Moving forward: Bearing witness with communities caught in crisis

Avril Benoît: 
Welcome. Thank you for joining us for this final episode in a series that we've been bringing to you called Moving Forward. We started this four-part series in March, and we've been exploring how aid workers and humanitarians are tackling some of the world's most complex challenges today while preparing for the future emergencies. 

My name is Avril Benoît, and I'm the executive director of Doctors Without Borders, based in New York City. Our organization in various parts of the world goes by the international original name, which is Médecins Sans Frontières, and from that, we get the acronym that you will hear today, MSF. It means Doctors Without Borders in French. 

Today, we're going to be talking about some underreported humanitarian emergencies. Many of you have heard me speaking from Ukraine back in the spring. We have focused a lot on this work in the news. You see it every day. It's a place where obviously people are forced from home; they're struggling to access medical services, and we feel it's really important for us as a medical organization to be on the ground as the conflict escalates, as people have greater needs. To be able to respond is obviously important, and that's why we've tripled the size of our staffing there and we have invested quite a bit in logistical capacity to be able to pivot quickly and be responsive to newer and emerging places, crises, and reasons for interventions. That's something that you have probably heard a lot about, and many of you have supported our work in Ukraine. 

At the same time, of course, we work in 70 other countries with humanitarian operations. That's what we wanted to take some time today to focus in on, just to give you a bit of a spotlight on what we're seeing in those places because whether it's the international news and major calamities and all the things that make the headlines or what's happening domestically, locally, nationally, in politics and whatnot, that tends to suck all the air out of the room when it comes to news coverage. We know that you have an interest in other places that have great needs, and we really appreciate your support in allowing us to do this work. 

Today, we're going to be hearing how our teams are bearing witness, speaking out, and describing situations on the ground, specifically in Haiti, in Somalia, and in Pakistan. We have some great MSF experts with us today, and they can turn on their cameras as I introduce each one of them. They will be describing what they're seeing, and you can ask your questions to them directly. 

Just before I continue, here's how to ask your questions. This is a live webinar that will be recorded for later posting, but the discussion will run around 45 minutes. You have a chance, if you're watching here on Zoom, to submit a question in the Q&A function. You've also got the options on YouTube, LinkedIn, Twitch, to send your questions into the comments or the chat section, and they will be compiled and sent on to me, and I'll be happy to ask your questions. So please go for it. 

We also have the live captions for this event, and that's available on all the channels, so that if you can't turn on your volume, you can still follow along. Joining me today are Alexandre Michel. He is our communications officer for MSF, Médecins Sans Frontières, or Doctors Without Borders, joining us from Port-au-Prince in Haiti. Hello, Alexandre. 

We also have... 

Alexandre Michel: 
Hello, Avril. 

Avril Benoît: 
Great to have you with us, and I'm glad you're doing well. We also have Djoen Besselink, our MSF country representative, so this is one of the top positions for Somalia. He is connecting with us from Nairobi today. Hello Djoen.  

Djoen Besselink: 
Hello, Avril. Nice to see you. 

Avril Benoît: 
We also have Abdullah Shah, is a logistics advisor for MSF, supporting multiple countries. He is here to really help us understand what's happening on the ground in Pakistan. Hey, Abdullah. Good to have you with us today. 

We're going to hear from a number of perspectives, places, situations that maybe are not always in the news wherever you are, but I know that there's a lot of curiosity about this work. Maybe we could start with you, Djoen, to describe the kind of work that MSF is doing in Somalia. Why are we intervening there at this point in time? 
Djoen Besselink: 

Yes. Thank you, Avril, and very nice to be here and so happy to see so many people joining us. Somalia is one of the countries where we've been the longest, almost 50 years. Almost as long as we exist, we've been in Somalia. One of the first countries where we have teams on ground. Actually, ever since we've been here, with a very short period where we left for a few years, but the needs are so extremely high in this country that we always felt the extreme urge to be present. 

At this moment, well, we have been running malnutrition, cholera, and measles, which are very much linked to the recent drought that you would consider started in October, 2021, and really had a heavy impact on the people and the communities here. I would actually describe it as another layer on top of the crisis, what is already in Somalia for many decades. There's a conflict going on many different levels. We see that the access to healthcare is extremely challenging. It's difficult for people to reach the hospitals where there are even enough hospitals and staff. Then on top of that, you had several droughts in the last 12 years. I think the one that we see now that's really for failed rainy season since last year is an extremely heavy impact on the population and thereby make it extremely necessary that Doctors Without Borders is indeed present in six locations all across Somalia. 

Avril Benoît: 
Somalia is a place with tremendous security risks, and this is also the case in Haiti, especially in the capital at the moment, and that for the last few years it's been extreme levels of violence. Alexandre, can you describe what MSF is doing in Haiti? 

Alexandre Michel: 
Currently in Haiti, as my colleague mentioned, that MSF is present in Haiti since 30 years. Actually, we have a sexual violence, gender-based project, trauma project and sexual and reproductive health for women. We have seven health facilities across the country, and we are currently participating in a response to cholera. 

For those security issue, I would say that since the things are getting steadily deteriorating in Haiti since 2018. As I speak, the situation in Haiti can be summarized in seven point: no, school doors are closed; gangs have surrounded the metropolitan area of Port-au-Prince; there is an increase of kidnappings and assassinations; the government is silent; the superior council of the national police is nonexistence; and there is also an exponential increase in the price of transportation and necessities. As the need for healthcare outgrowing or increase, why MSF has to, I would say, also increase the scale of our capacities to give response to those needs. Our supply chain are facing great challenges in the current situation in Haiti. 

Avril Benoît: 
Well, and that's very much your area, isn't it, Abdullah? As somebody responsible for logistics, bringing in the supplies into a country that was so affected by the floods this year is a tremendous challenge. Can you describe what MSF is doing in Pakistan these days? 

Abdullah Shah: 
Thanks, Avril. Hi, everyone. Glad to be here with you today. MSF has been in Pakistan since the 1980s. MSF has primarily engaged in access to healthcare-related issues, primarily focusing on sexual reproductive health, pediatric health in Pakistan. Over the years, MSF has also branched into other areas where there have been gaps in the healthcare system and working with the Ministry of Health to cover some of those gaps. For example, MSF in Pakistan is running cutaneous leishmaniasis programs for the last several years and also has started a Hepatitis C program in Pakistan as well. 

What MSF is doing right now to the floods, is that in August floods have inundated a country covering upwards of 30% of the land mass in the country. Much of that have been affected by the flood is where MSF has already been providing healthcare services to communities there locally prior to the flooding. Since the flood, MSF has also jumped into the first responder role just because we were co-located with the communities and our staff and our colleagues were also affected by the ongoing flood. 

Avril Benoît: 
It's sometimes in volatile areas, too. For all of the work that we're doing in these three areas that we're focused on today, there's a tremendous burden of responsibility to not only meet the medical needs of people, but to do so in a way that allows staff to work safely and for patients to reach the medical facilities safely. 

Djoen, let's come back to you for Somalia. How do we work and conduct ourselves in an area that is so volatile at times, where peaks of violence come and go and where there can be very direct threats to the providers of medical care? 

Djoen Besselink: 
Yes. A very good question, and unfortunately also a very difficult one. Somalia is indeed, it's described by, I would say, multiple levels of violence, where there's international violence or there's internal actors on ground, international armed actors fighting indeed non-state armed groups within the borders of the country. But it's also a country that has seen a lot of historical communal violence. There's different clans that are indeed fighting each other, often and over resources. In a country where resources are extremely scarce, this can be extremely heavy in times. The challenge there is that as MSF, well, we're an outsider, we're not clan based. 

Avril Benoît: 
I don't know if it's just me, it froze for a minute there with you, Djoen. Others are also catching that? All right. We'll let Djoen reconnect, hopefully, and take it back to you, then, Abdullah, because we do have a question here from Louise. She's asking, related, how MSF works with governments in those particularly sensitive contexts. For example, she mentions the Taliban in Afghanistan or the Houthis in Yemen. In Pakistan, you've got obviously a very strong government, strong authorities. So how does MSF approach that when you've got forces of authority and leadership that are considered quite sensitive to be working alongside, working in support of? 

Abdullah Shah: 
Yeah. Thank you for the question, Louise. That's a very good question. I think for MSF, our approach, in whichever country or context that we work within, we want to work with local healthcare partners. The role of MSF is not to go and run a parallel system to the ministry of health. Within specific relationship to Pakistan, all of the MSF healthcare facilities that MSF runs inside Pakistan are co-located within the Ministry of Health facilities. 

So, we would go in, let's say, there is a hospital that we see a tertiary care or secondary care hospital or a primary healthcare center, even for that matter. After doing a needs assessment, if MSF feels that there's a gap in the services available, and then this is the gap where MSF would then develop a project proposal to go in and to try and reinforce that gap with the intention of one day handing over the services back to the Ministry of Health because that's within their mandate to deliver healthcare services. The role of MSF is to come in and to just do the capacity building or to do that immediate support or the emergency support as needed before moving on. 

Avril Benoît: 
Yeah. It's difficult, though, to try to negotiate that. I imagine Alexandre, it's similarly sensitive in Haiti where there are dozens of gangs controlling different neighborhoods or armed groups that are de facto in control, as you described, where the public health services are just not able to meet the challenges. How does MSF then negotiate our presence in a city like Port-au-Prince? 

Alexandre Michel: 
Oh. At Port-au-Prince, I do have to mention that we enjoy a great acceptance from the population and also the armed group and as we support the Ministry of Health also. So, sometimes it's really easy for us to run our activities, and there is no threat directly on MSF or on our staff because they are from MSF. MSF is one of the rare organization present in Haiti that the population knows that we are non-affiliated. So we are independent. The population knows that. 

I would say from the past and until now, where when there is road block, sometime the protestors open the barricade and let the MSF vehicles keep his way. But there is true challenge, I would say, because, yes, our car can go through the town, can get across the town when there is protests and so on, but our shipment at the port, we cannot reach to them. The patients who are our primary target cannot reach our health facilities when there is protests. I would say on a regular basis, we do have to share a press release to call to open the road, to let the patients come to the facilities, to open the road to give access and so on. These are our big challenge in the context. We are well known, well accepted, well respected, and so on. 

Avril Benoît: 
Yeah. That also highlights the important work that you do in communications. I know that you have a background, as I do, in journalism before coming into to MSF. Part of your work is to help patients understand where the help is available, where, for example, right now, cholera treatment is available and how they should go and seek help if they start to feel that they have the symptoms. 

We do have a question from Ken on Zoom, who's asking if you could please speak a bit more about how we're responding to this cholera outbreak. How bad is it and what are we really doing? The question of inoculations or vaccines against cholera, is that something that we're able to do right now? Just give us an overview of some of the work we're doing and the challenges, also, to getting supplies into the areas that need the most to respond to this outbreak. 

Alexandre Michel: 
Days after the confirmation by the Ministry of Health of the resurgence of cholera, so we've launched our emergency response and we were able to open five cholera treatment center that we call CTC, Cholera Treatment Center. Right now, I would say our figures talk about 303,500 cases. One of the biggest, I would say, challenge is that most of the people in the other area of Port-au-Prince, because the national roads are blocked at Martissant and other national road is also blocked in the north third of Port-au-Prince. People that are behind those road block cannot reach our facilities. For our response, we also were able to see that more than half of our patient, the suspect cases, are under 12 years old, and most of the case are coming from Cité Soleil, a famous neighborhood in the north of Port-au-Prince, and from Martissant, specifically from Cité Doleil d'enell. So, a place called like this. 

We can see that in the most of the case are on, I would say, the elite, the coastline of Port-au-Prince. Most of the major cases are coming from the coastline of Port-au-Prince neighborhood, which are on the coastline of Port-au-Prince. Also, in the Cité of Soleil, there is an also on, I would say, warning, I would say, thing is that there is some of the childrens that are coming in the CTC, the Cholera Treatment Center, they are malnourished child. So you have a malnourished children with cholera, who gets cholera. It's quite difficult. 

Also, about vaccination, so we had a conversation with our representative of Ministry of Health. It informed us that the vaccine, we do not have many dose for Haiti currently. I think they talk about, I would say, half of a million doses available for a country of 11 million person. So currently less, I would say, one month after the outbreak. We are actually at near to 4,000s person infected. 

Avril Benoît: 
Yeah. That would be a big issue for us to be speaking out on, bearing witness to, and constantly trying to drive home the message that people need more support on this. 
This brings me back to Djoen. Welcome back. I'm glad you were able to reconnect with the wobbly internet you might have there in Nairobi. Djoen, part of the reason that we convened all of you here is to help us understand some of the tensions that can arise when you're a medical responder and Médecins Sans Frontières or Doctors Without Borders, our primary role is medical humanitarian activity, saving lives, alleviating suffering. 

But we also have this aspect of our work, which is the bearing witness and speaking out occasionally. Where you're responsible for our operations in Somalia, very, very difficult place to work. Daniel is asking a question from our Zoom about how MSF balances this idea of speaking out, or in French we use the word témoignage, bearing witness, with the humanitarian principles that help ensure access to communities and when there are atrocities being committed. If we were to speak out about that, it can result in everything up to expulsion from that area of the country. How do you, as a country representative, as somebody responsible for those operations, balance the wanting to remain present with the wanting to decry, for example, atrocities? 

Djoen Besselink: 
Ah, thank you. Thank you for the question. I'm glad to be back. Indeed. Well, I would say that that is one of the daily challenges that we have. It's a choice that's made on different things that you throw in the balance, as you mentioned, indeed, it's our core. Well, we don't have a mandate; we're not mandated by anyone. We have our charter, how we operate. One of them is indeed the provision of medical care, and the other is indeed witnessing and speaking out of what we see. 

Somehow, witnessing can be just as simple as actually sharing a story of a patient, by really showing what is the impact of an outbreak or violence on a family that lives in Somalia. In Somalia, the challenge with speaking out, and I'm sad I lost you there before, I was describing a bit the different layers of complexity and violence that you see in Somalia. So international violence, but also a lot of communal violence. There's a lot of violence between different clans and different projects where we operate. We are perfectly vigilant. It's a extremely dangerous place to be, especially for outsiders that are not used to the context or are not Somali. In that case, if you want to speak out about what you see, you might actually... How do I describe? Hit one group or the other in the head and really create a friction which would put your staff at risk and thereby endanger your project. 

So when you speak out, often we also have to realize as MSF and Doctors Without Borders, what is the impact of this? For me and also for our doctors, we really want to oftenly go back to what is best for our patients, what's best for the people that come to our facilities and what's in their best interest. In this case, it's very often it's very powerful to show what does hunger mean for someone living in Somalia, or what does it mean to have measles? I'm also very lucky that I have actually a story of one of my colleagues; he's a doctor in one of our projects. This is a very good example of speaking out that in this case doesn't endanger our program, but it's very powerful because it describes what does it mean to be in a place where there's such a high malnutrition. So, I was hoping maybe I can show you that video for it for a few seconds and then... 

Avril Benoît: 
Okay. We'll take a look now. 

Speaker 5: 
We are seeing in our facilities, patients with different needs, with infectious diseases, with malnutrition, with cholera. So, we are responding to many different basic health issues that the community now are facing. 

I remember that we admitted a mother and her child. The child is admitted into the ITFC program in very general hospital with malnutrition, and the mother is admitted in with measles. The child died two days after the admission, and the mother also died in our facility one day after her child's death. It was a tragedy to the whole family that were four when they come and lost two of them because of measles and malnutrition needs. 

The most striking part of treating or running this malnutrition response is that when you see 900 plus cases in a week and also find that 80% of them admitted to the program, this really tells you the level of the malnutrition in the community, especially in the children. It tells you also how the population are suffering from food insecurity and the drought as well. 

Avril Benoît: 
Yeah. A great example there of somebody bearing witness, describing what they see, and yet not taking sides, not pointing fingers, necessarily. But of course sometimes we have to denounce and we have to take stronger positions. Abdullah, you have experience of this even in the logistics world that you're in, where sometimes things are just not getting unblocked, and we are trying to respond; we're trying to move medical supplies into a country or to the right location within a country. Can you give us an example in Pakistan or in your work, more broadly speaking, even in other countries, of times when you or the team and logistics has actually had to speak out? 

Abdullah Shah: 
Yeah. Maybe I can use the example of Pakistan right now. So far, MSF has shipped close to 350 tons of humanitarian relief supplies into Pakistan. The one thing I will note is that the government of Pakistan was very quick acting and forthcoming at the beginning of the current floods. They opened up the importation channels for humanitarian cargoes to be able to come into the country and to be expedited, to be cleared through the country. 

I can use the same example for within Pakistan, during 2019-2020, MSF was not able to import humanitarian relief goods for several months at a time related to bureaucratic issues. So during that period, MSF had to scale back medical activities, where we basically just could not run our operational programs anymore because of the inability to import medical relief cargoes into the country. It was at that time where the MSF country representative, we went and we lobbied the government. We said that for us to be able to actually be able to deliver life-saving services within the country, we need to be able to import goods into the country. So that's been one case. 

For the current response with Pakistan, it's actually really, really interesting. As I said, we have about 350 tons of relief cargoes that have been flown into the country. We easily have another 200-300 tons that's waiting somewhere within our different warehouses across the world to be able to fly in. The challenge we're having right now at a network level is that there's a lack of availability of air freight capacity within the world, especially within flights that are originating from the Middle East coming into Pakistan. A big reason for that is that the upcoming FIFA World Cup has greatly affected the availability of air freight services being offered. For example, we traditionally use Qatar Airways to fly in our cargo. We're not able to use Qatar Airways. So that's a very concrete outcome that's impacting our response within Pakistan. So, we're trying to find other flights. 

Up until last weekend, we had to charter a flight to fly in 50 tons of relief goods because we, essentially, even with the current emergency response, we were not able to sustain it. We had to cut back response activities because of the inability to be able to bring in the goods. Oftentimes, we find sometimes the challenge can be the government or with the government authorities, but sometimes we're also finding now that it's also challenging to be able to physically move the goods from one part of the world to another part. So, it's an ongoing challenge and we've seen both parts of it inside Pakistan over the last two years. 

Avril Benoît: 
Yeah. In situations like that, we just have to be very tenacious advocates, starting with bilateral behind-the-scenes discussions, and then maybe escalating if things are not unblocking, into a more public positioning or political positioning that we can relay to the broader world. 
Alexandre, I have a good question for you. We're always trying to work independently with our own assessments, but at the same time, we are a partner with local communities, with often the health authorities, the ministries of health, departments of health and whatnot. That is our local partner in many, many instances. We have a question from Dalia on Zoom, who's asking how does MSF collaborate with other health organizations, NGOs, non-governmental organizations in the countries or community groups that are focused on health? Can you describe how we do that in Haiti? 

Alexandre Michel: 
Most of the time, we can be self-sufficient while we are working, but we keep sharing our figures and our assessment with them. While we are working in an area, if there is a need for some specific care that we cannot provide, we have a recruitment, I would say, called Cadre de Liaison Inter-ONG, so Inter-NGO, I would say. It's a place where the non-government organization can sit together and speak about the situation and so on during those meetings so we can share this with the partners. As I mentioned a few while ago, months, like at the beginning of our response to the cholera outbreak, we receive donations from OMS and UNICEF to be- 

Avril Benoît: 
Yep. OMS being the World Health Organization. 

Alexandre Michel: 
Yeah. The world... Yeah. As you mentioned, as you said. Also, UNICEF, the United Nation fund for children. That allows us to start our response while our shipment were blocked at the port. We do not want projects together with other NGOs. But we work projects alongside of the Ministry of Health, like at Port-à-Piment, where we have a sexual and reproductive health project. So, we are running this project in the building of the Ministry of Health before the earthquake of August 2021. 

Yeah. This is an example of how we collaborate, or we are working with them. But also, we also have challenge because in the cholera outbreak, like two weeks ago, we had to share a press release without our figures about the cholera infections cases, received cases because the figures, the numbers shared by the Ministry of Health were lower than ours. So, we weren't able to share our true numbers because we were in negotiation with them to open a new CTC, to open a new emergency center in Kafu and a new cholera treatment center in Del Montatoi. So in order to not make them angry, we do have to share the press release without the figures. It's quite, I would say, sometimes easy, but there is peak in high and low, I would say. 

Avril Benoît: 
Yeah. There is sometimes some compromise, never on the facts, but sometimes on the number of details that we might include. 

Alexandre Michel: 
Number of details. Yeah. 

Avril Benoît: 
Hey, I'd like to ask, just to switch topics a little bit. We're getting in several questions from those who are watching us live around vaccination, specifically because we've mentioned cholera and measles vaccination over the course of this discussion. I'd like to hear from all of you on this, if you don't mind, and maybe starting with you, Alexandre. When MSF coordinates a vaccination campaign, and we tried with COVID, even, to bring vaccines into the country for health workers primarily, as a priority. Are people where you're working typically accepting of vaccines these days? Or are MSF teams facing this phenomenon that's called vaccine hesitancy? Is that something that you see? And we'll start maybe with you, Alexandre, and then go to Djoen. 

Alexandre Michel: 
Yeah. This vaccine hesitancy is also a challenge here in Haiti. Even health workers didn't want to take it. We are currently talking about the vaccine for cholera, and also at the communication department is one of our challenge, how we will phrase this to sensibilities, sensibilities people to accept it because it's not something new. So, decades before this vaccine, existence hesitancy was there. It's still the case today. 

Avril Benoît: 
Yeah. Djoen, what are you seeing in Somalia with respect to acceptance of the importance of vaccines to save lives? 

Djoen Besselink: 
Well, we had certain moments where I think, like any other country, there was some mis- and disinformation going around in communities where there were rumors that you would get actually sick or different ones. One of a very important component of our work is actually our health promotion. We have people that are constantly in touch with the communities, hear their concerns, and then feeding that back into right health messaging and really trying to address the questions and the challenges. 

After that, we actually noticed that it's quite well accepted. If you consider Somalia is also the country where we have one of the biggest measles outbreaks in the world. We saw more than 5,000 children this year alone, where in any other country in the world where you see two cases, there's an outbreak declaration. In Somalia, we treated 5,000 children. So, people are very well aware with these health promote messages that indeed vaccination to measles is the only way to eradicate this. We've seen during our measles vaccinations that it's quite well accepted. Unfortunately, in Somalia, we had to vaccinate even older ages than children for measles because it's such a low immunization level, let's say. People are very well aware of the impact of not being vaccinated. So, we were quite well received there, I would say. 

Avril Benoît: 
And how about in Pakistan, Abdullah?

 
Abdullah Shah: 
Yeah. I can see from my personal experience working in Pakistan with MSF, I think what Djoen and Alexandre both said, I think a lot of our communication, the health-seeking messaging that we pass on is through community engagement. We have teams that do nothing but community engagement. We have teams that very thoughtfully interact with our patients as they're accessing our healthcare facilities. We have teams that go out into the community to relay messaging. So, that's the one thing. 

Second thing, what we've done in Pakistan is we've held open houses for local community leaders to be able to come in and so they actually understand what MSF is doing, what services MSF is providing within their communities, but at the same time, to pass on some of the key messages around vaccination and the effectiveness of vaccination. 

I know from my personal experience, we've had measles outbreaks in several of the projects when I was working inside Pakistan. It was quite straightforward for us. If we have a outbreak, we actually see where the outbreak is happening and then we go in and we support the local community in doing the vaccination services. 

But in general, yes, there's a lot of disinformation out there. I think everyone's impacted by that. But what I've seen within MSF is that there's really a strong focus on the community engagement and the engagement with the purpose to pass on a lot of these messages that help us reinforce the services that we offer. 

Avril Benoît: 
All right. That's really good to understand how we put those things together in order to increase the acceptance. A completely different question now for you, and this one is coming from Michael, who sent it in during the registration period. When people hear us talk about humanitarian work, often their first thought is, "Wow, that sounds incredibly stressful." I can confirm after 16 years in this work that they are right. It is very stressful work. Michael's question is, how do you deal with the stress of working in a dangerous climate? Barbara was also wanting to know how do you de-stress? 

Now, this is something that has very much been on our minds for Haiti because we know our staff risk their lives just going to work and coming home from work every single day just because of all the insecurity in Port-au-Prince. Alexandre, can you tell Michael how you deal with the stress of working in a dangerous place and how you de-stress? 

Alexandre Michel: 
There is no specific words to really describe what we are currently facing in Haiti. As a personal experience, I was born and I grew up at Kafur, a city in the south of Port-au-Prince, a beautiful city, a beautiful city. In the last 12 months, I had to move three time because of insecurity. As you mentioned, on a daily basis while I was living at Kafur, so I had to take the bus to come here to the office while I was listening to gun shots in the morning and in the afternoon. I had to move because of the progression of the armed group, and the front line comes so close that at the moment that we are speaking, people are getting wounded by stray bullets in my neighborhood. The last week we had like four, one dead because of stray bullets. 

Currently, as I mentioned, I moved to a second place at Patonville, a neighborhood which has the reputation of a safe place. Four months later, I had to move again to the mountains, Tumase, still because of the insecurity. Two weeks before, an armed group showed up a police precinct at five minutes from my home. I would say there is no word to describe that. 
While we are speaking, in the majority of the neighborhood in Port-au-Prince, you cannot let your kid play outside because of stray bullets. We have dozens of people who came to our health facilities who has been wounded by a stray bullet while they were in bed inside of their house. When you leave your house to go to work, as soon as it's getting, I would say, 4:00 or 5:00 o'clock, so you are on a hurry to go back home in order to reach what you can consider as a safe place because of those streets are really dangerous. You can get shot at any moment by a stray bullet or you can be the target of an armed group. 

There is a lot of things to say, like the national ward number two, on a daily basis, on a daily basis people get hurt or get killed since the 3rd of June of 2021. Until now, they keep going. 
To de-stress, I will spend quality time with the family. You cannot go out. You cannot go to the movie. You cannot go to a restaurant. So, working and living in Haiti's quite hard, living in Port-au-Prince, because not all Haiti, but the metropolitan area of Port-au-Prince where MSF has the majority of its operations and capacities is really dangerous. 

Avril Benoît: 
Yeah. So, for you, spending time with your family. 

Alexandre Michel: 
Yeah. 

Avril Benoît: 
Quality time. That's the de-stress formula for you. Well, my heart, I think we're all listening to this with a tremendous amount of compassion for what our colleagues are going through, not only in Haiti, of course, but in the other places. It is really something that, as an organization, we know that there's also a need for many of us to reach out to the mental health supports that are there for staff that we provide because we know that sometimes hugging your family is not always going to be enough and that we need sometimes to really approach it with a kind of spirit of, look, this is healthcare, mental health is healthcare, and we need it as much as anyone. So do hang in there, Alexandre. I hope that you and the colleagues do remain safe as you move through the city, coming and going from work and doing this incredible work that we so appreciate. 

We are at time. This is the end of our discussion here. Since we heard from you, Alexandre, maybe I'll bring it round to Djoen and Abdullah, just with a final question. What would be an important message that you would want the world to know about where you're working and why they should pay attention? Djoen, do you want to go first? 

Djoen Besselink: 
Yeah. No problem. No. I'm very thankful for also this, well, evening here, afternoon where you are, I think these kind of webinars for... The important thing for Somalia, let's keep discussing it. Let's bring it up at the dinner table. Let's make sure that what's going on in Somalia and Haiti and Pakistan, in the Horn of Africa, the malnutrition that we see, I think the most important thing is that we don't let it slip away. The discussion needs to be there. People are in extreme need for our support. Well, we try to provide, but we're definitely not the only one. So that will be the message, that these kind of crises don't disappear, don't let it desensitize us and move on. 

Avril Benoît: 
And Abdullah? 

Djoen Besselink: 
I think that's most important. 

Avril Benoît: 
Yeah. No. Thank you for that. Abdullah? 

Abdullah Shah: 
Yeah. I think from my side, why Pakistan should stay within the spotlight, it's a country that's been listed as one of the top 10 countries that is the most susceptible to climate change. Outside of the North and the South Pole, Pakistan has the largest number of glacier cover, outside of the poles. With climate change, that is going to be impacted. It's a country of 240 million people. More than 50% of the people in that country live on less than $2 a day. 
If we just look at the numbers, the current floods in Pakistan have an estimated damage up about $30-35 billion. If you look at Hurricane Ian that passed through Florida in September, that was estimated at $50 billion. But in a country where the GDP, the gross domestic product is $1,500 per person, it's devastated the country and the fact that much of the area that is impacted right now is prime agricultural land. So, for sure, we are anticipating that the effects from what's happened in Pakistan right now will continue for the next several years. I think it's really important for everyone to keep engaged with that. Unfortunately, more and more countries will become impacted by the changes. 

Avril Benoît: 
I really appreciate all of you for sharing what you're seeing, for witnessing, and for allowing us to have a better understanding of the importance of this humanitarian action where you're working. So, thanks to every single one of you for taking the time away from your regular work. Alexandre Michel, communications officer in Haiti; Abdullah Shah, logistics advisor responsible for Pakistan; and Djoen Besselink, MSF country representative responsible for Somalia. Great conversation. 

Thanks to all of you, and thanks for joining us, if you've been watching. Apologies if we didn't get to your question, but by all means, stay in touch. We have an email address. You can write to us and the team that puts these webinars together. It's [email protected]. For more information, of course, go to our website. The one for the US is doctorswithoutborders.org. Internationally, our website is msf.org. Of course, you can find us on Facebook, Twitter, Instagram, and all the others. So, thanks a lot for joining. I'm Avril Benoît, signing off from New York. Take care.