May 8, 2012
This interview originally apeared on AllAfrica.
Dr. Unni Karunakara, the international president of Doctors Without Borders/Mèdecins Sans Frontières (MSF), is midway through his three-year term as president of the international humanitarian organization. He visited South Africa recently—the site of groundbreaking work started 12 years ago when MSF, together with local activists and health workers, changed conventional thinking about how to provide antiretroviral (ARV) therapy to people living in poor communities.
AllAfrica met Karunakara at the MSF offices in Cape Town where he spoke about the significant but precarious gains made in reducing medicine costs and providing treatment for AIDS, tuberculosis (TB), and malaria. He also discussed the challenges MSF faces in remaining independent and principled in conflict situations, and the complexities of deciding when to intervene—or withdraw.
Parts of Africa have made progress in treating HIV, TB, and malaria, but there have been reversals as well. What are the prospects for greater achievement?
We've made incredible progress in the last 10 years. We saw several institutions take shape and make huge contributions to global health. We've been able to scale-up treatment for HIV, for tuberculosis, for malaria, and there was much more focus on international health and willingness of governments to engage in health issues.
But I think we're at a point where all of the gains we've made are at risk. There are several factors. One is the financial crisis, which has been used as an excuse to hold back funding for global health initiatives. It's becoming more difficult for politicians to sell international aid and international commitment in their own countries, but this is a case politicians need to make much more emphatically.
The Global Fund (to Fight Aids, TB and Malaria) is central to the scale-up of care and treatment for millions of people with HIV— 6.6 million people. But the Fund had to cancel their Round 11, which can have very bad consequences. We really need to make sure the momentum we've gained over past years continues.
Another factor that allowed us to scale-up treatment to millions of people: generic competition. In 1999/2000 the cost of ARV treatment for a person per year was between U.S.$10,000 and $12,000. Today it's around $75—a remarkable decrease in price! The Global Fund, Pepfar (U.S. President's Emergency Plan for Aids Relief), Clinton Foundation, Unicef—they all buy generic drugs, which makes it possible to put many more people on treatment. It also makes it possible for governments like South Africa and other countries to provide free treatments.
But that's at risk because India has signed on to WTO (World Trade Organization). There are several bi-lateral agreements, especially the Free Trade Agreement between the European Union and India, that could shut down the possibility for more generics in the future.
We are at that point—well we have been for a few years—where people on first-line treatment are now transitioning. They need second- and third-line treatment and these treatments are frightfully expensive. We need to have these affordable medicines, but also diagnostic tools. My fear is that if we don't address these issues, not only does the funding dry up, but the cost will also go up. That can be catastrophic.
The third thing at risk is research and development for all sorts of new therapies, particularly for pediatric formulations and better diagnostics. To make progress against TB, for example, we need better diagnostics— more sensitive and more specific. We also need better diagnostics for children; it's very difficult to diagnose some of these illnesses in kids.
The market has pretty much failed people living in poor countries. Endemic countries, the countries that are affected by diseases, including neglected diseases like sleeping sickness, need to take leadership in setting agendas for research and development.
It seems ironic, given Belgium's history with the Democratic Republic of Congo (DRC), that it is withdrawing its support for the sleeping sickness programme in that country.
Exactly. But it is also the job of the DRC government to see that it remains a priority and that this is conveyed to donors. We are in one of those perfect storms, where all these different elements are clashing, and if we don't fight, I think we'll have a very difficult time ahead.
So do you think national governments should bear greater responsibility for meeting the health needs of their people?
Sure, absolutely, national governments have to take responsibility. Of course there are poor countries, but many of those countries with high burdens of HIV and TB, and perhaps malaria, are countries where economies are booming. But we have to be clear that for the next few years, any solution will require support from the international community. Given the amount of funds that are required to address problems, you cannot absolve the international community.
How do you see things panning out in trade negotiations with the European Union and India, the world's the biggest producer of generic drugs?
We're at a sensitive stage of the discussions. Activist groups in India, in Europe, have made positions very clear, and we've made our position known as well. Now it's up to the Indian government as to how much they give.
This is high politics, so we hope that the Indian government keeps the interests of their people in mind. Part of aspiring to be a global power is also to take a moral responsibility and to understand that the policies they make in their own country have huge impact outside their borders.
I mean for MSF, 80 to 90 percent of the drugs we use to treat these diseases come from India. And not just us—the Global Fund and Pepfar, all of these organizations buy massively from India. The Indian government has to realize this.
Has MSF engaged with the Kenyan government about its anti-counterfeiting legislation and how it can be misused to deny access to quality generic drugs?*
There has been some attempt in the past years, especially by industry lobby groups, to say that generics are bad drugs, but we know that's not the case. All of the generics that are being purchased by organizations such as MSF and others have been pre-qualified by the World Health Organization. That means they are as effective and they meet the therapeutic standards that we need. That is a very false argument.
The idea of a pre-qualification program is that countries that don't have regulatory processes in place can avail of this international centralized system, and it makes it easier for all of us to import drugs. But now, more and more, countries are putting regulations in place, and this comes with a lot of challenges. It takes a while for systems to mature, and there can be lapses. In the past, and even now for the most part, we buy our drugs centrally, because it's an easy way for us to assure quality, and then we bring it into the country. Local purchase has its own problems, but more and more countries are requiring that drugs be purchased locally. That puts an additional strain and burden on organizations like us.
We are a humanitarian organization. Speed is of the essence, we don't always have the time to come in, assess quality, and then buy drugs. Having said that, we are thinking about these problems and sending people to these countries to do the due diligence that's needed, approve certain suppliers and approve certain companies, et cetera. It's not foolproof, but we have to do the best we can to ensure the quality of the drugs we provide to our patients.
There has been talk in South Africa, and some other African countries, that we should be producing our own generics for the continent. It has a great rhetoric to it, but do you think this is viable?
You need a certain critical mass of skilled labour—whether it's scientific or manual—to be able to produce the drugs cheaply. The gains you make in drug production, in terms of prices, comes from being very innovative about processes you use to develop the drug.
Of course, I think it's great that African countries have the aspiration to produce drugs, but in the short- to medium-term I don't see the generics produced in these countries as being cheaper. You need to bring skills and expertise from outside, and all of that adds to the cost.
MSF has not confined itself to responding to medical emergencies—it has been outspoken about treatment of refugees, especially in South Africa during the xenophobic violence that broke out in 2009. How does MSF see its mandate in Africa?
Our mandate has pretty much been the same. We respond to needs. We work in places where people have been affected by conflict, of course, but not just conflict—natural disasters, epidemics, neglect, hunger, fear. One important element of our independence is the ability to come in, assess needs, assess vulnerabilities, and then respond as we think is most appropriate. We talk to all of the stakeholders, and we find the way forward.
I very rarely call us an emergency organization. Emergency implies that we're always responding to earthquakes, floods. But an epidemic is an emergency, a social emergency. We know in the last 10 to 15 years, the nature of the HIV epidemic—and now drug-resistant TB in South Africa—is a crisis situation. That's what guides us.
Of course we are a humanitarian medical organization and we have to be humble about what we can achieve. We are under no illusion that we will be able to treat every patient in all of the countries where we work, but we always try to make sure that we serve as a catalyst for change. Our way of working—and we do a lot of operational research—is to look very hard at how we can provide the best possible care to people living in very disadvantaged situations. And we engage governments and other policy makers in a dialogue, so that some of the lessons we learn can be scaled up. That's how we see our action reaching a wider population.
MSF has shown a willingness to be transparent about the debates you face in taking decisions. [In January this year MSF published Humanitarian Negotiations Revealed and in 2004 it published In the Shadow of Just Wars.] How does MSF decide when to stay in a particular area, when the compromise is too much, and when to walk away?
We have no hard and fast rules; it has to be taken on a case-by-case basis. Every day we work in the field is a delicate balance about being principled and responding to the needs of people. It's a balance between principles and action.
You can be very principled, but that means in many places we will not be acting, that people will suffer. And then we can be all action and throw principles out of the window, but that's a slippery slope as well, because the principles ground us. Anytime we compromise or move away from principles, it's a reference point for us to come back to.
Independence, impartiality, and neutrality are the three main humanitarian principles. But equally important is the principle of humanity, of treating people with dignity. In the end, you want to provide medical care that is effective, that will heal people and create wellbeing. If at any time our action is limited to a point that we no longer can provide effective care to the people, then it's time to leave or speak out and be vocal about it.
Typically, when aid is being diverted by governments for nefarious purposes or dodgy aims, then we speak out. When we are denied access to places after trying again and again, and we're not allowed in, then we speak out, because we believe all people in crisis should have access to health care. When safe spaces for health workers to deliver care and for people to receive care do not exist, it's another instance where we absolutely have to talk about it and be very vocal. These are general operational principles, but we have to approach each situation on a case-by-case basis and then make that judgement, and not be very dogmatic about it.
Are you back in the Dadaab refugee camp in northern Kenya now?
Dadaab is the biggest refugee camp of our time, and there's a big role for us to play. We are still there. We have hospitals, provide nutritional support, and treat patients. We also deal with epidemics like cholera. The (MSF) people who were abducted from Dadaab—I can't comment. They remain abducted and we are calling for their safe release.
You've been with MSF since 1995 and you are midway through your three-year term as president. Do you have particular targets or things you'd like to see happen?
The presidency of MSF is an elected position—elected for three years and a second term is a possibility. We have a very flat organization and a very vibrant association. An association is made up of people who work for MSF currently, or have done so in the past. There are really extensive debates each year about the direction of the organization. It can be a bit chaotic and cumbersome, but it's an essential nature of our organization and it allows us to be who we are. So yes, I'm the president, but I reflect the will of the association members and we want to continue to be an organization that is able to provide the kind of care that people need.
The world is going through several transitions. Even in the poor countries where we work, people are living longer, so they're moving away from an infectious disease epidemiology to a more chronic disease epidemiology. While recognizing that the poorest of the poor still have an infectious diseases epidemiology, what we want to do is on top of what we are doing now, so we need to have the capacity for that.
In a lot of places, because people are living longer, we need to look at the plight of older people and other vulnerable people.
So, there's an epidemiological transition, a demographic transition and also a migratory transition. We've always dealt with refugee issues, but there are also people moving within countries from rural to urban areas. It doesn't make any sense to classify people as political refugees or economic refugees. People are moving for whatever reasons because they do not feel secure in their homes.
For the first time in our history we are now an urban civilization and we need to understand the complexity of urban health and address that. We already have some experience in working in urban areas—we have a project in Johannesburg—but we need to do more.
Then we have climatic transitions. How that will affect things? For example, we will start seeing malaria in places where people were not exposed to malaria before.
So these are some of the transitions we need to navigate in the coming years. And my job is to make sure our organization is prepared to meet these challenges, and to do that in a responsible, ethical way, to make sure we keep the needs of people front and center.
What would be some of things that require attention in urban settings? MSF has been working in Khayelitsha (in Cape Town) for more than 10 years, that's an urban setting, although it includes a lot of informal housing.
When I say urban I'm thinking more of a setting like Johannesburg where people are caught in a downward spiral of poverty, disease, and violence. And of course exclusion, it just gets worse and worse. So in Rio (de Janeiro), in Johannesburg, in Mumbai, all of the big mega-cities, these are the things we need to look at—how to provide effective care and how to access patients. It's not easy and it's a very different kind of work than what we were used to in our 40-year history. So these are things we are learning as we go along and we have some experience now.
We also need to focus on the plight of children. Trafficking, for example, these are issues we don't always work on, but we will need to look at the plight of all these different groups of people.
Does that imply much more engagement at a political level?
We're not a political organization, but the medical work we do has a political character to it because we are raising uncomfortable questions to policy makers and health ministries. Because in the end, our action is emblematic of failure. We are there because the system has failed.
Almost everywhere we work, we operate in a failed system where those responsible, especially the governments, are not able to meet people's needs—for various reasons. In some countries it can be very deliberate, in other countries it's just because they don't have the means, they don't have the expertise, or they're not structured to do it.
Having said that, we also need to be careful about what we do, as a humanitarian organization, and what development agencies do. We tend to put everybody in the same aid basket, but there are very different mandates and very different paradigms.
To boil it down to bare essentials, we treat patients; we don't treat systems. Of course we engage with systems, but our objective is always to treat patients and not to treat systems or to set up a new health system for any country. However, when we work, we want to work in a responsible way, so a lot of the initiatives and innovations, a lot of our operational research, has enabled us to scale up our treatment either by countries or other organizations in a big way.
What we've learned in Khayelitsha has had enormous impact. The (HIV/Aids treatment) program itself treats about 20,000 to 25,000 patients in Khayelitsha, but what we've learned and how we've structured things—that goes towards building sustainability. Yesterday I was in Khayelitsha and met some adherence clubs and support clubs, they might seem minor activities, but the impact they have on keeping people on treatment and improving their quality of life is enormous. These lessons can then be taken up by governments and policy makers and they can implement them.
And that's the difference when we say "sustainability." We're not necessarily talking about sustainability of that one project where we work, but sustainability of ideas and sustainability of policies or evidence that can then be scaled up by others.
This goes back to the earlier statement I made that we as an organization are not able to treat all patients. So we have to make sure that where we work we have the right policies in place, the right tools are available, and the right environment exists for patients to access drugs and support tools. Then, when it all clicks into place, it's for us to get policy makers and other communities to take notice and hopefully scale up and reach more people.
We've done that in HIV, we've done that in malaria, we've done that in nutrition, and with neglected diseases like sleeping sickness, like kala-azar, so that's how we look at it.
We need to be very clear that as a humanitarian organization our mandate is very limited. Actually, when you look at it from a health perspective, it is not that narrow, but when you look at all of the other social issues that are taken on by development agencies, it's quite narrow.
I'm not for one second saying that development enterprises are any less important, but they have a different way of approaching their mandates and they usually work with systems. They want to create systems that can provide. We look at it from the other way— rom the patients' perspective—and that determines the kind of system you need to put in place.
In the current financial climate MSF seems to be extremely robust and active, and there are no signs of needing to scale back. What is the situation?
We've always believed that the health of our organization and our ability to carry out essential life-saving programming depends on the goodwill of the public. Today we are lucky we have around five million people around the world donating on a regular basis. For us it's not about one or two people donating U.S.$2 million or $3 million, for us it's about the grandmother in France who donates 30 euros a month, or a grandfather in Japan, or even South Africa. We even have people from Khayelitsha who donate. So we have that diversity and that is important to us.
We consider MSF to be a movement and part of being a movement is to have an idea that inspires people. It's an idea that makes people want to express solidarity with people who are going through a difficult time in different parts of the world, and sometimes in their own community. In doing that we are very conscious of our moral and ethical responsibilities. We take the wishes of our donors very seriously and we try to speak to our donors as adults. We don't just feed them stories about how many kids we've vaccinated, but we really communicate the challenges we face in carrying out our actions and take them on a journey with us.
So far our donors have stuck with us in this crazy journey. That doesn't mean we don't have our constraints, we live in the same world, but we are still able to carry on. And we're very careful. Our fundraising is completely dictated by operational needs, not the other way around. We only raise as much money as we need to carry out our operations. We have gotten big, that's undeniable, but at the same time it's important that we're clear about what guides the organization. We don't raise money and then say, "Okay, what can we do with this money?" It's the other way around. We have to be very clear what it is that we need to do—not even what we want to do, but what we need to do.
*Update: On April 25, 2012, the Kenyan High Court ruled that the country's anti-counterfeit law was unconstitutional in its determination that generic antiretroviral drugs were classified as illegal counterfeits.
© 2013 Doctors Without Borders/Médecins Sans Frontières (MSF)