IN THIS ISSUE 1
Niger: Why a nutritional crisis?
Visiting health clinics high in the Andes
MSF in Sierra Leone
Earthquake in India and Pakistan
Helping tsunami survivors
Denied treatment: Children with HIV/AIDS
Memorial: Patrice PagĂŠ Executive Director, MSF Canada
why a nutritional crisis?
ince the beginning of 2005, MSF has taken major steps to respond to the food emergency in Niger. Our teams treated over 30,000 severely malnourished children between January and October, and expect to have helped another 20,000 children by the end of 2005. In September 2005, 140 international volunteers and 1,400 national employees were sent to our 51 stationery and mobile therapeutic feeding centres, admitting over 3,000 malnourished children every week. Our teams also run two paediatric units that
provide free care to children under five years of age and distribute some 90,000 monthly food rations to families with moderately malnourished children in the villages most affected by the famine. In October 2004, the first signs appeared that this would be a far greater food crisis than before. Following a joint evaluation between the United Nations and certain governments, it was announced that 3.5 million people in nearly 3,000 of the poorest agro-pastoral villages in (continued on page 2)
1999 Nobel Peace Prize Laureate
Niger would be at risk of suffering from major food shortages until the harvest in October 2005. For the first four months in 2005, three times the children than the previous year were admitted to MSFâ€™s therapeutic feeding centres. In April, a nutritional survey conducted by MSF revealed that one in five children in the provinces of Maradi and Tahoua were suffering from malnutrition. In August, a new MSF survey in the Zinder region showed a major decline in health and nutrition. Nearly one child in three younger than two and a half was malnourished, with 5.6 per cent of them suffering from severe malnutrition. In addition, the mortality rate in children under five had jumped to 5.3 deaths per 10,000 people per day (the emergency threshold being two deaths per 10,000 people per day). Almost 90 per cent of families surveyed no longer had food reserves. This foreseeable crisis was not an inevitable occurrence due to uncontrollable natural factors. Several governments and assistance organisations attributed the deterioration of this situation to drought and a locust plague. However, these two factors combined are responsible for only an 11 per cent decrease in annual cereal production versus the average over the past five years. The nutritional crisis in Niger is rather a problem of the most vulnerable people not
Dispatches Vol.8, Ed.1
having access to food. Since the market is tightly controlled by large companies, the prices in 2005 are 75 to 80 per cent higher than the average for the previous five years, and are far too high for poor families to afford. They must dip into their reserves and cannot provide adequate food until the next harvest time. As well, they do not have access to health care, since a cost recovery system has been set up that establishes a fee for each medical procedure or medication prescribed. Determining the nature of the crisis in Niger in order to define a humanitarian response is completely inappropriate. Whether famine, an isolated situation of extreme malnutrition, chronic or critical food insecurity, the needs must define the operational response and type of assistance programme to be set up to ensure the survival of these populations in distress. Faced with such high levels of malnutrition and infant mortality, MĂŠdecins Sans FrontiĂ¨res (MSF) set up assistance measures based on the needs of the people affected. However, MSF alone cannot meet the needs of this food crisis. The major decision-makers involved in food assistance in Niger (the Nigerian government, the World Food Program (WFP) of the United Nations and the partners in the Sahel and
MAKING SUFFERING, DESTITUTE FAMILIES PAY OR GIVING THEM CREDIT ARE COMPLETELY INAPPROPRIATE MEASURES OF CONTROLLING SEVERE MALNUTRITION.
West Africa club, including Canada, the United States and the European community) have deliberately chosen to set up a policy making long-term development and market protection a priority instead of emergency measures to control malnutrition among the poor in Niger. It is a political choice regarding food security for future generations rather than immediate food assistance to preserve lives. The nutritional crisis in Niger is unfortunately primarily because of human reasons. On July 28, 2005, at the height of the food crisis, a document prepared by the United States Agency for International Development clearly reiterated: “Recent media coverage and NGO reports have claimed famine conditions…. The heavy and sensational media attention, and the possibility that more resources will be made available to treat the problem… may actually impede the market.” Since the onset of the crisis, MSF has asked donor agencies, the United Nations and the Nigerian government to set up pragmatic emergency measures to meet the needs. That is, general distribution of free food in the high-risk areas and free access to health care for children affected. However, between November 2004 and June 2005, the response to the crisis in
Dispatches Vol.8, Ed.1
Niger involved setting up a moderately priced cereal sales system for 3.4 million people. The quantity of subsidized cereals is far from sufficient (12 kilograms per person for nine months when they should have 20 kilograms a month). The poorest families affected by the nutritional crisis in the six regions are unable to pay for food, even if it is subsidized. In June, the nutritional situation continues to deteriorate and the Nigerian government decided to create a new credit programme through which families must pay back the quantity of “borrowed” food. Making suffering, destitute families pay or giving them credit are completely inappropriate measures of controlling severe malnutrition.
has never, in spite of its promises, set up even temporarily free health care for the children in the most affected regions.
It was only in August, following major media coverage, that WFP decided to distribute free food. Unfortunately, these distributions favoured areas in which the previous years’ harvests had been the lowest instead of the regions directly affected by malnutrition. Again here the assistance measure did not benefit the most vulnerable and did nothing to control the ravages of malnutrition. In order not to overly destabilize the markets, WFP announced in its last emergency report that, after only two monthly distributions, the free rations programme would end at the beginning of October. Moreover, it is important to specify that the Department of Health of Niger
Patrice Pagé Executive director, MSF Canada
The people suffering from malnutrition in Niger were not victims of drought or a plague of locusts, but rather the refusal of decision-makers to change their focus from long-term market-based assistance to emergency measures for the more affected regions. Faced with this crisis, the governments, United Nations and humanitarian organisations must give priority to the needs and not to market principles. Political arbitration between preserving human life in the short term and development imperatives in the long term is unacceptable.
With deep sadness we must inform you that Patrice Pagé, our executive director, passed away in Toronto on Dec. 12, 2005. We are shocked and devastated by this news. We grieve the loss of this bright young man who was such a passionate and committed humanitarian. We share this loss with Patrice's family and his girlfriend. Please see page 14 for more about Patrice and his contribution to MSF.
Letter from the field
“Yesterday we admitted another 120 severely malnourished children, last night seven of them died. I need doctors and nurses now – not in a week – now!” his was the message from the medical nutrition expert, distributed by email to the Médecins Sans Frontières (MSF) international network on Aug. 4, 2005. On Aug. 8 I was on a plane heading for Niger in subSaharan Africa as a volunteer doctor.
MSF had been operating feeding centres in Maradi, situated at the extreme west of Niger, since 2001. In response to the nutritional crisis that erupted in 2005, we decided to set up a therapeutic centre further east, in Zinder. These centres, known by the French acronym CRENI (Intensive Nutritional Rehabilitation Centre), are staffed by doctors and nurses to provide medical treatment to the severely malnourished children who need hospitalization. The task allocated to me was the initial examination of children at the CRENI. Some were brought by their mothers, in trucks that came from the villages. Many arrived in vanloads operated by other nongovernmental organisations (NGOs) in the area with whom we had established an excellent and coordinated working relationship locally. When they brought a sick child we took her. When the child was better they took the child and mother home, often a long and hard day’s drive. The therapeutic centre has strict admission criteria. Those needing immediate medical care were documented by name and admission number and taken to the intensive care unit (ICU) – about 20 per cent of new cases. All were hypo something – low temperature, low electrolytes, low glucose – I had even rushed some across to the ICU in my own arms and administered glucose as a life-saving measure. The less severely ill
were weighed, dangling from a scale, their length measured. The weight to length ratio is compared against a known standard and had to be more than 30 per cent below the norm to justify admission to the CRENI; required upper-arm circumference was less than 110 mms, not twice the circumference of my little finger! Almost all children met the criteria. Few of these malnourished children have ever seen a doctor. Infections flourish in the impoverished underfed child. Eyes were filled with pus; thrush, a fungal infection of the mouth, was common, as was scabies and even pneumonia. All children had suffered from diarrhoea, most of them also from vomiting – the only variation was for how long. Half the children tested positive for malaria, an illness that can provoke severe anaemia and is the largest killer of children in Africa, accounting for 20 per cent of all deaths under the age of five. Treatment for these conditions, including medication for malaria and vaccination against measles, was initiated at admission. Food alone cannot treat advanced malnutrition. A medically supervised programme is required to restore a normal balance of electrolytes and correction of potassium loss, followed by diluted milk, and then full strength reinforced milk, then packets of peanut-based Plumpy’nut® therapeutic food. Children are discharged from the CRENI when health is improved and are followed as outpatients in the ambulatory therapeutic feeding centres, or CRENA, with food provided for all family members. These ambulatory centres operate near the villages and are visited weekly by medical teams. Severely malnourished children who do not
suffer from associated pathology and can feed themselves are directly admitted to these CRENAS. This ambulatory system of care allows MSF to drastically increase the number of severely malnourished children admitted to the programme. The CRENAS also help to ensure proper follow-up and provide easier access to medical care for mothers, through the elimination of travel time and hospital stays far away from home. As the medical work proceeded, logisticians arranged food distribution points, latrines, clean water and washing areas. By the third week of September, MSF had in Zinder established two CRENIs, 16 CRENAs, admitted 7,506 severely malnourished children and continued to provide care for 5,042 children. The death rate had not been reduced to zero but deaths became uncommon. With my 40 years of experience, I believe there is no other organisation that could have achieved this result in such a short period of time.
By the end of September, MSF’s Niger programmes in Maradi, Tahoua, Zinder, Diffa and Tillaberi had treated 40,000 severely malnourished children and distributed 8,000 tonnes of free food to moderately malnourished children and their families.
Michael Hall Medical doctor, Zinder, Niger
Michael Hall is a surgeon from Guelph, Ontario. He spent six weeks volunteering in Zinder, Niger with MSF in 2005.
Chagas disease in Bolivia riving for hours on single-track dirt roads through the Andean mountains is an experience one does not soon forget. I had recently arrived in southern Bolivia to document MSF’s prevention and treatment activities for Chagas disease. Bereft of a CD player, with only the two-way radio squawking, the sound of the wind blowing by the windows and dirt crumbling under wheel,
CHAGAS IS A SLOW-MOVING BULLET THAT ATTACKS THE HEART AND DIGESTIVE TRACT OVER THE COURSE OF 10, 20 OR 30 YEARS.
Dispatches Vol.8, Ed.1
Visiting health clinics high in the Andes
it was a good time to practice my Spanish. Josef, the driver, asked me what I thought of his homeland, while expertly navigating deadly hairpin turns marked every 50 metres with dusty shrines to fallen loved-ones. I replied simply: "It is so completely different than where I come from." He smiled and we continued our journey, where I felt like the lucky one who gets to see exactly what Médecins Sans Frontières (MSF) does and why. Treating medical needs in remote locations like this proves to the naysayers that it can be done. Whether it is the littleknown Chagas in rural Latin America, or HIV/AIDS in resource-poor areas of Africa, such projects show it is possible to provide health care to marginalised communities who previously had little or no access to health care.
Chagas disease affects the poorest in Latin America because it is a parasite transmitted via the bites of insects that infest the rural homes of agricultural families. Following harvest season, when natural habitats are cleared or burned, insects of the Triatominae family (known as chinches in Guatemala and vinchucas in Bolivia) hop on the backs of domestic animals and move into rural homes constructed of natural materials such as banana leaves, tree branches, grass and mud. At night, the insects emerge from burrows in thatch roofs, cracks in adobe walls, and animal beds, and feed on blood meals provided by sleeping family members. The bug’s faeces, left behind at the itchy wounds, are then scratched into the bloodstream. Infected with the parasite Trypanosoma cruzi that causes Chagas disease, the human hosts often remain asymptomatic for decades.
This is the insidious nature of Chagas disease – it is a slow-moving bullet that attacks the heart and digestive tract over the course of 10, 20 or 30 years. Without detection and treatment, Chagas shortens life expectancy by an average of nine years. Its victims usually succumb to unexplained and early heart failure. Marginalised indigenous populations, such as the Guarani of southern Bolivia and the Ch’ortí of southeastern Guatemala, face difficulty accessing health care services offered by the few state-run facilities that do exist in rural areas. Linguistic differences, urban-rural dichotomies, and disagreements between traditionalist and modernist belief systems result in integration problems for indigenous populations – those most affected by Chagas disease – in an already underdeveloped health care system. To combat these challenges, MSF provides mobile health clinics. Driving for several hours into the rural Andean communities demonstrates that it is possible to bring health care to remote populations; the prevalence of Chagas, evidenced through the toma de muestra (blood screenings) in these communities, demonstrates the pressing and underreported need for prevention, education, treatment and followup. Using a rapid test kit, initial blood
screenings can be done on-site in rural areas without costly diagnostic technologies and distant medical laboratories. Blood lancets, capillary tubes, rapid test blotters, and chromatography drops give simple positive or negative results in 15 minutes. Patients with positive screenings in the rapid test are then asked to provide full blood samples for detailed laboratory diagnostics. Treatment is individualised according to age and weight, a dosing schedule is demonstrated and outlined graphically on a chart (without reliance on literacy levels), files are created, and follow-up visits are scheduled to check for treatment side effects and dosing adherence. Sadly, there is no vaccination for Chagas and one of the two medicines that can be used for treatment, Benznidazole, frequently produces toxic side effects and is generally ineffective if the disease – through lack of diagnosis and early treatment – reaches its chronic phase. The other drug, Nifurtimox, costs $48 US for a course of treatment – the equivalent of a Bolivian miner’s monthly salary. MSF participates in education and prevention activities, using radio programmes and puppet shows that present information on what to do when people find the offending
insects in their homes, and explain the importance of testing, treatment and followup. Capacity-building workshops are also conducted for local health care workers. While these strategies are well adapted to local communities and address the pressing issues surrounding a pervasive disease at a micro-level, Chagas, presenting a risk of infection to 100 million people, is largely neglected by national governments, international bodies and pharmaceutical companies. The Drugs for Neglected Diseases initiative, a not-for-profit drug development organisation co-founded by MSF, currently has two Chagas drug projects in pre-clinical development, but this is not enough. Large-scale participation in rural home reconstructions, vector control strategies, pharmaceutical research and development and public health protocols are urgently needed to address a devastating disease that now affects more than half of Bolivia’s inhabitants and more than 18 million people worldwide.
Kenneth Tong Manager, Web development, MSF Canada
Read more about Chagas disease and the Drugs for Neglected Diseases Initiative at www.dndi.org
PROVIDING QUALITY CARE AND A CHANCE AT SURVIVAL
SIERRA LEONE magine having to live for more than 10 years a life filled with daily fears and suffering brought on by a civil war. Then imagine a post-conflict situation that presents little hope or improvement towards the fulfillment of basic human needs. This is the harsh reality for the people living in Sierra Leone.
West Africa remains a politically unstable region with many humanitarian needs. Sierra Leone is presently considered stable by the United Nations and key governments; however, the country remains fragile as it continues to experience lack of access to health care, lack of infrastructures, lack of education and slow economic growth.
Dispatches Vol.8, Ed.1
Sierra Leone ranks number 176th in the Human Development Index, making it second-last in the world next to Niger. Its health indicators are alarming, including an average life expectancy of only 40.8 years. Health care in Sierra Leone is frequently scarce and discriminatory; fees are applied for the services rendered and it’s a matter of “wealth means health.” Given the fact that many are unemployed and 68 per cent of the population is living under the poverty line, it is not difficult to understand why individuals lack the capacity to pay for the services they require.
Sierra Leone has also provided refuge for tens of thousands of Liberians who fled across the border while their own country was ravaged by civil war. Even though the peace process has begun in Liberia, these refugees continue to live in the relative safety of camps in Sierra Leone rather than return to harsh, uncertain living conditions and an unsafe environment in their home country. The Médecins Sans Frontières (MSF) clinics help to alleviate suffering by providing quality and proper health care to these refugees as well as to the surrounding host communities. Kati, Katuma and Doris (names changed) are pregnant women living in
Largo, one of the refugee camps. Their day begins by waking up before sunrise, and after having completed all domestic chores – fetching water, collecting firewood and preparing food – they attend the MSF clinics for consultation, prenatal visits and follow-up. Mother and child health care is an important part of MSF’s programme in Sierra Leone, a country where two women out of every 100 die from pregnancy-related causes, and nearly 17 babies out of every 100 born never reach their first birthday. (The Canadian rates are 6 per 100,000 and 5 per 1,000, respectively.) MSF has provided free quality health services in the country for well over a decade. Services were maintained during the war and still continue. Throughout the country MSF has provided primary and secondary health care, immunization programmes, therapeutic feeding centres, mental health services, water and sanitation, as well as maternal and child health care. MSF services are integrated with a referral system and follow-up.
One beneficiary whose life has improved from the quality care is Mr. Mohammed, a 22-year-old man abandoned by his family and stigmatized by the community because of the disfigurement he has endured from leprosy. MSF provided Mr. Mohammed with daily visits from qualified staff that performed daily dressing changes and provided him with food and medicine before finding an appropriate medical centre in Freetown that could continue his care. Here he is accepted and his daily feedings and dressing changes are financially supported by MSF. These actions ensure he gets the basic care he needs and also help to improve the young man’s dignity and quality of life. Malaria is a huge and year-round problem in Sierra Leone and is one of the main causes of death for both children and adults. But here, as in many other African countries, classic anti-malarial treatments prove largely ineffective. An MSF survey conducted in 2002 proved that Artemisinin-based combination therapies (ACT) were the optimal treat-
ments for malaria in this region. In response to advocacy and lobbying, the Sierra Leonean Ministry of Health has finally included these new treatments in the national malaria protocol. By the end of 2006, ACT should be available throughout the country. In 2004, MSF also had to respond to an outbreak of cholera, which is endemic in this region. Over 700 patients received treatment comprising hydration, medications and health services in the area of Freetown. Even though the war has been officially claimed to be over, concerns remain about the future of Sierra Leone. In the post-emergency period we have witnessed a continuing need for support and rehabilitation. MSF has been in the country providing quality, reliable, free health care in the hope to give a population a better chance for survival.
Johana Amar, R.N. Head of mission, Sierra Leone
India and Pakistan
earthquake INDIA AND PAKISTAN SCENES REMINISCENT OF A WAR ZONE Excerpt from Dr. Jean-François Corty’s account of an exploratory mission to Mansehra, Pakistan immediately following the earthquake that struck Kashmir on Oct. 8, 2005. While Médecins Sans Frontières (MSF) did not collect earmarked donations for its earthquake relief missions in India and Pakistan, a swift response was enacted using resources from the MSF Emergency Fund. This fund provides MSF with the flexibility to respond to crises quickly, without the additional costs and time required to launch a specific fundraising appeal. Donations to our Emergency Fund provide valuable support for our work. very minute helicopters drop off more injured people with terrible, infected wounds. The operations and surgical procedures are endless. All around, amputees and people in plaster wade through mud. It’s a total emergency, with everything happening at breakneck speed. It reminds me of a war zone.
Many people suffered fractures when their traditional Pakistani stone dwellings crumbled in the quake. Seven days after the quake we’re seeing complications such as wounds and infected fractures, gangrene, and tetanus. When the quake struck at 8 a.m., many men were working outside. Consequently, I’ve seen mainly women and children injured following the collapse of houses and schools.
Dispatches Vol.8, Ed.1
In a medical emergency of this scale there is no time to carry out micro-surgery: there are many amputations. We’re planning to set up medical “camp” in Mansehra for 500 to 1,000 patients, plus their families, a potential total of 5,000 people requiring ambulatory follow-up, medical care, shelter, water, latrines and food. We’ll also need a resuscitation ward and the necessary materials to handle tetanus. There are people suffering from crush syndrome: kidney insufficiencies caused by muscles being compressed for long periods of time under the rubble. Cases of psychological trauma will require treatment as will people suffering from chronic illnesses such as diabetes. Provisions are needed to treat those who fall sick when the hospital system is overloaded. The earthquake will not itself cause epidemics, but the grouping of the quake’s victims in precarious conditions means we have to be vigilant. Winter is coming and we can expect to treat hypothermia and respiratory infections. Traditionally, mountain populations spend the summer at altitude before going down to the towns to spend winter with their families. Without food and basic needs, the majority will probably decide to leave as the cold arrives, but there is no guarantee their families will be able to accommodate them or that they will even be there.
Within one week of the earthquake, MSF operations in India and Pakistan had: • Mobilised 80 international aid workers to provide medical assistance, mental health counselling and relief operations. • Airlifted 100 tonnes of medical (surgical kits, wound dressings) and relief (tents, blankets, water tanks, food) supplies to the Pakistani capital of Islamabad. • Distributed 10,000 blankets, 5,000 metres of plastic sheeting for shelters, 80 tents, 10,000 sets of clothes, 7,000 bottles of water, 2 tonnes of food and 1 tonne of medical supplies in Kashmiri India. Focusing its response in the most affected areas, MSF operations were most extensive in Kashmiri Pakistan. By Oct. 31, MSF had: • Mobilised 150 international and 100 national staff. • Provided health care and psychosocial counselling to hundreds of survivors. • Flown in four dialysis machines to treat crush syndrome. • Supplied 620 tonnes of relief goods.
Mental health care in Aceh, Indonesia OFFERING SUPPORT TO TSUNAMI SURVIVORS woman tries desperately to hang on to her three kids while the water swirls around them. After long minutes of hanging on amidst the chaos, she loses her grip and one child is washed away and never found. A blind man finds himself alone, swept away by the wave. A young girl finds him and they hold on together for several hours. I don’t know what happened to the girl. I do know that the man found out, upon discharge from the hospital, that seven of his closest family members had died. As a social worker, these are the stories I heard every day during my six-month mission with Médecins Sans Frontières (MSF) in Meulaboh, Indonesia following the tsunami that hit so powerfully on Dec. 26, 2004.
The intense feeling of loss I felt when confronted with the devastation and losses the people of Aceh had survived led to a sense of puzzlement and amazement when I understood that very few organisations were providing mental health counselling. There was also a significant gap in mental health knowledge and training
within the local health infrastructure. Therefore, it was an interesting challenge for MSF to provide basic mental health training to nurses and staff in local health centres when so many of them were dealing with their own losses and fears. There was a real need to help the local people to better deal with their feelings and anxieties and we addressed this through individual counselling, group therapy and community-based discussion groups. We talked about why children ran home from school when the wind picked up and why, several months later, people still ran for higher ground on certain days when the tide seemed higher than usual. Rebuilding homes, rehabilitating farmers’ fields and constructing new fishing boats is very important; however, it is also important to restore people’s capacity to believe that their environment is safe for them and their children – allowing them to fall asleep each night without thinking that, when all is quiet in the camps they live in, another wave is on its way.
At times I felt our work was such a tiny piece of what needed to be done, given the number of people that had been affected by the tsunami, the limits we had in providing support and the few organisations that were involved in mental health activities. However, I do know that for those people whom we were able to reach, it did make a difference, even if it was only to tell their story to someone objective who had not been through the same horrifying experience as they had. My hope is that mental health issues will be much more in the forefront for humanitarian organisations working in crisis zones, where people’s lives have changed forever.
Michelle Chouinard Social worker, Meulaboh, Indonesia
Go to www.msf.ca to read a full, oneyear report on the work of MSF in Southeast Asia since the tsunami.
WE TALKED ABOUT WHY CHILDREN RAN HOME FROM SCHOOL WHEN THE WIND PICKED UP AND WHY, SEVERAL MONTHS LATER, PEOPLE STILL RAN FOR HIGHER GROUND ON CERTAIN DAYS WHEN THE TIDE SEEMED HIGHER THAN USUAL.
THE SILENT VICTIMS OF
n rich countries, paediatric HIV/AIDS is largely under control: prevention of mother-to-child transmission is successful, and infants and children have access to effective diagnosis and treatment. But 88 per cent of the 2.2 million children living with HIV/AIDS are in Africa, and most are beyond the reach of these health services. They are condemned to die because they have no access to treatment.
HIGH RATES OF MOTHER-TO-CHILD TRANSMISSION More than nine times out of 10, children acquire the HIV virus through mother-tochild transmission during pregnancy, childbirth, or breastfeeding. This “vertical transmission” is easily preventable in rich countries – by giving highly active antiretroviral therapy (HAART) to HIV-positive mothers during pregnancy and to infants within a few hours of birth; by carrying out elective caesareans; and by providing safe alternatives to breast milk. Wealthy countries have been very successful in reducing mother-to-child transmission with these strategies. Poorer countries are unable to replicate this success because the majority of mothers do not have access to diagnostics to establish their HIV status and so never initiate treatment. Nor do they have access to antiretroviral therapy for them-
Dispatches Vol.8, Ed.1
selves or their children. Elective caesareans are rarely performed in developing countries. And even assuming that mothers know the risks, something basic like an alternative to breast milk can be unavailable, or dangerous because the water is unsafe in more remote locations.
These disparities between North and South explain the gap in paediatric HIV/AIDS today: of the 640,000 children in the world newly infected during 2004, 560,000 live in Africa, and only 100 in either Europe or North America. With infections in the developing world rising rapidly, the gap can only widen. NO DIAGNOSIS, NO TREATMENT HIV antibodies, part of the body’s immune response, appear in the blood within a few weeks following infection. Accurate diagnosis of HIV infection through an antibody test is necessary so antiretroviral therapy can be started as quickly as possible. It usually cannot be established on clinical symptoms alone, as these have often not manifested or are confused with other typical childhood illnesses. But detection of antibodies is ineffective for newborns, because all babies born to women with HIV acquire their mother’s antibodies, which can remain
in the infant’s body for as long as 18 months. Establishing whether the antibodies belong to mother or child is highly complex. Difficulties in diagnosis cause delays in the initiation of treatment, and are key to understanding why half of all infected babies die before the age of two.
The current strategy for diagnosing children requires high-tech and hugely expensive laboratory equipment to measure the viral load, or the amount of viral particles in the bloodstream. Costing up to $140,000 US, such equipment is not available in most developing countries – even the technologies most suitable for use in these locations can cost from $7,000 to $30,000 US. In addition, each test can cost up to $125 US. A further constraint is that the laboratory cannot function without highly skilled laboratory technicians and a constant supply of electricity. Today we need a simple, affordable, and rapid viral load test that can be used in low-tech settings, enabling doctors to make a diagnosis and begin treatment. Multinational diagnostic companies, answering to commercial interests, have so far not shown any interest in addressing this problem. Médecins Sans Frontières (MSF) is currently trying to identify and promote projects aimed at developing appropriate tools.
/AIDS INAPPROPRIATE AND EXPENSIVE DRUGS
In wealthy countries, infected children and babies – diagnosed rapidly – are treated with antiretroviral (ARV) therapy, a proven strategy for reducing illness and death. Until the child is able to swallow tablets, the drugs are commonly administered orally in syrups or as powders to be mixed with water. These seemingly simple procedures can be ill suited to remote or resource-poor settings, however. Some syrups must be refrigerated after opening, requiring a reliable electricity supply in patients’ homes. Those in powder form require clean drinking water. To ensure accurate dosage, some drugs must be measured with a syringe, which can be too complex for caregivers. Several products are also foul tasting.
CONDEMNED TO DIE WITHOUT TREATMENT, HALF OF ALL CHILDREN INFECTED WITH HIV IN DEVELOPING COUNTRIES DON’T LIVE TO SEE THEIR SECOND BIRTHDAY.
one year with Stavudine, Nevirapine and Lamivudine, for example, can cost up to $816 US, while treating an adult with the same drugs costs $182 US. Next, appropriate drugs simply don’t exist. Most pharmaceutical companies only produce liquid formulations. Today there are no equivalents for children of the fixed-dose combinations (FDCs - different drugs combined in a single pill) developed for adults. FDCs are particularly useful, as they simplify treatment and show excellent clinical, immunological and virological results. PROFITS BEFORE HUMAN LIFE
To address these issues, UNICEF and WHO consulted experts in November 2004 to improve access to appropriate paediatric ARV formulations. They recommended that liquids be used only for infants weighing under 10-12 kilograms, and that solid drugs be preferred for older children. While guidelines are welcomed, the recommendations do not provide an adequate solution.
While patient-friendly treatments have become available to adults in the past few years, only two producers of generic medicines, in Thailand and India, are in the later stages of developing an FDC for children, neither in syrup form. Most pharmaceutical companies have little interest in developing paediatric formulations because wealthier countries are largely successful in preventing mother-to-child transmission. The market for new formulations is mostly limited to the developing world and there isn’t enough commercial incentive to stimulate action.
One problem is the high price of liquid and solid drugs in paediatric formulations, much more costly than the adult equivalents – treating a child weighing 10 kilograms for
Meanwhile, children with HIV/AIDS in developing countries are often denied any possible treatment based on the perception their deaths are unavoidable – a perception that
must be overcome. By 2004, AIDS had left 15 million children under the age of 18 orphaned in its deadly wake, many of them infected with HIV. Most are in the care of their grandparents and other caregivers, live in orphanages or in the streets. This devastating outcome shows that drug development must be needs-driven. Governments, international donors and industry have the responsibility to ensure access to appropriate and effective diagnostics and treatment. Almost all countries of the World Trade Organization, including Canada, committed to the Doha Declaration of “medicines for all.” Children included. We cannot wait for these words to be translated into action. MSF TOURING EXPO Watch out in the summer of 2006 for an interactive exhibit MSF will bring to eight cities in Ontario and Quebec. Participants will learn what it's like to live with neglected diseases from the perspective of an MSF patient in a developing country and experience a consultation with MSF physicians who have worked in the field. Learn firsthand about the limited treatment options and the ongoing struggle for access to essential medicines. The exhibit will finish in Toronto at the same time as the XVI International AIDS Conference in Toronto in August. For up-to-theminute information on the touring AIDS Expo, go to www.msf.ca/tour2006
PATRICE PAGÉ Executive Director, MSF Canada A DYNAMIC ADVOCATE ON BEHALF OF POPULATIONS IN DANGER, PATRICE BROUGHT A SHARP INTELLIGENCE AND INSIGHT, A KEEN SENSITIVITY TO THE CAUSES OF MSF’S PATIENTS. HE DEMONSTRATED HIS PASSION FOR JUSTICE IN EVERYTHING THAT HE DID.
Dispatches Vol.8, Ed.1
atrice Pagé joined Médecins Sans Frontières (MSF) in 1999 as a field coordinator in southern Sudan after working for two years with UNHCR in Rwanda. He went on to work as field coordinator for MSF in Sierra Leone and Kosovo, and as head of mission in Eritrea, Democratic Republic of Congo, Guinea, and Liberia.
Patrice joined the New York office of MSF in 2001 as a programme officer. He was deeply involved in the Arjan Erkel case, pushing for and achieving meetings at the highest of levels with the US government and the UN; he was also instrumental in advocating for the UN Security Council resolution (1502) on the protection of aid workers that was passed in August 2003. He left MSF in 2004 to head up UNICEF’s emergency operations on the
Chad-Sudan border. In August 2005, he was appointed executive director of MSF Canada. A lawyer who graduated from the Université de Sherbrooke and the École du Barreau du Québec, Patrice also held a degree from the Institut International des Droits de l'Homme, Strasbourg, France. He practiced labour law with the Montréal Conféderation des Syndicats Nationaux / Confederation of National Labour Unions for two years. A dynamic advocate on behalf of populations in danger, Patrice brought a sharp intelligence and insight, a keen sensitivity to the causes of MSF’s patients. He demonstrated his passion for justice in everything that he did. He was 33 years old. He will be sadly missed.
CANADIANS ON BURUNDI Pierre Labranche Diane Rachiele Isabelle Rioux Catherine Mason
CAMBODIA Nicole Tanguay
Leslie Shanks Sophie Villemaire
Jim Newton Manisha Rajora
Catherine De Ravinel Jacinthe Larivière Dominique Proteau Danielle Trépanier
Rosianne Ayotte Sylvain Charbonneau
CENTRAL AFRICAN REPUBLIC
INDIA Karen Abbs
Alain Calame Émilie Frédérick Jacinthe Pressé
Fredédéric Beaudoin Aloma Boyce Adam Childs Nancy Dale
CHAD Kevin Coppock Mike Fark Frédéric Dubé François Riffaud Jacques Caron Benoît Wullens Lindsay Bryson
COLOMBIA Tyler Fainstat Darryl Stellmach
DEMOCRATIC REPUBLIC OF CONGO Heidi Chestnut Stéphanie Ferland André Fortin Jean-François Harvey Dawn Keim Judy MacConnery Jean-Sébastien Matte John Paul Morgan Marlene Power
Bruce Lampard David Michalski
Vivienne Rowan Christo Wiggins Beverly Winder
Ian Adair Adrienne Carter David Croft David De Bold Marise Denault Michael Hall Sajida Hussain Kathleen Skinnider
IVORY COAST Matthew Calvert Denise Chouinard Jennifer Grant Hélène Lessard Claudine Maari Brian Ostrow Elaine Sansoucy David Tu
KENYA Sylvain Groulx
LIBERIA Brian Baker Patricia Gould Serena Kasparian Patrick Laurent Chris Monnon
MALAWI Chantal St Arnaud
REPUBLIC OF CONGO Brenda Holoboff Martine Vézina Sophia Kapellas Grace Tang
SIERRA LEONE Laura Lau
SOMALIA Violet Baron Sylvain Deslippes Naomi Fecteau
Reshma Adatia Frank Boyce Stephanie Faubert John Hazleton Harry MacNeil Zayd Majoka Tiffany Moore Michel-Olivier Lacharité Simona Powell Mireille Roy Nasser Salam Arun Sharma Sheila Stam Vanessa Van Schoor Richard Zereik
Dispatches Médecins Sans Frontières/ Doctors Without Borders 720 Spadina Avenue., Suite 402 Toronto, Ontario, M5S 2T9 Tel: 416.964.0619 Fax: 416.963.8707 Toll free: 1.800.982.7903 Email: firstname.lastname@example.org www.msf.ca Editors: Dominique Desrochers Caroline Veldhuis Editorial directors: Laurence Hughes linda o. nagy Contributors: Johana Amar, Michelle Chouinard, Jean-François Corty, Nancy Forgrave, Michael Hall, Patrice Pagé, Kenneth Tong Circulation: 95,000 Layout: Artshouse Communications Inc. Printing: Warren's Imaging and Dryography Winter 2006
Rhiannon Hughes Safo Visha
UGANDA Richard Poitras Tom Ripley
ZAMBIA Eva Lam Sima Patel Paulo Rottman Chris Warren
ZIMBABWE Don Chambers Cheryl McDermid
Photo credits: Cyril Bertrand , Sebastian Bolesch, Doris Burtscher, Roger Job, Didier Lefevre, David Levene, Bruno Stevens / Cosmos, eduard compte verdaguer, Anne Yzebe
JOIN THE SANS FRONTIERES SOCIETY ne of the greatest joys of my work at Médecins Sans Frontières (MSF) is the chance to connect meaningfully with our wonderful donors.
MSF recently launched our Sans Frontières Society to thank and recognize individuals who have named MSF as a beneficiary in their will, or have made gifts through annuities or life insurance. As a member, you will be invited to MSF events in your local region and receive name recognition in our annual report and website. Your show of support also encourages others to make a gift of this kind. I invite you to get in touch with me to learn more about the Sans Frontières Society and the options available to you.
Nancy Forgrave Associate Director, Planned and Special Gifts (416) 642-3466 / 1 800 982-7903 email@example.com
MSF exists because of the humanitarian principle that all people should have access to medical assistance. Your promise of support helps ensure that we can provide this assistance rapidly and effectively to populations in need around the world, while bearing witness to the conditions of the people we help and advocating for them when necessary. Thank you for extending your compassion and generosity.
Nancy Forgrave Associate Director, Planned and Special Gifts