Field Notes - January 2014

YOUR SUPPORT IN ACTION

Volume 15

Number 1

2014

Field notes

© Sydelle WIllow Smith

End of a journey with XDR-TB

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he medicine lay on a saucer – five yellow capsules, a big white tablet and a brown capsule. With one gulp Phumeza Tisile, 23, put an end to her daily ritual of the last two years.

She swallowed the last of 20,000 pills she had taken to cure a severe form of drug-resistant tuberculosis: extensively drug-resistant TB (XDRTB). When it was done she cried tears of joy.

“I never thought this day would come,” Phumeza said, beaming. “I’ve beaten XDRTB! Getting cured at last is very exciting. It was scary at first. But you live in hope – hope that one day you will be cured.”

Phumeza beat XDR-TB against all odds. The disease has a cure rate below 20 per cent.

Before being treated by Médecins Sans Frontières/Doctors Without Borders (MSF), it took a long time to diagnose Phumeza’s XDR-TB using the tests available in the public health system. Phumeza received ineffective treatment before learning she had XDR-TB. She also suffered serious side effects, including permanent deafness.

By the time MSF TB doctor Jennifer Hughes started treating Phumeza, she had been under-

going ineffective treatment for nine months.

Phumeza’s story illustrates the two biggest obstacles to treating drug-resistant TB: the lack of diagnostic tools, and the limited range of drugs available to treat it.

Affordable, quality generic versions of linezolid are available in other parts of the world. But despite MSF’s calls for action, South Africa has not made use of legal mechanisms that would allow access to generic linezolid.

“We really need better diagnostics if we want to save lives and fight drug-resistant TB,” said Dr. Hughes. “It’s also crucial that we find and use better drugs for patients like Phumeza.”

Phumeza wrote a blog about her two-year journey. “The support from people who followed my blog kept me going. They kept praying for me, encouraging me.”

For patients trying to beat drug-resistant TB, the two years of treatment are gruelling. “I had to take more than 20 pills daily, supplements and injections. It is just too much,” said Phumeza.

Cured of XDR-TB, Phumeza can pursue her dreams again. “XDR-TB has changed me. I’m not the same person I used to be. I want to register at university again. I know it’ll be difficult because of my deafness. The business world will not accept me, but maybe I can study healthcare.”

MSF’s program in South Africa provides XDRTB patients with individually-tailored combinations of new, more effective drugs. One of the drugs that helped cure Phumeza is an antibiotic called linezolid.

MSF has seen promising results with linezolid, but the drug is not widely available as a TB medicine in South Africa for two reasons: It is extremely costly because it is under patent, and it is not registered as a DR-TB treatment, making it difficult to access. A two-year course of treatment for a patient like Phumeza costs half a million rand (over $50,000 Canadian).

Phumeza Tisile and Dr. Jennifer Hughes coauthored a DR-TB manifesto that calls for governments, drug companies, researchers and the TB community to step up the fight against DR-TB. Sign on to support the manifesto at msfaccess.org/TBmanifesto/.

Read Phumeza’s story and the story of other TB patients in their own words at blogs.msf.org/tb/.

LETTERS FROM THE FIELD

Life-saving team work in the Central African Republic

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fter several busy weeks, having seen pain, grief, death and despair, I finally participated in a happy event: bringing a child back from the brink of death.

When a child suffers from a respiratory infection, traditional healers often blame the uvula, that little piece of flesh that hangs at the back of the throat.

To treat the child, the traditional healer may remove the uvula, often using a non-sterile instrument. The child ends up with both a respiratory infection, and an infection caused by the dirty instrument.

This is usually when the parents come to us, seeing that the child isn’t getting better. Here, many people doubt the benefits of Western medicine. They often come to us very late – we are a last resort.

On top of his fever, Alfred’s body responded to the malaria with seizures. We started treatment with antibiotics, antimalarials, analgesics, anticonvulsants and oxygen. Alfred was stable and seemed to respond well.

But the next day I found Papa David, the attendant, at Alfred’s bedside looking over-

© MSF

Alfred, only six months old, was admitted for severe malaria, a respiratory tract infection, and removal of the uvula.

whelmed. Alfred had a low blood oxygen level and respiratory distress. He had started convulsing – his breathing was erratic and his eyes were empty.

My adrenaline took over.

I told David to bring me the portable suction.

Nurses Thomas, John and Wilfred came running. I told one to prepare a diazepam IV, another to call Dr. Maurice, and the third to help me with suction. We had to act fast.

David operated the foot-powered suction machine to draw mucus out of Alfred’s tiny body. But his secretions were so thick that it wouldn’t work. I sent David to get our battery-powered suction unit.

Meanwhile, we gave Alfred diazepam, but the convulsions did not diminish. His mouth was contracted and wouldn’t open. I called for a device to keep his airway open and a resuscitation mask.

We tried to open his airway without success. Meanwhile his oxygen level continued dropping. And the resuscitation mask was too big. “David,” I said, “bring me a child mask, quick!”

Finally the suction machine materialized and Dr. Maurice appeared. He got Alfred’s airway open while I started the suction unit, and Jean got the proper resuscitation mask in place.

After removing a good amount of mucus, with Alfred’s oxygen level at 80 per cent, I began to oxygenate the little baby with the resuscitator.

Everyone waited and watched his oxygen levels. 80 per cent … 85 … 92, finally 100 per cent! At last we could all breathe a little.

Gradually his breathing slowed a little, his heart rate calmed down and his blood oxygen level stabilized. His seizures finally subsided.

We had been working for 45 minutes.

I stayed for the next hour – I wanted to be certain that Alfred would continue breathing.

CENTRAL AFRICAN REPUBLIC: ONGOING CRISIS In recent months, MSF teams have witnessed extreme violence in the Central African Republic (CAR). MSF has urged the international community to increase its aid response to meet the massive humanitarian and medical needs.

CAR has been in a state of crisis for years.

The country has few government services, poor infrastructure, and is often affected by floods in the rainy season. Hunger is widespread and in some regions the mortality rate has reached emergency levels.

Malaria is the biggest killer.

Violence and insecurity have worsened significantly since a rebel coup in 2013.

Tens of thousands of people have been displaced. Health facilities have been looted and medical staff have fled. Even where healthcare exists, few people can afford to pay for it.

MSF has been working in CAR since 1997.

MSF is currently running seven hospitals, two health centres and around 40 health posts. There are more than 1,100 locallyhired MSF staff in CAR, and more than 100 international staff, including 17 Canadians.

A week later, Alfred was fine. He was looking healthy and left the hospital with his parents.

Janique Gagnon Nurse

Janique Gagnon is a nurse at the Children’s Hospital of Eastern Ontario, in Ottawa. She recently returned from a mission to Boguila, a village in the Central African Republic. The following is adapted from a blog she wrote about her experience (blogs.msf.org/janiqueg).

MAJOR EMERGENCY RESPONSES IN 2013 TYPHOON HAIYAN

© MSF

In November 2013, Typhoon Haiyan struck the Philippines, causing the deaths of thousands of people, as well as massive destruction. MSF Canada donors responded generously, contributing more than $2 million to MSF’s relief efforts.

Philippines first responder

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arrived first in Manila and then flew the next day to Roxas City on Panay Island. I went to assess the eastern coast of Panay.

In some of the places we visited, up to 95 per cent of the homes were destroyed.

These are fishermen’s villages, and the houses were constructed from bamboo. There was no way they could survive the force of the typhoon.

The people have completely lost their livelihoods.

I’ve been surprised and humbled that even in the face of all this, the people in the villages were so happy to see us. They welcomed us, shaking our hands, always with a smile. I was impressed by their determination to rebuild their lives, only days after they were torn apart.

We are now based in Estancia. We’ve got three mobile clinic teams who go to a different location each day, trying to reach the more remote locations where people have not been helped yet.

Yesterday, we went to a village near Estancia. It was completely destroyed. We set up in the former health clinic and received a lot of patients.

Today was the same. We went to another remote village and the patients did not stop coming. It is clear that there are massive needs.

We are also seeing people who have been affected mentally by the typhoon. Psychological care is going to become an important part of our program.

We are working alongside Filipino Ministry of Health staff, who have been so generous with their time and their insights. The cooperation is impeccable.

One of the nurses has been working since the day after the typhoon and hasn’t stopped since. She has been traumatized herself. It is remarkable that she continues every day, that she still wants to give everything to her people.

Working with the international MSF staff has been great. It is so impressive to see an emergency team swing into action. Everything happens so fast.

This is the first time I have worked in an emergency, and it has been superb to learn from all the people who have experience working in these situations.

The Filipinos have been through hell, but I have only seen strength in the past week.

That has been incredible to witness. Their resilience is nothing short of extraordinary.

As MSF, we are not going to save the country.

But many people are currently without medical care and we will try to fill that gap until services are restored.

Martine Bouchard Nurse

We are mainly treating respiratory infections, and we’ve also seen some patients with diarrhea. Without proper shelter, a lot of people have colds and fevers, especially the kids.

Martine Bouchard is an MSF nurse from Saint Jerome, Quebec who responded to the aftermath of Typhoon Haiyan. She posted this to her blog on November 20.

Thanks to your support, MSF was able to mount a rapid response. Within the first two weeks after the typhoon struck, we: • Had more than 200 international staff on the ground • Delivered more than 230 tonnes of aid cargo • Supported four hospitals and eight health centres • Ran mobile clinics in 37 locations • Performed 6,452 outpatient consultations • Delivered 14 babies • Performed 220 surgeries • Gave 400 mental health consultations SYRIA CRISIS In 2013, Canadian donors also contributed generously for MSF’s ongoing assistance to the Syrian people. We received $1.5 million to support Syrians affected by the crisis.

By the end of 2013, inside Syria, MSF: • Ran six hospitals and two health centres, including burn units, surgery for war-wounded, maternity wards, outpatient care, chronic disease care and mental healthcare • Provided drugs, surgical kits, dressing materials and medical equipment to health facilities • Trained Syrian healthcare workers in hygiene, first aid, triage and treatment of war-wounded • Supported 28 hospitals and 56 medical posts throughout Syria • Performed more than 4,500 surgeries, more than 90,000 consultations and more than 1,500 deliveries • Vaccinated more than 100,000 people • Supplied more than 450 tons of non-medical items and 150 tons of medical items By the end of 2013, in the surrounding countries: • MSF performed more than 265,000 consultations for Syrian refugees • In Lebanon, MSF delivered primary healthcare services, chronic disease treatment, prenatal services, mental healthcare and relief items • In Iraq, MSF was the main healthcare provider in Domeez refugee camp • In Jordan, MSF ran reconstructive and emergency surgery programs, a pediatric hospital, and maternal healthcare and emergency surgical care programs

PROFILE

AnneMarie Pegg: © Brigitte Breuillac / MSF

physician

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nneMarie Pegg has been living out of a suitcase for almost a year. Since joining MSF’s emergency team in January 2013, the physician from Kitchener, Ontario has been constantly on the move, flying from one humanitarian emergency to the next. This year she worked in Syria, the Central African Republic, Iraq and Jordan.

AnneMarie started her career as a nurse, working in a pediatric hospital in Toronto, before studying medicine at McMaster University. She became interested in international work when she did an internship in South Africa as a young nurse.

She has also been drawn to remote parts of Canada. She worked as a nurse in a small health centre in the Northwest Territories and did part of her residency in the territory as well. Later she worked as a family physician in Yellowknife, doing emergency room shifts and obstetrics.

With her experience in remote settings, and her keen interest in humanitarianism and international travel, working with MSF seemed a natural fit. AnneMarie’s first mission was in Ethiopia in 2008. She later worked as a doctor, medical team leader and medical coordinator in Haiti, Pakistan, the Central African Republic and Congo-Brazzaville.

Between missions she went back to work in Yellowknife, until she decided to commit a whole year to working with MSF’s emergency team. The 20 aid workers in this group can be sent to any emergency around the world on short notice.

AnneMarie says she has always been drawn to this kind of work. “I like the idea of arriving somewhere at the beginning of a project and I like the pressure,” she says. “I do a lot of work in the emergency department back home so I think it speaks to that.”

but could not get any medication inside Syria because of the conflict. I wrote a letter about her condition so that the border guards would let her into Turkey to seek treatment but I am not sure if the family managed to get across the border.”

“I really had a sense that the project I worked for in the capital, Bangui, saved people’s lives.

There are people that would have died without our presence, and who walked out of the hospital happy and smiling.”

There were also satisfying moments in 2013, including in the Central African Republic, a country that plunged into violence when rebels took power earlier that year. “I really had a sense that the project I worked for in the capital, Bangui, saved people’s lives.

There are people that would have died without our presence, and who walked out of the hospital happy and smiling. We were really able to see huge progress in the time we spent there.”

Her toughest mission was in Syria, where the team’s living and working conditions in the freezing winter months were hard, security was tight and the medical work challenging.

The MSF hospital, initially set up for trauma patients, was increasingly dealing with burn victims and patients with chronic illnesses.

Not always being able to help was frustrating.

“I remember a little girl of four with leukemia who was nearing the end of her treatment

Packing for her various missions has been a bit of a logistical nightmare. AnneMarie’s belongings are spread between the homes of friends and family around Canada, and she had to remember where her winter clothes were stored before heading back to Syria in November.

One thing she has learned is to keep a minimum of creature comforts during emergency missions. “I always pack nice soap, body lotion and shampoo.”

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