Bringing medical humanitarian action to you

DECEMBER 2013

PHILIPPINES TYPHOON

EmErgEncy rEsponsE

Urgent care for Afghanistan

nEEds rEmain high as conflict continuEs

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A s I write today, Médecins Sans Frontières is facing massive constraints. Local medical infrastructure has gone,

medical supplies washed away, and many of the local health staff themselves cannot be accounted for. Our emergency response is being hampered by more atrocious weather. Communications systems within the islands are still offline, transport into our base of operations in Cebu is chaotic, with essential supplies at risk of being diverted to Manila, and our teams already frustrated in their attempts to secure air and ocean transport to reach the affected populations. In the words of our emergency coordinator on the ground “it’s a logistical nightmare...”.

Having managed emergency responses elsewhere, I know it’s also the reality we have come to expect in situations of massive natural disaster. Getting access and basic information on what is going on in the first days of an emergency (even with the advanced technology at our fingertips today) is often the biggest hurdle, and greatest frustration for teams on the ground. I fully expect, as the national and international response gears up along with ours, the shortage of available transport, undamaged landing strips and freight and storage options will come under even greater pressures from those wanting to help. Emergency logistics has to be coordinated, something which often falls to the military where they can bring their logistics and engineering skills to bear. UN agencies along with the host government assume coordination of information and along with it the emergency relief sector. Often, coordinating among those arriving and wanting to help becomes as complex and time consuming as the response itself. Organisations like Médecins Sans Frontières bring an invaluable knowledge, experience and capacity into these situations, but many others, albeit with good intentions,

unfortunately will not. As we saw in Haiti, the choice of who gets in first can make little sense. Indeed in the Philippines we have already witnessed the press successfully mobilised, while aid agencies on the sidelines call for access.

Médecins Sans Frontières was prepared for a regional natural disaster of this kind. The Sydney office plays a role in regional monitoring and surveillance, and we have experienced Australian and New Zealand staff on an emergency roster 365 days a year. Our staff were among the first to reach the Philippines for that essential rapid assessment phase. In fact, this is the fifth emergency we have responded to in the Philippines in the last three years.

While the wake of destruction left by Typhoon Haiyan is catastrophic, we can at least be optimistic that the national and international response will be proportionally large, and despite the confusion and challenges in these situations a humanitarian response will be secured. In stark contrast to this I cannot help but reflect again on some of the other emergencies Médecins Sans Frontières continues to manage in parallel to this horrific disaster. There is virtually no humanitarian response across much of opposition held areas of Syria

today. Nothing. There is no Government agreement to deliver aid, there are no UN agencies to coordinate with, and there is no NGO community presence at all. Another winter is approaching and a population of around two million people in opposition-held areas struggle for survival as the conflict rages on. As featured in this copy of The Pulse, the situation in Central African Republic is another catastrophic emergency, but one that is gaining very little attention, and receives completely inadequate international support. Médecins Sans Frontières contribution, as a single medical organisation, is equivalent to the entire investment of the European Union’s humanitarian response. How can such stark disparities exist in times of such acute human suffering?

I rarely use this editorial to do this, but I would like to take a moment to frankly thank all our supporters who make the work of Médecins Sans Frontières possible. It is in a large part our financial independence that enables us to plan for such contingencies as the disaster in the Philippines. We don’t waste time, we don’t have to chase emergency funds, we are not instructed where to work and what to do on the basis of ‘what the money is targeted for’. And most importantly, the many other ongoing emergencies programmes we continue to manage will not suddenly stop, or lose priority either. Our responsibility to act and speak out about the unacceptable absence of care and support in so many other emergencies elsewhere today is paramount, in addition to the vast humanitarian needs unfolding in the Philippines.

Paul McPhun Executive Director Médecins Sans Frontières Australia

dEcEmbEr 2013msf.org.au

From Tacloban to Aleppo, urgent needs require attention As this issue of The Pulse goes to press, the first Médecins Sans Frontières emergency teams have been arriving in the devastated town of Tacloban, to set up emergency medical services in the aftermath of Typhoon Haiyan in the central Philippines. Several other Médecins Sans Frontières teams are accessing other remote island regions that were among the worst hit. There is no doubt about the shocking scale of this disaster, with loss of life in the thousands, livelihoods and communities literally washed and blown away and hundreds of thousands trying to survive with nothing.

Médecins Sans Frontières AustraliaPO Box 847, Broadway NSW 2007, Australia 1300 136 061 or (61) (2) 8570 2600

office@sydney.msf.org msf.org.au

abn: 74 068 758 654 © 2012 médecins sans frontières australia

facebook.com/msf.aus @MSFAustralia

Damaged houses in a coastal community after Typhoon Haiyan struck the Central Philippines.

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Front Cover: Nurse Lisa Rydell applies a dressing to a patient at a clinic in Guiuan, in the east of Samar island, an area hit first and hard by the typhoon. Almost all the buildings in the town were destroyed. © Caroline Van Nespen/MSF

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3 EDITORIAL: PHILIPPINES4 NEWS-IN-BRIEF6 FEATURE: MEDICAL CARE IN AFGHANISTAN8 PHOTO ESSAY: CENTRAL AFRICAN REPUBLIC10 LETTER FROM PAPUA NEW GUINEA11 SUPPORTER PROFILE12 FEATURE: CHILDHOOD TUBERCULOSIS14 FIELDWORKER PROFILE: ANAESTHETIST15 CURRENTLY IN THE FIELDCO

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médecins sans frontières is an international, independent, medical humanitarian organisation that was founded in france in 1971. the organisation delivers emergency medical aid to people affected by armed conflict, epidemics, exclusion from healthcare and natural disasters. assistance is provided based on need and irrespective of race, religion, gender or political affiliation. When

médecins sans frontières witnesses serious acts of violence, neglected crises, or obstructions to its activities, the organisation may speak out about this.

today, médecins sans frontières is a worldwide movement of 23 associations, including one in australia. In 2012, 167 field positions were filled by australians and New Zealanders.

ABOUT MÉDECINS SANS FRONTIèRES

EDITORIAL

The Pulse is the quarterly magazine of Médecins Sans Frontières Australia.

design, artwork and production: marlin communications • marlincommunications.com

“It is in a large part our financial independence that enables us to plan for such contingencies as the disaster in the

Philippines.”

By Paul mcPhun

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AleppoMediterranean Sea

Ar Raqqah

Deir Ezzor

IdlibLatakia

TartusHamah

Homs

DamascusBeirut

Amman

TURKEY

SYRIA

* source : UN October 2013

450 Médecins Sans Frontières team members working in 6 hospitals, 2 health centres, mobile clinics

4,491 surgical acts by Médecins Sans Frontières teams

89,367 consultations, of which 40% are emergency room consultations

77,800 children vaccinated against measles

1,426 babies delivered

84 health structures across Syria supported remotely with medical supplies

SYRIA 4.25 M people displaced in Syria*

3 health structures with Médecins Sans Frontières teams providing healthcare to refugees

140,544 consultations including mental health and antenatal consultations

19,500 people vaccinated

IRAQ 197,844 refugees*

513,081 refugees*TURKEY

TURKEY

4 health structures with Médecins Sans Frontières teams providing care to refugees

18,069 consultations including emergency room consultations and post-operative follow up

412 war wounded operated in Amman and Ramtha hospitals

JORDAN 549,575 refugees*

9 health structures with Médecins Sans Frontières teams providing care and 3 receiving regular support

85,511 consultations including mental health and antenatal consultations

LEBANON 798,885 refugees*

NEWS IN BRIEF

for thE latEst msf nEws @ msfaustralia facebook.com/msf.aus

2 SYRIA

4 SOMALIA

1 AFGHANISTAN

5 SOUTH AFRICA

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Médecins sans Frontières provided EMERGENCY RESPONSE TO

Médecins Sans Frontières in Syria: by the numbers

Closure of Somalia projects BACKGROUNDmédecins sans frontières worked continuously in somalia from 1991 to august 2013. staff provided services including free primary healthcare, malnutrition treatment, maternal healthcare, surgery and epidemic response. however, ongoing abuse and manipulation of humanitarian action undermined the minimum security guarantees needed to maintain programmes. In its 22-year history, 16 médecins sans frontières staff members were killed.

ACTIONmédecins sans frontières closed all programmes in somalia in august 2013. this was due to extreme attacks on its staff in an environment where armed groups and civilian leaders increasingly supported, tolerated, or condoned the killing, assault, and abduction of humanitarian aid workers. “We are ending our programmes in somalia because the situation in the country has created an untenable imbalance between the risks and compromises our staff must make, and our ability to provide assistance to the somali people,” said Dr unni Karunakara, médecins sans frontières’ then international president.

Médecins sans Frontières provided MEDICAL CARE IN SOMALIA

1991-2013vomiting • permanent deafness • psychosis •

hallucinations • jaundice

“Over the coming years we hope to develop new projects in different areas… to go beyond the walls of our hospitals and really try to reach people directly in their communities”– RENzO FRICKE, MÉDECINS SANS FRONTIèRES’ OPERATIONAL COORDINATOR FOR

AFGHANISTAN. rEad about médEcins sans frontièrEs’ work in afghanistan on pagE 6.

Beating drug-resistant TBBACKGROUNDextensively drug-resistant tuberculosis (XDr-tb) is a very severe form of drug-resistant tb with less than 20 per cent chance of cure. treatment is long and painful and hindered by a lack of diagnostic tools and appropriate drugs.

ACTIONmédecins sans frontières piloted a ‘strengthened regimen’ programme in Khayelitsha, south africa to treat XDr-tb. after two years of highly intensive treatment and 20,000 pills, 23-year old phumeza tisile is the first patient to be cured in the programme. phumeza is now looking forward to resuming her dreams of studying.

– rEad morE about médEcins sans frontièrEs’ tb work on pagE 12.

Phumeza prepares to take the last of 20,000 pills that were part of her XDR-TB treatment.

Médecins sans Frontières assisted

16,580 BIRTHS IN AFGHANISTAN IN 20123 IN THE PHILIPPINES IN 2012

TYPHOONSSide effectS of

tB treatment include:

3 PHILIPPINES BACKGROUNDon the morning of friday 8 November, category 5 typhoon haiyan (locally known as Yolanda) hit the eastern Visayas region of the philippines. médecins sans frontières’ emergency teams – including two australians and one New Zealander – immediately responded to assess the situation and determine médecins sans frontières’ full response.

ACTIONat the time of writing, 152 international staff are currently in the philippines, along with 232 tons of medical and humanitarian supplies. médecins sans frontières teams continue to assess areas outside the main cities while providing immediate medical care in a growing number of locations.

médecins sans frontières is now active on the islands of samar, leyte, and panay, and has most recently started assessing needs on masbate. an inflatable hospital is being set up at the site of the destroyed bethany hospital south of tacloban and additional staff are en route with further cargo flights scheduled.

some of the serVIces that méDecINs saNs froNtIères Is proVIDINg IN Syria

• Mental healthcare

• Primary healthcare

• Surgery

• Physiotherapy

Philippines: Médecins Sans Frontières medical activities start taking shape

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Survivors of Typhoon Haiyan gather at the airport hoping for an evacuation – Tacloban City, Leyte.

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Developing new medical projectsAs Australia and other foreign powers prepare to reduce their presence in Afghanistan, Médecins Sans Frontières is looking to increase activities beyond its four existing projects (see box, right).

“Over the coming years we hope to develop new projects in different areas, particularly in places outside government control, but also to go beyond the walls of our hospitals and really try to reach people directly in their communities, something that has been extremely difficult given the security situation.”

For example, Médecins Sans Frontières has recently started running mobile clinics in the outer suburbs of Kabul, providing services such as pre- and post-natal care, family planning, vaccinations and nutrition services. As Afghanistan faces an uncertain future, Médecins Sans Frontières hopes to meet the increasing medical humanitarian needs.

*Name has been changed to protect the patient’s privacy

“Some patients have told us they prefer to travel hours to a Médecins Sans Frontières hospital, rather than go to a

closer clinic run by the military as they fear reprisals from an

opposition group.”

As Australia prepares to withdraw most of its military personnel from Afghanistan, conflict still rages and medical and humanitarian needs remain high.

zukia*, aged 21, is a mother of two who lives in Khost province, eastern Afghanistan, on the border of Pakistan’s

volatile tribal areas. Zukia had just fallen pregnant with her third baby when her husband was killed by a bomb blast in Kabul.

Now a single mother, she has been making difficult decisions about her pregnancy and delivery in an area where medical needs are enormous and maternal mortality is especially high. Medical facilities are few, and often expensive. Ongoing insecurity means that qualified Afghani staff from other provinces are reluctant to work in Khost and few international organisations are present. There is a public hospital in Khost city, but many women prefer not to go there because most of its surgical staff are male.

Zukia has decided to deliver in Médecins Sans Frontières’ maternity hospital in Khost city, which provides free care to women and

newborns, and has female-only medical teams. The 56-bed hospital also has the capacity to deal with obstetric emergencies including providing caesarean sections if needed.

However, Zukia has to travel for several hours to reach the hospital, and the roads are not safe. “I went to the maternity hospital during the day because it was too dangerous to travel at night,” she explains.

“In the area where I live, there is a lot of fighting. We hear shooting all night. People

are so poor that they have no choice but to travel for hours or days to reach a centre like this one where they can get good and free treatment in safety.”

The conflict continuesAfter more than ten years of military intervention in Afghanistan, the media focus is increasingly on the international troop withdrawal timeline. But the war is not over. Afghans continue to be affected by conflict in many parts of the country. This ongoing insecurity has caused qualified health staff to leave, impeded the supply of drugs and medical materials, and prevented people from travelling to reach health facilities.

The maternity hospital in Khost has been directly affected by the insecurity. In April 2012, six weeks after it opened, Médecins Sans Frontières had to suspend activities after an explosion inside the hospital injured seven people. The hospital was closed for eight months while Médecins Sans Frontières assessed the situation and worked to secure greater support from the

“Over the coming years we hope to develop new projects in different areas… to go beyond

the walls of our hospitals and really try to reach people

directly in their communities.”

Urgent care for Afghans stuck in an ongoing war community and political and religious leaders. Now reopened, the team assists around 1,000 deliveries each month.

Today, one of those deliveries is for Zukia, whose contractions have worsened over the past four days. “I asked the doctor and midwives for a Caesarean section because I find it harder and harder to bear the contractions. I am afraid of complications, but the doctor told me that I will have a normal delivery,” she says.

The doctor was right – several hours later, Zukia delivered her baby safely.

Humanitarian aid, military agendaMédecins Sans Frontières’ independence from political and military agendas allows us to gain the acceptance of local communities and leaders in places like Khost, and provide medical care based on need alone. However, much humanitarian aid delivered in Afghanistan over the past decade has not been so impartial. Renzo Fricke, Médecins Sans Frontières’ operational coordinator for Afghanistan, says much humanitarian assistance has been delivered as part of a combined military-humanitarian approach by international coalition forces.

“What this means is that we have seen humanitarian aid consistently co-opted to serve a military agenda, with dangerous results. Aid has not been delivered based on the needs of the people, but has been driven by the national security interests and foreign policy objectives of the countries involved in the conflict.”

“Some patients have told us they prefer to travel hours to a Médecins Sans Frontières hospital, rather than go to a closer clinic run by the military as they fear reprisals from an opposition group,” he says.

Although some aid money has gone towards restructuring the health system and expanding medical infrastructure, Renzo adds that there is a huge discrepancy between what exists on paper and the reality on the ground.

“Many of these buildings lie empty: there are no supplies, no drugs, no staff and no patients. The system that has been implemented is based on the premise that Afghanistan is in a ‘post-conflict’ phase, and it does not reflect the reality of a country still at war.”

32.4 million population

1,111 fiEld staff

AFGHANISTAN ©

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Médecins Sans Frontières staff transfer a severely injured

patient to the operating table at Kunduz Trauma Centre.

médecinS SanS frontièreS firSt worked in afGHaniStan

KEY MEDICAL FIGURES:• 332,300 outpatient consultations• 16,580 births assisted• 7,240 surgical procedures

Afghanistan

Cities, towns or villages with MSF activities

KUNDUz

KABUL

KHOSTLASHKARGAH

OUTPATIENT CONSULTATIONS by Médecins Sans Frontières in 2012

332,3001981

MÉDECINS SANS FRONTIèRES IN AFGHANISTAN

Médecins Sans Frontières currently has four projects in Afghanistan.

• In ahmad shah baba hospital in eastern Kabul, teams provide a variety of activities including mental healthcare, maternity care and tuberculosis treatment.

• In lashkargah, helmand province, médecins sans frontières provides surgery, internal medicine, maternity, paediatric and emergency services at boost hospital.

• In Kunduz, northern afghanistan, médecins sans frontières runs a trauma centre, providing lifesaving surgical care to victims of general trauma or with conflict-related injuries.

• In Khost, eastern afghanistan, médecins sans frontières runs a 56-bed maternity hospital.

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A displaced person’s camp in Kabul, where Médecins Sans Frontières ran a mobile clinic during the harsh winter.

(Pictured above) Patients wait for treatment at the male outpatient department of Boost hospital, Lashkar Gah, Helmand province.

cities, towns or villages with msf activities

FOR EvERY 1,000 AFGHAN BABIES, 101 WILL NOT LIvE TO SEE THEIR 5TH BIRTHDAYAfghanistan’s under-5 mortality rate is 20 times worse than Australia’s

SurGical ProcedureS7,240

conducted BY médecinS SanS frontièreS in 2012

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CENTRAL AFRICAN REPUBLIC

Central African Republic’s ongoing humanitarian emergency deteriorated further following a coup in March. Increasing violence has sparked the displacement of tens of thousands of people and reduced already limited access to healthcare. Médecins Sans Frontières runs six regular and four emergency programmes in the country.

Crisis deepens in Central African Republic

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A group of mothers and children wait to receive medical care at the Médecins Sans Frontières clinic in Bossangoa. Médecins Sans Frontières has launched an emergency project in response to increasing violence in this area.

Mothers and babies wait for treatment at a Médecins Sans Frontières mobile clinic.

A baby has his temperature taken at the malnutrition ward in Carnot where Médecins Sans Frontières has worked since 2010.

Some 28,000 people have sought refuge in Bossangoa’s Catholic

Mission, where Médecins Sans Frontières is providing

medical care and water and sanitation activities.

People are eating, sleeping, washing and defecating

in the same overcrowded space, increasing the risk

of disease.

A doctor examines a small child in a hospital in Batangafo. Malaria is the most commonly seen illness in Batangafo and is the number one killer in Central African Republic.

People line up for treatment at a mobile clinic in Bossangoa.

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Kate White

and Hepatitis B as well as psychosocial support. Three days later she returned to give me the vegetables and some seeds so that I could grow my own. She made me want to cry: she had gone through an incredibly awful experience yet all she could do was think of others.

Accidental stabbingThe second moment was a patient who became much closer to my heart than I would normally allow. His name was Will. I received a call from a company in the

Kate White is a nurse from Brisbane, Queensland, who has done six field placements with Médecins Sans Frontières.

I am currently working in Tari in the Southern Highlands of Papua New Guinea. Tari is one of the most beautiful

places I have ever been. All around the town are mountains covered with trees. In the morning the cloud rolls into the valley and you can see the tops of the mountains poking through. It is so beautiful it is almost magical.

On a Saturday night towards the end of my mission, one of our logisticians asks me what my top moments in Tari have been. I think about all the experiences I have had as medical team leader, and come up with two moments that had a real impact.

“It is seen as a woman’s fault”The first was a patient that we received in our Family Support Centre, which offers integrated care to survivors of family and sexual violence. Basically we provide a one-stop shop where people can access both medical and psychosocial care for the injuries they have sustained from violence.

The patient was a woman in her late 30s, not that much older than me, who had been walking home from the market when a man grabbed her, dragged her into bushes, threatened her with a knife and raped her. She came to us as she was very scared about getting pregnant from the rape. She was a single mother of three and could not afford to have another child. She lived in the compound of her husband’s family even though it had been many years since she had seen him. But if they found out that she had been raped they would throw her out. In Tari it is seen as a woman’s fault if she is raped.

The most confronting part was that this was the fourth time in her short life that she had been raped. Yet her level of trauma appeared quite low. In fact one of her biggest concerns was that I was too skinny and needed to be fed. She offered to give me veggies from her garden to fatten me up. We provided her with drugs to prevent HIV and other STIs, emergency contraception to prevent pregnancy, vaccinations to prevent tetanus

SUPPORTER PROFILELETTER From PaPua neW guinea

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Kate White at work in Libya in 2011.

namE: barbara and francis debonohomE: long pocket, Qldoccupation: librarian and

school teacher

Barbara and Francis have been regular supporters of Médecins Sans Frontières since 2011. In September 2012, their son Gabriel Debono was killed in a hit and run. Ever since then they have continued to seek donations from their community in memory of their son.

We were inspired to support Médecins Sans Frontières because of its absolute independence and

non-judgemental focus on healthcare. When our son was killed by a hit and run driver, our lives were shattered. Having lost our son at the hands of someone that we do not know and in circumstances that we will never be sure of, we think we now understand a little of the powerlessness of those affected by conflict.

As a medical student Gabriel had spoken about working with Médecins Sans Frontières one day, once he was a qualified doctor. So we directed people to donate to Médecins Sans Frontières in lieu of flowers. The response was overwhelming and we received over $4,000 in less than 24 hours. Since then we have continued to hold events in memory of Gabriel and have now raised over $25,000. Many people have also become regular supporters of Médecins Sans Frontières, which is a wonderful way to remember Gabriel.

When something tragic happens to any of us in Australia we have many supports to lean on, including the best medical services in the world. Our medical services even spent time and expertise, used donated blood and hospital resources just to keep Gabriel with us as long as possible so that we could gather and take our time to say goodbye. But there are millions without the most basic medical services, let alone the luxury of a long goodbye.

for more information on ways to donate, please visit www.msf.org.au/donate

A woman is treated by a specialist nurse

in the Médecins Sans Frontières minor

operating theatre at Tari hospital. The

woman was brought in with deep wounds to

her head after she was attacked by a co-wife

with a bush knife.

Scan to read more letters from the field on msf.org.au

area to say that a child had walked into their clinic with a penetrating wound to his abdomen. He was stable but needed urgent surgery and they were organizing a helicopter to bring him to Tari if we would accept him.

In addition to running the Family Support Centre, Médecins Sans Frontières also provides emergency and trauma surgery to the people of Tari and Hela province, so I immediately said yes.

The surgeon and I went to the airport and finally the helicopter landed to reveal a scared looking seven year old. I picked him up and carried him to our car and he stared at me with his big brown eyes. I remember thinking that he had the most incredible eyelashes. At the hospital, we removed his dressing to reveal that his bowel was on the outside. He was taken straight to the operating theatre.

While the rest of the team was operating I tried to discover what had happened. It turned out that Will and his older sibling had been playing and he was accidently stabbed. I was not surprised because unfortunately this is an all too familiar story in Tari.

As Will recovered we built quite a rapport. The staff seemed to think it was because I was the first person he saw after he came off the helicopter; I like to think it is because I am a naturally likeable person, but we will never really know the truth. After ward rounds I would take him out in a wheelchair to ‘harass’ other people. We would create water guns out of syringes and target passers by. By the time he left the hospital, 10 days later, he was back to his old mischievous self.

violence should not be ‘normal’Writing this letter I had to confront the fact that what I have been seeing should not be normal. Yet during the nine months that I have been in Tari it has become that, completely normal. Violence in all forms, including sexual violence, has become normalised for the population here. But there are many people trying to change this. Not only is Médecins Sans Frontières working hard to create awareness and change but individuals are setting up safe houses for women and children affected by family and sexual violence. And gradually we see the attitude of our own local staff and patients changing.

In the end I leave with hope. Hope that more of the community will want and accept change. Hope that violence becomes the exception to the rule and not the rule itself. Hope that one day the beauty of Tari lies not only within the landscape but also with a community that has changed their society for the better.

“She made me want to cry: here was a woman who had gone through

an incredibly awful experience yet all she could do was think

of others.”

“In the end I leave with hope… hope that violence becomes the exception to the rule and not the rule itself.”

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“Hopefully with implementation of these recommendations, more young children with TB will be diagnosed promptly,” says Dr Van Gulik.

When the drugs don’t workAlthough TB is an ancient disease, an effective, well-tolerated treatment has not yet been developed. The disease is curable, but patients must take a cocktail of antibiotics for a minimum of six months. Worse still, the disease has begun to mutate so that the most commonly used drugs are sometimes ineffective.

Médecins Sans Frontières is seeing more and more patients with drug-resistant TB, including people who have never had the disease before. This is a major concern because it means the drug-resistant strains are being directly transmitted from person to person. Half a million people worldwide are now infected with drug-resistant TB, including little Oisha. But how many more are infected is difficult to say because accurate data on drug-resistant TB among children is hugely lacking.

Improving treatments for childrenOisha has been on treatment for multidrug-resistant TB (MDR-TB) for six months, and has another 18 months to go. Luckily she has responded well to treatment, and wants nothing more than to fill the entire sheet with gold stars. Of course, she knows there are other reasons to take the medication besides the gold stars. "If I stop, I get a fever," she says.

Treatment for drug-resistant TB can be extremely gruelling. Patients must endure two years of up to 20 pills a day, plus an intensive eight month phase of painful daily injections. Side effects include constant nausea, vomiting, severe rashes, permanent deafness, hallucinations and psychosis.

New TB treatments are in development, but research often ignores paediatric patients. While there are child-friendly formulations of TB drugs, MDR-TB drugs are completely non-adapted for children. This means adult medicines have to be broken up, carrying a risk of under or overdosing. The massive research gap also puts kids at risk of toxic effects from the medication.

“For paediatricians, an increasing concern with regards to potential toxic effects are hearing loss and hypothyroidism [underactive thyroid gland], both of which can significantly affect the overall development of a child,” says Dr Van Gulik.

Children with HIV are particularly susceptible to TB because of their compromised immune systems. Almost half of all children with TB are co-infected with HIV, and pose a particular challenge to treat.

“Fortunately, children who do get treated can be completely cured of the disease – and often have better results than adults,” says Dr Van Gulik.

* Patient names have been changed

CHILDHOOD TUBERCULOSIS

F ive-year-old Oisha* plays outside her aunt’s home in Shariston, Tajikistan. She holds up a chart filled with gold stars –

but it’s not a reward for doing her homework or chores. Instead each gold star represents a day she has taken her tuberculosis (TB) medicine properly. Oisha is one of around half a million children diagnosed with TB this year, comprising about six per cent of all TB patients.

Difficult diagnosisWhen Oisha got sick, she lost a lot of weight and was very weak. She could barely talk, and had great difficulty breathing. TB diagnosis remains a huge challenge in children. The most common test uses microscopy to look for TB mycobacteria in a sputum (phlegm) sample, but most children

can’t cough up enough sputum for this test. Plus many children have a form of TB that does not reveal much bacteria in the lungs. As a consequence, treatment is often delayed or not provided.

For many years, Médecins Sans Frontières has called for more research to develop better diagnostic tools for children as well as adults. A new test called Xpert MTB/RIF is promising, as it reduces the time taken to detect TB, including drug-resistant TB, from two weeks to two hours.

Although this test does currently rely on sputum-based samples, Dr Clara Van Gulik, Médecins Sans Frontières’ paediatric HIV and TB advisor, says upcoming World Health Organization recommendations widen the use of this test to non-sputum based samples. The recommendations also expand the use of Xpert among children suspected of having TB, particularly drug-resistant TB.

Young patients grappling with an ancient disease

BEATING TB médecins sans frontières’ tajikistan tb project recently celebrated a huge victory as 18-year-old Indira* (left) became its first fully-cured patient. "in 2011 i was hospitalized. i had a fever, was nauseous and was coughing up blood. it made me terribly worried. that seems so long ago now," she says. médecins sans frontières’ project coordinator beatrice lau says: “indira is proof that people, children, with mdr-tB can be cured and have a future.” the tajikistan project provides treatment, nutrition and psychological support, as well as educational activities for children who need to be hospitalised.

trEating pEoplE with tb for morE than 25 yEars

The mother of a boy (left) with drug-resistant TB cries as nurse Cindy Gibb reassures her.

“Fortunately, children who do get treated can

be completely cured of the disease – and

often have better results than adults.”

a SHort film on mdr-tB msf.org.au/tajikistantB

Multidrug-resistant TB: No Promises, features new Zealand nurse cindy gibb discussing her work with médecins sans frontières’ paediatric tb project in tajikistan.

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MédECiNS SaNS FrONTièrES

REACHING MORE PATIENTS

one of the key ways to ensure that more children with tb receive the treatment they need is to integrate tb services into existing healthcare programmes. médecins sans frontières is working on strategies to introduce tb screening for all malnourished children, as well as in antenatal care consultations, because mothers are often the source of their child’s tb. screening can be as simple as asking if the child or anyone else in the household has had a cough for longer than two weeks, persistent fevers or unexplained weight loss.

Dr Van gulik says tb screening also needs to be available at local clinics as well as larger hospitals. “mothers bring their children to health centres regularly for check ups, routine vaccinations and simple consultations. ensuring tb screening occurs here is essential to pick up tb as early as possible.”

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Oisha plays outside her aunt’s home.

Tuberculosis has been around since antiquity but unfortunately it is not confined to the history books. It remains a modern-day disease, infecting millions of adults and children each year.

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CHILD AND ADULT TB PATIENTS TREATED by médecins sans frontières in 2012

30,780 ARMENIACAMBODIACOLOMBIAETHIOPIAGEORGIAINDIAKENYA

KYRGYZSTANMOZAMBIQUEMYANMARRUSSIASOUTH AFRICASOUTH SUDANSWAZILAND

TAJIKISTANUKRAINEUZBEKISTANZIMBABWE

BANGLADESHCENTRAL AFRICAN REPUBLICCHADDEM. REP. OF CONGOGUINEA

LESOTHOMALAWIMALIPAKISTANPAPUA NEW GUINEASOMALIAUGANDA

TB Projects dr- TB Projects

TB TREATMENT PROGRAMMES

IN 2012

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JOIN OUR TEAMSurgeons and anaesthetists: challenge yourself and help us keep operatingmédecins sans frontières performs more than 75,000 major surgical procedures each year.

to learn more, visit www.msf.org.au/join-our-team

Could you describe your work in Nigeria?I worked as the anaesthetist at Teme Trauma Hospital in Port Harcourt. We operated on around 10 patients each day for injuries from road traffic accidents, gunshot wounds and machete attacks, so it was a very busy hospital.

Teme was one of the first humanitarian hospitals in the world to provide internal fixation of fractures. I was a bit surprised to find that procedure available, as it involves relatively major surgery and anaesthesia. But the results were good. With the internal fixation of leg fractures it meant that patients could walk out of the hospital in days instead of spending months in traction.

Did your role involve a lot of hands-on operating work?Yes, as an anaesthetist with Médecins Sans Frontières an extremely high percentage of your day is spent doing the hands-on clinical work. One of the things I like most is that compared to work back home you don’t have to worry much about things like meetings, reports, phone calls. You’re freed up to put all your energy into clinical work. The anaesthetist’s role on mission also includes more than anaesthetising patients in the operating theatre. We assist in prioritisation and resuscitation of patients in the emergency room, day-to-day care of surgical ward patients, including pain management, and training local staff.

You’ve recently returned from Pakistan. What did your work there involve?I was working at Médecins Sans Frontières’ Hangu Hospital. This hospital is in a fascinating cultural context, adjacent to

Pakistan’s north-west tribal areas and the highly conservative society that lives there. I saw many children with burns from domestic accidents and many obstetric emergencies. There is little antenatal care in the area and women often only get brought to hospital when they are in extreme difficulties with obstructed labour or haemorrhage.

In the week leading up to Pakistan’s elections there was an increase in violence with multiple bomb blasts in the area. In 2.5 days we received 68 injured patients, on whom we performed 21 operations. That’s a huge amount of casualties for a hospital with only a small staff, limited beds, and a single operating theatre. But all the people we took to surgery survived. That was a very good result under that pressure and conditions. What was done really well was the prioritisation. Médecins Sans Frontières had a great triage system which everyone followed. I actually brought all the paperwork back with me explaining the system because it was simple and effective and I think it certainly has lessons for a western hospital.

Do any particular patients stand out in your memory?One of the bombing victims in Pakistan had injuries to his chest and abdomen, and was bleeding heavily from both. We’d identified

him as the worst of the injured on that day. We took him to theatre, and as well as the surgery to stop the abdominal bleeding, we used a technique of retransfusing his own blood that was coming out of his chest injury. I had never done that before, but it worked

– despite him bleeding out his entire blood volume he survived. He was well enough to leave hospital in less than a week.

Had you always wanted to work with Médecins Sans Frontières?Like many doctors I’d always thought I’d do it at some stage, but it wasn’t until I met a Médecins Sans Frontières anaesthetist that I thought ‘maybe I could really do this’. I looked at the website and realised that the requirements were within my experience and that the time commitment was manageable. It’s generally a six week placement for surgery and anaesthetics, which means I’m able to keep my family life and normal career. My plan is to keep doing one field placement each year.

What would you say to other anaesthetists considering this work? One motivating factor is that the patients are all emergency cases, usually young, with conditions that are readily cured by surgery. It’s amazing how relatively uncomplicated, good anaesthetic care can have such benefit. There are challenges of course – expensive drugs, high-tech equipment, and post-op critical care wards are not available. But the anaesthetist on a mission like this does authentic medicine and useful, worthwhile work for pretty much every patient.

FIELD WORKER

“As an anaesthetist with Médecins Sans Frontières, an extremely high percentage of your day is spent doing the hands-on clinical work”

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médEcins sans frontièrEs ExpEriEncE:• april to June 2012,

Port Harcourt, nigeria• may to June 2013,

Hangu, Pakistan

namE: dr colin chilvershomE: launceston,

tasmania

Médecins Sans Frontières' surgical team in Hangu.

CURRENTLY IN THE FIELD

Dr Colin Chilvers is an anaesthetist from Launceston who recently returned from a placement in Pakistan.

AFGHANISTANJohn Coopergeneral logisticianlower hutt, NZ

Felicity HeathnurseNedlands, Wa

Keiole RimaPharmacistboroko, NcD

ARMENIAYvette Stantonnursecardiff, NsW

CAMBODIAHelen Tindallnursealice springs, Nt

Sarah DonconnurseVictoria park, Wa

CHADRobyn Silcockmedical doctorcharters towers, QlD

Bethan McDonaldmedical doctorWilloughby east, NsW

CHINARose Stephensnurselower plenty, VIc

DEMOCRATIC REPUBLIC OF CONGO

April Murphynursehappy Valley, sa

ETHIOPIADeclan Overtonlogistician coordinatorWynn Vale, sa

HAITISally Thomasconstruction logisticianrozelle, NsW

INDIAPrue CoakleyField coordinatorenmore, NsW

Simon Janesmedical coordinatorascot, Wa

IRAQMee Moi Edgaradmin/ financial coordinatorWest melbourne, VIc

JORDANKylie Gaudinlogistician/ administratorauckland, NZ

Elizabeth MilroymidwifeKiama Downs, NsW

LEBANONBrett Adamsonmedical team leaderKempsey, NsW

Sita Cacioppemedical team leaderNaremburn, NsW

MALAWIJayne Martinhead of missionedgewater, Wa

Melissa Schulzmedical scientistedmonton, QlD

Ellen Kamaraadmin/ financial coordinatorQueensland

MYANMAREddy McCallcommunications officerchippendale, NsW

NIGERKaheba Clement HondanurseNorthmead, NsW

NIGERIAJennifer Duncombeepidemiologistlaguna, NsW

PAKISTANSarah DinaPsychologistbeeliar, Wa

Lisa ErrolnurseKaitaia, NZ

David McGuinnessnurseredcliffe, QlD

Brooke McReynoldsmidwifemackay, QlD

Siry IbrahimField administratorWellington, NZ

Stephanie JohnstonPharmacistgordon, NsW

Rodney Milleradmin/ financial coordinatorelsternwick, VIc

Jessica Holdenmedical doctorYarram, VIc

Bill Wilsongeneral logisticianfremantle, Wa

Shelagh Woodshead of missionrose park, sa

Ann-Marie Wilcockcommunications officerbondi, NsW

PAPUA NEW GUINEARobert Onusgeneral logisticianchittaway bay, NsW

PHILIPPINESLouise JohnstonnurseWendouree, VIc

Chatu Yapamedical doctorauckland, NZ

Damien Moloneygeneral logisticianedithvale, VIc

SOUTH AFRICAMatthew ReidField coordinatorchristchurch, NZ

Ester valleroField administratorchristchurch, NZ

SUDAN SOUTHMatthew NicholsonPharmacistbuninyong, VIc

Rachel Creeklogistician coordinatormillswood, sa

David Nashhead of missionleichhardt, NsW

Monica Burnsnurseeast Doncaster, VIc

SWAzILANDShannon Lo Riccologistician team leadercolac, VIc

SYRIAPeter MathewSurgeonalice springs, Nt

Rose KillaleaField administratorhowrah, tas

Lisa Mazlinnursemalanda, QlD

Michael SeawrightField coordinatorauckland, NZ

Caroline Wademedical doctorhamilton, NZ

Chris Withingtonlogisticianeast Doncaster, VIc

TAJIKISTANMarie ReyesnurseYagoona, NsW

UKRAINECarmel MorsinurseNuriootpa, sa

UzBEKISTANRamona Muttucumarumedical doctorKings park, VIc

Jay Acharmedical doctormelbourne, VIc

YEMENRebecca Walleynursecoolbellup, Wa

Susan PetrieField coordinatorWellsford, NZ

zIMBABWELinda PearsonField coordinatorauckland, NZ

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At the time of going to press, Médecins Sans Frontières Australia was preparing to send additional field staff to the Philippines in the aftermath of Typhoon Haiyan.

This list of field workers comprises those recruited by Médecins Sans Frontières Australia. We also wish to recognise other Australasians who have contributed to Médecins Sans Frontières programmes worldwide, but are not listed here because they joined the organisation directly overseas.

“It’s amazing how relatively uncomplicated, good

anaesthetic care can have such benefit.”

fiEld rolE: anaesthetistanaesthetists play a crucial role in médecins sans frontières’ increasing number of surgical projects. anaesthetists working with médecins sans frontières facilitate high quality, safe perioperative care for patients ranging from those wounded in conflict to women requiring emergency obstetric care.

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AID WITHOUT AGENDA

NOT WITHOUT yOU. msf.OrG.AU msf.Tv

COmpAssION WITHOUT prEjUDICE ACTION WITHOUT sIlENCE DOCTOrs WITHOUT bOrDErs

Doctors Without Borders provides medical aid to people based on need and irrespective of race, religion, gender and political affiliation.

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