In many places, Doctors Without Borders/Médecins Sans Frontières (MSF) is able to have an impact beyond its immediate activities, reaching populations or pioneering the use of practices in ways that have far-reaching and lasting consequences. The following case studies, which document instances in which MSF’s medical work did indeed have an impact beyond the moment, are adapted from MSF-USA’s 2012 Annual Report:
A Burn Unit in Port-au-Prince
MSF has been working in Haiti since 1991, a time during which the country has been stricken with everything from widespread streetfighting to devastating natural disasters, including the 2010 earthquake and the cholera outbreak that followed.
Through it all, MSF teams have tended to patients, assisted in births, and provided access to medical care for hundreds of thousands of Haitians who otherwise would have gone without. Among them have been innumerable people suffering from burn injuries, many of them linked to cramped living conditions. The dangers of burns also increased after the 2010 earthquake, as those rendered homeless were forced to move into shanties and tents and the overall quality of housing declined throughout Port-au-Prince. More than 300,000 displaced people, in fact, still live in temporary shelters where domestic accidents involving cooking stoves and boiling water are distressingly common, as are injuries connected to fires associated with carelessness, defective equipment, or bad wiring.
Seeing the high mortality rates and overall damage caused by these types of injuries, MSF incorporated major burn treatment into its programs. Before the earthquake, teams at MSF’s Trinité Hospital had been caring for burn victims, but last year, MSF went further and opened the first dedicated burn unit in the country, in the 127-bed Drouillard Hospital MSF built to replace Trinité, which was damaged by the earthquake, in the Cité Soleil neighborhood.
In 2012, staff at the Drouillard burn unit treated 481 burn victims, and since the housing problems in Port-au-Prince are far from solved, they will likely remain busy in the year ahead. “Unfortunately, the unit is always full,” says Dr. Guyguy Manangama. “On average, we receive more than one new admission every day.” The program draws on MSF’s experience in Haiti and on collaboration with other specialist hospitals, Dr. Manangama notes: “MSF has developed expertise in burn treatment over the last 10 years, thanks particularly to a partnership with the Edouard Herriot Hospital in Lyon, France.” The care doesn’t happen in a vacuum, either. Drouillard offers a range of complementary treatments for burn patients. The emergency, surgery, physical therapy, and mental health departments work closely with the burn unit, doing all they can to speed care and recovery—marshaling everything that’s been learned during past work in Haiti in order to treat the patients of the present and the future.
Surgery in War Zones
Soon after Syria descended into all-out war between the national army and an array of opposition groups, the country’s once-capable health system completely collapsed. Medical structures were targeted and destroyed, health care workers threatened or killed—all at a time when people who’d been shot or injured in bombing or missile attacks desperately needed surgery and trauma care.
Treating war injuries is never easy, but the situation in Syria has been particularly challenging. At first, MSF provided medical supplies to networks of doctors already in the country while trying to lay the groundwork to eventually provide direct care to victims of the war. With the government in Damascus refusing to grant MSF (or most other NGOs) access to the country, however, our teams were forced to work clandestinely. MSF set up its first ad hoc hospital facility in a house in an opposition-held area in northern Syria.
Thereafter, teams set up other hospitals in northern Syria where it was possible and safe to do so, including one in a cave. Despite the challenges, MSF performed more than 1,000 surgeries inside Syria in 2012 (and many more in 2013). The work has been specific to the context in Syria, but it’s also an extension of the surgical care MSF has delivered in war zones and other extreme circumstances—the Lebanese Civil War of the 1970s and 80s, for instance, or the Soviet-Afghan conflict and the Afghan civil war that followed, or, more recently, in Port Harcourt, Nigeria, where MSF surgeons pioneered the use of internal fixation for orthopedic care in settings with limited resources, and in post-earthquake Haiti.
Staff still must adapt to their surroundings and the limitations they present. “When you’re faced with casualties, the surgery is fairly straightforward,” said MSF surgeon Paul McMaster, who worked in Syria and had previously worked in Sri Lanka, Haiti, and other emergencies. “You do what’s called damage limitation, surgery to stop hemorrhages, and deal with damaged internal organs. The difficulty came when we moved to the reconstructive phase—things like physiotherapy and rehabilitation and more complex orthopedics—this was work we just couldn’t do in [a] cave.”
Having encountered similar issues in the past, MSF had some sense of how to respond when war convulsed Syria. Additionally, when possible, patients requiring major reconstructive surgery followed by extensive physiotherapy were sent to MSF’s program in Amman, Jordan, which was opened in 2006 to serve victims of the war in Iraq during a time when it was too dangerous to work inside the country itself. The hospital now serves people from across the greater Middle East who need more advanced care than they can get in their home countries. It also testifies to what MSF has learned over time: reaching people in conflict areas requires persistence, creativity, and a willingness to be flexible within the confines of war.
A Medical Mystery in Nigeria
In 2010, MSF doctors and nurses responded to outbreaks of measles and meningitis in northern Nigeria by traveling across vast landscapes, visiting remote villages to provide treatment and vaccines. Along the way, team members heard a disturbing rumor: in the village of Yargalma in Zamfara State, a settlement of only 2,000 people, more than 40 children had died in three months, and no one knew why.
An MSF team sent to investigate arrived to find six children at the local health dispensary suffering from high fevers and seizures. “When we see a child with these symptoms, we first think of infection,” recalled MSF nurse Kaci Hickox, who was part of the team. “Malaria is always present in this part of the world. Meningitisalso affects the brain and can cause fevers and seizures.”
Every symptomatic child was given treatment for severe malaria and meningitis, which seemed like plausible diagnoses, but they didn’t get better. Something else was responsible for the sickness. It was known that gold mining was taking place in the village, but the picture didn’t become clear until MSF logistician Frank Peters started asking questions. “He saw women breaking stones, their babies on their backs,” Hickox said. “He was shown machines used to grind down rocks, sending fine dust far and wide. He realized that a heavy metal such as lead, arsenic, or mercury was probably getting released as well.” Samples were sent to Europe for testing. Results confirmed the theory: the children were suffering from severe lead poisoning.
It wasn’t just Yargalma. In total, an estimated 400 children in Zamfara State died as a result of lead poisoning associated with gold mining. Through late 2012, MSF had treated more than 2,000 children, reducing mortality significantly, and several villages were environmentally cleansed of the deadly particles. In addition, MSF worked with experts from the World Health Organization and the US-based Centers for Disease Control to define new protocols for chelation therapy in situations with such widespread lead poisoning; none had previously existed.
Some unsafe mining practices continue, however, and the Nigerian government’s promise to fund further clean-ups went too long unfulfilled. MSF therefore launched a public advocacy campaign designed to spur the government to devote the necessary resources to remediate the problem. At any time, MSF is ready and willing to treat those who need care—to finish a job that started when teams on the ground chased down a rumor and figured out how they could help.
Small Steps, Big Impact in Battle Against Maternal Mortality
In Burundi and Sierra Leone, the act of giving birth can be fatal. Would-be mothers in both countries have precious little access to obstetric care—there are only three registered obstetricians in all of Sierra Leone, for example, and only one in Burundi who works outside the capital—because civil wars and a lack of resources have crippled the health care systems of both countries. Poor roads and limited transportation options compound the problem, making it difficult to reach medical care of any kind.
Many women thus try to delay seeking care as long as they can, or avoid it altogether. As a result, the national maternal mortality rate in Sierra Leone was the third-highest in the world in 2010, with 890 deaths for every 100,000 live births, and Burundi was fourth-highest, with 800 deaths for every 100,000 live births. (For perspective: the maternal mortality rate in Sweden is 4 in 100,000.)
In order to counteract these deadly trends, MSF initiated programs in Burundi’s Kabezi District and Sierra Leone’s Bo District that set up free-of-charge central referral facilities and emergency ambulance services to bring women from remote health centers to hospitals where they could deliver safely, 24 hours a day, seven days a week.
Technically speaking, these were not the most medically sophisticated or resource-intensive responses—the annual costs amounted to about $2 per person per capita in Bo District and $4 in Kabezi—but they efficiently addressed clear and present needs, and the results have been dramatic. In 2011, with the programs up and running, maternal mortality decreased by 74 percent in Kabezi and 61 percent in Bo. “If MSF were not here, many of these women who come to us every day would be dead,” says Betty Raney, an MSF obstetrician from Indiana who worked in the hospital in Bo. “The best part of my job is feeling that I make a difference and experiencing the gratitude that I get from my patients.”
The MSF programs in Kabezi and Bo have proven that lifesaving emergency obstetric care doesn’t have to be expensive or state-of-the-art to substantially reduce the number of women who die in childbirth, a powerful lesson for donors, governments, and other NGOs working to save the lives of mothers and children worldwide.
TB and Children
In 2012, MSF teams in Tajikistan opened the country’s first project dedicated to treating children suffering from multidrug-resistant tuberculosis (MDR-TB). Though linked to a disease once thought to be on the wane, the number of MDR-TB cases in Tajikistan (and several other countries) has risen in recent years, as people have either received substandard care or been unable to adhere to the lengthy, grueling treatment regimen for TB. Tajikistan, one of the poorest former Soviet countries, has been particularly hard-hit and now has the highest rate of TB in what the World Health Organization designates as the Eastern European region.
MSF, based in part on its refusal to accept the neglect of certain patient populations, has run TB programs in many former Soviet countries, but in Tajikistan, as elsewhere, finding ways to treat children has been an especially vexing issue. Because there’s been so little research and development for TB over the past 50 years, there are no pediatric versions of the tests or drugs needed to detect and combat the disease. Children therefore must use the same tests and drug formulations as adults do, taking regular doses of large, hard-to-swallow pills for up two years and enduring debilitating side effects that include fever, headaches, hearing loss, nightmares, even psychosis. And they still only have a 50 percent chance of being cured.
Before MSF launched its program, not a single child in Tajikistan had received treatment for MDR-TB. At the end of 2012, MSF was treating 30 children in MSF’s TB ward at Machiton Hospital, near Dushanbe. To improve both prospects and the experience, our medical teams take innovative approaches to care—dissolving drugs in a flavored liquid, for instance, so they’re easier to ingest, and fashioning a special sputum induction room, the first of its kind in Central Asia. They also lead adherence and prevention education efforts for children and families and make it possible for children to complete the regimen at home.
More significant changes are needed, however, if we want to offer better treatment options to more children infected with DR-TB. That’s why MSF has mounted a sustained advocacy campaign to highlight TB’s resurgence and to call for research and development around the disease, for children and adults alike. This includes using new tests to detect TB resistance and welcoming the anticipated release of two promising new medicines that can combat TB and DR-TB. “The current standard treatment for MDR-TB has too many obstacles to a successful outcome, from duration, to toxicity, to efficacy,” says Dr. David Olson, MSF medical advisor. “We need an entirely new regimen that is patient-friendly and effective. The new drugs coming into use finally offer an opportunity to construct such a regimen. We need to find a way for these new drugs to reach our patients ASAP.”
Vaccinating for Cholera
One-fifth of the world’s population, or 1.4 billion people, is at risk for cholera. At present, the customary response to outbreaks is to treat those who’ve contracted the illness and conduct public awareness campaigns designed to help uninfected people avoid the disease. Until recently, vaccination was a small part of the conversation.
That is changing, however. Oral cholera vaccines have been used preventively in a handful of instances, and pilot studies have demonstrated that vaccination can also be effective even after an outbreak has begun. In 2010, the World Health Organization added vaccination to its cholera outbreak response guidelines as well, even though large “reactive” cholera vaccination campaigns were widely considered too difficult to implement on short notice given the logistical challenges of delivering hundreds of thousands of refrigerated vaccine doses to remote areas and mobilizing communities to get the two-dose vaccine.
In April 2012, however, after cholera cases began appearing along the border between Sierra Leone and Guinea in West Africa, MSF tried to find a middle ground of sorts. With the rainy season approaching, the stage was set for a devastating epidemic. Rather than wait for people to present with symptoms to respond, MSF, working with the Guinean Ministry of Health, identified and vaccinated populations that were at imminent risk of contamination—populations that were in the disease’s path, so to speak.
Dozens of teams spread out across hundreds of vaccination sites. Within six weeks, and with tremendous community support, teams immunized more than 170,000 individuals—nearly three-quarters of the population in the target area. Over the next six months, it became clear that the campaign had significantly reduced the impact of the region’s outbreak on this population.
These results surpassed MSF’s own expectations, demonstrating that rapid mobilization in remote areas is both feasible and effective, and paving the way for the vaccine’s wider use during future outbreaks.
Rapid Mobilization When Emergencies Hit
In late 2011, refugees fleeing fighting in Sudan started flowing into South Sudan’s Upper Nile and Unity states. The following spring and summer, the numbers jumped dramatically, to more than 170,000. A full-fledged emergency was underway. The refugees massed in remote, barren stretches of an under-developed country still scarred by decades of civil war with Sudan, which it was part of until early 2011. There was no medical care and no way to reach it. MSF, therefore, as it has in many emergencies over the years, had to import a full complement of medical personnel and services, and build facilities in which they could be housed.
That meant mobilizing emergency teams of field workers from numerous countries around the world (including dozens from the US) and hiring local and national staff as well. It meant getting the necessary materials to the location sites, driving them in when possible, or using planes and/or boats when rains rendered roads impassable. It also meant mounting a concerted advocacy campaign when MSF epidemiological teams documented mortality rates in the camps well above the emergency threshold, along with an unusually frank appeal for funds when budget projections for the emergency response rose well above what had been allocated for South Sudan programs in 2012.
On the ground, teams were treating malaria, diarrhea, respiratory tract infections, and malnutrition, making the most of the resources available. Early on, said Dr. Matthew Horning, who worked in the Yida camp, “We had only the most basic medications, equipment, and laboratory tests. We did tests for malaria and we could do a basic urine test, and we could do hemoglobin and blood sugar, and that was it.” As MSF scaled up, teams ran measles vaccination campaigns, built inpatient facilities and emergency rooms, conducted surgeries, even drilled boreholes to reach potable water.
By the end of the year, even as the pace of the emergency subsided somewhat, MSF was still running three field hospitals and seven health posts and providing around 5,500 consultations per week across four refugee camps. Medical teams also stood ready to respond to any new crises, like the Hepatitis E outbreak that occurred late in the year.
It was extremely challenging work, and many lives were lost due to the size and severity of the emergency. But by marshaling available resources, calling on lessons learned during bygone emergencies, and pressuring other organizations to do their share, MSF made a profound difference. “Seeing MSF’s ability to respond quickly and make changes—to really bring about an improvement in the health and lives of the people—was really incredible,” said Jon Johnson, a nurse from Virginia who also worked in Yida. “It was an honor to be there.”
A New Tool in the Fight Against Malaria
Malaria, which kills more than 1,500 people around the world every day, is a leading cause of illness and death in many countries in which MSF works. The majority of its victims are children under the age of five in sub-Saharan Africa, where malaria’s vector, the Anopheles mosquito, thrives.
MSF is therefore constantly confronted by the question of how to reach as many children as possible across vast regions where health care provision is limited or non-existent. In the summer of 2012, teams working in Mali and Chad implemented a new approach, something called “seasonal malaria chemoprevention,” which basically means treating all children in a given location for malaria during the times when the disease is most likely to proliferate. The working theory is that treatment during the months of highest incidence (usually the rainy season) makes it possible to both treat existing cases and prevent new ones.
Using this approach, MSF treated 160,000 children under five in Mali and 10,000 more in Chad. It was a significant step, says Dr. Estrella Lasry, MSF tropical medicine advisor, with encouraging results. “This was the first time children had been treated at this scale outside research conditions. Results showed more than a two-thirds drop in simple malaria cases and a significant drop in severe malaria in the weeks that followed. The number of transfusions in the hospital in Mali also decreased over 70 percent. We saw malnutrition levels go down, too, an important and unexpected outcome.”
The numbers treated in Mali and Chad represent a fraction of the malaria cases MSF treats in a given year, and an even smaller fraction of all malaria cases worldwide. Furthermore, the evidence only shows that this approach is effective in places where malaria is seasonal. MSF has also already identified several ways to improve its implementation and data gathering operations in the year ahead.
That said, seasonal malaria chemoprevention is an important new tool in the battle against malaria, one that looks very promising for certain contexts. “We had good results and our main objectives were reached,” says Lasry, “but we are still looking at ways to improve this intervention.”