Dispatches (Winter 2011) by Doctors Without Borders / Médecins Sans Frontières (MSF) Canada

MSF CANADA MAGAZINE

Volume 14

Edition 1

Winter 2011

DISPATCHES AFGHANISTAN NO WEAPONS. NO FEES.

NIGERIA: Continuous emergencies, overlapping health threats, p. 05 HAITI: Offering assistance and earning trust, p. 08 | HAITI: Cholera outbreak, p. 09 PAKISTAN: Aid for survivors of massive flooding, p. 10 | SUDAN: Breaking a taboo. A message from within, p. 11 DJIBOUTI: “I am still not used to losing kids. I started to think I was…”, p. 13 | MSF READS: Hope in Hell, p. 14

AFGHANISTAN

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Relying on private donations for lifesaving care

02 édecins Sans Frontières (MSF) started working again in Afghanistan in October 2009, after a five-year absence following the assassination of five MSF staff in Badghis province in June 2004. MSF’s return was motivated by an overall worsening in healthcare for Afghans with the country once again engulfed by war. People in Afghanistan have been trapped for years in conditions of poverty and a general lack of access to medical treatment, particularly to secondary healthcare.

“This breakdown of vital services will only get worse as this conflict continues,” says Michiel Hofman, MSF’s country representative for Afghanistan. “So MSF decided to concentrate on the most conflict-hit regions and to focus on secondary care, like surgery and

maternal services, as this is what helps save lives.” It was crucial for MSF to secure agreements with all parties involved – including the Afghan army and police, troops from international military forces and various opposition groups – to ensure the hospitals where its staff would provide care are safe places for patients to be treated. “The most visible consequence of this agreement with all sides is a strict ‘no weapons’ policy in the hospitals,” explains Hofman. “Having armed people in or near a hospital naturally makes it a target. This principle is usually well understood in conflict zones, but Afghanistan was the first conflict setting I’ve worked in where I found a large presence of armed people inside the structures.”

AhmAd Shah Baba’s ﬁrst surgical patient

But just over a week later, shortly before sunrise, Akram felt an excruciating pain in his lower abdomen. “I think everyone in the neighbourhood heard my shouting,” he says. His son again brought him to Ahmad Shah Baba Hos-

MSF chooses to rely solely on private donations for its work in Afghanistan, and does not accept funding from any government.

AHMAD SHAH BABA DISTRICT HOSPITAL, EAST KABUL Ahmad Shah Baba – or Arzan Qimat (‘cheap land’ in the Dari language) as it used to be known – is a sprawling urban settlement of 200,000 to 300,000 people on the outskirts of east Kabul. Kabul’s overall population has increased dramatically in the last 10 years, from around one million to three to five million today. The increase is related to insecurity, as well as people coming to the capital for economic reasons.

pital, where the operating room had opened for the first time that morning and the surgeon and anaesthetist were now in place. He was diagnosed in the emergency room with a strangulated hernia – a critical condition where an organ pushes through a weak area in the abdominal wall and cuts off blood supply to the area – and sent straight to the operating room.

Two days after his operation, Akram is sitting cross-legged in his inpatient ward room. He’ll be discharged the next day and is in good spirits. He plans to spend this winter with his family in Kabul but is looking forward to heading back to his farming life. “I only found out afterwards that I was the first person to be operated on in this hospital,” he says. “I’m lucky to be alive, so it’s quite a victory for me.”

“Even though Kabul is a relatively stable, urban setting, we decided that Ahmad Shah Baba represented a vulnerable group largely neglected by international donors who tend to go where their government’s troops are based, outside the capital,” says Hofman. MSF international and Afghan doctors, midwives and nurses are working together with Ahmad Shah Baba District Hospital’s medical staff to improve quality of care. The building was rehabilitated and improvements made to the maternity section, emergency room, laboratory and X-ray departments. More recently, an operating room and small inpatient department were completed. This means basic but lifesaving surgical procedures like caesarians can now be done locally instead of being referred to hospitals an hour away.

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Akram initially went to the emergency room at Ahmad Shah Baba Hospital, which is close to his house. But with the new operating room not yet ready, the medical staff referred him to a hospital in the centre of Kabul. “They gave me medicine and an ultrasound which found nothing. Instead, they told me to go home.”

“Now I’m responsible for everyone at home: three sons and a sick wife,” says 70-year-old Akram. “I wasn’t feeling very well myself and I had a lot of pain here,” he says, pointing to his abdomen.

Mohammed Akram, a farmer from eastern Laghman province, moved to Ahmad Shah Baba, a sprawling settlement on the far outskirts of east Kabul, just a few months ago to join his family.

hospital’s total intake, the pediatric wing had a bed occupancy rate of 150 per cent until September 2010. This meant additional beds and occupants lining drafty hallways with little privacy. “When I arrived, we had patients in the corridors – it was the totally wrong place for our children,” says MSF pediatrician Laura Mendicoa, who works alongside Afghan doctors and nurses. “Most of them were in serious condition. Many times when we had lifethreatening cases... we had to resuscitate children in front of the fathers, in front of all the relatives, with little to no proper equipment.” A much-needed 16-bed extension, added at the beginning of September 2010, brought the ward up to 30 beds, spread out over three sections: a six-bed intensive care unit, an eight-bed therapeutic

feeding centre and 16-bed general pediatric centre. An upgraded emergency room, staffed by a permanent doctor and nurse, now offers a 24-hour stabilization point for an increasing number of violent trauma and war-wounded patients, which are then referred to other departments for more specialized care. Since the emergency room opened in May 2010, around 20,000 patients – 10 per cent of which are considered critical cases – have received treatment. MSF planned to begin extending its support to hospitals and rural health centres in other provinces in Afghanistan towards the end of 2010.

Kate Ribet Communications officer

BOOST HOSPITAL, LASHKARGAH, HELMAND PROVINCE In November 2009, MSF also started to work in Boost Provincial Hospital in Lashkargah, the capital of Helmand province. The region’s roughly one million inhabitants have been among the people most affected by the ongoing conflict. As one of only two functioning referral hospitals in south Afghanistan, Boost Hospital was seeing 120 to 160 patients per month. The main hospital is now treating an average of 1,200 patients a month. MSF’s support to the 145-bed hospital includes maternity, pediatrics, surgery, the intensive care unit, inpatient services and emergency rooms. MSF is also involved in the rehabilitation of key facilities, as well as putting in place sterilization and hygiene protocols. With a current average of 200 deliveries each month, the maternity section now offers pre- and post-natal care, family planning and an increased capacity for caesarian sections and complicated deliveries. Surgical procedures including caesarian sections have doubled since January 2010, with an average of 200 surgeries and 20 caesarians now performed each month. Most critically, while children’s cases form between 25 and 30 per cent of the

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Lisbet Pettersen is an MSF nurse at Ahmad Shah Baba. Her work includes training some of the 50 new Afghan nurses recruited for the hospital’s expanding services. “Treating the common, everyday cases is what really counts here: skin problems, diarrhea, pneumonia,” says Pettersen. “But we also get a lot of traffic accidents coming in, serious ones. And lots of burn cases. One of the worst cases I saw recently was a girl, around 17, whose pan had exploded while she was cooking. Her face, her neck, her chest were totally burnt. They brought her little baby in too, but she couldn’t breastfeed.” An average of 10,000 medical consultations and more than 350 deliveries take place each month at Ahmad Shah Baba Hospital. A new outpatient area is currently being built and, once complete, the leftover space will be used to expand the inpatient department.

Selema Selema is 11 years old and has been ill for much of her life. Her family used to live in Naw Zad until their house was ruined in the conflict five years ago. “Everything was destroyed,” says her mother Aysah. “We moved to Lashkargah where we live with my son. We’re stuck here because we don’t have any money to go back.” Selema was admitted to Boost Hospital with pneumonia and signs of meningitis and has a host of suspected conditions that would make anyone’s head spin: hyperthyroidism, blindness, abdominal swelling, malformed spine and joints,

and malnutrition. Plus she proved allergic to the antibiotics first prescribed, which made her eyes swell up severely. Pediatrician Laura Mendicoa suspects an underlying neurological condition and tuberculosis, which she and the Afghan staff discuss at length during the morning bedside round. “We’re going to start a course of tuberculosis treatment, because although we can’t treat the neurological problem, Selena will be stronger, she’ll be less prone to infections and she might even be able to walk and eat properly again.”

NIGERIA

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NIGERIA © Misha Friedman

Continuous emergencies, overlapping health threats

05 After working for almost 14 months with MSF in Nigeria – responding to one emergency after another in the country’s north – former head of mission Gautam Chatterjee has no doubts about why MSF medical humanitarian aid is needed here. he thought remains with me that in places like northern Nigeria, the poor are relatively powerless and lack the voice to demand state support and intervention during crisis situations. While other bilateral agencies and UN bodies try to engage the government in discussions and dialogue about a rapid response, organizations like Médecins Sans Frontières (MSF) jump in to start emergency responses so lives can be saved and unnecessary suffering reduced.

In Nigeria, more than 70 per cent of people live below the poverty line. They

have little access to hugely underresourced and poorly managed state health and social service systems. Thirteen out of every 1,000 women die during childbirth, and 94 newborns out of 1,000 do not survive. State health services charge for services and medication, though local health providers don’t inform communities of which demographic groups and diseases are actually exempt. The somewhat fragile coping mechanism of the poor fails when confronted with outbreaks, epidemics and natural disasters. MSF has been working in Nigeria since 1996, responding to disease outbreaks mostly in the epidemic-prone north. Since 2009, MSF has been able to provide rapid response to meningitis, measles and cholera in 18 of the country’s 36 states. In addition, MSF also provides free primary maternal and

child healthcare in selected states in the north and south. I was based in Sokoto State in the northwest, where MSF works in collaboration with the Ministry of Health to provide maternal and child healthcare in the city of Goronyo. From here we also monitor and do surveillance of epidemics and outbreaks in Sokoto, Kebbi, Niger and Zamfara states so we can provide a fast medical response to emergencies when a crisis occurs.

MEASLES AND MENINGITIS ALL AT ONCE We were very busy in 2010 with multiple and concurrent emergency responses in these four states. A measles outbreak started in Kebbi in January 2010 and spread quickly to other states. MSF had to scale up activities rapidly; we set up treatment centres at

local health facilities offering 24-hour, sevendays-a-week service in villages, provided the drugs and paid allowances to local health staff so they were available to work in shifts. By the time the emergency phase was past and we handed work over to the Ministry of Health, MSF had treated more than 42,000 people for measles and vaccinated 128,000 children under five years of age.

pregnant women

Many women in Nigeria suffer an acute and ongoing health crisis, with approximately 59,000 women dying each year in the country from complications in childbirth according to the UN.

Despite thorough preparations that included involving the traditional leaders to inform the target population, the vaccination campaigns had mixed results. The measles vaccination campaign (for children under the age of five only) exceeded our expectations with more than 90 per cent coverage; however, we could only cover about 50 per cent of the target population for the meningitis vaccination.

The numbers are high as the pre- and post-natal services for pregnant women in state-run health centres are not easily accessible or effective. Lack of transportation from villages to referral hospitals also greatly limits access to emergency obstetrics care for many women. MSF medical teams have tried to address this situation by offering pre- and postnatal checkups to pregnant women in selected villages through mobile clinics, and by referring complicated cases to primary health centres or hospitals for follow up. The population has accepted our support and, in one year, the number of women delivering at MSF’s primary health centre in Goronyo has increased from six to 70 a month.

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Critical care for

The meningitis outbreak started around February as we were scaling up for the measles response. The strain of meningitis was different from the one seen in 2009. To make things even more challenging, the outbreak was not explosive in particular locations but was more sporadic and aggressive. Mass immunization was not the answer. Instead, we had to balance our response strategy by doing meningitis vaccination in the most populous areas affected by the meningitis outbreak and provide treatment through the treatment centres as we had done for the measles response.

Teenagers and young people refused to get vaccinated but brought children under five to be vaccinated. At one of the sites in Zamfara I asked some of the young boys hanging out at the vaccination sites why they refused to be vaccinated: they told me they were strong and fit and only infants needed vaccination. We explained how vaccinating all age groups kept more people safe and healthy. By the end of the meningitis response in July 2010, MSF had treated 2,300 patients and vaccinated more than 80,200 Nigerians between two and 30 years old.

MSF SPECIALISTS DISCOVER CAUSE OF UNUSUAL SICKNESS With spring came a situation that would have been difficult if not impossible to anticipate. In April, we investigated reports of an unusually high number of deaths among children under the age of three from two districts in Zamfara State. Initial investigations couldn’t find the cause so we enlisted specialists from one of MSF’s stand-by emergency units. An experienced team of epidemiologists, doctors, water and sanitation engineers and public health nurses conducted a rapid assessment. Blood samples were taken from children reported to be ill and

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sent to a referral laboratory in Germany for analysis. The results showed the children had an unusually high content of lead in their blood: lead poisoning. This is a consequence of villagers practising small-scale gold extraction from lead-containing ore. The processing involves crushing and drying, often inside the homes of villagers, resulting in soil contamination. With the support of local authorities, MSF started providing a lifesaving treatment called chelation to young children and breast-feeding mothers, those who are the most vulnerable to lead toxicity. Between June and November more than 450 children under five and more than 100 breastfeeding mothers received treatment. 40,000 DISPLACED BY FLOODS After one of the wettest rainy seasons on record, the Goronyo dam on the

Rima River collapsed in September and flooded a large area in northern Sokoto, causing damage to houses, crops, cattle and roads. More than 40,000 people’s homes were destroyed. MSF immediately started providing essential items such as blankets, soap and clean drinking water. I was part of a team that at one point distributed items in a camp where 9,000 displaced people were living. We met many people who asked if they could do something for us, which under the circumstances was incredible. As my team and others offered them basic survival items, MSF staff also gave information about the risks of malaria and explained how to use the specially treated mosquito nets we provided. We also explained safe hygiene practices to prevent outbreaks of water-borne diseases like cholera. MSF set up preventive health clinics and lobbied other

07 healthcare providers to scale up the response to reduce the spread of cholera. Unfortunately an outbreak of cholera did occur in northern Sokoto and, at the time Dispatches was in production, MSF was carrying out an emergency response to provide treatment and try to prevent as many deaths as possible. By late November, in cooperation with the Ministry of Health, MSF had treated 19,000 people. Unfortunately 542 people died during that time. While MSF occasionally speaks out, urging governments or other organizations to act in times of critical need, in Nigeria as elsewhere, our priority is always to provide people urgent medical aid in the hopes of saving as many lives and easing suffering as much as possible. Gautam Chatterjee Head of mission

Offering assistance and earning trust arrived in Haiti seven months after the earthquake. The scale of the devastation is still staggering; the streets full of rubble and twisted metal framing, buildings half standing at crazy angles and garbage everywhere. Patches of raw earth show through where everything on it has simply slid downhill.

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People are crammed into every available space in Port-au-Prince, the capital city that prior to the quake already had the dubious distinction of being the poorest major city in the Western hemisphere, and the only one without a sewer system. Since the earthquake, more than a million people now live under rotting plastic sheeting, despite the months of effort by aid agencies and the billions of dollars in pledged assistance.

Médecins Sans Frontières (MSF) has an enormous presence here. MSF’s work in Haiti after the earthquake has been the largest disaster intervention in our organization’s history. We have been doing trauma surgery, initially in a tarp-covered street amidst the rubble, lit by the headlights of a running truck. Later we arranged to replace our destroyed hospitals, some with inflatable structures and others housed in schools, churches or shipping containers. MSF is providing maternal care amidst grotesquely unsanitary and undignified conditions – pediatrics, emergency nutritional care and outpatient services for the injured, sick and those displaced from their homes. Teams also provide safe drinking water, proper latrines and

some tents, as well as kits with basic essential items like pots, pans and water jugs. Staff organize counselling for those suffering from the trauma of the earthquake and the ongoing conditions. In a broader sense, we hope to show some solidarity for the people of this battered island nation. The challenges are many, but two stick out in particular: the historically rooted tension between the Haitian people and outsiders, and the sheer scale of the disaster. The life of Haiti has been influenced by outsiders for half a millennium. A nation founded in history’s only instance of slaves successfully fighting for and winning their own freedom, Haiti has

MSF activities in Haiti MSF continues to provide many health services in Haiti, including postoperative care, maternal care, secondary care, surgery and mental health programs. More than 3,000 Haitian and international medical and non-medical MSF staff are working in the country. They run seven private, free of charge, secondary-level care hospitals and support two Ministry of Health structures in Port-au-Prince, accounting for nearly 1,000 hospital beds

in the capital city. These facilities provide emergency, trauma, obstetrical, pediatric, maternal and orthopedic care services. Mental health care and treatment and counselling for survivors of sexual violence are also provided. Outside the capital, MSF supports Ministry of Health hospitals in the cities of Léogâne and Jacmel with nearly 200 patient beds. MSF opened a 120-bed container hospital in Léogâne in October.

Between Jan. 12 and Sept. 30, 2010, MSF treated more than 339,000 people. Staff performed more than 15,700 surgeries and delivered more than 9,900 babies. MSF also provides primary medical care and relief supplies to people displaced by the earthquake and living in various camps in Port-au-Prince through mobile and fixed clinics. Teams are carrying out water and sanitation services to displaced persons in the city’s Cité Soleil slum.

HAITI

were killed by the 35-second quake and its immediate aftermath, concentrated in a densely populated urban centre. This was an event of staggering intensity, compressed in a small space and short time.

To offer assistance in Haiti, MSF strives to recognize and respect this feeling, and works to earn the trust of the Haitian people. We try to maintain strict independence, high-quality programs, impeccable ethical standards and a proactive communications strategy reaching out to the population, our Haitian staff, the government and others. It is not easy, and the mistrust and insecurity often have a serious impact on our staff’s ability to work.

MSF, along with the other aid agencies attempting to bring some dignity and assistance to the people of Haiti, has struggled in the face of these challenges. The people of Haiti, not to mention the international media, demand to know why the quake-affected are still living in precarious conditions. We have saved thousands of lives, yet the survivors continue to live from day to day, vulnerable to disease, violence and exposed to the elements. The struggle is far from over for Haitians, and MSF will continue to offer critical medical care and aid to those most in need.

On top of this, the needs are truly daunting. Had this level of destruction occurred in a wealthy developed country, it still would have been extraordinarily difficult to manage. In an already fragile country, it has been so catastrophic that one must see it to believe it.

The earthquake on Jan. 12, 2010 measured 7.0 on the Richter scale. It hit near Port-au-Prince, where, of nine million Haitians, nearly 3.5 million made their home. More than 250,000 people

To put the numbers in perspective, this is more than the estimated death tolls from the nuclear bombings of Hiroshima and Nagasaki, and nearly a hundred times the number of people killed in the Sept. 11, 2001 attacks in the U.S. Despite the massive aid effort, the needs in Haiti were, and still are, overwhelming.

Ivan Gayton Deputy head of mission

Since contributing this article, Gayton returned to Haiti to assist in MSF’s emergency response to the cholera outbreak.

cholera outbreak By late November 2010, MSF had set up more than 20 cholera treatment facilities throughout the capital, Portau-Prince, in the Artibonite region, and in the north of Haiti. MSF teams working around the clock treated more than 16,500 people between Oct. 22 and Nov. 14 alone. More than 1,000 Haitian staff were dedicated to cholera treatment, working alongside 150 international staff. More than 240 tonnes of medical and logistical supplies were brought into the country during the same period. Critical shortfalls in the deployment of well-established measures to contain cholera epidemics undermined efforts to stem the outbreak in the first two months, despite the huge presence of international organizations. On Nov. 19, MSF called for all groups and agencies working in Haiti to step up the size and speed of their efforts to deal with the deadly epidemic.

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been occupied at various times by Spain, France and the United States. After centuries of ill-treatment, the people of Haiti are not quick to trust the intentions of those who come with promises of assistance. The presence of thousands of aid organizations and UN agencies, whose foreign staff live in comparative luxury amidst the grinding poverty of the Haitians and whose work output is not always obvious, has not helped to win them over; many Haitians feel a profound resentment toward outsiders, including nongovernmental organizations.

“Cholera is an easily preventable disease,” said Caroline Séguin, MSF emergency medical coordinator. “It may be new to Haiti, but the ways to prevent and treat it are long established. Without an immediate scale up of necessary measures by international agencies and the government of Haiti, we alone cannot contain this outbreak.” In Port-au-Prince, the number of people seeking treatment at MSF-run and MSFsupported medical structures jumped from 350 for the week ending Nov. 7, to 2,250 cases for the week ending Nov. 14. In the north of the country, MSF medical structures logged 280 cases during the week ending Nov. 7, but that number jumped to 1,200 cases for the week ending Nov. 14.

PAKISTAN

Aid for survivors of massive ﬂooding Dispatches Vol. 14, Ed.1

During this time MSF teams in Pakistan: • conducted 80,150 consultations through 5 hospitals, 7 mobile clinics and 6 diarrhea treatment centres • screened more than 29,000 children and pregnant and lactating women

and treated more than 4,500 malnourished children • distributed 1,825,000 litres of clean water per day and built 843 latrines, 280 shower sites and 130 hand washing points • distributed a total of 64,836 relief kits and 16,300 tents • distributed 122 transitional shelters Three months after the floods that inundated the country, MSF stopped the emergency response activities in some parts of the country where people have started returning to their homes, such as in Khyber Pakhtunkhwa province and in northern parts of Sindh province. However, in southern Sindh and eastern Balochistan province, MSF teams continue to provide medical care, nutrition programs, safe water and transitional shelters to those affected.

looding in Pakistan from July to September of 2010 directly affected millions of people, caused widespread destruction to houses and infrastructure and is estimated to have killed more than 1,500 people. Médecins Sans Frontières (MSF) teams, including doctors, nurses, logisticians and water and sanitation experts, responded with emergency assistance, providing clean drinking water, shelter, food for malnourished children, and primary healthcare for tens of thousands left displaced and vulnerable by the disaster.

Additionally, MSF opened a new base in Gulshan-e-Iqbal Town and Gadap Town in Karachi (southern Sindh) to support 30,000 people affected by the floods who had not received any kind of assistance. Activities include mobile clinics, nutrition screening, health promotion, and provision of safe water, relief item packages and tents. In total, 125 international staff worked alongside nearly 1,200 Pakistani staff in MSF’s existing and flood response programs in Pakistan. Since 1988, MSF has been providing medical assistance to Pakistani nationals and Afghan refugees suffering from the effects of armed conflicts, poor access to healthcare and natural disasters. MSF does not accept funding from any government for its work in Pakistan and chooses to rely solely on private donations.

Breaking a taboo A message from within For people living in the communities surrounding the city of Port Sudan, discussing women’s reproductive health was often taboo. But in the last three years community members have begun taking a leading role in health promotion, and talking more openly. MSF medical teams are confident the work they began in Tagadom Hospital in 2005 providing free reproductive healthcare will continue in 2011 under the Ministry of Health, which is taking over responsibility for running the medical program. nder blue skies reflected on azure, salty waves of the Red Sea, A’m (uncle) Tita, a grandfather, health promoter and one of the community leaders amongst the Beja people of Port Sudan,

recalls the days when he was mocked and his words were not accepted. “I was told to respect my grey hair because I was speaking frankly about the medical effects of female genital cutting.” A’m Tita is part of the team of 10 health promoters – eight women and two men – working in a reproductive health unit supported by Médecins Sans Frontières (MSF) in the Sudanese city of Port Sudan, located in Red Sea state. MSF is providing free health services for those living in Tagadom and other nearby communities, where the majority of people do not have access to reproductive healthcare. In the last three years, MSF’s health promoters have been knocking on doors five days a week, visiting people to discuss reproductive and general health issues

in Beja and Arabic languages. They speak with the community about the benefit of delivering babies in the hospital, of family planning, breastfeeding, sexually transmitted infections and vaccinations, as well as discussing the sensitive topic of female genital cutting. In 2006, about 69 per cent of females in Sudan and 80 per cent of females in Red Sea state had undergone some form of female genital cutting. In Tagadom and neighbouring areas the numbers were even higher, with 98 per cent of females undergoing some form of it. The women of Tagadom and nearby areas endure the most harmful form of female genital cutting: type 3 or pharaonic. This involves the removal of the outer female genitals, and infibulation or the

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SUDAN

MSF health promoters explain that female children and adults who have undergone this procedure may face fatal bleeding, and infections such as tetanus. They are likely to develop cysts, experience painful menstruations and recurrent urinary tract infections. Many women will suffer acute pain during sexual intercourse. If they give birth, their labour is likely to be prolonged, increasing medical risks for the newborn. “We find abscesses and cysts even in female children. For future newborn baby girls we explain to the mothers all the possible complications of genital cutting,” says Medilyn Guevarra, an MSF gynecologist.

“Whenever a woman comes to us and gives us her trust, we make sure we give her complete information, so she can make an informed choice about her health,” says MSF counsellor Awadia Siddig.

De-infibulation, the de-stitching of the vaginal outer lips, is performed when preparing an infibulated woman for delivery. MSF’s gynecologist does not re-infibulate or stitch back the mother after delivery because of the grave medical consequences.

Now the community is talking about the benefits of delivering in the hospital, the medical consequences of genital cutting and sexually transmitted infections, and discussing family planning with the health promoters and the counselling team. Three years ago this was unthinkable.

The trauma of living with female genital cutting is great: “My organ is not complete because my family circumcized me, but now I am better because I am not closed [infibulated],” says Muzna, one of

The health promotion team also collaborates with community members, including local imams, community leaders and singers, to convey health-related mes-

the thousands of women who chose to deliver in MSF’s reproductive health unit. As female genital cutting is a deeply ingrained cultural practice, MSF health promoters, who are from the very communities to which they reach out, play an unrivaled role in transmitting medical messages on this subject. At first the female health promoters were thought of as beggars, and the team was considered indecent for speaking openly about reproductive health issues. But in the face of strong criticism they were resilient and persisted in relaying their important health messages. In time the health promoters gained the interest of the first few people and began to form discussion groups to talk about various health issues.

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stitching of the remaining outer vaginal labia, leaving but a small hole for urine and menstrual flow to pass through. The painful procedure of the cutting and infibulation is often performed on babies as young as seven days old, and affects a child into puberty and adulthood, with serious consequences for motherhood.

sages or raise awareness about sexually transmitted infections and the harmful medical effects of female genital cutting. Most of the residents of Tagadom and nearby are from the Beja community. Before MSF opened its reproductive health unit – the only one in the area – the majority of the women delivered in their homes with the assistance of a traditional birth attendant. Now more and more women are coming to deliver in the hospital. In collaboration with the Ministry of Health, MSF provides a range of free services in the reproductive health unit, including prenatal and post-natal care, delivery services, and family planning as well as sexually transmitted infection treatment and counselling. Earlier this year MSF built and furnished an operating room to assist women with complicated deliveries. In 2010, Tagadom Hospital’s medical teams conducted 54 caesarean sections and helped deliver approximately 1,500 babies. In September 2010, the Sudanese National Committee on Traditional Practices organized training sessions for the health promotion team to increase their skills. Ministry of Health staff continue assisting the women of Tagadom and its surroundings since MSF handed over the reproductive health unit at the end of 2010. Asia Kambal Communications officer

DJIBOUTI

“Are you comfortable with ICU for kids? In a slum?” my MSF recruiter asked. As an emergency room doctor who works at the Children’s Hospital of Eastern Ontario and has spent time in the Arctic, I’ve seen sick kids and I’ve seen them in remote places. Nevertheless, the ICU for kids is a gulp-inducing affair. I sent MSF my résumé. They hired me. I guess we would all see. s the world moves into cities, Médecins Sans Frontières (MSF) is adapting its resource-efficient bush-style medicine to urban contexts. In the Balbala slum in the east African country of Djibouti, MSF has set up a pediatric malnutrition project. It includes a community-based ambulatory malnutrition program that screens kids for severe malnutrition and distributes therapeutic ready-to-use food. The sickest kids get sent to the intensive care unit (ICU).

The day before I left for Djibouti, I hugged my husband Darcy and put him on a plane to go be a pediatrics resident on Baffin Island. I reflected on the ironies: an MSF lecture in medical school had led to shared smiles and our first date. Now, six years to the day after that, our common interests were taking us to opposite sides of the world to take care of kids. My first day in Balbala, I looked around. We have bedside hemoglobin and glucose, oxygen extractors, a bag-valvemask. And that’s it. I knew the target was for our mortality rate to be under five per cent. Still, I hoped it would be a while before I found out what it was like to pull the last tool out of my kit and have it not be enough. It happened the next day. The poor little guy was sick from the start. He had a blood infection and Kwashiorkor, the puffy, salt-retaining kind of malnutrition

as opposed to the stick-thin kind. His liver was big, he was swollen around his eyes, and he’d stopped peeing. Modeste, the ultra-experienced African doctor who was on-call, thought he looked septic, that he had a blood infection. So, should we give him fluids to help the kidneys or furosemide, a drug to deal with his swelling and the threats to his heart? It’s a dance we do every day, blind by first world standards. No chest X-ray or ultrasound. We were called when the boy didn’t wake up with the morning vital signs check. With my hand on the child’s foot, feeling a good pulse there, we watched his breathing become irregular. He breathed again, a big one, his skinny ribs straining, his belly pushing out.

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“I am still not used to losing kids. I started to think I was...”

Then no more breaths. I waited for a second. There is such an anticlimax in an event that is, in fact,

Right now the food aid system provides poor quality foods to malnourished children, affecting the lives and futures of 195 million children around the world. This flawed approach must stop. Sign the Starved for Attention petition to demand that food aid meets the nutritional needs of young children.

www.starvedforattention.org At the G8 Summit in 2011, MSF will present the petition to the top food aid donor countries, including Canada.

the absence of something. It is not like there is gunfire and someone drops. No action then reaction. Simply a lack of. Une manque.

nurse, Souleiman, appeared at my elbow to translate. “Here we say: ‘The doctor cares but God cures.’ She says her son has gone to heaven. She says thank you.”

It is not a good feeling to watch a child stop breathing.

I was grateful for her generosity but still felt like going home to cry. But I looked around, suddenly conscious we hadn’t seen a single other kid yet. My self-reproach was selfindulgent. I went to the outhouse, peed, washed my hands. Breathed. I walked back in and started rounds.

Then a blur of work, resuscitation. Still no pulse. “I don’t think we should continue,” said Modeste, resigned. I kept my hand on the mask, torn, but stopped ventilating. My other hand sought the comfort of the child. Felt his warm, beautiful young chest. Kids don’t die in my medical world. Darcy has had to rush to every resuscitation in an effort to practise what almost never happens. He just ran his first one – on Baffin Island. He intubated the child and flew her down to Ottawa where she rode out her illness on a ventilator.

Dispatches Vol. 14, Ed.1

We don’t have ventilators.

“We don’t resuscitate for more than 15 minutes here,” said Modeste. I nodded. I don’t know if there is such a thing as a resuscitation where the person doesn’t live where the doctor doesn’t end up with doubts. My tidal wave of self-reproach was nauseating. The mother came over. Quiet. She looked at me, kissed my hand and spoke. A young

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Thus began an obsession with pediatric resuscitation. I have emailed colleagues (thanks Raghu) researched online, and conducted a million teaching sessions. I have distilled down what is possible in this context to a tight flow of actions. My team is well-honed. And we have had many successes. To sit on a bed where once there was a wan little being and instead have lively sticky fingers reach for your stethoscope, curling round and tugging – that is a sweet, sweet thing. But malnourished kids still die. Every time the code ends with a blanket wrapped around a small, still-warm body, someone comes over and repeats to me, “The doctor cares but God cures.” The wisdom of the people I meet here is starting to seep in along with their complete lack of illusions that the world is under their control. My role is to know my craft, to smile at them as I meet their eyes, and to do my part, the ‘caring’ part, very, very well.

I am still not used to losing kids. I started to think I was. But this morning, after a sleepless night where I inserted two injection lines into little bones and gave five doses of adrenaline fruitlessly to a child still wiggling her fingers and trying to live, I couldn’t stop thinking that her needs may have been met back in the Ottawa intensive care unit where Darcy is now working. When Modeste, comfort personified, sat down on a bed rail next to me, I knew that the moment I looked into his understanding eyes I was going to cry. And I did, spoiling the rugged seen-it-all Africa-toughened image I’d created in my mind’s eye. “No, not at the end of your time here. You have to think of all of the children we have helped,” said Modeste. I went to look at Abdourahman, a little guy with tuberculosis and HIV who has been septic and limp at least three times and with us so long his chart looks like a book, whose mom smiles at us like family, and who, today, was sitting up plumply in bed. Body drawn to his liveliness like a hand to a kitten, I pulled him onto my lap. Smiling sweetly, he peed on me, considered a benediction around here. “You’re going to have sons!” said my nutritional assistant, Khaltoum, laughing. Abdourahman was very pleased with himself. He reached up, eyes wide, and grabbed at my stethoscope.

Courtney Howard Doctor

hope in hell anadian journalist Dan Bortolotti again invites us into the world of the aid worker in this updated third edition of Hope in Hell: Inside the World of Doctors Without Borders.

Bortolotti shares MSF field workers’ stories of deep commitment to and personal struggle with humanitarian principles. Readers also get a glimpse into the challenges staff face when they return home to family and friends who sometimes don’t want to hear about a world so different and so far from their own.

The book’s new edition includes updates on MSF’s work in some of the most complex crisis situations around the world. It also adds a chapter on the author’s experience visiting with MSF staff in Haiti in 2009, and a postscript written after the earthquake that rocked that country’s capital on Jan. 12, 2010. Hope in Hell is published by Firefly Books and is now available in stores. Visit www.msf.ca to hear Bortolotti talk about his research delving into the complexities of MSF.

CANADIANS ON MISSION

BANGLADESH Marjorie Middleton Calgary, AB

Nurse

BURUNDI Lysanne Lafetière Montréal, QC

Nurse Medical coordinator Financial coordinator

CENTRAL AFRICAN REPUBLIC Colette Badjo Laval, QC Doctor Jean-Guy Bisaillon Mont-Laurier, QC Water & sanitation specialist Anne Connelly Ottawa, ON Logistician Pascal Desilets Montréal, QC Logistician Peter Heikamp Montréal, QC Project coordinator Kanadi Ibrahim Gatineau, QC Logistician Stella Carine Kengne Tine Montréal, QC Doctor Jean-Baptiste Lacombe Montréal, QC Logistician Judith Letellier Montréal, QC Logistician Antoine Maranda Gatineau, QC Logistician Alphonsine Mukakigeri Montréal, QC Logistician CHAD Grant Assenheimer Edmonton, AB Project coordinator Frédéric Dubé Québec, QC Logistician Mario Fortin Montréal, QC Logistician Jean-François Harvey Rivière-du-Loup, QC Project coordinator Clea Kahn Toronto, ON Head of mission Chantelle Leidl Edmonton, AB Water & sanitation specialist Sarah Levine Vancouver, BC Nurse Jeff Peters Beaconsfield, QC Logistician François St-Amant Montréal, QC Logistician Elizabeth Savoie Whitehorse, NWT Nurse COLOMBIA Raquel De Quieroz Smithers, BC

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DEMOCRATIC REPUBLIC OF CONGO Adham Abo Shahbo Toronto, ON Logistician Tamiko Andrews Montréal, QC Nurse Bryce Burger Kelowna, BC Logistician Michelle Chouinard St-Quentin, NB Head of mission Oonagh Curry Toronto, ON Project coordinator Marika Daganaud Québec, QC Nurse Steffen De Kok Kingston, ON Project coordinator Martha Gartley Toronto, ON Water & sanitation specialist Fabienne Gilles Toronto, ON Human resources coordinator Marie-Michèle Houle Victoriaville, QC Nurse Stéphanie Jodoin Mont St-Hilaire, QC Logistician Samantha Kemp Thunder Bay, ON Nurse Barbara LeBlanc Guelph, ON Surgeon Shannon MacDonald Halifax, NS Midwife Thierry Oulhen Montréal, QC Field coordinator Todd Philipps Winnipeg, MB Logistician Margaret-May Raymond Montréal, QC Doctor Grace Tang Toronto, ON Head of mission Stephanie Taylor Vancouver, BC Doctor Martine Verreault Rivière-du-Loup, QC Pharmacist DJIBOUTI Courtney Howard Ottawa, ON

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ETHIOPIA Rachida Aouameur Montréal, QC Humanitarian affairs officer Justin Armstrong Toronto, ON Project coordinator Brice Garnier Montréal, QC Field administrator Sarah Lamb Ottawa, ON Project coordinator Cynthia Wonham Vancouver, BC Nurse HAITI Valérie Auger-Voyer Gatineau, QC Administrator Cindy Barbe Farnham, QC Nurse Anne-Josée Boutin-Trudeau St-Bruno QC Logistical coordinator Jean-Daniel Duhaime Montréal, QC Doctor Fabrice Fotso Montréal, QC Water & sanitation specialist Nicolas Gauvin Weedon, QC Logistician Maude Giboudeaux Montréal, QC Nurse Bernard Lachance Québec, QC Logistician Joanne Liu Montréal, QC Doctor Yvan Marquis Québec, QC Project coordinator Michael Minielly Toronto, ON Logistician Jean-François Nouveaux Laval, QC Logistician Nadia Perreault Mascouche, QC Nurse Luella Smith Waterside, NB Doctor Eyal Tapiero Montréal, QC Human resources administrator Nicolas Verdy Montréal, QC Logistician Brenda Vittachi Calgary, AB Nurse Robin Williams Montréal, QC Doctor INDIA Andrew Cullen Toronto, ON Logistician Rehana Permall Ottawa, ON Liaison officer Roberta Wynne Vancouver, BC Nurse IRAQ Reshma Adatia Vancouver, BC Project coordinator Sebastien Hogan Ottawa, ON Field coordinator JORDAN Géraldine Jacquemin Montréal, QC Doctor KENYA Carlo Testa Blandford, NS Logistician MALAWI Mariam Kone Montréal, QC Doctor MALI Nina Hodonou Montréal, QC Doctor MOZAMBIQUE Isabelle Casavant Montréal, QC Nurse NIGER Claire Adbulahad Sutton, QC Logistician Laura Archer Montréal, QC Medical coordinator Breno Horsth Toronto, ON Logistician Editor: linda o. nagy Editorial director: Avril Benoît Translation coordinator: Jennifer Ocquidant Contributors: Gautam Chatterjee, Ivan Gayton, Courtney Howard, Asia Kambal, linda o. nagy, Kate Ribet Cover photo: © Kate Ribet / MSF

Isabelle Major Montréal, QC Logistician NIGERIA Jodi Enns Burlington, ON Nurse Karen Friesen Vancouver, BC Nurse Marilyn Hurrell Winnipeg, MB Medical coordinator Douglas Kittle Wasa, BC Head of mission Harry MacNeil Toronto, ON Logistician Paulo Rottmann Toronto, ON Human resources coordinator Darryl Stellmach Calgary, AB Head of mission PAKISTAN Erwan Cheneval Montréal, QC Deputy head of mission Rink De Lange Ste Cecile de Masham, QC Water & sanitation specialist Maude Giboudeaux Montréal, QC Nurse Zelda Goad Falardeau ,QC Medical team leader Mathieu Vandal Montréal, QC Administrator PAPUA NEW GUINEA Judy Adams Moncton, NB

Mental health officer

REPUBLIC OF CONGO Nicolas Bérubé Québec, QC

Logistician

SRI LANKA JL Crosbie Toronto, ON

Project coordinator

SUDAN Loretta Beaulieu Vancouver, BC Logistical coordinator Jaroslava Belava Vancouver, BC Nurse Kevin Coppock Toronto, ON Head of mission Steve Dennis Toronto, ON Project coordinator Tyler Foley Fredericton, NB Logistician Jeffrey Grass Toronto, ON Logistician Arif Hasan Toronto, ON Doctor Megan Hunter Prince George, BC Logistical coordinator Richard Maunsell Waterloo, ON Nurse Ryan McIver Stouffville, ON Logistician Letitia Rose Vancouver, BC Nurse Tara Seon Toronto, ON Human resources coordinator Michael White Toronto, ON Project coordinator TAJIKISTAN David Croft Squamish, BC UGANDA Alia Tayea Oakville, ON

Project coordinator Humanitarian affairs officer

UZBEKISTAN Susan Adolph Dartmouth, NS Calvin White Salmon Lake, BC

Nurse Mental health officer

ZIMBABWE Tammy McIntyre Vancouver, BC Circulation: 145,000 Layout: Tenzing Communications Printing: Warren’s Waterless Printing Winter 2011 ISSN 1484-9372

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Dispatches Vol. 14, Ed.1

CAMEROON Serge Kaboré Québec, QC John Orr Vancouver, BC

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