p2 p4 aids pandemic · aids inventing as we p2 messages msf n°143 november 2006 dossier pandemic...

> N° 143 / November 2006 / Médecins Sans Frontières internal newsletter www.msf.fr

MISSIONS - Sri Lanka: MSF

withdraws from theJaffna Peninsula P16

- Southern Sudan: whatrole is there for NGOs ina region undergoingreconstruction ? P18

DOSSIERPANDEMIC DESPERATELYSEEKING SOLUTIONS- Inventing as we

go along P2

- The Ugandan model:reportage P4

- Arua Meeting:discussions between3 heads of mission P6

- Prevention of mother-to-child transmission P10

- Interview with ProfessorWin Van Damme of the Institute of Tropical Medicine P12

- MSF treatment of Aidspatients> Map P14

DEBATES - Darfur :

Humanitarian aid heldhostage P20

- Somalia :

Should MSF open aprogramme ? P22

INFOS- Watch and read

- Seventh volume of the“MSF Speaking out”collection P24

> M

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i© J

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Rém

y -

May

200

6

AIDS

Pandemicdesperately

seekingsolutions

In late 2000 and early 2001, MSF’sobjective was to start treating AIDSpatients with antiretroviral (ARV)therapy, and to show that it wasperfectly possible to treat poorpatients in developing countries. Atthe time, patent-protected tripletherapies cost over 10,000 dollars perperson per year. And there were manysceptics – major sponsors in particu-lar – who believed that it was impossi-ble, and even pointless. Then thecontext changed. The Global Fund toFight AIDS, Tuberculosis and Malariawas set up in June 2001. With genericversions coming onto the market, in2001 triple therapy was available forless than 350 dollars per patient peryear.

For MSF, two years on from the firstpatients, the objective was no longerstarting individual treatment, butmoving on to “scaling up”, increasingthe number of patients on ARVtherapy. This meant identifying all thebottlenecks that were preventing usfrom making the move to treatinglarger cohorts. It led to a simplifica-tion of treatment: initiating therapywithout a CD4 count1, longer periodsbetween patient visits, new allocationof tasks, with a start on trainingnurses to take responsibility for somepatients.

In parallel, the “global response” tothe pandemic was making slowprogress: the Global Fund was having

trouble getting enough funding tomatch the needs, and nationalprogrammes were taking a long timeto set up, or were even non-existant.“The World Health Organisation’s “3 x 5” initiative launched in December2003 – 3 million patients undertreatment by 2005 – certainly gave it aboost by mobilising the variousplayers” says Annick Hamel from theOperations Department. Even if theWHO “3 x 5” was widely disparaged,and not only by MSF (see the Win VanDamme interview on p. X), there weremore and more initiatives being set upin the field, and national programmesare gradually starting up.

“Decentralisation of care is nowunder way in a great many countries,in the sense of increasing the numberof places where treatment isavailable, to get closer to the patientsand offer therapy to everyone whoneeds it. It’s the only way to cope withthe high demand, especially in high-prevalence countries”, Annick Hamelexplains. The question is therefore:how should it be done? In MSFprogrammes, implementing decen-tralisation also depends on thepolitical will shown by the countriesand the constraints they have to face.“Some countries, such as Uganda,have set up a decentralisation policythat is mainly aimed at meeting targetfigures. Here it is harder for MSF toget involved in the process because ithas to be done by improving theexisting system. In Malawi, wherethere is a willingness at national level,the government is encouraging MSFto implement the decentralisation sothey can learn from our experience.”

But in practical terms, the dynamic isthe same as for “scaling up”. “It’s onlythe scale that changes. And one of the

AIDS

Inventing as we

P2 messages MSF N°143 November 2006

DOSSIERPandemic desperatelyseeking solutions

MSF/November 2006/Translated by Alison Quayle

“To treat as many of the AIDS patients who come to us as we possibly can.” This is theobjective of our HIV/AIDS programmes, especially in Africa. We must now turn ourefforts towards covering the needs as widely as possible. It is a very unusual concept forMédecins Sans Frontières to say, and above all a radical step forward, five years on fromthe start of our first AIDS programmes.

We are conducting a series of cross-sectional surveys to determine theefficacy of treatment for patients being treated by MSF. MSF has aresponsibility to be credible, demonstrating that its treatment strategy iseffective.

Our work involves taking a blood sample of patients who have beenreceiving antiretroviral treatment for 12, 24, 36, or even 48 months. If theviral load is detectable, we study the genotype of the virus in order todetermine the most frequent viral mutations. At the same time, we try tomeasure how consistently patients have been following the treatment andassess the side effects they have experienced. We also try to identifyclinical signs of treatment failure by comparing viral load values withpossible clinical signs that may appear during treatment.

This will allow us to make more accurate assessments of our programs,i.e. to measure treatment failure rates, adherence problems andtreatment toxicity. For patients experiencing treatment failure, analysis ofthe genotype allows us to determine the most suitable second-linecombination. The first studies on adults show immuno-virological resultsthat are comparable to those in economically developed countries, takinginto account the patients’ health condition when MSF began administeringtheir treatment.

Dr Mar Pujades, epidemiologist, Epicentre.

Interview by Olivier Falhun

EPIDEMIOLOGICAL RESEARCHTRANSLATED BY AARON BULL

Number 143WE CAN ALWAYS DO BETTER

Although we procrastinated at lengthbefore starting, MSF is among the‘pioneers’ treating Aids in developingcountries. Thanks to its experienceMSF, alongside other organisations,helped initiate a response to thepandemic and compelled others tobecome actively involved in the fightsagainst Aids. MSF is now innovatingan approach to try and treat as manypatients as possible. Our teams arealready helping 60,000 patients tosurvive.

Ok, but what next? ‘No hailing ofvictory” is the message in thisdossier. Above all we must not fallinto the trap for which we criticisedthe WHO concerning tuberculosis:soothing self-satisfaction in order toconceal our failures and difficulties.Our programmes have their failures,and they are considerable: treatmentis given priority over prevention,especially in mother-to-child trans-mission, the ever neglected elementof our Aids programmes. Thetreatment of TB/HIV co-infectedpatients is the next challenge forMSF. A complex challenge that willcall us to rack our brains.

It is because we have made progressthat our weak points and where weneed to better ourselves are all themore visible. That’s all par for thecourse. MSF can only be considered a‘pioneer’ if it continues to break newground and improve treatment forpatients. MSF must not be a heroclinging to past success, but aclinician in the field continuallyinventing new approaches.

go along


> Nigeria © Ton Koene - July 2006

main issues is the lack of medicalpersonnel. But it’s possible to care formore patients by asking for help fromother patients or people in thecommunity, to look after the patientsclose to their home.” Hence theexperiments in Malawi, for instance,or in Kenya (see also p. 4).

Nevertheless, not everyone wants totreat all patients and provide every-thing needed to ensure they survive.“We must keep repeating thateveryone must be treated. And at thesame time, it’s important not to forgetthat treating an AIDS patient is notjust a matter of making drugsavailable”. It also involves making adiagnosis, being able to treat opportu-nistic infections, detecting anddealing with treatment failure,adapting therapy if there are sideeffects, working on compliance,having enough trained staff, having a

reliable supply of drugs, and so on.While quality of care is of vital impor-tance, it is not incompatible withquantitative objectives.

And what about tomorrow? What isthe future for MSF programmes onceall the requirements for treatment at

population level are covered? “It willnever be MSF’s job to treat all acountry’s patients”, Annick Hamelinsists. MSF has a clear lead overnational programmes. Once we are

able to transfer our activities tonational programmes that arecapable of offering good-quality carefor stabilised patients, we hope MSFwill be further ahead: for instance intreating children, or complicatedmedical cases in outlying healthcentres.

There remains the question oftreating patients outside the verticalHIV/AIDS programmes. Although MSFsays it wants to treat HIV/AIDSpatients within other programmeswhere possible, this is still nothappening everywhere. At themoment it is done in Liberia, Sudan,the Democratic Republic of Congo,Thailand, Georgia and Ivory Coast. Butas Annick Hamel points out, “treatingAIDS patients is not that complicated.There are guidelines2 available now,which the teams have found veryhelpful. We have learnt from the

experience of the first few years. Evenif some teams still feel that treatingAids is complicated, treating a fewpatients as part of their programme isno longer anything out of the ordinary.What is extraordinary is having to‘make it up as we go along’. There isno care model for large cohorts ofpatients. There has never been achronic disease quite like this, sothere is no referring back to earlierpractice. We have to invent it, countryby country, to suit their specific requi-rements and constraints, so we cantreat all the patients who comeknocking on our door”. ■

Caroline Livio

1- the CD4 or T-lymphocyte count

indicates the level of immunosuppression.

2- ARVs for dummies, available on MSF

medical service.

There has never been a chronicdisease quite like this, so thereis no referring back to earlierpractice. We have to invent it,country by country...



> Uganda © Jean-Marc Giboux - July 2006

THE UGANDAN MODEL

A reality checkTranslated by Penny Hewson

Often quoted as an example, Uganda is showing a declining prevalence and more than80 000 patients on treatment. This outward appearance masks a more complex reality.The hospitals and health centres are short of staff, financial means and materials. Never-theless, MSF is treating 2 700 patients in Arua and supports the decentralization of HIVcare by the State in the West Nile region. Report.

It is 5pm in the HIV clinic of Aruahospital in the north west of Uganda.Patients have been there since earlythis morning; and the public is a bittired. But when Helen begins toharangue those present in Lugbarainterspersed with English words, sheachieves the feat of making laugheveryone by deploying her actingtalents. “The main thing, insists Helenwho has herself been undergoingtreatment for two years, is to leavewith your medication. Interruptingyour treatment is just too dangerous.Do not let yourself be discouraged bythe wait."

In 2002, MSF started treating aidspatients here. “We are have 4 603 HIVpositive patients on our registers, ofwhom 2 704 have begun tripletherapy,” explains WilliamHennequin, field coordinator in Arua.This Tuesday, more than 150 patientshave appointments. They come tocollect their medication for the monthor months to come, and for a medicalconsultation. They can also discusswith a counsellor any difficulties theymay have in taking their treatmentregularly and see how they canremedy it. A young woman onreception calls 4 or 5 patients at a

time. On her desk, between the schoolexercise books which are used forhealth records, sits a yellow flag withthe MSF logo where you can read “2pills a day, treat HIV/AIDS now!”Sometimes patients turn up who donot have appointments but whosehealth has suddenly got worse. Suchas this man, being treated sinceOctober 2004, who is continuallyconvulsing and will die two hourslater. A sad reminder that AIDS stillkills. Since the launch of the project, 244patients have died (i.e. 7% of thepatients having started treatment has

> A showcase which

suits everyone

In the fight against Aids,Uganda has often beenpresented as a model, not without an ideologicalulterior motive. The nationalprevalence has been reducedfrom 28% in 1988 to 6.4% in2005, even if large regionaldisparities still persist. Thissuccess has been attributed by some to abstinence andfidelity, whereas the creditshould rather go to increaseduse of condoms and the deathof a large number of patients.The moralistic approach to prevention has concreterepercussions. Last year therewas a period when Uganda ranout of condoms. And between2003 and 2005 the prevalenceof AIDS in the country wentback up from 5.6% to 6.4%.The other trump card whichUganda has in terms of imageis to have exceeded the objec-tives assigned by the WHO’s "3 by 5" plan, which was apoint of optimism in theoverall results of failure. There are now over 80 000patients on treatment, and the rhythm of inclusion isaccelerating with more than200 district hospitals andhealth centres giving out ARVs.There are doubts howeverabout the quality of caredispensed.


well as, doubtless, some of the 426patients lost to follow up (12%).Caring for AIDS patients well involvesgiving them antiretrovirals, makingsure of their compliance – regularlytaking the prescribed medication –but also timely diagnosis andtreatment of any opportunistic infec-tions. The work carried out to improvefollow-up compliance is beginning tobear fruit. The proportion of patientslost to follow up has fallen, as also hasthe death rate. The team has alsorenovated the tuberculosis clinic andhas started providing integrated careto co-infected patients. On the otherhand, MSF no longer intervenesdirectly in the other departmentswhose functioning is burdened withmany problems: the roof of the mainbuilding containing 80 beds which hasbeen threatening to cave in for fouryears, the paediatric ward where thewomen are all piled together, minis-terial credits which are a long timecoming…

"We need to strengthen our linkswith the other hospital departments,to improve the quality of care of thepatients in hospital and identify other

sick people who need ARVtreatment," notes William. Workingbetter with the paediatric servicewould allow us to increase thenumber of children treated with ARVswhich is still too small (only 3%).MSF tries to reinforce the differentwards with MSF stuff, but withoutsucces. “We would prefer themedical staff at the hospital to cometo the MSF clinic for training in thecare of opportunistic infections,explains William. But we are havingdifficulty in setting it up."

For it would first be necessary toreorganize the MSF clinic to reducethe work load and be in a position totake in more patients. At the moment,about 3 600 patients come everymonth for their follow-up appoint-ment. “We are beginning to space outthe appointments of stable patientsevery 2 or 3 months, and we arehoping that they will be followed up bythe nursing staff to ease the burdenon the clinicians, explains William.That will also allow us to devote moretime to complicated cases."

For a long time, Arua hospital was theonly facility in the West Nile regionoffering free antiretroviral treatment.Patients flooded in from all over theregion and even beyond, since morethan 600 patients live in DRC andsome of them have more than a day’sjourney every month to come and gettheir medication. But things havebegun to change. The process ofdecentralization of HIV care launchedby the government goes as far as theWest Nile where ten or so publicfacilities are putting patients on ARVs. Indeed, the rhythm of patientinclusion is accelerating. But thequality of care dispensed leaves a lotto be desired. A visit to some ARVcentres in the West Nile region isenough to see that the difficultiesencountered in the MSF project inArua are there multiplied tenfold bylack of means. First of all, the lack ofstaff limits the number of patientswho can be treated. “We have only sixqualified staff for the whole hospital.If the HIV clinic opened more than oneday a week, the other departmentscould not function,” states theDirector of the Hospital of Nyapea.Because of this, the number of HIV-positive patients followed up in July2006 in the whole of the West Nilepeaked at 3 000 of whom 800 were on

ARVs – and counselling was kept to aminimum. The overburdened medicalstaff give reminders about the impor-tance of taking the treatment properlybut have scarcely the time to givemore advice. “To reinforce thecounselling, patient associations is anew route,” considers PatrickAnguzu, the Director of Health for theArua district.

Another difficulty is supplying thehealth centres with medication. “Inthe West Nile region, there have beenincomplete courses of treatmentdelivered and supply shortages, andthis is very dangerous for patients,says William. To limit the damage, wehave given several loans or one-off

donations thanks to our emergencystocks.” At national level, followingmanagement errors, the centralpurchasing agency National MedicalStore (NMS) was in Septemberrelieved of supplying ARVs to thebenefit of the World Health Organiza-tion’s office in Kampala. It remains tobe hoped that the ordering systemwhich is finally starting to work in thehealth centres will not be changedcompletely.

Medication for opportunistic infec-tions poses another acute problem.The health facilities purchasemedication for opportunistic infec-tions from the NMS. Not withoutproblems. “Deliveries are late and youare lucky if you get 50% of what youordered,” deplores a district doctor inthe West Nile region. At the end ofSeptember it was supplies of Cotri-moxazole which were beginning torun out. Cotrimoxazole is a thepreventive treatment which is given toall HIV-positive patients followed up inpublic hospitals. In theory, the moneyfrom the Global Fund should also beused for the purchase of medicationfor opportunistic diseases and makeup for the deficiencies of the NMS, butthis funding is only just being set up.

> For lack of treatment

available in their

area, 600 Congolese

come to Arua.

Marie-Jeanne’s t-shirt reads“Sida nous te vaincrons”(“Aids, we will beat you,”). To come to her follow-upappointment in Arua, for thisCongolese woman it took firstof all a day to get from hervillage to Aru, the border town.Then, this morning, shepedalled for 3 hours to get tothe clinic. “Of course, I wouldlike health centres near myhome to give free ARVs, shesaid, but that isn’t happeningfor the moment,”The Ugandan governmentagreed to accept a few yearsago that Congolese patientscould be treated in Arua, buton the condition that,beginning in 2006, they wouldbe referred to facilities set upin their own country. The process however has notstarted yet. And the team atArua is trying to support thesetting up of treatments in Aru, on the other side of theborder, without yet sendingpatients there.

•••

Caring for AIDS patients wellinvolves giving them antiretrovi-rals, making sure of theircompliance – regularly taking theprescribed medication – but alsotimely diagnosis and treatmentof any opportunistic infections.

ARUA MEETING

Doing more, without sacrificing quality Translated by Nina Friedman

The first regional field meeting dedicated to AIDS took place on 27 – 29 September inUganda. The heads of mission and coordinators for our three AIDS programs in sub-Saharan Africa met in Arua for discussions; here we present the main points of thesediscussions.



But this is still not the case and thereis resistance on the part of the NMSwhich is afraid of losing part of itsrevenue with the reduction of itsprerogatives. “We will have to makeup for the lack of medication that isessential to treat opportunistic infec-tions,” thinks William.Furthermore, the ARV programmesdo not include an evaluation or aprecise follow-up of the resultsobtained. There are said to be 80.000patients on ARVs in the country, but itis impossible to know the exactnumber of patients who have died orlost to follow up. Very few treatmentcentres study the levels of viral loador the resistances developed by theirpatients. The initiatives in this areaare manifold and sometimes concur-rent. The WHO and the programme

financed by PEPFAR (The QualityAssurance Project) are working ontwo different systems of data collec-tion.

In Uganda, and perhaps even more soin the North and the rural areas, thequality of care for HIV-positivepatients must improve quickly beforethey die of opportunistic infectionswhich could be treated. Before incom-plete or intermittent ARV treatmentsaccelerate the appearance of resis-tances, making it necessary toprescribe second-line treatmentswhich are more complex and moreexpensive. In the West Nile region, inaddition to prompt donations ofmedication to prevent stockshortages, the Arua team is thussupporting the facilities of the

Ministry of Health who are puttingpatients on ARVs. “I shall go regularlyto 4 centres to share with the carestaff my experience of the care ofAIDS patients," explains Julien, adoctor. The support will also apply tothe organization of the counselling forcompliance and the administration ofthe pharmacy. A few months fromnow, the impact of this aid will beevaluated for the possible redirectionof our support to other facilities. “Theobjective is that the quality of HIV carebecomes good enough to transfer thepatients being followed up in the MSFclinic to hospitals or health centresnearer where they live," concludesWilliam. ■

Rémi Vallet

•••

> Participants present

at the meeting in Arua

Present at the meeting wereRenaud Leray, WilliamHennequin and JohnnyByarugaba, head of mission,field coordinator and assistantmedical coordinator, respectively, in Uganda;Christine Genevier, head of mission, Isabelle Gerneron,field coordinator in Mathare,and Bintari Dwihardiani,medical coordinator, repre-senting Kenya; Chantal Saint-Arnaud, head of mission, and Sylvie Goossens, medicalcoordinator, from Malawi, as well as Annick Hamel,wearing her two hats from the Operations departmentand the Essential MedicinesCampaign; the Epicentre teamin Kampala, represented by Laurence Ahoua, epidemiologist, and WilliamWatembo, regional managerfor AIDS projects.

At first glance, things seem to be off toa good start. The number of patients onantiretrovirals (ARVs) continues to growa bit faster, and the dropout ratesobserved in 2004 no longer apply. InMSF projects, the number of patientsunder treatment—and still alive—hasmarkedly increased: 2,704 patients inArua, Uganda; 5,293 in Malawi’sChiradzulu district; and 4,886 in ourtwo projects in Homa Bay and Mathare,Kenya. And the virologic results arecomparable to those obtained in thedeveloped world (see sidebar, page 2).

The discussions at the Arua meetingshowed, however, that we can’t claimvictory yet. Presentation of the manyadvances quickly gave way to concernsand questions. Questions about ourown work, first of all: how do weimprove patient follow-up and qualityof care, and how do we get theresources needed to treat morepatients? Next came questions about

the quality of care in national healthcare systems.

Our projects’ goal is to continueimproving treatment for our patients,to keep them alive as long as possible.But also, if conditions are right, tomaximize the number of patientsbeing treated. There is much to bedone.

> A DIFFERENT COMBINATION DRUGTHAN TRIOMUNE?

The first-line ARV for the vast majorityof our patients is Triomune, a genericdrug that combines d4T, 3TC andnevirapine in a single tablet. We aren’tquestioning this choice—overall, theresults are satisfactory. The tablet,taken twice daily, makes it easier tofollow the treatment. In some patients, however, d4T causesloss of sensation in the limbs (periphe-

ral neuropathies). And resistance totreatment can develop after severalyears, requiring a switch to second-line therapy. For now, only about ahundred patients in our four sub-Saharan Africa projects are on second-

line treatment. This number could goup, though. More than ever, we need amore effective first-line drug—one thatis less toxic, and delays resistance foras long as possible. To improve thequality of the ARVs we prescribe, AIDSprogram coordinators expect theMedical department, with help fromthe Essential Medicines campaign, tobe on the lookout for new drugs, so

Our projects’ goal is to continueimproving treatment for ourpatients, to keep them alive aslong as possible.

that our patients can benefit from themost effective treatments.

> STEP UP TB DETECTION

Better management of opportunisticinfections remains a priority for us.Operational research projects onKaposi’s sarcoma and cryptococcosisare now underway. On the other hand,our programs for TB—the mostcommon opportunistic infection—arefarther along, though much remains tobe done, particularly on managementof multidrug-resistant tuberculosis.

The three AIDS programs haveintegrated care so that patients withHIV/TB coinfection can use a “singlecounter.” Instead of going to the TBclinic, and then going to the HIV clinic,patients receive treatment and follow-up for both diseases in a single facility.

This new approach may seem simple,but it’s running into resistance. InKenya, for example, it took two yearsfor the team to persuade all of theactors—that’s how firmly entrenchedhabits were. Yet the impact on patientscan be dramatic; separate treatmentsometimes leads to serious confusion,even a total lack of understanding,about the drugs to be taken for onedisease or the other.

This integrated approach is nowshowing convincing results. The Arua

team’s efforts to step up TB detection(routine screening of our patientcohort, better quality lab tests) hasquickly paid off. “The number ofpatients in whom coinfection wasdiagnosed went from 256 in 2005 to 712for the first 9 months of 2006,” notesWilliam Hennequin, field coordinator inArua.

And TB diagnosis in AIDS patientscontinues to be a problem. Microscopicexamination of sputum doesn’t alwaysdiagnose the disease in AIDS patients.Caregivers must have a faster, simplerdiagnostic tool. A study was done in

Mathare, in 2006, to find a moreeffective technique. One method—FASTPlaque—was evaluated, but as itstands doesn‘t seem to be an attractiveoption. A new study to look at bleachplus auramine is planned.

And the results from Homa Bayhighlight the importance of detecting

AIDS in TB patients. “The nationalprogram in the district, which gets a lotof MSF support, puts an average of 218patients on TB treatment each quarter.Of these, 72% agree to the HIVscreening test, and 90% turn out to bepositive,” explains Bintari, the medical


> Monitor patients

closely to assess

the quality of care

Monitoring & Evaluation—M&E to insiders—is of majorconcern to everyone. Detailedfollow up of patient outcome(prescribed treatment, sideeffects, opportunistic infec-tions, etc.) is the only way toevaluate program quality. MSFuses cards, which are quick tofill out and easy to enter in theFUCHIA software. With theprocess of decentralization,this system—very thorough,but cumbersome to managewith increasing numbers ofpatients to follow—cannot bemaintained. Should we createa light version of FUCHIA, orthink about a new tool…or relyon the monitoring systemsused by the nationalprograms? Ultimately, this lastoption seems inevitable—which is why we have toadvocate for high qualitymonitoring systems in thecountries where we work.

> Kenya © Andrew Njoroge - January 2003

•••

MULTI-DRUG RESISTANT TUBERCULOSIS:THE NEXT BIG THREAT

Two confirmed cases in Arua, three in Homa Bay (two of whom died beforethe results came back), six in Mathare. The appearance of patients coinfec-ted with the AIDS virus and the multi-drug resistant form of TB is worryingteams in the field. “It’s the next big threat,” says Annick. “MSF can’t fight italone, we have to push for a stronger international response.” In themeantime we have to try to treat our patients.In Mathare, a Nairobi shantytown, MSF is trying to set up an outpatienttreatment system, asking patients to come to our HIV clinic twice a day. Inthis precarious social context, the most vulnerable are offered shelter, on acase-by-case basis, for the duration of their treatment. “It’s a gamble,because we’re not sure how effective such an approach will be,” Christineexplains. “But we really don't have a choice, because there are notreatment programs for multi-drug resistant tuberculosis in Kenya. Thegovernment has a waiting list of 50 patients. It has the funding, but settingup a dedicated inpatient unit in the national reference hospital will take ayear or two, at least.”



coordinator in Kenya. “At the moment,we’re only managing to test fivepatients a month in the Arua hospital’sTB unit," regrets William.

Finally, six-month TB treatment

(instead of eight) has been in place inChiradzulu since April, and Malawiadopted it as its national protocol inJuly. In Arua, the Ministry of Health hasagreed to let us use this protocol forour patient cohort, and wants to followthe results closely, though for the timebeing it continues to use the standardDOTS (Directly Observed Treatment)protocol for its own patients. Thesituation in Kenya is more complicated,because local authorities would be onboard if we committed to providing thistreatment regimen to all TB patientstreated in the district. Negotiationshave just gotten underway.

> INTEGRATE NUTRITIONALSUPPORT

All four AIDS programs now include anutritional component for malnouris-hed patients or those at risk for malnu-trition: children, and certain extremelyvulnerable adults, such as hospitalizedpatients. Prescription of Plumpy’nut—a ready-to-use therapeutic food—isaimed at reducing the mortality rate."This is an issue that MSF has beenslow to address,” emphasizesChristine Genevier, head of mission inKenya. This effort is too recent to allowits impact to be measured, but all theprojects will be closely following theresults.

> PROMOTING ADHERENCE

Adherence—that is, strict compliancewith the prescription (the amount andtiming of medication taken), isessential to maximizing the effective-ness of ART and delaying the appea-rance of resistance. Unfortunately, forlack of a magic recipe for convincingpatients to follow their treatment to theletter, and reliable tools for measuringadherence, our practices provoke amixture of anxiety and confusion. “Pillcounts, patient interviews, and theadherence scale are biased methods;patients may be tempted to cheat outof fear of being reprimanded by thedoctor or counselor,” Christineexplains.

Encouraging results on survival ratesindicate, however, that despite its

flaws, our system functions welloverall. But this argument doesn’tsweep aside all doubt, especiallyregarding long-term adherence; whenpatients feel better, they might betempted to become more lax. “It wouldbe interesting to look at what’s beingdone in countries that started ART along time ago," suggests AnnickHamel. “We should take a look atadherence practices for other chronicdiseases, as well.” Diabetes might be aparticularly interesting example,because it too affects children, andadherence is even less well controlledin children than in adults.

> LAUNCHING DECENTRALIZATION

While improving the quality oftreatment and follow-up, increasingthe number of patients who receivetreatment is our only other weaponagainst the epidemic. This meansgetting involved in a process of decen-tralization, and coping with the lack ofqualified medical personnel.

In Malawi, for example, we would haveto accept 250 patients a month to coverneeds in the Chiradzulu district. “We

already support the district’s ten publichealth centers, with mobile teams anda training plan for these centers’nursing staff, so that eventually they’llbe able to initiate ART and follow stablepatients,” explains Sylvie Goossens,medical coordinator. A pilot project—the “village unit”—goes even further byidentifying, at village level, a personwith no medical background who iscapable of re-supplying very stablepatients with their drugs, and referringthem to a medical facility if their healthdeteriorates. “This will allow us to focuson the complicated cases, while at thesame time increasing treatmentcapacity,” she adds. But for the timebeing, the inclusion rate has topped outat between 150 and 200 patients amonth. “We should also be treatingmore children, approaching them byway of their family, get more involved inmother-to-child transmission preven-tion, and figure out why only half ofpatients diagnosed as HIV-positivecome in for treatment,” Sylvie reckons.

This project, with its goal of coveringoverall needs, truly reflects MSF’s2005-2008 AIDS objectives. In severalways, however, Chiradzulu remains aspecial case.

> Lost to follow up

In addition to the adherenceeffort, better monitoringinvolves quickly looking forpatients who don’t show up fortheir visit. Because interrup-ting ART for a few days can bedangerous, the projects inKenya, Malawi and Uganda aresetting up an early searchsystem in the days following amissed visit.

> Local organizations

and patient groups:

precious allies

To cope with the shortage ofmedical personnel, all theprojects believe it necessary to strengthen their networkingefforts with local organizationsor patient groups, for help withadherence counseling andlocating patients lost tofollowup. In Kenya, they plan tohire a social worker trained incommunity organization toidentify and train local helpers.In the Arua region of Uganda,MSF supports four patientorganizations.

> Malawi © Julie Remy - May 2006

•••


The situation in Uganda and Kenya

seems more complex. “In Homa Bay,it’s still premature to talk aboutcovering needs. With projectsfocused on the hospital and a preva-lence of over 30%, the demand fortreatment greatly exceeds thecapacity of MSF and the Ministry ofHealth combined,” points outChristine Genevier, head of mission.For the past three years, MSF hasbeen providing nursing staff follow-up of stable patients in three decen-tralized health centers. “The Kenyanauthorities are interested in thisapproach, but it's taking a long timeto turn talk into concrete decisions,"Christine continues. So delegatingresponsibility to nurses, so that theycan follow patients on ARVs, is notalways formalized by directive. “TheMinistry of Health very much needsour support, but wants to know theextent to which MSF is planning tocommit. It’s up to us to decide if wewant to get involved in new healthcenters, and if we’re ready to trainpublic health personnel.”

In Uganda (see report), decentraliza-tion has been underway in the WestNile region since the summer of 2005.

But it is still going slowly, and there aredoubts about the quality of care. Sowe’ve started by supporting fourcenters, in order to assess the impactafter three months and, if necessary,redirect our support to other centers.

In the end, to varying degrees, all thenational programs are running upagainst the same obstacles: a lack ofqualified personnel, inadequatepublic health infrastructures(especially in rural areas), problemsensuring a regular supply of ARVs anddrugs to treat opportunistic infec-tions, etc. We have advocated for agreater global response to the crisis,repeated over and over the slogan“two pills a day,” and documented theresults from our programs to provethat rapid “scaling-up” was possible.Now that the number of HIVtreatment centers is increasing, ourteams’ goal is to continue to come upwith innovative approaches, to showthat quantity and quality can go hand-in-hand. And to take up this demandfor quality in both our speaking outand in our relationships with thenational programs. ■

Rémi Vallet> Malawi © Julie Remy - May 2006

KAPOSI’S SARCOMA AND CRYPTOCOCCOSIS:TWO OPPORTUNISTIC DISEASES

Kaposi’s sarcoma is a cancer that exists in endemic form in Africa, anddevelops especially in individuals coinfected with HIV. In 2005, more than8% of patients seen in our African AIDS projects had it. It usually occurs inthe form of skin lesions, and is thus relatively easy to diagnose. To treat itwe use ARVs in combination with a single chemotherapeutic agent,bleomycin, administered by intramuscular injection once every two weeks,20 injections maximum. After this treatment, however, we have nothingelse to offer, because there is a very high risk of pulmonary fibrosis, andrelapses are common. MSF wants to test another drug, taxol, although it’scumbersome to administer (several IV injections that must be administeredin a hospital setting), and expensive (1,600 euros). The feasibility study willstart off in Ouganda and Malawi.

Cryptococcosis is a mycosis that occurs in very immunocompromisedindividuals, and often manifests as meningitis. Its prevalence amongpatients admitted to the Phnom Penh hospital, in Cambodia, is 30%. Whilediagnosis, by lumbar puncture, is relatively simple, its treatment withAmphotericin B causes significant side effects. Above all, it is very hard toimplement, because it requires a two-week hospital stay and is toxic.Doctors therefore have a tendency to rush the switch to the second, oral,phase of treatment, which is less effective. In view of this, MSF should bestarting a clinical trial in Cambodia to test a new two-drug oral protocol(high dose of fluconazole + fluocytosine).

With prevalence in the country at1.9%, the Cambodian NationalProgramme estimates that out of120,000 people with HIV, between25,000 and 30,000 urgently needARV therapy. At the end of 2006,taking all programmes together,16,000 patients have access totriple therapy. Nearly 7,000 arereceiving treatment in MédecinsSans Frontières programmes(MSF-France and MSF-Belgium).

“Cambodia is going through atransition period in the fight againstAIDS”, says Dr Jean-FrançoisCorty, deputy programme manager.“When we started our programme,we were more or less the onlypeople involved. Now there’s apolitical readiness to commit to theissue, and national policy isbecoming a reality, particularlywith large numbers of healthcentres introducing ARV therapy”.

A major problem remains: arepatients surviving after a year oftherapy? “There’s still a skills gapin all aspects of quality of care andkeeping patients alive”, Jean-François Corty adds.

Nearly a thousand NGOs areworking in Cambodia, including 200involved with AIDS, most of themconcentrating on preventiveprogrammes or support fororphans. MSF still has an importantrole in the treatment and follow upof AIDS patients and in treatingtuberculosis.

“We are thinking about graduallyhanding over part of our activitiesto the National Programme” saysJean-François Corty. The firststage is to assess the treatmentcapacity of the Cambodian organi-sations, so that stable patients canbe referred to them, and have

access to first-line therapy in goodconditions. In parallel, MSF isconcentrating on treating the moredifficult cases – children, pregnantwomen, or patients on second-linetherapy (around a hundred people)– and on monitoring hospitalisedpatients, particularly those who arecoinfected with HIV and TB, whomake up 60% of the hospitalisedpatients in our two programmes.“Especially because we’re nowseeing cases of multiresistant TB –three patients have been on MDRtherapy since July and there is afourth suspected case. No-one elseis working on multiresistant TB,which is a real time-bomb in thiscountry. Tuberculosis is not beingadequately treated, and there arean estimated 2000 cases of multi-resistant TB. So our involvement inthis area is vital.”

C.L.



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> To be continued?

The Arua meeting provided anopportunity to share an overallview of the problems, and theteams from Kenya, Malawi andUganda would like to continuethis exchange on prevention ofmother-to-child transmission,pediatric care, treatmentadherence, the role of localand patient organizations, andtraining. A second regionalmeeting may take place inJanuary, in Nairobi, withmembers of the Medicaldepartment, Operations, oroutside participants invited tocontribute to the discussions.

Press Contact:[email protected]@msf.org

For further information:

- on the activities of the Frenchsection of MSF: www.msf.fr

- on the activities of the otherMSF sections: www.msf.org

CAMBODIA, A LOW-PREVALENCE COUNTRY, WHERE WE MUSTCONCENTRATE ON THE MOST DIFFICULT CASES - TRANSLATED BY ALISON QUAYLE


PREVENTION OF MOTHER-TO-CHILD TRANSMISSION

A weak link in our programmesMSF/November 2006/Translated by Alix Hague

Reducing child mortality due to AIDS requires addressing mother-to-child transmission as well as screening andtreating infants. These two approaches are essential but little implemented in our programmes. An interview with Dr Myrto Schaefer, paediatrician at the Medical Department of MSF, and head of the project unit in MSF Sydney.

> Nine out of ten children with

HIV contracted the AIDS virus from

their mothers. What can MSF do to

combat the problem?

These children contract the AIDSvirus during pregnancy and aboveall during labour and delivery, aswell as during breastfeeding. Andalmost one out of two children whocontracts the HIV virus duringpregnancy or at birth dies before theage of two. This is what happens ifwe do not diagnose early enough inorder to provide appropriatetreatment. Treating children withHIV is therefore a challenge forMSF, but we must also try to combatmother-to-child transmission bybreaking the "transmission chain".Otherwise, we are only dealing withone side of the problem.

> What exactly can we do?

We need to do two things. First ofall, we must reduce mother-to-childtransmission. Secondly, we mustidentify HIV children early enoughalong to provide appropriatetreatment. Otherwise, we are notattacking the problem completely,and we will not be able to keep themajority of infected children fromdying.

In order to reduce mother-to-childtransmission, action must be takenduring women's pregnancies. Thiswill not be easy, as there are veryfew centres for prenatal care in thecountries where we work. Yet I thinkthat we should, first of all, offer AIDStests in the prenatal consultationcentres around where we are

presently working. In certain areas,we are already conducting mother-to-child transmission prevention forpregnant women we are treating inour AIDS program. The newchallenge will be to establish contactwith those women who do not knowif they are HIV positive or not.

Once a diagnosis has been made,appropriate care can be offered towomen, including triple-therapy,prenatal care and advice on breast-feeding. There are also women whoare not at a point in their illnessrequiring triple-therapy. In thiscase, prescribing ARVs can putthem at risk of side-effects of thesedrugs. In order to prepare for this,we can implement a strategyconsisting in reducing mother-to-child transmission during labourand delivery and providing care fornewborns from birth.

After birth, we need to provideprophylactic treatment for one weekto these babies, then monitor themfor infection. If, despite everything,these babies are infected, we mustbe able to offer treatment. In

Mathare, in Kenya, where we domother-to-child transmissionprevention, we have begun testingbabies whose mothers are HIVpositive. At present, we have foundone HIV positive baby out of 26

tested. Unfortunately, this numberis probably not representative of thewhole, but it shows that we can dosomething against transmission.

> In your opinion, does MSF do

enough to prevent mother-to-child

transmission?

We are doing something. But it's notenough. A few years ago, it was toocomplicated to set up ARVtreatment for adults. But we did itanyway. And I think that we havewhat it takes to deal with mother-to-child transmission of the virusduring pregnancy and for thetreatment of newborns. ■

Interview by

Sally McMillan and

Philippe Tanguy,

MSF-Australia


The new challenge will be toestablish contact with thosewomen who do not know if theyare HIV positive or not.

« [...] Treating children with HIVis therefore a challenge for MSF,but we must also try to combatmother-to-child transmission bybreaking the "transmissionchain ».



A COMPREHENSIBLE RESPONSE

“There is a glaring lack of long-term political vision”MSF/October 2006

Over the years the battle against AIDS has seen considerable changes. The comprehen-sive response to the epidemic seems to be stalling, despite the optimistic statements ofinternational organizations. Below is an interview with Professor Win Van Damme of theInstitute of Tropical Medicine in Antwerp, Belgium, by Dr Arnaud Jeannin, MSF DeputyProgramme Manager in charge of Malawi.

> Arnaud Jeannin : What actions are

currently being taken at internatio-

nal level against the HIV epidemic?

With regards to funding, has the

emergence of bilateral and multi-

lateral funding sources produced any

sustainable solutions?

Win Van Damme : Funding remains animportant issue. For the treatment ofpeople living with AIDS, the two mainfunding sources today are the GlobalFund to Fight AIDS, Tuberculosis andMalaria (see inset) and PEPFAR (Presi-dent's Emergency Plan for AIDSRelief), launched by George W. Bush.The Bill and Melinda Gates Foundationis becoming an important actor, too(allocating 100 million dollars to theGlobal Fund in 2006, for example), butit invests more in the search for avaccine and on microbicides. TheGlobal Fund intervenes in all countries,while PEPFAR concentrates on 15countries where the prevalence ofHIV/AIDS is very high.

The problem with PEPFAR funding,which was stated from the start, is thatits funding operations cover a limitedperiod of only five years. The USpresident is probably convinced thatthis type of action is necessary for thenational security of the United States.And US evangelical Christian organiza-tions have seized the opportunity toexert their influence with, for example,the “ABC” strategy: Abstain, Befaithful, and Correct and consistentuse of condoms, which is at the heartof PEPFAR-funded prevention actions.With regard to the Global Fund, thefunding dilemma is twofold. It funds ahigh number of countries that arelargely dependent on those funds fortheir national programs. At the sametime, Global Fund donors do notprovide sufficient funds to cover theestimated needs (5-10 billion per year).

And promises and funding arereviewed every year. The system istherefore very unstable. There is noassured continuity over the years. Theprevailing global funding strategy is avery short-term one, which isdangerous.

> A.J. : Can the situation change?

W.V.D. : The percentage of total North-South international aid (i.e. approx. 80billion dollars a year) allocated to AIDSis still low—about 5%. UNAIDS,notably, argues that this percentagemust increase radically by pointing outthe uniqueness of the battle againstAIDS. But other problems exist. Otheractors receiving international aid alsoclaim unique measures for education,water or the reconstruction of Iraq. Atthe same time for international institu-tions like the World Bank, AIDS andhealth in general do not merit a uniquestatus because they are not profitable

investments. Therefore, there is anespecially fragile balance of forcesbetween those who argue forincreased aid and those who believethat this type of aid is a bottomlesswell. The danger is that sooner or laterdonors will stop increasing their aidand could even decrease it, especiallynow when embezzlement scandals atthe Global Fund have started to appear.

> A.J. : Speaking of “investment

effectiveness,” some countries,

like Brazil, are deemed more “

profitable” because they have imple-

mented a national policy for treating

all people living with AIDS with the

idea that it’s in the economic interest

of the country - the treated people

no longer being a burden to society

because they can re-enter the

labour market. Doesn’t this model

demonstrate the effectiveness of

large-scale national treatment

policies?

W.V.D. : The Brazilian authorities werenot thinking in terms of profitability butrather of how to manage Ministry ofHealth money better. The cost/effecti-veness argument is meaninglessanyway because it is very short-termthinking. Some studies, like the onepublished in The New England Journalof Medicine dealing with 10,000 hospi-talized AIDS patients, make that clear.Calculating the cost of taking care ofthese patients for a year—not treatedwith ARVs—is simple, and so is calcu-lating how much their ARV treatmentwould cost, which is almost the sameor even less. That’s the “honeymoon”period, when it is worthwhile to treatwith ARVs. In the second year, thecalculation is different. Non-treatedpatients don’t cost anything becausethey’re dead. Treated patients costmoney. They can develop opportunisticillnesses and resistances and will costeven more then. So, of course, treatingmore and more patients is far fromprofitable. The cheapest… is thatpatients die. To find solutions, we can’tthink in economic terms.

> A.J. : Today, nearly 1.6 million

people living with AIDS are under

treatment. Looking back over the

past few years, what lessons can be

learned from implemented interna-

tional strategies, in particular the

World Health Organization’s (WHO)

> Money from the

Global Fund and

PEPFAR

• Global Fund to Fight AIDS,Tuberculosis and Malaria

Since its creation in 2002, 3.1 billion dollars have beenallocated to programsconducted in 127 countries. Inthe latest allocation decision,total funds to be allocatedwere increased to 1.039 billiondollars distributed among 52countries. Programs specifi-cally related to HIV/AIDSincreased to 469 milliondollars in 27 countries.

• PEPFAR (President's Emergency Planfor AIDS Relief)

In 2006, PEPFAR’s budgetincreased to 3.2 billion dollars, 868 million of which is dedicated to antiretroviraltreatments. 561,000 peopleare currently being treatedthrough this funding in 15 countries: South Africa,Botswana, Ivory Coast,Ethiopia, Guyana, Haiti, Kenya,Mozambique, Namibia,Nigeria, Uganda, Rwanda,Tanzania, Vietnam andZambia.

The system is therefore veryunstable. There is no assuredcontinuity over the years. Theprevailing global fundingstrategy is a very short-termone, which is dangerous.

“3 x 5” initiative (3 million patients on

ARVs by the end of 2005)?

W.V.D. : In the long term, the mostimportant variable is the number ofpatients being treated who survive.And the news is good there. Where itisn’t good is in the disease’s expansionbecause infections continue toincrease. In the future, there will be tenor twenty million people in need oftreatment. I have criticized the 3 x 5initiative from the start because it is avery short-term strategy as far isfunding is concerned. It was necessaryto find some way to start the process,but the initiative was presented as afinal objective without anticipating thefuture or providing the means to reachthat objective. And this strategy hasshown its limits.

> A.J. : In fact, isn’t it three million

people who need to start treatment

every year?

W.V.D. : Yes, or 10 million in 2010 and20 million in 2020.

> A.J. : Nothing long-term has been

considered?

W.V.D. : There aren’t any long-termstrategies or funding initiatives. InToronto [at the 16th International AIDSConference in August 2006], thediscussions mainly focused ontechnical aspects: resistancephenomena, HIV/TB co-infection…

However it seemed as if talking aboutreality were censored. There was aglaring lack of long-term politicalvision. It was a little like, well, we haveto convince the internationalcommunity to continue to contribute,but let’s avoid talking about the badnews that won’t serve our cause.

> A.J. : However, ARV delivery

models are essential in order to treat

patients on a large scale and for

coming up with more comprehensive

political solutions. Are things

progressing in this direction?

W.V.D. : Up to now it has mainly beenclinicians who have started treatmentprograms, focusing on the doctor-patient relationship. These firsttreatment programs had limited objec-

tives, such as: “to treat 1,000 patientsand then stop taking new onesbecause it would not be possible tomaintain a good doctor-patient

relationship.” Two years ago, nobodywas thinking in terms of globalcoverage (treating all those sufferingwith AIDS in a given area). The clini-cians developed responses, but theydid not consult public health experts,for example, to imagine more compre-hensive solutions. However, few publichealth actors are interested in AIDS…Even at the WHO.

> A.J. : To what extent do technical

difficulties affect the search for

comprehensive solutions?

W.V.D. : At first, the price of medica-tions was the main obstacle, but thenprices decreased. Pilot projectsshowed that it was possible to treatpatients in developing countries, andso then the issue of funding arose.Today, money is no longer a problem,although it will become one again in afew years. The main issue is rather thelack of human resources to register,treat and monitor thousands ofpatients. There the solutions are yet tobe found. But it will difficult to applycomprehensive responses becauseeach country’s problems are specific.

> A.J. : Are there any national

programs proposing innovative

solutions?

W.V.D. : Malawi and Uganda, with verydifferent environments, are goodexamples. Malawi, in its national

program, despite enormous restric-tions (lack of medical personnel and anunder-developed health system), hasset up an extremely simplified system:no laboratory, the same first-linetreatment for everyone. In a healthcentre I visited in August, they aretreating 800 patients. Consultationstake place three mornings a week. InUganda, the national program iscertainly poorly coordinated, but thereare interesting initiatives, like “expertpatients,” patients who are stable intheir treatment and who monitor otherpatients, or “field officers,” treatedpatients who distribute ARVs to homeseach month.

But, in fact, it is MSF and what it’sdoing in Thyolo and Chiradzulu inMalawi that is cutting-edge. It is basedon the experience of pilot projects, inwhich the work was done on a districtlevel and that could result in reallyinnovating responses. MSF maypropose innovations, but it may also berestricted by its own limitations. In anorganization of doctors, any methodsthat do not put doctors at the centre ofthe process may generate internalresistance. However, we must continueto consider other methods to achievereal advances. ■

Transcribed by Caroline Livio



It is MSF and what it’s doing inThyolo and Chiradzulu in Malawithat is cutting-edge. It is basedon the experience of pilotprojects, [...] that could result inreally innovating responses.

An increase in violence and fighting in 2006 led Médecins Sans Frontières to return to SriLanka to provide medical assistance to the war affected population. Since August of thisyear, approximately 200,000 people have been displaced by the fighting. Despite requestsfrom the Ministry of Health for MSF to provide assistance to several hospitals in the North,we had so far only been allowed to start activities in Point Pedro Hospital on the JaffnaPeninsula. However, MSF teams have now had to suspend their medical activities andwithdraw from the only hospital we had been permitted to work in. Explanation by Dr Guillermo Bertoletti, director of operations.

MISSIONSRI LANKA

SRI LANKA

MSF withdraws fromJaffna peninsulaAll medical activities of MSF are suspended in Sri Lanka

MSF/October 2006

> Sri Lanka © Yann de Fareins/MSF - January 1989


> Why has MSF suspended

its activities and withdrawn from

Jaffna Peninsula?

Since the 30th of September, falseallegations have been leveled in theSri Lankan media accusing MSFteams of participating in the conflict.We have been cited as a ‘threat tonational security’ and have beenaccused of actively supporting theTamil Tigers. Simultaneously wereceived a letter from the govern-ment canceling our existing visasand asking us to leave the country,followed shortly by a second officialletter saying we could stay in thecountry until ‘further notice’ statingwe are under investigation. Though we have not been officiallyaccused of anything, the false allega-tions made in the media combinedwith a lack of clear support from thegovernment as a whole, have madethe risk for our personnel unneces-sarily high. As a result, our team inPoint Pedro has ceased providingmedical assistance, and has left theJaffna Peninsula.

> Seeing as the government has

now said MSF can stay, isn’t it

an overreaction to stop medical

activities just because of some

articles in the media?

This is not a decision we have takenlightly! It was extremely hard to leavethe patients and to stop the collabo-ration with our colleagues in thehospital, knowing that the situationon the peninsula continues todeteriorate and that currently thereis heavy bombing in the area. Throu-ghout 2006 the security situation inthe country has greatly degraded,creating acute needs for the civilianpopulation as well as increasing therisk taken by humanitarian organiza-tions. The assassination of 17members of ACF was a terribleshock to us and illustrates howdangerous the situation can be forhumanitarian workers also. Within this context, like in any armedconflict, our independence andneutrality must be respected. If weare to help the civilian populationaffected by the conflict, we need thefalse allegations and inaccuratestatements made in the mediacleared up. We need a strongmessage that the government as awhole and that authorities at alllevels are ready to welcome andfacilitate the work of an internatio-

nally recognized, independent andneutral medical-humanitarianorganization. Without these assuran-ces, we cannot send our teams toprovide medical assistance to thosein need.

> Why were these accusations

leveled against MSF? Maybe this is

just an misunderstanding?

The accusations are absurd andcompletely unfounded! MSF has along record of impartial and indepen-dent action in all the major armedconflicts of the last 30 years. Wespeak out on the humanitarianissues we face, but we don’t takesides in a conflict. We worked in SriLanka during 17 years of armedconflict, and have proved that we area medical emergency organisation

responding to the needs of thepopulation. This situation is all themore puzzling taking into accountthat the hospitals we had proposed tosupport are all governmenthospitals, in government controlledareas, following requests made bythe Ministry of Health. Yet, thousandsof people living in the LTTE controlledareas are also in desperate need ofassistance.

However, there are a series of factorsthat may help to understand why thishas happened. The accusations andrestrictions on MSF, and otherhumanitarian organizations, areoccurring in a context of increasingdistrust and sometimes outrightrejection of the involvement of inter-national actors in Sri Lanka. On theone hand the general disappointmentand frustration with the reconstruc-tion efforts following the tsunami hastranslated into a profound disap-pointment and mistrust of NGOs. Onthe other hand, there is a strongopinion against the involvement offoreign organizations in the conflict.Many foreign entities, be they inter-

national organizations, states, orinternational NGOs, are all groupedtogether and perceived as being pro-LTTE (Tamil Tiger) or as profitingfrom the war. This is why it isextremely important for us to explainour action and to be publicly andofficially recognized as beingindependent, neutral and impartial.Finally, it may be that the govern-ment does not want an internationalpresence in the areas where war isbeing waged.

> Following your visit, do you think

this situation will be resolved?

What will MSF do if there is no

progress?

We have made a commitment towork in Sri Lanka, and are preparedto honour that commitment. We havegrave concerns for the populationliving in the war affected areas.Fighting is increasing. Heavybombing has displaced tens ofthousands of people who are in needof assistance. Hospitals are in needof support in order to meet thedemands. It is deplorable that weare not allowed to bring medicalassistance to the population living inareas where heavy fighting isunderway.

Following several meetings we had inColombo, the capital of Sri Lanka, Ibelieve there are members of thegovernment who are concerned bythe need for medical assistance inthe north and east, and would likeMSF to provide this assistance.However, this needs to translate intoconcrete actions. MSF surgeons,nurses and other staff have been onstandby for months in Colombo andin Europe, ready to provide care to SriLankans. Nevertheless, we cannotkeep our teams on standby indefini-tely. Today our name is not clearedup and we are not granted permitsand authorizations to carry out ourwork. This means that we remainblocked, with no security for ourteams and no humanitarian space tocarry out our activities. If this doesn’tchange soon, if the government as awhole doesn’t show that we arewelcome to work in Sri Lanka, then Iwill consider that we will be forced toleave the country. ■

Dr Guillermo Bertoletti

Transcribed by Kate de Rivero


Many foreign entities [...] areperceived as being pro-LTTE(Tamil Tiger) or as profiting fromthe war. This is why it isextremely important for us toexplain our action and to bepublicly and officially recognizedas being independent, neutraland impartial.

POINT INFO> 20 october 2006

Niger : 61 000

admissions since the

beginning of the yearThe number of admissions is not decreasing but isstable, with 2300 admissionsfor the month of September,and a total of 61,000 admis-sions since the beginning ofthe year. The great majorityare moderately malnourishedchildren. This corresponds to the number of admissionswe had excepted for thewhole year, between 75,000 and 80,000 for 2006.

> 3 November 2006

CAR : Explo mission

to BiraoOn Monday 30 October, thecity of Birao – located in thenorth-east of the CentralAfrican Republic, the regionon the border with the south-east of Chad and the west of South Darfur – fell into thehands of rebels. Birao is a cityof 15,000 people, and thereare about 50,000 people livingin the zone. A team is going to try to go to Birao. This isnot easy, as the zone isdifficult to access whether by road or air.

Around Paoua, where we’reundertaking our activities,violence erupted again at theend of the rainy season andthere have been more villagesburned down. People areleaving again to hide in thebush, and the number ofconsultations in our clinics is slightly decreasing.However, our activities within the Paoua hospitalitself remain consistent and for now, admissionshaven’t declined.


MISSIONSOUTHERN SUDAN

SOUTHERN SUDAN

“NGOs and the United Nationscannot serve as subcontractorsfor this enormous reconstructionproject" MSF/October 2006

Dr Rony Brauman, former president of Médecins Sans Frontières (MSF) in France andresearch director of MSF Foundation , recently returned from Southern Sudan. He describesthe situation nearly two years after the peace agreement was signed, and also raisesquestions about the position aid organizations have taken in the context of reconstruction.

In January 2005, after 20 years of warinterrupted occasionally by short-livedceasefires, the south Sudan rebelsand Sudanese government signed apeace agreement. It took three yearsof negotiations, sponsored and guidedby the U.S. government, to reach acompromise acceptable to bothparties. Trust is hardly to be expectedamong former warring parties, parti-cularly in a country so deeply woundedby an endless history of violence.Indeed, the human cost of the war hasyet to be determined: One millionpeople, perhaps more, have died, andthree to four million have beendisplaced, mostly around the capitalcity, Khartoum. These numbers beginto describe the disaster from whichSouthern Sudan is emerging and theproblems that await it.

However, Juba, the southern politicaland administrative capital, is not inmourning. The city is very much alive.A match has been scheduled betweentwo local soccer teams and theirrespective supporters spill out into thestreets, wearing team jerseys, blowingwhistles and waving flags. We could bein Nantes or Manchester. Shops andrestaurants have multiplied, themarkets are well-stocked andcrowded and the bus stations are

teeming. That is all as it should be.The city’s population has doubled in ayear, so merchants are pleased, buthousing has not kept pace and rentshave skyrocketed.

> HUMANITARIANAGENCIES HAVE AMASSIVE AND VISIBLEPRESENCE

The massive international presence isvisible as soon as your plane touchesdown and you set foot in Juba interna-tional airport. More than 10 huge whitetrucks bearing the logos of various U.N.agencies are parked outside. Everyoneis here: from the World Food Program(WFP) to UNICEF, the UN HighCommission for Refugees to the WorldHealth Organization (WHO), as part ofthe United Nations Mission in Sudan(UNMIS), a major deployment of 6,000Blue Helmets and 4,000 civilians. Theyhave been assigned to back up thepeace accord, and, more specifically, tosupport the integration of rebel forcesand the regular army, to help refugeesreturn home, to participate in protectingcivilians and to restore part of the roadsystem.

Dozens of NGOs and government aidagencies are here, too, based in Jubaand operating throughout the South.Hospitals, schools, roads and bridgeshave been rebuilt, thanks in part to aidgroups and, also, to oil companies(primarily Chinese) that are prospectingand drilling in the major oilfieldslocated on the border between theNorth and South. However, theseprojects constitute only a small share of

a huge undertaking, most of whichremains to be carried out.

The new government authorities mustorganize a power-sharing arrangementamong the movements that fought inthe war or that have substantial forcesat their disposal. These talks are tense,particularly when long-serving comba-tants are pushed aside latter daysupporters. The authorities are alsoworking as best they can to establish anadministration, which for the moment is

> Sudan © Kevin Phelan/MSF - April 2006

POINT INFO> 13 october 2006,

DRC – North Kivu,

opening of an emergency

project in Nyanzale Since August the number of victims of sexual violencecoming to our programme in Rutshuru has increasedconsiderably. From anaverage of 60 new cases permonth the first 7 months,we’re now up to 220 cases for August and 316 cases for September.A large proportion of thevictims are referred fromNyanzale health centre.Violence broke out in theperiphery of Nyanzale, in thenorth and south-east, duringfighting between variousarmed groups in the areaafter the first round of theelections on 30th July 2006.The population sleep in thebush and return to theirvillages during the day. 50 severely malnourishedchildren were registered. We will start by providingtreatment for rape victims inNyanzale, and will carry outfurther evaluations of thenutritional situation.

The new government authoritiesmust organize a power-sharingarrangement among themovements that fought in thewar or that have substantialforces at their disposal.

non-existent, in the ten states that formthe new South. The distribution of jobsis, naturally, the subject of difficultnegotiations.

Nonetheless, everything remains to be(re)built from scratch. This is theprogram to which NGOs have beeninvited to contribute. Some havealready gotten down to the job.Norwegian People’s Aid (NPA) flags andstickers are visible on many publicbuildings and an endless fleet ofvehicles. This large NGO has decided toserve as the Juba government’s inter-mediary for a range of functions, fromde-mining to rebuilding hospitals,supporting the press and providingprofessional training. This is a paradoxi-cal choice for a non-governmentalorganization. Where is the “non-governmental” in this role? However, itis a respectable position because it isbeing done openly.

> RECONSTRUCTIONTHROUGH THE AIDSYSTEM IS AN ILLUSION

Despite appearances, however, NGOsand the United Nations cannot serve assubcontractors for the enormousreconstruction project facing the SouthSudanese. Public goods—health,

education and other community facili-ties—cannot be cobbled together frompiecemeal contributions from aidorganizations, whether private or U.N.-based. These groups have neither themandate nor the means to become thegovernment’s human resources agencyor its operational administrators. The

government would be unable to orches-trate such a disparate collection, with itshost of constraints and diverse skills—and not only for lack of resources.Rather, the more important reason isthat it is impossible to coordinate agroup of heterogeneous institutions.These are not temporary employmentagencies. It is also impossible toexercise real authority over them.However, this illusion that the interna-tional aid system will carry out recons-truction seems to be one of the mostwidely-held beliefs in South Sudan.

It calls to mind the unrealistic state-ments issued by the same actors afterthe tsunami. One might well suggestthat the country consider recruiting themanagers it needs from today’s veryopen international labor market. Suchan approach would certainly be moreexpensive but thanks to oil income andoutside aid, government coffers are notempty—not by a long shot.

> ADAPTING OURPROGRAMS TO THIS NEWCONTEXT

Does this mean that aid organizationsare no longer necessary? Certainlynot. They provide a range of servicesand will continue to be useful insupplementing government activities.MSF has not yet determined whatform our activity will take. However, itis already clear that we must avoid thetrap of involvement in public healthsystems, despite their deficiencies.The government and the WHO wouldvery much like us to respond tochronic and acute epidemics, givenour expertise in this area. That iswhere we can provide concrete assis-tance, particularly because it wouldinvolve adapting and refocusingexisting programs. Regardless, we willhave to make major changes to ourprograms as they are no longer appro-priate to the population’s needs.

As mentioned above, the politicalcontext has, indeed, changed. Andeven though peace is the order of theday, the future remains unclear.Hatreds and resentments have notdisappeared, violent incidents arefrequent, oil income stirs up envy, andthe various armed forces throughoutthe South have not been integrated. Inshort, the political outcome of thepeace accords is unknown. Criticalmoments are already on the horizon,including the census and elections in2007 and the referendum in 2011.Violent flare-ups—and worse—couldoccur, but as of now, there is no way toknow what course events will take.This uncertainty alone is hardly areason to remain in South Sudanbecause humanitarian aid focuses ontoday, not on the future. But it doesoffer one more reason. Let’s hope thatthis one remains in the realm of thehypothetical. ■

Rony Brauman


POINT INFO> 3 november 2006,

Chad - Extensive fighting

in the east In the last week of October a rebel division made an incursion in Chad andpenetrated as far as thecentre of the country, withoutencountering opposition. But even though this armedgroup then retreated towardsthe border, it was ambushedby the Chadian NationalArmy. Extensive fighting tookplace, causing many woundedwho flocked towards GozBeida and Abéché. Some of these wounded have nowbeen referred to N’Djamenaafter they stabilised. In Adré, the situation hasbeen rather calm and in themain part, the city is empty of soldiers, who have left for the front.In Koloye, where the teamhas been preparing to closethe project, the renewal of tension has acceleratedour retreat and the team has been evacuated towardsDogdoré. In Dogdoré theteam has been reduced forsecurity reasons. Theyreceived a few woundedpatients, but were able to run activities almostnormally.In Goré, the hospitalcontinues to operate and the number of admissions is more than significant.

MSF has not yet determinedwhat form our activity will take.However, it is already clear thatwe must avoid the trap of invol-vement in public health systems,despite their deficiencies.


DEBATES

A shorter version of this article waspublished, under a different title,in Le Monde dated 3 November 2006.

DARFUR

Humanitarian aid held hostage MSF/October 2006

> Sudan, Darfur © Michael Zumstein/L'Oeil Public - August 2004

The intensification of fighting inDarfur and the general increase ininsecurity have forced MédecinsSans Frontières (MSF) to drasticallyreduce its activities over the lastthree months. Since July 2006, gangs and militiasoperating in cities and along govern-ment-held roads have stepped uptheir death threats, beatings, sexualassaults and killings, along with theransom of aid organizations. Thearmy and paramilitary forces controlroads providing access to the JebelMarra mountains, but they havebecome so dangerous that MSF andother humanitarian organizationshave had to suspend activities in themountain regions under rebelcontrol. At least 100,000 people,including a large number ofdisplaced persons, have beendeprived of assistance, while severalcholera outbreaks have beenrecorded and the number of war-

wounded has increased sharply.Other assistance missions in thegovernment-held region have had toclose. Vital services, like thetransfer, via roads, of patients whorequire emergency hospitalization,have been suspended. However,MSF can still work in the largedisplaced persons’ camps, whichtogether house close to 2 millionpeople who are almost entirelydependent on outside aid.

> XENOPHOBIEPROPAGANDA

The Sudanese government bearsgrave responsibility for the mountinginsecurity along roadways and intowns it controls. First, the serious,repeated attacks underway couldonly be carried out with the compli-city—if only passive--of the regime’simposing security structure thatcontrols Darfur. Second, Khartoum

responded to United Nations’ threatsof military intervention withxenophobic propaganda, likening allforeigners to "new crusaders"motivated by hatred of Arabs andIslam. In all likelihood, the increased

violence of the attacks againsthumanitarian workers is part of agovernment strategy to confine aidorganizations to garrison towns.That way, the government canconduct its counter-insurgencycampaign without hindrance orwitnesses and resist the threat ofinternational intervention by holdinghumanitarian workers hostage. “If

Humanitarian organisations find themselves hostages between the Sudanesegovernment and the international community. Op-ed Fabrice Weissman, CRASH.

The Sudanese government bearsgrave responsibility for themounting insecurity alongroadways and in towns itcontrols.

you move ahead with the plan tosend in blue helmets, you will thepay the price in the deaths of aidworkers.” That, in so many words, iswhat the gangs and militiasoperating with the regime's endor-sement have said.

Fighting has resumed in westernand northern Darfur, outside theareas under Khartoum’s control. Thehostilities pit supporters of theDarfur Peace Agreement against itsopponents. The government and justone rebel faction signed theagreement under strong internatio-nal pressure on May 5. In the Kormaand Tawilla regions, that faction haskilled more than 70 civilians. Up tonow, the areas currently affected byfighting are those that have beenless dependent on international aid.However, the resumption of violencecould produce many woundedpeople, as well as new populationdisplacements.

It has been nearly impossible toconduct an independent evaluationof needs because effective securityguarantees are lacking. The splinte-ring of the opposition into some 10factions, often without logisticalnetworks and operational chains ofcommand, requires aid organiza-tions to negotiate with a growingnumber of fluctuating territorial-and militarily-based groups moreinterested in pillaging aid resourcesthan in setting up aid operations.

We wish to emphasize that thecurrent situation involves resumedhostilities, not the implementationof a program intended to systemati-cally exterminate a portion of theSudanese population. From a purelylegal perspective, the atrocitiescommitted in Darfur may fall underthe 1948 Genocide Convention.However, historically speaking, theyare more akin to “pacificationcampaigns” carried out byEuropean armies during periods ofcolonial conquests than to theRwandan state apparatus’ methodi-cal destruction of part of itscitizenry in 1994. As the war insouthern Sudan illustrated,Khartoum has always managed itsoutlying areas with the brutality of acolonizer--destroying villages,burning harvests, killing men andrapid women--to punish and control

those who refuse to accept itsauthority.

In the face of this renewed, widesp-read violence, the United States,Great Britain, France, the EuropeanUnion, the African Union, the highestleadership in the United Nations andmany Western advocacy groupsbelieve that sending U.N. troops isthe best way to assist the Darfurpopulations. The war has left200,000 victims, one-quarter to one-third of whom have died in theviolence. According to U.N. SecurityCouncil Resolution 1706, approvedon August 31, the 7,000 soldierscurrently deployed by the AfricanUnion are to be replaced by 20,000blue helmets. The latter will beauthorized to use force to implementtheir mandate, defined as ensuringcompliance with the peaceagreement, protecting displacedpersons and international workersand disarming the belligerents.

> A WAR AGAINST SUDAN

Khartoum now refuses to accept thisdeployment. At this phase, Resolu-tion 1706 provides for a war againstSudan and military invasion of itswestern region. However, no nationappears ready to take that on.Assuming that the Sudanese govern-ment ultimately agrees to acceptU.N. troops, no country is willing,either, to provide the 20,000-personforce that Resolution 1706 calls for.Nearly 80,000 blue helmets arealready deployed around the worldand the U.N. is struggling to find anadditional 15,000 soldiers to streng-then UNIFIL contingents in southernLebanon.

But most importantly, nearly all therebel factions—as well as thedisplaced populations—reject thepeace agreement whose implemen-tation the U.N. troops are supposedto guarantee. With the resumption of

fighting and the opposition of manyarmed groups to the U.N.’s deploy-ment, it is difficult to imagine howthe blue helmets will carry out theirmission. As deputy U.N. secretary-general for peacekeeping Jean-Marie Guehenno emphasized onOctober 4, “When peacekeeping isconfused with enforcing peace, yourun into major problems… Anyonewho tells me that a 500,000-kmÇarea can be pacified by a foreignforce, and that law and order can berestored that way, is mistaken.”Countries are well aware of that andbalk at providing troops to a U.N.mission that they voted to support. Despite its own doubts, the interna-tional community continues tosuggest to the people of Darfur thattheir salvation will come from a U.N.military intervention—one that,today, is highly unlikely to bedeployed or to succeed. Somehumanitarian actors, like JanEgeland, U.N. deputy secretary-general for humanitarian affairs, areparticipating in this campaign.Moreover, they are embroiling aidorganizations in the “just war” campand contributing to exposing themfurther to reprisals by Khartoum andits militias.

The neutrality required to intervenein a war zone prohibits aid workersfrom making judgments about therecourse to force or from speakingout on the international pressurethat could prompt warring parties torespect the requirements of interna-tional humanitarian law. Further-more, the international community’scurrent strategy cannot stem theresumption of violence againstcivilians as long as it endangers thevital aid operations that more thanone out of three Darfur residentsdepend on. This observation is not,of course, intended to exonerate thewarring parties from their primaryresponsibilities. They alone canensure that the lives of non-comba-tants are respected and thathumanitarian agencies can provideimpartial assistance to the victims ofthe conflict. ■

Fabrice Weissman


> Sudan © Hugues Robert/MSF - August 2004

««

DEBATES


I THINK THAT AN ORGANISA-

TION LIKE OURS SHOULD BE

PRESENT IN MOGADISHU

TODAY. When the French section ofMédecins sans Frontières closed allits projects in Somalia in July 1997following the assassination of one ofits staff in the hospital in Baidoa, thecivil war in progress since the early90s was still weighing heavily on thepopulation. Everyday violence, consis-ting of rapes, kidnappings andextortion, marked the daily existenceof Somalian citizens. It gave them norespite, even between two skirmishesbetween opposing warlords trying toconquer a few square metres fromtheir adversary.

The death of a member of MSF forcedus to leave – a period of mourning wasnecessary. Since the early 80s,however, MSF had been present inSomalia almost without interruption,which put the Somalian mission at theheart of MSF’s project. Our departurecould only be permanent if the civilwar ended.

Almost ten years later an exploratorymission was sent to “regain ourfooting in the Somalian context”. Adeliberately evasive expression whichallowed the two members in chargeof the visit to propose reopening aproject in the country. As far as can beseen, working conditions have notchanged. They differ significantlyfrom those in other countries wherewe have operations and require parti-cular vigilance on the part of theteams in charge of the mission.Violence against civilians alsocontinues unabated. Emergency aidorganisations involved with the localpopulations and working on relevantprojects are rare. Only the ICRC, otherMSF sections and a few isolated NGOscan claim to be anything more than“remote, but without control”. Thegreat majority of Somalians have tofight on a daily basis to find the water

and food they need to survive. InMogadishu, the capital city torn apartby various warlords for years, thosewho are severely ill have few alterna-tives to simply dying in their houses.

The only private not-for-profithospital in the town begins registra-tions at three o’clock in the morningas there are so many requests andthe capacity to treat them is so limited

(around one hundred beds). Thepublic hospitals which in the pastwere able to accommodate over 500in-patients, are now just enormousbuildings, either entirely empty orpopulated by displaced persons(200,000 displaced persons inMogadishu, out of a total population ofone and a half million) and the privatecommercial clinics are obviouslycompletely unaffordable, except onthe one day a week when free consul-tations are offered to indigents. It’s a

gloomy picture and the future looksno better.

Since June 2006 a new political powerhas taken military control ofMogadishu and a few neighbouringprovinces: the Islamic tribunals. Dailyviolence has suddenly dropped anotch and the fighting has movedaway from the capital, but the fragilityof the new régime can be felt. Thethreat still exists that fighting inMogadishu and for the control of afew key towns will return. Once againthe populations will be caught up inthe fighting and again their strugglefor survival will be made moredifficult.

There can be no doubt that Mogadishushould be at the core of MSF’sconcerns, even if this means develo-ping a special operational frameworkas it did in the 90s, requiring everyo-ne’s commitment to the project. ■

Denis Gouzerh

1- Marie Noëlle is programme

manager (in New York), Denis in

charge of coordinator follow-up

and Guillermo is operations director

for the French section.

FOR OR AGAINST

MSF/October 2006

Denis Gouzerh returning from an exploratory mission to Somalia, accompanied by Marie-Noëlle Rodrigue1, lobbies for the French section to return to Mogadishu, 10 yearsafter withdrawing from the country. Dr Guillermo Bertoletti does not agree: the securityconditions are still uncertain and the proposed activities are little relevant.

The only private not-for-profithospital in the town beginsregistrations at three o’clock inthe morning as there are somany requests and the capacityto treat them is so limited.

> Somalia © Espen Rasmussen - May 2006for

Debate on Somalia : should MSF

Press Contact:[email protected]@msf.org

Reactions and contributions:[email protected]

For further information:

- on the activities of the Frenchsection of MSF: www.msf.fr

- on the activities of the otherMSF sections: www.msf.org

««IN THE CURRENT CIRCUMS-

TANCES, I DO NOT HAVE A

CLEAR VIEW OF THE REASONS

WHY WE SHOULD DECIDE TO

INTERVENE IN SOMALIA.

Following the return of the exploratorymission we have, however, discussedthe matter at length. The discussion wasdeliberately focused less on the proposalfor opening a project in the maternitydepartment of a hospital in Mogadishu –an idea brought up by Denis and MarieNoëlle Rodrigue and which would allowus to “regain our footing” in Somalia –than on the issues at stake and the“room for manoeuvre” that exists for anemergency aid organisation like MSF.Although the presentation clearlydescribes the way the hospitals work, ordon’t work, it doesn’t give us preciseinformation on the health situation of thepopulation – displaced or not – whichwould justify our intervention.

First of all I should stress that there arealready four MSF sections in Somalia.Even if they are not all present in thecapital, their presence is neverthelessproof of an operational willingness tobecome involved in situations of conflict.So we wouldn’t be going into virginterritory, devoid of any humanitarian aid.

But beyond these operational considera-tions, which are fully compatible with myperception of MSF, the discussionsurrounding this decision to intervenecannot avoid a certain number ofquestions concerning the risks taken bythe teams, our working environment andultimately the resources needed to fill it.

When I mention the danger for theteams, I first think of the tragic death ofone of our volunteers in 1997, which ledto our withdrawal. The recent assassina-tion of a nun working at the only privatehospital offering free care in Mogadishu– for reasons which appear to have beenrelated less to religion than to aninternal human resources problem – is

an additional factor, which, if it doesn’tconstitute an insurmountable hurdle, atleast leads me to believe that thesituation in the capital has not changed.Of course one can say that we aredifferent, especially in terms of ourindependence, but when one knows thatany intervention would have to be witharmed guards accompanying our teams,then this concept also becomes relative.

This is where the question of ourworking environment comes up, and inview of the presentation made in theoperations meeting, I do not think thatwe are capable today of clearly andreliably defining the issues at stake and

the motives for providing assistance thatwould allow us to intervene, bearing inmind the risks taken and the meansrequired to deal with them. In otherwords, the relation between the risksconnected to the presence of a team inMogadishu and the medical “needs” thatcan be satisfied by an organisation likeMSF, does not, having seen the presen-tation, allow us to decide to open aproject.

Finally, I must stress that this type ofintervention is not possible without thehuman resources capable of sustainingit. This means that we need experienced

individuals, capable of working under themore or less permanent protection ofarmed guards and of staying in thecountry long enough, despite the risks.

These resources are rare, and arealready sufficiently exposed in otherareas, in Darfur, in Congo or in Haiti.Without a magic wand to propagate

them, I can’t see myself suggesting amission of this kind to our volunteers.What for? And at what price? Those arethe questions that need to be examinedin greater detail if we’re not to fall prey toa feeling of omnipotence. Because at themoment and looking at the presentationgiven in the operations meeting, asdirector of operations I will not takeresponsibility for the return of our teamsto Mogadishu. ■

Dr Guillermo Bertoletti

Interview by Olivier Fahlun


open a programme?

> Somalia © Espen Rasmussen - May 2006

against

Médecins Sans Frontières8, rue Saint Sabin75544 Paris Cedex 11Tél: +33 (0) 1 40 21 29 29Fax : +33 (0) 1 48 06 68 68www.msf.frEditor in chief: Bénédicte JeannerodEditing: Caroline Livio, BrigitteBreuillac Photo librarian: Alix MinvielleTranslation : Caroline Serraf/TSF -Layout: Sébastien Chappoton /TC GraphiteDesign: Exces communicationPrint: Artecom.

[...] the relation between the risks[...] and the medical “needs” thatcan be satisfied by an organisa-tion like MSF, does not [...] allowus to decide to open a project.

MSF SPEAKING OUT

Violence against KosovarAlbanians, NATO’s intervention

1998-19991

MSF / September 2006

The “just published” seventh volume of the “MSF Speaking out” collection’s case study2 isdedicated to the dilemmas met and to the stances during the 1998-19999 Kosovo crisis.


6TH SURGICAL DAYMSF is organising its 6th SurgicalDay on the 9th December 2006 onits Paris premises. The topic will betraining.

Presentations and debates: • Surgeon training on mission• Getting across knowledge in

humanitarian situations or co-building ? Transculturalaspects

• Developing self-evaluation• Choosing what to teach/train ?• E-training in surgery• The point of view of the

surgeon being trained • Hand trauma resulting from

mine explosions• Training in Africa: the paradox

of vesico-vaginal fistulas• The art of surgical

companionship• The difficulties of training

programmes: the case ofEthiopia

9th December 2006, MSF, 8 rue Saint Sabin, 75011 Paris. For further information, and toconfirm attendance, please contactDr. François Boillot, MSF medicaldepartment.Email : [email protected]

DOCUMENTARY

« L’AVENTURE MSF »

(THE MSF ADVENTURE)

Following her book on MédecinsSans Frontières, Anne Vallaeys hasnow released a documentarycalled, L’aventure MSF , whichcovers the main events in the worldin the past 35 years viewed throughthe eyes of MSF. Following fieldteams, Anne Vallaeys shows howMSF “sharpens its criticial analysisthrough its activities and theconflict situations it is confrontedwith “. In two parts, the firstretraces the period between 1968and 1989 (from Biafra to the end of the cold war) and the secondcovers the 90’s (Rwanda, Kurdexodus, Somalia, war in Afghanistan and Iraq).

To be shown on France 5, 17th

December at 8.40pm.

INFOSWATCH AND READ

From March 1998, attacks on Albanianvillages by the Federal Yugoslav armyand the Serb police increased: theviolence was exacerbated by theguerrilla action of the Kosovo LiberationArmy (UCK). Several thousand peoplewere killed and tens of thousands morefled into the interior and over the border.

In autumn 1998, conscious of thedeteriorating situation, MSF, which hadbeen working in Kosovo for severalyears, decided to inform Europeanpublic opinion and to increaseawareness by publishing communiquésand refugee eyewitness accounts. Thiscampaign was widely reported in thepress.

In Spring 1999, after several months offruitless negotiations, violence andpopulation movements continuedincreasing.

On 24 March 1999, NATO began aerialbombardments of Serbia and Kosovo.The Serb forces responded by increa-sing terror, forcing hundreds ofthousands of Albanian Kosovars to fleeto neighbouring Albania, Macedoniaand Montenegro. MSF organised anumber of relief operations for theserefugees at the borders of Kosovo. Atthe same time, NATO mobilised military

assets as a means of organising andcontrolling aid.In April and May 1999, MSF on severaloccasions publicly denounced both thecontrol being exercised over the refugeecamps by NATO - which was a party tothe conflict - and the marginalisation ofthe United Nations High Commissionfor Refugees (UNHCR). MSF underlinedthe need to provide refugee protectionand warned about what was happeningto the Albanian Kosovars who were stillin the province, under the control ofSerb forces. Throughout the period ofmilitary operations, MSF managersactively refuted the notion of “humani-tarian war” promoted by NATO.

On 30 April 1999, MSF published areport entitled “Kosovo: Accounts of aDeportation.” Compiled on the basis ofrefugee accounts and an epidemiologi-cal study, this report showed that theKosovar Albanians were the victims of asystematic process of terror andexpulsion, described by MSF as “depor-tation.”

These different stances were taken inthe context of an armed conflict inwhich western countries were partici-pating directly and which they justifiedby evoking human rights and humanita-rian requirements.

This particular political environmentconsiderably reinforced the dilemmasand difficulties for MSF:

- Should it speak out to denounceviolence being committed against theKosovars, at the risk of seeing itselfexcluded by the Serb authorities fromaccess to these people?

- By denouncing and describing theviolence against Kosovars, was notMSF a party to encouraging/suppor-ting the NATO intervention?

- Should MSF take a position on theNATO intervention, or not?

- What sort of relationships (financial,cooperation, etc) should be establis-hed with countries that werecommitted either militarily (such asNATO members) or politically (Greece)in the conflict?

- By raising the alert about UNHCR’sabsence/withdrawal/lack of effective-ness in managing the refugee camps,was not MSF taking the risk of reinfor-cing this marginalisation?

- Is it justifiable, by invoking an interpre-tation of the impartiality principle thatimplies a responsibility to assistvictims on both sides of a conflict, tocarry out an exploratory mission thatsacrifices the principles of operationalindependence?

Your comments are very welcome:[email protected] ■

Laurence Binet

1- « Violences against Kosovars Albanians,

NATO’s intervention 1998 – 1999 » MSF

Speaking Out – Laurence Binet –

CRASH/MSF International, September

2006, 324 p, internal document.

2- In the same collection “MSF Speaking

out “ : “Salvadoran refugee camps in

Honduras (1988) “; Genocide of Rwandan

Tutsis (1994) ; Rwandan Refugee camps

Zaïre and Tanzania (1994-1995); “The

violence of the new Rwandan regime (1994-

1995) ; “ Hunting and Killings of Rwandan

Refugee in Zaïre-Congo ( 1996-1997) ;

“Famine and forced relocations in Ethiopia”

(1984-1986). Available in English and in

French through the documentation center,

the CRASH – distributed in the field and

headquarter – orders through the opera-

tional library strongly encouraged.

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