This year health workers everywhere are reeling from the response to the COVID-19 pandemic. Doctors Without Borders/Médecins Sans Frontières (MSF) teams across our medical projects had to adapt to this new emergency while keeping other essential services running. In the United States, we have seen how the spread of the pandemic put one of the world’s most advanced and well-resourced health systems under tremendous strain. In countries with already weak or fragile health systems, the coronavirus poses even greater threats. Meanwhile, the world’s obsession over this exotic new disease threatens to distract from other global health crises—including tuberculosis, HIV/AIDS, and measles.
For this special edition of Alert, we highlight some of the world's forgotten emergencies—forgotten by many in the international community but certainly not by our teams on the ground. In this photo essay, we bear witness to suffering, survival, and extraordinary strength during a tumultuous year.
Reaching out to tuberculosis patients at risk
Although the death toll due to COVID-19 is staggering, it is just starting to overtake tuberculosis (TB) as the world’s deadliest infectious disease. (COVID-19 had claimed the lives of more than 1.5 million people by December 3—compared to the 1.5 million people who die each year from TB, according to the World Health Organization.)
As the world’s largest nongovernmental provider of TB treatment, MSF is working hard to keep people on lifesaving treatment programs. For example, when the Indian government instituted a strict national lockdown in March to contain the spread of the pandemic, our teams immediately reached out to TB patients and other vulnerable groups living in the poorest areas of Mumbai—one of the most densely populated cities on earth. “In the initial phase [of the outbreak], there was a lot of fear in the community with regard to spread of the coronavirus,” said Santosh B. Choure, MSF health promotion manager. “I still remember, when I heard about the ﬁrst case in my neighborhood, I didn’t know how to react.”
MSF quickly mobilized to reach over 2,000 patients with drug-resistant TB (DR-TB) enrolled in treatment programs at our independent clinic in Mumbai’s M-East ward and two area hospitals. We provided clinical consultations, sent WhatsApp messages, and made phone calls. Our health promotion team conducted a campaign to tackle the spread of misinformation and reduce stigma, which can lead to targeted violence against patients. Tensions were high in this densely crowded area, as both TB and COVID can spread through the air.
Our independent clinic also adapted its DR-TB services to ensure uninterrupted treatment. We delivered medications to patients’ homes and provided video and telehealth services. “In the absence of public transport during the lockdown, it was not possible to travel from my home to the clinic for a monthly appointment,” said Rabiya, a 27-year-old woman with extremely drug- resistant tuberculosis (XDR-TB). “But my drugs were sent home, and I was consulted over the phone.”
MSF is working with India’s national TB program and the WHO on strategies to maintain the continuity of essential services for people living with TB during the COVID-19 pandemic, including through more widespread access to community-supported testing as well as newer all-oral treatment regimens. Internationally we are calling on governments to make use of newer tests and drugs that could save hundreds of thousands of lives each year.
Ensuring continuity of care for people living with HIV
We are also maintaining and adapting programs to treat people living with HIV, who may face increased risk from COVID-19 due to their underlying medical conditions. The interruption of health services and supplies caused by the pandemic could be disastrous. In May, a modeling study by the WHO and UNAIDS estimated that a six-month disruption of antiretroviral therapy could lead to more than 500,000 extra deaths from AIDS-related illnesses, including from TB, in sub-Saharan Africa alone in 2020–2021.
South Africa is still struggling with the world’s largest HIV epidemic—with around 7.7 million people living with the disease. When COVID-19 hit, one of the biggest questions for the medical community was how to protect people living with HIV and TB from the risk of infection in health facilities while ensuring that vital health services for vulnerable groups are maintained.
At MSF’s project in Eshowe—a small town in KwaZulu-Natal province where one in four people is living with HIV—the team came up with a strategy to deliver medications for stable, asymptomatic patients with chronic conditions at pick-up points in their communities. “We worked out that there are approximately 19,000 individuals on antiretroviral treatment in our area and designed a process for identifying who would be eligible,” said Dr. Liesbet Ohler, who works with MSF in Eshowe.
Fortunately, the team was able to build on a program set in motion in 2019. “MSF and the Department of Health had previously established 12 health care hubs in the rural communities, called luyanda sites,” said MSF community program manager Neliziwe Mazibuko. Luyanda means “increase” in the Zulu language, and the idea is to expand access to HIV and TB services for rural communities. Four additional permanent sites were opened in August, as well as 21 more pick-up points in community sites such as schools and churches. “It is very ambitious—we worked until 10 or 11 at night in order to set this up—but it is a great thing,” said Mazibuko, noting that people in this rural area will beneﬁt from improved access to medicines regardless of the additional threat posed by the pandemic.
Vaccinating children against measles and other preventable diseases
Measures to prevent the spread of COVID-19, such as social distancing, have led to many routine and reactive vaccination campaigns being put on hold. This risks creating dangerous immunity gaps and a rise in vaccine- preventable diseases. We are particularly concerned about the spread of measles, which continues to be a leading killer of young children despite the availability of a safe, inexpensive, and eﬀective vaccine.
This year, MSF teams have responded to measles outbreaks in countries including Democratic Republic of Congo (DRC), Central African Republic (CAR), Chad, and Mali. Together, these measles outbreaks have infected hundreds of thousands of children and killed thousands more. Some children die at home, never having reached proper medical care, or having been seen only by a traditional healer.
MSF teams have provided outbreak response and routine vaccination, and treated children for the disease and for other illnesses, such as malnutrition. These eﬀorts continued despite logistical and security challenges, even as the COVID-19 pandemic loomed as a potential threat and distraction for governments, donors, and other health organizations.
In September, we worked with Mali’s Ministry of Health to carry out a vaccination campaign in Timbuktu, a region in the northern part of the country where pervasive insecurity and criminality have limited people’s access to health care—including routine vaccinations. A number of measles cases were reported in the area starting in February. Working together, the teams reached more than 50,000 children between six months and 14 years old.
The campaign coincided with the start of the rainy season, and rising waters meant that traveling by river was the only way to access remote areas. This did not deter the mothers, though, many of whom made the journey from surrounding villages to protect their children. “I came because vaccination is vitally important to protect children against disease,” said Mariam Hammadoun Maïga, mother of 16-month-old Amadou. She watched cautiously as the nurse slipped the needle into his arm. “We say that prevention is better than a cure, therefore it’s better to vaccinate children than to treat them.”