Ebola unmistakably changed global health, revealing gross failings and recasting the roles of a host of aid groups, agencies and community first responders. That reckoning also happened on an organization-wide level, including at Médecins Sans Frontières, which was a leader in on-the-ground treatment during the crisis and an outspoken critic of the broader response.
After leading much of the response and outcry on Ebola, MSF found itself with a newly-influential voice in the public health community. Now, the organization is grappling with how to take a seat at the global policymaking table while keeping its identity as a fiercely independent emergency responder.
The question carries ever greater weight as MSF sits at the center not just of outbreak response but of growing health crises in conflict zones across the globe. In Syria, Yemen and Afghanistan, the organization’s facilities have been attacked or bombed in violation of international humanitarian law, or IHL. So great is the threat that MSF is now rethinking the risks it faces and asking warring parties directly what their rules of engagement are, if they do not abide by IHL.
MSF board member Dr. Javid Abdelmoneim has been at the heart of MSF’s rising prominence in international health policy. He was part of a team working on the ground to respond to Ebola in Sierra Leone, and helped set up a support network for doctors inside Syria, where MSF is unable to send its own personnel. He spoke to Devex during a visit to the United Arab Emirates. Our conversation has been edited for length and clarity.
Now several years out from the West Africa Ebola crisis, do you think the global health community has drawn the right lessons? What are those lessons?
We are always very critical of how we manage any intervention. There was a huge internal debate as to whether we did the right things, at the right time, in the right way. So we’ve had that debate. We’re still having it actually. [In] the wider community — there were errors, it could have been done better.
“We’re not in a position, and don’t necessarily want to be in a position, to impose conclusions on the wider health community.”— Dr. Javid Abdelmoneim, MSF board member
We’re fiercely independent and the debate that has been subsequent for MSF is that, through our leading action in Ebola, we have been invited to the table. By being at the table, there’s responsibility. We see ourselves as being independent and not part of the collective. That gives us a chance to work in an effective manner. At the table, you’re holding hands and you’re a little bit constrained, and then you bear responsibility wider than just what your responsibility and your remit is. So we have a little bit of tension internally: Do we want to take that seat at that table? It is being forced upon us. How do we engage? Will it be meaningful? Will it still align with how we see ourselves? We’re not in a position, and don’t necessarily want to be in a position, to impose conclusions on the wider health community.
What’s the status of that discussion within MSF? Are you leaning toward greater engagement?
It depends who you speak to. We’re very organic in our structure. We have multiple heads, different nationalities, different cultures. Different ages. Some people have been in the organization since it’s inception. [Then we have newer] people who have a very different outlook on the global health community.
Not to say that we’re polar, but there is always one camp that wants to engage ever more with our newfound louder voice, and there is one camp that wants to continue our disengagement. Some people might say that’s throwing stones at a gas house from the outside. Some would say that’s our role; the international community needs that voice. We enjoy that little bit of tension, it’s our nature.
What about in terms of field operations — did Ebola spark any changes in the way you think about responding to outbreak emergencies?
Internally, we have five operational centers, and historically, whether formally defined or otherwise — and there are instances of both — one operational center has been the lead thematically. For example, Paris has traditionally been on top of trauma surgery. It just fell to Brussels to be on it for hemorrhagic fevers, encompassing Ebola. Everything that MSF did [during the response] was just from that one operational center, and in hindsight, they were too late even in calling for help internally from the other four operations.
However we also recognize that we like the model: One center has an expertise, because necessarily there isn’t a demand for all five centers to maintain an expertise in all the thematic [areas]. In hindsight, our conclusion is that we like the leading operational center model, but we also recognize that there needs to be established mechanisms for [those centers] to seek help, bring help in, and then to deploy and raise that expertise in other operational centers when needed. It took a while for Amsterdam to come in, which was [the center] selected as the follow up to Brussels internally.
It’s hypertechnical, Ebola, so you can’t just say, go and set up an Ebola center. Opening an Ebola center is critical. When you open an Ebola center and let in that first patient, there are accidents — from someone who hasn’t put the flow of patients correctly, to no one thinking that rubbish bin shouldn’t be there because you’ll trip. That means that your staff members gets infected. That was laborious. We’ve learned, and are continuing to learn from it.
Do you still have a residual presence in some of the Ebola-affected countries? How have your operations in those countries changed?
All of them. We were there before and we will be there after. Their health structures are broken.
For Ebola, it’s about surveillance and rapid identification of cases, and then [containment]. Now, because of the vaccine which we know works, we have to do a double contact ring vaccination. That needs to be in place rapidly, people need to be trained, the system needs to be there to do all of that. That wasn’t in place in any organization — international, national, charity or governmental — so there was a learning for that type of context. MSF is maintaining that capacity internally and locally.
Now, the maternal death rates are much higher than pre-epidemic, and they were much higher compared to global rates as it was. That’s why we’re concentrating so much on maternal and pediatric.
Over the last several years, MSF facilities in conflict zones such as Afghanistan and Yemen have been hit or attacked to devastating effect. How has that changed your operating procedures or thinking about risk?
The thinking is obviously that the risk is greater. When you’re looking at security planning, there’s the threat and the likelihood. You multiply them together to find the impact.
The Safeguarding Health in Conflict Coalition released its latest findings on attacks on health care workers and facilities from 2016, showing a continued "widespread and extremely serious problem."
It’s uncertain now in engaging with governments — the rules seem to have changed. We say, the doctor of your enemy is not your enemy. That’s not necessarily the way some national forces and armies in these regions look at it. They don’t. So we need to ask them at the highest levels: If we treat your enemy, how do you see us? We know what international law says, but what do your rules of engagement say, and are you ready to affirm it to us either way, so that we can understand what the risk is? That’s the dialogue we’re having with multiple nations that are involved in these places in the highest level.
At the end of the day, we need to maintain operations. What do you do? Should we reopen [bombed facilities in] Konduz, [Afghanistan]? The need is still there. In what way shall we reopen Konduz? Will it be fixed? Should we make it mobile? We have to think about how to adapt to the rules on the ground, while we figure out what are these rules are — because they don’t seem to be what we are applying. IHL does not seem to be respected with regards to health structures in those zones.
For example in Syria, we were trying to act in all parts with all actors. We were burnt in ISIS territory. They reneged on their commitments to us. We cannot be guaranteed safety for our staff in ISIS territory, so we have no operations. We have decided that the risk to our personnel and our organization is too great, despite the lack of health care access. We’re not willing to take that risk.
“One of our core operating values is proximity: To be there ourselves with our patients so we know they are getting the best of the materials we are providing medically.”—
In other parts of Syria where we used to have personnel — actual MSF staff in MSF hospitals — again because of the bombings, we’ve had to change our operations. Now we do supporting rather than being on the ground. One of our core operating values is proximity: To be there ourselves with our patients so we know they are getting the best of the materials we are providing medically. We find we can’t have that operational construct in Syria, so we’ve had to resort to supporting the health structure that’s already in place with materials, training, procedural support. I opened that project in 2011, so we know [the doctors], we know what they’re doing, we know they’re doing good, proper work. We know that they’re not just selling these materials on the black market. We’ve made our due diligence about the donation of these materials. We know what’s being treated, we have the statistics.
After seven years meeting these doctors face to face, giving them trainings and Skyping daily, you have to trust them. You’ve built up a relationship with them. They’ve been killed. They’re putting themselves at risk in a way that we have deemed we can’t put ourselves at risk. Yet this is the only way we’ve found to be active in those areas of Syria. Because of these dangers, we’re forced to work in a way that isn’t optimal, but it’s the best we can do.
Do you think this sort of remote operation is going to have to become a greater part of your toolkit in the future?
Each context is so different that we wouldn’t plan to go in in the same way everywhere. This model in Syria was entirely organic and unplanned. It just so happened that when I met these Syrian activists in 2011 in August, we said to them, “What do you need us to do? Shall we come, and be there?” I had my visa, I was ready to go. All the people we met that month said: “Don’t come to Homs, it’s too unsafe. You won’t be able to put a hospital.” We’d asked Damascus, “can we act on both sides of this, it looks like you need help.” They were not allowing us, so it would have been illegal.
Instead, I said, “What do you need? People are being shot in demonstrations.” They answered, “to be honest, we’ve run out of tetanus, because you need that after a gunshot wound — we’ve run out of blood transfusion kits and we’ve run out of antibiotics.” I said “I’ll provide that to you next week.” That was our first donation, and the need was there the week later. It was as organic as that, and here we are seven years later — it ended up being millions and millions of Euros of donations.
Returning to your work with Ebola, how did the coordination mechanisms function on the ground, and how did MSF fit into that structure? How well did the system work?
Understanding the disastrous international response to last year’s Ebola pandemic in West Africa is important to ensure mistakes won’t be repeated. In this essay, Council on Foreign Relations’ senior fellow for global health Laurie Garrett takes a closer look at WHO’s missteps and makes the case for why the U.N. health agency needs to evolve.
Whether pre-planned or not, the International Committee of the Red Cross was dealing with disposal of the dead, the World Health Organization was supposed to do contact tracing, and we were supposed to do case management. Those were three broad pillars. And the fourth pillar of public health information wasn’t really being done. If you want to boil it down, that’s what was happening at the beginning. Now whether each actor did their utmost best in the right way at the right time is up to debate. There were failings on behalf of everyone, including ourselves, and we say that.
Public health messaging was what made the difference, really. I arrived in Sierra Leone on the weekend of the face-to-face, the lockdown: They did face-to-face, house to house, visits to every house in the country over three days, messaging. It was only after that messaging that the population mindset went from, “this is nonsense, this is a manufactured threat, we don’t believe it,” to “Ebola is real.” And that came in mid-September, we’re talking how many months into the crisis? It was late.
It was hugely necessary. Particularly with Ebola, [telling people] don’t shake hands — and in that region they have very elaborate, very cool handshakes, very touchy feely. Also washing the dead is ritualistic and everyone does it. [A dead person is] highly infectious. These were the centers of infection. That message needed to get in, and it really didn’t get in until very late.
How was it personally to work in that environment?
“It’s hard work, it’s physically draining, you get tired, you make a mistake, you get Ebola. We don’t want that.”—
You have to be on guard for your personal safety, respecting all the health protocols, wearing all the equipment in the right way. Personally, I felt that I wanted to be quick and open to act in a palliative way. We were told before we went in that really, this was a palliative mission. The best you can hope for really, as we don’t have a cure, is a comfortable death for your patient. It’s a very different perspective to an emergency room doctor, used to very quickly making an intervention to save a life. I’m an emergency physician. It was a really charged mission.
We only did four to six week rotations, because it’s quite intense. It’s hard work, it’s physically draining, you get tired, you make a mistake, you get Ebola. We don’t want that. It isn’t ideal because you learned an expertise and then you go, but a lot of people did four weeks in, four weeks out.
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