March
2003
Doctors
Without Borders: Not Your Typical House Call
The Satya Interview with Brigg
Reilly
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Médecins Sans Frontières
(MSF), also known as Doctors Without Borders, is today
the world’s largest independent medical relief organization. MSF
was founded in 1971 by a small group of French doctors who believed
that “all people have the right to medical care regardless of
race, religion, creed or political affiliation, and that the needs of
these people supersede respect for national borders.” Universally
recognized for their independence and their strictly humanitarian approach
to providing medical aid to people in need regardless—or in spite
of—conflicting political interests, MSF was awarded the Nobel
Peace Prize in 1999.
MSF has field projects in areas of Africa, the Americas, Australia,
Asia, and Europe—wherever a population’s medical needs
are not being met by available services. Need arises typically from
one
of four scenarios: war and conflict; refugees and displaced people;
natural or man-made disasters; and long-term assistance, in countries
with collapsed or insufficient health care systems.
In addition to direct medical relief, MSF works to raise awareness
and educate the public. MSF recently released its annual “Top 10 Most
Underreported Humanitarian Stories of 2002”, to highlight some
of the most devastating crises in the world today, issues we don’t
hear about on the evening news. It also recently launched its Campaign
for Essential Medicines, demanding that drugs be made accessible to
those who need them, so that needless suffering and avoidable deaths
can be minimized, if not eliminated.
Brigg Reilly, Program Officer for the U.S. division, MSF-USA, worked
in field projects around the world for years until he returned to the
U.S. and settled in the New York office. Dr. Reilly took a few moments
to speak with Rachel Cernansky about MSF and some of the issues they
are currently dealing with.
Can you give a brief description of Doctors without Borders/Médecins
Sans Frontières?
MSF is an international, humanitarian, medical organization. Half our
mandate is to provide medical care to populations in need; the other
half is witnessing and speaking out for populations that often can’t
speak for themselves. We have no political or religious affiliation,
we’re completely independent, and have been working since 1971,
when we were founded in Paris.
What’s your history, personally, with MSF?
I started working with MSF in 1996. I was in New Orleans working for
the State Health Department of Louisiana when I applied to MSF. I didn’t
really know what to expect, and about six months later I was on a cargo
plane to Rwanda—it’s kind of a case of “Be careful
what you wish for.” I have worked with them since, always in the
field—in Rwanda, Russia, Ukraine, Honduras, Sri Lanka and Mongolia— until
my recent start in the New York office.
What are some of the more outstanding situations you’ve
been in?
A couple have been emergency situations: Honduras was after Hurricane
Mitch, and Rwanda was after the civil disturbances there. In an emergency
situation, it’s often just trying to get a handle on what the
medical priorities are—how big the crisis is that we’re
dealing with, and how big it might get—and to make the right
decisions.
In other countries, it was very different. I was in Russia for about
18 months and was dealing more with the HIV/AIDS epidemic, which was
just getting started at the time. They were going through a lot of
the
same things we saw here in the U.S.—a lack of understanding,
a lot of fear and unfounded prejudice, and a general lack of coming
to
grips with the situation. So we were there in a medical capacity, but
also trying to get them into action, to accelerate them through that
first knee-jerk phase where they want to isolate or test everyone.
Did receiving the Nobel Peace Prize change anything for MSF?
Mainly it helped make our voice a bit louder, opened new doors that
wouldn’t usually be open to us, so we can take our message to
a wider level, the public and policy-makers.
What are some of the problems that MSF cites in terms of the
relationship between aggressors, victims, and humanitarian organizations
in times of war?
One of the biggest difficulties is just the code of conduct. There
are, even in a war, certain rules that need to be observed to minimize
the
suffering of the civilians that are involved. Sometimes—often—those
rules aren’t observed, and our job is to push as much as we can
to improve the situation of the civilians that are caught in these conflicts.
But it’s often difficult to figure out who is actually doing what.
One international law is that civilians are allowed to flee a conflict,
and sometimes that’s not happening; a country will close its borders
and in fact trap those people within the situation they’re trying
to escape.
You see forced recruitment or child recruitment into armed forces,
or systematic intimidation of or violence against civilians, or denial—denial
of access to food or medical care. These are all tactics that everyone
knows are against international law but are still employed. We try to
point that out and get that to change, but it varies from context to
context. In some places, like Chechnya, you don’t even know who’s
in charge, who you’re dealing with.
In trying to point out such violations, how is it possible
to remain apolitical?
Well it depends. It’s very important to show that we are independent
and neutral, and our main concern is to get care to the people that
need it. The best thing is to be working where it’s clear the
medical need is the highest and both sides will recognize that. In Sri
Lanka, for example, we were working on both sides of the front lines—the
government-controlled and the rebel-controlled areas.
Personally it’s a different story. In the places I’ve worked
that have been in conflict, it was easy to stay neutral—there
were no good guys. Both sides tend to have very dirty hands, doing whatever
it takes to further their own goals, with very little consideration
for the people caught in the middle—people who want nothing to
do with the conflict and either want to get on with their lives or
escape
altogether.
Peace-keeping is arguably the best way to avoid some of the
most traumatic medical emergencies. How does MSF remain “neutral” in
politically inflamed situations, where the offending side is obviously
culpable?
We speak out, against one side or both—whoever is standing in
the way of medical care or is committing atrocities. That is a really
important part of our witnessing. Sometimes it’s an unpopular
message, with the authorities or even with the international community.
It doesn’t happen often, but MSF has been ejected from countries
where the ruling authorities have not liked our message.
Can you talk about the current situation in Russia with Arjan
Erkel, the MSF volunteer who was abducted several months ago (see sidebar)
?
That’s really a difficult one. This is the third time in the past
several years we’ve had someone abducted. The first person actually
escaped, the second person was released, and of course this recent abduction
remains unresolved. It’s very frustrating when you don’t
know why the person’s been taken or who you’re dealing with.
There’s so many theories—was it the Russian side, was it
the Chechan; was it political, was it economic?—although the
complete lack of contact for six months now is suggesting that it was
political,
because there has been no demand for money.
One of the persons that was abducted in the days surrounding Arjan
was a Russian humanitarian aid worker who was released after four months
in captivity, so that gives us reason to hope. But he was held in really
difficult conditions, and I can only assume that Arjan’s having
the same problems. We’ve had no proof of life. So we’re
really pushing. His birthday is in early March, so we’re presenting
a petition to Russian and Chechan authorities to let them know that
he’s not forgotten and this won’t go away.
Does MSF have an estimate of civilian and soldier deaths from
the war on Afghanistan?
Not that I’ve seen. We can talk about patients we have seen, and
we saw quite a few killed after an attack on Jalalabad. During the height
of the war, we didn’t have access to a lot of the places that
were under attack. There are huge variations in estimates, and differences
as to whether they were civilian or military, Taliban or al Qaeda, so
we don’t really have a number.
What’s the situation there now?
I would describe it as an armed peace. It’s a difficult time.
Health-wise it’s still very rudimentary, with very high rates
of maternal mortality—women dying of complications relating to
childbirth—and difficulty getting vaccination levels up to where
they need to be, and a high shortage of Afghan medical professionals.
Can you cite any experiences that might illustrate the balance
between speaking out and remaining impartial?
There was a time when international organizations providing medical
care and other assistance were more respected and it was clear who
they
were and why they were there. I think in the past few years that line
has been frayed quite a bit. Humanitarian aid is often manipulated
by
both sides, and from that has come less neutrality. I look at Arjan’s
kidnapping—these sorts of incidents have increased markedly over
the years because of this fraying of respect for humanitarian organizations,
humanitarian neutrality; and it’s made situations much more precarious.
MSF recently published its fifth annual “Top 10 Most
Underreported Humanitarian Stories of 2002.” Who is this report
intended for and what results are expected?
This is to highlight all the non-CNN emergencies that get very little
airtime. One of the statistics from that report is that in 2002, more
time was devoted to the British royal family than to all ten of those
crises combined. The report tries to show that these issues are going
on, to hopefully get journalists and the public interested to find out
more.
What are some of the more seriously neglected issues?
Some of the public health issues and treatments that our doctors are
struggling with—generally diseases specific to poor people, like
malaria and tuberculosis. A lot of people think these crises have been
solved and are behind us, when in fact, they’re getting worse
and we’re actually taking steps backwards in some cases. Tuberculosis
is still killing an estimated four million persons a year, and malaria
about the same, and for some of these other diseases, there’s
no cure at all.
Is that what got the “Campaign for Access to Essential
Medicines” started?
That campaign came about from our doctors in projects around the world.
We kept seeing the same things coming up: the medicine needed is too
expensive or not available, or it’s not being made or not working
anymore. A lot of the causes of death are communicable diseases, ranging
from malaria to diarrheal disease. These literally kill millions of
persons a year, and a lot of them are avoidable, and that’s very
frustrating for us.
Speaking mainly about HIV/AIDS drugs, a lot of these drugs are protected
by patents that make their price unrealistic for developing countries,
where the burden of this epidemic is.
Suppose HIV/AIDS drugs were available, but their distribution
was obstructed by local corruption. Does MSF help ensure proper distribution?
That’s the other half of the equation, isn’t it—what
is the host government doing to make AIDS a priority, and will they
disperse the medicines in a just way?
There was a case recently where drugs targeted for Africa were found
to be resold in Europe at a profit. We have people saying, “Well
it’s going to be pirated off and there’s no infrastructure
in these countries anyway—they’ll never manage.” There
are situations where this makes it more difficult, but these are things
that are solvable and aren’t reasons for denying access or keeping
the price high. There are also ways of safeguarding against some of
these piracy issues: drug companies will generally package drugs that
are for developing countries in a different way, in a different color
for example, so if someone sees it, they know it’s been diverted.
Why is research and development so inadequate for those other
communicable, deadly diseases?
These aren’t profitable diseases; the people that tend to get
them are not well-off enough to merit development of any drug. Right
now we’re treating tuberculosis with drugs mainly from the 1950s
that are losing their effectiveness. There’s a good chance someone
will develop resistant tuberculosis (not a surprise with these “outdated”
antibiotics); and chances are it’s going to be fatal. Any chance
of survival is going to take about 18 months of daily treatment: a
handful
of pills that cause miserable side effects and probably take you out
of the workforce, so it gets back into this poverty begets disease,
which begets further poverty.
We call the diseases we highlight “neglected diseases” because
they don’t get any research and development attention. They include
malaria, tuberculosis, and a lot of other tropical diseases; kala-azar
(Hindi for black fever) is 100 percent fatal; sleeping sickness, same
story, just about 100 percent fatal; Dengue fever; there’s no
shortage of those. There are new therapies for malaria that came not
from our huge pharmaceutical research machine; but from a Chinese traditional
medicine. So if I talk about research and development, we’re
going to come out with 25 new acid-reflux and Botox treatments before
we come
out with anything for these global killers.
If you look at the curative side, in the past 25 years only about one
percent of new drugs have been for tropical disease, and most of those
have come from veterinary research. That means it’s more lucrative
to find a cure for our house pets or cattle; and it just happens to
have an effect for people living in the tropical zones. One example
is sleeping sickness: this is transmitted through the bite of a fly,
a parasite, and is 100 percent fatal with no medical intervention. The
treatment, developed in the 1950s, was developing resistance; and it
was an arsenic-based drug—very toxic—so it would actually
kill five to ten percent of the patients that we gave it to. A new drug
came out that wasn’t going to be produced because sleeping sickness
only affects Africa. It was put back in the manufacturing line because
they found that the same compound had a lucrative effect in its creme
form—it turned out to be a good hair remover.
The problem is, tropical areas are much more conducive to a parasitic
lifecycle. Any place with an appreciable winter will often break that
chain, that’s why you don’t get a lot of these things further
north or further south—unless of course global warming starts
to heat everything up, but I won’t even talk about that.
Are there areas in the U.S. where DWB offers humanitarian relief?
Some of our European sections have started working with what they call
the “Fourth World” population, people in the First World
that have fallen through the safety net. We’re not operational
yet, but MSF USA is looking to play a role among asylum-seekers in
the
U.S., starting in our own backyard here in New York. Many people are
detained for an indefinite length of time and have no idea what their
outcome is going to be.
What’s going through your mind right now, as a physician
who has dedicated his life to caring for sick and injured people, as
the U.S. is on the brink of war?
Overseas I sometimes hear: “You Americans don’t understand,
you never had a war on your home soil that anyone can remember.”
With our recent conflicts where a lot of it is done by remote control
and we’re able to watch the results on the news, and the loss
of life, at least on the U.S. side, is kept to a minimum, I think war
is getting employed perhaps earlier than it would have been otherwise,
and that war is not really a last resort for the U.S. as it should be,
and that’s a big worry.
What gives you hope?
In this job, you see the best and the worst of human nature. We’ve
talked about some of the difficult situations and lack of respect for
basic human rights and human dignity, but in a lot of these situations
you also see extreme bravery and selflessness on the part of the people
you’re working with. The people that live in that country don’t
have a plane ticket out when this is all over, and these are people
often living in the most basic circumstances, with nothing but the
clothes
on their back, working as hard as they can to alleviate the problems
being suffered by their colleagues.
There was a translator I worked with; riots had broken out in the city
she was living in, basically targeting her ethnic group. She tried
to
escape and she saw people being stopped at a checkpoint leading out
of the city, and if they were from that ethnic group their cars were
being doused with gasoline and they were being burned alive. So she
ran back to her employer who was from the other group; he was hiding
about 50 people like her. When the mob came to ask him to turn them
out onto the street, he refused. He really put himself in a lot of
personal
danger. In a way that encapsulates it: the horrible cruelty, but from
the same side, this extreme heroism. Just when you think it can’t
get any worse you see an example of someone who really steps up.
What can people do to learn more or to help stop violence?
The first thing is to be informed; I would encourage people to look
at the Top 10 list and follow one of the issues that they hadn’t
been aware of before.
Also, I’d like to ask them to sign the petition to procure Arjan’s
release. There’s also a petition on the access issue, and research
and development, so that we have more of the U.S. government and private
sector involvement in trying to find cures for what’s killing
the most people rather than what’s only the most lucrative.
To learn more about MSF, to read their Top Ten report, or to sign
a petition, visit www.doctorswithoutborders.org.
To contact them, call (212) 679-6800. Private donations account for
the large majority of MSF funding, donations can be made online, or
call (888) 392-0392.
Arjan Erkel: Still Missing
On August 12, 2002, MSF volunteer Arjan Erkel was abducted by three
unidentified gunmen while serving as Head of Mission in the Russian
Republic of Dagestan. Now, six months later, there has still been no
contact or demand for money, and all efforts by Russian and Dagestani
authorities to solve the case remain unsuccessful. MSF does not know
whether the abduction was politically or economically motivated and
has no information on why or by whom Arjan was abducted; they do not
even know whether or not he is still alive. MSF is presenting a petition
this month to Russian authorities to demand his release, calling on
President Putin and the Chairman of the Dagestani State Council, Mr.
Magomedov, to treat Arjan’s investigation not as just another
criminal case. You can sign their online petition by visiting www.doctorswithoutborders.org.
—R.C.
