Science Spin July 2007

Medicine without borders

By Marie-Catherine Mousseau

David Curtis is a registered nurse, and head of the Irish office of Médecins sans Frontières (MSF). David, who enrolled with MSF in 1997, has just come back from a field visit to South Sudan, where he was sent following recent outbreaks of cholera and meningitis.

While most people (about 60 per cent), stay one to two years in MSF, and some may stay five years, very few stay 10 years like David. One of the main reasons he chose MSF is that it is politically independent.

This is a point made by Fiona O'Neill, PR and Communications Officer with MSF in Dublin. "It is the private funding which is most important to us as this is what allows us to act independently," Indeed, private donations play a much more important role for MSF than State support, accounting for 80 per cent of the agency's funding.

MSF

MSF was founded in 1971 by a group of French doctors in the afterglow of the idealism of Paris in 1960s. Like Concern, it was born out of the Biafran crisis, and since then, it has acquired a reputation for intervening in some of the most difficult situations.

MSF now works in over 75 countries and sends about 3,000 people overseas each year. David Curtis insisted that it is not all about dealing with emergencies as is often believed. "We have basic healthcare projects such as immunisation or feeding projects going on in places where there are repetitions of several emergency outbreaks," he said. The fact remains that MSF often goes where no one else wants to go. This was the case during the Liberia war, where MSF was on the ground before any other NGOs.

Dr Aileen Kitching, a medical doctor who graduated from UCD, has spent nine months with MSF-Holland in Liberia following the war. Her motivations in choosing MSF were similar to those of David. "I chose to work with MSF because of their mandate to deliver quality healthcare to those in need regardless of race, religion, political beliefs etc," said Aileen.

Submitting project proposals and waiting for donors to approve funding takes time. "Because MSF is funded by private individuals like you or me, it is much freer to respond to the needs on the ground immediately," she explained. What's more, she said, everybody is paid (around €800 a month for newcomers) and everybody participates in decision making - with 30 per cent of newcomers each year, this guarantees constant questioning that challenges the old guard and protects against conservatism.

Aileen also had a vocation. "Doing aid work was something I always wanted to do -- even while in school and before I started medicine," she said. When she was in medical school, she went to Botswana for a summer; "that confirmed for me that I wanted to work overseas again," she said, "and I fell in love with Africa," she added.

Recruitment

However, not everyone can follow their dreams. MSF work is tough and, as emphasized by David, it is not for everybody. They need a wide range of health professionals (including doctors and nurses, but also midwives, nutritionists, epidemiologists, lab technicians, mental health professionals) as well as logistical support staff/technical experts such as water and sanitation engineers, and construction engineers.

Qualifications are important, bu not everything. According to David, only 40 to 50 per cent of applicants are successful. Firstly, they don't take people straight out of medical school; they recruit doctors that have a minimum of two years professional experience or are registrars, or consultants. In addition, they will preferably have a diploma in Tropical Medicine, or overseas work experience. "It is necessary that volunteers have at least three months experience either working or travelling in a developing country," said Fiona.

Aileen's curriculum vitae is indeed quite impressive. Initially, she worked two and a half years in hospital medicine in Dublin (as a Senior House Officer (SHO) in the Mater hospital and as a Registrar in St. James's hospital). Then she went to Australia where she worked as a Registrar in Emergency Medicine in Queensland for one year. After that she did some paediatrics and psychiatry before doing GP training for one year in Scotland. "I was working as a GP doing locums before going away with MSF in October 2005," she explained. "I had also done a Diploma in Tropical Medicine (DTM&H) and a Diploma in Humanitarian Assistance (DHA) at the Liverpool School of Tropical Medicine, with a view to doing aid work."

Career

Some specialists are difficult to find. "We need more surgeons and anaesthetists," said David. In Ireland, one of the problems is that there is resistance within the medical professions to taking breaks in the course of the training cycle for overseas work. "Doing aid work is not something that was encouraged in medicine when I was training, particularly in hospital medicine," Aileen commented.

Unlike EU countries like France, the Republic does not have specific schemes actively encouraging doctors and nurses who wish to take short-term leave to provide much-needed assistance to aid agencies. "I feel that overseas work experience is something that should be encouraged more for doctors in Ireland," Aileen said, "as it is in the UK, where time spent in the developing world can be counted towards specialist training in Paediatrics, Obstetrics and Gynaecology, and Public Health," she added.

However, the situation here is improving. As David pointed out, MSF is building links with the medical community in order to secure accreditation with medical bodies; even though he agreed that this is only at an initial stage.

Challenges

Recruitment is only one of the many obstacles facing the MSF mission. The challenges are also political and economic, and MSF staff set out to tackle most sensitive issues -- drug production, pricing and delivery, targeting diseases in places that have been completely forgotten, places where people and governments have no money at all to spend on healthcare (see panel next page on drug access).

The MSF response to those critical issues is to raise awareness -- i.e. raising awareness of the need to use generic drugs and research for new drugs for developing countries. "Many otherwise unreported stories get out there thanks to MSF," said David. "Real stories, where we speak on behalf of the patients."

But, at the end of the day, the main MSF challenge lies with the individual staff members on the ground. The extent of the aid which is needed is enormous. Aileen tried to explain some of the challenges she had to tackle: "there were many difficulties working in Liberia. It was a country coming out of 14 years of a brutal civil war, where more than 200,000 people were killed."

"We were based in Buchanan, the second biggest 'city' in Liberia, in Grand Bassa county," she continued. "We supported four clinics in the interior of Grand Bassa, and three clinics and a small hospital in River Cess county." She then explained how MSF were the only healthcare NGO in River Cess, and as there were no Ministry of Health doctors, effectively she was the only doctor available to this county. Between their seven clinics and the St. Francis hospital, with a team including just one doctor, they had a catchment population of 191,000 people.

Their task was made even more difficult as they had to face basic problems in Liberia -- no running water, no electricity (apart from power provided by private generators), and roads that were in a very bad state (or no road access at all). "Because people had no refrigeration, as there was no electricity, salt was used a lot to preserve food and in cooking, and we saw many people with high blood pressure and subsequent heart disease as a result."

There was also a lot of tuberculosis (TB). "This was a big public health problem as one person with infectious TB can infect 10-15 others per year if left untreated," Aileen said. "This means treating TB was crucial for prevention."

But the main medical problems Aileen and her team encountered were malaria, diarrhoeal illnesses, or chest infections and pneumonia. "Many deaths were from these diseases -- all easily treatable, and/or preventable if people had access to clean water, and simple antibiotics," she commented. "We saw many children with malnutrition," she added. "It was very difficult seeing children die from what are preventable diseases, particularly the vaccine-preventable diseases such as seeing newborn babies dying a painful death with the spasms of neonatal tetanus because their mothers had not been vaccinated due to problems in getting the vaccine."

In response, MSF in Liberia have set up several programmes including a feeding programme for malnourished children and a TB programme. Aileen also started a programme to tackle sexual violence, a serious problem which appeared during the war, but which also persisted afterwards. "Rape was a particular characteristic of the war there, and some UN figures estimate that more than 70 per cent of women in Liberia were raped in the war," said Aileen.

Another feature of the Liberian war was child soldiers. "In many instances children were the perpetrators as well as being the victims of many atrocities," Aileen said. One of their drivers said to her that 'the children made the war ugly'; they couldn't be reasoned with, many were high on drugs, and they often killed indiscriminately.

MSF felt they could respond to the needs on the ground -- which is how their TB and SGBV programmes developed. Aileen trained local staff how to diagnose and treat diseases. And she pointed out that it is MSF policy that no patient pays. "In clinics run by the ministry, often patients have to pay for care," Aileen said. And even though money is not always used (chickens can be used as currency), often they cannot pay. This means some patients would walk six to seven hours to go to a MSF clinic, while some others would be carried by their family in a hammock. Aileen also saw a man who walked six hours to the clinic and six hours back each week with his child to get her treatment.

Benefits

However, the benefits drawn from the adventure may well be worth all the hardship. "I loved the work; it was challenging, but hugely satisfying and rewarding. We had a great team and we all got on very well -- we had great fun together," said Aileen. "This is a huge broadening of your horizon," said David, "it is also a management experience; you learn to listen, to be patient, to adapt."

Aileen, who is now doing a Masters degree in Public Health in UCD, confirms that she draws on her experience in Liberia a lot. "I feel I learnt more in that nine months than I did in years of clinical practice at home," she said. The benefits were both personal and professional, as she developed an enormous range of skills.

"Because of the lack of available tests, as a doctor you develop your clinical skills more; but you also have to learn to prioritise, make resource allocation decisions, manage staff and teams more so than you would at home," Aileen said. "I had to manage huge time and workload pressures, teach large groups of people, organise and run workshops etc." She added: "I was in many meetings with Ministry of Health staff, the National TB programme co-ordinator, UN personnel etc -- something which would just not happen in Ireland!"

When asked if she'd think of going back, she replied: "Yes, I would definitely like to work overseas again. It was a fantastic experience, and I have no regrets at all about it."

She added on a more philosophical note: "Bernard Kouchner, one of the founders of MSF said, Mankind's suffering belongs to all men." Some of us have been a lot more fortunate than others, and going to work overseas is a way of giving something back.

MSF in Liberia

Mission: sent by MSF Holland to Liberia after the war - Oct 05 to Aug 06

Responsibility: seven Clinics (out patients) - four in Grand Bassa and three in River Cess and one hospital (St Francis) in River Cess. Aileen is the only doctor in River Cess.

The team
Expatriate team of six people -
- Aileen, from Ireland: medical doctor
- Chuma, from Zambia: nurse responsible for management of the clinics in GB
- Bonno, from Holland: nurse responsible for management of the clinics in RC
- Chantal, from Holland: midwife
- Brian, from Canada: logistician
- Elamma, from India: Project Coordinator

National staff - medical team of nine people (no doctors).
The team worked in collaboration with the Ministry of Health staff in the clinics and hospitals. The catchment population for the team was 191,000 people.

Programmes

MSF had several programmes in Liberia. It started with a feeding programme where they gave specially made Ready To Use Food (RTUF). This was a biscuit form, and a nut-based mixture called Plumpy Nut with a particular balance of protein, vitamins, minerals, adapted to the physical needs of malnourished children -- food as medicine. The team diagnosed a lot of children with TB, and reintroduced a TB programme that had stopped in 2003.

Aileen and her MSF team trained local staff referred to as 'medical officers' (including physician assistants, pharmacists and trained nurses) how to diagnose and treat TB and other diseases. There was no doctor, so they had to be trained to diagnose and treat as if they were doctors. Aileen explained how these medical officers were paid "incentives" by MSF (not called 'salaries' as they were all on the Ministry of Health payroll, but the Ministry had no money to pay them). Their training included formal sessions, bringing together national staff from all clinics, but Aileen also did teaching on the wardrounds, discussing cases etc. "Sometimes 10-12 people would follow me in my wardrounds," Aileen said.

Additionally, Aileen set up a programme to respond to sexual and gender-based violence (SGBV) that had started during but went on after the war. This included one six-day workshop where medical officers were trained to examine and treat victims of sexual violence while traditional midwives were trained as counsellors and a local women's group in SGBV awareness. Aileen was also involved in setting up a Taskforce in order to get the local police trained by the UN police to deal with rape as a crime. As Aileen put it, "the response of local police to rape cases was often inadequate or dismissive."

Aileen's typical day

"It is difficult to say what a typical day was. There was no typical day or week for me really, as I had to move around a lot. But, usually, I would start with getting up at 6am. We could not leave base before seven am for security reasons, but by seven the Land Rover would all be packed up, with national staff on board, ready to leave for the clinics that were scheduled for that day. The journey to the clinics took from between two to five hours depending on what clinic it was, and if it was in the rainy season or not. For the more remote clinics we would stay the night there, sleeping in the clinic. When we would get to the clinic, there would be lots of people waiting to be seen.

I would try to plan my schedule to inform the clinics when I was coming; thus if they had particular cases they wanted me to see, it could be arranged. After seeing patients in the clinics, we would have some food there, usually prepared by a woman in the village. We had to be back at base by six pm at the very latest (security reasons), so we had to plan our departure according to that. Often the Land Rover would be very full travelling back, with staff and patients on board.

Some days, we might not make it to the clinic, if we met someone ill on the road, e.g. a woman in obstructed labour who needed to get to hospital urgently. Other days I stayed at base -- for meetings with e.g. the TB programme manager in Grand Bassa county, or with other NGOs or to do some teaching, or run workshops.

But, anything could happen. One day, the police came, saying they needed a doctor to examine a "possible homicide". So we ended up travelling miles to a rural village, having a meeting in the centre of the village with the whole village present -- elders, possible suspects, family of the bereaved, children, UN and local police -- and then examining the body in a little hut nearby. We also did some outreach visits to villages where we seemed to be getting a lot of TB cases from.

There was always something to be done.

For more information on MSF in Ireland click here.