Executive webinar series

Dr. Rasha Khoury

Welcome, and thank you for joining me today. I'm Dr. Rasha Khoury, and I'm an obstetrician/gynecologist with MSF, Doctors Without Borders, and I'm also a member of the board of directors of MSF USA. We've invited you to this session because you're among our most generous supporters, and you already know us from our international name, Médecins Sans Frontières, or MSF, which is how I'll refer to Doctors Without Borders today.

 

I'm really delighted to be with you, and I'm even more delighted because I'm joining you from my home in East Jerusalem, in Palestine. We've been doing a special series of webinars on COVID-19 and crises impacting our patients since the pandemic began, and this session is really more of an intimate version of those, with the opportunity for you to ask questions about a range of humanitarian issues that our medical teams face around the world. We'll talk for around 45 minutes or so, and you can ask questions throughout. I really encourage this as a chance for us to connect with one another and for you to ask questions of me, as one of the medical doctors who works for and with Doctors Without Borders.

 

Questions can be placed in the Q&A option that you see at the bottom of your screen, and really my intention today is to reflect with you on the importance of our medical action and our medical work to our organization and to share my personal experience with MSF. I'll take you a little bit more deeply into the heart of the humanitarian work that we do as a medical organization and the issues that we address around the world.

 

My role with MSF, as I mentioned, right now, is I'm a member of the board of directors of MSF USA, based in New York, but I've been working for MSF since 2014 as an obstetrician/gynecologist or women's health provider, and I've primarily been working in our projects around maternity and neonatal and pediatric care around the world. My journey with MSF began in 2014 in Sierra Leone, in a small town called Bo, which is landlocked in the middle of Sierra Leone. It was at the time of the emergence of the Ebola epidemic which really ravaged the country. I was sent as an obstetrician to really work in maternity, one of our largest maternity projects in the region at the time, where the burden of maternal morbidity and mortality is enormous, and as Ebola really ravished the community and impacted everything that we did, we had to shift and transition and adapt our project from a maternal and child health center to an Ebola treatment center. That was really my first experience with our emergency medical aid.

 

After Sierra Leone, I went to Lebanon, where I worked in our refugee camp Shatila, in Beirut, and there our project was really focused on assisting Syrian refugees who had been internally displaced in Syria and then displaced again in Lebanon. Again, I worked with women to ensure safe pregnancy care, safe delivery care, and safe postpartum care. 

 

After Lebanon, I joined our team in Ivory Coast, in a project bordering the border with Mali. Again, an area incredibly impacted by the depths of maternal morbidity and mortality around the world.

 

From there, I went to a project which I'd like to speak more with you about in Khost, Afghanistan. A project near and dear to my heart. Almost everyone who knows me at MSF knows that I love this project. I think about it daily, I speak with the team daily, even now more than a year after I've left. Khost is a very rural area in the southeastern border of Afghanistan, really bordering Pakistan. It's an area that serves around 1.5 million people, and it's our largest obstetric facility in MSF in the world, where we care for around 22,000 to 24,000 women and newborns every year, which is really a staggering number. When I think about the hospital in the Bronx in New York where I work, where we deliver around 2,500 women and babies every year, that's around what we deliver every month in Khost, Afghanistan.

 

In this project, I was acting as both a referent or a resource, an advisor to the obstetric team, which was composed of more than 80 Afghan midwives and around six national Afghan physicians who worked as obstetricians, six pediatric Afghan specialists, and six national nurse anesthetists who provided anesthesia to the women as they experienced various obstetric complications. This project is served by more than 400 Afghan staff who are actually from the community, from Khost, serving their own community. It's a project that dates back to 2013 and it really only expanded in both volume, but also quality, as the years have gone on.

 

I'm really proud to say that, in this project, the quality of medical care that's delivered to women and newborns really surpasses the quality that I've experienced in many facilities in the global north; in terms of the dignity that women were treated with, in terms of the community and family support that was engaged around their labor and birth experiences, in terms of how women were treated as really in the context of their lives, as part of a whole, as part of their family, as part of the village or the district that they were from, and not just as isolated people.

 

This allowed for a kind of obstetric practice that really was person-centered, that took into account what people wished for themselves and their families, for their babies, and delivered such excellent medical care that the maternal mortality in and around this project was less than it is in the United States. Granted the maternal mortality in the United States is nothing to be proud of, but Afghanistan is one of the top 10 most dangerous places to give birth in the world, so for us to be able to achieve such low maternal mortality was really something that the staff and the community was very proud of.

 

It's this excellent and high-quality medical care that's person-centered that really allows MSF to continue to exist in these spaces, to be welcomed by the community, to be embraced, and to be safeguarded, which is ultimately what our teams rely on in order to be able to continue to function with the social mission that we have.

 

I'd like to tell you a story from Khost, Afghanistan that really stays with me, and probably will stay with me for the rest of my life. Again, I invite as many questions as possible through the Q&A function. I was in Afghanistan twice with MSF, the first time for approximately a six-month period, and the second time around a seven-month period, in the years 2016 to 2018 and then 2018 to 2019.

 

Something occurred in the second time that I was present in Afghanistan that had never happened to me before in an MSF project, where I met, again, a patient that I had cared for two years earlier, and got to know the story of what happened to her after we treated her.

 

In January of 2019, I was in the caretaker area in our facility, where I was speaking with a family member about how their female relative, who was within our facility giving birth was doing, when a woman spotted me from across the way. She smiled an enormous smile and waved at me. I was struggling to understand where I knew her from. She looked so familiar, but I couldn't quite place her. As she approached me, she really embraced me, which is not a common thing to occur in Khost, Afghanistan, and she was gesturing to me and asking me if I remembered her. We used the medical interpreter who was assisting me that day to sort of understand what was going on.

 

She told me her name, and as she told me her name and began to recount her birth story, I realized that, of course, she was absolutely unforgettable. I had cared for her in 2017 on a day where I had been summoned from the area where we slept, which was within the hospital compound and right near to the delivery room, and I had arrived to the delivery room to really find a woman who looked lifeless on the floor of the delivery room, and she was embraced, at the time, by her female caretaker, who was rocking back and forth and sobbing. Her clothes were completely drenched in blood, and I couldn't tell, actually, if she was dead or alive. It was not uncommon in this project for us to receive women who were, unfortunately, dead on arrival after having had a birth at home or en route to the facility.

 

So, as I approached her to check her pulse and I realized there was a faint pulse, I began to speak with the family through our medical interpreter to understand what had happened. She had had a birth at home six or seven hours prior to arriving. The family had waited for daybreak in order to safely bring her to our facility because it was not safe to travel by night. This female relative was her mother-in-law, and she was pleading with us to do everything we could to save her life.

 

When women arrive in this type of condition, we often move them directly to our operating theater in order to have the best lighting, staffing, exposure, and ability to really intervene quickly. We quickly removed all her bracelets and her blood-soaked clothes and moved her onto a stretcher and into the operating theater, where I had the help of a nurse anesthetist and three midwives, all Afghan staff who were incredibly skilled and professional, and had really worked in this project for many years. We quickly began to remove her clothing and understood that what she was having was a postpartum hemorrhage, or a severe episode of bleeding after delivery.

 

With the consent of her family, we proceeded with a surgical intervention that was really necessary to save her life, and we realized, on beginning the surgery, that what she had was a rupture of her uterus, so a sort of break in the uterine wall that can lead to profound bleeding, and, ultimately, death. This is not an uncommon complication that occurs in many of the places where Doctors Without Borders works. It can happen spontaneously, it can happen because of the use of mediation outside of a dedicated facility, it can happen from multiple births, it can happen from a prior scar or incision in the uterus that weakens the wall. It can happen for several reasons, but really almost always it is deadly unless there's a rapid intervention.

 

In our project in Khost we have the advantage, and, really, the lifesaving facility of an operating theater. In fact, we have two operating theaters that are maintained by our staff. We have a blood bank where we're able to receive donors from the community who donate fresh whole blood, which is really a lifeline in this setting. So we proceeded to do a surgical intervention where we removed her uterus, again, with the consent of her and her family, and provided her with around 17 units of whole blood in order to replace what she had lost, but also to stop the catastrophic bleeding complication that she was having.

 

She subsequently required two or three further surgeries in order to ensure that the bleeding had completely stopped and ensure that she didn't have an infection. We observed her in our recovery room, where we have the ability to provide a midwife who can watch her 24/7 with one-to-one care, which really is care that, in many places that I've worked, is just not possible. She then recovered with us in our MSF facility for around 12 days, where we nursed her back to health by helping her slowly start to take in food, be able to walk in the garden. I'll never forget, on the day that she was discharged home, she allowed me to take a photograph of her as she was sitting on the bench in the garden in the sun with her mother-in-law, draped in a beautiful red scarf, and I have and treasure this photo to this day.

 

The opportunity I had in 2019 to see her again, is really a rare opportunity to sort of know what happened to a patient of MSF after discharge, after you send them back into the world, back into their daily life that's filled with many kinds of challenges and certainly risks. Being a woman in Afghanistan, certainly a war-torn country that continues to suffer many, many different types of conflicts, poverty, climate destruction, is not an easy thing to actually let a patient go out, back into the world and hope that they would be okay. What I learned in 2019 was that she was really thriving. That her family was doing well, that her children, who were alive, including the baby that had been born that night, were doing very well.

 

Moments like that are really transformational for me, and the reason why I continue to do the work that I do with MSF, and the reason why I think it's really critical for us as an organization to exist with the help of our generous donors, absolutely, without whom none of this work could be possible, but that people all over the world, especially the most vulnerable women, children, and other groups really deserve the highest-quality care, regardless of their geographic residence, national origin, race, ethnicity, etc.

 

I see that there's a question and I'm going to turn to it.

 

 “What is the state of hospitals in Afghanistan compared to US hospitals?” It's probably not a surprise to this audience, but the healthcare system in Afghanistan is certainly suffering the ramifications of 100 years of war, of economic, certainly a very tough economic situation, poverty. Khost is a very rural area, and rural areas are even more vulnerable in Afghanistan. It also depends, different parts of Afghanistan are ruled by different parts of factions, and, depending on those political entities, the government may or may not be able to access those areas or be able to service those areas or have the willpower to service those areas, so hospitals, certainly, are lacking much equipment, but also much staffing. Afghanistan is not unusual compared to many of the contexts where we work where they suffer a huge brain drain, where educated nurses, physicians, and other health workers, if able, leave Afghanistan and don't really remain in the country as they secure better futures for themselves and their families.

 

There is a question from Michelle asking “How is the political situation in Khost the risk to your facility in the negotiations with the Taliban?” So Khost is an area with a tenuous political situation for sure. MSF carries a lot of favor in the community because we've been in existence for several years, and I think it's really our medical work, our medical outcomes, that continue to carry our favor. I think certainly we're all committed to the highest-quality medical care, but really it's an issue of life and death for both our patients, our staff, and our projects. I think that that work really helps us temporize a lot of risk to our facility.

 

I'm sorry, I'm catching up on our questions. “Someone would be interested in hearing about COVID programming and messaging.” Absolutely. COVID is ravishing all of our projects, as it is the entirety of the world. We continue to work on infection prevention/control in many of our facilities, on isolation and case detection. It's been more difficult to employ things like certain levels of intensive care, respirator or ventilator support, which, in many of our projects, did not exist before COVID and is difficult to exist even within COVID. We primarily are supporting many existing health structures in the neighboring areas in order to improve infection prevention/control and contact tracing.

 

“Can I describe the people who are interpreting and what their roles are?”

Yes, absolutely. I know I spoke a number of times about medical interpreters in the Afghanistan project, and primarily they are women from the community who are often educated, actually, as nurse assistants or midwife assistants and are working on their midwifery or nursing degree who speak fluently both Pashto, which is the dialect spoken in Khost, as well as English. So they're often working, they accompany us, they're female only because of the gender segregation in our projects in Afghanistan. Many of them advance, as they work several years in our project, as they work on their midwifery degree, graduate to be midwives, and take on a position, perhaps, in our project as midwives, but they're really indispensable to the daily work.

The number of international staff in this project are very few, and so primarily the staff are native speakers of Pashto. Often it's just five or six people who may need medical interpreters' assistance, and, in that case, they're available 24/7.

 

“How do you procure and pay for medication in these Afghan hospitals where you've worked?”

The supply chain of MSF, I think, is what makes it unique in terms of humanitarian organizations. Of course, all supplies are procured, actually, all medications and supplies are procured primarily outside of the country and brought into the country through various agreements with the political entities that control borders. What's remarkable about the Afghanistan Khost project that I spoke about is really the experience of stock-outs, or rupture of certain medications almost never occurs. The reason I think this is vital is we're often relying on lifesaving medications to stop a postpartum hemorrhage, and really in a project like that, where you're delivering 2,500 women a month, you really can't stock out of those kinds of essential medication.

 

In all the times that I've been in Khost, we've maybe stocked out of one or two medications that have been very quickly procured with the help and assistance of, often, ICRC planes are what's helping us fly supplies to this project, because the road between the capital and our project is not very safe.

 

“Tearing up hearing you describe this miraculous case. Would love to hear more about your work with the local healthcare workers with Afghanistan, but also elsewhere in MSF, what kind of training do they get to be able to continue this work if there are gaps in MSF expertise coverage, for example?”

Absolutely. This is actually a huge part of learning and development within our project. Certainly in my experience in the Khost project, so learning and development portfolios for each healthcare worker portfolio is created and created in an iterative way and tailored to that particular person, so that, for example, my job as an obstetric and gynecology advisor was really to focus on the midwifery supervisors, which are the senior midwives, as well as the Afghan physicians with obstetric skill, and to really work on certain competencies in order to help them become absolutely independent in many of the higher order emergency cases.

I say this, but we're talking beyond what an obstetrician/gynecologist is learning in a global north country. They're able to really manage some of the most critical cases that, for example, in my hospital in New York, would require the assistance of five or six different kinds of teams to really gather all the expertise in order to save that particular person. There's a lot of capacity building ongoing in Khost, both at the midwifery level, at the nursing level, and at the physician level. Many of our physicians that have worked with us through the Khost project have gone on to complete their specialization in various cities in Afghanistan, such as Kabul, where many university hospitals exist, but also Jalalabad and others. Physicians essentially graduate from the MSF project and also go on to lead lives in other cities in Afghanistan. I'm happy to say that many of them also stay in Khost and continue to provide excellent care in collaboration with MSF, but outside the walls of MSF, in either independent clinics or the local government hospital.

 

“Countries like Israel and the US have about three hospital beds per 1,000 people. Most likely MSF operates where there are far fewer. How many MSF beds are there per 1,000 in a country like Afghanistan?”

I actually don't know the exact number on the level of Afghanistan, but to say, for example, on the level of Khost, where the catchment area is around 1.5 million people, we had 10 delivery beds and 68 postpartum and antepartum beds for 2,500 women a month, so we're talking, certainly, a very high turnover, and I don't know that MSF, in and of itself, is making a dent in the number of beds per 1,000 people in Afghanistan, which is a very enormous country.

 

“Andrew is asking what birth control efforts are in place.”

All of our maternal health projects are really comprehensive reproductive health projects, so we manage sexual and bodily rights, we manage cases of sexual violence, we manage safe abortion care, and, of course, we offer contraception to those who are interested. We also have to balance not being coercive in terms of our contraceptive delivery. Contraceptive delivery is really focused on person-centered care, what women desire and for how long they desire it. While we offer things like long-acting reversible contraception, such as IUDs, intrauterine contraceptives and implants, we also offer short-acting methods like contraceptive pills, condoms, injections. We're also working in collaboration with local healthcare entities so that people can continue to receive that free care after they've commenced it at MSF.

 

I'm sure it's not news to this audience, but, of course, one of the big values of the high-quality care that MSF provides in these contexts is also that it's free, and so it's really equitable and available and accessible to the most vulnerable populations who may otherwise have to pay for care even in public facilities in the areas where they live.

 

“Afghanistan remains within the top 10 country expenditure programs for MSF as of a 2019 report. Can you highlight the overall work being done there?”

Yeah, absolutely. Multiple sections of MSF are working in Afghanistan. The project that I spoke about is run by the operational center in Brussels, Khost. There are also projects in Helmand, in Kunduz, and in Kandahar. While many of the projects are related to maternal and child health, some are very specifically related to, for example, in Kandahar, to tuberculosis, in Kunduz to, really, emergency, trauma, and outpatient care. The project in Helmand is enormous, Boost Hospital is an enormous joint effort between MSF and the Ministry of Health. It's, I believe, a 1,000-bed hospital that's really serving a general population, as well as maternal health. I believe that the reason it's at the top of the expenditures is related to just the sheer volume of people served, and also some of the very specialized projects, like the tuberculosis project.

 

“Someone's asked me to speak further on the impact of COVID-19 on our existing projects and the impact on patients we're seeing in New York.”

I may have spoken about this very quickly, but I'm an obstetrician/gynecologist. Actually, I'm a high-risk obstetric provider in the Bronx, in New York, where we've certainly been hit by COVID-19 very hard in the beginning, and now we're seeing it, unfortunately, spread to the rest of the country. But again, not new to this audience, but the people hardest hit by COVID-19 have really been the very most vulnerable in every population, so while the Bronx is an area that's incredibly impoverished, it's also a place where, primarily, women of color live, so it's not a surprise that the people I've seen hardest hit, in terms of my practice, are Black and Latinx women. Hardest hit, I say, by both the biological impact of the virus and the pandemic, but also the economic fallout.

 

That's something that's very parallel to much of what we're seeing in our MSF projects around the world. Women and children are the most burdened, but also people who are displaced and might not have access to clean water, to safe shelter. It's really been, it's taken a staggering toll, and I think sort of remains to be seen how we continue to adapt our humanitarian intervention. Much of what's happening right now is we're being very creative in terms of, how can we remote support many areas where we may not be able to access because we aren't able to fly?

 

How can we locally procure and safely procure medications and supplies in areas where we may not be able to bring them in by air or road? I think it's requiring a lot of adaptability and flexibility, which is sort of the hallmark of what MSF does, and it's the way that we're able to reach populations in the most remote areas, whether it's remote geographically or remote politically.

 

“As a board member of Planned Parenthood, I'm curious about the abortion care you mentioned. Can you expand on that?” Yeah, absolutely. MSF is committed to safe abortion care around the world, and this is a commitment that's been outlined in our principles for several years. I think we've been more and more vocal about it as the years have gone on. It, of course, takes a different shape in every context where we work, because we are constantly balancing how to work within the mandate or the requirements of a certain culture, community, population. Not so much nation states, but what the local community expectations are, traditions are. I don't mean that we don't provide safe abortion in areas where abortion may be restricted on a social level, but just the way that we work on values clarification and the ability to safely provide that care changes depending on where we are.

 

So, in Afghanistan it might take the shape of really collaborating strongly and deeply with local community elders, whether female elders or male elders, family members, working on this idea of sort of community consent or family consent around the ability to provide a safe abortion.

 

Nobody is turned away from a medically-needed procedure ever, but the way that that medically-needed procedure is provided and who's involved in the provision might change depending on where exactly we're working.

 

In certain projects, we have access to methylprednisolone and misoprostol, where we're able to provide safe medication abortion. In other projects, we might network with local health facilities that have access to those medications where we can safely refer patients and ensure that all costs are paid so that cost is not a barrier. In certain projects we have access to, as I mentioned, operating theater or blood bank, where perhaps a high-order surgical abortion might be feasible if that's necessary for a woman's health and life. So, it just takes a different shape in every project, but it's certainly a priority, as it is the way to provide comprehensive reproductive healthcare.

 

Linda's asking, “I heard that MSF is also providing care in the US. Is that true? If so, a sad reflection on our healthcare system.”

Yeah, to Linda's point, our projects in the US have closed as of October in 2020, but it is true that MSF was providing various COVID-specific support in areas in the US, and it, again, took a different shape in every place, so in Florida we were working with migrant farmworkers. In New York, we were working with the homeless population. We've also been working in the southwest with the Navajo Nation and Pueblo peoples. In each of these instances, certainly, those are vulnerable groups that are sort of at the outskirts or excluded from US healthcare, which, I agree with you, Linda, is a sad reflection on US healthcare, but it was done more in support of populations that, at the time, weren't getting the services that they needed.

 

We've since transitioned, and many local entities have taken over some of that care, but it was important for us to do that, because we are highlighting, again, that in times of a pandemic or this political instability, what we needed was to recognize the most vulnerable people in that area and provide the services that they need.

 

“Is there any request I can make of my Congressional delegation that would help MSF?”

Yes, and I will refer you, actually, to my team that's supporting me on this webinar, who can provide more direct, perhaps, information on how exactly to do that.

 

I'm just looking through our questions.

 

Certainly, MSF is constantly relying on advocacy, on testimony. Part of what I'm doing here today is really bearing witness to what I've seen and what I've worked with MSF on populations that may seem very remote to a US population, but I think a Congressional delegation might help us with, yeah, spreading the word about what vulnerable populations, for example, we did service in the US, or what vulnerable populations we're standing in solidarity with around the world.
 

I hope I didn't miss any questions. I'm just in search here.

 

I have a question here: “What do I see as the top challenges that MSF faces in the coming year?”

I think the pandemic remains the most enormous challenge of our time at the moment, and what I mean by that is not just the biologic impact of the virus on everyone's lives, or on the impact of how organizations are running, how fundraising is being generated, how people are being moved around the world in support and in service of other people. The economic toll, absolutely. I think MSF is also facing the challenge of also internal reflection on how do we define ourselves as a humanitarian organization in 2021 in the age of, really, a lot of deep thought and probing around what does it mean to be a truly equitable humanitarian aid organization in the world today? How do we work with authenticity around what does it mean to be, for example, an anti-racist organization? What does it mean to be an anti-colonial organization, as we are in collaboration with communities around the world to service the most vulnerable people within those communities?

 

I think these are questions that many, many entities are grappling with, and MSF is grappling with movement-wide, beyond MSF USA. COVID-19 is going to continue throughout 2021. It's going to be a huge impact on how we deliver care, but I also think it's, with these challenges come a lot of opportunity for reenvisioning, for transformation, for propelling that work further and faster in service of the people who are relying on us.

 

“Was there medical knowledge/experience you had access to there that you don't have here in the US, and could you share with us a brief story of your journey to becoming an MSF doctor?”

 

In terms of the question around medical knowledge and experience that I had access to that I don't have in the US, I'll say that, certainly as an obstetrician/gynecologist in the US, there is a certain narrowing of what your job description is in the US, and I don't mean that disparagingly, I just mean that there's a hyper-specialization in the US, so while I'm, right now, a maternal-fetal medicine doctor, so a doctor of high-risk pregnancies, there are five or six other types of OB/GYNs or obstetrician/gynecologists that work with me in the hospital.

 

In the most recent hospital I worked in in the Bronx there were 60, 65 obstetrician/gynecologists for serving around 4,000 women a year, and so the remit of what each individual person needed to know to do was much narrower than what an MSF OB/GYN really needs to be able to know and do. Certainly, I had excellent training in the US, in terms of my medical training, but I also learned an enormous amount and continued to learn an enormous amount from colleagues around the world So, working in Sierra Leone, I learned from midwives who have been in practice for 20 years. In Afghanistan, I learned from pediatricians, nurse anesthetists, and general doctors or general surgeons who have been working in Afghanistan for many years.

 

Certainly, you have the fund of knowledge and the base skills that you learn in a US or a European or an Asian or African medical education, but what you learn in an MSF project is so much more than that, and the ability to be open, certainly, to that type of learning, but also to know your limits, to know when something is really beyond your skill set and would not be safe to perform and to stop and to ask for help.

 

So often in many, certainly in the Afghanistan project, I had the opportunity, once I identified something was really beyond what a maternity facility could provide, to refer to the local government hospital in order for a general surgeon to take over, or in order for a pediatric surgeon to take over, and I think that's an important, certainly important to say about our MSF projects.

 

“Can I share a brief story of my journey to becoming an MSF doctor?”

I actually went to medical school because I wanted to work for MSF, and it was really before I learned that most people who work for MSF are not doctors, I'm sure, as you're well aware. I really came to medical school and medical training out of a sense of social activism. I'm a daughter of two human rights journalists and my father was a political prisoner, so I came to medicine more from the sense of activism than from the sense of a purely scientific pursuit of medical knowledge. I trained in obstetrics and gynecology out of, again, a sense of feminism, and really wanting to do the most for women in the world, and my training took me into the area of safe abortion care, where I became a specialist in complex family planning, which is safe abortion, and complex contraception. After that I joined MSF, wanting to really stand in solidarity with communities around the world. I'm from the Middle East. I came to the US for medical training. I traveled, again, around the world with MSF, and with organizations in my home country.

 

It's important to me to not practice medical elitism in just a small silo of the world. I really want to remain engaged with the rest of the world, and that's why I continue to work for MSF.

 

“Do you have male OB/GYN positions?”

Absolutely. Many of our projects and many of our OB/GYNs who were native to the communities where we're serving are male. In certain, very select projects, only female physicians are allowed due to gender segregation, but those are very few in the grand scheme of the 72 locations where MSF works. So, in Afghanistan specifically, the physicians with obstetric skill working in our projects are women. That said, in bigger cities in Afghanistan, in Kabul, in some of the university hospitals, the OB/GYNs are men. I've worked with many, many male colleagues in West Africa, in Lebanon, in Iraq, and so I think it's really just specific to the geography, but absolutely we have male OB/GYNs. We also have male midwives, male nurses, so there's not really any kind of gender divide there.

 

Just to clarify, I guess, when I said gender-segregated project, it's just for the privacy of women as they're laboring and giving birth, but many of the staff in that project are male as well.

It looks like we're out of questions, and so I would just like to send you a really enormous thank you for your time and thank you for your generous support always.

 

I think that our donors and our funders are absolutely indispensable to our social mission. Nothing really can happen without the funding to support staff, projects, supplies, medications. I think our project in Khost would not exist, and when you think about some of our projects not existing, the thing that I'm really left with is the staggering morbidity and mortality that can occur in that location without our projects.

As we continue to work with communities all over the world to safely handover various projects and find collaborators to continue the work where we might not be able to continue, I think that your generous support of our ongoing work is really vital, so I thank you greatly for both that and for your time.

 

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.

 

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.