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Chapter I In the beginning

Humanitarian medicine is made up of a wide range of practices with few obvious connections between them. Battlefield medicine and surgery, rural dispensaries in remote areas, campaigns to raise awareness about health problems in poor countries, emergency teams in disaster situations, vaccination campaigns, health education, help for marginalised groups in affluent countries and public health advice are just some examples of actions that fall within the scope of “humanitarian medicine” when they are carried out by organisations and in circumstances that can be classified as “humanitarian”.

Chapitres

Introduction

Chapter II Exceptional situations

Chapter III Ordinary situations

Epilogue

Bibliography

To cite this content :
Rony Brauman, Humanitarian Medicine, 1 February 2009, URL : https://msf-crash.org/index.php/en/publications/medicine-and-public-health/humanitarian-medicine-0

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Humanitarian Medicine

Controlling an HIV Hotspot. A Realistic Ambition?

elba.msf — Wed, 02 Nov 2022 11:53:36 +0000

Date de publication

30/11/2022

elba.msf Wed, 11/02/2022 - 12:53

HIV

AIDS

Pierre Mendiharat, Elba Rahmouni & Léon Salumu Luzinga

Pierre

Mendiharat

Deputy Head of Operations, MSF France

By the same author

Elba

Rahmouni

Since April 2018, Elba has been in charge of dissemination at CRASH. Elba holds a Master's degree in History of Classical Philosophy and a Master's degree in editorial consulting and digital knowledge management. During her studies, she worked on moral philosophy issues and was particularly interested in the practical necessity and the moral, legal and political prohibition of lying in Kant's philosophy.

By the same author

Léon

Salumu Luzinga

Responsable des programmes à Médecins Sans Frontières, Centre opérationnel de Paris (OCP)

By the same author

This article was published on December 22nd, 2021, in the Journal of Humanitarian Affairs (Issue 3, Volume 3). A synthesis of this roundtable is available, both in English and in French.

Despite a concerted international effort in recent decades that has yielded significant progress in the fight against HIV/AIDS, the disease continues to kill large numbers of people, especially in certain regions like rural Ndhiwa district in Homa Bay County, Kenya. Although there is still no definitive cure or vaccine, UNAIDS has set an ambitious goal of ending the epidemic by 2030, specifically via its 90-90-90 (treatment cascade) strategy – namely that 90 per cent of those with HIV will know their status; 90 per cent of those who know their status will be on antiretroviral therapy and 90 per cent of those on antiretroviral therapy will have an undetectable viral load. These bold assumptions were put to the test in a five-year pilot project launched in June 2014 by Médecins Sans Frontières (MSF) and Kenya’s Ministry of Health in Ndhiwa district, where an initial NHIPS 1 study by Epicentre (MSF’s epidemiology centre) in 2012 revealed some of the world’s highest HIV incidence and prevalence, and a poor “treatment cascade”. Six years later a new Epicentre study, NHIPS 2, showed that the 90-90-90 target had been more than met. What explains this ‘success’? And given the still-high incidence, is it truly a success? What follows is an interview on the political, scientific, and operational challenges of the Ndhiwa project with MSF Deputy Director of Operations Pierre Mendiharat and physician Léon Salumu, Head of MSF France Kenya programs, conducted by Elba Rahmouni.

Introduction: MSF and the Fight against the HIV Epidemic

Elba Rahmouni: To start, I’d like to broaden the scope of this interview by looking at how Ndhiwa fits into MSF’s long history with AIDS. Almost forty years after the epidemic began, can you retrace MSF’s action in the fight against this catastrophe?

Pierre Mendiharat: In the early 1990s there were HIV outbreaks in nearly all the places where MSF was already working. Without any treatments, caring for those patients was impossible and end-of-life support very difficult. Patients were highly stigmatised, even by some in the medical profession. There was an internal debate at the organisation about whether it was pertinent for MSF to do prevention projects; because there was no vaccine, prevention was based solely on behavioural changes like condom use and abstinence.

In 1996, the advent of triple therapies [combinations of several antiretroviral drugs (ARVs) against AIDS] raised the question of access to treatment for the hardest-hit populations. The vast majority were in the South – particularly in sub-Saharan Africa – and the drugs were in the North. The extremely high price of treatment [$10,000 per patient per year when triple therapy first arrived], the lack of generic versions and the requirement that patients pay part of the costs put triple therapy out of the reach of patients in resource-limited countries. Taking its cues from patient organisations in the North, such as ACT UP, MSF began doing public advocacy to make triple therapies accessible to patients in all countries.

The first treatment-related actions by MSF members consisted of helping individual colleagues and friends by secretly bringing in drugs that were impossible to find locally. That was also the era of our first HIV programmes, in particular in Thailand and Kenya [in Homa Bay County, where the operation began in 1996], the creation of the Access CampaignAccess to Essential Medicines Campaign: https://msfaccess.org/ (accessed 24 November 2021).in 1999, our activism in South Africa alongside patient organisations and the first victories against the pharmaceutical companies, who agreed to go beyond their policy of charging the same price worldwide and adjust their prices to a country’s resources.https://msf-crash.org/en/publications/agir-tout-prix-negociations-humanitaires-lexperience-de-msf/i-stories#south-africa.-msf,-an-african-ngo? (accessed 24 November 2021).By the early 2000s the price of the treatments had fallen considerably, to about two hundred dollars per patient per year.

With the arrival of two global actors with multibillion-dollar budgets, namely The Global Fund to Fight AIDS, Tuberculosis and Malaria in 2002 and the United States’ PEPFAR programme President’s Emergency Plan for AIDS Relief.in 2003, the 2000s were a time of worldwide consensus on radically boosting the number of patients on treatment. At MSF, the number of HIV projects supplying drugs to initially small, and then larger, patient cohorts in Africa, Asia and Latin America multiplied. To offset the burden such large cohorts were placing on health systems, we had to find ways to simplify and decentralise care. MSF contributed greatly to the operational research, and that effort brought us a certain fame in the global health world. The PEPFAR and Global Fund programmes were bearing fruit, and by the early 2010s, ARVs were available in most of the world’s countries; the barriers to treatment for people living with HIV lay [and still lie] mostly in local health systems’ weaknesses and a lack of political will.

For the past decade or so, MSF has had two main objectives. The first is to design projects with a population-based approach in an attempt to impact virus transmission, as was the case with the Ndhiwa project. The second is to improve medical quality, in particular for more difficult-to-care-for patients like children or patients in treatment failure, given that national systems are now capable of managing the simple cases relatively effectively. For the medical teams it’s a question of ensuring successful treatment for all patients – in particular, by measuring viral loads and by taking drug resistance and individual constraints like mobility into account. The number of HIV projects has decreased, and in a sense they have become more specialised.

In contrast to the 2000s, MSF is now a minor player in the fight against HIV. We are, however, influential with regard to developing innovative strategies and care models such as simplified management. Thanks to our long-standing efforts in the fight against HIV, we have developed some competence in following patients with chronic disease.

Controlling an Epidemic Hotspot

Elba Rahmouni: What were MSF’s initial aims in Ndhiwa district?Since the decentralisation of governance required by the new constitution (adopted in 2010), Kenya has been made up of 47 counties, themselves divided into districts. Thus, the former Nyanza Province, located in southwestern Kenya on the shores of Lake Victoria, includes Homa Bay County, which itself contains eight districts, of which Ndhiwa is one.

Léon Salumu: The Ndhiwa project was designed with the admittedly ambitious aim of reducing HIV incidence in the district using every known biomedical tool – that is, mass testing, early treatment of all positives, better patient care and follow-up and circumcision – to ensure continuity of treatment and sustained viral suppression. It was a medium-term four-year population-based approach;A population-based approach aims to improve the health status of a population in a given territory via collaboration among different health actors in that territory.it targeted the entire population of Ndhiwa [rather than just a cohort of patients] in the hopes of controlling this health calamity.

Pierre Mendiharat: The Ndhiwa project was being devised at a key moment in HIV research. In 2008, the Swiss health authorities claimed – in what would come to be known as the Swiss Statement – that patients who were taking their medications correctly were no longer contagious. That claim, which was especially crucial to serodiscordant couples,In a serodiscordant couple one partner is HIV-infected and the other is not.was the subject of debates at that year’s IAS [International AIDS Society] conference in Mexico: Has this really been proven? and Can we tell the patients this? Then, in July 2011, the HPTN 052 randomised trial in a cohort of serodiscordant couples showed that early ART (antiretroviral therapy) had resulted in a 96 per cent reduction in transmission to non-infected partners. That confirmation of the Swiss Statement gave rise to the notion that it might be possible to control the HIV epidemic, because the treatment becomes a means of prevention; if everyone with HIV has access to treatment, then transmission will stop.Up to that point, prevention programmes had recommended only condom use or abstinence, two behaviours that failed to control the epidemic. In the absence of biomedical tools, public health policies called for behaviour changes; these required a lot of discipline and gave an unreliable result.In practical terms, that meant urging everyone to get tested, making access to treatment universal, establishing long-term relationships with patients and then watching to see whether the strategy resulted in a lower incidence at the population level. The plan was totally conjectural; although a halt or dramatic reduction in transmission had been shown to occur in a cohort of serodiscordant couples, it had never been proven at the population level.

Elba Rahmouni: How did MSF take up the 90-90-90 strategy?

Pierre Mendiharat: MSF fully subscribes to the objectives summarised by the ‘90-90-90’ slogan, which was only ever the quantitative expression of good practices for controlling an epidemic, i.e. giving the greatest possible number of patients access to diagnosis and treatment and then providing high quality care to ensure follow-up and successful treatment. The question then becomes whether those objectives are sufficient. What about the other 10-10-10? Adopting those targets means being satisfied that only 73 per cent of HIV-positive people have an undetectable viral load. UNAIDS now recommends aiming for 95-95-95.UNAIDS (2015), ‘Understanding Fast-Track: Accelerating Action to End the Aids Epidemic by 2030’ (Geneva: UNAIDS), www.unaids.org/sites/default/files/media_asset/201506_JC2743_Understanding_FastTrack_en.pdf (accessed 24 November 2021).

When the Ndhiwa project started in Kenya in 2014 – before the results from Epicentre’s 2018 epidemiological survey Ndhiwa HIV Impact on Population Survey 2 (NHIPS 2) became availableMSF (2020), ‘VIH : l’amélioration de la prise en charge a fait chuter la proportion des personnes infectés dans l’un des foyers les plus touchés au monde’, press release, 24 November, www.msf.fr/communiques-presse/vih-l-amelioration-de-la-prise-en-charge-a-fait-chuter-la-proportion-des-personnes-infectees-dans-l-un-des-foyers-les-plus (accessed 24 November 2021).– we weren’t really sure whether the 90-90-90 strategy was realistic, though we had already come close in Chiradzulu, Malawi. I don’t even think most of us believed in it, given the enormous amount of individual and collective discipline the strategy demanded.

Léon Salumu: All programmes have targets – otherwise it would be impossible to measure the progress made by organisations or countries more generally. In addition, our organisation frequently adjusts its objectives as new studies come out. While the 90-90-90 targets – which were based on the latest knowledge on the individual and collective benefit of early HIV treatment – were certainly ambitious, they were necessary, insofar as they made it possible to set a course. The targets also made it possible to link individual benefit – i.e. treating people to reduce mortality – to collective benefit – i.e. reducing transmission by identifying patients and starting early treatment in the hopes of controlling the epidemic.

Elba Rahmouni: How did the organisation position itself with regard to the UNAIDS slogan about ending the epidemic by 2030?

Pierre Mendiharat: Unlike the 90-90-90 targets, eliminating HIV by 2030 has never been part of our strategy. Generally speaking, that type of objective is very foreign to how MSF works, i.e. having narrowly focused projects and more short-term objectives. ‘Ending AIDS by 2030’ is a slogan that UNAIDS has been using since the 2011 IAS conference in Vienna to re-energise institutional donors, given what was perceived to be ‘donor fatigue’ [decline in donations for fighting the HIV epidemic]. We certainly should have distanced ourselves more sharply from that misleading slogan, because I think anyone who has studied the subject seriously knows that there’s no hope of being finished with HIV by 2030. MSF communications have always evoked the reality of the disease as experienced by the patients, the treatment failures, the day-to-day problems and the still-high mortality, often oversimplifying, without really doing justice to the very significant progress that has also been made.

The Ndhiwa Project: Toward a Simplified Model of Care

Elba Rahmouni: What were the major phases of the project?

Léon Salumu: During the first two years [2014 and 2015], MSF expended significant resources in the villages in testing and awareness-raising campaigns conducted outside of the health centres, whose capacities we also strengthened. Then, beginning in 2016, we worked to decentralise care and laboratory activity in order to improve access and follow-up [increasing the number of facilities that could test, start treatment and dispense the medications] and to simplify our model to ensure continuity of care, particularly after we left. In 2018, after we had done testing in the entire district, we continued testing at healthcare facilities, reserving home testing for the contacts [family and friends] of those who tested positive in the centres. We also focused on specific categories like children and adolescents, severe cases and patients in treatment failure.

Elba Rahmouni: What, in concrete terms, does this idea of developing a simplified care model mean?

Pierre Mendiharat: At the Ndhiwa project, like at others, it meant further reducing the number of visits. In countries with weak health systems, you have to lighten the workload for the personnel who are following cohorts with thousands of patients and enable them to focus on visit quality. From the patient’s perspective, less frequent visits can be a significant advantage in terms of time and transportation costs. We offered visits every six months and the option of picking up the medications every three months. That is not so easy to implement because we had to ensure that there was always a stock in health centres and that the patients were able to store their drugs at home. We also set up Community ART Groups (CAGs), a model used at other MSF missions in the southern region; in remote villages, the patients constitute a group. The group members take turns going for an annual visit and bringing back the drugs for the other patients, who don’t have to go anywhere. We’ve been trying to do all that for the past few years as part of the DSDM, or differentiated service delivery model; rather than forcing patients to be followed in a certain way, each person can choose how they would like to be followed. Though it seems obvious, in practice it wasn’t being done systematically. So, even in the HIV sector, which is supposed to be somewhat advanced in terms of considering the patients’ opinion, there is still lots of room for improvement.

Partnership with the Ministry of Health

Elba Rahmouni: This project was conducted in partnership with the Ministry of Health. Why? What did that entail?

Pierre Mendiharat: What we had in mind right from the start was to create an activity that was sustainable [because HIV infects patients for life, treatment doesn’t stop until they die] and replicable. By demonstrating that it’s possible to have a population-scale impact on transmission, we were hoping the health authorities would try to do the same thing in other districts. Another major aim of this project was behaviour change, since the entire adult population would have to be screened every year. So we had to act in concert with legal authorities like the Ministry of Health (MoH), and also other leaders like traditional chiefs and local notables.

While we always say that we work with the ministries of health, we generally prefer to find a place within the health system that allows us to be as autonomous as possible. MSF has historically worked hard to be able to act as independently as possible; while this has been successful, it has also had the disadvantage of making us notorious isolationists who have learned little about working in partnership. MSF staff are unaccustomed to consulting with ministerial authorities before making important decisions; we tend to make our decisions after internal consultation, and then think about how to convince the ministry that it was the right decision. There are many situations, however, where we could benefit by working with others – certainly more than there were 30 years ago, because the capacities of the countries where we work and of other aid actors has increased. Now we’re trying to fight our isolationism. Right from the start, work at the Ndhiwa project aimed to be much more balanced, with technical committees and steering committees within which the MoH, MSF and other HIV actors in the county were supposed to make joint decisions. Yet the first head of mission explained that he had to constantly struggle with his colleagues to make sure that the time frame for decision-making allowed for discussion with the other actors.

Léon Salumu: We didn’t have just one collaboration, but two: one with the MoH and the other with the village chiefs and influential figures at the local level. It was essential to ensuring continuity of care after our departure. In order to work with the MoH we had to revise our own standards to adapt to the realities in the field, in particular regarding the number of caregivers, the protocols and compensation. On the other hand, the participation of village chiefs and local figures in developing our activities was an important aspect of their success. They were involved in all phases of the project, especially when it came to setting up testing and awareness-raising activities. That collaboration was a way of asking ourselves, ‘What is essential to the patients with regard to their care?’ One answer, for example, was being able to get medications close to home.

Elba Rahmouni: This project was developed at a time when Kenya was undergoing significant changes in its constitution, with the so-called devolution process giving the regions and their subdivisions greater autonomy. Did that decentralisation process have an impact on how the project was conducted?

Léon Salumu: The decentralisation of power also meant decentralisation of our interlocutors. The devolution was a great help to us, because the decision-makers were nearby in the field, and not in the capital. Hence our interlocutors were well acquainted with the reality in the field. However, the central government retained responsibility for defining policies and protocols and for supplying diagnostic tests and drugs. While we often had to deal with coordination problems between the two levels, devolution enabled us to quickly decentralise care by enabling more facilities to test and dispense HIV drugs. It also allowed us to test some simplified care strategies without having to get validation by national authorities.

Social Mobilisation

Elba Rahmouni: The project’s success was predicated on significant behaviour changes on the part of the population. What did you do to bring about those changes, and with what successes and failures?

Pierre Mendiharat: The relationship between caregivers and the cared-for is always unbalanced, with the caregivers in a position of superiority. This is true for both psychosocial and patient education visits and for public health messages aimed at the population as a whole. HIV programmes have relied heavily on attempts to change population behaviour, in this case prescribing abstinence [particularly PEPFAR-funded programmes], fewer sexual partners and routine condom use. These rules overwhelmingly continued even after such policies failed. That was particularly true in this part of Kenya, where the anthropological literature had established a link between the HIV epidemic’s explosion and traditional sexual practices in the Luo community. A survey conducted by Dr Xavier PlaisancieXavier Plaisancie’s MD thesis, Representations of HIV and Impact on Care Seeking among the Men of Homa Bay, Kenya, 9 June 2020, https://msf-crash.org/en/publications/medicine-and-public-health/representations-hiv-and-impact-care-seeking-among-men-homa (accessed 24 November 2021) was the subject of a Cahier du CRASH. That process was the subject of a regular dialogue between Xavier Plaisancie and MSF-CRASH research centre members Jean-Hervé Bradol and Marc Le Pape. The survey described, in particular, the wide range of institutional actors (doctors, politicians, religious leaders, etc.) responsible for the abstinence directive.among the male population of Homa Bay showed the contradictions that existed between the social rules regarding normalcy and virility and the public health messages, and the difficulty individuals had in resolving them.

In Ndhiwa, we immediately made clear our desire not to venture onto this ‘anthropological’ terrain and to focus more on ‘biomedical’ tools: screening, treatment, viral load measurement and circumcision. While that required that patients adopt certain health behaviours, it had little impact on sexual practices and we scrupulously avoided any moralising. We were mindful of the quality of the caregiver-patient relationship both in the design phase of the project and in its implementation, conducting surveys in an attempt to understand how our actions and messages were perceived by patients. I think that strategy contributed to the project’s success, as measured by the very good testing numbers.

Léon Salumu: A number of studies have shown the tensions that existed in the caregiver-patient relationship. Caregivers often act like deciders who give orders without explanation, and ask that patients simply obey. In Ndhiwa, village-based activities allowed us to break those habits to some extent. At home visits, the medical team had to start by introducing themselves, and then explain and justify what they were doing. It was the person who welcomed the caregiver; that person had the opportunity and ability to ask whatever questions he or she wanted in order to understand, and the caregiver took the time to answer. The patient could then make an informed choice about refusing or agreeing to the test. In the health centres, in contrast, caregivers spend little time explaining and patients have hardly any opportunity to ask questions. Caregivers tend to assume that if a patient has come in, they consent to the various medical acts – including testing! It’s unfortunate that we did not do enough to improve that aspect at healthcare facilities. Home visits enabled the teams to understand and integrate the importance of real dialogue with patients.

I had an opportunity to participate in that activity and I was impressed by the teams’ engagement and willingness to listen; their work was appreciated and undoubtedly helped change behaviours in terms of testing, as evidenced by the fact that more than 93 per cent of HIV patients knew their status at the time of the 2018 Epicentre survey, compared to 60 per cent six years earlier.

Pierre Mendiharat: There are indeed guidelines and trainings that all stress empathy, listening, respect and being non-judgmental. We can reasonably hope that they will pay off. But the quality of the caregiver-patient relationship is hard to assess. The survey conducted by MFS between 2016 and 2018 among Ndhiwa patients who had gone through periods of treatment failure showed the lack of social and economic support in the programme, though some patients in serious difficulty could have used them.Rose Burns et al. (2019), ‘“I saw it as a second chance”: A qualitative exploration of experiences of treatment failure and regimen change among people living with HIV on second- and third-line antiretroviral therapy in Kenya, Malawi and Mozambique’, Global Public Health, 14:8, 1112–24, doi: 10.1080/17441692.2018.1561921.It also showed that the conversation and care were not personalised enough. Lastly, there was no robust mechanism for preventing and detecting patient abuse. Nevertheless, the inequality and in some cases violence that characterises the relationship between the medical profession and patients goes beyond the therapeutic relationship, reflecting the inequalities in society as a whole.

Elba Rahmouni: What was the impact of mobile testing campaigns in Ndhiwa’s villages?

Léon Salumu: The testing campaigns, both home-based and in the villages, gave us access to hard-to-reach people – primarily men who did not frequent healthcare facilities on a regular basis. Screening ‘outside the walls’ of health centres [by MSF or other actors] accounted for 15–20 per cent of the tests; 80–85 per cent of people were tested at healthcare facilities. While we focused on mobile testing at the start of the project, we later chose to support the healthcare facilities more [compared to the community-based part], to make testing activities sustainable. At the healthcare facilities, we set up a strategy for tracing the contacts of those testing positive. That involved asking the person who tested positive to encourage family members and contacts to come get tested.

Pierre Mendiharat: When encouraging people to get tested, it is essential not to underestimate the terrible ordeal that learning their HIV-positive status always is, due to the impact on their emotional, family and sex lives – on top of their fear of illness and death. Nevertheless, we surely benefitted from an underlying change that was occurring: the HIV epidemic had become so widespread in the region that stigmatisation was declining. A quarter of adults there are HIV-positive, and everybody among the three-quarters that are HIV-negative knows, or has known, several HIV-positive people.

Elba Rahmouni: The project also considered expanding access to male circumcision, which several studies say reduces the risk of contracting HIV by 50–60 per cent. Why did you end the circumcision activity?

Léon Salumu: We ended that activity because other organisations were taking care of it and getting better results. Culturally, circumcision isn’t readily accepted by Ndhiwa’s Luo community. Unlike us, the other actors were giving cash or clothing to candidates who agreed to be circumcised. We didn’t use that strategy because we couldn’t agree on it internally. The ‘opponents’ argued that paying someone to be circumcised would influence their choice. To me, it was a matter of compensating them for the lost income from the days they couldn’t work after the operation. Aside from that debate, we would have done it if others weren’t doing it or weren’t getting good results.

The Results

Elba Rahmouni: After the first Ndhiwa HIV Impact in Population Survey (NHIPS 1) epidemiological survey, conducted prior to the project’s opening in 2012, Epicentre did a new survey (NHIPS 2) in 2018. A comparison of those two studies was needed to provide follow-up and assess the project. The results showed a markedly improved treatment cascade and a reduction in incidence and prevalence. What conclusions can we draw from this?

Pierre Mendiharat: The results were better than we had hoped; according to the NHIPS 2, it wasn’t 90-90-90 that we achieved, but 93-97-95. Fewer than 12 per cent of HIV-positives had a detectable viral load and were potentially contagious. That represents 16,000 people who had access to a treatment that was working, which is a remarkable result.

It was harder to answer the question about the decline in the incidence of new infections, due to a statistical problem of overlapping confidence intervals. In 2012 there was a 95 per cent probability that the incidence was between 1.1 and 2.5 per cent per year, and in 2018 there was a 95 per cent probability that it was between 0.4 and 1.2 per cent per year. So, there was an extremely low, but not zero, probability that the incidence fell somewhere between 1.1 and 1.2 per cent in both 2012 and 2018. A larger sample would have been needed to ensure the robustness of the comparison. There were, however, other indicators pointing to reduced transmission of the virus. In 2018, 88 per cent of HIV-positives had an undetectable viral load and thus were not contagious, compared to only 40 per cent in 2012; that’s a huge difference. Next, the prevalence among 15- to 24-year-olds fell compared to 2012; that is consistent with low incidence in that age group. So we at MSF were in agreement on the claim that the incidence likely fell in the years prior to 2018, and that we therefore achieved the unheard of and very ambitious goal of markedly reducing virus transmission in a place where the HIV epidemic had been most devastating. I think we can be proud of having contributed to that outcome.

Elba Rahmouni: To what extent can MSF take credit for those good results, given that other actors – the Ministry of Health and EGPAF [Elisabeth Glaser Pediatric AIDS Foundation], in particular – were also working in the district?

Pierre Mendiharat: It’s impossible to know how much can be attributed to MSF, since the project was conducted in partnership and in complementarity with the Ministry of Health and the other healthcare actors, themselves funded by institutional donors. The advantage of a partnership lies in the outcomes that can be achieved together. To try to determine MSF’s added value we would have to compare with similar, neighbouring districts or with other actors we weren’t working with, but we don’t have any equivalent, equally detailed, surveys.

Elba Rahmouni: What led to those good results?

Pierre Mendiharat: There is no magic formula in the fight against HIV. Without a vaccine, we had to use whatever we had – from health centre laboratories to hospitals to village-based actions. That general mobilisation took a lot of resources, sometimes to the detriment of other diseases, but given the prevalence in Homa Bay, I think it was justified.

And then there are the people behind the projects. The determination and long-term commitment of some key people were crucial to achieving those good outcomes; they had to stay on course despite the inertia inherent to any large organisation, whether MSF or the Ministry of Health. I’m thinking about the heads of mission, the project coordinators, the deputy medical coordinator, the epidemiologists, the desk manager and the Medical Department HIV advisor who supported the project for many years.

Elba Rahmouni: The KENPHIA (Kenya Population-based HIV Impact Assessment) survey is a national survey on HIV done in 2018 by the Kenyan Ministry of Health. How would you interpret the results of that survey?

Pierre Mendiharat: The results of the KENPHIA national survey are broken down by region. The only results in Homa Bay County that weren’t as good as the NHIPS 2 results in Ndhiwa [a district within that county] pertained to the percentage of HIV-positives tested. Systematic home testing in Ndhiwa district and the massive mobilisation it both required and generated was key to gaining a few extra percentage points. However, the results were almost the same for the percentage of patients who tested positive and actually started treatment, and for the percentage of those patients who had an undetectable viral load [the second and third ‘90’]. In that regard, the 2015 change in the national protocol in favour of Test & Treat [offering treatment to patients as soon as they test positive] was crucial.

Léon Salumu: I’m not surprised that there wasn’t much of a difference between our results and those from the KENPHIA survey. First, they aren’t our results, but the results of a collaboration with the Ministry of Health and the other actors [working throughout the country]. It also proves that more resources aren’t always needed to get better results. We contributed to that success, and I think the most important thing now is being able to sustain it.

Elba Rahmouni: In Ndhiwa district, MSF was willing to take on a very large endemic focus and provide an enormous amount of resources [200 healthcare personnel, free care, etc.] for a small population [the district had 242,726 inhabitants in 2015]. Is this type of project really sustainable and replicable?

Pierre Mendiharat: As explained earlier, we were hoping from the start to set up a sustainable, replicable activity, and that premise led us to work very closely with the Ministry of Health, and even have university partners [INSERM (French National Institute of Health and Medical Research) and Harvard] do a ‘cost-effectiveness’ analysis of the intervention – with very positive results, fortunately. The cost-effectiveness aspect of the intervention is important, because it suggests that the Kenyan political authorities can economically justify devoting the resources needed to use the approach on a broader scale. The question of institutional capacity and the number of qualified people that that would require still stands, however.

MSF’s Departure and the Project as It Now Stands

Elba Rahmouni: How did you organise MSF’s departure?

Léon Salumu: From the start of the project, our concerns centred on the continuity of our activities; as a result, we based what we were doing on MoH standards. All additional personnel were recruited in accordance with MoH standards and at MoH salaries, to facilitate their retention [50 per cent of the staff were ultimately retained in 2020]. The MSF teams did the mentoring, which consisted of long-term individual support for healthcare personnel. We had about twenty MSF mentors at the start of the project, and then gradually reduced the number and more accurately gauged the MoH teams’ autonomy. We currently have only four mentors, who intervene at the request of MoH staff. It’s a good transition that can go on as long as necessary.

Elba Rahmouni: What are your current objectives?

Léon Salumu: We currently have two major objectives: to preserve the gains achieved during our six years in Ndhiwa, and to continue to collaborate with the other actors to address any jointly identified gaps or challenges. In practical terms, we are working on initiating third-line treatment in patients who need it.Patients who fail the second-line treatment are put under third line following the resistance genotype result.These patients are currently waiting six to eight months before switching treatments. We are working together to shorten that wait, and in particular are proposing to speed up the process by facilitating local decision-making without going through a national committee [as is recommended at the central level]. We are also working with the MoH to improve follow-up for adolescents, for whom the treatment failure rate is still about 20 per cent. In the hopes of improving their treatment adherence, we are devising specific management strategies for adolescents: special days and clinics and support that is appropriate to each adolescent’s specific needs.

Elba Rahmouni: Once the Ndhiwa project ends, will the treatment cascade be maintained?

Léon Salumu: It’s hard to say. In 2019, I had hopes that that would be the case. Since our involvement was significantly reduced, we have continued to monitor the various indicators, using MoH data, to make sure that the cascade is preserved and to offer support if needed. I was convinced that the Kenyan health system would be able to continue testing, treating and following patients, and retain them, without an outside partner. The KENPHIA survey was very encouraging in that regard. What concerns me now is knowing how to sustain those positive results in the current context of the COVID-19 pandemic and its attendant restrictions.

Elba Rahmouni: What have you done in response to the COVID-19 epidemic?

Léon Salumu: The COVID-19 pandemic caught everyone by surprise. I think we overreacted by quickly applying overly restrictive measures. In April 2020 we thought, ‘patients with HIV are at high risk and we have to protect them by limiting their contact with healthcare facilities’. To ensure that they continued their treatment, we focused on giving out three-month supplies of drugs. But distributing the drugs was not enough; we should also have kept in contact with the patients and known whether they were taking the drugs – especially the high-risk patients. In many countries, a lot people were in difficulty, and didn’t have food. We should have come up with some innovative strategies that would have allowed patients to continue their treatment and get appropriate social support and follow-up, without being put at risk. We realised that most of our patients didn’t have a phone, so we couldn’t do telephone follow-up. With the patient group system, you only have to contact one person to get access to the others. But that system doesn’t work for every patient [in Uganda, where the practice was developed, only 20 per cent of patients are on that model]. And using community leaders to reach patients isn’t easy either, because some patients don’t want to disclose their illness.

Patients began returning in summer 2020, but we still don’t know whether there were gaps in their treatment. These are things we’ll have to explore in order to determine the impact of the COVID-19 pandemic on our HIV patients.

Elba Rahmouni: How does MSF manage AIDS patients in projects that do not specialise in HIV?

Léon Salumu: Although we adopted a resolution in 2008–09, on the medical department’s initiative, to include HIV management at all of our projects, that is currently far from being the case. The teams always find some reason not to do it. Some still don’t think it’s a good idea to start lifelong treatment at a short-term MSF project. I have a hard time understanding this position, because it’s the patient’s decision, not ours. HIV treatments are now available in every country. So we have the option of starting treatment and at the same time support patients by referring them to another facility where they can continue their treatment. And if that’s not possible, we can explain the situation and let the patient decide. In addition, MSF projects that are only supposed to last six months often go on for years. As inconceivable as it may seem, there are still some projects where people being tested for blood donations are not informed that they tested positive for HIV. We should aim for a whole-patient management approach, including HIV management, and use what we’ve learned from HIV to develop ‘simple’ models for chronic disease management and follow-up.

Elba Rahmouni: What is the current status of the worldwide effort to control the HIV epidemic?

Léon Salumu: Mobilisation against the HIV epidemic is still strong, and we should keep it up so that previous efforts can be sustained. Now, with the COVID-19 pandemic, we need to remain vigilant, especially when it comes to the countries that the Global Fund considers somewhat higher-income [Kenya, in particular] and, as a result, are supposed to have their funding cut. That change will have to be taken into account so that they are not penalised. That’s an issue we’ll need to keep a close eye on.

To cite this content :
Pierre Mendiharat, Elba Rahmouni, Léon Salumu Luzinga, Controlling an HIV Hotspot. A Realistic Ambition? , 30 November 2022, URL : https://msf-crash.org/index.php/en/publications/medicine-and-public-health/controlling-hiv-hotspot-realistic-ambition

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Controlling an HIV Hotspot. A Realistic Ambition?

MSF and Ebola in Nord Kivu. Positioning, Politics and Pertinence

elba.msf — Fri, 14 Oct 2022 13:54:10 +0000

Date de publication

04/11/2022

elba.msf Fri, 10/14/2022 - 15:54

Natalie Roberts

Natalie

Roberts

Doctor, qualified in emergency medicine, surgery, and tropical medicine, with a Master's degree in the Political Economy of Violence, Conflict and Development (SOAS University of London) and a Master's degree in the History and Philosophy of Science (University of Cambridge), Natalie Roberts joined MSF in 2012. She completed field missions in Syria, Yemen, CAR, Pakistan, Ethiopia, Ukraine, and the Philippines before joining the Paris headquarters in 2016 as Emergency Programs Manager. Since joining Crash in late 2019, she has focused particularly on issues around epidemics, including Ebola, and access to medicines.

By the same author

This article was published on December 22nd, 2021 in the Journal of Humanitarian Affairs (Issue 3, Volume 3).

This article explores the actions of Médecins Sans Frontières during the 2018–20 Ebola outbreak in Nord Kivu, in the Democratic Republic of Congo. Based on the experiences of practitioners involved in the response, including the author, and on the public positioning of MSF during the first year of the epidemic, it argues that although the actions of response actors were usually well intentioned, they could rarely be described as lifesaving, may have exacerbated disease transmission as much as limited it and had the perverse effect of fuelling corruption and violence. The article documents and analyses contradictions in MSF’s moral and technical positioning, and the complicated relationship between the organisation and the international and Congolese institutions leading the response. It argues that the medical and social failure of the response was the result of an initial belief in a strategy designed at a time when the only realistically attainable outcome was to relieve suffering, and of the later inability of the organisation to convince the authorities in charge of the response to adjust their approach. It suggests that for future success new protocols must be elaborated and agreed based on a better social and political comprehension and a better understanding of the tools now available.

Introduction

The Ebola epidemic that occurred in eastern Democratic Republic of Congo, primarily Nord Kivu, between 2018 and 2020 was the first major outbreak of the disease since West Africa 2013–16. Dramatic biomedical progress was made before and during the Kivu outbreak, including the rapid development of effective tests, treatments, vaccines and care interventions. Response efforts were marked by an extraordinarily large budget dispersed among a plethora of scientific, public health, UN and humanitarian organisations, as well as the Congolese government and state institutions. Building on its long-standing presence in the region as well its prominent role in the response to the West African epidemic, Médecins Sans Frontières (MSF) positioned itself as a key response actor from the first day of the outbreak. Yet despite incorporating all the elements considered requisite for success, the Kivu response was eventually labelled ‘a systematic and catastrophic failure that left thousands dead’Médecins Sans Frontières (2020), ‘How the Ebola Response Failed the People of DRC’, opinion, 24 March, www.msf.org/how-ebola-response-failed-people-drc (accessed 5 October 2021)..

After working in Nord Kivu for the French section of MSF between February and September 2019, I was asked by the Director of Operations to research the epidemic and MSF’s activities in response to it, to inform future choices. Why and how did the response ‘fail’, and what was MSF’s contribution toward that? Could we avoid repeating these errors in future, and how? As well as reflecting on my own experience and reviewing MSF internal documents related to the outbreak, I interviewed MSF and non-MSF practitioners involved in the response, asking them to describe their intentions, their actions, the obstacles they faced and their evaluation of the results. Working on the basis that MSF’s freedom of action ‘depends largely on the organisation’s ambitions, the diplomatic and political support it can rely on, and the interest taken in its action by those in power’Magone, C., Neuman, M. and Weissman, F. (eds) (2011), Humanitarian Negotiations Revealed: The MSF Experience (London: Hurst & Co)., this article explores the contradictions in MSF’s moral and technical positioning before and during the Kivu epidemic, and analyses what impact the complicated relationship between the organisation and the international and Congolese institutions leading the response had on MSF’s actions, and on our perceptions of them. The article is organised chronologically, first providing background, then examining the significance of selected key events during the first year of the epidemic on the positioning of the actors executing the response. It focuses on MSF, for whom two pivotal events occurred during that period: attacks on two MSF-run Ebola treatment facilities in February 2019, and changes in the leadership of the response in July 2019.

Context

MSF and Ebola in West Africa

The largest epidemic of Ebola ever recorded started in West Africa in late 2013 and ended in 2016. MSF received praise for the rapidity and scale of its response, and for highlighting the inadequacy of the World Health Organization (WHO) Birrell, I. (2014), ‘The Ebola Outbreak Has Produced Some Real Heroes – but Western Governments Are Not among Them’, Independent, 19 October, www.independent.co.uk/voices/comment/ebola-outbreak-has-produced-some-real-heroes-western-governments-are-not-among-them-9804894.html (accessed 5 October 2021).. MSF was ‘considered a reference point as a medical and humanitarian organisation, with major legitimacy in the Ebola response’ and was the driving force behind the implementation at massive scale of an operational strategy originally developed to react to the usual, much smaller epidemics of the disease Médecins Sans Frontières (2016), MSF OCB Ebola Response – Medico-operational. Report. MSF Stockholm Evaluation Unit, http://cdn.evaluation.msf.org/sites/evaluation/files/attachments/ocb_ebola_review_medop_final_2.pdf (accessed 5 October 2021)..

When in 2014 recommendations were made at the European Parliament that ‘the lead [for the response] should be given to an NGO [non-governmental organisation] – in this case, Médecins Sans Frontières’, MSF directors insisted that it had ‘neither the legitimacy nor the skills nor the desire to take on the political leadership of the Ebola crisis in West Africa’ Nierle, T. and Jochum, B. (2014), ‘Ebola: MSF n’a pas à remplacer les Etats pour gérer la crise’, Le Temps, 30 October, www.letemps.ch/opinions/ebola-msf-na-remplacer-etats-gerer-crise (accessed 5 October 2021).. Based on his past ethnographic research of the organisation, RedfieldRedfield, P. (2015), ‘Medical Vulnerability, or Where There is No Kit’, Limn, Issue 5: Ebola’s Ecologies, https://limn.it/articles/medical-vulnerability-or-where-there-is-no-kit/ (accessed 5 October 2021)agreed that MSF was constitutionally ill suited to lead the response as the organisation ‘operates as independently as possible … and issues moral exhortations, not commands’, making its role reliant on the existence of a political as well as technical health infrastructure. However, in a situation where the unfamiliarity of national health authorities with the disease was exacerbated by the failure of the WHO to provide effective leadership, MSF’s apparent technical superiority, capacity for rapid action and vocal public positioning meant the organisation was still regarded by many as the de facto leader of the responseCheck Hayden, E. (2015), ‘Ebola Outbreak Thrusts MSF into New Roles’, Nature, 522, 18–19, doi:10.1038/522018a.. After criticising the leadership of the WHO as ‘slow, derisory and irresponsible’Médecins Sans Frontières (2014), ‘The Failures of the International Outbreak Response’, opinion, 29 August, www.msf.org/ebola-failures-international-outbreak-response (accessed 5 October 2021)., MSF convened international discussions and trained other organisations, including the WHO, on its Ebola protocols. During the height of the epidemic, between March 2014 and March 2015, MSF spent €77 million on the Ebola response and employed 5,300 response workers in West Africa, among whom 28 were infected with the virus and 14 diedMédecins Sans Frontières (2016), An Unprecedented Year: Médecins Sans Frontières’ Response to the Largest Ever Ebola Outbreak. Report, www.msf.org/report-ebola-2014-2015-facts-figures (accessed 5 October 2021)..

Yet once the epidemic was over, after more than 28,600 cases and 11,300 deaths, there was little critical reflection on the quantifiable or qualifiable outcomes of the MSF intervention, notably on whether it had resulted in any tangible reduction in mortality, disease transmission, or the duration of the outbreak; or whether the results achieved warranted the massive resources deployed and the heavy physical and psychological consequences suffered by responders. Prior to 2013 MSF had accepted the failure of its Ebola responses to save lives or limit transmission, partly due to the absence of effective vaccines or treatments, but had justified continuing to intervene primarily to alleviate suffering Redfield, P. (2015), ‘Medical Vulnerability, or Where There is No Kit’, Limn, Issue 5: Ebola’s Ecologies, https://limn.it/articles/medical-vulnerability-or-where-there-is-no-kit/ (accessed 5 October 2021).. During the West African outbreak, disagreement arose about the prospect of MSF’s actions meeting even those ambitions. Some doctorsMcNeil, D. G Jr. (2015), ‘Ebola Doctors Are Divided on IV Therapy in Africa’, New York Times, 1 January, www.nytimes.com/2015/01/02/health/ebola-doctors-are-divided-on-iv-therapy-in-africa.html. ;

Médecins Sans Frontières (2016), MSF OCB Ebola Response - Medico-operational. Report. MSF Stockholm Evaluation Unit, http://cdn.evaluation.msf.org/sites/evaluation/files/attachments/ocb_ebola-review_medop_final_2.pdf (accessed 5 October 2021).felt that MSF care protocols prohibiting the use of intravenous fluids both missed an opportunity to attempt to increase survival and did not go far enough to relieve suffering. Rony Brauman, a former president of MSF, observed that the organisation would have to decide whether it prioritised ‘treating the epidemic, or the patients of the epidemic’ Losson, C. (2015), ‘Interview. Rony Brauman : contre Ebola, « le traitement symptomatique a parfois été négligé, voire oublié »’, Liberation, 3 February, www.liberation.fr/terre/2015/02/03/parfois-le-traitement-symptomatique-a-ete-neglige-voire-oublie_1194960/ (accessed 5 October 2021).. Yet despite calls by another former MSF president, Jean-Hervé Bradol, to open a debate around some of MSF’s operational choices in West Africa Bradol, J-H. (2016), ‘The Response to the Ebola Epidemic: Negligence, Improvisation and Authoritarianism’, Alternatives Humanitaires, inaugural issue, https://alternatives-humanitaires.org/en/2016/01/15/the-response-to-the-ebola-epidemic-negligence-improvization-and-authoritarianism/ (accessed 5 October 2021)., few efforts were made to continue the discussion. The MSF International President, Joanne Liu, who had privately expressed support for doctors dissatisfied with the quality of care that the organisation had to offer, publicly commented: ‘We’re going to get a lot of people who haven’t treated a patient who are now the world experts, and who are going to give us lessons’ Check Hayden, E. (2015), ‘Ebola Outbreak Thrusts MSF into New Roles’, Nature, 522, 18–19, doi:10.1038/522018a.. The general belief inside and outside the organisation was that MSF’s intervention in West Africa had been an overwhelming success.

The Equateur Outbreak

By 2018, the landscape of Ebola response had changed. The weakness of the WHO in West Africa had directly contributed to the establishment of the WHO Emergencies Programme, intended to ensure rapid deployment capacity and the establishment of clear leadership at international, regional and country level in response to public health emergencies WHO (2017), Emergency Response Framework – Second Edition (Geneva: WHO).. Since its launch in 2016 the Programme had intervened in other crises, but an outbreak of Ebola declared in Equateur region of the DRC in May 2018 was considered its first real test.

The DRC had already experienced eight previous Ebola epidemics, mainly small and self-limiting, but in Equateur the WHO, working jointly with the Congolese Ministry of Health, deployed at unprecedented scale when case numbers were still low, aiming to ‘go big and go fast’ to avoid the mistakes it had been accused of in West AfricaCrawford, A. et al. (2021), The Democratic Republic of Congo’s 10th Ebola Response: Lessons on International Leadership and Coordination (London: ODI).. An initial budget of $57 million was requested from donors, and most was spent within the first month WHO (2018), ‘Bulletin humanitaire, R.D. Congo, Numéro 8’, 8 May, https://reliefweb.int/sites/reliefweb.int/files/resources/bulletin_mensuel_mai_2018.pdf (accessed 5 October 2021).. In apparent agreement with this approach, three MSF operational centres also intervened, mobilising 60 international and 106 national staff along with 60 tonnes of material Médecins Sans Frontières (2018), ‘Update: Ebola Outbreak in Equateur Province, DRC’, press release, 29 May, https://reliefweb.int/report/democratic-republic-congo/update-ebola-outbreak-equateur-province-drc-may-29-2018 (accessed 5 October 2021).to the remote rural province within the first three weeks of the response. Their ambition was no longer limited only to the relief of suffering, as MSF public communications now claimed that ‘with the correct intervention and careful monitoring of the situation, it is possible to limit the spread of the outbreak’ Médecins Sans Frontières (2018), ‘Update: Ebola Outbreak in Equateur Province, DRC’, press release, 29 May, https://reliefweb.int/report/democratic-republic-congo/update-ebola-outbreak-equateur-province-drc-may-29-2018 (accessed 5 October 2021).via the tracing and early isolation of people suspected to be suffering from the disease. These claims would not be proven in Equateur, however. Most of the fifty-four Ebola cases were identified in the ten days after the declaration of the epidemic WHO (2018), ‘Ebola Virus Disease: Democratic Republic of Congo. External Situation Report 17’, 25 July, http://apps.who.int/iris/bitstream/handle/10665/273348/SITREP_EVD_DRC_20180725-eng.pdf?utm_source=Newsweaver&utm_medium=email&utm_term=click+here+to+download+the+complete+situation+report&utm_content=Tag%3AAFRO%2FWHE%2FHIM+Outbreaks+Weekly&utm_campaign=WHO+AFRO+-+Situation+Report+-+Ebola+Virus+Disease+Outbreak+in+DRC+-+Declaration+of+End+of+Outbreak (accessed 5 October 2021)., before any real response activity had begun. Sixty per cent of them died, a fatality rate equivalent to previous epidemics in the DRC. Ebola vaccines were introduced only toward the end of the outbreak, once transmission had essentially already stopped. Still, when the epidemic was declared over, almost two months after the last new case had been identified, response actors claimed to have rapidly ‘controlled the outbreak’ under the leadership of the WHO and the Congolese Minister of Health, Dr Oly Ilunga Dowell, S. (2018), ‘The Democratic Republic of Congo Just Stopped a Killer Disease in Its Tracks. What’s Next?’, 31 July, www.gatesfoundation.org/ideas/articles/drc-stops-ebola-outbreak-lessons-learned-polio (accessed 5 October 2021).. Before any critical reflection could be initiated, attention moved to Nord Kivu.

First Phase of the Kivu Epidemic

Chasing after Cases

MSF had long been familiar with Nord Kivu, first intervening in the province in the early 1990s. During one reflection exercise held at MSF’s Paris headquarters, the consequences of operating in the region had been discussed, including the inevitable destabilisation of local health systems linked to the parallel payment of salaries and the provision of free care Brauman, R. (2017), ‘Should I Stay or Should I Go? Médecins Sans Frontières et les stratégies de sortie’, 2 May, http://msf-crash.org/fr/publications/acteurs-et-pratiques-humanitaires/should-i-stay-or-should-i-go-medecins-sans (accessed 5 October 2021).. The context of insecurity in Nord Kivu was also well understood by MSF. Four members of the association were abducted by an armed group near Beni in 2013; three of them have never been found Médecins Sans Frontières (2019), ‘Six Years on, Still No News of Our Colleagues Held Hostage by Armed Group ADF’, statement, 11 July, www.msf.org/six-years-still-no-news-our-colleagues-held-hostage-armed-group-adf-drc (accessed 5 October 2021).. Consequently, in early 2018 MSF France had decided not to intervene in Beni despite evidence of poor access to paediatric and surgical care in the town. Still, MSF was operational in six projects throughout the province when an Ebola outbreak was confirmed in Nord Kivu on 1 August 2018.

In late July, after hearing rumours that unexplained deaths had been occurring for months in Mangina, in the far north of Nord Kivu, members of the MSF Lubero project team accompanied local Ministry of Health and WHO staff to investigate. The rapid laboratory confirmation of Ebola virus in blood samples taken from four patients at the local health centre led to the declaration of the outbreak by the Ministry of Health. The MSF team, mainly comprised of local staff with little experience of Ebola, began installing an ad hoc setup within the health centre to provide care for those patients and any other sick people suspected to be suffering from the disease. A Congolese MSF logistician described it as a short and intense period of ‘constructive collaboration’, where MSF and local health staff worked long hours in difficult conditions to reorganise the existing facility. This locally focused approach would soon however change under the weight of a fast-growing national and international response.

The news of a new epidemic in the east of the country triggered the mass movement of Ministry of Health and WHO personnel from Equateur, Kinshasa and Geneva to Nord Kivu. Two days after the confirmation of the first cases, an Emergency Operations Centre (EOC) was installed in Beni, 30 km away from Mangina, under the coordination of a director from the national Ministry of Health and an incident manager from the WHO. Local health authorities from Nord Kivu province had little involvement in this coordination group. The EOC adopted technical and organisational protocols elaborated in West Africa and Equateur to develop the first Strategic Response Plan (SRP1), described by an MSF coordinator as a ‘copy-paste’ of the strategy used in Equateur.The primary response structure detailed in SRP1 consisted of eight ‘pillars’: surveillance (including contact tracing, points of entry and vaccination), laboratories, case management, communication and community engagement, psychosocial support, infection prevention and control (including safe and dignified burials), logistics and security. The initial aim was the rapid installation of the fundamentals of an ‘effective’ response following the template used in previous outbreaks (WHO (2019), WHO’s Response to the 2018–2019 Ebola Outbreak in North Kivu and Ituri, the Democratic Republic of the Congo. Report to donors for the period August 2018 – June 2019 (Geneva: WHO), www.who.int/docs/default-source/documents/emergencies/drc-ebola-response-srp-1-3-october2019.pdf?sfvrsn=41319fa1_2 (accessed 5 October 2021). An initial budget of $44 million was requested to cover three months of response activitiesCrawford, A. et al. (2021), The Democratic Republic of Congo’s 10th Ebola Response: Lessons on International Leadership and Coordination (London: ODI)..

As in Equateur, MSF also adopted the approach to ‘go big and go fast’. The day the Kivu epidemic was declared, after only four known cases, three MSF operational centres mobilised emergency teams to respond to the outbreak. Considered a ‘privileged partner’ due to MSF’s Ebola expertise as well as the fact that a team was already operational in Mangina, an MSF representative was invited to be part of the EOC taskforce coordinating the intervention from BeniMédecins Sans Frontières (2018), ‘New Ebola Outbreak Declared in North Kivu’, project update, 5 September, www.msf.org/new-ebola-outbreak-declared-north-kivu (accessed 5 October 2021).. This role was assumed by the Belgian section of MSF, which had the most experience in responding to Ebola outbreaks, thus putting them effectively in the lead of defining MSF’s actions. However, all sections initially agreed on the strategy elaborated in SRP1. When the Ministry of Health called for ‘partners’ to position themselves, MSF proposed to take the lead in case management, or the care of Ebola patients. The intention of this choice was not explicitly documented at the time, but in later interviews MSF staff described their ambitions as being ‘to relieve suffering’, ‘to save lives’ and ‘to control the epidemic’. Many considered that, as demonstrated in West Africa, only MSF had the necessary expertise and experience to achieve those aims. Some also noted MSF’s intention to be involved in the study of new treatments for Ebola, which would necessitate access to a cohort of Ebola patients and structures in which to implement the studies. Others recalled that during the initial planning meetings MSF coordinators had also requested to be involved in community ‘health promotion’ and vaccination activities, but this had been refused by the direction of the taskforce. According to one MSF staff member, ‘the WHO said they didn’t want partners to spread themselves too thinly, but really they didn’t want us to be seen as taking the lead’.

MSF quickly decided that the Mangina health centre was unsuitable for Ebola care, so began constructing a tented Ebola treatment facility nearby. Within two weeks MSF had equipped the structure, recruited and trained personnel and started receiving patients. However, when agreeing to offer ‘case management’ services, MSF coordinators had accepted that personnel would only be selected from lists provided by the Ministry of Health, who also determined the barème or salary scale that MSF would pay. MSF had also accepted to have no control over which patients would be admitted to the facility, agreeing to isolate and observe all ‘suspect’ cases brought to the centre by Ministry of Health and WHO surveillance teams, only allowing them to leave when two laboratory tests performed two days apart ruled out infection with the virus. MSF staff present at these early discussions recalled that there was little room to negotiate these points, noting that other NGOs had to abide by the same rules. However, it is unclear whether these ‘compromises’ were discussed more widely within the organisation, or whether the potential consequences were considered at the time.

The consequences soon became apparent, however. Opening with thirty beds, at a cost estimated by the MSF project coordinator at a million dollars, the Mangina Ebola centre was rapidly overwhelmed. Within days the capacity had to be increased to seventy beds to cope with the number of admissions. After an initial cluster of positive cases in the first month, most people brought to the centre tested negative for Ebola. Some were mildly unwell or not sick at all, others suffered from critical illnesses that the facility was not equipped to manage. Supportive care interventions in West Africa had been rudimentary due to the fear of occupational contamination of staff, and due to disagreements within MSF about the benefits of administering intravenous fluids for the disease. Intentions to develop new Ebola care protocols in Kivu were impeded by the wide range of pathologies and severity of illness of the patients, although from September all patients who did test positive for Ebola were offered an intravenous experimental curative treatment that the Congolese authorities had agreed could be administered in designated treatment centres via a ‘compassionate use’ protocol. Although not noted in MSF documents written at the time, in later interviews medical staff reported frustration at not being able to provide individualised supportive care such as blood transfusions, and a perception that in indiscriminately admitting everyone for testing they were acting more as ‘attendants in a laboratory waiting room’ than skilled doctors and nurses. They also compared the quality of care offered by MSF unfavourably to that provided by the NGO Alima, who had opened an Ebola treatment centre in Beni’s General Hospital and were contributing to the documentation of a new ‘paradigm’ of improved supportive care, which included the administration of intravenous fluids, blood transfusions and oxygen therapy as necessary to any patient with signs of critical illness, whether they eventually tested positive for Ebola or notFischer, W. A., Crozier, I., Bausch, D. G., Muyembe, J-J., Mulangu, S., Diaz, J. V., Kojan, R., Wohl, D. A. and Jacob, S. T. (2019), ‘Shifting the Paradigm – Applying Universal Standards of Care to Ebola Virus Disease’, New England Journal of Medicine, 380: 15, 1389– 91..

Although cases had remained circumscribed to a small area before the outbreak was detected, infected people soon began to leave Mangina and new ‘imported’ cases emerged in different locations across Grand Nord Kivu and neighbouring Ituri province. MSF, with its private funds and rapid access to resources, was quick to volunteer its services in each location where an infected person was found (Figure 1). In several areas an MSF team set up an Ebola unit, recruited and trained staff and began observing and testing patients, only to never receive another positive case. In some instances, MSF chose to close units again when there was no evidence of local disease transmission, so that equipment could be deployed elsewhere; in other locations Ministry of Health coordinators insisted the structure must remain open, ‘suspect’ cases continue to be admitted and staff continue to be paid. To free up operational capacity, MSF tried to hand some facilities over to other response actors, but as these actors first needed to confirm the availability of funds from the response budget, the handovers were often delayed. By November Ebola facilities were full of people suffering from malaria or complications of pregnancy, but over a third of the 400 Ebola cases had died ‘in the community’, mainly in local health structures, having never made it to a treatment facility at all (Aruna et al., 2019). According to an MSF nurse, it seemed like the organisation was trying to be everywhere but was still ‘never in the right place at the right time’.

Figure 1: Map of MSF Ebola activities in Nord Kivu and Ituri provinces, August 2019.
Source: MSF, www.doctorswithoutborders.org/what-we-do/news-stories/story/ebola-outbreak-democratic-republic-congo-november-crisis-update.

Social and Political Tensions and Profits

Climbing infection and mortality figures were not the only indications of problems with the response. By the time I visited Nord Kivu in early 2019, Congolese MSF staff were openly alluding to endemic corruption in the ‘riposte’ – the name commonly given to the WHO and Ministry of Health-led Ebola response – particularly in recruitment practices, in car rentals and in vaccination activities. They complained about flagrant injustice and nepotism, remarking that an Ebola response worker’s salary, set by the national health authorities, was higher than that typically paid by international NGOs, and far higher than in the public health system. They also complained about corruption causing difficulties in accessing vaccination.

A Congolese MSF staff memberFirst discussion in Nord Kivu, March 2019; interviewed by telephone April 2020.described how he had heard of admission to MSF Ebola facilities being used as a form of punishment – for example, for people unable to pay fees at local health facilities. Just the threat of referral to an Ebola centre was an effective extortion tactic, as no-one wanted to be detained for three days in solitary isolation in a tent, where food was considered inadequate and where people died alone from diseases other than Ebola. He had also heard that local health workers, upset that Ebola centres provided free care and medicine to patients suffering from minor illnesses, were spreading rumours about foreign aid workers stealing organs; and that even people clearly suffering from Ebola could pay to avoid referral to a centre.

Political tensions around the epidemic were also rising, impacting the response efforts. On 26 December 2018 the Congolese President Joseph Kabila announced the suspension of presidential elections in Beni and Butembo, citing the risk of Ebola transmission occurring in polling stations. Opposition political leaders, suspecting this to be a political manoeuvre to deny people in areas known to be unfavourable to Kabila the right to vote, called for the local population to mobilise in protest. The protests, occurring the next day, quickly turned violent. An MSF centre built to triage ‘suspect’ Ebola patients in Beni was attacked by protesters Mohamed, H. (2018), ‘Protesters in DRC’s Beni Target Ebola Centre over Election Delay’, Al Jazeera, 27 December, www.aljazeera.com/news/2018/12/27/protesters-in-drcs-beni-target-ebola-centre-over-election-delay (accessed 5 October 2021)., and the patients and staff fled. MSF staff also recalled crowds trying to force entry into the hotel where they were staying before being dispersed by members of the Congolese armed forces, who fired live ammunition.

MSF Relations with the ‘Riposte’

MSF field reports and public communications from the first months of the outbreak reveal few signs of concern about the response strategy, although they note that the epidemic might not have been ‘under control’, possibly because patients ‘do not understand the importance of early hospitalisation and treatment’Médecins Sans Frontières (2018), ‘New Ebola Outbreak Declared in North Kivu’, project update, 5 September, www.msf.org/new-ebola-outbreak-declared-north-kivu (accessed 5 October 2021).. Rohan and McKayRohan, H. and McKay, G. (2020), ‘The Ebola Outbreak in the Democratic Republic of the Congo: Why There Is No “Silver Bullet”’, Nature Immunology, 21, 591–4, doi:10.1038/s41590-020-0675-8.attribute this failure to adjust the strategy to a phenomenon of ‘evidentiary inertia’, arguing that the size and complexity of the Kivu response prevented actors from adapting quickly to new evidence, due to ‘reasonable concerns about the logistical challenges of changing response-wide protocols as well as the belief that redesigning standard operating procedures and retraining staff would simply be too great a challenge’. Yet this assumes that practitioners recognised problems with the approach but decided that it was just too difficult to make changes. This is not apparent when reviewing MSF’s actions. The decision of the WHO not to declare the epidemic a Public Health Emergency of International Concern (PHEIC) passed without comment Butler, D. (2018), ‘WHO Says Africa’s Latest Ebola Outbreak Is Not an International Emergency’, Nature, 17 October, www.nature.com/articles/d41586-018-07116-3, https://doi.org/10.7227/JHA.017.. In October 2018 and January 2019 MSF coordinators were present during the elaboration of further governmental strategic response plans (SRP2 and SRP3), essentially unchanged from SRP1 but calling for budget increases of $61 million and $147 million respectively Crawford, A. et al. (2021), The Democratic Republic of Congo’s 10th Ebola Response: Lessons on International Leadership and Coordination (London: ODI).. Only the institutional donors to the response efforts remarked that the epidemic seemed to be accelerating despite the resources being deployed to contain it, and that they ‘did not perceive the SRP3 to be a viable basis for issuing funding’ Independent Oversight and Advisory Committee [IOAC] for the WHO Health Emergencies Programme (2019), IOAC Mission Report. Democratic Republic of the Congo 24 April–2 May 2019 (Geneva: WHO), www.who.int/about/who_reform/emergency-capacities/Mission-Report(English).pdf?ua=1 (accessed 5 October 2021).. However, the funds were still allocated, and as described by a non-MSF practitioner involved in the response, ‘the solution endorsed by everyone seemed to be to just throw more money at the problem’.

When disagreements occurred between MSF and the Congolese authorities at the Beni EOC meetings during this period, they were not over the strategy. In November 2018, MSF, looking to be involved in implementing studies of experimental treatments under the direction of the Congolese national research institute, requested to open a second Ebola treatment centre in Beni, then the epicentre of the epidemic. The EOC response coordinator refused, noting the existence of another facility managed by Alima. He authorised only a ‘transit’ centre where patients could be tested and receive supportive care but must be referred to the Alima facility for any Ebola treatment. MSF agreed to open the ‘transit’ centre, but an MSF coordinator, frustrated at having failed to negotiate access to Ebola patients, complained that MSF had been ‘blocked’ by the Congolese authorities and did not have enough ‘space’ in the response.

The next disagreement with the Congolese authorities was more dramatic. Early in February 2019 armed members of the police arrived at the Butembo MSF Ebola centre with a patient for admission. Displaying no signs or symptoms of Ebola, this person had apparently been beaten, but the MSF team still admitted him for testing. Once it was confirmed he was negative for the disease, MSF coordinators addressed a letter to the Minister of Health complaining about the use of excessive force. A member of MSF France staff described the subsequent taskforce meeting in Beni, where the Congolese EOC response coordinator, furious at the letter, accused MSF of undermining Congolese efforts to control the epidemic, while also reminding all partners that the Ministry of Health held no responsibility for the behaviour of the Congolese armed forces or police.

In Europe differences of opinion did arise between MSF Operational Centres about the choice of activities and the practical details of their implementation, leading to a decision in January 2019 that MSF Belgium would no longer be the lead for the organisation in Beni, and that each responding MSF section would determine and negotiate their own strategy Médecins Sans Frontières (2019), ‘Intersectional meeting/review on the Ebola epidemic strategy and operational response of MSF in DRC’. Internal document.. However, this decision resulted in little immediate change in MSF’s activity or in its relationships with the ‘riposte’. By late February 2019 an average of thirty new cases were being identified each week throughout the Grand Nord, with hotspots in Beni and Butembo. MSF continued running Ebola-related interventions across the region, paying incentives to hundreds of staff and attending the Ministry’s daily taskforce meetings, with apparently few premonitions of what was about to happen.

Attacks and Fallout

On the night of the 24 February 2019, during a visit to Nord Kivu by Joanne Liu, then MSF International President, an MSF Ebola treatment centre in Katwa was attacked by armed men, and the structure set alight. The staff and patients fled. Three nights later, a second MSF centre a few kilometres away in Butembo was also attacked and burnt Médecins Sans Frontières (2019), ‘Medical Activities Suspended after Ebola Treatment Centre Attack’, statement, 28 February, www.msf.org/medical-activities-suspended-after-ebola-treatment-centre-attack (accessed 5 October 2021).. All MSF activities in Butembo and Katwa were immediately suspended, and international staff evacuated. Liu met with the Congolese Health Minister in Kinshasa to explain that the organisation would not return to Butembo or Katwa until the cause of the attacks could be verified. At the time Liu described the conversation as ‘cordial’, with the Minister thanking her for MSF’s ongoing support of response efforts.

A press conference was held in Geneva on 7 March, where Liu announced the withdrawal from Butembo and read a statement claiming that despite the availability of treatments and vaccines, the epidemic was out of control Médecins Sans Frontières (2019), ‘Ebola Response Failing to Gain the Upper Hand on the Epidemic’, press release, 7 March, www.msf.org/ebola-response-failing-gain-upper-hand-epidemic-democratic-republic-congo (accessed 5 October 2021).. Linking the attacks on MSF centres to ‘various political, social and economic grievances [that] are increasingly crystallising around the response’ she noted as contributing factors the massive deployment of financial resources in a ‘neglected’ region affected by conflict and violence and where the population suffered from long-standing health needs, the cancellation of the elections and the coercive practices of the armed forces and police. The statement positioned MSF as a ‘patient and community centred’ organisation, calling for patients to be ‘treated as patients, and not as some kind of biothreat’. Resulting press reports focused on the ‘militarisation’ of the response Miles, T. (2019), ‘Battle against Ebola Being Lost Amid Militarized Response, MSF Says’, Reuters, 7 March, www.reuters.com/article/us-health-ebola-congo-idUSKCN1QO1F1 (accessed 5 October 2021)., with several implying that MSF had withdrawn from all Ebola activities in the DRC in protest.

The Minister of Health, enraged over the press conference, immediately announced that MSF was no longer authorised to intervene in Butembo or Katwa until further discussions were held in Kinshasa. A spokesperson for the ministry noted to the press that MSF appeared ‘confused’ about the role of security forces, explaining that these forces operate under the control of the Interior Ministry and not the Ministry of Health, and had only been deployed to ‘protect health officials and facilities, and to guarantee the security of response workers’, just as MSF was demanding Miles, T. (2019), ‘Battle against Ebola Being Lost Amid Militarized Response, MSF Says’, Reuters, 7 March, www.reuters.com/article/us-health-ebola-congo-idUSKCN1QO1F1 (accessed 5 October 2021)..

Following the press conference, confusion reigned in eastern DRC, where Ebola-related MSF activities continued to the north and south of Butembo. Visiting the region at the time, I was inundated with questions from Congolese colleagues about whether all MSF Ebola activities would be stopped. Some noted a contradiction in MSF claiming to be primarily concerned for patients while simultaneously withdrawing from the epicentre of the outbreak and questioned whether MSF was abandoning the population of Butembo on a matter of moral principle. The Ebola treatment centre in Butembo was reopened by Ministry of Health staff, now operating under the direct supervision of the WHO, using funds mobilised from the overall response budget. MSF staff recalled that the ‘riposte’ returned quickly to ‘business as usual’, and that some representatives of the WHO, so heavily criticised by MSF in West Africa, pointed out with a note of triumphalism that the tables had turned. This time it was the WHO that was directly operational in all elements of the Ebola response, and MSF that was confined to the margins. Liu’s observation that the epidemic was ‘out of control’ was overlooked.

Second Phase: Life on the Periphery

A ‘New’ Response Coordination

The MSF withdrawal from Butembo coincided with a reorganisation of the response, if not the strategy. From March 2019 the Ministry of Health established a new Ebola response coordination committee in Goma, inviting representatives of institutional donors and key UN organisations. Although the Minister was still furious at MSF’s withdrawal from Butembo, and some WHO staff continued to remark on MSF’s lack of pertinent contribution to the Ebola response, MSF was also invited to join. The invitation was accepted. Despite the agreement for each to pursue their own operational strategy, the MSF operational centres involved in the Ebola response nominated a shared representative to the committee, tasked with following updates, reporting on MSF activities and negotiating with the ‘riposte’.

The information presented at the daily meetings of this committee revealed an increasingly catastrophic situation. By May the number of new infections climbed to reach a peak of 120 each week, mainly localised around the densely populated urban zones of Butembo and Katwa. Vaccination teams, moving with armed escorts, were regularly attacked, as were peripheral health facilities Congo Research Group (CRG) (2021), Rebels, Doctors and Merchants of Violence: How the Fight against Ebola Became Part of the Conflict in Eastern DRC’ (New York: Congo Research Group/Center on International Cooperation).. Several local workers were killed, and on 19 April armed men assassinated the WHO epidemiologist Dr Richard Mouzoko Kiboung in Butembo WHO (2019), ‘WHO Ebola Responder Killed in Attack on the Butembo Hospital’, statement, 19 April, www.who.int/news/item/19-04-2019-who-ebola-responder-killed-in-attack-on-the-butembo-hospital (accessed 5 October 2021).. Yet the level of catastrophe was not publicly acknowledged by the authorities in charge of the ‘riposte’. In April 2019, a group tasked with independent oversight of the WHO Emergencies Programme visited DRC and noted ‘the absence of an effective forum for identifying, reviewing, and resolving shortcomings in response effectiveness’ Independent Oversight and Advisory Committee [IOAC] for the WHO Health Emergencies Programme (2019), IOAC Mission Report. Democratic Republic of the Congo 24 April–2 May 2019 (Geneva: WHO), www.who.int/about/who_reform/emergency-capacities/Mission-Report(English).pdf?ua=1 (accessed 5 October 2021).; but in the same month a committee of experts convened by the WHO reviewed the epidemic situation and again decided that it did not justify the declaration of a PHEIC. According to the chairman of this committee, they remained optimistic that ‘this outbreak can be brought under control’ Green, A. (2019), ‘DR Congo Ebola Outbreak Not Given PHEIC Designation’, The Lancet, 393: 10181, 1586, doi: 10.1016/S0140-6736(19)30893-1.. This time, MSF representatives did criticise the decision in The Lancet Green, A. (2019), ‘DR Congo Ebola Outbreak Not Given PHEIC Designation’, The Lancet, 393: 10181, 1586, doi: 10.1016/S0140-6736(19)30893-1., arguing that although more resources were not required, a PHEIC declaration would raise important questions about the response strategy and force a re-evaluation and adjustment of the approach.

Attempts to Reorient MSF Operations

Meanwhile, MSF had little to report at coordination meetings. No longer present in the disease epicentre and with no Ebola treatment centre in which to offer care, the organisation was forced to reconsider its operations. MSF Belgium, whose main activity had been at the Katwa centre, temporarily withdrew from the Ebola response. MSF Switzerland, who had been running the Butembo centre, pulled back from Nord Kivu to focus on Ituri province. MSF France did not have so much choice. Days after the February attacks a patient died of Ebola in Lubero hospital, where an MSF France team was already supporting general medical activities. The Médecin Chef de Zone, the head of the local health authorities in the area, approached the MSF project coordinator to request support. Explaining that he had lost many staff to better paid Ebola response jobs, he suggested that MSF help reorganise and equip the existing health structure, rather than construct a separate Ebola centre. In return for intervening more widely in the hospital, he would grant the MSF team the authority to determine which patients would be tested for Ebola, as well to make decisions over recruitment, training and the salaries of hospital staff, in collaboration with the hospital management. The MSF project coordinator agreed.

Although the number of Ebola patients in Lubero remained low, members of the MSF France team used the experience to elaborate a new strategy Médecins Sans Frontières (2019), ‘Stratégie générale Urgence Grand Nord Kivu dans un contexte Ebola’. Internal document., working from a hypothesis that by integrating MSF staff into health structures routinely used by the local population, MSF could make earlier and more precise clinical diagnoses of Ebola, facilitating earlier targeted treatment and supportive care and thus reducing mortality. Still unauthorised to work in Butembo or Katwa, MSF teams approached the local health authorities in Beni to offer support to selected health facilities. An MSF coordinator recounted that most local interlocutors were rapidly convinced by the proposal, particularly when it was accompanied by an offer of material and financial support which until then had been distributed only via the ‘riposte’. Yet although these arguments persuaded local authorities, they foundered when they were put to the response hierarchy.

A False Independence

In the months following the attacks, putting new operational intentions into action proved difficult, as MSF struggled to convince the authorities in charge of the Ebola response. Encouraged by the enthusiasm of local health authorities for MSF support to existing facilities, some MSF France managers had begun claiming that they had found a way to operate ‘independently’ from the ‘riposte’. However, as the national Ministry of Health and WHO were the official leads of the Ebola response, authorisation for any new activity was still required from the response coordination in Goma. MSF staff described a game of ‘cat and mouse’, where they would agree activities with local health authorities, then draft a Memorandum of Understanding (MOU) to submit to the Congolese response coordinator. The standardised MOU format requested that the Congolese Ministry of Health respect the MSF charter and principles. The response coordinator, happy to have his claims that MSF was uncooperative justified by this use of authoritative legal documentation, routinely refused to sign. On some occasions, the MSF team launched the activity anyway, without waiting for a green light from the ‘riposte’. On others, the lack of official approval deterred MSF staff who were already reluctant to let go of familiar practices and protocols. In one location, the local authorities withdrew their support and asked MSF to leave the area.

From February 2019 MSF France also attempted to become involved in Ebola vaccination, including via public communications calling for a rapid increase in vaccination coverage of the at-risk population Médecins Sans Frontières (2019), ‘Not Contained, New Cases: Three Questions on Vaccines and the Ebola Outbreak in DRC’, interview, 31 July, www.msf.org/not-contained-new-cases-three-questions-vaccines-and-ebola-outbreak-drc-democratic-republic-congo (accessed 5 October 2021).. However, although at the beginning of the outbreak MSF had been allowed to vaccinate selected frontline workers, all offers to support Ebola vaccination in DRC were now refused by the WHO team leading the activity, who claimed that MSF would not respect the ‘study’ protocols for use of the vaccine. Looking for alternative options, MSF France and Epicentre, an MSF satellite organisation dedicated to epidemiology and research, agreed in April 2019 to support a clinical trial of a second Ebola vaccine, as part of a team led by the Congolese national research institute, the INRB (Institut National de Recherche Biomédicale). I was based in Goma from April until September 2019 to coordinate MSF France’s involvement in the study.

The attempts to introduce a second vaccine were however also impeded by a lack of official approval. Funding and scientific and ethical approval had been quickly obtained for the study, but although the proposal was instigated by a Congolese state institute, the INRB, it was not endorsed by the ‘riposte’. This seemed less related to the vaccine itself and more to animosity between the Minister of Health and Professor Muyembe, the Director of the INRB. In April 2019, Muyembe had produced a scathing analysis of the response, accusing the health ministry of ‘weak governance and a leadership deficit’ Kupferschmidt, K. (2019), ‘Ebola Veteran Promises an End to Congo’s Epidemic’, Science, 6 August, doi: 10.1126/science.aaz0268., and proposing a new strategy and leadership that would include the greater implication of local authorities and of state institutions beyond the Ministry of Health. As for the vaccine, although its introduction had been recommended by a WHO advisory panel, some in the WHO perceived a risk of interference with ongoing studies of the first vaccine BBC (2019), ‘Ebola Vaccine: Why Is a New Jab so Controversial?’, BBC News, 4 August, www.bbc.com/news/world-africa-49164066 (accessed 5 October 2021).. The Congolese Health Minister claimed that the use of a second vaccine would ‘confuse’ the local population Kupferschmidt, K. (2019), ‘Ebola Veteran Promises an End to Congo’s Epidemic’, Science, 6 August, doi: 10.1126/science.aaz0268.. Made nervous by controversy around the study in the media, and worried about becoming involved in a clash between Muyembe and the Health Minister, MSF coordinators in DRC were reluctant to engage in discussion with the ‘riposte’ about Ebola vaccination, preferring that a small group of MSF France and Epicentre staff handle all negotiations separately. The Minister of Health did give approval for the study in June 2019 Nakkazi, E. (2019), ‘Apply to Trial Ebola Vaccines in DR Congo, Says Ministry’, The Lancet, 6 July, doi: 10.1016/S0140-6736(19)31524-7.but retracted it shortly afterwards Branswell, H. (2019), ‘Debate over Whether to Test a Second Ebola Vaccine Turns Acrimonious’, STAT, 17 July, www.statnews.com/2019/07/17/debate-testing-second-ebola-vaccine/ (accessed 5 October 2021).. In July, the President of MSF France wrote to the Minister and the Director General of the WHO to express concern about the vaccination strategy, but did not receive a reply. In September, believing that the population’s access to protective vaccines was still insufficient a year after the epidemic had begun, MSF issued a press release accusing the WHO of a lack of transparency in the management of Ebola vaccination in the DRC Médecins Sans Frontières (2019), ‘Independent Ebola Vaccination Committee Is Needed to Overcome Lack of WHO Transparency’, press release, 23 September, www.msf.org/ebola-drc-independent-ebola-vaccination-committee-needed (accessed 5 October 2021)..

Third Phase: The Donors Take Control

In June 2019, although MSF activities remained limited, the organisation was present once again for the drafting of a fourth Strategic Response Plan (SRP4), which was associated with a tripling of the budget; $540 million was now requested to fund six further months of response interventions Crawford, A. et al. (2021), The Democratic Republic of Congo’s 10th Ebola Response: Lessons on International Leadership and Coordination (London: ODI).. The request was finally refused by donors unwilling to commit to any further funding until there was a re-evaluation of the strategy and clearer accountability for the money that had already been allocated to the response Crawford, A. et al. (2021), The Democratic Republic of Congo’s 10th Ebola Response: Lessons on International Leadership and Coordination (London: ODI).. This decision provoked major repercussions. In a first public display of division between the WHO and the Congolese health ministry, a PHEIC was declared on 17 July 2019 Maxmen, A. (2019), ‘Ebola Outbreak Declared an International Public-Health Emergency’, Nature, 17 July, doi: 10.1038/d41586-019-02221-3.. The following day the Congolese president Félix Tshisekedi announced that he was placing the leadership of the Ebola response directly under his authority, nominating Professor Muyembe to head up the response efforts. In protest, Oly Ilunga resigned from his post as Minister of Health. He was later imprisoned for embezzlement of Ebola funds Cohen, J. (2019), ‘Congo Arrests Former Health Minister for Alleged Misuse of Ebola Funds’, Science, 16 September, doi: 1126/science.aaz5248, www.sciencemag.org/news/2019/09/congo-arrests-former-health-minister-alleged-misuse-ebola-funds, doi: 10.7227/JHA.017..

By August 2019, a new leadership was in place, a new strategic response plan had been drafted and donors, reassured by Muyembe’s forecast that the epidemic would be over within months Kupferschmidt, K. (2019), ‘Ebola Veteran Promises an End to Congo’s Epidemic’, Science, 6 August, doi: 10.1126/science.aaz0268., approved the requested budget. Partly due to mutual understandings developed during the planning of the vaccine study, and partly due to Muyembe’s inclusion of local authorities into the coordination of the response, MSF negotiations with the new leadership were more fruitful. Activities in support of local health facilities were finally officially approved, and the ‘integrated’ model was eventually considered a success Park, S-J., Morisho, N., Muhindo, K. W., Anoko, J., Gobat, N., Brown, H. and Borchert, M. (2020), ‘What Do Adaptations Tell Us about the Production of Trust? Shifting the “Burden of Change” from People to the Response’, Humanitarian Exchange, Number 77: Special Feature – Responding to Ebola in the Democratic Republic of Congo, https://odihpn.org/wp-content/uploads/2020/03/HE-77-web.pdf (accessed 5 October 2021).. MSF France was authorised to take over the running of the Beni Ebola treatment centre in September 2019 and so began again providing care to Ebola patients, this time adopting protocols put in place by Alima. The study of the second Ebola vaccine began in November 2019, with MSF support. However, the new response coordinator, Professor Ahuka of the INRB, also complained about MSF’s insistence on the signature of MOUs for each new activity, noting that he preferred to engage in collective discussion about the approach rather than be presented with lengthy documents that left little room for debate.

From September 2019 cases began to decline, dropping to under ten new Ebola infections a week by the end of the year, although the epidemic was not finally declared over until June 2020. Over nearly two years, 3,470 people were infected with Ebola and 2,280 of them died, a static mortality rate of 65 per cent, roughly the same as in previous Congolese Ebola epidemics. It is estimated that between $800 million and $1.2 billion was spent on the response Crawford, A. et al. (2021), The Democratic Republic of Congo’s 10th Ebola Response: Lessons on International Leadership and Coordination (London: ODI)..

Discussion

Perceptions of success and failure are inherently subjective. The response to the West African Ebola outbreak was considered a success for MSF; the response in Nord Kivu a failure for everyone involved. Yet even if the results in Nord Kivu would appear as good as in West Africa, if not better – fewer frontline staff infected, in fact, fewer cases overall and therefore fewer deaths – a comparison between the two epidemics is not helpful. Although actions of response actors in DRC were usually well intentioned, and the funds and resources provided were more than adequate, the Kivu response efforts could rarely be described as lifesaving, may have just as well exacerbated transmission of the disease as limited it, and had the perverse effect of fuelling corruption and violence.

This medical and social failure of the Kivu response can be attributed to an initial belief by the response leadership, including MSF, in a strategy that had never been proven to work, and which had been designed at a time when the only realistically attainable outcome was to relieve suffering. Despite early evidence of failure, it took three attacks on MSF-led structures for the organisation to mount a challenge to this strategy, which, as it was established on moral indignation and not on medical or operational reasoning, could be easily discounted as frustration at having been confined to the periphery of the response. In a context of apparently unlimited funding and with a multitude of actors willing to take its place, MSF’s withdrawal from Butembo, and therefore effectively from the response, had few repercussions.

When MSF did try to reorient its actions, the organisation’s proposals failed to convince the authorities in charge of the response. Although negotiations may have anyway been futile, given the entrenched corruption and the unwillingness of the authorities to acknowledge failure, MSF’s position vis-à-vis the response leadership was perpetually contradictory. While claiming to want independence from the ‘riposte’, MSF continued to participate in the coordination of the response strategy and to demand official approval for each new activity. Neither completely assuming a confrontational attitude with the national authorities and the WHO, nor a political role aiming to influence the direction of the response via relations with those in power, MSF chose to ally with local authorities who were excluded from the coordination of the response rather than join forces with the institutions that had the greatest influence, the donors, who were looking for a convincing alternative strategy and leadership to support. MSF did however probably contribute unintentionally to changes in the response leadership via support to a ‘controversial’ vaccine study.

So, what about the future? Returning to the debates that occurred prior to 2013, why should MSF continue to intervene in Ebola if the association’s actions are so unlikely to improve the situation and risk contributing to making it worse? Fundamentally, because there is now actually a chance of success. For the first time, new ‘gamechanger’ products are available, including vaccines to protect people that may encounter the disease and monoclonal antibody treatments that effectively neutralise the virus. The ambition to establish a new, effective, approach to Ebola is finally attainable; it should now be possible to develop strategies that make the best use of these products and incorporate both new knowledge about the disease and a better comprehension of the social and political circumstances in the places where Ebola epidemics occur. To not grasp this opportunity would be a failure. But to elaborate any new public health policy, the national and international authorities that will oversee future Ebola responses must also be convinced. It is not yet certain how Ebola activities in the DRC will be run, or how they will be funded, but it is definite that epidemics will continue to occur in the country. There have already been three since the Kivu epidemic ended in 2020. MSF must not wait until the next major outbreak and then attempt to impose a new strategy, or worse, attempt to recreate the old one. To avoid future failure, any new approach must be built via collective discussion with the Congolese and international institutions that will be involved in executing the response, and MSF must agree to share in the responsibility for the outcomes.

To cite this content :
Natalie Roberts, MSF and Ebola in Nord Kivu. Positioning, Politics and Pertinence, 4 November 2022, URL : https://msf-crash.org/index.php/en/publications/medicine-and-public-health/msf-and-ebola-nord-kivu-positioning-politics-and-pertinence

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MSF and Ebola in Nord Kivu. Positioning, Politics and Pertinence

De la possibilité de contrôler un foyer épidémique de VIH

elba.msf — Mon, 03 Oct 2022 08:59:23 +0000

Date de publication

14/11/2021

elba.msf Mon, 10/03/2022 - 11:10

VIH

AIDS

humanitarian medicine

antiretroviral

Elba Rahmouni, Pierre Mendiharat & Léon Salumu Luzinga

Elba

Rahmouni

By the same author

Pierre

Mendiharat

Deputy Head of Operations, MSF France

By the same author

Léon

Salumu Luzinga

Responsable des programmes à Médecins Sans Frontières, Centre opérationnel de Paris (OCP)

By the same author

This article was first released in the 18th volume of the Humanitarian Alternatives magazine.

Designed to reduce the incidence of HIV/AIDS in a Kenyan district, a Médecins Sans Frontières project successfully exceeded the “90-90-90” target set by UNAIDS. A look back on the results that the authors of this article - Pierre Mendiharat, Deputy director of operations at MSF France and Léon Salumu Luzinga, Program manager at MSF France, interviewed by Elba Rahmouni - believe are encouraging but by no means a guarantee that the epidemic will be over by 2030.

Despite strong international mobilisation over the last decades that has enabled significant advances in the fight against the human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), the disease continues to kill on a massive scale, as is the case in Kenya, in the rural district of Ndhiwa in the county of Homa Bay.Kenya has been composed of forty-seven counties, each divided into districts, since the decentralisation of power introduced by the new constitution adopted in 2010. The ancient province of Nyanza, situated on the shore of Lake Victoria in the southwest of Kenya, includes the county of Homa Bay, itself divided into eight districts, including the district of Ndhiwa.Although there is still no definite treatment or vaccine, the Joint United Nations Programme on HIV/AIDS (UNAIDS) has set itself the ambitious goal of ending the HIV/AIDS epidemic by 2030, in particular through the implementation of the strategy known as the “90-90-90” target (or “treatment cascade”): 90% of all people living with HIV should know their HIV status, 90% of all people with diagnosed HIV infection should receive sustained antiretroviral therapy (ART) and 90% of all people receiving ART should have viral suppression. These bold claims were put to the test in a five-year programme launched in 2014 by Doctors Without Borders (Médecins sans frontières – MSF) and Kenya’s Ministry of Health in the district of Ndhiwa. Previously, the Ndhiwa HIV Impact in Population Survey 1 (NHIPS 1) conducted by Épicentre (MSF’s epidemiology centre) in 2012 had brought to light HIV incidence and prevalence figures amongst the highest in the world. Six years later, a new Épicentre study, NHIPS 2 Médecins Sans Frontières, VIH : l’amélioration de la prise en charge a fait chuter la proportion des personnes infectées dans l’un des foyers les plus touchés au monde, 24 novembre 2020, https://www.msf.fr/communiques-presse/vih-l-amelioration-de-la-prise-en-charge-a-fait-chuter-la-proportion-des-personnes-infectees-dans-l-un-des-foyers-les-plus, demonstrated that the “90-90-90” target had been exceeded. With incidence in significant decline, yet still elevated, can this truly be considered a success?

The Ndhiwa project: simplifying the treatment model

The Ndhiwa project was designed with the objective of reducing HIV incidenceThe incidence of a disease is the number of new cases occurring in a population during a specified period. in the district by implementing every known biomedical method, i.e. mass testing, medical male circumcision MSF abandoned male circumcision campaigns as participation levels were too low. Other organisations were conducting circumcision campaigns with better results., early treatment initiation of HIV-positive persons and proper care and medical monitoring of patients to ensure that their viral load remains undetectable. The population-based approach involved working with Ndhiwa’s entire population, not simply with a cohort of patients. During the first two years (2014 and 2015), MSF deployed significant resources in Ndhiwa’s villages, conducting awareness-raising and testing campaigns outside of health facilities as well as increasing the capacities of health facilities. Awareness-raising and testing campaigns enabled hard-to-reach populations to be accessed, in particular men who did not regularly attend health facilities. Then, from 2016, the team worked on decentralising delivery of care and laboratory practices in the district as well as simplifying the care pathway. In 2018, after testing the population of the entire district, the team pursued testing activities within the health facilities, saving home-based testing for the contacts (family and friends) of all persons tested positive in health care facilities.

In conjunction, a care delivery simplification process was launched, for example spacing out consultations to reduce the overall number of appointments. In a country in which the health care system faces staff shortages, it was important to reduce the workload of the teams monitoring cohorts of thousands of patients so that they could focus on the quality of consultations. From the patient’s point of view, travelling to health facilities less frequently can be advantageous as it lessens the burden of time and money. MSF thus proposed clinical consultations once every six months and introduced the option of collecting medication refills once every three months. MSF teams also set up Community ART Groups (CAGs) in remote villages whereby patients form a group and each group member travels to a consultation once a year and brings home medication for the other patients in their group. In the last few years, MSF has been implementing the Differentiated Service Delivery Model (DSDM) where, rather than imposing a model of care to all patients, patients can choose their care pathway from a number of different options.

Partnering with Kenya’s Ministry of Health and local populations

MSF was determined from the outset that its action would be both long-term (since HIV treatment and care is lifelong) and replicable. From working with the Kenyan Ministry of Health, the team revised its standards to adapt to on-the-ground realities, particularly regarding the number of healthcare workers, protocols and remuneration. By demonstrating that HIV transmission could be impacted at a population level, the organisation hoped that health authorities would do the same in other districts. In addition, this project was very ambitious in terms of community mobilisation, as the entire adult population had to be tested every year When encouraging people to be tested, the devastation caused by discovering one’s seropositivity must never be underestimated. Consequences upon emotional, family and sexual life inevitably add to the fear of illness and death. Yet the organisation has no doubt benefited from a significant development: the HIV epidemic had become so widespread in this region that stigmatisation had become inverted. One quarter of adults are HIV-positive, and, amongst the three quarters of HIV-negative adults, everybody has personally known – or still knows – more than one HIV-positive individual.. There was therefore a need for concerted action with the authorities, including the Ministry of Health, traditional chiefs and local notables. The participation of these influential figures was a key criterion of the project’s success.

While MSF claims to work with ministries of Health, in practice MSF teams often seek to create positions for themselves within health systems so that they can work as autonomously as possible. The organisation has historically managed to remain as independent as possible – above all financially –, which has been instrumental to its success. However, the downside of this approach is that it has turned MSF staff into notorious isolationists, with a limited ability to work successfully in partnership. Yet nowadays there are so many contexts in which MSF would benefit from operational partnerships, certainly more so than thirty years ago. Indeed, in the last three decades, the capacities of countries of intervention and of other humanitarian aid stakeholders have increased significantly. Consequently, the organisation is trying to tackle its isolationism. For the Ndhiwa project, MSF teams therefore sought to work in a participatory fashion from the outset, forming technical committees and steering committees within which the Ministry of Health, MSF and other district HIV stakeholders had to make concerted decisions. However, the MSF head of mission present at the beginning of the project explained that he continually struggled with his MSF colleagues to bring the decision-making process timeframes in line with the consultation time required with other stakeholders.

Community mobilisation and the health care worker/patient relationship

For many years, international programmes to fight HIV have been shaped by attempts to change population behaviour, with strategies ranging from directives to encourage abstinence (in particular in all the programmes funded by the President’s Emergency Plan for AIDS ReliefPresident’s Emergency Plan for AIDS Relief (PEPFAR): an emergency aid plan for combatting AIDS launched by the American president George W. Bush in 2003 [Editor’s note].) to those promoting the reduction of the number of sexual partners and the systematic use of condoms. Even after the patent failure of such policies, these directives were overwhelmingly continued. This is particularly true in this part of Kenya where an anthropological literature established a link between the explosion of the HIV epidemic and traditional rites involving sexual acts within the Luo community. A study conducted by Xavier Plaisancie President’s Emergency Plan for AIDS Relief (PEPFAR): an emergency aid plan for combatting AIDS launched by the American president George W. Bush in 2003 [Editor’s note]. among Homa Bay County’s male population, clearly demonstrates a contradiction between the social expectations of normality and virility and public health messages, and showed how difficult it is for any individual to resolve these contradictions. MSF made it very clear that in Ndhiwa it wished to rely upon biomedical methods rather than venture onto this anthropological terrain.

Relationships between healthcare workers and patients are by nature unbalanced, with healthcare workers frequently finding themselves delivering directives. To some extent, the activities conducted in Ndhiwa’s villages caused a rupture from these habitual dynamics and patterns. Indeed, this strategy contributed to the project’s success, as measured by the remarkable testing results. During the home-based visits, medical teams had to introduce themselves and then explain and justify what they were doing. As patients were welcoming healthcare workers into their own homes, they were empowered to ask all the questions they needed to understand while the healthcare workers took the time to provide answers, enabling patients to make informed choices. In health facilities, healthcare workers presume that if patients come to the facility they accept the various medical procedures, including testing.

MSF has not yet sufficiently improved the health care worker/patient relationship in health facilities. Yet various recommendations and trainings systematically emphasise the importance of empathy, the act of listening, respect and non-judgement. The organisation may therefore reasonably hope that these trainings and recommendations will soon bear fruit. Nonetheless, evaluating healthcare worker/patient relationship quality in the field remains challenging. Rose Burns’s study Rose Burns et al.,“‘I saw it as a second chance’: A qualitative exploration of experiences of treatment failure and regimen change among people living with HIV on second- and third-line antiretrovial therapy in Kenya, Malawi and Mozambique”, Global Public Health, vol.14, no.8, 2019, p.1112-1124, https://www.tandfonline.com/doi/full/10.1080/17441692.2018.1561921 conducted with a cohort of Ndhiwa patients having encountered periods of treatment failure demonstrated the programme’s poor economic and social support as well as the inadequate personalisation of messaging and care to individual patients. Finally, it is regrettable that no robust mechanism was implemented for preventing and detecting patient abuse.

Highly encouraging results

This project was assessed by comparing the two previously cited studies (NHIPS 1 and 2). Results exceeded all expectations, demonstrating an improvement of the treatment cascade as well as a decrease in HIV incidence and prevalence. The 90-90-90 target was even exceeded as results of 93-97-95 were achieved respectively. This means that fewer than 12% of HIV-positive individuals have a detectable viral load and are potentially contagious, representing 16,000 people with access to effective treatment.

Due to a statistical problem caused by overlapping confidence intervals In 2012, 95% probability of incidence between 1.1 and 2.5% per year. In 2018, 95% probability of incidence between 0.4 and 1.2% per year. Therefore there is an admittedly extremely low probability that – in both 2012 and 2018 – incidence fell somewhere between 1.1 and 1.2%., the question of whether the incidence of new infections had fallen was more challenging to answer. A much larger sample would have been required to guarantee the robustness of such a comparison. However, other factors did corroborate a reduction of HIV transmission. In 2018, 88% of HIV-positive individuals had an undetectable viral load and were therefore non contagious, compared to only 40% in 2012. Amongst young people between the ages of 15 and 24, prevalence fell in comparison to 2012. This is consistent with low HIV incidence within this age group. The project’s managers agreed on the likelihood that HIV incidence had declined in the years running up to 2018 and that the previously unseen and highly ambitious target of significantly reducing HIV transmission in the very place on the planet where the epidemic was most devastating had been reached. In the Ndhiwa district, MSF decided to tackle a very large endemic hotspot by deploying significant resources for a relatively small population (in 2015, the district counted 242,726 inhabitants). In light of the prevalence observed at Homa Bay, the organisation considered that such a mobilisation of resources, sometimes at the cost of other diseases, was justified.

MSF’s departure and the project today

Since the launch of the project in 2014, ensuring its continuity was considered a priority. Project coordinators therefore adopted Ministry of Health standards. All additional staff were recruited based upon Ministry standards, especially in relation to remuneration. MSF teams were responsible for mentoring, meaning providing long-term one-to-one coaching to healthcare workers. The team was convinced that the Kenyan healthcare system could maintain the treatment cascade without external partners. MSF’s concern is how to safeguard positive results in the context of the current Covid-19 pandemic and its associated restrictive measures. Vigilance is required, in particular for countries – such as Kenya – considered by the Global Fund to Fight AIDS, Tuberculosis and Malaria as having slightly higher economic capacities and therefore been identified for receiving reduced allocated funds.

Furthermore, MSF continues to collaborate with other stakeholders to respond to the shortcomings and challenges identified: improving the treatment and care of adolescents (for whom the treatment failure rate is still around 20%) and patients with a failure treatment or patients requiring a third-line treatment regimen Patients failing a second-line treatment regimen are placed on a third-line treatment regimen, based upon genotypic resistance testing results.. These patients are currently having to wait six to eight months before their treatment is modified. To reduce this delay, MSF favours a local decision-making process that does not go through a national committee (as recommended by the central level).

Avoiding easy slogans

The Ndhiwa project coincided with a key moment in the history of HIV research. In 2008, Swiss health authorities declared – in what was to become known as the Swiss Statement – that patients who took their treatment correctly were no longer contagious. This momentous announcement, particularly for serodiscordant couples In a serodiscordant couple, one partner is infected by HIV and the other is not., sparked a double controversy at the International AIDS Society (IAS) conference held in Mexico City the same year. The question was raised as to whether the statement was based on sufficiently robust scientific research and, if so, whether patients should be informed. A few years later, in July 2011, the HPTN052 randomised study demonstrated that, within a cohort of serodiscordant couples, early ARV treatment initiation had led to a 96% decrease in HIV transmissions to the non-infected partners. From this corroboration of the Swiss Statement emerged the theory of the possible control of the HIV epidemic, as treatment becomes a means of prevention: if all HIV-positive persons have access to treatment, transmissions will cease Prevention programmes used to recommend exclusively the use of condoms or abstinence, two behaviours that have not managed to control the epidemic. In the absence of biomedical tools, public health policies called for changes in behaviour, i.e. a high level of discipline required from populations and uncertain results.. Concretely, this requires urging the entire population to be tested, generalising access to treatment, entering into long-term relationships with patients and then observing whether this strategy leads to a decrease in incidence at the population level. This plan was completely theoretical, as although at the level of a cohort of serodiscordant couples the halting or drastic reduction of transmission had been demonstrated, this had never been proven at the population level.

MSF endorsed the objectives summarised by the 90-90-90 slogan, which are simply a quantitative translation of good practices in fighting an epidemic: ensure access to diagnosis and treatment, provide high-quality care and achieve effective treatment. The question raised now is whether these objectives are sufficient: what about the remaining 10-10-10? Accepting these targets also means accepting that only 73% of HIV-positive people have an undetectable viral load. Indeed, UNAIDS now recommends a 95-95-95 treatment target UNAIDS, “Understanding Fast-Track, Accelerating action to end the aids epidemic by 2030”, June 2015, https://www.unaids.org/sites/default/files/media_asset/201506_JC2743_Understanding_FastTrack_fr.pdf. At the outset of the Ndhiwa project in Kenya in 2014, and until the results of the NHIPS 2 epidemiological study were published, MSF was not certain that the 90-90-90 target was realistic, given the high level of individual and collective discipline required.

Furthermore, contrary to the 90-90-90 targets, the eradication of HIV in 2030 has never been a part of MSF’s strategy. As a general rule, this type of objective differs from the organisation’s modus operandi, which focuses on projects with clearly defined aims. “The end of AIDS by 2030” is a slogan that has been used by UNAIDS since the IAS conference in Vienna in 2011 in order to re-engage donors in the face of what was perceived as “donor fatigue” (a fall in donations to fight the HIV epidemic). MSF should surely have distanced itself further from such a misleading slogan, as anybody studying HIV of course knows that we cannot hope to be done with HIV by 2030. MSF’s intention has always been to report on the reality of the disease, as illustrated by the lived experiences of patients, patient treatment failures, the challenges of everyday life and the still elevated death rate. This communication strategy has no doubt been implemented in an overly schematic fashion, without truly acknowledging the significant advances achieved elsewhere. The results of the NHIPS 2 study suggest that these two imperatives may be reconciled.

Translated from the French by Naomi Walker

To cite this content :
Elba Rahmouni, Pierre Mendiharat, Léon Salumu Luzinga, About the possibility of controlling an HIV epidemic hotspot, 14 November 2021, URL : https://msf-crash.org/index.php/en/publications/medicine-and-public-health/about-possibility-controlling-hiv-epidemic-hotspot

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About the possibility of controlling an HIV epidemic hotspot

Conseils de lecture sur le Covid-19 : l'édition spéciale vaccins

elba.msf — Fri, 07 May 2021 09:39:02 +0000

Date de publication

07/05/2021

elba.msf Fri, 05/07/2021 - 13:16

vaccination

Michaël Neuman & Natalie Roberts

Michaël

Neuman

Director of studies at Crash / Médecins sans Frontières, Michaël Neuman graduated in Contemporary History and International Relations (University Paris-I). He joined Médecins sans Frontières in 1999 and has worked both on the ground (Balkans, Sudan, Caucasus, West Africa) and in headquarters (New York, Paris as deputy director responsible for programmes). He has also carried out research on issues of immigration and geopolitics. He is co-editor of "Humanitarian negotiations Revealed, the MSF experience" (London: Hurst and Co, 2011). He is also the co-editor of "Saving lives and staying alive. Humanitarian Security in the Age of Risk Management" (London: Hurst and Co, 2016).

By the same author

Natalie

Roberts

By the same author

We can all agree that the emergence of Covid-19 vaccine is “an absolutely astonishing development”, but vaccines are unlikely to completely halt the spread of the virus, let alone eradicate it. Yet even without achieving herd immunity, the ability to vaccinate vulnerable people seems to be reducing hospitalizations and deaths from Covid-19. This article in Nature points out that although the disease might not disappear any time soon, we may soon be better able to live with it.

However, the devastating global impact of the pandemic is unlikely to end until there is adequate roll-out of these vaccines that protect against severe disease. Just having developed and licensed vaccines is not enough: they also need to be produced at scale, priced affordably, allocated rationally so that they are available where they are most needed, and deployed adequately widely – because a vaccine is no use just sitting in a vial in the fridge.

But before we all become too pessimistic about this pandemic potentially never ending, we should acknowledge the fact that over a few months in 2020 we saw the culmination of nearly a decade’s worth of technological breakthroughs. The pandemic has accelerated (at Warp Speed!) the development of a new arsenal of vaccine technologies, with mRNA at the forefront. But just why is everyone so so excited about mRNA vaccines?

Meanwhile teams are working on developing the second generation of vaccines, beyond just mRNA. This generation can potentially be manufactured more quickly and cheaply, don’t require difficult cold chain management, or can tackle virus variants.

A particularly promising candidate could be manufactured at massive scale using existing flu vaccine production sites, and has already entered clinical trials in Brazil, Mexico, Thailand and Vietnam.

And finally, some groups are working on producing the ‘super’ vaccine that will protect us from all coronaviruses, meaning we would no longer have to worry about the next SARS, MERS or Covid-19 : the technical explanation and the easy to read version - in fact you can even listen to it.

All very promising for the future, but in the short term there are just simply not enough vaccines to go around. The People’s Vaccine Alliance and many organisations (including MSF International) have called for intellectual property rights for Covid-19 vaccines to be suspended, claiming that would directly lead to an increase in global supply. But Charles Clift argues that promoting voluntary sharing of intellectual property and knowhow makes more practical sense than just waiving intellectual property rights.

This note by Maurice Cassier from the Cermes CNRS lab explores the feasibility (but not the desirability) of making the Covid vaccines into public goods. It emphasizes the huge number of actors that must be involved and the multiple questions that must be answered in order achieve this goal.

Although Cassier does not address the question of desirability, it was explored in this piece published in November 2020 for ID4D blog of l’Agence française de développement), back before any vaccine was being distributed.

This fascinating but somewhat complex article goes into finer detail about intellectual property rights to explain why even if Moderna agreed not to enforce patents on their vaccine, this is an empty gesture that will not increase vaccine supply. In fact, it seems that today’s patents are not even worth the cost of the paper they are written on.

So if calls to waive intellectual property rights alone are too simplistic, what can be done to increase global vaccine supply? To return to our star amongst the current crop of vaccines, no other platform may offer the flexibility and relatively low barrier to entry than mRNA technology. In this piece, Tom Frieden and Marine Buissonnière outline the steps the United States could take so that facilities in low- and middle-income countries can manufacture their own mRNA vaccines, including encouraging companies to transfer their technology and accompany these new manufacturing sites through the process.

But what is involved in manufacturing these mRNA vaccines? What does this technology and infrastructure that would need to be transferred to new manufacturing facilities actually look like? According to this interactive look at the Pfizer facilities in the USA, it’s not so simple – a complex manufacturing and testing process that takes 60 days, involves facilities in three US states, and requires purpose-built machines.

Despite all the challenges in scaling-up production, millions of vaccine doses are now being distributed worldwide. But even when vaccines are made available to countries, it does not mean they are being used. In Malawi, people are asking doctors how to flush the AstraZeneca vaccine from their bodies. In South Africa, health officials stopped giving the Johnson & Johnson shot, two months after dropping the AstraZeneca vaccine. And in the Democratic Republic of Congo, 1.7 million AstraZeneca doses went unused.

While the NYT article points the finger at safety fears and over-precaution in countries that can afford to be picky about which vaccines they use, anthropologist Oumy Thiongane argues that Western notions of vaccine hesitancy shouldn’t be naively applied in Africa, ignoring the political, social and pharmaceutical context and issues of inequality of access to care.

And this notion of ‘vaccine hesitancy’ is discussed further in this piece by historians of medicine Anne-Marie Moulin and Gaëtan Thomas, who argue that it appears really quite convenient to stop engaging with more sensitive questions around the governance of public health issues.

In practical terms, one of the key obstacles to wider deployment of vaccines is that the COVAX initiative does not cover implementation costs – COVAX’s responsibility ends once the vaccines hit the airport tarmac in the receiving country. Yet, as this article points out, vaccines don’t vaccinate; health-care workers do – and many countries already have too few health-care workers.

While in this blog, a Ugandan researcher and South African medical practitioner put the blame squarely on longstanding issues of corruption and denial in Sub-Saharan Africa: “African countries were reluctant to engage or put in place processes to procure the vaccine and now, there are cries around vaccine inequities and lack of equitable distribution. While there are definite inequities, developed countries are not solely to be blamed. Corruption, denialism, poor budgets, lack of procurement prioritisation and dependency on the COVID-19 Vaccine Global Access (COVAX) has led to the situation we find ourselves in as a continent”.

But Africa is not a country. So why, when Morocco has vaccinated 9 million people, has the DRC only vaccinated 2000 despite receiving nearly 2 million doses in early March? It seems to be a combination of precaution about the side effects of the AstraZeneca vaccine, a population that does not see an interest in being “guinea pigs”, and logistical difficulties.

Meanwhile South Africa, despite large epidemic peaks, has not fared much better than the DRC. Despite receiving vaccines earlier than most African countries, only 300 000 people have been vaccinated so far. Apart from the expected problems related to logistics, corruption and weak infrastructure, the country also chose to suspend the use of both the AstraZeneca and J+J vaccines.

And in Kano, Nigeria, specific concerns are being expressed about the Pfizer vaccine, given the history of a flawed clinical trial of a Pfizer-manufactured meningitis treatment in the 1990s.

It is probably a little too extreme to compare vaccination deployment in sub-Saharan Africa with Europe. Africa may not have any real vaccine production or distribution capacity, but mortality due to Covid-19 (even if largely under-reported) also remains fairly limited. But what about India? The country is facing a catastrophic epidemic wave, despite being one of the world’s largest vaccine manufacturers with a strong experience in deploying large-scale immunization programmes. So what went wrong? According to National Geographic, it's complicated.

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Commentaires

Dr Cherbal Walid
- 30/03/2023 - 03h25

L'utilisation généralisée d'un vaccin contre la COVID-19 ayant un taux d'efficacité d'au moins 50 % pourrait contrôler la pandémie de façon efficace. Merci beaucoup

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To cite this content :
Michaël Neuman, Natalie Roberts, Covid-19 Reading List : the vaccines special edition, 7 May 2021, URL : https://msf-crash.org/index.php/en/blog/medicine-and-public-health/covid-19-reading-list-vaccines-special-edition

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Covid-19 Reading List : the vaccines special edition

Communiquer et convaincre : un regard d’humanitaires sur la réponse française à l’épidémie de coronavirus

elba.msf — Wed, 02 Dec 2020 10:28:06 +0000

Date de publication

02/12/2020

elba.msf Thu, 02/25/2021 - 17:58

vaccination

Michaël Neuman & Emmanuel Baron

Michaël

Neuman

By the same author

Emmanuel

Baron

Emmanuel Baron is a general practitioner who graduated from the University of Nantes. He spent several years working with Médecins Sans Frontières in the field and at headquarters. He was trained in epidemiology in London and joined Epicentre as General Director in 2008.

By the same author

This article was published first punlished in Alternatives Humanitaires, in the section "Covid-19: Feedback and Future Challenges", on November 20, 2020.

In this paper, the two authors examine certain aspects of the French response to the epidemic in the light of the experience of Médecins Sans Frontières (MSF) in that field, primarily with respect to the relationship between the actors of the response and the beneficiaries.

While centuries of experience have taught humanity that there is no universal recipe for controlling an epidemic, we know that the response lies in a combination of political, social, economic, medical, and scientific action. Leaders in the field of epidemics recognise that while experience is a helpful guide, it is no guarantee. Practices have been defined to limit the number and improve the management of new cases, but their implementation requires having access to knowledge and skills that have been more empirically developed than rigorously demonstrated.

Undeniable progress has been made since the Black Death of the 14th century. Countries are far less overwhelmed today than in the past by tsunamis of cases and deaths, yet the challenge of controlling epidemics still exists. The recent examples of SARS in Southeast Asia in 2003, H1N1 flu in Europe in 2008, cholera in Haiti in 2010, Marburg virus disease in Angola in 2004, Ebola in West Africa in 2014, and Zika virus in South America in 2015-2016 are reminders that “new epidemics” are not uncommon. Environmental changes, increased global travel and trade, and precarious socio-economic conditions continue to favour the emergence of new diseases with no end in sight.

Changes and reversals: which direction should the response take?

The response to an epidemic outbreak is seldom earth-shattering, especially when a new virus appears or when an epidemic reaches unprecedented proportions (for example, the cholera and Ebola epidemics in Haiti and in West Africa respectively). When it does happen, uncertainty prevails or the response system has to navigate through it, at times in a dense fog, which at best will clear as knowledge of the pathogen progresses. Reversals and changes of tack are, therefore, unavoidable, but nevertheless have to be accounted for.

In early March 2020, the French Minister of Health, Olivier Véran, explained, with the use of graphs, that since it was impossible to control person-to-person viral transmissions, the government’s strategy was designed to assure that hospitals would have the capacity to treat Covid-19 patients. This strategy has prevailed in most other countries too and served to justify national and local decisions to enforce lockdowns. “What we want is to slow down the virus, prevent severe forms, reduce resuscitation efforts and deaths. Not only are we protecting the capacity of our hospitals, but also the lives of our citizens”, tweeted the minister on 11 October.

While the response to an epidemic undoubtedly depends on a population’s behaviour, training people to observe health guidelines has much to do with the powers of persuasion of the authorities in charge. This is even more true when the disease is novel. Yet our experience tells us that the French government’s initial assessment of the epidemic, the types of decisions made and the reasons why, and its public announcements, can be examined with the same critical eye as that directed to the population’s behaviour.

The French government’s initial assessment of the epidemic, the types of decisions made and the reasons why, and its public announcements, can be examined with the same critical eye as that directed to the population’s behaviour.

Now armed with more knowledge about the disease’s characteristics, its intensity, the mode of viral transmission, and the difficulty of imposing a protracted country-wide lockdown, French political and medical authorities have stated that the success of an adopted strategy is solely contingent on the proper and strict application of the guidelines set out. These measures have been divided into “barrier” and “behavioural”, and include restricted social, family, professional, and recreational contacts, the early identification of infected people and their contacts, and the acceptance of the digital tracking of people’s movements, all of which are announced in repeated public messages. Wearing a mask, initially thought to be unnecessary or even counterproductive, has gradually been made compulsory in an increasing number of places. The need to ventilate enclosed spaces was not mentioned until much later, in early October, even though it was already known that the disease was airborne. Yet in the absence of persuasive evidence, authorities are struggling to convince people of their decisions and encourage them to follow the advice. The metaphor of a war being waged, which President Macron alluded to six times in his speech on 16 March, did manage to mobilise French society. But it did not provide them with any further understanding of the strategy that had been adopted.

The overlooked value in the epidemiology of intervention

Under these circumstances, leaders can, however, rely on epidemiological research, of which population surveys conducted in real-life situations provide a tool for describing, measuring, and analysing a given outbreak and evaluating any resulting response programmes. In the context of our interventions, we apply epidemiological practices, for example, to pinpoint places and populations at risk of outbreaks such as measles in sub-Saharan Africa or cholera in Yemen, to cite two recent examples. The intention is to collect and analyse field data that could serve as a guide and help focus our efforts in reducing transmissions. However, epidemiology has been largely underexploited in France. Very few population studies have been carried out to document situations and places at risk or regional situations that would allow responses to be adapted according to time and place. To put it simply: how and where do people become infected? It seems the authorities have not adequately mobilised the French Public Health Agency to investigate this point.

The arguments that followed the decisions to close bars, restaurants and gyms perfectly illustrate the importance of clear explanations to be understood and accepted. As a prime example, if a restaurant is considered a high-risk environment because people of all health levels are gathered in an enclosed and possibly poorly ventilated place, and customers are not required to wear masks, there are two factors missing to assess the importance of these conditions: first, the excess risk of this exposure compared to the risk of people who never go to restaurants (and it is regrettable that French authorities referred to an American study in July, whose authors themselves recognised its limitationsDelphine Roucaute, « Les restaurants sont-ils des lieux plus à risque pour la transmission du Covid-19 ? », Le Monde, 2 octobre 2020, https://www.lemonde.fr/planete/article/2020/10/02/les-restaurants-sont-ils-des-lieux-plus-a-risque-pour-la-contamination-par-le-sars-cov-2_6054448_3244.html and, second, the proportion of infections contracted at the restaurant in relation to all infections. In other words: how great is the risk and to what extent is it a national problem? Epidemiologically speaking, these two questions complement each other when seeking to identify the source of a health problem. The answers are, of course, important to provide explanations and, of course, develop a response. In France, although this approach has not been implemented thus far, its application appears even more crucial as a new lockdown is declared, after a curfew has been imposed in certain areas of the country. There is a need for people to understand and accept the scientific arguments that justify the measures that have been adopted.

Communicating and convincing

The main thrust of the response, which is admittedly difficult to implement, amounts to disseminating information and messages to explain the causes and consequences of the spread of the disease, to provide people with the means to protect themselves, and to describe the expected evolution of the disease. Regardless of the content and format of these messages, one segment of the population will be unresponsive while another will be receptive. In between, success will mostly depend on the trust people have in the bearer of the message. Without any understanding of the response and the confidence it can instil, a situation can dramatically deteriorate. In Angola, when responding to an epidemic of Marburg haemorrhagic fever, MSF was accused of bleeding patients and drinking their blood. In Haiti, some fifty voodoo priests accused of spreading cholera were murdered. In Guinea, eight civilian representatives and journalists were murdered during the Ebola epidemic in 2014. And treatment centres were set on fire in the Democratic Republic of Congo (DRC) during the recent epidemic in North Kivu. It is worth noting that this violence is largely attributable to underlying political and financial conflicts, with the epidemic used as an excuse. In France, claims were made on social media that the Pasteur Institute created the coronavirus so that it could make money on the back of a vaccine. Similar claims involve Bill Gates or say the Chinese manufactured the virus in a biosafety laboratory (BSL-4 level) in Wuhan built with French funding. These types of rumours are widespread – and existed long before they ever proliferated on social media.

Successful communication is partly dependent on the accuracy and consistency of the messages delivered. Where this is not the case, information can quickly become a target of criticism and ridicule. Early on in the epidemic, France’s Director-General of the Ministry of Health, Jérôme Salomon can take credit for diligently holding a daily briefing. But while the primary indicator mentioned was clearly the number of intensive care unit beds occupied by Covid-19 patients, the message got lost by spelling out information such as a number of cases that we all knew was nothing like the actual number, numbers of deaths that had long excluded those occurring in care homes, and even an inaccurate number of deaths among hospitalised patients Rémi Dupré et Stéphane Mandard, « Coronavirus : la mortalité en réanimation beaucoup plus fort qu’annoncée en France », Le Monde, 27 avril 2020, https://www.lemonde.fr/planete/article/2020/04/27/coronavirus-la-mortalite-en-reanimation-beaucoup-plus-forte-qu-annoncee-en-france_6037853_3244.html

. Not to mention that flooding the public with data is not a strategy: it is hard to garner support from graphs.

However, gaining popular support is not just a matter of clarity, it’s also a matter of resources. Our experience in caring for patients with tuberculosis has long included a financial component to ensure that screening and care do not burden potential patients or their families. We have thus created incentives in a number of programmes, in the Caucasus, for example MSF, « Tuberculose multirésistante : Soigner les patients à domicile », 4 juillet 2011, https://www.msf.fr/actualites/tuberculose-multiresistante-soigner-les-patients-a-domicile. It is clear that in this area, the European response, and the French one in particular, has forcefully demonstrated this need. Faced with the health crisis and the need to mobilise the entire population in the response to the epidemic, economic support is necessary. The support measures developed by the government since March illustrate this need and, in contrast, explain the delay taken by humanitarians with regard to epidemics in recent years. During the Ebola crises in West Africa in 2014-2015, and in North Kivu in the DRC in 2018-2020, we lamented the lack of support programmes for patients, their families and all those who the humanitarians would have preferred to encourage to go to hospital for testing and treatment. Calling on the French to adhere to the lockdown first required making sure that they had the means to do so.

Science and politics

Medicine and science have served as a basis for some decisions, but this has led to muddled discussions on the role of politicians and scientists. Several researchers from different disciplines publicly complained about scientists having been instrumentalised, not only amidst discussions on the ongoing acquisition of knowledge of the virus and the disease, but also amidst public controversies that were “scientific” in name only. This call to mind the very French debate on hydroxychloroquine and the appearance of Didier Raoult Pierre-Henri Castel, « L’hydroxychloroquine : quelle(s) controverse(s) ? », AOC, 13 avril 2020, https://aoc.media/opinion/2020/04/12/lhydroxychloroquine-quelles-controverses to the public stage. The chaotic distribution of roles between politicians and scientists is not specific to France. It should be noted, moreover, that even the social sciences are not immune to these controversies, as illustrated by the discussions following the position taken by the sociologist Laurent Muchielli, a specialist in juvenile delinquency, in support of Didier Raoult Josquin Debaz et al., “Academic debates and the complexity of the hydroxychloroquine controversy”, Montréal, Centre interuniversitaire de recherche sur la science et la technologie, 2020, https://cirst2.openum.ca/publications/academic-debates-and-the-complexity-of-the-hydroxychloroquine-controversy. The division of roles is no stranger to power struggles, between knowledge acquisition and decision-making. While the members of the Scientific Council were appointed in March by President Macron himself, there was never any question of the Council standing in place of the government. The statements and opinions given by many doctors (few of whom have, it should be said, any experience in responding to epidemics) in the media and on social networks has contributed to confusing this divvying up of roles « “Covid-19 : nous ne voulons plus être gouvernés par la peur” : la tribune de chercheurs et de médecins », Le Parisien, 10 septembre 2020, https://www.leparisien.fr/societe/Covid-19-nous-ne-voulons-plus-etre-gouvernes-par-la-peur-la-tribune-de-chercheurs-et-de-medecins-10-09-2020-8382387.php.

Furthermore, the credibility of these doctors largely rested on the care they gave to Covid-19 patients. In this regard, they have been the illustration of the very hospital-centred approach taken to the response. An approach that broadly contributed, at least in the initial months of the epidemic, to summing up the strategy as far more a response to an influx of patients than to an epidemic and its multiple components. A similar weakness could be said to have described until recently the responses to the Ebola epidemics, characterised by insufficient attention to bringing the patients physically closer to the healthcare system. The value of relying on peripheral structures, or families, is nevertheless proven, whether responding to a cholera epidemic, or an acute nutritional crisis.

On 15 June, the President complimented the fact that the government had been able to “hold out” Élysée, « Adresse aux Français, 14 juin 2020 », https://www.elysee.fr/emmanuel-macron/2020/06/14/adresse-aux-francais-14-juin-2020, while others maintained that it was the health service that had “held out”. But what does “hold out” mean when 30,000 people lost their lives over a three-month period and nearly half of them had been living in confined places like care homes, where people vulnerable to the serious form of the disease were residing? Or when the virus had spread far and wide among migrants in sheltersMSF, « Covid-19 : une enquête épidémiologique révèle une sur-contamination dans des lieux de regroupement de personnes en grande précarité en Île-de-France », 6 octobre 2020, https://www.msf.fr/communiques-presse/Covid-19-une-enquete-epidemiologique-revele-une-sur-contamination-dans-des-lieux-de-regroupement-de-personnes-en-grande
and among those living in precarious conditions « Épidémiologie sociale : santé, inégalité, comorbidité », France Culture, 3 juin 2020, https://www.franceculture.fr/emissions/la-methode-scientifique/epidemiologie-sociale-sante-inegalite-comorbidite? Or when hospitals had to massively reorganise their activities to the disadvantage of patients scheduled for planned services? We are well aware of the difficulty of maintaining routine care during out-of-the-ordinary periods. Epidemic disaster situations require activities to be reshuffled based on a triage system Jean-Hervé Bradol et Elba Rahmouni, « Le triage », CRASH, 6 avril 2020, https://www.msf-crash.org/fr/blog/medecine-et-sante-publique/le-triage. In this case, triage gives two results: one to the detriment of patients with chronic diseases, including cancer, or suffering from acute illnesses, heart attacks or strokes, for example, and the other to the detriment of elderly patients.

Many reports will be analysing the response to the Covid-19 epidemic. Lessons will be learned. Our experience has taught us that pitfalls arise as much from an unclear strategy as from unresolved practical and operational details, just as they can arise from a misunderstanding of the non-medical aspects of a response. Another major epidemic, the AIDS epidemic, taught us to revisit concepts, in particular, by having caregivers profoundly redefine their relationship with their patients. The same should apply to the current pandemic. That is, we should refrain from any type of moral judgment, place the decision-making process close to people in order to instil them with greater confidence, reaffirm the importance of citizen participation in the response effort, and give people the means to adhere to this.

If there is one lesson to be learned from this epidemic, it is that biomedicine, scientific research, epidemiology, and the social sciences are all tools to be used in combination. While the crisis is far from over in France and around the world, it is not too late to tackle it.

Translated from the French by Alan Johnson.

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Isabelle Defourny

Blog written by Jean-Hervé Bradol, director of studies at the Crash.

Today, in order to obtain supplies of vaccines against Covid-19, there is neither a major difficulty related to price, nor a major obstacle related to intellectual property rules, nor a deficit in bio-medical research. However, these three topics are generally at the heart of MSF's communication in the area of access to medical care for those in most need. Our discourse must therefore evolve.
With the emergence of worrying variants of the virus present in the early stages of the pandemic and, as a consequence, the need to vaccinate on a global scale as quickly as possible, the world is facing a double challenge: biological engineering and ultra-industrial production – “ultra” echoing the need to produce on a global scale in a short period of time.

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To cite this content :
Michaël Neuman, Emmanuel Baron, Communicating and convincing: a humanitarian perspective on the French response to the coronavirus epidemic, 2 December 2020, URL : https://msf-crash.org/index.php/en/blog/medicine-and-public-health/communicating-and-convincing-humanitarian-perspective-french

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Communicating and convincing: a humanitarian perspective on the French response to the coronavirus epidemic

Que penser, faire et dire au sujet de la vaccination Covid-19 ?

elba.msf — Thu, 18 Feb 2021 16:47:08 +0000

Date de publication

19/02/2021

elba.msf Tue, 02/23/2021 - 16:35

Jean-Hervé Bradol & Isabelle Defourny

Jean-Hervé

Bradol

Medical doctor, specialized in tropical medicine, emergency medicine and epidemiology. In 1989 he went on mission with Médecins sans Frontières for the first time, and undertook long-term missions in Uganda, Somalia and Thailand. He returned to the Paris headquarters in 1994 as a programs director. Between 1996 and 1998, he served as the director of communications, and later as director of operations until May 2000 when he was elected president of the French section of Médecins sans Frontières. He was re-elected in May 2003 and in May 2006. From 2000 to 2008, he was a member of the International Council of MSF and a member of the Board of MSF USA. He is the co-editor of "Medical innovations in humanitarian situations" (MSF, 2009) and Humanitarian Aid, Genocide and Mass Killings: Médecins Sans Frontiéres, The Rwandan Experience, 1982–97 (Manchester University Press, 2017).

By the same author

Isabelle

Defourny

Operations Director at MSF-OCP.

By the same author

Blog written by Jean-Hervé Bradol, director of studies at the Crash.

With the emergence of worrying variants of the virus present in the early stages of the pandemic and, as a consequence, the need to vaccinate on a global scale as quickly as possible, the world is facing a double challenge: biological engineering and ultra-industrial production – “ultra” echoing the need to produce on a global scale in a short period of time.

Two false problems

In the face of a public safety crisis, leaders may decide to activate intellectual property exemptions for vaccine procurement. Indeed, States possess all the legal tools at the national and international levels to take the initiatives they deem necessary to ensure collective security; they do not deprive themselves of these tools, judging by the current state of our individual liberties.

If patents are not a barrier to access to vaccines, neither are price levels. Vaccines against Covid-19 are not expensive, and the share of vaccines in the "cost of the pandemic" is of little importance - the denominator is so high that the numerator is relatively low. For example, the total amount pledged by France for its 67 million inhabitants for the Covid-19 response is 86 billion euros. If one bought 180 million doses at 10 euros for France, one would spend 1.8 billion, or 1.8 out of 86, or 2% of the total public expenditure for Covid-19. Not an excessive amount to prevent the economy from continuing to plummet. And even if the State had to commit this expenditure every year, it would remain feasible and economically interesting.

Biomedical uncertainty

A few weeks ago, hopes were expressed as follows: limiting and protecting human-to-human contacts; treating severe forms of Covid-19 in hospital and in intensive care units if needed and possible; detecting and isolating positive cases as well as contact cases; prioritizing vaccination of most-at-risk groups; and in parallel waiting for the arrival of herd immunity to ensure a return to an acceptable level of economic and social activity. The cards have been reshuffled with the arrival of variants on all continents, threatening to accelerate the transmission of the virus and render certain diagnostic tests, antibody treatments and vaccines obsolete. Today, the main uncertainty is therefore biological. No one can say whether researchers will be skilled enough to follow the evolution of the viral genome at the pace it imposes.

A supply problem

Biological uncertainty complicates the difficulty of producing and distributing supplies on a global scale. It is likely that in order to obtain such volumes in such a short period of time (several billion in less than a year), States must become involved in industrial activities one way or another. However, MSF has little knowledge on this subject and therefore cannot express any opinions. We could also learn from Sanofi; this company is well placed to teach us about the constraints of providing industrial support for the production of a vaccine developed by others. Pfizer's vaccine, produced in part with Sanofi's participation, is scheduled for distribution in July 2021.

What is the current status in different countries?

While the national and continental situations are diverse, the short-term trend is towards vaccination on all continents. Some (UK, Israel, USA...) have understood the strategic dimension of vaccine supply and have agreed to spend further by buying more expensive vaccines earlier in order to ensure that they can launch their national pandemic project. Other countries, such as Russia and China, had already made significant investments to guaranty their autonomy of action within their national framework and to ensure international outreach with their Covid-19 vaccines. About 100 countries, including Japan, have not started vaccinating. The African Union is working to secure its access to 300 million doses. The WHO is trying to activate a mechanism adapted to low-income countries. Algeria and Chile have started vaccination.

Too early to judge?

In this general picture, where information on the commercial and industrial dimension is evolving daily, one cannot judge the consequences that the problems of access to vaccines encountered by EU members in the first quarter of 2021 will have at the end of the year. It is also difficult to assess the effectiveness and efficiency of early vaccination campaigns, given that the time frame envisioned for their implementation is approximately 6 to 9 months for countries with significant resources. However, in order to appreciate the speed of this unprecedented attempt to carry out emergency vaccinations on all continents, and with antigens that were still unknown a few months earlier, one has to remember very different situations. At the end of the 1990s, it took 5 years (1996-2001) for countries with limited resources to prescribe HIV triple therapies.

An operational subject

Given the context, we should avoid intervening in the public debate to recommend general solutions such as intellectual property reform, instead focusing on concrete, local vaccination actions. For example, vaccinating caregivers and at-risk groups, within a reasonable timeframe, in a country like Malawi where we are already treating cases! This would ground our discourse on barriers to vaccine supply into reality, based on experience that matches our skills and capacities.

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Faced with the emergence, or resurgence, of the Covid-19 epidemic, many countries where MSF works, particularly in sub-Saharan Africa, do not yet have access to the vaccines they need to protect the populations most at risk. Isabelle Defourny, director of operations at MSF, and Jean-Hervé Bradol, director of studies at the CRASH, give their analysis of the inequalities in access to Covid-19 vaccines and the main areas of intervention for MSF in this field. This video is a shorter version of the original interview, which is currently only available in French.

THIS BIOMEDICAL INSTABILITY IS COUPLED WITH AN INDUSTRIAL UNKNOWN AND THEN A LACK OF POLITICAL CLARITY, I.E. WHICH GROUPS SHOULD BE CONSIDERED AS PRIORITIES? WE SAY THE CAREGIVERS BUT ALSO SOME COHORTS OF CHRONIC PATIENTS WHO ARE AT RISK. WHAT WE DON'T WANT IS TO SACRIFICE HEALTH CARE PERSONNEL IN THE LEAST AFFLUENT COUNTRIES AND A FEW COHORTS OF CHRONIC PATIENTS FOR A HYPOTHETICAL COLLECTIVE IMMUNITY IN COUNTRIES THAT ARE MUCH MORE AFFLUENT.

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To cite this content :
Jean-Hervé Bradol, Isabelle Defourny, What to think, do and say about the Covid-19 vaccination? , 19 February 2021, URL : https://msf-crash.org/index.php/en/blog/medicine-and-public-health/what-think-do-and-say-about-covid-19-vaccination

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What to think, do and say about the Covid-19 vaccination?

Catastrophes naturelles : « Do something ! »

elba.msf — Wed, 26 Feb 2020 09:12:07 +0000

Date de publication

17/02/2012

elba.msf Wed, 08/12/2020 - 16:52

Natural disasters

Rony Brauman & Claudine Vidal

Rony

Brauman

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).

By the same author

Claudine

Vidal

Claudine Vidal is a sociologist whose research has mainly centred on Rwanda (from its pre-colonial history to the genocide of Tutsi Rwandans in 1994) and Côte d'Ivoire (history and sociology of urbanisation in Abidjan). This research has been carried out in the framework of the Centre d'Études africaines de l'Ecole des Hautes Etudes en Sciences Sociales. Since 1995 she has collaborated with MSF on various publications and regularly participates in the reflection and work of the CRASH.

By the same author

In this interview conducted by Claudine Vidal in 2012 and published in the book Agir à Tout Prix (Humanitarian Negotiations Revealed: the MSF experience), Rony Brauman speaks about emergency humanitarian aid set up following natural disasters. Time constraints, access to victims, cooperation with local institutions, misleading representations of the disasters' effects, controversial assessments of the number of casualties; various topics related to these interventions are discussed and illustrated with specific examples.

Has MSF always considered natural disasters part of its mission?

Alongside armed conflicts, natural disasters are the first category of intervention to be cited by the authors of MSF’s charter and by-laws. Moreover, among the events that led to the founding of MSF were the earthquake in Peru that killed 30,000 people in May 1970, and the Bhola cyclone that hit eastern Pakistan in November in the same year, leaving 250,000 to 500,000 people dead. Natural disasters have always taken centre stage for the organisation. If you remember, MSF was formed through the merger of two associations created in 1970: GIMCU (Groupe d’intervention médico-chirurgicale d’urgence— Group for Medical and Surgical Emergency Intervention), founded by former Red Cross volunteers in Biafra, and SMF (Secours médical français—French Medical Relief), set up by medical journal Tonus to respond to the disaster in eastern Pakistan. This was the time when emergency medicine was gaining momentum as a specific category of care and “collective accidents”, as they were curiously named in the charter, were the ideal field in which to practise it.

But GIMCU’s first experience in a disaster situation, Peru in 1970, was a failure: the French doctors arrived on the scene a week after the earthquake and, in spite of the scale of the disaster, didn’t encounter a single injured person. What they did find was that the countries in the region, including the United States, had already delivered emergency relief.

The lesson learnt from this first attempt at emergency intervention held sway for a long time and became a principle for all earthquakes: to implement a life-saving operation in such situations, medical assistance had to come on stream within the first forty-eight hours. Any later and the victims trapped under rubble, the injured suffering from multiple trauma—with or without crush syndrome—would have no chance of survival. So, MSF focused from the outset on reducing deployment time by ensuring emergency supplies (“kits”) were ready and waiting, and doing its utmost to get its teams out to the disaster area within twenty-four hours of the alert. But to no avail. It wasn’t until 2005 and the earthquake in Pakistan’s Kashmir that we actually operated on casualties for the first time—although we weren’t on site and operational immediately.

Earthquakes and other disasters have become more frequent in recent years. According to the CRED (Centre for Research on the Epidemiology of Disasters), the yearly average number of earthquakes causing more than ten fatalities increased from twenty-one between 1960 and 1990 to thirty at the beginning of the twenty-first century, with peaks recorded in 1990, 2003 and 2004. But only a few led to an international relief operation. In fact, we only respond to large earthquakes, when the initial estimate of fatalities is in the thousands and the national authorities call for international assistance. This is a useful reminder to us that, in spite of this type of disaster’s high rank in the hierarchy of emergency humanitarian assistance, MSF had had very little experience in the field until the beginning of the new millennium. Furthermore, as over 80% of earthquakes occur in the “Pacific Ring”, the distance from Europe makes the objective dictated by the precepts of emergency medical assistance of getting to the disaster site within forty-eight hours totally unrealistic. But distance and time to deploy do not explain everything, as we saw in 1990 when an earthquake leaving 37,000 dead hit Zandjan in Iran. MSF’s medico-surgical teams were on site twenty-six hours later, but as their sole medical activity was providing routine consultations and totally unrelated to the traumatology they were expecting, ten days later they packed their bags and left.

It took us some time to realise that earthquakes didn’t lead to a particularly high number of casualties, and that most of these received immediate treatment in local health facilities around the disaster area. Foreign medical teams, unless they were already on site, were in fact superfluous to requirement. Earthquakes were far from providing the situation par excellence that we had imagined for exercising emergency medicine, in spite of breathtaking figures evoking thousands, or even tens of thousands of casualties. However, given the symbolic importance of natural disasters in emergency assistance, it was almost inconceivable for an organisation claiming emergency response as its culture and expertise not to be part of the action. So, at the beginning of the 1990s, MSF changed direction and focused on its other skill, logistics, securing the supply of drinking water, for example, and when necessary setting up medical consultations in the places where the victims were assembled. The images of numerous surgical teams rushed off their feet and operating non-stop that we have witnessed since the earthquake in Port-au-Prince are so close to conventional representations of disaster medicine that we tend to forget that they are, in fact, relatively new, as they were seen for the first time in Kashmir in 2005.

What happened in Kashmir in October 2005? Did the relief operations launched in response to this disaster differ from previous experience?

When news of the earthquake reached us, MSF-France’s operations managers were initially extremely reluctant to intervene, for all the reasons I’ve just mentioned. But MSF-Belgium and MSF-Holland were in the country at the time and their teams were reporting back to us on the enormity of the disaster and particularly on the huge number of casualties. The province’s health facilities were all completely overwhelmed. According to official estimates, there were tens of thousands of critically and seriously injured people in need of orthopaedic and intensive medical care. However accurate these figures, and I’ll come back to this point later, it was clear that for the first time in an emergency situation the local facilities were submerged by the inflow of polytraumatised patients and unable to cope.

I think the explanation behind this sudden increase in the number of injured is the trend towards urbanisation, in other words, the densification of badly built dwellings in a high-risk seismic region. In Kashmir, people were no longer living in shantytowns, but in unsound houses made of poorly cemented breezeblocks and stones. While partial collapse of this type of construction results in crushed limbs, the victims are not buried under rubble, as they would be in buildings with several floors. But shantytowns at least have an advantage in that the wooden, plastic or sheet metal partitions used to build them cause little damage when they collapse. A reminder that all that is “natural” in a disaster is what causes it, i.e. the origin of the seismic or climatic event. Whereas the aftermath is the result of decisions made by people, such as the location or construction standards or insufficiently protected industrial installations in hazard zones. To return to the situation in Kashmir, urban densification was not simply the result of the rural exodus common to all countries, but was also part of a deliberate population distribution strategy linked to separatist intrigues and the ongoing territorial dispute with India since partition in 1947. Nonetheless, for the first time in the history of emergency responses to an earthquake, international medical and surgical teams had a real and major role.

In 2005, the press reported that access to the victims was often impossible. What practical solutions were found to overcome this?

Access to the region was indeed difficult at first because of its geography, but also because of its politics. Kashmir is a sloping plateau in the east and is easily accessible from India. But, on the Pakistani side, there is a barrier of escarpments which is difficult to cross. Landslides stopped us from using the roads and as it was early winter, poor weather conditions further complicated matters. We had to use helicopters, which are great for transporting personnel, but their low cargo capacity meant they were not suitable for a disaster of such magnitude. These practical difficulties were the main problems we encountered, if we don’t count the initial resistance of the Pakistani army, whose main concern at that point was to provide assistance to its own troops and maintain control over a province of strategic importance in its dispute with India.

The physical obstacles could have been overcome by bringing aid in via India, and the Indian government did indeed offer assistance to Pakistan. But such an offer was unacceptable to the Pakistani army, which refused it outright, although it did agree to a partial opening of the border. This doesn’t mean, however, that the army only concerned itself with its own personnel and territorial security, leaving the population without assistance. On the contrary, after a few days, it did more and more, bringing in aid supplies, treating and evacuating the injured by helicopter, and managing the coordination of the relief operations. Restrictions on movements were lifted and special permits were no longer required to travel around the tribal areas.

A multitude of local NGOs quickly got down to work, helping the victims get organised in collective centres and providing shelters. Some had highly competent personnel and were particularly well-equipped— in particular, the Al Rasheed Trust. An Islamic organisation ideologically close to the Pakistani Taliban, it set up a sixty-bed hospital for orthopaedic surgery and ran outreach and relief activities. Our collaboration with the army, the Health Ministry and Al Rasheed was excellent on the whole, much to the surprise of MSF’s management staff, who had expected things to be more complicated. The local Islamic organisations, which benefit from well-established social aid networks, took immediate action and supplied a considerable amount of aid.

Let’s not lose sight of the fact that most of the search for survivors and provision of food and shelter in the early stages of any disaster situation are always handled by local people and organisations. Contrary to conventional belief, it isn’t a state of shock that we witness but rather active solidarity, at least during the first few weeks. So, although there was nothing surprising about the extent of local mobilisation in Kashmir, it needs to be said that once they had seen that MSF wasn’t involved in any proselytising and that patients were being properly cared for, the Islamic NGOs were particularly cooperative. Islamic organisation members even praised the invaluable logistical assistance it had received from the American army.

The situation was one of close cooperation with the Ministry of Health, the army—whose helicopters we even used on occasion—and religious NGOs. Our constructive relationship with our natural partners, the health authorities and the Pakistani NGOs, raised no issues for MSF. However, despite the crucial role it played, as we have seen, the same could not be said of the army, viewed by MSF as a compromising partner. Some of the MSF operational leaders even suggested trimming down the teams in order to limit contact. This determination to reassert the distinction between military and humanitarian operators, motivated by concerns for the teams’ safety, ended up taking a back seat to imperatives for urgent action in a context marked by the ongoing emergency and the otherwise fruitful working relations with all the different actors, whatever conflicts may have opposed them in the past.

In situations of natural disaster, the national army is usually the best placed and the best equipped to respond and, apart from exceptional cases (such as in the zone controlled by the LTTE in Sri Lanka after the 2004 tsunami), is welcomed by the victims. So there is no reason to actively distance ourselves, as we rightly do in situations of conflict. This applies equally to medical relief and logistics provided by foreign armed forces.

Taking into account the material difficulties caused by the geography of the area, the deployment of the aid operation was dynamic and, within three weeks, had reached a level where the needs were being met. However, when it came to medical care MSF’s teams noted that, whereas the country’s response had been rapid and profuse, standards were not so satisfactory: amputations were numerous, probably overly so, and already conservative orthopaedic interventions—for saving injured limbs—were often below par. Let’s keep in mind that most of the surgery performed by MSF’s teams, who had not dealt with the initial influx of casualties, consisted in secondary surgery. However, I should point out that any reservations regarding the quality of the medical treatment stem from clinical impressions rather than from the findings of epidemiological studies, and that this was a context of damage-control surgery in the face of a very high number of wounded patients.

But overwhelmed medical facilities do not explain everything. In my opinion, we should also examine why war surgery techniques were used. Penetrating wounds caused by projectiles (bullets, shrapnel, etc.) can lead to complications, notably infections, which, in the uncertain environment of an armed conflict, may prompt the surgeon to perform more radical surgery. But wounds caused by crushing, the common lot of civilian surgery, permit the use of more conservative techniques. Yet, as we saw in Indonesia during the 2004 tsunami and again after the Haiti earthquake in 2010, the paradigm of war, or in this case a blitzkrieg, always seems to prevail. The medical teams are just as much influenced by this representation as the observers, as revealed by a remark made by a team of American relief workers: “Overworked surgeons […] amputated limbs and debrided infected tissue. […] For the next two days, we practiced continuous battlefield medicine”.Paul S. Auerbach et al., “Civil-military Collaboration in the Initial Medical Response to the Earthquake in Haiti”, The New England Journal of Medicine, Feb. 2010.We are justified in asking ourselves if this kind of representation has an impact on the techniques used, and studies are being conducted using medical data collected in Haiti, the only other natural disaster, along with the one in Kashmir, to have caused such massive numbers of casualties.Notably led by Prof Anthony Redmond and Dr Simon Mardel, HCRI, University of Manchester.

The very recent experience of mass surgery in such circumstances explains the current lack of systematised knowledge on the subject.

We also lack reliable quantitative data to draw up a comprehensive evaluation of the relief operation in Pakistan. The figures provided the day after the disaster—54,000 dead, 77,000 injured and hundreds of thousands made homeless—give an indication of the scale of the catastrophe, but should be viewed with caution, particularly from a medical standpoint. In the light of the absence of civilian registration and demographic data, the number of fatalities can only be a rough estimate.

The civil-military cooperation—read “military leadership” of the relief operations—was hailed as a success by the United Nations and the NGOs. The dividing up into sector-based groups of responsibility or “clusters” (logistics, health, sanitation, etc.), which the army had less trouble adapting to than the humanitarian operators (as was noted with some irony by the United Nations representative),Lieutenant General Ahmed Nadeem and Andrew Mc Leod, “Non-interfering coordination: the key to Pakistan’s successful relief effort”, Liaison Online 4, no. 1 (2008) was also a success.

However, de facto truces resulting from a natural disaster do not signal an end to hostilities, and we mustn’t lose sight of the political or even counter-insurrectional dimension of aid. The extremely sensitive deployment of US and NATO forces in response to the earthquake was explicitly dictated by such considerations. It encountered no visible opposition, as all the population was concerned with what was provided and not with who was providing it. As for the Islamic groups, they mostly kept silent, although some of them did express their approval publically. A study conducted by the US Institute for Peace concludes that the objective of “winning hearts and minds” remained theoretical, for the activist groups and for the United States and NATO, as momentary gratitude does not lead to political loyalty. But as this belief tends to hold sway, it results in more latitude for action, as nobody wants to be seen as the one depriving the people of valuable aid during a period of acute crisis.

What is your definition of a natural disaster?

A disaster disrupts the ordinary course of things. From the purely practical standpoint of an emergency medical organisation, this first means earthquakes and then severe climatic events—storms, cyclones and flooding—occurring in or close to densely populated areas. Earthquakes have been our sole topic of conversation so far, as they have recently become the main cause of emergency medical operations. But looking at things from a broader angle, and to use more commonly accepted definitions, a disaster can be defined as a sudden encounter between natural forces of harm and a people in harm’s way, where demands exceed the disaster-affected community’s capacity to cope or, in other words, it is “the product of the encounter between hazards and vulnerability”.Grégory Quénet, “Catastrophe naturelle”, in Yves Dupont (ed.), Dictionnaire des risques, Paris: Armand Colin, 2007.

The problem with these definitions resides in the definition of “natural”. The causal event may be natural, but the aftermath is closely linked to the way society is organised in the places where they occur. For example, you may remember that in Ethiopia (1985) and Niger (2005), the drought and the ensuing invasion of locusts were described by the authorities as a “natural disaster”, and the primary cause of a situation of acute malnutrition or famine. The stakes were high because attributing these consequences to this cause determined the response. MSF was expelled from both countries after a political controversy on these issues.To be more precise, MSF-France’s activities were suspended in Niger in 2008 on the orders of the head of state two years after the public controversies, but directly related to them.

Remember the ironically evocative titles of the two books published by the organisation on the subject: Ethiopie. Du bon usage de la famine [Ethiopia: How to make best use of a famine], and A Not-So Natural Disaster, Niger 2005.Respectively, François Jean, (ed.), MSF, 1986; Xavier Crombé & Jean-Hervé Jézéquel (eds), London: Hurst and Co., 2009.

The cholera outbreak in Haiti during the winter of 2010 to 2011 was the source of an intense controversy of the same nature: the advocates of a “natural” hypothesis attributed its origin to plankton and opposed all those who claimed that the infestation was of human origin (caused by the emptying of a septic tank containing cholera germs into a river). Everyone agreed that the disease had only been able to result in so many fatalities (4,800 in total) because of the country’s deplorable hygiene conditions, but the circumstances that led to the outbreak were the subject of virulent dissension, even within MSF. The fact that the human origin was blamed on a contingent of United Nations peace-keepers, themselves embroiled in political clashes as a result of the election campaign underway at the time, only served to accentuate the political dimension of the epidemic. As it happens, an enquiry conducted by the United Nations later confirmed the second hypothesis.“Final Report of the Independent Panel of Experts on the Cholera Outbreak in Haiti”, May 2011.

Once again, it was not simply a matter of determining the origin of the epidemic; understanding its cause had practical consequences on how the immediate medico-sanitary response was organised.

The controversies seem to be as much due to the definition of natural disasters as to the evaluation of their consequences?

As we have just seen, the rebranding of a situation from major crisis to natural disaster can lead to controversy because of the political responsibilities that such a categorisation engages. But independent of any disagreement on this aspect, the consequences of a disaster can also be a source of controversy, particularly (but not exclusively), with regard to the epidemics they might cause, and hence the emergency resources that should be deployed. Because of the unprecedented media attention it attracted, the 2004 tsunami saw this question propelled into the public arena.

A few days after this exceptionally large-scale disaster, the WHO’s operations director announced: “We may see as many fatalities from disease as from the actual disaster itself”.“WHO warns up to five million people without access to basic health services”, 30 Dec. 2004.

So the subject was raised of a possible second wave of mortality due to epidemics, which threatened to double the number of victims caused by the actual tsunami. It was brought up by the WHO at subsequent press conferences and passed on enthusiastically by the media, with the result that the relief effort focused on providing emergency assistance to save some 150,000 people supposedly in danger of imminent death. The success of such announcements, without scientific or empirical basis, stems from how well they fit in with the widespread belief that decomposing bodies are a source of infectious contamination. Yet as several research studies have shown, there have been no cases of a fatal epidemic in the wake of a disaster, whatever the scale.C. de Ville de Goyet, Stop Propagating Disaster Myths, The Lancet, 2000, 356: 762–4, Nathalie Floret et al., “Negligible Risk for Epidemics after Geophysical Disasters”, Emerging Infectious Diseases, www.cdc.gov/eid, Vol. 12, 4 Apr. 2006.

Put quite simply, epidemics cause corpses, but corpses don’t cause epidemics. Some epidemic foci of digestive and respiratory infections may occur and require preventive and curative action, but their effects are nothing like the scaremongering announcements I just mentioned.

More generally, and for reasons similar to those I talked about earlier in relation to earthquakes, there was no life-and-death emergency after the tsunami. The horrendous ordeal suffered by a large number of survivors, some of whom lost everything, justified in itself the appeal for solidarity, and I’m certainly not disputing the need to respond to it. But the model adopted of “rescuing a population in peril” was totally inappropriate. At one point, we saw up to twelve surgeons gathered around just one casualty in Indonesia, right when we were talking in terms of hundreds of thousands of casualties! In practice, to be of real help to the victims of the disaster, the need was for financial and material resources to clear up and start rebuilding—quite different from launching an emergency medical operation. However, media pressure was such that it made it difficult for MSF to stay away. The field teams lost no time in raising the issue; some of the most experienced members had grasped what was happening within a few days. But withdrawing from the country would not have been understood in a situation so emotionally-charged, and the organisation’s leadership decided to switch the focus to non-medical aid.

Can the way a disaster is presented after the event make a difference then?

As we’ve seen, the scale of mobilisation shrank all the narrations, beliefs and prevailing representations of the event. Talk was of casualties, refugees, epidemics and, when UNICEF issued a statement, orphans too. We have already discussed casualties and epidemics, but the issue of refugees and orphans was much the same. I’ll say more about this in a moment, but first I want to emphasise that these four themes, recurrent during the first few weeks, formed a narration of the consequences usually observed in armed conflicts. In other words, with the benefit of a little hindsight, it becomes clear that we were unconsciously reacting to a natural disaster as if it were a war.

There were endless pictures and non-stop television images of the after-effects of the disaster, focusing on a few hundred people assembled in makeshift shelters, “showing” the existence of refugee camps, whereas, in reality, people were not gathering, but rather dispersing. Most of them wanted to stay as close to their homes as possible and were living with neighbours or family and moving back and forth between their former homes and their temporary accommodation. The same goes for the destruction caused by the tsunami. In Sri Lanka, for example (except in the hardest hit region in the north), it was concentrated along a narrow strip of land between 50–300 metres wide, depending on the lay of the land where the wave hit. So the survivors were in fact only a few minutes’ walk at most from the unaffected parts of the country, something we couldn’t tell from the pictures we were seeing. This kind of metonymical representation, of which aid workers are as guilty as journalists, is seriously misleading. I should also add that the thousands of Sri Lankan doctors and nurses, who arrived within hours to help their colleagues and fellow citizens, were no more visible as they were indistinguishable from the disaster victims. These misinterpretations were given such credence because they fit in so well with the preconceived notion mentioned earlier of disaster victims in a state of total shock, passively waiting for help to arrive.

As for the orphans described by the director of UNICEF as wandering the streets at the mercy of child prostitution gangs, this was a rumour spread all too hastily, but rapidly dissipated by other humanitarian organisations, and by UNICEF itself. Obviously there is no question that some children had lost their parents, but what I do contest is that they had been abandoned. I should perhaps explain at this point that the post-tsunami solidarity movement, often portrayed in the North as exemplary and cited as a reference, in fact left the concerned countries with memories of an agitated, arrogant and ineffectual mob. Despite its endeavours to distance itself from the prevailing discourse, MSF did not escape from harsh collective judgement.

But let me return for a moment to the schema of war superimposed on that of natural disaster. In spite of images that make them look very similar, they are in fact diametrically opposed. Disasters are concentrated into a very limited time period and a very restricted geographical area, whereas armed conflicts are spread over an extended time period and wide geographical area. Wars are drawn out affairs, erratic in their movements, killing and injuring in their path, causing the displacement and re-assembly of populations between one region and another, creating intense and relentless pressure, rampant and massive impoverishment and wide-spread destruction, including of health facilities. These vulnerability factors, producing all these effects and creating a high potential for epidemics, cannot be caused by a one-off event. A natural disaster, however horrendous, cannot engender the same consequences as a war.

Is there a clear association between the myths surrounding events after a disaster and political situations?

International emergency aid is loaded with a specific kind of symbolism that has nothing to do with its real usefulness, as we have just seen.

It is inevitably an intrinsic part of the pre-existing dynamics of international relations—and becomes an extension of them. For example, when Iran was hit by an earthquake in June 1990, the French government offered to send in specialised teams, even though the two countries had broken off diplomatic relations: the emergency aid brought to light the fact that Paris and Teheran had secretly resumed talks. The same can be said of China sending a plane full of aid supplies to Haiti after the earthquake in January 2010, in spite of the absence of diplomatic relations between the two countries owing to Haiti’s recognition of Taiwan. This was a first. Beijing had never before contributed towards disaster relief operations outside its regional sphere of influence in Asia. However, the fact that China now wants to assert its status as a global power meant taking part in the international relief effort. Just as the earthquake in Pakistan proved the existence of a “disaster policy”, there is also “disaster diplomacy”, whereby the special circumstances created by an emergency allow governments to dem-onstrate their strategic choices at little cost.

In this respect, the case of Cyclone Nargis, which hit Myanmar in 2008, merits attention. In May 2008, the Irrawaddy delta was swept by winds reaching 240 km per hour, followed by a wave four to six metres high, which surged up the river resulting in extensive loss of life and massive destruction in this densely populated and fertile region. The Myanmar junta, faithful to its obsession with maintaining order and as ever indifferent to the fate of its people, did not react, simply appealing to the United Nations for international aid and refusing any new foreign presence on its soil. However, right from the first few days, members of MSF and other NGOs already working in the country were able to travel to the area, assess the extent of the damage and launch the relief effort with the local resources at hand. At the same time, planes from neighbouring India, Thailand, Bangladesh and Malaysia, as well as from western counties acting on behalf of UN agencies, were landing in the capital city, Yangon. In the meantime, the press and western governments, apparently unable to see beyond the junta’s sovereigntist and isolationist rhetoric, were talking about restrictions and even a total blockade of outside aid. On 11 May, the NGO Oxfam issued a communiqué and the first few lines set the tone: “International agency Oxfam said today (11 May) that in the coming weeks and months the lives of up to 1.5 million people are in danger in the Myanmar cyclone zone because of the risk of disease and a public health catastrophe if clean water and sanitation are not urgently provided”.

Seen from the field, this scaremongering was far from justified. It was true that the army had been seen diverting aid for its own purposes or to make a profit out of distributing it but, as always, the population got itself organised on different levels. Local organisations and authorities, the Red Cross, Buddhist temples and wealthy businessmen all distributed water, food and equipment, and foreign aid began arriving via the NGOs. As for the injured and the threats of epidemic, I repeat what I said earlier about the tsunami; they were non-existent.

It was striking that most of the television coverage, whether videos made by local people or official television reports, all showed scenes of aid distribution almost everywhere. We saw endless short scenes of businessmen arriving with their lorries and handing out bottles of water, sacks of rice, etc. Elsewhere, Buddhist monks were similarly shown, as was the army, an NGO or the Myanmar Red Cross. Basically, we were seeing the usual images of food distribution and, here and there, one or two bodies. Watching the media coverage attentively, I realised that the commentaries accompanying the pictures were actually contradicting everything they were showing, insisting on the total absence of aid and the numbers of decomposing bodies, which were described as bacteriological time bombs on the brink of spreading their deadly emanations. When I asked some journalists during interviews on the subject what they thought about the dissonance between the pictures and the commentary, they said they hadn’t noticed it and were obviously suspicious of any challenge to the general alarmist view.

So it was in this context that threats of military intervention to impose aid by force first began to appear in the press. Gareth Evans, one of the authors of the UN’s “Responsibility to protect” concept, started the ball rolling on 12 May,Gareth Evans, “Facing up to our responsibilities, The Guardian, 12 May 2008followed two days later by Robert Kaplan, one of the most prominent neo-conservative strategists, who sketched the outline for armed intervention in an article entitled, “Aid at the Point of a Gun”.The New York Times, 14 May 2008.

And on 19 May, French foreign minister Bernard Kouchner published an article reminding us that “the Secu-rity Council can at any time decide to intervene to force a passage for humanitarian aid, as has been done in the past”.Bernard Kouchner, “Birmanie: morale de l’extrême urgence”, Le Monde, 19 May 2008.

Three military vessels, British, French and American, were thus hastened to the Myanmar coast as a sign of their governments’ determination to prevent the supposed deaths of hundreds of thousands of innocent people.

It must be said that this time, unlike after the tsunami, the WHO posted on its website that corpses posed no risk and that survivors of the cyclone were in no danger of a deadly epidemic. But this was not enough to prevent the British Foreign Office from warning of the “peril”, or to dissuade the advocates of armed interventionism, governments and associations alike, from using it to encourage the Security Council to activate the “Responsibility to protect” mechanism.John D. Kraemer, Dhrubajyoti Bhattacharya, Lawrence O. Gostin, “Blocking humanitarian assistance: a crime against humanity?”, The Lancet, Vol. 372, 4 Oct. 2008.

Until the war in Libya in March 2011, instigated by the same governments (France, UK and the US), this was the only debate in which the Security Council had actually envisaged implementing this mechanism.

Did emergency relief organisations learn any new lessons from the earthquake in Haiti?

The January 2010 earthquake in Haiti was the second mass medico-surgical emergency after the one in Pakistan in 2005. MSF had been working in Haiti for several years when the disaster struck and so was in the right place to respond rapidly. Three surgical units were set up in a container and the first major operations were performed three days after the earthquake. During the first forty-eight hours, care had been provided in the streets. The inflatable hospital used in Pakistan was sent out, so we were operating in optimum conditions from day thirteen, which is the time it took to get this really imposing piece of equipment on site and up and running. By the way, the famous fortyeight-hour window beyond which casualties cannot survive can now be filed away under “conventional wisdom”, as the Pakistan precedent had already confirmed. MSF thus took up position alongside the multitude of local and international organisations, governmental and private, which had rushed to set up operations in Port-au-Prince and the surrounding region during the two weeks following the earthquake.

There was a lot of talk at the time about the chaos in which the “humanitarian expeditionary corps” was deployed. The lack of coordination and information on needs and the running of the relief operations were severely criticised in the press, but these criticisms don’t actually hold water. Firstly, because disorder is the hallmark of a disaster, all the more so when it hits a country’s capital and therefore its seat of power. Secondly, because the shortcomings of Haiti’s public institutions were already notorious and the country was without an army, which had been dissolved under US pressure during the “Restore Democracy” operation in 1995. Lastly (and most importantly), because the response to the urgent needs was focused on a limited area, it was carried out correctly, in spite of everything, with the notable exception of the shelters, which were both unsuitable and insufficient.

There are two medically-related issues that I would like to single out: the first, quite specific, concerns the use of techniques derived from war surgery, which tend to be more radical but can be inappropriate; the high number of military surgeons in such a setting, as well as the ever-present juxtapositions with the representation of war as mentioned earlier, give pause for thought. The other issue is more general and concerns the criteria adopted explicitly or otherwise by medical teams from different professional culturesFrédérique Leichter-Flack, “Sauver ou laisser mourir”, http://www.laviedesidees.fr. for deciding which cases, medical as well as surgical, should be given priority and which should not be treated. Do the exceptionally high workload and the logic of rationing induced by a disaster, which is where triage usually comes in, lead to laxity in procedures?http://www.theworld.org/2010/02/doctors-face-ethical-decisions-in-haiti/.

We have only fragmented and flimsy data, so I won’t attempt to answer these questions. I just want to stress the need for a methodical reflection on them.

Why is estimating the number of victims in a disaster the subject of such frequent debate?

Estimating the number of victims is another major issue as the figure is a crucial emotional marker, the trigger that “allows us to feel the disaster”Sandrine Revet, “Anthropologie d’une catastrophe, Les coulées de boue au Venezuela”, Presses Sorbonne Nouvelle, 2007, p. 267. and determine where it features on the scale of gravity. Unlike what we see in many conflict situations, the disaster toll (usually an approximation) announced by the governmental authorities and the United Nations a few days after the event is accepted by the press and aid organisations as objective, in spite of its unreliability. Three days after the Haiti earthquake, the government announced that 50,000 bodies had been recovered. This figure was to increase day after day to reach 250,000, or even 300,000 a month later,“Death toll from the earthquake could reach 300,000, according to the president of Haiti”, Le Monde, 22 Feb. 2010. making the disaster one of the most serious ever.

These evaluations were based on an estimate of population density and the number of collapsed buildings in a given district, which left considerable room for uncertainty. Respect for the victims does not proscribe challenging figures drawn up in a chaotic environment and with no credible foundation. Heads of some of the UN agencies encountered six months after the earthquake privately agreed on a death toll of somewhere between 50,000 and 70,000, based mainly on the number of mass graves dug by Minustah, the only organisation charged with the task.Encounters by the author in Port-au-Prince in June 2010.

Similarly, after a survey of the different actors in their field, Handicap International Belgium’s head of mission estimated that the number of disabled people was closer to 1,000 than 5,000, the figure that had ended up becoming official after being bandied about in aid circles.

Reducing the estimated loss of human life is clearly a sensitive issue, as it ties into collective emotion. Bringing down the numbers exposes us to suspicions of hard-heartedness, or even hostility or shameful ulterior motives, whether in situations of natural disaster or, even more so, in other settings with a more direct political dimension, such as armed conflict, population displacement, or the quantification of atrocities.Peter Andreas, Kelly M. Green (eds), Sex, Drugs and Body Count, The Politics of Numbers in Global Crime and Conflict, New York: Cornell University Press, 2010.

The death toll after the earthquake in Armenia in 1988, established at 100,000 deaths a few weeks after the disaster, was later reduced to 23,390 in figures published by the authorities. This reduction in the official death toll produced reactions of incomprehension, hostility even, as the original number had become a symbol of Armenian suffering and changing it was seen as a denial of this suffering. In practice, it is likely that such distortions and amplifications abound in many similar situations.

Estimating the number of victims—and the number of fatalities among them—is most definitely not a superfluous exercise, not only because this is the first question that everybody asks, but particularly because, however vague and fluctuating it may be while the aid is being set up, it allows a threshold effect to operate. It has been observed that we reason in terms of a major disaster justifying international-level deployment when the death toll reaches or exceeds ten thousand. The practical importance of such estimates from a relief agency’s point of view is, however, limited, but I raise this issue here to underline how the highly uncertain nature of the figures makes it extremely difficult to know which resources to activate, other than basing ourselves on the threshold mentioned earlier. In concrete terms, the specific information required to guide relief operations would be, on the one hand, the number and condition of the survivors in order to gauge the medical assistance requirements, as well as needs for other types of aid—shelter, food, water, telecommunications, damage clearance and transport—and on the other, information on what the other relief operators, local as well as international, are doing.

Although not victims of an executioner, disaster victims are caught up in high stakes, as the examples given above have shown. Funding, media coverage, rallying sympathy for traumatised people, all combine to produce an escalation that nobody plans, but which is fostered by the apparently indisputable nature of the cause defended—that of increasing emergency aid as high as it can go.

Translated from French by Mandy Duret

To cite this content :
Rony Brauman, Claudine Vidal, Natural Disasters: “Do Something!”, 17 February 2012, URL : https://msf-crash.org/index.php/en/publications/natural-disasters/natural-disasters-do-something

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Natural Disasters: “Do Something!”

Covid-19 : les réactions de sociologues confinés

elba.msf — Wed, 22 Jul 2020 13:08:25 +0000

Date de publication

22/07/2020

elba.msf Wed, 08/12/2020 - 16:22

sociology

Marc Le Pape

Marc

Le Pape

Marc Le Pape has been a researcher at the CNRS and then at the EHESS. He is currently a member of the scientific committee of the CRASH. Formerly with the CNRS, Marc Le Pape is currently a researcher at the l'Ehess (Centre d'études africaines). He has carried out research in Algeria, Côte d'Ivoire and Central Africa. His recent studies have focused on the Great Lakes region in Africa. He has co-directed several publications: Côte d'Ivoire, l'année terrible 1999-2000 (2003), Crises extrêmes (2006) et dans le cadre de MSF : Une guerre contre les civils. Réflexions sur les pratiques humanitaires au Congo-Brazzaville, 1998-2000 (2001) and Génocide et crimes de masse. L'expérience rwandaise de MSF 1982-1997 (2016).

By the same author

In France, from March onwards, many sociologists regularly appear in the media. Based on this observation, Marc Le Pape analysed 37 articles written during the containment period, dealing with the Covid-19 pandemic.

Sociologists becoming HSS-emergency workersHSS: Human and Social Sciences, of which sociology is a part.? This is what started happening in France in March 2020, so I analysed thirty-seven articles they wrote on the Covid-19 pandemic during the lockdownOf the 37 articles, five deal with China, one with India, and two with the United States. These will be discussed in a future blog post.. Prior to March 2020, many of these researchers had done studies on the hospital system, intensive care units, access to emergency care, the public health administration (Agence Régionale de Santé and Santé Publique France), health emergency response systems, the harmful consequences of “neo-managerial reforms in recent years” (Thomas Denise, Jérémy Geeraert, and Déborah Ridel, “Les soignants des urgences: ‘des pros pas des héros’ [Emergency caregivers: ‘pros, not heroes’]”, 25 March). In most of the articles that came out between March and early June, the authors referred to these studies in their commentary on or analysis of the epidemic.

A diverse set of questions

The sociologists’ writings ask a disparate set of questions in the moment, not after the fact. The diverseness of those questions can be attributed, in part, to professional specialisation – in the sociology of organisations (Bergeron, Borraz, Castel, and Dedieu, AOC, 2204 and 0306)2204 means 22 April 2020. The publication dates are indicated in day/month order, and all are from 2020.; in hospital systems, particularly emergency and intensive care departments (Thomas Denise, Geeraert, and Ridel, AOC, 2503 and Thomas Denise, AOC, 0105); in medical knowledge (Marichalar, La vie des idées, 2503 and Amélie Petit, AOC, 0804); in public policy (crisis management and emergency situations, Borraz and Bergeron, AOC, 3103 and 0306); in class relations and the stigmatization of the working-class disadvantaged neighbourhoods (Epstein and Kirszbaum, AOC, 1504, Latour, AOC, 0206); in the analysis of mathematical models used to predict (or anticipate) the dynamics of the epidemic (Gianluca Manzo, La vie des idées, 2104 and Emmanuel Lazega, La vie des idées, 0106); or in the social history of quantification (Emmanuel Didier, AOC, 1604). In short, readers are seeing many different ways to react, as a sociologist (in lockdown), to the pandemic situation.

The corpus

The texts analysed came from three websites. The first article on Covid-19 by a sociologist on the AOC website is dated 17 March (Justine Rochot, “Le virus et la Nation – regard historique sur la santé publique chinoise en temps de Covid-19 [The virus and the Nation – a historical look at Chinese public health in the time of Covid-19]”); the list of writings I chose from AOC is not selective, but serial“Serial” means a complete study of the series of documents signed, in this case, by sociologists from a website within a given date range, provided they deal with Covid-19. In other words, the texts were not selected based on value judgements.(or exhaustive) up to 3 June 2020, and includes 28 articleshttps://aoc.media/ . Using the same non-selective method, I included seven articles from the “Les visages de la pandémie” dossier on the La vie des idées website (from 25 March to 1 June 2020); and finally, two of the sociologists’ texts I analysed were published during the pandemic by the Fondation Collège de France (Pierre-Michel Menger and Didier Fassin, “Face à la pandémie” dossier). I interrupted my survey at the point where Phase 2 of the reopening began, on 3 June. Are the public writings by sociologists from 3 June to 11 July – when the public health state of emergency in France was partially lifted, in the reopening period – different than the ones that came before? Emmanuel Macron promised that we would “turn a new page” on 14 June; in a future blog post I’ll examine the “new pages” by sociologists.

Methodologies of sociology in lockdown

Several different methods were used: examination of medical documents (scientific articles and reports), questionnaire-based survey, and analysis of options, discourse, policy decisions, public debates, and controversies.

First, the publication of factual knowledge based on medical documents: on 25 March, Pascal Marichalar tackled a question frequently asked in the mainstream media – when was the pandemic first discovered and then declared? His method did not consist of selecting sources to justify a critical attitude or condemnation; his sources were limited and public, and thus verifiable – a series of articles that appeared in Science from 3 January to 2 March 2020, and World Health Organisation statements from late December 2019 to 28 February 2020. He used a serial approach, based on a research question: since what point in time could responses to the pandemic be defined in full knowledge of the facts? Few authors, in the pieces I studied, made reference to medical journals or to the chronology of articles on Covid-19 treatment; there were a few references to the debate over the effectiveness of hydroxychloroquine. The chronological approach taken by Marichalar was uncommon. Another exception was the article by Gianluca Manzo (“Les réseaux sociaux dans la lutte contre le Covid-19 [Social networks in the fight against Covid-19]”; he gave a chronology of the predictions based on mathematical modelling and whether they were considered (or not) by political decision-makers from 12 March to 23 March.

Another retrospective approach was the questionnaire. One example was the online questionnaire for parents of locked-down students (“more than 30,000 responses were received by late May”, Romain Delès, AOC, 28 May). An analysis of the data supported criticism of the widespread presumption that poor children would get less supervision and support from their parents than would the children of affluent families or teachers. The sources I am commenting on rarely used that method. During the pandemic, however, social scientists conducted a number of questionnaire-based surveys on a large population in France. These surveys were done by INSEE, INED, IRD, the Pasteur Institute, and research groups from the CNRS, INSERM, and several universities and schools (ENS, EHESS, EHESP, etc.). The articles I am studying were written before these survey results came out.

The third approach, taken by many of the authors, was to analyse the public health authorities’ justifications and decisions and their reliance on scientific experts. As I already indicated, reflections on governance in the time of the pandemic combined a study of the present with sociological surveys conducted before, in hospitals and agencies, and in particular in health crisis management structures (Olivier Borraz and Henri Bergeron, “Covid-19: impréparation et crise de l’État [Covid-19: unpreparedness and government crisis]”, AOC, 31 March).

Were other investigatory methods feasible during the lockdown? Undoubtedly – like, for example, that of describing personal experiences of the pandemic, in particular during the total lockdown. This type of approach was used little in the texts that I studied; there were few “as-a-sociologist” narratives (unlike the many personal accounts published in the media and written about in books). In their analysis process, however, several authors injected brief personal comments. This was the case with Emmanuel Didier (“Politique du nombre de morts [Number-of-deaths politics]” AOC, 16 April), where he reacts to the figures recited each evening: “daily, chilling counts of the dead and infected”; “these figures should scare us”. “The restriction of civil liberties, the sick, and the death of loved ones; we are all affected, to a greater or lesser degree, by this crisis”.

Bruno Latour wrote about how he was affected by two months of lockdown; the experience led him to “an incredible discovery”: “If we can stop everything, then we can question everything” – hence anxiety about what comes after the crisis: “The last thing we should do is go back to doing everything like we did before”. (“Imaginer les gestes-barrières contre le retour à la production d’avant-crise [Imagining the barrier gestures against a return to pre-crisis production]”, AOC, 30 March).

Sociology and political critique

Some of the sociologists took normative positions and issued prescriptions; these were connected to their area of specialisation and survey experiences. The prescriptive authors come, in particular, from the Centre for the Sociology of Organisations (CNRS-Sciences Po)This research unit was founded in the early 1960s by Michel Crozier. https://www.sciencespo.fr/cso-50ans/en/content/cso-yesterday-and-today.html : Borraz and Bergeron (AOC, 3103), Bergeron, Borraz, Castel, and Dedieu (AOC, 0306). The latter detail the profusion of crisis management entities that existed prior to Covid-19 within the French public health system; nevertheless, new entities and expert committees started to be created in March 2020: sociology of organisations specialists highlighted that aspect of government power, which reflects a determination to reinforce the government’s word and legitimise it via the authority of experts. However, as Pierre-Michel Menger observes, “expertise creates trust and its opposite” ("Forces et fragilités de la confiance en contexte critique de pandémie [Strengths and weaknesses of trust in a critical pandemic context]”, 10 April). Looking less at the past, Emmanuel Didier underscored one effect of what government experts were saying: the numbers announced each day “serve to convince us that the number of deaths is increasing, and makes us feel as though we, personally, could be one of those deaths. They’re holding death over our heads. They are motivating us, of course, to obey government instructions” (16 April).

Many of the authors took a critical approach based on their examination of hospital policies and situations observable prior to March 2020. For them, it’s a question of rendering the effects of two decades’ worth of pre-epidemic policies on the healthcare system visible. While their critiques differ in intensity, they converge in condemning the “increasingly harsh working conditions that have resulted from neo-managerial reforms in recent years: a lack of resources, chronic understaffing, increased pace of work, etc.”; “new hospital governance (more procedures, pay for performance, professional practice evaluation, benchmarks, audits, etc.)” ; “neoliberal ideology” and “social selection practices”, particularly in access to specialty care”; and the “crusade against precautionism” (observable since the mid-1970sBiophysicist and oncologist Maurice Tubiana was a strong proponent of this movement. His anti-precautionist activities are recounted in sociologist Sylvain Laurens’ book, Militer pour la science, Paris, Éditions de l’EHESS, 2019. See also Michel Callon and Pierre Lascoumes, “Covid-19 et néfaste oubli du principe de precaution”, AOC, 27 March.). The fate of the elderly in our EHPADs and ICUs (where their access has been limited) is a scandal that Sylvie Morel links to the restrictive policies forced on the hospitals before the pandemic, the casse du sièclePierre-André Juven, Frédéric Pierru, and Fanny Vincent, La casse du siècle. À propos des réformes de l’hôpital public, Paris, Raisons d’agir, 2019.(“Principes médicaux ou critères économiques: quand le système de soins choisit ses morts [Medical principles or economic criteria: when the healthcare system chooses its dead]”, 19 May). The EHPAD tragedy has been covered in the newspapers, caregiver accounts have been published, investigations will be coming, and complaints have been filed.

Concepts developed and legitimised in the scientific domain of the social sciences are used in critiquing these policies. Here are a few of them: the division of labour and range of actions (Denise, Geeraert, and Ridel, AOC, 25 March), norms and apparatus (Borraz and Bergeron, AOC, 31 March), hierarchy of credibility, affinity groups (Menger, Collège de France, 8 April), moral panic (Epstein and Kirszbaum, AOC, 15 April), interaction networks, interaction data (Gianluca Manzo, La vie des idées, 21 April and Emmanuel Lazega, La vie des idées, 1 June), and class relations (Latour, AOC, 2 June). This diversity of concepts is characteristic of the social science field. It is not always a sign of disagreements, but can be linked to internal debates within sociology – for example, to discussions on the analysis of the determinants of Covid 19 spread and of its social repercussions. A future blog will explain the practical value of the concepts that the sociologists used in the texts I studied. They are analytical tools, useful to understand emergency situations like the ones in which MSF rescuers work.

11 July 2020 (partial lifting of the public health state of emergency in France)

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Marc Le Pape, Covid-19: reactions of sociologists in lockdown, 22 July 2020, URL : https://msf-crash.org/index.php/en/blog/medicine-and-public-health/covid-19-reactions-sociologists-lockdown

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Covid-19: reactions of sociologists in lockdown

An epidemiologist’s analysis of the Covid-19 crisis - Part 2

elba.msf — Mon, 11 May 2020 11:00:35 +0000

Date de publication

11/05/2020

elba.msf Mon, 05/11/2020 - 13:00

health measures

Emmanuel Baron & Elba Rahmouni

Emmanuel

Baron

By the same author

Elba

Rahmouni

By the same author

Crisis situation, response strategies, hydroxychloroquine, interventional epidemiology and the state of scientific research in Africa: Elba Rahmouni interviews Emmanuel Baron, Director of Epicentre, Médecins Sans Frontières

The first part of the interview is available here.

Interventional epidemiology

How should we interpret the avalanche of statistics?

There are two difficulties here: there are too many statistics and they are unintelligible. We are given huge quantities of statistics, but most of them are a very flimsy. This profusion has encouraged numerous journalists, bloggers and statisticians to make their own calculations, recycling the same data and reproducing it in different forms. Thus, pie charts are turned into squares, rectangles into graphs, etc., all saying the same thing, while the essential data, such as the real number of cases or fatalities, is missing. But it is difficult to avoid this profusion because without public data, the population would be up in arms about the lack of transparency.

The second difficulty is making existing data intelligible so that it can be used to explain how the epidemic is evolving. Every day, the Health Directorate announces figures – partial for that matter - on the actual number of cases and deaths. But this data is given to us raw, with no explanation and no curves to help us put them into perspectives. A rate is a difficult notion to understand, but at least it provides us with a means of comparison and allows us to adapt decisions at a local level. The authorities have asked the population, who - as I said earlier - are key players in the response, to respect the lockdown without providing the pedagogy needed to explain the figures.

Is it useful to compare data from different countries?

It seems to me that the majority of countries have responded to the inflow of cases according to the same principle: reducing transmission through social distancing. But some have used moderate measures to achieve this, while others have imposed a tough lockdown. In countries such as Sweden, Switzerland or Germany, people were not required to self-isolate but have tended to do so spontaneously.

It is not useful to make comparisons based on weak (or unreliable) data taken out of context. And they are very often worthless because different countries have used different methods to report cases or fatalities. Today, we are seeing major disparities: the mortality rates in Belgium are twice as high as in the Netherlands; Portugal and Spain, despite being neighbours, are in incomparable situations; Switzerland has large infection sites along its borders but hasn’t been submerged by the disease, and the east of Europe has less affected than the west. There is no single mysterious explanation for all this. Possible contributory factors are the date and nature of the measures taken, personal and professional travel, ways of life, population density, different age structures, random travel, encounters and interactions and collective events organised (such as the gathering in Mulhouse in France). But we don’t really know the extent to which each of these factors contributes towards the differences seen within a country, between countries and between continents. And I think it’s a shame that our social scientist colleagues haven’t been asked to contribute more towards clarifying this point. As if only biomedical explanations are the only ones that count.

What can emergency epidemiology contribute?

It’s difficult, but the role of epidemiology is to describe and explain situations in real time. To use an old but still pertinent definition, epidemiology describes a situation in terms of time, place and person based on data collection and analyses. We start by providing some simple explanations. Who is affected? Since when? And where? This requires investigation; we have to “go out and find the cases”. In the epidemics that we work on with MSF, this is our most important task. Guiding the action by monitoring the trends is the primary function of our epidemiologists in the field. Epidemiological surveillance is a difficult activity whatever the country. We do everything in our power but we must acknowledge our limits. All surveillance systems do things to excess, by default, late, imprecisely. We can never be very precise.

Epidemiologists can be asked to study something in more depth to provide an answer to a specific question. For example, on Covid-19 in France, if studies had been able to determine where and how people were being contaminated during the lockdown, recommendations could have been made on how to strengthen protective measures. I haven’t seen anything along these lines so far.

What is the purpose of epidemiological models?

Models can be useful, provided we don’t see them as the be all and end all. It’s easy to understand their attraction because it’s natural to look to the future and want to know what’s going to happen in the coming months. But models don’t have this power. Their results should always be clearly explained. When models are delivered without explanation, there is a high risk that they will be reduced to data that is broadly communicated and interpreted. When in fact a model is more than a set of figures: it’s a process and an approach.

The usefulness of models lies in the fact that, on the scale of a whole continent, it is impossible to test different solutions on different populations to determine which measures are the most effective. For obvious reasons, including, if nothing else, that the initial epidemiological situations are very different, we can’t decide for example, that Germany will close its schools, France will go into lockdown, Italy won't impose any measures, Spain will only impose lockdown in the worst-affected provinces and the United Kingdom will only ban travel and close public spaces - and then, in two months’ time, see who controlled the outbreak the most effectively. This kind of study is unthinkable. What we can do is artificially recreate a fictional population, “impose” parameters of contamination, disease development and recourse to healthcare observed in real lifeHence the need for real, good-quality data.on this fictional population and then calculate the impact of these scenarios on the disease’s evolution, at different dates. Obviously, there is a great deal of uncertainty involved, and this uncertainty increases the further forward we look. And, what’s more, without accurate data from the countries (for example, the proportion of comorbidities among the population in the Democratic Republic of Congo), it is difficult to constitute a fictional population and scenario, adding even more uncertainty.

At the end of the day, modelling introduces quantitative data and reasonable orders of magnitude into the discussion. Models offer a framework for our operational discussions, but they don’t provide direct solutions. When discussing operational strategies at MSF and Epicentre, we consider models as an additional element to be combined with the common sense and experience of our field colleagues, for example. Just as it’s not the weather forecaster who decides whether a plane should take off, it is not the modeller’s job to decide on public health measures.

Wouldn’t it be better to use gross mortality rate compared to the same time last year and in comparable areas as a severity indicator?

Yes, that would be a pertinent indicator, and INSEE (France’s national institute for statistics and economic studies) has already established very high increases in the overall mortality rate of the Grand Est and Ile-de-France departments. But this rate doesn’t give us the causes of these deaths, and it’ll take several months to gather this information. There are people who have died of a heart attack this year who would have survived the same heart attack last year, for example. This data concerning the causes of deaths is essential and needs to be modelled to give us a clearer picture on which to base future decisions.

It would appear that, in France, we find it hard to plan for our seniors becoming victims in a health disaster. The 2003 heatwave is a perfect example of this. The initial figure of 11 000 mortalities was corrected to 15 000 a few months later, and then to 19 500 fours years afterwards. This is edifying when we consider the short period over which this event occurred. It may be socially acceptable for an elderly person to die in winter of a complicated infection, but there is nothing acceptable, in my opinion, about letting people die of avoidable causes because they are alone in August and forget to drink. Surveillance has since been put in place by the town halls. Yet today, once again, nursing homes are taking a heavy toll, with elderly people representing almost half of the deaths caused by Covid-19 and identified.

Scientific research in Africa

What can be said about the controversyhttps://www.youtube.com/watch?v=GKajchR7Gg8&feature=youtu.be&app=desktopcaused by the comments made by Jean-Paul Mira and Camille Locht on 2 April regarding clinical trials in Africa?

People were hurt by these comments and the authors have apologised. So there’s nothing more to say about this very clumsy, overly mediatised conversation, the real meaning of the comments or the authors’ actual intentions. On the other hand, the issue of scientific research in Africa is a real one that we are familiar with at Epicentre and I think it is important to talk about it in order to make a few things clear.

What is the state of research in Africa?

There are very many researchers in Africa, African and foreign, as well as numerous scientific training programmes and centres of excellence in the field of research, including the Kenyan Medical Research Institute (KEMRI) in Nairobi, the Centre for Vaccine Development in Bamako, the Uganda Virus Research Institute in Entebbe and the Centre de recherche médicale et sanitaire in Niamey. The context has evolved enormously. For example, in its 2016-2021 strategic plan, KEMRI states its intention to conduct phase 1 vaccine studies, i.e. to carry out the first trials with humans, so as not to be held back by slow research in the North. You need to look at what these researchers are doing and what they are publishing in high-level scientific journals to realise how much high-quality research is being done in Africa. And of course, all clinical trials to demonstrate the effectiveness of a treatment or vaccine are carried out according to the same ethical and scientific standards as in the North. Ethical committees are consulted prior to each study. There may be some shoddy studies, often under the influence of industrialists, which are methodologically weak and non-essential. But this is a universal problem, in no way specific to Africa.

Are enough studies carried out on the African continent?

In relation to the rest of the world, there are far fewer trials in Africa as many vaccines and drugs are not developed to address the health priorities of Southern countries or the conditions in which they practice medicine. In an editorial published on 8 April, entitled « Non, l’Afrique n’est pas, ni de près ni de loin, la cible privilégiée des essais cliniques » [No, Africa is not by any stretch of the imagination the preferred target for clinical trials], the Cameroonian researcher Fred Eboko stated that too few clinical trials are conducted in Africa and that, ‘Africans may be guinea pigs, but less so than anyone else”. To accelerate Covid-19 clinical research in countries with weak health systems and limited resources, especially in Africa, a coalition was created at the beginning of April and Epicentre has joined.https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30798-4/fulltext

Why is it important to do trials specific to Africa?

Studies that are not conducted in Africa cannot be conducted anywhere else in the same conditions. Indeed, the immunological and demographic profiles tested in clinical studies conducted in Europe (notably age) are not the same as those of the African population. And the vaccines and drugs tested will not necessarily be available or easily accessible in Africa. Trials have to be carried out in accordance with the medical, sociological and demographic environment in which the vaccine or drug concerned will be prescribed. In other words, trials carried out in Europe are not always adapted to the African context.

Examples?

The Epicentre study carried out in Niger in partnership with the Ministry of Health resulted in WHO’s recognition of the usefulness of a vaccine for rotavirus (primary cause of death by diarrhoea in young children) specifically adapted to the context of Sub-Saharan Africa as not requiring a cold chain. The manufacturers of existing vaccines in the North had not taken this major logistical issue into consideration.

Another example of constraints, this time linked to the health system itself: managing the monoclonal antibodies currently being tested in the North for the treatment of Covid-19 requires technical competences that often don’t exist in African settings. Consequently, if there are no clinical trials for this type of drug in Africa, large-scale use of these drugs will not be possible.

Finally, the epidemiological constraints are not the same. At Epicentre, we are looking to conduct a study with several African research groups that will lead to the inclusion in the vaccine schedule of a vaccine active against all the strains of bacteria responsible for meningitis epidemicsCurrently only a vaccine against the meningococcal strain A is available for the meningitis belt . If the studies required are not carried out in Africa, they won’t be conducted anywhere because this is not a priority for Northern countries, much less affected by these strains of the disease.

To conclude…

Looking at these three examples, we seem to have two choices: we either maintain the status quo and pray that, by chance, medical innovations will correspond to Africa’s specific requirements, or, through well-run studies, we draw attention to the limits of the current pharmaceutical R&D paradigm. The Covid-19 pandemic offers a new opportunity to lobby leaders. I think that some of them have understood, considering the commitments made on universal access to diagnostic tests, vaccines and therapeutics at the behest of WHO. But they will be judged by their deeds.

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