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Forty Years Of Medical Innovation
Since it was first created by a small group of doctors and journalists in France in 1971, Médecins Sans Frontières (MSF) has always striven to find better ways of saving the lives and improving the health of more people through emergency medical action. This persistent search for innovation in public health emergencies is rarely highlighted, but has been crucial in how MSF delivers humanitarian medical assistance today.
MSF provides medical aid to people whose lives are threatened by epidemics, malnutrition,healthcare exclusion, natural disasters and armed conflict. During its first decade, it gradually became clear that certain obstacles were standing in the way of MSF making a difference to the lives of people most in need. For example, the very nature of medical humanitarian intervention is working with large numbers of people from poor communities in remote and insecure places, but the capacity to train staff of varying levels in such settings can be limited. These environments are often unfamiliar to international doctors, material and facilities tend to be limited, and staff turnover is generally high, limiting the possibility of building an experienced workforce. That is why MSF piloted and implemented a number of innovations, in order to adapt its work to the demands specific to the countries it is present in.
One of the earliest innovations took place in the 1980s, when, in a bid to standardise medical procedures, streamline operational management and empower staff, MSF adapted a technique already used by the emergency medical service in France, and introduced guidelines and standardised drugs and equipment. This soon led to MSF developing pre-packed, ready-to-go, custom-designed medical kits that contained basic drugs, supplies and equipment and were adapted to specific field situations, climates and diseases. The first emergency kit, applicable to many emergency situations, formed the basis for an interagency kit. The World Health Organization (WHO) coordinated the development of this kit, which was first available in 1990 and has been regularly revised since. Advances such as these resulted in an increased capacity for rapid intervention on a higher technical level, which had previously existed only in the military and civil defence forces of developed countries. MSF has since developed many other kits for vaccination campaigns, surgery, and even one to build a field hospital from inflatable tents.
In continually trying to find innovative ways to supply the best drugs to patients, and in recognising the need for further research, MSF created the non-profit organisation Epicentre in 1987. The aim was to provide scientific evidence that would support operations. Epicentre carries out studies on the incidence, prevalence and causes of epidemics and infectious diseases in large populations. At the time, few other non-governmental organisations were capable of doing research in the emergency situations in which MSF operated.
For more than 20 years, Epicentre has conducted many surveys, often under very difficult conditions, producing research that has contributed to improving patient care. Between 1996 and 2004, the centre, mandated by MSF, carried out studies and clinical trials on malaria treatment, in order to officially prove drug-resistance to the most commonly used medication at the time, and to give leverage to changing the protocols. Epicentre’s research also contributed to proving how much more effective several artemisinin-based combination therapies (ACT) were. In several malaria-endemic countries, these results helped support changes in national treatment protocols for malaria.
Throughout the 1980s and 1990s, MSF teams worked in the “meningitis belt” of sub-Saharan Africa. Their experience, regarding the mostly successful use of oily chloramphenicol as a first-line treatment for bacterial meningitis, led to a study to prove its efficacy, and in 1991, it was included on the WHO’s essential medicines list. An equivalent study, comparing this drug with another, ceftriaxone, was carried out in 2002, with the result that both treatment protocols became international standards for outbreaks in the meningitis belt. MSF also worked closely with the WHO to define new control strategies for the disease.
Unfounded perceptions and unfairness were preventing many HIV-positive people from receiving treatment in the 1990s. Although medication to treat the pandemic already existed in the form of antiretroviral (ARV ) treatment, the cost was between US$ 10,000 and US$ 15,000 per year – prohibitive for millions, particularly in developing countries. Some also had the perception that it would be too difficult to implement complex ARV regimens in resource-poor settings.
MSF, seeing the need for advocacy to challenge this notion, and in order to overcome the price barriers to treatment, set up the Campaign for Access to Essential Medicines in 1999, which pushed for the manufacturing of more affordable, generic versions of ARV medicines. Soon, the drugs were being produced in Brazil, India and Thailand, opening up the possibility of treating many millions of HIV-positive people. Today, the price of a year’s treatment has dropped by 99 per cent and more than six million patients are being treated with ARV drugs. MSF alone provides ARV treatment to more than 170,000 patients in 19 countries. MSF’s Access Campaign has also been very active in raising awareness about other neglected diseases prevalent in developing countries, and in securing the production of much-needed affordable or adapted medication to treat them. In recent years, major changes have occurred in the international pharmaceutical market, as drugs are now being produced in countries
Although drugs for specific diseases are now being manufactured in more countries, the market-driven nature of the pharmaceutical industry meant that in the 1990s, drugs for certain diseases were still too expensive, or else ineffective or highly toxic. In some rare cases, manufacturing had stopped altogether. In 2003, seven agencies from around the world, including MSF, came together to form the Drugs for Neglected Diseases initiative (DNDi), a non-profit drug research and development organisation.
In 2003, MSF and Epicentre sponsored clinical trials for the treatment of sleeping sickness (human African trypanosomiasis), a deadly parasitic disease threatening 60 million people across sub-Saharan Africa. The medication available was either highly toxic or difficult to administer, especially in remote settings. The following year, DNDi, along with other organisations, joined the research. The trials proved that nifurtimoxeflornithine combination therapy (NECT) was the best combination medication, showing it to be efficient, well tolerated by patients and easier for healthcare staff to administer. In 2009, nifurtimox (to be used in combination with eflornithine) was added to the WHO’s list of essential medicines, so NECT could be used throughout Africa, leading to improved healthcare for patients with sleeping sickness.
The nature of MSF is to act as a medical humanitarian organisation in crisis periods when people’s very survival is threatened. Over the years, it has implemented sustainable models of care that have proven effective, efficient and affordable, and which have since been built upon by other actors, including ministries of health. In South Africa, for example, MSF operates an HIV and tuberculosis treatment project in the township of Khayelitsha, near Cape Town. The programme uses a decentralised model of care in its operations, training nurses to initiate treatment and counsellors to test for the virus. This increases the number of people being diagnosed and treated, and also provides training that benefits people long after MSF has gone.
These are examples of only some of the innovations that MSF has initiated in its first forty years. As Dr Unni Karunakara, MSF International President, summarises, “Throughout the decades, the organisation has always tried to adhere to its social mission of protecting and alleviating the suffering of the poorest and most disadvantaged, while respecting human dignity. MSF will strive to continue its work of saving lives, reducing pain and suffering, and helping restore the lives, potential and dignity of people who find themselves in life-threatening circumstances.”
This article is largely based on Jean-Hervé Bradol and Claudine Vidal (eds), 2009, Innovations médicales en situations humanitaires, L’Harmattan. The English translation, Medical Innovations in Humanitarian Situations, is available here.