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The FoMSF Magazine


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Note from the Editor “We are not sure that words can always

save lives, but we know that silence can certainly kill”.

(Dr James Orbinski)

Welcome to the first issue of the new Friends of MSF magazine! The Friends of MSF are student societies based in universities in the UK and Ireland, the official student support network for Médecins sans Frontières. Our aims consist not only of fundraising for MSF, but perhaps more importantly, raising awareness about their work around the world, and promoting campaigns related to humanitarian issues. MSF’s focus on témoignage, literally bearing witness, is what makes it unique as an organisation: speaking out against acts of injustice in order to alleviate the suffering of individuals around the world, not only providing them with medical aid, but also reassurance, security and comfort. Advocacy is a core principle for the Friends of MSF, and our goal is to enhance public understanding of the plight of populations, regardless of race, religion, gender, or political affiliation. The first issue of Insight concentrates primarily on three significant humanitarian issues faced by MSF: malnutrition, conflict and the lack of access to medication. The MSF Starved for Attention campaign was launched last year in an attempt to rewrite the story of childhood malnutrition, and we have explored the importance of nutrition and providing nations with satisfactory supplies. Conflict is a continuous, long-standing challenge internationally, but what are the consequences for the country, for the populations, and indeed, for MSF? And finally, with the recent developments in the Free Trade Agreement between the European Union and India, we have addressed the campaign for Access to Essential Medicines. World AIDS Day presents us with the chance to say “Europe! Hands off our medicines”; this is a hidden crisis that is threatening the supply of essential medication to people in the developing world who need it most. I hope this magazine provides you with an insight into the world of MSF and encourages you to get involved. Education is the key to success: only by raising awareness can we move forward and protect the basic human rights of those who are oppressed. Four key notions were ascertained when MSF was first established forty years ago, and these still stand today. Act. Speak. Treat. Witness. Alisha Allana Editor Advocacy Liaison, Friends of MSF National Committee advocacyliaison.fomsf@gmail.com


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Contents 4

Welcome to FoMSF

6

Are you sold by sustainability?

8

Living in Emergency: challenging our limits

10

Learning through experience

12

Finding my humanitarianism in Tanzania

13

We can’t wait for another crisis to act

15

MSF Fast Diary - 23rd October, 2011

17

Somalia

18

Interview with an MSF Field Logistician: Simon Heuberger

20

Conflicted Medicine

22

Violence and indignity: victims of immigration policy

25

Film Review - Hotel Rwanda

26

HIV Treatment: 10 years in Mozambique (2001-2011)

28

AIDS: The synergy of prevention and treatment

29

Success story: MSF’s HIV/AIDS project in Cambodia

31

Novartis, India: A final stand

32

Malaria vaccine trial gives hope

33

Pushed for pills - bridging the gap between human rights and essential medicines

37

Focus on FoMSF

39

Food for thought


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Welcome to FoMSF! Who are MSF? Médecins Sans Frontières/Doctors Without Borders is a private international organisation that consists mainly of doctors and health sector workers, but also assisted by those simply wanting to help people in need. MSF strives to provide assistance to populations in distress: victims of natural or man-made disasters, and of armed conflict. MSF provide emergency medical relief in more than 60 countries globally irrespective of religion, race or government policy. Below are some examples of the inspirational work they carry out.

“If the earth were a ship carrying

humans, pregnant

women would be our

most precious cargo.”

Aid in a natural disaster After the Japanese earthquake and tsunami in early 2011, MSF sent an emergency mission to Minami Sanriku, one of the worst hit areas. Between four evacuation centres and a mobile clinic, doctors worked tirelessly to provide medical care to local people and ensure they had water, food and shelter. One doctor reported that he “came across one sick and bedridden lady, in a house without electricity, water or gas. It was freezing cold; she was covered in bedsores and had none of the medicines she

needed. We treated the sores and made sure her daughter-in-law had the supplies she needed to look after her.”1 In such unforeseen natural disasters, it is important that MSF continues providing emergency aid to these vulnerable people. Lack of Resources MSF also provides aid in areas affected by a longterm lack of resources. MSF doctors have been providing health care, specifically maternity services, on the Kenyan/ Somalian border at the world’s largest refugee camp at Dadaab throughout 2011. Women should not die during childbirth simply because of where they live and the lack of help they receive. MSF recognise this and invest many of their resources into reducing the number of deaths from childbirth. Dr James Maskalyk writes: “if the earth were a ship carrying humans, pregnant women would be our most precious cargo.”2 Armed Conflict Armed conflict has been active in Libya since February of this year. When the fighting intensified in Misrata in April and the number of injured rose to hundreds, MSF intervened and began to evacuate patients via boat to Tunisia, away from the conflict. 6.5 tonnes of medical supplies were donated and the worst affected were carried by stretcher to the boat. Annas Alamudi, a member of the evacuation team, describes the operation: “it was incredibly choppy, a lot of patients were

suffering from seasickness and, at times, it was too rough to stand. But the nurses were still there, crawling around on their hands and knees attending to everybody.”4. Who are Friends of MSF? Friends of MSF are student led societies, which offer opportunities for students interested in the work of MSF to get more involved in humanitarianism. First set up in 2005, Friends of MSF now has active groups at over 30 UK universities and works towards 3 main aims:

1. Awareness:

FoMSF aims to raise awareness of the ongoing work of MSF and of humanitarian issues in general e.g. speaker events and conferences, films

2. Careers: Provide insights into working for organisations such as MSF in the future e.g. information evenings.


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3. Fundraising:

To raise funds for MSF e.g. charity fashion show, sponsored fun runs.

“...it was too rough to stand. But the nurses were still there, crawling around on their hands and knees attending to everybody.” What do they do? Students from the different branches of Friends of MSF unite in activities locally and nationally to achieve their aims. All over the country, committees organise social and educational events such as film screenings, pub quizzes and debates about political issues and international aid. In the past, Friends of MSF have organised

workshops and conferences on topics such as humanitarianism, global health careers and the latest advocacy campaigns. What is ‘humanitarianism’? When asked to define humanitarianism, most people tend to respond that it is ‘helping people’ or ‘working in disasters’. This can take place in different situations, for example environmental disasters (hurricanes, earthquakes, disease) or more complex emergencies (war, breakdown of health services and vaccination programmes). This alleviation of suffering is what MSF attempts to work towards. However, this is not the only criterion for an act to be considered humanitarian. It is important to note that whilst providing relief, MSF aims to adhere to policies of independence, neutrality and impartiality. Independence: the ability to make a choice to act to alleviate suffering without political, religious and economic influence Neutrality: not taking sides; militarily – not allowing aid to

advantage a side (e.g. smuggling weapons in an ambulance) or ideologically – not allowing aid to endorse a particular viewpoint (e.g. not publically favouring a party) Impartiality: providing assistance equally, as a far as possible, and without bias, for example treating a child and soldier with gunshot wounds according to who has the greatest needs and not subjective bias.

“It was freezing cold; she was

covered in bedsores

and had none of the

medicines she needed.”

Stephanie Siddall, 2nd year War Studies and Philosophy student, King’s College, London.

• http://www.msf.org.uk/ • FoMSF Discussion Set - What is Humanitarianism Anyway?

• Publicity Leaflet 2011 - "All About...Friends of MSF"

• h t t p :// w w w . m s f . o r g . u k /

ourwork.aspx Sans Frontieres, Dispatches, Summer 2011. Issue No. 61

• Medecins

Medecins Sans Frontieres, Dispatches, Summer 2011. Issue No. 61 2 Ibid 3 Boat evacuation in Libya, April 2011 (photo taken from http:// www.msf.org.uk/ourwork.aspx) 4 Ibid

SHELIZA DARVESH

1


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Are you sold by sustainability? Introduction Google: ‘medical elective’. Do it. Right now! 12,700,000 hits or more and what have you got? A fantastic array of opportunities, yes! Paralleled however with countless considerations for the average fourth year medical student, as a battle between idealism and realism begins – with the practicalities of prioritising: cost, safety, future career aspirations and travel experience. But whilst all of these factors are essential considerations in deciding whether an elective placement is right for you, have you yet considered whether you are right for the elective placement? Medical Electives do not last long: 2-3 months in most cases. So what happens when you leave; what happens to the space in someone’s healthcare that you filled? You could argue that as a student you are not ‘filling’ a space in the first place, simply observing. In some elective experiences this is certainly the case. But more often than not, a student’s enthusiasm in a resource stricken situation does mean you are filling or creating a role – so what does happen when you leave?

“So what happens

when you leave; what happens to the space in someone’s

healthcare that you

filled?”

The same question can be asked when considering MSF’s humanitarian aid campaigns. It is undeniable that it is essential to have a system in place to alleviate immediate disruption to a healthcare system. When the funds dry up however, and attention focuses elsewhere, what happens to the systems we leave behind: what value should we place on sustainability? Arguments for and Against Sustainability For health development advocates, the value of sustainability cannot be underestimated. It is a bit like writing an essay: if you do not save it as you go along, you risk losing it entirely if the computer crashes. But if you save it, even if something does go wrong, there will be something left

to build on. Now apply this to a healthcare system: educating local people as you resolve the immediate crisis is essentially your ‘save’ button. If the computer crashes e.g. resources run dry, those you leave behind will have something to build on – they will not have to start from scratch. As well as education, there are other ways in which campaigns can be made more sustainable, for example, by conducting research to identify the health needs of a population and liaising with local government to adjust budgets accordingly. It may also be valuable to highlight issues to international development organisations who may be more able to offer long term support e.g. VSO (Voluntary Service Overseas)3. Not only does sustainability allow continuity of care, which has been associated with better health outcomes5, it also maximises the efficacy of resources that have been provided; an estimated 50% of medical equipment in developing countries is not used because of lack of maintenance or because health workers do not know how to use it5. What is the value of such resources if they cannot be utilised? But is sustainability the be all and end all? As said before, it is undeniable that immediate health

Humanitarian aid = resource allocation to immediately alleviate a situation involving widespread human suffering e.g. natural disaster or conflict1 Sustainability = a form of progress that meets the needs of the present, without compromising the ability of future needs to be met2


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care is essential and you could argue that in an ‘all or nothing’ situation, doing something is better than doing nothing at all, particularly if you only have the resources to deal with immediate challenges. There is also the argument that taking time to consider sustainability in an acute situation could compromise the primary objective of humanitarian aid: to alleviate acute human suffering. Cultural issues should also be addressed when considering sustainability. Although short term relief may be welcomed to prevent acute mortalities, long term healthcare changes may be rejected. What we may consider as substandard healthcare may constitute traditional practices that already meet the desires and expectations of local people. Conclusions In my opinion, it is important to strike a balance when considering the issues of sustainability. In the UK you can gain open access to healthcare whether you have suffered an acute or a chronic illness and we should strive to

“An estimated 50% of

develop the same open access in the developing world, only where such an approach is not only viable, but also welcomed. I believe MSF do strike this balance, by conducting campaigns that address a spectrum of health needs: from offering i m m e d i a t e humanitarian aid to support for the long term issues of malnutrition, disease prevention and fairer access to medicines6. There are no easy answers regarding how organisations like MSF can improve the sustainability of their humanitarian aid campaigns, and in a sense, they have different primary objectives that should be respected. So going back to your elective: if you are concerned, what can you do to assess the sustainability of your placement?

1. Research the history of the

medical equipment in

developing countries is

not used because of

2.

lack of maintenance or because health

workers do not know how to use it”

3.

organisation – how long have they worked and what have they achieved in the country they are working in? Contact them – find out exactly where your money is going; how much is going directly to the project you will be working on? Consider the project itself – does it involve people from the local community (particularly in education and training) or always rely on outsiders?

Harriet Joy Blundell, 4th year medical student, University of East Anglia References 1 Adapted from: "humanitarian". Oxford Dictionaries. April 2010. 2 Adapted from: United Nations. General Assembly Resolution 42/187. 11 December 1987 3 Voluntary Services Overseas, 2011: http://www.vso.org.uk/. 4 Journal of Korean Medical Science, 2011: Hong JS, Kang HC, Kim J. Continuity of care for elderly patients with diabetes mellitus, hypertension, asthma, and chronic obstructive pulmonary disease in Korea. 5 World Health Organisation. Everybody’s business: Strengthening healthcare systems to improve health outcomes. 2007. Accessed: 06/11/11. Available at: http://www.who.int/healthsystems/ strategy/everybodys_business.pdf 6 MSF, 2011: http://www.msf.org.uk/ ourwork_whatwedo.aspx


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Living in Emergency: challenging our limits “We are the guys that go unarmed, white flagged, to give assistance to the population”. As an independent humanitarian organisation, MSF plays a crucial role in providing medical aid to those individuals around the world who desperately need it, be it in war-torn countries or nations subject to epidemics. However, as depicted in the recent MSF film, Living in Emergency, the needs of these populations may be infinite, and can be overwhelming for the MSF workers; more often than not, only a small fraction of these needs can be met. The frustration of trying to decide what to do, and justifying these choices, can trigger doubts in the minds of the aid workers, questioning whether there is any point in trying at all. So what can MSF really achieve?

“It’s like getting thrown in with the lions at the Colosseum”. Living in Emergency gives an idea of what life can truly be like as a doctor working on an MSF mission, deviating from the glamour and excitement, instead conveying the stark reality. There is a huge amount of pressure for the doctors, a number of whom are young: many may approach their mission with numerous ideas and plans for the future, but it is impossible to know how to deal with the situation unless you are there yourself. MSF workers have offered countless reasons as to why they chose to get involved with the organisation and working abroad, and despite their motivations, each appears to have a similar incentive: offering healthcare to those who need it the

most. Doctors have a duty of care: if they see someone who needs help, they are obliged to stop; is this also the case with countries such as Darfur or Sudan? Equally, this involves practising medicine in conditions that are far from ideal, with very limited resources: the responsibility of triage can prove both stressful and distressing, and we can question whether it is fair to put people in this position. Yet this aspect is fundamental in humanitarian aid work: we make our own choices about getting involved, and each need to appreciate how far beyond our limitations we can go.

“The conflicts are real and the people are just normal people: no different to you or I”. It could

be very easy for individuals to travel to nations that require medical care, with the best intentions of helping the population, but embracing their culture and understanding their ideas is key in humanitarian aid. Entering a country for the first time, we know very little about services such as transport, food and water supplies, and above all, their existing system of healthcare. Any assumptions made about the country can be criticised, deemed as arrogance or a lack of respect, and every attempt should be made to engage with the local population, integrating medical aid with their approach so as not to undermine their own services. However, how much can MSF do to fix the underlying problem? And more importantly, once the crisis has abated, are we right to try and ‘fix’ their normal pattern of everyday life? There are several philosophical and ethical issues associated with

“It is impossible to know how to deal

with the situation

unless you are

there yourself.”


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humanitarian aid, and the role of organisations needs to be defined carefully in order to ensure that the rights of the local population are not violated.

Through managing the situation carefully and establishing basic protocols, aid workers can work efficiently and develop their own initiatives. Mistakes and medical errors should be discussed and learnt from, rather than hidden, while quality standards, documenting, and even basic hygiene all need to be maintained in each situation. Despite some cynical attitudes, humanitarian aid work can work well when carried out with the right approach, and the scope of humanitarianism allows for this.

“There are limitations to what you can do, but it’s just taking that thinking to an extreme setting like this”. MSF remains neutral, impartial and independent, yet there is no doubt that they are constantly fighting a medical battle. But with the inability to resolve the roots of the problems, is it a losing battle? The organisation was formed in the early 1970s by a small number of individuals in France: doctors and journalists, who were unlikely to have known how successful MSF would become forty years later, with offices and missions in over sixty countries worldwide. The original goal was to provide emergency medical aid, yet today, MSF are pushing beyond their boundaries: treating HIV and multi-drug resistant TB, researching new techniques such as telemedicine, and establishing Living in Emergency effectively campaigns against malnutrition humanises the individuals involved and the lack of access to in the MSF mission, allowing the medication. audience to view the situation

“...with the

inability to resolve

the roots of the

problems, is it a losing battle?”

through their eyes and gain an understanding of the weight of the responsibility, both on the individual, and the organisation as a whole. The film also focuses on the role of the local healthcare workers and an aspect that is fundamental to the work of MSF around the world: only by working with the expatriates, and building capacity, can a project be truly sustainable for future generations. Humanitarian aid allows for ambition and aspirations, but there are a lot of choices involved, and many compromises to be made. There is no doubt that aid work is a huge challenge, but it is possible to alleviate suffering: sometimes by curing illnesses or treating injuries, and at other times, simply by comforting an individual. Ultimately, “we all have the same question: what is our limit?”

Alisha Allana, 3rd year medical student, University College London. References MSF film: Living in Emergency www.msf.org.uk


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Learning through experience t is a dream for many young students and budding professionals to go off and work with Medecins Sans Frontiers. They are drawn to ‘the cause’, the thrill of adventure and sense of self-worth it brings. Many overlook the fact that the work is often carried out in hostile environments, which are both physically draining and emotionally testing. Cultural differences, corruption and greed clashing with your morals and beliefs may push you to the limit. Before you embark on a humanitarian career ‘in the field’ it is important to know if you can cope and adapt in these situations. Experience is golden. Learning to function efficiently outside of your comfort zone is vital seeing as certain situations may make you step out of them or even, at times, throw you out!

I

In the summer 2009 I set off to Kenya for 6 weeks to work with Special Education Professionals (SEP). SEP is a registered society working mainly throughout Nairobi, Kenya to improve the quality of life of children with special needs such as autism, cerebral palsy, down syndrome, stammering, learning difficulties and a number of physical disabilities. In an area such as Kenya where 46% of the population lives under the poverty line

Kenyan slum houses.

the needs of children with disabilities often go unnoticed. Disabilities develop from genetics, birth, accidents or illness and are often left untreated seeing as families don’t know how to treat or deal with them. In many cases these children are left in a corner of the house to cope or abandoned to the street particularly when their condition is deforming (e.g. neural tube defects). SEP is working hard to spread awareness and educate the Kenyan population. They do this by “providing quality interventions to children with special needs and empowering their families by including them in the intervention programs, through out the country" (SEP Kenya website). SEP has set up many education centers throughout the slums where the children can be brought by their parents to see the appropriate visiting therapist and teachers. As each intervention is geared towards selfsustainability the families are taught how to care for their child. The mothers sell t-shirts, bags and merchandise to raise money for the project and SEP builds and donates all the necessary physiotherapy equipment to the education centers. It is incredible what education can do to people. When the mothers and families learn what is possible to help their children most of them respond positively spreading the word, not only helping their children but others as well. Volunteering with SEP allowed me to really get a feel for working towards a large goal in an impoverished area: how to remain safe, how to build a project towards sustainability, how to work with my emotions and how to prioritize. Even though some of the days were the most shocking, emotionally charged, morbid and draining days ever the experience

Children with Cerebral Palsy need daily physiotherapy to prevent deterioration.

Mothers create t-shirts and other merchandise to spread awareness and raise funds. The t-shirts read 'Become Aware'.

Small education centre slums of Nairobi


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~ It never ceases to amaze me,

that in some of the most impoverished areas of the world;

the facility people have to smile. They’ll come over all

passive

going

about

their

business but then the smallest

thing cracks them into a smile that cannot be missed. ~ remains one of the most experienced NGO’s. A fabulous enlightening and happiest of my life. experience to start off with is within a group such as SEP that is working In many cases the best way to learn towards fixing a long-term problem is to experience. It isn’t possible for within an area with a sustainable you to work with MSF just yet but solution. In these situations people that doesn’t mean you can’t travel often have more time to teach you and volunteer. Use your summer and you in turn will have a chance to time off as a student and electives test out the environment, adapt and as a medical student to gain some learn. For me the most valuable experience ‘in the field’. Don’t lesson was that although your help always go for the obvious seemingly could pass unnoticed or even ‘ heroic’ choice of a natural disaster unappreciated at times you are or war zone where ‘an emergency there for them. It put my search for fix’ is needed. These areas are approval to rest and was the most fantastically extreme to start off in humbling experience to realize I and also tend to get the most media could learn more from the people I attention and aid from numbers of

Karolein Remmerie-Tuts Chairperson of the SEP Kenya Society.

Interactive boards created by SEP for the children. The child on the right is strapped into a specialized chair to aid his posture.

was helping than they could learn from me.

Chloe Porter, 3rd year Biomedical Science student, University College London. Notes You can learn more about SEP at: http://sepkenya.com/ Follow them on facebook: h t t p :// w w w . f a c e b o o k . c o m /#!/ sepkenya


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Finding my Humanitarianism in Tanz

Finding my humanitarianism in Tanzania n January 2011 I was visiting a friend in Dar Es Salaam, Tanzania. The weather was hot, humid and sunny, and one afternoon, we went to find the Qatar airways office. It took us a couple of loops around the main streets in the city before we actually found the place. When we arrived at the office building, and before we had the chance to go in, a little Tanzanian girl approached us. She was about 6 years old, and held her two hands out to us in the shape of a bowl, asking for money. I didn’t give her any money, and after I turned away I knew that the decision not to give her anything, not even food, would haunt me forever. Yet, despite that moment of realization, I didn’t go back to make things right. I felt hesitant, confused, and selfish, and I am sure I am not the only person who has experienced a similar situation, in country like Tanzania, or even in the UK. Admit it.

I

“She was about 6 years old, and held

her two hands out to us in the shape of

a bowl, asking for

money.”

This wasn’t my first time in Tanzania, but my third visit since December 2008. After my first and

second visits, I started to wonder about the impact of aid and NGOs in developing countries; it is reasonable to consider their impact considering the large number of NGOs around the globe – and despite this, there are still children roaming the streets and asking for money. The point is that nowadays, you may assume that money you give to a homeless person won’t necessarily end up in their stomach, but in their brain (through drugs). Then there are other stories about parents making their children go onto the streets to ask for money from tourists so that they can fuel their addictions. In reality, such cases happen in both the developed and developing countries. So what should we do? In my opinion, the answer is: do what feels right so you will not have regrets. I will admit that it was my selfishness that got the best of me. That afternoon after visiting the Qatar airways office, my friend and I went out for lunch. The two bottles of orange soda that I bought could have made a meal, or two, for the little girl. It shows how a small decision can make such a difference to another person: it is true that food should be seen as a luxury. So just have a think next time you order food or buy drinks, and please don’t forget about the children who don’t have that luxury.

Hua Wang, 2nd year Chemistry DPhil student, Oxford University

A Ba jaj Salaa ride into m co Dar E m subu s rbs w ing from the hen an ex I s ta trem yed w e kind ith -hea ly genero rted fami Tanz us and ly. ania n


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We can’t wait for another crisis, to act Malnourished children should not have to become victims of war or famine to have access to life saving, nutritious foods. SF have joined forces with VII Photo Agency in the production of this latest campaign, Starved for Attention, in the continued fight against childhood malnutrition. As part of the campaign, VII photojournalists travelled alongside MSF volunteers to malnutrition ‘hotspots’ – including Bangladesh, the Democratic Republic of Congo, and India - to expose the neglected, and largely invisible crisis of childhood malnutrition. The video footage and photos taken in these countries have been compiled into eight individual documentaries, which shed light on the underlying causes of the malnutrition crisis, and the innovative approaches that are being used to tackle this condition; these documentaries can be viewed at www.starvedforattention.org.

M

Why Malnutrition? An estimated 195 million children worldwide suffer from the effects of malnutrition, with 90% living in sub-Saharan Africa and South Asia. The map below is a visual representation of these statistics.

With these statistics in mind, it is clear why MSF have centred this campaign on raising awareness of the inadequacy of the international food aid system, and how it is failing children around the world. Malnutrition contributes to more than a third of all child deaths in developing countries, as well as having lasting consequences for the people, and countries that it touches - “it blunts the intellect, saps the productivity of everyone it affects, and perpetuates poverty” (UNICEF, 2011). Being malnourished does not mean, simply, that someone is hungry. Malnutrition is the state of being poorly nourished; having insufficient levels of protein, micronutrients and vitamins in the diet. These vitamins and nutrients are essential for cognitive and physical development, as well as a strong immune system. Consequently, children under the age of two are the most vulnerable. Without access to nutritionally rich foods, these children face debilitating lifelong consequences, if they survive beyond childhood. With the world producing “enough food to feed every man, woman, and child on earth” (UNICEF, 2011): malnutrition is an unacceptable reality that we can no longer choose to ignore. The majority of food aid today lacks adequate nutrition Most of the food aid that is currently donated to international food-assistance programmes is a flour based product; comprised of corn

and soya, which is then fortified with vitamins- something called Corn Soya Blend (CSB). The USA is the single largest donor of CSB. It provides approximately 130,000 metric tonnes of the 400,000 metric tonnes of CSB that is channelled into the international food aid system every year (MSF, 2011). CSB fulfils its purpose of staving off hunger, and in some instances is the only food that adults and children have access to.

However, CSB is a relatively recent donation, as until 1989, the US donated a more nutritious version of this mix: Corn Soya Milk Blend (CSMB). The milk is an essential ingredient in the mix; it provides high quality protein which is readily absorbed, as well as a good balance of calcium and phosphorous, and all of the 20 essential vitamins needed for growth (minus iron). However, in 1989, CSMB was replaced with CSB- its nutritionally inadequate counterpart (MSF, 2011). What are the alternatives? Some would argue that because a significant amount of food aid is being donated on an annual basis, and is fulfilling its role in reducing


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the occurrences of hunger worldwide, there is no need to find an alternative to CSB. Also, some would question why we are targeting the US, and condoning the food products they donate, when they contribute such generous quantities of CSB to the international food aid system every year. However, in response to the first argument, it is important to note that CSB can do more harm than good in some instances (MSF, 2010). When consumed together, cereals and soy bean can hinder the absorption of vitamins, minerals and proteins. As a result, many children fail to gain weight, thus, increasing the severity of malnourishment experienced. Recent revelations in nutritional science have further proven the nutritional inadequacy of CSB. A new generation of nutritionally rich foods have been developed, called Ready to Use Therapeutic Foods (RUTFs). Plumpy’nut is a Ready to Use Therapeutic Food.

Originally intended to be used during food crises- such as the Haitian earthquake in 2010 and Pakistan floods in 2011- RUTFs have revolutionised the treatment of

chronically malnourished children. These foods can be eaten straight from the sachet, so are more easily distributed, and consumed; with rapid improvements in the nutritional well-being of children as a result. In response to the second argument made above, the US has been duly criticised for their removal of the milk component in Corn Soya blend, meaning nutritionally substandard food products are donated. There is evidence of a double standard here, in that the nutritional supplements the US provides its own impoverished population through the Women, Infants and Children (WIC) programmes are far nutritionally superior to the food aid it donates to developing countries around the world. Another reason that the US is being targeted is because they are the world’s largest food aid donator, so have the potential to be the most influential in bringing about change. However, it is wrong to target solely the US; there are other major donors such as the European Union Member States, Canada and Brazil who also need to change the food products they donate. A growing body of scientific evidence has concluded that donations of food aid need to move away from cereal-based fortified flours, and towards RUTFs, so that the outreach of these foods extends beyond emergency response, and into treating on-going cases of malnourishment. Malnutrition is a preventable, curable condition However, we do not need to become disheartened- malnutrition is a treatable, preventable condition. It does not require a miracle solution: the solution already exists. Part of this solution requires all food aid donors to ensure that their contributions to

food programs are nutritionally adequate, and meet all the appropriate standards, whilst ceasing to finance programs using substandard food. Another part to this solution is to ensure that children who are not caught up in attention-grabbing crises are too given access to nutritiously adequate food products. It is the presence of malnutrition, after all, and not the attention of the world’s media, that should determine the use and distribution of nutrient-rich foods to children in need. What can you do? The Starved for Attention campaign hopes to rewrite the story of malnutrition, by convincing governments to ensure the food aid they donate meets the nutritional requirements of children. More than 123,000 people from over 180 countries have already joined MSF in the campaign against childhood malnutrition; go to www.starvedforattention.org to pledge your support today. If you would like further information on the Starved for Attention Campaign, or the work Médecins Sans Frontières MSF (Doctors without Borders) does around the world, visit www.msf.org.uk.

Rebecca Boyd, 3rd year Geography student, University College London


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MSF Fast Diary - 23rd October, 2011 6:00

as possible for the 24 th as many calories wi elf ys m d ffe d an stu I se ee Got up, made sure chicken, spinach, ch layer sandwich with ple tri a e ad m I t. hour fas mayonnaise.

7:30

n theatre with my ing off to the Pearso ad he re fo be ay -d 5-a I made sure I ate my out to start. when the fast was ab m 8a r fo g sleeping ba

8:00 Fast begins. A mouse scuttles across the floor

of the Pearson theatre.

9:53 2 hours into fast. So far so good. Just found Monty Python on IPlayer. Yes that should keep us busy...

rs, no commute g in lk a rw No powe msbury. o lo B m Tesco. o d fr n r f wate re arou e o h L p 0 s 1 o g 11:00 lu orning atm s. Perfect time to n Sunday m o e ti n ta re s e e s b the rowded tu Enjoying and no c s b a c g yet... speedin rumbling g ’t n is y m good, tum So far so t. h 12:00 g u o th le, not us ost peop m r fo e Lunchtim

12:30

Just passed the half way mark for the fundraising target of £15 0 on the Justgiving page.

13:00 More people join us in the Pea rson theatre. There is a consen sus that fasting is a lot easier wh en you’re surrounded by oth er people who are not eating .

14.00

goin r e g Hun

min e th g to

d?

Parisa walks past a buffet in the UCL Quad. Some people are so just so inconsiderate sometim es “Thank you people in the quad for roasting a pig and waftin g the smell in my direction wh ilst I'm fasting.”


Page 16

MSF ban ner in Pea rs

15:00 We all watch a terrible episod e of Grey’s Ana slow mo clich tomy, full of d és. ramatic

on theatre

18:00 We have £16

0!! 106% of ou r fundraising

target!

20:29 Just gone past the halfway mark of the fast and the gurgling orchestra in my tummy has already starte d in the library.

21:00 Watching ‘Bridesmaids’, bad film to watch when fastin g as it’s filled with close up pictures of chocolate fountains and wedding cake.

0.00 Wrapped in sleeping bags, Parisa and I have a cosy night

in the Pearson theatre.

Fast is OVER!

5:00 - 24/10/2011 Woken up by security guards and cleaner.

7:00 Get up after a reasonably comfortable sleep

in a lecture theatre.

8:00

e member). She has brought us food! Fast is over! So happy to see Kat (committe Yum! Croissants, pain au chocolat, tea and bananas.

I would just like to say a big thank you to all the generous people who donated money and those who lent their support and encouragement. You can still donate on http://www.justgiving.com/UCL-FoMSF-24hrFast The fast made me realise how vital food is for our day to day functioning and 24 hours without food was quite tough but it was sobering to think that many people in the world have to go without food for much longer than 24 hours. I feel privileged that I can afford to eat three meals, when so many others don’t have the resources for this. If you want to donate to MSF or find out more about the MSF Starved for Attention Campaign please go to http://starvedforattention.org/

Cindy Lai, 2nd year medical student, University College, London.


Page 17

Somalia Walking seven days seven nights Fighting for a life, trying to find the light The only light, the sun shining bright A drought cleaning out the only supply of food and water Carrying a son, a wife a daughter Finally reaching a camp site with only a son No energy no freedom to run A face of a child unrecognisable What is visible‌ Bones painted Tired of waiting Crying with no hope No movement, no life A common site A moment to pray for the children of paradise Somalia, a starving nation Corruption, deprivation A country plagued with war People pray for no more Famine A disease spreading so quick So difficult to fix And the world is watching Watching our sisters and brothers Losing their mothers Others and others An hour, a minute and with a click they’re gone It is time Time to reverse the impossible Make it possible To silence the violence Petition to relieve the malnutrition Let us reach an ending The clock is ticking To save a nation A starving population To save Somalia.

Ayat Bashir, 2nd year medical student, Newcastle university


Page 18

Interview with an MSF Field Logistician: Simon Heuberger FoMSF is really passionate about the importance of increasing awareness of the work of MSF. How did you first find out about it? I guess that aid work was always somewhere in the back of my mind. Maybe growing up in apartheid South Africa, I am a white South African, made me more sensitive to fairness. During my GAP year I prepared and led an expedition driving myself and four friends from London to Johannesburg in a land rover. Looking back this was risky. I am not sure I would undertake the same trip now. We were really fortunate that we did not have any bad experiences.

“MSF was the right aid organisation for

me.”

Africa opened up in 1989-1990 to overland travel –proxy cold war conflicts, at least temporarily ended. We were innocent and enthusiasm 18 year olds. We did not approach border guards, customs officials or any authorities thinking we knew better because we came from Europe. We were guests in someone else’s country. Looking back now I think the trip inspired me to make a difference. I then studied a Masters in philosophy before joining a law firm in London where I spent my days working hard looking after legal records and making other people –partners of the law firmlots of money. I lost my way a little and it was around this time that a friend, a doctor, told me that many

aid agencies (like MSF) have roles for non-medics. I made a decision to become a logistician and spent a year gaining practical and theoretical experience by taking courses with RedR, ‘The essentials in Humanitarian practice’ and a diploma in ‘Humanitarian Assistance’ at the Liverpool School of Tropical medicine, spending time working as an electrician and volunteering with Merlin1. I applied for work with many organisations and was offered a ‘field’ position with both Merlin and MSF. I was advised to go with MSF. MSF, I was told, would provide me with the best training and the rest is history! What training did you receive from MSF to prepare you for your first logistics role? Everyone who joins MSF does a preparation for primary departure course (PDP). It is a 1-2 week general induction that teaches you the aims of MSF and the standards that you have to adhere to. There is a mix of medics and non-medics. During this course Marc DuBois2 came and spoke to us about MSF’s commitment to ‘speaking out’ or témoinage. Marc was inspiring. MSF was the right aid organisation for me. In fact it made me feel foolish, having joined MSF, only now did I

“I get to be

everything from an accountant to an architect!”

understand the type of organisation MSF was –its particular way of acting and reasons for acting.

“I mostly remember

feeling really

welcomed and very secure.”

How did you feel when you stepped off the plane into your first role with MSF? I mostly remember a feeling of being very welcomed...Coming from the familiar space of a commercial aeroplane I walked into the customs area where there was a mix of familiarity and new sights, I then walked into a whole new world as I left the airport –Indian administered Kashmir, with the highest concentration of troops in the world. However, I quickly saw a friendly face wearing an MSF t-shirt who immediately made me feel very secure. I didn’t feel too daunted about the task at hand because the context was complex and the workload huge –no one could do everything or even enough. I was really lucky because the staff that I worked with during my first project were absolutely wonderful: really supportive and knowledgeable. I have not always been so lucky in other projects. Your experience, I think, is very dependent on the team of people you will be working so closely with.


Page 19

As a logistician, what were your typical daily activities? The role of a logistician is really varied depending on the country and the project. In Srinagar, Kashmir I would wake up really early and unlock the office for Mr Pir (an old Kashmiri cook). Mr Pir would put on the filter coffee (amazing stuff!) and we would sit on the veranda looking at the snow covered mountains and smoking before our work started. In Srinagar we were providing mental health counselling so there were not too many drugs to order, so I would generally spend most of the six course breakfast planning vehicle movements –which driver would take which team where and when. It is the responsibility of the project co-ordinator to define security procedures but, as the project logistician, it was my responsibility to make sure that they were adhered to. To do this I would have to check all the daily and weekly plans and ensure that all the drivers had the correct equipment in their vehicles and everyone knew the plans.

“I now feel as though I have built up enough knowledge and experience to be able to really help.” My experience in the law firm really helped me in my role as an MSF logistician. Team management is the most important skill that you could bring to a logistics role as most of the people that you work with already have the technical knowledge and skills. What’s needed is someone to co-ordinate all the work.

What has been one of the most rewarding experiences to date? The most satisfying experience for me was in Assam, India; we were completing the construction of a small anti-natal clinic (made of bamboo, plastic and corrugated iron). Before opening the clinic we needed to complete the clinics drainage –large pits filled with pebbles. The MSF team were all busy; I began to move the stones from the piles into the pits. A couple of the children from the IDP camp started helping and soon a line of about 30 children had joined in, each carrying one large pebble, laughing and running. We soon filled the pits. One of the best parts of being a logistician is that it is so varied. I get to be everything from an accountant to an architect! What has been your worst feeling during your work for MSF? It was when I watched my project co-ordinator try to persuade the MSF staff in Malakal, Sudan not to go on strike. There was a cholera outbreak expected. A cholera intervention is largely a logistics intervention. You need lots and lots of clean water and lots and lots of people to run a Cholera Treatment centre. I just couldn’t believe that they were still deciding to strike in the face of what was about to happen. Looking back now I can understand their point of view, but at the time it felt awful. Looking at the range of countries and project that you have worked in, what have been the main differences? Well, I started off working as a logistician in Kashmir Northwest India and then moved to a project in Assam Northeast India. I then worked in Sudan as a technical logistician after receiving some technical training. Since then I have worked as a project co-ordinator in Diktel, Nepal and as the financial

Simon Heuberger at Malakal airport

co-ordinator in Kathmandu. There were similarities between India and Nepal but Sudan is at a different stage of development. I think that the main difference is a consequence of the violent conflict –the Sudanese in 2005 had just agreed a comprehensive peace ending decades of war. It is really striking to see how much devastation that active war wreaks on a population –not only active fighting but the indirect consequences. What has been your favourite role and what will you be doing in the future? Well, I will be going abroad again next year as a project co-ordinator. I now feel as though I have built up enough knowledge and experience to really add value. Working abroad with MSF is really engaging and inspiring. It involves being given and taking on a lot of responsibility (a lot more than I’d get working in London). I think I might find it more daunting going back into the field now. Tamsin Smith, Post-graduate, Open University Merlin is an aid agency that also specialises in provided medical assistant overseas. : http:// www.merlin.org.uk/ 2 Marc DuBois is now the Executive Director of MSF UK 1


Page 20

Conflicted Medicine I was woken by the sound of gunfire and quickly grabbed my rifle and ran out to where Matak was already crouched behind one of the trucks. All around us was complete panic; I couldn’t see the rest of our group and the shots were getting louder. A large rocket lit up the sky and for a moment I imagined that all the shadows were enemy fighters waiting to attack me. Then we saw them. The enemy. They were much bigger than us and looked really angry as they raced towards our camp. Matak stood up and ran towards them firing his rifle so I stood up and tried to do the same, but I must have tripped over a rock or something because the next thing I knew I was lying on my front and watching my best friend be shot down by about twenty different rifles... I am a soldier for the Lord’s Resistance Army in Sudan, my name is Tahir and I am 13 years old.*

I watched, helpless, from the clutches of one of the gang members as Tahir and his father were dragged into the truck with the other men of our village. When the man released his grip I struck out at him and he slapped me so hard that I collapsed on the ground and started to weep. My eldest daughter, Subin, ran to me and helped me up. It has been two weeks since they were taken and Subin and I have tried to continue to live as normally as possible, but the food supply has been cut off and the water pump has stopped working because the man who usually maintains it was taken away in the trucks. The baby is really sick and I can’t feed him. At night they come into the village and make us line up and choose which of the women they want...Every night Subin is picked....I curse myself for making such a beautiful daughter as I hear her screaming from the other side of the village. I had a husband, a daughter and 3 sons...I just want our lives back. My name is Fatimah*.

Tahir represents many lives that are being played out by young boys and men all over the world. They are often torn from their families against their will by captors that use brutal force on anybody that does not obey them. Fighters like Tahir suffer from psychological conditions caused by the traumatic conditions that they are forced to fight in and their inexperience means that there is a high death rate during fire fights. They often sustain injuries from shrapnel and also suffer from malnutrition, dehydration and from the mistreatment that they receive from the army leaders. MSF work without prejudice for what side the fighters represent, how old they are or whether they were fighting by choice or not. In order to treat them, MSF often has to move into the midst of conflict areas and work in extremely difficult conditions. In doing this, MSF workers risk their own lives to try to reduce the suffering of the young men and boys who fight in these areas.


Page 21

The women and children who are left behind in war torn areas live in constant fear for their lives and the lives of their men. The women are at risk of becoming victims of violence and rape and it is not uncommon for mothers and daughters to be mistreated in the same room with younger siblings crying next to them. Women who find themselves pregnant from these acts face further violence and are often put to death. MSF workers help them by treating any injuries that they have sustained, counselling them and assisting them through their pregnancy. Women who have been raped often need urgent medical attention and they will describe the pain and the horror of their experience.

“I was lying on my

front and watching

my best friend be shot down by about twenty

different rifles...” The MSF report “Shattered Lives” describes some of the ways that MSF offers assistance to rape victims; by treating injuries, bearing witness to the atrocities of war and working to reduce the longer lasting psychological effects. By working directly with the women in their villages MSF helps to empower them and allows them to regain their dignity and their lives. The children often do not understand everything that they witness, but the shock of seeing their family mistreated as well as any physical injuries/illnesses that they might sustain (through

violence, malnutrition, poor sanitation or drinking dirty water) can often leave them scarred for life. MSF bears witness to their suffering and acts to ensure that they have access to clean water, food and treatment. MSF logisticians work to alleviate the problems caused by food insecurity whilst water and sanitation engineers make sure that people coming to MSF camps have access to clean, safe drinking water. Physical injuries are treated by MSF doctors and nurses using a system of triage to ensure that resources are allocated according to need. Field psychologists and counsellors try to alleviate the psychological damage created by the conflict by allowing people to discuss the trauma that they have experienced with an unbiased professional. MSF also hopes to make a difference to people living in conflict zones by bearing witness to these atrocities so that they can stand up to the injustice done to the local people. This is why the advocacy campaigns run by MSF are so important and make the organisation stand out against other aid agencies. Sudan is one of the conflict zones where MSF workers are currently deployed and they are one of the few aid agencies with a presence in the county Leer (Unity State) which lies close to the contested north/ south border near the oil fields. Food security in this area is a massive problem and there is a constant threat of cattle raiding and resistance fighting. In the Warrap state the town of Abyei saw heavy clashes in May of this year causing the people to flee to the south. They often walked for up to 12 days to reach the town of Agok where MSF has a secondary healthcare centre. MSF teams distributed hundreds of non-food items to provide shelter and

“He slapped me so hard that I

collapsed on the ground and

started to weep” comfort to all the displaced people and responded by increasing the medical provision in the area. They also run mobile teams to access more remote villages and make shift camps. In conflict situations MSF has to prioritise access to clean water and food, performing life-saving surgeries and providing reproductive and child health care. This can be difficult to do when it means denying help to so many people as part of the triage process. In conflict zones there is always more that needs to be done but never the resources available to do it...It is conflicted medicine.

Tamsin Smith, Open University

Post-graduate,

Notes: *The characters in this article are fictional, but their stories are real. If you would like more information about the struggle of children in conflicts then you should consider reading War Child: A Child Soldier's Story by Emmanuel Jal. If you would like an insider view point of working for MSF in conflict areas then you should consider reading The Photographer: Into War-torn Afghanistan with Doctors Without Borders by Emmanuel Guibert.


Page 22

Violence and indignity: victims of immigration policy Introduction Every year, tens of thousands of sub-Saharan Africans attempt unofficial migration into Europe. Most of those attempting the journey pass through Morocco, Tunisia and Algeria, on their way to the Mediterranean. Stricter border controls however, introduced by EU member states, have resulted in a growing population of sub-Saharan migrants (SSMs) stranded in these “transit countries”. This tightening up of border control has also prompted migrants to embark on longer, more dangerous journeys and has increased the numbers being held in detention centres. Over the last decade, MSF have carried out surveys documenting the destructive consequences of ill-equipped border control facilities on the health of migrants. Additionally, MSF has also established programmes to provide equal and sustainable

medical care to this neglected demographic. Perilous paths of migration The majority of SSMs embark on precarious journeys from their country of origin to the North African coast before crossing the Mediterranean Sea. These journeys involve long periods of travel in the back of pickup trucks where migrants are deprived of food, water and sleep. Migrants are also vulnerable to violent attacks and robberies by trafficking networks. A recent MSF census found that 39% of migrants interviewed had suffered some form of violence.1 This is particularly prominent amongst women and young girls who are often victims of sexual violence. An MSF investigation into the violent border between Algeria and Morocco found that over half of the women interviewed had been the victim of sexual attacks, sometimes carried out by military personnel (see box 1). During the 2009 MSF project in Morocco, 14% of medical consultations were for injuries sustained during violent attacks.1 Victims of sexual violence also presented with psychological complaints including anxiety; insomnia; depression; strong feelings of guilt and shame as well as suicidal thoughts. In an attempt to tackle unofficial immigration, the EU established the border control agency ‘Frontex’ in 2004. As a result of coordinated patrols involving Italy, Greece and Malta, smuggling networks have resorted to undertaking increasingly dangerous journeys to avoid detection. These involve the use of smaller boats in which

Box 1 - Taken from MSF: Sexual Violence and Migration: The hidden reality of Sub-Saharan women trapped in Morocco en route to Europe. March 2010. 14 year old girl AA was flown by a family friend to Casablanca and then to Paris where they were turned away at the airport Morocco.

After being woman who was sent to Oujda. That

and

deported

to

separated from the accompanied her, AA the police station in same night she was

deported to the border with 15 other SSMs of various nationalities. She was the only woman in the group and the only minor.

Four policemen with dogs drove them to a place in the middle of the desert. Then two policemen took AA aside. As she explains, they told her to lift up her clothes and when she said no, a “soldier” slapped her and threw her onto the ground. The other grabbed her arms while they took her clothes off. After raping her, the policemen picked her up off the ground and brought her back to the rest of the migrants and the other two policemen who guarded them.


Page 23

Box 2 - Human Rights Watch: The EU’s Dirty September, 20114

Hands.

14-year-old boy, detention camp in Fylakio, Greece: I have been here 26 days, after I came from Turkey. For three days in the beginning I was sleeping on the floor. Now I'm sharing a bed with another five people: a Somali, a Bangladeshi, an Afghani, an Egyptian, and one other Eritrean. We use the bed in shifts, which means that some use the bed during the day and others during the night. In general, we are 83 people in a room with 30 beds”.

migrants are subject to overcrowding and greater risk of sinking. It has been estimated that at least 14,921 people have died at Europe’s borders since 1998, of which 10,925 deaths occurred at sea2 Living Conditions in Detention Centres There has also been a rise in the number of transit migrants being placed in detention centres. In Greece unofficial migrants are systematically detained upon arrival and can be detained for six to twelve months until deportation is organised.7 These detainees are often forced to endure living conditions that are detrimental to their mental and physical health, further exacerbated by inadequate access to medical attention. Appalling

conditions

were

identified in the 2010 MSF report following visits to three detention centres in Greece.3 The following concerns were documented and raised with the authorities: - Overcrowding - Lack of natural light or fresh air Inadequate heating/cooling systems resulting in extremely hot or cold temperatures - Insufficient quantity and quality of food - Insufficient supplies of baby milk and infant food - Insufficient numbers of latrines and showers leading to overuse and flooding - Poor quality of water - Lack of electricity - Inadequate sanitary items - Lack of clothing and shoes These conditions have contributed to medical issues from dermatological infections such as scabies to viral infections such as measles and upper respiratory tract infections. Furthermore, detainees are often separated from family members which impacts on mental health. MSF psychologists observed: posttraumatic stress disorder; symptoms of anxiety (such as constant worry, fear, panic) and depression (such as sadness, hopelessness and self-harm) (box 3). Reports estimate that 4500 SSMs are living displaced in Morocco.1 The health inequalities associated with this population are summarised in figure 1. Police raids in Moroccan border zones frequently leave migrants including: pregnant women; children and those with medical conditions. They are subsequently stranded without shelter, food or

Migrants in Detention: Lives on Hold. June 2010.

water. The organisation Fondazione ISMU estimates that 422,000 unofficial migrants live in Italy.5 Often migrants travel to Italy in the hope of finding work as fruit pickers. More than 2000 pickers are housed in abandoned factories without any basic facilities such as

Box 3 – taken from MSF: Migrants in Detention: Lives on Hold. June 2010.3 16 year old boy: “People will get crazy in here. We have not killed anybody. We have not robbed anybody. Why are we kept in prison? I have been here for 10 days and I find life going backwards. I want my life to go forward. Here the only thing I can do is think and sleep. I do not want to think of my life. It upsets me and I might hurt myself or others. If I have to stay in here much longer I will do something bad to myself”.


Page 24

lavatories, running water, food or sleeping space.6 These conditions have added to the insurgence of respiratory disease, malnutrition, musculoskeletal problems and gastroenteritis. MSF Missions in tackling health inequalities amongst subSaharan Migrants. Morocco MSF began working with SSMs in Morocco in 2000 where their objectives were:

Provision of direct medical care

Facilitation of access to the Moroccan health system

They have carried out several healthcare projects in: Tangier; Casablanca; Rabat and Oujda. MSF carried out 27,431 consultations between 2003 and 2009. Over 7,500 people were also accompanied and referred to Moroccan health facilities as MSF worked in close collaboration with the country’s Ministry of Health.1

influxes as a result of the recent upsurge of violence in Syria. Conclusion Despite successes in distributing healthcare to this population, MSF has stressed the significance of EU member states recognising the poor international standards with which these detention centres are operated. Authorities should be urged to assess the direct impact of detention on migrants and acknowledge the importance of seeking alternatives to the detention of new arrivals. In the light of recent events unfolding across the Middle-East and North Africa, immigration is likely to remain a pressing issue for years to come. NGOs, international bodies and national governments need to work collaboratively to ensure that the welfare of migrant populations is protected.

Natasha Palipane, 2nd year medical student, University College, London

1.

2.

3. 4.

5. 6.

7.

MSF, 2010: The hidden reality of Sub-Saharan women trapped in Morocco en route to Europe. Fortress Europe: L’ Osservatorio sulle Vittime dell’ Emigrazione, http:// fortresseurope.blogspot.com/ 2006/02/immigrants-dead-atfrontiers-of-europe_16.html MSF, 2010: Migrants in Detention: Lives on Hold. Human Rights Watch: The EU’s Dirty Hands. September, 2011. Interview S-19, Fylakio, December 1, 2010. www.msf.org.uk/italy.focus MSF, 2005: Survey on life and health conditions of foreign workers employed in the Italian agriculture. Article 76 of Migration Law 3386/2005: Entry, stay and social inclusion of third country nationals in Greek territory, amended by article 48 of Law 3772/09 which extended the period of detention from up to 3 to up to 12 months.

Italy In Italy, MSF has set up 35 clinics in six regions to provide health and psychological care to unofficial migrants.5 These clinics are gradually being handed over to local health authorities. MSF also distributed 1500 hygienic kits containing a sleeping bag, soap, dental floss, toothbrushes and toothpaste to citrus pickers in Puglia and Calabria.6 Others Their work on tackling healthcare exclusion in the sub-Saharan migrant population extends to Malta and Greece (where MSF have been working since 1996). MSF have also resumed activity in two additional regions of Greece (Evros and Rodopi) following recent

Figure 1 – Main pathologies among patients attended by MSF in 2009. Taken from MSF: Sexual Violence and Migration.1


Page 25

Film Review - Hotel Rwanda otel Rwanda, starring Don Cheadle, encapsulates the sheer brutality of genocide and war. Terry George’s film is set against the backdrop of the HutuTutsi conflict that ravaged the small east-African nation in the 1990s. Here, a combination of exacerbated ethnic tensions, coupled with an arbitrary class system, led to the outbreak of civil war in 1994 between opposing tribes.

H

The film documents the actions of the assistant hotel manager and Hutu Paul Rusesabagina (Don Cheadle) who forms one half of a mixed ethnic marriage with a Tutsi wife, played brilliantly by Sophie Okonedo. Rusesabagina is an astute and successful businessman; however the outbreak of civil war not only dampens his financial stability, but also brings into focus the terrifying reality of the systemic slaughter of 80,000 Tutsis in less than 100 days of conflict. Cheadle channels the emotions of a man who realises that in the face of such stark brutality, wealth, fortune and social status are all subordinate to humanitarianism. His character draws on his resources to shelter Tutsi and Hutu refugees in the Hotel des Mille Collines, preserving over 1,200 lives. The film deserves its talented supporting cast, including actor Nick Nolte who plays UN Colonel Oliver, and Joaquin Phoenix as American journalist J a c k Daglish. T h e s e characters highlight the failed diplomacy that blighted the Rwandan conflict as foreign nations trod upon political eggshells and adopted a passive response to the genocide that resulted in near 1,000,000 deaths. Small contingents of UN peacekeepers were unable to exert any intervening force as the savagery raved, and whilst Daglish

captures the explicit brutality on camera, it is in the knowledge that it will not receive the global coverage it warrants in the western media.

“The West. All the super powers.

Everything you

believe in, Paul. They

think you’re dirt.

They think you’re dumb. You’re worthless.”

Colonel Oliver - Hotel Rwanda All In all Hotel Rwanda is an important, well-crafted and viscerally emotional film. This engrossing and uplifting tale exposes the harsh reality of conflict, hatred and terror and shows how, despite this, the bravery of one individual shines through. Indeed, it is an educational must-see and it is sobering to think that the conflict occurred within our own lifetime – a mere seventeen years ago. The film serves as a warning: an example as how humanity must not turn a blind eye nor adopt a passive approach to such harrowing and inhumane conflict. Maria McAlary, 3rd year medical student, Queen’s University, Belfast


Page 26

HIV Treatment: 10 years in Mozambique (2001-2011) 80% of the 17.5million children who

have lost at least one parent to AIDs live in sub-Saharan Africa which is a far cry from the 6th Millennium Development Goal 6 (Combat HIV/AIDs)1. Tuberculosis (TB) is the main reason that people with HIV die and over a quarter of HIV patients are co-infected with this disease2. Co-infection is particularly prevalent in subSaharan Africa with nearly 60% of HIV patients in Mozambique having TB. These statistics place the work of MSF in sub-Saharan Africa into a global perspective and illustrate the depth of the HIV problem in Mozambique

“Approximately 18% of pregnant women in Mozambique are infected with aids.” Take the case of Mozambique – a country with a crippling healthcare system; a country without the capacity to treat such a large burden of HIV patients. MSF has been assisting by treating HIV patients in Mozambique for the last 10 years where MSF has standardised the treatment for HIV and TB. MSF provides multiple HIV clinics in rural areas where people have little access to hospitals and these clinics have acted to re-focus treatment from central hospitals into areas where it is more accessible. By training specialist HIV nurses, MSF workers are able to reduce the burden on

Mozambique’s limited number of doctors and extra drugs are provided to existing Mozambique clinics that struggle to access HIV medication. In this way MSF’s HIV projects cater for the range of treatment from the point of testing through to palliative care. One of the major hurdles of encouraging people to be tested for HIV is the stigma associated with being tested and being HIVpositive. To try to overcome this, MSF encourages everybody to get tested no matter what their risk factor is. This means that many more people need to be tested and increases the cost of the project, but ensures that everyone at risk is screened. The earlier HIV is diagnosed, the earlier MSF can begin treatment and the longer the patient will live. If you lived in Mozambique, the first time you came across MSF might be through a talk given about HIV testing. You would sit in a room with a number of your neighbours and a local man would announce that he is HIV positive. MSF employs local HIV positive people to give talks to encourage other people to be tested for HIV. These workers are instrumental in reducing the stigma associated with being HIV positive and they demonstrate how people taking ARVs can live long and healthy lives. MSF treat HIV patients using a combination of different drugs known as anti-retroviral (ARV) drugs. These act to support the immune system (which is attacked during HIV) and therefore allow HIV patients to live longer. In 2010, 33000

of the 200000 HIV patients being treated with ARVs in Mozambique were being treated with the assistance of MSF. The correct administration of ARVs has been shown to decrease the rate of viral infection and reduce mother-tochild transmission during pregnancy and breastfeeding. The treatment of HIV with ARV ties in with the education campaigns and outreach programs run by MSF to ensure that patients understand how to take their medication effectively. If you decided to go ahead and be tested for HIV you would probably first face a long queue to visit your nearest clinic, then be seen by an MSF mental health worker who would provide you with pre-testing counselling. This would prepare you for the outcome of your test and inform you of all the resources that are available. A nurse would take a sample of your blood and pass it onto one of the MSF microbiologists who would test your blood for the HIV virus. The microbiologists look for HIV antibodies in the blood as these confirm the presence of HIV. However, there is a window period of three weeks to six months when a patient may be infected with HIV


Page 27

but their body may not have started producing anti-bodies to the virus. False negative results can give patients false security in their HIV status and consequently encourage the unknown spread of the infection. To try to counter act this, MSF runs parallel education and outreach programs to try to encourage behaviours that reduce the spread of HIV (such as wearing condoms and reducing blood contamination).

patients” - you would be able to ask an HIV-positive local any questions on your mind. Newly diagnosed patients are often most worried about how they will be able to keep their jobs and how their lives will change once they start taking ARVs. The use of expert patients allow such patients to have a conversation with someone that they can more easily relate to and to see the advantages of taking ARVs.

If you were HIV-positive you would be given post-test counselling to reduce your risk of mental health difficulties arising from the shock of the diagnosis. You would also be given further instruction on how to prevent passing on your virus (especially if you were pregnant). In sub-Saharan Africa most children with HIV were infected during birth or breastfeeding and approximately 18% of pregnant women in Mozambique are 3 infected with aids . It is especially important for HIV positive women to understand how to reduce the spread of the infection to their children as children can experience a much quicker immune system decline during infection. Many children infected at birth will die before the age of five4.

A good example of the relationship between MSF education programs and medical projects is the work currently being carried out in Tete (a rural province in Mozambique) where MSF has set up a community ARV group. These community groups empower HIV patients to take control of their own treatment and work together to reduce the spread of the disease and lift the stigmas associated with being HIV positive. If you were a part of one of these community groups you would be able to reduce the costs associated with travelling to the clinic by allowing a group representative to pick up the drugs for the entire group once a month. This reduces the amount of time taken off work and the number of people queuing for the limited health clinic resources.

Receiving medication, Maputo.

You might be lucky enough to be at a clinic where MSF uses “expert-

Since 2001 MSF has seen an increase in the number of people prescribed ARVs in Mozambique, however a large proportion of this increase is due to the work of the outreach programs. Of the 1.4 million people in Mozambique who are HIVpositive, 650,000 need ARV treatment, but only 250,000 currently have access to it. MSF are committed to improving this statistic by continuing to create HIV health clinics in the less accessible rural communities of Mozambique and increasing the areas covered by the outreach programs. One of the main challenges of the MSF HIV

Patients waiting to see health care workers in Tete

projects in Mozambique is the short fall in qualified medical staff and MSF workers report seeing patients that have waited in queues for up to six hours. MSF is currently campaigning to allow nurses to prescribe ARV drugs for uncomplicated cases. In addition, MSF’s “Access to Medicine” campaign is hoped to increase Ministry of Health’s budget for the HIV drugs.

Tamsin Smith, Postgraduate, Open University Notes If you are interested in reading more about the work of MSF in Mozambique, look at http:// www.msf.org.uk/mozambique.focus and read the MSF report from 18th May 2007 “Help Wanted: Confronting the health care worker crisis to expand access to HIV/AIDS treatment” that can be downloaded at: http://www.msf.org.uk/ f o c u s i n d e p t h.a s p x?i d=2c77968ec952-49ea-92f3-76340566278d. http://www.un.org/millenniumgoals/ pdf/MDG_FS_6_EN.pdf 2 http://www.who.int/tb/publications/ TBHIV_Facts_for_2011.pdf 3 http://www.msf.org.uk/ mozambique_HIV_article_20110315.ne ws 4 http://www.unicef.org/media/ media_23419.html 1


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AIDS: The synergy of prevention and treatment Facts and Figures With its discovery almost 30 years ago, Acquired Immune Deficiency Syndrome (AIDS) has made its reputation in countries across the globe. Along with this, the number of deaths and the number of new patients being infected with it is are also on the rise. Despite the fact that there have been many medical and scientific advances, the number of deaths related to AIDS continues to rise, and has surpassed the millions1. Even with the help of several major organizations to raise the global funding against AIDS from US$2.1 billion in 2001 to US$6.1 billion in 2004 (just to name a few: “The World Health Organization (WHO), The US President’s Emergency Plan, and The Global Fund to Fight AIDS, Tuberculosis, and Malaria”), the battle continues as around 95% of preventative treatment does not reach individuals who actually need it1. As discussed in this article, the battle against AIDS not only includes money for testing/ research purposes (as this is a misconception), but also needs education for prevention. As the saying goes, the rest will follow. Prevention or Treatment? Like most things in life, balance is ideal, and the balance between prevention and treatment of AIDS is no different. There are many things to think about when determining where the partition of prevention efforts and treatment efforts begin or end. “Which drugs will be used? How much will it cost? How will their quality be monitored and assured? How much will it cost to produce and ship? How will they be distributed?”2

To many, these two points are seen independent of one another. However, the truth is that prevention and treatment are mutually exclusive with one another. Preventative efforts include the likes of counselling and testing for diseases or changing of behaviour. Effective prevention methods can lead to a reduction in the number of new infections arising, and will ultimately lead to a decrease in the number of people needing treatment3. At the same time, with this decrease in the number of people needing treatment, the costs to produce these drugs can be cut down. The chain reaction does not stop there; with the costs to produce the drugs being lessened, the cost of drugs on shelves can be cut down as well. This can all happen with just counselling and changing the behaviour of individuals towards the disease. Raising awareness can be more effective than people think. However, it cannot be that simple, of course. People need to be able to have access to these counselling stations and/or testing stations. Improving the accessibility to HIV/ AIDS testing provides people with an entry point into the prevention and treatment services. Without these stations, people cannot determine whether or not they have the disease. Without determining who has the disease, the correct measures to combat the disease cannot be taken. Similarly, antiretroviral therapy (ART) can help prevention efforts by reducing the “stigma associated with selfeducation and responsible 2 behaviour” .

“95% of preventative treatment does not

reach individuals

who actually need it.”

Conclusion Both preventative programs and treatment care have a synergistic effect as they do not compete with one another, but rather help each other be more effective. The truth of the matter is that the combat against AIDS is not a localised battle, and it affects each and every one of us in some way or form. Money is not the only tool we have to use in this battle against AIDS; we have a voice, whether that voice is vocal or written. Use it. Spread the word. Spread the knowledge.

Aven Sidhu, 1st year student, Royal College of Surgeons (IrelandBahrain) 1 Cameron,

D.W, 2006: Twenty-five years of AIDS. Canadain Medical Association Journal, 175(3), 225 2 Lamptey P, Wilson D, 2005: Scaling up AIDS treatment: What is the potential impact and what are the risks? PLoS Medicine 2(2): e39, 102-104 3 Smith, R.j., Li, J., Gordon, R., & Heffernan, J.M.,2009: Can we spend our way out of the AIDS epidemic? A world halting AIDS model. BMC Public Health. 9(Suppl 1):S15.


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Success story: MSF’s HIV/AIDS project in Cambodia History of Cambodia and MSF Healthcare From the magnificent Kingdom of Angkor to the ruthless Khmer Rouge of the Pol Pot Regime, Cambodia has a long and rich history. Watching the sunrise over the Angkor Wat Temples is said to be one of the most breathtakingly beautiful sites in the world. Tourists travel from across the globe to experience the wonders of the Tonle Sap lake ‘the sinners paradise’ where fishing is a way of life and the floating villages lay home to a bright eyed smiles and close knit communities, hardly an image which depicts a country with a history of outside occupation, civil conflict and mass genocide. Today the country is still recovering from decades of war & political instability but has made great steps towards recovery and peace. Slowly but surely, the country is trying to tackle its many problems, one of the main concerns being health. Since 1991 the country has been free from civil unrest and some economic growth has occurred. However, whilst the Cambodian government is trying hard to find ways of improving the health situation, the country is still relying heavily on provision of aid from outside NGOs such as MSF.1, 2

The 17th of April 1975 marked the end of five years of civil war in Cambodia but this by no means meant peace. This was the day that the Khmer Rouge gained power. To the civilians, this meant that there would finally be peace in Cambodia; however, celebrations were short-lived as the victorious Khmer Soldiers started ordering people to leave their homes for the country side with the threat of the American’s bombing the city. This was simply a way in which to get people into the countryside to carry out the plans of ‘Saloth Sar’, better known to the world as ‘Pol Pot’, in which everyone was to be made peasant’s and they would try to recreate the country’s history from scratch - year zero. The Khmer Rouge were ruthless, murdering anyone who stood against the regime. People started to flee the country in order to escape execution and starvation1. They took refuge in Thailand and this is when MSF started providing healthcare to the people of Cambodia. In 1975 MSF set up its first ever large scale medical programme in the refugee camps for those fleeing the ‘Pol Pot’ regime to Thailand6. Whilst MSF was involved in the emergency provision of healthcare

Angkor Wat Temple Cambodia

Pol Pot genocide

in the refugee camps, it has continued to provide health care and remains in Cambodia today. This has not been easy and in 1980, the Vietnamese authorities tried to stop MSF bringing aid to Cambodia, leading to MSF’s first international appeal - the ‘Walk of Survival for Cambodia’ in which they protested against the actions of Vietnam6. Long term provision of relief by MSF started in 1989 with the aim of helping to reconstruct Cambodia’s own healthcare system and provide long-term care for those affected by the revolution6,7. HIV and AIDS in Cambodia Today, Cambodia is trying to leave its past behind and tackle the problems left by the destruction of the Khmer Rouge. There are many problems due to lack of adequate provision of healthcare and resulting from poverty and mental health problems inflicted by the country’s past including that of HIV. Around 160,000 Cambodians live with HIV/AIDS and the incidence of the general population was estimated to be 2.6%3. In 2005 the ‘Cambodian Demographic Health Survey’ was carried out, which investigated the HIV status of the population through household surveys using methods that were released by the ‘National Institute

MSF aid - Cambodia


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of statistics, ministry of planning in 2007’4. This showed a national HIV prevalence among 15-49 year olds of 0.6%4. This study also found demographic differences in prevalence- those living in urban areas had a higher prevalence than those in rural areas. Furthermore, there are several high risk groups. There are an estimated 100,000 sex workers within Cambodia and 18,000 in Phnom Penh alone3. This large sex industry is a reflection of the poverty created by past conflict, many women and girls being forced into the industry as the only means of providing for their family. The prevalence of HIV and AIDS among sex workers is much higher than the general population due to spread through sexual contact and increased rates of use of injectable drugs such as heroin and needle share3,6. These behaviours, coupled with a lack of education about HIV and its prevention, significantly contributes to transmission among Sex Workers and their clients6. Other high risk groups include illicit drug users and those in Prisons. The use of illicit drugs is high, perhaps due to mental health problems left by years of conflict. Furthermore many crimes are acts of poverty with increases in crimes such as armed robbery. An MSF

5

‘Cambodia 2008 update’

survey reported a prevalence of 3% in Phnom Pehn prisons compared with 0.6% in the general population. Whilst treatment is being provided, a huge emphasis has been placed on the importance of tackling the underlying problem7. Cambodia’s HIV/AID Treatment Requirements Met by MSF Cambodia’s healthcare system is still being built up and although there have been some measures taken to tackle HIV infection and transmission; this has been slow due to lack of funds and education. Access to antiretroviral therapy (ART) is mostly confined to those living in the capital. The Cambodian government reports that less than 3% of people with HIV/AIDS actually receive antiretroviral therapy3, since access is limited by cost. The Geneva Report of 1997–2004 estimates that it would cost as much as 7% of Cambodia’s gross national product to support AIDS drugs for all Cambodians with HIV/AIDS3. It has also been suggested that there is a proportion of people living with HIV who are unaware that they are infected and uninformed about testing. A number of programmes have been put in place to reduce transmission rates and increase the time it takes for the virus to progress to AIDS. Education is key in the prevention of transmission, particularly in high risk groups. Success has been made in increasing the use of condoms by sex workers in certain provinces. However, to allow Cambodia to reconstruct its own healthcare s y s t e m , continuation of

“Less than 3% of people with HIV/AIDS actually receive antiretroviral therapy” education and training given to local endogenous healthcare workers must continue beyond the end of NGO projects to ensure future sustainability and continuation of care. In 2001 MSF started providing ART to the Cambodian people. They carried out comprehensive testing, counselling and treatment for HIV in Phnom Pehn prisons as well as providing general healthcare. MSF’s HIV programme in Cambodia came to an end in 2010 but MSF ensured continuation of care by handing over the work to the infectious disease department of the KhmerSoviet Friendship hospital7.

Emma Nash, 4th year medical student, University if East Anglia References 1Delivering

Aid Differently, Lessons From the Field; W Fengler, H Kharas, 2010. 2Pol Pot, The History of a Nightmare; Philip Short, 2004. 3The Lancet, Vol 5, October 2005: J S Soothill, P E Lock; The HIV/ AIDS epidemic in Cambodia, Reflection and Reaction. 4Ministry of Health, National Centre for HIV/ AIDS Dermatology and STDs; HIV estimates and projections- Cambodia 2006-2012; Surveillance Unit, Phnom Pehn, 25-29 June 2007. 5WHO, UNAIDS, UNICEF; Epidemiological Fact Sheet- HIV and AIDS, 2008. 6Ministry of Health, National Centre for HIV/ AIDS, Dermatology and STDs; Report on HIV Sentinel Surveillance in Cambodia 2006, USaid, 7http://www.msf.org.uk/Timeline.aspx


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Novartis, India: A final stand n 2005, India introduced new patenting laws to meet its obligations as: 1. A member of the World Trade Organization 2. A signatory to the Trade Related aspects of Intellectual Property Rights (TRIPS) Agreement. These new laws extended patent protection of Intellectual Property to both drug substances themselves, and the technology used to produce them.

I

Before 2005, many generics firms sprang up in India, producing cheaper variants of drugs subject to patents elsewhere. A huge number have been used in developing countries and by MSF4. They represent the only way that billions of people can access lifesaving medicines, such as antiretroviral drugs and child formulations2.

India is one of the only developing countries with the capacity to manufacture drugs. Safeguards were subsequently placed within these new laws to protect the healthcare of the poor, including the infamous safeguarding law: ‘Section 3(d)’, which is the basis of a now 6-year legal battle between the Indian Government; patient groups;

and Novartis, one of the world’s largest pharmaceutical companies. Section 3(d) protects against ‘evergreening’: the release of new variants of old essential drugs, which allows pharmaceutical companies to gain 20 year monopolies over drug production and subsequent prices. Section 3(d) requires that a new drug must show a marked improvement in efficacy to be eligible for a new patent: something that Glivec, Novartis’s lifesaving drug used to treat chronic myeloid leukemia, does not. And so in 2006, Novartis took legal action against the Indian government on two accounts: 1. To change Section 3(d) 2. To appeal against the rejection of a new Glivec patent. Novartis claimed that this safeguarding law does not comply with the TRIPS Agreement and fought for ‘efficacy’ to be redefined in such a way that would render Glivec eligible4. Novartis also argued that the production of cheaper generics would do little to improve access for the poor, as the annual cost of these drugs would still be higher than the average Indian salary. They also argued that innovation and progress depend on financial rewards for the 3 development of new drugs . Unfortunately, innovation by the pharmaceutical industry is marketled, to meet the consumer demands and incomes of the developed world. Defiantly 2007 and 2009 saw the rejection of both claims, by the High Court in Chennai. This year however, Novartis began a new case, this time with the Supreme

“Novartis is trying to straightjacket Indian patent offices. It wants to stop them from being able to reject patents on new forms of old medicines that show little improved therapeutic efficacy,”

- Leena Menghaney, MSF Access Campaign Court of India, once more to weaken the meaning of Section 3(d) 1. The gravity of this case is great; a triumph for Novartis’s Glivec will be a triumph for many other such cases in the future, forcing many generics manufacturers to stop production. The impact on India and swathes of people in other developing nations will be huge. The next court hearing will take place on 17th January 2012.

Orchid Vishkaiy, 3rd year Human Sciences student, University College London References 1http://www.msfaccess.org/about-us/

media-room/press-releases/drugcompany-novartis-tries-weaken-indianpatent-law-protects 2http://www.actnow.com.au/Issues/ Access_to_essential_medicines__the_N ovartis_case.aspx 3http://www.swissinfo.ch/eng/Home/ Archive/ NGOs_attack_Novartis_over_drug_acce ss.html?cid=5499608 4http://www.doctorswithoutborders.org/ press/release.cfm?id=1870


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Malaria vaccine trial gives hope very year, over 3 billion people are exposed to malaria, with 225 million cases of the disease and around 800,000 deaths, found mainly in children in sub-Saharan Africa;1 in fact, malaria kills an African child every 30 seconds2.

said Andrew Witty, Chief Executive at GSK, whose company has already spent $300 million on the vaccine, with an additional $200 million grant from the Bill and Melinda Gates Foundation6. Witty said that he was thrilled for the scientists, who were thought by many of their peers to A malaria vaccine trial involving be attempting the impossible when 15,460 babies and small children3 they started working on the has shown extremely promising vaccine. “When the team was first initial results, raising hope of a shown the data, quite a number of breakthrough in the fight against them broke down in tears7", he said. the mosquito-borne tropical GSK has pledged to keep costs to disease. The first of three studies, an absolute minimum and will be which are being conducted across 7 selling the vaccine at a fraction over African countries, shows that the production cost, with the overage prototype vaccine named ‘RTS,S’ going back into research into dramatically decreases the chances tropical diseases8. of children contracting malaria. The trail involves two age groups: However, the trail is not yet over. It newborns aged 6-12 weeks, and is scheduled to continue through to babies aged 5-17 months3. The first 2014, when scientists will then know study results from the elder age the outcome of the third and final group have shown that on receiving trial, which will show how well the the vaccine, the baby’s risk of protection of the vaccine lasts, and contracting the disease decreases whether it wanes over time4. The by 55%, compared to babies who World Health Organization has said received the placebo1. The second that if the results are satisfactory, it study examines the outcome from will recommend its use and the the vaccinations amongst vaccine may be rolled out as early newborns, and will be published as 20151. If so, the vaccine will be the next year; early small-scale tests on first of its kind, with the potential to newborns show very similar protect millions of children who are positive results. affected by such a devastating disease. The British pharmaceutical company GlaxoSmithKline is responsible for developing the nd year vaccine, alongside the non-profit Luke Anthony Johnson, 2 organization PATH Malaria Vaccine Pharmacy student, London School Initiative4, whose mission is to of Pharmacy. develop the malaria vaccine and 1. WHO, 2011: ensure its availability and www.who.int/immunization/ accessibility in the developing newsroom/ world4. ‘RTS,S’ , which has been over newsstory_malaria_vaccine_trial_resu 20 years in the making, is down to lts/en/index.html the collaborative team efforts of 2. WHO, 2009: www.who.int/features/ dozens of scientists across Africa, factfiles/malaria/en/index.html the USA and Europe. ‘It’s an 3. NEJM, 2011: www.nejm.org/doi/full/ incredible scientific achievement5,’ 10.1056/NEJMoa1102287#t=abstract

E

4. GSK Press Release, 2009: www.gsk.com/media/pressreleases/ 2009/2009_pressrelease_10124.htm 5. Briggs, Helen, BBC News Health News, 2011: www.bbc.co.uk/news/health-15358554 6. NY Times, 2011: www.nytimes.com/ 2011/10/24/opinion/two-cheers-for-themalaria-vaccine.html? ref=gatesbillandmelindafoundation 7. Boseley, Sarah, The Guardian, 2011: www.guardian.co.uk/society/2011/oct/ 18/malaria-vaccine-save-millionschildren 8. GSK, 2011: www.gsk.com/media/downloads/ malaria-vaccine-phaseIII-factsheetSep-2011.pdf


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Pushed for pills - bridging the gap

between human rights and essential medicines

C

ontroversy rages around an emerging ill-defined human right: universal access to lifesaving drugs. While in the UK death via a preventable disease seems medieval, the global reality is “at least one third of the world's populations have no regular access to medicines” (The World Medicines Situation 2011, WHO). The first finger of blame is always pointed at the hugely wealthy and influential pharmaceutical companies – giants like GlaxoSmithKline, Pfizer and Johnson & Johnson. These multinationals invest millions every year into researching and developing medicines, which they then defend with an equally hefty legal framework of patents. The upshot of this: monopolies on drugs with the potential to save countless lives lies solely in the hands of organisations whose primary raison d'être resides in shareholder value and profit margins. The real issue is whether the right medicines, at appropriate prices for the individual economic area in question, can be sourced to where they are most needed. World Health Organisation data for medicine access in the world’s poorest countries suggests that this is far from the case – in 2004, only 20% on average of essential medicines were publicly available in Uganda, and in Ghana this figure was 17.9%. Many other countries face similarly low statistics, with pharmaceutical companies blamed for pricing developing countries out of the market. Companies have also been widely criticised for pouring vast sums into marketing their products – often in excess of research and development budgets. When such medicines

represent only marginal improvement on current drugs, those outside the industry accuse corporations of p u t t i n g capitalism before ethics. Another misuse of money accusation is funding political campaigns: Tea Party candidates by Bayer in 2010 for example, and i n d u s t r y donations to both Obama and McCain. Critics argue that the same money could be channelled into developing vital medicines – companies protest that activities like marketing are essential business management, without which new drugs research would be impossible. And despite charitable donations of drugs by companies like Johnson & Johnson, many feel this is a smokescreen tactic to avoid more meaningful action in the third world. Action like lowering prices, relaxing intellectual property (IP) rights so cheap substitutes can be made and producing more medicines for less profitable diseases. So, are pharmaceutical companies businesses like any other, with market competition to consider above charity, or is it right that we should expect more of them? One issue key issue in this debate is the appallingly high mortality figures for treatable diseases in the third world – many of which remain neglected simply because they do not represent a profitable enough market.

“At least one third of the world's

populations have

no regular access to medicines.”

The World Medicines Situation 2011, WHO


Page 34

However, the companies themselves often claim they are being unfairly labelled as the sole culprits for a complex issue in international development. A recent report by the pharmaceutical company Novartis, in 2008 suggested that not enough consideration was given to “misdirected governmental resources and poor health infrastructure as the basic problem of access to health” in some of the world’s poorest areas. GlaxoSmithKline, currently ranked top for corporate responsibility by the Access to Medicines Index, claims it offers “substantially reduced pricing” for its patented medicines in Least Developed Countries, as well as “tiered pricing for GSK vaccines worldwide”. Not unreasonably they argue the need to make up their profits in more developed economic areas - like Novartis, they point out that drug price reduction “does not by itself guarantee that more patients will be able to access them”.

“In 2004, only 20% on average of

essential medicines were publicly available in

Uganda, and in

Ghana this figure was 17.9%.”

There is also concern that medicines supplied at reduced to rates to one area could then become a focus for wealthier external groups looking for cheap alternatives.

A number of non-governmental organisations (NGOs) like Oxfam and Médecins Sans Frontières have blamed the patent system. Protected globally by the World Trade Organisation's Agreement on Trade Related Aspects of Intellectual Property Rights (TRIPS), they argue this prevents cheap copies of essential medicines being made where they are desperately needed. This view was recently attacked by Paul Herring, head of Corporate Research for Novartis International, who wrote in Nature (2008) that “in the absence of a patent, the only way inventors can protect their inventions is through total secrecy, which is counter to furthering innovation”. He went on to argue that patents were essential for three main reasons: firstly “drug companies can allocate resources to non-profit projects only if they are financially sound”. Secondly, that emerging economies like China and Brazil, where huge divides between the richest and poorest merits tiered pricing, would require “legislation that prohibits copying before patents have expired but that allows generic-drug production after patent expiry”. Herring's more controversial reason was that “therapeutic molecules or pathways that are targeted by drugs for neglected diseases might also be relevant for treating diseases that affect people in more affluent regions”. It is also worth noting that a recently agreed exception to Article 31(f) of the TRIPs Agreement allows countries, even those with no manufacturing capacity themselves, to override intellectual property protection and import generic copies of patented drugs during public health crises. However, when the vast majority of drugs development lies in the commercial sector, unprofitable

“So, are

pharmaceutical

companies businesses like any other, with

market competition to consider above

charity, or is it right

that we should expect more of

them?”

diseases lie neglected. Research into tuberculosis and malaria are inadequately supported by a fragile corner of profitable market, while dengue fever, leishmaniasis and African trypanosomiasis (sleeping sickness) are critically lacking in effective treatments. Outside of the corporate machine, there is some hope in working groups like Drugs for Neglected Diseases Initiative (DNDi). The group was founded in 1999 by Médecins Sans Frontières, with the aim of bringing together international experts to research and develop medicines for neglected diseases. It has today grown to include public sector institutions, as well as the Special Programme for Research and Training in Tropical Diseases (TDR), which is itself contributing to this area. DNDi has programmes running for sleeping sickness, leishmaniasis, malaria, and recently started work into paediatric HIV and heleminth infections. Their work is uncovering promising results, including the fledgling


Page 35

drug fexinidazole sickness.

for

sleeping

Yet even here there is no escaping the influence of the pharmaceutical industry. Get to Chagas disease and leishmaniasis on DNDi's wishlist, and you find that future research hinges on discussion with GlaxoSmthKline, owner of large catalogues of medically promising 'molecular entities'. Yet this could still be a rewarding model for the future, if the right relationships – with governments and pharmaceutical companies - can evolve around such groups. Funding, as ever, will be an issue.

Dr Deogaonkar argues that this is being perpetuated by difficulties in accessing existing systems. These include geographic distances in a poorly connected country. Another is the 'socio-economic' distances in urban areas between the richest and poorest - including “cost of healthcare, social factors such as lack of culturally appropriate services, language/ethnic barriers, and prejudices on the part of providers”.

“Drug price

reduction does not

by itself guarantee

To what extent is medical access, including access to essential medicines, a governments responsibility? WHO's World Medicines Situations 2011 report stated “inequality in access to medicines is part of inequality in health care” and that by “relying on medicine supply through the private sector” governments “ignore the fact that this policy largely excludes the poor and vulnerable from obtaining even the most basic medicines”. The report goes on to say that there is widespread disregard amongst governments for public healthcare as a human right, even amongst those who have ratified international treaties in this regard.

He also highlighted gender differences, explained as how woman's health is often “completely disregarded in many of the south Asian countries”, because they are traditionally subordinate to men and thus “less likely to seek appropriate and early care for disease, whatever the socioeconomic status of family might be”.

India is one example where widespread and gaping differences in socio-economic levels, aggravated by mismanagement of resources, can prevent access to healthcare. A 2004 study in Electronic Journal of Sociology by Dr Milind Deogaonkar claims that “healthcare resources in India though not adequate, are ample”, but that “pre-existing inequalities in the healthcare provisions” cut off the most vulnerable from the treatments they need.

Studies based in third world Africa tend to echo these sentiments. Inappropriate diagnostic and prescribing practices, inefficient public distribution systems and urban hospital bias for drugs (depriving rural health centres and their patients) are established issues in countries like Kenya and Tanzania. And a 2011 report from experts at the Bloomberg School of Public Health (Johns Hopkins University) argues that “government-imposed barriers to

that more patients

will be able to access

them”

professionalism” within countries can translate as “overt restrictions on or bureaucratic hurdles to obtaining” medical supplies as well as “abdication of responsibility to ensure medical training”. Amid the plethora of vehemence that any development issue attracts, perspective and objectivity can start to fade away. If one thing is certain, it is that the problem of essential medicine access is not one-sided. From one perspective, we often ask more of pharmaceutical companies than any normal company, perhaps sometimes at the expense of their survival and profitability. However, from another perspective, they are not normal companies. These companies hold most of the world's medicine production and development in their hands. Perhaps we will have no other choice than to ask, even force, these organisations to take greater responsibility than any other money-making entity. It will then be up to us to better delineate their role internationally; but this should not be used as an excuse for governments to shirk responsibilities that are ultimately

Protest against the Novartis patent, India


Page 36

theirs, or for NGOs to pile disproportionate blame on to a scapegoat.

“This policy largely excludes the poor and vulnerable

from obtaining even

the most basic medicines”

The World Medicines Situation 2011, WHO Hope for the future lies in improving the fragmentary statistics and research into medicine access, as well as its real causes. If an improved framework of international legislation can be built between NGOs, governments and businesses, then perhaps we can begin to move towards this goal. After all, disease and economics will continue to evolve so should these relations. Some Facts and Figures: - The UN High Commissioner for Human Rights has created

indicators of human rights, which include: −the right to housing and shelter; −the right to education; −the right to freedom of expression; −the right to health. Indicators for the right to health centre around five main areas: 1. sexual and reproductive health; 2. child mortality and health care; 3. natural and occupational environment; 4. prevention, treatment and control of diseases; 5. access to health facilities and essential medicines. - WHO publishes an official 'essential medicines' list, which includes everything from basic painkillers right up to infectious diseases treatments and anaesthetics. - 60 countries do not recognize the right to health in their national constitution (The World Medicines Situation 2011, WHO). - Public access to medicines in countries of less than 1,100 GDI per capita (World Bank data, PPP, and WHO statistics): * Democratic Republic of the Congo: 55.7% (2007) * Mali: 81% (2004) * Ethiopia: 52.9% (2004) - Annual global deaths in 2008 according to WHO estimates: *in lower income groups: 39.94 million, of which 13.81 million is due to communicable diseases *in higher income groups: 16.95 million, of which 1.82 million is due to communicable diseases. Top 5 best performing pharmaceutical companies in the Access to Medicines Index 2011: 1.GlaxoSmithKline 2. Merck & Co. Inc. 3. Novartis AG 4. Gilead Sciences 5. Sanofi-Aventis Annual profits alone (i.e., not total

revenue) according 2011 figures: − − −

Fortune

500

Johnson & Johnson: $13,334 million Novartis: $9,794 million Pfizer: $8,257 million

“Healthcare resources in India

though not

adequate, are ample”

Dr Milind Deogaonkar

Anna Friedler, 2nd year Biological Sciences student, Oxford university Find out more on this topic •The Access to Essential Medicines Index: http:// www.accesstomedicineindex.org/ •The WHO - global health, disease and policy: http://www.who.int/en/ •Universities Allied for Essential Medicines http://essentialmedicine.org/ •For relevant statistics, Global Health Observatory Data Repository: http://apps.who.int/ghodata/ •MSF: http://www.msf.org.uk/ access_to_medicines.focus •Drugs for Neglected Diseases initiative: http://www.dndi.org/ •Nature -neglected diseases September 2007 (volume 449). PLoS Medicine, September 2010 -'Are drug companies living up to their human rights responsibilities?'


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“The advocacy done by MSF, and now Friends of MSF, is so important because it allows students and the public to hear the voices of people around the world. It brings out into the light those things that are otherwise unseen, ignored or forgotten.” Peter Siordet Scolding, 5th year medicine, University College London

“Advocacy is crucial as it empowers all on so many different levels - whether it be through their rights, challenging attitudes and misconceptions, and through bringing about control over a whole array of situations.” Shirwa Ali, 3rd year iBsc student, King’s College London

“Advocacy is important because it highlights fundamental issues, spoken on behalf of individuals. It is a tool of equality and righteousness.” Hua Wang, 2nd year, DPhil Chemistry student, Oxford University

“For me, advocacy is all about raising public awareness and giving voice to those with little power and influence, whether the issue be local or global. It allows the public to become more understanding of different peoples' situations and increases funding to particular areas that are underrepresented, making a huge difference to the people who are most vulnerable. “ Parisa Torabi, 1st year medical student, University College London

“There is a vast amount of human suffering in the world and often those who are least able to cope are the most severely affected. Having witnessed some of this suffering firsthand, I feel strongly about bringing these situations into the public eye to increase awareness and to help promote the righting of these wrongs.” “Advocacy is important because it sheds light on issues that were once in the dark. It gives one a voice and allows oneself to take control of something that means a lot to them. Without advocacy we wouldn't be where we are today.” Aven S. Sidhu, Junior Cycle, 1st year, Royal College of Surgeons, Ireland-Bahrain

Emily Brown, GraduateEntry Medicine, 2nd year, Oxford University

“Advocacy and the Insight magazine are important to me personally because it gives myself the opportunity to educate the reader on a wide range of current issues which are affecting people today.” Luke Johnson, 2nd year Pharmacy student, London School of Pharmacy


Page 38

“Through advocacy we can help to ensure that important issues are raised at public and political meetings so that we can develop a link between best practise and implementation. Without this link, agencies (such as MSF) have to work independently in an inefficient and small scale manner and the good work that they do remains unknown.”

“I believe everyone should have access to a decent standard of healthcare regardless of where you happen to be born in the world. There are many reasons why we have not achieved this so far. The work MSF does is an essential bridge for those who need emergency care immediately but without advocacy we will never achieve the broader aim of universal healthcare for all. Advocacy is   hugely important in exposing   all the issues that are holding us   back in this target.”

Tamsin Smith, Postgraduate, Open University Kelly Ameneshoa, 5th year medical student, Imperial College

“Advocacy is important to me because without it successful change cannot be achieved. Through other people advocating MSF and related issues, I have come to realise my interests in this area and hope to make a difference. I feel it is important to give other people that opportunity. It is a small, simple measure that can lead to big changes.” Emma Nash, 4th year medical student, University of East Anglia

“Advocacy provides us with the power to make a difference. Simply by being motivated by a cause we can educate people about the situation, raise awareness, and as part of a larger group, make a change.” Chibuzo Mowete, 3rd year medical student, University College London

“People can't be expected to help if they don't know what is out there and what is going on in the world! The more awareness spread the more people can be stimulated and compelled to contribute. Nothing can start without awareness."

“Without it, I wouldn't know about MSF and Chloe Porter, 3rd year Biomedical Science student, the amazing work they University College London do and so being part of that ensures “To me advocacy that other students enables us to make small but significant get the same opportunity to have changes that in turn engender long term an epiphany like beneficial outcomes I have and change for the future!”   their direction!” Maria McAlary, 3rd year medical  

Katie Barnes, 3rd year iBsc student, Kings College London

student, Queen's University Belfast


Page 39

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Hilary Clinton

James Orbinski - Former President of MSF

little a h laug o t your y r a o w , g a thin find y hat r t o e t y v e o e j te hav f the espi o d t “You u y a o run ch d a y l e p t bi an's ll sim i esm b w i r t T hear .” or: A t o a g l s t n es i e Tra h T mak , i r d Ha ur Daou Darf f o oir Mem

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“What I’ve experienced is that I can’t know the future. I can’t know if anything that I do will change what happens tomorrow. I can’t know with certainty, but what I do know is if I do nothing, nothing will change.”

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“I think one of the reasons I became interested in health and medicine was because of Doctors Without Borders, they ran the clinics in the camp where I was born ... Without them, my mother and I probably wouldn't be here now.” Santa cruz sentinel, Haiti


Page 40

The FoMSF Magazine

This year the FoMSF National Committee are launching “Insight”, a magazine that focuses on MSF’s work around the world and the challenges faced by the world everyday. We are recruiting a team of editors, writers and photographers. If you are interested, email advocacyliaison.fomsf@gmail.com as soon as possible!

INSIGHT Issue 1 - Dec 2011  

The FoMSF Magazine

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