At the height of the crisis, confrontations, shootings and abuses occurred daily. Today, tension and violence have subsided and we are now in a particularly delicate phase – a sort of false calm that is both fragile and potentially explosive. Seleka’s two main groups will have to begin negotiations to establish an imminent power-sharing arrangement. There could be friction and clashes within this young coalition.

Central African Republic 2013 © Jean-Paul Delain/MSF
A patient receives emergency care from an MSF staff in the hospital in Bangui, Central African Republic following violence after the coup in March.

The CAR context has also become more complex. Seleka undertook a massive recruitment campaign four or five months ago, bringing in foreigners, mercenaries and, unfortunately, child soldiers. On March 24, approximately 3,000 men entered Bangui and recruitment continues. There are two sets of leadership – the official Central African Armed Forces (FACA) and the de facto Seleka. Many outside actors have also been involved in this conflict, with Chad, Sudan, Libya and others supplying men, weapons and uniforms. 

As a medical organization, we are very concerned about the unmet needs among a population that was already very vulnerable prior to the Seleka offensive. There are thousands of displaced persons who now live in extremely precarious conditions, without medical care, shelter, food or water. The health situation is critical in several regions. There are serious shortages of drugs and supplies and there are no health care personnel in the medical facilities. Based on our latest admission figures, the seasonal epidemic of malaria, which is endemic in CAR, appears to have begun and will surge in the rainy season. Medicine will arrive, but it will be a challenge to distribute it on flooded, impassable roads and in areas lacking security and healthcare workers. Food stores have also been looted, the fields cannot be maintained and, although it is too soon to tell, nutritional status could deteriorate.  

MSF is working throughout CAR, regardless of which party to the conflict is controlling the particular region. In Carnot, in the southwest area of the country, for example, the situation remains calm for now. The Seleka does not know this area very well. It has no support or economic interests there, given that the diamond mines are not currently operating.

However, several men were recruited locally to maintain a minimal presence in this “gray” area, where we must also take account of other actors, including members of the former presidential guard who are now unemployed, poachers, highway bandits taking advantage of the chaos and armed groups from neighbouring Cameroon. When economic activity resumes, the risk of theft and looting – including of international nongovernmental organizations (NGOs) – will increase. It may now be possible to launch the MSF measles vaccination campaign scheduled prior to the conflict, to begin in Carnot, but only in the city. Given the lack of security in surrounding areas, it will be more complicated to work in the outskirts.

We have also decided to transfer part of our activities in Paoua to various partners. However, while we may be able arrange this transfer working with local and, possibly, regional authorities, it will be more complicated at the national level. Last, on May 1, our teams treated 850 patients at the Bangui community hospital, most of whom had bullet wounds. We have been supporting the emergency and surgery departments there since late March. We expect to withdraw in the next few weeks. We will draw up an organizational and action plan so that we will be able to resume our activities immediately in the event of new spikes of violence and based on needs.

The NGOs – including MSF, which has become a leading health actor in the country – will have a critical role because the emergency continues. We must assess the risks and determine how we can best meet the needs.

Life expectancy in CAR is 48 years, among the lowest in the world. At a time when people are in great need of help – particularly medical assistance – the latest looting and destruction of healthcare facilities will create additional obstacles to obtaining care for people who have already suffered greatly.  MSF is particularly concerned about patients who have had to stop their HIV/AIDs or tuberculosis treatment.

MSF has been working in CAR since 1996. The teams are leading seven projects in five of the country’s seven health districts. MSF supports seven hospitals and approximately 38 health centres. In 2012, MSF provided 600,000 medical consultations and treated more than 260,000 cases of malaria. More than 1,600 people receive antiretroviral treatment.

Respecting access to healthcare in CAR

During the crisis, MSF was targeted several times by armed groups and the teams have experienced looting, theft and threats. We have called on all parties several times to respect patient access to healthcare, the safety of medical staff and the integrity of the healthcare infrastructure.

Therapeutic medical food and hospital beds were looted from MSF’s hospital the weekend of May 11. But more extraordinary is the systematic and purposeful damage to the infrastructure that renders the hospital unusable until major repair work has been conducted. “A special effort was made to destroy drug supplies, strewing them on the ground, to cut and slash the warehouse tents, to ransack the hospital wards, and even to cut electricity cables and rip them from the walls,” says Richard Veerman, MSF coordinator of operations for South Sudan. 

South Sudan 2013  © MSF
The scene at the MSF hospital in Pibor, South Sudan after facilities were deliberately damaged and drug supplies destroyed. 

The MSF hospital is the only hospital facility for Pibor county, the nearest alternative being more than 150 kilometres away. Three thousand patients were treated during the first three months of the year in this hospital. More than 100 patients, including SPLA soldiers, received surgery for war wounds. 

“The rainy season has just started and we know from previous years that malaria and respiratory diseases such as pneumonia will start to claim lives if there is no healthcare available,” says Veerman.  In a report issued in November last year called, South Sudan’s Hidden Crisis, MSF documented the devastating health consequences when people have to flee to the bush and when medical assistance is unavailable.

Humanitarian access and medical assistance need to be resumed in Pibor county in the coming days or weeks. “It is unthinkable that there will be no healthcare whatsoever for the next six months for some 100,000 frightened and vulnerable people hiding in the swamps ,” says Veerman. “But unless we can return to resume medical activities and have the freedom to move to wherever people need assistance, this unthinkable scenario may become the horrific reality.”

South Sudan 2013  © Robin Meldrum/MSF
A patient and medical staff during a consultation in 2012 at the MSF hospital in Pibor.

This is the sixth time an MSF medical facility has been looted or damaged in Jonglei State in the past two years. More recently, MSF had suspended activities in Pibor on April 19 this year because of threats and intimidation of staff and patients. Having sought assurances that medical humanitarian activities and staff would be respected and could be pursued without hindrance or obstacles, an MSF team was preparing to return and restart medical activities when the looting and destruction occurred.

MSF urges the government of South Sudan to meet its responsibilities to ensure full respect of medical humanitarian facilities and activities. MSF also calls urgently for assurances from all parties in the Jonglei State conflict that its medical teams will have unhindered freedom to return to Pibor and impartially reach out to any people on either side of the conflict in need of medical assistance.

MSF works in Akobo, Nyirol, Pibor and Uror counties in Jonglei State. The activities in all locations, including Gumuruk clinic in Pibor county, continue to function, with the exception of the hospital in Pibor town, and the MSF clinic in Lekwongole village in Pibor County, which was targeted and damaged in August last year and where insecurity and fighting have since made access impossible for MSF to continue to provide medical care.

As negotiations for the Trans-Pacific Partnership (TPP) restart in Lima, Peru, tomorrow, countries must prioritize fixing critical flaws in the agreement that could leave millions of people in developing countries with limited access to affordable generic medicines, Médecins Sans Frontières/Doctors Without Borders (MSF) said today.

“Substantive discussions on access to medicines have languished for more than a year, with negotiating countries and many other groups, including MSF, voicing concerns about the damaging impacts of the proposed rules,” said Judit Rius Sanjuan, manager of the MSF Access Campaign. “The Lima round offers a key opportunity for TPP negotiators to remove harmful provisions from this trade agreement before it’s too late.”

Negotiations on the TPP – a far-reaching trade agreement between 11 Pacific Rim countries and including Canada, – continue to be shrouded in secrecy, but leaked copies of the agreement reveal that the United States is demanding the most harmful package of intellectual property protections ever proposed for a trade agreement with developing countries. 

These rules would make it extremely difficult for generic competitors to enter the market, keeping prices unaffordable, with devastating public health consequences. The proposed provisions would, for example, lower patentability standards, making it much easier for pharmaceutical companies to obtain secondary patents and extend product monopolies for existing drugs; prohibit challenges to weak or invalid patents until after they have been granted; and grant monopolies by locking up clinical data needed to approve generic drugs.

 The TPP threatens to constrain signatory countries’ ability to limit abusive patenting and to ensure timely access to the affordable generic medicines that are critically important to treatment providers like MSF.  “Alarmingly, the TPP is slated to become the ‘gold standard’ for future trade agreements across the globe, which means that unless these provisions are rejected now, they will be replicated and imposed on many more developing countries in the coming years,” said Stephen Cornish, executive director of MSF in Canada.

International rules require governments to grant 20-year patents on pharmaceuticals, but they also allow critical flexibilities in controlling the quality of patents, and in determining under what conditions companies can obtain additional patents on existing drugs.  Companies have developed a variety of tactics to extend monopoly protection on their drugs beyond the initial 20-year period, a practice commonly referred to as ‘evergreening.’ It is up to governments to prevent evergreening by putting safeguards in place which balance commercial interests with public health needs.  

One example is India’s Section 3(d) law, which aims to achieve this balance, and curb evergreening, by prohibiting the granting of secondary patents on existing drugs unless they are substantially more effective than the original drug. Pharmaceutical company Novartis recently lost a seven-year legal battle – which was taken all the way to the Indian Supreme Court – in an attempt to challenge the application of this law. If accepted in its current form, the TPP would take away governments’ ability to implement similar safeguards.

MSF urges governments involved in the TPP negotiations to reject provisions that will harm access to medicines.

Last week’s fighting forced thousands of people to flee into the forests. Eleven Congolese Médecins Sans Frontières (MSF) staff had been missing since the violence began on April 28, but as of yesterday, all are accounted for. “Two staff walked for about 160 kilometres in the past couple of days and reached Goma few days ago,” says Hugues Robert, MSF’s head of mission in DRC. Providing medical services remains challenging and difficult, as many health workers fled or are exhausted and overstretched.

MSF is the only medical aid organization supporting the DRC’s Ministry of Health in Pinga and surrounding areas. Located in the territory of Walikale, MSF staff support the main hospital in town, providing services to a population of more than 60,000. Before the recent fighting, MSF was providing primary healthcare in three health centres (Kasseke, Mpety and Nkassa), and also through mobile clinics. Unfortunately, medical activities in Mpety and Kasseke had to be suspended because of the fragile and uncertain security situation.

Democratic Republic of Congo 2012 © MSF
MSF medical staff care for a war-wounded patient in 2012.

Executive director for Médecins Sans Frontières in Canada

First published online by The Globe and Mail on May 6, 2013

We are failing the Syrian people. Right now, women, men and children are suffering and dying needlessly. We can and must do more to help them.

I recently returned from a two-week mission to Syria, Lebanon and Turkey. There I met with Syrians struggling to survive a brutal civil war that has so far killed more than 70,000 people and forced more than one and a half million to flee to neighbouring countries.

Syria 2013 © Brigitte Breuillac/MSF

I also met with aid workers providing lifesaving assistance – from my own organization, Médecins Sans Frontières/Doctors Without Borders (MSF), and from the few others present.

One thing became absolutely clear to me on this trip. We, the international community, are not living up to our responsibility to meet the escalating humanitarian needs of the people caught up in this intractable war.

Truly, we are failing the Syrian people. The medical needs are overwhelming – from shrapnel injuries that go untreated for lack of accessible care, to pregnant women who must risk their lives to deliver their babies, to sufferers of chronic illnesses like diabetes and cancer who can't obtain treatment, to the miserable and unsanitary conditions of the camps for displaced people.

I cannot overstate the scale and severity of the humanitarian emergency I witnessed. The Syrian conflict is already the world's largest refugee crisis. We can do more to save lives and reduce suffering, and we must do it now.

Click to listen to Stephen Cornish talk about the Syrian humanitarian catastrophe on CBC's Metro Morning.

What can we do? The crisis requires political will and leadership on the part of national governments to persuade Damascus, opposition groups and Syria’s neighbours to increase humanitarian access and reduce barriers to aid. It also requires more resources to meet the escalating needs.

Targeting of medical personnel and restrictions on crossing the constantly shifting frontlines are major impediments to providing lifesaving care where it is needed most. Syrians often have to risk their lives on long, circuitous journeys in order to get medical help. All parties to the conflict must be pressured to respect medical facilities, as well as the rights of aid workers and their patients. 

In opposition-held territories in the north of the country, where MSF is operating three hospitals, there are too few aid organizations present to meet the needs. The increased security risks are also making it difficult to work.

Inside government-controlled areas, restrictions on the UN and Red Crescent hinder their abilities to respond in areas where needs are highest. Despite repeated requests, the government still refuses to give MSF and others permission to work, which further impedes the aid effort.

Iraq 2013 © Michael Goldfarb/MSF

Outside Syria, the UN expects the number of refugees to reach three million by year’s end. Lebanon, Turkey, Jordan and Iraq are doing what they can to care for the refugees. But these countries are stretched to the limit and need help, in the form of financing, technical assistance, and more aid organizations to help them respond to the unprecedented flow of refugees.

Resources have been promised, but now they need to be mobilized. In January of this year, 60 countries pledged more than $1.5 billion in aid for the Syrian people. So far, only a fraction of this money has materialized. Donor countries not only need to honour their existing commitments, they need to significantly increase them to keep pace with the escalating needs.

In many camps, conditions are woefully inadequate. Relief supplies and food are being stretched to cover the steady stream of new arrivals. Insufficient access to clean water and sanitation presents the risk of disease outbreaks as we move into the hot summer months.

For the refugees inside Lebanon, medical care is frequently poor or nonexistent  ̶  about half are unable to access it. During my visit, I met a pregnant woman who was ready to risk returning to Syria to deliver her baby, because she couldn't afford to pay medical fees for a caesarean section.

Neighbouring countries should also be encouraged to do more to facilitate the delivery of aid for Syrian refugees – especially by removing bureaucratic hurdles. This includes faster registration of international aid organizations, reducing barriers to import relief supplies and easing visa restrictions for aid workers.

The conflict in Syria shows no sign of abating, and the needs of the Syrian people are increasing daily. There is no excuse for our continued humanitarian failure. We must act now.

 “MSF is very concerned about civilians routinely exposed to this violence – this is the eighth time Pinga has changed hands since 2012,” says Jan Peter Stellema, MSF’s operations manager in Goma, DRC. “A number of patients had to be transferred for emergency surgery to Goma, among them a 70 year old woman after she was shot in the arm.” 

After the first wave of attacks on Sunday a large part of the town’s population fled into the surrounding forest. The remainder sought refuge at the local hospital, but was forced out by armed men. Houses have been burned and looted, and a combatant was decapitated, further increasing the level of panic and alarm in town. Eleven Congolese staff members have not reported for work and are currently missing.   

DRC 2013 ©MSF - MSF team arriving in a village in Pinga Healthzone for outreach activities

In the past year, an MSF team has managed to support the town hospital, continue to run a large clinic in the town and has been able at times to cross frontlines to support clinics in the surrounding area. However, negotiating access with the multiple armed actors and alliances present in the area remains extremely challenging. Health centres have been looted and medical equipment destroyed.

“Providing healthcare is proving a challenge when medical facilities are not respected, staff are missing, people have fled the area and those who remain fear being subjected to harsh treatment, illegal taxation, forced recruitment or worse,” says Stellema.

Despite challenging conditions, MSF continues to provide high-quality medical care in four reference hospitals, 12 health centres and four health posts in North Kivu and four reference hospitals, 19 health centres and five health posts in the province of South Kivu. This is in addition to running several cholera treatment centres, weekly mobile clinics, and emergency response activities as required.

In Iraq, an estimated 133,000 refugees are registered or awaiting registration, many in the north of the country. Domeez camp, in Duhok province, was initially designed to host 1,000 families, but is now hosting more than 35,000 refugees. As many as 1,000 people have been crossing from Syria into this part of Iraq every day but there are not enough services in the camps to keep pace with the increased demand.

Syrian refugees in Domeez camp, Iraq © Pierre-Yves Bernard/MSF

Lack of shelter is especially critical and newly arrived refugees must share tents, blankets, mattresses, and even their food with other families. Water and sanitation services are poor, and access to water will remain difficult with summer approaching.

Médecins Sans Frontières (MSF) is the main healthcare provider in Domeez refugee camp, providing general healthcare, mental health care, and reproductive health care. The teams have provided more than 64,800 consultations and have carried out a measles vaccination for 31,000 people. 

In Jordan, more than 450,000 Syrians refugees are registered or awaiting registration and around 1,000 to 3,000 people continue to arrive daily. It is estimated that if arrivals continue at this rate then 1 million refugees may have arrived by the end of 2013. The Jordanian health system is overburdened with the continuous influx of refugees and wounded from Syria, leading to the terrible situation where some patients die while waiting for referral.

Zaatari camp has become a makeshift home to more than 100,000 Syrian refugees. Access to water is a growing concern with the upcoming summer, as Jordan normally has to deal with water shortages even without a refugee influx.

MSF is running a 24-hour pediatric 30-bed hospital in Zaatari camp and an emergency room with three beds for children from one month up to 10 years old. By mid April MSF had hospitalized 72 patients and carried out 277 emergency consultations. In addition, MSF was already running a reconstructive surgery hospital in Amman. Major surgical cases are referred from the camp to this MSF hospital where they are offered physiotherapy, psychosocial support and post-operative care, as well as technically advanced surgical procedures.

In Lebanon, the main identified needs for over 450,000 refugees are primarily accommodation, food, primary and secondary healthcare, and mental health care.

MSF is assisting refugees through primary healthcare including immunization, treatment of chronic diseases, prenatal care, and mental health care, as well as distributing relief items. MSF’s project locations are in Tripoli, northern Lebanon, where the biggest number of Syrian refugees is staying, as well as in the Bekaa valley, the main crossing point for people fleeing Syria. Teams have also carried out activities in northern Akkar district and in the southern town of Tibnine. 

In Turkey, the number of people fleeing from the area around Aleppo keeps increasing. Official figures of Syrians registered and accommodated in 13 camps in Turkey amount to 177,387, reaching the capacity of these camps. But there are also many refugees  ― estimates range from 70,000 to 100,000 Syrians  ― without passports who are not taken into account for any distributions or relief services.

MSF is working in an outpatient clinic in Kilis and is providing mental health support to unregistered refugees not living in the camps as well as for refugees in Kilis and Islahiya camps.

Some 1.4 million Syrians have fled to neighbouring countries that are overwhelmed and where the humanitarian response has so far been unable to meet their needs. MSF is carrying out medical consultations and distributing relief items to refugees in Iraq, Jordan, Lebanon and Turkey.

Syrian refugees in Iraq 2013 © Michael Goldfarb/MSF

Emergency aid inside Syria 

Within Syria, the MSF operations are scaling up as fast as is safely possible, but are still limited to four pockets where MSF is able to have teams on the ground running high quality medical activities. While MSF continues to negotiate for access through Damascus, for now it is only possible for MSF to work in opposition-controlled areas.

Near Aleppo an MSF hospital provides more that 1,500 consultations and around 70 surgical operations per month. Another MSF team set up a blood bank (now handed over to Syrian doctors) to supply the hospitals in Aleppo area, and then started providing vaccinations for children as the war had brought normal vaccination activities to a halt.

In Idlib governorate, MSF has two hospitals. “We’re on permanent standby for mass casualty influxes but on a day-to-day basis this is not our core activity,” says Alex Buchmann, recent project coordinator of one of the hospitals. “Any medical services that are still somehow operational in this area are focused on war wounded, so for people with difficult pregnancies, chronic diseases, fevers or general illnesses, the only options are our hospital and mobile clinics. Sometimes there are wounded, but all the time there are other illnesses that need treatment.”

The other MSF hospital in this area has a highly specialized trauma and surgical department, where so far more than 1,160 surgical operations have been performed mainly for violence-related injuries and more than 2,800 patients have received emergency care, including many patients with extensive burns sustained from accidents with home heaters or when using home-made crude oil refining kits. Physiotherapy care is also provided to patients after surgery, in the hospital or in a post-operative unit.

To improve the water and sanitation situation in a camp for those displaced from their homes, MSF is building 50 latrines and 50 showers. A vaccination campaign was organized for children under five; 3,300 were immunized against polio and 2,000 against measles.

In Al Raqqah governorate, fighting and bombing in and around Al Raqqah town has led tens of thousands to flee to already-struggling villages in the area. MSF has already seen some 300 measles cases (a clear sign of the collapse of the healthcare system). The MSF team has started providing outpatient consultations in a health centre and will soon start a maternity service, treatment for chronic diseases, and open both an emergency room and an inpatient department.

Most of the MSF teams are also engaged in mobile clinic activities and some of the projects have introduced a mental health service, which is critically needed after two years of intense conflict. MSF also has an extensive activity of supplying medical and emergency relief supplies to hospitals and clinics on both sides of the conflict in Syria, including Al Raqqah, Damascus, Deir Ezzor, Deraa, Hama, Homs and other areas.

Most of the migrants referred to the Al-Mazraq hospital were victims of human trafficking, forced labour and slavery. They showed signs of torture and verbal, physical and sexual abuse from their captors. Some of them have had their nails pulled off or their tongue partially cut off, others have been severely beaten. MSF staff have also treated people who suffer from life-threatening diseases like pneumonia, complicated malaria or dengue fever.

Yemen 2013 © Anna Surinyach/MSF
Haradh town, Yemen, where many migrants from the Horn of Africa pass through on their way to Saudi Arabia, whose border is just a few kilometres away. MSF is providing medical assistance to migrants, including referring severely ill people to a nearby MSF-run hospital.

MSF has provided mental health assistance to the migrants after their release and transfer to a compound on the outskirts of Haradh town. “Many of them are physically and mentally exhausted and suffer from severe mental trauma due to the horrific conditions and treatment they experienced during their detention,” says Angels Mairal, an MSF psychologist working in Haradh. Most of the migrants who have received psychological support by MSF said they were victims of torture.

The migrants’ medical and humanitarian needs were extensive as some of them did not eat for up to seven days before their release by Yemeni authorities. MSF provided some supplementary food rations and also intervened to improve the sanitary conditions in both Haradh and Amran transit locations.

From Haradh, 800 Ethiopian have been transferred to migrant centres in Sana’a, where they await repatriation; 550 Somalis were transferred to Kharaz refugee camp, in Lahj governorate. MSF is extremely concerned as those centres do not have the means, capacity and services to adequately assist people.

Yemen is located along one of the main routes for people leaving the Horn of Africa to get to Arab Gulf States. Many of the migrants from Ethiopia are fleeing extreme poverty and unemployment, trying to enter Saudi Arabia through Haradh. Often they end up in the hands of smugglers who try to extort money using torture and psychological abuse.

“We are facing an emergency on top of this chronic situation and we are extremely worried about the future of thousands of migrants who are stranded in Yemen generally and Haradh in particularly with very limited assistance,” says Tarek Daher, MSF’s head of mission in Yemen. “They are exhausted after so many attempts to cross the border and with no resources; the majority of them become beggars in the street of Haradh. They try to survive, and live without any decent shelters, sanitation or regular meals.”

MSF acknowledges the efforts the Yemeni government has made to free, host and protect the newly liberated migrants in Haradh and emphasizes that this support must continue. The organization urges the international community to help restore the dignity of these migrants by supporting institutions working with them.

MSF, together with authorities and some nongovernmental organizations, is scaling up its intervention in order to improve the living conditions of the migrants stranded in Haradh and to improve access to healthcare for those who are released or in transit waiting for repatriation.

MSF has been working in Hajjah governorate, in the north of Yemen, since 2009. The organization manages the hospital near Al Mazraq, which provides local and displaced people with basic and specialist healthcare, surgery and emergency services. Since last year, MSF also provides mental health assistance for migrants in Haradh town. MSF is also carrying out medical activities in Aden, Ad-Dhale, Abyan and Amran governorates.

MSF’s report, Healing Iraqis: The Challenges of Providing Mental Health Care in Iraq, records examples of the impact daily violence has had on many Iraqis –adults and children – and describes the development, together with the Ministry of Health, of a program to provide counselling care.

There is an urgent need to scale up mental health care services in the country. MSF calls on the Iraqi Ministry of Health, and those who support them, to improve the quality and access to mental health services by integrating counselling into existing health facilities across Iraq.

MSF also notes that more must be done to reduce the stigma of mental health to encourage people to come forward for counselling.

Since 2009 MSF has been working in Iraq providing mental health counselling to men, women and children in conjunction with the Iraqi Ministry of Health. MSF’s programs focus on non-pharmaceutical approaches to address anxiety and depressive disorders commonly experienced by those exposed to violence and uncertainty.

“Many Iraqis have been pushed to their absolute limit as decades of conflict and instability have wreaked devastation,” says Helen O’Neill, MSF’s head of mission in Iraq. “Mentally exhausted by their experiences, many struggle to understand what is happening to them. The feelings of isolation and hopelessness are compounded by the taboo associated with mental health issues and the lack of mental health care services that people can turn to for help.”

Over the past four years, MSF and the Iraqi Ministry of Health have introduced psychological counselling services in two hospitals in Baghdad and one in Fallujah. There are plans to use this as a model of care that can be replicated in other healthcare facilities across the country, with the health ministry starting new units in Kut, Karbala and Sulaymaniyah Hospitals. MSF’s also recommends the Iraqi health system integrate psychological counselling into community-based primary healthcare services to increase access, particularly for women and children.

According to patient data collected in 2012 by MSF and the Ministry of Health, 97 per cent of people who presented for counselling reported clinically significant psychological symptoms at admission. When measured on the last visit, this figure had reduced to 29 per cent.

Even excluding domestic conflict, almost half of all cases seen in the program (48 per cent) were violence-related. Nearly all staff and patients in MSF’s mental health program have either experienced or know someone near to them who has been directly impacted by a violent event over the past few years. 

The report carries testimony from Iraqis traumatized and struggling to rebuild their lives after witnessing extreme violence.

A 36-year-old widowed mother of three describes how she started counselling sessions after her life has been turned upside down two years ago when her husband was killed:

“I started attending the mental health counselling sessions when I felt I’m so tired and very sad. I felt I had a psychological problem and that made me disturbed because I’m unable to cope well with others. I lost my husband two years ago and the incident affected my life. It changed my life, it turned my life upside down. I’m now the only one left responsible for raising my kids.”

A 10-year-old child describes how counselling has helped her improve her speech:

“I started attending the sessions to help improve my speech and help me overcome my fear. I’m scared of everything. My body is always shivering. I can’t spell words correctly anymore. My teacher and my fellow classmates beat me all the time in school. I can’t study or learn anything. I’m unable to concentrate. I don’t talk to anyone. This is the first time I’ve talked to anyone about my problems.”

Providing care for such traumatic experience is not easy, but the counselling model has proven to be beneficial in helping people regain a level of dignity and control over their lives.