Dispatches (Summer 2009)
Dispatches is the english-language newsletter of Doctors Without Borders / Médecins Sans Frontières (MSF) Canada.
MSF CANADA MAGAZINE Volume 11 Edition 2 DISPATCHES Why we put our lives on the line MSF FIELD WORKERS: Why we put our lives on the line, p. 02 PAPUA NEW GUINEA: Caring for women, p. 06 | ZIMBABWE: Cholera: A child's perspective, p. 10 SRI LANKA: Medical care for a traumatized people, p. 12 | DRC: The terror was swift, p. 13 MSF READS: The Photographer, p. 14 | MSF ON FILM: Living in Emergency, p. 14 MSF FIELD WORKERS "i can't stand aside in the face of suffering" Dispatches Vol. 11, Ed.2 The March abduction of Canadian nurse Laura Archer and four colleagues serves as a stark reminder of just how dangerous this work can be. Steve Dennis sheds light on why he keeps revisiting the world's most troubled places. W hen I first applied six years ago to work overseas with M�decins Sans Fronti�res (MSF), I wrote on my application that my goal was to help the world become a better place. I didn't really know what that meant or how I would do that, but it sounded like a good answer at the time. I hadn't even arrived at my first project location before I started seeing the dark side of my chosen line of work. A month before I left on my first mission in 2002, MSF worker Arjan Erkel was kidnapped in Dagestan, a troubled Russian republic on the Caspian Sea. For the next 20 months while he was held hostage, I met anxiously with my team members to discuss the weekly updates about either progress on his release or silence about his fate. I felt outraged and betrayed because the risk Erkel faced went beyond what I had expected when I signed up. This feeling came back to me last week when I heard about the kidnapping of Canadian nurse Laura Archer and four other staff with MSF in the Darfur region of Sudan. How could this happen to people bringing aid to a country in distress? When Arjan Erkel was finally released, I breathed a sigh of relief, as did many of my fellow aid workers. Still in my early years of humanitarian work, I felt order had been restored. But that feeling was short-lived. Just two months later, five MSF staff members were ambushed and killed in Afghanistan. My outrage turned to disbelief and cold numbness. For me, the illusion I had been living of bulletproof principles had been shattered, and order would not be restored this time. As aid workers have increasingly fallen victim to kidnappings, sexual assaults and killings over the past decade, it's only natural to wonder how we justify taking such risks. The answer is far from simple. � Tim Dirven 02 � Alexander Glyadyelov � Julie R�my 03 providing non-medical care for people living with HIV/AIDS. And on Dec. 1, World AIDS Day, more than 600 people came out for the events, including races, speeches from local authorities, live music, dramas and game-show-style quizzes all about HIV. I believe that our HIV/AIDS intervention in that community significantly improved the lives of thousands of people. But after working in various projects for six years and seeing the longer-term results of what I had been part of, I realize that it isn't always apparent how our efforts make a difference. I remember one cold day on vacation when I received three e-mails with disheartening news about how my previous work had been THE PAYOFF One fact that many aid workers will tell you is that being part of an organization that is in the business of saving lives and restoring dignity feels good; you are reminded that success is possible. This was reaffirmed for me in 2006, when I was in Ivory Coast working on a large hospital project. Since the prevalence of HIV is as high as 15 per cent in some parts of the country, MSF started many HIV activities there. We established a voluntary counselling and testing centre, but in the first couple of months, fewer than a dozen people came. We worked hard to tell the community about these services, and this number quickly rose. We optimistically set the bud- get for an average of 300 consultations per month over the year. We reached that number in March, and by October more than 900 people were visiting the centre for counselling each month. The demand for other activities related to HIV/AIDS rose as well. We started a program to stop mother-tochild transmission of the virus, so HIVpositive mothers could safely deliver and care for their HIV-negative babies. And antiretroviral drugs were offered to an increasing number of patients, turning around their deteriorating conditions. In the town, we made contact with people at school assemblies, orphanages, rebel battalions and local groups Dispatches Vol. 11, Ed.2 erased. One described how a compound I had helped build in south Sudan was looted and destroyed, another how the international team of a tuberculosis project I had started had to be evacuated for their safety, and the third one reported that fighting had broken out, ending a four-year ceasefire in Sri Lanka, where I had earlier helped wrap up our mission in peaceful times. The world I had worked so hard to make a better place had taken two steps backward. I had a similar feeling when I heard that MSF withdrew staff in Darfur after the kidnapping of the MSF staff members [in March]. This act will be a devastating blow to the survival of hundreds of thousands of people there. To many people in towns, villages, refugee camps and city slums, aid organizations do more for the populations than provide food, clean water or healthcare. For many people defeated by the effects of a conflict, the presence of aid organizations gives hope and restores some dignity by recognizing their plight. Conversely, the evacuation of an aid organization from an area needing its service and recognition, can extinguish that light. TOO GREAT A RISK In my most recent posting with MSF, I took over as co-ordinator of an emergency surgical program in Kismayo, So- malia, when three MSF staff had been killed there. In the months after the incident, after the memorials and funeral services, the organization made the difficult decision to end the project. The risk was too great. The surgical program had given women with labour complications life-saving caesarian sections. During the eightmonth duration of the project, more than 400 (principally obstetric) surgeries and 1,200 emergency consultations were performed by the MSF team of six international and 35 Somali staff. After MSF closed the program, patients had to pay $350 U.S. for a caesarian section. For many Somalis, this lifesaving service became financially inaccessible, so a population of 100,000 people were left without this essential service. We feared that many women would probably die. Imagine in your home country a collapse of all systems and structures of authority and governance. Imagine violence chasing you and your family out of your homes to walk 100 kilometres to a safer, but desolate area. Imagine carrying some clothes, some food and a cooking pot. Imagine food running out. Imagine drinking water from a dirty river. Imagine children dying from diarrhea. Imagine simple infections leading to amputations or death. Imagine women dying in childbirth. Imagine that all of this is happening while people with the power to do something hold meetings and decide not to intervene. People shouldn't die from the lack of a 50-cent medication or vaccine. People shouldn't die from the lack of clean water or soap. People shouldn't die from the lack of a proper shelter. But they do. Over the years, I have seen that a medical and logistics team of just five people supplied with basic medicines, and materials can save the lives of thousands of people. I have begun to realize that our simple actions do change the world from the perspective of each individual patient who is carried into a clinic and walks out some days afterwards. The troubles of the world will continue, and my contribution is to be engaged in bringing life-saving aid to individuals in desperate need. The reason for taking action couldn't be any clearer. I accept a degree of personal risk, because I can't accept standing aside in the face of another person's suffering. I fear that Laura Archer and her colleagues may not be the last aid workers to be kidnapped or harmed, but fortunately their ordeal ended with their release. For most of the aid workers going overseas every year, no critical security incidents will occur and they, too, will return home safely. Though, because of the risks they take, millions of people in precarious situations will be given a better chance of surviving that year. Walking away from this kind of accomplishment would be too hard for many people to justify. 04 Dispatches Vol. 11, Ed.2 Steve Dennis Project coordinator As a logistician and then project coordinator, Steve Dennis has worked with MSF in Ivory Coast, Somalia, Sri Lanka and Sudan. � Mikkel Dalum / MSF Article reprinted with permission from The Globe and Mail. Published: March 21, 2009. SUDAN � Charlie Kunzer / MSF Darfur: Expulsions and insecurity leave thousands vulnerable Dispatches Vol. 11, Ed.2 � Julie Damond / MSF 05 � MSF n March 4 and 5, 2009 two sections of M�decins Sans Fronti�res (MSF) were expelled by the government of Sudan from the country's northern Darfur region. The expulsions forced the closure of five large MSF projects in Feina, Muhajariya, Niertiti, Zalingei and Kalma displaced persons camp. O Between 2004 and 2008, MSF teams in projects throughout Darfur conducted more than three million medical consultations, treated 60,000 people through hospital admissions and provided nutritional support to more than 110,000 children. After the March 11 kidnapping of four MSF staff in Serif Umra, Darfur, including Canadian nurse Laura Archer (pictured above, bottom left, white shirt), as well as numerous other serious security incidents, MSF teams made the difficult decision to close the Serif Umra and Kebkabiya projects as it was no longer possible to continue providing medical assistance in a safe and meaningful way in these locations. Archer and her colleagues, who had been working in Serif Umra, where released unharmed March 14. Prior to the expulsions, more than 100 MSF international staff and approximately 1,625 Sudanese staff worked tirelessly to deliver essential medical aid to hundreds of thousands of people throughout Darfur. Today, six MSF projects continue to remain open in north Sudan � run largely by those Sudanese staff still present � though all MSF teams in the region continue to struggle to provide meaningful humanitarian assistance to those most in need. MSF continues to strongly protest the expulsions of some of its teams from Darfur and appeals to the government to allow MSF to resume independent and impartial humanitarian assistance in these locations immediately. Kevin Coppock Humanitarian affairs liaison PAPUA NEW GUINEA 06 "I get to see them smile and say thank you" Caring for women in Papua New Guinea � Karen Mulchinock/ MSF Dispatches Vol. 11, Ed.2 � Karen Mulchinock/ MSF � Karen Mulchinock/ MSF P hysical and sexual violence against women and children in Papua New Guinea is extreme. Two out of three women experience domestic violence and 50 per cent of women have experienced forced sex, rape or gang rape. Children too suffer enormously from daily abuse. In December 2007, in response to a lack of specialized care, MSF took over the Women and Children's Support Centre in Lae, the country's second biggest city. Working closely with staff from the Ministry of Health hospital, the team provides comprehensive medical and psychosocial care to survivors of genderbased violence. Violence appears to be an accepted part of the culture in Papua New Guinea. "A lot of the women I saw didn't know that being beaten by their husband is against the law," says Karen Stewart, a mental health specialist with MSF. "Most thought it was acceptable. We had to let these women know that all they are experiencing after an event like rape is a normal reaction. They have a lot of fear, are anxious or can't eat, but they don't know why. We have to show them the link between their reactions and what happened to them." The problem permeates throughout society, as Stewart explains: "I truly do see that women and children in Papua New Guinea live in a constant low state of terror. Most families are dealing with domestic violence in some form. Simple errands are dangerous and avoided if possible. There were times when our staff would miss lunch, and I would suggest that they leave early to go and eat, but they refused to go alone. They weren't travelling through a rural area or � Karen Mulchinock/ MSF "We're on the way back to base after an HIV/AIDS training session," says Chris Houston, logistics manager for M�decins Sans Fronti�res (MSF) in Lae, Papua New Guinea. "My colleague and I are chatting about condoms: `Do you think we could give out female condoms in the clinic?' he asks. I joke about how difficult female condoms are to use. Then he explains: `Women on long bus journeys wear them. Just in case they get raped.' I stop smiling." the jungle, just to the bus stop in town. But all the same they were afraid of going alone, so they all left as a group at the end of the day." Before MSF came to Lae, the Women and Children's Support Centre had been run by Ministry of Health nurse Elvina Yaru and a colleague. They gave basic counselling and legal advice in a room with little privacy next to the hospital's emergency ward. Since MSF took over, the centre has moved to a dedicated nearby site, medical services have been strengthened and a team of counsellors has been trained. "Counselling children affected by sexual violence is a pretty advanced skill," says Stewart. "Our counsellors have to manage some very difficult cases, be it attempted suicide, rape, gang rape or kidnapping. There's just a lot of stuff that happens in Papua New Guinea. I remember one child that was really far removed, pretty much catatonic � non-verbal, not eating, not sleeping � and the fact that no one noticed. I was trying to educate the mother; her response had been to beat the child because the child was not responding to her. The child would be in the corner and her mother would call her and she wouldn't come, so she'd go and physically assault her to get her to listen. To educate the mother about why her child is this way and then to have the mother say, `Wow, okay,' is what keeps us motivated." MSF's input is making a tangible difference in this community. "The women say they like the good service," says Yaru. "At the other hospitals you have to wait four hours just to be seen. They feel frightened very quickly and then leave. But here, with rape cases we explain as soon as they come that they will have to stay almost half a day because of the medical [exam and follow-up care] and then they have to be seen by a counsellor. We then see them for medical treatment once a week for a month to prevent HIV infection and we make follow-up dates for them to come back." To raise awareness of sexual and genderbased violence in the community, the MSF clinic supports outreach programs, enlisting the help of influential people such as Adam Patung, captain of the Lae Bombers rugby team, who regularly visits schools and community groups to talk about the effects of violence. By December 2008, one year after the clinic opened its doors, the team had treated 2,500 patients. This project is intended to be a model of care � the government has a long-term goal of opening 21 centres like the MSF one throughout the country. "MSF is making a big difference," says Yaru. "Now that MSF is here, more and more women are coming because they know it is a free service. I enjoy seeing women getting treatment and access to services; I get to triage them and give them human feeling, see them smile and say thank you." Marie Smith Communications officer 07 Dispatches Vol. 11, Ed.2 PAPUA NEW GUINEA 08 In 2006 and 2007, two M�decins Sans Fronti�res (MSF) staff undertook an exploratory mission to assess the possible healthcare needs in Papua New Guinea. What they found were very high levels of social and domestic violence against women, children and men, which were resulting in massive medical and psychosocial needs. People � especially women � are living in a constant state of fear, with minimal medical care and with no access to psychosocial services. NAOMI'S STORY fell down he was trying to stab me with a knife. He was just trying to stab me and I was trying to protect myself and he pulled me into the bushes. I tried to be confident, and when I looked in his eyes he started punching me in the face and said, "Don't look at me, I'm gonna kill you." He just kept trying to stab me and I was using both hands to stop him. He had two big knives. I was fighting for my life. I didn't want to have sex with him because I know it's unsafe. I know about HIV and STIs [sexually transmitted infections], but he tried to stab me with a knife and then he kicked my left shoulder � it still has pain � and I felt like I was helpless and I couldn't fight for my rights anymore. I asked "Do you have a condom?" and he said "Don't talk to me about condoms." And I knew I was in hell now. After he raped me he pulled me out of the bush with a knife on my neck. I was scared so when he was trying to talk to me I ran to find help. When I came near a neighbourhood I started to call for help. There was a group of boys on the side of the road, and they helped me. They went to find their sisters and brought me into the house. I told them what happened and they went and found my family who was looking for me. My family was good. At first I just went into my room and I did not want to come out. But my mother was calling me and said I couldn't just be alone. I know that HIV can transmit in 48 to 72 hours and I wanted to get some help, and also not get pregnant or an STI. When I came to the centre I can see they're helping me well. The clinic service is great. I was happy to be a patient here. The staff I was a victim of a robbery and rape. It was the first time something like this happened to me. After work, I was walking home and there was a holdup on the way with three males. They took my bag and then one chased me, and when I � Karen Mulchinock/ MSF "After it happened I was having flashbacks and nightmares" Dispatches Vol. 11, Ed.2 is friendly, and openly speaking to us. When I saw staff they said, "Morning, come in." It felt open. They gave me the medicine for STIs and HIV. When the incident happened my body was in great pain. But then I took the tablets and injections and I felt free. After it happened I was having flashbacks and nightmares and when I came to see the counsellor she talked to me and told me it wasn't my fault. She helped me. I did what she said and it helped me. I'm happy now. I think some of my own clients [whom I see as an HIV awareness worker] feel the same thing too � talking about it is good. As a patient here, I'll try to make awareness for women and abused children and treatment and counselling. I'm feeling better now. I had the test and I was negative for HIV. At the end of this month I will get my shoulder joint checked again, but everything is completed. I finished all the pills. Because I got treatment here, I can go out and tell other people that they can too, because I know that these cases will be seen. Naomi (name changed) is a 30-year-old single mother who lives in Lae, Papua New Guinea. As an HIV awareness worker she is able to support people living with HIV. She is a sister to five siblings, daughter to two church elders and mother to a teenage boy. After this interview, Naomi collected more leaflets about the clinic to continue telling people about the services. Hospital without a doctor for 15 years VIOLENT INJURIES AND INFECTIONS NOW RECEIVING MUCH-NEEDED CARE 07 Julia Payson Project coordinator Following a new assessment, in September 2008 MSF started a second project in Papua New Guinea, focusing on trauma and surgery, in the small township of Tari in the Southern Highlands province. Tari itself has 15,000 inhabitants, but the town is a central marketplace and service provider for the wider community of upwards of 200,000 people. The existing hospital was barely functional, understaffed and difficult trauma cases needed to be referred to a mining hospital by helicopter. For 15 years, no qualified medical doctor worked at the hospital. "The operating theatre was not functional. There was no surgical ward. We used to send all the medical and surgical cases to the intensive care unit at another hospital. We have a separate surgical ward now. MSF is taking care of the op- erating theatre and all surgical patients," says nurse Elizabeth Tubiako. Since the project opened, MSF teams have treated patients for a range of cases, including infections, abscesses and complicated births as well as many cases of lacerations and deep wounds from violent bush knife and machete attacks. In January 2009 alone, medical teams treated 639 patients, of which 133 were major surgery cases. "I would say that among the patients, we see quite a lot of trauma cases, normally violence related," explains Jose Sanchez Giron Delgado, the project's medical doctor and surgeon. "They can represent up to 30 per cent of the total number of operations we perform in the hospital. But apart from that, there are also quite a number of infections, or what we call infection neglect cases, which we see in up to 70 per cent of the cases." � MSF Dispatches Vol. 9, Ed.2 � MSF ZIMBABWE Cholera:A child's perspective Dispatches Vol. 11, Ed.2 10 ugust 2008 saw the beginning of a massive cholera outbreak in Zimbabwe that ravaged both villages and cities for many months. Between the onset of the outbreak and March 2009, M�decins Sans Fronti�res (MSF) treated roughly 56,000 people through its mobile teams and by setting up and running dozens of cholera treatment centres around the country. A in total since the epidemic started. And, indeed, only shortly after my inquiry, Juliette, our MSF head nurse in Harare's main Cholera Treatment Centre, calls me to tell me that yes, there is a 10-year-old kid that was admitted two days ago and I could see him since his guardian agreed. When I arrive, Dennis refuses to open his eyes when Juliette addresses him. His grandmother, a handsome elderly lady with a crucifix hanging from her front gently shakes his shoulder. "He is pretending," she says to us with a smile. "He thinks you will make him drink the ORS [oral rehydration salts, necessary for recovery]." Gogo (grandmother in Zimbabwean dialect) is about to try and rouse Dennis again, but I confer with Juliette and decide just to come back tomorrow. Before I leave, I sit and talk with Gogo a bit, with the help of Juliette translating. MARCH 26: THE CHOLERA KID My assignment today is to find a cholera kid � that is, find a child above five that has cholera and whose guardian would allow me to talk to them in order to get a child's perspective on this disease that has hit Zimbabwe. My task may seem straightforward, since even today there are hundreds of cholera cases around the country � over 93,000 Gogo lives in Mbare. This is one of the poorest high-density areas of the capital. It is dusty and dirty; it is where the bus terminal arrives from southern Zimbabwe and also where the wholesale fruit and vegetable market is located. There are a number of three-storey overcrowded and derelict flats there which our water and sanitation experts have already identified as highly unsanitary. I have already heard stories of sewage pipes bursting and flowing into people's apartments, while toilets are backed-up and completely infested. Gogo, 69, lives in a small two-bedroom apartment with her two remaining children and nine grandchildren. I stumble on the word "remaining" and turn to Juliette. "How many children did she have?" I ask. Gogo answers the question matter-of-factly. "She had nine children in total; now only two are alive," trans- � Joanna Stavropoulou / MSF lates Juliette. I ask about their conditions of life. Gogo says there is no one with an income in the house so they rely on Catholic Relief for a monthly supply of basic food commodities. Gogo's daughter � Dennis' mother � just two weeks ago gave birth to another child. That is why Gogo is at the hospital caring for Dennis; the mother is still at home with the newborn. I thank Gogo for chatting and she smiles and graciously inclines her head telling me "mashvita" � thank you. MARCH 27: A BURNING STOMACH Today Dennis is awake and sitting up. Gogo is happy to see me, while Dennis cannot take his eyes off the notebook and pen I brought him, together with some crayons. I do not understand until later why these are so important to him. Juliette, the MSF head nurse, is here as well. She is the kind of nurse you would want if you are sick. Kind eyes, beautiful face and always with a smile. Dennis is obviously feeling much better today. He had been quite severely dehydrated when he came in and had to be put on a drip, which he was still on today but which Juliette hoped they could stop later on. "He's finally drinking his ORS," says Juliette with a smile. Dennis is small for a 10-year-old and now he is so thin it makes him look even smaller. He is quiet and polite. I ask him what it feels like to have cholera. "I had a burning in my stomach," he says rubbing his abdomen just at the memory. "How do you think you got it?" I ask and Juliette helps me with the translation. He is thoughtful for a moment, then says he thinks it wasn't anything he ate, but, "because I was playing outside in the rain in muddy water." I am surprised at his perceptiveness and think that he is probably right � sewage runs openly through the neighbourhood and rain would be a great disseminator of the bacteria. "When I go back, I will tell the other kids not to dig through the rubbish," says Dennis quietly. Dennis tells me he wants to be a doctor when he grows up so that if his mother gets sick he can take care of her. It was his mother who brought him to the hospital. Even though she had recently given birth, she carried Dennis on her back all the way; they don't have the money for transport. I ask him what he would wish for if he had the chance. He looks down at his thin hands resting on the red hospital blanket and says almost in a whisper, "I want to go to school." When Juliette questions him further he says he can't go to school because he doesn't have books, notebooks or pens. I say goodbye and hope Dennis recovers fully soon. Maybe next week, once they are back at home, I will try and visit them at their flat in Mbare. For now, I turn and cup my hands in the Zimbabwe indication of gratitude and say, "Mashvita, Gogo, mashvita Dennis." They both laugh and repeat the same for me. what is cholera? Cholera is a highly contagious diarrheal disease spread mainly through water or food that has been contaminated by feces. Patients show symptoms of acute diarrhea or vomiting, and must be continuously rehydrated, orally or through an IV, until symptoms disappear. They must be treated in special isolation units called cholera treatment centres. How does MSF respond to a cholera outbreak? Responding to cholera requires a lot of materials, and MSF usually purchases much of it locally when available, such as buckets, beds and blankets. In addition, MSF provides field staff with pre-assembled emergency cholera kits to use during outbreaks. Some examples of items in an MSF cholera kit: SUPPLIES & MATERIALS Joanna Stavropoulou Field communications officer Joanna Stavropoulou wrote the blog "Chol�ra, Chol�ra!" while working as a field communications officer for MSF in Harare, Zimbabwe. To read more entries, go to www.msf.ca. Medical � Oral rehydration salts (ORS) � Ringer's lactate � a rehydration solution administered intravenously if a patient is too ill to drink water with ORS � Gastric tubes, IV catheters, syringes, and other medical materials � Gloves � always used during cleaning and examinations 09 � Joanna Stavropoulou / MSF Logistics � Chlorine � to disinfect water supplies � Soap � Watertight boots � to protect from contaminated water and soil � Graduated cups for drinking and administering ORS � Pool tester � to monitor chlorine levels � Buckets � every patient has two buckets, one for vomit and one under a hole in the bed for diarrhea Administrative � Cholera control guidelines � Water treatment guidelines � Patient follow-up cards Dispatches Vol. 9, Ed.2 SRI LANKA as much on-the-spot medical treatement as was possible, and stabilized patients who had to be transferred to the hospital in Vavuniya. Medical care for a traumatized people In response to the increased need for medical care, MSF opened a field hospital on May 22 near Manik Farm, a camp in Vavuniya district that houses 226,000 internally displaced persons. "Patients are mainly referred by the Ministry of Health [at the] Manik Farm camp to our hospital," says Severine Ramon, MSF coordinator for the field hospital. "We received more than 100 patients during the first week, mostly for wound infection, severe respiratory infection among children and dehydration because of diarrhea." MSF surgeons have also been treating patients in the state-run Vavuniya hospital. Dispatches Vol. 11, Ed.2 "I've been doing around 30 surgical procedures per day," says Matthew Deeter, one of four MSF surgeons working in Vavuniya hospital. "Normally I would do five. We sometimes work together on the same patient; one is amputating the leg and the other is amputating the arm." Physical and mental wounds travel together in people escaping war-torn areas. MSF doctors and nurses are treating many kinds of physical wounds. But the scars that lie beneath also need attention. There's an urgent need for mental health professionals. "This is a large traumatized population," says Cooney. "There's a need to be able to deal with not just the individual cases, who perhaps need a high level of psychiatric care or counselling, but also to be able to deal with people on a group basis � to just be able to discuss with people what's happened to them." As of the end of May, MSF teams were providing medical care to more than 500 patients a day in hospitals in Vavuniya and near Manik Farm, as well as through a post-operative care program in Pompaimadhu Ayurvedic Hospital. ver a period of five days in May 2009, tens of thousands of people fleeing the conflict zone in northern Sri Lanka streamed into the town of Vavuniya. Many of them needed urgent medical care. All of them needed food and shelter. O loss for words to describe the scene in Vavuniya. The sheer volume of people was like nothing she had ever seen before. "The situation's been overwhelming for all of us. In fact, many of us are very experienced in emergencies and it's really the worst thing that we've seen." MSF teams have been working side by side with the Sri Lankan Ministry of Health to provide emergency medical care to the thousands who have fled. A small four-person MSF team treated the first wave of people coming through the Omanthai checkpoint, close to the former frontline. Nearly 10,000 people passed through Omanthai daily. MSF staff did "It was very distressing to see people with these wounds, to see people coming out that have been really living in a terrible situation, having experienced terrible events," says Lauren Cooney, emergency coordinator with M�decins Sans Fronti�res (MSF) in Sri Lanka. Weeks after the first people emerged from the conflict area, Cooney was nearly at a � Anne Yzebe / MSF 12 Monica Tanaka Communications intern DEMOCRATIC REPUBLIC OF CONGO � Avril Beno�t No one understood why they came, but the terror was swift Josephine is too young to know that she has come to represent injustice to all who have met her and to all who have heard her story. The three-year-old girl's life changed irreversibly one day in late December 2008, when some outsiders came to her town of Doruma, in the northeast region of Haut-U�l�, Democratic Republic of Congo (DRC). No one understood why they came, why they started burning huts, grabbing teenagers, raping women in full view, and slaughtering people of all ages with machetes. They picked up Josephine, grabbed her head and twisted it with a jerk � a neck-breaking technique they had perfected in northern Uganda. Whatever their motives, the effect was to terrorize onlookers including Josephine's parents, whom they promptly bludgeoned to death. he Lord's Resistance Army (LRA), chased out of northern Uganda in 2006, was reactivating its historical pattern of rampages against villages in its new roaming grounds in Haut-U�l�, at the crossroads of DRC, Sudan and Central African Republic. emergency specialists flew into the area aboard a small plane to support the local hospital. As elsewhere on this gruelling mission, the emergency team helped treat the few survivors the LRA had left for dead. That's when they first determined that Josephine was paraplegic. The attacks and widespread fear of future attacks by the LRA triggered the massive flight of families in the months that followed. MSF publicly denounced the UN forces for failing to provide any protection to the civilian population, and urged other aid agencies to help provide assistance. Much to MSF's regret, reports of LRA attacks and sightings in and around Doruma prevented the MSF team from checking in on Josephine for long stretches at a time. Six weeks later she was still at the hospital, surrounded by a rotation of family members who would sit on her bed and just stare at her while Josephine turned away and looked worried. They said she cried at night. Prospects for war-affected children with disabilities are never good. Pediatricians with expertise in this area express concern about the risk of deadly urinary tract infections and other medical vulnerabilities. Schools aren't equipped to accommodate them. Sexual exploitation is common. So is abandonment. MSF physician Fabrice Coppex organized for a special chair with a tray to be built for Josephine. He coached hospital staff and Josephine's family on some activities that might bring her arms back to strength and engage her mind. "She will do so much better," he explained, "if you love her and interact with her like a normal child." Later that day she was included, for the first time, in a play therapy group that hospital volunteers had created for children distressed by the conflict. As a nurse playfully swayed a stuffed bear in and out of the toddler's reach, it was the first time in a long time that anyone had seen Josephine giggle. MSF has more than 2,700 staff working in DRC, the organization's largest humanitarian commitment. Most medical projects have been concentrated in the eastern Kivu provinces, where one finds numerous armed rebel groups, Congolese forces, Rwandan troops, UN peacekeepers � and, of course, lucrative mining interests. In late 2008, MSF expanded emergency operations to respond to increasing insecurity in the region of Haut-U�l�. Dispatches Vol. 11, Ed.2 13 T After the devastating attack on Doruma, M�decins Sans Fronti�res (MSF) Avril Beno�t Director of communications MSF READS The Photographer T he Photographer: Into War-Torn Afghanistan with Doctors Without Borders uses stunning photography and graphic art to tell a story about the work of M�decins Sans Fronti�res (MSF) in Afghanistan, through the eyes of Didier Lef�vre's experiences as a photojournalist on an MSF mission in 1986. The book brings together Lef�vre's words and evocative photos with the intensely moody and poignant art of graphic novelist Emmanuel Guibert. the local people. The hardships the MSF teams endure in the field as well as the importance of their work to those they treat weigh heavily on each page, drawing the reader in over and over again through Guibert's poignant illustrations. Especially compelling are the patients' own stories, some of which are sad, others triumphant. The unique and seamless mix of photography, graphic art and dramatic narrative give The Photographer wide appeal. Anyone who reads the book may take something different away, whether from the storytelling, the art or the window into the plight of the Afghan people. The Photographer was first published in three volumes in France (Le Photographe) and was wildly successful, selling more than 260,000 copies. It has since been translated into 11 languages and won numerous awards. The book was released in English in Canada on May 12. Jessica Jepp Communications intern The Photographer begins by laying the groundwork for understanding the complexity of the world Lef�vre was stepping into, explaining the recent history of Afghanistan and MSF missions there. The book goes on to follow Lef�vre and the MSF team as they endure the dangerous trek across the border from Pakistan to Afghanistan to set up health clinics for MSF ON FILM Living in Emergency capturing the complexity of compassion I n the documentary, Living in Emergency, director Mark Hopkins puts the probing camera's eye on the personal dilemmas of M�decins Sans Fronti�res (MSF) humanitarian workers in the field. The film follows four doctors � both firsttimers and veterans � through their experiences in war-torn Democratic Republic of Congo and post-conflict Liberia as they examine their work, their role and their own crises. The illnesses and traumas the aid workers deal with in these environments are shown in a straightforward and frank manner; viewers see the urgent and diffi- cult decisions they must make every day and the consequences of their actions. Pushed to their limits, stressed, and riding on waves of success and disappointment, each field worker finds his or her own ways to deal with these extremes. Unguarded and honest, the doctors speak to their motivations and why as individuals they are driven to help others in need far from their own homes, despite what they themselves endure. Yet, the situation is not helpless. What they do is life-changing to them and to their patients. For MSF, they demonstrate the complexity of compassion and the need for all of us as individuals, in the face of this, to support MSF's efforts to maintain access to people living in crises and in urgent need of medical care around the world. As a Liberian staff member puts it so plainly and convincingly, while MSF's workers come and go, "The work must go on. It must go on." The film had its world premier at the Venice Film Festival last year and at press time was in the process of seeking distribution. Visit www.livinginemergency.com to learn more. Amy Coulterman Fundraising officer BANGLADESH Kylah Jackson Unionville, ON Nurse BRAZIL Joel Montanez Moncton, NB Mental health specialist BURKINA FASO Mich�le Lemay Montr�al, QC Doctor BURUNDI Rachelle S�guin Greenfield Park, QC Nurse CENTRAL AFRICAN REPUBLIC Patrick Boucher Montr�al, QC Logistician Duncan Coady Pinawa, MB Financial coordinator Edith Fortier Montr�al, QC Project coordinator Tara Newell London, ON Project coordinator CHAD Eva Adomako Montr�al, QC Human resources officer Frank Boyce Belleville, ON Doctor Nicholas Gildersleeve Montr�al, QC Logistician Nathalia Guerrero Velez Montr�al, QC Logistician Guylaine Houle Montr�al, QC Logistician Mathieu L�onard Sherbrooke, QC Logistician Audra Renyi Toronto, ON Logistician Sonya Sagan Binbrook, ON Logistician Matthew Schraeder Massey, ON Logistician Ada Yee Calgary, AB Financial coordinator CHINA Peter Saranchuk St. Catharines, ON Doctor COLOMBIA Martin Girard Montr�al, QC Project coordinator DEMOCRATIC REPUBLIC OF CONGO Grant Assenheimer Oakville, ON Logistician Michelle Chouinard St-Quentin, NB Project coordinator Nadine Crossland North Battleford, SK Nurse Marika Daganaud Montr�al, QC Nurse Denis Desch�nes St-Barnab�, QC Nurse Marc Forget Montr�al, QC Doctor Claire Foulon-Abdulahad Montr�al, QC Logistician Chantal Gauthier Varennes, QC Nurse Elizabeth Kavouris Vancouver, BC Nurse Pierre Langlois Ste-Catherine de Hatley, QC Administrator Barbara Leblanc Toronto, ON Surgeon Ali Parandeh Port Moody, BC Financial coordinator Bruce Reeder Saskatoon, SK Doctor Patrick Robitaille Montr�al, QC Project coordinator Denis Roy Montr�al, QC Mental health specialist Sylvie Savard Hull, QC Financial coordinator Jake Wadland Toronto, ON Logistician DJIBOUTI Tricia Newport Saltspring Island, BC Nurse ETHIOPIA Erwan Cheneval Montr�al, QC Project coordinator Brenda Holoboff Calgary, AB Financial coordinator CANADIANS ON MISSION HAITI Asha Gervan Toronto, ON Humanitarian affairs officer Wendy Lai Toronto, ON Doctor Gabriella Pahl Kingsville, ON Medical coordinator INDIA Judy Adams Miramichi, NB Mental health specialist Rhona Bhuyan Toronto, ON Logistician Diane Rachiele Montr�al, QC Financial coordinator KENYA Maguil Gouja Montr�al, QC Financial coordinator Luis Neira Montr�al, QC Medical coordinator MOZAMBIQUE Isabelle Casavant Montr�al, QC Nurse Serge Kabor� Qu�bec, QC Doctor MYANMAR Fr�d�ric Dub� Qu�bec, QC Logistician NEPAL Charmaine Brett Mississauga, ON Project coordinator Marilyn Hurrel Winnipeg, MB Nurse NIGER Marisa Cutrone Montr�al, QC Nurse David Descossy Montr�al, QC Logistician Sherri Grady Peterborough, ON Nurse Marie-Mich�le Houle Victoriaville, QC Nurse Catee Lalonde Montr�al, QC Logistician Simon Riendeau Chicoutimi, QC Doctor NIGERIA Nicolas B�rub� Montr�al, QC Logistician Megan Hunter Prince George, BC Nurse Sharon Janzen Vancouver, BC Nurse Michelle Lahey St. John's, NL Nurse Eva Lam Toronto, ON Epidemiologist Christene MacLeod Ottawa ON Nurse Vivian Skovsbo Calgary, AB Doctor Susan Witt Calgary, AB Nurse PAKISTAN Peter Heikamp Montr�al, QC Logistician Luke Shankland Montr�al, QC Project coordinator Editor: linda o. nagy Editorial director: Avril Beno�t Translation coordinator: Jennifer Ocquidant Contributors: Avril Beno�t, Kevin Coppock, Amy Coulterman, Steve Dennis, Jessica Jepp, Julia Payson, Marie Smith, Joanna Stavropoulou, Monica Tanaka Cover photo: � Siavash Maghsoudi Back page created by Graham MacInnes and Katherine O'Brien as part of the Young Lions ad competition. Darryl Stellmach Calgary, AB Head of mission Susan Tector Ottawa, ON Doctor PALESTINIAN TERRITORIES Mark Kostach Calgary, AB Anesthetist Susan Trotter Fairview, AB Nurse PAPUA NEW GUINEA Shannon Lee Fredericton, NB Project coordinator Harry MacNeil Toronto, ON Project coordinator Julia Payson Vernon, BC Project coordinator Alanna Shwetz Smiths Falls, ON Nurse PHILIPPINES Kevin Barlow Hamilton, ON Nurse SOMALIA James Squier Saltspring Island, BC Logistician SOUTH AFRICA Cheryl McDermid Vancouver, BC Doctor SUDAN Reshma Adatia Vancouver, BC Coordinator Justin Armstrong Haileybury, ON Project coordinator Edith Cabot Halifax, NS Nurse Rink De Lange Sainte-C�cile-de-Masham, QC Water and sanitation specialist Jason Friedman Montr�al, QC Doctor Sylvain Groulx Montr�al, QC Head of mission Leanne Olsen Sainte-C�cile-de-Masham, QC Nurse Sheryl Spithoff Burlington, ON Doctor TURKMENISTAN Sharla Bonneville Toronto, ON Logistician UGANDA Alphonsine Mukakigeri Montr�al, QC Financial coordinator Emily Marie Shalhorn Pincourt, QC Nurse UZBEKISTAN Ada Yee Calgary, AB Financial coordinator ZIMBABWE Nicolas Hamel Montr�al, QC Nurse Dominique Poissant Montr�al, QC Water and sanitation specialist Circulation: 90,500 Layout: Tenzing Communications Printing: Warren's Waterless Printing Summer 2009 ISSN 1484-9372 15 DISPATCHES M�decins Sans Fronti�res (MSF) 720 Spadina Avenue, Suite 402 Toronto, Ontario, M5S 2T9 Tel: 416-964-0619 Fax: 416-963-8707 Toll free: 1-800-982-7903 Email: email@example.com www.msf.ca Dispatches Vol. 11, Ed.2 NOT ALL FIGURES DECLINE IN A RECESSION. VIOLENCE-RELATED TRAUMA 48,871 HIV/AIDS 227,591 CHOLERA MALNUTRITION 68,293 331,918 +46% +36% +58% +77% reverse the trend. www.msf.ca *Increase in number of patients cared for by MSF in 2008. donate today.