Cape Town — Part 1 of a conversation with the international president of Mèdecins Sans Frontières.
Dr. Unni Karunakara, the international president of Mèdecins Sans Frontières (MSF), is midway through his three-year term as president of the international humanitarian organization. He visited South Africa recently - the site of groundbreaking work started 12 years ago when MSF, together with local activists and healthworkers, changed conventional thinking about how to provide antiretroviral therapy to people living in poor communities.
AllAfrica met Karunakara at the MSF offices in Cape Town where he spoke about the significant, but precarious gains made in reducing medicine costs and providing treatment for Aids, tuberculosis and malaria. He also discussed the challenges MSF faces in remaining independent and principled in conflict situations, and the complexities of deciding when to intervene - or withdraw.
Parts of Africa have made progress in treating HIV, TB and malaria, but there have been reversals as well. What are the prospects for greater achievement?
We've made incredible progress in the last 10 years. We saw several institutions take shape and make huge contributions to global health. We've been able to scale-up treatment for HIV, for tuberculosis, for malaria, and there was much more focus on international health and willingness of governments to engage in health issues.
But I think we're at a point where all of the gains we've made are at risk. There are several factors. One is the financial crisis, which has been used as an excuse to hold back funding for global health initiatives. It's becoming more difficult for politicians to sell international aid and international commitment in their own countries, but this is a case politicians need to make much more emphatically.
The Global Fund (to Fight Aids, TB and Malaria) is central to the scale-up of care and treatment for millions of people with HIV - 6.6 million people. But the Fund had to cancel their Round 11, which can have very bad consequences. We really need to make sure the momentum we've gained over past years continues.
Another factor that allowed us to scale-up treatment to millions of people: generic competition. In 1999/2000 the cost of ARV (antiretroviral) treatment for a person per year was between U.S.$10,000 and $12,000. Today it's around $75 - a remarkable decrease in price! The Global Fund, Pepfar (U.S. President's Emergency Plan for Aids Relief), Clinton Foundation, Unicef - they all buy generic drugs which makes it possible to put many more people on treatment. It also makes it possible for governments like South Africa and other countries to provide free treatments.
But that's at risk because India has signed on to WTO (World Trade Organisation). There are several bi-lateral agreements, especially the Free Trade Agreement between the European Union and India, which could shut down the possibility for more generics in the future.
We are at that point - well we have been for a few years - where people on first-line treatment are now transitioning. They need second- and third-line treatment and these treatments are frightfully expensive. We need to have these affordable medicines, but also diagnostic tools. My fear is that if we don't address these issues, not only does the funding dry up, but the cost will also go up. That can be catastrophic.
The third thing at risk is research and development for all sorts of new therapies, particularly for paediatric formulations, and better diagnostics. To make progress against TB, for example, we need better diagnostics - more sensitive and more specific. We also need better diagnostics for children; it's very difficult to diagnose some of these illnesses in kids.
The market has pretty much failed people living in poor countries. Endemic countries, the countries that are affected by diseases, including neglected diseases like sleeping sickness, need to take leadership in setting agendas for research and development.
It seems ironic, given Belgium's history with the Democratic Republic of Congo (DRC), that it is withdrawing its support for the sleeping sickness programme in that country.
Exactly. But it is also the job of the DRC government to see that it remains a priority and that this is conveyed to donors. We are in one of those perfect storms, where all these different elements are clashing, and if we don't fight, I think we'll have a very difficult time ahead.
So do you think national governments should bear greater responsibility for meeting the health needs of their people?
Sure, absolutely, national governments have to take responsibility. Of course there are poor countries, but many of those countries with high burdens of HIV and TB, and perhaps malaria, are countries where economies are booming. But we have to be clear that for the next few years, any solution will require support from the international community. Given the amount of funds that are required to address problems, you cannot absolve the international community.
How do you see things panning out in trade negotiations with the European Union and India, the world's the biggest producer of generic drugs?
We're at a sensitive stage of the discussions. Activist groups in India, in Europe have made positions very clear, and we've made our position known as well. Now it's up to the Indian government as to how much they give.
This is high politics, so we hope that the Indian government keeps the interests of their people in mind. Part of aspiring to be a global power is also to take a moral responsibility and to understand that the policies they make in their own country have huge impact outside their borders.
I mean for MSF, 80 to 90 percent of the drugs we use to treat these diseases come from India. And not just us - the Global Fund and Pepfar, all of these organisations buy massively from India. The Indian government has to realise this.
Has MSF engaged with the Kenyan government about its anti-counterfeiting legislation and how it can be misused to deny access to quality generic drugs?*
There has been some attempt in the past years, especially by industry lobby groups, to say is that generics are bad drugs, but we know that's not the case. All of the generics that are being purchased by organisations such as MSF and others have been pre-qualified by the World Health Organisation. That means they are as effective and they meet the therapeutic standards that we need. That is a very false argument.
The idea of a pre-qualification programme is that countries that don't have regulatory processes in place can avail of this international centralised system, and it makes it easier for all of us to import drugs. But now, more and more, countries are putting regulations in place, and this comes with a lot of challenges. It takes a while for systems to mature, and there can be lapses. In the past, and even now for the most part, we buy our drugs centrally, because it's an easy way for us to assure quality, and then we bring it into the country. Local purchase has its own problems, but more and more countries are requiring that drugs be purchased locally. That puts an additional strain and burden on organisations like us.
We are a humanitarian organisation. Speed is of essence, we don't always have the time to come in, assess quality, and then buy drugs. Having said that, we are thinking about these problems and sending people to these countries to do the due diligence that's needed, approve certain suppliers and approve certain companies, etc. It's not fool proof, but we have to do the best we can to ensure the quality of the drugs we provide to our patients.
There has been talk in South Africa, and some other African countries, that we should be producing our own generics for the continent. It has a great rhetoric to it, but do you think this is viable?
You need a certain critical mass of skilled labour - whether it's scientific or manual - to be able to produce the drugs cheaply. The gains you make in drug production, in terms of prices, comes from being very innovative about processes you use to develop the drug.
Of course, I think it's great that African countries have the aspiration to produce drugs, but in the short to medium term I don't see the generics produced in these countries as being cheaper. You need to bring skills and expertise from outside, and all of that adds to the cost.
MSF has not confined itself to responding to medical emergencies - it has been outspoken about treatment of refugees, especially in South Africa during the xenophobic violence that broke out in 2009. How does MSF see its mandate in Africa?
Our mandate has pretty much been the same. We respond to needs. We work in places where people have been affected by conflict of, course, but not just conflict - natural disasters, epidemics, neglect, hunger, fear. One important element of our independence is the ability to come in, assess needs, assess vulnerabilities and then respond as we think is most appropriate. We talk to all of the stakeholders. and we find the way forward.
I very rarely call us an emergency organisation. Emergency implies that we're always responding to earthquakes, floods. But an epidemic is an emergency, a social emergency. We know in the last 10 to 15 years, the nature of the HIV epidemic - and now drug-resistant TB in South Africa - is a crisis situation. That's what guides us.
Of course we are a humanitarian medical organisation and we have to be humble about what we can achieve. We are under no illusion that we will be able to treat every patient in all of the countries where we work, but we always try to make sure that we serve as a catalyst for change. Our way of working - and we do a lot of operational research - is to look very hard at how we can provide the best possible care to people living in very disadvantaged situations. And we engage governments and other policy makers in a dialogue, so that some of the lessons we learn can be scaled up. That's how we see our action reaching a wider population.
MSF has shown a willingness to be transparent about the debates you face in taking decisions. [In January this year MSF published "Humanitarian Negotiations Revealed" and in 2004 it published "In the Shadow of Just Wars".] How does MSF decide when to stay in a particular area, when the compromise is too much, and when to walk away?
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We have no hard and fast rules; it has to be taken on a case-by-case basis. Every day we work in the field is a delicate balance about being principled and responding to the needs of people. It's a balance between principles and action.
You can be very principled, but that means in many places we will not be acting, that people will suffer. And then we can be all action and throw principles out of the window, but that's a slippery slope as well, because the principles ground us. Anytime we compromise or move away from principles, it's a reference point for us to come back to.
Independence, impartiality and neutrality - are the three main humanitarian principles. But equally important is the principle of humanity, of treating people with dignity. In the end, you want to provide medical care that is effective - that will heal people and create wellbeing. If at any time our action is limited to a point that we no longer can provide effective care to the people, then it's time to leave or speak out and be vocal about it.
Typically, when aid is being diverted by governments for nefarious purposes or dodgy aims, then we speak out. When we are denied access to places after trying again and again, and we're not allowed in, then we talk out, because we believe all people in crisis should have access to health care. Third, when safe spaces for healthworkers to deliver care and for people to receive care do not exist, it's another instance where we absolutely have to talk about it and be very vocal. These are general operational principles, but we have to approach each situation on a case-by-case basis and then make that judgement, and not be very dogmatic about it.
Are you back in the Dadaab refugee camp in northern Kenya now?
Dadaab is the biggest refugee camp of our time, and there's a big role for us to play. We are still there. We have hospitals, provide nutritional support, and treat patients. We also deal with epidemics like cholera. The (MSF) people who were abducted from Dadaab - I can't comment. They remain abducted and we are calling for their safe release.
*Update: On April 25, 2012, the Kenyan High Court ruled that the country's anti-counterfeit law was unconstitutional in its determination that generic antiretroviral drugs were classified as illegal counterfeits.
Part two of this interview looks at the future of MSF in a changing world.
