For those children who have a mid-upper arm circumference (MUAC) scoring of red, meaning that they are severely malnourished, there is a significantly increased risk of dying. MUAC measurements are a quick and simple process whereby a measuring band is placed around the upper arm. A reading is then made and the measurement indicates the severity of their nutritional status.

We continue throughout the day, walking from house to house, assessing every child in the village. We come across one small girl who clearly needs admission into our in-patient feeding program. The girl, four years old, is quietly listless in the arms of her mother, whose face is a mask of hopelessness. I take the measurement of the child’s arm. It reads a circumference of 9.8 centimetres – clearly another red, and clearly at risk of dying.

You can see for yourself just how malnourished this child is. Get a piece of string now and measure 9.8 centimetres. Make it into a circle and there you have it – the upper arm circumference of this four-year-old girl. You do not have to be an expert to know that this arm is far too thin.

Understandably, the mother initially refuses permission for her child to be admitted to the hospital – she has three other children, so who will look after them? After some negotiation she agrees, and the child is taken to the hospital in Leer where MSF provides for special feeding.

The next day we leave by landcruiser and head to a remote area that we know has experienced food shortages before. However, it is not long before swampy ground forces us to abandon our vehicle and continue on foot. It takes us most of the day before we arrive at our destination, set up camp and rest in preparation for more long days ahead. 

After two weeks, having assessed 12,000 children, we sit eagerly awaiting the analysis of our results, although we know in the back of our minds what it will be.

Arriving back in Leer, we support the staff in the hospital in-patient feeding facility. More than 20 of the patients are critical and, if they were in a developed country, would be in an intensive care unit. One small child arrives, dehydrated and limp. We start initial emergency treatment but for this two-year-old, the complexities of his condition are just too much and he dies shortly after admission. I have worked in a feeding program before and always ask myself afterwards if it becomes any easier, seeing a child die of hunger. In reality, you are just too busy to think about it. 

There are positive things about working here; it is not all doom and gloom. There’s nothing better than seeing a bouncing, lively child discharged home after watching them improve from a condition where they were so weak they were unable to stand. And many, many children do go down this route. 

From January to April this year there was a 200 per cent increase in the number of children admitted into the program as compared to the same period last year, and it was here in Leer that alarm bells first began to ring. Children were, and still are, arriving at an increasing rate each day. I checked the attendance figures this morning [June 17] and there are more than 500 children admitted to the program; six weeks ago, when I first arrived, it was 205. Apparently the other feeding programs run by MSF in Lankien and Nasir are both seeing similar increases.

Malnutrition is complex. Although now is the start of the traditional hunger gap in southern Sudan, the situation has been compounded by an even worse than usual harvest, plus sporadic insecurity following recent elections. Food prices in the markets have increased by more than 100 per cent since January, and people here are helplessly doing what they can to manage.

We have increased our capacity drastically in Leer to care for these children.  But, following our assessment, there is a clear need for intervention now, and this will increase in the coming weeks and months. Without the specialist feeding care we can provide, the situation will only become much worse. And that’s the next challenge. Plans are already underway to access more areas. That is what I like most about MSF: the freedom to be able to see the problem, then get stuck right in and get on with the job. 

What is the nutritional situation in southern Sudan today?

The situation is extremely worrying, especially in the Upper Nile region. More than 800 children are being treated in MSF’s feeding centres in Unity State alone. The annual hunger gap is not entirely to blame for this, as there was a 200 per cent increase in the number of children treated compared to the same period last year.

Why do you think the situation is so bad this year?

There is a combination of factors, but the main one is the scarcity of food. Basically, we are six or eight weeks away from the harvest and there is very little food to be found in the market. The price of the main staple food, sorghum, has more than doubled since last year, resulting in people having to sell capital assets such as goats and cows to buy basic foodstuffs.  There are significant gaps in basic healthcare, whereby patients have to walk for several hours to receive the most basic of treatments, which contributes to children getting sick and further weight loss. But of course, the violence and insecurity also make things even worse.

What do you mean?

There are some pockets of violence where tribal disputes or more political post-election clashes have happened. Whatever the root of the violence, many families have had to flee their homes and therefore cannot farm their land.  This has had a direct impact on the agricultural output and families’ capacities to feed themselves.

How did MSF react to the upsurge in malnutrition?

As we saw the numbers going up, we first made sure that we could deal with the increasing number of patients in our own clinics and feeding centres. In many places, we’re pretty much the only aid organization providing nutritional support. But we also figured that if the situation was bad where we were, it was probably at least as bad in other areas where there was no health actor providing assistance. When analyzing the origins of our patients in our feeding centre in Leer, we found that 15 per cent of patients were coming from the capital of Unity State, Bentiu, more than 100 kilometres from Leer – this is what led us there.

You were part of the team doing the assessment in Bentiu. What was the situation when you got there?

Bentiu is a big town of about 100,000 inhabitants where 80 per cent of the people are unemployed and rely heavily on humanitarian aid. Ironically, during the war, they could count on regular food distributions, but this has stopped with the peace agreement. Bentiu has a relatively big hospital, but the staff there did not have the capacity to respond to the nutritional emergency. Children are admitted for an array of pediatric conditions, but cannot be treated for malnutrition because the hospital staff have no specialized food for therapeutic feeding.

When we visited the hospital for the first time, they had admitted four children suffering from malnutrition, but two had died. The staff there told us the only thing they could provide was counselling to the families of the two others. There was a lack of supplies, human resources and training, which meant that starting to treat malnutrition was not even an option.

That’s when MSF decided to intervene?

As we’re already intervening in many parts of southern Sudan, we tried to encourage the authorities and other organizations to get involved in Bentiu. But there are very few organizations with spare capacity to go beyond their current program areas and in Bentiu there was no one present in a position to react.

What will MSF do to improve the situation?

Our team has opened two feeding centres in Bentiu Hospital. The first one provides intensive care for children who need to be hospitalized and carefully monitored. The second centre provides ambulatory feeding care, which means that mothers can come with their children to be weighed and measured and then receive specialized therapeutic food they can take home to administer, only having to return to the centre after a week or two.

Within three days of the feeding centres opening in Bentiu, 28 children were hospitalized and 70 children were enrolled in the ambulatory feeding program.

Once we identify where most of the affected kids are coming from, we may open new ambulatory structures in different areas, but keep referring the kids who are worst off to Bentiu for hospitalization.

In addition to providing life-saving care to malnourished children in and around Bentiu, the MSF team will focus on training local health staff to treat malnutrition so that the capacity to respond remains even after MSF’s departure.

Can MSF do more?

MSF is already intervening in many parts of southern Sudan, often as the only organization treating malnutrition. We have managed to find some local partners whom we have trained and helped with supplies, but there is a real need for more people to expand their interventions in the country to tackle this acute crisis.

How long will MSF stay in Bentiu?

That’s not an easy question, but we hope that the nutritional situation will improve after the harvest and that the hospital staff will be able to manage the remaining cases.  Our initial plan is to stay for three or four months. We will re-assess the needs at that time and we may well have to stay longer if the needs are there.

Five weeks after violent clashes erupted in the south of Kyrgyzstan and despite an apparent return to a more peaceful situation, doctors, psychologists and nurses working for Médecins Sans Frontières (MSF) continue to deal with cases of violence on a daily basis. More concerning still, the capacity of victims to receive adequate healthcare depends on the community to which they belong.

“Every day, in our mobile clinics and health facilities with which we collaborate, our medical teams treat patients who have suffered heavy beatings or who even show signs of torture. Many people, especially from the Uzbek community in Osh, are not going to hospitals as they are afraid of being arrested,” says Andrei Slavuckij, MSF program manager for Kyrgyzstan.

Amid a climate of fear and deep mistrust between Uzbek and Kyrgyz communities, access to healthcare is still a major concern due to the presence of armed personnel in and around some health structures in Osh. The fear of not receiving adequate and impartial medical services deters many people requiring urgent medical attention from seeking adequate care.

“In such a tense and volatile context, we call on all responsible authorities to preserve the neutrality of medical facilities. It is essential that any patient who needs care can receive adequate treatment, regardless of their origin,” says Bruno Jochum, director of operations for MSF.

Since the start of the current crisis, MSF has provided more than 1,400 medical consultations through four mobile teams in and around Osh and Jalalabad. MSF has also been supporting 25 health structures with donations of drugs and medical equipment. Today, thousands of people are still in a state of deep shock after the extremely violent and traumatic events that took place in June. Mental health needs are immense and MSF is increasingly focusing its action on psychological support.

MSF has worked in Kyrgyzstan since 2006, providing medical treatment to tuberculosis patients in the penitentiary system, including those suffering from the most resistant forms of this disease. Today, 45 MSF employees, including 19 international and 26 Kyrgyzstani staff are running the current emergency operation.

“Today international donors expect doctors to tell patients to come back for treatment when they’re at death’s door,” said Dr. Eric Goemaere, medical coordinator with MSF in South Africa. “This is bad medicine. As a doctor I’d much rather give a patient pills today and send her home, than delay treatment and see her in six months at the hospital with complicated tuberculosis.”   

With data from its project in the southern African country of Lesotho, MSF will present “late-breaker” evidence at the AIDS conference this Thursday that shows how earlier treatment reduced the mortality rate and hospitalization among HIV patients by more than 60 per cent.

Morija, Lesotho 2010 © Zethu Mlobeli/MSF
MSF nurse Patricia Nyoni examines baby Relebohile, who is co-infected with HIV and TB. Both Relebohile and his mother, Majakobo Mkubu get their treatment at St Barnabas clinic, one of 14 rural clinics at the time supported by MSF in Lesotho and now managed by local health authorities. Majakobo and Relebohile need to make an arduous six hour mountain trek five times a month to reach the clinic.

But this type of research is being ignored by international donors, particularly the United States – the world’s primary HIV treatment donor – which is now advising countries to restrict treatment to those in the more advanced stages of HIV disease.

In addition to medical and financial benefits of earlier treatment initiation, studies are also showing that making treatment widely available at the community level is one of the most effective ways to prevent people from getting HIV.

Despite this evidence, there is a general trend toward backtracking on HIV funding which will increasingly mean treatment being delayed, deferred or denied. The Global Fund –the world’s principal funding mechanism for HIV treatment – faces a major financing gap. PEPFAR is the U.S. President’s Emergency Plan for AIDS Relief. The U.S. is proposing both continued PEPFAR program flat-funding and a decrease in its contribution to the Global Fund. Just this week, the German media reported top-level discussions to cut its contribution to the fund three-fold. Austria, the International AIDS Conference host country, has not contributed a single dollar to the fund since 2001.

This retreat comes after a decade of progress – more than 5.2 million people alive on treatment today – made possible by the emergence of affordable generic drugs and the commitment of donor countries. With 1.2 million people starting treatment in 2009, progress has been rapid. Yet there are still 10 million people waiting to start treatment and the current climate suggests a decreased commitment to fund treatment for those waiting in line.

“Donors repeatedly promised millions of people a lifeline to treatment,” said Goemaere. “It is a matter of choice: will donors help pay for treatment or let people die?”

Despite the growing evidence that rapid scale up of HIV/AIDS treatment reduces unnecessary death, staves off disease, and reduces transmission of the virus, international donors are wavering and sending the message to scale back treatment plans.

On July 15, Médecins Sans Frontières (MSF) held a media teleconference on the key issues that will be discussed at the XVIII International AIDS Conference (IAC) in Vienna this month, presenting some of the findings from MSF field projects. These include:

• How starting HIV treatment earlier has dramatically reduced mortality and boosted treatment success, clearly supporting the benefits of pursuing an aggressive international response to the AIDS pandemic

• How using medicines, which for the moment are more expensive but cause fewer side effects, would actually reduce costs in the long-run and mean an end to the second-class care patients in the developing world currently receive

• How newer medicines can become more affordable and an explosion in drug costs can be staved off

Yet as donors retreat from funding AIDS, progress threatens to be stopped dead in its tracks. MSF already sees the consequences of donors backtracking on commitments to fund expanded HIV treatment worldwide. MSF is launching its report: The Ten Consequences of AIDS Treatment Delayed, Deferred, or Denied – a guide to the devastation that can be expected if the trend continues.

"We're at a fork in the road: either governments summon the political will and financial resources to treat AIDS in developing countries, or current funding for AIDS treatment stagnates, which means patients will see their treatment delayed, deferred and denied,” says Dr. Tido von Schoen-Angerer, director of the MSF Campaign for Access to Essential Medicines. “It's a question of choice: if they don't help us treat AIDS, there will be more graves."

“Soon after the blast occurred we started to receive a steady flow of people at the emergency room of Saidu Group Teaching Hospital. We’ve seen 58 patients, including women and children. Most are now in a stable state, but two patients are still in critical condition,” said Sonoko Shidehara, a doctor working with MSF in Swat.

Emergency preparedness is crucial for an adequate response to events like this, so hospital staff are being trained to implement triage and mass casualty plans which enable the sorting of injured people into groups according to their needs.

 “This means that we can first give immediate and urgent medical care to those most seriously wounded,” explained Dr. Shidehara. “People arrived with severe head traumas, chest injuries and serious shrapnel related wounds in their arms and legs.”

“The explosion occurred at a busy time of the day, and afterwards, crowds rushed to the hospital to see what happened and to check on family and friends. When people gather in the emergency room, this compromises the space we need to carry out urgent medical activities. However, through the cooperation of those around, we did manage to keep only patients and medical staff inside the ER,” said Josep Prior, MSF field coordinator in Swat.

After a one year absence, MSF recently returned to Swat to address specific medical needs identified in the casualty department of this hospital. Working together with staff from the Ministry of Health, MSF teams are now boosting work in the emergency room by providing medical personnel, regular trainings, specialized emergency equipment, and life-saving drugs all free of charge.

As a medical organization focused on providing emergency medical care, MSF is not involved in any efforts to rebuild Swat, nor is it part of any military or political strategy. To maintain its independence, MSF chooses to rely solely on private donations, and does not accept funding from any government for its work in Pakistan.

To be able to provide life-saving assistance to patients in need, MSF urges all members of the community, political parties, armed forces and armed opposition to respect the neutrality of health facilities.

On Tuesday a UN agency, the International Organization for Migration, provided 100 tents to people. After being informed by the UN about the situation, MSF gave out 245 tents.

MSF has distributed about 27,000 tents in the aftermath of the earthquake on Jan.12, but as a medical organization keeps its focus on ongoing medical needs of the people affected by the earthquake. Only a small emergency stock of tents is maintained for exceptional cases.

While more than one million people are still displaced and living in undignified settings under pieces of plastic sheeting in makeshifts camps in Haiti, waiting desperately for better solutions, little progress has been made in providing people better and more permanent structures. The rain and hurricane season pose additional risks.

MSF is following the situation closely and will do its best to support the population with emergency medical care in response to hurricanes or further deteriorating conditions due to the rainy season, but the organization has little capacity to respond to shelter needs.

With the ongoing rainy season and the threats of hurricanes hitting Haiti in the coming months, MSF is very worried for the wellbeing of the population of Haiti.

MSF’s medical work in Haiti has evolved during the past six months, from an emergency response to a wider range of medical and relief activities. “Haitians were the first to respond to this disaster and we have reinforced their effort with a massive aid intervention. Today, medical provision for Haitians has improved, and is certainly more accessible than before the earthquake, allowing poor people to receive proper health care,” explains MSF Head of Mission Stefano Zannini, who was already in Port-au-Prince when the earthquake killed and/or injured hundreds of thousands and left over a million people without shelter.

However, the situation for many Haitians is still hugely precarious, while frustration grows among people who are disappointed with the pace of rehabilitation. “There is a staggering gap between the enthusiasm and promises for aiding the victims of the earthquake in the early weeks, and the dire reality on the ground after half a year,” adds Zannini.

MSF’s report publishes figures on the scale of its relief intervention. Up to May 31, in the first 138 days following the disaster, MSF staff treated more than 173,000 people and performed over 11,000 surgical procedures. More than 81,000 Haitians received support to help them cope with their psychological trauma. MSF brought in almost 27,000 tents and distributed more than 35,000 relief kits.

In the report, MSF describes some of the choices which had to be made in the first few weeks following the earthquake. For example, the extremely high number of injuries forced teams to focus almost exclusively on the stabilisation of patients and emergency surgery at the expense of other crucial activities. Finding locations for temporary medical facilities was done in haste as there was little time for more in-depth assessments.

An extraordinary number of foreign aid workers had to be brought into the country quickly; two months after the earthquake MSF had over 350 international staff in Haiti, since many Haitian health workers were also victims of the earthquake. This put a huge strain on MSF’s human resources and management capacity. MSF was eventually able to reduce the number of foreign workers, as more Haitians were hired to work in the organization’s facilities. By the end of May, 93 percent of MSF staff-members on the ground were Haitians.

MSF also reports that, up to May 31, around C$120 million was received in donations from the public earmarked for Haiti relief. The organization spent $70 million by that same date, including more than $14 million on surgery, $5 million on maternal health (MSF helped deliver 3,700 babies) and over $11 million on shelter. MSF foresees that, by the end of the year, it will have spent around $118 million on assistance to the Haitian population.

Although there are uncertainties around the speed of reconstruction and the extent to which other organizations will still provide health care, MSF commits to continue working for the victims of the earthquake in years to come.

“Health care was already fragile in Haiti before January 12,” says Dr. Unni Karunakara, the International President of MSF. “The earthquake destroyed much of the medical services that were available. It will take many years before the country is back on its feet. MSF is determined to play our part in rebuilding health care for Haitians and will dedicate our staff and means to this task as required.”

http://www.msf.ca/

“This is the highest number of injured women and children we have received in 24-hour period in the past four months,” said MSF Head of Mission Axelle de la Motte St. Pierre. “Many suffered very severe wounds.”

Since the beginning of the year, 450 war-wounded women and children have been admitted to Daynile Hospital, reflecting the very high price the civilian population continues to pay in the ongoing conflict.

At a time when fighting is raging and medical facilities are being hit in Mogadishu, MSF calls upon the belligerents to the conflict to take all measures to avoid civilian casualties and to respect the protected status of medical facilities.

MSF is an independent medical organization with projects in eight regions of Somalia. Over 1,500 Somali staff, supported by approximately 90 staff in Nairobi, provide primary health care, malnutrition treatment, surgery, support to displaced people, and water and relief supplies. MSF does not accept any government funding for its projects in Somalia. Donations come from individuals around the world.

However, the volume of admissions recorded to nutritional centres in previous years indicates that Niger’s nutrition crisis is a recurrent problem. A recent nutritional survey[1] carried out between May and June 2010 revealed that 455,000 children aged between six months and five years are currently suffering from acute malnutrition, of whom 86,800 are severely malnourished. The severely malnourished children account for 3.2% of the total number of children in this age range in the country. The youngest children are the most affected, with 4.6% of all children between six and 35 months old in Niger suffering from severe malnutrition.

The international medical humanitarian organisation Médecins Sans Frontières (MSF) has been addressing the recurring nutritional crisis in Niger since 2001. In 2009, 86,000 children were treated in nutritional centres supported by MSF. This year, MSF and its partners - the Nigerien non-governmental organisations (FORSANI) and (BEFEN) - are boosting their capacity to respond to projected increases in severe acute malnutrition.

Today, MSF supports – directly or through partners - 57 government-run integrated health centres offering outpatient nutritional care in three regions: Maradi, Tahoua and Zinder. Between January and June 2010, 43,633 severely malnourished children under five years old were admitted to these centres. In addition, MSF supports 7 inpatient centres for intensive nutritional rehabilitation, where 6,264 children with medical complications associated with severe malnutrition have been hospitalised since January 2010.

In order to stop Nigerien children from becoming malnourished year after year, and to allow nutritional care to be effectively integrated into healthcare facilities, the curative response must be combined with stronger preventive action. This year, MSF, together with the government of Niger, will distribute ready-to-use foods adapted to the needs of young children in an effort to protect them from developing severe malnutrition and reduce the risk of mortality.

MSF has worked in Niger since 1985. Besides providing nutritional support to children, MSF supports paediatric and maternal healthcare services in government-run health centres and hospitals in the regions of Maradi, Zinder, Tahoua and Agadez. In Agadez, MSF also provides medical care to migrant populations. MSF responds to emergencies such as outbreaks of disease, and supports vaccination campaigns.

[1] Enquête Nutrition et Survie des Enfant de 6 a 59 mois – Institut National de la Statistique, INS et Direction Nutrition du Ministère de la Santé – Gouvernement du Niger, Mai -Juin 2010