“I met people whose villages had been burnt to the ground by one military group or another; they had run into the bush and were living with trees over the top of them and no mosquito nets. The malaria – I’d never seen anything like it,” says Tom de Kok, former Médecins Sans Frontières project coordinator in North Kivu.

Tom has returned from North Kivu. His first field mission for MSF was in Pakistan after the earthquake in 2005. Since then he has worked for MSF in Darfur and in Iraq and has completed two field missions in the Democratic Republic of Congo.

Huge health needs
Tom says that local people are trapped in the middle between different armed actors constantly shiftng. Those displaced from their villages by the fighting hide in makeshift shelters in the forest, not knowing where the next danger will come from and often cut off from all medical care.

For some, even travelling to town for provisions as basic as salt is too dangerous, as they run the risk of robbery, extortion and harassment. “In one village I came across, people had no salt. We’re a medical organisation, but we can still barely imagine that people are desperate to get salt.”

In such an insecure and unstable environment, where many lack the most basic of necessities, people’s health needs are huge. Despite the enormous challenges of working in a conflict zone, across shifting frontlines, MSF is running a therapeutic feeding centre for malnourished children in Pinga town, supporting two health centres in the surrounding area, and running mobile clinics on motorbikes. MSF staff in Pinga carried out 40,000 consultations in 2010.

Hiding in the forest
Most people – even old people – don’t know what it’s like to live without conflict, it has always been part of daily life. But still, the people who live in Pinga town have a far different experience from somebody who lives just five kilometres away, on the other side of the frontline. Whole villages are often burnt to the ground by non-government militias to deter nearby government forces from advancing and occupying them. When this happens, the villagers are forced to hide in the forest in makeshift shelters, without mosquito nets.

It is no surprise that in the hot, rainy, densely forested hills around Pinga, malaria is endemic. In 2010, the team in Pinga treated more than 6,500 cases. Children with malaria are particularly likely to have life-threatening complications, but getting these children to a doctor in town is far from straightforward.

To get medical care or reach the hospital in Pinga town, villagers “have to cross frontlines and land controlled by different military groups. They are accused by all sides of being sympathizers. […] The military suspects everybody. These are serious cases: these are parents with a dying infant who has got malaria maybe with anaemic complications. They’ll move, they’ll get harassed, they’ll turn around and the result is their child won’t make it.”

Mobile clinic, transferring patients
With so many people prevented from going to find a doctor, MSF’s mobile teams are crossing the frontlines themselves, and travelling on motorbikes (below) into the dense bush to find the sick and traumatised people who are so desperately in need of help. “Road conditions are horrible; we do our mobile clinics with motorcycle convoys because cars can’t go there.”

For many patients, on-the-spot treatment is not enough, and they need to be transferred to the nearest hospital, which may be across two frontlines and territory controlled by three different warring groups. In these cases, “the endeavour of trying to transfer a patient is about as lifesaving as the medical care itself.

We cannot just transport sick patients on motorbikes for hours over rough terrain – children cannot hold on, neither can pregnant women. We fill out a referral form and try to get them to meet us at the checkpoint so we can cross together with them. We tell the armed men at checkpoints the names of those patients who will attempt to cross that day, and we tell them we will follow up on these people. But still, some never arrive at our clinics on the other side of the frontline.” MSF teams are trying to find ways around these difficulties.

Treating rape survivors
MSF also provides specialised medical care to women and girls who have been raped. Treatment includes post-exposure prophylaxis, which can help protect against the HIV virus and other sexually transmitted infections.

MSF has treated 53 women and girls who were raped in several attacks in South Kivu. Most of the victims said they were attacked by armed men near the village Nakatete on the way home from the market on 19 January. They were held throughout the day, raped and subjected to other degrading treatment.

– The victims are between 13 and 60 years old. Women and girls were separated from the men, and their clothes and possessions were stolen,” said MSF Norway information chief Nils Mørk.

Civilians in eastern Congo has for years been subjected to sexual violence associated with conflict. Yet this is the first time in over six years that the MSF has treated Congolese rape victims in such a large scale.

Pills to prevent unwanted pregnancy
MSF treats injuries and provide preventative treatment against sexually transmitted diseases. Patients will also be vaccinated against hepatitis B and tetanus.

– Women and girls who received treatment within 72 hours after the rape, had also offered contraceptives to prevent unwanted pregnancy,” said Mørk.

Sexual violence is a terrible part of the war in eastern Congo that is perpetrated by military groups on all sides of the conflict. Many women are afraid to seek treatment because of fear of being stigmatised by their families. They also risk further harassment when attempting to cross military checkpoints in search of medical care. In 2010, the team provided specialised medical care to more than 200 women and girls who managed to reach MSF’s clinics against all the odds.

Providing maternal healthcare is another major priority, as women living in the bush who suffer complications during pregnancy and childbirth have no access to doctors or trained midwives. In and around Pinga in 2010, MSF carried out 4,000 antenatal consultations and 65 babies were delivered within an MSF facility.

Despite the difficulties of travelling by motorbike on muddy jungle tracks, of being held up at checkpoints, of negotiating access across frontlines and having to deal with various armed groups, MSF is capable of working in these conditions. “Our reputation on the ground is better than good. We’ve got the maximum amount of space you could have under these difficult circumstances. We are still reaching people in need and our work is respected across the lines,” said Tom de Kok.

Background
In South Kivu, MSF provides emergency healthcare to a population suffering from violence, sexual violence, displacement, malaria, malnutrition and disease outbreaks such as cholera and measles. In 2010, MSF medical teams in the Fizi region treated 20,000 malaria patients, gave 65,000 medical consultations, cared for 10,000 inpatients at Baraka hospital and helped to deliver 4,000 babies.

Throughout the Kivus, MSF runs hospitals, mobile clinics, health centres, vaccination campaigns and cholera programmes, and provides treatment and psychosocial care to survivors of sexual violence. In 2009 alone, MSF provided medical and psychosocial care for 5,600 rape victims in North and South Kivu.

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