Today MSF is an international medical
humanitarian movement with national
sections in 19 countries. In 2008, over 26,000
doctors, nurses, and other medical professionals,
logistical experts, water and sanitationengineers and administrators provided
medical aid in over 65 countries.

MSF Activity Report 2008

Médecins Sans Frontières (MSF) was founded in1971 by a small group of doctors and journalists
who believed that all people should have accessto emergency relief. MSF was one of the first non
governmental organisations to provide urgently
needed medical assistance and to publicly bear
witness to the plight of the people it helps.

MSF Activity
Report 2008
MSF International Office
78 Rue de Lausanne, Case Postale 116, CH-1211 Geneva 21, Switzerland
T (+41-22) 8498 400, F (+41-22) 8498 404, E office-intl@bi.msf.org, www.msf.org

The Médecins Sans Frontières Charter

About this Book
Country text and sidebar material written by

Médecins Sans Frontières is a private international
association. The association is made up mainly of doctors
and health sector workers and is also open to all otherprofessions that might help in achieving its aims.
All of its members agree to honour the following principles:

Caroline Abu-Sada, Sylviane Bachy, Koen Baetens, Frédéric Baldini,
Niklas Bergstrand, Jason Cone, Natacha Bühler, Susan Doettling,
François Dumont, Romain Gitenet, Alois Hug, Olivier Falhun, Isabelle Ferry,
Irene Jancsy, Isabelle Jeanson, Clémentine Lacroix, Claude Mahoudeau,
Megan McKenna, Isabelle Merny, Anna-Karin Moden, Niamh Nic Carthaigh,Naomi Pardington, Yasmin Rabiyan, Susan Sandars, Francois Servranckx,

Médecins Sans Frontières provides assistance to populations
in distress, to victims of natural or man-made disasters andto victims of armed conflict irrespective of race, religion,
creed or political convictions.

Natalia Sheletova, Clara Tarrero, Véronique Terrasse, Theodora Theodoridou,
Anna Tsuji, Mirjam van den Berg, Erwin van ‘t Land, Alessandra Vilas Boas.

Neglected diseases essay material written by
Francois Chappuis, Pedro Pablo Palma, Nines Lima, Myrian Henkens

Médecins Sans Frontières observes neutrality andimparti­ality in the name of universal medical ethics andthe right to humanitarian assistance and claims full andunhindered freedom in the exercise of its functions.

Special thanks to
Liane Cerminara, Gaëlle Fedida, Corinne Galland, Myriam Henkens,
Alice Kociejowski, Sally McMillan, Djamila Mili, Jordi Passola,
Michel Peremans, Miriam Schlick, Monique Smulders, Kris Torgeson,

Members undertake to respect their professional code of
ethics and to maintain complete independence from allpolitical, economic or religious powers.
As volunteers, members understand the risks and dangersof the missions they carry out and make no claim forthemselves or their assigns for any form of compensation
other than that which the association might be able toafford them.

Emmanuel Tronc, Alessandra Vilas Boas, and all the field, operations
and communications staff who reviewed material for this report.

English Edition
Managing Editor Siân Bowen
Research & Editorial Support Hélène Ponpon
Photo Editor Bruno De Cock
Editor Diane Pengelly
French Edition
Coordinator & Editor Hélène Ponpon
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
The country texts in this report provide descriptive overviews of MSF work

An Arabic version will also be available. For copies please contact

throughout the world between January and December 2008. Staffing figures

the MSF international office.

represent the total of full-time-equivalent positions per country in 2008.
Reasons for Intervention classify the initial event(s) triggering an MSF

Graphic Design

medical-humanitarian response as documented in the 2008 International

Studio Roozen, Amsterdam, The Netherlands

Typology study. Country summaries are representational and, owing to space

Printing

considerations, may not be entirely comprehensive.

Kunstdrukkerij Mercurius, Westzaan, The Netherlands

cover photo © Marta Ramoneda, Pakistan

12|

2 | MSF missions around the world
4 | The year in Review
			 Kris Torgeson, Secretary General, MSF International
			 Dr Christophe Fournier, President, MSF International Council

7 | Overview of MSF operations

4|

8 | under-reported Crises of 2008
			Photo story
10 | Three neglected killers
15 | Glossary of diseases
			 MSF projects around the world
17 | Africa
47 | Asia and the Caucasus
65 | The Americas
71 | Europe and the Middle East
			 Sidebars
24 | MSF challenges in Eastern Congo
79 | New humanitarian concerns in Iraq

10|

17|

84 | MSF Country Programme closures
86 | Audited Facts and figures
88 | Contact MSF

79|

Médecins Sans Frontières Activity Report 2008

Contents

3

MSF Missions around the world
MSF opens and closes a number of individual
projects each year, responding to acute crises,
handing over projects, and monitoring andremaining flexible to the changing needsof patients at any given location. Several
projects may be running simultaneously
in a single country as needed.

48 | Armenia	
49 | Bangladesh
72 | Belgium
66 | Bolivia
66 | Brazil
18 | Burkina Faso
19 | Burundi
50 | Cambodia	
20 | Cameroon
21 | Central African Republic
22 | Chad
51 | China
68 | Colombia	
23 | Democratic Republic
		 of Congo
25 | Ethiopia
72 | France
52 | Georgia	
73 | Greece69 | Guatemala
26 | Guinea-conakry
27 | Guinea-Bissau
70 | Haiti

RUSSIANFEDERATIONBELGIUM
FRANCEMOLDOVASWITZERLANDITALYUZBEKISTANGEORGIAARMENIAGreeceKYRGYZSTANTURKMENISTAN

LebanonMalta

59 | Papua New Guinea
60 | Philippines
76 | Russian federation
37 | Sierra Leone
38 | Somalia
39 | South Africa	
60 | Sri Lanka	
40 | Sudan
43 | Swaziland
77 | Switzerland
62 | Thailand
63 | Turkmenistan
44 | Uganda
64 | Uzbekistan
80 | Yemen
45 | Zambia
46 | Zimbabwe
closed countries
84 | CONGO-BRAZZAVILLE
84 | CÔTE D’IVOIRE
84 | Laos

CHINA

PALESTINIANTERRitories

Morocco69 | Honduras	
52 | India
54 | Indonesia	
78 | Iran78 | Iraq
74 | Italy
28 | Kenya
55 | Kyrgyzstan
80 | Lebanon
28 | Lesotho
30 | Liberia
31 | Malawi
32 | Mali
75 | Malta
76 | Moldova
32 | Morocco
34 | Mozambique
56 | Myanmar
57 | Nepal
35 | Niger
36 | Nigeria	
58 | Pakistan
82 | Palestinian Territories

IRAQ

IRAN
PAKISTAN

NEPAL

BANGLADESH
INDIA
HAITI

Mali

GUATEMALAHONDURAS

Chad

GuineaCOnakry
SierraCÔTE
Leone
D’IVOIRE
Liberia

Nigeria

Cameroon

LAOS
THAILAND

Yemen

Sudan

Burkina
Faso

Guinea-Bissau

COLOMBIA

Niger

MYANMARCAMBODIA
Ethiopia

CentralAfricanRepublic

Philippines
SRi LANKA

Somalia

CONGOBRAZZAVILLE

UgandaKenya
INDONESIA

Democratic
republic ofcongo

BurundiPAPUA NEW GUINEA

BrazilMalawi
Zambia
BOLIVIA

Zimbabwe
Mozambique

swaziland
LesothoSouth Africa

Médecins Sans Frontières Activity Report 2008

M SF M I SSIONS A R OUD THE WO RLD

2

5The year in review
Kris Torgeson, Secretary General, MSF International
Dr Christophe Fournier, President, MSF International Council

These emergencies made the world news in
2008, if only briefly. But most of what
MSF teams accomplished during the year –and even more disturbingly, what they
were unable to accomplish – did not makeit into the headlines and is difficult tosummarise in statistics or brief reports.
Accessing the victims of armed conflicts incountries such as Somalia, Iraq, Pakistan,
Sudan, and the Palestinian Territories
posed a tremendous challenge throughout
the year. Insecurity and administrative
barriers – sometimes raised intentionally– contributed to these challenges. MSF
relied heavily on national staff to help
provide independent humanitarian assistance to those most in need in theseconflict zones.
In Somalia, the kidnapping and release of
two members of staff over the 2008 New
Year, and then the brutal killing of threecolleagues in January, forced MSF to close
programmes and reassess how to deliver
assistance in this highly violent conflict.
MSF Somali staff kept working: theytreated 2,300 people wounded by gunshots
or mortar rounds and cared for 10,000
children suffering from acute malnutritionin camps for people displaced by theviolence. In Iraq, MSF continued to provide
medical assistance at the periphery of theconflict through reconstructive surgicalprogrammes and by providing training andsupplies to hospitals in the country.

© Kris Torgeson

2008 was a year of achievement as well
as frustration for MSF. While advances
in malnutrition treatment allowed morechildren to be helped, teams trying toreach victims of some of the most acuteconflicts in the world faced considerable obstacles.

Throughout the year, MSF aid workers
carried out 8.8 million consultations and47,500 surgical interventions in over 65
countries. They provided treatment for
more than one million people withmalaria, and nutritional care for morethan 200,000 malnourished children.

In Myanmar, they provided medical andpsychosocial support, shelter and food tosurvivors of Cyclone Nargis. For months,
MSF was one of the only organisations
with access to all cholera-affected areas inZimbabwe, and by early 2009 had treated
45,000 people.

When post-election violence broke out inKenya, a cyclone devastated Myanmar’s
Irrawaddy Delta, and a cholera epidemic
swept Zimbabwe, MSF medical teams werealready in place and ready to offer
urgently needed assistance. In Kenya, MSF
reinforced its teams on the ground withextra surgeons, emergency physicians,
nurses, and logistical specialists in
response to the escalating violence.

In the Democratic Republic of Congo(DRC), MSF provided critical medical carein towns affected by fighting in theeastern part of the country. Throughout
the region, teams treated war-wounded insurgical programmes, set up cholera treatment facilities, and provided other basic
essentials such as clean water and relief
items to displaced people and local
residents.

After more than two decades working in
Afghanistan, MSF was forced to leave in2004 following the deliberate slaughter offive colleagues. In 2008, teams began
exploring the possibility of returning toprovide medical assistance again to thoseaffected by escalating insecurity. In neighbouring Pakistan, where 600,000 people
fled due to fighting in the North West
Frontier Province, MSF teams helped
people to access healthcare by offering
ambulance services. But ensuring that all
parties to the conflict recognise andrespect independent humanitarian assistance continued to prove difficult. In early2009 MSF was forced to suspend thisservice after two members of staff travelling in a clearly identified MSF ambulance
were killed.

In Sudan, increasing administrative
obstacles and insecurity hindered MSF’s
response to those most in need in Darfur
and other regions. For example, in August,after a series of attacks against staff,
teams were forced to leave projects in
Tawila, North Darfur, where 35,000 displaced people had gathered, and in
Shangil Tobaya, where MSF had provided
medical care for 28,000 displaced people.
Leaving so many people without access to
medical care, even if only temporarily, wasextremely hard, but without a guaranteeof minimum security for humanitarian
workers, MSF had no option but to suspend
activities for several weeks. Despite this,
70,000 consultations where carried out inthese two areas in 2008.

In Ethiopia, between May and August, MSF
conducted a large programme treating
more than 28,000 people for acute andmoderate malnutrition. In Niger, work was
threatened in July when local authorities
suspended MSF projects in some regions.
This decision was based largely on theauthorities’ desire to re-integrate activities into the national healthcare systemand to avoid independent action andpublic awareness campaigns. MSF believed
this decision was taken prematurely, considering the number of children affected,
and after two months of discussions, teams
were able to partially restart some nutritional activities. In 2008, MSF treated97,600 children under five who were moderately or severely malnourished.

In December, Israel launched the ‘Hard
Lead’ offensive in the Gaza Strip. During
the fighting, MSF struggled to send in
additional medical teams due to Israeli
restrictions on the movement of people
and aid. However, teams already in Gaza
were able to respond immediately by supporting the local hospitals overwhelmed by
the influx of wounded. Only once theIsraeli forces had declared a ceasefire in
January were a surgical team and 21 tonsof supplies (including two inflatable
hospital tents) able to reach Gaza City.
MSF then concentrated its activities on
specialised surgery and on postoperativeand physiotherapy treatment.

In Southern Africa, where TB/HIV coinfection is endemic, MSF stepped up
efforts to increase access to diagnosis andtreatment. In recent years, the number ofpeople with TB alone has more thantripled in countries where HIV prevalence
is high. Worldwide, an estimated one thirdof all HIV sufferers have TB, but only one
per cent receive treatment. Most people
are not tested for TB and even if they are,the standard diagnostic method is a
century old and ineffective for mostpeople living with HIV. In addition, thecurrent treatment protocols are difficultfor people on antiretroviral therapy (ART)
to use. MSF repeatedly called on governments and donors to invest in TB researchand the development of new diagnostic
and therapeutic tools, estimating thatcurrent investment falls at least four times
below what is needed to combat the resurgence of this deadly, but treatable,disease.

Another key objective in 2008 was to find
new ways to fight malnutrition andneglected diseases. Throughout the year,
MSF lobbied to improve the standards ofinternational food aid so that young
children would receive the nutrients theyneed. In the areas most chronically devastated by malnutrition, such as South Asia,
the Sahel, and the Horn of Africa, manyfamilies cannot afford nutritious food.
However, food aid provided by international agencies and donors is mainly cereal-based and does not include
animal-source foods, such as milk, whichcontain essential nutrients. In 2008, MSF
committed to treating undernourishedchildren with the animal-source food theyneed and lobbying for wider availability of
appropriate food aid for children aroundthe world.

HIV also affects an estimated 1.9 million
children worldwide, but only around
200,000 of those who need it receive ART,
meaning that nine out of ten children do
not have access to the lifesaving medicines they need. In response to this, MSF
called on governments and donors to makeexisting tests more widely available andto increase considerably the use of apaediatric version of a standard fixed-dose
combination drug. A combined effort bygovernments and aid agencies is needed,and MSF will continue to provide

Médecins Sans Frontières Activity Report 2008

THE YE A R IN R EVIEW

47In July 2008, MSF was shocked by ajudgement made by Switzerland’s highest
judicial body, the Federal Tribunal. The
case concerned the repayment of a ransom
paid by the Dutch authorities to obtain
the release of Arjan Erkel, a Dutch civilian
and MSF head of mission, who was held
hostage in the North Caucasus region for
20 months having been abducted inAugust 2002. Following four years of proceedings, and in spite of two previous
rulings in favour of MSF, the Federal
Tribunal found partly in favour of the
Dutch government by ruling that thefinancial burden should be shared between
MSF and the Dutch government. Thisdecision sets a grave precedent for independent humanitarian action. By agreeing
to downgrade the consequences of theabduction to a mere commercial dispute,
as requested by the Dutch government,
the Federal Tribunal’s ruling is contributing to making unpunished crimes against
humanitarian workers part of everyday
life.

© Joanne Wong

comprehensive treatment, including theprevention of mother-to-child transmissionof HIV.
MSF also continues to support the search
for new treatments for neglected diseases
and in 2008 an important step towards
improving treatment options for sleeping
sickness was taken. The Drugs for
Neglected Diseases Initiative (DNDi),
together with MSF and Epicentre, pioneered a new, less toxic and easier-toadminister treatment for sleeping sickness,called NECT (Nifurtimox-Eflornithine
Combination Therapy). This ten-day treatment is of particular interest to MSF sincemost of the 50,000 patients currently
needing treatment are in remote andunstable areas.

Challenging the deliberate exclusion fromhealthcare that many people experience
remained a focus of MSF’s work in 2008
and teams in Europe, the Middle East andAfrica sought to help refugees andmigrants in need of medical assistance.
Restrictive entry policies in Europe havenot stopped people from arriving in searchof refuge, protection, or better living
conditions. In response to their healthneeds, MSF is running emergency medical
programmes in a number of countries
including Malta, Italy and Greece. In South
Africa, too, teams provided these services
to a mostly Zimbabwean migrant population. It is clear that migration and displacement is a global challenge – MSF
assisted displaced people in 37 countries
in 2008.

There is no doubt that, in 2009, MSF willcontinue to challenge barriers to the provision of independent, emergency medicalcare to those affected by conflict or
excluded from healthcare. MSF will seek
new, innovative ways to treat malnutrition
and infectious diseases, will ensure that
medical tools are effective and field-adapted, and will work to increase preparedness
to respond to natural disasters. But thisvital work can be done only with thecontinued support of the millions ofdonors – including 3.7 million individuals
worldwide – and the tens of thousands of
MSF staff who make it possible every day.

Overview of MSF OPERATIONS 2008
Largest interventions based on
project expenditure
1 Democratic Republic of Congo
2 North Sudan
3 Somalia
4 Ethiopia
5 South Sudan
6 Niger
7 Chad8 Myanmar
9 Kenya10		 Zimbabwe
11		 Haiti
12		 Central African Republic

Project locations
Africa | 68%
Asia | 16%
Americas | 7%
Europe | 6%
Middle East | 4%Context of interventions
Stable | 41%
Armed conflict | 34%
Internal instability | 19%
Post-conflict | 6%

Thank you.

Event triggeringintervention
Armed conflict | 42%
Epidemic/Endemic disease | 33%
Social violence/Healthcare
exclusion | 21%
Natural disaster | 4%

Activity highlights(Non-exhaustive and inclusive only of activities with MSF direct patientcare. Activity may involve diagnostics, treatment and follow up.)

ACTIVITY	DEFINITION	TOTAL
Outpatient
Outpatient consultations
8,814,813
Inpatient
Admitted patients
312,509
Malaria
Confirmed cases treated
1,178,679
Therapeutic
Severely malnourished children admitted tofeeding centres inpatient or mobile centres
212,565
Supplementary Moderately malnourished children admitted
feeding centres		
119,353
Deliveries
Women who delivered babies, including by 		
Caesarean section
101,858
Sexual violence People affected by sexual violence who were
medically treated
15,145
Surgical
Major surgical interventions including obstetric 		
interventions surgery, under general or spinal anaesthesia
47,515Violence
Medical and surgical interventions in responsetraumato direct violence
48,871
HIV/AIDS
HIV/AIDS patients registered under care
227,591
Antiretroviral Patients on first-line treatment
therapy (first line)
130,214
Antiretroviral Patients on second-line treatment 		therapy(first-line treatment failure)(second-line) 		
1,761
Prevention of HIV-positive pregnant women who received
mother-to-child preventive treatment
transmission(mothers)
8,664
Prevention of Babies who received post-exposure treatment
mother-to-childtransmission(babies)		
8,807
Tuberculosis
New admissions to first-line treatment(first-line)		
29,369Tuberculosis
New admissions to second-line treatment(second-line) 		
971
Mental health Individual consultations
126,831(individual) 		
Mental health Counselling or support-group sessions(group) 		
22,173CholeraPeople admitted to cholera treatment centres ortreated with oral rehydration solution
68,293
Measles
People vaccinated for measles in response
vaccinations
to an outbreak
1,913,793
Measles
People treated for measles
32,652treatment
Meningitis
People vaccinated for meningitis in response
vaccinations
to an outbreak
706,787
Meningitis
People treated for meningitis
7,188
treatment

Médecins Sans Frontières Activity Report 2008

THE YE A R IN R EVIEW

69under-reported crises of 2008
1.
Somalia’s humanitariancatastrophe worsens

Somalia has some of the worst health indicatorsin the world, and its people have little or noaccess to even basic healthcare services. An
estimated one in ten women die during childbirth, and more than one in five children die
before their fifth birthday.
In 2008, violence in the country escalated tolevels not seen in over a decade. Since fighting
began in December 2006, a million Somalis havefled their homes. More than 250,000 people from
Mogadishu now live in appalling conditions on
the road out of the capital, and have little
prospect of respite.
Some Somalis head for Kenya where, according to
the UN refugee agency UNHCR, some 200,000 livein three camps. Others go north and board boats
to be smuggled across to Yemen. More than
43,500 people – mostly Somalis, but also
Ethiopians – attempted the journey in 2008.
Crammed into small vessels, many of thesewould-be refugees suffocate; many others drownin the Gulf.
Targeted attacks against aid workers have also
increased. Staff have been kidnapped and some,including three MSF staff, have been killed. MSF
and others have been forced to withdraw teams
and curtail medical activities, exacerbating thechronic difficulty of delivering urgently needed
help.

2.

Outside the spotlight, Myanmar’s
critical health needs are still
ignoredIn May, Cyclone Nargis devastated the Irrawaddy
Delta, leaving around 130,000 people missing or
dead. As news broke, MSF teams and othersbrought emergency assistance to the worstaffected areas. Most of MSF’s help was provided
by local staff, who were diverted from otherprogrammes in the country to respond to theemergency.
But beyond the media’s focus, the country’s
chronic health needs are barely acknowledged.
State health expenditure was $0.70 per person in
2007; international humanitarian aid amounted
to about $3 per person, the lowest rate worldwide. HIV/AIDS claimed 25,000 lives in 2007, yet
fewer than 20 per cent of the estimated 75,000
people who need antiretroviral therapy (ART) in
Myanmar can access treatment. MSF provides
around 80 per cent of the country’s freely available ART: an unsustainable situation that alreadyforces teams to restrict admissions to the HIV/AIDS programme.
Other treatable epidemics contribute to thecountry’s woeful health statistics: deaths frommalaria, the number-one killer, account for morethan half those in all Southeast Asia. More than80,000 people are diagnosed each year withtuberculosis (TB), and multi-drug-resistant TB ison the rise. More action by the national authorities and agencies is urgently needed to protect
thousands more vulnerable people from unnecessary suffering and death.

3.

Violence and economic collapse
exacerbate Zimbabwe’s growing
health crisis
In 2008, inflation in Zimbabwe reached 231
million per cent. Political violence escalated and,in the lead up to contested elections in June,
additional restrictions constrained the work ofhumanitarian organisations even further.
There are two million people living with HIV inthe country. The violence and economic
meltdown has forced many of those undergoingantiretroviral therapy to interrupt or abandon
their treatment, risking grave health consequences. Some can no longer afford to eat
properly or to travel to clinics for treatment,
others are afraid to leave their homes or havebeen forced to flee.
A huge number of Zimbabweans – including
much-needed medical staff – have left thecountry. About three million have fled to neighbouring South Africa. Every day, thousands morecross the Limpopo river to reach the border townof Musina, risking attacks by bandits. Many of
those who reach the other side have to live
outside the law to avoid arrest and deportation.
In May, violent xenophobic attacks in South
Africa displaced more than 100,000 people.
A cholera epidemic centred in Harare began inAugust and quickly spread. New outbreaks weredetected even before the rainy season – whencholera spreads more easily – had arrived. A
national emergency was declared and MSF
responded, treating more than 11,000 patients.

4.

Civilians trapped as war rages ineastern Democratic Republic ofCongo
Renewed fighting among armed groups and theCongolese armed forces (FARDC) have driven
hundreds of thousands of people to flee from
North Kivu, leaving them with little or no accessto food, water, basic shelter or healthcare.
The UN peacekeeping force MONUC has been
largely unable to protect people trapped by theviolence. It did lead an armed ‘humanitarianrelief’ convoy into Rutshuru after rebel forces
took control of the town, but such moves canmake the work of independent aid agencies evenharder, by blurring the distinction between
military and humanitarian action.
Out of the spotlight, people in Haut-Uélé
district, some 50,000 of whom had already been
driven from their homes, fell prey to cross-border
raids by the rebel group Lord’s Resistance Army.
Here as elsewhere, the fighting renders someareas inaccessible to humanitarian organisations
while overcrowding, poor sanitation and the lackof clean water in many camps for displaced
people leave thousands vulnerable to easily
treatable conditions and recurring epidemics.

5.

Ready-to-use food could bringswift recovery to millions ofmalnourished children

The World Health Organization estimates there
are 178 million undernourished children acrossthe globe. According to UNICEF, the situation is
actually getting worse in 16 countries. Up to fivemillion children under five years old die eachyear of complications related to malnutrition.
Combating hunger depends on having food in
sufficient quantity, but conquering malnutrition
depends on having foods of adequate nutritional
quality and quantity. Tens of millions of children
receive assistance from nutrition programmes –but many of these programmes are using thewrong foods. Fortified blended flours made fromeither corn or wheat plus soya are not enough:foods rich in nutrients, vitamins, and minerals
are essential to the healthy development ofbabies and children.
At any given moment, 20 million children are
suffering from severe acute malnutrition, yet
only seven per cent of them receive
UN-recommended treatment with nutrient-dense
ready-to-use food (RUF). These energy-dense
dairy-containing pastes and biscuits contain the
nutrition children need for catch-up growth andto ward off infection, and severely malnourishedchildren can recover rapidly by being given a
short course at home.
MSF has successfully treated more than 300,000
malnourished children in 22 countries in the last
two years. If RUF were more widely used, community-based and outpatient feeding programmes worldwide could treat millions more.

6.

Nomadic people isolated and incritical danger in Ethiopia’s
Somali region
Drought has already helped to destroy harvests,
food stocks, grazing lands and livestock in
Ethiopia’s Somali region, making life a continual
struggle for the country’s indigenous herders andbush-dwellers. But these largely nomadic people
are now also caught between battling rebel
groups and government forces. Some have been
directly exposed to the violence; many more are
becoming increasingly isolated.
Soaring prices and restrictions on importing
goods have rendered food and other staples
unaffordable. A limit on movement in somezones has not only left people unable to findfood for their livestock, but also prevented MSF
and other aid agencies from assessing andresponding to the situation. Administrative
hurdles radically increase the difficulty of providing desperately needed assistance.
There has been a significant increase in thenumber of children with severe acute malnutrition in the region, and inadequate water andsanitation have contributed to rising levels of
disease, yet MSF estimates that in at least one ofSomali’s nine zones, three-quarters of the people
have no access at all to healthcare.

7.

Civilians pay dearly as fighting
intensifies in northwest Pakistan

Fighting intensified between government forces
and militants in the North West Frontier Province
and the Federally Administered Tribal Areas ofPakistan throughout 2008. Air strikes by the US
military added to the destruction and in August,thousands of Pakistanis fled, many of them to
Afghanistan. Hundreds of people in the Bajaur
Agency, Swat and Mohmand regions in the NorthWest Frontier Province were killed or injured insuicide bombings, air attacks, and shootings.
Thousands more were displaced.
In October, more violence sent hundreds ofthousands of people into neighbouring regions injust a few days. Many found refuge in private
homes, mosques, schools, and makeshift camps.
Local health clinics were forced to close becauseof the violence and, in Kurram Agency, danger
posed by sectarian armed groups prevented all
but the most critical patients from travelling toreach medical services. MSF ambulances, sometimes the only vehicles allowed to travel during

the regular curfews, were attacked, forcing teams
to seek refuge.
Conflict has also been simmering in the easternregion of Balochistan for more than 30 years,
with grimly predictable consequences. In
October, a magnitude 6.4 earthquake that shook
the mountainous regions to the northwest
brought further devastation, killing some 300
people and leaving 40,000 more without homes.

8.

No end in sight to violence andsuffering in Sudan

One-third of the people of Darfur have been
displaced by the bitter civil war. Although morethan 80 humanitarian organisations provided
assistance in 2008, it was still difficult to accessand assess the needs of thousands of people.
Even the help that did get through was in dangerof being withdrawn because of unstable frontlines, shifting alliances and the attacks andincreasing government restrictions on aid
workers. Eleven were killed in Darfur in 2008 and
189 abducted, according to the UN.
In February, bombings, attack helicopters andground troops returned to West Darfur’s northern
corridor. Villages were burned and emptied,affecting some 50,000 people. After an attacknear Abyei, South Kurdufan, thousands fled tocamps in northern Bahr-el-Ghazal state and an
estimated 10,000 fled into the bush. In May,
fighting virtually destroyed Abyei, forcing
another 60,000 people to flee.
An estimated 1.2 million people returned tosouthern Sudan after 20 years of civil war to findthe infrastructure, services, and healthcare of
their former homeland had all but disappeared.
Malnutrition is endemic, maternal mortality rates
remain among the highest in the world, tuberculosis and kala azar (visceral leishmaniasis) arecommon and large-scale outbreaks of meningitis,
measles, cholera, and malaria are relentless.
And now, though violence could reignite at any
time, the number of humanitarian agencies isdeclining as some important donors redirect
their funds.

9.

Thousands of Iraqis left with
nowhere to turn

One of the many challenges facing humanitarianorganisations is reaching people caught up inarmed conflicts. Since 2003, efforts in Iraq havebeen frustrated not only by the usual physicaland administrative obstacles, but also by militaryand political factions’ using humanitarian action

for political purposes, so making workers themselves targets for attack.
Four million people have been displaced by the
war in Iraq, and half of them are trapped within
the country itself, according to the UN refugee
agency (UNHCR) and the Norwegian RefugeeCouncil.
Bombings and sectarian violence kill and cause
injuries that often require immediate and intensive attention, but the long-neglected healthcare
system leaves thousands of Iraqis with little orno medical care, even at primary level. Diseases
spread easily in the overcrowded camps, anddrug-resistant bacterial infections thrive.
The Iraqi government has tried to develop healthservices, but many medical staff have fled thecountry and there are still enormous gaps to fill.
MSF provides surgical programmes, training for
Iraqi professionals, supplies, emergency response,
education campaigns and psychological support– but it can reach only a tiny fraction of those inincreasingly urgent need.

10.

Better tools and techniquesvital to combat HIV/tuberculosis co-infection

Every year, tuberculosis (TB) kills about 1.7
million people. It is one of the leading causes ofdeath for people with HIV/AIDS, roughly a thirdof whom (11 million worldwide) are infected withlatent TB. Yet in 2006 less than one per cent of
those living with HIV/AIDS were screened for TB.
Diagnosis of TB is difficult: a standard test,
invented more than a century ago, cannot detectthe disease in most people who are HIV-positive.
Rapid culture tests achieve better results, but are
too complex to perform in the places where mostpatients live.
Treatment for TB is outdated, complicated, andnot adapted to the specific problems of coinfected patients. At least four TB drugs are
required initially. Sometimes they have serious
side-effects; sometimes they compromise thepatient’s HIV medication. No new TB drugs havebeen developed for large-scale use in decades,
and the increasing incidence of drug-resistant TB
complicates matters even further.
In 2006, investment in the development of TB
medicines, diagnostic tools, and vaccines
amounted to an estimated $429 million, according to the Treatment Action Group: a sum
woefully short of the $2 billion annual investment urgently needed to give millions of coinfected people a fighting chance of survival.

Médecins Sans Frontières Activity Report 2008

under-reported crises of 2008

8

11

Three
neglected
killers

MSF dedicated the award’s prize money to its
neglected diseases programmes. In the same year
the Access to Essential Medicines campaign was
launched which became a fundamental aspect of
MSF’s work, as did its commitment to improving thequality of drugs available, and ensuring that eventhe poorest communities have access to them.

Médecins Sans Frontières Activity Report 2008

P h oto essay | three neglected killers

10Over the years, MSF has been able to report that
globally research and development has improved forneglected diseases. Yet the needs of victims of themost neglected diseases are still largely unmet.
Together three diseases - Kala Azar, Chagas andSleeping Sickness - endanger the lives of more than
80 million people every year.
Kala Azar, or visceral leishmaniasis, frequently
affects poor communities often in isolated regions.
Spread by the sand fly, and fatal if left untreated,the disease is endemic in 88 countries. Ninety percent of cases occur in Bangladesh, Brazil, India,
Nepal and Sudan. Treatment is hampered by drug
resistance, high prices, lack of access to existing
medicines, and slow progress on research into newcures.
Chagas disease is endemic in many Latin Americancountries, where it affects an estimated ten to 15© Francesco Zizola / Noor

Ten years ago, when the Nobel Peace
Prize was awarded to Médecins Sans
Frontières, MSF’s president at thetime, James Orbinski, said that
more than 90 per cent of all deaths
and suffering from infectious
diseases occur in the developingworld because “life-saving essential
medicines are either too expensive,
are not available because they are
not seen as financially viable, or
because there is virtually no newresearch and development forpriority tropical diseases.”© Juan Carlos Tomasi

million people and claims up to 40,000 lives every
year. The condition damages the heart, nervous anddigestive systems in one-third of patients.
Sleeping sickness affects 36 countries in subSaharan Africa, where 60 million people are at risk.
It was nearly eliminated in the 1960s, but has
re-emerged in the 1990s due to war, population
movement and the collapse of health systems.
Despite a decrease in reported cases due to improved
efforts in some areas, sleeping sickness remain
undetected and therefore untreated in remote and/or
unsafe areas of several countries where it is endemic.
A recent survey produced by the George Institutefor International Health revealed that less than
five per cent of worldwide research and developmentfor neglected diseases has been directed towards
the most neglected diseases, that of, Kala Azar,
chagas and sleeping sickness.
In 2008, MSF committed 18 million Euros to theDrugs for Neglected Diseases initiative (DNDi).
At the same time MSF will continue to support
operational and clinical research through its field
programmes, will call for new research into more
efficient drugs and demand that governments,
companies and agencies take action so that these
diseases receive the urgent attention and funding
they need.
© Juan Carlos Tomasi

13Kala Azar in India

Médecins Sans Frontières Activity Report 2008

P h oto essay | three neglected killers

12

Many of the worldwide cases of Kala Azar areconcentrated in the northeast Indian state of Bihar.
The most common treatment is sodium stibogluconate; however, resistance to the drug is a growing
problem – especially in India, where as many as 65
per cent of patients become drug resistant. MSF has
been working in Bihar’s Vaishali district since 2007,
assisting Kala Azar patients with one of the mosteffective and safest treatments available to fight thedisease: liposomal amphotericin B. Medical teams
have diagnosed and treated more than 3,000
patients suffering from Kala Azar and achieved acure rate of 98.4 per cent. The mortality rate is
0.7 per cent and there is a low incidence of adverse
reactions.
Armed with this evidence, MSF is calling forliposomal amphotericin B to be included in the
Indian treatment protocol as a first-line treatment
option or to be used as one of the main drugs incombination therapies in the coming years.

© Juan Carlos Tomasi© Juan Carlos Tomasi

Chagas in Bolivia
In Bolivia, the country with the highest incidenceof the disease worldwide, Chagas is a major publichealth concern. Yet despite a presidential decree in
Bolivia which states that Chagas treatment inchildren needs to be routine, treatment is rarely
available and the people most at risk cannot afford it.
MSF is treating Chagas patients up to 50 years of age
in rural and suburban Bolivia, an important step
forward in the fight against Chagas which even today
is often not treated. Often this is due to the need for
greater access to proper diagnostic tools, for safer,
shorter treatments, for paediatric formulas and forearly cure rate predictors to monitor the efficacy ofthe drugs.
MSF is campaigning for the production and availability of two existing Chagas drugs - nifurtimox andbenznidazol - to be secured, and for efforts to findsimple, less toxic, more affordable and efficient
treatments for all forms of Chagas disease, forchildren and adults alike, to be stepped up.

© Juan Carlos Tomasi© Juan Carlos Tomasi

14

15

P h oto essay | three neglected killers

Chagas Disease
First described by the Brazilian doctor Carlos
Chagas, this parasitic disease is found almost
exclusively in Latin America, though increased
global travel has led to cases being reported in
the US and Europe. This potentially fatal
condition damages the heart, nervous anddigestive systems.
The disease is transmitted by blood-sucking
insects that live in cracks in the walls androofs of mud and straw housing, common inrural areas and poor urban slums in Latin
America. People can be infected but show nochronic symptoms for years. Debilitating andpossibly life-threatening chronic symptoms
develop in approximately 30 per cent of people
infected. Chagas can cause irreversible damage
to the heart, oesophagus and colon, shortening life expectancy by an average of ten years.
Heart failure is a common cause of death for
adults with Chagas.

Sleeping sickness
in Democratic
Republic of Congo

In Doruma, Ando and Bili, located in northeastern
Democratic Republic of the Congo, MSF has beentreating more than 1,500 patients with sleeping
sickness since July 2007. Disease prevalence in theregion is high, above 10 per cent in some villages.
Word of MSF’s work quickly spread, and people travelled from up to 90 miles away to receive treatment.
The treatment of patients in the second stage of theillness relies on eflornithine, a safe but complicatedtreatment that requires 56 infusions over 14 days.
Over the past 20 years, MSF has screened more than
two million people for the disease which is spread by
the tsetse fly, and treated 48,000 in several Africancountries.
In a major step forward in improving treatment
options, MSF, Epicentre and DNDi have pioneered a
new and easier-to-administer treatment for sleeping
sickness based on a combination of intravenous
eflornithine and oral nifurtimox. However simpler,preferably oral treatments are still needed.

© Claude Mahoudeau

Although most people infected with cholera
will have only a mild infection, the illness canalso be severe, causing profuse watery diarrhoea and vomiting that lead to severe dehydration and, without rapid treatment, 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 in areas where there areoutbreaks. Control and prevention measures
include ensuring an adequate supply of safe
drinking water and implementing strict
hygiene practices.

MSF treated over 68,000 people forcholera in 2008.

HIV/AIDS

Treatment must be given in early acute stagesof the infection, and so far drugs have beeneffective only in the acute and asymptomaticstage of the disease in children. Diagnosis iscomplicated: doctors need to perform two or
three blood tests to determine whether apatient is infected with the parasite. There arefew drugs developed to treat the disease andthe current line of treatment can be toxic,
taking one to two months to complete. Apartfrom managing symptoms, there has been noeffective treatment for chronic Chagas inadults.

The human immunodeficiency virus (HIV) is
transmitted through blood and body fluids
and gradually weakens the immune system –usually over a three- to ten-year period –leading to acquired immunodeficiency
syndrome or AIDS. A number of opportunistic
infections such as candidiasis, pneumonia,
and various kinds of tumours are able toflourish as the immune system weakens. Some
opportunistic infections can be treated, whilst
others are life-threatening. The most common
opportunistic infection leading to death istuberculosis.

MSF Chagas programmes in Bolivia focus
primarily on education, preventive measuresand screening and treatment for children. MSF
is now also attempting to treat adults througha project in Bolivia.

Many people live for years without symptoms
and may not know they have been infectedwith HIV. A simple blood test can confirm HIV
status. Combinations of drugs known asantiretrovirals help combat the virus andenable people to live longer, healthier lives
without rapid degradation of their immune
systems. It is simplest and easiest to take thesedrugs properly when they are combined into
single pills (fixed-dose combination). MSF’s
comprehensive HIV/AIDS programmes generally include education and awareness activities so people understand how to prevent the
spread of the virus; condom distribution; HIVtesting along with pre- and post-test counselling; treatment and prevention of opportunistic infections; prevention of mother-to-child

MSF treated over 2,000 people for
Chagas in 2008.

Cholera
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 cause sudden
large outbreaks.

transmission; and provision of antiretroviraltherapy for patients in advanced clinical stagesof the disease.

MSF provided care for more than
227,000 people living with HIV/AIDS
and antiretroviral therapy for morethan 130,000 people in 2008.

Human African
trypanosomiasis(Sleeping Sickness)
Frequently known as sleeping sickness, thisparasitic infection is seen in sub-SaharanAfrica and is transmitted by tsetse flies. Morethan 90 per cent of reported cases of sleeping
sickness are caused by the parasite
Trypanosoma brucei gambiense. The parasite
attacks the central nervous system, causing
severe neurological disorders and leading todeath if untreated.
During the first stage of the illness, people
have non-specific symptoms such as fever andweakness. At this stage the disease is difficult
to diagnose but relatively easy to treat. The
second stage occurs once the parasite invades
the central nervous system. The infected
person begins to show neurological or psychiatric symptoms, such as poor coordination,
confusion, or convulsions and sleep
disturbance.
Accurate diagnosis of the second stage of theillness requires taking a sample of spinal fluid
and treatment is painful, requiring daily
injections. The most common drug used totreat trypanosomiasis, melarsoprol, was developed in 1949 and has many side-effects. A
derivative of arsenic, it is highly toxic and fails
to cure up to 30 per cent of patients in someareas of Africa. It also kills up to five per centof people who receive it. Though eflornithine
is somewhat difficult to administer because it
has to be given intravenously and requires acomplicated treatment schedule, it is a safer
alternative and is used by MSF in its projects.
In 2009, a new treatment option called NECT
(Nifurtimox-Eflornithine Combination
Therapy) was added to the World HealthOrganization’s Essential Medicines List, basedon the application submitted by the non-profit

Médecins Sans Frontières Activity Report 2008

Glossary of Diseases

17Drugs for Neglected Diseases initiative (DNDi)
and supported by Epicentre and MSF. Somestudies have demonstrated that NECT, a coadministration schedule of oral nifurtimox
and intravenous eflornithine, is a better treatment option for people with advanced-stage
sleeping sickness, because it is safer than melarsoprol and easier to use than eflornithine.

MSF admitted more than 1,900
patients for treatment for human
African trypanosomiasis in 2008.

Leishmaniasis(Kala Azar)
Largely unknown in the developed world,leishmaniasis is a tropical, parasitic diseasecaused by one of more than 20 varieties ofLeishmania and transmitted by bites fromcertain types of sand flies. The most severe
form, visceral leishmaniasis, is also known askala azar, Hindi for ‘black fever’. Over 90 per
cent of cases occur in Bangladesh, Brazil,
India, Nepal and Sudan. Without treatment,
this form of leishmaniasis is fatal in almost allcases.
Kala azar attacks the immune system, causing
fever, weight loss, anaemia and an enlarged
spleen. There are considerable problems withexisting diagnostic tests, which are either
invasive or potentially dangerous and requirelab facilities and specialists not readily available in resource-poor settings. Treatment
requires painful, daily injections of drugs for
30 days. The drug most widely used to treat
kala azar, sodium stibogluconate, was developed in the 1930s, is relatively expensive andcauses a toxic reaction in some patients.
Co-infection of leishmaniasis and HIV isemerging as a growing threat, since bothdiseases attack and weaken the immune
system. Infection with one of these diseases
makes a person less resistant to the other andtreatment becomes less effective.

MSF treated more than 4,400 people
for leishmaniasis in 2008.

Malaria
Caused by four species of the parasite
Plasmodium, malaria is transmitted by infectedmosquitoes. Symptoms include fever, pain in

the joints, headaches, repeated vomiting,convulsions and coma. Malaria caused by
Plasmodium falciparum, if untreated, may leadto death.

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.

Malaria is commonly diagnosed on a basis ofclinical symptoms alone, such as fever andheadaches. Around half the people who
present with fever and are treated for malaria
in Africa may not actually be infected with theparasite. An accurate diagnosis can be madethrough a count of parasites by microscope ora rapid dipstick test. Both methods are used by
MSF in its projects.

Meningitis occurs sporadically throughout theworld, but most cases and deaths are in Africa,
particularly across an east–west geographicalstrip from Senegal to Ethiopia, the ‘meningitis
belt’ where outbreaks occur regularly.
Vaccination is the recognised way to protect
people from the disease.

Anti-malarial drugs are used to treat theillness. Chloroquine was once the ideal
treatment for malaria caused by Plasmodium
falciparum because of its price, effectivenessand few side-effects; however, its effectivenesshas decreased dramatically in the past few
decades. MSF field research has helped provethat artemisinin-based 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 many governments haveofficially made the change, in many cases the
drug is still not available to their people.

MSF treated more than 1.17 million
people for malaria in 2008.

Meningitis
Meningococcal meningitis is caused by
Neisseria meningitidis and is a contagious andpotentially fatal bacterial infection of themeninges, the thin lining surrounding thebrain and spinal cord. People can be infected
and carry the disease without showing
symptoms, spreading the bacteria to others
through droplets of respiratory or throat
secretions, for example when they cough orsneeze. The infection can also cause sudden
and intense headaches, fever, nausea,
vomiting, sensitivity to light and stiffness ofthe neck. Death can follow within hours of theonset of symptoms.
Without proper treatment, bacterial meningitis kills up to half of those infected. Suspectedcases are properly diagnosed through examination of a sample of spinal fluid and treatedwith a range of antibiotics. Even when given
appropriate antibiotic treatment, five to ten

MSF projects
around the world
AfricaMédecins Sans Frontières Activity Report 2008

Afri cA | Asi a an d t he C aucasus | Th e A m er i cas | E u r op e a n d t h e Mi d d le East

16

MSF treated more than 7,100 people
and vaccinated some 706,000 people
against meningitis in 2008.

Tuberculosis
One-third of the world’s population is currently infected with the tuberculosis (TB)
bacilli. Every year, nine million people develop
active TB and close to two million die from it.
Ninety five per cent of these people live inpoor countries.
This contagious disease affects the lungs andis spread through the air when infectious
people cough or sneeze. Not everyone will
become ill, but ten per cent of people willdevelop active TB at some point in their
lifetime. Symptoms include a persistent cough,fever, weight loss, chest pain and breathlessness. TB is also a common opportunistic infection and leading cause of death amongst
people with HIV/AIDS.
Drugs used to treat TB are from the 1950s anda course of treatment for uncomplicated TB
takes six months. Poor treatment management
and adherence has led to new strains of bacilli
that are resistant to one or more anti-TB drug.
Multi-drug-resistant TB (MDR-TB) is a serious
form of this, identified when patients areresistant to the two most powerful first-line
antibiotics. MDR-TB is not impossible to treat,
but the required regimen causes many sideeffects and takes up to two years. A newer
strain, extensively drug-resistant TB (XDR-TB),
is identified when resistance to second-line
drugs develops on top of MDR-TB, making thetreatment even more complicated.

MSF treated more than 29,000 people
for TB, including 971 for MDR-TB, in2008.

© Anke Raber19

contents

Burkina Faso

18 | Burkina Faso
19 | Burundi
20 | Cameroon
20 | CENTRAL AFRICAN REPUBLIC
22 | Chad
23 | Democratic republic of congo
25 | Ethiopia
26 | Guinea-conakry
27 | Guinea-Bissau
28 | Kenya
28 | Lesotho
30 | Liberia
31 | Malawi
32 | Mali
32 | Morocco
34 | Mozambique
35 | Niger
36 | Nigeria
37 | Sierra Leone
38 | Somalia
39 | South Africa
40 | Sudan
43 | Swaziland
44 | Uganda
45 | Zambia
46 | Zimbabwe

Reason for Intervention • Endemic/Epidemic disease• Social violence/Healthcare exclusion Field Staff 471

emergency healthcare and, as a last resort, acaesarean. The medical care offered by MSF is
crucial because obstetric emergencies place
the mother’s and baby’s lives in danger andcan cause serious after-effects such as sterility or a fistula between the vagina andbladder.’

Decentralising HIV/AIDS care
MSF is decentralising care for people living with HIV/AIDS in two districts in
Ouagadougou, and increasing the number of care sites. As MSF’s head of
mission, Francois Giddey, explains, ‘Task shifting, the process of allowing
trained health workers other than doctors to perform clinical tasks when
doctors are scarce, has allowed decentralisation of services in some primary
health structures. Decentralisation, combined with task shifting within secondary health structures, spreads the workload among more of the health staff,
helping to overcome the shortage of medical doctors. Decentralised care helps
more people to have easier access to treatment.’
By September 2008, MSF was treating 4,275
patients, 3,410 of whom, including 126
children, had started antiretroviral therapy.
On average there are 100 new cases a month.

Via its mobile ambulance service MSF refers
emergency cases 24 hours a day from a dozen
health centres to its 35-bed centre in Kabezi.
MSF intends to use this project to draw
attention to the scale of mother and baby
mortality in Burundi and emphasise theimportance of accessible and free medicalcare in this domain. A presidential decree
adopted in 2006 guarantees free healthcare
for pregnant women and children under fivein Burundi. Yet this free access remains
hypothetical for the population of
Bujumbura Rural, due to the poor state ofroads and the lack of specialised staff,
material and medicine.

northern region of Burkina Faso where malnutrition is endemic. Children under five years
old are deprived of basic nutrients during theannual ‘hunger gap’, when food reserves fromthe last harvest become depleted.

Helping street girls and their children
MSF has been providing healthcare to girls
living on the streets of Ouagadougou and their
young children since 2005. Street girls are
particularly vulnerable because most are
separated from their families. They are minors
with very little education and have no one toprotect them. To survive, many of the girls
engage in prostitution. They are at physicaland psychological risk and are often victims ofsexual exploitation. They also suffer fromstigmatisation and discrimination. Because of
their marginal situation, they don’t haveaccess to health services, but even if they did,‘standard’ medical care would not meet their
particular needs.
MSF provided treatment for sexually transmitted infections, and reproductive, obstetric, andantenatal care. MSF also cared for victims ofsexual violence, and gave psychologicalsupport. During 2008, MSF conducted morethan 2,500 consultations – 500 of which werepsychological – with street girls, and treatedabout 160 children.
MSF handed over the programme in December
to a local NGO, Keoogo, which has been helping
street children in Burkina Faso for several
years. Keoogo will continue the programme
and in time expand it to include more services.

Treating acute malnutrition andmalaria in the north
MSF treats children suffering from malnutrition in two districts – Yako and Titao – in the© Elisabeth Griot

BurundiMSF provided ready-to-use food that families
could use at home to feed their malnourishedchildren, ensuring that only the children withmore complicated cases needed to be hospitalised. During the peak emergency period in
September, MSF admitted an average of 600
malnourished children each week to its
clinics.
‘We are focusing on children under five, as
they are the most vulnerable to malnutrition,’says Jean-Luc Anglade, MSF programmemanager for Burkina Faso. ‘Childhood malnutrition is an underlying cause of death for somany children, yet it receives little publicattention. Young children need the rightamount of both macro and micro-nutrients intheir diet.’
Since the programme was launched in
September 2007, more than 23,440 children
have been admitted, 88 per cent of whom wererecovered.
Many children in Burkina Faso also suffer frommalaria: between 65 and 70 per cent of thechildren admitted to MSF malnutrition programmes also have malaria during the annual
malaria peak in the last months of the year.
MSF provided malaria treatment to more than
10,700 children, including those not sufferingfrom malnutrition.
MSF has worked in Burkina Faso since 1995.

Treating sexual violence© Joanne Wong

Via its mobile ambulance service MSF refers
emergency cases 24 hours a day from a dozen
health centres to its 35-bed centre in Kabezi.
Reason for Intervention • Armed conflict • Social violence/Healthcare exclusion
Field Staff 101

In April, two years after a peace deal was signed to end more than a decade ofconflict in Burundi, rebels of the National Liberation Forces (FNL) launched an
offensive against the capital, Bujumbura, prompting fears of a return to war.
In June, the government and the rebels signed a ceasefire.
However, the long years of war have weakened
the country’s health system. Therefore MSF
teams constantly monitor potential healthemergencies, such as epidemics or nutritional
crises.

centre provides medical care, including
caesareans, to an average of 100 women presenting with complications during pregnancy
or delivery who cannot be treated in healthcentres.

Maternal healthcare‘Complications arise in 15 to 20 per cent ofdeliveries,’ explains Dr Pablo Nuozzi, the MSF
project coordinator. ‘The mother has to bewithin reach of an operating theatre and ablood transfusion in order to benefit fromIn June, MSF opened a new centre for obstetricemergencies in Kabezi, in the vast province of
Bujumbura Rural, which has around 565,000
inhabitants. Every month, this specialised

Despite the end of years of open conflict,sexual violence has remained a concern in
Burundi. In 2008, the MSF’s Seruka centre –seruka means ‘coming out of the dark’ in
Kirundi, the national language – provided
medical and psychological treatment tovictims of sexual violence in Bujumbura
Mairie. Since the opening of the centre in
2003, more than 7,000 victims have beencared for. The Seruka team has seen an
increasing number of young patients visiting
the centre. In 2008, 60 per cent of the victims
had not yet turned 19 years old; half of thesewere under 12 years old. Statistics clearlyshow that a large proportion of aggressors
are civilians known to the victims.
The Seruka centre remains an exception in
Burundi: it is difficult for the victims ofsexual violence to find appropriate care, inspite of the fact that rape represents a
medical emergency.
In 2008 the Seruka Initiative for Rape Victims
was created by local medical staff and is due
to take over all activities of the Seruka centre
from MSF in 2009.
MSF has worked in Burundi since 1992.

Médecins Sans Frontières Activity Report 2008

M SF P R OJE C TS A R OUND THE WO R LD | A fr i cA

18

21

Cameroon
Reason for Intervention • Armed
conflict • Endemic/Epidemic disease• Social violence/Healthcare exclusion
Field Staff 170

MSF continues to be involved in thetreatment of Buruli ulcer, one of themost neglected but treatable diseases
in the world. Buruli ulcer is a bacterial
infection related to tuberculosis andleprosy. The infection destroys skinand bone tissue and, if not treated(for example with physiotherapy),
can lead to deformity.
The Buruli ward in Akonolinga hospital in
Cameroon’s Centre Province offers free andcomprehensive care for patients affected bythis disease. More than 700 patients have beentreated since the opening of the project.

Most patients come from the Akonolinga
district, but others come from different
provinces and regions.

During 2008, on average 54 patients every
month were hospitalised. The hospital bed
occupancy rate reached 77 per cent.

In 2008, many changes were made to theprovision of care: treatment and care weredecentralised and a different kind of dressing
used so that people living in remote areas
could receive treatment without being
hospitalised.

In 2008 MSF closed the PRETIVI project for theprevention and integrated treatment of HIV/
AIDS, which started in 2003 and provided
antiretroviral therapy (ART) to people with HIV/AIDS in Douala, the second-largest city in
Cameroon. The creation of a national projectfor HIV/AIDS treatment financed by the Global
Fund to Fight AIDS, Tuberculosis and Malaria
enabled MSF to take this step.

Each year MSF gains more experience intreating Buruli ulcer and as a result is able toprovide better-quality care adapted to patients’needs. MSF is also trying to draw the attentionof researchers and donors to this disease,which affects not only African countries suchas Cameroon and Côte d’Ivoire, but also
Australia.

Central African
Republic

Médecins Sans Frontières Activity Report 2008

M SF P R OJE C TS A R OUND THE WO R LD | A fr i cA

20

MSF also closed its projects in Baturi, eastern
Cameroon, which provided humanitarianassistance to refugees from the Central African
Republic.
MSF has worked in Cameroon since 2000.

© MSF

Reason for Intervention • Armed conflictField Staff 1,188

Since late 2005, fighting between the government and various rebel groups hascaused large-scale displacement of people in the Central African Republic (CAR).
Many villages have been looted or burned, forcing their inhabitants to flee. Most
people have sought refuge in the bush, or with host families in towns, often far
from their destroyed homes.
Despite another increase in international aid
in 2008, much of the population continues tolive exposed to the elements, in constant fearof new attack and with no access to healthcare or clean water. People struggle to findfood and are particularly vulnerable tomalaria, respiratory infections, and diarrhoeal diseases.

Treating conflict patients© Claude Mahoudeau

MSF focused on providing medical assistanceto populations affected by the conflictthrough a network of mobile clinics, hospitals, and health centres across the northwest
in Kabo, Batangafo, Markounda, Paoua,
Bocaranaga, Boguila, and in the northeasternareas of Birao and Gordil. More than 385,000
outpatient consultations were conducted andmore than 14,800 patients were hospitalised.
Patients are being treated for diseases such as
malaria, tuberculosis, HIV/AIDS, sleeping
sickness, and for malnutrition.

Helping mothers and children
CAR also has a very high mother and childmortality rate. In response MSF projects
provided 30,000 antenatal consultations andassisted at more than 5,000 deliveries during
2008. Mental-health services were also
provided to communities living with thethreat of displacement and violence. MSF also
supported health centres in remote areas
through training, the donation of medical
supplies, and by setting up referral systems
for patients who needed to be hospitalised.
However support to peripheral health centres
has been restricted by the tense security
situation, which often limits the teams’
ability to move.
MSF has worked in the Central African Republic
since 1997.

In memory
On March 10, all MSF vehicle movements
came to an abrupt halt after the fatalshooting of Mariam Atim, the mother ofan MSF patient. Mariam was struck by
a bullet while accompanying one of herchildren in a well-marked MSF vehicle inthe Vakaga region. MSF condemned themurder. Movements and emergency
referrals were drastically limited
throughout the rest of the year.

‘We have seen more andmore patients whose stateof health has been worsenedby their flight into thebush. Children come insuffering from malaria,
respiratory infections, diarrhoea and conjunctivitis;
and adults suffering froma range of other conditions.’
Stéphane Hauser, MSF coordinator,
Batangafo

23

Chad
Reason for Intervention • Armed conflict • Endemic/Epidemic disease• Social violence/Healthcare exclusion
Field Staff 1,155

The various armed conflicts thatmarked the first half of 2008 left Chadfearing a troubled year ahead. In fact
the rest of the year proved less tense,
but Chad remained a highly unstablecountry. Insecurity continued to affectmany of the people living there and tohamper humanitarian work.
Violence and displacement
Confrontations between government forces
and rebels, lawlessness and banditry meanthat for many people exposure to violence ispart of everyday life. The conflict between
rebel and government forces reached a peak in
February, when the capital N’djamena cameunder attack. An MSF surgical team supported
N’djamena Bon Samaritain hospital, treating
126 wounded and performing more than 80
surgical procedures. Emergency assistance wasalso offered to victims of fighting in Ade andGozbeida in April and June.
In eastern Chad alone, an estimated 185,000
Chadians who have been forced to flee theirhomes and 250,000 refugees from neighbouring Darfur still live in camps, and there is no
short-term prospect of their returning to theirvillages.
MSF worked to meet the basic medical needsof people in Iridimi and Touloum refugee
camps, in Iriba hospital and in the Tine healthcentre. More than 71,000 consultations, 140
surgical interventions and 1,000 deliveries
were carried out. In the refugee camps inArkoum, Farchana and Breijing, more than
44,300 consultations, including nutritional
interventions, took place. As the health emergency subsided, MSF was able to hand overprojects in Farchana, Arkoum and Breijing in
June 2008, and will hand over the Iridimi andTouloum projects to partners in 2009.
In Adre, Guereda, and Abéché however, despite
MSF’s continuing interventions, healthcare for
Chadian people and Sudanese refugees is still
inadequate. MSF focused its efforts in theseareas on healthcare for women and children,and implemented a surgical programme totreat obstetric fistula. MSF continued toprovide assistance at Adre’s health facilities,
where almost 2,400 people were admitted.
More than 56,000 outpatient consultations
were provided in Guereda district’s healthcentres, including in Birak, where approximately 10,000 new Sudanese refugees arrived
early in the year.
Further south, MSF provided healthcare to
80,000 displaced people and residents in thevillages of Gozbeida, Kerfi and Ade. The mobile
clinics in Kerfi and Ade began providing inpatient facilities in early 2008. More than 81,800
consultations were carried out and an additional 1,700 people were treated for malnutrition. The situation in Gassire camp in
Gozbeida has stabilised, so MSF will hand overthe camp’s clinic to partners in 2009.
In Dogdoré, a remote village in the district
worst-affected by the internal conflict, MSF has

been providing medical assistance to the
27,000 displaced people and 3,000 residents
since July 2006. In 2008, 25,000 primary healthconsultations were carried out, 1,000 patientswere admitted to hospital, and 600 severely
malnourished children were admitted to the
MSF nutritional centre. In addition, 3,000
antenatal consultations took place and 350
deliveries were performed. However, repeatedsecurity incidents forced MSF to reduce thesize of the team and eventually evacuate allinternational staff from the projects in
October. Local staff were able to maintainsome basic health services during this time,and international staff began returning at the
beginning of 2009.

Support in the southwest
In the southwest of the country, MSF continued to support Goré’s hospital, responding to
the secondary healthcare needs of about
30,000 refugees from Central African Republic(CAR) and 137,000 residents of the Goré
district. Overall, MSF provided 20,000 consultations, 4,300 hospital admissions and 1,000
surgical interventions.
Following the arrival of about 5,000 refugees
from CAR, MSF provided, between May andOctober, emergency water supply, primary andperinatal health consultations, and preventive
measles vaccinations for children under five
years old. Patients in need of secondary care
were referred to a nearby Ministry of Healthhospital.
After 25 years, MSF left Bongor in December
2008, handing the city hospital over to the
Ministry of Health. In 2008 alone, around
154,000 malaria cases were treated, 5,815
patients came for medical consultations, 1,440
deliveries and 850 surgical interventions wereconducted.
In 2008, MSF also responded to epidemic
outbreaks throughout the country. Following
outbreaks of measles, MSF immunised morethan 11,000 children in Goré and approximately 15,000 children in Adre. The population of
Abéché was also vaccinated in early 2009.
MSF has worked in Chad since 1981.

© Hu O Reilly

Democratic Republic of Congo
Reason for Intervention • Armed conflict • Endemic/Epidemic disease • Social violence/Healthcare exclusion
Field Staff 2,465

For the population living in the eastand northeast of the Democratic
Republic of Congo (DRC), 2008 was a
bleak year. In January, a peace agreement signed in Goma between theCongolese army and various armed
groups brought a glimmer of hope tothe people of North and South Kivu.
However, sporadic fighting continued
throughout the year until full-scale
war resumed at the end of August.
Hundreds of thousands of civilians
were forced to flee the violence andmost aid organisations had to suspend
their activities.
MSF activities in 2008 gradually increased
across the provinces of North and South Kivu.
In Rutshuru, a town about 43 miles north ofGoma, the MSF team continued working in thehospital during the periods of heaviest
fighting. More than 3,700 surgeries werecarried out in Rutshuru hospital, 19 per centof which were for gunshot wounds, reflecting
the high level of violence.
MSF opened a programme in Kabizo to managea measles epidemic and provide healthcare tointernally displaced people who had recently
arrived in the area. The MSF team had toevacuate from Nyanzale several times forsecurity reasons during the last four monthsof 2008. An MSF team started working in Aprilin a hospital in Mweso. A team was alreadyworking in Kitchanga hospital, northwest of
Goma. Between them, they conducted morethan 550 major surgeries, 120 of which were
war related. In Masisi town, about 50 miles
northwest of Goma, MSF admitted more than
500 patients a month to the hospital.
Further south, MSF worked in the hospitals of
Kirotshe and Minova in North Kivu, andKalonge in South Kivu. In Minova, MSF had
carried out 34,000 consultations by the time
the project closed in December. By the end of
the year, MSF had admitted more than 4,000
patients to Kalonge hospital, providing among
other things surgery, deliveries and treatment
for malnutrition.
In a highly insecure and rapidly changing
situation, running mobile clinics, assessing
new areas, and quickly re-locating teams are© Cedric Gerbehaye

In a highly insecure and rapidly changing
situation, running mobile clinics, assessing newareas, and quickly re-locating teams are key toproviding an effective response.
key to providing an effective response. MSF
teams ran mobile clinics and supported healthcentres in villages and camps around
Rutshuru, Nyanzale, Kabizo, Kayna, Mweso,
Kitchanga, Pinga, Masisi, Kirotshe, Kalonge,
and Minova. MSF also provided latrines andaccess to clean water in various locations suchas Kitchanga, where more than 70,000 displaced people had gathered in camps.
In 2008, more than 6,700 victims of sexual
violence received specialised medical care andcounselling in various MSF programmes acrossNorth and South Kivu. In Nyanzale alone,
more than 3,500 victims were treated; 1,450 in
the areas of Kitchanga and Mweso.
In August heavy fighting broke out, leading to
disruptions in humanitarian aid. Hygiene
conditions deteriorated and access to cleanwater for displaced people was reduced, which
resulted in an increase in the number ofpeople contracting cholera. In response MSF
treated more than 2,280 patients in Rutshuru
and Buturande.

The weak healthcare system in South Kivu wasfurther stretched by large groups of Congolese
refugees returning from camps in Tanzania
and Burundi. MSF continued support to thehospital and a cholera treatment centre in
Baraka, Fizi region. In Minova, MSF responded
to a cholera outbreak by treating more than
800 patients.
In North Kivu, MSF teams also treated malnourished children in various supported
health structures, and vaccinated more than
215,000 children against measles.
While years of conflict in the district of Ituri,
in northeast DRC, had come to an end in 2005,
renewed fighting between militias and theCongolese army forced up to 100,000 civilians
to flee. MSF teams have worked in Gety
hospital and launched mobile clinics inSongolo and Soke to bring healthcare to about
50,000 displaced people and refer patients to
Bunia hospital. In Bunia, 11,500 patients and26,000 children under five years were admitted
to Bon Marché hospital.

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In December 2008, Uganda, DRC and Sudan
launched a joint offensive against Ugandan
rebels of the Lord’s Resistance Army (LRA). In
response to military operations against them,
LRA fighters started in September to perpetrate acts of extreme violence on the civilian
population of Haut-Uélé district. Hundreds ofmen, women, and children were killed andmany young men were enrolled by force into
the LRA. By the end of the year, more than
100,000 people were displaced and left largely
unprotected from assailants.
MSF teams ran mobile clinics in several locations around the town of Dungu, and in
Doruma, Bangadi and Faradje. However, MSF
medical activities were hampered by extreme
insecurity in the region. Teams could move
only by plane to remote areas, where they
were able to stay for only a short time. Despite
the insecurity and logistical challenges, MSF
has been able to screen 21,600 people andtreat more than 680 patients for sleeping
sickness in Haut-Uélé.
In Opienge, Tshopo district, an MSF teamprovided some 5,500 consultations for civilians affected by fighting between the nationalarmy and local militias.

In stable areas of DRC, health needs remainhuge and MSF teams constantly responded to
medical emergencies. In December 2008,
central DRC was again hit by an epidemic ofthe deadly Ebola haemorrhagic fever. An MSF
team responded by isolating and caring for
those who may have contracted the disease,and controlled the outbreak.
In the first months of the year, MSF teams
responded to outbreaks of cholera in thesoutheastern cities of Lubumbashi, Likasi, andKolwesi. Further north in the Tanganyika
region, several MSF teams vaccinated half amillion children of between six months and 15
years old against measles during the summerof 2008.
Although the conflict in Katanga ended in
2006, the medical situation remains precarious. MSF works in three hospitals in
Shamwana, Dubie, and Pweto, as well as in 13
health centres. MSF handed over Kilwa
hospital in June. Among the focuses in thesefacilities are maternal healthcare, including
emergency obstetrics, and mental-health carein Shamwana and Dubie.
MSF continued to treat patients with HIV/AIDS
in Kinshasa, the capital city, as well as in

Bukavu and Bunia in the east. In December
2008, MSF handed over its Bukavu project to apartner organisation and local health authorities. Two MSF clinics in the northern city of
Kisangani treated an average of 5,000 patientsmonthly for sexually transmitted infections,and more than 120 patients a month were
hospitalised at the MSF hospital in Lubutu,
Maniema.

It is in this context that MSF works to help those most in need. It is
crucial not to assume the situation in the Nyanzale zone is similar tothat in Lubero, Bunia or Baraka. The problems are complex andReason for Intervention • Armed conflict • Endemic/Epidemic disease• Social violence/Healthcare exclusion
Field Staff 1,152

Condition Critical
A website dedicated to telling the storiesof those living alongside the fighting inEastern Congo was launched in 2008.
Condition-Critical.org is regularly
updated by MSF with new eyewitness
accounts, photos and video from thepeople living through the crisis.

In Degahbur medical teams work in a hospitalproviding inpatient and outpatient care andnutritional assistance. In 2008, more than
7,300 outpatient consultations were provided
and more than 6,000 people received nutritional care.
In July MSF had to close its project in Fiiq, in
the Ogaden region due to administrative
hurdles and insecurity. This prevented teams
from providing medical care to people in andaround the town. Despite various agreements
signed with the federal authorities, MSF
international staff did not receive the necessary work permits and could work for only
short periods at a time.

Thousands of people are on the run,fleeing a war raging in the provinces ofNorth and South Kivu, and in thenorthern Oriental province. MSF believed
there was a need to highlight theirstruggle to survive – using their words
to express the dire situation they are in.

diverse. Armed groups allied in one zone could declare war on thosein another. Rebel movements could collaborate with the nationalarmy in some places and oppose them in others. MSF must understandthese parameters and be able to identify reliable sources of information as well as the leaders of armed forces or militias who influence
their troops. However the Congolese army is in decline. Deserters are
numerous and have swelled the ranks of all sorts of bandits.
Extortion by army soldiers, armed men in rebel movements and those
operating independently occur daily.
Attacks on the road, recurring rape, pillaging and murders almost
systematically go unpunished because the state lacks virtually all
authority. The justice system and the army do not function. The
resulting impunity only serves to increase the level of insecurity. In
Eastern Congo, taking up arms to meet personal needs, to settle
accounts often linked with local rivalries and to escape the intolerable living conditions has become a way of life for a small part of the
population. The other part of the population, the vast majority, flee,
sleep in the bush, suffer from hunger and the cold, sustain gunshot
wounds, and all too often die without ever having their voice heard.
Romain Gitenet, head of mission,
Democratic Republic of Congoand the town inhabitants. However, from
September, teams could no longer use mobile
clinics throughout the wider Wardher area
due to insecurity in the region.
Projects continued in Cherrati and Degahbur,
also in the Somali region. In Cherrati MSF
provided primary healthcare and treatment
for tuberculosis (TB). Over the course of theyear more than 18,500 outpatient consultations were undertaken and nearly 700 people
were started on TB treatment. In December the
Cherrati project was handed over to the local
health authorities.

MSF has worked in DRC since 1987.

MSF challenges in Eastern Congo
Making the decision to intervene in Eastern Congo implies the understanding of a complex and volatile situation. The conflict has its rootsin access to land, the scramble for power and a sense of ownershipand entitlement of the land by some groups who perceive others as
foreigners. These problems are exacerbated by the economic recession
and social precariousness as well as the disintegration of stateauthority. These realities and perceptions reflected in local opinions
had only to be mobilised by political leaders or armed groups for theeastern part of the country to be set ablaze.
The two Congolese wars from 1996-1997 and from 1998-2002 that
followed the Rwandan genocide were the work of a number of armies(notably the Rwandan, Ugandan and Burundian) for political andeconomic gains. However this coalition would not have foundCongolese allies if they hadn’t known how to rally certain populations
around local divisions. In the same way, the powers that be in
Kinshasa, aided by local politicians, applied these same antagonisms
to mobilize other populations at the heart of the resistance army
movements. It is not surprising therefore that the peace accords of2002 did not lead to peace.

ETHIOPIA© Robin Utrecht

A nutritional crisis that devastated a number of regions in the south of thecountry struck Ethiopia in 2008. A combination of several factors, including
droughts and a dramatic rise in food prices, left hundreds of thousands ofpeople without food, struggling to survive. MSF teams, were able to launch an
immediate emergency response.
Initially teams could care only for those suffering from severe malnutrition, and focused onchildren since they were the most at risk. In
mid-July feeding programmes for moderately
malnourished children and their families wereopened. By September, more than 700 staff
were working in MSF’s nutritional programmes. By the end of the emergency intervention they had treated more than 34,800
severely malnourished and more than 37,600
moderately malnourished people. A targeted
feeding programme had also provided food to
14,000 children who were at risk of being
malnourished. In February and March ameasles vaccination campaign was also carriedout in Oromiya region and around 93,000
children were vaccinated.
Although the nutritional crisis hit hardest in
the south, other areas were also affected.
In August a nutritional intervention was
launched in the Afar region of northeast
Ethiopia. In September MSF teams reported adeteriorating humanitarian situation around
Wardher in the conflict-affected area of theSomali region. Thousands of people who had
fled their homes gathered on the town’s outskirts in search of food and water. With aclinic in Wardher town, MSF was able toprovide medical care to the displaced people

In the north, MSF continued to care for people
with kala azar (visceral leishmaniasis) in
Humera, Tigray region, and Abdurafi, Amhara
region; and lobbied for an improved responseto this neglected disease. Kala azar, transmitted by sand fly, is almost always fatal if left
untreated, but with proper care it is possible
to cure over 90 per cent of primary cases. In
the health clinic in Abdurafi, MSF also caredfor people living with HIV/AIDS, including
those co-infected with kala azar and TB.
In 2008 some 500 patients were provided withtherapeutic food and more than 360 children
under the age of five were treated for malnutrition. In the clinic’s emergency medical unit,
MSF treated more than 670 people throughout
the year, including patients with severe casesof malaria and meningitis.
MSF has worked in Ethiopia since 1984.

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GuineaConakry

GUINEA-bissau
Reason for Intervention • Endemic/Epidemic disease
Field Staff 7

Reason for Intervention• Endemic/Epidemic disease
Field Staff 229

MSF mounted an emergency response to a cholera epidemic in Guinea-Bissau.
An outbreak of the highly contagious bacterial disease was first detectedin May, and by July the government had declared an emergency and requested
international assistance.

© Julie Rémy

MSF continued to carry out HIV/AIDS
programmes in the eastern city of
Guéckédou in the Guinée Forestière
region, and in the capital.

countries, owing to the health department’s
lack of resources and a shortage of qualified
staff.

Pushing for better malaria treatment
MSF remains the main provider of care for thecountry’s HIV-positive patients. To allow
patients to be treated closer to their homes,
MSF started to decentralise HIV/AIDS care tosmaller health centres in Conakry and in
Guinée Forestière. Treatment, voluntary
testing, and psychosocial counselling were
provided, medical staff trained and supervised
and the medical units upgraded.
More than 3,500 patients were receiving
antiretroviral therapy (ART) at the end of 2008,
including many HIV patients co-infected withtuberculosis. It seems unlikely that MSF will
be able to hand over the HIV/AIDS care programmes to local agencies, as it has in other

In Dabola, MSF handed its malaria treatment
programme over to the local authorities.
Having lobbied the national health authorities
for the use of artemisinin-based combination
therapy (ACT), a more efficient treatment formalaria, MSF pushed in 2008 for the use of
ASAQ, a combined single-dose easy-to-use,
efficient and non-costly formula developed by
the Drugs for Neglected Diseases initiative(DNDi).
A film aimed at promoting the use of thiscombined drug was produced in partnershipwith Guinean actors in three languages, in
French, Malinké and Peulh. The health authorities of Dabola, which integrated the use of the
ASAQ formula in its health structures, took
over MSF’s programme in November 2008.

Unacceptable prison conditions
In September 2008, MSF started an emergency
intervention in the civilian prison of
Guéckédou. On arrival, MSF found malnutrition in one in three adult male prisoners, one
in five of whom suffered severe acute malnutrition. Appallingly unhygienic conditions had
led to dehydration and rampant skin andrespiratory infections. Overcrowded cells
mixed minors together with adults, and prisoners with tuberculosis with other inmates.
Healthcare was only occasionally available.
MSF responded to the situation with emergency therapeutic food distribution for about
three months. Teams also conducted medical
consultations, donated medicines andprovided material for water supply, sanitationand personal hygiene, and carried out assessments and vaccinations in three other prisonsin the country (in Mamou, Boké and Gaoual).
MSF produced a report and spoke out publicly
to denounce the situation early in 2009.

More than 3,500 patientswere receiving antiretroviral therapy at the endof 2008, inclu­ding many
HIV patients co-infectedwith tuber­culosis.

© Clara Tarrero

Mobile teams were deployed to improve waterand sanitation provision and make home visits
to patients.
Cholera can spread rapidly through contaminated water and is endemic in Guinea-Bissau,
where there is no sewage system and access toclean drinking water is severely limited.

Combating cholera
Cholera remains a problem in Guinea. While it
severely hit Conakry in 2007, it stayed more orless contained within the coastal Guinée
Maritime region (north of Conakry) in 2008.
MSF donated medical material and drugs in
Boké, and organised training for some 100
medical staff from different health centres in
the capital.
MSF has worked in Guinea Conakry since 1984.

By the time MSF started work in August 2008,nearly 4,000 cases had been reported nationwide and 93 people had died. Bissau, thecapital, was the area most affected, accounting
for 70 per cent of all registered cases. MSF staff
helped the Ministry of Health to control theoutbreak: teams of coordinators, nurses, logisticians, and epidemiologists took charge oftreatment centres, strengthened local capacity
and improved early detection and treatment.

Mobile teams were deployed to improve waterand sanitation provision and make home visits
to patients.
MSF treated more than 8,000 people, and its
sanitation and prevention strategies helped tocontain the epidemic. By the end of November,
MSF handed over the projects to local healthauthorities and other humanitarianorganisations.
MSF worked in Guinea-Bissau from August to
November 2008.

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KENYA

empty just a few days later. Faced with such amobile population, MSF had to be flexible inits response. Medical teams travelled tonumerous different locations in the Rift Valley
every week to provide care to those with little
or no aid.

Reason for Intervention • Armed conflict • Endemic/Epidemic disease• Social violence/Healthcare exclusion
Field Staff 659

At the beginning of 2008, disputes over Kenya’s presidential election sparked
two months of violence, leaving more than 1,000 people dead and, according to
the Kenyan Red Cross, as many as 300,000 displaced. MSF medical staff, whonormally focus on providing treatment to thousands of people living with HIV/AIDS and tuberculosis (TB) in the capital, Nairobi, and western Kenya, were on
hand to respond.
Emergency medical care was provided to thevictims of violence. Mobile clinics for Kenyans
fleeing violence in their communities werealso established and activities started in somecamps for people who had fled their homes.
MSF reinforced its teams on the ground withextra surgeons, emergency physicians, nurses,
and logistical specialists.
The violent protests and clashes that erupted
throughout Kenya during the crisis left
hundreds injured. In Nairobi, teams adapted
long-running HIV/AIDS projects to provide
basic first aid for the victims. Because many

people were unable to move, MSF sent ambulances around the slums to assist the injured.
For the most-seriously injured, a referral
system was set up involving both public andprivate hospitals.
In early January an MSF surgical team worked
in Eldoret and Nakuru hospitals to help treat
victims of violence, many of whom had
machete wounds or burns. Later in the samemonth MSF teams supported Kenyan Ministryof Health staff as violent clashes erupted in
Nakuru and Naivasha, two popular tourist
destinations close to Nairobi. In Nakuru MSF

LESOTHO© Eva-Lotta Jansson

Reason for Intervention • Endemic/Epidemic disease
Field Staff 9

In the ‘Mountain Kingdom’ of Lesotho, life expectancy is only 35 years. HIV/AIDS is a significant killer and over 23 per cent of the adult population livewith the disease. Most HIV/AIDS-related deaths are due to co-­infection withtuberculosis (TB). The country urgently needs more health workers, having
just five doctors and 62 nurses per 100,000 people.

Mount Elgon displaced© Juan Carlos Tomasi

teams helped treat more than 150 wounded
patients in two days.
The violence prompted thousands of people toflee their homes. The Rift Valley region wasparticularly badly affected. Many people
sought refuge in large sites such as stadiums
and showgrounds. In a number of sites thathoused thousands of displaced people, including Eldoret, Nakuru and Kitale, MSF teams
provided medical care and relief supplies.
Other Kenyans sought protection at police
stations, prisons and churches or stayed insmall groups in remote areas. In parts of thecountry people moved around regularly, sosites that were once filled with people were

In January 2006, MSF and the Ministry of
Health and Social Welfare launched a joint
programme to provide HIV/AIDS care andtreatment, including antiretroviral therapy(ART), at the primary healthcare level in rural
Lesotho.
The programme was launched in Scott
Hospital health service area, which includes a
district hospital and 14 primary-care clinics inremote rural communities, and has a catchment of approximately 200,000 people. In
addition to general primary care, the clinics
provide comprehensive HIV/AIDS services
including ART, HIV testing and counselling,
prevention of mother-to-child transmission,
early diagnosis in infants, and management ofopportunistic infections and co-infections
such as TB.

authorities to strengthen the primary healthcare system by improving laboratory services,
drug supply, infrastructure, and programmemonitoring and supervision.

‘One-stop’ integrated services have been established for patients co-infected with TB and HIV.
Among other steps taken to ensure the integration of TB and HIV/AIDS care, all HIV/AIDS
patients are systematically screened for TB,
and TB patients are routinely offered an HIV
test. MSF is also working with local health

Decentralised care

By December 2008, 39,500 HIV tests had been
carried out since the beginning of the projectin 2006, and more than 4,300 patients had
been initiated on ART. The clinical outcomes
for the first two years are quite encouraging:
86 per cent of adults and 93 per cent ofchildren are still in care after 12 months on
ART. In addition, HIV transmission frommother to child has been reduced to less than
five per cent for pregnant women who received
prevention care. TB recovery has also
improved, with treatment success rates
reaching 78 per cent in 2008.

Because the hospital-based ART clinics are so
full, there are so few staff and many patientsfind it hard to reach or afford healthcare, MSF’s
goal from the outset was to decentralise all
HIV/AIDS care and treatment services to healthcentre level. The objective has been to bring

As the political situation stabilised towards
the end of February, MSF gradually phased out
its emergency response. Yet activities continued in the Mount Elgon region of western
Kenya where tens of thousands of people had
been displaced by the violence that started inAugust 2006. Trapped between a number ofdifferent warring parties, people living in the
Mount Elgon region were struggling to survive.
MSF first started providing assistance in theregion in April 2007, focusing on primary andmental-health care, referrals and the distribution of non-food items such as blankets.
In 2008, more than 23,000 outpatient consultations were provided, including nearly 1,600
antenatal consultations. MSF also treated 110
victims of sexual violence, and 349 patientscare and treatment as close as possible to thosein need, and to ensure HIV/AIDS care is free.
Nurses were trained to assume high levels ofclinical responsibility for HIV/AIDS care,including initiating and managing ART for
adults and children. Lay counsellors (primarily
people living with HIV/AIDS) were recruitedand trained to reinforce clinic capacity andprovide essential support in the delivery of
HIV/AIDS and TB services, particularly treatment adherence. As of December 2008, there
were 45 lay counsellors working across the 15
facilities.
Joseph Ramokoatsi, a lay counsellor working
at one of the mountain clinics, knows what it
is like to live with HIV and commit to lifelong
ART. ‘The work that I do here is my passion,’ hesays. ‘When I tell my patients to take theantiretrovirals to feel better, they trust me
because I am a living example. I tell them to bevery committed to taking the antiretrovirals,
and not to stop in spite of the side-effects.’
MSF lobbied for the elimination of user fees atprimary healthcare level, and in the meantime

suffering from violent trauma wounds. By theend of the year, as the security situation
improved, MSF was able to hand over its activities to the Ministry of Health.

Specialised healthcare
For many years MSF teams in Nairobi and the
Nyanza, Western and Rift Valley provinces of
Kenya have provided specialised care forpeople suffering from chronic and neglecteddiseases.
By the end of 2008, more than 18,600 people
living with HIV/AIDS were cared for in MSF
projects, and 14,000 were receiving life-saving
antiretroviral therapy. In projects in the capital’s slums of Mathare and Kibera as well as in
the rural areas of Busia and Homa Bay, MSF
staff tested 17,250 people for HIV/AIDS.
In the Pokot region of northwestern Kenya,medical teams tested more than 1,700 people
for the deadly disease kala azar (visceral leishmaniasis) and treated some 640 patients.
MSF has worked in Kenya since 1987.

subsidised all essential HIV/AIDS-related
services in the Scott Hospital catchment area,
including drugs and other commodities, lab
investigations, equipment, and hospital fees.
In January 2008, the Ministry of Health abolished all user fees at primary healthcare level
and lowered the fees for other district-levelservices. However, the costs that remain,
including hospital admission for HIV-positive
patients not on ART and chest x-rays, are still
obstacles to accessing care, including thediagnosis of TB.
The aim of the MSF-supported programme in
Scott Hospital was to develop a model that was
replicable and sustainable in the long term
while meeting ambitious early targets for ART
enrolment. The first three-year phase of the
programme has now come to a close and the
project has entered a handover phase, during
which MSF will gradually transfer all responsibilities to the Ministry of Health and otherlocal partners by late 2010.
MSF has worked in Lesotho since 2006.

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LIBERIA
Reason for Intervention • Endemic/Epidemic disease • Social violence/
Healthcare exclusion
Field Staff 875

in Bushrod Island, more than 70 per cent ofwhom were younger than 19 years old. Some
11 per cent were younger than four years old.

MALAWI

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Reason for Intervention• Endemic/Epidemic disease
Field Staff 700

Primary care handoverThough Liberia has made significant moves towards stability and reconstruction following its brutal 14-year civil war, many Liberians still live in crushingpoverty, and the weak health sector cannot provide adequate healthcare.
Women and children remain particularly vulnerable.

MSF manages a health centre in Saclepea in
Nimba county, northeastern Liberia. Plans areunder way for handing the project over to the
Ministry of Health, but in 2008 the centre
conducted more than 3,000 outpatient consultations. More than 100 people took advantage
of free anonymous tests for HIV. MSF is alsocollaborating at the centre with the Ministryof Health, the Centre for Research and Field
Epidemiology (Epicentre), and the Drugs for
Neglected Diseases Initiative (DNDi) on a study
aimed at making artemisinin-based combination therapy available for malaria sufferers
throughout Africa.

© Isabelle Merny

Treating Lassa hemorrhagic fever© Alessandra Vilasboas

Maternal healthcare
MSF provided free secondary healthcare inMontserrado county in the northwest of thecountry, home of the capital, Monrovia. In thesuburb of Paynesville, MSF worked in Benson,
a women’s and children’s hospital, helping todeliver over 3,000 babies and conducting morethan 770 emergency gynaecological surgeries.
Handover of this project to the Ministry of
Health is under way.
MSF also provided free access to healthcare ina paediatric hospital, Island Hospital, inBushrod Island. This overcrowded area in
Monvrovia is home to more than 500,000
people: admissions exceeded 12,600 in 2008.
Care was focused particularly on mothers andchildren, on malnourished children who havemedical complications and on integrating carefor chronic diseases such as HIV/AIDS andtuberculosis into the system. MSF teams
helped deliver more than 3,900 babies.

MSF also helped provide primary care in two
centres run by the Ministry of Health in Clara
Town and New Kru Town. Teams supported arange of services for mothers and children
such as antenatal and postnatal care, vaccinations and prevention of mother-to-child transmission of HIV. Together the centres provided
more than 122,300 consultations in 2008.

Sexual violence
Incidence of sexual violence remains high in
Liberia. In Benson, MSF provided healthcare forvictims of sexual violence, treating more than
880 rape survivors. In July the project washanded over to Think, a local NGO, though MSF
still provides technical and material support.
The partnership carried out more than 2,260
psychological consultations in 2008.
Victims of sexual violence were offered
medical and psychosocial support at Island
Hospital as well as at both health centres. In
2008, MSF teams treated more than 770 people

In 2008, some 80 people with Lassa hemorrhagic fever were admitted to Saclepea’s special
hospital unit for treatment. The fever is deadly
if not treated quickly with ribavirine, a costly
medicine protected by a pharmaceuticalmonopoly. As part of its planned 2009 withdrawal from Saclepea, MSF is trying to ensurethat ribavirine becomes affordable in Liberia.
Teams are also lobbying health officials forcontinuity of care for HIV-positive patients
after the withdrawal. It has now been agreed
that HIV-positive patients will be able to receive
treatment at Ganta hospital in northern
Nimba county, and that screenings for HIV andtuberculosis will continue in Saclepea.

Lobbying for free healthcare
In 2006, the government introduced a policyof free healthcare across Liberia. Not all thecountry’s health structures are able to offer
services free of charge, however, so in someplaces people cannot afford to be treated. MSF
is lobbying for consistent implementation offree care throughout the country.
MSF has worked in Liberia since 1990.

In recent years the Malawi government
has made increasing efforts to provide
more antiretroviral therapy (ART) in
response to the spread of HIV/AIDS.
An estimated 12 per cent of the adult
population are infected. But there is
still an acute shortage of nurses anddoctors, which means many people arestill going untreated.

In 2008, the MSF team in Chiradzulu carriedout an assessment of patients who had abandoned their treatment, finding and interviewing them to discover why they had notfinished the course. The main reasonsinvolved the stigma associated with thedisease expressed by their family or community, lack of information about the medication or the disease itself, or a perceived overall
improvement in their health.

Tackling the HIV/AIDS problem
MSF has been providing ART in two southernrural districts: Chiradzulu (since 2001) andThyolo (since 2003). Since these projects began,
MSF has started more than 28,000 patients on
ART – 12,000 in Chiradzulu and 16,000 in
Thyolo. In 2007, MSF achieved its goal of providing universal access to ART in Thyolo,
starting 11,520 people on the therapy. In 2008,
MSF placed more than 4,300 new patients on
ART in Chiradzulu, and more than 4,400 in
Thyolo.
MSF is involved in increasing the number andcapacity of health centres in the two districts.
In 25 health centres, Ministry of Health staff
have been trained to prescribe ART and to give
follow-up treatment to patients who are in astable condition.
Prevention of mother-to-child transmission
services are available in 20 locations in Thyolo,
and in ten health centres in Chiradzulu. Since
the incidence of HIV/TB co-infection is high in
Malawi, MSF has also been active in identifying potential patients and providing early
diagnosis of TB.

MSF is collaborating with local health authorities to implement a national HIV/AIDS treatment plan. Through technical working groups
at national level, MSF has participated in thedevelopment of healthcare protocols andguidelines that have been disseminatednationwide.
‘HIV/AIDS is not just a medical problem. It isalso a cultural, social problem. We want toenable people to take responsibility themselves. To do this we have started giving communities a lot of information about HIV/AIDS,
such as where to find services, how to address
problems associated with taking the drugs,
how to stay healthy,’ explained Jomah Kollie,
MSF community programme manager.

Task-shifting and decentralisationof services
To retain existing patients and to cope withan increasing caseload, MSF has focused on
training nurses to prescribe ART – a responsibility previously carried out only by clinicalofficers, medical assistants and doctors.

MSF has decentralised some services to fixedlocations in more rural areas in order to reducethe distance that patients have to travel forroutine consultations and medication. Nurses
treat opportunistic infections and chronic
diseases, and lay counsellors and dedicatedvolunteers from the community, often HIVpositive themselves, undertake testing andcounselling duties. The counsellors and volunteers also provide other essential services suchas helping people to adhere to treatment andtracing patients who have stopped coming fortreatment. Advances in treatment methods
now also allow patients who are in a stablecondition, and who have been on treatment for
at least a year, to have their medical consultations only every six months as opposed to every
two to three months.

Cholera epidemic
In mid-November 2008, a cholera epidemic
swept through the country. MSF intervened inthree rural districts as well as in the capital
Lilongwe. MSF provided care for more than
3,700 patients during the epidemic, andlogistical support to improve water and sanitation services in nine health centres and one
district hospital. MSF also trained local
medical and logistic staff, helped a healthcentre in Blantyre and carried out situationassessments on the border to Mozambique.
MSF has worked in Malawi since 1986.

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MALI
Reason for Intervention • Armed
conflict • Endemic/Epidemic disease
Field Staff 143

Malaria is one of the biggest killers in
sub-Saharan Africa. In Mali it is aleading cause of death in children
under five years old. MSF works in the
Kangaba region in southern Mali
where malaria is most prevalent. Thisis a poor area where few people haveaccess to healthcare, particularly
during the rainy season when many
villages become isolated, and whenmalaria spreads the most rapidly.
MSF supports 11 health centres in Kangaba.
It has helped ensure that healthcare is free forchildren under five years old and for pregnant
women, and available at low cost for children
over five who have a fever. As a result, morecases of malaria are treated early, which helps
prevent recurrences that can be fatal. There
has been a similar trend in the treatment ofother diseases.
MSF has also established mobile teams ofcommunity workers. They are trained andequipped by MSF to rapidly detect and treat
uncomplicated malaria cases in children
under ten years old in remote villages during
the rainy season. In 2008, MSF carried out
more than 83,500 consultations. The numberof people with malaria in 2008 exceeded
35,700 – there were 25,640 in 2007. The percentage of malaria cases that were severe
continued to decrease: from 2.13 per cent in2007 to 1.68 per cent in 2008.

Comprehensive approach to treating
fistulasIn Timbuktu, MSF also treats obstetric fistulas.
Fistulas occur most often during childbirth if
there are complications and little healthcare isavailable. A fistula is a hole created between
the rectum and the vagina, or between the
bladder and the vagina. It causes incontinence.
Women who suffer from fistulas are often
treated as outcasts. In 2008, MSF held three
sessions in collaboration with the Timbuktu
regional hospital and operated on 160 women
without charge. The free care is part of acomprehensive approach including pre- andpost-surgery care, health promotion, education, psychosocial support, physiotherapy anda shared place to stay where women can
discuss their experience and prepare to returnhome. MSF also encourages women to
overcome the fears many have about undergoing treatment.

MOROCCO
Reason for Intervention • Social
violence/Healthcare exclusion
Field Staff 27

Providing care in Kidal
Between May and December, MSF also provided
care in the Kidal region, which is affected by a
low-intensity conflict between government
forces and Touareg rebels. Half of the estimated 52,000 people who were living in Kidal
are thought to have left the area due to thetense situation. MSF provided primary healthcare consultations through two mobile teamsin the main centres where people gathered,supported Kidal hospital’s paediatric wards,
and facilitated surgical referrals to Gao city’s
hospital.
MSF has worked in Mali since 1992.

© MSF‘Morocco has become atransit country but also a
country where people
stay longer, and thiscauses frustration,
uncertainty and violence.
In order to reach thispopulation – which doesits best to go unnoticed– trust needs to be built,
and you can only do thisby being where thepeople are.’
Jorge Martín, MSF head of mission.

© Bruno De Cock

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Many migrants find themselves unexpectedly based in Morocco when they
can’t cross into bordering countries. They end up in cities such as Rabat andCasablanca where they often cannot access basic healthcare services.
The MSF teams in Rabat, Casablanca and Oujda
run curative and preventive activities; theyfacilitate access to the health structures andguarantee the quality of the healthcare. In
2008 MSF undertook over 4,000 consultations.
In addition MSF is lobbying the authorities

and other agencies to ensure they take responsibility for the migrants’ health. In 2008, areport on violence and migration was given toauthorities in both Spain and Morocco outlining the challenges faced.

S is a 27-year-old man who left Côte d’Ivoire in February 2005.
He thought he would arrive in Europe in a month. He is still in
Morocco. He lives in the bush between Nador and Berkane. He has
tried to cross to Melilla four times by jumping the fence, but the
Spanish authorities sent him back and Moroccan military forcesbeat him before taking him to the border with Algeria. S also
tried to swim across, but he was caught by the Spanish authorities
and sent back to Morocco.

Because the migrants are trapped in Moroccowith no means of generating income, illegal
practices have started to emerge such as prostitution and forced labour associated withhuman-trafficking networks. As a consequence,
new health problems linked to sexual andreproductive health are becoming prevalent.
MSF has worked in Morocco since 1997.

In 2006, S became really sick. He did not have access to healthcare, so MSF took him to the hospital and has followed his casesince then. Begging is the only way he can obtain food. S is
stranded in Morocco: he has no money to pay for the journey toEurope and cannot go back to his country since the situation thatforced him to leave remains unchanged.

35

MOZAMBIQUE

NIGER

Reason for Intervention • Endemic/
Epidemic disease • Natural disaster
Field Staff 662

Reason for Intervention • Endemic/Epidemic disease • Social violence/
Healthcare exclusion
Field Staff 1,810

Between May and the October harvest every year, Nigerians face a‘hunger gap’. Families exhaust their food reserves and their healthdeteriorates as malnutrition starts to take its toll.
In 2008, the health authorities took steps tofight malnutrition by registering as essential
medicines a ready-to-use, vitamin-enrichedpaste, and therapeutic milks. New growthstandards established by the World HealthOrganization that allow malnourishedchildren to be identified and treated at an
earlier stage were also adopted.

further supplies. This approach makes it
possible to treat a large number of children
with good results: in Zinder for example, thecure rate reached 72 per cent in 2008.

Providing nutritional support

healthcare consultations in outpatient units.
More than 100,000 children attended suchconsultations in the districts of Madaoua andBouza (Tahoua region) and in Dakoro in 2008.

MSF has been running programmes to combat
malnutrition since 2001. In 2008, teams
worked with the national and local healthauthorities in the regions of Maradi, Zinder,
and Tahoua (Madaoua and Bouza).

© Benjamin Bechet

Mozambique is still recovering from a
17-year civil war that ended in 1992.
The country’s healthcare system has
been left weak and understaffed, its
facilities overwhelmed by the HIV/AIDS epidemic. Around 16 per cent ofpeople over 15 years old are HIVpositive, and 68 per cent of tuberculosis (TB) patients are co-infected with
HIV. MSF is helping patients withthese two diseases in the rural provinces of Niassa in the north, Tete in
the centre of the country, and thecapital Maputo in the south.

In Tete, MSF provides HIV/AIDS care in three
districts and encourages the local communities to support patients – by helping them toadhere to treatment, for example. Equipping
health facilities in remote locations also
reduces the time many patients have to takeand the distances they have to travel for medication and routine consultations.
During 2008, MSF carried out more than
229,000 consultations for HIV/AIDS in
Mozambique, and initiated more than 6,600
new patients on antiretroviral therapy (ART).

Decentralisation of health services
In Niassa, MSF provides care in the provincial
hospital, in health centres in the town of
Lichinga, and in three other rural areas. In
Maputo, MSF operates in the Alto Mae andPrimeiro de Maio hospitals in the city centre
as well as in nine health centres outside themain towns.

MSF has been working with local authorities
to transfer to local health units responsibility
for first-line HIV treatment. This includes
counselling services, prevention of mother-tochild transmission and tracing patients who
allow their treatment to lapse. Such decentralisation is especially valuable in rural areas

where resources are limited. It helps bringtreatment closer to patients’ homes and helps
to reduce the pressure on the central healthcare structures.

MSF treated some 97,600 children under five
years old who were moderately or severely
malnourished. Other high-risk groups, such as
pregnant and lactating women, were also
targeted for nutritional care. Care is provided
mostly through a network of more than 40
mobile nutritional centres, which allow
children to be treated closer to where theylive. Many are treated at home with ready-touse food and come to the centre once a week
for a check-up while their families collect

As well as treating malnutrition and associated health problems such as diarrhoea, MSF
provides medicines to fight malaria, which isendemic in certain regions, and primary

The health of young children especially deteriorates during the seasonal hunger gap, whenthe quality of their diet worsens and thequantity of food available diminishes. Eachyear the number of admissions to feeding
centres grows markedly between June andOctober. To prevent children from becoming
severely malnourished, MSF distributed a
supplementary nutritive paste to 30,000
children aged from six to 36 months invillages around Maradi and Zinder each month
during the lean period. This preventive project
initiated in 2007 had promising results,

sharply reducing the incidence of severe
malnutrition in the targeted areas.

Challenges
In July, the authorities decided to suspend
MSF’s activities, although teams had worked in
the country for more than eight years on
emergency programmes devoted particularly
to nutrition. The authorities wanted to reintegrate nutrition into the national programme and avoid independent interventions
and publicity about the problem. After twomonths of discussions however, MSF was able
to partially restart its activities.

Responding to emergencies
MSF continues to respond to emergencies andcarry out vaccination campaigns. Between
April and May, during a seven-week intervention in Zinder and Maradi regions, teams
vaccinated about 700,000 children aged fromsix months to 15 years against measles. MSF
also supported national health structures tohelp care for children affected by the disease.
In the districts of Birni N’Konni, Bouza andMadaoua (Tahoua region), MSF cooperated with
Ministry of Health staff to vaccinate some
437,000 people against meningitis. Starting in
September, MSF also supported the treatmentof cholera at the Birni N’Konni district hospitalfollowing a surge in the number of people
contracting the disease. In Agadez, a region
affected by the conflict between the government and Touareg rebels, MSF supports maternity services in three health centres.
MSF has worked in Niger since 1985.

To support the local treatment centres, MSF
has strengthened the staff’s clinical knowledge, provided management and staffing
support, ensured a steady drug supply topharmacies, and upgraded medical facilities.
MSF is lobbying to allow local paramedical
staff to prescribe ART drugs and to administer
repeat prescriptions, and to use lay counsellors. Such measures would allow nurses todevote more time to their medical
responsibilities.
MSF has worked in Mozambique since 1984.

© Olivier Asselin

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NIGERIA
Reason for Intervention • Endemic/Epidemic disease • Social violence/
Healthcare exclusion
Field Staff 518

9,300 patients in its emergency room andperformed more than 3,000 surgeries. MSF has
also recently begun offering support to victimsof sexual violence. A team of specialists treated
265 people, and will continue focusing on thisissue in a city where victims often have
nowhere to go for care.
Last October, MSF opened a health centre in
Oloibiri, in the south of Bayelsa state, in orderto provide primary and mother-and-childhealthcare to people there. The ten-bed centre
has been fully occupied. In December, morethan 800 consultations were carried out, 31
per cent of which concerned children underfive. The main pathologies treated include
malaria, respiratory infections and diarrhoea.
The centre where pregnant women come forantenatal care will also provide assisteddeliveries.

Improving maternal healthcare andreacting to epidemics in the north
MSF has also started a maternal health projectin northern Sokoto state to help address
alarming maternal and infant mortality rates.
While Nigeria already has the seventh highest
maternal mortality in the world, claiming the
lives of approximately 59,000 women every
year, the rates in Sokoto are estimated to beeven higher. MSF is supporting the maternalcare programme at the Goronyo hospital in
Sokoto state.

© William Martin

In 2008, Nigeria enjoyed a relatively calm political environment after the 2007
presidential elections. However, towards the end of the year there were several
days of ethnic clashes in Jos, Plateau state.
In the Niger Delta, despite another wave ofviolence in Port Harcourt in July, the situation
has cooled down. However access to goodquality healthcare remains difficult for people
who cannot afford it, and in several places,
MSF has worked closely with the Ministry of
Health to improve the situation.

Trauma care and primary healthcare
in the Niger Delta

where people cannot always afford healthcare,
MSF has worked to improve the quality of careprovided at its hospital for trauma victims.
Teams have enhanced the use of internal
fixation, a procedure involving the insertion ofa metal component inside a bone to joinbroken segments. This has significant advantages over external fixations because it reduces
the length of hospital stays, allowing patientsto return to normal life more quickly.

In the oil-rich Niger Delta, MSF is running
programmes in Rivers state and in Bayelsa state.
In Port Harcourt, capital of the Niger Delta

Port Harcourt is prone to peaks of violence andthis year MSF teams have treated more than

MSF opened a new surgical programme
focusing on emergency obstetrics and women
suffering from fistulas in Jahun, Jigawa state.
Fistulas are usually a consequence of poor
obstetric care: a woman develops a fistula after
being in labour for many hours, or even days.
In 2008, 63 women underwent surgery tocorrect fistulas, and the team helped morethan 530 women to deliver. In 2008, around
480 women with obstetric complications wereadmitted to the hospital.
MSF has responded to various medical emergencies in the northern states, dealing withcholera outbreaks in Sokoto state, undertaking
vaccination programmes for meningitis in
Katsina and Kebbi state (more than 71,000
people vaccinated), measles in Niger state(more than 11,000 people vaccinated) and anutrition campaign in Yobe state. MSF also
provided non-food items after riots in Jos andcarried out an assessment of the condition of

refugees from Bakassi peninsula (disputed
territory between Cameroon and Nigeria)
located in the Nigerian Cross River state.

Handing over the HIV/AIDS
programme in Lagos
In September 2008, after five years of activity,
MSF completed the handover of its HIV/AIDS
programmes in Lagos. When MSF started

Sierra Leone
Reason for Intervention• Social violence/Healthcare exclusion• Endemic/Epidemic disease
Field Staff 402

In Sierra Leone the main barriers toaccessing healthcare are cost anddistance. MSF has been active in the
country since 1986 and is currently
focusing on combating malaria,
providing maternal and paediatrichealthcare, and treating malnutrition.
MSF supports the Gondama referral centre in
Sierra Leone. It offers inpatient services for
women and children and malaria treatment,
as well as a therapeutic feeding programme.
MSF also runs five outpatient clinics in collaboration with local health authorities andsupports 30 smaller rural health posts to maketreatment more accessible for people inremote areas. In 2008 MSF performed morethan 417,000 consultations.

providing free, life-prolonging antiretroviraltherapy (ART) and comprehensive care for
HIV-positive patients in 2003, there were noother agencies offering that medical support
in Nigeria. In 2006, a presidential decreelaunched a national programme offering free
ART to all HIV/AIDS patients in Nigeria. Overthe last few years, MSF has cared for more than
1,900 HIV-positive patients. By 2008, when it

was clear that the Nigerian government had
made substantial progress in providing freeART, MSF handed over the programme to local
partners and the Lagos general hospital.

As the volunteers are based in their own
villages, they help overcome the geographicalbarrier to accessing malaria treatment.

deliveries (including Caesarean section),family planning, treatment for sexuallytransmitted infections and care for survivorsof sexual violence. Malnourished children
receive nutritional rehabilitation through atherapeutic feeding centre at the Gondoma
hospital. A therapeutic feeding programme in
the mobile health clinics also makes it
possible to treat more children at home.

Jabaty, a 31-year-old man chosen to be a volunteer by his village, says: ‘I feel very happy to be a
volunteer because I am saving lives, especially the
lives of children. My village has benefited very muchbecause our people no longer have to walk for miles
to the nearest clinic.’ Through the use of a rapid
diagnostic test it is easy for Jabaty to make adiagnosis. If malaria is detected, he will
provide ACT to the patient. ‘I have treated people
every day, and we have had 44 malaria cases in thelast three weeks. They are all very happy because
they got treatment quickly and they are all well.’Maternal health and malnutrition
Sierra Leone has one of the highest maternalmortality rates in the world. The five healthclinics and the Gondoma referral centre offer
services for women such as antenatal, postnatal and obstetric care, normal and complicated

Malaria: the number one killer
In Sierra Leone the entire population is at riskof developing malaria. As in other countries,
those most at risk include children under fiveand pregnant women. Although artemisininbased combination therapy (ACT) is supposedly
free in Sierra Leone, people still cannot afford
the registration fees, the doctor’s consultationor the cost of other drugs that they mightneed. During 2008, MSF treated more than
180,000 people with malaria using ACT free ofcharge.
During 2008 MSF built up a network of 140
community malaria volunteers and taught
them how to diagnose and treat the disease.

© MSF

MSF has worked in Nigeria since 1996.

Johan Mast, MSF’s head of mission in Sierra
Leone, stresses the importance of tackling thecountry’s health problems appropriately: ‘The
huge number of people still lacking basic
healthcare due to financial, geographical andhuman resource barriers is worrying.
Increased efforts need to be directed at providing appropriate diagnostic tools and making
sure that patients receive adequate treatment.
Free access to healthcare is an issue of huge
importance.’
MSF has worked in Sierra Leone since 1986.

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39

Somalia

In memory

Reason for Intervention • Armed conflict • Endemic/Epidemic disease
Field Staff 1,348

On Monday, January 28 2008 a brutal
attack took place as the MSF teamreturned from lunch after another productive morning of emergency surgery in
the Kismayo hospital. A roadside bomb
ripped through the second vehicle in the
team’s convoy, killing three international
staff inside.
Victor Okumu, 51, was a surgeon;
Damien Lehalle, 27, a French logistician;and Mohamed Abdi Ali (Bidhaan) was
the driver.

© MSF

For many years Somalis have been subjected to violence, forced to flee theirhomes, had inadequate food and no access to healthcare. A range of factors
including the collapse of the local economy, the inability to transport and deliver
food aid, drought, inflation, high international food prices and a drastic reduction in humanitarian aid have exacerbated people’s already appalling living
conditions.
MSF experienced the impact of this insecurity
at first hand. In January three colleagues
were killed in Somalia and three projects in
Kismayo, Mogadishu and Bosasso had to close.
In April 2008, intense fighting across thecountry and specific threats against foreign
aid workers forced MSF to evacuate all its
international staff from Somalia. However
MSF’s projects continue, run by dedicatedSomali staff, supported by international
staff based in Nairobi who visit wheneversecurity allows.
On the road from Mogadishu to Afgooye,
where thousands of people have been forced toflee the violence of the capital, there arethought to be more than 300,000 displaced
people living in terrible conditions. MSF has
been in the area since 2007 supporting a
private clinic and running an outpatient
department, paediatric ward and cholera
treatment centre, nutrition programme, andmanaging the distribution of water, blankets
and other non-food items.

During 2008 MSF staff saw a huge rise in thenumber of children needing nutritional carein its intensive and mobile feeding centres in
Hawa Abdi and Afgooye. Medical teams treatedmore than 15,500 malnourished children
under the age of five. More than 2,000 of thechildren were admitted to intensive care, but
most were cared for as outpatients.
In Mogadishu, staff in the surgery departmentof Danilye hospital treated 5,250 patients in theemergency room, including more than 3,000
people wounded in the conflict. More than half
the patients were women and children under
the age of 14. At an outpatient clinic in
Mogadishu North, a further 1,400 patients who
had been operated on for war-related injuries
were provided with dressings. Nutrition was
also a key concern: early in the year MSF teams
started a programme for severely malnourishedchildren and 1,800 patients were admitted
and treated. Throughout the country, MSF
treated more than 18,400 children for severe

Both Victor and Damien were relatively
new to the Kismayo project but not new
to the MSF family. Victor will always beremembered for his dedication to hispatients in Sierra Leone, Darfur and formany years in South Sudan.
Damien also had joined the Kismayo teamrecently, after finishing his first missionin Democratic Republic of Congo. He will
be remembered for his hard work and his
warmth of character.
Bidhaan will be remembered for his
committed service to MSF.

malnutrition and more than 16,000 children formoderate malnutrition.
Although most international attention focusedon the capital and its surroundings, MSF
teams responded to huge needs in nine regionsof south and central Somalia. To the north inGalcayo, medical staff treated 470 victims ofviolence over the course of the year. In
Galgaduud, more than 600 people wereoperated on.
Yet it is not just victims of violence who needassistance in Somalia. Curable and preventablediseases such as diarrhoea, malaria and respiratory tract infections cause many thousandsof deaths every year. Basic healthcare such asantenatal consultations and vaccinations werecrucial to MSF’s efforts to save lives. Medical
staff provided more than 727,000 outpatient
consultations, 55,000 antenatal consultations,
82,000 vaccinations and, in Jowhar, 1,500
deliveries.
MSF has worked in Somalia since 1991.

South Africa
Reason for Intervention • Endemic/Epidemic disease • Social violence/
Healthcare exclusion
Field Staff 92

An estimated 18 per cent of adults in South Africa are HIV-positive, andmany urgently need antiretroviral therapy (ART). Tuberculosis (TB), including
drug-resistant TB (DR-TB), is the main cause of death and illness among
those living with HIV/AIDS.
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 May 2001, MSF has
been running an ART programme there in
partnership with local health authorities. This
was the first such programme in the South
African public sector and has prompted similar

The projects provide general primary healthcare, mental-health support, and referrals to
hospitals and specialised medical facilities.
MSF treats up to 5,000 Zimbabweans eachmonth in these two projects, mainly for respiratory tract infections; sexually transmitted
infections, including HIV; gastrointestinal anddiarrhoeal conditions; and stress-related

initiatives in other parts of the country. Morethan 11,000 patients are now benefiting fromthe ART services in Khayelitsha.

ailments. MSF teams are also treating an
increasing number of people who have been
subject to sexual violence, and are seeing a
growing number of unaccompanied minors.

A high proportion of HIV/AIDS patients areco-infected with TB. The case notification rate
for TB here is at least 1,500 per 100,000 people
per year – among the highest incidence in theworld. As in the rest of South Africa, increasing numbers of people are being diagnosed
with drug-resistant tuberculosis (DR-TB). MSF
has been piloting a project to provide decentralised care and treatment for patients with
DR-TB in Khayelitsha. The project is based on
the theory that more patients will be diagnosed and successfully treated if they areencouraged to follow treatment in theirhomes, rather than being isolated in specialised hospitals. This model of integrated carefor HIV/AIDS and TB patients has been replicated in many other settings and is promotedby the World Health Organization as a model
for best practice.

‘Zimbabweans face significant risks, including thoseof sexual violence, physical and verbal abuse, andpolice harassment when crossing the border into
South Africa,’ says Sara Hjalmarsson, MSF fieldcoordinator in Musina, a town on the Zimbabwe
border. ‘And these risks persist in South Africa,
where many continue to be harassed by the police
and are unable to find sustainable employment.’
Between May and September 2008 there wasan upsurge of violence aimed at foreign
nationals, which led to 62 deaths and thedisplacement of more than 100,000 people
across the country.
MSF responded to this emergency in morethan 15 locations in Johannesburg, Pretoria
and Cape Town. Teams treated injuries such as

The Simelela Centre for survivors of sexual
violence in Khayelitsha provides comprehensive services for rape survivors such as emergency medical care, counselling and social andlegal support. Links with community activist
groups aim to reduce the number of victims ofsexual violence by raising awareness anddenouncing rape as a crime of violence. The
clinic saw nearly 700 patients in 2008.

Medical and humanitarian assistancefor Zimbabwean refugees
Since December 2007 MSF has been working
in central Johannesburg and in Musina toprovide Zimbabweans with medical care.

© Benedicte Kurzen

gunshot wounds, head traumas and wounds
resulting from beatings, lacerations andburns. They provided primary healthcare to
those who had been forced to flee, and distributed hygiene kits, blankets and plastic
sheeting.
In Johannesburg, where the violence was mostextreme, MSF incorporated mental-healthactivities into the work of the medical teams.
MSF also pressured the South African authorities to improve basic services such as shelter,
water and sanitation in temporary camps.
During the crisis, MSF provided 11,000 medical
consultations and an additional 8,000 mentalhealth consultations.

Cholera outbreak
In November, a cholera epidemic spread from
Zimbabwe to South Africa. Authorities in thenorthern province of Limpopo declared
Vhembe district, on the Zimbabwe border, adisaster area. MSF reinforced teams in Musina
in Vhembe district and in Johannesburg,
shifting from providing basic primary healthcare for Zimbabweans to prioritising cholera
diagnosis and treatment and hygiene promotion. During the outbreak, the MSF team inMusina referred more than 300 people withcholera via three mobile medical teams
working on farms, villages and in other highrisk areas in and around Musina. At theCentral Methodist Church in Johannesburg,
MSF, together with local health authorities,
managed to contain the spread of the disease
through intensive health promotion, earlycase detection, treatment, and water andsanitation improvements.
MSF has worked in South Africa since 1999.

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Sudan

of people. In Jonglei, Upper Nile and Unity
states, medical staff provide all levels of
healthcare, ranging from consultations forrespiratory tract infections to life-saving
surgery. In 2008 medical teams carried out
more than 365,000 outpatient consultations;
19,000 antenatal consultations; 1,000 operations, many of them emergency surgicalinterventions for gunshot wounds; andadmitted more than 8,000 people as
inpatients.

people suffering from cholera. More than
1,200 cholera patients were also cared for in
Juba, the capital of southern Sudan, wherecases were first detected in May. Because
vaccination coverage is low in Sudan, children
are vulnerable when there are measles outbreaks. MSF vaccinated more than 19,200
children during two campaigns in July andNovember 2008 in Pibor county, Jonglei state.

Throughout the country MSF teams areprepared to respond to emergencies andIn the north of Sudan, in addition to its programmes in Darfur, MSF runs a project in Port
Sudan, in Red Sea state, providing maternal
healthcare with a particular focus on pregnant
women who have been circumcised. It isestimated that more than 97 per cent of
women in Red Sea state are circumcised. This
procedure causes serious medical complica-

epidemics. In July heavy rains and flooding
exacerbated a cholera outbreak in Aweil.
Working with the Ministry of Health andother agencies, MSF treated more than 6,700

tions for many women for the rest of theirlives. During delivery, circumcised women
have to be cut open, or ‘defibulated’, to enable
the birth of the child. After a birth it is

Overall, MSF treated 9,000 children for severe
acute malnutrition in south Sudan, as well asover 600 people for violent trauma.

common practice to re-stitch, or ‘re-infibulate’,women. However, in Port Sudan the MSF
project in Tagodom hospital MSF does not
re-infibulate any women following delivery.
In 2008 MSF carried out an average of 1,000
consultations and 64 deliveries each month in
this programme. Community teams also
provided basic health education and raised
awareness of the medical risks of female
circumcision.
Where possible MSF has handed over activities.
In June 2008, MSF handed over to the local
health authorities its activities in Bor hospital,
Jonglei state, after two years. At the end of theyear, MSF handed over its sleeping sickness
programme in Yambio, Western Equatoria
state, to the Ministry of Health.
MSF has worked in Sudan since 1979.

© Brendan Bannon

Reason for Intervention • Armed conflict • Endemic/Epidemic disease• Social violence/Healthcare exclusion
Field Staff 3,240

Throughout 2008, MSF field staff provided medical services in a country whereattacks and outbreaks of violence frequently occur, malnutrition is prevalent,
and maternal mortality rates remain among the highest in the world.
Tuberculosis and kala azar (visceral leishmaniasis) are common here, as arelarge-scale outbreaks of meningitis, measles, cholera, and malaria.
Clashes between armed forces and tribal
militias along the disputed border of northernand southern Sudan, coupled with politicaltensions, led to the displacement of several
thousand people in Bahr-el-Ghazal statethroughout the year. In January MSF opened a
new project in the city of Aweil. Because manyof the displaced people had to leave behind
everything, staff initially focused on distributing kits containing essential items such assoap, jerry cans, mosquito nets, tarpaulins,and cooking sets to the most vulnerable,
covering the needs of more than 15,000
people.
MSF also started working in Aweil hospital,
providing nutrition and healthcare to mothers
and children. Since malnutrition was a key
concern, six additional outreach clinics were
set up to try to reach as many people aspossible. In the course of the year more than

21,000 outpatient consultations were provided
and more than 6,000 children were treated formalnutrition.
In February, after an extremely violent attacknear the town of Abyei, thousands of people
fled to camps in northern Bahr-el-Ghazal state,
and an estimated 10,000 people fled into thebush. In May, fighting virtually destroyed
Abyei, displacing another 60,000 people. MSF
teams have been working in Abyei since 2006
and were able to provide immediate emergency assistance. Owing to the large numbersof war-wounded, surgical and post-operative
teams were sent to support the existing MSF
team.
In order to reach the people who had fled tothe bush, mobile clinics were set up in both
Abyei and the nearby town of Agok, andmobile and inpatient nutrition programmes

Darfurwere put in place. By the end of the year 8,950
outpatient consultations had been given andmore than 1,200 severely malnourishedchildren had been treated. MSF also organised
distribution of non-food items in Muglad,
north of Abyei, for around 400 families. Teams
remain ready to respond quickly to any further
needs that might arise in this unstable area
where people are struggling to survive.
Towards the end of 2008, attacks by the
Ugandan rebel group, the Lord’s ResistanceArmy, in the south of Sudan near theCongolese border and in the Democratic
Republic of Congo (DRC) caused thousands of
Sudanese people to flee their homes.
Congolese refugees also crossed the border toseek refuge in Sudan. In response MSF started
supporting two primary healthcare clinics in
Gangura and Sakura, in Western Equatoria
state, close to the border with DRC. By the endof the year, 7,200 medical consultations had
been provided to the residents and refugees inthese two areas.
In other parts of southern Sudan MSF continues to provide care to hundreds of thousands

MSF has provided medical and humanitarian aid in the Sudanese region of
Darfur since 2003. This is when government forces and allied militia
began fighting the rebel groups who
sought greater autonomy and resources for the arid and impoverishedregion. Since the start of the conflictthe political environment has become
increasingly complex. The armed
groups have fragmented, leading tofurther outbreaks of violence andheightened insecurity. Harassment
from armed groups, increased banditry
and clashes between nomadic tribes
have forced more people to leave theirhomes to seek refuge.
In 2008, Darfur remained one of the largest
humanitarian aid operations in the world.
More than 80 organisations and 15,000 aid
workers – including 2,000 MSF staff – provided
assistance here, where an estimated one-thirdof the population has been displaced. Yet
despite all these efforts, hundreds of thousands of people remain cut off from aid.
Thousands more are at risk of losing assistanceas a result of unstable frontlines, shifting
alliances among armed factions, targeted© Jan-Joseph Stok

attacks on aid workers, and increasing government restrictions on the provision of humanitarian assistance.

Insecurity challenges
The security situation deteriorated throughout
the year. In February, a military offensive
around Seleia, in West Darfur, left 300 people
dead and caused another 10,000 to flee toneighbouring Chad. MSF teams had left Seleia
before the attacks. After a month they wereable to return to provide medical care throughmobile clinics.
In August, after a series of attacks against MSF
staff, teams were forced to leave projects inNorth Darfur: Tawila, where about 35,000
displaced people have gathered in three camps
since August 2007, and Shangil Tobaya, where
MSF provided medical care for about 28,000
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Teams also worked in Niertiti and Zalingei inWest Darfur, providing healthcare services toaround 170,000 people. Most of the 130,000
people who live in Zalingei have fled there
from their homes. MSF works in three departments of Zalingei hospital, supporting paediatric surgery and the emergency room. The
increase in malnutrition prompted teams to
distribute supplementary food to 11,000
children aged from six to 36 months during
the ‘hunger gap’ before the new harvest. In
Niertiti, MSF provided outpatient and inpatientcare: 86,000 consultations were performed and
4,900 people were admitted to hospital. In
response to a meningitis outbreak in February,
MSF vaccinated over 28,000 people.

and 110 patients were admitted to the clinic. In
Jebel Si, MSF ran a clinic in Kaguro and five
health posts in the surrounding area. These
provide medical care to around 40,000 people
who had been cut off from assistance since2003, when the area was attacked and mostvillages were burned down. In the rural town of
Kebkabiya, 90 miles west of North Darfur’scapital El Fasher, MSF supports two clinics andfive health posts providing basic healthcare
including vaccination and the treatment ofmalnutrition. Teams also support the obstetricdepartment of Kebkabiya hospital and provide
comprehensive emergency obstetric care.

people received care from the MSF team in
Muhajariya, as did 1,300 inpatients and 440
surgical patients. In April 2008, MSF restarted
mobile clinics in Labado and Um Shegeira toenable better access to healthcare. In 2008, 660
malnourished children were assisted throughthe MSF clinics. In the mountains of theeastern Jebel Mara, a team based in Feina ran aclinic providing outpatient care, antenatal
care and a mobile feeding programme. Thereis also an inpatient department for severely
malnourished children and people who needemergency care. Mobile clinics were also run
in Gulombei and Deribat.

In nearby Serif Umra medical staff provided

In South Darfur MSF ran a 25-bed clinic thatprovides medical care to around 70,000 people
living in and around the town of Muhajariya.

In 2008, MSF opened a new project in Adila,following an assessment in March that showedthat the incidence of acute malnutrition inprimary and secondary healthcare, including
antenatal and inpatient care, vaccination andthe treatment of malnutrition. Each montharound 4,000 consultations were carried out.
More than 45 children received nutritional care

Staff offer surgical care and run inpatient andoutpatient departments and a laboratory, in
addition to providing obstetric health services.
Treatment for survivors of sexual violence isalso available. In 2008 more than 55,000

children had reached 14 per cent. By the end of
October, 4,700 children had received treatment.
MSF has worked in Darfur since 2003.

© Jan-Joseph Stok

rounding villages. Leaving so many people
without access to medical care, even if only
temporarily, was extremely hard, but without
a guarantee of minimum security for humanitarian workers, MSF had no option but tosuspend activities. The team was able to returnto Shangil Tobaya in September. In 2008,
almost 45,000 consultations where carried out
and more than 4,000 women received antenatal care. The team returned in October toTawila, where 25,000 consultations wereconducted in 2008, but had to leave again in
December.

In August, attacks on Kalma camp, home tomore than 90,000 displaced people, resulted inmany injuries. At least 65 patients wereadmitted to the camp clinic and MSF ambulances evacuated 49 patients suffering fromgunshot wounds to a hospital in the region’s
capital, Nyala.
MSF also had to relocate the staff from Kaguro
project in the Jebel Si in mid-September during
an aerial bombardment campaign by thegovernment. The team returned ten days later.

Fatima, who lives in Motorwat camp in the
Muhajariya town area with her husband and fourchildren, told MSF that she and her family have
had to move eight times so far, from town, toforest, to camp, and back again.
‘Every time we moved, we lost our property’, shesays. ‘It is exhausting, but if you don’t movequickly, you could be killed, or you and yourchildren could be killed. Anger is pointless: even
if I get angry, there’s nothing I can do.’Mental-health care
In order to help people traumatised by the
conflict and repeated and prolonged displacement, MSF introduced mental-health care in2006. Staff provided 9,380 counselling sessions
for more than 1,600 patients. In 2008, 84 percent of these patients reported improvementsin their symptoms or a full recovery. Howeverlater in the year MSF was ordered by the
Sudanese Humanitarian Aid Commission andthe federal Ministry of Health to stop mentalhealth counselling in South Darfur, or risk
expulsion.
MSF teams treated 64,000 patients, provided
care to 19,000 pregnant women and delivered
1,750 babies. Despite this, MSF was given no
choice by the authorities but to end theintervention.
In West Darfur, new projects in Golo andKillin, in the Jebel Mara region, were opened
in April. Medical teams provided primary andsecondary healthcare, focusing on women’s
health and combating malaria and malnutrition. In 2008 around 3,800 consultations were
performed each month.

SwazilandReason for Intervention• Endemic/Epidemic disease
Field Staff 55

In Swaziland it is estimated that HIV/AIDS affects one adult in four, and 80
per cent of patients with tuberculosis(TB) also have HIV. Since November
2007 MSF has been working in the
Shiselweni region with public healthstaff to treat these two diseases.
MSF is decentralising the services offered to
HIV-positive people and TB patients in the
Shiselweni region. The goal is to establish a
one-stop system, to give patients the opportunity to be treated for these two diseases at thesame time in the same location by the same
health workers. Screening and treatment are
now offered at Hlatikulu hospital and in the
Nhlangano and Matsanjeni health centres, aswell as in nine out of 20 other health centresin the region. In 2008 in the Shiselweni region,
nearly 2,300 patients received TB treatment,
and 1,870 TB patients co-infected with HIV/AIDS received antiretroviral therapy.

© Alexander Glyadyelov

In 2008 an estimated 12,000 new cases of TB
were identified in Swaziland, including 200
people who had contracted a form resistant totreatment. Of these, 42 were diagnosed andmonitored in Shiselweni. Identifying andtreating resistant forms of TB is a priority
because of the dangerous and complex natureof the disease.

MSF works directly with communities andpeople living with HIV/AIDS on prevention andeducation, research and detection of cases andpatient follow-up. Encouraged by their good
adherence to treatment, ‘expert patients’ whohave personal experience of chronic disease
help other patients to gain control of thedisease and live positively with HIV/AIDS.
MSF has worked in Swaziland since 2007.

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UgandaAt the height of a cholera outbreak between
January and April in Arua district, up to 40
patients were being admitted each day to an
MSF cholera treatment centre.

Reason for Intervention • Armed
conflict • Endemic/Epidemic disease
Field Staff 719

HIV/AIDS affects an estimated eightper cent of the population. According
to the World Health Organization there
are more than one million people livingwith HIV or AIDS in Uganda, including
312,000 who need antiretroviraltherapy (ART). It is estimated that
42 per cent of patients are on ART
nationally, but the percentage is much
lower in northern Uganda.

Refugees fleeing fighting in the Democratic
Republic of Congo at the end of 2008 havebeen assisted by MSF in Ishasha/Matanda andin Nakivale through a health clinic and theimprovement of water and sanitation facilities
in the camps.

Malnutrition in Kaabong and Karamoja
In Karamoja, northeastern Uganda, a poor
harvest in 2006, little rain in 2007, and laterains in 2008 made food scarce, leading toincreased prices and depleted livestock. MSF
started a nutritional intervention in June 2007
in Kaabong district. This intervention lasted
throughout 2008, ending in a handover to
Action Contre la Faim in December.

In Arua, MSF’s HIV/AIDS clinic includes integrated treatment for tuberculosis/HIV coinfection, nutritional support for
malnourished adults and children living with
HIV/AIDS, and a programme providing antenatal care and prevention of mother-to-childtransmission of HIV/AIDS. More than 4,700
patients are undergoing ART in Arua regional
hospital. In parallel, MSF supports three decentralised HIV/AIDS clinics in the West Nileregion, to ensure that people can access local
healthcare.

MSF in Kaabong treated almost 900 cases ofsevere malnutrition and 2,500 cases ofmoderate malnutrition in 2008. Malnutrition
was treated in the stabilisation centre in
Kaabong hospital between January and July. In
July 2008, MSF started to expand its project inKaabong into paediatrics and all areas ofreproductive healthcare. The project will growin 2009 to include victims of violence resulting from government disarmament activities.

Only ten per cent of HIV-positive patients haveaccess to care in Madi Opei, Kitgum district.
MSF made HIV/AIDS/TB care available, andprovided treatment in the outpatient, inpatient and maternity departments. Every montharound 2,000 outpatients were seen and 100
patients were admitted to the clinic.
In Gulu district, MSF teams continued theirintervention in the health centre in Lalogi,
about 21 miles southeast of Gulu town. To
build up a system that can be taken on by the
Ministry of Health, the teams are making thecomprehensive secondary healthcare in Lalogi– which includes maternity, inpatient care,mobile services and HIV/TB care – as sustainable as possible. In 2008, they treated morethan 53,000 patients.

Following reports of increased rates of malnutrition in Karamoja, MSF initiated a second
nutritional intervention in the districts ofMoroto and Nakapiripirit, treating almost
4,000 malnourished children.

ZambiaReason for Intervention• Endemic/Epidemic disease
Field Staff 68

HIV/AIDS is still highly prevalent inZambia and a significant healthproblem. The disease and related
deaths are laying a heavy burden on
society. The impact of the pandemic in
the country is attested by the decreasein life expectancy at birth which,according to the World HealthOrganization, was 52 in 1990 but by
2003 had dropped to 35.
However, the government of Zambia has raised
awareness of HIV/AIDS over the years and has
implemented policies to increase the provisionof treatment. In July 2005, the government
started providing HIV/AIDS care free of charge
and in 2006 abolished the national cost-sharing system of healthcare.
MSF has focused on providing assistance topeople with HIV/AIDS through a project in the
district of Kapiri M’Poshi. Kapiri is a fast-growing town with little infrastructure, situated ina transit area. Because of the central position
and transit character of the town, the population of Kapiri is particularly exposed todiseases such as sexually transmitted infections, HIV/AIDS, tuberculosis (TB) and cholera.
It is estimated that 20 per cent of the city’s
general population is affected by HIV/AIDS.

Access to healthcare in general and HIV/AIDS
care in particular is limited for the 250,000
inhabitants of Kapiri district, who are spreadover a vast area that has no roads or means oftransport. The care provided through theexisting facilities is poor due to lack of
medical supplies and human resources. MSF
has shown that some of the tasks and responsibilities, such as HIV testing and counselling,that were formerly undertaken by doctors canbe handed over to clinical officers or nurses.
MSF runs an HIV/AIDS clinic inside Kapiri
district hospital and works in 14 rural andfour urban health centres. By implementing
such a decentralised model of HIV/AIDS care,people living outside large urban centres canreceive care and treatment. MSF is also involving the community in preventing the spreadof HIV and the treatment and support ofpeople living with HIV/AIDS.
At the end of December, MSF had enrolled
more than 10,500 patients in the project, morethan 5,000 of whom were receiving antiretroviral therapy. During 2008, MSF teams carriedout more than 2,600 medical consultations amonth. At the same time, and in preparation
for the handover of the HIV/AIDS programme,
MSF started to integrate the project with the
Ministry of Health’s activities.
MSF has worked in Zambia since 1999.

MSF has worked in Uganda since 1980.

© Julie Remy

Emergency response
In November 2007, hepatitis E appeared in
Kitgum as a consequence of the deplorable
sanitation in the camps. Hepatitis E is a virus
spread through contaminated water or food.
There is no cure or vaccine, therefore MSF
teams focused on case management of infectedpatients and prevention of the spread.

Pregnant women and children are at greatest
risk so were particularly targeted. By the endof 2008, MSF had treated more than 1,500
patients in Kitgum. MSF also implemented
prevention and referral activities to preventthe spread locally and to other districts.

At the end of 2007 into the beginning of 2008,
MSF responded to an outbreak of Ebola haemorrhagic fever in western Uganda in the two
key areas of Bundibugyo and Kikyo.

© JulieRémy

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Zimbabwe
Reason for Intervention • Endemic/Epidemic disease• Social violence/Healthcare exclusion
Field Staff 579

Political instability has led to economic freefall in Zimbabwe: aggressive
inflation, the collapse of basic infrastructure and services, food shortages and a
total implosion of the country’s health system. In its regular programmes, MSF
focuses on the treatment of HIV/AIDS patients and provides nutritional support
to severely malnourished children.
One in five adults in Zimbabwe is infectedwith HIV/AIDS, and too few of those in urgent
need of treatment can access antiretroviraltherapy (ART). In its HIV/AIDS programmes in
Bulawayo, Epworth, Gweru, Tshlotshlo andvarious locations in Manicaland province, MSF
is supporting free care for 40,000 people. In

2008, 26,000 of these people began ART. But
increasingly, patients are missing their
appointments and risk interrupting theirtreatment because they cannot get to the few
functioning clinics. This is due mostly to thehigh cost and unreliable nature of the transport system, but sometimes it is because

Dadirai started antiretroviral therapy atthe Epworth programme in 2007. Before
that, she was so sick she could not walkor eat unaided. Her husband had died,having refused to seek treatment, andboth her daughters are HIV-positive.
After starting with the programme,
Dadirai first worked as a volunteer HIV
counsellor, but then went back to schooland earned her Nurse Aide certificate.
Now she is an MSF staff member working
at the Epworth clinic.

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patients have had to flee to neighbouring
countries. In response to this problem, MSF
has started to decentralise treatment, making
its services more accessible, especially in rural
areas.
Many Zimbabweans who leave the country –an estimated three million to date – flee toSouth Africa. Since May 2008, MSF has worked
in Beitbridge, the exit point most used bythese people. The project ensures primary
healthcare reaches the most vulnerable, suchas refugees, migrants, orphans or commercial
sex workers; and deals with victims of violence
and abuse. In 2007, MSF started to provide
medical assistance to Zimbabwean refugees inthe border town of Musina, and in central
Johannesburg.

Combating Cholera
By December 31, MSF had helped more than
30,000 people suffering from cholera andmore than 1,500 deaths had been recorded.
MSF medical teams supported government
structures with supplies, staff incentive
payments and training, and establishedseparate cholera treatment units in areas that
had no other health facilities.
MSF has worked in Zimbabwe since 2000.

‘From what we see each
day it couldn’t be clearer– this is an enormous
medical emergency,
spiralling out of control.’© Joanna Stavropoulou

Manuel Lopez, MSF head of mission© Vali Faucheux-Georges

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contents

ARMENIABANGLADESH

48 | ARMENIA
49 | BANGLADESH
50 | CAMBODIA
51 | CHINA
52 | Georgia
52 | INDIA
54 | INDONESIA
55 | KYRGYZSTAN
56 | MYANMAR
57 | NEPAL
58 | PAKISTAN
59 | Papua New Guinea
60 | Philippines
60 | SRI LANKA
62 | THAILAND
63 | TURKMENISTAN
64 | UZBEKISTAN

Reason for Intervention• Endemic/Epidemic disease
Field Staff 56

Reason for Intervention• Social violence/Healthcare exclusion• Natural disaster • Endemic/Epidemic
diseaseField Staff 150

In the area bordering Myanmar(Burma), thousands of Rakhine
Muslims, often referred to as
Rohingya, struggle to survive. Denied
citizenship at home, many escaped
persecution only to find themselvesliving in appalling conditions in
Bangladesh, with poor access tohealthcare and inadequate protection.

© Vali Faucheux-Georges

D and her family lived in difficult
conditions. D had had pneumonia twice,
and then was diagnosed with TB. All she
knew about TB was that it was infectious.
When they knew she had the disease
everybody was scared of her, even her
close family. She spent a long time in
hospitals, but was discharged because
the drugs were not working. At home
she became sick again and was taken to
hospital in Nor-Nork by ambulance.
She was operated on and diagnosed with
DR-TB. After the surgery she was moved
to Abovian and was included in the MSF
programme. She stayed in hospital for a
few months and, after making good
progress, was discharged. She continued
her treatment via a mobile clinic. In all,the treatment lasted two years. In the
beginning, D found it hard to take thedrugs because of the side-effects, but shepersevered. Now she is cured and can get
on with life again.

Armenia has one of the world’s highest incidences of drug-resistant tuberculosis(DR-TB). In September 2005, in collaboration with the Armenian Ministry of
Health, MSF started a pilot programme for diagnosis and treatment of DR-TB in
the capital city, Yerevan, where almost half the country’s population lives. Since
then, response to the DR-TB epidemic in the country has improved, with support
from international agencies and donors helping to strengthen local capacity.
At national level, MSF is advising on the setting up of a ‘directly observed
treatment short course’.
MSF’s DR-TB programme in Yerevan covers thecity’s population of approximately 1.2 million.
Once DR-TB has been diagnosed, patients
receive initial treatment at the inpatient unit
where MSF has refurbished a 35-bed facility.
When patients are no longer contagious, they
are discharged and their treatment continues
via mobile polyclinics or home-based care
until it is complete.
Adhering to the treatment is not easy, since
it can take 18 months to two years, involves
taking handfuls of drugs daily and there
are often side-effects. MSF provides multidisciplinary services to encourage adherence

to treatment: teams of doctors, nurses,
psychologists and social workers assist patientsin different ways and emphasise the importance of finishing the course.
MSF offers social support to the patients andtheir families. Food parcels help ensure abalanced diet, a transport allowance covers
the costs of getting to the clinic every day
and heating allowances help make the coldest
months of winter bearable. More than
200 patients have been admitted to theprogramme since September 2005.

In 2008, MSF continued to deliver healthcare
to more than 7,500 Rakhine Muslims living in
Tal makeshift camp, as well as to those in theneighbouring community. The camp, positioned next to flood-prone waters and adanger­ously busy road, was appallingly overcrowded and insanitary. In the primary
healthcare clinic, MSF staff regularly treatedpeople who had diarrhoea, skin infections andrespiratory tract infections that were due tothe squalid living conditions. Services also
included a therapeutic feeding centre forseverely malnourished children, a mentalhealth programme and projects to improvedrinking water and sanitation. After months
of intense lobbying led by MSF, the camp was
eventually moved to a new site in Lada Bazaar
in July and other agencies stepped in, allowing
MSF to hand over activities.

MSF project coordinator, Yvonne Cuppens

In the isolated districts of the Chittagong Hill
Tracts, the least-developed area within
Bangladesh, the ethnically diverse population
is especially vulnerable. Years of conflict,discrimination and marginalisation haveforced the standard of the area’s healthcare
far below that of other areas of the country.
During 2008 people faced increased foodinsecurity. This was worsened by a plague ofrats that badly affected supplies of rice – themain staple of people’s diets.
Tensions between established tribal groups,
the more recently arrived (and arriving)
Bengali settlers, the large government militarypresence and local opposition groups keep thearea prone to outbreaks of violence and causesome people to flee their homes. One of themain markets in the area remained empty formuch of the year as a result of fear, boycotting
and intimidation.
In response to the increased levels of foodinsecurity and a 13 per cent incidence ofacute malnutrition in children under five

years old, MSF set up an emergency nutritional
intervention programme in the Sajek Union
area of Chittagong Hill Tracts. The intervention, which ran from April to December,sought to assist those already affected bymalnutrition and to prevent the situationfrom worsening. A mobile feeding programme
was set up, as well as an inpatient stabilisation
centre for treating children who needed closer
medical attention. MSF began to provide
essential food items such as such as oil, fishpaste and salt to around 28,000 people.
Alongside the nutritional programme, MSF set
up a basic health clinic and eight healthoutposts, which were supported by a laboratory service for tests such as malaria.
While the nutritional situation steadily
improved, MSF continued to treat around 200
people a week, largely for diarrhoea, upperrespiratory-tract infection and malaria, in theclinics.
MSF has worked in Bangladesh since 1985.

‘I don’t think I’llever get back to
Myanmar. It is clearthat things are still
very bad there andeven if we live withminimal support andhelp here, at least we
do not have to livein fear.’

MSF has worked in Armenia since 1988.

‘Some patients are reluctant to start DR-TB treatment. In some cases patients interrupt treatment
because of the side-effects of the second-line
drugs. A nurse, a social worker and a psychologist
work with each patient individually to try to
encourage them to continue treatment.’
Auxiliary TB nurse‘The Chittagong Hill Tracts have a long history ofunrest and the growing population seems to be
exacerbating disputes over land and property
rights. For everyone, land means the ability tofeed one’s family and to earn a living.’

Thirty-year-old woman, Tal Camp
© William Martin

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CAMBODIA

CHINA

Reason for Intervention• Endemic/Epidemic disease
Field Staff 334

Reason for Intervention • Endemic/Epidemic disease • Natural disaster
Field Staff 70

Last year, HIV/AIDS became the top fatally infectious disease in China for
the first time. According to the Ministry of Health, 44,839 new cases werereported between January and September 2008. UNAIDS, the United Nations
programme on HIV/AIDS, estimates that 700,000 people were living with thedisease in China at the end of 2007, 190,000 of whom need antiretroviraltherapy (ART). Fewer than 20 per cent of them are receiving the treatment
they need.
Although the Chinese government provides
ART medication through its national programme, HIV testing and the management ofopportunistic infections are not free, so people
can die from HIV-related illness before being
able to access the treatment. Stigma caused byassociation with the disease also prevents
people from visiting national facilities to betested and receiving treatment at an earlier
stage.

© Lauren Cohen

The main health problems in Cambodia
include HIV/AIDS, diabetes and tuberculosis (TB). A substantial increasein funding by international donors
has helped strengthen efforts by thegovernment of Cambodia and its
partners to tackle such prevalentdiseases. As a result, MSF has begun
reducing its activities in the country.
In the provinces of Siem Reap and Takeo, MSF
is running two clinics that use an innovative
approach to treat HIV/AIDS as a chronic
disease alongside diabetes and hypertension.
The approach aims to de-stigmatise HIV/AIDS
by treating it as another chronic disease.
Another aim is to increase the focus on
diabetes – a disease that is rarely treated in
Cambodia and yet affects five to ten per cent of
the population.
‘In Cambodia, care for people with HIV/AIDS is
expanding and attracts a lot of attention from theinternational donor community. However, care forpeople with diabetes, arterial hypertension andother treatable chronic diseases remains limited andthe level of government spending on drugs is insufficient,’ says Philippe Berneau, head of mission.

‘Some sufferers even say that they “wish they had
AIDS”, since the HIV/AIDS care provision is muchbetter. MSF’s approach of integrating care for HIV/AIDS with care for hypertension and diabetes has
resulted in satisfactory outcomes for patients andefficiency gains for the services.’
At the end of the year, the two clinics weretreating more than 3,000 HIV patients, morethan 1,700 diabetes patients and 390 patients
suffering from hypertension. MSF was also
treating a small number of patients with TB
and multi-drug-resistant tuberculosis(MDR-TB). Preparations have now started forthe handover of these activities to local healthauthorities and partner NGOs.
In Phnom Penh, MSF is treating HIV/AIDS
patients in the Khmer-Soviet Friendship
Hospital, where 3,650 patients were given
antiretroviral therapy (ART). In June, MSF
began integrating the treatment into the
public health system. The handover wasachieved by transferring patients from otherprovinces to local centres providing ART. Now,
the remaining MSF activity in the hospital is
the treatment of patients who are co-infectedwith MDR-TB.

Since 2006 MSF has been providing HIV/AIDS
care to prison inmates in Phnom Penh. In
June, access to care and treatment in two of
the city’s main prisons was increased.

While some important second-line antiretrovirals were eventually registered in 2008, many
essential medicines are still inaccessible. The
cost of many anti-opportunistic infection
drugs is still too high and paediatric formulations of drugs to treat HIV and tuberculosis areunavailable within the country.

In Kampong Cham, the handover process of
HIV/AIDS care to local health authorities wasin its final stages by the end of the year. The
Cambodian health authorities were thenmanaging the adult caseload, while the paediatric consultations were still carried out by
MSF. A project dealing with HIV patients
co-infected with TB as well as patients withdrug-resistant strains of TB was set up in June.

In collaboration with the Guangxi Public
Health Bureau and Guangxi Centre for Disease
Prevention and Control, MSF has been providing free and confidential care and treatment
for HIV/AIDS patients in Nanning since 2003.
This comprehensive programme provides
voluntary counselling and testing (VCT), diagnosis, management of opportunistic infections,
ART, and outreach activities in some communities. In 2008, more than 3,000 people received
free VCT and around 300 patients were startedon ART. At the end of 2008, 1,550 patients had
been enrolled in this programme, more than
900 of whom had been started on ART.

Emergency assistance
On May 12, a magnitude 8.0 earthquake hit
Sichuan province, leaving more than 80,000

people dead and ten million homeless. In
collaboration with the Sichuan Red Cross, MSF
donated 4,310 family-size winter tents andmedical supplies to Mianzhu city. MSF also
provided support to hospital patients sufferingfrom ‘crush syndrome’ in Chengdu, andassisted a triage centre in Guanghan City,
Deyang. However getting access to the areaand population affected by the earthquake
proved difficult due to government
restrictions.
MSF provided psychological care to survivors of
the earthquake in Hanwang, Mianzhu County
and Long Men Shan, Pengzhou City. ‘In theaftermath of the earthquake, people were in shock
and intensely afraid. They clearly needed psychological care,’ said Dr Misa Sugawara, who worked as
the MSF field coordinator in Sichuan. MSF
continues to provide psychological care in
Mianzhu and Beichuan County, where 238
consultations were conducted between
November and December of 2008.
In response to the snowstorms that hit Maocao
village in Guizhou province in February, MSF
distributed 9,000 kg of rice as well as cooking
oil and water to villagers.
In June, in response to floods in Guangxi, MSF
provided 115,000 kg of rice, 1,900 bottles of
cooking oil and 140 sets of plastic sheets tovictims in Zhongdu Township, Luzhai County
in Guangxi.

Project handover
In May 2003, MSF began providing care andtreatment in Xiangfan, targeting the esti­
mated 45,000 people living with HIV/AIDS in
Hubei and the neighbouring Henan province.
This programme was handed over to Chinese
authorities in March 2008. 		

MSF has long pushed to create a working
group on drug-resistant TB, which would
involve Cambodia’s health authorities andother interested parties. Such a group was
finally created at the end of 2007. Throughout
2008 a series of meetings were held, focusing
on establishing national guidelines and longterm plans to tackle MDR-TB.

Blocked from the Inner Mongolia
region
MSF tried to open a multi-drug-resistanttuberculosis programme in the Inner
Mongolia region, where an estimated 6.5 percent of people who tested TB-positive andhaven’t received treatment are infected with adrug-resistant strain. Repeated negotiations
with Chinese authorities aimed at signing amemorandum of understanding were unsuccessful. In early 2009, MSF gave up trying toopen the programme.

MSF has worked in Cambodia since 1979.

© MSF

MSF has worked in China since 1988.

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GEORGIA
Reason for InterventioN • Armed
conflict • Endemic/Epidemic disease• Social violence/Healthcare exclusion
Field Staff 164

MSF treats drug-resistant tuberculosis(DR-TB) in Abkhazia, one of theseparatist regions of the republicof Georgia, and in Zugdidi, western
Georgia. In August 2008, a war
erupted over another separatist regionof South Ossetia, which caused thousands of people to flee the violence.
TB is the scourge of the Caucasus region: it isestimated that ten per cent of new cases are
drug resistant, but that as many as half thepeople who have already been treated havedeveloped DR-TB. In 2008, an average of six toseven new patients with DR-TB were admitted
every month to the Zugdidi project. Since theopening of the programme in November 2006,
more than 150 patients have been treated.
They have adhered well to the treatment, but
it is still lengthy and difficult and the drugs
cause many side-effects. The war in August
2008 briefly interrupted treatment for 30 per
cent of the patients.
In July 2008, the first Zugdidi programmepatient completed his treatment, having taken
handfuls of medicine daily for 20 months.
Although it is still too early to declare him
fully cured, given the risks of relapse, the factthat he finished the course is encouraging.
Since then, nine further patients in Zugdidi
have finished the treatment programme.
In Abkhazia, MSF treats patients in Gulripsh,
near the capital Sukhumi. MSF has supported
the national TB programme in Abkhazia since1999 and, since 2001, has focused on DR-TB.
Since then, 204 patients with DR-TB havebegun treatment, 38 of those in 2008. MSF
refurbished the hospital near Sukhumi andsupplied it with drugs, materials and laboratory equipment. A third of the MSF patients
have few material resources and, without thepsychological and social support, firewood,
clothes, proper nutrition and other necessities
that MSF provides, many of them would beunable to follow their treatment correctly.
MSF introduced life-prolonging antiretroviraltherapy (ART) in Abkhazia for HIV/TB co-infectedpatients. Currently nine patients are on ART.
MSF also supports the newly opened national
DR-TB programmes in the Georgian cities of
Tbilisi and Abastumani, providing training for
local nurses and adherence counsellors.
The health access programme for vulnerable
people in Abkhazia has been downsized. In
2008, 143 vulnerable people, mainly elderly,
were registered in the programme.

Assisting those displaced
Tens of thousands of people were displaced asa result of the fighting in August 2008. MSF
provided healthcare services and psychologicalsupport in Tbilisi and Gori to people who had
been forced to flee their homes. Over 30 per
cent of the 8,500 medical consultations dealt
with chronic conditions. Many people sufferedfrom depression, anxiety, post-traumatic
disorder and psychological problems. MSF also
strived to keep patients on their DR-TB treatment programmes. Though international MSF
staff were evacuated due to the violence,national staff continued the programme. Mostof the patients maintained their treatment
schedule, which is vital because any interruptions can lead to a relapse or complications.

‘These first recoveries are very encouraging forthe 93 patients undergoing treatment. For doctors,
nurses and all the staff, it’s a daily struggle toensure that patients retain the strength tocontinue their treatment.’ Jocelyne Madrilène, head of mission

MSF has worked in Georgia since 1993.

© Julie Damond

INDIA

Despite India’s fast economic growth,millions of people have limited or noaccess to healthcare. MSF provides
medical assistance to people affectedby conflicts or natural disasters inrural India and offers tuberculosis(TB) and HIV/AIDS treatment tomarginalised groups in Mumbai andManipur.

Reason for Intervention • Armed conflict • Endemic/Epidemic disease• Social violence/Healthcare exclusion • Natural disaster
Field Staff 394

MSF provides free care and treatment to groups
who can become marginalised from society,such as transgender, commercial sex workers
or homosexuals who have not been able toaccess HIV/AIDS healthcare through the publichealth system. Working in a clinic in south
Mumbai, MSF also offers services preventing
mother-to-child transmission of HIV, and has
trained NGOs and Ministry of Health staff in
HIV testing and counselling. Throughout theyear, MSF conducted more than 4,200 consultations in Mumbai and more than 300 patients
started antiretroviral therapy (ART).
In the northeastern state of Manipur, which
has been affected by a chronic low-intensity
conflict, MSF runs four clinics providing basic
healthcare, HIV/AIDS and TB treatment andcounselling as well as maternity services.
© Sami Siva

In 2008, MSF conducted more than 50,000
consultations in Manipur. MSF has so far put
781 HIV-positive patients on ART, about aquarter of them have now been transferred to
the national HIV/AIDS programme.

patients were screened for the disease and 1,974
received treatment with liposomal amphotericin B – a relatively new therapy for the disease.
The success rate for treatment is very high:more than 98 per cent of those treated recover.

Primary healthcare in Chhattisgarh
and Andhra Pradesh

Mental health in Kashmir

A low-intensity conflict between Maoist rebels
and government forces has displaced tens of
thousands of people in government-run
camps, or forced them to hide in the jungle
where there is little access to healthcare. MSF
provides primary healthcare and nutritional
support to the people living in camps in
Chhattisgarh, in settlements around villages
in Andhra Pradesh and the Chhattisgarh
border area, as well as in local communities in
Bijapur district. In 2008, MSF’s mobile clinics
treated more than 3,300 people affected withmalaria in the Bijapur and Dantewada areas,
while 32,600 consultations were conducted in
the camps and villages around Andrah Pradesh
and the Chhattisgarh border.

Kala azar (visceral leishmaniasis)in Bihar
MSF provides free diagnosis and treatment forpeople suffering from kala azar in Vaishali
district in Bihar state. In 2008, more than 4,800

In Indian-administered Kashmir, MSF offers
basic healthcare and psychosocial counsellingto a population traumatised by over 20 years ofviolence in the Kashmir valley. In 2008, MSF’s
mental-health programme treated 6,324
patients. MSF supported six clinics in Kupwara
district with basic healthcare and vaccination
services and conducted more than 10,000
consultations in 2008.

Emergency response
MSF has carried out several emergency interventions in response to serious natural disasters in India over the years. In September 2008,
teams provided humanitarian assistance totens of thousands of people in Bihar state who
were displaced after the Kosi river burst its
banks and wreaked havoc in the area. Many
families, already desperately poor, lost all theirpossessions. MSF provided medical assistanceto the victims of this flood and distributed
non-food items such as plastic sheeting andblankets to more than 18,000 families.
In 2008 MSF teams conducted more than
22,200 medical consultations.
MSF has worked in India since 1999.

‘Most people have heard little if anything about visceral leishmaniasis. This serious
disease is best known as kala azar, and the incidence in India is amongst the highest
in the world. Up to 90 per cent occurs in just one state – Bihar. This disease mainly
affects the lowest castes, the poorest of the poor. The most frequent treatment for kalaazar in Bihar is old, painful and, to cap it all, barely effective. But without treatment
the disease is almost always fatal. The MSF team working in Bihar, at Hajipur hospital,
are using for the first time on a large scale a drug that shortens treatment to just tendays and has a success rate of over 98 per cent. Our patients are living proof. Seeing
how they improve day after day is a marvellous experience.’
Dr Gaurab Mitra, MSF doctor

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INDONESIA
Reason for Intervention • Social violence/Healthcare exclusion• Natural disaster • Endemic/Epidemic disease
Field Staff 137

MSF has assisted patients suffering from infectious diseases, violence andnatural disasters in Indonesia since 1995. In 2008, however, due to an
improved Indonesian capacity to respond to national disasters, MSF decided to
end activities here by early 2009. Yet, throughout 2008, MSF continued tomonitor and react to emergencies and to provide healthcare in remote areas.
Responding to emergencies

Treatment for a neglected disease

Although the number of emergencies requiring assistance from MSF dropped in 2008, MSF
supported survivors of a powerful earthquake
in central Sulawesi in November with mentalhealth activities and mobile clinics. Almost
2,600 people were given psychological training
on how to handle stress and what to do in caseof another earthquake. More than 1,000
patients also had medical consultations.

While studying the pros and cons of using
rapid diagnostic tests for malaria in Asmat, aswampy and difficult-to-reach district in the
Papua province, MSF found disturbing levels of
microfilaria, the parasite that causes lymphatic filariasis. Also known as elephantiasis, thisdisease is endemic in 304 of the 414 districts inIndonesia, but remains a neglected disease in
the country.

When the powerful cyclone Nargis struck
nearby Myanmar in May 2008, the MSF emergency team in Indonesia reacted rapidly:
within a month, eight chartered flights containing 39,000 tarpaulins, 14,400 hygiene kits
and other items – 260 metric tonnes altogether– were sent from Jakarta, to assist the victims.

MSF decided to intervene in two phases: a mass
drug administration campaign followed bysurgery for people with chronic filariasis. The
campaign was conducted in collaboration withthe local health authorities, which also
guaranteed the necessary follow-up over the
next four years. Over three months, 36,644

people were treated in the seven sub-districts of
Asmat, and later 36 surgeries were performed.

KYRGYZSTAN

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Focus on mother and child
Malaria, diarrhoea and respiratory infections
are the main causes of death and disease
among children in the Asmat district, and theharsh living conditions in the thick tropicalforest and swamps pose additional health risks
for pregnant women. In 2008 MSF continued
its programme to improve access to primaryand emergency healthcare and services for thevulnerable population. Projects ranging from acomprehensive referral system at village levelto a fully operational surgery room in Agatswere completed. MSF trained staff at all levelsof the health system, put in place safe bloodtransfusions and set up a radio system so thevillagers can call for an ambulance boat inemergencies. Also more than 8,000 consultations were performed through mobile clinics
visiting villages in remote districts. Much
effort was put into health promotion, since
many people in the villages were unfamiliar
with modern medicine.
MSF has worked in Indonesia since 1995.

© Alexander Glyadyelov

Reason for Intervention • Social violence/Healthcare exclusion
Field Staff 48

Tuberculosis (TB) is the most common cause of death in the prisons in
Kyrgyzstan. Its prevalence is around 35 times higher than it is in the civil
sector, and the proportion of resistant forms of TB is particularly high. Bad
ventilation, dark overcrowded cells and insufficient nutrition help TB toflourish. Prison hospitals lack medicines, equipment and trained staff.
MSF contributes to the treatment of TB
patients in a prison and pre-trial detention
centre near the capital Bishkek, in the northof the country. In 2008, MSF helped to treat
400 patients for drug-susceptible TB, and 50
people who have strains resistant to first-line
anti-TB drugs.
This project is implemented in collaboration
with the medical department of the penal
administration, the Ministry of Justice of
Kyrgyzstan and the International Committeeof the Red Cross (ICRC). MSF’s role is to assist
with the detection and diagnosis of all suspected TB cases in prisoners and the treatmentof people who have TB that is susceptible tofirst-line anti-TB drugs, while the ICRC focuseson the treatment of patients who have multidrug-resistant forms of TB.

MSF improved cells and TB facilities in theprisons, equipped TB laboratories and continues to provide medical and lab materials. In
2008, MSF helped set up a system for the faster
diagnosis of TB that is resistant to first-line
anti-TB drugs in the national TB laboratory.
Also, TB patients in the MSF-supported prisonsare being screened and vaccinated for
Hepatitis B. MSF doctors and psychosocial
workers ensure the application of treatment
protocols and the patients’ adherence totreatment.
The new set-up will ensure strict separation of
TB patients with different forms of the diseasein order to avoid cross-infection and further
contamination.
MSF has worked in Kyrgyzstan since 2005.

‘The main difficulties
faced by released
prisoners who need tocontinue their treatment for TB involve thelack of interaction andinformation between
the prisons and theoutside world. TB is acomplex, multi-faceted
problem in society, andit cannot be handled
by medical treatment
alone. We can see thepolitical will to resolvethese problems, but inreality not much is
being done.’
Markus Frits, head of mission© Massimo Mastrorillo

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MYANMAR

NEPAL

Reason for Intervention • Armed
conflict • Endemic/Epidemic disease• Social violence/Healthcare exclusion• Natural disaster
Field Staff 1,427

Reason for Intervention • Armed conflict • Natural disaster• Endemic/Epidemic disease
Field Staff 114

Decades of neglect have hampered the development and improvement ofhealthcare in Nepal. Local medical authorities are under-equipped and lackdedicated staff. MSF has been in the mountainous Kalikot district since 2005,
upgrading the local health centre into a district hospital and providing primaryand secondary healthcare.

In May 2008, Cyclone Nargis wreaked
destruction throughout the Irrawaddy
delta leaving an estimated 130,000
people missing or dead. The disaster
was a devastating blow to a people
who have suffered repression, neglect
and low-intensity conflict for decades,leaving many living in abject poverty
and without basic human rights.

In the outpatient department, MSF’s team,alongside medical staff from the Ministryof Health, conducted over 22,000 consultations. Free medication was given after consultation. The hospital admitted 1,346 people,
170 surgeries were performed, and 66 womendelivered via Caesarean section.

Emergency relief after Cyclone Nargis
MSF began its emergency intervention in thedelta within 48 hours of the cyclone. During thecritical period when the government restricted
external aid, MSF delivered food, shelter, water,
healthcare and essential non-food items. As
access improved, MSF developed its programmes
to include psychosocial support.
Between May and November, around 450 staff
assisted a population of more than 520,000
people throughout four townships - Laputta,
Ngapudaw, Phya Pon, Bogaley (comprising morethan 1,100 villages), until emergency needs had
been met. However a number of MSF activities,
primarily nutrition and mental health, continued in some of the harder to reach areas which
lacked adequate assistance. These
programmes have now finished. Meanwhile,ongoing support for reconstruction, especially
livelihoods, nutrition, and water & sanitation
remains crucial throughout the Delta.

Assisting Myanmar’s vulnerable
For the hundreds of thousands of people
suffering from treatable infectious diseases
such as malaria, tuberculosis and HIV/AIDS,
the chronically under-resourced healthcare
system provides little assistance. The government spends just 0.3 per cent of its grossdomestic product on healthcare, the lowest
proportion worldwide. Official development
aid to Myanmar is also one of the lowest perperson worldwide.

HIV/AIDS: a preventable fate
Of an estimated 240,000 people infected with
HIV, 76,000 are in urgent need of antiretroviraltherapy (ART), but fewer than 20 per centPatients in mobile clinics
MSF started a new project in Central Terai in2008 in response to internal disturbances
prompted by ethnic tension. MSF provided
healthcare through mobile clinics, and saw
some 12,000 patients during the year. This
project has recently been expanded to support
the inpatient department of the district
hospital, particularly the maternal and childhealthcare and obstetric emergency surgeries.

© Eyal Warshawski

Responding to malnutrition andcholeraMalnutrition has been a particular concern
throughout 2008, with a so-called mid-upperarm circumference screening disclosing a
global acute malnutrition incidence of 10.8
per cent. MSF has treated several thousands ofchildren through mobile therapeutic feeding
programmes. In one extremely remotelocation, accessible only via a two-day walk on
steep mountain trails, MSF opened a seasonal
clinic. MSF teams prepared emergency facilities to combat cholera in a location that has

been particularly vulnerable to the disease due
to a lack of water, inadequate sanitation andpoor hygiene practices. More than 2,200 consultations were carried out, and more than
450 children were admitted to the nutritional
programme.

Koshi floods
On August 18, the Koshi river broke its banks.
Some two million people were affected in
Nepal and India. MSF dispatched a team to the
Nepalese side of the border, where about
50,000 people were directly affected. For twomonths, teams focused on medical emergencies and cholera prevention.
In 2009, MSF will hand over its project in
Kalikot to the Nepalese Ministry of Health andPopulation. MSF will maintain its presence inTerai, and retain a capacity for a quick
response to emergencies.
MSF has worked in Nepal since 2002.

Safe deliveries
receive it. Most of the treatment available in
Myanmar is provided by MSF. Working in theformer capital of Yangon and the states ofShan, Kachin and Rakhine and in Thanintaryi
division, MSF provides comprehensive care to
16,000 HIV/AIDS patients, 11,000 of whom
received ART. Preventive and educational
assistance is also targeted towards high-risk
groups including sex workers, intravenous
drug-users and migrant labourers.
Nearing its capacity for ART provision, MSF has
continued to lobby for increased assistance,
calling for the government of Myanmar andthe international community to scale up HIV
services urgently and rapidly, especially ART
provision.

HIV/TB co-infection
From its clinics throughout Myanmar, MSF
also provides care and treatment for people
suffering from tuberculosis (TB), one of themost common opportunistic infections forpeople living with HIV/AIDS. During 2008, MSF
admitted more than 2,800 patients for TB
treatment, providing additional support suchas food supplements and transport fees for theespecially vulnerable. In the Thanintaryi
division, southern Myanmar, MSF provides TB
and HIV care in three townships in Dawei
district. In Thayetchaung township, MSF also
provides primary healthcare. From March
2008, MSF launched a programme for TB in
two townships of Dawei, providing healtheducation and free diagnosis to the people, as
well as treatment at the clinic.

Malaria
Malaria is one of the leading causes of death inMyanmar. MSF provides malarial testing andtreatment in a number of locations wheremalaria is endemic. In Rakhine state, forexample, MSF supports 30 clinics and threemobile health teams dedicated to providing
diagnosis and treatment. In 2008, MSF staff in
Rakhine treated more than 200,000 people formalaria alone.
MSF has worked in Myanmar since 1992.

Nepalese women have little access to skilled
birth attendants. Adherence to traditional
practices can lead to high maternal andneonatal mortality rates. Operational manager
Katrien Coppens was shocked after she met
women in Terai. ‘Without exception, they had
all lost at least one child during pregnancy orjust after delivery. One woman even told me
how she had lost four of her babies. Especiallyin this area it is so important for expectant
mothers and newborn babies to have regularcheck-ups.’
MSF raises awareness amongst the community
about the need for women to seek care at our
medical facilities in good time, and provides
among others things family planning andantenatal care. November saw the opening of apatient waiting house for pregnant women in
high-risk situations such as those expecting
twins or with a co-existing medical condition.
By staying in the waiting house some time
before the expected delivery date, women
increase their chances of a safe delivery.
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PAKISTAN
Reason for Intervention• Armed conflict• Social violence/Healthcare exclusion
Field Staff 478

Throughout 2008, there were increasing numbers of attacks on civilians
leading to the displacement of
hundreds of thousands of people.
People’s overall health and living conditions have greatly deteriorated in acountry that already had high infant
and maternal mortality rates. Womenand children in the rural areas ofNorth West Frontier Province, theFederally Administered Tribal Areas
and Balochistan are particularly vulnerable due to a shortage of medical
staff and unaffordable health services.
While needs have increased dramatically, insecurity and targeted attacks
on aid workers have made it extremely
difficult to provide assistance.
In Bajaur Agency, Swat and Mohmand regions,hundreds were killed or injured in suicidebombings, or by aerial attacks and fighting.
Thousands of people have been repeatedly
uprooted from their homes. In October, a peakin violence sent an estimated 600,000 people
into neighbouring regions as well as toIslamabad, Lahore and Karachi over the courseof a few days. Many found refuge in private
homes, mosques, schools, and makeshift
camps. MSF provided basic materials such as
food, hygiene kits, shelter items, blankets andmats. Teams also set up water and sanitation
facilities in the camps. Host families took in
more than two-thirds of the displaced people.
MSF adapted its primary healthcare programmes to respond to sharply increasing
numbers of victims of violence. Teams
provided medical supplies to treat war
wounded, assisted in referrals and, together
with local health structures, provided care forthe treatment of watery diarrhoea caused by
the poor quality of the water.
As local health clinics began to close due tofears of insecurity, MSF opened mobile clinics
in partnership with local providers and established a clearly identifiable ambulance service
to bring patients safely to hospitals. During
the many curfews imposed by the military, thePapua new Guinea

In memory

Reason for Intervention • Social Violence/Healthcare exclusion
Field Staff 32

On February 1, 2009 two MSF staff were
killed during fighting in Swat district,north-western Pakistan. Riaz Ahmad, 24,
and Nasar Ali, 27, had left Mingora, themain town in Swat valley, in two ambulances to collect people injured during
fighting in nearby Charbagh and bringthem to the hospital for treatment.
Tragically their ambulances, though
clearly identified as medical vehicles,
came under fire inside Charbagh and both
men were killed.

Some 40 per cent of the population live under the national poverty line according
to the World Health Organization. Violence at all levels of society presents asignificant health burden and the causes are complex. According to the 2008
report by AusAID, Australia’s aid programme, two out of three women experience
domestic violence and half the country’s women have experienced rape inconnection with tribal fighting.

Both were working on their day off, such
was their commitment to MSF and to thepeople in Swat valley. They will be greatly
missed. Their dedication will remain an
inspiration to many inside MSF andbeyond.

© Seb Geo

MSF ambulance was one of the only vehicles
allowed to travel around, transporting 700
patients over a five-month period – primarily
women in labour and victims of violence.
However in Swat this service was suspended
after two MSF staff members were caught incross fire and killed.
Similarly, in Kurram Agency, providing assistance is increasingly difficult due to violence
and insecurity caused by armed groups operating in the area. In addition to mother andchild healthcare, including obstetric surgery
and neonatal services, MSF teams provided
emergency supplies during clashes, andnon-food items to displaced families.

Earthquake response
In October, the mountainous region of northwestern Balochistan was hit by a magnitude
6.4 earthquake. Most of the mud-brick houses
were destroyed. People were forced to sleep out
in the cold due to the damage and fears ofaftershocks. The official death toll rose toapproximately 300, 35,000 people were
injured, and 40,000 left homeless. In addition
to emergency medical support and relief
supplies, MSF teams also provided mentalhealth care.

Treating infection
In Mansehra district MSF set up a programme
to respond to the parasitic infection cutaneous‘Gaining acceptance is a challenge when starting to work in a new area. A mother had
brought her two-year-old baby from a long way away by donkey-cart. The baby was
severely malnourished so we had to give him special therapeutic food rich in vitamins
and minerals. The first time the mother came with just the baby, but when she brought
him back for a check-up, her mother and mother-in-law came as well. The baby was
doing much better already, and there were tears in all their eyes. The baby had
vitamin A deficiency, had probably had it since birth, and was blind. They explainedthat he used to just lie there limp, but now he was getting a bit more active, showing
signs of liveliness. I saw tears of joy and happiness running down the mother’s face.
This is the best thing, better than words, and it makes me feel that what we are doingis really worthwhile.’
Aleem Shah, programmes officer in Balochistan

leishmaniasis. MSF teams estimate that insome villages 60 to 70 per cent of children are
infected. Cases are referred to the hospital in
Darband in Mansehra district, where an MSF
medical team works in the outpatient department and hospital wards and supports the
management of emergency cases.

Refuge assistant
Further south, in Balochistan, MSF assists
Afghan refugees by supporting mother andchild healthcare in Kuchlak, a town near thecapital Quetta. In the border town of Chaman,
health agencies are struggling to provide carefor city residents, so MSF assists local communities and patients coming from Afghanistan
by providing reproductive healthcare, including emergency obstetrics, neonatal services
and nutritional support.
In September, MSF was authorised to open new
projects in the eastern districts of Jafarabad
and Nasirabad following findings of malnutrition. By the end of the year, the feeding programme had admitted 1,300 children, andmother and child healthcare was being incorporated into the programme.
MSF has worked in Pakistan since 2000.

© MSF

In 2008, MSF supported a clinic in the eastern
coastal city of Lae, the country’s second-largest
metropolitan area. At the Women andChildren’s Support Centre, MSF staff offered
medical and psychosocial care to survivors of
sexual and domestic violence. By December
2008, one year after the clinic opened its doors,
the team had treated more than 2,500 patients.

of Tari town, in the western part of the island,
which had been abandoned for the last ten
years owing to insecurity. MSF is responsible
for emergency care, including surgery forsurvivors of violence, and obstetric care in thehospital. In just three months, by the end of
December 2008, MSF had given more than
1,000 consultations.

In September 2008, MSF started providing
surgical care for patients in the local hospital

MSF has worked in Papua New Guinea since 2007.

Naomi is a 30-year-old single mother and HIV/AIDS activist who lives in Lae.
‘I was a victim of a robbery and rape. They took my bag then one chased me and when
I fell down he tried to stab me with a knife and he raped me. After it happened I had
flashbacks and nightmares and when I came to see the counsellor she talked to me andtold me it wasn’t my fault. She helped me – I did what she said and it helped me, I’m
happy now. As a patient here, I’ll try to make women and abused children aware oftreatment and counselling.’

Médecins Sans Frontières Activity Report 2008

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Philippines

SRI LANKA

Reason for Intervention • Armed conflictField Staff 2

Reason for Intervention• Armed conflict • Natural disaster
Field Staff 128

The conflict between the Sri Lankanarmy and the Tamil Tiger rebels(LTTE) escalated in 2008. In January,
the government pulled out of thesix-year ceasefire between the twoparties and stepped up its militaryattacks against the LTTE, progressively regaining control of key rebelheld territories in the north of thecountry.
Heavy fighting resumed on the frontlines andadded to the plight of civilians who had
already been oppressed for years by various
militia groups operating with impunity.
Subject to abductions, unlawful executions,arbitrary arrests and restrictions of movement,
people live in a constant state of fear andintimidation, which seriously limits theiraccess to healthcare.
In 2008, MSF supported local hospitals in thegovernment-controlled areas close to theconflict in Point Pedro, Vavuniya and Mannar.
MSF also worked in Kilinochchi (Vanni area),an LTTE-held territory, until the government
ordered all NGOs to leave the conflict area in
September 2008. The projects offered medical
and surgical support as well as obstetric andgynaecological treatment and emergency care.
In 2008, MSF conducted 2,550 deliveries andassisted in 1,885 surgical interventions inpartnership with the Ministry of Health. MSF
has been asking the authorities for access tothe area since it was expelled, to provide
medical assistance to the thousands of trapped
civilians.

In Point Pedro, at the northern tip of the
Jaffna Peninsula, the hospital serves a population of 100,000 people but lacks qualified
health specialists, medical equipment anddrugs. Security restrictions on movements
impede the referral of patients; Jaffnateaching hospital is the only facility forreferral. Antenatal and surgical consultations
were conducted in two other local hospitals in
partnership with Ministry of Health staff. MSF
trained the hospital staff to be prepared formass casualties, in emergency medical andparamedical care, and gave specific nurse
training on hygiene, dressings and patientsobservations.
In Vavuniya district, MSF has been supporting
the general hospital since 2006 with medical
specialists including at different times
surgeons, anaesthetists and lab technicians. A
general nutritional assessment was conductedin the district and more than 150 children
were treated in MSF’s mobile feeding programme. MSF has also been supporting a local
NGO specialising in mental health by training
its staff and offering clinical supervision to
improve the quality of care available.
Until September 2008, MSF worked in
Kilinochchi, in the LTTE-controlled area. Mostof the people in the conflict area have had toflee their homes and live in basic conditions. In
November, heavy flooding destroyed paddy
fields, which led to further deterioration of theliving conditions in Vanni. Floods also displaced thousands of people in Point Pedro. MSF
set up an emergency response and distributed
relief items such as food, blankets and buckets.
MSF’s surgery and emergency obstetric care in
Mannar hospital was closed in December 2008.
MSF has worked in Sri Lanka since 2007.

© Andrew Caballero-Reynolds

Since the breakdown of peace negotiations between the Philippine government and the Moro Islamic Liberation Front (MILF) in August 2008, fighting
resumed in some parts of Mindanao Island. The sudden violence uprooted
hundreds of thousands of people. This period of uncertainty lasted fivemonths, and the damage caused meant that some who had fled, had nothing
to return to, as their villages had been burned to the ground.
Some found refuge with host families,
although many of them were already nearing
the limit of their own meagre resources. Other
displaced people lived in makeshift shelters innearby forests or by the roadside, and somefound shelter in evacuation centres set up by
the government.

MSF teams also ran mobile healthcare clinics
in ten locations for the displaced population,and carried out some 3,000 medical consultations. Most of the cases were directly related
to the harsh living conditions – respiratory
tract infections from sleeping outside anddiarrhoea from drinking contaminated water.

MSF has been providing medical treatment,
clean water and sanitation services to displaced people in Region XII and ARMM
(Autonomous Region of Muslim Mindanao).

MSF started in the Philippines in 2008.

In addition MSF provided staff support andmedicines for health centres overwhelmed by
the influx of new patients. In the town of Datu
Piang, for example, the population grew from
42,000 to 82,000 in a few months, overwhelming the local health services.

© Anne Yzebe

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Thailand

Patchara, aged 43, is serving the last year of a three-and-a-half-year sentence in Minburi
prison in Bangkok. ‘I tested HIV-positive in another prison. Stigma was so widespread at
the time. There were no HIV/AIDS drugs inside and you could see that women with thedisease were just dying one after the other.’
Patchara developed her first opportunistic infection in Minburi, where MSF had beenworking in partnership with the department of corrections to provide HIV/AIDS treatment
and care. ‘In Minburi the atmosphere was very different from what I had known before.
The staff encouraged me to take a blood test and provided moral support, and I began
antiretroviral therapy in March 2006.’
For Patchara, access to information played a critical role in changing the environment in
the prison, along with the availability of treatment. ‘I disclose my status, there’s no discrimination here since we know about transmission and that HIV doesn’t mean death.
Groups for people living with HIV/AIDS in the prison are very supportive and I can consult
them whenever I need to.’TURKMENISTAN
Reason for Intervention• Social violence/Healthcare exclusion• Endemic/Epidemic disease
Field Staff 65

The MSF mission in Turkmenistan
operates in a restrictive context
that limits its ability to implement
effective medical programmes. Thereis little reliable data on death anddisease in the country: officially,
diseases such as HIV/AIDS do notexist in Turkmenistan, and the true
prevalence of other infectious diseases
is extremely difficult to establish.
Meanwhile, people suffering from suchdiseases have no access to treatment,so their condition worsens and therisks to public health grow.
MSF has been in Turkmenistan since 1999
and is currently working in Magdanly, in the
remote eastern Lebap Velayat region. There,
MSF is supporting paediatric and maternal
health, and laboratory activities at the local
district hospital.
MSF works in an advisory capacity andcarries out visits to nearby health posts. Oneof the main activities is the training of local
doctors and nurses up to international
standards to treat diseases. Teams also
refurbished the local medical facilities, andprovided drugs, medical materials, andlaboratory equipment.

© Espen Rasmussen

Reason for Intervention • Armed
conflict • Endemic/Epidemic disease• Social Violence/Healthcare exclusion
Field Staff 221

MSF is providing medical assistanceto displaced people and vulnerable
groups, ethnic minorities andmigrants who would not otherwise beable to access healthcare.
HIV/AIDS: handover of projects
MSF introduced antiretroviral therapy (ART) in
Thailand in late 2000. This played a key role inshowing that lifelong and complex HIV/AIDS
care and treatment can be implemented insettings that are less developed. Working
closely with the Ministry of Health and local
partners, MSF has offered treatment and careto thousands of patients over the years. MSF
has also supported HIV/AIDS patient groups

and Thai civil society in their fight for accessto high-quality and affordable treatment
through the production of generic drugs.
Widely praised for its universal access to ART,
Thailand has progressively improved its
capacity and the quality of the treatment andcare available. The Thai government has beenable to include an increasing number ofpatients from ethnic minority groups andmigrants in its national health scheme, andMSF progressively handed over all its HIV/AIDS
projects throughout 2008.

Tuberculosis: Mae Sot
In Mae Sot on the Thai-Burmese border, MSF
has been treating undocumented migrants
from Myanmar for tuberculosis (TB) and multidrug-resistant TB (MDR-TB) since 1999. TB is
endemic in Thailand and Myanmar and represents a serious problem for a population withlimited access to healthcare. In 2008, MSF

conducted 4,620 medical consultations: 319
patients tested positive for TB and 43 began
MDR-TB treatment. MSF also offers HIV/AIDS
care and ART to HIV-positive and co-infectedpatients. In 2008, 2,085 HIV consultations werecarried out and 52 new HIV/AIDS patients wereregistered in the programme.

Malaria: Sangklaburi/Mon StateIn Sangklaburi, along the border with
Myanmar, MSF is running a cross-bordermalaria project that supports ethnic Mon
living in resettlement sites and villages inside
Mon State (Myanmar). Malaria is endemic in
the area and MSF carried out more than 13,542
consultations in 2008, confirmed 4,360 casesof malaria and distributed 8,381 bed nets,
meeting the needs of 16,698 inhabitants. MSF
has also provided essential drugs to nine
health posts in Mon State, and runs small
vaccination campaigns regularly.

Providing primary healthcare to
Lao Hmong refugees
MSF has been providing primary healthcare to
the Lao Hmong in Huai Nam Khao village,
Petchabun province, northern Thailand, since
July 2005. In 2008, the Thai government repatriated more than 2,000 people to Laos, leaving
only 5,700 Hmong in Petchabun by the end of
the year. In protest the Hmong staged a march,hundreds began a hunger strike and the camp
was set on fire. This left the displaced withlimited access to safe drinking water andinadequate sanitary conditions for weeks.
MSF is the only health organisation active inPetchabun and has repeatedly denounced theforced repatriation of Hmong people. In 2008,
MSF conducted more than 27,600 consultations, mainly for respiratory infections, diarrhoea, and skin infections. This also included
more than 2,500 antenatal care consultations,an important focus for the project. Three

psychologists are providing mental-healthsupport and MSF is in charge of the distribution of food and non-food items in the camp.
In Phang Nga, MSF has been providing healthcare to undocumented migrants crossing fromBurma to work in Thailand. MSF runs mobile
clinics at migrants’ work sites and supports
the local hospital and health posts. In 2008,
more than 3,600 medical consultations werecarried out at the hospital’s outpatient department and 235 patients were hospitalised. MSF
also conducted over 1,500 antenatal consultations and 222 deliveries. In December MSF
began the handover of its activities, whichshould be finalised by mid-2009.
MSF has been working in Thailand since 1985.

© James Kambaki

MSF is negotiating to start a new project in
Turkmenabad, the second-largest city in the
country. This project will focus on treating
patients with TB, including drug-resistantstrains, and patients who are co-infectedwith HIV. These will be the first suchservices to be available in Turkmenistan.
MSF has worked in Turkmenistan since 1999.

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The Americas

UZBEKISTAN

Médecins Sans Frontières Activity Report 2008

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64© Stephan Grosse Rueschkamp

Reason for Intervention • Endemic/Epidemic disease
Field Staff 96

In Karakalpakstan, an autonomous region of Uzbekistan, MSF treats multidrug-resistant tuberculosis (MDR-TB). Many patients need to be admitted tohospital. MSF is in its second year of handing over treatment to the Ministry of
Health. Patient management for new admissions was formally handed over inJuly 2008.
The incidence of MDR-TB in the region is oneof the highest in the world – estimated at 13
per cent among new cases of tuberculosis and40 per cent among people who have beentreated previously. Some patients develop
strains of TB that are resistant to the secondline drugs designed to treat drug-resistant TB.
In 2008, more than 230 people were admitted
to the MSF hospital in Nukus, the regional
capital. The number could have been higher
but the Ministry of Health had to restrict
admission of new patients due to delayed
approval to supply second-line TB drugs.
Overall, 830 patients were enrolled in the
MSF programme.
On average, MDR-TB patients have to stay inhospital for about two months. Afterwards,
they must continue treatment outside thehospital for between 18 months and two years.
Many, however, for a number of reasons, do

not manage to adhere to the treatment once
they have left hospital. The treatment successrate is 59 per cent; MSF aims to increase this toover 70 per cent.
MSF has also equipped and supports a modern
laboratory in Nukus, which performs tests for
drug sensitivity. The psychosocial componentof the MSF programme is critical. Here,patients can discuss with their counsellors
how to handle side-effects, and find out about
the disease and its treatment as well as thegeneral implications TB has for their personal
lives. MSF supports voluntarily testing andcounselling for HIV/AIDS and provides regulartraining for local staff. Training topics range
from infection control and outpatient care, tothe management of side-effects, new diagnostic methods, improving adherence to treatment, sputum collection, and transport.

Makset, 36, has been being treated for
MDR-TB since August 2006. He was
supposed to complete his treatment in
May 2009. After his sputum smear test
showed that he was no longer infectious
he was discharged from the hospital tostart the outpatient phase – only toreturn shortly afterwards. He lived too
far away to get to his treatment regularly
and had no food to eat; he was moved to
the TB-negative ward of the hospital to becared for. In early 2009 he became contagious again and had to move back to theregular TB ward. For over two years,
Makset has hardly left the hospital. Like
him, many patients spend months in thenegative ward because they have nowhere
suitable to go. Some have no home; others
are rejected by their family due to thestigma and fear associated with thedisease.

MSF has worked in Uzbekistan since 1997.

© Clement Saccomani

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contents

BOLIVIA

Brazil66 | BOLIVIA
67 | Brazil
68 | COLOMBIA
69 | GUATEMALA
69 | HONDURAS
70 | Haiti

Reason for Intervention• Social violence/Healthcare exclusion
Field Staff 45© Anna Surinyach

Reason for Intervention • Endemic/Epidemic disease
Field Staff 33

The parasitic disease Chagas is endemic in 60 per cent of Bolivia’s territory.
Access to diagnosis and treatment is limited and there is almost no treatment
for sufferers over 15 years old. MSF is currently treating both adults andchildren, and is promoting and lobbying for wider access to treatment in the
country. To date teams have treated some 3,000 patients with Chagas in Bolivia.
Their challenge is to demystify this disease and integrate treatment into thenational public health system.
MSF opened a project in Sucre in 2005, andimproved access to diagnosis and treatment
for under-18s in this semi-urban setting. The
project was finally closed in March 2008.
In Cochabamba, MSF worked in five healthcentres with the Ministry of Health, aiming tointegrate the diagnosis and treatment of
Chagas into the health system. Weekly followups allow side-effects to be detected in time to

Médecins Sans Frontières Activity Report 2008

MS F PROJE C TS A R OUND THE WOR LD | T h e A m er i cas

66transfer patients to the hospital if necessary.
In 2008, more than 500 patients were treated.
In Tarija, where MSF closed its project in 2006,
nearly 1,400 children were treated. In 2008,
969 of these children were seen again to assess
the efficacy of treatment and the project’s
long-term impact.
MSF has worked in Bolivia since 1986.

‘My mum died of Chagas when I was a child,now I am 25 years old and I have managed to
get the treatment.’
Rosario, patient from the Cerro Verde health centre

Pamela from Cochabamba is the
21-year-old mother of Griselda, one,and Kevin, three.
‘One day I was in the health centre
waiting for the doctor and a woman
approached me and started talking about
Chagas. I did not pay attention to her
until she mentioned that the vinchuca
was the insect that transmitted thedisease. I realised my house was full ofthem when I was a girl. She persuaded me
to take the test. I was positive, and mychildren were, too. I cried a lot. I had
transmitted the disease while I was
pregnant. We were all treated and now weare fine. I am very grateful I could get the
medication free, since few health centres
give it freely and even fewer give it topeople over 15 years old.’© Roberto (Bear) Guerra

Local armed groups have for years
controlled slum areas in Rio de Janeiro
called favelas, where they recruit
young men as soldiers and imposesocial rules that include harsh punishment for those who do not obey.
Clashes between armed groups for
territorial control, as well as fighting
between police forces and the rulinggroups, leave thousands of people
trapped by violence. People risk beingcaught up in fighting and severely
injured as they go about their everyday
business.
In one of these favelas, Complexo do Alemão,MSF runs a medical structure that provides
emergency care and psychosocial support. The
complex, a conglomerate of 11 communities
on the outskirts of Rio, has a population
estimated at 150,000. At the MSF emergency
unit, people affected by fighting receive immediate assistance, improving their chances ofsurvival and recovery. Once stabilised, patientsare referred to a government hospital outside
the community. MSF ambulances can alsoreach patients inside their homes. Due tocheckpoints and blockages set up by thearmed groups, no other ambulance can enter
the area. Patients presenting with othermedical emergencies, such as the hemorrhagic
form of dengue fever, a seasonal disease in Rio,
were also seen at the MSF centre. In 2008, MSF
provided 11,315 consultations in Complexo doAlemão. In nearly one-third of them, patientswere under five years old.
Living permanently surrounded by violence
has a serious impact on people’s mental
health. MSF provided psychological support toapproximately 900 people in 2008. Most ofthem had been caught up in fighting or had
directly witnessed acts of violence. One in ten
has had a family member murdered.
To promote the services available at thecentre, a team of four community healthworkers liaises with schools, churches and‘One of our goals is to
reduce the time between
trauma and hospitalisation. We need to treat thepatient during the first
60 minutes after the timeof the injury.’
Gianfranco De Maio, medical doctor

other local institutions, organises activities
in the streets and conducts home visits.
MSF has worked in Brazil since 1991.

‘With the emergency unit inside thecommunity, we can get down here and receive
medical care much more quickly than if we
had to go to another hospital.’
Patient at the MSF emergency unit in Complexo do Alemão

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Colombia

also works on the border between Meta andGuaviare, where the team gave 4,650 medical
consultations.
In Tolima’s southwest areas, where access tohealthcare has improved significantly, MSF
gave more than 6,470 medical consultations.

© Clement Saccomani

Reason for Intervention• Armed conflict • Social violence/Healthcare exclusion
Field Staff 294

Territorial conflicts linked to the narcotics trade caused increasing numbers ofpeople to flee their homes in Colombia in 2008, aggravating the country’s
alarming humanitarian crisis. Assistance for those most affected, including theprovision of healthcare, is limited. Mental-health care for victims of violence isneeded across the country. People living in rural areas and in marginalisedurban areas continue to suffer from diseases that could be easily prevented andtreated.
There are MSF programmes in 17 of Colombia’s
32 departments. The range of services
includes: primary healthcare, mental-healthprogrammes, mobile clinics in urban andrural areas, reproductive healthcare, emergency obstetric care and assistance to victimsof sexual violence, antenatal care, water
sanitation, basic refurbishment of healthstructures, voluntary counselling treatment,
pregnancy termination and emergency
response.
In the Uraba region, mobile clinics provided
medical access to the most isolated communities in the rural areas surrounding Saiza andin Rio Sucio. Here MSF also supported hospital
services, offering mental-health and reproductive services and carried out more than 14,700
consultations. In the Norte de Santander
department, the teams assisted communities
isolated by conflict in El Tarra and La Gabarra.
Through mobile clinics, they provided morethan 8,400 consultations to rural people who
had been forced to flee their homes.
In the Sucre and Bolivar departments, MSF
gained greater access to the disputed Montes
de Maria region. MSF provided basic healthcare in mobile clinics and carried out morethan 10,550 consultations. Services in
Sincelejo focused on the basic and reproductive health of people who had been forced toflee their homes, supporting those affected bysexual violence and providing access to HIV
testing and counselling.
In the urban area of Buenaventura, MSF set up
a fixed health post, mobile clinics in theneighbourhood and a referral system to thestate’s healthcare facilities. The programme
has offered care for victims of sexual violence,
reproductive healthcare, paediatric care andpsychological assistance, providing 8,375
medical consultations. A mobile medical team

There were also 8,670 medical and 180 psychological consultations conducted throughmobile clinics in Barbacoas, Magui Payán andRoberto Payán. The medical activities wereclosed in October 2008. However a reduced
team remained in the area attending to displaced people who continued to arrive in
Barbacoas. MSF provided medical care (including psychological care and health promotion)in the Piamonte municipalities of Cauca andPuerto Guzman in Putumayo. In 2008, 5,860
medical and 755 psychological consultations
were conducted in mobile clinics.
MSF closed its urban project for people who
had been forced to flee their homes in the
Soacha municipality after ten years and morethan 100,000 consultations.
In Chocó, one of the poorest regions in
Colombia, MSF provides sexual and reproductive healthcare in urban and rural areas,
including assistance to victims of sexual
violence. In Quibdó, the main city, MSF runs
an urban mobile clinic and supports thematernity ward in the only hospital providing
second-level healthcare. In Istmina, a mobile
team travels by boat to reach remote villages
on the banks of the San Juan river, where
10,470 consultations were provided in 2008.

GUATEMALAHONDURAS

Reason for Intervention • Social violence/Healthcare exclusion
Field Staff 21

Reason for Intervention • Social
violence/Healthcare exclusion
Field Staff 46

Civil war, poverty, street gangs, the spread of Mexican drug cartels and thefailing judicial system have contributed to a soaring crime rate and everincreasing violence. On average, more than 17 people were killed every day
in 2008: the highest rate of homicides in Guatemala since the end of thecivil war.
This situation increases social inequality,
unfair distribution of wealth and the disintegration of the family, and there has been an
enormous incidence of sexual violence. Morethan 10,000 cases were officially reported in
Guatemala last year.

an open-all-hours service within the
Guatemalan Ministerio Publico (office forcrime reporting). Women who report asexual assault are able to receive free
medical and mental-health care in the
Ministerio Publico.

The violence is concentrated in the capital cityand is most prevalent in suburban zones 7 and
18 on the outskirts of Guatemala City. MSF
opened programmes in these two zones in2007. Teams offer medical and psychologicalsupport, provide medication, and coach staff
from the national Ministry of Health. In 2008
MSF teams gave comprehensive medical andpsychological assistance to more than 400
victims. The medical response includes presumptive treatment or prophylaxis, administered to prevent the development of any
sexually transmitted infections. Last year the
programme was extended to provide further
points of access for patients. MSF has installed

MSF has established a mobile clinic andplans to set up another open-all-hours
medical and mental-health service in
Guatemala City’s general hospital, whichacts as a central point for referrals fromother health facilities.
To raise awareness further, the teams haveconducted extensive information campaigns in the communities, but more
efforts are required to improve the knowledge of health professionals, authorities,
and the broader community.
MSF has worked in Guatemala since 1984.

Homeless young people living on thestreets of the capital city, Tegucigalpa,
are vulnerable. They barely have accessto medical care, live in precarious
circumstances and are the first targetof violence in an already volatile environment. Last year, more than 500
street people under the age of 24 weremurdered in Tegucigalpa.

© Claude Mahoudeau

MSF provides medical and psychological treatment and social care in a therapeutic day-care
centre that opened its doors to the homeless in
2005. In 2008, more than 370 street youngsters
came to the centre, which is situated in
Comayaguela, a deprived district in the capital.
MSF provided medical treatment for 310 people
in 2008. Most were suffering from respiratory
infections; others had skin diseases, dental
problems, injuries resulting from violence, andHIV/AIDS.

In the municipality of Tame, MSF teams
provided more than 15,000 consultations,giving primary, family planning and antenatal
healthcare and psychological support.

MSF also coordinated a vaccination service forvisitors to the centre. Visitors receive hepatitis
B and tetanus vaccinations amongst others.

During 2008 MSF also responded to the emergency of the Nevado del Huila volcano, Cauca
department, and the River San Juan floods in
Chocó.

MSF psychologists help young people cope withstreet life, fear, and drug abuse. Teams havealso set up a medical and psychological referral
system for patients who cannot be treated in
the day-care centre. Such patients werereferred to the psychiatric hospital due todepression, suicide attempts, psychotic
episodes or alcohol abstinence syndrome.

MSF has worked in Colombia since 1985.

MSF has worked in Honduras since 1988.

© Marcell Nimfuehr

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Europe andthe Middle East

HAITI
Reason for Intervention• Social violence/Healthcare exclusion • Natural disaster
Field Staff 813

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As the security context continued to stabilise in the capital, MSF teams treatedan average of 45 people with gunshot wounds each month at the Trinité trauma
centre. This is the only emergency room providing free care in Port-au-Prince.
After emergencies such as the food riots in
April 2008 and the collapse of a school in
Petionville in December 2008, most of thepatients were brought to the Trinité emergency room. This facility offers internal
fixation, an orthopaedic technique that allows
patients to recover much faster than is usualwith traction.
MSF provides surgical care at the centre. In 2008
more than 17,950 patients were treated, and morethan 6,100 underwent surgical interventions.

Jude Anne emergency obstetric hospitalThroughout 2008, MSF managed the 65-bed
Jude Anne emergency obstetric hospital in
Port-au-Prince. In addition to the hospital, MSF
runs three mobile clinics in three slum areas
offering antenatal, perinatal and postnatalcare. The service provides emergency
Caesarean sections, voluntary counselling,
testing, prevention of mother-to-child transmission of HIV, care for those affected bysexual violence, and the referral of womenwith uncomplicated deliveries to otherhospitals.

Pacot rehabilitation centre
MSF operates a physical rehabilitation centre
where patients in need of specialised postoperative treatment receive physiotherapy andpsychological care. Here, more than 600
patients were hospitalised and more than
10,900 people were given orthopaedic
consultations.

Treatment for victims of sexual
violence
MSF increased its capacity to treat victims ofsexual violence in the capital, offering comprehensive psychological and medical care. The
programme treated 468 people in 2008, 51 percent of whom were under 18 years old.
Awareness campaigns in the shantytowns andcity centre continued, emphasising thatwomen need to receive treatment within 72
hours of an attack.

of the slum, but now patients are coming
directly to the clinic. In 2008 MSF teams received
25,445 patients – 16,942 of whom were trauma
patients.

By the end of December 2008, more than
14,700 babies had been born at this hospital.
The average number of deliveries per month is
1,000, half of which involve complications. The
hospital also provides a newborn care unit,
where an average of 90 babies a month areadmitted to be stabilised before being transferred to the general hospital in Port-au-Prince.

Martissant emergency rooms andmobile clinics
Since December 2006, MSF has worked in theslum of Martissant, in Port-au-Prince, to assist a
population that is heavily affected by armed
violence. The medical team has an emergency
room where patients are stabilised, and refers
those in need of surgery to other hospitals in
the city. Until December 2007, mobile clinics
offered first medical assistance in different parts

Emergency response after hurricanes
Following two tropical storms and two hurricanes that hit Haiti at the end of August andbeginning of September, MSF launched an
emergency intervention in the town ofGonaïves in the north of the Artibonites.
MSF re-opened an 80-bed hospital in Gonaïves
in cooperation with the Health and Population
Ministry. This structure is the only one in theregion that can respond to emergencies andprovide obstetric and paediatric services.
During the last three weeks of 2008, 675
patients were admitted to the emergency roomand more than 110 deliveries and 50 surgicalinterventions were performed.
MSF has also distributed hygiene kits for 5,000
families (including plastic sheeting, soap andjerry cans) to help as many people as possible
who had been left with nothing after thestorms.
MSF mobile medical teams travelled by car,on horseback and on foot around Gonaïves
and the surrounding isolated villages toprovide assistance to the most vulnerable
people staying in temporary shelters. In total
MSF teams performed more than 3,500 consultations via this service.
MSF has worked in Haiti since 1991.

© Siavash Maghsoudi

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contents
72 | BELGIUM
72 | FRaNCE
73 | Greece
74 | ITALY75 | Malta
76 | Moldova
76 | RUSSIAN FEDERATION
77 | SWITZERLAND
78 | IRAN
78 | IRAQ
80 | Lebanon
80 | Yemen
82 | PALESTINIAN TERRitories

BELGIUM
Reason for Intervention• Social violence/Healthcare exclusion
Field Staff 9Everyone in Belgium is entitled tohealthcare. This includes undocumented migrants and asylum
seekers, although in practicenumerous administrative obstacles
restrict their access to healthservices. Since 1987, MSF has been
assisting migrants by providing
medical care and lobbying forgovernment services to fulfil their
responsibilities.
From January to April 2008, more than
600 consultations were carried out inBrussels. In April, MSF was able to handover this project.

FRANCE

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Reason for Intervention • Social violence/Healthcare exclusion
Field Staff 11

In response to the difficulties some asylum seekers and non-French-speaking
patients face in accessing psychological care in France, MSF set up a newprogramme in Paris in 2007. It aims to provide medical and psychological careto these people, as well as social support.
The Paris centre offers psychological care topeople in distress who came to France seeking
asylum and protection. Most of them have fledfrom a conflict zone or political violence.
Some arrived in France only recently, whileothers have been living in the country forsome time. For MSF patients, as for asylum
seekers in general, access to existing psychological care and services is hindered by a
combination of several factors including thenature and intensity of their psychologicaldistress, social and administrative insecurity,and the language barrier.
The MSF centre can offer assistance tailored toeach patient: therapeutic care is comple­
mented with medical, social and legal referrals
and advice. Since the centre opened almost
two years ago, it has conducted more than

7,000 consultations. Half of these were related
to psychological care, a quarter to medical
aspects, the remaining quarter to social
assistance. Psychological care has been given
to 365 people and 160 are still receiving it.
The precarious conditions in which people
without valid immigration papers live,
combined with what they went through intheir home countries, make them extremely
vulnerable. They are likely to suffer from highlevels of anxiety. Psychological care is therefore essential to avoid a deterioration of theircondition, which can lead to suicide attempts.
Of the patients attending the centre, 41 percent have reported that they have had suicidal
thoughts.
MSF has worked in France since 1987.

L was born in Afghanistan, some 30 years ago. Like most Afghans, he reached France
after a long and painful journey across Afghanistan, Iran, Turkey, Greece and Italy.
Part of his family died in a bombing in Afghanistan. He fled his country with his wifeand children to seek refuge in Iran because he was scared. L travelled alone to France.
He is in constant fear of being sent back to Afghanistan. He has applied for asylum,
but his request has been rejected, and he no longer has the right to remain on French
territory.
L has been receiving healthcare at the MSF centre for a year, supervised by an MSF
psychologist. The violence he shows towards himself reveals his distress. Every day,his thoughts are haunted with what he suffered in Afghanistan.

In Antwerp, MSF continues to provide
medical and psychosocial consultations topeople who cannot access them throughnormal channels. More than 2,000 consultations were conducted in 2008: most of thepatients were undocumented migrants andasylum seekers. Rather than create a parallelsystem, MSF aims to direct people towards
the national system responsible for providing the service. MSF will hand over its activities in Antwerp at the end of April 2009.

© Giorgos Moutafis

Reason for Intervention • Social violence/Healthcare exclusion
Field Staff 6

Greece is a crossroads between Asia, Africa and Europe. In recent years thenumber of people arriving in Greece from the Middle East and Asia has rapidly
increased, mainly due to armed conflicts and political instability in the migrants’countries of origin. Most of the people arriving without papers are fromAfghanistan, Iraq, Palestine and Somalia, and among them are a significant
number of unaccompanied children.
The migrants are using Greece mainly as apassage to Europe – their common intention is
to be forwarded to Italy and then to other
European countries, but the Greek authorities
systematically refuse to grant them refugee
status. More than 25,000 applications were
submitted in 2007, but only eight asylum
seekers received refugee status.
Following an overall review of the situation,
MSF decided to conduct an exploratory mission
in February. The results highlighted the
problems faced by undocumented migrants.
These included limited or no access to healthcare services, difficult living conditions, lack of
special measures for vulnerable groups such as
women and children, absence of mental-healthservices and inadequate provision inside thegovernment detention centres and the makeshift migrant camp in Patra.

MSF has worked in Belgium since 1987.

© Julien Lévêque

Lesvos island
In June, MSF started work at the detention
centre of Lesvos island and at the port landing
point, providing medical, psychological andhumanitarian assistance. However, MSF
decided to end the intervention in September
due to limited access to the detention centre,
which severely affected efforts to provide
medical assistance and improve the undocumented migrants’ living conditions. ‘There
were many occasions when the medical team
had to examine patients through bars, since
the migrants were not allowed to leave therooms,’ explained Yorgos Karagiannis, head of
the MSF mission in Greece. Despite the limitedaccess, MSF carried out more than 1,700 consultations at the Lesvos detention centre,
addressing pathologies such as respiratory
infections, dermatological diseases, anxiety,post-traumatic stress disorders and depression.

Makeshift migrant camp in Patras
Patras is the main exit port to Italy. During thepast ten years there has been a constant influxof migrants crossing to Italy hidden inside
trucks. The makeshift migrant camp in Patra isa shantytown of cardboard, plastic and wood
structures that have no heating or electricity. It
hosts mainly people from Afghanistan and
Iraq. In May MSF opened a clinic inside thecamp, providing primary healthcare services
and psychosocial support to the undocumented
migrants. The teams also carried out regulareducational activities to improve good hygiene,
sanitation and disease prevention practice. The
people’s main medical problems were skindiseases, respiratory infections and gastrointestinal disorders. Bruises and other injuries werealso common, resulting from migrants’frequent attempts to board ships leaving theport, or from resisting arrest. By the end of
December, MSF teams had carried out 6,000
consultations, and more than 400 cases werereferred to the local hospital.
MSF has worked in Greece since 2008.

75

ITALY
Reason for Intervention • Social violence/Healthcare exclusion
Field Staff 23

Italy has experienced a growing influx of undocumented migrants and asylum
seekers since 2002. Looking for refuge, jobs or better living conditions, thesepeople bear the brunt of increasingly strict measures designed to deter migration. As these measures are tightened, so reception conditions deteriorate. As aresult, these already vulnerable people face a system unable to meet their basic
needs, including protection and healthcare.

Every year, the agricultural lands of southern
Italy attract thousands of undocumented
migrants, a cheap labour force that is subjected to exploitation and intolerable living
conditions. Since 2005, MSF has worked in
Sicily, Puglia, Calabria and Campania toprovide assistance to this population. In 2008,
MSF undertook more than 700 consultations
and distributed 3,750 hygiene kits, 1,500
sleeping bags and 800 blankets.
To help improve these people’s living conditions, MSF lobbied the authorities for ahumanitarian intervention for all migrant
workers, regardless of their legal status. As aresult, regional authorities in Puglia, Calabria
and Campania undertook emergency measures
to guarantee basic living conditions – toilets,
showers, water tanks – and adequate medical
services for the 4,000 migrants working in thearea. These measures followed recommendations in the MSF report, A Season in Hell, which
exposes the deplorable health, work and living
conditions of migrant workers in southern
Italy.

© MSF

MSF provides healthcare to the migrant population, including seasonal migrant workers,
and lobbies for better access to services andliving conditions for them.
Naples is the third largest city in Italy. It
attracts large numbers of migrants: an estimated 25,000 live there unofficially, outside
the state system. They are excluded fromsociety and public services. In order to improvetheir access to healthcare, MSF has set up
clinics integrated into the country’s national

health services with a view to handing themover to authorities in the future. To reducebarriers created by the patients’ irregularsituation, assistance is provided in a way that
ensures their anonymity. In 2008, MSF
provided nearly 5,000 consultations in theclinics. To respond to the high incidence ofsexually transmitted infections amongst
female undocumented migrants, MSF also
launched a sexual and reproductive healthcare
programme that provided more than 1,000
consultations in 2008.

‘The health problems we find are mainly
osteo­muscular, dermatological, respiratory andgastro-intestinal, all related not only to harshworking conditions but also to the unhygienic
situation in which the people live. Seasonal
migrant workers in southern Italy also havescant access to primary healthcare.’
Francesca Faraglia, MSF medical coordinator

Until October 2008, MSF provided medical carefor migrants arriving by boat in Lampedusa,
south of Sicily. The harsh journey poses a risk
to their health and only through MSF wasmedical care available to newly arrived
migrants. In October 2008, Italian authorities
refused to renew the agreement that allowed
MSF to work on the island. As a result, MSF
was forced to leave and the thousands of
migrants who arrive now in Lampedusa haveno access to healthcare. Between January andOctober, MSF provided consultations to 1,420
people. Pathologies such as respiratory infections and skin diseases were mostly associatedwith the harsh conditions of the sea journey.
MSF is negotiating with authorities a possible
return to Lampedusa. In 2008, more than
30,000 undocumented migrants and asylum
seekers landed on the island.
Throughout Italy, the work with migrants iscarried out with the support of cultural mediators, who help bridge communications andcultural gaps between the team and thepatients.
MSF has worked in Italy since 1999.

Malta

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Reason for Intervention • Social
violence/Healthcare exclusion
Field Staff 4

Despite stricter border controls at theEuropean Union’s southern frontier,the number of migrants landing in
Malta increased in 2008 to 2,740.
Once on the island, undocumented
migrants and asylum seekers are sent
to detention centres. MSF provides
them with medical and psychosocial
care on their arrival and inside thecentres.
Undocumented migrants and asylum seekers
set off to Malta on boats leaving the coast of
Libya. Nearly 60 per cent originate from countries affected by conflict or widespread violations of human rights; almost half of all newly
arrived come from Somalia. Although most ofthem will eventually be granted refugee statusor humanitarian protection by Maltese authorities, they are forced to wait in detention
centres for up to 18 months first. There they
face overcrowding, inadequate sanitation andpoor general living conditions. The environment has damaging effects on their physicaland mental health.
In August 2008, MSF started providing healthcare and psychological support to thesepeople. Activities included medical assessment© Elisa Finocchiaroof new arrivals soon after their transfer to thedetention centres and follow-up medical
consultations, psychological support, medical
triage and health and hygiene promotion
inside living areas.
Between August and December 2008, MSF
provided more than 1,700 consultations to

18-year-old S, a woman from Eritrea, arrived in Malta on August 24, 2008
‘I escaped from Eritrea because I wanted to avoid being recruited to fight in theendless war against Ethiopia. In Libya I was put in a detention centre, where I was
harassed, beaten, abused and raped several times. For two years, I was treated as aslave for the guards and soldiers.
‘When I arrived in Malta I thought I would be free at last. As soon as I realised that I
was going to be kept in a detention centre again, I lost hope and became severely
depressed. I had difficulty in sleeping and had gastric and heart problems. Memoriesof the rapes, fears of guards and soldiers resurfaced and it was difficult to be crowded
together with so many others.’
The MSF psychologist found S collapsed in the toilet zone and referred her to thehospital. After a few days in the hospital she tried to hang herself. After more than amonth in the psychiatric hospital, she was sent back to the detention centre. Twenty
days later, she tried to hang herself again. In mid-November, she was finally recognised as a vulnerable person, released from the centre and accommodated in an open
centre.

migrants and asylum seekers in Malta. Amongthe newly arrived, health complaints often
resulted from the harsh conditions enduredon the journey. Most people had spent up toseven days on a boat with limited food andwater, unable to move, and exposed to theelements. Scabies, respiratory infections andintestinal parasites are common. Musculo­
skeletal problems, such as joint problems andback pain, are also frequent in a population
with limited access to outside space andactivity. MSF has continually expressed its
concerns to Maltese authorities over the living
conditions and inadequate medical care in thecentres.
MSF also works in open centres. Once asylum
seekers have had their application successfully
processed and are granted refugee status, they
are transferred to open centres, where they
have freedom of movement. They stay there
until they are able to rent private accommodation. MSF provides medical consultations to
refugees in these centres and facilitates theiraccess to public health services.
MSF has worked in Malta since 2008.

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RUSSIANFEDERATION

Moldova

Reason for Intervention • Armed
conflict • Social violence/Healthcare
exclusion
Field Staff 292© Alexander Gyadyelov

Reason for Intervention • Social violence/Healthcare exclusion
Field Staff 33

Transnistria, a politically isolated and predominantly Russian-speaking region,
is a strip of land separated from Moldova by the River Dniester. Once the sceneof a violent separatist war, Transnistria is not recognised by the international
community and little international aid has reached it despite the enormous
assistance Moldova receives from international institutions to tackle the HIV/AIDS epidemic.
MSF, working with the Transnistria Ministry of
Health, established the region’s first HIV/AIDS
programme in early 2007. Owing to theurgency of the situation, the first patients
started receiving life-prolonging antiretroviraltherapy (ART) four months before the first
outpatient department opened in the main
hospital of the capital, Tiraspol. MSF also
extensively refurbished the hospital’s laboratory and installed a new waste disposal system.
The programme’s activities were extended toweekly visits to Bender tuberculosis (TB)
hospital for people co-infected with bothdiseases; to Slobozia, the region’s only inpatient facility for HIV/AIDS patients; to Ribnitza
in the north of the country to operate a weekly
clinic in the city’s polyclinic; and into theprison system where the incidence of HIV/AIDS
is around 13 times higher than in civil society.
The incidence of co-infection is also muchhigher, particularly co-infection with tuberculosis (TB). Previously prisoners had no access at
all to specialised HIV care and treatment.
By December 2008, MSF was able to hand over
all activities in the civil sector to the Ministryof Health. At this point, MSF and the ministrywere jointly providing HIV care to around 860
patients – more than half the HIV-positive
people registered in Transnistria. More than
180 of these people had been initiated on ART.
MSF also trained hospital staff to ensurehigh-quality services. Most importantly, MSF’s
lobbying resulted in an extension of HIV/AIDS
resources from Moldova to Transnistria. The
prisoners’ programme is scheduled to behanded over to the Ministry of Justice and theMinistry of Health early in 2009.
MSF has worked in Moldova since 2007.

Once a week the MSF team goes to Ribnitza, in the north of the region. On the way theteam stops to see an HIV-positive young mother, who lives alone in a remote village.
She comes to the mobile clinic every week to have her baby checked by the MSF
doctors. The baby has not tested HIV-positive so far, but it will be some time before
she can be certain her baby has not contracted the disease. She cannot buy food andessentials for her baby and cannot breastfeed, so MSF provides not only her ART drugs,
but also food for the infant.

Magomed, 59, is on intensive TB treatment in the Grozny TB hospital. He feels weak
and is partially deaf as a side-effect of TB medicines. Magomed first contracted TB five
years ago when he was in prison. At the time, war was ravaging the land and there wasno place and no means to treat people like Magomed effectively. Magomed didn’t
complete his treatment and this caused his current relapse. ‘This disease is treacherous – it comes out of the blue, and takes a long time to get rid of,’ he says.

The MSF programmes in the North
Caucasus, in Chechnya andIngushetia provide surgery, motherand-child healthcare, mental-healthsupport, and tuberculosis (TB) care.

treatment throughout Chechnya, including topatients in the remote mountainous regions
who had no access to TB care. Since the beginning of the programme in 2004, 1,800 patients
have been treated.

In the post-conflict region of Russian North
Caucasus, the situation remains volatile.
Security in Chechnya has improved, while inneighbouring Ingushetia it has worsened
dramatically. For security reasons, visits by
MSF international staff to the project sites
remain short if regular, and much of the
responsibility for running the programmes
lies with the national staff.

A powerful earthquake hit Chechnya in
October 2008, killing 13 people, injuring morethan 100 and causing destruction. Shocks
continued over several days and people spentcold nights outside, fearful that the remaining
buildings would collapse. MSF sent mobile
teams to the five most severely affected villages
and provided more than 1,000 medical and
3,000 psychosocial consultations.

Because MSF does not aim to duplicate theexisting or emerging local services, a few MSF
programmes in the region were closed down
or handed over in 2008. MSF handed over thetwo refurbished polyclinics in Grozny in which
teams had run free pharmacies and a reproductive health and family-planning clinic.
Mobile medical teams no longer serve temporary accommodation centres in Grozny. In
2009, MSF will stop its emergency surgery
programme in Grozny, since the number ofinterventions performed there each month isdeclining.
MSF has worked in Russia since 1988 and North
Caucasus since 1995.

Thousands of people who lost their homesduring the wars are still living as refugees inIngushetia or Dagestan, or in Grozny itself.
MSF ran a medical centre in Nazran,Ingushetia, which provides medical and mental-health consultations for these people. The
clinic conducted up to 1,200 consultations amonth in 2008. Doctors provided women’s andpaediatric healthcare in clinics in Grozny. On
average, more than 1,300 gynaecologicalconsultations were provided each month in
the Staropromyslovsky area. MSF also supported the Republican Women’s Hospital in
Grozny and district hospitals in the mountainous villages of Shatoy, Sharoy and Itum-Kale,
supplying drugs and medical materials.

Reason for Intervention • Social
violence/Healthcare exclusion
Field Staff 4

Meditrina, a project launched in 2006
in Zurich, provides medical care topeople excluded from the state system.
In late 2007, MSF decided to expand it
by establishing contacts with the city’scommunities of illegal immigrants.
The new strategy, which also involved
diversifying the medical services
offered, was aimed at boosting attendance at the centre. It quickly brought
results: Meditrina staff provided anaverage of 120 consultations a monthin 2008, approximately 60 per cent of
which were for new patients.
Once Meditrina’s services had been diversified,people suffering from chronic ailments suchas hypertension, diabetes, tuberculosis, andHIV/AIDS were able to gain access to the carethey needed.
To make the changes possible, the staff paid
closer attention to the work done by mediators. The seven mediators belong to several
communities of different origin, including
Latin America, Southeast Asia, and East Africa.
They form a direct link between Meditrina andthe people who use the service. Thanks tothem, the necessary trust was more easily
established and the benefits were considerable.
The medical work carried out throughMeditrina revealed, as much for city officials
as for local associations, how difficult it is formany people in Zurich to find treatment. Theinterest being shown by other institutions andassociations makes the withdrawal of MSF andthe handover of Meditrina’s medical and social
efforts in 2009 a possibility.

In 2006, MSF opened a surgery project in the
republic’s main hospital, Grozny Hospital
Number 9, to treat long-standing injuries andchronic disabilities sustained in the war, andvictims of road traffic accidents. In 2008, MSF
operated on 445 patients and conducted 11,056
physiotherapy consultations here.
TB became a problem for the region after
patients’ treatment and follow-up were interrupted because of the war. MSF restored theremaining TB hospitals, set up waste-disposal
facilities, trained the local medical staff andstarted treating patients. Early in 2008, theprogramme expanded to include a TB dispensary in the capital, Grozny. MSF will provide TB

SWITZERLAND© Misha Friedman‘Before the war, there were more than 120 TB doctors
for a population of one million. During the two wars
the TB service infrastructure was completely destroyed.
The MSF programme showed that TB treatment in a
post-war setting is possible and yields good results.’
Shamsudin Ikhaev, Chechen TB doctor

MSF has worked in Switzerland since 2003.

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IRAN

IRAQ

Reason for Intervention • Armed conflictField Staff 96

Reason for Intervention• Armed conflictField Staff 489

Since 2001, MSF has been assisting Afghan refugees in Zahedan, capital of the
Iranian province of Sistan-Baluchistan, where they have been crossing theborder for the last 30 years. In 2002, despite a deterioration in conditions inconflict-ridden Afghanistan, the Iranian government implemented a policy offorced repatriation. Many people are reluctant to return to their home country
and prefer to remain in Iran; some even return after deportation. With Iranian
restrictions on work, educational opportunities and health services, living conditions for refugees are difficult. Despite this, people continue to migrate fromAfghanistan, essentially for economic reasons, because of drought in thenorthern provinces or increased insecurity in other areas.
Iran is in economic crisis, and resentment
towards refugees has increased. In November
2007, officially for security reasons, the government declared the regions next to theborder ‘no-go areas’. This included areas suchas Sistan-Baluchistan, where more than half amillion Afghans still remain illegally.
Iranian authorities estimate that most Afghans
are economic migrants, and therefore are notentitled to legal status or access to free healthcare. In Sistan-Baluchistan, MSF continues toprovide primary and secondary healthcare to
this population, which has little or no accessto the Iranian healthcare system. In 2008, theteams visited an average of 23 newly arrived
families a week at Zahedan – an increase froman average of eight families a week in 2007.

MSF runs three medical clinics in Shirabad,
Karimabad and Besat, offering free medical
consultations and nutritional support forchildren. In 2008, MSF carried out an averageof more than 7,000 consultations a month. MSF
also refers patients to secondary structures andcovers costs for specialist consultations, treatments and hospitalisation. A team of social
workers is in place in the refugee community
to identify people in need of medical care andto ensure they can access consultations. The
team distributes material goods such asblankets and heaters where needed.
MSF has worked in Iran since 1996.

In the sixth year of war the overalllevel of violence has decreased.
Nevertheless, bombings and killings
continue in many regions, causing
dozens of deaths and injuries every
week. Owing to security constraints,
MSF cannot give direct assistance inthe worst-affected areas. Aid to the
Iraqi population is therefore delivered
mostly from more secure parts of thecountry or from outside the border.
Access to healthcare is problematic, especiallyafter bomb blasts, when it is difficult for the
wounded to reach hospitals. Patients withchronic diseases suffer from a general lack of
medicines and proper follow-up care.

© Kloie Picot

this programme. The programme was developed in partnership with the Jordanian Red
Crescent hospital and the Iraqi Medical
Association.

Reconstructive surgery
Large numbers of doctors and medical staff
have fled the country since the beginning of
the war in 2003. Those who stayed faceenormous hardships, even threats to theirlives. According to the Iraqi Ministry of
Health, more than 600 medical employees,
including 132 doctors, have been killed in thecourse of the war. Humanitarian organisations have also been targeted.
MSF has struggled for years to gain access tothe people. ‘The dilemma we face in Iraq is symptomatic of many conflicts today,’ says Gustavo
Fernandez, head of mission for the programmes in Ninewa and Tameen governorates.
‘Reaching civilians caught in midst of conflict andviolence has become a huge challenge.’
For the first time since the change of regime
in 2003, MSF was able to establish an international team in southern Iraq in 2008. In
October a training project was started in
Basra general hospital in the south of thecountry. The project intends to improve preand post-operative care.

Cross-border support© Siavash Maghsoudi

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Since 2006, medical programmes have been set
up in neighbouring countries. MSF has been
providing orthopaedic, maxillo-facial andplastic surgery for Iraqi war-wounded in
Amman, Jordan, since August 2006. Almost 600
patients who needed treatment too complex tobe provided in wartime Iraq were treated in

In the Kurdish governorates of northern Iraq,
MSF provided surgical assistance to thewounded in hospitals in Sulaymaniyah, Erbiland Dohuk, focusing on prosthetic and orthopaedic reconstructive surgery and care forburn victims.
Reconstructive surgery for war-wounded
Iraqis was also provided in Mehran, Iran. MSF
had intended to develop a referral system forpatients from the war zone to these hospitals,
but attempts proved unsuccessful for a numberof reasons. MSF decided to stop some of these
programmes in the course of 2008 to concentrate reconstructive surgery activities in thehospital in Amman, Jordan, and to give more
specific support to hospitals within the conflictzone. The programme for burn victims in
Sulaymaniyah continues, and deals with anaverage of 80 admissions a month. The injuries
are caused mostly by accidents or in failedsuicide attempts.

material, equipment and training. Emergency
psychological counselling has been introduced for victims of violence in four of these
hospitals. In the northern governorates of
Tameen and Ninewa, MSF supports five hospitals by providing medical supplies and emergency responses after violent incidents.
While the situation in Iraq remains violent
and highly volatile, MSF hopes to seize theopportunity presented by some relative
improvements in security to extend medical
humanitarian assistance in 2009.

Psychological support
In Baghdad, central and south Iraq, MSF
supports eight hospitals by providing medical

MSF has worked in Iraq since 2006.

New humanitarian concerns in Iraq
Humanitarian challenges have evolved over the past few years in
Iraq. The Status of Forces Agreement, signed between the UnitedStates and Iraq at the end of 2008, has paved the way for thewithdrawal of foreign forces from the country – American forces
are to withdraw from the main Iraqi cities by the end of June2009 – and national elections took place in January 2009.
Nevertheless, the situation is still tense, especially in Baghdad
and in northern areas: Kirkuk’s future is still undecided, forexample, and Mosul is still volatile. The withdrawal of foreign
troops is increasing fears of a rise in violence, which will certainly have operational consequences for MSF.
MSF has worked hard to find the most appropriate approach in
Iraq: the best way to balance serious security concerns against
the medical needs of the people. The organisation has had to
adapt quickly to establish networks and build trust with its
counterparts in Iraq. For security reasons, MSF’s operations are

restricted to urban settings, so it is difficult to make an accurate
assessment of the medical and humanitarian needs in rural areas.
Teams have had to find ways to reach vulnerable people without
endangering the organisation’s reputation and the security of its
staff. Many western NGOs, as well as the United Nations, areperceived to be allied with the American forces. This has blurred
the important distinction between the armed coalition andhumanitarian agencies, creating a challenge for MSF and underlining the critical importance of its neutrality, independence andimpartiality in operational matters.
Since the Iraqi Ministry of Health has begun to take over healthcare provision, MSF has reduced the quantity of drugs it supplies
and scaled down its support to health structures. MSF is now
turning its attention towards more technical medical projects in
Iraq, such as complex reconstructive surgery.
Caroline Abu-Sada, interim head of mission

81

LebanonYemen

Médecins Sans Frontières Activity Report 2008

MSF PROJEC TS AROUND THE WOR LD | E u r op e a n d t h e Mi d d le East

80

Reason for Intervention • Social
violence/Healthcare exclusion
Field Staff 8

After an evaluation in 2008 that
focused on the mental-health needs ofLebanon’s people, MSF began a threeyear programme in Burj el-Barajneh.
This southern suburb of Beirut ishome to many Lebanese, recently
arrived Iraqi refugees, and Palestinian
refugees who have lived there since
1948.
In Lebanon, 17 per cent of the population havemental-health problems, but only 11 per centof this group have access to medical treatment. The health system is expensive because
it is heavily privatised, and mental-health care
is not covered by public health services. The
few existing mental-health centres focus only
on children, but adults also need this kind ofcare, including those in the refugee population. The 2006 war highlighted this needamong Lebanese people, but the necessary
measures have been slow to be implemented.
On 18 December 2008 MSF opened its community mental-health centre on the south side ofBeirut. The centre saw around a dozen patientsin the last few days of the year, and a rapid
increase in patient numbers is expected in2009. The MSF team comprises internationaland Lebanese staff. They offer psychologicaland psychiatric assistance to all those whoneed it, regardless of age, gender, or national
origin. To establish the programme in the area
and to overcome the stigma associated withmental-health issues, MSF, with the help of
local NGOs, also organises psychosocial activities for the community. Promoting mental
health among the area’s residents should
facilitate the future handover of the project,and make it easier for people to participate inindividual, family, and group therapy sessions
at the community centre.
MSF has worked in Lebanon since 2008.

© Michael Goldfarb

Reason for Intervention • Armed conflictField Staff 352

Yemen is considered a haven for thousands of people fleeing from war andpoverty in the Horn of Africa, but is affected by its own internal tensions. Since
June 2004, a conflict in the governorate of Saada (northwest of Yemen, near theborder with Saudi Arabia) is believed to have killed more than 9,000 and injured
about 20,000 people. A local group called the Al Houthis, opposes government
troops. Five periods of high-intensity fighting have erupted since 2004. The ‘Fifth
War’ took place from May to July 2008. Meanwhile the number of refugees comingfrom Somalia and Ethiopia, risking their lives crossing the Gulf of Aden, continued
to increase in 2008.
Healthcare for those affected by the
conflict
MSF opened a project in Saada governorate inJuly 2007 to provide healthcare to people
affected by the conflict, develop a capacity totreat war-wounded, and respond to the needsof displaced people during periods of fighting.

When the Fifth War broke out in 2008, MSF
was running hospital and outreach activities
in Haydan and in Razeh; and in Al Tahl,
hospital and mobile primary health consultations for the nearby village of Dahyan.
Although the security conditions during the
war forced all expatriate teams to evacuate

Saada governorate, some activities were maintained thanks to the Yemeni staff.
International staff were able to return to
Saada governorate in September 2008. At theend of the year, MSF still supported Al Tahl
and Razeh hospitals as well as consultation
activities in Dahyan, and operated a referral
system to MSF secondary care facilities.
In 2008, around 3,000 consultations werecarried out in MSF’s hospitals or outreachprojects; about 15,000 patients were seen in
emergency rooms; more than 1,500 patientswere admitted to hospital; and 500 surgicaloperations were carried out. Around 1,000
children were admitted for severe malnutrition, nearly 3,000 antenatal consultations
were provided as well as 700 deliveries.

Assisting refugees from the Hornof Africa
In the south of the country, in the Abyan andShabwah governorates, MSF has been providing support to migrants coming from the Hornof Africa across the Gulf of Aden since
September 2007. In 2008, according to figuresfrom the United Nations High Commissioner
for Refugees, more than 50,000 people fleeing
from war, persecution and hunger in Somalia
and Ethiopia made the perilous journey insmugglers’ boats, hoping to reach Yemen.
Almost 950 died in the attempt.
MSF provides medical, psychosocial andhumanitarian assistance to the refugees when
they arrive. A mobile team attends to those inmost urgent need on the shore before they aretransferred with other new arrivals to a reception centre in the city of Ahwar. Refugees stayhere for a few days to be registered. MSF has
set up a health centre where medical assistance is available to everyone and vulnerable
groups (women and children) are especiallyencouraged to attend consultation andundergo screenings and vaccination. In 2008,
the MSF team in Ahwar helped almost 10,000
people.
MSF has worked in Yemen since 2007.

83

PALESTINIANTERRITORIES

Riyad, 19, was born in the City of Beit Lahia in the northern Gaza
strip, a zone especially affected by the ‘Hard Lead’ Israeli military
offensive. On January 5, he was seriously wounded by shellfire.
His left leg had to be amputated. He was given follow-up care in
the MSF clinic in Gaza City, where he received post-operative
treatment. ‘I was at home. It was a quiet day; we did not hear any
planes or tanks. I decided to go out to do some shopping. On myreturn, I don’t know what happened, but I found myself on the
ground. I think I must have been unconscious for a few minutes.
My father dragged us, my brother and me, inside the house. He
tried to call for help, but in vain.
‘I was unconscious most of the time, but I remember being hit
by the shell. I saw my leg half torn off. It was attached only by asmall piece of flesh. I lost a lot of blood. I was stretched out on
the ground and I was thinking “I’m going to die!” My father
brought me outside to get help. We waited almost an hour anda half in the street, but no car or ambulance passed. A neighbour
finally loaded seven people, including me and my father,on his tractor.

Médecins Sans Frontières Activity Report 2008

MSF PROJEC TS AROUND THE WOR LD | E u r op e a n d t h e Mi d d le East

82

© Frederic Sautereau / Oeil Public‘When I woke up at the hospital in Al Shifa, my leg had been
amputated. I screamed. Everything seemed so unreal. But after
all, it is not so serious. I am not sad. Naturally, when I see otherpeople with two legs, it’s difficult, but it could have been worse.
I am not going to stay at home. I intend to regain my independence and get a job.’© Bruno Stevens‘It is essential that civilians, the healthauthorities and the humanitarian workers be
respected by all parties to the conflict. That has
not been the case thus far. Humanitarian law
exists to be applied in all conflicts and to berespected by everyone, including governments.’
Dr Marie-Pierre Allié, president of the French section of MSF

Reason for Intervention • Armed conflictField Staff 127

In the Gaza strip, 2008 was marked by a dramatic deterioration of theeconomic, security and health situations. Israeli military incursions andoffensives continued, reaching a peak of violence at the end of the year.
The inter-Palestinian conflict left many wounded, and the strengtheningof the blockade aggravated the situation.
In the Gaza Strip
In three clinics MSF offers post-operative andphysiotherapy treatment. The many wounded
have no other access to this specialised care tohelp them regain their mobility and independence. In 2008, more than 480 patients were
followed up via this programme.
A paediatric programme began operating in
February 2008 in the northern Gaza Strip. This
was MSF’s response to the general lack of careand the overload on the only existing paediatric referral hospital. Outpatient consultations,medical care and follow-up are offered tochildren under 12 years of age. In 2008, MSF
teams treated more than 6,600 children. A
psychological-medical-social programme
enables people suffering from psychologicalproblems related to violence to continue tocope in this particularly difficult and stressful
situation.

Early in 2008, the strengthening of the Israeli
blockade drastically restricted supplies. MSF,
fearing that access to medication would be
restricted, hospital services would become
dysfunctional and access to care would be
limited, monitored the situation closely.
Between February and March, in response torocket attacks against Israel, the Israeli army
launched an offensive in the northern Gaza
Strip. MSF cared for the wounded in its GazaCity clinic, made donations of medical
supplies and medication and supported thehospitals, which were overwhelmed by the
influx of patients. This offensive resulted insome 120 deaths and 360 people being
wounded, including many women andchildren.
The shortage of fuel seriously hindered MSF’s
activities as well as those of the entire healthsystem. In addition, the contradictory policiesof the two Palestinian Ministries of Health, theinternationally recognised Palestinian authority in Ramallah, and that of the de facto Hamas
government in Gaza, led to the general strikeof health workers that started on August 30.
In this very fragile health situation, on
December 27, Israel launched the ‘Hard Lead’
offensive. MSF responded immediately bysupporting the hospitals overwhelmed by the
influx of wounded, and by making medical
donations. Throughout the war, because of theintensity of the bombardments and the lack of
security, MSF clinics could not open. Some of
the Palestinian staff had emergency medical
kits that enabled them to provide care to thoseliving near them. MSF’s dispensary in GazaCity remained open, but few patients could
reach the health facilities.

In the West Bank

building of the separation wall by the government of Israel, Jenin district has been characterised by a deteriorating economic situation,
serious socio-cultural problems and social
unrest.

June 2008, after months of negotiations, MSF
teams arrived to start a project to remedy this.
Unfortunately the lack of cooperation and thehostility in the camp forced the closure of the
project when it was still in its start-up phase.

The psychological services available to respondto the mental-health needs of the people livingin the camp were inadequate. In response, in

MSF has worked in the Palestinian Territories since
1988.

In 2008, at Nablus – which did not experience
the same degree of violence as Gaza – MSF’s
activities remained concentrated on mental
health and medical and social support.
Cooperation was established with the otherlocal mental-health care providers and continued with mutual referral of patients. In 2008,
more than 300 patients received care.
In Hebron, MSF aims to provide psychological,
medical and social assistance to people suffering from the violent consequences of theIsraeli-Palestinian conflict, especially those in
the Hebron governorate.
To alleviate the psychological suffering, MSF
also provided short-term psychotherapy topatients. Teams also refer patients to the MSF
doctor and social worker or to the appropriate
mental-health structure.
There are about 13,000 Palestinian refugees
living in Jenin camp. It is a violent place: there
are regular incursions by the Israeli defence
forces and frequent clashes between the different Palestinian armed factions. Since the© Bruno Stevens‘Each of us has been affected. Every
inhabitant of the Gaza Strip, without exception,
has suffered from the war.’ Abu Abed, MSF doctor

85

Other
information

MSF COUNTRY PROGRAMME CLOSURESCongo-Brazzaville
A peaceful period continued in CongoBrazzaville in 2008, completing a fifth year of
post-conflict stability. This peace, and theresumption of economic activities, hasenabled the country to take over healthcare
services in the Pool region where MSF had
been working for the last five years.
MSF’s hospital services included outpatient,maternity and emergency surgical care, treatment of infectious diseases such as tuberculosis and HIV/AIDS, and psychosocial
counselling. Teams also provided healthcare
through mobile clinics to communities near
the towns of Mindouli and Kindamba. MSF

Côte d’Ivoire
provided 12,825 consultations in 2008.
MSF handed over its programmes at Mindouli
and Kindamba hospitals in 2008. Those in
Kindamba were handed over to the Ministry of
Health and local partners, such as Psy Sans
Frontières and Global Outreach Mission.
Although those activities were closed in June,MSF returned to Congo for a three-month
period later in the year to provide treatment
for patients with human African trypanosomiasis (also known as sleeping sickness).

MSF worked in Congo-Brazzaville from1997 to 2008.

Médecins Sans Frontières Activity Report 2008

MSF PROJEC TS AROUND THE WOR LD | c ou n t ry p r ogramm e c los u res

84© Thierry Dricot

After 18 years, MSF ended all its programmesin Côte d’Ivoire in October 2008.
Following the peace agreement signed in 2007,
the dismantling of the Zone de Confiance andthe gradual return of staff to medical facilities
in the north and west, MSF carried out successive withdrawals from Bouaké, Guiglo, Man,
Danané and Bangolo, although teams responded to a short-term nutritional crisis in
Odienné, in the northwest of the country.
In March, teams handed over the mobile
clinics and the mobile nutrition programme
they had managed in the western region ofCôte d’Ivoire to the local authorities.
Handing over the Bangolo programme, where
400 hospital admissions, 8,000 consultations
and 130 deliveries had been provided eachmonth, MSF lobbied for the free healthcare tocontinue.

© Jiro Ose

MSF worked in Côte d’Ivoire from1990 to 2008.

The international financing institution The
Global Fund to fight AIDS, Tuberculosis andMalaria is now overseeing the funding of thecountry’s HIV/AIDS programmes.

MSF worked in Laos from 1989 to
2008.

Laos
Five years ago, MSF was one of the first organisations in Laos to treat HIV/AIDS patients with
antiretroviral therapy (ART). At the time, it wasnecessary to demonstrate that ART could be
used effectively in remote, impoverishedsettings. The strategy included lobbying at
national level for the adoption of ART, andthe aim from the beginning was to hand theprogrammes over to Laotian health officials.
MSF’s programmes were based at Savannakhet
provincial hospital and at Setthathirath
hospital in Vientiane.
In 2008, nearly 850 patients benefited from theART provided free of charge by MSF. During
the year the teams finalised the handover tolocal medical staff, who had been trained towork independently.

© Bruno Stevens© Renzo Fricke

87

Audited FACTS AND FIGURES
Médecins Sans Frontières (MSF) is an international, medical humanitarian organisation that is also private and not for profit. It comprises
19 national offices in: Australia, Austria, Belgium, Canada, Denmark,France, Germany, Greece, Holland, Hong Kong, Italy, Japan,
Luxembourg, Norway, Spain, Sweden, Switzerland, the UK and the US,
and has an international office in Geneva.
The search for efficiency has led MSF to create specialised organisations called satellites to take charge of specific activities such as
humanitarian relief supplies, epidemiological and medical researchstudies, and research on humanitarian and social action. They
include: MSF-Supply in Belgium; MSF-Logistique, Epicentre, Fondation
MSF, Etat d’Urgence Production, MSF Assistance, SCI MSF, SCI Sabin in
France; Artze Ohne Grenzem Foundation in Germany and MSF
Enterprises Limited in the UK. Because these organisations are controlled by MSF, they are included in the scope of the financial statements presented here.
The figures presented here describe MSF’s finances on a combinedinternational level. The 2008 combined international figures havebeen set up in accordance with MSF international accounting standards that comply with most of the International Financial ReportingStandards. The figures have been jointly audited by the accounting
firms KPMG and Ernst & Young in accordance with international
auditing standards. A copy of the full 2008 financial report may beobtained from the International Office upon request. In addition, each
MSF national office publishes annual audited financial statements
according to its national accounting policies, legislation and auditing
rules. Copies of these reports are available from the national offices.
The figures presented here are for the 2008 calendar year.
All amounts are in millions of Euros.

NB: Figures in these tables are rounded off and this may result inslight addition differences.

2008

Programme expenses by country/region
Countries/Regionsin Me

AfricaCountries/Regions

Asia/Middle East

Sudan
Democratic Republicof Congo
Somalia
Ethiopia
Niger
Chad
Kenya
Zimbabwe
Central African Republic
Nigeria
Malawi
UgandaMozambique
Liberia
Burkina Faso
South Africa
Sierra Leone
Cameroon
Côte d’Ivoire
Guinea-Conakry
Mali
BurundiZambiaSwaziland
Congo-Brazzaville
Other countries*

47.2

Total

301.0

43.8
22.7
22.1
21.1
20.4
17.1
14.4
12.8
9.7
8.8
8.7
8.6
7.6
6.0
5.1
4.3
3.9
3.2
3.2
2.5
1.9
1.5
1.4
1.0
2.0

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

Myanmar
Iraq
India
Pakistan
Cambodia
China
Thailand
Yemen
Palestinian Territories
Iran
Georgia
Uzbekistan
Sri Lanka
Nepal
Bangladesh
Armenia
Indonesia
Other countries*

17.6
12.2
6.2
5.2
4.4
4.4
4.0
3.8
3.5
3.0
2.9
2.0
1.8
1.8
1.5
1.4
1.4
4.1

Total

81.2

Americas
Haiti
Colombia
BrazilOther countries*

14.3
9.0
1.0
2.4

Total

26.7

EuropeChechnya / Ingushetia /Dagestan
Russia
Italy
Other countries*

6.1
2.0
1.5
2.5

Total

12.1

Where did the money go?
Programme expenses* by nature
National Staff | 28%
International Staff | 23%
Medical & nutrition | 22%
Transport, freight, storage | 14%
Logistics & sanitation | 7%
Operational running costs | 5%
Training & local support | 1%
Other expenses | 1%

in Me

Programme expenses* by continent
Africa | 70%
Asia | 19%
Americas | 6%
Europe | 3%
Non-allocated | 1%

As part of MSF’s effort to guarantee its independence
and strengthen the organisation’s link with society,
we strive to maintain a high level of private income.
In %In 2008, 89.9% of MSF’s income came from private
sources. More than 3.7 million individual donors and87.6%
private foundations worldwide made this possible.
9.1%		
Public institutional agencies providing funding to
3.3%
MSF include ECHO (the European Commission’s
Humanitarian Aid Office), the governments of
100.0%
Belgium, Denmark, Germany, Ireland, Luxembourg,
Spain, Sweden and the UK.

Income

In Me

In %

In Me

PrivatePublic institutional
Other

587.4
67.7
20.3

86.9%
10.0%
3.0%

518.7
54.2
19.8

Total income

675.4

100.0%

592.7

Operations*Témoignage
Other humanitarian activities
Total social mission
Fundraising
Management, general & administration

494.8
24.7
7.2
526.8
81.2
40.2

76.3%
3.8%
1.1%
81.2%
12.6%
6.2%

439.1
19.4
9.1
467.6
76.9
32.8

Expenditure
76.1%		Expenditures are allocated according to the main activi3.4%		
ties performed by MSF. ‘Operations’ includes pro1.6%
		gramme-related expenses as well as the headquarters’
81.0		
support costs devoted to operations. All expenditure
13.3%		categories include salaries, direct costs and allocated
5.7%		

Total expenditure
Net exchange gains & losses(realised and unrealised)Surplus/deficit

648.2

100.0%

577.4

100.0%		
Permanently restricted funds may be either

How was the money spent?

-4.7		
22.5		

overheads.

capital funds, where the assets are required by the-3.2			donors to be invested or retained for actual use
12.1			

rather than expended, or they may be the minimum
compulsory level of retained earnings to be
maintained by some of the sections.

* Programmes & HQ programme support costs

Unrestricted funds are unspent non-designatedBalance sheet 		In Me		In Me

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

37.0		
73.3		
375.6		

37.1				61.0				Other retained earnings represent foundations’350.2				Total assets		
Permanently restricted funds		
Unrestricted funds		
Other retained earnings		
Total retained earnings and equities		
Non-current liabilities		Current liabilities		
Unspent donor-restricted funds		

485.9		2.5		423.8		
-13.9		412.4		4.6		66.6		
2.3		

2.5					402.2				MSF’s retained earnings have been built up over the-14.6			years by surpluses of income over expenses. As of
390.1			the end of 2008, the available part (the unrestricted
3.5			
funds decreased by the conversion difference)
52.5			represented 7.6 months of activity. The purpose of
2.3		

Total liabilities and retained earnings		

485.9		

HR Statistics
International departures (full year):
Medical pool
Nurses & other paramedical pool
Non-medical pool

4,617
1,052
1,452
2,113

100%
23%
31%
46%

4,134
1,117
1,303
1,714

donor funds expendable at the discretion of MSF’s
trustees in furtherance of our social mission.

capital as well as technical accounts related to the
combination process, including the conversion
448.4				difference.

maintaining retained earnings is to meet thefollowing needs: future large-scale emergencies for
448.4
which sufficient funding cannot be obtained, and/or
a sudden drop of private and/or public institutional
funding, sustaining long-term programmes (such as
antiretroviral therapy), and pre-financing operations
100%		
to be funded by forthcoming public funding
27%		
campaigns and/or by public institutional funding.

32%		
41%		
Unspent temporarily restricted funds

are unspent donor-designated funds that will beFirst time departures (full year):
1,142 * 25%
1,152* 28%		spent by MSF strictly in accordance with the donor’s* in % of total international departures								Field positions:International staff
National staff*project and coordination team expenses in the countries

2007

Sources of Income

Medecins Sans Frontieres Activity Report 06|07

Au d i t ed fac ts a n d f i g u res

86

25,973
2,029
23,944

100%
8%
92%

24,3481,994
22,354wishes (for example specific countries or types ofinterventions).

100%		
8%		The complete Financial Report is available on www.msf.org
92%

88

CONTACT MSF

Switzerland Médecins Sans Frontières/Australia Médecins Sans Frontières/Holland Médecins Sans Frontières/Ärzte Ohne Grenzen

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Other Offices

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T 41 22 849 8405 | F 41 22 849 8404

T 45 39 77 56 00 | F 45 39 77 56 01

Pr André di Prospero (interim)

www.accessmed-msf.org

info@msf.dk | www.msf.dk

GD Karine Van Houte (interim)

GD Dr Tido von Schoen-Angerer

Norway Médecins Sans Frontières/UN Liaison Office – New York

Leger Uten Grenser

333 7th Avenue | 2nd Floor | New York, NY

France Médecins Sans Frontières

Postboks 8813 Youngstorget | 0028 Oslo

10001-5004 | USA

8 rue Saint Sabin | 75011 Paris | France

Norway | Youngstorget 1 | 0181 Oslo | Norway

T 1 212 655 3777 | F 1 212 679 7016 | MSF UN

T 33 1 40 21 29 29 | F 33 1 48 06 68 68

T 47 23 31 66 00 | F 47 23 31 66 01

Liaison officer: Fabien Dubuet

office-par@paris.msf.org | www.msf.fr

epost@legerutengrenser.nofabien.dubuet@newyork.msf.org

Pr Dr Marie-Pierre Allié | GD Dr Filipe Ribierowww.legerutengrenser.nomsfcan@msf.ca | www.msf.ca
Pr Dr Joni Guptill | GD Marilyn McHarg

Pr Dr Søren Brix Christensen
GD Michael G Nielsen

Germany Médecins Sans Frontières/Pr Dr Håkon Bolkan | GD Patrice Vastel

MSF Office in Brazil
Rua Santa Luzia, 651/11° andar | Centro - Rio deÄrzte Ohne Grenzen

Spain Médicos Sin Fronteras

Janeiro | CEP 20030-041 | Rio de Janeiro | Brazil

Am Köllnischen Park 1 | 10179 Berlin | Germany

Nou de la Rambla 26 | 08001 Barcelona | Spain

T 55 21 3527-3636 | www.msf.org.br

T 49 (30) 22 33 77 00 | F 49 (30) 22 33 77 88

T 34 93 304 6100 | F 34 93 304 6102

GD Simone Rocha

office@berlin.msf.org

office-bcn@barcelona.msf.org | www.msf.es

www.aerzte-ohne-grenzen.de

Pr Dr Paula Farias | GD Aitor Zabalgogeazkoa

Pr Dr Tankred Stoebe | GD Dr Frank DoernerGreece Médecins Sans Frontières/MSF Office in South Africa
Orion Building | 3rd floor | 49 Jorissen Street,

Sweden Médecins Sans Frontières/Braamfontein 2017 | Johannesburg

Läkare Utan Gränser

T 27 11 403 44 40/41 | www.msf.org.za

Gjörwellsgatan 28, 4 trappor | Box 34048

GD Sharon Ekambaram

15 Xenias St | 115 27 Athens | Greece

100 26 Stockholm | Sweden

T 30 210 5 200 500 | F 30 210 5 200 503

T 46 8 55 60 98 00 | F 46 8 55 60 98 01

info@msf.gr | www.msf.gr

office-sto@msf.org | www.lakareutangranser.se

Pr Ioanna Papaki | GD Reveka Papadopoulou

Pr Kristina Bolme Kuhn | GD Dan Sermand

Pr President | GD General Director | SG Secretary General

MSF Office in United Arab Emirates/
PO Box 47226 | Abu Dhabi | UAE
T 971 2 6317 645 | www.msfuae.ae
GD Marc Sauvagnac