Vol. 6, Ed.2
Dispatches M S F
C A N A D A
N E W S L E T T E R
IN THIS ISSUE
2
Chagas: Fighting back
4
Sexual violence as a weapon of war
6
Letter from the field: Haiti
8
New ARV treatment programme in Humera, Ethiopia
CHAGAS: FIGHTING BACK
10
Introducing ACT in Africa’s fight against malaria
13
Hostage Arjan Erkel freed after 607 days
14
How Canada failed the international community with Bill C-9
15
Hope in Hell: New book follows MSF doctors in the field
1999 Nobel Peace Prize Laureate
AGAINST A NEGLECTED DISEASE
Chagas onions, firewood or in farmyards. Children follow them everywhere. “They are our helpers,” says Félix. Félix and Raúl, along with a third member, Jesús, are in charge of registering the number of children under 15 in each household. It is part of their job as one of the search and kill wings of the Chagas prevention and treatment programme MSF opened one year ago in Entre Ríos, O’Connor province, southern Bolivia. In this area, the disease affects 30 per cent of children under 14. The other wing in the MSF programme is treatment. The search and kill wing is methodical. The team sprays the roofs, walls, rooms, floorboards, checks the food supplies, beds, parcels, wardrobes, cracks and crannies in the mud walls. It is A local MSF team member sprays homes for vinchucas, the bug that carries Chagas.
CHAGAS FIGHTING BACK Two young men, equipped with a flashlight and an iron rod and carrying some small boxes in their pockets, are looking for insects in each and every one of the 72 houses within the San Simón community. In this village, these youngsters are known as vinchuqueros – a play on the word rancheros (ranchers) and vinchucas, the name locally given to the bug that carries the Chagas disease. The hunters are working for Médecins Sans Frontières (MSF) as part of its struggle against one of Bolivia’s most deadly diseases. The vinchucas is about five centimetres long when fully grown. It climbs high on the clay walls inside the houses and then jumps and glides until it lands on exposed arms of sleeping children. The disease spreads when the bug bites the flesh, defecates and the victim unknowingly scratches minute parasites into the blood system. It can linger for as many as 10 to 15 years before symptoms appear. These two vinchuqueros are Félix and Raúl. They sometimes have to walk up to seven hours before reaching a house where they then search high and low to spot the deadly bug among the
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”Children only have a 60 to 80 per cent chance to recover. As they get older, though, the side effects of the medicines needed increase while their efficacy decreases.” DR. FERNANDO PARREÑO, PROJECT PAEDIATRICIAN
a thorough inspection for the bugs and their nests. The team sprays the area to kill bugs hidden from view during the inspection. The eradication is essential for the treatment to be effective. Because, no matter how well an area is cleared of the bug, if it returns, people given treatment can be re-infected. The odds are only barely in the patients’ favour. The problem is that there is no effective treatment for Chagas. Eradication and treatment are constant companions with this disease. “The treatment is not a vaccine,” explains Francisco Román, field coordinator in the Entre Ríos municipality. “Children can get infected again that very evening, while sleeping at home. This is why being on the alert for the presence of the vector (the bug) is a must, followed by administering the appropriate treatment.” ”Children only have a 60 to 80 per cent chance to recover. As they get older, though, the side effects of the medicines needed increase while their efficacy decreases,” explains Dr. Fernando Parreño, the project’s paediatrician. Bolivia holds the unfortunate record for Chagas infections in Latin America. The disease is endemic in 60 per cent of the country. Half of the population — some 3.5 million people — are at risk. Chagas is said to be the fourth highest cause of disease and responsible for 13 per cent of deaths in the country. In the developed western world, these figures would have long ago motivated pharmaceutical companies to develop a cure – or at least an effective treatment or vaccine. But Chagas is also
known as a disease of the poor and consequently, for 30 years now, there has only been one treatment, already obsolete, with side effects, resistance and incompatibilities. At first, the symptoms are no cause for concern: tiredness and stomach ache. But eventually fatigue takes root in the person, preventing them from going to work, raising horses or performing the slightest task. Heart failure is the usual cause of death. When MSF arrived in Entre Ríos a year ago, the infestation rate for Chagas was 19 per cent. By then the situation was so severe the most immediate need was to try to eradicate the bug. “Starting treatment was out of the question,” says Román. “However, by fumigating and repairing each and every household as part of the government programme, the chance of infection has decreased considerably.” MSF has already visited six of the most populated communities surrounding Entre Ríos, with the objective of treating 2,000 children in three years and covering the 103 communities within O’Connor province. The project started in September 2003 and is scheduled to last until September 2005. Currently, MSF is the only organisation offering treatment to children under 14, the age group for whom treatment is most effective. The procedure for treatment is long. To start, children have blood samples taken and tested. “The use of filter paper for the tests is an achievement as it allows us to take samples en masse in rural areas,” explains field coordinator Román. Once the laboratory results are ready, the MSF team visits the parents of children who have tested positive – there have been 606 so far in this community alone – and offers free treatment.
Currently, MSF is the only organisation offering treatment to children under 14, the age group for whom treatment is most effective.
gives each of them a small bag, with their name tag attached, containing the pills broken into quarter pieces. The method is two quarter pieces per day for a whole week. This means Parreño himself must break up the pieces as best he can. “The treatment is complicated but, to top it all off, the main users are children and no formula adapted to children, such as a syrup, has ever been developed,” he complains. “MSF administers benzinadol (Roche), a drug which started being used in cattle in the 1970s. Even though Chagas was discovered at the beginning of the century, we know hardly anything about it.” The MSF team takes special care of their small patients and keeps a watchful eye on any possible adverse reaction. A few days ago, the MSF four-wheel-drive vehicle drove for three hours along the road between Entre Ríos and Tarija to refer a Guarani child, Grecia, to the hospital there. Grecia’s skin was suffering from a chemical burn – an adverse reaction to the treatment. But even this reaction was a surprise to the MSF staff. “She is OK now. This is the first time we have seen something like this, but it means we must be very careful,” explains Parreño.
Bolivia holds the unfortunate record for Chagas infections in Latin America
If MSF did not pay for medicines, the affected families who could actually get to the pharmacy would have to pay $50 US per child, a prohibitive amount in such a context. In the Buenavista school, several children are already waiting for the MSF vehicle. The paediatrician Fernando Parreño shakes hands with each patient and, after finding their name on a list,
MSF has been trying to increase community awareness of Chagas through a series of commercials, short radio-theatre pieces designed to inform people of the disease and what they can do to prevent it or be treated. Children are most likely to absorb the information. Señor Reinaldo, from the San Simón community, says that his children are playing their part in the eradication of the vinchucas. “They grab the bug, separating its head from its body and giving it to the hens to eat.” But he also admits not that he did not know how harmful these insects were. “My father died of Chagas, I think. A heart attack.” — Olga Ruiz Page 3
Sexual
violence
ENOUGH IS ENOUGH SEXUAL VIOLENCE AS A WEAPON OF WAR
“The day before yesterday I went to the bush to look for wood. There were three government soldiers with guns. One of them saw me and he asked, ‘Where are you going?’ I said I was looking for wood. Then he told me, ‘You are assigned to me for the day.’ I was very afraid. He forced me to go far into the bush and he undressed me. Then he raped me. When I got dressed afterwards he took 50 Liberian dollars from me. I came back to the camp and yesterday I felt very sick. My stomach is very painful, but I don’t have any money to go for treatment.” Woman, 27 years old (not pictured), living in a camp for displaced people, in June 2003
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Rape as a weapon of war Wars leave women and girls particularly vulnerable. Women, girls and even young children are all too often raped, abducted and forced into sexual slavery as social and economic structures fall apart. When forced to flee their homes, women and girls frequently become separated from their families and are left open to attack. They may be forced to trade sex for protection, or simply food or shelter. The incidence of rape and sexual violence in these situations not only increases but often becomes systematic. Rape becomes a weapon of war with women and girls the targets. Seen this way, sexual violence is not “only” a consequence or side effect of war and displacement. It is, instead, a deliberate tool of war. Women and girls are singled out because the harm and humiliation inflicted on them not only hurts them but also deeply harms and humiliates their families and often the entire community.
Silhouettes placed in the streets of Brazzaville, Republic of Congo, as part of a campaign run by MSF, symbolising the damage done to rape victims.
MSF’s response Impunity has to stop Unfortunately, impunity is often the norm. While some progress has been made in recognising rape and other acts of sexual violence as war crimes (rape is now specifically mentioned in the Statute of the International Criminal Court), the international and national response so far remains unclear and inadequate. Local, national and international actors must take all necessary measures to address impunity and help prevent such acts. Counselling sessions with rape survivors have also highlighted the importance to the healing process of having rape declared a punishable crime, even in international law.
Consequences of rape: women and girls are scarred The medical consequences of sexual violence are devastating. The physical injuries can be life threatening and many rape victims are at risk of contracting sexually transmitted diseases, including HIV/AIDS. Being raped leads to long-lasting trauma and suffering. Sometimes this takes the shape of mental health disorders and at other times it surfaces in less obvious ways such as shame, guilt, sleeping problems, difficulties in daily functioning and withdrawal. On top of the physical and psychological trauma caused by sexual violence, the raped woman is often stigmatised by the community and sometimes even rejected by her husband. These women, isolated and ashamed, are then forced to find their own way and live in poverty. It is imperative that the stigma of rape is removed so they can regain their livelihoods and their full place in society.
Dealing with sexual violence is difficult and there are many obstacles, including cultural ones, to treating and supporting victims appropriately. Working in emergency or semi-emergency settings where there may not be even basic health care, let alone a private space for treatment and counselling, only adds to these difficulties. But we have a responsibility to provide care. MSF is striving to provide comprehensive and quality care to victims of sexual violence in confidential settings. We treat the victims’ wounds, offer emergency contraception and provide treatment for the prevention of sexually transmittable diseases. This includes HIV, for which we administer antiretroviral drugs to prevent post-rape infections. These drugs are effective only when taken within 72 hours after of the rape, one reason why immediate medical assistance is so vital. Given the fact that sexual violence is often a taboo, it is as important to have education activities in place to raise awareness about the issue and the fact that medical treatment is available. In some projects, MSF also organizes the psychosocial counselling. Here, women are enabled to talk about – often for the first time – what they endured.
MSF programs MSF is providing care and support to victims of sexual violence in a number of countries where we work, including Democratic Republic of Congo, Burundi, Republic of Congo and Liberia. The dominance of African countries does not mean that sexual violence does not happen elsewhere. It does, however, reflect the fact that it is extremely difficult to support victims of sexual violence in countries like Chechnya, Pakistan and Afghanistan where the taboo and stigma is even greater and where women risk being expelled or possibly killed once their family finds out.
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Letter from the field
HAITI
The news on television painted a bleak picture of the situation in Haiti. Two hundred years after independence from its colonial masters, the country once again plunged into chaos. In early February an armed group took over Gonaives, the fourth largest city in Haiti. A domino effect began which was to result in the president’s departure into exile less than a month later.
I arrived in the capital Port-au-Prince, along with a nurse, at the end of February. The main objective was the provision of basic health care in the north and north east. We also wanted to guarantee hospitals’ ability to cope with a possible influx of victims of violence. Insecurity was evident by the lack of people and traffic on the street as we drove from the airport to an MSF office. The country was paralysed and the capital was tense. In light of information indicating security in the north was somewhat stable, our team decided quickly to fly to neighbouring Dominican Republic and from there travel back to Haiti. The airport was closed but we were able to obtain permission
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to land a chartered plane. We were the last to fly out of the airport until international troops arrived days later. From Santo Domingo in Dominican Republic we took a bus to the border. We crossed on foot and rented an old fourwheel-drive vehicle. Five hours of bumpy roads later we arrived in Cap-Haitien, the second largest city in Haiti. We covered as much territory as possible to understand the situation. I was pleasantly surprised to find most health structures functional, albeit with small problems such as ruptures in drugs, less personnel than usual and a drop in daily consultations. Most problems were a direct result of the lack of fuel – fuel became a rare commodity, affecting the
price of transportation and thus discouraging people from seeking consultations. Fortunately, with the president’s departure and the arrival of the international troops, roads were opened and the situation quickly started to normalize itself. MSF did contribute logistically to eliminate drug ruptures and other necessities such as propane, oxygen and fuel but as such, our intervention proved to be limited.
amount for a family with almost no income. “How were you able to pay for it?” I asked. “Friends and family,” she answered. This was common – the immediate family, community and diaspora often help out when people are in need. That is not to say that the system is perfect. The public health staff are poorly paid, resulting often in a lack of motivation. Practically all public doctors compensate by having their own private clinic.
My previous experiences in developing countries had shown me health systems can sometimes be truly ineffective if lacking infrastructure. In past emergency interventions I have witnessed health
The health system here works on cost recovery. However, there is an exoneration system in place for the poor. This works on a case-
systems completely paralysed by extensive looting from armed groups and health personnel who have fled due to insecurity. In Haiti’s case none of this was true. The ruptures were minimal, most health personnel were still at their post and the public health infrastructure was functional even with a political vacuum in the capital.
by-case basis and is usually left to the discretion of the administrator. The percentage of people who receive free or partially free health care varies from 10 to 20 per cent. Many people who cannot afford health care wait until complications arise, increasing the eventual cost of treatment.
We met very qualified staff at most health structures. Many rural dispensaries benefit from a cooperation program with the Cuban government, so a Cuban doctor and sometimes a lab technician are also present. As well, because Haiti is geographically small and has many hospitals, health centres and dispensaries, the population does not seem to lack access to basic health care. Even though we read official reports that as many as 50 per cent of Haitians lack access to basic health care, we have scoured various areas of the two departments and have yet to talk to one person who said they could not seek medical help.
It seems unlikely MSF will be involved in any basic health care program in this region. We continue our visits to better understand the system and discover if and how MSF could provide a quality program.
I spoke with one lady, Gabrielle, age 54, who lives with four children and her disabled husband. The family’s only income is from a small kiosk. When I inquired about her health she told me she had recently been sick. Initially she took a local medicine, a sort of tea. When she was still ill she went to a traditional practitioner. When this last solution didn’t work she went to the hospital. Her consultation fees and drug bills totalled $23 US – a substantial
One dire need for the population we have identified would be an HIV/AIDS program. There are few in the country. As I write these last few lines, we have joined two new members of the team to better analyse these possibilities. — Sylvain Groulx
Sylvain Groulx is a Canadian logistician. He spent seven weeks in Haiti this past winter as an MSF volunteer. This was his fifth volunteer mission.
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Ethiopia
ACCESS TO HOPE NEW ARV PROGRAMME IN ETHIOPIA Feb.14, 2004 Humera The week started with a march through town heralding the arrival of antiretrovirals (ARVs). Balloons, children and a loudspeaker gave away information about the test clinic, HIV follow-up clinic and the antiretroviral treatment program. Quite a big deal here in Humera. It is also a big deal in Ethiopia in general as this is the only programme where ARVs are available to people who can’t afford them. The challenge is in the patients we see. They come in with a serology (evidence of disease) that would classify them as dead in the west. The patients are emaciated, fly-riddled, gaunt live skeletons. Tuberculosis, kala azar, malaria, poverty, hunger, homelessness, stigma, 45-degree weather and HIV beset them. You cannot imagine how any human can endure this, yet I came
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here to speak of a better future, of responsibility and a resolve to change this picture. How are we attempting this? First we give them a reason to test. With a volunteer and an anonymous testing site with counselling they have their first step into the program. This already allows women the possibility to deliver healthy, uninfected babies should they test positive. Our HIV follow-up clinic gives patients information on what they can do to stave off disease progression and provides them with the lab work necessary to arm themselves with prophylactics as well as therapeutic treatments. Those who qualify on the agreed patient selection criteria can then move to our ARV program. These little pills, taken twice a
day, can reduce patients’ viral load and allow their immune systems to regroup so they can recover lost weight, energy and their future. Reducing their viral load also reduces their infectiousness as well as the propensity to be sick all the time. Attention to the nutritional side of patients’ lives is another key. Even with all the right medical care, poor nutrition can make the plan go nowhere fast. MSF is working hard on the nutritional component of the programme. The third component is attitude. How do you get people to be positive about life when they are mostly immigrant workers with no family or home? These people believe it is their fate to die as theirs is the fate of the poor. They have been refugees in different countries according to the troubles of the day. For one period they are in Eritrea, another in Sudan, and now here in Ethiopia. They bare the scars of these movements in an area prone to droughts, disease and misery. We start by building shelters. There we try to meet basic needs like access to water, latrines and a kitchen. It's not a home in the way we view a home, but it is a safe place for them to be stable and settled. We also have a repatriation program for those wanting to go home. Patients opting for the repatriation program are out of the ARV program by default, as they must be in Humera to access the medications.
find it more difficult to deal with the news as they associate HIV with AIDS. They believe one cannot be without the other. This is why my participation here is important. I show the asymptomatic face of the illness by testing live in front of them and showing them the face of HIV. There's a lot to be done about stigma and we have trained a team of health educators, to be deployed soon. Another team of HIV counsellors will go out shortly. All this works toward a more educated and healthier community. It also reduces stigma and hopefully allows these people back into the wheel of life as the productive members they can and will be if they do their part. All we are asking is for them to take their meds as prescribed, make an effort to eat better cooked food with emphasis on eating more protein and drinking cleaner water, and keep a positive attitude. When you see where they start from, it is not difficult to believe in a better day. — Carlos Cordero Treatment adherence councellor
The patients can now, with basic needs met, start to organize themselves because they now have two support groups. These groups will be the force behind the nutritional program. It is in their hands to turn their fates around and construct a new way of life as people now living with the very disease that was killing them. MSF can only provide access to medical care with quality and compassion, but it is these people who must take it where they need to go. My role is to show them that death is not inevitable unless you believe it is so. Even against this backdrop, I believe it can be done. So does the huge team of drivers, cooks, doctors and nurses, counsellors, lab technicians, pharmacists, health educators and community leaders who contribute time and energy to this vision. Just this month, Mycadra tested 11 people for HIV. Eight were tested between Wednesday and Friday this week. What happened? We did health education on Wednesday and this made people aware, informed and confident to take the test. For those who test and already have symptoms, getting them plugged into our services is no big deal. Those getting tested in preparation for marriage who test positive but are asymptomatic
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Malaria In Nigeria, MSF runs a malaria programme in the Niger Delta, focusing on testing and treatment of children under five and pregnant women.
WAKINGUP TO WHAT WORKS INTRODUCING ACT IN AFRICA’S FIGHT AGAINST MALARIA Dispatches
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Malaria kills more than one million people every year, most of them in Africa, and most of them under the age of five. More children die from malaria in Africa than from any other cause. The facts are discouraging. From the mid 1950s to 1969, when the World Health Organization (WHO) led the Global Eradication of Malaria programme, malaria mortality rates dropped significantly. From then on, however, the trend began to reverse in sub-Saharan Africa; from 1970 to 1997 the death rate rose by more than 50 per cent, and the number and severity of recent outbreaks has increased sharply. Commonly used treatments have become less effective in many cases because the parasite has developed a resistance to them. In recent years, however, a dramatically more effective treatment has become available. Derivatives of artemisinin, a plant extract first used in China more than 2,000 years ago, combined with certain other drugs works in almost all cases against P. falciparum, the most widespread and deadliest strain of malaria. The problem now is that governments are reluctant to adjust national treatment protocols to use artemisinin-based combination therapies, or ACTs, as first-line treatment. If that is done, as MSF believes it must be, many lives will be saved. Working directly with malaria patients, MSF has witnessed the extraordinary results of ACT in clinics, hospitals and refugee camps around the world. ACT works rapidly with few side effects, relieving clinical symptoms and reducing parasite load faster than any other anti-malarial. This also means the parasite is less exposed to subtherapeutic levels of the drug (present in the body but not actively fighting the disease) and thus has little opportunity to develop resistance of which there is as yet none documented. In contrast, resistance to chloroquine, one of the main first-line anti-malarial drugs currently used in Africa, has reached higher than 80 per cent in places. Another commonly used drug, sulphadoxine-pyrimethamine (SP), which goes under the brand name Fansidar, is useless more than a third of the time in many parts of the continent. WHO states that when resistance reaches 15 per cent or higher a more effective treatment must be adopted. WHO also specifically recommends, as a response to increasing resistance, that countries use combination therapies and preferably those using artemisinin derivatives for falciparum malaria.
lumefantrine). Over the long-term, switching to ACT makes sense, even in purely economic terms, but the immediate price tag is intimidating and even prohibitive for many cash-strapped African governments. Making the leap therefore requires not only domestic political will, but international support as well. In Burundi, for example, the government until recently rejected calls for the introduction of ACT despite catastrophic rates of malaria and extremely high resistance to first- and second-line drugs (SP and chloroquine). In 2001, MSF together with the Ministry of Health, carried out a series of resistance studies and found in three different provinces a range from 64 to 93 per cent resistance to chloroquine, and a 33 to 67 per cent resistance to SP. A later study showed no resistance to ACTs. MSF, unable to justify sticking to national protocols, illegally though
MALARIA FACTS • 300-500 million new cases of malaria occur every year, over 90 per cent of them in subSaharan Africa. • The disease is present in over 100 countries and threatens 40 per cent of the world’s population. • Malaria is transmitted by the Anopheles mosquito and caused by the plasmodium parasite. Of the four species of plasmodium, falciparum accounts for the majority of infections and is the most lethal. • The parasite causes high fever, headache and joint pain. Infection with falciparum can progress to severe malaria if left untreated, resulting in coma and eventually death. • Malaria hits poor and rural communities more than any other disease.
Why then are governments not rushing to change their malaria treatment protocols? Politics aside, the simple answer is that ACT costs too much. Chloroquine costs just pennies per patient, and even other combinations without artemisinin derivatives, such as amodiaquine with SP at $0.25 US, cost little more. ACTs are much more expensive, ranging from about $1.30 US (for amodiaquine and artesunate) to more than $2 US (for the brand name drug Coartem, which combines artemether and
• In some regions, malaria has taken on epidemic proportions. This is mainly the result of armed conflicts, mass population displacements, economic crises and climatic changes.
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publicly began using ACT and advocating for a switch in protocol. Faced with overwhelming data and encouraged by funding pledges from major donors, the government finally announced that it would introduce ACT as first-line treatment by July 2003. By the end of 2003, MSF had helped ensure that ACT was available in health facilities throughout the country.
MALARIA FACTS • In Burundi, nearly a third of the population is infected with malaria in a normal (not an outbreak) year. • Between 1997 and 2002, outbreaks of severe malaria
Unfortunately, only five of the 41 other African countries where malaria is endemic have made the switch. Several more have committed to do so, but considering what is at stake change is occurring too slowly. In Ethiopia, where a recent malaria outbreak hit between 10 and 15 million people, the government, in line with the current rationale of major donors like UNICEF, hems and haws while millions are given less effective drugs. MSF sees the results — sick and dying children — in the clinics and hospitals it supports and has been pressing for the introduction of ACT. Yet the Ethiopian government did not permit MSF to use ACT during the country’s recent malaria epidemic – even as mortality rates soared above emergency levels – let alone change the national protocol. Each day 3,000 people die of malaria. Many of them would live if they had access to ACT. National governments and the donors who fund them must commit to making ACT the firstline treatment against malaria. There is no other humanitarian option. Each day that antiquated national protocols continue to prescribe less effective drugs, people needlessly suffer and die. — Joseph Leberer
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occurred in 358 areas in Africa. • Preliminary results of a resistance study in Ethiopia show resistance to SP ranging from 40 to 70 per cent, and 100 per cent efficacy of the combination drug Coartem. • MSF believes that with a large increase in demand, the price of the combination amodiaquine plus artesunate could fall to $0.60 US by the end of 2004. • According to WHO, malaria costs Africa an estimated $12 billion US per year. The economic cost of malaria is enormous in terms of lost income and financial burden on health services. • MSF estimates it would cost only $19.1 million US more than current expenses to introduce ACT to Burundi, Kenya, Rwanda, Tanzania and Uganda combined.
Update
Arjan Erkel (centre) addresses the media in Moscow following his release.
HOSTAGE ARJAN ERKEL FREED AFTER 607 DAYS CAPTURE HIGHLIGHTS PROBLEMS IN REGION Arjan Erkel has been freed. He is now safe at home in the Netherlands with his family. The MSF volunteer and head of mission in Dagestan, was taken hostage on Aug. 12, 2002, and was held for a total of 607 days. Arjan was reunited with his father, Dick Erkel, at the Moscow airport on April 11. Dick Erkel flew out on a Dutch military flight that was specifically dispatched to bring Arjan back to Holland. Father and son were reunited and then flew home together. MSF heard news of Arjan’s release when representatives received a call at 3 a.m. local time on Sunday, April 11 from a group called Veterans of Foreign Intelligence. The Erkel family was immediately informed. While Arjan’s release was a great relief to the organization, MSF emphasized the heavy toll Arjan's prolonged detention exacted on the ability to provide aid to war-affected civilians in the region. “MSF is extremely happy that Arjan is finally back home,” said Dr. Rowan Gillies, president of MSF’s International Council. “But it must be remembered that a huge price was paid not only by Arjan but countless others as well. Arjan's kidnapping led to drastic reductions of aid programmes to displaced and war affected people throughout the region. It reinforced the climate of intimidation against humanitarian actors that has existed in the region for years.” The fact that Arjan was kept in prolonged detention for 20 months, and the need for MSF to hire a private Russian security
company to arrange for his release, highlight the continued acceptance, by the government of the Russian Federation as well as its allies and partners, of a climate of violence in the region. Acts of violence and threats directed against humanitarian organizations have been an ongoing phenomenon in the region over the past decade. Since 1995, more than 50 international humanitarian aid workers have been abducted. Today, the violence continues and humanitarian assistance remains crippled. “This cannot drag on any longer. It is the responsibility of the host country to redress this situation now,” said Dr. Gillies. Dr. Gillies expressed MSF’s appreciation for the mobilization around Arjan’s case. “MSF is extremely grateful to everyone who has shown solidarity with Arjan, from the hundreds of thousands of people in Russia, Dagestan and around the world who signed our petition, to the many representatives of national and international organizations and government officials who have shown their support.” During the nearly 20 months of his capture, Canadians rallied with others around the world to show their support for efforts to secure Arjan’s release. In 2003, more than 450,000 people worldwide signed a petition calling for his immediate liberation. The Globe and Mail newspaper donated space for ads urging people to sign the petition, and authors such as Margaret Atwood, Michael Ondaatje, Karen Connelly and Ronald Wright joined the appeal.
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MSF
Canada
news
BILL C-9:
HOW CANADA FAILED THE INTERNATIONAL COMMUNITY Bill C-9, the much-touted Canadian government bill originally intended to allow access to drugs for developing countries, sets a dangerous international precedent. In practice, the legislation does not improve the situation for people in developing countries who need to access desperately needed affordable medicines. By passing a flawed bill in the House of Commons in May of this year, the Canadian government has effectively reneged on its international commitments. The Bill contains several critical flaws that will make the production of generic medicines and their exportation to developing countries very difficult, even impossible in some cases. In particular, the flaws include a list of medicines that does not even include first-line AIDS fixed-dose combination treatment drugs, and a clause that could stop NGOs from importing medicines into developing countries. Bill C-9 has been at the centre of debate since September 2003, when the Canadian government announced it would implement legislation that would enact domestically a World Trade Organization (WTO) decision made Aug. 30, 2003. The decision aimed to resolve difficulties posed by the TRIPS agreement related to exports of generic medicines produced under compulsory licenses to poor countries with insufficient capacity to produce them on their own. The Canadian government is the first G8 country to attempt to implement the decision into national law. However, the end-result is an example of how the Canadian government ultimately prefers to protect the rights of patent holders over patients. “After years of bitter negotiations at the WTO, developing countries were told they had won a victory when all WTO members agreed to the Aug. 30 decision,” says David Morley, executive director of MSF Canada. “Canada’s commitment to implement this decision should have been straightforward. Instead, we come out after eight months of intensely debated negotiations with nothing more than a bill that pays lip service to the poor.”
Communicable diseases alone kill more than 14 million people every year, more than 90 per cent of whom live in the developing world. Yet one in three people in the world do not have access to essential medicines, and more than half in regions of Africa and Asia.
“Canada’s commitment to implement this decision should have been straightforward. Instead, we come out after eight months of intensely debated negotiations with nothing more than a bill that pays lip service to the poor.” DAVID MORLEY, EXECUTIVE DIRECTOR OF MSF CANADA
MSF continues to urge the Canadian government to uphold the commitment it made in Doha to protect public health over commercial interests. MSF is committed to testing the viability of the new Canadian legislation in good faith, but remains deeply concerned that it will do little to improve access to all medicines needed in developing countries, while setting a dangerous international precedent. — Isabelle Jeanson
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MSF
reads
HOPE IN HELL At the forefront of Médecins Sans Frontières are the volunteer doctors who risk their lives to perform surgery, establish or rehabilitate hospitals and clinics, run nutrition and sanitation programs, and train local medical personnel. This book follows these volunteer doctors as they risk their health and lives to treat patients in desperate need. Combining engaging text with dramatic colour photographs from around the world, Hope in Hell examines the lives of individual MSF volunteer medical professionals. Topics include: • performing emergency surgery in the war torn regions of Africa and Asia • treating the homeless in the streets of Europe • understanding cultural customs and societal differences that affect health care • witnessing and reporting genocidal atrocities
Recent world events are explored and how MSF is reacting to them. These include the challenges of delivering aid during the Rwandan massacre and the controversial decision to criticize the U.S. for delivering humanitarian aid to Afghan citizens while at war. The book also covers the raucous founding of MSF in 1971 as the first non-governmental organization to both provide emergency medical assistance and publicly bear witness to the plight of the populations they serve. Hope in Hell is written by Dan Bortolotti and published by Firefly Books. It will be available in fall 2004.
Mike Fark Judy McConnery François Riffaud
Russia Nicole Aubé Steve Cornish Gabriele Pahl
Sierra Leone Catherine Wright
Somalia Sylvain Deslippes Mario Fortin Sheila Stam Current MSF Missions
CANADIANS ON MISSION
Liberia
Sri Lanka
Josée Pepin
Afghanistan
Adam Childs Doug Kittle
Mauritania
Ronald Henbest Suaad Mohammad
Angola Maryse Bonnel
Democratic Republic of Congo
Armenia
Berthier Bourque Heather Culbert Julie Doldersum Vincent Echavé Jean-Francois Harvey Véronique Mogé Lynda Moore Richard Poitras Katiana Rivette Heather Thomson
Marise Denault Sonya Jacques
Bangladesh Violet Baron
Burundi Rachelle Brière Ivan Gayton Tara Neville Jason Peat Dominique Proteau Claude Trépanier
Chad Hélène Genest Clea Kahn
Georgia Robert Parker
Guinea Alnaaze Nathoo Michel Paradis
Haiti
Mozambique Dolores Ladouceur
Myanmar
Cathy Huser
Marilyn Abraham Stephanie Faubert
India
Nigeria
Kevin Coppock
Ivory Coast Adèle Leblanc Shelina Musaji Brigitte Robichaud Vanessa Van Schoor
Ethiopia Isabelle Aubry Alexandra Conseil Cara Kosack Joseph Leberer Rik Nagelkerke
Jacinthe Pressé
Kenya Christina Cepuch Françoise Goutier Denis Guzzi
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
South Africa Peter Saranchuk
Christine Nadori Patrick Robitaille Jean Sander Sophie Villemaire
Dispatches Médecins Sans Frontières/ Doctors Without Borders
Editorial Director: Tommi Laulajainen Contributors: Carlos Cordero, Sylvain Groulx, Isabelle Jeanson, Joseph Leberer, Olga Ruiz
Sudan Isabel Batten Lia Copeland Nancy Dale Steve Dennis Claudine Maari David Michalski Tiffany Moore Leslie Shanks
Nicole Fulton Nayana Somaiah
Turkmenistan
Pakistan
Uganda
Ronald Henbest
Lynne Chobotar
Palestinian Territories
Zambia
Circulation: 65,000 Layout: Company B Communications Printing: Warren's Imaging and Dryography Summer 2004
Christine Hwang ISSN 1484-9372
Johana Amar
Tim Christie Paige Davies
Republic of Congo
Zimbabwe
Frédéric Beaudoin Lindsay Bryson Mario Cusson
Chentale de Montigny
Photo credits: Remco Bohle, Alixandra Fento, Alain Fredaigue, Erwin van der Landt, Isabel Leal, Simon Lourie, Olga Ruiz, Sven Torfinn, Linda Van Weyenberg
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Just a few words in your will... Create a living legacy to provide life-saving medical care for populations in distress around the world.
Photo © Gilles Saussier
For information about making a gift in your will to Médecins Sans Frontières, please use the enclosed envelope or contact: Nancy Forgrave Personal Giving Officer (416) 642-3466 / 1 800 982-7903 nforgrave@msf.ca Charitable Registration Number: 13527 5857 RR0001
www.msf.ca 402 - 720 Spadina Ave., Toronto ON M5S 2T9