Ops update Week 26, 2017

Friday, July 28, 2017 —

Ops Updates – Week 26

DISCLAIMER: This Operational Update is a summary of internal operational information from the five MSF Operational Centers. The information contained herein is strictly internal and should not be shared outside MSF.

OCA

SYRIA (24 July)

Over the weekend, the Tal Abyad hospital received 15 wounded from Raqqah, consisting of several injured in a motor accident and several injured in the offensive, arriving within a short space of time. Although 15 may seem few, the hospital’s surgical ward has a capacity of 18 beds so 15 is in fact a substantial amount of wounded to deal with. This also stresses the importance of getting the mass casualty plan up and running. The team is busy but doing well under the circumstances.

TAJIKISTAN (24 July)

As of July 2017, our first Bedaquiline cohort of five pre-XDR and XDR patients who started treatment between April and June 2015 are confirmed cured with a success rate of 100%. All five patients have finished 24 months of treatment. Although it was a difficult decision for the medical staff to enrol these first patients on Bedaquiline two years ago, they are proud of the achievement today. The outcome will also reinforce the continuous advocacy for the use of new TB drugs in for the national TB programme of Tajikistan.

LIBYA (26 July)

The team managed to get back into the Tariq al Shook detention centre and was able to do a mobile clinic last weekend. They found that, while at the last visit there were an estimated 700 detainees, on Sunday there were 308 left. Only one TB patient is left from the previous cohort, all other TB patients have been moved out. Most of the ANC patients the team previously engaged with were not at the DC either, so only several new ANC patients have been assessed during the mobile clinic. It seems that some of the malnutrition cases are likely to have left as well.

While it’s good that we have regained access, it’s very bad that we have no way of knowing what happened with more than half of the people we saw in earlier visits. There is no system that allows for following people who have been moved out of one DC to another or into the community, nor is there any bearing of accountability. It’s a staunch reminder of the reality that we work in, but it also indicates the relevance of the mission in Libya.  

SYRIA (26 July)

Yesterday, the Tal Abyad hospital received another influx of wounded. Eight family members arrived from Hazima, an area north of Raqqah, after sustaining injuries from an explosive ordinance, which was carried into the house by a seven-year-old child. The entire household was affected by the blast. The family received first aid before being transferred to the hospital. Unfortunately, the child died from his injuries. His family members are all currently in stable condition although some are critical. The case, while incredibly sad, reinforces the decision made in terms of locations picked for advanced medical points, and the continued involvement in Tal Abyad hospital as one of the few secondary referral centres in North Eastern Syria.  

TAJIKISTAN (26 July)

In a first for OCA’s TB programme, the team in Dushanbe, Tajikistan, have started a two-year-old child on an injection-free XDR TB regimen using Delamanid. The baby girl has bone TB (in her spine and knee) after close contact with her grandmother who died of XDR TB and was under treatment with the standard MDR TB regimen. She weighs 10 kilogrammes and we are hoping that everything goes well so she can be fully cured and other children can benefit from the same regimen. Historically, only 20-25% of XDR TB patients are ever cured.

If successful, the innovative approach is good news for the toddler as it means she will not have to face one of the worst side effects of the injectable TB drugs: hearing loss. In children, this side effect is particularly challenging to address as it means they may not ever be able to communicate through speech, whereas in adults – those skills are already developed and unlikely to be so crucially affected.

It's believed this is the youngest child ever to receive Delamanid outside of a clinical trial anywhere.

OCB

CAR (26 July)

There has been an upsurge in violence in and around Bangassou. Thursday evening WFP conducted a food distribution for the IDPs sheltering in the Catholic Church compound (these IDPs are majority Muslim). It seems an Anti-Balaka militia member came to the distribution site and was severely beaten by the IDPs. And then it appears the Anti-Balaka group in the area decided to loot the food in the WFP warehouse as retaliation. The MSF base is close to the WFP warehouse, so while this was happening the MSF team remained in the base and avoided movements.

On Friday the situation deteriorated. What is reported is that an Anti-Balaka group kidnapped a Peul (Muslim) girl, and the Muslim IDPs then wreaked violence and burned houses in Anti-Balaka areas on the outskirts of the town. It seems the IDPs seized humanitarian workers from another NGO and threatened to harm them if the kidnapped girl was not returned. The Anti-Balaka group then tried to attack the IDP camp at the Catholic Church, at which stage MINUSCA intervened to stop the attack, and fought back the Anti-Balaka militia.

On Saturday and Sunday tensions remained high, and four MINUSCA staff were injured and one killed when they were doing water-trucking near the river.

Most recently, on Tuesday another UN convoy was ambushed when collecting water to distribute to IDPs and two peacekeepers were killed. MSF received three wounded militia patients in the hospital.

The team has partially-evacuated, leaving a core team to continue life-saving medical activities in the hospital.

DRC (26 July)

The team in Kasai did an assessment in the town of Luiza last week, which has been affected by heavy fighting over the past six months. Similar to what we see around Kananga, there are signs of conflict and destruction (villages have been burned, the health centres looted and the population displaced). There is no active fighting there now.

IRAQ (26 July)

The Ministry of Health has made a request to all MSF sections to prepare for medical activities before the next big battle, which is likely to take Tal Afar from IS control. OCB is looking into ways to support another OC rather than doing a full stand-alone project or intervention.

SEARCH & RESCUE (26 July)

Yesterday MSF was present at a meeting between SAR NGOs and the Italian Ministry of the Interior to discuss the proposed Code of Conduct for NGO SAR activities. While the meeting was not as fruitful as we hoped, we do have a door somewhat open for bilateral dialogue. We are going to see how far this bilateral approach can take us. We issued a short quote to media, confirming that we are willing to keep an open and constructive dialogue on the Code and reiterating that there are ambiguities and elements of the draft Code that do seriously need further discussion and clarification. There will be more concrete public positioning when we have a better view of how our bilateral discussions are going.

OCBA

INTERNATIONAL ACTIVITY REPORT (24 July)

The International Activity Report for 2016 is now live and can be accessed here: http://www.msf.org/sites/msf.org/files/msf_activity_report_2016_web.pdf

NORTH SYRIA & TURKEY (24 July)

There has still been no final announcement on the implementation of the de-escalation zones to be set around Syria.

On the Afrin/Syria Democratic Forces (SDF) – Free Syrian Army (FSA) frontline, the situation continues to be tense in Afrin area, where sporadic clashes and shelling between SDF and FSA/Turkish Armed Forces (TAF) continued. Turkish artillery was deployed on the border posts along Kilis-Afrin borders. Expectations remain for a TAF-backed FSA offensive as reported in previous weeks. Movements in the Afrin canton are getting more complicated and need to be planned in advance with daily security checks of movements in Afrin.

Heavy clashes started between the two main groups in the Idlib governorate, Hayat Tahrir al-Sham (HTS) and Ahrar Al Sham (AAS). Clashes between these two groups are recurrent. It is expected that they will be repeated in the near future, should the de-escalation zones agreement advance and as Turkey puts more pressure in the area. An open war between the two groups is a possibility. At a certain point, Bab Al Hawa became the most severe location of the clashes and the border crossing there was and remain closed.

In Turkey, the Emergency State has been extended by three additional months. A new cabinet council has been formed, with no signal on a change of government domestic and foreign policies.

The Idlib explo currently underway has been affected by the tensions in Idlib and had to be postponed for a few days. Ten hospitals have already been visited out of the 17 planned.

Negotiations with SIG/WHO regarding the extension of MSF EPI programme to the district of Al Bab have been concluded. It will be done following the immunisation calendar and MSF will lead the micro plan and implementation.

JORDAN/SOUTH SYRIA (24 July)

Although discussions are still being held on the implementation of the de-escalation zones, the ceasefire announced on 9 July in Dara’a is still being respected.

There is an aggressive conflict between the GoS and Russian Military Forces against Iranian militias with heavy weapons and artillery in Namer village, on the Daraa international road towards Damascus.  On 21 July, the Azro Hospital was closed for security reasons. 

There have been several initiatives from Da’ara authorities to ensure a functioning society once an agreement on de-escalation zones is reached. They have been calling for skilled people, engineers and teachers in addition to people who had their housing damaged due to the bombarding to register for an initiative to rebuild Daraa.

On 22 July the Nasseb crossing was opened under the supervision of Daraa city council with the protection of the FSA and a neutral civil administration, with no flags, UN to monitor convoys and crossing at Nasseb.

TURKEY-ISTANBUL (24 July)

Six of the 10 human rights defenders were arrested in Istanbul pending terrorism related charges, among them two Citizens Assembly staff. Last week four were released with conditions (also one from our partner), only to be re-arrested again later in the week.  Among the group there is a German citizen, a fact that has spurred tensions between Germany and Turkey, turning into a diplomatic crisis, as Turkey is accusing Germany of supporting terrorism. Germany called for economic sanctions against Turkey.

Overall the environment for foreign-funded Turkish Organisations and foreign-sponsored foundations involved in HR is deteriorating. 

For the moment there have been no consequences on the Citizens Assembly organization, MSF’s partner. Our activities in the centre for victims of ill-treatment continue, though the team is putting together a contingency plan.

CAR (24 July)

Following the Rome peace agreement, a road map from the Africa Union was signed on 17 July. Negotiations are still taking place after incidents in Paoa, while access to Bocaranga for NGOs is still not possible. In Zemio, South-East, anti-balaka retreated towards Bangassou, and there is a lot of tension in Bria; in Bangassou MINUSCA was attacked on July 21.

Clashes were reported south of Alindao, provoking more displacement towards DRC. Batangafo and Kabo were more or less calm.

We are seeing an increased number of malaria cases in Kabo. In Batangafo the number of cases at the periphery is down, while going up at the hospital, with a 22% increase in hospitalisations.

The MSF Eureka team is in Gbadolite (DR Congo), where refugees and IDPS have fled to the neighbouring country and on the islands of the Ubangui River. Since they have not been declared refugees, the authorities are not allowing a response and there are difficulties in assessing the situation. The team managed to do an explo in Kambo, where there is a total of 13,000 IDPs who fled armed groups in the river islands two weeks ago.

ANGOLA (24 July)

In Lunda Norte/Dundo, there was no significant influx of refugees reported last week. The move to Lovua camp and the dismantling of Cacanda camp in Dundo was postponed until August 8. There is uncertainty over what will happen to the refugees staying with the host population in Dundo town and around. These refugees represent two-thirds of the total refugee population. Our operations will adapt to that and to the severity of the situation.

SUDAN (24 July)

There was an incident in Gara Zawia, a site of the El Sireaf project, when the installation of a Cholera Treatment Unit made the community uncomfortable, resulting in a threat to the MSF teams. The team decided to do a preventive relocation to Kabkabiya. Now the team is back in the location after agreements with community members and authorities on safety, as well as commitments on how to reinforce the efforts on health promotion and education and the acute watery diarrhoea response.

The South Kordofan assessment took place last week. The main locations visited were Abu Jubeiha and the South Sudanese refugee camps. Unfortunately, the rain has blocked access to some of the camps and the team could not reach them. Another trip will be considered to get a full picture.  Despite the difficulties, the team has managed to get in touch with key actors and to gather first-hand information about the humanitarian situation in the area.

SOMALIA (24 July)

Two interventions/assessments were approved last week by the Security Core Group (OCBA) and OCA, including the Dolo (Somalia) cross-border Nutrition support, which will be done in close conjunction with the Ethiopia and Somalia missions. Strong lobbying and advocacy work has been done at Nairobi level and once the Baidoa assessment is finalised the Somalia team will travel to Ethiopia to finalise details.

Baidoa: a team of four internationals from OCBA and OCA are currently doing an assessment in the area. The main objective is to visit the three functioning hospitals in the town, and to assess potential support to the ongoing drought crisis and a more long term engagement in other areas.

ETHIOPIA (24 July)

Some unrest was reported in various areas of Oromia and the police were on heightened alert in Addis Ababa. The trigger for the unrest is believed to be the latest tax assessment, which involved a tax increase for many small and medium-sized businesses. Government officials have so far not expressed any intention to soften or reverse the new taxation. The events did not have any impact on MSF movements or projects.

After the assessment in Garbo was interrupted by the Regional Health Bureau (RHB) two weeks ago, the team went back to Garbo last week and are expected to finish on Tuesday. A decision on if or how to intervene in Sagag (SAM 5,7%) will be taken after the assessment team is back. MSF is now also working in Degehabur hospital’s stabilisation centre in collaboration with the RHB, but we need to increase our involvement in the facility as the level and motivation of the staff is questionable. From this week on we are also going to support outpatient treatment.

IRAQ (24 July)

Fighting is ongoing in West Mosul between the Iraqi Security Forces and some ISIS cells. However, the situation in East Mosul is more stable. Last week, Iraqi Security Forces took back Imam Gharbi, pushing ISIS to the Eastern bank of the Tigris River (Hawija).

Since July 24, MSF-OCBA is officially registered in Kurdistan, which will facilitate the administrative part of our operations (visas, clearances, travel permits). We have started our ITFC at Al Khanssa hospital, in West Mosul. In Qayyarah a team is now in place to open the logistics base and to finalise the ATFC site at Jeddah 6 camp.

YEMEN (24 July)

The ongoing cholera outbreak remains out of control and is the worst one since Haiti and the largest epidemic ever registered in Yemen, with a record number of cases in a single year (372,900 to date) and over 1,800 deaths (Case Fatality Rate: 0.5%). Up to 600,000 people may have fallen sick by the end of the year, according to ICRC, which would equate to one in 45 Yemenis.

MSF has treated about 20% of the patients recorded across the country: a total of 73,776, in 9 governorates. This week the Heads of Mission are meeting with the global chiefs of UNICEF, WHO and WFP in Sana’a to underline the importance of balancing case management with preventative activities at community level. They will call for an improvement in the quality of aid delivery and reiterate the urgent need to ensure that staff from the Ministry of Public Health and Population receive salaries or, at least, sufficient incentives.

MALI (24 July)

In Ansongo, continuous incidents across the region show that the situation is very volatile, mainly in the area of Menaka, where there have been a large number of casualties. Some of these incidents showed a cruelty not seen before in the area, including the public decapitation of several presumed jihadists by members of “Groupe d’autodéfense touareg Imghad et allies” (GATIA) in the village of Indelimane.

In Kidal, the situation remains tense but there are mediation efforts to halt the hostilities between GATIA and “Coordination des mouvements de l'Azawad” (CMA). In Takalot one of the Health Centres supported by MSF was attacked and looted. We need to do the inventory of losses but they should be low.

In Douentza, tension continues to increase little by little in the area between different actors and communities.

In Ansongo, a low frequentation of the medical services provided is reported, probably owing to the start of the agricultural labour in the area. The Deputy Head of Mission visited Kidal to evaluate the possibility of resuming operations at the end of the week.

In Douentza, there is a slight increase in admissions in the hospital compared to the previous week, most of the cases are malaria related.

GUINEA BISSAU (24 July)

In Bafatá, the MoH responsible for vaccination confirmed the availability of vaccines, including measles, for the joint SMC vaccination campaign that MSF will start in the region on 7 August. All preparations and trainings are ongoing.

There is a slow but steady increase in the cases of malaria up to 39% of the total admissions, with a bed occupation rate of 81%.

PEC project:  There was a 35% increase in malaria cases seen at the Emergency Room in one week. About 886 cases in total were seen at the triage, of which 123 were admitted (13, 9%). 3 children died.

NIGER (24 July)

In Diffa, the SMC malaria prevention campaign will start on July 28.

In Madaoua, the Hospital Water Supply, a subproject that will last for a year, has already started last week.

COLOMBIA (24 July)

There are restrictions on the mobility of International Organizations by Disidencia Bloque 1 in Meta and Guaviare departments.

In Tumaco, there were two new cases of Termination of pregnancy on request (ToPR) and 1 case of rape under 72h were fully attended by the MSF team.

In Buenaventura, there were three new cases of ToPR.

MEXICO (24 July)

According to official figures, last June was the most violent month since 1997, with 2,124 cases of intentional homicide. There are also unprecedented increases in kidnappings and robberies this year. Deportations have decreased 53% in June, compared with the same month last year. Nevertheless, institutions and shelters on the US border say that the detention centres on the American side are full of migrants.

The Haitian embassy in Mexico created a “mobile consulate” in Tijuana in order to assist their citizens with the regulation of their migrant status.

In Acapulco, a recent survey conducted by the National Institute of Statistics and Geography (INEGI) indicates that 83.2% of the city’s population fears to live in their city.

There is a significant increase in the migrants’ flow in Tenosique. Infiltration of members of “maras and coyotes” has been reported as well. UNHCR and other organizations in Tenosique agreed to pay the expenses of urgent migrant cases that need medical assistance and can’t be covered by the Ministry of Health.

VENEZUELA (24 July)

The General Assembly (with opposition majority) “nominated” 33 new juries for the Supreme Court, as they accused President Maduro of irregular nomination of current juries.

Protests and demonstrations are increasing as of July 30 (election day for a new General Assembly called by Maduro) approaches. Demonstrations over the last four days left seven people dead, hundreds injured and almost 600 arrested across the country. The total death toll is 103 in almost four months, with a worrying increase of gunshot deaths.

The team continues to support health facilities by attending to the injured.

OCP

YEMEN (27 July)  

Sa’dah, Amran and Khamir were hit by a wave of air strikes during the night of 22 July. By chance, there were only two victims. These attacks are used by the coalition to exert pressure on the Houthis. Despite this, front lines remain fairly static because the Houthis continue to control all the west of the country (from Sa’dah to Sana’a to Ta’ezz) and to defend themselves.

The CTC in Sa’dah was partially destroyed in an airstrike and the authorities moved it into a school. They now want the building back and have asked MSF to help with setting up and running a CTC.

The Al Koweit CTC in Sana’a is maintaining the same level of activity. The team want to hand over to another organisation their support to the hospital’s emergency room and operating theatre in order to focus efforts on the north but have yet to find any takers.

The strategy in Khamir is to reduce the number of staff in the CTC and hand over CTU/health centres in outlying areas to the ICRC.

In the south of the country (Aden, Abyan), the situation remains volatile and uncertain due to tensions among the various armed and political groups backed by either the Emirates or Saudi Arabia. Our teams are monitoring the situation but are not able to get to Abyan yet where targeted attacks by groups affiliated to AQAP are still frequent. We are supporting Lawdar hospital in Abyan Governorate and health centres and hospitals along the front lines.

The situation in Ta’ezz, where there are groups affiliated with Al Qaida, has deteriorated in recent weeks. OCA is for the time being continuing its activities.  

The teams have been able to get to Mocka that is south of Hodeidah, a strategic port town in the west of the country the coalition has been seeking to retake for over six months. Destroyed during the fighting, the town’s hospital is being refurbished and only the OPD is open. We are supplying the hospital with drugs and Plumpy Nut and our team is helping with setting up a CTC. The security situation in and around the town remains tense.

Last week, MSF heads of mission met a United Nations delegation to draw their attention to the difficulties encountered in the response to the cholera epidemic in the country. They gave the delegation an intersection advocacy document.

After the meningitis alert during which 8 of 200 cases were confirmed, the teams continue to monitor the situation in Sana’a. As the rainy season approaches, they are also preparing for an outbreak of malaria in valleys around Khamir where access to medical treatment is particularly inadequate. The strategy put forward focuses on Test & Treat, with pregnant women and children under the age of 15 years the priority, and distributions of bed nets.

Discussions are underway regarding the issuance of visas for the north of the country. Visas for the south and for the north would thus be required to go to the north. If this should come into effect, our operations would be impacted.

The HART went to Riyadh last week to meet with the authorities.

RDC – Update on the situation in Kasai (27 July)

In recent months, particularly high levels of violence have been reported in Kasai, DRC. In March, two experts from the United Nations were killed in the region; their execution was filmed and attested to the ongoing violence in the area. Since then, the security has improved somewhat, but it is only during the last weeks that any organization has been able to access areas outside the main towns.

According to humanitarian agencies, fighting between the army and armed groups has resulted in the displacement of over a million people in Kasai. The situation remains unclear and the dynamics of conflict (political, ethnic) are still difficult to understand. Sexual violence and abuses against women and girls seem to be frequent.

OCP is launching an explo from Mbuji Mayi, a city that is reportedly calm and quiet, but where the areas outside have been heavily affected, with the health posts burned or looted, the crops spoiled and many people displaced in the bush. The Emergency Coordinator and the Deputy Director of Operations will over the next week attempt to visit these areas in order to have a better understanding of the situation. Paediatric health care, especially malnutrition (SAM: 7%), measles and malaria are likely to be the main issues. Hence, the team proposes to adopt a flexible and mobile strategy in order to offer access to basic health care via mobile clinics and is also considering how to address the sexual violence issue.

OCB runs trauma surgery activity in the hospital of Kananga, but there is a worry that injured people do not arrive at the hospital because the access is difficult from the outside of Kananga and probably also because people fear to be targeted/denounced. Meanwhile, OCBA is based in Tshikapa, to the west of the Kasai.

HAITI – Bacterial outbreaks a the Drouillard Burn Centre (27 July)

Since June 13, 2017, there have been three separate bacterial outbreaks at the Drouillard Burn Centre in Haiti: Pseudomonas Aeruginosa Imi R; Acinetobacter Baumanii (Multi-Drug-Resistant – MDR); Klebsiella Pneumoniae (Extended-Spectrum Beta-Lactamase – ESBL). An outbreak is defined as two or more patients with the same multi-drug resistant bacteria with the SAME multi-drug resistant antibiogram.

June 13, Acinetobacter Baumanii, an opportunistic pathogen in humans, affecting people with compromised immune systems (particularly severe burns) was discovered.

Acinetobacter Baumanii is an increasingly important hospital-acquired (nosocomial) infection. Since the beginning of the outbreak, 11 cases have been confirmed (6 carriage and 5 infections) with no deaths. 3 cases are still hospitalized in ICU 2. A sampling of surfaces in ICU 2 revealed that a trolley was positive for the bacteria responsible for the outbreak. On July 14th, a new sampling, performed after extensive cleaning and strengthening of infection prevention and control measures, showed that there was no longer any bacteria present.

June 20 an Imipenem-resistant Pseudomonas Aeruginosa outbreak was declared. There have been 8 cases, one death case was tested positive. One of the patients infected with Acinetobacter in ICU2 was found positive with the imipenem-resistant Pseudomonas also. Further sampling showed that the imipenem-resistant Pseudomonas was found on anaesthesia trolley in OT. On July 14th, performed after extensive cleaning and strengthening of infection prevention and control measures, a new sampling disclosed that there was no longer any bacteria present.  

Since June 30th, a Klebsiella pneumoniae outbreak has also been declared. Four cases have been confirmed and no deaths registered.

The project is working hard to improve infection, prevention and control (IPC) and reinforce basic hygiene messages about hand washing. Each burn patient is considered as MDR positive in the OT until the reception of Bacteriology results proving otherwise. A deep cleaning of the OT has been completed and there is now only minimum equipment available inside to reduce the risk of persistent reservoirs of infection.

Cell six is proactively communicating about the outbreaks to promote a nonjudgmental dialogue to best learn from and reinforce identification, management, and prevention of resistant bacterial pathogens outbreaks as OCP strategic objectives in our Drouillard project. This was in part possible because of the presence of a dedicated antibiotic steward in the field - an infectious disease clinician who collaborated with the laboratory, IPC, pharmacy and our HT teams to address this issue.

Located in the commune of Citée Soleil in Port au Prince since 2011, the hospital of Drouillard with a capacity of 40 beds, specialises in 2014 in the treatment of burns.

In 2016 the teams provided 1,319 emergency room visits, 801 hospitalisations with an average stay of 17 days and an occupancy rate close to 90%.

PALESTINE – Communications Director Claire Magone reports on her field visit (27 July)

Claire Magone spent several days in Gaza and Nablus in July. The purpose of her visit was to clarify and refresh the challenges arising from MSF’s speaking out. Many discussions were held, not only with the teams but also with international, Palestinian and Israeli civil society organisations.

Since 2014 and Israeli offensive “Protective Edge”, MSF has communicated regularly on the impact of the Israeli occupation on the population. MSF was extremely vocal during the offensive itself, in its role as the first-hand witness and as one of only a few international organisations present at the time. Immediately after, Mego Terzian wrote an opinion piece calling for the lifting of the Israeli blockade. Then Jason Cone, executive director of MSF USA, wrote an article entitled “Aiding & Abetting? The Limits of Humanitarian Aid in the Occupied Palestinian Territories” in which he questioned the “support” provided by humanitarian organisations to the occupying power. In 2015, one year after “Protective Edge”, MSF joined those condemning the toll of the occupation and the stranglehold endured by Palestinians for the past 50 years.

The multimedia installation “In Between Wars” enabled visitors to immerse themselves in the lives of Palestinians through a life-size reconstitution of where they live accompanied by sound and video recordings of patients and colleagues. Presented in Paris in 2015, the installation was a source of controversy both within and outside MSF. Later put on show in Amman and Dubai, it did not make it as initially planned to New York or any other European cities.

The situation of Gaza’s population has continued to deteriorate since the imposition by Israel of its blockade 10 years ago. This is compounded by the Palestinian Authority’s attempts to exert pressure on Hamas to discredit it in the eyes of the population. The Palestinian Authority has thus announced that it will no longer pay Gaza’s electricity bill to the Israeli government. The Israeli government has therefore drastically reduced its supply of electricity and taken on the role of a mere agent of this decision, thereby erasing its prime responsibility for 10 years of rationing in the enclave. The people of Gaza have just 3 hours of electricity a day, which also impacts the provision of drinking water. Other measures introduced by the Palestinian Authority are equally detrimental to the population. These include huge pay-cuts in salaries paid to civil servants—many of whom are health sector workers— in Gaza. More retaliatory measures are to come, with around 6,000 of these workers to be compulsorily retired. Gazan Palestinians are virtually prisoners (travel outside Gaza now amounts to 2% of what it was in 2000) as all applications to leave the territory, including for medical reasons, are subject to approval by Israel, which can block them without explanation. The only other way out is the crossing point to Egypt, which is open only sporadically and to no particular schedule. The health system is increasingly ill-adapted as doctor, nurse and bed ratios decrease with the continued growth in population and training standards fall due to the lack of interaction with the outside world.

In Gaza, MSF treats 600 burn patients every month and holds surgery campaigns for trauma and burn patients in Shifa hospital. One issue the MSF team has to contend with is pain management, particularly among children who represent the majority of the patients we see in our clinics. We are now unable to use effective painkillers, such as morphine, as Hamas prohibits us from using it. The team has decided to tackle this problem head on by addressing it during discussions with medical staff and the Gaza authorities within the next few months.

In the West Bank, Palestinians are no longer able to move freely from one zone to another as Israeli settlements have expanded to encircle the places where they live. They must, therefore, apply for and obtain authorisation from the Israeli authorities to move around—the 101 different types of travel permits imposed on Palestinians illustrate only too well the difficulties they have to face. In Nablus, MSF runs a programme of psychological support in an area where people’s lives are partially governed, not only by Israeli army incursions but also by search operations targeting alleged Hamas sympathisers ordered by the Palestinian Authority.

Against this background, the propaganda war waged between Hamas, the Palestinian Authority and Israel is omnipresent and manifest in high levels of intolerance to criticism. In the West Bank the Palestinian Authority blocks Internet news sites it deems biased while Israel threatens and intimidates representatives of Palestinian and Israeli civil society organisations. We were able to meet two such organisations, Betselem and Breaking the Silence. They continue to document and condemn human rights violations committed by the army and Israeli settlers. Their target is Israeli, but more particularly international public opinion, and their objective to upset the “cost” (electoral, image, international respectability)/benefit ratio of pursuing the occupation to its detriment.

Concerning MSF, while we must take a position regarding the human toll of the occupation, we must take care not to exceed our remit—that of one of the few organisations on the ground (and as such first-hand witnesses to the de facto occupation of Gaza) whose word has credence on the international stage. In our public communications, we must enhance our description of the daily lives of Palestinians and their environment, notably medical, without automatically seeking to link this description to the occupation. Above all, we must not let ourselves be intimidated by the “normalisation” argument that condemns as a matter of principle all interaction with Israeli society on the pretext that these interactions contribute to perpetuating the occupation.