MSF struggles to respond to Covid-19 in 70 countries

An interview with Meguerditch Terzian, President of Médecins Sans Frontières – France, conducted by Alain Boinet.

©Faith Njeri Kariuki, an ambulance driver at MSF’s Maison Lavande – which also houses the trauma room – in Mathare, Kenya, checking a patient’s vital signs. Photo taken by Paul Odongo on 4 May 2020.

Alain Boinet : The rapid spread of covid-19 has paralyzed air transport, closed borders, caused global containment. Médecins Sans Frontières’ missions have had to find themselves cut off from the headquarters and the dispatch of expatriates, medicines and protective equipment. How does an emergency medical organisation cope with such a blockage?

Meguerditch Terzian: The paralysis of air transport deeply disrupted our missions, especially at the beginning of the containment policies. MSF’s work is based on a constant ballet of personnel in our 70 mission countries around the world, and the supply of medicines and equipment needed for our medical activities. We have had to restrict our travel considerably in order to be able to negotiate on a case-by-case basis when transport opportunities arose and to prioritise the most urgent or essential actions. For example, we have suspended our numerous international training sessions and institutional meetings, which are essential for the coordination of our actions, replacing them as much as possible with videoconferences.

We are negotiating on a case-by-case basis with the embassies of countries that have closed their borders, such as Iraq, for example. We juggle with the airlines that still fly in the regions of our missions.

All in all, MSF teams are fighting to respond to the COVID-19 pandemic in more than 70 countries, either by adapting existing activities to the COVID-19 pandemic or by opening projects in new countries as they become pandemic hotspots. MSF’s response focuses on three main priorities: helping health authorities provide care for patients with VIDC-19, protecting vulnerable and at-risk people, and keeping essential medical services functioning.

You’ve had extreme cases like in Yemen, a kind of emergency within an emergency. What happened, were you forced to apply a policy of triage of the sick as can sometimes happen in times of war?

Yemen remains an extreme case, described by the United Nations as the biggest humanitarian crisis today. Since 2014, more than 12,000 civilians have died, more than 60,000 have been injured and 4 million people have been displaced in a country of 22 million inhabitants. In 2017 more than 1 million cases of cholera, and intercurrent epidemics of diphtheria, malaria and dengue fever will occur. The recent appearance of the coronavirus adds to all these plagues, especially as its importance is underestimated and totally underestimated. The few reported or estimated cases are only the tip of the iceberg of a possible immense disaster. In Aden, where we have opened a specialised centre for the treatment of Covid-19 patients, we have admitted 288 cases since 30 April and 99 deaths have been recorded. Seriously ill, often young, apparently healthy patients die within a few days despite the oxygen they are given in high doses. This oxygen poses enormous logistical problems: 8,000 litres of oxygen are used per day, while the country remains under embargo…Aden finally benefits from a privileged situation due to the presence of MSF. But what about the other cities in South Yemen?

©Yemen, Aden, 16 December 2018. The entrance to the MSF trauma hospital in Aden. The hospital opened in 2012. A photo taken by Agnès Varraine-Leca.

There are also collateral consequences such as the obligation to stop projects. Has that happened? How are such decisions made between the field and headquarters and how is it explained on the spot to patients and authorities?

We have not diverted any activities because of or for the benefit of the fight against coronavirus. For example, while we have mobilized on the treatment of severe cases of coronavirus in Yemen, this has in no way slowed down our mobilization on trauma surgery generated by the civil war. However, we have closed our cervical cancer screening clinic in Malawi to protect the health workers involved, but patients scheduled for planned cervical cancer surgery continue to be treated.

MSF has also been active in France. What was your action?
In Ile-de-France, MSF set up a Covid team to help people in precarious situations living on the streets or in emergency shelters. The ARS Ile-de-France asked for the association’s support in dismantling the Aubervilliers migrant camp. The cell of eight people, supplemented by volunteers, intervened in six emergency accommodation centres to set up protocols and an anticipated process for triage of suspect cases.
In Paris, the two Covid+ centres are respectively intended for families and isolated adults. Other structures have been identified in Argenteuil and Val d’Oise.
In the rest of France, 69 young people are accommodated in the emergency accommodation centre in Marseille. In Bordeaux, the Departmental Council has requested medical assistance from MSF to open a centre and other alerts are being issued in Lyon, Toulouse and Grenoble.
Finally, MSF is being asked to provide support to the hospital sector. Three types of intervention have been identified, the extension of triage space at the emergency level, support to the crisis unit of the establishments and the secondment of medical staff to meet the needs of hospitals in Créteil, Libourne, Montfermeil, Reims, Chartres, Saint-Cloud, Saint-Louis, Lyon, the CHU Henri-Mondor and the CHU of Reims, among others. MSF also analysed the situation of EHPADs in Seine-Saint-Denis and Val-de-Marne.

©Aubervilliers, France. Bastien Mollo, an MSF doctor, examines people evacuated from a camp in Aubervilliers near Paris on 24 March 2020. Photo by Agnes Varraine-Leca.

Were you able to use the regional hubs and World Food Programme (WFP) logistics under good conditions? What is the interest for you of the airlift set up by the NGOs of the humanitarian logistics network with the support of France and ECHO funding for the European Commission?

Indeed, we use the various flights set up by the WFP and ECHO. Thanks to the airlift set up we can make sure that we can send our international staff to the different missions so that we can continue to meet the different needs of the populations, either to cope with the Covid-19 pandemic or to meet the needs of our already existing projects. In that regard, we are very grateful for the support of the Department of Foreign Affairs, which is behind all these initiatives.

You have faced significant challenges in protecting health care workers, with the risk that health centres could become places where the virus could be amplified. What are your observations on this subject, what are your reactions and your proposals on the provision of protective equipment in times of pandemic?

Everything is being put in place to protect staff from possible contamination with the material and equipment needed for this protection, despite international shortages of masks for example, including those initially caused by the requisition ordered by the French government on our stocks available in our logistics centre (MSF Logistique in Mérignac). We even support the local and artisanal production of masks.

The supply of all the protective material and equipment needed for processing has been organised and coordinated at the level of MSF’s international movement.

How do you see the continuation of this pandemic and your role while waiting for a vaccine?

The next steps in the response are based on our daily analysis of the evolution of the epidemic in each mission, and the proportional response to the morbidity and mortality it causes. The vaccine will not be available for 18 months, industrial production is likely to be even later, and international discussions on intellectual property patents despite the mobilization of 80 countries with the WHO against financial abuse by the major pharmaceutical production groups do not bode well.

One could hope for the sudden appearance of an effective and cheap drug, easily administered (orally?) and without side effects, with more than 300 clinical trials underway worldwide, which would totally change the face of the world today. But this is still not the case today, despite the false hopes raised by hydroxychloroquine, which is paradoxically already instituted in the protocols of some African health ministries.

The hypotheses of the cause of new emerging diseases such as the disappearance of millions of animal and plant species and their diversity associated with industrial pollution of the soil and seas, and the words of activists trying to warn on these subjects are not the focus of our activities, although they are respectable.

Our vocation remains in the fight for populations and patients who are victims of epidemics, natural disasters and conflicts, and we use the therapeutic or preventive means available to everyone today and try to produce them until the end of the pandemic.

©MSF nurse Nouhoum Diakité shows people in the Faladjè district of Bamako, Mali, where positive cases have been reported, how to effectively wash their hands with soap and clean water. Photo taken by Lamine Keita, 18 May 2020.

In the face of this crisis, which is exceptional in terms of its scale and consequences, what are the first lessons you have learned and what measures do you plan to take in the future to remedy the difficulties you have encountered?

To date, we are not yet capable of a global analysis of the dramatic situation caused by this pandemic, as we are no more familiar than the scientific world with the genius of this new virus and the immune response that the infected populations will put up against it.

Like all health actors, we are not following this evolution step by step, and are trying to develop a response with a rather pragmatic attitude, by exchanging and discussing our information with all our health partners.

Nevertheless, our twenty-year fight for access to medicines, screening tests and medical devices embodied by our Access to Essential Medicines Campaign remains indispensable for the research and development of treatments and vaccines that do not yet exist, so that they are distributed equitably to both affluent and low-income countries.

As conclusion, would you like to add something?

Yes : we must consider that the pandemic does not affect people in the same way in all regions or in all countries in the same region. We are making every effort to carry out epidemiological surveillance in each country of direct concern to us with the help of our epidemiological research centre, Epicentre. We try to follow the evolution of the epidemic in each country by cross-referencing all possible sources of data: data from the Ministry of Health, data provided by our operational teams, mortality surveys in cemeteries (new graves are counted), etc. We also try to monitor the evolution of the epidemic in each country by cross-referencing all possible sources of data.

We found that the pandemic appears to be more serious in Yemen, Haiti, Sudan and Brazil.

However, it is essential that we remain very clear about our choices of priorities in terms of public health. Our action for the displaced populations, victims of the various jihadist groups and other private and traditional militias, remains the priority in Burkina Faso. We take care of enclaves with populations of 40 to 100,000 inhabitants, where we provide traditional health care activities for displaced or refugee populations: hospitalization and hospital referrals, support to dispensaries, mobile clinics, support for vaccination, distribution of kitchen tools and water transport containers, water distribution by tanker truck and well drilling, distribution of temporary shelters, and construction of latrines, etc.

Finally, it should be noted that decrees imposing containment or barrier measures against coronavirus are rarely applied in low-income countries where they are imposed. In northern Yemen, despite the bans and even the admission of administrative officials, the closure of mosques and food shops is not observed, especially at the end of Ramadan and during the Eid holiday period. As for the African countries where these measures are also imposed, one should not dream, the confinement only ruins the so-called informal economic activity that feeds the populations on a daily basis and cannot be formally applicable.

Meguerditch Terzian

A child of the Lebanese civil war (1975-1990), he was marked by his childhood under the bombs also during his time with MSF. Mego and his family were forced to leave Beirut several times in the middle of winter to take refuge in the mountains where they rented a holiday home in the summer.

He enrolled in the medical faculty of the Lebanese university, but by the late 1980s, much of Lebanon was under Syrian occupation. Mego’s parents, fearing that their son would be arrested, decided to send him to study at Yerevan University in Armenia.

Then came 1994. In May, the ceasefire is signed between Armenians and Azeris. Mego is then in her fourth year of medical school and is approached by a French MSF doctor who asks him to work as a translator in Karabagh. The young man jumps at the opportunity.

The years passed and once he graduated in pediatrics, he worked as a doctor in the outskirts of Yerevan, while at the same time working in an institution that looked after street children.

An expatriate from Doctors Without Borders offered him a mission in Sierra Leone. This mission marks the beginning of his real humanitarian action which will never leave him. He will then carry out a series of missions, notably in Afghanistan, followed by a series of emergency missions in war zones, disaster zones and in the face of the food crisis wherever MSF is active: in Democratic Congo, Nigeria, Liberia, Côte d’Ivoire, Pakistan, Iran…

In 2010, he became director of MSF’s Emergency Department, a key position where he is noticed by his superiors and in the field for his courage to carry out missions successfully. In particular, he was responsible for opening clandestine hospitals in Syria as soon as the war broke out.

Finally, in June 2013, he was elected by the members of the association to be the president of the French section of MSF. His 3-year mandate was renewed twice and therefore runs until June 2022.

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