MSF Activity Report

T (+41-22) 8498 400, F (+41-22) 8498 404, E office-intl@bi.msf.org, www.msf.org

Médecins Sans Frontières (MSF) was founded in 1971 by a small
group of doctors and journalists who believed that all people havea right to emergency relief. MSF was one of the first nongovernmentalorganizations to provide both urgently needed medical assistance andto publicly bear witness to the plight of the people it helps.
Today MSF is an international medical humanitarian movement with
branch offices in 18 countries. In 2003, MSF volunteer doctors, nurses,
other medical professionals, logistical experts, water-and-sanitationengineers, and administrators departed on more than 3,400 missions
and joined more than 16,000 locally hired staff to provide medical aid
in nearly 80 countries. MSF was awarded the 1999 Nobel Peace Prize.

2003/04

MSF-International Rue de Lausanne 78, CH-1211 Geneva 21, Switzerland,

MSF Activity Report 2003/04

The Médecins Sans Frontières Charter
Médecins Sans Frontières is a private international association.
The association is made up mainly of doctors and healthsector workers and is also open to all other professions whichmight help in achieving its aims.
All of its members agree to honor the following principles: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.
Médecins Sans Frontières observes neutrality and impartiality
in the name of universal medical ethics and the right to humanitarian assistance and claims full and unhindered freedom inthe exercise of its functions.
Members undertake to respect their professional code of ethics
and to maintain complete independence from all political,
economic or religious powers.
As volunteers, members understand the risks and dangers ofthe missions they carry out and make no claim for themselvesor their assigns for any form of compensation other than thatwhich the association might be able to afford them.

CO V E R P H OTO An MSF nurse holds a three-year-old girl on her knee while her
assistant helps a mother feed her child at the feeding center in the Iridimi refugee
camp in Chad, near the border with the Dafur region of Sudan. When the little girlfirst arrived in the camp, she was severely malnourished, now she has gained weight
and will soon be able to leave the therapeutic feeding center’s daily program.
© Gael Turine

About this publication
E D I TO R Lisa Hayes
CO N T R I B U T I N G W R I T ER S Karie Atkinson, Eva van Beek, Rosilyne Borland, Marine
Buissonnière, Tobias Buhrer, Stephan Grosserueschkamp, Juliane Ineichen, Frida Lagerholm,
Caroline Livio, James Lorenz, Michael Nielsen, Lars Nygaard, Kevin Phelan, Olga Ruiz, MarkWalsh and Wyger Wentholt
E D I TO R I A L A SS I S TA N C E Barbara Kancelbaum
PH OTO ED I TO R Bruno de CockFE AT U R E D CO N T R I B U TO R S Alexandra Calmy, Kenny Gluck, Laura Hakokongas,
Sally Hargreaves, Mit Philips, Carlos Ugarte and Fabrice Weissman
S P E C I A L T H A N K S TO Laure Bonnevie, Marine Buissonnière, Anouk Delafortrie,
Rowan Gillies, Laura Hakokongas, Sean Healy, Remi Obert, Kris Torgeson and all of
the operations and communications staff who reviewed material for this report.
ARABIC EDITION
CO O R D I N ATO R Tahar Hani
T R A N S L ATO R Marlene Massaad
FR E N C H E D I T I O N
E D I TO R S Carol Sacré and Dominique Desrochers
T R A N S L ATO R Translate 4 U sàrl (Aliette Chaput, Emmanuel Pons and Alex Woos)
I TA L I A N E D I T I O N
E D I TO R Francesca Pispisa
T R A N S L ATO R Marina Minute
S PA N I S H E D I T I O N
CO O R D I N ATO R Carmen Vicente
E D I TO R S Amaia Esparza and Eulàlia Sanabra
T R A N S L ATO R Pilar Petit
G R A PH I C D E S I G N Studio Roozen, Amsterdam, The Netherlands
PR I N T I N G Drukkerij Mercurius, Wormerveer, The Netherlands2003/04

MSF Activity Report

MSF Missions
around the World

Contents
MSF Missions around the World

2

The Year in Review

4Rowan Gillies, M.D., President, MSF International Council
Marine Buissonnière, MSF Secretary-General

Military humanitarianism:
A deadly confusion

7

By Fabrice Weissman, Research Director,
MSF-Foundation, Paris

The struggle to reach people in need

10

By Kenny Gluck, MSF Director of Operations, Amsterdam

No cash, no care
MSF’s confrontation with cost recovery

12

By Mit Philips, M.D., MscPH., Analyst,
Access to Health Care Research Unit, Brussels

Darfur: A disaster unfolds

14

Photo essay
62

MSF Projects around the World
Africa
MSF and HIV/AIDS:
Expanding treatment, facing new challenges

19
20

60

57

40
58

By Alexandra Calmy, M.D., Advisor to MSF’s Campaign
for Access to Essential Medicines

Asia and the Caucasus
Running out of breath?
Tuberculosis control in the 21st century

59 61
63

64

45

55

52

By Sally Hargreaves and Laura Hakokongas for
the MSF Campaign for Access to Essential Medicines

54

The Americas

61

Europe and the Middle East
Helping immigrants at Europe’s door

69
70

By Carlos Ugarte, Head of Mission
for MSF’s projects in Spain

Facts and Figures

78

Contact MSF

80

2 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2003/2004

56

Africa15 Liberia p. 30
1 Angola p. 20
16 Madagascar p. 31
2 Benin p. 20
17 Malawi p. 31
3 Burkina Faso p. 21
18 Mali p. 31
4 Burundi p. 22
19 Mauritania p. 32
5 Cameroon p. 21
6 Central African Republic p. 22 20 Morocco p. 33
21 Mozambique p. 32
7 Chad p. 23
22 Niger p. 33
8 Democratic Republic
23 Nigeria p. 33of the Congo p. 24
24 Rwanda p. 34
9 Republic of Congo p. 26
25 Sierra Leone p. 34
10 Cote d’Ivoire p. 29
26 Somalia p. 35
11 Ethiopia p. 27
27 South Africa p. 36
12 Guinea p. 28
28 Sudan p. 36
13 Guinea Bissau p. 28
29 Uganda p. 38
14 Kenya p. 29

75

71
69
65
67 76
68

73
70
74 66

39

53

72

52

34
43

77

20

42

38

49
37

33
46

47

35

40
19

18

13
12
25
10
15

22

7

3
2

23

50

28

9

1

8 24

29 14
4
30
17

31
32

51

36
11

6

5

44

45

48
26
41

21
16

27

30 United Republicof Tanzania p. 43
31 Zambia p. 43
32 Zimbabwe p. 44
Asia and the Caucasus
33 Afghanistan p. 49
34 Armenia p. 46
35 Bangladesh p. 54
36 Cambodia p. 54
37 China p. 56
38 Democratic People’s
Republic of Korea
and South Korea p. 58
39 Georgia p. 46

40 India p. 55
41 Indonesia p. 55
42 Iran p. 50
43 Iraq p. 50
44 Lao People’s
Democratic Republic p. 57
45 Myanmar (Burma) p. 57
46 Nepal p. 58
47 Pakistan p. 51
48 Sri Lanka p. 59
49 Tajikistan p. 48
50 Thailand p. 60
51 The Philippines p. 59
52 Turkmenistan p. 48
53 Uzebekistan p. 48

The Americas
54 Argentina p. 62
55 Bolivia p. 62
56 Brazil p. 64
57 Colombia p. 64
58 Ecuador p. 66
59 Guatemala p. 65
60 Haiti p. 66
61 Honduras p. 67
62 Mexico p. 67
63 Nicaragua p. 68
64 Peru p. 68

Europe and the Middle East
65 Belgium p. 72
66 Bulgaria p. 72
67 France p. 73
68 Italy p. 73
69 Luxembourg p. 74
70 Romania p. 74
71 Russian Federation p. 74(North Caucasus) p. 47
72 Spain p. 75
73 Ukraine p. 75
74 Serbia and Montenegro p. 76
75 Sweden p. 76
76 Switzerland p. 76
77 Palestinian Territories p. 77

ACTIVITY REPORT 2003/2004 MEDECINS SANS FRONTIERES 3

The Year in Review

Karima, an elderly woman by Sudanese standards, sat in the rainoutside an MSF clinic in western Darfur, Sudan, when MSF staff
first saw her. She was sitting, exhausted, in the mud and her legs
were covered with her own excrement, suffering from diarrhea andsubsequent dehydration. The clinic was closed. Together, with thehelp of a Sudanese nurse, MSF medical volunteers took her to the
nearby hospital, washed and fed her, and found a relative to lookafter her. She stayed at the hospital for only one night, became
rehydrated and left for her own shelter the next day.
Karima’s desperate situation was not unique. Millions around theworld face the same suffering and feeling of abandonment. Yet she
ref lects the foundation on which MSF’s work is based, every day, inhundreds of projects around the world. Each patient is an individual
deserving care simply because they have none and need it. Every
individual deserves assistance that helps restore personal dignity.
Our work, whatever the context, can be simplified into thousandsof these individual interactions taking place between MSF caregivers and our patients. Our aim is clear. Assist those who need
medical help now.
The past twelve months have been turbulent by any standard. The
tragedy in Darfur, Sudan unraveled before our eyes, growing worse
as the months went by. Extreme violence against civilians led to a
massive displacement of more than a million people. Access to thiswhole population was denied and then restricted for months, with
only occasional but ineffective protests from the international
community as their condition deteriorated. The scant attention
given to the crisis until recently was due partially to a desire not to
upset the North-South Sudan peace process – effectively sacrificing
a group of the country’s civilians for future stability. At the time ofthis writing, although the humanitarian response to the crisis has
improved dramatically, the presence of food and medical aid has
done little to end the fear and abuse that haunt the people ofDarfur.
While Darfur finally started receiving public attention by mid2004, many other crises causing immense human suffering
remained hidden from view, rarely mentioned in headlines. The
forgotten war taking place in the Democratic Republic of theCongo continued to claim lives, both directly through violence andmore insidiously because of displacement and disease. Increasing
violence in Uganda also sent thousands on the run, but made little

4 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2003/2004

impact on the outside world. MSF’s independence makes it possible
for us to go to these “neglected” crisis zones and help those whohave been forgotten. While we cannot provide assistance to all of
those who need it, our presence in nearly 80 countries provides aid
for many of the most vulnerable and allows us to speak out on what
we witness there.

Neutrality under attack
The murders of our five colleagues in Afghanistan’s Badghis province on 2 June 2004 were a shock to the movement and to theworld. The tragedy highlighted both the dedication of our national
staff and volunteers and the increasingly difficult and dangerous
environment in which they work. The decision to withdraw fromAfghanistan was a tragic consequence of MSF becoming a target.
While MSF feels a great sense of frustration and sadness at
diminishing aid to people who need it desperately, there are limits
to the risks the organization can accept.
The targeting of humanitarian aid workers for political gain is,
unfortunately, not a new phenomenon. However, the current “waron terror” in all of its guises makes maintaining our neutral andindependent position an ongoing struggle we cannot afford to lose.
Within this report you will find an essay that explores the emergence of “military humanitarianism” and what it may mean for
MSF and its work.
Although the entire MSF movement was relieved when volunteer
Arjan Erkel was released in April 2004 after 20 months in captivity,
the North Caucasus’ insecurity remains a daily reality for the peopleof the region. Effective assistance is severely curtailed through an
atmosphere of violence and intimidation, compounded by the
impunity shown for attacks on humanitarian workers. The difficulties we face pale in comparison to the daily suffering of the people
we try to help. Humanitarians will always be needed who will seekout and assist people in crisis, whatever the political framework of
the day, regardless of the obstacles placed between them and the
populations they seek to help. The ongoing struggle to reach those
who most need assistance and the challenges involved in getting
help to them are also discussed in this report’s pages.

When people are “sacrificed”
Today there are plenty of crises and conf lict zones requiring
humanitarian assistance. While a few are caused by natural disasters

© Jacob Maikere

Severe flooding in 2004 caused the main road between the Haitian cities of Gonaives and Port-au-Prince to disappear. MSF teams provided emergency relief
and psychological support to many people affected by the devastating water.

or epidemics sparked by natural conditions, most are man-made.
The need for humanitarian action usually arises when those inpower refuse to uphold commitments they have made to protect
those living within their borders or to shoulder responsibilities
promised under national or international law. While action can belinked to cases of violent conf lict, humanitarian action can also becalled for when states allow the most vulnerable to be excluded
from needed protection or care. The growing use of cost-recovery
programs is an illustration of this type of problem. Related user
fees require payment to obtain health care in many countries – asystem that has proven exclusionary and dangerous for the mostvulnerable groups. Today MSF is trying to eliminate all user fee
requirements involving its own programs. Whether or not MSF
should address this issue at the advocacy level is currently the subject of an internal debate within the movement. A piece in thisreport sets the groundwork for developing our position on it.
When civilians are not protected or are actively harmed by governments or other actors, it is the role of humanitarians first to
respond to their needs but also to expose the conditions and livesof those who are sacrificed – and to remain in solidarity with thesepeople. Such situations not only occur in Africa, Asia and Latin
America. Civilians escaping from Darfur and other crisis zones
have been met with harsh treatment in Europe when they tried togain political asylum or immigrate. An article included here
describes the dismal welcome awaiting many immigrants when
they arrive on Europe’s beaches and what MSF is doing to help
them.

Urging expanded treatment
Humanitarian action is called for in silent wars as well. The death
toll caused by treatable infectious diseases such as HIV/AIDS,
malaria and tuberculosis (TB) remains staggering, especially in thepoorest countries. During the past few years there has been a paradigm shift in the “accepted” thinking on infectious diseases.
Patient treatment is becoming the focus as opposed to economic or
public health mores. The World Health Organization (WHO) andmany governments and donor agencies now agree with MSF that it
is unethical to keep giving chloroquine to patients suffering fromhighly resistant strains of malaria. In the same way, it is no longer
considered ethical to allow the 30 million people currently infectedwith HIV/AIDS to die due to lack of treatment. Before 2002, WHOand donor governments used what could be called a “public health”

approach on HIV/AIDS treatment in poor countries. They believed
it was too difficult and expensive to treat people with HIV/AIDS
using antiretroviral (ARV) drugs, so the focus was placed on
prevention programs – essentially sentencing millions to an early
death.
Civil society action during the last three years has caused the pricesof ARV medications to plummet. The WHO and the US government have professed desires to treat millions of HIV-positive
people and close to 500,000 people in developing countries are now
getting treatment. This change is no doubt a success, but the struggle
is far from over. Major obstacles are keeping effective treatment
out of reach for many who need it, as another article in this report
explains. Other diseases, such as TB, have not received the samestrong political push to improve and expand treatment. An essay
included here describes how current TB diagnostic tools and treatment fail many hard-to-treat patients, often the kind we see in ourown programs, because their care is considered too difficult to provide. The Campaign for Access to Essential Medicines, which has
had so much success with reducing the price of HIV/AIDS drugs, is
now advocating for an urgent global approach to the lack of
research and development on TB.
Whether we are working directly with patients like Karima or
advocating for policy change on their behalf, principles are essential to MSF’s work. Impartiality allows us to assess who are themost vulnerable, the most excluded, so that we can make practicaland ethical decisions about our interventions and actions.
Independence and neutrality are tools we use to enable us to gain
access to these people and create the trust essential to help those
who have been betrayed, attacked or neglected by others. These
principles also allow us to speak out on what our teams witness inthe field, perhaps helping to bring about change, but certainly
raising the question, is such suffering necessary? In the end,
however, our goal is simple: to treat other humans with respectwhen they are at their most vulnerable and to do so in a pragmaticand palpable manner.

Rowan Gillies, M.D., President, MSF International Council
Marine Buissonnière, MSF Secretary-General

ACTIVITY REPORT 2003/2004 MEDECINS SANS FRONTIERES 5

In Memoriam
On 2 June 2004, five MSF colleagues were brutally murdered on a lonely stripof road between Khairkhana and Qala-i-Naw in Afghanistan’s Badghis province.
In this single violent episode, MSF lost five volunteers and staff members:
project coordinator Hélène de Beirlogistician Pim Kwint
physician Egil Tynaestranslator Fasil Ahmad
and Besmillah, the team’s driver.
We mourn the deaths of all of these individuals committed to carrying out MSF’s workand our deepest sympathies and support go to their families.
The murder of five of our colleagues is an unprecedented tragedy for MSF. We havenever faced a loss of such magnitude in the more than three decades we have spentworking in some of the world’s worst conflicts.
MSF seeks to assist civilians affected by conflict or struck by disaster. MSF honors theseparation of aid from political motives as a founding principle. The sole aim of theorganization is to provide assistance to populations in distress in the name of medical
ethics and based only on their needs.
Despite the tragic loss of these dedicated staff members, MSF will continue to provide
help for those most in need in countries around the world. It will also continue to speakout strongly on the plight of populations and against the violence now being targeted© Luke Tchalenko

at humanitarian aid workers.

6 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2003/2004

BY FAB R I CE W EISSM AN , R E SE ARCH D I R EC TO R , MSF FO U N DAT I O N , PAR IS© REUTERS/Saeed Ali Achakzai

Military humanitarianism:
A deadly confusion

A man holds a sign calling on local residents to help US soldiers find members of Al-Qaeda and the Taliban or risk losing humanitarian aid provided by the coalition.

On 11 June 2004, nine days after five MSF staff members were killed in Afghanistan, a Taliban spokesperson
offered the following justification for their murder:“Organizations like Médecins Sans Frontières work
for American interests and are therefore targets for us.”As horrific as the crime is that this accusation seeks
to legitimize, the statement itself is hardly surprising
given the confusion that currently characterizes the
symbol of humanitarianism.

Getting access to the battlefield from belligerents in order toprovide impartial aid to non-combatants is a difficult and dangerous undertaking. Field armies are not comfortable with thepresence of foreign actors, who are often suspected of serving theenemy’s interests. Under these conditions, the safety of international aid workers, and their room to maneuver, is tied closely tothe credibility of the humanitarian symbol under which they
operate. That symbol says, “We refuse to take sides in this war.
Our only goal is to provide aid to its victims.” When all is said anddone, the only protection humanitarian actors have is the clarityof their image. It must ref lect their position as outsiders to the conf lict and the transparency of their intentions. Both coalition forces
and the majority of aid actors have seriously abused this image in
Afghanistan, thus perpetuating a deadly confusion between
humanitarian organizations and political-military institutions.

ACTIVITY REPORT 2003/2004 MEDECINS SANS FRONTIERES 7

“ We should remember the
obvious: international aid
workers have no enemies.”

Camouflage and cooperation
In Afghanistan, the first aspect of this confusion was caused by camouf laging psychological warfare and intelligence operations
as humanitarian action. Clear-cut examples
include the coalition’s “humanitarian” fooddrops during the first aerial strikes in 2001,
its deployment of special forces in civilian
dress who claim to be on a “humanitarian
mission,” and threatening to suspendhumanitarian aid to populations in southern Afghanistan if they refuse to provide
information about the Taliban and AlQaeda. Winning the hearts and minds ofcivilian populations and encouraging themto cooperate with military forces are classic
and legal military techniques according to
the Geneva Conventions. On the other
hand, presenting a combat tactic as ahumanitarian operation blatantly violates
the humanitarian symbol, just as using a
Red Cross vehicle to transport weapons
clandestinely alongside a patient would be.
After the defeat of the Taliban, many institutional donors required NGOs and UN
agencies to help stabilize and rebuild
Afghanistan. The vast majority of humanitarian actors placed themselves at theservice of the UN Assistance Mission in
Afghanistan (UNAMA) and of the interim
government. Both of these actors receive
varying degrees of support from coalition
forces. NGOs and UN agencies thus abandoned the independence essential to providing independent aid and modeled theirpriorities on those of the new regime and its
Western allies, who were still at war with
the Taliban. This scenario constitutes thesecond element of confusion: making it
impossible to distinguish between a subcontractor working on behalf of a warring
party and an independent, impartial
humanitarian aid actor.
Finally, the use of humanitarian rhetoric tojustify going to war is another confusing
element. Beyond retaliation for the 11
September attacks, the defense of humanrights and international humanitarian law
were presented as forceful arguments infavor of armed intervention in Afghanistan.
The world was told that force and occupation were required to save an exhausted
population from famine, to improve
women’s access to medical care and to easerefugees’ return, among other goals. Thismartial and imperial use of humanitarianrhetoric contributed significantly to blurring the image of aid organizations. If an
appeal to humanitarian considerations canjustify both a medical aid operation and a
military campaign, doesn’t that suggest thataid workers and international troops
represent two sides of the same coin? Aid
actors do not, of course, have a monopolyon the words they use. However, using thesem antic and legal terms that aid workers
rely on for military ends obscures the imageof humanitarian organizations, making it
difficult to determine whether thoseorganizations are outsiders to the conf lictor the vanguard of expeditionary troops of
new “just wars”.

War as a continuation of aid
It would be wrong to hold governments
alone responsible for the confusion surrounding the humanitarian symbol today,
as many aid actors are also confusing thesituation. A liberal, universalist strain
within the charitable aid movement andamong human rights defense groups holds

8 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2003/2004“Armed interventions
intended to assist andprotect civilian populations
put aid workers’ safety atrisk from the moment they
are deployed under thehumanitarian banner.”that war can be the continuation of humanitarian aid by other means. In the belief
that the worldwide export of market
democracy is the highest philanthropic
calling, this movement considers any action
to be “humanitarian” if it contributes toachieving that mission. Such actions
include assisting and protecting “goodvictims” (those whose survival does notthreaten the project’s success), imposing
economic sanctions, dropping bombs, andinvading and occupying nations “guilty ofmassive violations of human rights”.
Consequently, organizations that take this“ The clarity of the humanitarian symbol may
not guarantee absolute security but it is,
nonetheless, an essential precondition.”© Roger Job

mind, it is no surprise that the Taliban
could believe that we “work for Americaninterests”. More than 30 Afghan humanitarian aid workers and 9 international volunteers have been killed in recent months
by forces hostile to the coalition, leading toa significant reduction in aid activities andto MSF’s withdrawal from Afghanistan
after 24 years.
Let us be clear, however, that the murdersof our colleagues cannot be reduced to “aterrible misunderstanding”. Forces hostile
to the interim government and to the coalition intend to conduct a total war, one that
accepts no compromise with the adversary,
including the saving of lives as part of independent and impartial aid operations.
We are not so idealistic as to think that a
clear understanding of our action principles
would be enough to dissuade anyone fromattacking us. However, the confusion
between occupation forces and humanitarian organizations undoubtedly has
encouraged acts of violence against aid
agencies. The clarity of the humanitarian
symbol may not guarantee absolute security
but it is, nonetheless, an essential precondition.

Aid workers’ safety at risk
position have no objection to supporting“just wars” and serving the governmentsthat pursue them. From this perspective,
the term “humanitarian action” is only aeuphemism for a colonizing mission that
imposes, by force, institutions whose every
feature is supposed to embody a value
system believed to be universal. This interpretation has terrible ramifications for aid
workers who display that same humanitarian symbol to conduct their aid missions.
Weakening the meaning of humanitarian
language has had the effects we feared it
would. On the Afghan political scene,international aid actors are perceived as
back-up troops to the Western intervention
forces – if not to the Crusaders. How canaid groups make a convincing claim thatthey are outsiders to the conf lict when thesymbol they display is used to justify anarmed offensive and, subsequently, an
occupation? And when it is used to consolidate the institutions of one party
to the conf lict and to provide cover forpsychological operations? With this in

The blurring of the humanitarian symbol
and its disastrous consequences for teamsafety and aid activities are not limited to
the Afghan theater. They may be found in
most places where international forces are
deployed. Those include, of course, Iraq,
where many perceive – even more so thanin Afghanistan – aid actors as mere auxiliaries to occupation forces. They have beentargeted for bloody attacks to such an
extent that there is little room for humanitarian action in Iraq. This is also the case incountries like Liberia, where the humanitarian symbol encompasses UN peacekeeping operations, including combat actions
and inf luences operations against groups
hostile to the peace process. Those groups
then consider anyone who claims to be ahumanitarian as a potential enemy.
Whatever their legitimacy, armed interventions intended to assist and protect civilian
populations put aid workers’ safety at risk
from the moment they are deployed under
the humanitarian banner. If a protection
operation is to be serious, it necessarily
involves the use of force against the enemy“ The safety of international
aid workers, and their room
to maneuver, is tied closely
to the credibility of thehumanitarian symbol underwhich they operate.”

and, creates a risk of non-combatantvictims. How can a humanitarian organization provide aid to victims if it is equatedwith the “humanitarian” protection force
doing the fighting? This is the danger thatthreatens aid organizations in Sudan today.
By brandishing the threat of armed intervention in Darfur in the name of humanitarianism, the Security Council and certain
Western nations are including humanitarian actors in their camp. In so doing, they
are designating those actors as enemies inthe eyes of Khartoum’s authorities.
We should remember the obvious: international aid workers have no enemies. The
Revolutionary United Front in Sierra
Leone, UNITA in Angola and the Taliban in
Afghanistan are not their enemies. Neither
are the Sudanese pro-government militias.
These armed groups are parties to a conf lict, just like a potential international
intervention force. If the latter claims ahumanitarian role – or worse, if it appeals
to aid organizations to provide military
intelligence – then humanitarian organizations’ position as outsiders to the conf lict is
discredited. How long until an aid worker
in Sudan is killed because he or she “works
for the interests of the intervention force”?
It may be good for the UN or Western
powers to intervene in Sudan to assist andprotect civilians in Darfur. However, that is
not a question for aid actors to decide. But
conducting a “just war” in the name, andwith the participation, of humanitarianorganizations poses a deadly threat to aid
organizations and the people they assist.
After the Iraqi and Afghan populations,will the Sudanese people on the wrong sideof the front line become the newest victims,
abandoned by humanitarian organizations
forced to evacuate the country after theirsymbol has been militarized?

ACTIVITY REPORT 2003/2004 MEDECINS SANS FRONTIERES 9

Sudan © Olivier Jobard

BY K EN N Y G LUCK , MSF D I R EC TO R O F O PER AT I O NS ,A MS T ER DA M

The struggle to reachpeople in need
The decision to withdraw from Afghanistan following

a spirit of human solidarity in a place which has

the killings of five of our colleagues was sad and painfulabsorbed so much passion and dedication in the history

because it represented a rupture in a quarter century ofof MSF. We are forced to ask if this foreshadows the loss

commitment and engagement with victims of this crisis.

everywhere – the beginning of our irrelevance as

It was jarring to lose the ability to provide health care in

humanitarians and as a movement.

The only protection we carry is hope,sometimes a naïve one – that we will berecognized as people outside of the framework of violence and therefore will not beseen as a legitimate target for it. When wetalk with faction leaders about gaining
access to victims and respect for the safetyof aid workers, our key arguments are thecontent of our aid and our humanitarian
identity, that is, our independence frompolitical and military forces and agendas.
Living conditions in Chechnya are inhuman after years of war and destruction. Residents are terrorized by
However, during the last ten years, many
soldiers in a daily and structural way and disappearances and executions are common.
governments have sought to rob us of thisidentity and undermine our argument.
More importantly, most other United Nations and private aid
When aid is blocked
agencies seem to have given up on the very idea of a limited humaniIn many countries where we work our access to populations intarian mandate. Today even UN relief agencies uphold the notion
crisis continues to be threatened in other ways. We have seen it inthat their assistance has to be coherent with their political strategies.
Darfur. Starting in the middle of 2003, villagers in Darfur,
western Sudan, have faced a violent campaign of terror, in which
Many NGOs explicitly mix the promotion of democracy and humantheir villages have been burned and their livelihoods destroyed.
rights with their humanitarian agenda. In Iraq, NGOs sought to use
Thousands have died and hundreds of thousands more have been
humanitarian arguments to advance their political positions against
forced to f lee across the border into Chad or into overcrowded,
the United States invasion of Iraq. In Afghanistan, many of the larger
makeshift camps in Darfur itself where they have sought, but
NGOs even called for NATO deployment throughout the country innever found, safety in numbers. In addition to the massacres andorder to improve the security situation. The promotion of a partisan
campaign of rape which occurred during attacks, hundreds ofmilitary advance is a clear breach of the humanitarian ethic of neuthousands of displaced people soon started a slow slide into maltrality. These groups freely depart from humanitarian principles but
nutrition and death. In spite of the enormity of the abuse andstill seek to be covered by protections associated with humanitarianurgent needs, it would take months before MSF could mountaction. Sharing the same institutional form, their rejection ofinterventions of any scale. Although we had small teams on thehumanitarian principles erodes the protections for all and underground back in November 2003, the large-scale intervention
mines the entire field of humanitarian aid.
demanded by the situation would not become a reality until April
and May 2004. For months, the displaced lived in destitution andmisery with little aid from MSF or anyone else. MSF watched“ The survival of those abused and neglected inwith frustration as the Sudanese government blocked volunteers’visas and cargo shipments while we were torn between the desire
crisis often holds little interest for the powerful.”

10 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2003/2004© Eddy van Wessel

The murders in Afghanistan highlight thefundamental vulnerability of our work andremind us of the frailty of the humanitarian position. Our allegiance to a humanitarian ideal demands that we go unarmed
into areas of crisis to provide assistance
where it is most needed. We are not willingto turn into an armed agency of medical
providers. We believe that going unarmed
into an area of conf lict, trying to save
lives, trying to alleviate suffering, is areaffirmation of human dignity.

yto denounce their delay tactics and the hope that
we could still negotiate our way in. It was only
months later that international pressure forced thegovernment to lower the barriers, allowing MSF
and other agencies to provide some of the massive
amount of assistance required.

© Hans Jurgen Burkard“Access to people in need has always
been blocked and manipulated by those
who control the violence against them.”

While such situations conjure up a feeling of
An MSF health worker discusses problems with a soldier in Angola.
frustration, it would be wrong to assume that thisis a new phenomenon. Access to people in need has
always been blocked and manipulated by those who
control the violence against them Humanitarians have had to“ The murders in Afghanistan highlight thecontinuously struggle to ensure that aid is provided in a way that
fundamental vulnerability of our work and remindallows dignity and does not get turned against the very victims weseek to assist. But to be honest, it is not difficult for governments or
us of the frailty of the humanitarian position.”
military forces to keep us out. The humanitarian aid worker is nota powerful negotiating partner. We come to the table with no force
of arms. We offer practical assistance to those in need, but theassistance was controlled by the government which would not allow
survival of those abused and neglected in crisis often holds little
us to reach those most in need or ensure that the aid was notinterest for the powerful. In the negotiation for access, we offer
diverted by those in power, contributing to further oppression oflittle else but a clear and compelling position on caring for thosethe most vulnerable. Denied access to the vast misery in the counin need.
try, MSF has, for years only been able to provide limited assistanceto the lucky few who manage to escape its borders. Knowing the
There are other ways in which our ability to reach people in crisis is suffering of millions inside the country, the denial of the ability toblocked. For many years, we have been unable to provide the levels
provide aid to all but these few refugees, who have risked forcedof assistance in Somalia which the crisis demands. Ravaged by 15
repatriation, imprisonment and execution, should be a constantyears of war, massive levels of malnutrition periodically plague
provocation to our conscience.
much of the country. Armed clashes between warring militias continue to leave hundreds or even thousands of wounded who receive
Overcoming suspicion in communities
little or no care. In spite of the clear needs, neither MSF nor otherAs humanitarian workers, we always seek to negotiate our presence
agencies has been able to negotiate safe and secure arrangementswith the armed actors that rule an area. However, the degree of
which allow us to work fully and openly in the country. The armed
respect and understanding that we generate in the communities
groups are too fractious and numerous to allow a stable negotiation where we work is even more crucial. Our acceptance by aid recipiof access. The blurred lines between humanitarian assistance andents and their communities keeps us safe too. In some countries, a
the international military takeover in the early 1990s as well as theloss of acceptance and even the demonstration of mistrust or suspiUN’s use of aid to advance its military strategy has crippled thecion due to changes in global political contexts are a great threat torespect which humanitarians could have enjoyed as neutral andour relations with the communities we seek to serve. In a time ofindependent caregivers.
Western political and economic domination, many communities
find it hard to imagine that our activities represent individual
In Chechnya, where civilians have endured a brutal bombing camaction with a separate set of ethics and objectives. Instead of healthpaign and waves of oppression, MSF and other humanitarian aid
care and human solidarity, they fear that we bring unwantedgroups have likewise been forced to reduce, if not completely stop,
Western inf luences or carry hidden motives. While we cannot force
assistance. As in Somalia, MSF has found it impossible to negotiate our help on those who do not want it, we also cannot passively
a protected space to work amid the intertwined mix of criminal
abandon our ambition to ignore boundaries in our increasingly
and military endeavors in the region. More insidiously, the Russianpolarized world.
government and some Chechen rebel groups have tolerated andeven encouraged attacks on humanitarian actors. After dozens of
The struggle to reach populations living in crisis is not new.
kidnappings, assassinations and other abuses, the powers that be
Providing care to those who are abused and neglected inevitably
do not need to construct administrative obstacles to bar our entry
brings humanitarian aid workers into conf lict with those who conwhich we can publicize and denounce. We are no longer willing toduct this violence. This is a confrontation we should not avoid.
take the risk of sending our volunteers there. We want our work to
The greater tragedy would be if our daily, hands-on work withbe a gesture of solidarity with those who suffer in crisis, but we doindividuals and communities fails to create an understanding and
not want to martyr ourselves on the suffering of others.
tolerance that overrides the fears and suspicions generated by anincreasing global divide.
It is simple for totalitarian regimes to keep out humanitarians.
North Korea has, for years, denied any possibility for independent
humanitarian action. MSF left the country when we saw that our

ACTIVITY REPORT 2003/2004 MEDECINS SANS FRONTIERES 11

BY M I T PH I L I P S , M . D. MSCPH . , ANALYS T, ACCE SS TO H E ALT H C AR E R E SE AR CH U N I T, B R USSEL S

No cash, no care

“I was very worried and I brought my little girl to the health center in my district in the south of
Bujumbura. But the nurse wouldn’t see us as I didn’t have any money to pay for the consultation. So I had to take my girl back home without having received any care. Then I had no choice
but to borrow 2,000 francs (about euro 2) from my neighbors for the consultation. I also boughta few medicines on the black market. Every day I pay back 150 of the 250 that I earn each dayfrom carrying bags for people. I have 100 francs left to feed my family. It’s not a lot.”– Simeon, an unemployed man who brought his three-year-old daughter suffering from second-degree burns to an MSF
health clinic in Burundi

Simeon’s situation is a common one. A
recent MSF survey done in 2,700 households throughout rural Burundi revealed
that almost one in five people did notreceive medical care the last time they wereill. The main reason for that was a lack ofmoney. While the cost of a basic consultation might not seem excessive: approximately two to three euros, the average
Burundian has to work for 12 days to earn
this amount. Although theoretically thepoorest patients are exempt from paying, inreality, less than one percent actually does
not have to pay. The survey also found nocorrelation between a payment exemption
and extreme vulnerability. Among those
who did attend a health clinic, the vast
majority had to borrow money or sell somegoods to pay the medical bill, feeding thevicious circle of illness and poverty.

With civil conf lict ending and peace negotiations progressing, the country’s emergency phase seemed to be coming to an end
and donors wanted to move from relief todevelopment aid.
As a result, people who could not obtain
medical assistance for years because of
insecurity are now excluded from carebecause of their inability to pay for it.
Currently Burundi is listed as one of theworld’s three poorest countries. About 99
percent of its population lives on less than
US$1 per day, and a staggering 85 to 90 percent lives on less than US$1 per week.
Nevertheless, if nothing changes, healthcare will remain available only to those who
can afford it, keeping it out of reach foralmost a million people.

User fees in the real world
In Burundi, this situation is the consequence of a government edict issued two
years ago that led to the liberal use of user
fees in primary health care. The introduction of cost recovery was not so much a newhealth policy, but rather the activation ofpart of the planned health sector reformthat had remained dormant since the 1990s.

Today, user fees are an increasing part ofthe environment in which MSF works. Due
to failing state funding, user fees havebecome the cornerstone of public healthcare financing in many countries.
Implemented without any effective solidarity measures, they are a barrier for thepatient and a major constraint for MSF. In

12 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2003/2004

many places, MSF has been pressured bygovernments to introduce user fees, even incomplex emergencies. For example, in poverty-stricken southern Sudan, user fees
were introduced in 2003 as part of a USsponsored health program. Health centers
supported by MSF were forced by authorities to ask patients for money in exchange
for care. The result was immediate:
attendance rates plummeted. In particular,
women and children stopped coming to thecenters for help.
Beyond emergency situations, people alsoneed access to effective care. Poor people
are particularly vulnerable and the majorpart of the disease burden is concentrated
among the poor. In low-income countries,
the poor do not constitute a fringe part ofthe population – poverty affects the vast
majority of the people. The exclusioncaused by user fees implies that it has
become increasingly difficult to reach thepoor through existing health services.
Besides ethical considerations, this raises
questions of accountability for any agency
serious about reaching its beneficiaries.
Moreover, out-of-pocket expenses forhealth care pose a serious risk for further
impoverishment. Medical expenses cause© Didier Lefevre

MSF’s confrontation with cost recovery

“My wife died a few months ago. Very probably from malaria because she had a lot of fever and was
also vomiting. But she never went to a health center. Because of the lack of money. I don’t even haveenough to feed my two children so how could I have paid the price of a consultation? I thought that
she would eventually get better. That didn’t happen. After four months in that state, she finally died.”– Révérien, an unemployed Burundian man, living on the outskirts of Bujumbura

While some countries are implementing
cost recovery systems at a rapid rate, others
are dismantling them to remove barriers tocare. Recent examples from countries thatare working to abolish user fees show spectacular increases in attendance rates. In
South Africa, for example, use of curative
services doubled when fees were no longer
requested. In Uganda, consultations saw a
120 percent increase in the months after
fees were stopped. And interestingly, more
people took advantage of preventive careincluding vaccinations, although they werealready free. MSF has experienced similar
increases when user fees were stopped in
the places its teams worked. During therecent crisis in Cote d’Ivoire, attendance
rates rose significantly when consultations
became free, leading to commentaries thatthe emergency situation was improving
access to health care! A similar tendency
was noticed by MSF in Liberia and Sierra
Leone.
However, in most countries, our teams facea great deal of resistance to the idea of free
medical care, even when MSF agrees to subsidize all of the involved costs. Often theministry of health is reluctant to give permission for MSF to provide free care, as it
relies on user fees to pay functioning costsin the absence of central funding. Freeessential care means higher utilization
rates, which is good news from a medical
point of view, but which brings higher costswith it.

Taking a stand against user fees
Over the years, MSF teams have struggledwith the user fee issue as MSF had to workwithin or around the existing system. In
some projects, attempts were made to
improve cost recovery systems, focusing onrationalizing care-seeking, moving to more
effective waiver systems and making betteruse of collected revenues. Sometimes MSF
teams saw user fees as a necessary condition
to be able to operate within a country.
However, based on disappointing experiences and serious self-critique, MSF is now
strengthening its opposition to user fees.
Humanitarian assistance, by definition,

helps the most vulnerable. That help should
be organized in a way that makes it asaccessible as possible. With that in mind,
how can MSF participate in a system that
accepts exclusion from essential health carefor the sake of sustainability, efficiency orother benefits for part of the population?
In 2004, MSF decided that as a humanitarian association dedicated to assisting people
in times of crisis and targeting the mostvulnerable, we could no longer accept or
allow exclusion within our projects.
Currently, MSF is in the process of implementing a policy whereby the health care
we provide is free at the point of delivery inconf lict contexts. The crucial issue is thatpeople in crisis should not be forced tochoose between spending scarce resourceson health care or going without it. In postconf lict or stable contexts as well, MSF’s
starting position will be that health care in
our programs should be free at the point ofdelivery.
Changing our position is not easy or cheap.
In many countries, MSF will have to challenge state or donor agency policies that
result in the exclusion of the most vulnerable. Providing free care to patients will
also imply that extra financial resources arenecessary, not only to compensate the lossof income from the fees, but also to face theincreased demand. MSF is committed toensure free medical care for patients in its
projects. But is this enough?

MSF’s confrontation withmacroeconomics
In a context of deficit health budgets andpressure from international agencies suchas the International Monetary Fund and theWorld Bank to restrain public spending,health services are doomed to focus on
making ends meet instead of responding to
the needs of the ill.
Does it make sense for MSF to provide freehealth care to its own patients, without
advocating for it for vulnerable populations
we don’t reach? Should MSF go further andadvocate for a whole new health development paradigm? One that allows sufficientpublic health expenditure? Probably not.
Does it make sense for MSF to advocate formore effective (but also more expensive)
treatment regimes like artemisinin-based

combination therapy (ACT) for malaria
patients or antiretrovirals (ARVs) for HIVpositive patients, without advocating forsuch a new health development paradigm?
Probably not. On the other hand, is it ourrole to become involved in this highly
political debate, where so many other actors
are already trying to inf luence the policiesof the international financial institutions?
Can MSF make a difference?
It could be a logical step for MSF now topromote better access to health care.
Through its success in lowering prices foressential drugs in poor nations, MSF’s
Campaign for Access to Essential Medicines
has challenged the inevitability of poor
people’s exclusion from life-saving drugs.
However, maintaining user fees and healthbudget ceilings will keep even these lowered
prices out of reach for large numbers ofpatients.
Cost recovery policies need to be changed
so that lives are not sacrificed for the sakeof macroeconomic theory. MSF could play asignificant role in showing donor agencies,
policy makers and health care providers thetrue, cruel consequences of their choices.
By challenging their declarations of goodintent, MSF could insist on transforming
existing policies so that they improve
people’s health and lives, instead of causing
further suffering. At least the choice tosacrifice thousands of people should berecognized as such and publicly debated.
MSF believes a person’s needs should again
be central to the provision of health care,
not a person’s ability to pay. In this way,refusing user fees in MSF’s own projects
could be a first but necessary step topromote a crucial policy change.
To read more about the consequences of cost
recovery programs in Burundi, download
MSF’s April 2004 report “Access to healthcare in Burundi: Results of three epidemiological surveys” at: www.msf.org.

ACTIVITY REPORT 2003/2004 MEDECINS SANS FRONTIERES 13© MSF

poverty. How can we accept the fact thatpoor people in poor countries are asked to
pay a greater share out-of-pocket for healthcare than people in high-income countries?

Darfur: A disaster unfolds
Since the summer of 2003, the people of western
Sudan’s Darfur region have endured a campaign ofviolence and terror which forced many to flee fromtheir destroyed villages in search of safety. The
wave of attacks against villages throughout Darfur
came after clashes between government of Sudan
forces and rebels earlier this year. What started for
MSF as an exploratory mission in September 2003
to assess the condition of Sudanese refugees
rumored to be flooding into eastern Chad grew
into a massive relief effort involving thousands ofstaff in Sudan and Chad within a few months.
People from Darfur have told of the scorched earth policy
carried out by so-called Janjaweed militias backed by thegovernment of Sudan. The displaced have been attacked andchased from their homes. They describe their villages being
bombarded by government forces only to be attacked, burnedand emptied later by groups of Janjaweed fighters. Many were
killed, others were raped. Water points and crops have been
destroyed and food and livestock have been looted or ruined.
By August 2004, the terror and destruction caused by thisgroup had resulted in the forced displacement of more than
one million people within the Darfur region. An additional
180,000 civilians were also forced to f lee to neighboring Chaddespite harsh conditions there.
Life in makeshift shelters or displacement camps has bred its
own suffering. The displaced have endured a nightmarish
combination of violence, panicked f light, and deprivation,
only to find more of the same in the place where they sought
refuge. Sandstorms, extreme changes in temperatures and alack of assistance have confronted those entering Chad. In
Sudan, people who attempt to leave the camps, even to findfirewood are often attacked or sexually assaulted.
Overcrowding and insufficient access to health care have led
to outbreaks of diarrheal diseases and measles. The rainyseason, which began in late June and will continue until
October, aggravates the health situation in the areas where
people have gathered. Heavy rains promote the spread ofmalaria, and poor hygiene contributes to respiratory infections and diarrhea, which are the primary reasons people seek
treatment at MSF’s health facilities. Since June, an epidemicof hepatitis E has been rampant in Darfur and eastern Chad,proving particularly fatal for pregnant women.
In the face of this disaster, MSF launched one of its largest aid
operations ever. By August 2004, approximately 200 international volunteers and 2,000 national staff members were
providing health care and nutritional aid in more than
25 locations in north, west, and south Darfur. Another 35

14 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2003/2004

“Our actions remain a drop in the ocean incomparison to the tremendous needs.”– Ton Koene, Emergency Coordinator in an address before
the United Nations Security Council, May 2004

international volunteers and hundreds of national staff
were giving assistance in nearby parts of Chad. Despite theenormous needs, humanitarian organizations, the donor
community and United Nations agencies have been slow to
respond to this emergency.

The continued attacks on the displaced and their inability toplant or harvest have made them completely dependent on
humanitarian aid, a situation that will continue for many
months to come. Despite harsh living conditions in thecamps, people have made it clear to MSF that they would
rather stay together in overcrowded, unsanitary camps with
their risk of disease, then go back to their home areas, mainly
because they fear more attacks and have little waiting forthem there.
With newly displaced still arriving in the camps around
Darfur and new war-wounded and rape victims coming to
MSF clinics each day, responsibilities need to be assumed andacted on to stop the continuing violence against the civiliansof Darfur.

ACTIVITY REPORT 2003/2004 MEDECINS SANS FRONTIERES 15

Chad © Olivier Jobard

In spite of the needs, it took many months before MSF
could mount the large-scale intervention demanded by thesituation. For months, the displaced lived in destitution andmisery with little aid as the Sudanese government blockedvolunteers’ visas and cargo shipments. By mid-2004,
Sudanese authorities became more lenient in giving out travel
permits and authorizations which enabled aid to arrive more
quickly and allowed more organizations to set up operations.
By September 2004, humanitarian aid had made a significant
impact in the large displaced persons’ camps but many needs
remained uncovered. More food, health care, water and shelter is needed in isolated villages as well as the camps in
Darfur.

A lack of clean water
Refugees in Chad often have no alternative but to dig forwater in a dry riverbed. They drink the brownish, sandyliquid unfiltered, as boiling water to purify it uses up
precious firewood needed for cooking. The dirty water
increases people’s risk of becoming ill.

“Digging a latrine for every 20 people and providing 20 liters of water a day per person saves
more lives than any fancy medical programs.”© Dieter Telemans– Greg Elder, M.D., MSF Head of Mission in Sudan“In October we dug a hiding
place in the earth to save us
from attacks. Each time there
was danger we threw ourselves
into our refuge. We lived like thisfor three months until one day
we met some inhabitants fromthe village of Adlkheir who wererunning away and they told us
what was happening. We had
no choice, we had to abandon
everything and escape. We
loaded the children and water
onto our donkey and headed
west. We walked at night so
we wouldn’t be seen.”© Marcus Bleasdale/IPG

Fleeing to Chad

Refugees struggle to raise a collapsed donkey after a 34-day march towards safety in Chad.

– Alsadig, a 32-year-old male refugee whoworks in MSF’s supplementary feeding
center in Touloum, Chad.

16 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2003/2004

Rainy season
In late June, the rainy season began. In usual times the rains
would be welcome for filling the dry riverbeds and watering
freshly planted crops. This year, it is just one more hardshipto endure. The rains exacerbate the severe health risks topeople already weakened by violence and malnutrition.
With only a few latrines and drastic shortages of water, manycamps become ponds of stagnant sewage. Roads are impassable, further hampering already slow and irregular relief
efforts.

“ We have no beds and the water just rushed in.
We had to stand up all night – me, my wife,
my nine children.”© Ton Koene– Adam Abaka, 43-year-old refugee in Mornay camp,West Darfur

Malnutrition
According to nutrition studies conducted by
MSF, there are dangerously high levels of malnutrition in some areas, especially among
young children. MSF has distributed morethan 300,000 survival rations in several places
in western Darfur and the organization
expects that an estimated 800,000 will be distributed by the end of 2004.

“I am shocked by the poor condition of some of the children. Someare definitely beyond saving – evenwith our intensive approach. The
mothers clearly realize that there is
no hope for their children.”© Stefan Pleger– John Heeneman, MSF Project Coordinatorin Nyala, Darfur

A young girl feeds her malnourished brother at MSF’s therapeutic feeding center inMornay, Sudan.

ACTIVITY REPORT 2003/2004 MEDECINS SANS FRONTIERES 17

© Francesco Zizola/Magnum Photos© MBE
Teenagers and children are routinely sent out from the camps to finddrinking water and firewood for their families despite the ever-present
risk of rape or assault while they travel outside camp borders.

MSF staff carry out a vaccination campaign in Guereda refugee camp on
the Chad-Sudan border.

Insecurity“It’s unbelievable to see little 14 or 15-year-old girls
on donkeys going over the hill with all their stuff
for three days. They’re sure to be beaten and raped,
but they tell me, ‘We don’t have any choice.’ “– Jennifer Pahl, an MSF nurse working in the camps around
El Genina Hospital in Darfur© Gael Turine

Violence and abuses continue to be perpetrated against thecivilian population despite the international attention focusedon Darfur. The people have become imprisoned in the places
where they have gathered because they are surrounded by thesame militias that attacked their villages and forced them tof lee. Men cannot leave the camps for fear of being killed andwomen are often beaten or raped if they go outside the camps tosearch for food or firewood.

18 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2003/2004

An MSF team at Iriba Hospital in Chad examines a 12-year-old girl woundedby an explosive device she thought was a toy before it exploded.

© Marcus Bleasdale/IPG

MSF Projects
around the World
AfricaRefugees from the Darfur region of Sudan battle theelements during their journey to find safety in Chad.

ACTIVITY REPORT 2003/2004 MEDECINS SANS FRONTIERES 19

AfricaI N T ER NAT I O NA L S TA FF 118
NAT I O NAL S TAFF 1, 49 0

I N T ER NAT I O NA L S TA FF 3
NAT I O NAL S TAFF 2 5AngolaBenin

Addressing a lack of care

© MSF

Although Angola’s long civil war has ended, the country’s civilians still lack the carethey need in many places. In some areas,
MSF is the sole health care provider, with
programs that assist those affected by anumber of infectious diseases.
MSF malaria projects have demonstrated
the success of artemisinin-based combination therapy (ACT), contributing to thegovernment’s decision to change thenational treatment protocol to ACT by the
first part of 2005. MSF is treating people
with malaria at facilities in Caala. In
February 2004, MSF responded to an outbreak of malaria in Matala, in Huila province, by treating more than 16,000 people.
From January to May 2004, an MSF teamran a malaria-treatment center in Kuito, thecapital of Bié province, which treated 4,594
children under the age of 13.

As part of its work to improve thedetection and treatment of sleeping
sickness in Caxito, in Bengo province, MSF
treated 817 patients and screened morethan 45,000 people for this often deadly
disease. In April 2004, MSF also begantreating patients with sleeping sickness inCamabatela, in Kuanza Norte province.
MSF carries out this work in collaboration
with the Angolan Ministry of Health andother organizations.
In many parts of Angola, MSF teams treat
patients with tuberculosis (TB) and strive
to improve both diagnosis and treatment.
In Bié province, MSF manages a TB centerin collaboration with the Angolan Health
Ministry, providing drugs and supplies,
managing the laboratory and pharmacy
and training staff. MSF is treating morethan 600 patients in the province. In
Huambo province, an MSF-built TB centerin Caala was handed over to local
authorities in August 2004.
MSF also provides care to many people
living with HIV/AIDS. Since July 2003, theorganization has provided HIV/AIDS
training and education at three health carefacilities and at a voluntary testing andcounseling center in the town of Malanje.
The project targets low-income women,
returned refugees and sex workers.
Activities include treatment for opportunistic infections and voluntary counselingand testing. Plans are under way to begin
providing treatment with life-extending
antiretroviral medications.
MSF also works withother vulnerable populations in Angola,
including those livingin camps for internally displaced
persons and returning refugees. In April
2004, MSF spoke out
about the treatmentof illegal diamondminers expelled from
Lunda Norte province. Some miners
were held in areas
without food, wateror sanitation facilities
for weeks, whileothers were forced to walk 65 kilometers
to the border of the Democratic Republicof the Congo without basic supplies.
In late 2003, MSF handed over activities atthe provincial hospital in Kuito to local
health authorities. In Saurimo, Lunda Sul
province, MSF staff ended a project inNovember 2003 that had targeted displaced people. MSF completed basic
health care projects in Bailundo, Huambo
province, in December 2003 and in Luena,
Moxico province, in March 2004.
MSF has worked in Angola since 1983.

20 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2003/2004

Helping those with
Buruli ulcer
Treating people who suffer from Buruli
ulcer remains MSF’s principal work in
Benin. Buruli ulcer is a bacterial infection
related to tuberculosis and leprosy. It
causes skin swelling and suppresses theimmune system. The infection destroys
skin and bone tissue over a wide area ofthe body. To date, there is neither a medicinal treatment for the disease nor avaccine to prevent it; surgery to relieve its
effects is the only option.
In the town of Lalo, in Mono-Couffo
department, MSF runs a treatment center
to help those with this illness. The staff
diagnose the disease, oversee surgery andhelp rehabilitate people disabled by it. MSF
also teaches local health professionals
about diagnostic and curative techniques,with particular emphasis on surgicaltraining. At present, MSF supervises anaverage of 25 surgical interventions per
week. Through operational research, MSF
strives, with other partners, to improve
care for people with this disease and raiseawareness about it so that this care can be
integrated into the national health system.
Although official statistics place the HIV/AIDS prevalence rate at 4.1 percent in
Benin, figures differ among regions andpopulation groups. Surveillance of womenseeking prenatal care in the town of
Dogbo, Mono-Couffo department, revealed
a prevalence rate of 7.4 percent. Because
this region has no health facility that
implements HIV/AIDS-related care, MSF
has opened such a program there.
The team started by providing voluntary
testing, information, and medical consultations for opportunistic infections. By theend of 2003, MSF had signed an agreement
to launch a treatment program using lifeextending antiretroviral (ARV) therapy inthis rural area. In the second half of 2004,
in Dogbo, MSF will begin to treat patientswith ARVs and start a program to prevent
mother-to-child transmission of thedisease. MSF’s goal is for 300 of its patientsto be taking ARVs by the end of 2004.
MSF has worked in Benin since 1997.

I N T ER NAT I O NA L S TA FF 10
NAT I O NAL S TAFF 76

Burkina Faso

Cameroon

AfricaI N T ER NAT I O NA L S TA FF 11
NAT I O NAL S TAFF 89

Caring for people withAIDS and Buruli ulcer© MSF

MSF is helping people with two healthproblems in Cameroon: HIV/AIDS, which
affects an estimated 13 percent of the
population, and Buruli ulcer, a debilitating
disease.

MSF helps children and youngsters livingon the streets of the capital, Ouagadoughou. Instead of operating from acenter, the team works on the streets inclose proximity to these children. Today,
the program reaches around 700 children
and 80 teenage girls. MSF’s team carriesout 40 to 60 medical consultations andvarious psychosocial activities each month.
MSF organizes meetings with teenage girls
to raise awareness about health issues
related to prostitution. It has also trained
local health groups to treat sexually transmitted infections and started a medical
program for survivors of sexual violence.
Advocacy is a key part of MSF’s work withstreet children. Since August 2003, theorganization has held 65 information
sessions on the predicament facing theseyoung people. A total of 85,550 people
living around Ouagadougou have taken
part and watched the MSF movie “TheStreets Are Not Paradise.” Information
sessions have also been held in schools
and at the national police academy. The
national television station has broadcast
the movie twice.
In the remote town of Sindou in Leraba
province, MSF advocates for improved
health care by raising awareness of healthissues among the residents and by supporting their demands for quality care. MSF
focuses particularly on maternal and childhealth care. The team provides assistanceto seven regions in Sindou: Wolonkoto,
Bagera, Niassogon, Negueni, Oueleni,Kangoura and Konadougou.
Burkina Faso is facing a growing AIDS epidemic. In order to help those with the illness, MSF runs a project to improve thequality and duration of life for HIV-positive
people living in the health district of Pissy
in Ouagadougou. Now 1,300 patients areenrolled in the program and receive
medical care for opportunistic infections.
A program to prevent mother-to-childtransmission of the virus started in January
2003 and is now operating in two maternity centers. In April 2003, MSF started
providing life-extending antiretroviral(ARV) treatment as well. By the end of
2004, MSF hopes to have 600 HIV-positive
patients enrolled.
In early 2004, MSF was able to help halt ameningitis outbreak in the district ofNanoro by vaccinating 135,000 people
against the less common W135 strain of
meningitis.
MSF has worked in Burkina Faso since 1995.

Cameroon © Juan Carlos Tomasi

Helping street children

MSF has been caring for people living with
HIV/AIDS in Cameroon since December
2000. The following year, the organization
began treating patients with life-extending
antiretroviral (ARV) medicines. In thecapital, Yaoundé, MSF runs an AIDS projectthat assists 1,000 people, of which 600 are
receiving ARVs. Another prevention andtreatment project began in the city of
Douala in 2002, with ARV treatment started
in early 2003. By June 2004, 736 patientswere participating in that project with198 receiving ARVs. The project staff
anticipates that 400 people will be using
ARVs by the end of 2004. MSF’s project also
focuses on counseling and helping to easeaccess to treatment.
In the district of Akonolinga, MSF treatspeople suffering from Buruli ulcer. Similar
to leprosy, this disease seems to be contracted by people who come into contact
with the bacteria in swamps and stagnant
water. Once in the body, the bacteria
destroy skin tissue and cause massive
mutilations. A 2001 study done by MSF andanother NGO in the districts of Ayos andAkonolinga found that more than 400
people out of every 100,000 had the disease.
At present, there is no curative treatment
for this disease, and surgery is the only
remedy available to ease symptoms. MSF
began a surgical program to treat people
with Buruli ulcer in 2002 and has assisted
235 patients so far. Sixty-six people
received surgery in the first half of 2004.
In February 2004, MSF responded to acholera outbreak in the city of Douala andhelped the district’s health facilities in theireffort to contain the disease. More than
1,700 cases were reported during thecourse of the outbreak. In May 2004, MSF
ended its intervention.
MSF has worked in Cameroon since 2000.

ACTIVITY REPORT 2003/2004 MEDECINS SANS FRONTIERES 21

I N T ER NAT I O NA L S TA FF 6
NAT I O NAL S TAFF 24

BurundiCentral African
Republic

Providing care to those with none

Giving emergency care

Civilians in Burundi have lived through years of conflict – years inSince civil war started in thewhich infectious and parasitic diseases, especially malaria, have

Central African Republic in 2002,

remained immense health problems. To meet some of the various

MSF has focused on providing

health needs, MSF’s work in Burundi is diverse.

emergency medical relief to theTeams treat patients in clinics and hospitals
in parts of the country where war anddisplacement have left civilians without
health care or with little access to it. In
the capital, Bujumbura, MSF treats war
wounds, manages a health center and runs
a medical/surgical program in a local hospital. In 2003, MSF opened a new center in
Bujumbura to assist survivors of sexual
violence.
The country’s civil war and resulting economic crisis have left civilians with little
access to care. MSF is concerned that a new
cost-recovery policy, implemented nationwide, will further reduce people’s ability to
get needed care (see page 12). A national
survey conducted by MSF during the final
quarter of 2003 suggested that approximately one million of the country’s six million inhabitants had no means to attainhealth care and three million had to use
extreme measures to gain even limitedaccess.
MSF overcame significant barriers to open
a sexual violence project in Bujumbura – acity where the term “rape” does not exist in
the local language. Now the clinic, opened
in September 2003, sees 120-150 new
cases each month. Housed in a downtown
shopping area, the clinic treats gynecological wounds and helps patients to prevent
being infected by HIV or other sexuallytransmitted infections as well as to avoid
unwanted pregnancies. MSF also provides
counseling services to give survivors a safe
environment in which to talk about theirexperiences and learn how to cope withthem.
In addition, MSF operates nutrition programs, prepares to respond to epidemics
and treats people with infectious diseases.
In Bujumbura Rural province, MSF provides
basic medical care in the district of
Rwibaga where the most common illnesses
treated are respiratory infections, diarrheal
diseases and malaria. Special attention andsupport is given to the Karinzi healthcenter, which assists an estimated 50,000
people living in an insecure area. MSF
supports various health care structuresby providing training, medical assistance,
supervision and supplies. Since thebeginning of 2004, emphasis has beenplaced on maternal health. A mobile MSF
clinic at a camp for internally displaced
persons in Kivoga provides first- andsecond-level medical care to approximately
10,000 people. MSF has also launched several cholera interventions, most recently inMarch 2004 in the district of Rubiza.
In response to a number of malaria epidemics, MSF has launched a large-scale
emergency program that offers both curative and preventive care. In 2003, the teamhelped change the national malaria protocol to implement the use of artemisininbased combination therapy (ACT). MSF
now supports training of medical personnel and supervises implementation of the
new protocol.
In June 2004, MSF began to assist thousandsof people who had gathered at Burundi’s
border in their attempt to flee fighting in
the eastern region of the Democratic
Republic of the Congo. MSF teams set up
two mobile clinics and opened a cholera
treatment center in Cibitoke Hospital andisolation areas in two displaced persons
camps. Later in August, about 150 people
were killed and 105 wounded when a refugee camp in Gatumba, on the border
between the two countries, was attacked
by a military group who set ﬁre to buildings
where the refugees were sleeping, andused guns, machetes and hand grenades
to kill others. Victims were brought to the
nearby capital, where MSF treated morethan 20 of the wounded and operated oneight. MSF also provided victims withpsychological support at its center for the
war wounded and at its health center for
women in Bujumbura.
MSF has worked in Burundi since 1992.

22 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2003/2004

victims. MSF staff also run a sleeping sickness project – which was
halted for part of 2003 because of
the conflict – in the southeastern
town of Haut-Mbomou.
MSF aided civilians attempting to escapethe violence by crossing into neighboring
Chad. A team based just over the bordercarried out medical consultations and surgery while also distributing medicine andneeded supplies. MSF also gave urgent
medical care to those who were sexuallyassaulted during the conflict.
During 2003, MSF carried out a number of
exploratory missions in the country. A teamvisited Bouzum to determine the needs ofthe people in the area. In Bouar, MSF carriedout a measles vaccination campaign andevaluated the situation of displaced people
living in the region. In Bossemptele,
Bouzum, Paoua and Bocaranga, MSF distributed medicines and medical supplies
and in Sibut, Paoua and Gore, a teamassessed operations at local health facilities.
MSF has worked in the Central African
Republic since 1997.

Children living in Nana Bakassa wait to be vaccinatedagainst measles during an epidemic in the area.

© Joan Ignasi Soler

AfricaI N T ER NAT I O NA L S TA FF 83
NAT I O NAL S TAFF 8 42

Helping desperate refugees© Espen Rasmussen

Chad

AfricaI N T ER NAT I O NA L S TA FF 6 6
NAT I O NAL S TAFF 58 0

In 2002-2003, Chad was the destination for waves of refugees

Fleeing from Darfur

fleeing conflict in neighboring“I arrived here about two months and ten days ago. I came here byCentral African Republic. During

people fleeing atrocities in thefoot. I came here without anything. I only have my clothes that I am
wearing. I asked for food from the Chad people and they gave mesomething but it is not enough. Here it is very difficult. There is notenough food and we are cold during the night.”

Darfur region of western Sudan.

– Female refugee, 45, in Birak, Chad

The exhausted, malnourished and often ill
people who have been arriving in Chadhave little hope of receiving the care thatthey need. The country has a chronic
shortage of qualified staff and even manyof its residents do not obtain basic healthcare. Treatment for tuberculosis andmalaria is hard to come by, and HIV/AIDS
care is practically non-existent. Epidemics
including cholera, measles and meningitis
often sweep through parts of the country,
and food can be scarce depending on the
success of harvests. Moreover, the country’s
medical system which includes user fees,
excludes many in dire need of care for lackof ability to pay.
Malaria is the most lethal disease in Chad.
In January 2004, MSF started a malaria
project in Bongor district, which aims to
reduce levels of illness and death in thearea. MSF is also working to improve treatment by introducing a new protocol that
includes artemisinin-based combination
therapy (ACT). The project will include a
prevention component targeting pregnant
women and children under five. MSF also
runs a surgical training program at Bongor
Hospital.

Since July 2003, refugees from the Darfur region of Sudan have been setting up makeshift
shelters along a 600-kilometer stretch of border between Chad and Sudan. MSF teams
have followed them there, starting projects to help the exhausted, hungry civilians whomake it across the border. Thousands more remain trapped by violence in Darfur.

2003-4, Chad was again inundated with refugees, this time

In the first part of 2004, MSF teams launched a meningitis-vaccination campaign andimmunized almost 83,000 children in the Iriba area, a coverage rate of 82 percent. An
immunization campaign against measles was also conducted. An MSF team runs the hospital in the town of Adre where 30 to 60 surgical interventions are performed eachmonth. The number of referrals to the hospital has increased since an ambulance service
was started in August 2004. Admissions now average between 130 and 150 each month.
A nutritional unit has been opened to treat children suffering from severe malnutrition.
In August, in Breidjing camp, where 100 to 300 people continued to arrive each day, an
MSF team provided food and medical care to an estimated 42,000 refugees. Most of thepatients were suffering from diarrhea, malaria, malnutrition or respiratory infections. In
the northern Toulum and Iridimi refugee camps near Iriba, and in refugee areas near thetowns of Tine and Birak, there were few malaria cases at first, although they began toappear with the onset of the rainy season. This region of Chad has also been hit by a hepatitis E epidemic which is plaguing Darfur, Sudan as well. By mid-August, Goz Amer campreported 875 hepatitis E patients and 24 deaths, including 8 pregnant women, who are
extremely vulnerable to the illness.
Additional MSF teams have spread out along the border area to provide prenatal services,more nutritional activities and desperately needed water. As refugees are moved by UN
agencies away from border towns to safer locations deeper within Chad, MSF moves its
activities to areas where new refugees are arriving.
Although a large amount of aid has now entered the country, MSF remains concerned
about the health of the refugees. While MSF and other organizations have been able toprovide food aid, water and health care to many, the needs are overwhelming and willcontinue for many months as long as the refugees remain too afraid to return to theirown villages to begin farming again.

g

In August 2004, more than 1,500 people
were infected with cholera around thetown of N’Djamena. When nearby healthfacilities became overwhelmed by the outbreak, MSF, in collaboration with the ministry of health, built a cholera-treatment
center able to accommodate 100 patients.
MSF also flew in cholera kits containing
supplies and needed medicines. An MSF
medical coordinator, nurse and water-andsanitation specialist were also brought into oversee patient care and the construction of the treatment center.
MSF has worked in Chad since 1981.

MSF set up health posts in the border towns of Tine and Birak in September 2003 to provide medical care and food. More than 10,000 medical consultations were completed by
MSF staff in these two towns between September and December 2003. Although the firstrefugees to arrive were taken in by the local communities, their numbers soon ballooned,
exhausting the region’s resources. Since December 2003, thousands of refugees havebeen arriving each month in eastern Chad. By the end of August 2004, an estimated180,000 refugees had arrived. The conditions they face upon arrival are harsh. Most havewalked for days, and when they arrive, there is no shelter or food for them. The region’s
extreme weather conditions only worsen the problems. Many of the refugees are in a
deplorable state, with young children the most vulnerable. A large number of thesefamilies have already lost relatives during attacks on their villages.

ACTIVITY REPORT 2003/2004 MEDECINS SANS FRONTIERES 23

© Frida Lagerholm

AfricaI N T ER NAT I O NA L S TA FF 212
NAT I O NAL S TAFF 1, 829

Democratic Republicof the Congo
A never ending health crisis
After years of war in the Democratic Republic of the Congo (DRC),
efforts to end the conflict moved ahead in 2003-4. A transition government is now in place and elections are scheduled for June 2005. Yet thepath to a lasting peace is fraught with obstacles and little has been
done to alleviate the miserable conditions in which most civilians live.
Throughout the country, medical services
are woefully inadequate if they exist at all,and much of the country remains in a stateof emergency in terms of health. MSF continues to witness massive humanitarianneeds in many of the places where it works.
Since 1998, the International Rescue
Committee estimates more than three million people have died as a result of the war,
mainly from malnutrition and disease. Partsof the DRC continue to be inaccessible tohumanitarian aid due to fighting, forcing
the population to live under the specter ofviolence, displacement, malnutrition anddisease. In reality, few civilians can get the
medical care and health services theyurgently need.
The eastern district of Ituri, in Orientale
province, which last year became notorious
for instances of mass murder, remains volatile even after European Union troops andlater United Nations troops pacified partsof the region, re-establishing law and orderin at least some of the main towns. In May
2004, seven armed militia groups from theembattled district signed an agreementwith the government to disarm andparticipate in the country’s transitional
democracy process. However, renewed
fighting broke out shortly thereafter
between armed factions in Ituri, with masspillaging and rape sending thousands ofcivilians on the run again.
Long-term conflict in the DRC has left people in most provinces vulnerable, and hundreds of thousands depend on external
assistance for basic medical care and food.
The end of active fighting between most of
the belligerents has enabled MSF to travel
into areas that, until recently, were too
unsafe to enter. New projects have opened,
and the quantity of humanitarian assistance being provided has increased. Greater
stability has also made it possible forCongolese people to travel farther fromhome or from their area of displacement toseek assistance.
MSF continues to provide hospital andbasic health care, nutritional assistance tomalnourished children, care of war-injured
civilians, and psychological counseling.
In many areas, the organization has beentreating patients affected by outbreaks ofinfectious diseases such as cholera, meningitis and measles which are endemic inmany parts of the DRC. MSF has launchedvaccination campaigns to tackle such outbreaks, having vaccinated 500,000 children
against measles in the Equateur andOrientale provinces. In these two
provinces, the transportation infrastructure
is appalling, and many areas can only bereached by dug-out canoe or motorbike.
MSF is running basic health care clinics
there, serving some 700,000 people. Someof these clinics are among the most remotein the country.
In the Equateur province and in the villageof Isangi, in Orientale province, MSF is also
working to combat sleeping sickness, adeadly disease that is extremely prevalent
in the region. The project in Isangi includes
a research component aimed at introducing more efficient drugs to treat those withthe disease. In 2003-4, national healthauthorities agreed to allow MSF to carryout several research studies examining theefficacy of various antimalarial drugs. The
results should aid MSF’s efforts to advocate
for the national malaria protocol to bechanged to artemisinin-based combination
therapy (ACT), a more effective therapy, in
2005. Teams that are treating malaria in
the DRC have already introduced ACT intheir projects.

Treating survivors of sexual violence
During the past year it has become increasingly clear that sexual violence, mostly
against women, has been a terrifying reality for people during the years of war. MSF

24 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2003/2004

is now working in several areas including
Baraka, in South Kivu province (see page25) and Bunia, in the Ituri region, to help
survivors of this violence by treating their
physical symptoms and providing counseling to address trauma. Hundreds ofpatients have received medical care andcounseling from the MSF teams in Baraka,
and more than 1,600 women have beentreated since July 2003 in Bunia. MSF has
also treated patients who have experienced sexual violence in Kinshasa andKisangani, and the organization makes
such treatment a part of the integral care it
provides in North Katanga, North Kivu andEquateur. MSF hopes that a national protocol will be developed to ensure proper
treatment for survivors of sexual violence.

Giving AIDS care
HIV/AIDS is beginning to take a massive
toll on the DRC. There is very little data on
the prevalence of the disease let alone
adequate treatment for those living with it.
MSF has been treating people with AIDSrelated opportunistic infections, providing
testing and counseling services and raisingawareness about HIV prevention. The
organization has developed a comprehensive program in Lubumbashi, Kisangani,
Mbandaka and the nation’s capital,
Kinshasa, to fight sexually transmitted
infections among those carrying out highrisk behavior, especially commercial sex
workers. In October 2003, MSF started atreatment program using life-extending
antiretroviral (ARV) medicines for severely
ill AIDS patients in the eastern town of
Bukavu, located in South Kivu province
near the Rwandan border. MSF is the only
organization providing such treatment ineastern DRC. Similar programs have beenlaunched in Kinshasa and Lubumbashi. By
the middle of 2004, 66 people wereenrolled in the treatment program in
Bukavu and 250 were enrolled in Kinshasa,
while thousands of medical consultations
were done each month.

Ongoing crisis
In late May 2004, renewed fighting brokeout in Bukavu, and tension quickly spreadto the surrounding regions. The upsurge ofviolence forced MSF temporarily to evacuate most of its staff from five project sites
in the Kivu provinces, but local staff managed to keep the programs running. MSF

Africaprovided crucial medical care to approximately 32,000 Congolese who fled to
Burundi following this outbreak of violence. Displacement caused by fighting
north of Bukavu prompted MSF to bring
medical assistance to civilians near the
town of Kalehe who had been forced toflee their homes.
In Kitenge, in the province of North
Katanga, more than 40,000 people weredisplaced and 50 villages set ablaze in thefirst five months of 2004 amid fighting
among various militias and government
troops. Since June, displaced people havestarted returning to their villages, yet they
have few if any resources now that theircrops have been destroyed by armed
groups. MSF has been working in theregion since 2002 providing medical careand treating severely malnourished children. Admissions to MSF’s therapeutic
feeding center doubled to 200 in April
2004 with 60 percent of the children fromfamilies that had been displaced recently.
Two of the health centers in which MSF
works were closed due to nearby violence.
One of them, in Kaloko, was looted andpartially destroyed during fighting. The
other, in Kileo, was reopened in March
2004. MSF is now strengthening the referral hospital in the town of Ankoro torespond to emergencies in North Katanga.
While sporadic outbreaks of extreme violence capture headlines in the media, hugeswathes of the DRC exist in a constant stateof catastrophe. MSF has four permanent
emergency teams covering the length andbreadth of the country. These staff members respond to emergencies ranging frommeasles and cholera outbreaks, to displacements due to violence, to nutritional
crises.
The transition process in the DRC has continued to be severely tested in 2004, andthere is concern that war may resume. MSF
is again launching interventions to
respond to the needs of the newly displaced. From east to west, needs in the
DRC remain vast and while it is clear thatthe transition represents a step forward, it
is only an early step on a long road.
MSF has worked in the DRC since 1981.

© Jodi Bieberg

MSF uses all possible means to reach civilians cut off
from health care because of offensives carried out byarmed groups. Teams travel into the deep forests of thecountry using motorbikes and canoes to reach isolated
villages and offer basic medical care.

Alleviating the suffering caused by sexual violence
The town of Baraka, in eastern DRC, located on the shore of Lake
Tanganyika, in the province of South Kivu, has been the scene of massive suffering since the outbreak of war. Caught between rival armed
groups, civilians have faced brutal killings and lootings that haveforced many to flee and have created myriad hardships including
illness and malnutrition.
In August 2002, during a lull in the fighting, MSF began providing hospital services in
Baraka. The team was quickly confronted with another horrific dimension of war perpetrated by all warring parties – sexual violence against civilians. Hundreds of women, girls
and men of all ages had been raped or subjected to other forms of sexual violence. Most
did not seek medical care at the time because either there was simply no care available orthey felt too ashamed or sick after the event.
The medical consequences of sexual violence are many, including transmission of HIV/AIDS and other sexually transmitted infections, unwanted pregnancy and serious complications of reproductive health. In July 2003, MSF began providing special care for survivors of sexual violence. MSF gives “morning-after” emergency contraception to prevent
pregnancy and post-emergency prophylaxis (PEP), which can help prevent the possible
transmission of HIV/AIDS for those who are treated within 72 hours of the rape. MSF staff
members counsel survivors to address psychological and emotional trauma. Between
August 2003 and April 2004, more than 500 people came to MSF for medical consultations and counseling. MSF believes that hundreds more need care but live in areas fromwhich it is difficult to reach the MSF clinic.
“ That night, I was at home with my husband and my four children. Suddenly, there was an
attack on our village. My husband managed to escape, but I was eight months pregnant. I
had no strength to run and my children were with me. I had to protect them and so I couldn’t
escape. Three armed men entered our house and tore off my clothes, as I remained naked in
front of my children. They hit me with the butt of their guns and then raped me – all three ofthem, in front of my children. I lost consciousness. When my husband came back, he called
the neighbors and they took me to the health center…. I am very afraid to have caught diseases and at night I suffer from insomnia. The baby I was carrying at the time of the rape survived, but he is always sick and has constant diarrhea. Since what happened, my husband
insults me every day calling me the wife of the militiamen who raped me and sometimes hedoesn’t even sleep at home. I have no joy, no peace of mind anymore.”– 23-year-old woman, raped in January 2003
This material is drawn from the MSF report “I have no joy, no peace of mind: Medical,
psychosocial and socio-economic consequences of sexual violence in eastern DRC”
published in April 2004 by MSF-Holland.

ACTIVITY REPORT 2003/2004 MEDECINS SANS FRONTIERES 25

AfricaI N T ER NAT I O NA L S TA FF 36
NAT I O NAL S TAFF 363© Steve Harris

Republic of Congo (Congo Brazzaville)

Caring for victims of war
A peace accord signed in March 2003 brought a halt to open hostilities
in the country’s Pool region near the capital city, Brazzaville. But theuneasy peace has not led to political progress in disarming the Ninja
militia or integrating combatants back into community life. Tension
remains high and MSF is one of the few organizations present in thearea, which remains unstable, lawless and dangerous.
For more than two years, MSF has been
responding to medical needs resulting
from the area’s devastation by civil war.
Currently, MSF staff members work in hospitals and mobile clinics in the Pool region
towns of Kinkala and Kindama providing
basic health care, performing emergency
surgery and treating people with malaria
and tuberculosis. Between December 2003
and May 2004, MSF averaged more than
10,000 patient consultations each month in
the Pool region. In 2004, MSF added mental health care activities, including counseling and community outreach, to its
health care program in Kinkala. MSF teammembers use individual and group counseling to help civilians work through traumatic war experiences.
Since June 2003, MSF staff members havebeen working in the Pool’s Mindouli district, operating mobile clinics that visit tensites, vaccinating children against common
diseases including measles, polio andtuberculosis and offering medical support
at the district hospital. Each month theteam conducts about 3,000 medical consultations and admits 250 people to thehospital for further care.
In 2003, MSF rehabilitated the healthcenter in the northeastern district of Bétou.
This is an isolated area where many refugees from the Democratic Republic of theCongo and Central African Republic now
live. The construction project enabled MSF
to increase the kinds of care available in
the area. Teams can now offer tuberculosis
treatment, more surgical care, prenatal
consultations and other medical activities.
The team in Bétou also carries out vaccination campaigns and runs mobile clinics.
More than 50,000 consultations wereconducted in 2003. Approximately 26,000
people received outpatient consultations
at the hospital and 35,000 were helped in
the district health center and its mobile
clinics.

26 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2003/2004

Care for victims of sexual violence is anotherimportant part of MSF’s activities in
Brazzaville. Patients who visit Makélékélé
or Talangaï Hospital within 72 hours of anassault are given preventative treatment
for sexually transmitted infections, a voluntary HIV test, and, if female, emergency
contraception to prevent pregnancy.
Pregnant women receive treatment to
reduce the risk of transmitting the virus totheir baby. All of these patients are encouraged to meet with an MSF psychologist to
talk about their experience. Health careassistants, trained by MSF, visit the patients
at home later to ensure that they are continuing their medical treatment and toencourage them to regularly consult thehospital psychologist. MSF has treatedmore than 600 people since the program
began four years ago.
MSF also aids people suffering from sleeping sickness (African trypanosomiasis) inNyazi, Bouenza, in the south of the country
and in Mossaka, Cuvette Est, on the Congo
River, some 450 kilometers north ofBrazzaville. Since 2000, MSF has screened
more than 250,000 people for sleeping
sickness and treated more than 2,000
patients with the disease. Caused by parasites spread by tsetse flies, the disease isfatal unless treated.
MSF has worked in the Republic of Congo
since 1997.

AfricaI N T ER NAT I O NA L S TA FF 57
NAT I O NAL S TAFF 671

Ethiopia

The past year has brought about importantdevelopments in treating people withmalaria and AIDS in Ethiopia. One positivechange has been the country’s movetoward a new, more effective protocol fortreating malaria, which is endemic in the
country. This policy shift came about after
many months of advocacy work done by
MSF and numerous national and international organizations in the midst of asevere malaria epidemic that started near
the end of 2003.
In most of Africa, conventional malaria
treatments such as chloroquine and sulfadoxine-pyrimethamine (SP) are no longer
effective in many patients due to theincreased resistance of parasites to thesedrugs. To counter this problem, MSF has
been promoting the use of artemisininbased combination therapy (ACT) which isderived from a centuries-old Chinese herbal medicine.
The malaria epidemic of late 2003 affected
the southern Ethiopian state of Oromiya
and other parts of the country. When theWorld Health Organization (WHO)announced that an estimated 15 million
Ethiopians were at risk of contracting thedisease, MSF asked the government for
permission to use ACT. MSF believed that
this combination therapy was vital to stopping the further spread of the epidemic.
However, the government refused. It said it
wanted more scientific evidence before
determining whether the national treatment protocol should be changed. As aconsequence, health staff from someorganizations were forced to treat thousands of sick patients in the epidemic areawith largely ineffective medicines, and MSF
was obliged to adapt to the situation byusing quinine as first-line treatment. The
death toll from this outbreak was substantially higher than it was from malaria in
2001 and 2002. According to government
figures, approximately 3,500 people died ofmalaria during the outbreak.
In response to intensive advocacy conducted by MSF and others, the ministry ofhealth announced in May 2004 that it
would change the protocol by July. The
government planned to introduce ACT in© Kurt Tonini

Advancing treatment for
deadly diseases

August as the country’s standard malaria
treatment. The episode also pushed major
institutions, such as the WHO and the
Global Fund to Fight AIDS, Tuberculosis
and Malaria to strengthen their support for
ACT. While implementation was still pending in September, the change in policy
enabled MSF to bring ACT drugs into thecountry. MSF teams are now starting to
implement the new treatment in MSF
projects.

A resettlement nightmare
Tension also erupted between the
Ethiopian government and MSF around thegovernment’s three-year program toresettle approximately 2.2 million farmers
from overcrowded, low-yield agriculturalareas to underpopulated, more fertile land.
The scheme is part of the government’s
plan to solve recurring hunger problems
and increase agricultural production.
However, in 2003, during the pilot phase of
the program in which more than 150,000
people were moved, MSF discerned poor
planning and insufficient monitoring insome settlements, leading to high levels of
malnutrition and disease. In various locations there was also insufficient water tosupport the increased population. MSF
made a decision to intervene in a numberof emergency situations by providing
urgently needed health care and foodprograms for thousands of sick and malnourished settlers in the Amhara region. It
opened a therapeutic feeding center forchildren and adults, a supplementary
feeding program and mobile “fever clinics”
to detect and treat malaria as well as thedisease kala azar (visceral leishmaniasis).
Kala azar is a sandfly-borne disease that
affects the immune system and, if left
untreated, kills almost all who contract it.

avoid future problems. With the resettlement program continuing and thousandsof new settlers arriving, MSF fears that new
health emergencies will erupt again in themost vulnerable new settlements.

Treatment for AIDS
Early 2004 also saw the start of Ethiopia’s
first free AIDS-treatment program using
life-extending antiretroviral (ARV) medicines. In close cooperation with district
health authorities and HIV/AIDS patientgroups in the northern Tigray region, MSF
began treating patients with ARVs in the
district hospital in Humera. By mid-2004,
67 patients were receiving ARVs, and theprogram aims to admit 15 new patients permonth. As part of the project, the MSF
team provides voluntary HIV counselingand testing to the wider Humera community. It also provides medical care toapproximately 500 HIV-positive people andfood for patients with HIV/AIDS, kala azar
or tuberculosis who require it.

Other MSF activities in Ethiopia
MSF has helped control multiple meningitis outbreaks in the Gurage and Haydia
zones in the southern Oromia region andmost recently in the Wag Hamra zone in
the Amhara region. In Wag Hamra, MSF
also provides community therapeutic feeding in an area where people experiencefrequent food shortages and cannot get
quality health care. In June 2004, MSF
opened a primary health care clinic in theSomali region of southeastern Ethiopia.
Based in Cherati, the clinic covers about
75,000 people living in an area in which
health facilities are scarce or not working.
Finally, at the border with Sudan andEritrea, MSF treats people with kala azar inthree locations.
MSF has worked in Ethiopia since 1984.

In 2004, MSF urged Ethiopian authorities toevaluate the program’s pilot phase to help

ACTIVITY REPORT 2003/2004 MEDECINS SANS FRONTIERES 27

AfricaI N T ER NAT I O NA L S TA FF 30
NAT I O NAL S TAFF 414

I N T ER NAT I O NA L S TA FF 7
NAT I O NAL S TAFF 8

GuineaGuinea Bissau

Helping refugees and treating infectious diseases
MSF teams have been assisting the hundreds of thousands of refugees

Providing help during
a measles outbreakfleeing to Guinea to escape armed conflicts in Sierra Leone, Liberia andAn outbreak of measles in Bissau,

Côte d’Ivoire. As some areas became considered more secure, MSF

the country’s capital, raised alarm

aided refugees returning to Sierra Leone by setting up transit camps

in the early months of 2004. The

and supplying medical screenings for them.

country has a national vaccination
coverage rate of less than 60 per-MSF has begun work to improve the careand treatment of Guineans living with diseases such as HIV/AIDS, tuberculosis andmalaria. In the capital city of Conakry andthe Moyenne Guineé region, MSF trains
local doctors and health workers to manage care for tuberculosis (TB) patients.
Teams are working to improve detection
and treatment of the disease and raiseawareness about it. MSF has also set up a
database to help health workers track TB
patients who stopped taking treatment
and to provide follow-up care. The organization currently provides TB drugs for 4,500
patients a year and supplies 15 TB laboratories. MSF has been actively involved in
Guinea’s National Program for the Fight
Against Tuberculosis (TB) since 1988.
In August 2003, MSF started providing carefor people living with HIV/AIDS in Conakry
and Guéckedou prefecture. Teams haveopened free HIV testing and treatment
centers. MSF offers care for opportunistic
infections, provides treatment with lifeextending antiretroviral (ARV) medicinesand gives information on the disease.
Currently, 250 patients are receiving carefor opportunistic infections in Conakry and150 obtain such care in Guéckedou. The
MSF team started treating people with
ARVs in July 2004 and hopes to have 200
people using ARV treatment by the end of
2004.
Malaria is one of the leading causes of illness in the country. Health authorities currently promote drug treatments which areconsidered ineffective in many countries
due to growing resistance to them. MSF is
now conducting a resistance study in
Dabola using two new artemisinin-based
combination therapies (ACT), more effective treatment that does not have the sameproblems with resistance. The study, carried out in cooperation with local healthauthorities, may lead to the opening of apilot project introducing a more efficient

treatment protocol to treat those with thedisease.
Since May 2003, MSF has conducted surgical activities at Macenta Hospital locatednear the Liberian border. MSF staff carriedout more than 600 surgical interventions in
2003. In the first half of 2004, about onethird of the surgical procedures were doneto alleviate gynecological and obstetricalproblems. Staff also manage the water andsanitation systems for the 75-bed hospital.
In N’zérékoré prefecture, MSF cares for refugees in Lainé camp which houses morethan 22,000 people and Nonah campwhere 3,700 people live. MSF staff members provide basic medical and maternity
care, vaccinations and therapeutic feedingfor malnourished women and children. In
July 2004, MSF carried out 3,894 medical
consultations in Lainé camp and 1,687 consultations in Nonah camp. Though MSF
stopped its medical activities at Kuankan
camp in August 2003, a new influx of
Liberian refugees prompted MSF to restartthem in February 2004. The MSF team provides water and sanitation for approximately 6,500 camp residents. In addition,
MSF runs a clinic and dispensary. MSF
plans to stay in Kuankan camp as long as
refugees continue to need assistance.
In August 2004, MSF closed a project thatprovided aid to refugees in Boreah camp in
Kissidougou prefecture. Repatriation of
Sierra Leone refugees in 2003 and 2004
greatly reduced the camps’ populations
and the need for help. Since 2001, MSF
teams had provided medical consultations,fed malnourished women and children andprovided water and sanitation facilities
within the camp. In the same month, MSF
also ended a project which entailed
providing equipment and training to staff
at Kissidougou Hospital to reduce HIVtransmission through blood transfusions.
MSF has worked in Guinea since 1984.

28 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2003/2004

cent and even below 45 percent insome regions.
Concerned about the potential for an epidemic, MSF sent a team to assess medical
needs in April 2004. The team found that
more than 964 measles cases had beenregistered in the first three months of theyear. The central cold chain system was notworking well and no measles vaccines wereavailable.
MSF transported vaccines as well as logistical and medical material in cargo planes
from Brussels and started an emergency
vaccination campaign in early May.
Targeting a population of 200,000 children
between the ages of six months and 15
years old, the team ran vaccination programs in the areas of Gabu, Oio, the Bijagos
islands and Bolama. Awareness activities
were conducted to improve future routine
vaccinations. The vaccination campaign
ended in June 2004 with 89 percent of thetargeted population having been vaccinated.
MSF last worked in Guinea Bissau in 1998
to assist the population in a conflict andpost-conflict situation. Since then, MSF
keeps in regular contact with healthauthorities to respond to any health emergencies that arise.

I N T ER NAT I O NA L S TA FF 39
NAT I O NAL S TAFF 2 53

Côte d’Ivoire

AfricaI N T ER NAT I O NA L S TA FF 6 8
NAT I O NAL S TAFF 851

Kenya

Giving care amid violence
In 2002-3, a violent civil war divided this once peaceful country inhalf and sparked a political and medical crisis that continues today.
Ongoing political unrest has kept thousands of impoverished, displaced civilians from returning to their homes, especially in the northand western regions of the country.
The violence caused hundreds of thousands of workers to abandon their farms,
and hunger is a persistent problem. The
conflict has severely damaged the country’s health care system, which lacks personnel and medical equipment, leaving
many civilians without basic care. At thesame time, there has been a resurgence of
epidemics and diseases in overcrowded
cities and towns.
Working on both sides of the frontlines,
volunteers and national staff provided
urgently needed medical care and personnel for health facilities. Throughout thepast year, MSF restored medical facilities
that had been plundered and whose personnel had fled. Teams were based in thewestern towns of Man, Kouibly, Bangolo,
Bin-Houyé and Danané, as well as in thecity of Bouaké in central Côte d’Ivoire andin the city of Korhogo in the north of thecountry. At hospitals in Bouaké, Man and
Danané, MSF staff members provide essential medical care including pediatrics,
emergency medicine, gynecology/obstetrics and surgery for area residents. Since
April 2003, MSF has run mobile clinics invillages along the northwestern borderwith Liberia. Projects were also begun in
the western towns of Guiglo and Toulépleu
to decrease malnutrition and assist people
displaced by violence. MSF teams havecontinued to carry out thousands of medical consultations each month. In 2004,

MSF handed its project in Toulépeu over tothe government.
War wounds were most prevalent in theearly days of the conflict, but now most
MSF patients suffer from severe malnutrition and infectious diseases, especiallymalaria. MSF opened a therapeutic feeding
center in Man Hospital in May 2003, andadmitted more than 350 children during
the July 2003 peak. During the past year,
MSF staff vaccinated children and provided
care during outbreaks of measles, yellow
fever and meningitis.

Treating inmates with TB
MSF continues to provide medical care to
the more than 5,000 inmates crammed into
the Maison d’Arrêt et de Correctiond’Abidjan (MACA) prison in the capital city,
Abidjan. In a facility designed for merely
1,500 inmates, the prison’s horrendous
living conditions give rise to frequentcholera epidemics and high levels of tuberculosis (TB). MSF has been conducting
nearly 2,000 medical consultations thereeach month. During 2004, MSF extended
its activities in the prison’s TB ward in collaboration with the country’s national TB
program and also began treating people
with multidrug-resistant strains of thedisease. More than 200 detainees benefit
from a supplemental nutrition program
established by MSF in 2003.
MSF has worked in Côte d’Ivoire since
1990.

MSF’s long relationship with Kenya has
been focused in recent years largely on
helping those living with HIV/AIDS. Today
more than 2.5 million of the country’s 32
million residents are living with this disease. In several locations, MSF has begun
providing HIV testing and counseling services, care for patients with opportunistic
infections and treatment with life-extending antiretroviral (ARV) medicines. As of
August 2004, MSF staff working in the
Mathare slums of Nairobi were providing
care and ARV treatment to 386 people
including 49 children, as well as treatment
for tuberculosis (TB), a common co-infection of HIV/AIDS. In the city’s Mbagathi district hospital and in the Kibera area, MSF
has started treating 600 people with ARVs
including 80 children. And in Homa Bay inwestern Kenya, MSF works in the city andin three peripheral health centers to provide ARVs to 1,565 people, including 86
children, as well as TB treatment.
In and around the rural town of Busia inwestern Kenya, MSF provides home-based
AIDS care to more than 1,500 patients who
are too weak to seek health care themselves and who lack social support. A totalof 502 people, including 20 children, areparticipating in Busia’s ARV program. In all,more than 3,000 Kenyan patients are now
receiving ARVs through MSF. Based on its
own experience, MSF also shares information with the government on ways to get
ARV treatment to the estimated 250,000
people in Kenya who need it urgently but
cannot afford it.
In April 2004, MSF responded to alarming
malnutrition in the drought-stricken northof the country by starting a therapeutic
feeding program in Turkana. MSF continues
to monitor the nutritional situation ofpeople living near Marsabit.
MSF has worked in Kenya since 1987.

ACTIVITY REPORT 2003/2004 MEDECINS SANS FRONTIERES 29© David Levene© Frida Lagerholm

Expanding treatment forpeople with AIDS

Liberia
War ends, but the crisis
continues© Kadir van Lohuizen

AfricaI N T ER NAT I O NA L S TA FF 70
NAT I O NAL S TAFF 450

In September 2003 MSF opened therapeutic feeding centers in the cities of Buchanan and Monrovia.
The centers had hardly opened their doors when severely malnourished children started pouring in.

Fierce fighting between rebel
and government forces on thestreets of the capital, Monrovia,
between June and August 2003,
killed more than 2,000 people
and wounded many civilians.

“Because the war has gone on for so long there are teenagers
who have known nothing for the last 14 years but violence.
So for them to go back to being a farmer will be very
difficult – I don’t know whether they will be able to cope.”– Carolyn Merry, nurse and project coordinator for MSF in Liberia

Although the fighting has ended,
the war’s long-term consequences
continue to cause suffering
among the civilian population.
In August 2003, Liberia’s president, Charles
Taylor, stepped down and accepted
Nigeria’s offer of political asylum. Soon
after, the three warring parties signed apeace agreement ushering in a transitional
government and a process of military disarmament and demobilization. Yet the longyears of war, the latest round since 1999,
have severely damaged the social fabric of
Liberian society. Families have been separated as people were forced to flee to otherparts of the country or neighboring
nations. Many civilians died from war
wounds, malnutrition or the epidemics
that plagued the weakened population.
The country’s infrastructure, including thehealth care system, is destroyed. More than
40 percent of the population lacks healthcare and less than 20 percent have safe
drinking water and sanitation facilities.
Today there are only about 30 Liberian
physicians working in this country of morethan three million people.

Monrovia:during and after the battle
When Monrovia was under siege in July
2003 and other health facilities were forced
to close as fighting neared, MSF staff converted their living compound into an emergency surgical hospital. By September, thefighting had ceased but Monrovia
remained a city of squatters living without
electricity, running water, shelter, sanitation or adequate food. Every new clinic
opened by MSF was immediately flooded
with people seeking treatment and cleanwater. Days after the fighting ended, MSF

staff re-opened Redemption Hospital andconverted a school into Mamba Point
Hospital, both free, full-service facilities.
They also restarted the 50-bed Island pediatric facility and Benson Hospital. MSF staff
continued to run three cholera treatment
units until they were no longer needed
shortly after fighting ended. Teams also
managed therapeutic feeding centers in
the city, including one, still in operation,that treats severely malnourished children
who also have tuberculosis. Among all ofthese facilities, the MSF teams were treating 1,500 to 2,000 people a day by
September 2003. Later, in October, two
medical clinics called Red Light and Loganwere opened in the city to provide additional care to the local population. Onceneeds began to subside, MSF closed the
Red Light clinic in April 2004 and Loganclinic in July.
The most common health problems seen
were cholera, malaria, watery diarrhea,
measles, sexually transmitted infections
and pregnancy-related conditions. MSF
introduced artemisinin-based combination
therapy (ACT), the most effective malaria
treatment today, to several of its clinics in
Monrovia during the fighting. It also supplied more than 300,000 liters of drinking
and washing water to centers for displaced
people.

Devastation in rural areas
In the weeks following the battle in
Monrovia, MSF assessment teams traveledbeyond the capital to Grand Bassa, Grand
Gedeh, Lofa, Montserrado and Nimba
counties to assess health needs in parts ofthe country that had been cut off fromhumanitarian aid for months or, in somecases, even years. In the city of Buchanan

30 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2003/2004

in Grand Bassa county, MSF fed malnourished children from September 2003 until
the early part of 2004 when needs
declined. In Bong county, international
staff rejoined Liberian staff who had continued providing medical consultations
and clean water to more than 70,000 displaced people despite nearby fighting.
In some areas, MSF staff found people surviving amid horrendous living conditions
in displacement camps and villages. Many
had inadequate food, water and medicalcare. Malaria, respiratory infections, cholera, sexually transmitted infections andmalnutrition rates were high. MSF beganproviding care in local hospitals and started
health clinics which together carried out
thousands of medical consultations eachmonth. MSF also organized blanket feedings for more than 10,000 children.
In early October 2003, MSF began a program to treat survivors of rape and sexual
violence in three displacement camps
located north of Monrovia which shelter
about 35,000 people. The project encourages rape survivors and their families toseek care quickly after sexual assaults inorder to receive medical treatment necessary to prevent unwanted pregnancies andsexually transmitted infections, including
HIV/AIDS. The team’s Liberian staff works inthe camps to spread the message thattreatment is available and to encourage
camp residents to take advantage of it. By
July 2004, more than 800 people had cometo MSF for treatment. All individuals whoreport being raped are examined andtreated in the camps. Those needing extra
care are referred to Redemption or Benson
Hospital in Monrovia.
MSF has worked in Liberia since 1990.

I N T ER NAT I O NAL S TAFF 19
NAT I O NAL S TAFF 181

I N T ER NAT I O NA L S TA FF 9
NAT I O NAL S TAFF 8 0

Madagascar

MalawiMali

MSF offers medical, nutritional, social andjudicial assistance for children and families
in severe need in the capital city of
Antananarivo. Staff seek contact, often atnight, with vulnerable civilians living on
the streets, in detention centers and in
temporary shelters. During 2003, MSF
intensified its medical activity in the Isotry,
Andravohangy, and Anosibe health centers
in Antananarivo. The team gives outpatient
medical consultations, vaccinations, preand post-natal care and refers patients to
Befelatanana Hospital when needed. At
present, approximately 3,700 children andpregnant women are being assisted by the
program. MSF staff also continue to provide health care to patients and to train
staff in the therapeutic feeding center for
malnourished children located in
Befelatanana Hospital. MSF also givessocial and legal assistance on a case-bycase basis.

Relief after a cyclone© Paula Llavallol

After a cyclone hit the northeastern regionof Antalaha, MSF distributed medicines,
helped reconstruct roofs and supplied
other materials to the affected population.
When malnutrition became a serious problem in the areas surrounding the southwestern province of Morondave, whichwere difficult to reach due to flooding, MSF
opened a therapeutic feeding center toprovide urgently needed food and medical
treatment to children. In June 2004, MSF
started a medical-nutritional program forchildren and families who had been affected by the cyclone. The main objective wasto reduce mortality and to prevent further
illness linked to malnutrition.
MSF has worked in Madagascar since 1987.

© Didier Lefevre

Providing care forchildren and families

Giving comprehensive
AIDS care
The southern African nation of Malawi is
one of the countries most severely affectedby HIV/AIDS. One million adults and children are estimated to have HIV/AIDS, andlife expectancy has fallen below 40 years ofage. In this country, where most people
live in rural areas and have little or noaccess to health care, MSF provides medical treatment including life-extending
antiretroviral (ARV) therapy to people livingwith AIDS in the districts of Chiradzulu andThyolo in southern Malawi. MSF also
responds to nutritional emergencies andoutbreaks of diseases such as cholera.
In the Thyolo district, MSF is providing
health care to people living with HIV/AIDS
through activities in two hospitals, ten
health centers and multiple clinics andother sites. MSF works with volunteers,
traditional healers and birth attendants toprovide an integrated approach to HIV/AIDS prevention, care, treatment andsupport. Team activities include voluntary
counseling and testing services, treatment
for opportunistic diseases (including tuberculosis), prevention of mother-to-childtransmission and home-based care. MSF
staff also hold monthly mobile clinics forcommercial sex workers. By the end of
August 2004, about 1,250 patients werereceiving treatment with ARVs.
In Chiradzulu, MSF staff carry out daily HIV
clinics in the central district hospital andbimonthly clinics in 11 district health centers. MSF sees an average of 400 newly
diagnosed patients per month. The MSF
team also cares for hospitalized HIV/AIDS
patients. By July 2004, more than 3,200
patients were taking ARVs, at the rate of
200 to 250 new patients per month. MSF
also works to educate the public to fightthe stigma associated with HIV/AIDS.
MSF has worked in Malawi since 1986.

AfricaI N T ER NAT I O NA L S TA FF 8
NAT I O NAL S TAFF 72

Treating eye illnesses
and infectious diseases
The people of Mali are confronted withchronic health emergencies that include
epidemics of meningitis, cholera, measles
and yellow fever. Because exclusion fromhealth care is a large problem, the primary
focus of MSF’s medical programs in Mali isto provide treatment to those who mostneed it.
Since 1996, MSF has provided support toone hospital and three health centers in
the Ansongo district of Mali’s Gao region.
MSF’s work includes surgical training, providing essential medicines and materials,
and vaccination and outreach activities.
MSF also trains traditional birth attendants
and supervises overall management of thehealth centers. In Gao district, MSF supports the Sahel Formation nursing school
which prepares health staff for Mali’s threenorthern regions: Gao, Tombouctou andKidal.
The region of Mopti, located about 600 kilometers northeast of Bamako, has a particularly high prevalence of eye illnesses. In
2003, an MSF mobile team carried out 650
surgical operations for cataracts (400 at themobile site and 250 at the hospital) andcorrective surgery for 1,200 people withtrichiasis, another damaging eye condition.
More than 265,000 people received generic
medicine to treat trachoma, a viral disease
that can lead to blindness.
In 2003, MSF sent an emergency medical
team in Mopti to address meningitis andcholera epidemics both in Mali and neighbouring Burkina Faso.
In Bougouni (Koumantou) research done
by MSF’s malaria program staff foundsevere resistance to chloroquine and fansidar, two long-time treatments for the disease. MSF plans to use the collected medical data in its efforts to convince thegovernment to change its national malaria
protocol to implement artemisinin-based
combination therapy (ACT).
MSF has worked in Mali since 1992.

ACTIVITY REPORT 2003/2004 MEDECINS SANS FRONTIERES 31

I N T ER NAT I O NAL S TAFF 38
NAT I O NAL S TAFF 3 4 6Mauritania

Mozambique

Providing care where
there is none

Scaling up AIDS treatment

Widespread poverty, lack of infrastructure and insufficient resources haveleft many of Mauritania’s inhabitants
without needed health care. MSF’s
projects seek to assist those who mostneed care and to reduce malnutrition. In
Bouhdida, a poor neighborhood on theoutskirts of the capital, Nouakchott, an
MSF team runs a primary health careclinic. In the southern region of
Guidimakha, MSF operates a project
aimed at reducing maternal morbidity
and mortality – among the country’s
most pressing health problems. MSF
staff provide basic obstetrical services
for 30 percent of the region’s pregnant
women. In Saada, another povertystricken neighborhood of Nouakchott,
MSF supports a supplementary feeding
center to reduce malnutrition. The
results of a study begun in the
Guidimakha region at the end of 2002
prompted MSF to open a therapeutic
feeding center in Selibaby, the region’schief city, in the middle of 2003.

of those who live with HIV/AIDS – an estimated 1.8 million of the

MSF is also intervening in small- andmedium-scale emergencies. A teamassisted the population of the
Guidimakha region after heavy floodingin August 2003. It also supported thecountry’s ministry of health during ameasles vaccination campaign held inthe same region.
MSF is now reducing its activities in
Mauritania and plans to hand over theseprojects to local authorities or local
NGOs by the end of 2004.
MSF has worked in Mauritania since
1994.

Most MSF activities in Mozambique are focused on improving the lives
country’s approximately 19 million people. Life expectancy has alreadybegun to be affected by the AIDS epidemic.
Since 2001, MSF has provided comprehensive care to people living with HIV/AIDS,
conducted HIV education and assisted
patient-support groups in Maputo. In the
Chamanculo health district, MSF supports
the Alto Maé health center and one unit ofChamanculo Hospital. Activities include
voluntary counseling and HIV testing, prevention of mother-to-child transmission of
the virus and treatment with antiretroviral(ARV) medicines. As of June 2004, 935
patients were receiving life-extending ARVtherapy. MSF hopes to increase the numberof patients using ARVs by at least 80 amonth.
In the city’s Mavalene district, MSF staff
work at the Primeiro de Maio health center,
providing comprehensive AIDS prevention
and treatment services primarily to a
destitute urban population. As of May
2004, MSF was providing ARVs to 473
patients in this region. The team conducted
6,942 consultations in the day clinic
between January and May 2004. In addition, 975 women had been tested for HIV
as part of the mother-to-child prevention
program. The MSF staff hope to expand
ARV treatment to an additional 700 people
in Mavalane district during 2004.

crimination through street theater, radio
programs and other activities.
MSF also runs two HIV/AIDS projects in
Tete province and another in the northern
district of Angonia. Tete has a high concentration of displaced people who arrived
during Mozambique’s period of civil conflict. The most recent epidemiological surveillance shows an HIV infection rate of 20
percent. As of May 2004, through theseprojects, MSF had conducted 5,150 medical
consultations, had tested 972 women for
the virus as part of the mother-to-childprevention program, and was treating 279
people with ARVs.

Combating cholera
To help the government cope with cholera,a recurring health problem, MSF began avaccination project in December 2003 inthe city of Beira, in the province of Sofala.
This was the first large-scale field test of acholera vaccine and was carried out incooperation with the World Health Organization and others. MSF also responded toa cholera outbreak in Maputo between
January and March 2004. In mid-2004, MSF
will hand over another cholera prevention
program to a local association.
MSF has worked in Mozambique since thelate 1980s.

In Lichinga, an isolated city in the north ofthe country, MSF supports two voluntary
counseling and careclinics (one in the proMSF uses street theatre and personal stories to educate the public about
vincial hospital and one
AIDS in Mozambique. A man in the crowd embraced one speaker afterin the city’s health center)hearing his story about living with HIV/AIDS.
and one hospital.
Activities include comprehensive HIV/AIDS
treatment and educationand training of staff
members who work inthese health structures.
As of June 2004, 81
patients were receiving
ARVs. MSF recently
began a campaign toreduce stigma and dis-

32 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2003/2004© Martin Beaulieu

AfricaI N T ER NAT I O NA L S TA FF 7
NAT I O NAL S TAFF 18

I N T ER NAT I O NAL S TAFF 9
NAT I O NAL S TAFF 10 0

I N T ER NAT I O NA L S TA FF 2 3
NAT I O NAL S TAFF 70

Morocco

Niger

Nigeria

AfricaI N T ER NAT I O NA L S TA FF 5
NAT I O NAL S TAFF 8© Amanda Sans

© Julien Poublan

Alleviating the burden of
illness and violence

Helping immigrants
bound for Europe

Aiding epidemic victims

Morocco is a transit country formeasles epidemic occurred inthousands of immigrants and asy-

Niger’s capital city, Niamey.

lum seekers on their way to

In March and April 2004, MSF, in

Europe. MSF is focusing attention

cooperation with the ministry ofon sub-Saharan undocumented

health, carried out a massive

immigrants based in the city ofmeasles-vaccination campaign

Tangiers and its surrounding areas.

there and in two other districts.

In Tangiers, MSF runs a clinic in the city
center and makes visits to patients inhostels and private houses where undocumented immigrants seek shelter. MSF alsouses mobile clinics in the surrounding
neighborhood of Massnana to carry out
patient consultations and referrals.

Before the epidemic had ended, more than
30,000 people had contracted the disease,and MSF had vaccinated 100,000 children
between the ages of six months and five
years. MSF also supplied 500 medical treatments to Niamey’s largest hospital to treat
children suffering from critical complications related to the disease.

MSF works with health authorities toensure that undocumented sub-Saharanimmigrants receive other needed healthcare services, such as pre- and postnatalcare, tuberculosis treatment and HIV/AIDS
care. At the same time, the team tries toraise awareness among Moroccan authorities and organizations about these immigrants’ vulnerable situation.

Responding to the earthquake
emergency
On 24 February 2004 an earthquake hit thenorthern region of Al Hoceima. An MSF
team traveled to the area to assist theaffected population. MSF distributed 2,000
blankets and plastic sheeting to families
that had lost their homes. These samematerials were also distributed in surrounding villages affected by the earthquake.
MSF has worked in Morocco since 1997.

In the first quarter of 2004, a

Epidemics have led to an increase in malnutrition in Niger. Currently, MSF runs anemergency nutrition program in the easterncity of Maradi. During 2003, 6,500 children
received high-protein treatment in MSF’s
therapeutic feeding center. The objectiveof this program is to set up a new approach
to treat severe malnutrition, which consistsof reducing or even eliminating the hospitalization stage. One-third of the children
admitted to the center and all of those whoare not severely malnourished are treatedas outpatients.
MSF has worked in Niger since 1985.

Malaria is the main cause of death amongvery young children living in the Niger
Delta. The mosquitoes that spread the parasites causing the disease breed in theregion’s wetlands. In isolated and swampy
parts of southern Bayelsa State, MSF teams
provide basic health care at three healthcenters covering a population of more than
50,000 people. The care includes artemisinin-based combination therapy (ACT), themost effective treatment now available formalaria. Team members educate local residents about ways to prevent malaria and to
improve basic hygiene. This project is MSF’s
first using ACT in Nigeria, and the organization believes it will play an important rolein promoting the country-wide introductionof this treatment.
An estimated 300,000 of the 12 million
people who live in Nigeria’s largest city,
Lagos, are thought to be living with HIV/
AIDS. Most of them have no way of getting
treatment for related illnesses. MSF staff arecaring for HIV-positive patients at Lagos
General Hospital and have improved thehospital’s laboratory and pharmacy, rehabilitated a special treatment department,
and started a voluntary counseling andtesting center. Patients receive care foropportunistic infections that can develop
when the HIV virus undermines theimmune system and can also receive
psychological counseling. The team will
start treating patients with life-extending
antiretroviral (ARV) drugs during thesecond half of 2004.
With no fewer than 350 ethnic groups,
Nigerian society is extremely complex.
Incidents of violence rooted in ethnic, religious or socio-economic differences occur
frequently. After clashes and a massacre
took place in May between rival groups in
Yelwa, Plateau State, MSF assisted thousands of destitute, displaced people who
had fled to neighboring Bauchi andNasawara States. MSF mobile teams beganproviding basic medical and psychologicalcare to displaced people living in a numberof makeshift camps in the area. They also
improved water and sanitary conditions toimprove the camps’ difficult conditions.
MSF has worked in Nigeria since 1996.

ACTIVITY REPORT 2003/2004 MEDECINS SANS FRONTIERES 33

AfricaI N T ER NAT I O NA L S TA FF 13
NAT I O NAL S TAFF 12 5

I N T ER NAT I O NA L S TA FF 56
NAT I O NAL S TAFF 6 42

RwandaSierra Leone

Providing psychological and medical care
MSF works with local groups to provide psychological help to survivorsof the genocide that occurred in 1994. A team of five psychologists
helps women – many of whom were raped during the genocide and havesubsequently developed AIDS – to express their anxiety and anger.
Group therapy aims to help them copewith their emotions and rebuild social connections. The team supervises 14 MSFtrained trauma counselors from partner
associations who manage 496 psychosocial
assistants (local people trained in basic
psychosocial care who work in villagesaround the country).
MSF developed an HIV/AIDS projectencompassing both prevention and treatment in 2002. The project first served
patients in the zone around the healthcenter in Kigali’s Kimironko area, and sinceJune 2003 it has also included patientsfrom a second health center in Kigali’s
Kinyinya area. MSF staff provide voluntary
counseling and testing, home-based care,treat opportunistic infections and give
drug therapy to prevent mother-to-childtransmission. MSF introduced antiretroviral(ARV) drugs in Kimironko in October 2003
and in Kinyinya in January 2004. MSF plans
for at least 500 people to be receiving ARVs
by the end of 2004.

In October 2002, MSF opened a reproductive health program in Ruhengeri province,a region where inadequate services raiserisks for an already vulnerable population.
Working closely with the local community,
this program targets obstetrical emergencies, implementation of family planning
programs in health centers and maintenance of all general reproductive healthservices (e.g. staff training, prevention ofsexually transmitted infections andimproved prenatal care, delivery and postnatal care). Program components related
to AIDS and sexual violence are being
developed.
MSF operates a cholera-prevention program in Cyangugu province located on
Lake Kivu. Activities include educating the
population about hygiene and progressively
rehabilitating water points (pumps andsources). MSF collaborates with Rwandan
health authorities on these activities aswell as on constructing wells, providing
training and conducting epidemic surveillance.
MSF has worked in Rwanda since 1991.

© Dieter Telemans

Every day, thousands of children in Rwanda spend hours collecting water from a river or if they are lucky, a nearby tap.
Running tap water in the house remains a luxury enjoyed only by the middle and upper classes.

34 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2003/2004

Giving medical care to
survivors of war
Much of MSF’s work today in this West
African country is focused on providing
and improving basic health care for both
Sierra Leoneans and refugees from othercountries. Approximately 60,000 of the refugees are Liberians who continue to residein Sierra Leone because of continuing insecurity and food scarcity in their homeland.
Poverty and unemployment remain high in
Sierra Leone and the introduction of a costrecovery system involving user fees for
medical services has led to a situation
where fewer than half of all the people in
Sierra Leone can obtain needed care.
In the southern districts of Bo and Pujehun,
MSF teams treat patients in public healthclinics. Since April 2003, the 50-bed referral
hospital in Gondama that was built by MSF
has been operating at full capacity. In
August 2004, 300 people were admitted to
its wards. Its facilities include a pharmacy,
isolation ward and therapeutic feeding
center. Near the Liberian border, MSF staff
assisted people until August 2004 at healthclinics in Zimmi, Fairo and Sulimo.
In northern Sierra Leone’s Koinadugu district, MSF worked to improve health careamong the local population and Sierra
Leoneans returning from Guinea now thatpeace has returned. MSF treated patientsat Kabala and Kailahun Hospitals and ninearea clinics. Thousands of medical consultations were carried out in 2003, many due
to malaria. MSF’s work at Kabala Hospital
was handed over to local authorities in May
2004. Now that Kailahun Hospital has beenrehabilitated, MSF plans to hand over its
activities there to the ministry of health by
the end of 2004.
In the northern Kambia, Bombali and
Tonkolili districts, MSF staff members provide maternal and child health care, emergency obstetrical and general emergency
surgery, training and supervision of local
medical staff, epidemiological surveillanceand health education delivered in 3 district
hospitals and 15 clinics. MSF is beginning
to integrate HIV/AIDS activities into thecurrent program by supporting voluntary
testing and counseling. It is in the processAfricaI N T ER NAT I O NA L S TA FF 45
NAT I O NAL S TAFF 38 4

of setting up a program to prevent motherto-child transmission of HIV and to treat
patients with opportunistic infections at
Kambia Hospital.
As Liberian refugees begin to return totheir own country and the populations in
Sierra Leone’s refugee camps decline, MSF
continues to assist those remaining incamps. MSF works in five refugee camps inthe districts of Bo and Pujehun, offering
basic health care to camp residents andthose in nearby communities. In 2003, MSF
began a sexual violence program in Bo.
Team members train medical staff to treat
victims and provide direct medical andpsychological care for survivors of rape orother forms of sexual violence. In the
Taiama and Tobanda refugee camps, MSF
provides medical care as well as mental
health care for refugees who have beentraumatized by violence, including former
child soldiers.
Malaria is the main cause of death for children under five and the leading cause ofillness and death for adults in Sierra Leone.
Because traditionally used malaria drugs
are often ineffective due to growing parasite resistance, the government of Sierra
Leone in March 2004 changed the country’s malaria-treatment protocol to artemisinin-based combination therapy (ACT).
MSF has advocated strongly for the transition to these more effective drugs and is
now working closely with health authorities in all of the medical facilities in which
the organization works to implement ACT.
MSF has worked in Sierra Leone since 1986.

© Espen Rasmussen© Doris Burtscher

Somalia

A camel kick broke this little girl’s leg. She waits for her crutches to be made at the pediatric ward of the MSF
health center in Huddur.

Providing care amid prolonged conflict
Despite ongoing conflict, the absence of aformal government and frequent evacuations due to insecurity, MSF teams continue
to bring medical aid to thousands ofSomalis who would otherwise lack healthcare. In southern Somalia, where medical
infrastructure is completely lacking, MSF is
working to reach the 200,000 people wholive in the Bakool region. MSF has recently
expanded its work to four of the region’s
five districts, providing treatment for
diseases such as tuberculosis and kala azar,
and reaching out to nomadic populations.
Since 1997, MSF has worked in Galkayo, in
the Mudug region, home to an estimated350,000 people. MSF supports pediatricand maternity services in two hospitals
there, one of each side of the “green line”
which divides the town between warring
factions. In addition to supplying medicines and materials, training local staff andproviding direct patient care, MSF is rehabilitating both hospitals. Between Octoberand December 2003, MSF intervened threetimes during repeated clan conflicts in
Galgudud, 200 kilometers south ofGalkayo. MSF teams traveled to both sidesof the conflict, treating more than 180
wounded people and replenishing stocksof emergency drugs and supplies.
In Lower Juba Valley, in the Marere region,an area in which most people are membersof the marginalized Bantu group, MSF
focuses on maternal and child health.
While working to improve vaccination coverage and reproductive health, the MSF

team also treats people with communicablediseases. In late December 2003, a Somali
MSF staff member was killed in the crossfire between attackers and guards during arobbery at the compound of a Somali aid
organization. The rest of the team wasevacuated. By January 2004, the remaining
team members had returned and were caring for 48 children in a therapeutic feeding
center.
In the southwestern part of the country,
MSF runs a 35-bed health center in Dinsor,
a town in the western Bay region, near
Baidoa. The MSF clinic is the only healthfacility for the 100,000 people who live inthis region. In February 2004, the teamresponded to tribal clashes near Boale bytreating the wounded and referring themost severe cases to the Dinsor healthcenter. MSF staff also have monitored andresponded to epidemics, such as a measles
outbreak that occurred in January 2004.
MSF is also working in Somalia’s capital,
Mogadishu, running a primary health careclinic and responding to cholera outbreaks
as necessary. At the clinic, MSF provides
maternal and child health care, nutritional
screening and monitoring of infectiousdisease outbreaks. MSF also provides
primary health care in 11 clinics in thesouthern regions of Banaadir andShabeellaha.
MSF has worked in Somalia since 1991.

ACTIVITY REPORT 2003/2004 MEDECINS SANS FRONTIERES 35

AfricaI N T ER NAT I O NA L S TA FF 7
NAT I O NAL S TAFF 29

I N T ER NAT I O NA L S TA FF 282
NAT I O NAL S TAFF 3, 657

South Africa

Sudan© Francesco Zizola

Caringfor victims
of warAn HIV-positive support group gives AIDS education courses in the waiting room of the MSF village clinic in Lusikisiki.

Treating AIDS patients at the heart of the problem
With approximately 5.3 million people infected with HIV, South Africa
has the highest number of people living with HIV/AIDS of any country.
In November 2003, the South African government approved a newnational HIV/AIDS plan that added life-extending antiretroviral (ARV)
therapy to the existing protocol and set a goal of treating 600,000
people with ARVs by 2008.
The government’s revised HIV policy
marked the start of an intensive effort tobroaden the use of ARVs in Khayelitsha
township, in the Western Cape province.
MSF runs three HIV/AIDS clinics within primary health care centers in Khayelitsha.
These clinics provide prevention information, HIV testing, counseling and management of opportunistic infections, as well as
ARV treatment to people at advanced stagesof AIDS. By July 2004, clinic doctors andnurses were conducting 150 to 200 medical consultations per day and providing
ARVs to nearly 1,200 people. MSF’s aim isfor 2,000 people to be receiving ARVs by
the end of 2004.
In collaboration with the Nelson Mandela
Foundation, MSF operates a second rural
HIV/AIDS program in Lusikisiki, in the
Eastern Cape province, one of the country’s
poorest areas. The program has tested
more than 600 people for the virus eachmonth and has demonstrated an HIV-positive prevalence of 30 to 40 percent. MSF
manages opportunistic infections in 11
rural clinics and in the district hospital andbegan offering ARV treatment in the clinics
in November 2003.
In October 2003, MSF opened the Simelela
Rape Survivors Center in Khayelitsha. The
center offers medical and psychosocial
care, including post-exposure prophylaxis
to prevent HIV transmission, and trauma
counseling. The center’s staff conducts 25
to 35 consultations per month. More thanhalf of the rape survivors treated are children younger than 14 years of age.
MSF continues to work in partnership with
the Treatment Action Campaign to advocate for increased access to treatment.
Together, the two groups support patients’adherence to treatment and community
education about treatment options, promote the use of fixed-dose combinationsof ARVs and monitor the impact on healthof southern Africa’s free trade negotiations
with the United States.
MSF first worked in South Africa in the mid1980s and returned in 1999 to respond to
the needs of people affected by HIV/AIDS.

36 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2003/2004

The peace process
between northernand southern
Sudan that has
been underway
since 2002 has
renewed hopes foran end to Africa’s
longest-running
civil war. The conflict has cost almost
two million lives, mostly civilians who havedied from hunger and disease. Yet amid
talk of peace between the north and thesouth, the westernmost region of Sudan,
Darfur, became the site of a growing catastrophe in the past year (see box on Darfur
crisis and photo essay, page 14.)
The ceasefire between the Sudanese government and the southern rebels of the
Sudan People’s Liberation Army (SPLA) has
held – with few exceptions – for two years.
The absence of fighting has greatly
improved MSF’s ability to reach new areasand has reduced the displacement ofgroups of people fleeing violence.
For years, MSF has assisted people in both
northern and southern Sudan, providing
basic health care at hospitals or throughnetworks of clinics and health centers. Its
work has included treating people withtuberculosis (TB), kala azar (visceral leishmaniasis) and other diseases; providing
food; and treating the severely malnourished. MSF also delivers clean drinking
water and provides sanitary facilities inareas where displaced people have sought
shelter.
In 2003-4 the organization continued these
crucial, basic services and also assisted
people affected by measles, meningitis,
malaria and other infectious diseases. MSF
treats people with TB in the towns of
Akuem and Mapel in Bahr el Ghazal province, Bentiu in Western Upper Nile province
and in Lankien in Eastern Upper Nile province. During the last year, MSF treatedapproximately 430 TB patients in Sudan.

Africa“I walked through the town asking new arrivals about their villages and what had
happened to them. They said that hundreds from each village had been killed. They
told stories of children strangled, women burned alive, and men shot to death.”– MSF logistician Jean-Sébastien Matte in Mornay, Sudan

Darfur: Living in a nightmare© Marcus Bleasdale/IPG“ What you see there is widespread suffering, inadequate relief efforts
and continuing violence. Hardly anyone is getting the care civilians
should get in a conflict, and there are real pockets of disaster, where
people are at grave risk of dying in large numbers.”– Rowan Gillies, M.D., President of MSF’s International Council, after returning from Darfur

During the past year, brutal killings, rape and razed villages became
all too common occurrences for the people of Sudan’s western regionof Darfur. Attacks carried out by government-backed militias known as
Janjaweed terrorized civilians and forced them to flee to what they

Because the treatment takes from six toeight months, curing people with TB
remains highly challenging. MSF’s pioneering experience in this field has paved theway for other organizations to set up similar TB programs elsewhere in the country.
In southern Sudan, sleeping sickness(African trypanosomiasis) is endemic, andunless outbreaks are brought under control, epidemics can emerge rapidly. The
disease is fatal if left untreated. MSF is now
treating those with sleeping sickness
around the towns of Kajo Keji, Ibba andKotobi in Western Equatoria province. MSF
closed a sleeping sickness program in theWestern Equatoria town of Kirii after successfully reducing the number of cases tothe region’s normal level.
MSF also runs a special program to treat
people with kala azar, a parasitic disease
spread by the tiny sandfly that is fatal in 95
percent of untreated cases. Approximately
3,300 patients received treatment for the
disease through MSF projects in the townsof Walgak, Wudier and Lankien in Upper
Nile province, in Umm el Kher in the eastern state of Gadaref and in Bentiu inWestern Upper Nile province.
In May and June 2004, an outbreak of thehemorrhagic Ebola virus occurred near
the town of Yambio, in Eastern Equatoria
province. MSF set up an isolation unit andtreated 28 patients, of whom 6 died.
MSF has worked in Sudan since 1979.

hoped would be safer locations. Yet after having survived massacres,
raids and looting, the displaced still face continuing violence and adevastating shortage of assistance.
By mid-2004, more than one million people had been driven from their homes. An
additional 180,000 people had sought safety in Chad (see page 23). More than 200 international MSF volunteers and 2,000 national staff members are working in an area whereapproximately 700,000 people have sought refuge, helping those weakened by disease
and malnutrition. In July alone, the organization shipped and flew in more than 1,400
tons of supplies, valued at more than three million euros, to Sudan. The supplies included
large quantities of medical and logistical material as well as full containers of food.
Across Darfur, MSF is providing medical care in hospitals and clinics for those wounded in
the violence, victims of sexual violence and displaced living in camps who suffer frommalaria, respiratory infections and diarrhea – the latter the main cause of death, particularly for young children and the elderly. Another important part of the organization’s
activities centers on feeding malnourished children. MSF has organized “blanket feedings”
to distribute survival food rations to children under the age of five. MSF estimates that by
the end of 2004 it will have distributed more than 800,000 survival rations. Teams also
provide clean water and latrines to reduce the risk of cholera, dysentery and other diseases.
In late July, MSF was treating some 10,000 malnourished children in its feeding centersand performing almost 12,000 medical consultations a week.
An MSF assessment carried out in late August found that people living in remote regionsof northern Darfur still lacked food and medical aid despite the increased mobilization ofinternational aid agencies in the region. Aside from addressing these needs, MSF will also
hold a massive measles vaccination campaign there, targeting 80,000 children between
the ages of six months and 15.
In addition to providing immediate relief, MSF has been speaking out on the precarious
situation of the displaced and the need for immediate action. Despite the efforts madeby MSF and others, many people remain exposed to hunger, disease and violence. The
people of Darfur need much more assistance than MSF can provide. The organization
continues to call on international aid agencies to increase significantly their delivery ofaid, especially in areas that remain cut off from help at present, in order to meet theimmense needs and avoid further deaths.

ACTIVITY REPORT 2003/2004 MEDECINS SANS FRONTIERES 37

AfricaI N T ER NAT I O NA L S TA FF 50
NAT I O NAL S TAFF 277

UgandaAiding civilians targeted by war
For more than 19 years, civilians living in northern Uganda have faced
massive violence inflicted by local insurgents as well as by the nationalarmy. Brutal attacks, carried out in countless villages, have led to thedisplacement of much of the rural population in the districts of
Kitgum, Gulu, Lira and Pader, as well as in the many camps set up to
shelter them. In 2003, the crisis escalated further, bringing the war to
Lira and Teso – regions previously unaffected by the violence. Some 1.6
million people – or 80 percent of the region’s population – has been
forced to flee, and the northern Uganda economy is in tatters.
Scattered over more than 150 sites, displaced people try to survive by doing smalljobs, cultivating pieces of land around thecamp sites, or engaging in small-scaletrading in nearby villages. Those without
these sources of income are completelydependent on food distributions fromrelief organizations. In many areas, healthstaff have fled, leaving the local and displaced population without functioning
health facilities. It is no surprise that malnutrition levels are high – above emergency
thresholds in some locations – and thatpeople are weakened and vulnerable todisease. Since late 2003, MSF has been providing several of the camps with basic
medical care, clean drinking water, latrines,
and therapeutic feeding for severely malnourished children.
The government’s response to the violence
has been sluggish, with few officials
acknowledging the vast scope of the problem, and the ministry of health has beenslow to deploy staff to assist overburdened
regional hospitals and health centers. An
MSF measles-vaccination campaign proposed in October 2003 for the town ofSoroti, where 100,000 displaced people
have gathered, was delayed by the government’s lack of cooperation. As a result, an
epidemic claimed many lives among thedisplaced population.
The region continues to suffer from foodshortages because people are not able tofarm, and World Food Program food distributions hover around 50 percent of thedaily requirements. The reason: authorities
want civilians to return to their own villages
and begin farming again as quickly as
possible to relieve overburdened public

services. Understandably, civilians haverefused to return, knowing that doing so
will expose them to more killings, rape andkidnappings.
Moreover, the fighting factions do not wait
for people to return. The rebels attack
camps and abduct young children to swelltheir ranks. Once captured, the children are
terrorized into cooperating. Thousands ofyoung people have been kidnapped over
the years, and tens of thousands more fearstaying in their homes at night as a result.
Instead, every evening they walk to major
towns such as Gulu or Kitgum to spend thenight there. The United Nations estimatesthat approximately 50,000 children makethis “commute” each night. In April 2004,
MSF opened a reception center in the townof Gulu offering some of them shelter after
dark (see page 39).

Treating AIDS, kala azar and malaria
Like most other African countries, Uganda’s
population has been hard hit by the AIDS
pandemic. In the northwestern town of
Arua, MSF provides medical care for nearly
2,500 people living with the virus. MSF was
also one of the first organizations to offer
free antiretroviral (ARV) treatment in
Uganda, and it uses generic drugs in fixeddose combinations. Today, nearly 800
people are receiving ARVs, and MSF adds
60 to 80 new patients to the program eachmonth. During the second half of 2004,
MSF will open an additional HIV/AIDS program in Koboko, north of Arua, near theborders with Sudan and the Democratic
Republic of the Congo (DRC). This program
will link ARV treatment and prevention of
mother-to-child transmission of HIV with

38 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2003/2004

existing voluntary counseling and testing
programs.
Along with a number of other African and
Caribbean countries, Uganda will be arecipient of funding through PEPFAR, theUS government initiative to increase AIDS
treatment in countries that are hardest hit
by AIDS. PEPFAR requires that the medicines procured be brand-name drugs, a
policy that deeply concerns MSF. By using
generic drugs, MSF has been able to treat
three to four times as many patients for thesame cost.
The patient load in Arua is increasing
sharply each month and patients havestarted arriving from neighboring provinces,indicating the lack of access to HIV/AIDS
care and treatment in many other parts ofUganda. Despite government openness totreatment and important donor support,
expanding access to HIV/AIDS care andtreatment is painfully slow throughout thecountry. MSF also supports Arua Regional
Hospital in the implementation of adequate universal precautions and improvement of waste management and nursingcare.
In Amudat, a remote town in the eastern
district of Moroto near the border with the
DRC, MSF teams contribute diagnostics,
treatment and care for patients affected by
the infectious disease kala azar (visceralleishmaniasis). Some 30 to 35 people areadmitted for treatment each month. The
MSF team also carries out a number of
research projects related to prevention andbetter diagnosis of this disease. The teamalso gives support to Amudat Hospital.
Over the years, MSF has made importantchanges to the treatment of malaria in
Uganda, promoting the use of artemisininbased combination therapy (ACT).
Although the government initially resistedchanging its national protocol, despitehigh levels of resistance to current first-line
treatments, in June 2004 health officials
finally agreed to adopt ACT. However,
because of changes in treatment protocols,
additional cost and complexities of procurement, teams on the ground fear thatthe change will not be implemented until
well into 2005.
MSF has worked in Uganda since 1982.

© Jehad Nga-Corbis- Bastien Vigneau, director of operations for MSF’s
projects in Gulu

Africa“ You can see the distress in the kids’ eyes.
They are really tired but can’t sleep.”Night commuters: Children in search of shelter
Every night, they arrive in droves in the northern Ugandan town of Gulu. Up to 12,000 children,some as young as two years old, walk several miles from the villages and camps for internallydisplaced people surrounding Gulu, hoping to find shelter for the night. The next morning, theyleave again, to attend school near their home, only to return again that evening.
They are called “night commuters” a euphemism that obscuresthe cruel reality of thousands of children taking part in such an
exodus each night. They seek shelter in town centers out of the
sheer terror of being attacked or kidnapped by soldiers to serve
as soldiers, porters or sex slaves.
Gulu is home to 30,000 people, and its well-stocked markets bustle
with activity during the day. By nightfall, though, the streets aredeserted, and the gates of Lacor Hospital on the northwest fringes
of town close at 9:00 p.m. on a sea of nearly 5,000 children
gathered in the hospital’s central square.

Justin* is one of the night commuters in Lacor Hospital. Every
evening he walks about two kilometers to the shelter in order tosleep.
“I have five sisters and one brother. Three of them come here. My
older sister lives with the soldiers, because that is easier. The rebels
attack our town very frequently. I come here because of them. I was
abducted when I was 13-years-old and I don’t want it to happen
again. The night I was abducted I couldn’t go to a shelter because I
was sick. So I stayed home. Then the rebels came and took me. I
managed to escape. Because I acted so smart, the rebels trusted me
and they gave me a group to lead. They showed us dead bodies, tomake us harder. We were forced to attack villages, but I always discouraged my group to kill. And then one night, there was a big
attack on a village. I hid in the grass and waited until it all was overand the rebels had left.
I am glad to come here. I like it that there are so many activities. It
keeps me from having all those negative thoughts about the things
that happened to me and the dead bodies I saw. In the morning I go
home to my parents and attend school. I want to be a pilot one day.”Every night in the square, an MSF team treats up to 600 children
for scabies, a severe skin disorder caused by burrowing mites,
which is exacerbated by crowded living conditions.
In addition to providing needed medical care, the MSF team alsooffers psychological support to the children through individualand group counseling to help them cope with their experiences
during the war.
Below are stories from two children who have received counselingfrom MSF staff in Gulu:

Denis* also walks about two kilometers to Lacor Hospital every
evening.
“I come on my own every night. The place where I live is more isolated
than Lacor Hospital. So I feel more secure here and I like the counseling that I get. It keeps me going and helps me forget what happened to me. I had five brothers and two sisters. One night in 1998,
the rebels came and took me and one sister and three brothers. Theytied us all to a long rope. We started moving and they would beat us.
Then it was my turn and they hit me very hard, and while they did
that, the rope got cut. They became very angry with me and blamedme for the cutting of the rope. So they brought my sister and handed
her to my brothers and me and told us to kill her. We refused. But
they hit us even harder. So we killed her. We walked all the way to
Sudan. On the way the rebels killed one of my brothers. I was so
afraid, that I was going to die too. I was very scared all the time. But
at some point I just did what they told me to do and withdrew in myhead to pray, that helped me to go on…. “* Not the boys’ real names

ACTIVITY REPORT 2003/2004 MEDECINS SANS FRONTIERES 39

BY ALE X AN D R A C A L MY, M . D. , ADV ISO R TO MSF’ S C A M PAI G N FO R ACCE SS
TO E SSEN T IAL M ED I CI N E S

MSF and HIV/AIDS: Expanding
treatment, facing new challenges
Signs of success, but a long road ahead
Six million people are in urgent need of life-extending antiretroviral(ARV) therapy. Today only 440,000 of them, or a mere seven percent,have access to it in developing countries.
MSF estimates that at least half of themwould have died within one year.
MSF’s patients live in capital cities,
slums, remote rural areas and regions in
the midst of armed conf lict. More thanhalf of all of those treated by MSF are
women of childbearing age, and there arehigh numbers of children in need of ARV
treatment. Patients tend to be in very
advanced stages of HIV/AIDS before theyseek treatment and are often affectedwith one or more complex co-infection
such as tuberculosis (TB).
The aim of MSF’s ARV programs is toprovide comprehensive care for those living with HIV/AIDS. That means projects
include prevention efforts (health educa-© Espen Rasmussen

MSF has been caring for people livingwith HIV/AIDS since the mid-1990s. In
2001, the organization started offering
ARV treatment to patients in Cameroon,
Thailand and South Africa. A sharp
decrease in prices caused by generic competition and the simplification of treatment protocols, including the use of
three-in-one “fixed-dose combinations”(FDCs) enabled MSF to rapidly increase
the number of patients using ARVs in its
programs. In the past two years, MSF’s
AIDS treatment programs have jumped
from 1,500 patients in 10 countries to
13,000 patients in 25 countries. ARVs
have transformed the lives of thosereceiving them, allowing them to workand have normal lives. If these 13,000
patients had not begun ARV treatment,

40 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2003/2004

tion, prevention of mother-to-childtransmission of HIV, condom distribution), voluntary counseling and testing,nutritional and psychological support,
care and prevention of opportunistic
infections and ARV treatment.
MSF has gained substantial knowledge
and learned important lessons from its
hands-on experience treating people with
HIV/AIDS, but the organization does notpretend to have developed a uniquemodel for implementing large-scale ARV
treatment programs. The responsibility
for scaling up comprehensive HIV/AIDS
treatment programs rests with governments which have a responsibility to provide adequate health care to their people.
Of course these governments will continue to need massive sustained technicaland financial support from international
donors and the World Health Organization if real progress is going to bemade.

A patient with AIDS takes her antiretroviral medicine at Bukavu General Hospital in the Democratic Republicof the Congo where MSF began giving treatment in October 2003.

The need for more treatment options
MSF promotes fixed-dose drug combinations (FDCs) to treat people
with severe AIDS. By combining various medicines within a few
tablets, FDCs improve treatment compliance, simplify usage guidelines and help prevent dosage errors. Yet there is only one triple
FDC now available in our programs and this does not solve all of
the related treatment problems. For example, patients co-infectedwith tuberculosis (TB), the most common opportunistic infection
affecting people living with HIV/AIDS, cannot use this simple
treatment. This situation has to change as TB is intrinsically linked
to AIDS by the growing number of co-infections. Globally an estimated 12 million people are now living with both diseases. In somesouthern African countries with high HIV prevalence, up to 70 percent of the people who have TB also have HIV/AIDS. Diagnosing
TB is difficult in HIV-positive patients. Clinical diagnosis is also
more difficult in co-infected patients as weight loss, swelling of thelymph nodes and pulmonary infections can be caused by various
AIDS-related infections as well as TB.
Every year an estimated 2.2 million women with HIV/AIDS givebirth. Treatment is now available to prevent transmission of thevirus from mother to child. But experience has shown that exposure to a single dose of the drug, nevirapine, used at delivery toprotect the newborn may induce resistance in the mother andtherefore reduce the effectiveness of ARV therapy if the motherneeds treatment later.

Koeut Chrel (38) is HIV positive and receives antiretroviral treatment
from MSF in Cambodia. He lost his leg in a landmine explosion whileserving in the army. He did not know his HIV status when he married.
Both he and his wife were tested for HIV, found positive and sent to
MSF’s chronic diseases unit in Siem Riep. Thanks to his faithful adherence
to treatment, he can now work. The couple has three children. Two ofthem have tested negative for HIV, the youngest has yet to be tested.

© Pep BonetThe fact that more than 13,000 people
are now receiving life-extending
antiretroviral (ARV) treatment throughMSF is encouraging. However, huge
numbers of people still lack treatment –far beyond MSF’s capacity for providing care. Doctors and nurses today
face real challenges in giving urgently
needed treatment. Limitations on
existing care options continue to block
treatment for the millions who need it
now. MSF is calling for more to be done
to dismantle these barriers now.

“HIV treatment for adults is slowly becoming
easier, with increased availability in developing countries of a three-drug cocktail in one
tablet. But children who need treatment still
have to drink large amounts of foul-tasting
syrup or swallow large tablets – that’s if they
can actually access treatment at all.”– David Wilson, M.D., medical coordinator, MSF, Thailand

A glaring lack of medicines for children
The estimated worldwide number of children living with HIV/AIDS was more than 2.5 million in 2003. Around 50 percent of allchildren with HIV/AIDS die before reaching the age of two. Efforts
to prevent transmission of the virus from mother to child havebeen largely successful in developed countries meaning that relatively few children are born with HIV. Ironically, the low numberof pediatric patients in developed countries means there is little
profit to be made by developing and manufacturing pediatric treatment formulations there. As a result, these formulations are notavailable in developing countries despite the growing need forthem. This means children with HIVAIDS do not benefit from
active research and have no access to affordable and easy-to-taketreatment.
While MSF began treating children with ARVs in early 2002, only
five percent of the organization’s patients were children under 13
by March 2004. MSF is now attempting to include more children in
its AIDS projects but those efforts are frustrated by the lack ofproper tools. Most methods used to diagnose HIV are unreliable inchildren younger than 18 months old. The lack of pediatric ARV
formulations makes determining and administering doses complex
and burdensome. Doctors are forced to break tablets in two or
crush and dissolve them. Care providers have to give small children
foul-tasting syrups and large pills. Syrups and oral solutions are
not suitable for older children because of the large amounts needed,
but low-dosage tablets and capsules are not produced for mostARVs. What pediatric formulations do exist come at a high price.
Both first and second-line ARV treatments for children cost several
times more than those for adults.

ACTIVITY REPORT 2003/2004 MEDECINS SANS FRONTIERES 41

© Pep Bonetthe health systems that serve them cannot afford the treatment theyneed once first-line treatment no longer works. With treatment
costs already a concern, second-line treatments only increase theproblem. MSF and others must continue to fight for price cuts on
new treatments and in particular, on second-line treatments, as
they become an indispensable part of our programs.

During a home visit in Bukavu, Democratic Republic of the Congo,
an MSF physician provides new pills to an HIV-positive patient.

“If we have no way of telling when first-line
treatment no longer works and no affordable
alternative for people to switch to, we will
have failed our patients.”– Alexandra Calmy, M.D., MSF

When first-line treatment is not enoughAs a medical humanitarian organization, MSF feels a responsibility
not only to start people on ARVs but to ensure that their lives are
improved and prolonged. This means being able to detect when afirst-line treatment no longer works and it is necessary to switch tosecond-line drugs. From experience in developed countries, MSF
knows that the benefit of a first-line combination treatment will
not be indefinite for most AIDS patients. People can develop resistance to the medicines they are taking. Patients can also develop
side effects that cause them to discontinue treatment. Yet there are
few therapeutic choices beyond the first-line and the challenge is toknow how long patients can be kept on first-line regimens without
threatening their future treatment options and their long-term
prognosis. In developing countries, monitoring treatment effectiveness remains very difficult due to the largely unaffordable or
impractical equipment that is commonly used.
However, there is no point in diagnosing treatment ineffectivenessif there is no affordable second treatment combination to prescribe
instead. Second-line treatments can be more than 20 times more
expensive than first-line therapies. Unless things change, the costof treatment will increase dramatically over the next few years inmost countries because of the need to switch patients to expensive
second-line treatment. Mortality will also increase if people and

42 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2003/2004

In an ideal world, there would be one universal FDC that would besuitable for patients with co-infections (such as TB) and for children and other groups with special needs. It would be non-toxic,lack side effects and be highly effective. However, this perfect tool
does not exist. For that reason, health care providers need more
options to treat HIV-positive patients who also have TB, who arechildren, who are pregnant or for whom first-line treatment nolonger works.

Protecting access to treatment
After the World Trade Organization’s TRIPS Agreement on intellectual property rights is implemented in 2005, access to new drugs
will become more difficult. All new drugs will be subjected to 20
years of patent protection in all but the least developed countries.
This will affect producers in key manufacturing countries such as
India. It will drive up prices and make new medicines more difficult to obtain. Generic producers will be blocked from developing
FDCs until patents expire. MSF believes patents should never be abarrier to treatment. This means the public health safeguards in
intellectual property law, affirmed in the 2001 Doha Declarationon the TRIPS Agreement and Public Health must be used to protect
access to treatment.
Increased attention on the need to expand treatment has not yet
been translated into real action in countries hit hard by the epidemic. Governments, international donors and health care providers, including medical NGOs must mobilize the necessaryfinancial and human resources to make ARVs available to those
who need them.
The HIV/AIDS pandemic won’t be defeated with existing tools. Yet
ARVs are the only option we now have to prolong life. Innovative
strategies to provide ARVs more efficiently to patients who needthem have to be developed. We must be more ambitious and invest
resources into vaccine research, immunotherapy and other easy-touse therapeutic approaches too. At the same time we need to boost
efforts to simplify current treatment and monitoring tools. MSF’s
experience in the field shows that ARV treatment is possible, evenin the poorest and most difficult settings, despite the challenges
ahead. With more than 13,000 patients on ARVs and about fivetimes as many AIDS patients in our consultation rooms, there is notime to lose in addressing these treatment obstacles.
To read MSF’s briefing document “MSF AIDS treatment experience:
Rapid expansion, emerging challenges” published for the XVInternational Conference on HIV/AIDS in Bangkok, visit:www.accessmed-msf.org.

I N T ER NAT I O NAL S TAFF 17
NAT I O NAL S TAFF 69

United Republicof Tanzania

ZambiaAfricaI N T ER NAT I O NA L S TA FF 7
NAT I O NAL S TAFF 35

Promoting better
treatment for those with
infectious diseases

Targeting people living with AIDSThe success of local healthmore than 20 percent of adults estimated to be HIV-positive.

In Zambia, MSF activities are focused on helping people with AIDS.
Zambia has one of the worst rates of HIV infection in the world withworkers in stopping an outbreakof cholera in the southeastern
Mtwara district in September
2003 suggested that MSF’s
training of staff to respond to
epidemics had been fruitful.
The ministry of health’s quick reaction tothe outbreak stopped it in its early stages.
After seven years of operating this cholerapreparedness project, which aimed at
improving patient care and government
response in Mtwara, MSF handed it over tothe ministry in February 2004.
In May 2004, MSF started a project inZanzibar to improve treatment for malaria
patients. The program’s key component isto help local health authorities implementa national treatment protocol that includes
the most effective first-line treatment,
artemisinin-based combination therapy(ACT). In Kigoma, the capital of Western
province, MSF closed a malaria project
because local health authorities refused toallow the use of ACT, while high parasite
resistance to the medicines being used
there impeded the organization’s ability totreat patients effectively.

Since 2002, MSF has worked to provide
comprehensive care to those living with
HIV/AIDS – about one in four people – inthe Nchelenge district of Luapula province
in northeastern Zambia. Many of thesepeople have little access to medical care,so in addition to education and prevention
work, voluntary counseling and testing,care and treatment of opportunistic infections, MSF began to treat people with lifeextending antiretroviral (ARV) medications
in February 2004. By July 2004, 59 patientswere receiving ARVs and MSF aims to treat
400 patients with ARVs by the end of 2005.
MSF also carries out operational research in
Zambia, documenting the progress anddifficulties of providing comprehensive
HIV/AIDS care in a poor, rural setting.
Cholera is endemic to Zambia, and outbreaks are common during the rainy season, which lasts from October to April. In
January 2004, MSF responded to a cholera
outbreak in the capital, Lusaka. In collaboration with others, MSF helped establish
seven cholera treatment units and to train
local staff. In two cholera-treatment units,
located in Matero and Chawama, the MSF
team focused on installing latrines andshowers, educating the public about thedisease, and providing direct patient care,
as well as improving sanitation in nearby
neighborhoods. Before the end of the epidemic, nearly 6,500 cases of cholera had
been registered and 205 people had died.
When the epidemic began to decline in
April 2004, MSF handed the project over tolocal authorities.
The recent peace in Angola has encouraged
thousands of displaced Angolans to returnhome from Zambia and other neighboring
countries. MSF began working in Maheba
refugee camp in 1999, when an influx ofAngolan refugees nearly doubled the sizeof the camp to more than 50,000. MSF
oversaw water distribution and provided
support to medical clinics in the camp. The
MSF team also assisted the United Nations
High Commissioner for Refugees’ official
return program by providing medical
screening of returnees. As the camp has
emptied, in October 2003, MSF handed the
project over to the Zambian Ministry of
Health.
MSF has worked in Zambia since 1999.

During a recent cholera epidemic, patients received treatment at a medical center set up in an old school in Chawama.

© Keni Soler

An exploratory mission carried out in threesites in the southwestern Makete district toassess the impact of HIV/AIDS on civilians
found that many people were in need ofcare. MSF is now preparing a project thatwill include activities to prevent the spreadof the virus as well as treatment with lifeextending antiretroviral (ARV) drugs. MSF
will also advocate for free access to ARVs
for those who urgently need them.
MSF has worked in the United Republicof Tanzania since 1993.

ACTIVITY REPORT 2003/2004 MEDECINS SANS FRONTIERES 43

AfricaI N T ER NAT I O NA L S TA FF 17
NAT I O NAL S TAFF 73© Tom Stoddart/IPG

Zimbabwe

An MSF nurse takes care of an AIDS patient in one of the villages of Mashonaland.

Expanding care for AIDS patients
While the government of Zimbabwe continues to face international
criticism for its policies, the country’s civilians bear the brunt of theongoing political crisis. Life expectancy in the country has fallen to 33
years and many Zimbabweans can no longer get basic health care.
HIV/AIDS is the leading cause of death inZimbabwe, affecting an estimated 25 percent of the population, or two million
people. In March 2004, MSF opened a clinic
to treat people with opportunistic infections in Murambinda Hospital. This is thefirst stage of an HIV/AIDS project in Buhera
district of Manicaland province, located200 kilometers south of the capital city,
Harare. In addition to improving treatment
for opportunistic infections, MSF teams areproviding training for local medical staff tosupport ongoing HIV/AIDS activities in thehospital, such as voluntary counseling andtesting and prevention of mother-to-childtransmission. As of June 2004, 900 patientswere using the clinic. MSF staff plan to
introduce treatment with life-extending
antiretroviral (ARV) medicines in the next

few months and hope to have 50 patientsusing ARV treatment by the end of 2004.
In July 2004, Murambinda Hospital took
over the therapeutic feeding activities that
MSF had provided in Buhera district when
low admissions eliminated the need for a
fully operational feeding center. In addition, MSF teams assisted emergency-preparedness planning for the district, having
held three cholera workshops in 2004 andplanning additional trainings throughout
the year.
In April 2004, MSF began treating patientswith ARVs in the city of Bulawayo. Currently
150 patients are now taking part in the
program, and the MSF team hopes to have
700 patients receiving ARVs by the end of

44 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2003/2004

2004. The team also supports the work of
the National Prevention of Mother to Child
Transmission program and participates in
AIDS research in Zimbabwe as a partner in
the Zimbabwe AIDS Prevention Project.
In early 2004, MSF ended a successful nutritional program in Masvingo province.
However, in March, initial activities to treat
opportunistic infections at a new HIV/AIDS
clinic in Masvingo, the capital of theprovince, were suspended after MSF was
asked to leave the province by local healthofficials. At the time of going to press, MSF
had still not received an explanation forthis request. MSF is currently identifying
other potential locations for HIV/AIDS
activities.
In January 2004, a nutrition project that
MSF had supported in the Tsholotsho district of Matebeland North province washanded over to the ministry of health.
MSF has worked in Zimbabwe since 2000.

© Espen Rasmussen

Asia andthe Caucasus

Doung Srei Pich (8) weighs nine kilos and is HIV positive. Both of her parents havealready died of AIDS. She lives in Phnom Penh, Cambodia, in an orphanage for HIVpositive children which receives antiretroviral drugs from MSF.

ACTIVITY REPORT 2003/2004 MEDECINS SANS FRONTIERES 45

The Caucasus

I N T ER NAT I O NA L S TA FF 10
NAT I O NAL S TAFF 75

I N T ER NAT I O NA L S TA FF 14
NAT I O NAL S TAFF 65

Armenia

Georgia
Treating tuberculosis
patients and the excluded
Prolonged political instability and exhaustion from a variety of violent internal divisions have left Georgia’s health care systemunable to cope with the demands placed
upon it. As a result, thousands of the country’s civilians lack the most basic care andmedicines. MSF focuses on getting desperately needed help to groups lacking assistance including the disabled and the elderly.

© Tim Dirven

The separatist republic of Abkhazia is thefocus for MSF’s tuberculosis (TB) work. At
Gulripsh Hospital, MSF staff members provide care and medicines for approximately
240 people suffering from TB. They also
recently began treating about 20 patientsliving with multidrug-resistant TB, a type of
TB that is more difficult to treat because of
its resistant to the first-line drugs usuallyused to cure the patient. MSF is working to
involve the ministry of health in the program’s management. A team also screens
all prisoners in Dandra prison and separates
contagious patients from non-contagious
ones in an effort to stem the spread of thedisease among this confined group.

Participants in MSF’s mental health project attend a day center where they receive care and can do projects
that increase their coordination such as sewing.

Improving care for the mentally ill and children

In June 2004, after seven years, MSF’s workwith the children in a “special education
center” in Vardashen ended. The project
demonstrated that there was an effective,
humane alternative to the violent methods
through which such institutions have traditionally controlled their inhabitants. MSF
used an educational approach based on
respect for the child as an individual. MSF
staff also showed that by providing help tothe children’s families, children could
remain at home for longer periods of time
and would not have to resort to begging
on the streets. MSF has been sharing its

conclusions with Armenian authorities inan ongoing attempt to press the government to reform the ways in which these atrisk young people are treated.
In mid-2004, MSF started providing healthcare for civilians living in the regions of
Vardenis and Tshambarak. Many residents
in this area are refugees from neighboring
Azerbaijan who fled the country after the
1991-4 war, and unemployment is high.
MSF is offering basic medical care as wellas treatment for women and children in six
health centers, two clinics and two hospitals. The team will also train and supervise
local ministry of health staff. In addition,
MSF will provide medicines and neededmaterials and help rehabilitate the facilities.
The organization plans to undertake advocacy action to make national authorities
and donor agencies more aware of theneeds of this regional group.
MSF has worked in Armenia since 1988.
A patient sits in his room during his months-longtreatment for tuberculosis in Gulripsh, Abkhazia.

46 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2003/2004© Simon Lourie

MSF has expanded its activities amongpeople with mental health problems ineastern Armenia’s Gegharkunik region. The
priority is to improve the way mentally ill
outpatients are cared for, reduce their hospitalization rate and minimize their social
isolation. The project involves psychologists, nurses, social workers and community educators. In northern Armenia, on theborder with Georgia, MSF runs a project
which treats patients with sexually transmitted infections (STIs) and HIV, and aims
to reduce their prevalence among high-risk
groups including commercial sex workers,
truck drivers and migrant workers. Eachmonth, approximately 300 people receive
services which include treatment of STIs at
the MSF clinic, condom distribution andeducation.

In Abkhazia’s capital, Sokhumi, and that ofGeorgia itself, Tbilisi, MSF uses a network offamily doctors to provide health care forthe most vulnerable and excluded. The priority has been to improve the referral system to hospitals and the overall quality of
the free care available to these patients.
Some 60 percent of these people are single,
isolated individuals above the age of 65,
who cannot afford to pay for health careand who have no one to help them get it.
In Sokhumi, the program’s 13 general practitioners care for approximately 19,000
people, carrying out 2,000 consultations
and 30 surgical procedures each month. In
Tbilisi, an average of 880 consultations aredone every month.
MSF doctors perform surgery, mostly
involving emergencies, within Akhmeta’s
district hospital located in the political andmilitary flashpoint of the Pankisi Valley.
The organization created a surgical point in
the valley where a local surgeon handles
minor operations and emergencies before
referral to the district hospital. This first aid
point also provides follow-up for patients inthe valley after hospitalization.
MSF has worked in Georgia since 1993.

Arjan Erkel freed

North Caucasus

One of the year’s few positive developments was the release of Arjan Erkel, MSF
head of mission in Dagestan, on 11 April 2004. He had been held captive for 20
months. For Arjan, his family and for MSF, his release came as a huge relief after
continual lobbying and campaigning. The euphoria surrounding his release was,however, short-lived as MSF and the Dutch government soon became embroiled
in a very public argument about a sum of money paid by the Dutch in exchange
for his release. As this report goes to press, the dispute remains unresolved andthe Dutch government has initiated legal action against MSF.

Helping a displaced,
desperate population

The Caucasus

I N T ER NAT I O NA L S TA FF 14
NAT I O NAL S TAFF 24 6

The closing of camps – the last of which
occurred in June 2004 – was the result of aso-called “twenty point plan” published by
the Russian authorities in March 2002,
which scheduled the closures as part of a“normalization” process in Chechnya. This
plan has proceeded despite the fact that,during the past year, political uncertainty
and violence have, if anything, increased in
Chechnya, and despite calls by MSF andother NGOs to give displaced people a real
choice between staying and going. While
there is little evidence that physical force
was used to persuade the displaced people
to return home, a campaign of psychological coercion that featured threats and thecutting off of gas and electricity, as well as
promises of compensation that have subsequently gone unfulfilled, resulted inmany people returning. The same process
of squeezing people out was then applied
to those living in more dispersed and informal settlements.
Those who returned to Chechnya wereplaced in what are called Temporary
Accommodation Centers. MSF at first hesitated to provide assistance in these newsettlements because it did not want toappear to condone the process of “normalization” or run the risk of accelerating thecamp closures in Ingushetia. However, as
the numbers swelled and the conditions
became abysmal, MSF was left with nochoice but to provide aid to alleviate thesuffering caused by atrocious overcrowding and extremely poor sanitation. MSF
now also offers primary health care andcounseling services in the settlements.
MSF has continued to run mobile clinics,
improve hygiene standards, augment© Eddy van Wessel

The past year has proved particularly difficult for MSF in the North Caucasus. There
has been a further deterioration in security
in the Chechen and Ingush republics, withviolence increasingly spilling over into
Ingushetia from Chechnya. At the sametime, authorities have conducted a systematic closure of the internally displaced persons camps in Ingushetia in which MSF has
been working. The closures have forced
thousands of people to return to Chechnya
or find private assistance in Ingushetia.
Beslan and his brother play in front of a window covered only with plastic in a house with no electricity.
In 2000, a grenade wounded Beslan in the stomach, he was lucky to survive.

maternity facilities, increase pediatric care,and provide medical supplies and drugs forthe displaced people remaining in
Ingushetia. In the first four months of 2004,
the MSF team working in three maternaland child health care clinics had conducted
more than 7,400 medical consultations
among a population of whom 95 percent
are displaced people and 5 percent are
local residents.
The organization also continues the difficult work of supplying hospitals and clinics
in Chechnya itself and has started a tuberculosis (TB) treatment project there. In
addition to providing medical treatment tothose with TB, MSF makes available psychosocial counselors for TB patients, trauma
victims and medical personnel caught up
in the bloody crises that make up daily life
in Chechnya. Since the start of 2004, MSF
has conducted more than 10,000 medical
consultations in Chechnya including 225
surgical interventions and 960 newborndeliveries.
One small success, though not a lasting
one, was that the 140 housing units that
MSF had built in Ingushetia for displaced
people who wished to stay were finallyapproved by the Russian authorities. In early 2003, these houses had stood empty
while the authorities argued about theirlegality and at one stage ordered theirdestruction. However, in February 2004,
displaced people received permission tomove into them. As this report goes topress, however, the authorities have once

again decided to question the houses’
legality and have reversed the decision tolet displaced people live in them. In themeantime, MSF has constructed more than
150 new housing units and rehabilitatedmany more.
The continuing danger in Chechnya andthe failure of the “normalization” project
were exemplified by the assassination of A.
Kadyrov, the Kremlin-backed president of
Chechnya, and its aftermath. His death in abombing in May 2004 was followed by asurge in violence, culminating in an attackby armed groups on the headquarters of
the Ingush Interior Ministry, which left
more than 90 people dead. MSF provided
surgical help and emergency medical kits
to nearby health facilities in response toboth incidents.
The increase in violence, the level of threat
to civilians and aid workers and bureaucratic hurdles have further diminished thespace in which independent humanitarianorganizations can operate. Because of
security concerns, the activities of all of
MSF’s projects in the region have been carried out mostly by national staff members
and managed by international volunteers
who are obligated to communicate withthe aid team from outside of the area.
MSF’s core values of providing independent
witnessing and solidarity and of working inclose proximity with those most in needhave become increasingly strained in thisregion.
MSF has worked in the North Caucasus
since 1999.

ACTIVITY REPORT 2003/2004 MEDECINS SANS FRONTIERES 47

Central AsiaI N T ER NAT I O NA L S TA FF 9
NAT I O NAL S TAFF 0

I N T ER NAT I O NA L S TA FF 7
NAT I O NAL S TAFF 50

I N T ER NAT I O NA L S TA FF 132
NAT I O NAL S TAFF 12

Tajikistan

Turkmenistan

Uzbekistan

In December 2003, after six years of activity,
MSF closed its mission in Tajikistan, a country deeply affected by the breakup of theSoviet Union and a resulting civil war.
Tajikistan is one of Central Asia’s poorest
republics, with little health care for themost vulnerable residents. Among the latter are the mentally ill, who are stigmatized
and forgotten. During 2003, MSF continued
to help patients in 17 psychiatric clinics inwhich doctors and other caregivers lackthe means to provide proper care, andmany patients receive medication only iftheir families can pay for it. MSF supplied
food, clothing, blankets and heaters anddrew national and international attention
to the predicament of those living in these
institutions. In September and October
2003, the organization mounted a photo
exhibition in the capital, Dushanbe, tohighlight the problems faced by thisneglected group. At the end of 2003, MSF
transferred responsibility for this project tothe World Food Program.

© Kadir van Lohuizen

In December, the ministry of health andanother aid organization took over a
project MSF had established in the Rasht
Valley to improve basic health care, particularly for expectant mothers. This was
one of MSF’s final programs to be transferred once the organization determinedthat its presence was no longer needed in
Tajikistan.
MSF has worked in Tajikistan since 1997.

© Rip Hopkins

MSF ends activity

An elderly couple receive care at a medical facility in Kolkhoz, Sirdariya region, Uzbekistan.

Improving care for children
In December 2003, MSF phased

Moving forward on TB
treatmentout its involvement in the DOTS

MSF is now focusing on the par-(Directly Observed Treatment

ticularly difficult issue of provid-

Short-course) tuberculosis pro-ing care for people with multi-

gram that it had run in Dashoguz

drug-resistant tuberculosis (TB).

since 1999, handing over all
remaining activities to theministry of health.
MSF then started a new project providing
care for children in the economicallydeprived eastern town of Magdanly. Work
started in April 2004 in the local hospital in
the pediatrics and children’s infectiousdisease wards, as well as in the children’s
intensive care unit. Primary emphasis isplaced on implementing more rational
drug use and improving diagnostic techniques, with education for health care
workers as an additional component. MSF
staff members are now refurbishing someof the hospital wards and plan to improve
its water supply and waste management
system.
MSF was forced to halt abruptly its support
to projects in Afghanistan from the
Ashgabad Logistical Support Office in
Turkmenistan following the brutal murdersof five MSF staff members in Afghanistan inJune 2004. During the first six months of
2004, that oﬃce had handled approximately
120 tons of cargo.
MSF has worked in Turkmenistan since
1999.

48 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2003/2004

A survey found that the Karakalpakstan
area has the highest incidence of resistant
TB in the Aral Sea region. MSF is now
treating 100 patients there in an intensive
DOTS–Plus (Directly Observed Treatment,
Short-course) treatment program. This program builds on the regimen already inplace and adds second-line drugs to overpower the resistant bacilli. Currently, MSF
is exploring the potential of expanding
the program to treat all patients withresistance in two pilot regions.
MSF has worked in Uzbekistan since 1997.

Central AsiaI N T ER NAT I O NA L S TA FF 67
NAT I O NAL S TAFF 658(before 2 June 2004)

MSF leaves country
following staff killings
and threats
The people of Afghanistan today
face a harsh and desperate reality
as a result of more than 25 years© Carl De Keyzer/Magnum

Afghanistanof war, shifting political leader-p

alleviate their suffering, MSF haspship and years of drought. To help
been providing Afghans withmedical care for almost 24 years.
Tragically, on 2 June 2004, five MSF staff
members were shot and killed on the roadbetween Khairkhana and Qala-i-Naw innorthwestern Badghis province. After
weighing the options, MSF sadly decided
to close all of its medical projects in
Afghanistan by the end of August 2004.
Most activities were handed over to localgroups, international NGOs or the ministryof health.
Although Afghan officials presented MSF
with credible evidence that local commanders conducted the attack against thethree international volunteers and twonational staff members, these officials haddone little to bring the perpetrators to justice. In addition, after the killings, a Taliban
spokesperson claimed responsibility forthe murders and later stated that organizations like MSF work for US interests and are
therefore targets for future attacks. MSF
believes that humanitarian assistance isonly possible when armed actors respect
the safety of humanitarian workers, morethan 30 of whom have been killed in
Afghanistan since the beginning of 2003.
The targeted killing of MSF staff, the government’s failure to arrest the culprits andthe false allegations made by the Taliban
made it impossible for MSF to continue
providing assistance, despite the greatneeds.
The violence directed at humanitarian aid
workers in Afghanistan comes amid consistent efforts by the US-led coalition touse humanitarian aid to build support for
its military and political aims. MSF has
repeatedly denounced the coalition’s
attempts to do so. The organization has
also spoken out against the military’s“After having worked nearly without interruption alongside themost vulnerable Afghan people since 1980, it is with outrage andbitterness that we take the decision to abandon them. But we simply cannot sacrifice the security of our volunteers while warring
parties seek to rage and kill humanitarian workers. Ultimately, it is
the sick and destitute who suffer.”– Marine Buissonnière, Secretary General of MSF, at the Kabul press conference
announcing MSF’s withdrawal from Afghanistan

attempt to usurp humanitarian aid. In May
2004, MSF publicly condemned the coalition’s decision to distribute leaflets insouthern Afghanistan that conditioned thecontinued delivery of aid on local people’s
willingness to provide information about
the Taliban and Al-Qaeda.

MSF’s activities in Afghanistan
Before the murders of five of its staff, MSF
had been providing health care in 13
provinces of Afghanistan, performing tensof thousands of medical consultations eachmonth. Teams gave basic and hospitalbased care, treated people with malaria
and tuberculosis and worked to reducematernal mortality. MSF staff also provided
safe drinking water and sanitation facilities.
When a malaria epidemic started in
October 2003 in Badghis province, MSF
teams treated 1,300 patients within thespace of a month. In the same year, MSF
carried out a study to test the efficacy ofchloroquine, the conventional malaria
treatment in Afghanistan, because of growing concerns about resistance to the treatment. In its projects, MSF had made a more
effective medicine, artemisinin-based combination therapy (ACT), the standard treatment. In addition, staﬀ members vaccinatedtens of thousands of children across thesouthern region between the ages of six
months and 12 years old in response torepeated measles epidemics there. In five
districts of Bamiyan province, teams were
working to improve access to primary
health care and maternal and child care.
At the beginning of 2004, a surgical unit
was opened in the Panjab district to help
pregnant women in need of emergency
obstetrical care.
Afghanistan’s wars and natural disasters
have caused massive population movements in recent years. Before the killings
took place in June, MSF was helping displaced people living in various camps
inside Afghanistan as well as assistingAfghan refugees living in neighboring
Pakistan and Iran. In 2003, under government pressure, many of the displaced
returned to their homes or moved to new
locations. In response, MSF was gradually
reducing its medical activities in thecamps. Yet MSF continued to provide basic
health care to 40,000 displaced people
living in Kandahar province’s Zhare Dasht
camp and to 22,500 displaced people inthe camps near Spin Boldak across the
Pakistani border. In the Afghan capital,
Kabul, MSF assisted returnees and provided clean water to squatters living intents in the city’s Jangalak and ShahrakI-Police areas.
MSF worked in Afghanistan from 1980 until
August 2004.

ACTIVITY REPORT 2003/2004 MEDECINS SANS FRONTIERES 49

Central Asia
© Tim Dirven

I N T ER NAT I O NA L S TA FF 17
NAT I O NAL S TAFF 30

I N T ER NAT I O NA L S TA FF 4
NAT I O NAL S TAFF 87

Islamic Republic of Iran

Iraq

Aiding earthquake survivors and refugees

A spiral of violence

Since the fall of the Taliban regime in November 2001, millions of

After having been blocked fromAfghan refugees in Iran have faced pressure to leave Iran and return

entering Iraq between 1992 andhome despite the continuing insecurity and difficult living conditions

the very end of 2002, MSF wasin Afghanistan.

given permission by the former

treated civilians
suffering fromemergency healthproblems includingtrauma wounds,
lung infections
caused by dust andgastritis. They alsocared for people
with chronic conditions such as asthma, diabetes,
hypertension andepilepsy, who nolonger had accessIn the city of Kerman, earthquake victims pulled out of the rubble received
treatment for “crush syndrome”.
to their daily
treatment. After
three months of activity, approximately
MSF assists refugees in the city of
9,000 consultations had taken place. MSF
Mashhad, in the northeastern borderalso sent a team of nephrologists (kidney
province of Khorasan, and in the city of
specialists) and a nurse to help treat vicZahedan, in the southeastern province oftims with “crush syndrome” in two hospitals
Sistan-va-Baluchestan. The latter is Iran’sin the nearby city of Kerman. (Crush synleast-developed region and the main entry
drome is a condition in which muscle tissue
point for refugees. MSF provides medical
damaged by severe internal injury canconsultations and nursing care at bothrelease massive quantities of toxins into
locations through standing facilities andthe bloodstream and lead to kidney failure.)mobile clinics. At present, there are seven
MSF flew in six dialysis machines andmobile clinic sites in Mashhad and four inmedicines needed to treat the syndrome.
Zahedan. In addition, the Mashhad project
offers prenatal care and midwifery services, Teams also built sanitary facilities including
and the project in Zahedan treats malnutri- 300 latrines and 200 showers.
tion. Teams in both cities each carry out
MSF psychologists treated trauma related
approximately 4,000 consultations every
to the earthquake and developed a mental
month. The teams also provide food aid
and other basic necessities to the most vul- health project to support those needing
psychosocial care in Bam and in the surnerable families.
rounding area. Approximately 3,000 people
met with members of this team in the
Earthquake relief
weeks after the disaster.
In the final days of 2003, MSF sent medical
and logistical staff to the southern city of
In March 2004, MSF ended its program in
Bam to offer assistance after a devastating
Bam and transferred oversight of its mental
earthquake on 26 December 2003. With an
official death toll of 40,000 people, the city, health activities to the ministry of health.
along with many of its health facilities, was
MSF provided aid in Iran following thealmost completely destroyed. MSF set up
1990 earthquake and has worked there
mobile clinics and tent facilities offeringcontinuously since 1995.
medical care, nursing care and midwifery
services in several parts of Bam and in thesurrounding villages. The medical teams

50 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2003/2004

government to start providing
care to civilians in Baghdad
shortly before the war began in
March 2003.
Weeks later after the most active combat
between Iraqi forces and the US-led coalition had ended, MSF visited more than 70
health facilities in 25 cities, assessing themost urgent medical needs and donating
medical equipment and drugs as necessary. In some hospitals that were facing
staff shortages, MSF also offered the helpof its own medical volunteers. While many
civilians could not get care amid the chaosthat followed the conflict, the country’s
civilians did not suffer from disease epidemics or huge refugee movements as had
been predicted by some.
MSF staff quickly concluded that the mostpressing medical problem facing Iraq in
the days following the fighting was a lackof leadership within the country’s centralized health care system. MSF called on themembers of the US-led coalition, as occupying powers, to assume their responsibility as stipulated under the Geneva
Conventions and provide basic services,
including health care, to the Iraqi people.

Humanitarian aid workers targeted
Although heavy fighting ended in April
2003, the country’s security situation deteriorated sharply in mid-2003, and humanitarian aid workers began to be viewed bysome as a component of the Western military effort. On 19 August, a bomb attack on
the UN compound in Baghdad killed many
international and Iraqi humanitarian workers, including UN Special Representativefor Iraq Sergio Vieira de Mello. Later, in
October, an explosives-packed ambulance
slammed into the Baghdad headquartersof the International Committee of the Red
Cross, killing 12 Iraqi staff members andinjuring 15 others. MSF condemned bothof these violent actions as heinous assaults

I N T ER NAT I O NA L S TA FF 6
NAT I O NAL S TAFF 4 0 0

Pakistan– Hans van de Weerd, MSF Head of Mission, Baghdad

Central Asia

“ While the official war has ended, Iraqi civilians continue tobe killed and wounded almost every day. Many people
can’t get the medical care they need because of the threatof violence. People here are still living in a war zone.”© Andrew Stern

Assisting Afghan refugees

on innocent civilians and on the principle
of independent humanitarian aid work. In
a statement, MSF emphasized that recent
actions and statements made by Western
officials attempting to incorporate aid into
their political plans were contributing tohumanitarian groups’ vulnerability to
attacks.

Providing care for those trappedby violence
While MSF had withdrawn many of its
international volunteers by September
2003 due to both unacceptable risks andreduced emergency health needs, teams
continued to provide assistance in a
number of ways. MSF began helping civilians in Sadr City, one of Baghdad’s poorest
areas, where the slum’s two million residents had little ability to access clean
drinking water, sanitation facilities or basic
health care. By mid-2004, MSF teams were
providing basic and prenatal care as well as
treatment for malnourished children inthree of the area’s health clinics, each ofwhich includes a first-aid post. More than
3,000 medical consultations were provided
each week in these clinics. MSF staff
trained medical and paramedical personnel, supervised nurses and rehabilitatedthe pediatric unit in the hospital in Sadr
City’s Al Thawra district. When Sadr City
underwent a siege in mid-2004, the teamtreated 40 to 50 people wounded during
the stand off. In August, MSF began an
ambulance service, in cooperation withother NGOs, to transport the injured to
local hospitals.
In August 2004, MSF distributed 1.5 tons of
medicine and material to Najaf Hospitaland nearby clinics during heavy fighting
between US forces and Shia militants
around the city’s holy shrine. Although thearea had an adequate drug supply, MSF
found that civilians had trouble entering
local hospitals and clinics that were guarded
by military forces.
In September 2003, MSF ended the distribution of medicines to treat people withthe deadly disease, kala azar (visceral leishmaniasis) which is endemic in the southernpart of the country. The project was started
because supply deliveries had been interrupted by the war. The materials were distributed among pediatric hospitals andother facilities in Ramadi, Karbala, Falluja,
Hindiyah, Najaf, Diwaniyah, Afaq,
Samawah, Baghdad (Sheikh-Zaid Hospital)
and Nasiriyah. Another organization will
now supply the drugs. MSF also donatedequipment, reagents and material to help
diagnostic-testing facilities resume operations in the public health laboratories of
Baghdad and nine other governates in theupper southern region of Iraq.
MSF has worked in Iraq since 2002.

In 2003-4, MSF teams continued to provide
basic health care and vaccinations in thecamps along the Afghan border at Chaman
and Spin Boldak, where approximately
60,000 Afghans are housed. A measles-vaccination campaign held in Chaman’s
Roghani camp during 2004 reached about
6,000 children, and MSF was treating 42
people for tuberculosis (TB) by June 2004.
In January 2004, MSF took over the provision of medical care at three health postsin the Mohammed Kheil refugee camp in
Balochistan, near Quetta, which has
approximately 47,000 residents. On MSF’s
first day of operations, hundreds of refugees came to the posts due to the poorlevel of health care which had been provided previously. The most common healthproblems seen by the team have been respiratory tract infections, diarrhea, skindiseases and worms.
MSF projects in Pakistan were scaled backin response to the killings of five staff
members in neighboring Afghanistan
during June 2004 and additional death
threats made against MSF volunteers by
the Taliban. While many MSF international
volunteers were sent home or werereassigned to other MSF projects, membersof the national staff, supported by a small
team of international MSF volunteers, continue to provide basic services including
limited consultations, vaccinations and TB
treatment.
From August to October 2003, MSF provided
emergency aid following flooding in five
districts of Sindh province in southeastern
Pakistan. This assistance included basic
health care, drinking water and sanitation.
In 2004, the team in Pakistan completed
several health assessments of Kashmir,near the Line of Control. MSF is reviewing
the feasibility of working in villages bordering the line and cut off from the rest of
Pakistan by mountains and weather conditions for a large part of the year. The
project would address maternal and infantmortality.
MSF has worked in Pakistan since 2000.

ACTIVITY REPORT 2003/2004 MEDECINS SANS FRONTIERES 51

BY SA L LY H A R G R E AV E S A N D L AU R A H A KO KO N G A S
FO R T H E MSF C A M PAI G N FO R ACCE SS TO E SSEN T IAL
M ED I CI N E S

Running out of breath?

© Espen Rasmussen

Tuberculosis control in the 21st century

In 2003, MSF’s medical staff
treated 20,000 TB patients in MSF
projects across 21 countries.
An MSF physician examines a patient in the TB ward of MSF’s health center in Huddur, Somalia.

Treatment of patients with tuberculosis (TB) is at a
crossroads. Care providers are forced to use decadesold, difficult-to-use medicines because there are nonew, improved drugs and diagnostic tools available.
In addition, current treatment strategies focus onreaching those who are easiest to treat while a growing
number of people are infected with resistant strains or
suffer from another life-threatening illness such as HIV/
AIDS. To counter this reality, MSF is calling for a revised
global TB treatment strategy and much more effort toexpand options for diagnosis and treatment.
Until the 1990s, management of TB was disorganised and ineffective. Treatment regimens varied widely; ambulatory non-observed
treatment was common, and reporting mechanisms were largely
absent. There was little interest in TB from the international community, including the World Health Organization (WHO), which
only allotted US$10 million for TB in 1992-93.

DOTS focuses on identification of the most infectious (smearpositive) patients. This approach was partly based on evidence that
detecting 70 percent of smear-positive patients and curing 85
percent of them could reduce TB incidence by 6 percent per year –effectively halving the incidence in 10 years. Yet it is accepted that
diagnosis and reporting based on the existing smear-microscopy
test, which can only pick up smear-positive patients, represents
only 45 to 60 percent of TB patients overall, and therefore relianceon DOTS cannot curb TB globally. DOTS was not only conceived asa medical approach but also as a brand, designed to convince
Western donors and developing country policy makers. The
message was that DOTS – and only DOTS – could deliver global
TB control.
However, WHO’s decision to back DOTS as the answer to TB wasquestioned by the medical, academic and scientific communities.
There were widespread objections in industrialized countries toWHO’s conservative decision to build its TB strategy around
existing TB tools rather than developing more effective diagnostics,
vaccines and drugs. WHO and its supporters, on the other hand,

52 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2003/2004© Alessandro Cosmelli

A variety of factors, including an outbreak of multidrug-resistant
TB in New York in 1991-93, and growing evidence of the link
between TB and HIV/AIDS, began to change this situation. The
WHO and the International Union Against Tuberculosis and Lung
Disease started to raise the profile of TB as a global crisis and todevelop a new global approach to it. Directly Observed Treatment,
Short-course (DOTS), was launched in 1994 as a public healthbased management strategy aimed at controlling the disease.

A TB patient receiving care from MSF in Muynaq, Uzbekistan.

TB kills roughly two million people every year.
Around 95 percent of all patients with active TB
live in the developing world, where 99 percent
of TB deaths occur.

argued for “restraint in the adaptation of new technologies by
non-industrialized nations”. They noted that “new technologies are
expensive and there is a danger that their introduction would
divert attention and money away from the real issues … the global
challenge of TB lies in the implementation of old, tried and tested
technologies.” Others were troubled by DOTS’ simplified “one size
fits all” strategy, noting that it was based on pilot studies in ninedeveloping countries, and that the results – particularly the failures(Senegal, Mali and Yemen) – had not been properly analyzed.

p

The debate over DOTS has calmed down during the past five years.
Critics have learned to appreciate DOTS’ good points and WHO
has toned down what some saw as an inf lexible approach to implementation. Multilateral funding has also increased, with new
Global Fund and World Bank money becoming available, although
WHO still reports serious shortfalls in funds available to DOTS
programs.
Although DOTS has many shortcomings, and the normal scientificprocess of scrutinizing and testing its premises and principles was
cut short by its launch as a brand, specialists agree that it can anddoes work in “normal settings”. That is, in the absence of HIV or
multidrug-resistant TB (MDR-TB), where targeting the mostinfected patients can deliver six to ten percent annual declines in
TB incidence.

Room for improvement
TB kills roughly two million people every year. Around 95 percent
of all patients with active TB live in the developing world, where 99
percent of TB deaths occur. Improving DOTS is crucial if we aregoing to try to effectively treat the growing number of patients withthe disease.
MSF has had first-hand experience of the current WHO-recommended strategy to control TB. In 2003, MSF’s medical staff treated
20,000 TB patients in MSF projects across 21 countries. While most
MSF and other experts agree that DOTS is the best approach we
have, DOTS has demonstrated serious limitations in its nearly
decade-long existence in the kinds of settings in which MSF works.
The greatest challenge to TB control is HIV/AIDS. An estimated 12
million people are now co-infected with HIV and TB, a rapid
increase in recent years. More than two-thirds of them live in subSaharan Africa. DOTS was not designed to address the specificcontext of HIV/AIDS and TB and a major re-think is required here
if we are to treat these patients. Even in MSF’s programs, only 4 of
the total 25 HIV/AIDS programs directly provide TB treatment in
sub-Saharan countries although TB is the most important opportunistic disease affecting HIV/AIDS patients. Most patients arereferred to national tuberculosis programs that are often unable totreat co-infected patients.
In addition, far too few patients have access to second-line treatment for MDR-TB. Defined as resistance to at least rifampicin andisoniazid, the two most powerful TB drugs, this strain might bespreading as fast as by 250,000-400,000 new cases each year.

The fate of difficult-to-treat patients?
Elizabeth, a 33-year-old Liberian woman, came to an MSF
clinic for care. She was emaciated, short of breath, and had
the classic stare of tuberculosis. During examination, an
MSF physician discovered a tuberculose abcess had eroded
through her chest wall. All the doctor could do was relieve
her breathing for a short time by draining two liters of pus
from her chest. She died three days later.
Her story is a familiar one. She was a mother of fourchildren, though one was dead and another was missing.
She had fled the fighting, moving from one refugee camp
to another for more than a year. During that time, she hadgone to three temporary camp clinics for care. Her TB
sputum test had been negative. She died after being
diagnosed too late and never receiving any treatment for TB.
This is the reality of many of MSF’s patients.

TB is the most important opportunistic
disease affecting HIV/AIDS patients.
Vigorous action for improved, more inclusive DOTS and forresources to develop new tools to fight TB is needed. Improving
and expanding DOTS to address “low-priority” patients – those
who are not detected as smear-positive with the tests currently
available – is crucial if we are going to try to treat effectively thegrowing number of TB patients. New, shorter treatments need to be
developed as the old ones are cumbersome to administer and treatment courses take months to complete. The development of new
diagnostic tests and ensuring research and development of new
drugs is now urgent. Investment into new tools is critical if we are
to have any hope of tackling the global burden of TB. It is criticalthat the most promising diagnostic tools are prioritized and that
their development is properly resourced. Most novel drugs are stillon the bench, months if not years away from early trials, and theirdevelopment should be promoted.
MSF believes that the global TB strategy needs to be revised. WHOshould lead the process of adequately addressing the HIV/AIDS
pandemic and its consequences for TB care. Access to treatment forsmear-negative patients must be ensured. Innovative means ofimproving treatment adherence must be found, including reduced
need for direct observation.
More resources must be brought together to develop new tools tofight TB within resource-poor settings. The development and validation of new diagnostic tools need to become a priority. There isalso a need to quicken the pace of developing new, easier-to-use
drugs and make them available at affordable prices. WHO and governments must work together to develop and fund an essential TB
clinical research agenda, ensuring that needed clinical trials takeplace. The agenda should consist of developing new tuberculosis
treatments among both existing drugs and new compounds.
Governments should insist that companies which make compounds
that could be used to help treat TB in the future make them available
to those willing to develop them into drugs. When commercial
interests hamper the development of a potential tuberculosis treatment, governments need to intervene.
To learn more about MSF’s activities on TB, read its report“Running out of breath? TB care in the 21st century” availableat www.msf.org.

ACTIVITY REPORT 2003/2004 MEDECINS SANS FRONTIERES 53

I N T ER NAT I O NA L S TA FF 20
NAT I O NAL S TAFF 145

Bangladesh

CambodiaAsia

I N T ER NAT I O NA L S TA FF 12
NAT I O NAL S TAFF 151© Stephan Grosse Rüschkamp/MSF

Expanding care for AIDS
and malaria patients

Rose Per brings her six-month-old daughter for malaria treatment at MSF’s mobile clinic in Bandarban district.

Improving care for malaria patients
MSF’s work in Bangladesh takes place in three districts that make up
the Chittagong Hill Tracts region, an isolated area near the country’s
borders with Myanmar (Burma) and India, in which the need for
medical aid is tremendous.
Government policies and insurgent groups
have inflicted discrimination, deprivationand marginalization on the region’s indigenous people, resulting in decades of conflict and massive displacement. Moreover,public health care services are scarce, andfew other NGOs are present.
Since 1999, MSF has a wide network ofclinics, malaria-treatment sites and healtheducation outreach posts in the northernpart of Khagrachari district. Recently, theorganization extended its activities to theneighboring Rangamati district. The
Chittagong Hill Tracts, unlike other parts of
Bangladesh, are hard hit by malaria, which
produces high rates of illness and death.
MSF treats people with malaria using highly effective artemisinin-based combination
therapy (ACT). The organization is conducting research on the effectiveness of various
treatment regimes, and its studies haveshown that resistance to chloroquine, thegovernment’s current first-line treatment
for falciparum malaria, is as high as 40 percent. As a result, MSF is actively advocating
for a change in the treatment protocol andthe introduction of ACT as the first-line
treatment in Bangladesh.

Beside running two standing clinics in
Khagrachari, the MSF team uses threemobile clinics to bring health care to
remote villages. Many of these areas are sodifficult to access that MSF staff must reachthem by foot or by boat. Rapid diagnostic
tests for malaria and subsequent treatment
are also offered in a number of “malaria
field sites” and health-education outreachteams visit villages that are near the clinics.
The outreach workers promote the clinics
and use games and drama to increaseawareness of health topics such as malaria
prevention, prenatal care and basic
hygiene. In December 2003, MSF started asecond project in the Bandarban district
that also employs a mobile clinic, several
malaria field sites and health-education
activities in remote villages.
By June 2004, with the malaria season
approaching its peak, more than 8,600
medical consultations had been conductedin MSF’s health facilities.
MSF has worked in Bangladesh since 1985.

54 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2003/2004

Cambodia has the highest prevalence of
HIV/AIDS in Southeast Asia, standing at 2.6
percent of the population. In a number ofprojects around the country, MSF promotes
prevention and offers many facets of care,including treatment with life-extending
antiretroviral (ARV) medicines. By July
2004, MSF was giving ARVs to 1,428 adults
and 56 children at Phnom Penh’s Norodom
Sihanouk Hospital, and to 303 adults and19 children at the hospital in Kompong
Cham. In the Takeo and Siem Reap
provinces as well as Sotnikum district, MSF
treats those needing ARVs at Chronic
Disease Clinics (CDCs). MSF’s CDC in Takeo
Provincial Hospital treats some 900 people
with chronic diseases, mostly HIV/AIDS,
diabetes and hypertension. By June 2004,
276 of these people were receiving ARVs
and MSF expects to have enrolled 600
patients in its ARV program there by theend of 2004. At a CDC in Siem Reap
Provincial Hospital, where MSF runs an ARVtreatment and counseling program, as ofJune 2004, 384 patients were taking ARVs.
MSF plans to increase this number to 700
by the end of 2004. In addition to treating
HIV/AIDS, the Siem Reap CDC staff treat
other chronic diseases. At the Sotnikum
CDC located in a poor, rural area in thenorthwest of the country, 104 patientswere receiving ARVs and counseling byJune 2004. This number is expected toincrease to almost 200 by the end of theyear.
Although malaria prevalence has
decreased in the last few years, it remains aserious health concern in Cambodia due to
growing resistance to available treatment.
In the town of Pailin, located near the Thaiborder, MSF is providing early diagnosis
and treatment of malaria. MSF is seeking toprove that artemisinin-based combination
therapy (ACT) can be effective in treating
patients in remote areas like this one. The
project uses this new combination therapy
as first-line treatment and monitors its
effectiveness.
MSF has worked in Cambodia since 1989.

IndiaI N T ER NAT I O NA L S TA FF 17
NAT I O NAL S TAFF 19 4

Asia

© Carl de Keyzer/Magnum

I N T ER NAT I O NA L S TA FF 21
NAT I O NAL S TAFF 9 0

Indonesia

Improving TB care andtreating victims of violence
Each year, nearly two million people develop tuberculosis (TB) in India and more than
450,000 people die from it. In 2003, MSF
reoriented its work on TB to better benefit
individuals living in Mumbai, where manyof those with the disease are excluded
from the national TB program. MSF wants
to improve the level of TB diagnosis andtreatment and to document cases of multidrug-resistant TB and co-infection with HIV.

Helping victims of infectious disease and violence
MSF is assisting patients suffering from infectious diseases, violence
and natural disasters in Indonesia. Malaria is a serious illness in various
parts of the country, made more serious because there is growing
resistance to existing drugs used to treat patients with it. MSF is treating people with artemisinin-based combination therapy (ACT) andpromoting its use as first-line treatment for the disease.

Since January 2003, MSF has assisted internally displaced people (IDP) in the
Kokrajhar district of Assam state in thewake of violence that displaced more than
300,000 people. MSF provides care to an
estimated 45,000 people living in eightcamps and to those in surrounding villages.
MSF offers primary health care, malaria
diagnosis and treatment, prenatal care andwater and sanitation services. MSF teams
care for patients in existing health centers
as well as in the organization’s own clinics
and they carry out health promotion activities in the region. As malaria is an important concern in India, MSF has conducteddrug-efficacy studies as part of its efforts
to change India’s malaria treatment protocols from recommending chloroquine toartemisinin-based combination therapy(ACT). As of April 2004, MSF has been permitted to use ACT as a first-line treatment.
In the state of Jammu and Kashmir, MSF
gives medical and psychosocial care to a
population caught in the ongoing violenceover Kashmir valley. Both sides of this 14year conflict have targeted the local civilian population: disappearances, arrests,
torture and rape are common. As a result,the people of Kashmir suffer from highlevels of trauma and stress-related illnesses.
MSF teams work in the districts of Srinagar
and Kupwara to raise awareness of psychosocial problems and to improve the level ofmental health care available. MSF-trained
counselors work with patients in an MSFsupported clinic and directly in communities through mobile “on-the-spot” counseling in Srinagar. MSF counsels about 200
patients daily at the outpatient department of the Srinagar psychiatric hospital.
MSF has worked in India since 1999.

From July to October 2003, ACT was used
in a malaria-treatment campaign that took
place in South Halmahera, North Maluku.
Over the course of 10 weeks, the MSF teamvisited 89 villages and conducted 11,125
medical consultations.
The global HIV/AIDS epidemic has alsoreached Indonesia, especially the provinceof Papua. On 15 July 2003, an agreement
was signed between MSF and the Merauke
district health office to provide care andtreatment for HIV/AIDS patients. MSF
assists both inpatients and outpatients inthe district hospital. By July 2004, throughthe outpatient clinic, MSF was caring for
70 patients, of whom 26 were receiving
antiretroviral (ARV) treatment.
In 2003, MSF started to carry out psychosocial activities in Ambon to help residents
cope with violence and subsequent trauma
caused by religious conflict in the region.
In 2004, the team expanded its activities toinclude individual counseling sessions, discussion groups and training sessions. In
addition, in September 2003, MSF began ashort-term, community-based TB project tosupport and monitor all patients receiving
treatment at two health centers.
In April 2004, violent clashes erupted in
Ambon between Muslims and Christians,
and the MSF office was burned down amid
the turmoil. MSF donated medicines andmedical material to the city’s five main
hospitals and began to circulate mobile
clinics to assist people unable to reachhealth services. MSF also undertook waterand sanitation activities in the areas of
most urgent need. The mental healthprogram was adapted to the conditions,with psychologists joining the mobile clinic
teams and doctors referring patients withpsychosomatic symptoms to the psychologist for individual counseling. Two weeks
after the clashes had begun, MSF’s local
TB-project supporters went back to theirrespective communities and tracked down
the 105 patients MSF had been following.
They then resumed their home visits andeducational work aimed at adherence totreatment.

Assisting earthquake survivors
On 6 February 2004, a powerful earthquake
shook the town of Nabire, Papua and its
surrounding region. MSF quickly responded
by sending a medical and logistical team,along with 600 kilos of supplies. Over fivedays, the medical team conducted medical
consultations in four villages near Nabire.

Responding to disease outbreaks
MSF’s emergency-preparedness-systemproject in Jayawijaya, in the province ofPapua, enabled MSF to respond to 28
disease outbreaks in 2003. After evaluating
and analyzing alternative ways to carry out
the project, MSF decided to end it inDecember 2003.
In August 2004, after two years of activity,
MSF closed its project aimed at improving
access to basic health care services forcommercial sex workers in Indonesia’s capital, Jakarta. The organization will continue
to pay for ARV treatment for the 40
patients whom its team had been monitoring, until another organization can befound to assume their care.
MSF has worked in Indonesia since 1997.

ACTIVITY REPORT 2003/2004 MEDECINS SANS FRONTIERES 55

Asia

I N T ER NAT I O NA L S TA FF 19
NAT I O NAL S TAFF 6 0“ When we talk to HIV-positive patients
about their experiences, they often cry
when they remember how they weretreated by hospital staff. HIV-positive
patients are frequently unable to get thehospital care they need because nobody
wants to touch them. But health staff
In Baoji, MSF’s program for children helps youngsters rediscover the joy of playing.
themselves can also be discriminatedagainst if they work with people who are HIV positive. I was once on a train wearing an MSF t-shirt
with a logo about AIDS. People looked at me strangely, kept their distance and even asked me if I was
HIV positive. I felt very stigmatized myself.” – Yuxin, a member of the MSF health education team in Xiangfan

Providing AIDS care and helping street children
In China, where an estimated 1.5 million people are living with HIV/
AIDS, MSF has begun working with local medical staff to provide careand treatment. In May 2003, MSF opened a free clinic in Xiangfan city
as part of a project targeting the estimated 45,000 people living with
HIV/AIDS in Hubei province. Most of those who are HIV-positive in thispart of central China were infected after selling blood to blood banks.
Many are rural subsistence farmers with noaccess to the local, fee-based health caresystem. MSF teams are training local staff
at various hospitals in safe blood andbody-fluid handling and disposal techniques as well as in providing comprehensive care to those living with HIV/AIDS.
Other activities include voluntary counseling and testing, treatment for opportunistic infections, home-based and palliativecare. At the end of August 2004, 40 people,
including 9 children, were receiving full
treatment, including antiretrovirals (ARVs),
in Xiangfan, and 189 patients overall werereceiving care at the clinic.

On 1 December 2003 MSF began a second
HIV/AIDS project, in Nanning, Guangxi
Autonomous Region. In collaboration with
the Guangxi Ministry of Health and theprovincial center for disease control, MSF
has set up a clinic to provide care and ARVtreatment for 10 to 20 new patients amonth. As of July 2004, 137 patients werereceiving care at the clinic, and of these,
82 were receiving ARV treatment. MSF’s
goal is for 250 patients to be receiving
ARVs before the end of the year. MSF is also
creating patient support groups as part of
the ﬂedgling network of HIV-positive people
in this part of China.

“ We are extremely excited about the launch of this project since
it marks a breakthrough for HIV/AIDS treatment in a country
with an escalating HIV/AIDS problem. Although many Chinese
hospitals have the capacity to provide treatment to people living with HIV/AIDS, the huge cost of the drugs means that mostsufferers have no hope of ever being able to afford them.”– Luc van Leemput, Head of the MSF project in Xiangfan

56 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2003/2004

Getting children off the street
MSF continues to provide psychosocial
support to marginalized children in Baoji
city, Shaanxi province where homeless children have become a growing social problem. Many of these youngsters have been
exposed to physical and psychologicaltrauma, neglect, abuse, hunger and rejection. In cooperation with authorities in
Baoji, MSF has been running the Baoji
Children’s Center since March 2001. The
MSF team and civil-affairs educators workwith the children to provide temporary
accommodation, medical and psychological care, food, schooling, and access tolegal assistance. The full team has also
started conducting outreach activities on
the streets of Baoji.

Closing a sanitation project
MSF officially closed a water and sanitation
project in Kashgar province of Xinjiang
Autonomous Region in October 2003. Thisregion of western China is predominantly
made up of Muslim minority communities.
In the townships of Yarkand and Yengisar,teams worked in cooperation with local
authorities to bring clean drinking water to
8,500 people in the area. In addition to
installing 58 water points (each providing
water for an average 125 people), MSF staff
promoted hygiene in the communities.
MSF has worked in China since 1988.

© Isabelle Merny/MSF

China

I N T ER NAT I O NA L S TA FF 8
NAT I O NAL S TAFF 26

Myanmar (Burma)

Lao People’s
Democratic
Republic

Extending care for malaria and AIDS patientsAsia

I N T ER NAT I O NA L S TA FF 4 8
NAT I O NAL S TAFF 6 69

Malaria is the leading cause of illness and death in the country, andylocal strains of the disease are highly resistant to common treatments.
MSF provides maternal and child healthcare and treats patients suffering fromcholera, sexually transmitted infections
and tuberculosis in Yangon. Patients withthese health problems or HIV/AIDS can also
receive needed assistance from MSF in Rakhine, Kachin and Shan states and in Dawei
and Myiek districts.

Assisting isolated civilians© Laurence Hugues

Providing care for those living with HIV/AIDS is another large part of MSF’s medical
activities in Myanmar (Burma). MSF started
the country’s first program using lifeextending antiretroviral (ARV) treatment in
February 2003 in the capital, Yangon. As of
August 2004, 205 people were receiving
ARV treatment, including 20 children. The
team also treats people with opportunistic
infections. An additional 50 patients now
obtain ARV treatment from MSF staff in
Shan state and 20 more receive this care in
Kachin state. A similar ARV treatment program is due to start in September 2004 in
Dawei, located in Thaninthyari division.
MSF also provides care to pregnant women
to prevent mother-to-child transmission of
the virus in 14 MSF clinics located aroundthe country. The organization is extendinghome-based care and adult and pediatriccounseling services to support HIV-positive
patients and raise awareness about MSF
programs.

In Rakhine state, the majority of the population is Muslim and they are known as
the Rohingyas. This group continues to bepersecuted by the authorities and is denied
basic civil rights and liberties, most notably
the right to move, leaving them essentiallytrapped within their own villages. MSF aids
these civilians by providing primary healthcare and specifically, treatment for malaria,
a common disease in the area. By August
2004, an estimated 35,000 people hadreceived medical assistance.

© Ahmed Zouiten

For this reason, in 1996, MSF started giving
malaria patients highly effective artemisinin-based combination therapy (ACT). Thisnew therapy cures more patients than older
treatments and there is no known resistance to it. During the past year, MSF staff
members screened more than 300,000
people for the disease and treated morethan 160,000 patients.

Expanding AIDS care
MSF’s work in this country focuseson the growing problem of HIV/
AIDS. During 2003-4, MSF has
been adding care components

Near the Thai border, in Mon and Karenstate, MSF has started giving medicalcare to villagers who are isolated by theongoing conflict between rebel groups
and government troops. MSF has also
begun providing health care to displaced
people living in Kayah state, close to theThai border.
MSF has worked in Myanmar since 1992.

to its pilot project based in the
170-bed district hospital in
Savannakhet.
MSF initially focused its efforts on prevention, home-based care and treatmentof opportunistic infections. However, inJune 2003, the Laotian government
authorized MSF to import antiretroviral(ARV) medicines. In September 2003, thefirst patient in Laos was treated with ARVs.
By the middle of 2004, 110 patients werereceiving these medicines. With the goal ofadding 12 new patients a month, the MSF
team hopes to treat 170 people with ARVs
by the end of 2004.
MSF has worked in the Lao People’s
Democratic Republic since 1997.

ACTIVITY REPORT 2003/2004 MEDECINS SANS FRONTIERES 57

Nepal© Tomas v Houtryve

Asia

I N T ER NAT I O NA L S TA FF 10
NAT I O NAL S TAFF 24

I N T ER NAT I O NAL S TAFF 2 (based in Seoul, South Korea)
NAT I O NAL S TAFF 6

Democratic People’s
Republic of Korea

Assisting civilians
trapped by conflict

MSF works in the Rukum district of midwestern Nepal, where living conditions areprecarious because the national army
occupies the district capital and Maoists
hold the surrounding rural areas. Most of
the approximately 200,000 people who livein the mountainous region are indigenous
farmers. Since February 2003, MSF has run
the district hospital in Rukum, carrying out
approximately 900 inpatient and outpatient consultations each month. MSF has
rehabilitated some hospital wards, thelaboratory and the waste area. MSF staff
members also treat 70 people with tuberculosis in the hospital. In 2004, MSF conducted mobile clinics in Maoist-controlled
territories where access to health care isalmost nonexistent.
MSF facilitates airlifts to Nepalganj insouthern Nepal for patients needing surgery, in an effort to make urgently neededcare more accessible. Although this assistance helps the critically injured, most
Nepalese must walk for days to reach thenearest heath post.
In March 2004, MSF ended its activities inJumla, a district in Karnali zone, located in
mid-western Nepal. The organization had
begun to rehabilitate health posts in Jumlaas part of a general health project, but
pressure from both sides of the conflictmade the work impossible. MSF was forced
to withdraw from the district after local
authorities asked MSF to suspend its
activities in January 2004.
MSF has been working in Nepal since 2002.

© Peter van Quaille

In Nepal, chronic political instability has
made it difficult for patients to receive carein a weakened health care system alreadyhindered by poverty and insufficient
medical personnel and supplies. For years,
government and insurgent groups havevied for control of this mountainous
kingdom, creating a bloody civil conflict inwhich all forces target civilians. In August
2003, the most recent ceasefire in Nepal
was broken, further diminishing MSF’s
ability to bring aid to the Nepalese people.

Helping refugees fleeing deprivation and violence
In 2003 and 2004, the food situation remained critical for most people
in the Democratic People’s Republic of Korea, better known as North
Korea, for whom access to international assistance remains impossible.
Economic reforms, introduced in July 2002,
officially dismantled the public food distribution system and installed a new priceand salary scheme to reflect production
costs, but since then, salaries haveremained largely unpaid. The reforms haveresulted in runaway inflation and haveundermined people’s ability to find basic
food items on the black market, a systemincreasingly controlled by the North
Korean regime.
Amid these stark conditions, North Koreanscontinue to flee deprivation and violenceorchestrated by the country’s leaders inPyongyang. They keep crossing the border
into China in search of food for theirfamilies or a temporary job that will enable
them to buy medicines or other essential
goods needed to survive. Consideredunwanted economic immigrants by the
Chinese authorities, they live in hiding andface the risk of being arrested at any time,
forcibly repatriated and subjected to
imprisonment and brutal treatment back in
North Korea.
For the past year, the systematic hunt for
North Korean refugees has continued tointensify on the Chinese side of the border.

58 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2003/2004

Every month, hundreds of North Koreans insearch of assistance and asylum have been
forcibly repatriated to the North. The
humanitarian aid workers who attempt to
rescue refugees also face the brutal determination of the Chinese authorities, whodeem such assistance a criminal offense.
Bounties are commonly given to those who
identify humanitarian aid workers or North
Koreans. Predictably, in this context, support for refugees in distress is diminishing
and assisting them has become a challengethat increasingly few aid organizations,crushed by this sanctions policy, are able
to undertake.
The systematic and organized dragnet
taking place in China leaves most North
Korean refugees no alternative but toundertake a desperate flight to a third
country. They cross thousands of kilometers in order to reach more welcoming
southeast or northeast Asian countries.
Most gain assistance after jumping overembassy walls or dashing through thedoors of diplomatic offices. A few hundred
North Koreans manage to find their way toSouth Korea each year, bringing thenumber of defectors there to more than
5,000 in June 2004.

Since 1998, MSF has provided shelter,
clothing, food and medical care to hundreds of refugees hiding in China and third
countries. In 2003, MSF opened a medical
and psychosocial program based in Seoul,
South Korea for vulnerable refugees facing
immense difficulties resettling in theSouth. Many are traumatized by years oforganized violence in North Korea including man-made famine, a lack of medicalcare and the resulting deaths of loved
ones. Some have faced denunciation,
imprisonment and torture. North Koreans
may also have experienced brutal situations during their flight such as forced
prostitution, arrest, the death or disappearance of friends or relatives and the pain of
exile. Plus, once they arrive in South Korea,
the refugees encounter stigmatization andrejection. Not surprisingly, North Koreans
often find themselves completely unable
to restart their lives in South Korea. Of the
60 patients followed by MSF psychologists
and medical doctors during the first ninemonths after their arrival in South Korea,
almost 70 percent experienced mild toextremely severe psychological problems.

Sri Lanka

Asia

The Philippines
Assisting street children© Marco van Hal

MSF operated inside North Korea from1995 to 1998. During this time, the organization attempted to supply drugs andmedical training for approximately 1,100
health centers and to run 60 therapeutic
feeding centers for malnourished children
in three provinces. In 1998, convinced thatits assistance was not reaching the mostvulnerable people, and was, on the contrary, helping to feed the regime oppressing them, MSF withdrew from the country.
Certain however that North Koreans werestill in dire need of assistance, MSF tried todevelop, with local networks, alternative
ways of directly assisting North Koreans in
the region.

I N T ER NAT I O NA L S TA FF 18
NAT I O NAL S TAFF 76(until March 2004)

MSF operates a program targeting
200 out of an estimated 200,000
children who live on the streets ofthe capital, Manila.

MSF hands over activities

The program addresses the medical andpsychological problems encountered bythese children, their families and theircommunities. Among its activities, MSF
gives medical and psychosocial care tostreet children who engage in commercial
sex work as well as to victims of sexual,
physical and psychological abuse. MSF
focuses particularly on sexual and reproductive health, because sexually transmitted infections are a key health problem.
MSF also helps street children gain accessto further health care and to legal support.
Because malnutrition is a recurring phenomenon in the Philippines, MSF continued to operate a supplemental feeding
program in Malabon, one of the city’sslums, during 2003.
MSF has worked in the Philippines since1997.

In addition to providing direct assistance,
MSF systematically documents the hardships faced by North Korean refugees bycollecting personal testimonies fromrefugees and speaking out at international
forums about their plight.
MSF has been providing support for North
Korean refugees since 1995.
© Roger Job

Q

MSF in North Korea and the region

I N T ER NAT I O NAL S TAFF 2
NAT I O NAL S TAFF 30

The 2002 ceasefire between LTTE rebels(Tamil Tigers) in the north of the country
and the government held firm in 2003. As aresult of the truce, the humanitarian situation in the north has improved. For the firsttime in years, hospitals are adequately supplied with medicines, and most people
who had fled their villages have been able
to return home. As a result of the improved
conditions, MSF spent much of 2003 preparing for its departure and ended its workin the country in March 2004.
During 2003, MSF continued to support
regional hospitals in the northern Wanni
region. In Mallavi, the organization assisted
the surgical and maternity departments,
completed the training of supplementary
staff and constructed a modern systemfor processing medical waste. A similarsystem was installed in the hospital in
Puthukkudiyiruppu. In December 2003, an
MSF doctor worked in the latter hospital tohelp the nursing department and to prepare the maternity department for theorganization’s departure. From August
until November, MSF supplied a doctor tothe outpatient department of the hospitalin Mullaitivu. In September and October,the organization provided training courses
for laboratory technicians at the hospitals
at Mullaitivu and Puthukkudiyiruppu.
In the town of Vavuniya, just outside of the
Wanni region, MSF continued a projectproviding psychosocial care and healthinformation for traumatized people who
had been displaced from their homes in
the north.
In March 2004, MSF handed over its
activities to a new Sri Lankan NGO. This
organization is comprised of Sri Lankans
who had worked for MSF and who willcontinue the psychosocial program in the
town and district of Vavuniya. The activities
in Mullaitivu district have been handed
over to medical staff working for thenational ministry of health.
MSF starting working in Sri Lanka in 1986.

ACTIVITY REPORT 2003/2004 MEDECINS SANS FRONTIERES 59Asia

I N T ER NAT I O NA L S TA FF 21
NAT I O NAL S TAFF 135

ThailandScaling up AIDS treatment
In Thailand, HIV/AIDS affects an estimated 1.5 percent of the population and is the leading
cause of death. MSF’s work there is increasingly focused on helping those who are HIV positive.
MSF works closely with the ministry of public health, which aims to provide life-extending
antiretroviral (ARV) medicines to 50,000 people in 800 public hospitals across Thailand by theend of 2004. As part of the “Access Network” supporting the plan, MSF gives training, supervision and technical support to staff at comprehensive care centers in 100 hospitals acrossThailand’s six regions. Currently, about 1,100 people are receiving ARVs supplied by MSF.

Assisting refugees© Stefan Pleger

MSF’s first projects in Thailand targetedrefugees living along the border with Laos,
Cambodia and Vietnamese “boat” refugees.
Work with refugees continues today. In
Maela camp in Tak province, MSF provides
basic health care to 38,000 refugees, primarily members of the Karen ethnic minority. MSF runs two inpatient and two outpatient health facilities and manages thewater supply. MSF also provides food topeople who are sick and to pregnant andbreastfeeding women, and has set up atherapeutic and supplementary feeding
program.

MSF staff examine an X-ray during a bedside visit to a patient with AIDS in Surin province.

MSF is also providing comprehensive
AIDS care in seven district hospitals infour provinces as part of a pilot project todecentralize HIV/AIDS treatment. MSF
works in the provinces of Nonthaburi,
Petchaburi, Kalasin and Surinas well as intwo provincial hospitals in the provinces ofSurin and Maharasakam.
In Bangkok, MSF runs a home- and community-care project for people living with
HIV/AIDS who have limited access toexisting health services, such as women
prisoners and migrant workers. Activities
include palliative care and crisis intervention, as well as follow-up for thosetaking ARVs. Community care is offered inpartnership with hospices and shelters in
the capital city.
Because children living with HIV/AIDS in
Thailand have been identified as a population in need of better care, MSF began apilot project in late 2002 targeting thoseliving in Petchaburi province. Together
with local partners, MSF provides training,technical support and medicines to thepediatric department of the provincial
hospital. MSF aims to treat 100 children
with ARVs through this program by theend of 2004. Elsewhere, in Surin and
Maharasakam, 79 children have received
ARVs through MSF.

60 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2003/2004

People living with HIV/AIDS in Maela camp
have access to ARVs through MSF. Currently
15 people are receiving such treatment. In
Tham Hin camp, in Ratchaburi province,
MSF provides water and sanitation for the
9,000 Karen refugees and carries out morethan 2,000 health consultations per month.
In both camps, MSF works to prevent andrespond to epidemics that are a constantconcern due to overcrowding. Finally, MSF
has extended tuberculosis (TB) treatment
from Maela camp to the surrounding communities, particularly to the migrant workers who live in this border region and havelittle access to health care. In 2003, MSF
reached 493 TB patients, including somewith multidrug-resistant strains. MSF is
working closely with the Thai authorities toimprove access to the medicines needed totreat this type of TB.
MSF has worked in Thailand since 1983.

© Linda Van Weyenberg

The Americas

Children at play in Nicaragua.

ACTIVITY REPORT 2003/2004 MEDECINS SANS FRONTIERES 61

The Americas

I N T ER NAT I O NA L S TA FF 5
NAT I O NAL S TAFF 5(until December 2003)

I N T ER NAT I O NAL S TAFF 7
NAT I O NAL S TAFF 2 2Argentina

Bolivia
Chagas disease (American trypanosomiasis) kills more than 50,000
people every year in Latin America. Bolivia is the hardest hit country. The
disease affects more than half of the country’s inhabitants, mostly those
who live in poverty or in rural areas. Approximately 3.5 million people
are at risk of contracting it and 300,000 children younger than 12 are© Juan Carlos Tomasi

infected. Chagas accounts for 13 percent of all deaths in the nation. Yet
the problem extends far beyond Bolivia’s borders. More than 18 million
people have the parasite causing the disease in their blood stream, and100 million people in 21 Latin American countries are at risk of infection.

Providing essential
medicines and supplies

A killer that preys on the poor: Chagas disease

Argentina’s economic collapse inprovince, Tarija department since October 2002. Its teams have found,late 2001 had severe consequences

despite considerable challenges and difficulties that programs to diag-

for the country’s civilians.

nose and treat people with the disease are not only needed, but possible.

Extreme financial hardship made it difficult
for many people to pay for medical care.
The public health system went from providing care to 30 percent of the population
to assisting up to 70 percent (many ofwhom previously had been covered by private insurance). While demand at all healthstructures increased enormously, supplies
dwindled and health staff could not meetthe ever-growing needs.

MSF has been treating people with Chagas disease in Bolivia’s O’Connor

The Tarija region was chosen because of its particularly high prevalence(28 percent among children under 14), the lack of health care available
and the presence of a government program that methodically tracks andkills the insects responsible for the disease’s transmission. Controllingthe number of insects, and in the long term, their eradication is essential
for treatment to be effective as there is no vaccine against Chagas. Even
those who are recovering from it can be easily re-infected if no control
and surveillance activities are taking place.

MSF started a project in 2002 to provide
basic medical supplies and medicines tohospitals in the country’s northern region –historically one of its most disadvantaged
areas. MSF assisted hospitals in the Salta
and Jujuy provinces and in 2003 also aided
facilities in the Formosa and Chaco provinces. MSF donated medicines and medical
supplies to the hospitals and helped manage pharmacies until December 2003. The
project concluded at the end of 2003.
In May 2003, heavy rainfall caused floods
affecting more than 110,000 people living
in Santa Fe province. For two months after
the disaster, an MSF team provided emergency help to improve shelter and increasewater and sanitation facilities. The teamalso monitored the area for disease outbreaks.
MSF worked in Argentina from 2001 until
2003.

MSF’s project includes information, education and communication for the general
population and for key groups including
health personnel and teachers. It also
involves active screening of newborns andblood donors in the hospital and for children between 9 months and 14 in the community. Children who test positive for the
disease are treated with the drug, benznidazol. The drug, nifurtimox, is used asa second-line treatment for those who
cannot tolerate benznidazol. Both drugs
were discovered during veterinary research
conducted in the 1970s. Because of thepossible side effects, children getting
treatment are followed weekly at healthcenters or schools and whenever needed.
At the end of 2003, 89 percent of thetargeted children had been screened and aprevalence rate of 20 percent was found.

62 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2003/2004

Sixty-one percent of the newborns
delivered in the province’s hospitals werescreened and no positive cases were identified. Prevalence among blood donors wasfound to be 25 percent. MSF has treatedhundreds of people with the disease since
the project started.
MSF’s experience in Bolivia underlines therelevance of diagnosis and treatment in
the framework of a global approach to
Chagas disease. Prevention activities,
including information and education, need
to be included within Chagas programs
and all activities should be performed
within primary health care systems under
the supervision of a hospital physician.
Further, congenital protocols need to beadapted to rural contexts where hospitaldelivery is rare. MSF is now asking theThe Americas
effect on access to medicines for millions
of people living in the country and theAndean region.
Under current trade conditions, if a new
drug for Chagas were developed, theBolivian government would be able toissue a compulsory license to overcome
the patent barrier and produce the drug
locally. (A patent allows only the company
holding it to produce the medicine andprofit from it. A compulsory license enables
others to produce the medicine, usually ata much lower cost, while paying a compensatory fee to the patent holder.) This ability
would be lost if Bolivia signed the free
trade agreement with the US, because the
US wants to limit dramatically the circumstances under which compulsory licenses
can be issued. It would also affect the availability of generic drugs by reducing competition in the market. This could lead to amonopolistic situation with devastating
effects for access to treatment, making the
drug unaffordable for the majority of the
Bolivian population, the poorest on thecontinent after Haiti.

© MSF

Providing emergency assistance

Bolivian national Chagas program to prepare and implement a protocol for diagnosis and treatment and to create a systemfor case notification and drug surveillance.

Focusing on a neglected disease
Chagas is a neglected disease – there is virtually no research being done to develop a
new and effective drug to treat those
infected with it. The reason? There is no
profit to be made from drugs that treat thepoor. MSF doctors have witnessed the lackof life-saving medicines and diagnostic
tools available for Chagas. This “empty
pipeline” is a direct consequence of thelack of research aimed at finding less toxic
and more eﬀective drugs that would enable
Chagas patients of all ages to receive better treatment. Today MSF is doing everything it can to ensure Chagas is recognized

as an international public health risk, butthere is a long way to go before new drug
treatments become available. MSF is also
working with the newly established Drugs
for Neglected Diseases Initiative to findpotential new drugs to treat this disease
and thereby circumvent the lack of interest
shown by the pharmaceutical industry.

MSF also provides emergency assistance in
Bolivia. In January 2004, torrential rains
flooded the town of Trinidad, the capital of
Beni province. Floods affected nearly
40,000 people – more than half of thetown’s population – and approximately
12,000 people had to be evacuated. MSF
aided those taken to temporary shelters,
donated medicine and organized waterand sanitation facilities. The MSF team also
worked closely with local health authorities
to strengthen the existing epidemiologicalsurveillance network.
MSF has worked in Bolivia since 1987.

MSF teams in Bolivia are actively raisingconcerns related to access to essential
medicines and treatments at the national
level, particularly those involved in the current negotiation of a free trade agreement
between Bolivia and the United States. In
May 2004, MSF urged the Bolivian government to exclude intellectual property provisions from the US-Andean free tradenegotiations. MSF remains concerned that
their inclusion will have a devastating

ACTIVITY REPORT 2003/2004 MEDECINS SANS FRONTIERES 63

I N T ER NAT I O NA L S TA FF 4 0
NAT I O NAL S TAFF 133

BrazilColombia© Patricia Rincon Mautner© Fabrizia Granatieri

The Americas

I N T ER NAT I O NA L S TA FF 3
NAT I O NAL S TAFF 4 8

A homeless man brushes his teeth at the MSF clinic in Rio de Janeiro. MSF has been working with the city’s homelessaiming to improve their living conditions and ability to obtain health care and social services.

Aiding women, children and the homeless
Vulnerable groups living in poor sections of Rio de Janeiro, thesecond-largest city in Brazil, are the focus of MSF’s current workin this country. Since July 2003, MSF has been running a primary
health center in Marcílio Dias, an impoverished community in thenorthern part of the city.
The center provides care for the community’s 10,000 people, who live in poor
conditions with limited access to healthcare or social services. MSF’s project targets
women, children and the elderly. The teamoffers consultations on a daily basis, provides medicines and promotes preventive
health. Each month, approximately 1,500
people consult the clinic. A recent vaccination campaign against poliomyelitis undertaken by MSF staff reached all 784 children
in the Marcílio Dias community.
MSF has created discussion groups inwhich residents can talk about their problems, addressing issues such as health,violence and early pregnancy. The team iscomposed of medical doctors, nurses, a
psychologist, a social assistant, an educator, and a group of six local community
health agents who visit families on a regular basis to help prevent problems. Anothergroup of women from the community workas volunteers to establish links between
the families and the MSF center, mainly
through psychosocial activities.

MSF also provides social, medical and psychological assistance to adults living on
the streets of the city’s downtown andCopacabana neighborhoods. A multidisciplinary team of a doctor, nurse, social
worker and psychologist offer help tothose who live or depend on the streets tosurvive. More than 1,000 people havereceived care from the team since July2003.
MSF also carries out advocacy efforts withgovernment authorities and within civilsociety. For example, in an effort to minimize the prejudice and stigma encountered by the homeless, the team has developed a photo exhibition that illustrates
their stories, difficulties, needs and expectations. In addition, MSF is doing advocacy
work to stop local authorities from carryingout a “clean-up operation” in which the military police, employing a garbage truck,
forcibly remove street people’s belongingsfrom the places where they are kept.
MSF has worked in Brazil since 1991.

64 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2003/2004

Caring for those isolated
by warIn Colombia, decades of protracted violence have made conflict a daily reality forcivilians. Each day, people are killed,wounded or forced to flee their homes, orthey simply “disappear”. Trapped amid thisunending war, many rural dwellers facerestrictions on their movement caused by
nearby violence or the fear that they will
be seen as sympathetic to one of thearmed groups. At the same time, many
health professionals are reluctant to provide care in isolated areas for fear that military groups might target them.
MSF attempts to break through this isolation by running mobile clinics that provide
medical and mental health care to people
who desperately need it. MSF’s presence insuch harsh locations, rarely visited byauthorities or other international organizations, also brings some psychological relief
to those forced to live amid chronic violence.
MSF’s mobile-clinic teams provide basic
medical consultations, deliver essential
drugs, treat mothers and children, giveindividual and group counseling and evenperform dentistry. MSF also addresses
water and sanitation needs. The mobileclinic teams are composed of international
and local doctors and nurses, a psychologist, a dentist, logisticians and drivers.

The Americas

I N T ER NAT I O NAL S TAFF 26
NAT I O NAL S TAFF 132

GuatemalaIn some areas of the country, where healthfacilities do exist, the profit-based healthsystem excludes displaced or vulnerable
people. In addition, fierce political tensions
make it dangerous for some people to register for health care. Because being associated with particular territories imply loyalty to certain armed groups, some people
fear that by providing detailed personal
data they could be inviting the armed
group from which they fled right to theirdoor. Therefore, in a country where no one
is outside of the conflict, many displaced
civilians remain reluctant to use the healthsystem.
In urban areas such as Quibdó, MSF has
persuaded local authorities to stop charging consultation fees for civilians not yet
registered with the public health system.
The team also helps people navigate thebureaucratic registration process, whichmust be completed before an individual
can obtain medical care. Since 2000, MSF
has been working near Bogotá, the capital,in the Soacha district, which is home toone of the country’s largest reception
centers for displaced people. Each week
newly displaced families arrive from allover the country. To assist them, MSF
operates a health post that provides
medical care, nutrition for malnourishedchildren, and sexual and reproductive
health care. The team also refers victims ofdomestic violence to other care givers.
After six years of activity in Cali, Colombia’s
third largest city, MSF is handing over its
violence-prevention project to local healthauthorities. The project assists victims ofurban violence in the Aguablanca district.
Since its creation in 1998, MSF has carriedout 34,000 consultations and treated 2,700
victims of urban violence and members of
their families.
MSF has worked in Colombia since 1985.

Promoting generics and helping street children
Approximately 67,000 of Guatemala’s 14 million people are HIV-positive and 4,800 of them are children. More than 7,500 people havealready developed AIDS and are in need of immediate treatment.
Today MSF staff give nearly 1,100 patients life-extending antiretroviral(ARV) medicines in two Guatemala City hospitals, and health centers in
Coatepeque and Puerto Barrios.
Getting treatment to those who need it is
not easy, though. A number of legal
obstacles and heavy US pressure for
Guatemala to sign the US-Central American
Free Trade Agreement (CAFTA) will limit theavailability of medicines to fight AIDS aswell as other diseases like Chagas. Since
ARV medicines are not under patent in the
country, MSF had been able to treat people
with generic medicines, which are 75-99
percent cheaper than the brand-namedrugs bought by the government. But inJuly 2003, the government introduced legislation that will limit the use of generics,
block the entry of inexpensive treatments
and harm local medicine production. The
recently signed CAFTA includes excessive
levels of intellectual property protections
that will restrict access to essential medicines throughout the region. Guatemalangroups and MSF have urged the
Guatemalan congress to repeal the July
2003 decree, and insist that intellectual
property provisions in CAFTA not go
beyond pre-existing World Trade
Organization agreements. Removing
obstacles to generics and improving
access to quality medicines will help savethousands of lives in Guatemala.
Since 1999, MSF has run a project inGuatemala City that provides free healthcare and psychological counseling to morethan 700 street children and young adults,
some of whom have been living in thestreets for a decade or more. There are highsuicide and substance abuse rates among
the street kids. MSF psychologists and educators help them on a daily basis, providing
basic health care, accompanying them tohospitals and providing counseling to
improve their self-esteem. The team works
alongside members of the street community to raise awareness of the misery ofstreet life with the aim of relieving the discrimination many street kids face from© Thierry Buignet

They visit sites in the departments of Nortede Santander, Tolima, Sucre, Bolivar,
Córdoba, Caquetá and Nariño. Their rounds– made by car, boat, mule or on foot – enable tens of thousands of people to obtainbasic health care. For many, MSF is the sole
health care provider.

authorities and public services.
The therapeutic day care center in Lomasde Santa Faz, a slum on the outskirts ofGuatemala City, provides medical and psychological care for children coping withthe consequences of chronic domestic violence and neglect. These children, whoseparents were displaced during years of civil
war in Guatemala, suffer from malnutrition,
physical or sexual abuse and developmental problems. The project, unique in
Guatemala, includes a nutrition program,a variety of psychological and social therapies for the children, and offers parents
counseling to help them learn to protect
and nurture their children. MSF will handover this program, started in 1996, to a
local NGO this year.
MSF has worked in Guatemala since 1988.

ACTIVITY REPORT 2003/2004 MEDECINS SANS FRONTIERES 65

The Americas

I N T ER NAT I O NA L S TA FF 12
NAT I O NAL S TAFF 16

I N T ER NAT I O NAL S TAFF 10
NAT I O NAL S TAFF 82

Ecuador

Haiti

More than half of Ecuador’s inhabitantscannot obtain proper medical care – aproblem made more dire by the spread of
HIV/AIDS. Approximately 40,000 of thecountry’s people now have the virus, andmost of them cannot obtain treatment. The
combination of insufficient resources, aninadequate number of qualified staff andlimited political will impede the development of comprehensive HIV/AIDS programs throughout the country.
In January 2004, MSF launched a project toimprove care for people with HIV/AIDS in
Guayas province, an area deeply affectedby the virus. Each month, the MSF teamseeks to treat 10 new adult patients and 6
children with antiretroviral (ARV) medicines, as well as provide treatment to all
HIV-positive pregnant women in the area
to prevent mother-to-child transmission of
the virus. The ministry of health has asked
MSF to help develop a system to cope withthe treatment needs of people living with
HIV in Ecuador.
In addition to providing direct patient care,
MSF is working proactively at the national
level on policy issues related to access to
medicines and treatment. For example,
MSF is urging the government to use lessexpensive generic medicines at a time
when Ecuador buys brand-name ARVs at amuch higher cost. Another main area ofconcern involves the negotiations on aregional free trade agreement between
Ecuador, Colombia, Bolivia, Peru and theUnited States. MSF is worried that thisagreement will have a devastating effecton access to medicines for millions ofpatients in the Andean region.
MSF also runs a sexual and reproductive
health program in a neighbourhood of
Guayaquil, Ecuador’s largest city. The program started in the slum of Flor de Bastionin April 2002 with the objective of making
quality sexual and reproductive health careservices available to this excluded area’s
inhabitants, especially teenagers. The MSF
staff provide counseling and care related
to family planning, prevention of sexuallytransmitted infections and HIV/AIDS, andeducation on sexual and reproductive
health.
MSF has worked in Ecuador since 1996.

© Olga Ruiz

Getting care to those
who need it

Assisting victims of violence and flooding
When civil unrest broke out in Haiti in early
2004, MSF teams who were already working there began providing emergency
medical care. In February, MSF started
running emergency rooms at the SaintFrançois de Sales Hospital in the capital,
Port-au-Prince, and at Saint Nicolas
Hospital in Saint Marc, providing free medical care to those wounded in the fighting
or during demonstrations.
Heavy rains in May 2004 resulted in severe
flooding in villages located near the border
between Haiti and the Dominican Republic.
The water devastated an already poor
region destroying houses and crops andkilling hundreds. MSF organized helicopter
emergency evacuations from the region to
Port-au-Prince, where victims received
medical treatment in Saint François de
Sales Hospital. In the flooded region, MSF
focused its medical activities on the southern coastal area between the town ofJacmel and the border with the Dominican
Republic. MSF treated the most urgent cases
at a health center in the village of Ford
Verrettes and donated a basic emergency
kit for 1,000 people. In the town of Mapou,
the team set up a base in a school and conducted more than 100 medical consultations a day in the period immediately after
the flooding. For the next two months, theorganization operated a dispensary there,
providing free medicines. In addition, MSF
offered psychological counseling to thosetraumatized by the disaster and started
running mobile clinics in Bodarie, Grand
Gosier and Thiotte.
Though these recent crises briefly focusedworld attention on Haiti, the health situa-

66 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2003/2004

tion in this tiny country might well be considered its own emergency. Women in Haiti
have a significant chance of becoming ill or
dying while pregnant or when giving birth.
Therefore, most of MSF’s ongoing activities
have focused on ensuring proper care forpregnant women and improving delivery
conditions in the district of Artibonite.
Since 1994, MSF has provided nurses anddoctors as well as supplies to Saint Nicolas
Hospital in Saint Marc, part of a Communal
Health Unit comprised of an estimated240,000 people. Because the unit now has
qualified medical staff and the necessary
equipment, MSF handed over the project’s
activities to local health authorities inAugust 2004.
In another part of Artibonite, MSF staff
members continue to work in the communes of Petite Rivière, Jean-Denis andSegur, providing care to a population of
about 90,000 people. Teams carry out medical consultations at three health facilities
and work with local health authorities toimprove maternal health. MSF built amaternity care facility in Petite Rivière.
Haiti is a country that experiences frequent
natural disasters including hurricanes,
tropical storms and floods. MSF has createda special quick-response evaluation teamcomposed of a Haitian doctor and logistician, based in the capital, to assess whether
or not MSF can play a role when emergencies or disasters strike the country. This
team oﬀers MSF a way to respond extremely
quickly to disasters without disrupting
the organization’s ongoing work in the
country.
MSF has worked in Haiti since 1991.

The Americas

I N T ER NAT I O NAL S TAFF 7
NAT I O NAL S TAFF 35

Honduras

MexicoHelping those livingwith HIV/AIDS

Changing care to fit current needs

Honduras is home to 60 percent of thepeople living with HIV/AIDS in Central
America. For this reason, in August 2001,
MSF set up a clinic in the town of Tela,located in northern Honduras, to offer
complete treatment for opportunistic
infections that often manifest in HIVpositive people. MSF also began prevention efforts, counseling, patientmonitoring, prevention of mother-to-childtransmission of the virus and community
visits. In July 2002, these efforts were
supplemented by the use of life-extending
antiretroviral (ARV) treatment. By June
2004, 200 people were receiving ARVtherapy through MSF’s program.

improving military and political situation in the country’s southern

This project was started within the framework of MSF’s campaign to increase accessto essential medicines for people living inpoor countries. MSF’s initiative was a firststep in demonstrating that it is possible to
make progress against AIDS in a country
such as Honduras. Other actors, including
the Honduran government and the Global
Fund on AIDS, Malaria and Tuberculosis,
have now promised nearly US$45 million
to provide care and treatment for thosewith the disease. With funding available
and adequate political will and staff
present to implement the program, MSF is
now handing over its HIV/AIDS activities tolocal health authorities.
In addition, MSF is exploring the needs ofpoor, homeless children living in violenceridden areas of the capital, Tegucigalpa. By
conducting qualitative and quantitative
research, the organization plans to better
define and respond to the needs of theseneglected children.
MSF has worked in Honduras since 1998.

During the past year, MSF reviewed its activities in Mexico due to theChiapas state. MSF had been providing basic health care to civilians
living in Zapatista-controlled areas for years.
With military fighting ending and thestruggle becoming a political one instead,
MSF decided to close its programs there as
the Zapatista “conflict” no longer resulted
in urgent civilian health problems. Before
its closure in mid-2004, MSF had beenusing mobile clinics to give basic healthcare and hospital referrals at ten sites within Chiapas’s Las Cañadas region. In addition, the team had trained a network ofhealth promoters and vaccinated children
living in the clinic areas. In the program’s
last few months, MSF followed up on theremaining medical needs and trained local
health promoters who would continue
activities after MSF withdrew.
During 2004, MSF gave extra attention to
the need to improve treatment for marginalized groups suffering from neglecteddiseases including Chagas disease(American trypanosomiasis). Chagas is aparasitic disease transmitted by an insect’s
bite. Once in the blood stream, it attacks
the heart and digestive organs, often
resulting in early death. In most cases, it is
impossible to diagnose the disease clinically and so it is often overlooked. In
Mexico, an estimated two million people
are infected. However, Mexico stands alone
as the only Latin American country lacking
a comprehensive national program to fightthe disease and help those infected. The
problem is bigger than this. Because
Chagas disease almost exclusively affects
the poor, efforts to develop medicines totreat those with the disease have beenminimal. Treatment is only possible for children, otherwise the risk of serious side
effects is high and treatment too often
ineffective. Even among children, the curerate is not better than 70 percent.

not high rates of infected people in thestudied areas. However, the team will
provide care for those found to have thedisease during the exploratory researchphase. MSF will also carry out health promotion activities in the exploratory areas
and encourage policy change to get thedisease recognized at a national level.
Furthermore, MSF’s involvement with a
network of individuals and groups working
on Chagas disease is expected to help
advance the momentum to formulate anational or regional strategy to improve
care for those with Chagas in Mexico.
In May 2004, MSF staff investigated thehealth problems facing undocumented
immigrants traveling along the
Guatemalan border. This activity was triggered by reports of attacks carried out byorganized groups against undocumented
immigrants trying to enter the country.
However, because others are already providing emergency aid to this high-risk
group and the government seems to berespecting the rights of immigrants withsevere medical needs, MSF did not intervene. MSF also undertook exploratory missions following an earthquake in Colima
and severe flooding in Tuxtla. MSF plans to
end its work in Mexico at the end of 2004.
MSF has worked in Mexico since 1997.

MSF launched an exploratory mission in
Chiapas to look at the prevalence of thedisease and transmission rates to determine if there was a need to launch a newprogram to help those with Chagas. The
exploratory mission found that there were

ACTIVITY REPORT 2003/2004 MEDECINS SANS FRONTIERES 67© Kadir van Lohuizeng

I N T ER NAT I O NA L S TA FF 7
NAT I O NAL S TAFF 37

The Americas

I N T ER NAT I O NA L S TA FF 6
NAT I O NAL S TAFF 52

I N T ER NAT I O NAL S TAFF 6
NAT I O NAL S TAFF 42

Nicaragua

Peru

Focusing care on women’s
health and Chagas disease
Poverty and unhealthy living conditions contribute to a vicious
cycle of early pregnancy, maternal
morbidity, infectious disease andother illnesses and preventable
deaths among women and otherTo combat these problems, MSF
focuses on women’s health andneglected diseases.
During 2003 and until June 2004, MSF continued its sexual and reproductive healthproject in Ciudad Sandino, a shantytown
on the outskirts of the capital, Managua.
With high levels of adolescent pregnancy
and maternal death following unsafe abortions, MSF’s project aimed to improve thelevel of reproductive health care for thiscommunity. Special attention was given to
pregnant women, postpartum mothers andtheir babies, adolescents and commercial
sex workers. The staff provided prenatal
and postpartum care, offered advice onfamily planning and treated sexually transmitted diseases. The MSF team also supported three health posts and one healthcenter and worked with a community
health worker network in four parts of thisshantytown.
In northern Nicaragua, MSF is treating
patients with Chagas disease (American
trypanosomiasis) around the municipalityof Esquipulas in Matagalpa province, where
almost 30 percent of the population is estimated to be infected. The project targets
8,000 children under 15 and focuses on
prevention and treatment as well as on
improving access to good-quality diagnostics and treatment. As part of its international campaign to increase access toessential medicines, MSF is also advocating
for national institutions to improve Chagas
control and access to diagnosis and treatment.
MSF has worked in Nicaragua since 1983.

© MSF

vulnerable civilians in Nicaragua.

An MSF volunteer prepares to give medication to an AIDS patient during a home visit in Peru while
the children in the family watch.

Helping those affected by violence
Domestic violence, a hidden but common problem in Peru, is often
underestimated among the children and adolescents living in urban
slums. Recognizing the enormous human cost of such violence, MSF
has developed a program of workshops and trainings in the slum of
Villa El Salvador that aims to empower children and adolescents and to
improve their potential to succeed despite their violent childhoods. By
developing protective mechanisms, learning about healthy relationships and understanding the need for resilience, the program’s beneficiaries gain the confidence needed to escape the cycle of violence surrounding them.
Expanding AIDS-related care
Although health conditions in Peru continue to improve, many of the nation’spoorest people still cannot obtain care.
An estimated 76,000 people live with HIV/
AIDS, and very few of them have access toaffordable treatment. In 2003, MSF focused
its activities on HIV/AIDS, with programs in
Villa El Salvador, a slum on the outskirts ofLima, the capital; and in the Lurigancho
prison. In the prison, MSF staff carry out
more than 1,600 medical consultations
each year, mostly involving care of people
with sexually transmitted infections andopportunistic infections related to HIV/
AIDS. While awaiting permission from
authorities to begin an antiretroviral (ARV)
drug treatment program, MSF undertook
awareness-raising activities, home-care visits and outpatient consultations to treat

68 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2003/2004

opportunistic infections in HAMA Hospital.
Due to bureaucractic delays, the first 20
patients started receiving ARVs in August
2004.
MSF also spoke out on issues related toaccess to essential medicines – access thatis threatened by current free trade negotiations between Peru and the United States.
MSF emphasizes that a number of generic
medicines, including ARVs, are available
today for people living with HIV/AIDS but isconcerned that the new trade agreement
may undermine this situation for all future
treatments and force people to buy more
expensive, patented drugs.
MSF has worked in Peru since 1985.

© Layla Aerts

Europeand theMiddle East

A family enters the MSF health center in Brussels, Belgium which offers free basic
health care to people who do not have access to it.

ACTIVITY REPORT 2003/2004 MEDECINS SANS FRONTIERES 69

BY C AR LOS UG AR T E , H E AD O F M ISSI O N FO R MSF’ SPR OJ EC T S I N SPA I N“ We were about to go to bed when we heard
screaming and shouting…. We thought it must
be loads of people drowning at the point! We
ran over there and they were clinging onto alarge rock. There were about seven or eight ofthem. In the time it took us to get to our boatand return, several of them had already fallen
off…. We managed to save five of those stillon the rock. The sea swept the others away.
The ones we pulled out were almost dead withexhaustion. The rest we found with the lanternby their shouting. It sounded like a turkey farm,with all the screaming. The howling and wailing
was pitiful. Some others came barefoot… theirfeet shattered and dripping with blood. They
were crawling to the huts. We gave them someclothing and hot milk and biscuits and they
were so grateful, hugging us, asking us for ouraddress to write to us some day. I gave one ofthem my shirt, I felt so sorry. And my friend
gave his to another. It was a terrible night.
A young boy from Kenya told me that there
were 29 of them. The next day I passed bythere and they were recovering 11 bodies
from the bottom of the sea. Only 18 survived.”

Undocumented Algerian immigrants are rescued by the Coast Guard off
the coast of Lampedusa, Italy.

This dreadful episode is only one of the many stories
that can be heard along the southern coastline ofEurope these days. While the setting may change,
the human drama is always the same. In 2003,
19,500 north African, sub-Saharan and Asian immigrants arrived in such appalling conditions in Spainalone. Hundreds more died before reaching its
shores. Some European governments do not officiallyrecognize the problem and offer little or no assistance to these immigrants. Help only appears in theform of spontaneous aid given by sympathetic local
residents like Spanish fisherman Juan Rodríguez.

© Espen Rasmussen© Francesco Cocco

Helping immigrants
at Europe’s door

– Juan Rodríguez, a fisherman from the island of
Fuerteventura (Spain) recalling the night a small ship
wrecked near Gran Tarajal. Testimony published in
La Vanguardia Magacine (Spain), 13 June 2004.

70 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2003/2004

A Sudanese refugee living in the Tiburtina train station in Rome, Italy.

After a grueling 20-hour crossing from Africa, ill immigrants arrive in Fuerteventura,
Spain.

“... The next day I passed by there and they
were recovering 11 bodies from the bottomof the sea. Only 18 survived.”

In the past few years, MSF teams working on the beaches
or in immigrant reception centers have seen more andmore undocumented immigrants arrive at the edges ofEurope. This desperate group is part of a growing waveof economic and political immigration to Europe whichshows no signs of slowing. Countries such as Morocco,
are a common transit point for refugees from Africa,
while Spain and Italy receive thousands of immigrants
along their beaches each year. The path continues into
France, Belgium, Switzerland, Holland and the United
Kingdom where immigrants ultimately try to settle andwork. All of these countries and more play a part in thecurrent immigration drama and each has a large number of
undocumented immigrants and asylum seekers trying to survive
within its borders. MSF’s work with this vulnerable group aims toensure that immigrants obtain quality medical care and information at a time when they most need it.
MSF assists immigrants and asylum seekers in places where
authorities refuse to shoulder their responsibilities for them. Our
objective is to alleviate the suffering of populations in vulnerable
situations. For this reason, our work is not only limited to giving
people the medical attention they need. MSF is also denouncing theinhumane manner in which many undocumented immigrants aretreated. By speaking out on the conditions we witness for immigrants arriving in France or in Tarifa, Ceuta and Fuerteventura,
Spain, to name but a few, MSF hopes to help provoke needed political action and legislative change to improve the situation for new
arrivals.

© Juan Medina

A lack of political response

The team in Belgium also assists immigrants whose serious illness
would make it dangerous for them to return to their country oforigin. With the help of its field missions, staff in the Belgian
health centers can provide documentation on the quality of careavailable in specific home countries. This can help immigrants
avoid being repatriated to a country where their illness cannot betreated adequately.

Promoting a humanitarian approach
There have been some humanitarian successes along the way. MSF
closed its project in Fuerteventura after the Spanish government
finally committed (after an intense denunciation and lobbying
campaign) to take responsibility for providing medical attention
to the immigrants arriving on its coast. Similar commitments haveenabled MSF to end projects in the Spanish port of Tarifa, inAndalusia, and Ceuta, on the coast of northern Africa.

Aiding a vulnerable group
Immigrants do not only face problems at points of entry into
EU territory. If able to slip through this initial net, an immigrantlacking identification papers will join the growing ranks of theillegal immigrant workforce, and may be subjected to exploitationin the underground economy. These individuals are extremely vulnerable, given their lack of recognition as citizens. They are prime
targets for economic and physical abuse and have no legal protection. Many of them also lack medical care.
MSF’s experience in Belgium demonstrates this troubling trend.
After conducting 10,000 medical consultations in MSF clinics
based in three Belgian cities during 2003, our teams concluded thatthe national health care system does little for undocumented
immigrants and is hampered by complexity, incoherence and compounded by a lack of will to reform. While the Belgian health caresystem proports to provide care for everyone in the country,
undocumented or otherwise, the reality is that red tape, hidden
costs and incoherent policies keep thousands of people outside ofit. Many of them are undocumented immigrants and asylum
seekers who have few other options for medical care. To help curbthese effects, MSF’s three Belgian clinics offer free care to those
who need it. MSF staff also try to arrange care for people throughthe official health care system. To date, 70 percent of the Belgian
clinics’ patients come from outside the European Union.

However, these small victories are the exception. Outrageous
treatment and rights violations happen every day. For example, inJune 2004, a group of people arriving by boat on the Sicilian islandof Lampedusa, were detained for three days in a reception center.
They were then transferred to another location, where they wereforced to sign expulsion orders without understanding what they
were signing. Among them was an 18-year-old student, Haysam,
who was f leeing the violence of his home region, northern Darfur,
Sudan. Haysam told MSF how he had f led to save his life in
November after his village was attacked and his father and two
brothers were murdered before his eyes. After traveling for six
months to get to Europe, he planned to seek asylum and start a newlife. However, after being detained for three days in Lampedusa
without access to information, translation, legal advice or medical
attention, he signed his own expulsion order. Authorities may now
decide to return him to the horror he tried to leave behind.
At the gateways to Europe, MSF will continue to provide emergency
care to immigrants. From a medical and humanitarian perspective,
MSF will keep on fighting so that these immigrants and asylum
seekers become informed about their rights and can easily accessrequired medical care. MSF believes all immigrants deserve to betreated in a decent and humane way.

ACTIVITY REPORT 2003/2004 MEDECINS SANS FRONTIERES 71

EuropeI N T ER NAT I O NA L S TA FF 27
NAT I O NAL S TAFF 0

I N T ER NAT I O NA L S TA FF 3
NAT I O NAL S TAFF 2 5

Belgium

Bulgaria

Providing care to thedisadvantaged
Belgium is one of the mostdeveloped countries in the worldand has a sophisticated healthcare system. However, real accessto care is often denied to undocumented migrants and asylum

MSF’s work in Belgium focuses on increasing access to health care for the disadvantaged and most vulnerable part of the population. At present, undocumented
migrants, asylum seekers and other disadvantaged people may obtain free medicalcare at MSF clinics in Antwerp, Brussels andLiège. During 2003, clinic staff carried out
10,000 consultations with 4,500 patients.
Four percent of the patients were nativeborn Belgians and 70 percent came fromcountries outside of the European Union.
Since 1998, MSF has also operated the Elisa
Center, which provides free, voluntary andanonymous HIV testing. Because the risk ofstigmatization remains high, this center
also offers confidential counseling.
In recent years, MSF has been asked by several patients with serious illnesses to provide documentation on the quality of careavailable in their home countries. MSF provides this information to help immigrants
avoid being repatriated to a country where
their illness cannot be treated adequately.
MSF recently coordinated and systematized this information for more general use.
Today a patient may fill in a form to request
such information, and MSF, with the support of its field missions, can provide clear
information about the medical situation in
the country in question.
MSF offers assistance to the Rwandan population now living in Belgium – the majority of whom fled Rwanda during the 1994
genocide. Through a project known as“Mpore” (meaning “Get up” in the
Kinyarwandan language), MSF provides
psychological assistance to Rwandans traumatized by the genocide. Mpore carries
out therapy in the form of peer group discussions and individual sessions.
MSF has worked in Belgium since 1987.

© MSF

seekers.

MSF provides training sessions at the sexual health clinic in Sofia.

Helping Romas get care
Increasing access to treatment is the aim of MSF’s work within thelarge Roma community in the capital city of Sofia. In June 2003, MSF
began to work in a primary health care center in Sofia’s Fakulteta area,
which is home to many Romas. Today, six general practitioners oversee
health care for a population of about 20,000 people.
In May 2004, more than 7,000 patients(including 1,000 children under the age offive) had registered with these doctors. In
order to encourage people to consult
health services, MSF employs five community outreach workers. They promote theclinic, help register patients, and refer othersocial problems to the relevant institutions.
In August 2003, Bulgarian health authorities determined that only 40 to 60 percentof the children in Fakulteta had all of theirrequired vaccinations. MSF started a “catchup” campaign in collaboration with local
authorities to vaccinate vulnerable children
against diphtheria, pertussis, and tetanus(DPT), polio and measles between Marchand June 2004.

Improving sexual health care
MSF also runs the diagnostic, treatment
and prevention center known as Maïchin
Dom (center for sexual health), located in auniversity hospital in Sofia. The center’s
staff members provide treatment for sexually transmitted infections (STIs) and work

72 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2003/2004

to help prevent HIV/AIDS. The very poor –a group considered most vulnerable for
STIs and HIV – receive medicines free ofcharge to ensure that they do not go without treatment. The center is also increasing
its health education activities in schools.
MSF began making rounds with a mobile
clinic in September 2003 to reach marginalized residents of Sofia who do not visit
the center. Every week the clinic visits four
different locations within the metropolitan
area. The team offers immediate treatmentof acute STIs, information and education
on safe-sex practices and STI prevention,and voluntary HIV testing and counseling.
Most patients are commercial sex workers
and intravenous drug users.
The center’s STI program has been replicated in the city of Plovdiv. A clinic in
Plovdiv University Hospital has been rehabilitated by MSF and Bulgarian medical andparamedical personnel now carry out
activities related to treatment and prevention of STIs.
MSF has worked in Bulgaria since 1997.

I N T ER NAT I O NA L S TA FF 0
NAT I O NAL S TAFF 35

FranceItaly

Helping those excluded from care
At the end of December 2003, the French government narrowed theAssisting vulnerable
refugeeseligibility criteria for its state medical aid program, better known as

Italy’s economic growth and its

AME (Aide Médicale d’Etat). AME was created to help the estimatedstrategic position on the Mediter-

150,000 economically disadvantaged people residing in France who

ranean Sea have made it a prime

lack residency permits to obtain needed medical care.

destination for immigrants from

EuropeI N T ER NAT I O NA L S TA FF 0
NAT I O NAL S TAFF 41

other lands.
Yet the modifications to AME effectively
ended their immediate access to the system and to free medical care. Many medical and social organizations, including MSF,
have advocated strongly against thesechanges in AME and in the related universal sickness coverage system called CMU(Couverture Maladie Universelle). An MSF
petition demanding better health coveragefor undocumented residents gathered
more than 100,000 signatures.
In June 2004, six months after the AME
reforms were introduced, teams from MSF
and other France-based medical NGOs
released testimonies describing the new
system’s harmful effects on undocumented
residents. These accounts included stories
of people forced to use already overburdened hospitals for non-emergency treatment. The testimonies also told of people
arriving at hospital emergency rooms withserious illnesses because they waited much
too long for treatment. Statements by thehealth minister of France suggesting thataccess to AME would be re-established for
undocumented migrants in need of urgent
medical care have not been put into effect.

Before these new restrictions came into
effect, the coverage granted by AME andCMU enabled MSF to close a number of the
medical/social-service centers it had set up
in the city of Marseille in southern France.
MSF teams working at these centers had
been assisting the most vulnerable people
in French society. MSF also ran shelters in
the cities of Lille and Colmar (the latter inpartnership with another organization) tohelp young people in extremely precarious
situations. A team also started a program
to help immigrants in Marseille to demand
their legally entitled social benefits.
Today, MSF continues to provide care fordrug-addicted individuals living in the capital, Paris. The organization also operates
two medical/social-service centers, one in
Paris and the other in Marignane (Bouches
de Rhône), where local residents canobtain medical consultations and help insecuring the care to which they are legally
entitled.
MSF has worked in France since 1987.

© Espen Rasmussen

Sudanese refugees who attempted to escape the violence in their own country found themselves living in Rome’s
Tiburtina train station for months amid very poor conditions.

Yet the current government’s immigration
policy severely limits the number of immigrants able to receive legal status andremain in Italy.
In 2003, MSF worked with the national
health system in Rome, Sicily and
Lombardy to push for implementation of alaw that enables immigrants lacking identification documents to receive medical care.
Because of its location, Sicily is the point at
which boat refugees most frequently landin Italy. Many are fleeing conflict or otherdangerous situations in their home countries and risk their lives in crossing theMediterranean Sea. On Lampedusa, a small
island south of Sicily, an MSF nurse provided
medical care at the reception center set up
to help newly arrived refugees. From
September 2002 until December 2003, MSF
assisted more than 10,000 people at thecenter. MSF also offers emergency medical
aid to refugees arriving on Sicily’s southerncoast. An MSF mobile unit remains on
standby 24 hours a day so that the teamcan provide aid and explain Italy’s immigration policy to newly arrived immigrants.
In addition, approximately 400 asylum
seekers sought shelter in the rundown
Tiburtina train station in the center ofRome. They were refugees from Sudan,
Ethiopia, Eritrea and other African countries, living in Italy. Facilities at the station
were terrible with no running water, electricity or heat. In October 2003, MSF beganproviding medical care to these asylum
seekers. The team also participated in an
advocacy action calling for a permanent,
humane solution to this dire situation. The
action coincided with the reconstruction of
the station, whose owners started to evict
all of the asylum seekers in August 2004.
City authorities have now relocated all ofthem to other locations in Rome.
MSF has worked in Italy since 1999.

ACTIVITY REPORT 2003/2004 MEDECINS SANS FRONTIERES 73

EuropeI N T ER NAT I O NA L S TA FF 0
NAT I O NAL S TAFF 4

I N T ER NAT I O NAL S TAFF 0
NAT I O NAL S TAFF 19(until December 2003)

I N T ER NAT I O NA L S TA FF 6
NAT I O NAL S TAFF 135

Romania

RussianFederation

Assisting adolescentdrug users

Caring for Bucharest’s
homeless

Helping those living on
the streets

While Luxembourg’s inhabitants enjoy ahigh standard of health, hidden problems
remain – particularly the growing use ofillegal and psychotropic drugs. Although
Luxembourg’s conservative culture andstrict rules forbidding these drugs keep
many from taking them, the number ofyoung people, especially adolescents,using these drugs has rapidly risen in thepast few years. Today about 50 percent ofminors have used illegal substances atleast once. This contradiction between traditional social norms and adolescents’experimentation with drugs can lead tostrife within families and between generations as well as severe reactions fromschool and judicial authorities.

In December 2003, MSF ended a

The continuing crisis in the Republic of
Chechnya and the related kidnapping caseof MSF volunteer Arjan Erkel, who was
abducted in Dagestan in August 2002 andheld for 20 months, have been the dominant issues affecting MSF’s work in the
Russian Federation during the past year
(see page 47 for more information on thesituation in the North Caucasus).

Luxembourg

In response to this problem, MSF runs the
Solidarité Jeunes project. Through it, MSF
works with young people who use drugs,
their families and concerned institutions
including 40 schools and 10 outreach programs. The program provides medical care,information about drug use and addiction,
psychosocial care and individual and family
therapy. Between August 2003 and July
2004, more than 230 consultations werecarried out.

Exploring the needs of immigrants

which provided medical andsocial care to homeless people
living in the country’s capital,
Bucharest.
After 355 homeless adults were reported tohave died in Bucharest in 1997, MSF begana project to improve the lives of those livingon the streets. Through direct medical andpsychosocial care and information activities, the MSF team brought essential services to thousands of homeless people. MSF
staff members used mobile teams, night
clinics and outreach campaigns to reachthe homeless and carried out nearly 500
consultations per month. In addition, areferral network was created with local
hospitals. Extensive advocacy work targeted
at authorities eventually contributed toimportant legislative changes including a
new social security act which greatly
improved the homeless’s ability to obtain
medical and social services.
In December 2003, a new Romanian association was launched to carry on the work
MSF had begun.
MSF worked in Romania from 1997 until
the end of 2003.

© Chien-C hi Chang

MSF started a working group with otherNGOs in December 2003 to monitor thehealth situation of undocumented immigrants and asylum seekers entering
Luxembourg. The organization also maintains regular contact with government
authorities to assess and develop medicalcare for asylum seekers.
MSF has worked in Luxembourg since 1996.

seven-year program in Romania

74 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2003/2004

MSF’s projects in other parts of the country
have yielded mixed results. MSF was forced
to close its long-term tuberculosis (TB) program in Siberian prisons after Russianauthorities prohibited MSF from implementing its treatment regimen for prisoners
with drug-resistant TB, which was based oninternationally accepted standards.
However, MSF refused to agree to theRussian treatment schedule in the prison
because of concerns that it would result ina high risk of treatment failure and theemergence of super resistance to thedrugs. The project had been running forseven years and had treated more than
1,000 patients.
MSF’s project serving the homeless in
Moscow, on the other hand, was successfully handed over in November 2003 to city
authorities, who are continuing to provide
free medical and social assistance topeople living on the street. Still, last winter303 people died from the cold, down fromthe 437 the year before. MSF is now preparing to publish a book in Russian on its
11 years of experience caring for people
living on the street. The aim of the publication will be to promote similar projects
for the homeless in other Russian cities.
A new program to help street children is
now being developed. MSF doctors andpsychologists are working with youth
living in railway stations and other places
where young people are neglected andexploited.
MSF has worked in the Russian Federation
since 1988.

I N T ER NAT I O NA L S TA FF 5
NAT I O NAL S TAFF 35

Spain

UkraineEuropeI N T ER NAT I O NA L S TA FF 0
NAT I O NAL S TAFF 13

Expanding HIV/AIDS care
In the past year, MSF has
expanded the scope of its HIV/AIDS project in the southern© Juan Medina

Ukrainian cities of Odessa,
Mikolaev and Simferopol, where
the disease is particularly
prevalent.
An MSF staff member helps an exhausted, cold African refugee who has just arrived in Fuerteventura after
a harrowing boat trip.

Giving a warmer welcome to immigrants
grants attempting to enter the European Union. Located at the edge ofEurope and close to Africa, the country is now home to 800,000 to one
million undocumented immigrants. However, the government’s systemof receiving immigrants takes little account of their medical and© Philip Wolmuth

In the last few years, Spain has become a primary destination for immi-

humanitarian needs and focuses instead on expelling those who lackdocumentation.
In 2003 and 2004, MSF’s projects in Spain
centered on giving medical and humanitarian assistance to exhausted and sick immigrants arriving in the country’s most popular entry areas: the Canary Islands andCeuta and Melilla, two Spanish enclaves innorthern Africa. MSF also collects personal
testimony from the immigrants as part ofits campaign to raise awareness of theirplight among government officials and the
public.
On 1 March 2004, MSF started an emergency
intervention in Fuerteventura, CanaryIslands, to provide humanitarian assistanceto immigrants arriving on the island’s
shores. The 7,858 immigrants who arrived
in Fuerteventura in 2003 and the nearly
3,000 who arrived in the first part of 2004
had received no assistance.
The team set up a field hospital and amobile team who work right on the beaches
and in the port where immigrants intercepted by the coast guard are taken. The
MSF team provides basic medical care andfirst aid, identifying those with serious illnesses and referring them to health centerson the island. The team also distributes
blankets, water, warm drinks and biscuits.

Fuerteventura has become the main destination for immigrants, especially thosecoming from Asia and sub-Saharan Africa.
Their physical condition, whether on arrivalon the beaches or after their interception,is always the same: hypothermia, hypoglycemia, exhaustion, dehydration, hunger
and thirst. Many also have cuts, bruises andsprains sustained during their journey.
MSF has denounced the government’s current system of reception and is working tobuild support for an advocacy campaignthat calls on the government to takeresponsibility for these immigrants. MSF is
also attempting to improve undocumented
immigrants’ access to the health care system.
During the first part of 2004, MSF closed a
project through which it had provided
assistance to undocumented immigrants in
Ceuta. The organization’s strong advocacy
campaign had helped influence the
Spanish government to begin to provide
the immigrants with appropriate medical
and humanitarian assistance.
MSF has worked in Spain since 1994.

MSF’s objective is to help improve care forpeople living with HIV/AIDS and increase
access to treatment. The project, which was
originally aimed at preventing motherto-child transmission of HIV, has beenbroadened to include medical care foropportunistic infections, treatment withlife-extending antiretroviral (ARV)
treatment, laboratory support and psychological care for both children and adults.
In addition, MSF collaborates with theministry of health to train health care professionals. Currently, some 1,000 motherand-child pairs participate in the motherto-child transmission-prevention programand 106 adults and 29 children are now
treated with ARVs.
Counseling for infected mothers and theirpartners, as well as psychosocial training
for medical staff, are particularly importantelements of the project given the highlevels of stigmatization and discrimination
suffered by the HIV-positive community in
Ukraine. MSF has developed a psychosocial
component in which HIV-positive women
are trained as peer counselors for newly
infected mothers taking part in the program. The peer-counseling program offers
psychological support and empowers
these women in coping with HIV/AIDS.
MSF has worked in Ukraine since 1999.

ACTIVITY REPORT 2003/2004 MEDECINS SANS FRONTIERES 75

Helping Kosovo’s displaced
In the early 1990s, MSF started
providing assistance in what wasthen the Socialist Federal
Republic of Yugoslavia. MSF
teams worked in five of the six
republics of former Yugoslavia toprovide basic health care, waterand sanitation services to thoseaffected by conflict as the country
broke apart. Today MSF staff

I N T ER NAT I O NAL S TAFF 0
NAT I O NAL S TAFF 2 . 5(full-time equivalents)

I N T ER NAT I O NA L S TA FF 0
NAT I O NAL S TAFF 3

SwedenSwitzerland

Caring for refugees

Seeking out the uninsured

Sweden is a common destination

An estimated 150,000 to 300,000

for refugees and asylum seekers,

people in Switzerland – roughlywith more than 10 percent of its

two percent of the population –population composed of immi-

lack legal resident status and gen-grants. The official estimate oferally cannot afford to pay for

undocumented individuals is

health care. Most of these people

approximately 10,000 people.

are economic migrants, asylum
seekers whose applications forAccess to health care is severely restricted
for this group. Undocumented migrants
can only obtain “immediate” care. This policy
is widely misinterpreted to mean that only
the most urgent care should be offered,although even for this, payment isrequired. The Swedish health care system
has no budget to cover the cost of care forthese people and they are sometimes identified by health care staff to the police. A
pregnant undocumented immigrant has no
officially sanctioned access to a midwife
and cannot receive maternity care from thenational health care system unless she has
the 18,000 euros needed to cover delivery
costs.

assist some of the estimated200,000 Kosovars now living in
Serbia.
In July 2003, MSF began making mental
health care available to internally displaced
people living in camps in the southern
Pcinja district’s municipalities of Vranje andBujanovac. In addition to providing direct
psychological and social care, MSF staff arelobbying authorities to grant displaced
people the same legal status as Serbian
citizens. While the government has
extended these rights in theory, this is still
not the case in practice. Equal status would
help the displaced obtain needed medicalcare and social services.

MSF began working in Sweden to organize
clinicians to provide care for this population. MSF is working with volunteer doctors (many with previous MSF experience)
who conduct examinations and treat
undocumented immigrants from within
the country’s health care system. MSF’s
goal is to raise the quality of services provided to this group and to challenge theinevitability of their receiving second-classcare. Because the supply of medicines iscontrolled by a state monopoly, leavingsome people without access to them, MSF
also promotes the idea of improving accessto essential medicines as part of its work.
MSF has worked in Sweden since January
2004.

MSF is monitoring reforms to the healthsystem and their impact on people’s lives.
The organization is also cooperating withlocal authorities on emergency preparedness and response to earthquakes andfloods which are both common in theregion.
MSF started working in parts of former
Yugoslavia in 1991.

76 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2003/2004

asylum have been refused or
people who have lost their legal
resident status due to divorce or
unemployment.
The vast majority of migrants without legal
status are uninsured and have very limitedaccess to health care services. According toan MSF evaluation, nearly 50 percent of thepeople in this group never consult a medical doctor. Of those who do, many wait
until they are suffering from an advanced
stage of disease.
Since November 2003, MSF has run a pilot
medical project in the canton Fribourg.
Under the name Fri-Santé, MSF runs a
medical facility staffed by one nurse.
Consultations at the facility are free ofcharge. A network of voluntary health professionals (general practitioners and medical specialists, dentists and a psychologist)
and pharmacies has been established totreat patients. Depending on their financial
capacity and the availability of drugs in the
program’s reference pharmacies, patients
may be asked to contribute toward thecost of their medicines and/or treatment.
During the first half of 2004, the MSF teamsaw 173 patients during 233 consultations.
MSF is now exploring the need to replicate
the Fri-Santé approach in other parts of thecountry.
MSF has worked in Switzerland since 2003.

© Susana Simoes

Serbia andMontenegro© Rene de Vries

EuropeI N T ER NAT I O NA L S TA FF 2
NAT I O NAL S TAFF 2 2

Middle East

I N T ER NAT I O NA L S TA FF 14
NAT I O NAL S TAFF 3 4

Palestinian Territories“ We’re not safe here – I’d have
hoped we could live in a properhouse, at least. This morning, forinstance, the helicopter started
firing. I left the washing that I
was hanging out to be with mychildren. My seven-month-old
baby was screaming. We live inconstant fear.”assesses the situation for Palestinians living
in communities near the wall. Using mobile
clinics, teams also made regular visits to
the Bedouin people living in Hebron’ssouthern Yatta district who lack basic
health care.

© Philippe Conti– Maghboul, a 42-year-old mother of nine,
living in the Tal al Sultan district of Rafah
in the Gaza Strip

Treating trauma
The Palestinian territories of the West Bank and Gaza Strip have witnessed a dramatic deterioration of living conditions since the outbreakof the second Intifada in October 2000. In 2003 and 2004, continuing
violence in this area left behind many wounded and dead civilians anddestroyed property. MSF teams provide medical and psychologicalcare to those affected by the violence and lacking medical support inthe cities of Hebron, Jenin and in the Gaza Strip.
Using outreach consultations, MSF teams
comprised of medical and psychiatricexperts as well as translators, visit families
exposed to violence and daily militaryactivities. Through home visits, the team
identifies affected people and proposesappropriate treatment. The main diagnoses
are depression, anxiety, post-traumaticstress disorder and psychosomatic disorders. Those suffering from psychologicalproblems are referred to psychologists or
psychiatrists. MSF uses brief therapy for
individuals, families and groups by giving“on the spot” counseling as soon as possible after a traumatic event has taken place.
In the city of Hebron, MSF psychologists
play a key role due to the high number ofpatients referred to them by the team’s
doctors and social workers. MSF’s consultation room in the old city enables theteam to stay in close contact with the local
population. The team is also investigating
ways to reach more adolescents and to
start psychotherapy groups.
The Israeli authorities’ decision to construct
a high concrete security wall to separate
Israel and the West Bank has made it
extremely diﬃcult for civilians in some areasof the southern and eastern part of Hebron
district to obtain needed health care.
Demolition orders are constantly issued
and implemented and the wall alreadyblocks many Palestinians from reachingnearby health facilities. MSF continually

In the Gaza Strip, a series of Israeli military
incursions have left thousands of people
homeless, especially in the town and refugee camp of Rafah. Since January 2004, thewaves of incursions and demolitions haveincreased in Rafah and approximately 90
homes have been demolished each month.
MSF staff work with local residents who are
confined to the area by strict security rules
and numerous military checkpoints. An
MSF medical doctor, psychologist andsocial worker also visit families in theirhomes. The team listens to their stories andprovides counseling. They also use drawings and games to help children overcome
trauma or the destruction of their home.
In May 2004, more than 200 families –2,197 people – were made homeless inRafah after several hundred homes weredestroyed by the Israeli army. The incursion
left dozens of civilians dead or injured.
Many people told MSF that they had been
given no time to leave their homes andothers who did escape reported being fired
upon. On 19 May 2004, more than 60
people were wounded and about 10 killed
while taking part in a demonstration in thearea. MSF doctors helped triage and treat
patients at Najar Hospital where theinjured were brought for treatment. MSF
gave the hospital basic medical materials
including anesthetics, antibiotics, compresses and bandages. Two MSF psychologists also counseled groups of students
from nearby schools and met with local
townspeople. MSF teams experienced
enormous obstacles in reaching the
hospital or parts of Rafah that had beenaccessible until they came under attack.
Since 2002, MSF teams have also beentreating Palestinians needing medical careor psychological counseling in the city ofJenin. MSF staff members visit people intheir homes or provide needed care at theorganization’s office.
MSF has worked in the Palestinian territories since 1988.

ACTIVITY REPORT 2003/2004 MEDECINS SANS FRONTIERES 77

Facts and Figures
Médecins Sans Frontières (MSF) is an international medical
humanitarian organization that is also private and non-profit. It iscomprised of 18 national branches in Australia, Austria, Belgium,
Canada, Denmark, France, Germany, Holland, Hong Kong, Italy,
Japan, Luxembourg, Norway, Spain, Sweden, Switzerland, theUnited Kingdom and the United States, with an international
office in Geneva (which moved from Brussels in 2004).
The figures presented here provide an estimate of MSF’s financeson an international level. These combined international figures

have not been audited and are therefore not certified. However,each entity 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 eachbranch, and the information used for the preparation of the international figures has also been audited.
The figures are for the 2003 calendar year; the Activity Report itself
covers the period August 2003 to July 2004. All amounts are in millions of euros.

2003

2002

Income

In M€

In %

In M€

In %

Private Income
Public Institutional ECHO* & EU
Public Institutional Other
Total Income

296.6
30.5
46.7
373.8

79.3%
8.2%
12.5%
100.0%

295.6
24.6
45.5
365.7

80.8%
6.7%
12.5%
100.0%

288.4
14.2
1.7
304.3
42.8
23.1
370.2

77.9%
3.8%
0.5%
82.2%
11.6%
6.2%
100.0%

256.1
19.2
0.1
275.4
39.7
21.8
336.9

76.0%
5.7%
0.0%
81.7%
11.8%
6.5%
100.0%

How was the money spent?
Operations
Témoignage
Other humanitarian activities
Total Social Mission
Fundraising
Management, general & administration
Total Expenditure
Net exchange gains & losses(realized and unrealized)
Surplus/(deficit)

-7.5
-3.9

-6.8
22.0

* European Community Humanitarian Office

2003
Program expenses* per continent
Africa 69.3 %America 5.7%
Asia 17.4%
Europa 6.5%
Non-allocated 1.1%

* projects’ and coordination teams’
expenses in the countries

78 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2003/2004

As part of our efforts to guarantee our independence
and strengthen our link with society, we have been
striving to maintain a high level of private income. In
2003, 79.3% of MSF’s income came from private sources.
More than 2.6 million individual donors and private
funders worldwide made this possible.
Additional public institutional agencies include, among
others, the governments of Belgium, Denmark,Luxembourg, Norway, Sweden, Switzerland and theUnited Kingdom, as well as the United Nations HighCommissioner for Refugees (UNHCR).

2003
Where wasthe money spent?
(Program expenses above 3 million euros)Countries/Regions
In M€
Democratic Republic of
the Congo
Sudan
AngolaLiberia
Afghanistan
Ethiopia
BurundiIvory Coast
Sierra Leone
Chad
Chechnya / Ingushetia/ Dagestan
Kenya
Republic of Congo
Mozambique
Guinea
Iraq
Somalia
Malawi
Myanmar (Burma)
UgandaCambodia
Russia** Excluding the republics of Chechnya,
Dagestan and Ingushetia

26.4
20.1
19.6
14.5
10.9
10.3
9.5
8.4
8.2
7.9
6.7
6.1
5.2
5.0
4.6
4.4
3.8
3.6
3.4
3.2
3.2
3.0

2003

2002

Balance sheet (year-end financial position):

In M€

In M€

Non-current assets
Current assets
Cash & equivalents
Total assets
Permanently restricted funds
Unrestricted funds
Other retained earnings
Total retained earnings and equities
Non-current liabilities
Current liabilities
Unspent temporarily restricted funds
Total liabilities and retained earnings

33.6
47.9
160.0
241.5

32.2
47.8
173.2
253.2

4.2
193.6
-2.8

4.3
199.3
0.0
195.0
5.2
38.4
2.9
241.5

203.6
5.6
41.3
2.7
253.2

HR Statistics
International departures (full year):
Medical pool
Nurses & other paramedical pool
Non-medical poolFirst time departures (full year):(*) in % of the international departures
Field positions:
Expatriate staff
National staff

3,444
972
1,068
1,404
1,092

100%
28%
31%
41%
(*) 32%

2,950
837
897
1,216
915

100%
28%
31%
41%
(*) 31%17, 995
1,896
16,099

100%
11%
89%

16,623
1,714
14,909

100%
10%
90%

2003
Statement offinancial activities
Private Income
Public Institutional Income
Total Income
Social Mission Expenses
Other Expenses
Total Expenditure
Net exchange gains & losses(realized and unrealized)
Surplus/(deficit)

Balance sheet(year-end financial position)
Non-current assets
Current assets
Cash & equivalents
Total assets
Total retained earnings and equities
Non-current liabilities
Current liabilities
Unspent temporarily restricted funds
Total liabilities and retained earnings

Includingsatellites in %
304.2
77.7
381.9
308.3
66.8
375.1
-7.2

79.6%
20.4%
100.0%
82.2%
17.8%
100.0%-0.4

Excludingsatellites in %
296.6
77.2
373.8
304.3
65.9
370.2

79.3%
20.7%
100.0%
82.2%
17.8%
100.0%-7.5-3.9

Includingsatellites

Excludingsatellites

31.6
56.8
163.7
252.1
202.9
7.1
39.0
3.1
252.1

33.6
47.9
160.0
241.5
195.0
5.2
38.4
2.9
241.5

Permanently restricted funds may be capital funds,
where the assets are required by the donors to beinvested, or retained for actual use, rather than
expended, or they may be the minimum compulsory
level of retained earnings to be maintained by someof the sections.
Unrestricted funds are unspent donor non-designatedfunds expendable at the discretion of MSF’s trustees infurtherance of our social mission.
Other retained earnings represent foundations’ capitalas well as technical accounts related to the combination
process, including the conversion difference.
MSF’s retained earnings have been built up over theyears by surpluses of income over expenses. As of theend of 2003, their available part (the unrestricted funds
decreased by the conversion difference) represents
6.2 months of activity. The purpose of maintaining
retained earnings is to meet the following needs: futuremajor emergencies for which sufficient funding cannot
be obtained, and/or a sudden drop of private and/or
public institutional funding, and the sustainability oflong-term programs (e.g. ARV treatment programs), as
well as the pre-financing of operations to be funded byupcoming public funding campaigns and/or by public
institutional funding.
Unspent temporarily restricted funds are unspent
donor-designated funds, which will be strictly spent by
MSF in accordance with the donors’ desire (e.g. specificcountries or types of interventions) as needs arise.

Additional disclosures:
The information presented here only pertains to the 18
national branches and the international office.
However, the search for efficiency has led MSF tocreate specialized organizations – called “satellites” –in charge of specific activities such as humanitarianrelief supplies, epidemiological and medical researchstudies 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 Foundation Kikin, MSFLogistique, SCI MSF, SCI Sabin, Transfer S.C. andUrgence Développement Alimentaires.
As these organizations are controlled by MSF, thedecision was made to include them in the scope of the
combined financial statements in 2003 for the first time.
However, the 2002 figures have not been restated andconsequently they do not include the financial information related to the satellites. In order to allow a propercomparison of the 2002 and 2003 figures, the tables
present the impact of including the satellites in thescope of the 2003 combined financial statements.

ACTIVITY REPORT 2003/2004 MEDECINS SANS FRONTIERES 79

Contact MSF
Australia Médecins Sans Frontières
Street address: Suite C, Level 1, 263 • Broadway
Glebe NSW 2037 • Postal address: PO BOX 847
Broadway NSW 2007 • Australia
T 61 29 552 4933 • F 61 29 552 6539
office@sydney.msf.org • www.msf.org.au
Pr: Rowan Gillies • GD : Philippe Couturier
Austria Médecins Sans Frontières /Ärzte Ohne Grenzen
Taborstrasse 10 • A-1020 Vienna • Austria
T 43 1 409 7276 • F 43 1 409 7276/40
office@aerzte-ohne-grenzen.at • www.msf.at
Pr: Dr. Clemens Vlasich • GD: Franz Neuteufl

Belgium Médecins Sans Frontières /Artsen Zonder Grenzen
rue Dupré 94 / Dupréstraat 94
1090 Brussels Belgium
T 32 2 474 74 74 • F 32 2 474 75 75 info@msf.beor info@azg.be
www.msf.be or www.azg.be
Pr: Dr. Jean-Marie Kindermans • GD: Gorik Ooms
Canada Médecins Sans Frontières /Doctors Without Borders
720 Spadina Avenue, Suite 402 • Toronto
Ontario • M5S 2T9 • Canada
T 1 416 964 0619 • F 1 416 963 8707
msfcan@msf.ca • www.msf.ca
Pr: Joanne Liu • GD: David Morley
Denmark Médecins Sans Frontières /Laeger Uden Graenser
Bernstorffsvej 20 • 2900 Hellerup • Denmark
T 45 39 62 63 01 • F 45 39 62 61 04
info@msf.dk • www.msf.dk
Pr: Dr. Soren Brix Christensen • GD: Philip Clarke

France Médecins Sans Frontières
8 rue Saint Sabin • 75544 Paris Cedex 11 • France
T 33 1 40 21 29 29 • F 33 1 48 06 68 68
office@paris.msf.org • www.paris.msf.org
Pr: Dr. Jean-Hervé Bradol • GD: Pierre Salignon

Germany Médecins Sans Frontières /Ärzte Ohne Grenzen
Am Köllnischen Park 1 • 10179 Berlin • Germany
T 49 30 22 33 77 00 • F 49 30 22 33 77 88
office@berlin.msf.org
www.aerzte-ohne-grenzen.de
Pr: Dr. Stefan Krieger • GD: Dr. Ulrike von Pilar

Pr=President
GD=General Director
SG=Secretary General

Holland Médecins Sans Frontières /Artsen Zonder Grenzen
Plantage Middenlaan 14 • 1018 DD Amsterdam
PO Box 10014 • 1001 EA Amsterdam
The Netherlands
T 31 20 520 8700 • F 31 20 620 5170 / 72
office@amsterdam.msf.org
www.artsenzondergrenzen.nl
Pr: Dr. Lisette Luykx • GD: Geoffrey Prescott(as of Jan 05)
Hong Kong Médecins Sans Frontières
Shop 5B • Laichikok Bay Garden • 272 Lai King
Hill Road • Kowloon • Hong Kong
T 852 2338 8277 • F 852 2304 6081
office@msf.org.hk • www.msf.org.hk
Pr: Emily Chan • GD: Dick van der Tak

Italy Medici Senza Frontiere
Via Volturno 58 • 00185 Rome • Italy
T 39 0644 86 921 • F 39 0644 86 9220
msf@msf.it • www.msf.it
Pr: Stefano Vajtho • GD: Stefano Savi

Japan Médecins Sans Frontières
2-4-10 Shimo-Ochiai • Shinjuku
Tokyo 161-0033 • Japan
T 81 3 5988 0560 • F 81 3 5988 0561
msf@japan.msf.org • www.japan.msf.org
Pr: Saeko Terada • GD: Armand Virondeau

Luxembourg Médecins Sans Frontières
70, rue de Gasperich • L-1617 Luxembourg
T 352 33 2515 • F 352 33 51 33
info@msf.lu • www.msf.lu
Pr: Dr. Romain Poos • GD: Laure Belin
Norway Médecins Sans Frontières /Leger Uten Grenser
Raadhusgata 30 A • O151 Oslo • Norway
T 47 23 31 66 00 • F 47 22 33 45 51
epost@leger-uten-grenser.nowww.leger-uten-grenser.no
Pr: Dr. Atle Fretheim • GD: Patrice Vastel
Spain Médicos Sin Fronteras
Nou de la Rambla 26 • 08001 Barcelona • Spain
T 34 93 304 6100 • F 34 93 304 6102
oficina@barcelona.msf.org • www.msf.es
Pr: Dr. Emilia Herranz • GD: Rafa Vila-SanJuan
Sweden Médecins Sans Frontières /Läkare Utan Gränser
Högbergsgatan 59 B • Box 4262
SE - 102 66 Stockholm • Sweden
T 46 8 55 60 98 00 • F 46 8 55 60 98 01
office-sto@stockholm.msf.org
www.lakareutangranser.org
Pr: Pehr Olov Pehrson • GD: Dan Sermand

80 MEDECINS SANS FRONTIERES ACTIVITY REPORT 2003/2004

Switzerland Médecins Sans Frontières /Ärzte Ohne Grenzen
Street address: 78 rue de Lausanne
1207 Genève Postal address: Case Postale 116
1211 Geneva 6 • Switzerland
T 41 22 849 84 84 • F 41 22 849 84 88
office-gva@geneva.msf.org • www.msf.ch
Pr: Isabelle Segui-Bitz • GD: Christian Captier
UK Médecins Sans Frontières (UK)67-74 Saffron Hill • London EC1N 8QX • UK
T 44 207 404 6600 • F 44 207 404 4466
office-ldn@london.msf.org • www.uk.msf.org
Pr: Greg McAnulty • GD: Jean-Michel Piedagnel

USA Médecins Sans Frontières /Doctors Without Borders
333 7th Avenue • 2nd Floor
New York, NY 10001 • USA
T 1 212 679 6800 • F 1 212 679 7016
doctors@newyork.msf.org
www.doctorswithoutborders.org
Pr: Darin Portnoy • GD: Nicolas de Torrenté
Other Offices
Médecins Sans FrontièresInternational Office and
UN Liaison Office - Geneva
Street address: 78 rue de Lausanne
1207 Genève • Postal address: Case Postale 116
1211 Geneva 6 • Switzerland
T 41 22 84 98 400 • F 41 22 84 98 404
office-intnl@bi.msf.org • www.msf.org
MSF Policy and Advocacy Coordinator:
Emmanuel Tronc • T 41 22 84 98 915
emmanuel.tronc@msf.org
Pr: Rowan Gillies • SG: Marine Buissonnière

UN Liaison Office – New York333 Seventh Avenue • 2nd Floor • New YorkNY 10001-5004 • USA
T 212 655 3777 • F 212 679 7016
MSF UN Liaison Officer in NY:
Catherine Dumait-Harper
Catherine_harper@newyork.msf.org

MSF Access to Essential MedicinesCampaign
78 rue de Lausanne • Case Postale 116
CH-1211 Geneva 6 • Switzerland
T 41 22 849 8405 • F 41 22 849 8404
www.accessmed-msf.org

MSF United Arab Emirates
Abu Dhabi Head Office • P.O. Box 47226
Abu Dhabi • UAE
T 971 2 6317 645 • F 971 2 6215 059
msf-abou-dhabi@paris.msf.org
www.msfuae.org