone
Liberia

Chad

Cameroon

CentralAfricanRepublic

Ethiopia

Democratic
Republic of
Congo

Somalia

UgandaKenya
BurundiBrazilMalawi
ZambiaBolivia
Zimbabwe
Mozambique
SwazilandSouth
Africa

MSF MISSIONS AROUND THE WORLD

LesothoRussian
Federation

40 Afghanistan

22 Liberia

41 ARMENIA

23 Malawi

42 BANGLADESH

24 Mali

58 Bolivia

69 Malta

59 Brazil

69 Moldova

12 Burkina Faso

25 Morocco

13 Burundi

26 Mozambique

43 CAMBODIA

49 MYANMAR

14 Cameroon

50 NEPAL

15 Central African
Republic

27 Niger

16 ChadUzbekistan
Turkmenistan

60 Colombia

China
Iran

17 Democratic
Republicof Congo

Afghanistan
Pakistan

51 PAKISTAN

44 CHINA

Kyrgyzstan

Nepal

18 DJIBOUTI

Bangladesh
India

MyanmarThailandCambodia
Philippines
Sri Lanka

Indonesia
Papua
New Guinea

28 Nigeria

75 Palestinian
Territories
52 Papua
New Guinea
53 Philippines

18 Ethiopia

70 RussianFederation

66 France

29 Sierra Leone

45 Georgia

30 Somalia

67 Greece

31 South Africa

60 Guatemala

54 SRI LANKA

19 Guinea-Conakry

33 Sudan

62 Haiti

34 Swaziland

64 Honduras

70 Switzerland

46 INDIA

76 Syria

47 INDONESIA

55 THAILAND

71 Iran

56 TURKMENISTAN

72 Iraq

36 Uganda

68 Italy

71 Ukraine

20 Kenya

57 UZBEKISTAN48 KYRGYZSTAN

76 Yemen

74 Lebanon

37 Zambia

21 Lesotho

38 Zimbabwe

MSF MISSIONS AROUND THE WORLDThe Year in
Review 2009
Kris Torgeson, Secretary General, MSF International© Spencer Platt/Getty Images

Dr Christophe Fournier, President, MSF International Council

A man has his injured foot bandaged at the MSF medical centre which serves the Dagahaley Camp in Dadaab, Kenya, which is home to 91,000 people.



OVERVIEW OF MSF OPERATIONSFor Médecins Sans Frontières, an organisation that has specialised in responding toemergencies as well as working in fragile and unpredictable contexts, no two years are
the same. There is of course the ongoing work carried out by our thousands of staff
around the world, who provide healthcare where it’s lacking and deal with diseases that
continue to take a high toll on populations. But over and beyond the more constant
medical activity, each year brings new challenges to our organisation.

Two worrying developments stand out for
2009: the dwindling commitment of donor
bodies for continuing the battle against HIV/AIDS and a sharp increase of security incidents
that affect our ability to bring assistance.
In 2009, we started looking closely at
the funding for HIV/AIDS in eight Africancountries. A clear pattern is starting to showof donor backtracking on earlier, widely
publicised commitments to scale up thefight against the epidemic. The effects onavailability and level of care for those infected
are becoming clear in countries where wework. In some countries where infection rates
for HIV/AIDS are high, patients are turned
away from clinics, and clinicians are once
again being forced into the unacceptable
position of rationing life-saving treatment.
MSF will emphasise the unacceptable natureof this withdrawal in appropriate private andpublic forums throughout 2010.
In conflict areas, where MSF is often one ofvery few providers of healthcare, our ability toassist has been put under immense pressure
with a string of extreme security incidents. In
February, two of our colleagues were brutallykilled in Pakistan’s Swat Valley, as they
were trying to collect wounded people byambulance from the scene of heavy fighting.
Nasar Ali and Riaz Ahmad were known andadmired for their dedication to the healthand survival of others, but tragically paid theultimate price for this.
In 2009, MSF workers were abducted inPakistan, Sudan, Somalia and Chad. Luckily,
we saw all of them released in good health.
But if humanitarian workers are not safe
from violence, the organisation that employs
them faces tough questions. For MSF, ourdetermination to be with the victims ofconflict has not diminished – if anything,it has only grown – but we are forced tocontinuously evaluate how to bring lifesaving
assistance in areas where our colleagues are
so exposed to acts of violence.
A situation of war creates victims in a variety
of ways. There are the direct victims, thosethat our surgical teams help and support. And

then there are hidden victims. The impact ofconflicts and subsequent mass displacement, on
often precarious pre-existing health systems, isin most cases disastrous. It generally stimulatesa dramatic rise of maternal and child fatalities
or an eruption of epidemics. Victims of sexual
violence and survivors affected by profoundmental health traumas are also among thehidden casualties of war, and our medical teams
assist them with a sense of urgency in manydifferent countries
The military offensives in the Palestinian
Territories left 1,300 people dead, 5,300
injured and an entire population dependent
on medical aid and relief. We had a team on
the ground before the offensive was launched– we have been offering mental health support
for years in the Gaza Strip – but it was only
when the offensive was put on hold that acomplete MSF surgical team was allowed toenter Gaza City, despite our repeated efforts
to enter earlier. We then set up two inflatable
hospitals, and between January and July
performed over 500 operations. Meanwhile,
the psychological toll of the fighting was
especially heavy on children. Additional
MSF staff were brought in to help with
consultations; more than half of the 400 new
patients they saw for counselling were under
12 years old.
In the Democratic Republic of the Congo(DRC), ongoing conflict continues to cause
huge critical needs, prompting one of MSF’s
largest interventions year after year. Again,
we try to carry out a full range of medical
activities there in the midst of what has
become a chronic health emergency. MSF
carried out 530,000 medical consultations in
2009, vaccinated 650,000 children against
measles and cared for 5,600 rape victims in
North and South Kivu.
In conflict-ridden Afghanistan in 2009, thedeadliest year for civilians since the war
began in 2001, we resumed our medical
work after a five-year absence following thedeliberate killings of five of our colleagues in
2004. Our immediate preoccupation, bothin Kabul and in the province of Helmand,
was to offer medical assistance to the general

population rather than only focusing on war
wounded. In Mardan, Pakistan, where around
one million displaced people settled, having
fled fighting in the Swat district, our teams
supported referral hospitals, health centres
and mobile clinics.
Our ability to bring care to people trappedin conflict is sometimes restricted by policies
and actions of governments. In Sudan,
providing food, water and health care forpeople in Darfur became much more difficultin March 2009 when the Sudanese authorities
expelled 13 international aid agencies– including two sections of MSF—and three
Sudanese organisations in the wake of theInternational Criminal Court’s indictment of
Sudanese President Omar Al-Bashir for war
crimes and crimes against humanity.
The decision by the government effectively
meant that not only MSF but also the needsof the population of Darfur were held
hostage to political and judicial agendas.
It also ignored MSF’s binding and publicly
communicated policy to refrain from any
cooperation with the aforementioned
Court, a policy based on the recognition
that humanitarian activities must remain
independent from political and judicial
pressure in order to be able to provide
medical assistance to populations insituations of violence. Today more than ever,it seems that we must relentlessly explain
the principles of neutrality, impartiality andindependence that guide our choices as ahumanitarian organisation.
The conflict in Sri Lanka came to a climax,
leaving many civilians in a vulnerable stateas they tried to reach safe zones, but they all
too often found themselves trapped by theviolence. Access to medical facilities and aid
was extremely difficult. More often than not, by
the time they finally reached those who could
help them, their health needs were critical.
Our work extends way beyond theconflict areas described above. In 2009,
MSF organised large-scale immunisation
continued overleaf

OVERVIEW OF MSF OPERATIONScontinued The Year in Review 2009

campaigns, particularly against meningitis inwestern Africa, where we vaccinated almost
eight million people in both Nigeria andNiger. Our teams intervened after major
natural disasters throughout the year, by
providing medical and mental health care, as
well as shelter and other logistical support.
Likewise we helped 150,000 people madehomeless by floods in the Burkina Faso capitalof Ouagadougou, in September, when theamount of rain that usually falls in a year
fell in one single day. And other teams
assisted 75,000 people hit by Cyclone Aila
in Bangladesh, and 60,000 flood victims in
India’s Andhra Pradesh.
Our contribution towards reducing the
HIV/AIDS and TB epidemics continued
unabated. In 2009 over 190,000 people
were being treated by MSF for HIV, and some
160,000 were on antiretroviral treatment.
Many of these patients live remotely, havelittle money, and under normal circumstances
would not receive medical care. But MSF
continued to address this lack of access totreatment where possible. Teams offeredtesting and counselling, provided ART free ofcharge, reduced rates of transmission frommother to child and trained ‘expert patients’often HIV patients themselves, to help others
adhere to treatment. For example in Lesothoalone, 54,000 HIV tests were carried out and6,000 patients began ART.
TB, which has become the leading causeof death among HIV patients, is also a
growing concern for MSF: failure to adhere
to the difficult course of treatment for TB
can lead to drug-resistant strains of thedisease developing, and these are even more
problematic to treat, especially if the patient’s
immune system is already compromised byHIV. MSF is working hard to combine thetreatment of HIV and TB in resource poorsettings to try and reverse this trend. In 2009
MSF treated over 21,000 TB patients.
A number of neglected diseases are still
not getting the international attention
they require. Three in particular - sleeping
sickness, Kala Azar and Chagas leave morethan 500 million people at risk from infection.
In response, in 2009 MSF committed 18
million Euros over the next six years to a
joint initiative with the Drugs for Neglected
Diseases initiative (DNDi) for continued
research into critically needed new drugs totreat these diseases more effectively. MSF will
also continue to provide support throughits field programmes to the operational andclinical research needed to advance drug
development. In 2009 MSF treated over
6,000 patients for these three diseases.



OVERVIEW OF MSF OPERATIONSThe neglected needs of migrants remainamong our most pressing concerns. Migrants
undergo journeys fraught with danger anduncertainty, and when they arrive – if they
arrive – their health often continues tobe compromised. Some are held for long
periods in overcrowded detention camps;
some are forced to live hidden away from theauthorities, where their undocumented status
makes it impossible for them to access basiccare. MSF offers such people free medical andmental health consultations, protecting theiridentity where possible and referring themwhen necessary to local hospitals.
We give medical assistance at different stagesof their journey. In countries of origin, suchas Somalia, Afghanistan, DRC and Nigeria, wetreat the medical consequences of violenceand deprivation. In Morocco, Greece, Malta,
Italy and France, our teams provide medical
and psychological care to those who survived
the journey; many migrants and asylum
seekers are subjected to violence and abuse,
are imprisoned and exploited or fall victim to
smugglers and traffickers.
We equally assist migrants outside Europe.
Many refugees and asylum seekers from theHorn of Africa seek safety in Yemen. The
harsh conditions of the trip and sea accidents
cause hundreds of deaths, and the state ofhealth of those who do manage to reach the
Yemeni coast is often poor. Around 9,000
people received medical assistance from MSF
in Abyan and Shabwah governorates in thesouth of the country in 2009.
In Bangladesh, many thousands of Rohingya
refugees from neighbouring Myanmar
face a daily struggle to survive. Out of an
estimated population of up to 400,000
Rohingya who have fled across the border,
only 28,000 are recognised as official refugees
by the government and accordingly entitledto assistance by UNHCR. MSF set up an
emergency healthcare project to help 20,000
unrecognised Rohingya refugees living in harshconditions in Kutupalong makeshift camp.
Just outside the scope of this reporting
period, early 2010 saw the launch of thelargest emergency operation in MSF history
following the devastating earthquake thatruined large parts of Haiti and claimed many
thousands of lives. Within the first fourmonths MSF teams assisted 173,000 patientsand performed more than 11,000 surgeries.
This tragedy has stretched our organisationand forced us into a difficult balancing act ofstaging such a massive and urgent emergency
relief effort while fully retaining ourcommitment to the health and lives of people
in many other parts of the world. Together
with the need to mobilise donors for theircontinued support to reverse the HIV/AIDS
epidemic, and the growing concern about
increased violence against humanitarian
workers, Haiti will set the tone for 2010.
The continued contribution of millions bypeople around the world who support MSF
financially is key to our ability to bring medical
assistance to those who need it urgently, andfor keeping interference from political, militaryor economic agendas at bay. We are immensely
grateful to all donors who make MSF’s work inover 65 countries possible.
Thank you.

© Robin Meldrum / MSF

Treating a child with cholera in the midst of a huge outbreak in Zambia’s capital, Lusaka, in March 2010.

OVERVIEW OF MSF OPERATIONSOverview of MSF Operations
Largest interventions based on
project expenditure

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

1. Democratic Republic ofCongo (DRC)

6. Nigeria

2. Zimbabwe

8. ChadActivity

Definition

3. Somalia

9. Haiti

4. Niger

Outpatient

Total number of outpatient consultations

10. Central African Republic(CAR)

Inpatient

Total number of admitted patients

Malaria

Total number of confirmed cases treated

1,110,495

Therapeutic
feeding centres

Number of severe malnourished children
admitted to inpatient or ambulatory
therapeutic feeding centres

154,133

Supplementary
feeding centres

Number of moderately malnourishedchildren admitted to supplementary
feeding centres

41,288

Deliveries

Total number of women who delivered
babies, including Caesarean sections

110,236

SexualViolence

Total number of cases of sexual violence
medically treated

13,624

SurgicalInterventions

Total number of major surgicalinterventions including obstetric surgery,under general or spinal anaesthesia

49,680Violent
traumaTotal number of medical and surgicalinterventions in response to direct violence

88,765

HIV

Total number of HIV patients registeredunder care at end 2009

190,254

Antiretroviraltherapy treatment( first-line )Total number of patients on first-line
antiretroviral treatment at end 2009

162,728

Antiretroviraltherapy treatment( second-line )Total number of patients on second-line
antiretroviral treatment at end 2009.
First-line treatment failure.

1,781

PMTCT - mother

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

8,704

PMTCT - baby

Number of eligible babies born in 2009
who received post-exposure treatment

10,406Tuberculosis( first-line )Total number of new admissions totuberculosis first-line treatment in 2009

20,569Tuberculosis( second-line )Total number of new admissions totuberculosis treatment in 2009,second-line drugs

Mental Health( Individual )Total number of individual consultations

109,755

Mental Health( Group )Total number of counselling or support
group sessions

7,895

CholeraTotal number of people admitted tocholera treatment centres or treated withoral rehydration solution

130,220

Measles
Vaccinations

Total number of people vaccinated formeasles in response to an outbreak

1,419,427

MeaslesTreatment

Total number of people treated for measles

Meningitis
Vaccinations

Total number of people vaccinated formeningitis in response to an outbreak

Meningitis TreatedTotal number of people treated for meningitis

7. Kenya

5. Sudan South

These 10 countries total a budget of 193,530,586 or 49.2 per centof the MSF operational budget.

Project locations by country
Number of projects

Percentage of programme portfolio

Africa | 32
11.8 %

Europe | 7
Asia | 28

42.1 %

Americas | 9
36.8 %

9.2 %Context of interventions
Number of projects

Percentage of programme portfolio

Armed Conflict | 99
Post Conflict | 13
27.3 %

Internal Instability | 9642.5 %

Stable | 154

3.6 %26.5 %

Event triggering intervention
Number of projects

Percentage of programme portfolio

Armed conflict | 136

7.2 %Epidemic | 113
Health exclusion | 87
Natural disaster | 26

24 %37.6 %

31.2 %OVERVIEW OF MSF OPERATIONS

Total
7,509,512
292,347

943

28,261
7,932,403
77,901Glossaryof Diseases
Chagas Disease

CholeraFirst described by the Brazilian doctor Carlos
Chagas, this parasitic disease is found almost
exclusively in Latin America, though increased
global travel has led to an increased numberof cases being reported in the US, Europe,
Australia and Japan. This potentially fatal
disease can cause irreversible damage to theheart, oesophagus and colon, shortening life
expectancy by an average of ten years.

The Greek word for diarrhoea, cholera is awater-borne, acute gastrointestinal infection
caused by the Vibrio cholerae bacterium andspread by contaminated water or food. The
infection can spread rapidly and large outbreaks
can occur suddenly.

The disease is transmitted by blood-sucking
bugs that live in cracks in the walls and roofs of
mud and straw housing, common in rural areasand poor urban slums in Latin America. It canalso be transmitted through blood transfusions,from mothers to their children during pregnancy
and, less frequently, through organ transplants
or via the consumption of contaminated food.
Debilitating and possibly life-threatening chronic
symptoms develop in approximately 30 per centof people infected, with heart failure being themost common cause of death for adults. Somepeople can have the disease but show no signs
of it for years.
There are currently only two medicines
to combat the disease: Benznidazole andNifurtimox. Both were developed over 35 years
ago, but through using research not specifically
aimed at finding a cure for Chagas disease. The
cure rate is almost 100 per cent in newborns
and infants, but in older children, adolescentsand adults, treatment is only around 60 or 70
per cent effective.
Diagnosis is complicated, as doctors need toperform two or three blood tests to determine
whether or not a patient is infected with theparasite and there is no test to know whether
the treatment has been successful or not.
The current lines of treatment can be toxic,take one to two months to complete andcan have multiple side effects. They must be
administered under medical supervision, whichmeans having a weekly check-up with a trained
healthcare worker. Despite the clear need formore efficient and safer medication, there are
few new drugs in development.
MSF has tested over 65,000 people for Chagas
disease and treated more than 3,000 patients
since 1999.1
1 Feasibility, Drug Safety, and Effectiveness of
Etiological Treatment Programmes for Chagas
Disease in Honduras, Guatemala, and Bolivia:
10-Year Experience of Médecins Sans Frontières.’

Although most people infected with cholera
will have only a mild infection, the illness
can be very severe, causing profuse waterydiarrhoea and vomiting that can lead to severe
dehydration and death. Required treatment is
the immediate replacement of fluid and salts
with a rehydration solution administered orally
or intravenously.
MSF has developed cholera treatment kits toprovide rapid assistance and sets up cholera
treatment centres where there are outbreaks.
Control and prevention measures include
ensuring an adequate supply of safe drinking
water and implementing strict hygiene practices.
MSF treated over 130,220 people for cholera
in 2009.

HIV/AIDS
The human immunodeficiency virus (HIV) is
transmitted through blood and body fluids andgradually weakens the immune system - usually
over a three to ten year period – leading toacquired immunodeficiency syndrome or AIDS.
Many people live for years without symptoms andmay not know they have been infected with
HIV. A simple blood test can confirm HIV status.
A number of opportunistic infections (OIs) suchas candidiasis, pneumonia, and various kindsof tumours are able to flourish as the immune
system weakens. Some can be treated, whileothers are life-threatening. The most common
OI leading to death is tuberculosis (TB).
Combinations of drugs known as antiretrovirals
help combat the virus and enable people tolive longer, healthier lives without a rapid
deterioration of their immune systems. It issimplest and easiest to take these drugs properly
when they are combined into single pills(fixed-dose combination). MSF’s comprehensive
HIV/AIDS programmes generally include
education and awareness activities so thatpeople can learn how to prevent the spread of
the virus, through condom distribution, HIV
testing, pre and post-test counselling, treatment
and prevention of opportunistic infections,prevention of mother-to-child transmission, andprovision of antiretroviral treatment for patientsin advanced stages of the disease.
MSF provided care for over 190,000 people
living with HIV/AIDS and anti-retroviral therapy
for more than 162,000 people in 2009.

Human African
Trypanosomiasis(Sleeping Sickness)
Generally known as sleeping sickness, thisparasitic infection occurs in sub-Saharan Africa
and is transmitted by tsetse flies. More than 90
per cent of reported cases are caused by theparasite Trypanosoma brucei gambiense (T.b.g)
which is found in west and central Africa. It
attacks the central nervous system, causing
severe neurological disorders or even death.
The other 10 per cent of cases are caused by
the Trypanosoma brucei rhodesiense (T.b.r.)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, suchas poor coordination, confusion, convulsions
and sleep disturbance. At this stage, accurate
diagnosis of the illness requires taking asample of spinal fluid, and treatment is painful,requiring daily injections.
The most common drug used to treat thedisease is the highly toxic Melarsoprol, aderivative of arsenic that was developed in1949, that causes many side effects. In partsof Africa, it fails to cure up to 30 per cent ofpatients and actually kills up to five per cent ofthem. Eflornithine, though somewhat difficult
to administer because it requires an intravenous
drip and a complicated treatment schedule, isa safer, more recent alternative being used by
MSF in its projects.
In 2009, a new treatment option called NECT( Nifurtimox-Eflornithine Combination Therapy )was added to the Essential Medicines Listof the World Health Organization. It is now
the internationally recommended treatment,
although access to it must be carefully
monitored. The development of NECT is a hugecontinued overleaf

GLOSSARY OF DISEASEScontinued Human African Trypanosomiasis

Malariaadvancement, as studies have shown that thetherapy, a co-administration of oral Nifurtimox
and intravenous Eflornithine, is a better treatment
option for advanced-stage sleeping sickness,being safer than Melarsoprol and easier to use
than Eflornithine. However, it is still far from ideal.
Research and investment are urgently neededin order to further improve treatment (without
injections) and to ensure that it is affordable,
effective in both stages of the disease, and easy
to use in remote health centres.

Caused by four species of the parasite
plasmodium, malaria is transmitted by infectedmosquitoes. Symptoms include fever, painin the joints, headaches, repeated vomiting,convulsions and coma. Malaria caused by theplasmodium falciparum parasite causes themost severe form of the disease which, if left
untreated, leads to death.

MSF admitted over 1,870 patients for treatment
for Human African Trypanosomiasis in 2009.

Visceral Leishmaniasis(Kala Azar)
Largely unknown in the developed world,
Kala Azar, which is Hindi for black fever, is atropical, parasitic disease that is transmitted
through bites from certain types of sandflies. It is endemic in 62 countries, and of theestimated 500,000 annual cases, 90 per centoccur in India, Bangladesh, Nepal, Sudan,
and Brazil, often affecting the poorest people.
It is characterised by fever, weight-loss,
enlargement of the liver and spleen, anaemia
and immune-system deficiencies. Without
treatment, nearly all patients will die.

Malaria used to be commonly diagnosed ona basis of clinical symptoms alone. As thesymptoms are similar to those of other illnesses,
about half the people who presented with fever
and were treated for malaria in Africa may notactually have been infected with the parasite.
An accurate diagnosis can now be madethrough detection of parasites by microscope ora rapid diagnostic test. Both methods are now
used by MSF in its projects.
Chloroquine was once the ideal treatment formalaria caused by plasmodium falciparum
because of its price, effectiveness and few side
effects; however, its effectiveness has decreased
dramatically in the past few decades. MSF fieldresearch has helped prove that artemisininbased combination therapy (ACT) is currently
the most effective against this type of malaria
and has urged governments in Africa to change
their drug protocols to use ACT. Although all
governments have made the change in writing,in many cases the drug is still not available forthe majority of patients.

Very suitable rapid diagnostic field tests areavailable, although backup confirmation
testing is potentially dangerous and requires
lab facilities and specialists not readily available
in countries with poor resources.

MSF treated over 1,100,000 people for malaria
in 2009.

Current treatment options include pentavalent
antimonials* and combination therapies will beavailable in the near future. Although extensive
and evolving to become more simplified,treatment options have significant limitations.
Despite this, studies showing the efficacy andsafety of Ambisome® in the Indian sub-continent
are promising, and the anticipated combination
therapies intend to reduce the risk of the parasite
developing resistance to the drugs, optimise theefficacy and safety of treatment, and reduce costs
and hospitalisation time.

Meningitis

A major challenge is co-infection of kala azarand HIV. Both diseases influence each otherin a vicious spiral as they attack and weaken
the immune system making the person lessresistant to the other disease and the treatment
less effective.
MSF treated nearly 3,700 people for Visceral
Leishmaniasis in 2009.
* (Pentostam®, generic SSG, Glucantime®),amphotericin-B deoxycholate, liposomal amphotericin
B (Ambisome®), paromomycin and miltefosine)

Meningococcal meningitis is caused by
Neisseria meningitidis and is a contagious
and potentially fatal bacterial infection of themeninges, the thin lining surrounding the brain
and spinal cord. People can be infected andcarry the disease without showing symptoms,
spreading the bacteria to others throughdroplets of respiratory or throat secretions,for example when they cough or sneeze.
The infection can also cause sudden and intense
headaches, fever, nausea, vomiting, sensitivity
to light and stiffness of the neck. Death canfollow within hours of the onset of symptoms.
Without proper treatment, bacterial meningitis
kills up to half of those infected. Suspectedcases are properly diagnosed throughexamination of a sample of spinal fluid andtreated with a range of antibiotics. Even when
given appropriate antibiotic treatment, five toten per cent of people with meningitis will die
and as many as one out of five survivors may
suffer from after effects ranging from hearing
loss to learning disabilities.
Meningitis occurs sporadically throughout theworld, but the majority of cases and deaths

10

GLOSSARY OF DISEASES

are in Africa, particularly across an east-west
geographical strip from Senegal to Ethiopia,
the “meningitis belt” where outbreaks occur
regularly. Vaccination is the recognised way
to protect people from the disease.
MSF treated nearly 78,000 cases and vaccinatedmore than 7,930,000 people against meningitis
in 2009.

Tuberculosis
One-third of the world’s population is currently
infected with the tuberculosis (TB) bacilli. Every
year, nine million people develop active TB andclose to two million die from it. Ninety-five percent of these people live in poor countries.
This contagious disease affects the lungs and isspread through the air when infected people
cough or sneeze. Not everyone will become
ill, but ten per cent of non HIV-infected people
will develop active TB at some point in their
lifetimes. Symptoms include a persistent cough,fever, weight loss, chest pain and breathlessness
in the lead up to death. TB is also a leading
cause of death among people with HIV.
Drugs used to treat TB were developed in the
1950s and a course for uncomplicated TB takes
six months. Poor management of or lack ofadherence to treatment has led to new strainsof bacilla that are resistant to one or moreanti-tuberculosis drugs. Multi-drug-resistant
TB (MDR-TB) is the most serious form of this,identified when patients are resistant to thetwo most powerful first-line antibiotics. MDRTB is not impossible to treat, but the required
regimen causes many side effects and takes up
to two years. A newer strain, extensively drug
resistant tuberculosis (XDR-TB), is identified
when resistance to second-line drugs develops
on top of MDR-TB, making the treatment evenmore complicated.
MSF treated over 20,500 people for tuberculosis,
including over 940 for MDR-TB in 2009.

© Isabel Corthier

AMERICAS

Kabezi, Burundi. A grandmother surrounded by her family.
12 Burkina Faso
13 Burundi
14 Cameroon
15 CENTRALAFRICAN REPUBLIC

24 Mali
25 Morocco
26 Mozam bique

16 Chad27 Niger

17 Democratic
republic of congo

28 Nigeria

18 Djibouti

30 Somalia

18 Ethiopia

31 South Africa

19 Guinea

33 Sudan

20 Kenya

34 Swaziland

21 Lesotho

36 Uganda

23 Liberia

37 Zambia

23 Malawi

38 Zimbabwe

29 Sierra Leone

AfricaAFRICABurkina Faso
REASON FOR INTERVENTION• Endemic / Epidemic disease

Around 80 per cent of the
14.3 million people in Burkina
Faso depend on subsistence
farming, and it is often astruggle for farmers to
produce sufficient foodfor their families.
This can particularly affect children because
if they do not get the nutrients and vitamins
they need in the early phase of life, theirmental and physical development can be
impaired. They also become susceptible toinfections and potentially fatal illnesses.
Since 2007 MSF has been working in two
provinces in the north of Burkina Faso wherechildhood malnutrition is frequently found.

Field Staff 285

ill are hospitalised free of charge by MSF teams
in regional health facilities. However around85 per cent of the children can be cared for athome by their parents because the ready-to-use
nutrient-rich food is simple to administer. MSF
also admitted patients suffering from tuberculosis,
HIV/AIDS and malaria.
In 2009, the worst measles outbreak in years
erupted in Burkina Faso. In poor communities
with little or no access to care, around ten percent of people with the illness can die. MSF had
earlier offered to help the Ministry of Health invaccinating against the outbreak, but the offer
was declined. MSF then went on to assist the
Ministry of Health to treat people with measlesin the capital Ouagadougou, as well as in four
districts in the east of the country where MSF
treated nearly 4,000 children in total.
Flash floods
In one day in September, the same amountof rain that usually falls in a year fell on
Ouagadougou. The resulting floods destroyed
24,000 houses and made 150,000 people
homeless. Five MSF teams provided healthcare
to those displaced by the flooding, andprovided medical supplies to the regional
health authorities.

HandoverIn 2009 MSF handed over a long-running
HIV/AIDS programme to the Ministry of Health.
The programme was based in the capital andhad been providing around 4,480 people with
antiretroviral therapy.
MSF has worked in Burkino Faso since 1995.

Fati
A 35 year old mother of four, Fati, left
her home in the capital Ouagadougou tocome to the town of Titao in the northof Burkina Faso because her mother had
fallen ill. However, she found it hard tofeed her children and her youngest, afour year old girl, became malnourished.
‘I came to the centre because mydaughter’s weight was too low,’ said Fati.
Health workers had spread the message
in the area that parents could bring theirchildren for treatment free of charge.
‘My aunt heard about it and told me tocome. All the women around here knowthat the treatment here is good. I havebeen coming for three weeks and now mydaughter is better.’© Kazuma Momoi

In 2009, 16,000 malnourished children weretreated in MSF centres in the two northern
districts of Yako and Titao. Since the project
began, 39,000 children have been helped. Usinga decentralised and simplified system of testing
and treatment, MSF teams are able to reach huge
numbers of children. Those who are seriously• Natural disaster

Yako hospital, Burkina Faso. A nurse with a baby who is recovering well, after having received treatment for acute malnutrition.
12

MSF PROJECTS AROUND THE WORLD – AFRICA – BURKINA FASOAFRICABurundiREASON FOR INTERVENTION• Endemic / Epidemic disease• Social violence / Healthcare exclusion• Natural disaster© Isabel CorthierField Staff 61

An MSF ambulance transfers a mother and her new born baby.

Despite a presidential decree
in 2006 that guaranteed freehealthcare for pregnant
women and children under five
years old, Burundi has oneof the highest maternal andneonatal mortality rates in
the world, according to theWorld Health Organization.
Every year 1,000 women suffering fromobstetric fistulas as a result of a complicateddelivery are reported to the Ministry of
Health. MSF works to provide care forwomen before and during delivery. MSF
also responds to health emergencies suchas nutritional crises or natural disasters.
Life-saving maternal care
In 2009, the MSF Centre for Obstetrical
Emergencies in Kabezi assisted 2,300 women
who were facing complications during

pregnancy or delivery. The centre, which
MSF constructed, has a capacity of 48 beds, adelivery room and an operating theatre. Thereis a 24-hour emergency service that can beused by the 20 community health centres in theregion. The MSF team also provided treatment
to 30 women with obstetric fistulas.

In March, when severe floods devastatedseveral areas near the capital city Bujumbura,
MSF ran mobile clinics and worked to improve
hygiene conditions and access to clean water.
Later in July and August, MSF responded to acholera outbreak in several neighbourhoodsof the capital, treating 90 patients.

Treating sexual violence
In the capital Bujumbura, MSF handed over
the Seruka Centre, which specialised in thetreatment of victims of sexual violence, to a
Burundi association known as Initiative Seruka
pour les victimes de Viol (ISV). It was createdin 2008 by staff working in the MSF centre. In
the six years before the handover, the centre
provided care for more than 7,800 victims ofsexual violence.

MSF has worked in Burundi since 1992.

Emergency response
Between February and June, MSF responded
to a nutritional emergency in the northern
province of Kirundo, where teams admitted
more than 500 severely malnourished children
to the centre in town. In addition, MSF
provided support to therapeutic centres acrossthe region and referred those needing further
care to the hospital in Kirundo.

Mary
30 years old
She is one of thousands of women who
have received help at the MSF birth centre
in Kabezi. Mary, already a mother offive, was hospitalised before giving birth
because she was severely malnourished.
Her daughter was born anaemic andunderweight, and was vomiting a lot after
the birth. However, bit by bit she started to
improve, and Mary also began to feel better.
Her lips regained colour and the swelling in
her legs decreased. ‘If it wasn’t for MSF mychildren wouldn’t have a mother,’ she said.

MSF PROJECTS AROUND THE WORLD – AFRICA – Burundi

13© Marcell Nimfuehr

AFRICAA medical team treat a patient for Buruli Ulcer.

Cameroon
MSF is working in Cameroon
to treat Buruli ulcer, one of
the most underfunded,
under-researched, but
treatable diseases in theworld. This bacterial infection
causes deformation of limbs
and disability if it is nottreated in time.
As part of its Buruli programme, MSF has
introduced modern wound dressingsthat reduce the need for complicatedsurgical procedures.
Buruli ulcer is an infection related to tuberculosis
and leprosy. It is present in around 30 countries
worldwide, but since the number of people
affected is relatively small, there is no treatment
available in most countries. In the rural district of
Akonolinga in Cameroon, MSF has set up a Buruli

14

centre that screens patients and treats the disease
with antibiotics, skin grafting and physiotherapy.
Treatment can take up to a year and, since setting
up the centre in 2002, MSF assisted around 800
patients. The new wound dressing has enabled
people living in remote areas to receive treatment
without being hospitalised. The challenges ahead
are to implement decentralised screening in order tobetter reach people in rural areas, and to make theBuruli centre a referral point for the whole country.
MSF set up its first HIV/AIDS programme in thecity of Yaounde in 2000, and then another inDouala in 2003. After handing the programmes
over to the Ministry of Health in 2008, MSF has
been preparing a new project that will start in early
2010. This will help patients who, after five to ten
years, have developed resistance to antiretroviral
medication. These patients have had to be moved
on to second-line treatment, without which thedisease would develop and ultimately lead todeath. However, this is still not widely available
through the national health system in Douala, so
MSF is returning to support the Ministry of Healthin widening access and training staff.

MSF PROJECTS AROUND THE WORLD – AFRICA – CAMEROONREASON FOR INTERVENTION• Endemic / Epidemic disease
Field Staff 83

DarlyseShe is a 17 year old girl from Libreville,
Gabon who suffered with Buruli ulcer forover five years. After undergoing a numberof ineffective treatments she was referredto the MSF Buruli centre in neighbouring
country Cameroon. ‘My case became very
severe because it took so long to find theright treatment,’ she explained. ‘When I
got there I was so tired of the pain andthe many unsuccessful treatments that
I just wished that they would cut my leg
off.’ Darlyse stayed in the centre for nearlya year, receiving wound care and skintransplants. It was a great relief for her
eventually to be able to leave, cured. ‘I still
limp a little, but it is getting better everyday. I can return home and go back toschool again.’

MSF has worked in Cameroon since 2000.

AFRICA

CentralAfrican Republic
REASON FOR INTERVENTION• Armed conflict• Natural disaster

Field Staff 963© Jaume Codina

Since late 2005,
fighting between thegovernment and armed
opposition groups andinsecurity related tobanditry has caused
the displacement of
hundreds of thousandsof people in thenorthern regionsof Central African
Republic ( CAR ).
Nutritional centre, Central African Republic. A paediatric doctor cares for a child with malnutrition.

The situation remained fragile throughout
2009, in spite of a peace accord between thegovernment and various opposition groups
signed the year before.
People still live in extremely precarious
conditions and access to healthcare remains
a major problem even in areas that have notbeen directly affected by conflict. Despite an
overall increase in aid over the past five years,
CAR struggles with high infant and maternalmortality rates and little health infrastructure.
People are particularly vulnerable to malaria,
respiratory infections, diarrhoeal diseases
and malnutrition.
MSF provided healthcare for people affectedby armed conflict and violence in the northby offering medical assistance to displaced
people and returnees through a network ofmobile clinics, hospitals and health centres.
Throughout 2009, more than 420,000
consultations were conducted. Thirty percent of the patients were treated for malaria,
and more than 24,600 patients needed to behospitalised. MSF teams also assisted more than
3,600 deliveries and carried out more than
5,000 surgical interventions. Patients begantreatment for tuberculosis and HIV/AIDS aswell as malnutrition, and basic relief items were
distributed to those who had been displaced by
the violence.
In the northwest, close to the border with
Cameroon, the situation remained relatively
calm in comparison to previous years. Many
cattle-raising communities that had fled toneighbouring countries returned, and people
who had fled into the bush began coming backto their villages. This made access to healthcentres easier, and MSF teams were able toimprove and expand their support to healthposts further afield.

acute malnutrition, which prompted MSF to
open an emergency nutritional programme.
A combination of poverty and insecurity inthe region, and the lack of functional healthfacilities, contributed to the problem.
In response MSF opened six programmes in
the region and between July and December
treated more than 7,200 malnourished people:
67 per cent were severely malnourished and25 per cent required hospitalisation.
MSF has worked in the Central African Republic
since 1997.

A medical programme was opened to help
people suffering from sleeping sickness along
the Chadian border in the northwest of thecountry. By the end of the year more than
1,500 patients had been treated. In 2009 a
new treatment known as NECT (NifurtimoxEflornithine Combination Therapy) was
introduced. These drugs, which are lessexpensive and easier to administer thanprevious treatments are now being provided
to cure this potentially fatal disease.
In July in the southwest of the country, local
health authorities reported high levels of

MSF PROJECTS AROUND THE WORLD – AFRICA – Central African Republic

15

AFRICAChad
REASON FOR INTERVENTION• Armed conflict• Endemic / Epidemic disease• Healthcare exclusion
Field Staff 723

Health services were restricted because of alack of funding and qualified staff, and thesituation was particularly severe in the east,
where banditry, criminality and insecurity
were widespread. More than 170,000
Chadians are still displaced in the east,
having fled from the insecure regions near
the Sudanese border which is also home
to more than 256,000 Sudanese refugees
and 67,000 refugees from the Central
African Republic. MSF has been providing
health services where the authorities havebeen unable to, paying special attention todisplaced people and refugees.
Security challenges
Insecurity made it difficult to assess the healthneeds of resident and displaced people,
especially those living in more remote villages.
According to the United Nations Departmentof Safety and Security, 500 security incidents
against civilians, UN workers and NGO
workers occurred in the east of Chad last year.
In the Dar Sila region in the east of thecountry, MSF provided care to 15,000
displaced people in Gassire camp. In nearby
villages Kerfi and Adé, MSF provided careand treatment to 40,000 people affected byinternal displacement and continuing violence.
Activities were suspended in August, however,after two MSF staff members were abductedduring a robbery in Adé. In Kerfi, the fullmedical programme was resumed only in
October, and in Adé, services were resumed
only in late November, when MSF provided
remote support to Ministry of Health staff.
Before the suspension, MSF carried out 1,600- 2,000 consultations a month in Kerfi, andadmitted 100 malnourished children eachmonth for therapeutic feeding.
Overall, MSF was able to perform more than
106,000 consultations in collaboration with the
Ministry of Health, despite these difficulties.
Eastern Chad
In Adré, a town with a population of 300,000
on the border with Sudan, MSF supported the
local hospital throughout 2009. From January
to October, more than 2,600 people were
hospitalised, more than 900 of them children

16© Minh-Ly Pham-Minh

Hundreds of thousandsof people were affectedby conflict, violence anddisplacement in Chad in 2009.
Adré District, Eastern Chad. An MSF convoy travels to sparsely populated and highly insecure areas
near the Sudanese border to bring measles vaccinations to the local people.

under five years old. Nearly 33,000 consultations
were given in the first nine months of the year.
However, insecurity made it impossible to accessareas outside the town where other internallydisplaced people have settled.
In Dogdoré, a remote village near the
Sudanese border, MSF provided healthcare to
30,000 people, 27,000 of whom are displaced.
Security remained a challenge here, too, as
banditry and criminality affected the people
as well as the relief organisations. Relocationof international staff was necessary on two
occasions, though local MSF staff ensured thecontinuity of medical activities.
In total, more than 23,600 consultations werecarried out. 2,600 women received antenatal
consultations, some 280 of whom gave birthin Dogdoré hospital. A tetanus vaccination
campaign was also run to reduce the risks ofneonatal deaths linked to this disease, andmore than 5,500 women received the vaccine.
As a result, newborn deaths linked to tetanus
were reduced from 35 in 2008 to 11 in 2009.
Obstetrical fistulas
In Guereda in the east, near the border with
Sudan, MSF closed the programme that wasproviding aid to the displaced and to the Birak
refugees, since the International Committeeof the Red Cross had begun working in
the hospital and together with the healthauthorities were able to cover the needs.
However, since maternal mortality in thearea is still very high and the developmentof obstetrical fistulas common (the United
Nations Population Fund estimates thatbetween two and five fistulas develop every
1,000 deliveries), MSF continued to send
women with the condition to be treated in
Abéché General Hospital in the east of thecountry. Between January and October, morethan 140 women were treated.

MSF PROJECTS AROUND THE WORLD – AFRICA – CHAD

Epidemics
MSF responded to an outbreak of measlesin the Ouaddai region in the east of Chad.
More than 226,000 children were vaccinatedagainst the disease. MSF also responded toan outbreak of measles in Abéché, where
130,000 people under 15 years old were
vaccinated, and in Adré where a further 6,000
children under five years old received thevaccine. More than 5,500 girls and women
between 15 and 49 were vaccinated against
tetanus in the same region.
There was also a meningitis outbreak in thesouthern regions of Mayo Kebbi Est andOuest, and in the capital city N’Djamena. MSF
supported the Ministry of Health in treating
more than 1,200 people, and in a masscampaign that vaccinated 105,000 people.
Southern ChadIn the south of the country, the arrival of
refugees from Central African Republic
has meant that existing health services are
struggling to cope with diseases such as
malaria, meningitis and measles.
In Goré MSF continued to respond to
medical needs until November when the
programme was handed over. Between
January and November, teams provided
16,800 consultations, more than 730 surgicalinterventions, and assisted 600 deliveries.
Emergencies
In March, 8,000 refugees escaped instability
and violence in Central African Republic bymoving to the Haraze district in the southeastof the country. MSF provided healthcare, set up
a drinking water supply system and organised
the referral of patients who needed surgery.
More than 5,400 consultations were carried out
during the two months of the intervention.
MSF has worked in Chad since 1981.

AFRICA

Democratic Republicof Congo (DRC)

REASON FOR INTERVENTION • Armed conflict• Endemic / Epidemic disease • Healthcare exclusion
Field Staff 2,832

In 2009 the people in eastern Congo suffered continuous violence from different armed
groups. Hundreds were killed, thousands raped and hundreds of thousands fled their homes.

In January 2009, Congolese and Rwandan armies
launched military operations against the Forces
Démocratiques de Libération du Rwanda (FDLR)
rebels. This offensive led to a mass displacementof people and many villages were attacked,
looted and burned. Throughout February andMarch some 100,000 displaced people arrived
in the Kayna area and Lubero town. In response,
MSF extended its existing programmes in Kayna
and Kanyabayonga to the Lubero district.
North Kivu
In North Kivu, MSF provided emergency care andhealthcare in the places most affected by armed
conflict, and continued to work in the hospitalsof Rutshuru, Nyanzale, Masisi, Mweso, Kitchanga
and Kirotshe. MSF also supported health centres
and ran mobile clinics and nutrition programmes
in the surrounding areas, as well as providing
medical and psychosocial care for victims ofsexual violence. Overall MSF provided more than
177,000 consultations in these areas.
In Rutshuru, a 280-bed hospital, three surgical teams
worked round the clock, performing an average of
15 operations per day. MSF also extended its activities
by opening units to treat burns victims and provide
neonatal care in Rutshuru hospital, north of Goma.
South Kivu
In the southern district of Kalonge, where 42,000
people were forced to flee their villages, teams
provided free access to healthcare through the
Chifunzi hospital and five rural health centres.
MSF also supported a 148-bed hospital and a
100-bed cholera treatment centre in Baraka andprovided medical and psychosocial care for 5,600
rape victims throughout North and South Kivu.
Mobile surgical teams went to Bunyakiri, Kayna
and Nyamilima, three sites affected by violence
whose people, until then, had no access tosurgical care. Teams performed nearly 300
surgeries. More than 30 per cent of the injuries
were caused by violence.
Epidemics, emergencies and challenges
MSF responded to recurring epidemics such as measles
and cholera by treating people with cholera in
special units in Rutshuru and Goma, and vaccinating
children under five years old against measles.
In response to the violence in Shabunda Territory,
MSF started an emergency four month programmein Lulingu in South Kivu, providing internallydisplaced people as well as the local communities
with healthcare and nutrition. MSF treated morethan 15,700 people during this period.

Insecurity continued to undermine MSF’s
attempts to support the weak and overstretchednational healthcare system. In October, seven
MSF vaccination sites came under fire duringattacks by the Congolese army against the FDLR
in the Masisi district, despite an assurance ofsafety from the government. MSF denounced thisas an unacceptable attack on civilians.
Haut-Uélé, Bas-Uélé and Ituri
Since late 2008, the civilian population of northeastern
DRC has been caught in a cycle of violence linked
to attacks perpetrated by the Ugandan rebel group
the Lord’s Resistance Army (LRA), and a military
offensive against the LRA. MSF continued to workin Dungu hospital and began to support hospitals
and health centres in Faradje, Niangara, andDingila. MSF also resumed its activities in Doruma
after a suspension due to insecurity. In all its project
locations, MSF provided psychosocial support,
vaccination against measles, and distributed relief
items to thousands of displaced people.
In the course of 2009, violence and armed
confrontations have gradually expanded, now
stretching from Haut-Uélé into Bas-Uélé innortheastern DRC, and to the neighbouring
regions of southern Sudan and eastern Central
African Republic. In the Faradje area, the situation
improved so MSF decided to hand over its
medical and psychosocial activities. But further
west in Bas-Uélé new attacks displaced thousandsof civilians. In response, MSF supported Ango
Hospital by providing free medical care to thedisplaced and local people. During the first partof the year, teams assisted people who had fled
to the Ariwara area in the province Ituri on theborder of Uganda.
Following previous attacks, MSF had to suspend
its activities in treatment centres for sleeping
sickness (trypanosomiasis) in Bili and Banda,
where MSF had treated 228 people in the first
three months of the year.
In Bunia, Ituri district, 700 children under five years
old were hospitalised and a further 2,000 received
care through consultations every month. More than
1,000 women received medical and psychologicalcare, mostly for rape. More than 8,000 people
who fled violence in the Similiki area sought refugein the town of Gety. MSF provided healthcare
to 18,000 patients and, when security allowed,
brought medical care to neighbouring Tchekele,
Aveba and Songolo. Teams also vaccinated 15,000
children against measles in these areas.
Other areas
In more stable areas of DRC, health needs persist.
Emergency teams based in Kinshasa, Lubumbashi
and Kisangani responded to 12 emergencies
including a cholera epidemic in Katanga and an

outbreak of Ebola fever in West Kasai. MSF carried out
vaccination campaigns against measles, inoculating
more than 400,000 children mainly in the provincesof Orientale, Maniema, and North Kivu.
MSF continued to provide treatment to morethan 2,000 patients with HIV/AIDS in the capital
Kinshasa, but closed its two clinics offering
treatment for sexually transmitted infections in thenorthern city of Kisangani as another organisation
took over, ensuring continuity of treatment. At the
MSF hospital in Lubutu, Maniema province, morethan 120 patients a month were hospitalised.
In Katanga, MSF ran two hospitals in Shamwana
and Dubie, and offered basic and maternal
healthcare in 12 health centres. For the thirdyear running, MSF organised a camp providing
specialised surgery for women suffering fromobstetric fistulas, a debilitating condition often the
result of complications in childbirth. MSF teams
also operated on women suffering from fistulas inNorth Kivu and Maniema provinces.
Refugees flee to Congo Brazzaville
Between October and December in Equateur
province, western DRC, fighting started between
different communities reportedly over farming
and fishing rights. More than 100,000 people
fled violence to the other side of the border inthe Republic of Congo Brazzaville and more than
30,000 were displaced inside DRC.
According to a survey conducted in December
among refugees in the neighbouring Republicof Congo Brazzaville by MSF’s epidemiologicalcentre “Epicentre”, approximately 1,700 persons
out of a population of 40,500 died from violenceover a 50-day period.
In November, MSF started to assist Congolese
refugees in the neighbouring Republic of Congo.
At the same time, another MSF team assessed theneeds and started working in western DRC.
MSF has worked in the Democratic Republicof Congo since 1981.

© Martin Beaulieu

MSF provided medical assistance by running
hospitals, mobile clinics, vaccination
campaigns and cholera programmes andtreating victims of sexual violence.

North Kivu, DRC. Refugees standing in front ofKitchanga camp.

MSF PROJECTS AROUND THE WORLD – AFRICA – Democratic Republic of Congo

17

AFRICA

Djibouti
REASON FOR INTERVENTION• Healthcare exclusion

Ethiopia
REASON FOR INTERVENTION© Jean-FranÁois Herrera

Field Staff 90• Armed conflict

In 2009 MSF refocused
its activities in Ethiopia,
opening new projects in
the Somali, Oromiya andGambella regions of thecountry and handing overa long running kala azar
project to the local healthauthorities in Tigray region.
Teams also treated people with HIV/
AIDS, tuberculosis (TB) and malnutritionand provided aid to refugees in camps.

A young mother waits with her child outside
a malnutrition screening centre.

Child malnutrition rates in the
shantytowns of Djibouti are high.
This is partly because this small country is dependenton imports from abroad. Fluctuations in food prices
affect its 800,000 inhabitants deeply, especiallysince 60 per cent of the people are unemployed.
MSF is providing medical care for children aged
between six months and five years who are sufferingfrom acute malnutrition, particularly those who livein the shantytowns of the capital. Those forced tolive in these shantytowns are mainly unregisteredmigrants, asylum seekers and poverty stricken
Djiboutians who have fled drought-ridden rural
areas. Thousands come each month to swell the
shantytowns located west of the city. Moreover,according to the UNHCR, the country officially hosts
some 10,000 refugees, most of them Somali.

Kala azar treatment
In July, MSF handed over to the local healthauthorities its kala azar treatment programmein Humera on the border with Eritrea andSudan. The move followed a series ofimportant steps taken by the government andother organisations in tackling this parasitic
disease which, if left untreated, is fatal. Steps
have included treatment of the disease in all
health structures and the introduction of anational training curriculum for health staff.
In the 11 years that MSF worked in the
Humera district, approximately 8,000 people
suffering from kala azar were treated.
In the northwest Amhara region near theborder of Sudan and Eritrea, a remote andoften inaccessible area particularly during
the rainy season, MSF continued to provide
care for people infected with kala azar.
Throughout the year, more than 800 people
were screened for the disease and nearly 250
patients treated for it.

• Endemic / Epidemic disease

Field Staff 589

MSF also treated people with HIV, TB andmalnutrition. Last year, more than 4,000
people received counselling and testingfor HIV and 250 patients started their
antiretroviral therapy. More than 500 people
received therapeutic food including 250
malnourished children under five years old.
Somali region healthcare
In Ethiopia’s conflict-affected Somali region,
where many people have no access tohealthcare, teams continued to provide
free medical assistance. In one centre in
Wardher, MSF provided general and maternal
healthcare and treated malnutrition and
TB. Staff focused on strengthening andpromoting the maternal health services here,
since few pregnant women in the region werecoming to the clinic for help. These efforts
were successful: more than 1,600 women
received antenatal consultations and 200
women received assistance for births during
the year. In Degahbur, MSF supported ahospital by providing general and maternalcare and nutrition services. Mobile clinics werealso placed in the area to help reach ruralcommunities. Teams in Degahbur carried out
nearly 20,000 consultations and treated nearly
13,000 children for malnutrition.
In February, MSF provided emergency medical
assistance to Somali refugees living in transit
camps as well as to those who had foundaccommodation within the local community.
In Dolo Ado transit camp, teams provided
free basic healthcare, nutritional screening
and measles vaccinations for children under
15 years old. In the town of Dolo Ado MSF
supported the health centre in providing general
healthcare, maternal care, paediatric care,nutritional assistance and various vaccinations.

© MSF

MSF medical teams take care of children with severe
malnutrition in Balbala, a suburb of Djibouti City,
where some 200,000 people live. Mobile teams areworking their way through the Balbala, Hayableh,
Arhiba and PK12 districts, identifying those withsevere malnutrition and referring them to healthcentres where they are treated. The most severe cases
requiring hospitalisation are brought to the MSF
therapeutic feeding centre for appropriate care. In thelast few months of 2009, more than 14,000 children
were screened, 16 per cent of whom needed further
care. Overall in 2009, MSF treated nearly 1,730
malnourished children under five years old.
MSF has worked in Djibouti since 2008.

Wardher town, Ethiopia. A team of midwives and local women outside the local health centre.
18

MSF PROJECTS AROUND THE WORLD – AFRICA – DJIBOUTI / ETHIOPIAAFRICAIn May, MSF supported the local healthauthorities in opening a health centre in Geladi,also in the Somali region. MSF’s intervention
was initially focused on responding to an
outbreak of diarrhoea, however in the last
six months of 2009, teams worked on
developing other services at the centre suchas maternal and general healthcare.

GuineaConakry

REASON FOR INTERVENTION• Armed conflict• Endemic / Epidemic disease• Social violence / Healthcare exclusion
Field Staff 175

Nutritional Support in Oromiya,Amhara and Somali regions
In November, MSF started providing
nutritional care in Anchar worreda in theWest Hararghe zone of Oromiya region.
A stabilisation centre was built and morethan 60 severely malnourished children withmedical complications were admitted. The
children received treatment over two months
and a further 540 severely malnourishedchildren were treated without being
admitted. MSF also responded to nutritional
emergencies elsewhere. More than 80
malnourished children under five years old
were cared for in Bokh between September
and November, and over 550 children weretreated for malnutrition in Legehida.
Displacement in Gambella
Throughout the year escalating violencein the neighbouring regions of Sudan
displaced people in the Gambella Region
in the west of the country. MSF openeda programme to provide healthcare toapproximately 20,000 residents and 15,000
displaced people living in the district ofWantaho Woreda. The clinic offers general,maternal and nutritional care. In 2009,teams provided nearly 1,800 consultations.
Diarrhoea outbreak
MSF responded to other emergencies
throughout the year, primarily outbreaksof acute watery diarrhoea. Interventions inMoyale, on the border of Kenya, treatedmore than 500 people in one month andin the Afar region more than 1,000 people.
MSF also intervened in South Omo in
Southern Nations, Nationalities and People’s
Region and in the Oromiya region. In
August diarrhoea became endemic in thecapital, Addis Ababa, and its surroundings.
Working together with the Ethiopian healthauthorities, teams treated more than 10,000
people in nine facilities throughout the city.
MSF has worked in Ethiopia since 1984.

© Johann Buchot

In August, medical teams started working
in East Imey, providing outpatient care,antenatal services and treatment formalnutrition. The centre has a 15 bed
capacity and a maternity ward. In December,
MSF expanded its activities to West Imey,
where teams are supporting a healthcare
centre and a nutritional centre.

Conakry, Guinea. MSF workers hand out insecticide-treated mosquito nets to local people in
the fight against malaria.
In September, government security forces
cracked down violently on a large opposition
rally in the capital city of Guinea Conakry,
leaving 150 people dead and hundreds injured.
Political instability remained throughout 2009,and poverty and limited access to quality healthservices continued to affect the lives of most
Guineans. MSF provided medical care, including
treatment for HIV/AIDS and paediatric care.
Violence
On September 28, hospitals in Conakry were
overwhelmed by hundreds of people that had
been wounded in the government repressionof the opposition protest. MSF responded byproviding local hospitals and health centreswith medical material and assisting withthe evacuation, triage and treatment of thewounded. Teams treated more than 400
wounded, a third of whom for serious injuries
and set up a centre where victims of violence
could seek medical and psychological care.
Paediatrics
In February, MSF started a new paediatricprogramme in collaboration with the Guinean
health authorities in Matam, a district of Conakry.
Offering care specifically to children under fiveand to pregnant and breast-feeding women,
this project aims to reduce the mortality rate ofyoung children in the district, many of whom areaffected by malaria, malnutrition, diarrhoea andother diseases. More than 5,500 consultations,half of which were for malaria, were carried out
in Matam’s three health centres in 2009. MSF
also provides neonatal and nutritional care atConakry’s National Institute for Children’s Health.

HIV/AIDS care and decentralisation
In 2009, MSF continued to run HIV/AIDS
treatment programmes in the city Guéckédou in
the southeast of the country and in the capital
Conakry. MSF provided testing, treatment andpsychosocial counselling, trained and supervised
medical staff and upgraded medical units. By theend of the year, MSF was supplying more than
4,000 patients with antiretroviral therapy, including
many patients co-infected with tuberculosis (TB).
MSF has continued to push for the decentralisationof HIV/AIDS care to smaller health centres to allow
patients to be treated closer to their homes.
Health in prisons
Having carried out an emergency medical andnutritional programme in several Guinean prisons,
MSF issued a report to highlight the poor living
conditions of prisoners. The report ‘No foodor medicine here until you die’ found that in
Guéckédou, one in three adult male prisoners was
suffering from malnutrition, and the unhygienic
conditions had led to dehydration and widespreadskin and respiratory infections. Overcrowded cells
meant that minors were being detained together
with adults, and prisoners with TB alongsideuninfected inmates. MSF demanded that thenational and local authorities act immediately
to meet the prisoners’ basic needs.
Bednets
Malaria is the main cause of death in Guinea.
Between August and October, MSF teams
distributed more than 78,000 mosquito
nets impregnated with insecticide to 38,000
households living in Matam district.
MSF has worked in Guinea Conakry since 1984.

MSF PROJECTS AROUND THE WORLD – AFRICA – Guinea Conakry

19

AFRICAKenya
In early 2009, as people
fleeing the fighting in
Somalia arrived in Kenyain their thousands, MSF
teams re-started working
in Dadaab refugee camp in
Dagahaley in the northeastof the country after a five
year absence.

Teams also responded to numerous
emergencies, including fuel tanker
explosions, the return of a cholera epidemic,
and treated people with kala azar, HIV/AIDS
and tuberculosis (TB).

• Endemic / Epidemic disease

the camp via a 100-bed hospital that carries
out surgeries and offers medical care, and fourother health centres that administer vaccinations
and give antenatal and mental healthcare. The
medical needs are huge: the hospital provides
around 10,000 patient consultations and admits
600 people every month. Between August andDecember last year, MSF cared for more than
67,000 patients, including more than 2,200
malnourished children.
Responding to emergencies
In January, more than 100 people died after a fueltanker exploded in Molo town in Nakuru. Later inthe same year, there was another tanker explosionin Kericho. Teams provided medical care to thesurvivors, many of whom suffered burns.
After a 12-year absence, cholera returned to
Kenya in late 2008. In 2009 MSF responded
to several outbreaks around the country andtreated approximately 5,000 people.
Kala azar
In the West Pokot District in western Kenya,teams cared for people infected with kala azar,
a parasitic disease transmitted by the sand flythat is deadly without medication. Every month
teams treated 40 to 50 people.

• Healthcare exclusion

MSF is lobbying for treatment to be provided
free of charge by the Ministry of Health andfor rapid testing methods for the disease to bemade readily available.
HIV/AIDS and TB
In western Kenya, MSF runs a HIV/AIDS and
TB programme in Nyanza province, where
the prevalence rate is one of the highest in
the country. Working in Homa Bay District
Hospital, MSF staff cared for 9,500 people
living with HIV, 73 per cent of whom arereceiving anti-retroviral treatment (ART).
As a result of MSF’s intervention, Homa Bay
District Hospital was the first public facility in
Kenya to offer free anti-retroviral treatment
in 2001. However in this rural community,
where poverty is rife, transport unreliable or
expensive and stigma commonplace, medical
teams were still seeing many patients who
would only come to seek help when they
were very seriously ill with HIV/AIDS. To try
and prevent this, since 2006 MSF staff havefocused on decentralising care in the district,working with the Ministry of Health to ensurethat HIV/AIDS care is available in healthcare
clinics around the district.

© Dominic Nahr

Assisting Somali refugees
Dagahaley is one of three camps in Dadaab thatwere set up in the early 1990s to house Somali
refugees. By the end of 2009, camps that hadoriginally been built to accommodate 90,000
people were struggling to cope with close to300,000 people. MSF provides healthcare in

REASON FOR INTERVENTION
Field Staff 629

Dagahaley camp, Dadaab, Kenya. A young Somali boy who has reached the later stages of cancer without any proper treatment is seen by a doctor.
20

MSF PROJECTS AROUND THE WORLD – AFRICA – KENYA

AFRICA

LesothoIn the Nairobi slums of Mathare andKibera, MSF provides free comprehensive
care for around 7,000 people living with
HIV/AIDS and anti-retroviral treatment
for more than 4,800 people. In 2009,
outpatient consultations in MSF’s
three clinics in Kibera increased fromaround 4,700 a month to over 7,000. In
Mathare, medical teams started providing
voluntary counselling and testing indifferent locations around the slum inorder to try and provide care for more
people living with HIV/AIDS. Specialised
treatment for survivors of sexual violence,a huge problem in the city’s slums, isalso provided. Post exposure prophylaxis,
which greatly reduces the risk ofinfection with HIV, counselling and social
support is offered. In Mathare MSF treats
between 20-30 survivors every month,
many of whom are children
Handing over
In Nairobi, MSF handed over its activities
in Mbagathi hospital to the Ministry of
Health after 12 years of intervention. In
Busia, in Western Province near the borderof Uganda, MSF also handed over its
activities in the main district hospital andthe support of eight out of nine healthcentres throughout the year. The handoverof the last health centre is planned for April
2010. In the ten years that MSF worked in
Busia, good progress was made in treating
people living with HIV. Working closelywith the Ministry of Health and ensuringthat care was decentralised and integrated
into healthcare clinics around the district,teams provided care for more than 13,300
people living with the disease, and morethan 4,300 of these received ART.
MSF has worked in Kenya since 1987.

REASON FOR INTERVENTION • Endemic / Epidemic disease
Field Staff (this figure is integrated with those of South Africa)© Zethu Mlobeli

As tuberculosis is the leading killer ofpeople living with HIV/AIDS, a focus of
MSF’s work in Homa Bay is treating people
with TB and multi-drug resistant TB (MDRTB). In 2009, MSF constructed an eight
bed isolation ward for MDR-TB treatment
in Homa Bay district hospital. Medical
teams also provide treatment for MDR-TB
in Nairobi’s slums, where people live in
extremely cramped conditions without
sanitation, running water or electricity.

St Barnabas clinic, Lesotho. Two nurses comparing notes.

In Lesotho, one of the countries worst-affected by
HIV/AIDS, 270,000 people live with the virus, 117,000 ofwhom need antiretroviral therapy ( ART ). Yet only 41,000
people are receiving the life-prolonging treatment.
Four years ago, MSF and the national healthauthorities jointly launched a programme
to provide HIV/AIDS care, including ART, inrural Lesotho. MSF has now handed over sixof the 15 clinics it has been supporting in the
Scott Hospital Health Service based south of thecapital Maseru.
These six centres will now be run by the local
health authorities to help decentralise care andbring treatment closer to people in rural areas.
Nurses will be trained to administer treatment for
HIV/AIDS and tuberculosis ( TB ). Lay counsellors,
often HIV-positive themselves, will also be trained
to support new patients and help them to adhere
to the treatment.
The programme launched in Scott Hospital includes
a district hospital and 15 health centres in remoterural communities. This covers around 220,000
people, 30,000 of whom are HIV-positive. In
addition to general healthcare, the clinics provide
comprehensive HIV/AIDS care including testing,
ART and counselling as well as prevention of
mother-to-child transmission. MSF has also worked
to strengthen laboratory services, drug supply,
infrastructure, and programme monitoring.

Throughout the year, nearly 54,000 HIV tests
were carried out, and more than 6,000 patientswere started on ART. The results for the firsttwo years are encouraging; 80 per cent of
adults and 93 per cent of children are still alive
after 12 months of treatment. In addition, HIVtransmission from mother to child has been
reduced to less than five per cent.
However since 90 per cent of patients with HIV/AIDS are co-infected with TB, the programme is
now also focussing on improving TB diagnosis
and integrating HIV and TB services.
MSF has worked in Lesotho since 2006.

Mamatsoele
HIV-positive and a counsellor working ina remote mountain clinic‘When I talk to people about HIV, I make an
example of my life and how I lived before
knowing my status. Even if you are taking the
medicine, if you don’t accept your status, it
won’t help. Accepting my own HIV-positive
status made me feel like a new person.’

MSF PROJECTS AROUND THE WORLD – AFRICA – Lesotho

21

AFRICA

Liberia
REASON FOR INTERVENTION• Endemic / Epidemic disease• Social violence / Healthcare exclusion

Though Liberia has madesignificant moves towards
stability and reconstruction
following its 14-year civil
war, many people still live inpoverty and the weak healthsector often struggles toprovide adequate healthcare.
Women and children are
particularly at risk.
Maternal and paediatric healthcare
In 2009, MSF provided free healthcare in
two hospitals and two health centres inMontserrado County in the northwest,
which is home to more than 30 per centof the country’s population.
In a suburb of Paynesville, MSF worked in
a 106-bed women and children’s hospitaloffering neonatal intensive care and maternal
emergency services for women, including surgery.
Throughout the year, teams assisted nearly 7,000
patients, including more than 1,100 deliveries
and 2,600 emergency surgeries.
MSF also provided healthcare in a 187-bed
private paediatric hospital in Bushrod Island, an
overcrowded area of Monrovia that is home tomore than 500,000 people. More than 12,400
children were admitted in 2009. Teams focused
primarily on maternal health, malnourishedchildren with medical complications andintegrating the treatment of chronic diseases
such as HIV/AIDS and tuberculosis.
MSF also supported two health centres incollaboration with the Ministry of Health in
Clara Town and New Kru Town, in the capital.
Teams provided a range of services such asantenatal and postnatal care, vaccinations andthe prevention of mother-to-child transmissionof HIV. Together, the centres carried out morethan 112,000 consultations, and delivered
2,200 babies.

22© Julie Rémy

Field Staff 694

A mother watches over her daughter who is recovering from measles.

HandoverIn 2007, MSF started a gradual handover ofprojects to the Ministry of Health and otherpartners. In 2009, with the country firmly
in a post-conflict reconstruction phase, MSF
continued to hand over activities, including in
Nimba County, northeastern Liberia in April,followed by activities in Clara Town healthcentre in August. MSF also scaled down
activities in its two hospitals in Monrovia.
Before the handover of Saclepea in Nimba
County, MSF successfully finalised a research
project in collaboration with other partners
for testing the anti-malarial drug known asartemisinin-based combination therapy.
Sexual violence
Sexual violence remains common in Liberia.
MSF offered emergency medical andpsychological support to survivors of sexual
violence at Island hospital in Monrovia and at
two health centres, treating an average of 70
patients a month in 2009. More than threequarters were younger than 18 years old.
In the last months of 2009, MSF ran anawareness campaign in Monrovia, using radio
advertisements, interviews, posters, banners,
text messages and drama groups to urge moresurvivors of sexual violence to seek vital medical
and psychological treatment, particularly in thefirst three days after an attack.

MSF PROJECTS AROUND THE WORLD – AFRICA – LIBERIAFree medical care for all
MSF continued to lobby for free carethroughout Liberia. Though the government
introduced a free treatment policy in 2006,
and reconfirmed its willingness in 2009
to provide free healthcare to its people,
considerable political will and resources fromthe international community are still needed
to ensure these promises become a reality.
MSF has worked in Liberia since 1990.

Bestman
10 years old, a TB patient in Island
Hospital, Monrovia‘I was very sick when they broughtme here. I couldn’t even play with myfriends anymore and I was sweating
and coughing so hard. My motherwas worried. She thought she would
have to pay a lot of money, but myfamily doesn’t have money to pay.
But everything here was free. After
two weeks in hospital I had to comeback once a month for six months to
get medicine. Now I can play with myfriends again.’

AFRICA

MalawiREASON FOR INTERVENTION• Endemic / Epidemic disease• Natural Disaster

Field Staff 514

Malawi has been hit hard by the HIV/AIDS pandemic: nearly one million people,
that is 12 per cent of those aged between 15 and 49 are infected.
There is chronic shortage of healthprofessionals and demand for antiretroviraltherapy (ART) remains considerable. At
the end of 2009, more than 300 centres
were supplying ART to more than 183,000
patients, but 300,000 people were still on
the waiting list.
HIV/AIDS programme
Good quality HIV care is now provided in the
districts of Chiradzulu and Thyolo, but is rarethroughout the rest of the country. Indeed
the scale of the need combined with theshortage of health staff has led MSF to adjust
its approach, simplifying treatment protocols
and delegating patient care to nurses within
local health structures to bring care closer
to patients’ homes. Only where children
and pregnant women are involved, or when
there are complications, are cases referred tohealth specialists. Screening and psychosocial
and nutritional support are provided bycounsellors who help patients follow thetreatment properly.
MSF is working to provide further care for HIV
patients, such as preventing mother-to-childtransmission, detecting treatment failure andproviding paediatric care. There is a strongemphasis on integrating HIV services with generalservices, and integrating MSF’s HIV support
services into the Ministry of Health centres.

Since July 2009, the supply of ART drugs to
Malawi has been unreliable. In response,
MSF sent an emergency stock to the districtsof Chiradzulu and Thyolo to help avoid any
disruption to the medication of the 30,000
people on the programme. Any breaks
in treatment increase the risk of patientsdeveloping drug-resistance.
At the end of 2009, MSF was providing ART
to more than 15,000 patients at Chiradzulu,
and another 15,000 at Thyolo.
In July last year at the International AIDS
Conference in Cape Town, South Africa, MSF
gave a presentation on Malawi. This was anopportunity to show that offering ART on alarger scale need not increase the burden on
the health system. The programme in Thyolo,
where 80 per cent of those in need have accessto this life-saving care, was used as an example.
Shortage of staff
In Malawi the nurse and doctor-to-patient
ratio is dangerously low. Medical staff
in the districts where MSF works facehigh workloads: as many as 150 to 200
consultations a day. These shortages makeit nearly impossible to provide good-quality
healthcare and improve HIV services. Oneof the reasons why staff numbers are so low
involves sickness and death that is often HIVrelated. MSF has addressed this by supportinga clinic in Thyolo hospital where staff canreceive health services.
Cholera outbreak in Lilongwe
The capital, Lilongwe, was hit by a cholera
outbreak at the end of 2008 and in early
2009. The principal cause was the lackof access to safe water and sanitation.
Authorities requested assistance and MSF
provided supplies and medical staff and gave
intensive training to health workers. Teams
cared for more than 3,700 patients during
the epidemic, and gave logistical support toimprove water and sanitation services in nine
health centres and one district hospital.
Earthquake in the north of the country
On December 20, an earthquake ofmagnitude 6.2 hit the rural province ofKaronga in the north of the country, killing
four and injuring 200 people. Some 1,500
people were made homeless. Since thefinancial and material assistance provided byother agencies was adequate, MSF focusedmore on technical support, setting up ahealth centre in the camp for those who had
been made homeless and providing sanitation
and access to drinking water. The team also
ensured that the earthquake victims hadaccess to HIV care.
MSF has worked in Malawi since 1986.

Nouma
MSF patient from Chiradzulu© Isabelle Merny‘It was difficult for me to get to the
district hospital. I have difficulty walking
and don’t have a vehicle. Finding themoney for transport is a problem too
because it’s a long way to go. Now,
I just need 30 minutes to get to thehealth centre.’

Chiradzulu, Malawi. Children outside a health centre, from which MSF provides antiretroviraltreatment to more than 15,000 patients with HIV.

MSF PROJECTS AROUND THE WORLD – AFRICA – Malawi

23

AFRICAMali

REASON FOR INTERVENTION• Endemic / Epidemic disease• Healthcare exclusion
Field Staff 133

A combination of factors makes access to healthcare difficult for Malians, including cost,
the distance people live from health centres and, in the northern part of the country,
the nomadic lifestyle.
Malaria is a leading cause of death inchildren under five years old, and thematernal mortality rate is high.
Throughout 2009, MSF provided general
healthcare, treatment for malaria andobstetric fistulas and nutritional support
to children.
Malaria
Teams worked in the Kangaba region insouthern Mali, where malaria is most prevalent.
MSF supported 11 health centres and mobile
teams, including 66 ‘malaria village workers’.
These people are trained to detect and treat
uncomplicated malaria in children in remotevillages during the rainy season. Workers also
learned how to recognise signs of severe
malaria so they could refer the more serious
cases to health centres.

in remote villages in the Timbuktu and Gao
regions. The most severe cases were referred to
MSF centres, where more than 2,800 patients
received care.
Although the number of infected people hadalready surpassed the epidemic threshold,
MSF carried out a vaccination campaign in
the Timbuktu region in collaboration with
the Ministry of Health in order to prevent thedisease spreading further. More than 322,000
children between six months and 15 years ofage were vaccinated.

In 2009, MSF carried out more than 118,000
consultations. 60,000 people were treated for
malaria and more than 1,150 patients were
hospitalised for severe malaria. Early detection
kept the number of people needing hospitaltreatment relatively low.

Fistula operations
In the northeast regions of Timbuktu andGao, MSF treated women for obstetricfistulas. This condition is common in remoteregions because there are few hospitals andtherefore little access to Caesarean section
operations. Fistulas occur during childbirthwhen complications leave those who survive
with permanent injuries to the birth canal.
They can lead to chronic leaking of urine and/or bowel waste and women who suffer fromthe condition are often socially isolated andtreated as outcasts.

Measles epidemic
MSF responded to a measles epidemic in thenorth of the country by providing treatment

In collaboration with the Timbuktu regional
hospital and the Gao regional hospital, MSF
operated on more than 80 women.

High infant mortality rate
According to a 2006 study by Enquete
Démographique et de Santé du Mali, one infour children die before reaching the age offive in the southeastern region of Sikasso. Morethan 40 per cent of the 120,000 children in theregion suffer from malnutrition, and high levels
of infant malaria also contribute to this statistic.
Diarrhoea and respiratory infections are also
common and cause numerous infant deaths.
In collaboration with the Ministry of Health,
MSF launched a medical and nutritional
programme in 2009. MSF supports five healthcentres with supplementary staff and provides
medicines and therapeutic food. Children
requiring hospitalisation are transferred to
Koutiala hospital where a Paediatric Intensive
Care Unit and a Therapeutic Feeding Centre
have been set up.
Between July and December more than
22,300 consultations were carried out in thehealth centres supported by MSF. Two outof three children were treated for malaria,
3,200 children were treated for severe
malnutrition and more than 1,100 children
were hospitalised.
MSF has worked in Mali since 1992.

Ablo
A 10 year old malaria-sufferer from avillage in the Kangaba region.

© Barbara Sigge‘Every month, I get sick with malaria
because of the mosquitoes. The healthworker from MSF came to our schooland explained it to us. At home, we
sleep under a mosquito net, but themosquitoes also bite in the evening andI like to run around with my friends atthe end of the day. But the medicine
works very fast. After two days, I cango back to school, I can look after ourcattle and care for my baby brother.’

A community from a small village listen to a talk on malaria prevention.

24

MSF PROJECTS AROUND THE WORLD – AFRICA – MALI© Anna Surinyach

AFRICAA consultation is carried out in the back of an MSF vehicle.

MoroccoDue to the migration policies
adopted by the Moroccan
authorities, the global
economic situation, thefinancial crisis and rising
unemployment, the number of
migrants arriving in Morocco
decreased in 2009.
However, the migration of young women
is still high, mainly because of trafficking
networks. Many are victims of sexual violenceand suffer from resulting health problems.
In the cities of Oujda, Rabat and Casablanca, teams
used mobile clinics to reach people in need ofhealthcare and referred those with more complex
problems to the Moroccan health authorities.
However the projects in Rabat and Casablancaclosed in December when direct access to the

REASON FOR INTERVENTION• Social violence / Healthcare exclusion
Field Staff 30

national healthcare system improved for migrants
and the MSF programme was no longer needed.
In 2009, MSF treated 5,550 patients and provided
help to many people who had suffered fromsexual violence. However, as teams consideredthese people to be only a small proportion of
those who had actually been attacked, they
began asking all patients directly whether they
had experienced sexual violence -38 per centreported that they had.
Stranded between countries
Currently, migrants are being expelled from
Morocco to a ‘no-mans land’ known as‘Kandahar’ on the border between Mauritania andMorocco. In Mauritania, they are detained by theauthorities and kept in a detention centre called
Guantanamito. During 2009, an exploratory
mission was conducted in Mauritania and, basedon this, a project will open in 2010 to provide
medical care to the migrants. A further assessment
will take place in 2010 in Argelia on the easternborder with Algeria to assess the needs of migrants
along the migration routes there.

Patient story
Woman from Democratic Republic ofCongo interviewed in Morocco‘We came on foot. To make this journey
on foot you have to be very strong. You
have only the water that you can carry,
and when this water runs out you haveto drink water that you get from camels.
There is so much sand, and when you arewith small children, it’s hard, it’s really
hard. When we arrived in Gadamés we
had only a few things to eat. Some mencame to us and said, “We need women.”
I asked them why they needed women.
They told me again that they needed
women and started to beat me. They
were so strong. I was raped. I cried to
God but there was no miracle that could
help me escape. You find yourself wishingfor death. But death didn’t come.’

MSF has worked in Morocco since 1997.

MSF PROJECTS AROUND THE WORLD – AFRICA – Morocco

25

AFRICA

Mozambique Niger
REASON FOR INTERVENTION• Endemic / Epidemic disease

Field Staff 502

HIV/AIDS, malaria and tuberculosis are widespread in Mozambique.
15 per cent of people aged 15 to 49 are infected with HIV
making it one of the worst affected countries in the world.
Maternal mortality is high and diarrhoeal
diseases are endemic. Furthermore, the national
healthcare system was shattered during the 16
years of civil war that ended in 1992, as weremost social and economic infrastructures.
All MSF projects are focused on HIV/AIDS
treatment and care, including the prevention of
mother-to-child transmission of the disease.
In the capital Maputo, teams work in two
districts, supporting two day-hospitals and nine
health centres. Teams train staff, and provide
psychosocial counselling for HIV-positive
patients, including children. 18,000 patients
receive antiretroviral therapy (ART).
MSF is developing and promoting innovativemodels to help meet the high demand for
healthcare and is lobbying the government tointroduce a ‘task shifting’ approach in hospitals to
help to counter the shortage of doctors and nurses.
This includes training local medical staff to prescribe
ART drugs and administer repeat prescriptions, andpermitting the use of lay counsellors.

During 2009, MSF carried out 240,500
consultations and provided ART to
25,500 patients.
MSF has worked in Mozambique since 1984.

Margarida‘I live in a village outside the city of Tete, in
northwest Mozambique. Other people knowthat I’m HIV-positive, but I’m not worried orashamed of my disease. MSF encouraged
me to help others with HIV. I am now theleader of one of MSF’s HIV patient groups.
My role is to collect medication at the healthcentre and distribute it to the others in thegroup. Before, each member used to pay
one hundred meticals ($3.40) to travel backand forth to the health centre. Now, eachmember pays me seven meticals ($0.24),
and I bring the medication to their house.
The patients in the group appreciate this,because many don’t have enough money totravel to the health centre.
It’s great to be able to help others to takecare of their illness. I’m taking medication
but I am healthy and working like otherpeople. I want other HIV-positive people tojoin me and enjoy life.’

Maputo, Mozambique. A doctor explains antiretroviral drugs to a man with HIV and his brother.
26

MSF PROJECTS AROUND THE WORLD – AFRICA – MOZAMBIQUE

MSF has been working to provide
nutritional aid to malnourishedchildren as well as general andmaternal healthcare, and lastyear launched a large meningitis
vaccination campaign.
Zinder
The high level of malnutrition among
young children during the dry seasonfrom June to October is an ongoingproblem. According to a survey
conducted by UNICEF in June 2009, 15
per cent of children under five and almost
22 per cent of children between six
months and three years old were acutely
malnourished in the Zinder region in thesouth of the country.
In Zinder, within the first nine months ofthe year, MSF admitted 6,400 children
under five who were suffering fromsevere malnutrition, a third of whomneeded to be hospitalised. MSF also
supported two hospitals and 11 healthcentres in the region of Tahoua in thewest of the country where 16,500
children under five received treatment formoderate and severe malnutrition. Nearly
12,000 other children were admitted tothe clinic in the Nigerian border town ofMagaria during the same period, 1,800 ofwhom needed to be hospitalised. In total
MSF treated more than 34,000 severely
malnourished children and provided
a further 150,000 people with freehealthcare in 2009.

© Tomas Munita

MSF is supporting the care and follow-up
of HIV-positive patients in provincial hospitals in
the northwest of the country and is providing
technical support to health centres. In Tetecity, following a decentralisation of patient carefrom hospital to health centre level, the project
is now focused on training and supervisionof Ministry of Health staff, with the view tohanding back the project in 2010.

The people in this mainlyrural, sub-Saharancountry have only limitedaccess to healthcare,and the facilities thatdo exist are largely
underequipped andunderstaffed.

The country was repeatedly hit by
epidemics requiring emergency responses
throughout 2009. One outbreak ofmeningitis lasted more than threemonths. MSF together with the Ministryof Health treated 3,300 people andimmunised 1.5 million in the Zinder
region, as well as a further 670,000
people in Tahoua.

AFRICA• Endemic / Epidemic disease• Natural disaster

Field Staff 1,189© Guillaume Ratel

REASON FOR INTERVENTION

Doutchi, Niger. A doctor vaccinates children in one of MSF’s biggest meningitis vaccination programmes ever.

MaradiIn Guidam Roudji district in Maradi region,
severe malnutrition remains one of the maincauses of death among children under five
years old. In 2009, MSF provided treatment
for more than 1,700 malnourished children infour health centres. MSF teams also worked in
the paediatric ward of Guidam Roudji hospitalwhere children with severe malnutrition
are treated, and during the malaria season
provided additional staff to the hospital.
In Dakoro district, Maradi, malnourishedchildren received specialised care in MSF
supported health centres. Those in need ofintensive care were transferred to Dakoro
hospital, where an MSF team provided
intensive medical and nutritional care,paediatric care and emergency obstetricservices. In 2009, there were over 2,300
admissions in the paediatric ward and morethan 1,700 in the maternity ward, including
nearly 280 caesarian sections. In five healthcentres – Adje koria, Sabon Machi, Alforma,
Goula and Dakoro services including maternal
health, family planning, ante and post natal

consultations were offered. Altogether,
MSF conducted an average of 10,000
consultations every month.
In Madarounfa district, still in Maradi
region, a joint project for the treatmentof malnutrition was started by MSF and‘Forsani’, a Nigerian medical organisation. In
the three sites of Gabi, Madarounfa and Dan
Issa, more than 12,600 severely malnourishedchildren were admitted to the programme– with more than 90 per cent successfully
treated. During the malaria season between
July and December, support was provided
to three health centres in the district to help
treat malaria cases in children under five. In
total nearly 11,300 children were helped.

In September, severe floods hit Agadez. MSF
teams provided emergency medical assistancethrough mobile clinics to more than 9,500
people and distributed relief items to morethan 2,000 displaced families.
MSF has worked in Niger since 1985.

In May last year, MSF began working in threehealth centres in the city of Agadez in thenorth of the country, providing maternity
and reproductive health services. At the endof the year, teams had conducted more than
5,700 consultations and had assisted morethan 2,000 births.

MSF PROJECTS AROUND THE WORLDS – AFRICA – Niger

27

AFRICA

Nigeria
REASON FOR INTERVENTION• Endemic / Epidemic disease• Healthcare exclusion

Field Staff 524

Approximately 59,000 women die every year in Nigeria from complications in childbirth,
giving the country the seventh-highest maternal mortality rate in the world according
to the United Nations Population Fund.
In 2009 MSF provided maternal healthcare
and surgical support, launched a widespreadmeningitis vaccination campaign thattreated 4.7 million people, and provided
treatment for cholera.
Improving maternal health in northern Nigeria
In the north of the country, the focus wason improving access to emergency maternalcare in Sokoto State, where MSF supports themother and child care programme at the main
hospital. 8,100 malnourished children underfive years old in Sokoto State and Kebbi State
were also cared for.
MSF worked in emergency maternal care in
Jigawa State. The team helped nearly 1,600
women give birth and treated more than
2,500 women for complications in pregnancy.
In addition 219 women were operated on for
fistula repair surgery.
Emergencies and epidemics
Throughout 2009, emergency teams dealt
with epidemics and emergencies. This included
conducting a comprehensive meningitis
campaign that involved vaccinating 4.7 million
people across nine states. Teams also provided
4,500 people with treatment following acholera outbreak in Borno state.

In the southern part of Bayelsa State, MSF
worked at the Oloibiri Health Centre. 1,000
consultations were carried out each month anda mobile clinic service provided consultations
to more than 1,100 people in 14 different
locations.

© Francois Servranckx

Trauma care in the Niger Delta
MSF runs programmes in the Rivers and Bayelsa
states in the Niger Delta. Here in Port Harcourt
hospital MSF provides medical care via a
75-bed health centre. In 2009, 8,300 people
received care, 42 per cent of whom weretreated for violence-related injuries. Overall,more than 2,100 patients were admitted andmore than 2,850 surgeries were carried out,
and 450 victims of sexual violence received
medical support and counselling.

A doctor carries out a bedside consultation for a young boy with meningitis.

MSF has worked in Nigeria since 1996.

28

MSF PROJECTS AROUND THE WORLD – AFRICA – NIGERIAAFRICA

Sierra Leone
REASON FOR INTERVENTION• Endemic / Epidemic disease• Healthcare exclusion

Field Staff 393

Patient story© Vikki Stienen

In January, two exhausted parents
arrived at the Gondama Referral Centre
carrying a cold and pale child who washaving difficulty breathing.
His body was covered in multiple
abscesses. The parents had carried theboy for three days so that he could
receive treatment at the MSF hospital.
The three had slept out in the open withno food or money, and had been soakedby torrential monsoon downpours. In thefour subsequent weeks the child received
treatment for severe pneumonia, an
extensive staphylococcal skin infection
and severe malaria. He recovered fully
and returned home to his village, some70 miles away.

MSF carries out a vaccination campaign targeting 525,000 people in response to an outbreakof yellow fever.

Since civil war ended in
2002, Sierra Leone has been
relatively stable politically.
However, the economy has
not yet recovered. Poverty
is extreme, a severe lackof healthcare provision has
resulted in the highest childmortality rate in the world,and malnutrition and malaria
are widespread.

MSF is currently providing healthcare in a
hospital near Bo. The hospital has 215 beds, apaediatric ward, a maternity ward, an intensive
care unit and an intensive therapeutic feeding
ward for severely malnourished children. MSF
also supports the operation of five community
health centres and 30 community health postsin the Bo and Pujehun districts, providing
healthcare including curative consultations,basic obstetric care, and treatment formalnutrition and malaria. In addition, MSF
supports a network of 140 community
volunteers who have been taught how todiagnose and treat malaria in their own villages.

In 2009, MSF carried out 355,000
consultations, which included treatmentof 202,000 people with malaria and 6,000
with severe acute malnutrition.

Over the last few years there has been a sharp
increase in the number of patients in MSF
programmes, mainly due to a growing numberof people coming from further afield in searchof treatment. At the end of 2009, the hospital
was overcrowded, with the paediatric ward andthe therapeutic feeding ward overstretched by
up to 40 per cent. Such overcrowding means
people have to share beds or sleep on the floor.

In January, MSF carried out a vaccination
campaign in response to an outbreak of yellow
fever in the city of Bo and the surrounding area.
In total, 178,500 people were vaccinated.

MSF’s experience in Sierra Leone has shownthat moving to a system of free healthcare
produces a sudden and dramatic increase in
the number of patients seeking help for serious

medical conditions. Currently, all patients are
required to pay a fee when seeking treatmentin the national health system. A doctor’s
consultation can cost the equivalent of 25days’ income. MSF has publicly called for theabolition of user fees and, in 2009, both thegovernment and donors stated their support
for it, starting with free care for children underfive years old and pregnant women. However,it remains to be seen whether the authorities
will receive the necessary funding and technicalassistance to implement this policy fully.
MSF is an important provider of medicalcare countrywide, and is also the only major
maternal and paediatric health provider outside
Freetown. Each year, MSF provides primary
healthcare to more than 300,000 patients.
MSF has worked in Sierra Leone since 1986.

MSF PROJECTS AROUND THE WORLD – AFRICA – Sierra Leone

29

AFRICA

Somalia

REASON FOR INTERVENTION • Armed conflict• Healthcare exclusion Field Staff 1,201• Endemic / Epidemic disease

In 2009, the people of Somalia continued to be the victims
of indiscriminate violence due to ongoing internal conflict.
Many thousands needed emergency
healthcare but the overall humanitarian
response was inadequate. MSF worked innine regions to provide urgent medical care.
Insecurity and violence
Abductions and killings of international andSomali aid workers, and ongoing insecurity
remained the biggest obstacles to MSF’s
efforts to respond to the vast medical needs
throughout the country. In April two staff
members were abducted in the Bakool region
and held for ten days before being released.
Following the abduction, MSF decided thatit could no longer safely provide care to thepeople living in this region and closed its
largest health centre in south and central
Somalia, along with four other health posts.
In June an MSF employee died in an
explosion in the Hiraan region that also killed
30 other people. In July, for the first time in
17 years, MSF had to suspend activities in
its paediatric hospital and three other healthclinics in northern Mogadishu because ofheavy fighting. The following month, armed
men raided the MSF nutritional treatment
centre in Jilib, taking crucial medical supplies
and forcing staff to leave hundreds of severely
malnourished children without access toessential medical care. By the end of 2009
MSF had not been able to restart activities

in Jilib. In December, two mortars hit Belet
Weyne Hospital, injuring two MSF staff.

surgeries, nearly half of which were for
injuries caused by violence.

Overcoming the challenges
Despite these risks, MSF is still determined
to provide medical care to the Somali
people. In 2009, more than 1,300 dedicatedSomali staff, supported by more than 100
staff based in Nairobi, carried out some
650,000 consultations, 238,000 of whichwere for children under five years old. Morethan 49,000 women received antenatal
care and 26,000 people were admitted to
MSF-supported hospitals and health clinics.
Nearly 3,000 surgeries were performed, morethan 900 of which were for injuries causedby violence. Teams treated more than 200
people suffering from the deadly neglecteddisease kala azar, 2,600 people for malaria
and 1,300 for tuberculosis. More than
34,000 people suffering from malnutrition
were provided with food and medical careand 224,000 children were vaccinated,
including 92,000 for measles.

In February, at a hospital just outside thecapital, MSF staff treated people who
had been injured in a dramatic upsurge
in fighting. There were more than 120
admissions in just one day. More than 1,000
people, nearly half of whom were womenand children under 14, were admitted forblast injuries. MSF’s hospital in the central
town of Belet Weyne received more than
170 war-wounded patients needing surgery
and, in Guri El, in the neighbouring regionof Galgaduud, more than 230 patients weretreated following renewed fighting.

Responding to emergency needs
In two different regions, MSF was able torestart emergency surgical activities byrecruiting doctors who had graduated frommedical school in the capital Mogadishu in
2008. In the last five months of 2009, these
doctors performed more than 100 major

In early 2009, fighting in Guri El and Dhusa
Mareb, central Somalia, prompted thousandsof civilians to flee their homes. MSF supplied
water and medical care to displaced people
in the area. Throughout the year, teams also
responded to outbreaks of cholera, treating
1,000 people. When the number of reported
measles cases increased, MSF launched largescale vaccination campaigns in four regionsof Somalia. Approximately 73,000 children
between six months and 15 years old were
vaccinated in Belet Weyne, Hiraan, Middle
Shabelle, Lower Shabelle and Bay regions
and around 1,500 people suffering from thedisease were treated.
Drought, combined with chronic poverty, badharvests, high food prices, and continuing
violence meant that the number of children
needing treatment for severe malnutrition
reached an all-time high in MSF’s nutritional
programme in Galcayo. Nearly 2,300 children
were treated between October and December
alone. Teams working in the Mogadishu
suburbs treated more than 14,000 children
for malnutrition during the year.
MSF has worked in Somalia since 1991.

Dr Hafsa© Jan Grarup

MSF surgeon, Marere

Feeding centre, Galcayo, Somalia. Prolonged drought, fighting and high food prices means
MSF’s nutritional centre is often packed to capacity.

30

MSF PROJECTS AROUND THE WORLD – AFRICA – SOMALIA‘I chose to become surgeon because
I wanted to help Somali women,
particularly mothers who don’t get good
medical care, especially when they havedifficult births and need surgery.’AFRICASouth Africa
REASON FOR INTERVENTION• Endemic / Epidemic disease• Healthcare exclusion

In 2009 the new South
African government
completely reversed its
stance on two of thecountry’s biggest healthchallenges, and is now
addressing HIV/AIDS andtuberculosis (TB) as major
health priorities.

On World AIDS Day, President Jacob Zuma
announced a number of long-awaitedchanges to strategies on HIV/AIDS
treatment, including the use of higherquality drugs for initial treatment, and a
new model of care to address the deadly
HIV/TB co-infection directly. Treatment will
also be available for pregnant women andmore nurses will be trained, which will givepatients greater access to care. MSF has
been continuing to provide HIV/AIDS and TB
care to those in Khayelitsha and healthcare
to refugees from Zimbabwe.
Khayelitsha, a township on the outskirts ofCape Town, is home to half a million people
and has one of the highest incidences of
HIV/AIDS in the country. Since 2001, MSF
has been running a programme there in
partnership with local health authorities
offering antiretroviral therapy (ART). The
Khayelitsha programme was the first in South
Africa to provide ART free of charge to the
public. By December 2009, more than 13,550
patients were benefiting from the service.
But challenges remain including the lack of
specific HIV/AIDS medication to treat children
and adolescents, and the need for further
integration of HIV/TB treatment to cope with thehigh numbers of patients who are co-infected.
There are also increasing numbers of people
being diagnosed with drug-resistant TB (DRTB). MSF hosts a pilot project in the country
offering DR-TB treatment through regular healthcentre visits, rather than in specialised isolation© Finbarr O’Reilly

Field Staff 158

Khayelitsha township, Cape Town. A grandmother with one of five grandchildren that she isbringing up since the death of their mother from AIDS.

hospitals. This model of integrated care for
HIV/AIDS and TB patients has been replicatedin many other settings and is promoted by theWorld Health Organization as a model for bestpractice. The programme has enrolled over 580
patients in the last three years.
Zimbabweans seek refuge in South Africa
MSF has been continuing its work in central
Johannesburg and in Musina, a town on
the border with Zimbabwe, to provide
Zimbabweans seeking refuge in South Africawith medical care and mental health services. In
2009, MSF also made regular mobile healthcare
clinics available to the farms along the borderwhere many migrants work. Since April lastyear, MSF has been focusing on HIV/TB careand on improving services for victims of sexualand gender-based violence.
In these two projects, MSF treated more than
5,000 Zimbabweans a month, mainly for
respiratory tract infections, sexually transmitted
infections, gastrointestinal conditions andstress-related ailments. Almost 4,000 HIV tests
were carried out across the two projects. In
Musina, close to one third of people tested
were found to be HIV-positive, 64 per cent ofwhom were women.

In 2009 MSF medical staff treated more than
140 adults in Johannesburg who had beensexually abused, and more than half of thesevictims had been abused while crossing
the border.
MSF has worked in South Africa since 1999.

AndileAn HIV-positive patient at the MSF clinic
in Khayelitsha‘When I arrived in the support group
I was able to see that there are otherpeople living with HIV, who share theirstories, who talk about it. That’s when
I started telling myself “No, man ... HIV
is not the end of the world... maybe Ishould just stand up and look towards
the future... maybe God has something
here for me.”’More and more migrants are being sent back to
Zimbabwe from Musina by the authorities. But
they often attempt to re-cross the border into
South Africa at unofficial border crossing points,
where they are sometimes attacked or raped byviolent gangs.

MSF PROJECTS AROUND THE WORLD – AFRICA – South Africa

31

AFRICA

Punishing Success?
Risks of faltering HIV funding
Ten years ago, Médecins Sans Frontières(MSF) began pioneering HIV/AIDS treatment
in South Africa and Thailand. Today, millionsof lives have been saved and people ontreatment are able to live longer and enjoy abetter quality of life. At the end of 2009, MSF
was providing antiretrovirals (ARVs) to morethan 160,000 patients in over 27 countries. In
Khayelitsha in South Africa alone, more than
13,550 patients are benefiting from the HIV
care that MSF is providing in collaboration
with the local authorities.

For some countries, this means a cap on theirfunding or restricting the numbers of thoseput on treatment, as seen in South Africa andUganda, and in DRC – where the number of
new patients has been cut six-fold. Alreadyfragile health systems will become increasingly
strained by an increasing patient load requiring
more intensive care. What this means is that
more patients are now being turned awayfrom clinics and, as though we have regressedten years, doctors are being forced to ration
HIV drugs. There is also a risk that the newrecommendations of the World HealthOrganization that call for the earlier initiation of
improved drugs cannot be implemented.
MSF’s Campaign for Access to Essential Medicines
is a team of medical, scientific and advocacy
experts that explores and champions solutions
to the medical challenges MSF staff face inthe field. Today, the Campaign is working
with other health activists to demand thatthe international community adhere to theirpromises to fight HIV/AIDS, while supporting

ambitious and innovative methods to ensurethat the cost of drugs stays affordable.
We are also encouraging countries to make useof legitimate flexibilities in international trade
rules to overcome the barriers to medicines
posed by patents on drugs and to encourage,
through competition, the development ofaffordable generic medicines. We are pushing
pharmaceutical companies to participate in
UNITAID’s patent pool for HIV/AIDS medicines
which could help speed up the availability ofaffordable, generic versions of new drugs.
We are at a critical point in fighting this disease,and this is not the time to turn back. HIV/AIDS
remains an emergency. Much has been achieved
but there are still nine million people who don’t
have access to the medicines they need. Donors
and governments must not be allowed to throw
away the gains we have so far made, but instead
must move forward and commit to continued
and increased funding in order that we may bringthis devastating pandemic under control.
More on the Campaign’s activities on accessto medicines and medical innovation:www.msfaccess.org© Mariella Furrer / THINK Pictures

This progress is now under threat. There are
now worrying signs that international donors
are capping, reducing or withdrawing theirfunding for HIV/AIDS. The Global Fund to Fight
AIDS, Tuberculosis and Malaria, which funds
around two-thirds of all HIV/AIDS treatment indeveloping countries is currently facing a major
funding shortfall. Donors are going back on
their promises to fund and provide universal
access to HIV care. The main U.S. initiative tocombat the global HIV/AIDS pandemic, thePresident’s Emergency Plan for AIDS Relief,
known as PEPFAR, reduced its budget for thepurchase of ARVs in 2009 and 2010, and also
introduced a freeze on its overall HIV/AIDS
budget. Other donors, such as UNITAID and

the World Bank, have announced reductions
over the coming years in the funding for
antiretroviral drugs in the Democratic Republicof Congo (DRC), Malawi, Mozambique,
Uganda, and Zimbabwe.

HIV patients on antiretroviral treatment have to follow a strict drug regime to stay healthy.
32

MSF PROJECTS AROUND THE WORLD – AFRICA – PUNISHING SUCCESS? RISKS OF FALTERING HIV FUNDING

AFRICA

Sudan
There was a sharp rise in medical
emergencies in several partsof Sudan in 2009. In addition
to the continuing crisis in
Darfur, people in southern
Sudan faced escalating
violence and outbreaks of
disease. They have little orno access to healthcare.

people were killed than were wounded, and highnumbers of women and children were affected.
Surgical teams in Nasir and Leer performed morethan 1,000 surgeries in 2009, more than half ofwhich were for injuries caused by violence.
Throughout the year the Ugandan rebel
group, the Lord’s Resistance Army launchedfrequent attacks on villages near the bordersof the Democratic Republic of Congo (DRC)and Central African Republic, and in DRC
itself. These caused thousands of Sudanesepeople to flee their homes and Congolese
refugees to cross the border to seek refuge inWestern Equatoria State in Southern Sudan.
MSF has been in this area since the end of
2008, and adapted its activities to meet thechanging needs. Medical staff started towork in Ezo, Naandi, Yambio and Makpundu,
providing assistance to around 45,000 people
living in camps or integrated within hostcommunities. In 2009 teams carried out 14,000
consultations and provided psychologicalsupport to more than 800 people in Western
Equatoria. Materials such as plastic sheeting,jerry cans, blankets, pans and mosquito nets
were distributed to nearly 1,000 families, andlatrines and water points were installed in• Endemic / Epidemic diseaserefugee camps in the area. In February, MSF
also launched an emergency response in Lasu,
Central Equatoria State, providing medical care
to more than 6,000 people.
Emergency medical needs
In October, there was a new outbreak of thedeadly disease kala azar in Jonglei and Unity
States. Teams had screened and treated morethan 450 patients by end of the year.
These emergency interventions were in addition
to medical care that MSF provides in its longerterm projects in southern Sudan. Throughout theyear, 1,400 staff provided treatment and medicalcare to hundreds of thousands of people in sevenstates in southern Sudan and in the transitional
area of Abyei. Over 431,000 people received
care and more than 10,300 were admitted
to MSF’s clinics. Nearly 63,000 women had
antenatal consultations and over 8,000 children
were treated for malnutrition. More than 50,000
people suffering from malaria were treated and
188,000 people were vaccinated.
Humanitarian access reduced
Access to healthcare for people in the Darfur
region of western Sudan was difficult in 2009,
continued overleaf© Brendan Bannonr

Assisting victims of violence in southern Sudan
Escalating violence and disease outbreaks led
MSF to launch several emergency interventions
in southern Sudan in 2009. Medical needs, whichwere already at emergency levels in many partsof the country, increased dramatically during thecourse of the year as clashes between different
communities left hundreds dead and thousands
displaced. MSF led emergency interventions in
Akobo, Torkej, Lekwongole, Panyangor, Duk
Padiet and Terekeka. In the areas where MSF
responded, staff recorded that three times more

REASON FOR INTERVENTION • Armed conflict• Healthcare exclusion Field Staff 2,458

Naandi, South Sudan. A Congolese woman and her malnourished son being treated in a refugee camp for those fleeing unrest.
MSF PROJECTS AROUND THE WORLD – AFRICA – Sudan

33

AFRICA
continued SUDAN
especially following the expulsion by Sudanese
authorities of 13 international aid agencies– including two sections of MSF. Shortly after
the expulsions, four MSF staff were kidnappedin Serif Umra, North Darfur. They werereleased unharmed after a few days, but thesekidnappings, the first of their kind in Darfur,
marked the start of a spate of kidnappings in
the region: 14 people were abducted by theend of the year. This increased risk forced manyof the remaining aid agencies to scale backtheir activities in parts of Darfur.
More than half of MSF’s programmes wereforced to close as a result of the expulsions
and insecurity. Two more projects in Serif
Umra and Kebkabiya in North Darfur, andactivities in Tawila, also in North Darfur, weresuspended. MSF nonetheless provided over
168,000 consultations, more than 28,000
antenatal consultations, admitted nearly 2,500
people to hospital and treated some 4,500
people for malaria throughout the year. Teams
handed over projects in Golo and Killin to the
Ministry of Health in October, and in the samemonth were able to restart activities in Tawila.
At the end of the year, MSF started working
in a remote area of North Darfur, Um Baru,
providing medical support to five rural healthcentres that care for very isolated communities.
In the city of Port Sudan, in the northeastof the country, MSF continued to provide
reproductive healthcare in Tagadom Hospital.
More than 13,500 women received antenatal
consultations and 1,000 women received help
giving birth. MSF operates a zero-tolerance
policy on any type of female genital cutting.
It is estimated that more than 97 per cent of
women in the state are cut. This procedurecauses serious medical complications for many
women throughout their lives. MSF does not
re-infibulate women following delivery or at
any other time.
MSF has worked in Sudan since 1979.

Patient story
Woman from Burmath, Jonglei State,
May 2009‘There were so many people whocame to attack – all with guns. They
burned the area and took the young
girls, but not the boys, who they killed.
Normally, they only deal with the men,but this time they killed the womenand children. I am crying because weare not protected and our children are
abducted or wounded. That wasn’t thefirst time we were attacked but it was
the first time it was like that.’

34

Swaziland
Swaziland has the world’s
most severe HIV/AIDS
epidemic. A report from2006 / 2007 * estimated theprevalence of the disease
among adults to be 25.9
per cent.
Tuberculosis (TB) in HIV-infected people isthe number one cause of death, and more
and more patients who are being treated by
the joint MSF and Ministry of Health teams
are being diagnosed with drug-resistantforms (DR-TB). Since November 2007, MSF
has been working in close collaboration
with the Ministry of Health to respond to
this epidemic by providing diagnosis andtreatment for HIV/TB infected patients via
rural clinics.
Currently, MSF is working in the south of thecountry in the rural Shiselweni region, where afifth of the country’s population live, mostly invillages or on remote farms. They often haveto travel for hours to get to the closest healthfacility. MSF’s aim is to reduce the number ofdeaths from TB and HIV by providing diagnosis,
treatment and care as close as possible towhere the patients live through small rural
clinics, and also to bring some aspects of care
into the communities themselves. In 2009, MSF
supported one hospital, two health centres
and 18 clinics in the area. By the end of 2009,
more than 8,000 HIV patients were receiving
antiretroviral therapy and 3,381 patients werereceiving treatment for TB.
One important component of MSF’s
programme is to help patients to adhere to
their treatment using guidance and counsellingfrom ‘expert patients’ to teach others how tomanage it. This is especially relevant today,
since more and more TB patients in Swaziland
are failing to respond to standard drugs. Thosewith DR-TB have to commit to an especiallylong, painful and difficult treatment regimen. In
2009, MSF teams provided intensive support to96 patients infected with DR-TB.
A lack of qualified medical staff is anotherchallenge facing the country’s health system. In
order to overcome this obstacle, MSF advised
the authorities to implement a ‘task shifting’policy that would allow nurses to take oversome of the medical tasks currently performed
only by doctors. This policy change was one of

MSF PROJECTS AROUND THE WORLD – AFRICA – SUDAN / SWAZILAND

the recommendations of an International
Consultative Workshop on the DR-TB andHIV crisis in the Southern African region,
co-organised by MSF and the Swaziland
Ministry of Health in October 2009.
MSF has worked in Swaziland since 2007.
* USAID Demographic and Health Survey

AFRICA• Endemic / Epidemic disease

Field Staff 113© Alexander Glyadyelov

REASON FOR INTERVENTION

A doctor examines a young boy’s x-ray for signs of TB while the boy looks on.

Nonkululek
A 25 year old woman, HIV-positive and suffering from drug-resistant TB.
‘I take a minimum of 15 pills each day just to fight against drug-resistant TB. These drugs
are of different sizes. Some are the size of wheat grains or even bigger than that, the sizeof a big bean. It is difficult, but I don’t have a choice because I want to live a normal life.
After many months, I finally got used to taking a lot of drugs. But it would be better if all the
drugs could be combined into one.’

MSF PROJECTS AROUND THE WORLD – AFRICA – Swaziland

35

AFRICA

UgandaREASON FOR INTERVENTION• Armed conflict• Endemic / Epidemic disease• Healthcare exclusion
Field Staff 424

Cavine© Brendan Bannon

10 years old, HIV-positive
Cavine’s father died during the fighting.
Her sick mother went to the hospitalwhere she was diagnosed with TB
and found to be HIV-positive. Cavine
was also tested and found to be HIVpositive. Her mother was heartbroken
when she found out Cavine was sick,but relieved when her other children
were found to be not infected by thevirus. Cavine said, ‘I feel good now.
I was sick, but when I started taking
the drugs I got well.’ Her grandmotheradded, ‘I feel happy because I see that
there is no difference between her andany other child in the family anymore.
She is OK; she is doing all the work theothers do. At school she is very bright.
I am impressed!‘

Madi Opei Camp, Kitgum District, Uganda. A doctor treats a baby, whose mother is HIV
positive, for malaria. As yet it is too early to determine the baby’s HIV status.

MSF is working to fight
HIV/AIDS, tuberculosis(TB) and malaria in the
country, and is providing
nutritional programmes
for malnourished children.
In the West Nile region, inthe northern part on theborder with Sudan, MSF has
provided treatment to morethan 16,000 people with HIV
since 2002.

In these northern districts, the healthcare
system is slowly being rebuilt after yearsof conflict. The main challenges are theshortage of trained health staff and an
irregular drug supply, especially for HIV/
AIDS, TB and malaria. In the northwest
Arua district MSF provides treatment for
HIV patients co-infected with TB, nutritional
support for adults and children living withthe disease and antenatal care to preventthe transmission of HIV from motherto child. Of the 7,740 patients currently
treated at the hospital, more than 5,000 are
receiving antiretroviral therapy. MSF also
supports decentralised HIV clinics in otherrural areas.
MSF continued to provide assistance torefugees who had fled fighting in the
Democratic Republic of Congo at the end of
2008, and brought medical and sanitation
support to a refugee settlement in thesouthwest of the country from February to May.
Malaria is endemic in Uganda, but the mosteffective treatment, Artemisinin Combination
Therapy, is not always readily available. In 2009
in Madi Opei, a rural area in the north of thecountry, MSF treated more than 27,000 people
infected with malaria.
Hepatitis E is a viral infection transmitted
through contaminated water or food. It cannot
be cured and there is no vaccine available.
The epidemic that started in Kitgum and36

MSF PROJECTS AROUND THE WORLD – AFRICA – UGANDA

Pader districts in the north of Uganda in 2007
continued throughout 2009. MSF teams
provided patient care, worked to improve waterand sanitation facilities and tried to prevent thedisease from spreading further by seeking out
new cases and carrying out health education
campaigns. In 2009, MSF cared for more than
1,450 patients with this condition.
Decades of political neglect and underdeveloped
health services have badly affected the people
in the remote nomadic Karamoja region in
the northeast of the county. Violence here has
caused dozens of people to die each month.
Access to healthcare has been impeded by
insecurity, poor health exacerbated by a chronic
food crisis, and there have been peaks of acutemalnutrition. In 2009, MSF provided some
20,000 consultations, and 2,500 pregnant
women were seen in either mobile clinics or at
the hospital.
MSF has worked on Uganda since 1980.

AFRICA

ZambiaREASON FOR INTERVENTION

According to a 2007 national report, 14 per cent of theZambian population aged between 15 and 49 are HIV positive.
Here the pandemic has affected mostly
women and, in 2008, world development
indicators estimated life-expectancy at birth
to be only 46 years. It has laid a heavy burden
on the country, but the Zambian government
has taken significant steps to deal with the
problem in the last few years.
MSF has worked since 2004 to provide
treatment and care to thousands of people
living with HIV/AIDS in Zambia, throughantiretroviral therapy (ART) and medical care.
MSF has also worked to raise awareness about
the reality of HIV in Kapiri M’poshi district in thenortheast of the country. MSF ran an HIV/AIDS
clinic in the local district hospital and has been
supporting 14 rural health centres in the area.
Between 2004 and 2009, more than 66,500
people were tested for HIV, more than 12,000
were enrolled in the programme and more than
6,000 began ART.

MSF will continue working in Zambia,
redirecting its focus towards the prevention of
HIV transmission from mother-to-child.
MSF will also respond to other unmet
emergency medical needs, especially cholera,
and will continue to call for improved cholera
preparedness measures in the country. Teams
responded to an outbreak in March by setting
up two treatment centres in the capital city of
Lusaka, and treated more than 4,300 patients.
MSF has worked in Zambia since 1999.

Field Staff 94

Mary
She is one of the first patients to havereceived ART from MSF’s HIV/AIDS
programme in Kapiri. Since 2004, she
has been involved in awareness-raising
activities in the community to encourage
people to be tested for HIV / AIDS.
‘I was one of the first patients whostarted ART with MSF in Kapiri, which
has been great for me. Now I can work,
I even have a field from which I harvest
50 bags of maize. I have a garden; I
feel happy, very happy. I didn’t feel wellwhen I was sitting at home. I feel happy
to come out, just to come and help myfellow friends. A lot of them knew me
when I was sick; they saw the way I
was, and today I give my testimony tothem. So they are happy and a lot havecome out in the open about HIV, andstigma has been reduced in
the community.’© Brendan Bannon

In July 2005, the government began providing
care free of charge to HIV patients, and in2006 the national cost-sharing system of
healthcare was abolished so that all treatment
became free. In June 2009, MSF handed overits HIV/AIDS programme in Kapiri M’poshi to
the Ministry of Health and a non-governmentalorganisation, Zambia HIV/AIDS Prevention,
Care and Treatment Partnership, assured that all
the services provided to the Kapiri community
would continue to be free of charge.

• Endemic / Epidemic disease

Lusaka, Zambia. MSF responds to one of the worst cholera outbreaks in the country for many years.
MSF PROJECTS AROUND THE WORLD – AFRICA – Zambia

37

AFRICA

Zimbabwe
In June 2009, the cholera
epidemic that had started
in August 2008 was
officially declared over.
According to the UN, almost 100,000
people had contracted cholera and morethan 4,000 people had died from thedisease. Furthermore, the prevalence of
HIV/AIDS is among the highest in theworld. MSF responded to the cholera
outbreak, treating more than 65,000
people, and also provided treatment for
HIV and tuberculosis (TB).

MSF has been improving TB care andintegrating TB and HIV/AIDS services. HIV
care has been decentralised in order to bring
services closer to the patients’ homes, andnurses have been trained to administer ART.
Such ‘task shifting’ frees up the doctors sothey can concentrate on more complicatedcases, and allows the nurses to carry out thedaily HIV care.

Field Staff 911

south in the country. More than 1,700
severely malnourished children were cared
for in 2009.
Sexual violence
In collaboration with the Ministry of Health,
MSF has been providing both medical andpsychological help for survivors of sexual
violence in Gweru, in the heart of thecountry. More than 180 victims of sexual
violence were treated last year.
Healthcare for migrants
Due to the political and economic crisisof recent years, many migrants have beenleaving Zimbabwe to go to South Africa.
MSF opened a project in Beitbridge, near
the border most used by migrants and on
a commercial route between these twocountries. On average MSF teams carried out
more than 1,000 consultations a month there.
MSF has worked in Zimbabwe since 2000.

Nutrition
MSF is running nutritional programmes in
Epworth, near Harare, and Buhera, further© Joanna Stavropoulou

Cholera and malnutrition
By June 2009, MSF had treated 65,000
people. MSF also worked in prisons to treatcholera patients and to prevent the spreadof the disease. In addition, teams responded
to a severe malnutrition crisis in 13 different
prisons, providing treatment and improving
sanitation and water supply.

Fighting HIV/AIDS and TB
According to the United Nations joint
programme on HIV/AIDS (UNAIDS), there
are 120,000 children living with HIV in
Zimbabwe and at least one million children
have been orphaned because of it. MSF
increased the number of children under
its care and provided treatment to prevent
mother-to-child transmission of the virus, aswell as counselling and patient education.
MSF responded to the HIV/AIDS epidemic
in five districts: more than 52,000 people
received care, 39,000 of whom were put onantiretroviral therapy (ART).

REASON FOR INTERVENTION• Endemic / Epidemic disease• Healthcare exclusion

A doctor writes up her notes on an HIV patient who is improving since starting antiretroviral treatment.

38

MSF PROJECTS AROUND THE WORLD – AFRICA – ZIMBABWE© Yuri Kozyrev / Noor

Kutupalong camp, Bangladesh. A Rohingya woman and her child wait for medication.

40 Afghanistan

49 MYANMAR

41 ARMENIA

50 NEPAL

42 BANGLADESH

51 PAKISTAN

43 CAMBODIA

52 Papua New Guinea

44 CHINA

53 Philippines

45 Georgia

54 SRI LANKA

46 INDIA

55 THAILAND

47 INDONESIA

56 TURKMENISTAN48 KYRGYZSTAN

56 UZBEKISTANASIA & THE
CAUCASUSASIA & THE CAUCASUS

Afghanistan
REASON FOR INTERVENTION• Armed conflictField Staff 51

The country has some of the worst
health indicators in the world. Infantmortality rates are especially high, with anestimated 257 deaths per 1,000 live births
according to UNICEF. When it comes tocomprehensive healthcare, until recently
there was only one hospital in Kandahar,
supported by the International Committeeof the Red Cross, providing a complete
range of medical services for the entire
south of Afghanistan. In general people
have to travel hundreds of miles throughvery dangerous areas, in order to get the
medical care they need.
A return after five years
Having left the country after the brutal killingof five staff in Badghis province in June
2004, MSF returned to Afghanistan in 2009.
Increasing signals that the overall situation
for Afghans was getting worse rather thanbetter motivated the return. The people
have been trapped for years in impoverishedconditions, and many lack access to medical
treatment. Public hospitals do not function
well and private clinics are often prohibitively
expensive. In October 2009, MSF started
supporting activities in a district hospital eastof Kabul and in a hospital in the capital ofHelmand province.
The lack of respect for medical facilities
shown by all the belligerents involved in theconflict in Afghanistan has turned hospitals
into battlefields where staff and patients do
not feel safe. It was crucial for MSF to secure40© Pascale Zintzen

Conflict reignited
throughout Afghanistan
in 2009, especially inthe east and south ofthe country. It was thedeadliest year for civilians
since 2001, when the war
between Coalition and
Afghan government forcesand various oppositiongroups began.

Ahmed Shah Baba Hospital, Eastern Kabul. A doctor records the notes of a consultation.

agreements with all parties to ensure thehospitals were safe environments, so a ‘noweapons allowed’ policy was successfully
implemented. This approach seems to
be working, and MSF is supporting both
hospitals to ensure quality medical care freeof charge.
Critical support and services
In the district hospital in the east of
Kabul, MSF worked to improve treatment
procedures, the emergency room, andmaternity services. By the end of the year,
nearly 19,000 consultations and 1,000
deliveries had been carried out, and almost
9,900 people had been immunised throughthe Extended Immunisation Programme,
which protects against diphtheria, tetanus,
pertussis, hepatitis B and Haemophilus
influenza. MSF also repaired and refurbishedparts of the hospital.
In November 2009, MSF also started
to support Boost provincial hospital in
Lashkargah, the capital of Helmand province.
Lashkargah’s inhabitants have been severely
affected by the conflict, and this 150-bed
facility is one of only two general carepublic hospitals in south Afghanistan. MSF

MSF PROJECTS AROUND THE WORLD – ASIA & THE CAUCASUS – AFGHANISTAN

extended its support to all health services in
the hospital, including maternity, paediatrics,
surgery and emergency rooms. Since the startof the project, 1,100 consultations, morethan 60 surgical interventions and nearly 160
deliveries have taken place. By ensuring apermanent presence of medical staff and freeservices, MSF aims to get the hospital running
24 hours a day, seven days a week.
MSF plans to extend its support to hospitals
and rural health centres in other provinces in
Afghanistan in 2010.
MSF worked in Afghanistan between 1980
and 2004, and returned again in 2009.

ASIA & THE CAUCASUS

Armenia
REASON FOR INTERVENTION• Endemic / Epidemic disease

Field Staff 54

Armenia has one of the highest per capita rates of drug-resistant tuberculosis (DR-TB)
in the world, and since 2004 MSF has been collaborating with the Ministry of Health,running the only DR-TB treatment programme in the former Soviet Union country.
In the capital Yerevan, MSF has beenrunning a project to diagnose and treat
DR-TB in collaboration with the Ministry of
Health’s National Tuberculosis Programme.
In 2009, 130 new patients were enrolled inthis project free of charge.
The treatment for DR-TB involves a daily
cocktail of drugs that can cause side effects
such as severe nausea, vomiting, renal
problems and skin allergies. Treatment
can last for up to two years, so MSF
provides psychological and social support
to encourage patients to complete it. ‘The
non-medical support for patients is an
essential component, since it increases the
chances that they will stick to the difficult
drug regimen they must follow for months
and sometimes years,’ said MSF programmemanager Jean-Luc Anglade.
MSF helps patients in five districts around
Yerevan as well as prisoners in the central
prison. In 2009 MSF also made more than
5,000 home-based visits to patients anddistributed more than 1,600 food parcels.

© Bruno De Cock

MSF has worked in Armenia since 1988.

National TB Centre, Abovian, Armenia. A doctor examines a patient with drug-resistant TB.

MSF PROJECTS AROUND THE WORLD – ASIA & THE CAUCASUS – Armenia

41

ASIA & THE CAUCASUS

Bangladesh
REASON FOR INTERVENTION• Social violence / Healthcare exclusion• Natural disaster

Field Staff 185

In the Cox’s Bazar district bordering Myanmar (Burma), thousands of ‘unrecognised’
Rohingya refugees face a daily struggle to survive. Out of an estimated refugee
population of up to 400,000 Rohingya in Bangladesh, only 28,000 are recognised as official
refugees by the government and accordingly entitled to assistance by the United
Nations High Commissioner for Refugees (UNHCR). In sharp contrast, the vast majority of
Rohingya refugees live in an appalling state, exposed to health risks and exploitation.
children in its feeding programme andtreated more than 3,700 children under five
years of age.
The project soon developed into a primary
healthcare programme responding to theincreasing medical needs of those from boththe makeshift camp and the host community.
Over the year, MSF staff at Kutupalong
performed more than 23,000 consultations,more than 1,000 antenatal consultations
and, in response to a measles outbreak in the

makeshift camp, vaccinated more than
11,000 children.
In June and July, MSF was outraged to witness
local authorities violently removing thousandsof people from parts of the makeshift camp.
MSF teams treated a number of people fortrauma related injuries, and spoke out against
the abuse. The violence ceased for a shorttime, but in October MSF once again received
refugees suffering from violence related
injuries. This time patients told of being driven© GIULIO DI STURCO\nIn March, MSF became aware of more than
20,000 unrecognised Rohingya refugees
who were living in atrocious conditions
in Kutupalong makeshift camp, situatedon the edge of UNHCR camp for official
Rohingya refugees. In response, MSF set
up an emergency healthcare project,which included the treatment of large
numbers of malnourished children andthe improvement of water and sanitation
facilities. Within one month, MSF hadenrolled more than 1,000 malnourishedKutupalong camp, Bangadesh. A doctor checks the health of a new-born baby in a camp for Rohingya regugees.

42

MSF PROJECTS AROUND THE WORLD – ASIA & THE CAUCASUS – BANGLADESH

ASIA & THE CAUCASUS

from their homes in the Bandarban andCox’s Bazar districts by the authorities andlocal citizens.

Cyclone and disease
MSF assisted 75,000 people hit by Cyclone
Aila in May by distributing relief items,
repairing water sources and providing
healthcare services. MSF also opened ahealthcare programme in the Chittagong
Hill Tracts region in the southeast of thecountry, an area lacking in health services
and marked by ethnic tension. Teams havealso been working in a clinic in Baghaihat
in the southeast and have extended
services to eight village health centres.
In 2010 MSF will launch a programme in
the northeast of the country to provide
treatment for kala azar, a parasitic disease
that can lead to death. A new projectwill be opened to provide general
healthcare and treatment for malnutritionin Kamrangirchar, the largest single
concentration of slums in the area of
Dhaka. Plans include opening a number ofhealth centres, supporting existing healthcentres, and providing a system of homebased care for children under five years old
who are suffering from severe malnutrition.
MSF has worked in Bangladesh since 1985.

Patient story
A Rohinga refugee at MSF’s clinicin the Kutupalong makeshift camp
‘I used to think I had a home in
Bangladesh but, after two monthsof threats from people I have lived
among for 15 years, I felt sad andcame to the makeshift camp.’© Brigitte Breuillac

At the end of the year MSF initiated an
advocacy campaign calling for an end tothe violence, and urging the governmentof Bangladesh and UNHCR to take urgent
action to protect all refugees.

Phnom Penh prison, Cambodia. A prison inmate receives a medical check-up for TB.

Cambodia
REASON FOR INTERVENTION• Endemic / Epidemic disease

Field Staff 143

MSF has been in Cambodia since 1979. Public health problems
are dominated by HIV/AIDS and tuberculosis (TB) but MSF, thefirst to provide antiretroviral therapy (ART) for HIV patients,
has helped to improve the situation by developing national
treatment guidelines in tandem with the Ministry of Health.
A substantial increase in funding byinternational donors has helped fortify
government efforts to tackle prevalentdiseases, allowing MSF in turn to reduce
its HIV programmes. Teams now focus on
the treatment of TB and drug-resistant
TB (DR-TB) in Kampong Cham, and on
the detection and treatment of TB andHIV in prisons.
In Takeo and Siem Reap, MSF introduced a
new model of care that treats HIV/AIDS as achronic disease in clinics alongside diabetes
and hypertension. The approach proved
successful and teams were able to handover these activities in June.
In the provincial hospital of Kampong
Cham, MSF handed over HIV patient careto health authorities and local partners in
March. At the same time, teams extended
the TB programme started in September
2008 by building a new TB ward in thehospital and by providing technical support
to the hospital laboratory. The initiative
is focused particularly on drug-resistantpatients, children, and patients co-infectedwith HIV, but aims to improve case detection
and access to care for all TB patients.

In the Khmer-Soviet Friendship (KSF) hospitalin Phnom Penh, MSF has been handing over
the treatment and follow-up of patients in
the infectious diseases ward, and has alreadytransferred the 3,600 HIV-positive patients tohealth authorities in preparation for a formal
handover in March 2010.
HIV and TB are particularly challenging tomanage in closed settings such as prisons.
Since 2007, MSF has been treating HIV
patients in Phnom Penh’s prisons via
mobile clinics run by the KSF hospital team.
MSF supported voluntary confidential
counselling and testing, but teams havenow scaled up activities to include HIV
and TB case detection and improve accessto care, treatment and follow-up of all
prisoners in the three prisons. In the prison
near Kampong Cham, MSF helped toprovide healthcare to all inmates as wellas conducting a five-month nutritional
programme for those who had become
severely malnourished.
MSF has worked in Cambodia since 1979.

MSF PROJECTS AROUND THE WORLD – ASIA & THE CAUCASUS – Cambodia

43

ASIA & THE CAUCASUS

China

REASON FOR INTERVENTION• Endemic / Epidemic disease

China’s Ministry of Healthestimates that 740,000 people
in the country were living with
HIV/AIDS at the end of 2009.

particularly on vulnerable groups such as
injecting drug users, commercial sex workers,
men who have sex with men, and migrant
workers. The outpatient clinic provides
treatment free of charge and MSF pays forpatients who need to be admitted.

Although less than one per cent of the overall
population is infected, the minister warned
that the disease is threatening to become aserious epidemic among high risk groups.
Stigma and discrimination against people
living with HIV remains strong in China, andthis deters people from being tested. Where
the condition remains undiagnosed, there is a
far greater risk that it will be spread.

In 2009, more than 1,000 people living withHIV were under MSF care at the clinic, 900
receiving first-line antiretroviral therapy (ART),and 27 receiving second-line therapy, which isneeded when a patient develops a resistance tothe original treatment. Teams performed over
8,500 consultations. MSF also worked with theCentre for Disease Control to set up voluntary
counselling and testing centres in the city. Of
the 4,300 people who used centres in 2009,
147 tested positive for HIV.

HIV treatment and care
Testing for and treatment of HIV is officially free
under Chinese health policy, but in practice,hospitals and clinics often charge for thetreatment of opportunistic infections associatedwith the disease. As a result, no matter how
urgently some people need help, if they cannot
pay they simply cannot access treatment.

Field Staff 42

2008 to August 2009. Teams conducted home visitsand established five counselling centres in Mianzhu
and Beichuan, two of the worst affected areas.
Patients received between six and 20 consultations
to help them to recover.
MSF has worked in China since 1988.

The Nanning project will be handed over toChinese authorities in October 2010.
Post disaster mental health
In May 2008 there was an earthquake of magnitude
8 near Chengdu in Sichuan province, southwest
China. Some 80,000 people were killed, ten million
made homeless and vast numbers were left mentally
traumatised. Working with the Chinese Academyof Science and the Crisis Intervention Centre, MSF
provided psychological care for survivors, andtrained mental-health workers from November

Chen
A 35 year old patient at the MSF clinic in
Nanning tested positive for HIV in 2006.
The news was devastating. ‘When I foundout, I felt that life had no meaning andI had no idea what to do next,’ he said.
After his diagnosis, Chen was referred to
the MSF centre. ‘The counsellor helped
me to think a lot more positively. He
explained that HIV is not a disease thantakes your life immediately and that if
you adhere to the treatment, you can live
for years.’ Only one trusted friend knows
about Chen’s HIV status. ‘There is more
information about HIV/AIDS available thesedays, he explained. ‘Things are improving,
but there is still a long way to go before
discrimination will be eliminated.’© Anna Tsuji

Since 2003, MSF has been operating an
HIV/AIDS centre with the Guangxi Public
Health Bureau in Nanning. The centre provides
confidential care and treatment focusing• Natural disaster

Nanning City, China: A doctor carries out a consultation in an HIV/AIDS treatment programme centre.
44

MSF PROJECTS AROUND THE WORLD – ASIA & THE CAUCASUS – CHINAASIA & THE CAUCASUS

Georgia

REASON FOR INTERVENTION • Armed conflict• Healthcare exclusion Field Staff 85• Endemic / Epidemic disease

When conflict broke out between Russia and Georgia in South Ossetia in August 2008,
MSF set up a programme to provide support to people who had been displaced by theviolence in Georgia, and as a consequence had little if any access to healthcare.
In June 2009 the programme finishedbecause medical needs had decreased andmany of those displaced had returned
home. MSF has also been working to treat
drug-resistant tuberculosis (DR-TB) andHIV/TB co-infection.
Until June 2009, MSF provided healthcare
services and psychological support to people
in the cities of Tbilisi and Gori who had been
forced to flee their homes. About 10,000
consultations were carried out. Most of thepeople seen were suffering from depression,anxiety, post-traumatic stress disorder andpsychological problems.
TB treatment success
The Georgian Ministry of Health opened a new
TB hospital in Tbilisi in March 2009 and this,combined with a project that started in 2008
known as the National Tuberculosis Plan (NTP),
has strengthened the country’s fight against
DR-TB. Therefore, MSF started to hand over its
project in Zugdidi to the government in 2009.
The transfer should be complete by September
2010. More than 50 new patients with DR-TB
were admitted in 2009 and 80 per cent ofthem adhered well to the treatment despite thedebilitating side effects. This success rate wasdue to a home-based approach that patientsfound easier to follow.

© Julie Damond

In Abkhazia MSF continued to support thenational TB programme, providing treatment
for patients with DR-TB and life-prolonging
antiretroviral therapy for those co-infectedwith HIV. This project will also be handed
over to the national programme.

Abkhazia, Georgia: A patient who is receiving treatment for drug resistant TB.

Outreach programme
A health access programme for vulnerable
people in Abkhazia, which started in 1993
and at its peak had 6,000 patients, was also
reduced in size as the Ministry of Health’s
willingness to take responsibility increased. In
2009, some 100 people, mainly homeboundand bed-ridden, were registered on the
programme.
MSF has worked in Georgia since 1993.

Nugzari
60 years old, now cured of drug-resistant TB‘I had so many side effects: I couldn’t get up and I didn’t leave my room because I felt
ashamed. Someone who hasn’t taken these drugs can’t imagine how hard it is. I knew a
man who went mad taking this medicine. Me too, I used to lose my patience and my wife
was worried about me.’MSF PROJECTS AROUND THE WORLD – ASIA & THE CAUCASUS – Georgia

45

ASIA & THE CAUCASUS

India

REASON FOR INTERVENTION• Armed conflict• Endemic / Epidemic disease• Healthcare exclusion• Natural disaster
Field Staff 533© Cristina De Middel

Providing healthcare toa growing populationof more than abillion people poses
great challenges tothe Indian healthauthorities and there
are huge disparities inservices between the
different states.

Mumbai, India. A doctor checks the progress of a patient with multi-drug-resistant TB.

In 2009, MSF responded to epidemics andnatural disasters, and treated diseases
such as tuberculosis ( TB ) and HIV/AIDS.
The poorest and most remote parts of thecountry often have inadequate medical
facilities, poor healthcare infrastructure,
low-quality health standards, and a lack of
medical staff.
Up to three million people are living with
HIV in India, according to the World HealthOrganization. The MSF Antiretroviral Centre in
Mumbai offers HIV care to patients who require
treatment that is not yet available in the public
sector. This includes patients who experience
severe side-effects to the most commonly used
medication, and those who are co-infectedwith TB. In 2009, MSF provided more than
400 patients with antiretroviral therapy.
Providing basic healthcare
In the northeastern state of Manipur, where
political and social violence is common, MSF
runs four clinics providing basic healthcare,
HIV/AIDS and TB treatment and counsellingand maternity services. In 2009, MSF teams
carried out more than 40,600 consultations,
including treatment for HIV-positive pregnant
women to prevent transmission of the disease
to the child.
In Chhattisgarh State, tens of thousands ofpeople were forced to move into governmentrun camps, or into the dense forests in thesouth of the state because of the conflict
between Maoist rebels and government forces.

46

MSF provided healthcare to people living in thecamps, and in other settlements in the Andhra
Pradesh region. MSF conducted more than
55,000 consultations.
In Jammu and Kashmir, MSF carried out basic
healthcare and psychosocial counselling to a
population traumatised by over 20 years ofviolence. MSF has worked to increase awarenessof psychosocial problems and in 2009 morethan 5,800 people were treated on the mental
health programme. MSF also provided support
to six clinics in Kupwara, conducting more than
20,500 consultations.
Healthcare for kala azar and malnutrition
In the Vaishali district in Bihar state, MSF treatedmore than 2,000 patients for the deadly parasitic
disease kala azar. In Darbhanga, teams cared forchildren aged between six months and five years
who were suffering from acute malnutrition.
Emergency response
In 2009, MSF assisted the state governmentsof Meghalaya and Tripura in response tooutbreaks of meningitis. MSF also responded
to the Cyclone Aila emergency in West Bengal
State, distributing relief items and setting up
a medical surveillance system in the worstaffected districts to prevent possible outbreaksof disease. In October, MSF responded to thefloods in Andhra Pradesh and distributed relief
items to 60,000 flood victims.
MSF has worked in India since 1999.

MSF PROJECTS AROUND THE WORLD – ASIA & THE CAUCASUS – INDIA

JukelhaA 40 year old mother of six, who has
kala azar.
‘I was really sick. I had fever and pain
and I didn’t feel like eating. However,after my third dose of treatment I
began to feel much better. I couldn’t
even walk when I first came here. My
mother had to help carry me to thebus. I’m from a village about sevenand a half miles away from this healthcentre. I have to come every day forthe treatment. MSF staff told me about
the sand flies and the disease. I didn’tknow anything about this but I knowthat other people got sick from it in ourvillage. Our neighbour got sick from it
six months ago and he came here fortreatment too.’ASIA & THE CAUCASUS

Indonesia
REASON FOR INTERVENTION• Natural disaster

MSF first started working
in Indonesia in October 1995,
when it provided emergency
aid to the victims of adevastating earthquake in
Kerinci, Sumatra.

medication for diseases such as malaria,
tuberculosis and HIV/AIDS, as well as
general healthcare, surgery, vaccination
campaigns, sanitation programmes andtraining of staff.
After the Asian tsunami in 2004, MSF
refurbished 28 health facilities, conducted
more than 40,000 medical consultations andprovided 2,000 individual counselling sessions.
In 2008 it was clear that the Indonesian
government’s capacity to deal with natural
disasters had considerably increased. Most
internal conflicts had been resolved or had
subsided and a large proportion of thepreviously displaced people had been able
to resettle. Therefore the MSF projects werehanded over to local authorities and partners,
a process that was completed by March 2009.

Sumatra earthquake
On September 30, a powerful earthquake
hit the Indonesian island of Sumatra leaving
more than 1,000 people dead. MSF returned
temporarily to provide survivors withemergency medical assistance via mobile
clinics in some of the most neglected rural
areas, as well as water and sanitation facilities
and psychological care. Teams distributed
essential relief items such as hygiene kits,
kitchen utensils, blankets, mats and plastic
sheeting to 1,600 families.
MSF has worked in Indonesia since 1995.

© Juan-Carlos Tomasi

Since then, MSF responded to various
natural disasters and epidemics until
March 2009, when it withdrew due tothe Indonesian government’s increased
capacity to deal with natural disasters.
Before the withdrawal, MSF had worked
throughout Indonesia including informer conflict zones such as Aceh andAmbon. Teams provided treatment andField Staff 11

MSF staff walk through an area destroyed by the earthquake that struck the island of Sumatra in September 2009.
MSF PROJECTS AROUND THE WORLD – ASIA & THE CAUCASUS – Indonesia

47

ASIA & THE CAUCASUS

Kyrgyzstan
The prevalence of TB is still 20
to 30 times higher in prisons
than it is in the general
population: 500 new cases ofthis infectious disease areregistered each year despite
recent prison reforms.
Around two-thirds of those infected havedrug-resistant forms of the disease (DR-TB)
that require a particularly long and difficult
treatment programme. In recent years, MSF
teams have put greater emphasis on ensuringthat ex-prisoners are able to continue theirtreatment correctly after release.

In 2007 MSF opened a ‘social support’ office inthe south of the country to help ex-prisoners. In
2009, social workers and a network of volunteers
supported around 100 former inmates to continue
their TB treatment, through counselling, provisionof food parcels and transport money.
To highlight the poor living conditions ofprisoners and to fight against the disease, MSF
organised a photography exhibition in the capital
Bishkek to raise awareness about the issue and to
reduce the stigma surrounding it.
An important step in the fight against TB in
Kyrgyzstan was made when the country’s
application to the Global Fund’s Round 9 offinancing was approved in 2009. It included
funding for medication for multi-drug resistantField Staff 52

forms of TB (MDR-TB) and for systems to be set inplace to ensure that former prisoners can adhere
to their treatment after their release. However, thisfinancial aid was put on hold because of an audit
investigation, and now an adequate supply of
drugs is jeopardised because of a lack of funding.
MSF has worked in Kyrgyzstan since 2005.

RuslanAn ex-prisoner who suffered drug-resistant TB‘It was like a nightmare; you can’t imagine howdifficult it was to take those drugs. You wantto sleep but you can’t, you feel dizzy, you feelnauseous... you vomit, but you don’t feel any
better. I took the drugs even though I felt awful,
but my former cell-mate couldn’t keep going:for him the side-effects were too much. I was
released in May 2008, right in the middle of
my treatment. While I was in prison, the social
workers explained to me how I could continue
treatment in the civilian sector. But when I got
to the hospital, the doctors looked at me withsuspicion. “Ex- prisoner... drug dealer,” theysaid. But after a while, because of my good
behaviour, their attitude towards me changed.’© William Daniels

MSF works with the Ministry of Health, the prison
authorities and international organisations including
the International Committee of the Red Cross to
support the treatment of TB in prisons. In 2009,teams treated more than 400 prisoners for TB
including 92 patients for the drug-resistant form.
MSF teams organised training sessions and supplieddrugs, constructed laboratories and refurbished theprisons’ hospitals and the patients’ living quarters.

With TB, one of the challenges is in maintaining
continuity of treatment, because once
interrupted, there is a risk that drug-resistancecould develop. In Kyrgyzstan, one out of threeprisoners with TB is released before treatment
is complete. Outside the prison system, former
inmates often struggle for the bare necessities oflife, and so do not see the continuation of their
medication as their highest priority. Furthermore
they may not have the money to reach thenearest TB facility.

REASON FOR INTERVENTION• Healthcare exclusion

A doctor talks to a prison inmate with TB.
48

MSF PROJECTS AROUND THE WORLD – ASIA & THE CAUCASUS – KYRGYZSTAN© MSF

ASIA & THE CAUCASUS

An HIV patient is visited by a staff member who is also HIV positive and on ART treatment.

MyanmarREASON FOR INTERVENTION• Endemic / Epidemic disease• Healthcare exclusion• Natural disaster
Field Staff 1,189

A health crisis, exacerbated by devastating diseases such as malaria,
HIV/AIDS and tuberculosis ( TB ) has developed in Myanmar.
The government spends just 0.3 per cent of
its GDP on healthcare, the lowest percentage
worldwide, and international aid to thecountry remains completely inadequate atjust $3 per person per year.
MSF has been working to provide antiretroviraltherapy (ART) to people with HIV/AIDS and totreat those with TB and malaria.
Malaria is one of the biggest killers in Myanmar
because there is so little access to effective andaffordable diagnostic tools and drugs. In 2009,
MSF treated approximately 160,000 people formalaria in Rakhine State.
Prevalence of TB is also high: the latest
government figures report 134,000 known
cases. Because the national TB programme
is underfunded, there are sometimes
interruptions in the supply of medicines.
Patient’s treatment is in turn interrupted,
which increases their drug-resistance andreduces the effectiveness of the drugs. MSF
continued to treat patients co-infectedwith HIV and TB throughout the year, andin July initiated the country’s first multidrug-resistant TB programme in Yangon incollaboration with the Ministry of Health.

HIV/AIDS kills thousands of people every year in
Myanmar because so little antiretroviral therapy(ART) is available. As many as 76,000 people
are living with HIV, but only 20,000 people
receive treatment, mostly from MSF. In Shan,
Kachin and Rakhine states and in Yangon, thecountry’s largest city, MSF runs 17 HIV clinics,
nine health centres and more than 30 malaria
field posts. MSF also provides TB and HIV
treatment and general healthcare programmes
in both the rural and urban parts of the Dawei
and Myiek districts in the south of the country.
The programmes offer help to 700,000 people
and target in particular more vulnerable people
such as migrant workers and fishermen in thearea. Last year, MSF supplied more than 14,300
people with ART.
Throughout 2009, MSF continued to lobby
strongly for an increased response from thegovernment and the international community
to address the HIV/AIDS crisis.
The MSF mental health programme thatassisted victims of the 2008 cyclone ‘Nargis’
closed in May, as emergency needs diminished.
Between January and May 2009, 17,000 people
received counselling.

Tin
A 29 year old mother living in Dawei,
is HIV-positive and has TB.
It took Tin a month to find diagnosis andtreatment for TB. After visiting two private
clinics, she went to an MSF clinic andreceived free TB care.
‘I was feeling very tired and couldn’t work,’
she said. ‘My mother is taking care ofme now and MSF’s counsellor visits me
regularly. I need to go to the clinic once amonth and if I can’t afford the transportcost, MSF covers this for me. MSF also gives
me food such as rice, beans, salt and oil. It
helps a lot and I have gained some weightand I feel better. They explained about TB
with a chart and told me it’s very importantto take my treatment until the end. When I
got to the MSF clinic, they screened all thefamily members for HIV and TB. It turned
out that my four-year-old daughter also has
TB, and is also HIV-positive. She has been
taking TB treatment for two months now.’

MSF has worked in Myanmar since 1992.

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ASIA & THE CAUCASUS

Nepal

REASON FOR INTERVENTION• Armed conflictField Staff 101

Between 2002 and 2009, MSF teams provided healthcare to people still affected by the
conflict between government forces and the Communist Party of Nepal which lasted from 1996
until 2006, and by the resurgence of violence that accompanied a chaotic peace process.
MSF worked where help was most needed,
including in general and reproductive
healthcare and water and sanitation provision.
Despite Nepal’s struggles with political stability
since the peace process, MSF is now leaving
the country as government agencies anddevelopmental organisations start to take alonger-term approach to covering the people’s
health needs. Capacity-building and training on

the job are consequently key objectives in theremaining MSF projects.
Teams worked to increase knowledge about
reproductive health and called for better accessto good-quality public health services. Througha number of national radio announcements andeducation at local level, MSF also addressed
the issue of oxytocin misuse. The drug, used
to stimulate contractions in pregnant women,

is widely misused. This can result in foetal andneonatal deaths, and in ruptures of the uterus.
The drug can be used safely in small doses if
the baby is overdue, but in Nepal it is common
to take high doses to try to induce a birthprematurely, especially to make the birth takeplace on a religiously significant date.
In May, MSF handed over programmes in theisolated mountainous Kalikot district. Up until
then MSF had offered general healthcare,tuberculosis treatment, and emergency services
with a special focus on care for pregnant
women and children under five. In 2009, MSF
carried out more than 10,000 consultations andassisted with 192 deliveries.
In December, MSF handed over its last remaining
programme in the Terai region of Nepal,
which provided medical services, emergency
consultations, maternal healthcare, and treatmentof acutely malnourished children. In the areas
affected by internal unrest, MSF used mobile
clinics in the most neglected areas and transferredpatients needing more care to its facility at Gaur
District Hospital. MSF carried out more than
10,000 consultations and assisted more than
1,300 deliveries.
In the areas where it worked, MSF leaves
behind an improved level of care for mothers
and newborns, and better trained staff.
Since 2002, MSF provided more than 30,000
consultations, antenatal care to 6,000 women andtreated around 2,000 malnourished children.
MSF has worked in Nepal since 2002.

Ranjana© Corb!no23 years old

Kalakot, Napal. A patient receives treatment for injuries to his hands.

50

MSF PROJECTS AROUND THE WORLD – ASIA & THE CAUCASUS – NEPAL

She was brought into Gaur District
Hospital in the Rautahat district by herhusband. She was about to deliver her firstbaby and was experiencing complications.
On examination, MSF doctors discoveredthat her uterus had ruptured. Doctors
realised that Ranjana had taken oxytocin,
a drug available over the counter that isused to stimulate uterine contractions.
Ranjana and her baby survived, but she
lost so much blood that she needed tohave a blood transfusion and her uterus
had to be removed.

ASIA & THE CAUCASUS

Pakistan
REASON FOR INTERVENTION• Armed conflict• Endemic / Epidemic disease• Healthcare exclusion

Field Staff 819

More than two million people have been
displaced by the armed conflict in the
North West Frontier Province (NWFP)
and in the Federally Administered Tribal
Areas (FATA). Despite the difficulties, MSF
offered emergency medical and relief
services in more than 12 sites in NWFP,
FATA and Balochistan province. This
included healthcare to people woundedor displaced by fighting, and maternal andchild healthcare in some of the poorest
areas of the country.
In February, two MSF medical technicians were
killed as they travelled in an MSF ambulance on
their way to pick up civilians injured in fighting
in the Swat District of NWFP. This direct attack
and the continuing increase in hostilities in
the area led MSF to withdraw from the Swat
District. Later in the year, travel restrictions
prevented MSF teams from providing medical
support to communities displaced by fighting
in South Waziristan.
Critical care for displaced people
Local health structures in districts hosting
displaced families were overwhelmed bypatients, particularly in Mardan where around
one million displaced people settled as theyfled fighting in Swat. MSF supported referral
hospitals, health centres and mobile clinics.
In Mardan District alone between Juneand September, MSF provided emergency
medical care to more than 3,200 people,
treated 880 hospitalised patients and provided
more than 16,000 consultations. During thecholera season, MSF set up five treatment
facilities in the region and treated 4,500
patients. An additional 56,000 medical
consultations were carried out throughout theyear for displaced people living in Lower Dir,
Charsadda and Peshawar.
MSF teams also distributed basic relief
items to thousands of displaced families
and provided tents, latrines, and water andsanitation facilities to five camps hostingaround 23,000 displaced people.

© Jodi Bieber

In 2009 there was a rapid
escalation of violenceacross the country as
fighting intensified
and attacks on civilianbuildings increased.

A mother and daughter in their tent in a refugee camp having fled violence in Malakand.

Trauma treatment
Throughout the year, nearly 5,300 trauma
patients were cared for in the emergency
room of the main referral hospital of Lower
Dir, where MSF teams treat on average 4,000
patients each month. MSF also worked in all
departments of Dargai Hospital in Malakand
District, where surgical teams carried out
more than 880 surgical interventions with
Ministry of Health staff. Teams also support
Darband rural hospital of Mansehra District
and, in June 2009, started providing
medical consultations to the neighbouring
Kala Dhaka tribal area where the parasitic
disease cutaneous leishmaniasis is endemic.
In Kurram Agency, MSF donated medical
material to three hospitals to help treat warwounded, and carried out more than 2,000
paediatric consultations each month in Alizai
and Sadda hospitals.
Improving mother and baby care
Pakistan has one of the highest infant andmaternal mortality rates in the region.
Women and children tend to be mostaffected by the shortage of medical staff andunaffordable health services, particularly inremote rural areas. MSF strives to have female
medical staff to provide healthcare to womenpatients in nearly all of its medical activities.
In Balochistan in particular, teams havedeveloped an extensive mother-and-childhealthcare programme. In Kuchlak, Chaman
and in the eastern districts of Nasirabad andJafarabad, teams carried out 18,000 antenatal
consultations, helped with 4,000 deliveries
and treated nearly 5,000 malnourishedchildren. An additional 110,000 consultations
were also carried out.
MSF has worked in Pakistan since 2000.

Patient story
Woman displaced by fighting in Bajaur‘My husband was killed in crossfire. I
was preparing a meal for him when myneighbour told me that he had died.... I was very worried for my children
and wanted to leave but I did notknow how or where to go and there
was continuous shelling. After a few
days one of my neighbours agreed tocome with us, so we left home andtook nothing except the clothes wewere wearing. We walked for a day anda night until we found some families
already travelling in trucks. We joined
them and reached Peshawar by truck.’

MSF PROJECTS AROUND THE WORLD – ASIA & THE CAUCASUS – Pakistan

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ASIA & THE CAUCASUS

Papua New Guinea• Endemic / Epidemic disease• Healthcare exclusion

Field Staff 79© Nathalie Muffler

REASON FOR INTERVENTION

Lae, Papua New Guinea. Outreach workers talk to the community about the problem of domestic violence which particularly affects women and children.

The people of Papua New
Guinea are caught in aself-perpetuating cycleof violence. The rapid
development of the country
in recent years has had
the unintended consequenceof aggravating existingtensions.

For the most part, it is women and children
who bear the brunt of this, suffering rapeand other forms of violence - that creates
an urgent need for both medical care andpsychosocial support.
In addition, infectious diseases claim many
lives, there are serious public health risks
from endemic diseases such as malaria, andan emerging HIV/AIDS epidemic. Healthcare
provision however, remains limited.
In the coastal city of Lae, MSF worked incollaboration with the Ministry of Health toprovide care for survivors of sexual and domestic
violence. MSF also began integrating medical carewith psychosocial care and in 2009 more than
2,500 people received counselling.
In the Southern Highlands, MSF has been
supporting the district hospital of Tari toaddress the physical and psychosocial needsof survivors of domestic and other types ofviolence. MSF also managed the operating
theatres and water and sanitation facilities in

52

MSF PROJECTS AROUND THE WORLD – ASIA & THE CAUCASUS – PAPUA NEW GUINEA

the hospital. Psychological counselling andsupport for emergency obstetric patients werealso provided.
In December, the international team was
temporarily withdrawn after some members
were threatened in the Tari hospital, thoughnational staff continued to work with Ministryof Health doctors. International staff began toreturn at the end of the year. Overall, morethan 650 medical procedures were performed
throughout the year, including more than 240
major surgeries, and more than 150 people
received counselling.
Cholera outbreak
MSF set up several emergency centres to treat
the first cholera outbreak to have affected
Papua New Guinea in 50 years. Teams helped
train hospital staff to implement a choleraintervention programme and treat patients.
MSF has worked in Papua New Guinea
since 2009.

ASIA & THE CAUCASUS

Philippines

REASON FOR INTERVENTION• Armed conflict• Natural disaster
Field Staff 76

Mindanao Island in the southern Philippines has been at the heart of an armed conflict
between Philippine government forces and the Moro Islamic Liberation Front since the1970s. In the summer of 2008, between 400,000 and 500,000 people fled the area toescape the violence, and despite the announcement of a ceasefire in July last year,
some 300,000 people remain displaced. The country can barely cope with such numbersof displaced people.
MSF provided medical care via mobile
clinics and supported existing healthstructures for an estimated 70,000
displaced people in five camps in Region
XII and in the Autonomous Region in
Muslim Mindanao Region. Teams focusedon helping people who were particularly
vulnerable or not well-served by local
medical centres.
Throughout 2009, MSF provided almost
43,000 consultations including 1,500 for
pregnant women.

Natural disasters
In September and October last year, thePhilippines were hit by a series of typhoons
that caused widespread damage and floods
in and around the capital Manila, and on thenorthern island of Luzon.
MSF helped improve living conditions in thecamps for those who had been displaced, bybuilding latrines and strengthening hygiene
and sanitation services. Mobile clinics wereused to reach people in need of medicalcare in the camps and surrounding areas.
Teams also used boats to reach parts of thecity where people had been cut off by thefloodwaters. In total, 4,300 consultations
were carried out.

© Benoit Finck

In March, MSF psychologists started a mental
health programme to help the many people
who were suffering from psychologicalproblems and showing psychosomatic
symptoms due to stress. In collaboration withthe psychiatric unit in Cotabato hospital in the
Mindanao Region, MSF started treating patientswith severe mental health disorders. More than
2,100 patients received psychological support
and psychiatric treatment.

Manlia, Philippines. An MSF team registers people staying at a temporary camp set up after
several typhoons and tropical storms.

In northern Luzon, MSF intervened in Ilocos
Norte, Cagayan, Pangasinan and Tarlac
provinces and conducted more than 3,400
consultations. In Rosales, where waterfrom local dams flooded and destroyed thesurrounding area, MSF helped by distributing
relief items, including plastic sheeting,hygiene and construction kits. MSF also
assisted the victims of landslides caused by
weeks of heavy rain in Benguet.
MSF has worked in the Philippines since 2008.

Ramon
30 years old‘Everything happened so quickly.
It was terrifying. I was in my housewhen suddenly I heard a bomb
exploding. At first, I didn’t realise what
was happening, but later I realisedthat a bomb had fallen on my house.
Outside, everybody was runningaround, and some people were looking
at me strangely. I felt very tired and I
was in a lot of pain so I lay down. Later,some people told me that I had been
covered with blood and that they had
thought I was dead. However, someone
was able to feel my heart beating
and so they brought me to the healthcentre. I had two pieces of shrapnel
in my stomach. The doctors thentransferred me to the general hospital in
Cotabato where I stayed for nine days.
‘Later, when I was back with my family,
I went to the MSF mobile clinic to getsome drugs. The doctor advised me
to meet a psychologist, which I did.
Then I realised that I was still in shock
because of what had happened andthat I needed support. Now, my wounds
still hurt me and I very often think
about what I’ve been through, but I am
feeling better.’

MSF PROJECTS AROUND THE WORLD – ASIA & THE CAUCASUS – Philippines

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ASIA & THE CAUCASUS

Sri Lanka
REASON FOR INTERVENTION• Armed conflictField Staff 347

Rajasekaran
29 years old, married with two children© Marit Helgerud‘After doctors told me I would never
be able to walk again, I lost all hope. I
spent my days lying in a hospital bed,
which caused painful pressure sores that
became infected. I was embarrassed that
I was unable to control my bladder andbowel movements and that I was entirely
dependent on others and could notprovide for my family.

Menik Farm camp, Sri Lanka: A nurse treats people displaced by the war between Sri Lankan
security forces and the separatist Tamil Tigers.

The decades-long civil war
between the Sri Lankan
security forces and theseparatist Tamil Tigers(Liberation Tigers of Tamil
Eelam) came to an end in
May 2009.
During the final phase of the bitter
conflict, tens of thousands of civilians weretrapped on a narrow strip of beach andjungle in the northeast of the country withlittle or no access to healthcare.
In 2009, surgical teams worked in hospitals in
the north of the country to treat those who
had escaped the war zone. MSF also helped
to provide clean water in government-run
camps for 300,000 displaced people andprovided supplementary feeding for around
10,000 undernourished people.
From mid-April till the end of May, thousandsof people managed to escape the conflictarea. Many needed medical assistance aftermonths of limited access to it, and others
needed treatment for severe injuries inflicted

54

by shrapnel, gunshots or landmines. Hospitals
in the area treated as many civilians as they
could, but the numbers were overwhelming.
On April 21st, in just one 36-hour period,
more than 400 patients were treated for lifethreatening conditions in Vavuniya hospital.
Overall, MSF treated almost 4,000 warwounded between February and June.
More than 150 MSF staff supported patients,
many of whom had been separated from theirfamilies. Medical teams also cared for morethan 60 patients with spinal-cord injuries whoneeded rehabilitation.
Many displaced people were malnourished,so in February, MSF started to distributesupplementary food daily to every child underfive years old, as well as to pregnant andlactating women and the elderly. In August, atthe peak of its activity, the programme reachedmore than 26,000 people.
In late May, MSF was authorised to open a
160-bed referral hospital in Vavuniya withan inflatable operating theatre and surgicalfacilities. It was set up just outside thegovernment-run Menik Farm camps that house
hundreds of thousands of people displacedby the conflict. Between May 2009 andJanuary 2010, there were more than 4,200
admissions. Teams performed more than

MSF PROJECTS AROUND THE WORLD – ASIA & THE CAUCASUS – SRI LANKA‘I signed up to the MSF rehabilitation
programme for patients with spinalcord injuries in November and now nolonger feel so depressed about my future.
After physiotherapy, nursing care, andmedication, I am now out and about inmy fitted wheelchair, can wash and dress
myself and go to the bathroom alone.
I hope to continue my work as a motor
mechanic and learn more English.’1,600 surgical procedures and more than
13,500 consultations. A further 850 people
were treated for war-related injuries, and 200
patients began receiving psychological support
after conflict-related trauma.
Towards the end of the year, people detainedin the government camps were released, andmedical needs decreased. By the end of 2009,
around 100,000 people remained in thecamps and government health facilities wereable to cope, so activity at the MSF hospital
was scaled down. It was closed in January
2010.
Throughout the year, MSF also supported
surgical, emergency and obstetrictreatment for patients at the Ministry of
Health hospital at Point Pedro in Jaffna
district. Healthcare needs in the district on
the northern tip of the island started toincrease in October, because around 70,000
people who had been displaced by the war
returned. MSF performed more than 2,000
emergency consultations and 1,300 surgicalinterventions. The hospital psychologicalsupport team carried out 430 consultations.
MSF has worked in Sri Lanka since 2007.

ASIA & THE CAUCASUS

ThailandREASON FOR INTERVENTION• Endemic / Epidemic disease• Healthcare exclusion

Field Staff 85

For decades Thailand has been a magnet for economic migrants and asylum seekers
fleeing poverty or political unrest in the surrounding regions.
The country introduced a Universal Health
Coverage Scheme in 2001, and although thenational healthcare scheme was extended toinclude registered labour migrants, it does
not cover those who are undocumented.
These people make up more than threequarters of the total migrant population andusually cannot afford treatment. MSF has
been working to help such migrants, and has
been continuing to give medical assistanceto displaced people and marginalised ethnic
minority groups.
Cross-border activities
MSF continued to support people living in New
Mon State (Myanmar) throughout 2009. Alongthe border with Thailand, the area enjoys semiautonomy and has its own health authority but
it lacks drugs and equipment. The Mon people
live in small, scattered and remote villages. The
MSF programme focuses mainly on treating
and preventing malaria, which is endemic here.
Teams train village malaria workers and support
local health centres. In 2009, MSF distributed
more than 1,400 bed nets and carried out
3,700 consultations.

Hmong refugees
Having worked in the refugee camp for four
years, MSF ended its activities in May 2009
because the Thai army attempted to empty
the camps by forcibly repatriating the Hmong
people to Laos. In addition, the army increased
restrictions on access to medical treatment andfood to pressurise refugees to return, which
reduced MSF’s ability to work.
MSF repeatedly denounced the Thai and Laotian
government’s policy of forced repatriation andcalled for an independent third party (the UN
High Commission on Refugees – UNHCR) to be
involved to help guarantee the refugees’ rights
and safety upon their return to Laos.
Before leaving, MSF had conducted 11,200
consultations, mainly for diarrhoea and respiratory
and skin infections, and provided psychologicalsupport to people suffering from stress, anxiety
and depression. MSF also provided family© Espen Rasmussen

In March 2009, drawing on its experience in New
Mon State, MSF began training Thai medical staff

operating in the remote areas of Kayah State,eastern Myanmar, near the border with Thailand.
These staff have direct contact with isolated ethnic
minorities hiding in the jungle who have no accessto healthcare. MSF also donated malaria treatment
and diagnosis kits.

Mae La refugee camp in Thailand, at the border to Myanmar, which houses more than
30,000 refugees.

planning and immunisation programmes for
pregnant women and children.
After MSF’s departure, camp activities werehanded over to a local non-governmentalorganisation with the support of UNICEF. At
the end of 2009, the Thai government forcibly
repatriated more than 4,000 Hmong from thecamp, without involving UNHCR.
HIV handover2009 marked the end of MSF’s HIV/AIDS
projects with the handover in July of its last
programme in Phang Nga, southern Thailand.
MSF has been working in Thailand since 1976.

YH
22 years old
She used to live in the forests of
Xiangkhouang province in Laos. She
fled to Thailand in May 2005 after
five cousins and two sisters were killedduring attacks on her family. She lives
with her husband and their three-yearold daughter in Huai Nam Khao.
‘I lived all my life in the forest in Laos. Laoand Vietnamese soldiers chased us all thetime. Soldiers killed my family members.
Sometimes the planes attacking us would
drop bombs that produced a poisonous,
yellow-coloured gas. We would have to
run and hide among the trees. I saw a lotof people die. During one attack, one of
my younger sisters breathed in poisonous
gas and she passed out. My mother had
to carry her.
‘My husband decided we could nolonger stay in the forest and that weshould come to Thailand. All we had
when we arrived was my husband’s
Hmong knife that he used to dig forroots. We started to receive food from
MSF. Ever since we fled Laos our life has
improved because we have had foodto eat and we don’t have to hide fromattacks. But I am so afraid that we will
be sent back to Laos. I don’t want to besent back to Laos to be killed. Everyone
is saying we are going to be sent back.’

MSF PROJECTS AROUND THE WORLD – ASIA & THE CAUCASUSA – Thailand

55

ASIA & THE CAUCASUS

Turkmenistan
REASON FOR INTERVENTION• Healthcare exclusion

Despite the fact that
Turkmenistan is rich in oil
and gas reserves, many
people lack access to goodquality basic healthcare.
The government actively promotes anadherence to international healthcare
standards in order to uphold a façade ofprosperity while the true picture of publichealth concerns remains hidden, andhealthcare workers are unable to provide
adequate care.

Field Staff 57

The existence of HIV/AIDS is often denied byauthorities, and the relatively high prevalenceof communicable diseases such as tuberculosis(TB) and sexually transmitted infections do notreceive adequate attention in the health centres.
MSF worked in Magdanly District Hospital in
the east of the country supporting paediatricand reproductive healthcare from 2004 until
September 2009. The project supported morethan 1,600 hospitalised children and assisted
more than 780 deliveries. However, having
come to a limit of what could be achieved inthis programme, MSF decided to close theproject in September 2009.

MSF had planned to start a new project to treat
Multi-Drug Resistant Tuberculosis (MDR-TB) andHIV co-infected patients. So far, MSF has not been
granted permission to start or be involved in acomprehensive MDR-TB programme, despite thefact that Turkmenistan has no such programmein place and that drug-resistance rates arecomparatively high. Negotiations have beenslow: they started in summer 2008 and continued
until the end of 2009. Therefore, MSF closed its
operational presence in December 2009, but
stays committed to reengaging and assisting the
Turkmen population as soon as an agreement canbe reached.
MSF has worked in Turkmenistan since 1999.

Uzbekistan
REASON FOR INTERVENTION• Endemic / Epidemic disease

The incidence rate oftuberculosis ( TB ) in
Uzbekistan is one of
the highest in the world.

Field Staff 95

This is most evident in the Autonomous
Republic of Karakalpakstan in thenorthwest of the country.
MSF’s project in this region sees high rates
of drug-resistant tuberculosis (DR-TB).
However, the appropriate tools for diagnosis

and treatment are only available frominternational organisations such as MSF.
Throughout 2009, MSF focused on improving
infection control and supplying patient careand treatment. Great concern still remains
however, regarding the high proportionof people who fail to finish the treatment
programme for DR-TB, which requires along course of medication with difficult
side effects.

© Donald Weber

MSF’s experiences in Uzbekistan highlightthe insufficiency of current diagnostics
and treatment methods in treating DR-TB
properly. MSF has called on governments
and international organisations on several
occasions to increase their research anddevelopment activities. The National
Tuberculosis Programme in Uzbekistan has
admitted that it is unable to tackle the DR-TB
epidemic alone.

Nukus, Uzbekistan. A doctor holds in her hand a sample of the daily dosage of medicationneeded to combat multi drug-resistant TB.

56

MSF PROJECTS AROUND THE WORLD – ASIA & THE CAUCASUS – TURKMENISTAN / UZBEKISTANIn 2010, MSF will begin to establish
comprehensive TB care, providing diagnostics
and treatment for all patients in all districts of
Karakalpakstan, together with the Ministryof Health.
MSF has worked in Uzbekistan since 1997.

© Yuri Kozyrev / Noor

AMERICASSan Francisco de Asis hospital, Columbia. Carmen, 31 years old and her husband Moyses caring for their newborn son.

58 BOLIVIA
59 Brazil
60 COLOMBIA
61 GUATEMALA
62 Haiti
64 HONDURASAMERICAS© Anna Surinyach

AMERICASA child being tested for Chagas.

Bolivia
One hundred years after
the discovery of Chagas, apotentially fatal parasitic
disease, access to diagnosis
and treatment is still
limited in Bolivia and there
is almost no treatment
offered to people over
15 years old.
MSF is treating both adults and children andis lobbying for wider access to treatmentin the country. MSF launched a ‘Break the
Silence’ advocacy campaign in 2009 to callon governments of all countries where
Chagas is endemic to fight the disease.

58

REASON FOR INTERVENTIONIn October 2009, MSF started working in rural
Cochabamba in the heart of Bolivia, one of theareas in the country with a higher rate of Chagas.
MSF is working with the rural communities on
the prevention, diagnosis and treatment of thedisease. Of the 700 adults and children who were
tested here for Chagas, more than 300 tested
positive. Two thirds of these people completed
the 60-day treatment successfully.
In Cochabamba there is a high presence ofvinchuca beetles that can be found in people’s
homes and which transmit the disease tohumans. MSF is working to implement a
new strategy of insect control and is raisingawareness among the population of thepossible risks.
MSF also supports a programme in the capitalof the Cochabamba department in collaboration
with the Ministry of Health. The programme
works to integrate assistance for Chagas patients
into the national public health system.

MSF PROJECTS AROUND THE WORLD – AMERICAS – BOLIVIA• Endemic / Epidemic disease

Field Staff 36Laura
39 years old and lives in Cochabamba town.
Seven years ago she found out she had
Chagas disease but the parasite hadalready seriously damaged her heart andshe needed a pacemaker. ‘I could barely
walk a block without getting tired. I went
to the doctor and I had a blood test
and a full check-up and they found out
I had Chagas. From that moment I kept
worrying about the disease.
I went to MSF and the doctor said it was
too late to receive treatment, so there wasno option but to get a pacemaker fitted.’

MSF has worked in Bolivia since 1986.

AMERICAS

BrazilREASON FOR INTERVENTION• Social violence / Healthcare exclusion

Field Staff 51

Approximately 170,000 people live in Complexo do Alemão, which is a conglomerate ofeleven poor communities in Rio de Janeiro, Brazil. Like hundreds of other slums in Rio,
it is controlled by heavily armed groups that traffic drugs in the area.
Violent clashes can erupt at any time,
anywhere, as a result of police incursions
or fighting between rival groups. Besides
physical wounds, the effects of theviolence also leave psychological scars.
MSF offered emergency medical care andpsychological support to the residents
from 2007 until the end of 2009, when alocal organisation took over the activities.
After a series of violent clashes between
police forces and armed groups in 2007,
during which residents caught in the crossfire had no access to emergency medicalcare, MSF started a project in Complexo doAlemão. Even in peaceful times, ambulances
do not enter slums such as these, leaving
residents with little or no life-saving
assistance. The MSF project aimed atproviding much-needed help right inside thecommunity, where no other medical service
was available, even at times when violence
was at its peak. To enable rescues andreferrals, MSF converted a van into a basic
ambulance narrow enough to go through thealleyways and roadblocks. In two years, MSF
provided 19,000 medical consultations andundertook 650 emergency rescues using thecustomised ambulance.
Having established a presence inside thecommunity, MSF teams recognised amuch less visible facet of the violence: thepsychological scars it leaves on both adults
and children. Although mental health services
were part of the project from the start, they
have become a crucial component of theassistance provided. Through individual
consultations, a team of psychologists
helped residents cope, and many for the firsttime in their lives took the opportunity to
express their suffering in a professional andconfidential environment.
Between 2007 and 2009, MSF gave morethan 3,000 psychological consultations to
1,300 patients in the area. Psychosomatic
complaints, depression and anxiety are
the most common symptoms found in
adults, whereas in children aggressiveness,behavioural problems and learning difficulties
are common. Half the patients seen by MSF’s
psychologists had a story of violence to tell.
More than one third had been in a situation of
conflict, and one in five patients reported thata family member of theirs had been killed.
After two years of activities, MSF ended its
presence in Complexo do Alemão at theend of 2009. The decrease in violent clashes
in the community and the creation of newhealth services nearby that are available forall residents meant MSF’s emergency role
was no longer needed. By the end of 2009,
negotiations were in place with a localorganisation willing to take over the services
established by MSF, ensuring continued
medical and psychological care for the
residents of Complexo do Alemão.
MSF has worked in Brazil since 1991.

Patient story©©
Yuri
Kozyrev/ NoorDavid
Prichard

A patient at the MSF clinic.
‘My brother was killed in the community
when he was 16 years old and eversince I have suffered from depression.
There were times when I didn’t want toleave the house, I didn’t want to talkto anybody, I was completely isolated.
Twice, I wanted to kill myself. Then I lost
my daughter in an accident. I just wanted
to die. It was during one of these crisesthat I found out there were psychologists
here at the clinic and I was able to findthe support I needed to carry on living.’

Complexo do Alemo, a poor area of Rio de Janeiro controlled by armed drug dealers. Here,MSF supports the population trapped by violence.

MSF PROJECTS AROUND THE WORLD – AMERICAS – Brazil

59

AMERICAS

Colombia
The conflict between
guerrilla groups andgovernment forces has
been going on for 40
years in Colombia.
Paramilitary groups that were supposedly
demobilised have re-emerged in many areas
across the country. Many people have moved
from rural areas to towns to escape theinsecurity, but end up living in poverty withlittle access to care. MSF has been providing
healthcare to those affected by the conflict
as well as treating people with Chagas
disease and offering maternal care.

Maternal care
More than 2,600 babies were born under MSF
care in the main hospital in Quibdó, the capitalof Chocó department, in 2009. Since this is thereferral hospital for complicated obstetric cases,
60 per cent of the deliveries involved Caesarean
sections. MSF also provided training for hospital
staff, and medical equipment. Elsewhere
teams set up fixed health posts to supplement
mobile clinic activities. By maintaining a regularpresence in some isolated villages on theriverbanks, MSF is able to offer better-quality
medical care, improve patient follow-up andstabilise emergency cases before referring them.
Overall, 6,300 consultations were carried out.
Emergency response
In the Tumaco municipality southwest ofColombia, the river Mira overflowed its banks in
February, disrupting the lives of 30,000 people.
Teams provided emergency healthcare in themost isolated areas and supplied medicine tothe main hospital in Tumaco town.
Back in 2007 MSF opened a trauma centre in
Buenaventura in response to increasing levels

Field Staff 327

of violence in the shantytown. As the situation
evolved, the centre broadened out its services tocover general healthcare needs and introduced amobile clinic service. However by 2009 demand
for the facility had decreased so the mobile service
finished and efforts concentrated instead on thehealth centre, which in 2010 may be relocated toanother area where the needs are greater.
Healthcare provision
MSF runs a boat-ambulance that serves
riverbank villages. In 2009 more than 14,500
riverbank consultations were carried out. In
December, the fixed health post and mobile
clinic activities on the San Juan river werehanded over to the municipality and MSF wasable to focus its activities on the Baudo river.
More than 6,300 consultations were carriedout in the department of Norte de Santander,
where MSF managed two clinics and several
rural mobile clinics. These included sexual andreproductive healthcare, mental healthcare
and care for survivors of sexual violence.
Nearby in the Bajo Atrato area, MSF also
provided healthcare services including nutrition
surveillance and mental healthcare to avulnerable and isolated community. MSF handed
over the mental health centre it was running in© anonymous

Conflict
Armed conflict escalated in Nariño, andaccording to official figures there were 12,400
displaced people between January and
September, by far exceeding the country’s
response capacity. MSF mobile teams worked to
improve access to healthcare for people affectedby the armed conflict and provided treatment

to those who were displaced. MSF conducted
more than 5,000 medical consultations overall.

REASON FOR INTERVENTION• Armed conflict• Healthcare exclusion• Natural disasterA young girl sits on an examination table, having received treatment for a wound to her forehead.
60

MSF PROJECTS AROUND THE WORLD – AMERICAS – COLOMBIAAMERICAS

MSF provided more than 8,000
consultations in the Cauca and Putumayo
departments, including medical andpsychological healthcare and promotion
and prevention consultations. The
programme supported the health network
in both departments by training staff,
supplying materials and refurbishingmedical facilities. At the end of the year,
MSF handed over the activities in Cauca to
the local authorities.
The disease Chagas is endemic in most
Latin American countries and, if left
untreated, can lead to serious healthproblems and eventually death. The Arauca
department in the northeast of the country
on the border with Venezuela has one of
the highest rates of Chagas in the country,with an estimated eight per cent of thecommunity infected. MSF carried out nearly
15,000 consultations via mobile clinics inrural and urban areas last year.
MSF has worked in Colombia since 1985.

Manuel40 years old, shop-owner in a rural partof the Nariño district‘Our life here is quiet; nothing usually
happens. However, a few months ago,
several uniformed men arrived looking
for a criminal they thought was in the
district. They entered the houses kicking
the doors open and forcing people out.
Everybody was very scared; nobody
understood what was happening.
They seized me and took me to thebush because they thought I wascollaborating with the criminal. They
threatened me with a gun and thena chainsaw to make me talk. I cannot
remember how long I was detained, but
I could not make them understand that
I didn’t know anything. When I was
finally released I left the area because
I was scared. Nearly all of us fled, butwhat could we do so far from our land?
Some people returned, but I couldn’t, I
was frightened. Then, when I saw MSF
was coming, I returned and managed totalk through my experience with them.’© Juan Carlos Tomasi

Florencia, the capital of the department ofCaquetá last year, although teams continue
to conduct mental health consultations inother administrative centres and provide
mental health support in rural areas.

Sexual violence is a huge problem in Guatemala, with 10,000 rapes reported in 2009.

GuatemalaREASON FOR INTERVENTION• Healthcare exclusion

Field Staff 33

According to the World Bank, about 51 per cent of
Guatemalans live on less than two US dollars a day and15 per cent on less than one US dollar.
Social development indicators such as
infant mortality, chronic child malnutrition
and illiteracy are among the worst in thehemisphere. Violent crime, including murder,
rape and armed assault, presents further
serious challenges with an average of 20
people being killed every day. In 2009, 10,000
cases of rape were reported to the Ministryof Justice.
Such a climate left national authorities withfew resources to devote to survivors of
sexual violence. To address this, MSF set up
a programme providing urgently needed
treatment in the capital Guatemala Cityin 2007. The centre now provides medical
and psychological assistance to 100 new
patients every month. Through education andinformation initiatives, teams are also making
the authorities, the medical community and
the Guatemalan public aware that sexual
violence is a medical emergency and that
effective treatment is available.
MSF works in local clinics in the two mostviolent districts, supporting the main referral
hospital in Guatemala City and teams also
run a mobile clinic. As a result of the local
education campaigns and national lobbying,

MSF’s services are now successfully integrated
into the public health system. One of the
future challenges is to persuade patients tocome to the clinic as soon as possible after anattack. Many treatments, including anti-HIV
medication are effective only if administered
within 72 hours of the assault. Althoughpatients who were attacked by individuals
unknown to them usually seek treatment early,
victims of interfamilial sexual violence tend not
to seek help until much later.
MSF has worked in Guatemala since 1984.

Maria
She was abducted by a criminal gang in
Guatemala City, taken to a house and raped.
Having managed to escape, she made her
way to the MSF clinic and arrived distressedand badly shaken. ‘I was terrified, I didn’t
want to live,’ she explained. ‘MSF gave me
pills to protect me from HIV and injections toprevent other sexual diseases.’ Psychologists
also helped Maria find coping mechanisms todeal with the mental trauma.

MSF PROJECTS AROUND THE WORLD – AMERICAS – Guatemala

61

AMERICAS

Haiti

Political stability in Haiti,
however weak, was achieved
with the election of a new
government in 2006. However,2009 was characterisedby rising food prices,chronic unemployment, anda dysfunctional healthcare
system.

•Social violence / Healthcare exclusion

Women’s health
In 2009, a surge in the number of births
prompted MSF to move its maternity hospitalin Port-au-Prince to a larger facility known as
Maternité Solidarité. To avoid any duplication of
public health services, MSF focused on helping
women who were experiencing complications,and transferred those with straightforward
pregnancies to government-run centres in thecity. MSF also managed the provision of antenatal
care in three slum locations in the capital, carryingout 1,500 consultations a month. Since theemergency obstetric programme was openedin 2006, more than 40,000 babies have beendelivered, clearly indicating the huge need formaternity care in the slums.
Emergency trauma care and training
At Martissant Emergency Centre, MSF provided
life-saving medical care in one of the most poverty
stricken neighbourhoods of Port-au-Prince, where
400,000 people live. Opened in 2006, the project
was created to respond to medical needs resulting
from the high level of armed violence in theMartissant area. Today, although armed violence
has decreased, the medical needs remain huge. In
2009, MSF teams performed more than 97,000
medical consultations for nearly 48,000 patients.
Over 60 per cent of the new patients were victims

Field Staff 849

of trauma, such as car accidents, and one in ten
was wounded as a result of violence.
In Martissant, patients with severe medical needs
were stabilised and those requiring surgery or
specialised treatment were transferred to othermedical structures, including MSF facilities in Portau-Prince, Maternité Solidarité and Trinité Trauma
Center. Referrrals to public medical structures
were difficult because the lack of personnel, poororganisation and high cost of services meant thatmany patients were left without the medical carethat they urgently needed. To increase the capacityof Martissant Emergency Centre, the number ofbeds in the centre was increased from 13 to 35 andshort term hospitalisation was also provided.
MSF provided comprehensive trauma care atits 75-bed hospital called the Trinité Trauma
Center. Here MSF introduced a programme
for internal fixation, a technique that enables
injured patients to walk again within acouple of weeks, instead of months. After theprocedure patients were transferred to Pacot
Rehabilitation Center for physiotherapy andfollow-up consultations. In 2009, nearly 10,000
patients were treated in the emergency room of
Trinité and over 4,260 underwent surgery.
MSF has worked in Haiti since 1991.

© Espen Rasmussen

Slum dwellers in the capital Port-au-Prince
continued to live in deplorable conditions.
Haiti has the highest level of maternalmortality in the western hemisphere (67deaths for every 10,000 live births). Poverty,
in combination with a mostly privatised
healthcare system, has compromisedmaternal healthcare for women living inslum areas. MSF was one of the main publichealthcare providers in Port-au-Prince before
the earthquake in January 2010, providing
obstetric, emergency and trauma care to
the inhabitants.

REASON FOR INTERVENTION

Port-au-Prince, Haiti. A nurse looks after a premature baby in MSF’s maternity hospital known as Solidarité.
62

MSF PROJECTS AROUND THE WORLD – AMERICAS – HAITIAMERICASHAITI: The 2010
earthquake response

MSF has been working in Haiti since 1991.
Immediately prior to January 12, MSF was
running three programmes - a maternity
project, a trauma and rehabilitation centre,
and an emergency stabilisation programme- all necessitated by the cumulative impact of
decades of violence and instability in a placewith limited medical and governmental
capacity. In the best of times, life in Haiti
was precarious, but the earthquake brought
unprecedented conditions. In a matter ofmoments, hundreds of thousands of people
were killed or injured and millions wererendered homeless. The organisations thatwould usually coordinate a disaster response- the Haitian government and the UN - were
badly hit themselves.
At the same time there were hundreds ofthousands of people in desperate needof help. As Dr. Jeanne Cabeza, a medical
coordinator for MSF in Haiti wrote, “Fiveminutes after the quake, people werebanging on our door.” A trickle of patientsquickly became a deluge. “Within a few
hours, there were hundreds of people in needof surgery,” Cabeza recounted.
She and her colleagues worked through thenight, attending to crush wounds, fractures,concussions, and other injuries. Care was given
in courtyards or in the streets in front of MSF
structures which had all partially collapsed.
Car headlights were used to illuminate
procedures. Sheeting was hung from trees andan old shipping container that had served asa pharmacy was cleared out to create adhoc
operating theatres. Veteran MSF staff likened it
to doing surgery in a war zone when everyone
is injured at the same time.

© Julie Remy

As the first reports camein about the destruction
caused by the earthquakethat struck Haiti on
January 12, within hours
its consequences becamedevastatingly clear, andMSF, who was already inthe country, launched its
largest emergency effort in
the organisation’s history.

A patient, who has suffered two broken legs, is cared for just outside Carrefour Hospital which
partially collapsed in the earthquake.

Simultaneously, MSF offices around the world
mobilised, launching what Dr. Greg Elder,
deputy operations manager for Haiti, later
described as “the single most concentrated
response by MSF.” Personnel, medication,
medical supplies, and even an inflatable
hospital were soon on its way. Whencongestion at the Port-au-Prince airport delayed
arrival, MSF re-routed cargo through the
Dominican Republic and lobbied coordinating
bodies to give priority to aircraft carrying lifesaving emergency medical equipment which
they did after some days.
Within a week, MSF sent more than 250
metric tonnes of medical and material
equipment to Haiti. The next week another
260 tonnes arrived. In total, over the firstseven weeks, nearly 1,200 tonnes of supplies
were flown, driven, and carried by boat into
Haiti. Putting it to use were waves of medical
and logistics personnel. Before the earthquake,there were some 800 people working in
MSF’s projects in Haiti, the vast majority ofthem Haitian. By the end of the February,that number was above 3,300. Collectively,
four months after the earthquake struck,
MSF was running approximately 20 medical
facilities and several mobile clinics and 15
operating theatres. Teams had assisted some
137,000 patients, performed more than 7,600
surgeries, distributed roughly 28,000 tents and40,000 hygiene and kitchen kits, and carriedout nearly 70,000 mental health consultations.
The national healthcare system before theearthquake was very weak, and now it’s worse off.
Estimates put the number of wounded between
200,000 and 300,000. MSF must therefore
continue to respond to immediate needs while
also planning for the future. “More than one
million people are still living in deplorable
conditions, beneath tents or plastic sheeting,without a clear sense of what’s ahead in the
coming months,” Stefano Zannini, MSF’s head of
mission in Haiti, said in May. “In the meantime,
the rains are intensifying, flooding the sites several
times a week where earthquake victims live.”
It is already clear that MSF will be making avery substantial commitment to Haiti for at least
the next 18 months. Beyond that there are still
likely to be more specific gaps in provision that
require a longer term presence. This ongoingcommitment is very large by MSF’s global
standards. As a rough guide, MSF multiplied its
activities by a factor of five after the earthquake.
And in 2011 the work will still be around threetimes more than it was before the disaster.
MSF would like to pay tribute to the seven
Haitian staff who were killed in the earthquake,and to those staff who were injured or lost
relatives. Their bravery and commitment will
not be forgotten.

MSF PROJECTS AROUND THE WORLD – AMERICAS – Central African Republic

63

AMERICASHONDURASREASON FOR INTERVENTION• Armed conflict• Social violence / Healthcare exclusion

MSF runs a therapeutic day-care centre
in Comayaguela that provides medical,
psychological and social support in one of thepoorest areas in the city. In 2009, the centre
saw on average 220 young people on a regularbasis and the MSF team recorded over 8,000
therapeutic visits, including over 2,000 medical
interventions. Many suffered from respiratory
infections, skin conditions, dental problems,
injuries resulting from violence, and HIV/AIDS.
Some patients show symptoms too severe
to be treated in the day-care centre. In 2009
MSF referred to national hospitals 37 people
suffering with depression, psychotic episodes,
severe drug or alcohol withdrawal symptoms,
or who had attempted suicide.
In 2009 MSF implemented a new model of carefor those with drug or alcohol addiction. The
service helps people to confront their addiction,
which is often the first step to recovery.

Maria
She was seven when she was raped.
At the age of eight, she ran away fromhome. Since then, she has been injuvenile detention centres 18 times, has
worked as a prostitute and was addicted
to drugs and alcohol. However, since
starting at the day-care centre, she has
never missed a session and has stopped
taking drugs and alcohol.‘ Whenyou stop the drugs, you start having
responsibilities. It becomes not enoughto sit and feel sorry for yourself.’ With
the support of the MSF psychologist, she
is now more stable.

MSF has worked in Honduras since 1988.

© Marion Jaros

Homeless young people
living on the streets inthe capital Tegucigalpa arevery vulnerable. Their living
conditions are dangerous
and they are often thetargets of violence.
Last year more than 500
homeless people under theage of 24 were murdered.
They have little or noaccess to healthcare.

Field Staff 41

Tecucigalpa, Honduras. Young homeless people sleeping on the street.

64

MSF PROJECTS AROUND THE WORLD – AMERICAS – HONDURAS© Yuri Kozyrev / Noor

Island of Lesvos, Greece. Undocumented migrants, many of whom have fled unstable regions including Afghanistan, Iraq, Somalia and Palestine,
live in extremely precarious conditions.

66 FRaNCE

71 UKRAINE

67 Greece

72 IRAN68 ITALY

72 IRAQ

69 Malta

74 Lebanon

69 Moldova

75 PALESTINIAN TERRitories

70 RUSSIAN FEDERATION

76 SYRIA

70 SWITZERLAND

76 Yemen

EUROPE & THE
MIDDLE EASTEUROPE & THE MIDDLE EAST

FranceMany asylum seekers andnon-French speaking people
have problems accessing
medical and psychologicalcare in France.
Many migrants have escaped violence anddeprivation in their home countries only
to find themselves homeless and destitutein France. Undocumented asylum seekers
are extremely vulnerable, and may besusceptible to psychological disorders as
a result of the stress of their experiences.
In 2009, MSF continued to provide
asylum seekers with medical assistance,
psychological care and social support.

• Healthcare exclusion

why asylum seekers have difficulty accessing
psychological care and services, including
their undocumented status, the language
barrier, and the nature and intensity of their
psychological distress.
Psychotherapy is complemented with medicalcare, legal referrals and advice. Since thecentre opened in 2007, more than 690 people
have received care and more than 11,000
consultations have been given. Psychologicalcare is essential if mental health is deteriorating:of the patients attending the centre, 41 percent reported that they had experienced
suicidal thoughts.
Healthcare on Mayotte Island
In May, MSF opened a healthcare centre in ashantytown in the capital of the French island
territory of Mayotte in the Indian Ocean.
Free healthcare was given to people living
in precarious conditions, many of whom are
migrants (mostly from the Comoros) who
have no valid papers or are waiting to receive

Field Staff 11

them. Among those waiting for their papers
are people who were born in Mayotte but
are unable to prove it. MSF teams noted two
significant obstacles to obtaining medical
treatment: first, those without papers are afraidof being arrested and expelled, and second,
healthcare is not free and most people cannot
afford to pay for it.
MSF gave more than 10,000 consultationsin the healthcare centre, 35 per cent of
which were for children under the age offive. An additional 340 were conducted inremote villages. The main medical complaints
were upper respiratory tract infections andgynaecological problems. Doctors also
checked the children’s vaccination andnutritional status, and 1,500 people wereseen for accidental injuries.
MSF has worked in France since 1987.

© Dragan LEKIC/Libre arbitre

MSF runs a centre in Paris that offers
psychological care to people in distress who
have come to France seeking asylum andprotection. There are a variety of reasons

REASON FOR INTERVENTION

Many migrants and refugees in Paris have to sleep rough on the streets.
66

MSF PROJECTS AROUND THE WORLD – EUROPE & THE MIDDLE EAST – FRANCEEUROPE & THE MIDDLE EAST

GreeceREASON FOR INTERVENTION• Healthcare exclusion
Field Staff 17

Patient story‘My entire family, my parents, my threebrothers and my sister were killed when abomb fell on our house. I went to answer
the phone and then the bomb fell. The
roof collapsed over the room my family
was sitting in. There was a lot of dust.
I could see their hands under the debris.
I could not see their faces. I only saw theface of my youngest brother. Here, I need
to be able to go outside the cell because
inside I think of the bad things that
happened at home.’© Michela Taeggi

Palestinian boy, aged 16,
Pagani detention centre, Greece

Patra, Greece. A young migrant in the makeshift Afghan migrant’s camp.

In recent years, the numberof undocumented migrants
arriving in Greece has been
increasing. In 2009, morethan 36,400 people werearrested at the Turkish
border trying to gain
access to Greece.
Often, these people come from countries
such as Afghanistan, Pakistan, Iraq, Somalia
and Palestine and are trying to escapeconflict and instability. Migrants often
endure poor living conditions and are
not entitled to access the national publichealthcare system except in emergencies,
when they must pay for care. Throughout
2009, MSF worked in a makeshift migrant’s
settlement in the city of Patra andin three detention centres for
undocumented migrants.
Assistance to migrants in Patra
Patra is the main exit port for migrants
hoping to reach Western Europe. Many
leave hidden in trucks in an attempt to reach
Italy. Between May 2008 and August 2009,
MSF ran a clinic here in a shantytown, andorganised mobile clinics in other locations toassist the migrants. MSF offered healthcare
and psychosocial support and worked to help

improve living conditions. More than 8,000
patients were examined and referrals weremade to hospitals. The most common medical
complaints were dermatological problems,
upper respiratory infections and injuries, andmost of these were related to the poor living
conditions endured by the migrants. MSF
psychologists frequently identified symptoms
of depression, anxiety disorders and posttraumatic stress disorder. The MSF project
was closed in September 2009 following
the demolition of the makeshift migrantsettlement by Greek authorities and a resulting
decrease in the migrant population in the area.
Detention in Greece
In August 2009, after negotiations with the
Greek authorities who had closed a detention
centre on the island of Lesvos in 2008, MSF
started new psychosocial support programmes
in three detention centres in Pagani, Venna andFilakio. MSF psychologists provided support
to undocumented migrants via individual
or group counselling sessions. Most of the
migrants come from unstable regions, andmany of them have had traumatic experienceson their journey to Europe. Furthermore,detention in the camps, which involves difficult
living conditions, overcrowding, confinement,
and the threat of forced repatriation, canincrease the pressure on their mental health.
Unaccompanied minors, children, women andvictims of torture are especially vulnerable.

detained in a facility with an official capacity of
275 was often more than 800, and reached up
to 1,200. There was often only one functioning
latrine for up to 200 people. During periods ofovercrowding many migrants had to sleep on
dirty mattresses, on floors that were covered
with stagnant water from overflowing showers.
The migrants were rarely allowed to go outside
and families were split up.
In Venna and Filakio migrants faced shortagesof food, clothes and hygiene items, andoutdoor access was irregular and insufficient.
In Filakio migrants regularly complained
about inhumane treatment from police
officers, including verbal and physical abuse.
MSF raised concerns with authorities regarding
the poor living conditions in detention centres, thelimited provision of medical care, the absenceof mental health services, the inadequate careof unaccompanied minors, and the absenceof a follow-up system for people with medical
problems. The Pagani detention centre closed
in November 2009, following repeated MSF
appeals to the authorities to address thehumanitarian emergency taking place there.
MSF has worked in Greece since 2008.

In Pagani, overcrowding led to a dramatic
deterioration of living conditions and people
began to protest. The number of migrants

MSF PROJECTS AROUND THE WORLD – EUROPE & THE MIDDLE EAST – Greece

67EUROPE & THE MIDDLE EAST

Italy
Italy has long been adestination or a transit
country for migrants
and asylum seekers,
often escaping conflictor deprivation. The
organisation Fondazione
ISMU estimated thenumber of undocumented
migrants living in Italy
to be nearly 422,000.

REASON FOR INTERVENTION• Healthcare exclusion

In 2009, the Italian government introduced
stricter immigration policies, which haveworsened the situation for migrants,
increased stigma and hampered theiraccess to healthcare. Last year MSF focusedon responding primarily to the medical
and humanitarian needs of seasonal
migrant workers in southern Italy. MSF also
continued to speak out about the difficult
living conditions of migrants in order toput pressure on the authorities to improvetheir situation and increase their accessto healthcare.
The Italian government has introduced policies
to crack down on unofficial immigration,
resulting in an increasingly hostile environment
for undocumented migrants. The new law has
criminalised unlawful entry into the country
and people who are living there without
visas. The maximum period in detention
centres for undocumented migrants has been
extended from two to six months, despite
the fact that longer periods of detention arelikely to contribute to a further deterioration• Natural disaster

Field Staff 33

in detainees’ physical and mental health. MSF
assessed 21 detention centres for migrants andreception centres for asylum seekers, and foundovercrowding, poor living conditions and aserious lack of healthcare provision.
Border controls have been tightened, resulting
in migrants taking longer and more precarious
journeys in smaller boats to avoid being detected.
Over the past seven years, MSF has set up 35
clinics providing healthcare and psychologicalcare to undocumented migrants in six Italianregions which are gradually being handed
over to local health authorities. The clinics
were integrated into the country’s national
health services and respected the migrants’wish to be anonymous.
In Puglia and Calabria in 2009, teams
carried out more than 700 consultations anddistributed hygiene kits and other essential
items to seasonal migrant workers. MSF ran
four clinics in the Campania region and assisted
more than 1,600 migrants. In April, MSF
provided psychological care to victims of theearthquake in the Abruzzo region. Between
2003 and 2009 in Lampedusa, a frequent
entry point for migrants and refugees, teams
provided migrants with medical assistance.
However, last year there was a sharp decreasein the number of migrants due to a new
agreement between Italian and Libyan
governments to reinforce border patrols.
As a consequence, MSF closed the project.
MSF has worked in Italy since 1999.

© Paolo Soriani

Patient story

Turin, Italy. Migrants at their residential block which is surrounded by bars.

68

MSF PROJECTS AROUND THE WORLD – EUROPE & THE MIDDLE EAST – ITALY‘I come from Côte d’Ivoire. I have been
in Italy for two months. After crossing
the Libyan Desert, I was put in prison
for six months without any explanation.
I lived in a cell measuring five by ten
metres with 20 other people. There
was no toilet and we could hardly evergo out. Then I travelled to Sicily on aboat. It was a horrible journey: there
were more than 15 people, we didn’t
have food or water, some were throwing
up. Now I have come to Italy to picktomatoes. They pay us three to fourEuros a box. If all goes well I earn € 30
a day here, but I don’t work every day. I
live in a shack and I sleep on a mattresson the floor. I didn’t think I would havesuch a bad life in Italy.’EUROPE & THE MIDDLE EAST

Malta’s location in the
Mediterranean has made it
a common port of arrival
for thousands of migrants
and asylum seekers who
set off from the coast of
Libya towards Europe.
They are then kept for up to 18 months
in detention centres where they face
overcrowding, inadequate sanitation andpoor living conditions. This environment
often has damaging effects on their physicaland mental health. MSF has been treating
patients both within and outside thedetention centres.
Between January and October 2009, more than
1,150 migrants and asylum seekers landed in
Malta, more than half of whom were Somali.
Many were already suffering from psychologicalproblems as a result of their often traumatic
experiences in their home countries and theirjourneys to Malta. Most migrants have spentdays on boats exposed to the sun and rain,
unable to move, and with limited supplies ofField Staff (this figure is
integrated with those of Italy)

food and water; conditions that can cause skin,gastrointestinal, urinary and musculoskeletal
health problems. Poor living conditions in thedetention centres and uncertainty about the
future also contribute to a high incidence ofmental health problems.
At the start of 2009, teams were providing
medical and psychological care for migrants
inside two detention centres known as theSafi and Lyster Barracks. By March 2009,nearly 20 per cent of conditions diagnosed by
medical staff were respiratory problems linked
to exposure to cold and lack of treatment for
infections. After repeated attempts to pushauthorities to take steps to improve matters,
MSF withdrew from the centres, and in April
published a report exposing the appalling
conditions endured by migrants in Maltese
detention centres.
After further negotiations with the Maltese
authorities, MSF established a temporary
programme inside the detention centre in
Takandja. Here, between June and December,
MSF provided more than 1,600 medical
consultations. By the end of the year, MSF was
phasing down the activities in Takandja.
In 2009, MSF also ran a clinic in Hal Far in thesouth of Malta, where migrants and asylum

Moldova
Transnistria, a politicallyisolated region in Moldova,
has received little aid in thepast despite the enormous
assistance Moldova
receives from international
institutions to tackle thecountry’s HIV/AIDS epidemic.

MSF is assisting people living with HIV in thisregion where prevalence is four times higher
than it is in the rest of the country.
Before this intervention there was notreatment available.
In early 2007, MSF, together with the Ministryof Health and local authorities, set up the first
HIV/AIDS programme in the region. Patients
started receiving antiretroviral therapy (ART)at the new department in the main hospital in
the capital, Tiraspol. Activities were extended toweekly visits to Bender Hospital to treat patients
co-infected with TB, to Slobozia at the region’s
only facility for HIV patients, and to Ribnitza
in the north of the country to give weekly
consultations in the city’s clinic.

© Julie RemyMalta

REASON FOR INTERVENTION• Healthcare exclusion

A Somali woman and her baby who have to stayin a detention camp in Malta.

seekers outside the detention centres could
have access to medical and psychological care.
After their release from detention, migrants
and asylum seekers are given a place in one of
15 open centres on the island. Although they
can move freely and begin to build a new lifeon the island, integration into Maltese society
remains difficult. Living conditions are still poor,
as many centres are overcrowded and lackadequate water and sanitation facilities. MSF
teams organise health and hygiene promotion
activities in the open centres.
Throughout 2009, MSF provided more than
4,200 medical consultations and more than
780 mental health consultations for migrants
and asylum seekers in Malta, both in detention
centres and at the clinic in Hal Far.
MSF has worked in Malta since 2008.

REASON FOR INTERVENTION• Healthcare exclusion
Field Staff 8

the general population. The prevalence of
HIV/TB co-infection is also much higher. The
programme has now expanded to cover theentire prison system.
In February 2009, MSF handed over all
activities to the national authorities. Some
850 patients, representing more than halfof all HIV cases registered in the region, arenow on the programme.
With its work in the prisons and in the public
HIV hospitals, MSF was able to demonstratethat it is possible to work in Transnistria andprovide much-needed medical assistance tothose most in need.
MSF has worked in Moldova since 2007.

MSF began providing treatment within theprisons, where the prevalence of HIV is as
much as 13 times higher than it is among

MSF PROJECTS AROUND THE WORLD – EUROPE & THE MIDDLE EAST – Malta / Moldova

69

EUROPE & THE MIDDLE EASTREASON FOR INTERVENTION• Armed conflict• Healthcare exclusion

The situation in the three
republics of the North
Caucasus region of the RussianFederation remains volatile.
Nearly every day there are attacks and violent
incidents, and the insecurity worsened during
the latter half of the year when the number ofsuicide bomber attacks increased alarmingly.
MSF has been providing support to hospitals
and through clinics and has been raisingawareness of the mental health problems
caused by the conflict.
Medical situation and priorities
Healthcare needs vary across the North
Caucasus regions in Russia. For MSF, thepriorities are to provide treatment for
tuberculosis (TB), to offer psychosocial support,
and help vulnerable groups such as displaced
people and illegal migrant workers who have

© MSF

RussianFederation
Field Staff 14

experienced neglect or violence. Prevalenceof all strains of TB remains high, particularly in
Chechnya where the entire health infrastructure
was ruined during the war. Furthermore, there
is an irregular supply of TB drugs, the necessary
diagnostic tools are not yet in place, andinfection control measures are unsatisfactory.
In the region of Ingushetia in the south of thecountry, the mental health of the populationis also becoming a serious concern. Intense
insecurity coupled with political instability has
exacerbated chronic psychological problems.
Throughout 2009, MSF doctors continued
to offer free paediatric care in two clinics in
Grozny in the south, and to provide womenwith free healthcare in two clinics in the nearby
Staropromyslovsky district. Together theseclinics gave consultations to more than 1,500
women every month, many of whom weredisplaced or from low-income, rural families.
MSF also supplied drugs and medicines toa hospital in Grozny and to regional healthcentres in three mountainous villages.

Ingushetia, Russian Federation.
A paediatrician checks the health of a childin a camp for internally dispaced people.
After several years’ absence, MSF returned
to Dagestan, again in the south, to provide
treatment for migrant workers and internallydisplaced people in a health centre there.
MSF has started to hand over its support for the
TB programmes in the more stable northernarea of Chechnya as mental health activities
respond to acute psychosocial needs and support
patients with chronic conditions. In July 2009,
MSF also ended its surgery and physiotherapy
programme in the main hospital in Grozny, since
fewer patients required treatment for injuries andchronic disabilities than during the war.
Access to the mountainous southern region
remains a tough challenge due to the remotelocation of the communities. MSF’s priority is toimprove the treatment for TB, including drugresistant forms of the disease.
MSF has worked in Russia since 1988 and
the North Caucasus since 1995.

Switzerland
Undocumented migrants havegreat difficulty accessing
healthcare in Switzerland.

Although officially the Swiss Constitution
guarantees access to the health system for
all, thousands of people, often due to theirlack of health insurance or their fear of being
reported and expelled from the country, areleft without proper medical care. In January
2006, MSF set up a project called Meditrina,
which provided free medical consultations
for these people.
Located in a small alley of downtown Zurich,
the MSF Meditrina clinic provided more than
1,100 free consultations in 2009, bringing
the total since the beginning of the projectin 2006 to more than 3,400. Furthermore,
hundreds of patients were referred toa network of medical and paramedical

70

specialists who provided confidential
consultations and medical care.
Around 50 per cent of Meditrina’s patientsare migrants living without documents in the
Zurich area, but many others, despite theirlegitimate status, came to the MSF clinic
because they could not or did not know
how to access public healthcare. The mostcommon conditions found in patients at theMeditrina clinic were gastrointestinal, dental
and dermatological. Many patients also showed
psychological disorders, often linked to theirdifficult living conditions. Meditrina also
provided testing, counselling and longterm
treatment for chronic diseases such as HIV/AIDS
and tuberculosis.

REASON FOR INTERVENTION• Healthcare exclusion
Field Staff 10

of the Swiss Red Cross, already involved inproviding care to those who need it most, took
over the project at the beginning of 2010.
MSF has worked in Switzerland since 2003.

After setting up and establishing Meditrina as areliable and functioning entry point to the Swiss
healthcare system for Zurich’s undocumented
people, MSF looked for an organisation to takeover the project longterm. The Zurich branch

MSF PROJECTS AROUND THE WORLD – EUROPE & THE MIDDLE EAST – RUSSIAN FEDERATION / SWITZERLAND

Patient story‘B’, 36, from Cameroon‘Living here in Zurich as a“Sans-Papiers” is very difficult. You
always fear the police will catch you,detain you and eventually send you
back to your country. Meditrina people
were of great help to me, they evenmanaged to get me health insurance.
They took great care of me and referred
me to a doctor who can treat me in the
future if necessary.’

EUROPE & THE MIDDLE EAST

UkraineREASON FOR INTERVENTION• Healthcare exclusion

Field Staff 1

Ukraine is often used as a transit country by migrants andrefugees trying to reach the European Union ( EU ).
Under growing pressure to contain thismovement, the country has received EU
funding and technical support to implement
stricter border controls and increase thecapacity of detention centres for migrants.
As a result, a large number of migrants
and refugees without proper papers, fromcountries such as Afghanistan, Pakistan,
Georgia, Moldova and many others, remain
blocked in the country, unable to continue
towards Europe or unwilling to return home.
MSF has been working to improve conditionsin the detention centres and has been
providing the migrants with medical care.

Migrants are transferred to new Migrant
Accommodation Centres (MACs) in Volynand Chernihiv Oblast in the northeast andnorthwest of the country when they are
released from the detention centres. MSF
conducted a medical assessment in boththese centres (which were built with EU
financial support) and found that, althoughmaterial conditions were better, the qualityof medical services remained poor. People
detained in these centres frequently suffer
with skin diseases like scabies, as well as
respiratory infections and digestive disorders

such as diarrhoea, stomach-aches and nausea.
They also show psychosomatic symptoms
such as headaches and insomnia. However,mental health services are often nonexistent.
To share its concerns over the detention of
migrants in Ukraine, MSF will launch a reportwith the results of the assessment and will also
warn of the possible consequences of the‘re-admission agreement’, which came into
force in January 2010. Under this agreement,
all migrants without proper documents arrested
in the EU after having travelled through Ukraine
could be sent back to the country, resulting inincreasing numbers of migrants and asylum
seekers being trapped in Ukraine.
MSF has worked in Ukraine since 2009.

© Lana Abramova

Under national legislation, migrants arrested
when trying to cross the Ukraine border
into the EU illegally should be detained fora maximum of ten days. However, in reality
they are often detained for much longer underconditions that fall far below basic standards
and which offer limited access to healthcare.

MSF conducted an assessment in the detention
centres in the Zakarpattya province near theEuropean Union border, after reports in 2008
from the European Council of Refugees andExiles denounced the poor living conditions
there. While making the assessment MSF also
repaired and installed toilets and showers to
improve conditions in the detention centre.

Chop, Western Ukraine. Illegal migrants detained in a camp.
MSF PROJECTS AROUND THE WORLD – EUROPE & THE MIDDLE EAST – Ukraine71

EUROPE & THE MIDDLE EAST

Iran

Iraq

REASON FOR INTERVENTION• Healthcare exclusion
Field Staff 73© Siavash Maghsoudi

In Iraq, even though overalllevels of violence havedecreased, highly volatile
areas still remain. Bombingsand assassinations continue
in many regions, and dozens
are killed or wounded
every week.

Zahedan, Iran. A child has their arm bandaged at the MSF supported hospital.

Iran hosts one of the highest numbers of refugees in
the world. The UN refugee agency UNHCR reported
more than 930,000 documented Afghan refugees in
Iran in 2009, while estimates of undocumented Afghansreached two million.
MSF supplied relief aid to refugees
in Zahedan, the capital of the Iranianprovince of Sistan-Balochistan, where
refugees have been crossing the borderfrom Afghanistan for the last 30 years.
The number of ‘illegal’ Afghans isestimated to be around 200,000 in thecity, and as many as 500,000 in
the province.
In Zahedan, MSF runs three medical
clinics and in 2009, carried out morethan 6,700 consultations a month. A
team of social workers identified people
in need of medical care in the refugeecommunity and distributed food andbasic relief items to 1,290 families.
Maternal and child healthcare activities
were increased last year to meet thegrowing needs. Antenatal and postnatal
care are now offered in the three clinics,
and further postnatal care is provided in
the community by a home-visit team that
includes midwives.

72

In 2002, the Iranian government
implemented a policy of repatriation,and the practice has continued eventhough conditions in Afghanistan havedeteriorated. Many people are reluctant
to return to Afghanistan and prefer toremain in Iran. Some even return after
they have been deported in spite of the
difficult living conditions imposed on the
refugees. These include work restrictions,lack of educational opportunities andhealth services. MSF teams provide
general healthcare and maternal care to
the Afghan people who have little or noaccess to the Iranian system.
MSF has been working in Iran since 1996.

MSF PROJECTS AROUND THE WORLD – EUROPE & THE MIDDLE EAST – IRAN

Although many health facilities function
inside of Iraq, the quality of care has been
undermined by a shortage of staff, and there
has been no upgrading of skills since the earlynineties. As in previous years, MSF could notgive direct assistance to the most affectedareas in 2009 due to security constraints.
However MSF still worked to provide aid from
more secure parts of the country or from theoutside, especially Jordan.
According to the Iraqi Health Ministry, hundredsof medical employees have been killed in thecourse of the conflict and even greater numbers
have fled the country. Iraq is critically short ofnurses and of specialist doctors, including
psychiatrists and psychologists. MSF has identified
some of the main challenges to be the inabilityof hospitals in conflict zones to deal with masscasualty incidents due to deficiencies in skills andmanagement, and a virtual absence of psychologicalcare for patients with mental trauma.
MSF supports hospitals in different parts ofthe country such as Anbar, Baghdad, Ninewa
and Kirkuk, by training medical staff, providing
materials and supporting mental healthcounselling and conducting health education
campaigns. MSF also established a programmein neighbouring Jordan in August 2006, from
where it has been operating a reconstructive
surgery project for the Iraqi war-wounded,focusing on orthopaedics, facial reconstruction
and plastic surgery. In 2009, MSF remotely
supported nine Iraqi hospitals from Amman
that had been severely affected by the violence.
In 2009, some of the remote hospital support
was closed as the security situation hadlargely improved in Iraq, permitting MSF
to open a mental health counselling unit in
Baghdad in September, followed by a similar
unit in Fallujah in December. The units arelocated within Ministry of Health hospitals
and seconded staff provide the counselling
services. Over 175 patients were treatedduring the last quarter of 2009.

EUROPE & THE MIDDLE EASTREASON FOR INTERVENTION• Armed conflictField Staff 289

For the first time since returning to Iraq
in 2008, MSF was able to establish aninternational team in the southern part of thecountry. There, in Basra General Hospital, MSF
provided technical support and training onanaesthesia, post operative care, hygiene andsterilisation throughout 2009. In addition, MSF
is currently participating in the rehabilitationof the emergency operation theatre in this 600
bed hospital, as well as focusing on improving
emergency response capacity and better
management of emergency surgical cases.

In Jordan, by the end of 2009, thereconstructive surgery programme lead by
MSF in Amman treated nearly 900 wounded
patients. The project has developed with thehelp of a small group of doctors in Iraq, who
identified patients and organised their transfer
to Amman, based on the specialist care weare able to provide (orthopedic, maxillo-facialand plastic). Treatment and follow-up arecomplex, requiring months of hospitalisation ina specialised environment. Beyond the complex
surgery, MSF provides physiotherapy andpsychological care to patients in need.

In the governorate of Kurdistan, MSF started a
project in 2007 in the Sulaymaniyah teaching
hospital, in order to respond more quickly to thewounded victims from the north of Iraq, andto improve the quality of care given to severely
burnt patients. After two years working to
improve the quality of care in the burn unit, MSF
handed over this project to the authorities at theend of 2009. Despite the difficulty in improving
survival rates in such a medical context (due tothe high number of severe burns), progress wasmade in pain management, infection control andpalliative care.
MSF is continually assessing the possibility ofproviding further medical assistance to the
Iraqi people and weighs this possibility against
maintaining staff security.
MSF’s current intervention in Iraq started in 2006.

© Khalil Sayyad

MSF is directly supporting the emergency
units of four hospitals in the Ninewa andKirkuk governorates in northern Iraq throughcontinuous medical supplies and training of
medical and paramedical staff, such as thetraining to manage mass casualty situations.
MSF provides emergency response support
to hospitals after violent incidents and isengaged in health education campaigns aimed

at the prevention of communicable diseases.
Campaigns promoted water treatment andpersonal hygiene, while others focused on
raising awareness of leishmaniasis and on
preventing swine flu ( H1N1). In the Kurdish
North of Iraq, MSF is also giving psychologicalsupport to persons displaced due to conflict

Basra General Hospital, Southern Iraq. A team of medical staff operate on a patient.

MSF PROJECTS AROUND THE WORLD – EUROPE & THE MIDDLE EAST – Iraq

73

EUROPE & THE MIDDLE EAST

© Lara Arapguirlian

LebanonREASON FOR INTERVENTION• Healthcare exclusion
Field Staff 21

Bourj el-Barajneh district of Beirut, Lebanon. Staff give out brochures to help raise awareness of mental health issues.

In Lebanon, 17 per cent of the population suffer from mental health problems according
to a recent national survey, but few have access to treatment.
The problem is even more acute amongpeople living in refugee camps, whether they
are Palestinians who have lived there for
decades, or more recently displaced people
from Iraq. In December 2008, MSF opened amental health centre in Bourj el-Barajneh, inthe southern suburbs of Beirut, near a large
Palestinian refugee camp. As well as providing
psychological and psychiatric assistance,
MSF has also started activities to promote
the integration of mental healthcare within
existing healthcare services for Palestinians
and Lebanese communities.
Bourj el-Barajneh is a suburb of the Lebanese capital
Beirut. It is home to a mix of Lebanese people,
Palestinian refugees who have lived in camps since1948, and recently arrived Iraqi refugees. Following
a 2008 study on medical needs in Lebanon,
MSF decided to start a new project that would
provide mental health services to the poor andmost vulnerable people living in this area.
The first full year of operations for this three-year
programme was 2009. Throughout the year,
between the MSF Mental Health Community
Centre in Bourj el-Barajneh and the United Nations
74

Relief and Works Agency clinic in the Palestinian
refugee camp, MSF psychologists, psychiatrists andnurses carried out 2,300 consultations. Patientswere mostly of Palestinian and Lebanese origin,and some were Iraqi refugees. Depression was themost commonly observed mental health problem,
followed by anxiety disorders, psychosis, epilepsy
and personality disorders. Further diagnoses
included drug and alcohol abuse, bipolar disorderand dementia.
At first, the MSF team encountered difficulties inconvincing people to come and consult mental
health specialists, since mental health disorders
are very much stigmatised in the communities. In
order to challenge this, health education sessions
were regularly held in the refugee camp and at
the nearby MSF centre, and MSF community
health workers regularly visited marginalised anddisadvantaged patients’ families.
As yet, mental health is not seen as a primary
public health concern in Lebanon. There are
only about 50 registered psychiatrists in the
country. MSF has therefore been pushingfor a better integration of mental healthcare
within the existing healthcare services, and has

MSF PROJECTS AROUND THE WORLD – EUROPE & THE MIDDLE EAST – LEBANON

been promoting its community-based mental
healthcare approach during meetings with
Lebanese health authorities and other partners.
MSF has worked in Lebanon since 2008.

Salwa

A Lebanese mother of four, who is married
to a Palestinian man‘A few months ago, following the advice ofa friend, I went to the MSF Mental HealthCommunity Centre. I knew I could get free
psychological support there. Session after
session, I started feeling better and I evenstarted participating in the centre’s activities.
I was lucky enough to meet other women
suffering with the same problems, and I did
not feel alone any more. My life has turnedin a new direction. Today, I am able to talkabout my psychological problems and toaccept them, without fear of other peoples’
opinions. I am happy I could find somebody
to talk to who enabled me, for the first time,
to believe in myself.’

EUROPE & THE MIDDLE EAST

Palestinian
Territories
REASON FOR INTERVENTION• Armed conflictField Staff 206

The conflict that followed
the rise to power of Hamas
in the Gaza Strip in June2007 and the continuing
Israeli-Palestinian conflicthave resulted in many
deaths and injuries.
The Palestinian people have been badly
affected physically and mentally, but notenough post-operative services such as
physiotherapy and psychological care areavailable. MSF is working to remedy this while
trying to adapt its operations to the volatile
situation in the Palestinian Territories.
In June 2007, internal clashes within the Gaza
Strip divided the Palestinian Authority into the
Fatah government based in Ramallah and theHamas government in Gaza. Internal clashes
persist, continuing to claim victims.
The Israeli-Palestinian conflict continues.
In response to rocket attacks against Israel,
the Israeli army launched a large-scale
offensive on December 27, 2008. ‘Cast
Lead’ was characterised by intensive air
raids and bombing, paving the way for aground offensive launched on January 3,
2009. Twenty-two days of war left about
5,300 injured, and nearly 1,300 Palestinians,
including 300 children, dead.

care for the influx of wounded people who
needed operations. Between January and July,when this programme ended, more than 500
operations were performed.
Psychological care was also strengthened,with a special focus on local emergency staff
such as ambulance crews and doctors, who
endured much during the war.
Post-conflict programmes in the Gaza Strip
MSF has been providing post-operative careand physiotherapy to the war-wounded at
its three health centres and through mobile
teams. More than 120 patients are still
being cared for within this programme. A
microbiology programme was also set up to
improve the care of wound infections andresearch resistance to antibiotics. In 2009,
more than 1,900 people received treatment:
three times as many as in 2008.

The psychological effect of the Israeli
offensive in January has been substantial,
especially on children. Additional MSF staff
were brought in to help cope with the influxof patients. 400 new patients, more than halfof whom were under 12 years old, received
psychological support.
The West BankIn Nablus, MSF runs a programme for people
suffering from trauma related to the conflict.
In 2009, more than 300 new patients received
psychotherapy, and MSF psychologists carriedout 2,100 consultations.
HebronMSF is also working in Hebron on the southernWest Bank, operating a psychosocial programme
for the victims of the ongoing violence.
MSF has worked in the Palestinian Territories
since 1989.

In 2009, improved local paediatric services andthe arrival of new aid workers helped to strengthen
the only specialised paediatric hospital in the
Gaza Strip. From January until the end of the
programme in September, more than 9,000
children under 12 years old were seen.

On January 18, Israeli forces announced
a ceasefire. A surgical team and 21 tonsof equipment (including two inflatable
hospitals) were then able to enter Gaza City.
In the days immediately following, MSF
opened an emergency surgical centre to© Frederic Sautereau

Emergency intervention
In response to the Israeli offensive, MSF
supported the hospitals in Gaza with donationsof medical equipment and medicine. Due tothe intensity of the bombing and the lack of
security, emergency activities were restricted,
and though MSF’s post-operative care centre
in Gaza city remained open, few patients wereable to reach it.

A psychologist greets a child at a centre for post-traumatic stress, which is often brought onby the experience of war.

MSF PROJECTS AROUND THE WORLD – EUROPE & THE MIDDLE EAST – Palestinian Territories

75

EUROPE & THE MIDDLE EAST

Syria
REASON FOR INTERVENTION• Healthcare exclusion
Field Staff 2

Approximately 4.7 million Iraqis havesought refuge outside their country
and, according to the latest figuresfrom the UN refugee agency UNHCR,
the number of registered Iraqi
refugees in Syria is around 215,000.
However many thousands more remain unregistered.
Most of these people live in precarious conditions andcannot afford to pay for medical care.
In August 2009, MSF started a healthcare project inDamascus, Syria, in partnership with a local organisation
which is known as the Migrant’s Office. The aim of the
project is to provide free healthcare and mental healthsupport to the unregistered refugees and migrants and theunderprivileged residents of the city.

Yemen
REASON FOR INTERVENTION• Armed conflictField Staff 248

In August, the conflict between thearmed group Al-Houthi and Yemeni armed
forces broke out again in the northerngovernorate of Saada.
This war was the most intense in recent years, and caused thedisplacement of at least 150,000 people. This is in addition to100,000 others who had already been displaced by previous
wars (UNHCR, 2009). MSF has been working to provide carefor displaced people, migrants and refugees.
Conflict
Dealing with the consequences of the Saada war in northern Yemen wasa priority for MSF in 2009. Health structures throughout the governorate
were affected, and most of them had to interrupt their activities or becamevery difficult to access. Therefore, MSF worked to provide healthcare torural communities while also helping the Yemeni authorities and other relief
organisations to cope with the medical needs caused by the displacement of
more than 150,000 people in neighbouring governorates.

With the support of MSF, the clinic provides primary healthcare
services, prenatal consultations and mental healthcare. In thefirst six months, more than 2,800 patients received medicalcare, including 400 pregnant women, and 280 people were
given psychological support.
In Syria there are also migrants and refugees from othercountries, such as Afghanistan, Somalia and Sudan who livein poor conditions. Some 2,000 undocumented migrants
from Afghanistan and Somalia live in Damascus with little
or no access to medical care. MSF intends to increase theservices provided in the Migrant’s Office clinic to meet thisgrowing demand.
MSF has worked in Syria since 2009.

A family share a meal in a refugee camp in Yemen.

76

MSF PROJECTS AROUND THE WORLD – EUROPE & THE MIDDLE EAST – SYRIA / YEMEN

EUROPE & THE MIDDLE EAST
Despite difficult safety conditions and logistical challenges, MSF set up
an emergency programme for displaced people seeking refuge in thenorthern village of Mandabah in Saada, providing water and medicalcare for more than 10,000 people. More than 1,500 consultations werecarried out.
In Al Talh and Razeh hospitals, not far from the city of Saada, morethan 31,000 consultations were carried out and 2,100 people were
hospitalised. More than 550 children were admitted to the nutritional
programme and 700 women were assisted in giving birth. However theinsecurity caused regular interruptions to MSF’s work.
Another consequence of the violence in Sadaa was the massive
displacement of civilians to neighbouring Governorates. According to the
UN refugee agency UNHCR, about 90,000 displaced people had groupedin the Hajjah governorate. MSF found that eight per cent of children
under five years old were severely malnourished in the al-Mazraq camp.
Teams opened a nutrition intervention programme in the area and, within
two months, more than 550 children had received treatment.
Many migrants, refugees and asylum seekers from the Horn of Africa
continue to seek refuge in Yemen. The harsh conditions of theirjourneys and sea accidents cause hundreds of deaths, and the stateof health of those who do manage to reach the Yemeni coast is often
poor. Around 9,000 people received medical assistance from MSF in
Abyan and Shabwah governorates in the south of the country.
MSF has worked in Yemen since 2007.

Country Closures

Belgium
MSF worked in Belgium for 20 years,
between 1989 and 2009. MSF closed
its last project when socio-medical
consultations in Antwerp endedin April 2009.
Over the years programmes to ensure access tohealthcare for those most in need were implemented
in four cities: Verviers, Liège, Brussels and Antwerp.
In 2008, MSF provided more than 3,900 consultations
for more than 1,000 patients in Antwerp. In May 2009,
the Antwerp programme was handed over to theorganisation Medecins du Monde, which had alreadytaken over the MSF project in Brussels in 2008.
In November 2009, after closing its healthcare programmes,
MSF returned to set up a refugee camp in the centre of
Brussels in order to highlight the political gridlock aroundthe reception and accommodation of asylum seekers in
Belgium. The camp was meant to be a symbolic act and notintended to serve as an alternative to the accommodation
provided by the government. However over the course of
five days, more than 270 people stayed at the camp.

© Juan Carlos Tomasi

Although MSF no longer has operational programmes
in Belgium it continues to work there via its national
headquarters in Brussels to raise awareness of MSF’s work,
to fundraise for MSF programmes worldwide and to recruit
staff as required.

MSF PROJECTS AROUND THE WORLD – EUROPE & THE MIDDLE EAST – Country Closures - Belgium

77

FACTS AND FIGURES
Médecins Sans Frontières (MSF) is aninternational, independent, medical
humanitarian organisation that is
also private and not-for-profit.

AFRICA

It is comprised of nineteen main national sections in Australia, Austria,
Belgium, Canada, Denmark, France, Germany, Greece, Holland, Hong
Kong, Italy, Japan, Luxembourg, Norway, Spain, Sweden, Switzerland,
the United Kingdom and the United States. Additionally, there is theinternational office in Geneva and a branch office in South Africa.
The search for efficiency has led MSF to create ten specialised organisations- called “satellites” - in charge of specific activities such as humanitarian relief
supplies, epidemiological and medical research studies, and research on
humanitarian and social action. These satellites, considered as related parties
to the national sections, include: MSF-Supply, MSF-Logistique, Epicentre,
Fondation MSF, Etat d’Urgence Production, MSF Assistance, SCI MSF, SCI
Sabin, Artze Ohne Grenzen Foundation and MSF Enterprises Limited. As
these organisations are controlled by MSF, they are included in the scopeof the Financial Statements presented here.
The figures presented here describe MSF’s finances on a combined international
level. The 2009 combined international figures have been set up in accordancewith MSF international accounting standards, which comply with most ofInternational Financial Reporting Standards (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 2009 Financial Report
may be obtained from the International Office upon request. In addition, eachnational office of MSF publishes annual, audited Financial Statements according
to its national accounting policies, legislation and auditing rules. Copies of thesereports may be requested from the national offices.
The figures presented here are for the 2009 calendar year. All amounts
are presented in millions of Euros.
Note: Figures in these tables are rounded, which may result in slightdifferences in addition.

in million E

Democratic Republicof the Congo

49.7

Sudan
Zimbabwe

National staff 			
International staff 		
Medical and nutrition		
Transport, freight and storage
Operational running expenses
Logistics and sanitation 		Training and local support		
Consultants and field support

10.1

32.9

Pakistan

9.0

20.7

Myanmar8.5

Somalia

18.6

India

8.5

17.4

Sri Lanka

5.9

Kenya

14.6

Palestinian Territories

5.2

Nigeria

14.5

Yemen

3.6

Central African Republic

12.6

Cambodia

3.0

Chad

12.4

Philippines

2.9

Ethiopia

11.0

Bangladesh

2.5

Malawi

8.8

Papua New Guinea

2.5

Mozambique

7.6

Afghanistan

2.3

Uganda

6.9

Iran

2.3

Liberia

6.7

Georgia2.0South Africa

5.7

Indonesia

2.0

Burkina Faso

5.3

Thailand

1.9

Sierra Leone

4.8

Uzbekistan

1.9

Guinea

4.4

China

1.6

Mali

4.0

Armenia

1.4

Swaziland

2.7

Jordan

1.4

Burundi

2.2

Nepal

1.2

Djibouti

1.6

Other countries **2.7

Cameroon

1.5

Zambia1.3

Other countries **

2.4

Total

THE AMERICAS
Total

270.3

Programme expenses* by continent
31%
25%
19%
12%
5%
6%
1%
1%

in million E

Iraq

Niger

Where did the money go?
Programme expenses* by nature

ASIA AND
THE MIDDLE EAST

Africa			Asia			Americas		Europe		
Oceania		
Unallocated		

69%
20%
6%
2%
1%
2%

* Project and coordination team expenses
in the countries

82.4

in million E

Haiti

12.8

Colombia

8.8

Brazil

1.4

Other countries **

2.4

Total

EUROPE

25.4

in million E

Chechnya / Ingushetia/ Dagestan

5.1

Italy

1.3

Other countries **

2.6

Total

9.0

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

78

AUDITED FACTS AND FIGURESINCOME

2009

2008

in million E

in percentage

in million E

in percentage

Private

572.4

86%

587.4

87%

Public institutional

77.9

12%

67.7

10%

Other

15.1

2%

20.3

3%

665.4

100%

675.5

100%

in million E

in percentage

in million E

in percentage

Operations *

462.4

75%

494.9

76%

Témoignage / Awareness raising

21.7

4%

24.7

4%

Other humanitarian activities

6.4

1%

7.2

1%

490.5

80%

526.8

81%

Fundraising

87.4

14%

81.2

13%

Management, general and administration

38.9

6%

40.2

6%

Other expenses

126.3

20%

121.6

19%

Total Expenditure

616.8

100%

648.2

100%

Total Income

HOW WAS THE MONEY SPENT?

Total Social mission

Net exchange gains/losses
Surplus/(deficit) after exchange

2009

2008

2.9

-4.7

51.5

22.5

* = Programme and HQ support costs

BALANCE SHEET (year-end financial position)

2009

2008

in million E

in percentage

in million E

in percentage

Cash & equivalents

433.3

80%

375.6

77%

Other current assets

68.5

13%

73.3

15%

Non-current assets

36.6

7%

37.0

8%

Total assets - Net

538.4

100%

485.9

100%

2.5

0%

2.5

1%

475.5

89%

423.8

87%

-9.8

-2%

-13.9

-3%

468.2

87%

412.4

85%

70.2

13%

73.5

15%

538.4

100%

485.9

100%

in million E

in percentage

in million E

in percentage

Medical pool

1,239

26%

1,052

23%

Nurses and other paramedical pool

1,459

31%

1,452

31%

Non-medical pool

2,046

43%

2,113

46%

Total international departures (full year)

4,744

100%

4,617

100%

International staff

2,015

9%

2,029

8%

National staff

20,447

91%

23,94492%

Total field positions

22,462

100%

25,973

100%

874

18%

1,142

25%

Permanently restricted funds
Unrestricted funds
Other retained earnings
Retained earnings and equities
Current liabilities
Total liabilties & retained earnings

HR STATISTICSFirst time departures (full year)

2009

2008

Sources of Income
As part of MSF’s effort to guarantee
its independence and strengthen theorganisation’s link with society, we strive
to maintain a high level of private income.
In 2009, 88.3% of MSF’s income camefrom private sources. More than 3.8 million
individual donors and private foundations
worldwide made this possible. Public
institutional agencies providing funding
to MSF include, among others: ECHO, thegovernments of Belgium, Canada, Denmark,Germany, Ireland, Luxembourg, Spain,
Sweden and the UK.
Expenditure
Expenditures are allocated according to themain activities performed by MSF. ‘Operations’
includes programme-related expenses as wellas the headquarters’ support costs devoted tooperations. All expenditure categories include
salaries, direct costs and allocated overheads.
Permanently restricted funds may either becapital funds, where the assets are requiredby the donors to be invested, or retained for
actual use, rather than expended, or they
may be the minimum compulsory level ofretained earnings to be maintained by someof the sections.
Unrestricted funds are unspent nondesignated donor funds expendable at thediscretion of MSF’s trustees in furtherance of
our social mission.
Other retained earnings represent
foundations’ capital as well as technicalaccounts related to the combination process,including the conversion difference.
MSF’s retained earnings have been built
up over the years by surpluses of income
over expenses. As of the end of 2009,
their available part (the unrestricted funds
decreased by the conversion difference)
represented 9.1 months of activity. The
purpose of maintaining retained earnings is
to meet the following needs: future major
emergencies for which sufficient funding
cannot be obtained, and/or a sudden dropof private and/or public institutional funding,and the sustainability of long-term programs(e.g. ARV treatment programs), as well as thepre-financing of operations to be funded byupcoming public funding campaigns and/or
by public institutional funding.
Unspent temporarily restricted funds areunspent donor-designated funds, which willbe spent by MSF strictly in accordance withthe donors’ desire (e.g. specific countries ortypes of interventions).
The complete Financial Report is available on
www.msf.org

AUDITED FACTS AND FIGURES

79

Contact MSF
Australia Médecins Sans Frontières
Suite C, Level 1 | 263 Broadway Glebe NSW 2037
PO BOX 847 | Broadway NSW 2007 | Australia
T 61 (0) 29 552 4933 | F 61 (0) 29 552 6539
office@sydney.msf.org | www.msf.org.au
Pr Dr. Nicholas Coatsworth |GD Philippe Couturier
Austria Médecins Sans Frontières/Ärzte Ohne Grenzen
Taborstraße 10| 1020 Vienna | Austria
T 43 1 409 7276 | F 43 1 409 7276/40
office@aerzte-ohne-grenzen.at |www.aerzte-ohne-grenzen.at
Pr Dr. Reinhard Doerflinger |GD Franz Neunteufl
Belgium Médecins Sans Frontières/Artsen Zonder Grenzen
Rue Dupré 94 / Dupréstraat 94 |1090 Brussels | Belgium
T 32 2 474 74 74 | F 32 2 474 75 75
info@azg.be | www.msf.be or www.azg.be
Pr Dr. Jean-Marie Kindermans |GD Christopher Stokes
Canada Médecins Sans Frontières/Doctors Without Borders
720 Spadina Avenue, Suite 402 | Toronto
Ontario M5S 2T9 | Canada
T 1 416 964 0619 | F 1 416 963 8707
msfcan@msf.ca | www.msf.ca
Pr Dr. Joni Guptill | GD Marilyn McHarg
Denmark Médecins Sans Frontières/Læger uden Grænser
Kristianiagade 8| 2100 København Ø | Denmark
T 45 39 77 56 00 | F 45 39 77 56 01
info@msf.dk | www.msf.dk
Pr Dr. Jesper H.L Jbrgensen |GD Michael G. Nielsen
France Médecins Sans Frontières
8 rue Saint Sabin | 75011 Paris | France
T 33 1 40 21 29 29 | F 33 1 48 06 68 68
office@paris.msf.org | www.msf.fr
Pr Dr. Marie-Pierre Allié | GD Filipe Ribeiro
Germany Médecins Sans Frontières/Ärzte Ohne Grenzen
Am Köllnischen Park 1 | 10179 Berlin | Germany
T 49 (30) 700 13 01 00 | F 49 (30) 700 13 03 40
office@berlin.msf.org |www.aerzte-ohne-grenzen.de
Pr Dr. Tankred Stoebe |GD Dr. Frank DoernerGreece Médecins Sans Frontières
15 Xenias St. | 115 27 Athens | Greece
T 30 210 5 200 500 | F 30 210 5 200 503
info@msf.gr | www.msf.gr
Pr Ioanna Papaki |GD Reveka Papadopoulou

80

Contact MSF

Holland Médecins Sans Frontières/Artsen zonder Grenzen
Plantage Middenlaan 14 | 1018 DD Amsterdam
The Netherlands
T 31 20 520 8700 | F 31 20 620 5170
office@amsterdam.msf.org |www.artsenzondergrenzen.nl
Pr Dr. Pim De Graaf | GD Hans van de Weerd
Hong Kong Médecins Sans Frontières
香港無國界醫生
22/F Pacific Plaza | 410 – 418 Des Voeux RoadWest | Sai Wan | Hong Kong
T 852 2959 4229 | F 852 2337 5442
office@msf.org.hk | www.msf.org.hk
Pr Dr. Fan Ning | GD Dick van der Tak
Italy Medici Senza Frontiere
Via Volturno 58 | 00185 Rome | Italy
T 39 06 44 86 92 1 | F 39 06 44 86 92 20
msf@msf.it | www.medicisenzafrontiere.it
Pr Raffaella Ravinetto | GD Kostas Moschochoritis
Japan Médecins Sans Frontières /国境なき医師団日本
3F Waseda SIA Bldg | 1-1 Babashitacho |Shinjuku-ku | Tokyo 162-0045 | Japan
T 81 3 5286 6123 | F 81 3 5286 6124
office@tokyo.msf.org | www.msf.or.jp
Pr Dr. Nobuko Kurosaki | GD Eric Ouannes
Luxembourg Médecins Sans Frontières
68, rue de Gasperich | 1617 Luxembourg |Luxembourg
T 352 33 25 15 | F 352 33 51 33
info@msf.lu | www.msf.lu
Pr Dr. Bechara Ziade | GD Karine Van Houte
Norway Médecins Sans Frontières/Leger Uten Grenser
Postboks 8813 Youngstorget | 0028 Oslo |Norway | Youngstorget 1 | 0181 Oslo | Norway
T 47 23 31 66 00 | F 47 23 31 66 01
epost@legerutengrenser.no |www.legerutengrenser.no
Pr Dr. Håkon Bolkan | GD Patrice Vastel
Spain Médicos Sin Fronteras
Nou de la Rambla 26 | 08001 Barcelona | Spain
T 34 93 304 6100 | F 34 93 304 6102
office-bcn@barcelona.msf.org | www.msf.es
Pr Dr. Paula Farias | GD Aitor Zabalgogeazkoa
Sweden Médecins Sans Frontières /Läkare Utan Gränser
Gjörwellsgatan 28, 4 trappor | Box 34048 |100 26 Stockholm | Sweden
T 46 8 55 60 98 00 | F 46 8 55 60 98 01
office-sto@msf.org | www.lakareutangranser.se
Pr Kristina Bolme Kühn | GD Johan Mast
Switzerland Médecins Sans Frontières/Ärzte Ohne Grenzen
78 rue de Lausanne | Case Postale 116 |
1211 Geneva 21 | Switzerland
T 41 22 849 84 84 | F 41 22 849 84 88
office-gva@geneva.msf.org | www.msf.ch
Pr Abiy Tamrat | GD Christian Captier

UK Médecins Sans Frontières
67-74 Saffron Hill | London EC1N 8QX | UK
T 44 207 404 6600 | F 44 207 404 4466
office-ldn@london.msf.org | www.msf.org.uk
Pr Paul Foreman | GD Marc DuBois
USA Médecins Sans Frontières/Doctors Without Borders
333 7th Avenue | 2nd Floor | New York, NY
10001-5004 | USA
T 1 212 679 6800 | F 1 212 679 7016
info@newyork.msf.org |www.doctorswithoutborders.org
Pr Dr. Matthew Spitzer| GD Sophie DelaunayInternational OfficeMédecins Sans FrontièresInternational Office and UN Liaison Office - Geneva
78 rue de Lausanne | Case Postale 116 |
1211 Geneva 21 | Switzerland
office-intl@bi.msf.org | www.msf.org
T 41 22 849 84 00 | F 41 22 849 84 04
Pr Dr. Christophe Fournier (until June 2010),
Dr Unni Karunakara ( July 2010 onwards) |SG Kris Torgeson
Policy and Advocacy Coordinator: Emmanuel Tronc
emmanuel.tronc@msf.org
Other Offices
MSF Access to Essential MedicinesCampaign
78 rue de Lausanne | Case Postale 116 |
1211 Geneva 21 | Switzerland
T 41 22 849 8405 | F 41 22 849 8404
www.accessmed-msf.org
Director: Dr. Tido von Schoen-Angerer
UN Liaison Office – New York 333 7th
Avenue | 2nd Floor | New York,NY 10001-5004 | USA
T 1 212 655 3777 | F 1 212 679 7016
MSF UN liaison officer: Fabien Dubuet
fabien.dubuet@newyork.msf.org
MSF office in South Africa
Orion Building | 3rd floor | 49 Jorissen Street,Braamfontein 2017 | Johannesburg
T +27 11 403 44 40/41 | www.msf.org.za
MSF office in Brazil
Rua Santa Luzia, 651/11° andar |Centro - Rio deJaneiro | CEP 20030-040 | Rio de Janeiro
T (+55) 21 2220-8277 | www.msf.org.br
MSF office in United Arab Emirates
P.O. Box 47226 | Abu Dhabi, UAE
T (+971) 2 6317 645 | www.msfuae.ae
MSF office in Argentina
Carbajal 3211 | Código Postal 1426 | BelgranoCiudad de Buenos Aires | Argentina
T 54 11 4551 4460 | www.msf.org.ar

Pr President | GD General Director
SG Secretary GeneralAbout this report
Articles written by
Alessandra Vilas Boas, Anne Yzebe, Andrea Bussotti, Brigitte Breuillac, Clara Tarrero,
Claude Mahoudeau, François Dumont, Francois Servranckx, Frédéric Baldini, Gemma Ortiz Genovese,
Irene Jancsy, Isabelle Ferry, Isabelle Jeanson, Isabelle Merny, Javier Sancho, Jehan Bseiso,
Julia Kourafa, Julie Damond, Kate de Rivero, Koert Ritmeijer, Laura Brav, Laura McCullagh,
Linda Nagy, Marcell Nimfuehr, Maria Masha, Dr Martin De Smet, Naomi Pardington,
Naomi Sutorius-Lavoie, Niamh Nic Carthaigh, Niklas Bergstrand, Olivier Falhun, Pascale Zintsen,
Philippe Latour, Sam Taylor, Silvia Fernández, Susan Sandars, Susanne Doettling, Sylviane Bachy,
Véronique Terrasse, Victoria Russell, Yasmin Rabiyan.
Special thanks to
Christophe Fourner, Kris Torgeson, Erwin van ‘t Land, Jordi Passola, Emmanuel Tronc,
Corinne Galland, Djamila Mili and Scottie McLaren.
English Edition
Managing Editor Siân Bowen
Editorial Support Rachel McKee
Photo editor Bruno De Cock
Proof Reader Diane Pengelly
French Edition
Editor Frédéric Baldini
Translation Translate 4 U sàrl ( Aliette Chaput, Emmanuel Pons )Editorial Support Isabelle Palacin-Chen
Italian Edition
Coordinator Barbara Galmuzzi
Translation Selig S.a.S.
Editor Barbara Galmuzzi
Spanish Edition
Coordinator Alois Hug
Translation Pilar Petit
Editor Eulalia Sanabra
Arabic Edition
Coordinator Tracy Crisp
Translation Mounir El Boughdadi, Saoussen Haouet
Editor Jessica Moussan-Zaki
Design and produced by
ACW, London, UK
www.acw.uk.com

Médecins Sans Frontières (MSF) is an international,
independent, medical humanitarian organisationthat delivers emergency aid to people affected byarmed conflict, epidemics, healthcare exclusion
and natural disasters. MSF combines the provisionof emergency medical care with a commitment
to speaking out about the suffering people endure
and the obstacles encountered in providing
assistance. MSF offers assistance to people based

only on need and irrespective of race, religion,
gender or political affiliation.
Today MSF has national sections in 19
countries. In 2009 over 22,000 doctors,
nurses and other medical professionals,
logistical experts, water and sanitationengineers and administrators provided
medical aid in over 65 countries.

MSF International Office
78 Rue de Lausanne, Case Postale 116, CH-1211, Geneva 21, Switzerland
Tel: (+41-22) 8498 400, Fax: (+41-22) 8498 404, Email: office-intl@bi.msf.org, www.msf.org
COVER PHOTO
Mobile clinic, Masisi, DRC. A staff member carries out a consultation on a 43 year old woman who suffered rape at gun-point.
She received medication and psychological support.
© Sarah Elliott, Democratic Republic of Congo