MSF-USA: Emergency Medical Response in Darfur, Sudan

July 8, 2004
Emergency Medical Response in Darfur, Sudan
An Interview with Greg Elder, MD, Head of Mission for Doctors Without Borders/Médecins Sans Frontières (MSF) programs in Sudan

After surviving a severe campaign of massive repression, civilians throughout Darfur now face an emergency health crisis. In addition to treating malnutrition, Dr. Greg Elder, head of mission for MSF in Sudan explained MSF's medical response to infectious diseases and sexual violence.

To what extent are people's health needs in Darfur being met?

The medical needs are simply overwhelming. More than 1.2 million people were driven from their homes and now live in about 140 camps or gathering areas. The UN and NGOs have access to only about half of this population. In some places, the Crude Mortality Rates (CMR) are greater than the emergency threshold of 1 death per 10,000 people per day, there is 25% global malnutrition, the food supply is short, and water and sanitation is abysmal. There is only about 1 doctor for every 50,000 people, and 50% of people who die do so at home, without getting to a health center.

What are the main causes of death and sickness?

The usual triad in this type of context: respiratory infections, watery diarrhea, and malaria. Reflecting the season, poor sanitation, and overcrowding, these three problems account for nearly 80% of the morbidity and 60% of the mortality. All three are exacerbated in children under 5 by malnutrition, which has a multiplying effect on mortality. Measles is now disappearing, but malaria is on the rise. The other main cause of death remains violence.

For diarrhea, we are all very late and greatly under prepared. Unfortunately many of the big agencies with water and sanitation expertise have only just begun activities. Digging a latrine for every 20 people and providing 20 liters of water a day per person saves more lives than any fancy medical programs. It's up there with measles vaccinations in terms of a priority but just has not been done. We have already seen a few cases of shigella and if we don't see cholera it will be good luck and not good management. The mortality of these would be huge.

How good is the measles vaccination coverage?

Measles is a major killer in displaced and refugee settings, especially when people's nutritional status is poor. Background measles coverage in Darfur was believed to be less than 20% - nowhere near adequate to prevent outbreaks. MSF always sets measles vaccination as an absolute priority and we vaccinated in collaboration with the Sudanese Ministry of Health in all of the settlement areas where we are working. We mainly tried to reach children from 6 months to 5 years old. There were outbreaks in several of the camps and we treated over 1,500 cases of complicated measles in 2 of our projects. Since only 55% of the cases were in children under 5, we extended the vaccination coverage to include children up to 15 years old. MSF still sees cases in North Darfur and some isolated pockets of West Darfur, and Unicef is currently carrying out a massive campaign across all three States. In a recent survey in our program areas we confirmed coverage of 80-90% and weekly incidence rates have dropped. While the Unicef vaccination campaign is welcome, it could be more rapid, flexible, and reactive.

What will the toll be from malaria?

Malaria peaks with the rainy season and will likely claim more lives because children are already weakened by malnutrition. After a very successful conference last year that brought together the WHO, the Sudanese Ministry of Health, MSF, and other international experts, the national protocol has been changed in favor of artemisinin-based combination (ACT) therapy. Its availability and use will certainly reduce malaria specific mortality. There have been disturbing reports that some agencies are only using chloroquine in Darfur. If true, this would be a deadly insult added to the massive injuries already inflicted on people.

How is MSF treating victims of sexual violence?

In Mornay alone, we treated 12 rape victims in June, so the violence is continuing. Cultural mores and fear probably prevent more women from seeking or receiving treatment because throughout West Darfur women and community health workers continue to tell our doctors and nurses about the scale of the abuse. We have tried to establish outreach programs in some of our projects.

MSF uses a three-part protocol for treatment: drugs to prevent sexually transmitted diseases (STDs), emergency contraception, and post-exposure prophylaxis with the anti-retrovirals (ARVs) lamiduvine and AZT to prevent HIV infection.

The first two courses are done in 24 hours. But we see a pretty dramatic decline in those finishing the 30-day post-exposure prophylaxis, and there are a variety of reasons for this - late presentation, stigma, lack of education about HIV/AIDS, the difficult situation women are in, and the complexity of the regimen. Of course we follow every patient to teach her about the importance of adherence.