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Nigeria: Escaped…...but still no escape

Nigeria: Escaped…...but still no escape

Borderline

05 Apr 2017

In the face of suffering

The new design of this “Borderline” will, I hope, help to draw your attention to three humanitarian crises through different perspectives. The fighting between the Nigerian military and Boko Haram in Borno State in the northeastern of the country has been ongoing for the past several years. Our teams on the ground witness the nutritional crisis in the region continuing as a repercussion of the widespread of displacement due to the fighting. As of today, our teams still don’t have access to the majority of Borno state because of the insecurity. At the same time, people continue to flee the violence and only have limited access to food, water, and healthcare, having to rely on external assistance.

A few countries to the east on the same continent, South Sudan continues to be plagued with conflicts. Neighbouring Uganda has become the refuge for hundreds of thousands of South Sudan refugees. The border camp was originally expected to accommodate 40,000 people but is now already overwhelmed with 270,000 refugees, becoming one of the largest refugee settlements in the world. The Photo Feature presents the struggles that the refugees have endured throughout the journey and the new challenges in the settlement area.

On the other side of the world, in Asia, Afghanistan remains one of the most dangerous places in the world for women to give birth. While any maternal death will definitely be headline news in Hong Kong and many other developed countries, there are 4,300 women who die due to complications during pregnancy or childbirth in Afghanistan. That’s more than 10 deaths every day¹. In Khost which is one of the provinces most severely affected by the more than a decade-long conflict, MSF is running a maternity hospital, providing free medical care for the women and newborn babies. An anaesthetist shares her second-time field assignment in this hospital in the Frontline Sharing.

Confronted with this suffering, MSF has committed to provide life-saving medical care to people in need. And we are always driving to improve the quality of care that we provide in these difficult settings. Technology has allowed us to provide better diagnostic tools, for example. The new section MSF Knowledge shares our experience of using new smartphone technology to help diagnose cerebral malaria – a very common disease in places where we work and one which can be deadly if not treated – in situations where resources are limited.

All these activities could not happen without the help of our committed supporters in Hong Kong and worldwide. In return, MSF wants to be transparent about the use of those donations. As discussed in the MSF-Hong Kong section, the way we use donors’ money, including the expenditure on fundraising, is closely linked with our principles. We hope you will continue to support our mission and our principled approach, and that even more people will join us.

Rémi Carrier

Executive Director, Médecins Sans Frontières Hong Kong

¹Maternal mortality country profiles, World Health Organization: http://www.who.int/gho/maternal_health/countries/en/

Cover Story

Nigeria: Escaped… but still no escape

Borno State in northeastern Nigeria, West Africa, has been the main battleground between Boko Haram and the Nigerian armed forces in the past few years. At the same time, the state has a severe lack of food1. MSF teams witness people being displaced by the conflict every day and then having to live in camps, trapped under military control or those of different forces. They have to rely on external aid to provide them with essential food and medical care. However, lots of areas in Borno State are still inaccessible to aid organisations because it is too dangerous to go there. The situation in these places is even more worrying.

Bama was once one of the most heavily populated towns in Borno. It has however been emptied by the prolonged fighting between the Nigerian Army and Boko Haram, except for a camp located inside the compound of a hospital. 11,000 people live there, taking refuge in makeshift shelters made of iron sheeting taken from nearby damaged houses. Most of the residents are women and children. The camp is controlled by the military and everything that the people need, including food, has to come from outside aid. MSF was allowed to visit Bama for the first time last June to evaluate the medical needs. The team quickly screened over 800 children for malnutrition, only to find that 19% of them suffering from severe acute malnutrition. The team also counted 1,233 graves located near the camp, which had been dug in the past year. Of those, 480 were for children. “Bama is largely closed off,” said Ghada Hatim, MSF’s the then head of mission in Nigeria. “We have been told that people there, including children, have starved to death."

Children are missing

In fact, the whole of Borno is struggling to find enough food. From last July to September, MSF conducted epidemiological retrospective mortality surveys in four locations we could reach. They revealed that the emergency thresholds of mortality were exceeded, particularly in the under-five population, and that malnutrition rates were excessively high. MSF International President Dr. Joanne Liu visited three places in Borno last November and saw that something was terribly wrong. Normally, when camps are set up for internally displaced people, there are almost always small children buzzing around. But in Borno, children under 5 years of age were missing from the therapeutic feeding centres, the inpatient wards and the outpatient department that she visited. “Where have these children gone?” she wondered. The stories that she heard in Borno were all about how fighting forced people from their homes, and how food shortages then caused toddlers to die from malnutrition, compounded by infections.

Over the past few months, MSF has been able to start to provide medical care and nutritional treatment, and even distribute food, to more places as we gained access. Like other accessible areas in Borno, Bama was given some respite as more aid agencies have been able to come in. With the end of the rainy season, food shortages, malaria, diarrhea and similar problems have declined.

MSF however keeps seeing new arrivals in a number of displacement camps, implying that some areas in Borno are still too dangerous to live. But getting away from them however does not guarantee stability in life.

Gwoza and Pulka in southwestern Borno are both held by the Nigerian army. Displaced people keep arriving in the camps, while people inside cannot leave. Medical director Jean François Saint-Sauveury was in Gwoza and Pulka earlier this year and he recalls that the people there were totally deprived. Many displaced people had nothing but at the same time it was impossible to cultivate there and leaving the town to collect firewood to cook with was extremely dangerous. They had no choice but to depend on external aid. “In just one day, 500 people arrived in Pulka, mainly elderly, women and children. A camp has been built with some tents, but it has no latrines or water points so the displaced have not occupied it. Hundreds of people have been living for weeks around the health centre run by MSF,” he said.

What about those places that haven’t been seen yet?

MSF is currently running ten medical facilities in six towns in Borno and regularly visits another six to provide medical care.

However, the part MSF is able to reach is just a small area of Borno. “MSF still does not have access to many areas for security reasons and we do not know what is happening,” explained Jean François. What he could confirm is a deteriorated health system caused by the fighting²: primary care is not working well; hospitals are overwhelmed; dramatic gaps are found in emergency care, surgery, transfusions, mental health and suchlike. In some areas, MSF is the only medical organization that provides aid.

MSF calls on the Nigeria authorities and aid organisations to ensure food distributions and free healthcare throughout Borno. We ask that they should not relocate people into areas that are still unstable and without sufficient aid. People should be allowed to choose where to seek safety and when they want to return.

Know more: Background of the Borno crisis

The conflict in Borno State started in 2009 when Boko Haram (BH) launched attacks in northeastern Nigeria. By 2014, BH controlled large swathes of territory in Borno State and caused large-scale population displacement. In 2015, Nigeria elected a new President who vowed to take back control of all Nigerian territory from BH. Since then, the Nigerian army escalated their operations and has been engaged in active fighting with BH across Borno, including launching airstrikes in areas under BH control. This has caused further mass displacement of the population, particularly towards Maiduguri, the capital of Borno State. The population of Maiduguri has increased to around 2 million; half of them are internally-displaced persons. The conflict with BH has a spillover into Nigerian neighbours including Cameroon, Niger and Chad. According to the United Nations Office for the Coordination of Humanitarian Affairs, 2.3 million people are displaced following the conflicts in the four countries. 80% of them are from northeastern Nigeria.

Fleeing with children

“We left our village in Bama one year ago. Our life there was comfortable; we had everything that we wanted. At home we could farm, but here we do not have access to any land.

We left our village because of an attack. We left at night, in such a rush that we took nothing with us apart from our children. We trekked on foot – it took four days to reach Maiduguri. We knew that armed men were patrolling the area so we hid every time we heard a motorbike or a car. We stayed out of sight until we couldn’t hear the sound of the vehicle any longer.

It was really difficult for the children. Two of them fell sick and they have not yet recovered. They have fever, coughing and are stressed. But we are here now and managing with what we have. Most days we only eat once and have to go to sleep with empty stomachs. We have only been given food twice by MSF; otherwise we rely on family members who live in Maiduguri. They give us food not because they have a lot, but because they have human feelings.

It’s very difficult to sleep at night. Nine of us sleep in this shelter and there is not very much space. Some of us sleep outside. We would like a blanket, shelter, food and to go back to our community. We would like people to know about the hardship that we face. Life is difficult for us here. We don’t have water, food or detergent to wash our children’s clothes. At home they could go to school, they had a playground. We know that our home has burnt down, like most of the homes in our village. But we still want to go back when it is peaceful.”

- Maira Modu, 30-year-old, has six children and is now living in a camp in Maiduguri.

¹United Nations, 22 February 2017︰http://www.un.org/apps/news/story.asp?NewsID=56223#.WMK8TVV97IU

²According to Borno State Ministry of Health, over 40% of the health facilities are known to be destroyed︰http://www.who.int/health-cluster/news-and-events/news/Borno-Health-Sector-Bulletin-Issue3.pdf?ua=1

Photo Feature

South Sudanese Refugees in Northern Uganda

Since 2016, more than 600,000 South Sudanese refugees have arrived in Uganda¹. The first waves of refugees came last July, following clashes that erupted in South Sudan’s capital, Juba. More recent arrivals have fled the widespread insecurity in the country. They usually entered through informal border points or arriving through neighouring Democratic Republic of Congo, in order to avoid the direct routes in South Sudan, where soldiers are present. Since men often stayed behind to fight or defend their properties, the majority of the refugees are women and children, arriving exhausted.

¹Figures from the office of the United Nations High Commissioner for Refugees

MSF Knowledge

The Smartphone that Saves Lives

The smartphone has become indispensable in our daily life. But now it can also help medical doctors to save more patients in vulnerable situations. MSF teams in Mali are testing new mobile phone technology to help diagnose children with cerebral malaria. This new technology is cheap but effective, and suitable for use in places with few other resources. But the key is helping medical staff to get a quick diagnosis that will lead to appropriate treatment for patients.

MSF’s pediatric department in Koutiala hospital, Mali, sees huge numbers of children under five with severe forms of malaria, many of whom have cerebral malaria. This form of the illness can lead to serious brain damage and even death if not treated properly. Some child survivors of cerebral malaria have an increased risk of neurological and cognitive deficits, behavioural disorders, and epilepsy. However, as MSF tropical medicines advisor Estrella Lasry explains, “The problem is that cerebral malaria can be easily confused with other diseases, such as meningitis. MSF was seeing an increase in the number of children with suspected cerebral malaria, but with the limited diagnostics available in the front lines, we couldn’t be sure which disease they had.”

In Koutiala and many other places where MSF works, complicated examinations such as brain biopsies are not plausible. But actually, the retina is like a mirror of what is happening in the brain. With cerebral malaria, the retina can undergo certain visible changes, known as malarial retinopathy, which are hemorrhages, white patches and abnormal vessels. So cerebral malaria can be diagnosed by identifying these changes.

The difficulty is that the usual tools for looking at a patient’s retina are fancy and expensive, along with an ophthalmoscope or well-trained technicians. But they are rarely available in the field. MSF knew that it needed a better tool at the bedside. When one of the pediatricians heard about the “PEEK” (standing for “portable eye examination kit”), they realized that this could be just what MSF was looking for.

PEEK was developed by scientists at the London School of Hygiene and Tropical Medicine and the University of Strathclyde. The best things about PEEK are that it’s simple, cheap and accessible. And with a few days’ training, it can be used just as effectively by a non-specialist doctor. PEEK includes a sleeve that can be put on the smartphone. It channels the light and focuses automatically on the retina while the phone is taking pictures. An app that comes with it can store the patient’s notes on the phone. The doctor can examine the image with their colleagues, or email it to other experts for a second opinion.

The prototype is still being approved. MSF hopes to use it wherever there are high numbers of children with cerebral malaria, which is mainly in countries in East and West Africa. Some other diseases- such as diabetes and HIV-are also associated with changes to the retina, so MSF really hopes to be able to use PEEK for these patients too.

How does it work?

1. Fit the PEEK sleeve onto the phone.

2. Shine the inbuilt light at the patient’s dilated pupil.

3. The images are recorded and stored on the phone for identifying malarial retinopathy :

A--Haemorrhages – caused by the red blood cells sticking together and not allowing microcirculation.

B--White patches

C-- Abnormal vessels – caused by malaria parasites sticking to the lining of the small blood vessels in the brain and eyes where they disrupt the supply of oxygen and nutrients

Illustrations： Ian Moores

Frontline Sharing

Back to Khost: Embracing the Good and the Bad

Coming back to the MSF Khost maternity hospital in Afghanistan in the beginning of January, I was recognized and welcomed by a lot of people from my previous mission half a year ago, which made me feel delighted and relieved. So, this meant I was doing alright in the last mission!

Last year we assisted almost 24,000 deliveries in Khost; around 10% of them were complicated cases. As winter came, the hospital had been receiving more serious, difficult and complicated cases. I had to deal with a number of emergency cases every day.

I experienced a sad moment on the third day of my working here. On my way to the hospital, I received an urgent call from my colleagues, who were moving a pregnant woman to the operating room and performing chest compression. The pregnant woman was about to deliver but suffered a sudden crisis. We tried various resuscitation measures for 45 minutes but still in vain......She had been pregnant 11 times, had five miscarriages and six kids. She had no antenatal care before. Based on her clinical manifestations and our experience, it may have been sudden death caused by aortic dissection or amniotic fluid embolism, and that means there would have been not much we could do even if it had happened in a top hospital in Beijing.

After that, I joined my colleagues to talk with the patient’s family. The pregnant woman’s husband, a tall man about 40 years old, turned away from us and sobbed deeply. Later he told us that he and his wife had been married for many years and planned to have no more kids after this one.

I felt so sad. That night, I chatted with my colleagues, and we recalled that maternal mortality used to be high here. Death still occurs once in a while even now. If MSF was not there, I can’t imagine what would happen to all those patients who had postpartum hemorrhage, uterus rupture, fetus asphyxia......Most of them cannot afford to go to private clinics. Without healthcare like MSF’s, who will all these mothers turn to? Thinking about these I gradually recovered from the sadness.

Besides bad times, there are positive moments, too. I have been deeply touched by the way our staff care for the patients. Most of the patients have never been away from home. So when they are suddenly in a hospital and an operating room, they feel helpless. Some female staff of the hospital will surely be there to hold their faces and tell them what will happen.

I have also been moved by the local people as well. Our blood bank is almost always full because many local people come to donate blood. 90% of them are men. Here men usually do not speak about their feelings but by donating blood, they express their love for their community.

What will Aysha bring to the front line?

1.Chili sauce

2.Green tea and black tea

3.Handicrafts and ornaments from hometown as gifts for colleagues in the field

Aysha Nawan is an anaesthetist from Xin Jiang, China. She worked in MSF Khost Maternity hospital in July 2016 for six weeks, and returned to the mission in the new year of 2017.

MSF-Hong Kong

Some thoughts on donations

Members of the public and the media often refer to the percentage of their budget that non-profit organisations (NGOs) spend on administrative and fundraising expenses, as a way of assessing whether donations made actually go to people in need. This subject certainly deserves attention. And one of the important factors concerns the mission, principles and practices of each organisation.

MSF, as an emergency medical humanitarian organisation, delivers care directly through our field workers and local staff on the ground. All medical consultations, operations, treatments and vaccinations provided are free of charge. That explains some of our priorities in spending in the projects. On the office costs side, although NGO spending ratios are not legally binding in Hong Kong, MSF seeks to allocate a minimum of 80% of the financial resources for our field work. In 2015 alone, MSF-Hong Kong received a total of HKD390 million, of which 9.4% and 3% were devoted to fundraising and administration. The rest, 87.6%, was used for relief operations.

That spending on fundraising is closely tied to the principle of financial independence we endeavour to uphold, which is part of our identity. Maintaining diversified, predictable and sustainable funding is critical for our neutral and impartial life-saving activities.

In conflict zones and complex contexts especially, MSF teams in negotiation with various authorities and armed groups are often confronted with the same question, “Where is your money from?” One of the ways to demonstrate our independence is to ensure that we do not accept funds from governments or other parties who are directly involved in conflicts. In these circumstances, funding from private individuals is particularly vital for us to gain acceptance and access to populations in extreme need.

Currently, over 90% of MSF’s worldwide funding comes from private sources. Our decision to intervene in any crisis is based solely on people’s needs – not political, economic, nor religious interests. Supported by 5.7 million donors around the world, including 170,000 people channelling their donations through the Hong Kong office, MSF is able to respond to crises immediately, without awaiting official funds to be released.

Those individual donors come from many varied backgrounds themselves, and they support our work because they agree that our common humanity with the people we help is the most important interest that unites us. We value our relationship with those supporters. It would cost us much less to cultivate a few dozen governments around the world, who could then provide large grants. Instead, we choose to invest more in finding and convincing individual, private donors to help our patients with some of their hard earned cash. And that in turn is a major reason why we believe they deserve clarity about our spending.

The general public and the media should continue to monitor the donations entrusted to NGOs while those organisations must be accountable and transparent, communicating comprehensively and regularly how money is spent and the impact made. Beyond that, MSF hopes that donors share our mission and principles, and support us to put them into practice.