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	Simply put MSF provides care to people who need it most by Medecins Sans Frontieres/Doctors without Borders   February 2016   F**k you, Ebola, by Benjamin Black   Months of talking, over a year of reflecting, and finally on Wednesday 6 January we entered officially into Magburaka Government Hospital working alongside the Ministry of Health, immediately boosting the clinical teams in maternity and paediatrics and supporting their life-saving activities.   Our international presence is small, but we are highly motivated and fortunate to have developed a strong relationship with our Sierra Leonean colleagues.   There are many events I will remember from that first weekend: introducing new team members to those who have been in the hospital for years, trying to maintain a culture of training, and encouraging experienced staff to mentor those who are newly qualified.   I will also remember the first of three newborn babies to present with neonatal tetanus, watching his tiny face scrunch-up in pain as his muscles uncontrollably contracted, our presence enabling the hospital to deliver medicine, analgesia and care for him.   In maternity the ambulances kept coming, sometimes two patients squeezed in the back together, often with long and complicated labours. There were several women with ruptured uteruses, one needing an emergency hysterectomy, a teenager in labour for days, who subsequently developed a fistula and a woman who came with a massive placental abruption, a haemoglobin of four and needed emergency surgery. We also had to call in extra help into the hospital at night to stabilise one patient whilst we operated on another. I will remember too, that no woman died.   That first weekend will stay etched in all our memories, not only for the patients we saw but for those we didn’t see too.   Whilst we were busy in the operating theatre with a 16-year-old girl whose body was fighting with her unborn stillborn child, a 22-year-old woman came to visit the outpatients.   The woman had travelled from another part of the country, she presented with vague and general symptoms. She was seen by Ministry of Health staff, sent for some tests, and went home.   She died three days later at a family home in Magburaka and then had a traditional burial. As with all deaths in the country she was swabbed for Ebola before burial.   Thursday evening we gathered together for a team meeting, the mood was good. One week into the project and the teams were working-out well. We made a brief toast as the WHO was due to finally announce the Ebola outbreak in West Africa over.   We first heard rumours that the swab was positive approximately 10 minutes later.   Imagine, suddenly you are no longer just in a hospital in Africa; you are at the centre of the world and everyone is watching your next move.   There are few of us in the project who were here during the peak of the outbreak, a time of huge loss and heartbreaking sights. Paranoia swept through the minds of whole societies, the loss of rationality and massive increases in mortality.   When Ebola first visited back in 2014 no-one knew what to expect, and though we tried to withstand the force of the disease and find ways to keep going, it was ultimately stronger than us.   Closing the maternal and child health project back then was the safest decision, given the uncontrolled situation, but still remains a painful one for many of us. It is also that experience that kept so many of us returning during the outbreak, and talking, arguing and pushing for the need to create a project that was set-up to withstand another outbreak.   Turns out the test was on our own doorstep, less than a week from opening.   The rumour mill in Sierra Leone is incredible, knowing who to ask can get you information much earlier than official announcements.   At 5am the next morning a small group of us got up and quietly left for the hospital in the dark. The confirmation had not yet come, but all the town knew.   We made our way from ward to ward, checking on every single patient, regardless of whether they were part of the MSF project or not. We talked to all the staff, ensuring there was sufficient protective equipment, hand washing and observations for any worrying signs.   We re-traced the flow of patients through the hospital and put plans in place for isolation facilities. We already had a tent at the front gate, this was expanded and teams were put together in case any cases would need isolating.   Pregnant women and children are especially challenging groups in an Ebola outbreak setting, lessons of the past kicked into action. Separate isolation areas, thought out according to their needs, were quickly discussed and set-up. Before the sun had risen, before the world was told, we were there preparing and implementing. This time we were not going to be behind Ebola, we were putting up defenses and we were getting ready to fight. Three words we all knew, “F**k You, Ebola.”   The challenges though were the same. I previously wrote that Ebola is more than a disease, it is a state of mind. The pressure to “catch” patients is huge, and soon everyone is guilty till proven innocent. The outcome being many (mostly pregnant women and children) dying for nothing other than seeking healthcare.   Prior to this case we were screening all patients for signs that could indicate the disease, however this is a fine art and an even finer balance between help and harm. The definition of Ebola suspicion changes according to the context you are working in, the non-outbreak setting accepts that most people will not have Ebola and focuses on non-response to treatment.   However, once a case is confirmed the definition reverts to outbreak, which is wide and general, and if not carefully applied with scrutiny of patients and their symptoms, can result in the unnecessary isolation of many sick (and easily treatable) conditions. We carefully question each patient, and use universal precautions for everyone. But this takes time, and can lead to delays in treatment.   When the official announcement finally came it was of no surprise to any of us. The reactions were mixed, some were thoughtful, lost in their memories of the past, others were motivated and pumped for action, and some just philosophically took it onboard and then continued with business as usual.   I had assumed our fledgling project would suffer and that new staff would not come to work, I was wrong. Everyone came, and the team has stood taller and stronger than I would have ever dared to expect.   The decision to isolate a patient carries huge responsibility. Labelling them with Ebola, treating them in a tent and only whilst wearing the restrictive protective suits. It is vital to interrogate the patient’s condition so that a safe and rational decision is taken. Many of us have found that continuing non-Ebola healthcare is the most difficult aspect of working in an Ebola outbreak.   On Saturday, I had just come home for a break when I was called; there was a difficult case at the screening tent. I returned to find the team struggling with an isolation decision. A nine-year-old girl had been brought by her mother with a high fever, weakness, difficulty breathing and not eating.   This meant she had enough symptoms to meet outbreak case definition. The girl was visibly very sick, most probably with severe malaria, in her critical condition isolating her would limit the care she could receive.   If we did not isolate her though we would be risking a very precarious situation. We questioned the mother again, she sat across the orange plastic fence from us with her daughter in her lap. Lovingly supporting her head she looked at us, the defendant facing the judge and jury. We searched for a way to justify the decision, but we knew we were cornered. Together we agreed to isolate her and then immediately begin resuscitation, intensive antimalarial and broad antibiotic treatment.   Ebola demands speed control, nothing happens fast. As we got prepared to isolate, putting the protective clothing on, the girl’s breathing slowed, then stopped.   The mother still sat opposite us with her daughter in her lap, face-to-face with us and our decision. We could not touch her, we could only throw a cloth over for her to wrap her daughter’s body as she murmured and sobbed. The child had been labelled a suspect and we needed to maintain cool clinical management. The body had to be treated as if Ebola positive and the whole area decontaminated. The posthumous test was negative.   Ebola is a cruel disease, not only for the illness it causes but for the collateral damage it forces us to be a part of and bear witness to.   The tests of conscience, ethics and clinical judgement kept coming. Each one we discussed and relied not only on the proforma in front of us, but on our professional acumen and personal experiences. There is no perfect, but there is being human and trying to do the best that can be done in a far from perfect situation.   Early Wednesday morning news came that a woman who had cared for the person with Ebola was going to be sent to us for assessment. We had been expecting that sooner or later contacts of the first case might develop symptoms.   The challenge would be making sure she could be assessed and cared for, whilst maintaining normal hospital services. In the previous outbreak we saw the number of patients at the hospital dwindle whenever a case was suspected, that has not happened this time. Maternity and paediatrics remain busy, emergency cases continue to come and care is being safely delivered.   We managed to discreetly admit her into isolation, away from prying eyes and far from other patients. There are some characteristics to Ebola infection, a certain way of moving, a look in the eyes and lethargy. They can be subtle, but they are also recognisable. The test was taken, but we already knew what the result would be.   The concept of the project was now being truly tested. Isolating the only suspect Ebola case in all of West Africa, while running busy general healthcare.   A woman with twins was in labour, but they were not coming. She had been injected in the community with a high dose of oxytocin, a common problem often resulting in ruptured uterus. The twins were “locked” together, a rare complication that put all three of their lives at imminent risk.   Together as a team we rapidly got her to theatre and delivered the babies, all three of them alive and now safely home. In-between managing the screening and isolation we continued to see ambulance after ambulance come.   The woman tested positive, we mobilised counsellors to get the news to her before the local gossip spread. We then transferred her to the referral centre in Freetown that evening. The day was not over though. Three more maternity ambulances arrived; obstructed labour, severe eclampsia showing life threatening signs of organ failure and then another woman with a ruptured uterus.   Isolating and testing for Ebola, whilst a stone throw away we continue to perform emergency surgery, resuscitate mothers and babies in the country with highest mortality figures in the world. That’s right; “F**k You, Ebola.”   Despite being the last place with an Ebola outbreak, we are seeing an increase in patients. The opposite of what was experienced the last time around.   More women are coming to stay at the end of pregnancy to wait for a safe delivery than ever before, word has gotten out that Magburaka Government Hospital offers quality care, and we (a partnership of Ministry of Health and MSF) do so with pride.   Late on Friday night three of those waiting went into labour, one woman from a remote village birthed twins, another had her eleventh child. The third woman, a 25-year-old in her seventh pregnancy, had no living children.   She had cried with fear, afraid to push in case history returned again. United we supported her, gently coaching her through. The baby came with cord tightly round the neck, calmly and quietly we helped him breathe. The girl then had a massive haemorrhage. We got her to the operating theatre, eventually managing to stop the bleeding.   If there is any symbol of this last two weeks it is the image of this short woman looking contently at her healthy boy, being cared for in the proud arms of his grandmother.   The ability to respond from within our own team, alongside the professionalism and resilience of our colleagues has turned the dream into a reality.   We have seen what this horrible disease can do, and we are committed to not let it disrupt the vital services we are supporting the hospital to provide.   There was no emergency team, there was no influx of international staff or trucks of supplies. We have managed with what we have and who we have, the same as the day before and the same as tomorrow.   Ebola came and showed its ugly face again, but I am glad it came to where we are. Together, national and international we have stood firm.   One woman died from Ebola in the last month, but many lives were saved.   Calling myself an ''MSF midwife'', by Mara Evans   The principles of Medecins Sans Frontieres (MSF)/Doctors without Borders have always appealed to me. MSF is a non-profit organization offering independent, neutral and impartial medical and humanitarian assistance. Simply put MSF: provides care to people who need it most by working in places of conflict and emergency giving medical care to populations facing violence, epidemics, natural disasters, or displacement.   The people MSF cares for may be the people who need help the most. I’ve known for a long time I’ve wanted to volunteer with MSF. After waiting for an assignment, attending several briefings, wrestling my belongings into an overstuffed backpack, and then saying goodbye to dear friends, family, and supportive fiancé I am finally officially part of the MSF movement.   Agok, is in the disputed Abyei Special Administrative Area located between South Sudan - the world’s newest and perhaps poorest country, and Sudan - the country from which it gained independence in 2011.   Stepping off the plane I am enveloped in a hot cloud of the ever present dry red dust of this place. The dust blankets everything.   There is no airport in Agok, the landing strip is one and a half football field length of cleared flat dirt dotted with a few brave or naïve goats. The plane only lands to refuel and exchange passengers before making its way back to bigger cities.   I am whisked off by my new colleagues in the back of a Land Cruiser traveling the dirt roads past Tukuls, a mud walled hut topped with a round roof of dried grass which comes to a peak at the center. Children wave as we pass. The men and women are tall people with a physical and emotional strength that comes from living a hard life.   The MSF Hospital is a large project, providing secondary health care to many. Some walk many hours to reach the hospital as there are little other options for care in the area. Others may wait until their somewhat stable condition deteriorates to an emergency before deciding to make the journey.   The hospital is free to patients, who bring their own bed sheets, and one care taker. In the maternity ward the caretakers are often patient’s mothers, sisters, or sister-wives. It is rare to see a husband accompany a laboring women in to the hospital, and never is the husband present during the birth.   MSF provides meals to the patient and the caretaker, showers and latrines are also available for their use.   The wards are made of platform tents or brick buildings with corrugated tin roofs. Ceiling fans turn slowly, but do little to suppress the heat which can cause fevers to spike come mid-afternoon. The mosquito-netted beds line up side by side down the length of the ward and are often fully occupied.   Staff who are not from Agok, live next door to the hospital in a compound. The nearness of the living quarters allow quick access to the hospital if there is an emergency.   This small village of Tukuls houses expatriates from France, Germany, Iraq, England, Japan, Spain, Switzerland, Kenya, Nigeria, the United States and others.   Humans are not the only ones sharing this compound, half a dozen cats, one naughty puppy, and a goat named Mr. Brandon also live here providing insect control, entertainment and companionship.   Often a flock of vultures or other large loud mouthed birds cruise the skies above. Caution must be taken if food is eaten outside as these birds have been known to swoop down and disrupt plates of spaghetti, or snatch whole apples mid bite.   The shared latrines are of the standing model and can take some time, skill, and thigh muscle to master. Communal showers provide cool relief at the end of a long shift, no one seems to mind the cold temperature as often the weather here is above 100 degrees Fahrenheit at noon. Living close to the equator, night falls early and the stars are vividly bright.   For the next six months I will be working side by side with colleagues from around the world, observing how access to basic medical care can change an entire region, and learning how to practice midwifery in a low resource setting.   Most of all, I look forward to being an active part of this organization and its reputable principles, and being able to call myself an ''MSF midwife''.   http://blogs.msf.org/en/staff/blog-posts Visit the related web page
	Corporal punishment in schools linked with poor outcomes for children by UNICEF Office of Research – Innocenti   Corporal punishment in schools linked with poor outcomes for children   For the first time, using data from low and middle-income countries, researchers have shown a link between schoolchildren experiencing corporal punishment and later test scores.   A new study produced by the Young Lives Longitudinal Study on Childhood Poverty, found that corporal punishment experienced by eight-year-old children is linked with lower maths scores when the same children reach the age of 12, as compared with their peers who did not report being hit. The research also reveals that boys and poorer children were the most likely to report being struck by their teachers.   The research was commissioned and published by the UNICEF Office of Research – Innocenti, as part of its Multi-Country Study on the Drivers of Violence Affecting Children.   In India, Vietnam and Peru, researchers found that children who reported experiencing corporal punishment when they were eight were associated with lower maths scores even after controlling for a range of child and household characteristics and when comparing children in the same community.   Examining the same children’s test scores at the age of 12 showed that corporal punishment was associated with a negative effect equivalent to that of having a mother with between three to six years less schooling (depending on the country) than their peers. It is widely accepted that a mother’s education has a strong influence on her children’s educational attainment.   In Ethiopia, while there was still a negative link between corporal punishment and test scores, the researchers found it was not significant, which may be related to much lower typical test scores in general in Ethiopia.   Young Lives lead researcher Kirrily Pells said: “Previous studies have found negative consequences associated with corporal punishment, including students being absent and feeling scared and confused. What’s new is that our results suggest that corporal punishment has a lasting impact on children’s education. Since poorer children are more likely to be hit that reinforces educational disadvantages.”   According to Catherine Maternowska, coordinator of the UNICEF’s global research on the drivers of violence affecting children at the Office of Research—Innocenti: “Because Young Lives measures children’s outcomes at multiple points in time, throughout their life course, the data is powerful in suggesting when, where and how risk factors manifest in children’s lives. Linking early experiences of violence to poor performance is a call for educational reform.”   Maternowska believes that the multi-country study powerful analysis will contribute to global, regional and national level dialogues and understanding of interventions on violence prevention.   The Young Lives data draws on surveys in Ethiopia, India, Peru and Vietnam. In India, nearly eight out of ten eight-year-old children interviewed by researchers said they had been hit in the last week. More than nine out of ten eight-year-old Indian children said they had seen someone else being struck in school that week.   In Peru and Vietnam, more than half of the eight-year-old children surveyed said they had seen someone else being hit in the school in the last week; one-third of eight-year-old children in Peru and one-fifth in Vietnam said they had been struck themselves in the week before the survey. Eight out of ten children in Ethiopia reported seeing corporal punishment being used in their school.   The children’s surveys show the reported incidence of corporal punishment among children at the age of eight was twice that of 15 year olds (in all four countries). Boys were significantly more likely than girls to say they had experienced corporal punishment. The study suggests that gender norms might play a part so hitting boys may be perceived as more acceptable by wider society in the countries studied. It adds that it is important to note that girls are often at greater risk of other forms of humiliating treatment and sexual violence, according to existing academic literature.   In all four countries greater efforts are needed to make school a safe place for children. Although corporal punishment is prohibited, a large gap exists between the law and the daily reality experienced by many children. Greater attention is required to addressing the barriers within schools systems that prevent such laws being implemented properly.   The study also suggests that supporting positive teaching practices while also pushing to further understand the social dynamics among teachers and school officials that favor the practice of corporal punishment is necessary. Safe practices must be promoted if we are to build safe, supportive environments for all children to flourish.   http://www.unicef-irc.org/article/1203/   Best of UNICEF Research 2015: Building an evidence culture   The Office of Research – Innocenti has just released the third edition of its annual publication Best of UNICEF Research 2015. With each edition learning about a key element in a global development organization’s effort to gather evidence increases.   Over the course of its existence Best of UNICEF Research has grown in terms of the quality of research represented, the range and complexity of research questions addressed and the geographic scope of the submissions.   Research is an essential part of UNICEF’s effort to improve the situation of the world’s children. Quality data gathering, appraisal and analysis can fuel informed decision making and planning, assess intervention impact, question practices and improve policy discourse.   Best of UNICEF Research is a vital tool for sharing quality research, recognizing excellence and identifying many useful lessons.   It provides short synopses of research projects that emerged from the year. These projects cover traditional and emerging programme areas. They range in geographic focus from global to regional to country level and cover a wide array of research questions, topics and approaches:   Reducing Newborn Deaths is a systematic assessment of bottlenecks to scaling up essential maternal and newborn healthcare in eight of the countries with the highest number of neonatal deaths.   Sanitation in Mali documents the use of a randomized control trial to assess the impact of the well-known “Community Led Total Sanitation” approach to reducing open defecation.   Early Childhood Development in East Asia and the Pacific is a multi-year evaluation effort across six countries to test the validity of a region-wide early childhood development scale which measures progress in seven development domains.   Emergency Preparedness conducts a rigorous return on investment analysis of emergency preparedness measures in Chad, Madagascar and Pakistan.   Child Poverty in South Africa analyzes a wide range of data sources to determine the extent to which children have been caught in poverty traps and recommends interventions to escape the cycle.   Food and Nutrition Policy presents a theory-based rapid assessment model for assessing a national government’s commitment to food and nutrition security.   Teacher Incentives in Namibia evaluates a scheme to attract qualified teachers to work in rural communities through the provision of financial incentives.   Violence in Serbian Schools is one of the largest school surveys ever conducted in that country and gathered data on context-relevant indicators of school violence.   Child Grants Lesotho evaluates unconditional cash transfers presenting evidence on a range of positive impacts and making specific policy recommendations.   Water and Health Worldwide is a global review to assess the validity of one of the most important indicators for safe drinking water evaluating data from 319 studies representing almost 100,000 water sources.   Violence Against Children in ASEAN Countries assesses the level of compliance of national legislation on violence against children in ten member countries in this sub-region.   http://www.unicef-irc.org/article/1193/ http://www.unicef-irc.org/article/1207/ http://transfer.cpc.unc.edu/?page_id=1094 http://transfer.cpc.unc.edu/?page_id=2 Visit the related web page
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