MSF Activity Report 2007

MSF Activity
Report 2007
Médecins Sans Frontières (MSF) was founded in1971 by a small group of doctors and journalists
who believed that all people should have accessto emergency relief. MSF was one of the first non
governmental organisations to provide urgently
needed medical assistance and to publicly bear
witness to the plight of the people it helps.

Today MSF is an international medical
humanitarian movement with national sectionsin 19 countries. In 2007 over 26,000 doctors,
nurses, and other medical professionals, logisticalexperts, water and sanitation engineers andadministrators provided medical aid in over
60 countries.

MSF International Office
78 Rue de Lausanne, Case Postale 116, CH-1211 Geneva 21, Switzerland
Tel (+41-22) 8498 400, Fax (+41-22) 8498 404, Email office-intl@bi.msf.org, www.msf.org

The Médecins Sans Frontières Charter

About this Book
Country text and sidebar material written by

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

Wei Baozhu, Siân Bowen, Jean-Marc Jacobs, Anthony Jacopucci, Alois Hug,
Isabelle Jeanson, Duncan Mclean, Sally McMillan, Anna-Karin Moden,
Alessandra Oglino, Hélène Ponpon, Susan Sandars, Natalia Sheletova, Sheila
Shettle, Véronique Terrasse, Elena Torta, Caroline Veldhuis, Joanne Wong

Special thanks to

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

Montserrat Batlló, Daniel Berman, Laure Bonnevie, Karen Day, Tory Godsal,
Myriam Henkens, Pierre Humblet, Anara Karabekova, Fernando Pascual, Jordi
Passola, Barry Sandland, Miriam Schlick, Susan Shepherd, Emmanuel Tronc,
Caroline Veldhuis, Tido von Schoen-Angerer and all the field, operations andcommunications staff who reviewed material for this report.

Médecins Sans Frontières observes neutrality andimpartiality in the name of universal medical ethics andthe right to humanitarian assistance and claims fulland unhindered freedom in the exercise of its functions.
Members undertake to respect their professional code of
ethics and to maintain complete independence from allpolitical, economic or religious powers.
As volunteers, members understand the risks and dangersof the missions they carry out and make no claim forthemselves or their assigns for any form of compensation
other than that which the association might be able toafford them.

Managing Editor Siân Bowen
Research & Editorial Support Hélène Ponpon
Photo Editor Bruno De Cock, Sofie Stevens
Proof Reader Emily Wood
French Edition
Coordinator Hélène Ponpon
Translation Translate 4 U sàrl
(Aliette Chaput, Emmanuel Pons)

Editor Hélène Ponpon
Italian Edition
Coordinator Barbara Galmuzzi
Translator Selig S.a.S.
Editor Barbara Galmuzzi
Spanish Edition
Coordinator Javier Sancho
Translator Pilar Petit
Editor Eulalia SanabraGraphic Design
Studio Roozen, Amsterdam, The Netherlands

Printing
Kunstdrukkerij Mercurius, Westzaan, The Netherlands

The country texts in this report provide descriptive overviews of MSF workthroughout the world between January and December 2007. Staffing figures
represent the total of full-time equivalent positions per country in 2007.
Reasons for Intervention classify the initial event(s) triggering an MSF
medical-humanitarian response as documented in the 2007 International
Typology study. Country summaries are representational and, owing to spaceconsiderations, may not be entirely comprehensive.

cover Photo Nurse working with MSF treating baby with severe dehydration in Pieri, in Jonglei State (South Sudan)© Sven Torfinn

1

4|

2 | MSF missions around the world
4 |	The year in Review
Dr. Christophe Fournier, President, MSF International Council

7 | Accountability: An MSF perpective
Christopher Stokes, Secretary General, MSF International

10 | Overview of MSF operations

7|

11 | Reasons for intervention
Emmanuel Tronc, Policy and Advocacy Coordinator, MSF International

13 | Deciding when to leave
Emmanuel Tronc, Policy and Advocacy Coordinator, MSF International

14 | MSF Country Programme closures		

15 | Photo story
			 Most under-reported crises of 200713 |25 | Glossary of Diseases
			 MSF Projects around the World
27 | Africa
57 | Asia and the Caucasus
71 | The Americas

15 |77 | Europe and the Middle East
			 Sidebars
43 | Prevention of mother-to-child transmission of HIV
47 | Leaving Rwanda
66 | Child malnutrition
85 | Gaza strip
86 | Audited Facts and Figures
88 | Contact MSF

27 |Médecins Sans Frontières Activity Report 2007

Contents

3

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

RUSSIANFEDERATIONBELGIUM
FRANCEMOLDOVASWITZERLANDITALYUZBEKISTANGEORGIAARMENIAKYRGYZSTANTURKMENISTANCHINAPALESTINIANTERRitories

MoroccoIRAQ

IRAN
PAKISTAN

NEPAL

BANGLADESH
INDIA
HAITI

Mali

GUATEMALAHONDURAS
GuineaSierraLeone
Liberia
COLOMBIA

Niger

Chad

Nigeria
Ivory
Coast
Cameroon

LAOS
THAILAND

Yemen

Sudan

Burkina
Faso

MYANMARCAMBODIA
Ethiopia

CentralAfricanRepublic

58 | Armenia
58 | Bangladesh
78 | Belgium
72 | Bolivia
72 | Brazil
28 | Burkina Faso
29 | Burundi
59 | Cambodia
30 | Cameroon
30 | Central African Republic
32 | Chad
60 | China
73 | Colombia
32 | Democratic Republic
		 of Congo
34 | Ethiopia
78 | France
61 | Georgia
74 | Guatemala
35 | Guinea
74 | Haiti
76 | Honduras
62 | India
63 | Indonesia
81 | Iran82 | Iraq
79 | Italy
36 | Ivory Coast36 | Kenya
64 | Kyrgyzstan
64 | Laos
38 | Lesotho

39 | Liberia
40 | Malawi
40 | Mali
79 | Moldova
41 | Morocco
42 | Mozambique
65 | Myanmar
66 | Nepal
44 | Niger
45 | Nigeria
66 | Pakistan
84 | Palestinian Territories
68 | Papua New Guinea
76 | Peru
46 | Republic of Congo				 (Congo-Brazzaville)
80 | Russian Federation
46 | Rwanda
48 | Sierra Leone
48 | Somalia
50 | South Africa
68 | Sri Lanka
51 | Sudan
54 | Swaziland
81 | Switzerland
69 | Thailand
70 | Turkmenistan
54 | Uganda
70 | Uzbekistan
83 | Yemen
55 | Zambia
56 | Zimbabwe

SRi LANKA

Somalia
UgandaRepublicof
Congo
Democratic
republic of
congo

Kenya

RwandaBurundiPAPUA NEW GUINEA

BrazilPERU
Malawi
Zambia
BOLIVIA

Zimbabwe
Mozambique

swaziland
LesothoSouth Africa

INDONESIA

Médecins Sans Frontières Activity Report 2007

M SF M I SSIONS A R OUD THE WO RLD

2

5The Year in Review
by Dr. Christophe Fournier, President, MSF International Council

If we were asked whom we treat the most often, we would
reply: first young children, then young women. Amongst thedisplaced, refugees and populations caught up in fighting or
whose health structures have collapsed, beside the directly
wounded or those affected by specific epidemics, women andchildren occupy the majority of our consultations. This is thereason why we have to put a particular energy into improving
the way we address some of the main pathologies responsible
for the mortality and the morbidity of these two categoriesof population.

Overcoming childhood dangers
Once beyond the first days of life, children who die before theirfifth birthday usually succumb to infectious pathologies such as
pneumonia, diarrhoea, malaria, measles and AIDS, particularly as
half of them suffer from malnutrition. The good news is that ourweapons against the main diseases decimating young children are
increasingly effective and may even, potentially, allow us toprevent a good number of them including:Once beyond the first days of life,
children who die before theirfifth birthday usually succumb toinfectious pathologies such as
pneumonia, diarrhoea, malaria,
measles and AIDS.
Nyakabanda camp in Kisoro, Uganda© Vanessa Vick•

Pneumococcus is a class of bacteria responsible for a large
number of lower respiratory infections. A particular vaccinethat covers the prevalent strains in Africa exists and we arestarting to use it.

•

Rotavirus is responsible for more than a third of diarrhoea
cases in children. We are looking forward to seeing the use of
the existing vaccine against this virus being recommended for
Africa and other contexts where we have to intervene.

•

The measles vaccine has been around for a long time and its
systematic use has increased. Unfortunately, the vaccination
coverage is often too low, particularly in some regions of
sub-Saharan Africa to prevent repeated epidemics.

•

With the new conjugate vaccine for meningitis, we will beable to durably immunize populations exposed to recurrent
epidemics particularly in the Sahel region of Africa. But this
vaccine will only be available for use in 2009.

•

We are still waiting for a malaria vaccine, but at least theArtemisinin based Combination Therapies give us a highly
effective therapeutic weapon.

•

There is no vaccine for HIV yet either, but an antiretroviraltreatment protocol can considerably reduce the risk ofmother-to-child transmission when administered correctly,
and we can effectively treat infected children with improved
paediatric forms of antiretroviral drugs.

•

Finally, we now have ready-to-use therapeutic foods thatallow us to treat far more children suffering from acute malnutrition more effectively and as out-patients in most cases.
We also use them at increasingly early stages of malnutrition
and are measuring their impact on morbidity and mortality ofchildren in their first years of life.

Addressing maternal mortality
Maternal mortality represents a quarter of female mortality inthe majority of the countries we work in. Half of the deaths arelinked to the moment of delivery or the subsequent 24 hours.
Another quarter happen during pregnancy.
This explains why we should put so much of our attention into
antenatal care and deliveries. The more direct complications ofdelivery for the women (haemorrhage, eclampsia) are difficult toanticipate but if handled in time should not prove fatal. The
medical technology required for treating these complications wasstandardised half a century ago in developed countries. It is wellknown and not difficult to use. Obviously it requires qualified
personnel, appropriate drugs and adequate transfusion products,
but it saves the lives of both mother and child. In 2007, we
carried out over 500,000 antenatal care consultations and almost
100,000 deliveries. Yet, a dramatic impact on maternal mortality
is difficult to achieve as the vast majority of pregnant women are
not coming to any health structure for follow up and even lessfor delivery except when a complication occurs. Among the different post delivery chronic complications, vesico-vaginal fistulas
are the most disabling and stigmatising and we are exploring thepossibilities of further developing our surgical care to women
affected.
Access to family planning is obviously a precondition for all
women in being able to determine how many pregnancies theychoose to have. This is one activity that we have to reinforce andextend systematically to post delivery care, nutrition programmes, HIV activities, so that all women can access these kindsof services.

The pre-requisites to progress
We have the sense that we should be at a turning point in the
medical care we can offer to our patients. Yet, considerable steps
and obstacles have to be overcome. This is in particular why wecontinue to fight to ensure that the Doha agreements, allowing
the production of generic medicines, are not constantly called
into question. In 2007, we were once again the instigators of apetition, this time against the laboratory Novartis for its law suitattacking the Indian Patent Act. We were reassured when thelaboratory lost as this meant we could continue considering India
as a source of good quality and affordable medicines for ourpatients. The current system for encouraging research is based on
the market and the patent protection. Discussions are underway
at World Health Organisation level for setting up a system encouraging research into essential health needs that have a disproportionate impact on poor countries. These discussions aim to
set up new mechanisms that will not rely on the sale of medicines or vaccines for financing research but rather will put funds
upfront for the research stages of well-defined products - like forexample through the creation of prize fund to boost the development of tuberculosis diagnostics.

Médecins Sans Frontières Activity Report 2007

THE YE A R IN R EVIEW

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7

Our daily struggle to gain accessIf we were asked what represents our major daily challenge, wewould reply access to civilian populations in areas of war or
conflict. Despite the Geneva conventions signed by States nearly
60 years ago, and some superficial posturing we are hardly everwelcomed by warring governments or factions into the field of
their own action. This reality can carry a heavy price. Both international and national MSF staff have been kidnapped or killedduring the last year. In Somalia, an MSF nurse and doctor were
kidnapped and held captive for several days in December 2007
and three of our colleagues were deliberately murdered in
February 2008. And in Central Africa a logistician was killed inJune 2007.
The reality is that we face continuing difficulties intervening in
numerous conflict areas in 2007:•

In Darfur, where we have a high presence, we struggle toreach some areas, our convoys are attacked and we are looted
right down to our stocks of medicines.

•

In Ethiopia, we tried in vain to intervene in Ogaden, whereanti-governmental counter-insurrection operations were displacing local populations. This access was consistently refused.

•

We increased the presence of our teams in Somalia, particularly in and around Mogadishu, where a third of the population has fled the latest wave of violence. Yet, despite our appeals, our work is at best not respected and at worst deliberately
targeted. The recent murders of our colleagues forced us towithdraw our international teams, which has obviously reduced
our capacity to meet the increasing needs of civilians fleeing or

Médecins Sans Frontières Activity Report 2007

THE YE A R IN R EVIEW

6

held hostage by the fighting. Somalia was one of the major crisesof 2007 and the situation is only getting worse.
•

We are not present in Iraq, except in the autonomous regionof Kurdistan where we are based in two hospitals capable ofhandling large numbers of wounded from neighbouring towns.
Yet, transferring these patients remains problematic. We arealso trying to open a hospital in Iran to handle serious surgical cases that cannot be properly treated in Iraq. Our orthopaedic and reconstruction surgical programme in Amman
continues for those seriously wounded patients we manage totransfer to Jordan and we provide essential supplies to a large
number of hospitals where we cannot sustain a real presence.

•

The ongoing deterioration of the conflict situation in
Afghanistan drastically reduces the access to medical andhumanitarian facilities for the civilian population in several
provinces. Today, most humanitarian actors, apart from theICRC, are mainly absent from the unstable areas where thecoalition forces and the opposition groups are fighting. MSF
left the country in 2004, following the murder of five colleagues in Badghis province on June 2, and to date there havebeen no concrete results from the judicial investigation.
However, we remain very concerned about the potential medical needs of the most vulnerable. MSF has to consider anoperational return to an environment where it will be a greatchallenge to be perceived as a neutral actor to the conflict.

We will persevere because this is the mandate we have given
ourselves but the reality of our working environment means wewill never assume that our action, the perception of it and its
legitimacy are clearly and universally accepted.

Accountability:
An MSF perspectiveby Christopher Stokes, Secretary General, MSF International

It is access to victims
in areas of war or
conflict that remains
the major challenge.

A woman holds her child in a IDP camp in Kabo in the northern Central African Republic.
© Spencer Platt/Getty Images

The general drive for accountability of humanitarian organisations is necessary and timely. Aid organisations have toboth ‘give account’ and ‘be answerable’ for the choices they
make. However, there are different ways of approachingaccountability and each organisation has to find its own way
based on its field of activity, mission and principles.

Displaced flee fighting in Karuba and Mushake as fighting rages in Karuba, Kivu Province, DRC.
© Marcus Bleasdale / VII

Since the early 1990s, the ‘humanitarian sector’ has embraced
increasingly ambitious efforts to measure humanitarian assistance. There has been a significant increase in the number of
initiatives trying to ensure degrees of accountability. These initiatives started by trying to define common principles of action(ie: The Red Cross Red Crescent Code of Conduct). They continued

9

to focus on promoting evaluation (ALNAP) and standardising
methods for project planning (logical framework) and creating
common standards (Sphere) and consistent methods for information gathering.
An important driver was the desire of governmental donor agencies to better account for their funds, and to bring order to asector seen as largely unregulated (it effectively remains so).
The drive for greater accountability was also shaped by a desire
to exert greater governmental control over aid delivery to ensurethat aid contributed to the greater goal of coherence in terms ofhumanitarian assistance to countries in need. This integrated
approach requires that all sectors act in synergy to promote forexample the peace-building priorities of the donor community ina given country. They consider humanitarianism more as a technical action rather than as a principles-based political challenge.
Being an aid organisation firmly attached to principles such as
impartiality and independence MSF has been cautious in approaching the accountability issue as framed in the humani­tarian
sector. There is a need for appropriate, innovative and adaptable
tools to monitor and evaluate the effectiveness of aid deployed,
to avoid the development of bureaucratic mechanisms that will
not improve our standards or relevance.

Being an aid organisation firmly
attached to principles such as
impartiality and independence MSF
has been cautious in approaching
the accountability issue as framedin the humani­tarian sector.
The way we look at accountability in MSF, assessing the resultsof our action in order to improve our operations and the qualityof medical assistance to patients, is our main objective.
For example, as an early protagonist of artesunate combination
therapy to alleviate malaria and anti-retroviral therapy for people
living with AIDS in resource-poor settings, MSF has developed
careful programme monitoring tools to be able to publish theresults of these interventions in order to effect wider change.
Subsequent advocacy efforts led to some national health priorities and protocols being modified after the release of this data,
to the benefit of previously neglected patients.
MSF has increasingly sought to give a strong scientific base to its
field work; through initiatives such as its epidemiology centre,
known as “Epicentre”, which carries out research and training inlatest epidemiology practices. This initiative aims to increase thecapacity to monitor and evaluate the effectiveness of interventions through mortality and morbidity surveys.

Médecins Sans Frontières Activity Report 2007

essay | Accountability: An MSF perspective

8

MSF’s approach to accountability
is based on several principles.
MSF’s approach to accountability is based on several principles.
We consider that we are accountable for what we set out toachieve and the means that we use to do this. In that respect,
our action is primarily to be assessed in terms of its relevance,
meaning the extent to which our interventions reach and correspond to the actual needs of the most affected populations in acrisis, as well as to our scope and competence as a medical humanitarian organisation.
Our action should also be assessed in terms of its effectiveness,meaning the extent to which our programmes achieve expected
results based on their objectives.
Thirdly, our action should be assessed on its efficiency, meaning
the way in which inputs (human, material and financial resources) are used to achieve intended outputs.

Treating a child with cholera in a MSF cholera treatment center in Luanda, Angola.
© Paolo Pellegrin/Magnum Photos

Beyond these three key criteria, the intervention’s broader
impact, meaning its effects, both direct and indirect, intended
and unintended, should also be considered.

Saving lives and learning lessons

Our approach to accountability aims to be realistic, taking into
consideration the fact that the often highly volatile and insecurecontexts in which we work offer ‘only bad choices’.

In 2006, Angola’s worst-ever recorded outbreak of cholera affected 15 of the 18 provinces. The crisis emerged justas MSF was withdrawing from the country after 23 years, a fact that may have restricted the initial reaction anddelayed intervention. Despite treating almost 40,000 people, MSF directors requested a full evaluation of the
programme to determine MSF’s effectiveness and efficiency and, equally important, document any lessons learned.

We seek to recognise the diversity of constituencies, at local,
national and international levels, that have a stake in our medical humanitarian work and aim to address their particular needs
and interests.
Finally, we view our assessments as an ongoing learning process.
Mistakes will continue to be made and failures will occur, due tothe fact that humanitarian aid is a real-time response to acuteneeds in exceptional circumstances that require risk-taking,innovative approaches and difficult judgment calls.
In conclusion, accountability for MSF could be defined as a proactive process of deeper “engagement” with those who we define as
our stakeholders, reporting the reasons for our choices, the results of our actions and the limits, challenges and dilemmas
inherent in our work, based on our responsibilities as a medical
and humanitarian organisation in order to change and improve
our response.
Accountability to beneficiaries is still in its infancy and it is thehardest to achieve. The example of Angola given here concerns
the effectiveness and impact of MSF’s intervention during themassive 2006 cholera epidemic. The Angola report is part of amutual accountability drive whereby critical reviews of interventions are conducted and debated within MSF.

Although cholera had previously been endemic in Angola,
there had been no significant outbreaks in 10 years. However,
the many years of civil war had seen massive population movements into towns without any significant expansion or improvements to sanitation systems.
Population density, poor sanitation and regular population
movement combined with catastrophic effect in mid-February.
Within six days of the first cases being detected in the capital
Luana, an epidemic was declared. The disease quickly spreadalong the main transport routes to neighbouring provinces.
As MSF was preparing its withdrawal from Angola, there wasan assumption that the outbreak would be handled by the
Ministry of Health, without investigating its capacity to do so.
Relying on official data on the epidemic that eventually
proved anything but reliable meant MSF teams also underestimated the potential scale of the crisis and took longer thanusual to become functional. Even then, continual surveillancesystems were weak and data recording patchy.
These factors were exacerbated by the failure to appreciate thechanged context of this emergency. Whereas previous cholera
outbreaks had been restricted to the capital and coastal areas,
the greater freedom of movement and accessible transportsystems meant there was a significantly increased risk thattransmission of the disease would spread inland.

At the same time, the dramatic growth of Luanda’s population
rendered the classic urban strategy, which relies on the
speedy movement of ambulances to ferry patients to a single
treatment centre, unsuitable and ineffective. And MSF’s late
reaction meant the usual balance of early prevention andcurative activities became, by necessity, focused on curative
activities only.
All these lessons to be learned were highlighted in theevaluation report. Yet, despite these oversights and obstacles,
MSF teams still cared for nearly 80 per cent of all cases treatedin the country during the crisis accounting for more than
40,000 people of which most survived (with a case fatality
rate of only 2.3%). In addition MSF organised appropriate
logistics, coordinated sufficient supplies to be brought into
Angola, and acted when no one else did. MSF also raised
awareness of this forgotten epidemic and called on otheragencies to also intervene.
No intervention can ever be described as ‘perfect’. There will
always be a system that might have been more effective, a
process that might have been more efficient, a treatment thatmight have been more available. No organisation can ever
become truly accountable unless it accepts this reality –because it means there is always room for improvement andit is always worth striving for more.

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11

Largest Interventions Basedon Project Expenditure
1 Democratic Republic of Congo
2 Chad3 Somalia
4 Sudan South
5 Niger
6 Sudan North
7 Haiti
8 Kenya
9 Liberia
10 Myanmar

Project Locations
Africa | 67.2%
Asia | 21%
America | 7.5%
Europe | 4.3%

Context of Interventions
Stable | 44%
Armed Conflict | 29%
Internal Instability | 17%
Post Conflict | 10%

Event Triggering Intervention
Armed Conflict | 43%
Epidemic, Endemic Disease | 34%
Social Violence,
Healthcare Exclusion | 15%
Natural Disaster | 6%

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

ACTIVITY	DEFINITION	TOTAL
Total number of outpatient consultations
8,447,106
Total number of admitted patients
340,689
Total number of confirmed cases treated
1,201,358
Number of severe malnourished children
admitted to inpatient or ambulatory therapeutic
feeding centres
122,231
SFC
Number of moderately malnourished children
admitted to supplementary feeding centres
64,980
Deliveries
Total number of women who delivered babies,
including Caesarean sections
111,292
Sexual Violence Total number of cases of sexual violence
medically treated
12,791
Surgical Total number of major surgical interventions
Interventions
including obstetric surgery, under general or
spinal anaesthesia
53,626Violence Trauma Total number of medical and surgical interventions
in response to direct violence
33,441
HIV
Total number of HIV patients registered undercare at end 2007
166,481
ARV first-line
Total number of patients on first-line anti-retroviraltreatment
treatment at end 2007
111,125
ARV second-line Total number of patients on second-line
treatmentanti-retroviral treatment at end 2007.
First-line treatment failure.
1,212
PMTCT - mother Number of HIV-positive pregnant women who
received prevention of mother-to-child transmission(PMTCT) treatment
11,463PMTCT - baby
Number of eligible babies born in 2007 who
received post-exposure treatment
9,254
TB
Total number of new admissions to tuberculosis
first-line treatment in 2007
29,107
TB second-line - Total number of new admissions to tuberculosis
treatment
treatment in 2007, second-line drugs
640
Mental Health - Total number of individual consultations
126,454
Individual
Mental Health - Total number of counselling or support groupGroup
sessions
34,768CholeraTotal number of people admitted to cholera treatment 		
centres or treated with oral rehydration solution
43,202
Measles Total number of people vaccinated for measles in
Vaccinations
response to an outbreak
429,996
Measles Treated Total number of people treated for measles
22,181
Meningitis Total number of people vaccinated for meningitis
Vaccinations
in response to an outbreak
2,498,241
Meningitis Total number of people treated for meningitis
10,829TreatedReasons forintervention
By Emmanuel Tronc, Policy and Advocacy Coordinator, MSF International

Outpatient
Inpatient
Malaria
TFC

A woman walks in the rebel held town of Kaga Bandoro, Central African Republic. December 2008
© Spencer Platt/Getty Images

At its core, the purpose of humanitarian action is to save
lives, relieve acute suffering and help restore the potential
of individuals who find themselves in life threatening
circumstances. In each country where MSF is working,one or more of four events has taken place. This triggers
a medical humanitarian response, and if required, theobligation to speak out to ensure those in need are
assisted. The four events are armed conflict, endemic/
epidemic disease, social violence/healthcare exclusion
and natural disasters.
However, in reality life is not this simple or clear so MSF uses its
previous experience and judgment to decide whether its expertiseis needed. MSF also recognises the inherent limits that exist
in delivering aid and, therefore, MSF does not intervene in allconflicts or respond to all natural or man made catastrophes.
Our actions reflect an analysis of the potential added value wecan bring, and we question the pertinence of our presence orabsence in any given situation on a regular basis.

Armed conflict
Populations affected by armed conflict require comprehensive
medical and humanitarian support. These people are victimsof violence, civilian populations that have been harassed andaffected directly or indirectly through attacks, rapes and killings.
They are weakened, subordinated, and may be forcibly displaced
from their homes, looking for refuge within or outside their homecountries.

In an environment of such destruction and disruption of healthcare systems, medical, surgical and psychological care is needed.
Indirect effects of conflict and instability, including a collapse ofgeneral infrastructures and a ruined economy, also lead to suffering. As a result, people are excluded from essential medical careand services, and can be devastated by epidemics such as AIDS,
TB, malaria, or lesser known diseases such as sleeping sickness.
MSF operations are based on medical teams working in healthstructures/hospitals offering medical services to cover the rangeof medical crises inherent to a conflict, such as malnutrition ormental health problems. When needed, MSF also constructs wells
and dispenses clean drinking water and offers shelter materials.

Natural disasters
Populations affected by natural disasters require an immediate
medical humanitarian response. They find themselves indesperate conditions, having suddenly lost their homes, material
goods, family members and relatives. They are highly traumatised, in need of rapid and diverse medical care and support.
Access to the disaster area and the victims is usually complex
and demands fast identification of multiple needs.
The poorest people are particularly affected, having precarious
habitats and living conditions. MSF supplies a wide range ofanswers: medical support such as surgery, psychological andnutritional programmes, and preventative actions addressing
potential epidemic risks. These are provided in existing hospitals

Médecins Sans Frontières Activity Report 2007

Overview of MSF OPERATIONS

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Médecins Sans Frontières Activity Report 2007

essay | r eason s f or i n t erv en t i on

12or through the erection of temporary buildings if needed.
Provision of relief items such as blankets, tents and cooking oil
may also be distributed. These operations are developed throughextensive collaboration with national actors, taking into accountthe importance of local efforts and strategies, and the limitations of an international intervention with regards to time,quality and pertinence.

Populations affected by epidemic or endemic
diseaseSuch populations arise in variable contexts of stability andconflict. Emergency capacity and innovative medical actions areimperative to ensure a viable response.
People who live in precarious regions, remote and/or underdeveloped areas, slums of capitals and cities, camps or shantytowns, often do not receive strong support from the local andinternational authorities. They are often minority groups,
refugees or nomads. They are at increased risk in situations of
economic and social dependency. Women and children are themost worrying categories. Exposed to infectious and communi­
cable diseases, vulnerable during pregnancy, and traditionallyless able to express their pains and concerns, women’s
realities go unnoticed in many countries. The dependency of
infants and children further increases their vulnerability.
MSF works in existing medical structures and also establishes new
structures if needed. It responds quickly to outbreaks of disease
including cholera, measles and malaria. It targets the most vulnerable to infection. In addition, it raises awareness about the risksof an epidemic through training and prevention initiatives.
Collaboration with local governments and authorities is a condition
for implementing activities and rapidly improving the situation.
Engaging in advocacy to support medical action, as in the case of
HIV/AIDS, is also crucial in identifying responsibilities, understanding political intentions and mounting effective responses.

Labuta, Delta area, Myanmar, May 2008
© Eyal Warshawski
IDP camp of Kilimani, near Masisi, North Kivu.
© Cedric Gerbehaye/Agence VU

Deciding when to leave
By Emmanuel Tronc, Policy and Advocacy Coordinator, MSF International
The decision to close or hand over a medical programme orleave a country for whatever reason is always based on an
analysis of whether our presence and operations are stillrequired and relevant.

Stable or unsafe situations

Bongor, Chad, October 2007. An MSF volunteer giving advice to villagers how to prevent households from malaria
infection by using mosquito nets. © Tim Dirven / Panos

Social violence and healthcare exclusion
Populations affected by social violence and healthcare exclusion
often suffer because of who they are. They could be minority
groups, ethnic groups, migrants, displaced people or refugees.
They may be street kids or night commuters. They may be sex
workers or simply a patient with HIV/AIDS or TB.
Living in environments where their conditions and rights arelimited or non existent, they frequently do not receive adequate
support from local authorities and also suffer the limits ofinternational aid.
MSF becomes directly involved to alleviate such daily sufferingwith medical, psychological and social activities. Healthcare
exclusion requires projects that bring attention to healthcare
access and the absence of medical services. MSF’s identity
includes the act of speaking out, and united with patient care is
a commitment to bringing attention to the causes of sufferingand the obstacles to providing effective healthcare, and raising
the concerns and the realities of our patients to national andinternational actors.

MSF will leave or close a programme when a previously violent
situation is sufficiently stable and displaced populations havesafely been able to resettle in their native areas. On the other
hand, teams may leave if it becomes necessary to denounce thediversion of aid away from the most vulnerable civilians (refugee
camps in Zaire 1995 and DPRK 1998). Equally, a conflict situation
can deteriorate to the point when MSF and other humanitarianstaff are threatened or murdered (Somalia 1997, Iraq and
Afghanistan 2004). While infrequent, this does happen and often
results in the temporary or permanent withdrawal of our teams
for their own safety. However, if an authority or armed/politicalgroup deliberately obstructs MSF’s access to operations in a
specific area, MSF may use humanitarian positioning or public
lobbying to try and reverse the situation.

Capacity and responsibility
Leaving will be considered when local or national authorities andlocal actors have the capacity and motivation to restore anddevelop a medical system able to meet the needs of the population. If there are other actors, humanitarian or otherwise, providing medical support, MSF teams will also assess whether theirpresence brings a risk of effort being duplicated.

Every year thousands of migrants are employed as seasonal farmer workers in the fields of Southern Italy.
These workers remain “invisibles” despite their support to an entire economical sector. © Lorenzo Maccotta

A decrease in acute needs
MSF will leave when our presence interferes with local activities
and capacities. MSF will end an intervention when a medical

emergency, such as a meningitis or measles epidemic or natural
disaster, ceases to exist. In these cases, relief operations are
eventually replaced by longer-term development activities by otheractors (which was seen eventually after the Asia tsunami). Teams
will also move on when marginalised populations, such as prisoners
and street children, are no longer excluded from healthcare.
Of course, the decision to stop, close, handover a programme orleave comes with no guarantee that MSF will not need to returnin future (such as with Sri Lanka when MSF left in 2003 but had
to return in 2006 when the conflict escalated again). There is
no guarantee that a conflict will not resume, that medical andhumanitarian needs will be correctly addressed or will not againreach a medical crisis-point or that the resources and strategies
put in place will not be diverted and misused.
The decision to bring an end to assistance is, therefore, based on
our experience, our perception of the situation and our concernthat our short-term solution should not wrongly substitute morepermanent solutions. It is an acknowledgement that our actions
and presence are limited and replaceable. MSF does not represent
a long-term response to the public health responsibilities ofa State but contributes to strategic healthcare improvements bytraining national teams before leaving.
While it can appear a significant decision to make, ending
activities reflects the will and identity of MSF to carry out its
specific mandate as an emergency medical-humanitarian actor
that exists to help the most vulnerable people at times ofextreme crisis.

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15

AngolaMSF started working in Angola in 1983 in
response to conflict-related medical
emergencies. It expanded its activities both
geographically and medically as unmet needs
were identified. Broad support was provided
for basic healthcare including medical
attention for people with tuberculosis (TB),
HIV/AIDS and Human African Trypanosomiasis(sleeping sickness). MSF regularly responded
to outbreaks of diseases such as meningitis,
measles, cholera, haemorrhagic fever, andother health problems including nutritional
crises. In 2007, as the state was continuing torehabilitate the healthcare system, MSF completed a two-year long handover process of
its projects to government, local andinternational development NGOs.

MSF worked in Angola from 1983
to 2007.

Benin
In Mono-Couffo department, a rural area of
Benin with the highest prevalence of HIV, MSF
established an HIV/AIDS programme including
education, counselling, testing and treatment
in 2002, and started providing anti-retroviral
medicines two years later. In total, MSF treated903 HIV-positive patients during the course of
the project. At the end of June 2007, theproject was transferred to local healthauthorities and partners, who are now
providing free anti-retrovirals.
Since June 2005, MSF had also been providing
medical care to people in a refugee camp ofTogolese at Agamé, in the south of Benin.
At the end of 2006, MSF handed over respon­
sibility for medical activities in this camp of
8,000 people, to the Benin Red Cross.

MSF worked in Benin from 2002
to 2007.

Ecuador
MSF was the first NGO to treat HIV in Ecuador.
In 2004 MSF began an HIV/AIDS project inthree health areas of Guayaquil town, which
had the highest prevalence of HIV in Ecuador.

Until then, Guayaquil had only one reference
hospital and one health unit. MSF opened an
additional health and treatment unit in thehospital, and also started three maternity
units and eight health centres, providing
free access to counselling and testing, anti­
retroviral treatment (ART), lab follow-up, andhealth education. By December 2007, MSF
finalised the handover of this project to the
Ministry of Health. Over the course of the
project, MSF attended to approximately 1,770
patients and initiated 530 of them on ART.

MSF worked in Ecuador from 1996
to 2007.

Japan
Despite the existence of a welfare system thattargets the socially disadvantaged in Japan,
the system imposes a multitude of restrictions
and complex procedures, leaving the majorityof homeless people without access to proper
medical care. To tackle this socio-medical
problem, MSF launched a programme in Osakain 2004, site of Japan’s largest homeless population, with the objective of providing medicalcare through a fixed clinic. However, this was
not immediately possible so over the next 14
months, MSF used mobile clinics to conduct
1,351 medical consultations, offering treatment to 296 patients for conditions including
hypertension, diabetes and joint pain. Despite
several attempts to establish the fixed clinic,
this never came to fruition due to opposition
from the local community and authorities.
Therefore, after much deliberation, MSF
decided to close the programme in early 2007
and referred patients to other health facilities.

MSF worked in Japan from 2004
to 2007.

Malaysia
MSF started working in Malaysia in 2004 to
improve access to medical and mental healthservices for refugee and asylum seeker communities in and around Kuala Lumpur. These
people often have no official status and facedifficulties in accessing healthcare. In 2006,
MSF opened three mobile clinics, working inclose collaboration with local partners, carrying out 8,159 medical consultations.
The clinics offered primary healthcare, mental
health consultations and referrals. MSF alsoorganised community health education,
psychosocial and mental health training forNGOs, community groups and volunteers fromrefugee and asylum seeker communities.

Most under-reported
crises of 2007

Médecins Sans Frontières Activity Report 2007

MSF COUNTRY PROGRAMME CLOSURES

After building up the capacity of local partners
through training and direct support of clinicalservices, in April 2007 MSF handed the project
over to local partners, to continue the medical
and mental health work.
The health services provided by NGOs, althoughvitally important, are seen as temporary
measures to alleviate some of the healthproblems faced by refugees and asylum seekers.
A more permanent solution needs to be foundthat addresses the underlying causes for thelack of access to healthcare.

MSF worked in Malaysia from 2004
to 2007.

Rwanda
MSF has ended its activities in Rwanda after 16
years in the country. Over the years, MSF’s work
has included assistance to displaced persons,
war surgery, programmes for unaccompanied
children and street children, support to victims
traumatised by the conflict, programmes toimprove access to healthcare, responding toepidemics such as malaria, cholera andtuberculosis, and projects linked to maternal
and reproductive health.
Rwanda has now begun a clear shift towards
long-term development plans. The number oforganisations in the country now covers theneeds of the population. The AIDS epidemic
appears contained due to the high level ofinvestment by local authorities and the supportof many international actors. As a result, MSF
felt able to end its presence in the country at
the end of 2007.

MSF worked in Rwanda from 1991
to 2007.

Displaced fleeing war in
Somalia face humanitarian crisis
As some of the worst violence in over 16 years escalated inSomalia, international aid and interest appeared to fade. Ethiopian
troops and Transitional Federal Government forces clashed witharmed groups, including remnants of the Islamic Courts Union.
Civilians were killed or injured and thousands displaced from thecapital, Mogadishu.
MSF increased its presence in Mogadishu and opened an emergency
response programme in Afgooye, 30km outside the capital. Here, anestimated 200,000 displaced people live in harsh conditions withlittle access to food, water and shelter. Many of those remaining in
Mogadishu are staying in makeshift camps and suffer exposure to
heavy violence frequently.
Somalia’s 16-year conflict has resulted in some of the world’s worst
health indicators, with an estimated life expectancy of just 47
years. In 2007 MSF ran projects in 10 of the 11 regions of south
and central Somalia. But security concerns prevented MSF staff
from reaching more patients, particularly in Mogadishu.
In August, MSF called on all parties to respect the safety of
medical workers and allow them access in and around Mogadishu.
Throughout MSF hospitals, from Jamaame to Galcayo, the medical
services provided range from primary and maternal to surgical care.
Nurses and doctors treat malnutrition, tuberculosis, kala azar,
cholera and war-related trauma on a daily basis.
However, in December the security situation worsened with the
kidnapping and release of two MSF staff, followed by the killing of
three MSF staff in January. In response to this MSF temporarily
evacuated its international staff from Somalia and relied on national staff to run activities.

Thousands of Somalis live incamps like this one north of
Mogadishu, suffering from alack of water, food, shelter andaccess to medical treatment.

© Jehad Nga

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Médecins Sans Frontières Activity Report 2007

Photo essay s | m os t u n d er - r ep ort ed c r i s es of 200716

An MSF physician examinesa tuberculosis patient in
the Maela refugee campnear Maesot.

Women queue to collectwater outside the capital
city of Harare. Zimbabweans,particularly in high-density
areas, face massive water
shortages.

© Dirk-Jan Visser© Francesca Di Bonito

Political and economic turmoil sparks
healthcare crisis in Zimbabwe
Zimbabweans continue to suffer rampant unemployment, rocketing
inflation, food shortages and political instability. According to the
UN up to a quarter of the country’s 12 million people are believed
to have fled to neighbouring countries in recent years.
The healthcare system now threatens to collapse, with particularly
serious consequences for the estimated 1.8 million people livingwith HIV/AIDS. Less than a quarter of those in urgent need oflife-extending anti-retroviral (ARV) treatment receive it and some
3,000 die each week. Medical professionals are leaving the country,
the government HIV/AIDS treatment programme is oversubscribed
and the lack of ARV supplies has stifled further expansion. The
high cost of fuel and transport often make travelling to hospitals
or clinics difficult.

Through programmes in Bulawayo, Tshlotsho, Gweru, Epworth andManicaland province, MSF provides free medical care to 35,000
people living with HIV/AIDS. Of these, 16,000 are receiving ARVtreatment, nearly a tenth of all people on treatment. However,
MSF’s ability to care for more people is restricted by the lack oftrained health workers, restrictions on who can prescribe ARV
drugs and increasingly strict administrative requirements forinternational staff to work in the country.
Zimbabweans also face the health consequences of deteriorating or
non-existent water and sanitation systems. Outbreaks of diarrhoea
have affected the populations of Harare and Bulawayo. Nor is it
easy to flee the country, as the numerous reports of refugees
attacked along the South African border testify. Some of those who
do make it live with little or no access to healthcare.

Drug-resistant tuberculosis spreads as new
drugs go untested
Every year, an estimated nine million people develop tuberculosis(TB) and two million die. Yet there have been no advances in treatment since the 1960s and the most commonly used diagnostic test,
sputum smear microscopy, developed in 1882, detects TB in only
half of cases. Only $206 million of the estimated $900 million
needed annually for TB research and development is invested
worldwide.
Treatments and diagnostics are even less adapted for people livingwith HIV/AIDS, the easiest prey for the TB bacilli. For the morethan 450,000 people a year who become infected with multi-drugresistant TB (MDR-TB) or develop it following incomplete treatment, the prospects of survival are even bleaker. The few who
access treatment have to endure up to 24 months taking a daily
cocktail of highly toxic and expensive drugs that often trigger
violent side effects.

Even under the best conditions in MSF programmes in Armenia,
Abkhazia, Georgia, Cambodia, Kenya, Thailand, Uganda andUzbekistan, only 55 per cent of MDR-TB patients completed thetreatment. The rest of them either died, did not improve or could
not cope with the side effects.
A further problem for medical staff on the TB pandemic’s front lineis the fact that not all new drugs are tested on those in greatest
need: patients with MDR-TB. A recent article by international
experts published in the medical journal PLoS Medicine called
for new drugs to be tested on patients whose TB is resistant tostandard treatment. This could make it easier to detect anti-TB
activity of new drugs and ultimately accelerate drug development.

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Expanded use of ready-to-use foodto reduce child malnutrition

Child eating highly
nutritious ready-touse-food product inNiger which is used totreat malnutrition inchildren under five.
Acute malnutrition in early childhood is common in large areasof the Horn of Africa, the Sahel and South Asia, known as theworld’s ‘malnutrition hotspots’. Every year, five million children
under the age of five die.
Nutrient-dense ready-to-use foods (RUFs) have recently emerged
as an effective response, capable of saving the lives of acutely
malnourished children. RUFs are milk and peanut based pastes
enriched with all the vitamins and nutrients needed for rapid
recovery. They do not require refrigeration or preparation, so mostmalnourished children can be treated at home. Yet, only a tiny
fraction of severely malnourished children are getting RUFs.
Supplementing their daily diets with ready-to-use supplement
foods can also prevent children from becoming acutely malnourished in the first place. Treatment and prevention should form
part of all international food aid programmes targeting young
children in areas of high prevalence.
In Niger in 2007, MSF launched a pilot programme using amodified RUF as a supplement to prevent some 62,000 children
from becoming malnourished during seasonal food shortages.
MSF is therefore urging international donors to support thesystematic purchase and use of RUFs as a treatment andpreventative measure worldwide.

© Anthony Jacopucci

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A wounded woman and childreceive treatment at MSF’s
surgical programme in
Vavuniya, a town close to thefront lines of the ongoing
conflict between governmentand rebel forces.
© Henk Braam / HH

Civilians increasingly under fire in
Sri Lankan conflict
Caught in the middle of fighting between government forces andthe Liberation Tigers of Tamil Eeelam, civilians in Sri Lanka’seastern and northern regions live in terror. Sri Lanka has been in
the grips of this fighting on and off for nearly 25 years but theconflict, particularly the toll it has taken on civilians, has
attracted minimal attention.
Targeted bombings, killings, mine attacks, suicide bombings,
abductions, forced recruitment, extortion, restrictions on movement and arbitrary arrests make day-to-day life in Sri Lanka
increasingly precarious. Hundreds of thousands of Sri Lankans inneed of humanitarian assistance have been displaced since theresumption of major fighting in August 2006.

This dire situation is compounded by a general climate of hostility
towards, and suspicion of, humanitarian aid organisations.
Humanitarian aid is increasingly restricted and civilians sufferfrom lack of access to lifesaving emergency assistance. This comesat a time when areas near the front line of fighting have lostnearly all medical specialists and hospitals no longer have thehuman resources to treat the wounded.
After having to evacuate temporarily in late 2006, MSF is now
providing medical, obstetrical and surgical care in Point Pedro,
Vavuniya, Kilinochchi and Mannar.

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Médecins Sans Frontières Activity Report 2007

Photo essay s | m os t u n d er - r ep ort ed c r i s es of 200720

An IDP camp in Bulengo,near Goma in North Kivu.

Graciela and her family
are a few of the millions
of Colombians who have
had to flee their homes toescape fighting between
government, rebel andparamilitary forces.
© Cédric Gerbehaye / Agence VU© Espen Rasmussen / Panos

Escalating conflict causes destitution in
Democratic Republic of Congo
More than a year after the first democratic elections in decades,fighting between armed groups has continued in the Democratic
Republic of Congo (DRC) eastern province of North Kivu. Supported
by MONUC, the UN force, the government is in open combat withthe forces of rebel leader, Laurent Nkunda. Different groups suchas the Mai Mai and the Rwandan Hutu rebels of the Democratic
Forces for the Liberation of Rwanda are also involved.
Hundreds of thousands of people have fled their homes, often
forced to hide in the forest, with little access to food or basic
healthcare and under constant threat of attack. They are
increasingly vulnerable to easily treatable diseases and conditions
such as malnutrition, malaria and respiratory infections.
Outbreaks of cholera have also struck.

MSF has reinforced its activities but the insecure environment
makes it difficult to deliver comprehensive humanitarianassistance. Large areas are inaccessible and incidences of sexual
violence are increasing alarmingly. In North Kivu, MSF cared formore than 3,000 victims of sexual violence in 2007.
In Ituri district, where different armed groups to those in North
Kivu are in conflict, 150,000 displaced people are utterly destitute,vulnerable to exploitation and assaults. Through the Bon Marché
hospital in Ituri’s capital, MSF has treated 7,400 rape victims
over the last four years, with more than a third admitted in thelast 18 months.
MSF also responded to several disease outbreaks in other provinces,including an epidemic of Ebola hemorrhagic fever in southern West
Kasai province.

Living precariously in Colombia’s
conflict zones
As many as 3.8 million people have been driven from their homes
by violence, according to UNHCR, ranking Colombia third in theworld for the largest number of internally displaced people. As
the conflict in Colombia enters its sixth decade and armed groups
continue to target civilians, many Colombians do not remember atime when daily life was not ruled by guns and terror.

Families flee their homes for urban slums with little morethan the clothes they wear, only to find equally threatening
conditions on arrival. They live in overcrowded shacks where
living conditions can lead to respiratory infections and diarrhoeal
disease but there is little access to healthcare. Very few have theoption of returning safely to their homes.

Armed groups have a stranglehold on roughly half of Colombia’s
rural areas. Impassable roads deprive civilians of access tohealthcare, children are forcibly conscripted into militias andsuspected armed forces collaborators are murdered. At the sametime, anyone suspected of working with rebel groups face harshreprisals by the armed forces.

MSF works in 13 of Colombia’s 32 departments. Teams work in
isolated rural areas through mobile and stationary clinics and in
urban areas where displaced families have gathered. Teams
provide medical care ranging from vaccinations to reproductive
care and emergency services, as well as offering psychologicalcare to victims of violence.

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22

A father and son wait
at an MSF clinic.
A mother sits with her
child in Massabiou, avillage that was attacked
by armed militia in April,causing thousands to flee.
Those who have returned
are now destitute, struggling to survive without
food, water or shelter.

© Claude Mahoudeau© Spencer Platt/Getty Images

Humanitarian aid restricted in Myanmar
Isolated from the outside world since the military junta came to
power in 1962, the people of Myanmar (formerly Burma) suffer
repression and neglect. September’s crackdown on monks marchingfor democracy attracted international attention but the reality ofdaily life for ordinary people remained hidden.

Health services are particularly poor in the western Rakhine state,
where MSF treated 210,000 people for malaria in 2006 and where
Muslims, known as Rohingyas, are denied citizenship rights by thestate and suffer numerous forms of abuse. MSF provides Rohingyas
with basic medical care and HIV/AIDS treatment.

Few humanitarian aid groups work in Myanmar where the humanitarian space is limited. Donors are reluctant to fund programmesthat could support the regime. Time-consuming administrative
procedures can make responding to emergencies impossible andneeds assessments challenging. In some regions, such as thosegripped by armed conflict involving Karen and Mon rebels along theThai border, government restrictions have thwarted aid efforts. Only
1.4 per cent of the regime’s budget supports healthcare services.

The slow response to the HIV/AIDS epidemic has fuelled the spreadof the disease. MSF offers comprehensive HIV/AIDS programmes in
Yangon, Rakhine, Kachin and Shan states but these meet only afraction of the need. Only 10,000 of the UN-estimated 360,000
people living with HIV are believed to be receiving life-prolonging
anti-retroviral treatment and 8,000 of them receive it from MSF.
Few have access to care for opportunistic infections such as
tuberculosis. The UN estimates that HIV/AIDS kills 20,000 people
in Myanmar every year.

Civilians caught between armed groups inCentral African RepublicFighting between government forces and rebel groups innorthern Central African Republic (CAR) since late 2005 has caused
significant displacement of the population. Villages have beenpillaged and burned, forcing people to flee into the forest, severely
restricting their access to healthcare and leaving them prey toroadside bandits.
In 2007, MSF supported health structures and provided primaryand secondary healthcare in and around Kabo, Batangafo, Paoua,
Kaga Bandoro, Markounda and Boguila in the north-west, and Birao
and Gordil in the north-east. In the first eight months, morethan 100,000 consultations were carried out. Tens of thousandsof people, including many children under five, were treated for
malaria and other infectious diseases often associated with poor
living conditions.

Harassment and general insecurity frequently forced MSF to stopits vital mobile clinics at short notice, sometimes for up to eightweeks. In June, MSF operations in north-western CAR were subject
to a lengthy reduction after MSF aid worker, Elsa Serfass, was killed
by rebel gunfire.
The violence has also forced nearly 30,000 people into neigh­bouring Cameroon, where they lack shelter, food and medical
assistance. In 2007, MSF intervened when alarming rates ofchildhood malnutrition were discovered among this refugee
population. Affected children were treated and supplementary foodrations distributed. More than 45,000 CAR refugees also gatheredin southern Chad, where MSF works in a district hospital andprovides assistance to refugees in camps and local residents.

25

Glossary of Diseases
A paediatrician examinesa child in Hospital No.5
in Grozny.

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

© Misha Galustov / agency.photographer.ru

As the Chechen conflict recedes, medical
needs remain
It has been nearly four years since the most intense fighting
subsided between Russian government and rebel forces in the
republic of Chechnya. Tens of thousands of those who had fled to
the neighbouring republics of Ingushetia and Dagestan have now
returned home. The capital, Grozny, is being rebuilt and therepublic’s airport has reopened.
Yet the situation in the region remains highly volatile. Fighting
outside Chechnya has increased and there is still a large militarypresence. Abductions, disappearances, assassinations and bombings
continue. Inside Chechnya, the security situation for civilians isprecarious. Dangers range from being caught in sporadic gunfire togetting into a car accident involving heavy military vehicles, anincreasingly common cause of trauma.

Basic health services, particularly obstetrical and gynaecologicalcare, are woefully lacking. Through clinics in and around Grozny,
MSF and local Chechen doctors see a population with high levels ofchronic illness, including lung, kidney and cardiovascular diseases.
The teams also witness a widespread need for psychosocial carecaused by years of violence and displacement. An MSF survey ofpeople living in temporary centres in Ingushetia and Chechnya
found that nearly all were suffering from anxiety, insomnia or
depression.
Chechnya’s wars also took their toll on the republic’s tuberculosis(TB) control system. MSF, therefore, supports TB hospitals, serving
a population of 350,000. Since 2006, MSF staff have also run areconstructive surgery programme in Grozny to meet the needs ofsurvivors with crippling injuries.

Treatment must occur in early acute stages of
the infection, and to date, drugs have only
been effective in the acute and asymptomaticstage of the disease in children. Diagnosis iscomplicated, with doctors needing to perform
two or three blood tests to determine whether
a patient is infected with the parasite. There
are few drugs developed to treat the disease
and the current line of treatment can betoxic, taking one to two months to complete.
Apart from managing symptoms, there has
been no effective treatment for chronic Chagas
in adults.
MSF Chagas programmes in Bolivia andGuatemala focus primarily on education,
preventive measures and screening and treatment for children. MSF is now also attempting
to treat adults through a project in Bolivia.

MSF treated 685 people for Chagas in2007.

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

Although most people infected with cholera
will have only a mild infection, the illness canalso be very severe, causing profuse waterydiarrhoea and vomiting, leading to severe
dehydration and death without rapid treatment. Required treatment is the immediate
replacement of fluid and salts with arehydration solution administered orally or
intravenously.
MSF has developed cholera treatment kits toprovide rapid assistance and sets up cholera
treatment centres (CTCs) in areas where there
are outbreaks. Control and prevention
measures include ensuring an adequate supplyof safe drinking water and implementing strict
hygiene practices.

MSF treated over 43,000 people forcholera in 2007.

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
infections (OIs) such as candidiasis, pneumonia, and various kinds of tumours are able toflourish as the immune system weakens. SomeOIs can be treated, whilst others are life-threatening. The most common opportunistic infection leading to death is tuberculosis (TB).
Many people live for years without symptoms
and may not know they have been infectedwith HIV. A simple blood test can confirm
HIV status.
Combinations of drugs known as anti-retrovirals help combat the virus and enable people
to live longer, healthier lives without rapid
degradation of their immune systems. It issimplest and easiest to take these drugs properly when they are combined into single pills(fixed-dose combination or FDC). MSF comprehensive HIV/AIDS programmes generally
include education and awareness activities sopeople understand how to prevent the spreadof the virus; condom distribution; HIV testingalong with pre and post-test counselling;treatment and prevention of opportunistic
infections; prevention of mother-to-childtransmission; and provision of anti-retroviraltreatment for patients in advanced clinicalstages of the disease.

MSF provided care for over 166,000
people living with HIV/AIDS andanti-retroviral therapy for more than
112,000 people in 2007.

Human African
Trypanosomiasis(Sleeping Sickness)
Frequently known as sleeping sickness, thisparasitic infection is seen in sub-SaharanAfrica and is transmitted through the bite ofcertain types of the tropical tsetse fly. Morethan 90 per cent of reported cases of sleeping
sickness are caused by the parasite
Trypanosoma brucei gambiense (T.b.g). The
parasite attacks the central nervous system,
causing severe neurological disorders andleading to death if untreated.
During the first stage of the illness, people
have non-specific symptoms such as fever andweakness. At this stage the disease is difficult
to diagnose but relatively easy to treat. The
second stage occurs once the parasite invades
the central nervous system. The infected
person begins to show neurological or psychiatric symptoms, such as poor coordination,
confusion, or convulsions. People may also
have difficulty sleeping during the night but
are overcome with sleep during the day.
Accurate diagnosis of the second stage of theillness requires taking a sample of spinal fluid
and treatment is painful, requiring daily
injections. The most common drug used totreat trypanosomiasis, melarsoprol, wasdeveloped in 1949 and has many side effects. A
derivative of arsenic, it is highly toxic and fails
to cure up to 30 per cent of patients in someareas of Africa. It also kills up to five per centof people who receive it. Eflornithine, thoughsomewhat difficult to administer because it
requires an IV and a complicated treatment
schedule, is a safer, more recent alternative
being used by MSF in its projects.

MSF admitted over 1,700 patientsfor treatment for Human African
Trypanosomiasis in 2007.

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

MSF treated over 4,200 people for
Leishmaniasis in 2007.

Malariaparasite. An accurate diagnosis can be madethrough a count of parasites by microscope ora rapid dipstick test. Both methods are used by
MSF in its projects.
Antimalarial drugs are used to treat the illness. Chloroquine was once the ideal treatment for malaria caused by plasmodium
falciparum because of its price, effectivenessand few side effects; however, its effectivenesshas decreased dramatically in the past few
decades. MSF field research has helped provethat artemisinin-based combination therapy(ACT) is currently the most effective against
this type of malaria and has urged governments in Africa to change their drug protocols
to use ACT. Although many governments havemade the change in writing, in many cases the
drug is still not available for their patients.

MSF treated over 1.3 million people
for malaria in 2007.

Meningitis
Meningococcal meningitis is caused by
Neisseria meningitidis and is a contagious andpotentially fatal bacterial infection of themeninges, the thin lining surrounding thebrain and spinal cord. People can be infected
and carry the disease without showing symptoms, spreading the bacteria to others throughdroplets of respiratory or throat secretions, forexample when they cough or sneeze. The
infection can also cause sudden and intense
headaches, fever, nausea, vomiting, sensitivity
to light and stiffness of the neck. Death canfollow within hours of the onset of symptoms.

Caused by four species of the parasite
Plasmodium, malaria is transmitted by
infected mosquitoes, particularly during rainyseasons, and mainly strikes poor and ruralcommunities, slum dwellers and refugees.
Symptoms include fever, pain in the joints,
headaches, repeated vomiting, convulsions
and coma. Malaria caused by plasmodium
falciparum, if untreated, may progress
to death.

Without proper treatment, bacterial meningitis kills up to half of those infected. Suspectedcases are properly diagnosed through examination of a sample of spinal fluid and treatedwith a range of antibiotics. Even when given
appropriate antibiotic treatment, five to ten
per cent of people with meningitis will die
and as many as one out of five survivors may
suffer from after-effects ranging from hearing
loss to learning disabilities.

Malaria is commonly diagnosed on a basis ofclinical symptoms alone, such as fever andheadaches. Around half the people who
present with fever and treated for malaria in
Africa may not actually be infected with theMeningitis occurs sporadically throughout theworld, but the majority of cases and deaths are
in Africa, particularly across an east-west
geographical strip from Senegal to Ethiopia,
the “meningitis belt” where outbreaks occur

regularly. Vaccination is the recognised way toprotect people from the disease.

MSF projects Around the world
AfricaMSF treated over 10,800 people andvaccinated 2.5 million people against
meningitis in 2007.

Tuberculosis
One-third of the world’s population iscurrently infected with the tuberculosis (TB)
bacilli. Every year, nine million people develop
active TB and close to two million die from it.
Ninety five per cent of these people live inpoor countries.
This contagious disease affects the lungs andis spread through the air when infectious
people cough, sneeze or talk. Not everyone will
become ill, but ten per cent of (HIV negative)
infected people will develop active TB at somepoint in their lifetime, suffering from a persistent cough, fever, weight loss, chest pain
and breathlessness in the lead up to death.
TB is also a common opportunistic infection
and leading cause of death amongst people
with HIV.
Drugs used to treat TB are from the 1950s anda course of treatment for uncomplicated TB
takes six months. Poor treatment management
and adherence has led to new strains of bacillathat are resistant to one or more anti-tuberculosis drug. Multi-drug-resistant TB (MDR-TB) isa most serious form of this, identified when
patients are resistant 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 resistanceto second-line drugs develops on top of
MDR-TB. XDR-TB is at this time virtually untreatable.

MSF treated over 29,000 people fortuberculosis, including 640 for MDRTB in 2007.

28 | Burkina Faso
29 | Burundi
30 | Cameroon
30 | CENTRAL AFRICAN REPUBLIC
32 | Chad
32 | Democratic republic of congo
34 | Ethiopia
35 | Guinea
36 | Ivory Coast36 | Kenya
38 | Lesotho
39 | Liberia
40 | Malawi
40 | Mali
41 | Morocco
42 | Mozambique
44 | Niger
45 | Nigeria
46 | Republic of congo
46 | Rwanda
48 | Sierra Leone
48 | Somalia
50 | South Africa
51 | Sudan
54 | Swaziland
54 | Uganda
55 | Zambia
56 | Zimbabwe

In Mali treatment for malaria is just 200 CFA through an MSF programme, making it affordable for local people.
© Bruno De Cock

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Burkina Faso

BurundiReason for Intervention • Endemic/
Epidemic disease • Social Violence/
Healthcare exclusion
Field Staff 248

Reason for Intervention • Endemic/Epidemic disease • Social Violence/
Healthcare exclusion
Field Staff 442

As development agencies increase their activities in Burundi, MSF has beenable to hand over some of its projects to the Ministry of Health and otherhumanitarian actors. However, the health situation in many parts of thecountry remains precarious, particularly in the area of women’s health.

In Burkina Faso high levels of infantmalnutrition remains problematic interms of detection and treatment. A
more decentralised programme has
now been developed to address this.
MSF also tackled meningitis through alarge scale inoculation programme,
and continued to treat HIV/AIDS patients. Treatment was also provided tostreet girls and teenagers, vulnerable
to disease and abuse.

Handing overIn 2007, two years after Burundi held its firstpost-war democratic elections and four years
after the end of the long-running civil war,
MSF handed over programmes in Kinyinya,
Kayanza and Karuzi.
MSF had been working in Kinyinya hospital,
Ruyigi district, since 2003. As well as providing
secondary care in the hospital, MSF staff also
provided medical and material support toseven health centres around the district.
However as development agencies increase
their activities in Burundi, MSF has been able
to hand over some of its projects to the
Ministry of Health and other actors. In

The vast majority of Burkina Faso’s population
depends heavily on successful harvests forsurvival. In the semi-arid Sahel region, bordering Mali, one of the most densely populatedareas, a poor harvest can quickly lead to extreme food shortages. As a result malnutritionis endemic, especially among children underfive years old.
In September 2007, MSF launched a project todecentralised the treatment of malnutrition in
the Yako and Titao districts by treating children close to their homes using mobile andlocal health clinics. Only acutely malnourishedchildren suffering from complications are hospitalised, while all other children are screened
and cared for through outpatient consultationsin the local health clinics. By the end of
December, 7,000 children under five years had
been enrolled in the nutrition programme.

© Yasuhiro Kunimori

Malnutrition is endemic, especially amongchildren under five years old.

Rapid response to meningitis

Decentralising HIV/AIDS care

In mid-February, a meningitis epidemic brokeout affecting over 25,000 people of which over
1,700 died. MSF rapidly intervened to support
health authorities and treat meningitis patients. By the end of the emergency, MSF hadtreated 1,500 people in the capital,
Ouagadougou.

MSF continued to run an HIV/AIDS project inPissy, now concentrating on improving
patients’ adherence to treatment through thedecentralisation of care. This is done bybringing care closer to the patient throughlocal health centres and increased community
support which improves the autonomy ofpatients living with HIV/AIDS. More than
23,000 medical consultations were conducted.
Since 2004, MSF has provided anti-retroviraltreatment (ART) to people with HIV/AIDS, withover 4,000 patients receiving treatment so far.

In March, MSF ran a meningitis vaccination
campaign in the Pissy health district, the mostdensely populated district of the capital.
Approximately 470,000 people were targeted
for inoculations. The following month, MSF
vaccinated the population of four rural districts: Manga, Po, Zabre in the south and
Gorom-Gorom in the north. In total, MSF
vaccinated about 955,000 people.

such centre in Burundi open seven days aweek. After five years of activities, the centre
is well established and well known by womenin the area.

Street girls in Ouagadougou
In Ouagadougou, MSF manages a project forstreet girls and teenagers aged nine to 20
years. Initially, the team was only referring

Musema, Kayanza Province where MSF has
been working since 2004, four clinics and ahospital were handed over to the Baptist
church in May. In Karuzi district, where MSF
had worked since 1995, the European
Community will start supporting a hospitaland 12 health centres at the beginning of 2008.

Addressing the health needs of women
Women’s health issues are often overlooked.
Sexual violence is extensive and there is aclear need for quality free care. Medical teams
at MSF’s Seruka centre in Bujumbura cared for
1,430 victims of violence, 63 per cent of whomwere under 19 years and 14 per cent were
under five. The Seruka centre remains the only

In the rural district of Bujumbura, MSF
supports 12 maternity clinics with the management of obstetrical emergencies.
Ambulances collect emergency cases andtransfer them to private clinics in Bujumbura
where they receive specialised care. However,
the worsening security situation around thecapital since August means that transfers are
now only posible during the day as the roads
are too dangerous at night.
MSF is currently building a specialised clinicin the Kabezi area. When finished, this will
provide free quality emergency obstetric careso that women with complicated deliveries
will not have to travel to the capital for
medical care.
MSF has worked in Burundi since 1992.

The health situation in
many parts of the country
remain precarious,
particularly in the areaof women’s health.

and accompanying the girls to public healthfacilities but since the beginning of the year it
has been more directly involved in providing
medical services. Activities include providing
treatment for sexually transmitted infectionsand HIV/AIDS, reproductive and obstetricalcare, antenatal care and support for victims ofsexual violence and improving their legal
protection. Some 1,200 consultations and 29
deliveries were carried out. MSF also continues
to reduce stigma by raising awareness with theauthorities and civil society about the violence
inflicted on these girls. In 2008, MSF will handover this project to a local partner called
Keogoo.
MSF has worked in Burkina Faso since 1995.

© Maartje Geels

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Cameroon
Reason for Intervention • Armed
conflict • Endemic/Epidemic disease
Field Staff 123

Patients received innovative treatment
for Buruli, a debilitating disease, thecause of which is unknown. Medical
and psychological care continued with
HIV/AIDS patients, and assistance wasprovided to refugees fleeing civil war
in Central Africa.
Overcoming Buruli
Buruli is an emerging and neglected disease in
several western and central African countries.
How people contract Buruli is unknown but it
appears to develop in populations living close
to rivers. It causes ulceration of the skin,primarily the arms and legs, and destructionof underlying tissue and bone. Untreated, it
can lead to permanent disability and limb
amputation.

There have been cases of Buruli in several
provinces of Cameroon, with the populationsof Ayos, Akonolinga and Mbalmayo particularly affected. Local rumour attributes the‘mystical’ disease to a curse, leading people toseek treatment from faith healers, often withcatastrophic results. Advanced Buruli requires
surgery and physiotherapy.

MSF is also undertaking innovative treatments
in wound care that includes using a new rangeof dressings which should simplify thetreatment and speed up the recovery process
which, in turn, should reduce the chance of
infection and complications.

treatment programme. At the D’joungoulo
district hospital in Yaoundé, MSF also provides
care for 800 patients with HIV, 525 of whom
are following ART.

Treating people with HIV/AIDS

MSF’s Buruli project in Akonolinga provides
medical and surgical care for those living in
the district. Since 2002, some 600 patients
have been cared for, 40 to 50 per cent of themaged under 15 years. MSF has also tried to raiseawareness amongst the population about thedisease and availability of treatment, with theresult that patients now seek medical help
sooner and receive antibiotic treatment before
the disease progresses. MSF also conducts
active screening and is focusing on a pro­
gressive decentralisation of medical care tonurses in district health centres.

In the Nylon district hospital at Douala, andthrough community facilities, MSF provides
medical and psychosocial care to some 7,500
patients with HIV/AIDS, 3,100 of whom arefollowing anti-retroviral treatment (ART). The
Cameroon government now provides freetreatment as part of a developing national
programme, although patients must still pay
for HIV testing, follow-up consultations andlaboratory tests. MSF has worked to simplify
protocols to enable the progressive transfer of
the Nylon project to Cameroon authorities.
Effort is also being put into the education offamilies and communities to follow the fullBy the end of 2007, a three-year-long civil war
in neighbouring Central African Republic led
to the exodus of over 200,000 people. Morethan 60,000 took refuge at 59 sites along
Cameroon’s eastern border, many without
adequate food. MSF assisted refugees in the
East and Adamaoua provinces, distributing
18 tonnes of supplementary food rations to
4,180 people. MSF also screened children formalnutrition and offered medical andnutritional care in collaboration with
Cameroon’s Ministry of Public Health for themost urgent cases.

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Feeding refugees from Central African
Republic

MSF has worked in Cameroon since 2000.

© Claude Mahoudeau

Local rumour attributes the ‘mystical’ disease toa curse, leading people to seek treatment fromfaith healers, often with catastrophic results.

Central African Republic
On June 11 all activities came to an
abrupt halt after the fatal shooting of
27-year-old MSF volunteer, Elsa
Serfass. Elsa was struck by a bullet
while travelling in a well marked MSF
vehicle in the Ngaoundai region. The
rebel group known as The Popular
Army for the Restoration of Democracy
was responsible for the shooting. MSF
condemned the murder. Following
discussions with all parties involvedin the ongoing conflict and after acareful evaluation of the humanitarian
space, a portion of activities resumed
one month later.

Reason for Intervention • Armed conflictField Staff 557

Many villages have beenlooted or burned, forcing
their inhabitants to flee.

© Spencer Platt/Getty Images

The population of northern Central African
Republic (CAR) continues to live in anenvironment of chronic violence where manyneeds are not being met through humanitarian assistance. Fighting between government
forces and rebel groups abated slightly in thesecond half of 2007, becoming a low-intensity
conflict with isolated but unpredictable
clashes. At the same time, there was anincrease in attacks by roadside bandits taking
advantage of the general lawlessness thatprevails in the region.

Since late 2005, fighting between the government and various rebel groups in the northeast and north-west of the country has caused
massive displacement of the population. Many
villages have been looted or burned, forcing
their inhabitants to flee. Most have sought
refuge in the bush, often a few kilometresaway from their destroyed homes. Displaced
people are mostly scattered in small groups
rather than gathering in camps, apart fromrecently in Kabo. Some villagers have had toflee several times after continued attacks bydifferent armed groups.
Despite an increase in international aid in
2007, many people who have fled continue tolive in makeshift shelters exposed to theelements and in constant fear of a new attack.
They have no blankets or mosquito nets, noaccess to healthcare and clean water, andstruggle to find food. They are particularly
vulnerable to malaria, respiratory infections
and diarrhoeal diseases.
MSF focused on providing medical assistanceto populations affected by the conflictthrough a network of mobile clinics, hospitals
and health centres across the north-west in

Kabo, Batangafo, Kaga Bandoro, Markounda,
Paoua, Boguila, and in the north-eastern areasof Birao and Gordil. More than 270,000 outpatient consultations were conducted and morethan 16,000 patients hospitalised. Treating
patients for diseases such as tuberculosis,
HIV/AIDS and sleeping sickness. Mental
health services were also provided tocommunities living with the ongoing threatof displacement and violence.
The chronic insecurity severely affected the
population’s access to healthcare, preventing
aid organisations from reaching people andstopping many people from venturing out andvisiting the health facilities. As the second
half of 2007 progressed, the growing presenceof bandits and the lack of clear control inmany areas made it extremely difficult forinternational organisations to work in suchan environment.
MSF has worked in the Central African Republic
since 1997.

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Chad
Reason for Intervention • Armed conflict • Endemic/Epidemic disease• Social Violence/Healthcare exclusion
Field Staff 1,437

Goz Beïda, Adé, Kerfi, Koukou, Arkoum, Am
Timam, Am Dam and Dogdoré. In December,
MSF had to suspend programme activities inKoukou after several serious security incidents.

In recent years, eastern Chad has experienced a humanitarian crisis affecting
the entire population, including residents, refugees and internally displaced
people. Over 240,000 refugees from Darfur depend entirely on internationalaid, and the number of internally displaced people sharply increased in 2007,
affecting in turn the host population of the sites where they gathered.

MSF continued to provide complete healthcare
to the resident population in Adré, Guereda,
Birak, Djiré and Wilikouré, ranging fromsurgery to prenatal care and vaccination
campaigns.

Violence increasingly affecting the
Chadian population

After a period of calm and a ceasefire agreement between the government and four rebel
groups in October, fighting broke out again
in late November, with an intensificationof the clashes in the last weeks of the year.
Anticipating an influx of wounded, MSF
improved the surgical infrastructure in the

In eastern Chad, increasing violence has led tomassive population displacement, with over
180,000 internally displaced Chadians living incamps by the end of the year. These people livein critical conditions resulting in emergency

sanitary and health crises, with high malnutrition rates and outbreaks of bloody diarrhoea
in the first half of the year. Despite difficult
security conditions, MSF managed to scale up
its assistance to internally displaced people,
providing primary and secondary healthcare,drinking water, food and relief items around

Over 180,000 internallydisplaced Chadians areliving in camps.
hospital of Abéché and prepared stocks ofemergency supplies.

Assisting refugees
Since 2003, more than 240,000 refugees from
Darfur have been living in camps in eastern
Chad, entirely dependent on international aid.
MSF continued to provide medical care,including paediatric and maternal care aswell as psychosocial support, to some 90,000
people living in Iridimi, Touloum, Farchanaand Bredjing refugee camps and to the sur-rounding Chadian population. The teams also
treated the consequences of sexual violence
and malnutrition, provided health educationand treated communicable diseases. In Adréand Iriba hospitals, MSF surgical teams
provided emergency surgery to refugees,
residents and displaced Chadians.
Since June 2005, increased violence inneighbouring Central African Republic has
prompted tens of thousands of villagers to flee,with some 50,000 seeking refuge in southern
Chad. MSF provided assistance including
water, sanitation and healthcare in the camps
around Goré until April 2007. MSF continues
to work in Goré district hospital, supporting
all wards to provide secondary medical careand surgery to refugees and local residents.

Decentralised care for malaria
Since 2003, MSF has been developing a
programme to treat malaria in the southern
district of Bongor, one of the most affected by
the disease. To overcome the lack of healthworkers, the high resistance to the treatment
and the difficult access to the area over long
periods, MSF introduced a therapeutic strategy
using Artemisinin-based combination therapy
and introduced decentralised care by empowering the local population to care for thoseaffected. In 2007, 110,000 people were treatedthrough this programme.
MSF has worked in Chad since 1981.

Democratic Republic of Congo
Reason for Intervention • Armed conflict • Endemic/Epidemic disease• Social Violence/Healthcare exclusion • Natural disaster
Field Staff 2,386

sexual violence every month. In 2007 MSF
carried out more than 25,000 consultations in
the hospital.

Malnutrition, epidemics and surgical emergencies continue in DRC.
Insecurity persists in many regions, particularly in North and South Kivu,
where the population is subject to violent attacks and causing continual
displacement. Many areas are totally isolated and deprived of any functioning
health infrastructures, illustrated by catastrophic health indicators.

Since 2003, Angolan authorities have on
various occasions expelled Congolese migrants
working in the Angolan province of Lunda
Norte. According to UN estimates at least
44,000 people were deported to DRC in 2007. In
October MSF teams set up a health centre in
Kamako, Western Kasai province, close to theAngolan border. Between November 2007 andJanuary 2008, the centre provided medical andpsychological care to Congolese migrants,
many of whom were women who had been
subjected to sexual abuse by Angolan forces.
MSF treated about 200 victims of sexual violence and offered primary health care to morethan 900 women and children in the Kamako
centre and through mobile clinics. The teams
also collected one 100 testimonies exposing
collective rape and physical abuse perpetrated
by the Angolan military.

Assisting victims of violence
Intense fighting between different armed
groups in the Kivu region has caused thousands of people to flee their homes sinceAugust. Some sought safety in camps fordisplaced people in the regional capital,
Goma. MSF strengthened existing projects andopened new projects to try and meet the hugeneeds but in many places the fighting andinsecurity forced the evacuation of staff andthe temporary suspension of work.
In North Kivu, MSF opened a new project in
Masisi, about 80 kilometres west of Goma, atthe end of August. In response to ongoingviolence and displacement, a team started
working in the hospital and a health centre in
Masisi town, focusing on emergency surgery
and nutritional care. The hospital’s capacity
was increased from 72 to 170 beds. In October,admissions to Rutshuru hospital, where MSF
has worked since 2005, increased by 50 per
cent. The MSF team added tents to increase
inpatient capacity, employed more staff andreinforced the pharmacy with additional
supplies. In October, 330 surgical operations
were performed, compared to a monthly
average of 220 since January.
Repeated displacement, lack of transport andongoing insecurity mean that mobile clinics
are an essential part of MSF’s work. Whensecurity permits, mobile teams visit numerous
sites in Masisi and Rutshuru districts. In
December, MSF carried out 3,299 consultations
in Kitchanga, Kilolirwe, and Mweso healthzones.
Responding to the needs of victims of sexual
violence has long been a key component of
MSF’s work. Between January and September,
MSF staff treated around 3,000 victims ofsexual violence in North and South Kivu. Yet it
is not only in active conflict zones where thismedical care is so urgently needed. In Bunia,
where MSF supports the Bon Marché hospital,
teams continue to see around 150 victims of

In Ituri, MSF responded to a Shigellaemergency in Pimbo in May and to a cholera
epidemic in Laudjo in June. A new project forsleeping sickness was opened in May in thehealth zone of Doruma, where this neglecteddisease is endemic. Within three months, MSF
had screened about 10,000 people and treatedmore than 450 patients.
In August, the influx of an additional 45,000
displaced people to crowded camps withlimited sanitation just outside Goma led to acholera epidemic. In September, MSF opened acholera treatment centre (CTC) in a central
location between four of the largest camps.
Teams also supported a smaller CTC in Goma
hospital, and CTCs in four health clinics: twoin Goma itself and two in the neighbouring
towns of Saké and Kiroche. By the end of
November, over 1,500 people had been treated,with only six deaths reported. In the last twomonths of 2007, MSF responded to anotheroutbreak of cholera in Rutshuru district,treating 1,600 people.

Responding to disease outbreaks
The retreat of humanitarian agencies has leftlarge areas of the country abandoned. Many
areas are isolated and the capacity of the new
government is often extremely limited. Whatfew health structures exist either do not
function fully or are not accessible to themajority of the population living below thepoverty line.

On 10 September, an outbreak of the deadly
haemorrhagic fever Ebola was declared in
Kampungu, Western Kasai province. Withindays, an emergency team had arrived and was
isolating and supporting infected people. Overtwo months, MSF teams admitted 46 peoplesuspected of having the disease. Medical staff
tried to trace anyone who had been in contact© Vanessa Vick

Repeated displacement, lack of transport andongoing insecurity mean that mobile clinics arean essential part of MSF’s work.
with the Ebola patients as well as searchingfor active cases.

Ongoing projects
As well as reinforcing and expanding medical
activities in the Kivu region, long-running
projects continue to provide HIV/AIDS carein Kinshasa and South Kivu, primary andsecondary healthcare in Katanga and Maniema

provinces and treatment for sexually trans­mitted infections in Kisangani. In some areasof Katanga, South Kivu and Dungu in Oriental
province, the situation has stabilised to suchan extent that MSF has been able to hand overactivities to the Ministry of Health and otherpartner organisations.
MSF has worked in DRC since 1987.

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ETHIOPIA
Reason for Intervention • Armed conflict • Endemic/Epidemic disease• Social Violence/Healthcare exclusion • Natural disaster
Field Staff 729

Conflict escalated in the Somali region of Ethiopia in 2007. As the violence
intensified, MSF exploratory missions in the five conflict-affected zones ofSomali region revealed an alarming humanitarian crisis in which civilians were
subject to violence and displacement, their livelihoods threatened and access tohealthcare severely limited. However, MSF was repeatedly blocked from accessing these areas following a team evacuation resulting from a security incident
in July. In September, MSF spoke out about the humanitarian situation and thegovernment’s refusal to allow staff to return to the region. By the end of theyear, MSF had still not gained adequate and independent access.

HIV prevalence of between 15 and 20 per
cent, MSF started providing anti-retroviraltreatment in Abdurafi health centre in April.
During the course of the year, around 120
patients were started on treatment. MSF staff
also travel by tractor to 12 sites in the region
to run mobile clinics.
MSF implemented a primary healthcare
project in Libo Kemkem, Amhara region,
providing quality treatment to some 364 kalaazar patients, treating patients with malaria
and TB in health facilities and supporting atherapeutic feeding centre for people sufferingfrom malnutrition.

GUINEA

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Reason for Intervention • Armed
conflict • Endemic/Epidemic disease
Field Staff 272

Rising commodity prices, falling living
standards and pervasive corruption in
Guinea triggered strikes and social
unrest at the beginning of 2007,
leaving an estimated 180 people deadand more than 1,000 injured. MSF
provided care to the wounded during
the violent turmoil and continued totreat HIV/AIDS patients in its projects
while also responding to cholera
outbreaks during the rainy season.

Emergency response© Jean-Pierre Amigo

Almost 500 people infected with kala azar were
cured in Humera hospital.
Delivering essential healthcare
Despite the disruptions, MSF’s Ethiopian staff
in Cherrati continued working with the
Ministry of Health to provide primary healthcare and tuberculosis (TB) care in Cherrati’s
health centre. Construction of a special ‘TB
village’ was completed during the year, providing a number of huts where patients can stayduring their eight-month treatment. As well as
medical care, patients receive food from MSF,
which appears to increase the likelihood ofthem completing treatment. A total of 430
patients were treated in the TB village.
When MSF was able to return to Somali regionin December, teams started supporting a
Ministry of Health centre and mobile clinics in
Fiiq zone. By the end of the year, MSF teams
were seeing up to 50 patients a day, mainly for

respiratory and urinary tract infections anddiarrhoea. Support to a Ministry of Healthcentre in Wardher resumed at the end of theyear. MSF also conducted an assessment in
Degahbur and will start activities in 2008.
Assistance to vulnerable populations in
Gambella region was not affected by the
conflict in Somali region. Working in a healthcentre in Itang and mobile clinics in five areas,
MSF staff provided integrated HIV and TB care,
inpatient care and primary healthcare.
Support to a health centre in Abdurafi,
Amhara region, continued throughout theyear, focusing on treating and caring forpeople suffering from kala azar, otherwise
known as visceral Leishmaniasis. Almost 400
people were cured. Given the high number of
migrant workers in the area and an estimatedThroughout 2007, MSF teams have responded
to emergencies in Ethiopia. In June, an emergency programme was set up at resettlementsites in Awi zone and in Quara district,Amhara region, to deal with an outbreak ofmeasles and prepare for the malaria season.
Almost 6,000 children were vaccinated against
measles in Awi zone and 5,000 in Quara
district. MSF also provided nutritional screening and support in affected areas throughmobile clinics. After the summer, MSF responded to a major cholera outbreak in Tigray
and Amhara region, treating over 1,700 people.
In October, teams in Gambella region distri­buted non-food items, such as jerry cans or
cooking sets, to around 41,000 people affectedby floods. In mid-November, MSF reacted toa nutritional crisis in Afar region by
establishing a therapeutic feeding centre andorganising mobile teams to visit the worst
affected areas. During the intervention, 116
severely malnourished children received care.
MSF staff continue to treat people infectedwith kala azar in Humera hospital and support
10 outreach sites around the region whererapid testing is undertaken. Almost 500 people
infected with kala azar were cured.

Closing and handing overIn other parts of the country, MSF was able tohand over its projects to the Ministry of Health.
In January, a primary healthcare project inFogera was handed over to the national healthauthorities. As the national TB programme wasbeing implemented in Galaha, Afar region, MSF
closed its TB project in this area in February. In
May, MSF transferred the HIV/AIDS componentof its programme in Humera, Tigray region, tothe Ministry of Health.
MSF has worked in Ethiopia since 1984.

Caring for the wounded
Violence unfolded in the capital, Conakry, andin cities like Guéckédou at the Liberian borderin February as a consequence of the country’s
worsening economic and political crisis. MSF
provided emergency medical assistance toConakry’s Matam health centre and to
Guéckédou hospital, transferring the mostserious cases to Donka hospital in Conakry.
MSF treated more than 150 injured people
during this two-month emergency operation.
With material and technical support from
MSF, Donka hospital also cared for a further
800 wounded people.

Treating TB, malaria and HIV/AIDS
Economic stagnation combined with theshortcomings of the cost-recovery healthcare
system has impeded the population’s access tohealthcare. MSF continued to address HIV/
AIDS, malaria and tuberculosis (TB). Around32,000 outpatient consultations wereconducted for patients with HIV and TB, with
about 700 diagnosed with TB and treated inConakry and Guéckédou, including many whowere co-infected with HIV/AIDS.
Existing actors and their capacities have been
insufficient to meet the needs of HIV-infectedpatients. MSF has, therefore, run two HIV/AIDS
programmes in Guéckédou and Conakry since2003 and offered anti-retroviral treatment(ART) since 2004. In 2007, MSF scaled up its
activities and initiated the decentralisation ofcare for HIV/AIDS patients from Matam centre
to several other health centres in order tobring free healthcare closer to the patients.
MSF followed the treatment of 3,900 people
with HIV/AIDS and provided ART to some 2,400
patients, more than 50 per cent of all patients
under ART in Guinea.

MSF has supported
care for people affectedwith malaria in Dabolaprovince.

© Claude Mahoudeau

Since 2005, MSF has supported care for people
affected with malaria in Dabola province andlobbied for the use of Artemisinin-based combination therapy (ACT), a more efficient
treatment to fight the disease. MSF has provided ACT and diagnostics tests to outpatient
services and nine health centres in the region.
Although the government agreed in 2005 to
modify the national malaria treatment protocol to include the use of ACT, this life-saving
treatment was still not available to a majority
of Guineans by the end of 2007, mainly due tothe cost. This may, however, be resolved in thenear future as The Global Fund finally decidedin October to grant funds to Guinea for ACT.
MSF is planning to leave Dabola in 2008; in themeantime, MSF will document the use of®Arthemeter to treat severe cases of malaria.

Responding to cholera outbreaks
Cholera is endemic in Guinea, where poor
hygiene and sanitation provide a breading
ground for epidemics. The cholera epidemic
was particularly extreme, especially inConakry, which accounted for half of all cases.
More than 8,000 cases and about 300 deaths
were registered. By November, MSF had opened
two additional cholera centres in the areas ofRatoma and Matoto, in Conakry. MSF treatedabout 4,000 patients during this operation.

Project handovers
In August, MSF ended its project in the regionof N’Zérékoré (in Guinée forestière), after theofficial closure of the Lainé refugee campfollowing the departure of most refugees. MSF
had provided assistance in the camp for five
years to people fleeing Liberia and Ivory Coast,
offering basic, inpatient, outpatient andmaternal care as well as treatment for womenwith HIV/AIDS and victims of violence. On
departure, MSF gave the hospitals of Lola and
N’Zérékoré a one-year supply of anti-retroviraldrugs for HIV positive patients who had
started their treatment with MSF.
MSF has worked in Guinea since 1984.

37

IVORY COAST
Reason for Intervention • Armed
conflict
Field Staff 1,098

2007 was a turning point for Ivory
Coast. After four years of civil war andpolitical deadlock, a peace agreement
was signed in March, leading to a process of reunification between the government-controlled south and thenorth of the country, previously heldby rebel forces. After a national union
government was formed, the ‘Zone deConfiance’, a buffer zone separating
the warring parties, was dismantled in
April. Previously monitored by United
Nations peacekeepers and French
military forces, the zone is now secured by ‘Brigades Mixtes’, a police
force integrating both sides.
Administrative and health civil servants have now redeployed to the northand west, enabling MSF to hand oversome projects to the authorities.

© Thierry Dricot

MSF also runs a primary health centre and mobile
clinics, providing basic healthcare and treatment
for malnutrition in the district.
Improving access to healthcare informer rebel areas
Despite political change, access to healthservices continues to be limited for mostpeople in Ivory Coast who cannot afford
healthcare under the current cost-recovery

KENYA
Reason for Intervention • Armed
conflict • Endemic/Epidemic disease• Social Violence/Healthcare exclusion• Natural disaster
Field Staff 463

Escalating violence has left many
people unable to access healthcare in
the Mount Elgon region. MSF has
responded by using mobile clinics toreach those in need. Throughout thecountry HIV/AIDS and TB infection
rates continued to rise. MSF is treating
many co-infected patients using newtechnologies and facilities. Meanwhile
MSF continues to campaign for accessto drugs to treat the neglected disease,kala azar.
Responding to ongoing displacement
Since August 2006, ongoing violence anddisputes over land in the Mount Elgon area ofwestern Kenya have caused thousands ofpeople to flee their homes and seek refuge inlarger towns, higher parts of Mount Elgon, theforest or nearby villages. These people areoften trapped between fighting groups andreceive little assistance. In April, MSF began

system. While continuing to support people
living in former rebel-held areas, MSF hascalled for a reorientation of the government’s
health policy and free healthcare.
Insecurity remained high until April in the
district of Bangolo, in the former Zone dedelivering humanitarian medical assistanceto this population in the Mount Elgon district.
MSF is mainly dealing with the healthconsequences of violence against civilians andrepeated short-term displacement. Through asystem of mobile clinics and support to primary
healthcare structures in the area, MSF teams
provide access to free quality medical care.
In Molo district, fighting, violence and intimidation displaced around 17,000 people byDecember. Many were living in small camps
scattered around the district, so MSF started
mobile clinics to assess needs and provide
medical consultations and water sanitation
services at different sites every week.

Kenyans. MSF’s first HIV/AIDS project opened in
1996. By the end of 2007, MSF was caring forover 17,000 people living with HIV/AIDS andproviding anti-retroviral treatment (ART) to
10,500.

Tackling tuberculosis
Treating HIV/AIDS without also addressing
tuberculosis (TB) is ineffective. TB is theleading killer of people living with HIV/AIDS.
Globally, around 11 million people are thought
to be ‘co-infected’ and half of all deaths of
HIV-positive people are due to TB. Throughout
2007, MSF expanded its efforts to treat people
infected with TB in Kenya. By the end of theyear, 1,445 people had been started on treatment in various projects around the country.

Ongoing HIV/AIDS care
Despite some positive progress in recent years,
HIV/AIDS continues to have a devastating
impact on every sector of Kenyan society.
While around 5.9 per cent of adults arethought to be infected, this can be as high as
35 per cent in some rural areas where MSF
works, such as Homa Bay. Working in two of
Nairobi’s slums, Kibera and Mathare, and two
locations in the west of the country, Busia andHoma Bay, MSF provides comprehensive HIV/AIDS treatment and care to thousands ofDiagnosing TB in patients who are HIV positive
can be challenging as the sputum samples
produced often do not show the presence of TB
when analysed in standard laboratory tests.
After months of building and preparation
work, MSF opened a TB culture laboratory in
Homa Bay hospital in November. One of only
five in the country, this laboratory will enablemuch more effective and accurate diagnosis of
TB, particularly in patients who are co-infectedwith HIV.

Confiance, where MSF treated several people
with gunshot wounds. This led MSF todenounce publicly the repeated attacks,robberies, assassinations and rapes
perpetrated against civilians living in the area
and to release a collection of testimonies. In
June, MSF upgraded the Bangolo health centre
to the level of district hospital. Here, MSF
offers free quality secondary healthcare,including inpatient and emergency services,in the absence of adequate national healthsupport. MSF also runs a primary healthcentre and mobile clinics, providing basic
healthcare and treatment for malnutritionin the district. About 85,000 outpatient
consultations were conducted during the year.
MSF continued to manage services at Danané
hospital in the west of the country at the
Liberian border. These included providing
secondary healthcare in inpatient services,integrated care for tuberculosis and HIV/AIDS,
treatment for malnutrition and paediatric andobstetric care.

Until October, MSF supported a local hospitalin Bin Houyé as well as the district hospital in
Zouan Hounien, in the south of the Zone deConfiance. These projects have now been
handed over to district health authorities.
MSF also managed mobile clinics and a mobile
nutrition programme in Danané and Zouan
Hounien districts. By the end of 2007, threemobile clinics and 13 ambulatory nutrition
sites remained. MSF will continue to monitor
malnutrition in the district until the planned
withdrawal from Danané in 2008.

health capacities, MSF handed over its projectto the Ministry of Health in April 2007. In thefirst four months of 2007, 1,243 patients were
hospitalised and 6,360 con­sultations conducted.
In June, MSF closed its project in the referral
hospital of Man in the west, where it hadprovided free primary and secondary healthcare since 2003, including anti-retroviraltreatment for HIV/AIDS patients and surgery
for the wounded and women with obstetricfistulas. Between January and June, MSF carried out more than 1,200 surgical interventions
and 28,000 outpatient con­sultations.

Project handovers
As public health structures started to function
again, the Minister of Health expressed awillingness to take over healthcare. Where
possible, MSF began to transfer projects to theauthorities. This process will continue in 2008.
During an emergency in 2002, MSF hadlaunched a project offering free healthcare in
the hospital of Bouaké, a major city in the
country. Following improvements in regional

In September, MSF ended its activities in
Guiglo in the west where it offered medicalcare in a primary health centre and treatedseverely acute malnourished children under
the age of five. Until September, about 26,800
outpatients consultations were carried out
and 611 children under five were included in
the nutritional programme.
MSF has worked in Ivory Coast since 1990.

Growing resistance to first-line TB treatment isanother challenge and MSF has been treating
people with multi-drug resistant MDR-TB since
May 2006. In addition social issues, including
housing and food availability, are assessed
because these are often the main reasons why
people fail to complete treatment. MSF remains the only provider of free treatment for
MDR-TB in Kenya.

Treating neglected diseases
MSF works in West Pokot district, Rift Valley
Region, treating people infected with kalaazar, otherwise known as visceral
Leishmaniasis. This disease, spread by the
sandfly, is fatal if left untreated and affects
around two million people globally every year.
In 2007, MSF teams screened over 1,678 people
for the disease and successfully treated 850.
Until mid-2006, the only drug available in
Kenya to treat kala azar was a patented drug
called Pentostan. MSF has lobbied the Kenyan
Government for the use of a cheaper genericdrug called Sodium Stibogluconate (SSG). In
2007, SSG was registered in Kenya, althoughmanufacturing problems indicate that it will
not be available for supply any time soon. MSF© Brendan Bannon

MSF is dealing with the health conse­quences ofviolence against civilians and repeated short-term
displacement.
continues to advocate for the inclusion of SSG
into the Kenyan Ministry of Health guidelines
for treating kala azar. Whereas Pentostan costs
150 USD per treatment course, SSG costs 30
USD, so it will be much more easily absorbed
into the Kenyan health system. As kala azar
can be difficult to diagnose, MSF is also
advocating for the use of a rapid diagnostic

test that is ideal for resource-poor settings andis encouraging the use of these tests in healthcentres around the district.
MSF has worked in Kenya since 1987.

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LESOTHO

LIBERIA

Reason for Intervention• Endemic/Epidemic disease
Field Staff 24

Reason for Intervention • Armed
conflict • Endemic/Epidemic disease• Social Violence/Healthcare exclusion
Field Staff 1,023

MSF services apop­ulation of 220,000
including an estimated
35,000 people livingwith HIV/AIDS.

© Alessandra Vilas Boas

Lesotho, also known as the Mountain Kingdom, is a small landlocked country
surrounded by South Africa. Of its 1.8 million inhabitants, an estimated 23,000,
more than 1% of the entire population, die each year of HIV-related causes. By
far the leading cause of death among HIV-positive people is tuberculosis (TB).
More than 90 per cent of TB patients in areas where MSF works are also infectedwith HIV.
Over two years, more than 2,200 people havestarted anti-retroviral treatment (ART) in
MSF-supported structures. The programme isbased at Scott hospital in Morija, 40 kilometres south of the capital, Maseru, and supports
14 primary care clinics in remote rural areas.
The health facilities supported by MSF serve a
population of 220,000, including an estimated
35,000 people living with HIV/AIDS.
In addition to providing ART, MSF works withhospital management and staff to give comprehensive care, including HIV counselling andtesting, prevention of mother-to-child transmission, early diagnosis of HIV in infants andmanagement of opportunistic infections andco-infections, particularly TB.
By the end of 2007, over 21,000 people had
been tested for HIV (34 per cent HIV-positive),
vertical transmission from mother to child
was reduced to six per cent when both themother and the baby received an intervention
and for whom an early test (DNA-PCR) result

for the baby was available. TB and HIV services
were integrated so that HIV-positive patientsare systematically screened for TB and TB
patients are routinely offered an HIV test.
Co-infected patients can therefore benefit froma ‘one-stop service’. Efforts were also made to
improve diagnosis of TB, including smearnegative and drug-resistant TB.
The programme achieved these results withina short timeframe by training more nurses;
ensuring weekly visits to each clinic by MSF
mobile medical teams; recruiting and training‘HIV/TB lay counsellors’ (mostly members of
the community living with HIV/AIDS enrolledon the programme) to take on multiple tasks,
including adherence support; strengthening
laboratory and pharmacy capacity at the
district hospital; and promoting treatment
literacy, openness about HIV and community
involvement in service delivery.

Lesotho and hopes for long-term continuity ofservices all the more daunting. There are fewer
than 100 doctors in the entire country, mostfrom other African countries, who are working
in Lesotho while awaiting their certification towork in South Africa, where they can gethigher-paying jobs, so their stay in Lesotho isusually only temporary. Additionally, in June,at a time when the HIV-related workload wasincreasing sharply, over half the professional
nursing posts in the 14 clinics supported by
MSF and 30 per cent of professional nursing
posts at the district hospital were vacant.
In May, the team in Lesotho, together withother projects in the Southern African region
made the decision to launch a report on thehealthcare worker crisis. This was reinforcedby advocacy at national and international
levels for measures to improve retention andrecruitment of professional health staff andensure ‘task-shifting’ of certain clinical tasks
from doctors to nurses and non-clinical tasks
from nurses to lay health workers. Without
fundamental change, the prospects for expanding access to ART and improving qualityof care in the long-term are bleak.
MSF has worked in Lesotho since 2006.

An acute shortage of healthcare workers
threatens further scale-up of activities in

Improving the health of mothers
and children is the main focus of
MSF’s work in Liberia. Although thesituation has improved in recent years,
many Liberians still live in crushingpoverty. Women and children remain
particularly vulnerable and in need of
specialised health services.

importance of seeking treatment within 72
hours of an attack is increasing, particularly
among police and community organisations,and more patients now seek care earlier.
However, despite positive changes to tackle theissue, MSF is still one of the very few organisations providing medical care to survivors of
sexual violence in Monrovia.

Reducing activities
As Liberia moves towards stability and reconstruction, humanitarian organisations in­cluding MSF, which work mainly in emergency
situations, are beginning to leave the country.
MSF gradually stopped working in some of thehealth facilities in Nimba county and withdrew from Lofa county. Most were handed overto the Liberian health authorities or to othernon-governmental organisations. MSF has also
closed the medical facility at Mamba Point.
Prior to an international donor conference inWashington D.C. in February , MSF released areport stressing the need to find alternatives tohumanitarian assistance and to build capacity
in the Liberian health services to address thecountry’s healthcare needs. The paper was used
to brief major donors and States.
MSF has worked in Liberia since 1990.

Protecting mothers and their children
Each month, more than 1,300 children aretreated at Island and Benson hospitals in thecapital, Monrovia. Benson hospital also
provides maternity care and obstetric surgery,as well as running a women’s health centre.
Two MSF-supported primary health clinics also
handle 13,000 consultations a month. The
majority of the patients are pregnant women,
new mothers and children. To prevent expectant mothers with HIV transmitting the virus totheir child, pregnant women attending MSF
clinics are offered free HIV testing and thosetesting positive are enrolled in treatment.
In April, MSF began offering HIV testing at
Island hospital for children showing symptoms
associated with the virus. Fifty-four children
who have tested positive are receiving antiretroviral treatment (ART). A new outpatient
section has been added to the hospital for HIV
and tuberculosis patients who get treatment
and medication but are able to live at home.
In Saclapea in Nimba County, MSF has built acomprehensive 42-bed health centre, replacing
the original tent structure with permanentbuildings. The hospital provides outpatient andinpatient services and has a clinic dedicated to
women’s health. The centre was completed inlate 2007. MSF also offers ART for HIV patientsat the health centre.

Providing recovery from, and raisingawareness of, sexual violence
Since 2003, MSF has provided medical care forsurvivors of sexual violence in Monrovia andcarried out activities to raise awareness of thisserious problem. Each month, MSF teams in
Monrovia treat approximately 140 survivors of
sexual violence, more than a third of whom
are under 12 years old. Awareness of the© Sofie Stevens

Pregnant women attending MSF clinics areoffered free HIV testing and those testing
positive are enrolled in treatment.

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MALAWI
Reason for Intervention • Endemic/
Epidemic disease
Field Staff 652

HIV/AIDS is one of the most acutehealth concerns in Malawi. In thiscountry of 13 million people, about
one million are infected and 86,000
die each year. Despite intensive efforts
by the authorities and international
bodies, more than 170,000 people
living with HIV in Malawi are stillin urgent need of anti-retroviraltreatment (ART).
MSF is supporting the implementation of anational HIV/AIDS plan. MSF is also closely
involved in increasing the number andcapacity of health centres to provide life-longcare for HIV patients in the southern rural
districts of Thyolo and Chiradzulu and in thefor nurses, who are now able to prescribe ART,a responsibility previously performed only byclinical officers, medical assistants and doctors. The decentralisation of HIV services
together with the task shifting and intense
training for care providers has allowed better
follow up through smaller, more local healthstructures and home visits. Now patients do
not have to travel long distances to hospitals
for routine consultations and medication.

Specially trained ‘expert patients’ andmembers of the community are now able toundertake testing and counselling as well as
providing support to help people continue
with their treatment. These tasks were traditionally undertaken by nurses but many became
overwhelmed by the increasing number of HIV
patients combined with a scarce workforce, so acomplementary approach was needed.
Nurses can now focus purely on medical
issues. MSF is providing HIV-related training

MOROCCO
Reason for Intervention • Social
Violence/Healthcare exclusion
Field Staff 13

Reason for Intervention• Endemic/Epidemic disease
Field Staff 54

Recent and increased barriers
preventing the transit of migrants to
Spain means Morocco has become adestination country. Longer-thanintended stays in the country haveresulted in the recent urbanisation of
migrant populations, notably in Rabat
and Casablanca. Although living
conditions are less precarious than inrural areas, the population faces ahigher cost of living with reducedmeans of subsistence and limited accessto healthcare. Migrants are exposed toincreased exploitation and violence.
Prostitution is common and infectious
diseases such as tuberculosis (TB) andHIV/AIDS are emerging.

This decentralised approach has allowed MSF
teams in Chiradzulu, Thyolo and Dowa to start
more than 27,000 people on treatment.
MSF also strongly focuses on detecting andtreating tuberculosis (TB) and malnutrition in
HIV patients. Both conditions jeopardise theefficiency of HIV treatment. Over 1,700 people,
many of whom were HIV positive, wereadmitted for TB treatment.

By December, approximately 19,000 people
were still on treatment in MSF-supported
structures across Malawi and more than 700
people were starting treatment in an MSF
structure every month.
central district of Dowa. In order to cope withan acute lack of doctors and other healthprofessionals, the strategy has been to shiftsome functions to more junior staff such as
health surveillance assistants. MSF has been
focusing on increasing the skills of existing
staff and lay people, including ‘expert patients’, to provide essential services.

MALI

These mobile ‘malaria
teams’ mean children
in isolated villages can
now receive free treatment during the rainyseason.
© Bruno De Cock

After more than seven years of working inDowa district hospital in central Malawi, MSF
has handed over its HIV/AIDS project to the
Ministry of Health. This project started in2000 with a strong focus on the prevention
and treatment of sexually transmitted infections. In December 2004, the first patients
started on ART. By the end of the project in
October 2007, more than 1,100 HIV patientswere undergoing treatment in Eastern Dowa
and more than 270 in Mponela. It is estimatedthat over 3,300 patients have enrolled in the
programme over the last three years.

Malaria is endemic in Mali, where itis the main cause of mortality forchildren under five. Access to healthcare is limited in this country, where
72 per cent of the population still live
below the poverty line. The costrecovery system of care is a serious
impediment and attendance at healthcentres is extremely low. MSF is working to offer quality care for malaria,
especially to the most vulnerable andthose excluded from the healthcare
system during the rainy season.

By December, approximately 19,000 people
were still on treatment in MSF-supported
structures across Malawi and more than 700
people were starting treatment in an MSF
structure every month.

Back in 2005, a medical investigation
conducted by MSF in southern Mali produced
alarming results. Significant mortality rates
were found, together with poor access to careand high levels of resistance to the chloroquine-based treatments. In collaboration withnational health authorities, MSF launched a
project in Kangaba to help people with

MSF has worked in Malawi since 1986.

Migratory routes have also shifted, with many
people now originating from southern countries
such as Mauritania, Senegal and, to a lesser
extent, regions of the Sahara. Many arrive only
to realise that there is little hope of crossing toSpain so unexpectedly stay in Morocco.

malaria by offering quality diagnostics andcare using Artemisinin-based combination
therapy (ACT), reducing the cost of treatment
and addressing the geographical barrier tocare.
MSF offers free treatment to all children under
five, and free consultations and treatment for
febrile diseases to pregnant women in sevenhealth centres in Kangaba. A flat rate policy of
only 200 FCFA (50 cents) is also implemented
instead of the cost-recovery system to enable
the rest of the population to access treatment
for malaria and other febrile diseases.
Since the implementation of this combined
system, the number of consultations has
increased four-fold. In 2007, each health centre
was seeing about 34 patients a day, compared
to an average of eight in 2005. Pregnant
women and children under five are the main
beneficiaries.

Distance between villages and health centres
has been identified as a main obstacle toaccess to care, particularly during the rainyseason when roads are impassable. MSF has
trained community groups and equipped themwith rapid screening tests and ACT, enablingthem to treat simple cases of malaria inchildren under the age of 10. These mobile‘malaria teams’ mean children in isolated
villages can now receive free treatment during
the rainy season.
The number of children with access to quality
healthcare at sites more than five kilometresfrom a health centre was five times higher in2007 than in 2006 during high transmission
periods. Malaria rates fell from eight per centin 2006 to 1.7 per cent in 2007 following theimplementation of this new model of care.
MSF has worked in Mali since 1992.

MSF continued to work on preventive andcurative healthcare for migrants. Healthcare
projects have followed the migrants from rural tourban areas, responding to their increasingneeds. A new project opened in October to address the medical and humanitarian needs of
migrants in Rabat and Casablanca. In Rabat, themajority of consultations centred on digestiveand respiratory infections exacerbated by precarious living conditions. MSF also treated migrants
for more serious and chronic diseases, including
TB and HIV/AIDS. In total, MSF conducted 2,584
medical consultations in 2007. MSF also worked toraise awareness of reproductive health issues.
A new phenomenon has been the increase inmental health problems due to the longer stayof migrants in the country and the resulting
loss of hope.
2007 saw some improvement in the access topublic healthcare for migrants in Tanger-Tétouan.
As a result, the MSF project in Tanger was scaled
down and closed by the end of the year. However
MSF will continue to assist migrants in Rabat andCasablanca, and in parallel will advocate for more
inclusive national healthcare provision.
MSF has worked in Morocco since 1997.

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MOZAMBIQUE
Reason for Intervention • Endemic/
Epidemic disease • Natural disaster
Field Staff 565

With more than 16 per cent of the
population infected, HIV is one of themain health concerns in Mozambique.
MSF runs various programmes tocombat the spread of the epidemic aswell as providing timely assistance toareas repeatedly affected by heavy
rains and floods.
Decentralised HIV/AIDS care
MSF has established long-term projects to
support the authorities’ response to the HIV/AIDS epidemic. The programmes are based in
the capital city of Maputo and the provinces ofTete in the north-west and Niassa in the north.
In December, about 14,300 patients werereceiving anti-retroviral treatment (ART)through MSF-supported facilities. Programmes

include health education, counselling, testingand prevention of mother-to-child HIV
transmission.
MSF continued to transfer care from hospitals
to health centres closer to communities. This
increases access to HIV care, including ART,and helps prevent hospital congestion and staff
being overwhelmed by the number of patients.
The current human resources crisis in thehealth sector due to emigration and theeffects of HIV on the workforce has been amajor challenge. MSF is providing intensive
training to local medical staff and continues
to simplify treatments for patients with HIV
and tuberculosis. MSF also lobbies the authorities to allow qualified paramedical staff, after
professional training, to prescribe antiretroviral drugs and to use ‘lay counsellors’ toreduce the workload of nurses. There is astrong belief that shifting tasks is the only way
to provide HIV/AIDS treatment on the scalerequired.

Seasonal floods and cyclone Favio
The year started with torrential rains flooding
the Zambezi valley and forcing some 250,000
people to leave their homes. Although heavy
rainfall is a seasonal phenomenon, thesefloods were the worst since 2001 and wereexacerbated by the arrival of cyclone Favio.
In February, MSF launched a two-month
emergency intervention to help people affected in Zambezia and Tete provinces. Morethan 50,000 people benefited. The main activities were distribution of clean and drinkablewater, construction of latrines and distribution of plastic sheeting for temporary shelters.
MSF also supported the Mozambican healthauthorities by providing medical care in
resettlement centres and helped implement a
surveillance system to detect malnutrition andpotential disease outbreaks such as measles,
diarrhoea and cholera.
MSF has worked in Mozambique since 1984.

With more than 16 percent of the population
infected, HIV is one of
the main health concerns
in Mozambique.
© Ana Rosa Reis

Prevention of Mother-to-Childtransmission of HIV
Prevention of mother-to-child transmission (PMTCT) of
HIV in developing countries is far from optimal. In 2007,
an estimated 420,000 children were newly infected with
HIV, with almost 90 per cent of them living in SubSaharan Africa. In contrast, in developing countries thenumber of new paediatric infections has dramaticallydeclined: in the United States, for example, only 250
infants are infected each year.
The vast majority of HIV-positive children are infected from their
HIV-positive mother either during pregnancy, in delivery, or
through breastfeeding. In the absence of any medical intervention,
the risk of such transmission is between 15 and 30 per cent if amother is not breastfeeding, and between 30 and 45 per cent if themother is breastfeeding on a long-term basis. PMTCT is, therefore, aunique opportunity to stop the transmission of this virus and avoid
a new generation being lost to HIV/AIDS.
Ironically, mother-to-child transmission is almost entirely
preventable. Developed countries have been successful in reducing
the risk of transmission to less than two per cent, by implementing
medical interventions that include: antiretroviral (ARV) treatment
to all HIV-positive women during pregnancy (irrespective of theirneed for ARV for their own health), and to the infant in the firstweeks of life; obstetrical interventions including elective caesareandelivery; and complete avoidance of breastfeeding. Such interventions cannot be simply replicated in developing countries, mainly
because it is often risky for the baby not to be breastfed, nor
acceptable for mothers not to breastfeed.
There lies the greatest difference between developed and developing countries regarding the risk of transmission. In developed
countries, formula feeding has totally replaced breastfeeding by
HIV-positive mothers. In developing countries however, formula
feeding is often not an option for cultural and financial reasons, butalso because the lack of access to safe water (needed to create theformula) increases the risk of infant death due to diarrhoeal andother infectious diseases. The only intervention recommended by
WHO and UNICEF so far to reduce HIV transmission through breastfeeding is that the mother exclusively breastfeeds her baby during
six months (i.e. giving breast milk only, at the exclusion of any
other liquid or food) and then weans the baby in a few days.
Indeed, trials have shown that HIV transmission is reduced in
exclusively breastfed infants, compared to those who received
mixed feeding during their first months of life.
MSF follows the above WHO guidelines, established in 2006. Thesehowever are difficult to implement on a large scale, because they
depend on the health status of the mother, but also because they

© Jean-Marc Giboux

In 2007, an estimated 420,000
children were newly infected with
HIV, with almost 90 per cent ofthem living in Sub-Saharan Africa.
rely on cultural changes about breastfeeding. This is particularly
true in settings where little support can be given to the motherbecause prenatal and delivery services are not well established or ofpoor quality. While theoretically, implementation of these guidelines could reduce the risk of transmission to between eight to ten
per cent, access to the full package of PMTCT interventions andtreatment is limited in many developing countries. In South Africa,
for instance, less than 11 per cent of women have access to services
offering PMTCT interventions.
Today some clinical trials provide convincing evidence to support a
regime of treating all HIV-positive mothers - even those who doneed ARV for their own health as yet - with triple anti-retroviraltherapy during pregnancy and delivery, as it is done in resourcerich settings, but also throughout the whole breastfeeding period.
This could help reduce transmission of HIV in contexts where
formula feeding is not possible.
Some questions, however, remain to be answered, and such a strategy still needs to be tested in routine programme conditions. MSF isplanning to start such field tests with the objective of showing that,even in programme conditions, it is feasible, simpler, safer, andmore effective than the currently recommended strategy. Results ofsuch pilot projects could hopefully lead to the improvement ofinternational recommendations.

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NIGER

NIGERIA
Reason for Intervention • Armed
conflict • Endemic/Epidemic disease
Field Staff 319

Reason for Intervention • Endemic/Epidemic disease• Social Violence/Healthcare exclusion
Field Staff 1,278

Improved treatment was provided topatients with trauma related injuries
in the Niger Delta. The handover of
HIV/AIDS treatment in Lagos was
possible, and MSF responded to ameningitis outbreak in Jigawa.

© Anthony Jacopucci

Acute child malnutrition is a serious medical issue that has not been adequately
addressed in Niger despite increased national and international attention since
the massive nutritional crisis of 2005. An annual ‘hunger gap’ exists between
April and September, when family food stocks run out and hundreds ofthousands of children have little access to food or the nutrients they need for
healthy development. Malnutrition reduces immunity, stunts growth, affects
brain development and can be fatal.
Child malnutrition is most severe in theregions of Diffa, Zinder and Maradi, where
low weight and stunted growth affect 41 percent of children living in poor households andjust over 32 per cent of those in wealthierhouseholds.
Following a nutritional survey in Dakoro
district, Maradi, MSF began a medical-nutritional programme in April, supporting sevenintegrated health centres to provide free carefor children aged five and younger. MSF also
supports the maternal health service, paediatric service, emergency obstetric surgery andmaternity activities of the Dakoro district
hospital. A total of 133,000 consultations were
undertaken during the year.

In June, with high numbers of children from
Aguie and Tessahoua arriving at existing
health centres, a five-month emergency intervention was launched in Aguie. MSF provided
support to the district hospital and ran the
nutritional rehabilitation centre during thehunger gap, eventually handing over activities
to Save the Children UK. In total, 1,102
children were admitted to the hospital,
925 for severe malnutrition.
In Tahoua district, MSF worked in two
hospitals and six health centres, providing
nutritional support and over 5,000 free monthly consultations for illnesses such as malaria,
diarrhoea, respiratory and skin infections.
Approximately 1,200 malnourished children
were treated every month.

In Zinder, almost a million packets of RUFs
were consumed and MSF treated 21,542
children. MSF is working in two intensive
nutrition centres in Magaria and Zinder andin 13 mobile centres.

Using RUFs to prevent acutemalnutrition
At the end of 2006, MSF research showed that
more than half of children under the age ofthree developed an episode of acute malnutrition in two districts in Maradi. MSF therefore
implemented a new approach aimed at preventing acute severe malnutrition and reducing thedeath toll linked to malnutrition. The new
approach involved distribution of supplemental
Ready-to-use foods (RUFs) to all children under
three at risk in the area. Such RUFs does not
replace regular meals but compensates for major
deficiencies in diet by providing a child’s daily
nutrient needs. MSF distributed supplemental
RUFs monthly to all 62,000 children aged fromsix months to three years in one district inMaradi during the seasonal hunger gap.
MSF has worked intermittently in Niger since 1985.

treatment of HIV/AIDS in Lagos state in 2007.
This national progress allowed MSF to begin
the handover of its HIV/AIDS project, which
provided ART to over 1,900 patients, to local
partners and authorities.

March and May in response to a meningitis
outbreak in Jigawa state, the most affectedareas being Gwaram and Dutse. MSF provided
support to health facilities, trained staff anddonated drugs and diagnostic tests. A total of
583 people were treated.

Meningitis outbreak in Jigawa
MSF provided case management between

MSF has worked in Nigeria since 1996.

In 2007, Nigeria was characterised by tensions
surrounding the April presidential election
and continuing strife in the Niger Delta, avolatile, densely populated area where various
armed and political groups continue to struggle
for power and control over natural resources.
MSF’s trauma centre was established in Teme
hospital in Port Harcourt in 2005 to provide
free emergency medical services and psychological care. The centre saw peaks of admissions in 2007, owing to several sporadic outbreaks of violence. In August, 70 casualties
were received in a two-week period, many
having sustained high velocity gunshot
wounds. During the year, 6,300 patients wereadmitted to the emergency room and 2,000
surgeries and 800 psychological consultations
were carried out. MSF also provides medical
and psychological care to victims of sexual
violence at the centre and is working to raiseawareness of this service.
The Teme centre underwent technical improvements in 2007 to advance the quality of care,including the introduction of internal fixation(an operation that mechanically unites theends of a fractured bone). This had a dramaticeffect on the quality of the management oforthopaedic injuries and the average length ofstay, which dropped from 23 to nine days andnearly tripled inpatient capacity.
Physiotherapy for orthopaedic cases was also
improved to reduce any loss of mobility.

Improved HIV/AIDS care in Lagos
When MSF started providing free anti-retroviral treatment (ART) and comprehensive carefor HIV/AIDS patients in 2003, there were noother agencies providing free ART in Nigeria.
In 2006, a President’s decree announced anational programme to offer free ART to all
HIV/AIDS patients in the country. As a result
20 centres started offering counselling and© Vanessa Vick

Improved treatment was provided to patientswith trauma related injuries in the Niger Delta.

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Republic of Congo(Congo-Brazzaville)

RwandaReason for Intervention • Endemic/
Epidemic disease
Field Staff 71

Reason for Intervention • Armed conflict • Endemic/Epidemic disease
Field Staff 190

At the end of 2007, MSF ended its
activities in Rwanda after 16 years in
the country. Over the years, MSF’s work
has included assistance to displaced
persons, war surgery, programmes forunaccompanied children and street
children, support to victims traumatised by the conflict, programmes toimprove access to healthcare,
responding to epidemics such as
malaria, cholera and tuberculosis,
and projects linked to maternal andreproductive health.

© Jiro Ose

MSF handed over the screening and treatment of
sleeping sickness patients to the Ministry of Health.
After more than a decade of war and unrest, the Republic of Congo has now
completed its fourth year of post-conflict negotiations. The formal cessation ofarmed hostilities has allowed the resumption of economic activities concentrated
principally in the oil town of Pointe Noire and the capital, Brazzaville. The
Ministry of Health has now taken responsibility for healthcare in the Pool region.
The situation is no longer considered an emergency and MSF has therefore started
handing over some activities.
However, medical needs are still numerous in
Mindouli and Kindamba, in the Pool region,
where malaria, respiratory infections,diarrhoea, HIV/AIDS and tuberculosis (TB) are
prevalent. The country remains prone tooutbreaks of infectious disease.
MSF provided integrated healthcare in thehospitals of Mindouli and Kindamba. Services
ranged from outpatient care, maternal careand treatment of infectious diseases such as TB
and HIV to voluntary-care treatment for HIV/
AIDS, psychosocial counselling and emergency
surgical care. Overall, MSF conducted over
78,000 consul­tations.
MSF handed over the screening and treatmentof sleeping sickness patients to the Ministry of
Health, though we will remain available toprovide assistance if required. MSF also
provided healthcare through its mobile clinics
to communities surrounding the towns of
Mindouli and Kindamba.

In 2000, Rwanda faced a growing HIV/AIDS
epidemic and a lack of available resources. MSF
joined the fight against HIV/AIDS, focusing
initially on prevention and awareness before
quickly including medical treatment.
In the health centres of Kinyinya andKimironko in Kigali, thousands of patients
have been cared for by MSF. At the time of final
handover to the health authorities in
December, more than 6,200 patients werereceiving medical care in these two healthcentres, with 2,700 benefiting from anti-retroviral treatment (ART). More than 10 per cent ofthese patients were children.
Caring for children with this life-long disease
brings particular challenges. MSF medical
teams, therefore, developed an innovative
approach focusing on the specific needs ofchildren living with HIV/AIDS in Rwanda. This
included discussion of HIV testing of children
in adult discussion groups, training specialised
staff in psychosocial care and disclosure of thechild’s status to the child and their caregiverusing adapted tools. A key part of MSF’s
approach was the creation of children-only
support groups, which not only give children avoice but also allow them to play an active rolein their treatment.
Rwanda has now begun a clear shift towards
long-term development plans. The number oforganisations in the country now covers theneeds of the population. The AIDS epidemic
appears contained due to the high level ofinvestment by local authorities and the support of many international actors. As a result,
MSF felt able to end its presence in the country
at the end of 2007.

Leaving Rwanda
After 16 years in Rwanda, MSF closed down its activities at the end of 2007, handing overto the health authorities its last remaining programme (see opposite). The handovermarks the culmination of an intervention that has spanned war, genocide, epidemics andreconstruction.
MSF first began work in Byumba and Ruhengeri districts in 1991, supporting those
displaced by the civil war. It was to prove to be the start of one of the most deadly andhorrifying periods in the region’s and the country’s history. Within a couple of years, MSF
teams were providing health and nutritional care not only to many suffering from theinternal unrest but also to refugees fleeing massacres in Burundi.
By 1994, MSF teams were witness to the brutal genocide unfolding in front of their eyes.
Efforts to help survivors were dangerous. Patients and members of the MSF medical team
were killed, and eventually, MSF had no choice but to evacuate.
However MSF medical teams managed to return after a few days, crossing the borderwith Uganda and Burundi. The scale of the suffering they found was such that the
number of staff increased quickly, offering urgent medical care at hospitals in Kigali and
Nyamata, and in Byumba and Gitare on the Ugandan border. A health centre was also
opened in Kigali.

The capacity of local systems and the involvementof other external actors have allowed MSF’s
gradual handover and withdrawal.

MSF has worked in Rwanda since 1991.
But providing direct care to the victims was not enough. Shocked by the international
community’s refusal not only to recognise the slaughter as genocide but also to intervene
to save lives, MSF went public. A high-profile witnessing campaign ran across Europe,
culminating in the handing over of a report on the genocide to the United Nations. This
collective lack of action remains one of the most shameful episodes of recent years.

Responding to cholera outbreakIn the months following the massacres, MSF gradually expanded its activities across thecountry, focusing particularly on displaced and unaccompanied children and supporting
health structures that were close to collapse. Massive medical assistance was also
provided to some two million refugees who had fled the killings and were now living in
precarious camps in Congo (formerly Zaire) but also Burundi and Tanzania.

In late January, an outbreak of cholera wasidentified in the city of Pointe Noire and a few
weeks later in Brazzaville. MSF supported theMinistry of Health by reinforcing an isolation
area for patients and providing medicines,
medical training and water and sanitationmaterials and expertise.

The need for MSF to bear witness impartially was unabated. Staff denounced inti­m idation
and atrocities both in a camp and in Gitarama prison, leading to the expulsion of some
MSF teams and the withdrawal of others. Essential work continued elsewhere in Rwanda
and, particularly that along the borders, was to prove essential in 1996 when fighting inCongo sparked a massive return of hundreds of thousands of Rwandan refugees to thecountry.

Project handover
In June, MSF announced that it would handover its activities and leave the country by
mid-2008. To ensure continuity of its medical
services, MSF will strive to identify otherpartners, including local non-governmentalorganisations and the United Nations, tosupport the Ministry of Health in the Pool
region. MSF will also support the Ministry of
Health to address small pockets of highincidence of sleeping sickness identified
during the final project evaluation of 2008.

As the 1990s drew to a close, the situation in Rwanda gradually moved from emergency
intervention to reconstruction and development. MSF teams continued their work, addressing the new challenges of rebuilding the healthcare infrastructure, providing mental healthsupport to traumatised survivors, helping the country cope with the surge of HIV/AIDS
cases, working to improve maternal and reproductive health and responding to epidemics
and other emergencies. Over the years, the capacity of local systems and the involvement ofother external actors have allowed MSF’s gradual handover and withdrawal.
© Julie Rémy

MSF has worked in the Republic of Congo since 1997.

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Sierra Leone

Malaria is the main killer of children
under the age of five in Sierra Leone.
In Bo and Pujehun districts insouthern Sierra Leone, where MSF is
working, malaria is the most common
disease. During 2007, staff in the
MSF-supported health centres treatedmore than 100,000 cases of malaria.

Reason for Intervention • Endemic/Epidemic disease
Field Staff 492

MSF-supported healthcentres treated morethan 100,000 cases ofmalaria.
© Ake Ericson

Somalia
Reason for Intervention • Armed
conflict • Endemic/Epidemic disease• Social Violence/Healthcare exclusion
Field Staff 1,061

2007 saw an escalation of violence inSomalia as fighting intensified between
the Transitional Federal Government,groups linked to the Union of Islamic
Courts and various other armed
factions, particularly in the capital,
Mogadishu. As a result thousands ofpeople fled Mogadishu, increasing the
medical needs in the country with aweakened health system.

non-food items, such as plastic sheeting andjerry cans. With cholera cases reported inseveral locations, MSF staff also focused onproviding clean drinking water through water
trucking distributions.

Alleviating the suffering

Throughout the year, people continued toarrive from Mogadishu and needs increased
every day. In Afgooye and Hawa Abdi, a large
majority of the 1,700 weekly medical consultations carried out by MSF teams were linked toprecarious living conditions: severe malnutrition, diarrhoea and acute respiratory tract
infections. MSF teams doubled the capacity
in Afgooye and set up a paediatric ward in
Hawa Abdi. The nutritional care centre in
Hawa Abdi also increased its capacity by theend of the year.

Thousands of those who fled Mogadishu foundthemselves living without shelter, food, wateror medical care. In April, MSF launched an
emergency response in Afgooye, a town some
30 kilometres west of Mogadishu where many
had sought refuge. MSF teams focused on
meeting immediate needs, supplying medicines to the few existing health structures,such as the Hawa Abdi clinic, and distributing

Despite the insecurity, MSF also opened new
projects in Mogadishu itself. A cholera treatment centre was opened in MSF’s primary
healthcare clinic in Yaqshid in March. By May,
the centre had admitted over 1,000 patients,
more than double the number treated inprevious cholera outbreaks in the capital. Overthe course of the year, three new outpatient

clinics for children under 12 were opened in
Balcad, Karaan and Lido. In December, the Lido
clinic was reinforced with an inpatient ward.
A paediatric clinic opened in the Hawladagarea of the capital in May had to be closed andrelocated in November due to insecurity. The
MSF team now carries out mobile clinics indisplaced person’s camps around the city andcontinues to run an inpatient and outpatient
clinic for children and an ante-natal care clinicin the K4 area of the city, reaching some 250
people a day. In late September, MSF started
providing emergency surgical care in a hospital in the Dayniile area, receiving 705 patientsin the emergency room and performing 140
surgical interventions in the first threemonths.

Expanding activities
Victims of violence and displaced people were
not the only ones needing medical assistance.
The absence of public health services, coupledwith chronic malnutrition, droughts, floods
and regular outbreaks of cholera and otherepidemics, have left the general population
extremely vulnerable.

MSF is fighting malaria through diagnosis andtreatment using effective tools and drugs.
Pinprick blood tests, so-called rapid diagnostic
tests, are easy to interpret and suitable to use
in areas where microscopy is not available. As
in all MSF projects, malaria patients aretreated with Artemisinin-based combination
therapy (ACT), drugs that are more effective
than earlier medicines, to which the malaria
parasite has developed a high resistance. MSF’s
experience has also shown that to improveaccess to effective treatment of malaria, both
healthcare and medicines have to be free.
Sierra Leone is one of the poorest countries in
the world and even low patient fees deter
people from seeking treatment.

MSF has increased its
operational presence inSomalia.
MSF expanded its activities, opening new
projects in Hiraan region, Lower Juba region
and Puntland. In Belet Weyne, Hiraan region,
MSF opened a hospital programme in February
focusing on surgical care. Once the surgicalcapacity of the hospital was functioning well,
MSF also started a paediatric ward providing
maternity care. In Jamaame, Lower Juba
region, MSF set up a 30-bed hospital with alarge nutritional programme and outreachactivities in March. Since then, 950 patients
have received nutritional treatment and MSF
teams have carried out 1,400 consultations amonth. Every day, four mobile medical teams
screened between 300 and 1,000 children andpregnant women for malnutrition. The major
health problems presented were malnutrition,
pneumonia, and diarrhoea.
In Kismayo, also in Lower Juba region, MSF
began an emergency surgical project in
September. In Bossaso, Puntland, a nutritional

To make malaria treatment more accessible topeople in remote areas far from the nearest
clinic, MSF began to support 30 smaller healthposts in rural areas. In November, a pilot
programme started to train community
malaria workers to test for malaria using rapid
diagnostic testing and to offer free treatment
for uncomplicated malaria with ACT in theirvillages. Information and education on how
to prevent and recognise malaria and toencourage people to seek care quickly are also
important components in combating malaria.
To prevent people from contracting thedisease, more than 64,000 bed nets were
distributed in 2006 and 2007.

Gondama referral centre
MSF runs the Gondama referral centre, ahospital outside Bo town that offers paediatricand maternity care and therapeutic feeding.
Each month, the centre admits around 500
paediatric patients, 100 malnourished children
and 50 pregnant women. In 2007, a new operating theatre opened where caesareans andother obstetric-related surgery are performed.

In March, an ambulatory therapeutic feeding
programme started making it possible to treat
a greater number of children. The children
come to the health centre once a week for a
medical check up and to receive their weekly
supply of therapeutic food, an enrichedpeanut paste.

The risks of pregnancy
Women in Sierra Leone face one of the highest
risks of dying from pregnancy and childbirthin the world. The five MSF-supported clinics
include a special consultation area for women,
where all medical staff are female. These
provide ante- and post-natal care, familyplanning, treatment of sexually transmitted
disease and medical and psychological care forvictims of sexual violence. Normal deliveriesalso take place in the clinics while complicated cases are sent to the referral centre.
MSF has worked in Sierra Leone since 1986.

emergency intervention was launched inlate August in camps where thousands ofinternally displaced people and refugees, both
Somalis and Ethiopians, gather before trying
to cross the Gulf of Aden to reach Yemen.
Between August and December over 1,000
patients were treated for malnutrition.

Healthcare in a hazardous environment
With 14 projects in 11 regions, MSF was one of
the biggest healthcare providers in Somalia in
2007. MSF’s medical teams performed morethan 2,500 surgical operations, 520,000 out­
patient consultations and admitted around23,000 patients to hospital. Yet the challenges
of working in such an insecure environment
were evident. MSF was occasionally forced toremove its international staff because ofviolence, or threats of violence, against staff
and patients, although MSF activities continued to be run by dedicated Somali staff.
At the end of the year, two international staff
members were kidnapped in Bossaso and held
captive for a week before being released without being harmed.
MSF has worked in Somalia since 1991.
© MSF

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South Africa

Sudan

Reason for Intervention• Endemic/Epidemic disease• Social Violence/Healthcare exclusion
Field Staff 56

Reason for Intervention • Armed conflict • Endemic/Epidemic disease• Social Violence/Healthcare exclusion • Natural disaster
Field Staff 3,174

The struggle to meet substantial needs

More than three years after the signing of the Comprehensive Peace Agreement,
medical needs in south Sudan remain critical. In many areas, MSF is struggling
to maintain primary healthcare services, while reinforcing secondary care andemergency outbreak response services.
Emergency response
In a country devastated by over 20 years of war,with little or no health infrastructure, where
deadly diseases are common and outbreaks ofmeningitis and cholera frequent, the ability of
MSF teams to respond quickly and efficiently
to emergencies remains crucial.

MSF introduced an
integrated TB/HIV clinicin the country in 2003.

© Benedicte Kurzen / Eve

In South Africa it is estimated by the UN that over 5.5 million people are HIVpositive and about a million are in urgent need of anti-retroviral treatment(ART), half of whom are still waiting. Tuberculosis (TB), including drug-resistant TB, is the leading cause of illness and death among those living with HIV. At
the same time, South Africa has become the leading destination in the region
for migrants fleeing economic and political chaos in neighbouring countries insearch of jobs and safety. An estimated 2,000 - 6,000 people cross the border
every day. Despite a constitution that guarantees healthcare for all, access toservices for this group is far from assured.
Providing HIV/TB treatment in a
townshipSince May 2001, MSF has been providing
primary care level HIV/AIDS treatment in thetownship of Khayelitsha, on the outskirts ofCape Town, in partnership with the Western
Cape Province Department of Health. MSF has
progressively handed elements of the programme over to provincial and local healthauthorities but continues to support TB andHIV services.
The Khayelitsha programme has the oldest
group of patients on AIDS treatment in the
public sector on the continent. A special
priority has, therefore, been set together withpartners, particularly the University of CapeTown, to monitor and evaluate treatment
results. As of December 2007, nearly 9,000
people had been started on ART in clinics
supported by MSF, including almost 3,000
who have been on treatment for more than
two years.

More than 200 new patients were started on
ART monthly but this rate was threatened bycomplete saturation of existing sites andsevere shortages of health workers. To copewith the ever increasing number of patients
and with the goal of reaching 15,000 people by2010, MSF focused on delivering HIV services
in new decentralised health centres using anurse-based model of care, improving clinic
organisation and triage of patients, re-defining
staff roles and training. MSF also launched
new strategies to address the challenges oflong-term adherence to ART, including creating ‘adherence clubs’ for stable patients on
ART for at least 18 months with nocomplications.
Given the extremely high incidence of TB in
the township and because 70% of TB patientsare also HIV-positive, MSF introduced an
integrated TB/HIV clinic in the country in
2003. Since then Ubuntu has become oneof the busiest primary care clinics in theprovince. Efforts were made to improve
diagnosis of drug resistant TB in Khayelitsha,
strengthen TB infection control and develop a
decentralised community-based model of care.

When meningitis swept through southern
Sudan in early 2007, MSF emergency teams
responded immediately. Between January and
April, the Ministry of Health reported 11,447
suspected cases of meningitis, including 632
deaths, in nine out of 10 states. MSF teams set
up a surveillance system to monitor cases,
supplied health structures with medicines,
treated people and launched mass vaccination
campaigns in all nine affected states. Around2,000 people were treated, including 255
severe cases, and more than 630,000 people
were vaccinated.
MSF teams responded to several cholera outbreaks throughout the year by setting up
isolation and treatment centres and reinforcing teams with additional staff. Some 2,400
people were treated for cholera. In July, MSF
supported the health authorities in Wau, in
Bahr-el-Ghazal state, after an increase indiarrhoea cases. MSF teams also ran measles
vaccination campaigns throughout 2007,
vaccinating 47,500 children. After flooding in
September, MSF staff distributed essential
survival items, such as cooking sets, to 3,000
families in Ayod, Jonglei State.

MSF continues to coordinate the township’s
Simelela Centre for Survivors of Sexual
Violence, which provides medical care, psychosocial support, forensic examination andpolice assistance to rape victims in one setting
open 24 hours a day, seven days a week. In
2007, nearly 1,000 survivors of sexual violence
attended Simelela.

MSF has worked in South Africa since 1999.

The security situation remains precarious.
Outbreaks of fighting are frequent and thenumber of patients in MSF wards sufferingfrom violent trauma is high, representing fourout of 10 patients undergoing surgery in Bor
Civil hospital (Jonglei State). In November, MSF
was forced to withdraw staff temporarily from
Bor when clashes between different tribes led
to the death of four people within the MSF
compound.
In some areas, MSF has been able to hand overor end its activities. In March MSF withdrew
from a hospital in Akuem, Bahr El Ghazal
State, which was established in 2000 during
the civil war, when people were unable toreach any other health facilities. Services
included in- and out-patient care, antenatalcare, deliveries, treatment for TB andemergency interventions for meningitis,cholera, malaria and malnutrition. In theseven years MSF worked in the hospital, teams
provided over 320,000 outpatient consultations
and treated 1,187 people with TB.

Improving access to care for migrants
In late 2007 and in response to an increasingly
dire situation, MSF carried out an assessment
and started providing essential healthcare tomigrants, primarily from Zimbabwe. In theborder town of Musina, Limpopo Province,
MSF provides primary healthcare throughmobile medical teams on farms and in townships. In Johannesburg, MSF opened a small
clinic next to the Central Methodist Church
where 1,500 migrants seek refuge every night.
MSF provides basic care and enables access topublic health services and more specialisedcare through a referral network.

An absence of healthcare staff and healthstructures, roads and transport, other actors
and investment means that MSF is the only
medical organisation present in many areas ofsouth Sudan and struggling to meet thesubstantial needs. MSF teams worked in fivestates, providing medical care ranging fromprimary healthcare to surgery and treatmentof malnutrition and sleeping sickness. Staff in
MSF’s health centres and hospitals in Jonglei,
Upper Nile and Unity State performed over
350,000 outpatient consultations and morethan 2,000 surgeries. In Unity State, around
150 patients operated on had to be airlifted infrom remote sites. As well as working in fixed
structures, mobile clinics and outreach teams
are an essential part of MSF’s work, ensuringthat people living in extremely remote areas
without roads or transport facilities canreceive medical care.

© Susan Sandars

A country devastated by over 20 years of war,with little or no health infrastructure

In October, MSF handed over responsibility for
Marial Lou rural hospital, in Warap State, to apartner organisation and as a new hospital
was opened in Bentiu, Unity State, MSF alsodecided to end its assistance in this area as
well. Activities there had focused on kala azar,
tuberculosis and HIV co-infections.
MSF has worked in Sudan since 1979.

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In the mountainous rebel-controlled Jebel
Mara, MSF provides healthcare in Niertiti,
where 23,000 of the 33,000 population areinternally displaced. On average, 5,500 con­sultations and 278 hospitalisations take placeeach month. MSF also travels to nearby Thur
twice a week, consulting 200 patients a day.
In Kutrum, MSF staff perform around 1,900
consultations a month and refer emergency
cases to Zalingei hospital. A polio and measles
vaccination campaign reached nearly 10,000
children.

South Darfur

2.5 million people
are currently displacedin Darfur.
© Yuri Kozyrev / Noor

Darfur
MSF has provided medical humanitarian aid in the Sudanese region of Darfur
since 2003, when government forces and allied militia began fighting rebel
groups seeking greater autonomy for the arid and impoverished region. In 2007,
the political environment became increasingly complex, with continued fragmentation of armed groups leading to outbreaks of violence and heightened
insecurity. Aid organisations including MSF were the target of numerous attacks
and robberies. Harassment from members of armed forces, increased banditry
and clashes between nomadic tribes led to new population displacements.
By the end of 2007, the number of displaced people in Darfur had reached close
to 2.5 million.
West Darfur
Access to medical care and emergency support
is a constant problem for populations facedwith ongoing violence in west Darfur, complicated by refugee arrivals from neighbouring
Chad. In June, MSF started working in Foro
Boranga on the Chadian border, caring for
20,000 people living in difficult conditions
whose basic needs included food and clean
drinking water. Mobile clinics were started toprovide general consultations, nutritional

assistance, vaccinations and referrals for theseriously ill. Mosquito nets were also distributed. Following a serious security incident,
MSF had to shut down its activities in Fora
Boranga in November.
In Habilah, another border camp with over
22,000 displaced, MSF’s health centre beganproviding mental health services in May. The
health centre is being handed over to Save theChildren, as their presence together with theincreased involvement of the Ministry of
Health in the area are sufficient to meet theneeds of the population. MSF also continued toprovide medical and technical support inprojects at the Aradamata and Dorti displacement camps from a base in El Geneina.
Seleia, in the north of the province, has witnessed significant fighting. MSF supports a
hospital in the town, providing reproductive
healthcare and medical services for victims ofsexual violence and surgical care. At the end of
the year, MSF evacuated its international staff
after an increase in fighting between the JEM
rebel group and the Sudanese armed forces.
In Zalingei, home to 100,000 displaced people,
MSF opened two outpatient feeding centres
and handed over some of its activities in thehospital, where there is an increased presenceof Ministry of Health doctors.

With a population of 100,000, Kalma is oneof the Darfur’s largest camps for displaced
people. Here, MSF runs an outpatient healthcentre providing 3,000 consultations a month.
The project includes a special component for
women’s health and a comprehensive mental
health service providing counselling, workshops, support groups and community outreach. In July, the MSF clinic was set on fire byarsonists. Tensions in the camp in Octoberforced up to 15,000 residents to flee and findrefuge around the capital with little access toaid. MSF responded by providing medical careto these displaced people using mobile clinics.
MSF provides medical care to approximately
70,000 people in the southern town of
Muhajariya. Services include inpatient andoutpatient care, surgery and treatment for
victims of sexual violence. Mobile and inpatient feeding are integrated into the basic
healthcare programme to respond to the highnumber of malnourished children. In October,an intensive attack on the town casued thedeath of two Sudanese MSF staff. Following
this tragic incident MSF evacuated part of its
team from Muhajariya.
MSF opened a new project to assist the residents and displaced in and around Feina,
providing basic healthcare, ante-natal care anda home-based feeding programme. About 130
patients were seen daily and the feeding
programme averaged 60 new admissions amonth. MSF also started running mobile
clinics to access a population that remains
scattered across a broad area.
In early 2007, newly displaced families beganarriving in the Bulbul area from west andsouth Darfur in search of security.
Approximately 25,000 people were in needof relief. MSF provided clean water anddistributed essential survival items such assoap and blankets.

North Darfur
In April, MSF was able to resume medical
activities in the dispensary in Kaguro, which
had been on stand-by since a deterioration insecurity in mid-2006. Care is provided toalmost 85,000 people completely cut off fromassistance since 2003, when the whole area
was attacked and most villages burned. Many
people were killed and most survivors fled tothe surrounding mountains. Activities wereextended to five additional health posts at theend of 2007 and a network of community
health workers was established. Transport andaccess remain a challenge and many of these
health posts are reachable only by donkey.
An international team returned to the medical
facility in Serif Umra in July. This has been run
entirely by Sudanese staff since an evacuationof international staff in 2006. There are 7,000
outpatient consultations each month. Patientsneeding secondary healthcare are transferred
to hospitals in Zalingei or El Geneina.
In August, MSF started working in Tawila,
where approximately 35,000 internallydisplaced people had gathered in three camps.
They had been without health services sinceApril, when the last relief organisation in thearea had to leave due to security problems.
MSF started mobile clinics and established asmall inpatient ward in Tawila town. The teamsuffered several security incidents and had tobe provisionally evacuated in mid-September.
Activities resumed in November. All services
are in place and an average of 3,000 consultations take place each month.
In Shangil Tobaya, MSF cares for 28,000
displaced people in the Shangil and Shadat
camps and residents of Shangil Tobaya village.
Services include inpatient and outpatient
departments, a therapeutic feeding programme, reproductive health services andtreatment for victims of sexual violence.
Malnutrition rose in 2007 because continued
insecurity meant people still could notcultivate or grow crops.

© Yuri Kozyrev / Noor

Many people were killed
and most survivors fled
to the surrounding
mountains.
MSF runs three health centres in Kebkabiya,
assisting some 75,000 people, many of whomsought refuge in the city at the beginning of
the conflict in 2003. Some 12,000 consultations take place each month. MSF also
supports the Kebkabiya public hospital, mainlyin the obstetric ward.

Project closures
MSF closed its clinics in Killin and Gorni in theJebel Mara. This area had been stable for many
months and had a number of other healthfacilities. MSF also withdrew from the Mornay
camp in west Darfur, handing over activities to
the government and other organisations.
In Um Dukhun, bordering Chad and CAR, MSF
offered primary, secondary and surgicalhealthcare for refugees and displacedcommunities until the middle of 2007.
Until April 2007, MSF teams worked in Shariya,
south Darfur, a government enclave where
27,000 people had regrouped before being
systematically dispersed by attacks. MSF wascompelled to scale down the programme after
repeated robberies from its mobile teams. MSF
also ended outpatient services and a feeding
programme for displaced people who had fled
Muhajariya in 2006 and had been living in
Seleah and Yassin.
MSF has worked in Darfur since 2003.

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SwazilandReason for Intervention • Endemic/
Epidemic disease
Field Staff 9

Despite a relatively stable politicalsituation and what appears to be areasonable resource base, about 69 percent of the population of Swaziland
still lives below the poverty line. The
health situation, which had improvedin the 1980s and 1990s, has entered adownward trend as a consequence ofthe HIV/AIDS and tuberculosis (TB)
epidemics.

In November, MSF launched a project tosupport the national authorities in providing
decentralised care to people affected by HIV
and TB.
Both diseases have already had a devastating
effect on the population and the economy. Life
expectancy at birth is only 32.5 years, thelowest in the world. The country has theworld’s highest HIV prevalence rate and one of
the highest levels of HIV-TB co-infection.
Twenty-six per cent of young adults are
infected with HIV and may die in the coming
years if not given adequate treatment. With
the escalation of the HIV and TB epidemics,
health infrastructures risk being overwhelmed.

In November, MSF opened a project in theregion of Shiselweni, populated by some
202,000 inhabitants. MSF works in the hospitalof Hlatikulu, in two healthcare centres in
Nhlangano and Matsanjeni and in 19 rural
health clinics throughout the region. This
project aims to reduce mortality from HIV/AIDS
and TB and to improve access to anti-retroviraltreatment (ART) and TB treatment for those
who urgently need it.
In collaboration with the health authorities,
MSF is focusing on decentralising integrated
care for HIV/AIDS and TB to the level of thehealth clinics, the closest health facilities tothe population. The strategy relies on wide

community involvement to enable prevention,
testing and adherence to treatment.
This is achieved through the contribution ofhealth workers and people living with HIV/
AIDS, known as ‘expert patients’, who provide
peer support and guidance. Special emphasis
is put on the improvement of prevention anddiagnostics, notably through carrying out
complete tests for HIV/AIDS and TB. MSF also
provides comprehensive care for complex casesof HIV/AIDS and TB, including patients withmulti-drug resistant TB.

ZambiaMédecins Sans Frontières Activity Report 2007

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In 2008, MSF aims to start 3,000 new patientson ART in the Shiselweni region.
MSF has worked in Swaziland since 2007.
© Juan Carlos Tomasi

UgandaReason for Intervention • Armed
conflict • Endemic/Epidemic disease• Social Violence/Healthcare exclusion
Field Staff 858

An improved security situation andongoing peace negotiations between
the Lord’s Resistance Army rebel groupand the government of Uganda haveresulted in the cautious return homeof thousands of internally displaced
people who have been living in camps
in northern Uganda for several years.
As the Ministry of Health takes on more
responsibility in many areas, MSF has
been able to hand over some projects
and focus on providing secondary care,
HIV/AIDS and tuber­culosis (TB) care.
However, the health situation remains
fragile. During 2007, regular disease
outbreaks and emergencies demon­
strated the need for MSF’s continued
presence in the country.
Refocusing activities
As some of the camps in the north empty, withpeople either returning home or moving tosatellite camps, MSF has handed over anumber of projects in Pader, Kitgum, Lira andGulu districts to other organisations or the
Ministry of Health. Yet many health needs,
such as hospital care and treatment for people
living with HIV/AIDS, remain unmet. In May,MSF opened a new project in Madi Opei camp

Reason for Intervention • Endemic/Epidemic disease
Field Staff 157

in Kitgum district. Working in a Ministry of
Health clinic, MSF staff provided HIV/AIDS and
TB care and secondary and reproductive
healthcare to around 70,000 people, most still
living in camps. In Arua district, MSF’s longrunning HIV/AIDS and TB project continues togrow. By the end of December, 11,618 people
had been enrolled in the programme, with
4,090 receiving anti-retroviral treatment.

In July 2005, the Zambian government started providing HIV/AIDS care freeof charge and in 2006 abolished the national cost-sharing system of healthcare. Although the number of medical consultations rapidly increased, noviable substitute system of healthcare was implemented. The drug supply was
not adjusted, resulting in occasional stock ruptures and patients sometimes
being asked to pay for drugs, placing an extra burden on those with chronicand debilitating illnesses such as HIV/AIDS.

Responding to emergencies
On 29 November, an outbreak of Ebola was
declared in Bundibugyo district, western
Uganda. This highly contagious hemorrhagic
fever has no known cure and is often fatal, so
MSF teams had to move quickly to contain theoutbreak and isolate and support those
infected. The MSF intervention started in
December and lasted approximately six weeks,during which 149 patients were treated.
Throughout the year, MSF also responded tooutbreaks of cholera, meningitis, marburg andHepatitis E.
In February, an MSF emergency team of morethan 75 staff supervised the meningitis vaccination of 291,000 people in Arua and Koboko
districts and assisted the Ministry of Health in
the vaccination of another 333,000 people bysupplying vaccines and medical materials.
MSF teams also provided assistance to refugees
who had fled violence in neighbouring countries. When approximately 12,000 Congolese
refugees crossed the border in October, MSF

MSF has focused on helping people with HIV
through a project in the remote ‘transit area’of Kapiri M’Poshi, a fast-growing town and thesite of main railway transfers. The national
figures estimate that 20 per cent of people in
Kapiri M’Poshi have HIV. Access to healthcare
in general and HIV care in particular is limited
for the 250,000 people living in the rural
Kapiri district, where there are few roads ormeans of transportation.
© Michael Goldfarb

staff set up a health centre in Nyakabande
transit camp. MSF also built shelter for the
refugees and provided clean water and sanitation facilities.
In February, an assessment by the World Food
Programme in the Karamoja district ofnorth-eastern Uganda revealed that 20 per
cent of those surveyed were suffering acutemalnutrition. MSF teams opened a mobile
therapeutic and supplementary feeding
programme for children under five in the

district, with eight locations for food distribution and treatment and a stabilisation centre
at the district hospital. Between July andDecember, 159 severely malnourished and2,698 moderately malnourished children weretreated, with 284 hospitalised at the stabilisation centre. An MSF assessment in Karamoja
district in November indicated that the situation was improving, with a global acute malnutrition rate of 15.3 per cent.
MSF has worked in Uganda since 1980.

The hospital in Kapiri was recently upgradedto a district hospital but still lacks essential
health facilities such as x-ray and surgery. MSF
runs a clinic in the hospital and works in 12
rural health centres, implementing a decentralised model of HIV care so people can accessmedical services closer to home. By the end of
2007, MSF had enrolled 7,000 patients in the
project, with 3,500 receiving anti-retroviraltreatment (ART). Teams conducted over 3,000
consultations a month.
In 2001, MSF established an HIV/AIDS projectin the rural district of Nchelenge, another

MSF worked at
integrating care into
regular health services
and provided ART to
700 patients.
transit area in northern Zambia. MSF
worked at integrating care into regular
health services and provided ART to 700
patients. A total of 4,195 HIV patients arefollowed up in the project. Patients are also
screened for tuberculosis (TB) and MSF
worked with health authorities to ensurethat treatment for people co-infected withHIV and TB was integrated into primary care.
MSF also involved the community in prevention, treatment and support of people with
HIV/AIDS. This project was transferred to the
Ministry of Health at the end of 2007.
MSF has worked in Zambia since 1999.

57

Zimbabwe

Asia and the Caucasus

Reason for Intervention • Endemic/Epidemic disease• Social Violence/Healthcare exclusion
Field Staff 389© Dirk-Jan Visser

According to the UN three million economic refugees are estimated to havefled Zimbabwe, a country characterised by 80 per cent unemployment, rampant
inflation, foreign currency shortages, food insecurity and a crumbling healthcare infrastructure. In addition to the HIV/AIDS crisis, MSF has seen the rise of
epidemic diseases such as cholera and tuberculosis.
Since 2002, MSF has implemented projects in
Zimbabwe to prevent and treat HIV/AIDS.
Despite the efforts of the Ministry of Healthand other donors, the prevalence of HIV/AIDS
among pregnant women in some areas ofZimbabwe is above 30 per cent and the generalprevalence is 15.6 per cent, still one of thehighest in the world.
MSF has supported the Ministry of Health indecentralising healthcare delivery to rural andcity clinics in Bulawayo, Tsholotsho, Gweru,
Epworth and Buhera. Increased proximity has
resulted in more patients accessing the treatment and care they need. By the end of 2007,
MSF was providing care to 35,000 patients with
HIV/AIDS, approximately 16,000 of whom werereceiving anti-retroviral treatment (ART).

The comprehensive approach to the prevention
and treatment of HIV/AIDS includes voluntary
counselling and testing, treatment for HIV
and opportunistic infections, prevention of
mother-to-child transmission, nutritional
supplements, medical care to victims ofviolence and general psychological support.
MSF also carries out HIV/AIDS educational
programmes and trains health workers tomanage the different components of the HIV/AIDS programmes and ART.
The effects of price policies, hyperinflation,
food shortages, recurrent droughts and poor
harvests in recent years, combined with a highprevalence of HIV and TB, have resulted inworrying trends in malnutrition. MSF supportsa therapeutic feeding centre in Tsholotsho

district hospital and, at the end of 2007, set up
a day feeding centre in Epworth to respond to
the increasing numbers of malnourishedchildren seen during the year.
MSF also provided emergency clinical support
for diarrhoeal outbreaks in the rural districtof Gokwe, the town of Kadoma, the Harare
suburb of Mabvuku-Tafara and in the city of
Bulawayo.
MSF has worked in Zimbabwe since 2000.

MSF has seen the riseof epidemic diseases
such as cholera andtuber­culosis.

58 | ARMENIA
58 | BANGLADESH
59 | CAMBODIA
60 | CHINA
61 | Georgia
62 | INDIA
63 | INDONESIA
64 | KYRGYZSTAN
64 | LAOS
65 | MYANMAR
66 | NEPAL
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68 | Papua New Guinea
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70 | TURKMENISTAN
70 | UZBEKISTANIn Sri Lanka, Vavuniya, MSF opened three surgical programs in Point Pedro, Vavuniya and Mannar, all in conflict-affected areas.
© Henk Braam / HH

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ARMENIAa few patients had completed the MSF
treatment programme in Abovian, near thecapital, Yerevan.

Reason for Intervention • Endemic/
Epidemic disease • Social Violence/
Healthcare exclusion
Field Staff 65

Poor adherence to treatment programmes and late diagnosis of tuberculosis (TB) are critical problems inArmenia. The treatment success rate is
low and the lack of control over the
spread of TB is one of multiple
problems facing the crippled healthcare system.
Armenia remains largely impoverished. The
complexity and high cost of TB treatment has
led to MSF being the only medical agency
dealing with drug resistant tuberculosis(DR-TB) in Armenia. When uncontrolled, thisdisease has serious consequences. Particularly
alarming is the emergence of extensive drug
resistant (XDR) TB, when a patient is resistantto the main second-line drugs.

© Clement Saccomani

Since the programme
started in Abovian,more than 100 patients
have been admitted.
Treatment for drug resistant TB takes up to
24 months and involves a daily intake ofdozens of medicines that can cause unpleasantside effects. Despite this, by the end of 2007,

CAMBODIA

providing HIV/AIDS care to 42 inmates fromthree of the city’s main prisons since 2006
and hospital-based and ambulatory medical
follow-up for HIV patients co-infected withdrug-resistant tuberculosis (TB).

When the programme started in 2005, it
covered a population of about 300,000 in two
Yerevan city districts and occupied a small
ward at the Republican TB Hospital. In early
2007, MSF started to treat patients in therenovated 36-bed facility in Abovian dedicatedto drug resistant TB treatment. Inpatient
treatment is offered, including to those withsevere cases of extreme drug resistant TB. Oncethe period of hospitalisation is over, patientsare followed up through mobile clinics or
home-based care until the treatment cycle iscompleted.
Since the start of the programme, more than
100 patients have been enrolled. In collaboration with the National TB Programme, theobjective is to expand the treatment to other
districts of Yerevan.

Kompong Cham, west of Phnom Penh, is one of
the most populated provinces in Cambodia.
MSF has been working here since 2003,
offering comprehensive HIV/AIDS care. During
2008, MSF will transfer HIV care to thenational programme and focus on treating
patients co-infected with HIV and TB,
inclu­ding building a new TB ward. Seventy percent of current HIV patients in the hospitalward in Kompong Cham also suffer from TB.

© Dieter Telemans

MSF increasingly focused on developing treatment
for patients affected by TB.

MSF has worked in Armenia since 1988.

BANGLADESH
Reason for Intervention • Endemic/
Epidemic disease • Social Violence/
Healthcare exclusion • Natural disaster
Field Staff 165

intervention supporting the existing facilities
in Dhaka. In September and October, MSF
treated over 1,800 diarrhoea cases, about 30 per
cent of which were cholera.

taking some 1,200 consultations a week, and afeeding centre (over 2,100 admissions in 2007)
near Tal camp. Respiratory and skin infections
were the most common conditions. Due to alack of access to health care of refugees in theofficial camps of Kutupalong and Nayapara,
MSF opened two 20-bed inpatient units in thecamps. By the end of the year, these facilities
had admitted 3,800 patients.

Rohingya find little support
In November a severe cyclone killed
and injured many. MSF responded tothis emergency providing essential
medical care. Parallel to this, work
continued to help the stateless peopleof Rohingya who have little access tohealthcare.

Stateless Rohingya people have been crossing
the border between Myanmar (Burma) and
Bangladesh for decades. They are a Muslim
minority in Myanmar, a country that does notrecognise them as citizens. They are subject
to forced labour, land confiscation and restrictions on movement and marriage but receive
little support when they get to Bangladesh.

Cyclone Sidr destruction
Cyclone Sidr killed more than 3,000 people andmade hundreds of thousands homeless. MSF
provided assistance to victims in some of theremote areas using mobile clinics. By
December, MSF had provided medical careto over 7,600 patients, most of whom had
diarrhoea and skin infections. In addition MSF
distributed 4,000 household kits.

Severe floods increased diarrhoea risk

MSF has worked with the Rohingya in
Bangladesh for many years. After opening a
project in the Teknaf region at the border with
Myanmar in 2006, MSF in 2007 focused on
improving access to healthcare, particularly forthe 9,000 people living in the makeshift ‘Talcamp’. MSF has also advocated on the plight of
the Rohingya to encourage other international
actors to recognise their vulnerable situationand take action to help.

Cases of diarrhoea increased following theearly severe flooding in July and August.
MSF initiated a severe watery diarrhoea

Throughout the year, MSF carried out medical
activities through an outpatient clinic, under-© Eddy Van Wessel

Cyclone Sidr killed
more than 3,000 people
and made hundreds ofthousands homeless.

At the beginning of May, MSF closed its projectin the Chittagong Hill Tracts after eight years.
It was partially handed over to the Bangladeshi
regional health authorities. When MSF firstintervened, the area was emerging from a
20-year armed conflict between the central
government and the indigenous people. Today,
access to healthcare is improving. A better
infrastructure allows people to reach existing
health structures and more assistance iscoming into the region.
With the government now offering betteraccommodation to the people living in TalCamp, MSF plans to hand over its project there
to another organisation. MSF is intending toleave the country by the end of 2008.
MSF has worked in Bangladesh since 1985.

Reason for Intervention • Endemic/
Epidemic disease
Field Staff 245

Improved health facilities and a government commitment to fight HIV/AIDS has ensured critical progress inthe scale-up of anti-retroviral treatment (ART) programmes in Cambodia.
Because of this improved situation
MSF has begun handing over some ofits HIV/AIDS projects. MSF is currently
offering HIV/AIDS care in four
locations and has 8,000 patients on
ART, 30 percent of all those on
treatment nationwide.
In its HIV/AIDS programmes in Siem Reap,
Phnom Penh, Takeo and Kompong Cham, MSF
provides ART including second line treatment
for those who do not respond well to standard(first line) treatment. Counselling, treatmentof opportunistic infections and information
on HIV/AIDS are also provided. A total of 360
patients are on second line treatment.
In Phnom Penh, MSF is working in the Khmer
Soviet Friendship Hospital, one of the largest
public hospitals in the city. Alongside its HIV/AIDS care, which began in 1997, MSF has been

In Takeo, Siem Reap and Phnom Penh, MSF
increasingly focused on developing treatment
for patients affected by TB, including multidrug resistant TB, independent of their HIV
status.
In Takeo and Siem Reap, MSF uses an innovative approach, treating HIV/AIDS as a chronic
disease alongside diabetes and hypertension,
which also have high prevalence rates. By
December 2007 over 6,200 patients had beentreated for diabetes and hypertension since
the beginning of the project in 2002.
In Siem Reap, MSF works closely with local
non-governmental organisations to increase
access to treatment and testing for HIV andother sexually transmitted infections. MSF
provides medicines, supports the transport ofsex workers to health centres and referrals toappropriate services for specific care such asabortion, post-abortion care and cervicalcancer.
MSF’s paediatric HIV/AIDS programmes
throughout the country have seen dramatic
improvements in children’s immune system,
growth, development and quality of life. Some
890 children were on treatment by the end of2007.
MSF continues to support the local healthauthorities’ response to seasonal epidemics
such as dengue fever. The 2007 dengue outbreak was particularly severe, with 35,000
cases and 190 deaths reported nationwide.
MSF provided assistance to Cambodian
medical staff in Takeo and Kompong Cham.
MSF has worked in Cambodia since 1979.

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CHINA
Reason for Intervention • Endemic/
Epidemic disease
Field Staff 63

MSF is providing free HIV/AIDS
treatment to complement the national
government programme, which still
has significant gaps. In addition,cases of drug resistant TB are on theincrease, and this trend needs tobe addressed using affordable, accessible drugs.

As tuberculosis numbers grow,
MSF implements programmes
According to the recent World HealthOrganisation Global Tuberculosis report,
China had 4.5 million cases of tuberculosis in
2006, with an estimated 1.3 million new cases
each year. The spread of drug resistant TB is ofeven greater concern, with over 130,000 new
patients estimated each year. At least half ofdrug resistant patients in China have nevertaken TB drugs before, a population equal to
10 per cent of the global burden.

Due to the growing epidemic and the lack ofaccess to affordable treatment, MSF plans tolaunch TB treatment programmes in colla­boration with the provincial and central
authorities. In Inner Mongolia Autonomous
Region and Jilin province, two northern
provinces where government statistics indicate
the situation to be more severe, MSF has
engaged in in-depth negotiations to establish
a drug resistant TB prevention and management programme.

GEORGIA

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Field Staff 202

MSF has worked in China since 1988.

Addressing gaps in HIV/AIDS
treatment
Official figures indicate that some 700,000
people in China were infected with HIV/AIDS
at the end of 2007. Of the 85,000 needinganti-retroviral treatment (ART), fewer thanhalf, including 600 children, are actually
receiving the drugs they need. Through anational programme, the government has
provided free testing and medication, including ART drugs, to people living with HIV/AIDS
and schooling for children infected with oraffected by HIV/AIDS.

© Jean-Marc Giboux

Nevertheless, HIV/AIDS treatment and care are
not integrated. ART drugs are delivered at the
Chinese Centre for Disease Control, whereas
treatment for opportunistic infections isprovided at a designated county hospital.
Tuberculosis (TB) treatment is provided inanother structure. Some patients also facehigh treatment costs, including the HIV
confirmation test, medical consultations,laboratory tests, drugs to prevent and treat
opportunistic infections, hospitalisation andtransportation. Many do not seek or receive
comprehensive care due to the stigma
associated with their situation.
The free HIV/AIDS comprehensive care andtreatment provided by MSF aims to addresssome of these problems. After five years, theproject in Xiangfan, Hubei Province in Central
China, will be handed over to local healthauthorities in March 2008. Another project inNanning, Guangxi Zhuang Autonomous
Region will continue. By the end of 2007,
almost 1,500 HIV/AIDS patients were registeredin the Nanning and Xiangfan MSF projects
and over half received ART drugs andother services.

In Sukhumi (Abkhazia) and Zugdidi (West Georgia), MSF treats multi-drugresistant (MDR) tuberculosis (TB). The estimated prevalence is over 10 per
cent of new TB cases and 57 per cent of re-treatment cases. The daily intakeof dozens of medicines and the extremely prolonged treatment are difficult toendure and patients’ adherence to the treatment course is generally poor.
Patients find it hard to stay isolated in hospital for several months. Many are from poorfamilies and cannot afford to stay too long in
hospital when their dependants are relying
on them for financial support. MSF has tackled this problem by reducing the period in
hospital from between six and eight months
to an average of just two. In this pilot project,
as soon as the sputum smear test shows apatient negative for active TB bacilli, he or she
can leave hospital and be cared for througha mobile service that provides follow-up
treatment and support.

© Joanne Wong

China had 4.5 million cases of tuberculosis (TB)
in 2006, with an estimated 1.3 million new cases
each year.

MSF also helps to improve patients’ homes,
which often do not provide good enoughinfection control or comfort. Mental healthsupport is another integral part of the programme, as is the additional resources provided to families to help fill the economic gap
caused by the patient’s incapacity.
In 2007, 78 MDR-TB patients were enrolled on
the programme in Zugdidi. Since the start ofthe programme in November 2006, no patient
has dropped out of the treatment. MSF
renovated the TB facility and provides aconstant supply of drugs and medical materials. MSF has also been working closely with
the Georgian national TB control services
providing technical assistance and training in
the management of MDR-TB. The Zugdidi
project is expected to be used as a model for
the Georgian national TB programme.

Patients find it hard to stay isolated in
hospital for several months.

In Abkhazia, MSF has supported the local TB
control service since 1999. MSF rehabilitated a
TB hospital near Sukhumi and supplies itwith drugs, materials and laboratory equipment. Since 2001, the programme has focusedon drug-resistant tuberculosis and by end of
2007, 166 drug resistant TB patients had been
started on treatment. MSF also introduced thelife-prolonging anti-retroviral treatment for
TB/HIV co-infected patients.
In early 2007, MSF handed over its regular
TB programme to the health authorities of
Abkhazia but continued to support TB
activities in Dranda. The health accessprogramme for vulnerable people has also
been considerably downsized, although MSF
mobile teams in Sokhumi and Tkwarchili
continue to provide care to a group of vulnerable elderly patients who have no means oraccess to basic healthcare.
MSF has worked in Georgia since 1993.

63

INDIA

In the heart of India, clashes between
Naxalites, the local Maoists rebels, and theIndian government have displaced tens of
thousands of people. Caught in the fighting,an estimated 56,000 people have been forced
to move to government-run camps in
Chhattisgarh. Thousands of others are hidingin the dense forest of southern Chhattisgarh
in Naxalite-controlled areas or have taken
refuge in settlements for the displaced aroundvillages across the border in Andhra Pradesh.

INDONESIA
Reason for Intervention • Social Violence/Healthcare exclusion• Natural disaster
Field Staff 174

Located on the ‘Ring of Fire’, Indonesia is prone to natural disasters such as
earthquakes, volcanic eruptions, floods and landslides. MSF began working in
the country in October 1995. After the 2004 Tsunami, MSF set up a clinic
in Aceh and ran projects in eight affected districts providing medical careincluding surgery, vaccinations and psychological support. MSF continues toassist victims of natural disasters through its emergency programmes andprovides healthcare in remote areas.

MSF tries to reach all those who have been
isolated by the conflict, providing medical
assistance including primary healthcare and amobile therapeutic feeding programme formoderate and severely malnourished children.
MSF works in three camps and has mobile

Reason for Intervention • Armed
conflict • Endemic/Epidemic disease• Social Violence/Healthcare exclusion• Natural disaster
Field Staff 446

In 2007, MSF worked in the statesof Kashmir, Manipur, Assam,
Chhattisgarh and Bihar, providing
basic healthcare to communities inconflict-ridden areas.
In Kashmir, MSF continues to provide community-based psychosocial support and basic
healthcare to those affected by years ofviolence, including over 12,000 consultations.

In Manipur, MSF runs integrated basic
healthcare clinics with an emphasis on the
diagnosis and treatment of HIV/AIDS. MSF is
also studying the extent of mental healthneeds arising out of the low-intensity conflictand continuing violence and has appointed amental health officer. In total over 61,000
consultations were conducted.
In October, MSF closed a basic healthcare
project in Assam, as the Ministry of Health wasable to cover the needs. A key focus had been
to optimise management of falciparum
malaria with Artemisinin-based combination
therapy (ACT). A total of 58,971 consultations
were conducted.

Providing healthcare in remote areas
Following a measles vaccination campaign on
the remote island of Papua in May 2006, MSF
launched a primary healthcare programme in
Asmat, southern Papua, in partnership with
the Ministry of Health. The programme aimed
to improve mother and child healthcare andaccess to basic and emergency medical care forthese isolated communities. In 2007, over 5,500
consultations were conducted, 269 babies weredelivered in the supported health facilities andan obstetric referral system was set up in caseof emergency. Other activities in Asmat included the rehabilitation of the surgery room, thedonation of surgery and medical materials andwater and sanitation activities.

In Bihar, MSF opened a project at the Hajipurreferral hospital to tackle the growing
problem of visceral Leishmaniasis or kala azar,of which India has 80 per cent of the world’s
cases. Ninety per cent of cases are in Bihar. In
July, MSF began treating this neglected disease
with a simpler, shorter and more effective
treatment than the one to which patients had
grown resistant. By the end of 2007, MSF hadtreated 675 patients with kala azar.
During the rainy season, MSF mobile clinics
also provided medical and humanitarianassistance to some 30,000 people affected by
the floods in three isolated districts of Bihar.
© Véronique Terrasse

MSF has worked in India since 1999.

MSF treated 1,132 cases of malaria in SouthHalmahera and distributed 3,701 bed nets in
Buano Island of Maluku Province. MSF also
provided healthcare to 1,291 miners in Mimika
in Papua after a high number of cases ofmeningitis was reported.

After the March earthquake in West Sumatra,
MSF set up four hospital tents to support
Padang Panjang hospital and Puskesmas
Lunang Silaut and donated medical supplies
to the local health authority. The teams
conducted 5,110 medical consultations anddistributed 43,600 blankets, 24,600 plastic
sheets, 1,400 cooking sets and 22,000
hygiene kits.

MSF began an HIV project in Mumbai in 2006,
with a specific focus on treating HIV/tuberculosis (TB) co-infected patients and other people
excluded from the national healthcare
programme. The project offers counselling,treatment for opportunistic infections andanti-retroviral treatment (ART) to the trans­
gender community and commercial sex
workers. By early 2008, over 530 patients wereregistered at the clinic, with 259 patients on
ART and 23 on second-line treatment. MSF has
also started treating multiple drug resistant
MDR-TB and currently has 19 MDR-TB patients.

By the end of 2007, MSF had treated 675 patientswith kala azar in Bihar.

MSF responded to a measles outbreak in
Mamuju District, West Sulawesi, and worked
with the local health authority to set up amass vaccination campaign reaching over
7,000 children.

MSF intervened after floods in Jakarta and aseries of earthquakes that jolted West
Sumatra, in Bengkulu, Muko Muko andMentawai Island. The teams ran mental healthactivities providing psychological support to
29,000 people.

clinics in Chhattisgarh and Andhra Pradesh.
Services provided include ante- and post-natalcare. A total of 22,700 consultations wereconducted.

© Jean-Marc Giboux

Responding to emergencies

MSF teams ran mental health activities providing
psychological support to 29,000 people.

In June, MSF handed over its tuberculosis
activities in Ambon, in the Moluccan islands,
to the local health authorities. This pilot
project focused on a patient-centred approachand provided fixed drug combinations. It
improved patients’ adherence to treatment
and strengthened the counselling skills of
local health staff.
MSF has worked in Indonesia since 1995.

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KYRGYZSTANMYANMAR

Reason for Intervention • Endemic/
Epidemic disease
Field Staff 46

Reason for Intervention • Armed
conflict • Endemic/Epidemic disease• Social Violence/Healthcare exclusion
Field Staff 1,200

Since 2005, MSF has worked to address
tuberculosis (TB) in two of
Kyrgyzstan’s prisons, where incidence
rates were estimated to be 25 times
higher than in civil society. MSF
supports TB detection and administers
TB treatment in the prisons. Together
with national institutions and otherinternational organisations, suchas the International Committee of
the Red Cross, MSF is also trying to
respond to the alarming rate of drug
resistant TB.
The Ministry of Justice has initiated a penal
reform process but the prisons remain among
the most overcrowded in the former Soviet
states. Despite high TB prevalence, cumbersome bureaucracy makes it extremely difficult
to set up mechanisms of TB control. Continuityof treatment when a patient is transferred orreleased is questionable and those leaving
prison often face stigma and discrimination.

© Alexander Glyadyelov

Many prisoners get sick in prison, while others
learn they have TB only when they arrive.
Prisoners used to be kept in crowded cells, withpoor ventilation and scarce light. To change
this MSF has implemented early detection ofpatients with different resistance patterns
from recovering patients. MSF provides TB carefor 550 patients a year and nutritious food to
support recovery.

TB in the pre-trial detention centres and has
rehabilitated medical rooms and the cells of TB
patients. MSF also undertakes infection control
and the separation of sick inmates.

To help alleviate the stigma, MSF organised a
photography exhibition depicting the lives andtreatment of TB patients ‘behind bars’. It was
the first such event to unveil this hidden world
to the wider public. MSF is also lobbying
respective authorities to take responsibility forsolving the problem of TB in prisons, particularly by providing sufficient human resources.

MSF refurbished and maintained the laboratory and rehabilitated the hospital in one ofthe prisons. The new facility ensures theisolation of highly infectious and drugresistant patients and the separation of

MSF has worked in Kyrgyzstan since 2005.

Laos
The gradual introduction of a decentralised cost-recovery system over the
past 10 years means there is no universal access to quality healthcare in Laos.
Access to treatment for people with
HIV/AIDS has been particularly lacking.

MSF’s project offers a free service for patients,
who until recently travelled from all prov-

In 2007, MSF continued its medical aid projects
in areas where it had secured humanitarianaccess: Rakhine, Kachin, Shan and Kayah states,
as well as Yangon and Thanintharyi divisions.
In Rakhine state, MSF provides basic healthcare with a focus on malaria, TB and sexuallyfrom the north of the country were pro­
gressively transferred from Savannakhet tothe hospital at Setthathirat in the country’s
capital, Vientiane. In 2007, this HIV unit
began receiving new patients and by
December, 300 patients were being cared for.

Reason for Intervention • Endemic/
Epidemic disease
Field Staff 36

When MSF opened its HIV/AIDS project in
Savannakhet in 2001, there was little
recognition of this disease in Laos. The medical centre became the first and only in the
country to offer care for people with HIV.
Along with providing urgently needed treatment, the project aimed to sensitise the general public and the authorities to the existenceof HIV/AIDS and the need for specialised care.

The population endures widespreadand often hidden suffering. Controlled
by a military regime since 1962 andlargely cut off from the outside world,the health and welfare of people in
Myanmar is affected by repression andlow intensity conflict. Ethnic minorities, many of whom are displaced andlive in border regions, are particularly
vulnerable. Provisions for healthcare
are inadequate, with 80 per cent ofpeople living in malaria risk areas andthousands going without treatment forconditions such as tuberculosis (TB)
and HIV/AIDS.

© Bruno Stevens / Cosmos

By the end of the year over 600 patients werereceiving care with 490 on ART in Savannakhet.
inces. In Savannakhet, southern Laos, MSF
provides prophylaxis and treatment for opportunistic infections and anti-retroviraltreatment (ART). By 2007, HIV testing andcoun­selling services had been handed over tothe hospital. By the end of the year, 608
patients were receiving care, with 490 on ART.
In August 2006, about 100 patients originally

MSF is progressively working towards a hand­over of all HIV activities to the Lao authorities.
Most medications are supplied by the Global
Fund and other non-governmental organisations (NGOs) are becoming involved in treatment and there have been positive developments within the government. This represents
a major improvement compared to previously,
when HIV/AIDS was not even officially recognised. However, technical capacity and training infrastructure remain inadequate, making
further external assistance from donors anddevelopment NGOs still necessary. Gaps incosts of laboratory testing and certain medi­
cations still exist and will need to be covered
if access to treatment is to be assured.
MSF has worked in Laos since 1989.

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© MSF

transmitted infections. Almost half a million
patients were tested for malaria and 210,000
were treated.
In Yangon, Kachin and Shan, MSF provided
medical care for 16,000 HIV/AIDS patients, halfof whom were receiving anti-retroviral treatmentby the end of the year. Focusing on high-risk
groups including sex workers, intravenous drug
users and migrant workers, MSF also provided
health education, distributed over 3.5 million
condoms and provided needle exchanges.

In Myeik, south of Dawei, MSF has run amalarial control and treatment project since
2002, including surveillance and emergency
response for epidemic diseases. Four mobile
clinics provide care in three townships ofThanintharyi. At the end of 2007, the project
was handed over to another international
non-governmental organisation (Aide Médicale
Internationale).
In Kayah state, a pocket of ongoing civil strife
previously off-limits to international aid, MSF

MSF also provided health education, distributed
over 3.5 million condoms and provided needle
exchanges.
In Thanintharyi division, southern Myanmar,
MSF runs a project aimed at controlling andtreating malaria. The goal was to ensure
adequate infrastructure for the screening
and treatment of malaria. There are now
seven fixed structures integrated into publicclinics, a private clinic and several mobile
clinics.

provides primary healthcare and TB treatment
for people trapped in poverty, low-level conflictand inadequate healthcare. A total of 22,350
consultations were provided through threeclinics in the north of the state, one in thesouth and a new clinic that opened in mid2007 to care for those living in the easternpart of Kayah.

In Dawei, Thanintharyi division, MSF hasdeveloped a more integrated approach to thetreatment of TB, malaria and sexually transmitted infections including HIV, illnesses
previously addressed through separate projects.
Care is provided through two fixed clinics andan additional health centre focusing specifically on HIV/AIDS and TB. In total, 914 patientswere receiving HIV/AIDS treatment and 586
people were treated for TB.

During the year, MSF advocated for its patients
nationally and internationally, raisingawareness of the situation faced by Rakhine
Muslims, Kayan and Karen minorities, as wellas the vulnerability of HIV/AIDS patients in
Myanmar. One of few international NGOs in
the country, MSF has urged and helped otheractors to become more engaged with thehumanitarian crisis in Myanmar.
MSF has worked in Myanmar since 1992.

67

Child malnutrition
To maintain health and growth, young children need 40 essential nutrients. Those who
do not get them become malnourished, a condition that contributes to more than fivemillion deaths in children under five each year. The World Health Organisation estimates there are 178 million malnourished children worldwide, all of whom are less able
to fend off disease and 20 million of whom are at risk of death. In an international
campaign launched in October 2007, MSF advocates for crucial change in the response tochildhood malnutrition.
The critical age is between six and 24 months. At six months, mothers usually start
supplementing breast milk with other foods. Yet, in ‘malnutrition hotspots’, such as
Africa’s Horn and Sahel regions and South Asia, adequate food is either too expensive or
simply not available. Ensuring a complete balanced diet for children is a significant
challenge that requires an urgent response.
MSF and several other NGOs working in resource-limited settings have seen excellent
results over the past five years through treating malnourished children with ready-touse foods (RUFs). These deliver all the nutrients a child needs in an energy-dense paste
made with milk powder. They are easy to eat and require neither refrigeration nor
preparation. A mother can effectively treat the child herself so only the most severecases need to be hospitalised. It is therefore easier to reach many more children, most ofwhom recover remarkably quickly. Despite all this, only five per cent of the 20 million
children at risk of death receive RUFs.
There is less certainty about how best to approach less severe forms of malnutritionand different strategies will work in different contexts. Yet the success of RUFs isundeniable and MSF would like to see a dramatic expansion of this response.

A mother can effectively treat the childherself so only the most severe cases need
to be hospitalised.
Wealthy countries must do more to prevent childhood malnutrition and stop donating
foods that are inadequate for small children. Food aid must include specific productsthat meet the nutritional needs of children below two years of age. Equally,
governments of affected countries must prioritise malnutrition and ensure acutely
malnourished children receive RUFs or other effective supplements. RUFs have to be
more affordable, available from more producers and in a wider range of products thatmeet local needs and address different levels of malnutrition.
Most important, however, is the will to challenge the status quo so that children indeveloping countries have equal access to nutritional food. This is a crucial step towards
dramatically reversing the number of children dying from malnutrition.

NEPAL
Reason for Intervention • Armed
conflict
Field Staff 125

People living in the mountainous
regions of Nepal suffer a wide rangeof preventable illnesses associatedwith poor living conditions including
respiratory infections, skin ailments
and diarrhoeal diseases. Healthstructures are poor and dilapidated,with blocked and unusable sanitaryfacilities, no healthcare waste
management, inadequate staffing
levels and a lack of medical supplies.
MSF initially began working in Nepal to carefor those isolated by the Maoist conflict.
However, projects are increasingly focusing on
upgrading basic healthcare and establishing
services for women. Often excluded from thehealthcare system by social discrimination,

PAKISTAN
Reason for Intervention • Armed
conflict • Social Violence/Healthcare
exclusion • Natural disaster
Field Staff 413

Life in Pakistan is slowly returning tonormal after the devastating earthquake of 2005. However in June, thisprogress was hampered by cyclone
Yemyin that caused widespread
damage in the South. MSF responded tothis crisis, and continued to provide
other health services in the country,
particularly around maternal health.
The aftermath of Cyclone Yemyin
Heavy monsoon rains exacerbated by cyclone
Yemyin, which swept through the southernpart of the country in June, caused flooding
and displaced thousands of people in thewestern province of Balochistan. MSF
responded to the emergency, complementing
the activities of the Ministry of Health.
MSF treated over 1,000 patients for diarrhoea,
malaria and skin infections in the first weeksof the floods and set up two cholera treatment
centres in Turbat and Jhal Magsi. A water

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women have little access to routine reproductive care or emergency obstetrical surgery.
In May, MSF organised and supervised awomen’s ‘surgical camp’ in partnership with
the Nepalese Ministry of Health and the Public
Health Concern Trust. The project provided
surgery for women suffering from uterinevaginal prolapse, often caused by obstetricaltrauma during labour and delivery. The con­dition results in a variety of debilitating anddifficult symptoms including pain, discharge
and bladder infections. Successful surgery wasprovided to over 80 women.
MSF also expanded its Kalikot project, which
focuses on women’s health as well as offering
general primary and secondary care. Almost
20,000 patients were seen. The infrastructure
and operating procedures of the hospital were
improved and MSF opened a day centre
providing therapeutic feeding for over 100
malnourished children. The team also

treatment unit in Ormara and a chlorination
unit in Pasni were established to provide safe
drinking water. MSF also provided relief andmedical supplies in Jaffarabad, Jhal Magsi,
Nasiribad and Turbat. Doctors and nurses weresent to provide additional support and ran
mobile clinics to target isolated communities.

Improving maternal health
In October 2006, MSF started a project inMalakand district, North West Frontier
Province. The project aimed to support Agra
hospital and a series of health centres indelivering primary healthcare, with aparticular emphasis on maternal health. By
December 2007, MSF had conducted some
6,300 consultations at the hospital, assisted
over 60 deliveries and admitted 100 patients,
many with respiratory infections, trauma andchronic diseases.
Delivering care in the federally administeredtribal areas since March 2006, MSF has provided
up to 1,000 paediatric consultations a monthin the Alizai hospital in Kurram Agency.
The project has been extended to cover reproductive health, including emergency obstetricsurgery and neo-natal services in Alizai and
Sadda hospitals.

© P.K. Lee

responded to numerous cholera outbreaks.
Despite the conflict between Maoists and thegovernment being officially over sinceNovember 2006, sporadic fighting has continued
to threaten the fragile peace. MSF opened a new
project in the Central Terai, Rauthahat district,
where the local population lives amid fighting
between Madheshi armed groups and government forces. The violence has resulted insevere restrictions on movement, limiting

people’s ability to reach healthcare services.
By mid-year, marked improvements in the
security situation of certain areas allowed MSF
to hand over three projects. Health authorities
took over the work in Khotang, while activities
in Rukumkot and Arviskot were transferred to
local non-governmental organisations.
MSF has worked in Nepal since 2002.

Sectarian violence
MSF teams also provided emergency medical
support and surgical supplies during sectarian
violence in March and distributed relief supplies
to displaced families.
In December, fighting in Swat district, northof Malakand, left many people injured andmany more were forced to flee. MSF donateddrugs and materials to the emergency room of
Mingora hospital and began a mobile clinic in
partnership with a local ambulance service
during curfew hours. Working together withlocal non-governmental organisations, MSF
also distributed food, hygiene and sheltermaterials to displaced people. However,the security situation prevented the full
deployment of MSF emergency operations.

Assisting Afghans in Balochistan
province
MSF provides care in a rural health centre andsupports maternal and child care in Kuchlak, alargely Afghan refugee settlement just northof Quetta, Balochistan. Over 5,000 medical
consultations are conducted every month,including mental health support. Healthservices in the border town of Chaman are
over-stretched, providing for the local© MSF

MSF treated over 1,000
patients for diarrhoea,
malaria and skininfections.
population, refugees and patients comingfrom neighbouring Afghanistan. In May, MSF,
therefore, started supporting Chaman hospitalin Balochistan through a reproductive healthproject that includes emergency obstetricsurgery and neo-natal services.

Earthquake project transfer
In October 2007, MSF transferred the only
remaining project related to the 2005 earthquake, a 60-bed temporary hospital in Bagh,to local authorities.
MSF has worked in Pakistan since 2000.

69

Papua new Guinea
Reason for Intervention • Armed
conflict
Field Staff 163

Papua New Guinea’s circumstances are
fairly unique. The island country has
only been independent for 30 years
and is comprised of hundreds of tribes(speaking more than a total of 860
languages).
The inhabitants are still unfamiliar with theidea of being one nation with a central government and much of the country is struggling toadjust. The country’s population of approximately six million people predominantly lives
in rural and often very remote areas of theisland.

Significant health issues
Papua New Guinea has some of the worst
health statistics in the Pacific region. Maternal
and infant mortality rates are high, and treatable diseases such as malaria, pneumonia andtuberculosis (TB) remain common. With an

overall estimated HIV prevalence of two percent among adults and pockets of much higher prevalence in some communities, AIDS has
become a significant health issue. Violenceoccurring at all levels of society causes anenormous amount of harm, with physical andsexual violence against women and children(particularly girls) being extreme. Currently,
the country’s health services cannot handle
the tremendous need for care.

Assessment
In mid-2007, a second assessment confirmedthat women and children continued to sufferfrom massive levels of domestic and social
violence and that appropriate medical andpsychosocial assistance for its survivors wasalmost entirely absent in most parts of thecountry. Based on these findings, MSF begansupporting the Women and Children’s Support
Centre in the city of Lae. The clinic, foundedby Soroptomists International, was handed
over to MSF by the signing of an agreementwith the Morobe province Angau Memorial
Hospital. This programme aims to establish

SRI LANKA
Reason for Intervention• Armed conflictField Staff 163

Whilst a cease-fire agreement
was signed between the warring
factions in 2002, conflict erupted
again in 2006.
In 2007, war escalated in the northern andeastern parts of the island. Daily life is dominated by the conflict, with fighting at thefrontlines, aerial bombings (sometimes on
civilian settlements), roadside mines,
restrictions on movements, suicide bombings,
abductions, judicial executions, disappearances and arbitrary arrests.
Insecurity seriously hampers access to people
affected by the conflict but so do thegovernment restrictions on humanitarianassistance. Few humanitarian organisations
are in a position to address needs and people
are left without access to healthcare.
Although MSF returned to the country in
2006, it was not until January 2007 that the© Henk Braam / HH

Daily life is dominatedby the conflict.
Minister of Health authorised the teams tostart providing care. MSF offers surgical,
obstetric/gynaecological and paediatric care ingovernment-controlled and LTTE-held zones in
the northern part of the island.
The conflict and resulting insecurity have led
many health workers to flee and there is now aserious shortage of health specialists in conflict areas. In government hospitals, MSF
nurses and doctors are filling health staff gaps
to assist victims of the conflict.
MSF has started three programmes in Point
Pedro (east of Jaffna Peninsula), Vavuniya and

THAILANDquality healthcare services and provide amodel of care for others. An additional new
facility was also built and the staff started
seeing patients in December 2007. The teamprovided comprehensive outpatient medical
and psychosocial care to survivors of genderbased violence, including rape. The MSF teamalso worked closely with staff from the
Ministry of Health in Lae Hospital, in an effort
to improve hospital services for victims ofviolence, particularly those services offered in
the emergency department.

Reason for Intervention • Endemic/Epidemic disease • Social Violence/
Healthcare exclusion
Field Staff 225

In Mae Sot, on the Thai-Burmese border, MSF
began treating tuberculosis (TB) among
unregistered migrant workers from Burma andrefugees in Mae Lae camp in 1999. The project
also offers counselling and health education.
In 2007, there were 5,234 consultations
invol­ving 581 TB patients, 70 per cent of whom
successfully completed treatment. Twenty-one
patients have drug-resistant TB. MSF alsooffers ART for those co-infected with TB andHIV and had 115 patients under ART at the endof the year.

New project sites
In 2008, MSF plans to further develop andexpand the existing clinic’s services while also
looking for potential, new project sites in the
country. When appropriate, MSF will carryout advocacy work to help establish national
protocols and service guidelines to better
meet the needs of those harmed by genderbased violence.
MSF has worked in Papua New Guinea since 2007.

Mannar, all government-controlled areas close
to the frontline of conflict where thepopulation is particularly at risk. Working
with local staff, MSF offers quality general andemergency surgery and obstetrics assistance.
MSF performed more than 6,000 surgicalprocedures.
MSF was also able to extend activities inconflict and LTTE-controlled areas. MSF holds asurgical outpatient clinic in Point Pedro andsupports the Vavuniya district hospital, which
also serves as the referral hospital for people
living in the LTTE-controlled area. In May, MSF
launched a project in Kilinochchi, in the heartof the LTTE-held region. However, due to thefighting in Mannar district, MSF was unable tostart supporting Adampan hospital, alsosituated in a LTTE-held region.
MSF established a project in Batticaloa toassist 12,000 internally displaced people byconducting mobile clinics and providing relief
supplies. However, as the situation improved, by
the end of the year MSF handed over the project.
MSF has worked in Sri Lanka since 2007.

Thailand has announced the repatriation of
Hmong refugees and is screening the pop­
ulation without involving an independent
party. MSF has urged Thailand not to repatriate refugees without proper guarantees of
their well being on return to Laos. MSF is also
asking for an independent third party, such as
UNHCR, to monitor the situation.

© Espen Rasmussen / Panos

In Mae Sot, there were over 5,000 consultations
involving over 500 patients, 70 per cent of whom
successfully completed treatment.
MSF provides medical care, including
HIV/AIDS treatment and prevention,
for vulnerable groups, ethnic
minorities and migrants.

MSF began screening and treating patientsfor retinitis CMV, a dangerous opportunistic
infection that can lead to blindness and death.
Twenty-eight patients have received treatment.

Establishing non-discriminatory carefor HIV/AIDSIn Chiang Saen and Mai Sai hospital, in Chang
Rai province on the Thai-Lao border, MSF offers
cross-border HIV/AIDS treatment and care to
unregistered minorities from Myanmar andLaos. MSF has also strengthened the capacityof three Lao hospitals and Lao patients can
now be referred and treated in their country.

MSF began its first anti-retroviral treatment(ART) programme in Thailand in 2000 andhas since worked closely with the healthauthorities and local partners to support
people living with HIV/AIDS and improvetreatment and care. Currently, 100,000
patients receive free first-line ART through thenational health security scheme. Second-line
treatments are also available free.
In Kalasin province, north-east Thailand, MSF
is working in partnership with Kuchinarai
district hospital and support groups tostrengthen and maintain first-line ART
through viral load monitoring and community
activities. Currently, 220 patients receive
first-line treatment and five patients are on
second-line treatment.

Providing healthcare to migrants andminorities
In Petchabun, northern Thailand, MSF has
been ensuring adequate medical care, watersupply and sanitation in the Lao Hmong
refugee camp since 2005. In late June, 7,900
refugees were relocated to a bigger holding
camp. MSF continued its medical and waterand sanitation services in the new camp andbegan food distribution. Mental healthactivities began in November, with the main
diagnoses including anxiety, depression andpost-traumatic stress disorders.

In Phang Nga, thousands of undocumented
migrant workers from Burma are still crossing
the border to seek jobs in Thailand. As they
have no official access to heathcare, MSF
provides mobile clinics, health centres andBurmese-speaking medical staff. The primary
healthcare services include mother-childhealthcare and treatment of communicablediseases including HIV/AIDS. MSF carried out
over 4,500 consultations and some 200 women
were assisted to give birth safely in hospital.

Providing healthcare to excluded
populations
Drug users are among the highest risk
groups for HIV infection. MSF provides healtheducation and trains peer workers in one of
Bangkok’s drop-in centres.
MSF is progressively handing over its project in
two prisons in Bangkok to the Department ofCorrection. The project, which began in 2003,
offered HIV prevention information andtreatment to prisoners. MSF also trained prison
medical staff and covered laboratory costs. MSF
is working with the Department of Correction
to develop a training curriculum, which will be
used to extend these services to all Thai prisons.
MSF has worked in Thailand since 1983.

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TURKMENISTAN
Reason for Intervention• Social Violence/
Healthcare exclusion
Field Staff 68© James Kambaki

High mortality rates among newborns, infants
and young children is a serious issue.
MSF is working to advance the quality of healthcare for children and pregnant
women in Magdanly – an impoverished area on the Eastern frontier of
Turkmenistan, predominantly populated by ethnic Uzbek communities. Despitesome bureaucratic problems improvements in paediatric care have been made.
Overcoming bureaucratic obstacles
High mortality rates among newborns,
infants and young children is a serious issue
and the prevalence of communicable diseases such as tuberculosis (TB) and sexuallytransmitted infections are also of grave
concern. The lack of accountability on

UZBEKISTAN
Reason for Intervention • Endemic/
Epidemic disease
Field Staff 81

The ex-Soviet republic of Uzbekistan
has a high tuberculosis (TB) incidence
rate and one of the world’s highest
levels of multi-drug resistant (MDR)
TB, a strain that is resistant to themost powerful anti-TB drugs. MDR-TB
rate accounts for 13 per cent of all
new TB cases and 40 per cent of
re-treatment cases.
MSF has been treating TB in Uzbekistan since1998, initially using the directly observed
treatment short course (DOTS) and more
recently DOTS-Plus for treating MDR-TB in theautonomous region of Karakalpakstan.

intensive care and maternity wards of the
Magdanly Town hospital. The project has set
up an intensive baby care room and childscreening facilities and makes regular
outreach visits to primary healthcare posts
around Magdanly. MSF also built andequipped a TB laboratory to help tackle therising number of cases.

MSF’s ability to work closely with patients,
local healthcare workers and healthcare
managers, enabled the team to gain anunderstanding of the country’s most acutehealthcare needs.
In 2008, MSF plans to expand its activities toother regions and will remain on standby
for any health-related emergencies.

MSF started working in the eastern
Magdanly district in 2004 and supports thegeneral paediatrics, infectious disease,

MSF has worked in Turkmenistan since 1999.

Inappropriate and inadequate treatment ofcommon sensitive TB increases drug resistance.
MSF has seen many alarming practices in thelocal healthcare system that fuel this epidemic,
from poor infection control in TB facilities andinappropriate use of first and second-line drugs,
to self-treatment with anti-TB medicines easily
available on the market. MSF is now seeing a
number of cases of extensive drug resistant(XDR) TB.

effects. After six months in hospital, patientsneed to continue on medication for another 18
months supported by a mobile DOTS-Plus clinic
or home visits from an MSF nurse. In 2007, MSF
enrolled 265 patients, compared to 150 in 2006.
Since the start of the programme in late 2003,
MSF has enrolled over 617 patients.

Patients from Nukus and Chimbay region
receive DOTS-Plus treatment in a renovated
MDR-TB hospital. The treatment is complex andlengthy. Some patients suffer unpleasant side

72 | BOLIVIA
72 | Brazil
73 | COLOMBIA
74 | GUATEMALA
74 | HAITI
76 | HONDURAS
76 | PERU

While MSF is attempting to improve
paediatric care in the city, its ability toprovide meaningful care has been hamperedby the fact that all healthcare services inthis district face bureaucratic obstacles anda lack of political commitment. Despite
these frustrations, MSF’s programme managed to support more than 4,000 hospitalbased consultations, about 15,000 outpatient visits and over 1,000 deliveries.

illness and death caused by disease has
led to a downward spiral in the quality ofhealthcare.

In a joint MSF and Ministry of Health programme, MSF has set up a reference laboratory
in Nukus where MDR-TB is diagnosed by testing
sputum for sensitivity to certain drugs.

The Americas

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At the end of the year, MSF signed a memorandum of understanding with the Ministry of
Health of Karakalpakstan on the gradualhandover of the MDR-TB treatment programmeover the next three years. MSF still has major
concerns about the sustainability and future of
the project and plans to address these by investing in local capacity-building and advocacy.
MSF has worked in Uzbekistan since 1997.

An MSF psycho-social team works with children and adults to help them recover from the August earthquake that rocked the Peruvian coast.
© Jodi Hilton / Corbis

73

BOLIVIA

Colombia

Reason for Intervention • Endemic/
Epidemic disease
Field Staff 35

Reason for Intervention • Armed conflict• Social Violence/Healthcare exclusion • Natural disaster
Field Staff 312

The Chagas parasitic infection affects
some 18 million people in Latin
America, with the highest prevalencein Bolivia. Transmitted by bloodsucking insects commonly found in
impoverished areas and rural dwellings,
Chagas can debilitate the heart andintestinal systems, shortening life
expectancy by about 10 years.
Chagas has attracted little investment in termsof diagnostics and drug development. The only
treatment is based on two older-class drugs
that risk many side effects and make patientmonitoring and follow-up essential. The main
target for medical interventions has always
been children as treatment for adults has
never proved completely successful.
MSF has undertaken several projects to preventand treat Chagas in Bolivia. Initially, theprojects treated children only but a new
project opened in Cochabamba in August also
treats adults and is integrated into six urban
health centres. The need to work with andtrain health workers meant a slow start but
Chagas is now a step closer to being treated© Juan Carlos Tomasi

Initially, the chagas projects treated children
only but a new project has opened in Cochabamba
for adults also.
like any other disease at the primary care level.
While the Chagas National Programme started
diagnosing and treating patients under 15
years old in various municipalities in the
country in 2006, access remains unavailable
for the majority and MSF has been increasing
its advocacy within the country to improvethis. Research has also been a key part of the
Chagas projects in Bolivia, and further
research into new diagnostic tools andtreatments is planned for the coming year.

Brazil

MSF works with national and internationalorganisations to raise awareness of Chagas andencourage more research and development
into effective diagnostics and drugs. MSF has
been a partner of the Pan American HealthOrganization and participates in the Global
Network for Chagas Elimination launched at
the World Health Organization in July.

Complexo de Alemão is a deprived andviolent neighbourhood of Rio deJaneiro. The area is well known forregular clashes between local armed
groups and with the Rio de Janeiro
police forces. The local population,
estimated to be around 150,000, lives
trapped in the violence.

© MSF

practiced by medical staff, establishing anefficient triage system for the quick diagnosisof patient needs. By December, MSF hadtreated around 2,000 patients, mainly for© Espen Rasmussen / Panos

Hundreds of thousands of Colombians are displaced, trapped, isolated and impoverished by the conflict that has ravaged their country for the past 45 years.
Guerrilla groups, government forces and paramilitary groups continue to fightin many areas. The violence has caused widespread physical and psychologicaldistress, yet many victims continue to be overlooked by their government andthe international community. Healthcare access is difficult and dangerous for
those in rural conflict zones and those forced to seek refuge in urban slums.

MSF has worked in Bolivia since 1986.

Delivering healthcare in conflict
stricken areas

violent and accidental injuries, respiratory
tract infections and suspected dengue fever.
Across Brazil, MSF offers training to municipalities, mainly on security risk managementin violent settings. Over 600 staff from thefamily health programme in Rio, Belo
Horizonte and other municipalities followed
this training programme during the year.

Reason for Intervention • Armed
conflict
Field Staff 42

Since October, MSF has been providing emergency and mental health services to thoseliving in Complexo do Alemão. MSF runs anemergency room in Fazendinha, at the heartof the neighbourhood, offering emergency
care, mental health services, MSF ambulatoryreferrals and an advisory service. Techniquessuch as advanced trauma life support are

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In partnership with the Oswaldo Cruz
Foundation, MSF has a Chagas diagnosis
project in the Amazon region. The project
aims to train health professionals to
identify the parasite that causes the disease
while screening for malaria. The project,
implemented in 12 health centres so far, has
identified some 200 cases of Chagas. The
project will expand in 2008, to include more
health centres.

MSF has a wide range of healthcare projects
across the country particularly in areas
affected by violence and conflict. Mobile
clinics provide primary care, sexual andreproductive healthcare and mental healthcare to patients in the rural areas of Norte deSantander , Sucre/Bolívar, Chocó, Córdoba,
Nariño, Cauca, Putumayo, Arauca and Caquetá.
In July, MSF began to provide medical
healthcare using mobile teams to assist the
populations in the rural areas of Cartagena delCharia and San Vicente de Caguán. Inhabitantsin southern Colombia are also suffering theeffects of the conflict, with Cauca andPutumayo witness to frequent fighting. In
March MSF began working in the area, supporting health facilities and providing
healthcare through mobile teams.
MSF also gained access to the Montes de Mariaregion following a three-year blockade of allinternational organisations.

In Buenaventura (Valle del Cauca), one of themost violent cities in Colombia, where accessto healthcare is limited by the dangers oftravelling in the city, MSF has establishedmobile clinics to provide urgent medical care.
MSF has also opened a centre to assist
patients who cannot access other healthfacilities for financial or security reasons.

Supporting IDPs
MSF also supported the internally displaced
populations (IDPs), seeing over 9,000 patientsin the urban clinic in Sincelejo, Sucre. On theoutskirts of Bogotá, Colombia’s capital, MSF
works with the displaced in Soacha, conducting medical consultations and providing
mental health support for those excluded
from the public health system. The team also
tells families about their right to national
healthcare and provides information on gaining access to the government-run healthsystem. Some 2,700 patients were seen in 2007,
many suffering from skin diseases, respiratory
infections and psychological distress.

In August, MSF began a new project for IDPs
on the Venezuelan border, in Tame, Arauca
department, where nearly 1,500 consultations
were carried out in the first two months.
Delays in receiving government social benefits
leave IDPs with gaps in healthcare coverage,
which MSF covers by providing medical care to
all recent IDPs. Mental health consultations
are also complemented with training andsupport for local mental health institutions.
Efforts to address mental health are made in
Caquetá department through mental healthcentres in Florencia and adjacent municipa­
lities. During 2007, 9,540 people were seen.

Prioritising maternity needs
In Quibdó, Chocó, MSF focuses on the maternity
needs of women and babies by providing direct
support to the maternity ward. MSF also
provides sexual, reproductive and mental
healthcare using mobile clinics in the IDP
areas of the city. Over 17,600 consultations
were carried out, with particular attention
paid to the medical and psychological needs ofvictims of sexual and domestic violence.

Projects closed in Tolima and Huila
After seven years, MSF has begun closing
projects that provided primary and mental
healthcare in rural Tolima and Huila and to
displaced people in Ibagué as there is now alesser need for mental health consultations as
the displaced population has decreased.

MSF has worked in Brazil since 1991.
MSF has worked in Colombia since 1985.

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GUATEMALA
Reason for Intervention • Endemic/Epidemic disease • Social Violence/
Healthcare exclusion
Field Staff 44

Poverty in Guatemala is widespread in the countryside and amongst indigenous
communities. Child mortality and malnutrition rates are the highest in theregion, and life expectancy is the lowest. The country is plagued by organised
crime and violent street gangs.
Not enough medical attention has been paid
to victims of sexual violence in Guatemala.
A protocol for addressing these patients inhealth structures approved by the Ministry of
Health in 2005 has yet to be implemented.
MSF started a project to treat survivors of
sexual violence in zone 18 of Guatemala City.
This is one of the ‘barrios’ most affected byviolence and organised drug crime. MSF activities included reproductive healthcare andpsychological services in a Ministry of Healthprimary care clinic and maternity clinic.

Healthcare is also provided by MSF through amobile unit working with several non-governmental organisations (NGOs) throughout
Guatemala City. The project also aims to raiseawareness of the violence and the importanceand availability of specialised care.

Handover of HIV/AIDS treatment
projects
Increased support from international donors
and gradual improvements in healthcare
services, funded and delivered throughGuatemalan government structures, led MSF

MSF started a project totreat survivors of sexual
violence in zone 18 of
Guatemala City.
to transfer its remaining HIV/AIDS projects in
Coatepeque, Puerto Barrios and Guatemala
City to health authorities.
The national health service has taken over
responsibility for HIV/AIDS care at the hospitalin Coatepeque, where 900 patients were treated, and treatment for most of the 750 patientsin the Guatemala City programme will now be
provided by a local medical NGO called
Fundación Marco Antonio.
However, issues of scale-up and continuity ofcare remain major challenges in Guatemala.
MSF supplied anti-retroviral drugs to treatment centres experiencing drug shortages.

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Such shortages were mainly due to low treatment targets that did not reflect the actual
number of people in need, budgetary issues,
inadequate coordination between thenational HIV/AIDS programme and the Global
Fund’s implementing partner and the late
procurement of drugs. MSF raised theseconcerns publicly, including to representativesof the Ministry of Health.
In September, MSF also highlighted gaps in
support for the HIV/AIDS department in
Coatepeque hospital and the risks associatedwith anti-retroviral drug shortages. MSF
believes the Global Fund should work with
its implementing partner to set realistic
treatment targets and use its financial leverage
to lower drug prices. MSF also advocated for
the Guatemalan government to take advantageof World Trade Organization mechanisms topurchase the most effective medicines at thebest prices.
MSF has worked in Guatemala since 1984.
© Juan Carlos Tomasi

HAITI
Reason for Intervention• Armed conflict• Social Violence/Healthcare exclusion
Field Staff 794

Large sections of Haiti’s population,
particularly in the capital, Port-auPrince, live in precarious conditions
due to poverty, neglect, urban violence
and lack of access to basic healthcare.
Violence continues, especially in
Martissant, where MSF treated over
200 gunshot injuries. An MSF survey
between January 2006 to July 2007
showed that nearly one in four deaths
in Martissant was related to violence.
Violence and conflict
Since December 2006, MSF has operated an
emergency health centre in Martissant, aneighbourhood characterised by daily violence
and a lack of medical facilities. Every day,patients are referred from the emergency
health centre to the other hospitals where MSF
works. MSF established a number of mobile
clinics in the heart of the Martissant neighbourhoods, with medical teams offering
primary healthcare to some 400 patients a day.
© Cristina De Middel

At the end of 2007, MSF handed over its projectin the slum of Cité Soleil, where the security
situation has improved, to the Ministry of
Health. The project started in July 2005 toguarantee access to care for victims of theviolence. The ongoing presence of MSF teams,
even during the most intense fighting, resulted in 72,000 consultations at the primary
health centre of Chapi and 32,000 at Choscal
hospital, where more than 13,000 patientswere hospitalised. However, since April thesituation has got better, with no patient with abullet wound seen at the Choscal hospital andpeople in the neighbourhood no longer living
in fear and isolation.
MSF continued to provide medical and surgicalcare at its Trinite trauma centre in Port-auPrince, admitting more than 14,000 patientscompared with 11,000 in 2006. The number ofadmissions for gunshot wounds fell from 1,300
in 2006 to 500 in 2007, although the numberof victims of stab wounds, rape and beatings
continued to rise. In total, 2,847 patients wereadmitted for violence-related trauma.

Throughout the year, MSF medical teams
focused on improving quality of care, working
to perfect the recently introduced surgical
technique of orthopaedic internal fixation.
A total of 205 patients benefited from thistechnique, which sharply reduced their lengthof stay in hospital.
MSF also operates a physical rehabilitation
centre where patients needing specialised
post-operative treatment can receive physiotherapy and psychological care.
In June, MSF increased its capacity to treat
victims of sexual violence in the capital,
offering comprehensive psychological andmedical treatment. The programme treated242 victims between July 2006 and June 2007.
Awareness campaigns emphasising confiden­
tiality and the need to seek treatment within

MSF mobile teams offer
primary healthcare tosome 400 patients a
day in Martissant.

72 hours resumed in July in the shantytowns
and city centre.

Maternal health needs
Maternal mortality rates in Haiti are thehighest in the western hemisphere(approximately 630 women die for 100,000
births), mainly due to eclampsia. The insecureurban slum environment where many women
live limits their access to healthcare as physical and sexual violence, extortion and common crime are serious threats.
In 2006, the emergency maternal Jude Ann
hospital was opened in Port-au-Prince, the only
hospital in Haiti to offer free emergency
obstetric care. By the end of 2007, over 13,000
women had given birth here. MSF also started
providing services in fixed clinics in selected
slum communities, with ante- and post-natal
care and a referral service in the three slumsof La Saline, Pelé Simon and Solino. Mental
health services will be added in 2008.
MSF has worked in Haiti since 1991.

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HONDURASPERU

Europe and the Middle East

Reason for Intervention • Social
Violence/Healthcare exclusion
Field Staff 41

Reason for Intervention• Endemic/Epidemic disease• Social Violence/Healthcare exclusion• Natural disaster
Field Staff 73

78 | BELGIUM
78 | FRaNCE
79 | ITALY79 | MOLDOVA
80 | RUSSIAN FEDERATION
81 | SWITZERLAND
81 | IRAN
82 | IRAQ
83 | Yemen
84 | PALESTINIAN TERRitories

Urban violence in the capital,
Tegucigalpa, often affects street
children who are already marginalised.
Many have drug addiction problems,
precarious employment, and poor
access to healthcare facilities.
MSF runs a day centre for young people on thestreet in Comayaguela, one of the poorest
neighbourhoods of Tegucigalpa. The projectprovides medical and psychological help tochildren and adolescents up to the age of 24
who live on the streets. Awareness campaigns
aim to make sure the young people know
about the centre and its services. They are also
informed of their rights and accompanied tohealth facilities in emergency situations.
The emphasis is on addressing the damage
caused by drugs, particularly the common
addiction of glue sniffing. Further medical
activities focus on sexual and reproductive
health, as young girls are often involved incommercial sex activities or become victims ofsexual violence. An estimated 400 young
people were seen at the day centre in 2007.
MSF advocates on behalf of these children,
highlighting their plight among governmental
and non-governmental agencies and the public
in an effort to improve their situation. In one
example, MSF documented the experiences ofyoung people living on the street in a book
distributed to the local authorities, partnerorganisations and the general public.
At the end of the year, MSF began to assist
other vulnerable and stigmitised groups
who also have limited access to health andsocial services.
MSF has worked in Honduras since 1998.

© Jodi Hilton / Corbis

Psychologists provided support group sessions
called ‘Charlas’.
When a powerful earthquake hit Peru
in August, MSF provided emergency
medical relief to remote communities.
Parallel to this, MSF continued tohelp vulnerable groups affected by
HIV/AIDS.
Helping the remote and thetraumatised
On 15 August, an earthquake measuring 7.9 on
the Richter scale shook the coast of Peru,
killing 600 people, wounding 2,000 andmaking tens of thousands homeless. The towns
most affected were Chincha, Pisco and Ica,around 200 kilometres south of Lima. The first
MSF team arrived within 24 hours to assess theneeds and launch emergency relief activities.
MSF focused its efforts in the most remoteareas to the east and Guadalupe, a town in thesouth-east. A centre for post-traumatic andpost-operative care was set up in the centre of
Pisco. Mobile clinics were established in many
towns, supported by 30 healthcare facilities
providing medicines and epidemiologicalmonitoring. Psychologists provided support
group sessions called ‘Charlas’, and individual
sessions to help people cope with the psychological effects of the disaster. When relief
activities ended in December, psychosocial
assistance had been provided to 8,000 people.
In addition, 12,000 people benefited from theprovision of medicines, water and sanitation
activities and distribution of relief goods.

HIV/AIDS. The prevalence of HIV in the country
is relatively low, although highly concentrated
in marginalised groups such as commercial sex
workers, drug users and prisoners.
In 2004, a project was started in Villa El
Salvador, the second biggest slum in Lima andhome to half a million people. This aimed todecentralise HIV/AIDS care and reduce stigma
and discrimination by promoting free access tocare with free single-dose medication.
MSF also implemented the manual CD4 countin five Peruvian provinces. MSF has trained
health providers from the Ministry of Healthon this technique, which is crucial to establishing immunity levels and determining when an
HIV-positive person should start anti-retroviraltreatment (ART).
Since 2006, MSF has gradually handed over thisproject to the Ministry of Health. By the endof the project, MSF had trained over 2,000
health staff and implemented voluntary counselling and testing in more than 30 healthcentres. A total of 482 patients affected by HIV
were enrolled in the programme, with 342
started on ART.
MSF also completed the closure of a projectfor sexually transmitted infections and HIV/AIDS in the state prison of Lurigancho, thelargest prison in Peru. The project was
replicated in Chorillos Common, Chincha andHuaral prisons.

MSF transfers HIV/AIDS projects
MSF’s recent work in Peru focused on providing comprehensive care to people living with

MSF has worked in Peru since 1985.

Thousands of Somali and Ethiopians risk their lives every year to cross the Gulf of Aden to escape from conflict and extreme poverty.
© MSF

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BELGIUM
Reason for Intervention • Social Violence/Healthcare exclusion
Field Staff 17© Dieter Telemans

MSF continues to provide medical and psychosocial
consultations in Brussels and Antwerp.
Everyone in Belgium is entitled to healthcare. This includes undocumented
migrants and asylum seekers, although in practice their access to healthservices is restricted by numerous administrative obstacles. MSF assists
migrants in Belgium by providing medical care and advocating for government
services to face up to their responsibilities.
MSF continues to provide medical and psychosocial consultations in Brussels and Antwerp topeople who cannot access these through normal channels. More than 5,000 consultations
were conducted in 2007, with the majority ofpatients being undocumented migrants andasylum seekers. Rather than creating a parallelsystem, the aim is to direct people towards theofficial system, which is supposed to provide
the service.
When necessary, MSF advocates for patientsboth with the social services and within
political spheres that has led to improvementsin access to national health services. As aresult, MSF will hand over its activities toanother organisation in April 2008 because
although the situation has improved, there
remains a need for a focal point to help migrants and asylum seekers find their way
through the complex health system.
Until the end of May, MSF also provided
psychological and medical consultations in
the five detention centres in Vottem,
Melsbroek, Steenokkerzeel, Merksplas andBrugge where illegal migrants are kept before
their expulsion. Most of the 206 people seen
since May 2006 were suffering from stressrelated psychosomatic problems. MSF
published a report highlighting the negative
impact of the detention centres on health andmore particularly on mental health.
MSF has also witnessed the human cost of detention for critically ill patients, including womenwith complicated pregnancies, people livingwith HIV, diabetics and acute psychiatric cases,
many of whom remain in detention centres forseveral months. MSF has called for a major
review and changes to the detention policies for
undocumented migrants in Belgium.

FRANCE

ITALY

Reason for Intervention • Social
Violence/Healthcare exclusion
Field Staff 5

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

2007 has seen an increase in thenumber of illegal immigrants deported
from France and new attempts toreform asylum policies. In addition,access to the French and European
territory is becoming more difficultand administrative procedures for
those seeking refuge are increasingly
complex. Psychological assistance forhomeless and non french speaking
refugees in France remains extremely
limited.

The plight of migrants arriving andliving Italy continues to be worrying.
MSF provides medical care, but for
many the reality of life in Italy ismore precarious than expected.

In March, MSF opened a centre in Paristargeting particularly those without valid
immigration papers who have sought refuge
after fleeing conflict, violence or persecutionsin their home countries. These people arelikely to be suffering psychological distress.
Their precarious living conditions only increase their anxiety. Psychological care isessential to avoid deterioration leading tosuicide attempts. Most do not speak Frenchand, without valid papers, have little access tohealthcare.

Every year, thousands of migrants arrive in
Italy having made the precarious boat journey
across the Mediterranean sea to Europe. Many
lives are lost. Survivors arrive exhausted anddehydrated, suffering from respiratory infections and skin complaints, caused by overexposure to salt and water and burns fromfuel accidents. MSF has established a base at
one of the most used landing points on the
Island of Lampedusa, providing medical help
to more than 12,000 migrants in 2007.
MSF continues to work in the Campania region, in Caserta and Naples provinces, runningvarious clinics for undocumented migrants.
The area is one of the most deprived in Italy

and home to a large number of illegal
migrants who live in extremely difficult con­ditions. The MSF project focuses specificallyon women migrants employed as sex workers.
It includes outreach activities and medicalcare for sexually transmitted infections and
HIV/AIDS prevention. More than 7,000
consultations were performed in the MSF
clinics in 2007.
Many thousands of migrants move aroundsouthern Italy to work as seasonal farm workers in the fields. Most are young men fromAfrica with no permit to stay in Italy. Between
July and November 2007, at the same time asproviding medical services, an MSF teaminterviewed over 600 seasonal workers. A fullreport of the results will be issued in 2008 but
the initial picture is one of poor living, working and health conditions.
After five years of carrying out programmes inSicily, MSF handed over all clinics for undocumented migrants to the Ministry of Health.
MSF has worked in Italy since 1999.

MOLDOVA
Reason for Intervention • Social
Violence/Healthcare exclusion
Field Staff 28

HIV patients in Transnistria, thebreakaway republic of Moldova, have
limited access to quality healthcare.
MSF is providing life-prolonging antiretroviral treatment (ART) for HIVpositive patients as well as supporting
local health authorities in introducing
HIV/AIDS care into the primary
healthcare system.
MSF is one of few agencies providing direct
assistance to people living with HIV/AIDS inthis isolated region. According to official
statistics, the prevalence of HIV/AIDS in
Transnistria is four times higher than in therest of Moldova. The region is not recognisedby the international community and little
international aid has reached here despite theenormous amount of assistance given to
Moldova by international institutions to tackle
the HIV/AIDS epidemic.
In May, MSF started HIV-positive patients on
ART. In August, after rehabilitation and inclose collaboration with the local healthauthorities, MSF opened an outpatient
department in the main hospital of the capital, Tiraspol, and trained Ministry of Healthmedical staff to enable the integration of HIV/AIDS treatment into the primary healthcare
system. In September, the programme was
extended into the prison system, where HIV/AIDS prevalence is significantly higher than
average. The rate of co-infection is also muchhigher, with TB being the main cause.

At its centre, MSF provides refugees withpsychological and medical care and advises
them on the social and legal aspects of theirsituation. The multidisciplinary team ofdoctors, psychologists and social workers
conducted some 2,700 consultations, including 1,300 for psychological distress.
MSF has worked in France since 1987.

The MSF team also visits Bender TB hospital
every week to treat co-infected patients andSlobozia, the region’s only inpatient HIV/AIDS facility. In December, the programme
expanded its activities to Ribnitza in the northof the country and began operating a weekly
clinic in the city’s hospital.

MSF provides information to people who face
expulsion and who will not have access to thetreatment they need in their country of origin.
A website, www.ithaca-eu.org, has beenlaunched making the information easily accessible to lawyers and other organisations trying
to contest expulsion on medical grounds.

© Lorenzo Maccotta

MSF provides medical care, but for many the realityof life in Italy is more precarious than expected.

MSF has worked in Belgium since 1987.

By the end of 2007, in partnership with the
Ministry of Health, MSF had enrolled over
360 patients on the programme and 65 hadstarted ART. MSF is now working to makethe programme sustainable so that it can behanded over to the local authorities by theend of 2008.
MSF has worked in Moldova since 2007.

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RUSSIAN FEDERATION
Reason for Intervention • Armed conflict • Social Violence/Healthcare exclusion
Field Staff 74

MSF’s focus is on the post conflict North Caucasus region, treating trauma-related
injuries, providing mental health support, healthcare for women and children
and tuberculosis (TB) care.
Healthcare in Chechnya has been crippled bymore than a decade of war. The majority of
doctors have fled and the security situation for
hundreds of thousands of civilians and internally displaced persons (IDPs) remains precarious. MSF has responded by providing basic
primary healthcare, surgery and mental
health services, as well as supporting
Chechnya’s TB programme. For security
reasons, there are few international staff onsite. Instead, programmes are run by national

Chechen staff, supported by the internationalteam based in Moscow.
In the Chechen capital, Grozny, MSF provides
primary healthcare to the most vulnerable
communities with limited or no access to
medical services. Mobile medical teams
consisting of a therapist, gynaecologist,
paediatrician and psychologist served six
temporary accommodation centres for
Chechen IDPs who returned from Ingushetia

to find their homes in ruins. In an attempt tosolve the IDP problem, the local authorities
attempted to close these centres but with noalernative housing available, they remain andare now called ‘communal hostels’. The MSF
mobile team conducted around 38,000 medical
consultations in 2007.
MSF rehabilitated two clinics in Grozny where
it runs free pharmacies. MSF doctors also
provided women’s health and paediatric medical care in four clinics and reproductive health,family planning consultations and medical
equipment to the capital’s maternity hospital.
Outside Grozny, MSF supports district hospitals
in the mountainous villages of Shatoy, Sharoy
and Itum-Kale, and has set up a primary healthclinic in remote Shelkovskoy district.
MSF runs a medical centre in Nazran, thecapital city of neighbouring Ingushetia,
providing medical and mental health consultations. Some 17,000 IDPs from the conflict in
Chechnya and 18,000 from the Ossetian
conflict of the early 1990s still live inIngushetia. They lead difficult lives with little
support and largely without access to healthservices. MSF conducts up to 1,200 consultations a month for IDPs and the few locals who
also use MSF’s clinic.
As Chechnya’s TB services were largely
destroyed during the war, MSF supports theimplementation of a directly observed
treatment short course (DOTS) programme infour TB hospitals serving around 350,000
people. Since the beginning of the programmein 2004, more than 1,500 patients have received treatment. The programme enrolled
455 patients in 2007. The success rate of over
80 per cent is made possible by the work of
MSF health educators and counsellors who
help patients adhere to the lengthy treatment.
The programme plans to double by extending
to the main TB hospital in Grozny.

© Misha Galustov / agency.photographer.ru

In the Chechen capital, Grozny, MSF provides
primary healthcare to the most vulnerable
communities.

MSF continued to perform violence-related
reconstructive surgery in Grozny’s hospital
No.9, the main republican trauma hospital.
MSF has also been supporting the neuro­
surgical and trauma wards, which performed
around 600 emergency surgeries throughout
the year.
MSF has worked in the Russian Federation since1988 and in North Caucasus since 1995.

SWITZERLAND

IRAN

Reason for Intervention • Social
Violence/Healthcare exclusion
Field Staff 7

Reason for Intervention • Armed conflictField Staff 78

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In January 2006, MSF launched the‘Meditrina’ project in Zurich. Free
consultations are provided to anyone
who has no access to the public healthservices because they have no medical
insurance or the means to pay for
medical consultations and treatment.
The centre has focused primarily on
undocumented foreign nationals living inunstable circumstances and unable to accessmedical care through the Swiss healthcare
system. Homeless people and asylum seekers
have also used the service. Gynaecological anddental problems, as well as diseases of theskeletal system, are the most common complaints. By December, some 70 consultations amonth were being provided.
Nine community ‘mediators’ of various
nationalities have been integrated into thecommunity of migrants living and working in
Zurich. These mediators have taken on the roleof raising awareness of this free service.

Free consultations areprovided to anyone
who has no access tothe public healthservices.
The Meditrina service now offers HIV
counselling and voluntary screening. As withthe detection of other medical conditions
requiring more specialised treatment, patients
may be directed towards other local medical
facilities after their initial examination.
Meditrina works with a network of national
doctors, chemists, hospitals and laboratories
to ensure consultations and to enable suchreferrals.
MSF has worked in Switzerland since 2003.

© Siavash Maghsoudi

In 2007, an economic crisis in Iran led toincreased resentment towards refugees.
Since 2001, MSF has been assisting Afghan refugees in Zahedan, capital of
the Iranian province of Sistan-Baluchistan, where they have been crossing theborder for the last 30 years. In 2002, despite a deterioration of conditions in
Afghanistan, the Iranian government adopted a policy of forced repatriation.
Many are reluctant to return to Afghanistan, some even returning to Iranafter deportation.
In 2007, an economic crisis in Iran led toincreased resentment towards refugees. Some
150,000 Afghan refugees were expelled
between May and August but over half amillion remain in Sistan-Baluchistan and an
average of 34 new families arrive at Zahedan
every week. With Iranian restrictions on work,
educational opportunities and health services,living conditions for refugees are difficult but
remain better than in Afghanistan. Iranianauthorities estimate that the majority ofAfghans are economic migrants and, therefore, not entitled to legal status or access tofree healthcare.
In response, MSF provides primary andsecondary healthcare to this population.
MSF runs three medical clinics in Shirabad,
Karimabad and Besat, offering free medical

consultations and nutritional support forchildren. MSF also refers patients to secondary
health facilities and covers costs for specialist
consultations, treatments and hospitalisation.
A team of social workers identify those in needof medical care and ensure they get access toconsultations. A total of 18,000 people wereassisted through this programme.

New project in Mehran
Given the extreme difficulties in accessing
patients and providing healthcare inside Iraq,a project started at the end of 2007 in Mehran,close to the Iraqi border, to provide surgicalcare for victims of violence coming from Iraq.
This project plans to receive between 30 and
50 patients each month.
MSF has worked in Iran since 1996.

83

IRAQ

Yemen

Reason for Intervention • Armed conflictField Staff 249

Reason for Intervention • Armed conflict • Healthcare exclusion
Field Staff 44

Since the reunification of its northern and southern parts in 1990, the Republic of
Yemen has been exposed to political and social tensions and sporadic waves ofviolence. The Saada province in the north-west has been particularly affected bytensions between governmental and rebel forces since 2004. MSF began working in
Yemen in September 2007, supporting health structures in the Saada province andassisting migrants and refugees in the Abyan and Shabwah governorates.
Supporting health infrastructures© MSF

Four years into the conflict, the gap between emergency medical needs and thecapacity of Iraq’s medical infrastructure persists. Bombings and lesser reported
sectarian violence result in devastating injuries requiring immediate andintensive medical attention, yet skills and supplies in many areas are limited.
The economy has collapsed and approximately 50 per cent of Iraqi doctors havefled the country. The high-level insecurity and ongoing violence reduces directaccess to civilian victims.
Movements are dangerous and people cannot
access medical care or may receive limited andinsufficient care leading to life-threatening
complications. Unable to run direct medical
programmes with a permanent presence ofstaff in violence-affected areas, MSF has sought
viable ways to provide assistance to Iraqis
within and outside the country.

these provinces with materials and drugs andenables referrals of severely injured war
victims to hospitals in Kurdistan. MSF is also
evaluating the situation of displaced people
and providing basic humanitarian assistanceparticularly in the governate of Dohuk, wheresome 1,000 families received support during
the harsh winter.

In the Kurdistan area, programmes have been
established in three hospitals in Dohuk, Erbiland Sulemaniyah to deliver surgical assistanceand psychological support. One of the mostcommon medical problems is skin burns
caused by domestic accidents, failed suicide
attempts or explosions. In Erbil, over ahundred operations a month were carried out,
about half of which were war-related. In July,MSF opened a programme in Sulemaniyah tocare for burn patients and provide orthopaedic
surgery. By December, 738 patients had beentreated, many for severe burns.

Operations in Jordan and Iran insupport of Iraqi population

The adjacent provinces of Tameem andNinevah experienced an upsurge of violence in2007. MSF supports healthcare structures in

An MSF team based in Amman, Jordan, beganoffering limited support to five Iraqi hospitals
in zones severely affected by the violence. This
involved providing essential medical supplies
including anaesthetics, analgesics and surgicalequipment. Some Iraqi staff also visit Amman
regularly for training on life support protocols
and mental healthcare in emergencies.
In Amman, MSF runs a surgical programme inpartnership with the Red Crescent, staffedmainly by Iraqi surgeons performing maxillofacial, plastic and orthopaedic surgery.
Patients have complicated bone and wound
infections and six or seven operations are often

required to restore functionality and aminimum quality of life. The project treated281 patients but its potential capacity islimited by administrative obstacles andimpositions on bringing patients to Jordan
from Iraq.
At the end of the year, MSF launched a reconstructive surgery project in Mehran, Iran.
The objective is to care for patients from theeastern provinces and south of Baghdad.

Confusing political and humanitarian
objectives
Security issues make Iraq an exceedingly
difficult context for independent humanitarian interventions. The US-led coalition and UN
system blurring roles demand a reaffirmationof MSF’s strictly impartial and humanitariancharacter and an insistence on the need topreserve, defend and protect the integrity ofhumanitarian action from political and military objectives. MSF struggles to reassert andgain recognition for its identity as an independent humanitarian organisation, separate
from any political, commercial, religious or
personal interests. In November, MSF
reinforced dialogue with all key stakeholders
and warring factions to secure safe space inwhich to carry out its work.
MSF has worked in the current Iraqi conflict
since 2006.

In the first half of 2007, some 56,000 people
fled their homes temporarily when violence
once again erupted in Saada province. In
September, following the signing of a ceasefire
agreement, MSF began working in Haydan
hospital to improve access to healthcare.
It is the first time since the beginning of thefighting that an international relief organisation other than the International Committeeof the Red Cross has been authorised to workin the region. The team supports inpatient andoutpatient services, antenatal and maternity
units, and the emergency room of the hospital.
On several occasions in November, MSF had totemporarily evacuate Haydan as fighting resumed, although activities were sustained bynational staff. In 2008, activities at the hospitalwill be expanded to cover surgery.

fleeing fighting in their country andEthiopians who cannot find employment backhome for political reasons or due to the conflict in the Ogaden region. In 2007, although
28,000 people reached the southern coast of

Yemen, some 650 died and the same number
went missing. The death toll is probably muchhigher. Since September, MSF has been assisting refugees who have survived this risky
voyage, providing medical and humanitarianassistance to over 3,000 refugees and migrants.
The MSF mobile team offers survivors
emergency medical treatment, food, waterand relief items on arrival. MSF also provides
counselling, as many migrants arrive exhausted
and emotionally shattered. In 2008, MSF willcontinue to provide medical assistance to thispopulation, notably at a new reception centre
opened recently by UNHCR in Ahwar.
MSF has worked in Yemen since 2007.

During the fighting of 2007, the hospitalof Razeh, west of Haydan, which serves a
population of 75,000, was looted and partiallydestroyed. MSF repaired it and in December
resumed medical activities in the emergency
room and in the inpatient, maternity,
antenatal and family planning services.
The volatile security situation makes
movement difficult in some areas so an MSF
team goes six days a week to the town of
Dhayan, home to 25,000 people in the rebel
zone. On average, 120 consultations are carried out each day, mainly focused on children
and women’s healthcare. MSF is also contributing to the rehabilitation of the hospital of Al
Talh, close to Dhayan, which will reopen in
April 2008 after seven years of closure.

Providing assistance to migrants andrefugees
Every year, thousands of people risk their lives
to cross the Gulf of Aden, the dangerous
stretch of water between Yemen and Somalia.
This treacherous journey is taken by Somalis© MSF

MSF supports health structures in the Saada
province and assists migrants and refugees in the
Abyan and Shabwah governorates.

Médecins Sans Frontières Activity Report 2007

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84

85

PALESTINIAN TERRITORIES

Gaza strip

Reason for Intervention • Armed conflictField Staff 91

As with the whole of the Occupied Palestinian Territories, theGaza strip had been subject to an international embargo since
early 2006. The already difficult situation deteriorated significantly in mid-2007 when Hamas took control after weeks of bitterinternal fighting. With an array of security services and militia
allied along factional lines, the bloody takeover was the culmination of an increasingly intense Hamas-Fatah rivalry. The remainder of 2007 saw violent repression of anti-Hamas demonstrations
and an emerging insurgency by disgruntled members of theformer security establishment.
While Israel and international donors quickly recognised andengaged the new Palestinian government in the West Bank, theGaza strip effectively remained under Hamas control and subject
to tougher sanctions. Israel limits passage into Gaza to basic foodand medicine and the number of medical referrals abroad is decreasing. Fuel and electricity supplies have been reduced in an
attempt to pressure the Hamas regime, which the Israeli cabinet
officially labelled a ‘hostile entity’ in September.
Alongside the political and economic isolation of the Gaza strip,
the Israel-Palestinian conflict fluctuates. Hamas and smallergroups continue to target neighbouring Israeli communities andmilitary bases with rocket and mortar-fire. Targeted air strikes
and limited incursions from the Israeli side ostensibly aim to
limit the rocket fire but inevitably lead to civilian casualties.

© Valerie Babize

Poverty, restricted movement and increasing violence in the Palestinian
Territories have inflicted a tremendous toll on mental health, yet there are few
trained psychologists. MSF focuses on supplying psychological support to victimsof violence in the Israeli-Palestinian and intra-Palestinian conflict. MSF also
provides medical assistance to people without access to health services. Teams
work in the West Bank and Gaza.
Patients live in exposed and insecure conditions such as refugee camps or areas where
they are subject to frequent incursions, often
close to checkpoints and Israeli settlements.
People suffer from depression, anxiety, posttraumatic disorder and psychosomatic troubles. They are burdened with symptoms suchas disrupted sleep, flashbacks and nightmares.

able context. Travel is difficult due to closuresand restrictions, so consultations and therapy
are often provided through home visits. A
total of 4,617 consultations (1,284 in Hebron,
1,851 in Nablus and 1,482 in Gaza) were provided in 2007. Almost half (42 per cent) of
patients were under 12 years old.

Emergency post-operative programme
MSF supplies psychologists to provide individual and group therapy for children, adolescents and adults. This clinical care is aimed at
reducing symptoms and helping people
develop coping mechanisms. Teams comprise a
psychologist, medical doctor and social
worker. The programme has remained flexible
and reactive in order to meet patient needs
while operating in a volatile and unpredict-

Following violent clashes with the Fatah in
May and June, Hamas took control of the Gaza
Strip. The violence left more than 1,200 people
injured and several needing specialised care.
By July, MSF had established a post-operative
care programme to help people recover fromtheir injuries and gain maximum mobility.
The service included follow-up consultations,pain management, antibiotic supply andphysiotherapy for several hundred people. As
well as meeting medical criteria, patients wereadmitted to the programme as a result offinancial, security or mobility problems.

MSF began working in
Yemen in September 2007,
supporting health structures in the Saada province
During the peak of internal Palestinian clashes in May and June,at least and200 people
were killed migrants
and some 1,200 andinjured. However,assistingthe subsequent split in the Palestinian Authority has had therefugees in the Abyan andmost far-reaching consequences. The already fragile health sector
has become
highly politicised,with the two opposing parties
Shabwahgovernorates.

often issuing contradictory instructions. Disputes result inpolitical appointments, strikes and a demoralised staff.
With the embargo making the re-supply of hospitals with drugs
and equipment highly problematic and a general economic collapse, access to healthcare has been significantly reduced. MSF
has, therefore, expanded its activities beyond the mental healthsphere to include post-operative care in addition to rehabilitationand paediatrics.
The increased need for external medical assistance is a result not
only of the violence and reduced capacity of secondary medical
structures but also of the political climate. As the positions of themain antagonists become increasingly polarised, individuals withspecific or perceived affiliations have correspondingly limitedaccess to health services.
The parallel Ministries of Health and many local organisations areseen as directly influenced by Hamas or Fatah while some international non-governmental organisations, particularly those fundedby key institutional donors, are believed to have wider politicalmotives. Therefore, being financially independent as a medical
relief organisation is not just relevant but also necessary in orderto operate in Gaza. MSF repeatedly explains and highlights thisindependence to the recognised Palestinian authorities in theWest Bank, the Israelis and, of course, local actors on the ground,in an effort to gain as much access as possible to the communities
in need.
Disputes continue however, and healthcare becomes simply another political tool through which pressure can be applied. As
positions remain entrenched, health services are likely to deteriorate further, making independent humanitarian action increasingly relevant and important.

Supplying drugs and medical material
The 2006 embargo by western states has led toa general deterioration in the health system
and numerous strikes by health workers. The
Ministry of Health is completely dependent on
donations from the international community.
Although a mechanism is now in place toalleviate financial pressures and supply
medical materials, health workers still do notreceive full salaries and recurrent strikes in
the public sector have disrupted healthcare
access, particularly in the West Bank. MSF
made periodic drug donations in Hebron to
help cover critical shortages, as well as
donations of drugs and emergency medical
material to hospitals in Gaza.
MSF has worked in the Palestinian Territories since1988.

© Lea Saoufianne

87

Audited FACTS AND FIGURES
Médecins Sans Frontières (MSF) is an international, medical
humanitarian organisation that is also private and not-for-profit.
It is comprised of 19 national branches in Australia, Austria, Belgium,
Canada, Denmark, France, Germany, Greece, Holland, Hong Kong,
Italy, Japan, Luxembourg, Norway, Spain, Sweden, Switzerland, theUnited Kingdom, the United States, and with an international officein Geneva.
The search for efficiency has led MSF to create specialised organisations – called satellites - in charge of specific activities such as humanitarian relief supplies, epidemiological and medical research studies,and research on humanitarian and social action. They include:
Epicentre, Etat d’Urgence Production, Fondation MSF, MSF Assistance,
MSF Enterprises Limited, Médecins Sans Frontières - Etablissementd’Utilité Publique, MSF-Logistique, MSF-Supply, SCI MSF, SCI Sabin,and Wali-Nawaz. As these organisations are controlled by MSF, they
are included in the scope of the financial statements presented here.
The figures presented here describe MSF’s finances on a combinedinternational level. The 2007 combined international figures havebeen set up in accordance with MSF international accounting standards which comply with most International Financial ReportingStandards (IFRS). The figures have been jointly audited by the accounting firms KPMG and Ernst & Young, in accordance with international
auditing standards. A copy of the full 2007 financial report may beobtained from the International Office upon request. In addition, eachnational office of MSF publishes annual, audited financial statements
according to its national accounting policies, legislation and auditing
rules. Copies of these reports may be requested from the national
offices.
The figures presented here are for the 2007 calendar year. All amounts
are in millions of euros.

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

Where did the money go?
Program expenses* by nature
National Staff | 28%
International Staff | 25%
Medical & nutrition | 20%
Transport, freight, storage | 13%
Logistics & sanitation | 6%
Operational running costs | 5%
Training & local support | 1%
Other expenses | 1%

2007

Programme expenses by country/region
Countries/Regionsin Me

AfricaSudan
Democratic Republicof the Congo
Chad
Somalia
Niger
Kenya
Liberia
UgandaIvory Coast
Zimbabwe
MalawiMozambiqueCentral African Republic
Ethiopia
Sierra Leone
BurundiNigeria
Burkina Faso
GuineaRepublic of the CongoSouth Africa
ZambiaAngolaCameroon
RwandaMali
Other countries*
Total

Countries/Regionsin Me

Asia/Middle East
40.9
39.9
25.3
21.9
15.8
13.1
10.1
9.8
9.0
9.0
8.6
8.3
8.1
7.3
5.3
5.3
4.9
4.7
3.5
3.0
3.0
2.9
2.4
2.4
1.2
1.2
1.7
268.7

* “other countries” combines all of the countries
for which program expenses were below 1
million euros.

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

10.0
8.9
5.9
4.9
4.2
3.9
2.9
2.8
2.4
2.3
2.1
2.1
1.7
1.6
1.5
1.5
1.3
3.0

Total

62.9

Americas
Haiti
Colombia
Peru
GuatemalaOther countries*

12.6
7.5
1.7
1.5
2.4

Total

25.8

EuropeChechnya / Ingushetia /RussiaItaly
Kyrgyzstan
Belgium
Other countries*

6.3
2.0
1.1
1.1
1.0
1.1

Total

12.7

Program expenses* by continent
Africa | 72%
Asia | 17%
Americas | 7%
Europe | 3%
Non-allocated | 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 level of private income.
In 2007, 90.9 per cent of MSF’s income came fromprivate sources. More than 3.8 million individual
donors and private funders worldwide made thispossible. Public institutional agencies providing
funding to MSF include, among others, ECHO, thegovernments of Belgium, Canada, Denmark, Ireland,
Luxembourg, The Netherlands, Norway, Spain,
Sweden, Switzerland and the UK.

Income

In Me

In %

In Me

In %

Private Income
Public Institutional
Other Income

518.7
54.2
19.8

87.6%
9.1%
3.3%

488.4
61.8
18.5

85.9%
10.8%
3.2%

Total Income

592.7

100.0%

568.7

100.0%

Operations*Témoignage
Other humanitarian activities
Total Social Mission
Fundraising
Management, general & administration

439.1
19.4
9.1
467.6
76.9
32.9

76.1%
3.4%
1.6%
81.0%
13.3%
5.7%

431.2
18.0
7.9
457.1
71.8
30.9

Expenditure
77.0%		Expenditures are allocated according to the main
3.2%		
activities performed by MSF. ‘Operations’ includes
1.4%		
program-related expenses as well as the head­quarters’
81.6%		support costs devoted to operations. All expenditure
12.8%		categories include salaries, direct costs and allocated
5.5%		

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

577.4

100.0%

559.9

100.0%		
Permanently restricted funds may either be

How was the money spent?

-3.2		
12.1		

overheads.

capital funds, where the assets are required by the-4.5			donors to be invested, or retained for actual use,
4.3			

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

* Programs & HQ program support costs

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

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

37.1		
61.0		
350.2		

35.8				66.2				Other retained earnings represent foundations’
347.5				Total assets		
Permanently restricted funds		
Unrestricted funds		
Other retained earnings		
Total retained earnings and equities		
Non-current liabilities		Current liabilities		
Unspent donor-restricted funds		

448.4		2.5		402.2		
-14.6		390.1		3.4		52.5		
2.3		

2.5					389.4				MSF’s retained earnings have been built up over-7.1			the years by surpluses of income over expenses.
384.7			As of the end of 2007, their available part (the3.7			
unrestricted funds decreased by the conversion
55.5			difference) represented eight months of activity. The
5.6		

Total liabilities and retained earnings		

448.4		

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

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

100%
27%
32%
41%

4,623
1,292
1,500
1,831

donor funds expendable at the discretion of MSF’s
trustees to further our social mission.

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

purpose of maintaining retained earnings is to meetthe following needs: future major emergencies for
449.5
which sufficient funding cannot be obtained, and/or
a sudden drop of private and/or public institutional
funding, and the sustainability of long-term
programs (e.g. ARV treatment programs), as well as
100%		
the pre-financing of operations to be funded by
28%		
upcoming public funding campaigns and/or by
32%		
public institutional funding.

40%		

Unspent temporarily restricted funds
First time departures (full year):
1,152 (*) 28%
1,332(*) 29%		
are unspent donor-designated funds, which will(*) in % of total international departures								Field positions:International staff
National staff*project and coordination team expenses in the countries

2006

Medecins Sans Frontieres Activity Report 06|07

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

86

24,3481,994
22,354

100%
8%
92%

26,981
2,022
24,959be spent by MSF strictly in accordance with thedonors’ desire (e.g. specific countries or types of
100%		
interventions).

7%		
93%

88

CONTACT MSF
Australia Médecins Sans Frontières

Holland Médecins Sans Frontières/Switzerland Médecins Sans Frontières/Suite C, Level 1 | 263 Broadway Glebe NSW 2037

Artsen zonder GrenzenÄrzte Ohne Grenzen

PO BOX 847 | Broadway NSW 2007 | Australia

Plantage Middenlaan 14 | 1018 DD Amsterdam |78 rue de Lausanne | Case Postale 116 |T 61 (0) 29 552 4933 | F 61 (0) 29 552 6539

The Netherlands

1211 Geneva 21 | Switzerland

office@sydney.msf.org | www.msf.org.au

T 31 20 520 8700 | F 31 20 620 5170

T 41 22 849 84 84 | F 41 22 849 84 88

Pr Dr. Nick Wood | GD Philippe Couturier

office@amsterdam.msf.org |office-gva@geneva.msf.org | www.msf.ch

www.artsenzondergrenzen.nl

Pr Isabelle Segui-Bitz | GD Christian Captier

Austria Médecins Sans Frontières/Ärzte Ohne Grenzen
Taborstraße 10| 1020 Vienna | Austria

Pr Dr. Pim De Graaf | GD Wouter Kok (interim)(as of Oct. 08, Hans van der Weerd)

UK Médecins Sans Frontières (UK)67-74 Saffron Hill | London EC1N 8QX | UK

T 43 1 409 7276 | F 43 1 409 7276/40

Hong Kong Médecins Sans Frontières

T 44 207 404 6600 | F 44 207 404 4466

office@aerzte-ohne-grenzen.at |22/F Pacific Plaza | 410 – 418 Des Voeux Road West |office-ldn@london.msf.org | www.msf.org.uk

www.aerzte-ohne-grenzen.at

Sai Wan | Hong Kong

Pr Dr. Christa Hook | GD Marc DuBois

Pr Dr. Reinhard Doerflinger | GD Franz Neunteufl

T 852 2959 4229 | F 852 2337 5442

Belgium Médecins Sans Frontières/Artsen Zonder Grenzen

office@msf.org.hk | www.msf.org.hk
Pr Carmen Lee | GD Dick van der Tak

USA Médecins Sans Frontières/Doctors Without Borders
333 7th Avenue | 2nd Floor | New York, NY 10001-

rue Dupré 94 / Dupréstraat 94 | 1090 Brussels |Italy Medici Senza Frontiere

5004 | USA

Belgium

Via Volturno 58 | 00185 Rome | Italy

T 1 212 679 6800 | F 1 212 679 7016

T 32 2 474 74 74 | F 32 2 474 75 75

T 39 06 44 86 92 1 | F 39 06 44 86 92 20

doctors@newyork.msf.org | www.doctorswithout-

info@azg.be | www.msf.be or www.azg.be

msf@msf.it | www.medicisenzafrontiere.it

borders.org

Pr Dr. Jean-Marie Kindermans

Pr Raffaella Ravinetto | GD Kostas Moschochoritis

Pr Dr. Matthew Spitzer| GD Nicolas de Torrente

Japan Médecins Sans FrontièresInternational Office Médecins Sans Frontières

3-3-13 Takadanobaba | Shinjuku | Tokyo |International Office and UN Liaison Office - Geneva

Canada Médecins Sans Frontières/169-0075 | Japan

78 rue de Lausanne | Case Postale 116 |Doctors Without Borders

T 81 3 5337 1490 | F 81 3 5337 1491

1211 Geneva 21 | Switzerland

720 Spadina Avenue, Suite 402 | Toronto |Ontario

office@tokyo.msf.org | www.msf.or.jp

office-intl@bi.msf.org | www.msf.org

M5S 2T9 | Canada

Pr Satoru Ida | GD Eric Ouannes

T 41 22 849 84 00 | F 41 22 849 84 04

GD Meinie Nicolai (interim)(as of Oct. 08, Christopher Stokes)

T 1 416 964 0619 | F 1 416 963 8707
msfcan@msf.ca | www.msf.ca
Pr Dr. Joanne Liu | GD Marilyn McHarg

Luxembourg Médecins Sans Frontières
68, rue de Gasperich | 1617 Luxembourg |Luxembourg

Policy and Advocacy Coordinator: Emmanuel Tronc
emmanuel.tronc@msf.org
Pr Dr. Christophe Fournier | SG Christopher Stokes(as of Oct. 08, Kris Torgeson)

Denmark Médecins Sans Frontières/T 352 33 25 15 | F 352 33 51 33

Læger uden Grænser

office-lu@msf.org | www.msf.lu

Other Offices

Kristianiagade 8| 2100 København Ø | Denmark

Pr André di Prospero (interim) |MSF Access to Essential Medicines Campaign

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

GD François Delfosse

78 rue de Lausanne | Case Postale 116 | 1211

info@msf.dk | www.msf.dk
Pr Dr. Søren Brix Christensen
GD Michael G. Nielsen

Norway Médecins Sans Frontières/Leger Uten Grenser
Postboks 8813 Youngstorget | 0028 Oslo |Geneva 21 | Switzerland
T 41 22 849 8405 | F 41 22 849 8404
www.accessmed-msf.org
Director: Dr. Tido von Schoen-Angerer

France Médecins Sans Frontières

Norway | Youngstorget 1 | 0181 Oslo | Norway

8 rue Saint Sabin | 75011 Paris | France

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

UN Liaison Office – New York 333 7th Avenue |T 33 1 40 21 29 29 | F 33 1 48 06 68 68

epost@legerutengrenser.no |2nd Floor | New York, NY 10001-5004 | USA

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

www.legerutengrenser.noT 1 212 655 3777 | F 1 212 679 7016

Pr Dr. Marie-Pierre Allié | GD Thierry Durand

Pr Dr Øyun Holen | GD Patrice Vastel

MSF UN liaison officer: Fabien Dubuet(interim)

Spain Médicos Sin Fronteras

fabien.dubuet@newyork.msf.org

Germany Médecins Sans Frontières/Nou de la Rambla 26 | 08001 Barcelona | Spain

MSF office in BrazilÄrzte Ohne Grenzen

T 34 93 304 6100 | F 34 93 304 6102

Rua Santa Luzia, 651/11° andar | Centro - Rio de

Am Köllnischen Park 1 | 10179 Berlin | Germany

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

Janeiro | CEP 20030-040 | Rio de Janeiro

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

Pr Dr. Paula Farias | GD Aitor Zabalgogeazkoa

T (+55) 21 2220-8277 | www.msf.org.br

office@berlin.msf.org | www.aerzte-ohne-grenzen.de

Sweden Médecins Sans Frontières /MSF office in South Africa

Läkare Utan Gränser

Orion Building | 3rd floor | 49 Jorissen Street,

Greece Médecins Sans Frontières

Gjörwellsgatan 28, 4 trappor | Box 34048 |Braamfontein 2017 | Johannesburg

15 Xenias St. | 115 27 Athens | Greece

100 26 Stockholm | SwedenT  +27 11 403 44 40/41 | www.msf.org.za

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

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

info@msf.gr | www.msf.gr

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

Pr Ioanna Papaki | GD Reveka Papadopoulou

Pr Anneli Eriksson | GD Dan Sermand

Pr Dr. Tankred Stoebe | GD Dr. Frank Doerner

Pr President | GD General Director | SG Secretary General

MSF office in United Arab Emirates
P.O. Box 47226 | Abu Dhabi, UAE

T  (+971) 2 6317 645 | www.msfuae.aeThe Médecins Sans Frontières Charter

About this Book
Country text and sidebar material written by

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

Wei Baozhu, Siân Bowen, Jean-Marc Jacobs, Anthony Jacopucci, Alois Hug,
Isabelle Jeanson, Duncan Mclean, Sally McMillan, Anna-Karin Moden,
Alessandra Oglino, Hélène Ponpon, Susan Sandars, Natalia Sheletova, Sheila
Shettle, Véronique Terrasse, Elena Torta, Caroline Veldhuis, Joanne Wong

Special thanks to

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

Montserrat Batlló, Daniel Berman, Laure Bonnevie, Karen Day, Tory Godsal,
Myriam Henkens, Pierre Humblet, Anara Karabekova, Fernando Pascual, Jordi
Passola, Barry Sandland, Miriam Schlick, Susan Shepherd, Emmanuel Tronc,
Caroline Veldhuis, Tido von Schoen-Angerer and all the field, operations andcommunications staff who reviewed material for this report.

Médecins Sans Frontières observes neutrality andimpartiality in the name of universal medical ethics andthe right to humanitarian assistance and claims fulland unhindered freedom in the exercise of its functions.
Members undertake to respect their professional code of
ethics and to maintain complete independence from allpolitical, economic or religious powers.
As volunteers, members understand the risks and dangersof the missions they carry out and make no claim forthemselves or their assigns for any form of compensation
other than that which the association might be able toafford them.

Managing Editor Siân Bowen
Research & Editorial Support Hélène Ponpon
Photo Editor Bruno De Cock, Sofie Stevens
Proof Reader Emily Wood
French Edition
Coordinator Hélène Ponpon
Translation Translate 4 U sàrl
(Aliette Chaput, Emmanuel Pons)

Editor Hélène Ponpon
Italian Edition
Coordinator Barbara Galmuzzi
Translator Selig S.a.S.
Editor Barbara Galmuzzi
Spanish Edition
Coordinator Javier Sancho
Translator Pilar Petit
Editor Eulalia SanabraGraphic Design
Studio Roozen, Amsterdam, The Netherlands

Printing
Kunstdrukkerij Mercurius, Westzaan, The Netherlands

The country texts in this report provide descriptive overviews of MSF workthroughout the world between January and December 2007. Staffing figures
represent the total of full-time equivalent positions per country in 2007.
Reasons for Intervention classify the initial event(s) triggering an MSF
medical-humanitarian response as documented in the 2007 International
Typology study. Country summaries are representational and, owing to spaceconsiderations, may not be entirely comprehensive.

cover Photo Nurse working with MSF treating baby with severe dehydration in Pieri, in Jonglei State (South Sudan)© Sven Torfinn

MSF Activity Report 2007

MSF Activity
Report 2007
Médecins Sans Frontières (MSF) was founded in1971 by a small group of doctors and journalists
who believed that all people should have accessto emergency relief. MSF was one of the first non
governmental organisations to provide urgently
needed medical assistance and to publicly bear
witness to the plight of the people it helps.

Today MSF is an international medical
humanitarian movement with national sectionsin 19 countries. In 2007 over 26,000 doctors,
nurses, and other medical professionals, logisticalexperts, water and sanitation engineers andadministrators provided medical aid in over
60 countries.

MSF International Office
78 Rue de Lausanne, Case Postale 116, CH-1211 Geneva 21, Switzerland
Tel (+41-22) 8498 400, Fax (+41-22) 8498 404, Email office-intl@bi.msf.org, www.msf.org