The FoMSF Magazine
Note from the Editor Welcome to the fourth issue of the Friends of MSF magazine! Walking into the Freshers’ Fair at University College, London, five years ago, what caught my eye (amongst the hundreds of stalls) was the red and white logo representing MSF: a simple emblem that would soon become so familiar to me. My interest in global health, and more specifically, the work of this independent humanitarian organisation, was fuelled initially by my passion for medicine; yet even more so by my desire to genuinely change the lives of individuals around the world living in dangerous warzones or areas of poverty. It was all very well to enter university with this perhaps idealistic viewpoint in mind, but what I wanted to know was what I could actively do at that point in time. With a six-year long degree to study medicine in front of me, working with MSF in the field was obviously totally out of the question. Joining the Friends of MSF society provided me with the perfect opportunity: not only giving me the chance to actively raise both money and awareness for populations that faced appalling conditions for a long time after initial crises, but perhaps more importantly, driving me to explore fundamental humanitarian concepts and ideas, such as access to healthcare and the importance of advocacy. This magazine is a testament to the students involved in each Friends of MSF society, who invest an enormous amount of energy and enthusiasm into organising speaker events, film screenings and fundraisers. And it is during the larger-scale, UK wide events, such as the annual Friends of MSF Charity Run, that we can truly understand the passion that drives these individuals to take initiative and get involved. 2013 has proven a critical year for the MSF Access Campaign, with the introduction of newly developed drugs for the treatment of tuberculosis, for the first time in fifty years; but with this, we see threats towards the production of generic medicine in India, and the negotiation of further trade agreements within the European Union. Despite representing a large part of the global burden of illness, only a fraction of the drugs registered during the last ten years were for tropical diseases, TB and other neglected infections. In this issue of Insight, we delve into the ‘fatal imbalance’ between worldwide suffering from these conditions, and drug development, together with access to medication. MSF’s focus on témoignage, literally bearing witness, is what makes it unique as an organisation, and advocacy is a core principle for the Friends of MSF. Our goal is to enhance public understanding of the plight of populations, regardless of race, religion, gender, or political affiliation. Further to this aim, I hope that this magazine will result in an increased appreciation of the need to take action and fight for the rights of individuals suffering from discrimination, prejudice and inequality. Five years on, my eyes have been opened to the immense challenges faced by humanitarian organisations such as MSF, and the realisation that it is impossible to provide aid to every individual, in every country around the world. But it is the hope that each penny raised, and each letter or article that is written, will make a difference to someone, somewhere.
“It may seem naively idealistic, but as long as we can imagine a better tomorrow, we can work towards a better tomorrow.” Dr James Orbinski, former President of MSF, ‘An Imperfect Offering’ Alisha Allana Editor firstname.lastname@example.org
MSF: first in, last out
Surgery in Sierra Leone
11 What is the future for drug innovation? 12 Novartis lost the case 13 The global burden of disease 15 A lost generation? 16 ‘If you contract AIDS, you will die’ 18 STIs: there is still much to do 19 The access is there; is equality in place? 20 Focus on Syria 22 Working with MSF in Syria 25 Damien Brown: an insight 26
Band-Aid for a Broken Leg
The world in denial?
30 Re-emergent humanitarian dilemmas in
32 Global health diplomacy 34
Unravelling Bosnia’s past and present
The FoMSF Charity Run 2013: revisited
MSF: first in, last out hat can you actively do for global health? This is a question that many people are searching for an answer to; every day we are confronted by newspaper headlines about natural disasters, epidemics and wars. These situations result in populations facing appalling conditions for a long time after the initial crisis, including lack of access to healthcare, inadequate nutrition and very little security. This is where Médecins Sans Frontières (Doctors Without Borders) plays a huge role in establishing both short and long term programmes to assist numerous countries: primarily in the medical sector, but also through the work of other skilled professionals.
Enter MSF Médecins Sans Frontières was founded in 1971 by a group of French doctors and journalists who were frustrated by the lack of an independent humanitarian medical aid organisation, and quickly ascertained that MSF would adhere to the basic ethical principles of independence, neutrality and impartiality. The heart of MSF lies in the fact that everyone is entitled to assistance, medical or otherwise. This is regardless of their race or religion, and irrespective of any political connections they may be associated with. After all, is it
not a fundamental human right for every individual to have access to basic healthcare? Today, almost thirty years later, it has expanded into a worldwide organisation, with branches in nineteen countries. MSF aid work has taken place in over sixty countries: in areas of conflict such as Darfur; after the earthquake that took place in Haiti; and above all, in places such as India and Burma where much of the population are constantly struggling to survive, lacking in basic needs such as food and clean water. The aid delivered by MSF workers includes surgery and basic medical care in MSF hospitals and clinics, however their long term plans range from vaccination programmes, to continuous treatment of infectious diseases, for example tuberculosis, malaria and HIV/AIDS. Doctors without borders “Working with MSF is what being a doctor is really about – you are literally saving the lives of desperately ill people every day.” Simon Burling, speaking about his experiences working with MSF in Somalia, explains the reasons for which many medical students
“...the reward s
with MSF a
“you’ll walk a way with more than y ou ever gave”.
“...once abroa d, MSF workers may be thrown into situation s and medical case s where they have little pr evious experience, b ut learn through the support of their fellow staﬀ and the rigorous MS F protocols.” “...majority o f
MSF workers belie ve that their missions abr oad can be compared to “recharging [their] doctor batteries”
“Working with MSF is what being a doctor is really about – you are literally saving the lives of desperately ill people every day.” Simon Burling
and doctors wish to work with MSF at some point in their careers. Nevertheless, many do not truly understand the reality of working in harsh conditions, with very few comforts, including electricity and running water. More importantly, the pressure of such hard work in these circumstances requires a great deal of professionalism, commitment and flexibility. Yet the rewards and skills gained from working with MSF are priceless: “you’ll walk away with more than you ever gave”. Medical students who wish to get more involved with MSF’s work later on in their careers are encouraged to carry out their electives in developing countries to get a feel for the challenges they may face working out in the field.
MSF continues to recruit a large range of medical staff: from surgeons and anaesthetists, to nurses and midwives. Lab specialists with degrees in biomedical sciences also play a huge role in the field, for access to rapid diagnoses in clinics. Doctors who have been specifically trained to treat infectious or tropical diseases, and those with experience in obstetrics and gynaecology are especially sought after. Nonetheless, once abroad, MSF workers may be thrown into situations and medical cases where they have little previous experience, but learn through the support of their fellow staff and the rigorous MSF protocols. A great deal of creativity is also needed, as doctors attempt to re-create procedures using the only materials that are available to them. A recent development in the work of MSF includes establishing programmes dedicated to those suffering from mental illnesses, particularly for those who have been affected by political conflict or war, which would have a profound impact on them psychologically. Similarly, victims of disease such as HIV/ AIDS may feel marginalised and excluded by their families and communities, hence the reason for which MSF has called for more mental health specialists, that is to
say, those with qualifications in psychiatry, psychotherapy, clinical psychology and psychiatric nursing. It has recently come to light that many doctors working in the National Health Service in the UK are worried about how developments in the NHS, such as Modernising Medical Careers, may affect their later careers if they do choose to get involved with MSF, since the minimum requirement is nine months abroad. Some doctors did speak negatively about their experiences working in “stressful, frustrating and demanding conditions”, and 16% of doctors questioned believed that working with MSF had a negative impact on their careers (BMJ Careers, 2009). However, despite this, the majority of MSF workers believe that their missions abroad can be compared to “recharging [their] doctor batteries”, enabling them to gain invaluable skills, understanding and experience. MSF without borders Despite its name, MSF provides numerous opportunities for
non-medics to get involved: the programmes would come to a standstill if it were not for the logisticians, financial controllers and specialists who accompany the medical staff. Technical logisticians are wholly responsible for reconstructing hospitals and clinics that may have been damaged as a result of conflict; maintaining electricity supplies in clinics; and organising the transport of medical supplies. Administrative and finance positions can also become available, managing the workers on the camp, and frequently interacting with the local authorities about the ongoing MSF work. While MSF focuses primarily on providing medical aid, they also realise the importance of longterm management. A contaminated water supply in itself can rapidly lead to a health crisis, giving rise to outbreaks of cholera that could otherwise have been avoided. Hence MSF also recruits specialists in water and
sanitation, particularly those with backgrounds in engineering, to design and build wells and other such water sources, and moreover, to formulate ideas about managing waste management well, particularly close to the hospitals and clinics, to minimise transmission of water-borne diseases. So what can students do? It is not possible for students to work directly for MSF on their missions abroad, owing to the difficult conditions as well as the scarcity of equipment and facilities, and it is for this reason that MSF do not offer electives to students. Nevertheless, in emergency conditions such as the aftermath of the earthquake in Haiti in January earlier this year, some local students were recruited to help the MSF aid workers with their basic tasks. The challenges faced by these students were undoubtedly unlike anything they had experienced during their studies, but the skills and understanding they developed as a result have proven invaluable for their future careers. The main way in which students can get involved is through ‘Friends of MSF’: numerous universities have established societies where they promote awareness and raise money for MSF. Here at UCL, the
“independent humanitarianism is a daily struggle to assist and protect… it is lived most deeply, most intimately in the daily grind of the forgotten war and forgotten crisis.”
Dr. James Orbinski
Friends of MSF group organises talks, screenings and other events, which are open to everyone, which may inspire you to work for MSF one day. As Dr James Orbinski said in his acceptance of the Nobel Peace Prize on behalf of Médecins Sans Frontières: “independent humanitarianism is a daily struggle to assist and protect… it is lived most deeply, most intimately in the daily grind of the forgotten war and forgotten crisis.”
Alisha Allana , 5th year medical student, UCL
Surgery in Sierra Leone he very name ‘Sierra Leone’ conjures up images of conflict, diamonds and despair. This view, from the recent war in Sierra Leone 1990- 2001, was compounded by the Hollywood portrayal of its troubled past in the film with Leonardo DiCaprio: ‘Blood Diamond’. With recent democratic elections passing smoothly and the country declared safe by the Foreign Office, I was given approval to conduct an intercalated research project in this small West African Nation. Collaborating with John Hopkins University (USA), I developed a questionnairebased project investigating the training and the continued professional development of surgical and anaesthetic staff in Sierra Leone. The idea behind this project was based on the exposure to surgery in developing countries I had experienced during time spent working in hospitals in east Africa.
Sierra Leone, one of the poorest countries in the world, ranking 180th out of 187 in the United Nations Development Index (UNDI), seemed an appropriate environment in which to investigate surgery and anaesthesia in the developing world. The planning stage of this project taught me that this was not to be an easy process. For
all you budding researchers in International Health: prepare for a long hard slog to prepare the logistics of conducting research abroad. Applying for ethical approval in 3 different continents proved problematic, with month after month of delays. Finally however my departure date was set. From London, via Morocco, via Liberia, I arrived at the break of dawn ready for the next stage of the adventure. A bus, boat and a taxi later I had arrived in Freetown, the capital of Sierra Leone and a city steeped in History. The ‘Athens of Africa, the origin of the slave trade, then a first settlement for freed Slaves from the Americas, and most recently the sight of horrific of atrocities committed during the decade long war. Today however it is hot, frenetic hub of activating encircled by the glistening blue of the Atlantic Ocean. When ethical approval was finally given, the research began in earnest. The staggering contrasts between surgical and anaesthesia provision between Sierra Leone and the UK were immediately apparent. The structure of the healthcare system in Sierra Leone is complex and fragmented – two tertiary referral hospitals based in the capital with the vast majority of surgeons and anaesthetists
compared to only a few staff and the barest of resources in the small satellite hospitals in the outskirts of Freetown. Whilst Sierra Leone’s government has recently introduced free care for children and pregnant mothers, all other patients are required to pay fees even for critical care. Due to the repercussions from Sierra Leone’s decade long civil war the number of charities and NGOs involved in the health sector is staggering. Whilst these institutions add to the breadth and quality of surgical care for patients assessing these institutions was beyond the stretch of our research. In Freetown, we navigated bustling streets to reach over stretched government hospitals, the staff greeting us with typical Sierra Leonean warmth and hospitality and seemed please to discuss which areas were well catered for and which require more resources and training to deliver effective surgical and anaesthesia care for patients. I then set off for the provinces with a Sierra Leonean medical student in a 4x4 to explore all 3 far afield districts, often not reached by locals and researchers alike. Beyond the edges of Freetown the hospitals had far fewer surgical and anaesthesia staff, their relative isolation from the specialists in Freetown leaving newly trained doctors to deal with whatever surgical emergency presented itself. As one junior doctor put it: “if we refer them on to another hospital, they will die,
her final exams the day the RUF rebels entered Freetown and returned home to discover her house had been burnt down. She still managed to graduate and was soon posted to ex-rebel strongholds to continue to treat the victims of war.
“The ‘Athens of Africa, the origin of the slave trade, then a ﬁrst settlement for freed Slaves from the Americas, and most recently the sight of horriﬁc of atrocities committed during the decade long war.” the costs and time of travel are simply too great. So we do the best we can for them”. These staff, often on call all hours of the day 7 days a week are lacking in supplies and training, but work tirelessly to do the best they can for their patients. Tales from nurses who had trained through the war were inspirational. One particular nurse who had been due to sit
My time in Sierra Leone is drawing to a close. A country shrouded in brutal history of war, now growing and developing. This is a country which highlights many of the problems facing the delivery of effective surgical care in developing countries. It needs to develop it’s internal training schemes for locally trained surgeons, and a need to improve its supply of essential anaesthesia drugs in order to provide the level of surgical care its patients deserve, not only in Freetown but also the far flung district hospitals. It is crucial for the international community to continue its work to group together and build structures and educational programs to allow continued professional development in countries with relatively new medical institutions. With well trained staff and adequate equipment, health professionals in Sierra Leone can continue to improve their skills – enabling them to give the best care to their patients.
Emily Vaughan, 4th year iBsc student, The University of Birmingham
Fatal neglect Fatal Neglect is a six-part documentary film project, which tells the stories of millions of patients left behind by the global health Doctors With revolution. Borders/Medecins Without Sans Frontieres (MSF), VII Photo and UNION HZ sent a w a r d-w i n n i n g photojournalists to travel around the world to capture the stories of frontline health fight to trying workers diseases that affect millions of people and kill hundreds of thousands each year.
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MSF´s project in Tajiskistan, there was no treatment for children available in the country. This documentary shows the struggles of diagnosis, the strain of forcing children to take 7-8 tablets a day plus an injection and dealing with the debilitating side-effects of the treatment. This documentary also shows families having to deal with the stigma and fear of having to deal with a fatal disease. Two new drugs – the first in almost fifty years – are about to come to the market this year. This could mean a better future for the treatment for children – fewer tablets and less side-effects.
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SLEEPING SICKNESS The Long Road by John Stanmeyer in South Sudan Sleeping Sickness (Human African Trypanosomiasis) is endemic in 36 African countries and around 60 million people are at risk of being infected. Without treatment, anyone infected will die. The main issue surrounding this disease is access; the most people at risk live in remote parts of Africa and it can sometimes take up to 2-3 days to get to the nearest health facility. The diagnostic procedure is also expensive and time consuming. Perhaps more disconcerting, until 2010 the most widely used treatment killed 1 in 20 patients. Between 1986 and 2010, MSF teams in several countries screened and treated more than 51,000 for the disease. MSF has several Sleeping Sickness programs in African countries; this documentary shows a photojournalist following one of the mobile teams. It is a firsthand look at the MSF is currently battling this horrific disease.
KALA AZAR Still Waiting by John Stanmeyer in South Sudan Annually there are 400,000 new cases of Kala Azar (Visceral Leishmaniasis) resulting in almost 50,000. Three decades ago an epidemic across what is now South Sudan cased the decimation of countless communities. Despite MSF working against this disease since this epidemic, there is still limited focused research on diagnosis and treatment. The diagnostic rapid test is unreliable and can often present with false negative diagnosis and is also painful. The mainstay treatment is also toxic and kills patients. This documentary painfully highlights the need to provide better, more specialized, more accessible treatment and testing, and to prevent further devastation.
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What is the future for drug innovation? hen a pharmaceutical company patents a drug it gives that company exclusive rights to production and sale of that drug without competition from other parties. A current patent life is 20 years, this may seem like a long time before a generic can be made, but in reality it is generally the lead compound that is patented, not the finished product; the time spent modifying and testing a lead compound is around 10 years, i.e. half the life of the patent, after this the finished medicinal product is safe and ready to be used by the public.
Drug patents give pharmaceutical companies the time to recuperate the insanely expensive cost of novel drug production, as well as balancing the costs of those compounds that are found to be not viable as future drugs; from 10,000 drug candidates to treat a disease only 10 will make it to human trials. Recently India’s Supreme Court rejected a Novartis re-patent bid for its blockbuster cancer drug Glivec that is used to treat chronic myeloid leukaemia. Novartis argued that changes to Glivec such as increased absorption rate, improved physiochemical qualities, and enhanced efficacy, merited a new patent, but despite this the court argued that the minor changes to the drug molecule did not show new drug innovation, hence rejecting the bid insisting Novartis where simply refreshing the previous drug to attain a new patent, a process known as ‘evergreening’. The ruling has set a precedent that in India pharmaceutical companies will not be able to obtain fresh patents for updated versions of drugs, and that patents will only be given to new
drugs. The pharmaceutical world has reacted claiming that these actions directly discourage not only the innovation of the improvement of current medicines, but also the innovation of new medicines, as the potential to work and improve future new medicines after the initial patent has now gone. India is the world’s third largest drug producer of generic medicines, globally exporting around $10b’s every year. The Glivec hearing is by the no means the first of its kind. Companies involved in re-patent disputes with the Indian Supreme Court claim that rejections to re-patents are a tactical move to increase India’s ever growing generic market. Despite these disputes between the companies and the courts, an increase is a generic drugs market and the number of generic medicines available, should increase the availability of more medications to a greater number of people improving health worldwide. With this being said, there is still a need for drug patents to exist, as without them future drug innovation would cease to exist, and the tackling of some of the world’s most lifethreatening conditions would stop.
Luke Johnson, 3rd year, UCL School of Pharmacy
“...from 10,000 drug
candidates to treat a disease only 10 will
make it to human trials.”
Novartis lost the case
Box 1: For a detailed explanation of the patent process, see this comprehensive MSF publication: http://tinyurl.com/ d2zecrp In 2005, the Indian Government corrected its existing patent legislation, in line with the multilateral Trade-Related aspects of Intellectual Property Rights (TRIPS) agreement (see Box 2).
Box 2: The Trade-Related aspects of Intellectual Property Rights (TRIPS) agreement came into affect in 1995, and established legal obligations for all World Trade Organisation (WTO) members. However, the existing Section 3(d) of the Indian law stipulates that patents should only be granted to truly innovative drugs, i.e. they must represent a novel development, or show a significant improvement in efficacy. When the Indian patent office rejected a patent application filed for a modified version of an existing anti-cancer drug, imatinib, a process commonly referred to as ‘evergreening’ (see Box 3), Novartis launched its first court case to challenge the ruling.
“the price at which imatinib has been oﬀered for sale by Novartis… has caused me
Photo taken by Syddharth Singh
even years after Novartis launched its first court case against the Indian Government, the Indian Supreme Court has ruled in support of India’s Patents Act, a decision that represents a major step towards ensuring access to affordable medicines for many millions of patients in low-income countries.
considerable discomfort. Pharmaceutical companies…should achieve a return on their investments. But this does not mean the abuse of these exclusive rights by excessive prices and seeking patents over minor changes.” Brian Druker, the scientist who discovered imatinib would later say Yet why should it matter whether a patent is granted for a highly selective anti-cancer drug? If the Indian Government had granted patent protection to the modified version of imatinib, there would be legal precedent to challenge India’s relatively lenient patent laws. Long known as the ‘pharmacy of the developing world’, protection of India’s pharmaceutical industry will have direct benefits for many
millions of patients in developing countries.
Box 3: Evergreening refers to an attempt to patent-protect an old drug following minor modifications, thereby extending a company’s market monopoly over a product. However, the struggle is far from over. With closure finally granted to the Novartis case, the European Commission is attempting to limit the flexibility with which the Indian pharmaceutical industry is able to produce and distribute generic drugs. While some dangerous provisions have been removed from the proposed Free Trade Agreement (FTA), many of the remaining clauses are a threat to patient access to quality, affordable drugs. Find out more about the Europe! Hands Off Our Medicines campaign here: www.msfaccess.org.
James Smith, MSc Global Health, UCL. Intercalating final year student, Newcastle University.
The global burden of disease Introduction In recent decades, global health has come to fore in political and social discourse, highlighting the vast inequalities in health across the world today. In the search for tools with which to accurately assess and compare health across the world, the disability-adjusted life year (DALY) was created. The DALY was first used in the 1993 World Development Report, in an attempt to quantify ill health and make comparisons between interventions to aid priority setting. It has since been modified slightly and become the primary measurement tool used in the Global Burden of Disease and Risk Factors (GBD), a report compiled by the WHO and World Bank that is the most comprehensive assessment of global health available. The much anticipated 3rd edition was published in December 2012. In the past, crude proxies of population health such as mortality rate were used to assess global health, however, these measures often overlooked wider population health needs. The DALY aimed to address this problem by combining the impact of disease mortality and morbidity into one metric, using the formula:
DALY = Years life lost due to premature mortality (YLL) + years of life lived with disability (YLD)
Where YLD = (duration of disease) x (disability weight) x (age weight) x (future discount). Each disease state was given a disability weighting of between 0 (full health) and 1 (death), which when input into the formula, allowed the burden of each disease, and latterly risk factors, to be assessed. The use of age weighting and future discounting were omitted in the recent 3rd edition, as will be explained later. By assigning disease weights, the DALY has drawn attention to diseases that previously passed under the radar, such as neglected tropical diseases. Conditions now be ranked in terms of burden, thus providing an easily understandable measure for policy makers with which to prioritise interventions.
Image 1: The DALY has brought attention to Neglected Tropical Diseases such as Lymphatic Filariasis.
Drawbacks of the DALY and the response to critics The DALY has been widely used over the last two decades; however, it has evolved during this time in response to criticism. In particular, the use
of age weighting and a discount rate have been particularly controversial. Age weighting states that years of life at different ages are worth more, with the years between 20 and 45 being the most valued years (Figure 1); it was said to be based upon societal preference, however, this has been argued to represent an ethnocentric view.
Figure 1: The value of a year of life, Box 1.3 pg. 26, World Development Report (1993)
Discount rate relates to the depreciation in value of future DALYs. When considering goods like electronics reducing future value is understandable, however, applying this approach to human welfare risks over commoditising human life. Furthermore, discounting can reduce the impetus to address future problems since prevention appears comparatively less effective. The impact of applying a discount rate is illustrated in Figure 2. Researchers chose to level these criticisms by omitting the use of age and discount weighting in the recent Global
big impact on an individual’s ability to mitigate the problem. There are also wider implications of morbidity and death which can overlook important aspects of health. For example, mortality of a mother Figure 2: Adapted from Global Burden of Disease and during birth or during Risk Factors (2006) childhood has serious Burden of Disease report and implications for the well-being using the revised formula: of the new-born. This also has impacts on any other dependents as well as the YLD = (duration of disease) x (disability weight) overall family structure. The DALY construct was built on the assumption that the health a) Other controversial areas which can defined by the presence or were maintained in the recent absence of disease, and b) report include the use of causes a quantifiable degree of universally standardised disability which is the same for disability weights. This, by people all in all places. Social default, disaggregates individual roles and values vary across the health from geographical and world yet the DALY necessitates socioeconomic context and uniformity, it embodies the therefore overlooks the ability individualistic approach to of different individuals to deal health generally found in highwith illness. income countries. Take deafness as an example: in certain contexts such as deaf communities this condition is the norm; in countries such as the United Kingdom, there is quality healthcare provision, charitable support mechanisms in place and equality law to protect the disabled; and in other places, particularly in lowincome settings, lack of assistance renders deafness a debilitating condition which can severely limit a child’s learning, and restrict the ability of a person to engage in society. Financial security and access to healthcare clearly both have a
The future This article is intended as a brief overview of the DALY, there are several other important elements including the role of epidemiological data which are outwith the scope of this article. DALY statistics are generally presented in an easily comprehensible manner, however, care must be taken not to misinterpret this as simplicity; the DALY is a conceptual metric seeking to aid resource distribution by balancing the complexities of
short and needs.
The disability weights assigned to individual diseases was revised in the new GBD report, utilising a new methodological approach in order to better reflect disease impact– it remains to be seen how the global health community responds to these revisions. It has been argued elsewhere that universal weights are the DALY’s “fatal flaw”, only time will tell if this prophesy comes true.
“The recent GBD report represents a truly great collaborative eﬀort to create the most comprehensive overview of global health available today.” The recent GBD report represents a truly great collaborative effort to create the most comprehensive overview of global health available today. This herculean task must be lauded; however, we must ensure that health is not viewed in isolation to the reality. After all, the purpose of assessing global DALY burden is not merely its reduction, but to improve the wellbeing of the citizens of the world.
Anand Bhopal , 4th Year medical student, Manchester
A lost generation?
round the globe, a staggering 287,000 women die each year during childbirth.
To put some perspective on another banded-about statistic, that’s roughly the equivalent of a bursting-at-the-seams Wembley Stadium, times three. And sadly, whether it’s an unborn fetus or a motherless baby that is devastatingly left behind – the statistics don’t stop there. Even if the baby survive, this lost times more prematurely as mother’s death.
is lucky enough to generation are ten likely to die a result of their
The major causes of maternal morbidity and mortality include: • Haemmorhage • Infection • Hypertension • Unsafe Abortion • Obstructed Labour Fortunately, MSF’s introduction of low cost health interventions has radically reduced maternal deaths by as much as 74% - in their projects in Sierra Leone and Burundi. Simple initiatives, such as the development of an ambulance referral system and the provision of emergency obstetric services have made a huge difference in these parts of Africa. “You do not need state-of-the-art facilities or equipment to save many women’s lives” – Vincent Lambert, MSF Medical Advisor Despite this, it remains a sad reality that the natural process of childbirth is the greatest cause of mortality in women aged 15-44 in developing countries – where 99% of maternal mortality occurs.
However with simple initiatives, such as those demonstrated by MSF in Sierra Leone and Burundi, this does not have to continue. By providing open access emergency obstetric services, 24 hours a day and 7 days a week, a phenomenal difference can be made, for as little as 2 dollars per person, in Kabezi, Burundi. 2015 is approaching faster than ever and if the Millennium Development Goal (MDG) for reducing Maternal Mortality by a third is to be achieved, these footsteps must be followed with haste. It should also be emphasised, that most maternal deaths are avoidable – hence preventative medicine is also key, whether this is preconceptive family planning to prevent unwanted births and dangerous abortions, or antenatal care and the presence of skilled birth attendants. The lifetime risk of maternal death in a developing country is 1 in 150, compared to 1 in 3,800 in a developed country. We need to help developing countries develop infrastructures to spot rectifiable challenges before they become irreversible problems – we have the knowledge, it’s time to apply it. “Why is it that we rejoice at birth and grieve at a funeral? It is because we are not the person involved.” – Mark Twain
“You do not need state-of-the-art facilities or
equipment to save
many women’s lives” Vincent Lambert, MSF Medical Advisor
Harriet Blundell, 5th year medical student, University of East Anglia
‘If you contract AIDS, you will die’ ‘If you contract AIDS, you will die.’ This is a statement printed in the textbooks of hundreds of school children in Tanzania, a statement that is incorrect in today’s world of modern medicine and technology. However, this myth is the harsh truth for much of the population of Zanzibar, as I discovered working in a school there. The Zanzibar archipelago is situated off the coast of Tanzania in East Africa, where the main health concern is infection with malaria. Nevertheless, much of the population is underfed, leading to poorer immune system function and increased risk of infection. With half of the inhabitants classified as below the poverty line, access to healthcare is limited, particularly for those living in rural areas. Furthermore, as is indicated, the transmission of HIV is rife, and without effective healthcare and education, this will quickly develop into AIDS. For the children in Zanzibar whom I taught, their lives had already been planned in their minds: the girls would get married early, have many children and become housewives, while the boys would take over their fathers’ businesses. As in many less developed countries, there is a blatant gender inequality, and unfortunately this has a huge impact on the health of the population. Indeed, for every
one man carrying the HIV virus, five women are infected, and this is mainly owing to the patriarchal traditions of the country. Polygamy is practiced today, leading to further infection within the family. Moreover, there is a widespread belief that sexual intercourse with a virgin will cure AIDS, which means that young girls are often attacked and later infected with HIV. This not only has an effect on their physical health, but also their general emotional and mental wellbeing. IMPORTANCE OF EDUCATION Despite the obvious issue of HIV and AIDS in Zanzibar, the basic problem is the fact that it is not perceived to be a health crisis in the country. Health education is the key to prevention, and although children are taught about contraception in school, cultural beliefs play a larger role in shaping their ideas. An individual who is HIV positive is seen as immoral, shameful and contaminated, rejected by their family and friends: an outcast of the society in which they live. The stigma and prejudice associated with AIDS means that someone who suspects that they have the disease would be afraid to get tested for fear of the consequences. Hence, more and more people are untreated and thus pass the virus onto other individuals, increasing the spread of HIV.
“...there is a
intercourse with a virgin will cure
AIDS, which means
that young girls are often attacked and later infected with HIV.”
“An individual who is HIV positive is seen
as immoral, shameful and
family and friends: an
society in which they live.”
According to UNICEF, young children and mothers are rarely taken into account when discussing AIDS, with the main focus being on teenagers and young adults. However, a large percentage of HIV transmission in Zanzibar is from mothers to their children during childbirth and in the period afterwards. The discrimination faced by these children can be detrimental not only for their
development, but also for their opportunities in the future. Not only are contraception and antiretrovirals crucial for minimizing transmission, so too is treatment for pregnant women who are also HIV positive. Furthermore, it is essential to educate the male population of the country, since they generally feel uncomfortable discussing such topics as sex, pregnancy and sexually transmitted disease. LOOKING TO THE FUTURE Although the constant battle against HIV and AIDS appears to be never-ending, a positive stance needs to be taken in order to succeed. If more action is taken to ensure that there is enough support for those suffering from AIDS, and to minimize the spread of HIV, the struggle can be overcome. You may ask how this can be done, with the majority of sufferers being in less developed countries such as Zanzibar. Donating money and volunteering abroad are two options, yetby simply raising
prejudice are fuelling
the spread of a
it’s up to you, me and
us to stop the spread of HIV and end
World AIDS Day, 2006 awareness of the issue, other individuals can be educated about the problem. Indeed, “ignorance and prejudice are fuelling the spread of a preventable disease… it’s up to you, me and us to stop the spread of HIV and end prejudice”. Alisha Allana, 5th year medical student, UCL.
STIs: there is still much to do exually transmitted infections (STIs) remain a major public health problem worldwide. Latest global estimates suggest that 489.9 million new cases of Chlamydia trachomatis, Neisseria gonorrhoeae, Syphilis and Trichomonas vaginalis occur each year. According to the World Health Organisation, at any one point in time (in 2008), it was estimated that 9.1 million adults were infected with C. trachomatis, 8.2 million with N. gonorrhoeae, 14.3 million with syphilis and 42.8 million with T. vaginalis in the African region alone.
In the past two decades, efforts to prevent and control the transmission of HIV/AIDS, and to improve access to treatment have seen a phenomenal rise. High-level political commitment to the cause (e.g. PEPFAR) coupled with the availability of financial resources from major donors such as the Gates Foundation, and extensive HIV/AIDS treatment programmes by organizations including MSF, have all contributed to making the goal of achieving universal access to HIV prevention, treatment, care and support, one in sight. An excellent article by Jonny Elliot in a previous issue of Insight (Insight, Dec 2012) sets out in a clear and concise manner, the challenges facing HIV/ AIDS and the future ahead. Yet, despite a more than 10-fold increase in disease prevalence of HIV/AIDS (prevalence ~ 34.2 million), the cause to improve access to treatment and prevention of other STIs including chlamydia, syphilis, gonorrhea, and trichomoniasis, is often forgotten. Given current social, demographic and migratory trends, experts predict that the population at risk for sexually
transmitted infections will continue to grow dramatically. Although disease burden is greatest in the developing world, a larger burden is also projected in industralised nations due to increased travel and trends in sexual behavior. Chlamydia, syphilis, gonorrhea and trichomoniasis can all be treated with antibiotics. Gone untreated, however, the consequences of these STIs are devastating: syphilis in pregnancy causes 305 000 fetal and neonatal deaths each year, and leaves an additional 215 000 infants at an increased risk of dying from prematurity, low birth weight or congenital disease. STIs such as gonorrhea and chlamydia are an important cause of infertility; in sub-Saharan Africa, untreated genital infection may be the cause of up to 85% of infertility in women seeking infertility care. Additionally, having an STI such as syphilis increases the chances of acquiring or transmitting HIV infection two to five-fold; in some populations, STIs may account for almost 50% of all new HIV infections. What then can be done? The key to maximizing limited resources lies in synergy. Strengthening dual HIV and STI screening and treatment programmes and incorporating STI monitoring and evaluation into established HIV programmes, kills two birds with one stone. The United Nations Declaration of Commitment on HIV/AIDS (2001) acknowledges that, “prevention of HIV infection must be the mainstay of the national, regional and international response to the epidemic”. This includes the prompt
and effective treatment of other sexually transmitted infections. Countries including Mongolia and Uganda, the United Kingdom and Sweden have implemented a diverse range of interventions and shown successful results that indicate that sexually transmitted infections can be controlled, provided that “sufficient political will and resources are mobilized in order to achieve and maintain activities at a necessary level”. In the UK, the days when tertiary syphilis was a mainstay in neurology wards and mental health institutions have passed. Globally however, it is clear that sexually transmitted infections still remain very much a public health problem. Directly relevant to Millennium Development Goals (MDGs) 4, 5 and 6, the prevention, control and treatment of all STIs, not just HIV, must be strengthened. Approaching 2015, the case for eradicating STIs is greater now than ever.
Germaine Liu, 3rd medical student, King’s College London
The access is there; is equality in place? nequality is something that we tend to associate with gender, ethnicity, jobs and financial status. But do you think of access to mental health? With the events in Syria still at a peak, it is likely that many individuals will suffer from conditions such as PTSD, depression and anxiety; yet so many will never get diagnosed. Many won’t want your help.
including Spain, France and Germany believe that professional help for mental health problems is worse than no help at all. This shame seems to be felt throughout the world and yet we have evidence that the treatments we have not only help but can lead to a longterm reduction in symptoms and can, in many cases, eventually be completely withdrawn.
Whilst in the UK we are increasingly aware of mental health problems, in many countries worldwide, these disorders are shameful; to both the individual and to the family. In some cases you will be shunned for your depression. It is seen as a sign of personal weakness, a lack of mental strength and as a consequence, service use is incredibly poor. For example, in Zimbabwe, mental illness is seen as a curse: your family, instead of leaving you in a mental asylum, would abandon you. In Zambia, the diagnosis of depression simply means the person is ‘mad’ or has been punished by God.
This leaves a difficult job for MSF Doctors who know they can help these patients. For many of us, a diagnosis is a relief- we know we can treat PTSD, schizophrenia, depression. In these countries however, a diagnosis brings fear and guilt.
These beliefs extend beyond Africa and third-world countries. A recent study has found up to 33% of those in various European countries
would abandon you.”
“In Zimbabwe, mental illness is seen as a
curse: your family,
instead of leaving you in a mental asylum,
So what can we do with this worldwide inequality to accessing mental health services? Perhaps this isn’t how you would normally see ‘inequality’… they have the access so there is equality. But is it really accessible? Should we not be thinking of different strategies for getting this help across to them so it is anonymous, it is ‘safe’. To put it into context, MSF has given the numbers of consultations they have completed in Syria; 11,600 medical consultations compared to 1,700 psychiatric consultations. Now, of
course, one can argue that at the moment the conflict is leading to more physical problems but in the years to come as the conflict hopefully begins to settle, we should logically see an increase in the number of mental health disorders. But will the statistics actually show this? Perhaps education is key but for many of these countries, it is not a stigma associated with opinion per se but cultural and religious beliefs. So are we wrong to tell them their religion is incorrect and these disorders are nothing to be shameful of? Alternatively we try and teach at the level of the health professionals. Perhaps if we reduce stigma in the doctors we can increase the number of people who feel comfortable seeking help rather than risking rejection. In other words, the people suffering from these disorders may know they are not mad and that they shouldn’t be ashamed and can get treatment but they won’t due to the stigma from family, friends and medical professionals. You’d expect that we wouldn’t have stigma towards such disorders but it indeed still exists and varies depending on the mental health disorder being suffered. In conclusion, it is vital that we begin some process in order to improve access to mental health professionals and help. With so many countries currently suffering, we need to do something before we miss the chance to help these people. We must help them fight their demons.
Katie Barnes, 3rd year medical student, Kings College London
Focus on “We are in an extreme situation, we don’t have enough food, and we don’t know who to go to for help” Syrian refugee in Lebanon
“MSF is one of the few international aid organisations assisting civilians in the opposition areas, and our presence is making a difference.”
“The situation is dire; the needs are massive and the overall humanitarian response is extremely limited.”
Syria “Kids don't play with marbles, they play with bullets.”
“It’s strange to have women giving birth just ten metres from the area where we’re brought the bodies of dead or dying children. But it’s good, a sort of relief that there’s new life too.”
Donate to MSF'S Syrian Crisis Appeal today at www.msf.org.uk
Working with MSF in Syria ‘m part of an MSF team based in the Aleppo region of in the north of Syria. This area continues to see an enormous amount of conflict, and the health needs are massive. Before I was in Aleppo I worked in Idlib region, where MSF runs a surgical trauma hospital with an operating theatre, an emergency department and a small in-patient department. There are a number of expats there, including a surgeon and an anaesthetist along with about fifty Syrian staff. It’s a small hospital, but it’s actually very full and busy. We’re currently providing support to other hospitals and health facilities in Aleppo. Much of the healthcare infrastructure in this part of Syria has essentially collapsed, and although there are dedicated people working hard to keep facilities going, sometimes they don’t have the training, the experience or the equipment to provide the medical care that people need. That’s where we can help.
Not long after I arrived, I was working at an MSF hospital and a six-year-old girl was brought to us. She’d been with her family on the roof of her house, when a plane had flown over to bomb the village. Understandably, children in Syria are now very scared of planes, so when this girl had seen the plane she ran across the roof. The family had a diesel heater because of the cold, and as the girl ran she knocked it over and splashed the burning fuel all over her legs. She suffered serious burn injuries to her legs, and was rushed to a local health centre, but they really didn’t have the equipment or even the proper pain relief to treat her.
This is a problem that we see a lot. Even when facilities are still open, often they don’t have the medicines or the equipment to properly treat patients. Or if they do have the equipment, it’s been damaged by bombing or by lack of maintenance. Hospitals are a target and many have been bombed. And then there’s the lack of electricity, which is a huge problem. Equipment in hospitals is dependent on electricity but most places now don’t have a supply so everything is run from generators, but that requires diesel which is very expensive and not always available. Vaccines and blood need to be kept in fridges, but if you don’t have power, those things are useless. At one of the emergency rooms I go to, they don’t have a means of sterilising equipment. So when they get patients from a bomb blast, they’ll do procedures like suturing, but they can’t really sterilise the equipment so they just have to reuse. And that obviously causes problems down the line. By the time the girl came to us, she was really traumatised and even walking into the hospital left her screaming and in tears. It took a long time for her to trust us, but eventually we were able to change her dressings and give her the beginnings of the care that she needed.
“The family had a diesel heater because of the
cold, and as the girl ran she knocked it over and
splashed the burning fuel all over her legs.”
Natalie Roberts, Syria
“This poor girl has seen and experienced things
that nobody - let alone a
six-year-old girl - should have to experience.”
For me, that really summed up the horror of the situation in Syria. Yes, there are acute injuries from the bombings and from the violence, but there is also the psychological trauma caused by the whole situation. This poor girl has seen and experienced things that nobody - let alone a six-year-old girl - should have to experience. When I visit different hospitals in Syria, often the casualties are children. Bombings will hit residential areas and whole families are injured or killed. Alongside the acute injuries, children are suffering from a range of medical problems. Vaccination has essentially stopped in some areas. Whole families are living in tents or in houses with no heating or clean water, often all together in one room. Infectious diseases are starting to spread. I've seen a lot of children with basic disease like pneumonia and Hepatitis A. There’s no school. They’re coping, but that doesn’t mean they’re behaving normally. Sometimes the children will be playing on the streets when planes
children will be
playing on the streets when planes ﬂy over,
and they just accept it and keep playing,
even when the plane is bombing their town.”
“You know, MSF is ver y good at being eﬃcie nt, at knowi ng how to provide a good medica l service with not ma ny facilities . We’re used to wor king in thes e types of conﬂict area s and we’re one of the rare aid organisation s I’ve seen workin g in the regi on.” fly over, and they just accept it and keep playing, even when the plane is bombing their town. There’s a man I know who has a four-yearold son, and sometimes this man helps in a local field hospital. One night he was going to help after a bombing and his four-year-old son asked him not to go, saying that if a bomb hits the house, he wanted the family to all be together so none of them would feel lonely. That’s not a normal thing for a four year old to say. You know, MSF is very good at being efficient, at knowing how to provide a good medical service with not many facilities. We’re used to working in these types of conflict areas and we’re one of the rare aid organisations I’ve seen working in the region. The health system in Syria was very sophisticated before, and now that the infrastructure has broken down, they’re struggling to optimise how they work. That’s how we can help. But building that
trust takes time. These people have been doing this for two years and doing an amazing job, and it does take time to build up trust. I have to tell them what I’ve seen and done before, and tell them what MSF does. I remember I was visiting an emergency department at one hospital in Aleppo. It was the first time I’d been there, and we were discussing with the staff how we could help them when news came that a mortar bomb had hit a nearby market. Very quickly we started to receive casualties, brought to us in private cars, the back of pick-up trucks and on motorbikes. Ten fatalities arrived almost immediately, then four more, two who had sustained massive head injuries. In situations like that, it’s vital you triage and prioritise patients that can be helped, and it was very clear
“The ﬁrst time I was really scared was when a very
large missile landed not too far away where we
were staying. We could
“But as MSF we do what
“It’s a scary continue to help. This is a situation in massive humanitarian Syria.”
feel the windows of our house shaking.”
that these two patients were beyond help. But it was equally clear that there were other patients - particularly two eight-year-old girls with shrapnel wounds - who could be saved. My role in the midst of all the panic and crisis was to point out that these girls were our priority and that we needed to focus our attention on them. Pointing that out, though, requires that the team trust me. I think one of my main roles at the moment in these hospitals is to use my experience to train people and demonstrate what should be done in terms of prioritising patients during a mass casualty event. To that end, I’ve been delivering a training programme in different hospitals. We teach them about triage, about managing war wounded patients, about blood transfusion, and how to do all that with reduced facilities and equipment. It’s a scary situation in Syria. This is the second period of time I've spent there, and over the last weeks I've really noticed the escalation of violence. But you do get used to it. Incidents that initially made me very frightened, I now take for
we can, and it’s vital we
emergency and the Syrian
people need our help. It’s as simple as that.”
granted. The first time I was really scared was when a very large missile landed not too far away where we were staying. We could feel the windows of our house shaking. There were two of us in the house and we were both afraid. But within a month, we were getting missiles every night - some very near – and we’d get out of bed and go to our safe room but be complaining that it was cold and our sleep was being interrupted. You even start making jokes about it, but it’s just a way of coping. In reality, you never really lose the fear. People are grateful that we’re there. But we can’t do everything. We can help with what we can, but the needs are huge. We set up a blood bank. We provide vaccinations. We helped with supplies for dialysis machines. We need to set up more MSF clinics and structures. There is a need for more acute trauma surgery, but there’s also a need to continue basic healthcare, treating chronic diseases and providing outpatient services. We need to continue helping with equipment and advice and support.
Take our blood bank. We’ve set one up in the Aleppo region in a secret location which supplies all hospitals in that area. People have been coming from 50km away to access it. It required a bit of work, a lot of training and equipment, but it’s now up and running. Before people were getting unsafe blood, blood that hadn’t been tested and stored correctly, but now they are. Something like that is really easy to do, but it’s cost effective and it saves lives. But this is just a drop in the ocean. The suffering that people are experiencing in that country is incredible and it’s frustrating and upsetting to see so many problems and know that because of security or for other reasons you can’t solve it all. But as MSF we do what we can, and it’s vital we continue to help. This is a massive humanitarian emergency and the Syrian people need our help. It’s as simple as that.
Natalie Roberts, MSF -UK
Damien Brown: an insight t the end of February, King’s College Friends of MSF were honoured to host a talk given by Damien Brown, author of ‘Band-Aid for a Broken Leg’, who described the harsh reality of being a medic thrown straight into the deep end; the deep end here, being a middle-of-nowhere part of Angola, connected to the rest of civilisation by nothing other than landmines. And that was just to start with…
From his very first photograph, Damien had his audience hooked. As he talked of the set up of the small and over-crowded healthcare centre in Mavinga; the trials of securing the trust of the local staff through the seemingly impenetrable bubble of being the ‘new doctor’, and the occasional landmine explosion – just to name a few hurdles! – we began to get a sense of what it meant to be working in a country that was still on the edge of crisis. To us, as university students, this seemed light years out of any of our comfort zones. ‘What was one of
“...the harsh reality of
being a medic thrown
straight into the deep end;
the deep end here, being a
middle-of-nowhere part of Angola, connected to the
rest of civilisation by nothing other than landmines.”
the biggest trials on his first mission?’ Damien was asked. Undoubtedly, not knowing Portuguese was one, he answered. It is difficult for us to imagine, perhaps: all those hours we have spent learning to ask the right questions to patients, having it drummed into us that eighty five percent of the diagnosis is made
“...all those hours we have spent learning to ask the
right questions to
patients, having it
drummed into us that
eighty ﬁve percent of the
diagnosis is made on the
history – and yet this all initially rendered
on the history – and yet this all initially rendered useless, in an area almost devoid of investigative resources. Yet it was the acquisition of another language that enabled Damien to work on his next, very different mission in Mozambique; this might be a good point to refer to ‘Band-Aid for a Broken Leg’ to find out more! The book is based on Damien’s unbelievable, often difficult, often funny and always humbling experiences. Damien was an inspiring speaker, not least because of his down to earth and honest recounts. Here were the frank truths, little thought
about by us healthcare-trainees; the baggage of the real, hardcore slog and uncertainty of unanswered questions that balance so precariously with the satisfaction of putting our longlaboured-for skills to use where they are most needed. Yet the photographs of children recovered from their malnourished states, the stories of painstakingly built and resolutely solidified relationships, of winning the fight against cholera, of remarkable and resilient people, successful water sanitation and many, many other unique moments and discoveries left us with the sense that all this is for something indescribably worthwhile. So thank you Damien for sharing your experiences and all the best for the future!
Nabiha Essaji, 3rd year medical student, King’s College London
Band-Aid for a Broken Leg ...is a book by Australian doctor and former (and probably future) MSF expat Damien Brown. To give you a flavour, here’s the publisher’s dustjacket blurb: Damien Brown, a young Australian doctor, thinks he’s ready when he arrives for his first posting with Médecins Sans Frontières in Africa. But the town he’s sent to is an isolated outpost of mud huts, surrounded by landmines; the hospital, for which he’s to be the only doctor, is filled with malnourished children and conditions he’s never seen; and the health workers – Angolan war veterans twice his age and who speak no English – walk out on him following an altercation on his first shift. In the months that follow, Damien confronts these challenges all the while dealing with the social absurdities of living with only three other volunteers for company. The medical calamities pile up – a
leopard attack, a landmine explosion, and having to perform surgery using tools cleaned on the fire being among them – but it’s through Damien’s evolving friendships with the local people that his passion for the work grows. Band-aid for a Broken Leg is a powerful, sometimes heartbreaking, often funny, always honest and ultimately uplifting account of life on the medical frontline in Angola, Mozambique and South Sudan. It is also a moving testimony of the work done by medical humanitarian groups and the extraordinary and sometimes eccentric people who work for them. INTERVIEW WITH DAMIEN BROWN What drew you to MSF? DB: The money (very obviously joking!). No, I think it was a combination of things. As a student I’d long been drawn to the idea of working in less privileged settings, so it wasn’t really MSF as such that I was intent on working with. But when I finally started to look at how I could actually work most effectively in such places as a medical doctor, MSF seemed the right option for me. Their principles of neutrality and impartiality are ones I agree strongly with, and they’re well resourced, practiced, and good at that they do. I’d previously done a brief stint with a very small organization, which was a great experience, but with them I’d often run out of drugs and equipment. MSF have the resources to be able
to back their programmes – which means that as a medical worker, I can just get on with my job. How many missions have you done for MSF, where and when? DB: My first mission was in Angola, for six months, in small town that had been devastated by the war. A year after that, I worked in Mozambique with a team that was assisting villagers who’d been displaced by floods, and after that was sent to a hospital in a regional town in South Sudan. Will you do any more? DB: Definitely. At the moment I’m completing a Masters course in International Health, but after that I’d love to get back to the field. I understand you were already blogging. What gave you the impetus/confidence to write a book? DB: In retrospect, the confidence came from utter naïveté - from being completely unaware of what writing a book would actually entail. I’d had some good feedback about the blog, so thought that I’d just cobble the pages together and sell it to a publisher. Three years later, however, I was still re-writing.
As for the impetus, that never diminished. I’d met some great local people in the field – health workers, patients, and their families – and the thing that struck me repeatedly was their resilience and humility in the face of these incredibly difficult circumstances. I felt compelled to communicate that to as wide an audience as possible. How did the writing process work? Did you fit it in between medical responsibilities? DB: For me, the process was both extremely difficult and incredibly satisfying. To get the material onto paper, I had to spend years wading through some difficult memories in order to find the right stories, but at the same time I got to spend years reliving some wonderful friendships, and moments, in my head (which I admit sounds a little odd). The technical aspect of it was a huge challenge; no publisher would take it until it was finished, yet I had no training as a writer and despite a dozen re-writes I couldn’t get it right. Ultimately, after two years of trying to juggle
writing and practicing as a doctor, I took a year off of medicine to work on the book full time – which paid off. What kind of response has the book had? DB: The book was launched in Australia about 6 months ago and seems to be doing pretty well. Contrary to what I’d feared, MSF have really got behind it – in fact, the most positive responses I’ve got tend to be from those who’ve been in the field.
and having to
using tools cleaned on the ﬁre...”
sometimes heartbreaking, often funny, always honest and ultimately uplifting account of life on the medical frontline in and South Sudan.” member’s profile as her favourite book. I love that – I love that someone out there thinks that mentioning my book may in fact help get them a date! (I love the irony, too - it’s not gotten me a date.) Are you likely to abandon medicine for full-time writing? Plans for another book?
calamities pile up – landmine explosion,
Leg is a powerful,
a leopard attack, a
“Band-aid for a Broken
A few readers have said that they’d laughed and cried at the same time, that they were really moved by it, which is what I’d always hoped it would be able to do. Someone else emailed a while back to say that the book had been passed around their backpackers’ bus in Turkey, which I thought was lovely, but the most flattering feedback I’ve had was from a mate who said that he’d seen it listed under a dating website
DB: I don’t think I’ll ever leave medicine permanently – it’s what I trained in, and I love certain aspects of it. As well, medicine gave me the material and inspiration to write. I’d love to write another book though, but for the moment I feel like I’ve put everything I have into this one. That said, I’m always on the lookout for the next story, but it’d have to be true, and uplifting, and have elements of humour as well as tragedy. Like life, I suppose.
Credit to Talking Drums, the internal MSF-UK publication
The world in denial? he Royal Society of Medicine’s annual Global Health conference held on 26th and 27th March 2013 focused this year upon Global Mental Health. It was dedicated to Professor Hamid Ghodse, an international expert on addiction and a leading figure in global mental healthcare, who died in 2012. The conference coincided with the Royal College of Psychiatrists’ publication of a key report, Whole Person Care: From Rhetoric to Reality, which focuses upon achieving parity between physical and mental healthcare with the advent of changes brought into force by the Health and Social Care Act 2012 on 1st April 2013.
Bringing together an impressive speaker group of world authorities from the World Health Organisation, United Nations, World Federation for Mental Health (WFMH), Institute of Psychiatry, London School of Hygiene and Tropical Medicine (LSHTM) and NGOs from around the world, the conference highlighted the momentum gathered by the Global Mental Health movement since the publication of the Lancet’s landmark series of articles in 2007.
that refugee populations recover better in terms of mental health when
treated with employment
Opening the conference, Professor Graham Thornicroft of the Institute of Psychiatry outlined the challenges to global mental health, specifically the gap in provision of treatment adequate to meet the burden of mental illness worldwide, premature mortality of people with mental disorders and the stigma and discrimination they still face. He proposed to remedy these challenges through strengthening evidence on treatment interventions and health systems, and formation of collaboratives. On its second day, Professor John Copeland of the WFMH described the momentum which gathered behind this movement. Over 500 NGOs supported the WFMH and Movement for Global Mental Health’s ‘Great Push for Mental Health,’ encouraging ministers at the UN Special Session on NonCommunicable Diseases in 2011 to demand a mental health Action Plan. The NGOs were then surveyed on what they wanted the action plan to include, creating a ‘People’s Charter for Mental Health,’ which contributed to the WHO’s Global Mental Health Action Plan 2013-20, which will be launched in May, and was discussed by Dr Shekar Saxena of the World Health Organisation. The case forms a striking example of the power of campaigning for change. In terms of meeting the treatment gap, there was a focus of taskshifting, with work presented by Professor Vikram Patel of LSHTM providing evidence that well-trained and supported community health workers can have a high impact on community mental health ‘where there is no psychiatrist’. Furthermore, the WHO Mental Health Gap Action Programme
(mhGAP) offers a model of care and series of decision-making protocols for primary care workers to assess priority conditions including depression, psychosis, substance abuse disorders and self-harm. The conference was impressively balanced in its approach, offering a platform to critiques of the movement for Global Mental Health. Professor Derek Summerfield of the Institute of Psychiatry argued vociferously for the culture-bound nature of Western conceptions of mental illness and challenged the premise that a genuine burden of unmet mental illness exists in need of treatment. He cautioned against what he called an ‘imperialist’ vision of globalising health and disease. Dr Bhargavi Davar followed Professor Summerfield, presenting work from urban slums in Pune, India, arguing that failures to implement crucial public health work result in exaggerated prevalence data for mental illness and cautioning against the medicalisation of social problems. The second day of the conference commenced with a focus upon addressing mental health human
rights, with Professor Norman Sartorius of the World Psychiatric Association outlining the challenges, when the ‘Universal’ Declaration of Human Rights (1948) is in no way legally binding on nation states and there is widespread variation in which rights are prioritised by each. He argued that there is a need to promote human rights education and that the rights of people suffering from mental illness need to be highlighted. He stressed the need to develop health, mental health and social services with the rights of service users in mind. Next, a set of talks discussed mental health post-conflict, with Dr Mohammed Al-Uzri describing experiences from the Iraq mental health survey, which found high rates of exposure to trauma in the population, with anxiety disorders the most common mental disorder, followed by mood disorders. Comparisons were made with Lebanon, a post-conflict state which has been stable for longer than Iraq, and where rates of documented mental disorders are higher. He described the work of the Iraq Mental Health Forum UK, a professional diaspora group, which collaborates with local services, NGOs and volunteers to address un-
met mental healthcare needs. He argued that post-conflict, NGOs have the flexibility and resources required to fill a gap in infrastructure. Professor Kamaldeep Bhui, a specialist in cultural psychiatry and epidemiology, contrasted this discussion with findings on the mental health the over 40 million worldwide refugees: an extremely difficult population to research, due to its intrinsically mobile nature. He described compelling evidence that refugee populations recover better in terms of mental health when treated with employment rather than psychological interventions, and emphasised the protective power of social support. Professor Richard Williams of the University of Manchester’s Humanitarian and conflict response unit offered his perspective on the impact of conflict on global health, based on his experience in the military. He discussed the risks to the mental health of healthcare workers and argued that “you can’t care well for the beneficiaries without caring well for the staff”. He used the military as an example of the mental health benefits of social groups, which provide a sense of social identity, and that a psychologically safe workplace is one in which people are able to make mistakes. Another controversial point was Professor Copeland’s discussion of GMHAT: a “computer assisted clinical interview to be used in routine clinical practice to detect and manage mental disorders in most settings,” designed to enable trained healthcare workers to screen for mental disorders in isolated or under-resourced settings. Some audience members questioned the reduction of the clinical art of psychiatry to a computer algorithm, but ultimately,
“Well-trained and supported community health workers can have a high impact on community mental health ‘where there is no psychiatrist’.” the pragmatic reality that there are few psychiatrists outside the Western world prevailed in the need to find a solution to be implemented on the ground. In her summing up at the close of the conference, Professor Sue Bailey, President of the Royal College of Psychiatrists, acknowledged the need for clinicians to achieve consensus, to prevent distraction from the bigger picture of global mental health. She pledged follow-through on the conference, to be picked up in a full global mental health stream at the College’s 2014 International Congress in London and urged attendees to support the People’s Charter for Mental Health. She ended by reminding delegates of Professor Ghodse’s dedication to the vision of harnessing the power of public health practice to achieve ‘whole health’: genuine parity between mental and physical healthcare. While the task is a daunting one facing many obstacles, this wide-reaching conference made me believe it might be possible.
Dr. Roxanne Keynejad, FY1 doctor, St. Helier Hospital
Re-emergent humanitarian dilemmas in conflict settings
iolent conflict has changed since the end of the Second World War. While there are notable exceptions, most conflicts now occur as civil wars, i.e. between groups within countries rather than between the armies of warring nations. There can be multiple actors with fluid agendas, loyalties and narratives. The lines between civilians and combatants are increasingly blurred, particularly due to the urban settings of many modern conflicts. This, alongside the use of targeting civilians as a weapon in protracted conflicts, means that civilian casualties have become more commonplace. The response of the international humanitarian community must similarly adapt to tackle these challenges.
The unfortunate involvement of civilians in violent conflict often leads to mass sections of the population fleeing from their homes. Some of these Internally Displaced People (IDPs) are able to count on friends and relatives for accommodation, but the longer a conflict continues, the more strained the resilience of these support networks become. Those less fortunate flee to refugee
camps, often in neighbouring countries, and have to cope with make-shift shelters in extremes of weather. Governments or the armed forces ought to possess the absorptive capacity to deal with depleting individual resources during such catastrophes; if these structures fail to cope, or worse still, are active contributors to rising insecurity, there is a strong case for intervention by international NonGovernmental Organisations (NGOs). The dilemmas that have plagued the international humanitarian community since its inception have gone largely unresolved and have continued to resurface in the twenty-first
â€œObjective neutrality is an elusive concept in a world of subjective narratives. Maintaining it in an
article is diďŹƒcult enough; on the ground it can
prove near impossible.â€?
century. This article hopes to explore questions around providing effective healthcare in low resource settings to a wide range of populations while maintaining neutrality. The first task for any NGO intervening in a humanitarian emergency is to access the vulnerable population in question. Access to work within a sovereign state usually requires authorisation by the government in question. The decision to cooperate with the national government and its associated health structures or whether to bypass it altogether can shape the answers to many of the questions above. NGOs must collect data about disease patterns so that services can respond to the needs of the population, and thus have the highest impact. Without government structures in place, field hospitals with separate areas for surgery, outpatients and inpatients must be set up. Auxiliary staff may need to be recruited and trained. The local population has to be informed of the new services so that they know to access them. All of this is expensive and time
consuming and working within the national health services, where many of these structures exist, can prove to be far more cost-effective. Yet, working solely within the national health care hospitals can limit NGOs to a ‘keyhole’ perspective of the conflict. Governments have their own personal agendas and it can be in the interest of governments, not to provide effective healthcare, or any healthcare whatsoever, to opposition groups or minorities. This would also affect the perception of the NGOs in areas of sympathisers with opposition forces, who may feel that working within government health centres is an act of passively legitimising government action, or worse still, becoming an extension of it. On the other hand, if an NGO were to circumvent the government and set up field hospitals, there may be accusations of NGOs being an extension of foreign agendas to subvert, delegitimize, and ultimately destabilise the current government. The very act of providing effective healthcare in a country where that is not possible for the majority of the population can alienate and antagonise an already failing government, particularly when the source of the assistance is widely perceived to be outside government initiatives.
This increasing unpopularity can lead governments to be defensive and obstructive towards NGOs. In such situations, it can be difficult to maintain the balance between the duty of advocacy and continued access. The expulsion of NGOs from working in Darfur by the Sudanese President, Omar AlBashir, in 2009 demonstrates the difficult dilemmas faced by organisations such as Médecins Sans Frontières (MSF) in practically following the principle of ‘témoignage’, or bearing witness and reporting on human rights abuses committed. The alternative approach is to prioritise access to vulnerable populations above advocacy on behalf of those populations. This is the methodology adopted by the International Committee for the Red Cross (ICRC) which, by agreeing to maintain silence over any human rights abuses witnessed, has enabled them to access and assist those in controversial locations where other organisations have been refused entry such as Guantanamo Bay and Kashmir. Security in zones of conflict can cause further complications. NGOs increasingly have to rely on government, opposition or private security personnel; these decisions can lead to being seen to compromise on the basic principle of neutrality. This leads to the blurring of humanitarian space and can lead to increased targeting of healthcare workers by government or opposition groups. Healthcare workers will always be caught amongst a series of conflicting
political and social agendas and will be subject to manipulation by different groups. There is often a case to circumvent the already existing structures to assist populations that are deliberately ignored, yet engaging with the government can be necessary to ensure long-lasting solutions. Objective neutrality is an elusive concept in a world of subjective narratives. Maintaining it in an article is difficult enough; on the ground it can prove near impossible. The international humanitarian community has not come up with concrete answers to these dilemmas and I would not pretend to do so either. These are, of course, entirely dependent upon individual contexts. Our aim is not perfection, but we must go beyond just providing basic healthcare. Ultimately, we must create an impact by empowering local communities to withstand and transform violent conflicts through solutions that last beyond NGO interventions. That is the gold standard.
Adil Ahmad, 5th year medical student, UCL
Global health diplomacy "To
citizen is to concern oneself both with the
realms of politics and
social justice and with clinical judgment" Charles Rosenberg
Throughout history, nearly all of the progress that we have made towards a more just and peaceful world has started with seeds of discomfort with the status quo, and a growing sense that a better way is possible. That feeling is what gave birth to the bold, audacious visions that fuelled our greatest gains over the past century, such as the eradication of Polio from India to the recent cure of HIV in a young child in USA, providing hope for millions of HIV/AIDS sufferers across the globe. At the coalface of this innovatory movement to sculpt a society that is equitable, healthy and happy lays the field of global health diplomacy. The world is developing at an ever-increasing rate, and globalisation has spread to every corner of the earth. The world we live in today is vastly different from the social, cultural and political landscape seen perhaps even ten years
ago. But this also presents us with threats that health professionals and policy makers must be keenly aware of. The SARS outbreak of 2003 and the 2009 H1N1 influenza A pandemic show how quickly emerging infections can spread, costing lives, as well as curtailing travel and trade among interdependent economies. One nation's health status and risks can affect not only its own prospects and those of its neighbors, but also those of the entire world. As a result, global health has increasingly become a part of foreign policy agendas and is included in national security, trade, and diplomacy discussions. In 2009, Assistant US Secretary of State Kerri-Ann Jones affirmed that “better global health promotes stability and growth, which can deter the spread of extremism, ease pressure for migration, reduce the need for humanitarian and development assistance and create opportunities for stronger political alliances and economic relations.” Global Health Diplomacy (GHD) situates this concept firmly within the human rights dialogue, and provides a solid framework for understanding global health issues and their negotiation. It is used for activities ranging from formal
negotiations, to an array of partnerships and interactions between governmental and nongovernmental actors. In a recent article published in the Milbank Quarterly, ”Defining Health Diplomacy: Changing Demands in the Era of Globalization,” Julie Fischer describes these activities as falling into three different categories of interaction around international public health issues. Core diplomacy involves negotiations of a bilateral and multilateral nature between and among nations to resolve disputes and enact formal agreements. Multi-stakeholder diplomacy refers to international negotiations and exchanges in which various state, non-state, and multilateral actors work together to address common issues, not necessarily intended to lead to binding agreements. Informal diplomacy touches on interactions between public health actors working around the world and their counterparts in the field,
including host country official representatives of multilateral and nongovernmental organizations, private enterprise, and the public. My interest in GHD emanates almost exclusively from the desire to reach back and provide an arm of support to those who need it and give a voice to those who cannot speak up for themselves. Perhaps it stems from my own sense of pervasive optimism that we can all achieve a better world if we are willing to put the work in. Recently I engaged in my first mission as a ‘health diplomat,’ representing UK medical students at the United Nations Framework Convention on Climate Change in Doha, Qatar through student led body Healthy Planet UK. My mission was to engage and stimulate dialogue on the health effects of climate change that we are currently seeing around the world: a hard debate to articulate when unemployment levels and cost of living in recent years have skyrocketed. However, climate change is not a problem of tomorrow; it is already a problem for people all over the world today. The science is irrefutable and many accept this but it is the tragic personal accounts that often communicate the very real human tragedy to the lives of people as a direct result of a changing climate. To this end, I staunchly agree with Ivona Kickbusch, a world leader in GHD when she says that it “is a world to which outsiders find it difficult to
relate, where the art of diplomacy juggles with the science of public health and concrete national interest balances with the abstract collective concern of the larger international community in the face of intensive lobbying and advocacy. No longer do diplomats just talk to other diplomats – they need to interact with the private sector, nongovernmental organizations, scientists, activists and the media, to name but a few, since all these actors are part and parcel of the negotiating process.”
“My interest in GHD emanates almost
exclusively from the desire to reach back
and provide an arm of support to those who need it and give a voice to those who
cannot speak up for themselves.”
GHD is increasing in importance every year; particularly in a climate where health and global health budgets in particular are being squeezed by political policy, which is many cases shows no real foresight and little appreciation of the economic benefit that investment in health can bring to a donor country. Countries that are staying ahead
of this curve include places such as Brazil, Chile and the USA, with some adding a fulltime health attaché to their diplomat teams. The USA have taken the unprecedented step of opening a new Office of Global Health Diplomacy in the State Department and to paraphrase Ambassador Goosby to “using their political clout to amplify and elevate this dialogue and to advertise successes to other members of the global community as examples of jobs well done.” It is simply no longer practical for the big decisions in global health diplomacy to be made by a few specialists. Key figures like Hillary Clinton and Bill Gates have made great advances in the field, each leveraging unique positions and networks to achieve common goals. However, these great names along with many others will come and go. This rapidly expanding field calls on health professionals at all levels; but particularly students and recent graduates with an interest in global health, willing to cut their teeth in the political sphere of advocacy and lobbying. The modern day doctor is so much more than a specialist in one field; he must have a multifaceted armory of technical and social skills at his disposable to deploy, when necessary to get the best for the patient, wherever or whenever that may be.
Jonny Elliott, Masters of Public Health, Queen’s University.
Unravelling Bosniaâ€™s past and present
efore travelling to Bosnia I had expectations of a remote and possibly hostile region, fed by misinformed stereotypes from people in England. I was not only proved wrong, but moved to tears on occasions with memories that will last a lifetime. I intend to share my opinion on what I saw in terms of the structure of the society and the identity issues that are still present. I travelled with a group of 12 volunteers with a charity called MADE In Europe to Sarajevo and Eastern Bosnia. Together, we helped to set up strawberry farms for families who had been victims of the genocide in 1995, and were returning to their land. Â These farms would provide them with a sustainable income. Attending the annual memorial at Potocari, Srebrenica, the scene where over 8000 Bosnians were massacred in 1995, was an overwhelming experience; even the toughest of hearts would be moved. As a volunteer, I had heard horrendous war-time stories from my host family, but it was only upon attending such an emotional event that I realised the true scale of the genocide. Bosnia was split into two entities after the war, The Federation, with a large Bosniak (Muslim) population, and Republika Srpska, with a large Serb population, both operating under separate governments. Republika Srpska was the scene of the worst fighting, outside the siege of Sarajevo. In recent times, some of the displaced families have returned to their homes. Villages are dotted around the beautiful rugged valleys, the majority of which are Bosniak, whilst the larger
towns, including Zvornik and Srebrenica, are now almost entirely Serb. It is with some surprise then, that I learned that the largest mosque in Eastern Bosnia is located in the centre of Zvornik. The reason for this, I believe, lies in the events that took place two decades ago. My experience volunteering in Bosnia revealed to me that severe cracks remain in the tense and complex structure of a nation rife with identity politics. Bosniaks and Serbs make an open visual display of their grief and their religious identity â€“ churches and mosques are built to be seen as much as used. A culture of memorialisation is apparent especially in the East of the country; both sides appear to be competing as to the losses suffered in the war.
Prayer for the victims
River Drina separating Bosnia and Serbia
through the town of Zvornik The two groups do i n t e r m i n g l e, although not as actively as they probably could. Bosniaks and Serbs speak the same language and have to integrate in schools and workplaces. The majority of Bosniaks I spoke to were quick to dismiss any hatred for Serbs. Their qualms were with Two Bosnian women mourn the loss of their male the military generals relatives after finally burying them 16 years on from the and nationalists who Srebrenica massacre in 1995 repeatedly call for
“So welcoming were
the people that they allowed me to recite
the call to prayer on a hilltop mosque, a
that I owe to the locals.”
Muslims to leave a land they have cultivated and graced for centuries. The breadwinner of the host family I lived with works and studies with many Serbs, yet he was keen to stress one point – ‘we will never forget what happened’. He had lost many family members in the war; I was not one to question his attitude.
Me helping a local man build a house
Serbs are also still steadfast in showing the pride of their identity. On a cool summer’s evening I watched a dance show on the banks of the River Drina (that elegantly dissects Bosnia and Serbia through a valley) where youth chanted and danced to traditional Serb music. Both ethnicities share a long and fascinating history yet they appear to only cross roads intermittently, the elephant in the room being the 1992-95 conflict. It is a great shame to say that such a fascinating group of people still have a cloud of injustice and doubt hanging over their heads, a cloud that will undoubtedly remain for the foreseeable future. The tense undertone still exists – be it daily interaction at a school or supermarket, or in the everfractious parliament. However, the glimmer of hope I saw was of a people who saw past conflict and beyond prejudices. The most touching words were from a former military commander, who reiterated how he merely wished to live peacefully with his Serb brothers and sisters, in a united Bosnia. Needless to say, my lasting memories from the trip will be the jaw-dropping scenery, and sounds of Arabic echoing in remote villages. Bosnians are possibly the most hospitable people one will come across. They were testament to the kind of human nature so hidden from view of the rest of the world when discussing this region. So welcoming were the people that they allowed me to recite the call to prayer on a hilltop mosque, a personal highlight that I owe to the locals. The subject of religion is another pertinent factor in the two
“Attending the annual
memorial at Potocari, Srebrenica, the scene where over 8000 Bosnians were
massacred in 1995, was an overwhelming
experience; even the toughest of hearts would be moved.”
groups mingling, with Bosniaks claiming that Serb Orthodox churches have been illegally built on their land, but also accepting the Serb population is there to stay and has a right to practise their faith. On the surface, Bosnia appears to be as healthy as any other European nation and the only physical signs of war are evident in mass graves or bullet-laden buildings. However, deep under the thin cover of peace is a psychological tension between Bosniaks and Serbs. Coming back to the UK, I realised the privilege I have here to practise my religion freely, and to mix with people from countless other backgrounds. If those in Bosnia, with the terrible memories they have, can make an effort to co-exist, then surely we can do the same here in the UK.
Wasim Mir, student, UCL.
â€œOn Saturday 16th March 2013, over 300 individuals took to the paths of Regent's Park running either 5km or 10km in aid of MSF. Despite the awful weather conditions on the day itself, with typical British wind and torrential rain, the runners, volunteers and huge numbers of supporters turned up on the morning of race day, brimming with excitement and enthusiasm. It was absolutely brilliant to see so many individuals run for MSF, and raising over ÂŁ10,000 for such a great cause made it all worthwhile. A massive thank you to all the volunteers; all our donors and sponsors; staff at MSF-UK; and above all, the runners; without whom it would not have happenedâ€? Alisha Allana, Run Co-ordinator 2013
"It w as tr ul volun teeri y a great ng fo cause exper r . i not i Although such a wor ence n fav the w t hy ou e volun teers r of us, ather was t it ha a ppen. nd the or he ganiz been I'm h e part o of su noured to rs made I am ch a looki have gr ng fo next rward eat team year. an " to th Eranja e run d n padu madas a
â€œGreat Â fun Â despite Â the Â rain Â Ââ€“ Â it Â felt Â like Â everyone Â helped Â each Â other Â to Â keep Â going!â€?
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e 7.30am on th t a k r a P s Regent’ “Arriving in I had dered what n o w I n u r the ber of morning of e huge num th g n ei se t – bu smiles signed up to d rain with n a d in w e aving th runners br spiring.” was truly in ani Vruti Datt
“A thoroughl y cold day. R ain teeming blustery win down, ds and a lost g a zebo. Still, nothing was more warmin g than seein enthusiasm g the and fun expr essed by the numbers of r large unners! It w a s t r u and whether ly a fun run or not I had s ensation in the end, I wa my feet at s jumping fo r jo y by the end willing each , and every pe rson on. An day out!” amazing
Roosey She th
and enjoyed “Had a lovely day the cold and running (despite was very well rain!). The event was great to organised and it y for such a raise so much mone ” worthwhile cause. Fatema Pirmohamed
enjoyed Â Â I , Â t n ve e Â at re g Â a Â as w Â n â€œThe Â friends Â of Â MSF Â ru staff Â and Â e Â h t f Â o s Â t or ff e g Â in az m it Â a Â lot Â due Â to Â the Â a Â and Â despite Â t n ve e Â at re g Â a Â ed iz an rg o volunteers Â - Â they Â uch Â as Â I Â m s Â a Â t i d Â ye jo n e e Â on ry the Â weather Â I'm Â sure Â eve me Â down Â and Â I Â g Â in t vi n i Â or f Â ch u m y Â er did! Â Thanks Â v ext Â yearâ€™s!â€? n Â n i Â t ar p e Â ak t Â an c Â I e Â hop Daniel Furze
â€œThis was m y first time volunteerin really enjoy g at the MS ed meeting F fun run. I new people the day wa , s an incred and being a part of ible experie Breyoni Selv adurai nce.â€?
t day, â€œI think it was a grea ganised and which was very well or g turn out, I was amazed by the bi weather. despite the atrocious e Huge compliments to th cially the organisation and espe t there in marshalls who stood ou howling wind the pouring rain and while for such a long time, d cheering remaining so upbeat an d the whole us on! I really enjoye event!â€? Bart-Jan Bekker, MSF UK.
is organ l l e w eally making r s a w se her ht it ful weat r all tho g u o h w "I t e the a icult fo t f despi hing dif t y UK. ever ed." . MSF g n i s i v ra invol , Fund Marya
n m Kha
nteering at the run. “I had a great time volu ne was cheerful and the yo er ev , in ra e th ite esp D t job! I’m looking runners did such a grea again next year!” forward to helping out Teromi Selvadurai
ifully un t u a as be vided a f w n u r ro nd p y for a “The a d nise e mone orga is to ra y a w use.” a c t grea Voelker Josep
"Well o rg atmosph anised with a er weather e, despite t great he awfu . Go fo l r the h next ye alf mar ar..." Lee But a thon le
r, Digi sing Ma tal Marketing nager. MSF UK. and
here the route w t in po e th at g in al “Marsh soft mud, I was turned from gravel to yone's really inspired by ever mination to er et d y ad re d an m as enthusi -than-desirable run through these less guys!” conditions; well done Germaine Liu
“It was a great da y, full of fantastic energy a to see so nd it was many pe support ople com of MSF”. ing out in Sarah Bra nd
Issue 4 FoMSF magazine