Without BordersMédecins Sans Frontières/Doctors Without Borders | msf.org.uk

Ebola is one of the world’s most deadly diseases. The virus can kill up to 90 percent of the people who catch it. Ebola is so infectious that

patients need to be treated in isolation by staff wearing special protective clothing. MSF has launched an emergency response to combat an Ebola outbreak in west Africa, which has claimed hundreds of lives. MSF epidemiologist Michel Van Herp reports on efforts to combat this terrifying disease.

I received a message at home about this strange disease which had

broken out in southern Guinea. They thought that perhaps it was Lassa fever, but when I received a description of the patients’ symptoms, it was clear to me we were talking about Ebola. A couple of days later I was in Guinea.

‘It’s like detective work’I’ve worked in every major outbreak of Ebola since 2000. What makes this one different is its geographical spread, which is unprecedented. There are cases in at least six towns in Guinea, as well as across the border in Liberia.

The problem is that everybody moves around – infected people move from one village to another while they’re still well enough to walk; even the dead bodies are moved from place to place. Tracking the disease is like doing detective work.

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Ebola: fighting the killer virus

MSF staff at our Ebola treatment centres in Guinea and Sierra Leone risk infection to treat hundreds of patients each month. But they can’t operate without donations. Please support our medical teams working around the world today.

Phone: 0800 408 3894 Visit: www.msf.org.uk/support Or use the form on page 3

INSIDE: 4-5 MSF FIGHTING EBOLA6 CENTRAL AFRICAN REPUBLIC7 THROUGH THE LENS8 YEMEN

MSF staff help each other dress up in protective suits before coming into close contact with any patients. Credit: Kjell Gunnar Beraas/MSF

Médecins Sans Frontières/Doctors Without Borders (MSF) is the world’s leading emergency medical humanitarian aid organisation. We help people affected by armed conflict, epidemics and natural or man-made disasters, without discrimination and irrespective of race, religion, creed or political affiliation. We work in over 70 countries and go to places where others cannot or choose not to go. We can do this because we are independently funded, with 90 percent of our funding coming from individual or private donors, like you.

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Your support makes our work possible – thank you!£10 a month – or 33p a day – can help provide an MSF team with an emergency dressing kit containing sterile equipment, dressings and bandages to help people caught up in conflict.

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We’ve learned from our previous experiences with Ebola that patients have a 10 to 15 percent better chance of survival if they receive good medical support. But if they stay at home, the fatality rate generally reaches up to 90 percent.

‘Fear is normal’For health staff , it is normal to feel some kind of fear when you enter the isolation area for the first time, even if you are well protected. But you follow a kind of ritual – for dressing and undressing, and for all the activities you perform inside – little by little, you gain confidence.

You never enter the isolation area alone – you always enter in pairs. And you only go in for short periods, because it is very hot in Guinea and even hotter inside the yellow protective suits. It is tiring, especially if you are doing physical work. We always write our names on the front of our aprons so that the patients know who is in front of them.

WHAT IS EBOLA?i

The Ebola virus is thought to live in fruit bats and to spread to humans through contact with sick animals. Highly infectious, the disease is passed from person to person through bodily fluids including saliva, sweat, blood and semen. The current outbreak involves the Zaire strain, which can kill up to 90 percent of people infected. There is no vaccine against Ebola, and no cure, but good medical care can help patients develop antibodies to fight the disease and can bring the mortality rate down by 10 or 15 percent.

The Ebola virus is thought to live in fruit bats and to spread to humans through contact with sick animals. Highly infectious, the disease is passed from person to person through bodily �uids including saliva, sweat, blood and semen. The current outbreak involves the Zaire strain, which kills up to 90 percent of people infected. There is no vaccine against Ebola, and no cure, but good medical care can help patients develop antibodies to �ght the disease and can bring the mortality rate down by 10 or 15 percent.

Inside the centre, we try and make the patients as comfortable as possible. Sometimes we bring the parent of a sick person in to visit them. They have to wear a protective suit with a mask and goggles and gloves. The relatives are supervised, so there is no possibility of any contact with a patient’s bodily fluids.

Patients who are deeply affected by the disease do not have a lot of energy to communicate. The mood can be very sombre with those in a terminal stage, who have only a few hours left before they die.

When a patient dies, we put them in a special body bag so that the burial can be done

WHAT IS MSF DOING?i

In recent weeks, further cases have been reported in Guinea and in neighbouring Sierra Leone. The virus has already affected more than 300 people and MSF is continuing its work supporting health authorities in the two countries, treating patients and putting measures in place to contain the epidemic.

MSF has 300 staff on the ground and has brought in more than 40 tonnes of equipment and supplies to help fight the epidemic. It’s the financial support of individuals like you that enables us to do this. Thank you.For more information, visit: msf.org.uk/ebola

according to family traditions. If the patient comes from a village, we take the body back and advise relatives about what they can do – and what they should not be afraid to do – during the funeral.

Once the body bag has been sprayed, it can be handled with gloves, so the mourners can wear their normal clothes to the funeral. We do not steal the body from the family; we try to treat it with dignity, and respect their traditions as much as possible.

‘People can survive’The mortality rate for Ebola is high, but there are survivors. Just before I left Guinea, our first two patients left the MSF centre cured of the disease: Thérèse, 35, and Rose, 18. Both are from the same extended family, which had already seen seven or 10 deaths from the disease.

Their relatives were overjoyed. There was a huge celebration in the village when they returned.

They come from a family of local healers, so the news that they were cured will spread to other villages, and I hope this will create further trust.

People can survive; as the patients left, our teams were cheering. To know that they survived helps you forget all the bad things.

Physical contact and lots of talking help patients in the isolation zone feel less alone. Credit: Sylvain Cherkaoui/Cosmos

After ten days in the isolation zone, Ebola survivor Rose receives a farewell hug from the nurse who cared for her. Credit: Amandine Colin/MSF

Sierra Leone

Guinea

MaliSenegal

Côte d’IvoireLiberia

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How we treat Ebola When Ebola haemorrhagic fever broke out recently in Guinea, west Africa, MSF set up three specialised treatment centres in the worst-hit areas. Ebola is so infectious – and so deadly – that patients need to be treated in isolation by staff wearing special protective clothing. Emergency coordinator Henry Gray and logistician Pascal Piguet, both just back from Guinea, explain why, with Ebola, every little detail counts.

staff entrance to high-risk zone

staff exit fromhigh-risk zone

high-risk zone suspected cases

low-risk zone

high-risk zone confirmed cases

triage tent

entrance for staff

entrance for patients

exit for cured patients

treatment ward

treatment ward

showers & latrines

showers & latrines

laundry, showers and latrines

water tank

pharmacy

changing area

office

stores

incinerator

meeting tent

ward

visitors’ area

ward

morgue

shower

5 Exit for cured patients

When a patient is feeling better and has had two negative lab tests in a row, they are allowed home. Before leaving, they shower in chlorinated water and receive clean clothes and a package containing therapeutic food and vitamins to build up their strength.

2 High-risk zone – confirmed cases

“The high-risk zone’s not an easy place to be – you’re isolated, you’ve got no access to the outside world. So we try and make it as friendly as possible, with a TV, radios, plastic chairs and shaded areas to sit,” says Henry.

3 Treatment ward

“With a mortality rate of up to 90 percent, we know that most people in the treatment ward will not come out. We do the most we can for them: whatever the patient wants, the patient gets – special food, new items of clothing... It’s easy to do and it does them good,” says Pascal.

4 Visitors’ area

Family members talk with patients through the fence, local religious leaders offer moral support, and MSF psychologists provide counselling.

2 Changing area

Before entering the high-risk zone, staff help each other put on their protective suits, while respecting the strict ‘no body-to-body contact’ rule.

3 Staff entrance to high-risk zone

“Each time we go in, we have to plan it down to the finest detail. To prepare, we have a 30-minute briefing about what we are going to do, and we get all the equipment ready beforehand.” says Pascal.

4 Staff exit from high-risk zone

On leaving the high-risk area, staff remove their protective suits and disinfect themselves.

5 Laundry

All recyclable items of clothing are washed in chlorinated water every day and reused.

6 Incinerator

Everything used in the high-risk area which can’t be disinfected is burnt.

1 Protective clothing

“The suits are so stifling that it’s hard to stay inside for more than 40 minutes. You sweat a lot - up to two litres each time - but you don’t cool down because the sweat doesn’t evaporate,” says Pascal.

1 High risk zone – suspected cases

Many of the early symptoms of Ebola are similar to diseases such as malaria and TB. “It’s really important that there are separate zones for suspected and confirmed cases, because you don’t want to contaminate someone with TB with Ebola – that’s basically a death sentence,” says Henry.

A lab test takes as little as four hours to confirm the disease. Patients who test positive are admitted to the zone for confirmed cases.

Graphic: Natasha Lewer/Lou Lewer

Plastic goggles: £5.16

Protective mask: 67p

Protective suit: £16.41

Chemical-resistant gloves: £2.66

Plastic apron: £4.05

Rubber boots: £9.22

YOUR SUPPORT

£38.17pays for a complete protective suit for an MSF staff member working in one of the Ebola treatment centres in Guinea.

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CENTRAL AFRICAN REPUBLIC THROUGH THE LENS

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Central African Republic, April 2014 – A Muslim resident of Bossangoa seeks safety from Christian militias in the grounds of a school, in a country that is being torn apart by intercommunal violence. Credit: Ton Koene

Niger, April 2014 – Ahead of the rainy season, children line up for their first dose of drugs to prevent malaria, a disease transmitted by mosquitoes. This new preventive strategy – known as ‘seasonal malaria chemoprevention’ – has already saved thousands of children’s lives. Credit: Juan Carlos Tomasi/MSF

South Sudan, April 2014 – MSF teams unload essential supplies in Bentiu after a major battle led to tens of thousands of people fleeing their homes for UN camps, where living conditions pose a serious health risk. Credit: Hosanna Fox/MSF

Around the world with MSF

Bulgaria, May 2014 – Five-year-old Aya Abbas and her three-year-old brother Ala Abbas, from Syria, have a medical check-up from MSF doctor Rebwar Mustafa in Harmanli refugee camp. Credit: Alessandro Penso

Uganda, March 2014 – A South Sudanese man is treated by an MSF doctor in Dzaipi hospital, Adjumani district, where more than 65,000 refugees are living in overcrowded camps to escape the conflict in their own country. Credit: Matthias Steinbach

Burkino Faso, April 2014 – In remote Oudalan province, the only free healthcare available to refugees from Mali is provided by MSF. Credit: Marie Hortense Koudika

Jordan, April 2014 – An MSF doctor performs surgery. Most of MSF’s patients in Jordan were wounded in fighting in neighbouring Syria. Credit: MSF

YOUR SUPPORT

£10.76pays for a box of 300 surgical gloves

£17.26pays for a surgical gown

£30.20pays for a box of 300 surgical masks

£161.41pays for a basic surgery set of 27 instruments

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A sick woman is rushed to the hospital where MSF works in Bossangoa. Credit: Marcus Bleasdale/VII

The violence affecting Central African Republic continues unabated, with civilians bearing the

brunt of the clashes between militias and armed groups. MSF nurse Alison Criado-Perez describes what it is like to work in this conflict zone.

2 April, 2014

I’ve just come back from a bike ride. The sky is blue and cloudless, the green verges

are splashed with the bright yellow of the first daffodils. Birds are singing, ponies graze happily in the fields. Spring is arriving, and all is tranquil in the peaceful countryside of Rutland, where I‘m lucky enough to live.

My mind turns to where I will be in just four

days. Bangui, capital of Central African Republic, and scene for the last few months of the most horrendous acts of violence. When I came back from DR Congo just before Christmas, I said I’d done my last mission with MSF. It was incredibly tough physically, and I thought that at my age — which is a secret, but I’ll admit to having my bus pass — I didn’t think I wanted to put myself through that again. But I always say going on mission is rather like having a baby: you forget what an ordeal it was and just go for it again!

Getting a request to help in such an extreme situation is a challenge I can’t refuse. Tough it will be, probably tougher than anything I’ve done before, but we’ll be providing healthcare to a terrified and distraught population where otherwise there would be none.

Which is why I’ll be on the plane to Bangui in a few days, far from this green and pleasant land, where, in the lottery of life, I had the good fortune to be born.

9 April, 2014My natural alarm clock woke me this morning, as usual, at 5.15: a bird warbling in a mango tree outside my room. That sounds idyllic, a far cry from the horrors that are occuring just a kilometre or so from our house here. As I sit writing on my day off (in spite of the emergency, we try to have a day off each week, to recoup our strength for the week ahead) – the birds are still singing, but their sweet

Gunfire amid the birdsong

sound is interspersed by the rattle of gunfire.

It’s surprising how quickly you get used to an abnormal situation. As well as the background of gunshots and shelling, I’m getting used to the strong military presence, with heavily armoured cars rolling down the main streets heading to the flashpoints. Although I was fairly alarmed on leaving the hospital one afternoon to find the perimeter wall surrounded by crouching soldiers, machine-guns at the ready. For a brief second I thought we were being attacked, but quickly realised they were protecting a journalist who was interviewing someone.

I’m also getting used to different classifications for the MSF statistics. Normally I’m filling in details of how many cases of malaria, respiratory tract infections, diarrhoeal diseases or malnourished children we’re treating; now I’m classifying the admissions to the emergency department by wounds from gun shot, grenade or “arme blanche” – the latter being any other type of weapon, mostly machetes.

I’ve been here two weeks now, as the nurse/medical focal point for the hospital MSF started running on behalf of the Ministry of Health. Previously a maternity hospital, we have provided a team to deal with the emergency trauma cases as well as keeping the maternity department going.

Joy amidst the tragedyOn my first day, our departure to the hospital was delayed because of an “incident” in a largely Muslim neighbourhood bordering the hospital. When we arrived, several people were in the emergency room being treated for shrapnel wounds. It seems a young boy had thrown a grenade.

And so it has continued most days, although this last week the number of admissions for conflict trauma has diminished. There are joys among the tragedies. Belen, one of our doctors, came into the pharmacy where I was doing the boring but necessary task of counting stock. “Do you want to see a miracle?” she asked. Of course I did. I looked down at the tiny bundle, the 800-gram baby, who had arrived prematurely. Tiny but alive. This conflict brings hardship to so many, but delivering a baby safely can be especially difficult. This little mite could now be referred to a specialist paediatric centre run by MSF.

It’s good to have the miracles in the midst of the ongoing tragedy.

MSF is running 20 projects across Central African Republic, providing lifesaving medical care and humanitarian assistance. Since January, we have treated more than 3,250 people for violence-related injuries, conducted more than 300,000 outpatient consultations and treated over 3,000 people for malaria. For more information, visit: msf.org.uk/car

WHAT MSF IS DOINGi

Dr Tahir Wissanji changes the dressing on the leg of a 10-year-old boy in MSF’s clinic at Mpoko camp, Bangui. Credit: Christian Nestler

SUDANCHAD

S. SUDAN

CENTRAL AFRICAN REPUBLIC

Bangui

Bossangoa

CONGODEMOCRATIC REPUBLIC OF CONGO

Bouca

CAMEROON

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Delivering medicine in a city under siege

In late 2010 and the beginning of 2011, the situation in my country

started to deteriorate. First, there were the demonstrations and protests in the capital, Sana’a; then violent clashes broke out all over the country.

At the time, I was working for MSF and the Ministry of Health at the HIV clinic in Al-Gumhuri hospital, the only facility in Sana’a that provides livesaving antiretroviral (ARV) treatment to patients suffering from the virus.

Prepared for the worstIt was clear to us that we needed to be prepared for the worst. With more than 350 patients receiving livesaving ARV treatment at our facility, we needed to put a plan in place that meant we could continue to get drugs to patients if conflict broke out.

In Yemen, getting treatment for HIV is already difficult. As a general rule, HIV-positive patients find getting tested and treated for the illness very difficult because of the stigma associated with it. They’ve been misinformed about the disease, and have lived their whole lives seeing how HIV-positive people are discriminated against – even by health workers. Even I personally had misconceptions around HIV until I trained as a nurse, and learned the science behind it.

In spring 2011, the fighting intensified and Sana’a was divided into two sides. Different armed groups took over sections of the city, and moving around became extremely difficult. Clashes around the hospital meant the staff were trapped inside for three days. The situation became too dangerous for foreign staff to hang around – they were all moved to safe houses and flown out of the country.

‘Without the drugs, our patients could die’But most of the Yemeni staff – myself included – stayed on. Though we could no longer run our regular activities at Al-Gumhuri, we still needed to get ARV drugs to the HIV patients, or else their condition could deteriorate, and they could even die. So we put our well-laid plans into action.

In the months leading up to the conflict, the MSF and Ministry of Health staff had given special cards to each of our patients. The cards

were a way for patients to get in touch when they needed their medication delivered, should we have to suspend our normal activities. These health cards didn’t have any information on them that could identify them or me – they had my phone number on it, and that’s all.

Undercover drop-offsThe patient would call me and give me their patient number. From that number, I’d know what kind of drug regimen they were on and I’d be able to collect the appropriate ARVs from storage. The patient would then give me a location, and I’d either take my car to drop the appropriate ARV medication off there, or I’d leave it – tucked discreetly into a shopping bag – wherever they requested. Doing this, I visited some pretty unusual locations – I once was asked to leave the drugs in a supermarket; another time, a photographer’s studio.

Sometimes patients would even come to my home and collect the drugs that they required; or I’d pick them up in the street, give them their drugs while I drove, and then drop them off in

another location so as to avoid putting ourselves in danger. People would call me day and night; I had no idea how long this was going to go on for, so at times it seemed like it would never end. It didn’t matter to me how it happened, though. All that mattered is that the sick people got treated, even while the two sides of the city were on lockdown.

Scary and stressfulAfter three months, the active fighting came to an end, and we were able to resume full activities in Sana’a. And for all the hard work, the plan was a success: we were able to reach all of the 363 patients needing ARV treatment during the fighting, with 97 percent of them coming back to us to continue their treatment after it was over. There were some scary and stressful times, but I never felt like it was too much for me. In fact, the patients became like family to me – I was often the only person they could trust. I hope there will never again be unrest like this in my country. But if ever there is, we’ll be ready.

YEMEN

Abdulbaset Alzamar is a Yemeni nurse working for MSF and the Yemeni Ministry of Health. He talks about his experience providing live-saving medicines to HIV patients as unrest tore the capital, Sana’a, apart.

YOUR SUPPORTConflict, hunger, disease, disaster. MSF tries to go where we are needed most. But our staff can only help if they have training and resources. We can only provide these if people give to us. Please support us today.Phone 0800 408 3894 Visit: www.msf.org.uk/support Or use the form on page 3

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HIV is a hidden problem in the Yemeni capital, Sana’a. Credit: Anna Surinyach/MSF

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Despite a volatile security situation, MSF teams are finding ways to work in Yemen, including with HIV patients, migrants and people in need of emergency surgical care. Credit: Anna Surinyach/MSF

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