Dispatches (Summer 2010) by Doctors Without Borders / Médecins Sans Frontières (MSF) Canada

MSF CANADA MAGAZINE

Volume 13

Edition 2

Summer 2010

DISPATCHES Haiti: an evolving emergency

HAITI: Healing a wounded country, p. 02 | ACCOUNTABILITY: The earthquake and the tsunami p. 05 HAITI: Progress, but little recovery, p. 06 | Some assembly required, p. 08 | Songs of healing and hygiene, p. 09 PAPUA NEW GUINEA: Aid dilemma, p. 10 | ADVOCACY: Starved for Attention, p. 12 DEMOCRATIC REPUBLIC OF CONGO: The donkey delivers, p. 13

healing a wounded country The hours, weeks and months following Haiti’s devastating and enduring tragedy have brought unique challenges, both to the shattered population, and to the MSF staff trying to help. édecins Sans Frontières (MSF) medical teams were surrounded by small fires, corpses on the streets, frantic crowds, frantic rescues, severe injuries, and widespread physical destruction. The wounded poured into MSF’s makeshift hospitals on the streets. Staff struggled to treat the influx, while at the same time trying to locate their own colleagues and families, many trapped in rubble.

Survivors pulled patients and other staff – both dead and wounded – from the rubble. Canadian logistics-administrator Danielle Trépanier survived 24 hours un-

derneath the wreckage of an MSF house before Haitian colleagues were able to free her. Three MSF hospitals were severely damaged. La Trinité trauma centre collapsed with patients and staff inside, including the senior surgeon, Erick Edouard, who was one of seven MSF employees killed in the quake. The Maternité Solidarité emergency obstetrics hospital managed by MSF was rapidly evacuated as it was on the brink of collapse. Babies don’t stop being born when disaster hits, and more than a few were delivered outside that night surrounded by the chaos. An estimated 300,000 people were wounded at once. They arrived in agony with multiple and open fractures, crushed limbs, deformed faces, skull fractures, spinal cord injuries and lifethreatening burns. This called for a dras-

tic approach to triage, with priority given to those who could survive with the smallest amount of medical resources possible. Teams concentrated on wound cleaning, debridement and dressing, and fracture stabilization. In the meantime, MSF teams rapidly set up emergency first aid posts and attended to the hundreds of wounded that sought care. They rigged makeshift lighting with generators, cars and flashlights. On the four street corners in front of the collapsed hospital, patients filled every available space on the ground.

ADAPTING TO NEEDS Since the entire population was living outside, infection of untreated wounds set in quickly. Within the first week

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HAITI

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03 medical teams encountered gangrene, hemorrhagic shock and septicemia, as well as crush syndrome – a type of major shock and renal failure common after earthquakes. Logistical teams searched damaged MSF hospitals for equipment, material and drugs. Contingency stocks for emergency preparedness were quickly used up in the first weeks of response. Staff expended significant effort to secure direct landing access for essential medical and nonmedical supplies in the capital, Port-au-Prince. However, the small airport in the Haitian capital was damaged and overloaded with flights competing to land. Air traffic priorities were unclear, and flights with supplies and disaster experts were diverted to Dominican Republic. Recalling that the timeframe to save the lives

of those wounded is around 10 days, even one day delay caused by diverted flights has an impact. In the end, most MSF supplies were routed through Dominican Republic where MSF established a supply base in Santo Domingo. Despite the longer route, it provided a more stable and reliable option for the initial months as the airport and the seaport remained overburdened. The influx of medical nongovernmental organizations and hospital teams from the U.S. and Canada was tremendous. In the first days, the MSF teams were easily able to find hard-hit areas where no other aid agencies were working. But as new organizations deployed or expanded, MSF found itself adjusting efforts, assuring that those organizations were aware of MSF’s existing activities, and

evaluating referral opportunities within new health structures. By the end of the first week, MSF treated more than 3,000 wounded people in the Haitian capital and performed more than 400 surgeries, of which some 10 per cent were amputations.

A DIFFERENT KIND OF EMERGENCY When the earthquake hit, MSF had been providing healthcare in Haiti for 19 years, with four medical facilities run by a staff of 800. Within two months this had grown to a massive emergency operation of 3,400 staff working in 26 hospitals, clinics, post-operative care facilities and rehabilitation centres. Three months after the quake, MSF had 16 operating theatres on the go, and more than 1,200 hospital beds at 19 medical sites.

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Port-au-Prince. What capacity will exist to treat the daily influx of car and motorcycle accidents; people injured trying to recover their property from destroyed buildings; burn victims resulting from tents catching fire with paraffin stoves; violence-related trauma such as gunshot wounds, stabbings and rape; and other emergencies such as complications during pregnancy?

Staff had provided medical care to more than 92,000 patients and performed nearly 5,000 surgeries. While this sounds impressive, it’s important to realize that the emergency has by no means abated. Many humanitarian agencies left Haiti a few weeks after they arrived, referring their patients to MSF facilities for post-operative and wound care. Hundreds of thousands of Haitians, many of them still wounded, remain homeless and without work in the impromptu tentcities that have popped up around Haiti.

In these crowded, inhuman conditions, where fresh water and sanitation are marginal at best, contagious diseases are rife. Recovery is slow and difficult, and post-operative complications such as wound infections are common. With so many severe traumas, spinal injuries and amputated limbs, the need for long term medical rehabilitation will remain high for years to come. Added to the burden of post-operative care are the daily medical emergencies experienced within any city the size of

Especially worrisome is this summer’s hurricane season, when many more injuries and displacements are expected. In 2008 alone, storms left 793 dead, 593 injured and 310 missing. Over 100,000 homes were damaged or destroyed, and floods wiped out 70 per cent of the nation’s crops. Imagine the effect those storms would have on today’s weak, wounded and tented population. Haiti’s healthcare system before the earthquake was insufficient to address its basic medical needs to begin with. Before the catastrophe, less than half of the Haitian population could afford healthcare. More than 70 per cent of them were said to live on less than $2 per day. The capital had 21 public health facilities and only four hospitals serving a population of 3.5 million people. These fee-for-service facilities lacked medical staff, equipment and supplies. In October 2009, alone, MSF admitted 1,470 mothers into our emergency obstetrics hospital. Now that international donor governments and the United Nations have started planning for the longer-term, MSF is arguing that to restore Haiti’s healthcare system to what it was before the quake would be a travesty — because Haitians deserve, and have long deserved, so much better.

Paul McPhun Operations manager Kevin Coppock Humanitarian affairs liaison

An expanded version of this article was first published in the April 2010 issue of Policy Options www.irpp.org

The earthquake and the tsunami MSF stopped accepting earmarked funds only days after the 2004 tsunami. Why was the earthquake in Haiti treated differently? anadians and donors all around the world were there for the victims of Haiti’s earthquake. MSF experienced a tremendous outpouring of generosity in support of its relief efforts, and many of you went above and beyond your already vital monthly and annual support to make additional gifts – some specifically for Haiti. Thank you. Your generosity is never taken for granted. In turn, MSF will always be transparent and accountable to you about how your funds are used.

Many people have asked what the differences are between this most recent disaster and the 2004 tsunami which devastated parts of southeast Asia and elicited a similarly extraordinary response from donors. You may recall that following the tsunami, MSF stopped accepting designated funds after several days, a decision not taken for Haiti. MSF realizes that sometimes its decisions on accepting earmarked gifts, or not, may seem confusing. The reasoning in the case of Haiti was consistent and simple: it comes down to the needs of the people, and to MSF’s specific ability to respond to those needs. As an emergency medical relief organization, MSF will only accept designated

funds if it is sure it can spend them in two to three years following a particular disaster. The tsunami caused a massive and sudden loss of life, as was the case in the Haiti earthquake, but the resulting medical needs were not as great as the longer-term reconstruction and development challenges that other organizations and governments were better placed to address. The quake in Haiti was, by contrast, very much a medical disaster – in which MSF has a vital role to play, as do our supporters. Within hours of the Haiti earthquake, MSF was treating patients in makeshift emergency treatment centres in the worst hit areas. The single most significant reason MSF was able to respond so quickly was because staff were already providing medical support in Haiti – thanks, in large part, to your unrestricted donations. Consistent and stable funding from donors had enabled MSF to address serious chronic medical needs in Haiti for 19 years, well before the world media’s attention shifted there in January. In an extraordinary display of public support (and as of the writing of this article in May 2010) MSF offices worldwide have received the equivalent of over $130 million in private donations to support MSF’s emergency medical response in Haiti. Of this, Canadians have sent and pledged an estimated $13 million, and in Canada MSF has declared all eligible donations ($10.6 mil-

lion) to the government of Canada for the government matching program for Haiti. MSF anticipates that its program expenses in Haiti in 2010 will be $98 million. The designated support received to date will be used to meet the immediate needs of the Haitian people. However, knowing the difficulties facing millions of Haitians before the disaster struck and the challenges ahead, MSF’s role in Haiti will remain large and long. With your committed support of the organization’s work in close to 70 countries around the world, MSF will strive to ensure that Haitians and others at risk continue to receive care as their needs evolve. Thank you for being such an important part of this work. As an emergency response organization, MSF’s actions are driven by need and require a great deal of flexibility. Donors like you continue to demonstrate the same flexibility: in trusting MSF’s decisions about when and where to intervene, and whether the work can absorb restricted gifts or that you instead give to the organization’s general emergency fund. Your commitment allows MSF field workers to respond to the disasters of tomorrow.

Rebecca Davies Fundraising director

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ACCOUNTABILITY

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Progress, but Little Recovery Arriving at the hastily erected orthopedics hospital in Carrefour just two weeks after the earthquake, a doctor measures the impact of the quake on her patients’ paths to recovery. here are thousands and thousands of stories about the earthquake and afterwards, the unimaginable destruction and loss. I can only tell you a few. I didn’t live the terror of upheaval, of dust, of crushing. I wasn’t there to hear the screams of people trapped. I arrived more than two weeks later, on Feb. 1. Here are three patients I met at the orthopedics hospital in Carrefour, one of many MSF projects to treat survivors of the earthquake.

DEARIE Nineteen-year-old Dearie was there from the beginning, before our hospital could really even be called a hospital. She had a large infected hematoma that took up most of her right thigh, and surgeons were changing her dressing under anaesthesia every five days. Dearie had lost everything in the earthquake: home, husband, and a one-yearold child. She had no other family and never had any visitors. She had made friends with her tent-mates and their families, so they were her social supports. Illness and immobility make strong social

ties, I suppose. I think also that Haitians feel and value their community acutely. She learned to walk with her crutches; then she complained when we took them away from her. “I need them,” she pleaded. “I don’t have the strength.” “You will regain it with more exercise,” we answered. “There is no need to depend on crutches.” Her wound cleaned up nicely after a few weeks, but she was depressed and fearful for her future. I found her often writing or drawing. She read the children’s books that the mental health team circulated. She told me she had nowhere to go. On the morning of her planned skin graft, after weeks of waiting for the electric dermatome, and then for the blades that go into it, I found her crying. She was worried about getting better, because if she did, we would discharge her from the hospital... and then what? LUCY We had just moved the obstetrics department from being in the road to the grounds of a school. There was a lot of confusion. Bed numbers were not consecutive, the charts were incomplete, and we were a bit vague on patients’ names. You might think this unprofessional, but in reality, the team was overwhelmed.

HAITI

We were doing everything at once, trying to make order out of chaos and provide medical care throughout. Lucy, a 31-year-old woman, had a fracture of her right tibia and fibula (both bones of the lower leg). We had many patients with similar injuries. She had an external fixation, which is awkward external metal scaffolding with anchors drilled into the bone to stabilize the fracture site. Here at home, this fracture would have been treated with internal fixation: plates and screws reattaching the two ends of the fracture. But in Haiti, where our rough concrete-floored operating room had plastic sheets over the doors and windows to keep out the dust, infection of the hardware was a serious risk. I saw Lucy every day when we did rounds but I never saw any family by her bedside. She was polite, but her voice was quiet and monotone and her eyes were always downcast. I asked her why she was always sad. “It’s in my nature,” she said softly, looking at her hands in her lap. I wasn’t convinced, and suspected that she was profoundly depressed. I asked the mental health team to see her. They were bringing toys and activities to the patients and were doing one-on-one counselling, but over six weeks, I couldn’t say I saw any improvement in Lucy’s mood. She had an aura of sadness around her that you could feel the moment you stepped into it.

Carol was carried in by her family. She was 34 years old and had a long-leg backslab plaster on her left leg, and a splint and bulky bandages on her right forearm. It was unclear on her arrival what her injuries actually were. So we undid the bandages and X-rayed everything, just to figure out what she had. Under the dressing on her right hand we found a healing wound, amputation of the fourth finger, no fracture. For the left leg she had a femur fracture treated surgically, and the placement of an internal nail. The surgery looked great. We removed both of her splints. She needed physiotherapy because she had been immobile for about a month and was skinny as a rail. So we admitted her for that. Like Lucy, she wasn’t very motivated. Her right hand was stiff and although the wound was by this time quite minor, swathes of gauze impeded her movement even more. The problem of the hand compounded the problem of the leg, because she couldn’t properly use her crutches.

Many patients asked if we could give

them something: some plastic sheeting or a tent. No one had adequate housing, including our Haitian staff (until we distributed tents and household items to them). It was mid-March before we had enough stock to give patients some survival items on discharge: some plastic sheeting, a mosquito net, a hygiene kit, and a tiny bit of money for transportation. It wasn’t much, and rainy season had started. The camps of displaced people showed no signs of going anywhere soon.

My six-week emergency assignment, which ended in mid-March, was long enough to see some clinical progress, but much, much too brief to witness full recovery. Multiply realities like these by thousands, and the impact of the earthquake is staggering.

Wendy Lai Doctor

In exasperation of her lack of progress, I undid the bandages and redressed her wound myself. Despite her protests, we got her up on her crutches to see how she moved. Walking the length of the tent exhausted her. “You’re tired because you haven’t done anything,” we scolded her. “You have to practice.”

Another organization has begun to make prostheses for patients with leg amputations. Severe fractures take months to be solid enough to put weight on them. Regaining strength and balance, then learning to walk again are similarly long. Some patients, like Lucy and Carol, have had setbacks in their healing. And the mental trauma and social issues? There is no standard trajectory for those.

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CAROL

I left the country shortly after that. When I passed through the tents to say a hurried, emotional goodbye, she said nothing, only looked at me, tragically, her face a waterfall.

Our hospital had almost a hundred patients by the time I left. We were preparing for more – as other aid groups were leaving, their patients needed follow-up and care if they had complications.

That meant back to the operating room. It was, at that point, eight weeks after the earthquake. Her healing, of both body and soul, will be very long.

Two days later she spiked a fever. Her thigh, with the internal fixation, was hot to touch. The surgery that had looked great, now looked infected. The surgeon debrided it urgently and put her on highdose antibiotics to treat a presumed osteomyelitis (bone infection).

Eventually she was moved next door where we had opened a rehabilitation/ physiotherapy facility. She was not motivated to do her exercises – I think her depression was the reason. One night she fell out of bed and then said she could feel her fracture move. I thought she was okay until I saw her walk. She was allowed partial weight-bearing on her right leg, with crutches, and the fracture was so unstable that when she stepped, I could see it move.

hether responding to a sudden catastrophe like an earthquake or a tsunami, or trying to contain a viral outbreak, saving lives depends on getting people, equipment and supplies into the field as quickly as possible.

Time spent shopping for the right equipment or pharmaceuticals is time spent not responding, so MSF has spent 30 years developing and refining pre-packaged disaster kits ready for transport

MSF’s pre-packaged emergency kits: from instant vaccination programs, to pop-up hospitals.

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some assembly required

HAITI

within hours. These cover the gamut of typical response needs ranging from a couple of pallets with all the equipment necessary to set up an office, to all the sterile equipment required to perform 50 surgeries, to all the medical materials for the estimated needs of a population of 10,000 for three months. MSF usually renovates existing buildings to use as clinics, feeding centres, or hospitals. However when existing buildings are unavailable or, as was the case in Haiti, structurally unsound, it builds temporary shelters. One of the original kits, the modular white tent, has sheltered MSF field operations throughout its 39-year history. In response to the desperate need for medical facilities in Haiti, MSF sent one of the jewels in its pre-packaged crown: a 900-square-metre, 100 bed, inflatable hospital with triage and emergency units and two operating theatres. The 41 tonne kit was immediately flown from a logistics warehouse in Bordeaux, France. Unfortunately authorities managing the runways refused to permit six MSF cargo flights from landing at the overstretched airport because, during the post-disaster chaos, they were prioritizing military planes. MSF protested the delays while rerouting the lifesaving medical supplies to Dominican Republic and trucking them in. Staff inflated the mobile hospital on a soccer pitch in the Delmas neighbourhood of

Port-au-Prince, where it remains filled to capacity. Kits are primarily used in the emergency and start up phases of interventions. Once things have stabilized and medium term program plans are more clear, tents and inflatables give way to more permanent structures. But with so few structurally sound buildings available in Haiti, MSF is turning instead to a relatively new addition to their logistical tool-kit – the container hospital. These buildings were first introduced as part of MSF’s response to the 2005 earthquake in Pakistan. Based on standard six metre shipping containers, the hospital modules are assembled in China and then flown and trucked to their destinations, where they are unpacked and transformed. Container walls fold down to triple the floor space; inner walls are pulled out; electrical, HVAC and plumbing conduits are attached. The containers that are headed to Portau-Prince this summer will add a 120 bed maternity facility to the inflatable surgical centre featuring two operating theatres and an emergency room. Mo Al-Nuaimy Communications officer Paul Caney Logistician

a way to express their thoughts, to connect to each other.’” She explained that, while talking is unidirectional, music is a participatory event, and a big part of Haitian culture. “Haitians love to sing, play music and dance. Even when they talk, it’s with a musical tone.”

“The troubadours went through the hospitals and into the field, singing their messages,” said Lebel. “Little kids were soon running around singing the jingles – they really stuck.”

But not all their songs had clinical content. Lebel and her troubadours would talk to people about what they’d been through, and then the group would jam on the topic, giving voice to their hopes and fears. “People would start singing, dancing and clapping, huge crowds formed with many joining in.”

Songs of Healing and

Hygiene n the days and weeks after Haiti’s quake, as rescue efforts turned to reconstruction, a curious sound rose from the fractured concrete and twisted metal – singing.

MSF psychologist Reine Lebel heard it. In fact, hers was one of the voices raised in song. Lebel went to Haiti to counsel those struggling with physical and psychosocial trauma. Two of her first patients were

Emmanuel and Diosman, two young musicians who’d both lost their fathers and still had family members missing. “We talked about the importance of creativity when dealing with traumatic events, and so both men wrote poems about their grief. Later, they returned with guitars and keyboards and sang their poems.” It was so emotional, said Lebel. “I cried with them and thought, ‘this is the way to communicate with Haitians right now. Talk only gets so far. What they need is

Song is the natural language to use for communication in a crisis environment, explained Lebel, especially when so much of what Haitians felt was beyond just words. “Singing actually helps with pain. It releases endorphins in the brain and eases suffering, both physical and emotional. It’s always been a coping mechanism, especially for Haitians,” said Lebel. “It helps them remember who they were before the tragedy, to return to their creative resources and strengths. Singing and dancing is a way to access joy.”

Buffy Childerhose Journalist

To hear songs by the Troubadours d’espoir, go to www.msf.ca and click on Podcasts.

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Lebel soon turned the idea into action, enlisting the two young musicians and two more to create a group she calls Troubadours d’espoir (Troubadours of hope). The team wrote songs in conjunction with the medical staff, songs that focused on pragmatic matters such as essential hygiene for reducing the chance of epidemics in the camps, and how to best keep latrines clean.

Aid dilemma in Papua New Guinea Is there a place for humanitarian aid in zones of social violence unrelated to armed conflict? irst impressions of Papua New Guinea tend towards the idyllic: flying over islands and atolls of white beach and emerald water, across green rolling hills backed by thickly-forested mountains. Then the people themselves, open and generous, not just full of smiles but easily reduced to giggling, as I learned on my bumpy local flight from Port Moresby to Lae where I was to visit a family support centre run by the humanitarian aid organization Médecins Sans Frontières (MSF).

There, my romantic idyll was abruptly shattered. The first patient I saw arrive was a woman with three deep blows of a bush knife to the back of her head and her lip and right cheek close to be-

ing severed from the rest of her face. She had had a quarrel with the second wife of her husband, she claimed. Really, just a quarrel. For an organization well-versed in the violent consequences of warfare, this sort of violence from within the family came as a shock. Even more astonishing was that this woman was not a once-in-a-month case, but an every day patient in the industrial city of Lae. Later in the afternoon in the waiting room at Lae, I noticed two women sitting next to each other, both with right arms bandaged and hung in a sling of white gauze. It was momentarily comical, until an MSF doctor explained that they were both suffering from snapped forearms having defended their heads from the blow of a pipe or a club or whatever weapon might have been handy.

MSF has a similar project in Tari, in the country’s beautiful isolated highlands and such cases of brutality within the family are just as common. I am sickened and baffled because I have never seen anything like it, not even in my imagination. Up in the mountains, MSF’s project coordinator told me that she recently interrupted a man beating his wife. The battered woman was sobbing loudly while the family’s children played happily only a few feet away as if even raised voices were nothing to be distressed about. I also heard about one of our own staff who delivered a machete chop to his daughter’s head inside our hospital grounds, because the girl had disobeyed him. When he was dismissed, he appeared not to understand why he was being punished – so normal was his act! These and so many other stories haunt the team of doctors and nurses working

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PAPUA NEW GUINEA

Yet I have to acknowledge that there are some very pragmatic challenges that also pushed MSF away from going to places like Papua New Guinea to help victims of social violence. There is no war in Papua New Guinea, nor is it a crisis with boundaries, like an epidemic, that will come to a natural end. Rather, people here face (and generate themselves) crisis-level violence on an everyday basis, to the point where it appears as a cultural norm. The violence is like poverty in need of longterm systemic change, rather than an emergency response.

MSF struggles in such settings, because there is no logical time for withdraw-

When I arrived in Tari I found a team exhausted, breaking all the MSF rules by ignoring the project strictures which is to deal with surgery and family violence only. Yet they are acting sans frontières and making the only choice possible. The problem of domestic violence requires a different set of strategies for MSF. It is difficult enough to advocate against attacks on civilians during combat, or for a government to grant us access to refugees. But here in Papua New Guinea, do we outsiders push for a change in culture? Do we enter into the political dynamics of bride-price, which appear to give men the feeling that their wives are their property, to “bash up” alarmingly frequently? Here is another example of the difficulties: in many countries, we provide a medical report to victims of sexual violence that can be used as proof of what happened. They’re often the only way a rape survivor can be believed and receive some recompense for her injuries. Yet, these reports are used in Papua New Guinea as

testimony in a traditional compensation system that is itself the source of so much violence. The extended family or ‘wantok’ of the victim demands to be paid for the injury against one of its own, a process that can swiftly erupt into yet more violent clashes. Worse still, in at least one case, we fear that our report was used to justify beating a perpetrator into a vegetative state. In their content and in the challenges they confront, the projects in Lae and Tari are groundbreaking for a humanitarian medical organization such as MSF. It’s exciting to see MSF pushing itself. We provide the sort of vital treatment and psycho-social counselling for victims of violence that do not exist elsewhere (there are a lot of education and prevention efforts focussed on sexual violence, but few resources devoted to caring for the victims). We will hopefully use the experiences we gain in Lae and Tari to catalyze change, to push for similar family service centres to be opened in other hospitals, and maybe even to cast more light on the phenomenal violence.

Marc Dubois Executive director, MSF UK

This piece was originally published in the Guardian Weekly.

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Only five years ago MSF was debating whether it could justify its intervention in violence not related to armed conflict. Mostly, the answer was no. It was suggested that domestic or social violence was a phenomenon completely distinct from the political violence of armed conflict, and that MSF’s role existed only in the latter sphere. I was attached to MSF’s humanitarian affairs department at the time, and we began to break down that false distinction by shifting the focus away from the perpetrators or causes of the violence, and towards the direct medical consequences on people. It certainly seems like a no-brainer.

ing, and because there are no soldiers or militia but husbands, wives, sisters and brothers. The surrounding poverty makes it even more difficult for MSF. There are no government doctors in the Tari district hospital and MSF’s team is pulled into wards full of infectious diseases, maternal child health problems, and people who are desperate for a loved one to be treated. Supplies and staff are unavailable. Yet what else can they do?

at the centres, not only because of their gruesome and disturbing detail but because there is nothing in our individual or collective experience that makes sense of this domestic violence.

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ADVOCACY

12 ÂŠ Franco Pagetti / VII

STARVED FOR ATTENTION alnutrition kills 3.5 to 5 million children every year. The World Health Organization estimates that 178 million suffer from this disease that leaves many mentally and physically stunted and often unable to fully contribute to their societies when they grow up.

agency VII, the exhibition will consist of seven short video pieces of striking visual imagery and messages from parts of the world where this crisis is being played out: Djibouti, India, Mexico, Burkina Faso, Bangladesh, Democratic Republic of Congo, and even the United States.

MSF presents Starved for Attention, a multimedia documentary campaign that highlights the underlying causes of global malnutrition and the innovative approaches being deployed to combat it. In partnership with top international photo

The videos feature the work of VII photographers Marcus Bleasdale, Jessica Dimmock, Ron Haviv, Antonin Kratochvil, Franco Pagetti, Stephanie Sinclair and John Stanmeyer. You can watch them online at www.msf.ca.

The photo and film installation travelled to Toronto, as part of a global tour, for the G-8/20 summits in June. Go to www.msf.ca to sign a petition urging government representatives and funding bodies to commit to stopping childhood malnutrition. You can also help raise awareness about malnutrition by sharing the Starved for Attention videos and messages through Facebook, Twitter and other social networking sites.

The Donkey Delivers Riding shotgun with a midwife, while dodging violence and storms in DRC. he odds were not great. Chantal Bamurange, 32, was in hard labour – fully dilated, ready to deliver her baby – but her membranes hadn’t ruptured and she was bleeding. The midwife couldn’t get the baby’s heartbeat. There was a storm coming in through the valley, pitching clouds so black the clearing where her Médecins Sans Frontières (MSF) jeep had stopped looked like it would be in the eye of the storm in minutes. And on that December mid-day in Democratic Republic of Congo, soldiers from half a dozen roving militias, the ones responsible for raping the women and setting their villages on fire, forcing them to flee to make-shift shelters like this one in Kilolirwe half-way between

Goma and Kitchanga, were lurking on the other side of the hills. The odds for a safe delivery, a healthy child and a hasty retreat were, at best, poor. MSF midwife Sigrid Kopp, a 35-year-old no-nonsense professional from Hamburg, Germany, needed to make a decision. Should she transport this woman who was labouring painfully but not productively? It would mean an almost three hour journey over roads with potholes so big you could lose a transmission in them. Or should she rupture the woman’s membranes here, deliver the baby and leave Chantal in the care of the local garde-malade and her friends? The consequences were dire: if the unexplained bleeding increased, the mother could die. If the baby’s undetected heartbeat was more than an issue of prenatal

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DEMOCRATIC REPUBLIC OF CONGO

13 positioning, the baby might not survive the journey down the birth canal and into the world. That’s what it’s like to travel with MSF: life and death decisions, quick thinking and an absolute abhorrence of anyone (this journalist, for example) suggesting they’re pulling off miracles in some of the most dangerous places on the planet. We’d started with what’s euphemistically called a “kiss manoeuvre.” That’s MSF-speak for getting from here to there without being delayed or detained by any of the hoodlums or soldiers credited with creating havoc in Congo. It works like this: if you have to go from point A to point B, rather than sending a vehicle the entire distance, you send vehicles out from both A and B to meet at the halfway point and transfer the goods – could be

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a sliding window, pulled it open, stuffed the IV bag into the space and jammed it shut. One job done.

14 medicines, could be staff, could be visiting journalists like me begging a lift. That’s not all. A kiss manoeuvre requires a driver, of course, but also what’s called a donkey. The donkey is the designated passenger who can be on the walkie-talkie every few minutes reporting in, making sure the location is recorded so that help can be sent if there’s trouble on the road. Along with delivering babies and repairing horrendous wounds and counselling rape victims who are hiding in the forests to escape re-rape, the MSF team needs to be meticulous about security. They are the only nongovernmental organization still operating with a permanent presence of international staff in this part of Congo, a country that is convulsing with violence and heaving with insecurity. The job is perilous to say the least.

Sigrid Kopp laughed off her designation as the donkey that day, and said she’d come along because she’d heard one woman in Kilolirwe was having difficulty delivering her baby. What followed was dramatic to the max and MSF to the core. While the storm crashed in with a vengeance, the high winds, the thunder and lightning bringing new meaning to the power of a tropical storm and the ever present danger of soldiers arriving on the scene, Kopp was busy turning the back of a jeep into a mini delivery suite. With torrents of rain lashing the side of the vehicle, she started an intravenous line and, needing a way to hook the IV bag higher than the patient so it would run correctly, she looked around, spied

Then she yanked the seatbelts out of their moorings, disabling them, and put the clips into the woman’s hands so she would have something to yank on during the contractions. And she talked to her – soothing, encouraging words in a voice of calm and confidence. The rain kept pelting down. Kopp glanced outside. She knew we couldn’t stay long, the security issue wouldn’t allow it. So the minute the rain let up, she told the driver, “Go. We’ll transport her to Kitchanga.” The next three hours were an agony for Bamurange, and for Kopp who was perched on a metal box in the remaining inches of space at the back of the jeep while she monitored every contraction and kept track of the worrying symptoms. “The women here have so much to deal with,” she explained. “They come to me and say, ‘My husband is dead, my other kids have been killed. Can you help me?’ There are thousands of women in the bush not getting the help they need. In the end this is one problem we can solve. Obstetric care here is like a miracle. Look at this woman. She’s had 10 pregnancies; only five have survived.” When the vehicle pulled into the clinic and Bamurange was moved to a cot, Kopp deftly broke the membranes and within seconds was holding a healthy baby boy weighing just over three kilograms. Clearly relieved by the happy outcome of a rather perilous voyage, Kopp said, “He’s the cutest baby I’ve delivered in my career.” Then she swaddled the child and handed the tiny bundle to his smiling mother. “Things can go wrong. But generally we know what to do, we can help many. Today there was destiny.” Then she was off, back to her MSF office to fill in the paper work and repack her obstetrical box for an early morning departure to another village. She’d be horrified if I called her a hero.

Sally Armstrong Journalist

BURUNDI Luella Smith Waterside, NB

CANADIANS ON MISSION Nurse Logistician Nurse Nurse Nurse Doctor

CENTRAL AFRICAN REPUBLIC Colette Badjo Laval, QC Doctor Nicolas Bérubé Montréal, QC Logistician Richard Currie Salmon Arm, BC Doctor Pascal Désilets Montréal, QC Logistician Peter Heikamp Montréal, QC Project coordinator Stella Carine Kengne Tine Montréal, QC Doctor Judith Letellier Montréal, QC Logistician Thierry Oulhen Montréal, QC Project coordinator Élizabeth Poirier Boucherville, QC Nurse Richard Poitras Noyan, QC Project coordinator Daniela Widmer Vancouver, BC Nurse CHAD Francine Belisle Montréal, QC Nurse Jean-François Harvey Rivière-du-Loup, QC Project coordinator Marie-Michèle Houle Victoriaville, QC Nurse Clea Kahn Toronto, ON Head of mission Michèle Lemay Montréal, QC Doctor Ada Yee Calgary, AB Financial coordinator COLOMBIA Elaine Sansoucy Montréal, QC

Nurse

DEMOCRATIC REPUBLIC OF CONGO Tamiko Andrews Montréal, QC Nurse Grant Assenheimer Fort Sask, AB Project coordinator Charmaine Brett Ottawa, ON Project coordinator Owen Campbell Montréal, QC Logistician Claire Foulon-Abdulahad Montréal, QC Logistician Martha Gartley Toronto, ON Water and sanitation specialist Samantha Kemp Thunder Bay, ON Nurse Chantelle Leidle Fort Sask, AB Water and sanitation specialist Isabelle Major Trois-Rivières, QC Logistician Tricia Newport Vancouver, BC Nurse Gabriele Pahl Windsor, ON Medical coordinator Todd Philipps Winnipeg, MB Logistician Gisèle Poirier Montréal, QC Nurse Grace Tang Toronto, ON Head of mission Nicolas Verdy Montréal, QC Logistician GUINEA José Godbout St-Colomban, QC Audrey St-Arnauld St-Colomban, QC

Project coordinator Nurse

HAITI Christine Bonneau Lac Beauport, QC Mental health specialist Maryse Bonnel Morin-Heights, QC Nurse Patrick Boucher Québec, QC Logistician

DISPATCHES Médecins Sans Frontières (MSF) 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

Sylvain Charbonneau Ste-Thérèse de Blainville, QC Logistician Jordi Cisa Sudbury, ON Surgeon Natalie Dickinson Deep River, ON Mental health specialist Marc Forget Montréal, QC Doctor Nancy Gabel Kapuskasing, ON Anaesthetist Asha Gervan Toronto, ON Project coordinator Guillaume Giard Montréal, QC Logistician Karine Godbout Toronto, ON Nurse Liz Kavouris Montréal, QC Medical team leader Michèle-Alexandra Labrecque Montréal, QC Doctor Laura Madsen Vancouver, BC Logistician Joel Melanson Vancouver, BC Water and sanitation specialist Susan O’Toole Collingwood, ON Doctor Anne-Marie Pegg Yellowknife, NWT Doctor Nadia Perreault Mascouche, QC Nurse Rachelle Seguin Greenfield Park, QC Project coordinator Emily Shallhorn Montréal, QC Nurse Eyal Tapiero Montréal, QC Human resources administrator Stephanie Taylor Iqaluit, NU Doctor Nadia Tijioti Toronto, ON Logistician Susan Trotter Edmonton, AB Nurse Fiona Turpie Hamilton, ON Anaesthetist Martine Verreault Rivière-du-Loup Pharmacist

MYANMAR Anne-Josée Boutin-Trudeau Montréal, QC

Logistician

NIGER Fabrice Fotso Montréal, QC

Logistician

NIGERIA Adam Aboshahbo Toronto, ON Frank Boyce Belleville, ON Stephanie Gee Vancouver, BC Caroline Kowal Winnipeg, MB Manisha Rajora Vancouver, BC

Logistician Doctor Nurse Doctor Doctor

INDIA Richard Crysler St. Catharines, ON Mental health specialist Anne MacKinnon Fredericton, NB Nurse Catherine Oliver Toronto, ON Doctor

SUDAN Jaroslava Belava Vancouver, BC Nurse Duncan Coady Toronto, ON Financial coordinator Oonagh Curry Toronto, ON Logistician Tyler Foley Fredericton, NB Logistician Sylvain Groulx Montréal, QC Head of mission Catee Lalonde Montréal, QC Project coordinator Sabin Lapointe Montréal, QC Logistician Letitia Rose Vancouver, BC Nurse Tara Seon Toronto, ON Human resources coordinator

IRAQ Reshma Adatia Vancouver, BC Mathew Schraeder Massey, ON

Project coordinator Project coordinator

KENYA Lori Beaulieu Prince George, BC Maguil Gouja Montréal, QC Luis Neira Montréal, QC

Logistician Financial coordinator Medical coordinator

MALI Nina Hodonou Montréal, QC

Doctor

MOZAMBIQUE Isabelle Casavant Montréal, QC Serge Kaboré Québec, QC

Nurse Doctor

Editors: Mo Al-Nuaimy, linda o. nagy Editorial director: Avril Benoît Translation coordinator: Jennifer Ocquidant Contributors: Mo Al-Nuaimy, Sally Armstrong, Paul Caney, Buffy Childerhose, Kevin Coppock, Rebecca Davies, Marc Dubois, Wendy Lai, Paul McPhun Cover photo: © Julie Rémy

PAKISTAN Ivan Gayton Vancouver, BC

Project coordinator

PAPUA NEW GUINEA Judy Adams Moncton, NB Nicolas Perez Montréal, QC

Mental health specialist Logistician

SOMALIA Justin Armstrong Haileybury, ON

Project coordinator

SOUTH AFRICA Cheryl McDermid Vancouver, BC

Doctor

SRI LANKA JL Crosbie Toronto, ON Nancy Graham Toronto, ON Sarah Lamb Ottawa, ON

UGANDA Miriam Lindsay Irlande, QC Alia Tayea Oakville, ON Elaine Wynne Vancouver, BC UZBEKISTAN Susan Adolph Dartmouth, NS Calvin White Salmon Lake, BC

Project coordinator Nurse Logistician

Logistician Humanitarian affairs officer Doctor Nurse Mental health specialist

Circulation: 140,000 Layout: Tenzing Communications Printing: Warren’s Waterless Printing Summer 2010 ISSN 1484-9372

Dispatches Vol. 13, Ed.2

BANGLADESH Margie Atkinson Westlock, AB Sharla Bonneville Unionville, ON Patricia Gould Comox, BC Amy Hollings Gabriola Island, BC Marjorie Middleton Calgary, AB

Quiet please. Hospital zone. Finding a safe space to work is just one of the challenges MSF doctors, nurses and other staff face in places affected by disasters or armed conflict. MSF is found where aid is needed most, providing emergency medical relief and care. But we need your help. To learn more or to make a donation, please call

Haiti 2010 ÂŠ Julie RĂŠmy

1-800-982-7903 or visit www.msf.ca

The world is our EMERGENCY room