Category: News & Stories

On 26 December 2021, an MSF nurse and ambulance driver were arrested in Nguti (South-West region of Cameroon), while transporting a patient with a gunshot wound to hospital. After being detained in prison for five months, for the charge of complicity with secessionists, both aid workers were provisionally released in May 2022.

Two other colleagues, a community health worker and assistant field coordinator, were detained in January 2022 under the same charge while another was accused in absentia.

On 1 November 2022, the Buea Military Tribunal ruled “no case to answer”, regarding one of the aid workers in question, citing a lack of evidence. The MSF staff member was released soon after the ruling, having spent 10 months in prison.

Finally, on 29 December, all remaining MSF staff members who had been detained were acquitted – the last of whom was released the following day. A judgement of acquittal was also declared regarding an MSF project coordinator who had been tried in absentia.

“We are enormously satisfied with the judgement that exonerates our five staff members – and, by extension, MSF as an organisation – of any wrongdoing,” says Sylvain Groulx, MSF coordinator in central Africa.

MSF deplores the fact that our staff were forced to endure almost a year of imprisonment, which caused untold distress and anguish for them and their families. 

“Accusing medical personnel for simply doing their job – treating patients in front of them – is simply against all medical and humanitarian ethics and laws,” says Groulx.

In May 2022, following the detention of MSF’s four staff members, our teams made the difficult decision to suspend activities in the South-West region of Cameroon. We are keen to restart our much-needed lifesaving services, but basic preconditions must be met to ensure that our medical activities can be conducted in a safe and secure environment, so that patients and staff are protected.

“Despite our attempts to open a channel of dialogue with the government, to ensure our teams can continue vital activities in South-West region, the government has been unresponsive. This has made it difficult to reach an agreement that ensures working conditions guarantee the safety of our teams and patients,” says Groulx.

“This prevents us from resuming critical lifesaving medical services, which are desperately needed in the South-West,” he says.

MSF teams must be able to provide medical care to every patient in need, in line with medical ethics and following the humanitarian principles of independence, impartiality and neutrality.

“We remain ready to continue discussions with the Cameroonian authorities to analyse the feasibility of restarting medical and humanitarian activities in South-West region under such preconditions.”

There already exists a comprehensive legal framework for SAR, namely the UN Convention on the Law of the Sea (UNCLOS) and the International Convention on Maritime Search and Rescue (SAR Convention). However, the Italian Government has introduced yet another set of rules for civilian SAR vessels, which impede rescue operations and put people who are in distress at sea further at risk.

Among other rules, the Italian Government requires civilian rescue ships to immediately head to Italy after each rescue. This delays further lifesaving operations, as ships usually carry out multiple rescues over the course of several days. Instructing SAR NGOs to proceed immediately to a port, while other people are in distress at sea, contradicts the captain’s obligation to render immediate assistance to people in distress, as enshrined in the UNCLOS.

This element of the decree is compounded by the Italian Government’s recent policy to assign ‘distant ports’ more frequently, which can be up to four days of navigation from a ship’s current location.

Both factors are designed to keep SAR vessels out of the rescue area for prolonged periods and reduce their ability to assist people in distress. NGOs are already overstretched due to the absence of a state-run SAR operation, and the decreased presence of rescue ships will inevitably result in more people tragically drowning at sea.

Another issue raised by the decree is the obligation to collect data aboard rescue vessels from survivors, which articulates their intent to apply for international protection, and to share this information with authorities. It is the duty of states to initiate this process and a private vessel is not an appropriate place for this. Asylum requests should be dealt with on dry land only, after
disembarkation to a place of safety, and only once immediate needs are covered, as recently clarified by the UN Refugee Agency (UNHCR).1

Midwifery v obstetrics

The obstetric model remains dominant in Lebanon’s vastly privatised healthcare sector.

Dr Kabakian explained that the marginalisation of midwives in Lebanon’s health sector was a “systemic issue” that stems from the struggling Health Ministry’s inability to impose national guidelines and standards of care on the mostly decentralised — not to mention deteriorating — health sector.

As a result, “hospitals have their own standards and practices. It’s different according to each provider and physician,” Dr Kabakian said.

Compounded by Lebanon’s worsening economic crisis, the large gaps and lack of regulation in the healthcare system have conjoined to create an environment where obstetric violence — the mistreatment and abuse of women during childbirth by their care providers — has become a matter of routine.

This includes “interventions that are not medically necessarily and may even be harmful to the mother and child, but are done almost routinely to women in Lebanon,” said Dr Kabakian, “such as episiotomies” — the process of cutting the perineum during childbirth to move the foetus through the vaginal opening more easily — “and caesarean sections. Women don’t know when they don’t need C-sections and care providers do it because it’s faster.”

Lebanon has one of the highest rates of caesarean sections in the world, hovering at about 50 per cent according to the World Health Organisation. They are not needed nearly as often as they are prescribed but are faster than normal deliveries and therefore more convenient for obstetricians. The procedure also incurs additional fees, which means more revenue for the hospital or doctor.

Overwhelmed physicians who are paid per-service and cash-strapped hospitals have little incentive to advance the midwife-led model, instead maintaining an obstetric model that priorities the needs of the doctor over the patient.

“This is a private, fee-for-service healthcare system,” said Dr Al Abiad of the challenges of bringing midwifery to the foreground in hospital settings. “Physicians are obviously not very happy to give up that route. At the end of the day, this is a source of income for them.”

By contrast, midwives attend to and prioritise the woman’s needs, “leading to an improved quality of care,” said Dr Kabakian. “It’s the healthier option, scientifically-speaking.”

Health advocates argue that a strong midwifery-led model might be able to reduce the impact of the economic crisis on patients.

“We could have higher value deliveries at lower cost to the patient,” said Dr Abiad. “This economic crisis is an opportunity for us to rethink our care delivery.” He added that he was eager to dispel perceptions that “midwife-led delivery is lower quality because it’s more affordable. That is not the case.”

But for mothers such as Mrs Moussa and Mrs Al Hamad who were driven to using midwives for financial reasons, it is also the comfort and quality of care which will keep them loyal to midwives.

“She was with me before and after I had Mariam,” Mrs Mousa told The National. “She told me how to care for her in the first few weeks. That I should stay warm and drink natural juice to maintain my body’s nutrients while breastfeeding.”

“I’ll definitely go to her if I get pregnant again.”

*First published in The National News

Port-au-Prince, 20 December 2022 – Médecins Sans Frontières (MSF) teams in Haiti are supporting the cholera vaccination campaign launched by the national health authorities. This campaign is the latest effort in response to the resurgence of the disease, which has affected more than 15,000 people and caused more than 300 deaths in the country since the end of September. On 12 December, the Ministry of Public Health and Population (MSPP) received 1.17 million doses of cholera vaccine from the International Coordinating Group, a mechanism to manage and coordinate the provision of emergency vaccine supplies to countries during outbreaks.

“We support the vaccination campaign in Cité Soleil, one of the most cholera-affected areas of Port-au-Prince”, says William Etienne, MSF emergency coordinator. “Our teams are helping with the transportation of the vaccine doses and other items, facilitating the movement of the MSPP vaccination teams, distributing soap and other hygiene items, and taking care of waste management.”

The ongoing cholera resurgence comes at a time when the population is already facing enormous difficulties in accessing health care. Fuel is becoming progressive available after weeks of extreme scarcity due to the blockage of the main oil terminal, but insecurity and violence combine with an unprecedented economic and social crisis to make access to basic services extremely complicated.

“Though the pace of contamination has apparently slowed down recently, vaccination remains a very useful tool in a fragile health context such as this” says William Etienne. “Haiti has been hit by a major cholera epidemic in recent past”. MSF teams have been part of the cholera emergency response since the first few patients were identified. We quickly opened several cholera treatment centres in Port-au-Prince and in the Artibonite province, work to provide access to clean water and run health promotion activities.

In a freezing classroom in Arsal, an isolated Lebanese town perched 1,500 metres above sea level near the Syrian border, one by one children line up for their cholera vaccine — taken orally, a quick gulp down the throat.

The teacher marks their hands with a pen, and now the jacket-clad children have an extra layer of protection against Lebanon’s first cholera outbreak in three decades.

Arsal, a largely Sunni Muslim town in the north-eastern reaches of the Baalbek-Hermel governorate, is one area of Lebanon that has been a focal point of the cholera spread — and efforts to fight the disease.

A poor, overcrowded town where informal settlements sit alongside houses, it’s the perfect place for the disease to take hold.

And while Lebanon is — at the moment largely successfully — countering cholera, there are fears that the looming winter could isolate Arsal, where the proportion of Syrian refugees is double that of the Lebanese population.

By the end of November nearly 450,000 vaccines had been administered. Since the outbreak in early October, there have been about 4,600 suspected or confirmed cases and 20 deaths.

The cholera strain found in Lebanon is similar to the one in neighbouring Syria, itself struggling with a much larger outbreak.

The World Health Organisation describes cholera as “an acute diarrheal disease that can kill within hours if left untreated”.

It can be easily treated with oral rehydration salts but in severe cases immediate medical attention is needed.

Lebanon’s economic crisis means the country lacks a sufficient supply of medicine, clean water and electricity.

Organisations such as Medicines Sans Frontiers, which recently opened a cholera treatment unit in Arsal, are going door-to-door in a bid to get people vaccinated.

One of those to take the vaccine was the family of Salah, a middle-aged Lebanese man from Arsal who lives near one of the small refugee camps that merge with the older homes.

Normally the family gets their water from lorries and a nearby well.

“You never know. Waste management is not properly functioning, so you never know if this water is clean or if the water in the well is clean,” he said.

Salah said waste management and infrastructure were already in a bad state before a series of crises hit Lebanon, including a devastating economic crisis that first became apparent in 2019 and an influx of refugees fleeing the war in nearby Syria that began more than a decade ago.

“It became worse with overcrowding but it was already bad,” he added.

For now, suspected and confirmed cholera cases are somewhat stable — and are even potentially going down slightly, according to government statistics.

The focus has been on prevention — whether through awareness or efforts to ensure that the water is safe — and on treating those who fall sick.

While cases have largely not been as severe as initially predicted, fears remain that cholera could be around in Lebanon for longer. It is also believed that Lebanon’s health system would struggle to tackle a larger or more serious outbreak. So, the focus is on ensuring that it does not become an epidemic, said Farah Nasser, medical co-ordinator for MSF Lebanon.

“If we want to describe [the situation] it would be we are still in control, as the cases are still mild to moderate. The phase we are in now, we still have the hospitals prepared, there are still places in the hospitals. So it is still under control,” she said, contrasting the current situation to that when cholera first broke out in Lebanon when authorities and humanitarian organisations had to rapidly mobilise.

“But now it is controllable and we are having the time to really work on the prevention arm of the outbreak. The idea is we should focus really on prevention. If we really worked on prevention, then we will be in a good place.”

Lebanon’s economic capitulation has been described as one of the worst in modern history by the World Bank, with much of the population plunged into poverty. It has led to shortages of vital medicine, a lack of clean water and hospitals impaired by power cuts.

“The health system is under the burden of all the crises,” said Ms Nasser. “We had a good health system, which was mostly private plus what the Ministry of Public Health was working on as primary healthcare centres.

“And then with the economic crisis, it put a huge burden on that system, which is near collapse. They are not getting what they need [financially] and it’s a huge burden on the patients themselves.”

All of Lebanon’s eight governorates have detected cholera, but it is most prominent in the areas neighbouring Syria, where the border between the two countries is porous. While Akkar to the north-west of Arsal has recorded more cases, the latter is bereft of a public hospital — although MSF does operate a clinic — and relatively isolated.

Akkar and Arsal, which briefly came under the control of ISIS in 2014, have particularly weak infrastructure and their residents have particularly poor access to clean water.

Winter is expected to be grim in impoverished Arsal — previous years have seen refugee camps covered in blankets of snow amid below freezing temperatures.

One family The National spoke to said they were forced to burn plastic to fuel their heater, despite the fact that it would likely worsen a heart condition of one of their young children.

Recent flooding, blamed on blocked pipes, was yet another issue to hit the area.

One of those affected was Raida, a mother of five who lives in a Syrian refugee camp in Arsal that was flooded. She was in an isolation unit and had taken her youngest — only three months old — to the MSF clinic when she had diarrhoea, a classic symptom of cholera.

“Two days ago I realised I was changing her diapers more than usual,” Raida said.

For now, Lebanon’s embattled health system is responding — but a wider, more serious outbreak could prove too much.

“With a bigger outbreak, I think we would be not in a good place,” said Ms Nasser. “The efforts since day one to prepare government hospitals to accept patients … most of the hospitals were prepared within the first two weeks of the outbreak.

“But if we had a really large outbreak, as we’ve seen in other countries, that would be a super-big burden on our health system.”

* First published in The National News

Technical capacity building of healthcare providers

“The key area of our intervention focused on training healthcare providers and their supporting staff on ensuring proper infection prevention and control (IPC) while engaging with patients suffering from CCHF. This is an essential element for frontline workers,” explains Dr Chen.

In parallel to IPC, MSF teams also worked on increasing healthcare providers’ capacity in clinical case management by conducting training sessions on diagnosing patients and providing them with proper treatment and support. This included laboratory testing methods, treatment options, techniques and approaches.

Rapid supply of essential medications

While the oral form of the drug Ribavirin – the drug of choice to treat CCHF – was already available in Iraq, this was not suitable for all patients. In severe cases, some patients might not be conscious, making it impossible to take the medication orally. On top of that, oral medications require more time until their effect occurs. The injectable form of the drug is therefore more efficient and lifesaving to many patients but was not available in Iraq at the time. After our recommendation to procure the drug, Iraqi authorities acted swiftly. “We were delighted to see the rapid response when we offered to import the medications from our existing international stock,” says Dr Chen.

Within a relatively short time, MSF imported 10,000 vials of Ribavirin and provided the technical support to healthcare providers to ensure the effective administration of the medication to patients.

Responding to the Outbreak: Patient Care & Vaccination

In the Bekaa Valley, MSF adapted a unit in its hospital in Bar Elias to be able to receive and treat cholera patients with a capacity of 20 beds, that can increase as needs arise. Since its opening on 31 October, we have received thirty three patients in our cholera treatment unit. The required adaptions made to the unitensures that the other services in the hospital, mainly for essential surgeries and wound care, can continue to run. MSF is also opening a field hospital with a capacity of twenty beds soon in Arsal, an area in the northern east of Lebanon where the nearest public hospital is at least forty kilometres away.

To limit the spread of the disease, MSF is vaccinating against cholera in Arsal, Tripoli, Akkar, and Baalback- Hermel in the north and north east of Lebanon as part of the three-weeks national vaccination campaign launched by the health authorities in the country. MSF is focusing on these areas that are poor and overcrowded where diseases such as cholera can spread more rapidly, putting people living there at heightened risk. In one week, our teams have managed to vaccinate 14,224 people and are targeting 150,000 people in total.

The vaccination activities are taking place as part of a coordinated effort between the Ministry of Public Health, international and local organizations to administer 600,000 cholera vaccines received by Lebanon, as first phase procurement, to combat the recently declared cholera outbreak in the country.

In addition to administering cholera vaccines, MSF is also providing patient care. In the Bekaa valley (Bar Elias and Arsal) MSF is running two cholera treatment centres with a total capacity of seventy beds. In Tripoli, north of Lebanon, and Arsal, oral rehydration points are being set up for people who do not require hospitalization. Five medical kits were procured by MSF to treat up to 3,125 cholera patients.

MSF is also providing technical training to Lebanese health workers on the treatment of cholera patients, mobilised teams to raise awareness about the disease and distributed hygiene kits to help people maintain essential household and personal hygiene in the Bekaa Valley, north, and northeast of Lebanon (Bar Elias, Akkar, Baalbak-Hermel, and Arsal).