Dispatches, Winter 2007 (MSF-UK) by Doctors Without Borders MSF

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Quarterly news from Médecins Sans Frontières UK Issue n° 47 Winter 2007

Médecins Sans Frontières is a leading independent organisation for emergency medical aid. In over 70 countries world-wide, MSF provides relief to the victims of war, natural disasters and epidemics irrespective of race, religion or political afﬁliation. MSF was awarded the 1999 Nobel Peace Prize. © David Levene [2007]

Peru earthquake:

Children doing colouring-in amidst the remains of their home.

devastation in a forgotten town MSF staff describe the scene as being like a battlefield or the set of a disaster movie. Almost every building in Guadalupe’s town centre had been destroyed or badly damaged and more than 10,000 of the town’s 12,000 inhabitants had been affected. No aid had reached the town and the people were barely coping. 1-3 Peru 4-5 Democratic Republic of Congo 6-7 Malaria 8 Kenya 2047

Charity n0 1026588

D I S P AT C H E S

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THE FIRST 48 HOURS Luis Encinas, one of MSF’s emergency coordinators, was in Bogota when the news first filtered through on the morning of the 16 August. “It’s an emergency, you can tell it from miles away...” he explains in his diary. “The lines are bad, but I stay on the phone trying to coordinate everything: get the green light from emergency headquarters in Brussels; work out what resources we can mobilise; charter a 12 ton cargo plane... I check my watch – 7pm, in other words two o’clock in the morning in Europe. My deadline for booking the plane is six o’clock tomorrow morning. Time flies by as I try to gather a team together and work out what we would need: surgical tents, surgery equipment, basic health kits, wound dressings, hygiene kits, blankets, plastic

sheeting… I check my watch again, it is 2am and I sink into bed. It seems mere seconds later that my phone begins to vibrate. I glance at the clock – 4.30am. It's Martin with the go ahead for MSF to start providing aid.” The next day the team arrived in Lima and immediately headed to the earthquake zone 200km to the south. Luis’ first hours in the affected area made a strong impression on him: “You can see the shock registering on people’s faces. Then I feel the aftershocks, 23 seconds that seem to last forever. We’re waiting at a red light. The Peruvian driver reassures me, saying that it must be a passing truck, but there are no trucks and no busses... We get to the MSF building, briefing, three hours sleep and then back to work.”

Peru earthquake: devastation in a f

A child walks through the rubble of Guadalupe. © David Levene [2007]

When a powerful earthquake (7.9 on the Richter scale) rocked the Peruvian coast on 15 August, 600 people were killed and tens of thousands were made homeless Peru Lima• overnight. The MSF emergency team •Ica immediately started working outside the Epicentre Magnitude 7.9 cities, in towns and communities that 15 August 2007 18:40 local time were receiving little or no attention. Every day, on expeditions to identify where people most needed aid, the team was discovering new scenes of destruction. Then, ten days into the emergency, David Weatherill, a Water and Sanitation specialist from Leicester, noticed a collapsed roadside church near the city of Ica…

www.uk.msf.org

“The doctor had no strength left: ‘I am empty’, he told me, with tears in his eyes.” “I had driven to Ica to see whether the hospital there needed any more help,” says Weatherill. “The hospital was coping reasonably well, so on the way back we drove up for a closer look at a collapsed church we’d seen by the side of the highway on the way down. The fronts of the nearby houses had all fallen in. We walked round the side of the church and it was the same, then into the next street, and the next. The whole place was destroyed. There was no one there, just emptiness, and it felt as though the town was paralysed. I called Luis on the radio immediately. We didn’t even want to wait till the next day. My first thought was: I’ve got to get the team down here right now.”

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The Castillo family clearing up the remains of their house in Guadalupe.

in a forgotten town The church marked the devastated town of Guadalupe, where almost every building had collapsed or was badly damaged and people had been struggling with no outside help. The health centre had somehow survived, but was overwhelmed. “Inside, the staff were like zombies,” David Weatherill outside the ruined church at Guadalupe. emergency co-ordinator Luis © Francois Dumont/MSF [2007] Encinas wrote in his diary. “Over a week, while they struggled to get back on their feet, the number of consultations escalated wildly. The doctor had no strength left: ‘I am empty,’ he told me, with tears in his eyes.” “While the physical damage was clear,” adds Weatherill, “the real damage was more insidious. Even where the houses only showed cracks, people feared another quake. The majority were sleeping outdoors with whatever shelter they could find to protect themselves from the sand blizzards and the biting night-time cold.” People were living next to the bricks and roof beams of their destroyed houses, in shelters made of cardboard boxes, bed sheets and small pieces of plastic. Many were still waiting for their injuries to be treated. “We met a woman who had been squashed under a wall with her child in her arms when her house collapsed,” says Dr. Loreto Barcelo, the team's medical director. “The woman broke her foot and the little girl suffered multiple pelvic fractures. But the child was simply put in plaster and discharged, and the mother, who needed orthopeadic surgery, was not even treated.” They had traveled to the hospital in Ica the day after the earthquake and had been sent home after two hours because their lives were not in danger. Over the following days the team saw many others in a similar situation: fractures of the pelvis, leg and vertebrae that had been summarily treated or left without any care.

An MSF psychologist comforts a woman who is waiting to see a doctor at one of MSF’s temporary clinics.

“My first thought was: I’ve got to get the team down here right now.” The earthquake had completely overturned peoples’ lives and alongside the physical wounds, people were deeply traumatised. “It was terrible, horrible,” says Flavio Donayre Castillo, a resident of Guadalupe. “Even now, we're still living in absolute fear. Everyone is nervous about the slightest thing, the smallest sound – when there’s a gust of wind at night, people rush into the street.” MSF doctor Jelke Verwimpen attending to a patient who was injured when part of a wall fell on him in Guadalupe. © Jodi Hilton/Corbis [2007]

A team of MSF psychologists started organising individual consultations and group sessions to help people come to terms with their situation. “We are trying to explain to people that loss of appetite, anxiety, nausea and difficulty sleeping are natural reactions to such an extremely unusual event,” says Carmen Martinez, head of MSF’s mental health programme. “Many of these people have lost loved ones, their whole lives have come crashing down. They have so much to mourn… And then there’s the worry about tomorrow – will there be another quake?”

At its height MSF’s team in the affected area comprised 55 Peruvian and international staff. Over 10,000 blankets and hygiene kits were distributed to people with little or no shelter. The team provided drugs and supported staff in around 30 health centres, provided psychological support to more than 8,000 people, arranged clean water and hygienic toilet facilities, and set up temporary clinics throughout the area, including in Guadalupe.

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Zoe Young ensuring proper cleanliness in the isolation compound.

“When I got back from holiday everyone was talking about a mystery disease in the Congo,” writes Zoe Young in her diary. “Then news came through that it was Ebola, and everything changed straight away; I boarded a plane two days later.”

Coping with a deadly virus For several weeks in August cases of an unknown illness were reported in the province of Western Kasai in the Democratic Republic of Congo. Although the mystery disease was initially suspected to be a virulent form of dysentery, on 10 September tests confirmed that it was an outbreak of Ebola, a rare disease with no known cure. Zoe Young, a Water and Sanitation specialist, was part of an MSF team sent to convert a small regional health centre into an isolation and treatment unit. Ebola is highly contagious and, like all MSF staff working with suspected patients, Zoe had to wear special protective gear: “We have head covers and enormous white plastic overalls with elasticated wrists and ankles. Two pairs of latex gloves, ski type goggles, a duck beak mask and an apron. The overall effect on the outside is rather like a space suit. On the inside it’s like a sauna. The tiniest activity, like moving a patient, causes sweat to cascade down my face. Of course, I can’t wipe it off as I am all covered and have no access to my skin until I disinfect and leave the high-risk area.” The isolation area was maintained with a strict disinfection process – chlorine wash basins, chlorine solution sprays and a low-risk area for changing into and out of the protective suits, which are burned after every use. With hundreds of litres of water required per patient per day to maintain proper disinfection, water supplies had to be carefully managed. This was vital for the safety of the staff, but difficult as all the water had to be brought in jerry cans from local springs.

www.uk.msf.org

Using chlorine spray to disinfect the house and belongings of an Ebola patient.

It is essential to keep the spread of such a contagious virus under control. Every confirmed case therefore means a vast amount of work checking ‘contacts’. “These are people who have lived in the same house as a patient, touched a patient during their illness or after death, touched any bodily fluids of a sick person, or handled a sick person’s clothing,” explains Zoe. Contacts are monitored for twentyone days, the maximum incubation period of the virus, and are transferred to the isolation unit if they develop suspicious symptoms. “I went back to one of the first houses we sprayed, belonging to a patient we’d buried earlier,” continues Zoe. “His wife was sitting there looking extremely desolate. What was really difficult was that I couldn't touch her arm or take her hand to show a bit of empathy. She is a contact and is being monitored.”

W H AT I S E B O L A ?

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Ebola is a rare viral disease that has a mortality rate of 70% to 90%. Initial symptoms are very similar to malaria and other tropical diseases and include fever, headaches, vomiting, diarrhoea and muscle pains. Later, the patient starts to develop ‘haemorrhagic signs’ – bleeding from internal and external parts of the body. Eventually patients typically succumb to multiple organ failure. The virus is extremely contagious and can be transmitted through any body fluid, including blood, sweat, urine, saliva and vomit. Even when a patient has died, they are still infectious and must be wrapped in a special sealed body bag. There is no known cure, although some patients are able to fight off the virus themselves. Outbreaks are rare but deadly and specialist skills and equipment are required to combat an outbreak effectively. MSF has substantial Ebola experience, having been involved in the response to most recorded Ebola outbreaks. The Centre for Disease Control, based in Atlanta, is usually a key partner, providing laboratory testing of samples, as are the World Health Organisation and various other international humanitarian groups.

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Democratic Republic of Congo below: Inside the isolation ward. all photos © Pascale Zintzen/MSF [2007]

“The tiniest activity causes sweat to cascade down my face. I can't wipe it off as I am covered and have no access to my skin until I disinfect and leave the high-risk area.” There is no cure for Ebola and the majority of victims die. Although doctors cannot treat the disease, they can increase peoples’ chances of fighting the disease themselves. Inside the isolation area, the medical team rehydrates patients, encourages them to eat high-protein food and gives them antibiotics. “But,” says Zoe, “survival is dependent on the strength and will of each patient.” Some patients develop enough antibodies to combat the virus, but these are the lucky few. The disease is so feared that communities sometimes need encouragement to accept patients who have got better back into daily life. “When we release patients who have recovered,” Zoe writes, “it is my role to wait on the other side of the fence acting as the ‘greeter’ to show that they are safe to touch. One old lady had lost three of her children to the disease and had been in our isolation area for over a week before starting to recover. She had a wash and was wrapped in a new brightly patterned piece of cloth. When I held out my hand her eyes widened and her face lit up. I led her out and handed her to her sister”. Monitoring contacts, disinfecting patients’ houses and raising awareness of the disease proved an enormous task. In a race against time to control the spread of the virus, MSF’s logistics team started improving muddy tracks through the jungle to enable vehicles to bring sick people to the Ebola ward. Over four days, 80 people from the local area felled trees and built three bridges along a 22km stretch of track to allow 4x4 access to one badly affected village.

Better access to these remote villages meant that MSF’s work to minimise transmission could continue apace. It also meant that patients who had died could be buried amongst their loved ones. “The grave had probably taken all afternoon to dig,” writes Zoe of one of the burials she attended. “It seemed like half the village were standing around while the grave was finished. Lots of people had their t-shirts tied over their noses to protect themselves from the disease. When we were finished, we passed by the family to say goodbye. It was very sad. The husband said, What about me? Now I am a contact.” Being a contact makes people very frightened, but not all contacts catch the disease; fortunately this man was one of the lucky ones.

“When I held out my hand her eyes widened and her face lit up. I led her out and handed her to her sister.” On 4 October the last Ebola patient entered MSF’s isolation area, and the team started counting down the days. When the twenty-first day passed with no further Ebola cases, the team started to pack up, confident that the outbreak had ended. Families have been decimated and it will take time for the bereaved to come to terms with their loss, but for people living in Western Kasai province, the outbreak is over. Read Zoe’s diary online at www.uk.msf.org

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In a remote hilltop village in the far south of Ethiopia, six-year-old Sinkenesh sits shivering. She went down with a fever two weeks ago. Her grandfather has struggled up the hill to bring her to an MSF clinic and now she waits, silent and serious, for the blood test that will confirm whether she has malaria.

Sub-Saharan Africa

Malaria: desperate for drugs © Petterik Wiggers [2005]

She winces as the nurse pricks her finger and squeezes a tiny drop of blood, but she doesn’t cry. Fifteen minutes later the rapid test confirms the malaria diagnosis and the nurse explains to her grandfather how she should take the treatment. They head back home clutching a health record and a small packet of yellow and white pills. Another little girl takes her place in front of the nurse. Sinkenesh is just one among half a billion people who suffer from malaria each year. Yet in some ways, her case is unusual. The pills she has been given, known as ‘ArteminisinCombination Therapy’ or ACT, are much more effective than most malaria drugs currently being used in Africa. As well as acting fast and having few side effects, they work better because the malarial parasite has not built up resistance to their action, unlike older drugs such as chloroquine. They should treat Sinkenesh’s malaria in just three days. Yet, astonishingly, although this new generation of drugs is now widely accepted to be the best anti-malarial treatment available, they are simply not getting to millions of people who desperately need them. For MSF, which has fought for more than five years to get ACT drugs established, it’s an extremely frustrating situation. Last year we treated over two million malaria patients like Sinkenesh with ACTs in over 40 countries. Yet our teams on the ground rarely see these drugs being used except in our own projects. “Almost all the global players involved in tackling malaria have made firm commitments to ACT drugs on paper,” says Dr Prudence Hamade, a malaria expert at MSF. “The World Health Organisation officially recommends that countries switch to using ACTs as soon as older malaria drugs fail to work well. 43 out of 54 African governments have re-written their national malaria policies and agreed to use ACTs as their ‘first-line’ treatment. The Global Fund to Fight AIDS, Tuberculosis and Malaria has pledged nearly a billion pounds to malaria programmes, and other big donors have also promised huge sums of money. It’s all there on paper, but way too little is happening on the ground.” So what needs to change? One major hurdle is the ubiquitous problem of bureaucracy. Applying for financing from the major funding bodies can be an extremely long and complicated procedure. And once funding has been agreed, lengthy internal procedures governing the import of drugs into certain countries can slow things down even further.

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It’s the job of the World Health Organisation (WHO) to test drugs for safety, quality and efficacy. Yet because the certification process has been extremely slow, only two types of ACT have been given the stamp of approval by WHO so far. This makes it very confusing for governments to know exactly which type of ACT they should buy (they need to ensure that they choose one appropriate to the resistance patterns in their country). There also needs to be much more community health education, so that patients understand what the new treatment is and how it should be taken. Understandably, people who have grown used to taking old drugs like quinine are suspicious when presented with something new and unfamiliar. MSF has successfully used drama plays, radio broadcasts and posters to teach communities about malaria and ACT drugs. The results have been striking – after an intensive education campaign in a region of Angola, people started to come forward for ACT treatment much earlier and the number of children admitted to the hospital with severe malaria went down by a quarter. © Francesco Zizola/Noor [2007]

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aharan

A man receives a rapid malaria test in southern Ethiopia.

“After six days he was smiling and laughing. I went home and told everyone they need to have the right medicine for the fever.” The experiences of a family in western Sierra Leone illustrates starkly how ACT drugs can make the difference between life and death. “When my daughter got sick last year she had a fever,” says Adamu, a mother of six. “For four days, I tried giving her native herbs from the traditional healer in the village. Then I took her to the government hospital and they gave me pills. The baby got a bit better, but after the pills finished the baby got sick again straight away. She was shaking with cold and I had to put her in front of the fire. She died the next day. The following year my son, Chernor, got sick with the same fever. He was very hot and his body was swollen. I was very afraid that he was going to die like my daughter. But when I took him to the hospital they did lots of tests and gave him a different medicine. After four days he got better and was starting to want to eat. After six days he was smiling and laughing. I went home and told everyone they need to have the right medicine for the fever.” For MSF doctors who witness the devastating impact of malaria every day, it’s shocking that these new drugs simply aren’t getting to the vast majority of those who need them. “Although there has recently been some good progress on the distribution of bed nets to prevent malaria, when you get sick you need effective treatment,” says Dr Hamade. “It’s unbelievable that malaria still claims the life of one child every thirty seconds in Africa. We have easy-to-use tests to diagnose malaria quickly and drugs to treat patients effectively. It’s absolutely time for things to change.”

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MSF UK volunteers currently in the ﬁeld Bangladesh Chris Hall LOGISTICIAN Kolja Stille DOCTOR Bolivia Tom Ellman HEAD OF MISSION Burundi Anna Halford FIELD COORDINATOR Central African Republic Anat Aharon PROJECT COORDINATOR Anthony Kilbride WATER & SANITATION EXPERT Colin Beckworth NURSE James Pallett DOCTOR Nicole Hendriksen NURSE Chad Alexis Gallagher FINANCIAL CONTROLLER Andrew Mews LOGISTICIAN Andrew Noden DOCTOR Emily Bell LOGISTICAL ADMINISTRATOR Paula Brennan PROJECT COORDINATOR Colombia April Baller DOCTOR Caroline Brant FINANCIAL CONTROLLER Haresh Mulchandari ANAESTHETIST Simon Midgley MENTAL HEALTH SPECIALIST DRC Adam Thomas LOGISTICIAN Alice Thomas NURSE Danielle Ferris LOGISTICAL ADMINISTRATOR Gail Leeder FINANCIAL CONTROLLER Katy Peters NURSE Matthew Arnold WATER & SANITATION EXPERT Nitisha Nababsing DOCTOR Simon Wright FINANCIAL CONTROLLER Cokie van der Velde LOGISTICIAN Gina Bark HUMANITARIAN AFFAIRS OFFICER Ethiopia Freda Graf NURSE Joanna Knight FINANCIAL CONTROLLER Karen Kennedy LOGISTICIAN Marjolein Jongepier CAMPAIGNER Tom White HEAD OF MISSION Haiti Sophie Tilt LOGISTICIAN Tuppin Scrace ANAESTHETIST India Anthony Soloman DOCTOR Ed Ramsay WATER & SANITATION EXPERT Hilary Evans DOCTOR Joanna Cox MEDICAL COORDINATOR Orla Condren NURSE Pawan Donaldson FIELD COORDINATOR Samuel Crawley LOGISTICIAN Simon Woods LOGISTICIAN Jacob Stringer HEAD OF MISSION Jordan Maria Siemer FINANCIAL CONTROLLER Liberia Annas Alamudi LOGISTICIAN Foday Kargbo FINANCIAL CONTROLLER Fran Miller MENTAL HEALTH SPECIALIST Kartik Chandaria DOCTOR Pauline Scheelbeek WATER & SANITATION EXPERT Malawi Margaret Othigo BIOMEDICAL SCIENTIST Bryn Button LOGISTICAL COORDINATOR Myanmar Anna Wilkins DOCTOR Helen Bygrave DOCTOR Johannah Wegerdt EPIDEMIOLOGIST Maria Doyle NURSE Michael Patmore BIOMEDICAL SCIENTIST Sabina Ilyas DOCTOR Nepal Simon Heuberger FINANCIAL CONTROLLER Nigeria Peter Dunkin ANAESTHETIST Pakistan Philippa Farrugia DOCTOR Russia Valerie Powell MEDICAL COORDINATOR Somalia Colin McIlreavy HEAD OF MISSION Declan Overton LOGISTICIAN Joan Wilson MEDICAL COORDINATOR Kiran Jobanputra DOCTOR Leanne Sellers NURSE Luke Arend ASSISTANT HEAD OF MISSION Paul Critchley PROJECT COORDINATOR Paul McMaster SURGEON Robin Aherne LOGISTICIAN Sarah Quinnell MIDWIFE Suzanne Edwards LOGISTICAL ADMINISTRATOR Tom Quinn HEAD OF MISSION South Africa Louise Knight EPIDEMIOLOGIST Nathan Ford HEAD OF MEDICAL UNIT Sudan Angela Cave NURSE Anna Greenham DOCTOR Elizabeth Harding NURSE Patricia Drain NURSE Siama Latif DOCTOR Simon Nash DOCTOR Stephen Cooper PROJECT COORDINATOR Tracy Crawford ASSISTANT MEDICAL COORDINATOR Aisa Fraser NURSE Anette Scholz ANAESTHETIST Anna Claire Hess NURSE Anna Kent NURSE Brigitte Daubeny de Moleyns ADMINISTRATIVE COORDINATOR Emily Russell LOGISTICAL ADMINISTRATOR Helen Austin FIELD COORDINATOR Malcolm Townsend LOGISTICAL COORDINATOR Boris Stringer PROJECT COORDINATOR Sarah Maynard LOGISTICAL ADMINISTRATOR Simon Burling DOCTOR Victoria Treacy NURSE Sri Lanka Bruce Russell PROJECT COORDINATOR Jonathan Henry PROJECT COORDINATOR Katarzyna Russell NURSE Susan Lowery ANAESTHETIST Terri Morris PROJECT COORDINATOR Thailand David Wilson DOCTOR Paul Cawthorne PROJECT COORDINATOR Turkmenistan Gemma Davies LOGISTICIAN Zoe Shimanska LOGISTICAL ADMINISTRATOR Uganda Alyson Froud PROJECT COORDINATOR Sandi Chit Lwin DOCTOR Sascha von Lieven Knapp PROJECT COORDINATOR Uzbekistan Jonathan Polonsky EPIDEMIOLOGIST Yemen Cristian Ghilardi PROJECT COORDINATOR Zimbabwe Cielo Rios DOCTOR Daniel Williamson LOGISTICAL ADMINISTRATOR Lily Cummins NURSE Stephen Hide HEAD OF MISSION

DISPATCHES is a quarterly publication designed to keep our supporters updated on the work of Médecins Sans Frontières. Editor:

Robin Meldrum For more information, contact:

top left: Sinkenesh waiting for her malaria test. left: Mariana Mohammed arrived at an MSF clinic in Sierra Leone with a respiratory tract infection and malnutrition as well as malaria. ACTs rapidly cured her malaria, enabling her to put on weight and start to fight her other infections.

MSF UK 67-74 Saffron Hill London EC1N 8QX Tel: 0207 404 6600 Fax: 0207 404 4466 E-mail:

office-ldn@london.msf.org Website:

www.uk.msf.org English Charity Reg No. 1026588

MSF UK Board:

Dr Christa Hook, Chair Robert Senior, Treasurer Dr Karen Adams Dr Mark Cresswell Paul Foreman Dr Pim de Graaf Jerome Oberreit Frances Stevenson Company secretary:

Rhonda Walker Director:

Jean-Michel Piedagnel 7

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How to make a donation If you would like to support MSF further, you can make a donation by:

Telephone 0800 731 6732 Online www.uk.msf.org Post Consultation in a health post in the Mt Elgon region.

MSF’s work in Kenya over the past decade has focused on drought and flood relief as well as HIV/AIDS. Since April, an MSF team has also been working in the midst of an entirely unreported conflict in the mountainous region of Mt Elgon, near the Ugandan border. Around 100,000 people are living in an area stricken by escalating violence. MSF is one of the very few aid organizations in the region and is the only international group on the ground on a permanent basis. This situation urgently needs more international attention. Although sometimes portrayed as a dispute between the Soy and the Ndorobo clans, the conflict is extremely complex; the civilian population is caught between groups that have rebelled against the government’s land allocation schemes, a strong police operation trying to address the lawlessness, and criminal groups profiting from the current chaos. “People are terrified,” explains Rémi Carrier, who coordinates MSF’s work in Kenya. “150 terrorised people rushed to find shelter and safety in the Kopsiro health post recently when there was heavy gunfighting outside.” A man who had moved down from the mountain explains why he fled: “I moved because people were fighting. People were being slaughtered. I had death threats. Our belongings were taken out of our houses and houses were being burned. We could not stay there. My mother and my brother were killed. They were just going up to get some vegetables and were attacked on the way. This happened last month.” Sexual violence, beatings, gunshot wounds and psychological trauma are all on the rise and hampered access to the crops is leading to an increasing malnutrition problem. The MSF team is running several health centres where most of the local staff have fled and is using large tents to run clinics in more remote or sensitive areas. Since April, MSF staff have carried out more than 15,000 consultations and have immunised around 2,000 children against polio, measles and hepatitis. Blankets and clothes have also been distributed, as the highlands can get bitterly cold at night. At a time of increased violence, the limited presence of aid organisations (MSF and the Kenyan Red Cross at the moment) is not sufficient anymore. “What MSF has witnessed in Mount Elgon district is a dire situation,” concludes Carrier. “It is of the utmost importance that those who have the mandate and the responsibility to protect these civilians step in and focus their attention on the plight of this population. Now more than ever.”

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Send a cheque/postal order (payable to MSF) to: Médecins Sans Frontières, FREEPOST NAT20938, West Malling, Kent ME19 4BR Please quote your supporter number (located on the top right hand side of the letter) and name and address when making a donation.

Why Dispatches? Dispatches is written by people in MSF and sent every three months to our supporters and volunteers in the field. It costs 8 pence per copy to produce and 22.5p to send, using Mailsort Three, the cheapest form of post. We send it to keep you, our donors, informed on how your money is spent and what our latest activities are. Dispatches also gives our patients, staff and volunteers a voice to speak out about the conflicts, emergencies, and epidemics in which MSF works, and about the plight of those we strive to help.

The Dispatches cover letter Over the years, many readers have got in touch to tell us how inspired or moved they are by the letters that are mailed with Dispatches. Some have wondered whether these letters are really written by MSF people working on the ground. The answer is that they are all written by doctors, nurses or logistics specialists who want to speak out, in their own words, about the work they are doing and the situations they are encountering. The letter sent with this issue is written by Chris Lockyear (pictured), a 28 year old engineer from Swaffham, who returned to the UK in November after spending nine months managing security and setting up two new MSF clinics in Somalia. He was not able to find time to write while out in Somalia, but his experiences of restarting MSF’s work in Mogadishu are so unique that we asked him to write a letter from back home. As this issue of Dispatches went to press Chris was preparing to return to Somalia.

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