Executive webinar series

with MSF-USA executive director Avril Benoît

MSF teams train care home staff on how to use personal protective equipment (PPE).
Spain 2020 © Olmo Calvo
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Doctors Without Borders/Médecins Sans Frontières (MSF) teams are responding to crises in more than 70 countries. In 2020, our teams are responding to COVID-19 while maintaining other essential health services. We’re learning how to adapt to the evolving needs—from dealing with supply shortages to supporting essential workers to strengthening public health promotion. MSF teams have been working with local health authorities and community groups in the US and around the world to help slow the spread of the disease and to respond to evolving needs. Thanks to your ongoing support, we're able to deliver lifesaving medical care to millions of people caught in crises around the world. 

This year, we're pleased to present our executive webinar series to our most valued supporters. Recordings and transcripts of our executive webinars are available below.

Past executive webinars

September 15, 2020 - Webinar with MSF-USA Executive Director Avril Benoît

Read transcript here

Avril Benoît:


So, I'll get started with Yemen, because this is, as you know, a place that's been in conflict since around 2014, and some agencies of the UN call it the world's worst food crisis at the moment. And it's mostly due, of course, to the conflict. It's a Civil War pitting the Houthis in the North against the Saudi-led coalition and the internationally recognized government more in the South. So, you've got separatist forces. It's a proxy war involving many governments in the region, and that's what makes it all the more devastating for the people there.


Thousands of people have been killed, injured. We have at least 3.6 million people are displaced by the conflict, forced to flee their homes to find safety. You've got the history of cholera, even of diphtheria. Malnutrition, of course, always present. The healthcare system, we have been trying to sound the alarm about the healthcare system. It's basically crumbled with only half the country's health facilities, little clinics in towns even operating. Lots of medical supply chain issues, or they don't have the equipment, the basic supplies they need to run the clinics. And then there are, of course, all kinds of staff shortages because there's no one paying.


24 million Yemenis, 80% of the country's overall population, are said to require humanitarian assistance at this time. And that's according to the UN. Compounding all of this, of course, you've got the fuel crisis, shortage of food, shortage of drinking water, clean drinking water, COVID-19. Very difficult to even know how many people have COVID-19. The testing capacity is extremely limited. A lot of healthcare workers have been testing positive. More than 2,000 cases of coronavirus, including 584 deaths by the last figures that I saw.


And again, the tally, as in many countries where we work is much higher. We just don't have the capacity, or it's not safe for us to go there and be able to do the kind of screening and testing that's necessary. Another thing that's going on in Yemen with respect to the pandemic is that there's an enormous amount of misinformation. There's a lot of fear for people who have it or who think they might have it, fear of being stigmatized, and so what ends up happening is that they don't get care. They don't get tested, they don't go in for support, so you've got the fear also of health workers who know that they will not be provided with the PPE necessary to protect themselves above all.


And so, they quit their jobs because they're afraid as well. They know their facilities are under-resourced, and so what MSF has been doing is urging countries that are involved as belligerents in this kind of proxy war in Yemen to make sure that the resources, health resources, the medical supplies, not to mention food and fuel, are made available so that people can have safe access to healthcare and aid of all kinds. Just yesterday human rights watch published quite a good report, actually, urging more attention to the health needs in Yemen and really calling out what what's been blockages in terms of the delivery of aid. There are all kinds of onerous restrictions that both the Houthis and other authorities have imposed on humanitarian organizations, aid agencies, even the UN, making it so much more difficult for us to get what we need to support people there.


And of course, we're still running the hospitals that we've always been running and all kinds of COVID-19 centers, really trying to work with authorities in whichever place we're working. Of course, we're in most of the governorates or the States within Yemen, and just trying to train up the health workers to do the best they can with what they've got. So a big point of concern for us, Yemen as always. It's really one of our most complex, and I would even say expensive, countries of operation. It's just so hard to work there. So that's Yemen.


Lebanon, of course, you heard about the explosion in the port. A lot of people injured. There's an economic crisis, of course, that underpins everything in Yemen political crisis, crisis of confidence in the government. The Lebanese pound, for example, just lost 70% of its value in the last year.


And so we had this economic collapse just continuing the healthcare system made up of both public and private, but a lot of the people in Lebanon no longer had the means to be able to pay for the private healthcare services, which is something we see in so many countries. And so when the explosion happened, we were quite concerned. Of course also because COVID-19 had really been appearing and having its ups and downs as elsewhere, when the explosion happened, you could see that the emergency responders were doing the best they can, but not always masked, not always able to the kind of protocols, and sure enough there's been an uptick in the number of COVID-19 cases since that explosion on August 4th. It was a very dramatic event. 4,000 people were injured to various degrees, a lot of them with minor lacerations, of course, and just from the flying debris and so forth. Not as many burn victims as we expected given that it was an explosion. So, you know, all we can say is that we were expecting these very severely burned patients to come in. One can only speculate that either you got out alive or you died in the explosion, and for the rest it was it was largely manageable with the local capacity that health officials, including the Lebanese Red Crescent Red Cross had, plus the extra support that MSF and other medical aid responders were able to provide. So that was our focus, just to be able to support local hospitals by providing them with some kits, first aid kind of kits, to support the Lebanese civil society organizations on the night of the explosion, and then making ourselves available for referrals to our various facilities in the country that we run normally. In parallel to all of this, as with many places where we work, it's not just the physical medical care that we provide, it's also the mental health care. And so our mental health team was also coordinating with the national mental health program in order to provide psychological and psychosocial care to those who needed it. So that's a real added value that we're increasingly offering in many of the places where we work.


Specifically, when you've got so many people affected by such a tragedy, it's very, very much appreciated. So, for all the people that were wounded, of course you still have the usual needs in Lebanon. There are a lot of refugees in Lebanon refugees from Syria and also the longstanding of Palestinian community there. You have people with chronic diseases, and that's often something that they don't manage with the private system and so MSF is able to provide that free healthcare for people with chronic disease and making sure also that, if we can pitch in for medical equipment to ensure continuity of care for the elderly or the disabled, people with specific needs, we've tried to do our best to respond.


Another place has fallen off the radar a little bit, and this always worries us, is Syria. So, for many years now, as you know, since the beginning of the war there, MSF has done its best to support Syrian medical teams on the ground. Sometimes we can't have our own teams there, the international teams that is, and so what we end up doing is trying to reinforce the capacity of medics who are volunteering within those communities to be able to support. But in the Northeast, it's often been possible, off and on, depending on the security environment and the willingness of authorities for us to be able to work. In Syria, we don't hear a lot about it in the US but it's still 700,000 people are displaced within Syria. And then you've got, of course, the millions that have fled the country and are now refugees or claiming refugee status in other places.


And what we have as a continuing concern are these camps, camps within Northeastern Syria, where people who have fled at different times say the conflict in Mosul some years ago in Iraq or people who have fled other parts of Syria have found themselves in these camps that are now managed by local authorities, and they're not allowed to come and go. They're not allowed to go out and seek work or find assistance. And a lot of these camps are home for women and children, largely, some of them up to 80, 90% are women and children or people who are much older. So, these are not fighting forces, but they're kept in these camps almost as suspects in the war, suspected to have allegiances to groups like Islamic state, suspected to be maybe on the other side. And so, as a consequence, they're in these camps, not allowed to come and go, mostly women and children, not given any opportunity to claim asylum or seek some way to move on.


I went to one of these camps a few years ago, and what was very clear in terms of how the people were describing it is that if they had money, they could probably buy their way out, but these were people who were largely abandoned and they didn't have relatives they could contact me outside. It was just so problematic from a, just from a human rights point of view. And in some of these camps, you also have the risk of COVID-19.


In the Northeast, as in other parts of Syria, an extremely fragile health system. We have been supporting hospitals in the region around Qamishli and Hassakeh, if you know your northeast Syria map. These are places where the general hospital had fallen into such terrible disrepair, gutted of equipment and supplies that we really try to reinforce that capacity and build it up again some years ago. And now we really are struggling with limited hospital beds to take in those severe cases, people with COVID-19 who require inpatient care.


So extremely difficult, very burdensome on those health workers that have chosen to remain with their people. They're very dedicated, and we do the best we can, not only to support them in those hospitals in the larger towns in the region, but also in some of the camps, such as Al-Hol where we, again, are deeply concerned about all the restrictions that are imposed on the thousands of people living there and just yet don't seem to have a way to move on with their lives.


So very much concerned in all the places where we work where you've got those refugee camp settings with an outbreak of COVID within them. And this is a struggle that, boy, since February, March, our teams all over the world, working in those camp settings, where you often have congregate conditions, people living all together in small structures or tents, multiple families living in one structure, or very large families living in them.


Often local authorities, when they start to have a suspected case or risk of an outbreak, they just lock everything down, and this is kind of what happened in Moria, on the island of Lesbos in Greece where you had camp dwellers, 12,000 people in this closed camp, so effectively an open air prison. Authorities say, "Oh, we're starting to see cases of coronavirus. Everybody stay in your tent and nobody can come and go”, and that's it. You've got maybe seven people in one of these structures. It's either a tent or a container, and people start to really struggle with this. They just can't see how this is ever going to end. And then compounding with that you've got local people, so people who don't like the presence of all these newcomers in their midst, and this is a factor we see in many parts of the world. We see it sometimes in Syria, but in Greece, for example, you had protests and fires lit, like even our own pediatric center was set fire by protesters from the local community, the host community, that resented the presence of all these migrants and refugees on their island and wanted them gone.


This is one of the very complicating factors when it comes to the pandemic is that we're already stressed and at the breaking point. Just think of how it is in the United States with all the issues going on, and then you add the pandemic to the strain. It becomes very, very, very difficult to manage. And the mental health burden on the people in these camps is something that preoccupies us a lot. To mention specifically the kids, the young children in Greece, on the Island of Lesbos. We've seen a lot of kids really struggling with anxiety, with depression, no longer speaking. We issued a report some time ago about how some of them were self-harming and talking about suicide. Their parents are despondent, despairing and hopeless about the situation. They don't know how things are supposed to get resolved. Since the big fire in the camp which destroyed pretty much all of it, we have succeeded with other organizations, local grassroots organizations and human rights groups to convince the authorities to at least move 400 unaccompanied minors to better conditions.


I mean, it was just untenable to have all these minors so exposed after the fires. Of course, we're scrambling to rebuild everything. Our clinic was able to continue functioning and providing basic healthcare, but it's one of those places where you just think, how is it possible that this is going on in Europe? It's just gob-smacking, honestly. It's shocking on absolutely every level.


One thing that we're also doing again, is the search and rescue on the Mediterranean. This is a controversial program in Europe, because you have a lot of people who feel very strongly that migrants and refugees should not be getting on boats, hey should not be trying to flee Libya to reach safety in Europe. They should perhaps just turn around and go back to wherever they came from, but the reality is that often there's no going back. And so, for many years now what we've done is partner with search and rescue organizations, and we provide the medical care on the boat.


So, this year it's Sea-Watch 4. Sea-Watch and another Civil society organization called United for Rescue. They run the boat. They provide all the logistical capacity of the boat and the captains and all of that, and they are the ones that do all the interaction with the coast guard authorities because everything is done according to certain protocols, well, it's the Maritime Laws. And then what we do is we provide a four person medical team that includes a doctor, a nurse, a midwife, and also somebody who's going to be capturing what's going on because, of course, bearing witness is one of the pillars of what we call our social mission, what we do. So there's medical action first and also bearing witness because we don't want people to forget the drama that's going on in the Mediterranean with people struggling with their families to escape the horrors of Libya, in particular, and trying to flee for safety.


Of course, all kinds of concerns, again, about COVID-19. We try to do everything possible on the boat to make sure that the infection prevention and control is looked after, that hand washing stations and the physical distancing, but you can imagine when you've got hundreds of people that you've rescued from drowning, we do have a hard time hovering over all of that and making sure that we do it as safely as possible. It's a big challenge, but we're up to it. Our teams are up to it.


You might ask, well, why do we even bother doing this? What is the point of this search and rescue on the Mediterranean? And It's quite simply that we're humanitarians, and we don't think anyone should be left to drown, to sink beneath the waves. The Mediterranean is the world's deadliest border, in a way, for people trying to get to safety. The number of people that have attempted to escape from Libya by sea in the first six months of 2020 increased four-fold in comparison to the same period last year, and the majority of people who departed the coast never made it. They drowned.


So, it's a big preoccupation for us. And what we try to do through this work is to bear witness to what's happening and try to convince the European union States to stop condemning people to drowning through these reckless policies of non-assistance. So that's where we're at with the search and rescue on the Mediterranean. Always very dramatic work that we do there.


And then finally, maybe I can mention with the pandemic you've probably, if you followed some of the webinars that we done over the course of the summer in terms of the operations in the United States, we were located in eight places, eight different locations in the US. It's not that we expected to be the first responder in the US. I mean, we have great hospitals and fantastic medical people, but we did see an added value to be able to use our expertise, to share that. And so we focused on people who specifically seemed to be vulnerable as a group, so migrant workers in Florida, homeless people, or housing insecure people in New York City. We also have focused on Navajo and Pueblo people in the American Southwest trying to boost up capacity for infection prevention and control and to support local teams just to train them up and help them with the flow through the different services they were providing, whether it was the testing sites or residences and health centers.


Our work in Michigan in long-term care facilities has now wrapped up and the team is focused on Houston. So, in Texas we're also working with local facilities to try to increase their capacity to be able to safely look after the people who are long-term residents of those places. And then in Puerto Rico, we also have a program. These are both going to wrap up in the next month or two. In Puerto Rico it's focusing on marginalized street-affected people and doing house calls, so very medical.


We're glad to be on the ground with the capacity we have and hope to hand over to a local organization being put together by our staff who want to continue this work. But Doctors Without Borders is not going to continue operationally responding in the US because we really have so much to do all over the world where there is much less capacity. And we also feel that in the US now we have a much better handle on what to do and we're willing to share our expertise, but we really have to focus on many other parts of the world. If you followed some of the statistics from the WHO, the world health organization, you know that on Sunday, we had the highest single day increase in cases ever, so it's really something that's hitting multiple parts of the world, and we still have all kinds of supply chain issues. It's not so much PPE at the moment. It's more oxygen right now. Initially it was all about ventilators and now it's just about oxygen for patients.


We also know that the wave of increased cases will really hit us in October, November. The world health organization is also warning of that, and the other thing that we're keeping an eye on along with the rest of the medical community are the long haulers, the people who are not fully, fully recovering from COVID-19 infection, and they're experiencing, it seems, lasting organ damage. So you think you're recovering, or maybe you're one of the people that's unlucky, and it just takes a very long time, but now we're seeing that there are long-term effects, that that we have to be very careful about. So, we'd much rather you not get COVID-19, that's for sure.


I think with that, I will wrap it up in terms of the little overview summary because I wanted to make sure that I have time for your questions. And so, I see them coming in through the chat, so thank you very much for jumping in. You've got them into Q&A. So, we have, let's see, John is... Hang on. I'm getting on a little note about my microphone. Sorry. I'll try it this way. I hope this helps. I hope that helps.


So, John is asking “What agencies are involved in the Moria camp response?” I don't have the names of all the agencies because there are actually a lot of them. If you follow the news of what's happened there, and all the ones that have spoken out there are a lot of Greek associations, a lot of civil society groups and of course, even the local health authorities very much involved. I'm trying to think, I'm sorry. Maybe we'll come back to you in the chat with an answer to that question. This is a perfectly legitimate question, but I don't have the answer to all the local partners.


We do like to work in partnership, by the way. We do like to see that, even though we're a humanitarian organization very much focused on emergencies, we feel it's absolutely necessary to support the building of grassroots capacity on the ground.


Can we talk about the DRC and Mali?” A question from Doreen. Yeah, so this is across the Sahel. We have a deterioration caused by a lot of insecurity and Malian, and I know the region quite well since I was working as a head of mission, or a country director, with Malian refugees who found themselves just a few hours from Timbuktu in Mauritania, so in a huge refugee camp on the border where MSF was providing the healthcare.


Definitely a deterioration, very difficult to work. The displacement continues and there seems to be no restoration of confidence for the people particularly living in the Northern regions of Mali. Quite a lot of terrorist acts that have been reported, engagement of the different peacekeeping units, notably the French, to try to stabilize things. A lack of confidence is what I would say in the ability at the moment of authorities to wrangle the violence that is pushing people into displacement. There's a lot of inter-communal violence. It's actually very complicated. You can't just say it's one side against the other. It seems to be full circle, and there's a lot of displacement.


I would say about Democratic Republic of Congo, our work continues there. Of course, we have the, certain Ebola outbreaks have been taken care of to the best of our knowledge. That is to say, we're not aware of any flare ups in the East of Ebola when it comes to COVID-19 in the Eastern regions it's interesting, you know, this is a major preoccupation for us, but for many of the people living in Eastern Democratic Republic of Congo, so namely in North Kivu or in Uele, Ituri, these are the provinces that have upsurges every once in a while of violence because there are so many malicious working. There are just so many opposition groups, armed opposition groups, a lot of tension with the national military. The UN peacekeeper's involved, and a general sense that COVID-19 is the least of people's worries, that they're much more worried about measles. They're worried about violence. They're worried about sexual violence, and even with the pandemic one of the things that is very important to MSF is to make sure that we maintain access to sexual and reproductive health care amidst all of this because a lot of services have been cut because of COVID-19 because of the fear of the virus spreading, services to women, services to women that keep them alive, and so this is something that we've been working hard to advocate, and this is definitely an effort underway in in DRC and Congo as well.


Ann Marie is asking, “I'm familiar with how and why the virus became stigmatized in the US but how and why did COVID-19 become stigmatized in Yemen and other countries?” It varies from place to place but if you think of the risk in Yemen where you have a lot of misinformation all the time, you will always have a suspicion, and this was actually the case also in Congo, Kinshasa as well, where there was a rumor started up that foreigners have brought it, that aid agencies have brought it, that this is a hoax just for certain people affiliated with the government or the ministry of health to make money, that this is something that is not real, all hype. We hear that in the US. It's just like a flu. This was some of the stuff that we heard at the beginning of the discourse here in the United States, so it's a lot of the same reasons. And you have, in a war, even more likelihood of propaganda and misinformation in order to discredit the others. So you might have in any given conflict zone, people saying, well, this is just the opposition trying to weaken our resolve by making us all lay down our arms because we have to hunker down and self-isolate, but that's not true. Let's go out and fight.


So it can be a variety of, of motivating factors, but one of them that makes it so difficult is that when there's a distrust of public health authorities, so you've got your ministry of health, your department of health, public health officials saying, “Look, everybody, take this seriously, please, let's just do the right thing here, wear a mask” and all the other instructions. When there's no confidence in the government, we see that people do not participate themselves in the holistic effort and the whole society effort that we need to be able to stop a pandemic, so a big part of the work that we do is called health promotion. It's people who are trained up with the right messages and they fan out into the community and do different kinds of presentations according to the local cultural interests. So, if you like puppet shows, we've got puppet shows. If you like individual messages, we've got individual messages, the radio, pamphlets, all these kinds of things can be techniques that our health promoters use to try to at least spread the right information and counter the misinformation.


Question from Sarah. “In Syria and Yemen, do you provide medical care to people who might be militants?” Well, this is a great question because as humanitarians, and also as medical practitioners, our doctors don't ask for people to declare their political or military allegiance. There's just a code of ethics that you treat the patient before you as a person, as a human being. And let's say it is a militant or somebody who's been bearing arms and they are now injured and they're in your care. Under international humanitarian law they're technically now non-combatants and worthy of, of course, assistance under the Hippocratic Oath and all the other normative kind of rules by which doctors conduct themselves.


So, what I would say is that in any kind of conflict zone, of course, everybody's mixed up and we don't know. So, you can make a lot of assumptions, and this is one of the reasons that sometimes health facilities get targeted. I remember years ago, we were having a crisis of hospitals being bombed and often the accusation against the hospitals and organizations like us who were supporting those hospitals, if not completely running them was well, you were treating militants. Well, attacking a hospital is a war crime and treating a non-combatant is not. So that was essentially the only position we could take ethically, ethically as humanitarians, and that continues to be the case everywhere we work in conflict zones.


Krishnan is asking, “How does Doctors Without Borders go about prioritizing projects given the overwhelming number of crises in the world today, how do you decide where to go?” This is an evaluation that we do ourselves. Initially, of course, we have to look at where would we have an added value? Where would we be able to respond? Because others are not. Where is there a specific need that we feel we're well positioned and staffed, and maybe we have the knowledge and the local contacts to be able to intervene.


So, we do an assessment, you send out a medical person, often a doctor, somebody who's good at logistics to figure out, can we access this place? Can we get our supplies in? Can we construct what's needed? And you start discussing with communities, local communities and leaders, to ensure that we have the buy-in of the community, because particularly if it's a place where insecurity is a factor, we have to make sure that we're going to be able to work safely and not get attacked, and that we'll get the right warnings and insights so that we can manage our security.


And then you look at the global map. We have to make certain determinations on our budget, and that's one of the reasons, for example, that we're not going to continue operations in terms of the response to the pandemic in the United States, just because we feel that by now the expertise that we have shared in terms of management of these new infectious diseases, when you've got an outbreak like this. We've done our best to try to convey that to be at the table when policies are being discussed, to try to translate that into sort of the real world, how do you implement. But we feel right now that there are so many places in the world where we are already present, where we already have medical teams, that that's where we have to reinforce the capacity. Countries like South Sudan worked, which are always huge in terms of our operational response. There are other medical actors in South Sudan, but a chronic and desperate lack of capacity in the country to be able to, you know,  after decades of Civil War and a new Civil War, they just don't have the staff, medical staff, trained up to be able to do a lot of the things we do. And so, in fact, even one of our activities there is to make sure that we do as best we can, the training of our locally hired staff, the South Sudanese colleagues that we have. So, it's a complicated project because you can't just keep expanding and opening new medical projects. You have to close some, and so with that in the balance, you look for places where there's another a nonprofit or an organization, or maybe it's the ministry of health that can now take up this work. Things have stabilized, and we can then say, all right. We set this up. We've been working here for a few years on this emergency. Can you please take over? It becomes a negotiation, and that allows us the capacity to continue responding to the emergencies as they arrive.


Sookyung is asking, “Does MSF have any projects in Brazil?” Yes, we do. It's been so heart wrenching to hear the cries from organizations, particularly in the Amazon, from indigenous groups calling out to us to say; “Please come and assist us here. We're in desperate need.” If you go on our website, doctorswithoutborders.org you'll see the updates on all the specific contexts, all the places where we work, and Brazil was a place where we really expanded quickly. Of course, sometimes the caseload of COVID-19 goes down and you can say, all right, we're handing over. So, there's a lot of opening and closing that happens, but we did set up an intensive care unit, and most of the focus was in the Amazon basin. We also had some work happening on the Peru side and in Latin America it was our colleagues from those countries that were saying; “We have to do something. We need to respond,” so it was very much led in terms of that, that response with the context that they had for us to be able to work in Brazil, including in other countries in South America.


Laurie is asking, “Are your TB and other vaccination projects impacted by the COVID-19 pandemic?” Absolutely. It's been very difficult to sustain vaccination campaigns in particular. In some countries, they just said, no, we're not bringing everyone together. This is dangerous. But we were able to work, say, in the Democratic Republic of Congo, we were able to work with local authorities to really convince them, look COVID-19 is serious. We need to all take it seriously, but measles is killing thousands of children every year. Please let us do this vaccination campaign.


It takes some negotiating. It takes some reassurances that you're going to do it in a safe way, but as with tuberculosis a lot of the work that can be managed just in a different way. And this is part of the innovation. So, with TB, you've got a lot of patients now in our programs, particularly in Southern Africa, places like Swaziland, where you will have home-based care.

We've trained up local people up, and some of the women from the neighborhood who will actually be doing a lot of the monitoring and administering the injections and things, having been trained by our nurses and supervised by our nurses. It's part of a task shifting in order to be able to continue providing that sort of care in the community, which was happening before COVID-19. This is something that we've been developing for some time, and it's essential in terms of allowing local communities to do what they can to look after their own, even if there's a shortage of doctors and nurses in the area.


And another question here, “How is MSF strategically planning for 2021? Are you having to reevaluate all programs?” One of the things with COVID-19 that's on our minds now is if there is a vaccine developed and made available, and of course we are very supportive of the scientific approach as far as this goes, and making sure that whatever is available is going to be prioritized for the places that need it the most. Not the people with the most money or the countries with the most money, but the places where perhaps the outbreak is likely to be most urgent. With the sequence of people who receive the vaccine to the health workers, those with preexisting conditions and the elderly, those who are specifically vulnerable, other essential workers. People like me who work in offices will be the last in line. We see that maybe 2021 with the pandemic would be a time when we really ramp up and share our capacity to run vaccination programs, if that becomes a need that's expressed by local communities and health agencies.


For 2021, though, I'll tell you one thing. We're really worried about the global economy. We're worried about people losing their jobs, their businesses, their stock portfolios, the ability to donate and support our humanitarian efforts around the world. I'm being perfectly honest with you. We've had an outpouring of generosity this year as people were able to see that we're very active and we continue as a medical organization to be extremely relevant in this pandemic, but for next year that's one of the main concerns that we have is that we is that we may have to scale back. There may be lots and lots of needs, but because people are worried, we're worried about people's capacity to support our work and, of course, we're independently funded.


We're funded by people like you and millions of people around the world who give very small amounts coming from their savings and so forth. It just becomes a very difficult thing to calculate what will be the impact on the global economy, and what effect will that have on our capacity to even sustain all the operations we already have going. So, we're going to be approaching the planning with a lot of caution, that's for sure.


I see that we're coming up to time. Thank you for all these questions. I hope I've done okay in answering them. The last one is people are asking what they can do to help MSF in the short-term, long-term, to support our efforts. I would say since you ask, first of all just know how grateful we are for your support already. You've done a lot.


If you're here, you've already done a lot, and you're interested in the work we do. We are very grateful for the kinds of donors that give us some prospects, some vision on how they'll support us in the future. So multi-year grants, the kind of un-earmarked or not-tied donations to a specific context. That flexibility gives us the ability to intervene when the needs are the most urgent and we're on the ground right away. In terms of the advocacy, there are a lot of important messages that we're trying to get across when it comes to even these months where the politics are such that people are not taking global humanitarian assistance as a priority the way maybe it might have been for them in the past.


I'm thinking we just have a tendency here in the US to look internally and to be quite transfixed as is absolutely justifiable and understandable, transfixed by the local domestic politics. We have all kinds of issues around structural racism, the public health, handling of the pandemic, the economy, and so on. These are all absolutely critical issues, and there's a worry that we have that people will forget about the international dramas unfolding every day, that they'll just stop paying attention because there's just so much going on in the United States. And so our request is that you just continue to pay attention and to express that even to leaders and to media organizations that we still want to know what's happening around the world. So that that's certainly a way that you can also help.


Again, thank you for your support. Really appreciate it. You've been fantastic. We couldn't do it without you. If you want to stay in touch with us, of course, we welcome your questions. There might be things I didn't answer today. We will try to get back to you with the answers to those.


We have a special email address, actually, the team that puts these webinars together, so if you have specific requests, we can actually set things up, put things in motion to have some of our staff and leaders from the field, from the projects be able to interact with you as well, if you have specific interests. The email address is event.rsvp@newyork.msf.org.


I think that's it. That'll be it. We're at time. We're over time. Thank you so much for joining us today, for joining me and the team behind the scenes. We thank you from the bottom of our hearts for your support. I'm going to sign off now. I'm Avril Benoît, the executive director, and I hope to see you soon. Bye-bye.


March 5, 2020 - Looking Ahead with MSF-USA Executive Director Avril Benoît

Read transcript here

Mary Sexton:
Hi everyone. I'm Mary Sexton, the Director of Major Gifts at Doctors Without Borders. Thank you so much for joining us this afternoon for our first webinar of 2020. You as our loyal and dedicated donors, we are so happy to have you joining us and for your interest and your commitment and trust in our work. It's my privilege this afternoon to introduce Avril Benoît to you. Avril is our executive director here at MSF USA. Avril has been with MSF since 2006. Most recently, she served in our operational center in Geneva where she had leadership roles. And she's also worked in the field with us in numerous locations, including South Sudan, Syria, Democratic Republic of Congo, Lebanon, all the hotspots that we work in. This afternoon, Avril is going to talk about our current priorities and challenges, and we hope this will generate lots of questions from you and comments.

Now to do this, I'm going to look at my notes here. On the bottom of your screen there's a Q&A button. You click on that and this will open a chat box in which you can type your question. This presentation will also be recorded. So if you have to step out, we're happy to send you a recording of the presentation. So thank you again, and now I'll turn this over to Avril.

Avril Benoît:
Thanks very much, Mary. So what I'd like to do for you today is just talk about a couple of things that are very much on our minds. As we work in more than 70 countries around the world. We respond to a lot of emergencies in different places, and many of them are those kinds of emergencies that you just don't get to hear about. The forgotten ones, the neglected ones, the ones where there aren't particularly international correspondence to bring it home to us here in the US. And so with that having been said, these days, there are a couple of topics that come up just all the time. One of them is COVID-19 coronavirus. I'd like to tell you what we're working on, how we see this particular epidemic, and also, I just want to start off with one of the emergencies, which despite all the news that we are consumed by with coronavirus and any number of other topics, this one is absolutely breaking our hearts, and we want you to feel the urgency of the situation and also to appreciate how your support makes it possible for us to help in this particular situation, in this crisis.

I'm talking about what's going on in Syria right now, particularly in the north near the border with Turkey in Idlib province, the governorate which has sustained a lot of violence these days. You may have followed this a little bit in the news, just the desperation of the situation. You've got roughly 3 million people trapped Idlib province, and a lot of this really kicked up December 1st of last year. That's when you started to see 950,000 people on the move, they were displaced and fleeing indiscriminate bombing, shelling on Idlib province. On the city, on the countryside, bombing of medical facilities, bombing of schools, shelters, housing for displaced people. Many of these people that were in that zone had already been displaced multiple times within Syria, and they had made their way to Idlib. And this was the last strong hold of opposition forces.

So right now these people are on the move having fled this indiscriminate violence, and what concerns us greatly is that they seem to have nowhere safe to go. Nowhere where they will really be looked after. And our greatest concern is that they feel abandoned and we want them to know that the international community is aware of their situation and is trying to help. We have now these popup camps, camps for internally displaced people. So they're not refugees yet because they haven't managed to cross the border and claim asylum. They're in these crowded thousands of little camps everywhere with not enough tents to accommodate some of these families. A lot of people are moving into the homes of friends, relatives, people that they've manage to pay a bit of money. So they're also trying to find homes or lodging in the communities that they're fleeing to.

And so that means there's a tremendous amount of overcrowding. There's a lot of stress on water, on sanitation. There's a shortage of just about everything for these people. And just to give you an idea of the tragedy of their situation, yesterday, a fire just caused all kinds of harm. It was an oil system that had burst into flame in a tent and it spread across other tents in this camp for internally displaced people in Maarrat Dibsah in Idlib province and 16 people were burnt. This is the kind of thing where MSF and the hospitals that we've always supported in Syria normally would be able to fully respond to a situation like this. It's a mass casualty influx as we call it. 12 people came in for urgent treatment of their burns.

Three of the children were under five among those patients and for this kind of situation as with cases of people who are suffering from gun shot wounds or shelling and so forth, you need top quality surgery. You need anesthesia, you need the capacity to really look after people and unfortunately the hospital system, the health system is on the verge of collapse if it hasn't already in many places. And there was another case of a family of four that died of asphyxiation because they were trying to burn an unsafe fuel, poor quality fuel, and to heat their tent in really cold temperature. So the temperature has been dropping to near freezing at night and this is the kind of situation that of course is just mobilizing us to see if we can get supplies in.

So we've got a lot of these compact safe fuel bricks that we've been able to get into the area. We're distributing those in some of the camps, and that to us is a lifesaving action. We're also very concerned about the water situation, safe drinking water, hygiene, sanitation in these camps. So we've got right now a situation where there's a lot of discussion about the border, will they be able to cross into Turkey? What's going to happen if the attacks, the violence of the conflict really comes closer and closer to where these thousands of families are trying to find some peace if you will from the violence that they fled from. So we've got a number of MSF supported hospitals that we've been supporting for many years, they've been hit by bombing.

Some have had to completely stop. Others were just minor damage and were able to keep working, a lot of concern though, about the lack of supplies for those. So that is the situation in Idlib province in Syria. Even last night, a shelter that was housing, many of these displaced families was hit by shelling. MSF is supporting this main hospital in that area and they reported more than 20 wounded, 15 dead came in and MSF also had to supply body bags for this situation. Of course, stretchers and everything else that they need. So access to medical care for these people is our number one concern in Northwestern, Syria right now. Because we know that the system such as it exists is on the verge of collapse. We're preparing urgently to scale up our medical assistance and aid distribution to these thousands of internally displaced people in the most vulnerable pockets.

We've asked Turkish authorities to immediately facilitate that movement because the supplies would be coming in through Turkey, the closest border. As I mentioned, we've begun distributing these kind of wood fuel blocks and other materials. So we're trying to organize a supply of tents at the moment and other medical supplies that we feel are urgently needed. Since December, we have provided more than 260,000 gallons of clean drinking water per day, but to water trucking and the supply of water is just untenable. We have to find a more long-term solution to that particular gap. And when you don't have clean drinking water, people get sick. So this is always a big concern of ours when it comes to a large mass sudden displacement crisis, such as we're seeing in this part of Syria.

So our number one concern is that the fate of these Syrian people. It's a situation that has been deteriorating, nine years of war. Again, the people have been displaced so many times. There is a lot of anxiety, a lot of stress, a lot of vulnerability with the cold. This is all the kind of stuff that that makes it possible... When your immunity is suppressed, when you're stressed, you're not sleeping, you're more likely to get sick and we're just doing everything we can, despite the ongoing security to support these very brave colleagues of ours on the ground in Syria.

So that's really top of mind for us. As I mentioned, there are many other places in the world where our teams are doing courageous work and really having that tenacity to get to the difficult to reach places. When it comes to coronavirus, just to switch briefly to that, we were getting a lot of questions about coronavirus, both as a health organization that has worked on a global scale in all kinds of outbreaks. I mean, even right now, in Democratic Republic of Congo, we have teams completely mobilized around a measles outbreak, which has already killed 6,000, mostly young children under five. Now it looks like at the tail end of the Ebola outbreak in Eastern Democratic Republic of Congo, they've had one last patient discharged, and now they have to wait a certain number of weeks to make sure that they can declare the outbreak over. But we're really hoping that this is the case.

There's been a lot of work in that one, but of course, coronavirus comes along, and this is the situation that since SARS and MERS and others has been predicted, and if anything we're quite aware that this is just one of what we can expect to be even worse outbreaks and possibly pandemics in the future. Now are about this one what we have concluded is that the world really isn't ready for this epidemic. Not ready with the tests, not ready with the protocols for the tests who should get tested, who shouldn't get tested, not ready with the necessary supplies. You've heard a lot about masks. We also have a run on hand sanitizer. We have a real need for ventilators.

We're not as ready as we should be everywhere for the level of infection control that you have to have in doctor's offices and in clinics and in hospitals. We need to protect the people who are working there, who are going to be looking after those cases, those patients, the suspected cases that are coming in. And the World Health Organization, which is really the lead in looking after the global scale of this COVID-19 is saying that it's not a pandemic yet but it could change and become under the definition of pandemic.

It seems to be moving in that direction and a lot of people have asked us, "Well, what's a pandemic versus an epidemic?" And a pandemic is when you have person to person spread of the disease causing a significant illness and death on an exceptionally broad worldwide scale. So if we think about the United States, obviously a lot of people who might have had and maybe even recovered from COVID-19 never got tested. So we don't even know that denominator. I could have had it and maybe had no symptoms. This is the kind of thing that the scientific community and the epidemiologists are trying to remind us is that it's possible that it's much more widespread than we even think in the United States, where just to remind you, MSF is not working in the US. We typically are working in places where the health system needs our support very specifically, and our specialty.

But we have to wrap our heads around the fact that this COVID-19 could be a very serious new virus in a lot of the places that we have our medical projects. So again we have tuberculosis projects, we have projects in conflict zones, we have surgery, maternity, newborn care, we do vaccination programs for different things. COVID-19 could affect how we work in a lot of our places and so a big part of the effort is in the education of our own staff, in terms of infection control, how to diagnose cases. We're doing a lot of advocacy around getting the supplies in. For the time being, we seem to have enough supplies for our own medical projects to continue, but a lot of governments are asking us, can we support them with supplies? Can we give them masks? Can we help them train their staff?

This is the number one concern we have because what we saw in China, and even in other places where you've had these pockets of this outbreak in the epidemic, really burdening the existing healthcare systems, is that you can imagine that in a country where the health system is already under enormous stress and overburdened, that this COVID-19 will fill up the beds pretty fast, it will spread quite quickly and there won't necessarily be the level of response that can really contain it. One of the things that we're learning also with all the scientific evidence that's coming in, and the research that's being published is that when somebody has, and this is the very small percentage that would have a severe or acute symptoms from COVID-19 from the Corona virus, is that it takes them about three to six weeks in hospital to recover.

So if you've already got a really full hospital, and then all these new cases come in and they're occupying beds for a long time, that means you really have to scale up. This is something we're good at. We saw that the Chinese authorities, the health authorities there were also very good at scaling up quickly. And that's the kind of mobilization that we have to do. At the same time, we have to push for transparency. We have to push that we really know where all the cases are, that the testing is available, that the results are published. And this is one of the things where I think MSF has a real added value because a lot of the disclosure around an epidemic gets colored by politics or economics.

Ans so for us as an organization that is making independent assessments, that is willing to tell it like it is and say what we see, that is independently funded, thanks to people like you and people around the world. We have more than 6 million donors around the world that are contributing to our ability to pivot, to shift, to respond to emergencies. We're actually able to be a trusted voice when it comes to the response. We are going to be pressuring for that transparency around how many cases there are, how things are being dealt with so that we can mobilize in the communities where we already have medical projects for other things.

We're also pushing hard so that the vaccine, for example, that will be developed perhaps in another year. I mean, for all the wishful thinking that it'll be very quick, nope, that's not the scientific way. You have to prove, you have to test, you have to publish. So this eventual vaccine if there's a lot of public money going into the research and development for it, we would insist that it'd be free at the point of care, at the point of giving it to people so that people who don't have access to great health insurance plans, or don't have governments that are necessarily wealthy, will get it for free. That those governments will get it at an accessible price and that there won't be the kind of stockpiling that we tend to think is really unhealthy when you're dealing with a global pandemic if we get to that stage.

Same goes for any therapeutic results from different efforts. In different countries, doctors are being quite resourceful in figuring out different ways of treating people who come in with severe cases. There's no treatment that exists per se, no cure, but they are trying different methods using medication, publishing the results and there's a lot of discussion that we're involved in to try to identify which of these different efforts seems to have the best results. And this is what we did also before in the past with things like Ebola, where until recently there wasn't a treatment for it. And now, thankfully in large part because of organizations like Doctors Without Borders, Médecins Sans Frontières, we've been able to participate with global health experts to prove that certain treatments are working and this is an enormous contribution that we're making at a global level.

And once the time comes in COVID-19, I expect that we will also be readily participating in that if there's a need for us to support these kinds of efforts for treatment and vaccines. So just to say in closing, I really welcome your questions on these topics or any topic. If there's something that you've been wondering about when it comes to our work. We do these webinars because we want you to feel that you have access to what we're doing, what we're thinking, what we're seeing, and that we have that level of accountability with you because without you, we couldn't be working independently and making such a significant contribution to global health. So I know that Mary has already received some questions and maybe I'll shift over to Mary and you can let me know what somebody wants to know.

Mary Sexton:
Well, our first question is how do we keep our people safe in the field?

Avril Benoît:
Great question. Great question and it's one that we get very often. In a place like Democratic Republic of Congo or South Sudan, I was a project coordinator in South Sudan for nine months. One of the things that we have to do is to have that full consent of our staff, that we have a duty of care for our staff. We're not going to be sitting ducks or martyrs or anything like that and when things start to get hot in the field, you have to have everybody on board and saying, "Okay, here's the information that we know. Here's what's going on." We have a real trust with our staff. We have to exchange, and don't forget, nine out of 10 of our staff are from the countries. They're locally hired. There they're from the countries where we're working.

We also spend a lot of time with community discussions, the gallons of tea with lots and lots of sugar in it that I had to drink when I was on assignment in South Sudan was mostly because I'd like to sit with the local leaders, sit with the women's leaders, sit with the military leaders and be able to just discuss things and have a regular flow of information back and forth so that they could warn us if something was happening. If we were maybe going to be in danger. And those warnings are the kinds of things that allow us to perhaps scale down our activities, withdraw activities for a time, and then we can go back when the fighting is over, when it's past, when the risk has passed.

Our colleagues are also very cautious. We have a lot of security rules in the places where we work. You can't just run around. We're a professional organization, and we have experienced real setbacks when it comes to security and from those bad experiences, we've learned, we've actually figured out, "Well, next time and for forever in the future, we will approach things a little differently. We will make sure that we have those contacts, that we don't expose our teams unnecessarily." So there's a lot of tracking of movements of staff. There's a lot of verification of different contact networks, and there's certainly a lot of dialogue with the community. And that's the kind of thing that also when they appreciate the presence of Doctors Without Borders teams and the added value to their communities, they do look out for us in most cases. It's a mutually beneficial arrangement and it's from just having that open, independent, neutral and accountable relationship with the communities where we work, that it really does improve our sense of comfort and security in these communities.

Mary Sexton:
Okay. Second question, what can people do to help the people of Idlib?

Avril Benoît:
We all want to help the people of Idlib and it's complicated. I would say number one, support organizations like Doctors Without Borders. We are dogged. We have a long standing relationship with a lot of the medical staff, the Syrians that are now displaced, trying to run hospitals. There were a couple of films that came out this past year about this medical work in Syria. One of them was called The Cave, a documentary and other one was called For Sama. And while these films are not MSF, they're not Doctors Without Borders films, these are the kind of medical teams that we support. These are the kinds of really brave Syrians that we think deserve our absolute admiration. And so in that respect, by supporting us, we are then able to support them.

We scrutinize where the aid goes, where our deliveries go. We have an ongoing relationship over the phone and telemedicine and with short visits and so forth to make sure that we are able to meet the needs of people as best we can under the circumstances. The other thing that I think we as a global community will have to reckon with, and this is really not something where we have the solution, but this war has to stop. These people have to have a sense of safety. And for all that we are going to holler and scream about humanitarian law and how it's against the rules to bomb civilians indiscriminately and it's against the laws of war, Geneva Conventions, to bomb hospitals, such has been the case for the last nine years.

We know that the security council is the way it is. So we recognize that all the screaming and hollering, which we'll continue to do, which the ICRC, the International Committee of the Red Cross will do about international humanitarian law. We know that that only goes so far. What these people need is peace, and for the life of me, I don't know how they're going to get it, but in the meantime, as MSF, as Doctors Without Borders, we can support them with the life saving needs that they have.

Mary Sexton:
Avril, here's a question from a former MSF aid worker. What is the current situation in South Sudan with respect to security matters and major ongoing health issues?

All right. Well, as you know with South Sudan, you have a lot of instability. There are certain areas of the country where you have peaks of violence. It's often as a result of the degradation of community relations over the years, this is a new country where there was so much hope that things would turn around and at the end of 2013, '14, it descended into full on war after having split from Sudan. We have an ongoing presence in South Sudan that's significant. And what we recognize also is that it's difficult to work there. We have to go with sometimes very harsh conditions for the medical teams that are working, difficulty sometimes with supplies, when there's fighting going on, you can't have the normal trucking of your supplies.

You've got to deal with planes and barges and delays, and the rainy season. It's an extremely complicated place to work. And of course we watch the political situation and the degradation of certain peace deals and the setbacks that we have, but we remain very tenacious in our commitment to working there. We have fantastic staff from South Sudan that are shoulder to shoulder with us, and they stick with their communities when things start to get really difficult. So Sudan is a place that both breaks our heart and inspires us tremendously because we really see the impact of MSF. The teams from Doctors Without Borders, I use the acronym MSF for Médecins Sans Frontières, the French international name.

We see that they really are making a substantial difference to the lives of South Sudanese. And so I can't tell you how it's going to play out there. I really wish for peace for those people and that they can establish social safety net systems, education, a healthcare system that can stand on its own. But for now, there's a huge need in certain areas of the country for MSF to remain present and we're absolutely committed to that.

Mary Sexton:
All right. Well, here's a question again about the coronavirus. Do we expect COVID-19 to spread in the refugee camps that we're working in specifically because of the close living quarters and how would we control that outbreak?

Avril Benoît:
Yeah, that's a question that we're getting often, and we're a little wary of some of the ways that this kind of questioning can become politicized. We wouldn't want borders to be closed because of coronavirus when in fact really it's just borders are closed and people aren't being given the chance to claim asylum. We're very sensitive to the stigmatizing effect of some discussions around migrants and refugees. The suggestion that they bring crime and they bring disease and things like that. At the same time, there's no question that coronavirus or any sort of virus like this, measles, when it gets into an area when people are in crowded conditions like refugee camps, that's why the first thing we do is vaccinate everyone for measles or the kids, especially. This is why we take a lot of precaution.

It does worry us. A lot of the places where we work, people are in overcrowded conditions. One of the things that we've done is to have a look at the places where we are working already, where we have medical teams, where we have relationships with health authorities. We've looked at where the WHO, the World Health Organization has a strong and robust presence. We've looked at where those health ministries have access to intensive care units, where we could perhaps refer patients. And what we've been doing is analyzing all that data to identify the places where we want to pay particular attention. And through that exercise, we've been prioritizing, okay, some of the countries around China, for example, Laos, Cambodia, Papua New Guinea, we have been prioritizing those places to do trainings of local health staff and they really appreciate it because they're learning a lot about our methods of how to get a hospital system prepared for the influx of patients if the virus should happen to become a big problem in their area. How to isolate patients, how do identify them.

This health promotion work that we've always done in many of our projects is something where we have a specific expertise. We've had a project now going in Hong Kong actually, where we've gone into some of the communities in Hong Kong that are particularly neglected. So places where you might have refugees or minority groups. This is an effort that now we're shifting and getting ready to do it in countries like Egypt, Lebanon and Nigeria, where we have a presence where we're responsible for a lot of hospitals and we see that with the refugee population, the camps where we work, there's probably a real added value for MSF to be on top of it.

Mary Sexton:
Here's a question about Ebola. Medical organizations had a very difficult time getting trust of the community in the Democratic Republic of Congo and has MSF developed any protocols to alleviate these fears? Number one, and the second question is how does MSF prepare and educate communities for medical procedures that may contravene local customs?

Avril Benoît:
Okay, well, two different questions there. On the community acceptance piece, this is something we recognize and as I was saying earlier, it's the real added value of being independent. We want to collaborate and seek all kinds of ways to work in support of local health authorities, in support of local health organizations, other nongovernmental organizations, but our independence and the fact that we are impartial, neutral, trying to make our own assessments actually really boosts our credibility with populations that are wary. I think this issue of community trust was one that we really suffered.

I mean, it's not our problem. It's the populations from, but in Eastern Democratic Republic of Congo with this outbreak that is now hopefully coming to an end, knock wood, we really struggled because we were associated with a government response in a community that did not trust their own government, they can trust their government and so sometimes when you change the people, you change the politics, you distance yourself from those who are maybe perceived as not being trustworthy. It allows us that space to create the dialogue to really talk to people about what's going on. This has been key. It took some time, even for the whole effort around Ebola, this latest outbreak to really involve the community in the decision making, really involve them to understand how they had a role to play.

We expect that this is also got to be the way that we approach COVID-19. And when it comes to the second question here, treatments that are maybe not locally accepted. We have found a surprising acceptance for the efforts, the Western medicine if you will, that MSF provides. It's true that we have to sometimes explain to people why these vaccines are the best idea in order to reduce the burden, why we offer certain family planning services to two different women in communities where you would think that there would be a huge no, no and in fact, there's a lot of demand for the services that we provide. It's through that dialogue though. One of the things that we know as an organization strategically is that when we are rushed, when we don't take the time to really talk to people and give them the agency over their treatment options, it's just not the right way.

And so we're really trying to be much more conscious now that as urgent as the situation is, as overwhelming as it is, we have to take the time with people one by one to really have that patient centered approach, to give people the full understanding of what's at stake. Why they're getting this pill, this treatment or not, and that's the kind of thing that we all recognize is our right in the US. We have to make sure that this is also our approach in all the places that we work. In our experience, though, it typically works. I mean, obviously you have huge setbacks. In the West Africa outbreak, one of the things that we reflected on with a lot of lament was the need for safe burial for the people who died of Ebola was not handled with the kind of cultural sensitivity.

It was an emergency, everyone was overwhelmed doing the best they could. I'm talking about the health responders and since then, we've really recognized that there are ways to explain to a community, you have to be very specific to their cultural approach but still get them to see that perhaps some of the practices that they have are putting them at risk. And when you take the time, when you do it deliberately with the expertise of local people and of anthropologists and others who have that that specialty, you can really make progress.

Mary Sexton:
Thank you. Here's a question about Syria. Do we have any international staff in Syria working on medical programs and also in the countries bordering Syria?

Avril Benoît:
Yes, absolutely. So to start, we've never had much difficulty at the border areas where you have a lot of refugees, where you have a lot of people that have crossed. We've had substantial efforts underway, for example, in Lebanon where one in four people is a refugee. One in four people in Lebanon is a refugees so at times when we sometimes feel overwhelmed by the numbers of outsiders, and you'd hear this political discourse about too many, think of Lebanon. In Syria itself, we've had moments where we could not have any international staff. There's no question that there are always places where we've never been able to have international staff. Right now we do have some, and we have them in places where we've been able to work out local arrangements.

We try not to attract too much attention to that fact. You don't hear us communicating about it very much precisely because it's not the Damascus government that is accepting our presence in those particular locations. It's other authorities, if you will and so that's something that we have to negotiate and we're very nimble. So we're coming and going and staying and then leaving. It's been extremely difficult to work over the last nine years in Syria, and to absolutely heartbreaking, not to be able to have your typical full on presence of an international team with the people, showing solidarity shoulder to shoulder, willing to carry the burden along with local medical colleagues.

Sometimes we felt that we were leaving some of our Syrian medical colleagues to their own devices and that doesn't sit well with us at all. We feel a lot of concern for their wellbeing and their safety, even if they're not our staff, because we know they're dedicated medical professionals. So at the moment, yes, we find our place, but from minute to minute, it changes.

Mary Sexton:
Here's the financial question. How does MSF USA decide how much money can be used in operational programs versus how much should be kept in reserve?

Avril Benoît:
Okay. So when it comes to reserves, we feel a particular duty here at Doctors Without Borders USA to guarantee the continuity of our operations globally. We typically go with the recommendation of some of the watchdog groups, some of the oversight groups of the sector. It's not a formalized thing, but it's a recommendation to try to always have six months of reserves. At a certain point though, you have to recognize that there are times when we will have colleagues in operations asking us to support an emergency, to support something like a surge capacity, if you will. Doctors Without Borders in the United States, thanks to all of you, our donors here. We're supporting a good quarter of the global funding for everything that we do in terms of our medical operations.

And there are times when there's a huge need and it's thanks to those reserves, and this happened last year too, that we're all able to say, "Okay, we've got that in reserve, we can offer it to you." So typically just to make it short, six months but globally, we don't believe we need that much everywhere and I think we're always aiming for about four months in terms of our particular needs and how much we really think we need globally.

Mary Sexton:
What support does MSF give for birth control and family planning and what are some of the cultural barriers?

Avril Benoît:
Happy to answer that question. We have a lot of programs that offer family planning. In fact, it's a core service that we provide in any place where we're delivering babies and we're looking after mothers both in their prenatal and postnatal care. In my experience, there are places where it's considered a real plus to have lots and lots of children. It's a cultural interest, it's a survival mechanism. Those children will not all survive themselves, but those who do what perhaps support you in your elder age, and they're a sign sometimes of strength, of courage, of health. At the same time, when we explained to mothers the importance of perhaps spreading out, of pacing of having a little more time between children, they're very interested because maternal mortality is a very real problem.

These moms who have had a very difficult childbirth, for example, when maybe they needed a cesarean section, they won't always necessarily have access to that in some of the places where we work and they're very open in fact, to staying alive. And some of those strategies involve not having so many kids close together. It's a sensitive topic though and it's one where I've had the pleasure of working with an anthropologist who really helped us work with women's groups to try to figure out what was the message that would encourage women to think about this as an option. But it's a bit like safe abortion care. We find that when it's offered, there is interest. It's not maybe accepted in the local community widely, but the women and the families are making these decisions often together.

And even in places where you would think there would be very traditional values, when you're in crisis, when you've already got a lot of children, a lot of mouths to feed, when maybe there's a lot of sexual violence, or you're just at a point where you do not want this pregnancy to have access to safe abortion care is absolutely saving the lives of these moms. And maternal mortality remains a critical issue, as I say, in so many places where we work. So family planning has also involved... it's a patch sometimes, a lot of condom distribution. This was also a big part of our programs when we had the initial work on HIV prevention. That is still the case. So, we do make all of that available and lots of discussions with women about their options.

Mary Sexton:
How does MSF gain access to insecure areas?

Avril Benoît:
Okay, well, how do we gain access? It's a lot of discussion. It's a lot of analysis. When there is a real clear risk, we have to make sure that we are not just going in without having done our homework. A lot of phone calls, a lot of sources. We do the analysis by talking to people. I mean, that's the essential thing, right? Is that we have to just know what we're going into. So when there's a new project, a new outbreak, a new crisis, and we think we need to send an assessment team right away, this is where our independence really shows its strength, because we can mobilize a team to go have a look. Typically, you would have somebody on that team who's very good at the political and security analysis.

It's somebody who can read the situation, have a look at the safety concerns, really consider with local leaders and other people in the community what the situation is. But for sure, there's a lot of discussion also with our headquarters, because we want to make sure that we are taking responsibility for the risks that our teams on the ground are going into. And it's something that weighs very heavily on us. So while it seems sometimes that we're working in the most difficult situations where there's a lot of violence all around, it has been very thoughtfully considered. There's been a lot of discussion, a lot of questioning, and we only hope that we will continue to have that constant dialogue with the right people to be able to maintain a sense that we can keep working there without being obstructed, without being targeted in any way.

Mary Sexton:
So here's a question about our work in Mexico and along the border. Can you update about what we're doing there and what our plans are?

Avril Benoît:
Sure. Yeah. I mean, for us what's going on in Central America, in some of those countries where you've got a lot of violence, what's going on in different places in Mexico is people are making their way through Mexico and find themselves at the Northern border of Mexico, is that you have people who have been through a lot. They've been through the kind of violence that would propel any of us to get out of wherever we're living. There's violence coming from different places. You've got the criminal activity, you've got people who have suffered an enormous amount and so in Mexico most healthcare is available. You can go into a local hospital and be treated. Where the gap really seems to be as mental health and that's why we have really focused on that because we can see that people are struggling so much. They've been through a lot and we recently published. And if you look on our website, doctorswithoutborders.org, you'll see a report called No Way Out. And it describes how half these people have just been through horrific violence, kidnappings, rape, extortion.

They've witnessed directly horrific violence against their family, their loved ones, their community members. And one of the big things that we're trying to just highlight is that with the Migrant Protection Protocols, the MPP or as some call it in the United States, the Remain in Mexico policy, we've been sending people back to a place where it's not safe and in our recent report, we talk about how more than 60,000 people were sent back under this new legislation as it has been applied including children and highly vulnerable people, pregnant women, LGBT, people with medical and mental health conditions and that this whole deterrence policy approach that we have is actually causing additional harm and suffering. So the US government is continuing to send people to these places along the border, knowingly sending asylum seekers back into extreme danger.

In Tamaulipas state at the Texas border in particular, we have one of the most dangerous places in Mexico, and it's largely under the control of violent criminal groups, and there's not much confidence in local law enforcement and so on. It's a level four travel warning. We're not supposed to go there. UN agencies don't want to go there. Nobody wants to be based there and level four is the same level as we have in Syria and Afghanistan, in Iraq in some places too. So the big part of our work is a combination of the mental healthcare and then also the advocacy, because we know as one of the few really independent witnesses to what's going on there, to the medical needs and the suffering, the mental health suffering that people are experiencing. We have a real role to play in highlighting this to remind officials, policymakers, that it's just not right to send people to wait for their asylum claims for their hearings in a place that is level four in terms of security warnings.

Mary Sexton:
Well, we have time for two more questions and this one dovetails nicely into what you were just speaking about. Can you share more about our mental health services? And is this something new to MSF and about how many programs do we have these services?

Avril Benoît:
Yes, I'm really happy to talk about this because it's something that I wouldn't say it's new, but it's new that it's so much more widespread. In a lot of the countries where we work and it's now more than 70 countries, and we have hundreds of projects around the world, more and more of them now hundreds have a mental health component as part of the general package of care. What we've seen over the years is an understanding of how we can be useful. So if you think of people on the move where maybe you get to see them once, and then they just want to get going and keep on their journey to get to safety, you have that one shot. Initially, we would have said, "We can't help people if you can't have ongoing mental health support. We don't have the skills for this, we don't know how to do it properly. It's probably going to backfire culturally."

You have to be very thoughtful about these kinds of things, not to retraumatize people. We found that even in those really emergency kind of quick response, where you might only get to see somebody once or twice, is that there are techniques that have been developed that have been shown to really help people. A lot of it is cognitive behavioral therapy. It's quick, it's this emergency mental health approach, which you can read about on the internet. It's an effort to give people the kind of coping skills to just be able to deal with their anxiety, their stress. A lot of people also historically have come in to all our programs saying, "I feel aches, I feel pains, I can't sleep." And you would never be able to really identify what is the medical problem and you realize after a while it's mental, it's a stress, it's a fatigue that's quite understandable.

So over time we've really been paying attention to this as one of the factors that will make people physically feel better as well. I've also seen really great programs even in situations where you might have a malnourished child. To do groups with the mothers who have those kids who are malnourished in one of our intensive therapeutic feeding centers. You can see how a lot of the stress of maybe being displaced multiple times or things going on in the family dynamic, things going on in her life are actually exacerbating her ability to care for this one child who's malnourished, to prioritize them getting better. I've seen also that mental health has been a huge positive when it comes to looking after kids. We do a lot of art therapy with kids.

A lot of play therapy just to get them moving again, feeling safe again, expressing themselves and having even through drawings that way to be able to start discussions about what they're feeling. And so this is the kind of thing that we're very... We don't make big claims about success rates or treating and curing but it's a contribution that we know is having a positive impact. I guess the last bit to mention is that in an increasing number of projects, we're able to access people who have been tortured. In Mexico City, for example, we have a center where we look after people who were by gangs, by violence where they were maybe kidnapped, beaten, maybe they were thrown into jail.

They were just in a terrible situation where they were interrogated. Any number of things by any number of factors and you end up finding people self-harming, looking for a way out. They don't have much hope that things will ever get better and so a mental health approach to their needs, whether it's psychiatric or just counseling, whether it's physio-therapy and just getting them moving again, an increasing number of programs have the social work dimension to help people get on their feet again. And this is the kind of flexibility that we have as MSF, where we look at the whole person and we try to help them with their medical needs, which include their mental health needs.

Mary Sexton:
Final question, how do we decide when it's time to close a program?

Avril Benoît:
Yeah, that's something that's always a bit difficult. We don't have a clear rule, but typically, the factors that would go into it is people getting better. I've closed a few projects myself, and one of them was for example, a malaria project where we were trying to deal with an outbreak of malaria in the very northeastern corner of Democratic Republic of Congo in OLA and it was that the curve went down. The kids weren't dying at the rates, it came down to normal thresholds as opposed to the emergency thresholds. So that's one decision that you make when you open the project to say, "Okay, we're just going to help you bring down the mortality and treat these patients," and then we will hand over to the local authorities, make sure that it's possible for them to continue with the ongoing work.

Another situation might be where there's another organization, and it could be a local health department, local authorities or it could be another nongovernmental organization that has a much more long-term perspective. And you say, "Look, we'd like to hand over this project to you. Will you take it?" It requires a certain amount of convincing sometimes, sometimes they're very willing but they don't quite know how to do it so we do a lot of training and the handover process is a lot about how to manage the pharmaceutical stock that they're going to receive as part of this project and this responsibility. So if there's somebody else that comes along, who can do the work great, because then we can move on to the next emergency.

And then other places where we close it's just because we run out of gas. This does happen where we say we've been here for a very long time. Somebody else needs to take over usually the local health authorities or the national health authorities, and they must, must, must do it. And so we announce we're going and usually there's a bit of pushback where they say, "No, you mustn't go, you're the only ones who can this." And we say, "No, you must absolutely do this. You have to take this on." Things sometimes are handed over beautifully and you can see programs continuing, other times you know there's a gap but it's no longer an emergency. Our work is done and it's not possible for us to just open indefinitely projects all over, unless we're willing to take the hard decisions sometimes to close them or hand them to those who can continue over the long-term.

But it's something that sometimes we've made mistakes and we've tried to learn from those mistakes. And a big part of my work in closing projects was just to very much work closely with local nurses, local health authorities, at that level where they're really going to take the responsibilities and often we find that they're proud to do so. They're ready to do it. They want to show they can, and we help them get ready to do it as well. That's it?

Mary Sexton:
That's it.

Avril Benoît:
That's it. Okay. Looks like that's all the questions we have and all the time we have when I look at the clock. So thanks a lot for joining us. This is the kind of recording that we're going to provide to you afterwards. So for those who didn't get to stay for the whole thing. I also just want to remind you that doctorswithoutborders.org is our website. Whenever you're looking for updates, we have lots of material there. All our accountability information is there and you'll see that it's thanks to your contributions that we're able to do all this work. So thanks a lot from all of us here at Doctors Without Borders. From our headquarters in New York, have a great afternoon. Take care.