Dispatches (Winter 2013) by Doctors Without Borders / Médecins Sans Frontières (MSF) Canada

Dispatches MSF CANADA MAGAZINE

Volume 17

Edition 1

Winter 2013

Syria:

the violence continues

Syria: Lifesaving care in a war zone, p. 02 | mali: â&#x20AC;&#x153;We will not abandon our patientsâ&#x20AC;?, p. 04 south sudan: Night shift in a refugee camp, p. 06 | maternal health: Safe delivery, p. 08 swaziland: Expert clients bring hope, p. 10 | innovation: Technical innovations that save lives, p. 12 profile: Wendy Rhymer, nurse-midwife, p. 14

Lifesaving care in a war zone No one said anything about missions in cold places.

his is what I thought to myself as I huddled under five layers of blankets, wearing three layers of clothes, on my second night in northwestern Syria. Before leaving for my first mission five years ago, the words Médecins Sans Frontières (MSF) conjured up images of sweltering African heat, dusty landscapes, and malaria-carrying mosquitoes. Now I often wonder how to organize my laundry, since it is difficult to send things to the wash when you are wearing all your clothes all the time. True, this is not my first mission in a non-tropical climate (northern Pakistan in January could hardly be described as toasty), yet the absence of reliable and effective heating brings a whole new dimension to “life in the field.”

The cold also means other things. Ironically, it means an increase in burn patients arriving at the hospital. People in the area face fuel shortages and a lack of proper receptacles for burning materials in. A large number of displaced persons living in camps lack effective shelter from the cold. What this means is people will burn anything, and burn it in anything, in order to stay warm. But as these methods are often insecure and unsafe, accidents are all too common – particularly for women, responsible for meal preparation, and children, who suffer most acutely from the cold and are therefore often closest to the source of heat. I am greeted some mornings by a small contingent of “masked crusaders”: children wearing facial burn dressings made of bandage material, with holes for their eyes, nose, and mouth making them look like a tiny band of balaclavaclad bank robbers ready for their next heist.

And of course, the violence of the war in Syria continues. Even as the front line, ever changing, moves farther away, the aftereffects remain – a plethora of arms means that disputes take on a more lethal tone, stray bullets are indiscriminate in their targets. We also see the effects of delays in treatment, or improper management in those patients arriving from centres ill-equipped and not at all trained to deal with the war injuries they now face on a regular basis. MSF has been working in this particular region since June 2012, operating a small surgical trauma unit, initially set up to treat war injured. While these activities continue, evidence of the conflict’s toll on the availability of other health services becomes increasingly apparent. People are unable to find treatment for longstanding chronic disease, leading to an increase in complications from things such as diabetes and heart disease.

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syria

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My job here officially is to be responsible for the supervision and function of several advanced medical posts, known as AMPs. This means making contact with, and providing training to, some of the civilian-run field posts that are closer to the front lines of the fighting. I have so far managed to make two visits – a combination of security and lack of staff here making more visits impossible thus far. Many areas are shelled on a near-daily basis.

gether to fill some of the gaps in health service delivery that has come with the destruction of hospitals and the loss of trained staff. They are students – of law, of engineering, one medical student, two dentists. Together with others they have joined the group with the hope of just lending a hand. They are eager to learn, but sure have a lot to learn. I am hoping a series of days in the hospital here can help them consolidate some basic skills.

be bombarded with lower extremity injuries in order to consolidate the words for “knee,” “foot,” “toe” and “leg.”

I am hoping, in the upcoming weeks, to bring some of the non-MSF staff from one particular post here to our emergency facilities and give them training to improve their capacity to treat the most common problems seen at their post. Yet here’s the wrinkle: the majority of the staff at the health post have no medical training. They are a group of local young men who have joined to-

Training is further complicated by my utter lack of ability to speak Arabic, although I am trying: I have started informal lessons with one of our translators, and have so far mastered: “hello,” “how are you,” “no problem,” “OK,” “my name is...” and “good bye.” Every day I also try and work a new body part into the mix, and use it as often as possible in conversation. Today I caught myself fervently hoping to

AnneMarie Pegg Doctor

And now, my follow-up clinic beckons. Our care doesn’t stop at hospital discharge – the dressing changes, wound assessments, and post-operative management continues. And I have some tiny bank robbers to entice into mischief before the end of the day.

AnneMarie Pegg (pictured on cover and top left on this page) is a family doctor from Yellowknife. She has worked for MSF since 2008, in Ethiopia, Haiti, Republic of Congo, Pakistan and Central African Republic.

“We will not abandon our patients now” Access to free, quality healthcare still vital

he volatile situation in early 2013 around Gao, Mali meant fewer patients were able to come to the Médecins Sans Frontières (MSF) health facilities, but physician Jose Bafoa says the priority for him and his teams was always to continue providing care to their patients.

It remains the leading cause of death in the country, including for children under the age of five.

An average of 120 patients were making their way to the MSF-run Wabaria and Sossokoira health centres near Gao every day as of mid-February. Even though the rainy season was over, 70 per cent came with malaria, a parasitic disease that leaves sufferers exhausted from high fevers and uncontrollable shivers. Despite the war, it is malaria that the medical teams battled against.

“Although there is a hospital and 10 health centres in and around Gao town, this is for a population of 400,000 and we realized that some people still had no access to medical care. And with the current insecurity, where people are on the move and often have even less means, giving them access to free and quality care is even more vital. So far we have seen 16,000 patients.”

“Since we started working in the health centres in September last year, we have generally seen a constant number of patients,” says Bafoa.

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mali

In January of this year, French and Malian forces launched an offensive against various armed groups operating in the north. In Gao, the most significant force is the Movement for Unity and Jihad in West Africa, a splinter group of the better known Al-Qaeda in the Islamic Maghreb. “People fled in fear of the air strikes and reprisal attacks. Some went to neighbouring countries, but others found shelter in small villages or in the bush where living conditions are harsh. So aside from malaria, we have seen an increase in the number of patients coming in with diarrhea and skin diseases due to the lack of hygiene, as well as an increase in cases of acute respiratory infections caused by the dust and wind,” says Bafoa.

In the vast desert areas of northern Mali, bringing treatment closer to patients is another essential aspect of the project. Mobile teams work in remote areas, the rationale being that if patients can’t come to MSF, then MSF has to go to them. But, with fears of land mines on the roads, MSF has been forced at times to temporarily suspend the work of those teams.

Epidemiological surveillance is another key part of the project, ensuring MSF staff are able to respond to disease outbreaks rapidly. “We need to be ready to respond to any medical eventuality, be it an outbreak, war wounded or people affected by displacement. In Ansongo we see some 100 patients a day,” says Bafoa. “Our patients tell us

“Through our mobile clinics, we of course offer primary healthcare, but we also try to ensure that pregnant women have routine prenatal consultations,” says Bafoa. MSF also supports community health centres, supplying them with medicines and essential materials.

that all they hope for is peace. And we are with them; we stayed here throughout the air strikes, we will not abandon our patients now. We hope that the health system will develop and eventually replace us. But until then, we will stay and ensure that the people of Gao and Ansongo continue to have access to quality and free healthcare.”

Physician Jose Bafoa (pictured below, right) worked in Mali as a medical team leader for MSF this past winter. He has worked for MSF since 1999, including in Uganda, Chad, and Central African Republic, as well as in his home country, Democratic Republic of Congo.

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The main aim of the project since it opened is to lower mortality rates by increasing access to healthcare and responding to emergencies. In the town of Ansongo, where MSF supports a referral hospital, mortality rates in the centre went down from more than eight per cent to 1.2 per cent in less than three months.

south sudan

“A strange and rather magical time”

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Night shift in a refugee camp 06 As of the end of 2012, more than 170,000 refugees had crossed from South Kordofan and Blue Nile states in Sudan and gathered in five camps in remote and inaccessible areas of South Sudan. Because of the camps’ geographical location – on a flood plain in the rainy season and a parched wasteland in the dry season – the refugees rely on humanitarian assistance for the food, water and healthcare they need to survive. Médecins Sans Frontières (MSF) is the main healthcare provider in all of the camps. Here, one physician shares his experience working a typical night shift at the field hospital in Batil refugee camp, as the work to keep saving lives continues around the clock.

he night time is considered a critical moment in the field hospital here. We start with a round of the wards so the doctors on the day shift can tell me about their patients. Last night we started with a man in the inpatient department who had just been brought in with suspect meningitis. We did a lumbar puncture, taking a sample of the spinal fluid, and the result was cloudy, which meant we needed to send

it off for further laboratory tests. He was in critical condition. Non-stop care The other place I need to know about is the intensive care ward for severely malnourished children. Last night all the patients were stable apart from one girl who was extremely dehydrated and was having constant diarrhea. We had to give her a special

fluid to replace what she was losing with the diarrhea and vomiting. We needed to weigh her every hour because we were giving her a lot of this fluid, but we needed to make certain we were not overloading her system as that can be very dangerous. These children are so weak that we need to give them this fluid extremely slowly with a syringe. And you have to do this carefully all through the night, give fluid, check weight, wait, give fluid, check weight again…

Remaining focused

But we always have some patients who are very ill and who can go from just about stable to seriously sick in just a few seconds. The other day a child we were treating for severe cerebral malaria started having convulsions. That was two hours of intense activity. When a child goes into seizure it can bring on a respiratory repression and so you have to stop the seizure immediately as the shortage of oxygen can bring about cerebral damage. We followed the usual emergency protocol for seizures, but then she stopped breathing. So we had to start manual respiration with a breathing aid, but this was difficult as she was having really bad convulsions, shaking and writhing around on the bed. It was a hard decision to make because the drug to stop the seizures has a side effect of lowering the breathing rate of the patient. We had to stop the seizure so we needed to keep giving the drug, even though it was having a bad effect on her breathing. After about 25 minutes we managed to stop the seizure, but this was really long for a seizure and the risk of cerebral damage was high. And throughout all this we were ventilating manually because if you stop ventilating for two or three minutes the patient could die.

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Sudden emergencies and difficult decisions

07 © Olga Overbeek / MSF

In a way you get much more of a connection with your patients and the medical staff during the night shift. For me it’s a strange and rather magical time: everything is quiet after the rush and noise of the day, just the sound of the generator and the falling rain, and you get to pause for a minute and drink some coffee with your Sudanese and South Sudanese colleagues. In between emergencies you get to stop and think.

The patients who are not stable often become critically ill during the night. And that can be difficult. You need to keep totally focused on the most critical cases. If you leave a weak patient for too long, they can become really unstable and die.

Sometimes we are lucky

which is really exhausting. And then suddenly her chest started to move and so I stopped and she was half breathing. So I continued to support her breathing for a while and little by little she started breathing by herself. Throughout the rest of the night she was unconscious but stable.

At one point I started thinking that this child was eight years old, the same age as my daughter. I think this somehow helped me to keep going, and I kept ventilating the girl for 40 or 45 minutes,

The next evening, when I came back at 6 p.m., she was sitting and drinking. She stopped and smiled at me. She must have recognized me from the previous night. So I did some quick examinations

and yes, her life was saved and it seemed without any obvious cerebral damage. I don’t believe in miracles, but sometimes we are lucky.

Roberto Scaini Doctor

Roberto Scaini (pictured above) is a physician working with MSF in South Sudan.

maternal health

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Burundi and Sierra Leone have two of the world’s highest maternal mortality rates. A 24-hour, emergency obstetric care and ambulatory care system started by MSF has helped save the lives of thousands of women.

Safe delivery

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Left to right Row 1: • Patients at MSF’s emergency centre for gynecological and obstetric care in Kabezi, Burundi line up for breakfast. All services at the centre, including meals, are free. • MSF staff examine a patient at the Gondama Health Centre in Bo District, Sierra Leone. Row 2: • An MSF nurse does a prenatal exam on a patient at the Gondama Health Centre. • An MSF nurse prepares to take a patient by ambulance to the emergency centre in Kabezi. • An MSF doctor meets with a new mother and her baby at the Gondama Health Centre. Row 3: • Staff prepare a patient for a C-section at MSF’s emergency centre for gynecological and obstetric care in Kabezi. • Women are transported by ambulance to MSF’s Gondama Health Centre.

swaziland

Why Swaziland? © Giorgos Moutafis

How does this tiny, landlocked kingdom have the highest rates of HIV in world? It’s a simple question with a very complex answer that involves traditional values, poverty, an absolute monarchy, gender inequity and a host of other factors.

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Some 31 per cent of adults are HIV positive and tuberculosis (TB) is rampant with 1,275 cases per 100,000 people. The result is that life expectancy has plummeted from 61 to 40.2 years in just two decades in this country of 1.2 million.

10 Expert clients bring hope to HIV-positive Swazis

ylvia Khuzwayo became an activist back in 1998 when she learned she was HIV-positive. “I was outraged,” she says, when physicians initially withheld the diagnosis from her because she couldn’t afford antiretroviral therapy (ART). They had also lied to her about her husband’s cause of death. “They said it was throat cancer. It was AIDS.” Khuzwayo’s CD4 count (the measurement of a type of white blood cell) was

210, making her eligible for ART. She couldn’t afford the medication, but knew that without it she would never see her three children as adults. She overcame her fear of discrimination and stigma, taking the risky but necessary step of disclosing that she was HIV-positive. She asked friends and family for help; some promptly ended the relationship. “Some friends don’t want to be seen with you because people would think they were positive too.” But others came through

For Elias Pavlopoulos, head of mission for MSF in Swaziland, it is one of the biggest crises he has ever seen. “I’ve been in Darfur [Sudan], in Burma too, but I couldn’t believe this.” Swaziland has a solid healthcare infrastructure with 13 public hospitals and health centres plus 186 clinics, but it’s not up to handling the dual epidemic of HIV and TB, especially given that there are only two physicians and 28 nurses per 10,000 people. Cultural traditions further complicate matters. Polygamy is common and 73 per cent to 95 per cent of transmission is through heterosexual contact between longer-term, older partners according to a UN and Swaziland report. (HIV Prevention Response and Modes of Transmission Study). In addition, the fertility rate is 3.8 children per woman, but since 69 per cent of Swazis live below the national poverty line, many women are forced to engage in transactional sex to obtain food or other necessities for their children. In general, women have very few rights amidst patriarchal traditions. One in three Swazi women is sexually assaulted in her lifetime; 25 per cent of pregnancies are among teens.

At the time of Khuzwayo’s diagnosis, Swaziland’s government was in denial about HIV prevalence. Today, the landlocked kingdom has the world’s highest rate of HIV; some 31 per cent of adults are HIV-positive. In addition, tuberculosis, an opportunistic infection, is rampant with 1,275 cases for every 100,000 people. After being diagnosed, Khuzwayo worked as a research consultant and on various pilot projects before Médecins sans Frontières (MSF) hired her in 2008 as one of eight expert clients. Expert clients work at the community level, conducting campaigns, meeting with chiefs and other leaders and working with patients living in remote areas, among other things. Swaziland faces a chronic shortage of physicians and nurses so shifting certain tasks

to lesser trained workers is essential. Expert clients are the key to MSF’s emphasis on task shifting. “The current system [staffing] couldn’t cope with demands,” says Pieterjan Wouda, the field coordinator at MSF’s project in Shiselweni region. “It’s a waste to use a doctor to do follow up. We’ve managed to achieve results through expert clients. It’s a beautiful system.” Initially, Khuzwayo’s job was to recruit and train expert clients in Shiselweni, the hardest hit of Swaziland’s four regions. The number of expert clients grew to 22 by 2010. “[We] are the key to reducing stigma because clients see someone who is positive and healthy, and then they believe they can also live a healthy life,” she says. Expert clients initiate testing and treatment and encourage adherence. Some experts specialize in TB, others work in hospitals. Today, 44-year-old Khuzwayo is the community psychosocial supervisor in one of three zones of Shiselweni, looking after 12 community expert clients.

Cynthia Cebo Dlamini, who works at the Hluti clinic, is one of them. Cebo Dlamini was diagnosed with HIV in 2004 when she was pregnant; her child subsequently died at just six months of age. Every day, Cebo Dlamini visits five to seven patients in their homes. She also hosts meetings for up to 40 clients at a time. “I get women together to talk about their HIV status at Liguma (a gathering for married women) and in traditional settings, as well as in schools.” Despite her managerial duties, Khuzwayo still sees clients. “It’s here,” she says, tapping her chest. “As a long survivor I can show people you can live with treatment. Without treatment you die in five years. I am giving them hope.”

Barbara Sibbald Journalist

Dispatches Vol. 16, Ed.1

with support she desperately needed. She’s been on ART since 2001 and has devoted herself to being a front-line activist by encouraging others to test, to treat and to live healthy, productive lives.

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Technical innovations that save lives W

hen Toronto emergency physician Raghu Venugopal worked in eastern Democratic Republic of Congo, he met patients with spinal tuberculosis (TB) whose backs were bent at an angle. Staff put these patients in corsets that kept them completely straight. One patient was wearing a cast that reached from his chest to his knees so that he was barely able to move. Venugopal was puzzled. “I had not come across this disease before,” he says “I was not sure if the treatment was good or bad for the patients.” Venugopal knows a wide personal network of medical specialists, including TB experts. He consulted with them by email. He learned that a simple soft back support combined with TB treatment was the best solution, and the treatment for the condition changed.

Many doctors working for MSF in the field face similar problems. They are often confronted with complicated medical issues they are not familiar with or are unsure about. Working in remote, isolated places, they usually don’t have access to a team of colleagues they can ask for advice as they would have at home. Not everyone has access to specialists they can contact. To support its medical staff and help them offer the best care possible for patients, MSF introduced a telemedicine system – or e-referral – at the end of 2010. The web-based, confidential, password-protected interface allows doctors and medical coordinators in the field to post questions about real, complicated clinical cases that require specialist help. They are able to not only describe the

clinical case but also to upload photos, X-rays or ultrasounds if needed and if those are available. To ensure anonymity, referrers are asked not to include any identifying information about the patient. The system breaks the isolation of MSF physicians from the medical community, and allows physicians elsewhere, including those in the academic world, to contribute to MSF’s lifesaving work. It is administered in multiple languages by two operators in Europe and a third in Canada, physician and former MSF president, Joanne Liu from Montreal. “As soon as I get an email alert that a referral has come in through the system, I try to find a specialist that can help,” she says. ”We generally get an answer in less than 20 hours.” Many cases are answered within a few hours, with the more complicated ones taking longer.

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innovation

Venugopal, who is currently working as a medical coordinator in Chad, is confident he will use the system during his time there to ensure his patients receive the best care possible. Simplifying TB testing, improving diagnosis In the city of Nukus in Uzbekistan, Newfoundland-based physician Jamal Ahmadian Yazdi learned to appreciate access to another technical innovation that helps save lives: a new, molecular TB testing device called Xpert® MTB/RIF (also known as ‘GeneXpert’) that makes TB diagnosis more accurate and faster in many cases.

ficult to detect tuberculosis. People with compromised immune systems – for example those with HIV/AIDS – often test negative for TB using microscopy although they are sick with the disease. If their TB is left untreated, not only is there a higher risk of death, but they can also spread the disease to others. The device also helps improve the diagnosis for multidrug-resistant TB, which is on the rise in many parts of the world. In an MSF test site in Zimbabwe, for example, a threefold increase in the number of multidrug-resistant TB cases was observed in the six months following the introduction of the new testing device, meaning that more people could be started on appropriate treatment sooner. Peter Saranchuk, TB-HIV adviser for MSF’s South African Medical Unit, says that while the new testing device is not perfect, MSF’s experience has overall been positive. But there are a few issues, he says. “The main challenge is logistics,” says Saranchuk. “For the device to work properly we need stable power supply and an operating temperature of less than 30 degrees Celsius. In many of the settings where we work, this re-

quires us to set up additional equipment that stabilizes the power supply for the machine and the air conditioning of the room it is in.” Once those conditions are in place the machine can be used even in smaller, decentralized health facilities. Another issue is cost: the current price of the machine is about $17,000 and the cost of each cartridge required to perform a single test is about $10, making it prohibitively expensive for many resource-limited health facilities – those that need better TB testing the most. However since the machine can potentially reduce the time to diagnosis of TB and the need for other tests (e.g. chest X-ray), it can reduce the workload of clinicians and laboratory technicians and so may still turn out to be cost-effective. Since 2011, MSF has introduced these testing devices in 25 sites in 14 countries, including South Africa, Mozambique, Myanmar and Uzbekistan.

Claudia Blume Communications officer

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Liu and the operators in Europe call on a pool of 400 volunteers who live across the globe, making it easier to get help around the clock. They offer support in English, French and Spanish. Many of them have experience working in developing countries, enabling them to give advice to colleagues working in low-tech environments. Each field hospital has its own profile within the telemedicine system, giving the specialist the chance to review the kind of facilities and equipment that is available at the site. According to Canadian physician Leslie Shanks, medical director at MSF’s operational centre in Amsterdam, the monthly average of referrals has increased from only a few cases a month when the project started, to more than a dozen a week.

“GeneXpert not only makes the testing faster, it is also extremely easy to use and a lot more reliable,” says Yazdi.”Now we have a better idea what medicine the TB strain is likely to be sensitive to and what anti-TB drugs we should give to a patient. The cure rate should improve. With the old way of testing there was often a lot of uncertainty.” The higher accuracy rate of the new device is important because it is often dif-

The machine (pictured, right) can detect within two hours whether a person has TB and whether or not the TB strain can be treated with rifampicin, one of the most common and important anti-TB drugs. This is a significant development, as the standard test for TB – looking at sputum under the microscope – has some serious limitations.

Previous page: Mothers with young children wait to be seen by an MSF doctor in Guri El, Somalia, part of a telemedicine consultation with a medical specialist in Nairobi. Above: The GeneXpert machine can identify the bacteria responsible for tuberculosis (Mycobacterium tuberculosis) and also drug resistance.

profile

Wendy Rhymer

hen people are fleeing armed conflict or when a healthcare system is failing, pregnant women and women in labour are left vulnerable. Maternal care is a critical part of many Médecins Sans Frontières (MSF) projects for women who otherwise may have little or no access to lifesaving medical care.

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Wendy Rhymer is a nurse-midwife from Winnipeg. Since 2007, she has worked in six field projects with MSF, including in Ethiopia, Somalia, Sudan, India and most recently Pakistan, where she worked as a deputy medical coordinator.

Why did you join MSF?

WR: From the beginning I liked the idea that MSF often goes where others don’t. People caught in a war or living through disaster have the right to lifesaving medical help. Also, we give quality care to our patients. These aspects were and still are part of what draws me to MSF. Providing care for people in such vulnerable situations can be emotionally draining, and the often long hours and workload can be tiring. However, even on my hardest day, I know am helping people and making a difference in their lives, and that this is where I should be.

MSF nurse-midwife

Who is part of your team in the field? How do staff work together? WR: It really varies, depending on the size of the project and people’s medical needs. Close to 90 per cent of MSF’s staff are from the countries where we work. In India, I worked with 100 Indian staff, including doctors, nurses, drivers and translators among others. The international members of the team included a project coordinator, a logistician, two doctors, a nurse, and myself, the nursemidwife. In South Sudan, the team included 10 international staff and 150 South Sudanese staff in both medical and nonmedical positions. My role in Pakistan was different because I was part of the coordination team and, in collaboration with the medical coordinator, was responsible for overseeing the medical programs for four hospitals. I supported the Pakistani and international doctors, nurses and midwives doing hands-on medical care. I still covered for them when it was needed and was always on call if there was an emergency.

Syria. South Sudan. Mali. Swaziland. Follow us across borders.

What is the best part of your job? WR: The best part of the job is that moment in the delivery room, when every possible problem and complication has occurred and you don’t realize you have been holding your breath, just hoping that it works out...and then the baby is delivered and you wait a second, and then the baby cries, and everyone starts cheering and laughing, and you smile to yourself and think yes, it’s going to be OK. Life is good.

What would you say to a midwife thinking about applying to MSF? WR: Working as a midwife for MSF will be one of the most challenging, frustrating, exhausting and rewarding experiences you will ever encounter. Some moments you will be heartbroken, as you can only do so much with the resources available. On the other hand, you will have so many miracle moments, when a baby or mother survives against all odds, and you will know that you are in the right place at the right time, doing what you were meant to do as a midwife.

MSF staff work around the world, providing emergency medical relief to people in crisis. Connect with us through Twitter and Facebook for our latest updates.

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Dispatches

Médecins Sans Frontières (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: msfcan@msf.ca www.msf.ca

Sébastien Gay Montreal, QC Logistician Oliver Sven Schulz Toronto, ON Head of mission India Patrice Beaulieu Montreal, QC Logistician Iraq Lorna Adams Toronto, ON Doctor Sarah Vanessa Atkinson Pemberton, BC Mental health specialist Joseph Baugniet North Lunenburg, ON Project coordinator Lori Demontigny Erickson, MB Nurse Stephanie Gee Vancouver, BC Nurse Nidal Tbaileh Toronto, ON Anesthetist MD Kenya Christina Cepuch Fonthill, ON Medical coordinator Kyrgyzstan Alexandra Vanessa Ascorra Torres Quebec City, QC Biomedical analyst Malawi Nancy Semkin Toronto, ON Human resources development officer Myanmar Jean Bédard Quebec City, QC Logistician Elaine Roy Montreal, QC Nurse Niger Sonia Jérémie Cadet Laval, QC Doctor Stéphanie Lebel-Rispa Greenfield Park, QC Nurse Alphonsine Mukakigeri Montreal, QC Logistician Nigeria Nicolas Bérubé Quebec City, QC Logistical coordinator Geneviève Biron Montreal, QC Nurse Anna Funk Chilliwack, BC Epidemiologist Ivan Gayton Nelson, BC Head of mission Patricia Gould Courtenay, BC Nurse Kanadi Ibrahim Ottawa, ON Logistician Crystal Van Leeuwen Toronto, ON Nurse Pakistian Peggy Mei-Yuk Chan Coquitlam, BC Mental health specialist Asha Gervan Toronto, ON Humanitarian affairs officer Karel Janssens Toronto, ON Head of mission Alexandra Marcil Montreal, QC Pharmacist Miroslav Stavel Burnaby, BC Doctor Republic of Congo Sara Badiei Coquitlam, BC Logistician Editor: linda o. nagy Editorial director: Micol Zarb Translation coordinator: Jennifer Ocquidant Contributors: Jose Bafoa , Claudia Blume, AnneMarie Pegg, Roberto Scaini, Barbara Sibbald Cover photo: © Brigitte Breuillac / MSF

South Africa Avril Benoît Ottawa, ON Nicholas Gildersleeve Frelighsburg, QC

Project coordinator Logistical coordinator

South Sudan Syed Imran Ali Toronto, ON Water and sanitation specialist Nicole Desi Toronto, ON Nurse Pascal Desilets Ottawa, ON Logistician Anabel Deumier Montreal, QC Water and sanitation specialist Jean-François Dubé Stratford, ON Logistician Tyler Foley Oromocto, NB Deputy logistical coordinator Melissa How Calgary, AB Nurse Michael Minielly Belleville, ON Logistician Claudine Marie Peleo-Castro Toronto, ON Doctor Robert Sanda Calgary, AB Surgeon Rachelle Seguin Longueuil, QC Medical team leader Abdullah Shah Toronto, ON Logistician Nila Somaia Vancouver, BC Mental health specialist Michael Talotti Bowmanville, ON Administrator Michael White Toronto, ON Head of mission Rosanna Wilson Vancouver, BC Nurse Jason Van Dyke Pembroke, ON Logistician Sudan Kevin Coppock Toronto, ON

Head of mission

Swaziland Jessica Burry Ottawa, ON Pharmacist Joanne Cyr Montreal, QC Mental health specialist Serge Kaboré Quebec City, QC Medical coordinator Pieterjan Wouda St-Lambert, QC Project coordinator Syria AnneMarie Pegg Yellowknife, NWT Claudette Seyer Outremont, QC

Doctor Nurse

Tajikistan Andrew Bohonis Thunder Bay, ON

Logistician

Uzbekistian Gregory Scott Delta, BC Administrator Alia Tayea Mississauga, ON Epidemiologist Trevor Toy Calgary, AB Pharmacist Yemen Miriam Lambert-Lindsay Saint-Joseph-de-Coleraine, QC Céline Langlois Montreal, QC

Project coordinator Nurse

Circulation: 109,000 Layout: Tenzing Communications Printing: Warren’s Waterless Printing Inc. ISSN 1484-9372

Dispatches Vol. 17, Ed.1

Afghanistan Layebe Ignegongba Montreal, QC Pharmacist Georgann MacDonald Shelburne, NS Nurse Ryan MacIver Stouffville, ON Logistician Thierry Poirier Montreal, QC Logistician J.L. Talbot-Crosbie Toronto, ON Project coordinator Bangladesh Paulo Rottmann Toronto, ON Finance and human resources coordinator Central African Republic Lucie Barré Quebec City, QC Nurse Étienne Blais Montreal, QC Logistician Piyali Chakraborti Thornhill, ON Logistician Daphne Hemily Toronto, ON Logistician Mark McCaul Mississauga, ON Logistician Todd Phillips Winnipeg, MB Project coordinator Kirsty Robertson Toronto, ON Nurse Jaime Zhen-Mei Scarborough, ON Nurse Chad Comlan Paulin Amoussou Montreal, QC Doctor Ève Charbonneau Sainte-Flavie, QC Nurse Réjean Côté Wickham, QC Project coordinator Ritu Gambhir Toronto, ON Humanitarian affairs officer Fabienne Gilles Toronto, ON Human resources coordinator Diana Nicholson Rosser, MB Water and sanitation specialist Raghu Venugopal Toronto, ON Medical team leader Democratic Republic of Congo Grant Assenheimer Edmonton, AB Project coordinator Janick Audy Gatineau, QC Human resources coordinator Julie Bédard Salaberry de Valley, QC Nurse Laélia Bilodeau Belœil, QC Nurse Franciscus Blom Westmount, QC Financial coordinator Martine Bouchard St-Jérôme, QC Nurse Patrick Boucher Quebec City, QC Logistical coordinator Dawn Catherine Brinkman Vancouver, BC Logistician Laura Crickett Toronto, ON Logistician Bertha Fuchsman-Small Sainte-Anne-de-Bellevue, QC Doctor Tomislav Jagatic Tecumseh, ON Doctor Sarah Lamb Kanata, ON Project coordinator Hélène Lessard St-Georges, QC Financial coordinator Judith Letellier Montreal, QC Deputy head of mission Melissa Maurus-Liben Montreal, QC Nurse Ellen Rachel Morgan Toronto, ON Administrator Anne O’Connor Toronto, ON Nurse-midwife Nicolas Perez Montreal, QC Logistician Ashley Sharpe Halifax, NS Nurse Elise St-Denis Quebec City, QC Information, education, communication officer Ethiopia Stephen MacKay Halifax, NS Logistician Haiti Maryse Bonnel Morin Heights, QC Nurse Lindsay Bryson Beaconsfield, QC Medical coordinator Judy-Fay Ferron Louiseville, QC Water and sanitation specialist Delphine Ferry Montreal, QC Human resources coordinator

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1999 Nobel Peace Prize Laureate

ÂŠ Giulio Di Sturco

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