Chapter 2 - MSF “Satellites”
A Strategy Underlying Different Medical Practices
Claudine Vidal and Jacques Pinel
In the mid-1980s MSF began creating entities that operated independently from headquarters. The first was MSF-Logistique in 1986, followed by Epicentre in 1987, the Campaign for Access to Essential Medicines in 1999, and, lastly, the Drugs for Neglected Diseases initiative (DNDi) in 2003. When MSF-Logistique was created, the organizers wanted to ensure that logistics specialists could prepare for field assignments without being under the direct authority of operational managers. They would then have more freedom for initiative and a more favorable time frame in which to prepare the logistical groundwork for an intervention. MSF has continued this policy ever since.
Has this strategy had repercussions for medical innovation? We offer a brief analysis of the intentions behind creating these satellite entities, and of their effect on working methods in the field.
The intention here is not to reconstruct a history of MSF satellites, determine who initiated these institutions, or describe their development. The objective is to see how MSF built a specific operating culture while expanding its operations. While the decision to create autonomous entities was in keeping with this culture, and a high value was placed on self-sufficiency, it also stemmed from a changing set of historical factors linked to globalization as well as the historical, geographical, and sociological diversity in the various fields of operation. MSF responded to this diversity by varying its operating methods and accepting a wider range of roles.
Medical care, however, remained paramount, which posed a challenge for MSF: finding the resources it needed to practice medicine in situations and areas with non-existent or poor practice conditions, particularly in refugee camps and wastelands where everything had to be built from scratch. Satellites were created to meet both the ongoing desire for self-sufficiency and the specific requirements of each operation. Lastly, another cultural characteristic is that satellites generally developed their activities based on field experiences and an examination of these experiences by practitioners.
The creation of MSF-Logistique and Epicentre in the late 1980s is therefore based on cultural choices or, if one prefers, on a practical rationale specific to MSF. In return, further developing these satellites helped MSF develop its specific medical practices and often gave the entities the opportunity to be different—and sometimes innovative—when replacing practices deemed ineffective.
It was over a decade after the founding of these first two satellites that the Access Campaign and DNDi were created. These were based on the same principles, but with two differences. Even though they continued to respond to situations in MSF’s most common fields of operation, they also tried to act earlier in the process by calling on outside players—mainly those in research and pharmaceutical production—in order to take into account medical shortfalls affecting populations stigmatized as unprofitable. This first difference explains the second: these new entities would, by necessity, initiate and fuel public controversies.
The two generations of satellites differed in focus and approach. For the first generation, in the late 1980s, the key task involved managing internal aspects of operations to ensure quality. Monitoring the technology used in operations or scientifically assessing health conditions required incorporating knowledge, techniques, and skills different from those available at the time MSF was created. This effort was carried out by MSFLogistique and Epicentre.
In the late 1990s and early 2000s, the second generation of satellites sought to transform the external environment. When it appeared that the vaccines, diagnostic tests, and drugs that comprised the medical kits developed by MSF-Logistique (particularly those designed to fight infections) needed to be replaced, the necessary products were not accessible. This was attributed to a series of obstacles—economic, legal, and political—that would have to be overcome. The association demonstrated the need for these products in their fields of operation and conducted advocacy campaigns based on the ethical obligation to save patients who could be saved if a number of external conditions were changed.
Here, too, other disciplines turned out to be essential to MSF’s work. In synergy with the Access Campaign and DNDi, MSF developed relationships with a wide range of organizations, including the World Trade Organization, the Group of Eight, multinational drug companies, patient associations, and health care advocacy groups, with the aim of influencing their policies and initiating new forms of cooperation. Since then, these relationships have played a central role in MSF’s political concerns and the controversies in which they have been involved.
The fact that this analysis of the satellites’ origins covers a relatively long period should not lead to an illusion in hindsight about any organizational genius specific to MSF. These new structures were based on the dominant practical rationale as well as operational dispositions, as suggested above, and as will be further explored below. If there is anything to be said about MSF’s organizers, it is that they did not demonstrate any proclivity for centralization, although they could have. They wanted to avoid excessive expansion of the central apparatus and also expected MSF-Logistique and Epicentre to cover a portion of their own costs through paid services. To highlight this anticentralist spirit, we will give a brief presentation on MSF-Logistique. Our source, who was instrumental in creating this entity, explains that for three years the organization’s leaders simply left him to his own devices. He was then asked to take charge of MSF-Logistique, and this subsidiary relationship has never been called into question.
From Support to Logistics
MSF’s expertise has largely been forged by the organization’s experience in refugee camps. The first major independent “refugee mission” undertaken by MSF—which, until then, had been working in facilities run by other organizations— was in the Sakeo and Khao I Dang camps for Cambodian refugees in Thailand in 1979. First, the organization developed an intellectual toolkit to understand how the geopolitical context could determine refugees’ safety and status. With concerns such as these, the operational quality of MSF’s missions was initially not a priority. For example, in late 1979, when the number of Cambodian refugees in Thailand rose from thirty thousand to three hundred thousand in just three months, an MSF team was working in a camp (Sakeo) that had only recently opened. Drugs were in boxes piled under a tarp and staff members took whatever medicines were easiest to find. This situation called for the first logistical measure: make drugs available and organize them in such a way that users were able, as much as possible, to understand the various nomenclatures, since the drugs originated from different donor countries. The second measure involved laying the foundations for a procurement system by tasking someone with supplying the medical teams with water and provisions, because the field teams at that time only consisted of doctors and nurses.
In 1980, the Khao I Dang camp housed one hundred thousand refugees. There were also other camps along the Thai–Cambodian border. The MSF team, numbering forty to forty-five members, was staying in a small town that they left every day to work in Khao I Dang and other camps. A logistical system was needed, even if it was only rudimentary. In addition to the physical organization of the pharmacy, lists of drug orders corresponding to the various diseases were created and sent to the doctors, who were required to follow procedures. It was also necessary to set up a car system, to know who needed to go where, and to make sure that staff put the keys on the board for the next person. There was obviously nothing novel about these measures in themselves, but they were completely new to MSF medical staff.
Every day, a doctor and two nurses would go to one of the border camps, where five thousand to then thousand refugees were taking shelter. Each camp included a clinic where women could give birth and a drug storage facility. MSF could, if necessary, receive authorization from the Thai military to evacuate patients to the Khao I Dang hospital. Some of these camps served as rear bases for combatants wanting to liberate Cambodia from Vietnamese occupation, however. The Vietnamese would attack and destroy the camps, people would flee into the forest, and everything would be looted. The camps might then become inaccessible for several days. So MSF had to call the military every morning to find out whether the medical team could enter the camp where it was scheduled to work. When the answer was affirmative, the team could only remain for two hours. This meant deciding what to take and then preparing it, a process which led to time-wasting debates.
There was no systematic solution to this problem. Nevertheless, even though the team could not know in advance what it was going to find on site, the camps’ medical situation was not unknown. There were women ready to give birth who might need to be evacuated. Other patients had injuries, respiratory infections, and malaria that needed attention. A standard toolkit appropriate for this general situation was created: a large box made by local carpenters that could serve as an examination table and that contained emergency kits and drawers in which supplies were classified by need. Time was no longer wasted when team members left for work because all they had to do was to put the box in the back of the truck. The box was called “semi-mobile equipment” because it was heavy and cumbersome. Several boxes were made, and each one was assigned a manager to ensure that it was kept up-to-date. Several copies of a document with the protocols of five or six diseases were included; this document was developed by the International Committee of the Red Cross (ICRC), which coordinated the medical teams working in the Khao I Dang camp.
The MSF teams in Thailand grew to include 110 people working at nine camps. They added experience at the national level to the skills they had already acquired in the Sakeo and Khao I Dang camps. A standard nomenclature was now used to order drugs, a manager was responsible for the cars, and an administrator was assigned to each team.
This system, introduced in 1980, seems rudimentary in hindsight, and indeed it was. Yet the fact remains that it heralded a decisive change in the way MSF perceived its organization. It now associated the effectiveness of its medical humanitarian work in emergency situations with logistics specifically designed for such situations—logistics that could be deployed quickly in response to supply and transport needs, along with communications between teams and headquarters. It took several years gradually to identify and resolve the major difficulties stemming from the integration of medical activities and logistical skills. In 1986, the decision was taken to give the teams working on these issues autonomy to set up a satellite— and thus was born MSF-Logistique.
A special study would be necessary to provide a detailed analysis of how the association between medicine and logistics produced specific organizational methods, and how these methods evolved as MSF’s activities rapidly expanded during the 1990s. A number of the practices and technologies adopted relied on existing models, but they were streamlined based on field experience and integrated in such a way as to remain consistent with the entire system.
MSF’s innovation was to become independent in practical matters by creating its own protocols and tools. It was necessary to set up multidisciplinary teams of medical and non-medical staff. Logistical specialists quickly became essential to these teams, even giving rise to “another” medical position (Diaz, 2006). Moreover, to maintain a balance between old and new medical players, MSF had to accept the fact that the usual medical hierarchies would not necessarily be reproduced in the field. Because medical personnel with practical experience in these regions were essential for the success of these missions, young physicians could exercise responsibilities that would normally be performed by department heads in their own countries, and nurses could take over medical management of a mission.
Kits and Guides
The semi-mobile equipment was the first in a series of kits designed by MSF. It was not itself an invention, having been modeled on techniques used by the French emergency medical service. It was, however, an embryonic innovation because it was part of the specific “ecology” of emergency humanitarian interventions: a large number of patients from poor communities facing precarious security conditions and typically living in unfavorable and hard-to-reach areas, combined with a high turnover of medical personnel, most of whom had no experience with the tropical diseases they now had to learn how to treat.
In Thailand, the Office of the United Nations High Commissioner for Refugees (UNHCR) drafted an emergency medical guide in the early 1980s. Oxfam designed a nutritional kit. MSF teams revised the guide based on their own experience to anticipate responses to situations in which it would be used. This became the Clinical Guidelines. Standardized drug and equipment lists were drawn up and everything, including user manuals, was packed into kits intended to meet the needs of ten thousand people for three months. The Clinical Guidelines was called the “green guide,” after the color of its cover. Together with the kit, it was expanded and revised by its users when they reviewed any of its chapters.
A guide to essential drugs was added to the green guide. It was designed for medical staff with very different levels of training: for doctors unfamiliar with tropical environments, for nurses, and for national doctors working with MSF. At the outset, the guides and kits met the need for streamlining operations management, but they also sought to standardize medical practices. Combined with MSF’s training program and operating culture, the kits turned out to be effective and applicable to many emergency situations. In 1988, the World Health Organization (WHO) put a label on the kit, calling it the “new emergency health kit.” Some advocated retaining the MSF label. Others pointed out that the WHO’s endorsement made it more influential, even if it had largely been developed by MSF. Since then, the International Committee of the Red Cross (ICRC) has become a major purchaser of the green guide for its operations. Furthermore, the kit has often been “borrowed”—which is to say, illegally translated—in various countries with MSF’s tacit approval. Its first editions, in fact, arrived in the field with “Please copy” printed on the endpaper.
Since the “historic” kit created in Thailand, MSF-Logistique has created many other kits. To cite one example, the vaccination kit for measles, meningitis, and yellow fever enables MSF quickly to set up a cold chain and includes all medical and logistics supplies necessary for a vaccination campaign by several teams of vaccinators. The surgical kit, which contained resources allowing medical personnel to perform three hundred operations and manage one hundred hospital patients, includes drugs, renewable supplies, and the necessary equipment to meet the needs of an existing hospital’s surgical program. There is also a kit for creating a hospital with inflatable tents.
While this type of kit was unquestionably inspired by military medicine, there are major differences between military surgery and the type of surgery practiced by humanitarian organizations. Military surgery as practiced by wealthy countries is much more sophisticated but gives priority to treating a more limited population—wounded soldiers. Even though the two concepts are close, in practice the MSF kit’s composition is different. It has enabled advance planning for surgery in humanitarian situations and has provided rapid intervention capacities under satisfactory technical conditions that previously existed only within the militaries and civil defense services of developed countries’ militaries.
Lastly, a three-fold imperative—consistency, simplification, and learning from experience—drove the process carried out jointly by MSF and its logistics satellite. In order for a kit to meet the needs of a given humanitarian situation, the supplies must be consistent with the operating method recommended in the reference documents, training must conform to these documents, and at least one or two team members must have experience in comparable situations. In the early 1980s, MSF practitioners were concerned about the continual loss of field expertise due to high staff turnover. This concern provided powerful motivation for producing the first guides. While even those guides may have seemed presumptuous given MSF’s modest experience, they were the best way to preserve and enhance field experience.
The effort to improve medical practices in response to emergency situations relied on the ability to codify and develop standards and to provide the elements necessary for conducting field operations. Through this normative process of preparing supplies appropriate to the circumstances, the teams could develop micro–working environments in contexts where it would not otherwise have been possible to conduct medical activities effectively.
In addition, any emergency operation inevitably involves risk-taking, even if a highly detailed understanding of the situation helps limit risk. This risk culture, adopted and controlled to the extent possible, was transferred to the medical arena. MSF doctors made recommendations that they felt were better suited to their patients’ living conditions and that they had the logistical means to implement. But these recommendations sometimes met with resistance from national or international medical authorities. At other times, recommendations that could be carried out in one region were rejected in another. Lastly, and most frequently, these recommendations concerned a large number of patients. As a result, it was considered essential to set up a system of epidemiological assessments and surveys in tandem with the development of a logistics system.
MSF officials then decided to create subsidiaries based on several disciplines—medicine, biology, statistics, and more—in order to conduct research and epidemiological activities. The aim was to provide scientific support to operations and sell epidemiological assessment services to other organizations. At the time, developing training and methods for the type of assessment sought by a practitioners’ association was an innovation in itself (a medical computer expert was even added to the Epicentre team in 1987). As with logistics, MSF decided to allow these specific professions, which differed from MSF’s core activities, to operate according to the principles of their own fields of expertise. And thus, Epicentre was created.
Epicentre’s strength is the ability to apply epidemiology quickly in crisis situations. This rapid response, which did not exist outside MSF, was made possible by MSF-Logistique. It was still necessary to come to a decision and create the opportunity. In fact, it was rare for a team to manage the requirements of a daily research project that did not come into play during the operation itself and did not appear to be a priority. Experience gradually won over the players in the field when, for example, epidemiological data validated the introduction of a single-dose injectable or oral drug to replace a one-week treatment.
The Campaign for Access to Essential Medicines
Epicentre’s creation reflected an aspect of the operating culture that was developed during the 1980s: trying to find upstream solutions to improve patient treatment, taking into account the specific needs of practitioners in the field. The Access Campaign, created in 1999 and based on the same rationale, was also set up as a subsidiary of MSF. There was more to it than that, however: the Access Campaign took on, albeit for its own specific objectives, a role regularly assumed by MSF— that of a “witness” engaged in political advocacy. The Access Campaign therefore worked from the beginning with human rights and health care activists.
In 1996, MSF and Epicentre organized an international colloquium for the purpose of exposing and condemning the lack of medicines necessary for treating infectious diseases— a worsening situation that was striking developing countries particularly hard. The speakers noted that while rich countries had achieved significant progress in all medical fields, humanitarian organizations were increasingly unable to respond effectively to epidemics for the following reasons: the production of certain drugs had been abandoned because they were not considered profitable by pharmaceutical firms (in the case, for example, of human African trypanosomiasis—also known as sleeping sickness); other drugs were no longer effective due to resistance developed by parasites (the chloroquine-resistant malaria parasite, among others) and no research was underway to discover new treatments; overly restrictive treatment protocols that were difficult to comply with and encouraged the appearance of resistance that left the patient without any recourse; and antibiotics that were effective but unaffordable.
Different levels of responsibility were identified: systems for protecting brand-name drugs that prevented the production of much cheaper generic drugs; the utopias endorsed by international organizations (the WHO and UNICEF) such as the program “Health for All in 2000,” which relieved states of their duty to provide medical care; pharmaceutical companies’ lack of interest in researching and producing medicines for disadvantaged populations; and the priority given, even by MSF, to prevention rather than treatment.
Some MSF management no longer accepted that they had no choice but to provide increasingly poor treatment or no treatment at all, and wanted the quality of care in crisis situations to become one of MSF’s priorities. First, a Medicine Unit was created within MSF-France in 1997, followed by a Research Group on Essential Medicines.
The Medicine Unit, initially consisting of only a few people, understood that other types of expertise had to exist alongside pharmacological and medical skills, especially legal knowledge of the patent system. The treatment of certain diseases also needed to be simplified in order to broaden and improve implementation, particularly by MSF. The unit realized that it had to appeal to public opinion worldwide by conducting systematic campaigns, but these campaigns required solid information based on the work of consultants and experts across a wide range of fields. Various disciplines were eventually grouped together in a separate body called the Access Campaign, which became a subsidiary as an MSF inter-sectional project, thereby giving it broad scope.
The Access Campaign achieved results by leveraging MSF’s reputation—the organization was awarded the Nobel Peace Prize in 1999—and its “ability to make itself heard.” The following recollection by one of the Medicine Unit’s members serves as an example. He recalled that a letter protesting the abandonment of an essential medicine (eflornithine) for the treatment of sleeping sickness had not received any response from the manufacturer. A few years later, the company resumed production and MSF received free supplies of the drug on condition that it manage the global stock and handle distribution.
MSF thus developed a strategy of operational independence in terms of logistics, scientific assessment, and advocacy for the production of essential medicines. This development resulted in a decision to avoid depending on other organizations. The emergence of different medical practices resulted indirectly from this policy of autonomy. This policy also prompted a gradual transformation in the role played by MSF physicians, who increasingly became both practitioners and promoters of new medical procedures, as evidenced, for example, by MSF’s conflicts with the WHO. MSF called for changes in protocols and new therapeutic strategies and criticized treatments and products it deemed ineffective, even when the WHO and national medical authorities continued to endorse them.
A press release issued in Geneva on July 3, 2003, announced that five prestigious medical and research institutions were joining forces with MSF to create DNDi.
Developing drugs from existing compounds was one of the main ideas motivating the partners to create DNDi. When the major pharmaceutical companies lost interest in tropical diseases, they had already developed compounds for potential medicines but had not yet reached the final stages. It was therefore necessary to conduct clinical studies, but that is not one of MSF’s activities. Several universities had conducted, and continued to conduct, basic research on neglected diseases and had discovered molecules without developing them into drugs. The companies could have used this research, but they lacked interest because it involved reportedly unprofitable markets. DNDi took the position that the development of new treatments for the most neglected diseases could not result from market incentives and that a public commitment to meeting these needs was required. It was therefore necessary to mobilize a network of institutions in agreement on this type of research and development strategy.
Medical innovation plays a key role in DNDi, and it could have a considerable effect on treating diseases that affect massive numbers of people in the southern hemisphere. For example, in the case of sleeping sickness, which is one of DNDi’s priorities, the development of an oral tablet to treat the two forms of the disease without being too toxic would be a radical change for patients.
Some at MSF consider DNDi a fundamental and innovative break with the past: neglected diseases can now be treated. One member, speculating how MSF might be perceived in a few decades, thought that people may one day forget its pioneering role as a medical organization, but not DNDi or its “invention” of a new political economy of drugs. Is this a utopian view bound for disillusionment? Perhaps, but without a touch of utopian idealism, how can we practice the “impossible discipline of innovation” in medicine (Latour, 2003)?
For more than two decades, the creations of structures that are autonomous yet retain an organic link to MSF’s medical activities have contributed to improving the quality of its operations. The studies in this book of certain diseases provide detailed examples. But contributions from satellites also weaken MSF’s crippling tendency to rigidly and endlessly reproduce its operating culture. By inviting contributions from those who have acquired experience outside MSF and have had professional relationships with a wide range of institutions, MSF’s satellites bring in a range of perspectives on humanitarian medicine. Their contribution is not limited to developing logistical or medical tools, producing scientific assessments, or trying to remove obstacles to necessary, but inaccessible, drugs. As intermediaries, they draw MSF into dialogue in many different settings, encouraging the association to open up and learn from others.