MSF Activity
Report 2010

The MÉdecins Sans
Frontières Charter
Médecins Sans Frontières is a private international association. The association is made up
mainly of doctors and health sector workers and is also open to all other professions whichmight help in achieving its aims. All of its members agree to honour the following principles:Médecins Sans Frontières provides assistance to populations in distress, to victims of natural or
man-made disasters and to victims of armed conflict. They do so irrespective of race, religion,
creed or political convictions.
Médecins Sans Frontières observes neutrality and impartiality in the name of universal medical
ethics and the right to humanitarian assistance and claims full and unhindered freedom in theexercise of its functions.
Members undertake to respect their professional code of ethics and to maintain complete
independence from all political, economic or religious powers.
As volunteers, members understand the risks and dangers of the missions they carry out and makeno claim for themselves or their assigns for any form of compensation other than that which theassociation might be able to afford them.

The country texts in this report provide descriptive overviews of MSF’s operational activities throughout the world between
January and December 2010. Staffing figures represent the total full-time equivalent positions per country in 2010.
Country summaries are representational and, owing to space considerations, may not be comprehensive. Some patients’names have been changed for reasons of confidentiality.

Contents
2
4

MSF Missions Around The WorldThe Year in Review
Dr Unni Karunakara, International President
Kris Torgeson, Secretary General

8

2

MSF Missions around the World

21

Africa59

Asia and the Caucasus

77

The Americas

87

Europe and the Middle East

Overview Of MSF Operations

10 Glossary of Diseases and MSF ACTIVITIES
14 Medical and psychological care in detention
16 FORTY YEARS OF medical innovation
18 Innovation in action: a tale of two vaccines

MSF Projects Around the world
21
59
77
87

AfricaAsia and the Caucasus
The Americas
Europe and the Middle East

99 MSF special reports 2010
100 Haiti: a year of crisis
104 Facts and figures
108 Contact MSF

Contents

1

MSF Missions
around theworld
FranceGeorgia
Armenia
GreeceMalta

Lebanon Syria
Occupied
Palestinian
Territory

Morocco

Iraq

EGYPT

Mali

Haiti
GuatemalaHonduras
GuineaNiger

Colombia

Yemen

Sudan

Burkinafaso

Djibouti
Nigeria

Sierra Leone
Liberia

Chad

Cameroon

CentralAfricanRepublic

Ethiopia

Democratic
Republic ofRep. Congo THE Congo

Somalia

UgandaKenya
BurundiBrazilMalawi
ZambiaBolivia
Zimbabwe
Mozambique

PARAGUAY

SwazilandSouth
Africa2

MSF Missions around the world

LesothoRussian
Federation

Uzbekistan

60 Afghanistan

95 Lebanon

61 ARMENIA

38 Lesotho

62 BANGLADESH

39 Liberia

78 Bolivia

40 Malawi

79 Brazil

41 Mali

22 Burkina Faso

90 Malta

23 Burundi

42 Morocco

63 CAMBODIA

43 Mozambique

28 Cameroon

69 MYANMAR

24  Central African
Republic

44 Niger

26 ChadKyrgyzstan

64 CHINA
China

80 Colombia

Afghanistan
Iran

29  Congo, Republicof thePakistan

BangladeshIndia

30  Democratic
Republicof THE Congo

MyanmarThailand32 DJIBOUTI

CambodiaPapua
New Guinea

96  Occupied
Palestinian
Territory
70 PAKISTAN
72 Papua
New Guinea
86 PARAGUAY
73 Philippines

33 Egypt

91 RussianFederation

34 Ethiopia

50 Sierra Leone

88 France

48 Somalia

65 Georgia

51 South Africa

89 Greece

74 SRI LANKA

82 Guatemala

52 Sudan

36 Guinea

54 Swaziland

84 Haiti

97 Syria

83 Honduras

75 THAILAND

66 INDIA

55 Uganda

94 Iran

76 UZBEKISTAN

92 Iraq

98 Yemen

37 Kenya

58 Zambia

68 KYRGYZSTAN

56 Zimbabwe

Philippines
Sri Lanka

46 Nigeria

MSF Missions around the world3The Yearin Review
Dr Unni Karunakara, International President,
Kris Torgeson, Secretary General© Ron Haviv / VII

The earthquake that hit Haiti on 12 January killed an estimated222,000 people, injured more than 300,000, and left 1.5 million
people homeless. Efforts to support the survival and recoveryof the Haitian people following this disaster tested Médecins
Sans Frontières (MSF) and the aid system as a whole to theirlimits. More than 8,000 MSF staff were mobilised to treat morethan 358,000 patients.

A patient is treated for cholera at MSF’s clinic in Sarthe, Port-au-Prince, Haiti.
4

The Year in Review

© Seb Geo

A doctor and interpreter speak with a malaria patient at MSF’s clinic in Dera Murad Jamali, Balochistan province, Pakistan.

In October, a cholera epidemic took on
overwhelming proportions. In less than threemonths, MSF treated more than 91,000
patients for the disease, around 60 per centof all registered cases (see pages 84 – 85).
The operating budget for MSF in Haiti in2010 came to almost 106.1 million euros.
One year after the earthquake, however,significant needs were still not being met.
As Stefano Zannini, Head of Mission for MSF
in Haiti, said: “Our staff worked tirelessly
over this last year, and in spite of that I feel
uneasy and sort of uncomfortable about
what is still a disaster situation for mostof the population”. The aftermath of theearthquake in Haiti has exposed serious
deficiencies in the wider aid system,
deficiencies that have also been revealedin Afghanistan and Pakistan, raising thequestion of whether the international aid
system in its current set-up is really meetingthe needs of the people it claims to help.
A year of natural disasters
The Haitian earthquake was not the only
major natural disaster MSF responded toin 2010. In Pakistan, MSF staff carried out
more than 80,000 medical consultations,
treated more than 4,500 children formalnutrition and distributed 1.8 million litresof clean water every day to people affectedby flooding in the provinces of Khyber

Pakhtunkhwa, Balochistan, Punjab andSindh. Parts of Chad, Nigeria and Somalia
also experienced the worst flooding in morethan a decade. MSF distributed blankets,
tarpaulins, plastic sheeting and mosquito
nets, and set up clean water supplies to help
the hundreds of thousands of displaced
people. In central Chile, a powerful earthquake
killed several hundred people and displaced
more than a million others. Nearly every
region of Guatemala was affected when aviolent tropical storm hit just hours after a
volcanic eruption. MSF assisted victims ofboth of these emergencies from projectbases in Central and South America.
Securing care during conflict
Elsewhere, millions of civilians living inconflict zones continued to suffer the effects
of armed violence. In 2009, MSF returned
to Afghanistan to respond to mounting
humanitarian needs as conflict spread toalmost every region of the country. MSF has
worked hard to find the space to provide
independent and impartial assistance in anenvironment where, as MSF’s Afghanistancountry representative Michiel Hofman
said, “seeking help amounts to choosing
sides in the war”. In 2010, MSF staff worked
in hospitals in the Afghan cities of Kabul
and Lashkargah, and we are continuing
negotiations with all warring parties in order
to extend our operations further.

In Pakistan, teams have been helping to
improve the emergency response capacityof hospitals in conflict zones. On several
occasions during the year, violent incidents
resulted in massive numbers of casualties
arriving at the District Headquarters
hospital in Timurgara, near the borderwith Afghanistan.
Its independence, impartiality and needsbased approach have enabled MSF to reachand assist people living in conflict areas in
Afghanistan, the Central African Republic,
Kyrgyzstan, Pakistan and Somalia in 2010.
Despite insecurity, MSF is generally able
to assure the continuity of medical care.
But incidents in parts of Sudan and the
Democratic Republic of the Congo (DRC)
have put MSF staff at unacceptable risk andrestricted our ability to provide healthcare.
Activities in Gumuruk in south Sudan had
to be suspended after therapeutic foodwas stolen from the clinic and MSF staff
were violently robbed while travelling toanother health centre. In DRC, soldiers fromthe Congolese army entered a hospital in
the South Kivu region and abducted four
patients. The complete absence of respectfor medical structures and access to medicalcare forced MSF to evacuate its surgicalteam from the hospital.
continued overleaf

The Year in Review

5continued The Year in Review

Medical staff at the operating theatre of Hangu hospital, Pakistan.

supporting the immunisation of more than
500,000 children and treating thousandsof patients.
Measles is not the only disease recurring.
Faced with a “new” disease, people may beafraid or unaware of how to respond, andlocal medical staff may lack experience intreatment. Cholera had not been seen in
Haiti for more than a century before theepidemic in 2010. Papua New Guinea also
experienced its first cholera outbreak in
50 years; MSF treated thousands of patientsand trained more than 1,000 health workers
and volunteers in clinical management andinfection control.

© Ton Koene

Outbreaks new and old
Other countries where MSF works simply
do not have the resources to provide
adequate care. Measles is endemic in many
developing countries, but in 2010 a numberof countries that had seen a decline incases were subjected to serious outbreaksof the disease: Malawi suffered its biggest
epidemic in 13 years. MSF led a campaignthat vaccinated 3.3 million children,and our staff provided care for 23,000
patients. Teams also provided assistancein responding to massive outbreaks ofmeasles in Chad, DRC, Nigeria, South
Africa, Swaziland, Yemen and Zimbabwe,© Vali

Mismanaged healthcare system
MSF was obliged to suspend activities in
Turkmenistan in 2010 for very different
reasons. Having worked in the country
since 1999, MSF decided it could no longer
provide effective assistance in a country
where national health authorities hide thetrue state of public health and disseminate
misinformation, and where the systemprevents health workers from providing
adequate care. MSF drew attention to
the problems facing people in need of
medical care in Turkmenistan in the report
Turkmenistan’s Opaque Health System.

Devastation caused by the floods in Gulabad, Pakistan.

6

The Year in Review

© Kate Holt

A patient with shrapnel wounds is transferred for post-operative care to Boost hospital, Lashkargah, Helmand, Afghanistan.

A global polio eradication campaign, begun
in 1988, had met with significant success,and the disease remained endemic in only
Afghanistan, India, Nigeria and Pakistan.
However, in 2010 serious outbreaks haveoccurred in DRC, the Republic of the Congoand Tajikistan. MSF teams assisted withtreatment and vaccination campaigns in
DRC and the Republic of the Congo.
We faced new emergencies too. MSF treatedalmost 400 children for lead poisoning, after
seven villages in northwestern Nigeria were
found to be contaminated with lead fromsmall-scale gold mining activities.
Access to new vaccines, affordable
medicines and adequate nutrition
2010 saw the roll-out of a new vaccinethat could prevent the worst meningitis
epidemics in Africa. MSF took part invaccination campaigns in Niger and Mali
and is actively advocating for widespreaduse of the vaccine (see pages 18 – 20).
And after campaigning for improved foodaid for several years, we are at last seeinginternational donors start to review andadjust their food aid policies. (To see theeffect of the improved policies, see thereport on Niger, pages 44 – 45.) 2010 also
saw the establishment of the Medicines
Patent Pool, which will allow genericmanufacturers to produce patented
medicines in exchange for royalty payments.
For the mechanism to work, however, weneed drug companies to step up and maketheir patents available.
Unfortunately, efforts to improve access to
HIV/AIDS treatment are facing a setback.
International donors are shifting theirfocus away from HIV/AIDS and funding isstagnating, while new evidence demonstrates
that providing better treatment earlier
prevents severe illness and helps reducetransmission. MSF is urging governments tocreate reliable funding mechanisms to ensurethat the progress made over the last decade
is not put at risk, and that more patients canbe treated more effectively.

Appalling living conditions, police harassment,
threats of xenophobic attacks and a lack ofaccess to essential healthcare still define thedesperate lives of thousands of these vulnerable
people. In just two months, MSF staff in South
Africa treated 71 Zimbabwean migrants who
had been victims of sexual violence.
As 2010 comes to an end and MSF
approaches its 40th year, it is clear thatchanging environments demand constantinnovation, so that MSF can respond tothe health needs of more people, more
effectively. Thanks to our supporters andour dedicated staff, we are able to remaincommitted to assisting people in need ofemergency humanitarian medical care.
Thank you.

Reaching “invisible” populations
In recent years, more and more migrants
have embarked on a long journey to escapeviolence, persecution or poverty, in searchof a more secure life, only to find themselvesin a prison cell. In 2010, the conditions in
detention centres in Greece reached criticallevels: undocumented migrants were being
forced to live in converted warehouses orpolice cells crowded to three or four times
their capacity. “No human being should be
subjected to such treatment”, said Ioanna
Pertsinidou, MSF’s emergency coordinator.

The Year in Review

7Overview of
MSF Operations
Project locations

Largest interventions basedon project expenditure
1. Haiti

6. Somalia

2. D emocratic Republicof the Congo

7. Chad

3. Sudan

9. Nigeria

4. Niger

10. Central African
Republic

5. Pakistan

14 %Number of projects

8. Zimbabwe

Africa260

Europe

6

Asia

102

Americas59

24 %These 10 countries total a budget of 334 million euros,
or 60 per cent of MSF’s operational budget.

Asia includes the Middle Eastand the Caucasus

Staff numbers

Context of interventions

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

Number of projects

1. Haiti

2,918

2. D emocratic Republic of the Congo

2,766

3. Sudan

2,226

4. Niger

1,599

61 %

1%

Armed conflict87

Post-conflict

16

20 %

Internal instability 125
StablePercentage ofprogramme
portfolio

199

47 %

4%

Percentage ofprogramme
portfolio

5. Somalia	 1,461
29 %Patients treated
Largest country programmes according to the number of
outpatient consultations held.

Event triggeringintervention

8%

Number of projects
1. D emocratic Republic of the Congo

1,225,175

2. Central African Republic	     564,457
3. Somalia	     460,347
4. Niger	     468,477
5. Haiti   4 68,156

Armed conflict

134

Epidemic

180

Health exclusion

78

Natural disaster

35

18 %

31 %
Percentage ofprogramme
portfolio

42 %8Overview of MSF Operations

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

Activity

Definition

Total

Outpatient

Total number of outpatient consultations

Inpatient

Total number of admitted patients

362,266

Malaria

Total number of confirmed cases treated983,425

Therapeutic
feeding centres

Number of severely malnourished children admitted to inpatient or
outpatient feeding programmes

301,297

Supplementary
feeding centres

Number of moderately malnourished children admitted to supplementary
feeding centres

69,258

HIV

Total number of HIV patients registered under care at end 2010

210,450

Antriretroviral treatment(first-line)

Total number of patients on first-line antiretroviral treatment at end 2010

180,868

Antiretroviral treatment(second-line)

Total number of patients on second-line antiretroviral treatment at end 2010
(first-line treatment failure)

2,936

PMTCT – mother

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

10,854PMTCT – baby

Number of eligible babies born in 2010 who received post-exposure treatment

9,745

Deliveries

Total number of women who delivered babies, including caesarean sections

151,197

Surgical interventions

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

58,326Violent trauma

Total number of medical and surgical interventions in response to direct violence

39,993Sexual violence

Total number of cases of sexual violence medically treated

10,430Tuberculosis (first-line)

Total number of new admissions to tuberculosis first-line treatment in 2010

30,090Tuberculosis (second-line)

Total number of new admissions to tuberculosis treatment in 2010,second-line drugs

Mental health (individual)

Total number of individual mental health consultations

163,799

Mental health (group)

Total number of counselling or group support mental health sessions

24,794CholeraTotal number of people admitted to cholera treatment centres ortreated with oral rehydration solution

174,220

Measles vaccinations

Total number of people vaccinated for measles in reponse to an outbreakMeaslestreatment

Total number of people treated for measles

Meningitis vaccinations

Total number of people vaccinated for meningitis in response to an outbreak

Meningitis treatment

Total number of people treated for meningitis

7,334,066

1,159

4,542,353
188,704
1,339,873
5,911

Overview of MSF Operations

9

Glossary of
diseases and
MSF activities
Chagas disease
Chagas disease is found almost exclusivelyin Latin America, although increased global
travel and migration have led to more cases
being reported in North America, Europe,
Australia and Japan. Chagas is a parasitic
disease transmitted by vinchuca beetles,
which live in cracks in the walls and roofs
of mud and straw housing. It can also betransmitted through blood transfusions,to the foetus during pregnancy and, lessfrequently, through organ transplants. Somepeople can have the disease but show nosign of it for years. Ultimately, debilitating
chronic symptoms develop in approximately
30 per cent of people infected, shortening
life expectancy by an average of ten years,
with heart failure being the most common
cause of death for adults.
Diagnosis is complicated, as doctors need toperform two or three blood tests. There are
currently only two medicines to combat thedisease: benznidazole and nifurtimox, bothdeveloped over 35 years ago. The cure rate isalmost 100 per cent in newborns and infants,
but in older children, adolescents and adults,
treatment is only around 60 or 70 per centeffective. The treatment currently used canbe toxic and can take one to two months tocomplete. Despite the clear need for more
efficient and safer medication, there are few
new drugs in development.
MSF admitted 1,254 new patients to Chagas
treatment programmes in 2010.

can lead to severe dehydration and death.
Treatment consists of a rehydration solution– administered orally or intravenously – which
replaces fluids and salts.

infections are able to develop as the immune
system weakens. Tuberculosis is the mostcommon opportunistic infection that leads
to death.

As soon as an outbreak is suspected, patientsare isolated in specialised treatment centres
to prevent the spread of the disease. Outside
the centres, strict hygiene practices must be
implemented and a safe water supply must
be assured. Cholera is most common indensely populated settings where sanitationis poor and water supplies are not safe.

A simple blood test can confirm HIV status,
but many people live for years without
symptoms and may not know they havebeen infected with HIV. Combinations ofdrugs known as antiretrovirals (ARVs) help
combat the virus, reduce the spead of theinfection, and enable people to live longer,
healthier lives without their immune systems
deteriorating rapidly. As well as treatment,
MSF’s comprehensive HIV/AIDS programmes
generally include education and awarenessactivities, condom distribution, HIV testing,counselling and prevention of mother-tochild transmission (PMTCT) of the virus.
PMTCT services involve the administrationof ARV treatment during pregnancy andlabour, and to the infant just after birth.

MSF treated 174,220 people for cholera
in 2010.

Health promotion
When MSF opens a project, the local
community needs to know what services
are available and how these services canimprove their health. Informing people andcommunicating about when and where staff
will be available and what they can do is oneof the first tasks for a team setting up a newclinic or programme.
During serious outbreaks of disease or
epidemics, MSF provides communities
with information on how the disease istransmitted and how to prevent it, whatsigns to look for in case someone becomes
ill, and what to do. If MSF is responding
to an outbreak of cholera, for example,
teams work to explain the importance ofgood hygiene practices as the disease istransmitted through contaminated water.

CholeraCholera is a water-borne, acute gastrointestinal
infection caused by the Vibrio cholerae
bacterium and spread by contaminated wateror food. The infection can spread rapidly
and large outbreaks can occur suddenly.
Most people will suffer only a mild infection,
but the illness can be very severe, causing
profuse watery diarrhoea and vomiting that

10

Glossary of diseases and MSF activities

HIV/AIDS
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

MSF provided care for over 210,000 people
living with HIV/AIDS, and antiretroviraltreatment for more than 183,000 people
in 2010.

Human African
trypanosomiasis(sleeping sickness)
Generally known as sleeping sickness,
human African trypanosomiasis is a parasitic
infection that occurs in sub-Saharan Africa
and is transmitted by tsetse flies. More than90 per cent of reported cases are caused by
the parasite Trypanosoma brucei gambiense,
which is found in west and central Africa. It
attacks the central nervous system, causing
severe neurological disorders or even death.
The other ten per cent of cases are causedby Trypanosoma brucei rhodesiense, which isfound in eastern and southern Africa.
During the first stage, the disease is relatively
easy to treat but difficult to diagnose, as
symptoms such as fever and weakness arenon-specific. The second stage begins when theparasite invades the central nervous system andthe infected person begins to show neurologicalor psychiatric symptoms, such as poor
coordination, confusion, convulsions and sleep
disturbance. At this stage, accurate diagnosis of
the illness requires a sample of spinal fluid.
Nifurtimox-eflornithine combination therapy, or
NECT, is now the internationally recommended
treatment. NECT is safer than melarsoprol, thedrug that was used to treat the disease before,
which is a derivative of arsenic, causes many side
effects and can even kill the patient.
MSF admitted 1,293 new patients for treatment
for human African trypanosomiasis in 2010.

MSF uses ready-to-use food (RUF) to treat
malnutrition. RUF contains fortified milk
powder and delivers all the nutrients thata malnourished child needs to reverse
deficiencies and gain weight. With a longshelf-life and requiring no preparation, RUF
can be used in all kinds of settings and allows
patients to be treated at home, unless they
are suffering severe complications. Wheremalnutrition is likely to become severe, MSF
takes a preventive approach, distributing
supplementary RUF to at-risk children.

Measles
Measles is a highly contagious viral disease,and one of the leading causes of deathamong young children. Symptoms appear
between 10 and 14 days after exposure to
the virus and include a runny nose, cough,eye infection, rash and high fever. There is no
specific treatment for measles – patients are
isolated and treated for a lack of vitamin A,
eye-related complications, stomatitis(a viral mouth infection), dehydration, protein
deficiencies and respiratory tract infections.

MSF admitted more than 300,000 malnourishedpatients to feeding centres in 2010.
continued overleaf

Malaria
Malaria is transmitted by infected mosquitoes.
Symptoms include fever, pain in the joints,
headaches, repeated vomiting, convulsions
and coma. Severe malaria, most often causedby the Plasmodium falciparum parasite,causes organ damage and leads to death if
left untreated. MSF field research has helped
prove that artemisinin-based combination
therapy (ACT) is currently the most effective
treatment for malaria caused by Plasmodium
falciparum. In 2010 World Health Organization
guidelines were altered to recommend theuse of artesunate, a derivative of artemisinin,
for the treatment of severe malaria in children.
Longlasting insecticide-treated bed nets are
one important means of controlling malaria.
In endemic areas, MSF systematically
distributes nets to pregnant women andchildren under the age of five, who are mostvulnerable to severe malaria, and staff advise
people on how to use the nets.
MSF treated 1,622,721 people for malaria
in 2010.

Malnutrition“Wasting”, when a malnourished person
begins to consume his or her own tissues toobtain needed nutrients, is a sign of acutemalnutrition. Severe acute malnutrition isdefined by very low weight for a person’sheight or visible severe wasting. Over a quarterof children suffering from severe malnutrition
will die if they do not receive treatment.

© Bruno De CockA lack of esssential nutrients causes
malnutrition: growth will falter and a child’s
susceptibility to common diseases increases.
The critical age for malnutrition is from six
months – when mothers generally start
supplementing breast milk – to 24 months.
However children under five, adolescents,
pregnant or breastfeeding women, the elderly
and the chronically ill are also vulnerable.

Medical equipment at the MDR-TB section of Blue House Clinic, Mathare, Nairobi, Kenya.

Glossary of diseases and MSF activities

11continued Measles
Most people recover within two to three
weeks, but between 5 and 20 per cent ofpeople infected with measles die, usually
because of complications such as diarrhoea,
dehydration, encephalitis (inflammation of
the brain) or respiratory infections.
A safe and cost-effective vaccine against
measles exists, and large-scale vaccination
campaigns have drastically decreased thenumber of cases and deaths from measles.
However, coverage remains low in countries
with weak health structures, or amongpeople with limited access to health services,and large outbreaks still occur.
In 2010 MSF treated 188,704 people
for measles and vaccinated more than
4,500,000 people.

Meningococcal meningitis
Meningococcal meningitis is an infectionof the thin membranes surrounding thebrain and spinal cord. Meningitis can cause
sudden and intense headaches, fever,nausea, vomiting, sensitivity to light andstiffness of the neck. Death can follow
within hours of the onset of symptoms.
Five strains of the bacteria Neisseria
meningitidis (A, B, C, W135, and X) cancause epidemics. People can be infectedwithout showing symptoms and spreadthe bacteria when they cough or sneeze.
Suspected cases are properly diagnosed
through the examination of a sample ofspinal fluid and are treated with specificantibiotics. However, even with treatment,
five to ten per cent of patients will die andas many as one in five survivors may sufferfrom after effects that can include hearing
loss and learning disabilities.
Meningitis occurs throughout the world, but
the majority of infections and deaths are in
Africa, particularly across the “meningitis
belt”, an east–west geographical strip from
Ethiopia to Senegal, where epidemics aremost likely to be caused by meningitis A. A
new vaccination against this strain provides
protection for 10 years and even prevents
healthy carriers from transmitting theinfection. Such long-term protection meansthat preventive vaccination campaigns are
now a possibility, potentially changing
the lives of millions of people living in themeningitis belt.
MSF treated 5,911 cases and vaccinated morethan 1,330,000 people against meningitis
in 2010, participating in the campaign
introducing the new vaccine in Mali and Niger.

12

Glossary of diseases and MSF activities

Mental healthcare
Traumatising events – suffering or witnessing
violence, the death of loved ones, thedestruction of livelihoods – can generateintense fear and horror, and are likely to affecta person’s mental wellbeing. MSF provides
early psychosocial support to victims of
trauma in an effort to reduce the possibility oflong-term psychological problems developing.
Psychosocial care focuses on supporting acommunity to build its own coping strategies
after trauma. Counsellors help groups totalk about their experiences and process
their feelings so that general stress levels are
reduced. This approach fosters mutual supportand enables a community to rebuild itself
according to its own cultural beliefs, taking backcontrol of the situation as soon as it is able. It iscomplemented with individual counselling andpsychiatric care for those who need it.
MSF staff held more than 188,000 individualand group counselling sessions in 2010.

Relief items distribution
MSF’s primary focus is on providing medicalcare, but in an emergency teams often
distribute relief items that contribute to
psychological and physical survival. Suchitems include clothing, blankets, bedding,shelter, cleaning and hygiene materials,
cooking utensils, and fuel. In many
emergencies, relief items are distributed as
kits – cooking kits containing a stove, pots,
plates, cups, cutlery and a jerrycan so that afamily can prepare meals, or a hygiene kit withsoap, shampoo, toothbrushes, toothpaste, andlaundry soap for a family to be able to washthemselves and clean their clothes.
A shelter provides both protection from theelements and a measure of security. Where
materials are not locally available, MSF
distributes emergency supplies – rope andplastic sheeting or tents – with the aim of
ensuring a roof for each family. A minimum
standard of 3.5m2 is allocated per person,with 2 metres between shelters to help
prevent fires. In cold climates more substantial
tents are provided or teams try to find morepermanent structures.
MSF distributed 341,507 relief kits in 2010.

Reproductive healthcare
Comprehensive emergency and neonatal
obstetric care is part of MSF’s emergency
response, and many of MSF’s longer-term
programmes offer more extensive maternal
healthcare. Medical staff assist births and perform
caesarean sections where necessary, perinatal
care is provided and sick newborns and babies
with a low birth weight receive medical care.

Several antenatal visits are recommended tomeet medical needs during the pregnancy andto identify potentially complicated deliveries.
Family planning counselling is provided as part ofpostnatal care, as is information and education on
sexually transmitted infections (STIs).
Around two million women are estimated tohave fistulas, which are injuries to the birthcanal. Fistulas cause incontinence, which
can lead to social stigma. They are often
the result of a long, obstructed labour, andcan be prevented by good antenatal andobstetric care. Fistulas can also be repaired.
In 2010 specialist MSF teams operated on
about 1,000 women with obstetric fistulas.
MSF held more than 700,000 antenatal
consultations in 2010.

Sexual violence
MSF offers medical care, treatment to prevent thedevelopment of sexually transmitted infections,and psychological, social and legal support topatients who have suffered sexual violence. In
settings where the incidence of sexual violence
is higher, such as conflict zones or refugee ordisplaced persons camps, dedicated teams carefor people who have experienced sexual violence.
Staff work with the community to raise awarenessof the problem of sexual violence, to inform themof the care that MSF provides, and to promotesocial and legal support.
MSF treated more than 10,000 patients forsexual violence-related injuries in 2010.

Tuberculosis
One-third of the world’s population is currently
infected with the tuberculosis (TB) bacillus. Every
year, nine million people develop active TB andclose to two million die from it. Ninety-five percent of these people live in low-income countries.
TB mainly affects the lungs and is spreadthrough the air when infected people cough orsneeze. Symptoms include a persistent cough,fever, weight loss, chest pain and breathlessness
in the lead-up to death. Not everyone becomes
ill, but 10 per cent of people will develop active
TB at some point in their lives. The incidence ismuch higher among people with HIV, for whom
TB is a leading cause of death.
The drugs used to treat TB were developedin the 1950s, and a course for uncomplicated
TB takes six months. Multidrug-resistant TB(MDR-TB) is 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 side
effects and takes up to two years. A newer
strain, extensively drug-resistant tuberculosis(XDR-TB), is identified when resistance tosecond-line drugs develops on top of MDR-TB.
The treatment options for XDR-TB are limited.
MSF treated over 30,090 people for tuberculosis,
and 1,159 for MDR-TB, in 2010.

Vaccinations
The use of immunisation to prevent infectious
diseases is one of the most cost-effective
medical interventions in public health.
However, it is estimated that approximately
two million people die every year from
diseases that are preventable by a series ofvaccines recommended for all children by
the World Health Organization. Currently,
these are DTP (diphtheria, tetanus, pertussis),hepatitis B, Haemophilius influenzae typeb (Hib), BCG (against tuberculosis), humanpapillomavirus, measles, polio and rotavirus.

Largely unknown in the developed world,kala azar – Hindi for “black fever” – is atropical, parasitic disease that is transmitted
through bites from certain types of sandfly. It is endemic in 62 countries, and of
the estimated 500,000 annual cases, 90
per cent occur in Bangladesh, India, Nepal,
Sudan and Brazil. It is characterised byfever, weight loss, enlargement of the liverand spleen, anaemia and immune-system
deficiencies. Without treatment, nearly all
patients will die.
Very suitable rapid diagnostic field tests areavailable, although backup confirmation
testing – involving microscopic examination ofsamples taken from the spleen, bone marrowor lymph nodes ­­– is invasive and requires
resources not readily available in developing
countries. Current treatment options include
pentavalent antimonials. Although expensive,and evolving to become more simplified –studies showing the efficacy and safety ofliposomal amphotericin B in the Indian
subcontinent are promising – treatment
options have significant limitations. The
anticipated combination therapies intend
to reduce the risk of the parasite developing
resistance to the drugs, optimise the efficacy
and safety of treatment, and reduce costs andhospitalisation time.

Co-infection of kala azar and HIV is a major
challenge. Both diseases influence eachother in a vicious spiral as they attack andweaken the immune system, making theperson less resistant to the other disease
and the treatment less effective.
MSF admitted 8,128 new patients forkala azar treatment in 2010.

Water and sanitation
Safe water and good sanitation are essential to
medical activities. MSF teams make sure there isa clean water supply and a waste management
system in all the health structures where MSF works.
In emergencies, MSF assists in the provisionof safe water and adequate sanitation topeople displaced by natural disasters or armed
conflict. Drinking water and waste disposal
are the first priorities. Latrines are built at aconvenient, yet secure, distance from camps.
Where a safe water source cannot be foundclose by, water will be trucked in containers.
Staff conduct information campaigns topromote the use of facilities and ensure goodhygiene practices.
In 2010, MSF distributed more than
577,000,000 litres of safe water andbuilt or rehabilitated 1,986 latrines.

© Bruno De CockIn countries where vaccination coverage is
generally low, MSF strives to offer routine
vaccinations for all children under five aspart of the basic healthcare programme.
Immunisation also forms a key part of MSF’s
response to outbreaks of measles, yellow fever
or meningitis. Teams often take part inlarge-scale vaccination campaigns. Staff work
to raise awareness in the community about
the benefits of immunisation, and vaccination
posts are set up in places where the community
is likely to gather. A typical campaign lasts
between two and three weeks and can reachhundreds of thousands of people.

Visceral leishmaniasis(kala azar)

A doctor checks a patient’s notes at Silanga hospital, Nairobi, Kenya.

Glossary of diseases and MSF activities

13Medical andpsychologicalcare in detention
Toward the end of 2010, the situation for migrants in detention in Greece became critical.
Cells in border police stations and detention centres in the region of Evros, on the borderwith Turkey, were exceeding capacity two- or threefold. Men, women and children were
obliged to share facilities, with 100 people typically having access to just two toilets.
Detainees were not being allowed outside.
“W hat we witness every day inside thedetention facilities is not easy to describe”,
said Ioanna Pertsinidou, Médecins Sans
Frontières’ emergency coordinator, in
December. “In Soufli police station, which
has space for 80 people, there are days
when more than 140 migrants are detained
there. In Tychero, with a capacity of 45,
we counted 130 people. In Feres, with acapacity of 35, last night we distributed
sleeping bags to 115 detained migrants.
One woman, who had a serious gynaecologicalproblem, told us there was no space to sleep
and she had no other option but to sleep inthe toilets.”
The MSF team distributed sleeping bags
and hygiene kits, and worked to improve
sanitation. In Soufli and Tychero police
stations, two MSF doctors treated patients
who were mainly suffering from respiratory
and skin infections as a result of the harshliving conditions.

MSF brings assistance to people in urgent
need. But also, as Dr Veizis says, “We push
the authorities to improve conditions byshowing the positive impact of our activities
and by speaking out on what we witness inthese centres.” MSF lobbies hard to ensure
the provision of acceptable living conditions
and adequate healthcare for detainees.

healthcare. MSF resumed its activities
in June 2009, and in October 2010 staff
handed over responsibilities to the Ministryof Health. The ministry had also started torecruit cultural mediators to help remove
language and cultural barriers between
medical staff and migrant patients inhealth centres and hospitals.

In Malta, MSF staff had been providing
medical care to detained migrants andasylum seekers since 2008, but in 2009
the team temporarily suspended activities
when it became clear that living conditions
were compromising the care and treatmentthat staff were providing. After persistent
lobbying, authorities began to improveliving conditions and the availability of

Mental healthcare
Despite feeling forced to leave their homes
in order to survive, enduring painful andtraumatic journeys, and experiencing
overcrowding, lack of food, lack of exercise
and insanitary conditions in the places where
they end up, the single most importantcomplaint for most migrants is the mere factof their detention. Three per cent of migrants

The conditions of detention, evendetention itself, have a significant impact
on people’s health, but MSF cannot takeon the responsibilities of immigration
authorities or the Ministry of Health.
As an emergency medical organisation,

14

Medical and psychological care in detention© William Daniels

Where detention is an instrument of
migration policy, the rights to medical care,humane treatment and respect for dignity
are often ignored. In 2010, MSF provided
humanitarian assistance and medical care in
detention centres or prisons in Cambodia,
the Democratic Republic of the Congo,
Greece, Kyrgyzstan, Malta and Myanmar.
“Our role is to provide emergency supportand medical care to help detainees survive”,
says Dr Apostolos Veizis, MSF head ofprogrammes support.

A prisoner with TB takes his daily medication, Bishkek, Kyrgyzstan.

© Nondas Paschos

A mental health counselling session at Venna detention centre, Rodopi, northern Greece.

who received care in Greek detention centres
attempted suicide or self-harm, 39 per centof detainees showed signs of anxiety, and31 per cent had symptoms of depression.
MSF offered psychosocial support to detainees
in Malta and Greece, providing individual andgroup counselling to help migrants cope after
their traumatic experiences.
But in an emergency intervention staff havelittle time to gain the trust that is necessary
for the provision of quality medical care,particularly mental healthcare. MSF’s
principle of independence is therefore crucial
to our work in places of detention. Teams
working in detention centres make it clear to
everyone that although they are present withthe consent of the authorities, their activities
are carried out independently. Confident of
MSF’s independence, trust can be built withthe detainees more quickly. According to
Dr Veizis, MSF staff members are “some of
the few people detainees can talk with”.
Tuberculosis care in prisonsPrisoners are also often in need of assistance,and MSF provides medical care in a numberof penitentiary facilities.
In Kyrgyzstan, MSF has been collaboratingwith the Ministry of Health, prison authorities
and international organisations such as
the International Committtee of the Red

Cross (ICRC) to support the treatment oftuberculosis (TB) in prisons. TB is 20 to 30
times more prevalent among prisoners thanamong the general population. Patientsdiagnosed with TB are referred to treatment
facilities in three prisons in and around thecapital Bishkek. Overcrowding and poor
ventilation are key factors in facilitating the
spread of the disease, so MSF staff haverefurbished the medical rooms in the prisonsand TB patients’ cells.
Prisoners with TB are often transferred orreleased before completing their treatment,
and former inmates often struggle for thebare necessities of life. They do not consider
the continuation of their medication to be
their highest priority. The disruption of TB
treatment not only risks the patient’s recovery,
but also the development of drug-resistant TB,
which involves a much longer and moredifficult treatment regime. In 2007 MSF staff
began providing counselling, food, and money
for transport to help ex-prisoners in Kyrgyzstan
continue their treatment.

When 17 prisoners died of malnutritionat the hospital in Bunia in just two months,
an MSF team visited the prison. The teamfound 540 men, women and children living
in a structure with a capacity for 100. There
was no guaranteed food supply and no safe
water. MSF immediately began treating
malnourished patients with ready-to-use
food and organised medical consultations.
A safe water supply was installed, thesanitary block was renovated, and a reliablefood supply was assured. The government
allocated extra funding to the prison and in
March 2010 MSF handed over its activities
to the government and the ICRC.

Improving conditions
In 2010, a successful collaboration with thegovernment and the ICRC in the Democratic
Republic of the Congo (DRC) ensured along-term improvement in prison conditions
in Bunia, eastern DRC.

Medical and psychological care in detention

15

FORTY YEARSOF medical
innovation
Since it was first created by a small group of doctors andjournalists in France in 1971, Médecins Sans Frontières (MSF)
has always striven to find better ways of saving the lives
and improving the health of more people through emergency
medical action. This persistent search for innovation in publichealth emergencies is rarely highlighted, but has been crucial
in how MSF delivers humanitarian medical assistance today.
MSF provides medical aid to people whose
lives are threatened by epidemics, malnutrition,
healthcare exclusion, natural disasters andarmed conflict. During its first decade, it
gradually became clear that certain obstacles
were standing in the way of MSF making
a difference to the lives of people most in
need. For example, the very nature of medical
humanitarian intervention is working with large
numbers of people from poor communities inremote and insecure places, but the capacity
to train staff of varying levels in such settings
can be limited. These environments are often
unfamiliar to international doctors, material andfacilities tend to be limited, and staff turnoveris generally high, limiting the possibility ofbuilding an experienced workforce. That is why
MSF piloted and implemented a number ofinnovations, in order to adapt its work to thedemands specific to the countries it is present in.
One of the earliest innovations took placein the 1980s, when, in a bid to standardise
medical procedures, streamline operational
management and empower staff, MSF
adapted a technique already used by the
emergency medical service in France, andintroduced guidelines and standardised
drugs and equipment. This soon led to
MSF developing pre-packed, ready-to-go,
custom-designed medical kits that contained
basic drugs, supplies and equipment andwere adapted to specific field situations,climates and diseases. The first emergency
kit, applicable to many emergency situations,formed the basis for an interagency kit.
The World Health Organization (WHO)coordinated the development of this kit,
which was first available in 1990 and has been

16

FORTY YEARS OF medical innovation

regularly revised since. Advances such as theseresulted in an increased capacity for rapid
intervention on a higher technical level, which
had previously existed only in the military andcivil defence forces of developed countries.
MSF has since developed many other kits for
vaccination campaigns, surgery, and even one
to build a field hospital from inflatable tents.
In continually trying to find innovative ways
to supply the best drugs to patients, and inrecognising the need for further research, MSF
created the non-profit organisation Epicentre in
1987. The aim was to provide scientific evidence
that would support operations. Epicentre carries
out studies on the incidence, prevalence andcauses of epidemics and infectious diseases
in large populations. At the time, few othernon-governmental organisations were capableof doing research in the emergency situations inwhich MSF operated.1
For more than 20 years, Epicentre has
conducted many surveys, often under very
difficult conditions, producing researchthat has contributed to improving patientcare. Between 1996 and 2004, the centre,
mandated by MSF, carried out studies andclinical trials on malaria treatment, in order
to officially prove drug-resistance to themost commonly used medication at thetime, and to give leverage to changing
the protocols. Epicentre’s research also
contributed to proving how much more
effective several artemisinin-based
combination therapies (ACT) were. In
several malaria-endemic countries, theseresults helped support changes in national
treatment protocols for malaria. 2

Throughout the 1980s and 1990s, MSF teams
worked in the “meningitis belt” of sub-SaharanAfrica. Their experience, regarding the mostly
successful use of oily chloramphenicol as afirst-line treatment for bacterial meningitis, led
to a study to prove its efficacy, and in 1991, it
was included on the WHO’s essential medicines
list. An equivalent study, comparing this drugwith another, ceftriaxone, was carried out
in 2002, with the result that both treatment
protocols became international standards foroutbreaks in the meningitis belt. MSF also
worked closely with the WHO to define newcontrol strategies for the disease.
Unfounded perceptions and unfairness werepreventing many HIV-positive people fromreceiving treatment in the 1990s. Although
medication to treat the pandemic alreadyexisted in the form of antiretroviral (ARV)
treatment, the cost was between US$ 10,000
and US$ 15,000 per year – prohibitive formillions, particularly in developing countries.
Some also had the perception that it would
be too difficult to implement complex ARV
regimens in resource-poor settings.
MSF, seeing the need for advocacy to challenge
this notion, and in order to overcome the pricebarriers to treatment, set up the Campaign for
Access to Essential Medicines in 1999, which
pushed for the manufacturing of more affordable,
generic versions of ARV medicines. Soon, thedrugs were being produced in Brazil, India
and Thailand, opening up the possibility oftreating many millions of HIV-positive people.
Today, the price of a year’s treatment has
dropped by 99 per cent and more than six
million patients are being treated with ARVdrugs. MSF alone provides ARV treatment tomore than 170,000 patients in 19 countries.
MSF’s Access Campaign has also been very
active in raising awareness about otherneglected diseases prevalent in developing
countries, and in securing the productionof much-needed affordable or adapted
medication to treat them.
In recent years, major changes have occurredin the international pharmaceutical market,
as drugs are now being produced in countrieswhere the markets are less regulated than thosein Europe and the United States. Therefore,
under the supervision of MSF medical directors,
the organisation’s pharmacists established andimplemented a qualification system that would
ensure that any medication used to treat people
in MSF projects is no less effective and no more
toxic than that used in developed countries.
Although drugs for specific diseases are now
being manufactured in more countries, themarket-driven nature of the pharmaceuticalindustry meant that in the 1990s, drugs forcertain diseases were still too expensive,or else ineffective or highly toxic. In somerare cases, manufacturing had stopped
altogether. In 2003, seven agencies fromaround the world, including MSF, came
together to form the Drugs for Neglected
Diseases initiative (DNDi), a non-profit drug
research and development organisation.

MSF has also taken an innovative approach
to treating malnutrition in areas prone tofood shortages by supplying nutritious“ready-to-use food”, before children at
risk develop severe malnutrition. It can beadministered to children at home. Since
opting for this pre-emptive tactic, rather
than the reactive approach alone, in whichmalnourished children are treated after
displaying symptoms, teams have found thatthe number of admissions to feeding centres
has been lower than in previous years.
The nature of MSF is to act as a medical
humanitarian organisation in crisis periods whenpeople’s very survival is threatened. Over theyears, it has implemented sustainable models
of care that have proven effective, efficientand affordable, and which have since been
built upon by other actors, including ministriesof health. In South Africa, for example, MSF
operates an HIV and tuberculosis treatment
project in the township of Khayelitsha,
near Cape Town. The programme uses a
decentralised model of care in its operations,training nurses to initiate treatment andcounsellors to test for the virus. This increases
the number of people being diagnosed andtreated, and also provides training that benefits
people long after MSF has gone.

These are examples of only some of theinnovations that MSF has initiated in its
first forty years. As Dr Unni Karunakara,
MSF International President, summarises,“Throughout the decades, the organisation
has always tried to adhere to its social missionof protecting and alleviating the suffering of
the poorest and most disadvantaged, while
respecting human dignity. MSF will strive tocontinue its work of saving lives, reducing
pain and suffering, and helping restore thelives, potential and dignity of people who findthemselves in life-threatening circumstances.”
This article is largely based on
Jean-Hervé Bradol and Claudine Vidal (eds),
2009, Innovations médicales en situations
humanitaires, L’Harmattan. The English
translation, Medical Innovations in
Humanitarian Situations, is available atwww.doctorswithoutborders.org/publications/book/medicalinnovations/

1. Interview with Alain Moren in Jean-Hervé Bradoland Claudine Vidal (eds), 2009, Innovations
Médicales en Situations Humanitaires,
L’Harmattan, p. 36.
2. Vincent Brown, Philippe J. Guerin, Dominique
Legros, Christophe Paquet, Bernard Pécoul,
Alain Moren, 2008, “Research in Complex
Humanitarian Emergencies: The Médecins Sans
Frontières/Epicentre Experience”, PLoS Medicine
5(4), at www.plosmedicine.org© H. de Ribaucourt

In 2003, MSF and Epicentre sponsoredclinical trials for the treatment of sleeping
sickness (human African trypanosomiasis),a deadly parasitic disease threatening
60 million people across sub-Saharan Africa.
The medication available was either highly
toxic or difficult to administer, especially inremote settings. The following year, DNDi,
along with other organisations, joined theresearch. The trials proved that nifurtimoxeflornithine combination therapy (NECT) was
the best combination medication, showing it
to be efficient, well tolerated by patients andeasier for healthcare staff to administer. In

2009, nifurtimox (to be used in combination
with eflornithine) was added to the WHO’slist of essential medicines, so NECT could be
used throughout Africa, leading to improved
healthcare for patients with sleeping sickness.

A nurse checks the contents of an emergency kit, Burundi.
FORTY YEARS OF medical innovation17

Innovationin action:a tale of two vaccines
Médecins Sans Frontières (MSF) teams have participated in
the launch in Africa of two eagerly awaited vaccines – one
against a deadly strain of meningitis and the other against
pneumococcal disease.
Both will undoubtedly save the lives of many people in the
countries where the vaccines have been rolled out. But thestory behind each also illuminates both the risks and rewardsof working to open up access to lifesaving vaccines as widely
as possible in the places where we work.
Every year, during the dry months– the epidemic season – the fear amongcommunities who live in Africa’s meningitis
belt is palpable as they wait for thisdebilitating and often fatal disease to strike.
And every year, there are many fatalities;
those who survive are often left with longterm mental and physical disabilities.

The traditional vaccine conferred very
short-term protection making truelong-term preventionimpossible”, says
Dr Cathy Hewison, medical advisor at MSF.
“This new vaccine gives four times greater
protection and lasts ten years. It’s a revolution
and a game changer to prevent epidemics
in the future.”

But beyond the public health revolution,
the way in which the vaccine was developed– tailored specifically to protect the target
population in sub-Saharan Africa for anaffordable price – is also groundbreaking.
Responding to urgent medical needs,
not only the market
Effective meningitis vaccines already exist
in high-income countries but, as withthe overwhelming majority of vaccines,
medicines and diagnostic tools, thepharmaceutical research and development
agenda has been driven by wealthy markets
and largely fails to address the needs ofpeople who live in poorer countries. Thismeans that drugs and other health tools aredeveloped to respond primarily to diseases
prevalent in rich countries, and are adapted
to developing country contexts in a second
stage. Diseases that mostly afflict developing
countries either go unaddressed, or patients
must wait far longer for new medical
products to reach them.

MSF has long been involved in fighting
the disease across the region and regularly
mounts large reactive vaccination campaigns
to combat the disease. However, in 2010,
MSF teams, supporting the national healthauthorities in Niger and Mali, helped rollout a new vaccine that could finally put an
end to the shattering cycle of meningitis
epidemics in this region once and for all.

The new vaccine has many advantages
over the older vaccines – it protects young
children more effectively and lasts up toten years. Most importantly, the vaccine
will stop transmission of the bacteria thatcauses meningitis within the population
by eliminating the carriage of the germ.
And this could mean an end to epidemics.
“This new vaccine opens up whole new
possibilities. In 2009, MSF vaccinated morethan seven million people for meningitis A.
We were confined to emergency response,
trying to slow and stop epidemics.

18

Innovation in action© Bruno De Cock“A revolution and game-changer toend epidemics”

The new pneumococcal vaccine is prepared, Silanga hospital, Nairobi, Kenya.

This project, in contrast, was launcheddirectly in response to a call from African
governments to tackle this merciless killer.
A clear brief set out the requirements:
the vaccine should be targeted to protect
people from meningitis A, the particularform of meningitis prevalent in sub-SaharanAfrica. And an affordable target price wasset at no higher that 50 US cents.
Following a period in which major
pharmaceutical companies considered andthen walked away from the brief, a consortiumof academics and scientists from bothdeveloping and high-income countries came
together to collaborate on the vaccine. The
scientific know-how on the production of thevaccine was transferred from a US institution
to the Serum Institute in India, linking top
scientific capacity to low production costs.
Further collaboration took place as African
scientists contributed to the design of theresearch and conducted the clinical trials.
Finally, the World Health Organization gave thevaccine its quality stamp of approval, providing
assurance of the product’s safety and efficacy,
and allowing the roll-out to begin.
With development costs a fraction of thoseusually incurred, the vaccine development
has been greeted as a victory for publichealth and a shining example of what canbe achieved outside the normal productdevelopment paradigms.

© Bruno De CockAs Dr Tido Von Schoen-Angerer, director of
the MSF Campaign for Access to Essential
Medicines, says: “This is a complete
revolution compared to the usual patentbased, profit-driven model. It’s a striking
contrast to the blockbuster vaccines
developed by the largest commercial
developers for Western markets that fetch
extremely high prices and aren’t producedwith developing country needs in mind.”
A different approach:the pneumococcal vaccine
Meanwhile, across the continent in Kenya,
MSF and other healthcare providers havestarted using a new pneumococcal vaccine thatagain could save thousands of young lives. But
a look at its development tells a very different
story to that of the meningitis vaccine.
For more than a decade, infants in wealthy
countries have benefited from a pneumococcal
vaccine, and research has kept on delivering,with two improved versions introduced inEurope and the United States in 2009 and2010. Now, finally, children in developing
countries also stand to benefit.
The medical benefits of the vaccine areclear – pneumococcal diseases include someforms of meningitis and pneumonia, and thevaccine has the potential to prevent millions
of bouts of illness and countless deaths – yet it

A child is vaccinated at Silanga hospital, Nairobi, Kenya.
has taken more than a decade for this vaccine
to become available to children in developing
countries. What’s more, the price tag is very
high, and raises fears that the vaccine may
prove unaffordable in the long run.
The devil is in the detail
So what’s gone wrong here? In an effort
to push this vaccine out more widely, aninnovative financial mechanism was devised
called the Advance Market Commitment.
Essentially this is an international subsidy
that donors pay to pharmaceuticalcompanies in exchange for them agreeing
to sell the vaccines in developing countries
at lower prices than those paid in wealthymarkets. The idea is that the poorest
countries get to access the vaccines at
discounted rates, and sooner than otherwise
would have been possible.
But the devil is in the detail and closer
examination reveals a different picture.
In contrast to the meningitis vaccine,where affordability was established asa core objective, the final prices for thepneumococcal vaccine negotiated withthe pharmaceutical companies are stillhigh. In addition to the multi-million dollar
subsidy received by each company, donors,

continued overleaf

Innovation in action

19continued Innovation in Action

with small co-payments from developing
countries, are paying US$ 10.50 for eachchild vaccinated. This is of great concern
both to donors who are currently footing
most of the bill, and for the developing
countries that must eventually pay the fullcost of the vaccines themselves. Securinglong-term affordability is all the more crucial
when you consider that the cost of this
vaccine will have to be added to the cost ofother routine vaccinations against measles
and other common childhood diseases.
The big picture shows that the big
pharmaceutical companies have received
a vastly inflated and unwarranted subsidy
for providing pneumococcal vaccine todeveloping countries – when they are
already reaping blockbuster profits fromthe same vaccines in wealthy countries.
And, once donor support ends, those samedeveloping countries may end up unable toafford the vaccine.

As Dr Nitya Uday Raj, medical coordinatorfor MSF in Kenya, says: “Pneumonia is a
primary morbidity for young children in
Dagahaley Camp, where we provide healthservices to Somali refugees and we are
excited about adding this vaccine. During
our conversations with the Ministry of
Health about the roll out, they expressed
concerns about how they would manage
when they stop getting donor subsidies.”

promoting the development of new vaccines,
medicines and tests, and challenging existing
barriers to treatment – such as cost –for patients in poorer countries.
To learn more about the Access Campaign’s
activities, visit www.msfaccess.org or
follow @MSF_access on Twitter.

MSF is committed to working with national
authorities to boost and expand effective
childhood vaccination programmes in
the places where we work. But to ensurethat those ambitions are sustainable overthe long run, it’s essential not only for us
to support and nurture new and creative
approaches to the development of vaccines,
but also to remain vigilant that the publichealth interest is prioritised above all else.
The tale of two vaccines is a cautionary one.
MSF’s Campaign for Access to Essential
Medicines works to help our medical teams
give quality care to the people we treat through© Bruno De CockIt’s likely that a considerably lower pricecould have been achieved if donors had
granted more support to low-cost producers– similar vaccines in the pipeline could
cost only US$ 6 per child vaccinated, butwill not be available for several years. Witha financial squeeze on all areas of global
health funding, the exaggerated sum spenton this project could now mean a shortfallin the funding available for other importantvaccines to protect young children in poor
countries from killer diseases.

The new vaccine could save thousands of lives.

20

Innovation in action© Robin Meldrum

A patient and her mother after the final surgery for a broken leg, Lubutu, DRC.

22 Burkina Faso

39 Liberia

23 Burundi

40 Malawi

24 CENTRAL AFRICAN
REPUBLIC

41 Mali

26 Chad
28 Cameroon
29 Republic of
the Congo

42 Morocco
43 Mozambique
44 Niger
46 Nigeria

30  Democratic republicof the congo

48 Somalia

32 Djibouti

51 South Africa

33 EGYPT

52 Sudan

34 Ethiopia

54 Swaziland

36 Guinea

55 Uganda

37 Kenya

56 Zimbabwe

38 Lesotho

58 Zambia

50 Sierra Leone

AfricaAFRICA© Jessica Dimmock / VII Network

Burkina Faso

Women wait for their weekly visit to one of MSF’s mobile feeding clinics, near Samba.

Titao

YAKO

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

Malnutrition is a chronic
problem in Burkina Faso,
but hits particularly hard in
the period between the twoannual harvests, known as
the “hunger gap”.
Young children are vulnerable to malnutrition
because a lack of essential micronutrients andvitamins can lead to restricted mental andphysical growth. Malnourished children are
also more susceptible to other diseases, such as
malaria, diarrhoea and respiratory infections,and severe malnutrition can cause death.

22

Treating malnutrition in young children
Since 2007 Médecins Sans Frontières (MSF) has
been treating malnutrition in children under theage of five in the northern towns of Yako andTitao. MSF testing and treatment programmes
are based in 16 local health centres, bringing
care closer to more people’s homes.
Staff measure the circumference of infants’
upper arms to test for malnutrition. Children
suffering severe medical complications, such asother diseases, are admitted to hospital. If there
are no complications the children are given
ready-to-use food, which is a peanut-based
paste containing all the calories, proteins,vitamins and micronutrients that a child needs
to recover. Caregivers are given enough foodsachets to last for a week so that they canfeed their children at home. This home-based
treatment does not interfere with the parent’s
work, and the child’s progress is monitored
weekly at the clinic. The children usually
recover fully after about four weeks.
“D etecting and treating malnutrition inits early stages is essential, as it meansthat treatment can be offered quickly andensures a much faster recovery time for the

MSF PROJECTS AROUND THE WORLD – AFRICA – Burkina Faso

children”, said Sylvie Goosens, medical
coordinator for the project. “Also, treating
children earlier requires fewer resources,
which means we can treat more”, she said.
Nonetheless, as more children are screened
for malnutrition and able to access treatment,
more will need to be hospitalised. MSF
expanded the hospital in Titao in 2010,
building an extra structure that increased
capacity from 80 to 150 beds. In 2010,
more than 11,700 children received care formalnutrition. Since the project started in
2007, 50,940 children have received care.
Reinforcing care for malaria
Malaria is very common in Burkina Faso andin 2010 MSF increased its efforts to combat
the disease, offering testing and treatment
to every visitor to every centre where it wasworking. Between August and December,approximately 74,300 people received
treatment, including 780 children who
had more serious forms of malaria.
At the end of 2010, MSF had 268 staff in
Burkina Faso. MSF has been working in
the country since 1995.

AFRICAburundiNgozi

KaruziKayanza
GitegaKabeziRegions where MSF has projects
Cities, towns or villages where MSF works

Although Burundi has a policy of
free healthcare for children andpregnant women, access to careis limited, primarily because ofa shortage of staff.

Obstetric fistulas
Obstetric fistulas are injuries caused to thebirth canal. Many women with obstetricfistulas have to live with the unpleasant anddebilitating effects of incontinence, which
can also result in social exclusion.
In July 2010, MSF opened the Urumuri centre
in the city of Gitega, central Burundi, totreat women with obstetric fistulas. It is the
only centre in the country that provides free,around-the-clock treatment. MSF is planningto treat 350 women per year for the next
three years, and will be training Burundian
doctors in specialist fistula surgery.
Malaria
Malaria is the main cause of mortality andillness in Burundi. It is responsible for48 per cent of deaths among children
under five. In 2010, two MSF teams treated
175,000 people for malaria and distributed
134,000 mosquito nets in the provinces of
Kayanza, Ngozi and Karuzi.
An MSF team is dedicated to the surveillanceand evaluation of medical alerts in Burundi.
The team supported the national healthauthorities during outbreaks of cholera
and measles in 2010, treating patients andassuring follow-up. MSF staff also took partin a measles vaccination programme.
At the end of 2010, MSF had 237 staff
in Burundi. MSF has been working in
the country since 1992.

© Martina BacigalupoThis particularly affects women. According to
the World Health Organization, 4,000 women
die in childbirth and approximately 1,000
women develop an obstetric fistula every year.

In western Burundi, Médecins Sans
Frontières (MSF) operates a centre providing
emergency obstetric and gynaecological carein the town of Kabezi, in Bujumbura Rural
province. The centre offers medical care forpregnant women experiencing complications indelivery and for newborn babies. MSF also runs
an ambulance service that transports womenneeding emergency care from 23 health centresin the area and brings them to Kabezi.

A woman feeds her child, who is recovering from malaria at Ngozi hospital.

MSF PROJECTS AROUND THE WORLD – AFRICA – burundi

23

AFRICA

CentralAfrican Republic
The Central African Republic has
suffered armed conflict between
rebel groups and the government
for the past five years. People
face enormous difficulties inaccessing healthcare.
Many live in extremely isolated regions, andtravelling is dangerous as banditry is widespread.
In 2010, Médecins Sans Frontières (MSF)
supported hospitals and health centres inviolence-affected areas in the north of thecountry, and responded to emergency healthneeds in the southwest and southeast.
Ouham-Pendé prefecture
Since 2006, MSF has been working in thereferral hospital in the town of Paoua in thenorthwest of the country. Teams provide
paediatric, surgical, maternal, emergency
and outpatient care. More than 35,150
consultations were carried out in 2010,
and over 6,900 patients were admitted tohospital. Staff held more than 7,400 antenatal
consultations, and assisted more than 1,500
births. Teams also cared for 320 HIV/AIDS
patients, including patients infected withboth tuberculosis (TB) and HIV. Staff worked
in seven health centres in the surrounding

Ouham-Pendé

BaminguiBangoran

Ouham

LobayeHaut-Mbomou

Mambéré-Kadei

Regions where MSF has projects

area, carrying out nearly 4,000 consultations
every month.
MSF provided a paediatric service in Bocaranga
hospital, 100 kilometres west of Paoua. Teams
admitted around 160 children to the hospitaland held an average of 1,000 consultations
with children under five every month.
Ouham prefecture
In Ouham prefecture, east of Ouham-Pendé,
MSF staff work in rebel-controlled territoryon the border with Chad. The Boguila
project was opened in May 2006 on thesite of a former missionary hospital, andit has since become the referral hospitalfor the region. The hospital has 115 beds
and a laboratory, and offers surgery,maternity care, mental healthcare, HIV
and TB treatment, outpatient services anda maternity waiting house. Women at riskof complicated deliveries can spend thelast few weeks of pregnancy at the waiting
house, where they are within easy reachof medical care. In November a four-week“surgical camp” was set up in the groundsof the hospital to help women sufferingfrom obstetric fistulas, debilitating injuries
to the birth canal that cause incontinence.
Seventy-eight women received repair
surgery at Boguila.

© Sarah Elliott

Staff train community members to provide
basic health services and treatment at sevenhealth centres in the surrounding area.
Among other tasks, the community healthworkers diagnose malaria, one of the maincauses of death in the country, and treat
milder cases of the disease.

An MSF nurse makes her morning rounds, checking on patients at Zémio hospital.

24

MSF PROJECTS AROUND THE WORLD – AFRICA – Central African Republic

Maitikoulou clinic was opened in early 2009
to treat sleeping sickness (human African
trypanosomiasis), after MSF teams recorded
a high prevalence of the disease in the district.
Sleeping sickness is a parasitic infection
transmitted by tsetse flies that occurs in© Sarah Elliott

AFRICA

Patients need to drink large amounts of water before and after fistula surgery, Boguila hospital, Ouham prefecture.
sub-Saharan Africa. It attacks the central
nervous system, causing severe neurologicaldisorders. If not treated it causes death.
In 2009, more than 1,000 people were treated forsleeping sickness, but screening in 2010 resulted
in only 50 people being diagnosed and treated.
The clinic was therefore converted into a 70-bed
general hospital. More than 48,320 consultations
were carried out, and more than 2,370 people
were hospitalised. Staff also provided medicalcare in four health centres in the area.
Not far from Maitikoulou clinic, MSF worked
in a Ministry of Health hospital in Markounda
town. Staff operated an outpatient department
and a 26-bed inpatient department. In October
MSF handed its work in these departments
over to Ministry of Health staff. Teams
continued to work in several health centres inthe district, most of which were located along
the Chadian border.
Many of the people living in the town of Kabo
have been repeatedly displaced by violence.
MSF staff provided emergency medical care,maternal and paediatric care, surgery andtreatment for HIV/AIDS and TB at Kabo healthcentre, and supported four neighbouring
health centres. Staff conducted almost 104,000
consultations and admitted more than 2,850
people to hospital. MSF also supplied basic
survival kits containing hygiene products, foodand blankets to families displaced by conflict.

Batangafo is in an isolated area around 60
kilometres from Kabo. The facility here wasoriginally a health centre, and has now becomea referral hospital with more than 170 beds.
Teams provide maternal and paediatric care,surgery, and general and emergency medicalcare. MSF supports five health centres on theoutskirts of the town and has one mobile clinic.
Nearly 48,000 people were treated for malaria,
more than 1,000 surgeries were performed,
and staff assisted almost 1,300 births.

staff to support several health centres and ran
a feeding programme for children under 15.

Bamingui-Bangoran prefecture
Armed conflict in Bamingui-Bangoran, inthe north of the Central African Republic,is displacing people from their homes formonths at a time. Some have found refuge
with host families in Ndele, the prefecture’s
capital, while others are in hiding in thebush. Almost all are living in very poor
conditions. MSF started working in Ndele
hospital in July 2010 and set up mobile
clinics to make basic healthcare accessible
to as many people as possible. More than
28,700 consultations were held and 300
patients were admitted to the hospital.

MSF staff provided medical care to 15,000
refugees as well as the host population,
carrying out 5,000 consultations eachmonth on average. In February, 12,500
children aged between six months and five
years were vaccinated against measles.

Treatment for child malnutrition
In the southwest of the country, MSF treatedmore than 2,800 children for malnutrition in
emergency programmes in Carnot, Mbaïki
and Pissa. Children with malaria, diarrhoea
and respiratory infections also received
treatment. In Gadzi, MSF supplied and hired

Emergency care for displaced people
In November 2009, MSF launched a programmeon the Ubangi River, on the border between
the Central African Republic, the Republicof the Congo and the Democratic Republic of
the Congo (DRC). The population in this area
had grown by tens of thousands as refugees
crossed the river to escape violence in DRC.

In May, thousands of people flocked into
the town of Zémio, on the border with DRC,
fleeing attacks from the rebel group the Lord’s
Resistance Army. An MSF team opened an
outpatient department in the town’s hospitaland a health centre near the refugee anddisplaced persons camps. Staff carried out
more than 14,750 consultations, set up afeeding programme and conducted a measles
vaccination campaign in an effort to prevent an
outbreak of the disease in the crowded camps.
At the end of 2010, MSF had 1,263 staff in
the Central African Republic. MSF has beenworking in the country since 1997.

MSF PROJECTS AROUND THE WORLD – AFRICA – Central African Republic

25

AFRICACHAD

In 2010, the heaviest rains
for 40 years destroyed crops,
flooded wells and cut off
entire villages in Chad. Thesefloods followed a long drought
in 2009, which had alreadyresulted in a significant drop
in farm production.

Abéché

Chadians faced a major food crisis and several
outbreaks of disease, including cholera,meningitis, measles and malnutrition.
One quarter of children under the age offive were suffering from acute malnutritionin the Sahel region of western Chad in 2010.
In eastern Chad, conflict continued.
Insecurity in eastern Chad
The political relationship between Chad andSudan improved in 2010. Based on anagreement between the two countries
regarding the provision of weapons andprotection of insurgent groups, the UN
peacekeeping mission MINURCAT left thecountry in December 2010. But sporadic
clashes continued to be reported in eastern
Chad and humanitarian staff were targets ofkidnapping, robberies and violence. Many
aid organisations were obliged to reduce
their activities, or stop work altogether,

DogdoréN’Djamena

Kerfi
Am Timan

BongorMoissala

Regions where MSF has projects

Cities, towns or villages where MSF works

making life even more difficult for people
living in the region.

people were admitted to the nutritional
rehabilitation programme.

In Dogdoré, 30 kilometres from the borderwith Sudan, residents live alongside a large
number of displaced people. Médecins Sans
Frontières (MSF) teams carried out morethan 12,100 consultations and treated 430
patients in hospital during the first sevenmonths of 2010. They provided 2,460
antenatal consultations, assisted more than
200 births and vaccinated some 1,060
children against measles. More than 430

In July 2010, however, MSF was forced toclose the programme. Repeated security
incidents made it impossible to maintaina team in Dogdoré. Before leaving, MSF
donated drugs and medical supplies to thehospital to help ensure the continuation of
medical care after the team’s departure.
In Kerfi, in the southeast, MSF staff worked
in a small health centre where both displaced
people and members of the settled community
came for treatment. In 2010, almost 26,700
consultations were carried out, and more than
1,500 patients were hospitalised. Staff held
more than 3,000 antenatal consultations,assisted close to 100 births, and admitted morethan 1,000 people to the nutrition programme.

© MSF

In February 2010, MSF staff beganproviding care to patients in the paediatricand maternity departments of Am Timan
hospital. By the end of the year the team
was also working in three health centres
around Am Timan. They set up mobile clinics
to make treatment for malnutrition moreeasily available to more people, and offeredantenatal care. In total, close to 1,030 babies
were delivered, more than 1,750 patientswere hospitalised, and 2,970 children wereadmitted to the nutrition programme.

Hundreds of people attend MSF’s feeding programme at Massakory hospital,
Hadjer Lamis region.

26

MSF PROJECTS AROUND THE WORLD – AFRICA – CHAD

In the city of Abéché, MSF assisted more than
3,400 deliveries and treated 144 women withobstetric fistula (injuries to the birth canal).
Malaria in Moissala
In Moissala, a district in southern Chad,malaria is endemic throughout the year,© Mathieu Bichet / MSF

AFRICA

Measles vaccination in N’Djamena, Chad.
although the number of cases peaks during
and after the rainy season, between July andNovember. If a person with malaria is nottreated quickly, the disease can cause death,especially in children and pregnant women.
In several health centres in the region, MSF
staff trained community health workers toscreen patients for malaria and offer early
treatment for simple cases. People suffering
complicated cases of malaria were referred toMoissala hospital, where MSF runs a 50-bed
malaria treatment unit. More than 20,000
patients were treated for malaria over fivemonths. More than 1,030 patients were
hospitalised in the malaria treatment unit.
MeaslesDuring the first months of 2010, there wasan outbreak of measles in the capital city,
N’Djamena. Staff cared for more than 1,000
patients, nearly 420 of whom had to behospitalised. MSF also donated drugs andmedical supplies to help health centres
treat more than 2,770 patients. In Marchand April, MSF immunised more than
482,000 children.

Emergency nutrition programmes
While responding to the measles outbreak,
MSF staff observed high rates of acutemalnutrition among children. This led tothe opening of a nutrition programme in
N’Djamena in March. The existing nutrition
programmes in Dogdoré, Kerfi and Am Timan
were strengthened, and a further 11
emergency programmes were opened in
N’Djamena, the western regions of Hadjer
Lamis, Kanem, Lac, Mayo Kebbi Est and Chari
Baguirmi, Batha and Guera in central Chad,and Salamat in the southeast. In total, MSF
treated more than 27,650 children, of whom
more than 21,740 were severely malnourished.
CholeraIn September, there was an outbreak of cholera
in N’Djamena. MSF teams set up treatment
centres in three of the city’s hospitals.
“T he fact that more people are getting sickwith cholera now is probably related to thefact that the heavy rains and floods hit a
population that was already weakened.

There have been recent outbreaks of measles
and high levels of malnutrition, so people’s
immune systems are low – a typical scenario
for cholera outbreaks”, said Alexis Bahati,
medical team leader in Bokoro. Staff treatedclose to 1,300 patients and donated drugs in
the Bongor and Madelia districts, southof the city, and responded to outbreaks
in Bokoro, Pala and Fianga, where almost
700 patients were treated. By the end of
the year, 6,300 cholera patients had beenregistered across the country.
Meningitis
In March and April, MSF treated more than
1,280 patients for meningitis in the southern
regions of Logoné Oriental and Tandjilé.
Vaccination campaigns were carried out in
Logoné Oriental, Mandoul and Tandjilé, andMSF and the Ministry of Health vaccinatedsome 765,000 people between the ages of
2 and 29.
At the end of 2010, MSF had 773 staff in Chad.
MSF has been working in the country since 1981.

MSF PROJECTS AROUND THE WORLD – AFRICA – CHAD

27

AFRICA

cameroon

A pilot HIV/AIDS project in Cameroon is working to switch
patients who have developed resistance to their first-line
antiretroviral (ARV) treatment regimen to second-line treatment.

ExtrêmeNord

DoualaAkonolinga

treatment in developing countries.
Fifty-eight patients began this lifesaving
treatment in the last months of 2010.

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

The first people to be put on ARV treatment inCameroon started in 2000, and the country
now has a longstanding group of patients ontreatment. About 10 per cent of all peopleon ARV treatment develop resistance to the
medication after a number of years, according toa study carried out by Médecins Sans Frontières(MSF) in Douala, Cameroon’s largest city. Thesepatients need to switch to a second-line protocol
in order for their treatment to remain effective.
However, second-line treatment is generally
unavailable in developing countries, primarily
because of its prohibitive cost.

Buruli ulcer
Buruli ulcer is an infection related to leprosy andtuberculosis, which can cause painful wounds
and physical deformations, and often leads
to social stigma for people with the disease.
Early diagnosis and treatment are vital toprevent irreversible deformities, but treatment
is complicated, expensive, and can take overa year, involving antibiotics, skin transplants,
special wound dressings and physiotherapy.

Cholera outbreak
Cholera is endemic in the far north of Cameroon.
But an outbreak that began in early May, andwhich also affected the neighbouring countriesof Chad, Niger and Nigeria, infected far more
people than usual. In Cameroon, MSF assisted
the authorities’ response by donating sanitationand medical supplies, setting up and managing
two cholera treatment units in the towns ofMaroua and Mokolo, and supporting units in
Kolofata and Mogode with expertise in hygieneand case management. Between May and
September, 6,200 cases were registered in theregion of Extrême Nord, and 410 people diedfrom the disease.

Since 2002, more than 1,000 patients have beentreated at MSF’s programme in Akonolinga,a town in central Cameroon. MSF has set up a

At the end of 2010, MSF had 68 staff in
Cameroon. MSF has been working in the
country since 2000.

© Marcell Nimfuehr

In Nylon District Hospital, Douala, MSF
supports a pilot project for the country thathelps switch patients to second-line therapy.
MSF is providing medical expertise, training,
medication and advocacy, and hopes thatthe project will help prove the feasibility
and necessity of implementing second-line

Staff are also working to improve care forthose still on first-line treatment, replacing themost widely used type of medication with one
that has fewer side effects, and should result in
fewer patients developing resistance. In 2010,295 people began ARV treatment on the new
medication and 187 patients were transferredto the new medication.

“Buruli pavilion” in the town’s hospital, where
120 patients received care in 2010. MSF is
conducting outreach activities from the pavilion
so that people living further away can accesscare more easily. In 2010, the Ministry of Healthdeclared the pavilion a national reference point
for the treatment of Buruli ulcer.

Wound dressing at MSF’s Buruli centre in Akonolinga.
28

MSF PROJECTS AROUND THE WORLD – AFRICA – CAMEROON

AFRICA

Republic of
the Congo
At the end of 2009, tens of
thousands of people crossed
the Ubangi River to the
Republic of the Congo, seeking
refuge from fighting in Equateur
province of the Democratic
Republic of the Congo.
The population of Likouala province, in the
Republic of the Congo, has doubled. Médecins
Sans Frontières (MSF) teams have been working
with people living along the river to improve
the availability of healthcare in the area.

aged 15 to 30 were the most affected groupwere all cause for grave concern.
At the request of the Ministry of Health and theWorld Health Organization, MSF began work in
the intensive care unit at a hospital in PointeNoire at the beginning of December. The peakof the epidemic had already passed by theend of the year, but dozens of patients werestill being admitted every day. Medical teams
treated the symptoms of the disease (such as
breathing difficulties and muscle spasms) andtwo outpatient physiotherapy centres were set
up to help patients who had left hospital before

Bétou
Impfondo
BolembéPointe-Noire
Regions where MSF has projects
Cities, towns or villages where MSF works

their treatment was complete. The programme
will end in 2011 and the association Handicap
International will take on the provision ofphysiotherapy and mobility aids to patients.
The health authorities and international agencies
carried out a polio vaccination campaign,
targeting around three million people. MSF lent
logistical support for the vaccination of some
90,000 people living around Bétou.
At the end of 2010, MSF had 384 staff in the
Republic of the Congo. MSF has been working
in the country since 1997.

When MSF arrived in the town of Bétou, only
the hospital and one of the three district
health centres were functioning. The hospital
had been built by MSF in 2003, and teams
set to work reorganising the emergency,
outpatient, medical, paediatric and surgicaldepartments. Gynaecological, obstetric,
nutrition and laboratory services were added.
Each month, 340 patients were admitted tothe hospital and around 3,000 consultations
were held, mostly in relation to respiratory
infections, malaria and diarrhoea.
There are now six functional health centresin the district. To reach more remotesettlements, mobile MSF medical teams travelup and down the river by boat, providing
general consultations and antenatal care, andtreating severe malnutrition. These teams
carried out on average 10,000 consultations
a month, with the most urgent cases beingreferred to Bétou hospital.

Polio epidemic
At the end of 2010, a polio epidemic brokeout in the southeast of the country, centredin the city of Pointe-Noire. In total, 542
cases were recorded by the national healthauthorities, and 220 people died. The
resurgence of the disease, the extremely
high mortality rate, and the fact that males© Myriam Loiseau

Further south, in the town of Impfondo, MSF
started the year supporting the medical,
emergency, maternity, surgical and paediatricwards in the general hospital. Teams also worked
in health centres and operated mobile clinics tothe north and south of the town, carrying out
around 3,600 consultations a month. In July,MSF moved its activities to the 20-bed hospitalin Bolembé, 60 kilometres south of Impfondo,
to be closer to the refugee population.

Polio vaccination in Likouala department.
MSF PROJECTS AROUND THE WORLD – AFRICA – Republic of the Congo

29

AFRICA

Democratic
Republic of
the Congo
In the east of the Democratic
Republic of the Congo (DRC),
civilians have borne the bruntof more than a decade ofviolent conflict. Villages havebeen pillaged and destroyed,
armed men have forced
people to flee, and rape has
been used as a tool of war.

Orientale

Équateur
NORth Kivu
maniemaSouth Kivu

Kinshasa

Katanga

In 2010, thousands more people were displaced
from their homes by violence. Throughout
the country, decades of neglect of the healthsystem have resulted in a rise in infant andmaternal mortality rates and, according to theWorld Health Organization, life expectancy isamong the lowest in the world.
Providing healthcare in conflict zones
The project in DRC – in terms of programmes,
staff and budget – is Médecins Sans
Frontières’s (MSF) biggest. Teams offer
general and specialised medical care in
hospitals, health centres and mobile clinics
in various provinces, including the capital
city Kinshasa and the wartorn east of thecountry. In 2010, MSF staff carried out morethan one million medical consultations,performed more than 10,000 surgeries
and assisted 19,200 births. Staff treatedpatients for HIV/AIDS, tuberculosis,
cholera, haemorrhagic fevers, measles,
malaria, sleeping sickness (human African
trypanosomiasis) and more. Teams carriedout vaccination campaigns and emergency
surgery, ran nutrition programmes andoffered paediatric care. Mental healthcare
was also offered, as well as women’s
healthcare, including specialised assistanceto victims of sexual violence.
After three years of relative stability in the
Bunia region, Orientale province, MSF
handed its activities in Bon Marché hospitalover to the Ministry of Health. SOFEPADI, a

30

Regions where MSF has projects

Cities, towns or villages where MSF works

Congolese non-governmental organisationthat specifically helps female victims ofsexual violence, will take on responsibility
for the women’s health department. Teams
provided care for 675 women in the six
months before the handover process began.
In other places, conflict intensified, and poor
infrastructure made accessing remote areas
even more difficult. Around the town of
Pinga in North Kivu, where the community
is trapped by fighting across a constantly
shifting front line, teams used motorbikes
to hold mobile clinics and provide medical
supplies. In Hauts Plateaux, a very isolated
and mountainous part of South Kivu, teams
walked for up to six hours to reach displacedcommunities and carried out close to 13,800
medical consultations. Supplies can only reachShabunda by cargo plane, and MSF teams
then used bicycles and motorbikes to bring
medical care to 22,000 displaced people. In
the Uélé area, in Orientale province, insecurity
means that many displaced people can only
be reached by plane.
Staff at mobile clinics, health centres andhospitals in Bunia, North and South Kivu,
and Haut-Uélé and Bas-Uélé provided

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

medical, psychological and social support
for almost 6,000 victims of sexual violence.
In North Kivu, where it is difficult to reachthe more remote settlements, MSF also
trained a network of women counsellors to
respond to the needs of victims of sexual
violence and, where necessary, to referpatients to the hospital for further care.
Rapid response units
In the capital Kinshasa, Kisangani in thenorth, Lubumbashi in the south and
Mbandaka in the west of the country,
MSF teams work closely with the Ministryof Health to monitor the epidemiologicalsituation in DRC. Evaluation teams
investigate any claims of infectious disease
outbreaks or other quick-onset medical
emergencies, and are prepared to respondwithin days. In 2010, the units responded
to ten crisis situations, including yellow
fever and measles outbreaks, and supplied
emergency medical aid to people caught up
in fighting in Équateur province.
Responding to outbreaks of disease
Measles epidemics occurred throughout
the country in 2010. MSF teams vaccinated2,700 children in Nyanzale, North Kivu,

© Robin Meldrum

AFRICAA support team and much-needed ice packs, which keep medication cool, arrive at Bebongo village, northern Bandundu province.

nearly 90,000 in the Baraka area in South
Kivu, 103,000 in Sakania, 40,000 in Dilolo
and 8,000 in Bendera in Katanga province.
The poor living conditions in displaced
persons camps and the lack of clean water
also facilitated the spread of cholera in South
Kivu in 2010. MSF emergency teams set up
cholera treatment centres and treated morethan 1,600 patients in Kabizo, Makobola,
Minova, Mwenga and Shabunda. MSF
staff supported the response to cholera
outbreaks in two displaced persons camps in
Kalemie, Katanga province, providing casemanagement expertise and medical supplies.
Malaria is among the leading causes of
illness and death in DRC. MSF teams treated
27,000 patients in Katanga province, 26,000
in North Kivu, and 19,000 in South Kivu.
Many were children under five.
Haut-Uélé and Bas-Uélé are two of theareas in Africa most affected by sleeping
sickness. MSF staff treated 829 patients forthis deadly disease, which is transmitted tohumans through the bite of the tsetse fly.
Obstetric fistula surgery
In Masisi hospital in North Kivu, and in

surgical “camps” in Shamwana and Manono
in Katanga, more than 130 operations
were carried out on women suffering fromobstetric fistulas. Fistulas are injuries to thebirth canal which can occur as a result ofcomplications in childbirth or, occasionally,
extreme sexual violence, and which can causeincontinence and crippling social stigma.
Specialised emergency burns intervention
In July, MSF launched a specialised
emergency intervention when a fueltanker crashed and exploded in Sange inSouth Kivu. More than 230 people diedand 96 were seriously injured. Teams
provided medical care and mental healthsupport to 52 patients with severe burns
in two hospitals in the region. Surgeons
conducted skin grafting (a skin transplantthat encourages rapid healing), and teams
provided burns patients with individual
intensive nursing care and physiotherapy.

MSF also began supplying medication,
financial and technical assistance to “Postes
de Distribution”. These are community-based
ARV distribution points that give patients
responsibility for their own care. The centres
were set up and are managed by people
living with HIV/AIDS who are members of
the Réseau National d’Organisations Assises
Communautaire (RNOAC), a nationwide
patient support group.
At the end of 2010, MSF had 2,766 staff in the
Democratic Republic of the Congo. MSF has
been working in the country since 1981.

HIV/AIDS
Teams started more than 850 new patientson antiretroviral (ARV) treatment in MSF’s
HIV/AIDS project in Centre Hospitalier de
Kabinda in the centre of Kinshasa in 2010,
bringing the total number of patients
receiving the medication to 2,631.

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

31

AFRICA© Marcus Bleasdale / VII

Djibouti

A child is given a gastric nasal tube to help feed her, MSF’s inpatient feeding centre, Djibouti.

Djibouti city
Ambouli
Regions where MSF has projects
Cities, towns or villages where MSF works

Drought, rising food prices
and increased numbers of
migrants passing through thecountry have had a profound
impact on Djibouti. Levelsof malnutrition exceeded
emergency thresholds in a
number of locations in 2010.
Médecins Sans Frontières (MSF) has
concentrated its efforts on reducing
malnutrition among children in theslums of Djibouti City.

32

Treating malnutrition in the capital
In 2010, MSF provided medical care formalnourished children in the districts ofBalbala, Hayableh, Arhiba and PK12. These
districts are home mainly to migrants,asylum seekers and Djiboutians who have
moved to the city from rural areas.
In order to reach as many of the 200,000
inhabitants of the slums as possible, teams
travelled from door to door to identify
acute malnutrition in children and to raiseawareness about the disease. According totheir level of malnutrition, children werereferred to one of six MSF feeding centres
that provide outpatient care, or to MSF’s
35-bed therapeutic feeding centre, wherechildren suffering from malnutrition withcomplications receive 24-hour medical care.
Almost 1,030 malnourished children were
hospitalised in 2010 and more than 3,620
received outpatient care.
MSF also vaccinated young patients against
measles and provided medical follow-up.
In 2010, almost 140 malnourished children
in the feeding centres tested positive fortuberculosis (TB). Staff treated the children

MSF PROJECTS AROUND THE WORLD – AFRICA – Djibouti

for both TB and malnutrition before referring
them to the national TB programme.
Chronic food insecurity
Fluctuating rainfall and drought are intrinsic
to arid and semi-arid lands such as Djibouti.
The agricultural community is able to meet
only 25 per cent of domestic food demand,and the country is heavily dependent on
imports. Rising food prices and migrants
passing through the country, who in manycases have left their homes due to foodshortages, place additional burdens on foodsecurity. Malnutrition is chronic, and cases
increase between the months of August andNovember, a period known as the hunger
gap, when food stocks tend to run out. MSF
found that admissions to some of its feeding
centres doubled during the hunger gap.
In August 2010, a fire in the district of
Ambouli left 125 families homeless. MSF
organised a distribution of food and otherrelief items for the affected families.
At the end of 2010, MSF had 128 staff in Djibouti.
MSF has been working in the country since 2008.

AFRICA

EGYPT
Cairo

Egypt’s public health system is well established, but has limitations
in fields like maternal health. Despite healthcare being subsidised,people with low incomes may still not be able to access care.

and migrants who mainly come from
Somalia and Sudan.
Regions where MSF has projects
Cities, towns or villages where MSF works

Since 2009, MSF has developed an extensive
network of contacts in the country, which
is helping us identify gaps in healthcare
and is facilitating our efforts to provide
assistance in Egypt. At the end of 2010,
MSF’s registration in the country was
being processed.
At the end of 2010, MSF had 19 staff in Egypt.
MSF started working in the country in 2010.

© MSF

In 2010, Médecins Sans Frontières (MSF)
began supporting the Egyptian organisation
Al Shehab in opening and operating amaternal and child health clinic in the
Cairo slum of Ezbet el Haggana, home tohundreds of thousands of people. Residents
include Egyptians who have left their rural
homes, long-term inhabitants of Cairo,

MSF provided technical and managerial
supervision to Al Shehab staff working in theclinic. From June until November 2010, clinic
staff carried out more than 5,200 paediatricconsultations, referring patients to national
health facilities for vaccinations. Almost 1,500
antenatal consultations were held, and morethan 200 women were referred to hospitalfor delivery. The referral system ensured
all patients received free care in hospital.
Administrative considerations relating to

Al Shehab’s clinic registration meant thatthe clinic’s activities had to be suspendedin November 2010.

A patient leaves a consultation with a prescription for free medication that can be collected from a designated pharmacy nearby, Cairo.
MSF PROJECTS AROUND THE WORLD – AFRICA – EGYPT33

AFRICA

ethiopia
In 2010, Médecins Sans
Frontières (MSF) helped tomeet health needs in four
regions: Somali, Oromia,
Amhara and Gambella.

Somali region
The Somali region is one of the least
developed in Ethiopia and is particularly
prone to food insecurity. Poor water
quality makes water-borne diseases likeeye infections, skin disease and diarrhoea
common, and tuberculosis (TB) is a major
public health problem. The few healthservices that are available are hard to reach.
Military confrontations between government
forces and insurgent groups make access tohealthcare even more difficult. Infrastructure
and public services suffer from the insecurity,and it is difficult to attract qualified medical
staff from other parts of the country.

Gambella

OromiaSomali Regional state

Regions where MSF has projects

programme was started in December 2010,
and 15 patients were admitted to theprogramme during that month.
In West Imey, MSF continued to support ahealth centre that provides general medical
consultations, antenatal care, treatment formalnutrition and vaccinations. Today, anaverage of 1,000 medical consultations areheld at the centre each month. Teams havestarted holding weekly mobile clinics for
those who live far from the centre. In 2010,
more than 29,300 people were treated in
East and West Imey.
Parts of Wardher zone, in the east ofSomali region, are also affected by armed
conflict between the Ethiopian army andthe Ogadeni National Liberation Front.

© Julie Rémy

East and West Imey districts are located on
the border between Gode and Afder zones,
toward the south of the Somali region. In
July 2009, an MSF team built a health centre
in East Imey town. By October, the centre
was able to provide a full range of services,
including antenatal care, a 15-bed inpatient
department, a maternity ward, a nutrition
programme and a vaccination programme.
In 2010 staff at the centre held medical
consultations with more than 800 people eachmonth. Patients requiring more specialisedcare were taken to the nearest hospital, in
Gindir, which is between six and eight hours’
drive away. A TB diagnosis and treatment

AmharaA nurse examines a patient in East Imey clinic.

34

MSF PROJECTS AROUND THE WORLD – AFRICA – ethiopia

MSF supported several Ministry of Healthfacilities in three of the zone’s four districts,
providing basic healthcare, reproductive
healthcare and treatment for malnutrition
and TB. MSF staff also cared for more than
1,400 patients at the inpatient department
in 2010. Staff held more than 63,700
consultations, assisted 342 births, andadmitted 158 patients to the TB programme.
In 2010 more than 1,200 patients weretreated for measles.
MSF supported the Regional Health Bureau’s
hospital in Degehabur, in the north of
the region. Teams provided antenatal andpostnatal care, family planning services,maternity services, treatment for sexual andgender-based violence, emergency services,
an inpatient therapeutic feeding centre,a general medical ward and outpatient
consultations. Mobile medical teams visited
more remote communities, offering healthand hygiene education, general consultations,
nutritional screening, psychosocial counselling
and referral of patients requiring more
specialised care to hospital.
Violence and insecure living conditions in
Somalia have led many Somalis to crossthe border into Ethiopia. At Dolo Adotransit camp, in the south of Somali region,
MSF provides emergency medical careto refugees before they move on to the
Boqolmayo and Malkadida refugee camps.
At these camps, MSF offers basic healthcare,a nutrition programme and measles
vaccinations. Staff also provide maternity
and paediatric care, nutritional assistanceand vaccinations at a health centre in the
town of Dolo Ado.
Oromia region
In Anchar district in Oromia region, 300
kilometres east of the capital Addis Ababa,© Julie Rémy

AFRICAA patient injured in a fight has his wound cleaned and dressing changed, West Imey clinic, Somali region.
there is not enough food even when theharvest is good. MSF staff make regular visits
to 25 Ministry of Health feeding centres,
where they also ensure supplies of drugs
and food rations. In 2010, 533 severely
malnourished children received treatment at
the centres. A 20-bed inpatient therapeutic
feeding centre provided care for 147 severely
malnourished children who also had medical
complications, such as pneumonia or
anaemia, and needed intensive medical care.
With the help of an MSF health promotion
team, community members set up committees
to improve the care being provided forchildren with malnutrition. Committee
members referred children they suspected tobe suffering from malnutrition to the feeding
programme and helped to trace patients that
had missed visits to the feeding centres.
In an effort to prevent children becoming
seriously malnourished, MSF started a
supplementary feeding programme, providing
food rations to children, pregnant womenand breastfeeding mothers in earlier stages ofmalnutrition. More than 1,000 children and680 women were admitted to the programme.
Amhara region
Migrant labourers travel north from allover Ethiopia to work in the Amhara region
during the sowing and harvesting seasons.

Levels of kala azar (visceral leishmaniasis)
and TB are high among the region’s largely
transient population, and the prevalence of
HIV/AIDS is twice the national average. But
there are few health structures in the region.
In Abdurafi, a town near the border with
Sudan, MSF focuses on diagnosing andtreating kala azar, a deadly disease spread by
the bite of the sand fly. Almost 1,500 people
were screened for kala azar in 2010, and394 patients were treated for the disease.
MSF staff also provide care for HIV/AIDS and416 patients began antiretroviral treatment.
Nearly 600 patients were admitted to thenutrition programme.
In the district of Telemt, MSF began an
emergency response to the deteriorating
food situation in the area. Working in eight
different locations, staff treated more than
960 severely malnourished children. The
project was handed over to the Ministry of
Health at the end of 2010.
Gambella region
The Nuer population of the Gambella
region, in the far west of Ethiopia, hasgrown as people have crossed the borderto escape violence in south Sudan. In May
2010 MSF moved into a new health centre.
Staff held close to 29,000 consultations,and 873 patients were hospitalised.

The main illnesses suffered by patientswere respiratory tract infections, diarrhoea
and malaria. Maternity staff assisted anaverage of 10 births per month. Dependingon the season, mobile teams travelled by
car or by boat to provide care to the mostisolated populations, carrying out 6,800
consultations between April and December.
At the end of 2010, MSF had 1,049 staff inEthiopia. MSF has been working in the country
since 1984.

Sefinas18 years old
Sefinas has kala azar. He has been in
MSF’s clinic for the past two weeks. “Theillness had weakened me, I would havedied if I had not come here”, he said.
“Now my body is strengthening, themedical staff are following me day andnight, I am getting injections and food.”
Sefinas says that he will make sure notto get reinfected with kala azar, and will
apply basic rules about prevention that hehas learned from MSF staff. “I will resume
my work in the farms after I get cured anddischarged. I have a bright hope now.”MSF PROJECTS AROUND THE WORLD – AFRICA – ethiopia

35

AFRICA

GuineaConakry
Guéckédou
Regions where MSF has projects

Health facilities are poorly
distributed across Guinea, andthe health system lacks staff,
medicine and equipment.
Where the national healthsystem cannot meet needs,
people are likely to turn to
expensive private clinics
or traditional medicine.
Médecins Sans Frontières (MSF) works inthe capital Conakry and the remote regionof Guéckédou, providing paediatric care,and treatment for malaria (the main causeof child mortality) and HIV/AIDS.
Paediatric care in Conakry
Residents of Matam, a district of Conakry,
can rarely afford to go to public healthcentres, and this has a particularly heavy
impact on the wellbeing of young children
and pregnant or breastfeeding women.
Almost half of all children who die before
they are one month old have never beentaken to a health facility.
MSF is working with the national healthauthorities to implement a paediatricprogramme in three centres in Matam.
Sixty community health workers have been
hired to help encourage people to makeuse of the health centres. More than 42,400
consultations were carried out in 2010,
including 14,200 for malaria.
MSF staff also work at the National Institutefor Children’s Health in Conakry, training
and advising medical staff and ensuring freecare and drugs for children referred to theneonatal and nutrition wards of the institute.
Almost 2,300 children were admitted to
the neonatal department in 2010 and morethan 1,000 were admitted to the feeding
centre from March 2010, when MSF started
activities, to December.

36© Julie Rémy

Cities, towns or villages where MSF works

A member of staff prepares medication for HIV patients at Matam health centre, Conakry.
Reaching rural populations
Each year, malaria affects more than aquarter of the population of Guéckédou, anarea in the south of the country around 700
kilometres from the capital. Artemisinin-based
combination therapy, which is more
effective than the treatment traditionallyused against malaria and prevents thedevelopment of drug resistance, is now
available in Guinea, but the drugs are still
difficult to obtain in remote areas.
MSF has begun a project in Guéckédou tobuild a community-based malaria prevention
and care system. Teams support the
emergency and paediatric departments in
Guéckédou hospital, but also work in
15 health centres. MSF’s community healthworkers distribute mosquito nets, conduct
awareness campaigns, and implement early
detection measures, ensuring that people
with malaria receive treatment as rapidly
as possible. In the last quarter of 2010,
when MSF started activities, more than
9,700 consultations were held with patientsthought to be affected by malaria. Morethan 5,800 patients were diagnosed withand treated for malaria.
Treating HIV/AIDS
The prevalence of HIV/AIDS in Guinea is
not high compared with some countries
in sub-Saharan Africa, but there are major
gaps in the national HIV programme. MSF’s
projects are the main initiatives on HIV inthe country, but only cover some of the HIV
care needs. More than 5,000 people werereceiving antiretroviral (ARV) treatment fromMSF PROJECTS AROUND THE WORLD – AFRICA – Guinea

MSF at the end of 2010, about one-thirdof those being treated in the country.
Four health centres in Conakry receive
support in providing HIV care. MSF supplied
medicines, power and water to the centres.
A team supervises activities relating to HIV/AIDS and trains HIV/AIDS staff. In 2011, MSF
will work with two more health centres in thecity, strengthening prevention of mother-tochild transmission services in particular.
At the end of 2010, MSF had 213 staff in Guinea.
MSF has been working in the country since 1984.

Aïssata“I am a 36-year-old woman, and it wasin 2009 that I found out about my HIV
status. I was very troubled by the news,
which almost pushed me to suicide. I was
discriminated against and stigmatised.
“I ended up being referred to the healthcentre in Matam, the centre of MSF’s
programme in Conakry. I had a checkup and I weighed only 42 kg. I felt I
was accepted and listened to, especiallyby the psychosocial team, who gave mea lot of information about HIV/AIDS– and the ARV treatment is free.
“A fter six months I weighed 82 kg. Notlong after, I was recruited by MSF asan ‘expert patient’ to help others withthe disease. Today, I feel positive about
my life.”AFRICA

kenya
Kacheliba

TurkanaBusianyanzaNairobiDadaabNorth Eastern province

There are 1.5 million people living with HIV/AIDS in Kenya,
and Médecins Sans Frontières’s (MSF) work in the country
continues with a strong focus on HIV care. Teams are also
providing relief and healthcare to hundreds of thousands ofSomali refugees living in camps around the town of Dadaab.

Regions where MSF has projects

Healthcare in North Eastern province
The camps near Dadaab, where Somalis seek
refuge from civil conflict at home, are filled
beyond capacity. Some 300,000 people
are living in a space made for 90,000, andnew arrivals have been forced to settle inmakeshift shelters outside. MSF has taken
charge of the healthcare needs of refugees
living in Dagahaley camp.
“E ach week, we have 1,400 or 1,500 new
arrivals from Somalia. This is making thecamp very overcrowded, and it means thereis less space and many more difficulties for
those who are already living here”, said
Mohammad Daoud, MSF’s field coordinatorin Dagahaley. MSF runs a 110-bed hospitaland four health posts, holding on average
10,000 general consultations and admitting
600 patients to the hospital every month.
In July MSF signed a memorandum of
understanding with UNHCR, the UN refugee
agency, for the provision of health services
in a second camp, Ifo 2, located less thanten kilometres away from Dagahaley, which
would accommodate 80,000 refugees.
Construction work began and refugees were
due to be relocated in November. However,negotiations between the Kenyan authorities
and the UN stalled and by the end of 2010
no relocations had taken place.
In addition to continuing medical services in
Dagahaley camp, MSF also provided sheltermaterial to 700 families and, with otherorganisations, ensured the supply of water
for the new arrivals.
In 2010 MSF teams began working in the
remote Ijara district, which is also host to
many refugees. Staff focused on reproductive
healthcare, working in Sangailu dispensaryand Hulugho hospital, and aim to expand
services to include immunisation andtuberculosis (TB) care.
Taking HIV care to the community
Massive gains have been made in the fightagainst HIV/AIDS and TB in Kenya, but many

people still suffer from these diseases. Homa
Bay, along the shores of Lake Victoria, is the
district most affected. In collaboration with
the Ministry of Health, MSF ensured thattreatment is available in eight clinics acrossHoma Bay: 10,000 people living with HIV
received care, of whom 850 were children
under 15 years of age.
In the capital Nairobi, MSF provides HIV/AIDS and TB treatment in two slum areas,
Mathare and Kibera. Here, some 7,400
people living with HIV/AIDS are currently
receiving care at MSF’s clinics and 5,800
are on antiretroviral (ARV) treatment.
In Kibera, MSF has set up a task force withlocal authorities to facilitate the handoverof three health facilities to the Ministryof Health. As part of the handover, a newhealth centre will be built just outside theslum to provide healthcare to local people.
After 10 years, MSF’s HIV/AIDS project inBusia, a rural region in western Kenya,
was handed over to other organisations.
The project has effectively shown that ARV
treatment with good outcomes is feasible
in resource-poor rural settings, and that
ARV treatment and the empowermentof people living with HIV reduce stigma
and discrimination.
Sexual violence in the slums
Both the Mathare and Kibera projects havea particular focus on gender-based violence.
In Kibera, the sexual violence clinic moved
into its own building, so that patients could
access services with greater confidentiality.
Meanwhile in Mathare, staff started operatinga 24-hour on-call service. The clinics offer
post-exposure prophylaxis – medicationthat greatly reduces the risk of HIV infection– counselling and social support. Staff treat
around 70 patients every month, many ofwhom are children.

© Julien Rey

Cities, towns or villages where MSF works

A doctor examines a patient sufferingfrom malnutrition in Dagahaley hospital,
North Eastern province.

neighbouring districts of Turkana Central
and Turkana South. Teams support and train
Ministry of Health staff in the use of first-line
medication and, where that fails, second-line
medication. Kala azar is spread by sand flies
and is fatal if left untreated. MSF is lobbying
for treatment to be provided free of charge
by the Ministry of Health and for rapid testing
methods to be implemented more widely.
At the end of 2010, MSF had 691 staff in
Kenya. MSF has been working in the country
since 1987.

Making kala azar a national priority
After seven years of working with kala azar
(visceral leishmaniasis) patients in Pokot,
near the border with Uganda, MSF started
a kala azar training programme in the

MSF PROJECTS AROUND THE WORLD – AFRICA – kenya

37

AFRICA© Zethu Mlobeli

lesotho

A nurse examines a baby at St Barnabas clinic.

MaseruRegions where MSF has projects

Lesotho is the poorest, highHIV-prevalence country in theworld, with an estimated 280,000
people living with HIV/AIDS.
More than 10,000 people havetuberculosis (TB) and 76 per centof them are HIV positive.
In 2010, Médecins Sans Frontières (MSF)
completed a pilot project in collaboration
with national health authorities that provided
integrated HIV and TB care in local health centres.
The project was carried out in 14 rural clinics
and a hospital south of the capital Maseru,
serving a population of around 220,000. At the38

start of the project, around 31,000 people in
the area were living with HIV and about 9,000
were in need of antiretroviral (ARV) treatment.

testing, ARV and TB treatment for adults andchildren, follow-up, and prevention of motherto-child transmission of HIV.

Integrated HIV and TB treatment
The project adopted a new operational
strategy in order to have a rapid impact on the
lives of people with TB and HIV in a context
of extreme health needs. The team in Lesotho
applied strategies and best practices from MSF
projects in other countries in the region. Staff
integrated HIV and TB care in local clinics, sothat co-infected patients could receive all theirtreatment in one place, not too far from home.
To enable provision of integrated HIV and TB
care in a context with a critical shortage ofhealth workers, routine tasks that had beenpreviously carried out by doctors were shiftedto trained nurses. This not only increased thenumber of medical staff available to carry out
the work, but also built up the skills of local
health staff and encouraged a cooperative
professional network. The project also
employed lay counsellors, many of whom are
HIV positive. By June, when the project washanded over to the national health authorities,
close to 7,000 people had been initiated on
ARV treatment. All 15 sites were staffed andequipped to provide comprehensive HIV and
TB services, including HIV counselling andFocus on maternal health
The annual number of deaths from pregnancyrelated causes has more than doubled in Lesotho
since 2000. According to the World HealthOrganization, almost 60 per cent of these deaths
are a result of HIV, as pregnant women with HIV
are more susceptible to opportunistic infections.

MSF PROJECTS AROUND THE WORLD – AFRICA – lesotho

In 2011, MSF will start a new project focusing
on reducing the rates of illness and deathamong pregnant women and babies inLesotho. It aims to demonstrate that the
number of infant and maternal deaths can be
reduced by integrating HIV and TB care withmaternal and reproductive health services, andby starting patients on ARV treatment sooner.
The project will also reinforce basic healthcare
services, decentralise services to bring themcloser to people’s homes, encourage nursecentred care and improve HIV care, particularly
prevention of mother-to-child transmission.
MSF will encourage robust community
involvement in order to reduce stigma, increaseawareness and provide advocacy.
Field staff working in Lesotho are integrated
with the figure for South Africa. MSF has beenworking in Lesotho since 2006.

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

After 14 years of civil war
ended in 2003, Liberia’s
government embarked on theenormous task of rebuilding
the country’s health systems.
In 2010, after 20 years of emergency healthcare
provision in Liberia, Médecins Sans Frontières(MSF) closed its final two hospitals and theMinistry of Health took over responsibility forthe services that MSF had been providing.
Today, MSF remains in the country to provide
comprehensive medical and psychologicalcare for survivors of sexual violence.

On Bushrod Island, a very densely populatedarea of Monrovia, MSF ran the 150-bed Island
hospital. The hospital provided neonatal
intensive care and maternal emergency
services, as well as offering treatment forchronic diseases such as HIV/AIDS andresponding to medical emergencies in thearea. In response to a measles outbreak in
2010, staff set up a tent within the hospitaland treated more than 550 patients.
Benson hospital was opened in 2003, inan eastern suburb of Monrovia known as
Paynesville, which is mainly home to displaced
people who had come to the city in search ofrefuge from the conflict. The hospital provided
a full range of services and housed the largest
care programme for sexual and gender-based
violence in Liberia. Between 2007 and 2008,
with improvements in the national healthsystem, MSF handed over many of its services
and concentrated on specialist paediatric,
gynaecological and obstetric care. From January

to April 2010, more than 1,560 children received
free medical care in Benson hospital and some
320 babies were delivered. The Ministry of
Health has now taken over these services too.
MSF has set up a new hospital (James N.
Davies Junior Memorial Hospital) in Jacob
Town Neezoe, Paynesville, and donated it
to the Ministry of Health. This should help
to ensure that the closure of Benson andBushrod Island hospitals does not create
major gaps in healthcare provision. MSF also
added 80 beds to the paediatric department
and increased support to the paediatricservices available in Monrovia’s main public
hospital, Redemption hospital, by providing
training, staff and medicines.
Sexual violence
In July 2010, MSF began a new project inMonrovia in collaboration with the Ministryof Health, providing free care to survivors of
sexual violence in two health centres. The
programme provides comprehensive care,including medical treatment, psychologicalcare and legal support. In 2010, staff treatedmore than 720 patients, 89 per cent ofwhom were under 18 years of age.
At the end of 2010, MSF had 147 staff in Liberia.
MSF has been working in the country since 1990.

© Julie Rémy

Hospital handoverDuring the civil war, MSF provided emergency
medical care and humanitarian assistance inmany of the 15 counties in Liberia. Since the endof the war in 2003, the organisation has been
gradually handing over its activities. In June
2010, MSF finalised the handover of its last two
hospitals in Monrovia, the capital. On average,
MSF treated more than 20,000 women andchildren each year in these two hospitals.

A mother at the door of her child’s room in the burns unit of Island hospital, Monrovia.
MSF PROJECTS AROUND THE WORLD – AFRICA – liberia

39

AFRICA

malawiThyoloassisting the Ministry of Health in instituting
the provision of decentralised healthcare for
HIV and tuberculosis (TB) from district-level
hospitals to community clinics and rural
health posts.
Chiradzulu

Regions where MSF has projects

In 2010, Malawi experienced
its worst outbreak ofmeasles since 1997: 105,000
cases and 251 deaths werereported. Between April
and August Médecins Sans
Frontières (MSF) teams
helped authorities deal withthe outbreak, conducting avaccination campaign in nine
districts among 3.3 million
children aged between six
months and 15 years.
MSF also supported the treatment of nearly
23,000 people for measles in 15 districts
across the country, with a particular focus on
the hard-hit southern region. The responseto the emergency involved almost 1,800
MSF staff.

Since 2007, MSF has helped local healthauthorities achieve and maintain universal
access to ARV treatment for people livingin Thyolo district, in southern Malawi.
(Universal access is defined as the provisionof treatment to at least 80 per cent ofpatients in need.) This was accomplishedthrough a combination of decentralisationof services, task-shifting from doctors tonurses, and the simplification of testing andtreatment protocols. As of December 2010
more than 29,000 patients in Thyolo had
started ARV treatment through Ministry of
Health facilities, with support from MSF.
In the neighbouring district of Chiradzulu MSF
supports HIV programmes in 11 health centres,
offering testing, holding consultations,
supplying medicines, and providing
dedicated TB treatment services. By theend of 2010 more than 18,000 people livingwith HIV in Chiradzulu were receiving ARVtreatment, with some 650 new patients
starting the programme each month.
Dealing with healthcare staff shortages
In Malawi’s rural areas, where few healthpersonnel choose to work, needs for medicalcare are huge. Between 2006 and 2009 MSF
established new approaches to providing HIV
care. Teams transferred skills from doctors tonurses and simplified treatment guidelines
to help improve the provision of care closer
to home. To meet the challenges of retaining
skilled health personnel in rural areas MSF has
also implemented scholarships for students
in healthcare training programmes andhosted health worker retention conferences.
In collaboration with the Ministry of Health,
MSF has contributed to several other nonfinancial incentives and motivation strategies.
Impact of international HIV funding retreat
Despite having ambitious HIV treatment
programme guidelines in line with new
World Health Organization recommendations,
implementation of these plans will be delayed
or staged according to available resources.
Malawi did not receive much-needed moneyfrom the Global Fund’s most recent round offunding, which ended in December 2010.
Dwindling funding commitments point to a
growing disconnect between the international
community’s bold and ambitious visions forachieving global health goals, and its inability
to fully support such recommendations.
At the end of 2010, MSF had 827 staff
in Malawi. MSF has been working in the
country since 1986.

HIV/AIDS treatment
In 2003 MSF started providing ARVtreatment to people with HIV in Malawi andits programmes soon evolved to include theprevention of mother-to-child transmission,
the detection of treatment failure, and theprovision of paediatric HIV care. MSF is also40

© Marit Helgerud

Malawi has an ambitious HIV/AIDS
treatment plan, but it continues to face asevere shortage of healthcare professionals.
A lack of international donor commitments
to implement the treatment plan makes thefight against HIV a mammoth task. In 2009
more than 920,000 people (11 per cent ofpeople aged between 15 and 49 years) were
estimated to be infected with HIV, while thecountry had an average of only two doctors
per 100,000 inhabitants. By the end of
2010, more than 345,000 people had beenenrolled in the national antiretroviral (ARV)
treatment programme, representing an
estimated 63 per cent of patients requiring
ARV treatment.

One of more than three million children vaccinated against measles in Malawi in 2010.

MSF PROJECTS AROUND THE WORLD – AFRICA – malawi

AFRICAMali
Koulikoro

SikassoMali has seen a reduction
in humanitarian assistancebecause of the presenceof groups linked to AQIM
(Al Qaeda in the Islamic
Maghreb) in the country.
Health needs are significant,and child mortality rates
are high. Médecins Sans
Frontières (MSF) focuses onchild healthcare in the regionsof Sikasso and Koulikoro.
Child health in Koutiala
Rates of malnutrition and malaria are highin Mali. In the southern district of Koutiala(Sikasso region), near the border with
Burkina Faso, more than one in five children
die before reaching the age of five. In July
2009, MSF started offering paediatric care,including treatment for malnutrition,
to children under five in Koutiala town andin five of the 42 health areas in the district.
In 2010, staff conducted consultations
with more than 48,100 children, 33,300
of whom were diagnosed with malaria.
A further 5,360 children were treated forsevere malnutrition.
MSF helped to increase the capacity of thepaediatric department in the district hospitalof Koutiala. A team of MSF and Ministry of
Health staff set up a paediatric intensive careunit, built wards to allow the hospitalisationof malnourished children, provided medicalcare, offered staff training and assured a
regular flow of drugs and medical material.
More than 9,900 children were admitted tothe hospital in 2010. Malaria was linked tomore than 82 per cent of hospitalisations in
the paediatric ward.
Early detection andprevention in Konseguela
The Ministry of Health and MSF began a joint
project in the district of Konseguela, also in© Antoine Prus

Regions where MSF has projects

A paediatric consultation in Konseguela, Sikasso region.
Sikasso region, in March 2010. The project
aims to find new approaches to reducing
mortality among children under five, andfocuses on simplifying and decentralising thetreatment, early detection and preventionof the main killer diseases – malaria,
malnutrition, pneumonia and diarrhoea.
A baby clinic is held at the health centre inKonseguela, offering regular check-ups forchildren under two. These children receive
ready-to-use food in an effort to prevent
severe levels of malnutrition. In December
2010, more than 1,250 children were receiving
this food. Families with young children also
receive mosquito nets. Almost 50 per cent of
the 15,000 consultations held at the healthcentre in 2010 related to malaria.
Every month, a team visits all 17 villages
in the district and carries out routine
immunisations against tuberculosis, polio,
diphtheria, tetanus, pertussis (whooping
cough), hepatitis B, Haemophilus influenzae
type b (which can cause meningitis andpneumonia), measles and yellow fever.
In July 2010, trained staff in all of thevillages began carrying out early screening
for malaria, offering a rapid diagnostic
test and treatment in order to reduce thedevelopment of severe forms of the disease.
Staff treated 9,400 children under five fornon-complicated malaria in 2010.
The programme has achieved a very highlevel of adherence. Of 1,775 children who
received the first dose of the pentavalentvaccine (which provides protection against
five diseases), 1,773 successfully completed
the three-dose course. A sharp decrease inchild mortality has been reported by local

authorities and communities since MSF
began activities in Konseguela.
Preventive meningitis vaccination campaign
In December 2010, MSF participated in thenational preventive vaccination campaign
against meningitis using a new vaccinethat provides extended coverage against
the disease (over ten years) and stops
transmission by eliminating the carriageof the germ. With Ministry of Health staff,
85 teams vaccinated more than 728,900
people aged between 1 and 29 years inthree districts of the Koulikoro region.
Malaria in Kangaba
Since 2005, MSF has been supporting
11 health centres in collaboration with thehealth authorities in Kangaba province,
Koulikoro region. As well as increasing
access to basic healthcare, the project hasa specific focus on malaria. Free care isoffered to children under the age of fiveand pregnant women. Since the project
started, the number of children under fivevisiting health centres has increased by
800 per cent. MSF has also trained 66 healthworkers, who visit villages that are morethan five kilometres from the nearest healthcentre to test and treat people for malaria.
Child mortality in the area has decreased byhalf thanks to the provision of good quality,
free healthcare closer to home. MSF is using
these results to support its advocacy for thegovernment to provide free healthcare forall children under five.
At the end of 2010, MSF had 380 staff in Mali.
MSF has been working in the country since 1992.

MSF PROJECTS AROUND THE WORLD – AFRICA – Mali

41

AFRICA

morocco
Rabat

Oujda
Casablanca
Cities, towns or villages where MSF works

Morocco is a country of both transit and forced
stay for many migrants and asylum seekers from
sub-Saharan Africa. A growing number of people
are finding themselves stuck in the country,
unable either to continue their journeys to Europe
or return home.

Denise *© Anna Surinyachfrom the Democratic Republic of
the Congo“When we managed to reach the borderof Algeria and Morocco, we had towalk to get to the city of Oujda. The
children were very thirsty, so when I
saw a man on the street I asked him
where I could find some water. He
directed me to a nearby house. There aman gave water to my children. While
my children were drinking the wateroutside the house, two men forced
me inside the house and raped me,
one after the other. They beat me andthey raped me. And then they threw
me and my children into the desert todie. Luckily we were found by somemigrants who were crossing the desert,
and they brought us to Oujda. ThereMSF helped me receive medical andpsychosocial care.”* The patient’s name has been changed.

Migrants’ makeshift shelters among trees near Oujda.

Migrants and asylum seekers mainly comefrom central and west Africa. Many have left
poverty and unemployment; a large number
have escaped conflict and violence and, insome cases, sexual violence. In the wintermonths, migrants tend to head to the cities
of Rabat and Casablanca, or stay in andaround the town of Oujda, on the Algerianborder, before trying to reach Europe. Living
conditions are extremely poor.
Arrest and deportation across the Algerian
or Mauritanian borders is a frequent
occurrence. Migrants are easy prey for
trafficking and smuggling networks. They
are also at risk of attack and robbery bycriminals who act with total impunity, inpart because of their victims’ irregular
status. This precarious situation affects
migrants’ mental health: 25 per cent ofpeople who had medical consultations

42

with Médecins Sans Frontières (MSF) staff
reported non-specific symptoms usuallyrelated to stress and anxiety.
Direct medical care
MSF began working with sub-Saharanmigrants in Morocco in 2000, and has teams
based in Rabat and Oujda. There are twocomponents to MSF’s work: the provisionof direct medical care and the facilitationof access to the Moroccan health system.
In 2010, MSF staff carried out more than
2,500 medical consultations and provided
psychosocial help to migrants through 182
individual mental health consultations and48 group sessions. Psychosocial support
helps patients to cope with the stresses
and trauma of their lives. MSF staff also
accompanied migrants to health centres,
helping them to access medical care atnational health facilities.

MSF PROJECTS AROUND THE WORLD – AFRICA – morocco

Sexual violence
In 2010, medical staff provided care to 145
victims of sexual violence. MSF found that
one in three women treated by MSF medical
staff in Rabat and Casablanca between May
2009 and January 2010 admitted having
been subjected to one or more sexualattacks in their country of origin, on theirjourney, or in Morocco. Staff gathered
testimonies from 63 patients, 14 of whomwere under 18. These testimonies, which
contribute to MSF’s report Sexual Violenceand Migration, illustrate the extreme
vulnerability of these women throughout
their journey.
At the end of 2010, MSF had 28 staff in
Morocco. MSF has been working in the
country since 1997.

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

Despite Mozambique’s recent
economic growth many
people in the country remain
dependent on international aid.
Of the 1.6 million people livingwith HIV, about 430,000 are inurgent need of life-extending
antiretroviral (ARV) treatment.
Along with HIV, tuberculosis (TB) presents
a serious public health concern, and up to
60 per cent of TB patients are also infectedwith HIV. For the majority of Mozambicans,access to healthcare remains very limited
and the frail healthcare system struggles
with the high number of people infectedby both HIV and TB.
Médecins Sans Frontières (MSF) started caring
for patients with HIV in Mozambique in 2001,
striving to demonstrate the feasibility oftreating HIV in poorly resourced urban areas,such as Chamanculo and Mavalane in thecapital Maputo, and in remote areas such as
the northern provinces of Niassa and Tete.
Over the past decade, MSF has establishedstandardised procedures for HIV care andtreatment, paying special attention to treating
HIV and TB co-infections.
With the number of people receiving ARVtreatment steadily growing, it has become harder
to enrol people in treatment programmes,
especially in areas where there are no
hospitals close by. MSF has focused on
moving HIV care and treatment from central
hospitals to local health clinics. This vital stephas been successfully implemented in manyof MSF’s HIV programmes in Mozambique.
The comprehensive HIV/AIDS programmes
offer testing, pre- and post-test counselling,treatment and prevention of opportunistic
infections that can occur as a result of acompromised immune system, psychologicalsupport, paediatric diagnosis and treatment,

Shortages: doctors and drugs
To ensure that patients get care andtreatment despite the country’s shortageof healthcare workers, MSF is trying todevelop programmes such as task-shifting.
Task-shifting trains nurses to independently
assess patients, diagnose and treat
opportunistic infections, and initiate andmonitor ARV treatment, thereby taking
on some of the responsibilities of doctors.
Where the supply of HIV and TB drugs falls
short, MSF also provides a buffer supply tohealth facilities where it works.
Community ARV groups
In rural Tete province, MSF has piloted
community ARV groups, which empower
HIV patients to participate in the
management of their disease. Consistingof about six neighbours, the group selects
one person each month to visit the healthcentre to collect the ARV drug refills foreveryone. The representative has a medical
check-up while at the health centre and,upon returning, distributes the drugs toother group members, who sign in toconfirm that they have received their refill.
The community group system ensures thatmembers adhere to treatment and enables
group members to support each other inovercoming the stigma associated with
HIV/AIDS in their communities. Treatmentcomplications, however, are addressed
during clinic visits.
This model has reduced the burden on
healthcare services, since fewer patientsneed to queue at health centres for their
medication. It has simplified how patientsin remote areas obtain their ARV refills andhelped those who cannot sacrifice a day atwork for a trip to the clinic. The Ministryof Health has adopted the concept andcommunity ARV groups are expected tobe established nationwide.

© Niklas Bergstrand

Niassaand prevention of mother-to-childtransmission. At the end of August 2010,
more than 200,000 patients were receiving
ARV treatment in Mozambique, some 33,000of whom were being treated with theassistance of MSF.

A child is weighed at the Primero de Maio
day hospital, in Mavalane, Maputo.

were vaccinated in six districts. MSF staff
helped plan the logistics of the campaign
and trained ten vaccination teams from the
Ministry of Health.
MSF has an emergency preparedness system
in Mozambique that is ready to respond tonatural catastrophes and outbreaks of diseasein support of the national emergency bodies.
At the end of 2010, MSF had 507 staff inMozambique. MSF has been working in the
country since 1984.

Measles vaccination
In September 2010, MSF teams conducted
an epidemiological survey in Niassa province
following reports of measles cases andan epidemic in neighbouring Malawi.
As a result, MSF staff worked with the
Ministry of Health to conduct a measles
vaccination campaign: 250,000 children

MSF PROJECTS AROUND THE WORLD – AFRICA – mozambique

43

AFRICA

Niger
Nutritional crises are achronic problem in Niger, but aparticularly poor harvest in 2009
made the 2010 crisis far worse.
Global acute malnutrition rates
among children passed theemergency threshold of 15 per
cent, with more than three percent of under-fives sufferingfrom severe acute malnutrition.
The extent of the food crisis was recognised
early, and the Ministry of Health,international organisations and national
associations treated 328,000 children forsevere acute malnutrition. MSF cared formore than 148,000 malnourished children.
A preventive approach
Even when receiving good care in a high-quality
nutrition programme, between three andfive per cent of patients suffering severe
acute malnutrition will die. For some years,
Médecins Sans Frontières’s (MSF) nutrition
projects in Niger have been implementing
a preventive approach. Children under two
years of age who are suffering moderatemalnutrition or are at risk of malnutrition
are given ready-to-use supplementary food
before their condition can deteriorate to thelevel of severe acute malnutrition.

AgadezTahouaMaradiRegions where MSF has projects

ZinderCities, towns or villages where MSF works

In 2010, this innovative approach was taken up
for the first time by the Niger government, theUN and their partner organisations. An ambitious
target was set: to reach more than 650,000
children. MSF provided supplementary foodrations to more than 202,000 children aged six
months to three years, and preliminary resultsof a survey carried out in Mirriah, Zinder regionand Madarounfa, Maradi region, during thesecond half of 2010 show that this strategy
had a significant impact on mortality rates.
The worst-hit regions
Maradi, Tahoua and Zinder were some of theregions worst hit by the food crisis. MSF andits partner organisations worked to provide
malnutrition care in as many locations as
possible, so that treatment could be soughtcloser to home for more people.

© Yann Libessart

In Maradi, up to five per cent of children were
suffering from severe acute malnutrition. MSF
teams screened and treated children for theillness, trained staff, provided supervisionand supplied medicines to 19 health centres
spread across the departments of Dakoro,
Guidan Roumdji and Madarounfa, and in
Maradi commune.

A mother takes home a supply of ready-to-use
food, Madarounfa, Maradi region.

44

MSF worked with local medical organisation
FORSANI (Forum Santé Niger) in Maradi town
and Madarounfa, and more than 21,300 severely
malnourished children were admitted to theirfeeding programme, almost 5,000 of whom were
hospitalised in therapeutic feeding centres. Morethan 35,000 severely malnourished children
were admitted to the feeding programmes in
Guidan Roumdji and Dakoro. In Madarounfa
and Guidan Roumdji, supplementary ready-touse food was distributed as a preventive
measure to 44,200 children.

MSF PROJECTS AROUND THE WORLD – AFRICA – Niger

In Zinder region, MSF supported 19 healthcentres in the departments of Mirriah
and Magaria with feeding programmes,
providing extra staff and essential drugs toensure free care for children under five.
A network of 250 community health workers
was built up and dispatched across Magaria
to screen children for signs of malnutritionand encourage parents to seek treatment
for their children. MSF managed two
therapeutic feeding centres. More than
34,000 malnourished children received
treatment for severe and acute malnutrition.
The supplementation programme in
Mirriah district reached more than 106,500
moderately malnourished children or
children at risk of malnutrition. MSF also
provided technical support to BEFEN/ALIMA,a local association running 15 outpatient
feeding centres and one therapeutic feeding
centre in Mirriah department.
In Tahoua region, to the west, MSF provided
free medical care and treatment for severe
acute malnutrition at six health centres in
Madaoua department, and treated 18,370
severely malnourished children underfive. More than 2,000 of these children
were admitted to intensive nutritional
rehabilitation centres. In collaboration
with the World Food Programme andlocal associations ADRA and GADED,MSF distributed more than 128,000
supplementary food rations to children
aged between six and 23 months in thedepartments of Madaoua and Bouza.
Malaria
Malnutrition and malaria create a vicious spiral:malnutrition weakens a child’s immune system,
making it more difficult to fight against malaria.
In turn, symptoms of malaria in children© David Di Lorenzo

AFRICAA MUAC (middle upper arm circumference) bracelet is used to check a child for malnutrition, Zinder region.

include anaemia, diarrhoea and vomiting, all ofwhich can cause or complicate malnutrition.
In Zinder, MSF treated more than 72,500
cases of malaria. Over a quarter of thechildren hospitalised for malnutrition werealso suffering from malaria. In total, morethan 216,330 children under five received
treatment for malaria in the regions ofZinder, Maradi and Tahoua.
Maternal and child health
MSF teams supported local hospitals and healthcentres, particularly paediatric and maternal
health services, in many parts of Niger.
In Maradi, MSF supported the maternity andpaediatric departments, and the sterilisationand laboratory services of Dakoro hospital.
More than 2,500 births were assisted andmore than 9,100 children were hospitalised.
Staff also worked in health centres in Dakoro,
and carried out 183,000 consultations withchildren under five.
In Guidan Roumdji hospital, also in Maradi,
MSF provided medical supplies, medicines
and staff to the paediatric department, thelaboratory and the sterilisation service. A
team also installed a clean water supply andsanitation system.
In Tahoua, MSF built a new paediatric ward
for the Madoua district hospital. In Agadez,

MSF teams provided free gynaecologicaland obstetric care in five health centres.
Staff assisted more than 2,600 births.
Agadez is on the main migration routefor people heading to Europe from west
or central Africa, and MSF provided free
medical care to more than 730 migrants
and distributed 690 relief kits.
Meningitis
MSF supported the Ministry of Health’s
vaccination campaign against meningitis:
in total, 490,000 people were vaccinatedagainst various strains of the disease in
Zinder, Maradi, Agadez and Madaoua(in Tahoua region).
With the support of MSF and otherinternational organisations, the Ministryof Health carried out a second vaccination
campaign in Dosso and Boboye departments
in December 2010, using the new vaccine
against meningitis A. The new vaccine
provides four times greater protection thanthe one traditionally used, and this protection
lasts for ten years, compared with three
years for the older vaccine. Another major
benefit is that the new vaccine can help
stop meningitis transmission as it eliminates
the bacteria even in healthy carriers of thedisease so they cannot pass it on to others.
Initial results indicate that more than 90 per
cent of the 627,000 target population was

vaccinated. If the vaccine is used widely,
there is real hope of seeing a sharp dropin the number of meningitis A outbreaks.
CholeraFollowing a cholera outbreak in Zinder, MSF
teams treated 249 patients in two treatment
centres and cleaned four wells to help halt
the spread of the disease.
At the end of 2010, MSF had 1,599 staff in
Niger. MSF has been working in the country
since 1985.

Kelima, 32 andDjamilou, 15 months
Kelima is a mother of four. She brought
her son, Djamilou, who had lost a lot ofweight, to the MSF Intensive Nutritional
Care Unit in Zinder. The doctor
diagnosed both severe anaemia andmalaria and immediately fed the boy
intravenously. Later, he was given
therapeutic food. Day by day, he gained
weight until, two weeks later, he wassmiling again. “We will soon go back to
our village”, said his relieved mother. “This
year, it was really too difficult to feed thechildren, we had only a few handfuls of
millet for the whole family… .”MSF PROJECTS AROUND THE WORLD – AFRICA – Niger

45

AFRICAnigeria
Ethnic and religious tensions
flared again both in the northand the south of Nigeria
in 2010. Health services
continued to suffer froma lack of resources.

Emergency response teams
A Médecins Sans Frontières (MSF)
emergency response unit based in Sokoto, inthe northwest of the country, provided rapid
assistance for disease outbreaks, natural
disasters, violent crises and population
displacements in four states. The teamintervened after flooding in Sokoto state,
distributing relief items and basic medicalcare to thousands of displaced families. The
team also treated patients after outbreaksof measles, meningitis and cholera. In thestates of Katsina, Bauchi and Borno, MSF
teams treated 9,481 patients for cholera
between August and November.

Jigawa

Borno

Niger
BauchiKadunaPlateau

Lagos
Port Harcourt
Bayelsa

Regions where MSF has projects

Cities, towns or villages where MSF works

Lagos
Lagos has a population of around 18 million,
and in such a large city the needs of vulnerable
people are often neglected. In July 2010 MSF
began working at Aiyetoro health centre in
the slum area of Makoko, providing generaland reproductive healthcare, and emergency
care. Malaria, respiratory infections andchronic diseases were the most common
illnesses suffered by patients. Using thecentre as a base, MSF is extending its work via
mobile clinics. The first began work in Ottoin October 2010. In early 2011 a mobile clinic
will serve the Badia and Riverine lagoon areas.

A consultation at the Aiyetoro health centre, Makoko, Lagos.

46

Katsina

Kebbi© Silvia Fernández

In central Nigeria, emergency teams
responded to cholera and measles
outbreaks in Kaduna and Plateau states:
staff vaccinated more than 15,600 children
in Kaduna and treated some 2,600 patientsfor measles. Teams offered assistanceafter violence in the city of Jos, providing
medicines and medical supplies to the main
health facilities.

ZamfaraSokotoMSF PROJECTS AROUND THE WORLD – AFRICA – nigeria

Maternal and child health
The lack of access to healthcare in northern
Nigeria has a heavy impact on womenand children. In Sokoto state, a mobile
medical team supports the Goronyo healthcentre and surrounding villages. The teamprovides general healthcare, including
obstetric and paediatric care, and runs afeeding programme. In 2010, a preventionof mother-to-child transmission programme
was launched at Goronyo for pregnant
women with HIV.
In Jigawa state, 402 women underwent fistula
repair surgery. MSF’s centre in Jahun, which
opened in 2008, also offers comprehensive
emergency obstetric and neonatal care. Suchcare can prevent fistulas, which are injuries tothe birth canal often caused by long labour
without a midwife or the option of a caesarean
section. Many women with obstetric fistulas
have to live with unpleasant and debilitating
symptoms, including incontinence, which
can result in social exclusion. More and more
women are now coming to the hospital to
give birth: there were 3,649 deliveries in thematernity ward in 2010, more than double thenumber in 2009.
A team working from Kazaure hospital,
also in Jigawa state, started providing carefor severely malnourished children in Junefollowing a regional nutrition crisis. Morethan 6,600 children received treatment at thefeeding centre and 1,700 were hospitalised.
Trauma care
Violence remained a problem in the Niger
Delta. The team operating the 75-bed
trauma centre in Teme hospital, Port
Harcourt, was one of the first MSF teams to© Silvia Fernández

AFRICAA new arrival in the maternity ward of Aiyetoro health centre, Makoko, Lagos.
use internal fixation to repair fractures.
This technique allows patients to walk again
within just a few weeks, in contrast to theold traction system, which requires months.
In 2010, MSF staff treated 10,850 people in
the emergency department, 42 per cent ofwhom had violence-related injuries. Overall,more than 2,000 patients were admitted
to the trauma centre, and more than 3,500
surgical interventions were carried out. MSF
also treated 645 victims of sexual violence,
providing medical care and counselling.
Handover in Bayelsa
Since 2008, MSF has been running a healthcentre in Ogbia district, Bayelsa state, in
the Niger Delta. In the first few months of2010, MSF held 4,700 consultations andvaccinated 5,400 children after an outbreakof measles. Local and national authorities
took over the project in April 2010.
Lead poisoning
Small-scale gold mining was directly related
to severe lead poisoning in seven villages
in Zamfara state, in the northwest of the

Flora and Caroline
Flora took over the care of Caroline, her niece, when she was just one day old. The baby
had survived a complicated delivery that had killed her mother, and she herself was not
well. When Caroline was three months old, she weighed less than 3.5 kg. The family took
her to traditional healers and even travelled to neighbouring Benin in their search forsomeone who could help. But nothing worked.
Flora took Caroline to the Aiyetoro health centre soon after it opened its doors. “She wasgiven therapeutic milk and straightaway she started to improve”, says Flora. After tendays in Aiyetoro, Caroline was referred to a long-term treatment programme at the local
children’s hospital, where she stayed for a month. When she had been discharged from
hospital, Flora brought Caroline back to the centre for weekly check-ups. Caroline is now
six months old; she is thin, but strong and lively, and she smiles all the time as she sits on
Flora’s lap.

country. Villagers were crushing and drying
lead-containing ore in and close to theirhomes. At the request of the Ministry of
Health, MSF treated more than 400 children
for lead poisoning in two care centres, andstaff worked with villagers to raise awarenessof the risks of gold mining. The damage isconsidered one of the worst recorded heavy
metal contaminations in the world.
At the end of 2010, MSF had 954 staff
in Nigeria. MSF has been working in
the country since 1996.

MSF PROJECTS AROUND THE WORLD – AFRICA – nigeria

47

AFRICA

Somalia
ceerigabo

Woqooyi galbeed
hargeisa

Regional healthcare services
In the rural districts of Jowhar, Mahadaay
and Balcad, in the Middle Shabelle region incentral Somalia, MSF works from a network offour health centres. Through mobile and fixedclinics, staff offer general healthcare, motherand child care, a nutrition programme, andan extended immunisation programme.
In June, MSF teams began providing
tuberculosis diagnosis and treatment in
the districts of Mahadaay and Gololey.

Galkayogaladuud

Belet Weyne
Middle Shabelle
RegionDinsor

The security situation in Somalia deteriorated further in 2010
and while needs have grown, basic medical services continue
to dwindle. Despite a number of incidents directly affecting its
staff in recent years, Médecins Sans Frontières (MSF) is stillworking in the country.

Teams provide care in hospitals and clinics inanother five regions, working in the towns ofBelet Weyne, Dinsor, Dhusa Mareb, Galkayo,
Guri El, Hinder, Jamaame and Marere. Staff
offer maternal and paediatric care, general
medical care and treatment for malnutrition.
Altogether, more than 240,000 consultations
were carried out in the hospitals. Belet Weyne,
Guri El and Galkayo hospitals also have
surgical departments. In April 2010 MSF set
up a one-week “eye surgery camp” with theorganisation Right to Sight in Galkayo, whichis in the Mudug region in northern Somalia.
More than 3,000 people were screened
for sight problems and more than 600 had
operations to help them regain their sight.

ceased its activities in Hawa Abdi, an area on
the outskirts of Mogadishu mainly inhabited bydisplaced residents of the city. Over three years,
the team had admitted over 8,000 children to
its paediatric department, more than 34,000
children received treatment for malnutrition,and more than 330,000 consultations
had been carried out. MSF continued tosupport the community hospital in Afgooye:
staff provided maternity and general medical
services, consultations and an outpatient
feeding programme for children under five.

In Marere, in Lower Juba region, the provisionof medical care became more difficult after
the local administration imposed a numberof restrictions on operations, including aban on receiving medical supplies by plane
and a prohibition on visits from international
staff. These measures significantly disrupted
support to the project, while flooding,droughts and bad harvests increased healthneeds. Nonetheless MSF staff managed tocarry out 46,315 consultations and admitted
almost 2,000 patients to hospital.

Mogadishu
AfgooyeLower juba
Regions where MSF has projects

Cities, towns or villages where MSF works

International staff are unable to stay forlong periods in Somalia due to the security
risks, so MSF’s projects depend heavily on
the commitment of Somali staff, supported
by teams of specialist staff based in Nairobi
who visit the projects when possible.
Mogadishu
Fighting in Mogadishu was continuous in
2010, with major offensives in February andduring Ramadan in August. It is estimatedthat only 500,000 people remain in thecapital. For these remaining residents,
healthcare facilities are virtually non-existent.
There are two public hospitals, which provide
surgery only for war-related injuries. The
few clinics that are running charge fees forservices that are of unreliable quality.
Daynile hospital is nine kilometres northwestof Mogadishu. MSF provides free emergency
surgery and care for the war-wounded. The
hospital has 59 beds and is equipped with
two operating theatres and an intensive careunit. MSF also provides financial support andmedical supplies. In 2010, more than 5,500
patients were admitted to the emergency
department. Staff performed 1,136 surgeries.

In September, the agreed collaboration between
Dr Hawa Abdi and MSF came to an end and MSF

48© Siegfried Modola

Since it was forced to suspend activities in north
Mogadishu in July 2009, MSF has provided shortterm emergency assistance on several occasions.
The resumption of activities in south Mogadishu,
home to many displaced people and a scene offrequent conflict, is scheduled for early 2011.
MSF staff unload medical goods at Galkayo airport.

MSF PROJECTS AROUND THE WORLD – AFRICA – Somalia© Siegfried Modola

AFRICAA lab technician tests for tuberculosis at Galkayo hospital.
Telemedicine in Guri El
In December, MSF launched telemedicine
technology in Istarlin hospital in Guri El,
central Somalia, in order to provide direct andreal-time support to doctors working in thepaediatric department from a medical specialist
based in Nairobi. The nine telemedicine
consultations that were held in December had
excellent results, and the plan is to expand theuse of telemedicine to other departments.
Natural disasters
In Belet Weyne, central Somalia, after severe
flooding led to the displacement of over
10,000 people, MSF teams distributed plastic
sheeting to help build temporary shelters andscreened children for malnutrition.
Galgaduud experienced a significant drought
at the beginning of the year. The teams
working in Dhusa Mareb, Guri El and Hinder
trucked water to people living in the towns,
delivering 2.9 million litres.
Somaliland
Somaliland declared independence from
Somalia in 1991. The international community,
however, continues to recognise it only as anautonomous region of Somalia. Somaliland
has few natural resources and continued tosuffer from drought, lack of infrastructure
and lack of quality healthcare in 2010. Clanrivalries and tensions were held in check by
government and traditional leaders, andSomaliland remained relatively stable.

Ceerigabo hospital is the main referral
centre for Sanaag region, but it was barely
functioning when MSF’s team arrived in June.
MSF staff supported the emergency surgery
department, the paediatric and maternity
wards, and have established links with healthcentres in the area to encourage referrals.
Between June and December staff performed
28 major surgeries, admitted 127 patients tothe surgical ward, delivered 181 babies andadmitted 68 children to the paediatric ward.
In Hargeisa, regional capital of Maroodi
Jeex region and capital of Somaliland, MSF
provided free basic healthcare to people
who are not recently displaced but still livein camp conditions and cannot afford topay for healthcare. MSF staff carried out
more than 11,400 consultations withchildren under age five and more than
3,500 antenatal consultations.
Measles vaccination campaign
Vaccination coverage in Somalia andSomaliland is poor. MSF carried out a measles
immunisation campaign for children under 15
and a tetanus vaccination campaign for adults
aged between 15 and 49. The campaign
focused particularly on increasing the numberof women protected against tetanus, as they
are more susceptible to infection.
The campaign took place in a district inWoqooyi Galbeed, Somaliland, and in two
districts in Galgaduud, central Somalia. Staff
trained a team of “community mobilisers” toprovide information about the vaccine andthe date and location of the vaccinations.
A telecommunications company also
publicised the campaign by sending key
information to its mobile phone subscribers.
Almost 6,400 children were immmunised
against measles and almost 6,300 women
were vaccinated against tetanus.
At the end of 2010, MSF had 1,461 staff inSomalia. MSF has been working in the country
since 1991.

Abdiwahid
two and a half
When Abdiwahid came to the hospitalin Marere he was suffering from severe
malnutrition, pneumonia, malaria, oral
thrush and anaemia. He was too weakto eat or drink. Abdiwahid’s brother was
also malnourished, but less severely,
and was admitted to the feeding centre.
The boys’ parents had brought theirchildren to an MSF mobile team on theadvice of their neighbours, and theteam had referred the family to Marere.
After two weeks Abdiwahid was able todrink from a cup; he will be discharged
from the hospital in a few weeks.

MSF PROJECTS AROUND THE WORLD – AFRICA – Somalia

49

AFRICAsierra Leone
Freetown

Bo
PujehunRegions where MSF has projects
Cities, towns or villages where MSF works

Médecins Sans Frontières (MSF) continued its
longstanding focus on maternal and child healthin Sierra Leone throughout the year, and in thesecond half of 2010 assisted the Ministry of
Health in the implementation of the new policy.
Maternal and child health
Activities in and around Bo, the second largest
city in Sierra Leone, focused on maternaland child health, and treating malnutrition
and malaria. MSF runs the Gondama Referral
Centre, a 215-bed specialised emergency
hospital just outside the city. The hospital
has a paediatric ward, a maternity ward with
an operating theatre, an intensive care unit
and an intensive therapeutic feeding ward forseverely malnourished children.

general consultations, basic obstetric care, andtreatment for malnutrition and malaria. MSF
provides clinical, administrative and logisticaltraining, drugs and other medical supplies
and equipment, and access to its ambulanceservice to transfer patients to hospital.
Outside the capital of Freetown, MSF is one of
the major maternal and paediatric healthcare
providers in Sierra Leone. In late 2010, MSF
decided to expand its work on maternal
health. Teams supported and trained staff
working in women’s wards, assisted in the
management of critical paediatric cases, andcarried out health promotion activities in thefive MSF-supported centres in Bo and Pujehun.
Ambulance referrals
Many patients were arriving at the Gondama
Referral Centre in a critical condition, with very
severe complications. MSF decided to improve
its ambulance referral system for emergency
cases, positioning ambulances at strategic
locations, closer to the more distant clinics. MSF

also engaged more actively with the national
hospital in Bo and with other ambulance
providers in order to increase capacity for thetransportation of patients requiring emergency
care from rural clinics to hospital.
Malaria diagnosis and treatment
Malaria is extremely common throughout
Sierra Leone. The availability of diagnosis
and treatment for malaria has improved, but
slowness to recognise symptoms, the distanceto health centres and inconsistent drug supplies
can all prevent people from receiving timely
treatment. MSF has trained a network of 140
volunteers to diagnose and treat malaria within
their communities, bringing care closer topeople living in the district of Bo.
In total, MSF treated more than 14,000
hospital patients in a critical condition andcarried out more than 210,000 consultationsin Sierra Leone in 2010.
At the end of 2010, MSF had 439 staff in Sierra
Leone. MSF has been working in the country
since 1986.

© Juan Carlos Tomasi

In the Bo and Pujehun districts, MSF also
provides technical and material support to fivecommunity health centres. These centres offer

In April 2010, the government of Sierra Leone introduced a policyof free healthcare for children under five and for pregnant andbreastfeeding women. But fewer than 200 doctors are employedby Sierra Leone’s Ministry of Health to serve a population
estimated at more than 5.8 million.

An MSF doctor examines a malnourished child at the Gondama Referral Centre, Bo.
50

MSF PROJECTS AROUND THE WORLD – AFRICA – sierra Leone

AFRICA

south africa
MusinaJohannesburg

Khayelitsha
Cities, towns or villages where MSF works

HIV/AIDS and tuberculosis
In partnership with local health authorities,
Médecins Sans Frontières (MSF) conducts
an integrated HIV and tuberculosis (TB)
treatment programme in Khayelitsha, atownship on the outskirts of Cape Town,
which has the highest prevalence of
HIV/AIDS in the country. Seventy-one percent of MSF’s HIV patients in Khayelitsha
are co-infected with TB. The project has
been operational since 1999, and over
the years has demonstrated increasingly
innovative treatment integration of HIV
and TB. Antiretroviral (ARV) treatment was
introduced in 2001, and since then, morethan 17,650 patients in Khayelitsha havebegun ARV treatment.
Over its 12-year history, this project hascontributed to the turnaround in South
Africa’s stance on HIV/AIDS. Collaborations
with local and national health authorities,
as well as operational research partnerships
with the University of Cape Town, have helped
promote a change in approach. Civil society
groups and a vibrant local community have all
helped to reduce the stigma relating to HIV/
AIDS, increase public awareness, encourage
discourse and bring about tangible change innational health policy.
In 2011, MSF, the Ministry of Health and thecommunity of Khayelitsha will mark ten yearsof free ARV treatment and a community-basedmodel of care developed in MSF’s projects
that has had local, national and global impact.
Support groups
MSF’s community support groups for HIV,drug-resistant TB, and youth support© Kenneth M Tong

An estimated 5.7 million
people are living with HIV
in South Africa, which makes
up approximately 17 per centof the world’s HIV population,according to the World
Health Organization.
MSF staff carry out health screening in Caledonian, an inner city area of Johannesburg.
groups have helped people living with HIV
enormously. Facilitated by peer counsellors
and based in the communities where
patients live, the support groups help
members reduce the sense of stigma,
find mutual comfort, adhere to complex
treatment regimens, and encourage young
people to have fun while taking active
responsibility for their treatment. At the Zip
Zap Circus School – a partnership between
MSF, Zip Zap Circus, Cirque du Soleil andothers – children living with HIV learn about
teamwork, responsibility, community andcreativity. They have fun, learn new skills, andimprove their adherence to ARV treatment.
Survival migrants
The term survival migrant was coined todescribe people who leave their homecountry not merely in search of economic
opportunities, but to escape circumstancesthat challenge their survival, such as economic
collapse, a non-functioning healthcare system,
enduring conflict and insecurity, or sexual andgender-based violence.
Over the years, millions of people havearrived in South Africa in search of a better
life. The journey is often difficult and, after
arrival, migrants can face violent xenophobic
attacks. Vulnerable to exploitation fromagents pretending to offer assistance,
migrants do not qualify for refugee statusand, undocumented, they live in constantfear of discovery and deportation.
Many migrants from Zimbabwe find work as
informal agricultural labourers at farms aroundthe border town of Musina. MSF teams travel
to some of the largest farms, and provide freegeneral healthcare and HIV and TB diagnosis
and treatment. In 2010, teams carried out
more than 16,400 consultations in Musina.
More than 250 survivors of sexual violence
received treatment. These patients had all been
attacked on their journey to South Africa.
In central Johannesburg, MSF operates afree clinic located next to a church that hashistorically provided a safe refuge for migrants
living in the inner-city slums.
Healthcare in the slums
There are an estimated 1,300 slum buildings
in inner-city Johannesburg. Many of these
are controlled by organised crime networks
and, in many places, people live in squalid
conditions. There is little or no provisionof clean water or electricity, and residents
are at risk of forced eviction by corrupt
landlords or officials. Residents live inabject poverty, in cramped and unhygienic
conditions that have an impact on healthand personal security.
In 2010, mobile medical teams visited 40 ofthese buildings and carried out consultations
with more than 26,100 patients. Teams also
assisted residents in organising the clean-upof some buildings by providing materials andcontracting waste management services.
At the end of 2010, MSF had 154 staff in South
Africa. MSF has been working in the country
since 1999.

MSF PROJECTS AROUND THE WORLD – AFRICA – south africa

51

AFRICA

sudan
Medical needs among thepeople of Sudan remain
significant, with insecurity
and administrative constraints
hampering efforts to reachthe most vulnerable. In thesouth, access to healthcare isparticularly poor. Médecins
Sans Frontières (MSF)
responded to several medical
emergencies in 2010, including
the biggest kala azar outbreakin the country in eight years,
as well as treating victims ofviolence in Darfur.

Kala azar
The number of cases of kala azar (visceralleishmaniasis), which is endemic in Sudan,reached an eight-year peak in the south ofthe country in November. Transmitted by
the bite of a parasite-carrying sand fly, thedisease is deadly if left untreated. Timely
treatment can cure most patients.
MSF treated 2,600 people for the disease
in Upper Nile, Unity and Jonglei states.
Patients were treated with a new drug
called liposomal amphotericin B, whichsignificantly reduces the length of treatment
and has fewer side effects than other drugs.
In the north of the country, MSF openeda kala azar treatment centre in Al Gedaref
state in collaboration with the Ministry of
Health, and treated 1,100 patients.

north Darfur
Port Sudan

Tawilaal gedaref

Abyei
Unity

Northern
Bahr elGhazalWestern Bahrel ghazal

Upper Nile

warrapWestern
Equatoria

Jonglei
Central equatoria

juba
Regions where MSF has projects

Cities, towns or villages where MSF works

A new dawn for the south?
A five-year-old peace agreement between thegovernment in Khartoum and southern rebels
has ended 22 years of brutal civil war, but
conflict persisted in south Sudan as economic
and political changes following the agreement
have resulted in violent struggles for power.
Nonetheless, in anticipation of the January
2011 referendum on secession, hundreds ofthousands of people made the journey backto south Sudan, adding to the two million
who had already returned since the peaceagreement was signed.
The health system is weak. Few people haveaccess to adequate healthcare. Insecurity,
violence and the mobility of the population
facilitate the spread of diseases such as malaria,
diarrhoea, respiratory infections, intestinal
parasites, sleeping sickness (human African

trypanosomiasis) and kala azar, and there islittle capacity to deal with the consequences.
Preventable diseases – malaria, acute diarrhoea
and measles – are common causes of death.
MSF has been working in the emergency,
maternity and paediatric departments of
Aweil Civil Hospital, in Northern Bahr El
Ghazal state, since 2008. More than 18,000
returnees moved to camps around the town
in 2010. MSF helped the hospital to copewith increased demand for medical careand staff held more than 37,000 antenatal
consultations, assisted more than 3,000
births, and treated some 2,600 children formalnutrition. In August 2010, a team began
working in the extremely isolated Raja county,
Western Bahr El Ghazal state, focusing on
emergency preparedness, emergency surgery
and maternal and paediatric care.

© Joseph Thomas Noriega

In Western Equatoria state, which borders the
Democratic Republic of the Congo, in addition
to treating injuries and disease, MSF provided
mental health services to people who had
experienced violence, including children who
had escaped from captivity. MSF staff workin mobile teams to reach both remote settledcommunities and displaced people living incamps. A team also works in Yambio hospital.
Many patients had been injured in attacks
carried out by the Uganda-based rebel group,
the Lord’s Resistance Army.

Children in Gorgrial, south Sudan.
52

MSF PROJECTS AROUND THE WORLD – AFRICA – sudan

Working in eight states in south Sudan aswell as the territory of Abyei, MSF carried out
more than 588,000 outpatient consultations
and provided antenatal care to some 96,000
women. More than 25,900 patients received
treatment for malnutrition.
Emergency response and restricted access
Reaching people who are in dire need ofhealthcare in Darfur remains a struggle andAFRICAMSF faces many challenges in delivering
timely and lifesaving medical care. In May,MSF staff conducted a medical assessment ineastern Jebel Marra, a mountainous regionin Darfur. However, lacking the proper
authorisation, teams have not been able toreturn to provide medical care to the people
who need it. In Shangil Tobaya, in North
Darfur, staff held more than 30,000 outpatient
consultations over the course of the year. In
Kaguro, an MSF clinic offered emergency
surgery, a nutrition programme, immunisationand general healthcare, and staff conductedalmost 65,300 consultations. In coordination
with the Ministry of Health, nutrition
programmes were established in Abushok and
El Salam displaced persons camps.
Security remains a pressing issue, as banditry
and kidnappings continue to occur. This
has limited MSF’s freedom of movement
and in many locations international staff areunable to stay long-term in projects, instead
having to conduct ”flash visits” twice a week.
Nevertheless, MSF responded to several
emergencies, including treating over 40
wounded people and distributing essential
household items, like cooking and hygienekits, after fighting between different groups
in Tabarat, North Darfur, in September.
Three months later, MSF provided medical
and nutritional emergency care to newly
displaced people who had been injured afterfighting in Shangil Tobaya.

Reproductive healthIn the city of Port Sudan, the capital of Red Sea
State in northeastern Sudan, MSF provided
reproductive healthcare in the Ministry of
Health’s Tagadom hospital. Staff provided
a range of services including antenatal andpostnatal care, delivery services, family planning,
treatment for sexually transmitted infections,and counselling. In early 2010, MSF built andequipped an operating theatre to enable surgery
for women with complicated deliveries. Staff
conducted over 14,000 antenatal consultations,helped deliver almost 2,000 babies and carriedout 71 caesarean sections.
Approximately 98 per cent of women living in
Tagadom and surrounding neighbourhoods
have undergone some form of genital
cutting. Genital cutting causes a variety ofserious medical and obstetric complications
and de-infibulation, the de-stitching of
the vaginal outer lips, is performed when
preparing an infibulated woman for delivery.
MSF’s gynaecologists do not re-infibulate,or stitch back, the mother after delivery.
Community health workers raised awarenessabout the importance of seeking medicalcare during complicated deliveries and about
the harmful medical effects of female genital
cutting. At the end of the year, MSF handed
this project over to the Ministry of Health,and donated a six-month supply of medicinesand medical supplies to the hospital.
At the end of 2010, MSF had 2,226 staff in
Sudan. MSF has been working in the country
since 1979.

Thinjin“Three of my four children are receiving
treatment for kala azar here at the
Malakal hospital. My youngest boy,Deng, is two years old. He became very
sick in September with a very high fever.
He was vomiting, had diarrhoea andbecame very thin. I brought him to ourclosest health clinic. There they told me
he had malaria but the medicine formalaria did not help. Then they treated
him for typhoid. That failed too.
“We were transferred to Malakal hospital.
At MSF’s kala azar treatment centre
a doctor told us Deng had kala azar
and they began his treatment. The
treatment is very hard, and Deng
became very sick with jaundice. Then hegot pneumonia. He was so sick that wethought he wouldn’t live. But eventually
he got better. Now he is cured of bothkala azar and pneumonia and today
he has been discharged. Last month wewould never have believed he would bestanding healthy on his feet today!”© Kate Geraghty

In the east of the country, MSF launchedemergency nutrition programmes in
Al Gedaref state. Staff treated more than

6,000 malnourished children under the ageof five. Following the emergency response,
MSF began an observation project with the
Ministry of Health in order to formulate aquicker response if needed in the future.

A consultation at the MSF mobile clinic in Abien Dau transit returnee camp, Warrap State, south Sudan.
MSF PROJECTS AROUND THE WORLD – AFRICA – sudan

53

AFRICAswaziland
ManziniMatsapha

Shiselweni
Regions where MSF has projects

Swaziland is facing a healthemergency of immense
proportions. According to theWorld Health Organization,
HIV prevalence is the highest
in the world, at 25.9 per centamong adults aged 15 to 49,
and there are more than 1,250
cases of tuberculosis (TB)
per 100,000 people.
TB is the leading cause of mortality amongpeople living with HIV and, to makematters worse, cases of drug-resistant TB
are increasing: 10 per cent of all TB cases
diagnosed are resistant to TB medication.
Life expectancy in the country has
plummeted over the past two decades– from an average of 60 years to 41 years.
A community-based approach
Swaziland is a rural country of many small,isolated villages. The cost of long andfrequent journeys to health facilities isoften prohibitive for patients, so Médecins
Sans Frontières (MSF) has developed adecentralised, community-based approachto care. People living in the community havebeen trained as HIV counsellors and to test forthe disease. The aim is to increase the overall
number of people being tested, so that more
people with HIV can begin treatment earlier.
By decentralising care, MSF hopes that fewer
patients default from their treatment and, ingeneral, patients’ state of health will improve.
Throughout 2010, MSF supported all
21 clinics in Shiselweni, the poorest and mostremote region in the country. Each of theseclinics now provides fully integrated carefor HIV/AIDS and TB. MSF tested some
14,500 people overall for HIV, tripling thenumber of tests given each month. The
number of people starting antiretroviral(ARV) treatment has doubled. More than54

© Krisanne Johnson

Cities, towns or villages where MSF works

A care worker visits the home of a patient with MDR-TB and prepares her daily injection,
Mhlabeni, Swaziland.
2,550 new TB patients began treatment,
including over 100 patients infected withdrug-resistant TB (DR-TB). The results of TB
treatment, which is a notoriously long anddifficult process for the patient, also saw
marked improvement.
Managing DR-TB is a growing challenge.
MSF supported the decentralisation of DRTB care to the three main health facilities in
Shiselweni in an effort to improve patients’
access to treatment. A new DR-TB ward
with a laboratory is being built, and will befinished in June 2011.
In 2010, MSF began a new project in Manzini
region, south of the capital, helping Ministryof Health staff to integrate and decentralise
TB treatment from the hospital to healthcentres, and supporting the integration of
HIV and TB care in a hospital in the west of
the country. MSF also started treating DR-TB
and supported the national TB programme’s
decentralisation of DR-TB services.
MSF has constructed a clinic for comprehensive
healthcare, including HIV and TB care, in the
town of Matsapha, specifically targeting theworking population of this industrial centre.
MSF supported services at the National
Reference Laboratory.
Staffing crisis
Swaziland is desperately short of doctors,
and because of limited resources, not enoughnurses are being trained. For MSF, the solution

MSF PROJECTS AROUND THE WORLD – AFRICA – swaziland

is to entrust more tasks and responsibilities toother personnel by training nurses to prescribe
medicine or treat cases of uncomplicated,
non-resistant TB, for example.
In line with this idea, MSF has enlisted the
support of “expert patients”. These arepeople living with HIV/AIDS who carry out
screening, advise and inform new patients
about treatment, and raise awareness of HIV
in their communities. In 2010, 80 expert
patients were working for MSF in Swaziland.
At the end of 2010, MSF had 160 staff in
Swaziland. MSF has been working in the
country since 2007.

Caiphus *A multidrug-resistant tuberculosis patient“From where I live, the nearest road is two
kilometres on foot. I had to go every day
to the clinic for two months to get mydaily injection for TB. I left home at
4 am, arrived at 9 or 10 am at the clinic,
then reached home again at around4 pm. A few times I rented a donkey fortransport. Now it turns out that I havemulti drug-resistant TB, which means
I have to do this journey every day for six
months! I’m a sick patient. How can
I travel every day like this?”* The patient’s name has been changed.

AFRICA

ugandaWest Nile

kitgumand children living with HIV. Of the morethan 8,000 patients currently registeredat the hospital, almost 5,500 are receiving
antiretroviral (ARV) treatment.

Lamwo
Karamoja

Regions where MSF has projects

Security has improved innorthern Uganda since peacetalks began between thegovernment and rebel group
the Lord’s Resistance Army in2006. An estimated 95 per centof the 1.6 million people who
had been displaced by fighting
have returned home.
The healthcare system is gradually being
rebuilt, but there is a shortage of trained
health staff, an irregular supply of medication,
and a lack of care available to people sufferingfrom HIV/AIDS, tuberculosis and malaria.
HIV care
The Arua Hospital Aids Program in Arua,
northwestern Uganda, offers integrated
treatment for people co-infected withtuberculosis (TB) and HIV. Staff also provide
ready-to-use food for malnourished adults

Médecins Sans Frontières (MSF) has been
providing HIV treatment to patients living in
the West Nile region since 2002. In 2010, an
average of 158 patients were enrolled in the
programme every month.
In the towns of Madi Opei and Kitgum Matidi,
in the north, more than 1,120 HIV-positive
patients were registered on MSF’s treatment
programme by the end of the year, and 520 ofthem were receiving ARV treatment.
Tuberculosis care
For TB treatment to be successful, patients
must follow a long course of regular drug
administration. Inadequate TB services,
coupled with recurrent displacement due to
conflict in northern Uganda, have disrupted
treatment for many patients. This increases
both their resistance to the drugs, and theprevalence of drug-resistant tuberculosis(DR-TB), for which treatment is even more
complex and can take up to two years.
In 2010, MSF increased the number of TB
screening sites in the northern districts of
Kitgum and Lamwo from 7 to 13. More than
310 new TB patients started medication,
and DR-TB care was introduced.
Malaria care
Malaria is the main cause of death among
young children in Uganda, and the mosteffective treatment is artemisinin-based
combination therapy (ACT), which has low
toxicity, few side effects and acts rapidly
against the parasite. In 2010, MSF treatedclose to 26,000 patients for malaria, using
ACT where applicable.
Sleeping sickness
Sleeping sickness (human African
trypanosomiasis) is endemic in Uganda,
the only country where two forms of thedisease are present: an acute form known
as “Rhodesian”, and a slower-developing
chronic form, known as “Gambian”. Bothforms of sleeping sickness attack the central
nervous system and cause death. MSF
supports the Ministry of Health’s sleeping
sickness programme in the West Nile region
by offering screening and giving technicalsupport and training to community healthworkers and other staff.
Maternal healthcare
Karamoja region, in northeastern Uganda, isan underresourced area where health services
are scarce. MSF teams carried out more than
26,000 paediatric consultations at Kaabonghospital, in health centres and at mobile
clinics across the region. MSF also openeda maternity waiting house in Kaabong in
partnership with local non-governmentalorganisation AWARE. Here, women at risk of acomplicated delivery can spend their last few
weeks of pregnancy in a safe space close to
medical care.
At the end of 2010, MSF had 572 staff in Uganda.
MSF has been working in the country since 1980.

© Brendan Bannon

Christina
Christina is the mother of three-monthold Nancy. When she discovered she
was pregnant Christina was in despair
because of her HIV-positive status. She
went to the Madi Opei clinic where she
received counselling and was enrolled
in the prevention of mother-to-childtransmission programme. Now Christina
is waiting to see whether her daughter
has the HIV virus. “I was really worried
about passing on the disease to mychild. The last two tests for my baby
have been HIV negative. It is a struggle
and a long wait for that final day when
I will know for certain.”A pregnant woman is examined by a doctor at the Madi Opei camp health centre,
Kitgum district.

MSF PROJECTS AROUND THE WORLD – AFRICA – uganda

55

AFRICAzimbabwe
After years of political and economic crisis, the situation in Zimbabwe
has stabilised. However, the HIV/AIDS epidemic and outbreaksof disease continue to overwhelm the weakened healthcare system.

HarareTsholotsho
BuheraGweru
Bulawayo

beitbridge

Cities, towns or villages where MSF works

Fighting HIV/AIDS
An estimated 1.2 million adults and children
are living with HIV in Zimbabwe. Only 55
per cent of the almost 600,000 people inurgent need of life-prolonging antiretroviral(ARV) treatment are receiving it. Médecins
Sans Frontières (MSF) operates HIV/AIDS
programmes in health clinics in Bulawayo
city, Beitbridge, Epworth, Gweru, Tsholotsho
and Buhera. Each programme provides
comprehensive HIV/AIDS care, offeringcounselling, testing, treatment and theprevention of mother-to-child transmission of
the virus. In 2010, more than 34,000 patientswere receiving ARV treatment through MSF’s
presence in Zimbabwe.

© Kenneth M Tong

Regions where MSF has projects

In 2010 MSF responded to an outbreak ofmeasles alongside the Ministry of Healthand other organisations, and five million
children were vaccinated in total. Staff also
supported the national health authorities’
response to an outbreak of the H1N1 virus in
Tsholotsho district, providing treatment andcare to more than 14,000 patients.

A nurse takes a blood sample from a patient in Murambinda, Buhera.

56

MSF PROJECTS AROUND THE WORLD – AFRICA – zimbabwe

© Kenneth M Tong

AFRICA

A nurse manages patients’ referrals to MSF’s mobile team in the Murambinda area, Buhera.
The cost of transport restricts access to the few
functioning hospitals providing ARV treatment,
which puts patients at risk of interrupting theirtreatment, especially those living in remoteareas such as Buhera and Tsholotsho. MSF
seeks to remedy this by decentralising services
from hospitals to rural clinics, bringing free
HIV care closer to patients’ homes. MSF has
also implemented task-shifting and clinicalmentoring – training nurses in routine HIV care,including the administration of ARV drugs, sothat more staff are able to treat more patientsin more locations.
In Bulawayo, the MSF team focuses on tailoring
services to meet the special medical needs ofchildren and adolescents with HIV. Children who
are in a stable condition can now be treatedat local clinics rather than hospitals. Staff havealso piloted specific medical and psychologicalsupport programmes for adolescents.
Improving tuberculosis care
Tuberculosis (TB) is the leading cause ofdeath among people living with HIV/AIDS
in sub-Saharan Africa, and there is growing
concern over the spread of drug-resistant
TB (DR-TB) through the southern African
region, in part due to high levels of migration.
DR-TB is difficult both to diagnose and totreat, and the Zimbabwean national TB

programme is already stretched. The MSF
team in Harare is providing support andtechnical assistance to Zimbabwean healthauthorities in the implementation of anational DR-TB strategy. The number ofpeople infected with DR-TB in Zimbabwe
is not yet known. In December 2010 MSF
enrolled its first patient on treatment, andthe team has expanded service provision in
Epworth through a community-based modelof care. The aim is for 60 patients to start
treatment by the end of 2011.

for sexual violence. Teams worked to increase
the number of people who seek assistance,
establishing a support group for victimsof sexual and gender-based violence, andcampaigning for education about the issue.

Impact of the international
HIV funding retreat
In December 2010 the Global Fund to Fight HIV,
Tuberculosis and Malaria rejected Zimbabwe’s
application for US$ 220 million to financethe expansion of its HIV and TB programmes.
Such a cut in funding may limit the number of
new patients that can receive treatment, andit will further prevent the Zimbabwean healthauthorities from starting to implement the new,more progressive World Health Organization
guidelines on ARV treatment.

“A t the age of six months, our baby fell
ill. We would go to the hospital and getsome form of treatment for Nokutenda.
She would improve and then get sickagain. My husband got fed up and left
us. I was desperate. I went to an MSF
clinic and my child was admitted to thetherapeutic feeding programme. We
both were diagnosed HIV positive. They
also diagnosed TB in Nokutenda andstarted her on TB medication.

Sexual violence
All of MSF’s HIV programmes also offer carefor victims of sexual violence. In 2010 teams
in Bulawayo, Epworth, Gweru, Beitbridge andTsholotsho treated a total of 1,325 patientsAt the end of 2010, MSF had 895 staff in
Zimbabwe. MSF has been working in the
country since 2000.

Joyce“Now she is three years old and MSF
continues to supply her with ARVs. Being asingle mother and not having a job, there
was no way I could have done this on myown. My baby starts pre-school this year!”

MSF PROJECTS AROUND THE WORLD – AFRICA – zimbabwe

57

AFRICAzambiaThe government of Zambia is providing free antiretroviraltreatment to patients with HIV, but people living in rural areas
still struggle to find care, as the shortfall in skilled healthworkers hits the countryside hardest.

Cholera and measles outbreaks
One of the worst measles outbreaks in the
country since 2003 struck the capital Lusaka
in April. According to official figures, by theend of December 2010 more than 14,900
measles cases were reported in the city,and there had been 158 deaths. MSF staff
worked in two hospitals, providing medicalcare to more than 1,860 patients.

© Robin Meldrum

There are often outbreaks of cholera in
Lusaka during the rainy season, when houses
and latrines flood and water collects instagnant pools. Cholera is spread throughcontaminated water or food, and can spread
rapidly, particularly if people are living incrowded and unsanitary living conditions.
The disease causes watery diarrhoea andvomiting that can lead to severe dehydrationand death.

A young patient receives treatment for cholera during an outbreak in Lusaka, Zambia.

Luwingu

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

Preventing mother-to-childtransmission of HIV
Services preventing mother-to-childtransmission (PMTCT) of HIV are available
to just over 60 per cent of women in
Zambia, but only 36 per cent of women
who start treatment complete it, according
to the Ministry of Health. PMTCT demands
commitment from a patient: the pregnant
woman must first visit a clinic for counselling
and testing, and if she is HIV positive she
must return for treatment during pregnancy,
delivery and afterward. Only when the baby
is seven months old will staff be able to tellwhether the process has been successful.
The long distances that many have to travel
to reach clinics offering PMTCT services

58

and the social stigma attached to being HIV
positive are significant obstacles to womentaking up the service.
At the beginning of 2010 there was little
antenatal care available in Luwingu, a rural
district of northeastern Zambia. Without
antenatal consultations, pregnant womenare unlikely to find out whether they have
HIV, and those who are HIV positive cannot
receive PMTCT services. In June, Médecins
Sans Frontières (MSF) mobile teams started
working in four rural health centres in
Luwingu, providing reproductive healthservices, antenatal care, emergency obstetriccare and PMTCT services. Between Juneand December, more than 2,650 antenatal
consultations were carried out, and 150
women received postnatal care. Staff
provided special supplementary food to
52 HIV-positive women, and enrolled
41 women in the PMTCT programme. MSF
has been researching two new World HealthOrganization protocols for PMTCT, testing
their feasibility in remote settings andcomparing the outcomes. In Luwingu town,
an MSF team provided training in obstetricsurgery to surgeons in the district hospital.

MSF PROJECTS AROUND THE WORLD – AFRICA – zambia

In March, during an outbreak that infected
more than 6,000 people, MSF teams set
up three cholera treatment centres with a
total capacity of 570 beds, and supported
19 treatment units with staff and materials,
caring for around 5,000 patients in total.
Water and sanitation specialists worked hard
to halt the spread of the outbreak, providing
over 500,000 litres of chlorinated water per
day in the affected neighbourhoods. Morethan 100 volunteers conducted outreachactivities, teaching people how to prevent
cholera from spreading. MSF has been
responding to cholera outbreaks in Zambia
since 2004, and is urging local authorities
and international donors to improvethe country’s preparedness for cholera
outbreaks and prevent the loss of so many
lives each year.
At the end of 2010, MSF had 51 staff inZambia. MSF has been working in the
country since 1999.

© Giulio di Sturco / VII Mentor

Patients at the MSF health post in Bowen, Kupwara, Kashmir, India.

60 Afghanistan
61 ARMENIA
62 BANGLADESH

69 MYANMAR
70 PAKISTAN

63 CAMBODIA

72 Papua New
Guinea64 CHINA

73 Philippines

65 Georgia

74 SRI LANKA

66 INDIA

75 THAILAND

68 KYRGYZSTAN

76 UZBEKISTANASIA & THE
CAUCASUSASIA & THE CAUCASUS

Afghanistan
Kabul

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

Humanitarian needs grew in
Afghanistan in 2010, as the war
spread to almost all provinces.
Health structures throughout
the country lack medical
staff and essential supplies.
Unregulated and expensive
private health services areoften the only option.
The roads are dangerous and people often
risk their lives in travelling to seek medicalcare. Sometimes, by the time a person
reaches hospital, a condition that may haveinitially been relatively easy to treat has
become life-threatening.
This general deterioration in healthcare provision
motivated Médecins Sans Frontières’s (MSF)
return to Afghanistan in 2009. MSF secured
agreements with the different parties involved in
the conflict to begin activities in two hospitals:
Ahmed Shah Baba hospital in east Kabul, thecapital, and Boost hospital in Lashkargah, thecapital of Helmand province in the south.

More than 50 newly recruited hospital staff
were also given training and support. By
October, an operating theatre and a small
inpatient department had been put in place.
The first surgery was performed at the endof October, and 40 more operations had
been carried out by the end of the year.

Medicines and medical equipment were also
provided. As a condition of its support,
MSF requested that the hospital implement
a “no weapons” policy, which means all
weapons must be left at the entrance, making
the hospital less of a potential target andallowing patients to feel less threatened.

Throughout the year, patient numbers
increased significantly. Nearly 10,240
medical consultations took place in October,compared with 5,500 in October 2009,
when MSF started its activities. In 2010,
maternity staff held almost 7,400 antenatal
consultations, assisted more than 4,070
births, and carried out more than 1,500
family planning sessions. Overall, more than
118,200 patients were seen in the various
departments of Ahmed Shah Baba hospital.

Halfway through the year, a nearby hospitalfor the war-wounded, operated by the Italianorganisation Emergency, closed for fourmonths. Boost was able to cope with theincrease in trauma cases requiring surgery.
Around 1,500 surgical operations were
performed in 2010, nearly 400 of whichwere for war-related injuries. From May, theupgraded emergency department was able
to stabilise critical cases around the clock
before transferring them to Boost’s otherdepartments for more specialised care. From
May to December, around 26,000 patients– ten per cent of whom were in criticalcondition – received treatment. Services that
had been virtually non-existent before 2010
were approaching full capacity. Some 2,500
babies were born in the expanded maternity
department: 480 deliveries were complicated.

Boost hospital, Helmand
In November 2009, MSF started to support
Boost provincial hospital in Lashkargah.
Helmand’s one million inhabitants areamong those who have suffered most fromthe ongoing conflict. Many rural healthclinics are now dysfunctional, as qualified
health staff have left the insecure areas, andsupplying drugs and medical materials has
become increasingly difficult. Insecurity has
also made it difficult for people to reachspecialist health services.
In 2010, MSF worked to return the 155-bed
hospital to a functioning referral hospital– one of only two in southern Afghanistan.
MSF extended its medical support to all
wards, including the maternity, paediatric,
surgical and emergency departments.

Children accounted for 25 to 30 per cent of
hospital patients. In September, a 16-bed
extension of the paediatric ward meant children
were no longer obliged to share beds. Overall,around 2,200 children were treated at thehospital in 2010, 550 of whom were newborns.
At the end of 2010, MSF had 200 staff inAghanistan. MSF first worked in the country
in 1984.

In Ahmed Shah Baba hospital, MSF doctors,
midwives, nurses and surgeons worked withthe hospital’s existing medical staff. MSF
focused on the emergency department,maternity services and treatment protocols,
increasing the medical services available sothat fewer patients would have to be referredelsewhere. Improvements were made to thematernity and emergency departments,
and to the laboratory and X-ray services.

60© Kate Holt

Hospital care in Kabul
The population of Kabul has tripled overthe last ten years. Many people have fled
conflict-torn areas for the relative safety of
the capital; others have been pushed bypoverty to try and make a living in the city.
Returnees from Pakistan and other provincesof Afghanistan have also made their way to
Kabul. As a result, the fragile health system
has been stretched to its limit, leaving many
people without access to medical care.

A man with gunshot injuries is transferred to Boost hospital for post-operative care,
Lashkargah, Helmand province.

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

ASIA & THE CAUCASUS

armenia
ShirakLori

YerevanRegions where MSF has projects

In Armenia, Médecins Sans
Frontières (MSF) is working
with the staff of the national
tuberculosis (TB) programme
in tackling drug-resistanttuberculosis (DR-TB).
In the 1990s, as a result of patients notcompleting TB treatment or using drugs
incorrectly, resistant forms of tuberculosis
emerged. In 2005, an MSF team started
working in Yerevan, Armenia’s capital,
assisting doctors with diagnosis andtreatment of the various forms of DR-TB.
Regular TB treatment involves around six
months of medication. Drug-resistant forms
of TB require up to two years of treatment,
which is expensive and is not always easily
available. Treatment usually starts with aperiod of hospitalisation, where patients areclosely monitored. Once they return home,patients must continue a gruelling treatment
regimen. Many of the drugs are toxic and,for some patients suffering from side effects
such as headaches, vomiting or dizziness,the regime can become unbearable.
It can be very difficult to complete the cycleof treatment. The severity of side effects
is one of the most significant factors, butother patients stop their treatment because
they begin to feel better. MSF tries to help
patients cope with the side effects byproviding individual or group counsellingand offering food vouchers to ensure an
optimally healthy diet. In some cases, MSF
assists in the renovation of patients’ homes
to ensure adequate infection control.
Improving ventilation and sunlight in ahouse increases the chances that any TB
bacteria is killed or removed from thehome. In 2010 the MSF team received
intensive MSF training on patient education© Bruno De Cock

Cities, towns or villages where MSF works

A TB patient prepares to take his medication at home in Yerevan.

and counselling, and revised procedures
have been drawn up to attempt to further
improve adherence.
Some elements of the TB programme in
Yerevan were handed over to national bodies:
the Armenian Red Cross has taken over theprovision of social support in some districts,
and the national TB programme is now
responsible for providing drugs for TB patients.
Reaching rural areas
In 2010 MSF expanded the TB project into
Lori and Shirak, two rural provinces in thenorth of the country. Working in a rural
setting poses additional challenges, as somepatients live long distances from clinics
that they must attend on a regular basis.
As a result, the MSF team has introduced
new approaches to treatment and carethat are more convenient for patients andenable them to live at home. This also
makes it easier for patients to adhere to
the treatment regime.

Larisa *“When I found out it was drug-resistant
TB I was shocked. I didn’t expect it.
But it was a fact and I had to go to
the hospital and get treatment. WhenI heard that hospitalisation alone wasto last two months, I couldn’t imagine
being there for such a long time.
It was very difficult for me to get used
to it. I thought first of all, that’s it,
I will die. It was very difficult physicallyand psychologically. Most patients find
it difficult taking the tablets every day,starting the day with pills.
“But going to the clinic and seeing
smiling faces helped. They told me
there is no expression, ‘I can’t’ or‘I don’t want to.’ It gave me strength
to go ahead, to fight.”* The patient’s name has been changed.

A total of 559 patients have started TB
treatment since 2005, and 246 patientsare currently receiving care.
At the end of 2010, MSF had 68 staff inArmenia. MSF has been working in the
country since 1988.

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

61

ASIA & THE CAUCASUS

Bangladesh
Fulbaria
Dhaka
Chittagong
Hill Tracts
Cox’s Bazaar
Regions where MSF has projects

Many people who moveto Dhaka, the capital of
Bangladesh, end up living inslums where the availabilityof healthcare is oftenvery limited. In April 2010,
Médecins Sans Frontières(MSF) opened a health centre
and a therapeutic feeding
centre in the Kamrangirchar
slum, which is home to nearly
400,000 people.
MSF’s aim is to improve access to free careand treatment for children, focusing on severe
acute malnutrition. Pregnant and breastfeeding
women also receive treatment for malnutrition,
and antenatal and postnatal care are provided.
Two-thirds of all deaths of children under fivein Bangladesh are attributed to malnutrition.
MSF is taking a community-based approachin Kamrangirchar. Teams go out into thecommunity to screen children, and those who
are found to be severely malnourished areadmitted to a feeding programme and given
ready-to-use food to eat at home until theyregain normal body weight. During treatment,
teams of health promoters regularly visit thechildren and provide support to ensure that theready-to-use food is being given in the correct
way. In 2010, MSF admitted 378 children and
440 pregnant or breastfeeding women to its
nutrition programme and conducted over
10,000 consultations at its health centre.
Kala azar in Fulbaria
Kala azar (visceral leishmaniasis) is a deadly
parasitic disease caused by the bite of
infected sand flies, and is the second biggest
parasitic killer worldwide after malaria.
Medication to treat kala azar is expensive andhard to obtain. Few Bangladeshis are awareof the disease, its symptoms or its cause,so they do not know they need to protect
themselves from the flies around them.

62© Gazi Nafis Ahmed

Cities, towns or villages where MSF works

Villagers listen to a talk about kala azar, Fulbaria, Mymensingh district.
In collaboration with the Ministry of Health andFamily Welfare, MSF opened a clinic providing
free treatment of the disease in the subdistrictof Fulbaria, in the east of Mymensingh district.
Fulbaria and neighbouring Trishal accountfor about 60 per cent of kala azar cases in
Bangladesh. The clinic is the main provider ofkala azar treatment in the subdistrict and theonly such clinic in Bangladesh.
Outreach teams work with local communities
to educate people about the disease and to
identify suspected cases. Patients diagnosed
with kala azar are treated with a new drug
called liposomal amphotericin B, which ismore effective, cuts the duration of treatment,
and has fewer side effects than the drugs thatwere previously used. MSF also treats post kalaazar dermal leishmaniasis (PKDL), a relatedskin infection that can appear long after apatient has seemingly been cured. By the endof 2010, more than 400 patients had received
treatment for kala azar at the MSF clinic andmore than 400 people were treated for PKDL.
Chittagong Hill Tracts
In the Chittagong Hill Tracts region in
the south, MSF provided general andreproductive healthcare in Dighinala andBaghaichhari subdistricts. Teams operated
eight health centres, and carried out almost
25,000 outpatient consultations and morethan 1,000 antenatal consultations. Morethan 1,450 people were treated for malaria.
Kutupalong, Cox’s Bazaar
Kutupalong is in Cox’s Bazaar, a coastal
area bordering Myanmar. In 2010, MSF
continued to provide medical care to people

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

living in Kutupalong, including an estimated
30,000 unregistered Rohingya refugees
living in a makeshift camp on the outskirtsof the UNHCR-supported camp. MSF staff,
many of whom are from the local area, treat
common yet potentially deadly illnesses suchas respiratory tract infections and diarrhoea.
In February 2010, MSF spoke out publicly
to condemn a surge in violence against
the unregistered Rohingya refugees. Since
then the level of violence has dropped, butpeople remain highly vulnerable due totheir lack of official status and the limited
provision of assistance that this allows.
At the end of 2010, MSF had 291 staff in
Bangladesh. MSF has been working in the
country since 1985.

Abdul and Fatema
Abdul learned about the kala azar clinic
in Fulbaria through MSF’s outreach work.
He has had kala azar, and so have manyof his family members. Fatema, Abdul’s
five-year-old daughter, was treated forkala azar at the MSF clinic. It used totake 30 days of painful injections to treat
the disease, but Fatema was treatedwith the new drug, which requires justthree infusions over five days. Before,
Abdul had to spend his savings treating
his family for kala azar, but Fatema is
treated for free. She was soon able to gohome and return to school.

ASIA & THE CAUCASUS

cambodia
Kampong Cham

Phnom PenhRegions where MSF has projects
Cities, towns or villages where MSF works

In 2010, Médecins Sans
Frontières (MSF) completed thehandover of its activities in theinfectious disease departmentof the Khmer-Soviet Friendship
Hospital. More than 3,000 HIV
patients were transferred to thecare of the health authorities,
and MSF shifted its focus totuberculosis (TB) care.

prevalence of HIV in comparison with
0.6 per cent among the general population,and 3.9 per cent prevalence of TB in comparison
with 0.7 per cent among the general population.
Prevalence was slightly lower in the city’s
women’s and children’s prison, at 2.7 per centand 2 per cent, respectively.
Cholera outbreak
MSF teams also assisted during cholera
outbreaks across the country in 2010.
Staff provided technical support and cholera
kits that were adapted for use in national
treatment centres. In collaboration with otherorganisations, MSF helped to strengthen
the surveillance system for communicablediseases, especially cholera, dengue fever
and measles. Staff are working with healthprogrammes at national and provincial
levels, investigating suspected cases andanalysing the performance and challengesof the care given. This should enable timely
identification of a medical crisis and a more
efficient and appropriate response.
At the end of 2010, MSF had 145 staff inCambodia. MSF has been working in the
country since 1979.

Cambodia is one of 22 countries listed by theWorld Health Organization as having a highburden of TB. In Kampong Cham, theost
populous province in the country, MSF worked
to improve the diagnosis and care of people
with TB and drug-resistant TB (DR-TB). Staff
established a chest clinic within the TB ward of
Kampong Cham provincial hospital, and began
to actively seek patients with TB, visiting andoffering TB testing to patients who had been
admitted to hospital for other reasons.
By the end of 2010, the number of TB patients
had increased by 25 per cent, and revealed aneed for improved patient follow-up. MSF had
carried out an assessment of facilities for TB
care in four districts of Kampong Cham, andhad begun providing TB care in local healthcentres. However, decentralised activities were
temporarily suspended so that MSF staff could
focus on its work in Kampong Cham hospitaland ensure the follow-up of its patients.
In the coming years, MSF will develop acomprehensive TB care approach throughout
the province.

© Agnes Christophe

HIV and TB care for prisoners
Overcrowding, lack of ventilation and generally
poor living conditions in prisons mean there
tends to be a high risk of TB contamination.
MSF extended HIV and TB services in Phnom
Penh prisons to provide comprehensive testing,counselling and treatment for both diseases.
Teams also provided general healthcare.
In Phnom Penh men’s prison, more than
80 per cent of inmates agreed to be tested,and preliminary results showed 3 per centA team tests prisoners for HIV and tuberculosis in Phnom Penh Correctional Centre No. 1.

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

63

ASIA & THE CAUCASUS

china
Cui *

© Jon Browning

28 years old. Receiving treatment for
HIV since May 2008
“When I arrived in the clinic I wasvery sick, and people gave me a lotof encouragement. Before, I didn’tknow anything about treatment. I
didn’t understand the importance oftaking antiretrovirals at the right time.
However, the doctors and counsellors
emphasised the importance of this andmy health improved. It’s good to talkto the counsellors. Talking with themis the only way to relieve my burdens.
Every time I talk with them I cry.”* The patient’s name has been changed.

An MSF psychologist talks with another member of staff in the MSF/CDC clinic
in Nanning, Guangxi province.

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

In 2010, after seven years ofproviding HIV care in the cityof Nanning, Médecins Sans
Frontières (MSF) and the
Guangxi Centre for Disease
Prevention and Control (CDC)
handed over their project tolocal health authorities.
HIV/AIDS treatment in Guangxi
Guangxi province, in southwest China, has
one of the highest rates of HIV infection in
the country. MSF, together with the CDC,
established a project in the provincial capital
Nanning in 2003.
The project targeted high-risk groups: thetesting and treatment of injecting drug
users, sex workers and men who have sex
with men. Patients responded well to thetreatment and were able to stick to it. Prior

64

to the project’s opening, Chinese healthofficials had doubts regarding the likely
adherence of drug users to antiretroviral(ARV) treatment. Dr Wu Zunyou, directorof the National Centre for AIDS/STD
Control and Prevention, said: “In the earlystages, we had no experience in providing
treatment to drug users and AIDS patientsoverall. We just started in 2003 and wewere very hesitant to launch antiretroviraltreatment for drug users because we were
not convinced they had good adherence
rates, but we reviewed MSF data and foundthey did not have worse adherence rates
than non-drug users.”
Targeting people living with HIV fromparticularly marginalised populations
was a key part of the project in Guangxi.
Teams went out into these communities
to encourage people to seek testing andtreatment. This approach saved lives, andonce the disease was managed effectively
through medication, patients’ quality oflife was greatly improved. Counselling,
previously regarded with suspicion by healthauthorities, became an important part ofpatient care.
People on ARV treatment often suffer from
opportunistic infections that take hold as aresult of their weakened immune systems.
Over the course of the project in Guangxi,
MSF was able to implement new protocols
for the treatment of such infections.
Tuberculosis was the main opportunistic

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

infection targeted and treated. MSF also
helped train national staff to diagnose andtreat cytomegalovirus, a viral infection thatcan cause blindness in people with HIV.
Over seven years, the project team had
developed a system of care that addressed
the psychological and medical needs ofpatients. MSF staff assisted in drafting
guidelines for the testing and treatment
of HIV/AIDS that formed a basis for theprovince’s approach. Aspects of theprovincial guidelines were then used in thenational protocol for tackling the epidemic.
The project provided training for many
health workers in Guangxi, which now
has 45 antiretroviral treatment centres,
compared to a handful in 2003. A total of
1,724 patients received free and confidential
treatment and care. Around 80 per cent ofthese patients were continuing to follow
treatment at the time of the handover.
Earthquake in Tibetan Autonomous Region
In April, a 6.9 magnitude earthquake hit
Qinghai province, killing around 2,700
people and injuring some 12,000. MSF
sent a team to explore the possibilities ofassisting the population in Jiegu, the worst
affected town, where around 100,000
people were made homeless. MSF madedonations of coal, medical kits and otherequipment to help the affected population.
At the end of 2010, MSF had 24 staff in China.
MSF has been working in the country since 1988.

ASIA & THE CAUCASUSGEORGIA
Abkhazia

Black
Sea

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

Tuberculosis programmes
Treatment for TB was developed in the 1950s,
and is a long and complex process. It involves
daily medication over a period of six to eightmonths, which many patients struggle toadhere to. However, for patients to be cured,
it is crucial that the full course of treatment isfollowed without interruption. If medication
is interrupted, there is a risk of drug-resistant
TB (DR-TB) developing, which necessitateseven longer, more arduous treatment.

cases. Adherence teams of medical andpsychological staff tried to take into accountall the medical, social and economic factorsthat affect patients’ adherence in an effort
to detect problems earlier and manage themmore effectively. With a stronger support
structure around them, patients found theprogramme easier to follow and, despite thedebilitating side effects, about 70 per centof patients adhered well to the treatment.
Substantial funding, mainly from the Global
Fund to Fight AIDS, Tuberculosis andMalaria, has strengthened Georgia’s fightagainst DR-TB. The Georgian Ministry of
Health opened a new TB hospital in Tbilisi inAugust 2008, and in September 2010 it took
over MSF’s activities in Zugdidi. Over almost
four years of operation, 256 patients had
been enrolled in the programme.

MSF continues to support the national TB
programme in Abkhazia, a separatist region innorthwest Georgia, providing direct support
for DR-TB. Staff provide health educationand counselling in order to improve patients’adherence to treatment. In 2010, 36 newpatients were enrolled in the programme.
Health access
An MSF programme aimed at assisting
people who have difficulties accessing
healthcare in Abkhazia has been
considerably reduced as national capacity
has improved. The programme started in
1993 with a peak of 6,000 patients, and in2010 only 108 people, mainly home-boundand bedridden, were registered.
At the end of 2010, MSF had 133 staff in Georgia.
MSF has been working in the country since 1993.

© Alexander Glyadyelov

The DR-TB programme in Zugdidi,
western Georgia, opened in November
2006. In 2010, the programme adopted a
flexible, home-based and multidisciplinary
approach to the management of DR-TB

Almost 20 per cent of tuberculosis (TB) cases in Georgia are
estimated to be multidrug-resistant forms of the disease,according to the World Health Organization. Médecins Sans
Frontières (MSF) collaborates with the national TB programme,
and facilitates access to healthcare for marginalised people.

A consultation between a doctor and a patient with tuberculosis is carried out at Gulprish TB dispensary, Abkhazia.

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

65

ASIA & THE CAUCASUS

INDIA
In India, Médecins Sans
Frontières (MSF) provides
general healthcare andtreatment for tuberculosis,
malaria, HIV and kala azar
(visceral leishmaniasis) andoffers basic and specialised
medical care to people livingin areas afflictedby violence and conflict.

Kala azar and nutrition in Bihar
In Vaishali district, Bihar state, eastern India,
MSF provides free diagnosis and treatment
for people suffering from kala azar (visceralleishmaniasis). Between July 2007 andJanuary 2011 more than 7,000 patients
received treatment with liposomal
amphotericin B, which is more effective
and has fewer side effects than the drugs
previously used. More than 98 per cent ofpatients recover with liposomal amphotericin
B treatment and MSF hopes the nationalkala azar programme will adapt its treatment
protocol in the near future.
In Darbhanga district, MSF provides
healthcare for children aged between six
months and five years who suffer fromsevere acute malnutrition. In 2010, morethan 6,000 children received treatment,
mostly on an outpatient basis.

Darbhanga
VaishalinagalandManipur

Chhattisgarh
Bijapur
Mumbai
OngoleAndhra Pradesh

Regions where MSF has projects

Cities, towns or villages where MSF works

Pradesh and Chhattisgarh border as well as
in Chhattisgarh, eastern India. Healthcare isprovided to people living at the centre of aconflict between Naxalite (Maoist) groups
and government forces. Staff held almost
60,000 consultations, providing antenatalcare, nutritional support to malnourishedchildren and pregnant women, andtreatment for malaria and tuberculosis (TB).
Health promotion activities on malaria
prevention and hygiene practices, among
other topics, were also conducted.

The northeast
In August, MSF opened a new project in
the northeastern state of Nagaland. MSF
supported the district hospital of Mon
with human resources, management
expertise, training, rehabilitation of thehospital structure, waste and sanitation
management, and medical supplies. From
July to December, medical staff conductedalmost 6,250 consultations and performed
more than 150 minor surgeries in theoperating theatre.

In the district of Bijapur, MSF runs a motherand child health centre, and a team set up
a TB isolation room and opened an on-site
TB laboratory to allow for prompt diagnosis.
MSF also supports the district hospital’s
surgical activities.

In neighbouring Manipur, MSF continued
to provide medical assistance, including
reproductive and child health services, tovulnerable people who otherwise would
have difficulty accessing healthcare. In 2010,
25,500 general consultations and 6,650
antenatal consultations were carried out.
Staff provided HIV counselling, testing andtreatment as part of the basic healthcare
programme. The care of some 200 patientson first-line antiretroviral (ARV) treatment
in Churchandpur was handed over to the
Ministry of Health. MSF continued to care
for around 400 patients on second-line
treatment. TB care was also offered: morethan 100 patients received treatment for
tuberculosis and 11 for multidrug-resistant
TB (MDR-TB).

© Stephanie Sinclair / VII

Healthcare in Chhattisgarh
MSF operates fixed and mobile clinics
in villages and camps along the Andhra

India-administered Kashmir

A health educator gives a presentation at the feeding centre in Biraul block,Darbhanga district, Bihar State.

66

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

HIV/AIDS and TB in Mumbai
In Mumbai, the largest city in India, MSF
provides comprehensive care for people
with HIV who require treatment not yet
available in the public sector. This includes
people who experience severe side effects
from first-line medicines, patients withco-infections and those who urgently needsecond-line ARV drugs but do not meet

ASIA & THE CAUCASUS

the public healthcare system’s criteria
for treatment. The MSF team also offers
treatment to people who, because ofsocial stigmatisation, may face difficulties
in accessing the public system, such astransgender people, sex workers and men
who have sex with men. At the end of 2010,
310 patients were receiving ARV treatment
at the clinic, 186 of whom were on secondline treatment. In addition, 23 HIV patientswere also receiving care for MDR-TB.

As well as mental health activities, morethan 16,500 basic healthcare consultations
were conducted in remote rural areas ofIndia-administered Kashmir.
Emergencies
In May, MSF teams distributed 1,500
shelter, hygiene and cooking kits to people
in Ongole in Andra Pradesh who had been
affected by cyclone Laila. In June and July,in collaboration with the Ministry of Health,
MSF helped respond to an outbreak ofacute diarrhoea in south Chhattisgarh. In
August, teams provided medical assistanceto people affected by flash floods in Leh andsurrounding areas, and distributed shelterand cooking and hygiene kits to families
in need.
Following a sharp increase in malaria casesin Mumbai during the monsoon season,
MSF stepped in to support the Mumbai
health authorities’ fight against the disease
by providing malaria diagnostic kits andtreatment kits.
At the end of 2010, MSF had 656 staff in India.
MSF has been working in the country since 1999.

© Giulio di Sturco / VII Mentor

Mental health in Kashmir
MSF offered psychosocial care to a
population heavily traumatised by morethan two decades of violence, providing
mental healthcare to almost 4,500 patientsin 2010. After an escalation of violence inJuly, and with the cooperation of hospital
staff who treated physical injuries, MSF
counsellors visited 1,900 wounded patientsand offered psychological assistance tothem and their families. Such “psychologicalfirst aid” helps the patients to cope after
experiencing trauma. Counsellors listen to
the patients’ stories, helping them cometo terms with what happened, and offer
practical advice on how to deal with any
further psychological consequences.

An MSF doctor examines a young patient at the women’s clinic run once a week in Thyan, Kupwara, Kashmir.

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67

ASIA & THE CAUCASUSKYRGYZsTAN
Jalalabad
Bishkek

Osh
Regions where MSF has projects

In April 2010, President
Bakiyev of Kyrgyzstan wasousted by a popular revolt.
Then in June the south ofthe country was shaken by
violence between Kyrgyz andUzbek communities. Médecins
Sans Frontières (MSF), running
projects in Kyrgyzstan totreat prisoners infected withtuberculosis (TB), was able
to assist those in need during
the emergencies.
Political and intercommunal violence
When rioting began in the capital Bishkek,
MSF provided drugs and medical supplies
to four health centres. In the south, MSF
donated medical supplies and drugs to
hospitals and clinics in the provinces of
Osh and Jalalabad within days of violence
breaking out. Almost 400,000 Uzbeks
were displaced, and around 2,000 homes
were destroyed. Many people in need oftreatment were too afraid to leave theircommunities, so between June and August
MSF ran mobile clinics to reach people inneed of care. MSF psychologists held over
660 mental health consultations and 3,700
patients participated in over 550 grouptherapy sessions.
Months later, tension and mistrust between
the communities still hindered access tohealthcare. MSF identified 50,000 people
from all ethnic groups, in ten districtsof Osh city, as particularly vulnerable:some because they had lost their homes,

68© François Dumont

Cities, towns or villages where MSF works

An MSF nurse carries out a consultation with a returning refugee in Suratosh,a village on the border with Uzbekistan.

businesses or livelihoods in the clashes,others – single mothers, the elderly living
on very small pensions, or large families
with no income – were already in precarious
situations before the June events.
MSF operated in seven public healthfacilities, where staff helped to ensure theprovision of care in a non-discriminatory
and neutral manner.
Treating TB in prison
MSF has been treating prisoners infectedwith TB in Kyrgyzstan since 2005. The
incidence of the disease in prisons has
declined over the years: the number ofpatients detected each year dropped from
700 to 350 between 2006 and 2010. Thisis mainly because of a reduction in theprison population. Around two-thirds ofinfectious TB patients in the penitentiary
system have drug-resistant TB (including all
forms of drug-resistant TB). The treatment
programme for drug-resistant TB is oftenvery long and difficult. In 2010, MSF treated
230 new TB patients.
Prisoners diagnosed with TB are referred
to treatment facilities in three prisons inand around Bishkek, where staff work incollaboration with the Ministry of Health,

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

the prison authorities and internationalorganisations such as the International
Committee of the Red Cross.
One of the most important challenges is toassure uninterrupted treatment after release,as one-third of TB patients are released
from prison before treatment is completed.
MSF provides medical and social support
to former prisoners with TB and is working
to find ways to motivate them to complete
their treatment. In 2010, 78 TB patientswere released from prison, and 57 of themwere still receiving treatment at the end of
the year. MSF is advocating for a national TB
control policy in the penal system.
At the end of 2010, MSF had 93 staff in
Kyrgyzstan. MSF has been working in the
country since 2005.

ASIA & THE CAUCASUS

MYANMARRakhineKachinShan

YangonTanintharyi

Regions where MSF has projects

Myanmar remains largely isolated on
the international stage and faces severe
restrictions from the international aid
community. Despite the return of the Global
Fund, the country continues to suffer froma chronic lack of resources to tackle diseases
like HIV/AIDS, tuberculosis and malaria.
Working closely with local communities,
Médecins Sans Frontières (MSF) offers
lifesaving treatment to people living with
HIV/AIDS, basic healthcare, health education
and reproductive healthcare, including
antenatal and postnatal care, and nutritutional
assistance. MSF has been providing healthcare
in Shan, Rakhine and Kachin states as well as
in Yangon and Tanintharyi regions through a
network of HIV/AIDS clinics and health centres.
MSF teams conducted nearly 660,000 general
consultations across the country in 2010.
HIV/AIDS
More than 240,000 people are living with
HIV in Myanmar, and an estimated 120,000
are in need of lifesaving antiretroviral (ARV)
treatment. However, treatment is currently
available to only 21,000 people, and MSF wastreating 18,300 of these people in 2010. Staff
also provided symptomatic and palliative
care and managed common opportunistic

Low national and international investment in the healthsector combined with tensions and low-intensity conflicts
limit access to healthcare in many areas of Myanmar.

infections, which patients suffer from as aresult of their compromised immune systems.
In Yangon, MSF operated four HIV clinics.
In addition to treatment, staff offered healtheducation, especially to high-risk groups suchas intravenous drug users, men who have sex
with men and sex workers, and helped preventthe transmission of HIV through voluntary
testing and counselling and mother-to-childtransmission prevention services. MSF continued
to work in close collaboration with the Ministryof Health and other agencies in building up thetechnical capacities and resources of the various
HIV/AIDS care programmes in the country.
Tuberculosis and HIV
Myanmar ranks among the 22 countries withthe highest burdens of tuberculosis (TB)
in the world. The national TB programme
is underfunded and the lack of adequate
regulation of the private sector means that
there is no proper regimen for treatment,
which leads to high levels of treatment
failure and increased drug resistance.
TB is the most common opportunistic infection
and the main cause of death for people livingwith HIV. MSF provides TB treatment within thecontext of its HIV programmes and is currently
giving free treatment and counselling to 2,540
TB patients across the country, most of whom
are also HIV positive.
In Dawei, in the south of Myanmar, MSF runs
an HIV and TB clinic for a local populationconsisting mainly of migrant workers andfishermen. Staff also conduct outreach activities
in the surrounding district, going out in thecommunity to test people and see patients who
may not be following their treatment regime.
In Yangon, an MSF pilot project offers
treatment and care for multidrug-resistant TB(MDR-TB) in partnership with the Ministryof Health. This is the first programme in the
country offering treatment for MDR-TB. In
2010, 44 patients enrolled in the programme.
In October, MSF set up an HIV and TB
programme in Insein prison in Yangon.
Malaria
Malaria is one of the leading causes ofmortality in Myanmar. MSF clinics provide
free diagnosis, treatment and prevention
measures in areas where the disease hashigh prevalence rates. In Rakhine state, forexample, MSF tested more than 400,900
people and treated more than 122,380
patients for malaria in 2010.
Natural disasterCyclone Giri hit the west coast of Myanmar in
November. In its aftermath, MSF conductedaround 17,000 medical consultations throughmobile and fixed clinics and distributed foodas well as construction kits to help rebuild
affected communities.
At the end of 2010, MSF had 1,169 staff
in Myanmar. MSF has been working in the
country since 1992.

Myek *© P.K. Lee

33 years old“I came to the MSF clinic for the firsttime four years ago and was put on
ARVs around three years ago. It was
my mother who recommended that
I come here; personally, I had neversuspected my status. After discussing
with the counsellor, I decided to take atest. When it turned out positive it wasa huge shock for me. I thought ‘that’s
it; it’s the end of my life’. I talked a lot
to my mother and to the counsellor
and they really helped. This clinic offers
good care and is the only place where
I can find free treatment. Because I
can’t afford my treatment, it’s really
important that it’s free.”* The patient’s name has been changed.

Staff working in the dispensary at one of MSF’s clinics in Yangon, Myanmar.
MSF PROJECTS AROUND THE WORLD – ASIA & THE CAUCASUS – MYANMAR69

ASIA & THE CAUCASUS

PAKISTAN
The floods that hit Pakistan
in 2010 affected around
14 million people. The
waters swept down from themountainous northeast into
the heavily populated rivervalleys and plains, driving
desperate people ahead ofthem. In a country alreadysuffering gaps in healthcare
provision the need forassistance grew enormously.

SWAT
Federally Administered
Tribal Areas (FATA)

Sindh
Balochistan

KarachiRegions where MSF has projects

In the Federally Administered Tribal Areas(FATA) and Khyber Pakhtunkhwa province,
Médecins Sans Frontières (MSF) teams
continued to provide emergency services
for people caught up in fighting between
government forces and armed oppositiongroups. Further south, in Balochistan,
MSF worked with Afghan refugees andPakistanis, assisting with a range of medical
services, mother and child healthcare andnutrition programmes.
FloodsAs the exceptional monsoon rains fell, rivers
broke their banks, washing away bridges,
roads, villages and livelihoods. Food andsafe water were in short supply. The risks of

Khyber Pakhtunkhwa

Cities, towns or villages where MSF works

illness and contagion, and the sheer numberof vulnerable people completely exposed tothe elements were major challenges for therelief effort.
MSF staff fanned out to identify the areasand communities most in need. At theheight of the flood response, more than
1,600 staff were supporting hospitals,
treating injuries and illnesses, runningmobile clinics and distributing tents, sheltermaterials, and washing and cooking kits.
One of the most urgent needs was for safe
drinking water and MSF quickly engaged intrucking water, distributing up to 2.1 million

litres a day. Set against the requirements ofso many uprooted people, even these figures
were dwarfed by the scale of the disaster.
By October, the waters had largely retreatedand MSF reduced some of its activities,
but at the end of the year teams were still
providing medical care and water andsanitation services in Sindh, where thewaters were slowest to retreat. Staff were
working to provide shelters for the winterand to support the nutritional needs ofchildren whose families had lost their farms
or incomes. MSF also started running mobile
clinics, and distributing safe water and relief© Vali

GulatunStaff talk to a young patient in the operating theatre of Hangu hospital,
Khyber Pakhtunkhwa province.

70

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

Gulatun is due to give birth in twomonths’ time, but the placenta isblocking her uterus, meaning she willneed a caesarean section: “I became
worried about my baby when I started
bleeding for a few days. Someone in
the camp told me I should come to this
hospital. I really hope my baby will besafe.” Gulatun is one of the millions ofpeople who have been displaced by thedevastating floods that have destroyed
homes and livelihoods in many areasof Pakistan. Her home for now is amakeshift shelter in an open space on
the outskirts of Dera Murad Jamali in
Balochistan province, but Gulatun will
receive free emergency obstetric services
at Dera Murad Jamali’s hospital.

© Seb Geo

ASIA & THE CAUCASUS

Emergency relief kits are distributed to people displaced by the floods, Shahbaz, Punjab.

kits in the camps where people had taken
refuge in the city of Karachi. Overall in theemergency, MSF conducted over 100,000
consultations in five hospitals, seven mobile
clinics and six diarrhoea treatment centres.
SurgeryFighting continued in the northern regionsof the country before, during and after
the floods, as it had for the last five years.
In Khyber Pakhtunkhwa and FATA, theviolence shut down hospitals, access roads
and the transport of medical supplies. Evenif emergency patients found their way tohospital, the limitations of nursing care andlow standards of equipment and hygiene
did not ensure good quality services. Morethan one million people depended on
MSF to provide free emergency surgery.
In Khyber Pakhtunkhwa, MSF worked in
the emergency department and operating
theatre in Dargai in Malakand district, where
staff cared for around 130 patients eachmonth. MSF started working again in Swat
after having left in April 2009, when security
incidents had made it difficult for staff towork safely. In May 2010, the team returned
and was soon treating around 6,000
patients a month. In Timurgara in Lower Dir,
there were some 4,200 patients in MSF’s

emergency facilities every month. A new
project covering emergency department
services and emergency surgery was
opened in Hangu district, close to the tribal
areas, and treated around 1,300 patients amonth. In the town of Chaman, Balochistan
province, on the Afghan border, MSF
supported the emergency department of
the district hospital, ensuring that hospital
staff could treat and stabilise patients andprovide immediate lifesaving care.

Cutaneous leishmaniasis
In Quetta, the capital of Balochistan,
and also in Kurram Agency, in FATA, many
people suffer from cutaneous leishmaniasis,the most common form of leishmaniasis,a parasitic disease transmitted by sand flies,
which causes ulcer-like lesions and canlead to severe disfigurement. In 2010, MSF
launched programmes to provide the simple
but lengthy treatment required for the
disease, and treated more than 400 people.

Maternal and child health
Emergency obstetric care is only available
in urban areas of Pakistan, often becauseof a severe shortage of trained female staff.
Women traditionally give birth at homeand MSF has been working to reduce therisks by improving access to screening,
the availability of skilled birth attendants,
and provision of emergency obstetric andneonatal care. In Dargai, Timurgara, Hangu,
Kuchlak, Chaman and Dera Murad Jamali
hospitals MSF staff are equipped to carryout deliveries and can perform caesarean
sections in some facilities. In 2010, morethan 7,100 women delivered in an MSF
facility or an MSF-supported hospital;
481 delivered via caesarean section.

At the end of 2010, MSF had 1,177 staff inPakistan. MSF has been working in the country
since 2000.

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

71

ASIA & THE CAUCASUSPAPUA NEWGUINEA
East Sepik
Tari
Lae
Fly River
Regions where MSF has projects
Cities, towns or villages where MSF works

Social violence is rife in Papua
New Guinea and Médecins
Sans Frontières (MSF) provides
medical and psychosocial
care to survivors of sexualand domestic violence.

Lae is Papua New Guinea’s second largest
city, and MSF runs a Family Support Centre
at Angau Memorial General Hospital. Family
Support Centres offer a safe space to people
escaping domestic or social violence.
Patients receive medical care, but also socialand psychological support. MSF staff at thecentre offer comprehensive, free, medical
and psychosocial care to around 200 new
patients a month.
In the rural town of Tari, in the southernhighlands, MSF teams provide emergency
surgery at Tari hospital and work in a Family
Support Centre. In 2010, staff carried out
more than 13,000 general consultations andmore than 5,400 mental health consultationsin Tari and Lae general hospitals.
Hidden and Neglected: The Medical andEmotional Needs of Survivors of Family andSexual Violence in Papua New Guinea waspublished in December 2010 and reports

on MSF’s experience in the provisionof medical and psychosocial care in the
country. MSF makes a number of concrete
recommendations for action by national
authorities, civil society and international
donors, particularly regarding theestablishment and operation of Family
Support Centres.
Cholera outbreaks
The emergency response to a cholera
outbreak in East Sepik province, in the northof the country, concluded in mid-2010.
MSF set up 12 treatment units, 2 treatment
centres and 22 oral rehydration points, andtrained over 1,000 health workers in clinicalmanagement and infection control. MSF
also provided material, training and staff inresponse to a further outbreak in the Fly River
area in November 2010. In total, MSF treatedmore than 580 people for cholera in 2010.
At the end of 2010, MSF had 133 staff in
Papua New Guinea. MSF has been working
in the country since 2009.

© Fiona Morris

Contributing factors to the violence aremanifold and include poverty, urbanisation
and unemployment, drug and alcoholabuse, and limited government capacity
to provide adequate care.

Intensive care at Angau Memorial General Hospital in Lae.
72

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

Philippines
A renewed outbreak of the conflict between the Philippine
government and the Moro Islamic Liberation Front (MILF) in2008 resulted in the displacement of more than 750,000 people.
Jahaira© Jeoffrey Maitem

30 years old, MSF community health worker

People wait at an MSF clinic in a displaced persons camp, the Philippines.

North
Cotabato

Maguindanao
Regions where MSF has projects

Médecins Sans Frontières (MSF) started
working in Maguindanao, in theAutonomous Region in Muslim Mindanao,
and North Cotabato, in a neighbouring
region of Mindanao, because the local
health system was overwhelmed andstruggling to meet the people’s basic
healthcare needs.
Responding to trauma
In 2010, MSF provided healthcare in fiveevacuation centres. These government-run
centres provide a temporary home to people
displaced by violence. Special attention was
paid to children, women and individuals
suffering severe consequences of trauma
and violence. MSF held more than 27,500
consultations through mobile clinics or inexisting health centres, providing carefor 3,455 pregnant women and treating
267 children for severe acute malnutrition.
Mental health problems were a major
unaddressed issue in the evacuation
centres. Many of the displaced people had
had traumatic experiences, losing family
members and their homes, and living in
precarious circumstances for long periodsof time. The public health system did notoffer treatment of post-traumatic stressdisorder, so MSF integrated a mental healthcomponent into its medical response totrauma and violence and treated 1,155
people in 2010.

“I was in the small town of Butilen, visitingsome relatives, when the conflict erupted
unexpectedly. For the first time, I heard
bombs and the whirring sound of helicopter
blades. I was really afraid and very concerned
about my community’s fate. We had to
manage everything on our own. We did notwant to go to evacuation centres – they were
overcrowded and dirty – so we decided tostay at home, despite the daily bombings.
I was going to Cotabato to work every day,bringing all my belongings and important
documents in case I couldn’t go back home.
For months, there was bombing and fighting
every day. People of my community were
suffering from the lack of food. Many had
diarrhoea and high fever. Some of them had
to build their own shelters as their houses
were destroyed. Some decided to go toevacuation centres in the end.”fragile, but displaced people have started
moving back home or integrating into
host communities. As a consequence, MSF
reduced its medical activities. In October,
MSF handed over its projects to the
public authorities.
At the end of 2010, MSF had 51 staff in thePhilippines. MSF has been working in the
country since 2008.

The organisation helped rehabilitate healthstructures by setting up waste disposal andimproving water supplies and sanitation in
the districts of Datu Piang, Libutan,
Lumpong and Libungan Torreta. MSF also
distributed relief items, including plastic
sheeting and soap, to 800 families.
Stability returning
In May 2010, following the presidential
election, efforts have been made to settle
the conflict between the government and
MILF. The situation on the ground remains

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73

ASIA & THE CAUCASUS

Sri Lanka
Vavuniya

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

The 26-year civil war in Sri
Lanka ended in May 2009.
Hundreds of thousands ofpeople who had been displaced
from their homes in the northand confined to camps were
resettled or allowed to returnhome by the beginning of 2010,
and Médecins Sans Frontières(MSF) adapted its activities inlight of these developments.
Vavuniya
Set up at the end of 2009, the MSF
rehabilitation programme in Pampaimadhu
hospital, close to the northern town of
Vavuniya, assists patients who have sufferedspinal cord injuries. Such injuries are frequently
sustained in conflict zones as shrapnel, gunshot
and explosive blasts can cut, pull or compress
the spinal cord. Victims can become numb oreven paralysed from the point of injury down,

and frequently lose normal bladder and bowel
control. Rehabilitation has a huge impact not
only on patients’ quality of life but also on theirlife expectancy. This innovative programme
integrates medical treatment, physiotherapy
and mental healthcare.
In partnership with Ministry of Health staff,
MSF helped patients to manage their healthissues and assisted them with daily physicalrehabilitation activities to improve mobility.
MSF also conducted 840 counselling sessions.
In 2010, 40 new patients were admitted tothe programme.
In Vavuniya general hospital, MSF built
an operating theatre for reconstructive
orthopaedic surgery and supplied specialist
surgeons, anaesthetists and nurses tooperate on patients with complicated warrelated injuries. Patients received long-term
post-operative care to ensure full recovery.
In total, 58 surgical procedures were carriedout in the operating theatre during 2010.
Mental healthcare in Kilinochchi district
Since November 2010, MSF has provided
counselling to people suffering from mental
trauma in partnership with the Kilinochchi
District Mental Health Unit, in the far northof Sri Lanka. Most patients were sufferingfrom bereavement or missing family members
because of the conflict. Staff held bothindividual and family counselling sessions.
Menik Farm camp
Many of the people in the government-run
camp for displaced people at Menik Farm
witnessed deeply traumatic events during

the last phase of the civil war. To support
the efforts of the Ministry of Health and thepsychiatry department of Vavuniya hospital,
at the beginning of 2010 MSF began offering
mental healthcare to people living in the camp.
A psychiatrist and a psychologist worked
with Sri Lankan counsellors and community
social officers to identify and treat people
who needed care. The team treated a totalof 1,520 patients and gave around 4,300
counselling sessions in 2010. The project wasclosed in November, as over the course of theyear people left the camps to return to theirhomes. MSF provided mental healthcare to
many returnees in the district of Mullaitivu.
MSF also provided supplementary food to8,864 people in Menik Farm camp at the
beginning of the year to prevent vulnerable
groups from suffering from severe acutemalnutrition. By February, the need for
nutrition activities had decreased and
MSF handed its programme over to theorganisation World Vision International.
Hospital support
The scene of some of the fiercest fighting at
the end of the civil war, Mullaitivu district saw
a steady stream of people returning homein 2010. MSF assisted in the provision of
emergency care, gynaecological and obstetriccare, and surgery in the Mullaitivu district
hospital. An MSF team helped improve thewater supply and waste disposal in thehospital and also rehabilitated the laboratory.
In the last months of the year, a doctor andan operating theatre nurse started working
in the emergency unit, and over November
and December held 564 consultations.
Mobile clinics, providing basic healthcare,
were conducted in the surrounding area.

© Pete Masters / MSF

MSF continued to support specialist activities in
Point Pedro hospital, the second largest healthstructure in the Jaffna peninsula. Staff provided
emergency healthcare, gynaecologicaland obstetric services, as well as surgery.
Nearly 3,000 consultations took place in theemergency department, with around 390
patients admitted to the intensive care unit.
Surgeons performed 963 major surgeries,
which required general or spinal anaesthetic.
More than 4,200 women received antenatal
care and 1,130 babies were delivered.

An MSF physiotherapist holds a session with a patient at the spinal injury unit inPampamaidhu hospital, Vavuniya.
74

MSF PROJECTS AROUND THE WORLD – ASIA & THE CAUCASUS – Sri Lanka

MSF also offered training to hospital staff inlaboratory services, hygiene and sterilisation,
and was able to fill gaps in the provision of
medical supplies as well as medicines.
At the end of 2010, MSF had 428 staff in Sri Lanka.
MSF first worked in the country in 1991.

ASIA & THE CAUCASUS© Francesca Di Bonito

thailandPatients are transferred to an MSF clinic.

Mae Hong Son
Three
Pagodas Pass
Samut Sakhon
SangkhlaBuri

new mon state

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

Kayah backpackers
The Kayah backpackers project is based in
Mae Hong Son, in the north of Thailand.
MSF staff in Thailand train “backpackers”
from Myanmar so that they can provide basic
healthcare. The backpackers then travel backacross the border and work as mobile medical
teams, visiting people living in remote villages
in Kayah state, eastern Myanmar, who would
otherwise not have any access to medical care.
MSF closed its malaria project in New Mon
State, in Myanmar, at the end of June. Staff
working from a base on the Thai side of theborder had been supporting malaria control
initiatives in Myanmar, distributing mosquito
nets, training community health workers,
and diagnosing and treating patients.

In Thailand, Médecins Sans Frontières (MSF) helps improveaccess to healthcare for some of the estimated three million
unregistered migrant workers in the country. Staff also train
health workers to provide basic healthcare to people living
across the border in Myanmar.
Three Pagodas Pass
Thousands of migrant workers cross theborder between Thailand and Myanmar
at the Three Pagodas Pass every day. Many
come to work in factories, some move further
into Thailand. Unregistered migrant workers
are being excluded from healthcare, andundocumented migrants in need of careoften fear that a visit to a health centre may
result in deportation. MSF helps to provide
access to medical care by operating a mobile
clinic in the Three Pagodas Pass area, which
provides basic healthcare. Staff conducted
146 antenatal consultations and referredpregnant women to Ministry of Health hospitals
for delivery. Some 460 people were vaccinatedagainst measles. In May, MSF distributed relief
items when political tensions led to an influxof people from Myanmar. In November, staff
provided healthcare to 331 people whenpost-election violence in Myanmar led to some

3,000 people crossing the border to Thailand.
In December a fixed clinic was opened toincrease the availability of care.
Samut Sakhon
In Samut Sakhon province, an industrial
zone where thousands of undocumented
migrants live and work, MSF staff operated
a clinic offering basic healthcare, including
vaccinations for children under five, antenatal
care and medical care for people suffering
physical trauma. More than 540 people
attended health education sessions.
Working in collaboration with the Ministryof Health, MSF diagnosed and treated 170
people for cholera after an outbreak at theend of October.
At the end of 2010, MSF had 41 staff in
Thailand. MSF has been working in the
country since 1976.

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

75

ASIA & THE CAUCASUS

Uzbekistan
Gulziyma© Misha Friedman“I was so afraid of the disease.
I got good treatment, but what if it
happened again? What will people saywhen they find out I am sick? Can I
have a family? Will I be a mother?
I was afraid of all the things that might
never be. Like many patients, I was
afraid of never being a full humanagain. I felt like a disabled person.
“N ow I have completely forgotten all
my fears. I was a patient and now I ama counsellor. I began to get rid of myfears with the counselling I received.
Then I wanted to help others to get
rid of theirs. Now I can say that I had
TB. It’s important that I use the past:
I HAD tuberculosis. And recently I evenbecame a mother.”

An MSF laboratory scientist carries out tests to check for tuberculosis.

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

The prevalence of drugresistant tuberculosis (DR-TB)
in Uzbekistan is one of thehighest in the world, butless than ten per cent of the
population has access toadequate DR-TB treatment.
There is an urgent need to
expand comprehensive TB
care so that everyone in needcan be properly diagnosed
and treated.

76

In May 2010, Médecins Sans Frontières(MSF) began extending its programme in
the Autonomous Republic of Karakalpakstan,northwestern Uzbekistan, from the capital
Nukus and the district of Chimbay. By theend of 2010, MSF was working to provide
TB care in four districts.
In 2010, 385 patients started treatment anda new test, which diagnoses drug resistancefaster, was introduced. The aim of this test
is to speed up the beginning of treatment
and the isolation of DR-TB patients, helping
to prevent transmission. The first patients
to take the new test began treatment in
October 2010.
Social and psychological support
The provision of support to the patient
as well as to family members before andduring treatment has been at the centre of
the project. The majority of DR-TB patients
suffer from side effects of their medication.
Some of these, such as nausea, headaches
and sleep disturbances, are quite powerfuland long term, presenting a major obstacle
to treatment adherence. MSF staff holdindividual, group and family counsellingsessions to help patients manage theseside effects and the social effects of thedisease, and to improve their adherence.

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

MSF continues to promote new approaches
in diagnostics and treatment to Uzbekistan’s
Ministry of Health, including outpatient care
options and psychological and social support,
and will continue to lobby the ministry tointegrate these services into its structure.
Expanding the TB programme
In 2011, MSF will enrol its 1,500th patient in
the DR-TB programme in Karakalpakstan andfurther expand its comprehensive TB careprogramme to another three districts. MSF
will improve infection control mechanisms
and improve TB drug supply management
practices, as well as train health staff.
Assisting refugees
In June 2010 approximately 100,000
people crossed the border from Kyrgyzstan
to Uzbekistan in search of refuge fromcivil conflict. The relief operations for the
refugees were strictly controlled by thegovernment of Uzbekistan, but MSF staff
managed to visit almost all the camps.
The team provided relief items, including
washing and cooking kits, and offeredcounselling to traumatised refugees.
At the end of 2010, MSF had 117 staff in
Uzbekistan. MSF has been working in the
country since 1997.

© Mads Nissen

Father and son, Genareros, Arauca, Colombia.

78 BOLIVIA
79 Brazil
80 COLOMBIA
82 GUATEMALA
83 HONDURAS
84 Haiti
86 paraguay

The AMERICASThe AMERICAS

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

Chagas disease is one of theleading parasitic killers in theAmericas and Bolivia is thecountry most affected.
If not treated in the early stages, Chagas
can cause cardiovascular, gastrointestinal orneurological problems later in life. Diagnosis
is complicated, and the Bolivian Ministry of
Health does not have adequate financial or
human resources to diagnose and treat thedisease across the whole country.
The ministry concentrates on treating young
people with Chagas disease because treatment
is far more successful with children. For a childunder the age of 10, the likelihood of being
cured is almost 100 per cent, whereas an adult’schances could be less than 50 per cent. Children
are also more likely than adults to suffer the
more severe consequences of Chagas.
Chagas treatment programmes
In the department of Cochabamba, Médecins
Sans Frontières (MSF) runs free Chagas
programmes that are integrated into rural
health centres offering basic healthcare. MSF
staff diagnose and treat adults, but theirmain objective is to treat children under
15 years of age and women under 45.
Women in this age group are a priority tohelp prevent the possibility of them passing
the parasite to the child should they become
pregnant. The side effects of the medication
prevent women with Chagas from being
treated while pregnant or breastfeeding,so they are monitored and then treated assoon as they finish breastfeeding. More than
1,300 patients started treatment in 2010.
The prevalence of Chagas among womenof childbearing age is 70 per cent in someparts of Cochabamba’s Narciso Campero
province, and travel to health centres canbe difficult. MSF staff screen people for
Chagas and provide treatment in 26 ruralcommunities, as well as in Aiquile, Pasorapa
and Omereque hospitals. More than 1,450
people were diagnosed with Chagas and908 began treatment in 2010.

78

Raising awareness of Chagas
Besides diagnosis and treatment, MSF is
also working on prevention. Chagas istransmitted to humans by the vinchuca
beetle and preventing the beetles fromre-infecting patients who have finishedtreatment is vital. Since mid-2009, MSF
has been training patients to evaluate thepresence of vinchuca beetles in their homes.
MSF offers this training while visiting villages
and treating patients for the disease.
Another component of MSF’s awarenesscampaign is the “Chagas bus”, which travelledfrom the Altiplano region to the eastern
lowlands, through the semi-desert of the
Chaco and the central valleys. The team on
the bus informed people about prevention
and encouraged them to seek testing andtreatment. They also provided information
so that people could educate the rest of theircommunity about the disease and how it isspread. In addition, in the town of Aiquile andthe cities of Cochabamba and Santa Cruz, threepatient groups have been created to promote
education and awareness about Chagas.
In May 2010 the World Health Assembly
adopted a resolution on Chagas disease control
and elimination, which included many steps
advocated by MSF: the integration of thediagnosis and treatment of Chagas into primary
healthcare for all patients; the reinforcement of
the provision of treatment in disease-endemic
countries; and the promotion of operational
research on the control of Chagas to promote
the development of a valid and accessible testof cure. This step forward at the international
level should encourage the improvement ofcare and treatment for the millions of people
infected with Chagas disease.
At the end of 2010, MSF had 49 staff in Bolivia.
MSF has been working in the country since 1986.

Pamela21 years old“I have been living in Cochabamba
for 11 years and I have two children:
Griselda, aged one, and Kevin, aged
three. I was in the health centre waiting
for my consultation when I heard awoman talking about Chagas. Whenshe mentioned that the vinchuca beetle
transmitted the disease, I rememberedthat when I was a girl we had vinchucas
in my house. I was afraid of the injection
but I decided to do the test. I had to takemy children for testing too. Two weeks
later they confirmed that we were all
positive. When I got home I cried as I felt
guilty that my children, my only family,
were sick because of me. Kevin and
Griselda have completed the treatment
without pain. I am now reaching theend of treatment too.”© Anna SurinyachSanta Cruz

In Cochabamba city, MSF is working in
18 health centres, integrating Chagas care
into general healthcare. During 2010,
1,085 people were confirmed to have Chagas
and 436 started treatment. The Ministry of
Health will take over the project in 2011.

An MSF outreach worker explains how the vinchuca beetle is responsible for much of
the spread of Chagas disease, and how to protect against it.

MSF PROJECTS AROUND THE WORLD – The AMERICAS – Bolivia

The AMERICAS© Erico Hiller

BrazilMSF staff set up latrines after the floods in Alagoas state.

AlagoasRegions where MSF has projects

In June, Alagoas state innorthern Brazil suffered severe
flooding: 34 people died, 54
were reported missing and25,000 people were displaced
from their homes.

In the days after the floods, a Médecins Sans
Frontières (MSF) team found thousands ofpeople crowded into churches, schools andother public buildings.
“At one school, nearly one thousand people
were sharing six latrines”, said Cristina Sutter,one of the first MSF psychologists to arrive.
“The situation was chaotic in the bigger,
collective shelters. There was a strong smellof urine and a major lack of hygiene”.

depression. In the villages of Branquinha
and Murici, MSF staff carried out 300
psychological consultations.
“Mental health support is essential, as it helps
prevent psychological and mental problems frombecoming chronic. It helps people restructureand start their lives again in a healthier and morebalanced manner”, said Sutter.

Large, temporary shelters had been
constructed, and to improve living
conditions MSF teams installed taps,
showers and latrines where they were mostneeded. Teams also distributed washkits
containing items such as plastic bowls,
towels, soap and toothbrushes.

After two months, the emergency phasecame to an end. MSF handed over its
activities to local authorities and otherorganisations at the end of August. MSF
provided training to more than 200 local
medical staff as part of the handover process,in order to ensure continuity of psychologicalcare and to assist local organisations in
improving their emergency response.

Having lost everything in the floods, many
people were suffering from anxiety andAt the end of 2010, MSF had 11 staff in Brazil.
MSF has been working in the country since 1991.

MSF PROJECTS AROUND THE WORLD – The AMERICAS – Brazil

79

The AMERICAS

Colombia

In 2010, formally demobilised paramilitary groups re-emerged inmany areas across Colombia. The violence in the country prevents
many people from accessing healthcare and Médecins Sans
Frontières (MSF) projects focus on meeting the medical needsof people living in conflict zones or displaced by conflict.

Bolivar
Sucre

Norte deSantander

Caucasia
AraucaQuibdó
Cauca

Riosucio
Buenaventura
CaquetáNariñoPutamayo

Cities, towns or villages where MSF works

In Cauca, Putamayo and Nariño, in southwest
Colombia, mobile teams visited rural areasthat are often the scene of violent conflictand provided general healthcare, as well as
reproductive, antenatal and psychologicalcare. In Nariño and Cauca, MSF also assisted
in 11 emergencies, providing aid to morethan 2,600 displaced people.
In Caquetá, MSF provides mental healthservices and primary healthcare. Staff
managed to reach people living in rural
areas of the districts of San Vicente delCaguán and Cartagena del Chairá, who arehighly exposed to armed conflict, and where
health services are scarce. In total, MSF
teams carried out more than 50,777 general
medical consultations in Caquetá, Cauca,
Nariño and Putamayo.

© Mads Nissen

Regions where MSF has projects

Reaching people in conflict zones
In the north of the country, MSF carriedout more than 13,000 consultations in the
districts of Sucre and Bolivar that were mostaffected by violence. MSF also ran mobile
clinics in Norte de Santander, carrying out
almost 9,000 general consultations as well as
consultations on reproductive healthcare.

A member of staff examines test results for a patient with Chagas disease, Genareros, Arauca.
80

MSF PROJECTS AROUND THE WORLD – The AMERICAS – Colombia

The AMERICAS

Mental healthcare
Mental healthcare is particularly importantfor people who are exposed to high levelsof violence, but it is a service that has been
neglected by Colombia’s health system. MSF
provided care for more than 12,000 patients inthe departments of Caquetá, Cauca, Nariño,
Putamayo, Norte de Santander, Sucre andBolivar. Staff held individual consultations,group consultations and psychosocial support
sessions. In 2010, MSF drew attention tomental health needs with its report on
Caquetá: Three Times Victims: Victims ofViolence, Silence and Neglect, Armed Conflictand Mental Health in the Department ofCaquetá, Colombia. The report concluded
that there is a significant need for specialised
mental health services, and that it is possible toeffectively provide good quality mental healthservices to Colombians caught up in conflict.
Healthcare in Chocó
San Francisco de Asís hospital’s maternity unit,
in the town of Quibdó, Chocó department,is the referral centre for all complicatedobstetric cases in the department. Since MSF
started work in the unit in 2003, it has set up aneonatal ward, trained staff, provided care to
victims of sexual violence, and held more than
40,000 consultations. In 2010 MSF handed the
project over to a local healthcare provider thathas the capacity to take over the activities.

The MSF clinic in the town of Riosucio, in
Chocó department, will continue to provide
free healthcare. Staff offer mental health andreproductive health services, and a programme
providing medical and psychological assistanceto victims of sexual violence. More than 4,400
consultations were carried out in 2010. MSF
also supported and provided emergency
obstetric care in Riosucio hospital.
Healthcare in Buenaventura
People living in rural areas of Colombia areoften forced to choose between living under
the threat of violence and taking the risk ofgiving up everything to move to the city.
Many people displaced by conflict have
moved to the Pacific coast. A large number ofdisplaced people have moved to Buenaventura
city, in the department of Valle del Cauca.
In 2007, MSF set up a health centre providing
free consultations to those without anyother access to medical care. Staff provided
antenatal and postnatal care, vaccinations,emergency services, reproductive healthcare,mental healthcare, treatment for malnutritionand support for victims of sexual violence.

© Mads Nissen

The mobile and fixed clinics along the San Juan
River, as well as a boat ambulance, were also
handed over. Remote villages along the river willcontinue to receive healthcare, and MSF staff
will continue to operate along the Baudo River.
Chagas screening in Genareros, Arauca.
Between January and September 2010, 15,520
general consultations were carried out, mainly
treating skin and respiratory infections.
In Miramar, a district of the city built on stilts, lackof access to safe water was a significant factor in
the incidence of skin and gastric diseases. An MSF
team ensured a safe water supply to the residentsof the district and, in doing so, repaired morethan 700 metres of bridges.
The number of people in Buenaventura
suffering from multidrug-resistant tuberculosis
is more than three times the national average– Buenaventura is a busy port, and it is likelythat the movement of goods and people
facilitates the spread of the bacteria. At the endof December 2010, MSF began to support thenational tuberculosis control programme withtesting and treatment.
Chagas programme
Chagas disease in endemic in Colombia, yet
detection and treatment programmes are
non-existent at the departmental and national

levels. MSF’s Chagas programme in Arauca is
integrated into the mobile clinics that offer
general healthcare. More than 2,750 people
were screened, and 34 patients were foundto have Chagas in 2010, half of whom hadcompleted treatment by the end of the year(the others are still receiving treatment).
There are plans to extend Chagas care to thedepartment of Norte de Santander in 2011.
Relief after the rains
Higher than average rainfall in 2010 led toflooding, which made more than 1.5 million
people homeless. MSF participated in theemergency response by providing relief
items, including plastic sheeting for
temporary shelters, mattresses, blankets
and hygiene kits to thousands of displaced
people in the departments of Bolivar,
Caquetá, Chocó, Nariño and Sucre.
At the end of 2010, MSF had 306 staff in
Colombia. MSF has been working in the
country since 1985.

MSF PROJECTS AROUND THE WORLD – The AMERICAS – Colombia

81The AMERICAS© Marcell Nimfuehr

guatemalaA nurse explains to hospital visitors the consequences of sexual violence and the treatment services offered by MSF, Guatemala City.

Retalhuleu

GuatemalaCity
Santa Rosa

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

There is a national protocol in place fortreating victims of sexual violence, but it has
only been implemented at one clinic in thecapital. Many survivors are unable to accesstreatment, and are often unaware that their
physical and mental symptoms can be treated.
MSF’s programme takes a multidisciplinary
approach to treating sexual violence. MSF
offers medication that significantly reduces
the likelihood of patients contracting HIV
and other sexually transmitted infections
if taken within 72 hours of the incident.
In 2010 around 57 per cent of patientsarrived early enough for this treatment tobe effective. A psychological team provides
counselling to help patients cope with the82

In 2010, Médecins Sans Frontières (MSF) was providing medical,
psychological and social care to victims of sexual violence in two
clinics in Guatemala City, as well as in the General Hospital andthe Ministry of Justice, where assaults are reported. Althoughthousands of cases of sexual violence are reported each year,
it is estimated that 75 per cent of sex crimes go unreported.
acute stress, anxiety and other effects arisingfrom their experience. A social worker
is also available and provides support by,for example, helping patients to find a safe
place to stay if they are still in danger.
In 2010, MSF treated 870 new patients. Including
those who had started treatment in previous
years, 1,200 patients received medical care, and2,800 received psychological counselling.
In the coming years, MSF aims to encourage
more and better implementation of nationalguidelines in clinics. Teams will also use
community information networks, medical
conferences and the media to raise awarenessthat medication is available to help prevent thetransmission of infections such as HIV, and thattreatment must be sought as early as possible.

MSF PROJECTS AROUND THE WORLD – The AMERICAS – guatemala

Natural disaster
The eruption of volcano Pacaya and tropicalstorm Agatha at the end of May killed
almost 200 people. Overflowing rivers,
collapsed bridges and the damage caused
by mudslides resulted in the displacementof tens of thousands of people. Teams from
MSF assisted people in the departmentsof Retalhuleu, Escuintla and Santa Rosa.
Over 20 days, staff distributed hygiene kits
(containing toothbrushes, soap, sanitary
towels, buckets, etc.), and provided medicalcare, drinking water and mental healthsupport to people affected by the flooding.
At the end of 2010, MSF had 39 staff in
Guatemala. MSF has been working in the
country since 1984.

The AMERICAS

honduras
Tegucigalpa

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

From 2005 to 2010, MSF staff operated a centre
providing medical treatment for people under
the age of 24 who were living on the streets.
Staff gave medical and social support to 460
young people over five years. Patients mostoften required treatment for respiratory
diseases, skin infections and injuries resulting
from violence. The centre also provided a space
where visitors could wash, eat and try to recoverfrom the effects of drug abuse. Patients received
psychological support, which helped some tomove on and find work or a place to live.
A change in approach
In 2010 MSF undertook an evaluation of theservices it was providing to homeless people in
Tegucigalpa, and decided that a new approach
would meet the people’s needs more effectively.
The centre was closed at the end of August
and a team has begun preparing for a newprogamme. This will provide broader services
to all age groups in a larger geographic area.
Instead of expecting people to visit a centre,
MSF staff will go out on to the street and actively
reach out to vulnerable groups living in the mostdeprived areas of the capital. This approachshould enable MSF to assist more people and torespond better to the full range of their needs.
Dengue outbreak
An alarming increase in cases of dengue fever in
mid-2010 prompted MSF to offer support to local
health services’ response in the capital, where themajority of cases were reported. Dengue is a viraldisease transmitted by mosquitoes. Symptoms
are similar to flu, and its most severe form,
haemorrhagic dengue, causes bleeding and canlead to irreversible shock and death.
Between August and September MSF teams
provided medical care, vector control– controlling the means of transmission of thedisease – and community education. Staff set
up an emergency paediatric ward in San Felipe
hospital, where 163 children received treatment.
Mobile teams also worked to identify andeliminate sources of infection in the Manchen
settlement, on the outskirts of Tegucigalpa. Staff
travelled from house to house to raise awarenessof how to stop the mosquitoes breeding andspreading the virus. The teams also fumigatedsome 1,600 households and donated more than
400 mosquito nets to hospitals.
At the end of 2010, MSF had 28 staff in Honduras.
MSF has been working in the country since 1988.

© Juan Carlos Tomasi

Honduras has the highest murderrate in Central America, andpeople living on the streets ofthe capital city Tegucigalpa areespecially vulnerable to violence.
In a Médecins Sans Frontières(MSF) survey carried out in 2010,
almost 59 per cent of homelesspeople under the age of
18 reported having been subjectedto physical violence in the lastyear, and 45 per cent claimed tohave suffered sexual violence.

People living on the streets are therefore inparticular need of medical and psychologicalcare. Often, however, health centres in the city
deny treatment to homeless people becauseof a perceived security threat.

A young patient is examined in the MSF dengue ward at San Felipe hospital, on the outskirts of Tegucigalpa.
MSF PROJECTS AROUND THE WORLD – The AMERICAS – honduras

83

The AMERICAS

Haiti

In the wake of the devastating
earthquake of 12 January 2010,
which killed an estimated222,000 people and left
1.5 million homeless in Haiti,
Médecins Sans Frontières(MSF) mobilised the largest
emergency response in theorganisation’s 40-year history.
Just ten months later, MSF staff supported theirHaitian colleagues in tackling a nationwide
cholera outbreak that would infect more than
180,000 people in less than three months.
Before the earthquake struck, healthcare
was out of reach for most Haitians, as fees
charged by both public and private healthfacilities made it unaffordable. Public hospitals
and clinics were plagued by management
problems and strikes, and shortages of staff,
drugs and medical supplies. Patients could beturned away because the hospitals were full,or would have to abandon treatment when
they ran out of money. Giving birth was a risk:
Haiti’s reported maternal mortality rate was
630 deaths per 100,000 live births.
Then the earthquake hit and threw Haiti into aperiod of turmoil that went beyond anythingeven its most beleaguered residents had known.

Port-de-Paix

Limbé
Cap Haïtien

Gonaïves

Grande Rivière du Nord

Dessalines

Petite Rivière

Saint-Marc

Cange

LéogânePort-au-PrinceJérémie
Les Cayes

Bassin Bleu
Saint Michel

Regions where MSF has projects

Cities, towns or villages where MSF works

help MSF provide assistance. MSF’s regulardeployment of 800 field staff in Port-au-Prince
quickly expanded to 3,400 people working in
26 hospitals and four mobile clinics. From
12 January to 31 October, medical teams
treated more than 358,000 people andperformed more than 16,500 surgeries.
Treating the wounded
Sadly, 12 Haitian MSF staff members were
killed in the earthquake. The MSF obstetricand trauma hospitals were destroyed. Only
the Martissant emergency facility, in south
Port-au-Prince, was still operational, but it
was quickly overwhelmed. Within hours of
the earthquake, more than 400 criticallyinjured patients had arrived at Martissant.

© Moises Saman/Magnum Photos

Thousands of Haitians, most of whom weredirectly affected by the disaster, mobilised
along with hundreds of international staff toPlaisance

A man carries a woman infected with cholera into St Nicholas hospital, Saint Marc.

84

MSF PROJECTS AROUND THE WORLD – The AMERICAS – Haiti

At the MSF centre in Pacot, which provided
post-operative care, only one operatingtable was available for minor operations. In
and around the collapsed La Trinité hospital,
surgery was carried out in tents and, after a
few days, in a converted shipping container.
Within approximately 48 hours, MSF identified
available rooms and a dressing station at the
Ministry of Health’s Choscal hospital andmanaged to start surgical activities in two
operating theatres there. By 15 January, major
surgery was also being provided in tents
around Carrefour hospital. MSF surgeons
performed more than 5,700 major surgicalprocedures during the first three months,
150 of which involved amputations.
Emergency field hospitals were set up in
all kinds of structures – a dental clinic at
Bicentenaire, a school in Carrefour, andsemi-permanent buildings in Léogâne,
west of Port-au-Prince. An inflatable tent
hospital replaced the destroyed La Trinité
hospital and provided emergency medicalcare as well as more specialised trauma andorthopaedic surgical care. In Sarthe, MSF
opened a centre for post-emergency surgery
and post-operative care. More than 500
patients underwent specialised orthopaedicor reconstructive surgery. Handicap
International physiotherapists worked incollaboration with MSF to help patients
recover and adapt to prosthetics. Mental
healthcare was also provided.
Jacmel, a town on the south coast, was also
badly hit by the earthquake, and MSF teams
started supporting the 80-bed Saint Michel
hospital on 22 January. Staff carried out
662 surgical operations and delivered 1,443
babies over the course of the year.

© Julie Remy

The AMERICAS

Staff operate on a patient with broken legs at a makeshift surgery outside Carrefour hospital, Port-au-Prince.

Emergency obstetric care
As MSF’s emergency obstetric hospital had
been destroyed, MSF started offering staff,
drugs and obstetrics expertise to support the
Ministry of Health maternity hospital,Isaïe Jeanty, which had not been damaged by
the earthquake. Isaïe Jeanty treats pregnant
women with medical complications suchas eclampsia and malaria, and provides
neonatal and postnatal services and a bloodbank. In Léogâne, MSF set up a 120-bed field
hospital, which was later replaced with a morepermanent container hospital. More than
15,000 babies were delivered in MSF-supported
facilities in 2010.

Non-medical assistance
By the end of June, MSF had distributed morethan 28,640 tents, approximately 2,800 rollsof plastic sheeting, and close to 85,000 relief
supply kits (made up of items such as cooking
utensils, hygiene products and blankets)
to people living near the epicentre of theearthquake. In Léogâne, for example, MSF
made distributions to 3,000 families.
Much of MSF’s water and sanitation work focusedon creating the appropriate hygiene conditions
to carry out medical and surgical programmes.
Teams ensured the supply of safe water,
constructed or rehabilitated latrines, and set up
the safe evacuation of waste at MSF’s 26 facilities.

Specialised care
When La Trinité hospital was destroyed,
Haiti lost its only specialised treatment
unit for severe burns. Re-establishing thisunit became a priority, especially given thedangerous living conditions. By late March,a new 30-bed burns unit had been set up
under canvas within the nearby Saint Louis
hospital compound.

Cholera outbreak
In mid-October, suspected cases of cholera, adisease not reported in the country for decades,
emerged in the Artibonite region, western Haiti.
MSF dispatched teams to the town of SaintMarc and they immediately began treating
patients for severe dehydration fromdiarrhoea in the Ministry of Health hospital.

Psychiatric care was also organised at SaintLouis hospital for patients who required
mental health services and could be referredfrom other MSF programmes or other
health providers. MSF gave psychosocial or
psychiatric support to more than 40,000
people during the initial emergency phase.

The outbreak would eventually touch every
province in the country. From 22 October
until the end of the year, MSF treated morethan 91,000 of the 171,300 people reported
as having cholera nationwide. Specialised
treatment centres were set up for pregnant
women in Isaïe Jeanty hospital and in

Léogâne. Teams established over 4,000 bedsin 47 facilities around the country. Morethan 1,000 tons of medical and logisticalsupplies were delivered, and more than
5,500 staff dedicated to cholera treatment.
In 2011, MSF will relocate its medical activities– including the obstetric centre and theonly burns treatment unit – into three newly
constructed hospital facilities in Port-au-Prince.
Outside the capital, MSF will continue tooperate a 120-bed general hospital that it has
built in Léogâne. For more on MSF’s activities in
Haiti, see the photo essay on pages 100 –103.
At the end of 2010, MSF had 2,918 staff in Haiti.
MSF has been working in the country since 1991.

Nanoune28 years old“I was expecting twins and I gave birthprematurely at six months of pregnancy.
I live in a camp ten minutes from Choscal
hospital. My first baby came in the tent
but was stillborn. Immediately my sisteraccompanied me to the hospital. My
second baby was born here but she is too
small. The nurses have been taking careof my daughter for five days. She has yet
to be named … I pray to keep her.”

MSF PROJECTS AROUND THE WORLD – The AMERICAS – Haiti

85

The AMERICASPARAGUAY
Boquerón

Regions where MSF has projects

Boquerón department is in the Paraguayan
Chaco, a sparsely populated and semi-desert
region in the west of the country. Access tohealthcare is poor here and MSF teams are
visiting remote settlements, screening thepeople for Chagas and giving those infected
the treatment they need. MSF has trained
health workers in Boquerón to diagnose andtreat the disease, and the main laboratory in
the regional hospital has been equipped to
be able to confirm it. In the last two monthsof 2010, MSF staff screened 426 people for
Chagas disease.

The “Chagas Bus” arrived in Boquerón from
MSF’s project in Bolivia, and the team on
board has been travelling around schools
and villages, educating and informing
people about the disease and how to prevent
transmission, and encouraging them to seek
testing and treatment.
At the end of 2010, MSF had 6 staff in
Paraguay. MSF started working in the
country in 2010.

© MSF

Chagas disease is a parasitic, potentiallylife-threatening illness. Up to 30 per centof people infected end up developing
serious cardiovascular, gastrointestinal orneurological problems in their adult years
if the disease is not diagnosed and treatedin the early stages. Diagnosis itself iscomplicated, and staff or facilities are often
not available to carry out the necessary tests.

Chagas disease is endemic in the Gran Chaco region, whichborders Paraguay, Argentina and Bolivia. In November 2010,
Médecins Sans Frontières (MSF) began a Chagas diagnosis
and treatment programme in Paraguay.

An MSF team visits a village in the Paraguayan Chaco to inform people about Chagas disease and encourage them to get tested.
86

MSF PROJECTS AROUND THE WORLD – The AMERICAS – PARAGUAY

© Olmo Calvo

Migrants and asylum seekers held in a detention centre in Malta.

88 France
89 Greece
90 Malta

95 Lebanon

91 RUSSIAN FEDERATION

96 OcCupied
Palestinian Territory

92 IRAQ

97 SYRIA

94 IRAN98 Yemen

EUROPE & THE
MIDDLE EASTEUROPE & THE MIDDLE EASTFRANCE
Paris

MayotteCities, towns or villages where MSF works

Many asylum seekers in France
do not receive a residence
permit or their asylum
applications are denied. Not
having any legal status has
serious social consequences –no home, no social assistance,
no right to work – which
in turn cause problems inaccessing healthcare.

Anxiety levels are extremely high among
patients: 40 per cent speak of having
suicidal thoughts. Many have had traumatic
experiences in their home country, on theirjourney, or in Europe. The vulnerability anduncertainty of the migrant’s or asylum seeker’s
current situation can exacerbate stress.
Conditions for such migrants are likely to geteven worse, as at the end of 2010 restrictions
were placed on access to healthcare forvulnerable foreigners – undocumented
migrants and foreigners with serious illnesses
that cannot be treated in their home country.
Medical intervention
An outbreak of scabies in mid-2009, whenlocal hospitals were overstretched, led MSF
staff to begin medical consultations for
migrants living in the streets of the 10th
district of Paris. The team continued its

work in 2010, holding more than 1,900
consultations for around 400 patients.
Healthcare in Mayotte
In May 2009, MSF opened a health centre ina shanty town in Mamoudzou, the capital of
the French island of Mayotte, in the Indian
Ocean. Many of the people living in the
shanty town do not have a clear legal status,
despite around half of them having beenborn in Mayotte. Increasingly repressive
policies toward those with irregular status(in 2010 more than 21,000 people were
expelled to the Comoros Islands) makeaccessing healthcare very difficult. MSF
staff provided basic healthcare and carriedout more than 20,000 consultations for
7,500 patients between May 2009 and
September 2010. In September 2010 MSF
decided to halt activities. The objective had
been to provide access to healthcare for
marginalised people by bringing it directly
to them. It became clear over the course of
the project that critically ill people could
obtain treatment, especially in emergencies,
and that the main obstacles to medical care
were linked to legal issues and fear of arrest,
which are beyond MSF’s mission.
At the end of 2010, MSF had 14 field staff inFrance. MSF has had operational activities in
the country since 1987.

© Isabelle Ferry

Psychological support
In 2007, Médecins Sans Frontières (MSF)
established a centre for asylum seekers in needof psychological support in Paris. The patientsare mainly Afghans, Chechens, Guineans,

Eritreans or Sri Lankans who have escaped
armed conflict or persecution. MSF staff assess
the patients’ condition and ensure that they get
the necessary medical and psychological care.
The programme focuses on assisting those
whose distress is the most severe, who do not
speak French or who do not have a residence
permit, as these people find accessing
healthcare especially difficult. In 2010,
210 patients received psychological care.

A doctor examines a patient at the health centre in Kaweni, Mamoudzou, Mayotte.

88

MSF PROJECTS AROUND THE WORLD – EUROPE & THE MIDDLE EAST – FRANCEEUROPE & THE MIDDLE EASTGREECE
Azar *© Julia Kourafa

detained in a border police station
in Evros“It’s been 64 days now that I have beendetained at this border police station,and the conditions are unimaginable.
The cell is for 35 people, and there are
124 of us. There is no space to lie down
and sleep, you cannot get to the toilet.
All of us who are detained in this place
are reaching a point where we don’tknow how all this is going to affectour bodies or our mental health.
A free human being has two metres
free space to walk, and can go out inthe yard – why should we be treatedlike animals? I cannot have any
dreams for my future.”* The patient’s name has been changed.

A doctor examines a young patient who has been detained in theborder police station of Soufli, Evros.

Evros
Venna

paganiR egions where MSF has projects
C ities, towns or villages where MSF works

Irregular – undocumented – migrants andasylum seekers are systematically detained
upon arrival in Greece. In 2010, many of thedetention centres and police stations where
they are held were overcrowded, operating
at two or three times their capacity, andliving conditions were appalling.

In 2010, more than 47,000 undocumented migrants and asylum
seekers were arrested at the land border between Greece andTurkey, according to Greek police data. Many had left unstableor wartorn countries, or were escaping persecution, humanrights violations or extreme poverty.
Of the migrants who received care from MSF,
39 per cent showed signs of anxiety, while
31 per cent had symptoms of depression.
In June 2010, in the report Migrants in
Detention: Lives on Hold, MSF documented
the unacceptable living conditions in thethree detention centres and the impact
of detention on the wellbeing and mental
health of the migrants.

Psychosocial support
GreeceBetween August 2009 and May 2010,
Médecins Sans Frontières (MSF) provided
psychosocial support, helping migrants andasylum seekers to cope with their situationin three detention centres: Filakio and Venna,
both in northeastern Greece, and Pagani on
the island of Lesvos. Psychologists offeredindividual and group counselling sessions,and held more than 380 consultations
with 305 patients, as well as nearly
80 group sessions.

Emergency assistance in Evros
In December 2010, the situation for migrants
held in detention in the Evros region had
become critical. Men, women, young
children and unaccompanied minors werebeing crowded together in the same cells.
People had to sleep on the floor next to thetoilets. A typical situation was for two toilets
and two showers to be shared by more than
100 people, and cleaning and personal
hygiene materials were scarce. Freezing
temperatures and a non-functioning heating
system made conditions even worse.

Detention has exacerbated existing distressand contributed to new symptoms of trauma.

The Ministry of Health medical staff working
in some of the detention centres were too few

to care for the thousands of migrants. Medical
services were inadequate: new arrivals were
not systematically screened by medical staff
and there were no interpreter services.
Since the beginning of December 2010, MSF
teams have been providing emergency medical
and humanitarian assistance to improve living
and hygiene conditions in Evros, the borderpolice stations of Tychero, Soufli and Feres, andthe Filakio detention centre. Doctors treatedmore than 850 patients, referring 15 to local
hospitals, between December 2010 and the
beginning of 2011. The team also distributed
3,500 sleeping bags and 2,500 personal
hygiene kits.
At the end of 2010, MSF had 8 field staff in
Greece. MSF has had operational activities
in the country since 2008.

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89

EUROPE & THE MIDDLE EAST

MALTA
msida
Safi
Takandja

Hal Far

Medical care in detention centres
From August 2008 until October 2010, MSF
ran medical activities in Safi, Lyster Barracks
and Takandja detention centres. In Safi and
Lyster Barracks, appalling living conditions
and poor access to healthcare contributed tothe deteriorating physical and mental healthof detainees.

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

Thousands of migrants andasylum seekers are living indetention or in open centres
in Malta, and conditions canbe very hard. Unwelcoming
measures are affecting
migrants’ health. In 2008,
Médecins Sans Frontières(MSF) set up a programme
to provide medical andpsychological care in
the detention centres to which
all new arrivals were sent.
There have been improvements in making
healthcare available to migrants over the
past two years, but access remains difficult
for those without official permission to stayin the country, particularly those whoseasylum applications have been rejected.

Many migrants have experienced multiple
psychological traumas relating to violence,
including sexual violence. These may haveoccurred in their country of origin, on theirjourney to Europe or upon arrival in Europe.
Poor living conditions, a precarious social
situation and a lack of future prospects
exacerbate the effects of mental trauma andmany people have difficulty coping.
In 2009, MSF suspended its work in thedetention centres as the poor conditions in thecentres were compromising the effectivenessof its medical care. MSF resumed work in
Takandja between June 2009 and October
2010, screening new arrivals and carryingout consultations. In total, from 2008 until
2010, MSF staff held more than 4,670
medical consultations and 724 psychologicalconsultations in the detention centres, andalmost 3,000 people participated in health or
hygiene promotion workshops.

and asylum seekers who had been moved
from detention to open centres. Healthpromotion teams held 165 workshops on
hygiene and other topics both on site andat the open centres.
By the second half of 2010, fewer arrivals
and an improvement in healthcare provision
for asylum seekers and migrants meant thatthe emergency phase was over. MSF focused
its energy on the creation of a sustainablenetwork that would be able to provide
mental health support on a long-term basis.
Cultural mediation
Cultural mediators facilitate communication
between patients and health staff byremoving many barriers of language andculture. MSF successfully advocated for andinitiated the provision of cultural mediation
services, assisting almost 7,700 consultationsin this way. In 2010 the national healthauthorities employed five cultural mediators
to assist in the provision of care at healthcentres, four positions were opened in Mater
Dei hospital, the largest public hospital,and plans were made to create positions
at Mount Carmel hospital.
At the end of 2010, MSF had 9 staff in Malta.
MSF has been working in the country since 2008.

Working in open centres
Until June 2010, MSF medical teams worked
at a clinic located at Hal Far, in southern
Malta, holding more than 2,150 medical and
727 mental health consultations between
August 2008 and June 2010 for migrants

Abdi© Olmo Calvo

24 years old, from Somalia

Migrants sit outside their detention centre.

90

MSF PROJECTS AROUND THE WORLD – EUROPE & THE MIDDLE EAST – MALTA“I am now living in this tent… in thesun, in the rain. In the afternoon it is
impossible to stay inside because it is
too hot. And we have nothing to do.
In the camp there are these classrooms,
but there is no teacher. We don’t learn
anything. I have been here for one
year and I haven’t been taught one
single word of Maltese. I can’t study,
I can’t buy books, I can’t help myfamily back in Somalia either. In Malta
I have no future, no life, no education,
no opportunity for development. We
are all stuck. Our lives are wasted here.
But we can’t go back.”

EUROPE & THE MIDDLE EAST

RussianFederation
Leïla
35 years old© Lana AbramovaLeïla has just given birth to her eighthchild, by caesarean section. She
survived the two wars and, unlike
younger mothers, she managed to finish
school, but she has never worked. She
cannot afford to see a specialist for apostnatal consultation, and instead
visits the MSF gynaecological clinic in
Kalinovskaya, a large village in thenorth of Chechnya, where she can get
free medical care.

A counsellor holds the youngest member of a displaced Chechen family who
are receiving psychosocial support from MSF.

The security problems are affecting theavailability of medical care, and poor
economic conditions and a shortage of
medical staff make the situation moredifficult. MSF is working to improve accessto healthcare across the region.

ChechnyaIngushetia

dagestan

Regions where MSF has projects

The number of violent incidents
in the North Caucasus, in thesouth of Russia, increased
in 2010. Most occurred in the
Republic of Dagestan, although
Ingushetia, Chechnya andKabardino-Balkaria also
saw more deaths as a resultof violence.

Supporting victims of violence
In Ingushetia and Chechnya, Médecins
Sans Frontières (MSF) ran a psychosocial
support programme for residents anddisplaced people affected by violence. In
2010, the programme focused on providing
counselling services to people living inmountainous areas, where violent incidents
are more frequent.
In Dagestan, MSF staff are working in
the city of Khasavyurt, providing general
healthcare and counselling services todisplaced people and migrants in themarket area of the city.
Assisting mothers and children
Since 2005, MSF has been operating
gynaecological and paediatric clinics in two
districts of Grozny, the capital of Chechnya.
These clinics focus on providing care forvulnerable groups such as mothers raisinglarge families on low incomes. MSF also
donated drugs and medical supplies to themother and child centre in Grozny, andto health facilities in Shatoy, Sharoy and
Itum-Kale in the south. In August 2010, MSF
opened gynaecological and paediatric clinics
in two rural locations in northern Chechnya(Naursky and Shelkovskoy districts).
Strengthening the Chechen
TB programme
In 2010, MSF played a stronger role inhelping to develop capacity within the
Chechen tuberculosis (TB) programme.
The main focus was on improving quality
in TB dispensaries and laboratories. In 2010,
MSF found significant levels of multidrugresistant tuberculosis (MDR-TB) among its
patients, so in 2011 MSF is aiming to expand
its programme in Chechnya to include
MDR-TB treatment.
At the end of 2010, MSF had 192 staff in the
Russian Federation. MSF has been working
in the country since 1988 and in the North
Caucasus since 1995.

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91EUROPE & THE MIDDLE EAST

IRAQ

The seventh year of violenceand political tension since
the war itself saw continuingpressure on the emergency
capacity of the health system
in Iraq. The needs are not only
for trauma care following
explosions but for a whole
range of specialist services.
Médecins Sans Frontières (MSF) has been
attempting to fill some of the gaps that havebeen identified in obstetric care, mental
health and other specialised services. It
has also sustained its training and support
for general surgery and its reconstructive
programme for severely wounded people
who are brought to neighbouring Jordan
for treatment.

KirkukAnbar

Hawijahfallujahbaghdad

Basra
Najaf

Regions where MSF has projects

Cities, towns or villages where MSF works

and work in some of the more stable partsof the country has increased MSF’s capacity
to support these more complex areas of
medicine and to raise standards of care.
In the areas most affected by violence,bombings and assassinations continue anddozens of people are killed or wounded

every month. Fear of violence has driven
people from their homes, while others
are trapped inside them with significant
consequences for their physical and mental
health. Direct access to victims of theviolence in the most densely populatedareas remains limited for international andindependent humanitarian organisations.

© Philippe Conti

Activities are still considerably restricted by
the remaining threats to staff but the response
to pressing needs in the country developedin new directions in 2010. The ability to travel

NinewaA physiotherapy session for a patient with a hand injury, Amman, Jordan.
92

MSF PROJECTS AROUND THE WORLD – EUROPE & THE MIDDLE EAST – IRAQ© Khalil Sayyad

EUROPE & THE MIDDLE EAST

Neonatal care in Basra general hospital, Iraq.
Although many health facilities arefunctioning, the quality of care has been
affected by a shortage of specialised staff
and lack of training. According to the
Iraqi health ministry, hundreds of medical
employees have been killed in the courseof the conflict and great numbers have fled
the country. Iraq is short of nurses and of
specialist doctors, including psychiatrists
and psychologists. There has been no
upgrading of skills since the early 1990s.
Iraq’s doctors once provided some of thehighest quality and best resourced services
in the region, but now the quality of somemedical services is seriously impaired.
Maternal and child health
Just one of the consequences is that maternal
and infant mortality has been rising in the
country. In October 2010, MSF started a
project to improve the quality of obstetricand perinatal care in Al Zahra district hospital,
the main specialist referral centre in Najaf
governorate. Staff worked in the neonatal
unit, and also focused on supporting
emergency facilities, infection control,
drug supply and staff training. That form of
support has also been the pattern for MSF’s
work in the setting of the general hospital in
the major southern city of Basra, where MSF
has worked since 2006. Staff treat as many as

20,000 people a month for the whole range
of injuries and illnesses. In the northern cityof Hawijah, an MSF surgical team of Iraqi
doctors in the general hospital performs
around 300 operations a month.
Renal dialysis
In the city of Kirkuk, MSF supports thedialysis unit of the public hospital andstarted a renal treatment programme in June2010 for patients with severe kidney failure.
The target is to treat around 80 people whoneed the complex dialysis procedure.
A visiting Swiss specialist, Dr Patrick Ruedin,
was advising the team. “The number ofpatients concerned is indeed very limited.
However, they would all die if they couldn’t
get the treatment. One could look at dialysis
as an elite treatment while there are moreglaring needs, but Iraq has the means ofreintroducing the specialty; they just needa bit of a boost.”
Reconstructive surgery
The reconstructive surgery programmein the Jordanian capital of Amman, which
was started in 2006, continued to receive
Iraqi patients. In 2010, more than 300
people benefited from the orthopaedic,
maxillofacial and plastic specialties.
Treatment and follow-up are complex,

requiring months of hospitalisation. As an
illustration, 19,000 individual physiotherapy
sessions were carried out over the year.
Mental health services
A more recent development has been in
the neglected area of mental healthcare.
Hospital staff from the Ministry of Healthwere trained as counsellors by MSF and are
now working in units in two hospitals in
Baghdad and one in Fallujah. In 2010, over
5,000 sessions took place to reduce themental trauma patients were experiencing
from their exposure to violence andinsecurity. The counsellors are supported byvideo-conferencing systems, which allow
international staff to work with them fromoutside the country.
The pattern of remote support for Iraqi
staff and for Ministry of Health facilities stillprevails, with MSF providing triage training
to doctors from three hospitals in Kirkuk,
and in Ninewa.
At the end of 2010, MSF had 273 staff in Iraq.
MSF first worked in the country in 2003.

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93

EUROPE & THE MIDDLE EAST

IRAN
ZahedanSistan-Baluchestan
Regions where MSF has projects
Cities, towns or villages where MSF works

Hundreds of thousands of Afghans live inSistan-Baluchestan, a remote province insoutheast Iran where living conditions are poorand opportunities are limited. Afghans facerestrictions on work, access to education andaccess to health services. In 2007, the province
was declared closed to foreigners. According to
officials, this was to control cross-border crime.

clinics in Zahedan, the provincial capital of
Sistan-Baluchestan. In 2010 staff held morethan 6,300 consultations per month. MSF
refers patients requiring specialist medical
and surgical care to Ministry of Healthstructures, covering the costs of emergency
care, specialist consultations, treatment andhospitalisation. All referrals are followed up
by an MSF doctor.
Maternal care
In a fourth clinic, MSF focuses on maternaland paediatric care. The team ensures thatstraightforward deliveries are referred to thenational safe delivery centres, and high-riskbirths are referred to the city’s hospitals. A home

visitor team, which includes midwives, brings
some postnatal care directly to patients at home.
Relief for vulnerable people
Providing care for the most vulnerable people
remains MSF’s first objective, and there is ateam responsible for identifying vulnerable
people and ensuring that they get the carethey need. Staff make home visits in Zahedan
to find returnees, identify their needs, offer
training in basic hygiene and distribute
relief items such as food, cleaning materials,
blankets and heaters.
At the end of 2010, MSF had 94 staff in Iran.
MSF has been working in the country since 1996.

© Marit Helgerud

For more than a decade, Médecins Sans
Frontières’s (MSF) assistance in Iran has
focused on medical support for vulnerable
and minority groups. MSF has opened three

One to two million undocumented Afghans are estimatedto be living in Iran. People are continually crossing theborder between the two countries, both voluntarily andunder pressure from Iran’s policy of repatriation. Most of
the Afghans living in Iran are longstanding residents.

A patient is tested for malnutrition at the mother and child clinic in Zahedan, Sistan-Baluchestan.

94

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

EUROPE & THE MIDDLE EASTLEBANONbeirutRegions where MSF has projects

Following the 2006 war in
Lebanon between Israel and
Hezbollah, a Médecins Sans
Frontières (MSF) evaluationof the medical needs indicatedthat one in six people inthe country were in need of
psychological care.
In 2008, MSF opened a mental health centre
in Burj el-Barajneh, in the southern suburbsof Beirut. Close to the mental health centre
is Beirut’s most densely populated refugee
camp: some 18,000 Palestinians live in just
1.5 km 2. Despite some improvements
made in 2010, general conditions in
Burj el-Barajneh camp remain poor. Runningwater and electricity are available for only
a few hours a day and, on average, oneroom is shared by four people. There arefew education or employment opportunities,
and minimal health and social service
provision. This has a serious impact on
the mental wellbeing of individuals. Many
Palestinians are also deeply affected by theabsence of prospects for the future.
The MSF mental health centre provides freemental healthcare, including home visits,counselling and social support. It primarily
serves Palestinian refugees. In 2010, 780
new patients, mainly aged between 25 and40, received care from the MSF team of
psychiatrists and psychologists. The main

© Dina Debbas

Cities, towns or villages where MSF works

A girl on her way home from school, Burj el-Barajneh refugee camp, Beirut.

diagnoses observed so far are depression,anxiety, psychosis and personality disorders.
MSF mental health services have also been
established within the United Nations Relief
and Works Agency (UNRWA) clinic and thehospital run by the Palestinian Red CrescentSociety, which are both located inside thecamp. MSF’s community mental healthcentre serves as a referral clinic for themost complicated cases. This set-up should
facilitate the future integration of mental
healthcare into the health system available
for Lebanese residents as well as Palestinian
refugees in Lebanon.
To reduce the stigmatisation of mental
health issues among the people of Burj
el-Barajneh, to mark World Mental Health
Day in October 2010, MSF organised an art
exhibition in its mental health centre and atheatrical performance in the camp.
At the end of 2010, MSF had 23 staff in Lebanon.
MSF first worked in the country in 1975.

Hakim
resident in Burj el-Barajneh camp
“Living conditions here are very difficult;
I don’t think anyone can tolerate them.
Houses are congested and built inclose proximity to each other, metalroofs cause temperatures to rise in
the summer and allow them to drop
sharply in the winter, the infrastructureis nearly non-existent, and there is very
little privacy, which makes everyone
seem short-tempered. Sometimes, whensomeone says hello, you want to start afight with them.
“I was introduced to MSF randomly
one day, while at the UNRWA clinic.
They were distributing brochures that
described the symptoms related tomental health disorders.
“It said, if you have one of these
symptoms, you should consult atherapist. When I read it, I laughed tomyself because I realised I had themall. After speaking to the community
health worker, she advised me tovisit the MSF centre and gave me an
appointment, so I went.”

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

95

EUROPE & THE MIDDLE EAST

OcCupied
Palestinian
Territory
Ahmad

Nablus23 years old

Gaza

Ahmad has been arrested and detained
several times in Palestinian and Israeli
prisons over the last few years. He said
he had been badly mistreated on someoccasions. He talked about having
flashbacks of the arrests, sleeping
problems, aggressiveness, fear andanxiety. Since January 2010, Ahmad
has been seeing an MSF psychologist.
“Without exaggeration, MSF provides
me with psychological relief. If it is notcomplete, it has certainly alleviated myfrustration, the thinking, the worrying.
It is very useful.”

HebronRegions where MSF has projects

The conflict with Israel
and the inter-Palestinian
conflict within the Occupied
Palestinian Territory
continued to traumatise thepopulation in 2010. Economic,
social and political pressures
are all making an already poor
health situation far worse.

96© Isabelle Merny

Cities, towns or villages where MSF works

Staff help a patient outside the post-operative
care clinic at Nasser hospital, Gaza.

The demand for psychological care ishigh, but capacity is limited because ofa significant shortage of trained medical
staff. It can be difficult for people in needof mental healthcare to find help. Médecins
Sans Frontières (MSF) teams in Gaza,
Nablus and Hebron provide psychologicalcare as well as medical and social support
to address the traumatic and violent
consequences of the conflicts.

providing specialised surgery (reconstructive
and orthopaedic) and rehabilitation for trauma
patients, as well as medical and psychosocial
assistance to help patients cope after
experiencing trauma. In 2010, more than 180
surgical operations were performed and mental
health staff held almost 3,400 consultations.
The rehabilitation team carried out more than
33,000 physiotherapy sessions.

Gaza Strip
Teams have been working in the Gaza Strip
since 2000, adapting their activities according
to the needs of the population. In 2010, despite
having been partially lifted, the blockade wasstill affecting healthcare, restricting availability,
provision for people with special needs, andthe general quality of care. One of MSF’s main
objectives is to transfer expertise to local
Palestinian staff, who are unable to leave
the territory for professional training.
MSF is also filling specific gaps in medical care,

NablusIn the city of Nablus, MSF is running a
medical and psychosocial programme forpeople suffering from trauma because of
the conflicts. After therapy, and dependingon their needs, patients are referred to MSF
doctors and social workers or other aid
organisations for more support in resuming
everyday life. The team in Nablus extended
its activities to Qalqilya, to the west of thecity, and more than 2,700 psychologicalconsultations were held in 2010.

HebronIn 2010, MSF staff carried out 1,000 individual
mental health consultations, more than
350 group counselling sessions and nearly
300 medical consultations in Hebron andEast Jerusalem. The majority of patients
had suffered violence from Israeli forces orsettlers, but others had survived violence
related to internal Palestinian disputes,
or domestic or sexual violence. MSF has
started preparations to extend services tomigrants crossing from Egypt and nomadic
Bedouins in the neighbouring area of Negev
who are in need of medical attention or
humanitarian aid.
At the end of 2010, MSF had 169 staff in
Occupied Palestinian Territory. MSF has beenworking there since 1989.

MSF PROJECTS AROUND THE WORLD – EUROPE & THE MIDDLE EAST – Occupied Palestinian Territory

EUROPE & THE MIDDLE EAST

© Paolo Pellegrin/Magnum Photos

SYRIA

A young Iraqi refugee, Damascus.

Damascus

Cities, towns or villages where MSF works

During 2010, Médecins Sans
Frontières (MSF) carriedout medical activities inDamascus, the capital of Syria,
in partnership with the localorganisation Migrant’s Office.

According to UNHCR, the UN refugee
agency, around 152,000 Iraqi refugees wereregistered in Syria in July 2010. Far moreare living in the country without official
refugee status. Estimates of how many vary
between 200,000 and 1.1 million. Without
documentation permitting their stay in Syria,
many refugees and asylum seekers are living
in precarious conditions: they are excluded
from healthcare and suffer political neglect
and marginalisation. Syria is also host to
migrants and refugees from Afghanistan,
Egypt, Lebanon, Somalia, Sudan and othercountries in the region, who are living insimilarly precarious conditions.

reproductive and sexual health consultations
and mental healthcare to the most vulnerable
Iraqi refugees and migrants living in Damascus,
as well as to other vulnerable residents.
Last year, more than 6,200 patients received
medical care. Staff held more than 1,000
antenatal consultations and deliveries werereferred to the public university teaching
hospital in Damascus. More than 1,000
patients received mental healthcare throughindividual consultations and group sessions.
At the end of 2010, MSF had 5 staff in Syria.
MSF has been working in the country since 2009.

A Migrants’ Office–MSF medical team ofdoctors, gynaecologists and a psychologist
work in the clinic in the centre of the city.
They provide basic healthcare services,

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97

EUROPE & THE MIDDLE EAST

YEMEN
hajjahSaadakhameer
Sana’aAmran
Lahj

Shabwah

Yemen is facing a number of emergencies: multiple conflicts,
displacement and a massive flow of migrants. Many people
are in need of healthcare, and in 2010 Médecins Sans
Frontières (MSF) expanded its activities in the country.

Abyan

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

After having had to suspend activities forseveral months due to the intense fighting,
MSF resumed work in Al Talh hospital, justoutside the town of Saada, in March, and in
Razah hospital, near the Saudi border, in April.
In total, MSF staff carried out more than 32,000
consultations. During a measles outbreak
between April and June, MSF and Ministry of
Health staff treated more than 1,500 patients,
400 of whom were hospitalised, and carriedout a vaccination campaign. In July, MSF
opened a nutrition programme in Al-Jamouri
hospital, also in the town of Saada, and treated
820 severely malnourished children. Staff also
supported the teaching hospital in Saada.
MSF teams provided water, relief items andmedical care to people displaced by the conflictbut still living within Saada. Thousands more
have moved to neighbouring governorates.
In Amran, capital of Amran governorate,
MSF supported three health structures. Staff
provided emergency, postnatal and outpatient
services at the Beit-el-Sultan health centre
to help the centre cope with the increased
number of people needing care. MSF also began
assisting the emergency, surgery, maternity andreproductive health departments, as well as
the nutrition programme at Al-Salam hospitalin the town of Khameer. Staff carried out morethan 10,000 emergency consultations, admitted
some 900 people to hospital, performed 443
surgical interventions and assisted 313 births.
Around the small town of Al Mazraq, in the
Hajjah governorate, there are three camps
for displaced people. MSF provided general
healthcare to more than 21,500 patients in thecamps and ran a feeding programme, treating
more than 3,300 malnourished children.
Mental health teams carried out psychoeducational activities for more than 2,250
people and held 885 individual counselling© Agnes Montanari

Conflict in northern Yemen
The sixth round of conflict in the northerngovernorate of Saada, between the Yemeni
government and the al-Houthi armed group,
was the most intense since the beginning of
the war in 2004. A ceasefire was negotiated in
February 2010, but sporadic clashes continued
to occur throughout the rest of the year.

A newborn baby is examined by an MSF midwife, Amran governorate.
sessions. Special support was given to patientsin the nutrition programme, and for victims ofsexual and gender-based violence.

migrants’ arrival, teams brought first aid andpsychological assistance, as well as food, waterand kits with clothes and hygiene products.

In August MSF began managing the hospitalbuilt by the Organization of the Islamic
Conference and the Qatar Red CrescentSociety, the only hospital in Al Mazraq.
Since opening, staff have conducted around3,370 emergency consultations, admitted
more than 640 patients, and held antenatal
consultations with more than 1,750 women.

The migrants then moved on to be registeredand spend a few days at the Ahwar reception
centre. MSF ran the health facility at thereception centre and provided assistance inthe emergency department of Ahwar hospital.
In April 2010 MSF handed over the projectto the UN refugee agency UNHCR and its
implementing partners, as the number ofpeople arriving decreased and there was lessneed for MSF’s emergency assistance. Between
September 2007 and March 2010, MSF provided
medical to more than 25,000 new arrivals.

Southern Yemen
Conflict was not confined to the north ofthe country. There were frequent clashes
between the Yemeni army and separatistgroups in the south. In July 2010, MSF teams
began working in the public hospital in
Radfan, Lahj governorate. More than 5,000
people received emergency treatment, over390 surgeries were performed, and morethan 300 people were admitted to hospital.
Reception of migrants
Despite being a conflict zone itself, thousandsof refugees and migrants arrive in Yemen
every year, escaping conflict, poverty andinstability in the Horn of Africa. MSF staff
provided medical assistance to new arrivals
on the shores of the Abyan and Shabwah
governorates. Alerted by local people to the

98 MSF PROJECTS AROUND THE WORLD – EUROPE & THE MIDDLE EAST – YEMEN

HIV care in the capital
The number of people living with HIV in Yemen
is relatively low (prevalence is estimated at lessthan 0.2 per cent), but there is a very high levelof stigma and discrimination against people
who are HIV positive. MSF worked in Al Gumhuri
Hospital in Sana’a, the capital of Yemen,
supporting the Ministry of Health’s counselling
and testing services. Elsewhere in the city, MSF
supported a health centre offering a preventionof mother-to-child transmission programme,
and four counselling and testing services.
At the end of 2010, MSF had 467 staff in Yemen.
MSF has been working in the country since 2007.

MSF special reports 2010
Experience Treating the Most Neglectedof the Neglected Tropical Diseases
February 2010

Giving Developing Countries the Best Shot:
An Overview of Vaccine Access and R&D
May 2010, Oxfam and MSF

MSF documents its experience providing
diagnosis and treatment for kala azar
(visceral leishmaniasis), human African
trypanosomiasis (sleeping sickness),
Chagas disease and Buruli ulcer.

MSF and Oxfam show how access to newer
vaccines and the development of products
for developing countries is faltering andfailing to provide lifesaving vaccines tochildren in developing countries.

Bangladesh: Violent Crackdown Fuels
Humanitarian Crisis for Unrecognised
Rohingya Refugees
February 2010
Without official recognition, the statelessRohingya are prevented from supportingthemselves and are not permitted to receive
official relief. Action is needed now to stop
this humanitarian crisis.
Sexual Violence and Migration
March 2010
Sexual violence against sub-Saharan migrant
women who arrive in Morocco on their way
to Europe is a growing problem. Through data
and testimonies gathered in its projects,
MSF hopes to contribute to finding acomprehensive answer to this problem.
Afghanistan: A Return to
Humanitarian Action
March 2010
The space to provide neutral, independentand impartial humanitarian assistance inAfghanistan has been lost, given away ortaken. This has dire consequences for the
population of Afghanistan, but also forpeople caught up in other conflicts.
Turkmenistan’s Opaque Health System
April 2010

Migrants in Detention:
Lives on Hold
June 2010
This report documents
the unacceptable living
conditions in the three
Greek detention centres
where MSF intervened
between August 2009
and May 2010 and presents data frompsychological counselling sessions as wellas individual testimonies.
Emergency Response
after the Haiti
Earthquake: Choices,
Obstacles, Activities
and FinanceJuly 2010
Six months after theearthquake that devastatedHaiti, this report attempts
to explain the scope of the medical andmaterial aid provided to Haiti by MSF
since the catastrophe, and to set out theconsiderable challenges and dilemmas facedby the organisation.
The Ten Consequences of AIDS Treatment
Delayed, Deferred, or Denied
July 2010
This document draws upon data from MSF
field research and experience providing
antiretroviral treatment over the last ten years.

In Turkmenistan, HIV/AIDS, tuberculosis
and sexually transmitted infections are
more prevalent than reported figures would
suggest. This report sheds light on some of
the key issues in Turkmenistan’s healthcare
system and raises concerns about the role ofinternational actors in the country.

Three Time Victims, Victims of Violence,
Silence and Neglect: Armed Conflictand Mental Health in the Departmentof Caquetá, Colombia
July 2010

No Time to Quit:
HIV/AIDS Treatment
Gap Widening in Africa
May 2010

The mental health profile recorded among
patients in Caquetá demonstrates the
direct impact of the armed conflict on themental health of the population, which thecountry’s mental health services fail to cover.

After years of politicalwillingness andfinancial commitment
to combat HIV/AIDS,
donors now seem to bedisengaging from the fight. Any retreat will
have far-reaching and very real negative
consequences for people living with HIV.

Untangling the Web of Antiretroviral Prices
13th edition, July 2010
This report provides a window onto theevolution of antiretroviral drug prices
and sheds light on the continuing gaps
in treatments needed for patients indeveloping countries.

Joint Review of Guangxi CDC/MSF-F HIV
Project, Nanning, Guangxi Province,
China, 2003–2010
October 2010
In early 2003, Guangxi province had thethird highest rate of HIV infection in China.
Seven years later, 1,724 patients havereceived care, many clinicians have been
trained, and a comprehensive, adapted,
treatment and care model has been
designed and implemented.
Fighting a Dual Epidemic:
Treating TB in a High
HIV-prevalence Settingin Rural Swaziland
November 2010
Swaziland is at theepicentre of a co-epidemicof tuberculosis and HIV
affecting the wholeof southern Africa. MSF draws upon its
experience in the Shiselweni region to define
the urgent practical action that must be taken
in response to this major health emergency.
Hidden and Neglected: The Medical andEmotional Needs of Survivors of Family
and Sexual Violence in Papua New Guinea
December 2010
This report highlights the urgent unmet
medical and emotional needs of survivorsof family and sexual violence in Papua New
Guinea and recommends concrete action inorder to meet these needs.
MSF in Mozambique 2001–2010:
Ten years of HIV projects
MSF has been helping the Ministry of Healthin Mozambique develop a comprehensive
plan for widespread provision of
antiretroviral (ARV) treatment since 2001.
At the end of August 2010, more than
200,000 patients were on ARV treatment
in Mozambique, showing that the scale-up
and provision of ARV treatment is indeed
possible in a resource-poor country.
Ten Stories that Mattered in Accessto Medicines in 2010
December 2010
In 2010, new tools were developed formeningitis A and for tuberculosis, promisingresearch was published on severe malaria, aninnovative mechanism was created to makelifesaving HIV medicines more affordable,
and the quality of food aid improved. But
donors are turning their back on AIDS,
and pursuing policies that threaten accessto generic medicines, measles is making acomeback, and neglected tropical diseases
continue to take a heavy toll.
To read and download these reports,
go to www.msf.org/reports

MSF special reports 201099

Haiti:a year of crisis
On 12 January 2010, a 7.0 magnitude earthquake
rocked the capital of Haiti, Port-au-Prince, andsurrounding areas. As many as 220,000 people are
estimated to have died, and more than 300,000 were
injured. Médecins Sans Frontières (MSF) mounted
its largest ever single emergency response.

© Frederic Sautereau

For more details on MSF’s activities in Haiti,
see pages 84-85.

A surgical team carries out a lifesaving procedure on a young girl in a makeshift operating theatre in Port-au-Prince.

100 Haiti: a year of crisis© kadir van lohuizen / NOOR

Mental healthcare is given to patients at the MSF hospital in Léogâne.

© Tristan Pfund

Thousands of people needed surgery
and care for physical trauma. MSF
estimated that it had treated morethan 3,000 wounded people inPort-au-Prince by the end of the firstweek after the earthquake. Manypatients needed intensive nursing careafter surgery: wound dressing andcleaning, physiotherapy, rehabilitationand mental healthcare. MSF establisheda post-operative care centre in a former
nursery in the capital, and provided
similar services in a number of structures
around the city as well as in the townof Léogâne, west of Port-au-Prince.
In the capital, an MSF team in SaintLouis hospital focused on the provisionof psychosocial and psychiatric care.
During the initial emergency phase, MSF
provided mental health support to morethan 40,000 people.

MSF provides post-operative care, physiotherapy and mental healthcare in its Kindergarten Mickey centre, in Port-au-Prince.

Haiti: a year of crisis 101

© Kadir van Lohuizen/Noor

Prior to the earthquake, maternalmortality rates in Haiti were thehighest in the western hemisphere,
and MSF focused on maternity care,
operating a specialist emergency
obstetric hospital in Port-au-Prince.
The hospital was destroyed in theearthquake, so MSF offered staff, drugs
and expertise to support the Ministryof Health’s Isaïe Jeanty hospital, which
treats pregnant women with medical
complications. In Léogâne, MSF
established a new hospital offering
emergency obstetric and trauma care.
In 2010, more than 15,000 babies
were delivered in facilities supported
by MSF.

© Ron Haviv/VII

A father with his newborn at Isaïe Jeanty maternity hospital, Port-au-Prince.

Premature babies receive care at Isaïe Jeanty maternity hospital.

102 Haiti: a year of crisis© Spencer Platt/Getty

MSF medical staff treat cholera patients at a hospital in Saint Marc, where the outbreak began.

© Aurelie Lachant

In mid-October, suspected cases ofcholera were reported in western Haiti.
MSF dispatched a team to the townof Saint Marc who immediately begantreating patients in the Ministry of
Health hospital. From then until theend of 2010, MSF teams establishedover 4,000 beds in 47 cholera
treatment facilities around the country
and treated more than 91,000 of the
171,000 people reported as havingcholera nationwide.

MSF’s 600-bed cholera treatment centre in a gymnasium in Cap Haïtien.

Haiti: a year of crisis 103

FACTS AND
FIGURES
Médecins Sans Frontières(MSF) is an international,
independent, private andnot-for-profit organisation.

It comprises 19 main national offices inAustralia, Austria, Belgium, Canada, Denmark,France, Germany, Greece, Holland, Hong
Kong, Italy, Japan, Luxembourg, Norway,
Spain, Sweden, Switzerland, the United
Kingdom and the United States. There isalso an International Office in Geneva anddelegate offices in the Czech Republic,
Ireland and South Africa.
The search for efficiency has led MSF tocreate ten specialised organisations, called“satellites”, which take charge of specificactivities such as humanitarian relief
supplies, epidemiological and medical

research, and research on humanitarian andsocial action. These satellites, considered
as related parties to the national offices,
include: MSF-Supply, MSF-Logistique,
Epicentre, Fondation MSF, Etat d’Urgence
Production, MSF Assistance, SCI MSF,SCI Sabin, Ärzte Ohne Grenzen Foundationand MSF Enterprises Limited. As theseorganisations are controlled by MSF, they areincluded in the scope of the MSF Financial
Report and the figures presented here.
These figures describe MSF’s finances
on a combined international level. The
2010 combined international figures havebeen prepared in accordance with MSF
international accounting standards, which
comply with most of the requirements of theInternational Financial Reporting Standards(IFRS). The figures have been jointly auditedby the accounting firms KPMG and Ernst& Young, in accordance with International

Auditing Standards. A copy of the full 2010
Financial Report may be obtained atwww.msf.org. In addition, each national
office of MSF publishes annual, audited
Financial Statements according to its
national accounting policies, legislation andauditing rules. Copies of these reports may
be requested from the national offices.
The figures presented here are for the 2010
calendar year. All amounts are presented inmillions of euros.
Note: Figures in these tables are rounded,
which may result in apparent inconsistencies
in totals. Geographical divisions differ between
the Financial Report and the International
Activity Report: for financial reporting, Asiaand the Middle East are combined, and Papua
New Guinea is classified under Oceania.

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

Programme expenses by continent
29%
21%
19%
14%
5%
9%
1%
2%

The biggest category of expenses
is dedicated to the staff operatingin the field: about 50 per cent ofexpenditure comprises all costs
related to national and international
staff (including plane tickets,
insurance, accommodation, etc.).
The medical and nutrition category
includes drugs and medical
equipment, vaccines, hospitalisation
fees and therapeutic food. The
delivery of these supplies is includedin the category of transport, freightand storage.
Logistics and sanitation comprisebuilding materials and equipment
for health centres, water andsanitation and logistical supplies.

104 FACTS AND FIGURES

AfricaAsia
Americas
EuropeOceania
Unallocated

58%
18%
21%
1%
1%
1%

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

in millions of euros

120
100
80
60
40
20

di
a
In

ar
M

ya

nm

op
Et
hi

M

al

aw

ia

i

a
ny

Ce

Ke

ig
er
ia
nt
ra
lA
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pu ica
bl n
ic

m
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ba
bw

e

ad
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ia
al
m
So

Pa
k

ist
an

ig
er
N

da
n
Su

RC
D

Ha

iti

0

2008

AFRICA

in millions of E

2009

ASIA AND
THE MIDDLE EAST2010

THE AMERICAS

Democratic Republicof the Congo

54.5

Sudan

38.9

Niger

25.5

Somalia

19.5

Chad

19.0

Yemen

7.6

Zimbabwe18.4

Afghanistan

5.8

Nigeria

17.5

Occupied Palestinian Territory

4.6

Central African Republic

16.8

Sri Lanka

4.5

Kenya

15.1

Bangladesh

3.7

Malawi

15.1

Kyrgyzstan

3.5

Pakistanin millions of E

Haiti

in millions of E

102.3

21.8

Colombia

9.7

Myanmar11.2

Guatemala

1.0

India

10.4

Bolivia

1.0

Iraq

9.1

Other countries *2.6

Ethiopia

13.4

Uzbekistan

3.2

Total

EUROPE

116.6

in millions of E

Russian Federation

5.5

Other countries *

2.3

Total

7.8

Uganda

8.6

Iran

2.5

Mozambique

7.6

Armenia

1.8

Mali

6.2

Georgia

1.6

Burundi6.0

Cambodia

1.3

OCEANIA

Republic of the Congo

5.5

Thailand

1.2

Papua New Guinea

2.7South Africa

5.2

Other countries *4.4

Other countries *0.0Guinea5.2

Swaziland

5.2

Total

2.7

Sierra Leone

4.7

Liberia

4.1

Burkina Faso

3.0

Zambia2.4

Djibouti

1.8

UNALLOCATED

Cameroon

1.6

Transversal activities

4.4

Other countries *2.2

Others

2.9

Total

323

Total

7.3

Total

98.2

in millions of E

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

in millions of E

FACTS AND FIGURES 105

WHERE DID THE MONEY COME
FROM?

2010
in millions of E

percentage

in millions of E

percentage

Private

858.9

91%

572.4

86%

Public institutional

69.3

7%

77.9

12%

Other

15.1

2%

15.1

2%

Income

943.3

100%

665.4

100%

in millions of E

percentage

in millions of E

percentage

Programmes

555.3

68%

393.3

64%

Headquarters programme support

78.7

10%

69.1

11%

Témoignage/awareness-raising

26.4

3%

21.7

4%

Other humanitarian activities

5.7

1%

6.4

1%

Social mission

666.1

82%

490.5

80%

Fundraising

103.7

13%

87.4

14%

Management, general and administration

43.1

5%

38.9

6%

Other expenses

146.8

18%

126.3

20%

Expenditure

812.9

100%

616.8

100%

a

di

2010

2009

Institutional income
Other income
Private income

7%
2%
91%

Surplus
IncomeExpenditure

132.5
943.3
812.9

M

ya

In

ar

HOW WAS THE MONEY SPENT?

nm

2009

Net exchange gains/losses
Surplus

2.1

2.9

132.5

51.5

YEAR-END FINANCIAL
POSITION

2010

2009

in millions of E

percentage

in millions of E

percentage

600.9

84%

433.3

80%

Other current assets

71.1

10%

68.5

13%

Non-current assets

43.2

6%

36.6

7%

715.2

100%

538.4

100%

Cash and equivalents

AssetsPermanently restricted funds

2.5

0%

2.5

0%

608.1

85%

475.5

89%

Other retained earnings and equities

8.7

1%

-9.8

-2%

Retained earnings and equities

619.3

86%

468.2

87%

95.9

14%

70.2

13%

715.2

100%

538.4

100%

Unrestricted funds

Current liabilities
Liabilities and retained earnings

ere MSF expenditure is more than 10 million euros

106 FACTS AND FIGURESHR STATISTICS

2010

2009

no. staff

percentage

no. staff

percentage

Medical pool

1,672

25%

1,239

26%

Nurses and other paramedical pool

2,002

31%

1,459

31%

Non-medical pool

2,887

44%

2,046

43%

International departures (full year)

6,561

100%

4,744

100%

National staff

25,18591%

20,44791%

International staff

2,465

9%

2,015

9%

Field positions

27,650100%

22,462

100%

The majority of MSF staff ( 91 per cent ) are hired locally in the countries of intervention.
Headquarters staff represent 4 per cent of the total staff.

HQ staff
International staff
National staff

4%
9%
87%

Countries where MSF expenditure is more than 10 million euros

Haiti Emergency
120

responding to the cholera epidemic. The funds were used
for massive investments in health centres and hospitals, therehabilitation and construction of medical facilities, medical
supplies and equipment, drugs and the distribution of sheltermaterials and other relief items.

in millions of euros

The earthquake that hit Haiti on 12 January 2010 prompted an100
enormous response from the public worldwide. MSF received an
80
unprecedented
amount of donations in 2010; 110.7 million euros
were earmarked
for Haiti. The cholera epidemic that occurred60
in October 2010 further increased the scale of MSF’s emergency
40
response
in Haiti.

Programme expenses

Indirect supply costs

2008

2009
102.3

3.8

a
di
In

nm
ya
M

hi
o

pi

ar

a

i
Et

aw
al
M

ny
Ke

ig
er
ia
ra
lA
Re fr
pu icabl n
ic
Cein millions of E

nt

N

ba

bw

e

ad
Zi

m

Ch

ia
al
m
So

ki

st

an

er
Pa

ig
N

n
da
Su

D

RC

iti
Ha

ExpenditureaA balance of 2 million euros of restricted funds remained unspentat the end of 2010. This balance will be spent in Haiti in 2011.

20

MSF spent a total of 106.1 million euros in 2010 on operations
0in the regions
most affected by the earthquake and on

INCOME

in millions of E

2010
Restricted private income

108.1

Restricted institutional funds

2.6
110.7

Total funding of field-related expenses

2010 field-related expenses

106.1

Sources of income
As part of MSF’s effort to guarantee its independence and strengthen
the organisation’s link with society, we strive to maintain a high levelof private income. In 2010, 91 per cent of MSF’s income came fromprivate sources. More than 5.1 million individual donors and private
foundations worldwide made this possible. Public institutional
agencies providing funding to MSF include, among others, theEuropean Commission’s Humanitarian Aid Department (ECHO), andthe governments of Belgium, Canada, Denmark, Germany, Ireland,
Luxembourg, Norway, Spain, Sweden, Switzerland and the UK.
Expenditure is allocated according to the main activities performed
by MSF. All expenditure categories include salaries, direct costs andallocated overheads.
Social mission includes all costs related to operations on the field(direct costs) as well as all the medical and operational support
from the headquarters directly allocated to the field (indirect costs).
Social missions costs represent 82 per cent of the 2010 total costs.
Permanently restricted funds may either be capital funds, where
donors require the assets to be invested; or funds retained for actual

Remaining restricted funds to be spent in 2011

-4.6

Total funding of 2010 field-related expenses

106.1

use, rather than expended; or the minimum compulsory level ofretained earnings to be maintained by some of the national offices.
Unrestricted funds are unspent non-designated donor funds expendableat the discretion of MSF’s trustees in furtherance of our social mission.
Other retained earnings represent foundations’ capital as well as
technical accounts related to the combination process.
MSF’s retained earnings have been built up over the years bysurpluses of income over expenses. As of the end of 2010, theiravailable part (the unrestricted funds decreased by the conversion
difference) represented 9.1 months of activity. The purpose ofmaintaining retained earnings is to meet the following needs: futuremajor emergencies for which sufficient funding cannot be obtained,
and/or a sudden drop of private and/or public institutional funding,the sustainability of long-term programmes (e.g. antiretroviraltreatment programmes), and the pre-financing of operations to be
funded by upcoming public funding campaigns and/or by public
institutional funding.
The complete Financial Report is available at www.msf.org

FACTS AND FIGURES 107

Contact MSF
Australia Médecins Sans Frontières
Suite C, Level 1 263 Broadway Glebe NSW 2037
PO BOX 847 Broadway NSW 2007 Australia
T +61 28 570 2600 F +61 29 552 6539
office@sydney.msf.org www.msf.org.au
Pr Dr Nicholas Coatsworth GD Paul McPhun
Austria Médecins Sans Frontières/Ärzte Ohne Grenzen
Taborstraße 10 1020 Vienna Austria
T +43 1 409 7276 F +43 1 409 7276/40
office@aerzte-ohne-grenzen.at
www.aerzte-ohne-grenzen.at
Pr Dr Reinhard Doerflinger GD Mario Thaler
Belgium Médecins Sans Frontières/Artsen Zonder Grenzen
Rue Dupré 94 / Dupréstraat 94
1090 Brussels Belgium
T +32 2 474 74 74 F +32 2 474 75 75
info@azg.be www.msf.be or www.azg.be
Pr Meinie Nicolai GD Christopher Stokes
Canada Médecins Sans Frontières/Doctors Without Borders
720 Spadina Avenue, Suite 402 Toronto
Ontario M5S 2T9 Canada
T +1 416 964 0619 F +1 416 963 8707
msfcan@msf.ca www.msf.ca
Pr Dr Joni Guptill GD Marilyn McHarg
Denmark Médecins Sans Frontières/Læger uden Grænser
Kristianiagade 8 2100 København Ø Denmark
T +45 39 77 56 00 F +45 39 77 56 01
info@msf.dk www.msf.dk
Pr Jesper H.L Jørgensen, RN
GD Michael G. Nielsen
France Médecins Sans Frontières
8 rue Saint Sabin 75011 Paris France
T +33 1 40 21 29 29 F +33 1 48 06 68 68
office@paris.msf.org www.msf.fr
Pr Dr Marie-Pierre Allié GD Filipe Ribeiro
Germany Médecins Sans Frontières/Ärzte Ohne Grenzen
Am Köllnischen Park 1 10179 Berlin Germany
T +49 30 700 13 00 F +49 30 700 13 03 40
office@berlin.msf.org
www.aerzte-ohne-grenzen.de
Pr Dr Tankred Stöbe GD Dr Frank Dörner
Greece Médecins Sans Frontières/15 Xenias St. 115 27 Athens Greece
T 30 210 5 200 500 F 30 210 5 200 503
info@msf.gr www.msf.gr
Pr Ioanna Papaki GD Reveka Papadopoulou
Holland Médecins Sans Frontières/Artsen zonder Grenzen
Plantage Middenlaan 14 1018 DD Amsterdam
The Netherlands
T +31 20 520 8700 F +31 20 620 5170
office@amsterdam.msf.org
www.artsenzondergrenzen.nl
Pr Dr Pim De Graaf GD Arjan Hehenkamp

108 Contact MSF

Hong Kong Médecins Sans Frontières
無國界醫生 / 无国界医生
22/F Pacific Plaza 410 – 418 Des Voeux
Road West Sai Wan Hong Kong
T +852 2959 4229 F +852 2337 5442
office@msf.org.hk www.msf.org.hk
Pr Dr Fan Ning GD Remi Carrier
Italy Médecins Sans Frontières/Medici Senza Frontiere
Via Volturno 58 00185 Rome Italy
T +39 06 44 86 92 1 F +39 06 44 86 92 20
msf@msf.it www.medicisenzafrontiere.it
Pr Antonio Campopiano
GD Kostas Moschochoritis
Japan Médecins Sans Frontières/国境なき医師団
3F Waseda SIA Bldg 1-1 Babashitacho
Shinjuku-ku Tokyo 162-0045 Japan
T +81 3 5286 6123 F +81 3 5286 6124
office@tokyo.msf.org www.msf.or.jp
Pr Dr Nobuko Kurosaki GD Eric Ouannes
Luxembourg Médecins Sans Frontières
68, rue de Gasperich 1617 Luxembourg
T +352 33 25 15 F +352 33 51 33
info@msf.lu www.msf.lu
Pr Dr Bechara Ziade GD Dave Hudson
Norway Médecins Sans Frontières/Leger Uten Grenser
Postboks 8813 Youngstorget 0028 Oslo
Norway Hausmannsgate 6 0186 Oslo
NorwayT +47 23 31 66 00 F +47 23 31 66 01
epost@legerutengrenser.nowww.legerutengrenser.no
Pr Kyrre Lind GD Patrice Vastel
Spain Médecins Sans Frontières/Médicos Sin Fronteras
Nou de la Rambla 26 08001 Barcelona Spain
T +34 93 304 6100 F +34 93 304 6102
office-bcn@barcelona.msf.org www.msf.es
Pr Dr José Antonio Bastos
GD Aitor Zabalgogeazkoa
Sweden Médecins Sans Frontières/Läkare Utan Gränser
Gjörwellsgatan 28, 4 trappor Box 34048
100 26 Stockholm Sweden
T +46 8 55 60 98 00 F +46 8 55 60 98 01
office-sto@msf.org www.lakareutangranser.se
Pr Kristina Bolme Kühn GD Johan Mast
Switzerland Médecins Sans Frontières/Ärzte Ohne Grenzen
78 rue de Lausanne Case Postale 116
1211 Geneva 21 Switzerland
T +41 22 849 84 84 F +41 22 849 84 88
office-gva@geneva.msf.org www.msf.ch
Pr Abiy Tamrat GD Bruno Jochum

UK Médecins Sans Frontières /Doctors Without Borders
67-74 Saffron Hill London EC1N 8QX UK
T +44 20 7404 6600 F +44 20 7404 4466
office-ldn@london.msf.org www.msf.org.uk
Pr Dr Sid Wong GD Marc DuBois
USA Médecins Sans Frontières/Doctors Without Borders
333 7th Avenue 2nd Floor New YorkNY 10001-5004 USA
T +1 212 679 6800 F +1 212 679 7016
info@doctorswithoutborders.org
www.doctorswithoutborders.org
Pr Dr Matthew Spitzer GD Sophie DelaunayInternational OfficeMédecins Sans FrontièresInternational Office and UN Liaison Office – Geneva
78 rue de Lausanne Case Postale 116
1211 Geneva 21 Switzerland
T +41 22 849 84 00 F +41 22 849 84 04
Pr Dr Unni Karunakara SG Kris Torgeson
office-intl@msf.org www.msf.org
Policy and Advocacy Coordinator: Emmanuel Tronc
emmanuel.tronc@msf.org
Other Offices
MSF Campaign for
Access to Essential Medicines
78 rue de Lausanne Case Postale 116
1211 Geneva 21 Switzerland
T +41 22 849 8405 F +41 22 849 8404
www.msfaccess.org
Director: Dr Tido von Schoen-Angerer
UN Liaison Office – New York333 7th Avenue 2nd Floor New YorkNY 10001-5004 USA
T +1 212 655 3777 F +1 212 679 7016
MSF UN liaison officer: Fabien Dubuet
fabien.dubuet@newyork.msf.org
MSF office in South Africa
Orion Building 3rd floor | 49 Jorissen Street
Braamfontein 2017 Johannesburg South Africa
T +27 11 403 44 40/41 www.msf.org.za
MSF office in Brazil
Rua Santa Luzia, 651/11° andar
Centro - Rio de Janeiro CEP 20030-040
Rio de Janeiro Brazil
T +55 21 2220 8277 www.msf.org.br
MSF office in United Arab Emirates
P.O. Box 47226 Abu Dhabi UAE
T +971 2 6317 645 www.msf-me.org
MSF office in Argentina
Carbajal 3211 Código Postal 1426 BelgranoCiudad de Buenos Aires Argentina
T +54 11 4551 4460 www.msf.org.ar
Pr President GD General Director
SG Secretary GeneralAbout this report
Contributors
Halimatou Amadou, Valerie Babize, Aurélie Baumel, Niklas Bergstrand, Jehan Bseiso,
Andrea Bussotti, Brigitte Breuillac, Martyn Broughton, Talia Bouchouareb, Natacha Bühler,
Jason Cone, Susanne Döttling, Olivier Falhun, Silvia Fernández, Isabelle Ferry, Benoît Feyt,
Diderik van Halsema, Maimouna Jallow, Isabelle Jeanson, Julia Kourafa, Borrie la Grange,
Laura McCullagh, Scotti McLaren, Isabelle Merny, Djamila Mili, Niamh Nic Carthaigh,Marcell Nimfuehr, Simon Petite, Yasmin Rabiyan, Ricardo Rubio, Victoria Russell,
François Servranckx, Ewald Stals, Clara Tarrero, Sam Taylor, Véronique Terrasse,
Kenneth Tong, Pascale Zintzen.
Special thanks toJean-Clément Cabrol, Frédéric Capdevila, François Dumont, Myriam Henkens, Aloïs Hug,
Unni Karunakara, Erwin van ’t Land, Caroline Livio, Naomi Pardington, Jordi Passola,
Kris Torgeson, Emmanuel Tronc.
We would also like to thank all the field, operations and communications staff who provided
and reviewed material for this report.
English Edition
Managing Editor Jane Linekar
Editorial Support Rachel McKee
Photo Editor Bruno De Cock
Proof Reader Lory Frenkel
French Edition
Editor Laure Bonnevie, supported by Aurélie Grémaud
Translator Translate 4 U sàrl ( Aliette Chaput, Emmanuel Pons )Italian Edition
Coordinator Barbara Galmuzzi
Translator Selig S.a.S.
Editor Barbara Galmuzzi
Spanish Edition
Coordinator Aloïs Hug
Translator Pilar Petit
Editor Eulàlia Sanabra
Arabic Edition
Coordinator Jessica Moussan-Zaki
Translator Mounir El-Boughdadi, Khalid Faiz
Editor Jessica Moussan-Zaki
Designed and produced by
ACW, London, UK
www.acw.uk.com

Médecins Sans Frontières (MSF) is aninternational, independent, medical
humanitarian organisation that delivers
emergency aid to people affected byarmed conflict, epidemics, exclusion fromhealthcare and natural disasters. MSF offers
assistance to people based on need andirrespective of race, religion, gender orpolitical affiliation. When MSF witnesses
serious acts of violence, neglected crises, orobstructions to its activities, the organisation
may speak out about this.
MSF is a not-for-profit organisation that was
founded in Paris, France in 1971. Today, MSF is aworldwide movement with more than 19 national
offices and an international office in Geneva,
Switzerland. Thousands of health professionals,
logistical and administrative staff manage projects
in approximately 65 countries worldwide.
MSF International Office
78 rue de Lausanne, CP 116, CH-1211, Geneva 21, Switzerland
Tel.: +41 (0)22 849 8400, Fax: +41 (0)22 849 8404, Email: com-io@msf.org, www.msf.org
COVER PHOTO
A doctor holds a consultation with a woman displaced by the floods at a clinic in Shahbaz, Punjab, Pakistan.
© Seb Geo, Pakistan