Challenges in International Humanitarian Aid

Challenges in International Humanitarian Aid Unni Krishnan Karunakara Former International President Médecins Sans Frontières An Interview with Anna Pierobon and Pranav Sharma Providence, RI, 23 February 2015 Unni Krishnan Karunakara has been a humanitarian worker and a public health professional for two decades with extensive experience in the delivery of health care to neglected populations afected by conlict, disasters, and epidemics in Africa, Asia, and America. He was Medical Director of the medical humanitarian organization, Médecins Sans Frontières (MSF)/Doctors Without Borders’ Campaign for Access to Essential Medicines (2005–2007) and its International President (2010–2013). Dr. Karunakara currently serves on the Board of Directors of Drugs for Neglected Diseases Initiative (DNDi) India and on the Board of Trustees of MSF India and is currently a Senior Fellow of the Jackson Institute for Global Afairs at Yale University, an Assistant Professor in the Mailman School of Public Health at Columbia University, and a Visiting Adjunct Professor at Kasturba Medical College, Manipal University. 251 Brown Journal of World Afairs: Your career with Médecins Sans Frontières (MSF) has spanned multiple countries and continents. Starting with MSF as a medical doctor in Ethiopia, you went on to coordinate and advise medical activities in many countries in Africa, Asia, and Latin America before becoming international president of the organization. How has your approach, and that of MSF across the globe, changed to account for traditions, customs, and local realities speciic to areas you have worked in? Copyright © 2015 by the Brown Journal of World Afairs Spring/Summer 2015 t volume xxi, issue ii 21.2.indb 251 4/30/15 9:50 PM Unni Krishnan Karunakara Unni Krishnan Karunakara: he practice of health cannot just be biomedical in its approach. It has to take into account local beliefs and customs, but more than that, the economic, political, and social realities of communities. Humanitarian medicine is political medicine. It is not politics with a capital “P” but rather one encompassing a irm advocacy for and solidarity with people going through diicult times, and the consistent belief that people should be provided with good quality, efective medical care. Humanitarian medicine is also meant to provoke change, to put a spotlight on the sufering of the neglected, who are often denied or excluded from health care. Ours is a practice where we make choices about where and whom to provide assistance based on need. In the settings we work in, assistance can be a political act, on top of being an essentially medical act. Whether individuals and communities have been afected by conlict, disasters, epidemics, or neglect, one necessarily cannot ignore the political dimensions of the practice of humanitarian medicine, or the delivery of health care. 252 Journal: Could you provide an example of where an approach you, or MSF more generally, have taken in one country has difered vastly from your approach toward a similar issue in another country? Karunakara: A good example to help illustrate this is the provision of HIV care in South Africa. In the year 2000, it was illegal to treat HIV patients in South Africa. here was widespread denial in the government about the nature and cause of the pandemic. As one can imagine, the level of stigma attached to people with HIV/AIDS was high. Government policies prioritized prevention and nutrition and prevented AIDS patients from receiving ARVs [antiretroviral drugs]. Moreover, Big Pharma prices for ARVs were exorbitant. In order to overcome these speciic barriers to HIV care in South Africa, MSF had to work with a coalition of activists and patients. Looking at improving the provision of HIV care, I can say that interacting with the community, understanding how people seek health care, and learning how they experience health are all important aspects of fashioning an efective response to a particular health problem. Ebola today in West Africa is another good example of how you cannot contain an outbreak or halt the transmission of a virus like Ebola without engaging with the community, without understanding local practices, and without getting the local people to cooperate with you to understand the disease and work the brown journal of world affairs 21.2.indb 252 4/30/15 9:50 PM Challenges in International Humanitarian Aid with you to contain the outbreak. It’s not possible without their engagement and support. Everywhere you go, that engagement has to be front and center. his is similar for vaccinations, one of the most cost-efective public health interventions. However, even an act as simple as the administration of vaccines can be politicized. he recent measles outbreak in the United States is illustrative, with anti-vaxxers and decreasing herd immunity. he global polio eradication initiative has hit a wall in Pakistan and northern Nigeria, partly because of concerns, conspiracy theories, and people who doubt the motivations of the individuals providing care. his is particularly relevant when cases like that of Osama bin Laden, who was detected in Pakistan by means of a fake vaccination campaign mounted to collect DNA samples in Abbotabad, come to light. Such instrumentalization of health activities for political purposes have signiicant negative consequences today, not least of which are the close to 70 vaccination workers who have been killed in Pakistan. Health workers are now suspected of being political agents around the world with agendas other than the provision of health care. Overcoming cultural barriers speciic to health, as MSF does around the globe, does not mean that we need to become subservient to those cultures. Indeed, in that engagement, we also have to be willing to challenge cultures. Human progress and the paths through which we move forward come from a clash of cultures. hat clash of cultures is not something one should shy away from, even as we recognize that it has to be done in a respectful manner. 253 Journal: You mentioned Ebola, a recent global health concern that is being heavily covered in the news after the major outbreak in West Africa. Going forward, how do you see the role of MSF evolving to address this kind of emergency outbreak, which in this case took much of the world by surprise? Karunakara: MSF has been involved in Ebola responses for at least the past 15 to 20 years, so this is not a new thing for us. But the scale of the outbreak took everyone by surprise, including us. hat is not because the Ebola strain in West Africa was particularly virulent or anything like that. he outbreak happened in a part of the world that was densely populated and where people were extremely mobile, inside and across borders. Furthermore, the three most afected countries—Guinea, Liberia, Sierra Leone—had health systems that were extremely lacking in capacity. None of these countries had prior experience dealing with Ebola outbreaks. herefore, it was a perfect storm of conditions coming together with devastating consequences. Spring/Summer 2015 t volume xxi, issue ii 21.2.indb 253 4/30/15 9:50 PM Unni Krishnan Karunakara 254 It didn’t help that it took the international community, with a few notable exceptions, almost nine months to acknowledge the crisis and mount a response. By then, of course, the damage was done. MSF, I think, responded as best as it could have under the circumstances. here are, however, concerns and internal discussions that are being held to determine whether we could have done much more. One needs to keep in mind that MSF is just a nongovernmental humanitarian agency with limited capacities. While we could have done better in some regards, I am very conident that we scaled up our response as best as we could have. Going forward, there are now discussions about undertaking vaccine campaigns and drug trials. As you know, the Ebola virus disease has no wellestablished treatment. Current treatment protocols involve hydration, management of symptoms, and breaking chains of transmission. So it is a welcome development to have vaccines and drug candidates available to be tested. It has to be done in a responsible and ethical manner, and discussions are ongoing to ensure that this happens. But also keep in mind, as big as the Ebola outbreak was, with close to 25,000 people afected and 10,000 dead, TB [tuberculosis], HIV, and malaria still kill more people on an annual basis than Ebola ever has. We must not forget that such outbreaks are symptoms of a broken health system and a broken system of governance. his is why in Europe and the United States it is unlikely that we will see an Ebola outbreak, because these systems have the capacity to respond to it. Nigeria did it well. Nigeria had people they could immediately put on the Ebola response, and they responded successfully, so it can be done in West Africa. I have been part of the response eforts of two outbreaks in 2002 and 2003. hese outbreaks occurred in very remote, sparsely populated parts of the Republic of Congo. he capacities we are able to put in place today have evolved since those days. Still, there are underlying structural problems that need to be addressed if we are to respond to other outbreaks in a timely and efective fashion. Journal: Do you believe that the international community and nations with already strong health care systems hold a moral imperative to help those living without adequate access to medical care? Karunakara: I believe they do. Health problems can no longer be classiied as their problem or our problem. In the world we live in today, I think that is a very irresponsible thing to do. Ethicists and moral philosophers like Peter Singer the brown journal of world affairs 21.2.indb 254 4/30/15 9:50 PM Challenges in International Humanitarian Aid have articulated the responsibility of countries and individuals to alleviate the sufering of people in other parts of the world. I happen to believe that there is such a moral responsibility. Even in the case of the West African Ebola response a lot of people did not feel that there was an obligation to respond. I feel that as physicians, for example, we hold an ethical responsibility to provide care, especially when countries where these outbreaks happen Big Pharma should be able to do not have the capacity to provide care for their own citizens. So there make decent profits, but not is a certain focus on countries that at the cost of people’s lives. have the ability and the capacity to do it. I think it is the moral thing to do, and I believe it is absolutely necessary to do so because, as you have seen, it is only a matter of days before the problem lands on your doorstep. Nevertheless, the obligation to provide care should stem from a moral imperative to do so. Journal: How many NGOs, IGOs, nations, and individuals it into this vision of a moral response that you just outlined? Karunakara: I think they all represent diferent segments of public life, and they all act on their obligations in diferent ways. NGOs and humanitarian agencies like MSF are basically an expression of civil society’s impulse to express solidarity with people who are going through a very diicult time. In a world that is so connected—today you can sit on your couch and watch wars and disasters unfold live—I think that impulse is immediate. I also think that NGOs or organizations have causes and mandates that they give themselves for motivation to drive their actions. MSF does medical work and there are others that do education programs, among other kinds of initiatives overall. All international donors have their foreign policy and security interests. It’s not wrong to have foreign policy interests as long as they are enlightened and cognizant of the big picture. Like I said earlier, you can’t isolate yourself and your problems from the rest of the world. It’s all one big pot, and you have to igure out a way to coexist and assist each other. Otherwise it becomes “our” problem at the end of the day anyways. 255 Journal: What do you see as the role of companies, such as drug companies in this same moral framework? Spring/Summer 2015 t volume xxi, issue ii 21.2.indb 255 4/30/15 9:50 PM Unni Krishnan Karunakara 256 Karunakara: he predominant way of doing business in a liberal free-market economy involves a market-based, proit-driven approach where innovation is rewarded with patents and people make tons of money. And all of that is well and good. However, when we talk about Big Pharma, we are talking about corporations that make 5 to 10 billion dollars in annual proits. I do understand that corporations have to make proits, but when they proiteer and value proits over the lives of people, then there is something terribly wrong. If people’s lives matter and health is a public good, then pharmaceutical innovation should be supported and incentivized to produce goods in the public interest. Big Pharma should be able to make decent proits, but not at the cost of people’s lives. If the market fails to meet the needs of poor people, then governments are at fault and have the responsibility to regulate the market and ensure that their citizens who sufer from life-threatening diseases are not left out in the cold. Simply put, if the market is not able to cater to the needs of sick people, then the government has to step in. Most countries are signatories to the Universal Declaration of Human Rights and acknowledge a right to health. Talk about “health for all” is meaningless if governments do not work toward realizing the spirit and intent of the declaration and do not hold public and private entities in the ield of health responsible for their actions or inactions. Journal: One of MSF’s stated goals in its protocol is to establish itself as an apolitical force in today’s world. How has this apolitical form developed over the past decades? Is MSF still able to retain the ability or desire to be an apolitical force, or has that impetus changed? Karunakara: As I said earlier, the very act of delivering humanitarian assistance is political—meant to provoke change. But it’s politics with a small “p:” it is about not taking sides in a war against a government or a rebel group, or supporting a particular ethnic group against another. hat is not what we are talking about. If you ask me, we have consistently over the course of our history as an organization fought for the right of patients to receive health care. In that sense, we are political. We practice political medicine. We have a certain vision of people living in dignity, regardless of where they live and regardless of who they are, and having access to health care. If we are to achieve that, then we need to address some of the structural economic and political barriers that prevent people from getting the care they need. So the starting point has the brown journal of world affairs 21.2.indb 256 4/30/15 9:50 PM Challenges in International Humanitarian Aid always been patients, but over the last 10 or 15 years, we have been willing to go upstream and tackle problems higher up in the chain of problems. hat is invariably political because, for instance, the moment you tackle issues around intellectual property, you are making a political statement. You are attacking a certain liberal view of markets and a certain approach to how business should be done. hat is an intensely political act. We are stated humanitarians, motivated by the principles of humanity, which, above all, recognize the right of all individuals to live a life of dignity and respect. If you follow that chain of thought by means of action, you have no choice but to take on some of these arguably political issues. Journal: More speciically, MSF is known for making arguably political statements denouncing the actions of governments that do not adequately provide for the health needs of their people. For instance, Dr. Orbinski, at the start of his Nobel Acceptance speech in 1999, denounced the Russian government’s continuous bombing of Chechnya. How do these political statements made by MSF representatives either bolster or detract from MSF’s stated goal to help people? Karunakara: MSF has always had two missions. One is direct medical action— doctors and nurses provide medical care to communities and individuals in a state of crisis. MSF normally does fund other agencies to deliver care on its behalf. MSF does work with local partners in many of the countries. he second mission is to bear witness to the sufering of those afected and to speak out. When James Orbinski called on the Russian authorities to stop bombing Chechnya, it was with a view of alleviating the sufering of the people there. With the spotlight on MSF during the Nobel ceremony, it was an excellent opportunity to raise a critical issue that needed to be addressed by the international community. MSF tries to escalate our advocacy from the ground up. We try to deal with it locally irst, talking to regional or national authorities, advocating for change in policies that will alleviate sufering or improve the provision of health care for those afected. If the issues cannot be resolved locally, then it is escalated nationally or even internationally to bring about appropriate inluence or pressure for change. And we do this a lot. MSF does not shy away from advocacy. Any advocacy, however, has to be with the interest of the afected people in mind. Organizational considerations are not important here, what matters is that by speaking out, there is a concrete, or at least a theoretical or potentially beneicial, advantage to the people for whom we talk about. If we think that by speaking about Chechnya, 257 Spring/Summer 2015 t volume xxi, issue ii 21.2.indb 257 4/30/15 9:50 PM Unni Krishnan Karunakara like we did in Oslo, that the people of Grozny are going to be in deeper trouble because we spoke up, we have to rethink whether it is the right strategy or not. Journal: By doing so, does that limit opportunities for MSF in some areas? Karunakara: he practice of humanitarianism or humanitarian action is an everyday balance between being principled and being pragmatic. In the end, it is not about your principles. It The practice of humanitarianism is about whether people get the o r h u m a n i t a r i a n a c t i o n i s a n assistance they need or not. You can be very principled if you want, everyday balance between being but if that means people do not principled and being pragmatic. receive assistance, then how good are your principles? And there have been situations in Myanmar, in Sri Lanka, in other places, where we have had to keep our mouths shut, and that is the bargain or compromise that one makes in order to be able to provide assistance. Myanmar is a good case in point. Rohingya Muslims in Rakhine state have had their lives and their rights consistently and systematically eroded by the majority Buddhist population and by the state for a very long time. MSF 258 has been providing health care to all those in need in Rakhine state and other parts of the country for over two decades. Over time, more than 30,000 people have been placed on HIV treatment in Yangon and elsewhere in the country. Any speaking out on the plight of Rohingya Muslims would surely have resulted in state action that might severely disrupt our treatment programs. In fact, the ICRC [International Committee of the Red Cross] was asked to cease operations in 2006 and was not able to work for almost seven years. If speaking out on the Rohingya situation results in MSF’s inability to continue the provision of health care in Rakhine state and for those on ARVs [antiretrovirals], then what purpose does speaking out serve? And there are many such cases that I can recount where principled delivery of humanitarian assistance is challenged and compromises have had to be made. here can never be an absolutely pure form of humanitarianism. I think the world is too messy for that. Journal: As you mentioned in the case of Myanmar, MSF works primarily with structurally disadvantaged communities and populations. What is unique about MSF’s approach compared to other international organizations in giving care to such groups? the brown journal of world affairs 21.2.indb 258 4/30/15 9:50 PM Challenges in International Humanitarian Aid Karunakara: It is important to understand the diference between humanitarian action and development work. Earlier, I said humanitarian workers alleviate suffering, while development workers alleviate poverty. Development workers seek to address root causes of poverty. However, from a medical perspective—and this is a simpliication—humanitarians treat patients, while developmentalists treat systems. It goes without saying that even in the middle of an emergency, if we want to reach people, if we want to treat people, we have to engage with whatever systems are in place. Whatever is there, whatever little exists, you need the system, as the system is often the vehicle through which you can reach patients and get them on treatment. Especially for diseases that require longerterm treatment, you need that. Having said that, humanitarian agencies must be sensitive to concerns about sustainability, while not letting these concerns prevent the delivery of life-saving assistance. In contexts where epidemiological transition has resulted in high levels of chronic disease morbidity, humanitarian agencies, and even nongovernmental development agencies, are unable to guarantee lifelong treatment for anybody. When we talk about sustainability—how sustainable are MSF’s actions—the quick answer is, in the traditional sense, not very sustainable. MSF has had limited success with traditional sustainability approaches— capacity building, training, etc.—and has observed drastic drops in the quality and quantity of programming a few years after handover. What has been sustainable though are models of care, ield-adapted and optimized for the ield, such as for HIV, malaria, malnutrition, sleeping sickness, etc. hese models of care can be tinkered with, improved upon, and scaled up in a way that ensures that appropriate care reaches many more people and is available for those who need it long after the departure of MSF. So it is possible for a medical humanitarian agency such as MSF to be a catalyst for change, in a way that does not equate sustainability with brick and mortar buildings, or with an expectation that people on payroll will stay on in the program for the rest of their lives. hese are unrealistic expectations. But for me personally, a far more valuable contribution is the sustainability of ideas, and the sustainability of models that can be taken up by governments and other agencies and scaled up so that they reach many more people than any singular agency is capable of doing. 259 Journal: In Somalia in 2013, MSF decided to pull out volunteers and staf due to security and safety reasons. How does the organization draw the line between what is safe for its volunteers and what is not? Spring/Summer 2015 t volume xxi, issue ii 21.2.indb 259 4/30/15 9:50 PM Unni Krishnan Karunakara 260 Karunakara: his is a diicult one. If you are a doctor and you treat patients, there is always an element of risk. here is always a possibility that a patient might infect you. Always. But we know what measures to take so that we do not get that infection. It is a bit like that. As humanitarian workers in the ield, we assume a certain amount of risk, but we put risk mitigation measures in place so that individuals and teams are kept safe. Occasionally, one could be in the wrong place at the wrong time. Increasingly though, and especially in the current environment that we ind ourselves in the Middle East—one could easily be targeted for being a foreigner, a humanitarian worker, or even a doctor. All of that is unfortunately possible. One of the last things I did before stepping down as president was to announce MSF’s withdrawal from Somalia. MSF had been operational in Somalia for over two decades. During this period, MSF experienced over 1,000 security incidents and 16 casualties. In most contexts, humanitarian workers rely on the goodwill of communities and of authorities to gain access to insecure areas and to keep teams safe. hese spaces are obtained and secured after much negotiation. Great eforts are made to convey the neutrality and impartiality of assistance. Access is often granted because authorities perceive some advantage in the delivery of assistance, as in many instances communities may have little or no access to health care. And nowhere are our teams protected by armed guards or security forces, as this goes against the spirit of humanitarian assistance—except in Somalia. MSF’s withdrawal from Somalia resulted not so much from the heightened risk our staf faced but more so because of the realization that the individuals and authorities we had relied on for safety and security were directly or indirectly involved in creating an unsafe environment for our teams to work in and be efective. If teams can no longer trust communities, their interlocutors, or authorities who give security guarantees, then it becomes incredibly risky. he decision to leave was agonizing, as the needs in Somalia are enormous. here has to be a basic level of respect for humanitarian action—not necessarily for the organization—but for the people who need the assistance and for what the action itself stands for. And agencies have to be able to trust commitments and guarantees they receive from authorities and other stakeholders in the community. If these minimum conditions do not exist, it is hard to justify putting teams in contexts where risks cannot be mitigated or the conidence in security measures is lacking. In my time at MSF, there have been several conlicts during which we have had to evacuate for short periods of time. But there are two places from which the brown journal of world affairs 21.2.indb 260 4/30/15 9:50 PM Challenges in International Humanitarian Aid we have had to pull out: Afghanistan in 2004 and Somalia in 2013. And both decisions have been agonizing. here are no blanket policies for withdrawal. Each case is debated and discussed on its own merits, on the realities on the ground, on the political situation, and so forth. Unfortunately, these diicult decisions have to be made. Journal: How does MSF continue to keep communication channels open with governments that do not necessarily want the organization there? Karunakara: Today, if you look at what is going on in Syria and elsewhere, I feel that traditional negotiations are probably yielding far fewer results than what we could have expected 10 or 15 years ago. I mentioned Afghanistan, where we had to leave in 2004. It took us ive years, and at least two years of negotiations, to go back. hat means two years of sustained eforts at building trust, inding the right people to speak to, and getting the right sort of guarantees. Today, in a world that is so connected, even agencies, even outits like the Taliban or al-Qaeda or al-Shabaab, are connected to the Internet. And they know your history, they know how principled you have been in your actions, and they know where your funding comes from. 261 Given that, your best bet at gaining some room for negotiation and getting access to some of these diicult places is a consistency in the application of humanitarian principles, and transparency about the choices and compromises that you have made. However, increasingly, it is diicult in some parts—we have been trying since the beginning to get access to government-controlled areas in Syria, and we have not succeeded. So there are limits to negotiations, In the end, you have to align your there are limits to dialogues. In the interests with the interests of the end, you also have to align your interests with the interests of the dominant powers in the various areas. dominant powers in various areas. If, for instance, the Taliban feels that your presence is actually going to relect better upon them, then the likelihood of you being allowed to work there is higher. So you have to ind those connections, and you have to be slightly opportunistic. But in doing so, it is still of paramount importance that the assistance provided be as impartial as it can be. Journal: What do you see as the biggest long-term obstacle for global public health work today, and how do you see ongoing eforts, both through MSF and otherwise, changing to best address this challenge? Spring/Summer 2015 t volume xxi, issue ii 21.2.indb 261 4/30/15 9:50 PM Unni Krishnan Karunakara 262 Karunakara: From a very broad perspective, I do think that we need to look at the barriers that exist to access to health care. his cannot always be addressed in the ield. here has to be a sea change in the way we look at, or the way we address research and development, how we fund innovation, and how ield adapted solutions—diagnostic, vaccines, therapies, etc.—are developed for various diseases. his is, of course, in addition to all of the other challenges that exist in the delivery of health care. In the ield, we have to recognize the various transitions that are going on. Demographic transitions, even in poor countries, lead to people living longer. hen there is the epidemiological transition. As people live longer, they also sufer from a diferent set of diseases—noncommunicable diseases—that are more expensive to treat, and need new models of care. In the countries where MSF works, our teams see a lot of people with hypertension, a lot of people with diabetes and other chronic conditions. For the past 40 years, our focus has by and large been on communicable diseases. hat needs to change. Taking on Big Pharma to increase access to life-saving therapies for infectious diseases has been relatively easy compared to what lies ahead. As you know, the African market did not matter much in terms of proit. But if we start demanding access to afordable chronic diseases medications, and you are talking anti-diabetics, anti-hypertensives, antibiotics, etc., these are big earners and blockbusters for pharmaceutical companies, and so big ights lie ahead. he third transition is the massive migration from rural to urban areas. Today, for the irst time, we are an urban civilization. More people live in urban areas than in rural areas; that changes the dynamics of health care delivery. People move to cities seeking employment, stay in crowded slum-like conditions, and get caught in a downward spiral of disease, poverty, violence, etc. hen, of course, there are climatic transitions that are going on. Natural disasters seem to happen more frequently and with more intensity, causing immense devastation. How do we gear up to address these issues? Global warming and associated ecological changes are afecting disease vectors and transmission. MSF set up its irst-ever malaria treatment program in Greece a few years ago. Perhaps, we may see a return of kala azar in southern Italy and Spain where it was endemic not that long ago. hese are some of the areas that we need to keep an eye on and igure out how best to bring appropriate care to afected individuals and communities. Overall, I think there has to be a global consensus, a concerted efort, and adequate resources dedicated to delivering on health if we’re serious about health being a right and about health being a public good. We have much more work to do. WA the brown journal of world affairs 21.2.indb 262 4/30/15 9:50 PM