DispatchesM S F C A N A D A N E W S L E T T E R

Vol.8, Ed.1

IN THIS ISSUE

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1999 Nobel Peace Prize Laureate

Niger: Why a nutritional crisis?

Visiting health clinicshigh in the Andes

MSF in Sierra Leone

Earthquake in Indiaand Pakistan

Helping tsunami survivors

Denied treatment:Children withHIV/AIDS

Memorial: Patrice PagéExecutive Director,MSF Canada

(continued on page 2)

NIGERwhy a nutritional crisis?

Since the beginning of 2005, MSF has takenmajor steps to respond to the food emergency

in Niger. Our teams treated over 30,000 severelymalnourished children between January andOctober, and expect to have helped another20,000 children by the end of 2005. InSeptember 2005, 140 international volunteersand 1,400 national employees were sent to our 51stationery and mobile therapeutic feeding centres,admitting over 3,000 malnourished children everyweek. Our teams also run two paediatric units that

provide free care to children under five years of ageand distribute some 90,000 monthly food rationsto families with moderately malnourished childrenin the villages most affected by the famine.

In October 2004, the first signs appeared that thiswould be a far greater food crisis than before.Following a joint evaluation between the UnitedNations and certain governments, it wasannounced that 3.5 million people in nearly3,000 of the poorest agro-pastoral villages in

Dispatches Vol.8, Ed.1

Niger would be at risk of suffering frommajor food shortages until the harvest inOctober 2005. For the first four months in2005, three times the children than theprevious year were admitted to MSF’s ther-apeutic feeding centres. In April, a nutri-tional survey conducted by MSF revealedthat one in five children in the provinces ofMaradi and Tahoua were suffering frommalnutrition. In August, a new MSF surveyin the Zinder region showed a major declinein health and nutrition. Nearly one child inthree younger than two and a half was mal-nourished, with 5.6 per cent of them suffer-ing from severe malnutrition. In addition,the mortality rate in children under five hadjumped to 5.3 deaths per 10,000 peopleper day (the emergency threshold being twodeaths per 10,000 people per day). Almost90 per cent of families surveyed no longerhad food reserves.

This foreseeable crisis was not an inevitableoccurrence due to uncontrollable naturalfactors. Several governments and assis-tance organisations attributed the deteriora-tion of this situation to drought and a locustplague. However, these two factors com-bined are responsible for only an 11 percent decrease in annual cereal productionversus the average over the past five years.The nutritional crisis in Niger is rather aproblem of the most vulnerable people not

having access to food. Since the market istightly controlled by large companies, theprices in 2005 are 75 to 80 per cent high-er than the average for the previous fiveyears, and are far too high for poor familiesto afford. They must dip into their reservesand cannot provide adequate food until thenext harvest time. As well, they do not haveaccess to health care, since a cost recoverysystem has been set up that establishes afee for each medical procedure or medica-tion prescribed.

Determining the nature of the crisis in Nigerin order to define a humanitarian responseis completely inappropriate. Whetherfamine, an isolated situation of extrememalnutrition, chronic or critical food insecu-rity, the needs must define the operationalresponse and type of assistance programmeto be set up to ensure the survival of thesepopulations in distress.

Faced with such high levels of malnutritionand infant mortality, Médecins SansFrontières (MSF) set up assistance meas-ures based on the needs of the peopleaffected. However, MSF alone cannot meetthe needs of this food crisis. The majordecision-makers involved in food assistancein Niger (the Nigerian government, theWorld Food Program (WFP) of the UnitedNations and the partners in the Sahel and

N i g e r

page 3

MAKING SUFFERING, DESTITUTE FAMILIES

PAY OR GIVING THEM CREDIT ARE

COMPLETELY INAPPROPRIATE MEASURES

OF CONTROLLING SEVERE MALNUTRITION.

Dispatches Vol.8, Ed.1

West Africa club, including Canada, theUnited States and the European communi-ty) have deliberately chosen to set up a pol-icy making long-term development andmarket protection a priority instead ofemergency measures to control malnutri-tion among the poor in Niger. It is a politi-cal choice regarding food security for futuregenerations rather than immediate foodassistance to preserve lives. The nutritionalcrisis in Niger is unfortunately primarilybecause of human reasons.

On July 28, 2005, at the height of the foodcrisis, a document prepared by the UnitedStates Agency for InternationalDevelopment clearly reiterated: “Recentmedia coverage and NGO reports haveclaimed famine conditions…. The heavyand sensational media attention, and thepossibility that more resources will be madeavailable to treat the problem… may actu-ally impede the market.”

Since the onset of the crisis, MSF hasasked donor agencies, the United Nationsand the Nigerian government to set uppragmatic emergency measures to meet theneeds. That is, general distribution of freefood in the high-risk areas and free accessto health care for children affected.

However, between November 2004 andJune 2005, the response to the crisis in

Niger involved setting up a moderatelypriced cereal sales system for 3.4 millionpeople. The quantity of subsidized cerealsis far from sufficient (12 kilograms per per-son for nine months when they should have20 kilograms a month). The poorest fami-lies affected by the nutritional crisis in thesix regions are unable to pay for food, evenif it is subsidized. In June, the nutritionalsituation continues to deteriorate and theNigerian government decided to create anew credit programme through which fami-lies must pay back the quantity of “bor-rowed” food. Making suffering, destitutefamilies pay or giving them credit are com-pletely inappropriate measures of control-ling severe malnutrition.

It was only in August, following majormedia coverage, that WFP decided to dis-tribute free food. Unfortunately, these dis-tributions favoured areas in which the pre-vious years’ harvests had been the lowestinstead of the regions directly affected bymalnutrition. Again here the assistancemeasure did not benefit the most vulnera-ble and did nothing to control the ravagesof malnutrition. In order not to overly desta-bilize the markets, WFP announced in itslast emergency report that, after only twomonthly distributions, the free rations pro-gramme would end at the beginning ofOctober. Moreover, it is important to speci-fy that the Department of Health of Niger

has never, in spite of its promises, set upeven temporarily free health care for thechildren in the most affected regions.

The people suffering from malnutrition inNiger were not victims of drought or aplague of locusts, but rather the refusal ofdecision-makers to change their focus fromlong-term market-based assistance to emer-gency measures for the more affectedregions. Faced with this crisis, the govern-ments, United Nations and humanitarianorganisations must give priority to the needsand not to market principles. Political arbi-tration between preserving human life in theshort term and development imperatives inthe long term is unacceptable.

Patrice PagéExecutive director, MSF Canada

With deep sadness we must informyou that Patrice Pagé, our executivedirector, passed away in Toronto onDec. 12, 2005. We are shocked anddevastated by this news. We grievethe loss of this bright young man whowas such a passionate and committedhumanitarian. We share this loss withPatrice's family and his girlfriend.

Please see page 14 for more aboutPatrice and his contribution to MSF.

page 5

This was the message from the medicalnutrition expert, distributed by email to

the Médecins Sans Frontières (MSF) inter-national network on Aug. 4, 2005. On Aug.8 I was on a plane heading for Niger in sub-Saharan Africa as a volunteer doctor.

MSF had been operating feeding centres inMaradi, situated at the extreme west ofNiger, since 2001. In response to the nutri-tional crisis that erupted in 2005, wedecided to set up a therapeutic centre fur-ther east, in Zinder. These centres, knownby the French acronym CRENI (IntensiveNutritional Rehabilitation Centre), arestaffed by doctors and nurses to providemedical treatment to the severely malnour-ished children who need hospitalization.

The task allocated to me was the initialexamination of children at the CRENI.Some were brought by their mothers, intrucks that came from the villages. Manyarrived in vanloads operated by other non-governmental organisations (NGOs) in thearea with whom we had established anexcellent and coordinated working relation-ship locally. When they brought a sick childwe took her. When the child was better theytook the child and mother home, often along and hard day’s drive.

The therapeutic centre has strict admissioncriteria. Those needing immediate medicalcare were documented by name and admis-sion number and taken to the intensive careunit (ICU) – about 20 per cent of newcases. All were hypo something – low tem-perature, low electrolytes, low glucose – Ihad even rushed some across to the ICU inmy own arms and administered glucose asa life-saving measure. The less severely ill

were weighed, dangling from a scale, theirlength measured. The weight to length ratiois compared against a known standard andhad to be more than 30 per cent below thenorm to justify admission to the CRENI;required upper-arm circumference was lessthan 110 mms, not twice the circumfer-ence of my little finger! Almost all childrenmet the criteria.

Few of these malnourished children haveever seen a doctor. Infections flourish in theimpoverished underfed child. Eyes werefilled with pus; thrush, a fungal infection ofthe mouth, was common, as was scabiesand even pneumonia. All children had suf-fered from diarrhoea, most of them alsofrom vomiting – the only variation was forhow long. Half the children tested positivefor malaria, an illness that can provokesevere anaemia and is the largest killer ofchildren in Africa, accounting for 20 percent of all deaths under the age of five.Treatment for these conditions, includingmedication for malaria and vaccinationagainst measles, was initiated at admission.

Food alone cannot treat advanced malnutri-tion. A medically supervised programme isrequired to restore a normal balance of elec-trolytes and correction of potassium loss,followed by diluted milk, and then fullstrength reinforced milk, then packets ofpeanut-based Plumpy’nut® therapeuticfood. Children are discharged from theCRENI when health is improved and are fol-lowed as outpatients in the ambulatory ther-apeutic feeding centres, or CRENA, withfood provided for all family members. Theseambulatory centres operate near the villagesand are visited weekly by medical teams.Severely malnourished children who do not

suffer from associated pathology and canfeed themselves are directly admitted tothese CRENAS. This ambulatory system ofcare allows MSF to drastically increase thenumber of severely malnourished childrenadmitted to the programme. The CRENASalso help to ensure proper follow-up andprovide easier access to medical care formothers, through the elimination of traveltime and hospital stays far away from home.

As the medical work proceeded, logisticiansarranged food distribution points, latrines,clean water and washing areas. By the thirdweek of September, MSF had in Zinderestablished two CRENIs, 16 CRENAs,admitted 7,506 severely malnourishedchildren and continued to provide care for5,042 children. The death rate had notbeen reduced to zero but deaths becameuncommon. With my 40 years of experi-ence, I believe there is no other organisa-tion that could have achieved this result insuch a short period of time.

By the end of September, MSF’s Nigerprogrammes in Maradi, Tahoua, Zinder,Diffa and Tillaberi had treated 40,000severely malnourished children and dis-tributed 8,000 tonnes of free food tomoderately malnourished children andtheir families.

Michael HallMedical doctor, Zinder, Niger

Michael Hall is a surgeon fromGuelph, Ontario. He spent sixweeks volunteering in Zinder, Nigerwith MSF in 2005.

Treating malnutrition

IN NIGER “Yesterday we admitted another 120 severelymalnourished children, last night seven of them died. I need doctors and nurses now – not in a week – now!”

L e t t e r f r o m t h e f i e l d

Dispatches Vol.8, Ed.1

D riving for hours on single-track dirtroads through the Andean mountains is

an experience one does not soon forget. Ihad recently arrived in southern Bolivia todocument MSF’s prevention and treatmentactivities for Chagas disease. Bereft of a CDplayer, with only the two-way radio squawk-ing, the sound of the wind blowing by the windows and dirt crumbling under wheel,

it was a good time to practice mySpanish. Josef, the driver, asked me whatI thought of his homeland, while expertlynavigating deadly hairpin turns markedevery 50 metres with dusty shrines to fall-en loved-ones. I replied simply: "It is socompletely different than where I comefrom." He smiled and we continued ourjourney, where I felt like the lucky onewho gets to see exactly what MédecinsSans Frontières (MSF) does and why.

Treating medical needs in remote loca-tions like this proves to the naysayers thatit can be done. Whether it is the little-known Chagas in rural Latin America, orHIV/AIDS in resource-poor areas of Africa,such projects show it is possible to pro-vide health care to marginalised commu-nities who previously had little or noaccess to health care.

Chagas disease affects the poorest in LatinAmerica because it is a parasite transmit-ted via the bites of insects that infest therural homes of agricultural families.Following harvest season, when naturalhabitats are cleared or burned, insects ofthe Triatominae family (known as chinchesin Guatemala and vinchucas in Bolivia) hopon the backs of domestic animals and moveinto rural homes constructed of naturalmaterials such as banana leaves, treebranches, grass and mud. At night, theinsects emerge from burrows in thatchroofs, cracks in adobe walls, and animalbeds, and feed on blood meals provided bysleeping family members. The bug’s faeces,left behind at the itchy wounds, are thenscratched into the bloodstream. Infectedwith the parasite Trypanosoma cruzi thatcauses Chagas disease, the human hostsoften remain asymptomatic for decades.

Chagasdisease in Bolivia Visiting health clinics high in the Andes

CHAGAS IS A SLOW-MOVING

BULLET THAT ATTACKS THE

HEART AND DIGESTIVE TRACT

OVER THE COURSE OF 10, 20

OR 30 YEARS.

C h a g a s d i s e a s e

page 7

This is the insidious nature of Chagas dis-ease – it is a slow-moving bullet thatattacks the heart and digestive tract overthe course of 10, 20 or 30 years. Withoutdetection and treatment, Chagas shortenslife expectancy by an average of nine years.Its victims usually succumb to unexplainedand early heart failure.

Marginalised indigenous populations, suchas the Guarani of southern Bolivia and theCh’ortí of southeastern Guatemala, face dif-ficulty accessing health care servicesoffered by the few state-run facilities that doexist in rural areas. Linguistic differences,urban-rural dichotomies, and disagreementsbetween traditionalist and modernist beliefsystems result in integration problems forindigenous populations – those most affect-ed by Chagas disease – in an already under-developed health care system.

To combat these challenges, MSF providesmobile health clinics. Driving for severalhours into the rural Andean communitiesdemonstrates that it is possible to bringhealth care to remote populations; theprevalence of Chagas, evidenced throughthe toma de muestra (blood screenings) inthese communities, demonstrates thepressing and underreported need for pre-vention, education, treatment and follow-up. Using a rapid test kit, initial blood

screenings can be done on-site in ruralareas without costly diagnostic technolo-gies and distant medical laboratories.

Blood lancets, capillary tubes, rapid testblotters, and chromatography drops givesimple positive or negative results in 15minutes. Patients with positive screeningsin the rapid test are then asked to providefull blood samples for detailed laboratorydiagnostics.

Treatment is individualised according to ageand weight, a dosing schedule is demon-strated and outlined graphically on a chart(without reliance on literacy levels), files arecreated, and follow-up visits are scheduledto check for treatment side effects and dos-ing adherence. Sadly, there is no vaccina-tion for Chagas and one of the two medi-cines that can be used for treatment,Benznidazole, frequently produces toxicside effects and is generally ineffective ifthe disease – through lack of diagnosis andearly treatment – reaches its chronic phase.The other drug, Nifurtimox, costs $48 USfor a course of treatment – the equivalent ofa Bolivian miner’s monthly salary.

MSF participates in education and preven-tion activities, using radio programmes andpuppet shows that present information onwhat to do when people find the offending

insects in their homes, and explain theimportance of testing, treatment and follow-up. Capacity-building workshops are alsoconducted for local health care workers.

While these strategies are well adapted tolocal communities and address the press-ing issues surrounding a pervasive diseaseat a micro-level, Chagas, presenting a riskof infection to 100 million people, is large-ly neglected by national governments,international bodies and pharmaceuticalcompanies. The Drugs for NeglectedDiseases initiative, a not-for-profit drugdevelopment organisation co-founded byMSF, currently has two Chagas drug proj-ects in pre-clinical development, but thisis not enough. Large-scale participation inrural home reconstructions, vector controlstrategies, pharmaceutical research anddevelopment and public health protocolsare urgently needed to address a devastat-ing disease that now affects more than halfof Bolivia’s inhabitants and more than 18million people worldwide.

Kenneth TongManager, Web development, MSF Canada

Read more about Chagas disease andthe Drugs for Neglected DiseasesInitiative at www.dndi.org

Dispatches Vol.8, Ed.1

SIERRA LEONEImagine having to live for more than 10

years a life filled with daily fears andsuffering brought on by a civil war. Thenimagine a post-conflict situation thatpresents little hope or improvementtowards the fulfillment of basic humanneeds. This is the harsh reality for thepeople living in Sierra Leone.

West Africa remains a politically unstableregion with many humanitarian needs.Sierra Leone is presently considered stableby the United Nations and key govern-ments; however, the country remains fragileas it continues to experience lack of accessto health care, lack of infrastructures, lackof education and slow economic growth.

Sierra Leone ranks number 176th in theHuman Development Index, making itsecond-last in the world next to Niger.Its health indicators are alarming,including an average life expectancy ofonly 40.8 years.

Health care in Sierra Leone is frequent-ly scarce and discriminatory; fees areapplied for the services rendered andit’s a matter of “wealth means health.”Given the fact that many are unem-ployed and 68 per cent of the popula-tion is living under the poverty line, it isnot difficult to understand why individ-uals lack the capacity to pay for theservices they require.

Sierra Leone has also provided refuge fortens of thousands of Liberians who fledacross the border while their own countrywas ravaged by civil war. Even though thepeace process has begun in Liberia, theserefugees continue to live in the relativesafety of camps in Sierra Leone ratherthan return to harsh, uncertain living con-ditions and an unsafe environment intheir home country. The Médecins SansFrontières (MSF) clinics help to alleviatesuffering by providing quality and properhealth care to these refugees as well as tothe surrounding host communities.

Kati, Katuma and Doris (nameschanged) are pregnant women living in

PROVIDING QUALITY CARE AND A CHANCE AT SURVIVAL

S i e r r a L e o n e

Largo, one of the refugee camps. Theirday begins by waking up before sunrise,and after having completed all domesticchores – fetching water, collecting fire-wood and preparing food – they attendthe MSF clinics for consultation, prena-tal visits and follow-up. Mother andchild health care is an important part ofMSF’s programme in Sierra Leone, acountry where two women out of every100 die from pregnancy-related causes,and nearly 17 babies out of every 100born never reach their first birthday.(The Canadian rates are 6 per 100,000and 5 per 1,000, respectively.)

MSF has provided free quality healthservices in the country for well over adecade. Services were maintained dur-ing the war and still continue.Throughout the country MSF has pro-vided primary and secondary healthcare, immunization programmes, thera-peutic feeding centres, mental healthservices, water and sanitation, as wellas maternal and child health care. MSFservices are integrated with a referralsystem and follow-up.

One beneficiary whose life hasimproved from the quality care is Mr.Mohammed, a 22-year-old man aban-doned by his family and stigmatized bythe community because of the disfig-urement he has endured from leprosy.MSF provided Mr. Mohammed withdaily visits from qualified staff that per-formed daily dressing changes and pro-vided him with food and medicinebefore finding an appropriate medicalcentre in Freetown that could continuehis care. Here he is accepted and hisdaily feedings and dressing changes arefinancially supported by MSF. Theseactions ensure he gets the basic carehe needs and also help to improve theyoung man’s dignity and quality of life.

Malaria is a huge and year-round prob-lem in Sierra Leone and is one of themain causes of death for both childrenand adults. But here, as in many otherAfrican countries, classic anti-malarialtreatments prove largely ineffective. AnMSF survey conducted in 2002 provedthat Artemisinin-based combinationtherapies (ACT) were the optimal treat-

ments for malaria in this region. Inresponse to advocacy and lobbying, theSierra Leonean Ministry of Health hasfinally included these new treatmentsin the national malaria protocol. By theend of 2006, ACT should be availablethroughout the country.

In 2004, MSF also had to respond to anoutbreak of cholera, which is endemicin this region. Over 700 patientsreceived treatment comprising hydra-tion, medications and health services inthe area of Freetown.

Even though the war has been officiallyclaimed to be over, concerns remainabout the future of Sierra Leone. In thepost-emergency period we have wit-nessed a continuing need for supportand rehabilitation. MSF has been in thecountry providing quality, reliable, freehealth care in the hope to give a popu-lation a better chance for survival.

Johana Amar, R.N.Head of mission, Sierra Leone

page 9

Dispatches Vol.8, Ed.1

Excerpt from Dr. Jean-François Corty’saccount of an exploratory mission toMansehra, Pakistan immediately follow-ing the earthquake that struck Kashmiron Oct. 8, 2005. While Médecins SansFrontières (MSF) did not collect ear-marked donations for its earthquake reliefmissions in India and Pakistan, a swiftresponse was enacted using resourcesfrom the MSF Emergency Fund. This fundprovides MSF with the flexibility torespond to crises quickly, without theadditional costs and time required tolaunch a specific fundraising appeal.Donations to our Emergency Fund providevaluable support for our work.

Every minute helicopters drop off moreinjured people with terrible, infected

wounds. The operations and surgical pro-cedures are endless. All around,amputees and people in plaster wadethrough mud. It’s a total emergency, witheverything happening at breakneckspeed. It reminds me of a war zone.

Many people suffered fractures whentheir traditional Pakistani stone dwellingscrumbled in the quake. Seven days afterthe quake we’re seeing complicationssuch as wounds and infected fractures,gangrene, and tetanus. When the quakestruck at 8 a.m., many men were workingoutside. Consequently, I’ve seen mainlywomen and children injured following thecollapse of houses and schools.

In a medical emergency of this scalethere is no time to carry out micro-sur-gery: there are many amputations. We’replanning to set up medical “camp” inMansehra for 500 to 1,000 patients,plus their families, a potential total of5,000 people requiring ambulatory fol-low-up, medical care, shelter, water,latrines and food. We’ll also need aresuscitation ward and the necessarymaterials to handle tetanus.

There are people suffering from crushsyndrome: kidney insufficiencies causedby muscles being compressed for longperiods of time under the rubble. Cases ofpsychological trauma will require treat-ment as will people suffering from chron-ic illnesses such as diabetes. Provisionsare needed to treat those who fall sickwhen the hospital system is overloaded.

The earthquake will not itself cause epi-demics, but the grouping of the quake’svictims in precarious conditions meanswe have to be vigilant. Winter is comingand we can expect to treat hypothermiaand respiratory infections. Traditionally,mountain populations spend the summerat altitude before going down to the townsto spend winter with their families.Without food and basic needs, the major-ity will probably decide to leave as thecold arrives, but there is no guaranteetheir families will be able to accommo-date them or that they will even be there.

Within one week of the earthquake,MSF operations in India and Pakistan had:

• Mobilised 80 international aidworkers to provide medicalassistance, mental health counselling and relief operations.

• Airlifted 100 tonnes of medical(surgical kits, wound dressings) andrelief (tents, blankets, water tanks,food) supplies to the Pakistani capital of Islamabad.

• Distributed 10,000 blankets, 5,000 metres of plastic sheeting for shelters, 80 tents, 10,000 sets of clothes, 7,000 bottles ofwater, 2 tonnes of food and 1 tonne of medical supplies inKashmiri India.

Focusing its response in the most affected areas, MSF operationswere most extensive in KashmiriPakistan. By Oct. 31, MSF had:

• Mobilised 150 international and 100 national staff.

• Provided health care andpsychosocial counselling to hundreds of survivors.

• Flown in four dialysis machines totreat crush syndrome.

• Supplied 620 tonnes of relief goods.

earthquakeINDIA AND PAKISTANSCENES REMINISCENT OF A WAR ZONE

I n d i a a n d P a k i s t a n

WE TALKED ABOUT WHY CHILDREN

RAN HOME FROM SCHOOL WHEN

THE WIND PICKED UP AND WHY,

SEVERAL MONTHS LATER, PEOPLE

STILL RAN FOR HIGHER GROUND

ON CERTAIN DAYS WHEN THE TIDE

SEEMED HIGHER THAN USUAL.

page 11

Awoman tries desperately to hang on toher three kids while the water swirls

around them. After long minutes of hang-ing on amidst the chaos, she loses her gripand one child is washed away and neverfound. A blind man finds himself alone,swept away by the wave. A young girl findshim and they hold on together for severalhours. I don’t know what happened to thegirl. I do know that the man found out,upon discharge from the hospital, thatseven of his closest family members haddied. As a social worker, these are the sto-ries I heard every day during my six-monthmission with Médecins Sans Frontières(MSF) in Meulaboh, Indonesia followingthe tsunami that hit so powerfully on Dec. 26, 2004.

The intense feeling of loss I felt when con-fronted with the devastation and lossesthe people of Aceh had survived led to asense of puzzlement and amazementwhen I understood that very few organisa-tions were providing mental health coun-selling. There was also a significant gap inmental health knowledge and training

within the local health infrastructure.Therefore, it was an interesting challengefor MSF to provide basic mental healthtraining to nurses and staff in local healthcentres when so many of them were deal-ing with their own losses and fears.

There was a real need to help the localpeople to better deal with their feelingsand anxieties and we addressed thisthrough individual counselling, grouptherapy and community-based discussiongroups. We talked about why children ranhome from school when the wind pickedup and why, several months later, peoplestill ran for higher ground on certain dayswhen the tide seemed higher than usual.

Rebuilding homes, rehabilitating farmers’fields and constructing new fishing boatsis very important; however, it is alsoimportant to restore people’s capacity tobelieve that their environment is safe forthem and their children – allowing them tofall asleep each night without thinkingthat, when all is quiet in the camps theylive in, another wave is on its way.

At times I felt our work was such a tinypiece of what needed to be done, giventhe number of people that had beenaffected by the tsunami, the limits wehad in providing support and the feworganisations that were involved in men-tal health activities. However, I do knowthat for those people whom we were ableto reach, it did make a difference, evenif it was only to tell their story to some-one objective who had not been throughthe same horrifying experience as theyhad. My hope is that mental healthissues will be much more in the forefrontfor humanitarian organisations workingin crisis zones, where people’s lives havechanged forever.

Michelle ChouinardSocial worker, Meulaboh, Indonesia

Go to www.msf.ca to read a full, one-year report on the work of MSF inSoutheast Asia since the tsunami.

OFFERING SUPPORT TO TSUNAMI SURVIVORSMental health care in Aceh, Indonesia

I n d o n e s i a

Dispatches Vol.8, Ed.1

HIV/THE SILENT VICTIMS OF

H I V / A I D S t r e a t m e n t

In rich countries, paediatric HIV/AIDS islargely under control: prevention of

mother-to-child transmission is success-ful, and infants and children have accessto effective diagnosis and treatment. But88 per cent of the 2.2 million children liv-ing with HIV/AIDS are in Africa, and mostare beyond the reach of these health serv-ices. They are condemned to die becausethey have no access to treatment.

HIGH RATES OF MOTHER-TO-CHILD TRANSMISSION

More than nine times out of 10, childrenacquire the HIV virus through mother-to-child transmission during pregnancy,childbirth, or breastfeeding. This “verticaltransmission” is easily preventable in richcountries – by giving highly active anti-retroviral therapy (HAART) to HIV-positivemothers during pregnancy and to infantswithin a few hours of birth; by carryingout elective caesareans; and by providingsafe alternatives to breast milk. Wealthycountries have been very successful inreducing mother-to-child transmissionwith these strategies.

Poorer countries are unable to replicatethis success because the majority ofmothers do not have access to diagnosticsto establish their HIV status and so neverinitiate treatment. Nor do they haveaccess to antiretroviral therapy for them-

selves or their children. Elective caesare-ans are rarely performed in developingcountries. And even assuming that moth-ers know the risks, something basic likean alternative to breast milk can beunavailable, or dangerous because thewater is unsafe in more remote locations.

These disparities between North andSouth explain the gap in paediatricHIV/AIDS today: of the 640,000 childrenin the world newly infected during 2004,560,000 live in Africa, and only 100 ineither Europe or North America. Withinfections in the developing world risingrapidly, the gap can only widen.

NO DIAGNOSIS, NO TREATMENT

HIV antibodies, part of the body’simmune response, appear in the bloodwithin a few weeks following infection.Accurate diagnosis of HIV infectionthrough an antibody test is necessary soantiretroviral therapy can be started asquickly as possible. It usually cannot beestablished on clinical symptoms alone,as these have often not manifested orare confused with other typical child-hood illnesses.

But detection of antibodies is ineffec-tive for newborns, because all babiesborn to women with HIV acquire theirmother’s antibodies, which can remain

in the infant’s body for as long as 18months. Establishing whether the anti-bodies belong to mother or child is high-ly complex. Difficulties in diagnosiscause delays in the initiation of treat-ment, and are key to understanding whyhalf of all infected babies die before theage of two.

The current strategy for diagnosing chil-dren requires high-tech and hugely expen-sive laboratory equipment to measure theviral load, or the amount of viral particlesin the bloodstream. Costing up to$140,000 US, such equipment is notavailable in most developing countries –even the technologies most suitable for usein these locations can cost from $7,000 to$30,000 US. In addition, each test cancost up to $125 US. A further constraint isthat the laboratory cannot function withouthighly skilled laboratory technicians and aconstant supply of electricity.

Today we need a simple, affordable, andrapid viral load test that can be used inlow-tech settings, enabling doctors tomake a diagnosis and begin treatment.Multinational diagnostic companies,answering to commercial interests, haveso far not shown any interest in address-ing this problem. Médecins SansFrontières (MSF) is currently trying toidentify and promote projects aimed atdeveloping appropriate tools.

page 13

/AIDS CONDEMNED TO DIE WITHOUT TREATMENT,

HALF OF ALL CHILDREN INFECTED WITH

HIV IN DEVELOPING COUNTRIES DON’T LIVE

TO SEE THEIR SECOND BIRTHDAY.

INAPPROPRIATE AND EXPENSIVE DRUGS

In wealthy countries, infected children andbabies – diagnosed rapidly – are treated withantiretroviral (ARV) therapy, a proven strate-gy for reducing illness and death. Until thechild is able to swallow tablets, the drugsare commonly administered orally in syrupsor as powders to be mixed with water.

These seemingly simple procedures can beill suited to remote or resource-poor settings,however. Some syrups must be refrigeratedafter opening, requiring a reliable electricitysupply in patients’ homes. Those in powderform require clean drinking water. To ensureaccurate dosage, some drugs must be meas-ured with a syringe, which can be too com-plex for caregivers. Several products are alsofoul tasting.

To address these issues, UNICEF and WHOconsulted experts in November 2004 toimprove access to appropriate paediatricARV formulations. They recommended thatliquids be used only for infants weighingunder 10-12 kilograms, and that solid drugsbe preferred for older children. While guide-lines are welcomed, the recommendationsdo not provide an adequate solution.

One problem is the high price of liquid andsolid drugs in paediatric formulations, muchmore costly than the adult equivalents –treating a child weighing 10 kilograms for

one year with Stavudine, Nevirapine andLamivudine, for example, can cost up to$816 US, while treating an adult with thesame drugs costs $182 US.

Next, appropriate drugs simply don’t exist.Most pharmaceutical companies only pro-duce liquid formulations. Today there are noequivalents for children of the fixed-dosecombinations (FDCs - different drugs com-bined in a single pill) developed for adults.FDCs are particularly useful, as they simpli-fy treatment and show excellent clinical,immunological and virological results.

PROFITS BEFORE HUMAN LIFE

While patient-friendly treatments havebecome available to adults in the past fewyears, only two producers of generic medi-cines, in Thailand and India, are in the laterstages of developing an FDC for children,neither in syrup form. Most pharmaceuticalcompanies have little interest in developingpaediatric formulations because wealthiercountries are largely successful in prevent-ing mother-to-child transmission. The mar-ket for new formulations is mostly limited tothe developing world and there isn’t enoughcommercial incentive to stimulate action.

Meanwhile, children with HIV/AIDS in devel-oping countries are often denied any possi-ble treatment based on the perception theirdeaths are unavoidable – a perception that

must be overcome. By 2004, AIDS had left15 million children under the age of 18orphaned in its deadly wake, many of theminfected with HIV. Most are in the care oftheir grandparents and other caregivers, livein orphanages or in the streets. This devas-tating outcome shows that drug develop-ment must be needs-driven. Governments,international donors and industry have theresponsibility to ensure access to appropri-ate and effective diagnostics and treatment.Almost all countries of the World TradeOrganization, including Canada, committedto the Doha Declaration of “medicines forall.” Children included. We cannot wait forthese words to be translated into action.

MSF TOURING EXPOWatch out in the summer of 2006 for aninteractive exhibit MSF will bring to eightcities in Ontario and Quebec. Participantswill learn what it's like to live with neg-lected diseases from the perspective ofan MSF patient in a developing countryand experience a consultation with MSFphysicians who have worked in the field.Learn firsthand about the limited treat-ment options and the ongoing struggle foraccess to essential medicines. The exhib-it will finish in Toronto at the same timeas the XVI International AIDS Conferencein Toronto in August. For up-to-the-minute information on the touring AIDSExpo, go to www.msf.ca/tour2006

Dispatches Vol.8, Ed.1

P atrice Pagé joined Médecins SansFrontières (MSF) in 1999 as a field

coordinator in southern Sudan afterworking for two years with UNHCR inRwanda. He went on to work as fieldcoordinator for MSF in Sierra Leone andKosovo, and as head of mission inEritrea, Democratic Republic of Congo,Guinea, and Liberia.

Patrice joined the New York office of MSFin 2001 as a programme officer. He wasdeeply involved in the Arjan Erkel case,pushing for and achieving meetings at thehighest of levels with the US governmentand the UN; he was also instrumental inadvocating for the UN Security Councilresolution (1502) on the protection of aidworkers that was passed in August 2003.He left MSF in 2004 to head upUNICEF’s emergency operations on the

Chad-Sudan border. In August 2005, he was appointed executive director ofMSF Canada.

A lawyer who graduated from theUniversité de Sherbrooke and the Écoledu Barreau du Québec, Patrice also helda degree from the Institut Internationaldes Droits de l'Homme, Strasbourg,France. He practiced labour law with theMontréal Conféderation des SyndicatsNationaux / Confederation of NationalLabour Unions for two years. A dynamicadvocate on behalf of populations in dan-ger, Patrice brought a sharp intelligenceand insight, a keen sensitivity to the caus-es of MSF’s patients. He demonstratedhis passion for justice in everything thathe did. He was 33 years old.

He will be sadly missed.

A DYNAMIC ADVOCATE ON BEHALF

OF POPULATIONS IN DANGER,

PATRICE BROUGHT A SHARP

INTELLIGENCE AND INSIGHT, A

KEEN SENSITIVITY TO THE

CAUSES OF MSF’S PATIENTS. HE

DEMONSTRATED HIS PASSION

FOR JUSTICE IN EVERYTHING

THAT HE DID.

M e m o r i a l

PATRICE PAGÉExecutive Director,

MSF Canada

DispatchesMédecins Sans Frontières/

Doctors Without Borders

720 Spadina Avenue., Suite 402 Toronto, Ontario, M5S 2T9

Tel: 416.964.0619Fax: 416.963.8707

Toll free: 1.800.982.7903Email: msfcan@msf.ca

www.msf.ca

Editors:Dominique Desrochers

Caroline Veldhuis

Editorial directors:Laurence Hughes

linda o. nagy

Contributors:Johana Amar, Michelle Chouinard,

Jean-François Corty, Nancy Forgrave, Michael Hall, Patrice Pagé,

Kenneth Tong

Circulation: 95,000Layout: Artshouse Communications Inc.

Printing: Warren's Imaging and Dryography

Winter 2006

ISSN 1484-9372

Photo credits:Cyril Bertrand , Sebastian Bolesch,

Doris Burtscher, Roger Job, Didier Lefevre, David Levene,

Bruno Stevens / Cosmos, eduard compte verdaguer,

Anne Yzebe

page 15

BURUNDIPierre LabrancheDiane RachieleIsabelle RiouxCatherine Mason

CAMBODIANicole Tanguay

CENTRAL AFRICAN REPUBLICAlain CalameÉmilie FrédérickJacinthe Pressé

CHADKevin CoppockMike FarkFrédéric DubéFrançois RiffaudJacques CaronBenoît WullensLindsay Bryson

COLOMBIATyler FainstatDarryl Stellmach

DEMOCRATIC REPUBLIC OF CONGOHeidi ChestnutStéphanie FerlandAndré FortinJean-François HarveyDawn KeimJudy MacConneryJean-Sébastien MatteJohn Paul MorganMarlene Power

Leslie ShanksSophie Villemaire

ETHIOPIAIsabelle Aubry

HAITIRosianne Ayotte Sylvain Charbonneau

INDIAKaren Abbs

INDONESIAVivienne RowanChristo WigginsBeverly Winder

IRANMagdalena Gonzalez

IVORY COASTMatthew CalvertDenise ChouinardJennifer GrantHélène LessardClaudine MaariBrian OstrowElaine SansoucyDavid Tu

KENYASylvain Groulx

LIBERIABrian BakerPatricia GouldSerena KasparianPatrick LaurentChris Monnon

MALAWIChantal St Arnaud

MYANMARJim NewtonManisha Rajora

NIGERCatherine De RavinelJacinthe LarivièreDominique ProteauDanielle Trépanier

NIGERIAFredédéric BeaudoinAloma BoyceAdam ChildsNancy Dale

PAKISTANIan AdairAdrienne CarterDavid CroftDavid De BoldMarise DenaultMichael HallSajida HussainKathleen Skinnider

REPUBLIC OF CONGOBrenda HoloboffMartine VézinaSophia KapellasGrace Tang

SIERRA LEONELaura Lau

SOMALIAViolet BaronSylvain DeslippesNaomi Fecteau

Bruce LampardDavid Michalski

SOUTH AFRICAPeter Saranchuk

SUDANReshma AdatiaFrank BoyceStephanie FaubertJohn HazletonHarry MacNeilZayd MajokaTiffany MooreMichel-Olivier LacharitéSimona PowellMireille RoyNasser SalamArun SharmaSheila StamVanessa Van SchoorRichard Zereik

TURKMENISTANRhiannon HughesSafo Visha

UGANDARichard PoitrasTom Ripley

ZAMBIAEva LamSima PatelPaulo RottmanChris Warren

ZIMBABWEDon ChambersCheryl McDermid

CANADIANS ON MISSION

JOIN THE SANS FRONTIERES SOCIETY

One of the greatest joys of my work at MédecinsSans Frontières (MSF) is the chance to connect

meaningfully with our wonderful donors.

MSF recently launched our Sans Frontières Society tothank and recognize individuals who have named MSFas a beneficiary in their will, or have made gifts throughannuities or life insurance. As a member, you will beinvited to MSF events in your local region and receivename recognition in our annual report and website.Your show of support also encourages others to make agift of this kind. I invite you to get in touch with me tolearn more about the Sans Frontières Society and theoptions available to you.

MSF exists because of the humanitarian principle thatall people should have access to medical assistance.Your promise of support helps ensure that we can pro-vide this assistance rapidly and effectively to popula-tions in need around the world, while bearing witnessto the conditions of the people we help and advocatingfor them when necessary.

Thank you for extending your compassion and generosity.

Nancy Forgrave Associate Director, Planned and Special Gifts

Nancy ForgraveAssociate Director,Planned and Special Gifts(416) 642-3466 / 1 800 982-7903nforgrave@msf.ca