The epidemic is yet another sign of the worsening humanitarian situation. The country’s healthcare system is in a state of collapse after more than two years of civil war.

The population is unused to measles outbreaks. With the onset of violence in 2011, Syria’s vaccination program was disrupted throughout much of the country, leaving thousands of children unprotected. Over a million people have fled to camps or overcrowded accommodations where sanitary conditions are poor.

Médecins Sans Frontières (MSF) has vaccinated more than 75,000 children in the provinces of Aleppo, Ar-Raqqah and Idlib in an effort to stem the epidemic.
While mortality rates in the current outbreak remain relatively low, measles increases children’s vulnerability to other infections. When basic medical care is unavailable, complications arising from measles can be life-threatening.

Syria © Nicole Tung. MSF staff re-dress the wound of a patient who was brought in to the MSF clinic in northern Syria.

“Carrying out a vaccination campaign in a polarized conflict such as this one is proving extremely difficult,” said Teresa Sancristóval, MSF emergency desk manager, “but vaccination campaigns and basic healthcare are as much needed as war surgery.”

Apart from direct victims of violence in Syria, mortality rates are rising due to the lack of preventive measures such as vaccinations, and the lack of access to basic healthcare. MSF has prioritized vulnerable groups.

“Children, pregnant women and the elderly, as well as people suffering from chronic diseases like asthma and hypertension, have been a priority in our response to the humanitarian crisis in Syria,” said Sancristóval.

In Aleppo province, it was a struggle to complete the vaccination campaign, due to widespread violence and fear. Queues for vaccinations had to be avoided for fear they might attract airstrikes or rocket attacks.

In Ar-Raqqah province, MSF has vaccinated 35,000 children so far in just one of the three districts. The partial coverage is due to security constraints, and leaves thousands of children vulnerable to the disease.

In Idlib province, MSF is planning to perform a second mass vaccination in the camps and villages, for children under the age of 15. The new surge in measles in the Idlib area is probably due to the continuous arrival of displaced people fleeing the fighting.

“Wars tend to bring about a drastic reduction in basic medical services precisely when they are most needed,” said Sancristóval.

MSF in Syria

MSF runs five hospitals in northern Syria in areas controlled by armed opposition groups. The international medical humanitarian organization has yet to receive official authorization to work in Syria.

Since the conflict started, MSF teams in Syria have carried out 46,000 consultations, 2,481 surgical procedures and have attended 854 deliveries.

Across India there are stock-outs of pediatric TB drugs and those used to treat drug-resistant TB (DR-TB). Under India's public TB treatment program, the central government is responsible for buying drugs and distributing them to the states, which then provide treatment.

India 2013 © Siddharth Singh
TB Counsellor Loshon Wangshu keeps records of the medications to be given to DR-TB patients in Mon district hospital.

“India has such a high burden of tuberculosis,” said Leena Menghaney of MSF’s Access Campaign. “This stock-out can cost lives. The government must act urgently to fix the problems.”

The stock-out is related to the routine but deadly delay in tendering for these drugs. The resulting drug stock-outs are one of the reasons why India has one of the world's highest burdens of DR-TB.

“MSF is witnessing the impact this is having on our patients,” said Dr. Homa Mansoor. “I saw a girl arrive with her father after a long journey to get her medicine. The medicines were out of stock, but luckily we had six days worth of drugs from a patient who had died. Otherwise, we’re having to resort to breaking adult pills to give to children, which is really dangerous as it could over- or under-dose them.”

Other patients have been forced to purchase medicines from private pharmacies, but have received lower-dosage drugs, which can lead to resistance if a patient under-doses.

“A continuous, sustainable supply of quality-assured medicines is vital for TB patients,” Dr Mansoor said. “As a doctor, I know the disease, I know how to manage it, but I feel powerless because we don’t have the medicines.”

“India talks of scaling up DR-TB treatment, but finds the medicine cabinet empty at a time when the most vulnerable patients — those diagnosed with DR-TB — are most desperate to get the medicines that can treat them,” Dr Mansoor added.

In 2012, MSF treated 31,000 people in 36 countries for TB, 1,780 of whom had drug-resistant forms of the disease.

The government of South Sudan must allow immediate humanitarian assistance to these areas to prevent the deaths of thousands of internally displaced persons.

South Sudan 2012 © Robin Meldrum/MSF
Villagers displaced by fighting outside Lekwongole in Pibor County.

Over the past month, many of the displaced have fled for their lives into the bush amid intensified fighting between the South Sudan Army (SPLA) and the David YauYau militia group.

The heightened fighting has coincided with the destruction of medical facilities throughout the county, including the systematic looting of the MSF hospital in Pibor town in late May, and the refusal of the SPLA to allow or facilitate the provision of humanitarian assistance to the displaced population.

“Immediate action is required to avoid catastrophe,” said Dr. Bart Janssens, MSF director of operations.

“The area in Pibor County where the population is hiding will flood during the rainy season and this will not be a place where people can remain alive. At the moment we are not able to contact the people hiding in the bush, and we know from MSF’s years of experience in Jonglei that without medical care, mortality rates will rise rapidly with people dying of malaria, diarrhea, pneumonia, and other respiratory diseases. Furthermore, the communities will begin to run out of food this month before the next harvest arrives.”

The displaced population has fled the main towns in Pibor County most likely out of fear of being confused with rebels groups or being caught in the crossfire. The real or perceived lack of distinction between civilians of the Murle community and combatants will only increase the risk of disease and death for a population living with violence, displacement, and fear, MSF said. Nearly the entire Murle community from Pibor County has been cut off from any assistance.

Since the only two hospitals in Pibor County, in Boma and Pibor, have been looted and vandalized, there is no healthcare available anymore for the population, other than MSF’s basic primary health post in Gumuruk. From January to March, the hospital in Pibor treated 3,000 people and provided surgical care to more than 100 people suffering war-related injuries, including SPLA soldiers.

Repeated requests by MSF to the authorities to travel outside these towns to deliver assistance to the people hiding in the bush have been denied. Recently, MSF was informed unambiguously by the SPLA commanders that the organization would not be permitted to go to opposition-held territory to provide medical care. Travel into the bush to conduct assessments of the needs of displaced people would not be permitted until the government has "control" of the area.

“MSF teams stand ready to resume and scale up medical activities for all people in need regardless of the community they belong to, but South Sudan authorities must allow the unhindered provision of humanitarian assistance to the displaced,” said Dr. Janssens. “All parties to the conflict should respect medical facilities, staff, and patients. The urgency of this cannot be overstated. People are displaced in a zone that will shortly be under a meter or more of flood water.”

Now imagine that it will take more than four hours to reach the nearest health facility where you can get an assisted delivery. Imagine a journey mostly on foot over mountainous terrain.

This is the reality for many women in Lesotho. Mantebaleng Ntelekoa, a young mother from a rural area in the mountains, remembers: “For all of my three deliveries, I walked two hours to the main road and then continued by minibus to the hospital.

“I usually started walking when my contractions started and it took a long time, because I had to sit down every time I had a contraction. One of my children was born premature at seven months, so I am glad I made it to the hospital.”

Lesotho 2013 © Yasmin Rabiyan/MSF
Mantebaleng Ntelekoa, a young mother from a rural area in the Lesotho mountains.

Not everyone is as lucky as Mantebaleng. High HIV prevalence and poor access to maternity services have led Lesotho to one of the highest maternal mortality rates in the world, at 620 deaths per 100,000 live births. That’s about twice the global average.

More than 50 per cent of those deaths are attributed to HIV-related complications. The government of Lesotho wants to reduce maternal deaths to 300 per 100,000 live births by 2015. Yet the health situation for many expectant mothers in the small mountain kingdom remains uncertain.

Mortality rates in rural and isolated areas are particularly high. Women may have to travel long distances to the nearest health centre, and face a lack of transport, terrain that is impassable in the winter, as well as user fees at major hospitals.

This keeps many women from accessing antenatal care, lifesaving HIV treatments, and services for the prevention of mother-to-child transmission of HIV.

The Médecins Sans Frontières (MSF) team in Lesotho is supporting rural health facilities to ensure that more women have access to antenatal services and safe deliveries. A doctor, a midwife and several nurses are working in 10 health facilities across the districts of Roma and Semonkong.

At St. Leonard clinic in Semonkong, there is a small maternity ward and a mothers’ waiting lodge. Expectant mothers come to the lodge close to their due date, ensuring that they will be able to deliver their babies with the assistance of a trained midwife. New mothers can stay after giving birth until they are ready to return home with their newborns.

“I sleep in the waiting lodge with the mothers when I am in Semonkong, and the atmosphere is quite amazing,” said MSF midwife Marleen Dermaut. “There is a lot of chatting and giggling. The women feel safe and enjoy each others’ company.

“After all, they are all in the same position, experiencing the wonder of new life. They are away from their duties for a couple of days, and are able to just focus on themselves and their new babies.”

There are around six women at the facility at any time. Since last year, the number of assisted deliveries at St. Leonard almost tripled from seven to 20 deliveries per month. This is likely due to a combination of increased health promotion by centre staff and MSF’s donation of an ambulance.

“The ambulance takes women to the hospital in case of emergencies during labour or after delivery. The hospital is still a two-hour drive away from St. Leonard. It already happened that a baby was born in the ambulance,” said Dermaut.

A team of MSF health promoters regularly goes to communities to test people for HIV and TB, and to improve health education in remote areas. In places with high rates of HIV and TB, testing is crucial so people understand how to spot the diseases, test for them and be able to start treatment right away if necessary.

To reach as many people as possible and to directly involve people living in these areas, MSF trains community health workers to test for HIV and refer people to health facilities if needed.

“The motivation of many people we work with, be it nurses or community counsellors, and the willingness to make changes definitely makes my work here even more rewarding,” said Dermaut.

In the Bulengo and Mugunga III camps MSF medical teams have resumed seeing patients after a 24-hour interruption for security reasons. The security situation remains volatile, and humanitarian needs are pressing.

Sotraki camp

Nearly 5,000 people fled villages near the front lines of fighting that erupted in the week of May 20. After spending several nights in schools and parishes outside Goma, the displaced people were assembled at Sotraki Stadium to facilitate delivery of aid.

“My house was destroyed, and I couldn’t take a thing with me,” said Gertrude, who came to the stadium with her five children and 10 nephews and nieces.

Some people were able to hastily gather a few personal effects. A large number were hungry: they reported not having eaten for days.

Some families were separated as they fled. This was not the first such experience for many of these people. Most fled their homes during fighting in November 2012; some remember fleeing in 2008 and 1994.

DRC 2013 © Amandine Colin/MSF.
A woman sitting in front of her shelter in Bulengo camp.

MSF established a mobile clinic as soon as the displaced people arrived, treating over a hundred people a day. The most frequently-treated illnesses are diarrhea and respiratory infections.

“A quarter of the illnesses we are treating are cases of diarrhea, mostly in children under five,” said Carolina Lopez, MSF emergency coordinator. “Thirty-five per cent of our patients are seeing us for acute respiratory infections. Many of these illnesses are due to sleeping under the stars night after night. Overcrowding and poor hygiene breed these illnesses.”

In addition, MSF is trying to prevent an outbreak of cholera. “There are already patients suffering from cholera in other camps outside Goma—we absolutely have to avoid the spread of this disease,” said Lopez.

MSF has been running a cholera treatment center for several months at the Buhimba refugee camp.

Humanitarian situation still critical

Medical activity has resumed at the Bulengo refugee camp. The MSF team is providing primary care, vaccinations, and maternal health services.

The camp was established in November 2012. Because Bulengo is not an official camp, it receives only sporadic aid, and security is poor. Since November 2012 there has been only one distribution of essential items.

“We need plastic sheeting most of all. Some people did get some, but it’s been all torn up for a long time now,” said Sifa, who lives in the camp.

Relative calm returns

Since the fighting that took place a few kilometres away, the presence of uniformed men in the surrounding forest has been a concern for families. “You can’t go for firewood in the forest, because you might get raped, so we have to sell corn to buy charcoal for cooking,” Siada said.

Sexual assaults are commonplace at Bulengo, where 114 rapes have been reported since December 2012. The situation is similar at the Mugunga III camp, where medical teams observed a massive increase in sexual assaults just after the clashes, occasionally treating as many as 28 female patients a day. Rapes generally occur outside the camps, near the front lines.

MSF in North Kivu

MSF is providing primary and secondary health care in North Kivu province. On the outskirts of Goma , MSF is working in the Bulengo and Mugunga III camps and, since the end of May, in Sotraki Stadium as well.

Elsewhere in North Kivu the organization is supporting referral hospitals in Mweso, Pinga, Masisi, Rutshuru, Walikale, and Kitchanga, working in health centers, and operating mobile clinics.

Iraq 2013 © Pierre-Yves Bernard/MSF - Syrian families wait against the gates of the registration centre at Domeez refugee camp, Iraq.

Neighbouring countries must continue to allow the flow of essential medicines, medical supplies, and medical personnel into Syria.

Borders must also remain open to allow refugees to escape. In Iraq, the last remaining open border crossing, at Rabi’a, is now closed. Thousands are stranded inside Syria, along a sealed border more than 800 kilometres long.

In countries bordering Syria, MSF teams are witnessing overcrowded hospitals and poor access to healthcare for refugees and a growing number of local residents. Official aid is dwindling in Lebanon, for example, yet tens of thousands of refugees have still not been registered by the United Nations. Without registration papers, these people are not eligible for most aid, including health services.

An immediate international financial effort is vital to support public health services in host countries and improve the living conditions of refugees.

All actors represented here today hold the key to increasing lifesaving assistance in Syria, wherever there is need, and to improving the living conditions of people fleeing to neighbouring countries. Yet the reality is that the official international aid system is not working.

We must – and we can – find other solutions.

Donors must increase funding through the aid channels that are able to provide effective humanitarian assistance, even if those channels are not part of the official aid system.

Neighbouring countries must lighten administrative procedures to facilitate the delivery of urgent aid.

Finally, we must reiterate that warring parties must refrain from attacking health structures and respect the safety of humanitarian convoys. Humanitarian aid must be allowed access to all victims of the conflict, whether by crossing front lines or crossing borders.

After more than two years of war in Syria, humanitarian aid is far from meeting the massive needs, both inside the country and among Syrian refugees.

The United Nations will release its latest plans for responding to the Syria crisis in Geneva on June 7. Médecins Sans Frontières/Doctors Without Borders calls on the UN and member states to meet their political responsibilities and to urgently increase humanitarian assistance to the millions of Syrians affected by the conflict.

Syria 2013 © Nicole Tung/MSF

Syrians continue to flee a worsening civil war that has already claimed nearly 100,000 lives. The wounded and sick face near-insurmountable obstacles in trying to access healthcare, due to relentless bombings and the targeted destruction of Syria’s health system. Restrictions imposed by the Syrian government obstruct the provision of aid across frontlines within the country.

The UN acknowledged in January that too little aid was crossing Syria’s borders. The stark failure since then to deploy independent humanitarian assistance has allowed the toll of the crisis to climb ever higher.

Outside Syria, 1.5 million refugees face huge challenges. Many have found misery, deprivation, and inadequate essential services in neighbouring countries, where too few aid agencies are addressing the overwhelming needs.

In Jordan, the health system at the Zaatari refugee camp, home to 100,000 Syrians, remains fragile. Underfunding threatens Jordan’s ability to provide adequate healthcare for 350,000 more refugees living outside the camp.

In the Domeez camp in northern Iraq, more than 35,000 refugees live in crowded conditions, with many receiving far less than the minimum standard of 15 to 20 litres of water per person per day.

In Lebanon, where more than 500,000 Syrians have sought refuge, people are living in makeshift shelters, in the shells of half-built houses, or in squalid shacks. Tens of thousands of refugees have yet to be registered by the UN, making them ineligible for most types of assistance, including healthcare. Yet the aid response remains woefully inadequate.

In Syria’s neighbouring countries, MSF teams have performed nearly 150,000 consultations since the start of the conflict, and have witnessed alarming health indicators among the most vulnerable refugees. Children go without vaccinations; primary healthcare is limited at best; pregnant women are unable to deliver safely; and people with chronic medical conditions have limited access to treatment.

Despite efforts by Syria’s neighbours to cope with the crisis, their resources are stretched and tensions are rising. But even though these host countries require urgent support, they must keep their borders open to guarantee Syrians’ right to seek safety.

Donor states must urgently commit the necessary funds to meet the health and relief needs of refugees. All relevant states and actors must ensure the delivery of adequate humanitarian assistance, both inside and outside Syria.

Words must be turned into action.

Worldwide, millions of people die each year because they cannot afford the medicines they need. These numbers could climb even higher, unless Canada and other Pacific Rim countries involved in the Trans-Pacific Partnership (TPP) trade negotiations take decisive action to protect global public health.

The latest round of TPP trade talks took place in Peru in May. All negotiations are conducted in secret, but leaked documents reveal that the United States is pushing for stringent intellectual property protections for drugs. These protections could give pharmaceutical companies longer monopolies over brand name drugs. This would allow them to charge high prices for longer periods of time and either stop or delay the generic competition from producing less expensive versions that are vital to global health. If the U.S. proposals are not deleted from the text before the deal is sealed this Fall, the TPP risks being the most harmful trade deal for access to medicines ever seen.

India 2013 © Siddharth Singh/MSF

We know that generic drugs help save lives. Take HIV: Affordable generic medicines dropped the price of treatment from over $10,000 per person per year in 2001, to just $120 today. This price reduction has made it possible for 9-million people to receive treatment in developing countries.

So how is the U.S. seeking to make generic competition more difficult and hurt access to medicines? Among its long list of demands, the U.S. is asking to lengthen patents beyond 20 years, lower the requirements for patentability, and allow companies to sue governments for patent infringements through unaccountable tribunals.

Barack Obama referred to the TPP as a “model not just for countries in the Pacific region, but for the world.” Yet the TPP as currently drafted will undermine the public health exceptions agreed in the Doha Declaration in 2001, which reaffirmed governments’ rights to use generic versions of patented drugs to respond to public health priorities.

Protectionist trade deals add huge burdens to already stretched healthcare budgets, which ultimately limits access to medicines for patients. We have already seen the impact of these harmful trade agreement provisions before. In Jordan, brand name drug prices increased 20 % in the five years after similar patent protections were implemented in the U.S.-Jordan Free Trade Agreement. In Costa Rica, public spending on HIV drugs is expected to increase by at least 50 % as a result of the U.S.-Central America Free Trade Agreement. Protectionist trade deals add huge burdens to already stretched healthcare budgets, which ultimately limits access to medicines for patients.

While the impact of the TPP agreement may seem far removed from Canada, it could also put a dent in Canadians’ pockets. In 2012, for example, spending increases on prescription drugs in Canada slowed down thanks, in part, to the expiration of patents on several brand-name drugs, thus allowing for less costly generic versions to enter the Canadian market.

Eli Lilly is now demanding $100 million in compensation from Canadian taxpayers for alleged lost profits. Canada is also experiencing firsthand the consequences of using unaccountable tribunals to resolve trade disputes. Eli Lilly recently initiated proceedings under the North American Free Trade Agreement, to sue the Canadian government for what they believe was their right to the patent of an ADHD drug. They are now demanding $100 million in compensation from Canadian taxpayers for alleged lost profits. To avoid future lawsuits, Canada should join Australia in refusing to include these so-called investor-state dispute resolution mechanisms in TPP negotiations.

Instead of prioritizing brand-name pharmaceutical interests, the TPP could be used to improve patient health and reduce drug expenditures, especially in poor countries. Rather than stunt innovation and discourage market competition with its excessive patent protections, the TPP could provide an opportunity for a new approach to drug development and medical innovation. This could be achieved through new models of drug research and development, including incentives that promote more open innovation and that break the link between the drug prices and the costs of research and development that is used to justify excessive patent protections.

As an international medical humanitarian organization working in more than 70 countries, Médecins Sans Frontières/Doctors Without Borders (MSF) relies on affordable quality generic medicines to treat hundreds of thousands of patients. We strongly urge Canada to take a bold stand and protect public health interests. Access to medicines is a matter of life and death. We can’t ignore the millions of lives that hang in the balance.

MSF opened a new emergency health project in Bossangoa, north of the capital, Bangui, which is performing more than 300 consultations per day.

This week MSF is beginning a two-month emergency initiative to provide anti-retroviral drugs to HIV/AIDS patients at the Bossangoa hospital – patients who have been without drugs since the crisis.

CAR 2013 © Ton Koene 
Ngaikouma is diagnosed with malaria at an MSFs mobile clinic in Bolom village.

“There are approximately 11,000 HIV-positive people in CAR who have had their treatment interrupted due to a lack of drugs, which were looted during the political upheaval,” said Chury Baysa, MSF medical coordinator.

Ministry of Health officials estimate that 310 HIV/AIDS patients were registered in the Bossangoa hospital program before the coup. About 170 were on anti-retroviral therapy (ART) and 140 were pre-ART patients. In the last two weeks, 88 patients have sought drug refills at the hospital.

In Bossangoa, MSF is responding to an acute lack of healthcare for 150,000 people after healthcare workers in the town fled their posts. MSF teams are also running mobile clinics in districts where people are hiding in the bush, due to the presence of armed men.

The focus is on treatment of malaria, diarrheal diseases, malnutrition, and sexual and gender-based violence. To date, 53 per cent of children under five seen in the outpatient department have been confirmed with malaria. Fifty per cent of pregnant women receiving antenatal care have also been diagnosed with the disease.

At MSF’s project in Batangafo, in the northwest, 8000 people fled in April when more than a dozen villages were burned during clashes between the local population and a nomadic group from Chad. Next week, teams will start mobile clinics in areas where displaced people are congregating, and distribute essentials like mosquito nets, blankets and soap.

Relative calm has now returned to Bangui, where MSF just ended its three-month emergency response at the Community Hospital. The MSF team treated 1,072 patients – 36 per cent had suffered bullet wounds and 149 patients required surgery.
The hospital is now back to normal as staff who fled during the coup have returned. The operating theatre and sterilization unit are now properly equipped and the team has pre-positioned supplies of drugs in case of need.

As malaria season begins in CAR, the already high mortality rate may increase because most of the country is without medical assistance. 

“The health challenges in CAR are huge, especially outside the capital, where the healthcare system has been weak for many years. The biggest needs are basic healthcare, including adequate drug supplies in the health facilities. Drug importation and distribution are the biggest bottlenecks,” said Ellen van der Velden, MSF head of mission.

“We are calling on other non-governmental organizations, donors and the United Nations to come into the country to help the population.”

MSF has worked in the Central African Republic since 1996 and has projects in Batangafo, Boguila, Carnot, Kabo, Ndele, Paoua and Zemio.

Since early March, an estimated 50,000 Sudanese, Chadian and Central African civilians have crossed the border into Chad. The refugees are mainly women and children, with 40 per cent of those under the age of five.

They are traumatized, exhausted, and in need of basic healthcare, water, food, shelter and proper sanitation.

Chad 2013 © Ritu Gambhir 
Refugee children in Tissi. Thousands of Sudanese and Central African refugees have crossed the borders into Chad. 

The Tissi area has no functioning hospital. MSF teams are working to provide emergency and primary healthcare to the refugees and the Chadian population. An emergency room has been set up in the town of Tissi to treat wounded patients, children under five and pregnant women.

In the last four weeks, MSF has performed nearly 7,000 consultations in the area. The most common illnesses are diarrheal diseases and respiratory tract infections.

In addition, 32,000 children under the age of 15 have been vaccinated to contain a measles outbreak which killed 13 children before April.

Women and girls are facing an increased risk of sexual violence, with two cases of rape treated by MSF in the past week alone.

In ten villages, returnees and refugees have received plastic sheeting, blankets, mosquito nets, jerry cans and soap. MSF drilled six boreholes north of Tissi to help provide the population with water.

“With the rains starting, access to clean and drinkable water is of major importance,” said Delphine Chedorge, MSF emergency coordinator.

In some locations, such as Saraf Bourgou, north of Tissi town, Chadian returnees have left the area and re-settled in their villages of origin. But the Sudanese refugees are in a more precarious position. “The population’s health is at risk because of limited access to water, food and shelter,” said Stefano Argenziano, head of mission for MSF.

As the rains set in there is fear that roads to the refugee camps will become impassable, the only airstrip in the area will become unusable, and aid may be cut off. “We are doing everything we can to ensure that assistance will not be cut off,” said Argenziano.

Security in this cross-border area stretching between Sudan and the Central African Republic is volatile due to the presence of armed groups, militias and bandits.

MSF is calling on the Chadian government, the UN and the humanitarian community to ensure, throughout the rainy season, the security and continued support of the remaining refugees and returnees.

MSF has been working in Chad since 1980 and currently has projects in Am Timan, Abeche, Massakory and Moissala.