Médecins Sans Frontières’ epidemiological arm, Epicentre, co-host of our 2011 International Symposium on Reducing Child Mortality (held in Melbourne), will hold its 22nd Scientific Day in Paris. The day features presentations by internal and external experts on improving diagnosis and detection, the results of recent studies and surveys, and new research themes, all focused on better outcomes for Médecins Sans Frontières’ field operations and its patients.

Join our sister office in the UK for their annual Scientific Day to hear experts present original research from humanitarian projects in the field, with sessions dedicated to topics including HIV and TB; digital humanitarianism; and finding and treating hidden and neglected populations. The livestream starts 09:30 London time (08:30 GMT/18:30 Australian Eastern Standard Time).

Their first observation was that medical workers were so terrorised that they would offer only first aid in cases of extreme emergency. To treat broken bones, for example, they would simply use makeshift splints. In dealing with haemorrhage, they applied compression bandages even when they had access to technical resources enabling them to provide more appropriate and complete care.

"They told us that the risk was too high,” the Médecins Sans Frontières surgeon explained. “We were told that, 'being caught with a patient is worse than being caught with a weapon.' A Syrian colleague also told me that meant death both for the patient and for him."

The team also observed the targeting of hospitals and medical facilities by armed forces. In a small town that the team visited, a health centre that served as an improvised hospital had been burned down. There was nowhere else to treat the wounded. Another health centre, still in good repair, had only one consulting room.

In another town, the team found an actual, functioning hospital. It had a medical team, supplies and a well-equipped operating room. "We performed as many procedures as we could," the Médecins Sans Frontières surgeon said. "Then we had to leave in less than 10 minutes after being warned that the army was coming and launching an attack on the city. Later, we heard that the hospital had been severely damaged and that it has not yet resumed functioning."  

Fear is ever-present. Elsewhere in Idlib region, in northern Syria, the team was greeted at a public hospital whose operating room is closed. The staff refuse to perform surgery for fear of reprisals and will thus provide only first aid services that require 10 to 20 minutes. “If the tanks arrive, I can be warned in time,” the chief doctor explained to us. “I can get all the patients out and remove all traces of their presence.”  (The family remains nearby and can thus move the patient quickly.)

The Médecins Sans Frontières team asked what happens if a patient is in serious condition. The Syrian doctor responded with a helpless shrug. Then he added that some patients had managed to reach Turkey.

Médecins Sans Frontières has been seeking official authorisation for several months to work with medical personnel in the Syrian governorates most affected by violence. To date, none of our efforts, either directly with Syrian authorities or via various intermediaries, have succeeded.

Nonetheless, after reaching Homs, Médecins Sans Frontières managed to enter Idlib Governorate where the medical teams found patients and doctors at risk of attack and arrest.

"Being caught with patients is like being caught with a weapon," said an orthopaedic surgeon whom Médecins Sans Frontières met in a village in Idlib Governorate. “The atmosphere in most medical facilities is extremely tense; healthcare workers send wounded patients home and provide only first aid so that facilities can be evacuated quickly in the event of a military operation.”

"A number of Syrian colleagues are reported to be missing," said Marie-Noëlle Rodrigue, Médecins Sans Frontières’ director of operations in Paris. "The authorities and all parties to the conflict must ensure that medical workers can operate without fear of retribution and that wounded people can safely seek and receive immediate life-saving care, without resorting to inadequate improvised clinics for fear of arrest, or worse.”

While Médecins Sans Frontières has only a partial view of the medical situation inside Syria due to the lack of authorisation to work in the country, the information obtained by Médecins Sans Frontières in Idlib is consistent with what it witnessed in Homs. “We saw militarised healthcare facilities, meaning that access to medical care depends on which side you belong,” said Brice de le Vingne, Médecins Sans Frontières’ director of operations in Brussels. “Health facilities are being targeted, thus endangering patients and preventing healthcare workers from doing their jobs. Health facilities and pharmacies are looted and destroyed.”

During its short time in the Idlib area, the Médecins Sans Frontières team was able to perform some emergency medical work.

"In one public hospital we worked as hard as we could for three days straight," recounted a Médecins Sans Frontières surgeon. "We operated on 15 wounded people and then had to pack everything up in 10 minutes after being notified of an imminent attack. Elsewhere in the Idlib region, an operating room was closed because it was simply too dangerous to perform surgery on wounded patients,” he said. “Or doctors were threatened, and they discouraged us from setting up a medical facility because the situation was so risky,” adding that another hospital had been destroyed.
 
“You can see medical equipment and supplies,” the surgeon recounted. “Sometimes the resources and the infrastructure are there, but the fear and the risks of capture are so great that doctors hesitate to treat patients.”

Still without official authorisation to operate inside Syria, Médecins Sans Frontières continues to support networks of Syrian doctors in Homs, Derah, Hama, Damascus and Idlib, delivering supplies and medicines from neighbouring countries. Médecins Sans Frontières also treats those who were wounded or tortured in Syria at a surgical hospital in Amman, Jordan. Additionally, Médecins Sans Frontières is providing primary health care and psychological support to Syrian refugees in Lebanon.

Médecins Sans Frontières reiterates its call for authorisation to work inside Syria.  The organisation stands ready to quickly mobilise its medical and surgical teams, and is determined to operate independently, providing care to anyone requiring it.  

Despite the lack of effective ceasefire or sustainable political solution, all parties to the conflict must fully respect the physical integrity of wounded persons, doctors, and healthcare facilities, Médecins Sans Frontières said. Médecins Sans Frontières calls for increased political and diplomatic efforts to ensure the safety of patients and medical workers, without the use of force.

Médecins Sans Frontières first reported in early February on the abuse of health facilities and the targeting of patients and medical workers.

Since late January, nearly 160,000 Malians have fled their country for camps in Burkina Faso, Mauritania and Niger. While instability persists in Mali, leaving little hope that the refugees can return to their country soon, another imminent threat is looming - the rainy season, which will further complicate the deployment of aid.

According to the medical humanitarian organisation Médecins Sans Frontières, which is assisting Malian refugees in camps in Burkina Faso, Mauritania and Niger, the international aid provided to these people is insufficient.

“Médecins Sans Frontières calls on the United Nations High Commissioner for Refugees (UNHCR) and the World Food Program (WFP) to increase and speed up the distribution of aid in Burkina Faso, Mauritania and Niger before the rainy season makes aid distribution even more difficult,” says Malik Allaouna, Médecins Sans Frontières director of operations.

In the makeshift Mauritanian camp of Mbéra, located in the middle of the desert, residents share one latrine for 220 people. They receive only 11 litres of water/person per day and the food distributed by the WFP does not meet the specific nutritional needs of children.

"We received 4 kilograms of rice – the quality is mediocre and it's full of pebbles – two cups of oil and two cups of sugar for 10 days," says one resident of Mbéra camp. "They've given us just a single ration since we arrived."

In Burkina Faso, where Médecins Sans Frontières is working in four camps, the organisation notes that food supplies are distributed inappropriately. "The same quantity is distributed without regard for the number of people in a family," says Mohamed El Moktar, a refugee at the Gandafabou camp. "We are seven people. After two days, we have nothing left."

These living conditions are significantly below international aid standards and increase the vulnerability of people already weakened by a very long journey. Most of the diseases treated during Médecins Sans Frontières’ medical consultations in the camps are directly related to these poor living conditions.

At Médecins Sans Frontières’ treatment centre in Mbéra, four out of every 10 people are seen for respiratory infections and two out of 10 for diarrhoea. The next most-common complaints are skin infections and childhood malnutrition. Since the organisation began working in Mbéra, more than 500 children have been treated for malnutrition.

“Food insecurity is a threat both for the Malian refugees and for the host communities, which are already suffering from poor harvests," adds Mr. Allaouna. “Only food distribution, in sufficient quantity and quality, will prevent children’s nutritional condition from further deteriorating.”

In Burkina Faso, Médecins Sans Frontières is working in the Ferrerio, Gandafabou, Dibissi and Ngatourou-Niénié camps; in Mauritania, in Mbéra, Fassala and Bassikounou; and in Niger, it is active in the communities of Mangaïzé, Abala, Chinagodrar and Yassan

While Haiti’s Ministry of Health and Populations claims to be in control of the situation, health facilities in many regions of the country remain incapable of responding to the seasonal fluctuations of the cholera epidemic. The surveillance system, which is supposed to monitor the situation and raise the alarm, is still dysfunctional, Médecins Sans Frontières said. The number of people treated by Médecins Sans Frontières alone in the capital, Port-au-Prince, has quadrupled in less than a month, reaching 1,600 cases in April.  The organisation has increased treatment capacity in the city and in the town of Léogâne, and is preparing to open additional treatment sites in the country.  Nearly 200,000 cholera cases were reported during the rainy season last year, between May and October.  

“Too little has been done in terms of prevention to think that cholera would not surge again in 2012,” said Gaëtan Drossart, Médecins Sans Frontières head of mission in Haiti. “It is concerning that the health authorities are not better prepared and that they cling to reassuring messages that bear no resemblance to reality. There are many meetings going on between the government, the United Nations and their humanitarian partners, but there are few concrete solutions,” he said.

A Médecins Sans Frontières study in the Artibonite region, where approximately 20 percent of cholera cases have been reported, has revealed a clear reduction of cholera prevention measures since 2011.  More than half of the organisations working in the region last year are now gone. Additionally, health centres are short of drugs and some staff have not been paid since January.

“Rainfall is just one of the risk factors for contamination. But as soon as the rains end, cholera subsides, and funding stops until the next rainy season, instead of money being channelled towards cholera prevention activities. As a consequence, people are still highly vulnerable when cholera comes back,” said Maya Allan, Médecins Sans Frontières epidemiologist.

The majority of Haitians do not have access to latrines, and obtaining clean water is a daily challenge. Of the half-million survivors of the January, 2010 earthquake who continue to live in camps, less than one third are provided with clean drinking water and only one percent recently received soap, according to an April 2012 investigation by Haiti’s National Directorate of Water Supply and Sanitation.
 
“Hygiene advice is of little use if people are unable to put it into practice,” said Drossart. ”People urgently need the means to protect themselves against cholera.”

While the cholera vaccination being used in some parts of Haiti can help control the disease, it is not a foolproof solution. The vaccine provides immunity for approximately three years and is estimated to be only 70 percent effective.  Only major improvements of Haiti’s water and sanitation systems will provide durable solutions to the epidemic, but that will take time.

“The priority today is to save lives,” said Drossart. “All health actors in Haiti need to start working towards this goal immediately.”

Since cholera emerged in Haiti in October 2010, 535,000 people have been infected and more than 7,000 people have died, according to the Ministry of Health and Populations. To date, Médecins Sans Frontières has treated more than 170,000 people, or 33 percent of total cases, across the country.

For more information or to arrange interviews, please contact Sally McMillan – sally.mcmillan@sydney.msf.org or +61 447 482 379.

Athens, 27 April 2012 - Medecins Sans Frontieres opposes the police-style healthcare controls in the name of public health protection. “Public health cannot be promoted through police-led medical screenings and scaremongering about ‘ticking time bombs for public health’. It can be effectively safeguarded and promoted as long as the populations most in need have access to healthcare services and to effective public healthcare programs. It is promoted only when the medical needs of all social groups are met - people lacking health insurance, children, elderly, chronic patients regardless of their origin - especially today that thousands of households are living in destitution and the public healthcare system is in extreme stress due to horizontal budget cuts”, said the General Director of Médecins Sans Frontières Greece, Reveka Papadopoulou. “The involvement of public health care actors in police checks is contrary to medical ethics and dangerous as well”, she added.

Such operations can only spread fear among the population groups they target, and therefore compel them to go into hiding, preventing them from reaching healthcare services for medical assistance when needed. At the same time, the participation of health professionals in police “sweep” operations arouses serious ethical issues, according to the code of medical ethics.
 
The amendment of the Greek Presidential Decree 114/2010 - included in the law governing “Electronic communications, Transports and Public Works Regulations and other decrees” introduced on April 9, day of dissolution of the parliament and announcement of the national elections - foresees mandatory health screenings of persons who suffer from communicable diseases or belong to groups vulnerable to communicable diseases, and their detention in health structures defining these persons as a ‘danger to public health’. According to this specific legislation “the risk is perceived among persons who suffer from communicable diseases or belong to population groups vulnerable to communicable diseases, mainly due to their country of origin or the use of intravenous illegal substances, or the fact that she/he is a sex worker…, or due to his/her living conditions that do not abide to basic rules of hygiene”.

The article specifies “mandatory health screenings” whereas in Greece migrants who lack documentation have access to the healthcare system only in “emergency cases and until the stabilisation of their health is achieved” according to the law (Article 84/Ν.3386/2005).

Public health is an issue of state responsibility. However, by this specific legislation the government not only fails to assume its responsibilities but it also turns the “victim” into a “perpetrator”, as seen in the case of detention centres. According to medical data from Médecins Sans Frontières interventions in detention facilities in Evros during 2011, over 60% of the medical problems of detained are due to or directly related to their substandard living (detention) conditions. This was also duly noted by the European Centre for Disease Control and Prevention and the World Health Organization, which found migrants’ detention centres inappropriate for human habitation.

The Greek authorities in charge have so far failed to respond to public health care needs through integrated programs. Médecins Sans Frontières calls upon the relevant authorities to safeguard unhindered access to the healthcare system for the populations in need, which cannot be achieved by carrying out mandatory medical screenings in the context of police “sweep” operations.

New patients arrive daily at Médecins Sans Frontières' cholera treatment centres (CTC). Marie was admitted to the Martissant CTC on April 16. "I had diarrhoea and was vomiting a lot, then I fainted. A relative brought me here because it is the centre closest to where I live. The doctors told me that I had cholera and was dehydrated" she says. One hundred and thirty-four other people like Marie arrived at the Médecins Sans Frontières centre in Martissant between April 16 and 23 and nearly 400 at Médecins Sans Frontières’ other CTCs in Port-au-Prince and Léogâne.  

Médecins Sans Frontières had to reopen a CTC in Carrefour, in the southern part of the capital city, to deal with the new influx of patients and prevent the centres in Martissant, Delmas and Drouillard – closer to the city centre – from being overwhelmed. With all its facilities combined, Médecins Sans Frontières currently has more than 200 beds in Port-au-Prince and more than 45 in Léogâne dedicated to cholera patients and is prepared to open more sites based on the course of the epidemic.
 
"Cholera is easy to treat but specialised treatment centres must be accessible and patients must be brought there as soon as possible once symptoms appear," says Dr. Sophie Duterne, Médecins Sans Frontières’ medical coordinator in Haiti. "If left untreated, this disease can kill within a few hours. Treatment involves simple oral or intravenous rehydration, with antibiotics for the most severe cases. However, taking additional hygiene precautions and drinking disinfected water is still the best protection." Since the first cases were identified in October 2010, more than 500,000 Haitians have contracted cholera.

Inadequate access to disinfected water and insufficient numbers of latrines provide fertile ground for cholera. The arrival of the rainy season further promotes the spread of the disease by flooding water and sanitation systems. "The sewers in my neighbourhood are overflowing and we live in unhealthy conditions, without clean water or soap," Marie says. "I knew that I could contract cholera, but I had no choice." That is why along with treating patients, Médecins Sans Frontières continues to encourage Haitian health authorities and its international humanitarian partners to distribute disinfected water and soap and to install and maintain latrines so that Haitians can practice good hygiene and prevent the epidemic from spreading. 

Since the epidemic began in October 2010, cholera has killed more than 7,000 people (out of approximately 500,000 cases recorded), representing approximately 5% of the population.
As soon as the first cases were confirmed, Médecins Sans Frontières set up an unprecedented effort across the country, treating more than 30% of the total number of patients on its own.