On the front lines of conflict

Yemenis survey the damage caused by a Saudi-led airstrike on an MSF-supported cholera treatment center in Yemen’s Abs region in June. No staff or patients were killed or injured in the attack.
YEMEN 2018 © Essa Ahmed/AFP/Getty Images
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This article is part of the Winter 2018 issue of Alert—2018: The Year in Photos—featuring some of the most striking images and stories from our work around the world.

Doctors Without Borders/Médecins Sans Frontières (MSF) teams work in some of the most difficult and dangerous places in the world. Approximately one-third of the medical humanitarian assistance provided by MSF is for communities caught in armed conflict. War affects every aspect of life, often plunging societies into poverty and forcing people to live under siege or flee for their lives. Violent conflict can devastate essential health infrastructure, disrupt the flow of medical supplies, and exacerbate outbreaks of deadly diseases.

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A child waits in the emergency room of the MSF-supported Al-Salam hospital in Khamer, Amran governorate, Yemen. As ongoing conflict in Yemen causes prices of commodities and fuel to rise precipitously, many people cannot afford to travel to hospitals. In response, MSF runs outreach clinics to serve isolated communities in the region.
YEMEN 2018 © Agnes Varraine-Leca/MSF

Yemen

Yemen’s brutal war has decimated the country’s health system, leaving more than 22 million people in need of humanitarian assistance, according to United Nations estimates. Health facilities and other civilian structures have been hit by bombs, grenades, and artillery fire by the warring parties—including members of the Saudi- and Emirati-led military coalition backed by the United States, and Ansar Allah (Houthi) fighters and their allies. An economic blockade coupled with high inflation have led to chronic shortages of essential goods, including medical supplies. Even where medical facilities remain operational, most people can no longer afford the cost—and associated risk—of transport to reach them. Some delay care until their condition becomes critical. Pregnant women, for instance, generally receive no prenatal care and often arrive at health facilities with life-threatening complications during labor and delivery.

Despite growing international pressure for a ceasefire toward the end of the year, increased fighting across many parts of the country in November took a heavy toll on civilians. MSF has massively scaled up operations in Yemen since the conflict began in 2015, with 1,797 staff members in the country in 2017. Teams currently provide support to more than 12 hospitals and health centers in 11 Yemeni governorates, offering services ranging from trauma surgery to care for patients with chronic diseases.

MSF project coordinator Hisham Al Dawa sits on the roof of the MSF office in Saada, Yemen. The building is marked with the MSF logo to help ensure that it will not be targeted by airstrikes. The MSF-supported hospital in nearby Haydan was destroyed in a Saudi airstrike in October 2015. MSF teams returned to the hospital in March 2017, and now provide health care to isolated communities in the region and in surrounding areas. “What we see most are bullet wounds and injuries like shrapnel wounds sustained during bombing raids,” said MSF project coordinator Frédéric Bonnot.
YEMEN 2018 © Agnes Varraine-Leca/MSF
Three-year-old Ayman waits with his father Hamoud (left) and mother Karima (center) at Haydan hospital. Since falling from the second floor of the family’s home, the boy suffers from dizzy spells and no longer speaks. He is being referred to Al Joumhoury hospital, which has the facilities to perform radiography tests. The conflict in Yemen has made traveling to reach care a risky proposition for many Yemeni families and has wildly driven up the cost of fuel and transportation. Hamoud had to borrow 10,000 Yemeni rials (around $40 USD) to reach the hospital, a major expense in one of the world’s poorest countries.
YEMEN 2018 © Agnes Varraine-Leca/MSF
During surgery at Al-Salam hospital in Khamer, Amran Governorate, MSF physiotherapist Elizabeth Braga (second from left) tends to a child who suffered burns over 30 percent of their body. The hospital offers comprehensive care in a region where the health system has been decimated by years of conflict.
YEMEN 2018 © Agnes Varraine-Leca/MSF
MSF opened its 60-bed SICA Hospital in Bangui in 2017 to provide specialized orthopedic and visceral surgery, physiotherapy, and mental health support to trauma patients. Twenty-eight-year-old Haroun is being treated at SICA after being stabbed multiple times in the chest. Physiotherapy has helped him recover his lung capacity. “The support I received at the hospital allowed me not to sink; not to lose my head,” he said.
CENTRAL AFRICAN REPUBLIC 2018 © Elise Mertens/MSF

Central African Republic

Years of bloody conflict in Central African Republic (CAR) have resulted in thousands of deaths and the displacement of millions of people both within the country and across borders. MSF teams here address the consequences of the violence on the health of individuals and entire communities: conflict-related trauma; barriers to medical care; poor vaccination coverage; and more.

In the physiotherapy department of SICA Hospital in the capital city, Bangui, an MSF team performs an average of 150 consultations weekly for trauma patients, many of whom have been wounded by bullets or knives. Our physiotherapists aim to provide as much time as possible for patients to recover from their injuries, many of which are complex.

A surgical team at SICA Hospital works to close a gunshot wound in the operating theater. In April, heavy fighting in Bangui resulted in scores of injuries and several influxes of mass casualties to the hospital. The vast majority of patients suffered gunshot wounds, but the MSF team at the hospital also treated shrapnel and stab wounds.
CENTRAL AFRICAN REPUBLIC 2018 © Florent Vergnes/AFP
War wounds are not the only consequences of conflict. The attending damage to health infrastructure and a lack of supplies also contribute to the spread and exacerbation of disease. Here, Méda and Mathuri stand with their 18-month-old son Therence outside Bossangoa hospital. The boy is suffering from malaria, the fourth time he has contracted the disease in his short life. “We are very worried this time,” says Mathuri. “He hasn’t eaten anything for the past five days and he is extremely tired.” Most of the patients affected by malaria in Bossangoa are under the age of five.
CENTRAL AFRICAN REPUBLIC 2018 © Elisa Fourt/MSF
Eleven-year-old Mace-Grace recovers in a hospital in Bunia, DRC, in early March. She lost her mother, three siblings, and her left hand in an attack on her village in Ituri Province. Conflict in the region has displaced thousands, many of whom gathered at a temporary shelter site at the regional hospital. MSF provided basic health care, mental health support, and referrals for severe cases to two nearby hospitals.
DEMOCRATIC REPUBLIC OF CONGO 2018 © John Wessels/MSF

Democratic Republic of Congo

MSF responds to disease outbreaks and other emergencies across Democratic Republic of Congo (DRC)—and there is no shortage of need. We run some of our largest projects worldwide here, with thousands of staff working in 20 of the country’s 26 provinces. Long-simmering armed conflict has triggered massive population displacements, most notably in North and South Kivu, the greater Kasai region, Ituri, and Tanganyika.

MSF teams address the consequences of violence, providing lifesaving health care services to people displaced by fighting and mental health support for those suffering invisible wounds of war. We care for people displaced outside the country too, including tens of thousands who crossed Lake Albert into neighboring Uganda after fleeing intense violence in Ituri in early 2018.

Active conflict and insecurity have recently hampered the response to an outbreak of Ebola in North Kivu and Ituri provinces

An MSF nurse checks on cholera patients in an MSF-supported cholera treatment center on the shores of Lake Albert in DRC. Thousands of people displaced by violence in Ituri Province fled to this region, taking shelter in camps on the lake. MSF teams undertook water and sanitation efforts, installing a water supply and erecting latrines and showers, in an effort to curb the spread of diseases like cholera.
DEMOCRATIC REPUBLIC OF CONGO 2018 © John Wessels/MSF
People displaced by fighting in Ituri Province push a boat into Lake Albert, seeking to cross to the relative safety of Uganda. Many who chose to stay in DRC took shelter in Bunia town, where MSF supported several health centers, treating mainly malaria, respiratory infections, and diarrhea.
DEMOCRATIC REPUBLIC OF CONGO 2018 © John Wessels/MSF
Congolese refugees wait to receive measles and polio vaccinations for children and tetanus vaccinations for women of childbearing age at the reception center in Kyangwali, Hoima province, Uganda. From December 2017 to March 2018 more than 60,000 refugees crossed Lake Albert to Uganda after fleeing violence in DRC’s Ituri Province. The influx overwhelmed facilities at refugee camps in Uganda, sparking a deadly outbreak of cholera. MSF teams worked on both sides of the lake to care for refugees and curb the spread of the disease.
DEMOCRATIC REPUBLIC OF CONGO 2018 © Diana Zeyneb Alhindawi
Patients chat outside MSF’s Khan Yunis clinic in Gaza. About half of the thousands of patients treated by MSF from March 30 to October 31 suffered open fractures, and many suffered severe soft tissue damage. The consequences of these wounds—especially if untreated—can be lifelong disability, amputation, or even death.
PALESTINIAN TERRITORIES 2018 © Aurelie Baumel/MSF

Palestinian Territories

MSF provides medical aid to people affected by ongoing conflict in the Palestinian Territories with long-running mental health programs in the West Bank and specialized care for victims of burns and trauma in the Gaza Strip. Our patients have witnessed violence, experienced the arrests or deaths of friends or family members, and endured raids on their homes. As a result, many have developed anxiety, stress, and sleeping problems.

In the Gaza Strip, MSF teams also treat patients for burns and trauma in four hospitals and five postoperative clinics. From March 30 to October 31, MSF teams treated 3,117 patients injured during clashes between Israeli troops and Palestinian protesters, many of whom were shot in the legs. Gaza’s fragile health system is struggling to cope with the huge numbers of patients still in need of care for the serious wounds they sustained earlier this year, at the height of the Great Return March demonstrations, leaving thousands in danger of infection and permanent disability.

A staff member tends to a patient inside an MSF postoperative center in May 2018. Every day patients injured by gunshots must come to this facility for follow-up care and to change the dressings of their wounds. For months MSF and other organizations have been working to provide treatment, however, the scale of the needs is overwhelming.
PALESTINIAN TERRITORIES 2018 © Laurence Geai
Thirteen-year-old Abdullah al-Anqar was shot by a sniper during the Great Return March demonstrations at the Gaza-Israel border. He was initially treated at a hospital in Israel, where doctors amputated his leg. Back home in Gaza he is receiving postoperative care at an MSF facility, and has already undergone several subsequent operations.
PALESTINIAN TERRITORIES 2018 © Heidi Levine/Sipa Press