July 31, 2012

Dr. Mego Terzian, director of MSF's Emergency Team, discusses his group's role in MSF's interventions.

South Sudan 2012 © James Keogh/Wostok Press

An MSF staff member consults patients in Yida refugee camp, where an MSF emergency team set up a coordination office.

Dr. Mego Terzian started working with MSF in 2000 and has completed assignments in a dozen nations, including Afghanistan, Pakistan, Niger, Liberia, and Iran. Since 2009, he has led MSF's Emergency Team in Paris, one of five based in MSF's operational centers in Europe, which can rapidly respond when crises erupt and often represent the first stage of MSF's intervention in a conflict, natural disaster, refugee crisis or other emergency situation.

How does an Emergency Team differ from a regular MSF team?

The Emergency Team is always on standby to intervene in sudden crises. If we are already running programs in the country affected, we send in the Emergency Team to act as reinforcements. It carries out an exploratory mission, recommends any program openings, then sets them up using a parallel coordination system to allow the regular team to carry on its original programs as best it can. 

Who is on the Emergency Team?

In Paris, we have 20 people in our Emergency Pool right now—doctors, nurses, surgeons, anesthetists, pharmacists, logisticians. We need many different profiles. They’ve all left their regular jobs and are on standby to go within 48 hours to an emergency mission anywhere in the world. They are under contract for at least 12 months. We have Africans, Americans, Europeans, many different nationalities in the pool.

To qualify, you need to have at least 24 months MSF field experience in different types of missions. One must be epidemics, and one must be conflict zones. And because the Paris team works in so many Francophone projects—around 65 percent of our projects are in French-speaking countries—people must also speak French as well as English.

How does MSF decide when the Emergency Team should be deployed?

It depends if MSF has a presence in the country or not. If we have no presence in a country, like in Libya and Ivory Coast last year, we have to start from scratch. For instance, in Libya, we started off by using the media and contacts we have on the ground to follow the beginning of the armed revolution.

Then three or four days after the violence started in the east of the country, we sent a small exploratory mission of three people—a doctor, a logistician, and a coordinator—to Misrata. They had to go by boat because the whole town was surrounded by government troops and this was the only way to gain access. After two or three days, the team proposed we open a trauma center, so we sent in reinforcements and materials, again by boat. We were there with the Emergency Team from Brussels, which decided to run a hospital for women and children in the same town.

Were there any particular difficulties?

A major difficulty was finding local nursing staff. Before the war broke out, most nurses came from overseas—including India and the Philippines—and they had all left. So, despite the security risks, we sent in 19 international staff—including surgeons, nurses, and doctors—to set up 25 trauma beds. For at least two months, the team managed this small 24-hour trauma center with very few national staff members with them. It was a month before we recruited our first Libyan medical personnel.

We were in Misrata for six months and treated 1,200 men, women, and children, all trauma-related. We conducted 525 surgical interventions, all violence-related. 

And in Ivory Coast?

For Ivory Coast, it was the same process. The crisis started in late 2010-early 2011, following the elections. We followed the situation at HQ for two to three weeks via the media and the local network we were still in touch with, having worked there previously. We then sent in one coordinator, one doctor, and one logistics officer to evaluate the situation. They proposed an intervention and we sent in reinforcements and supplies right away.

Libya 2011 © Niklas Bergstrand

An MSF doctor tends to a boy shot during last year's fighting in Libya.

How do you get permission to set up so quickly?

Because we are a medical organization, the Ministry of Health is always our first contact. And because our organization is well-known, even if we are not operational, we don’t usually have any problems setting up meetings. The Ministry of Health describes the situation and makes recommendations on where we should go and what we should do, and once we have the green light, we do our own evaluation and decide what to do and what not to do. We worked in one hospital in an Abidjan neighborhood where there was a lot of violence going on. The Ministry of Health staff had left this particular hospital, so we set up an emergency room, operating theater, and a hospital ward for post-operative care. We stayed throughout the fighting. Overall, we treated 6,000 patients—2,200 were surgical interventions, 800 of them violence-related.

In Abidjan, we were able to recruit local staff, though we started with just international staff at the beginning. I remember three to four weeks after starting the project with seven or eight people, we were up to 60 staff.

How long does the Emergency Team normally stay in-country?

Every emergency mission opens during the acute phase—which lasted two months in Ivory Coast. Then we must stay on for a few months to hand over the project to the Ministry of Health, because following the emergency phase, local authorities are always in difficulty. We stayed in Abidjan for seven months.

How does the Emergency Team work when there is an MSF presence in the country already?

If we have a presence in the country already, like in Pakistan during the floods, or more recently in South Sudan, things can go very quickly because the Emergency Team will not have to spend time contacting the authorities, finding cars, or identifying a place to set up an office and a place to sleep.  All this is done by the national coordination team already in the country. If we have no offices or presence in a country we probably lose at least 48 hours setting everything up.

Traditionally there is a separate coordination for emergency programs so as not to disturb the ongoing programs. There is always a parallel team for a short period, then when it is all stable we hand the programs back to the national team.

Just recently, for example, around 20,000 refugees arrived in a place called Yida in South Sudan. The national coordination team sent an experienced colleague to evaluate the situation and after two days, he recommended MSF open a primary health clinic and a 20-bed hospital for secondary care. So they turned to us, and we sent an Emergency Team, which immediately set up a coordination office in the capital, Juba, that could also oversee any new explos and program openings. We opened two new projects in one month, managed them for three months, then handed them over to the national coordination team.

What were the programs doing?

We were treating all the classic pathologies we see following a population movement—children with acute respiratory infections, malaria, skin diseases, and diarrhea. The first week, at least, is always very bad, until things are organized, and the water and hygiene can be attended to. In South Sudan, fortunately, other NGOs were there to do water-and-sanitation and other types of assistance, so MSF could focus on the medical.

What are some of the operations where you feel MSF did well?

I would say, in recent years, our response to the earthquake in Haiti, and then, several months later, the cholera outbreak. It was a big emergency and a big intervention from our Emergency Teams across the network. Ivory Coast, too, was very significant. I only talked about one project, but we actually opened five projects last year. Libya was very important, as well, the fact we were capable of sending a team of 19 people to Misrata, which was surrounded and only accessible by boat.  It was very dangerous and one of our most important missions.

Do you provide mental health support to Emergency Team members?

We were a bit late to address the mental health needs of our staff, but now we have a special psychologist dedicated to supporting people returning from the field, and especially from insecure and dangerous places. They meet with the psychologist and are provided with follow-up support if they need it.

Where are your people right now?

We have a team in Mali working with people affected by the violence there, and another working with refugees who’ve fled to Niger. We also have teams working on the nutritional crises in Mauritania and Senegal.

Are there different security protocols from regular programs?

On its first explo, the Emergency Team normally takes some time to understand the country, including meeting with other nongovernmental organizations working there, before doing its own security evaluation. Two to three weeks after opening a project, it creates the first security guidelines and rules we need to follow in the country.

Where could MSF improve in its emergency responses?

I think we were a bit late with the Arab countries. We were late deciding what to do after the demonstrations started. In Tunisia and Egypt, we overestimated local capacity in terms of medical response and underestimated the needs, so it was several weeks before we even sent in explo teams. We learned that we need to be more reactive. Even if we estimate there is good quality of care in a country, we realized we need to at least send in a team.  

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