Dispatches (Summer 2006) by Doctors Without Borders / Médecins Sans Frontières (MSF) Canada

Vol.8, Ed.2

Dispatches MSF

CANADA

NEWSLETTER

IN THIS ISSUE 2

MSF Expo 2006: On mission in Canada

Access to Essential Medicines and DNDi

Insufficiencies and suffering: Chagas

Treatment for life

Witnessing white death in Uzbekistan

Community-based malaria treatment

Effective drugs must reach patients

The new tuberculosis: TB in the era of HIV

MSF profile: Peter Saranchuk

ACCESS to essential medicines and drugs for neglected diseases

1999 Nobel Peace Prize Laureate

woman was dying, and there was one drug that the doctors thought might save her. It had been discovered by a local druggist who made it at considerable personal expense. The druggist was, however, charging 10 times what the drug cost to produce. The sick woman’s husband went to everyone he knew to borrow the money, but could only raise about $1,000 – half of the price of the drug. He told the druggist that his wife was dying and asked him to sell it more cheaply or allow him to pay later, but the druggist refused. The man became desperate, broke into the store, and stole the drug for his wife.

Every year, millions of people worldwide die unnecessarily from disease because they are poor. The connection between poverty and lack of access to medicines can seem as simple as the story above, but the underlying causes and the search for viable solutions is highly complex. These include issues of international law, investment in research and development (R&D) overwhelmingly directed at patients in developed countries, and the willingness and capacity of governments to provide adequate treatments for people in poor and often remote parts of the world. Médecins Sans Frontières (MSF) is dedicated to ensuring that access to essential medicines for neglected diseases remains on the agenda of the world’s policy-makers. This edition of Dispatches and the interactive MSF Expo touring Ontario and Quebec this summer both aim to raise awareness of the plight of millions whose access to life-saving drugs is severely restricted by poverty and lack of political will. Years of innovative field work and advocacy are yielding results, however, and MSF has been a driving force behind several recent initiatives, including the World Health Assembly resolution in May 2006 to establish a global plan of action to address the current crisis in R&D. Such potential breakthroughs, however, cannot be considered a solution to the access to medicines crisis. This summer offers an opportunity for instigating even greater change. In August 2006, Toronto will host the XVI International AIDS Conference, bringing together approximately 20,000 participants from around the world. MSF will be there, presenting research and lessons learned, and pushing for more rapid progress. One of the key messages will be the critical role of governments as a driving force for aggressive, needs-based R&D, and MSF will call upon the Canadian government to take up the challenge. The story at the top of this page is actually a hypothetical dilemma designed by a psychologist more than 50 years ago as a tool to examine human morality. Presented with this scenario, the people judged to have reached the highest stage of moral reasoning were those who recognised that a human life has greater value than money or property. As a global society, we have not yet evolved this far, but with your help we are coming closer. Please visit our website at www.msf.ca to learn more about neglected diseases and access to essential medicines, including our message to Prime Minister Stephen Harper about the role the Canadian Government can play in making drugs more accessible to the people who need them.

Ben Chapman - General director (Interim) MSF Canada

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ON MISSION IN CANADA

MSF édecins Sans Frontières’ (MSF) ongoing campaign to improve access to essential medicines for the world’s poorest was, in a sense, a direct result of frustration. Around the world, in country after country, MSF’s doctors were confronted by disease on a mass scale – hundreds or even thousands of patients who needed life-saving treatment – and were hamstrung in their ability to help because diagnostic tools were too old or because the drugs they needed were too expensive. For many, accustomed to the resources available in the health systems of wealthy countries, this was outrageous.

This summer Canadians will have the opportunity to get a small taste of what this experience is like. The MSF Expo is an interactive exhibit touring eight cities across Ontario and Québec, giving Canadians an opportunity to ‘go on mission’ with MSF and confront for themselves some of the world’s most neglected diseases. An anticipated 10,000 visitors to the Expo’s 48-foot trailer will spin a wheel to decide which country they will work in, each with its own distinct challenges. Those on mission in Bolivia, for example, will confront Chagas, a disease virtually unheard of in Canada, but which takes the lives of an estimated 50,000 people each year in Latin America. In Uzbekistan the challenge is tuberculosis (TB), particularly in its multidrug resistant form. Depending primarily on a diagnostic test developed in 1882 and on drugs developed in the 1950s and 60s,

MSF Expo 2006

EXPO 2006 volunteers struggle to provide treatments that are expensive and burdensome for their patients. In countries where the population is already poor, directly observed therapy over six months, or up to two years in the case of multi-drug resistance, can be impractical, even impossible.

At the end of their virtual mission, each visitor will have the opportunity to debrief with MSF staff and volunteers, many of whom have actually confronted these challenges in the field. It is the experiences of MSF field volunteers that have informed the creation of the exhibit, and while the message is often one of frustration, it is equally one of hope. “With good nursing care, treatment of infections, and the introduction of

ARVs [antiretroviral medications], our team had excellent success at bringing a lot of people ‘back to life’ – from being on their death-beds to becoming well enough to lead normal lives after a few months of treatment,” recalls Dr. Peter Saranchuk of his work with AIDS patients in a South African hospice. Last year MSF’s AIDS projects in 29 countries provided treatment to more than 60,000 patients, approximately 3,500 of them children. The MSF Expo will profile four diseases in four different countries, and it is hoped that the exhibition will encourage visitors to learn more, and perhaps even to take action themselves. MSF’s work to improve diagnosis and treatment for neglected

diseases is a multi-pronged effort, aiming to encourage research and development for new diagnostic tools and drugs, more flexible legislation which will allow for better access to lower-cost generic medications, and expanded treatment of neglected diseases in resource-poor and insecure settings. Visitors to the Expo will learn how Canada and individual Canadians can make a difference, including signing a petition to join us in calling upon the Canadian government to do more, and supporting our field workers in their medical work. For more information about the Expo, visit us at www.msf.ca.

EXPO 2006 WILL VISIT THE FOLLOWING CITIES THIS SUMMER:

TORONTO HAMILTON LONDON WINDSOR

QUÉBEC CITY

MONTREAL OTTAWA

SHERBROOKE

Ottawa . . . . . . . . . May 17-28 Hamilton . . . . May 31 - June 4 Windsor . . . . . . . . . June 7-11 London . . . . . . . . . June 14-18 Montreal . . . . June 28 - July 9 Sherbrooke . . . . . . July 12-16 Québec City . . . . . . July 19-23 Toronto . . . . . . . . August 2-18

For exact locations or to learn more about the Expo, visit www.msf.ca

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DNDi

ACCESS

TO ESSENTIAL MEDICINES & DRUGS FOR NEGLECTED DISEASES

very day, worldwide, approximately 35,000 people die from diseases like malaria, tuberculosis, HIV/AIDS and kala azar. It is an enormous toll, yet the issue remains low on the list of international priorities. In 1999, using the media attention and funding awarded with the Nobel Peace Prize, Médecins Sans Frontières (MSF) set out to change this, launching the Campaign for Access to Essential Medicines. This initiative seeks to improve access to affordable medications for the world’s poorest, to lower the prices of existing medicines, to bring abandoned drugs back into production, to stimulate research and development for diseases that primarily affect the poor, and to overcome other barriers to access.

larly with and between developing countries, to share knowledge and stimulate research and development.

The campaign has been marked by significant successes, but there remains an enormous amount of work to be done. AIDS therapy can now cost as little as $165 per patient per year, as compared to more than $10,000 four years ago, for example, but second-line antiretroviral treatment can cost four to 10 times more than first-line treatments, even at discounted prices. In 2003 MSF joined forces with six other organisations to form the Drugs for Neglected Diseases initiative (DNDi), fostering international collaboration, particu-

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Neglected diseases are those which primarily affect people in developing countries and which do not represent a commercially viable market for pharmaceutical companies. While some of these are better-known, like tuberculosis, malaria and HIV/AIDS, others fall well beneath the radar in countries like Canada: human African trypanosomiasis (sleeping sickness), Chagas disease and schistosomiasis, to name but a few. While we hear little about these diseases, the toll that they take internationally is enormous. Each year malaria is estimated to kill between one and two million people, while Chagas claims an estimated 50,000 lives. The challenges of preventing, diagnosing and treating these diseases are enormous. They are prevalent primarily in poor countries with insufficient infrastructure and where highly trained medical personnel are thin on the ground. Victims of these diseases often also suffer from poverty and from stigma associated with their diseases. These enormous barriers are compounded by the lack of options available: tuberculosis diagnosis and treatment tools that are not available for infants, children’s dosages

of HIV/AIDS drugs that must be manually derived with painstaking care from adultsized pills, and treatments for sleeping sickness and kala azar that are dangerous, painful and have not been updated since the 1930s and 40s. For many years, the international community simply refused to acknowledge the scope of the problem. Not only is research and development commercially unpalatable, but diagnostic tools and treatment options are very difficult to implement in resourcepoor and conflict-affected countries. MSF’s pioneering work, particularly with HIV/ AIDS, has shown that this is not only possible, but critical. Treatment affects not only individual health, but also the health of communities that are often crippled by the socio-economic impact of disease. MSF continues to campaign actively for the development of simple, adaptable, affordable tools that can be used to curtail the deadly impact of neglected diseases in the world’s poorest countries.

For more information about the Campaign for Access to Essential Medicines, please visit us at www.accessmed-msf.org.

Chagas

Insufficiencies and the suffering caused by © Juan Carlos Tomasi

nother day of work in Guatemala. We put on our shirts with the little red figure placed strategically over the heart and set off to see our patients, whose average age is 10. These are children who are ill, who will one day be disabled, not because they are missing a limb or are deprived of one of their senses, but because of an insufficiency in their heart: insufficient to work, insufficient to run and, sometimes, insufficient to sustain life. These patients have Chagas disease which, among its numerous long-term complications, will produce a cardiac insufficiency.

Insufficiency begins here even before birth. With luck, the pregnancy will continue to full term and the baby will be born at home, in the insufficiently sanitary conditions of what are called ‘rubbish’ houses: bamboo cane structures covered with dried banana leaves, themselves insufficient to accommodate 10 people. Everything should continue well if the insufficient nutritional state of the mother, based on a diet of corn tortillas and frijoles, allows, but it shouldn’t be forgotten that this mother, whose average age at the time of her first birth is between 14 and 16, could herself already have Chagas, in which case fate has played her hand from the beginning.

CHAGAS In this land, luck is a variable commodity and when it touches someone, it is generally insufficient. Returning to our patient; assuming that he has started life with luck on his side, with no worse problems than insufficient nutrition, hard work from early childhood, insufficient education, and minimal hygiene and health care, he reaches adolescence and will continue to forge his path in a world full of insufficiencies not solely cardiac-related. Further along he will realise that his salary is insufficient to feed his family or buy medicine for him or his children. The production of medicines used to treat Chagas is insufficient because, according to those who produce them, there is an insufficient number of clients with purchasing power. The final straw is that he will have insufficient symptoms for a doctor with insufficient knowledge of the disease to detect it in time, since this illness, Chagas, is insufficiently known not only by doctors, but by the general population. So the lives of these people pass by, full of insufficiencies. It is the perfect breeding ground for diseases like Chagas, tuberculosis, AIDS, and a potentially very

long list of ills that continue to take the lives of the poorest of the poor. The strangest thing of all is that the numbers continue to rise. They make up millions all over the world and nobody with sufficient power to act can find sufficient reasons to put an end to all of this.

Jorge Nyari Medical doctor, Guatemala (Text translated from Spanish)

American trypanosomiasis, or Chagas disease, is caused by insects often found in cracks in the walls and roofs of the mud and straw housing common in poor rural areas and urban slums of Latin America. The bite is rarely visible and there are usually no obvious symptoms during the acute phase, allowing the parasite to multiply in the body for years, even decades. When the chronic phase begins, it is generally already too late for treatment: symptoms such as heart failure can be irreversible, causing gradual illness and resulting in a significant decrease in quality of life and life expectancy.

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HIV/AIDS

treatment for

LIFE © Jonathan Torgovnik

PROVIDING OVER 60,000 PATIENTS WITH LIFE-PROLONGING ANTIRETROVIRAL (ARV) MEDICINES IN 29 COUNTRIES, MSF TEAMS KNOW FIRST-HAND THE

NAIDS reported in December 2005 that some 40 million people worldwide are living with HIV/AIDS. Of the 6.5 million people in developing and transitional countries who urgently need life-saving AIDS drugs, only 1.3 million are receiving them. Despite promises and speeches, not enough is being done to make sure that the drugs needed to increase and sustain treatment are accessible to those who need them to stay alive.

because resistance develops. Today these new drugs are far too expensive. Without some dramatic price reductions, patients risk having vital treatment interrupted because it is priced out of their reach. Research and development on new medicines and diagnostics must be increased dramatically. These are just some of the many barriers to treatment.

SUCCESSFUL OUTCOMES OF TREATMENT OF ADULTS AND CHILDREN IN RESOURCE-POOR SETTINGS. THESE PATIENTS PROVIDE LIVING TESTIMONY THAT IT CAN BE DONE.

Providing over 60,000 patients with lifeprolonging antiretroviral (ARV) medicines in 29 countries, Médecins Sans Frontières (MSF) teams know first-hand the successful outcomes of treatment of adults and children in resource-poor settings. These patients provide living testimony that it can be done. But for how long? Patients will inevitably need second-line drugs after a few years on treatment,

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"95 per cent of our patients are now adhering to their treatment regimens. They know that if they really want to survive, they can." - MSF counsellor Loy Diep in Cambodia, where MSF provides life-extending ARV treatment to more than 5,400 of the 25,000 people in need.

NEW, ADAPTED AND AFFORDABLE MEDICINES NEEDED URGENTLY “If [my pills] are not kept in the refrigerator, after 4 weeks at an average temperature of 45 degrees, this is what you have: a useless blob of melted pills... As sweet as [a new version of the drug Kaletra] may sound, as it does not need refrigeration, it does not exist here. This makes nonsense of the whole effort. If these drugs are not here, a lot of lives will be put in danger.” - Ibrahim U., patient in MSF programme in Lagos, Nigeria Non-refrigerated versions like the one Ibrahim describes are still only available in the United States where, ironically, 99 per cent of the population has a refrigerator.

DEADLY DUO: TUBERCULOSIS AND AIDS CO-INFECTION Tuberculosis (TB) is a common opportunistic infection, and a leading cause of mortality among people with HIV/AIDS. Early TB diagnosis, prompt treatment and access to ARVs are essential to prolong lives. In rural China, a study conducted by MSF showed that one in four HIV-positive persons are diagnosed with active TB. Of these, a considerable proportion are unable to complete

anti-TB treatment, and many die. The most recent drugs for TB are more than 50 years old, and existing diagnostic tools are outdated and inadequate.

with medicines ill-adapted for poor countries, lack of formulations for children with AIDS, lack of infrastructure and inadequate human resources.

"I am sick and tired of watching TB kill my patients. It often feels as though I practice medicine with my hands tied behind my back. Since I have to use a 19th–century diagnostic tool that is wrong more times than not, it is like being blindfolded as well." - Dr. Martha Bedelu, an MSF physician working in South Africa

At the same time, MSF programmes provide results, not least of which is the number of people whose lives have been prolonged. They also provide valuable research data that outlines needs, lessons learned, barriers and successes. Importantly, MSF also bears witness to the effectiveness of treatment in resource-poor settings, and how lives improve drastically when people have the treatment they need.

AIDS SPOTLIGHT IN TORONTO AUGUST 2006: DON’T TURN IT OFF The XVI International AIDS Conference, a major biennial conference on the AIDS pandemic, takes place in Toronto from Aug. 13 to 18, 2006. There is no doubt that people in Canada and around the world will be hearing a lot about AIDS this summer. But the attention and action must be sustained much longer than just one week. MSF teams see the daily reality of AIDS: patients, including children, who will die without treatment but who cannot afford the ARV medicines taken for granted in developed countries. Our doctors grapple

XVI International AIDS Conference

2006

• MSF will share case studies and speak of positive outcomes for adults and children receiving ARV treatment from Cambodia to Cape Town. • MSF will share information on its direct medical care related to AIDS and opportunistic infections and will speak out about obstacles to providing effective assistance for HIV/AIDS and related diseases. • MSF submitted 57 scientific and non-scientific abstracts for the conference from AIDS programmes in over 20 countries. These represent the continuing learning process that is part of MSF’s ongoing efforts to improve HIV/AIDS treatment and care in the developing world. • MSF Canada HIV Consultant Dr. David Tu will make a presentation on Aug. 12 at a pre-conference event: HIV/AIDS, Conflict and Displacement. Dr. Tu will speak about his experience with groundbreaking AIDS treatment in Democratic Republic of Congo. • MSF’s Expo on access to essential medicines tours Québec and Ontario this summer, and will be in Toronto to coincide with the XVI International AIDS Conference.

“I am a mother of two. I have been living with HIV for 11 years now and have been on ARVs for one year, eight months. Living openly with my illness has been like a calling, especially since I am in a professional field. AIDS has been portrayed for poor people only, but we can come out and say, ‘Anyone can get it. People don’t have to die of AIDS.’” - Monique, student and social economist in Kenya

Carol Devine Programme officer

“I can’t believe it. I almost died! I’m so excited. I can do everything now. I am so happy.” - Prudence Radebe. Prudence is one of 40,000 HIVpositive people on ARVs in South Africa, and one of only 4,000 in the Eastern Cape, one of the poorest regions in the country. She has been taking ARVs supplied by MSF for the last 14 months. The BBC has been following her journey as she fights back and proves the effectiveness of treatment at almost any stage.

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Tuberculosis

WITNESSING

WHITE DEATH

• Every year, 2 million people die of TB and 8 million people develop active TB. • One third of the world is currently infected, and 16 million suffer from active TB. • 95 % of TB cases and 98 % of TB deaths occur in poor countries. The epidemic is expected to worsen in the next few years, especially in Africa and Southeast Asia. • Every year over 1.5 million people acquire active TB in sub-Saharan Africa. This number is rising rapidly as a result of the HIV/AIDS epidemic: TB is an opportunistic disease that preys on HIV-positive people whose immune systems are weakened. • TB is a leading cause of death among people with AIDS, and in some regions of Africa, threequarters of TB patients are HIV-infected. • TB spreads through the air and is highly contagious. On average, a person with infectious TB infects 10-15 others every year.

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IN UZBEKISTAN hey lay there, eight women in eight chipped metal beds, four against each wall, in the small shabby hospital room. Each was serving a term of six to nine months strapped in the vice-like plaster cast that was their treatment shell for the spinal tuberculosis (TB) they were all judged to have. No stimulation, no reprieve in the long days and only one family member there to attend to their needs and cook their meagre meals. On other wards in this post-Soviet hospital, deprived of basic amenities and essential medicines, 250 patients wandered the corridors and the grounds like ghosts searching for the life that was slowly and cruelly escaping them. Each would be there a minimum of nine months; many for years.

This is part of the picture that stays in my mind of my time volunteering as a medical doctor for MĂŠdecins Sans FrontiĂ¨res (MSF) in a tuberculosis project in Uzbekistan. Tuberculosis, the white death, continues to ravage this deprived, almost destitute region of Central Asia. This once prosperous area, where fish from the Aral Sea fed thousands of starving Russians during the famine after the First World War, has been dried out and cast aside now, after 80 years of over-extended cotton cultivation under an irrigation system that has deprived the sea of its life-giving water. The sea is now shallow, highly saline, dead and a fraction of its former size. The port town of Muynak is over 100 kilometres from the shore as it recedes. This is the Aral region of Uzbekistan and Turkmenistan where MSF arrived in 1997, identified tuberculosis as a significant cause of morbidity and mortality,

and started a tuberculosis diagnosis and treatment programme. Utilizing the World Health Organization (WHO) treatment protocol for TB, know as Directly Observed Treatment Short Course (DOTS), MSF started from scratch, set up diagnostic labs, established treatment procedures, arranged appropriate drugs, provided extensive training and documented failures and successes. Other than the crumbling physical structures there was very little to work with. Ministry of Health staff was irregularly paid and working with outdated equipment and unproven treatments. Many were suspicious and disdainful of the MSF programme and the usurpers that championed it. Over time and through example, however, the programme made headway. Diagnostics improved, regular treatment with appropriate drugs replaced interrupted treatments with inappropriate drugs, and hospital stays were confined to the infectious period only. Community treatment replaced extensive institutional confinement for the non-infectious and most Ministry staff steadily accepted the new approach. MSF continues to work in this forgotten region along the ancient silk route but has modified the programme to now concentrate on working with Ministry of Health staff in identifying and treating the most difficult and complicated cases of the white death: multi-drug resistant tuberculosis (MDR TB). It has identified shortfalls in the DOTS programme, made these known to WHO and is one of the few international medical organisations that has

embarked on developing a treatment model for MDR TB. MSF is learning once again as it moves forward. Tuberculosis has received little attention in laboratories and medical research centres since it largely made an exit from the Western world thanks to improved hygiene and living conditions, as well as the discovery of the wonder drug Rifampicin in the 1960s. The WHO had even predicted that TB would be no more after the year 2050. Unfortunately, unless improved medicines are discovered that are cheap, work over a shorter time and can be administered as one or two pills a day, there is little likelihood that tuberculosis will be consigned to history. Many of the old front line drugs, including Rifampicin, have developed resistance. Alternative drugs are very costly, highly toxic and require extensive usage to be hopeful of any effect against MDR TB. Without new efforts in research and development to address these concerns, the white death will be with us well into the future. A further frightening and complicating factor to reducing the prevalence of tuberculosis is the role this disease has as a co-infection with HIV/AIDS. With the global spread of HIV/AIDS, tuberculosis got a new lease on life as a principal opportunistic infection with this scourge. Riding on the coat tails of HIV/AIDS has multiplied its spread and it is now seen again in regions of the world where it had been almost forgotten.

Douglas Kittle Medical doctor

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Letter from the field

COMMUNITY-BASED

malaria treatment alaria is by far the biggest life-threatening disease in the Chittagong Hill Tracts of Bangladesh. Most tribal populations in the country live in the Hill Tracts and have poor access to health-care services. Many community leaders report the death of one or two people with fever each month.

In the absence of proper clinical assessments and diagnostic tests, people in many communities in Bangladesh receive ineffective treatment from poorly regulated drug distribution, often with no physician consultation. When I first arrived at the malaria programme in the Chittagong Hill Tracts with Médecins Sans Frontières (MSF), I was conflicted in my ideals about how to support existing traditional beliefs about illness while ensuring a modern, aggressive implementation of Western medicine in treating malaria.

MALARIA KILLS BETWEEN 1 AND 2 MILLION PEOPLE EVERY YEAR, ITS HIGHEST TOLL AMONG THE MOST VULNERABLE: YOUNG CHILDREN IN REMOTE RURAL AREAS, PREGNANT WOMEN, AND REFUGEES OR DISPLACED PERSONS.

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Accessing some communities involves driving on rough, steep roads for an hour, then hiking, climbing, and wading through water for an additional hour or two. Although I was thrilled to be hiking through such a beautiful jungle, I could not help but think how difficult it would be to transport a seriously ill community member to a health-care facility. Upon arrival in a village of 40 families, the outreach supervisor introduced me to the malaria field site worker. The malaria field site worker is a community member trained by MSF to assess and treat falciparum malaria, the parasite responsible for the majority of malaria infections and the most lethal. This person is part of MSF’s malaria field site programme, which travels to remote locations for education, assessment and treatment. The village I visited that day consisted of buildings made entirely of resources from the land; the community truly appeared to be self-sustaining. The people were full of energy and everyone seemed to have a role. Men and women were decorated in flowers, make-up, and jewellery. After a brief introduction to the area, the community members gathered for the health education presentation by an MSF outreach worker. Before the presentation, a woman with a fever presented herself to the malaria field

site worker. The malaria field site worker is able to diagnose falciparum malaria using a paracheck, a single-use slide that reacts to a single drop of infected blood. If the paracheck indicates that the patient has falciparum malaria, the field site worker can treat the patient with appropriate doses of Coartem, an artemisinin-based combination therapy increasingly used to treat malaria. In this case the woman withdrew from the assessment when she saw the finger prick needle used to extract the blood. Sheepishly she stood away from the malaria field site worker. The children and some other people in the community began clapping their hands and singing a teasing song, until the woman became amused and agreed to have a paracheck done. The same woman then helped the malaria field site worker ensure that other people with fever got tested as well, providing a reassuring message about the process to the community. All of this was evidence that this community approved and encouraged the life-saving malaria field programme. In my opinion, when treating malaria in communities that are difficult to access, community involvement is crucial. Kevin Barlow Registered nurse Bandarban, Bangladesh

Malaria

EFFECTIVE DRUGS MUST

reach patients

(ACT) is the quickest and most reliable way of clearing malaria infection, and it is very well tolerated. Using a combination of drugs shortens the treatment course, and has been shown to protect each individual drug from resistance.

In 2005, MSF treated approximately 1.8 million malaria patients in 40 countries in Africa, Asia and Latin America. MSF has been advocating for ACTs since 2001 and uses them consistently in its programmes worldwide.

Scientists now agree that the most effective treatment for malaria is a combination of drugs using artemisinin derivatives, highly potent extracts of the Chinese plant Artemesia annua. Artemisinin-based combination therapy

The World Health Organization (WHO) is now actively encouraging malariaendemic countries to switch to ACT. Overall, 40 countries in the world have included ACT in their malaria treatment protocols and a further 14 are considering doing so. However, of these, over 70 per cent are either not applying the policy at all, or are implementing it very slowly. This is due to a combination of obstacles, including lack of political will and financial and human resources; lack

hloroquine, one of the most common antimalarial drugs, was developed in 1934. It represented the ideal drug: effective, very cheap to produce (approximately 20 cents per treatment), and easy to administer. But after 60 years of use, its effectiveness has decreased dramatically due to growing drug resistance.

of training for health workers and the resulting poor recognition of the benefits of ACTs among the communities; shortages of ACTs of assured quality; the fact that health workers do not have access to rapid diagnostic tests; and poor access to health care in general. So malaria, a curable disease, continues to kill a child every 30 seconds. “Without rapid steps to ensure that effective drugs actually reach the people who need them, governments’ decisions remain virtual and end up having no meaning for those who were supposed to benefit from them,” says Dr. Karim Laouabdia, director of MSF’s Campaign for Access to Essential Medicines. “Giving patients chloroquine against malaria is about as effective as giving them a bag of sugar - medically and ethically, it is just wrong. We know implementing ACTs is no easy task, but no one should be allowed to drag their feet in making sure these life-saving drugs get to all those who need them.”

MALARIA KILLS ONE AFRICAN CHILD EVERY 30 SECONDS AND IS THE LEADING CAUSE OF DEATH FOR CHILDREN UNDER FIVE YEARS OF AGE.

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HIV/TB co-infection

THE NEW TUBERCULOSIS magine you haven’t been feeling well for weeks. You’ve been coughing, and wake up during the night sweating so much the sheets are soaked. You don’t feel like eating and have lost five kilograms.

Your spouse died a few years earlier from tuberculosis (TB), so a family member recommends that you go to the local clinic for a test. You give the nurse there two sputum samples, and are told to come back in two weeks for test results. The local laboratory uses the conventional test to diagnose TB, examining sputum

To prevent unnecessary death around the world, MSF demands that all HIV-positive children and adults are given access to: • quicker and more accurate tests for TB • newer and better TB medications, with fewer side effects • less cumbersome ways of receiving TB treatment than directlyobserved treatment, especially since the risk of developing multidrug resistant TB is increased if treatment is interrupted

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samples under a microscope to find TB germs. In your case, they can’t find any, so your samples are reported as negative. At your follow-up clinic appointment, you are told that you don’t have TB. But you are feeling worse: the cough is no better, you’ve lost another five kilograms, and you have never felt so tired. What is going on? You are, in fact, a victim of the new era of TB, a consequence of the HIV pandemic. Your spouse unknowingly passed on HIV to you, and the virus has gradually weakened your immune system. Despite what the clinic nurse told you, you are suffering from tuberculosis of the lungs; the TB germs are multiplying inside your lungs and are causing the cough, night sweats and weight loss. But the test traditionally used to diagnose TB (microscopy) no longer works in the majority of people who are co-infected with both HIV and TB. There are two ways this scenario can go now: 1. You have some money saved, and you use it to see a private doctor who sends you for a chest X-ray. The doctor sees evidence of tuberculosis and refers you to the TB clinic to start treatment. The good news is that you gradually start to feel better: the night sweats are gone, your

cough and appetite improve, and you start to regain weight. The bad news is that the TB treatment lasts six months, and the clinic insists on “directlyobserved treatment” (DOTS), which means you have to go in person every day, without exception, to receive the medication. As a result, you have to stop working for six months. You are poorer in six months, but at least the TB has been cured. Then your private doctor tells you that you need antiretrovirals (ARVs) to improve your weakened immune system (a result of HIV), and prevent further life-threatening infections. You can’t afford the ARVs and go on to suffer from repeated infections until you eventually die from a brain infection the following year. 2. You don’t have any money to see a private doctor or get an X-ray. The doctor who used to work in the public clinic has left to work in a Western country, and they haven’t been able to find a replacement. You see the clinic nurse again, who gives you some vitamins and a week’s worth of antibiotics. But these do not help. You gradually get sicker as the TB germs multiply and spread inside your body. You start to vomit regularly

and lose more weight. You soon become bed-ridden and your children do their best to make you comfortable at home. You die later that month from undiagnosed TB, simply because there was no quick and accurate test available to diagnose TB in HIV-positive people. Your four children are now orphans. This last scenario in particular is not unusual; it takes place over and over again in every community around the world where HIV prevalence is high. Countless people are dying from tuberculosis of the lungs (pulmonary TB) simply because the traditional test is not accurate in HIV-positive people. To make matters worse, the HIV pandemic has also resulted in tuberculosis occurring more often outside of the lungs (extra-pulmonary TB). Weakened immune systems allow the TB germ to cause disease in almost any part of the body: the brain (meningitis), the lymph nodes, the lining

around the heart, the breast, the abdomen, the bone marrow, joints, and so on. Extrapulmonary TB is also often difficult to diagnose, and a common cause of death in HIVpositive adults and children. Fortunately, there is some progress being made in the fight against TB. Médecins Sans Frontières has created an integrated HIV-TB clinic in Khayelitsha, South Africa, where different strategies are being used to correctly diagnose both pulmonary and extra-pulmonary TB earlier in both children and adults, thereby preventing unnecessary death from TB in many HIV patients. In addition, all TB patients are encouraged to be tested for HIV. If positive, they are given access to comprehensive HIV care, preventing death from other serious infections to which they are vulnerable.

Peter Saranchuk Medical doctor Khayelitsha, South Africa

Why HIV and TB together are

‘double-trouble’

In communities where HIV and TB are prevalent: • over 10 % of HIV patients develop TB each year, whereas HIV-negative people have a 5-10 % lifetime risk of developing active TB, following exposure to the TB germ • the traditional test for pulmonary TB (microscopy) is inaccurate in the majority of HIV-infected people, so correct diagnosis of active TB is delayed (or worse yet, never made). As a result, TB is the most common infection causing death in HIV-infected people. • the number of TB cases continues to rise every year, as the HIV pandemic spreads

TB IN THE ERA OF HIV

page 13

Profile

Peter Saranchuk, MD “I WANT TO DO SOMETHING TO HELP REDUCE THE ENORMOUS DISPARITY BETWEEN COUNTRIES IN THIS WORLD.”

fter 10 years working in family practices and emergency departments across Canada, Peter Saranchuk went on his first mission with Médecins Sans Frontières (MSF) in 2002. Here he reflects upon what brought him to the work and his experiences in the field.

How did you come to work with MSF? I became interested in the medical problems that kill millions of people around the world early in their lives, but which we rarely see in Canada. The more I thought about this disparity, the more it bothered me. I studied malaria, tuberculosis, and HIV at the London School of Hygiene and Tropical Medicine. I realised that I wasn't going to have total professional satisfaction until I did some international medical work. MSF had a good reputation, and I finally took the plunge and applied. What has your experience been like? I first worked in Democratic Republic of Congo, a country suffering from the ravages of chronic conflict. MSF’s project showed that comprehensive HIV care can be successful even in such settings. I suffered a bit of culture shock upon arriving. I wasn't prepared for the restrictions required by the constant threat of conflict. I also had difficulty with the language barrier: we usually had to translate from English into French, then French into Swahili (and back again!) when seeing patients.

Interested in working overseas with MSF? Visit www.msf.ca to learn more.

Dispatches Vol.8, Ed.2

My mission in South Africa was a perfect fit, so rewarding that I stayed two years. I worked with local nurses and doctors in an HIV clinic, seeing thousands of children and young adults suffering from infections (especially tuberculosis) as a result of immune systems weakened by HIV. We successfully treated most of these infections, then provided antiretroviral medication,

preventing death from further infections. The most striking thing was proving to the locals that people did not have to die from the disease. Five years ago in this same community, AIDS hospices were places where young adults and children went to die. Now, they are places of hope. What would you say to people thinking of working with MSF? If you are interested, just do it. Your television, car, money, and work opportunities will be here when you back! You will be challenged to do things you might not have had the opportunity to do in Canada – manage others, educate large numbers of people, stand up and give lectures, or even do operational research in your project to benefit your patients. I have had some of the best moments of my life in Africa: from being the only muzungu (white person) on the MSF football team playing on a lush hilltop in the Congo, to being overwhelmed by the sound of simple traditional music, to having the opportunity to camp in the Kalahari desert amongst the wildlife. I plan to continue to working with MSF because of the challenges and rewards. I enjoy travelling and experiencing other cultures – and working in a country's healthcare system is a fantastic way to experience their culture! Most of all, I want to do something to help reduce the enormous disparity between countries in this world.

CANADIANS ON ANGOLA

COLOMBIA

Anne Henderson

Tyler Fainstat Darryl Stellmach

ARMENIA Robert Parker

DEMOCRATIC REPUBLIC OF CONGO

BURUNDI

Nathalie Belleau Erwan Cheneval Stéphanie Ferland André Fortin Jean-François Harvey Thomas Kelley Dolores Ladouceur Michael Lewis Judy MacConnery Frédéric Manseau John Paul Morgan André Munger Ivik Olek Alexis Porter Marlene Power Dominique Proteau Leslie Shanks James Squier Julienne Turcotte Fred Wiegand

Francine Bélisle Michel Dumont Pierre Labranche Catherine Mason Richard Poitras Diane Rachiele Raghu Vengupal

CAMBODIA Nicole Tanguay

CENTRAL AFRICAN REPUBLIC Noah Bernstein Geneviève Côté Ivan Gayton Sherri Grady Pierre Kronstrom Mélanie Marcotte Jean-François Nouveaux

CHAD Christine Bonneau Maryse Bonnel Annie Desilets Mike Fark Mario Fortin Michelle Lahey Marie-Claude Lemay Paul N’guyen Omar Odeh Gislaine Télémaque Benoît Wullens

CHINA Michelle Chouinard Yvan Marquis

MISSION

Vincent Échavé Hélène Lessard Jean-Pierre Pagé Elaine Sansoucy Arun Sharma

KENYA Sylvain Groulx

LIBERIA Brian Baker Patricia Gould Patrick Laurent Miguel Mendoza Allana Shwetz Hidi Ullah

MYANMAR Vinay Jindal

NEPAL Katja Mogensen

NIGERIA Stephanie Gee Michel Lacharité John Pringle

ETHIOPIA

PAKISTAN

Isabelle Aubry Jaroslava Belava

Ian Adair Justin Armstrong Joe Belliveau David Croft Cara Kosack Thierry Petry

INDIA Karen Abbs

INDONESIA Asha Gervan

PAPUA NEW GUINEA Adam Childs

IRAN Magdalena Gonzalez

SIERRA LEONE Concetta Buonaiuto

SOMALIA Reshma Adatia Violet Baron Lindsay Bryson Sylvain Deslippes Naomi Fecteau Megan Hunter Tabata Malo David Michalski

SUDAN Lori Beaulieu Indu Gambhir Joni Guptill Caroline Khoubesserian Evelyn Lam Tiffany Moore Julia Payson Luella Smith Sheila Stam Susie Tector Danielle Trépanier Vanessa Van Schoor

UGANDA Eileen Skinnider Heather Thompson Claude Trépanier

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: Clea Kahn Editorial directors: Laurence Hughes linda o. nagy Copy Editors: Dominique Desrochers Jennifer Hoff Gregory Vandendaelen

Contributors: Kevin Barlow, Carol Devine, Clea Kahn, Douglas Kittle, Jorge Nyari, Peter Saranchuk

Circulation: 95,000 Layout: Artshouse Communications Inc. Printing: Warren's Imaging and Dryography

Summer 2006

UZBEKISTAN Michelle Tubman

ZAMBIA PERU Yanik Delvigne

IVORY COAST Andrea Boysen Denise Chouinard Kevin Coppock Steve Dennis

Pikka Lam Grace Tang Martine Vézina

REPUBLIC OF CONGO Brenda Holoboff Jessika Huard Kurt Jansen

Farah Ali Paulo Rottman Chris Warren Vanessa Wright

ZIMBABWE Joel Melanson

Cover photo: Pep Bonet ISSN 1484-9372

page 15

LEAVING A LEGACY OF HOPE ne of the great privileges of working with Médecins Sans Frontières (MSF) is being able to see the direct link between the compassion of our supporters and the life-saving work that takes place every day in the field.

MSF depends on the support of large numbers of people around the world who share our concern for those whose humanity and dignity is threatened by conflict, disaster or disease. This support is expressed not only through financial contributions, but also by helping us speak out on behalf of people whose voices are often not heard. In talking with Canadians, I am constantly

moved by their enormous compassion and their desire to reach out to those in need, no matter how distant or remote their plight may seem. Today, many of our MSF reach out to others with a as a beneficiary in your another basic necessity of

supporters are choosing to legacy gift. By naming MSF will, you continue to offer life: hope.

Nancy Forgrave Director of fundraising

Just a few words in your will...

For information about making a gift in your will to Médecins Sans Frontières, please use the enclosed envelope or contact:

Nancy Forgrave Director of fundraising (416) 642-3466 / 1 800 982-7903 nforgrave@msf.ca