Coming to grips with a new reality in Chad - MSF opens new project in Am Timan

"We have treated our first patients in Am Timan over the weekend!", Martine FLOKSTRA exclaims happily at the end of her mission, ready to head back to Holland. As a member of the emergency desk of Médecins Sans Frontières (MSF), she had been sent to Chad to facilitate the opening of a new project in the South East. From now on MSF will support the paediatric and maternity wards in AmTiman hospital, a 100 bed facility in what is one of Chad's major economic centers. She said, "We will have to start slowly but we can already see an increase in patients who come to seek our services after just a couple of days, which is great."

The move to Am Timan arose out of the need to adapt MSF's strategy in Chad to the tense security situation in the border area with Sudan – a situation that has been dire for years. Besides the camps hosting refugees from Darfur, an estimated 180.000 internally displaced people live in Eastern Chad, where MSF has so far focused its activities. Access to basic living conditions and services, including health care is difficult if available at all. Criminality flourishes because of impunity – bandits are not apprehended and punished. A survey carried out by MSF in 2008 shows that 90 percent of the displaced population included in the survey had either been a victim of violence themselves or one of their family members.

Also for aid organisations like MSF the tense security situation is a major challenge and one of the biggest obstacles in their work to deliver humanitarian assistance to those in need. Compound and road robberies are the most frequent incidents MSF has experienced in the East over the last years. "With the kidnapping of two of our staff last year, the risk for our staff by remaining in Ade in the border area to Sudan became too big", says Flokstra. Currently, three out of the four remaining MSF projects in Eastern Chad are managed via "remote control", which means that health facilities are kept running by a team of national MSF and Ministry of Health staff who ensure the provision of basic services. They receive support by flash visits and remote management from teams in the capital N'Djamena.

"We always have to balance the risk for our staff against the medical impact we can have on the population. In the east of Chad, more and more this difficult equation got out of balance. If we cannot be where we need to be due to security risks, we need to look for places where we can have a greater or equally great medical impact for the population while reducing the risk for our teams", says Flokstra. And needs are abundant in this resource-poor and conflict-prone country, which is ranked 175 of 182 countries on the Human Development Index.

It took more than two months from the first exploration in November to the start of activities in February next year. Thorough assessments of the hospital and area from a medical and logistical perspective take time: What are the major morbidities, what is the death rate, bed occupancy, organizational lacks, staff capacity? How is the water and sanitation situation on the hospital compound, how about electricity and cold chain provision? What is available on the local market, who are the local authorities, and above all: what is the intersection of medical and humanitarian needs? What are the biggest needs of the estimated target population of 188,000 people and how to address them responsibly?

"The team went through countless meetings and negotiations with different representatives, authorities, religious leaders, village chiefs and women's focus groups to find out what they need and to make clear who we are, what we can do and what we cannot do. We decided to start small and to concentrate on the most vulnerable: children and pregnant women."

"With the project in Am Timan MSF adjusted its operational strategy in order to reach a higher medical impact in a more stable project, while remaining flexible enough to react to epidemics or emergencies, particularly in the border area with Sudan," says Flokstra. Being located in the so-called Menengitis belt and with one of the lowest vaccination coverage in the world, the outbreak of epidemics is not unlikely; violent clashes between different ethnic or armed groups present further risks to be prepared for.