7 May 2012

Africa: Raising 'Uncomfortable Questions' in a Changing World

Photo: Joshua Lutz/Redux
Dr Unni Karunakara examining a child in Somalia.

Cape Town — Part 2 of a conversation with the international president of Médecins Sans Frontières.

Dr. Unni Karunakara is the international president of Médecins Sans Frontières (MSF). The humanitarian organization works in some 65 countries with a staff of some 30,000 people.  AllAfrica met him at the MSF offices in Cape Town where he spoke about the significant, but precarious gains made in reducing the costs of treatment for Aids, tuberculosis and malaria.

In the second part of this interview, Karunakara discussed the challenges facing the organization – the growth of non-communicable diseases, ageing populations, increased urbanization and the development of megacities where all too often health and social services are not keeping up with the need.

You've been with MSF since 1995 and you are midway through your three-year term as president. Do you have particular targets or things you'd like to see happen?

The presidency of MSF is an elected position – elected for three years and a second term is a possibility. We have a very flat organisation and a very vibrant association. An association is made up of people who work for MSF currently, or have done so in the past. There are really extensive debates each year about the direction of the organisation. It can be a bit chaotic and cumbersome, but it's an essential nature of our organisation and it allows us to be who we are. So yes, I'm the president, but I reflect the will of the association members and we want to continue to be an organisation that is able to provide the kind of care that people need.

The world is going through several transitions. Even in the poor countries where we work, people are living longer, so they're moving away from an infectious disease epidemiology to a more chronic disease epidemiology.  While recognising that the poorest of the poor still have an infectious diseases epidemiology, what we want to do is on top of what we are doing now, so we need to have the capacity for that.

In a lot of places because people are living longer, we need to look at the plight of older people and other vulnerable people.

So, there's an epidemiological transition, a demographic transition and also a migratory transition. We've always dealt with refugee issues, but there are also people moving within countries from rural to urban areas. It doesn't make any sense to classify people as political refugees or economic refugees. People are moving for whatever reasons because they do not feel secure in their homes.

For the first time in our history we are now an urban civilisation and we need to understand the complexity of urban health and address that. We already have some experience in working in urban areas – we have a project in Johannesburg – but we need to do more.

Then we have climatic transitions. How that will affect things? For example, we will start seeing malaria in places where people were not exposed to malaria before.

So these are some of the transitions we need to navigate in the coming years. And my job is to make sure our organisation is prepared to meet these challenges, and to do that in a responsible, ethical way, to make sure we keep the needs of people front and centre.

What would be some of things that require attention in urban settings? MSF has been working in Khayelitsha (in Cape Town) for more than 10 years, that's an urban setting, although it includes a lot of informal housing.

When I say urban I'm thinking more of a setting like Johannesburg where people are caught in a downward spiral of poverty, disease and violence. And of course exclusion, it just gets worse and worse. So in Rio (de Janeiro), in Johannesburg, in Mumbai all of the big mega-cities, these are the things we need to look at – how to provide effective care and how to access patients. It's not easy and it's a very different kind of work than what we were used to in our 40-year history. So these are things we are learning as we go along and we have some experience now.

We also need to focus on the plight of children. Trafficking for example, these are issues we don't always work on, but we will need to look at the plight of all these different groups of people.

Does that imply much more engagement at a political level?

We're not a political organisation, but the medical work we do has a political character to it because we are raising uncomfortable questions to policy makers and the health ministry. Because in the end, our action is emblematic of failure. We are there because the system has failed.

Almost everywhere we work, we operate in a failed system where those responsible, especially the governments, are not able to meet people's needs – for various reasons. In some countries it can be very deliberate, in other countries it's just because they don't have the means, they don't have the expertise, or they're not structured to do it.

Having said that, we also need to be careful about what we do, as a humanitarian organisation, and what development agencies do. We tend to put everybody in the same aid basket, but there are very different mandates and very different paradigms.

To boil it down to bare essentials, we treat patients; we don't treat systems. Of course we engage with systems, but our objective is always to treat patients and not to treat systems or to set up a new health system for any country. However, when we work, we want to work in a responsible way, so a lot of the initiatives and innovations, a lot of our operational research, has enabled us to scale up our treatment either by countries or other organisations in a big way.

What we've learned in Khayelitsha has had enormous impact. The (HIV/Aids treatment) programme itself treats about 20,000 to 25,000 patients in Khayelitsha, but what we've learned and how we've structured things – that goes towards building sustainability. Yesterday I was in Khayelitsha and met some adherence clubs and support clubs, they might seem minor activities, but the impact they have on keeping people on treatment and improving their quality of life is enormous. These lessons can then be taken up by governments and policy makers and they can implement them.

And that's the difference when we say "sustainability". We're not necessarily talking about sustainability of that one project where we work, but sustainability of ideas and sustainability of policies or evidence that can then be scaled up by others.

This goes back to the earlier statement I made that we as an organisation are not able to treat all patients. So we have to make sure that where we work we have the right policies in place, the right tools are available and the right environment exists for patients to access drugs and support tools.  Then, when it all clicks into place, it's for us to get policy makers and other communities to take notice and hopefully scale up and reach more people.

We've done that in HIV, we've done that in malaria, we've done that in nutrition, and with neglected diseases like sleeping sickness, like kala-azar, so that's how we look at it.

We need to be very clear that as a humanitarian organisation our mandate is very limited. Actually, when you look at it from a health perspective it is not that narrow, but when you look at all of the other social issues that are taken on by development agencies, it's quite narrow.

I'm not for one second saying that development enterprises are any less important, but they have a different way of approaching their mandates and they usually work with systems. They want to create systems that can provide. We look at it from the other way – from the patients' perspective and that determines the kind of system you need to put in place.

In the current financial climate MSF seems to be extremely robust and active, and there are no signs of needing to scale back. What is the situation?

We've always believed that the health of our organisation and our ability to carry out essential life-saving programming, depends on the goodwill of the public. Today we are lucky we have around five million people around the world donating on a regular basis. For us it's not about one or two people donating U.S.$2 million or $3 million, for us it's about the grandmother in France who donates 30 euros a month, or a grandfather in Japan, or even South Africa. We even have people from Khayelitsha who donate. So we have that diversity and that is important to us.

We consider MSF to be movement and part of being a movement is to have an idea that inspires people. It's an idea that makes people want to express solidarity with people who are going through a difficult time in different parts of the world, and sometimes in their own community. In doing that we are very conscious of our moral and ethical responsibilities. We take the wishes of our donors very seriously and we try to speak to our donors as adults. We don't just feed them stories about how many kids we've vaccinated, but we really communicate the challenges we face in carrying out our actions and take them on a journey with us.

So far our donors have stuck with us in this crazy journey. That doesn't mean we don't have our constraints, we live in the same world, but we are still able to carry on. And we've very careful. Our fundraising is completely dictated by operational needs, not the other way around. We only raise as much money as we need to carry out our operations. We have gotten big, that's undeniable, but at the same time it's important that we're clear about what guides the organisation. We don't raise money and then say, "ok, what can we do with this money?" It's the other way around. We have to be very clear what it is that we need to do – not even what we want to do, but what we need to do.

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