Emmanuel Baron

MSF stepped up the pace of its activities in the early 1980s. More interventions meant recruiting more staff and developing more technical and logistical resources. The perceived image of a responsive, efficient medical relief organization intervening in violent situations all around the world was confirmed. The general public had little doubt about the grounds for MSF’s decisions to intervene in particular situations and the effectiveness of its actions. After all, it was argued, MSF’s contribution was better than nothing: providing care, by definition, does no harm. Media coverage increased accordingly, with intense exposure when the organization took a public stand on a particular situation—for example its expulsion from Ethiopia in 1985.In October 1985 MSF-France denounced migration forced by the Ethiopian authorities. The majority of other relief organizations did not take a public stand and made no plans for a withdrawal. MSF received an expulsion order two months later.

This dynamism in the field was coupled at headquarters with an urge to see the organization acknowledged as a credible entity in the medical and scientific community. While MSF was highly regarded by many, the organization’s practices smacked of medical exoticism. Little of any tangible value in medical and scientific terms seemed likely to come from this pleasant team of doctors: while their good intentions were not in doubt, some saw them as cowboys, others as boy scouts, and this, along with their limited technical resources, inevitably placed them on the margins of scientific rigor and medical progress.

There was a need for the organization to be more rigorous and more efficient. For some, this meant developing internal resources that would allow the organization to generate more independent analysis, scientific output, and training methods. What MSF wanted at the time was to be able to describe and measure its activities without relying on staff and input from other institutions. Its decision to learn, master, and develop quantitative measurement methods applicable to the programs it ran and the situations in which it operated was in some sense a way for MSF to shed the lingering impression that it was a collection of newcomers rather than a serious medical organization.

To this end, MSF looked to skills being developed and taught primarily in the United States. American universities had, in fact, long since developed research and training programs in epidemiology, the public health discipline that describes, quantifies, and analyzes the situation of particular populations and patients. Several MSF doctors went to the US to be trained in epidemiology and played a part in planning a structured project that was being drawn up at the organization’s headquarters.

Epicentre was created as a French non-profit organization in 1987. Its status was that of an independent organization, although its board of directors was made up primarily of members of MSF. Its name is based on the broad notion of a center of energy and the term “epidemiology,” the discipline that underpins its actions. Its initial aim was the same as it is today: namely, investigating critical situations in the field, in particular population displacements and epidemics; carrying out research on behalf of MSF in the areas in which it operates; and training medical personnel in epidemiological techniques.

Epicentre’s position in relation to MSF—as an internal organization and yet a distinct entity—is in itself unusual. It is more common for international research institutes to be independent from operational organizations. It was because of its original organic relationship with MSF and its medical practice, freed from the ever-uncertain task of seeking external funding, that Epicentre was able to anchor itself in the realities of the situation in the field and build its capacity for scientific output.

This position would help it to formulate, in scientific terms, the practical constraints facing medical teams. The human and geographical environment in which MSF operated complicated such basic medical questions as, for example, diagnosing malaria without risk of error. Epicentre was able to assess difficulties of this kind and translate them into describing constraints on interventions, then into research, and sometimes even into international health issues. Taking a population census, comparing strategies and treatments, and measuring their effects all rely on a knowledge base that is constantly changing but has largely been developed in relation to stable, defined environments. Because MSF was engaged in humanitarian interventions in countries with inadequate health care facilities and with populations that were often on the move and of an uncertain size, Epicentre was placed in a scientifically challenging situation.

Stimulated by the pace of relief operations, Epicentre was able to support MSF in its choices at three levels: defining its intervention priorities; changing its practices; and sharing its experiences.

 

Measuring and Analyzing to Define Priorities

Epicentre’s main role initially was to describe, measure, quantify, and compare different situations. MSF’s programs were most often set up without the benefit of any health-risk indicators. Experienced volunteers had an intuitive understanding, based on their work in the field, which enabled them to mobilize resources and take action using their collective familiarity with general field conditions rather than an analysis of the quantitative data specific to a given situation. Making objective measurements of the characteristics of different health situations—the difficulties of providing relief, and their successes and failures—helped to highlight the constraints under which MSF teams were operating. It was this scientific analysis of tangible situations that drove the move towards innovative research.

This sequence (data collection–analysis–need–innovation) proved relevant in meningitis epidemics, the operational response to which consists of treating the sick while vaccinating those not yet ill. The large number of people requiring treatment (several thousand) and vaccination (tens or hundreds of thousands, and even several million in Nigeria in 2009), and the fact that the population is scattered are significant constraints. Traditionally, describing an epidemic relies on gaining access to information about timing (how long has the epidemic been going on, how many cases are there by unit of time?); location (where are cases occurring in geographical terms?); and people (what kind of patients are affected, particularly in terms of age?). Quantitative descriptions of these events by teams in the field and graphic representations of them are both ways of assessing the number and geographical origin of cases, the time taken for MSF teams to intervene, the proportion of patients who have died in hospital, and the resources mobilized. Epicentre has investigated several such epidemics in Niger, Burkina Faso, Sudan, and Nigeria. An analysis of the information gathered combined with the teams’ assessment of their own work, and particularly of the difficulty of providing antibiotic injections over several days, helped to highlight the need to cover a broader proportion of the population affected and to have access to a simpler, shorter treatment regime to cure a larger number of cases. Based on these observations, MSF and Epicentre carried out comparative clinical trials in West Africa, the results of which confirmed the effectiveness of therapy based on a different injectable treatment administered in a single dose. In using well-known, tried-and-tested methods to quantify MSF’s action in the field in the areas where it operated, Epicentre was not doing anything particularly innovative. But it was able to translate the constraints and consequences of mass treatment and vaccination into scientific language, thus helping a consensus to emerge in favor of alternative solutions.

Epicentre also used quantitative methods in the context of armed conflicts. During the 1980s, MSF frequently worked with displaced or refugee populations fleeing violence and assembled in more or less organized camps where they waited for help from non-governmental organizations or United Nations (UN) organizations. The precariousness of their physical and psychological state, and the conditions in which they had settled and were living, required a rapid deployment of medical and non-medical assistance. This was split into roughly ten priorities for action, which were supposed to reduce the risk of major levels of morbidity occurring within the population. Similar priorities had already been outlined in the late 1970s by the Centers for Disease Control and Prevention in Atlanta in relation to conflict situations, but they needed further consolidation (CDC, 1992). Using population survey methods that had been tested elsewhere—although never on a large scale in this type of context— Epicentre was able to shed light on general health indicators such as the incidence of certain pathologies, immunization levels, and mortality rates. These data were an indication of the vulnerability of the populations that MSF was assisting and provided the necessary basis for establishing the actions that should take priority in relation to health (Brown et al., 2008).

MSF’s work with the Kurds in Iraq is a good example of Epicentre’s contribution to relief activities. In 1991 MSF deployed human and medical resources on a significant scale to support a population fleeing in chaos and panic from the threat of the Iraqi army, then finding itself on the Turkish border, unable to escape. In one of the largest operations in the history of MSF, epidemiologists from Epicentre were dispatched and quickly gathered information that enabled them to describe the health situation and send relief to where it was needed most.

Epicentre thus confirmed the effectiveness of using methods that offered a swift estimate of health indicators for a given population on a large scale. Using these methods in the international context of responding to catastrophic situations—which would become a routine practice—provided essential quantitative data for establishing the gravity of such situations and an objective basis for organizing assistance. In fact, Epicentre’s work has become a benchmark in the world of humanitarian assistance (even if some surveys lacked rigor, were limited in methodological terms because they were carried out too late, or were not always adequately exploited by the operational staff who requested them.) In a document published in 2007 by the Humanitarian Practice Network The Humanitarian Practice Network is a forum run by a British organizsation, the Overseas Development Institute, a think-tank on humanitarian action and development policiesand designed to summarize existing information and recommendations for key players in the field of international humanitarian assistance, eighteen of the sixty-two bibliographical references were for research carried out by Epicentre and MSF.

Field studies routinely include questions on the conditions in which they have been carried out and on subsequent use of the results obtained. The complex environment in which these surveys are conducted needs to be taken into account to assess the validity and reliability of the measurement techniques used. Describing a health situation on the basis of calculating a rate that shows a risk means knowing the number of people exposed to that risk or the rate at which particular events, such as death, occur. The accuracy of such estimates is questionable when populations are unstable and migrating because of threats and violence. The very structure of these populations varies when, for example, young men become the victims of atrocities and disappear. The indicators produced are therefore subject to these kinds of uncertainty. Methods do exist to limit the effects, but the point is still the subject of discussions in several publications (Working Group for Mortality Estimation in Emergencies, 2007; Checchi, Roberts, 2005). Although the necessity and use of such surveys has not been called into question as such, the debate has gone so far as to cause public controversy, in particular around the publication by American researchers at Johns Hopkins University in Baltimore of an estimate of the number of deaths attributable to the invasion of Iraq by the US Army (Roberts, 2004; Burnham, 2006).

This issue was highlighted in late 2009 when the Health Nutrition Tracking Service—an inter-agency partnership set up under the aegis of the World Health Organization (WHO)— asked Epicentre to produce a critical review of mortality and nutritional surveys carried out between 2006 and 2008 in North Kivu, an area in the east of the Democratic Republic of Congo that had been the scene of intense fighting for some fifteen years (Grais et al., 2009a,b). From roughly thirty reports that tackled the question of mortality and nutrition in the region, four were selected on the basis of a list of criteria examining the methods used, results obtained, and their subsequent use. Each used different methodologies. Three had been carried out for the purpose of effectively targeting relief, while the fourth was designed to communicate to the public what the population was suffering. This research also highlighted the fact that, even if this kind of survey was based on tried-and-tested methods, questions could be raised around how they were applied. Furthermore, they are sometimes carried out too late to have any real influence on how relief is deployed.

There has also been lively discussion about operational teams’ motivation for requesting field studies. More precisely, the issue at stake was the use of the results: was their purpose to target actions more effectively, or to make a public statement about the situation the population was living in, which humanitarians felt was intolerable?

In the first case, the dilemma comes from the weight operational managers give to the figures when they compare them with a subjective assessment of the situation. In Chad in 2007, for example, there was a discussion within MSF on the significance of the high mortality rates obtained in a survey carried out among displaced Chadian and Sudanese families in the Ouaddaï region, close to the border with Sudan, and to the Darfur region in particular. The people who had requested the survey were MSF operational managers, who compared it with their first-hand assessment of the situation when setting up the relief program. The criticism that arose at MSF was that too much faith was being placed in the survey for fear that action would only be taken on the basis of the statistics. Although in this case the criticism did not completely reflect the reality of the facts and the decisions taken, the argument is still valid for other situations.

In the second case, the initial motivation for a survey may be public advocacy. Figures may be used in unintended ways by those outside the organization, however. The most emblematic example is that of Somalia in 1992, when the results of an Epicentre mortality survey on the displaced population were used, based on a false interpretation of the results by senior officials within the UN, to help justify the Restore Hope operation— led by the US Army—with its well-known consequences.

 

Measuring and Comparing to Change Practices

Over the years, through Epicentre, MSF became increasingly accustomed to using quantitative methods for health assessments in emergency situations. The knowledge it gained opened up other ways of assessing its actions. Populations in precarious situations and morbid phenomena such as epidemics were therefore not its only areas of research. Epicentre was also involved in research activities designed to improve medical treatment per se, and to measure, compare, and evaluate new diagnostic and therapeutic strategies in relation to standard practices.

MSF medical managers dealing with a number of conditions postulated that some of the diagnostic or therapeutic techniques being used were not the most effective or easiest options, or that others could be applied in situations where they were not yet in use. The treatment of meningitis was a good example, but work was also done on other pathologies that caused MSF problems, even real dilemmas: examples in the 2000s included malaria, human African trypanosomiasis (sleeping sickness), tuberculosis, and malnutrition.

Malaria: The Relationship Between Research and Political Decision-Making

In the late 1990s, chloroquine was still the standard treatment for malaria in Africa. Even then, there were clinical and parasitological indications that strains showing resistance to the treatment and responsible for fatal forms of the illness were becoming increasingly prevalent. Inspired by experts in the field and academics who had already described the same phenomenon in Asia, MSF decided to commit to widespread use of a combination therapy based on artemisinin derivatives in its program. The treatment, known as Artemisinin-based Combination Therapy (ACT), was well known and used in Asia (China, Vietnam, and Thailand, primarily) and was based on the principle of the synergy between two anti-malarial drugs (one of which was an artemisinin derivative) which acted in complementary ways. The treatment struggled to gain a foothold in Africa because of the medical and political authorities’ mistrust of new products, which were more expensive than the previous generation, and because of the relatively poor data available to confirm that chloroquine was no longer effective. MSF asked Epicentre to carry out a number of studies designed to confirm that chloroquine was not effective enough to be prescribed without endangering patients suffering from malaria. Support within MSF for carrying out studies of this kind was not unanimous. Some of the organization’s former senior figures argued that this was an overly technical and ultimately pointless approach to a situation to which the response was self-evident. The argument certainly made sense: it was reasonable to suggest that chloroquine was already less effective than previously thought and also to assert that the refusal of the national authorities in one particular country had more to do with other interests than public health concerns or the absence of concrete scientific evidence. Conversely, others argued that empirical decisions in a medical environment should make way for processes that lead to a rigorous demonstration of the efficacy of therapeutic choices. A consensus finally emerged for launching a series of surveys based on MSF programs. The results unambiguously supported a switch to combined therapies and were echoed in the thrust of MSF’s Campaign for Access to Essential Medicines under the slogan “ACT Now.” The results were also published in internationally recognized scientific journals (Guthmann et al., 2008). By verifying the comparative efficacy of two therapeutic strategies in children suffering from malaria, Epicentre provided part of the argument for the political battle being waged by MSF.

Despite the publication of basically conclusive results, the issue did not end there. Some countries took time to agree to the change in their national protocols. Furthermore, not all sections of MSF moved at the same pace in changing medical protocols. This resulted in some tense discussions, particularly in the case of Burundi, where some sections accepted the government’s delay in implementing the new recommendations, thereby placing their medical personnel in one of the most uncomfortable positions a doctor can face: namely, prescribing a treatment with a very high likelihood of failure.See the studies by M. Le Pape and I. Defourny, and S. Balkan and J.-F. Corty in this book.

Sleeping Sickness: The Relationship Between Research and Standards

Results from Epicentre’s clinical trials on sleeping sickness have contributed to significant progress over previous treatment recommendations. For fifty years, patients at the advanced stage of the illness had been treated with a drug (melarsoprol) derived from arsenic, the efficacy of which was decreasing due to the emergence of resistant strains of the parasite responsible for the disease. In addition, the treatment was so well known to cause death by damaging the brain that some infected patients refused to undergo screening for the illness. The only other drugs available were not officially recommended and of doubtful efficacy as a single treatment (nifurtimox), or difficult to administer (eflornithine). Furthermore, large-scale use of eflornithine on its own as a front-line treatment raised the threat of the parasite developing resistance. Conscious of the limitations of the existing treatments, but above all because there were no other therapeutic options available, MSF and Epicentre decided to carry out a clinical trial to compare the efficacy and tolerance of the three drugs in a combined therapy (melarsoprol–nifurtimox, melarsoprol–eflornithine, and nifurtimox–eflornithine). The supposed advantage of these combinations was that they could enhance the way in which each drug acted and avoid natural selection of the resistant strains of the parasite.

The initiative was opposed by a number of specialists in the illness, including at the WHO. Their accusations centered on the failure to comply with drug development rules. Good practice and standards in this area would, indeed, have meant going through some lengthy stages, and would have necessitated testing the three combinations of drugs in different doses, in vitro and in vivo, and not carrying out trials on patients until a later stage of the development process. MSF and Epicentre would be seen as behaving like sorcerers’ apprentices if they did not follow the requirements of each stage.

Epicentre and MSF managers put forward other arguments to justify their intentions. In addition to factors associated with the declining efficacy of melarsoprol and the absence of any other back-up solution in the medium term, the standard development process would delay the availability of a potentially effective solution for several years, while the situation demanded an immediate response. Their intention was to test several options and conduct the trial on the basis of a rigorous methodology, including the involvement of an independent monitoring committee which could stop the study should it be deemed ineffective or one of the combinations prove toxic. While they did not obey standard procedures to the letter, MSF and Epicentre thought they were complying with them in spirit. They were supported by several national program managers in the countries concerned.

The trial started in Uganda, in partnership with the Ministry of Health, in 2001 in consultation with French and Ugandan ethics committees. The monitoring committee swiftly decided to interrupt the trial after 54 of a planned 435 patients had joined, because of the higher than expected number of deaths in patients on a combination of melarsoprol and nifurtimox. The deaths did not call into question the basic principle of combination therapies, but were a harsh reminder of what was already known about the limitations of melarsoprol. The study was published; the combination of nifurtimox and eflornithine seemed promising in light of these albeit only partial results (Priotto et al., 2006). A process had been set in train and led MSF and Epicentre to do further research into this combination, still in Uganda, on a second series of cases (Checchi et al., 2007). Following further encouraging results, hopes of abandoning melarsoprol increased. Epicentre then embarked on a large-scale, multi-center trial designed to compare the efficacy and innocuousness of a combination of nifurtimox and eflornithine in a shorter (from fourteen down to ten days) and simpler treatment (number of drips cut by three-quarters) than with eflornithine alone, another standard treatment. This was met with the same reticence from the scientific community: MSF and Epicentre were failing to comply with traditional drug development procedures and were running the risk that nobody would support the use of this combination even if effective and well-tolerated. It was better, so the thinking went, to take the time required for the usual processes to guarantee future recognition and acceptance of possible positive results by the health care professionals and authorities concerned. Preferring to maintain the momentum they had built up, and confident of the results they had already achieved, MSF and Epicentre embarked on a larger trial that was also supported and co-financed by the Drugs for Neglected Diseases Initiative (DNDi).DNDi was founded in 2003 by a number of private and public sector partners (including MSF, the Institut Pasteur, Indian Medical Research Council, etc.), in order to fill the gaps in terms of research, development, and recording of neglected tropical diseases (see the study by C. Vidal and J. Pinel in this book).This trial, conducted from 2003 to 2008 at four separate sites in the Congo Republic and the Democratic Republic of Congo, confirmed what had been expected: the new combination was shown to be just as effective and well-tolerated as treatment with eflornithine alone at a high dose. The results were presented at scientific conferences such as the American Society of Tropical Medicine and Hygiene in New Orleans in December 2008 and published in 2009 (Priotto et al., 2009). The inclusion of this combination in the WHO list of essential drugs in 2009 marked an important step in the hoped-for amendments to the national protocols of the African countries concerned. There is still a long way to go, however, between demonstrating the superiority of a treatment and large-scale production, followed by registering it with the authorities, and finally its routine use in dispensaries and hospitals.

Tuberculosis: The Relationship Between Research and Scientific Inertia

Meanwhile, AIDS continued to kill through so-called opportunistic diseases, which gain a foothold because of the patient’s weakened immune system. One of these is tuberculosis. MSF had long been involved in treatment programs for the disease. One of the obstacles facing medical teams, however, was ensuring proper diagnosis. This relied on old methods and the limited effectiveness of microscopic isolation of the bacillus responsible for the illness in the sputum of patients suspected of having damage to their lungs—the most common clinical form. According to international recommendations, tuberculosis treatment, which lasts at least six months, means isolating the bacillus at least twice in three successive sputum samples over two days. If the results are negative, which is common among children and patients infected with the HIV virus, treatment can be instigated on the basis of a set of clinical and radiological criteria. These procedures mean patients have to travel to treatment centers and involve a significant workload for the laboratory. Following an internal discussion, supported by experts from the University of Liverpool and the Kenyan Medical Research Institute, and based on data from a study carried out in 2005 in Nairobi to assess a microscopic diagnostic technique using concentrated sputum samples, Epicentre was able to evaluate a simplified strategy for diagnosing pulmonary tuberculosis based on one rather than two positive sputum samples. This simple reduction was just as effective, but made it possible to diagnose two-thirds of patients with the disease at their first consultation, reduce the number of laboratory tests by a third, and avoid losing touch with patients while waiting for their test results (Bonnet et al., 2007). In 2007 these results contributed to the change in the WHO’s recommendations for microscopic diagnosis of tuberculosis.

Although this type of research is evidence of a refusal to accept the status quo, MSF and Epicentre nonetheless again found themselves obliged to carry out research designed to improve unsatisfactory diagnostic techniques for tuberculosis although their effectiveness did not, in fact, change radically. This is because MSF is at the end of the chain, and thus only “picks up” old techniques; even a minimal change to these seemed to represent an advance. Indeed, there were few new avenues in tuberculosis diagnosis or treatment suggesting any significant changes likely to improve patient care in the near future. There seemed to be few options for practitioners and patients in the countries of the South, where there is little scope for using sophisticated molecular biology techniques. Alongside its research and scientific papers, MSF added a public communications campaign, which it hoped would raise awareness among key players and funding bodies involved in public policy. In 2003, MSF’s Campaign for Access to Essential Medicines published a document setting out the resources and prospects for tuberculosis diagnosis and treatment (Access Campaign, 2004). The illness had been completely neglected in terms of research and solutions, and future prospects did not look at all promising. The epidemic had spread, and the situation for patients had been getting worse for decades in the face of a somewhat indifferent attitude on the part of public authorities, manufacturers, and medical officials. The public campaign that accompanied the report gave MSF the opportunity to denounce this situation by explaining the serious difficulties it was facing in treating more than twenty thousand new cases each year. While new research is now being pursued within a context of public–private research and development partnerships, and while the WHO’s message on treatment strategies for patients is less dogmatic than it was, there is still a shortage of momentum. MSF’s position has changed little since then, while the focus of Epicentre’s research and its commitment remain the same.

Malnutrition: The Relationship Between Research and Programs

Although it works in the field alongside MSF, Epicentre has not always agreed with the pace of operational priorities. In some situations, the relationship between MSF and Epicentre has been strained. This was the case when treating malnourished children in Niger in the early 2000s. MSF, the Campaign for Access to Essential Medicines team, and Epicentre disagreed at the time on the principles of their respective missions. The conflict was between those who lobbied to prioritize assessing the demand for operational innovation, those who believed in the need to communicate the emergency in necessarily simplistic language, and those who wanted to take the time needed to carry out an effective analysis of the effects of operational choices. Members of MSF who were advocating a change to nutritional protocols wanted data and analyses that would support their point of view. This was where they ran into a lack of understanding from Epicentre, which was focused on managing the constraints around scientific output in unstable areas and the issues that should be subjected to scientific analysis in relation to emergency relief. This example of internal tension within MSF, between groups whose roles and objectives should ideally work in synergy, resulted in the publication of a number of scientific articles (Isanaka et al., 2009).

 

Publishing Scientific Data

Since its creation, Epicentre has been expected to publish its research. Public dissemination of the methods used and results obtained is an integral part of scientific research. It is based on a codified process, the result of which consists of presenting, in a concise and well-argued manner, the essential details of the investigative methods used and the results gathered and analyzed, followed by a discussion of their validity. Epicentre was thus expected to engage in the exercise of scientific writing. Initially, several pieces of research were communicated in the form of letters to the editor of the British scientific journal The Lancet. Since then, the number of articles has increased: no fewer than 250 were published between 1988 and 2008, mostly in English.

An example of Epicentre’s ability to translate MSF’s operational decisions and their effect on the treatment of patients into scientific language was published in The Lancet in April 2006 (Ferradini et al., 2006). This study tried to assess the efficacy of antiretroviral (ARV) combination therapies on a sample of a cohort of HIV-positive patients accepted into a treatment program run by MSF and the Malawian Ministry of Health in the rural district of Chirazulu. This was an innovative project, primarily because of the high prevalence of the disease, the rural environment, and the use of a combination therapy in a single pill, a formulation that did not exist as such in developed countries at the time. The results showed that, in patients who had received more than six months of treatment, the presence of the virus in the blood, measured by its viral load, had fallen to a very low level. This figure suggested, among other things, that this form of treatment had an effect on patient survival. These results confirmed MSF’s operational choices and Epicentre, which had taken responsibility for conducting the study, could ensure they were published in a scientific journal.

A key principle of the submission process prior to publication is a critical peer review of the manuscript. But appropriating and generalizing from the results of Epicentre’s research by any other player in the private or public sectors would have been pointless unless they were rigorously expressed, even if in a very standardized way. It could certainly be argued that the cost of access to scientific journals tends not to favor scientific advances being made universally available, but in fact, the reasons for the lack of recent progress in the diagnosis and treatment of tropical diseases lie elsewhere. There have, however, been some moves towards other editorial models, based on free access to published articles.

Moreover, the editorial process highlights the primacy of channels that are certainly accessible, but which do not always reflect the realities of scientific progress. It is possible to see the effect of a final validation method, a sort of obligatory final stage, although the subject is known and has been discussed and covered extensively in forums, conferences, and journals with a more limited distribution. Sleeping sickness is a good case in point. In 2008, Epicentre reported on five years of work on the treatment of sleeping sickness by giving short presentations at a number of international conferences.In South Korea, at the International Congress for Tropical Medicine and Malaria; in the Democratic Republic of Congo; to the scientific and political authorities of the countries affected by the disease; and in the United States, at the conference of the American Society of Tropical Medicine and Health.A similar observation can be made on new treatments for malaria or the results of ARV treatment programs for HIV-positive patients in the countries of the Global South. Oral communications, or more informal forms of dissemination at meetings of experts, including within the WHO, are often a preliminary to the formal publication process. Epicentre has always made use of these unwritten rules.

Since its creation, Epicentre has sought to establish relationships in both the public and private sectors. It has always seemed quite normal to monitor changes in medical and scientific knowledge and thus identify the main avenues being pursued by other international medical research teams. It is difficult to assess the direct effect of this function, but Epicentre’s decisions to embark on new areas of research has at times clearly had as much to do with its observations on where the gaps lay in the international agenda as the operational constraints being faced by MSF.

Through Epicentre, epidemiology has played a significant role in providing relief in the areas in which MSF operates. The nature of Epicentre’s relationship with innovation is twofold: its integration into the MSF organization makes its work easier, but it is caught up in the rhythm of operations and their constraints.

Initially, introducing the techniques of descriptive epidemiology into work in the field was an innovative move. New light was shed on operational issues—where and how to act—and medical constraints—how to diagnose and treat. The transfer was not simply about reproducing a technology in exactly the same way, however; constant work was needed to adjust and refine quantitative measurement methods. The use of these methods and the results produced have been an ongoing source of criticism and debate.

The next step was MSF’s decision to propose the adoption of new medical practices. Epicentre embarked on studies on which MSF relied in the area of humanitarian medicine, which can be classified as a “latent area of science” (Kourilsky, 2006). Acquiring the techniques and language of science enabled MSF to propose the adoption of new medical practices and to be heard on occasion by both its peers and the public health authorities.

Epicentre’s use of epidemiology cannot be dissociated from the choices made by MSF in terms of medical policy. In fact, Epicentre has to reconcile the rigor of a scientific process with the specific constraints of humanitarian situations and the requirements expressed by the organization during the course of its actions. It is within MSF, as an integral part of its activities, that Epicentre has to confront the dilemmas inherent in the relationship between caring practices and scientific activities in sometimes extreme situations. There is no easy way of resolving these dilemmas: the judgment made depends on the political choices involved in the decision.

 

Bibliography

Bonnet, M., A. Ramsay, L. Gagnidze, W. Githui, P. J. Guerin, F. Varaine. 2007. “Reducing the number of sputum samples examined and thresholds for positivity: an opportunity to optimize smear microscopy.” The International Journal of Tuberculosis and Lung Disease 11 (9): 953–958.

Brown, V., P. J. Guerin, D. Legros, C. Paquet, B. Pécoul, A. Moren. 2008. “Research in Complex Humanitarian Emergencies: The Médecins Sans Frontières/Epicentre Experience.” PLoS Medicine 5 (4), e89.

Burnham, G., R. Lafta, L. Roberts. 2006. “Mortality after the 2003 invasion of Iraq: a cross-sectional cluster sample survey.” The Lancet 368 (9545): 1421–1428.

Campaign for Access to Essential Medicines (Access Campaign), Médecins Sans Frontières (MSF). 2004. Running out of breath? TB care in the 21st century. Internal report.

Centers for Disease Control and Prevention (CDC). 1992. “Famine-affected, refugee, and displaced populations: Recommendations for public health issues.” MMWR Recommendations and Reports 41: 1–76.

Checchi, F., L. Roberts. 2005. Interpreting and using mortality data in humanitarian emergencies. A primer for non-epidemiologists. Network Paper 52. London: Humanitarian Practice Network.

Checchi, F., P. Piola, H. Ayikoru, F. Thomas, D. Legros, G. Priotto. 2007. “Nifurtimox plus Eflornithine for Late-Stage Sleeping Sickness in Uganda: A Case Series.” PLoS Neglected Tropical Diseases, 1 (2), e64.

Ferradini, L., A. Jeannin, L. Pinoges, J. Izopet, D. Odhiambo, L. Mankhambo, G. Karungi, E. Szumilin, S. Balandine, G. Fedida, P. Carrieri, B. Spire, N. Ford, J.-M. Tassie, P. J. Guerin, C. Brasher. 2006. “Scaling up of highly active antiretroviral therapy in a rural district of Malawi: an effectiveness assessment.” The Lancet 367 (9519): 1335–1342.

Grais, R. F., F. Luquero, E. Greletty, H. Pham, B. Coghlan, P. Salignon. 2009a. Forest for the Trees: A critical review of rapid surveys conducted in North Kivu, 2006–2008. Report to an expert committee at the World Health Organization.

Grais, R. F., F. Luquero, E. Greletty, H. Pham, B. Coghlan, P. Salignon. 2009b. “Learning lessons from field surveys in humanitarian contexts: a case study of field surveys conducted in North Kivu, DRC 2006–2008.” Conflict and Health 3 (1): 8–13.

Guthmann, J.-P., F. Checchi, I. Van den Broek, S. Balkan, M. Van Herp, E. Comte, O. Bernal, J-M Kindermans, S. Venis, D. Legros, P.J. Guerin. 2008. “Assessing Antimalarial Efficacy in a Time of Change to Artemisinin-based Combination Therapies: The Role of Médecins Sans Frontières.” PLoS Medicine 5 (8): e169.

Isanaka, S., N. Nombela, A. Djibo, M. Poupard, D. Van Beckhoven, V. Gaboulaud, P. J. Guerin, R. F. Grais. 2009. “Effect of Preventive Supplementation With Ready-to-Use Therapeutic Food on the Nutritional Status, Mortality, and Morbidity of Children Aged 6 to 60 Months in Niger: A Cluster Randomized Trial.” Journal of the American Medical Association 301 (3): 277–285.

Kourilsky, P. 2006. Optimiser l’action de la France pour l’amélioration de la santé mondiale. Le cas de la surveillance et de la recherche sur les maladies infectieuses. Report to the French government. Paris.

Priotto, G., C. Fogg, M. Balasegaram, O. Erphas, A. Louga, F. Checchi, S. Ghabri, P. Piola. 2006. “Three drug combinations for late-stage Trypanosoma brucei gambiense sleeping sickness: a randomized clinical trial in Uganda.” PLoS Clinical Trials 1 (8), e39.

Priotto, G., S. Kasparian, W. Mutombo, D. Ngouama, S. Ghorashian, U. Arnold, S. Ghabri, E. Baudin, V. Buard, S. Kazadi-Kyanza, M. Ilunga, W. Mutangala, G. Pohlig, C. Schmid, U. Karunakara, E. Torreele, V. Kande. 2009. “Multicentre randomised non-inferiority trial of nifurtimox-eflornithine combination therapy for second-stage gambiense sleeping sickness.” The Lancet 374 (9638): 56–64.

Roberts, L., R. Lafta, R. Garfield, J. Khudhairi, G. Burnham. 2004. “Mortality before and after the 2003 invasion of Iraq: cluster sample survey.” The Lancet 364 (9448): 1857–1864.

Working Group for Mortality Estimation in Emergencies. 2007. “Wanted: studies on mortality estimation methods for humanitarian emergencies, suggestions for future research.” Emerging Themes in Epidemiology 4, 9.