A violent attack by men armed with hammers, and the burning of a village of internally displaced people are two in a series of recent violent events suffered by people living in the Kivu provinces of eastern Democratic Republic of Congo. In addition, the numbers of gunshot and rape victims treated by Doctors Without Borders/Médecins Sans Frontières (MSF) in its hospital in Mweso, North Kivu, rose in August, leading to heightened concern about the levels of violence suffered by people living in the conflict-affected areas. 

On August 26, MSF was alerted to a brutal attack in a small village 20 kilometers (12 miles) from Mweso.

“At 22:30, the 25th of August, eight men entered the village armed with hammers, and attacked more than 20 people,” said MSF medical coordinator Martins Dada. “As soon as we heard the next morning, we immediately drove to the village to provide emergency medical care. Once there, the seriousness of the situation became clear. We quickly took care of the wounded, putting in IVs. One of the victims died on the scene. Another person had passed away before we arrived.”

Fifteen people were admitted to the MSF hospital in Mweso, seven of who were in comas, having suffered severe skull fractures, and eight who were severely wounded. The first patient died on the evening of August 27, a 15-year-old boy. Since then, another patient has also passed away, while the rest remain in a serious condition, including a pregnant woman. All patients are extremely traumatized.

“We were stitching head injuries all day,” Dada said. “Everyone is in shock. The villagers are too shattered to speak. One man is totally confused and is constantly terrified; he calls and cries and kicks and beats until we calm him down and he returns to his coma. Then he wakes and relives the entire story again.”

Just days before the attack, MSF tended to patients wounded during the burning and looting of a camp for internally displaced persons. “One hundred and seventy shacks burned to the ground, and another 80 homes were looted,” said MSF mental health worker Joelle Depeyrot.

MSF does not know who the perpetrators of these horrific attacks are, but is shocked by the brutality of the incidents and the ongoing level of violence suffered by the people caught up in the conflict in eastern Congo. Since May 2010, the number of rape victims being treated at MSF’s hospital in Mweso has gone up nearly two-fold, with more than 40 patients being provided with treatment in August. Likewise, the average case load of victims of physical violence has doubled in August compared to previous months, to more than 20 cases.   

“Since these incidents, other patients have come to us in a state of agitation and fear,” Depeyrot said. “They were not there. But they have lived through other horrific events. And they have heard the stories. They report being scared, scared all the time. They spend their time wondering when they will be tortured and killed.”

MSF continues to provide much needed emergency healthcare to people in the places most affected by the conflict in eastern Congo, including emergency assistance, healthcare, treating victims of sexual violence, providing psychosocial care, running vaccination campaigns, and responding to disease outbreaks.    

Pakistan 2010 © Mai Tang/MSF

MSF staff set up an oral rehydration point in Sukkur, Sindh Province.

The battered sign reads: “Welcome to Sukkur: City of Rivers and Canals”.

More than five weeks have passed since the floods first struck Pakistan, and some of the water has started to recede in provinces including Khyber Pakhtunkhwa.  However, as it travels south—fresh floods have hit Sindh Province recently—it forces hundreds of thousands of people to leave their homes.

Fleeing Jacobabad, Kashmore, Shikarpur, and Shadadkot, more than 500,000 people have arrived in Sukkur. This city of rivers and canals in the North of Sindh is now home for those displaced by floodwaters. Reportedly, one out of every three people in Sukkur is a newcomer seeking dry shelter anywhere; empty school buildings, streets, and even old railway lines are full of people who need food, medicine, and safe, clean water.

Mohssen Ali, 54, and his family of ten were among the first to settle on a plot of land in Sukkur where Doctors Without Borders/Médecins Sans Frontières (MSF) has distributed tents to 150 families. “It took me years to make a house for my family, and now it’s just a pile of mud,” he said. “The water drove us out of Kashmore so quickly, I couldn’t even get my wife her medicine. She has a chronic heart problem and I don’t know how long she will last without her pills. I can’t even buy food for my children. I’m their father, I have to take care of them, but I can’t. What are we going to do?”

Medical Care on the Move

Improving access to essential healthcare services is one of the priorities of MSF teams working in Sukkur today.

“The influx of people has stretched the capacity of the 13 hospitals in this area to the limit,” said nurse Anja Braune, who is in charge of MSF medical activities in Sukkur. “At least half of the people being seen in hospitals now are from the displaced population. I’ve seen three or four patients on the same bed.”

To reach those who cannot access the health centers, MSF teams are now conducting mobile clinics in various locations in the area. Screening for malnutrition is one of the main components of the mobile clinics. By measuring the middle-upper arm circumference, health workers are able to identify moderate to severely malnourished children who need support, and refer them to the recently opened MSF-run intensive therapeutic feeding center (ITFC) in Railway Hospital. 

To prevent dehydration among the displaced population, MSF teams are setting up oral rehydration salt (ORS) points. Established in camps and schools and staffed by two health workers, these sites provide rehydrating solution for anyone who needs it. MSF nurse Petra Frankuizen is in charge of setting up more than nine ORS points and training the 15 health workers who all come from Sukkur. “The heat is unbearable, and the water is contaminated,” said Frankuizen. “The combination of the two means that a lot of people, especially children, are thirsty and dangerously dehydrated.”

The poor living conditions, including bad hygiene and sanitation, are quickly transforming the schools and makeshift camps into sites where waterborne diseases, such as acute watery diarrhea, can flourish. MSF epidemiologist Todd Swarthout has been working to get a better picture of the health needs of the displaced in Sukkur. “One of the main challenges is the size of the area and the overwhelming number of people,” he said. “I’ve visited schools where hundreds are using the same toilet. Cramped spaces with poor sanitation and too many people are simply breeding grounds for disease.”

Poor Quality Water

In Sukkur, there are three main treatment plants drawing water from the Indus River, which is the main source of water. However, the river has very high turbidity—a measure of cloudiness. This means that an efficient filtration system is essential for the water to be useable. Although some people can afford to purchase drinking water from private vendors, for the remaining majority there is not much water available, and what is available is not good quality.  For this reason, the provision of safe, clean water is another main priority for MSF staff working in Sukkur. Teams have installed two 5,000-liter refillable containers in an internally displaced persons’ camp, and put in place a purification system that treats water directly from one of the town’s water plants.

“We are targeting the health structure so that at least sick people are not given the same bad water that made them ill in the first place, ” said Imran Ali, an MSF water-and-sanitation technician.

By putting in place an assisted direct pressure  filtration system, up to 80,000 liters of safe water is now being provided daily to health structures around Sukkur, but more still needs to be done.

“The situation is very precarious here because there is no chlorination happening anywhere. If there is any contamination that enters the river, it’s going to wind up directly in people’s homes, boreholes, and wells, making everybody ill,” said Ali.

Nowhere to Go

Clearly, the relief efforts of national and international organizations working in Sukkur must scale up and continue working in order to match the various needs of the displaced people there.  In a few weeks, the schools are due to reopen, which means that most of the people huddled in the now empty school buildings will need to find another place to go. Children, like 12-year-old Yasmeen Haj, will bear the consequences of the floods long after the water recedes. “Maybe it is weeks or months from now,” said Haj, “but everybody is praying to go home eventually. Baba died last year, and we lost our mother in the floods. My brother is only five, so I’m his mother now. We have nowhere to go back to.”

Since 1988, MSF has been providing medical assistance to Pakistani nationals and Afghan refugees suffering from the effects of armed conflicts, poor access to health care, and natural disasters in KPK, FATA, Balochistan, Sindh, Punjab, and Kashmir.

Since the start of the floods in Pakistan MSF has distributed 24,834 non-food item kits and 6,801 tents; performed 27,151 medical consultations; set up seven diarrhea treatment centers; continuously conducts 12 mobile clinics; distributes 718,000 liters of clean, safe water per day; built 258 latrines and installed 11 oral rehydration salt points.

Currently, 152 international staff are working alongside 1,279 Pakistani staff in MSF’s programs in Pakistan.

MSF does not accept funding from any government for its work in Pakistan and chooses to rely solely on private donations.

Pakistan 2010 © Mai Tang/MSF

An MSF nurse examines a child at the MSF intensive therapeutic feeding center in Sukkur, Sindh Province.

Like hundreds of other flood-affected people, Nabila was forced to leave everything behind in Lori village, and she is now living with her family in a relief camp in Sukkur a town in the North of Sindh Province.

“My daughter does not stop vomiting; she also has diarrhea, and a very high fever. I took her to the hospital, but she didn’t get better, so the doctor told me to bring her here,” said Nabila, holding onto her frail one-year-old, Suha.

Suha is severely malnourished and is being treated at MSF’s recently established intensive therapeutic feeding center (ITFC) in the pediatric ward of Railway Hospital in Sukkur.

The floods still ravaging Pakistan have left people without access to life’s basic necessities, such as food, water, shelter, and basic healthcare. Hundreds of thousands of displaced people have recently fled to Sukkur, and children like Suha, are among the most vulnerable.

To provide essential nutritional support, Doctors Without Borders/Médecins Sans Frontières (MSF) medical teams have set up an ITFC to treat severely malnourished children. Most of the patients are referred through MSF’s mobile clinics in various locations around Sukkur, where a tool for rapid screening called a MUAC—which stands for middle-upper arm circumference—helps determine the nutritional status of children under the age of five.

“Displacement has only exacerbated existing health problems, and children become malnourished or even severely malnourished due to the lack of food, clean water, and a place to stay,” said MSF nurse Abdul Wasay, as he proceeded with the morning rounds, checking on every patient.

The ITFC is run by four doctors, eight nurses, and four health educators, and it is open around the clock. The therapeutic feeding program includes the provision of high-calorie, nutritious food, including fortified milk and ready-to-use food supplements rich in micronutrients and protein.

“It is important that the ITFC stays open all day and night,” Wasay said. “Each child has to be fed every two hours, and we need to be able to monitor their appetite, digestion, and weaning diet closely.”

In an isolated room, eight-year-old Kubra’s head rests in her mother’s lap. “We need water, food, and accommodation,” said Noor, Kubra’s mother. “We need everything.” Kubra is isolated from the other patients because, in addition to being malnourished, she also has tuberculosis, which is highly contagious.

“The reality is that most of the patients we are treating today were admitted with another associated disease such as acute watery diarrhea, skin infection, pneumonia, or tuberculosis. It is important that they are correctly diagnosed and treated. Our health workers help the mothers understand the treatment process and raise awareness about nutrition, hygiene, and disease prevention measures,” said  nurse Wasay.

Since it opened on the August 28, the ITFC has already treated around 100 severely malnourished children.

The floods have left people with little to be optimistic about, but still, Nabila is hopeful that her daughter’s condition will improve. “I can’t tell when my daughter will be discharged, but I can tell that she is getting better. I am very happy that her diarrhea has stopped. She is more active and is starting to eat little by little, and I hope she will gain weight soon.”

Since 1988, MSF has been providing medical assistance to Pakistani nationals and Afghan refugees suffering from the effects of armed conflicts, poor access to health care, and natural disasters in KPK, FATA, Balochistan, Sindh, Punjab, and Kashmir.

Since the start of the floods in Pakistan MSF has distributed 24,834 non-food item kits and 6,801 tents; performed 27,151 medical consultations; set up seven diarrhea treatment centers; continuously conducts 12 mobile clinics; distributes 718,000 liters of clean, safe water per day; built 258 latrines and installed 11 oral rehydration salt points.

Currently, 152 international staff are working alongside 1,279 Pakistani staff in MSF’s programs in Pakistan

MSF does not accept funding from any government for its work in Pakistan and chooses to rely solely on private donations.

Honduras 2010 © Juan Carlos Tomasi

An MSF staff member attends to a child in San Felipe Hospital in Tegucigalpa.

Due to an alarming increase in cases of dengue fever in Honduras this year, Doctors Without Borders/Médecins Sans Frontières (MSF) has launched an emergency intervention in Tegucigalpa, the capital, where the majority of cases have been reported. MSF is supporting local health services with a three-pronged approach that focuses on medical care, vector control, and community education.

This sort of intervention to a dengue outbreak is relatively new for MSF, but the organization has already set up an emergency pediatric unit and treated more than 80 children. Mobile teams are also working with the local health authorities to identify and eliminate sources of infection in 4,400 households in the Tegucigalpa area.

Dengue, which is endemic in Central America, is a viral disease transmitted by mosquitoes of the genus Aedes. Symptoms are similar to flu; they include headaches, fever, nausea, abdominal pain, and skin rashes. The most severe form, dengue hemorrhagic fever, causes bleeding and shock and can be fatal.

In Honduras, more than 50,000 cases of dengue have been reported to date in 2010, a significant increase from the previous year. However, the most alarming feature of this outbreak is the prevalence of hemorrhagic dengue. More than 1,500 cases have been reported—a massive 1,850 percent increase from 2009—and 160 people have died. “I had come across the previous kind of dengue,” said Herminia Moncada, whose son was recently admitted to hospital with the disease. “But this is different. This dengue kills.”

The Ministry of Health has been responding to the high number of cases of dengue by making more hospital beds available and setting up specialized units in health centers in outlying areas. Despite this, the main referral hospital has still been overwhelmed by the upsurge in patients. Until recently, children with dengue fever were transferred to the referral hospital, as the decentralized units were only receiving adult patients. To ease the overcrowding, MSF set up an emergency ward at the San Felipe Hospital, on the outskirts of Tegucigalpa, to care for children younger than 15 who showed symptoms of the disease. The 23-bed ward was filled to capacity on its second day of activity.

In the hospital, treatment for children includes hydration and rest. “With dengue, we are unable to identify beforehand the patients who will improve rapidly,” said Dr Elisabeth Bragança, who is in charge of the MSF emergency ward. “There is no vaccine or specific medicine for the virus, so all we can do is control the symptoms and treat the consequences while waiting for the body to stabilize.”

Even if the treatment sounds simple, hydration needs to be administered carefully to avoid a fluid overdose. Severe dengue alters the permeability of blood vessels and there is a risk of fluids invading other parts of the body, causing complications such as pulmonary edemas. “An ongoing balance in the amount of fluids given needs to be maintained,” said Dr Bragança.

MSF health staff are also spending time teaching the children’s parents and caretakers how to administer the fluid to their children. “In my opinion, the success of this medical intervention mostly relies on us collaborating with the parents,” said Dr Bragança. Frequently, parents stay in the ward throughout the night, giving their children fluids by mouth at set intervals and writing down the amounts so that they can tell the health staff later. Many go long stretches without sleep. MSF has therefore made sure to include emotional support for the parents as part of the intervention.

Seeing children recover can be a very rewarding experience. Just one day after being admitted to the ward, five-year-old Lucía Isammar Elvir was able to give her mother a big smile and declare that she wanted to go home, saying, “I want to paint and draw.”

Fighting Dengue at Home

Honduras 2010 © Juan Carlos Tomasi

Spraying homes in Tegucigalpa.

MSF's response to dengue includes steps designed to prevent outbreaks from spreading or from occurring in the first place. “Education is an essential component of fighting dengue,” said Luis Montiel, logistics coordinator for the project. “It is a crucial aspect that will define the course of future epidemics.”

In addition to providing medical care, MSF is fighting the dengue outbreak with “vector control,” which means going after the mosquitoes that spread the disease. Along with the Ministry of Health’s vector control body, MSF mobile teams are at work in the Manchen settlement, on the outskirts of Tegucigalpa, where the highest rates of affected people have been reported.

Mosquitoes carrying the dengue virus breed in stagnant water, so proper water management within households is vital. In the Manchen settlement, where houses sit on hillsides, families receive water only every fortnight and store it in tanks. Jerry cans and water containers sitting stagnant in the narrow corridors of houses provide a perfect environment for mosquitoes to breed. So do rubbish and rubble piles.

Among these mostly poor families, waste management is no easy task. María Mercedes Suazo Bustillo, 89, explained how, ever since one of the rooms in her house had collapsed, she had been unable to get rid of the rubble and useless furniture: “I am poor, and to throw this away costs money.”

An MSF team is going house-to-house in Manchen looking for potential sources of infection and explaining how to stop mosquitoes from breeding and spreading the virus. The challenge is to change people’s habits and social customs and to get them involved in the fight against dengue.

The mobile teams also treat stored water, which prevents mosquito larvae from hatching. Later, after gaining the trust of the families, they will return to spray houses in order to break the mosquitoes’ reproductive cycle. To date, MSF has treated the stored water in 700 households and sprayed 400 houses, while plans are in place to spray 4,000 more.
 

DRC 2010 © MSF

Some 25,000 people have been forced to flee thier villages in the Shabunda area of South Kivu.

Thousands of people have been forced to flee their villages in the Shabunda area of South Kivu Province, Democratic Republic of Congo (DRC), due to heavy fighting between the Congolese armed forces (FARDC) and other armed groups. Doctors Without Borders/Médecins Sans Frontières (MSF) is responding to the urgent needs of displaced people in this isolated area by providing emergency medical care, as well as treatment for cholera patients.

Since the beginning of August, there has been intense fighting in the northern part of South Kivu. More than 20 villages have been burned and looted, and more than 25,000 people have been forced to abandon their homes, in fear for their lives, seeking refuge in the towns of Shabunda and Katshungu and in the surrounding bush.

MSF teams were already at work in the south Shabunda area, where they had been providing medical care since late June to 20,000 displaced people. When this second wave of displaced people reached the Katshungu and Shabunda regions in early August, MSF was quick to respond, setting up two health centers in Shabunda—in the areas of Mbangayo and Lupinbi—and another center close to the hospital in Katshungu.

“Since we opened these health centers, our teams have been seeing large numbers of patients every day. They are carrying out around 200 consultations per day in each health center,” said Patrick Wieland, MSF’s head of operations for DRC. “Mainly we are seeing respiratory tract infections, sexually transmitted infections, and worms, related to the displaced people’s bad living conditions.”

Cholera has also broken out in the town of Shabunda, due to a lack of clean water and the poor conditions in which the displaced people are living. MSF teams responded to the outbreak, which began on August 17, by immediately setting up a cholera treatment center in Shabunda’s hospital, where they are seeing more than 30 new patients each day. As of August 29, MSF teams had provided medical care to 290 cholera patients. Two people have died from the disease. Most of the cholera patients are displaced people living with host families in the town, though some come from surrounding areas.

With the number of cholera cases continuing to increase steadily, MSF plans to scale up its activities, despite some major challenges. “The biggest challenge that we are facing is logistical,” says Wieland. “Shabunda is a very isolated area, and the only way to get our staff and medical supplies there is by cargo plane. Because of the cholera outbreak, we have already sent three planes with around 8,200 kg (nine tons) of supplies, and we plan to send onemore plane carrying two tons of supplies, and probably a car too. There are no cars in Shabunda, and the roads are in a very bad condition, so our teams move around on motorbikes or bicycles.”

MSF is currently the only humanitarian organization providing emergency medical care in the Shabunda region. Mostly due to the logistical challenges, humanitarian aid is difficult to bring to this isolated area. “The medical needs of the displaced people in the Shabunda area are enormous. More needs to be done to respond to this emergency,” Wieland said.       

MSF provides emergency medical care throughout North and South Kivu, running hospitals, mobile clinics, vaccination campaigns and cholera programs, and providing treatment and psychosocial care to victims of sexual violence.

Pakistan 2010 © Jean-Marc Jacobs/MSF

MSF water distribution point in Khyber Pakhtunkhwa province.

Since the beginning of the flooding in Pakistan:

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• Non-food item kits distributed: 24,834
• Tend distributed: 6,801
• Medical consultations performed: 27,151
• Diarrhea treatment centers: 7
• Latrines built: 258
• Oral Rehydration Salt points installed: 11
• Mobile clinics: 12
• Clean, safe water distributed: 718,000 liters per day

MSF’s existing and flood response programs in Pakistan are staffed by 1,279 Pakistani aid workers and 152 international aid workers.

More than five weeks after flooding began to overwhelm Pakistan's northern regions, Doctors Without Borders/Médecins Sans Frontières (MSF) emergency medical and water and sanitation teams are continuing to work in the north while also expanding operations to the southern provinces of Punjab and Sindh, where millions of people have been displaced by additional floods.

The prevailing concerns are the spread of waterborne diseases, malnutrition, and the lack of shelter and clean, safe water. Teams are rushing to establish new bases in the southern towns of Hyderabad and Sukkur, part of the effort to access flood-affected communities on either side of the Indus River. MSF is focusing on the water supply, shelter for the displaced, medical care for dehydration and acute watery diarrhea, and the distribution of essential non-food items (NFI).

SINDH PROVINCE

Sukkur

Officials report more than 4.5 million people displaced in Sindh province alone, including those who left their homes during mass evacuations of regional centers last week. MSF is planning further assessments to identify pockets of vulnerable people.

In Sukkur, in northern Sindh, MSF has been operational for four weeks, providing support to the intensive therapeutic feeding center (ITFC) ward of the Railway Hospital. The ITFC provides treatment for severely malnourished children under the age of five who have medical complications. Thirty children were admitted to the ITFC in the first five days it was open. MSF is conducting two nutrition-focused mobile clinics in surrounding areas and camps and distributing NFIs and hygiene kits. Work on Sukkur’s water plant has been completed, and now 80,000 liters of water are being distributed per day.

Last week, 110 consultations were completed in mobile clinics in a displacement camp in Sukkur and 24 of those patients were admitted to Railway Hospital with serious medical conditions. Oral rehydration therapy for diarrhea and dehydration was provided to 1,247 patients, and 2,561 people received health education in camps and at the hospital throughout the week.

NFI distributions also took place last week outside Sukkur. The result was that 265 tents, 453 hygiene kits, 539 cooking sets, 539 tarpaulins, and 539 jerry cans were handed out in the following locations: Sukkur Old Airport Road, Shara-e-Abassi Sukkur, C-Government High School, and C-Government College Pir Illahi Bux.

Hyderabad & Jamshoro

In southern Sindh, MSF has set up a base in the town of Jamshoro on the western side of the Indus River, near Hyderabad. MSF started up its activities in the area this week after identifying pockets of displaced people on both sides of the Indus who had received almost no assistance to date.

The main focus is the water situation; the aim is to provide five liters per day per person. On August 27, MSF distributed 30 cubic meters of chlorinated water in Jamshoro town. In the three days that followed, MSF’s distribution capacity grew to 180 cubic meters per day in six locations serving approximately 10,000 people.

Pakistan 2010 © Jean-Marc Jacobs/MSF

An MSF water bladder that was set up in Mingora.

Also this past week, mobile clinics were conducting 130 consultations a day per site. An additional 500 tents were ordered for NFI distributions that will begin this week and that will target between 5,000 and 10,000 families.

Going north along the western bank of the Indus, MSF located more than 10,150 people living without shelter and at least seven small pockets of displaced people living by the side of the road. Only one of these groups had received any assistance. Shelter is clearly a high priority—people are struggling just to find shade—along with access to clean water and medical services.

Approximately 50 percent to 70 percent of the villages MSF has encountered have been evacuated with the displaced populations taking up residence in camps. Some residents, however, have gotten little assistance and have very limited access to drinkable water or medical care. It seems clear that resettlement will take quite some time due to flood damage. Nonetheless, MSF has been able to identify abandoned structures in flooded districts that could potentially serve as locations for a diarrhea treatment center (DTC) if needed.

Around Jamshoro, there are two types of displaced people: those who’ve moved to relocation centers and those who are living out in the open. Four relocation centers are currently located inside government high schools, in extremely unhygienic conditions similar to those seen in northern Sindh. These centers have received some assistance, but MSF intends to monitor them and to provide hygiene kits if necessary. Clean water supply might be an issue in coming weeks as well.

There are several sites around Jamshoro where people are living out in the open. One is near a university medical college, where approximately 2,000 people from as far away as Jacobabad and Baluchistan province are gathered for the time being. Relief teams from the university are already providing food, water, and health care. There are other camps around Jamshoro, however, where needs remain high and tension exists amongst a population frequently desperate for help.

In Hyderabad, one main camp has been identified, the New Sabzi Mandi camp, where approximately 10,000 people have settled. Local organizations have already responded, so it remains to be seen whether MSF needs to support their efforts.

South of Jamshoro, on the road headed towards Karachi along the west side of the river, a large displaced population is staying in the Khuda Ki Basti Colony, a huge compound with around 300 blocks with four houses on each of them. The complex is completely occupied by approximately 6,000 to 8,000 displaced people, but sanitation and hygiene are poor. Two other tent camps are nearby, each with a population of approximately 1,000 people.

BALUCHISTAN PROVINCE

Nasirabad & Dera Murad Jamali

In Dera Murad Jamali (DMJ) in Nasirabad district, MSF continues to operate a DTC that had 46 admissions on August 28 alone. More information is also coming in about additional flooded towns and villages—places like Tambu and Babhakot—where people remain stranded.

More reports are likewise coming in about diarrhea-related deaths in displacement camps near DMJ such as Pat Feeder Canal, Degree College, Notal, and Model College camps. Clean water is still a major problem in DMJ and non-MSF tankers continue to supply water that is below emergency standards. MSF will not start distributing water until it is allowed to purify water sources first.

Pakistan 2010 © Ton Koene

MSF staff tending to a patient in Nowshera.

MSF is conducting several mobile clinics in the area and carried out 1,047 consultations in the past week. The mobile clinics are treating cases of acute watery diarrhea, skin infections, and malnutrition and distributing supplies for women. Malnourished children are being given a seven-day supply of ready-to-use therapeutic food (RUTF) and get follow up consultations a week later.

In the coming week, MSF mobile clinics will focus more on nutrition, antenatal care, and lactating women. Forty new cases of severe acute malnutrition were recorded in the past week in DMJ. Ten were referred to the hospital ITFC and 30 were tended to in the mobile clinic, along with 23 follow-up cases from the prior week.

MSF believes it can more effectively address morbidity through a more focused approach to nutrition in its mobile clinics. Pregnant women will also be offered limited antenatal care (including ferfol, albendazole, and a safe delivery kit) and supplemented with BP5 high energy biscuits.

In the meantime, following negotiations with local authorities, MSF should soon sign a contract to build 250 latrines in the same camp. MSF also plans to build more than 125 latrines and a 15 cubic meter water bladder for the 2,500 displaced people in Barchoki, in the Mangoli Camp, as soon as our tanker arrives and we produce enough water from the water plant.

There is currently one small filter plant In Mangoli Camp that has a capacity of about 300 liters per hour and can run for 12 hours a day. Three deaths related to diarrhea have been reported in this camp over the past week. Health educators have been dispatched in camps around town and soap will be distributed starting this week.

MSF tested and treated the water tank in DMJ last week; it was found to be acceptable and thus all tankers were re-rerouted to it on August 28. During the past week, 265 tents were distributed and the MSF team employed 20 day laborers to pitch 150 tents at the Degree College. The water and sanitation team will also provide 30 latrines and ensure water is delivered to the site as soon as possible.

Since the intervention in DMJ began on August 10, MSF has carried out 5,117 consultations, distributed packets of 100 aqua tabs to 551 families, and supported 1,050 consultations with Ministry of Health clinics.

PUNJAB PROVINCE

Kot Addu

On August 24, MSF’s 35-bed DTC in Kot Addu was fully occupied with severely dehydrated patients. MSF therefore expanded the center’s capacity to 75 beds. Additional personnel were brought in to augment the effort. More patients are still arriving, however—some referred by health centers in neighboring villages and transported by MSF ambulances—so it may be necessary to expand again in the near future.

MSF currently receives 150 patients a day in the DTC, 45 of them as inpatients. In total, 1,138 patients were treated for watery diarrhea last week; 338 were severe and 446 were children under five years of age. More patients with malaria, presenting with fevers, are being seen as well. And a small number of severely malnourished children are also presenting and being treated with therapeutic feeding.

MSF is also considering installing oral rehydration points in other health facilities in the area to ensure that dehydrated patients receive treatment quickly.

Places where internally displaced people (IDPs) have settled have been assessed north of Kot Addu. More than 2,000 flood-affected families were found who had not received any relief support so far. MSF is planning to assist them with NFIs and tents.

Rajanpur

This week, MSF teams are assessing the Rajanpur district in southern Punjab, a district bordering Sindh that was hard hit by the flooding. Medical teams are observing dozens of IDP settlements that have received very little assistance, if any. A significant upsurge of diarrhea and malaria cases has been recorded over the last few weeks at local health facilities, along with a worrisome number of malnourished children under the age of five. Based on the results of this assessment, MSF is considering opening a new project in this area.

KHYBER PAKHTUNKHWA PROVINCE

Peshawar

MSF performed 845 consultations in the last week at the three supported basic health units (BHUs), mainly for skin diseases and watery diarrhea. MSF may hand over daily activities of some health facilities to the Ministry of Health or another organization in order to focus solely on case management of malaria and watery diarrhea.

MSF is also continuing to distribute NFI and tents where flood-affected populations are not benefiting from the assistance of other organizations. Approximately 2,500 families received NFIs and tents last week in settlements near the river and in the north of the district, as well as in Afghan refugee camps south of Peshawar. Since the beginning of the flood response, MSF has provided NFIs and tents to more than 7,000 families in Peshawar district. New distributions are likely in the coming weeks in order to cover the needs of people who were living in schools but may have to find another refuge, since school is scheduled to open soon.

Charsadda

Mobile clinics in Charsadda have conducted 7,191 consultations since the flooding began. The main maladies are skin diseases, acute watery diarrhea, and respiratory infections. Four new sites were identified this week as well. Mobile clinics in Charsadda will reduce their activities in the coming weeks as more people return home and can will be able to more easily access primary health care facilities. Nevertheless, MSF is still working on emergency preparedness plans that include setting up a DTC should that be required in the second phase of the disaster.

MSF distributes an average of 93 cubic meters of water per day in Charsadda. From August 15 to 25, more than 10,000 cubic meters of water were distributed in Charsadda. Overall, MSF has distributed 2,250,000 liters of water in the towns of Painda Khel, Babra, Zoor Bazar, Giddra, and Shulgara.

MSF has installed 27 500-liter tanks in the so-called “Motorway camp” situated on the highway between Peshawar and Islamabad. MSF will provide 14 cubic meters of water per day there, 19 cubic meters per day in Hizara Camp, and 15 cubic meters per day in Utmanzai Camp

A well-cleaning program was started last week with two teams working on the periphery of Charsadda. The first team is working in Zoor Bazar, Babra, and Shulgara. The second started cleaning wells this week in the villages in the Tangi area. The hygiene promoters will also join the well-cleaning teams to conduct information campaigns.

NFI distributions in Charsadda will be finished this week; in total, 4,870 NFI kits have been distributed since the beginning of the intervention. Villages will also be assessed in coming weeks for distribution of reconstruction kits designed to help 2,500 families begin their return home.

Nowshera

At the beginning of last week, MSF performed 170 consultations at Nowshera Hospital's outpatient department and 474 at the emergency room. MSF has since handed management of the hospital back to local health authorities so that resources can be applied to regions experiencing more urgent medical needs, particularly in the south of the district. However, MSF will set up an epidemiological early warning system in order to follow up the evolution of acute watery diarrhea and to counteract a waterborne disease outbreak, should one occur.

As other medical organizations arrive in the area, MSF has decided to focus on water and sanitation activities, increasing daily the amount of chlorinated water it is providing to the populations and continuing to conduct NFI distributions. From August 9 to August 22, MSF distributed 903,000 liters of chlorinated water. In the past week, MSF provided almost 240,000 liters of water per day in 10 locations, including Pir Sabak, Akora Khatak, and the town of Nowshera itself. Three other water points were rehabilitated with automatic chlorination in Pir Sabak. Last week, MSF provided NFI distributions to 1,780 families and tents to 350 families. Since the beginning of the flood response, MSF has provided NFIs to almost 5,800 families in Nowshera district.

Swat

In Mingora hospital, there is a slight decrease in emergency room traffic, but MSF expects the numbers rise again after the bridges are repaired and people currently isolated are able to access health care services. MSF has trained senior nurses and laboratory technicians in blood bank management and the care and transport of blood and transfusions.

Mobile clinics continue in the Mingora area. MSF has started to refer surgical patients from mobile clinics to Timurgara because its more easily accessible from towns such as Kabal and Matta. As other actors return to Swat’s health structures, MSF is spreading its mobile clinics to areas where no other actors are present. The new locations include Manja, Kalagei, and Tarkani, all near the border of Dir district.

MSF plans to extend mobile activities for two more weeks, or until would-be patients who are still cut off can access Mingora hospital. All told, MSF has conducted 1,600 consultations in the region since the beginning of the flood intervention.

Mingora’s DTC was still receiving close to 100 patients a day last week, most suffering from watery diarrhea and mild to moderate dehydration. The emergency phase is most likely winding down in the DTC, but MSF is still sharing data with its health promotion and water and sanitation teams in order to respond to suspected cholera cases. Since the beginning of the flood response, MSF has treated 1,262 patients.

MSF’s water distributions continue in Swat, where a total of 4.5 million liters have been distributed. MSF’s water treatment unit has also provided 2 million liters of water that was distributed by other non-government organizations (NGOs). MSF’s health promotion team continues to join water and sanitation teams that are cleaning wells, carrying out hygiene promotion and education, and distributing hygiene kits around Mingora. Thus far, MSF’s water and sanitation team has cleaned 26 wells.

Timurgara (Lower Dir)

Last week, MSF conducted an assessment of the DTC at District Headquarters Hospital in Timurgara and plans to assist by supplying drugs and human resources, improving hygiene and rehydration capabilities, and providing infusions.

MSF is supporting the emergency room at the Rural Health Center in Munda and managing suspected cholera cases, which average six per day. MSF mobile clinics are ongoing in Summerbagh and Tauda China, and in Tauda China, MSF has distributed NFI kits to 55 families and 8,000 liters of water at the Khazana bypass.

Dargai (Malakand)

The acute phase of the emergency is over in Dargai, where the DTC now averages just two cases of acute watery diarrhea per day. NFI distributions have been completed in Malakand after 466 kits were handed out to families in the region. Mobile clinics have conducted 624 consultations, and 450,000 liters of water have been distributed.

In the past week, mobile clinics in Kalangi performed 105 consultations for diarrhea, respiratory infections, skin infections, and malaria. The mobile clinic found no serious medical conditions that cannot be treated by mobile clinics working on the other side of the river, in Dir, which is reachable via a traditional suspended chair. Some medical staff have been sent to Sindh to reinforce efforts there.

Hangu

In Hangu, MSF has been responding to an outbreak of acute watery diarrhea since July, treating more than 1,800 cases in an 80-bed DTC. The outbreak appears to be almost over, since MSF was seeing 55 patients per day two weeks ago but is now receiving only five patients per day.

FEDERALLY ADMINISTERED TRIBAL AREAS (FATA)

Sadda, Kurram Agency

In Sadda, Lower Kurram, where MSF has run a project since 2006, MSF set up a 30-bed DTC after an acute watery diarrhea outbreak was confirmed. The facility currently receives 20 patients per day, roughly a quarter who are severely dehydrated and need hospitalization.

Since 1988, MSF has been providing medical assistance to Pakistani nationals and Afghan refugees suffering from the effects of armed conflicts, poor access to health care, and natural disasters in Khyber Pakhtunkhwa, the Federally Administered Tribal Areas, Baluchistan, and Kashmir. MSF does not accept funding from any government for its work in Pakistan and chooses to rely solely on private donations.

How the international food aid system is failing children; and how MSF's multimedia campaign, Starved for Attention, aims to spur public awareness and push international food aid donors to make their food nutritionally adequate for young children. Sign the Starved for Attention petition to rewrite the story of malnutrition.

© MSF

MSF is the only organization working to provide people with free, good quality healthcare in the area. To get the treatment they need, people come from villages nearly 60 km (37 miles) away.

In August 2009, Doctors Without Borders/Médecins Sans Frontières (MSF) started working in Imey, in the Somali region of Ethiopia. For nearly a year now, together with personnel from the Regional Bureau of Health, MSF staff have been running a primary health care center in East Imey and supporting another in West Imey.

Separated by a river that staff and patients must cross on a small boat, the two sites provide regular outpatient consultations to more than 2,000 patients per month. Services include antenatal and postnatal care consultations for pregnant mothers and those who have recently delivered. Women with complicated deliveries are referred to the maternity department in East Imey. Both centers now feature a vaccination component and a nutrition program to treat malnourished children as well. Below, outgoing field coordinator Christian Sorensen talks about the project:

What are the most pressing needs of the community?

Chronic poverty and irregular rainfall make the hard life of Imey’s pastoralist and nomadic population even more difficult. Basic health services hardly exist, and the community has a lot of different needs. Especially in East Imey, the humanitarian situation is a real challenge because of insecurity and an undeveloped infrastructure.

We take care of 70 patients a month in East Imey’s 15-bed inpatient department (IPD). Children come to the center with respiratory infections like pneumonia or severe malnutrition. Sometimes people arrive with animal bites or gunshot wounds. And due to the poor quality of the water that is available, waterborne diseases like eye infections, skin disease and diarrhea are quite common among the population.
Tuberculosis (TB) is also a major health problem for the people of East and West Imey, so we are planning to start diagnosing and treating patients with TB in the near future.

In order to improve the access to health services for people who cannot even reach the center, we started running weekly mobile clinics in new locations. There are no other functioning health facilities in the district or any other organizations providing health services here. It’s true that our activities target primary health care, so we can only address some of the needs. Without a doubt, there is still a lot of work to be done in order to provide more people with free, good quality basic health care in these areas.

MSF refers people in need to the closest hospital, which is six to eight hours away by road. Practically speaking, what does that mean for the patients?

It means that most people do not have access to hospital services, and they also cannot afford to transport themselves there. Our health clinic is the closest place to go. I know that the community really appreciate that we refer people to Gindir; they know that if we can’t do something in our own structures to help them, then we will transport the patients to the hospital for necessary operations or complicated deliveries.

However, considering the drive is six to eight hours, we really do our best to treat the patients in the clinic. If you are sick or injured, eight hours on a bumpy road is a nightmare. But in Imey there are no other [hospital] options.

One night, we received a woman who had been in labor for several days. Our nurse and the midwife from West Imey had crossed the river at the middle of the night to bring the pregnant woman to the IPD in the East Imey center. We don’t have the surgical capacity in the clinic to deal with delivery complications, so when the woman’s condition was stable, we drove her to Gindir hospital for referral. Fortunately, both the mother and her new baby survived.

How do the people of East Imey see the activities of MSF?

As the only foreigners in the area, part of our responsibility is to talk regularly to the community that is hosting us, to explain why we are there, what we are doing, and that the services are free and for everybody.

We’ve visited villages near and far, and we found out that people know about the health center. Still, one of the main challenges is to get people to come to us earlier, before they get too sick to treat.

It’s easy to talk to the community. The Somali culture is a culture of meetings, discussion, and exchange. In fact, the midwife working in the clinic has made a lot of efforts towards meeting traditional birth attendants (TBAs) in the district in order to raise awareness about the kinds of problems they face and to discuss how to cope with the challenges like high risk pregnancies. These meetings are fruitful for the TBAs and the MSF midwife, but in the end, the winners are the patients.

What are the next steps for the Imey project?

We have to continue to target the most vulnerable people within the population, meaning those who most likely cannot even make it to our health center. Through opening mobile clinics in more locations, we can give people who can’t access the existing health structures an alternative.

The districts we are working in are big; some areas are more than 60 kilometers [36 miles] away from the clinics. And if you are sick, you can imagine that walking 60 kilometers under the burning sun is not what you want to do. If we could reach people, rather than them having walk for two days to come to us, that would make a difference to their health.

Starting a TB component in the project is also crucial. We have a lot of experience in working in TB in other areas of Ethiopia, and it’s much needed here.

What do you think is the impact of MSF’s work in Imey?

It’s clear that there are not many alternatives for people, if any, when it comes to health services in the two districts where we are working [and] also in neighboring areas.

We receive patients from villages far away and other districts. A few weeks ago, I met a mother who was walking for three days to bring her ill son to the center. Her child was diagnosed with Kala Azar, a tropical disease transmitted by the sandfly, which can be a deadly disease if left untreated.

We have a role to play in saving lives, giving treatment, and taking people’s health needs and worries seriously, because they have no other option. Also, by running these health centers we are involved in training health personnel in Somali region. In the long run, they will be the ones carrying on and continuing this work.
 

Somalia 2008 © Jehad Nga

In 2008, woman displaced by the kind of fighting raging again today in Mogadishu waited for food that was being distributed by a local NGO.

With intense fighting raging in Mogadishu, Doctors Without Borders/Médecins Sans Frontières (MSF) medical teams treated 127 casualties in Daynile Hospital in the three-day period between Monday, August 23 and Thursday, August 25. This is by far the largest influx of wounded people MSF hospitals have taken in since the beginning of the year, a result of the substantial escalation of the fighting in Mogadishu this week.

MSF is sending additional drugs and medical equipment to the hospital to support the medical team. A third Somali surgeon is scheduled to join the team on Thursday to provide much-needed relief to MSF teams that have been working around-the-clock since Monday.

“Our staff in Somalia is treating the war-wounded and doing its best to meet the massive medical needs in this increasingly volatile situation,” said MSF’s Head of Mission Thierry Goffeau. “We are relying on shipments of additional medical supplies and have set up tents outside the hospital to handle the overflow of patients.”

All the injuries were the result of blast or gunshot wounds. People suffered multiple injuries, predominantly wounds to the abdomen, lower limbs, and chest. So far, 22 patients have required immediate surgical intervention. Eight patients died as a result of their injuries, with four of these patients dying upon arrival.

“Thanks to the hard work of our staff in Mogadishu, we can continue to provide life saving surgery to the Somali population in the midst of this fighting,” Goffeau said.

MSF operates projects in eight regions of south central Somalia. More than 1,300 Somali staff, supported by more than 100 staff in Nairobi, Kenya, provide primary health care, tuberculosis and malnutrition treatment, surgery, and water and relief supplies to displaced people. MSF does not accept any government funding for its projects in Somalia, relying solely on donations from individuals throughout the world.

Pakistan 2010 © Ton Koene

A boy stands in a home wrecked by the flooding in Pakistan.

• Relief kits distributed: 14,675 kits to 14,675 families
  or approximately 102,725 people
• Tents distributed: 4,855
• Clean water distribution per day: over 540,000 liters
• Water Access Points: 52
• Consultations in hospitals and mobile clinics: 16,664
• Mobile clinics: 14
  3 in Dera Murad Jamali
  1 in Khabula
  1 in Sobhatpur (Baluchistan)
  1 in Malakand
  1 in Swat
  1 in Lower Dir
  3 in Charsadda (KPK) 
  3 around Sukkhur (Sindh)
• Diarrhea Treatment Centres: 6
  Malakand, Lower Dir, Swat, Hangu, Kot Addu, and DMJ
  

A month after floodwaters began spreading across Pakistan, uprooting thousands of families and many entire communities in the process, Doctors Without Borders/ Médecins Sans Frontières (MSF) continues to scale up activities in the affected areas while preparing to expand its work to serve new locations and places where thousands of people are cut off from assistance they vitally need.

Improving Access to Clean Water and Sanitation

To curb the possible outbreak of waterborne diseases, MSF is ramping up the distribution of clean water in larger towns and remote villages located throughout the Charsadda, Swat, Nowshera, Lower Dir, and Dargai districts in Khyber Pakhtunkhwa province. In the coming days, MSF will also start water and sanitation activities in Sindh and Baluchistan provinces as well.

Teams are also planning to assess the water supply systems in Dera Murad Jamali and Sukkur, towns in Baluchistan and Sindh provinces, respectively, in order to ensure that the public water supply plant sufficiently chlorinates its water before it reaches the population at large.

Across Pakistan, MSF is now providing at least 540,000 liters of clean through fixed and mobile water points—trucks, tanks, taps, and stands—and house-to-house distribution. MSF is also providing containers and buckets to families who need them and helping local communities clean and rehabilitate contaminated wells.

Pakistan 2010 © Ton Koene

MSF staff conducting an assessment in a Pakistani village that was battered by the flooding.

“It’s worrisome that some families with small pumps at home have started using their water source again,” explained Muhammad Shakeel, a member of MSF’s water and sanitation team in Nowshera. “This is not good because the water is still contaminated, and this can lead to many waterborne diseases. We will continue to provide safe water until we can put in place a system to check if the water is good enough for daily use.”

Distributions Continue

With the threat of more rainfall and new floods still looming, MSF continues to provide affected and displaced people with basic necessities to help them maintain a minimal standard of living and prevent the spread of diseases.

In Baluchistan and Khyber Pakhtunkhwa, more than 14,675 relief kits and 4,855 tents have been distributed. A typical kit includes buckets, soap, laundry soap, a tooth brush, a jerry can, hygiene items for women, a towel, plastic mugs, kitchen utensils, plastic sheeting, tents, a mattress, and water purification tablets. In the coming days, as teams assess new locations more relief kits and tents will be provided to those in need.

Health Workers: A Vital Component

Health promotion workers are playing a crucial role in raising awareness about health risks. During distributions, for instance, they show people how to use water purification tablets to obtain safe drinking water. Relief packages distributed typically include 20 purification tablets, which, when used properly, allow a family of seven to have safe, clean water for a period of two weeks.

In Dera Murad Jamali, to take another example, MSF is concerned that unhygienic conditions are compounding pre-existing malnutrition issues. Health workers are therefore also addressing both hygiene and nutrition. Furthermore, at an emergency feeding program that predates the floods, MSF is currently treating at least 300 children younger than 5 years old for severe malnutrition.

Boosting Mobile Clinics and Health Structures

Since August 1, MSF has provided more than 16,664 consultations to people affected by the floods. Roughly half of those consultations were conducted in 14 mobile clinics in and around Dera Murad Jamali, Khabula, Sobhatpur, Malakand, Swat, Lower Dir, Charsadda, Sukkur, and Peshawar.

Due to an increasing number of patients with acute watery diarrhea, MSF has also set up diarrhea treatment centers (DTCs) in Swat, Lower Dir, Malakand, Hangu, Kot Addu, and Dera Murad Jamali. At the same time, MSF has augmented its personnel and its medical and logistical capacities to treat waterborne diseases such as cholera. More DTCs will be opened as needed.

In Khyber Pakhtunkhwa’s Swat district, a 20-bed isolation unit has been established at the hospital in Mingora; it has a tent for oral rehydration treatments and hygiene promotion. In the town of Dera Murad Jamali in Baluchistan, the team has set up a 20-bed DTC in order to cope with the massive influx of patients from neighboring districts that are still flooded. In Kot Addu, in Punjab, MSF added another 70 beds to the 30-bed DTC. Thus far, the teams have treated approximately 1,600 cases of acute watery diarrhea.

More Needs, New Activities in New Locations

In Baluchistan and in the northern reaches of Sindh province, the rising water levels of the Indus River have driven 90 percent of people in areas such as Usta Muhammad, Dera Allar Yar, and Ganakha from their homes. In southern Kashmir and southern Sindh, floods have also forced families to seek refuge on higher ground, on embankments along the main canals, railway lines, or roads.

In Sukkur, in northern Sindh, MSF has started distributing relief items and has launched three new mobile clinics that are providing free medical services. Mobile teams in Sindh are finding groups of up to 1,000 people desperately in need of medical attention, particularly the children among them. Also in Sukkur, MSF is supporting a 30-bed pediatric ward for children under 5 years of age.

In southern Sindh, MSF set up an office in Hyderabad to coordinate relief activities in the area. Exploratory teams are still assessing other parts of Khyber Pakhtunkhwa, Punjab, Sindh, and Baluchistan, gauging the immense medical and humanitarian needs of the affected population and preparing to respond by providing safe water, DTCs, and medical care through mobile clinics.

More than 110 international staff are currently working alongside 1,200 national staff in pre-existing and flood response programs in Pakistan.

Since 1988, MSF has been providing medical assistance to Pakistani nationals and Afghan refugees suffering from the effects of armed conflicts, poor access to health care, and natural disasters in Khyber Pakhtunkhwa, the Federally Administered Tribal Areas, Baluchistan, and Kashmir. MSF does not accept funding from any government for its work in Pakistan and chooses to rely solely on private donations.

Pakistan 2010 © Jean-Marc Jacobs/MSF

An MSF water distribution point in northern Pakistan.

James Kambaki, MSF project coordinator in Balochistan province, reports on the situation and on MSF's activities.

We’ve been running a number of mobile clinics in Fadfedar canal, in the areas around Manjoshori, and in Khabula, where the people we struggled to reach not long ago are now relatively accessible.

Here in Dera Murad Jamali (DMJ) we are treating a lot of watery diarrhea and we’ve begun to support obstetric emergency in the hospital. The number of women needing consultations has really increased and the doctors are working 24 hours. We’re seeing a lot of women with placenta praevia, eclampsia and all manner of obstructions, complications, and obstetric emergency cases. Our doctors are working around the clock to treat them.

The sheer number of people in the city is complicating matters. DMJ usually has a population of approximately 50,000, but the flooding has meant that tens of thousands of people from the surrounding countryside and even from areas hundreds of kilometers away have poured into the city. The official figure for the influx is 60,000, but looking around, it’s easy to see that it could be much higher.

Most of the towns and areas around DMJ are completely underwater, and their inhabitants have come here. In the first few days of the flooding, there was a mass movement of people, which was terrible to witness. On the surrounding roads outside the city, there were thousands of people all moving in the same direction. People were on tractors, on ox carts, on donkey carts, on motorbikes, on tuk-tuks, and on foot, picking up anything to cover themselves. Children were being carried, and people were carting everything they owned perched on top of their heads. Animals were dying on the way, people were struggling to walk, and the heat was extremely intense. We distributed plastic sheeting and thousands of hygiene kits and cooking items.

With so many people in the city, clean drinking water is still a major concern. We’ve seen an increasing number of watery diarrhea cases, which we are managing, but in the past few days we have had a number of incidents when people have been so ill that they have died on the way to the hospital. In the hospital compound, workers have found bodies of people who died just before they made it to us. It’s terrible as we have no idea who these people are.

The water situation is really appalling. There are canals and small ponds filled with contaminated flood water that people are drinking from. We have a number of water bladders and we are distributing [water] constantly. At the moment, it is still not enough. But a major water purification system should be up and running in a few days, which will really help alleviate the situation.

There are tents and temporary shelters everywhere, pitched in sports stadiums, in school grounds, in colleges. There is one college with around 200 tents but not a single latrine. In the next couple of days, we are going to help build 250 latrines there and others in a number of other locations. In situations like this, where water-borne diseases are a continuing threat, prevention is vitally important.

With so much overcrowding, displacement and need, people are very angry. I’ve seen quite a few protests and when we do distributions it’s very tough. People tell me they are upset because a lot of them have not received food and some have no shelter. I met one man who had travelled over 200 kilometers [120 miles] with his family. They had nothing and were desperate for food and for somewhere to stay. He was extremely angry and I couldn’t blame him. But we’re doing all we can to help people like him.

The team I have working with me are amazing. They are strong and they are working long hours. In the next few weeks our main focus is going to be treating the diarrhea cases and ensuring that more clean water is distributed. It’s a massive task, but we are making progress.

Less than 100 babies contract HIV from their mothers in US every year, while 18,000 known cases occur in Uganda. We visit one MSF-supported program to prevent such transmission, in Madi Opei.

Sudan 2009 © Jenn Warren

Last year also saw a spike in kala azar cases in Jonglei State. A mother helped care for her infected 24-year-old son at an MSF kala azar clinic.

Doctors Without Borders/Médecins Sans Frontières (MSF) has set up an additional base in Pagil, in Jonglei State, Southern Sudan, to deal with an alarming increase in the number of patients infected with kala azar—or visceral leishmaniasis.

The new clinic comes in addition to MSF project sites in Leer, Lankien, and Nasir, as well as health centers run by other organizations in Ayod and Old Fangak, all of which report an unusually large number of kala azar patients seeking medical care, and many of which are seeing dozens of new admissions every week. Some patients have traveled for days to get treatment.

"Based on our experience last year, we expected an increase of patients from early September," said Chris Lockyear, MSF’s head of mission in South Sudan. "But the number of cases turning up at the various health centers in the region indicate that it will be even worse than the previous year."

If left untreated, the disease, which is transmitted through the bite of the sand fly, is fatal. Treatment includes not only providing kala azar drugs, but also intensive treatment of associated infections, such as pneumonia, diarrhea, and anemia. Treatment providers must also focus on malnutrition, which leaves patients more susceptible to the disease.

"The fact that we see these high numbers so early, in the traditional low season of the disease, indicate that we are on the brink of a massive outbreak later in the year," said Koert Ritmeijer, MSF health advisor and kala azar specialist.

The explanation for this early outbreak of the tropical disease is complex. "The last big outbreak of the disease was eight years ago," said Ritmeijer. "And as a result there is a whole new generation that has not built up immunity against the disease."

According to Ritmeijer, other influencing factors include climatic conditions which favor the sand fly, allowing it to thrive and transmit the disease. High levels of malnutrition this year in various regions of Southern Sudan, due to insecurity and failed harvests, compound the problem.

To relieve the pressure on existing health centers, MSF decided to set up this extra base in Pagil, a remote village with only one solid building that serves as a clinic. The MSF team members are living in tents and are treating most of the patients under canvas as well. Within the first two days, the team confirmed 16 cases of kala azar; this number is expected to rise once word spreads in communities that treatment is available in Pagil. The team, which consists, on average, of six international and national staff members, is facing some difficult logistical challenges.

"We aim to resupply the team every seven to 10 days," said Lockyear, "but that’s entirely dependent on the weather and the condition of the small airstrip, which is just black cotton soil that turns into sticky mud as soon as it rains. So we have to carefully select the drugs and medical supplies and not overload the small plane."

The team will assess the need to open other sites in the vicinity of Pagil depending on the trends of patients reporting to the various MSF clinics. As a result, the Pagil base will remain open well into 2011.

India 2010 © Guillaume Bonnet/MSF

MSF is providing training for local health center staff in diagnosing and treating malaria.

Following a sharp increase in malaria cases in Mumbai, Doctors Without Borders/Médecins Sans Frontières (MSF) has launched a malaria intervention to help local health authorities fight the disease. On August 18, MSF teams that were already working in an HIV treatment project in Mumbai began providing 100,000 diagnostic kits and 3,700 treatment kits to 64 health centers in the city. MSF will also provide training for health center staff in diagnosing and treating the disease.

Read more Quick Facts About Malaria

MSF is responding to a request from the Ministry of Health to reinforce the supply of treatment for the falciparum strain of malaria, which is the most deadly form of the disease and constitutes approximately 10 to 15 percent of all cases in Mumbai. The diagnostic tests that MSF provides are an efficient way of identifying which strain of malaria the patient is infected with.

The most affected areas of the city are home to half a million people. There, the 14,724 recorded malaria cases for the first six months of 2010 is nearly equal to the number of cases recorded for the whole of last year.

“Last year, MSF successfully treated over one million malaria patients in 30 different countries," said Tiago Dal Molin, MSF’s project coordinator in Mumbai. "We are pleased to share our resources and expertise with the Mumbai authorities. It is crucial that health staff can give a correct diagnosis so that patients can be treated appropriately. The diagnostic tests that we provide are reliable, easy to use, and require just one drop of blood to give results.”

Despite improvements in the diagnosis and treatment of malaria, the disease continues to kill almost one million people around the world every year.

“The disease is transmitted by infected mosquitoes, and areas with stagnant water are usually ideal breeding grounds," said MSF’s Sanjana Maurya, who is supervising the intervention. "Recent heavy rains in Mumbai are likely to be the cause of the current rise in malaria.” 

“Some of the most vulnerable people are the migrants in Mumbai who work in construction labor," added Tiago Dal Molin. "They often sleep close to construction sites where there is a lot of stagnant water following the heavy rains." 

Food insecurity is particularly severe in areas of the Sahel region this year; MSF is conducting emergency nutrition interventions.