Each month, the HRC Blog features a significant individual or team from the Human Rights community to go under the Spotlight, answering questions put by students from the University of Essex. This month, we feature the team from Médecins Sans Frontières (MSF) UK.
About MSF UK
MSF is an international, medical humanitarian organisation working to save people’s lives in conflict zones, natural disasters and epidemics. Independent, neutral and impartial, MSF aims to alleviate suffering, protect life and restore respect for human rights irrespective of religion or political affiliation. As COVID-19 continues to spread, MSF teams are responding to the pandemic in more than 70 countries where they already have programmes, while opening projects in new countries as required. In Yemen, for example, MSF is supporting the Ministry of Health to run Sanaa’s principal centre to treat coronavirus and is working across the country to support a collapsed health infrastructure during what the UN has described as the world’s worst humanitarian crisis.
Students’ Questions Answered
The students at Essex are really excited to have the opportunity to send in their questions to the team at MSF, to learn more about their humanitarian work and some of the challenges they face, particularly during this year of the COVID-19 pandemic. We are honoured to have two members of the their team to share their expertise:
Elizabeth Harding (EH) is MSF UK’s humanitarian representative, having previously held operational positions in Sudan, South Sudan, Philippines, Myanmar, India, Somalia and Ethiopia.
Roz Scourse (RS) is a policy advisor for MSF’s Access Campaign which works to bring down barriers that keep people from getting the treatment they need to stay alive and healthy.
What are the challenges MSF face in terms of humanitarian access in the COVID-19 context? For example, have you had any problems accessing countries that may have locked their borders?
(EH): Finding ways to continue with our regular medical activities has been a challenge in the COVID-19 context. Challenges with getting staff and supplies to where they were needed were particularly acute in the first few months of the pandemic. In fact, most of the issues that we had regarding getting and maintaining access was more of an exacerbation of our challenges in ‘normal times’.
In terms of the threat that Covid-19 poses for the people we serve, we know that social distancing is impossible in cramped camps like Moria on Lesbos, and hand hygiene is undoubtedly more challenging where there is no running water, for example. COVID-19 has shown how people who are already vulnerable are facing additional risks.
What would you see as some of the solutions that need to be put in place during the pandemic so that much needed aid reaches those most in need?
(EH): We need to ensure that regular health services continue, and that people can access them. Despite the pandemic, babies are still being born, children are still catching preventable diseases, and conflict is still causing life-threatening injuries. It’s crucial that these medical needs are not overlooked or deprioritised as this would have a lasting impact.
Blockages like insecurity, fear and movement restrictions present challenges but we are finding ways to adapt and minimise their impact. For example, rather than implementing mass vaccination campaigns at fixed sites where people would gather, our team in Burkina Faso used a door-to-door strategy to ensure that measles vaccinations could continue.
How has your experiences of dealing with other exceptional circumstances/disasters, such as “Ebola” or “terrorism”, helped in your response to COVID-19?
(EH): MSF has a long history of responding to epidemics and has been able to use this experience when responding to COVID-19. A crucial lesson learned from our experience responding to Ebola is that interventions must be targeted to the context – one size does not fit all.
Ebola also showed us that any intervention must be based in community acceptance. Community acceptance of the intervention and any necessary restrictions is the cornerstone for any public health intervention. An understanding of the need to be tested and treated is crucial.
But clearly there are unique elements to this pandemic too. COVID-19 is affecting countries around the world, rather than existing as an outbreak in a single region. This brings with it more challenges in terms of the different reactions of different states and availability of supplies.
Because of the pandemic, states have adopted state-centred approaches to regulations, giving them exceptional powers based on a medical emergency. What were the consequences of this for MSF at the initial phase in the complete lockdown of humanitarian activities?
(EH): While experiences differed across different countries, in some contexts it did became more difficult for staff to travel and for supplies to be sent where they were needed in the initial period. In some places we had to adapt our response and to prioritise what we really needed to do.
Crucially, almost 85% of MSFs workforce in our projects are host-country staff who are locally hired and were able to continue providing medical care.
I know MSF works very efficiently in developing countries, especially those with humanitarian emergencies arising. However, during the covid-19 pandemic developed countries have also complained that they do not have the resources to handle the crisis. Do you think that is true? Have you provided assistance or training in the UK ,for example, during the lockdowns?
In the UK we supported the COVID CARE centre for the homeless in London. This reflects MSF’s ambition to provide assistance according to the needs, irrespective of location. Our team in London were able to partner with other actors to fill a gap when needs were very high and then we were able to hand our programme over. This work in Europe did not divert from what we are doing elsewhere, with MSF present in over 70 countries.
Are MSF doctors having to make decisions about who gets priority for treatment when hospitals are overwhelmed with COVID cases? If so, how are those decisions made?
(EH): As a medical organisation, all care is done on a triage basis, so according to the urgency of the patient’s needs. In a lot of places where we work there is often limited resources so we have to adapt to work within such limitations, providing the best care possible and in the best interest of the patient.
(RS): Ideally, we would like to see a situation where these decisions don’t have to happen, and we don’t have shortages or the need to ration available treatments. In relation to COVID-19 medical tools (i.e. potential future treatments, ventilators, PPE etc.) we need to ensure there are no barriers that are artificially limiting supplies, such as intellectual property barriers and a lack of technology transfer from pharmaceutical companies. Past experiences have shown that when available supplies are limited, this can lead to nationalistic control and hoarding, and result in barriers to access predominantly for low- and middle-income countries (LMICs). We are already seeing this with COVID-19 vaccines.
As a starting point, we need to ensure global open sharing of data and knowledge related to COVID-19 medical tools, and that all intellectual property related to COVID-19 technologies are waived. This has already been proposed by South Africa, India and other countries at the World Trade Organisation in order to maximise global supplies of COVID-19 technologies and bring down prices. All products should be openly licensed, and technology transfer should be pursued to ensure that other manufacturers around the world are able to start producing successful products.
Will MSF get access to COVID-19 vaccines and how will the distribution of those vaccines to countries without stable governments, such as Yemen, be prioritised and managed?
(RS): We are pushing for proportional shares of COVID-19 vaccines to be made available to populations in crisis‐affected humanitarian settings, including refugees, asylum seekers, marginalised communities and people living in conflict areas. These are groups who have the least access to, or are excluded altogether from, national health services. A “global humanitarian buffer stock” was originally built into the design of the COVID-19 Vaccines Global Access Facility (COVAX), led by the World Health Organisation (WHO) and the Global Vaccine Alliance (Gavi), where 5% of supplies were to be dedicated to humanitarian needs. However so far this has not materialised, especially since COVAX is struggling in general to secure enough doses of future COVID-19 vaccines.
MSF is in discussions with WHO and others on how a humanitarian buffer stock could work, with supplies from COVAX or directly from companies or countries. France have already committed to contributing some of their doses agreed through bilateral deals with companies to a humanitarian buffer stock. We are asking other high-income countries (HICs) with bilateral deals (e.g. UK, EU) to commit to the same.
Countries such as Yemen are part of the COVAX Advance Market Commitment (AMC), which consists of 92 low and middle-income countries (LMICs) who will be able to receive donor support from other “self-financing” countries within the COVAX Facility, whose contributions will fund vaccine doses for these 92 LMICs. Allocation of doses should be in line with the WHO Fair Allocation Framework and aims to reach priority populations within all countries included. However, this remains to be seen, largely because many HICs have made bilateral deals with companies for their COVID-19 vaccines outside of COVAX, leaving limited available global supplies for COVAX and therefore LMICs.
The global health system seems to lack an international standard of response to global health crises, prompting a politicised and state-interest approach. Every state regulates for itself, prioritising its own needs, leaving those in greatest need at the back of the queue. However, IHL advocates a humanitarian principle of impartiality where help should go first to where it’s needed the most. How is MSF able to reconcile IHL with political reality?
(RS): In the area of access to medical treatments, diagnostics, and vaccines: MSF have been advocating for equitable access to COVID-19 medical tools, prioritising health-care workers globally and those at highest risk/of most need. This has not materialised in many ways: HICs have pre-booked the vast majority of future COVID-19 vaccines, as well as issuing export bans on potential treatments (e.g. UK export ban on dexamethasone). 85% of the available global supplies of the Pfizer vaccine until the end of 2021 have already been sold to HICs, meaning there will be months if not years of delay before LMICs could have access (the Pfizer vaccine may not be the most appropriate for LMICs due to the cold chain requirements, but it demonstrates this issue). 80% of the Moderna vaccine have also been sold to HICs.
As such, we are focusing on advocating for efforts which aim to maximise available supplies (e.g. IP waiver described above), as well as manufacture by developing countries so that in the medium to long term, they can supply to their own populations and regions. This requires the lifting of IP barriers, but also technology transfers from companies producing these products to transfer this technology, knowledge and know-how to manufacturers who are able to produce.
How would you assess peoples’ ability to access healthcare in conflict areas at the moment?
(EH): Conflict can undoubtedly hamper people’s access to healthcare. Some of the key barriers for individuals to access healthcare in conflict areas include whether the person knows and feels comfortable to come to a health centre, as well as very practical considerations including overcoming distance in order to reach care, and whether the routes available are safe. In some such settings, people can face limited options in terms of the type of care present (primary, secondary, maternity).
In conflict zones, as elsewhere, our teams consider the risk of acute health needs, for example trauma or epidemics (measles, diphtheria, cholera). These are made more challenging in situations of conflict where recent displacement or congested camp settings may also result in increased need for healthcare.
In MSF experience, what are some of the complementarities between public health and other frameworks such as international humanitarian law which contain fundamental legal protections including on the delivery of healthcare services?
(EH): Elements of these frameworks very much influence MSF’s work around the world. While MSF is founded on the principles of independence, neutrality and impartiality, we are also guided by the principles of medical ethics and see the influence of public health and IHL in our work. For example, under IHL, MSF expects access to medical care to be protected even in conflict zones, while public health approaches influence how we carry our work in conjunction with the communities we seek to serve.
What is the negotiating process when MSF enters war or conflict zones? What are the challenges of this process?
(EH): MSF teams try to communicate with all actors present in any given area, including the authorities, actors involved in the conflict, and the community. Our safe access depends upon the acceptance of all these actors. Of course these discussions can be complicated but the security of the team and the acceptance of the community are vital.
There is an increasing call to reduce the dependency of developing countries on foreign aid and, focus on strengthening the country’s autonomy to make decisions on their development priorities. As an organisation working in areas of conflict zones, natural disasters and epidemics, how does MSF feel they could strengthen the healthcare system in these countries during these periods of transition?
(EH): As a medical humanitarian organisation, MSF is designed to respond fast to emergencies. Our model, including our independent financial model, means that we can act quickly to help the people in greatest need. These are not normally intended as long-term responses, but as critical responses to meet urgent needs. Our medical teams step in where the needs are acute, and close projects or hand over to other actors when this acute phase ends.
The majority of our projects involve working with the existing health systems to provide support, supplies and to build capacity – for example, in Sana’a, Yemen, MSF supported the Ministry of Health to run the city’s principle centre to treat COVID-19.
When you are working in a country like Yemen, so politically fractured, what are the issues with negotiating access/delivery of supplies etc?
(EH): In negotiating access and the unhindered delivery of medical care, MSF commitment to its principles of independence, impartiality, and neutrality is crucial. These principles enable us to offer assistance based solely on our assessment of medical need.
Wherever we go, we make sure that people in the communities where we’re working understand that we will provide assistance to anyone who needs it. We run radio campaigns and hold meetings with everyone from government ministers to local armed groups, community elders to women’s groups.
Gaining their acceptance is key to our being able to work in difficult environments such as Afghanistan, Democratic Republic of Congo, and Yemen.
What transparency is there from western governments around their counter-terrorism activities in countries like Somalia, Pakistan and Yemen? In particular, what processes are in place between MSF and the US for example regarding potential drone strike activity that might impact on your work or endanger your field staff?
(EH): We expect states to uphold their responsibilities under IHL, which protects medical facilities against being targeted. In areas of high risk we do as much as possible to inform all actors of where we’re working, what we’re doing and why we are there.
When working in conflict zones, how do you ensure an equality of treatment for all sides, without intimidation from dominant political/tribal forces?
(EH): In a conflict situation, we don’t take sides. We go where people’s medical needs are greatest. In the ward of one MSF field hospital, you might find wounded civilians alongside injured soldiers from opposing sides. Hostilities and weapons have to be left at the gate. Wherever we work, we make sure that local people understand that MSF is politically neutral and will provide assistance to anyone who needs it.