Democratic Republic of Congo: Forgotten war

It is a struggle to do anything other than respond to the most serious emergencies. The complex and diverse nature of the violence, neglect, and discrimination in the DRC challenges any notion of simple, blanket solutions to redress even the immediate causes of so much death and suffering. Whilst MSF does not purport to provide a solution, we want to draw attention to what the Congolese people are enduring.

More than 3.8 million people have died in the Congo conflict since 1998. The majority of people die from disease and malnutrition.

Medical conditions

Chagas Disease

First described by the Brazilian doctor Carlos Chagas, this parasitic disease is found almost exclusively on the American continent, though increased global travel has led to cases being reported in the US and Europe. This potentially fatal condition damages the heart, nervous and digestive systems.

The disease is transmitted by blood sucking insects (Trypanosoma cruzi) that live in cracks in the walls and roofs of mud and straw housing, common in rural areas and poor urban slums in Latin America. People can be infected but show no symptoms for years. Developing over time, chronic Chagas causes irreversible damage to the heart, oesophagus and colon, shortening life expectancy by an average of ten years.

Heart failure is a common cause of death for adults with Chagas.

Treatment must occur in early stages of the infection, and drugs are only effective in the acute and asymptomatic stage of the disease in children. Diagnosis is complicated, with doctors needing to perform two or three blood tests to determine whether a patient is infected with the parasite. There are few drugs developed to treat the disease and the current line of treatment can be toxic, taking one to two months to complete.

Apart from managing symptoms, there is no treatment for chronic Chagas in adults.

MSF Chagas programmes in Bolivia and Guatemala focus on education, preventive measures and screening and treatment for children. MSF is also urging for more research and development on Chagas through its Access to Essential Medicines Campaign.

Cholera

The Greek word for diarrhoea, cholera is a water-borne, acute gastrointestinal infection caused by the Vibrio cholerae bacterium and spread by contaminated water or food. The infection can spread rapidly and may cause sudden large outbreaks.

Although most people infected with cholera will have only a mild infection, the illness can also be very severe, causing profuse watery diarrhoea and vomiting and leading to severe dehydration and death without rapid treatment. Required treatment is the immediate replacement of fluid and salts with a rehydration solution administered orally or intravenously.

MSF has developed cholera treatment kits to provide rapid assistance and sets up cholera treatment centres (CTCs) in areas where there are outbreaks. Control and prevention measures include ensuring an adequate supply of safe drinking water and implementing strict hygiene practices.

In 2005/2006, MSF conducted major cholera interventions in countries including Angola, Democratic Republic of Congo, Guinea, Guinea-B and Ethiopia.

HIV/AIDS

The human immunodeficiency virus (HIV) is transmitted through blood and body fluids and gradually weakens the immune system - usually over a three to ten year period - leading to acquired immunodeficiency syndrome or AIDS. A number of opportunistic infections (OIs) such as candidiasis, pneumonia, and various kinds of tumours are able to flourish as the immune system weakens. Some OIs can be treated, whilst others are life-threatening. The most common opportunistic infection leading to death is tuberculosis (TB).

Many people live for years without symptoms and may not know they have been infected with HIV. A simple blood test can confirm HIV status.

Combinations of drugs known as antiretrovirals help combat the virus and enable people to live longer, healthier lives without rapid degradation of their immune systems.

It is simplest and easiest to take these drugs properly when they are combined into single pills (fixed-dose combination or FDC).

MSF comprehensive HIV/AIDS programmes generally include education and awareness activities so people understand how to prevent the spread of the virus; condom distribution; HIV testing along with pre and post-test counselling; treatment and prevention of opportunistic infections; prevention of mother-to-child transmission; and provision of antiretroviral treatment for patients in advanced clinical stages of the disease.

In 2005/2006 MSF provided care for over 100,000 people living with HIV/AIDS and antiretroviral therapy for more than 60,000 people across 65 projects in 32 countries.

Human African Trypanosomiasis (Sleeping Sickness)

Frequently known as sleeping sickness, this parasitic infection is seen in sub-Saharan Africa and is transmitted through the bite of certain types of the tropical tsetse fly.

More than 90 per cent of reported cases of sleeping sickness are caused by the parasite Trypanosoma brucei gambiense (T.b.g) The parasite attacks the central nervous system, causing severe neurological disorders and leading to death if untreated.

During the first stage of the illness, people have non-specific symptoms such as fever and weakness. This stage of the disease is difficult to diagnose but relatively easy to treat. The second stage occurs once the parasite invades the central nervous system.

The infected person begins to show neurological or psychiatric symptoms, such as poor coordination, confusion, or convulsions.

People may also have difficulty sleeping during the night but are overcome with sleep during the day.

Accurate diagnosis of the second stage of the illness requires taking a sample of spinal fluid and treatment is painful, requiring daily injections. The most common drug used to treat trypanosomiasis, melarsoprol, was developed in 1949 and has many side effects. A derivative of arsenic, it is highly toxic and fails to cure up to 30 per cent of patients in some areas of Africa. It also kills up to five per cent of people who receive it.

Eflornithine, though somewhat difficult to administer because it requires an IV and a complicated treatment schedule, is a safer, more recent alternative being used by MSF in its projects. MSF through its Access to Essential Medicines Campaign works to ensure the production and supply of ef lornithine and urges for research and development aimed at new, easy-to-use drugs and accurate diagnostic tests.

MSF admitted 5,204 new patients for treatment for human african trypanosomiasis in 2005.

Leishmaniasis (Kala Azar)

Largely unknown in the developed world, leishmaniasis is a tropical, parasitic disease caused by one of over 20 varieties of Leishmania and transmitted by bites from certain types of sandf lies. The most severe form, visceral leishmaniasis, is also known as kala azar, Hindi for black fever. Over 90 per cent of cases occur in Bangladesh, Brazil, India, Nepal and Sudan. Without treatment, this form of leishmaniasis is fatal in almost 100 per cent of cases.

Kala azar attacks the immune system, causing fever, weight loss, anaemia and an enlarged spleen. There are considerable problems with existing diagnostic tests, which are either invasive or potentially dangerous and require lab facilities and specialists not readily available in resourcepoor settings. Treatment requires painful, daily injections of drugs for 30 days. The drug most widely used to treat kala azar, sodium stibogluconate (SSG) was developed in the 1930s, is relatively expensive and causes a toxic reaction in some patients.

Co-infection of leishmaniasis and HIV is emerging as a growing threat, as both diseases attack and weaken the immune system.

Infection with one of these diseases makes a person less resistant to the other and treatment becomes less effective.

MSF through its Access to Essential Medicines campaign is urging for more research into suitable diagnostic techniques and affordable drugs to treat this neglected disease.

MSF treated over 7,000 people for leishmaniasis in 2005.

Malaria

Caused by four species of the parasite Plasmodium, malaria is transmitted by infected mosquitoes, particularly during rainy seasons, and mainly strikes poor and rural communities, slum dwellers and refugees.

Symptoms include fever, pain in the joints, headaches, repeated vomiting, convulsions and coma. Malaria caused by plasmodium falciparum, if untreated, may progress to death.

Malaria is commonly diagnosed on a basis of clinical symptoms alone, such as fever and headaches. Around half the people who present with fever and are treated for malaria in Africa may not actually be infected with the parasite. An accurate diagnosis can be made through a count of parasites by microscope or a rapid dipstick test. Both methods are currently used by MSF in its projects.

Antimalarial drugs are used to treat the illness.

Chloroquine was once the ideal treatment for malaria caused by plasmodium falciparum because of its price, effectiveness and few side effects; however, its effectiveness has decreased dramatically in the past few decades. MSF field research has helped prove that artemisinin-based combination therapy (ACT) is currently the most effective against this type of malaria and has urged governments in Africa to change their drug protocols to use ACT. Although many governments have made the change in writing, in many cases the drug is still not available for their patients.

MSF treated over 2.2 million people for malaria in 2005.

Meningitis

Meningococcal meningitis is caused by Neisseria meningitidis and is a contagious and potentially fatal bacterial infection of the meninges, the thin lining surrounding the brain and spinal cord. People can be infected and carry the disease without showing symptoms, spreading the bacteria to others through droplets of respiratory or throat secretions, for example when they cough or sneeze. The infection can also cause sudden and intense headaches, fever, nausea, vomiting, sensitivity to light and stiffness of the neck. Death can follow within hours of the onset of symptoms.

Without proper treatment, bacterial meningitis kills up to half of those infected.

Suspected cases are properly diagnosed through examination of a sample of spinal fluid and treated with a range of antibiotics.

Even when given appropriate antibiotic treatment, five to ten per cent of people with meningitis will die and as many as one out of five survivors may suffer from aftereffects ranging from hearing loss to partial paralysis.

Meningitis occurs sporadically throughout the world, but the majority of cases and deaths are in Africa, particularly across an east-west geographical strip from Senegal to Ethiopia, the "meningitis belt" where outbreaks occur regularly. Vaccination is the recognised way to protect people from the disease.

MSF vaccinated over 100,000 people against meningitis in 2005.

Tuberculosis

One-third of the world's population is currently infected with the tuberculosis (TB) bacilli. Every year, nine million people develop active TB and two million die from it. Ninety-five per cent of these people live in poor countries.

This contagious disease affects the lungs and is spread through the air when infectious people cough, sneeze or talk. Not everyone will become ill, but ten percent of (HIV negative) infected people will develop active TB at some point in their lifetime, suffering from a persistent cough, fever, weight loss, chest pain and breathlessness in the lead up to death. TB is also a common opportunistic infection and leading cause of death amongst people with HIV.

Drugs used to treat TB are from the 1950s and a course of treatment takes six months.

Poor treatment management and adherence has led to new strains of bacilla that are resistant to the drugs commonly used. Drug resistant TB is not impossible to treat, but the required regimen causes many side effects and takes up to two years.

In 2005, MSF treated over 20,000 people with TB in more than 20 countries worldwide.

Footnotes: 1. "In larger freedom: towards development, security and human rights for all", Report of the Secretary-General, 24 March 2005 (A/59/2005).

2. Tsunami Evaluation Coalition, Joint evaluation of the international response to the Indian Ocean tsunami, July 2006.

3. "Note of Guidance on Integrated Missions". This document issued by the General Secretary of the United Nations was adopted on 17 January 2006 by the UN policy committee.

This body is made up of the most senior officials of the worldwide organisation and is responsible for advising the Secretary General and strategic decision making.

4. Faced with the increase in the number of peacekeeping operations in the 1990s and the failure of the international community in the management of certain internal conflicts, a number of analyses concluded that there was a need for better coordination between the different aspects of crisis response through the creation of suitable institutional