MSF and Development: the end of a taboo?

Transcription

Number One /Quarterly / March 2011
In-house newsletter
Médecins Sans Frontières
http://dl.msf.fr/borderline-en-1
C ritici z e
DOSSIER
Long-term
hospitals
Round table
int e ract
anal y z e
Kabizo
in North Kivu
Report
page 2
u n d e rstan d
40 Years of
procrastination
Flashback
page 6
page 9
E x chang e
“Never destabilize the
health system”
Other voices
page 12
Chronic Diseases
HIV: Requires long term care
Perspectives
page 16
MSF and Development:
the end of a taboo?
The word “emergency” doesn’t appear anywhere in the MSF charter. The new
OCP “ten-year hospital” project in Haiti is reviving the short- vs. long-term
debate that’s been shaking us up on a regular basis for the past 40 years.
Are we going to rob Peter (emergency) to pay Paul (long-term)? Are
we reconsidering free care? How is HR going to find people willing
to sign on for a minimum 2-year contract? Should we treat victims
or poor patients? The plan for a long-term charitable hospital in
Haiti is raising a lot of identity issues. While we wait to put the idea
to a vote at the June 2011 AGM, the number of debates is growing
(Joint board meeting; board of directors; Operations, HR, Finance,
and Medical departments; CRASH, etc.). For your enlightenment,
we give you 16 pages of interviews, contributions, news stories,
roundtable reports, opinions from other OCs, and the viewpoint
from Merlin, a development NGO.
In short, an ideal topic for the main theme of this first issue of
BorderLine, the new in-house quarterly offering a variety of opinions
on the humanitarian issues shaking up the association – like the
issue’s second topic, “MSF and Big Pharma.”
As is fitting, we threw it all together at the last minute, with
urgency and haste. Thanks to both Julies, Thierry and Sébastien.
All comments, suggestions, and encouragement welcome. Happy
reading, and be sure to come back for Issue #2 in early July!
Michel Janssens
- The main obstacle to healthcare is poverty...
- Development is boring
- … and nobody’s interested in the poor.
T h e 1 st T u e s day o n th e m o nth debate
Mediator affair
BORDERSTAFF
Editor-in-chief
Michel Janssens
Contributors
Julie Lerat et Julie Damond
Layout
Sébastien Besse / tcgraphite
Print
Groupe Bergam
A pharmaceutical company obsessed with profits;
health officials negligent at best, or complicit at
worst; doctors who prescribe drugs for off-label
use. The Mediator affair transcends our borders and
reminds us that information plays an essential role
in the pharmaceutical industry.
Read page 19
Big Pharma, WHO:
denouncing conflicts of interest
From the Mediator affair to the recent nomination of a
Novartis employee to a WHO expert committee, incestuous relations between public health authorities and
the pharmaceutical industry are of concern to us. Ten
years after the launch of the Campaign for Access to Essential medicines, MSF needs to get back into the fray.
Read page 23
FOCUS MSF AND DEVELOPMENT
RO U N D TA B L E
Alain
Deane
Emmanuel
Isabelle
François
MARC
Kelly
Laurent
Long-term hospitals
January 28/29th Joint Board Meeting debate
Start with a three-year
contract, sign for
ten years with
the Ministry of Health…
The “philanthropic”
hospital project entails
reinventing the way we
work. What
are the implications
for responding to crises,
MSF’s primary mission?
What will the impact
on HR and funding be?
Excerpts from the Joint
Board Meeting, a preview
of the discussions to come
at the General Assembly.
General Hospitals
These will not be trauma centers. We will offer
pediatric, maternity and surgical care. These
hospitals will be located in areas where the populations have poor access to healthcare, but
they will not be in conflict zones. The care will be
provided free of charge, at least for the poorest of
patients. From the very start, the hospitals will be
integrated into the MoH's healthcare programs.
“Long-term hospitals
aren’t necessarily
more expensive”
Paul McPhun
“If we implement a longterm strategy and try to be
innovative, I think it could
cost us less to set up long-term
hospitals. Especially since
hospitals are already one of
the settings we work in.”
“A long-term initiative
is better than a series
of short ones.”
Marie-Noëlle Rodrigues
“We already have long-term
hospitals but in the form of
a succession of short-term
hospitals. We’re not doing
things the right way. The short
timeframes don’t allow us
to consider things like HR,
stable funding or internal
management. Negotiations with
ministries of health are biased:
they criticize us for bringing in
resources that they’ll never be
able to replicate. Considering
longer commitments would
allow for much healthier
discussions and for issues to be
identified right from the outset.”
“Fifteen years is too long”
Marc Gastellu Etchegorry
“I think we should be looking at five or ten
years, which is essentially an assistance project.
Fifteen, 20 years is too long. Developing
local resources so they can take over could
be a secondary objective, but not the main
objective.”
“Let’s use social sciences
to help us innovate”
François Enten
“After repeated failures, MSF has steered away
from development programs. The question is what
would make a difference today. These programs
often fail because they’re set up in a way that
doesn’t take politics into account. If we want
to tackle these kinds of projects, we need to be
innovative. The social sciences and political
scientists can help us better understand the
dynamics in which we’ll be operating so that
we know what we’re likely to be getting
ourselves into.”
“We don’t want to see a
change of course in two
years”
Sophie Delaunay
“I think we need to establish a set of
principles as we go forward. First, state
clearly that we will maintain our ability
to respond to crisis situations. Second,
that long-term engagement means that
we’re committed to investing resources
and that we understand we may not
see results in the first year. Finally,
mobilizing considerable resources over
the long term implies that we’re not
going to change course in two years.
I’d also add free access for our patients and
not getting involved in setting rates
for health services.”
On what scale?
“What about our political
independence?”
Alain Fredaigue
“A long-term hospital involves intense
negotiations with the Ministry of
Health. What about our political
independence in all that? For example,
what would have happened if there had
been a long-term hospital in Colombo?”
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MSF N°1 MARCH 2011
We're looking at 10, 15, 20 years.
But MSF must be prepared to
continue the project until a partner
is available to take it over. The
goal is not to build ten hospitals
in the next five years, rather to
plan ahead for future projects. A
certain set of criteria will have to
be established: rural and urban
zones, anchoring strategy, etc.
RO U N D TA B L E
Nobuko
Marie-Noëlle
Offering free healthcare
This should never be called into
question for the poorest of
patients. No final decisions have
been made, but there are several
ways to make this possible: finance
a portion of the project by opening
a nursing school or training
center, charge for certain services
(cataract, hemorrhoids, etc) or
offer private beds, as in the clinics,
where conditions are better.
John
Marie-Pierre
Sophie
Philippe
“It’s crucial to identify partners
from the outset”
“MSF has never done it
before, which is why we
should do it”
Deane Morshbin
Emmanuel Drouhin
“Before the earthquake, we had decided to pull
out of Haiti and we didn’t find any partners
to transfer our operations to. I think we need to
look for partners right at the start. We have to
be realistic: in the places we work, we have no
reason to believe that the local community is
going to be able to take over our projects
10 or 15 years down the line. We go to these
places precisely because there’s no one else
doing what we do.”
“Link hospital care
and operational research”
Isabelle Defourny
“Secondary and tertiary health care is
central to our medical and operational
objectives. It should be possible to
establish a direct link between these
long-term hospitals and our operational
goals. The important thing for me is
that these hospitals meet the needs of
the populations they serve and that
they allow us to make progress on
issues related to hospitals in other MSF
projects, as well as in crisis situations.”
“The challenge of
access to care in
urban settings needs
to be considered”
Marie-Pierre Allié
“We have coordinating
offices in the cities yet we
head straight out into the
bush without looking at
what’s around us: there are
people in the cities who don’t
have access to care. Realizing
this, we are turning towards
trying to find longer-term
ways to help.”
“We can’t be dogmatic about free health care”
“There are enough studies showing that cost recovery is not
viable. What counts for me as a board member is not deciding
that care must be free; it’s ensuring access to care for
the people who need it and making sure that finances are
not an obstacle. If free care can guarantee this, then the care
must be free. Otherwise, we can try to come up with
other solutions. We need to keep things simple in that respect.”
“Will we be able to find candidates
for three years?”
Matthew
“I helped build the hospital in
Monrovia, which was quite successful
in my opinion. At the time, there were
lots of questions about medical and
operational issues and our ability to
manage a hospital. I remember the
same reluctance. People were saying,
‘We’ve never done this before.’ But MSF
is there precisely for that reason: to do
what’s never been done before.”
“Partnerships need
to be defined”
John Plum
“I haven’t studied the figures closely but
it’s quite clear that we don’t currently have
the necessary human resources. MSF’s past
experiences with hospitals have not been very
positive. I think we have to correctly frame
the issue of partnerships: we may want to
control the quality of service, but that doesn’t
necessarily mean that we need to control
the structure.”
“We shouldn’t
be charging for
MSF care”
Why Haiti?
Emmanuel Drouhin
MSF is already working here
alongside a Haitian team, making
the project very feasible and
opportune. The wave of emotion
sparked by the e arthquake
mobilized numerous institutional,
philanthropic and private players,
who have all pledged long-term
commitment to Haiti. This makes
it possible to find the necessary
partners, and to envision an exit
strategy.
“Emergency, long-term....
It all depends on how you
see things. Despite the risks
associated with getting
involved in the very complex
issue of managing a hospital
year after year, I think it’s
something we have to do.
However, one thing I’m
dead set against is having
MSF consider charging
for care. I know that
hospitalization is very costly,
but it’s a choice that we
have to take responsibility
for. If we start talking about
“cost recovery” for the poor,
then how is MSF going to
define poverty? The risk of
creating a multi-tier medical
system worries me.”
Emma Timmins
“I’d like to hear the HR perspective. Will you be able to find people willing to leave
on a three-year mission? I say this because it’s absurd to send people into a 20 year
program for three months. Are we going to be sending families into the field?
We want to keep our institutional costs below 10% but can we ensure that we’ll
have enough independent donors over the 20 years? Can we afford it?
We have to be realistic about what we can and cannot do.”
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MSF N°1 MARCH 2011
RO U N D TA B L E : ZO O M
Emergency yes, but development?
“Beware of abrupt
and radical change”
Issam Kanta
The debate raises concerns regarding MSF’s
social mission. But nothing in its charter forbids
a long term approach.
“React to emergencies above all”
Deane Marchbein
“The idea is good in itself, but there are risks
concerning MSF’s social mission, which is
to treat the maximum population on a large scale.
The change is abrupt and radical. I think it will
be necessary to go through a transitional phase
of reflection, which can help us to see clearly
what is at stake.”
“Victims and/or patients?”
“Long term hospitals are presented as an extension
of what we are currently doing. I think, on the
contrary, that they conflict with our desire to be able
to react to emergencies. We’re going to have very
long term fixed expenses, and it will be necessary
to manage human resources differently. It is
important to ask ourselves if that is going to have
an impact on our capacity to be effective in our
main raison d’être, namely to respond quickly to
emergencies in regions in conflict, where no other
organization is able to do so.”
“Complement emergency action”
“To the question whether it is being suggested
that we move or transition from an emergency
organization to a development organization, I
answer no. That is not my interpretation of the
plan. But I think there is a certain number of things
that need to be clearly defined: MSF remains first
and foremost an organization dedicated to aid and
emergencies. In my opinion, it’s a complementary
action that is not going to be substituted for
emergency action, but is going to complement it.”
Marie-Noëlle Rodrigues
“Up to now, we were always comfortable with the
idea of victims: there are victims when a war or
conflict takes place. But things get complicated
when these events do not produce sick people:
then we are faced with victims who are not sick.
By this logic, MSF is going to take care of internally
displaced persons, even if they are not sick, but is
not going to take care of people who don’t have
access to care in the neighboring village. It is
necessary to think about the concept of sick people
and victims, and one should not disqualify the
other.”
“Why Haiti?”
Laurent Mathon
“There are two questions. That of long term
hospitals: should MSF get involved in such a project,
and should we therefore modify our social mission?
And the second question: is Haiti an appropriate
place to set up such a program? If we link the two
things, I would have trouble voting for the overall
project, whereas the idea of thinking about a long
term hospital seems appropriate to me.”
3 q uest i ons for
Thierry Durand
Former director of operations of MSF France
D.R.
What are the limits to our long-term activities?
“Limiting
choices
will have
to be made”
We know that the needs that present
themselves at a hospital are infinite, particularly
when care is offered free of charge. There are
investments to be made, new equipment to
purchase, and we have a tendency to endlessly
increase our scope until it becomes impossible
to manage everything. So we know that limiting
criteria will have to be set. This might involve
certain categories of pathologies or certain
types of patients – with an emphasis on
children, for example.
What are the means of financing?
Funding can be sought from foundations or partners, but
it’s also possible to contemplate generating one’s own
resources. At a hospital that we visited in Lacor, Uganda,
a school for nurses was created. The funds generated by
the training are used to finance the hospital. To me, it is
4
clear that all care for infections that are life-threatening
over the short or medium term should be offered to
patients free of charge.
Certain hospitals carry out activities for particular
clienteles – which represents just a part of what they do.
Caring for cataracts or hemorrhoids can be charged for.
One can imagine that, as in clinics, a few private beds
may be available for fortunate clients who are able to
pay for better hotel service. But so far nothing has been
clear-cut.
Who are the partners?
The purview of the statute that we put in place allows
[us] to form partnerships in a joint venture mode. Since
there are a certain number of risks and uncertainties, we
would like MSF to start off as the sole shareholder – for
one, two, or three years. A large foundation may want
to be involved from the beginning. But we don’t want
certain principles to be potentially distorted by other
partners. For example, if one of our principles is costfree care for a certain category of person, and one of the
partners imposes cost recovery as a condition, I think
we should not enter into that partnership. n
MSF N°1 MARCH 2011
RO U N D TA B L E : ZO O M
“We have to tie these projects to the values that MSF represents”
Marc Ferrier, active recruitment coordinator
Does MSF have the human resources to take on this project?
which are part of our identity. Then we could recruit
people who subscribe to those values.
That’s not how HR looks at things. It’s obviously going
to have huge implications for our work, but HR is not
in the habit of impeding operations, and it won’t be any
different with hospitals.
Might MSF become less responsive to emergencies?
I don’t see why. I don’t think the project is being done
to the detriment of emergencies, which will continue
to be the mainstay of our action. But I understand that
there are concerns and questions. However, the longterm hospital project opens up numerous possibilities.
MSF could become a recognized organization for training doctors – medical residents from Europe could be
sent to these hospitals for training. It could be a way
to get students into MSF and encourage them to stay.
Until now, MSF has waited for candidates to come to us,
and that was enough to cover our needs. For the past
few months, however, with the need for specialists and
the increase in activity volume, we've had to be more
proactive. With hospital projects like these being set up,
we’re going to have to do more than just post small ads;
we’re going to have to spread the word about the quality
of our programs and the care we deliver, and go out looking for specialists.
We’ve already talked to Operations about the job
profiles we’re going to need to run these hospitals, in
order to come up with a recruitment strategy. We‘ve
canvassed the École de Rennes, which trains hospital
administrative directors. These are profiles we’re not
used to recruiting, and people who don’t know that MSF
needs them. We’re also in the process of restructuring
the team so that it’s capable of handling the active
recruitment effort.
If MSF is indeed seeking doctors for three years – and I
don’t know if this is the case — we may have to create
expatriate statuses like private businesses do, with family and a comfortable salary. I don’t know how far MSF
is ready to go in this direction, but this is going to impact
the HR effort. Things are already changing — once we
start actively seeking volunteers, they stop truly being
volunteers, with all the commitment that that implies.
MSF and hospitals
To me, the first priority is to state clearly why MSF wants
to open these kinds of hospital facilities. If it’s a question
of learning to run hospital facilities 100%, I understand
that that’s an operational need, but I don’t think it’s
enough. It seems essential to me to tie the long-term
hospital project to the values that MSF represents, and
D.R.
Is the volunteer profile going to change?
We could also help train doctors in the countries where
these hospitals will be set up. While that would be a radical change – worrying, perhaps, because that would
take us a step closer to development – it would open up
enormous possibilities. I just hope we’ll have the time to
understand these projects, so that we can look at things
in depth. n
1985-1995
2002-2003
2004
2005
MSF intervenes to
support public hospitals
in Mozambique, Sudan,
and Uganda, where it does
medicine, and in Mogadishu
and Sri Lanka, where it does
war surgery. In the years
that follow, there will be
few interventions in hospital
facilities.
At Mamba Point,
Liberia and Bouaké,
Côte d’Ivoire, MSF
does surgery and
treats the wounded
before broadening
its activities to
include maternity,
medicine and
pediatrics.
In Haiti, the
trauma center
is born. MSF
again offers
specialized
surgery,
and begins
performing
external
fixation.
MSF takes another step
closer to specialization
by opening a
reconstructive surgery
project in Amman, to
treat Iraqi wounded.
In October, after the
earthquake in Pakistan,
MSF uses inflatable
hospital tents. MSF
5
2010
opens a new trauma
center in Port Harcourt.
The teams grow: the
surgeon and anesthetist
are joined by an
operating room nurse
and physiotherapists,
to provide more
comprehensive care.
MSF N°1 MARCH 2011
Earthquake in
Haiti. All fourteen
inflatable hospital
tents are set up in
just over a week,
with complete
technical facilities
and 200 inpatient
beds.
RE P O RT
Kabizo
health
Center,
North Kivu
Report from Kabizo in North Kivu
What happens once MSF leaves?
What happens when MSF withdraws from a health center?
In Kabizo, North Kivu, the authorities took over the project.
The health post has since become a referral center.
Photos by
Marine Pariente
Perched on a hill dotted with little mud houses,
the Kabizo referral health center is working at full
capacity? Like the other centers MSF has build in
this mountainous region of the DRC, the buildings
are constructed out of wood. Outside the center, the
patients are waiting in line, evidently undeterred by
the cost recovery system it now operates. The co-payment scheme means they pay 300 Congolese francs
for a day's hospital treatment - or the equivalent of
just over 20 Euro cents.
“When we arrived, there were approximately 40
in-patients. It was midday and they had already delivered four babies,” explains Laurent Sabard, program manager, home from Kivu. There are still flowers along the paths. “The field coordinators had all
planted flowers around the health centre. Today, the
hygienists still look after them.” In the center, MSF's
presence can still be felt. Protocols are pinned up on
the walls, many procedures are recognizable as MSF.
A nurse has just put a child with malaria on a drip.
She's wearing gloves; she disinfected the child's arm
before inserting the catheter and then throws the
6
mandrin into a special container for used needles.
“These are reflex actions you don't find everywhere,”
adds Laurent Sabard.
When MSF first set foot in Kabizo in 2008, it was
a small health post made up of a few rooms built of
mud-brick. At the time, MSF was looking to set up
a base in the Birambizo health zone, which had been
weakened by the fighting and was trying to cope with
a measles epidemic. “Our initial objective was 20 to
40 inpatient beds. Then, as always happens when
MSF develops an activity, we quickly went up to 70
and then 90 beds. That was the need; there were lots
of displaced people,” recalls Laurent Sabard.
MSF stayed for just over a year and withdrew in November 2009. At that point, the Ministry of Health
decided Kabizo would not back to being a simple
health post. So, just after the team's departure, the
authorities turned Kabizo into a referral health center, which meant having at least one permanent doctor. Today, there's a team of 10 working in the health
center alongside the doctor.
MSF N°1 MARCH 2011
R E P O RT
“In Kabizo's case, MSF did not destabilize the local
health set-up,” confirms Bobo Makaso, an MSF doctor from the mobile DRC pool who was working in
Kabizo at the time. Quite the contrary, MSF encouraged the Congolese health authorities to implement
the existing health coverage plan. According to this
plan, the health center in Bambu was to be the referral health center. But the distance made it too hard
for people to reach.
So, in addition to organizing referrals by ambulance,
and in response to real needs, MSF began developing a number of activities from the Complementary
Package of Activities (CPA) in Kabizo itself, activities
that are usually only implemented in a referral health
center: inpatient care (internal medicine, nutrition,
intensive care and pediatrics), transfusions, and care
for victims of sexual violence. “CPA activities are not
usually carried out in health posts such as Kabizo, but
MSF was able to develop them and meet the needs of
the population without causing too much disruption
to the local health system”, according to Bobo.
Today, the team at the Kabizo health center is still
running a referral system (see interview opposite). To
help with the provision of everyday care, it receives
support from the NGO Merlin and, a year and half
later, it is still working with the equipment that MSF
left behind: a clear sign that the concept of rationalization has taken root in the health center. “The doctors, nurses, medical and paramedical personnel in
the Congo are competent. So, it just goes to show,
given the means to work properly, things run pretty
smoothly,” concludes Laurent Sabard. n
In-patient
service.
Today the
center has
40 beds.
Maternity
Unit.
Four
deliveries
in one
morning.
MSF redefines its
presence in Birambizo
UPPER CONGO
DR CONGO
Since 2006, MSF has been working at the
Nyanzale referral center, where it handles
all medical and nutritional emergencies and
treats victims of violence. Given the deteriorating
security situation and repeated incidents against
our teams, MSF is going to redefine its presence
in the Birambizo health district. MSF conducts
assessments in the district, backs up the local
authorities in responding to emergencies,
and will continue to ensure free care in Nyanzale
in 2011 via medical (provision of drugs and
medical supplies), personnel (financing human
resources), and logistical support at the
referral center. Our teams will provide this support
remotely from Goma. n
NORTH KIVU
Lake
Edward
SOUTH KIVU
Lake
7
MSF N°1 MARCH 2011
RE P O RT
“We’re positive about the time
MSF spent in Kabizo”
Norbert Simbilya, a nurse in the Kabizo referral health centre
One and a half
years in Kabizo
Norbert had been a nurse in Kabizo for 6 months when
MSF handed over its programs to the MoH. One and a half years later,
he outlines the impact of MSF’s time in Kabizo.
Kabizo is located in the
Rutshuru area, at the heart of
the North Kivu province. In
2008, following population
displacements and a measles
epidemic, MSF carried out
an exploratory mission in
the Birambizo health zone,
an area subjected to chronic
instability, like the rest of
the province, for years. Two
months later, the
Kabizo project
opened.
MSF constructed
three buildings
and developed
previously inexistent activities,
such as: nutrition,
care for victims of
sexual violence,
pediatrics, internal
medicine, etc.
The MSF teams
worked in Kabizo
until November
2009, when it felt
that the time had
come to handover
its activities to the
Ministry of Health
(supported by the international NGO Merlin at the time).
MSF continues to analyse and
monitor epidemic risks in the
Birambizo health zone, and
is ready to intervene if the
needs arises. MSF re-intervened in the Kabizo RHC
between 20th December and
31st January 2011, supporting
the Ministry of Health with
medicines and staff training. n
How did the local population and staff feel when
MSF handed over its activities?
There were some concerns regarding MSF’s
departure, among both the local population and the staff. MSF had generated a lot
of work in the area, and people knew that
MSF offered quality healthcare. There was
real fear that the center would not run as
smoothly as before, and it would be harder
to find healthcare and treatment.
Did some activities prove harder to handover than
others?
There are some real medical and health needs
in the Birambizo health zone. Even though
we’ve managed to reuse the tools and equipment left by MSF, we’ve struggled to provide
the same quality as MSF across the board.
Take nutrition, for example. We have stock
shortages in ready-to-use therapeutic foodstuffs. And sexual violence: since MSF left, it’s
been hard to re-start activities raising awareness in
the surrounding hills, and
ensure the same confidentiality for victims that MSF
could provide. There are
problems here and there
(shortage of laboratory
equipment, water sources
needing fitting out), but
generally speaking, MSF’s
impact was really positive,
and we haven’t lost hope?
We intend to keep on working to improve and rehabilitate these points.
Can you give me an example
of the added value of MSF’s
work in the Kabizo Center?
Out-patient
reception.
Cost
recovery
hasn’t
driven the
patients
away.
Did the local authorities manage to takeover
the activities developed by MSF without too much
trouble?
Even though the staff found the decision to
handover was taken quickly, we’re really positive about MSF’s time in Kabizo, because
all the services and activities it developed
are still running. The equipment left by MSF
is being used correctly, there is rational use
of the facility’s means and new buildings.
Despite the switch from free healthcare
to cost recovery, people keep coming to
the center, and we’ve kept all the activities
going.
8
At the time, it was really
hard for the local population to reach the Bambu
referral health center
for more extensive care
than a simple health post can provide. It
involved walking for over 20 kms. MSF started referring patients to health facilities in
ambulances, and it made a big difference
to people’s lives. This referral system continues today.
How does the local population see things, one
year after the handover?
MSF will always be welcome in Kabizo. To
take a concrete example, we recently had to
deal with a rise in cholera cases. MSF was
quick to provide support. We were alone in
dealing with the situation, the other NGOs
did nothing to help. This sort of thing means
that MSF is accepted here in Kabizo. n
MSF N°1 MARCH 2011
F L AS H B AC K
40 Years of procrastination
Emergency or Development? A debate as old as MSF
It’s one of the founding myths: MSF deals with emergencies.
Exit all other approaches to humanitarian aid, and all those who contest it.
The debate has nevertheless been present since the start of the association.
July 7, 1972 : Steering committee of
peers, Bernard Kouchner : “Created to
respond to emergencies, MSF seems to
be increasingly called upon to provide
assistance over the medium to long
term. In fact, it’s working like a (volunteer) recruitment
agency for sending doctors to the third world. We’re
drifting away from our original mission.”
70
December 23, 1972 : Earthquake in Nicaragua. First
“independent” MSF mission. But MSF arrives too
late: other players have taken care of the wounded.
Volunteers provide everyday medical care – pediatrics,
pulmonary infections, and tetanus vaccinations.
The Medical Tribune, April 13, 1974 : “It slowly became
clear to Médecins Sans Frontières
that the most important medical issues facing the third world were more
closely related to chronicity than emergency.”
D.R.
s
Le Figaro April 12, 1974 : “Convinced that help should
not stop after a catastrophe, Médecins Sans Frontières
will remain past the emergency stage to provide medical assistance needed to the third world together with
international organizations.”
First General
Assembly. Summary
of activities:
25 missions completed
for other organizations,
not a single emergency.
“Too hard a line on identity stifles discussion”
Jean-Hervé Bradol, member of the Crash
“The influence of Rony Brauman's definition of humanitarian action on the members of MSF explains why the assertion
that the organization's purpose is to offer
a response and - whenever possible - an
emergency response to a crisis is the subject of recurrent debate within the organization. What should our attitude be towards
crises whose successful resolution requires
long-term participation in a process of social transformation such as establishing
better infectious disease control? AIDS
projects and advocacy action on behalf of
the Campaign for Access to Essential Medicines, for example, are not in line with the
definition formulated by Rony Brauman
in 1992. The AIDS crisis has already last-
ed several decades and the introduction
of triple-drug therapies in low-resource
countries is clearly a social transformation.
Although Rony Brauman's formula frees us
from the shackles of belief in the unstoppable March of Progress guided by Law and
driven by Science and Economy, at the same
time it closes the door to other intervention possibilities, stipulating to any beneficiaries of humanitarian action that “its goal
is not to transform a society, but to help
its members through a period of crisis or,
in other words, to cope with a breakdown
in its former equilibrium.” These conditions
dictating the duration and the reach of our
humanitarian action are vague, restrictive
and unworkable. Is it possible to help n n n
9
MSF N°1 MARS 2011
D.R.
According to Jean-Hervé Bradol, we need to move beyond the definition of humanitarian action,
proposed by Rony Brauman in 1992, as “the restitution of people's capacities to make choices“ or,
in other words, helping the members of a society through a period of crisis.
FL AS H B AC K
80
s
El Mezquital, Guatemala
GUATEMALA
as deliverance. In addition to responding to typhoid,
MSF set up a health clinic with personnel paid by the
MoH, trained volunteer medical assistants, built a water purification plant with the help of slum volunteers,
and worked to secure safe drinking water. The first
drilling went down 300 meters, and questions bubbled
up: MSF had ‘overstepped its bounds.’ The project was
abandoned, but taken up by UNICEF, who MSF had
been working with. The UN agency built 400 houses,
with electricity and running water.
In El Mezquital, a slum on the outskirts
of Guatemala City, 50,000 people had
set up home illegally, which meant they
were excluded from the health care system. There wasn’t a single doctor. In 1986, MSF first
intervenes, responding to typhoid cases. A survey revealed the needs expressed by the population did not
prioritize health. In these conditions many viewed death
90
s
Kosovo
In 1999, MSF launches its “1000 roofs
for Kosovo” operation. It was presented
to headquarters as a preventative medicine program, since it helped improve
hygiene and kept people who were sleeping under tents
from getting sick.
© Jacky Courtin/MSF
Projects with wings
nnn
In 1999, MSF distributes chickens in Honduras in the
wake of Hurricane Mitch. The same year, in Liberia, it’s
“project ducks.” MSF plans to distribute ducks to Sierra
Leone refugees in Lofa, but the fowl were lost after a
holdup by Charles Taylor’s troops.
“Too hard a line on identity stifles discussion”
a population through a crisis while abstaining from playing a role in the transformation
of the society in which the crisis is occurring?
In MSF's internal debate, the claim that
priority must be accorded to “saving lives
here and now”, offers an authoritative argument. It expresses loyalty to the organization’s supposed origins. Yet we can find
no evidence of a clear choice ever being
made. We do, however, have evidence of a
conflicting discussion arising at MSF's very
first general assembly that has continued
until today. Emergency response to crises
is often raised (wrongly when you examine
our history) to the rank of “primary activity” with which we must all keep the faith.
In our collective mind, the contradiction
between the facts and the assertion that,
from the outset, MSF has never taken part
in development actions is masked to some
extent by the organization’s promotional
communication which presents an image
of a medical humanitarian organization
working heroically in emergency situations, beyond all political divides.
The hard line on identity adopted by those
who oppose so-called “development” action has led to them refusing to see anyone
who disagrees as legitimate bearers of the
“MSF identity”. Opposers are no longer just
dissidents; they have become strangers to
their own organization. Thus, one of the
managers on the Kenya team who advocated in favor of health development-type
projects was told by a head office representative that she “had the wrong organization.”
Yet the aim should not be to secure a
conclusive victory for any one side in this
debate on MSF's role. MSF is not a satellite
of the Red Cross movement, nor is it a
United Nations agency and it certainly isn't
an operator working under the mandate
of a former colonial power's international
cooperation service. MSF defines its own
mandate and reach, a fact that gives its
members the freedom to explore the
limits of its reach and makes volunteering
something other than a form of abnegation
in the execution of everyday tasks.
The authors of MSF's Charter used the
expression “populations in distress”, and
twenty years later Rony Brauman referred
10
to “populations in crisis”. These expressions
could be described as “plastic” or “holdalls”. They are inclusive to the point of
sometimes becoming blanket expressions
and thus make on-going critical reflection
essential. In this respect, the definition
given by Rony Brauman in 1992 is a healthy
attempt to reduce the size of the “hold-all”.
The objective is not to settle the debate,
but rather to keep it alive in order to
take advantage of the plasticity of the
expressions “populations in distress” or
“populations in crisis”. An overly hard
line on identity in our internal debate can
only serve to stifle essential discussion.
This debate on the reach and modalities
of humanitarian action can only be closed
once and for all at the cost of a reduction
in the scope of our activities. This would
prevent MSF from offering anything other
than a dogmatic response to the stimulating
and constantly renewed questions raised
by teams working in singular and everchanging fields of action. n
MSF N°1 MARS 2011
J-H Bradol
F L AS H B AC K
North Korea
Madagascar
In 1993, several thousand children and their families were
living in the streets of Tananarive, exposed to insecurity
and violence. Stigmatized, they were not accepted in
public clinics, and were victims of all types of prejudice.
A large portion of this population had no legal identity,
making them all the more vulnerable, and excluding
them from common law.
For twelve years, MSF provides assistance to these children in three social/medical centers. But due to sanitation policies in Tananarive, thousands of impoverished
people are forced onto the streets. If these people did
not have access to care, it was because they are poor,
and not because they live in the streets and are discriminated against. In 2005, MSF closes its street children’s
programs in Tananarive, but remains ready to help with
emergencies related to natural disasters or epidemics,
leveraging its past experiences in Madagascar, especially in the medical-nutritional area.
© Gilles Varela / 20 MINUTES
From February 25 through March 8, 1997, responding
to a request made by authorities, MSF distributes barley grain in two northern counties in North Korea. The
team is only authorized to travel to those areas where
the grain cars arrive from China.
00
s
20
Antananarivo, Madagascar
Tsunami
As the acute emergency phase came to
an end, MSF distributes 80 boats to fishermen in Sigli to help them provide for
themselves.
Colombia
Intervening in underprivileged neighborhoods in the
city of Buenaventura, MSF, in collaboration with the
community, restores pontoon roads that connect houses
on pilings in Miramar. n
“To stop now would be to avoid seeing what we’re really doing”
The concept of development aid as an
instrument for correcting social “anomalies” was born in the still-imperial
post-World War II era, and viewed as
“modernization” or “westernization.”
While there are many variations on the
development theme — community, integral, balanced, autocentric, sustained,
independent, human, leftist, rightist etc
— they all start from the common assumption that there’s a social anomaly
that needs to be rectified. All its versions,
both socialist and capitalist, contain two
consensual notions: the universalism so
dear to humanitarians (well, not all!)
and the progress that science makes possible.
To distance ourselves from this normative
and evolutionist view that does nothing
to help us understand our environment
— our working environment included — I
believe we would be better off thinking in
terms of “social change”.
Doing so would shift the discussion away
from “Is this development or not?”, i.e.,
kosher/halal or not, and toward the issue
of which social changes we want to push
for, and by what right.
That’s what I would like to add to Jean
Hervé’s analysis, while agreeing with
him that the definition I proposed is
dated. Like him, I think it’s an issue that
warrants clarification, because in our
day-to-day reflection and our operational
choices, decision parameters are influenced by these types of categories — in
particular, because they are also bureaucratic categories used by institutional
donors. This is no small matter, because
it tends to make them self-fulfilling: this
is “development” because it is funded by
X, this is “post-conflict” or “emergency”
because it is supported by Y. I’m not saying that MSF works that way, but we’re
immersed in this environment and not
impervious to what’s around us. And let’s
not forget that, taboo or not, this notion
has been present — as a magnet or a foil,
depending on who you talk to — throughout MSF’s history.
One quick word about my (attempt at a)
definition. In order not to limit myself to
emergencies — which for a medical organization should have a precise meaning — I introduced the notion of crisis as
the special province of humanitarianism,
11
© copyright M. Leroy, RTBF
Rony Brauman, member of the Crash
to preserve its conceptual boundary. I
wrote that definition soon after the Gulf
War, during the war and famine in Somalia. What I had in mind was to distance
us, as a matter of principle, from the social engineers, whether in flip-flops or
rangers. But I concur with Jean Hervé’s
criticism: to stop now would be to avoid
seeing what we’re really doing.
I still believe, however, that we should be
wary of acting like schoolmasters or head
supervisors, and the temptation to think
we’re the experts n
MSF N°1 MARCH 2011
Rony Brauman
OT H E R VOI C E S
“Our aim is to never destabilize
the health system”
Sally Clarke, ONG Merlin
where facilities and expertise might not be as good. But
the earthquake happened in the capital of the country,
where most of the hospitals and health workers were.
Many emergency organizations weren’t capable of absorbing national expertise.
Would you describe Merlin as a development organization?
Sally Clarke is campaign manager for Merlin’s Hands
Up For Health Workers campaign, and editor
of the report “Is Haiti’s health system any better?”,
calling for a more coordinated and collaborative
approach to disaster response.
We work in transition, in that window from emergency
to recovery which is something of a funding black hole,
because you have either humanitarian funding or development funding. Most of the countries in which we
work are in chronic humanitarian crises, they are technically sliding between emergency and transition. We
would not be in a developing country like Malawi or
Tanzania.
Development, transition, crisis… How do they fit the situation
on the ground?
What are the main lessons that should
be learnt from the international response
in Haiti?
D.R.
If we are to have long lasting effects, we need to engage much more
thoroughly with national health
systems. We have to do capacity
assessment, alongside needs assessments: what are the skills that
are on the ground? How does it fit
in with national emergency plans?
How can we complement rather
than take over? Humanitarian response must build on existing national expertise, talent
and system. Merlin’s aim is to never destabilize the
health system. If you look at many of the international
teams who arrived in Haiti, they destabilized what was
already an incredibly fragile health system.
How can this be done while dealing with
a major emergency?
ª http://www.merlinusa.org/
2011/01/is-haitis-healthsystem-any-better/
We all have a role to play but leadership should be
shown from SPHERE and IASC (Inter-agency standing
comittee), as well as the WHO. Health cluster systems,
which in some countries work effectively, didn’t perform
so well in Haiti initially. The cluster was set up outside of
Port-au-Prince, all meetings were conducted in English,
so there were no initial mechanisms for national actors
to feed in. If part of the needs assessments process was
made as a capacity assessment, we would have much
more obvious mechanisms for national actors to feed in.
How that works is up for debate, we’re not saying we
have all the answers.
What is your main criticism towards emergency organizations?
We’re not 100% critical, nor are we without fault. Our
criticism is that many international teams came in as
fully fledged teams, that didn’t require any national
help. People turned up as if they were in rural Congo
12
It is a massive debate the humanitarian sector as a
whole should have. The longer I’m in this sector the
more I think the architecture of funding is flawed, defined and driven by the arbitrary terminology of ‘humanitarianism’ and ‘development’. For me, and not necessarily Merlin, those concepts are not really fit for purpose,
especially in chronic crises. MSF is quite lucky. You’re in
a fortunate position, while organizations like Merlin who
are heavily reliant on institutional funding, need to do
massive lobbying with donors to get them to be aware
that health in crisis countries demands long-term funding to the health system.
We believe robust health systems are really strong
pillars of disaster risk reduction. Countries like Haiti, Somalia, Afghanistan, Congo, can’t be reliant on that humanitarian short term big injection of cash. They need a
long term predictable funding which will allow them to
train and pay their health workers.
When would Merlin decide to leave Haiti? At what point,
and based on what criteria?
It would be up to the Ministry of Health. Our ideal scenario is to leave when we’re no longer needed, knowing the
exit strategy of each country is an incredibly difficult thing
to define and it’s an ongoing process and assessment of
knowing if we’re adding value, and complementing.
We’re having talks with the Ministry about the training
of midwives, so what is likely to happen is rather than
being a service delivery agent, we might end up becoming an educational or training partner. It’s more of an
evolution of the program, but it is an ongoing process,
relying on dialogue with the Ministry of Health.
Working so closely with the MoH, how do you deal
with independence issues?
We take our partnership with the MoH on a country by
country basis, and adjust accordingly depending on the
context. In practice, that means we can work at different
levels within the Ministry, from grassroots clinic level
right up to the Minister, in order to ensure the work we
do reaches the most vulnerable and builds towards the
delivery of long-lasting, effective and appropriate health
care. n
MSF N°1 MARCH 2011
OT H E R MSF
“MSF treats patients, not systems”
Arjan Hehenkamps, DirOp MSF OCA
We have to distinguish between a situation which is developmental - whatever
that may mean - and our response, which can be developmental or not.
Very often, we intervene in situations that are developmental but with a humanitarian or medical response. This was the case in Haiti before the earthquake or Niger during the peak of nutritional crisis.
These are developmental periods: there is no event
that explains why there is such a nutritional crisis in
Niger; it is the socio-economic model that explains it.
health care system is able to take it over eventually.
It doesn’t make sense, and it is difficult to maintain
from a medical and ethical perspective.
We’ve generally refused to do that. At the end of the
day, it means that we still have projects that are very
difficult to handover, and that very often the handover does not work. It brings us to another question:
In a developmental situation which can produce developmental crisis, we treat the patients rather than
the system. To me it is a distinction that is important
to maintain. I believe MSF can legitimately intervene
in a developmental situation, I don’t believe that we
have any added value in a developmental capacity.
Our strategy has to be very medical.
That immediately raises the question of the exit. At
what point do you exit from these situations? When
the exceptional situation has disappeared, our added
value is no longer there, and therefore we leave. We
experimented with very brutal exits - MSF France
has also had the same kind of attitude in the past knowing that very often you cannot help the fact that
there will be a severe and long term deterioration of
medical services for the population. We’ve had a lot
of debate and confrontation, and eventually, for the
past couple of years, we have invested in something
called “responsible exit”.
We have asked MSF UK to develop a capacity in
order to assist in supporting the field in policy and
practice to exit in a reasonable manner. This includes
linking up with local institutions, i.e. the Ministry of
Health, but also with more developmental organizations, to smoothen our exit from a particular context.
For example, we left our HIV/AIDS project to the
Zambian government, but we were in contact with a
development organisation that took our place in order
to support the system. But this also produces contradictions and difficulties. One of the main ones is that
people feel we should lower the quality of our activities, both in terms of scope and of actual standards
of care, in order to be able to ensure sustainability.
This means compromising on the quality assistance
that you give in order to ensure that a sub-standard
D.R.
Our position at OCA is even more restricted than
this. We exclude certain situations from the range of
our operational choices. There has to be an additional
factor to the medical needs that justify our intervention,
whether it is a conflict, or other. It means that when
we find ourselves in a developmental situation, it is
because in the first instance we entered like in Haiti,
because it was a conflict situation or disaster. When
the situation transforms itself into something else, we
have to adapt our strategies, which we then do.
“Lowering the quantity or
quality of our activities in order
to ensure sustainability doesn’t
make sense.”
given the very poor results that we discover, should
we invest at all? We haven’t been able to answer that
question. Adapting your strategy as you go along is
one thing, but the exit will always be dependent on
the society having found answers to its own satisfaction. That is a point that we can only minimally affect
as MSF. We probably have to live with the fact that,
even with the best of our efforts, there will always be
a significant rupture in standard and scope of medical
assistance after our departure. n
13
MSF N°1 MARCH 2011
Further i n s i ght
When the fighting stops: a time of doubt
Jean-Hervé Jézéquel, historian
The notions of “post-conflict” and “reconstruction” do not really help us to understand
the particular nature of the situations in which MSF intervenes. Analysis of the Liberian experience.
Behind the
apparently black
and white, clear
linear scenario
from destruction
to reconstruction,
there are many
shades of grey.
For example, the
Ministry of Health
was present when
the fighting was at
its height. There
were salary scales
and it demanded
that they be
applied. There is
the impression
that after the war
ends, the regulatory
power of the State
returns, but it
had never really
disappeared.
The war left many
scars on the
Liberian landscape,
but from the
health standpoint,
destruction was
not the only legacy.
According to
the statistics, a
certain number of
health indicators
improved during
the war years.
Child mortality in
particular fell. The
fact that one third
of the population
was in camps
and was looked
after by medical
organisations which
applied certain
standards, meant
that for a part of the
Liberian population,
wartime was a time
of improved access
to health care. n
After nearly 15 years of civil war, 2003 was truly significant: Liberia was at peace. Those running the
MSF programs at the time all knew Liberia and had
first-hand experience of its stop and start war. This
was not the first time that the country found itself in
a “post-conflict” phase. This had already happened in
1997 with the election of Charles Taylor. In 2003, for
everyone dealing with Liberia, this was in the back of
their minds. But the peace held.
up with three different answers to this question.
For MSF-F, in Monrovia, medium-term commitment
to a hospital structure was still inconceivable. At the
time, Rony’s slogan was “the war + 2 years, and then
we’re out!”. MSF decided to close, but it was not a
sudden decision: the war ended in 2003 and the pullout was in 2007.
MSF-B was on the point of leaving in 2005, but took a
U-turn in 2006. MSF Belgium lobbied extensively for
a suspension of cost recovery. This came
from the head office, where some felt that
the period following the fighting would be
an interesting opportunity for promoting
public health policies. Talk however has
to be backed up with action, and MSF-B
opened the Island pediatric hospital.
A fresh look at diversity
At MSF Switzerland, Liberia was not a
priority for the head office and they let the
teams on site run things. In the Nimba region, they built hospital. MSF Switzerland
was therefore actually engaging in reconstruction without being aware that that was
what it was doing. They changed course
when they realized that there was a reference hospital
30 kilometres away, and it would be very difficult for
the State to take over the new hospital.
They each made their own choices, but in all three
cases, our action is always predicated on the notion
that the post-war period means reconstruction.
Whether one refuses to play a role, like MSF-F,
or whether one feels that one has something to
contribute, like MSF-B, the main issue of the postwar period is reconstruction, one that overshadows
all the other possible issues.
Reconstruction is perceived as being both technical
and natural: obviously, when something is destroyed,
you rebuild it. But this approach masks the political dimension of the choices made. I believe that it
is important for MSF to re-politicize these technical approaches and ask itself about alternatives. The
post-conflict period is often seen as one-dimensional,
in which the same types of operations can always be
deployed. It would seem to me, however, that this
example shows the importance of taking a fresh look
at the diversity of these post-conflict situations. n
D.R.
Blurred
lines
A post-war period is not simply a transition from
war to peace, it is a time of political choices by those
involved in reconstruction. Once Taylor had fallen,
a number of organizations wanted to use Liberia as
a sort of laboratory animal, a showcase for the reconstruction policies that were in the process of evolving, with the 2005 reform of the clusters. Suddenly
everyone was talking loudly about reconstruction,
although no consensus could be reached: reconstruction is a fuzzy concept and everyone has their own
priorities. For MSF the noise was becoming just a
little too intrusive.
Three sections,
three different answers
I focused on the operational choices of three
sections: MSF France, Belgium and Switzerland.
During the first two years, they all saw the postwar period through the prism of war. At that time,
MSF was able to act without having to worry about
reconstruction. The sections set up projects anchored
in the anticipation of yet another outbreak of fighting.
As of 2005, one felt that things were changing. Peace
was dragging on, which was worrying for the MSF
sections, who began to be concerned that what they
were doing did not correspond to what seemed to
be on the horizon. Considerable debate took place
within each team: do we still have a role to play now
that the war is actually over? The three sections came
14
Interview by Julie Lerat
MSF et les sorties de guerre.
JH Jezequel, C. Perreand,
MSF et les sorties de guerre
MSF N°1 MARCH 2011
Further i n s i ght
Should we abandon our impartiality principles
for the sake of “urgency”?
Fabrice Weissman, member of the Crash
Peace is not a less legitimate context for intervention then war,
even if it raises more difficult questions regarding how we effect the state
and our participation in the social and political innovation.
Necessary tradeoffs
Applying this principle is not as simple as it may
seem. On the one hand, the terms “urgent needs” and
“proportional assistance” lend themselves to diverse
interpretations, which evolve along with our knowhow, our means, international standards and our
stated priorities. On the other hand, we have neither
the means nor the ambition to impartially assist all
populations in distress. Our operational goal is far
from one of “two billion people in the waiting room.”
In practice, limited means force us to make trade-offs,
to choose which patients will receive assistance and
which patients, with comparable medical needs, must
make do without it.
Since MSF was created, the terms “emergency”
and “development” have remained key when
establishing triage criteria and distinguishing between
those included in, and excluded from, our offers of
assistance. Other terms have been introduced in the
meantime, including “crisis,” by Rony Brauman in
1992, and “direct victims of violence,” which surfaced
during the first decade of the new millennium.
Peace, a context
not any less legitimate
The nature of these selection criteria are based on
the “context” of the mission and not on an estimate
of “need.” A “medico-sanitary” [health] crisis
arising from an emergency situation--(war, natural
catastrophe, epidemic)--is more likely to attract
an MSF mission than one arising from a society’s
“regular state of affairs”—e.g. stressed by long-term
political and social changes (health system failure,
modification of health needs due to urbanization, to
an ageing population, poverty-stricken social classes,
etc.) Malaria cases occurring during an armed conflict
are more likely to be considered as within MSF’s field
than malaria cases in peace time.
This sort of political triage has some basis in logic:
crises, for example, create a more amenable mission
environment for foreign organizations like MSF, especially in conflict situations where legitimacy of humanitarian actions undertaken by foreign third parties is recognized by international law. Furthermore,
crisis situations make it possible to set mission time limits (to end along with the emergency situation) and
to justify deploying exceptional resources based on
short-term financial and organizational projections.
MSF can therefore temporarily substitute failing institutions without concern about the “long term” consequences of subcontracting public assistance functions
to international and private organizations.
“Malaria cases
occurring during
an armed conflict
are more likely
to be considered
as within MSF’s
field than
malaria cases in
peace time.”
D.R.
Maintaining impartiality is fundamental to MSF’s
mission. “A founding principle” for MSF, according
to the [1997] Chantilly Principles and the [2006]
La Mancha accords, impartiality compels us to
follow two related principles: “non-discrimination”
(racial, religious, political, etc.) on the one hand;
and “proportionality of assistance according to the
urgency of needs” on the other-- “those in the most
serious and immediate danger will receive priority,”
according to the Chantilly Principles.
Peace time operations are a totally different story. Not
only do our missions have no fixed end date, but they
must also adhere more closely to the national health
policies. We cannot take short cuts when establishing
longer-term missions or participating in the evolution
of societies and health practices—fields in which our
know-how and political basis are less guaranteed.
However, although peace time missions are more
complicated than missions undertaken during armed
conflicts, they are not any less legitimate (a similar
health crisis) as defined by our founding principles.
Issuing blanket statements to the contrary–“MSF
does not do development!”—would be short-sighted
and contrary to our goal of providing help to “those
in the most serious and immediate danger.” n
Fabrice Weissman
15
MSF N°1 MARCH 2011
PE RS P ECTI V E S
Chronic Diseases
HIV: a long-term committment
In Malawi, 300 new patients join the MSF cohorts each month. HIV/AIDS
is no longer an “emergency.” It’s because the needs are obvious that MSF
programs are relevant and will have to be long term.
© copyright Marit Helgerud.
“Why introduce antiretrovirals (ARVs)? Because our
doctors are dealing with opportunistic diseases, our
patients come back time and time again, and we end
up burying all of them. As a medical organization, it’s
our duty to treat people,” explained Mary Mulemba,
head of mission in Malawi. In the late 1990s, of
the approximately 24 million HIV-positive people
in sub-Saharan Africa, only 1,000 were receiving
treatment. Treatment for
a single patient cost 800
Euros a month and would
last the rest of the patient’s
life. “At the time,” recalls
Marc Gastellu, now a board
member, “the question was
whether to introduce ARVs
for five, 10 or 20 years. It
was thought that providing
people with five years of
care, five years of survival,
was worth the effort,
worth securing the human
resources and funding.”
In 2001, thanks to generic
drugs,
ARVs
became
available in MSF programs.
“We made a breakthrough
then,” says Marie-Pierre
Allié, “when we stopped
asking ourselves how we
were going to get out of
these kinds of programs
and decided to commit,
regardless of how long
things took.”
Malawi, zone rurale.
Lack of doctors
The goal then was to show
that these treatments could
be administered in a precarious environment. It was
achieved a few years later, but the treatment protocol
needed to be simplified and made more accessible. In
2003, MSF decentralized its programs and became
active in health centers. To address the shortage of
health-care workers, nurses were specially trained to
start patients on ARVs and ensure follow-up care for
stable patients.
The disease has since become a chronic illness. Ten
years after the introduction of ARVs, 18,000 people
are receiving ARV treatment in Malawi through
16
MSF programs. Since there is no “crisis” as defined
by MSF, the question of handing over programs has
now arisen. But who will take over? There is a serious
lack of health-care workers, with only two doctors
per 100,000 inhabitants. Authorities, who are “deeply
committed” according to the volunteers returning
from the field, are struggling to ensure the supply
of drugs and have just been denied funding under
Round 10 of The Global Fund program.
No choice
“When HIV programs started being funded by the
international community, we thought we could easily
handover our cohorts of stabilized patients to the
various ministries of health so that we could focus
our efforts on more complex cases. We now realize
that it’s not that simple,” explains Elizabeth Szumilin,
HIV/AIDS advisor. So what are the goals now? Stay
because there’s no other choice? “We have to show
that HIV patients who are taking their medication are
not that difficult to follow,” Elisabeth Szumilin goes
on to say. “If there are few side effects to the treatment
and the patients take their medication regularly, there
is no reason for complications to arise.”
New avenues
Doctors will, however, always be needed. “HIV patients will always need medical follow-up, particularly for things like viral load rates and CD4 cell counts
and monitoring the side effects of some of the drugs,”
she says. “Regular access to rapid biological tests in
outlying health centers could allow medical teams
to focus on patients with complications and let the
others simply ‘live their lives.”
Although HIV is a chronic disease, there are still
many avenues to explore and much to learn. Program
mortality rates continue to be very high in Malawi,
with one in five patients dying. It’s also important
to fight opportunistic diseases and improve the
management of certain categories of patients, like the
1,700 women currently being treated in the PMTCT
programs. A different way of looking at programs is to
do better, go further and improve the quality of care,
without time constraints. n
MSF N°1 MARCH 2011
P E RS P ECTI V ES
Diabetes, cardiovascular diseases: “
we need to take the first step”
Marie-Pierre Allié, President
Why does MSF want to offer care for chronic diseases?
When MSF covers the healthcare needs of a given population, it
is confronted with all manner of pathologies. Logically speaking,
MSF starts off by targeting what it considers to be the most
vulnerable groups, and the most acute pathologies, so as to bring
the mortality down. But as the years have passed, we’ve had to
address tuberculosis, first of all, which involves several months of
treatment, then AIDS, which involves a lifetime of care. We cannot
refuse these patients treatment. Even though it means involvement
with no predefined term.
If we’re aiming to offer global healthcare, we can’t then say to a
patient: “we’ll treat your malaria, but not your advanced diabetes
- we don’t handle that.” At MSF, we adapt. And right now, we need
to take stock of our patients’ global needs and adapt our offer of
healthcare accordingly.
If MSF is looking for involvement in chronic diseases, is it because these needs
have changed?
In many countries where we work, certain parameters have changed
in terms of health. The demographic has changed. Health care provision has evolved. We must consider what happens globally, but
also our own practice. At MSF, we evaluate the situations we face
and we tailor our medical practices based on the needs that we feel
emerge.
How far should we go?
That depends on each setting, what can be achieved, and our
capacity to ensure a steady follow up for these particular patients.
As things stand, we should aim to develop expertise in classic
“chronic pathologies”, such as diabetes and cardiovascular diseases.
We need to take the first step in this regard.
We should also think about cancer. It’s not a chronic disease, but
it does entail complicated care, and medicines that are not always
available. Prognoses are extremely poor when cancers are left
untreated.
Some cancers can be easily detected and treated when caught
early on, such as cervical cancer. Breast cancer accounts for many
deaths in the countries where
MSF works. We need to think
about these pathologies, which
occur relatively often, and can
have good prognoses when diagnosed up in time.
Does MSF need to adopt a development approach for treating these
pathologies?
I don’t think this is about adopting a development approach.
When we’re dealing with malnutrition or malaria, of course
we can lead the way, but in the
long term, it’s the public health
authorities who have to address
the issues. Political turnabouts take place because we demonstrate
that there are solutions, but it isn’t MSF that transforms healthcare
systems.
Is MSF giving an open-ended commitment?
Generally speaking, MSF is not the only actor involved. Contexts,
medical environments and social settings change as well. So we
can assume that someone will take over from us at some point. We
can’t say that we’re not going to get involved because there’s no
one to take over when we’re gone, that’s out of the question. We’ve
already been through this with TB and HIV.
We need to consider our responsibilities and our limits. We need to
find solutions for the patients we’ve started to treat, but this doesn’t
mean that we’re committed to providing healthcare for an entire
population in a given location ad infinitum. But once operations
have started, we must at least ensure people’s survival in proper
conditions for a certain number of years. n
“We must face up to the fact
that one day we’ll leave”
Brigitte Vasset, deputy director of the medical department
“It’s striking to see that the issue of medical
ethics most often arises when we’re talking
about long term projects or the treatment of
chronic diseases. It crops up far less in socalled “emergency” settings, or when we’re
pulling out from certain types of projects. In
Goré, Chad, or Sierra Leone, we left without a
second thought about ethics, yet we were supplying these regions with most of their ACTs.
But when it amounts to ARV treatment, or
care for a diabetic disease, we roll out the
big concepts: medical ethics, a doctor’s
responsibilities.
These arguments are often alibis for doing
nothing, when actually they don’t form adequate criteria for developing new activities
or not. That would be too easy: “we don’t
vaccinate children against measles, because
17
they’ll die of malaria.” We need to face
up to the fact that one day we’ll leave,
and our field doctors need to recognise
our limits. In Liberia, in 2006, we treated a handful of patients with AIDS, to
whom we said: “MSF will leave one day,
and when that happens, we’ll give you
the equivalent of one year’s treatment.
If ARVs aren’t available in your nearest
town, you’ll need to move, or go without
treatment. What do you think?” Which is
the most ethical? Not to give any care at
all? At the end of the day, for the time that
we’re present, fewer people will die. So there
are no absolute medical ethics at stake here.
It’s the setting – the patients, our means to
react – that guide our ethics. n
MSF N°1 MARCH 2011
For further i n formati on
Watch and Read...
ON THE WEB
Les pauvres, bénéficiaires ou otages des
stratégies de réduction de la pauvreté ?
« Tout changer pour aller plus loin ».
Bonnie Campbell and Bruno Losch, in
Politique africaine, issue 87, 2002
BOOKS
Over the course of five decades, “deve-lopment” has served to legitimise countless
economic and social policies, both in the
North and the South, and has led to a belief
that well-being for all will soon be with us.
So why, if it has largely failed in this, is “development” still the focus of heated debate?
Without a doubt because it relies on a belief
that is deeply rooted in western psyche.
◆
Anthropologie et développement. Essai en
socio-anthropologie du changement social.
Jean-Pierre Olivier de Sardan. Paris, APADKarthala, 1995.
Social anthropologists consider “deve-lopment” to be a special form of social change,
in which a complex group of stakeholders
seeks to promote “target groups”. The social anthropology of development can help
improve the quality of services offered by
development institutions to communities,
while making it easier to take account for
local dynamics.
◆
Utopies sanitaires. R. Brauman (ed.),
Le Pommier, Manifestes collection,
September 2000
The “average person” is a standard concept
used in medical science and public health.
Based on statistics, it is used for planning
healthcare initiatives. But it can be
dangerous to rely on this when there are real
people to be cared for. Utopies sanitaires,
designed and edited by Rony Brauman,
describes the practical consequences of this
modern medical approach.
◆
Innovations médicales en situation
humanitaire. Le travail de MSF. JH Bradol,
C. Vidal (ed.). L’Harmattan, 2009
This book recounts how the association has
gradually become recognised, through at
times heated struggle, as as much a stake-
holder in the development of transnational
medicine as a partisan.
◆
A not-so natural disaster catastrophe,
Niger 05. Xavier Crombé and Jean-Hervé
Jézéquel (ed.)
A collection of seven essays by authors
from very different perspectives, this work
throws new light on the 2005 famine in Niger
and the controversy between “emergency workers“ and “developers”. The book
recounts the events while analyzing the role
of each stakeholder and how politics took
center stage in a humanitarian response.
ªhttp://www.politique-africaine.com/
numeros/087_SOM.HTM
◆
Le besoin d’aider ou le désir de l’autre.
Christian Lallier, Autrepart, 42, 2007.
Development aid cannot be justified
solely by goodwill in providing it. This is
what the Mayor of Nioro-du-Sahel told
an NGO that had come to provide electric
power for his town: “You can’t wish for
someone’s happiness more than he does
himself!” A salutary reminder of how
a support operation can lead to many
misunderstandings and contradictions.
ªhttp://www.cairn.info/revueautrepart-2007-2.htm
Cahiers du CRASH
Child undernutrition : advantages and limits
of an humanitarian medical approach.
JH Bradol, JH Jezequel, (ed.)
Four years after the Nigerian crisis, many
things have changed in the nutrition field.
This Cahier du Crash aims to consider this
evolution and explore new possibilities for
action for MSF.
◆
MSF and the aftermaths of war.
JH Jezequel, C. Perreand
This publication presents two case studies on the work of MSF in post-conflict
situations in Liberia and Katanga. The two
studies confirm that there is no standard
“post-conflict” situation, which means that
the operational model for leaving one war
zone can never be applied to another, and
that the exit policies justified by the end of
the emergency will also differ.
18
MOVIE
D.R.
Le développement. Histoire d’une croyance
occidentale. Gilbert Rist.
Paris, Presses de Sciences Po., coll.
Références Mondes, 2007.
While anti-poverty policies are often
presented as innovative in their content
and approach, a closer look will reveal
that they first and foremost reinforce
the conditionalities currently prevailing
in the field of politics. To ignore the new
balance of power between players that is
the fruit of liberalization will lead to forsaking a strategic dimension essential
to the fight against economic and social
marginalization.
Nioro du Sahel,
une ville sous
tension.
A film by
Christian Lallier
Nioro du Sahel is an isolated town in Mali,
on the border with Mauritania. The State
of Mali has never brought electricity to
this community of 25,000 people. When
evening comes, the local people organize
things so that power runs along the lines
of relationships and neighbourhoods...
But under a twinning scheme, a French
team has for some years been looking at
how to bring power to the town. It’s not
just cables and poles that are involved:
the power network soon reveals some
social and political issues.
MSF N°1 MARCH 2011
T he 1 st T ues day on the month debate
Pharmaceutical Manufacturing:
why MSF needs to play a role?
From the Mediator affair to the recent nomination of a Novartis employee
to a WHO expert committee , incestuous relations between public health
authorities and the pharmaceutical industry are of concern to us.
The first topic chosen for the launch of ‘the first Tuesday of the month’ debates.
The Mediator affair
A pharmaceutical company obsessed
with profits; health officials negligent
at best, or complicit at worst; doctors
who prescribe drugs for off-label
use, the Mediator affair transcends
our borders and reminds us that
information plays an essential role
in the pharmaceutical industry.
- Phagocytoses
- Patient
- Medicines
- Health
Authorities
AFFSAPS, Servier: who is at fault?
Jacques Pinel – “The Mediator affair is a product
of research and development procedures and
drug marketing regulations. From a public health
perspective, companies engage in drug research—
seeking, if possible, newer, more efficient, less toxic
drugs than those currently in use. In each country,
in order for these companies to market the drugs,
they must heed regulations and, generally, an
administrative State-dependent authority, usually an
independent agency or a branch of the Ministry of
Health. This authority evaluates the risk-benefit ratio
for marketing a drug nation-wide. This entire process
occurs on a national level: no global or worldwide
authority shares responsibility. Each country deals as
it sees fit with these medications and, in particular,
with its own means of assessing the risk-benefit ratio
for marketing nationwide.
A drug may be deemed marketable when benefits
outweigh risks—there are always risks. But there is a
natural conflict of interest between an administrative
authority that manages the advantages and
inconveniences of marketing a drug, and the entities
that wish to market it-- commercial entities, therefore
profit-oriented.
The firm that markets Mediator eventually took
illegal steps to advance its own interests; as for the
regulatory authority, the AFSSAPS was no doubt too
lax, overwhelmed by its work load. The combination
of these two influences created the problem.
The journal Prescrire has been publishing articles
for 25 years that questioned the use of Mediator,
and went so far as to state that known benefits were
minimal while the risks were well known for this
n n n
family of drugs.
- Lab
The harmful effects of a drug
Between 1976 and 2009, more than 500 patients in France died
from taking the drug Mediator, and more than 3500 were hospitalized
for heart valve disease. A drug marketed by Servier laboratories
(second largest French pharmaceutical company after Sanofi-Aventis),
Mediator was originally limited to overweight diabetics or diabetics
prone to high levels of triglycerides. Mediator was later prescribed
to help people loss weight. Between 1976 and 2009, more than
140 million boxes were sold in France (excluding hospital prescriptions).
When Mediator was withdrawn from the market last November,
300,000 patients were using it. n
19
MSF N°1 MARCH 2011
The 1 st Tue sday on the month debate
THE BUSINESS OF MEDICINE
Emmanuel
Isabelle
Jean-Hervé
Sammuel
There are 56 references articles or references
in Prescrire in which Mediator is cited as a medicine
that should not be sold on the French market. The
AFSSAPS no doubt failed in meeting its job responsibilities. The agency is comprised of a small group of
people and calls on experts to provide their advice.
If these experts are not disinterested parties and are
paid by a laboratory, then the AFSSAPS shares their
responsibility. It is unacceptable that such a group of
experts not be independent.
French agencies have neglected to pay attention to
the benefit/risk ratio. The IGAS report indicates that
many parties were involved: Social Security, senior
health officials, the AFSSAPS. But they never shared
information. Health insurance officials knew early
on that Mediator was being used as an appetite suppressor; the health authority declared in 2006 that it
was not an anti-diabetic drug. Data became available,
but it was never shared. Therefore, no authority said:
“Let’s stop it.”
n n n
“It is up to the
doctor, every
time, to weigh
the risks and
benefits for
the patient
for whom he is
responsible.”
Jacques Pinel
The doctor shares responsibility
Doctors also share responsibility: a drug has a
restricted usage that is established by the AFSSAPS,
which makes determinations based on the drugs
properties. It is up to the doctor, every time, to weigh
the risks and benefits for the patient for whom he
is responsible. The laboratory and the drug agency
make decisions at a group level. It is up to the doctor
to make decisions for an individual and to evaluate
the risks described in the monograph provided by
the AFSSAPS and contained in the VIDAL drug
compendium, where each medicine is described
along with its side effects. The doctor thus shares
responsibility, since 75% of Mediator prescriptions
were written for weight loss purposes. It is inadvisable
to risk the use of amphetamine-like drugs for this
purpose.
We must add that the AFSSAPS had, nevertheless,
limited use to overweight diabetics on a diet. Therefore, a doctor who prescribed the drug off-label to a
non-diabetic as an appetite suppressant has a double
responsibility: he has the right to do so, but he must
do it in an informed fashion. Since he prescribed the
drug outside its marketing authorization, he has to explain why he took such risks help people lose weight.
Rony Brauman – “Sevier’s sleight of hand, which
kept benfluorex from being categorized as an
amphetamine and assigned it to the family of antidiabetic drugs, was outrageous. But many people
were not fooled into ignoring that the drugs shared
20
JACQUES
Jean
the name benfluorex, and that drugs that end in
“orex” are anorexiants, with clearly defined adverse
reactions. It is also an issue of medical competence;
our incompetence in pharmacologic and therapeutic
matters. We have been trained, and poorly trained,
but this is one lesson we can learn.”
What do doctors risk by prescribing
a drug for use outside its marketing
authorization (MA)?
Pierre Chirac – “Since the passage of the Kouchner
law of 2002 [on patients’ rights], patients should be
well informed before making health care decisions,
MA or not. Perhaps this has not yet become the
norm, but it is a patient’s right. This right is even
more important for drug use outside its MA, because
when a doctor prescribes a drug for unauthorized
use, he must justify the reasons for this decision. As
for Mediator prescriptions, doctors should admit
their irresponsible behavior in civil or criminal
proceedings, or when facing the medical board. They
could still accuse the company, but this does not
eliminate the fact that they share responsibility, even
if they obtained agreement from the patient—who will
therefore be hard pressed to complain. Nevertheless,
during legal proceedings, doctors must justify with
written proof their efforts to inform the patient of
both benefits and risks.”
“What makes drugs so
complicated is that we like to
view them as scientific and
medical products, whereas they
are also industrial products
subject to other interests.”
Pierre Chirac
Fabrice Weissman – “An article published in the
PLoS (Public Library of Science) journal warns readers about clinical tests undertaken by pharmaceutical companies that are signed off on by highly regarded researchers. This also raises concerns about
the knowledge base on which doctors rely for their
risk/ benefit analysis.”
Pierre Chirac – “It is safest to prescribe a drug for
authorized uses, since the MA will be taken into
MSF N°1 MARCH 2011
T he 1 st T ues day on the month debate
Filipe
Rony
Pascale
Pierre
account in the doctor’s defense. If the prescription
use is not covered under the MA and a proven
adverse reaction occurs, the company is considered
responsible: their drug is called a ‘defective product’-a product whose relatively well known side-effect is
not noted in official documents. There will be legal
proceedings against Servier for selling a defective
product, since heart valve disease and arterial
hypertension problems were not mentioned in the
most recent VIDAL drug compendiums.
If the doctor prescribed a drug for use outside of
its MA, he will need written documentation, so the
judges can determine the extent of his knowledge, the
state of the art. The judge could tell a doctor who
acts like he knows nothing about Mediator: ‘this was
published in the journal Prescrire, which has 30,000
subscribers.’ But there is nothing in the VIDAL
compendium; nothing there indicates the drug is an
amphetamine.”
Michel
“We have been
trained, and
poorly trained,
but this is one
lesson we can
learn.”
Rony Brauman
How to discern trustworthy
information?
Pierre Chirac – “It is important to note that a drug
involves both a product and information. What
makes drugs so complicated is that we like to view
them as scientific and medical products, while
they are also industrial products subject to other
interests; companies need to focus on their bottom
line. The multiplicity of conflicting interests involved
in marketing a drug often obfuscates available
information. The key is finding good information.
Mediator provides an extreme example, a caricature:
a company that managed to get its drug prescribed
as an appetite suppressant while convincing
all industry regulators that the drug was not an
appetite suppressant. This was an incredible feat of
disinformation.
Companies play a very important role in disseminating
information about their drugs. They try to control
this information. In the United States, many current
court cases involve medicines. Since the lawyers have
access to the companies’ proprietary information,
examples of unethical clinical test data manipulation
are coming to light. In France, with Mediator, we are
getting closer to this state of affairs, but Servier is not
alone: information manipulation begins with clinical
trials.”
Claire
Laurent
Fabrice
adding the drug to a treatment plan. If we cannot
replace regulation officials, we have a role in planning
for future new drugs and determining their place in a
therapeutic algorithm---this occurs through training
young doctors, medical visitors, journal articles,
conferences, all of the ‘grey matter’ that establishes
criteria for prescribing the drug for authorized as well
as off-label use.”
Pierre Chirac – “Companies make billions of euros in
sales each year and produce drugs that later belong to
the public domain. In the United States, for example,
next year they will lose 60% of their sales to generic
counterparts. They must constantly market new
drugs. The pharmaceutical market is unusual in that
there are drugs more than 10 years old that still work
well—paracetamol is more than 100 years old. There
is no technical obsolescence, as in other sectors. This
places a powerful constraint on the industry, leading
companies to market new products that are inferior
to those already on sale. In my opinion, this situation
will not last another 50 years, because it is highly
dysfunctional— only 20 to 30 drugs are now newly
In other countries
Begium recalled Mediator in 1997, claiming that it was not effective for
diabetics and caused amphetamine-like reactions. Switzerland withdrew
the medication the same year, after serious and real doubts about the
impact of the drug on the health of patients arose. Spain followed their
lead in 2003. Mediator was sold in very few western nations—primarily in
eastern countries. Since it was not marketed in the largest pharmaceuticalusing countries, problems raised few red flags, as was the case for other
medicines. Nevertheless, according to the IGAS (Inspectorate-General
of Social Affairs) report, “the decision to withdraw Mediator should have
been made in 1999.” n
marketed each year, compared with 200 to 300 during
the 1970’s. When pharmaceutical laboratories cannot
produce good drugs, they rely on marketing to make
them appear to be very good drugs. Nowadays, in all
countries, companies can market a new drug just by
showing that it is more efficient than a placebo. Our
main goal should be to modify the law: a drug should
not be marketed unless it can be proven more efficient
than those currently in use. And health providers and
patients must have access to this information. We can
work towards these goals.” n
Emmanuel Baron – “There are two complementary
steps: marketing authorization–believed to provide
the most protection—and, once a drug is marketed,
a more underhanded process follows, which involves
21
MSF N°1 MARCH 2011
Towards pharmacovigilance in the field?
As a medical organization, MSF has certain responsibilities.
New vaccines, new medicines, how vigilant can we be?
“MSF’s responisibilities”
“Always uncertain”
Michel Janssens – “Does MSF pay sufficient attention
Pierre Chirac – “The whole issue is about the information
to pharmacovigilance? Doctors prescribe off-label
– not everywhere has marketing authorities – so
everyone is responsible. What is MSF’s collective
responsibility? Do we have the means to carry out
pharmacovigilance? We participated in a vaccination
campaign for meningitis-A without having ways of
being sure that there are no side-effects. How can we
protect ourselves on this level?”
on which we base our actions. It MSF’s responsibility
to ensure that the guidelines are updated according to
the most current information available, and that the best
possible choices are made. MSF’s responsibility is all
the greater as the association intervenes in places where
neither patients nor local doctors understand these issues,
and in contexts where it is possible to do anything without
it being visible. Therefore, I think that the association has
a great responsibility in regulating activities in the field.
When we use new vaccines and new drugs, it is obvious
that we are always somewhat uncertain. The oldest
treatments have an advantage in the sense that we have
better perspective and more information.”
“The WHO is too discreet”
Claire Magone – “The advantage of older vaccines
and drugs is typically measured in response to
epidemics. Oral polio vaccine is an old medication.
So while we are seeing polio outbreaks in several
countries, the WHO’s strategy is very discreet on
the matter and minimal information is circulating.
What can MSF’s responsibility be in collecting the
most up-to-date data when the information on ways
of managing epidemics is very discreet, even in
the WHO guidelines? “Vaccinate first and see later”
I think it is very difficult for MSF to give itself
the means that this responsibility entails.”
“Almost impossible where MSF works”
Jean Rigal – “We know the risks of certain drugs. But
MSF has never monitored the side-effects of aspirins
or chloroquine. Pharmacovigilance is impossible in the
conditions in which MSF works, except within clearly
defined health centers or in vaccination campaigns.
If MSF did not want to innovate or introduce new
drugs, we would never have made progress on sleeping
sickness, for example. We have often taken risks and we
are not alone.”
“The limits of the exercise”
“MSF on the frontline”
Emmanuel Baron – “No once can be
expected to do the impossible. It is not
up to our group to define which drugs
are worthwhile or not on behalf of
a supranational entity. The problem
is that we do not have the latest news
or the luxury of asking ourselves this
type of question. As regards
the meningococcal vaccine, we have
monitored this project for several years
and have done a risk/benefit analysis,
and while we can attest that we acted
in good faith we are within the limits
of the exercise.”
Pierre Chirac – “Not being able to carry
“Difficult to set up”
Isabelle Defourny – “The introduction
of the meningococcal vaccine was
monitored because it had never been
used. With Epicentre, we first thought
of monitoring the side-effects ourselves,
but they are very rare – one episode
in 80 or 100,000 vaccinations. It was
difficult therefore to set this up from
our end, and we decided to join forces
with the Ministry of Health and the
WHO, and work with health centers in
order to track information. But there
was much debate, because it is quite
rare to monitor side-effects from the
introduction of new vaccines or drugs.”
22
out a study in the forest is one thing,
but not advising about a potential
side-effect noticed in a patient under
care is another. Epidemiological studies
only complete voluntary notification
of potential side-effects, but the early
detection of something that might be
a side-effect – particularly for new
vaccines where MSF is on the front line
- is made by field staff, not researchers.
However, information is very often lost
because field staff are not concerned
with this. The team of doctors are
the source of part of the information,
and it is important that the medical
directors remind practitioners
in the field to remember to pass
the information on to us”.
MSF N°1 MARCH 2011
The 1 st Tue s day on the month debate
Helping the World Health
Paul Herrling :
From Novartis
to WHO
Organization, iron bars in hand
More than ten years after launching the Campaign
for Access to Essential Medicine, MSF must renew
its efforts, according to Rony Brauman, Pierre Chirac
and Laurent Gadot. This time, they have the World
Health Organization in their sights.
Laurent Gadot – The fact that WHO apto large pharmaceutical companies has pointed a member of the pharmaceutical
not changed much since the Campaign for industry in the Herrling affair (see insert),
Access to Essential Medicine (the Access demands a swift and precise response. It
Campaign) began in the 2000s. This posi- reminds us that WHO does not understion should be revised as it concerns the tand the concept of a conflict of interest.
That confusion reminds
World Health Organization, with whom we work.
“Beyond WHO, there’s us of the Mediator affair:
it’s a small world and
Concerning the WHO/
the United Nations
there is far too little space
Novartis affair, we’ve
discourse which MSF
between those meant to
noticed that a consultashould analyse, and
control and those meant
tive group of experts on
to be controlled.
neglected diseases – one
on which MSF should
of MSF’s priorities – is
have a position, rather Herrling was known in
the field of neglected distrongly influenced by
than a consensus by
seases, and many find
the pharmaceutical comdefault in the midst of him to be “nice”. But
panies. It’s a shame that
that is poor reasoning.
MSF was not involved in
limp approbation.”
Things must be analysed
the campaign against the
nomination of the repreRony Brauman politically. People are
“nice”, but they have a
sentative of Novartis.
Whether we’re talking about the flu, Me- specific role: they work for MSF, for AFSdiator, the group of experts on neglec- SAPS (French Health Products Safety
ted diseases, there is a pattern here that Agency), or firms, and it’s not the same,
concerns us. It seems to me that MSF we shouldn’t confuse things. WHO is no
should communicate regularly – not ne- longer able to consider the complexity of
cessarily by declaring war on WHO – on neglected diseases than through the prism
the role of the pharmaceutical industry. of firms.
This issue must be on the mind of MSF
spokespersons who, whenever an occa- Rony Brauman – We shouldn’t overlook
sion presents itself, must be able to pu- the fact that public/private partnerships
blish columns, participate in talks, press are part of an ideology that has been in
conferences and public events, and turn motion for over twenty years. The objecthis issue into an essential part of global tives of the millennium are one manifeshealth security in which we participate. tation of that ideology. Beyond WHO,
We must help WHO escape the hold the there is the United Nations discourse
pharmaceutical industry has on it, which which MSF should analyse, and on which
may mean striking out at it, iron bars in MSF should have a position, rather than
hand. The idea being that WHO recovers a consensus by default in the midst of
limp approbation. Poverty reduction, of
an important role, one that it has lost.
which a large part is measured by medical
and health questions, is part of a process
Jean Rigal – Is the strategy that was that it would not be controversial to call
developed for the Access Campaign still ultraliberal, and which asserts that the
valid? At the time, we absolutely avoided solution to poverty is the extreme accuany criticism of the system – globalization, mulation of wealth, the crumbs of which
liberal society, etc. Will the same type of would fall down to and end up improfight be taken up against “big-pharma” via ving the sort of the most impoverished.
It seems to me that going beyond n n n
WHO, and how?
“It’s impossible to have a more blatant
conflict of interest,” was the reaction
of James Love of the American NGO
Knowledge Ecology International.
It was 17 January. Paul Herrling,
director of research at Novartis, had
just been appointed to the WHO
consultative group of experts on
neglected diseases. A field that this
professor knows well. “But he can’t be
the author of a proposal, the person
to evaluate it and the one who could
benefit from that evaluation via
Novartis,” continues James Love.
Margaret Chan, director of WHO, sees
no conflict of interest: WHO “often
calls on members of the industry.”
However it isn’t the first scandal surrounding this group of experts.
In 2010, the first group was formed to
23
D.R.
Rony Brauman – Our position with respect
stimulate research and development
on neglected diseases, the idea being
to propose innovative ideas that would
prevent the cost of research and
development having repercussions
on the cost of medicines. The
experts prepared an initial report
that was confidential at the time. But,
documents published by Wikileaks
reveal that the draft report had been
communicated to the International
Federation of Pharmaceutical
Manufacturers and Associations
(IFPMA) even before it had been
made public. The innovative proposals
were written off.
Faced with the controversy, the 63rd
World Health Assembly opted in May
2010 to create a new group of experts.
A group which includes among its
members the Swiss Paul Herrling, who
was already the author of one of the
proposals considered by the previous
group of experts, inspired by IFPMA. n
MSF N°1 MARS 2011
“Public/private
partnerships are
far from satisfying
needs in the field.”
Pierre Chirac
n n n WHO, MSF’s position could be
more precise. It wasn’t precise at the
time these objectives were launched because we cannot react to everything in
real-time. But just because it wasn’t done
does not mean it shouldn’t be done or
that we shouldn’t reflect on a position within the MSF movement, of which WHO
would be a specific case. When the United Nations pronounces a discourse that
has been taken on board by almost all
of the press and NGOs and we say nothing, then we’ve taken it on board well.
Pierre Chirac – For a laboratory, opening its
libraries or giving another organization the
means to innovate has an ‘opportunity cost’.
So, either the laboratory does something
that costs practically nothing, and does
it only for the sake of saying it has done
so, or the public/private partnership has
something to offer: lucrative markets on
which money can be made back. In those
two cases, there are two categories: markets
that are already or that have the potential to
be lucrative, and those that do not.
TB diagnostic tests are a good example.
For the past eight years, Find has been
conducting relatively inexpensive research
and development (between $5 and 10
million). The result is a diagnostic test
based on the hospital which cannot be
used in ambulatory care settings, the
equipment of which may cost up to
$20,000, and the test costs $17. That is far
from satisfying the needs of the majority of
people that need to be diagnosed. Public/
private partnerships have a tendency to
fall within this category of result. Some
do work, however. An NGO financed by
Bill Gates has been working seriously on
a meningitis-A vaccine and has financed
a technology transfer from the National
Institutes of Health to an Indian vaccine
producer, asking that a vaccine be
produced for 50 cents. It’s an achievement,
but also an exception. n
“The pharmaceutical industry has managed to make itself essential”
Laurent Gadot, économiste à la CAME
D.R.
We are in a position where emerging countries are
a priority for pharmaceutical industries, who seek to
transform them into markets. They therefore need to
convert these countries who don’t necessarily want
to buy into their logic. When the working group
on rare diseases was first created, there was a 2006
WHO resolution supported by Brazil and Kenya. The
goal was to respond to the
need to finance research
without this resulting
in high product costs,
because that would lead
to difficulties in having
access to the medicines –
something with which we
can sympathize.
In 2008, an intergovernmental group of WHO
was created and confirmed
the idea of not using
product cost to pay for
innovations. It concluded
that a working group should
be created. An initial report
was published in December
2009. But we learned that the pharmaceutical industry
had access to it before everyone else.
The high level of self-censorship of that report is striking. I don’t think the industry needed to take out
a pen to cross things out because the authors said
to themselves: “we have to make a realistic proposal.
24
Working with pharmaceutical companies, i.e. those
who make the medicines, is what is realistic.” On that
basis, the report’s proposal was to retain the status
quo.
The consultants chosen by WHO had, in the past,
already written things that have been reconsidered as
proposals. The general problem with the pharmaceutical industry is that we ask the producers to evaluate
what they are selling us.
Paul Herrling is, himself, the author of two proposals
that will be evaluated by the working group. From
knowledge production to the delivery of the medicine,
the pharmaceutical industry has managed to make
itself essential every step of the way.
While emerging countries contest this type of relationship between the pharmaceutical industry
and Western countries, and the expenditure of rich
countries will slowly erode, China and India are
really what are at stake: they must be made to adopt
the same dogma. It is that task which stands out, as
well as the danger that the working group report will
serve as an excuse: “look, we’ve done all that was necessary, we’ve recovered money to form public/private partnerships, everything is going great,” but in
reality, nothing has changed. The worst thing for us
would be to be in a position where we would have to
choose between accepting that or being marginalized
because we are the only ones to refuse. n
Laurent Gadot
MSF N°1 MARS 2011

MSF and Development: the end of a taboo?

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