Dispatches (Winter 2004)

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Dispatches M S F

C A N A D A

N E W S L E T T E R

IN THIS ISSUE

1

Remembering Rwanda

4

FTAA: Trading Away Health

6

Letters from Liberia

8

Nepal: A Hospital at the Top of the World

10

The Mechanics of Malnutrition

12

Updates

14

MSF in Canada

16

Canadians on Mission

1999 Nobel Peace Prize Laureate

REMEMBERING RWANDA The 1994 Rwandan genocide was a horrific event resulting in the deaths of some 800,000 Tutsis and moderate Hutus. As years go by, articles continue to diminish the estimated number of dead, as if the world is trying to forget this period of history that came so soon after it said "never again" with the Holocaust. MÊdecins Sans Frontières worked in Rwanda before, during and after the genocide and its brutality has personally

affected all of the expatriates that worked in the troubled "Great Lakes" region of Central Africa. This April marks the 10th anniversary of the start of the genocide and I would like to take the opportunity to remember one MSF Rwandan staff member who was among many that perished that year because they were considered "inyenzi", the Kinyarwanda word for "cockroaches", by the extremist Hutus. (continued, on page 2)

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Rwanda

Jean Nyiligira translating and mediating for Pierre LaPlante

In the spring of 1992, I was preparing for my first visit to MSF projects in the field. This was my opportunity to see field workers in action, together with their local counterparts, in addressing the health needs of populations in danger. I was to visit Pierre LaPlante, a nurse from Vancouver working in the tiny central African nation of Rwanda where war had left thousands of people from the area bordering Uganda subsisting in "internally displaced camps". Pierre requested that I bring him a number of items, including a Timex watch.

Rwanda’s lush beauty lived up to its tourism slogan, “pays des mille collines” or country of a thousand hills. I went to the Kigali office and met the team, and I remember meeting many Tutsi staff including Jean Nyiligira and his wife Odette (who also worked for MSF) and their five children. Jean was Pierre's driver and over the next week touring around the northeast of the country, I would learn that he was much more than a chauffeur. Jean was fluent in three languages and a fully trained mechanic. The MSF

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driver plays other roles: helping to keep the expatriate safe by reading an often complex security situation; a n d a c t i n g a s a t r a n s l a t o r, w i t h o u t w h i c h m o s t international MSF workers would be unable to function. While MSF sends some 3000 international workers to over 80 countries each year, it is the work of another 15,000 national staff that makes the organization effective in the field. It was remarkable to watch soft-spoken Jean walk through camps of tens of thousands of people - mostly Hutus displaced by a Tutsi rebel incursion - and ensure that Pierre was able to address basic health concerns for these people.

“ Health defines a humane way of pursuing life itself and is, without question, the fundamental human right. " Dr. James Orbinski, Former International President, MSF October 1994

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The Timex watch was a gift to Jean from Pierre in appreciation of his outstanding work. Pierre described Jean as his guardian angel who had helped him navigate some charged situations. I witnessed one close up. Just after nightfall, we approached a checkpoint at the town of Byumba, hit by 18 rebel rockets just a few hours before. Despite carrying a health ministry official, two drunken soldiers staggered out with a rocket-propelled grenade launcher and a machine gun pointed at us asking for a bribe. Jean negotiating with them allowed us to pass, I will never forget that night. The growing tension in Kigali was palpable. I asked Jean, "What will you do if this country explodes?" He calmly answered, "I'll attach myself to an expatriate and try to survive."

L e s s t h a n t w o y e a r s l a t e r, t h e a i r c r a f t c a r r y i n g President Juvénal Habyarimana and his Burundian counterpart was shot down and the genocide began.

D u r i n g t h o s e m o n t h s o f h o r r o r a n d i n s a n i t y, I o f t e n thought about these Rwandan MSF workers especially Jean. There was no way of knowing what had happened to them. Had Jean found an expatriate to shelter him? What had happened to Odette and the children?

“ When we got into Kigali, the airport looked really modern, but all the glass was broken… It was a modern looking place, but no one around, nobody on the streets, no cars. That was the front line, and there was nobody there. ”

Jean, Odette and 4 of their 5 children in the backyard of the MSF house in Kigali

It is strangely easy to become detached from the suffering that surrounds you. But Jean was one of the first MSF workers that I had met and will occupy a special place in my memory. The genocide will never be abstract statistics to me. But the strangest thought that I have had is, somewhere among the countless Hutus awaiting trial, one man is probably wearing a Timex watch that was given as a token of friendship but taken after an act of indescribable terror.

Ben Chapman, MSF Canada Board Member

Sidne Maddison, MSF nurse part of Dr. Orbinski’s team In 1996, I had the chance to return to Kigali as hundreds of thousands of the Hutu refugees, sheltered in Zaire for two years, started to stream home. What had been a quiet city with a handful of aid organizations had now become a gridlock of white humanitarian agency Land Cruisers. It was eerie to drive through streets where the Interhamwe militias had manned checkpoints and macheted thousands to death. When I reached the MSF office, I was amazed to see the familiar face of Odette. She explained that she and the children had found sanctuary in the stadium and rode out the brutality. However, she was a widow now. Jean had been caught in the streets and never seen again.

“In 1994, I was a doctor in Kigali, the capital of Rwanda. I witnessed the unfolding of one of this century’s great massacres, and I witnessed the apathy of the international political community in its unwillingness to respond adequately. I spoke out with MSF as we called on the international community including the members of the Security Council to stop the genocide - a genocide cannot be stopped by doctors.”

Dr. James Orbinski September 2003

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Americas

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MEDICINES FOR ALL: STEP FORWARD, STEP BACKWARDS.

TRADING AWAY HEALTH. IS THE AMERICAS NEXT? Dispatches

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Still too many medicines missing from our medical kits When MSF was created in the 1970s, our volunteer doctors lacked certain medicines to treat patients. Today, despite medical advancements, not enough has changed. The cost of life-prolonging anti-retrovirals has dropped dramatically due to generic competition yet the forgotten Chagas disease, which affects 25% of the population in the Americas, still has no medicine to treat its chronic stage.

Along the Thai-Burma border malaria resistance is high, and initially MSF doctors had largely ineffective anti-malarial drugs in their medicine kits. Today, effective anti-malarials, like artemisininbased combination therapy (ACT), exist and are in use in several countries. Yet, governments in countries such as Sudan and India refuse to make ACT therapies for malaria the national standard. As medical humanitarians, it is unethical not to use medicines we know are effective. Despite pressure not to in some countries, we use ACT medicines and/or campaign to change protocols for use of ACT. In Burundi, where malaria epidemics are too common, the government made the important national protocol change this year because of MSF, NGO and national health workers’ pressure.

For treatable diseases such as HIV/AIDS, until recently, the medicines were simply out of reach for our patients because of exorbitant prices. Today, only six percent of the 6 million people who could benefit immediately from anti-retrovirals for HIV/AIDS have them. It is unacceptable that people are still ‘too poor to cure’.

and the Caribbean, except Cuba concerns MSF. If implemented as planned in 2005, it will be the largest "free trade zone" in the world covering more than 800 million people with the most stringent intellectual property provisions globally. Draft intellectual property provisions within the FTAA Agreement threaten the positive pricing competition for affordable generic drug production.

MSF calls upon countries of the Americas to exclude intellectual property provisions from the FTAA Agreement altogether. We believe that the tougher intellectual property rules proposed in the FTAA Agreement will be bad for the health of the people in the Americas and around the world.

"Don’t trade away health with the FTAA. Drugs should not be treated like any other commodity… This will mean life or death for people in Latin America." – Dr. Luis Villa, MSF Head of Mission, Guatemala.

There are 1.9 million people living with HIV/AIDS in Latin America and the Caribbean, according to the World Health Organization– the second most-affected

Monumental Doha Declaration: "Medicines for All" In 1999, MSF launched the "Access to Essential Medicines Campaign" – one goal was to examine how trade laws and intellectual property (IP) can ease or block access to medicines.

We continuously refer to the landmark Doha Declaration in 2001 at the World Trade Organization (WTO) meeting. In Qatar, 142 WTO countries agreed they needed to protect public health over private commercial interests, and increase trade law flexibilities to help poor countries get the medicines they need. The declaration affirmed a country’s sovereign right to decide what measures to take to override patents when necessary to protect public health.

Trading away health Since the historic Doha Declaration, MSF has sadly observed developed countries’ efforts to undermine Doha, slowly introducing bilateral and regional trade laws that introduce more stringent patent protection than at the WTO level. Access to affordable medicines comes in part from flexibilities in trade laws.

The Free Trade Area of the Americas (FTAA), a proposed regional trade agreement between 34 countries in the Western Hemisphere, including all of North, Central and South America,

region in the world after Sub-Saharan Africa.

Canada says it will "not go beyond Doha" in the FTAA, meaning that they will not allow a regional trade agreement that imposes stricter intellectual property provisions that what Canada agreed to at the international level. MSF donors, advocacy and outreach groups signed a petition urging regional governments, including Canada, to maintain their commitment and be consistent nationally, regionally and internationally about patient rights over commercial interests. For diseases know no borders either. At the 8th FTAA ministerial meeting in November 2003 in Miami, MSF met with trade negotiators and NGOs from the Americas.

Latin American negotiators supported the MSF position but emphasized that they are negotiating under heavy pressure from the United States, implying that IP provisions could be included despite best efforts to exclude them. MSF will continue to pressure governments in the Americas to avoid IP provisions in the FTAA. A third FTAA draft is available for public viewing at http://www.ictsd.org/issarea/Americas/FTAA_ministerial/miami/F TAADraft_Text_191103.pdf Carol Devine, Access to Essential Medicines Campaign Liaison, MSF Canada

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Field Letter

LETTERS FROM LIBERIA

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Dr. Wei Cheng shares his experiences in Monrovia, capital of Liberia, with excerpts from e-mails written to his wife - Karin Moorhouse

September 7, 2003

17 September, 2003

As I expected, the immediate surrounding is much calmer than what’s on the news. The plane [is] piloted by three seemingly inebriated pilots. The young chap seated next to me works for some sort of supplier to NGOs, making money out of the humanitarian crisis. Here in Liberia we landed. No problem. The welcome committee at the airport consisted of 16 trucks of soldiers (about 500 of them) with AK47s. That did not worry me except I don’t like the sight of the weapons…

I will be leaving Monrovia in just over a week. Amazing! In a way, I am getting very good experience. On the other hand, the health care here is very basic. People are dropping dead like flies and yet, we don’t know what they die of. There is no basic biochemical test, there is no microbiological test, the x-ray is working but produces very, very poor quality film. You simply don’t know what you are treating…

The ex-pats’ quarters are actually the previous hospital, so our rooms are large - some of them face the ocean. From the little balcony of the office, you can see the ocean with three American war ships. Now and then, you have this low flying helicopter, gunships patrolling the area showing that they are in control.

September 14, 2003 I have already been here for more than a week and the workload is quite overwhelming. Today is really the first opportunity I have had, to sit down and write something, which is important as I fear I am rapidly becoming desensitised to life around me…

The hospital was looted but it is still functioning even though the local hospital staff has not been paid for two years. The local medical school has been closed for more than a year, however, there is a 3rd year medical student, called Fallah, day in day out, he came to the operating room, offering to carry the patients and scrub for the operations. [He] does everything from cleaning the floor to suturing the wound. He then goes home and reads up about everything he has seen. It is so easy to let go and feel despair in these circumstances, and yet, he refuses to give up. To me, this is truly inspirational!

I was doing all the emergency surgeries yesterday. It was like a factory. You can’t plan any elective cases if you are alone. It is fire fighting. Things just crash through the operating theatre door.

18 September, 2003 Today, the patient [Dr.] Juanita operated on last night, died.

Nobody knows what went wrong. We waited for Steve for a while, as Steve was finishing his work at around 6 o'clock. It turned that he had been treating an 8-year-old girl who had been repeatedly raped. Poor child. How utterly disgusting!

Dr. Wei Cheng, a paediatric surgeon, was sent on an emergency mission for three weeks to Liberia. He is currently in Toronto, Ontario working as a medical researcher for The Hospital for Sick Children.

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Nepal

“ Broken equipment, obsolete surgical equipment were piled up in many rooms.

We had to get rid of all that.

”

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RUKUM: A HOSPITAL AT THE TOP OF THE WORLD Nestled in the valley at the foot of the Nepalese mountains, the Rukum Hospital was in great need of major logistical and medical support. Kathryn Roberts, a young paediatrician, spoke to us about the time she spent in a project on top of the world.

"It was my first mission with MSF," smiles Dr. Roberts, a young doctor who spent five months at the Rukum Hospital in Rukum, Nepal. In the western part of the country, in a region between the government zone and the mountains controlled by the Maoist guerrillas, the Rukum district is home to approximately 200,000 people. "It’s a rural region dotted with highly isolated villages. Often patients must walk for two days to get to a hospital." Another particularity: at the foot of the Himalayas the diseases are not the same as in the tropical regions. "We’re lucky; we’re too high up for the mosquitoes so there is no malaria. However, we had to treat many cases of pneumonia in children."

Ambulances on the backs of men In this very steep landscape, falls are common. A young boy was brought to the hospital after falling from a tree, and then onto rocks—a total fall of eight metres. Transported on the back of a man in a large basket, the child had lost a lot of blood by the time he reached the hospital. "He had completely broken his nose and had a hole in his palate. He had to be stabilized before we could rush him to a modern hospital in Kathmandu, the capital," Dr. Roberts recounts. A few weeks later, the child returned, fully healed. "I saw his mother, his three little sisters and him, in their best clothes, really happy, really appreciative. I believe that this will be one of my fondest memories."

No glass panes at 1,800 metres "Along with medical activities, logistics helped us completely renovate the hospital, which first needed a thorough cleaning. Broken equipment, obsolete surgical equipment were piled up in many rooms. We had to get rid of all that," Dr. Roberts explained. Her team went ahead with more daunting work. "We had to put glass in the windows. Until our arrival, there were only wooden shutters.

Can you imagine winter at 1,800 metres? You had the

choice of either freezing or staying in the dark. When you’re sick, neither of these solutions are really acceptable." Other, more costly work carried out was restoration of the pharmacy to its original condition as well as the X-ray machine. Then the cleaning teams had to be trained to respect basic hygiene rules needed in the hospital.

During her five months in the field, Dr. Roberts saw many changes including political ones. "I arrived on January 30, 2003, the day the cease-fire was signed between the Nepalese government and Maoist rebels.

The military situation remained calm until I left at the end of June, when new tensions arose." With the renewed political problems, MSF decided to wait a little longer before determining which dispensaries, in the mountains around Rukum, needed the most medical and logistical help. That is the next objective of the new MSF team in Nepal despite the growing tensions between the government and the rebels. As for Dr. Roberts, she is now hard at work in Sierra Leone.

Laurence Hughes

In April 2003, MSF initiated a second program, in

Nepal’s

Jumla

district,

to

address

psycho-social health and basic health care needs for the 100,000 people living in the northwestern district, where health care is of poor quality and often unaffordable. Many people in the region were traumatized in November 2002 by the battle in Jumla town, when 10,000 Maoist rebels attacked the city and killed approximately 400 people.

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Angola

THE MECHANICS OF MALNUTRITION

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How Can You Die of Hunger?

Immediate Results

Malnourished, undernourished, dying of hunger - these expressions are far from our daily reality. A strict diet or a day of fasting are the only experiences to which we can relate when we try to understand what these words really mean, but it’s only a poor approximation.

Supplementary feeding centres treat moderately malnourished children, whereas therapeutic feeding centres take care of severely malnourished children.

What Happens in the Body This vicious circle begins when there is not enough or nothing to eat. Lack of food means a major loss of energy, leading to immense fatigue. Little by little, the person becomes apathetic, wanting less and less contact with the outside world. He no longer has the strength to move, talk or even eat. Moreover, this deprivation causes the stomach to waste away and lose its ability to accept large quantities of food. All hunger regulatory mechanisms such as hunger pangs, or, conversely, the feeling of fullness, which are controlled by gastric volume, will wane. The person is no longer hungry or thirsty. Malnourished children are so weak that they no longer want something to drink and are consequently very dehydrated.

"A child almost immediately starts putting back on weight there. They quickly return to life and start playing and singing as though nothing had happened. It’s like magic!" explains a physician who has worked at several nutritional centres.

Forms of Malnutrition The two main forms of malnutrition Marasmus and Kwashiorkor - are equally dangerous, painful and fatal.

Marasmus: People suffering from Marasmus are extremely thin. Without nutrition, required to maintain vital functions, such

Suffering and Weakness Although the extreme weakness brought on by malnutrition entails inhibited desire and apathy, it does nothing to dull the suffering. Children—and adults—suffer with every move, since their muscles have withered. This pain is also due to the fact that the skin is cracking from extreme tissue dehydration.

These people, ever more fragile from malnutrition, can therefore catch all sorts of diseases, which results in further suffering. For example, it is common for yeast to develop along the esophagus. Swallowing becomes a painful feat, likened to eating a lemon with a mouth full of ulcers.

Renutrition: A Medical Issue Feeding a malnourished child must be done very carefully since, if not done correctly, the child could die. The objective is to feed the body in small amounts, but ingest as many calories as possible, since the shrunken stomach cannot take much. Malnutrition makes the entire human body fragile: digestive system, kidneys, liver, heart… The body must be gradually returned to its normal level of functioning. Feeding a child in this situation too much or too quickly can overload already fragile systems, causing the body to shut down, such as with a heart attack. As well, the child should be immediately rehydrated, treated for malnutrition-induced opportunistic disease and vaccinated.

as respiration and cardiac activity, the body must take energy from the reserves in the muscles and fat. This especially affects children since their muscle and fat mass is far lower than that of an adult.

Kwashiorkor: People suffering from Kwashiorkor are swollen from oedema. In this case, the body uses its own resources to control all its functions, especially cellular homeostasis. Water, from the cells, moves into the body resulting in oedema or pockets of water. The skin of those affected is extremely dehydrated, cracks under pressure and forms characteristic ulcers.

It is not known why certain regions are more prone to Kwashiorkor and others to Marasmus. In Angola, Kwashiorkor is the predominate form of malnutrition.

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Updates

ARJAN STILL ALIVE

16 MONTHS AFTER ABDUCTION Arjan Erkel, MSF head of mission in Dagestan was kidnapped August 12, 2002. Russian authorities last provided proof that Arjan is still alive to the MSF on July 30, 2003. Dr. Morten Rostrup, MSF International Council President urged the European Parliament to call on the Russian authorities to step up efforts in finding Arjan and to hold the Russian President Vladimir Putin accountable for securing his safe release after more than a year of "unbearable captivity." Arjan Erkel is today the only foreign humanitarian worker hostage in the Caucasus. Independent humanitarian efforts are stymied in this unstable and insecure region, which has suffered through more than a decade of conflict, making it difficult to deliver effective assistance to the thousands who need it. Several Canadian and American authors have joined our petition to release Arjan, including John Irving, Margaret Atwood, Michael Ondaatje, Graeme Gibson, Karen Connelly, Ronald Wright, and many others.

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CHECHEN HEALTH CARE: VICTIM OF WAR The dramatic decrease in the possibility of carrying out humanitarian work in the North Caucasus has not been echoed by a decrease in needs, they remain pressing. MSF activity in the region is now focused on two things: securing the release of MSF staff member Arjan Erkel, who was kidnapped in Dagestan in August 2002; and assistance to Chechens affected by the ongoing conflict in Chechnya. In the face of mounting official pressure for Chechens in Ingushetia to return to Chechnya, MSF continues to speak out about the distressing living conditions of the displaced and to advocate against pressuring them to return while conflict continues in Chechnya. Despite obstruction, MSF continues to address the basic living conditions and sanitary situation of Chechens in Ingushetia, particularly through the provision and repair of shelters, targeted distribution of essential basic goods, and improvements in water and sanitation. During the past year, MSF continued to provide support to regional medical structures overwhelmed by the increase in violence and weakened by under-funding. MSF runs antenatal and gynecological, paediatric and general practitioner clinics in Ingushetia. MSF also donates medical material, equipment and medicine to most government health structures in Ingushetia. In Chechnya, MSF provides medicine, medical material and medical equipment to 30 structures and responds to emergencies stemming from the ongoing conflict.

SUDANESE REFUGEES FLOOD CHAD BORDER TOWNS Refugees have been fleeing western Sudan into Chad in the

The Sudanese refugees in Chad now find themselves

tens of thousands. They are fleeing from confrontations that

living in drought-stricken conditions. Initially refugees

have been responsible for the killing and displacement of

could count on help from local communities in Chad

thousands of civilians and that have forced people to seek

but the region has limited resources - insufficient

security in neighbouring Chad. In August 2003, MĂŠdecins Sans

even for the local population. MSF sent a team of 12

Frontières launched an emergency intervention in two small

people with 40 tonnes of assistance material. In

border towns, Tine-Chad and Birak - both have received large

Birak, malaria is currently the most pressing health

numbers of Sudanese refugees. The refugees live in close

problem. MSF opened a health centre in Tine-Chad

proximity to warfare, under extreme conditions and are acutely

and a therapeutic feeding centre for malnourished

distressed by disturbing memories. Refugees in Tine-Chad told

children. Apart from malnutrition, the most frequent

aid workers of the bombs from planes flying overhead all hours

health problems currently seen in Tine-Chad are

of the day. There were also reports of torture.

diarrhoea and respiratory infections.

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Canada

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News

MSF staff stage “street hockey” theatre to raise public awareness of Bill C-56.

BILL C-56: A “WAIT AND SEE” ACT? In September 2003, Stephen Lewis, the UN Special Envoy to Africa for HIV/AIDS, asked the Canadian government to show global leadership by introducing legislation to allow the production of generic medicines for HIV/AIDS. Though Bill C-56 has not been passed there remain four serious flaws. These include:

1. ‘ The Right of First Refusal ’ provision: This provision gives a patented pharmaceutical company the right to take over contracts initially negotiated by a generic pharmaceutical company with a developing country government. This deal would secure a lower price on a particular medicine for the developing country but would soon discourage generic manufacturers from negotiating future contracts because the patent-holders could repeatedly block the generic manufacturer. This flaw is the most serious and could undo all other positive aspects of the proposed amendment. The dramatic drop in medication prices, due to generic competition, has been vital in saving lives.

2. Limited list of pharmaceutical products: The bill includes a list of Canadian patented medicines that can be produced as generics. MSF is concerned about this limited list of medicines because no system currently exists to update the list efficiently. Therefore a medicine required to treat an infectious disease affecting people in a developing country but is not included on this list, may not be produced generically in Canada.

3. A limited list of countries allowed to import generic medicines: Bill C-56 has a list of countries recognized by the United Nations as "least-developed countries" that may benefit from generic medicines from Canada. However other developing countries not on this list (such as Viet Nam, Turkmenistan) cannot import generic pharmaceuticals from Canada, even though they express a clear need for them.

4. Non-governmental representatives are not allowed to buy generic medicines: C u r r e n t l y, B i l l C - 5 6 o n l y a l l o w s a g o v e r n m e n t o f a developing country - or an agent of that government - to enter into a contract with a Canadian generic m a n u f a c t u r e r. N o n - g o v e r n m e n t a l o r g a n i z a t i o n s , l i k e M S F, a r e n o t ' a g e n t s ' o f g o v e r n m e n t a n d a r e therefore not, by definition, permitted to contract generic companies to import generic medicines. For M S F, t h i s m e a n s t h a t w e m u s t s t i l l r e l y o n t h e w i l l of governments to obtain much needed cheaper generic medicines.

Bill C-56 has gone for further committee review and should be passed as law, with corrections, with Prime Minister Paul Martin in office. This should produce a bill that would truly benefit those who need it most: our patients in developing countries.

Isabelle Jeanson

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2003 - A RECRUITMENT SUCCESS STORY In November 2003, MSF Canada had 137 volunteers out in the

MSF Canada has shifted its structure and focused more on

field, surpassing the 2002 year-end total of 116. Though con-

recruitment from coast to coast. This was achieved by reorganiz-

siderably beyond forecasted numbers, the increase can be attrib-

ing the human resources department and refocusing recruitment

uted to the growing number of emergencies worldwide. Most

efforts. The bumper year of field volunteers included the most

Canadian field volunteers were posted to the Middle East and

first mission volunteers from all over Canada - divided equally

Africa - regions with acute emergencies like the crisis in Iraq and

between Western and Central Canada regions and Quebec. MSF

chronic emergencies such as the famine situation in Ethiopia.

is becoming active in the wider medical community – medical schools, professional conferences – to recruit more doctors.

Our field volunteers are often bilingual and able to get

Paramedical recruiting for lab technicians, mid-wives, and

to the field quickly. Many go to fill management roles

nurses also continues but medical specialists in HIV, TB and

in the field and French speakers are needed especially

infectious diseases are desperately needed. Also, mental health

in West and Central Africa: Democratic Republic of

specialists need to be recruited to treat the people affected by

Congo, Ivory Coast, Burundi and Congo Brazzaville.

wars, the people who end up being victims of violence and abuse.

Reshmi Kutty

MSF

Reads

CIVILIANS UNDER FIRE MSF examines its actions in Congo-Brazzaville MSF recently published Civilians Under Fire, a collection of articles that looks introspectively and self-critically at MSF’s operations during 1998 to 2000, an acute phase of the civil war that devastated the Republic of Congo (better known as CongoBrazzaville). The publication sheds light on some of the important ethical, medical and practical considerations that arise when organizations such as MSF make the decision to provide assistance to victims of rape, a category of victims that is often overlooked by humanitarian organizations.

The writers also ask the question: "What is an effective humanitarian aid operation?" answered by an exploration of the quality of aid, its complexities and its vital importance for people affected by conflict and crisis. Civilians, more than soldiers or guerrilla fighters, bore the overwhelming brunt of the death toll, loss and suffering. The acts of violence against them—ranging from forced displacement to summary executions, rape, looting, denial of food, and use as "human shields"— were boundless. This book describes how MSF teams were faced with a medical and nutritional emergency of staggering proportions and how the international media paid little notice to the catastrophe when the struggle for political power was playing itself out along geographical and ethnic lines and control over the civilian population became a central objective.

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CANADIANS ON MISSION Afghanistan Alexandra Conseil Anu Sharma David Croft Judy McConnery Kathleen Bochsler Mike Fark Angola Danielle Morin Gabriela Pahl Hélène Poliquin Philippe Blackburn Bangladesh Violet Baron Burundi Bruce Lampard Christopher Carter Claude Trépanier Clive Strauss Dominique Proteau Erin Culley Francine Belisle Jason Peat Kyra Abbott Michelle Milne Yves Cantin Chad André Fortin Caroline Tourigny Clea Kahn Dolores Ladouceur

Patrice Richard Philipe Mougeot Randy Bareham Congo-Brazzaville Claudette Chayer Frédéric Beaudoin Jennifer Weterings Lindsay Bryson Serena Kasparian Tammy Hinsche Democratic Republic of Congo David Tu Heather Thomson Josée Pepin Julienne Turcotte Patricia Simpson Reine Lebel Sophie-G. Gagnon Thomas Kelley Ethiopia Anders Lonnqvist Cheryl McDermid Isabelle Aubry Michel Plouffe Rik Nagelkerke Selig Wilansky Guinea Michel Paradis India James Squier Iran Yvan Marquis

Ivory Coast Alain Calame Jangh Bhadur Rai Jon Soehl Julia Puttergill Vanessa Van Schoor Jordan Theo Murphy Kenya Christina Cepuch Denis Guzzi Françoise Goutier Liberia J-Sébastien Matte Marie Skinnider Maya Harari Sylvain Groulx Mauritania Marisa Cutrone Myanmar (Burma) Stephanie Faubert Paul Mathers Nepal Robert Parker Nigeria Joanne Liu Nicole Fulton North Sudan Lia Copeland Pakistan Patrick Robitaille

Palestinian Territories Current MSF Missions Lynne Chobotar Russia Dispatches Ben Reentovich Médecins Sans Frontières/ Éric Tremblay Doctors Without Borders Sierra Leone 720 Spadina Avenue, Suite 402 Darryl Stellmach Toronto, Ontario, M5S 2T9 Tel: 416.964.0619 Kevin Coppock Fax:416.963.8707 Somalia www.msf.ca Jody Thomas Editors: Mario Fortin Reshmi Kutty Dominique Desrochers Nicola Woolley Sharon Janzen Editorial Director: Sylvain Deslippes Tommi Laulajainen South Sudan Contributors: David Michalski Ben Chapman, Carol Devine, Laurence Hughes, Isabelle Jeanson, Reshmi Kutty Janice Kopinak Marie-H. Mayrand Circulation: 65,000 Design: One Company Nancy Dale Printing: Warren's Imaging and Steve Dennis Dryography Tiffany Moore Winter 2004 Sri Lanka Adam Childs Bree Lenz Doug Kittle

Photo Credits: Remco Bohle, Alain Frilet, Roger Job, Olivier Jobard/SIPA Press, Jim Lavery,

Jehad Nga/Corbis, John Reardon, Andrew Schechtman, Stephan Vanfleteren

ISSN 1484-9372