Understanding the aid shift and its devastating impact on global health programs (podcast)

CHIGO: Hello and welcome. I am Chigo Ahunanya and I am stepping in to host this episode of Humanitarian Lens, a podcast of Doctors Without Borders USA.

Today, we are focusing on a critical issue that has a detrimental effect on the communities where we work, our patients, and our staff: funding cuts for humanitarian aid and global health programs. 

It's been one year since the US government effectively gutted its international assistance programs, and the impact has been immense. The massive funding cuts and policy changes are reshaping international aid. Many local and international organizations have been forced to scale back or halt activities altogether, and communities are seeing fewer services.

With me today is Dr. Javid Abdelmoneim, an emergency physician and our MSF International President. Thanks for being with us.

JAVID: Thanks for having me, Chigo.

CHIGO: So let's dive right into it, why don't we? So Javid, these cuts were swift and have created a lot of confusion with organizations that receive funding from the US government. You witnessed this firsthand in Sudan, where you were on assignment a year ago. Take me through the moment when you found out about these cuts, and what it was like in our projects in Sudan.

JAVID: Yes, I was working in Khartoum as the medical team leader in the Omdurman project. We had several sites in hospitals and we were doing emergency work in the communities around cholera and vaccinations. And the cuts were announced. And I, all of us, were like, OK, some cuts have been announced. You know, you don't imagine it'll have an immediate effect. But within days, different organizations were coming to the office and asking for support because their funding had been stopped. And it was really surprising that it happened so quickly. And so the examples, I mean, that I remember — one was an aid kitchen, one of the sort of famous Sudan aid kitchens. People should have heard of them because they've been nominated for the Nobel Peace Prize and they're part of the emergency response rooms, the ERR, which are civil society organizations and the aid kitchens doing the meals in the hospital. One of the three hospitals where we worked had lost their funding and came in to ask for help.

Another organization [was] running a primary health care center. And you might think, well, that's not a big deal, but actually there were only about six primary health care centers working at that time across the whole city. And this is a capital city of a country and more [of the] population were coming back as the front lines were moving away. So the loss of one primary health care center was a big deal.

And another organization came, also — saying [they’ve] lost funding for community midwives. They had been running about 45 community midwives. What was really interesting about that project is those community workers had a chance to go across front lines.

And so access at the time — across front lines which ran through the city and across the river — for the population trying to come to our health services or have health services reach them, it was really crucial that this particular organization carried on. So, you know, that was just three examples that I can remember. And it felt really chaotic actually, because people are now thinking, well, were you able to support them? And I could and I couldn't [answer] because of the way we work [at MSF].

Firstly, we're not affected by the cuts. We don't take government money. So you might think, well, it doesn't matter then. But you know, when you work in a health ecosystem, say here we were doing secondary care, maternal health care in a hospital, pediatric nutrition care, and emergency room in a trauma hospital — but other [humanitarian] actors are around you doing all the other parts of health care. At the end of the year — through October, November, December — would have gone through our needs assessments and our project planning in the annual budget cycle. And part of your need assessment is to ask yourself who is doing what, where, and when. And that tells you what needs are being met. And then you say, well, OK, we won't duplicate. We'll do this and we'll do that and we'll extend that or we'll go there. We'd done that already and set ourselves up for the year.

I was already recruiting, I had open recruitments to go more into malnutrition, you know, so you're starting to execute your project’s annual plan and suddenly the whole needs assessment changes because the who's doing what, where, and when was gone, it was completely different overnight. So it was really disruptive from our perspective, but really also a sense of shock. And you know, in MSF, you're used to being able to respond. You're used to being able to do the most you can. And yes, we did what we could, but to do a full-blown programmatic shift, handbrake turn almost is [needed]. We can't do that and we can't fill all the gaps.

So for example, with the aid kitchen, I can give you some money if would that be helpful for the community midwife program. OK, let's see what we can do. What are the bridging measures? Who else could we call in? An even worse, Chigo, was that it very quickly became apparent that this was happening across the country. So my staff members were saying, well, we're hearing this is happening in Madani and this is happening in Gedaref and in Port Sudan. And suddenly our advocacy manager within the program in the country was calling and saying, I'm getting these reports and your counterpart has said this.

So then we were a bit like, Oh my God, this is huge. And we needed to, at a minimum, just start documenting and create a database of what's fallen away, what's now what we call an unmet need, what service has gone suddenly, what could we react to, and how and when? So it was quite dramatic.

CHIGO: I can only imagine. And especially when you talk about how we usually have a plan, we make a need assessment. And this happened in January last year. So you're just about to get started with your plan and boom, next thing you know, you have to rewire, reassign people. So can you fill the gap? We just can't, even if we wanted to — it was too big. And I want to go back because earlier you were saying, as we all know, MSF does not receive US government funding. But even though it doesn't affect us directly, all these players, all these things that happen, they kind of fall downstream.

So my question for you is what are the concerns that you're hearing from our staff around the world? Because I'm sure this is affecting our staff in many different ways, which I probably can't even imagine. But what would you say are the main concerns of our staff?

JAVID: We've been trying to do a mapping now across everywhere that we work to really understand if there's a country that has had its funding most cut or a theme that has been most cut. By theme, I mean, for example, vaccination or sexual and reproductive health. And what we've found is that there are, yeah, there are certain thematics that are really exposed now by these cuts. And that's partly because of the way they were funded. 

I can give examples. So if you look at vaccination in Khartoum, right? And my project was supporting vaccination programs with the Ministry of Health. We were doing whole segments of the state. Because you also have to remember in many parts of the world, we're coming off the back of COVID-19 where for a year, nearly two routine immunizations were not being done. And then you also have outbreaks. And now you add a layer of war as in Sudan, and you've got four or five years there of broken [vaccination]. And there are children who have zero vaccines who are 5 years old. And by 5 years old, you've had multiple vaccinations normally. 

So you're under the shells, trying to do what's called a periodic intensification of routine immunization (PIRI). And that's really specific. And I want to get this across because when you do a PIRI that labeling activates a funding mechanism globally that means the Ministry of Health can draw down vaccines. So when we're there partnering, we'll provide the staff, we'll provide the training, we'll deal with the needles, we'll provide the vehicles, we'll pay the staff. Yeah, we did it all. But you have to get the vaccines. You're the Ministry of Health. So how can we do that vaccination program when the vaccines have gone, when the funding is gone. Even we can't fix that, you see.

And that's the issue now. So that's one thing that's gone away or going or at risk in many places. Another thing we've seen is nutrition, ready to use therapeutic food, Plumpy’Nut. Have you heard of those little sachets of peanut-based food? That's a medicine that's a very complicated, very specific pharmaceutical medicine.

That medicine is expensive and we as MSF have traditionally relied on the United Nations agency for children because it's predominantly children that get severe acute malnutrition who need that medical food. UNICEF has been providing it to us because it's their job historically with large amounts of Plumpy’Nut, but now we have to start buying that because their funding has been cut by about 40 percent. So we're now having to spend more just to do what we were doing before.

Now add in that the World Food Program, the United Nations agency for food ... When the World Food Program goes away and food isn't being distributed in places of war, then malnutrition goes up and then you have to do more malnutrition care, which is with the medical grade therapeutic food that I've just been talking about. Right. So there are therapeutic foods and there's food. So now food's gone away. So there's more malnutrition and therapeutic food. We're having to do more malnutrition care and pay for the medical grade therapeutic drug, which is the Plumpy’Nut, that we didn’t have to before. So yeah, we're not affected by the cuts, but where we work, the health ecosystem is affected by the cuts. So for us, that's another big one.

CHIGO: And I think that's such an interesting point that you bring up. You've given us so many examples, like when we hear that MSF doesn't get government funding, we're all, we always think, oh, it doesn't affect MSF, but inadvertently it does affect us because it affects the communities and the patients we work with. So somehow it does come back to affect us because now we have to do reassessment and see where we can support more.

JAVID: Absolutely, absolutely. It just means all the needs around us have changed. And you know, personally, at least from my vantage point now and my new role, when I look at this dossier and we've called it internally “the changing humanitarian landscape,” which is a relatively benign phrasing, I find, because it's changing all right. But it feels a lot more existential than that. It feels like an like a major sea change, and it's colored by my experience of having been in Sudan a year ago when it happened. 

But it's a health ecosystem, right? So in every health system, you need the people who are going to do primary health care, people who are going to do secondary, people who do vaccinations, people who do public health, people who do water and sanitation versus surveillance versus outbreak investigation. There are so many different things in a health ecosystem and we're one organization. We've never done all of those things in anyone system ... We can't be the totality of emergency health services anywhere. 

We're big, but we can't do everything, and we cannot fill the gap where governments have sort of absolved their responsibility. And it's not just the US, it's the UK, it's Germany, it's Sweden, it's Belgium, it's France. They've all cut their overseas development assistance in this last year.

CHIGO: Now I want to go back to something you said earlier, because we've been talking about the US funding cuts. Other countries who've been traditional donors have changed their policy to shrink resources available to respond to humanitarian and global health needs. So global health institutions such as Global Fund to Fight AIDS, Tuberculosis and Malaria [and] Gavi, the Vaccine Alliance have seen donors decrease their funding pledges. How does this impact the communities where we work?

JAVID: HIV, tuberculosis, malaria — big infectious diseases [that are] far and away the biggest killers when you put them all together — [are] very preventable treatable diseases. The Global Fund to Fight AIDS, Tuberculosis and Malaria, that's another fund that's seen huge shortages in the sort of cycle of funding this year. ... Drug resistant HIV or pediatric children's HIV or HIV-TB (tuberculosis co-infection) are difficult, marginalized diseases. They're difficult diseases to treat, often in very marginalized and overlooked and vulnerable communities. [MSF is] quite good at sort of going for the most vulnerable of the vulnerable. So while we've been doing that, many actors have been doing more ordinary, more normal HIV treatment or more straightforward tuberculosis treatment. Now when all of those go away — again, it's a big world out there. We can't fill that gap.

I sat down with the CEO of Gavi, actually, to try and really understand when they're facing such a funding shortfall, what choices are you going to make and who are you going to cut out of your portfolio because that should inform us. And the reason I needed to ask that very specific question and it comes down to technicalities, but it's real life.

The technicality is that countries are layered into the income of that country. So you may have heard of low- and middle-income countries, and high-income countries. So these funds normally tier price. So it changes the price of a vaccine or of a drug and how much you're allowed to get depending on whether you're a low- or a middle-income country or if you're stable or unstable or in conflict.

CHIGO: With everything you say, all the examples you've given, these are seismic changes in the humanitarian aid world, my question is: What is MSF doing differently? Because certainly the need for humanitarian response has not decreased. So what are we as MSF doing differently or trying to do differently?

JAVID: It's a good question, Chigo, and I can answer this in two ways which sound contradictory because one is [that] we're not doing much different. Because if I bring you back to what I've said about how we sort of decide at a very project level out there where we work, you do your annual scanning, you do your needs assessment, who's doing what, where, when you plan your project, you get it signed off, budgeted, and you start right. That doesn't change for us. So the process won't change, but maybe the outcome will. We could see just a complete, complete change, you know, a handbrake turn and now doing something completely different in a different context. That analysis we're still going to have to do. It's now only January and so forth. I won't get too technical, but the reality is we're always going to be trying to meet the greatest need in as best way that we can.

So in one way, as I say, little changes for us, but potentially it could be huge. As I said, imagine, anywhere we are, if vaccinations fall away and we would have to programmatically ensure that we can always carry the capacity to do vaccinations now and in an outbreak. Routine immunization is something that wasn't generally standard [for us] unless we were doing a maternal and child health project.

The process of generating our project plans and our sort of annual projections, nothing there would have changed because it'll be based on the needs assessments where we are. I think there's potential for a huge change in the content, in the outputs in terms of what we do.

It's actually a really difficult question to answer. Are we going to see, as things pan out through the year and into the longer term, predictably higher rates of global malnutrition, higher rates of global outbreaks and epidemics, including greater malaria deaths, greater tuberculosis deaths, greater HIV deaths? Yes, yes, yes, yes, and yes, we are. How will that change for us? We will carry on trying to do as much as we can, wherever we can, however we can. So that's why it's actually really difficult to say what's going to change for MSF. We're just going to have to do a lot more in a lot more places, and we're going to have to make some really difficult choices internally, right?

CHIGO: But of course, the world is changing. And as all these funding cuts are happening, we're also seeing a world where things are becoming more costly. So how does that affect us as MSF? How does it affect the communities in which we work in?

JAVID: Essentially, it's already more costly for us to do what we would have done before. And I gave previously the example of using the therapeutic foods for malnutrition, the peanut paste. So now we're having to spend money buying that, whereas the previous system was that we get that as a donation in kind from the UN agency for children, UNICEF. So it's costing us more just to do what we did before, let alone we will need to do more of that in the imminent future. So that's what we're facing. Various funds like Gavi, the Global Alliance for Vaccines Initiative, ministries of health, would draw down vaccinations or money for vaccinations. 

If they're now operating in deficits and we're working in countries that can't access those, we may well have to do more of those programs and pay for those medicines. But we have to be really clear that there is no way ever we will be able to plug those gaps fully, [we] simply cannot.

CHIGO: Thank you so much. I've hit you with some pretty hard questions. But I do have this question for you. In your view, are there any communities or services that you see these funding counts impacting the most?

JAVID: I mean, it comes back again to marginalized or more vulnerable [people]. I think people living with HIV, sex workers, men who have sex with men amongst the sex workers, you know, you could almost describe them as very niche, and a small group in a society. And at the other end, you've got all women and girls’ sexual reproductive health services. So it's small groups, but also half of humanity on one level.

So there's a spectrum here, but I think it's important to highlight the marginalized groups, all the most vulnerable, because our tradition in MSF is to really look for those people that are left behind or fall through the gaps or are discriminated against. And there are suddenly going to be more in those groups than ever before.  

CHIGO: You make this mistake where we're like, oh, that's a niche group, but we don't understand that it's a marginalized niche group. But the repercussions affect everyone, like you said, half the world. So Javid, you recently started your new role as the MSF International President, and my question to you is, what is your vision for MSF in the upcoming years? And [with] everything we've talked about today, are you optimistic about the future?

JAVID: Oh, gosh, these are big questions. Shall I answer truthfully? I'm not sure it's a happy ending if I answer too truthfully. No, no, let me be serious. I think, it's almost like the question about what keeps me up at night. It can feel bleak. It can feel bleak. 

Let's also be truthful. It’s been an acceleration right of a trend that we were seeing for years already. And that trend is what we're coming to categorize as a meta crisis, right? So, you've got this poly crisis of the climate emergency, antimicrobial resistance, and just conflict everywhere, it feels. Large swathes of the world becoming uninhabitable, all of these things compounding. And basically, the end of modern health care because there's only about two antibiotics left in the world.

So there's all of this already happening now, and one symptom of that is the global cuts, not just from the US but from all the other countries. There's this sort of anti-science, anti-solidarity, anti-humanity [atmosphere]. And then, stepping back for multilateralism. this almost denial of the other person's dignity just seems to be bubbling ever stronger.

And that's the meta crisis. And these two things together for me feel, when I've slept well, like an immense challenge that we will navigate because we know what we're good at. We're good at focusing almost conscious sort of short sightedness on the needs of that vulnerable community. And we will get it done. Whatever we feel that they need and they ask us for, that's within our capacity. When I've slept well, it's fine. We can tackle anything. We'll get it done. We always have.

When I haven't slept well, I'm a bit like, Oh my God, what the hell? This feels like the end of the world because at precisely the moment that we need every country to get together and do the right thing for the planet, forget about all the rest, we're doing exactly the opposite. 

We're just breaking up and it and it feels like a profound period of change, actually. But on a positive note, we will always do what we've always done, and that's important. And that's important in my role. We need that steely laser-eyed focus. We're not going to abandon our principles. Humanity, the core principle of humanity is not going to change for us. And we need to be very clever and very clear on understanding which countries, which communities, which powers still uphold that principle and make sure that we we know where our allies are.

Humanity is one, [and] medical ethics. We're not going to stop being medical, right? We're not going to abandon humanity. We still see the dignity in every human being and their worth. We're not going to stop being independent. And then we have impartiality, of course, which means that a patient is a patient is a patient. We don't discriminate.

So these things are core and they're not going to change. And it's really important. And my role and the role of all the leaders within MSF will be to make sure that we reaffirm constantly our principles, that we stand by them. We're not going to waver no matter how hard it gets.

CHIGO: I love that. I think as we've been talking, there's so much change happening in humanity. And I think it's so important that MSF sticks to our tenets. And as you explained in your vision, I see that a patient is a patient is a patient. Like that's not going to change. I think that's really on the days when you get good sleep and the world seems positive, those are the things that we do need to remember to really want to make. 

Thank you, Javid, for taking us through some fairly complicated topics that we've talked about today. And we really appreciate your time and your insight, especially with these topics that affect so many people's lives.

JAVID: Thanks for having me, Chigo. Thank you.

CHIGO: Thanks to our audience for tuning in. You can check out our website for more information about funding cuts, our work, and the ways you can help. Please subscribe and leave us a review. It will help us reach more people interested in our work.

This is Humanitarian Lens, a podcast of Doctors Without Borders USA. I am your guest host Chigo Ahunanya, until next time.