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).

Two infants died initially due to late arrival at the Médecins Sans Frontières health facility; the other 75 patients were successfully cured. The majority of affected patients were children under five years old. In addition to treating patients, Médecins Sans Frontières teams also carried out chlorination of the water sources, and distributed water purifying tablets to the affected communities.

In the absence of new cases in the last 2 weeks, the CTC is set to close down on 20 May, 2012. Médecins Sans Frontières teams will however keep on monitoring the situation in the villages surrounding Balcad, while informing the population on how to prevent the spread of the disease.

Cholera is endemic in the region, and cases occur almost on a yearly basis. The bacteria that transmits cholera, called vibrio cholerae, develops and spreads essentially in water sources and through humans. Last year already, Médecins Sans Frontières teams set-up a CTC in Balcad and admitted some 150 patients.

Dehydration is the most common cause of death amongst cholera patients, and it is therefore essential that patients with watery diarrhoea visit the closest health facility. The broad diffusion of preventive messages - such as the drinking of safe boiled water, regular hand washing with soap, and use of latrines - helps to control the expansion of the disease, as does the chlorination of infected water sources and reservoirs. Children are most at risk, and up to 50% of patients risk dying if they are not given appropriate medical care in due time.

Médecins Sans Frontières responded to the cholera outbreak in Middle Shabelle as an emergency. The medical organisation will not step up its activities or open up new projects in the country until its two colleagues - Montserrat Serra and Blanca Thiebaut - abducted in Dadaab and held in Somalia since October 2011, are reunited with their families.

As the Nurse Manager for the project, I was responsible for supervising the nursing activities in eleven health centres in the district of Chiradzulu. The distance of these health centres spanned 60 kilometres. I worked with 23 nurses, four of which are nurse supervisors and delegated to three health centres each. Each day six mobile medical teams, consisting of a clinical officer, nurse and counsellor would be allocated to run the HIV clinics in the rural health centres. The Ministry of Health staff also rotated among the HIV clinics, which also fell under my supervision. Each day I would make the rounds and visit alternating clinics, following through on pertinent issues and ensuring protocols and a high standard of care were being followed.
 
In Malawi, 18 percent of the population is urbanised, so most of the patients we treat live in rural areas that are only reachable in four-wheel drives. During the rainy season the roads become even more treacherous and the daily movements around the health centres become more of a challenge. However, regardless of the conditions, we had to continue to reach these health centres to run the clinics, as our patients are booked and clinics are scheduled every day. Our primary objective lies in the needs of the patients and even if our off road adventures took a little longer and were more perilous – we always made it!

Médecins Sans Frontières launched its first HIV/AIDS program in Malawi in 1996 and today is still present in Chiradzulu with the vision to continue for at least another five to ten years. We also have a team in the neighbouring district of Thyolo addressing the same issue. Médecins Sans Frontières celebrated ten years of distributing anti-retroviral therapy (ARVs) last year in Malawi and the positive impact of this is evident in many of the national staff working for the organisation, and of course our patients.

Médecins Sans Frontières is also working to reduce the prevalence of HIV through information, education and counselling and linking in with other local community non- profit groups, youth groups, HIV support groups and sex workers. Together, we collaborate in bringing the important messages of safer sex and cultural practices, the importance of knowing your HIV status before becoming ill, as well as deepening the understanding and breaking away the stigma of HIV as a disease.

One of my most memorable interactions was meeting an HIV-positive couple wishing to have a child. Through providing education about the disease, treatment possibilities and emotional support, the team managed to instil the hope and possibility for the couple to have a life where starting a family was a realistic aim. A future where both could pursue and maintain their working ambitions and be a part of their community without prejudice. This couple went on to have a beautiful baby boy who was HIV-negative.

Life in the field is a blast, most of the time. As an international team, you live and work in very close quarters. The working days are full and the hours long. Professionally and socially you have to be flexible and adapt to many different personalities and cultures. It is this diversity that brings so much joy to field life. You meet and work with people from all over the world who are united in a passion and motivation that is an absolute privilege and pleasure to be a part of. I have learnt to cook new dishes, begin to speak new languages and learn about so much more than I ever thought possible.  

What I find rewarding about humanitarian work are the insights and exposure you receive and how I appreciate so much more what we take so easily for granted in our every day life. I feel that it is much more than just a job; it encompasses what I value and strive for in my development as both a human being and within my professional capacity as a nurse. One of the most vivid memories is bringing out a smile on a patient’s face, or planting a seed of hope in someone who sees no future. This comes through connecting with each other on a level that is a basic human act. 

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.