Dispatches (Winter 2008) by Doctors Without Borders / Médecins Sans Frontières (MSF) Canada

Vol.10, Ed.1

Dispatches MSF

CANADA

NEWSLETTER

IN THIS ISSUE 4

Keeping aid workers safe

Letter from the field: Myanmar

Food is not enough

Earthquake response

Ebola outbreak

James Orbinski's imperfect offering

IRAQ © MSF

WHAT ARE WE IF WE DO NOT HAVE HOPE?

Canadians on mission ar and violence have come to a temporary end for Kamal M.* For two weeks now, the young man from Baghdad has been hospitalized in the relative safety of Kurdish-controlled northern Iraq. His left leg has a splint after several operations, his face is covered by deep cuts and nearly a quarter of his body surface is burnt. The 22-yearold tells his story in just a few words: Working as a guard for a security company he was on the first truck of a convoy that delivered goods from the north to Baghdad. His car hit a bomb. The driver is dead and the other two passengers were severely injured, as was Kamal.

The ward where Kamal is recovering is a friendly and light hospital room with 14 beds. Patients in some of the neighbouring beds tell similar stories. Wounded by blasts or shootings, victims of the war and the insurgency ravaging Iraq. It was Kamal's company that brought the wounded to this hospital in Erbil – a hospital supported by a Médecins Sans Frontières (MSF) team since March of 2007. Confronted with a huge humanitarian crisis for almost five years now, the Iraqi health system is no longer able to give proper care for these victims of violence. Thousands of doctors have fled the coun(continued on page 2)

1999 Nobel Peace Prize Laureate

Iraq

try and those who stay are often faced with harassment, arrest or the threat of kidnapping and assassination. Humanitarian workers have become targets in the conflict and, as a result, most international relief agencies have left the country. MSF is providing some medical assistance directly to Iraqis as well as operating from neighbouring countries such as Jordan. A major objective of the program in Kurdish-controlled northern Iraq – provinces that have seen far less violent incidents than the rest of the country – is to find ways to provide emergency medical assistance to people in neighbouring provinces to the south. For security reasons, it is impossible to access the wounded within the war zones, so the challenge lies in finding ways for patients from the conflict zones to reach the hospitals where MSF works. To achieve this, the teams in northern Iraq are establishing a referral system for patients from the more war-affected areas to these hospitals. Another way of assisting is by supplying healthcare

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facilities in war-affected zones with medical materials and drugs. In the Erbil hospital, where Kamal is, up to two surgeons, a burn unit nurse and a psychologist are supporting local physicians and staff in treating patients from the battle zone that lies only about 100 kilometres to the south. Many surgeries performed in this hospital deal with war wounds, while many others with burn injuries because the hospital has the only burn unit in the province. A few steps from the ward is the entrance to the operating room wing. Rémy, a French burn specialist, has come to Erbil with MSF to assist patients with severe burns and to teach his Iraqi colleagues. He vanishes inside the sterile operating theatre all day. A couple of spectators rally around him while he operates on a woman with retrograde burns on her neck, chest and forearm. The local surgeons are eager to learn. “The chin was stuck to the ribcage due to the burns. The woman was not able to move her head,” Rémy explains. A skin graft is

inserted to restore flexibility. The left hand was immobilized by the dilapidation of tissue. The surgeon measures the size of the patch of skin that has to be removed, about 5 by 12.5 centimetres. An area of that size is then cut from the thigh, the body fat removed from the skin with a scalpel, and then transplanted to the left hand. “The flexibility of the hand will be restored completely,” says Rémy. “Technically this procedure is not really difficult,” adds one of the Iraqi surgeons who watch attentively and make snapshots of the individual steps. “What we can learn from Rémy is

how to place the skin graft in order to restore mobility at an optimum.” In the meantime, the MSF psychologist makes the rounds through the wards. “Pain is an issue especially with burn patients,” he explains. “Changing bandages is incredibly painful. It's torture, especially to children. Usually patients don't receive pain therapy here.” That is an issue on which MSF is starting to work in order to keep the pain of burn victims at a bearable level. Otherwise some of these patients can't be helped under the given circumstances. Patients with over 80 per cent of their body burnt, many of them through self-immolation, usually die after a few days due to multiple organ failure. “Helping them is a special challenge,” the psychologist reports. Kamal's burn wounds will heal without skin transplantation. He covers the scarred facial parts with a cloth while he speaks. “I am glad I am still alive,” he says. “And I have to go on, what else can I do?” * Names have been changed for security reasons.

Irene Jancsy Communications officer

MSF is determined to do all it can to provide medical care to the Iraqi people. It has implemented several programs since 2006. Twelve hospitals in central and northern Iraq receive supplies, including drugs and medical equipment. In eight hospitals in central and northern Iraq, MSF is providing training for medical staff and psychological counsellors. The direct intervention of surgical teams has been set up in three hospitals in northern Iraq. In Jordan a surgical program provides maxillo-facial and reconstructive surgery for war-wounded Iraqis. Also from Jordan, MSF supplies numerous hospitals in Iraq with medical drugs and material and has set up a training program for Iraqi medical staff.

Iraqis vulnerable to fear and violence ike Fark of Calgary is a head of mission for MSF's work in Iraq. He is based in Jordan. Mike has worked with MSF in some of the most volatile and challenging contexts in the world, including Liberia, Uganda and Afghanistan. Here he talks about working in a war zone and the struggles of Iraqis left vulnerable to fear and violence.

Why is MSF in Iraq? MSF is working in Iraq in support of medical facilities to help save the lives of victims of the conflict, and to increase the capacity of Iraqi health staff to manage the trauma of the patients they receive.

What are the needs? Iraq is currently experiencing intense violence and insecurity resulting from coalition and insurgency conflict, sectarian and factional fighting and increasing criminality in the absence of rule of law. Although some regions are more affected than others all Iraqis are affected by the general insecurity, breakdown in social services and uncertainty about their future. The ongoing violence and large numbers of displaced people are creating more vulnerability and eroding people's coping mechanisms. In the areas most affected by violence people suffer not only from lack of services and mobility but also from the risk of being directly targeted or caught in the middle of a violent incident. Fear of violence is driving people from their homes, reducing their ability to move around and affecting the social structure of their lives with major consequences for their physical and mental health. A significant percentage of Iraqi health staff have either fled the country or stopped working because of targeted attacks or general insecurity, and health structures are lacking both in maintenance and in sufficient supply of essential medical material.

What is MSF able to do in Iraq? MSF is supplying essential medical materials, supporting the provision of mental health services and providing technical medical training to Iraqi health staff.

How are you able to provide assistance in such a volatile situation? With the exception of Kurdistan where MSF directly supports several hospitals, much of our work is managed via remote control, as having staff in other parts of Iraq is not currently possible due to the risk of MSF or those associated with us being targeted. This means managing Iraqi programs from a different country. Having a team working in Jordan allows us a safe location to refer patients to, and means an accessible place where we can train Iraqi medical staff.

What is MSF not able to accomplish in this context? Having MSF teams in areas outside of Kurdistan is not possible right now because of the extreme risk of MSF or our partners being targeted for political or criminal purposes.

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Sri Lanka

KEEPING AID WORKERS SAFE y its very nature Médecins Sans Frontières (MSF) often works in violent situations. Helping victims of violence is what we do. In the minds of many people this may conjure up images of the brave doctor working while bullets whiz overhead. But the reality is we do our best to avoid ending up in these situations and in fact rarely do. In all MSF missions the safety and security of our staff takes on a high priority and permeates everything we do. It begins with the doctors, nurses, logisticians and administrators in the projects and extends to our head offices.

The average first mission MSF expatriate field worker may not think they have much to contribute towards security management in a war zone. It is not exactly part of medical school, after all. But one of the key things we all do to keep ourselves safe in the field is simply talk to people. It starts at the beginning, when we first decide to open a mission in a country. Despite the sans

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frontières part of our name, it is fundamentally difficult to work somewhere if we don't have acceptance from the local population to be there. In Sri Lanka, for example, where I recently returned from helping restart our mission after the collapse of the 2002 ceasefire between the Sri Lankan government and Liberation Tigers of Tamil Eelam (LTTE), MSF spent months in negotiations with the government before we finally came to an agreement that allowed us to gain access to and work in the areas where our presence was needed most. On a project level it is essential we have good contact with all parties to the conflict. In Sri Lanka that means being in regular contact with both the Sri Lankan military and the LTTE. Everywhere MSF works it is important that all parties to a conflict know who we are and what we are doing. It means that everywhere we go we tell people the same things. That we are neutral, we

do not take sides in a conflict. That we are impartial, we treat whoever needs us the most, be that the village that has less access to healthcare because of its position in the war, or the patient who is in the worst condition in our waiting room, regardless of who they are. That we are independent, we make our own decisions about where we will work. It is the same thing we repeat to everyone, be they high up military commanders, local rebel leaders, clan elders, people on the street, or our patients. When we say it often enough, people begin to understand; when we prove it with our actions, people begin to believe us. When both sides in a conflict believe we are what we say and understand why we make the decisions we do, they usually respect the space we need to work. Building a good relationship with the community is also essential. We meet regularly with clan elders, community groups and most importantly, our patients and our local

staff. As expatriates we can never understand the nuances of what is going on in the places we work. An outsider in Sri Lanka will never notice a subtle shift in the power or activity of the local paramilitary groups, and in a place like Sri Lanka where nobody knows who is with what side and nobody knows who they can trust, no local will tell that outsider anything until they trust them fully. By developing trust and understanding MSF gets forewarning of worsening situations, advice on how to deal with local issues and assistance in times of trouble. Through our contact with the community we also keep very close watch on security incidents. We analyze risks and make plans for how we can best mitigate those risks. In Sri Lanka we had a period with frequent explosions of targeted bombs. We limited our movements around town, particularly during times when attacks were more common and in locations where they were more likely to occur. We made our vehicles more visible at night with flashing lights, large MSF logos, and lit flags, so

ÂŠ Frederik Matte/MSF

would-be attackers could see us coming and wait until we passed. Had the situation worsened, we would have moved to the hospital and stopped vehicle movements altogether. All MSF projects also have evacuation plans, so we can think through how we will get out in a crisis before the crisis occurs. There are years of experience in security management to fall back on within MSF. Who knew that a bunker could be made stronger by making sandbags with a six-toone ratio of sand to cement? Not something I ran into in nursing school. But in a place like Vavuniya, Sri Lanka where the sound of artillery is a daily experience and the antiaircraft system has been known to dump hundreds, if not thousands, of rounds of anti-aircraft fire into the air in a short period of time, the fine art of turning our bathroom into a solid safe room became a very important aspect of project set-up. Fortunately MSF has many experienced people who can offer advice and training on security management, be it what precau-

tions to take when working in a mined area, as sadly is still the case in Sri Lanka, or yes, how to turn our bathroom into a place where we can go for safety. Of course no two projects are the same. It is always essential for our teams on the ground to be well connected locally and to understand what the risks are before they happen. We will never be as safe in the field as we are in our living rooms in Canada, but by keeping focused on assessing and limiting the risks that do exist, we go a long way to keeping ourselves safe in the field.

Megan Hunter Project coordinator

Megan Hunter is a nurse from Prince George, British Columbia. She has worked for MSF as a nurse in Darfur, Sudan and as a project coordinator in both Somalia and Sri Lanka.

ÂŠ Jochen Ganter

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Letter from the field

MYANMAR

SCRATCHING BENEATH THE SURFACE © Nadine Crossland © Nadine Crossland

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n the surface, Myanmar, also known as Burma, appears to be fine. The fields are lush, the people are smiling, and there are beautiful, golden pagodas on the crest of every hill – a tribute to Buddha, teacher of peace and serenity. Scratch just beneath that surface, and the Myanmar that greets you shows a very different face.

I arrived in Myanmar in October 2006 to work for Médecins Sans Frontières (MSF) in a primary healthcare project in Kayah State. Kayah is the smallest state in Myanmar and is populated mainly by ethnic and religious minorities. The country's ruling authorities have tried, for many years, to stifle the “uprising” of insurgent groups in this area. The result is a failed infrastructure. People have little or no access to social or health services. The state has been closed to foreign tourism and the access and movement of Burmese is often restricted. With the exception of MSF, all nongovernmental organizations (NGOs) present in the area are working without international staff. This has the potential to limit or hinder activities as some local populations fear confrontation, or indeed any interaction with the authorities. The fear is not without reason as the ruling junta is infamous for its punishment and persecution of anyone who dares to question the regime or its actions. This persecution can be seen throughout the state in the form of decrepit roads, hospitals with little or no medicines or trained staff, restricted movement for much of the population, forced labour, relocation sites, and so on. All of these things have a huge impact on people’s health and well-being. As a medical NGO, MSF has its work cut out for it.

Truly, they are people who welcome strangers as their own. The medical problems in Kayah have been difficult to pinpoint and even more difficult to address. With limited access to the local people and few reliable statistics, MSF has spent the past several years trying to obtain a permanent presence, accepted by both the military authorities and the population, while at the same time trying to discover the main medical needs. In 2007, after years of making ourselves known and struggling to reach people in need, we seemed to have come to a turning point on this issue. We have now been given authorization to travel to some previously restricted areas and begin running medical activities in these places. Addressing specific medical needs has been more of a challenge. Malaria remains one of the top killers and there is a burgeoning problem of tuberculosis, quite possibly multi-drug resistant. MSF has had much experience and success in these areas, both in Myanmar and in other countries. What remains problematic for our program is the mingling of medical and social needs with the need for a complete restructuring of the social system. One of the most difficult things for me on this mission was to separate myth from reality in this land of contradiction. In a country so lush and fertile, why are we seeing malnourished children? In a country so rich in natural resources, why are the people of Kayah living in abject pover-

ty? Myanmar, unlike many other countries, is not suffering as a result of disaster or the forces of nature. The people here are suffering from years of neglect and oppression. I have often asked myself if MSF has the capacity to deal with these types of problems, particularly on this scale. It is certain that MSF cannot act as a substitute for a system completely lacking. The question is: can we have an impact while acting within our capacity and limitations? Unfortunately, after one year I have been unable to answer these questions, one way or another. What I do know is this: the people of Myanmar, particularly Kayah State, are in need of support and assistance. The people of Myanmar cannot be forgotten by the outside world. The people of Myanmar deserve better than this. My experience in Myanmar has had an impact on me in ways I can barely begin to describe. I have come to love this land and its people in a way I would never have thought possible. My hope for this country is that someday the veil of fear will be lifted and the people will breathe a collective sigh of relief.

Nadine Crossland Nurse

Nadine Crossland is a nurse from Spiritwood, Saskatchewan. This was her first mission with MSF.

Since beginning the project in 2004, MSF has had to struggle with both civilian and military authorities in order to reach the people in need. MSF expatriates are the only foreigners authorized to a have a presence in Kayah State. Thankfully, for those of us who find ourselves there, the people of Kayah State and the MSF local staff are genuinely kind and wonderful people.

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Malnutrition

FOOD IS NOT ENOUGH MSF CAMPAIGN FOR ACCESS TO ESSENTIAL MEDICINES

"Eating millet porridge every day is the equivalent of living off bread and water. With luck, toddlers here might have milk once or twice a week. Young children are so susceptible to malnutrition because what they eat lacks essential vitamins and minerals to help them grow, remain strong and fight off infections." - Dr. Susan Shepherd Medical coordinator for the MSF nutritional program in Maradi, Niger

ersistent high rates of child mortality in sub-Saharan Africa and South Asia will not be reduced if malnutrition is not addressed more aggressively. This is a medical emergency.

Médecins Sans Frontières (MSF) teams see the devastating impact of childhood malnutrition every day, having treated more than 150,000 children in 99 programs in 2006. Malnutrition weakens resistance and increases the risk of dying from pneumonia, diarrhea, malaria, measles and AIDS, five diseases that are responsible for half of all

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deaths in children under five. Despite its overwhelming contribution to child mortality and its impact on long-term health, treatment of malnutrition has not been a high enough priority in international and national public health planning and programming. Deprived of essential nutrients a young child will stop growing. Those that survive are often scarred by long-term consequences that include stunted growth and developmental delays, as well as an increased risk of chronic disease and lower life expectancies as adults.

Severe wasting in early childhood is common in large areas of the Sahel, the Horn of Africa and South Asia, which are the world's malnutrition hotspots. If nutritional deficiencies become intense a child will begin to waste – to consume its own tissues to obtain needed nutrients. The World Health Organization (WHO) estimates that there are 20 million young children with severe acute malnutrition at any given point in time. A new generation of simple, highly nutritious ready-to-use food (RUF) specifically designed for young children has greatly expanded the potential for effective nutritional interventions. Despite accumulated evidence of therapeutic RUF's effectiveness – high cure rates, low mortality and low default rates – only about three per cent of children with severe acute malnutrition have access to therapeutic RUF. INADEQUATE POLICIES INCREASE THE RISK OF CHILDHOOD DEATHS Current national and international policies to address malnutrition have fatal flaws. Many programs designed to reduce mortality of children under five from malnutrition focus on changing the behaviours of mothers, supplying enriched blends of flour and addressing poverty or food security. These strategies are important but do not effectively meet the needs of malnourished children under the age of three. Mothers in the Sahel, the Horn of Africa or South Asia don't just need advice about

how to feed their children. They need access to highly nutritious therapeutic and supplemental foods. READY-TO-USE FOOD TO ADDRESS A MEDICAL EMERGENCY In the last five years, the use of therapeutic ready-to-use food has radically changed the approach to the treatment of severe acute malnutrition. It is now possible to treat uncomplicated or stabilized cases of severe malnutrition as outpatients. The vast majority of malnourished children can now take treatment at home, under the supervision of their mother or other caregiver, instead of in hospital. There is accumulated evidence of therapeutic RUF's effectiveness. When it comes to the treatment of life-threatening forms of malnutrition in malnutrition hotspots, therapeutic RUF should be considered an essential medicine. The use of RUF is so effective it should not be limited to children with severe acute malnutrition. It should be expanded to address malnutrition in young children before it progresses to a life-threatening stage. While effective RUF alternatives exist, donors and UN agencies are still shipping hundreds of thousands of tonnes of enriched blended flours to be distributed as supplementary foods, even when the effectiveness of this strategy has proven to be limited for children under the age of three.

What MSF is calling for: While MSF continues to provide ready-to-use food (RUF) to malnourished children as part of life-saving treatment, it also calls on others to address malnutrition as a medical emergency. • Ministries of Health and those that support them need to address the critical issues that prevent 97 per cent of children suffering from severe acute malnutrition from getting life-saving treatment. • Donors need to review the quality of food aid addressed towards malnutrition in children under the age of three, and refocus their efforts away from fortified blended foods towards providing RUF with superior nutrient value, ease-ofuse and effectiveness. • UNICEF and The World Food Programme must ensure RUF is available in adequate supplies. This will mean both fundraising and finding solutions for sustainable production. • The World Health Organization (WHO) must support countries to implement new WHO growth standards, develop recommendations for effectively treating non-severe malnutrition and promote controlled and operational research to replicate and expand upon promising experiences of RUF. • Ministries of Health, academic nutritionists and other organizations working on malnutrition must implement projects to further document the benefits of therapeutic RUF beyond the treatment for severe malnutrition. • Researchers, producers and users of RUF must work together to develop new products, adapted for use in the early treatment and prevention of child malnutrition, but also, for other uses such as for maternal nutrition to prevent low birth weight.

RUF: What is therapeutic ready-to-use food? Commercialized therapeutic RUF takes the form of a peanut/milk-based paste with all nutrients essential to treat severe acute malnutrition. It comes in individually wrapped airtight foil packets, that are resistant to bacterial infection and easy to distribute. The product has a long shelf life, making it easy to store, transport and to use in hot climates as an efficient way to provide milk to children under three.

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Malnutrition

MSF's experience in Maradi, Niger

2005 Scaling up treatment In 2005, a year of exceptional food insecurity in Niger, MSF treated more than 60,000 severely malnourished children using therapeutic ready-to-use food (RUF). In Maradi alone, 38,000 severely malnourished children were treated, with a cure rate above 90 per cent. They were cared for at four hospitals and 17 emergency outpatient feeding centres.

2006 Expanding outpatient care © Christiane Roth/MSF

What is malnutrition? Malnutrition is often lost in discussions around the subject of hunger, especially in the context of the discourse to “end world hunger,” or to “feed the world.” These blurred definitions help perpetuate the inadequate response to malnutrition. It is crucial to distinguish between malnutrition and hunger, as malnutrition requires responses that go beyond food aid. Hunger is usually taken to mean a deficiency in caloric intake – any person whose daily diet gives fewer than the defined minimum of 2,100 kcal is considered suffering from hunger, or undernourished. The typical response to hunger is food aid that supplements a person's daily caloric intake. Malnutrition is not merely the result of too little food. It is a pathology caused principally by a lack of essential nutrients. Most food aid is an inadequate response to malnutrition because it either delivers insufficient amounts of essential nutrients or nutrients in it are destroyed by cooking or not taken up properly by the body.

After seeing excellent results on a large scale for severe cases, MSF extended the use of therapeutic RUF through the outpatient strategy to moderately malnourished children. Nearly 65,000 children were treated, 92.5 per cent of whom suffered from moderate malnutrition and 7.5 per cent from severe malnutrition. Recovery rates reached 95.5 per cent amongst the moderately malnourished and 81.3 per cent amongst the severely malnourished. The results confirmed the efficacy of using therapeutic RUF to treat moderate acute malnutrition. Recorded weight gain is markedly higher than that generally obtained in classic food supplementation programs using blended flour. Similarly, rates of default were very low compared to classic programs.

2007 Reaching more children At the end of 2006, MSF data showed more than half of children under three years old at some point were acutely malnourished in MSF's two catchment districts in southern Maradi. MSF implemented a new two-tiered approach: earlier access to treatment for severe cases and earlier access to supplemental RUF for all children at risk in the area. MSF began using the World Health Organization's new growth standards to define admission criteria. Based on these new standards, children suffering from severe acute malnutrition are treated with therapeutic RUF in outpatient feeding centres. In the case of serious associated illness, they are hospitalized. The second component of MSF's new approach involves distribution of supplemental RUF, which does not replace regular meals but compensates for major deficiencies in their regular diet by meeting a child's daily nutrient needs. In 2007, MSF distributed supplemental RUF to all 62,000 children from six months to three years of age in one district in Maradi on a monthly basis during the season when food supply is most precarious.

visit www.msf.ca FOR UP-TO-THE-MINUTE INFORMATION ON OUR WORK AROUND THE WORLD

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Peru

Restoring the dignity of earthquake victims n Aug. 15, 2007, the coast of Peru was devastated by an earthquake measuring 7.9 on the Richter scale. Tremors that lasted more than two minutes killed 600 people and destroyed large areas of the provinces of Pisco, Ica and Chincha, located south of the capital Lima.

The first Médecins Sans Frontières (MSF) team started offering assistance to the survivors less than 48 hours after the quake. The city of Pisco in particular was severely hit and received massive international aid. MSF therefore decided to concentrate its efforts on rural areas to the east of Pisco. At its height the MSF team in the affected area comprised 55 Peruvian and international staff. The team set up temporary clinics in many communities and supported 30 health centres with drugs and epidemiological surveillance. MSF also started

up a centre offering post-trauma and postoperative care in Pisco.

To offer psychological support to the victims, an MSF team made up of eight psychologists organized psycho-educative group sessions – called charlas – as well as individual consultations. The MSF logistical team distributed around 10,000 blankets and hygiene kits – consisting of soap, towels and other hygiene apparatus. MSF also gave 1,500 families material to build temporary shelters and distributed more than 2,000 jerry cans. In total, more than 60 tonnes of medical and non-medical material were flown into the region.

François Dumont Communications officer

Indonesia

Emergency response in Sumatra wo earthquakes, with magnitudes of 8.4 and 7.9 on the Richter scale, hit the Indonesian island of Sumatra on Sept. 12 and 13, 2007. The epicentres of the two earthquakes were 128 kilometres from the coast, southwest of Bengkulu, and 185 kilometres southwest of Padang. There were few deaths, but many houses and other buildings were destroyed.

Médecins Sans Frontières (MSF) teams, comprising of doctors, nurses, psychologists and logistics experts, were immediately sent to evaluate the situation. MSF concentrated its efforts along the coast south of Padang and north of Bengkulu, and at Muko Muko where the damage was particularly severe. More than 230 tonnes of basic supplies were distributed to the victims, including 12,903 hygiene kits, 18,414 plastic tarpaulins for constructing temporary shelters, 1,359 cooking kits, and 31,483

blankets. More than 80,000 people received these supplies. Medical teams also provided basic healthcare to people affected by the disaster. MSF extended its aid to people living on the Mentawai Islands, 150 kilometres from the west coast of Sumatra. Thirty tonnes of supplies including hygiene kits, blankets and plastic tarpaulins were transported there. “Our response was rapid and effective, but bringing aid to the Mentawai Islands was a logistical challenge,” explained Wim Fransen, MSF head of mission in Indonesia. “Access to the villages was difficult, and bad weather conditions slowed the teams down.”

psychologists consulted with patients suffering from post-traumatic stress syndrome to help those affected return to normal life.

The distribution of supplies was winding up in November, and psychological support work became a priority. A team of 18

Véronique Terrasse Communications officer

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Democratic Republic of Congo

EBOLA OUTBREAK

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ÂŠ Pascale Zintzen/MSF

ers. They also distributed drugs to 15 health centres. In order to reach all villages in the affected area, the MSF team had to travel derelict tracks. In the far northeast of the area, it was impossible to travel by car. In their race against time, the team decided to repair the road, making it possible for the cars to pass and if needed, to bring sick people from this isolated area to the Ebola ward.

y Oct. 26, 2007, it had been more than 21 days since the last person known to be infected with the Ebola virus was in contact with other people in West Kasai province in Democratic Republic of Congo (DRC). The number of new patients admitted to the isolation ward of Médecins Sans Frontières (MSF) in Kampungu had by this time already reduced to a trickle and none had arrived since Oct. 4.

From that day onward, it appeared the outbreak had been contained. MSF counted the days without new Ebola patients, as did the population, knowing that the incubation period for the disease can be up to 21 days. Ebola hemorrhagic fever is an extremely contagious disease for which there is no vaccine or cure. The type of Ebola seen in DRC kills 70 to 90 per cent of those infected. MSF's activities focused on isolating infected people, hydrating them, and easing their pain – actions which can help some to recover. From the time that the Ebola outbreak was officially declared on Sept. 10, the MSF team worked around the clock to isolate and treat those infected and try to halt a further spread of the deadly

disease. A large project was launched in Mweka health zone in the country's capital, Kinshasa, for the logistical preparation of the activities, and elsewhere for the technical support and recruitment of staff. Speed was of the essence, as the disease seemed to be spreading rapidly. The challenges were obvious from the beginning. The airstrip of Luebo, a town located 15 kilometres from Kampungu, had to be repaired. Many complex tasks had to be performed simultaneously, such as strengthening and organizing the work in the isolation unit; training medical staff of the Ministry of Health in safety rules and correct diagnosis; training the staff recruited locally for safe disinfection of materials coming out of the high-risk zone of the isolation wards; and supplying hundreds of litres of chlorinated water daily for disinfection activities. An MSF medical team searched for people suspected of being infected with Ebola. They tried, in most cases successfully, to trace people who had been in contact with suspected or confirmed patients, and verified each bit of information and every rumour of Ebola that reached them through community work-

Over four days, up to 80 people from the area cut trees and bamboo and built three bridges, coordinated by the MSF logistician. They turned the 22 kilometre track into a passable path and enabled the MSF team to finish their search for other people potentially infected with Ebola. The team member in charge of distributing information about the disease to the population was also able to go to the remote locations and give all necessary details on the outbreak and the precautions people should be taking. A total of 42 patients were hospitalized in the MSF isolation unit during the outbreak. Some of them could not be tested for Ebola because initially there was no laboratory available. More than 80 per cent of those with confirmed cases died. At 65 per cent, the mortality rate inside the isolation unit was lower, suggesting that the care offered by the medical team pulled some patients through, even though there is no specific treatment for Ebola. According to the World Health Organization, more than 380 suspected Ebola cases were reported since the beginning of May 2007, including more than 175 deaths. Out of 53 blood samples taken at one point, 24 tested positive for the Ebola virus. Other diseases with symptoms similar to those of the first stage of Ebola were also raging in this region at the time, including malaria, shigellosis and typhoid fever.

François Dumont Communications officer

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Bearing witness

James Orbinski's imperfect offering “I am here, I am present, I am capable and I must act.”

1994, where he served as MSF head of mission in Kigali and where the gutters around his hospital literally ran with blood.

Ethiopians. “You have to be more precise, more careful, more cautious about what you can say,” he acknowledged.

his is how James Orbinski summed up his philosophy at a November 2007 symposium, called Hope in the Balance, attended by more than a thousand people at the University of Toronto. The day-long event organized by Random House of Canada, which donated ticket proceeds to Médecins Sans Frontières (MSF), featured addresses on humanitarian action from MSF general director Marilyn McHarg, Nigerian novelist Chimamanda Ngozi Adichie, Senator Roméo Dallaire, HIV/AIDS activist Stephen Lewis and Stephanie Nolen, journalist and author of 28: Stories of AIDS in Africa.

During his time as president of the International Council of MSF, it fell to Orbinski to deliver the Nobel Laureate acceptance speech on behalf of the organization in 1999. His words resonated for their impassioned defense of the centrality of what the founding doctors and journalists who created MSF called témoignage:

Many Canadians wonder, for example, why MSF has remained so silent about the humanitarian crisis in many parts of Afghanistan. The straight answer, Orbinski explained, is that after the Taliban assassinated five MSF workers in 2004, the organization closed its medical programs there. Since then, it has not been in a position to re-establish the proximity of medical action that is the foundation of bearing witness with any credibility. Only medical evidence and eyewitness accounts provide the rationale for MSF to speak out. “The context today requires a very careful use of voice for an organization like MSF,” Orbinski said.

Orbinski has been spending a lot of time lately reflecting on why he has spent two decades as a humanitarian doctor. Working on his memoir An Imperfect Offering: Humanitarian Action for the 21st Century (Random House, April 2008), and filming the feature documentary Triage: The Dilemma of Dr. James Orbinski (a White Pine and NFB production) forced him to make peace with his role as a witness. The grinding effort to provide medical attention in the midst of humanitarian crises can only alleviate so much suffering and save so many lives. It never seems like enough. The act of bearing witness, then, becomes the lifeline against futility. “We had a responsibility to speak out about what we knew,” Orbinski told the audience in November about Rwanda in

Dispatches Vol.10, Ed.1

“…we speak not into the wind, but with a clear intent to assist, to provoke change, or to reveal injustice. Our action and our voice is an act of indignation, a refusal to accept an active or passive assault on the other.” Orbinski remains loyal to what he called the ‘imperfect movement’ that is MSF, while he balances his commitments at the University of Toronto and at Dignitas International, the nongovernmental organization he co-founded to develop, deliver and research community-based care for those with HIV/AIDS in Malawi. “At what point, by remaining silent, do you become complicit?” Orbinski asked the Hope in the Balance audience. He explained, as he has many times, that MSF was born of a refusal to accept a concept of neutrality that insists upon silence in response to the unacceptable. That said, the realities of contemporary conflict – especially post-Sept. 11 – increase the security risks for MSF workers who are responding to the needs of Iraqis, Darfurians, Somalis and

His memoirs will invoke the spirits of Hannah Arendt and Albert Camus in his commitment to telling his stories about the consequences of famine, epidemics of preventable and treatable diseases, war and genocide. He worked on the book, with documentary filmmaker Patrick Reed in tow, while on a journey back to Somalia, Rwanda and Democratic Republic of Congo. The film, which premiered at the Amsterdam Documentary Film Festival in late 2007 and is slated for broadcast on Global Television, captures his uncontainable rage and profound sorrow over what had happened in those countries.

Avril Benoît Director of communications

Canadians on mission ARMENIA Robert Parker Sutton, QC

Head of mission

BANGLADESH Shannon Lee Fredericton, NB Project coordinator Financial coordinator Julia Payson Vernon, BC BURUNDI Annie Desilets Ottawa, ON Project coordinator Sylvain Deslippes Montréal, QC Logistician CAMEROON Serge Kaboré Québec, QC Medical coordinator CENTRAL AFRICAN REPUBLIC Karen Abbs Vancouver, BC Mental health specialist Medical coordinator Lindsay Bryson Montréal, QC Carol Frenette St-Charles-de-Bellechasse, QC D'Arcy Gagnon Toronto, ON Barbara Leblanc Guelph, ON

Head of mission Doctor Surgeon

CHAD Erwan Chenval Montréal, QC Project coordinator Project coordinator Marise Denault Gatineau, QC Frédéric Élias Laval, QC Logistician Logistician André Fortin Montréal, QC Andrée-Anne Gauthier La Malbaie, QC Nurse Nurse Sherri Grady Toronto, ON Head of mission Sylvain Groulx, Montréal, QC Surgeon Jean-Luc Houde Québec, QC Financial coordinator Lori Huber London, ON Nurse Elizabeth Kavouris Vancouver, BC Logistician Catee Lalonde Montréal, QC Nurse Ivik Olek Montréal ,QC Midwife Nathalie Pambrun Winnipeg, MB Lab technician Mireille Roy Montréal, QC Logistician Luke Shankland Montréal, QC Financial coordinator Allison Strachan Calgary, AB Doctor Susan Tector Ottawa, ON

COLOMBIA Tyler Fainstat Kingston, ON Martin Girard Montréal, QC Esther Hsieh Vancouver, BC

Financial coordinator Project coordinator Logistician

DEMOCRATIC REPUBLIC OF CONGO Susan Adolph Halifax, NS Nurse Logistician Matthew Calvert Ottawa, ON Logistician Karla Hopp Saskatoon, SK Logistician Guylaine Houle St-Alexandre, QC Mai-Anh Le Van Montréal, QC Doctor Logistician Oonagh Skye Marie-Curry Montréal, QC Logistician Tara Newell London, ON Nicole Parker Stellarton, NS Logistician Nurse Shauna Sturgeon Toronto, ON Medical coordinator Heather Thomson Ottawa, ON ETHIOPIA Peter McKenzie Salt Spring, BC Logistician Nurse Wendy Rhymer Winnipeg, MB Project coordinator Ivan Zenar Brampton, ON GUINEA Dawn Keim Kamloops, BC Head of mission HAITI Lynn McLauchlin Montréal, QC Doctor Medical coordinator Gabriele Pahl Kingsville, ON Sylvie Savard Gatineau, QC Financial coordinator Logistician Kevin Tokar Ottawa, ON Lab technician Julienne Turcotte Québec, QC INDIA Leanne Pang Ottawa, ON Humanitarian affairs officer INDONESIA Patrick Laurent Montréal, QC

IVORY COAST Patrick Boucher Montréal, QC Nicolas Hamel Montréal, QC Diane Rachiele Montréal, QC Patrick Ulrich Ottawa, ON Lori Ann Wanlin Winnipeg, MB

SRI LANKA Logistician Nurse Financial coordinator Head of mission Logistician

KENYA Tiffany Moore Toronto, ON

Administrator

LESOTHO Peter Saranchuck St. Catharines, ON

Medical coordinator

LIBERIA Sharon Janzen Vancouver, BC

Nurse

MALAWI Michelle Chouinard Ottawa, ON Project coordinator Doctor André Munger Rivière-du-Loup, QC Pharmacist Martine Verreault Rivière-du-Loup, QC

MOZAMBIQUE Isabelle Casavant Montréal, QC

Nurse

MYANMAR Frédéric Dubé Québec, QC Robert Genest Montréal, QC

Logistician Nurse

NEPAL Assad Menapal Ajax, ON Grace Tang Toronto, ON

Medical coordinator Project coordinator

NIGER Farah Ali Burnaby, BC Marisa Cutrone Montréal, QC Michèle Lemay Montréal, QC

Nutritionist Nurse Doctor

NIGERIA Paulo Rottmann Toronto, ON Mary-Ellen Sweetnam Toronto, ON

Logistician Project coordinator

PAKISTAN Justin Armstrong Haileybury, ON Darryl Stellmach Calgary, AB

REPUBLIC OF CONGO Ahmed Alas Edmonton, AB Brenda Holoboff Calgary , AB Lai-Ling Lee Ottawa, ON Jeremy Parnell Perth, ON

Project coordinator Project coordinator Doctor Financial coordinator Head of mission Logistician

John Crosbie Toronto, ON Steve Dennis Toronto, ON Megan Hunter Prince George, BC Krista Mckitrick Calgary, AB

Logistician Project coordinator Project coordinator Nurse

SUDAN Reshma Adatia Richmond, BC Project coordinator Nurse Kevin Barlow Toronto, ON Nurse Carolyn Beukeboom London, ON Charmaine Brett Ottawa, ON Human resources administrator Stephanie Gee Vancouver, BC Nurse Logistician Daniel Nash Ottawa, ON Logistician Alexis Porter Vancouver, BC Michael White Toronto, ON Logistician Nurse Susan Witt Calgary, AB

UGANDA Maguil Gouja Québec, QC Kerri Ramstead Winnipeg, MB

Logistician Nurse

ZAMBIA Chris Warren Guelph, ON

Logistician

ZIMBABWE Carmen Bellows Edmonton, AB Mental health specialist Project coordinator David Croft Vancouver, BC Lab technician Jean-François Lemaire Montréal, QC

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 Editor: linda o. nagy Editorial director: Avril Benoît Translation coordinator: Julie Rémy

Contributors: Avril Benoît Amy Coulterman Nadine Crossland François Dumont Megan Hunter Irene Jancsy Véronique Terrasse

RUSSIA Adrienne Carter Victoria, BC

Psychiatrist

SOMALIA Denise Chouinard Montréal, QC Mario Fortin Beloeil, QC Mark Kostash Calgary, AB Susan Mann Vancouver, BC David Michalski Toronto, ON Christo Wiggins Chilliwack, BC Patrick Whelan Toronto, ON

Doctor Logistician Anaesthetist Nurse Head of mission Surgeon Surgeon

Circulation: 87,000 Layout: Tenzing Communications Printing: Warren’s Imaging and Dryography Winter 2008

SOUTH AFRICA Water and sanitation specialist

Cheryl McDermid Vancouver, BC

Doctor

ISSN 1484-9372

page 15

INSPIRED ACTION

Personal Giving Team

(From right to left)

MAKING AN IMPACT édecins Sans Frontières (MSF) can't know when or where the next disaster will occur. Yet, we must always be ready to help the people who are in the greatest need.

In 2007, MSF continued its large-scale medical efforts in Somalia and Sudan, places suffering from continuing conflict. Among many other activities, MSF also responded to disasters in Peru and Indonesia by distributing supplies and offering medical support, and contended with an Ebola epidemic in Democratic Republic of Congo.

When you plan to give a gift to MSF now and in the future, it means your support will help people access the essential medical care they need. There are a number of ways you can help make that difference. By leaving a bequest in your will, your gift ensures assistance to people in need. You can also arrange a gift of life insurance or a charitable gift annuity to make an impact later while enjoying tax benefits now. In addition to your regular donations, you may also wish to donate publicly listed securities, which are no longer subject to capital gains tax.

Emergencies like these underscore the importance of your support. Your contribution to MSF's work is essential because it allows us to act immediately where the humanitarian needs are greatest.

Please contact our personal giving team for more information on how you can contribute and have an impact on MSF's work.

We know it takes time and thought to make important decisions about your charitable contributions. You want your gift to have an impact.

However and whenever you choose to donate, we thank you for assisting us in our daily work to save lives and alleviate suffering around the world.

Dispatches Vol.10, Ed.1

Janice St-Denis Planned Giving Officer jst-denis@msf.ca 1-800-982-7903 ext. 3467

Jasmina Graho Major Gifts Officer jgraho@msf.ca 1-800-982-7903 ext. 3471

Amy Coulterman Personal Giving Assistant acoulterman@msf.ca 1-800-982-7903 ext. 3475