Médecins Sans Frontières Research Articles

Effectiveness of case-area targeted interventions including vaccination on the control of epidemic cholera: protocol for a prospective observational study

IntroductionCholera outbreaks in fragile settings are prone to rapid expansion. Case-area targeted interventions (CATIs) have been proposed as a rapid and efficient response strategy to halt or substantially reduce the...

LEGAL STATE OF DOCTORS WITHOUT BORDERS (MÉDECINS SANS FRONTIÈRES) IN THE INTERNATIONAL LAW

Médecins Sans Frontières (MSF) is a non-profit organization that offers health and medical services to people based on their requirements irrespective of race, gender, beliefs, religion, and political origins. Physicians, as the MSF's most important members, assist people in their greatest need. They provide services ranging from consultations, vaccinations, and primary care to the most complex surgeries. Given that the doctors in the organization are very active members of the MSF and understand the risk of their presence in dangerous regions with prevalent epidemic and contagious diseases or under distress, insecurity, and war in underdeveloped or third world countries, research into the legal status of this self-giving and venture group of the international society is critical. The legal status of humanitarian aid workers such as the physicians in doctors without borders in international law has not been studied and recognized. This is due to the absence of a complete definition of “humanitarian aid workers” in international humanitarian law. Furthermore, the issue of the status of humanitarian NGOs in international law is novel. Therefore, studying the legal status of the humanitarian aid workers is an essential case because they are exposed to many potential risks in facing armed conflicts. This research planned a web-based survey as part of our study to find articles, books, reports, or studies in relationship with national and international humanitarian organizations and workers, NGOs, and the legal status of these organizations and their workers. We did normative legal research using secondary data from the internet, references, etc. While the operation of the MSF is mainly aimed at supporting the survival and recovery of people within a war or disease outbreak-afflicted country, its efforts put the lives of its personnel at risk. Herein, we will investigate how the MSF can adequately support its primary staff, the physicians. We can get the response to this question by studying the legal status of the doctors without borders in international law.

LEGAL STATE OF DOCTORS WITHOUT BORDERS (MÉDECINS SANS FRONTIÈRES) IN THE INTERNATIONAL LAW

Médecins Sans Frontières (MSF) is a non-profit organization that offers health and medical services to people based on their requirements irrespective of race, gender, beliefs, religion, and political origins. Physicians, as the MSF's most important members, assist people in their greatest need. They provide services ranging from consultations, vaccinations, and primary care to the most complex surgeries. Given that the doctors in the organization are very active members of the MSF and understand the risk of their presence in dangerous regions with prevalent epidemic and contagious diseases or under distress, insecurity, and war in underdeveloped or third world countries, research into the legal status of this self-giving and venture group of the international society is critical. The legal status of humanitarian aid workers such as the physicians in doctors without borders in international law has not been studied and recognized. This is due to the absence of a complete definition of “humanitarian aid workers” in international humanitarian law. Furthermore, the issue of the status of humanitarian NGOs in international law is novel. Therefore, studying the legal status of the humanitarian aid workers is an essential case because they are exposed to many potential risks in facing armed conflicts. This research planned a web-based survey as part of our study to find articles, books, reports, or studies in relationship with national and international humanitarian organizations and workers, NGOs, and the legal status of these organizations and their workers. We did normative legal research using secondary data from the internet, references, etc. While the operation of the MSF is mainly aimed at supporting the survival and recovery of people within a war or disease outbreak-afflicted country, its efforts put the lives of its personnel at risk. Herein, we will investigate how the MSF can adequately support its primary staff, the physicians. We can get the response to this question by studying the legal status of the doctors without borders in international law.

State’s Repression toward INGO: the Dismissal of Médecins Sans Frontieres from Ethiopia

The primary purpose of humanitarian-based INGOs is to provide and distribute assistance to those who could not get it. One of the INGOs engaged in this field and is quite successful in the international constellation is Medecins Sans Frontieres, often called Doctors without Borders. Humanitarian INGOs generally have a noble mission and have no mission to engage in the host country's political dynamics. However, the noble mission became a boomerang when MSF became one of the INGOs who worked to save the famine in Ethiopia. MSF has a noble mission, but the Ethiopian government has another mission that aggravates the condition of hunger in Ethiopia. As INGOs sought to be neutral, MSF decided to remain silent and take no steps relating to the political constellation of one of the world's poorest countries. Things got worse when MSF realized that one of their programs was being misused by the government to blackmail the guerrilla groups in the north. MSF could no longer remain silent and objected to any Ethiopian government policy related to them, resulting in the dismissal of all MSF members from Ethiopia at the end of 1986. This paper will explain the weak position of NGOs toward state, the main reason of the dismissal. The authors will be using the qualitative method by explaining the history about MSF and NGOs in the perspective of state which resulted the justification of the weak position of NGOs itself.

The challenge of antibiotic resistance in post-war Mosul, Iraq: an analysis of 20 months of microbiological samples from a tertiary orthopaedic care centre

Iraq has suffered unrest and conflicts in the past decades, leaving behind a weakened healthcare system. In 2018, Médecins Sans Frontières (MSF) opened a tertiary orthopaedic care centre in Mosul providing reconstructive surgery with access to microbiological analysis. A retrospective cross-sectional analysis of microbiological and clinical data of patients admitted between April 2018 and December 2019. There were 174 patients who were included in this study; there were more males than females (135 to 38, respectively), and the mean age was 32.6 y. Of the 174 patients, the majority had more than one bacterial isolate detected (n=122, 70.1%); 141 (81.0%) had at least one multidrug-resistant (MDR) isolate detected during their hospital stay. Staphylococcus aureus (n=197, 48.2%) was the most common organism isolated. Overall, most isolates detected were MDR (n=352, 86%), mostly methicillin-resistant S. aureus (n=186, 52.8%) or extended-spectrum beta-lactamase-producing Enterobacterales (n=117, 33.2%). Among patients admitted to the operating department (n=111, 63.7%), 81.1% (n=90) were admitted for violent trauma injuries. Patients who had more than one procedure performed per surgery had significantly increased odds of having at least one MDR organism isolated (OR 8.66, CI 1.10-68.20, P=0.03). This study describes a high prevalence of antibiotic resistance in patients with trauma-related wounds in Mosul, Iraq. It highlights the importance of microbiological analysis and ongoing surveillance to provide optimal treatment. Additionally, it underscores the importance of infection prevention and control measures as well as antibiotic stewardship.

797-P: Usability and Satisfaction of a New Affordable Insulin Pen for All: Positive Outcomes of Two Usability Studies

Globally, 13 million people (4 million in USA) inject insulin with single use disposable syringes daily. Compared to syringe and vials, pens are known to increase adherence and diabetes control and to reduce healthcare utilization costs. Yet, pens are largely unavailable to low-income groups, due to prohibitive cost. GO-Pen has designed a new affordable pen for use with vial insulin and conducted usability testing in collaboration with Médecins Sans Frontières (MSF) , an international medical humanitarian organization working to improve diabetes care for people living in difficult circumstances. Here we report the results of two usability studies conducted among insulin pen users (n=19, f/m: 11/8, age: 23-64) and syringe users (n=20, f/m: 10/10, age: 24-70) in refugee populations in Malaysia and Jordan. A convenience sample of the first 20 to accept enrollment was set up after informed consent. After a short introduction, participants were asked to demonstrate the use of the insulin pen in front of a camera, without revealing their faces or any identifying information, while an interviewer noted their correct use and confidence level. Injection was simulated in a sponge. 100% (n=19) of pen users and 75% (n=15) of syringe users performed >90% of the tasks correctly. Among pen users, the most common failed tasks were priming the needle (n=4) . Among syringe users, the most common failed tasks were failing to check the vial label (n=9) and priming the needle (n=6) . 5% (n=1) of pen users preferred the new insulin pen over the pen they were already familiar with. 75% (n=15) of syringe users preferred the new insulin pen over syringes. The most common complaint among pen users was that there were too many steps in the process. In conclusion, we find current pen users require little training and prefer the pen they are already familiar with. Syringe users who are unfamiliar with pen usage require more training than pen users, however, they have largely favorable attitudes towards this new insulin pen. Disclosure O.K.Nielsen: Stock/Shareholder; GO-Pen ApS. G.Huisman: None. J.A.Qasem: None. C.Eng: None. A.F.Jørgensen: None. M.Torrone: None. B.S.Larsen: None. A.Reddy: None.

What it takes to get it right: A qualitative study exploring optimal handover of health programmes in Tonkolili District, Sierra Leone

ABSTRACT Since 2015 Médecins Sans Frontières (MSF) has been supporting the Ministry of Health (MoH) in Tonkolili district, Sierra Leone, with an integrated health care approach at the community, primary health centre (PHC), and hospital level. This programme is planned to be handed over to MoH. To prepare for this handover, a qualitative study exploring elements of a successful handover was undertaken in 2019. Focus group discussions (FGD) with the community members (n-48) and in-depth interviews (IDI) with MSF staff, community leaders, and MoH staff in Sierra Leone (n-15) were conducted. Data were audio-recorded, transcribed verbatim from English, Creole, and Themne, coded, and thematically analysed. Participants expressed that an optimal project handover and exit strategy should be a continuous, long-term, the staggered process included from the inception of the programme design. It requires clear communication and relationship building by all relevant stakeholders and demands efficient resources and management capacity. Associated policy implications are applicable across humanitarian settings on the handover of programmes where the government is functional and willing to accept responsibilities.

Antibiotic resistance in patients with urinary tract infections in Pakistan.

The level of antibiotic resistance of pathogens causing uncomplicated urinary tract infections (UTIs) is increasing. The 2017-2018 GLASS (Global Antimicrobial Resistance and Use Surveillance System) report indicated >70% resistance to ceftriaxone and ciprofloxacin in Escherichia coli in Pakistan. A prospective study was conducted in the Médecins Sans Frontières (MSF) supported Timurgara District Hospital, Timurgara, Pakistan, from September 2017 to December 2018. Women aged 18-65 years presenting to the Emergency Department with symptoms of uncomplicated UTI (cystitis/pyelonephritis) were invited to participate. We conducted microbiological culture and sensitivity testing for samples with positive dipstick or nitrite test. Of the 200 patients who participated, 109 (54.5%) were diagnosed with pyelonephritis and 91 (45.5%) with cystitis. Forty-three samples (21.5%) were culture-positive: E. coli was isolated in 27 samples, Enterococcus spp. in 7 and Klebsiella pneumoniae in 6. Overall resistance to ciprofloxacin was observed in 51.8% of E. coli isolates, and ceftriaxone resistance in 66.7% of E. coli isolates and in 33.3% of K. pneumoniae. Resistance to fosfomycin was low (one E. coli isolate). This study found resistance to first- and second-line antibiotics for treating UTIs as per the MSF protocol. Heightened awareness and potential changes to local prescription practices are necessary to curb the spread of antimicrobial resistance pathogens causing UTIs.

The burden of road traffic accidents in trauma in low-resource settings: a retrospective cohort analysis of patient admissions to 2 Médecins Sans Frontières trauma facilities

Introduction: Medecins Sans Frontieres (MSF) is known for its work providing surgical care for victims of violent trauma (VT) in conflict zones. However, the trauma centers also deal with road traffic accidents (RTAs) which may require different staffing, facilities and supplies as compared with those required for VT. This study aimed to compare differences in types of injuries, clinical outcomes, and resources needed to properly operate trauma centers in low and middle-income countries. Material and methods: This was a retrospective analysis of routine program data of >70,000 patient presentations in the emergency, in-patient, and operating departments of 2 of MSF’s major trauma centers, in Kunduz (Afghanistan) and Bujumbura (Burundi), using data from 2011 to 2018. Results: RTAs comprised a significant proportion of overall presentations to these centers (23% in Kunduz and 56% in Bujumbura). RTA patients presented with different patterns of injury, with higher rates of fractures, extremity injuries, and traumatic brain injury. RTA patients were 2.3 times more likely to have a peripheral injury (extremities and head) as VT patients, and 12.5 times more likely to undergo an orthopedic procedure. VT patients had higher rates of abdominal injury. However, there was no statistically significant difference in overall mortality and length of stay between the 2 groups. Conclusion: This study demonstrates that trauma centers, even in zones of conflict, need to be prepared and resourced to manage RTA cases. Policy-makers in such centers should be aware of the different injury patterns associated with this patient group and have appropriate, sustainable capacity to manage RTA trauma, particularly in terms of management of orthopedic injuries.

What matters in mental health care? A co-design approach to developing clinical supervision tools for practitioner competency development.

Specialised mental health (MH) care providers are often absent or scarcely available in low resource and humanitarian settings (LRHS), making MH training and supervision for general health care workers (using task-sharing approaches) essential to scaling up services and reducing the treatment gap for severe and common MH conditions. Yet, the diversity of settings, population types, and professional skills in crisis contexts complicate these efforts. A standardised, field tested instrument for clinical supervision would be a significant step towards attaining quality standards in MH care worldwide. A competency-based clinical supervision tool was designed by Médecins Sans Frontières (MSF) for use in LRHS. A systematic literature review informed its design and assured its focus on key clinical competencies. An initial pool of behavioural indicators was identified through a rational theoretical scale construction approach, tested through waves of simulation and reviewed by 12 MH supervisors in seven projects where MSF provides care for severe and common MH conditions. Qualitative analysis yielded two sets of competency grids based on a supervisee's professional background: one for 'psychological/counselling' and another for 'psychiatric/mhGAP' practitioners. Each grid features 22-26 competencies, plus optional items for specific interventions. While the structure and content were assessed as logical by supervisors, there were concerns regarding the adequacy of the tool to field reality. Humanitarian settings have specific needs that require careful consideration when developing capacity-building strategies. Clinical supervision of key competencies through a standardised instrument represents an important step towards ensuring progress of clinical skills among MH practitioners.

Health conditions of migrants, refugees and asylum seekers on search and rescue vessels on the central Mediterranean Sea, 2016–2019: a retrospective analysis

ObjectivesThis study will contribute to the systematic epidemiological description of morbidities among migrants, refugees and asylum seekers when crossing the Mediterranean Sea.SettingSince 2015, Médecins sans Frontières (MSF) has conducted search...

Leaving no one behind: the need for a truly global response to antimicrobial resistance

Universal and impartial access to health care for populations at risk is the driving force behind the work of Médecins Sans Frontières (MSF). The COVID-19 pandemic has exposed and magnified entrenched inequities in access to health care in many of the countries where we work. These same inequities also cause harm due to lack of access to life-saving antibiotics and insufficient funding and implementation of plans to respond to antimicrobial resistance (AMR). In low-income and middle-income countries (LMICs), where people already experience a disproportionately high burden of infectious disease, including tuberculosis, HIV, and malaria, the consequences of antibiotic-resistant infections threaten to become catastrophic at an individual, household, and community level.

Association between triage level and outcomes at Médecins Sans Frontières trauma hospital in Kunduz, Afghanistan, 2015

BackgroundFive million people die annually due to injuries; an increasing part is due to armed conflict in low-income and middle-income countries, demanding resolute emergency trauma care. In Afghanistan, a low-income...

TP8.2.23 Surgical education in low resource settings

Abstract Aims To help build medical capacity in low resource settings. Methods I researched and worked with two organisations, Médecins Sans Frontières (MSF) and Mercy Ships. I worked with Mercy Ships in collaboration with ASGBI Results MSF is a humanitarian organisation. Although MSF works in low resource settings, it is not developmental and therefore education was not part of its brief. I completed 2x 2 month missions with MSF, in Central African Republic and Chad. Mercy Ships is a developmental organisation. I worked with Mercy Ships, in four countries, to help deliver a total of 10 skills courses and 5 Training the Trainers courses which had been set up in collaboration with ASGBI. The first time was with a UK surgical trainee under this scheme. French was the working language in each setting. Conclusions There is a real and pressing need for basic surgical education in most low resource settings. Teaching with Mercy Ships is a good vehicle for teaching essential surgical skills locally and training local trainers to continue the process. It is also a good opportunity for providing a supervised introduction to working in a low resource setting for those trainees who wish to become involved in humanitarian work.

Human Mobility and Health: Exploring the Health Conditions of Venezuelan Migrants and Refugees in Colombia

Médecins sans Frontières (MSF) conducted a study to identify health needs and access barriers of Venezuelan migrants and refugees at La Guajira and Norte de Santander Colombian border states. The Migration History tool was used to gather information that included various health-related issues such as referred morbidity, exposure to violence, mental health, and access to health care services. A group migration profile with long-term permanence plans was identified. Was evidenced an important share of young population (50% under 20), indigenous people (20%), and returnees (11%). The respondents referred to a mixed pattern of chronic and acute diseases, for which the main difficulty was accessing diagnosis and continuous treatment. Health-seeking behavior was identified as the main barrier to access health care services. The article compiles main findings on the Venezuelan migrants and refugees' health conditions, contributing important evidence for the humanitarian responses in migration contexts.

Compromising Aid to Protect International Staff: The Politics of Humanitarian Threat Perception after the Arab Uprisings

Abstract Scholars expect operational compromises by humanitarian organizations to follow attacks on aid workers. However, in response to the War in Syria, organizations compromised aid and adopted clandestine, cross-border, remote management, and conflict-actor aligned approaches, which best protected international aid workers. This was despite declining rates of attack against them, relative to their national staff counterparts. This article asks why international aid workers were withdrawn and aid was compromised in the wake of the Arab Uprisings by traditional risk-taking organizations: Médecins Sans Frontières (MSF) and the International Committee of the Red Cross (ICRC). Drawing on political ethnography and interviews with aid workers, I show that shocking violent events, everyday insecurity, and changes in the nature of threat have significant effect on threat perception and explain compromises where rates of attack do not. This paper offers a picture of the micro- and field-level foundations of organizational threat perception and decisions about whose security matters.

Seroprevalence of SARS-CoV-2 Antibodies and Retrospective Mortality in a Refugee Camp, Dagahaley, Kenya

Background: Camps of forcibly displaced populations are considered to be at risk of large COVID-19 outbreaks. Low screening rates and limited surveillance led us to conduct a study in Dagahaley camp, located in the Dadaab refugee complex in Kenya to estimate SARS-COV-2 seroprevalence and, mortality and to identify changes in access to care during the pandemic. Methods: To estimate seroprevalence, we conducted a cross-sectional survey among a sample of individuals (n=587) seeking care at the two main health centres and among all household members (n=619) of community health workers and traditional birth attendants working in the camp. We used a rapid immunologic assay (BIOSYNEX® COVID‐19 BSS [IgG/IgM]) and adjusted for test performance and mismatch between the sampled population and that of the general camp population. To estimate mortality, we exhaustively interviewed all households (n=12860) in the camp about deaths occurring from January 2019 through March 2021.Results: We included 1206 participants in the seroprevalence study. In total, 8% (95% CI: 6.6%-9.7%) had a positive serologic test. After adjusting for test performance and standardizing on age, we estimated a seroprevalence of 5.8% (95% CI: 1.6%-8.4%). The mortality rate for 10,000 persons per day was 0.05 (95% CI 0.05-0.06) prior to the pandemic and 0.07 (95% CI 0.06-0.08) during the pandemic, representing a significant 42% increase (pInterpretation: We estimated that the number of infected people was 67 times higher than the number of reported cases. Participants aged 50 years or more where among the most affected. The mortality survey shows an increase in the mortality rate during the pandemic compared to before the pandemic. A decline in attendance at health facilities was observed and sustained despite the easing of restrictions.Funding Information: The study was funded by the Operational Centre of Geneva of Médecins Sans Frontières.Declaration of Interests: The authors have declared that no competing interests exist.Ethics Approval Statement: This protocol was approved by the MSF Ethics Review Board ( V. 1.1, 24.12.2020, ID: 20105) and the KEMRI SERU Scientific and Ethic Review Board (KEMRI/SERU/CIPDR/045/4164). All study procedures involving subject’s participation were conducted in compliance with the principles enunciated in the Declaration of Helsinki.

Comunicación digital de Médicos Sin Fronteras en España durante la crisis de la COVID-19

Este artículo analiza la comunicación digital de Médicos Sin Fronteras durante su intervención en España a causa de la emergencia provocada por la COVID-19. Mediante un análisis de contenido de los mensajes publicados en su página web, los correos enviados a sus socios y sus publicaciones en Facebook y Twitter, categorizamos las temáticas, objetivos, enfoques informativos o emocionales, el emisor o el formato de una muestra de 58 mensajes. De forma complementaria, consideramos la intensidad, la dirección positiva o negativa o los términos más frecuentemente utilizados. Concluimos señalando cómo MSF ha enfocado su comunicación durante la crisis en explicar al público su intervención en España como forma de reforzar su imagen y sus atributos como una entidad especializada en la atención sanitaria en situaciones de emergencia. La inédita intervención en España ha servido a MSF para rendir cuentas a sus públicos mostrando la forma en la que habitualmente actúa en otros países.

The effect of home-based care on housebound patients and their caregivers in two Palestinian refugee camps in Lebanon: a qualitative study

BackgroundThe incidence of non-communicable diseases (NCDs) increases annually by approximately 5% among older (age 50 years and older) Palestinian refugees in Lebanon, of whom around 10% are housebound. Care for housebound patients does not exist in the over-medicalised and highly privatised Lebanese health system or within the health system for Palestinian refugees in Lebanon. This has led to a neglected population. In 2016, Médecins Sans Frontières (MSF) started to provide home-based care (HBC) for housebound patients in two Palestinian camps: Bourj-el-Barajneh and Ain-al-Hilweh. HBC is carried out by a team comprising a doctor, nurse, and social worker, and includes basic medical monitoring, health literacy educational sessions, support for treatment adherence, as well as networking with relevant social service providers. MethodsA qualitative study was carried out between January and October, 2018, nine patients, ten caregivers, and personnel from two main international non-governmental organisations providing health care for refugees were interviewed, and one focus group discussion was conducted with MSF HBC staff. Thematic content analysis was carried out manually, with investigators’ observations for triangulation. The study was approved by the MSF ethical review board. FindingsThe housebound patients described various ways in which they felt socially isolated, useless, and unproductive. These are underserved needs. Caregivers reported feeling burdened socially, mentally, and financially. They also reported that they assumed full responsibility for the housebound relative, as there was no alternative. HBC was appreciated by patients and caregivers for providing psychosocial and medical support; patients viewed MSF staff as a “friend in care”, a temporary escape from isolation, and caregivers expressed appreciation for sharing the burden of caring for the housebound person. There was a decrease in anxiety expressed by caregivers and patients, as well as a declining sense of burden described by caregivers, during the provision of HBC by the MSF staff. To a lesser extent, patients and caregivers sensed improved self management as their disease literacy and treatment adherence increased, and as caregivers became more efficient in handling toilet care, bathing, and wound dressing. Missing components of HBC were perceived to be “outdoor” activities and mental health services. InterpretationHBC had an effect in reducing patients’ social isolation, decreasing caregivers’ burden and anxiety, and enhancing self management of disease for both. HBC should be considered for replication by all refugee health care providers as well as by the Lebanese Ministry of Public Health. This model of care needs to adopt a more holistic approach by including provision of mental health care and by increasing the focus on social isolation. FundingNone.

Preventing avoidable hospital admissions after emergency care in humanitarian settings: a cross-sectional review of Médecins Sans Frontières emergency departments

ObjectivesThe aim of this study was to describe the types of emergency departments (EDs), and the acuity, types and disposition of conditions managed at Médecins Sans Frontières (MSF)-supported EDs in...