Dispatches (Summer 2007) by Doctors Without Borders / Médecins Sans Frontières (MSF) Canada

Vol.9, Ed.2

Dispatches MSF

CANADA

NEWSLETTER

Emergency care for pregnant women

“There’s no happiness in this place”

Battling cholera in the Republic of the Congo

Field blog: “Suddenly…Sudan”

Impossible choices: The harsh reality of humanitarian aid

Working late in Somalia

Canada’s Access to Medicines Regime not working

Book review: Inspiration to act

IN THIS ISSUE

HAITI

EMERGENCY CARE FOR PREGNANT WOMEN

aiti has the grim distinction of being the poorest country in the western hemisphere, with the highest level of maternal mortality. This may be difficult to believe, considering that it is only four hours flight from Montreal. Today, Haitians suffer the consequences of systemic and insidious violence. Pregnant women are among the most vulnerable victims.

AN UNFORGIVING ENVIRONMENT Despite successful elections in 2006 and the presence of a UN stabilisation mission, Haiti continued to experience regular outbursts of violence:

kidnappings, rape, organised crime and shootouts between armed groups and UN forces. In this context of severe political and social instability, MSF opened an emergency obstetric care hospital in the Haitian capital, Port-au-Prince, in March 2006. MSF’s Jude Anne Hospital serves women who have little access to health care, who live in the poorest neighbourhoods of the city and are thus most at risk of violence. Pregnant women living in the slums of Port-auPrince are exposed to violence on a daily basis. An expectant mother from the Cité Soleil slum could be sexually assaulted by a family member, (continued on page 2)

1999 Nobel Peace Prize Laureate

Haiti

a neighbour or a gang member. She might get caught in the crossfire of a conflict between armed groups, or she might experience psychological trauma due to the violence. Because she lives in a gangcontrolled slum, she could be ostracised by people from other parts of Port-auPrince who fear that she is associated with the gang. Perhaps the sole caregiver for her children, she struggles against the increased vulnerability that comes with extreme poverty. She is systematically forgotten by her society and the international community. These women have very little choice, if any, when they seek healthcare. The healthcare system in Haiti is accessible only to those who can afford it and thus remains out of reach to women living in the poor areas of the city. Medical services in public hospitals are too expensive for the majority of expectant mothers. Should a baby be born by normal delivery, the mother would have to pay a $13 fee at a public hospital – six times the average daily salary of a working Haitian, and

Dispatches Vol.9, Ed.2

completely unaffordable for an unemployed mother. For women in the slums, the alternative to seeking hospital care is to give birth at home, perhaps with the help of a matronne (a local untrained midwife) using traditional medicine, which could increase the chances of complications at birth. “Despite promises made to the population that international funds would flood the country, the reality is that women’s situations continue to remain the same. MSF gives these women a chance to access free emergency obstetric care,” explains Colette Gadenne, MSF head of mission in Haiti.

MSF OPENS AN EMERGENCY OBSTETRIC CARE HOSPITAL When Jude Anne Hospital opened in March 2006, MSF projected that it would handle 300 births a month. In September of that year, hospital teams delivered 1,300 babies, about one every half-hour. This unexpected surge in births led to creative infrastructure planning, such as

the construction of a triage area in the hospital parking lot. Most importantly, the surge (accounting for one-fifth of total births in Port-au-Prince that month) drew attention to Haitian women’s desperate need for free, quality maternal care. The medical teams at the hospital, composed mainly of Haitian staff, felt overwhelmed at times by the sheer number of births. The most difficult part of their work is being unable to save the lives of babies, even mothers, who arrive at the hospital too late. Many maternal deaths are caused by eclampsia: an increase in blood pressure that leads to convulsions and the sudden death of both the mother and her unborn baby. When eclampsia is caught in time, the mother and child can survive if the baby is delivered by caesarean section. In June 2006, MSF started a programme to help prevent the transmission of HIV/AIDS from mother to child at birth by testing women for HIV and transferring them to a hospital that will provide medicine to protect the unborn baby. MSF also

offers psychosocial counselling to women and antenatal/postnatal care. To identify pregnant mothers who are potentially at risk, a team of outreach workers regularly visits the slums of Portau-Prince. They teach expectant mothers how to look for signs, such as bleeding or unusual headaches, that might require emergency care. They sing songs in Creole and play games to communicate their message to attentive audiences. A mobile MSF clinic also visits the slums to offer antenatal care to expectant mothers in their own neighbourhoods.

These figures clearly indicate a massive and ongoing need for emergency obstetric care for women living in the slums of Port-au-Prince. Throughout 2007, MSF will lobby the government of Haiti and the international community to prioritise the needs of pregnant mothers, and to provide them with the maternal care they require. To find out more about MSF’s activities in Haiti, please visit our website at www.msf.ca, and click on Countries.

Isabelle Jeanson Communications advisor

Since opening the Jude Anne Hospital, MSF has delivered over 10,000 babies.

Photographer Julie Rémy traveled to Haiti in May 2007 to document MSF’s work in the country. These are the stories of two pregnant women she met there.

JEANISE When I walked into the delivery room and met Jeanise, 38, she was so thin that I found it hard to believe she was about to give birth. I was even more incredulous to learn that she was having twins.

Jeanise was admitted to Jude Anne Hospital because she had a history of hypertension, which can lead to potentially fatal eclampsia. She was also there because this was her sixth pregnancy (and her second set of twins). Though I could see the pain on her face, she didn’t complain. She gave birth to two tiny girls, each less than 2 kg. The newborn sisters clung to each other as the nurses cleaned them. Jeanise seemed happy.

A few minutes after delivering she walked to a bed in the recovery area, in order to make room for the next labouring mother. Malnourished, with few resources and six other children, I wondered how Jeanise would feed these two new mouths.

NERLANDE We met Nerlande while on an outreach visit to the La Saline slum with the MSF Information, Education and Communication (IEC) Team. The pregnant 13-year-old girl was in great pain, and had tears rolling down her face.

impatient for her to give birth so she could get some relief. Her young hips were too narrow and she was too weak to deliver naturally, so doctors finally decided to perform a cesarean section. She gave birth to a beautiful 2.2 kg girl. © Julie Rémy

Her contractions had started the previous night and she felt ready to give birth, but had no money to pay for transportation and was scared to go to the hospital for the first time in her life. The IEC team quickly called a driver to take her to Jude Anne. At the hospital she was diagnosed with pre-eclampsia. The doctors judged that she would probably have lost her baby or died if we had not found her. Nerlande suffered through two and a half long days of labour surrounded by screaming women and throbbing generators. Most of the time she lay on a hard wooden bench at the hospital entrance because there was no bed available inside. I was

After two days resting in the post-delivery ward with other new mothers, she went home. She returned a few days later for treatment when her incision became infected, due to the unsanitary conditions in La Saline.

page 3

Bangladesh

“THERE’S NO HAPPINESS IN THIS PLACE” n 1992, more than 250,000 Rohingya Muslims fled from Northern Rakhine State, Myanmar, to Bangladesh. They were pushed off their land by discrimination, violence and the forced labour practices of the Myanmar authorities. Over the years, most of the Rohingyas returned to Myanmar while others have continued to come to Bangladesh.

On the Bangladeshi side of the border, more than 26,000 Rohingya refugees who refused to go back to Myanmar live in the two official camps of Kutupalong and Nayapara, south of Cox’s Bazaar. An unknown number of Rohingyas live in the Teknaf area, near the Myanmar border. Over 7,500 refugees live in the squalid, makeshift Tal camp and around 2,200 inhabit the beach area of Shamlapur. A minority of the Rohingyas have managed to integrate into Bangladeshi society. Some of these people have returned after being repatriated to Myanmar. MSF began serving the Rohingyas in Bangladesh at the time of their mass exodus from Myanmar 15 years ago, providing a wide range of basic healthcare services in

Dispatches Vol.9, Ed.2

the refugee camps. It left the region in 2003 but re-started activities last year.

FROM BAD… Rohingyas who were registered at the time of the big influx in 1992, and who have since been living in the official refugee camps, have access to food rations, basic healthcare and some education. In April 2007, MSF opened two 20-bed inpatient units in the Kutupalong and Nayapara camps. Over their first two months of operation, these facilities have admitted 650 patients. The MSF team is preparing to open birthing units in each of the camps. Although these Rohingyas are better off than the unregistered refugees, their lives are confined within the camps’ fences. They depend on aid and cannot work outside the camps. Their future looks bleak. R. is a 17-year-old mother. She was only two when she arrived at Kutapalong Camp and has lived there ever since. She doesn’t know anything of the world outside the camp. R. came with her mother, brothers

and grandparents, but her mother had to go back to Myanmar, her brother left after having problems with camp authorities, and her grandparents died. She is married but her husband is in hiding because he isn’t registered in the camp. “I haven’t seen him in more than five months,” she said. “I want to stay in Bangladesh but outside the camp. There is no happiness in this place.”

…TO WORSE For unregistered Rohingya refugees scattered across the Teknaf region, life is even harder. They survive by doing hard work for little money and must constantly fight for access to basic needs like food, water and healthcare. Tal camp consists of small ramshackle shelters situated between the river Naf and the highway leading to the city of Cox’s Bazaar. More than 7,500 Rohingya men, women and children have sought refuge here, on a stretch of land 800 metres long and 30 metres wide. Food and potable water are scarce and access to local healthcare facilities is limited.

In April 2006 MSF assessed the makeshift camp and found worrying health indicators among the residents as a result of squalid living conditions. Significant health problems include diarrhoea, respiratory infections and malnutrition. In May, MSF opened a clinic and a therapeutic feeding centre near the makeshift camp. By the end of the year, on an average day, the clinic performed over 140 consultations. Over that period, the feeding centre served a total of 665 children. J. came to the MSF clinic with her two premature twins. She is only 18 years old and got married eight months ago, but her husband later left her. He already had another wife and refused to look after J. and her babies. In March, she was evicted from her shelter by the authorities because it was located too close to the road. Now she lives with her mother. They survive by begging.

LIVING WHERE THEY LANDED

had,” she said. “Here we live on fishing. Everything we fish is taken by the boat owner and we get paid depending on how much we fish.” On average, there are about 10 fishing days each month, except during the three months of the rainy season, from June to August, when it is almost impossible to fish. Consequently their income is not enough to adequately sustain a family of ten. However these are the same problems confronted by many Bangladeshis. At least here the Rohingyas do not fear for their lives. “If I go back [to Myanmar] after all this time, they will put me in jail or shoot me,” she added, “here at least they do not say anything.”

Bangladesh. Long ago, some of them came and started businesses in the Chittagong region, north of Teknaf. The Rohingyas are Muslims like the majority of the Bangladeshi people and their language is not very different from the dialects spoken in the eastern region of Bangladesh. Today, however, they are facing great difficulties in integrating into Bangladeshi society. Since 1994, they are no longer recognised as refugees and they face discrimination and exploitation. Their living conditions, both in Tal camp and at Shamlapur beach, are appalling and yet they have continued to come for the past 15 years, leaving their land behind. If Tal camp is where they prefer to be, one can only wonder what it is like on the other side of the border.

BEYOND THAT BORDER The Rohingyas have a long history of crossing the border between Myanmar and

Elena Torta Communications advisor

Some Rohingyas never moved from the beach area where they landed with their boats after fleeing Myanamar. They live on the long beach of Shamlapur, where fishing is their only source of livelihood. They work for Bangladeshi boat owners and are paid little. MSF runs a weekly mobile clinic at Shamlapur beach, which provides healthcare and health education to the Rohingya refugees living here. Respiratory and skin infections are the most common ailments. Due to bandit activity on the roads, the team has to drive for an hour along the beach in order to reach the clinic, and coordinates its travel schedule according to the tides. Once there, they operate out of a converted storeroom partitioned with plastic sheeting. A neighbouring shop veranda serves as a patient waiting room.

N. came from Myanmar 14 years ago. Since then she has lived on the beach with ten members of her family: four daughters, two sons and their wives and children. Her husband died six years ago. “We came to Bangladesh because the Burmese army took our land, our cows and everything we

page 5

Republic of the Congo

Battling

Cholera Katja Mogensen is a registered nurse from Canmore, Alberta. She spent two months working with MSF in the Republic of the Congo in 2007.

An MSF emergency team arrived at the end of January, as the situation became critical. Over 1,000 cases of cholera had been reported between November and January, with more than 40 deaths.

ases of suspected cholera first occurred at the end of November 2006 in Pointe-Noire, on the coast of Republic of the Congo. Although there was laboratory confirmation in mid-December, the outbreak wasn’t publicly announced until January. Governments are often reluctant to announce cholera outbreaks due to the negative impact they can have on trade and travel.

The team opened four cholera treatment centres (CTCs) at local hospitals and health centres, setting up tents to provide additional capacity. MSF hired local nurses and doctors and trained them in recognising the signs of the disease and MSF protocols. Working alongside colleagues from the Ministry of Health, they dealt with more than 200 patients a day between all the centres.

MSF has been working in the Pool area east of Pointe-Noire for several years, providing healthcare services to populations affected by violent conflicts in the region. This facilitated collaboration with the Congolese Ministry of Health.

In a CTC, patients are divided into three classes – A, B and C – according to the severity of dehydration, C being the most severe. Triage is very important to ensure quick hydration for those who need it most.

Dispatches Vol.9, Ed.2

Patients with severe cases are given beds with holes in them so they don’t have to get up, as diarrhoea is almost constant. The treatment is rapid rehydration using intravenous solutions. A severely ill patient may require 8 to 16 litres of IV fluids per day. Antibiotics are only administered in severe cases. One of the main functions of a treatment centre is to contain the disease, as it is highly contagious. A specially-trained hygiene team uses chlorine solutions to wash hands and footwear, and to decontaminate stools, vomit, clothes, floors and walls. Patients’ bodies and their clothes are washed with solution when they enter the CTC. When a patient is hospitalised, the hygienists must go to his house to disinfect the outside and inside of the residence as well as the latrines.

When the government publicly announced the cholera outbreak, national and local crisis committees were established. Their main task was to educate the population and prevent the spread of the disease, using pamphlets and messages on radio and television. Cholera is called the disease of dirty hands, as it can be spread by failing to wash one’s hands after using the toilet. As a result there is a stigma attached to cholera, while people’s knowledge of it may be limited, leading to fear and ostracism of cholera patients even among local medical personnel. MSF mobile teams, composed of hygienists and nurses, delivered information about cholera and the precautions necessary to prevent infection at schools, markets and health centres around the city.

The teams would see patients suffering from diarrhoea and offer them oral rehydration salts in clean water. In many areas residents do not have access to clean water; in others, one tap may be shared by hundreds of people. Latrines are often built too close to one another, leading to contamination of water sources.

intravenous solutions, chlorine and other medical supplies as needed until the government decides to close the centres.

By the end of January, cholera had also spread to the capital, Brazzaville. MSF and the Ministry of Health set up a CTC at the main hospital and offered outreach services to the local population. New cholera cases in Brazzaville rose to about 45 per week but never reached the same levels as in Pointe-Noire. In April 2007, as the level of new cases declined, MSF handed over the CTCs in Pointe-Noire and Brazzaville to the Ministry of Health. MSF will continue donating

Katja Mogensen Registered nurse Brazzaville, Republic of the Congo

*The Republic of the Congo is often referred to as Congo-Brazzaville, after the country’s capital city, in order to distinguish it from its much larger southern neighbour, the Democratic Republic of the Congo.

page 7

Sudan

“SUDDENLY...SUDAN” BLOGGING FROM A RURAL OUTPOST IN ABYEI The following is an entry from “Suddenly... Sudan,” Dr. James Maskalyk’s blog (a kind of Internet diary). Dr. Maskalyk is an emergency physician in Toronto. He wrote his entries late at night from his tukul (a simple hut made from mud and grass) in Abyei, Sudan. Dr. Maskalyk worked with MSF in Abyei for six months in 2007.

with the change in weather, so too our moods. we are grateful for any texture in our days, even more for the respite from the heat, a chance to lie in our beds and listen to the soft patter of rain on our grass roofs. the rainy season has been slow to come this year. we wake up each morning and with all of abyei, scan the horizon for clouds.

24 May 2007: “crowds of clouds”

the atmosphere is different on the ground too, in town. tense. waiting for the change, for the sky to fall. there was a fight this afternoon, and someone was stabbed. i was in the hospital when it happened. i left the operating theatre, and found a crowd of people outside of the emergency room, huddling around its closed steel door. every so often it would open, a nurse or doctor would enter or leave, and close the door behind them. “what’s going on?” i asked my translator who was leaning against the wall. “hitting... with knife,” he said. i pushed through the crowd

tired. the sky looks like it will fall. after a dozen cloudless mornings, blueblue afternoons, and sweltering starred nights, heavy black clouds hang above us, looming, ready to crash down. the wind has whipped up sand, and as we rush to close our tukul doors, we can feel the tiny stings from the whipping grains. never a middle ground.

Dispatches Vol.9, Ed.2

and rapped on the metal door. it opened a crack and an eye peered out at me. as i walked in, people from behind tried to push past me, to enter the room. i held them back, moved them gently back into the throng, and closed the door. the room was full already. it was difficult to move. three nurses, soldiers, relatives, another medical doctor. “ok, everyone out. except staff and one relative. please. everyone. you. you. you. out.” reluctantly they left, one by one. as they did, others tried to push back in, removing their hands from the closing door only at the last minute. a young man was lying on his back, eyes wide in terror, his shirt red with blood and so was the bed. “two IVs,” i said, “19 gauge, and open them. call the lab technician for a blood group, and ask outside for a donor. blood pressure?”

this was the medicine i do at home. like waking. i examined the patient, and his wounds. there were two, one was definitely superficial, but the other i couldn’t tell if it went into his chest, or possibly his abdomen. his stomach was soft, his breathing clear. that’s good. i put on sterile gloves and poked my little finger into the hole. it didn’t pass through to his lung. i could feel a spicule of bone, as fine as a tooth on a comb, that the knife had sheared off, but i couldn’t feel the thin tract of the blade underneath it. perhaps the knife had bounced off of it, continued on a harmless path. we decided to go to the OT and explore the wound. i opened the metal door, and the crowd outside had grown. at least 30 people, more arriving through the gate. two women had thrown themselves on the ground in grief, wailing, rolling. someone tried to push past me. no. he stood fast. so did i. there were too many people for us to navigate a stretcher through. the little courtyard was nearly full, tilting towards chaos. “please move,” i said, “stand at the gate. i will come and talk to you soon.” some of our staff arrived from the compound and helped push the crowd back. we closed the gate, and people leapt over it. we started from the ER with our stretcher, people trying to follow from all sides. i ran interference where i could. we blocked the entrance to the OT, and went inside.

we prepped his chest, and cleaned the wound. i tried to pass forceps through to his abdomen or chest, but it appeared the track went underneath his skin instead of inside. so lucky. both of us. i left the other doctor to close the wound and went back outside. most people were now at the gate, their backs turned to the hospital, watching a fistfight across the football field, half a mile away. i spoke with them. i walked home an hour later on my worn path, with my translator. “today is a difficult day,” he said, “i don’t think i will make any movements tonight.” i agreed. a good night to be quiet at home.

population torn by war, but to encourage peace. we do it by being neutral, siding only with the sick. we make a place, the hospital, where everyone can find respite, regardless of which tribe they claim, or which border they cross to get here. but we also did it when we first put up our flag, already brown and frayed. we needed, from the beginning, to guarantee the safety of ourselves and our staff. the local authorities work, in part, to keep the roads safe because if they are not, we will not be able to move. the hospital must be safe or we will not be able to work. the rain is starting. i am to bed. a good night to be quiet, and i hope the people of abyei agree.

“but,” he said, “you know, abyei is better than before. two years ago, no one left their homes. the market would close early. everyone was too afraid. you could wake up one morning and step outside and see a dead body. it wasn’t safe for anyone.” “well, it seems much better now,” i said. “oh yes, much better,” he said. “safe. now there is peace.” peace. after so much war. i hear that word all the time, use it all the time, but never did it sound so correct, it’s meaning so obvious. the difference between then and now was complete. like the change in the sky. it is one of the reasons MSF is here, of course. not simply to show solidarity with a

Dr. James Maskalyk Medical doctor Abyei, Sudan

page 9

Sudan

IMPOSSIBLE CHOICES

The harsh reality of humanitarian aid n the mid-1990s, as war raged in southern Sudan, there was yet another outbreak of the deadly disease kala azar. The illness had already ravaged many villages, killing an estimated 100,000 people.

guided our thinking. We decided to treat patients in locations where we were most assured of successfully finishing the treatment and saving the lives of the sick.

Although this particular outbreak was not on the scale of previous epidemics, it was just as deadly for those affected. Our MSF team struggled to respond, hampered by the war and a worldwide shortage of the drug needed to treat this fatal disease.

As logical as this seemed, it meant cutting off a group of people in one of the most devastated areas. Although we had just gained access to this severely affected population, the level of insecurity there was too high to keep a team on the ground.

We had to decide which populations would receive life saving drugs and which would not. We had to decide who would live and who would die. As we scrambled to find supplies of the drug, Pentostam, we also sought generic preparations and alternative treatments. Country by country, we scoured the globe for supplies. Although these efforts contributed to saving more lives, there still wasn’t enough medicine. We had to make choices that were unacceptable both for those suffering from the disease and those forced to choose.

HOW TO CHOOSE? The security of our project locations and our capacity to deliver quality care

Dispatches Vol.9, Ed.2

People already on treatment were given the possibility of completing it. But we were forced to abandon others suspected of having the disease. They were left with no hope other than to walk for two weeks to our next location, across a frontline in the ongoing conflict. What had been an impossible choice for us turned into impossible choices for patients and their families. Their only hope lay in undertaking a gruelling and dangerous journey, which many did. When they arrived at the other end, project staff were overwhelmed at the sight of families walking together, some of whom had carried their sick relatives great distances across the savannah to reach MSF.

MAKING BEST USE OF SCARCE RESOURCES Today the situation in southern Sudan has stabilised in most areas. The greatest challenges are in accessing remote regions, training staff, and supporting local authorities in building a healthcare system. This has implications for MSF’s level of involvement. MSF believes that aid, like medicine, requires specialisation. We provide a humanitarian response to crisis, one that focuses on emergencies and those most in need, particularly in destabilised contexts involving war, conflict, violence and oppression. As security increases, so does the need to involve organisations that specialise in development. This has led us to a new set of impossible choices in southern Sudan. We have begun to hand over responsibility as other organisations have stepped in. When emergencies end and contexts become more stable, we believe it is our responsibility to plan an exit strategy and reallocate our limited resources to situations where other organisations can’t or won’t work. At times this generates criticism of MSF. It is difficult for those who

benefit from our care to understand why we would leave. It is difficult for some team members who have developed connections with local people to comprehend why we need to move on. Usually the level of care available is still far from what we would see in Canada. Considering this, how is it possible to hand over a project when we know that the medical care that follows may be less comprehensive? For instance, a few months ago the MSF team in Aweil, southern Sudan, met a young girl named Nyanut. Nyanut suffered from kala azar. The disease had progressed over months and as a result she was seriously malnourished. She was brought to our hospital by a group of Canadians traveling with journalists.

Upon arriving at the hospital, the Canadians learned that we were in the midst of a handover. This was inconceivable to them. How could we think of leaving when people like Nyanut needed care? Although we were able to save Nyanut’s life, along with the many patients who preceded her over the previous seven years, the question weighed heavily on us. It touched on the harsh reality of our work, on the impossible choices. In the case of Aweil, there is a second hospital 20 km away, a Sudanese doctor on location, and at least three other NGOs providing health services in the area. Does this amount to an acceptable level of care for this population? It does not. But only about 25 per cent of people in southern Sudan have access to even the most basic level of healthcare.

As a humanitarian organisation devoted to saving lives and alleviating suffering, it is our duty to seek out and respond to the most acute needs. The impossible choices we make ultimately take us beyond the small pockets where some level of healthcare is available, to places where other young girls like Nyanut have no access to care at all.

Marilyn McHarg General director, MSF Canada

page 11

Somalia

Dispatches Vol.9, Ed.2

ÂŠ Magnus Hallgren

WORKING LATE

Calgarian Darryl Stellmach recently returned from Somalia, where he worked as the project coordinator in the town of Marere. In this interview, he tells Dispatches how his team dealt with an outbreak of cholera. This was Darryl's fourth mission with MSF. He plans to go on mission again in the fall of 2007. was posted in Marere, in the Juba valley, to manage a hospital project where MSF provides basic health care to the local population, including maternal care, vaccinations and a nutrition program for children under five years old.

The Juba valley is a very fertile region, but due to clashes between clans and ethnic groups, and discrimination against certain groups, many suffer from health problems, especially related to malnutrition. Major floods hit the valley in October 2006. The floods destroyed most crops, contaminated water supplies, and made it very difficult for us to reach people through our mobile nutritional screening clinic. Soon after the flooding, we started seeing cases of cholera. We immediately set up our emergency response: a cholera treatment centre (CTC) and a second isolation unit were built near our hospital. We sent mobile teams to the areas affected by cholera. The outreach effort had a three-fold purpose: to educate the local population about the symptoms of the

disease; to distribute chlorine tablets, which people would use to purify water collected in buckets; and to find new cholera cases.

rhythm and worked well together. We quickly fell into a routine of reacting to these emergencies in a professional and organised way.

New patients were transported back to the CTC by rented minibus. The trip, though only about 40 km, could take up to six hours because of bad road conditions.

Since January 2007, the MSF project in Marere has treated over 250 patients for cholera. With the rainy season arriving, we expect the case numbers to go down, because people will be able to collect fresh, uncontaminated water from the rain, instead of drawing from the stagnant pools and lakes left behind by the flooding.

The hardest part about this mission was the unpredictability of our work. When you go to bed, you never know if you'll get a full night’s sleep – we're never quite sure what will come to our door. One night for example, just as we were going to bed around 10 pm, a staff member came to warn us that a busload of patients had just arrived. These patients were referred to us by a local health worker who took it upon himself to identify cases of cholera in his community. He had driven the minibus full of sick adults and children to our CTC, which was 40 km away. Our staff got dressed and went back out to the hospital to do triage. The patients who were most sick were sent to the isolation unit and given IV drips. Those with less severe symptoms were given oral rehydration salts, mattresses, and mosquito nets to protect them from malaria. The team was tired, but also became experts at working very quickly. We had a

Darryl Stellmach Project coordinator Marere, Somalia

page 13

Access to essential medicines

CANADA’S ACCESS TO MEDICINES REGIME

NOT WORKING

ince 2003, MSF Canada has worked to increase access to life-saving medicines and get drugs into the hands of patients using the Jean Chrétien Pledge to Africa Act, now known as Canada’s Access to Medicines Regime (CAMR).

The CAMR amends Canada’s Patent Act in accordance with changes to intellectual property rules set forth in 2003 by the World Trade Organization’s (WTO) August 30th Decision. These changes allow developing countries to import generic medicines even if the medicine is under patent. The purpose of this exemption is to allow universal access to medicines in the event of a major public health crisis. In the last issue of Dispatches (Winter 2007), we reported that the Canadian government was about to embark on a review of the CAMR legislation. A public consultation took place in January 2007 where many stakeholders, including MSF, submitted papers. Subsequently, the Parliamentary Committee on Industry, Science and Technology followed up with a study and hearings. MSF once again argued that the Canadian legislation was too bureaucratic and onerous to provide any incentive for developing coun-

Dispatches Vol.9, Ed.2

tries or generic pharmaceutical companies to make use of it. In one of the first tests of the new WTO rules, Thai authorities issued a compulsory license to produce a cheaper generic version of the HIV/AIDS drug Kaletra in January 2007. Abbott Laboratories, which holds the patent on Kaletra, responded by announcing that it would withdraw applications to register new drugs in Thailand. The case suggests that there may be difficult battles ahead for developing and newly industrialised countries that pit themselves against the pharmaceutical industry.

FLAWS ARE APPARENT

Who is responsible? MSF has highlighted its position in written submissions, presentations to parliamentary committees, media interviews and civil society forums: that the compromises made by the Canadian government to accommodate both brand name and generic pharmaceutical companies have failed to bring medicines to people who are most in need.

WHAT NEXT? The Committee on Industry, Science and Technology will table a report on its review of the CAMR as this issue of Dispatches goes to press. No meaningful changes are expected to be made to the legislation.

Critics have challenged MSF’s work on the Canadian front of the access to medicines battle, noting the many legal complications surrounding the issue. However, MSF has succeeded in making the issue resonate with the Canadian public and has rallied activists. The organisation has pointedly signalled to the Canadian government that it has followed an international trade mechanism that is itself flawed, and that it has a role to play at the WTO level in correcting these flaws.

In the meantime, MSF will continue to do what it does best, delivering life-saving medical assistance to those in need. MSF Canada directly manages health programmes in five countries in West Africa and Latin America and will continue to obtain quality medicines from the cheapest, most readily accessible sources in the world. We cannot limit ourselves to what is available in Canada; our patients don’t have the luxury to wait.

The flaws in the CAMR are apparent. To date, not a single pill has left the country.

Lai-Ling Lee Programme officer

Book review

INSPIRATION TO ACT

the author’s years of experience in areas affected by natural disasters, refugee crises and the AIDS epidemic.

At the heart of Healing Our World are the reflections of MSF field workers. What inspires these people, including a motorcycle dealer and a stage manager, to work in refugee camps and disaster zones? Morley offers insights into their varying motivations.

The book briefly chronicles the history of the organisation, from its inception in the aftermath of the Nigerian Civil War, through its development into the largest independent medical-humanitarian aid organisation in the world.

Photos and excerpts from interviews, journals and emails tell of their inspiration, the people they meet, the heart-breaking situations they encounter, and the small victories they achieve. Ultimately, young readers discover the strength of the human spirit and the capacity for compassion we all have within us.

nspired by the compassionate curiosity of students that the author encountered as executive director of MSF Canada, Healing Our World introduces young people to the work of MSF across the globe.

The book examines the structure of MSF and explains how the organisation operates in challenging environments, treating everything from mental health problems to malnutrition. Startling journal excerpts draw on

Healing Our World is written by David Morley, executive director of MSF Canada from 1998 to 2005, and currently the president and chief executive officer of Save the

INDIA Leanne Pang INDONESIA Patrick Laurent IVORY COAST Patrick Boucher Asha Gervan Nicolas Hamel Diane Rachiele Lori Ann Wanlin

CANADIANS ON MISSION ANGOLA Anne Henderson ARMENIA Robert Parker BANGLADESH Julia Payson BURUNDI Annie Desilets Danielle Trepanier CENTRAL AFRICAN REPUBLIC Magdalena GonzalezFernandez CHAD Rink De Lange

Marise Denault Frédéric Élias André Fortin Lori Huber Michel-Olivier Lacharité Leanne Olson Allison Strachan Gislène Télémaque COLOMBIA Tyler Fainstat DEMOCRATIC REPUBLIC OF CONGO Laura Archer Maryse Bonnel

Children Canada. It is published by Fitzhenry & Whiteside and is available in bookstores.

Anne-Josée BoutinTrudeau Guylaine Houle Elisabeth Martel Tara Newell Nicole Parker Vivian Skovsbo ETHIOPIA Wendy Rhymer Ivan Zenar GUINEA Dawn Keim HAITI Lynn McLauchlin Sylvie Savard

PAKISTAN Justin Armstrong Fahreen Dossa REPUBLIC OF THE CONGO Ahmed Alas Jeremy Parnell Shauna Sturgeon SIERRA LEONE Erwan Cheneval

KENYA David Michalski Tiffany Moore

SOMALIA Denise Chouinard Joli Shoker

LESOTHO Peter Saranchuk

SRI LANKA Megan Hunter Krista Mckitrick

MALAWI Michelle Chouinard Chantal St-Arnaud MOLDOVA Steffen Kramer MYANMAR Nadine Crossland Frédéric Dubé NEPAL Assad Menapal Grace Tang NIGER Farah Ali NIGERIA Richard Gosselin Paulo Rottmann Mary-Ellen Sweetnam

SUDAN Reshma Adatia Carolyn Beukeboom James Maskalyk Daniel Nash Alexis Porter UGANDA Maguil Gouja Mathieu Léonard ZAMBIA Chris Warren ZIMBABWE Carmen Bellows David Croft Jean-François Lemaire Joannie Roy

Healing Our World: Inside Doctors Without Borders By David Morley Ages 12+; 121 pages; $22.95 CAD / $18.95 USD (hardcover)

Amy Coulterman Personal giving assistant

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: Jake Wadland Editorial director: Avril Benoît Editorial advisor: linda o. nagy Translation coordinator: Julie Rémy Contributors: Amy Coulterman, Isabelle Jeanson, Lai-Ling Lee, James Maskalyk, Marilyn McHarg, Katja Mogensen, Julie Rémy, Darryl Stellmach, Elena Torta Circulation: 90,000 Layout: Tenzing Communications Printing: Warren’s Imaging and Dryography Summer 2007

ISSN 1484-9372

page 15

Just a few words in your will... Create a legacy to provide life-saving medical care for people in danger around the world.

For information about making a gift in your will to Médecins Sans Frontières/Doctors Without Borders, contact: Personal Giving Office (416) 964-0619 / 1 800 982-7903 msfcan@msf.ca

www.msf.ca 402 - 720 Spadina Ave Toronto ON M5S 2T9 Charitable registration number: 13527 5857 RR0001

Dispatches Vol.9, Ed.2