Dispatches (Winter 2005)

Vol. 7, Ed.1

Dispatches M S F

C A N A D A

IN THIS ISSUE

2

A crisis of immense suffering and immense need in Sudan

6

The trauma of Chechnya: The ongoing war against IDPs

8

Letter from the field: DRC

10

The contradictions of military humanitarianism

11

Tuberculosis: Suffering a curable disease

13

Making Bill C-9 work

14

New HIV/AIDS advisor for MSF Canada

1999 Nobel Peace Prize Laureate

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SUDAN

CRISIS

N E W S L E T T E R

Sudan

SUDAN

A CRISIS OF IMMENSE SUFFERING AND IMMENSE NEED Dispatches

Vol. 7, Ed.1

The mournful wailing of families as they vocalise their grief over yet another death are the sounds of night in Mornay camp in Sudan’s Darfur region. These sounds bring to bare the incomprehensible tragedy for people who have fled killings and destruction in their villages and seek some semblance of refuge in camps throughout the region and in neighbouring Chad.

In Mornay, Médecins Sans Frontières (MSF) is the only humanitarian agency operating on a scale large enough to provide desperately needed access to medical care for the 80,000 displaced people.

Here MSF has built a hospital that includes: inpatient units – adults and pediatrics; an intensive care unit; an isolation unit; an ER with war-wounded surgical capacities; a prenatal care and delivery room; two therapeutic feeding centres (TFCs); and two outpatient departments. MSF has also implemented vital programmes such as Home Visitors, Defaulter Tracing for children absent from the TFC, and a blanket feeding programme (BFD) for all children less than five years old. This is in addition to the water/sanitation system built by MSF, which is divided into three production and distribution water supply systems, wells, storage facilities (tanks and bladders), and water-tap stands throughout the camp.

Several nutritional programmes run in Mornay and there is nutritional surveying of all the children at the BFDs, the intensive care hospital-based TFC for the severely malnourished children with life-threatening illnesses, and the ambulatory-care TFC. A supplementary feeding centre (SFC) for almost 1,900 moderately malnourished children was created and eventually assimilated into the TFC and BFDs.

Almost 17,000 children attend the blanket feeding centre

The workload is overwhelming amongst an already overworked and overloaded team but things have improved somewhat. In one TFC, there are 30 to 40 children hospitalized with severe malnutrition and its associated critical pathologies—malaria, hepatitis, schistosomiasis, pneumonia, giardisis, dysentery, measles, pertussis, and

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psychological trauma, etc. — worsening their conditions. The ambulatory TFC treats 600 severely malnourished children that attend on assigned days for their medical examinations, therapeutic food, and measuring. Cumulatively, MSF has treated almost 2,000 children in Mornay for severe malnutrition — children whose weight is less than 70 per cent of normal.

The nutritional picture in the camp is precarious and there is the concern that many children will become severely malnutritioned if bad luck brings an epidemic, be it measles, meningitis, malaria or pneumonias. A Hepatitis outbreak at one point ended slowly and painfully. The almost daily meningitis deaths during another week were difficult and demoralising, especially as the families presented late and most of the patients were young children or young adults.

Almost 17,000 children attend the BFD, where each child receives an additional protective ration of 500 Kcal. An incredible amount

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of organisation is necessary to assemble the children, their mothers, and other siblings into ordered lines where they are screened to determine their ages, sex, nutritional status — segregate those that need further medical and nutritional assessments — and then distribute their rations. It all works extremely well — the occasional scuffle amongst mothers that jump the queue, or mothers that try to cheat and sneak back into the line — but all in all, it’s a perfect textbook operation of which the team is particularly pleased. The feeding programme is very popular with the omnipresent journalists to visit; that is, if they can bear waking up in the dark at 5:45 a.m. for the early-morning start, meant to lessen the time that the mothers must wait in the scorching sun.

Through a translator or on-the-job learning of the Arabic language, medical staff talk with patients about the details of their problems, everything from feeding patterns, diarrhoea, vomiting and fevers, to coughs and stomach problems. Some are even able to speak with

the mothers about their family situations, which are often too sad to hear, and it can be difficult listening to each and every sad tale of murdered husbands and children, burnt villages, and loved ones that have disappeared. As suspected, the sexual violence continues and workers receive reliable information on the horrible extent of the rapes — even within the camp itself. Sadly, due to fear, shame, and government interference, only a few of these women or young girls are able to come for help.

The work of the entire MSF team in Mornay is intense and focused, from the original teams to those still there, and there is much dedication and commitment towards meeting the oftenoverwhelming needs of the people. Despite the massive scope of the intervention, it still seems too little, and frustratingly lacking other agencies to partner with. Hopefully, this will change soon.

Hopefully, the world has not forgotten about Darfur.

For volunteers working in Mornay it’s difficult to have any sense of how the international community is reacting to the Darfur crisis.

From the inside it is evident that the conditions for the people continue to show little improvement. In Mornay camp, the people are not prepared to leave and certainly will not move until security conditions have improved — sanctions or not — meaning disarming the militias. If the authorities proceed with “voluntary” relocation of these internally displaced people to their home communities, it is now too late to return for any sort of sustainable cultivation that could see them through the dry season. Even gloomier is the certainty that the situation will not, cannot, improve for many months.

— Carrie Morrison Registered nurse Momay, Sudan

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Chechnya

TRAUMA OF CHECHNYA

CHECHNYA’S ONGOING WAR ON INTERNALLY DISPLACED PEOPLE

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Despite repeated claims from Russian and pro-Russian Chechen officials that the situation in Chechnya is normalizing, conflict and related human rights abuses continue. A decade of conflict has resulted in an estimated 260,000 internally displaced people (IDPs). By mid 2004, approximately 52,000 refugees remained in the neighbouring Republic of Ingushetia. Most live in places unfit for human habitation — tent camps or spontaneous settlements such as train wagons, abandoned farms, factories, and warehouses.

Since September of 2003, the Russian and Ingush authorities have been putting considerable pressure on internally displaced people in Ingushetia to return to Chechnya. Health systems and other public services in Chechnya are in a dire state, and a lack of security in the region means that aid agencies are severely restricted in their ability to move around the region to provide additional support.

Earlier this year, Médecins Sans Frontières (MSF) undertook quantitative health surveys in the displaced populations, both in the spontaneous settlements in Ingushetia and in temporary accommodation centres on the Chechen side, to obtain information on displacement history, living conditions, and psychosocial and general health status. Results show that insecurity and substandard living conditions prevail in both camps. Most people in the settlements and temporary accommodation centres have been displaced in two waves, either in 1994 or 1999, during periods of severe conflict in Chechnya, and have since been forced to relocate several times. Interviewees said they were prevented from returning home because of security fears or because their property had been destroyed.

Almost all people interviewed had been exposed to crossfire, aerial bombardments, and mortar fire. More than one in five had seen killings, and nearly half had seen maltreatment of family. About 90 per cent of people in the Chechen camps and 80 per cent in Ingushetia had had someone close to them die as a result of the war-related violence. Ongoing conflict in Chechnya continues to disrupt people’s lives. Over a third of people in Ingushetia felt unsafe, while in Chechnya two-thirds expressed concern about their security. Seven per cent of people in Chechnya and nine per cent

in Ingushetia reported that a family member had died in the two months before the survey, many as a result of violence. The arrest or disappearance of friends or neighbours was common on both sides of the border.

The health effects of these experiences continue to take their toll.

However, access to medicines and health services is problematic in both locations. Non-specific health complaints, such as headaches and joint pains, are common within these populations — a finding consistent with high levels of mental stress. Over two-thirds (80 per cent in Chechnya; 67 per cent in Ingushetia) of respondents said the conflict had triggered mental disturbance.

Overall, living conditions for the internally displaced populations are clearly inadequate in both Ingushetia and Chechnya. The population cannot protect itself against the bitter weather, sanitation is poor, and food insecurity is a problem in both republics. Health issues, including mental health complaints, are common, but services are poor. Many people (one in three in Ingushetia, twice as many in Chechnya) live in constant fear. Such miserable conditions have persisted for years and the results of the MSF survey show they are ongoing.

The current policy of moving people, against their will, from one inadequate and insecure location to another will only worsen the plight of this vulnerable population. The Russian authorities must guarantee a safe environment and ensure protection of civilians as well as acceptable living conditions and health services for this displaced population. The international community should pay greater attention to this conflict, which has been largely ignored for the past decade.

Visit www.msf.org/source/downloads/2004/chechnya_report.pdf to read the full report.

— By Kaz de Jong

MSF mental health advisor et al.

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Letter from the field

Heather Thomson (right) working as a registered nurse in a mobile clinic in DRC.

DEMOCRATIC REPUBLIC OF CONGO As I soaked in the sights, sounds and smells of my first journey to Baraka in Democratic Republic of Congo (DRC), I couldn’t imagine that this tropical paradise could hide such violence. Baraka was a start-up Médecins Sans Frontières (MSF) project with multiple components: set-up an emergency, secondary-care hospital; provide access to healthcare via mobile clinics; and provide medical and psychosocial care to victims of sexual violence.

Throughout my pre-mission training, we reviewed, discussed and debated MSF’s two types of action: providing medical aid and bearing witness. Providing medical aid was familiar and straightforward.

Bearing witness, however, was complicated, delicate, exhausting, overwhelming, challenging and essential.

We worked with a local women’s nongovernmental organization that linked us with the victims. As crude as it sounds, our sexual violence programme initially focused on getting through the backlog of

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more than 300 victims of sexual violence. How could we get through this backlog? We needed more staff than the few nurses we had.

We also needed to address the psychosocial impacts beyond the physical trauma. Our expatriate team was expanded to a psychologist, medical doctor and nurse. Three local women were trained as counsellors and also assisted with translation.

The women walked many kilometres to come to our hospital for a 45 to 60 minute consultation that included a physical exam. Walking into the room, I saw the women lying on the examining table tense, their bodies rigid and their face showing fear. They wanted reassurances that they were physically intact and disease-free, that their pain was real. Some wanted dawa (medication) but most sought validation and acknowledgement of their experience of sexual violence. Our psychologist coached them in relaxation breathing and massage techniques, had them draw a symbol of hope, asked them to sway like the mango tree to feel their body move and just be. I found the women to be resilient and very practical. They sought something, anything that would help their family in their desperate poverty: medicine, food, soap, fabric.

Many of the stories were similar but you could never get used to the tragic facts. The woman was working in the fields with other women and their children when 10 soldiers arrived. The soldiers asked for money but the women had none. The women were beaten then raped by ALL of the soldiers, in front of the children. Their clothes were taken. Their house was burnt down. Incredibly these women go on living and providing for their families. Soldiers from all of the military and rebel groups were identified as the aggressors, the violations often taking place during times of troop movements.

The life of women in DRC is unspeakably difficult. They are responsible for cultivating and preparing food, porting water, keeping

sister’s clothes. We were contacted within two hours of this violation and were able to give medications against HIV transmission. The girl was sent to Bujumbura, Burundi for child psychological counselling and further immunizations.

The sexual violence programme was renamed the Centre d’Ecoute, the Listening Centre, in an attempt to reduce the stigma of the label of sexual violence victim and also to broaden our psychosocial work to victims of the war, inpatients with a terminal illness or prolonged treatment, etc. We did get through the backlog of sexual violence victims and by May 2004, more than 600 women, men and a few children had been consulted. Hundreds more were identified on the

the house, tending to children and husbands. Here there are no conveniences, no electricity, no running water. The women are not educated nor do they have a say in their reproductive health. During our consultations, often the women didn’t know that they had been raped, been violated. Being a sexual object had been their reality since they became teenagers.

Ubwari peninsula and in Fizi, a village in the mountains were MSF had begun support to a hospital. The Centre d’Ecoute team went mobile to access these victims of sexual violence.

A 16-year-old girl arrived worried that her menses hadn’t started and that a clear fluid kept flowing out of her. She had been raped by several soldiers a few months earlier. The physical exam clearly identified a fistula between her urethra and vagina. It could be repaired but the girl would need to return to her village, a one-day walk away, to get permission from her husband to go to Bukavu, DRC for several operations over many months. Thankfully he agreed.

Heather Thomson is a registered nurse from

A four-year-old girl raped by a villager didn’t understand what had happened but her 15-year-old sister knew something was wrong when she saw the stranger leave her house and noted blood on her

consequences of sexual violence in eastern DRC.

— Heather Thomson

Ottawa. She spent nine months volunteering with MSF in Baraka, DRC. In addition to setting up a hospital and working on mobile clinics, she also participated in the creation of the book, “I Have No Joy, No Peace of Mind,” which detailed the

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Military

humanitarianism

MILITARY HUMANITARIANISM AID AS A MILITARY TOOL, INSECURITY AS A BYPRODUCT Attacks on civilian aid workers in Iraq and Afghanistan have increased sharply in recent years. More than 35 aid workers, including five from Médecins Sans Frontières (MSF), have been murdered in Afghanistan alone since March 2003. Offering neutral and impartial aid is no longer enough to get safe access to populations in need, particularly in places like Iraq and Afghanistan where aid and military operations are concurrent, and where aid may actually appear to be an element of conquest.

Unfortunately, western armed forces, including the Canadian military, are contributing to such appearances by using aid to facilitate conquest. The by-product of this practice is that aid, even neutral, impartial and independent humanitarian aid, may be perceived as part of a political endeavour and those who deliver it may find it more difficult and dangerous to access populations in need.

Military forces often insist upon adding a humanitarian component to operations in order to enhance the chances of military success.

Special military units are dedicated to it. Canadian military teams in Afghanistan run all kinds of “humanitarian-related” projects, from health clinics and small vaccination campaigns to giving food,

Certain military aid can cloud the distinction between military and humanitarian actors

This type of military aid does not represent a genuine or substantial contribution to the humanitarian endeavour. Any relief that may result is merely a byproduct, but it’s not the only byproduct. It can cloud the distinction between military and humanitarian actors and erode the trust that allows humanitarians to gain access to populations in danger.

In Afghanistan, provincial reconstruction teams (PRTs) are at the forefront of the military/humanitarian dilemma. PRTs are military entities that integrate military and civilian personnel and blend traditionally civilian relief activities with military objectives, often in the service of those objectives.

The Canadian military is set to take on its own PRT in Afghanistan.

Given its record of using aid as a military tool in Afghanistan, and the Canadian International Development Agency’s past direct financial support for such activities, the possibility that Canada’s PRT will be used in a way that further confuses roles is worrisome. MSF continues to engage both departments along with Foreign Affairs in an ongoing dialogue on the problem of military engagement in relief activities. The government has been generally responsive, despite its absence from an MSF-hosted public forum on the issue in Ottawa in October of 2004. Nevertheless, as the Canadian government remains highly engaged in Afghanistan, MSF remains concerned about a foreign policy that produces, as a byproduct, a dangerous confusion between military and humanitarian action.

— Joe Leberer

MSF programme consultant digging wells and rehabilitating schools. These quick impact, high visibility projects do not have as their primary objective the relief of suffering. Rather, such projects are used to increase force morale and force protection, and facilitate information gathering by winning local support.

Used in this way, aid is partial, conditional and politically strategic.

As an American soldier explained, villages that display a “progressive” attitude, in other words those less likely to support anti-coalition militias, are more likely to receive aid from the military. In April, 2004 the U.S. military dropped leaflets in the Afghanistan/Pakistan border area that read: “In order to continue the humanitarian aid, pass over any information related to Taliban, al-Qaida or Gulbuddin organizations to coalition forces.”

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Tuberculosis

TUBERCULOSIS SUFFERING A CURABLE DISEASE Juliet was one of the children who just didn’t seem to respond to the treatment we were administering in the feeding centre. Other children were gaining weight, and regaining their health. Juliet didn’t. At nine years old, she was already a refugee from the war in neighbouring Burundi. She came every day to the feeding centre with her older sister. But week after week, her weight didn’t climb, nor did her energy come back. We treated her for all the usual infections and vitamin deficiencies but still nothing. Eventually we decided enough was enough, and put her in our tuberculosis (TB) programme. Her matchstick legs and large swollen belly were textbook examples of abdominal tuberculosis. We didn’t have the tools to confirm our diagnosis, but the clues all pointed in one direction.

her weight started to creep upwards. Juliet was finally receiving the treatment she needed.

Now on my daily rounds I would witness her slow return to life.

Her previously solemn face changed to reveal a smile that would light up her whole face. The swelling in her belly went down, and

Tuberculosis is an ancient disease. Evidence of the disease has been found in Egyptian mummies. In past centuries TB was referred to as consumption or the "white death". Romantic poets coughed

This was one of my first tuberculosis patients, and eight years later I still remember her gradual but sure climb back to life.

I was hooked. **** One third of the world is infected with tuberculosis. Ninety-five per cent of infections are in the developing world. Each case of pulmonary TB left untreated will infect from 10 to 15 individuals.

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gently into the night and slipped away. Those that could afford it travelled to sanatoriums in the mountains where the crisp mountain air was believed to have curative effects. The majority that couldn’t afford the sanatorium would simply waste away and die.

As social and housing condition improved in the early part of the last century, tuberculosis rates decreased. In the developed world

but helps staunch the spread of this highly lethal form of TB in the community. Still, this small project is not nearly enough. MSF is calling on the world to renew efforts to fight TB and to prioritize new strategies and new research. The world desperately needs better diagnostic tools and above all, new research to develop better drugs at affordable prices to meet these challenges. ****

Globally, only two per cent of patients with multi–drug resistant TB are receiving the treatment they need

TB became a disease of the poor or the very old. It faded from public attention. Then came the AIDS epidemic and suddenly the disease was back with a vengeance. HIV infection drove an explosion of new TB infections. Now 12 million people are estimated to have co-infections of HIV and tuberculosis.

A second event in the early 1990s put TB back in the headlines in the West. New York City experienced a major outbreak of the disease. Only this TB was different. It was resistant to many of the drugs we commonly use to treat the disease. Suddenly the world woke up to the fact that TB is a disease that transcends borders, a disease that was becoming dangerously resistant to our standard arsenal of drugs.

The fight against TB currently relies upon a global strategy developed in the early 1990s. It targets infectious pulmonary disease, the kind that can be diagnosed by a simple smear done on a field microscope. The drugs used are those developed years ago in the 1940s and 1950s. Patients must take their medicines in front of a health worker for all of the six to eight months it takes to complete the cure. This strategy has been effective in many countries, but it has not kept up with the changing face of the epidemic. Much of the tuberculosis MSF now treats is that associated with HIV. Yet TB associated with HIV is not easily diagnosed by the use of a simple microscope, nor is the type of TB affecting children. The current strategy thus effectively excludes many of those with HIV and children like Juliet.

Multi-drug resistant (MDR) TB is an extremely worrying disease. The drugs we have now are losing their effectiveness. The backup drugs we use as second-line options are hugely expensive, have significant side effects, and require up to two years of treatment. These limitation means that globally, only two per cent of patients with MDR TB are receiving the treatment they need.

MSF is treating MDR TB in three different projects. The largest of these is in Uzbekistan, where 100 patients have been enrolled for the long course of treatment. Ensuring they have adequate treatment means not only a positive impact on these patients’ lives

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Eight years later I am in Southern Sudan. Teresa is 32 years old and weighs as many kilograms. Day after day I saw her lying on the floor in the dirty hospital ward. When I bent to examine her, she was not strong enough to sit up and breathe for me. I asked her story. She had three children, she told me. All three had died. She herself had been sick for a long time, with coughing and fevers. She started to lose weight and the cough got worse. She became unable to work and take care of her home. Her husband left. Now here she was, lying on the floor weakly spitting up into a rusted tin can.

Fortunately for Teresa, her timing was good. MSF had just negotiated with the hospital to take over the TB programme from the State Ministry of Health, and ensure a regular supply of drugs, training for staff and proper treatment protocols. We were hoping that multi-drug resistance had not yet taken hold, and aimed to prevent that from happening. I was there to start the programme, and Teresa would be one of our first patients. Four days after starting her on medication, I came into the ward to see Teresa sitting upright. Perched on the new mattress MSF had purchased, against a backdrop of bright yellow sheets, Teresa’s eyes were sparkling and her back ramrod straight. The drugs were working, yes. But more importantly, I was witnessing the power of hope that MSF had brought to her in that distant corner of war–torn Sudan.

— Dr. Leslie Shanks MSF field volunteer

Access

to

essential

medicine

MAKING

BILL C-9 WORK By early 2005, Bill C-9 will be law in Canada. Canadian companies will legally be able to produce generic versions of specific patented medicines for export to a broad range of developing countries facing public health crises.

Following up on a commitment to test the viability of the new legislation in good faith, MSF has been involved in discussions between the Canadian government and Canadian generic pharmaceutical manufacturers on making use of the legislation.

It must be remembered that while this legislation is humanitarian in spirit, it is calling on corporate bodies to act. Obviously corporations have financial objectives, not humanitarian ones, though some may choose to include a humanitarian component in their corporate vision.

In the Canadian context, there is a clear desire on the part of the Canadian government to see this legislation used and to see it work.

There was originally also an expression of goodwill and commitment from a group of Canadian generic manufacturers.

MSF and other nongovernmental organizations, as well as the generic manufacturers, have been speaking out on potential problems in making the legislation work. Testing the legislation now will provide information for its parliamentary review early in 2007. MSF will thus be able to identify any barriers in actually getting medicines onto the ground and into patients’ hands.

Barriers to getting drugs to patients Since the drugs on the list are all under patent, the molecules have in theory not been developed by Canadian generic manufacturers.

In this case, an estimated two years minimum are required for a generic manufacturer to develop and register a generic drug. This is a long time to wait.

Many needed drugs are not on the list. If a company wants to develop an unlisted drug it must first get the drug onto the list via a parliamentary committee that is not yet struck. It is not known how long a delay this could cause, nor if the committee will even approve the listing of the drug. This requirement to list the drug gives another chance for the originator pharmaceutical company to apply pressure to refuse the listing.

Making an order One of the goal’s of MSF’s Campaign for Access to Essential Medicines is to find ways to help people in resource-poor settings access low-cost and high-quality medicines. To this end MSF is willing to test the effectiveness of the new Canadian legislation by placing an order with a Canadian generic manufacturer to produce much needed drugs for our projects.

MSF has now sent a list of medicines which are of direct and immediate interest to our projects out to various generic manufacturers.

We focused mainly on drugs related to HIV/AIDS. We are currently waiting for responses from the companies on their interest.

Clearly, MSF alone will not provide a market for companies. We will also try to bridge the information gap between the ministries of health in our project countries and the Canadian government and Canadian generic companies. MSF heads of mission will receive a briefing document on the legislation and be asked to discuss this with their Ministry of Health partners. We hope this will stimulate them to approach Canadian generic manufacturers for their orders.

Another obstacle is the cost of production in Canada, which is much higher than in existing generic-producing countries such as India. Can Canadian companies charge a competitive price and still make a profit?

These issues among others appear to be making Canadian generic manufacturers reluctant to even discuss beginning the production of the drugs MSF has requested.

The long road to getting a reasonable piece of legislation into place to implement paragraph six of the World Trade Organization’s Doha Declaration marks the beginning of the practical task of making the legislation mean something to the people who are unable to afford treatment for preventable diseases.

The urgent need for these medicines exists. The will to make the legislation work is also largely present. MSF will be involved and hopes this will can be converted into practical, tangible and life–saving results for our patients.

— Rachel Kiddell-Monroe

Access campaign coordinator

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MSF

Canada

news

INTERVIEW WITH

DR. DAVID TU NEW HIV/AIDS ADVISOR FOR MSF CANADA Q: What kind before MSF?

of

international

experience

did

you

have

Q: What are the obstacles to making ARV treatment more available in developing countries?

A: As a medical student I worked for three months in a tuberculosis hospital in Pakistan. I also spent a year in China studying acupuncture, traditional Chinese medicine and anesthesia.

A: Many countries continue to need a better general infrastructure, a health-care infrastructure, financial and human resources, training in HIV care and cheaper drugs and monitoring equipment.

Q: Where have you worked with MSF and what did you learn from that fieldwork?

Q: What is the purpose of the partnership between MSF Canada and BCCE?

A: I have been on two missions with MSF for a project in Democratic Republic of Congo (DRC). The project focused on providing HIV care and establishing a model for comprehensive HIV care in a war-torn region.

A: There are two main objectives. The first is for the staff of the BCCE to act as a source of cutting-edge knowledge for MSF field staff struggling with HIV care problems. The second is for the BCCE to conduct research within MSF HIV projects to improve the quality and scale of care.

As a physician, I learned an enormous amount from my patients.

I learned what it means to be truly sick and truly healthy. I also learned that my work can make a difference.

As a North American, I learned about some of the richness that is African culture, and I gained a profound respect for the strength of the Congolese people.

Q: What is your current role at MSF? A: My focus is on clinical HIV education of field staff, and on operational research, focusing for the moment on DRC and Burundi. My responsibilities also include being a liaison between MSF and the B.C. Centre for Excellence (BCCE), and as an ad-hoc HIV technical advisor to MSF in Canada.

Q: What are the challenges of HIV/AIDS programming in the field?

A: In our programmes, HIV-related stigma remains one of the largest obstacles.

For programmes already focusing on HIV care, the medical challenges include: · diagnosis, prevention, and care of children with HIV · diagnosis and management of first-line antiretroviral treatment failure · issues around HIV and tuberculosis co-infection For MSF programmes operating in HIV endemic regions that focus on things like basic health care programmes, the challenge is how to introduce comprehensive HIV services without overwhelming the programme or detracting from other important services like care for pregnant women.

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Q: How has your fieldwork with MSF influenced your current role?

A: I gained a deeper understanding of the many complex pieces that need to come together in order to provide an effective HIV care programme — it is so much more than just providing antiretroviral drugs. I came away with an appreciation for the devastating magnitude of the HIV epidemic in countries like DRC, but I also retained a sense of optimism that significant positive change can be brought about.

— Ashleigh Clarke

MSF communications intern

MSF

Canada

update

MEMORIALS ACROSS CANADA HONOUR FIVE SLAIN MSF WORKERS AFTER 24 YEARS OF INDEPENDENT AID TO THE AFGHAN PEOPLE MSF WITHDRAWS FROM AFGHANISTAN FOLLOWING KILLING, THREATS AND INSECURITY Memorials took place in Vancouver, Calgary, Toronto, Montréal and Halifax on June 11, 2004, to mourn the loss of five Médecins Sans Frontières (MSF) workers murdered in Afghanistan on June 2.

The vigils were attended by dozens of MSF supporters from across Canada.

Hélène de Beir, a Belgian project coordinator; Egil Tynaes , a Norwegian doctor; Willem “Pim” Kwint, a Dutch logistician; Besmillah , an Afghan driver; and Fasil Ahmad, an Afghan translator, were mercilessly shot and killed after their clearly marked MSF vehicle was deliberately attacked and ambushed in the north western province of Badghis.

On July 27, 2004, MSF announced that it was closing all of its programmes in Afghanistan.

The lack of response to properly investigate the killings by the Afghan government represented a failure of responsibility and an inadequate commitment to the safety of aid workers on its soil.

A Taliban spokesperson claimed responsibility for the murders and stated later that organisations like MSF work for American interests.

Such false accusations are particularly unjustified as MSF honours the separation of aid from political motives as a founding principle.

Over the last 24 years, MSF has continued to provide healthcare throughout difficult periods of Afghanistan’s history, regardless of the political party or military group in power. Until the assassinations, MSF provided healthcare in 13 provinces with 80 international volunteers and 1,400 Afghan staff. Projects included the provision of basic and hospital-level healthcare as well as tuberculosis treatment and programmes to reduce maternal mortality.

As part of the withdrawal MSF handed over its programmes to the Ministry of Health and other organizations.

In closing its projects, MSF also leaves behind with great sadness, the people of Afghanistan.

Sierra Leone Eva Lam Anna Richley

Somalia

Sylvain Deslippes David Michalski James Squier Sheila Stam

South Africa

Peter Saranchuk

Sudan

Current MSF Missions

CANADIANS ON MISSION

Liberia

Angola

Malawi

Christene MacLeod

Democratic Republic of Congo

Francine Bélisle Philippe Blackburn Jean Gélinas Shelina Musaji Vivian Skovsbo Claude Trépanier

Jason Anderson Nicole Aubé Jennifer Buck Alain Calame Yves Cantin Heather Culbert Émilie Frédérick Jean-Francois Harvey Michel Plouffe Richard Poitras Marlene Power Jennifer Weterings

Chad

Ethiopia

Armenia

Marise Denault Sonya Jacques

Burundi

Julie Blanchet Bruce Lampard Jacinthe Larivière Jean-Sebastien Matte Jean Sander

Rik Nagelkerke

Georgia

Katja Mogensen

Haiti

Jean-Pierre Perreault

India

Kevin Coppock David Croft

Ivory Coast

Catherine De Ravinel Carol Frenette Michel Lacharité Brian Ostrow Johanne Primi Mireille Roy Grace Tang Vanessa Van Schoor

Kenya

Frank Boyce Marilyn Hurrell Anders Lonnqvist

Mario Fortin Kris Stephenson

Mozambique

Dolores Ladouceur

Myanmar

Marilyn Abraham

Nepal

Chris Warren

Nigeria

Nicole Fulton Nayana Somaiah

Republic of Congo Mario Cusson Tyler Fainstat François Riffaud

Susan Adolph Jérôme Aubin Isabel Batten Frédéric Beaudoin Jaroslava Belava Françoise Goutier Megan Hunter Ralph Heeschen Sharon Jansen Dawn Keim Yannick Lavoie Claudine Maari Tiffany Moore Alnaaze Nathoo Thierry Petry Jangh B. Rai Kathleen Skinnider Marie Skinnider

Uganda

Carrie Bernard Donald Chambers Mike Fark Asha Gervan É. V. LaperrièreNguyen Darryl Stellmach

Zambia

Tim Christie Paige Davies

Dispatches Médecins Sans Frontières/ Doctors Without Borders 720 Spadina Avenue, Suite 402 Toronto, Ontario, M5S 2T9 Tel: 416.964.0619 Fax: 416.963.8707 Toll free: 1.800.982.7903 Email: msfcan@msf.ca www.msf.ca Editors: linda o. nagy Dominique Desrochers Editorial Director: Tommi Laulajainen Contributors: Gerry Boots, Ashleigh Clarke, Debbie Cunningham, Kaz de Jong, Nathan Ford, Nancy Forgrave, Sally Hargreaves, Rachel Kiddell-Monroe, Joe Leberer, Sophie Lecomte, Carrie Morrison, Leslie Shanks, Heather Thomson, Saskia van der Kam, R van Oosten Circulation: 65,000 Layout: Company B Printing: Warren's Imaging and Dryography Winter 2005

ISSN 1484-9372

Photo credits: Lloyd Cederstrand, Johannes Daniel, Roger Job, Ton Koene, Bruce Lampard, Stefan Pleger, Espen Rasmussen, Juan Carlos Tomasi, Eddy van Wessel Page 15

MAKING A LEGACY GIFT TO MSF I have had the pleasure of working at Médecins Sans Frontières (MSF) for almost two years now and it has been a wonderful experience.

One highlight was my recent trip to Africa, where I visited one of our HIV/AIDS projects in Democratic Republic of Congo. I spent time speaking with patients, hearing their stories and learning how the treatment MSF is providing them is making a difference in their lives.

Another high point for me has been speaking with those of you who have contacted me because you are considering or have made a legacy gift to MSF in your will. The response has been encouraging and we are grateful to those of you who have already named MSF as a beneficiary.

I hope you too will get in touch with me and consider this wonderful way of expressing your compassion and reaching out to those in need around the world.

— Nancy Forgrave

Personal giving officer

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Dispatches

Vol. 7, Ed.1

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