Their first observation was that medical workers were so terrorized that they would offer only first aid in cases of extreme emergency. To treat broken bones, for example, they would simply use makeshift splints. In dealing with hemorrhage, they applied compression bandages even when they had access to technical resources enabling them to provide more appropriate and complete care.

"They told us that the risk was too high,” the MSF surgeon explained. “We were told that, 'being caught with a patient is worse than being caught with a weapon.' A Syrian colleague told me that that meant death both for the patient and for him."

The team also observed the targeting of hospitals and medical facilities by armed forces. In a small town that the team visited, a health centre that served as an improvised hospital had been burned down. There was nowhere else to treat the wounded. Another health centre, still in good repair, had only one consulting room.

In another town, the team found an actual, functioning hospital. It had a medical team, supplies and a well-equipped operating room. "We performed as many procedures as we could," the MSF surgeon said. "Then we had to leave in less than 10 minutes after being warned that the army was coming and launching an attack on the city. Later, we heard that the hospital had been severely damaged and that it has not yet resumed functioning."

Fear is ever-present. Elsewhere in Idlib region, in northern Syria, the team was greeted at a public hospital whose operating room is closed. The hospital staff refuses to perform surgery for fear of reprisals and will thus provide only first aid services that require 10 to 20 minutes. "If the tanks arrive, I can be warned in time,” the chief doctor explained to the MSF team. “I can get all the patients out and remove all traces of their presence." (The family remains nearby and can thus move the patient quickly.)

When the MSF team asked what happens if a patient is in serious condition, the Syrian doctor responded with a helpless shrug. Some patients, he said, have managed to reach Turkey.

MSF has been seeking official authorization for several months to work with medical personnel in the Syrian governorates most affected by violence. To date, none of these efforts, either directly with Syrian authorities or via various intermediaries, have succeeded.

2012 Syria © MSF
During its short time in the Idlib area, the MSF team was able to perform some emergency medical work.

Nonetheless, after reaching the Syrian city of Homs, MSF managed to enter Idlib Governorate where the medical teams found patients and doctors at risk of attack and arrest.

"Being caught with patients is like being caught with a weapon," said an orthopedic surgeon whom MSF staff met in a village in Idlib Governorate. “The atmosphere in most medical facilities is extremely tense; healthcare workers send wounded patients home and provide only first aid so that facilities can be evacuated quickly in the event of a military operation.”

"A number of Syrian colleagues are reported to be missing," said Marie-Noëlle Rodrigue, MSF’s director of operations. "The authorities and all parties to the conflict must ensure that medical workers can operate without fear of retribution and that wounded people can safely seek and receive immediate lifesaving care, without resorting to inadequate improvised clinics for fear of arrest, or worse.”

While MSF has only a partial view of the medical situation inside Syria due to the lack of authorization to work in the country, the information obtained by MSF in Idlib is consistent with what it witnessed in Homs.

“We saw militarized healthcare facilities, meaning that access to medical care depends on which side you belong,” said Brice de le Vingne, MSF’s director of operations. “Health facilities are being targeted, thus endangering patients and preventing healthcare workers from doing their jobs. Health facilities and pharmacies are looted and destroyed.”

During its short time in the Idlib area, the MSF team was able to perform some emergency medical work.

"In one public hospital we worked as hard as we could for three days straight," said an MSF surgeon. "We operated on 15 wounded people and then had to pack everything up in 10 minutes after being notified of an imminent attack. Elsewhere in the Idlib region, an operating room was closed because it was simply too dangerous to perform surgery on wounded patients,” he said. “Doctors were threatened, and they discouraged us from setting up a medical facility because the situation was so risky,” adding that another hospital had been destroyed.

“You can see medical equipment and supplies,” the surgeon said. “Sometimes the resources and the infrastructure are there, but the fear and the risks of capture are so great that doctors hesitate to treat patients.”

Still without official authorization to operate inside Syria, MSF continues to support networks of Syrian doctors in Homs, Derah, Hama, Damascus and Idlib, delivering supplies and medicines from neighbouring countries. MSF also treats those who were wounded or tortured in Syria at a surgical hospital in Amman, Jordan. Additionally, MSF is providing primary healthcare and psychological support to Syrian refugees in Lebanon.

MSF reiterates its call for authorization to work inside Syria. The organization stands ready to quickly mobilize its medical and surgical teams, and is determined to operate independently, providing care to anyone requiring it.

Read more about the MSF team's work in Syria in March.

2012 Nigeria © Olga Overbeek/MSF
A child after having their blood drawn at MSF’s Tungan Daji clinic. The child has developmental problems from the long-term effects of lead poisoning.

Delegates included Zamfara state ministers, the Emir of Anka, Nigerian government representatives as well as national and international aid workers, scientists, health, environmental and mining experts. They expressed disappointment that the decision-makers from the Nigerian government – the ministers of Mines, Environment, and Health – were not present and that no concrete action by the Nigerian federal government was announced.

Most urgently, the promised funds of 850 million Naira ($ 5.4 million Canadian) for environmental remediation and safer mining that have been languishing for months while thousands of children continue to suffer from acute lead poisoning, must be released without further delay to the people of Zamfara.

The conference agreed an action Plan to set the path to achieving the three key pillars necessary to solve the Zamfara crisis: medical care, environmental remediation and safer mining. To succeed the Nigerian government, in particular the ministries of Mines, Environment, and Health at both federal and state level must commit significant resources and coordination.

Release of the promised funds is a key priority of the action plan, as is the immediate remediation of the village of Bagega where an estimated 1,500 children have been suffering from lead poisoning since 2010, and continue to wait for their village to be made safe. MSF cannot provide effective treatment in locations such as Bagega, which have not been remediated. MSF treats the sickest children at its inpatient facility in Anka hospital.

2012 Nigeria © Olga Overbeek/MSF
Children working at the gold processing site in Bagega, Nigeria. Ten-year-old Ibrahim (right) is responsible for adding the crushed stones to the funnel in the grinding machine.

“The people of Bagega are desperate for help,” said Zakaria Mwatia, a nurse and project coordinator for MSF in Zamfara. “Some of the villagers are attempting to remediate their own compounds in hopes that MSF will be able to provide treatment.”

“To effectively cut the pathways of lead contamination requires specialized expertise and equipment,” said Simba Tirima, a scientist with environmental engineering experts Terragraphics. “The people of Bagega need the urgently required assistance to provide a safe environment for their children.”

Read more about MSF's work in the Zamfara lead poisoning crisis

Read about the next steps and actions agreed on by those who attended the conference

According to Médecins Sans Frontières (MSF), which is assisting Malian refugees in camps in Burkina Faso, Mauritania and Niger, the international aid provided to these people is insufficient.

“MSF calls on the United Nations High Commissioner for Refugees  and the World Food Program [WFP] to increase and speed up the distribution of aid in Burkina Faso, Mauritania and Niger before the rainy season makes aid distribution even more difficult,” says Malik Allaouna, MSF director of operations.

In the makeshift Mauritanian camp of Mbéra, located in the middle of the desert, residents share one latrine for 220 people. They receive only 11 litres of water per person per day and the food distributed by the WFP does not meet the specific nutritional needs of children.

"We received four kilograms of rice – the quality is mediocre and it's full of pebbles – two cups of oil and two cups of sugar for 10 days," says one resident of Mbéra camp. "They've given us just a single ration since we arrived."

In Burkina Faso, where MSF is working in four camps, the organization notes that food supplies are distributed inappropriately. "The same quantity is distributed without regard for the number of people in a family," says Mohamed El Moktar, a refugee at the Gandafabou camp. "We are seven people. After two days, we have nothing left."

These living conditions are significantly below international aid standards and increase the vulnerability of people already weakened by a very long journey. Most of the diseases treated during MSF’s medical consultations in the camps are directly related to these poor living conditions.

At MSF's treatment centre in Mbéra, four out of every 10 people are seen for respiratory infections and two out of 10 for diarrhea. The next most-common complaints are skin infections and childhood malnutrition. Since the organization began working in Mbéra, more than 500 children have been treated for malnutrition.

“Food insecurity is a threat both for the Malian refugees and for the host communities, which are already suffering from poor harvests," says MS’s Allaouna. “Only food distribution, in sufficient quantity and quality, will prevent children’s nutritional condition from further deteriorating.”

In Burkina Faso, MSF is working in the Ferrerio, Gandafabou, Dibissi and Ngatourou-Niénié camps; in Mauritania, in Mbéra, Fassala and Bassikounou; and in Niger, it is active in the communities of Mangaïzé, Abala, Chinagodrar and Yassan

While Haiti’s Ministry of Health and Populations claims to be in control of the situation, health facilities in many regions of the country remain incapable of responding to the seasonal fluctuations of the cholera epidemic. The surveillance system which is supposed to monitor the situation and raise the alarm is still dysfunctional, MSF said.

2012 Haiti © Mathieu Fortoul/MSF
Patients in the MSF cholera treatment centre in Martissant, one of the poorest neighbourhoods in Port-au-Prince. The centre has 82 beds for people affected by cholera.

The number of people treated by MSF alone in the capital, Port-au-Prince, has quadrupled in less than a month, reaching 1,600 cases in April. The organization has increased treatment capacity in the city and in the town of Léogâne, and is preparing to open additional treatment sites in the country. Nearly 200,000 cholera cases were reported during the rainy season last year, between May and October.

“Too little has been done in terms of prevention to think that cholera would not surge again in 2012,” said Gaëtan Drossart, MSF head of mission in Haiti. “It is concerning that the health authorities are not better prepared and that they cling to reassuring messages that bear no resemblance to reality. There are many meetings going on between the government, the United Nations and their humanitarian partners, but there are few concrete solutions,” he said.

An MSF study in the Artibonite region, where approximately 20 per cent of cholera cases have been reported, has revealed a clear reduction of cholera prevention measures since 2011. More than half of the organizations working in the region last year are now gone. Additionally, health centres are short of drugs and some staff have not been paid since January.

The amount of rainfall is just one of the risk factors for contamination. “But as soon as the rains end, cholera subsides, and funding stops until the next rainy season, instead of money being channeled towards cholera prevention activities. As a consequence, people are still highly vulnerable when cholera comes back,” said Maya Allan, an epidemiologist with MSF.

The majority of Haitians do not have access to latrines, and obtaining clean water is a daily challenge. Of the half-million survivors of the January, 2010 earthquake who continue to live in camps, less than one third are provided with clean drinking water and only one per cent recently received soap, according to a April 2012 investigation by Haiti’s National Directorate of Water Supply and Sanitation.

“Hygiene advice is of little use if people are unable to put it into practice,” said Drossart. ”People urgently need the means to protect themselves against cholera.”

While the cholera vaccine being used in some parts of Haiti can help control the disease, it is not a foolproof solution. The vaccine provides immunity for approximately three years and is estimated to be only 70 per cent effective. Only major improvements of Haiti’s water and sanitation systems will provide durable solutions to the epidemic, but that will take time.

“The priority today is to save lives,” said Drossart. “All health actors in Haiti need to start working towards this goal immediately.”

Since cholera emerged in Haiti in October 2010, 535,000 people have been infected and more than 7,000 people have died, according to the Ministry of Health and Populations. To date, MSF has treated more than 170,000 people, or 33 per cent of total cases, across the country.

The increase in the conflict between armed groups since early April has led to people fleeing their homes and villages, trauma wounds from the violence, and increased deaths as well as sickness from certain illnesses for the populations affected by this instability.

2011 DRC © Yasuyoshi Chiba/Duckrabbit
MSF staff help a patient from the back of an MSF ambulance at the health centre in the village of Nyabiodio in Masisi, DRC.

“In the last several weeks, we have seen an increase in cases of malnutrition, respiratory infections and sexually transmitted infections, in addition to treating or providing support to more than two dozen patients directly wounded from the fighting,” says Corry Kik, MSF medical coordinator in North Kivu.

The mother of one four-year old patient with Kwashiorkor malnutrition spoke about the effects of this increased instability on the general population.

“I arrived today at the hospital with my daughter who is suffering from severe malnutrition. We live in a village three hour’s walk from here. Because of the insecurity over these last few weeks we no longer sleep in our house but in the fields or in the bush. During the night, bandits attack the village and during the day there are military clashes. It is difficult to find food with the bullets flying, and preventing us from going to the fields.”

Other patients have been directly wounded by armed violence, such as Momo,* who was transferred to an MSF-supported hospital along with five other patients.

“I decided to leave my home and travel to Goma to see my family and take care of some business. I left on a taxi with 20 other passengers at about seven in the morning. Ten minutes after we left I heard a series of whistles and then 30 seconds later the shots began to ring. I was hit by two bullets in my right leg and one in my left. The four masked men did not even try to stop the vehicle before shooting. My greatest wish is for this war to end and that people will speak to each other and resolve their conflicts because it is the population who is suffering from these clashes.”

In spite of the logistical challenges of moving patients, staff and supplies in the midst of ongoing conflict, the majority of MSF teams remain in the field and are continuing to provide healthcare to all patients, while donating extra supplies to nearby health centres as needed.

“Although we are seeing an increase in difficulty of access, we have been able to keep operating in our project locations and maintain the resources and space to treat the patients in greatest need,” says MSF head of mission for North Kivu, Christine Buesser.

This growing conflict places an additional burden on people there who are already struggling to access healthcare and treatment.

In North Kivu province, MSF provides primary and secondary healthcare throughout the region, providing support to reference hospitals in Mweso, Pinga, Masisi and Rutshuru and to health centres, mobile clinics and health posts in Kitchanga, Mweso, Pinga, Masisi and Rutshuru, and cholera treatment centres in Goma and surrounding areas. Emergency teams regularly evaluate and respond to needs in other areas.

Due to a series of grave security incidents, in April 2012 MSF decided to evacuate from Nyanzale and Butembo, and significantly reduced their teams in Rutshuru. However, during this time the organization also returned to full operations in Masisi, after a five month’s absence due to an attack on the MSF base in which one staff member was seriously injured.

*Name changed to protect confidentiality.

2012 Chad © Andrea Bussotti/MSF
MSF staff examine a young malnutrition patient in Chad’s Yao district.

Even in a ‘good’ year in Chad, many people struggle to get hold of sufficient food during the April to September lean season, and thousands of children become malnourished. But no one is expecting 2012 to be a good year. Last year, the rains did not come, and food prices are on the rise – the Ministry of Agriculture says prices are almost 25 per cent higher than this time a year ago. In Chad, as in the other countries across Africa’s Sahel region, all it takes is lower than average rainfall, or higher than average food prices, to tip parts of the country into a major nutrition crisis.

Cutting down on meals

In Biltine, some people were already down to the last of their food supplies in April. “Many families only have half a month’s worth of food stocks left, and have had to cut down on the number of meals they eat each day,” says Edoh, who is also MSF’s head of mission in Chad. “The variety of food has also dwindled.”

It is not only food that is scarce; there is also a dangerous water shortage in the Biltine area. “Some people are walking for over seven hours to fetch water,” he says. “It is a major concern: the water shortage has a direct link with malnutrition in children.”

In February, an MSF team discovered that one in four children under the age of five in Biltine was acutely malnourished. In response, MSF opened an emergency nutrition program in April, which enrolled 67 children for treatment in its first week, eight of whom were so seriously malnourished that they are receiving intensive inpatient care. The program will run for the next nine months.

Urgent need for food distributions

“Our first priority is to reduce the mortality rate of the one in four children under five who are acutely malnourished, by providing them with medical care, including therapeutic food,” says Edoh. He is also keen for the World Food Programme to start general food distributions to the population of Biltine as soon as possible. “We need to prevent the remaining 75 per cent of the children from becoming malnourished as well,” he says. “There’s a real, urgent need for these food distributions.”

In much of Chad, healthcare is not widely available, making people particularly vulnerable to malnutrition, as well as to outbreaks of infectious diseases. At MSF’s longterm project in Am Timan, in the southeast of the country, malnutrition rates are also climbing rapidly, exacerbated by an outbreak of measles.

“Between January and March we admitted 1,600 children with malnutrition – almost twice as many as at the same time last year,” says Edoh. “To make things worse, we are experiencing a measles outbreak. We are really concerned, because measles increases the likelihood of children becoming malnourished.”

An increase in meningitis cases has been reported from 12 districts across Chad, of which seven had to declare outbreaks, among them Am Timan. Nationwide 3,190 meningitis cases had been recorded until end of April and 145 people have died from the disease. MSF organized vaccination campaigns in Oum Hadier, Moissala, Massakory and Lere targeting approximately 640,000 people between the ages of one and 30. Additionally MSF sent teams to provide medical supplies and treatment to people who had contracted meningitis.

No one expects 2012 to be a ‘good’ year for many people in Chad, but MSF teams are doing all they can to prevent it from becoming any worse.

MSF currently provides lifesaving surgery in Aweil and Agok for patients wounded in the recent violence. The organization also reinforced its surgical response capacity in case of a general deterioration of the situation.

Photo: Alfons Rodriguez | A malnourished child with his mother in the hospital in Aweil, South Sudan,

MSF has also donated medicines and medical supplies to local hospitals in Abiemnom and Bentiu, Unity state, both of which have received high numbers of wounded from the recent clashes. Two of MSF’s medical staff have been temporarily seconded to support the Bentiu hospital.

Along the northern border of Unity State, MSF provides lifesaving medical care and clean water to Sudanese refugees in Yida Camp. Over the last six weeks, over 6,000 new refugees have fled from armed conflict in South Kordofan. As the rainy season approaches and the population continues to swell, MSF is stepping up its medical services to respond to healthcare needs and epidemic management within the population.

MSF is also running mobile clinics in the Abyei region, near the conflict area, distributing shelter materials and relief items including blankets, soap and cooking equipment to people displaced by the violence. In Rumamer, where the number of displaced people has tripled in a few days, MSF has distributed relief items to 1,120 people, mainly women and children.

In addition to its current response to the fighting around the border, MSF continues to provide medical care in two refugee camps in Jamam and Doro, Upper Nile State, that host around 90,000 refugees who fled violence in Sudan’s Blue Nile State, North of the border. The number of refugees here continues to grow, and the refugees face serious water shortages. MSF and other humanitarian organizations are engaged in a race against time to bring in sufficient equipment and medicines before the rainy season that make roads in this remote area difficult or impassable.

The latest violence is not the only challenge in the country. South Sudan is facing multiple crises including a precarious food security situation, massive refugee influxes, large scale outbreaks of infectious and deadly diseases, and intense inter-communal tensions and violence.

In South Sudan’s Jonglei State, MSF continues to respond to the needs of thousands displaced in extremely violent inter-communal clashes and in Warrap State MSF is undertaking an emergency mass vaccination campaign for around 40,000 children between six months and 15 years old in response to an outbreak of measles.

MSF provides outpatient care in two locations in Renk county to newly returned Southerners who recently left Khartoum.

Médecins Sans Frontières (MSF) has been working in South Sudan since 1983. More than 2,000 South-Sudanese staff work alongside almost 200 international staff in more than a dozen projects in eight federal states.

New patients arrive daily at MSF's Cholera Treatment Centers (CTC). Marie* was admitted to the Martissant CTC on April 16. "I had diarrhea and was vomiting a lot, then I fainted. A relative brought me here because it is the center closest to where I live. The doctors told me that I had cholera and was dehydrated", she says. One hundred and thirty-four other people like Marie arrived at the MSF center in Martissant between Apr. 16 and 23 and nearly 400 at MSF's other CTCs in Port-au-Prince and Léogâne.  

Haiti © Yann Libessart, MSF.
Since the earthquake, MSF has opened five hospitals and fought a massive cholera epidemic throughout the country, an ongoing fight as MSF continues to treat patients for cholera as of May 2011.

MSF had to reopen a CTC in Carrefour, in the southern part of the capital city, to deal with the new influx of patients and prevent the centers in Martissant, Delmas and Drouillard – closer to the city center – from being overwhelmed. With all its facilities combined, MSF currently has more than 200 beds in Port-au-Prince and more than 45 in Léogâne dedicated to cholera patients, and is prepared to open more sites based on the course of the epidemic.

"Cholera is easy to treat but specialized treatment centers must be accessible and patients must be brought there as soon as possible once symptoms appear", says Sophie Duterne, doctor and MSF's medical coordinator in Haiti. "If left untreated, this disease can kill within a few hours. Treatment involves simple oral or intravenous rehydration, with antibiotics for the most severe cases. However, taking additional hygiene precautions and drinking disinfected water is still the best protection." Since the first cases were identified in October 2010, more than 500,000 Haitians have contracted cholera.

Inadequate access to disinfected water and insufficient numbers of latrines provide fertile ground for cholera. The arrival of the rainy season further promotes the spread of the disease by flooding water and sanitation systems. "The sewers in my neighborhood are overflowing and we live in unhealthy conditions, without clean water or soap," says Marie. "I knew that I could contract cholera, but I had no choice." That is why along with treating patients, MSF continues to encourage Haitian health authorities and its international humanitarian partners to distribute disinfected water and soap and to install and maintain latrines so that Haitians can practice good hygiene and prevent the epidemic from spreading.  

Since the epidemic began in October 2010, cholera has killed more than 7,000 people. Approximately 500,000 cases have been recorded representing around five per cent of the population. As soon as the first cases were confirmed, MSF set up an unprecedented effort across the country, treating more than 30 per cent of the total number of patients on its own.

* Name has been changed for confidentiality.

DRC © Gijs Van Gassen/MSF
A child gets his finger pricked as part of a rapid test to diagnose malaria. MSF teams have been travelling to remote regions of DRC treating outbreaks of malaria.

Most of MSF’s health centres and hospitals in DRC have observed a marked increase in malaria cases, including in its severe form. In six provinces (half of the vast country), the number of people treated for malaria in MSF projects increased more than 250 per cent since 2009. This outbreak is particularly alarming due to the high number of severe malaria patients requiring hospitalization and urgent blood transfusions due to malaria-induced anemia. Faced with such a wide-scale crisis, MSF is unable to respond alone, the organization announced.

"It is rare to see such a large proportion of patients with severe malaria," said Jorgen Stassijns, a physician and a malaria specialist with MSF. "But treatment outside the cities remains especially weak, due to unaffordability or geographic inaccessibility. In some areas healthcare is simply non-existent. Even when treatment is available, the drugs are sometimes inadequate or outdated," he said.

In response to the massive outbreak, MSF has deployed additional emergency medical teams in four provinces in DRC. In 2009, MSF teams treated more than 45,000 people who had malaria. In 2011, more than 158,000 people were treated. So far this year, more than 85,000 people have been treated.

DRC © Robin Meldrum/MSF
Malaria treatment for a child in the pediatric ward of Niangara hospital in DRC. The crucial pill is the white tablet, which treats malaria. The others are for reducing symptoms such as fever.

While the exact causes of the outbreak remain uncertain, this new crisis is unfolding in the context of a health system sorely lacking resources at all levels. The country lacks adequate medicines, medical supplies, and properly trained medical personnel. Malaria prevention and screening systems are deficient.

In North Kivu and South Kivu provinces, and recently in the northern area in Katanga province, ongoing insecurity and renewed fighting also prevent people from obtaining healthcare. In Maniema, Orientale, Equateur, and Katanga provinces, the absence of other healthcare providers and overstretched health systems leave people vulnerable to contracting malaria.

MSF’s emergency response is saving lives in the short term, but in the longer term the organization cannot address the crisis alone. MSF calls on the Congolese government and health-related national and international nongovernmental organizations to take rapid and sustainable prevention and treatment measures to combat this scourge.

Malaria is the leading cause of death in DRC, killing nearly 300,000 children under five, every year.