4
SUMMER 2012
Haiti: Beyond
Emergency
Events and Recruiting
MSF NEWS
WORK WITH MSF MSF-USA SPEAKING fact). These are just some of the sur-
EVENTS prising revelations found in In the Eyes
Between July 1 and September 30, MSF of Others: How People in Crises Perceive
will hold recruitment information MSF-USA plans to bring live events— Humanitarian Aid. Co-published with
sessions in the following cities: panel discussions, lectures, and talks— Humanitarian Outcomes and NYU’s
to Los Angeles, San Francisco, Portland, Center on International Cooperation,
July 18: New York, NY Seattle, and Denver this fall. In addition, the book is a result of MSF’s attempt to
August 8: San Francisco, CA we will continue to hold webcasts about better understand how its work and
September 18: Seattle, WA MSF activities, advocacy campaigns, principles of neutrality, impartiality,
September 19: New York, NY books, and medical interventions avail- and independence are perceived by
September 20: Portland, OR able around the world via the Internet. those who receive its emergency medi-
Please check our website, www.doctor- cal care. A variety of scholars, research-
All prospective medical and non-medi- swithoutborders.org, for event details. ers, students, and other humanitarians
cal aid workers are welcome to join us also contribute essays expanding on
for a presentation and Q & A to learn issues of perception and exploring the
more about MSF’s field work. A human MSF IN PRINT many facets of humanitarian action
resources officer will discuss the re- today.
cruitment process, and an experienced Over the past 40 years, Doctors With-
MSF aid worker from the local area out Borders/Médecins Sans Frontières The book is available in paperback from
will share stories of life in the field. (MSF) has developed a reputation as an Amazon and as a free PDF download at
Visit www.doctorswithoutborders.org/ emergency medical humanitarian or- w w w.do c tor sw it houtb or der s.or g /
events/public for more information and ganization willing to go almost any- perceptions.
to register, or participate in one of our where to deliver care to people in need.
regularly scheduled recruitment webinars. Yet when questioned about MSF, people
in countries where it works had differ-
Please note that there is an urgent need ent perceptions. One thought MSF was
for midwives and operating room staff from Saudi Arabia and financed by
and for French-speaking applicants to Muslim charities. Another thought it
work in countries such as the Demo- was a China-based corporation. And yet
cratic Republic of Congo, Chad, Niger, another believed MSF requires every-
and Haiti, where some of MSF’s largest one who enters their medical facilities
projects are located. to be armed (quite the opposite, in
2
EVENTS AND RECRUITING
Doctors Without Borders/
Médecins Sans Frontières USA HUMANITARIAN SPACE
Sophie Delaunay
Executive Director
Dear Friends,
Board of Directors
Deane Marchbein, MD
President In January 2010, a massive earthquake hit Haiti and necessitated the largest
Aditya Nadimpalli, MD
Vice-President
emergency response in MSF’s history. In this issue of Alert, we return to Haiti to
David A. Shevlin, Esq. look at how that response has evolved, and continues to evolve, in Port-au-Prince. In
Secretary
the years since the earthquake we’ve spent a lot of time discussing MSF’s activities
Bret Engelkemier
Treasurer in Haiti, and with good reason—high-quality, free-of-charge health services are
Nabil Al-Tikriti still sorely lacking, and the nation remains susceptible to large-scale cholera out-
Suerie Moon
Kelly S. Grimshaw, RN MSN APRN CCRN breaks. MSF has been and remains the largest medical organization responding
Marie-Pierre Allie, MD to these unmet needs. Teams are providing a number of essential services today,
Matthew Spitzer, MD
Navneet Bhullar, MD
such as the burn unit at MSF’s Drouillard hospital, which you will learn more
Michael Newman, MD about in these pages.
Ramin Asgary, MD, MPH
Martha (Carey) Huckabee
But we shouldn’t forget the other crises, in other countries, that would have been
Board of Advisors
Daniel Goldring among MSF’s largest-ever emergency responses before January 2010, and remain
Co-Chair of the Board significant medical emergencies today. Being able to respond to those emergencies
Susan Liautaud
Co-Chair of the Board
is the main reason MSF exists, and we have in this issue a discussion with the
Meena Ahamed director of MSF’s emergency desk, or “E-desk,” in Paris, Dr. Mego Terzian, about
Elizabeth Beshel Robinson
Goldman Sachs
how MSF prepares for and responds to emergencies as they happen.
Victoria Bjorklund, Esq, PhD
Simpson Thacher & Bartlett LLP
In the Haiti story, we touch on the transition from the emergency phase into the
Robert Bookman
Creative Artists Agency post-emergency phase, when gains made during the emergency phase must be
Charles Hirschler protected and the patients tended to must be further nursed back to health. In
Gary A. Isaac, Esq.
Mayer Brown LLP Haiti, hospitals like Drouillard illustrate MSF’s conviction that ongoing needs ne-
Laurie MacDonald cessitate ongoing involvement, and that where few options for care exist, we must
Parkes MacDonald Productions
Chantal Martell
provide that care and, at times, the facilities in which it occurs.
Larry Pantirer
Darin Portnoy, MD, MPH
Montefiore Medical Center
With HIV, MSF—and particularly some determined, visionary individuals within
Richard Rockefeller, MD the organization—started treating people living with HIV/AIDS before it was
Garrick Utley
deemed practical, affordable, or even useful. That was more than a decade ago,
Neil D. Levin Graduate School, SUNY
Robert van Zwieten and MSF has now treated hundreds of thousands of people and helped establish a
Asian Development Bank baseline for treatment that is widely accepted (even if not widely enough) around
US Headquarters the world. In this issue’s field journal, MSF HIV/AIDS Policy Expert Sharonann
333 Seventh Avenue, 2nd Floor
New York, NY 10001-5004
Lynch discusses traveling to Mozambique to study community antiretroviral
T 212-679-6800, F 212-679-7016 groups and the members who work together to make sure they all get the treatment
www.doctorswithoutborders.org
they need. It’s an incredible, inspiring initiative that was beyond anyone’s imagi-
Alert is a quarterly newsletter sent to friends and nation back in 2001—when HIV/AIDS was essentially a death sentence in so many
supporters of Doctors Without Borders/Médecins Sans
Frontières (MSF). As a private, international, nonprofit places, and thus very much an emergency.
organization, MSF delivers emergency medical relief to
victims of war and disaster, regardless of politics, race,
religion, or ethnicity.
The needs don’t end when the emergency is declared over. In places like Haiti, they
are in fact amplified because other actors leave. MSF will continue to respond to an
Doctors Without Borders is recognized as a nonprofit,
charitable organization under Section 501(c)(3) of the emergency as a holistic, kinetic entity, and, with generous support from people like
Internal Revenue Code. All contributions are tax-deductible you and the continued dedication of our field workers, stand ready to understand
to the fullest extent allowed by law.
and fulfill its role, delivering assistance to the people who need it most.
Editor: Phil Zabriskie
Contributors: Stephanie Davies, Melissa Pracht,
Elias Primoff Sincerely,
Design: CoDe, Communication & Design,
Jenny 8 del Corte Hirschfeld
Comments: alert_editor@msf.org
Cover photo: Haiti 2012 © Yann Libessart/MSF
3
HUMANITARIAN SPACE
A Haiti Emergency
By Melissa Pracht All photos Haiti 2012 © Yann Libessart/MSF
Dattchina and her mother in the triage room at Drouillard
Hospital (left), and a mother and child in the burn unit (right).
It’s mid-morning at MSF’s Drouillard Hospital, a sprawling, The mother takes a seat in a white plastic chair, her daughter
bustling facility situated next to Cité Soleil, one of the poor- still in her arms, and the doctor begins applying pads to the
est neighborhoods in Port-au-Prince, Haiti’s capital. People burns, following the blazing red wound that covers the child’s
with crutches, bandages, and external fixators used on bone back and creeps over one shoulder onto her chest. “How was
fractures sit on benches near the entrance to the outpatient she burned, madame?” the doctor asks.
ward waiting for follow-up treatment. Family members speak
softly to each other as cell phone ringtones go off constantly. In a halting voice, the mother explains that they don’t have
electricity or gas where they live and must use a portable
With the onset of spring, the mango trees on the hospi- coal stove for cooking. Earlier that morning, she says, “when
tal grounds are starting to bear fruit. The steady buzz of I was climbing the stairs with the stove and the spaghetti
motor scooters dodging potholes and pedestrians on the in the boiling water, these things slipped and fell on her.”
street outside rises in volume each time the security gate
rolls open. In one of these moments, a beat-up white car ac- The doctor calls for morphine to be prepared. One nurse takes
celerates onto the grounds and comes to an abrupt stop the girl’s temperature, while another asks for information.
in front of the triage station next to the emergency room.
A door opens and a woman maneuvers herself out of the back “What is the age?”
seat holding her young daughter, who is naked. The girl’s face “Seven years old.”
is blank with shock; her thin back is bright red with burns. “What is her name?”
A HAITI EMERGENCY 4
Her mother hesitates, as if searching for the answer. they venture out, they have to pick their way along the
“Dattchina… Dattchina Sary Chérilus.” roads, dodging speeding motor bikes and beat-up cars, try-
ing to keep themselves or their children out of harm’s way.
Dattchina’s mother stands once again with her now-bandaged Nearly 40 percent of the hospital’s admissions stem from
child clinging to her neck and walks the roughly 10 meters traffic accidents.
to the ER. The Haitian doctor who runs the ER, Josue Bince,
directs her to lay Dattchina on a gurney. A nurse covers the The lack of a functional sanitation system means the sides
girl with a hospital gown and readies the morphine. of the roads in poorer neighborhoods serve as dumping
grounds. As a result, undulating hills of trash and effluvium
“About 15 percent of the skin’s surface area was burned,” host luxuriant pigs and skittish goats and small fires emit
Dr. Bince says. “We are going to prepare her for surgery. toxic plumes of smoke. Conditions like these helped cholera
We’ll wash and clean the affected area, and then apply the spread like wildfire through the city’s slums in the fall of
ointment following the MSF protocol, and then she will be 2010, again last year, and, in all likelihood, in the year ahead,
moved to the burn unit.” particularly when the rains come.
Next to the gurney, her mother sits with her handbag in her It’s now been more than two years since a 7.0-magnitude
lap, cellphone clutched in one hand, eyes wide with worry. earthquake destroyed much of Port-au-Prince’s already
fragile infrastructure and many of its homes. Large numbers
Everything is Connected of people who were displaced by the quake are still living in
tent settlements scattered across the city. Many others, like
Outside the hospital grounds, the residents of Cité Soleil live Dattchina and her mother, have only rudimentary housing
in concrete block structures or in tent settlements. When with no facilities or services. In either case, families cook
5
SYRIA 6
7 SYRIA
over open fires, use candles for light, and hope exposed
electrical wires don’t become live at the wrong moment. It
amounts to perfect conditions for fires and burn accidents.
A HAITI EMERGENCY
8
Scenes from Drouillard (clockwise from top left): A patient MSF in Haiti
tended to by staff; a doctor checks an X-ray; two patients In addition to the hospital in Drouil-
recuperating from injuries; a child receives physiotherapy. lard, MSF runs an 80-bed referral cen-
ter for obstetric emergencies in Port-
dard dressings. We often have to do Her eyes fluttering open, but still un- au-Prince’s Delmas 33 neighborhood
amputations, tissue debridement. We der the effects of anesthesia, Dattchina and works in two operating theaters,
do almost all surgical procedures that is rolled out of the surgery block and the emergency department, and the
a burn patient may need here.” down the hallway towards the burn pediatric and maternity wards of
unit, where her mother will soon join Choscal hospital in Cité Soleil, while
Once the nurse-anesthetist puts Dattchi- her. Every two or three days a surgi- also providing care to victims of sexu-
na under full anesthesia, the surgery cal team will clean her wounds and al violence. MSF’s 40-bed stabilization
team begins the procedure. Three change the dressings while she heals. center in Martissant offers maternity
people hold her in position and the If all goes well, Dr. Salomon says, she care, internal medicine, and mental
surgeon cleans, treats, and wraps her should be able to go home within two health services, and MSF tends to
back, chest, and arms. weeks. In a ward full of children and wounds, performs orthopedic and
adults who have all been casualties of reconstructive surgery, and, with
“Before her,” says Dr. Salomon, “we a brutal, normalized neglect, the little Handicap International, offers phys-
had a patient who had very deep third- girl may be one of the relatively luckier iotherapy and rehabilitative services
degree burns. For this child, the wound patients. And, in fact, nine days after in Sarthe. MSF also runs a 160-bed
is not very deep. In theory, she should Dattchina was admitted, she was dis- hospital in Léogâne, west of Port-au-
recover without any major problems. charged in good condition and her Prince, focusing on trauma and ob-
There should be very little scarring, mother took her back home. stetric emergencies and basic health
perhaps some discoloration of the skin.” care to women and infants, and teams
throughout the country have treated
well over 170,000 patients for cholera.
9 A HAITI EMERGENCY
How MSF Works:
The E–Team
Dr. Mego Terzian started working with MSF in 2000 and
has completed assignments in a dozen nations, including
Afghanistan, Pakistan, Niger, Liberia, and Iran. Since 2009,
he has led MSF’s Emergency Team in Paris, one of five based
in MSF’s operational centers in Europe, which can rapidly
respond when crises erupt and often represent the first stage
of MSF’s intervention in a conflict, natural disaster, refugee
crisis or other emergency situation.
How does an Emergency Team differ from a regular An MSF staff member consults patients in Yida refugee camp, where an MSF emergency team
MSF team? The Emergency Team is always on standby set up a coordination office. South Sudan 2012 © James Keogh/Wostok Press
to intervene in sudden crises. If we are already running
programs in the country affected, we send in the Emergency we open a trauma center, so we sent in reinforcements and
Team to act as reinforcements. It carries out an exploratory materials, again by boat. We were there with the Emergency
mission, recommends any program openings, then sets them Team from Brussels, which decided to run a hospital for
up using a parallel coordination system to allow the regular women and children in the same town.
team to carry on its original programs as best it can.
Were there any particular difficulties? A major difficulty
Who is on the Emergency Team? In Paris, we have 20 was finding local nursing staff. Before the war broke out,
people in our Emergency Pool right now—doctors, nurses, most nurses came from overseas—including India and the
surgeons, anesthetists, pharmacists, logisticians. We need Philippines—and they had all left. So, despite the security
many different profiles. They’ve all left their regular jobs and risks, we sent in 19 international staff—including surgeons,
are on standby to go within 48 hours to an emergency mission nurses, and doctors—to set up 25 trauma beds. For at least
anywhere in the world. They are under contract for at least two months, the team managed this small 24-hour trauma
12 months. We have Africans, Americans, Europeans, many center with very few national staff members with them. In
different nationalities in the pool. six months in Misrata, we treated 1,200 men, women, and
To qualify, you need to have at least 24 months MSF children, all trauma-related, and conducted 525 surgical
field experience in different types of missions. One must be interventions, all violence-related.
epidemics, and one must be conflict zones. And because the
Paris team works in so many Francophone projects—around And in Ivory Coast? For Ivory Coast, it was the same
65 percent of our projects are in French-speaking countries— process. The crisis started in late 2010-early 2011, following
people must also speak French as well as English. the elections. We followed the situation at HQ for two to
three weeks via the media and the local network we were
How does MSF decide when the Emergency Team still in touch with, having worked there previously. We then
should be deployed? It depends if MSF has a presence sent in one coordinator, one doctor, and one logistics officer
in the country or not. If we have no presence in a country, to evaluate the situation. They proposed an intervention and
like in Libya and Ivory Coast last year, we have to start from we sent in reinforcements and supplies right away.
scratch. For instance, in Libya, we started off by using the
media and contacts we have on the ground to follow the How do you get permission to set up so quickly? Because
beginning of the armed revolution. we are a medical organization, the Ministry of Health is
Then three or four days after the violence started in always our first contact. And because our organization is
the east of the country, we sent a small exploratory mission well-known, even if we are not operational, we don’t usually
of three people—a doctor, a logistician, and a coordinator—to have any problems setting up meetings. The Ministry of
Misrata. They had to go by boat because the whole town was Health describes the situation and makes recommendations
surrounded by government troops and this was the only way on where we should go and what we should do, and once
to gain access. After two or three days, the team proposed we have the green light, we do our own evaluation and
How long does the Team normally stay in-country? Where are your people right now? We have a team in
Every emergency mission opens during the acute phase— Mali working with people affected by the violence there,
which lasted two months in Ivory Coast. Then we must stay and another working with refugees who’ve fled to Niger.
on for a few months to hand over the project to the Ministry We also have teams working on the nutritional crises in
of Health, because following the emergency phase, local Mauritania and Senegal.
authorities are always in difficulty. We stayed in Abidjan
for seven months. Are there different security protocols from regular
programs? On its first explo, the Emergency Team normally
How does the Team work when there is an MSF takes some time to understand the country, including
presence in the country already? If we have a presence meeting with other nongovernmental organizations working
in the country already, like in Pakistan during the floods, there, before doing its own security evaluation. Two to three
or more recently in South Sudan, things can go very quickly weeks after opening a project, it creates the first security
because the Emergency Team will not have to spend time guidelines and rules we need to follow in the country.
contacting the authorities, finding cars, or identifying a
place to set up an office and a place to sleep. All this is done How could MSF improve in its emergency responses?
by the national coordination team already in the country. If I think we were a bit late with the Arab countries. We were
we have no offices or presence in a country we probably lose late deciding what to do after the demonstrations started. In
at least 48 hours setting everything up. Tunisia and Egypt, we overestimated local capacity in terms
Traditionally there is a separate coordination for of medical response and underestimated the needs, so it
emergency programs so as not to disturb the ongoing was several weeks before we even sent in explo teams. We
programs. Just recently, for example, around 20,000 refugees learned that we need to be more reactive. Even if we esti-
arrived in a place called Yida in South Sudan. The national mate there is good quality of care in a country, we realized
coordination team sent an experienced colleague to we need to at least send in a team.
evaluate the situation and after two days, he recommended
MSF open a primary health clinic and a 20-bed hospital
for secondary care. So they turned to us, and we sent an
Emergency Team, which immediately set up a coordination
ALGERIA
Nouakchott
GAMBIA MAURITANIA MALI
CHAD
15˚
Dakar NIGER
SENEGAL
Banjul
Niamey
Bamako
Bissau Ouagadougou
N'Djamena
BURKINA FASO
GUINEA-BISSAU GUINEA NIGERIA
10˚
BENIN
Conakry
Mali An MSF staff member distributes shelter kits to displaced people in the village of Chad A group of mothers wait to have their children checked at a MSF ambulatory
Aglal, Timbuktu area. Mali 2012 © Foura Sassou Madi/MSF treatment feeding center in Dougine. Chad 2012 © Catherine Robinson/MSF
Mauritania A child is monitored at an Outpatient Nutritional Rehabilitation Center. Mauritania 2012 © Victor Raison
Sharonann Lynch is MSF’s HIV/AIDS Policy Adviser and a Lynch and others from MSF will bring to the International
veteran of the HIV advocacy and policy arena. Based in New AIDS Conference being held in Washington, DC, in late July.
York, she recently traveled to Mozambique to study Community Here, Lynch discusses her recent trip:
Antiretroviral-Therapy Groups, or CAGs, in which groups
of patients support each other and individuals take turns I wanted to see how community ART groups were
picking up medications for other members. CAGs are part functioning in Mozambique’s Tete Province. There’s been a
of MSF’s broader effort to decentralize HIV care by bringing lot of excitement about this model because we’ve seen that it
it closer to where patients live and empowering nurses and makes treatment more feasible and that it can help improve
community health workers to carry out treatment and testing adherence to treatment.
tasks that only doctors had done in the past.
Essentially, CAGs came out of an idea from Win Van Dam,
Initiatives like these, MSF believes, would make it possible who worked for MSF and has been advising MSF on strategies
to scale up treatment programs to the level necessary, even for providing chronic care in resource poor settings. It was
where resources are severely limited, if the political will and fascinating to see how this creative, innovative strategy—
financial backing are there. This will be part of the message which came not from headquarters, but from the field, as
And now they’ve been on ARVs for a while. And it was really
inspiring to hear CAG members say, “Don’t worry about us.
We’re fine. We’ve got our treatment. It would be great if you
could bring it even closer to our nearest clinics, but even
more importantly: help us fight HIV in our community. We
are still raising HIV positive babies. We are still caring for
HIV positive neighbors who are ill.”