January 13, 2011

Following the release of Doctors Without Borders/Médecins Sans Frontières (MSF)’s report, Haiti One Year After: A Review of Médecins Sans Frontières Humanitarian Aid Operations, Dr. Unni Karunakara, MSF International President; Stefano Zannini, MSF Head of Mission in Haiti; and Kate Alberti, MSF Epidemiologist discuss the issues facing Haiti and MSF one year after the earthquake. Avril Benoit, Director of Communications for MSF Canada, moderates.

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Avril Benoit, Director of Communications, MSF Canada: Thank you very much. Welcome to Médecins Sans Frontières/Doctors Without Borders media briefing today. My name Avril Benoit, I'm coordinating MSF communications at the moment, in Port-au-Prince. Today our organization published an accountability report entitled "Haiti One Year After: A Review of Médecins Sans Frontières Humanitarian Aid Operations." You can find it on most of our websites, if not right now, then a bit later today.

We have three speakers for you who will say a few words and then answer your questions. The first is Stefano Zannini, MSF Head of Mission in Haiti. He is one of the leaders running the operations and he'll be able to describe what it's been like over the last year. He was here during the earthquake itself. Kate Alberti is an MSF epidemiologist and a cholera specialist who's been here a few months following the epidemic, and Dr. Unni Karunakara is MSF International President, and he's going to start us off with a few words from Geneva. Go ahead, Unni.

Dr. Unni Karunakara, MSF International President: Thank you and good day everybody. So I'll say a few words rather quickly. The earthquake that struck Haiti on the 12th, the magnitude of it was really shocking. The damage to the city and the psyche of the people was still visible when I visited Port-au-Prince towards the end of November when the cholera outbreak was raging. MSF teams were working very hard to respond effectively to the outbreak and I think we were stretched at times, but we were able to do what was needed, an effective response to the cholera outbreak.

The post-earthquake response has been the largest humanitarian response in MSF history, and we've launched a review. We've done this review first and foremost to improve our response to large-scale disasters. It's only by reviewing that we learn what mistakes have been made, what lessons we've learned, and also to identify gaps in our response in Haiti at the moment. And I also believe that it's important to communicate the choices you make and also the expenditure that was incurred in carrying out our activities.

During the emergency phase, after January 12th until the end of April, by and large medical responses prioritized over non-medical help activities. That's where our expertise lies, and there were massive needs as well. Our activities were mainly in secondary-level services such as emergency medical, surgical, obstetric and also mental health care. Within a few weeks it was clear that non-medical needs were not being met as it should have been, and MSF also started providing tents and mosquito nets and other relief materials. We also carried out very modest water and sanitation activities as well, providing clean water to people, mainly.

Once the immediate emergency phase was over, we started looking at what our long-term plans should be. It wasn't very clear what the long-term reconstruction plans were for the country. There was the interim reconstruction committee commission which was concerned about long-term development, which is appropriate of course. But we felt that immediate life-saving activities should have also been prioritized, especially water and sanitation activities, which would have helped in a small way to address the cholera outbreak that followed as well.

The cholera outbreak itself was very fast-moving and started in the northern country and within a few weeks it was almost all over the country. MSF mobilized rapidly and sent teams to different parts of the country. When I visited, that was indeed the case, where we had several cholera treatment centers. Unfortunately, what was evident was the limitations of the aid system. Essential water and sanitation activities, waste management, community-level activities that were important to provide the right sort of information to the communities and also to have small prevention activities were not adequately present in the various villages and communities.

Now, very quickly to talk a little bit about the foreign aid, I think the people world over were incredibly generous as far as Haiti was concerned. We estimate our spending in 2010, last year, to be €104,000,000. And as of October, we had spent 76% of that amount. Just to give you a slightly more precise estimate, it's 94 million for the earthquake and 10 million for cholera.

The projection for next year is 46 million. It's important to remember that we've been in the country for almost twenty years. In 2009, our budget was between 13 to 15 million dollars, so it's a huge increase in terms of expenditure. We expect another $7.5 million to be spent in cholera-related activities in the coming year. As far as the next few years are concerned, we will continue to, we've been there for almost twenty years, and we'll continue to be in Haiti for, in the coming months and years. The focus will primarily be on secondary-level care, where the services that we are providing now, emergency medical, surgical, obstetric, activities and also supporting six hospitals with a total capacity of 1,000 beds, and also supporting a couple of Ministry of Health structures in the city, in the capital city Port-au-Prince, and also in Léogâne. So I'll stop there and I'll ask my colleagues to take over from here and will be happy to answer any questions. Thanks, Avril.

Avril Benoit: Thank you, Dr. Karunakara. And now we're going to hear from Stefano Zannini, Head of Mission for MSF in Haiti.

Stefano Zannini, MSF Head of Mission in Haiti: I'm Stefano Zannini. I was here at the time of the earthquake, and today, twelve months after the earthquake, after passing through a very long and hard year, I have mixed feelings. For one side, I am very, very proud of what we have done as Médecins Sans Frontières. Our teams managed to treat, assure a delivery every thirty minutes, more or less every thirty minutes on the hour, a man or a woman, a child or an adult, enter one of our operating theaters in Port-au-Prince or in the country. We have been able to treat about 350,000 patients either medically or mental health or both of them for some patients. Our staff worked tirelessly over this least year, and in spite of that I feel uneasy and sort of uncomfortable about what is still a disaster situation for most of the population.

Let me go back please to the first hours after the earthquake one year ago. One of our hospitals had collapsed with patients and medical staff inside and the other two facilities we were running at that time were dangerously damaged. So we proceeded to check how many facilities were running at that time, and I looked, I saw thousands of people in need of immediate care. We started working around the clock, first of all under tents, and then we grew quickly, more tents, clinics, mobile clinics, even converted some buildings into hospitals.

Over the last year, every, all of the MSF medical facilities we made open every day, 24 hours a day, seven days a week, despite of the situation we were facing at that moment. We passed through shortages of food, cholera epidemics, a hurricane struck Haiti, we had violence after the first round of the elections, rioting, riots, and despite of that, all of our structures remained open for the duration. And again, the Haitians now know that if and when they need medical care, they can always count on MSF. They can come to us. They can be treated for free and immediately. Let's take a figure. Nowadays, MSF represents a quarter of the total medical capacity in the country. About 1,100 people a day in all the hospitals we are running. And in spite of that, as I told you, I have the feeling that the global situation has not improved much.

In the first hours after the earthquake, when I was visiting the city, people asked, "Please help us." We cannot get through; we don't have the means there to respond. And today the question from the situation is how to help them to their feet. Get back on our feet, help us. In the cholera outbreak, we estimate we have treated more than 50% of all the patients in the country. And we are one NGO. We are only one actor.

Our presence in Haiti is massive. We currently have about 8,000 people working in our organization. I think it is good. It is remarkable. It shows commitment, it shows means, capacity, and technical expertise, willingness to help and to save people. But I think that we passed the phase in which humanitarians were helping with their jobs. We did what we are supposed to do. We did what we were supposed to do. Now it's time, I think, for longer-term efforts to develop, from other actors to intervene. One year after a disaster I think it should be a time for humanitarians to step aside and move on to other disasters, or keep prepared for new emergencies, even in this country, as we showed during the cholera outbreak.

But the reality now is that Haitians are still strongly dependent on the MSF services, on the MSF medical facilities. And personally, I would rather see the Haitians be closest to the stage of building their own country. I would like to see them to be in the first line, and to be working, decide what they need and what they want to do. It's true that the international community can help, it is clear, but during the last year, I've heard a lot of time talking about promises, plans, strategies, money. These three, four words, you know, over and over. Promises.

And what I currently see now is that these promises, these strategies, these plans, have yet to be followed by actions, by concrete actions. The health-care sector is still not a priority, for some reasons. Government lost staff during the earthquake, the means, the capacity, the expertise, the infrastructure, and again the government, the local Ministry of Health, the national authorities, have not been able to build even one hospital. They've got a lot of promises, and plans and strategies, this is clear, this is sure, and it seems that in good conscience, we, as humanitarian actors, we as Médecins Sans Frontières cannot leave now. It's still time to stay, and it's still time to cover a lot of unmet needs in the country, and especially in Port-au-Prince. When you go to one of our hospitals today, it's incredible to see, for example, how many people we are helping, how many people we are treating: women delivering, a patient in need of surgery, a cholera patient, a bunch of things.

And if I can, finish my interview, I would like to give you an example about what Haiti can be for an organization like Médecins Sans Frontières. Some months ago, in the morning, I was at the office and I received a call from one of my colleagues in the Artibonite confirming me that the number of cholera cases was increasing. At the same time, we had confirmation that hurricane Tomas was likely to strike Haiti, and we had to prepare for that. Some minutes later, I received a report of violence and shootings in some of the slums in Port-au-Prince. And on top of that, at the end of these two hours, I received another call from another slum in Port-au-Prince and apparently people had felt a tremor and they were in panic. It is an example of what Haiti can be. I realized in that moment that everything could happen here in Haiti, and in fact, it did, and it still does. Thank you very much.

Avril Benoit: Thank you, Stefano Zannini, MSF Head of Mission. Here's Kate Alberti, MSF epidemiologist to talk to you about cholera, and then of course we will be taking your questions.

Kate Alberti, MSF Epidemiologist: Thank you and good morning everyone. I'm just going to give a very brief overview of the cholera epidemic as its evolved here in Haiti. As many of you know, the epidemic began in the third week of October. Between that date and the end of 2010, more than 171,000 cases had been reported in the country and as Stefano mentioned, just over half of those reported cases have been treated by Médecins Sans Frontières.

I think it's important to recognize that cholera had not been seen for at least 70 years if not longer in Haiti so it’s a belief that it is unknown both to the population and to health care workers. It added a whole new dimension to the intervention, both to pass messages to the population of how to prevent the disease and the challenge of training health staff to provide adequate care for patients. The epidemic unfortunately has spread to all 10 departments of the country, both in rural and in urban areas. And just to give an example, in one week, in week 46 of the year which is in mid November, Médecins Sans Frontières/Doctors Without Borders alone treated more than 12,000 patients in one week, and that's more than is frequently treated during a whole epidemic that might last for four months. And in addition to those cases treated by MSF there were many thousands of patients that were treated by other organizations and by the Ministry of Health. I think I will leave it there and hand back to the moderator for your questions.

Question: Hello, good morning. MSF had said that the epidemic was probably going to reach its peak in late November and I would like to know if that really happened and what you expect from it now, if the cases are still going up or if the epidemic is going down now?

Kate Alberti: Thank you for the question. As far as I know Médecins Sans Frontières never gave a date of when we expected the end of the epidemic. Clearly the number of cases in the country is now reducing. As I said, the epidemic has spread to all 10 departments, both in rural and in urban areas. There are still new pockets developing in some rural areas but in most major cities the number of cases is declining quite significantly. One of the things we have to be careful about, particularly in Port au Prince, for example, is that when there are disturbances, such as there were after the announcement of the provisional results of the first round of the election, there were disturbances that meant that water trucks, for example, couldn't get through. We believe that the increase in the number of cholera patients that were reported in the days following that were linked to the disturbances in the provision of water, and that we may see that again in the days, the weeks that are upcoming. Although, as I said, generally the epidemic is now in decline, it is not yet over, but we don't expect that there will be as many cases as there were for example in November, we don't expect to see that again during this epidemic.

Question: Yes, Hello I am a newspaper journalist from Brussels in Belgium; I have a question regarding the coordination of the fight against cholera. Because in Haiti shortly after the earthquake, a lot of measures taken in the refugee camps were organized by the WASH cluster of the United Nations, they provided essential things for hygiene in the camps, yet months later we see that MSF is taking the burden of the treatment of cholera patients, and I was wondering how you explain that most cholera patients ended up in the hospitals of MSF, and how is it possible that a foreseeable epidemic like cholera happened.

Dr. Unni Karunakara: Hi, I will just take it in broad terms and them maybe Stefano can give some operational insight into it as well. The MSF doctors, its important to realize that to be able to address cholera, especially in a country where cholera was not known, as Kate pointed out for the last 70 or 80 years, you need some experience and you need some capacity to be able to treat, especially to set up cholera treatment centers and to kind of be with the massive influx of patients that we saw in Haiti.

As far as the coordination efforts that are concerned, several clusters that were involved, WASH clusters was of course one, but there was also the health cluster that was involved and there was also logistics involved in getting supplies etc to different parts of the country. What I think has happened is that the coordination mechanisms, I think the capacity was not there to coordinate the large number of agencies that were present in the country, but also many of the agencies that were present in the country also probably did not have the capacity to deliver the kind of services that were needed in a very difficult environment. Don't forget that it was a long year post-earthquake, but also the political climate, security, etc, etc. I think the lack of capacity at two different levels, one is capacity to coordinate but also capacity of several agencies to deliver the goods so to speak. Stefano, perhaps you can add a bit more about the differences between the camps inside the city where free water was available for the most part, and outside the camps.

Stefano Zannini: Yes, thank you very much Unni. It's clear that coordination is one of the points discussed most frequently to explain or to justify the delays in the response to the cholera outbreak. I personally think that the main objective of a humanitarian organization is to save lives and to treat people, and to give a response that is quick, effective, and pertinent. Coordination can be useful when it helps improve these responses but it can be an objective in itself. Some eight or nine days after the official declaration of the epidemic in Haiti, we as Médecins Sans Frontières, we met with the national authorities, the WHO, PAHO, and with the other most relevant medical actors present in the country, sharing our information, discussing about the possible scenarios, discussing about the most important needs to come, but then, at the end of the day, we are talking about lives, we are talking about patients, and we started focusing on the most operational response.

Question: I think my question is mainly for Stefano Zannini. You said that, first of all, do you still get one patient every half hour? That’s my first question - at Médecins Sans Frontières facilities, and the other thing that struck me was that you said it was time for humanitarians to step aside and move on to other disasters, and you would like to see the Haitians be closer to the effort to rebuild their country. What is your opinion and the opinion of the other speakers, the main barrier to the Haitians being more involved? Is it a lack of physical capacity or is there something else? Is it a lack of willingness is it a lack of the government responding adequately to the problems?

Stefano Zannini: Ok, thanks for the question. All over, the first ten months after the earthquake, every fifteen minutes, a woman delivered in one of our medical facilities, and more or less at the same time, someone entered in one of our operating theaters. This is a visual way to see and to look at our interventions here in the country.

The second part of the question was about the barriers. But I can't speak to points of barriers in what? In the medical response in general? Or in the cholera response specifically?

Question: The entire rebuilding. The Haitians not taking enough of a role, I think you said. I think you said that you would like for Haitians to be closer to the effort to rebuild there own country? You would like them to be on the front line?

Stefano Zannini: I think that actual main point on that, the first one, I would like the national authorities to assume more their responsibilities and this means also their capacity to assume these responsibilities. For example, in the case of cholera, they did not have any technical expertise to respond. So this is a point that we should focus on. And that the other is, I think, in a country where more than 50% of the year's budget comes from the international community, the role of the international actors should address this capacity to assume their responsibilities. I think that it's something we should discuss because this reality showed up during these last months and was especially evident when we speak about shelters and reconstruction, quite, almost no actions have been taken so far.

Question: What do you think the main lessons are that you have learned in terms of responding to a disaster of this magnitude?

Dr. Unni Karunakara: I think each large emergency is unique in itself. I think the context sort of defines the kind of response. But Haiti was a particular case. Don't forget that Chile was also hit by an earthquake of similar, maybe even greater magnitude but the damage to property and to people were very minimal there. That is in a nutshell sort of tells you that the situation in Haiti before the earthquake itself was in very bad shape.

As far as response is concerned, I think no one underestimates the need for coordination, as Stefano earlier pointed out. I think in many large emergences these days what you see is huge coordination bureaucracies, which as a colleague from the red cross put it, coordinates intentions of agencies rather than actions of agencies. So you have a lot of people sitting around the table talking about what they would like to do and what they can do but when it comes to action, very few agencies have the capacity, or the staying power, or the experience to actually deliver. So this is a huge problem.

When I was in Haiti, and Stefano was there as well, we witnessed the President himself was chairing a health coordination meeting and there were something like 420 health agencies in Haiti today. You can imagine some of the challenges involved in coordinating action between so many agencies. So I think the point that was made earlier about coordination in itself can't be an objective, so they have to be coordination in action rather than coordination of intention. That’s one thing.

Second, is that you have to have the government fully involved and implicated in the disaster response of any kind in their country. You can see that in the post Tsunami scenario. In many of the countries where they had civilian capacity, as well as, indigenous military capacity to respond to large emergencies the governments were fully involved and able to recover much faster than Haiti probably will. So there are many factors that come to play in being able to respond.

Most importantly I feel that agencies should play to their strengths. I think as a medical humanitarian organization, our focus has always been on providing medical care of a very high quality. If you look at the cholera outbreak, our ability to kind of take on all of the patients and provide the kind of care that we needed to provide depended a little bit, especially because the outbreak was so massive, depended on other agencies being able to do some of the other work, the community level work, the waste management, the water treatment etc. At one point we had, from 1 facility alone, we had 15,000 liters of waste that needed to be disposed of daily. And 15,000 liters of waste that needed to be treated and disposed. And we had only 1 waste disposal site in the whole of the city, the capital city. And that was rapidly filling up. And if it had filled up, we would have had to stop taking in patients. So this also illustrates the limits of what agencies by themselves can do. Government needs to be involved and otherwise it’s impossible to mount a response and recovery afterwards. Stefano, perhaps you want to add something?

Question: Hello, I'd like to ask, Mr. Zannini told us, that it would be good if humanitarian aid would step aside if there is a possibility to do that. Do you have any response from the authorities to these concerns of yours? Are they stepping up to their role? And in the light of the election, which is still inconclusive, do MSF see any way out of Haiti? Are you at all optimistic about being able to, I don't know if the word is leave the country, but to have them walk on their own feet? Is that possible in the near future?

Stefano Zannini: Thanks for the question. We are talking basically, we are talking about reconstruction. How many hospitals have been built during this last twelve months, by the national authorities with the money promised or pledged by international communities? Zero. Are the schools rebuilt for the children to go to study sufficient? Not at all. So I think that it's not a problem of money. Money has been pledged in New York. It's plenty of money. The interim commission is there available to address the most important needs and to build a better country. How many times did this commission meet during the ten months after its construction? Four times. Is this enough, in your opinion, to address the needs of the population here in Haiti? That’s not enough. More should be done to respond more effectively and to meet the needs of the population. Now about the second part of your question, can you repeat it?

Question: I don't know if it is your intention to leave Haiti eventually, but do you see any way out of Haiti right now?

Stefano Zannini: We committed, to the national authorities already, in late January to stay in the country to accompany the country on the way out of the emergency. We already built a new hospital, another one will be open in the next weeks, I hope. Another one will be built in the second semester of 2011, and a fourth one will be probably left for the next year to come. We committed on that. We do think that the medical needs, particularly the second-level care, the more specialized let's say, will remain very, very high. We want to stay in the country and we want to stay, respond to the needs of the population, but again, something more should be done to allow organization like Médecins Sans Frontières to progressively leave the country in the year to come.

Dr. Unni Karunakara: I think Stefano alluded to what MSF plans are for the next few years. It’s important to be very clear about this. Haiti has a long way to go in its process in the road to recovery and reconstruction. It’s going take a while. It’s going to need all the help it can get. MSF has been in the country, like I said for 20 years now, and we will be there for the next month and years to work with the, and Stefano made the very important point, to work with the Haitian Ministry of Health but also the Haitian people and professionals, to deliver the kind of care that they need. There is no end of sight at the moment, but we hope that the interim commission is able to lay out a plan that will address some of our concerns, and the concerns of the Haitian people. Thank you.

Question: Good morning. Not to beat the coordination horse to death, but someone has mentioned that money has been pledged, there is money there that is not the problem. In talking to Haitians in the diaspora, Haitians outside of Haiti, even a member of the commission, it seems to be that a lot people are concerned about just turning over a lot of this money. They don't see the money, and turning the money over to the Haitian government, which I've heard a lot of in this call--they need to step up and they need to be responsible for the country--doesn't seem likely given the history of aid money in Haiti. It seems that someone needs to make the first step. Is the thinking from MSF, in the humanitarian community and the medical community specifically, then that it’s the interim commission that is going to have to set the priorities and set the agenda for what is going to happen in the country? Because as it seems now from talking to different people, it seems that this coordination is not happening, and it seems to still be causing the sense that not enough is getting done on the ground that people can physically see.

Dr. Unni Karunakara: Sure. In the end the ultimate responsibility lies with the government. It’s not a commission that can plan for the country, its not the humanitarians that can plan for the country, it has to be the government together with the people. Right now the government, we don't know what the new government looks like, so we are entering a period of uncertainty. And given the history of Haiti, we will see how the new government is able to take on the challenge of reconstruction and development of the country.

The money, as far as you know, the money is going to be dispersed as, this is what we have heard from the president and the prime minister, it is project based, but other than that we don't have any more information, and frankly the humanitarian agencies and us as a medical organization, we are committed to the Ministry of Health as a partner and we work with them in the short term and the medium term to kind of continue to provide services. Questions have to be directed to the government and to the global community who has taken on the task of reconstruction at large. I think it is a tricky situation and it is difficult for humanitarian agencies to provide solutions or answers to those questions.

Question: I would like to know in which conditions you believe MSF should leave the country. What do you expect, and when do you intend to go?

Dr. Unni Karunakara: You are talking about the exit strategy, and this is an internal question for all our programs in MSF. It’s very difficult, it’s not always clear when humanitarians should exit a context. Very often we go as a response to a crisis or a conflict, there is an earthquake or a conflict somewhere, but what we respond to are medical needs, and medical needs don't always disappear when the event ends, so when the earthquake is over the medical needs don't end, and when the conflict is over, medical needs don't end. Medical needs continue for months and years after the event has occurred.

In any exit strategy the key word is responsible exit and we are committed to that in Haiti as well. We want to make sure that we are engaged in providing secondary level services, and we want to see that a certain level of services are being provided by other actors, such as the Ministry of Health, and perhaps even other agencies - that the population is no longer dependant on MSF as a major provider of health care in a country. We are also, as MSF trying to think outside of the box and work with the Haitian government and the public to create a public private foundation to perhaps even look at engaging slightly longer than we normally do in other situations, and also with the view to building up capacity of local professionals that Haiti surely needs. One thing that you see, something has been written up in the newspaper yesterday and today as well, the human resource crisis in the country is something that will hold the country back for a bit as well. And so in the medical area that we are working in, we are also thinking of ways to engage local professionals, etc. Responsible exit is the key word. It is very difficult today to say whether we will leave in two years, in three years, in five years, but this is something we give a lot of thought to and we are outlining our plans, and some of it has been outlined in the report that we published today as well. Thanks.

Question: I am wondering if you could tell me what you think the single most important project that should be financed, and also has MSF heard from any of the government ministries, in particular the health ministry, their frustrations with the situation?

Stefano Zannini: Ok, thank you very much. First of all, new houses, hospitals and schools, these are the priorities I would define for the next months to come. And about the national authorities and the Ministry of Health, what I can give you is an example. It's the willingness, the strong willingness of the Ministry of Health to build a new healthcare system, affordable to most of the population, especially the poorest of the poor. They complain about the fact that they get no means to create such a new healthcare system.

Avril Benoit: Thank you very much everyone for listening in to this teleconference briefing from Médecins San Frontières/Doctors Without Borders. I will just remind you that our three speakers today were Stefano Zannini, Head of Mission for MSF operations here in Haiti, Kate Alberti, MSF epidemiologist and cholera specialist, and Dr. Unni Karunakara, MSF International President who is calling in from Geneva. With that we will wrap up and remind you that our accountability report is on our website. Just go to www.msf.org and you can see everything we have been up to over the last year, and also some critical self reflection on our operations. I'm Avril Benoit signing off and if you have any more questions for us by all means contact one of our offices, our press officers will be happy to help you.

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