The Year in Review

If we were asked whom we treat the most often, we would reply: first young children, then young women. Amongst the displaced, refugees and populations caught up in fighting or whose health structures have collapsed, beside the directly wounded or those affected by specific epidemics, women and children occupy the majority of our consultations. This is the reason why we have to put a particular energy into improving the way we address some of the main pathologies responsible for the mortality and the morbidity of these two categories of population.

Overcoming childhood dangers

Once beyond the first days of life, children who die before their fifth birthday usually succumb to infectious pathologies such as pneumonia, diarrhea, malaria, measles and AIDS, particularly as half of them suffer from malnutrition. The good news is that our weapons against the main diseases decimating young children are increasingly effective and may even, potentially, allow us to prevent a good number of them including:

• Pneumococcus is a class of bacteria responsible for a large number of lower respiratory infections. A particular vaccine that covers the prevalent strains in Africa exists and we are starting to use it.
• Rotavirus is responsible for more than a third of diarrhoea cases in children. We are looking forward to seeing the use of the existing vaccine against this virus being recommended for Africa and other contexts where we have to intervene.
• The measles vaccine has been around for a long time and its systematic use has increased. Unfortunately, the vaccination coverage is often too low, particularly in some regions of sub-Saharan Africa to prevent repeated epidemics.
• With the new conjugate vaccine for meningitis, we will be able to durably immunize populations exposed to recurrent epidemics particularly in the Sahel region of Africa. But this vaccine will only be available for use in 2009.
• We are still waiting for a malaria vaccine, but at least the Artemisinin based Combination Therapies give us a highly effective therapeutic weapon.
• There is no vaccine for hiv yet either, but an antiretroviral treatment protocol can considerably reduce the risk of mother-to-child transmission when administered correctly, and we can effectively treat infected children with improved paediatric forms of antiretroviral drugs.
• Finally, we now have ready-to-use therapeutic foods that allow us to treat far more children suffering from acute malnutrition more effectively and as out-patients in most cases. We also use them at increasingly early stages of malnutrition and are measuring their impact on morbidity and mortality of children in their first years of life.

Addressing maternal mortality

Maternal mortality represents a quarter of female mortality in the majority of the countries we work in. Half of the deaths are linked to the moment of delivery or the subsequent 24 hours. Another quarter happen during pregnancy.

This explains why we should put so much of our attention into antenatal care and deliveries. The more direct complications of delivery for the women (hemorrhage, eclampsia) are difficult to anticipate but if handled in time should not prove fatal. The medical technology required for treating these complications was standardized half a century ago in developed countries. It is well known and not difficult to use. Obviously it requires qualified personnel, appropriate drugs and adequate transfusion products, but it saves the lives of both mother and child. In 2007, we carried out over 500,000 antenatal care consultations and almost 100,000 deliveries. Yet, a dramatic impact on maternal mortality is difficult to achieve as the vast majority of pregnant women are not coming to any health structure for follow up and even less for delivery except when a complication occurs. Among the different post delivery chronic complications, vesico-vaginal fistulas are the most disabling and stigmatizing and we are exploring the possibilities of further developing our surgical care to women affected.

Access to family planning is obviously a precondition for all women in being able to determine how many pregnancies they choose to have. This is one activity that we have to reinforce and extend systematically to post delivery care, nutrition programs, HIV activities, so that all women can access these kinds of services.

The pre-requisites to progress

We have the sense that we should be at a turning point in the medical care we can offer to our patients. Yet, considerable steps and obstacles have to be overcome. This is in particular why we continue to fight to ensure that the Doha agreements, allowing the production of generic medicines, are not constantly called into question. In 2007, we were once again the instigators of a petition, this time against the laboratory Novartis for its law suit attacking the Indian Patent Act. We were reassured when the laboratory lost as this meant we could continue considering India as a source of good quality and affordable medicines for our patients. The current system for encouraging research is based on the market and the patent protection. Discussions are underway at World Health Organization level for setting up a system encouraging research into essential health needs that have a disproportionate impact on poor countries. These discussions aim to set up new mechanisms that will not rely on the sale of medicines or vaccines for financing research but rather will put funds upfront for the research stages of well-defined products - like for example through the creation of prize fund to boost the development of tuberculosis diagnostics.

Our daily struggle to gain access

If we were asked what represents our major daily challenge, we would reply access to civilian populations in areas of war or conflict. Despite the Geneva conventions signed by States nearly 60 years ago, and some superficial posturing we are hardly ever welcomed by warring governments or factions into the field of their own action. This reality can carry a heavy price. Both international and national MSF staff have been kidnapped or killed during the last year. In Somalia, an MSF nurse and doctor were kidnapped and held captive for several days in December 2007 and three of our colleagues were deliberately murdered in February 2008. And in Central Africa a logistician was killed in June 2007.

The reality is that we face continuing difficulties intervening in numerous conflict areas in 2007:

• In Darfur, where we have a high presence, we struggle to reach some areas, our convoys are attacked and we are looted right down to our stocks of medicines.
• In Ethiopia, we tried in vain to intervene in Ogaden, where anti-governmental counter-insurrection operations were displacing local populations. This access was consistently refused.
• We increased the presence of our teams in Somalia, particularly in and around Mogadishu, where a third of the population has fled the latest wave of violence. Yet, despite our appeals, our work is at best not respected and at worst deliberately targeted. The recent murders of our colleagues forced us to withdraw our international teams, which has obviously reduced our capacity to meet the increasing needs of civilians fleeing or held hostage by the fighting. Somalia was one of the major crises of 2007 and the situation is only getting worse.
• We are not present in Iraq, except in the autonomous region of Kurdistan where we are based in two hospitals capable of handling large numbers of wounded from neighboring towns. Yet, transferring these patients remains problematic. We are also trying to open a hospital in Iran to handle serious surgical cases that cannot be properly treated in Iraq. Our orthopedic and reconstruction surgical program in Amman continues for those seriously wounded patients we manage to transfer to Jordan and we provide essential supplies to a large number of hospitals where we cannot sustain a real presence.
• The ongoing deterioration of the conflict situation in Afghanistan drastically reduces the access to medical and humanitarian facilities for the civilian population in several provinces. Today, most humanitarian actors, apart from the ICRC, are mainly absent from the unstable areas where the coalition forces and the opposition groups are fighting. MSF left the country in 2004, following the murder of five colleagues in Badghis province on June 2, and to date there have been no concrete results from the judicial investigation. However, we remain very concerned about the potential medical needs of the most vulnerable. MSF has to consider an operational return to an environment where it will be a great challenge to be perceived as a neutral actor to the conflict.

We will persevere because this is the mandate we have given ourselves but the reality of our working environment means we will never assume that our action, the perception of it and its legitimacy are clearly and universally accepted.

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