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無國界醫生 Médecins Sans Frontières

Brutal truth behind the applause

Borderline

08 May 2014

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A "Luxury" for Afghan Patients

 

It has been more than 12 years since international community launched its intervention in Afghanistan, and now many of the armies and donors are planning to withdraw, leaving the country to rely more on its own, fragile resources. 

 

MSF, which has worked in Afghanistan for more than 30 years, is one of the main healthcare providers in the country today. Despite optimistic accounts from the international community and the Afghan authorities about the achievements of rebuilding the national health system, our study found that there is inadequate access to healthcare and that many humanitarian needs are left unmet. What does this mean for an ordinary Afghan woman, her children and their father?

 

In Hong Kong, of course there are some issues about accessing healthcare, which include a long waiting time to get a medical appointment or have an operation in the public sector. In Afghanistan, access to healthcare means crossing some very formidable barriers. It’s about the long distances that people have to travel to reach a functional clinic with qualified medical staff and supplies, the number of checkpoints from hostile groups that they need to pass through on their journey, and the security risks they are taking when going out looking for a doctor.

 

By saying there is inadequate access to healthcare in Afghanistan, we mean that many Afghans don’t have the luxury to have a doctor next to them or proper treatment when they are sick. The situation today is alarming and MSF is trying to focus international attention on the practical issues facing the Afghans and the urgent business of saving lives.

 

This issue of Borderline will also look at the real risks of epidemic outbreaks in the aftermath of natural disasters like typhoons or earthquakes which kill lots of people. Are those bodies then a hazard to the people who survive? Medical Info will clarify this topic from a medical perspective. 

 

We also want to present to you what we are witnessing in the Central African Republic, a small country in a deep humanitarian crisis as communities are turning on each other, mainly due to religious and ethnic tensions. In the Photo Feature, you will be able to confront the acute situation on the ground.

 

MSF is committed to reach the most neglected and forgotten populations who are in urgent need of care and Borderline brings you some of the realities faced by our medical teams deployed in so many parts of the world today. For them to succeed, your help and support remains indispensable. 

Remi Carrier

Rémi Carrier

Executive Director, Médecins Sans Frontières Hong Kong

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Cover Story

Afghan healthcare: Brutal truth behind the applause

For Afghanistan, a country which has been trapped in war for so many years, 2014 is a critical year, with the presidential election in April and the withdrawal of the US army by the end of the year. Claims and reassurances have been made about the achievements of the international community in rebuilding the country, including the provision of healthcare. MSF's own study though finds that Afghan people are still facing multiple challenges in getting treatment.

 

Last year, MSF conducted six months of research, interviewing 800 patients and their caretakers in four distinct regions. One in every five of the patients had a family member or close friend who had died last year due to a lack of access to medical care, while 40% of patients faced fighting, landmines, checkpoints or harassment on their journey to MSF hospitals.

 

Barriers to healthcare

 

Distance, insecurity and high cost are the main obstacles. 12% of interviewees said it took more than two hours to get to the hospital. Some people, too afraid to go out and find a doctor in the dark, were forced to watch over their sick or injured relatives throughout the night, hoping they would survive until morning to bring them to a hospital.

 

Most interviewees live in poverty, with each household surviving on US$1 per day but having spent an average of nearly US$40 on a recent medical consultation. They also need to pay for transportation, accommodation and other costs, which push many into debt or force them to sell their few possessions.

 

Some public hospitals, while promising to provide free healthcare, lack quality medical staff, facilities and drugs. Waiting times are too long and the referral system is weak. A 33-year-old woman from Helmand province said, “The government clinics are always crowded with sick people. You have to bribe the doctors to be seen. They don't really care about the patients. They are just waiting in their office for the day to end so they can go home.” Many patients prefer to travel greater distances, at significant cost and risk, to seek care from private hospitals. But interviewees also spoke of misdiagnosing and overprescribing from the private practitioners they visited. All the more reason that public health facilities should offer quality care as an accessible and affordable alternative.

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Difficulties facing humanitarian organisations

 

One reason the health system is failing to address peoples' needs is that decisions taken by belligerent governments on where and how to provide assistance in Afghanistan have too often been based on considerations such as stabilisation, counter-insurgency strategies or “winning hearts and minds”, rather than medical needs. Aid was directed towards insurgency-affected areas where international troops were present, while other areas were overlooked.

 

The consistent insecurity and limitations on access to conflict areas prevent humanitarian organisations like MSF from providing a sustained response. Michiel HOFMAN, the former representative for MSF in Afghanistan, says the only answer is to talk to all sides. “MSF has been able to carve out operational space in Afghanistan through regular, direct, and transparent negotiations with all the warring parties, and complete financial independence from western and Afghan government sources.”

 

MSF is very concerned that continuing conflict in many parts of the country and a failure to meet rising medical humanitarian needs will coincide with a reduction of interest from international community after the withdrawal of the US army. International donors, aid providers and Afghan authorities must make more efforts to ensure impartial healthcare can be provided to all sick and wounded, while putting aside any considerations other than people's needs.

 

Afghan women: harsh fate

 

Statistics show that one in 42 women in Afghanistan is likely to die of issues related to pregnancy and childbirth. The maternal mortality rate is one of the highest in the world.

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One reason for this is the dire lack of female medical staff, particularly in rural areas. Many women are reluctant to be examined or treated by male medical staff. And then there are travel and safety fears. “The government clinic in our area is only open until 12 noon. So pregnant women with complications have to wait for the next day until the road is secure.” A resident from Lashkar Gar said. “Most of them die because they can't reach a hospital in time to save them.” What makes things worse is that women in most areas require consent from their husbands to visit a health facility, and usually have to be accompanied by a male relative.

 

To reduce the maternal mortality rate, MSF has operated a maternity hospital in Khost province since 2012, with an all-female medical team providing 24-hour free healthcare. In 2013, MSF performed nearly 12,000 deliveries in the hospital.  

 

“I've already paid so much to help my daughter. Now I’ve run out of money. I spent it all on private doctors or traveling to them. We came here (to Boost hospital) because it's free. Yet when she was discharged we needed to stay here in the town, near the hospital, to bring her for daily follow-up appointments. So, even though the healthcare here is free, it still costs money for me to stay close to it.”

- A 39-year-old Mullah* from Helmand

 

“We can't move at night or all of us would be killed on the road. So, we prefer that they die quickly rather than having to suffer through the night only to die the next day or on the way. This is our reality.”

- A 50-year-old farmer from Kapisa

 

“In my area, there's just one private doctor and he used to fix tyres. He didn’t study medicine, but has one big medical book in Pashto. When I went to see him with head pains he told me to look up the book myself to find a treatment. That’s not a doctor! How can he treat anyone who is seriously sick?”

- A 22-year-old farmer from Helmand

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* Muslim teacher

Worldwide Work

Mounted emergency response in Ukraine

 

Following violent clashes between anti-government protestors and police in mid-February, MSF sent an emergency team to support a health facility. It is also providing mental health support and making donations to other health structures.  

 

Responded to Ebola epidemics in Guinea

 

An outbreak of Ebola haemorrhagic fever was declared in southern Guinea in March. As of early April there were 122 confirmed cases and 78 deaths. MSF set up isolation units in affected areas and traced all contacts of patients to break the chain of transmission of the virus.

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Opened a Malnutrition Intensive Care Unit (MICU) in India

 

The facility started work in early March, jointly operated by MSF and the Ministry of Health to treat the most complicated cases of severe acute malnutrition in children in Bihar. The MICU is the first of its kind in India.

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Started preventing Chagas in Mexico

 

Medical teams started providing Chagas disease diagnosis and treatment to the populations in Oaxaca state, including technical support and training to medical staff and implementation of a vector control programme to eradicate the insect carrying the disease in intervention area.

Medical Info

Will Dead Bodies Lead to Epidemics?

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Super typhoon Haiyan ripped through the central Philippines last November, leaving over 6,000 people dead and millions displaced.  As in the aftermath of other large scale natural disasters, when people see images of dead bodies in media reports they often worry that unburied corpses can cause disease outbreaks. But is it true?

 

“There is a widespread myth that dead bodies cause the spread of infectious diseases, but actually it is not true,” says Dr Natasha REYES, Manager of the Emergency Response Support Unit in MSF-Hong Kong's office, who arrived at the Philippines for the emergency intervention the day after the typhoon hit. 

 

Myth and science

 

“Dead or decayed human bodies do not generally create a serious health hazard; unless they are polluting sources of drinking water with faecal matter, or they are infected with plague or typhus, in which case they may be infested with the fleas or lice that spread these diseases.”  

 

The World Health Organization guideline* agrees that dead bodies after disasters, as they usually have died from trauma, generally do not carry a high risk of disease outbreaks. It is the lack of access to adequate clean water, overcrowding, poor hygiene and sanitation facilities, low vaccination coverage among the population, poor coverage and quality of health services, or the local disease ecology, such as endemicity of malaria, dengue or other infectious diseases that pose the real risk of infectious diseases after natural disasters. 

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Biggest yet invisible impact

 

On the other hand, the major impact of dead bodies on survivors is through the psychological trauma, something which should not be neglected, Dr Reyes emphasizes. “People have lost their loved ones and witnessed death on a large scale. The presence of dead bodies makes it more difficult for the survivors to recover.” 

 

There were several groups led by the Philippine government dealing with the dead bodies during the Haiyan emergency response, while MSF focused on providing mental health support, including psychological first aid and preventive measures to the survivors. Over 27,000 people were assisted with mental health support from MSF in the first three months after the typhoon hit.

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Photo Feature

Relentless Violence in the Central African Republic

Since atrocious fighting broke out in Bangui, the capital of the Central African Republic (CAR) in early December 2013, inter-communal violence has swept the country and reached unprecedented levels. Civilians are being targeted – villages burned, women raped and people killed – all communities are slipping into this humanitarian catastrophe.

 

More than 1.2 million people – 25% of the population – have fled their homes. With the few existing health facilities being looted and destroyed, healthcare is hardly accessible. Half the country is now in desperate need of emergency aid.

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“When I was in Bozoum, we found 17 injured people with wounds from gunshots, machetes, and a grenade, hiding in a small courtyard. They were too scared to go to the hospital in case they were targeted again. Their injuries were serious—yet they were all sitting in silence, bleeding. That's how terrified people are of seeking medical care. They just sat there in silence, having lost all hope.”

- Dr. Joanne LIU, MSF International President, who visited MSF projects in Central African Republic in February 2014

 

“That morning we went out in our ambulances driving through the town in search of injured people…in that torrential rain we watched, as we drove past corners and avenues, dozens of dead bodies piled up in the streets. Some of them had been tied up and killed in cold blood opposite Hôpital Amitié, others were half naked and left as a warning for all passers-by. The rain splashed the streets with the mud concealing the blood…”

- Jose Mas COMPOS, MSF Emergency Coordinator in Bangui, Central African Republic

 

“I managed to go to the market. On my way back I was told that our neighborhood was being attacked. I met with my older brother and some neighbors gave us a lift in their truck. The two vehicles behind us in the convoy were hit by grenades. They finally reached the airport. It was horrible, everybody was running, I ran too to reach the plane."

- 18-year-old Mahmat planned to flee to Chad with his brother, but was separated from him at the airport and has not had any news since

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Frontline Sharing

Every cloud has a silver lining

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Assalam Alaykum!  Greetings from Tajikistan.  

 

I remember when I was the Director of Fundraising, TB was a topic that I was always shy of talking about to our supporters because many donors thought that treatment of TB is a long process, especially if it is multi-drug resistant tuberculosis (MDR-TB), and it is very costly. Donors would prefer to see MSF using their donations in medical actions that produce instant results and with massive impact, like vaccination campaigns.  

 

Indeed, MDR-TB treatment takes two years to complete, which is a very long process. There are a lot of side effects, causing both physical and emotional discomfort, pain, and even suffering.  Even adult patients find it difficult to stick to the treatment and many would give up, let alone young patients. With a long and costly treatment process and a relatively high chance of failure as patients drop out, what hope is there to offer to our donors and attract their support?

 

Until I met Michkona.  

 

Just a few days after my arrival in the project, the team threw this modest but very delightful “party” for Michkona – she is our first patient and her medical file is numbered “001”.  Two years ago when we first started treatment with her, she was just 15 years old – and like any other teenagers, Michkona went to school, liked to hang out with her friends and wear beautiful dresses to make herself pretty.  But when she was found out that she was infected with MDR-TB, she was kept away from school. One of the drugs she had to take had to be injected and it was very painful. The side effects of the other drugs made her even sicker as she was having nausea and serious headache. She didn’t have energy to make herself pretty any more. In fact, she felt really miserable, and she didn’t want to see anyone.

 

And just like any other teenager, she wanted to prove and establish her individuality by being “rebellious” – she put up big fights with her mother, ran away from our counselors and tried to skip treatment…all these behaviors are very “normal” and “reasonable” if I think of myself having to go through a similar treatment process.

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But with the help of MSF doctors, nurses and counselors, together with the support from her family, Michkona finally completed her two full years of treatment and she is now entirely cured from MDR-TB!  It was such a joyful moment! 

 

On the day of her “party”, many other kids infected with TB came to celebrate with Michkona. They came to witness her joy, and more importantly, the fact that there is indeed hope of being cured of this horrible disease. 

 

Beatrice LAU is a financial and administration coordinator from Hong Kong. She has served on missions in Niger and Haiti. She was formerly the Director of Fundraising in MSF-Hong Kong. In September 2013, she departed to Tajikistan as a Project Coordinator for 2 years.

 

In 2011, MSF and the Ministry of Health in Tajikistan started a paediatric TB programme. Under the holistic approach family members as well as the children are being treated. The programme promotes the use of sputum induction, a rapid test for every child with suspected TB, the scale up of contact tracing activities and paediatric drug compounding.

 

There are 450,000 people infected with drug-resistant tuberculosis (DR-TB) in 2012. They face similar challenges as patients in Tajikistan do, and are in urgent need for shorter, safer and more effective treatment. MSF has launched the “Test me, treat me” manifesto (http://msf-seasia.org/tb) to ask for global support in urging key power brokers, including governments, funders, pharmaceutical companies and policymakers, to radically transform DR-TB care.

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