NINEMILLIONLIVES

Shortstoriesfromthefrontlinesofmedicalcrises

MEDECINSSANSFRONTIERES

PublishingDetailsNineMillionLivesbyMédecinsSansFrontières

©2015MédecinsSansFrontières

Contributors:KimComer,AdamSharp,StephenTorres,EstherClark,AnnSellberg,AbdulWassay,SteveCohen,JosineBlanksma,KellyHildebrand,AliAl-Ani,NatalieRoberts,AneBjøruFjeldsæter,BenGupta,WilliamTurner,FloraEscourrou,EmmaPedleyandAoibhinnWalsh

Themoralrightoftheauthorshasbeenasserted.Allrightsreserved.Withoutlimitingtherightsundercopyrightrestrictedabove,nopartofthispublicationmaybereproduced,storedinorintroducedintoaretrievalsystem,ortransmitted,inanyformorbyanymeans(electronic,mechanical,photocopying,recordingorotherwise),withoutthepriorwrittenpermissionofthecopyrightowner,exceptinthecaseofbriefquotationsincriticalarticlesorreviews.

MédecinsSansFrontièresAustralia

www.msf.org.au

EbookVersion1stEdition2015,ePubandMobi

Ebookcreation:Convertedfromdigitalsourcefile

Ebookfilescreatedby:AustralianeBookPublisherwww.AustralianEbookPublisher.com.au

FirstEdition:May2015

FOREWORD

NineMillionLivesisacollectionofstoriesfromtheworldofMédecinsSansFrontières,aworldwhichwouldnotexistwithoutthesupportofsomanyindividualsthatfundourwork.

Thestoriesareofhardship,injuryandillness,butalsoofcommitment,hopeand-ultimately-triumphoverthemostdifficultandchallengingcircumstancesimaginable.

Manyofthefirsthandaccountsresonatestronglywithme,butnonemoresothan“WavesofPatients”,writtenbyDrEstherSterkfollowingTyphoonHaiyaninThePhilippines.ItremindsmeofmyexperienceinHaitinotlongaftertheearthquakewhichravagedthecountryin2010.

Asourteamswenttoworkintheaftermathofthatdevastatingevent,wetreatedthewounded,distributedfood,waterandshelter,dealtwithoutbreaksofdisease,helpedwomentogivebirthandbabiestotaketheirfirstbreaths.Weevencreatedafunctioninghospitaloutofashippingcontainer.

IhadworkedwithMédecinsSansFrontièresfor13yearsatthattime,butneverhadIseensuchdevastation,norahumanitarianresponseonsuchanimmensescale.

Whetherourteamsaretreatingpatientsintheaftermathofnaturaldisasters-inplaceslikeHaiti,thePhilippinesandNepal-orrespondingtoepidemicslikethedeadlyEbolaoutbreakinWestAfrica,itisthankstothegenerosityofoursupportersthatMedécinsSansFrontièrescandelivermedicalassistancesoeffectively.

Sopleaseread,enjoyandsharethisbook.Thestoriesspeakforthemselves.

PaulMcPhunExecutiveDirectorMédecinsSansFrontièresAustralia

INTRODUCTION

NINEMILLION.That’sthenumberofpeopletreatedbyMédecinsSansFrontièresmedicalteamsaroundtheworldinayear.Itincludeswomeninlabour,childreninneedofvaccinations,thewar-wounded,patientsinjuredduringnaturaldisastersandmanyothers.Whilesomeofthemedicalemergenciesfacingthesepatientsmakethenews,manydon’t.

Thisbookgivesaglimpseintothelivesofafewdozenoftheninemillionpeoplethatwetreateachyear.Thesearethestoriesbehindtheheadlines,andtogethertheypaintacoherentpictureoftheworkofMédecinsSansFrontièresaroundtheworld.

Manychaptersarefirsthandaccountstakenfromourfieldworkers’blogs.Somearethirdpersonstoriesandothersareinterviews.Allreflectthedifficultiesofworkinginchallengingcircumstances,thecommitmentofourmedicalandlogisticalteamsandthestrengthandcourageofourpatients.

ThereisthestoryofaformerrefugeefromtheMiddleEastwhowenttoworkinSouthSudantoassistothervictimsofconflict;afirst-handaccountofthechallengesoftransportingmedicalequipmentthroughforestsanddifficultterrainintheDemocraticRepublicofCongo;andastoryaboutourteamssecuringcontinuityinhealthcareforpeoplelivinginasluminKenya.ThestoriesreflectthediversenatureofMédecinsSansFrontières’workandthepatientswetreat.

Toensurethattheirprivacyisprotected,allpatientnameshavebeenchangedthroughoutthisbook.

MédecinsSansFrontièrestreatsthevictimsofnaturaldisasters,conflict,epidemicsandothermedicalemergencies.Eachyear,millionsofpeopleareseenandtreatedbyover20,000fieldstaffinmorethan60countries.Throughthesestories,youwillmeetthedoctorsandnurses,logisticiansandfieldcoordinators,andthededicatednationalstaffwhocarryoutthiswork.Andyouwillhearabouthowthisvitalmedicalaidhelpspeopleinurgentneedeveryday.

THEPATIENTSKEEPCOMING

ThisfirsthandaccountwaswrittenbyKimComer,aMédecinsSansFrontièresLogistician,inMay2014.Forthepastfewyears,MédecinsSansFrontièresteamshaveworkedonpreventingandtreatingmalariaintheMoissalaandBounadistrictsinChad.In2013teamsrecordedan

overallreductioninmalariaof60percentinMoissala.

©AndreaBussotti

THEMEDECINSSANSFRONTIERESprojecthereinMoissalaisamalariaproject.It’sthestartoftherainyseason,whichmeansit’sthestartofthemalariaseasonaswell.Wemanageawardforinfantswithseveremalariainthedistricthospital.

Therateofpositivityfortherapidmalariatestshasmorethandoubled,thereferencestothepaediatricwardhaveincreased,andtheruralhealthcentresareconductingmore

consultations.Thepaediatricwardhasexpandedintooneoftheunusedbuildingsforthemalariaward,duetohighpatientvolume.Itistime.

Thelogisticsdepartmenthasbeenbusy.We’vebeenrepainting,repairingbeds,orderinginblankets,soapandmosquitonetsfordonationtoallpatients,andarrangingthefurnitureinthewards.We’rehalfwaythroughtherehabilitationofthehospital’swastearea,butithasremainedoperationalthroughout.

Ihavefourdaystoprioritiseandshuffleresourcesaround,andtogetreadyforaprovisionalopeningof30ofoureventual80beds.Thereareplentyoftrainingsanddeliveriestobedonebeforeopening,plustheusualactivityofsettingeverythingup.Thehospitalbuzzesallweekendwithlogisticalandmedicalteamsmovingeverythingintoplace,checkingequipment,photocopyingforms,hangingmosquitonets.

Mondaymorningat8amisthehoursetforopening.Afterourall-staffmeetingat7.30am,themedicsheadtotheward.Itieupsomelooseendsattheoffice(westillhaveafullrangeofexternalactivities,includingconstructingwasteareasatseveralruralhealthcentres),thenheadovertothehospital.Theteamhasdoneanincrediblejobwiththepreparations.Twenty-fivecrispbedslinethewallsofourthreerooms.Theadmissionsroomisorderedandstocked.Igreettheseveralnurses,hygienistsanddoctorswhoarethereandwetaketimetodiscussanyneedsorrequests.

Wehavenopatients.

Well,allofourindicatorswerestrong,soweknowthere’stheneedtohaveourwardopen,butasthehoursstretchbyandwedon’treceiveasinglepatient,westarttowonder.

Didwetellthehealthcentresthatwe’reopen?

Yes.

Dothepatientsknowhowtofindusatthehospital?

Yes.

Weird.

Fivedayslater,notonlyarewefull,butwe’veopenedtwonewroomswith10bedseach,andhaveafurther18newbedsinathirdbuilding.

Everybedisoccupiedwithasmallchildwithmalaria,withthemothercurledup

besidethem(mostofourpatientsareunderthreeyearsold).ThepatientsstartedarrivingonMondaynightandhaven’tstopped.Thenursesanddoctorsmovethroughthewardwithanefficientair,settingIVdripratesandtakingvitalsigns.It’sbusybutcontrolled.Theadmissionsroomismorehectic,sinceit’stheplaceforthefirstexaminationandinterventionbyourmedicalteam.Cryingchildrenanddistraughtmothersarereceivedherebeforebeingadmittedintothebusycalmofourward.

Thecommunicationbetweenthemedicalteamandthelogisticsteamisstrong,withrepairs,equipmentrequests,roomopeningsandmedicalwastemanagementallhappeningsmoothly.Thesystemsareinplace,andwecancontinuetogrowtoourcapacity.Thekitchenispreparinganddistributingmealsconsistentlyandreliably.Iturnmyattentionbacktothewasteareaandlatrinesthatarestillunderconstruction.

I’mhopingtofinishtheconstructionwithintheweek,becausearainshelterforallthemothersneedstobebuilt,andwe’relessthanamonthawayfromourfirstdistributionofmalariaprophylaxistothepopulationthroughoutthedistrict.

Andthepatientskeepcoming.

UNDERNEATHALLTHEDRAMA

AdamSharpworkedinSyriawithMédecinsSansFrontièresduringtheconflictthatbeganasprotestsin2011.Herehedescribestheimpactof

MédecinsSansFrontières’workonthepeoplethathemet.

©NicoleTung

THEFIRSTAMBULANCEarrivesbeforeweareready.Itisapick-uptruckcarryingtwowoundedmenfromthefrontlines,pallidandsemi-consciouslyingonmattressesintheback.Awaveofyoungmen-volunteersfromthesurroundingvillages-surgetowardsthetruckand20handsfloateachpatientontoastretcherandinsidetotheemergencyroom.

Adoctorquicklyseesthatoneofthewoundedmenneedsimmediateabdominalsurgery.Itisamassiveinjuryandthesurgerywillbecomplicated.Theman’schancesofsurvivalarefairatbest.

Williamarrivesat6.30am,onlyminutesafterthefirstwoundedmen.Heisasurgeon

with20yearsexperiencewithMédecinsSansFrontières,heissixfootfourandhasanaturallycalmdisposition-aganglyrockinthemiddleofthehecticbuzz.Withinfiveminutesheisoperatingontheinjuredman.

Anhourlater,everyonehasarrived:90localstaff-doctors,nurses,midwives,drivers,guards,clerksand12internationalstaff-mostlymedicalprofessionals,allworkingflatout.

Idonotknowtheoutcomeforthatfirstpatientthatmorning.Ilosttrackofhim,andcountlessothers,asinjuredmenandwomencontinuedtoarrive.Thesurgicalteamworkeduntil3amthenextday-theyworkedstraightthrough-andthiscontinuedforthebestpartoftwoweeks.Williamconductedover40moresurgeriesinthefollowingdaysand,ashetoldme,thehardestdayheeverhadasasurgeonwasthatfirstone.

Buthere’sthecatch.Thisisn’tthemostimportantworkthatMédecinsSansFrontièresisdoinginSyria.Thisisnotwherethemostlivesarebeingsaved,orwherethemostsufferingisbeingalleviated,orwherethemosthumandignityisbeingdefendedandupheld.

IwishIcouldwriteproperlyaboutthepeopleIhavemet,depictingtheirstorieswiththeinterest,fidelityandsensitivitythattheydeserve.ButinsteadIwillsaythatunderneathallofthisdrama-thebombsandthebloodshedandtheheadlines-thattherearepeople,justpeople,alltryingtolivetheirlivesandcontinuefromdaytoday.

Thesepeoplewanttotendtheirland,attendschool,lookafteragedparents,orgrowuptobecomedentists,electriciansorwriters.Theywanttogivebirth,findlove,findhappiness,seeksecurityfortheirfamily,orfindanewplacetolivenowthatababyisontheway.Theywanttodoallthethingsthatpeopledoallovertheworldeveryday.Butthisisacountryatwar.

AndthisiswhereMédecinsSansFrontièresismakingadifferencebyprovidinghealthcaretopeoplewherethehealthsystemhasevaporated,maternitycareforpregnantwomen,mentalhealthservicesforthebereaved,medicationforchronicillnesses,andantibioticsforsimpleinfections.

Theprovisionofhealthcaregenuinelyhelpspeoplemaintainsomecontrolanddignityintheirlives.ThehospitalsarestaffedbydedicatedSyrians,enabledbythepresenceofMédecinsSansFrontières-theequipment,medicationsandadditionalmedicalexpertisetheybring.Sowhilemanyliveshavebeensavedonasurgicaltable,MédecinsSansFrontièresisalsocoveringperhaps90percentofallhealthneedsforacatchmentpopulationofapproximately100,000people.

ADRENALINE

DrStephenTorresisanobstetrics/gynaecologyspecialist.Hereherecountsthestoryofababyhehelpeddeliverwhenworkingwith

MédecinsSansFrontièresinSierraLeonein2012.

©MSF

I’M58YEARSOLD.Ispent22yearsinprivatepracticeaftercompletingmytraininginobstetricsandgynaecology.IhopetospendthecomingyearsworkingwithMédecinsSansFrontièresinareasofneed.

MyfirstplacementwithMédecinsSansFrontièreswasin2012attheGondamaReferralCentreinBo,SierraLeone.Thisisareferralhospitalforpregnancycomplicationsandforpaediatrics.Iwanttosharewithyouapositivestoryfrommytimethere.

Iwenttobedataround2amandsleptforacoupleofhoursbutthenIreceivedanurgentphonecall.IhurriedovertothelabouranddeliverywardasquicklyasIcouldandfoundapatientwhohadjustarrivedbyambulance,pushing,withthebaby’sbuttockshalfwaydelivered.Thiswasherfirstbabyandbasedonthesizeofthebaby’sbuttocks,itwasn’tasmallkid.Therewasn’ttimetogetherbackforacaesareansoIputmyhat,

mask,eyeshields,apron,gown,anddoubleglovesoninrecordtimeandpreparedforabreechdelivery.Ifeltprettycalmthinkingoptimistically,“Whatcouldgowrong?”Well,everythingapparently.

Thebabydelivereduptoitshipsprettyeasily.Mumpushedagainandthebabydeliveredtheumbilicalcord.That’swhentheclockstartstickinginmyhead.Fromthatpointonthebaby’sumbilicalcordisbeingcompressedbetweenthebaby’sskullandthemum’spelvicbones,effectivelycuttingoffthedeliveryofoxygentothebaby.Wehadmumkeeppushingbutthebabydidn’tbudge.Irememberbeingtoldduringmyresidencyaboutvaginalbreechdeliveries,“Keepyourhandsoffuntilthebabyhasdelivereduptothescapulas(basicallyjustbelowtheshoulders.”Ikeptthatinmindandavoidedtryingtohelpthemotherbypullingonthebabyuntilanotherminutepassedandthebaby,whohadbeenkicking,startedgoinglimp.Icouldfeelthepulseintheumbilicalcordanditwasveryslow.Iputsometractiononthebaby’shipswhilehavingthemumpullherkneesasclosetoherchestaspossibletotryandgivethebabymoreroom-butthebabywasstuck.

I’veheardhorrorstoriesaboutbabiesthatdeliveruptotheheadandthengetstuckbutthat’soneofthosethingsyoualwaysthinkwillneverhappentoyou.Buthereitwashappening.OutofoptionsIdidtheonlythingIcoulddoandreachedupintothemotherandfoundthatbotharmsweretrappedabovethebaby’shead.Iwasabletogetonefingerpastthemum’spelvicbonesandhookedaroundthebaby’srightarmneartheelbowandtriedtopullthearmdown,bendingitattheelbow,butitwouldn’tmove.Ireallydon’tknowhowmuchtimehadpassedbythen.Itmayhaveonlybeenacoupleofminutesbutitseemedlikeaneternity.Iknewthatifsomethingdidn’thappenquicklytoimprovethesituationthebabywoulddiesoIpulledashardasIcouldonthatarm.

Ieventuallymanagedtogetthebaby’sheadout.ButthebabywasaslimpasaragandIcouldnolongerfeelapulseintheumbilicalcord.

Wemovedthebabyovertotheresuscitationtableandstartedresuscitatingthebaby.Iusedthebagandmasktoforceairintothebaby’slungswhilethenursestartedchestcompressions.

Nothing.

Werolledthebabytothesideandmassageditsback,slappeditsfeet,andthencontinuedbaggingandcompressing.

Stillnothing.

Themotherwaswailing,watchingus,helpless.Andthenthebabygasped.Itwasn’t

muchanditdidn’tlastlongbutitwasenoughtogiveushopeandwekeptworking,allthewhilewatchingthebaby’sduskybluecolourstarttolightenandthenturnintoamottledpaleandthenfinallyapinkishcolour.

Whenthebabyopeneditseyesandstartedcryingeveryoneintheroomjustlookedatthepersonnexttothem,eyeswideinsomethinglikedisbelief.Ithinkwhenyou’reusedtoseeingbabiesdie,watchingonecomebackfromthedeadisespeciallymiraculous.Themotherstartedcryingandchantingandwithinaminuteortwothebabywasscreamingitslungsout.

Itcould’vegoneeitherway.IhopethatIdon’tsomedayhavetotellastorylikethatbutwithadifferentending.

IwassohypeduponadrenalineafterwardsthatIdidn’tgobacktosleep.I’dbeeninBoforthreeweeksatthattimeandwasfindingitallalittlehardtobelieve.InsomewaysitfeltlikeIhadjustarrived,butinotherwaysitfeltlikeI’dbeentherealong,longtime.

WAVESOFPATIENTS

TyphoonHaiyan–PartI

DrEstherSterkisamedicaldoctorwhoarrivedinthePhilippinestoassistinMédecinsSansFrontières’responsetoTyphoonHaiyan.EstherassessedtheimmediateneedsinsomeoftheislandswestofCebu.ShedescribesherethefirstdaysofMédecinsSansFrontières’emergency

responseandherinitialimpressionsofthesituation.

©MSF

THEEASTERNPARTofPanayIslandhasbeenheavilyaffected.Insomevillages,80percentofthehouseshavebeenpartiallyorcompletelydestroyed.Alotofrooftopsandwallshavefallenorbeentornapart.Inmanycases,thewholehousehascompletelycollapsed.Ourteamarefocusingontheisolatedvillagesalongthecoastandonthesurroundingislands.Atthemomentwedonotknowifhealthcareisaccessibleandfunctioningthere,butmedicalfacilitiesarelikelytobedestroyed.

Peopletellusthattheyneeddrinkingwater,becausethelakeshavebecomesaltysincetheseawatersurged.Intheruralareasmanypeoplehavenomeansofsubsistenceastheircropshavebeendestroyed.Usually,thoselivingonsmallislandstravelfromoneislandtoanotherbyboat,butmanyboatshavebeenruined.Sickpeoplehavenowayof

reachingthemainisland.Onbiggerislands,communitiesareworkingtocleartheroadsthatarecoveredwithfallingtrees.

ThehospitalthatwevisitedinRoxasCity,inthenorthernpartofPanay,hasbeendamagedbutisstillfunctioning.Localmedicalstaffhavedonewhattheycantocopewiththefirstwaveofpatientswhosufferedfromfracturesandwoundsduetofallingobjects.

Butithasbeenrainingalotandsurvivorshavenoshelter.Wearenowpreparingforasecondwaveofpatients.Theyarealreadyseeingcasesofrespiratoryinfectionsanddiarrhoea,andweexpectthenumberofcasestoincrease.MédecinsSansFrontièreswillfocusonsupportingthelocalmedicalfacilitieswithstaff,drugsandmedicalequipment.Wealsoplantooperatemobileclinicsinremotevillagesandsmallislands.Withthefloods,therearealotofmosquitoessoweneedtobefast.Weareworriedaboutanincreaseinmalariaanddenguecases.Leptospirosis,aparasiticdiseaseisalsoathreat,asitisendemicinthispartofthePhilippines.

INFLATABLEHOSPITAL

TyphoonHaiyan–PartII

IntheaftermathofTyphoonHaiyan,aMédecinsSansFrontièresteamconstructedaninflatablehospitalonthedamagedseafrontofTacloban

–thePhilippinescityhardesthitbythetyphoon.

©YannLibessart

CONSISTINGOFFOURinflatabletentswithanareaof100squaremetreseachandafifthtentof45squaremetres,thehospitalcontainsanemergencyroom,awoundcareroom,apharmacy,andupto45hospitalbeds.

AdditionalcarewillbeprovidedwithinBethanyHospitaloncerepairshavebeencompletedtothedamagedsurgicalward,maternityward,neonatalunitandtheunitforsterilisingequipment.

“AlongsideFilipinoandinternationalvolunteers,weworkedhardallnight,inthe

pouringrain,sothatthehospitalwouldbeinplacethismorning,”saysYannLibessartfromMédecinsSansFrontières’emergencyteaminTacloban.“Gettingthesitereadyandinstallingthehospitalwasamajorlogisticalchallenge.FirstwehadtoclearthecourtyardandoutdoorareasofBethanyHospital–itwasatitanictask.”

OurmedicalteamsbasedintheinflatablehospitalalsoaimtosupportthefewhospitalsinTaclobanthatarestillfunctioning,andtotakeoversomeoftheworkofthefirstrescueteamstoarriveonthescene,includingsoldiers,whoarenowstartingtoleavethecity.

“Thefirstphaseoftheemergencyisnowover,”saysLaurentSury,EmergencyCoordinator,“andweexpectmainlytobetreatingpatientswithcommondiseasesorconditionsrelatedtopooraccesstohealthcare,suchaswomenwithcomplicateddeliveriesandpeoplewithchronicillnesses.Ourgoalistosupportthehealthsystemintheregionforthetimeittakestoreturntonormality.”

MédecinsSansFrontières’standaloneinflatablehospitalwasdevelopedwiththespecificpurposeofhelpingitsemergencyteamsrespondquicklytonaturaldisasters,enablingthemtoprovidepeoplewithqualityhealthcarewhiledamagedhealthfacilitiesarebeingreconstructedorrepaired.

ANUGLYDISEASE

DrAnnSellbergdescribesMédecinsSansFrontières’worktreatingchildrenwithHIVinZimbabwe,oneofthecountrieshardesthitbythe

epidemic.

©AnnSellberg

IREMEMBERTHEfirstchildIbroughttothecounsellorfordisclosure–theprocessoffindingouttheyareHIVpositive.Irememberhowhestaredatherwithbigeyeswhilesheshowedpicturesofthe‘soldiers’(theimmunesystem)andthevirus.

“InonziHIV,”shesaid,pointingattheangry-lookinggreenblob,showingitsfangs.“It’scalledHIV.”

Thechilddidn’tsaymuch;hejustkeptstaringatthepictureswiththosebigeyes,smilingbashfullyattimeswhenshewasaskinghimquestions.Towardstheendsheaskedhimtodrawapicture.Hetookhistimedrawingagirl,makingsuretofillinthe

armsandlegswithmanysmallblacklines.Ontopofherhewrote:Ebola.Thecounsellorlaughed.

“NotEbola.HIV!”Shetookhispenandscratchedoutwhathehadwritten.

“Couldyouaskhimtoexplainhispicture?”Isaid.Theboyspokewithashyvoice,butheusedmorewordsthanIhadexpected.

“Heissayingthegirlisugly,likeHIV.HewroteEbola*becausetheylearntaboutitinschool,anditisscary,likeHIV.”

Hewasanine-year-oldboyandIhadtoconvincehismothertobringhimintobetoldabouthisHIVpositivestatus.“He’stooyoung,”shesaid.“Hewon’tunderstand.”

Iexplainedtoherthatitisbetterforchildrentofindoutearly,thatitislesstraumaticandhelpsthemtoadheretotheirmedication.

“Besides,thecounsellorhaswaysofexplainingthatkidsunderstand.”Iwassurprisedathoweasyitwastoconvinceher,asthoughshewasjustwaitingforapush.

ThenexttimeIsawhimhewassmilingatme,andwedida‘givemefive’.Itwasatthesupportgroupforkidsandhewastakingeverythinginwithbigeyes.Iwashappytoseehim.Iknewthatwehadmadeadifferenceasthischildhadabetterchanceofcaringforhimselfandhisconditionwhenheknewwhathewassufferingfrom.

Thenurseshavemadeasurveyofhowmanykidshavereceiveddisclosure.Ninety-eightpercentofkidsagedfiveto10,57percentofkidsaged11to15and14percentofadolescentsaged16to20didnotknowthattheyhadHIV.Imaginethat!Achildthathasbeentakingpillsallhislife,almostreachingadulthood,maybeevenhavingsex,withoutknowingabouthisstatus.Nowondersomanyofthemarethrowingawaytheirpills,pretendingtotakethembutsecretlyhidingthemundertheirpillow.

“Wewillfocusondisclosure,”Isaidontheproject’sannualpresentationsofourplansfor2015.Itmaysoundlikeemptywords,butitisreallyhappening.Thecounsellorsarehavingdisclosurediscussionswiththecaregiversandthenursesareencouragingmoreandmorecaregiverstogowiththeirkidstothecounsellorfordisclosure.

I’mamazedathowwellitisworking.Ifwearemanagingtogetmostkidstoknowabouttheirstatus,thenwewillhavemadeahugedifferencetothispopulation.AndevenifMédecinsSansFrontièresisn’taroundinthefuture,theimpactwillstillbehere.

*Todate,nocasesofEbolahavebeenreportedinZimbabwe.

THETIMETODECIDE

MédecinsSansFrontièreshasworkedinAfghanistansince1981.InDasht-e-Barchi,MédecinsSansFrontièreshasworkedhand-in-handwith

theMinistryofPublicHealth(MoPH)tosupportthematernitydepartmentofthedistricthospital.MédecinsSansFrontièreshasalso

supportedtheMoPHinAhmadShahBabahospitalineasternKabulandBoosthospitalinLashkarGah,Helmandprovince.

©MathildeVu

ITISfourO’CLOCKinthemorning.

Awakenedbyaphonecall,theMédecinsSansFrontièresteamhurriestothematernityward.ThedistrictofDasht-e-BarchiinWestKabulissleeping,butinsidethehospitaltheurgency,anxiety,andexcitementarepalpable.

Thebrandnew42-bedmaternitywardwasanemptybuildingnottoolongago.Ninemonthslater,thelaunchoftheprojecthasbeenalittlelikeacomplicatedpregnancy.Now,acoupledaysaftertheopening,ayoungpatientsufferingfromcomplicationshasarrivedinthemiddleofthenight.

Inthedeliveryroom,Sarai-theseventeen-year-oldpatient-liesonthebed.Shehasalreadybeeninlabourformanyhours.Sheissilent,butherfaceiscontortedinpain.Herlabourisobstructedandshewillneedanemergencycaesareansectiontodeliverherbaby.

Complicationslikethisarecommon,but,inAfghanistan,thenumberofmedicalfacilitiesequippedtomanagesuchproblemsiswoefullysmall,eveninthecapital.Mostwomenandtheirfamiliescannotaffordtopayforprivatemedicalconsultationsandendupgivingbirthunassistedintheirownhomes.Inthecaseofcomplicationslikethisone,andintheabsenceoftrainedmedicalassistance,givingbirthcanbefatal.

TheteaminMédecinsSansFrontières’newmaternitywardfocusesonsuchcomplicatedbirths,andonsavingthelivesofmothersandbabieswhohavenowhereelsetogotoreceivespecialisedcare.Locatedinabuzzingmarketplacebehindagasstation,Dasht-e-Barchihospitalandthreesmallsatellitehealthcentresaretheonlyoptionsforpublichealthcareinthedistrict.

ThepopulationofthisneighbourhoodofKabulisestimatedtohavegrowntenfoldoverthepast10years,andnowhasmorethanonemillioninhabitants.ThepublicmaternityhospitalsupportedbyMédecinsSansFrontièreswillnotbeabletocatertoallthehealthneedsinthearea,buttheteamexpectstoseemorethan130complicatedcaseseachmonthoutofanestimated600normaldeliveries.

Saraiwillneedtobeoperatedonsoon.MédecinsSansFrontièresmidwifeDanielatransfershertotheoperatingtheatreteam,RenatethenurseandDianathegynaecologist.

Thelightsareblazingintheoperatingtheatre.Everythingfromtheprobetotheanaesthesiamachineisbrandnew.Inthepastweek,duringthedressrehearsal,everypieceofequipment,electricalcircuit,waterpump,andinfectioncontrolinstrumentwastested.

LaunchinganewMédecinsSansFrontièresprojectreliesheavilyonthiskindofbehind-the-scenespreparation.Thelogisticalteamworkedformonthstorehabilitatethematernitybuildingintheexistingpublichospital,strivingtoachievethehighstandardsforwhichMédecinsSansFrontièresfacilitiesareknownthroughout

Afghanistanandtheworld.

At5am,ababycries-it’saseven-poundboy.Saraiissafeandshecatchesherbreath.Shehasn’tthoughtofanameyet,but,becauseofthecareshereceived,shehastimetodecide.

Patientnamehasbeenchanged.

SURVIVINGWARANDGOINGBACK

Aftersurvivingwar,notmanypeoplewouldchoosetogobacktoaconflictzone,butthat’sexactlywhatNurseAbdulWassaydid.AsanAfghanrefugeegrowingupinPakistan,hesawfirsthandtheurgent

medicalcareMédecinsSansFrontièresdeliverstopeopleinwarzones.Afterworkingwithusnearhishome,hevolunteeredtohelpothersin

anotherconflict-torncountry-SouthSudan.

©JasonCone

I’VEBEENTHEMedicalTeamLeaderforthepast11monthshereatMédecinsSansFrontières’100-bedhospital.AfterworkingforMédecinsSansFrontièresforseveralyearsinPakistanandseeingthecriticalassistancewedeliver,IdecidedtocometoSouthSudantotreatpeoplesufferingfromtheeffectsof30yearsofwar.

LankienHospitalistheonlyoneofitskindforhundredsofmilesineverydirection.

Ourwardsarefilledwithmalnourishedchildren,expectantmotherswithcomplications,andpeoplesufferingfromtuberculosisandkala-azar,aneglectedtropicaldisease.Patientscomefromhoursaway,mostlytravellingtheruggedlandscapeonfoot.And,whenviolencebreaksoutbetweenlocalgroups,wecanfacewaveafterwaveofwoundedpatients.

ThousandsofpeoplehavebeenimpactedbythefightinginSouthSudan,andmanymen,womenandchildrenhavenowheretoturnformedicalcare.

Wenotonlyfacedthechallengeoftreatingseriousinjuries,wealsoneededtomakesurethebattlefielddidn’tmakeitswayintothehospital.WhilemycolleaguesandItriedtostopthebleeding,checkvitalsigns,andadministerIVfluidsandantibioticstostaveoffshockandinfection,Iwasalreadythinkingaboutwhatwewouldneedtodotomaintainthesafetyofourstaffandpatients.

Becauseweweretreatingpeopleonbothsidesoftheconflict,wehadtokeepourpatientsseparatedindifferentwards.Wealsorestrictedtheaccessofpeopleenteringandleavingthehospital.Butevenwiththesechanges,ourstaffstillsearchedeverypersonenteringtheinpatientcareareaforweapons,toprovideanextralayerofprotection.

ImpartialityandneutralityarecriticaltoolsformaintainingthesecurityofMédecinsSansFrontières’teamsandpatients.Andtheindependentfinancialsupportwereceivefrommembersofthepublicplaysacrucialroleinhelpingustreatanyoneneedingemergencymedicalcareinthemidstofaconflict.

Deliveringqualitymedicalcareinconflictzonesisnevereasy,butourteamshavetheexpertiseandexperiencetodowhateverittakestosavelives.

STORYBOOKTHERAPY

SteveCohenisaforensicpsychiatristwhowaspartoftheresponseinthePhilippinesfollowingTyphoonHaiyan.StevewaspartofMédecinsSansFrontières’MentalHealthTeamwhoprovidedoutreachcareinhard-hitregions,evacuationcentres,schools,andinpatientandoutpatient

departments.

©MSF

MEDECINSSANSFRONTIERES’programstakeamassiveamountofcoordinationandeffort,spanningseveralcontinentsinreal-time,whichinturncanbeintense,complicatedandtrying.Attendingtothepersonalneedsofthehumanitarianstaffcontinues,allwhilesourcingaplacetosetupahospital,hiringstaff,andgettingeverythingfromsurgicalamphitheatres,neonatalunits,mobileandoutreachclinics,andmentalhealthservicesupandrunning.

Attimes,thebodilyneedsareeasiertounderstandthanmentalhealthneeds.Weseeabrokenbone,hearacough,andcanmeasuretheblood-glucoselevel.Thereasonsthatapersoncomestotheattentionofmentalhealthcareprofessionalsareoftenduetoconspicuousabsencesoffunctioningathome,socially,oratworkorschool.Thisisespeciallytrueinchildren,forexampleaquietchild,decreaseinconcentrationorattention,fearfulnessatnightandsomeavoidanceofsocialplay…thesethingscouldgounrecognised.

TheelementaryschoolprogramwassetupaspartoftheTaclobanProject.Thechildren,abouttenpersession,huddleinacirclewhileoneofourstaffreadsthe

storybook,ATerribleThingHappened,byMargaretHolmes.

Thestudentscomefromtwocoastalelementaryschoolswhichwereidentifiedasthehardesthitbythetyphoon.Thenumbersarestaggering.Sixty-sevenchildrendiedinoneschool,whichrepresentsabout15percentofthetotalnumberofstudents.Wordsfailwhentryingtocapturethetragedy,andtheheartbreak.

AndthisiswhereShermantheRaccooncomesin.Somethingbadhappenedtotheyoungraccoon,andhebeginstoshowsignsoffear,stress,andacting-outbehaviour.Therearefoursessionswitheachgroup;thefirstthreeinvolvereadingthebookinthreeparts.Afterthefirstsession,thechildrenareaskedtodrawonpaperwhatShermanmaybeafraidof.Inthesecondpart,Shermanishavingsomedifficultyinschoolandwithfriendsandfamily,andtriestofindwaystocalmhimself.ThechildrenareaskedhowShermaniscopingwiththe“verybadthing,”andhowheisfindingwaystoself-sootheorpacifyhisinnerturmoil.ThefinalpartofthebookinvolvesatherapistwhoShermantalksto,andeventuallyhefeelsbetter.ThechildrenareaskedtodrawtheirthoughtsaboutShermannowthathefeelsbetter,andwhatShermanmightdowithhisre-foundhappiness.

©SteveCohen

Thechildrenexplaintooneofourfourprogramstaffthemeaningoftheirdrawings,andthethemesaretrackedthroughoutthefourweeks.Itisatherapeuticprocessonitsown,butwhensomestudentsareclearlyexhibitingadeclineinschoolfunctioning

(sometimestothepointofrefusingtoattendschool),moreintensiveworkisdone.

CaregiversandteachersareconsultedandchildrenareassessedusingatooldevelopedbyMédecinsSansFrontières.Individualtherapyisalsodonewiththechildandcaregivers.

Thewindandraincomesandthechildrenstillexhibitsomehesitancyorfear,butitpassesquicklyformost,andasongissung.Moststudentsnowrunoutsidetoplayintherain.

Over100childrenperweekparticipatedinthestorybooksessions,andfivetotenperweekhadindividualtherapy.Primaryhealthcareincludesmentalhealthcare.Ifwedon’thavestaffwhoareknowledgeableandcommittedtomentalhealthwork,eitherinadisastersettingorinalonger-termcrisissetting,wearemissingsufferingthatisidentifiableandtreatable.

MYHEARTLEAPSFORJOY

DrJosineBlanksmaworkedforMédecinsSansFrontièresinBarakahospitalineasternDemocraticRepublicofCongoforeightmonths.

Duringhertimethere,Josinetreatedhundredsofpatientsformalaria,aparasiticinfectionthatcanbefatal,particularlyinchildren.

Hereshedescribeswhatitwasliketreatingheryoungpatientsforthedisease.

©JeroenOerlemans

INTHEWARD,thenursesarealwaysbusy:movingaround,takingtemperatures,checkingtheheartratesofthelittleones,checkinghowthey’rebreathing,administeringmedicationsorputtinginadripwhenthechildrenaretooweaktoswallowpills.

Igofrombedtobedexaminingthepatients.Inchildren,malariacanrapidlybecomefatal,soit’sreallyimportantthatwepaycloseattentiontotheirsymptoms.Arethey

breathingsoftly,oraretheyshowingsignsofrespiratorydistress?Aretheylosingconsciousness,oraretheyhavingseizures?

Atthatpoint,alotofredbloodcellshavebeendestroyed,andthebrainandotherorgansarenotgettingenoughoxygen.WebringthechildrenimmediatelytotheIntensiveCareUnit(ICU),administeroxygenandgivethembloodifnecessary.We’reworkingaroundtheclock,doingeverythingwecantosavechildren’slives.

ItisthepeakofthemalariaseasonintheDemocraticRepublicofCongo(DRC).Everyday,manypatientsarriveatthehospitalwithseveremalaria.

Luckily,inmostcases,we’reabletohelpthemintime.

“Twodaysagomysondevelopedafever.He’sbeenvomiting,”aworriedyoungmothertellsme.Shecradlesherunconsciousandverypalethree-year-oldboyinherarms.

Wedoabloodtestrightaway.Mysuspicionisconfirmed:thelittleboyhasmalaria.

Wemedicatehimthroughadrip,andhegetsabloodtransfusionasthemalariaparasitehasbeenattackinghisredbloodcells.Wegivehimoxygenthroughamask,andfeedhimtherapeuticmilkthroughanasogastrictube.

Wehavedoneeverythinginourpower;nowwemustwaittoseeifhislittlebodycandefeatthedisease.I’mafraidforhislife.

WhenIwakeupthenextmorningandgotothehospital,thelittleboyisawake.Hismotherisfeedinghimporridge.Twodayslaterhe’shealthyagain,andwecandischargehim.

Onanotherday,twochildrenarriveatthehospitalsufferingfromseveremalaria.Thefive-year-oldboyhasbeendriftinginandoutofconsciousness,andthethree-year-oldgirlisinacoma.Ifeartheworst.

ButmyheartleapsforjoythenextmorningwhenIseethem:thelittlegirlisawake,lookingatmewithinterest.Theboyissittingupinbedandiseveneatingagain.

Themalariaseasonwasparticularlybadthisyear,andourhelpmakesallthedifferenceforthefamilies.TherearemanyplacesinDRCwhereMédecinsSansFrontièresistheonlyprovideroffreemedicalcare.

InDRC,myteamandIprovidelifesavingtreatmenttochildrenlikethislittleboyevery

day.AsIknowI’llbeanauntsoon,patientsuccessstorieslikethistouchmeallthemore.

SMALLMIRACLES

HereDrKellyHildebranddescribeshertimeinthePaediatricUnitsintheAweilReferralHospitalinSouthSudan.

©MSF

IHAVENOWbeenhereforsixweeksandIhaveexperiencedeverypossibleemotionfromfatigueandhopelessnesstosheerjoyandgratefulness.

OurhospitalhasbeenovercapacitysinceIarrivedaveraging120to130patientsinPaediatricsonagivenday(Ibelievethebedsarefor70to80patientsbutwehavetwinsinmanybedsandmattressesontheflooreverywhere).

Inmyneonatalunit,Iacceptverylowbirthweightinfants(1.25kilogramsandabove)withgestationalagesasearlyassixmonths.Thetetanusroomhashadfivetoeightchildrenatatime,mostlyneonatesbornathomewhogettheinfectionfromtheumbilicalcordasithasbeencutwithoutanappropriatecleantool.ThePaediatricICUisoverflowingwithmalaria,malnutritionandrespiratoryillnesses.

Thefirstweekswereextremelyhardonme.IspentalotoftimeandenergyfocusingonwhatIcouldnotdo,insteadofacknowledginghowmuchwewereaccomplishing.IwasworriedaboutgapsinmyknowledgeasIamageneralpaediatrician,notanICUdoctor(thoughIamsogratefulfortheICUtrainingIreceivedinresidency).IwasdrainingmyselfemotionallyandrealisedmentallyIwouldnotsurviveifIkepttravellingthisroute.

Twosmallmiracleshappenedformerightaroundthesametimeanditwastheturning

pointIneeded.

Duringmyfirstweekhere,amumbroughtinhertwo-week-oldbabywhoshehadgivenbirthtoathome.Thebabyhadstoppedbreastfeedingandwashavingtroublebreathing.Weplacedapulseoximeteronthechildandheroxygenlevelwasreallylow.Shehadcracklesinherlungsandaloudmurmur.Iknewshewasinheartfailure.Itoldhermumwewoulddowhatwecouldbutthechildmaynotsurvivethenight.

Westartedoxygen,gaveasmallbolusfordehydration(asmallvolumeoffluid),startedantibiotics,somemaintenancefluidsasthechildwastoosicktobreastfeedandgavediuretics.Ireallydidnotthinkthechildwouldmakeitthroughthenight,butthenextmorningthereshewasbreathingfastandretractingbutstillalive.Shenowhadoedema(swelling)andaliveredge(signsofworseningheartfailure)sofluidswerestoppedandanasogastrictubewasplaced.Themumwastaughthowtoexpressbreastmilkandhowtoplaceitinthetubeforherchild.Thepatientsurvivedfordayslikethis,herlungswerefulloffluid,allIcouldhearwerecrackles.Sheweighedlessthan1.8kilogramsandallhereffortswenttowardsbreathing(allwehadwerefivelitresofoxygenbynasalcannulatosupportbreathing).ItalkedwithhermumdailyandsheknewIhadaguardedprognosis,butIwouldcontinuetodowhatIcould.

Thenonemorning,Ididmyexaminationandtheyweregone,thecrackleswerejustgone.Iheardclearbreathsounds.ImusthavelistenedforwhatfeltlikeagesbutIcouldn’tbelievewhatIwashearing,orwasn’thearing.Overthenext10days,shecontinuedtoimprove.Shestartedbreastfeedingandthefeedingtubewasremoved.

Shecameoffoxygenandfinally,shegainedweight.Onemonthandonedaylater,Iwassendingherhome.Shestillhasamurmurandshemaygetsickagainbutfornowshe’sthriving.Itoldhermumsheismymiraclechild.(Forthemedicalpeoplemyonlyexplanationwaspersistentpulmonaryhypertensionthatslowlyimprovedwithtime.)

Mysecondsmallmiraclehappenedrightaroundthesametime.Ihavebeenstrugglingwithmalnutrition.Themortalityrateishighwhenamalnourishedchildgoesintoshockandithasbeenextremelyfrustratingforme,especiallysincemalnutritionisnotsomethingIseeathome.

Apatientwastransferredtomefromthefeedingcentrefordecompensation-asuddendeteriorationincondition-andbythetimeshearrivedshewasinshock,non-responsive,withcoolextremities,andaweakpulse.Againmyhopeforresuscitationwasnotgreatandthefluidbalancesinmalnourishedchildrencanbetricky.

Wegaveasmallbolusandstartedantibiotics.Sherespondedalittletothefluidsowe

gaveanothersmallbolusandthenplacedanasogastrictubetorehydrate.Wegavearehydrationsolutionthroughthenight.Isaidgoodnightandgavestrictinstructionstothenightstaff.Ididn’thearfromthemthatnightsoIwasnotsurewhattoexpectthenextmorning,butonceagainwhenIarrivedthereshewassittingupinbeddrinking.Iwantedtocry,Iwassohappy.

Shewasmyfirstmalnourishedchildinshocktorecover.Shecontinuedtoimproveandstartedtogainweight.

ThedaysarestillupanddownandthebaddaysarestillbadbutI’mstartingtoseeallthegoodwedohereaswellandIkeepholdingoutforsmallmiracles!

RECONSTRUCTINGBODIES

ThisisaninterviewwithOrthopaedicSurgeonDrAliAl-AniabouttheworkhedidwithMédecinsSansFrontièresattheReconstructiveSurgeryProjectinAmman,Jordan.TheprojectservesSyrian,Iraqi,Yemeniand

Palestinianrefugees.

©EnassAbuKhalaf-Tuffaha/MSF

TellusaboutyourselfandyourroleattheAmmanproject?

MynameisDrAliAl-AniandIamfromIraq.ImovedwithmyfamilyfromIraqtoAmmanin2005becausethesecuritysituationwasverydangerousanditwasimpossibletoliveanormallife.Ibeganworkingwiththeprojectasanorthopaedicsurgeonin2007.

Whatkindofpatientsdoyousee?

Ourpatientsarevictimsofconflictintheregion.Forthefirsttwoyearsoftheproject,wereceivedonlypatientsfromIraq.In2008,weexpandedandstartedtoacceptpatientsfromothercountriesaffectedbyviolenceintheregion–we’vesincereceivedpatientsfromGaza,YemenandSyria.Themajorityofthecasesthatwedealwitharecomplex.

Whatkindofcasescanbeacceptedontheproject?

Ourselectioncriteriacoverthreespecialties:orthopaedic,maxillofacialandplasticsurgery.Manyofourpatientshaveboneinfections,requiringlengthytreatmentprocedures.Wealsoreceivepatientswhosebrokenboneshavenotfusedproperly,withorwithoutsofttissuedefect,aswellaspatientswithboneloss,nerveinjuries,andassociatedphysicaldeformitiesasalong-termconsequenceofuntreatedtrauma.

Duetothenatureofconflict-relatedinjuries,eachnewcaseisachallengeandeachwoundedpatientisincomparabletoanother.Howareyouaffectedpersonallybyyourwork?

IamasurgeonbutIamalsoahuman-beingandaffectedbywhatIseeinmywork.IfeelpainwhenIamface-to-facewithinnocentchildrenandoldermenandwomenwhoseliveshavebeenforeverchangedbyman-madeconflict.Butasasurgeon,Iaminapositiontotreatthesevulnerablepeople,tomakethemsmileandenjoyasenseofindependenceagain.Ifeelproudthatthisprojecthasrelievedthesufferingofsomanypatients–byreconstructingtheirinjuredbodiesandhelpingthemtoregainfunctionality–especiallyasthosewhoarereferredheremaynotbeabletoaffordsuchcareotherwise.

Eachpatienthastheirownstoryofalifeaffectedbywar.ButthestoryofasevenyearoldIraqiboywhowasadmittedtotheprojectin2009touchedmemost.Rahimwasonhiswaytovisithisgrandparentswhenaroadsidebombexploded.HismotherwaskilledandRahimwasbadlyinjured.Helosthisrightlegandhisleftlegwasseverelydamaged.Despitethecomplexityofthesurgeries,overthecourseofseveraloperationsthesurgicalteamwasabletoreconstructhisdamagedlegsufficientlyforthelegtobearweight,andtoattachprosthetics,sothatRahimwasabletowalkagain.

WhatdifficultiesdopatientsfacewhentheyreturntoIraq?

Themaindifficultyisaccesstofollow-uptreatmentbackhome.Thisincludespsychosocialsupportandphysiotherapy.AlthoughwetrytofinalisetreatmentinAmman,theseinjuriesoftenrequirealotoffollow-upaftersurgery,andthisisabig

challenge.

Whatareyourhopesforthefutureoftheproject?

Theprojecthasexpandedconsiderablysince2006,andwehavepositiveplansforthefuture.Wewillsoonbemovingtoanewfacilitywhichwillimprovethequalityofcareandincreasetheproject’stechnicalcapacityandscope.Itmayalsoallowustoaddnewtypesofsurgery.

Patientnamehasbeenchanged.

DAUGHTEROFTHEFLOODS

WeeksafterMalawiwasdevastatedbythelargestfloodsinlivingmemory,peoplewerestillstrugglingtogetonwiththeirlivesandpreparingasbestastheycouldforadifficultfutureahead,likethe

arrivalofanewbaby.

©RowanPybus/MSF

MARTHADIDN’TRUNwhenthefloodshit.Shedidn’trunbecausetherewasnowheretogo.Makhanga,aclusterofvillageswithapopulationof5,000,restsonwhatcanbarelybecalledahill,butisnonethelessonslightlyhighergroundthanthevastplainsofsouthMalawi.

ButtheotherreasonthatMarthadidn’trunisbecauseshewaseightmonthspregnant.

Thewatercameduringthenight.At3.00amMarthawokeup.Therewaswaterinherhouse,lickingtheblanketonwhichsheslept.

Slowly,slowly,itcreptup.Ankledeep,kneedeep…untilmidnightwhenitreachedherwindowsill.Itateupthecornfieldsthatfeedthevillage.Itcontaminatedthewellsthatsustainthefamilies.Itblanketedthelocalclinicwiththick,oozymudwhichclungto

drugs,toinstruments,toeverything.

Therewasnowheretogobutup;therewasnothingupbuttrees.Victor,Martha’shusband,hauledhisheavywifeandtheirfivechildrenupontothebranches,stilldrenchedfromtheheavyrains.

Theystayedthereforfourdays.Thebabykeptkicking.

Andthenitwastime.Earlyonemorning,13daysafterthefloodscameandwentandstoleallofherpossessions,Marthafeltthebabywasready,evenifshewasnot.

“Wewenttotheclinic,butitwasclosed.Therewasnoonetheretohelp.Iwastoldtowait,thatahelicopterwascoming,thatitcouldtakemetoanotherclinic,”sherecalls.Bythattime,Makhangavillagehadbecomeanislandcutofffromtherestofthecountry,apartfromaslowtrickleofaiddroppedfromtheair.

“Whenwelandedweweretoldtherewasawomaninadvancedlabour,butnobodytodeliverthebaby.Soitwasuptome,”saysCliveKasalu,aMalawiannurseandmidwifeworkingforMédecinsSansFrontières.Clivehadanemergencydeliverykitand14yearsexperienceunderhisbelt,sohefeltconfident.Butstill,“wehadtoimproviseabit,”hesays.

OnlypartsoftheclinichadbeencleanedupduringthethreedaysthatMédecinsSansFrontièreshadateamatworkinMakhanga.Cliveenlistedanassistantto“runupanddowntogetuswater,”whilefocusingonthesufferingmother.

Withinanhour,Marthawasengulfedbybirthingpains,sweatingandclingingtothebarebedwhileherhusbandVictor,thevillage’sheadman,waitedoutside,worrying–it’staboohereforfatherstoattendabirth.

Andthen,atnoon,Makhangahadonemorevillager:ahealthy,screaming,hungry,2.9kilogrambabygirl.

Patientnameshavebeenchanged.

ABEAUTIFULDAYINTAJIKISTAN

Rukhshonahadmultidrug-resistanttuberculosis(MDR-TB),butfollowingtreatmentinMédecinsSansFrontières’projectinTajikistan,sheisnowcured.“Thisisajoyful,memorableday”,saidproject

coordinatorBeatriceLau.“ThetreatmentforMDR-TBisextremelyhardandtakesalongtime.WeareveryproudofRukhshonathatshehas

persevered.”

©WendyMarijnissen

WHENRUKHSHONAARRIVESatherparty,sheisgreetedwarmlyandshoweredwithcongratulatorywishes.Allthepraisemakeshervisiblyuncomfortable.Nevertheless,sheisthrilledwiththepartyand,ofcourse,thereasonsforhavingit.“In2011,Iwashospitalised”,shesaid.“Ihadafever,wasnauseousandwascoughingupblood.Itmademeterriblyworried.Thatseemssolongagonow.”“Thedifferencecouldn’tbegreater,”Rukhshona’smothersaid.“Shewasveryill,shewasadifferentpersonthen.Hertreatmentwassohardandtookalotoutofher.”

PatientsreceiveaparticularlygruellingtreatmentforMDR-TB(multidrug-resistanttuberculosis),withapainfulinjectionandtakingupto20pillseveryday.Thedrugsareoftenaccompaniedwithserioussideeffects.“Igotterribleheadachesandpaininmystomachandlegs,”saysRukhshona.“Icouldbarelywalk.Iwasalsonauseousandhadtovomitoften.Ifeltsoweak.”

“AtfirstIdidnotevenknowwhatTBwas,”shecontinues.“Iwassick,butwhatdidIhave?Ididn’tknowifIcouldbetreated.Thatwasveryscary.EspeciallywhenIstartedtocoughupblood.IonlystartedtobelieveIcouldgetcuredwhenIstartedtakingmymedicationandbegantofeelalittlebetterbitbybit.”

Asateenagerwhocouldn’tgotoschool,whocouldn’tseeherfriends,Rukhshonaoftenfeltveryalone.ShefoundcomfortinthepoemsandsongsofRudaki,aPersianpoetwholivedcenturiesago,intheareawhereTajikistannowlies.“Hisversesareaboutlife,aboutrespectforpeople.Itmademeveryhappy.”

Shereceivedunconditionalsupportfromhermother,eventhoughthetreatmentwasafightforher,too.Shefoundithardtoseeherdaughtergothroughsuchhardtimes.“Shewasveryworriedaboutme,”Rukhshonasaid.“Butshewasalwaysbymyside,andhelpedmethroughthedays.Shewasveryscaredthough,andIhadtocheerherupandtellhereverythingwouldbeokay,eventhoughIwastheonewhowassick.”

Despiteherworries,Rukhshona’smotherwantedherdaughtertofinishhertreatment.“Someparentsdonotbelieveintreatment.Theirchildrendon’tsurvive,”shesaid.“I’mverygratefultoMédecinsSansFrontièresfortheircare,themedication,andtheirsupport.”

Meanwhile,thepartyisunderway.Thereisdancing,singing,andlotsoflaughter.“It’sabeautifulday,”hermothersaid.“ForMédecinsSansFrontièrestoo.Rukhshonaisproofthatpeople,children,withMDR-TBcanbecuredandhaveafuture.”Rukhshonanodsandaddressesthesmallpatientsaroundher.“IthoughtIwouldnevergetbetter,”shesaid.“ButthecareandsupportIreceivedhelpedmegetwell.I’mcurednow.Youhavetokeepbelievingthatit’spossible.”

Patientnamehasbeenchanged.

AISHA

WhenAisha’sgrandmotherbroughthertotheoutpatientpostwhereMédecinsSansFrontièresteamswereconductingoutreachactivitiesinAfar,Ethiopia,everybodythoughtshehadjustafewdaystolive.

©FaithSchwieker-Miyandazi

“IHADGIVENuphopeonmygrandchild,”saysEisa,Aisha’sgrandmother.“Ithoughtshewasgoingtodielikethethreeothersbeforeher.”

Theone-year-oldwassufferingfromsevereacutemalnutritionwhenshearrivedatouroutreachpost.Hermotherwasalsoailingandsuffersfrompsychosis.ShewasinnoconditiontotakecareofAishaandherolderbrother,leavingthegrandmotherastheirsoleguardian.

OurteamtravelledtoAfarinApril2013inresponsetoanutritionalemergency.Afarisvast,andTeru-theareathatwecover-isoneofitsmostremoteandneglectedregions.Subjecttohugesandstormsandextremetemperaturesinthedryseasonandviolentrainstormsthatfloodriversandrenderroadsimpassableduringtherainyseason,Teruisanextremelydifficultcontextinwhichtowork.

TheAfariareapastoralnomadicpeoplewhomovefromplacetoplaceinsearchofwaterandpasturefortheiranimals.Livingthiswaymakesitdifficulttoadheretotreatmentregimens,meaningthatmanypeopledefaultbeforecompletingtheprogram.Italsomakesitdifficultforourteamstofollowupwithpeoplewhodefault.

Ourinterventioncovered12Kebeles(provincialadministrativeunits),whoseinhabitantsarecompletelycutofffromhealthcare.Thedecisiontointervenewasreachedafteranassessmentrevealedanalarmingrateofsevereacutemalnutritionintheregion-26.6percentofanestimatedcatchmentpopulationof87,374peoplesufferfromthecondition.

“Mostofthecasesthatweadmitinthestabilisationcentrearesevereacutemalnutritionwithcomplications,”saysFrankKatambula,MédecinsSansFrontièresMedicalTeamLeaderinAfar.“What’smore,”headds,“mostofthesearecombinedwitheitherpneumoniaorTB.”

DespitethedifficultiesrelatedtoprovidingcareinTeru,mostcaseshavenowstabilisedandchildrenundertheageoffivecontinuetoreceivetherapeuticfood.Overall,atotalof726malnourishedchildrenwereadmittedtothetherapeuticfeedingprogramand1,154moderatelyacutemalnourishedpatients(including416pregnantandlactatingwomen)benefittedfromtheprogram.

“Intotalwehave78.2percentcuredcasesandadefaulterrateof4.5percent,whichtomeisquitegoodconsideringthataccess[tohealthcare]inthisareaisnotatalleasy,”saysJeanFrançoisSaint-Sauveur,MédecinsSansFrontièresMedicalCoordinatorinEthiopia.

Aftertwomonthsintheprogramandadmissionintothestabilisationcentrewhereshewasalsogivenspecialisedtreatmentforpneumonia,Aisha’sweightincreasedfrom3.2kilogramsto4.9kilograms.

“WhenIseethischildIfeelveryhappybecausethegrandmotherandtherestofthecommunitythoughtshewasgoingtodie,”saysNabiyuAyalew,MédecinsSansFrontièresOutreachNurse.“Butwesavedherlifeandsheisstillalive.”

Patientnamehasbeenchanged.

THESECRETBLOODBANK

DrNatalieRobertswaspartoftheMédecinsSansFrontièresteamprovidingtrainingandequipmenttohospitalsandhealthfacilitiesin

Aleppo,Syria.

©MSF

THEREISSOmuchavoidablediseaseandtraumainSyriathatweasMédecinsSansFrontièrescanreallyhelpwithandthereisreallynooneelsetheretodoit.Youcanreallyseethedifferencethatevenbasicthings,likeakitofmedicinescanmake.ThisismysecondtimeinSyria,andoverthelastweeksI’vereallynoticedtheescalationofviolence.Butyougetusedtoit.Incidentsthatinitiallymademeveryfrightened,Inowtakeforgranted.

ThefirsttimeIwasreallyscaredwaswhenaverylargemissilelandednottoofarawayfromwherewewerestaying.Wecouldfeelthewindowsofourhouseshaking.Thereweretwoofusinthehouseandwewerebothafraid.Butwithinamonth,weweregettingmissileseverynight-someverynear-andwe’dgetoutofbedandgotooursaferoombutbecomplainingthatitwascoldandoursleepwasbeinginterrupted.

Youevenstartmakingjokesaboutit,butit’sjustawayofcoping.Inreality,youneverreallylosethefear.

ThefirsttimeIvisitedoneparticularemergencydepartmentatahospitalinAleppowewerediscussingwiththestaffhowwecouldhelpthemwhennewscamethatamortarbombhadhitanearbymarket.Veryquicklywestartedtoreceivecasualties.Tenfatalitiesarrivedalmostimmediately,thenfourmore-twowhohadsustainedmassiveheadinjuries.

Insituationslikethat,it’svitalyoutriageandprioritisepatientsanditwasveryclearthatthesetwopatientswerebeyondhelp.Inthemidstofallthepanicandcrisismyrolewastopointoutthattwoeight-year-oldgirlswithshrapnelwoundswhocouldbehelpedwereourpriority.

Peoplearegratefulthatwe’rethere.Wehelpwithwhatwecan,buttheneedsarehuge.Weprovidevaccinationsandsuppliesfordialysismachines.We’vesetupabloodbankinasecretlocationwhichsuppliesallhospitalsinthearea.Peoplehavebeencomingfrom50kilometresawaytoaccessit.Itrequiredabitofwork,alotoftrainingandequipment,butit’snowupandrunning.Beforepeopleweregettingunsafeblood,bloodthathadn’tbeentestedandstoredcorrectly,butnowtheyare.Somethinglikethatisreallyeasytodo,butit’scosteffectiveanditsaveslives.

ThesufferingthatpeopleareexperiencinginSyriaisincredibleandit’sfrustratingandupsettingtoseesomanyproblemsandknowthatbecauseofsecurityorforotherreasonsyoucan’tsolveitall.ButasMédecinsSansFrontièreswedowhatwecan,andit’svitalwecontinuetohelp.

EBOLA

AneBjøruFjeldsæter,aNorwegianPsychologist,recountsherexperiencesworkingwithMédecinsSansFrontièresinSierraLeone

duringtheEbolaepidemicin2014.

©SylvainCherkaoui/Cosmos

IWASEXPECTINGtheEbolaepidemictobequitegruesomeandunlikeanythingIhadseenbefore.ButIreallydidn’texpectitsmagnitude-thisoutbreakisenormous.InSierraLeone,itkilledalotofhealthworkersbeforeMédecinsSansFrontièresevenarrived.

Notsurprisingly,medicalstaffwerereluctanttoworkwithusatfirst.They’dnevercomeacrossEbolabefore,butatleasttheyhadpreviousexperienceofpeoplesufferinganddying.Butforthenon-medicalstaff,likethehygienists-ourhospitalcleaners-it’sbeenanewanddisturbingexperience,andalargepartofmyworkinvolvesprovidingthemwithcounsellingandsupport.

Thehygienistshavethehardestjobofall,becausetheyaretheonesdealingwiththedeadbodies.Alotofthecleanersareyoung,unskilledworkers.Inanareawithanunemploymentrateof95percent,theyjumpedatthisopportunitytogetajob.

TheresaJones,19,livedinFreetownwithhersister,whereherschoolclosedaftertheEbolaalert.WhileshewastovisitinghermotherwholivesinKailahun,afriendtoldherthatMédecinsSansFrontièreshadatreatmentcentreandwaslookingforworkers.Shewentdailytothecentreforaweekandwasfinallyemployedasahygienist.Shewashesclothes,tents,patients,toilets,andalsopreparesthebodiesofthedeceasedpatientswhodidnotsurvivetheEbolavirus.

BeforejoiningMédecinsSansFrontièresshehadneverseenacorpse.Thefirsttimeshewasveryscared.Sheissadwhensheseesyoungpeoplewhohavedied.Herfriendsandfamilyareafraid,theydon’tdareapproachher,buttheyunderstandandappreciatetheworkshedoes.AtfirsttheysaidthatEbolakillsandifsheworksatthecentreshewilldie.Now,thankstoherworkatthecentre,theyknowthebasicrulestofollowtopreventcontractingthevirusthemselves.

Whileallourstaffarewelltrainedinprotectivemeasures,justknowingthatyouarepotentiallyputtingyourselfatgreatriskofcontractingthediseasecanbestressful.

Dealingwiththedeadbodiesisdisturbing;thehygienistsexperiencefeelingsofsadnessandfear,andalsodisgust.WithEbola,whenpatientsdietherecanbebleeding,vomitinganddiarrhoea.Thehygieniststellmetheyexperienceflashbacksofthingstheyhaveseenandsmelled.Evenwearingamask,youcan’tshutoutallthesmells.

Traditionally,inSierraLeone,thebodiesaretakencareofbythetribalelders.Alotofthehygienistsfeeltheyaretooyoungtobedealingwiththedead-theyfeelthey’rebeingdisrespectfuloftheirculture’straditions.Wemakesurethatoneachshiftthereisalwaysonemanandonewoman,sothatwhensomeonedies,therewillalwaysbesomeoneofthesamesextotendtothem.

Thelocalstaffalsoexperiencehugestigmafromthecommunitymakingithardforthehygieniststomaintaintheirimageofwhattheyaredoing.Wetellthem,“Youareheroes,you’redoingaveryimportantserviceforyourcommunity-it’sabsolutelyvitalthatsomeoneisdoingthisjob.”Butalthoughweseethemasheroes,thisisn’talwayshowtheyareperceivedbytheirfamilies,theirfriendsortheirvillages.

WhenwedischargeapatientwhohassurvivedEbola,itmakesanenormousdifferencetothem.Ononeoccasion,threepeoplewhohadbeencuredweredischargedfromtheisolationward,andallthehygienistsweredancingaroundtheward,deliriouslyhappy

andtakingphotographs.

Theyfindwaystomanagethestress:theytakegoodcareofeachother;whensomeoneisupset,theytalkaboutit;andtheyareveryopenaboutvoicingtheirconcernsanddifficulties.Butthefactisthatthelocalstaffhavehadtheirlivesturnedupsidedown.Forthisentiredistrict,everythingisupsidedown.

CONTINUITY

In2013,MédecinsSansFrontièresopenedanewclinicinKibera,aslumintheKenyancapitalofNairobi.Kiberaishometoaround250,000people-manyofwhomareNairobi’smostvulnerableresidents.

©PhilMoore

THEMEDECINSSANSFRONTIERESKiberaSouthclinicprovidescomprehensivemedicalcare,includinginpatientandoutpatientservices,24-hourmaternitycareandtreatmentfordiseasessuchasHIVandtuberculosis(TB),whicharecommoninKibera.

Parentsbringtheirchildrentotheclinicforessentialvaccinationsandnutritionalscreening.Victimsofsexualviolencecanalsogettreatment,supportandongoingcounselling.

InthepastyeararoundhalfofKibera’sresidentshavevisitedtheMédecinsSansFrontièresclinicformedicalcare.Theteamseesalargenumberofpatientswhoneed

treatmentforrespiratoryinfections,diarrhoealdiseasesandskindiseasesthatarecausedbythepoorhygieneandsanitationconditionsoftheslum.

Eachdayaround280peoplecomethroughthetriageroom,withthemajorityseekingtreatmentforupperandlowerrespiratorytractinfections,diarrhoealdiseases,skininfections,diabetesandhypertension.

Theclinichasa24-hourmaternitywardwhichincludesthreedeliverybedsandsixpost-natalbeds.Everyweek,around45babiesareborn.AsmanyofthelocalresidentsareHIVpositive,theclinicprovidescaretohelppreventbabiescontractingthevirusfromtheirmothers.

Chaniya,a26yearoldmothersaid,“Ihavecometobringmychildforimmunisation.AsamotherlivingwithHIVsince2008,theclinichasplayedabigroleintesting,counsellingandhelpingmetodeliverHIVnegativechildren.IhavelearntfromthestaffherethatbeingHIVpositiveisnottheendofmylife,Icanlivelonger,givebirthandbringupmychildreninahealthyway.”

Thecentreisalsoequippedwithafullyfunctioninglab,abletodobloodanalysisandtestsfortuberculosis.ThelaboratoryallowspeopletogettestedforHIVandTBandtostartontreatmentassoonaspossible.TheearlierthatpeoplereceivethecorrectdiagnosisandtreatmentforTB,thebettertheirchanceofbeingcuredandthesoonertheystopbeinginfectious.

AftermorethantwentyyearsofworkinginKibera,MédecinsSansFrontièresisplanningtohandoveritsmedicalactivitiestothelocalhealthauthoritiesin2017,andatthetimeofwriting,isworkingwiththemtomakesurethatthemedicalservicescancontinue.

Patientnameshavebeenchanged.

CHOPPED

BenGuptaisanAnaesthetist.HereherecountshistimeworkingwithMédecinsSansFrontièresinPapuaNewGuineahelpingvictimsof

violence.

I’VEBEENWORKINGasananaesthetistforMédecinsSansFrontièreshereintheSouthernHighlandsofPapuaNewGuinea(PNG)forfivemonthsalready,butthescenerystillhasthepowertoleavemebreathless.Thinkoftheword‘paradise’andyou’dprobablypicturealandscapesomethinglikethis.

Unfortunately,thisstunningscenerywasnottobethemostmemorableaspectofmyday.AsIgotbacktothehospitalaroundmidday,Max,theMédecinsSansFrontièressurgeon,cameouttomeetmewithagrimlookonhisface.

“Sorrymate,we’vegottogototheatrenow,”hesaid.“Awoman’sjustbeenbroughtin.She’sbeenchopped.”

Myheartsank.InthelocalPidginEnglish,‘chopped’meansattackedwithamachete.Irushedinsideandgotchanged.

Evenafterfivemonths,dealingwiththerepercussionsofthisviolenceonadailybasisneverfeltnormal.Ithad,however,becomedepressinglyfamiliar.AsIscrubbedup,Iwonderedhowsuchextremeandendemicviolencecouldexistinsuchanidylliclandscape,populatedbysuchfriendly,openpeople.

Lucy,oneofthelocaltheatrenurses,wasattendingtothewomanasshelayquietlyononeofthebedsoutsidetheatre.Shehadalreadyappliedpressuredressingstothewoman’sarmsandheadandwastalkingtohergently.

Despiteallthebandages,IfeltpositivewhenIsawher.ShewasalertandansweringquestionsfromLucy,asignthatsheprobablyhadn’tlosttoomuchblood.Shealsodidn’thaveanyfacialinjuriesthatwouldleaveherwithpermanentdisfigurement.

WetookherthroughtotheoperatingtheatreandIputalocalanaestheticblockintonumbherarm.Whilewewaitedforherarmtogonumb,Lucycleanedherhead-woundandchattedtoherinHuli,thelocaltriballanguage.Shetoldusherstory.

Itturnsoutshehadbeenarguingwithherbrotheraboutmoneywhen,withoutwarning,

hehadtakenamachetetoherheadandarms.

Thesurgeon,Max,beganremovingthebandagesfromhernumbarmwhileLucycontinuedtotranslate.Suddenlyhestoppedwhathewasdoing.Ilookedoverandsawthatunderneaththebandagethewoman’shandwasalmostcompletelyamputated,barelyhangingonbyatinystripofskin.

TherewasasplitsecondofsilencebeforeMaxgentlyexplainedtothewomanthatherhandcouldnotbesaved.

Wethengotonwiththejobofrepairingwhatwasleftofherforearm.Ittookusafewhours,butwemanagedtorepairmuchofthedamageandtidyupsomeofthemessthemachetehadmade.Afterthewomanhadbeenwheeledawaytotheward,wecleanedupandleftthetheatreinsilence.Noneofusfeltliketalking.

Overthefollowingweeksitwasgratifyingtoseeherslowlybutsurelymakingafullrecovery.WiththehelpoftheprofessionalpsychologicalsupportprovidedbyMédecinsSansFrontières,shealsobegantointeractmorewithstaffandevenoccasionallytosmile.

Therearenoquicksolutionsoreasyfixesfortraumalikethat,justastherearen’tanyforasocietywhereviolencehasbecomesuchanacceptedpartofdailylife.ButIhopethatbybeingthere,byprovidingmuchneededmedicalcare,wearehelpingtomakearealdifferencehere.Suchabeautifulcountryandsuchbeautifulpeopledeservethebestwecangive.

IknowthatifMédecinsSansFrontièreswasn’tinTariprovidingemergencysurgicalcare,thenalotofpeoplewhohavebeenattacked,woundedandmaimedinthisareaoverthelastfewyearswouldalmostcertainlyhavedied.

FRIDGESINTHEFOREST

ThisisafirsthandaccountfromWilliamTurnerofhistimeworkinginaMédecinsSansFrontièresmobileteaminremoteareasoftheDemocratic

RepublicofCongo.

©JohnStanmeyer

UNDERANYCIRCUMSTANCES,it’snotaneasytasktravellingalongmuddyrainforesttracksbymotorbikeandcrossingswollenriversbydugoutcanoes.Nowimaginedoingitwhilecarryingarefrigerator.ThisisexactlywhatmyteamandIdidaswemountedanexpeditiontotest40,000peopleinremotevillagesoftheDemocraticRepublicofCongo(DRC)forsleepingsickness.

ThemissiontookustothetownofBili,inthefarnorthofthecountry.BilisitsinaheavilyforestedareabetweentheriverUéléandtheborderwithCentralAfricanRepublic.Theareaisaglobalhotspotforsleepingsickness.Infact,some85percentofallsleepingsicknesscasesarefoundintheDRC.Buttheregionissoinsecureandremotethattheproblemhaslonggoneignored.

InearlyApril2013,ourMobileHAT(HumanAfricanTrypanosomiasis)TeaminstalledalaboratoryandtreatmentwardinBilihospitalandbegantestinglocalpeopleforthedisease.Oncetheentirepopulationofthetownwastested,theteamturneditsfocustoabout50othervillageslocateddeepinthesurroundingrainforest.

Theteamwasontheroadforaboutthreetofourweeksinarow.Sometimeswerodeonmotorbikestomakeourwayalongbarelyaccessiblepathsthroughtheforest.Wemovedfromvillagetovillageandsleptintentseverynight.

Thelogisticalchallengesareenormous.ItcantakeuptoamonthforsuppliestoreachBili.Smallplanes,landingonanimprovisedairstripintheforest,canbringinonlylimitedquantitiesofsupplies.Truckscarryingthecargo-whichincludessensitivetoolssuchasmicroscopesandcentrifuges-havetobeferriedacrossriversonrafts,whilemuddytracksareoftenblockedbytoppledtrees.Duringtherainyseason,manyofthevillagesarecompletelyunreachable.

Ontopofthis,thetestforsleepingsicknessiscomplex,withseveralcomponentsthathavetobekeptcoolatalltimes.Eveninthemostremoteareas,theteamstravelledwithageneratorandrefrigerators.

TheMobileHATTeamhavealsospentninemonthsinSouthSudan,anothersleepingsicknesshotspotthat’sstrugglingtoovercometheeffectsofdecadesofconflict.TheteamtargetedvillagesacrossCentralandWesternEquatoriastates,wheresleepingsicknessrateshadpreviouslybeenveryhigh.

Travellingthousandsofkilometresfromvillagetovillage,theteamscreenedmorethan60,000people.Thirty-eightconfirmedcaseswereidentifiedandtreated,indicatingthegoodnewsthattheprevalenceofsleepingsicknessintheseareashasdecreasedsignificantly.

Inadditiontoscreeningpatients,MédecinsSansFrontièreshasalsoworkedtoimproveourscreening,diagnosis,andtreatmentcapacities.Morethan200SouthSudanesestaffreceivedtrainingthattheywillbeabletoputintopracticeintheyearstocome.

Byscreeningandtreatingpeopleoverawidearea,wesavelives,firstandforemost,butwealsoreducetheprevalenceofthedisease.Eachpersontreatedisastepintherightdirection.

Butthedifficultterrain,unwieldykit,andregionalinsecurityarenottheonlychallenges.Untiltherearesimplerandmoresuitablediagnostictoolsandtreatments,anddependablefundingfornationalprograms,eliminatingthediseasewillcontinuetobeanuphillstruggle.

THEBUZZINGOFHELICOPTERS

Thisstoryshowsthemagnitudeofthefear,thepainandthesilencethataffectcommunitiesintheCaucaMountainsinColombiaand

demonstratestheirneedforpsychologicalsupporttohelpthemhealtheinvisiblewoundsandsufferingcausedbyongoingconflict.

©AnnaSurinyach

“WHENTHEFIGHTINGstarts,yousay,ohmyGod,andyourushthiswayandthatinapanictogethomeandshutyourselfinside,andthebulletswhistleoverthehouse.Thechildrenclingtoyourlegsandscreamwhentheyhearahelicopter,”saysManuela.“It’shorribletolivelikethat,andthisisthelifewearelivingherethroughouttheCaucadepartment.”

Manuelahasbeendisplacedseveraltimesbythearmedconflictbetweenarmedgroupsandthegovernmentalforcesthathasbeengoingonforthelast50yearsinColombiainvariousregionsofthecountry.

Despitethedecreaseintheamountofharassment,attacksandfighting,thepeoplecontinuetoliveinfear,painandsilenceintheCaucamountainsinthesouthofColombia.

Itisoneoftheareasinthecountrywiththemostarmedactivity.Theinhabitantsareaccustomedtothesoundofbulletsandthebuzzingofhelicopters.Theyruntohideintheirhousesorareforcedtomovetootherplaceswiththeirfamiliesuntiltheviolencestopsandtheycanreturn.

ItwasonsuchadaythatthebulletsshatteredthelivesofManuelaandherhusbandRicardooneyearago.Asusual,RicardowassowingcoffeeinhisfieldinthevillageinCauca.

“Aroundtwoo’clock,theshootingfromthefrontstarted.Weliveinbetweentwohillsandourhouseandourfieldareinthemiddlewhenthereisfighting.Welockedourselvesupinourhousetohavelunch.Forty-fiveminuteslatereverythingseemedcalmandmyhusbandwentoutsidetofeedthedog,”recallsManuelawithaseriousface.Hewashitbyabulletandfellatthefeetofhissix-year-olddaughter,whoranintothehousecrying,thinkingthatherfatherwasdead.

Thebulletenteredthroughhisfaceandexitedthroughhisribs,splittinghiscollarboneandleavinghisarmdisabledforlife.“Ican’tdothingsbymyselfanymore,nowIcan’twork.Ican’tholdanythinginmyhandforlong,”addsRicardoshyly,whileshowinghisscars.Untilthen,hehadbeenthefamilybreadwinner.Nowhecan’tevenaffordthetransporttoseethespecialist,whoisfivehoursawayfromhishouse.

Manuelaescapedthebulletsbutsufferspost-traumaticstress.“Wewereveryaffectedpsychologicallybywhathappened.Iwascryingallday.Wewerefightingandfedup.Evenourdaughterisnotwell,sheisbehindinschool,”saysManuela.

“Whenshehearsahelicoptershegoesstraighttothehouseandshetellsmetohideorshesays‘Daddy,thebadguysarecoming,’addsRicardo.Thegirlisfrightened.”

Thearmedconflicthasleftthemostdirectlyaffectedpeoplepsychologicallyscarredforyears.However,accesstomentalhealthintheseisolatedvillagesofthemountainsisnon-existent.Therearenoavailablepsychologiststodoindividualconsultationsattheprimarycarelevelnorinthemunicipalhospitals,whichareoftensix-hoursawayonunpavedroutes.

MédecinsSansFrontièrespsychologistsdobothindividualandgrouptherapysessionsinthemunicipalhospitalsandvillagesintheCaucamountains.Inthisway,thedispersedpopulationsalsohaveaccesstopsychologicalcare.

Inadditionthepsychologistsworkwiththecommunityleaders,healthpromoters,midwivesandteachersonpreventionissues.Theobjectiveistotrainthemsotheycanidentifywhichpeopleneedtobetransferredtoapsychologistorapsychiatristandsothattheycanoffersomeimmediatepsychologicalprimarycarewhenthereisanepisodeofviolence.

“Manyofthepeoplewhohavesufferedsexualviolenceorarmedconflicteventsrecently,ornotsorecently,andwhosufferpost-traumaticstresshaveneverreceivedpsychologicaltreatment,”explainsJuliana,aMédecinsSansFrontièrespsychologistwhoworksinthearea.

Paula’shusbandwaskilledin2005.AnotherresidentoftheCaucaMountains,ittookhereightyearstoseeapsychologist.SheisnowacommunityleadertrainedbyMédecinsSansFrontières.

“TheytoldmeIshouldn´tlivewiththispainandthatIcouldovercomeit.Thetherapyhasgivenmemotivationandstrengthandtrainedmetobeabletogotothecommunitiesandtellthemtheycancarryon,”saysPaula.“Idon’thavethatfearanymoreandIhavemanagedtogetoverthedeathofmyhusband.”

Patientnameshavebeenchanged.

VICTORY

NurseFloraEscourroudescribesherfirstplacementwithMédecinsSansFrontièresineasternChadwhereshetookpartinameaslesvaccination

campaign.

©MSF

IARRIVEDINthecapital,N’Djamena,inmid-AprilandwiththeotherfourmembersoftheteamIsetoffontheroadtoAbéché.Thejourneywouldtaketwodaystocrossthecountryfromwesttoeast.

InAbéché,therehadbeenreportsofcasesofmeaslesforseveralmonthsandbyApril,theepidemichadreachedanalarmingscale.MeaslesisadiseasewhichisundercontrolinAustralia,butitcanleadtoseriouscomplications.Intheworst-casescenario,whenaccesstocareisinsufficient,mortalitycanclimbto20percent.Yet,

epidemicscanbeavoidedasthevaccineiseffectiveandinexpensive.ThepreviousvaccinationcampaignintheAbéchéregionhadbeencarriedoutin2009so,withthesubsequentbirths,thenumberofunprotectedchildrenhadbeensteadilyrising.

WhenwearrivedinAbéché,preparationswerealreadywellunderwayand26districthealthcentreswereapprovedtotakepartbythelocalauthorities.Wehadtwoweekstovaccinatenearly100,000children.

Ourfirsttaskwastorecruitlocalstafftohelpinthecampaign.BytheendofApril,wehadputtogetherandtrained14teamsofsixpeopleincludinganumberoflocalstudentnursescomplementedbymembersofthelocalcommunities.Eachteamhadtovaccinateanaverageof500childrenaday.

Eachmorningwemetat5amtofinalisetheroadmaps;thenthe14supervisorsarrived;afterthat,wecheckedthattheequipment,startingwiththerefrigeratedvaccines,hadbeenproperlyloadedintothejeeps;finally,theteamssetoffataround6am.

Forthefirstweek,Iwasresponsibleforsupervisingouroperations.Thedrivetothemostfar-flungvaccinationsitescouldtakeuptothreehours.Sometimesthingshadtobereorganised,suchasaskingthevillagechiefforextrasecuritypersonneltomanagethecrowds.

Onlychildrenagedbetweensixmonthsandfiveyearsreceivethejab,butmothersdon’talwaysknowtheexactageoftheirchild.Asarule,iftheyareoldenoughtohaveteeth,theyareincluded.Asanexception,childrenfromnomadiccommunitiesarevaccinatedupto15yearsofage,astheyoftenslipthroughtheroutinevaccinationprograms.

Thesecondweek,Iwasmoreinvolvedintreatingmeaslescasesthathadbeenflaggedbyourteams.Mothersdidn’talwaystaketheirchildrenwithmeaslestothevaccinationsite,forfearofcontagion.Thereisnospecifictreatmentagainstthevirus.Instead,wetacklethesymptomsoftheillnesswithantibiotics,paracetamolforthefeverandeyeointments.Nutritionalsupportisoftennecessarytoo,asmeaslesisamalnutritionriskfactor.Allthosetreatmentscanbeadministeredonthespot.

However,childrenwithcomplicationsweretakentoAbéchéhospital,whereweensuredthattheywouldreceivefreetreatment.Themostupsettingsymptomsarerespiratorydistressandconvulsions.Whenchildrenhavethesesymptoms,it’seasiertoconvincetheparentstotakethemtothehospital.Forpeopleaspoorasthosewewereworkingwith,itcantakesomepersuadingtogotoAbéchéandstayawayforseveraldays.So,evenwhenweofferedtotakeandbringbackthechildbyambulance,each

successfulnegotiationwasavictory.

GLORIOUSLYCALM

NurseEmmaPedley,describesherworkwithMédecinsSansFrontièresinCentralAfricanRepublic(CAR).MédecinsSansFrontièreshasbeen

workinginthecountrysince1997.SinceDecember2013,inresponsetothecrisis,wehavedoubledourmedicalassistanceinCARandare

runningadditionalprojectsforCentralAfricanrefugeesinneighbouringcountries.

©MSF

INADDITIONTOkeepingthehospitalandmedicalsupplysideofthingstickingover,IhavealsohadtheopportunitytotraveloutwithourmobileteamsafewtimessincecomingtoZemio,CentralAfricanRepublic(CAR).

MédecinsSansFrontièressupportsfoursmallhealthpostsacoupleofhoursalongthemainroadsleadingintoandawayfromZemio,andalargeroneinMbokwhichisawholeday’sdriveaway.Thevillageswesupportaresmallbutisolated.Malariaanddiarrhoeaarethemainkillersouthere,andit’salongwalktothehospitalinZemiowithoutthesecentres.

Ourdaystartsearly,6am,packingacarfullofequipmentandmakingsurewehaveallthenecessarysuppliestorestockthehealthposts.By7amweareonrouteoutofZemio,andthedayisalreadybeginningtogethot.

WepassfamilygroupsofPeuhl-largelynomadiccattleherderswhohavemigrated

downintoCARoverthelastfewdecadesfromChadandothernorthernAfricancountries.Wewavetothemoutofthevehiclewindowsaswepass.

Infactthewavingismoreorlessmandatory-it’spartofoursecuritybriefings,aswellasbeingcommonsensetobeentirelyfrank.MédecinsSansFrontières,bothforinformationandsafetypurposes,reliesonmaintainingcloseandfriendlyrelationswiththecommunitiesitserves.Andyouarefarmorelikelytothinkkindlyofastrangewhitefaceinacarasitpassesyouifitsmilesandwaves,thanifitignoresyou.

Thevillagesareinsmallclearingsintheforest.Noelectricityhere,nomusic,justthebackgroundnoisesofpeoplequietlygettingonwithlife-pumpingwater,sortinggrain,raisingchildren.It’sgloriouslycalmafterweeksspentatthehospitalinZemio.

MypartnerJulietakestheleadatthefirsthealthpost,deliveringrefreshertrainingondehydrationtreatmenttothestaffandgoingthroughtheirstatisticswiththem.Ipokearoundinthesmallmudwalledpharmacy,doinganinventoryandreviewingprescriptionswiththelocalpharmacist.

Afteracoupleofhourswepilebackintothecarandrattleofftothenextclinicwherewerepeattheperformanceandconsultonacoupleofcomplexandchroniccases.

Acertainhopelessfrustrationissharedbybothofusatthispoint-MédecinsSansFrontières’concernouthereisacuteandemergencycareonly,andwehavelittleornoaccesstomedicationsandtreatmentforthingslikearthritisandheartfailure.

Thereissomethingdeeplyunjustaboutseeingthedignifiedolderpeopleofthesecommunities-whohavesurvivedsomuchintheirlifetimes,yetaresomehowsoneglectedintheirlastdays.

SlowlytheshadowslengthenandthecarbeginstoslowdownaswebegintopassthroughtheoutskirtsofZemioandthehutsbecomemorecloselyspacedtogether.Thevibrantgreensoftheforestcounterparttotherichochreofthedirtroad,andinplacesdizzyinglybeautifulcloudsofenormousbutterfliesscatteroutfromtheundergrowthaswebarrelpast.

Aslonganddrainingbothphysicallyandsometimesemotionallyasthejourneysare,theyarealsoincrediblybeautiful.

QUADRUPLETS

DrAoibhinnWalshisaPaediatricianfromDublinwhowasworkingwithMédecinsSansFrontièresinTimergarainnorthwestPakistan.Hereshedescribesthelasttwodaysofhermission.MédecinsSansFrontièreshasbeenpresentinPakistansince1986,workingwithPakistanicommunities

andAfghanrefugees.

©MSF

IAMLEAVINGtheprojecthereinTimergaraintwodays.Ithasbeenalongeightmonths,andforthemajorityoftimeIhavespenthereIhavebeeninthemotherandchildhealthcentrerunbyMédecinsSansFrontièresatTimergaraDistrictHospital.

AsaPaediatrician,myjobprimarilyhasbeentocareforthebabiesborninthisdepartment,andspendingsomuchtimeherehasgivenmeinsightintothestoriesofthewomenhere,bothourstaffandpatients.Onethingthatwillforeverstaywithmeisthestrengthofthesewomen.Theytakeeverythingintheirstrideandwhenadifficultsituationarises,insteadofcomplainingtheyjustsimplyact.Ihavebeenprivilegedduringmytimeheretobearwitnesstosomeofthestoriesofthesewomen,someofthemheartbreakinglytragic,someupliftingandhopeful.Therearetoomanytorecount.HoweveronSaturdaymorningsomethinghappenedinthecentrethatwasnothingshortofmiraculousandreallymademesoproudtohavebeenpartoftheteamevenforashortperiodoftime.

Therewerefourstaffondutyfordeliveries-Gulnaz,Rabia,LubnaandAsma.Awomancameinat4am,inactivelabour,fullydilatedandreadytodeliver.Shehadone

five-year-oldboyathomeandhadpreviouslyhadtwinsdieinthefirstfewhoursoflifeaftercaesareansection.Shetoldthestaffthatshewas33weekspregnantwithquadruplets!

IcanonlyimaginethepanicanddramathatwouldhaveensuedhadthisoccurredinahospitalathomeinIreland.Multiplebirths,particularlyprematurebabies,areincrediblyhighriskforbothmotherandbabies.Ifpossiblethebabiesaredeliveredduringthedayviaaplannedcaesareansectionwithmidwives,paediatricians,obstetricians,andpaediatricnursesallpresent.Usuallythereareatleasttwomedicalstaffperbabyinthedeliveryroom.

Here,withthisnotavailableorpossible,thecentrestaffdidwhattheyalwaysdo:theytookitintheirstride.Allfourbabiesweredeliveredsafeandwellwithintwentyminutes.Twobabiesdeliveredheadfirstandtwoweredeliveredbreech(feetfirst),anothertechnicallydifficultachievement.Thenurseworkingintheneonatalwardwascalleddownandallfourbabiesweresooncosilyensconcedtogetherintheneonatalunit.

Meanwhile,themotherwenttotheoperatingtheatreasshehadexperiencedsomebleedingafterdelivery,whichistobeexpectedaftersuchadramaticdelivery.Thetotalweightofthebabiesamountingto8.2kilograms!

Icametothehospitalthenextmorningtofindthesefourbeautifulbabieswaitingforus.Seeingthelookonthemother’sfacewhenweinformedherthatallthebabieswerehealthyandstablewillbeamemoryIcarrywithmeforever.ItwillremindmeofwhythecentreissoimportanthereinTimergara.Itgivesthesewomenachancetohavetheirbabiessafely,inanenvironmentwheremotherandchildwillbegivenahighstandardofcare.Italsoleavesmeinaweofwhattheteamachieves,inaplacewithlimitedresourcesandwheretheenormousvolumeofcomplicateddeliveriescouldeasilyoverwhelmandpaniceventhemostexperiencedpeople.Insteadtheyunfailinglycontinuetotakecareoftheirmothers,sisters,auntsanddaughters,andprovethatmomentslikethebirthofthesefourbabiesarepossibleanywherewiththerightamountofknowledge,passionandskill.

©AoibhinnWalsh

CONCLUSION

Ifyouhavereadthisbookfromstarttofinish,younowhaveaninsightintotheworkofMédecinsSansFrontières.

Despiteharshterrainandclimate,riskofviolenceandillnessandanynumberofotherdifficulties,MédecinsSansFrontièresteamsdelivermedicalassistancetovulnerablepeoplearoundtheclock,aroundtheworld.

Pleasesharethisbookwithyourfriendsandfamily.

Ifyouchoosetoalsomakeadonation,yourgiftwillbeusedtodelivermedicalaidtopatientslikeRukhshona,Aisha,RahimandthemillionsofothersthatwillbeassistedbyMédecinsSansFrontièresinthecomingyear.

MEDECINSSANSFRONTIERESCHARTER

MédecinsSansFrontièresisaprivateinternationalassociation.Theassociationismadeupmainlyofdoctorsandhealthsectorworkersandisalsoopentoallotherprofessionswhichmighthelpinachievingitsaims.Allofitsmembersagreetohonorthefollowingprinciples:

• MédecinsSansFrontièresoffersassistancetopopulationsindistress,tovictimsofnaturalorman-madedisastersandtovictimsofarmedconflict,withoutdiscriminationandirrespectiveofrace,religion,creedorpoliticalaffiliation.

• MédecinsSansFrontièresobservesneutralityandimpartialityinthenameofuniversalmedicalethicsandtherighttohumanitarianassistanceanddemandsfullandunhinderedfreedomintheexerciseofitsfunctions.

• MédecinsSansFrontières’volunteersundertaketorespecttheirprofessionalcodeofethicsandtomaintaincompleteindependencefromallpolitical,economicandreligiouspowers.

Asvolunteers,membersareawareoftherisksanddangersofthemissiontheyundertake,andhavenorighttocompensationforthemselvesortheirbeneficiariesotherthanthatwhichMédecinsSansFrontièresisabletoaffordthem.