DispatchesM S F C A N A D A N E W S L E T T E R

Vol.9, Ed.2

IN THIS ISSUE

1

4

6

8

10

12

14

15

1999 Nobel Peace Prize Laureate

Emergency care forpregnant women

“There’s no happinessin this place”

Battling cholera in theRepublic of the Congo

Field blog:“Suddenly…Sudan”

Impossible choices:The harsh reality ofhumanitarian aid

Working late inSomalia

Canada’s Access toMedicines Regime not working

Book review:Inspiration to act

(continued on page 2)

HAITIEMERGENCY CARE FOR PREGNANT WOMEN

Haiti has the grim distinction of being the poor-est country in the western hemisphere, with

the highest level of maternal mortality. This may bedifficult to believe, considering that it is only fourhours flight from Montreal. Today, Haitians sufferthe consequences of systemic and insidious vio-lence. Pregnant women are among the most vulner-able victims.

AN UNFORGIVING ENVIRONMENT

Despite successful elections in 2006 and thepresence of a UN stabilisation mission, Haiti con-tinued to experience regular outbursts of violence:

kidnappings, rape, organised crime and shootoutsbetween armed groups and UN forces. In this con-text of severe political and social instability, MSFopened an emergency obstetric care hospital inthe Haitian capital, Port-au-Prince, in March2006. MSF’s Jude Anne Hospital serves womenwho have little access to health care, who live inthe poorest neighbourhoods of the city and arethus most at risk of violence.

Pregnant women living in the slums of Port-au-Prince are exposed to violence on a daily basis.An expectant mother from the Cité Soleil slumcould be sexually assaulted by a family member,

© J

ulie

Rém

y

Dispatches Vol.9, Ed.2 page 3

a neighbour or a gang member. She mightget caught in the crossfire of a conflictbetween armed groups, or she mightexperience psychological trauma due tothe violence. Because she lives in a gang-controlled slum, she could be ostracisedby people from other parts of Port-au-Prince who fear that she is associatedwith the gang. Perhaps the sole caregiverfor her children, she struggles against theincreased vulnerability that comes withextreme poverty. She is systematically for-gotten by her society and the internation-al community.

These women have very little choice, ifany, when they seek healthcare. Thehealthcare system in Haiti is accessibleonly to those who can afford it and thusremains out of reach to women living inthe poor areas of the city. Medical servic-es in public hospitals are too expensivefor the majority of expectant mothers.Should a baby be born by normal delivery,the mother would have to pay a $13 feeat a public hospital – six times the aver-age daily salary of a working Haitian, and

completely unaffordable for an unem-ployed mother. For women in the slums,the alternative to seeking hospital care isto give birth at home, perhaps with thehelp of a matronne (a local untrainedmidwife) using traditional medicine,which could increase the chances of com-plications at birth.

“Despite promises made to the populationthat international funds would flood thecountry, the reality is that women’s situa-tions continue to remain the same. MSFgives these women a chance to access freeemergency obstetric care,” explains ColetteGadenne, MSF head of mission in Haiti.

MSF OPENS AN EMERGENCY OBSTETRIC CARE HOSPITAL

When Jude Anne Hospital opened inMarch 2006, MSF projected that it wouldhandle 300 births a month. In Septemberof that year, hospital teams delivered1,300 babies, about one every half-hour.This unexpected surge in births led tocreative infrastructure planning, such as

the construction of a triage area in thehospital parking lot. Most importantly, thesurge (accounting for one-fifth of totalbirths in Port-au-Prince that month) drewattention to Haitian women’s desperateneed for free, quality maternal care.

The medical teams at the hospital, com-posed mainly of Haitian staff, felt over-whelmed at times by the sheer number ofbirths. The most difficult part of their workis being unable to save the lives of babies,even mothers, who arrive at the hospital toolate. Many maternal deaths are caused byeclampsia: an increase in blood pressurethat leads to convulsions and the suddendeath of both the mother and her unbornbaby. When eclampsia is caught in time,the mother and child can survive if the babyis delivered by caesarean section.

In June 2006, MSF started a programmeto help prevent the transmission ofHIV/AIDS from mother to child at birth bytesting women for HIV and transferringthem to a hospital that will provide medi-cine to protect the unborn baby. MSF also

H a i t i

offers psychosocial counselling to womenand antenatal/postnatal care.

To identify pregnant mothers who arepotentially at risk, a team of outreachworkers regularly visits the slums of Port-au-Prince. They teach expectant mothershow to look for signs, such as bleeding orunusual headaches, that might requireemergency care. They sing songs inCreole and play games to communicatetheir message to attentive audiences. Amobile MSF clinic also visits the slums tooffer antenatal care to expectant mothersin their own neighbourhoods.

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

These figures clearly indicate a massiveand ongoing need for emergency obstet-ric care for women living in the slums ofPort-au-Prince. Throughout 2007, MSFwill lobby the government of Haiti andthe international community to priori-tise the needs of pregnant mothers, andto provide them with the maternal carethey require.

To find out more about MSF’s activities inHaiti, please visit our website atwww.msf.ca, and click on Countries.

Isabelle JeansonCommunications advisor

Photographer Julie Rémy traveled to Haitiin May 2007 to document MSF’s work inthe country. These are the stories of twopregnant women she met there.

JEANISE

When I walked into the delivery room andmet Jeanise, 38, she was so thin that Ifound it hard to believe she was about togive birth. I was even more incredulous tolearn that she was having twins.

Jeanise was admitted to Jude AnneHospital because she had a history ofhypertension, which can lead to potentiallyfatal eclampsia. She was also therebecause this was her sixth pregnancy (andher second set of twins).

Though I could see the pain on her face,she didn’t complain. She gave birth to twotiny girls, each less than 2 kg. The newbornsisters clung to each other as the nursescleaned them. Jeanise seemed happy.

A few minutes after delivering she walkedto a bed in the recovery area, in order tomake room for the next labouring mother.Malnourished, with few resources and sixother children, I wondered how Jeanisewould feed these two new mouths.

NERLANDE

We met Nerlande while on an outreachvisit to the La Saline slum with the MSFInformation, Education and Communica-tion (IEC) Team. The pregnant 13-year-oldgirl was in great pain, and had tearsrolling down her face.

Her contractions had started the previousnight and she felt ready to give birth, buthad no money to pay for transportation andwas scared to go to the hospital for thefirst time in her life. The IEC team quicklycalled a driver to take her to Jude Anne.

At the hospital she was diagnosed withpre-eclampsia. The doctors judged thatshe would probably have lost her baby ordied if we had not found her.

Nerlande suffered through two and a halflong days of labour surrounded by scream-ing women and throbbing generators. Mostof the time she lay on a hard woodenbench at the hospital entrance becausethere was no bed available inside. I was

impatient for her to give birth so she couldget some relief.

Her young hips were too narrow and shewas too weak to deliver naturally, so doc-tors finally decided to perform a cesare-an section. She gave birth to a beautiful2.2 kg girl.

After two days resting in the post-deliveryward with other new mothers, she wenthome. She returned a few days later fortreatment when her incision becameinfected, due to the unsanitary conditionsin La Saline.

© Julie Rémy

© Julie Rémy

© Julie Rémy

© Julie Remy

© Julie Rémy© Julie Rémy

Dispatches Vol.9, Ed.2 page 3

a neighbour or a gang member. She mightget caught in the crossfire of a conflictbetween armed groups, or she mightexperience psychological trauma due tothe violence. Because she lives in a gang-controlled slum, she could be ostracisedby people from other parts of Port-au-Prince who fear that she is associatedwith the gang. Perhaps the sole caregiverfor her children, she struggles against theincreased vulnerability that comes withextreme poverty. She is systematically for-gotten by her society and the internation-al community.

These women have very little choice, ifany, when they seek healthcare. Thehealthcare system in Haiti is accessibleonly to those who can afford it and thusremains out of reach to women living inthe poor areas of the city. Medical servic-es in public hospitals are too expensivefor the majority of expectant mothers.Should a baby be born by normal delivery,the mother would have to pay a $13 feeat a public hospital – six times the aver-age daily salary of a working Haitian, and

completely unaffordable for an unem-ployed mother. For women in the slums,the alternative to seeking hospital care isto give birth at home, perhaps with thehelp of a matronne (a local untrainedmidwife) using traditional medicine,which could increase the chances of com-plications at birth.

“Despite promises made to the populationthat international funds would flood thecountry, the reality is that women’s situa-tions continue to remain the same. MSFgives these women a chance to access freeemergency obstetric care,” explains ColetteGadenne, MSF head of mission in Haiti.

MSF OPENS AN EMERGENCY OBSTETRIC CARE HOSPITAL

When Jude Anne Hospital opened inMarch 2006, MSF projected that it wouldhandle 300 births a month. In Septemberof that year, hospital teams delivered1,300 babies, about one every half-hour.This unexpected surge in births led tocreative infrastructure planning, such as

the construction of a triage area in thehospital parking lot. Most importantly, thesurge (accounting for one-fifth of totalbirths in Port-au-Prince that month) drewattention to Haitian women’s desperateneed for free, quality maternal care.

The medical teams at the hospital, com-posed mainly of Haitian staff, felt over-whelmed at times by the sheer number ofbirths. The most difficult part of their workis being unable to save the lives of babies,even mothers, who arrive at the hospital toolate. Many maternal deaths are caused byeclampsia: an increase in blood pressurethat leads to convulsions and the suddendeath of both the mother and her unbornbaby. When eclampsia is caught in time,the mother and child can survive if the babyis delivered by caesarean section.

In June 2006, MSF started a programmeto help prevent the transmission ofHIV/AIDS from mother to child at birth bytesting women for HIV and transferringthem to a hospital that will provide medi-cine to protect the unborn baby. MSF also

H a i t i

offers psychosocial counselling to womenand antenatal/postnatal care.

To identify pregnant mothers who arepotentially at risk, a team of outreachworkers regularly visits the slums of Port-au-Prince. They teach expectant mothershow to look for signs, such as bleeding orunusual headaches, that might requireemergency care. They sing songs inCreole and play games to communicatetheir message to attentive audiences. Amobile MSF clinic also visits the slums tooffer antenatal care to expectant mothersin their own neighbourhoods.

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

These figures clearly indicate a massiveand ongoing need for emergency obstet-ric care for women living in the slums ofPort-au-Prince. Throughout 2007, MSFwill lobby the government of Haiti andthe international community to priori-tise the needs of pregnant mothers, andto provide them with the maternal carethey require.

To find out more about MSF’s activities inHaiti, please visit our website atwww.msf.ca, and click on Countries.

Isabelle JeansonCommunications advisor

Photographer Julie Rémy traveled to Haitiin May 2007 to document MSF’s work inthe country. These are the stories of twopregnant women she met there.

JEANISE

When I walked into the delivery room andmet Jeanise, 38, she was so thin that Ifound it hard to believe she was about togive birth. I was even more incredulous tolearn that she was having twins.

Jeanise was admitted to Jude AnneHospital because she had a history ofhypertension, which can lead to potentiallyfatal eclampsia. She was also therebecause this was her sixth pregnancy (andher second set of twins).

Though I could see the pain on her face,she didn’t complain. She gave birth to twotiny girls, each less than 2 kg. The newbornsisters clung to each other as the nursescleaned them. Jeanise seemed happy.

A few minutes after delivering she walkedto a bed in the recovery area, in order tomake room for the next labouring mother.Malnourished, with few resources and sixother children, I wondered how Jeanisewould feed these two new mouths.

NERLANDE

We met Nerlande while on an outreachvisit to the La Saline slum with the MSFInformation, Education and Communica-tion (IEC) Team. The pregnant 13-year-oldgirl was in great pain, and had tearsrolling down her face.

Her contractions had started the previousnight and she felt ready to give birth, buthad no money to pay for transportation andwas scared to go to the hospital for thefirst time in her life. The IEC team quicklycalled a driver to take her to Jude Anne.

At the hospital she was diagnosed withpre-eclampsia. The doctors judged thatshe would probably have lost her baby ordied if we had not found her.

Nerlande suffered through two and a halflong days of labour surrounded by scream-ing women and throbbing generators. Mostof the time she lay on a hard woodenbench at the hospital entrance becausethere was no bed available inside. I was

impatient for her to give birth so she couldget some relief.

Her young hips were too narrow and shewas too weak to deliver naturally, so doc-tors finally decided to perform a cesare-an section. She gave birth to a beautiful2.2 kg girl.

After two days resting in the post-deliveryward with other new mothers, she wenthome. She returned a few days later fortreatment when her incision becameinfected, due to the unsanitary conditionsin La Saline.

© Julie Rémy

© Julie Rémy

© Julie Rémy

© Julie Remy

© Julie Rémy© Julie Rémy

In April 2006 MSF assessed the makeshiftcamp and found worrying health indicatorsamong the residents as a result of squalidliving conditions. Significant health prob-lems include diarrhoea, respiratory infec-tions and malnutrition. In May, MSFopened a clinic and a therapeutic feedingcentre near the makeshift camp. By theend of the year, on an average day, the clin-ic performed over 140 consultations. Overthat period, the feeding centre served atotal of 665 children.

J. came to the MSF clinic with her two pre-mature twins. She is only 18 years old andgot married eight months ago, but her hus-band later left her. He already had anotherwife and refused to look after J. and herbabies. In March, she was evicted from hershelter by the authorities because it waslocated too close to the road. Now she liveswith her mother. They survive by begging.

LIVING WHERE THEY LANDED

Some Rohingyas never moved from thebeach area where they landed with theirboats after fleeing Myanamar. They liveon the long beach of Shamlapur, wherefishing is their only source of livelihood.They work for Bangladeshi boat ownersand are paid little.

MSF runs a weekly mobile clinic atShamlapur beach, which provides health-care and health education to the Rohingyarefugees living here. Respiratory and skininfections are the most common ailments.

Due to bandit activity on the roads, theteam has to drive for an hour along thebeach in order to reach the clinic, and coor-dinates its travel schedule according to thetides. Once there, they operate out of a con-verted storeroom partitioned with plasticsheeting. A neighbouring shop verandaserves as a patient waiting room.

N. came from Myanmar 14 years ago.Since then she has lived on the beach withten members of her family: four daughters,two sons and their wives and children. Herhusband died six years ago. “We came toBangladesh because the Burmese armytook our land, our cows and everything we

had,” she said. “Here we live on fishing.Everything we fish is taken by the boatowner and we get paid depending on howmuch we fish.”

On average, there are about 10 fishing dayseach month, except during the threemonths of the rainy season, from June toAugust, when it is almost impossible to fish.Consequently their income is not enough toadequately sustain a family of ten.

However these are the same problems con-fronted by many Bangladeshis. At leasthere the Rohingyas do not fear for theirlives. “If I go back [to Myanmar] after allthis time, they will put me in jail or shootme,” she added, “here at least they do notsay anything.”

BEYOND THAT BORDER

The Rohingyas have a long history of cross-ing the border between Myanmar and

Bangladesh. Long ago, some of them cameand started businesses in the Chittagongregion, north of Teknaf. The Rohingyas areMuslims like the majority of theBangladeshi people and their language isnot very different from the dialects spokenin the eastern region of Bangladesh.

Today, however, they are facing great diffi-culties in integrating into Bangladeshi soci-ety. Since 1994, they are no longer recog-nised as refugees and they face discrimina-tion and exploitation. Their living condi-tions, both in Tal camp and at Shamlapurbeach, are appalling and yet they have con-tinued to come for the past 15 years, leav-ing their land behind. If Tal camp is wherethey prefer to be, one can only wonder whatit is like on the other side of the border.

Elena TortaCommunications advisor

Dispatches Vol.9, Ed.2 page 5

In 1992, more than 250,000 RohingyaMuslims fled from Northern Rakhine

State, Myanmar, to Bangladesh. Theywere pushed off their land by discrimina-tion, violence and the forced labour prac-tices of the Myanmar authorities. Over theyears, most of the Rohingyas returned toMyanmar while others have continued tocome to Bangladesh.

On the Bangladeshi side of the border,more than 26,000 Rohingya refugees whorefused to go back to Myanmar live in thetwo official camps of Kutupalong andNayapara, south of Cox’s Bazaar. Anunknown number of Rohingyas live in theTeknaf area, near the Myanmar border.

Over 7,500 refugees live in the squalid,makeshift Tal camp and around 2,200inhabit the beach area of Shamlapur. Aminority of the Rohingyas have managed tointegrate into Bangladeshi society. Some ofthese people have returned after beingrepatriated to Myanmar.

MSF began serving the Rohingyas inBangladesh at the time of their mass exo-dus from Myanmar 15 years ago, providinga wide range of basic healthcare services in

the refugee camps. It left the region in2003 but re-started activities last year.

FROM BAD…

Rohingyas who were registered at the timeof the big influx in 1992, and who havesince been living in the official refugeecamps, have access to food rations, basichealthcare and some education.

In April 2007, MSF opened two 20-bedinpatient units in the Kutupalong andNayapara camps. Over their first twomonths of operation, these facilities haveadmitted 650 patients. The MSF team ispreparing to open birthing units in each ofthe camps.

Although these Rohingyas are better offthan the unregistered refugees, their livesare confined within the camps’ fences.They depend on aid and cannot work out-side the camps. Their future looks bleak.

R. is a 17-year-old mother. She was onlytwo when she arrived at Kutapalong Campand has lived there ever since. She doesn’tknow anything of the world outside thecamp. R. came with her mother, brothers

and grandparents, but her mother had to goback to Myanmar, her brother left after hav-ing problems with camp authorities, andher grandparents died.

She is married but her husband is in hidingbecause he isn’t registered in the camp. “Ihaven’t seen him in more than fivemonths,” she said. “I want to stay inBangladesh but outside the camp. There isno happiness in this place.”

…TO WORSE

For unregistered Rohingya refugees scat-tered across the Teknaf region, life is evenharder. They survive by doing hard workfor little money and must constantly fightfor access to basic needs like food, waterand healthcare.

Tal camp consists of small ramshackleshelters situated between the river Naf andthe highway leading to the city of Cox’sBazaar. More than 7,500 Rohingya men,women and children have sought refugehere, on a stretch of land 800 metres longand 30 metres wide. Food and potablewater are scarce and access to local health-care facilities is limited.

B a n g l a d e s h

“THERE’S NO HAPPINESS IN THIS PLACE”

© E

ddy

van

Wes

sel

© Eddy van Wessel

© Eddy van Wessel

In April 2006 MSF assessed the makeshiftcamp and found worrying health indicatorsamong the residents as a result of squalidliving conditions. Significant health prob-lems include diarrhoea, respiratory infec-tions and malnutrition. In May, MSFopened a clinic and a therapeutic feedingcentre near the makeshift camp. By theend of the year, on an average day, the clin-ic performed over 140 consultations. Overthat period, the feeding centre served atotal of 665 children.

J. came to the MSF clinic with her two pre-mature twins. She is only 18 years old andgot married eight months ago, but her hus-band later left her. He already had anotherwife and refused to look after J. and herbabies. In March, she was evicted from hershelter by the authorities because it waslocated too close to the road. Now she liveswith her mother. They survive by begging.

LIVING WHERE THEY LANDED

Some Rohingyas never moved from thebeach area where they landed with theirboats after fleeing Myanamar. They liveon the long beach of Shamlapur, wherefishing is their only source of livelihood.They work for Bangladeshi boat ownersand are paid little.

MSF runs a weekly mobile clinic atShamlapur beach, which provides health-care and health education to the Rohingyarefugees living here. Respiratory and skininfections are the most common ailments.

Due to bandit activity on the roads, theteam has to drive for an hour along thebeach in order to reach the clinic, and coor-dinates its travel schedule according to thetides. Once there, they operate out of a con-verted storeroom partitioned with plasticsheeting. A neighbouring shop verandaserves as a patient waiting room.

N. came from Myanmar 14 years ago.Since then she has lived on the beach withten members of her family: four daughters,two sons and their wives and children. Herhusband died six years ago. “We came toBangladesh because the Burmese armytook our land, our cows and everything we

had,” she said. “Here we live on fishing.Everything we fish is taken by the boatowner and we get paid depending on howmuch we fish.”

On average, there are about 10 fishing dayseach month, except during the threemonths of the rainy season, from June toAugust, when it is almost impossible to fish.Consequently their income is not enough toadequately sustain a family of ten.

However these are the same problems con-fronted by many Bangladeshis. At leasthere the Rohingyas do not fear for theirlives. “If I go back [to Myanmar] after allthis time, they will put me in jail or shootme,” she added, “here at least they do notsay anything.”

BEYOND THAT BORDER

The Rohingyas have a long history of cross-ing the border between Myanmar and

Bangladesh. Long ago, some of them cameand started businesses in the Chittagongregion, north of Teknaf. The Rohingyas areMuslims like the majority of theBangladeshi people and their language isnot very different from the dialects spokenin the eastern region of Bangladesh.

Today, however, they are facing great diffi-culties in integrating into Bangladeshi soci-ety. Since 1994, they are no longer recog-nised as refugees and they face discrimina-tion and exploitation. Their living condi-tions, both in Tal camp and at Shamlapurbeach, are appalling and yet they have con-tinued to come for the past 15 years, leav-ing their land behind. If Tal camp is wherethey prefer to be, one can only wonder whatit is like on the other side of the border.

Elena TortaCommunications advisor

Dispatches Vol.9, Ed.2 page 5

In 1992, more than 250,000 RohingyaMuslims fled from Northern Rakhine

State, Myanmar, to Bangladesh. Theywere pushed off their land by discrimina-tion, violence and the forced labour prac-tices of the Myanmar authorities. Over theyears, most of the Rohingyas returned toMyanmar while others have continued tocome to Bangladesh.

On the Bangladeshi side of the border,more than 26,000 Rohingya refugees whorefused to go back to Myanmar live in thetwo official camps of Kutupalong andNayapara, south of Cox’s Bazaar. Anunknown number of Rohingyas live in theTeknaf area, near the Myanmar border.

Over 7,500 refugees live in the squalid,makeshift Tal camp and around 2,200inhabit the beach area of Shamlapur. Aminority of the Rohingyas have managed tointegrate into Bangladeshi society. Some ofthese people have returned after beingrepatriated to Myanmar.

MSF began serving the Rohingyas inBangladesh at the time of their mass exo-dus from Myanmar 15 years ago, providinga wide range of basic healthcare services in

the refugee camps. It left the region in2003 but re-started activities last year.

FROM BAD…

Rohingyas who were registered at the timeof the big influx in 1992, and who havesince been living in the official refugeecamps, have access to food rations, basichealthcare and some education.

In April 2007, MSF opened two 20-bedinpatient units in the Kutupalong andNayapara camps. Over their first twomonths of operation, these facilities haveadmitted 650 patients. The MSF team ispreparing to open birthing units in each ofthe camps.

Although these Rohingyas are better offthan the unregistered refugees, their livesare confined within the camps’ fences.They depend on aid and cannot work out-side the camps. Their future looks bleak.

R. is a 17-year-old mother. She was onlytwo when she arrived at Kutapalong Campand has lived there ever since. She doesn’tknow anything of the world outside thecamp. R. came with her mother, brothers

and grandparents, but her mother had to goback to Myanmar, her brother left after hav-ing problems with camp authorities, andher grandparents died.

She is married but her husband is in hidingbecause he isn’t registered in the camp. “Ihaven’t seen him in more than fivemonths,” she said. “I want to stay inBangladesh but outside the camp. There isno happiness in this place.”

…TO WORSE

For unregistered Rohingya refugees scat-tered across the Teknaf region, life is evenharder. They survive by doing hard workfor little money and must constantly fightfor access to basic needs like food, waterand healthcare.

Tal camp consists of small ramshackleshelters situated between the river Naf andthe highway leading to the city of Cox’sBazaar. More than 7,500 Rohingya men,women and children have sought refugehere, on a stretch of land 800 metres longand 30 metres wide. Food and potablewater are scarce and access to local health-care facilities is limited.

B a n g l a d e s h

“THERE’S NO HAPPINESS IN THIS PLACE”

© E

ddy

van

Wes

sel

© Eddy van Wessel

© Eddy van Wessel

page 7Dispatches Vol.9, Ed.2

Katja Mogensen is a registered nurse fromCanmore, Alberta. She spent two monthsworking with MSF in the Republic of theCongo in 2007.

Cases of suspected cholera first occurredat the end of November 2006 in

Pointe-Noire, on the coast of Republic ofthe Congo. Although there was laboratoryconfirmation in mid-December, the out-break wasn’t publicly announced untilJanuary. Governments are often reluctant to announce cholera outbreaks due to the negative impact they can have on tradeand travel.

MSF has been working in the Pool area eastof Pointe-Noire for several years, providinghealthcare services to populations affectedby violent conflicts in the region. This facil-itated collaboration with the CongoleseMinistry of Health.

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

The team opened four cholera treatmentcentres (CTCs) at local hospitals and healthcentres, setting up tents to provide addition-al capacity. MSF hired local nurses and doc-tors and trained them in recognising thesigns of the disease and MSF protocols.Working alongside colleagues from theMinistry of Health, they dealt with more than200 patients a day between all the centres.

In a CTC, patients are divided into threeclasses – A, B and C – according to theseverity of dehydration, C being themost severe. Triage is very important toensure quick hydration for those whoneed it most.

Patients with severe cases are given bedswith holes in them so they don’t have toget up, as diarrhoea is almost constant.The treatment is rapid rehydration usingintravenous solutions. A severely illpatient may require 8 to 16 litres of IVfluids per day. Antibiotics are only admin-istered in severe cases.

One of the main functions of a treatmentcentre is to contain the disease, as it is high-ly contagious. A specially-trained hygieneteam uses chlorine solutions to wash handsand footwear, and to decontaminate stools,vomit, clothes, floors and walls.

Patients’ bodies and their clothes arewashed with solution when they enter theCTC. When a patient is hospitalised, thehygienists must go to his house to disinfectthe outside and inside of the residence aswell as the latrines.

R e p u b l i c o f t h e C o n g o

When the government publicly announcedthe cholera outbreak, national and local cri-sis committees were established. Theirmain task was to educate the populationand prevent the spread of the disease,using pamphlets and messages on radioand television.

Cholera is called the disease of dirtyhands, as it can be spread by failing towash one’s hands after using the toilet. Asa result there is a stigma attached tocholera, while people’s knowledge of itmay be limited, leading to fear andostracism of cholera patients even amonglocal medical personnel.

MSF mobile teams, composed of hygien-ists and nurses, delivered informationabout cholera and the precautions neces-sary to prevent infection at schools, mar-kets and health centres around the city.

The teams would see patients sufferingfrom diarrhoea and offer them oral rehy-dration salts in clean water. In many areasresidents do not have access to cleanwater; in others, one tap may be sharedby hundreds of people. Latrines are oftenbuilt too close to one another, leading tocontamination of water sources.

By the end of January, cholera had alsospread to the capital, Brazzaville. MSFand the Ministry of Health set up a CTCat the main hospital and offered outreachservices to the local population. Newcholera cases in Brazzaville rose to about45 per week but never reached the samelevels as in Pointe-Noire.

In April 2007, as the level of new casesdeclined, MSF handed over the CTCs inPointe-Noire and Brazzaville to the Ministryof Health. MSF will continue donating

intravenous solutions, chlorine and othermedical supplies as needed until the gov-ernment decides to close the centres.

Katja MogensenRegistered nurse

Brazzaville, Republic of the Congo

Battling

Cholera

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

© J

iro

Ose

© Jiro Ose © Jiro Ose

page 7Dispatches Vol.9, Ed.2

Katja Mogensen is a registered nurse fromCanmore, Alberta. She spent two monthsworking with MSF in the Republic of theCongo in 2007.

Cases of suspected cholera first occurredat the end of November 2006 in

Pointe-Noire, on the coast of Republic ofthe Congo. Although there was laboratoryconfirmation in mid-December, the out-break wasn’t publicly announced untilJanuary. Governments are often reluctant to announce cholera outbreaks due to the negative impact they can have on tradeand travel.

MSF has been working in the Pool area eastof Pointe-Noire for several years, providinghealthcare services to populations affectedby violent conflicts in the region. This facil-itated collaboration with the CongoleseMinistry of Health.

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

The team opened four cholera treatmentcentres (CTCs) at local hospitals and healthcentres, setting up tents to provide addition-al capacity. MSF hired local nurses and doc-tors and trained them in recognising thesigns of the disease and MSF protocols.Working alongside colleagues from theMinistry of Health, they dealt with more than200 patients a day between all the centres.

In a CTC, patients are divided into threeclasses – A, B and C – according to theseverity of dehydration, C being themost severe. Triage is very important toensure quick hydration for those whoneed it most.

Patients with severe cases are given bedswith holes in them so they don’t have toget up, as diarrhoea is almost constant.The treatment is rapid rehydration usingintravenous solutions. A severely illpatient may require 8 to 16 litres of IVfluids per day. Antibiotics are only admin-istered in severe cases.

One of the main functions of a treatmentcentre is to contain the disease, as it is high-ly contagious. A specially-trained hygieneteam uses chlorine solutions to wash handsand footwear, and to decontaminate stools,vomit, clothes, floors and walls.

Patients’ bodies and their clothes arewashed with solution when they enter theCTC. When a patient is hospitalised, thehygienists must go to his house to disinfectthe outside and inside of the residence aswell as the latrines.

R e p u b l i c o f t h e C o n g o

When the government publicly announcedthe cholera outbreak, national and local cri-sis committees were established. Theirmain task was to educate the populationand prevent the spread of the disease,using pamphlets and messages on radioand television.

Cholera is called the disease of dirtyhands, as it can be spread by failing towash one’s hands after using the toilet. Asa result there is a stigma attached tocholera, while people’s knowledge of itmay be limited, leading to fear andostracism of cholera patients even amonglocal medical personnel.

MSF mobile teams, composed of hygien-ists and nurses, delivered informationabout cholera and the precautions neces-sary to prevent infection at schools, mar-kets and health centres around the city.

The teams would see patients sufferingfrom diarrhoea and offer them oral rehy-dration salts in clean water. In many areasresidents do not have access to cleanwater; in others, one tap may be sharedby hundreds of people. Latrines are oftenbuilt too close to one another, leading tocontamination of water sources.

By the end of January, cholera had alsospread to the capital, Brazzaville. MSFand the Ministry of Health set up a CTCat the main hospital and offered outreachservices to the local population. Newcholera cases in Brazzaville rose to about45 per week but never reached the samelevels as in Pointe-Noire.

In April 2007, as the level of new casesdeclined, MSF handed over the CTCs inPointe-Noire and Brazzaville to the Ministryof Health. MSF will continue donating

intravenous solutions, chlorine and othermedical supplies as needed until the gov-ernment decides to close the centres.

Katja MogensenRegistered nurse

Brazzaville, Republic of the Congo

Battling

Cholera

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

© J

iro

Ose

© Jiro Ose © Jiro Ose

this was the medicine i do at home. like wak-ing. i examined the patient, and his wounds.there were two, one was definitely superfi-cial, but the other i couldn’t tell if it wentinto his chest, or possibly his abdomen. hisstomach was soft, his breathing clear. that’sgood. i put on sterile gloves and poked mylittle finger into the hole. it didn’t passthrough to his lung. i could feel a spicule ofbone, as fine as a tooth on a comb, that theknife had sheared off, but i couldn’t feel thethin tract of the blade underneath it. perhapsthe knife had bounced off of it, continued ona harmless path.

we decided to go to the OT and explore thewound. i opened the metal door, and thecrowd outside had grown. at least 30 peo-ple, more arriving through the gate. twowomen had thrown themselves on theground in grief, wailing, rolling. someonetried to push past me. no. he stood fast. sodid i. there were too many people for us tonavigate a stretcher through. the littlecourtyard was nearly full, tilting towardschaos. “please move,” i said, “stand at thegate. i will come and talk to you soon.”

some of our staff arrived from the com-pound and helped push the crowd back.we closed the gate, and people leapt overit. we started from the ER with ourstretcher, people trying to follow from allsides. i ran interference where i could.we blocked the entrance to the OT, andwent inside.

we prepped his chest, and cleaned thewound. i tried to pass forceps through to hisabdomen or chest, but it appeared thetrack went underneath his skin instead ofinside. so lucky. both of us.

i left the other doctor to close the wound andwent back outside. most people were now atthe gate, their backs turned to the hospital,watching a fistfight across the football field,half a mile away. i spoke with them.

i walked home an hour later on my wornpath, with my translator. “today is a diffi-cult day,” he said, “i don’t think i will makeany movements tonight.” i agreed. a goodnight to be quiet at home.

“but,” he said, “you know, abyei is betterthan before. two years ago, no one left theirhomes. the market would close early.everyone was too afraid. you could wake upone morning and step outside and see adead body. it wasn’t safe for anyone.”“well, it seems much better now,” i said.“oh yes, much better,” he said. “safe. nowthere is peace.”

peace. after so much war. i hear that word allthe time, use it all the time, but never did itsound so correct, it’s meaning so obvious.the difference between then and now wascomplete. like the change in the sky.

it is one of the reasons MSF is here, ofcourse. not simply to show solidarity with a

population torn by war, but to encouragepeace. we do it by being neutral, siding onlywith the sick. we make a place, the hospital,where everyone can find respite, regardlessof which tribe they claim, or which borderthey cross to get here. but we also did itwhen we first put up our flag, already brownand frayed. we needed, from the beginning,to guarantee the safety of ourselves and ourstaff. the local authorities work, in part, tokeep the roads safe because if they are not,we will not be able to move. the hospitalmust be safe or we will not be able to work.

the rain is starting. i am to bed. a goodnight to be quiet, and i hope the people ofabyei agree.

Dr. James MaskalykMedical doctor

Abyei, Sudan

page 9Dispatches Vol.9, Ed.2

“SUDDENLY...SUDAN”The following is an entry from “Suddenly...Sudan,” Dr. James Maskalyk’s blog (a kindof Internet diary). Dr. Maskalyk is an emer-gency physician in Toronto. He wrote hisentries late at night from his tukul (a sim-ple hut made from mud and grass) inAbyei, Sudan. Dr. Maskalyk worked withMSF in Abyei for six months in 2007.

24 May 2007: “crowds of clouds”

tired.

the sky looks like it will fall. after adozen cloudless mornings, blueblueafternoons, and sweltering starrednights, heavy black clouds hang aboveus, looming, ready to crash down. thewind has whipped up sand, and as werush to close our tukul doors, we canfeel the tiny stings from the whippinggrains. never a middle ground.

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

the atmosphere is different on the groundtoo, in town. tense. waiting for the change,for the sky to fall. there was a fight this after-noon, and someone was stabbed. i was inthe hospital when it happened. i left theoperating theatre, and found a crowd of peo-ple outside of the emergency room, huddlingaround its closed steel door. every so often itwould open, a nurse or doctor would enter orleave, and close the door behind them.“what’s going on?” i asked my translator whowas leaning against the wall. “hitting... withknife,” he said. i pushed through the crowd

and rapped on the metal door. it opened acrack and an eye peered out at me.

as i walked in, people from behind tried topush past me, to enter the room. i heldthem back, moved them gently back intothe throng, and closed the door. the roomwas full already. it was difficult to move.three nurses, soldiers, relatives, anothermedical doctor. “ok, everyone out. exceptstaff and one relative. please. everyone.you. you. you. out.” reluctantly they left,one by one. as they did, others tried to pushback in, removing their hands from theclosing door only at the last minute.

a young man was lying on his back, eyeswide in terror, his shirt red with blood andso was the bed. “two IVs,” i said, “19gauge, and open them. call the lab techni-cian for a blood group, and ask outside fora donor. blood pressure?”

S u d a n

© MSF© Sven Torfinn/HH

© J

ehad

Nga

BLOGGING FROM A RURAL OUTPOST IN ABYEI

this was the medicine i do at home. like wak-ing. i examined the patient, and his wounds.there were two, one was definitely superfi-cial, but the other i couldn’t tell if it wentinto his chest, or possibly his abdomen. hisstomach was soft, his breathing clear. that’sgood. i put on sterile gloves and poked mylittle finger into the hole. it didn’t passthrough to his lung. i could feel a spicule ofbone, as fine as a tooth on a comb, that theknife had sheared off, but i couldn’t feel thethin tract of the blade underneath it. perhapsthe knife had bounced off of it, continued ona harmless path.

we decided to go to the OT and explore thewound. i opened the metal door, and thecrowd outside had grown. at least 30 peo-ple, more arriving through the gate. twowomen had thrown themselves on theground in grief, wailing, rolling. someonetried to push past me. no. he stood fast. sodid i. there were too many people for us tonavigate a stretcher through. the littlecourtyard was nearly full, tilting towardschaos. “please move,” i said, “stand at thegate. i will come and talk to you soon.”

some of our staff arrived from the com-pound and helped push the crowd back.we closed the gate, and people leapt overit. we started from the ER with ourstretcher, people trying to follow from allsides. i ran interference where i could.we blocked the entrance to the OT, andwent inside.

we prepped his chest, and cleaned thewound. i tried to pass forceps through to hisabdomen or chest, but it appeared thetrack went underneath his skin instead ofinside. so lucky. both of us.

i left the other doctor to close the wound andwent back outside. most people were now atthe gate, their backs turned to the hospital,watching a fistfight across the football field,half a mile away. i spoke with them.

i walked home an hour later on my wornpath, with my translator. “today is a diffi-cult day,” he said, “i don’t think i will makeany movements tonight.” i agreed. a goodnight to be quiet at home.

“but,” he said, “you know, abyei is betterthan before. two years ago, no one left theirhomes. the market would close early.everyone was too afraid. you could wake upone morning and step outside and see adead body. it wasn’t safe for anyone.”“well, it seems much better now,” i said.“oh yes, much better,” he said. “safe. nowthere is peace.”

peace. after so much war. i hear that word allthe time, use it all the time, but never did itsound so correct, it’s meaning so obvious.the difference between then and now wascomplete. like the change in the sky.

it is one of the reasons MSF is here, ofcourse. not simply to show solidarity with a

population torn by war, but to encouragepeace. we do it by being neutral, siding onlywith the sick. we make a place, the hospital,where everyone can find respite, regardlessof which tribe they claim, or which borderthey cross to get here. but we also did itwhen we first put up our flag, already brownand frayed. we needed, from the beginning,to guarantee the safety of ourselves and ourstaff. the local authorities work, in part, tokeep the roads safe because if they are not,we will not be able to move. the hospitalmust be safe or we will not be able to work.

the rain is starting. i am to bed. a goodnight to be quiet, and i hope the people ofabyei agree.

Dr. James MaskalykMedical doctor

Abyei, Sudan

page 9Dispatches Vol.9, Ed.2

“SUDDENLY...SUDAN”The following is an entry from “Suddenly...Sudan,” Dr. James Maskalyk’s blog (a kindof Internet diary). Dr. Maskalyk is an emer-gency physician in Toronto. He wrote hisentries late at night from his tukul (a sim-ple hut made from mud and grass) inAbyei, Sudan. Dr. Maskalyk worked withMSF in Abyei for six months in 2007.

24 May 2007: “crowds of clouds”

tired.

the sky looks like it will fall. after adozen cloudless mornings, blueblueafternoons, and sweltering starrednights, heavy black clouds hang aboveus, looming, ready to crash down. thewind has whipped up sand, and as werush to close our tukul doors, we canfeel the tiny stings from the whippinggrains. never a middle ground.

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

the atmosphere is different on the groundtoo, in town. tense. waiting for the change,for the sky to fall. there was a fight this after-noon, and someone was stabbed. i was inthe hospital when it happened. i left theoperating theatre, and found a crowd of peo-ple outside of the emergency room, huddlingaround its closed steel door. every so often itwould open, a nurse or doctor would enter orleave, and close the door behind them.“what’s going on?” i asked my translator whowas leaning against the wall. “hitting... withknife,” he said. i pushed through the crowd

and rapped on the metal door. it opened acrack and an eye peered out at me.

as i walked in, people from behind tried topush past me, to enter the room. i heldthem back, moved them gently back intothe throng, and closed the door. the roomwas full already. it was difficult to move.three nurses, soldiers, relatives, anothermedical doctor. “ok, everyone out. exceptstaff and one relative. please. everyone.you. you. you. out.” reluctantly they left,one by one. as they did, others tried to pushback in, removing their hands from theclosing door only at the last minute.

a young man was lying on his back, eyeswide in terror, his shirt red with blood andso was the bed. “two IVs,” i said, “19gauge, and open them. call the lab techni-cian for a blood group, and ask outside fora donor. blood pressure?”

S u d a n

© MSF© Sven Torfinn/HH

© J

ehad

Nga

BLOGGING FROM A RURAL OUTPOST IN ABYEI

Dispatches Vol.9, Ed.2

In the mid-1990s, as war raged in south-ern Sudan, there was yet another out-

break of the deadly disease kala azar. Theillness had already ravaged many villages,killing an estimated 100,000 people.

Although this particular outbreak was noton the scale of previous epidemics, it wasjust as deadly for those affected. Our MSFteam struggled to respond, hampered bythe war and a worldwide shortage of thedrug needed to treat this fatal disease.

We had to decide which populations wouldreceive life saving drugs and which wouldnot. We had to decide who would live andwho would die.

As we scrambled to find supplies of thedrug, Pentostam, we also sought genericpreparations and alternative treatments.Country by country, we scoured the globefor supplies. Although these efforts con-tributed to saving more lives, there stillwasn’t enough medicine. We had to makechoices that were unacceptable both forthose suffering from the disease and thoseforced to choose.

HOW TO CHOOSE?

The security of our project locationsand our capacity to deliver quality care

guided our thinking. We decided totreat patients in locations where wewere most assured of successfully fin-ishing the treatment and saving thelives of the sick.

As logical as this seemed, it meant cut-ting off a group of people in one of themost devastated areas. Although we hadjust gained access to this severelyaffected population, the level of insecu-rity there was too high to keep a team onthe ground.

People already on treatment were giventhe possibility of completing it. But wewere forced to abandon others suspect-ed of having the disease. They were leftwith no hope other than to walk for twoweeks to our next location, across afrontline in the ongoing conflict.

What had been an impossible choice forus turned into impossible choices forpatients and their families. Their onlyhope lay in undertaking a gruelling anddangerous journey, which many did.When they arrived at the other end,project staff were overwhelmed at thesight of families walking together, someof whom had carried their sick relativesgreat distances across the savannah toreach MSF.

MAKING BEST USE OF SCARCE RESOURCES

Today the situation in southern Sudanhas stabilised in most areas. The great-est challenges are in accessing remoteregions, training staff, and supportinglocal authorities in building a health-care system.

This has implications for MSF’s level ofinvolvement. MSF believes that aid, likemedicine, requires specialisation. We pro-vide a humanitarian response to crisis,one that focuses on emergencies andthose most in need, particularly in desta-bilised contexts involving war, conflict,violence and oppression.

As security increases, so does the need toinvolve organisations that specialise indevelopment. This has led us to a new setof impossible choices in southern Sudan.We have begun to hand over responsibili-ty as other organisations have stepped in.

When emergencies end and contextsbecome more stable, we believe it is ourresponsibility to plan an exit strategy andreallocate our limited resources to situa-tions where other organisations can’t orwon’t work. At times this generates criti-cism of MSF. It is difficult for those who

S u d a n

page 11

benefit from our care to understand whywe would leave. It is difficult for someteam members who have developed con-nections with local people to comprehendwhy we need to move on. Usually the levelof care available is still far from what wewould see in Canada. Considering this,how is it possible to hand over a projectwhen we know that the medical care thatfollows may be less comprehensive?

For instance, a few months ago the MSFteam in Aweil, southern Sudan, met ayoung girl named Nyanut. Nyanut suf-fered from kala azar. The disease had pro-gressed over months and as a result shewas seriously malnourished. She wasbrought to our hospital by a group ofCanadians traveling with journalists.

Upon arriving at the hospital, theCanadians learned that we were in themidst of a handover. This was incon-ceivable to them. How could we thinkof leaving when people like Nyanutneeded care? Although we were able tosave Nyanut’s life, along with the manypatients who preceded her over theprevious seven years, the questionweighed heavily on us. It touched onthe harsh reality of our work, on theimpossible choices.

In the case of Aweil, there is a secondhospital 20 km away, a Sudanese doctoron location, and at least three other NGOsproviding health services in the area.Does this amount to an acceptable levelof care for this population? It does not.But only about 25 per cent of people insouthern Sudan have access to even themost basic level of healthcare.

As a humanitarian organisation devotedto saving lives and alleviating suffering, itis our duty to seek out and respond to themost acute needs. The impossible choic-es we make ultimately take us beyond thesmall pockets where some level of health-care is available, to places where otheryoung girls like Nyanut have no access tocare at all.

Marilyn McHargGeneral director, MSF Canada

The harsh reality of humanitarian aidIMPOSSIBLE CHOICES© Ian Cumming

© D

avid

Lev

ene

© David Levene

© Tomas Van Houtryve

© David Levene

Dispatches Vol.9, Ed.2

In the mid-1990s, as war raged in south-ern Sudan, there was yet another out-

break of the deadly disease kala azar. Theillness had already ravaged many villages,killing an estimated 100,000 people.

Although this particular outbreak was noton the scale of previous epidemics, it wasjust as deadly for those affected. Our MSFteam struggled to respond, hampered bythe war and a worldwide shortage of thedrug needed to treat this fatal disease.

We had to decide which populations wouldreceive life saving drugs and which wouldnot. We had to decide who would live andwho would die.

As we scrambled to find supplies of thedrug, Pentostam, we also sought genericpreparations and alternative treatments.Country by country, we scoured the globefor supplies. Although these efforts con-tributed to saving more lives, there stillwasn’t enough medicine. We had to makechoices that were unacceptable both forthose suffering from the disease and thoseforced to choose.

HOW TO CHOOSE?

The security of our project locationsand our capacity to deliver quality care

guided our thinking. We decided totreat patients in locations where wewere most assured of successfully fin-ishing the treatment and saving thelives of the sick.

As logical as this seemed, it meant cut-ting off a group of people in one of themost devastated areas. Although we hadjust gained access to this severelyaffected population, the level of insecu-rity there was too high to keep a team onthe ground.

People already on treatment were giventhe possibility of completing it. But wewere forced to abandon others suspect-ed of having the disease. They were leftwith no hope other than to walk for twoweeks to our next location, across afrontline in the ongoing conflict.

What had been an impossible choice forus turned into impossible choices forpatients and their families. Their onlyhope lay in undertaking a gruelling anddangerous journey, which many did.When they arrived at the other end,project staff were overwhelmed at thesight of families walking together, someof whom had carried their sick relativesgreat distances across the savannah toreach MSF.

MAKING BEST USE OF SCARCE RESOURCES

Today the situation in southern Sudanhas stabilised in most areas. The great-est challenges are in accessing remoteregions, training staff, and supportinglocal authorities in building a health-care system.

This has implications for MSF’s level ofinvolvement. MSF believes that aid, likemedicine, requires specialisation. We pro-vide a humanitarian response to crisis,one that focuses on emergencies andthose most in need, particularly in desta-bilised contexts involving war, conflict,violence and oppression.

As security increases, so does the need toinvolve organisations that specialise indevelopment. This has led us to a new setof impossible choices in southern Sudan.We have begun to hand over responsibili-ty as other organisations have stepped in.

When emergencies end and contextsbecome more stable, we believe it is ourresponsibility to plan an exit strategy andreallocate our limited resources to situa-tions where other organisations can’t orwon’t work. At times this generates criti-cism of MSF. It is difficult for those who

S u d a n

page 11

benefit from our care to understand whywe would leave. It is difficult for someteam members who have developed con-nections with local people to comprehendwhy we need to move on. Usually the levelof care available is still far from what wewould see in Canada. Considering this,how is it possible to hand over a projectwhen we know that the medical care thatfollows may be less comprehensive?

For instance, a few months ago the MSFteam in Aweil, southern Sudan, met ayoung girl named Nyanut. Nyanut suf-fered from kala azar. The disease had pro-gressed over months and as a result shewas seriously malnourished. She wasbrought to our hospital by a group ofCanadians traveling with journalists.

Upon arriving at the hospital, theCanadians learned that we were in themidst of a handover. This was incon-ceivable to them. How could we thinkof leaving when people like Nyanutneeded care? Although we were able tosave Nyanut’s life, along with the manypatients who preceded her over theprevious seven years, the questionweighed heavily on us. It touched onthe harsh reality of our work, on theimpossible choices.

In the case of Aweil, there is a secondhospital 20 km away, a Sudanese doctoron location, and at least three other NGOsproviding health services in the area.Does this amount to an acceptable levelof care for this population? It does not.But only about 25 per cent of people insouthern Sudan have access to even themost basic level of healthcare.

As a humanitarian organisation devotedto saving lives and alleviating suffering, itis our duty to seek out and respond to themost acute needs. The impossible choic-es we make ultimately take us beyond thesmall pockets where some level of health-care is available, to places where otheryoung girls like Nyanut have no access tocare at all.

Marilyn McHargGeneral director, MSF Canada

The harsh reality of humanitarian aidIMPOSSIBLE CHOICES© Ian Cumming

© D

avid

Lev

ene

© David Levene

© Tomas Van Houtryve

© David Levene

page 13Dispatches Vol.9, Ed.2

S o m a l i a

Calgarian Darryl Stellmach recentlyreturned from Somalia, where he workedas the project coordinator in the town ofMarere. In this interview, he tellsDispatches how his team dealt with anoutbreak of cholera. This was Darryl'sfourth mission with MSF. He plans to goon mission again in the fall of 2007.

I was posted in Marere, in the Juba val-ley, to manage a hospital project where

MSF provides basic health care to thelocal population, including maternal care,vaccinations and a nutrition program forchildren under five years old.

The Juba valley is a very fertile region, butdue to clashes between clans and ethnicgroups, and discrimination against certaingroups, many suffer from health problems,especially related to malnutrition.

Major floods hit the valley in October 2006.The floods destroyed most crops, contami-nated water supplies, and made it very dif-ficult for us to reach people through ourmobile nutritional screening clinic.

Soon after the flooding, we started seeingcases of cholera. We immediately set upour emergency response: a cholera treat-ment centre (CTC) and a second isolationunit were built near our hospital.

We sent mobile teams to the areas affect-ed by cholera. The outreach effort had athree-fold purpose: to educate the localpopulation about the symptoms of the

disease; to distribute chlorine tablets,which people would use to purify watercollected in buckets; and to find newcholera cases.

New patients were transported back to theCTC by rented minibus. The trip, thoughonly about 40 km, could take up to sixhours because of bad road conditions.

The hardest part about this mission wasthe unpredictability of our work. Whenyou go to bed, you never know if you'll geta full night’s sleep – we're never quitesure what will come to our door.

One night for example, just as we weregoing to bed around 10 pm, a staff mem-ber came to warn us that a busload ofpatients had just arrived. These patientswere referred to us by a local healthworker who took it upon himself to iden-tify cases of cholera in his community.He had driven the minibus full of sickadults and children to our CTC, whichwas 40 km away.

Our staff got dressed and went backout to the hospital to do triage. Thepatients who were most sick were sentto the isolation unit and given IV drips.Those with less severe symptoms weregiven oral rehydration salts, mattress-es, and mosquito nets to protect themfrom malaria.

The team was tired, but also becameexperts at working very quickly. We had a

rhythm and worked well together. Wequickly fell into a routine of reacting tothese emergencies in a professional andorganised way.

Since January 2007, the MSF projectin Marere has treated over 250 patientsfor cholera. With the rainy season arriv-ing, we expect the case numbers to godown, because people will be able tocollect fresh, uncontaminated waterfrom the rain, instead of drawing fromthe stagnant pools and lakes leftbehind by the flooding.

Darryl Stellmach Project coordinator

Marere, Somalia

WORKINGLATE

© M

agnu

s H

allg

ren

© Magnus Hallgren © Tom Quinn/MSF© Magnus Hallgren

page 13Dispatches Vol.9, Ed.2

S o m a l i a

Calgarian Darryl Stellmach recentlyreturned from Somalia, where he workedas the project coordinator in the town ofMarere. In this interview, he tellsDispatches how his team dealt with anoutbreak of cholera. This was Darryl'sfourth mission with MSF. He plans to goon mission again in the fall of 2007.

I was posted in Marere, in the Juba val-ley, to manage a hospital project where

MSF provides basic health care to thelocal population, including maternal care,vaccinations and a nutrition program forchildren under five years old.

The Juba valley is a very fertile region, butdue to clashes between clans and ethnicgroups, and discrimination against certaingroups, many suffer from health problems,especially related to malnutrition.

Major floods hit the valley in October 2006.The floods destroyed most crops, contami-nated water supplies, and made it very dif-ficult for us to reach people through ourmobile nutritional screening clinic.

Soon after the flooding, we started seeingcases of cholera. We immediately set upour emergency response: a cholera treat-ment centre (CTC) and a second isolationunit were built near our hospital.

We sent mobile teams to the areas affect-ed by cholera. The outreach effort had athree-fold purpose: to educate the localpopulation about the symptoms of the

disease; to distribute chlorine tablets,which people would use to purify watercollected in buckets; and to find newcholera cases.

New patients were transported back to theCTC by rented minibus. The trip, thoughonly about 40 km, could take up to sixhours because of bad road conditions.

The hardest part about this mission wasthe unpredictability of our work. Whenyou go to bed, you never know if you'll geta full night’s sleep – we're never quitesure what will come to our door.

One night for example, just as we weregoing to bed around 10 pm, a staff mem-ber came to warn us that a busload ofpatients had just arrived. These patientswere referred to us by a local healthworker who took it upon himself to iden-tify cases of cholera in his community.He had driven the minibus full of sickadults and children to our CTC, whichwas 40 km away.

Our staff got dressed and went backout to the hospital to do triage. Thepatients who were most sick were sentto the isolation unit and given IV drips.Those with less severe symptoms weregiven oral rehydration salts, mattress-es, and mosquito nets to protect themfrom malaria.

The team was tired, but also becameexperts at working very quickly. We had a

rhythm and worked well together. Wequickly fell into a routine of reacting tothese emergencies in a professional andorganised way.

Since January 2007, the MSF projectin Marere has treated over 250 patientsfor cholera. With the rainy season arriv-ing, we expect the case numbers to godown, because people will be able tocollect fresh, uncontaminated waterfrom the rain, instead of drawing fromthe stagnant pools and lakes leftbehind by the flooding.

Darryl Stellmach Project coordinator

Marere, Somalia

WORKINGLATE

© M

agnu

s H

allg

ren

© Magnus Hallgren © Tom Quinn/MSF© Magnus Hallgren

Since 2003, MSF Canada has worked toincrease access to life-saving medi-

cines and get drugs into the hands ofpatients using the Jean Chrétien Pledge toAfrica Act, now known as Canada’s Accessto Medicines Regime (CAMR).

The CAMR amends Canada’s Patent Act inaccordance with changes to intellectualproperty rules set forth in 2003 by theWorld Trade Organization’s (WTO) August30th Decision. These changes allow devel-oping countries to import generic medi-cines even if the medicine is under patent.The purpose of this exemption is to allowuniversal access to medicines in the eventof a major public health crisis.

In the last issue of Dispatches (Winter2007), we reported that the Canadian gov-ernment was about to embark on a reviewof the CAMR legislation. A public consulta-tion took place in January 2007 wheremany stakeholders, including MSF, submit-ted papers.

Subsequently, the Parliamentary Commit-tee on Industry, Science and Technologyfollowed up with a study and hearings. MSFonce again argued that the Canadian legis-lation was too bureaucratic and onerous toprovide any incentive for developing coun-

tries or generic pharmaceutical companiesto make use of it.

In one of the first tests of the new WTOrules, Thai authorities issued a compulsorylicense to produce a cheaper generic ver-sion of the HIV/AIDS drug Kaletra inJanuary 2007. Abbott Laboratories, whichholds the patent on Kaletra, responded byannouncing that it would withdraw applica-tions to register new drugs in Thailand. Thecase suggests that there may be difficultbattles ahead for developing and newlyindustrialised countries that pit themselvesagainst the pharmaceutical industry.

FLAWS ARE APPARENT

Critics have challenged MSF’s work on theCanadian front of the access to medicinesbattle, noting the many legal complicationssurrounding the issue. However, MSF hassucceeded in making the issue resonate withthe Canadian public and has rallied activists.The organisation has pointedly signalled tothe Canadian government that it has fol-lowed an international trade mechanism thatis itself flawed, and that it has a role to playat the WTO level in correcting these flaws.

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

Who is responsible? MSF has highlightedits position in written submissions, presen-tations to parliamentary committees, mediainterviews and civil society forums: that thecompromises made by the Canadian gov-ernment to accommodate both brand nameand generic pharmaceutical companieshave failed to bring medicines to peoplewho are most in need.

WHAT NEXT?

The Committee on Industry, Science andTechnology will table a report on its reviewof the CAMR as this issue of Dispatchesgoes to press. No meaningful changes areexpected to be made to the legislation.

In the meantime, MSF will continue to dowhat it does best, delivering life-saving med-ical assistance to those in need. MSF Canadadirectly manages health programmes in fivecountries in West Africa and Latin Americaand will continue to obtain quality medicinesfrom the cheapest, most readily accessiblesources in the world. We cannot limit our-selves to what is available in Canada; ourpatients don’t have the luxury to wait.

Lai-Ling LeeProgramme officer

DispatchesMédecins Sans Frontières/Doctors Without Borders

720 Spadina Avenue, Suite 402 Toronto, Ontario, M5S 2T9

Tel: 416.964.0619Fax: 416.963.8707

Toll free: 1.800.982.7903Email: msfcan@msf.ca

www.msf.ca

Editor:Jake Wadland

Editorial director:Avril Benoît

Editorial advisor:linda o. nagy

Translation coordinator:Julie Rémy

Contributors:Amy Coulterman, Isabelle Jeanson, Lai-Ling Lee,

James Maskalyk, Marilyn McHarg, Katja Mogensen, Julie Rémy, Darryl Stellmach, Elena Torta

Circulation: 90,000Layout: Tenzing Communications

Printing: Warren’s Imaging and Dryography

Summer 2007

ISSN 1484-9372

ANGOLAAnne Henderson

ARMENIARobert Parker

BANGLADESHJulia Payson

BURUNDIAnnie DesiletsDanielle Trepanier

CENTRAL AFRICANREPUBLICMagdalena Gonzalez-

Fernandez

CHADRink De Lange

Marise DenaultFrédéric ÉliasAndré FortinLori HuberMichel-Olivier

LacharitéLeanne OlsonAllison StrachanGislène Télémaque

COLOMBIATyler Fainstat

DEMOCRATICREPUBLIC OF CONGOLaura ArcherMaryse Bonnel

Anne-Josée Boutin-Trudeau

Guylaine HouleElisabeth MartelTara NewellNicole ParkerVivian Skovsbo

ETHIOPIAWendy RhymerIvan Zenar

GUINEADawn Keim

HAITILynn McLauchlinSylvie Savard

INDIALeanne Pang

INDONESIAPatrick Laurent

IVORY COASTPatrick BoucherAsha GervanNicolas HamelDiane RachieleLori Ann Wanlin

KENYADavid MichalskiTiffany Moore

LESOTHOPeter Saranchuk

MALAWIMichelle ChouinardChantal St-Arnaud

MOLDOVASteffen Kramer

MYANMARNadine CrosslandFrédéric Dubé

NEPALAssad MenapalGrace Tang

NIGERFarah Ali

NIGERIARichard GosselinPaulo RottmannMary-Ellen Sweetnam

PAKISTANJustin ArmstrongFahreen Dossa

REPUBLIC OF THE CONGOAhmed AlasJeremy ParnellShauna Sturgeon

SIERRA LEONEErwan Cheneval

SOMALIADenise ChouinardJoli Shoker

SRI LANKAMegan HunterKrista Mckitrick

SUDANReshma AdatiaCarolyn BeukeboomJames MaskalykDaniel NashAlexis Porter

UGANDAMaguil GoujaMathieu Léonard

ZAMBIAChris Warren

ZIMBABWECarmen BellowsDavid CroftJean-François

LemaireJoannie Roy

Dispatches Vol.9, Ed.2 page 15

A c c e s s t o e s s e n t i a l m e d i c i n e s

Inspired by the compassionate curiosity ofstudents that the author encountered as

executive director of MSF Canada, HealingOur World introduces young people to thework of MSF across the globe.

The book briefly chronicles the history ofthe organisation, from its inception in theaftermath of the Nigerian Civil War, throughits development into the largest independ-ent medical-humanitarian aid organisationin the world.

The book examines the structure of MSFand explains how the organisation operatesin challenging environments, treating every-thing from mental health problems to mal-nutrition. Startling journal excerpts draw on

the author’s years of experience in areasaffected by natural disasters, refugee crisesand the AIDS epidemic.

At the heart of Healing Our World are thereflections of MSF field workers. Whatinspires these people, including a motorcy-cle dealer and a stage manager, to work inrefugee camps and disaster zones? Morleyoffers insights into their varying motivations.

Photos and excerpts from interviews, jour-nals and emails tell of their inspiration, thepeople they meet, the heart-breaking situa-tions they encounter, and the small victo-ries they achieve. Ultimately, young readersdiscover the strength of the human spiritand the capacity for compassion we allhave within us.

Healing Our World is written by David Morley,executive director of MSF Canada from1998 to 2005, and currently the presidentand chief executive officer of Save the

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

Healing Our World: Inside Doctors Without Borders

By David MorleyAges 12+; 121 pages;

$22.95 CAD / $18.95 USD (hardcover)

Amy CoultermanPersonal giving assistant

INSPIRATION TO ACT

NOT WORKING CANADA’S ACCESS TO MEDICINES REGIME

CANADIANS ON MISSION

B o o k r e v i e w

© T

on K

oene

Since 2003, MSF Canada has worked toincrease access to life-saving medi-

cines and get drugs into the hands ofpatients using the Jean Chrétien Pledge toAfrica Act, now known as Canada’s Accessto Medicines Regime (CAMR).

The CAMR amends Canada’s Patent Act inaccordance with changes to intellectualproperty rules set forth in 2003 by theWorld Trade Organization’s (WTO) August30th Decision. These changes allow devel-oping countries to import generic medi-cines even if the medicine is under patent.The purpose of this exemption is to allowuniversal access to medicines in the eventof a major public health crisis.

In the last issue of Dispatches (Winter2007), we reported that the Canadian gov-ernment was about to embark on a reviewof the CAMR legislation. A public consulta-tion took place in January 2007 wheremany stakeholders, including MSF, submit-ted papers.

Subsequently, the Parliamentary Commit-tee on Industry, Science and Technologyfollowed up with a study and hearings. MSFonce again argued that the Canadian legis-lation was too bureaucratic and onerous toprovide any incentive for developing coun-

tries or generic pharmaceutical companiesto make use of it.

In one of the first tests of the new WTOrules, Thai authorities issued a compulsorylicense to produce a cheaper generic ver-sion of the HIV/AIDS drug Kaletra inJanuary 2007. Abbott Laboratories, whichholds the patent on Kaletra, responded byannouncing that it would withdraw applica-tions to register new drugs in Thailand. Thecase suggests that there may be difficultbattles ahead for developing and newlyindustrialised countries that pit themselvesagainst the pharmaceutical industry.

FLAWS ARE APPARENT

Critics have challenged MSF’s work on theCanadian front of the access to medicinesbattle, noting the many legal complicationssurrounding the issue. However, MSF hassucceeded in making the issue resonate withthe Canadian public and has rallied activists.The organisation has pointedly signalled tothe Canadian government that it has fol-lowed an international trade mechanism thatis itself flawed, and that it has a role to playat the WTO level in correcting these flaws.

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

Who is responsible? MSF has highlightedits position in written submissions, presen-tations to parliamentary committees, mediainterviews and civil society forums: that thecompromises made by the Canadian gov-ernment to accommodate both brand nameand generic pharmaceutical companieshave failed to bring medicines to peoplewho are most in need.

WHAT NEXT?

The Committee on Industry, Science andTechnology will table a report on its reviewof the CAMR as this issue of Dispatchesgoes to press. No meaningful changes areexpected to be made to the legislation.

In the meantime, MSF will continue to dowhat it does best, delivering life-saving med-ical assistance to those in need. MSF Canadadirectly manages health programmes in fivecountries in West Africa and Latin Americaand will continue to obtain quality medicinesfrom the cheapest, most readily accessiblesources in the world. We cannot limit our-selves to what is available in Canada; ourpatients don’t have the luxury to wait.

Lai-Ling LeeProgramme officer

DispatchesMédecins Sans Frontières/Doctors Without Borders

720 Spadina Avenue, Suite 402 Toronto, Ontario, M5S 2T9

Tel: 416.964.0619Fax: 416.963.8707

Toll free: 1.800.982.7903Email: msfcan@msf.ca

www.msf.ca

Editor:Jake Wadland

Editorial director:Avril Benoît

Editorial advisor:linda o. nagy

Translation coordinator:Julie Rémy

Contributors:Amy Coulterman, Isabelle Jeanson, Lai-Ling Lee,

James Maskalyk, Marilyn McHarg, Katja Mogensen, Julie Rémy, Darryl Stellmach, Elena Torta

Circulation: 90,000Layout: Tenzing Communications

Printing: Warren’s Imaging and Dryography

Summer 2007

ISSN 1484-9372

ANGOLAAnne Henderson

ARMENIARobert Parker

BANGLADESHJulia Payson

BURUNDIAnnie DesiletsDanielle Trepanier

CENTRAL AFRICANREPUBLICMagdalena Gonzalez-

Fernandez

CHADRink De Lange

Marise DenaultFrédéric ÉliasAndré FortinLori HuberMichel-Olivier

LacharitéLeanne OlsonAllison StrachanGislène Télémaque

COLOMBIATyler Fainstat

DEMOCRATICREPUBLIC OF CONGOLaura ArcherMaryse Bonnel

Anne-Josée Boutin-Trudeau

Guylaine HouleElisabeth MartelTara NewellNicole ParkerVivian Skovsbo

ETHIOPIAWendy RhymerIvan Zenar

GUINEADawn Keim

HAITILynn McLauchlinSylvie Savard

INDIALeanne Pang

INDONESIAPatrick Laurent

IVORY COASTPatrick BoucherAsha GervanNicolas HamelDiane RachieleLori Ann Wanlin

KENYADavid MichalskiTiffany Moore

LESOTHOPeter Saranchuk

MALAWIMichelle ChouinardChantal St-Arnaud

MOLDOVASteffen Kramer

MYANMARNadine CrosslandFrédéric Dubé

NEPALAssad MenapalGrace Tang

NIGERFarah Ali

NIGERIARichard GosselinPaulo RottmannMary-Ellen Sweetnam

PAKISTANJustin ArmstrongFahreen Dossa

REPUBLIC OF THE CONGOAhmed AlasJeremy ParnellShauna Sturgeon

SIERRA LEONEErwan Cheneval

SOMALIADenise ChouinardJoli Shoker

SRI LANKAMegan HunterKrista Mckitrick

SUDANReshma AdatiaCarolyn BeukeboomJames MaskalykDaniel NashAlexis Porter

UGANDAMaguil GoujaMathieu Léonard

ZAMBIAChris Warren

ZIMBABWECarmen BellowsDavid CroftJean-François

LemaireJoannie Roy

Dispatches Vol.9, Ed.2 page 15

A c c e s s t o e s s e n t i a l m e d i c i n e s

Inspired by the compassionate curiosity ofstudents that the author encountered as

executive director of MSF Canada, HealingOur World introduces young people to thework of MSF across the globe.

The book briefly chronicles the history ofthe organisation, from its inception in theaftermath of the Nigerian Civil War, throughits development into the largest independ-ent medical-humanitarian aid organisationin the world.

The book examines the structure of MSFand explains how the organisation operatesin challenging environments, treating every-thing from mental health problems to mal-nutrition. Startling journal excerpts draw on

the author’s years of experience in areasaffected by natural disasters, refugee crisesand the AIDS epidemic.

At the heart of Healing Our World are thereflections of MSF field workers. Whatinspires these people, including a motorcy-cle dealer and a stage manager, to work inrefugee camps and disaster zones? Morleyoffers insights into their varying motivations.

Photos and excerpts from interviews, jour-nals and emails tell of their inspiration, thepeople they meet, the heart-breaking situa-tions they encounter, and the small victo-ries they achieve. Ultimately, young readersdiscover the strength of the human spiritand the capacity for compassion we allhave within us.

Healing Our World is written by David Morley,executive director of MSF Canada from1998 to 2005, and currently the presidentand chief executive officer of Save the

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

Healing Our World: Inside Doctors Without Borders

By David MorleyAges 12+; 121 pages;

$22.95 CAD / $18.95 USD (hardcover)

Amy CoultermanPersonal giving assistant

INSPIRATION TO ACT

NOT WORKING CANADA’S ACCESS TO MEDICINES REGIME

CANADIANS ON MISSION

B o o k r e v i e w

© T

on K

oene

Dispatches Vol.9, Ed.2

Just a few words in your will...Create a legacy to provide life-saving medical care

for people in danger around the world.

Photo © Didier Lefevre

Personal Giving Office(416) 964-0619 / 1 800 982-7903

msfcan@msf.ca

For information about making a gift in your will to Médecins Sans Frontières/Doctors Without Borders, contact:

www.msf.ca402 - 720 Spadina Ave

Toronto ON M5S 2T9Charitable registration number: 13527 5857 RR0001