From the Ground Up: Building a Drug-Resistant TB Program in Uganda

Uganda is one of the world's 22 high burden countries for tuberculosis (TB). Despite having a national treatment program for drug-sensitive TB, there has been an emergence of drug-resistant strains of the disease, which are presenting a new and urgent threat to people's health. So far in Uganda, 226 cases of multidrug-resistant tuberculosis (MDR-TB) have been confirmed, spread across 40 districts, but the true figure is likely to be much higher.

Improvements in diagnostics in Uganda mean that drug-resistant tuberculosis (DR-TB) can now be diagnosed—but it can't yet be treated. As yet, there are no second-line TB drugs in the country. Until the government is able to offer treatment and care, people with drug-resistant TB will be left in limbo. Unless they can afford to leave the country and pay for treatment elsewhere, the most they can hope for is that the drugs become available in Uganda before their condition proves fatal. There is no data available for how many have already died.

The best way to stop the disease from spreading is to start patients on treatment early. Aware of the urgency of the problem, the Ugandan government is taking steps to start treating DR-TB. Funding for DR-TB drugs is on its way, the drug order has been placed, and the government is planning a 40-bed ward for DR-TB patients in Mulago hospital in Kampala.

However, MSF's experience of treating DR-TB in Uganda strongly suggests that centralized care is not the answer. Many patients and their caregivers from rural districts will find it impossible to manage a lengthy stay in the capital, and default rates are likely to skyrocket.

MSF firmly believes that a feasible model of care already exists in the Ugandan context. Since 2009, MSF has been running a community-based and comprehensive TB treatment program in Kitgum, in northern Uganda, hand in hand with the Ministry of Health.

The preliminary treatment outcomes of the DR-TB component in Kitgum have been promising: although the number of patients in the program is small, since it began in 2009 there have been no defaulters, no treatment failures and no deaths. MSF puts the success down to the model of care they are using, which is comprehensive, decentralized, and community-based. In addition to the conventional components of care, two constituents have played a vital part: psychosocial counseling by trained counselors to support patients through their treatment; and the use of village health teams, who are trained, supervised and rewarded for their work.

Community-based care has been shown to be safe, practical and extremely effective for DR-TB, leading to high adherence, close follow-up and encouraging outcomes. Patients treated within their communities benefit from the practical and emotional support of friends and family in coping with the side effects of the drugs and adhering to their treatment, while increased understanding of TB within communities leads to higher detection rates and reduced stigma associated with the disease. The model of care has proved to be feasible and widely accepted—by patients, local communities and healthcare staff alike.

As the Ugandan government prepares to start treating people with DR-TB, MSF is convinced that its focus should be on providing comprehensive, decentralized, and community-based care. In this report, MSF calls on all key stakeholders to assure quality rapid TB diagnosis, treatment and care, and argues that a scale-up of the decentralized and community-based approach, including access to second-line TB drugs at district level, is the most feasible method of averting the country's impending health crisis.

DRC: Civilians and Aid Workers Victims of Renewed Fighting in the Kivus

Paris/New York, April 11, 2012—Civilians and aid workers are increasingly the targets of violence in eastern Democratic Republic of Congo (DRC), where armed conflicts and large troop movements have recently intensified, and where security risks have made it increasingly difficult to continue to provide medical care, said the international medical humanitarian organization Doctors Without Borders/Médecins Sans Frontières (MSF) on Wednesday.

National and international stabilization forces in DRC have never been more important, but MSF questions their effectiveness given the worsening situation.

"The situation is not stabilizing in Kivu,” said MSF program manager Dr. Marcela Allheimen. “It is deteriorating again, and has been deteriorating over the last several months. We are noticing renewed violence, but what is most alarming is the commonplace nature of violence on civilian populations and aid actors.”

Since November 2011, MSF teams have been victims of more than 15 acts of violence, including a raid last week by armed and uniformed men of an MSF house in Baraka, South Kivu Province. More seriously, on April 4, two MSF staff members—a nurse and a logistician—were kidnapped on a road near Nyanzale in North Kivu Province. They were released a few hours later.

Items such as food, money, and mobile phones are also being extorted, mostly to supply military logistics.

As a result of the heightened security risks, MSF—one of the few medical aid organizations present in North and South Kivu—has suspended its activities in Nyanzale, reduced them in Rutshuru, and has withdrawn its team in the Butembo area.

For the civilian populations, access to medical care has become even more difficult, and movement is limited due to the heightened risk for civilians. Sick people are afraid to travel to reach the health centers. Few people go to work in the fields due to lack of security, afraid they will be robbed, become victims of extortion, or worse. In some cases, civilians have been drafted to transport the belongings of armed men and there have been reports of women being held as slaves.

Despite the fragile security situation, MSF continues to have teams on the ground in North and South Kivu providing medical care, notably in Kitchanga, Mweso, Pinga, Rutshuru, Baraka, Lulimba, Kalonge, and Shabunda.

CAR: Freedom From Fistula

In January 2012, 50 women from northwest Central African Republic (CAR) traveled to a hospital run by Doctors Without Borders/Médecins Sans Frontières (MSF) to undergo surgery that would change their lives forever. One of those women was 17-year-old Awa, who made the journey to Boguila to be treated for a fistula she developed two years ago, during the birth of her first child.

Obstetric fistulas are devastating child-bearing injuries that affect more than two million women around the world, mostly in Africa. “I came here because my bladder is torn,” says Awa. “It happened during my first delivery, which took two days, and was complicated. The midwife used an instrument during the delivery which hurt my bladder. My baby died.”

“Obstetric fistulas occur during the delivery of a child,” says MSF doctor Volker Herzog. “Delivery may stop at a certain point because the head of the child is too big or the pelvis of the mother is too small, or the uterus, the muscle, is not contracting correctly, and the head of the baby presses on one point of the birth canal. If you have pressure on one point the tissue dies and this then becomes a fistula, a connection, an abnormal opening from the bladder to the vagina. That means the woman is leaking urine all the time. It's very difficult for them and they often become social outcasts.” Women may also develop other health issues, including kidney infections, skin ulcers, and mental health problems.

Dr. Herzog, a surgeon from Germany, has been holding fistula surgery “camps” in the Central African Republic for the past six years. This year he and his assistant, Swiss midwife Agnes Matti, spent four weeks in Boguila, holding consultations and performing fistula repairs.

With good obstetric care, fistulas are preventable, but most women in the Central African Republic don’t have access to skilled birth attendants or the resources to pay for treatment at a hospital. Dr. Volker says the operation transforms these women’s lives: “They are really neglected. They have no lobby, they don't get money—I’m very happy MSF is doing so much for these women and that we hold so many fistula surgery camps.”

There was a special feeling at the camp in Boguila. For many patients, it was the first time they could speak freely about their illness, and share their stories and their feelings. “I was very happy,” said Awa. “MSF gave us mats, blankets, food, and doctors to take care of us. All the women at the camp suffered from the same disease. We got along very well. We told each other about our lives and the stages of our illness.” Following their surgery, Awa and the other patients spent three weeks recuperating in the camp. Dr. Volker and Agnes Matti visit them twice a day to monitor their progress. Awa is grateful for the treatment she received. She says she is looking forward to returning home, where she plans to find work as a farmer.

South Sudan: MSF Assists Patients Wounded in Aerial Bombardment

Doctors Without Borders/Médecins Sans Frontières (MSF) is treating patients wounded on April 10 during aerial bombardments of Abiemnom in South Sudan's Unity State. Violence has rocked the region over the past few weeks and the situation remains extremely volatile.

MSF’s hospital in Agok, 36 kilometers (about 22 miles) east of Abiemnom, received four wounded patients on the afternoon of April 10—a woman and three children—all of whom had severe open wounds requiring multiple surgeries. All four have now been stabilized. The MSF team in Agok has also donated drugs and equipment to the Ministry of Health’s medical center in Abiemnom to support the treatment of an additional 40 wounded patients there.

“In this region the population is on the frontline,” says Emmanuel Roussier, MSF’s head of mission in Juba. “Emergencies are unfolding one after another. Our teams are doing their best to respond to people’s most urgent needs—whether for food, shelter, or health care. Our constant concern is to provide comprehensive secondary health care and life saving activities to all the communities in the region.”

Since previous clashes in the Abyei region in May 2011, MSF has been running mobile clinics throughout the area, including in Machbong, Abathok, Mading Achueng, Akack Nyel, Leu, Marial Achak, Mabok, Rumamer, and Abiemnom, reaching approximately 100,000 people. MSF teams are monitoring the humanitarian situation, particularly among people affected by the violence, including those who have been displaced from their homes. All severely sick or wounded patients are referred to MSF’s hospital in Agok.

The MSF staff in Agok is prepared to respond to a further influx of wounded if the fighting continues. They are also ready to scale up distribution of health care, shelter materials, and relief items for the affected population.

In November 2011, following an assessment of food security and nutrition in the area, MSF began providing supplementary food for all children under five years old, reaching up to 15,000 children. It also conducted a mass measles vaccination campaign.

Haiti: Building Emergency Services

On January 12, 2010, the earthquake in Haiti destroyed 60 percent of the hospitals in the country. In February 2012, Doctors Without Borders/Médecins Sans Frontières (MSF) opened Nap Kenbé in the Tabarre neighborhood of Port-au-Prince, the fourth hospital MSF has opened in Haiti since the disaster. Nap Kenbé is a reference center for specialized surgery, offering high quality internal and orthopedic surgery to Haitians free of charge.

Sahel: As Likely Malnutrition Crisis Looms, MSF Prepares Short- And Long-Term Responses

The annual "hunger season" seems likely to be particularly serious in the Sahel this year, and a few particular regions may face acute nutritional crises in the coming months. Doctors Without Borders/Médecins Sans Frontières (MSF) is therefore expanding its nutritional activities to address the seasonal “peak” in malnutrition rates, while also developing longer-term approaches it can integrate into its regular programs.

A food crisis has been declared in the Sahelian Band of West Africa. UNICEF has estimated that up to 15 million people in six countries in the region are living with moderate or acute food insecurity. In a region where global acute childhood malnutrition rates regularly near the warning threshold of 10 percent, any factor that further reduces access to food can tip the situation into a full-blown nutritional crisis.

Although MSF has not yet noted a significant increase in cases in most of its current nutritional programs, the organization did have to open new malnutrition treatment programs in Biltine and Yao, in Chad, where rates of acute malnutrition of 24 percent and 20 percent, respectively, have been reported. Teams are also evaluating the nutritional situation in other areas of Chad, as well as in Mali, Niger, Mauritania, and Senegal.

"It is too soon to know the extent of the expected nutritional crisis," says Stéphane Doyon, manager of MSF's malnutrition campaign. "Traditionally, the most difficult period is still ahead, between May and July. However, we already project that hundreds of thousands of children will suffer from acute severe malnutrition, as they do every year in this region."

In Niger alone, 330,000 children received treatment of severe acute malnutrition in 2010, making it a “crisis year.” In 2011, which was deemed a "good" year for farming, the number still totaled 307,000. This suggests a recurring crisis.

"We have to rethink what constitutes a 'crisis' and what is 'normal' in this region," Doyon says. "More than 300,000 children severely malnourished, this is an enormous number—and that's just in Niger. Emergency humanitarian response is necessary as it allows saving lives, but it cannot be the only option."

This year, early warnings issued last fall by the governments of six countries in the region made it possible to develop an ambitious response. This response now exists on paper, but it will not be easy to implement. Financing has not yet been obtained and accessing the region's most remote areas will be a challenge. In addition, insecurity, and violence in certain areas are already complicating the deployment of aid. The populations from one country to another, and within countries as well, also have very different degrees of access to health services. This means that aid actors have a very complex set of task in front of them.

Many of the aid organizations working in the region have agreed they must start to transition from emergency response efforts towards structural measures that can assist the longer-term mission to fight illness. MSF, for its part, is already implementing strategies that can help combat the recurring malnutrition crisis in the Sahel over time, not just in the immediate moment.

For instance, in 2012, the organization will expand its activities in the region in response to the needs of the day. Projects that MSF has been operating for several years, however—particularly in Niger, Mali, Chad, and Burkina Faso—have been designed both to treat the children most at-risk and also to find new ways to address underlying dynamics of recurrent malnutrition.

"No one has the solution, but we now know that treating children by giving mothers responsibility for their care and encouraging prevention by using specialized milk-based products offer extremely encouraging results," Doyon says. "Our objective is to help identify the most simple, economical approaches possible so that all children have access to them, just like regular vaccinations or access to health care, which have already been recognized as being effective in reducing child mortality."

In 2011, more than 100,000 severely malnourished children received treatment in MSF's Niger programs alone. More than 90 percent of them recovered. In Niger and Mali, MSF also provided milk-based nutritional supplements to more than 35,000 children in conjunction with its regular pediatric programs.

Uzbekistan: A Mother With MDR-TB

Her coffin had already been built when Rohatay Abdullaeva learned she could get help in her native Uzbekistan. As World TB Day approaches, MSF celebrates her good health, but also remembers the huge number of people with TB who cannot get the help they need.

Iraq: Working to Reduce Neonatal Mortality

Shinjiro Murata, a Doctors Without Borders/Médecins Sans Frontières (MSF) field coordinator from Japan, worked with MSF in the southern Iraqi city of Najaf, where his main focus was setting up a new project focused on improving perinatal and obstetric care in one of the largest referral hospitals in the region. Here, he talks about his experience:

I arrived in Najaf more than a year ago, in October 2010, to start an MSF project in the Al Zahara District Hospital. Najaf is located 160 kilometers (99 miles) south of Baghdad and is one of the holiest cities for Shia Muslims. It was not an easy task, and surely a challenging experience to be working in such a different country. My previous experience with MSF was in Africa, so when I started working in Najaf I realized that I would need to see things from a different perspective and adapt to the reality of a country that used to have a very well organized health system but, due to decades of conflict and international sanctions, has seen a rampant deterioration in health care provision.

After the US-led invasion of Iraq in 2003, most of the nursing teaching structures (faculties and universities) were closed. This lead directly to a huge gap and shortage of specialized staff and a lack of training. Most of the nurses and the medical staff in the Iraqi health structures are under-trained and even less up to date on the latest technical and material medical developments. According to the Iraqi Ministry of Health, since February 2006, due to the aggravation of sectarian violence, over 70 percent of medical staff has fled the country, while hundreds have lost their lives.

The insufficient capacity of the Iraqi health system to respond to the medical needs of the population has contributed to an unprecedented increase of maternal and infant mortality rates in the country. In 2007, the World Health Organization estimated the Maternal Mortality ratio to be 300 per 100,000 live births. According to the latest UNICEF State of the World’s Children report, Iraq presents a neonatal mortality rate of 64, while neighboring Syria and Jordan presented a neonatal mortality rate of 7 and 16 respectively.

MSF decided to start a medical program to support the main Ministry of Health referral hospital, the Al Zahara District Hospital, for obstetrics, gynecology, and pediatrics in Najaf city. The hospital is one of the largest hospitals in the region, with a 340-bed capacity, and it deals with approximately 1,950 deliveries per month. These account for almost 50 percent of the deliveries carried out in the whole Najaf Governorate, which has a total population of 1.2 million people. It is most of the time overcrowded with patients and the quality of medical services provided is sometimes not adequate.

According to the medical data we collected in the hospital during 2010, although maternal and pediatric mortality rates were low, the neonatal mortality rates were remarkably high. Almost 70 percent of the newborn babies admitted in the pediatric intensive care unit lost their lives, while 26 percent of newborn babies admitted in the sterilized unit died. What is also very worrisome was the fact that Caesarean sections accounted for 37 percent of all deliveries carried out in the hospital. And about 60 percent of all babies admitted were born by Caesarean section deliveries. Almost half of the babies who have died in the sterilized unit were premature.

In our effort to improve this situation for newborn babies in the hospital, we have had frequent meetings with hospital authorities to work together with our teams. It was a big challenge!

Together with my MSF colleagues, we have worked a lot during the last year to improve the quality of the medical services in both the neonatal and obstetric departments of this huge hospital. MSF pediatricians have provided hands-on bedside trainings on how to receive babies in the baby reception rooms and how to resuscitate them in the pediatric intensive care unit. MSF obstetricians and gynecologists have been implementing the standard operational procedures for antenatal care, delivery care, caesarean sections indications and timing, and anesthesia. And MSF nurses and logisticians have tackled some important transversal issues in the hospital, like improving infection control measures, bridging supply gaps of essential equipment and renewable items, and improving maintenance by the hospital.

For me, working for MSF in Al Zahara District Hospital was an interesting experience. MSF´s work in this hospital, mostly directed towards capacity building, training, and the participatory approach, is not the typical work that MSF usually does in its projects. Although it was very challenging, I think it is worth the effort.

After more than one year in Najaf I have seen that medical needs in the country are still very high. Until peace is restored in Iraq, MSF needs to continue supporting these pregnant women and newborn children. MSF is one of the few international medical humanitarian organizations working inside Iraq thanks to its independent, neutral, and impartial nature.

Somali Refugees in Dadaab

Though the international spotlight has moved on, hundreds of thousands of Somali refugees in the Dadaab camps in northwestern Kenya, the largest refugee camps in the world, continue to struggle amid harsh conditions and pervasive malnutrition, particularly among children. Aid has been too slow in coming, however, and longer-term solutions are nowhere to be found.

MSF Book Reveals Perils of Negotiating Access to Crisis Zones

NEW YORK, NY, JANUARY 30, 2012 - In a new book launched in the United States today, the international medical humanitarian organization Doctors Without Borders/Médecins Sans Frontières (MSF) takes readers behind the scenes of humanitarian action, revealing the complicated negotiations and precarious compromises required to negotiate access to populations trapped by armed conflicts and health crises.

Inspired by MSF’s fierce internal debates on the evolution of its independence as a humanitarian organization, Humanitarian Negotiations Revealed: The MSF Experience offers a candid, self-critical examination of MSF’s decision-making processes in a dozen countries, including Afghanistan, Myanmar, Somalia, Sri Lanka, and Yemen.

The book, released in conjunction with MSF’s fortieth anniversary, reflects on MSF’s medical humanitarian efforts over several decades—some successful, some less so—and aims to ignite wider discussions of humanitarian ambitions and the best ways of fulfilling them.

“Humanitarian negotiations have life-or-death consequences for people in need,” said Sophie Delaunay, executive director of MSF-USA. “As MSF weighs the risks of delivering humanitarian aid in precarious situations, such as Somalia, it seems more important than ever to lift the veil that often obscures the difficult choices our teams confront on a daily basis.”

The book consists of a series of case studies, followed by thematic essays, which examine the delicate balance between upholding MSF’s founding principles of independence, neutrality, impartiality, and speaking out; and the practical realities of delivering humanitarian aid in complex and dangerous political environments.

The authors—MSF veterans with many decades of collective field experience—chronicle MSF’s experience in 12 countries: Afghanistan, Ethiopia, France, the Gaza strip, India, Myanmar, Nigeria, Pakistan, Somalia, South Africa, Sri Lanka, and Yemen. Journalist David Rieff contributes an afterword in the book.

In conjunction with the launch, MSF will present a live, interactive webcast, “At Any Price? Negotiating Access to Crisis Zones,” free and open to the public, on Tuesday, January 31, at 8:00 p.m. EST. A panel of experienced MSF aid workers, including Michael Neuman, one of the authors and editors of the book, will discuss their experiences in conducting humanitarian negotiations in the field.

Panel discussions, featuring editors of the book and other guest speakers, will be held at the Boston Public Library on Wednesday, February 1, at 7:00 pm, and at The New School’s Tishman Auditorium in New York City on Thursday, February 9, at 7:00 pm. Both events are free and open to the public; register online a here.

Humanitarian Negotiations Revealed: The MSF Experience follows MSF’s 2004 publication In the Shadow of Just Wars, and continues the “Populations in Danger” series produced by MSF’s research center in Paris, CRASH (Centre de Reflexions sur l’Action et les Savoirs Humanitaires) (Center for Reflection on Humanitarian Action and Knowledge).