Rony Brauman & Michèle Beck
Medical doctor, specialized in tropical medicine and epidemiology. Involved in humanitarian action since 1977, he has been on numerous missions, mainly in contexts of armed conflicts and IDP situations. President of Médecins sans Frontières from 1982 to1994, he also teaches at the Humanitarian and Conflict Response Institute (HCRI) and is a regular contributor to Alternatives Economiques. He has published several books and articles, including "Guerre humanitaires ? Mensonges et Intox" (Textuel, 2018), "La Médecine Humanitaire" (PUF, 2010), "Penser dans l'urgence" (Editions du Seuil, 2006) and "Utopies Sanitaires" (Editions Le Pommier, 2000).
Since 2006, Michèle Beck has worked with MSF in Niger, Chad, Jordan, Syria, Lybia, Ivory Coast and Haiti. In 2014, she was MSF medical team leader in Gaza.
The question of quality in the work of Médecins Sans Frontières has been asked from the very beginning of MSF’s existence. That should come as no surprise: on the one hand, the issue of improving the quality of practice is a part of ordinary professional activity; on the other hand, Médecins Sans Frontières’ work – even at a time when it was still very tentative and limited, in quantitative terms – involved working in distant lands and very specific environments, which demanded adjustments to medical practice as a result. The field work was limited, given the lack of resources, but concerns about improving it, developing it and therefore thinking and talking about it, were already in evidence. The same concern can be seen in the publication, by Médecins Sans Frontières’ founders, of a first joint book in 1976 – an extremely theoretical work that shares the latest findings on the subject of resuscitation and which teaches how to manage a displaced population, insert a chest tube or run a vaccination campaign, which bears no relationship to the reality of work on the ground at the time. Nonetheless, even then, this publication flagged up the necessity of reflecting on quality and practice.
As the next generation of MSF and the development of work in refugee camps came along in the late 1970s and throughout the 1980s, the concern about quality became stronger and more tangible, with the previously contentious question of professionalising and organising Médecins Sans Frontières having now been decided. An embryonic medical department was set up in 1982. I say “embryonic” because at the time it was just one person, but from whom the medical department (known as “med-tech” for “medical techniques”) later developed. Its role was to answer the questions that came in from the field: which antigen to use for a vaccination campaign? Which type of medicine, which diagnosis? These were very practical questions. MSF’s activities, particularly in refugee camps and conflict zones, ranged from curative medicine to various preventive practices, as well surgery and nutrition. As a consequence, it was important to complement everyone’s knowledge by providing back-up at head office. The medical department’s role was therefore to provide documentation and technical support, and it has grown consistently ever since.
Later, in 1986, came the creation of Epicentre and the introduction of guidelines.
The clinical and treatment guide – famously known as the “green guide” – was the first in a series that has been steadily expanded and re-worked to keep it up-to-date. Our concern, in this case, was on the one hand, to ensure a degree of continuity of care for the benefit of patients, since team rotations and the individual habits of carers resulted in repeated disruptions to treatment methods and practices; on the other, it was about simplifying the work of providing support at head office, by making a set quantity of equipment, medicines, everything needed for an operating theatre and essential resources for medical work available in the field. It was essential to improve consistency and standardise; otherwise, a whole array of different practices would have developed and it would have become impossible to answer the very specific requests of every volunteer in the field.
The result was the gradual development of lists of essential equipment and medicines. The creation of Epicentre, on the other hand, expressed a desire to establish a quantitative assessment of an initial situation and the impact of action on that situation, in other words, the health profile at the start of the mission and how it changed over the months, again mainly in the refugee camps. It is worth remembering that clinical practice was not well viewed at the time. MSF was often described, in international health circles, as a band of unthinking cowboys, not unpleasant but amateurs, who handed out medicines and contributed to maintaining bad habits and to spreading resistance to antibiotics and other medicines. Epicentre was our way of showing that we were serious to those who challenged us, and for whom public health was the only thing that mattered. MSF had the courage to talk about “medical care” when the common expression in aid settings was “health care” and behind this little battle of semantics lay seriously conflicting viewpoints. From this perspective, MSF – anchored as it was in the refugee camps – practised in a way that justified curative medicine, but in a less than promising atmosphere. It is important neither to exaggerate nor underestimate the hostility to medical work, given that today it is broadly accepted as both necessary and self-evident. This was not the case in the 1970s and 1980s.
Against this background, the first difficulty I personally observed related to data starting work on gathering and developing standards, which were beginning to become more uniform in a refugee camp, in this case in Malawi. The first paradox was that while MSF was organising its epidemiological data, a measles epidemic was raging in the camp without anyone realising, because of the time lapse between entering and processing the data. The reason I spotted it was not because I was better than anyone else, but because I was visiting, so I spent my days in the camp and had the chance to talk to local personnel. At the fourth dispensary I visited, having heard Malawian nurses talking about measles cases in each of them, I realised there was a measles epidemic in the camp. This raised a lot of questions within the team, which was one of the first to have to spend a lot of time in front of a computer screen, entering data.
Moreover, and again in Malawi, cholera outbreaks had occurred in parts of the camp where there were latrines and taps installed by MSF, yet no cases had been reported in the area around the camp, where no watsan installations had been possible because of the type of soil. This unexpected situation prompted questions over what results could be expected from watsan. In short, questions were raised pretty quickly, in a context where increasing the scale of MSF’s missions and budgets was prompting increased interest in quantitative indicators and assessing activities in numerical terms.
In spite of some undesirable side effects, which we were gradually becoming aware of, a more structured approach to practice was unanimously seen as necessary and was beginning to develop. It speeded up significantly at the beginning of the 1990s, as MSF increased in size at both the national and international levels and new communications methods appeared at the same time. Satellite phones, the internet and e-mail led – at least this is when I date them back to – to rules around validating practice, resulting in a kind of medical micro-management that has increased ever since. It seems to me that it was during the 1990s that the word “validation” began to invade every sphere in a way that makes a lot of people smile almost everywhere, although we use it about anything and everything.
In terms of the organisation of medical work, we have seen an accumulation of layers of control, from advice to medical supervision, with the Medref, the Comed, the CP, the desk doctor, the Medical Department and so on… it is difficult to figure out who is ultimately responsible in medical terms. This division of medical responsibilities has been heightened by an organisational division of specialisms: construction, watsan, HR, finance, admin, procurement, etc. In brief, we have created silos, whose members are all driven by a desire to improve quality within their own area of work. The underlying idea is that overall quality will be achieved by attaining the best quality in all these separate areas, which undoubtedly makes sense at an intuitive level, but breaks down when put to the test.
All of this contributes to improving the overall quality of the work, but at the same time makes decision-making processes more cumbersome, which can sometimes ruin efforts to drive improvements. The question of quality needs to be examined with both these things in mind. I would add, with regard to the temptation of constant control – the famous “micro-management” – that I do not believe there is any more mistrust of what is happening in the field or desire to control missions today than there was in the 1970s and 1980s. The main difference is that the means to exert control did not exist in those days, while since the 1990s, everyone has been just a click or a phone call away.
Everyone, at every level of MSF, is proud of what we have achieved and maintained consistently over the years, and everyone acknowledges the efforts made to improve quality, which is one of the trademarks of Médecins Sans Frontières’ actions. There are failures, which need to be examined, but also successes we can be proud of, and an overall dynamic that must, obviously, be maintained. That’s why questions of dosage and the gap between what is stated in the standard and what actually happens in practice remain unresolved. The complexity and in some cases opacity of procedures, and the gap between procedures and expectations in the field, is always a subject for discussion, question and criticism.
This is the reason we decided to turn our attention to quality for this event. It is not about producing a set of new recipes, which would only prolong the problems we are trying to resolve. It is a matter of thinking collectively about our relationship to current good practices, and to the gap between standards and practices. Should we focus our efforts on processes or outcomes? Who should assess them and based on which criteria? Moreover, is there one overall set of criteria or several possible sets? I am thinking, for example, of the patient point of view compared with the population point of view, or the potential tensions between clinical care for individuals and public health.
These are all questions we intend either to tackle head on, or touch on in passing, but which we will try to examine critically over the course of the day, which has been organised by Michèle, to whom I will now hand over to introduce and lead the day.