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At a makeshift MSF residence-turned hospital in Monrovia, an MSF doctor makes his rounds in what used to be the house's dining and living room. It is July 24, 2003. Wounded people are lying shoulder to shoulder on the floor, on woven straw mats. The entire facility is crowded: one area is now an operating room, another more isolated part outside holds cholera patients. The compound is teeming with sick, injured, dying people, families sleeping under stairwells, children peeping out from under tables – all victims of the vicious fighting that has engulfed Liberia's capital for the third time in two months. Needing to make space for the wave of injured people expected after the next attack, the MSF doctor is discharging patients who can walk, sending them home.
The irony of home
. The patients discharged from MSF's makeshift hospital (one of two) in Monrovia may go home (if they are from Monrovia and if their home is still standing). More likely "home" is a school building where people sleep 60 to a classroom, or the large sports stadium in the center of the city where 40,000 people have sought shelter, or on the street, or anywhere but where the shells and bullets are falling. Which doesn't leave many places. Often their original homes are hundreds of kilometers away; these towns and villages were abandoned days, weeks, months, sometimes years ago, as people sought to escape the fighting. If home is where a person's loved ones are, people may also have few choices: violence in the city has stripped young children of their mothers, mothers of their newborn babies, families of their fathers, people of their support network.
Unfortunately, this state of affairs is nothing new, nor is it limited to one city in Liberia. Over the last year alone, MSF has cared for people affected by conflict in many parts of Liberia; also in Côte d'Ivoire, Guinea and Sierra Leone. Population flows mean that work in one country can be intimately connected to work in another, which is why this single narrative looks at MSF work in all four countries.
MSF has been active in this part of West Africa for more than 20 years: supporting local clinics and hospitals and improving access to health care, responding to epidemics, and assisting vulnerable people, among them street children and prison inmates. Increasingly, however, MSF teams have focused on responding to emergencies associated with armed conflict, providing basic medical care, food, water and shelter to displaced people and refugees. MSF has also repeatedly spoken out about the plight of civilians and called for the protection of civilians, respect for international law, and access to those in need – unfortunately glaringly absent in too many parts of the region. To the contrary, in more than a decade of conflict, civilians have increasingly been targeted by warring factions, manipulated through violence as strategic "tools" of war.
People not populations
Across West Africa, as MSF volunteers have worked to ease pain and save lives, they have also documented the stories of survivors, in order to bear witness to the consequences of armed conflict on civilians. "Every day we listen to our patients telling us the terrible stories of what they have been through over the past months and years," says Dr. Nathalie Civet, medical coordinator in Liberia. In Côte d'Ivoire, a woman describes fleeing with her family, her husband carrying the baby. When her husband was shot she picked up the baby and kept running. In Guinea, armed men demand money from arriving refugees in exchange for food and safe passage. Because they have none, they are forced to "lend" their daughter for the night in order to survive. A young Liberian woman describes how she had no choice but to leave her sick grandmother behind to die when they fled the fighting. Endless stories of loss, physical violence, rape and murder.
Over the last year, Liberia has taken its turn as the epicenter of conflict in the region. The civil war which has simmered in the country for more than a decade intensified, forcing thousands to flee their homes and cutting off entire regions from medical services. Many civilians in Liberia have been displaced repeatedly by this conflict, reaching temporary safety only to run again when the fighting comes too close. By August 2002, 50,000 Liberians had already fled to Guinea, 30,000 were present in camps in Sierra Leone and many displaced people had gathered in and around the capital Monrovia. MSF was already working in Monrovia, supporting basic health care at Redemption hospital and five smaller health structures and running a special cholera treatment center. MSF was also working in Montserrado, Bong and Nimba counties, and in the town of Harper in the southeast. As the violence in Liberia escalated, MSF responded by increasing medical services already in place for refugees in neighboring countries and for internally displaced people inside Liberia itself.
Côte d'Ivoire into the shock of war
At the same time, in September 2002, West Africa destabilized further, with the outbreak of civil war in Côte d'Ivoire following attempts to demobilize part of the armed forces. Nearly one-third of the people in Côte d'Ivoire are immigrants who have come from surrounding countries (including Mali, Burkina Faso, Guinea and Liberia), many to work on the cocoa and coffee plantations. Pierre Boullet-Desbareau, of MSF's emergency unit, described the situation in neighboring Burkina Faso in late 2002, during an exploratory mission to the region: "When we got to Ouagadougou, the atmosphere was one of a tense wait-and-see.
The population would stand holding its breath every time the radio reported on events in Côte d'Ivoire. Everyone has a parent, a cousin or friend working in the cotton or cocoa fields 'over there.'" As the fighting and breakdown of basic services spread, thousands of people fled. Many tried to reach their countries of origin. Within Côte d'Ivoire itself, the civil war cut the country in two, with the north isolated and controlled by rebels. MSF teams traveling through the region were repeatedly approached by people who had messages for their families in the other half of the country. MSF, already providing medical care at the Maison d'ArrÃªt et de Correction d'Abidjan (MACA) prison since 1997, pressed for access to civilians trapped in the northern part of the country and began assistance (including nutritional programs) to hospitals and clinics in Bouaké, Korhogo and Man, areas deeply affected by the war. MSF was able to provide medical assistance on all sides of the conflict.
Displacement in all directions
As armed conflict in Liberia and Côte d'Ivoire gained in intensity, greater numbers of people were forced from their homes or the shelter of refugee camps. Thousands traveled huge distances on foot carrying what little they could, often trying to hide from armed groups. Many hoped to reach neighboring Sierra Leone or Guinea. MSF was present in all four countries and worked to respond effectively to the crisis, reinforcing teams at strategic points along the borders, identifying where the displaced were gathering, and setting up emergency clinics.
Groups of displaced people, seeking safety and shelter, often moved simultaneously in several directions. In December 2002, tens of thousands of Liberians trying to leave the country had massed in border camps inside Liberia in areas such as Nimba and Grand Gedeh counties, where MSF was present. Some were able to reach other countries in the region. At the same time, large numbers of Liberians were trying to return to Liberia, fleeing the violence in Côte d'Ivoire. Many gathered near the border in transit camps meant to serve as only temporary shelter.
Grand Gedeh cauldron
The fate of Zwedru and Toe Town transit camps in Grand Gedeh county, in eastern Liberia near the border with Côte d'Ivoire, illustrates the danger of leaving fleeing people so close to the border and the fighting, as well as the consequences of failing to provide them with adequate assistance and protection. In December 2002, MSF began to manage medical activities in Zwedru.
In addition to providing health screening, teams carried out measles vaccinations and established a therapeutic feeding center to treat malnourished children. Similar assistance began in Toe Town, about 100km to the north, in January 2003. The camps served thousands of refugees from Côte d'Ivoire, including Ivorians, Liberians who had taken refuge in Côte d'Ivoire and were now fleeing that fighting, and third-country nationals. However, because the camps were dangerously close to the fighting in Côte d'Ivoire and insufficient for the thousands of people pouring into the area, at the time MSF called in vain on the United Nations High Commissioner for Refugees (UNHCR) to move the people to permanent camps in a more secure location.
In March MSF's fears were borne out. As the situation in Liberia and Côte d'Ivoire deteriorated, an attack on Toe Town early in the month and subsequent attack on Zwedru several weeks later effectively cut off the camps – and the whole area – from humanitarian assistance. MSF could no longer reach the camps located along the border with Côte d'Ivoire. "Our teams were forced to leave the area because it was too dangerous to stay," stated Kostas Moschochoritis, an MSF operational coordinator, in March. "We are very worried now about the situation of the people in the region, both the local population and the refugees. Thousands of innocent people remain trapped in an extremely violent and volatile situation, cut off from medical care of any kind." The very transit camps that MSF had urged be moved had become inaccessible, leaving refugees and local residents with no emergency assistance whatsoever. "As long as they are forced to stay in the transit camps close to the border and fighting areas, they are too vulnerable," said Moschochoritis. According to Dr. Hani Khalifa, medical coordinator in Liberia, unofficial reports indicated that most of the refugees had fled the area. "During the attack on Toe Town in early March, refugees fled the camp and the host communities around Toe Town in all directions. Since then we have not been able to get any news about what has happened to them. Unofficial reports indicate that most of them have fled into the bush and that many families have been separated." MSF repeatedly spoke out about the lack of protection and called for access to the estimated 45,000 displaced people and refugees in the area.
Soon, attacks in Nimba County in the north also prompted many thousands to flee. MSF was forced to reduce its presence in the Saclapea refugee camp there. Fighting then reached Harper, in the southeast, ending MSF's work there. Nearly 75% of Liberia was now out of reach of any humanitarian assistance.
Responding to the regional crisis – Sierra Leone
In Sierra Leone, a country slowly beginning the transition to peace after years of brutal violence, MSF actively supports eight hospitals and over 30 clinics around the country, often caring for Sierra Leonean returnees arriving home after living as refugees in the surrounding countries. By October 2002, 30,000 refugees in camps in the district of Bo were also receiving MSF aid.
In order to provide equal access to health care to Liberian refugees and Sierra Leoneans, MSF sent mobile clinics to villages near the camps. Within the camps themselves, MSF established a system of home visits, carried out by Liberian refugees with medical backgrounds, trained and supervised by MSF. Through home visits, the MSF staff were able to refer patients to the mobile clinics and to monitor their progress and medicines. In some camps therapeutic feeding centers responded to malnutrition among the refugees. MSF was also active in refugee camps in Moyamba, Kenema and Zimmi. By February 2003, 200 Liberians were arriving per week in the district of Kailahun, many in poor condition from their journey. Because of Kailahun's location between the Liberian and Guinean borders, MSF teams there work with many Liberian refugees as well as Sierra Leoneans returning from Guinea.
During Sierra Leone's 11-year conflict, numerous clinics and hospitals were destroyed, and the country has only begun to rebuild itself during the fragile peace of the last couple of years. For a country just emerging from its own brutal civil war, the heavy influx of refugees is an extra burden. MSF hopes to ensure that the most vulnerable people are not forgotten during the gradual reestablishment of health services. At the same time, as reconstruction and repatriation gather pace, MSF is concerned that many Sierra Leoneans are being repatriated and "encouraged" to go home without sufficient assistance.
Responding to the regional crisis – Guinea MSF has had projects in Guinea for 17 years, many focused on refugees from surrounding countries. As of mid-2002, MSF was present in the capital Conakry and several prefectures. In Guéckédou, MSF was supporting four health centers and 11 health posts and in Konkouré MSF teams were working to improve rural health care by training birth attendants. Support to the national tuberculosis program was in its 15th year. As fighting escalated in Liberia and Côte d'Ivoire, MSF teams already in place along the borders responded to provide support in Macenta, Guéckédou, Kissidougou, Nzérékoré and Boreah. In addition to the many refugees seeking shelter in Guinea, many Guineans who had been living in Côte d'Ivoire were displaced.
By mid-December, 50,000 Guineans had returned to Guinea from Côte d'Ivoire, many living in transit camps along the border. MSF was present in the Senko region and responded by visiting villages close to the border with mobile clinics. By January 35,000 people were living in Kuankan camp in Guinea, where MSF was providing medical care for 7,000 people.
Sexual violence – a grim tool of war
One of the most damaging acts of war is the widespread sexual violence which often accompanies armed con. ict. MSF has documented sexual violence against unprotected civilians in many parts of the world, and West Africa is no exception.
Thousands have been raped by participants in these wars, and countless women have been forced to submit to sexual violence to save their lives or the lives of their children. Refugees tell stories of young women in their families who have been abducted by armed groups. "They took away my 16-year-old sister. We have not heard anything from my sister who was taken by the rebels – we think she is still with them in Bomi County. Lots of other girls were taken by them too," said a man in Plumcor camp in Liberia.
Sexual violence is perpetrated on vulnerable people by warring parties, soldiers, civilians, even aid workers. A February 2002 report issued by UNHCR and Save the Children outlined abuses of refugees by humanitarian workers in camps in several West African countries. MSF was one of the organizations mentioned. Despite the fact that the allegations concerning MSF could not be substantiated, MSF knows the problem exists and has responded by implementing sexual violence training in many of its projects, to sensitize and educate volunteers and better respond to the medical needs of victims.
In May 2002, sexual violence training was integrated into existing refugee health programs in Boreah camp in Guinea, and in November in Taiama, Bo and Pujehun camps in Sierra Leone. In addition to attending to the immediate medical consequences of rape (treatment for sexually transmitted diseases or to prevent pregnancy or HIV infection), these pilot projects involve psychological support for victims and documentation of the violence. Prevention and consciousness-raising about the problem are also important aspects of sexual violence projects. In May 2003, a new program for survivors of sexual violence began in Liberia, where doctors had reported seeing patients as young as five years old who had been raped (the project was suspended when the conflict escalated shortly thereafter).
In the context where people must leave their homes behind to find refuge elsewhere, women and girls are particularly vulnerable and often subject to violence and exploitation. MSF continues to advocate for sufficient humanitarian assistance for refugees and displaced people and for their protection through UNHCR.
Preventing and responding to outbreaks of disease
People on the run have no access to sanitation and often live near any source of water they can find, including swamps where disease-carrying mosquitoes proliferate. Those lucky enough to reach camps with clean water and sanitation facilities usually live in limited and overcrowded spaces, which increases the spread of contagious disease to what can be epidemic proportions. As part of the response to the crises in West Africa, MSF teams have worked to monitor and treat cases of infectious diseases such as cholera, which is endemic in the region. Cases typically occur during the rainy season, from April to November.
MSF teams also try to halt the spread of disease through vaccination campaigns. In Côte d'Ivoire, for example, MSF responded to an outbreak of measles in the Korhogo region, vaccinating more than 8,000 children in ten different villages. "It was important for us to move fast, because the local health care systems in the area have largely disintegrated," said Stephane Goetghebuer from MSF operations. "Since the beginning of the con. ict in the region, health workers have stopped working in the hospitals and health centers. With the situation as it is, outbreaks such as this one can easily go undetected. Even though this was a relatively small outbreak it was essential that it was addressed quickly, to avoid the risk of the virus spreading more widely." Measles vaccinations were carried out in all four countries in transit centers, mobile clinics and local health facilities supported by MSF.
Keeping hospitals open
Health services which are limited in times of peace often disappear with the outbreak of war, and many people are left with no access to medicine or the most basic care. During the past year MSF staff in West Africa worked to keep hospitals and clinics open where possible. While teams along the borders received displaced people – providing medical care, clean water and sanitation facilities, and distributing plastic sheeting, food, and supplies – other MSF teams worked to continue services inside Liberia and Côte d'Ivoire despite the violent upheaval.
In Côte d'Ivoire, the civil war forced many of the country's trained health professionals to flee. With rebels controlling the northern half of the country, travel in Côte d'Ivoire became increasingly difficult, and many medical facilities began to run out of medicines. In October 2002, MSF reinforced its emergency team in Bouaké and brought much-needed supplies to the central hospital, which had been paralyzed since the beginning of the conflict. In February 2003, MSF was able to reopen the regional hospital in Man, which had been looted and closed months before when the civil war began. As of March, Man hospital had resumed pediatrics, surgery and maternity services and medical staff were carrying out 170 consultations per day in spite of continued insecurity. Fighting in western Côte d'Ivoire was resulting in increasing numbers of wounded civilians arriving at Man hospital. Many were women, children and elderly people who reported they had been wounded during helicopter attacks. MSF spoke out about the attacks, urging all parties to respect civilians and medical installations. But in the face of the relentless violence of conflict, sometimes keeping a hospital open was in itself not enough. "The situation in the west of Côte d'Ivoire is extremely volatile at the moment and there is a genuine climate of anarchy and fear," stated MSF operations director Christopher Stokes in March 2003. "The people are becoming too afraid to come even for medical consultations. Last week, after hearing about an outbreak of fighting in Bangolo, a village 25km from Man, over 60 people fled the hospital, including a mother whose child was suffering from second and third-degree burns. With no care he will probably not have survived." In May, MSF also started a therapeutic feeding program in Man, to help cope with the precarious nutritional situation in the western part of the country.
Between October 2002 and May 2003, MSF teams along the front lines in Côte d'Ivoire carried out more than 90,000 medical examinations, performed 1,650 operations and attended 3,800 births.
By mid-2003, the situation in Liberia was as dire as the most pessimistic predictions could have foreseen. MSF had played an important role in maintaining health structures for the previous 12 months, despite the civil conflict. With access to health facilities deteriorating daily and many local medical workers forced to flee the violence, an average of 30,000 consultations per month were carried out at MSF-supported facilities (hospitals, clinics, health posts, and camps for the displaced) around the country.
However, as the front line advanced toward Monrovia in June 2003, the hospitals and clinics were forced to shut down and some MSF international staff evacuated. At the same time, more and more people crowded into the capital, in increasingly worse condition. The Liberian capital was gasping for breath.
The remaining staff discussed how to best serve the population. "We decided there was nothing for it but to build our own hospital right here in the compound," explained Tom Quinn, an MSF nurse in Monrovia. In response to the massive medical needs, an emergency clinic was created inside the MSF residences where MSF staff and their families were already sheltering, in the Mamba Point area of the city. "Everywhere there are people. You look under the stairs and there is a family. You look under the tables and there are some children," described Tom. "The staff have been working 72 hours straight. We would be nowhere if it weren't for their dedication." Both MSF compounds were transformed into hospitals.
Hundreds of people began arriving at the doors of the compounds as word of the clinics spread. Dr. Nathalie Civet described the massive need for medical services and the crowded conditions, noting that "it was never meant to be a hospital, so we are improvising as we go." The emergency clinics were soon able to accommodate minor surgery. Patients requiring major surgery were transferred to the only functioning unit – trauma surgery – of Monrovia's last functioning hospital (sustained by the Red Cross).
At the end of July (the end of the reporting period for this Activity Report), MSF was still active in Liberia; doctors and nurses, both expatriate and local staff, were working under extremely difficult conditions. Outside of Monrovia, MSF Liberian staff continued to provide assistance to about 60,000 displaced people at several camps in Bong county; MSF clinics in other camps near the capital had been forced to close.
In Monrovia, MSF also continued to provide care at the main sports stadium, "home" to about 40,000 people. Wheelbarrow and stretcher ambulances continued to weave through mortars and bullets, bringing the wounded to the makeshift clinics in Mamba Point. Stray bullets entering the compounds had become a fact of life. Some people were treated; some lives were saved. Many more had no access to care whatsoever. Most people weren't able to make it to the clinics.
Editor's note: In August 2003, a ceasefire, the stepping down of President Charles Taylor and the arrival of Nigerian peacekeepers eased the situation in Liberia, particularly in Monrovia. MSF was able to begin extending activities in Monrovia as well as expand work to Montserrado and Bong counties. However, in a September briefing to the UN Security Council, MSF reiterated that while fighting may have ceased momentarily in the capital, Liberia was not a country at peace. Fighting and violence against civilians continued in the countryside. MSF remains concerned that the predominant optimistic understanding among states, UN agencies and NGOs that Liberia is well on the road to peace and reconstruction is undermining the urgent response required to meet the massive needs of the people today.
Read MSF's special report - The collapse of healthcare, malnutrition, violence and displacement in western Ivory Coast.