2009.04 - Lessons from Doctors without Borders

Doctors without Borders' methods a lesson to us all

By Dr. Lusijah Marx
(With background historical information on AIDS in Africa added by Cassidy Sterling)

Lusijah Marx is a Subud member who twenty years ago started The Quest Center for Integrative Health (formerly called Project Quest) in Portland Oregon, USA. The Quest Center is a Susila Dharma project and Lusijah has a strong commitment to support the network of Susila Dharma projects around the world.

Over the past several years I have begun to feel that I should devote some of my time to support SD medical efforts in the developing world. I am a nurse practitioner and psychologist; but, visiting SD Projects over the years, I have been humbled to realize that, though I have important skills and knowledge, I do not understand how I can ever transfer what I know. But, in 2005, I attended the Subud bi-zonal conference in Kinshasa, DR Congo. I was impressed with how much has been done there with very few resources, either in terms of money or personnel. I felt that somehow I should find a way to support our clinics or perhaps one particular clinic in the Congo. But the need is overwhelmingly large and I am only one small person with many responsibilities. I didn't know what I could do that would actually be useful.

Then, last year, I met with Rachel Cohen, Executive Director of Doctors Without Borders (Médecins sans Frontières or MSF) in South Africa. She had initially been the director of MSF in Lesotho and had set up clinics that used many lay people, some of whom were illiterate, and trained them to do outreach and to teach health care and disease prevention. She described most of those clinics as being run by nurses. In the model that MSF uses, she said, task shifting is key.

Task shifting means that you place the best-trained people in teaching, supervising and direct care, while shifting every other task possible to people with less formal training. As she described the model Doctors without Borders used in Lesotho and South Africa, it struck me that it was one that could be transferred to our SD clinics in the Congo.*

I asked Rachel if I could bring several interested colleagues and visit her in Capetown so that we could go to the MSF clinics to learn more about their organizational model for delivering care to victims of HIV/AIDS. She was enthusiastic and I managed to convince Luther Schutz, a medical doctor who has specialized in emergency medicine for several years, and Wendy Neal, an osteopathic physician, both Subud members, to go with me.

The township of Khayelitsha, South Africa, is about 30 miles outside of Capetown. The South African "Group Areas Act," which was passed in the mid-1950s prohibited blacks from living in the cities. This did not prevent blacks from settling in the outskirts. During the 1980s, many blacks, mainly Xhosas, moved into the outskirts of Capetown looking for work. As the black population grew, the apartheid regime sought to solve the problem by establishing new black neighborhoods. Khayelitsha was established in 1985. The name is a Xhosa word that means, "Our new home."

Unfortunately, with the end of apartheid, the situation of the poor in South Africa did not improve greatly. By 1982, AIDS had found its way from America to the rest of the world and in Southern Africa the infection found a fertile medium in which to spread. At first, as in the United States, the infections concentrated in the male gay community, but in Africa it quickly spread to the heterosexual population where it predominates. All over the world governments were slow to react to the threat of AIDS, but in South Africa the stigma attached to AIDS as a sexually transmitted disease made open discussion of the disease extremely difficult. The first time it became widely known that a South African woman was infected with HIV she was stoned to death.

The Médecins sana frontières clinic in Khayelisha

The South African government's response was further complicated by the long history of black subjugation to white supremacists and colonialism. President Mbeki claimed, with some truth, that the real killer of Africans was poverty and that all other ills flowed from that source. Unfortunately, that either/or formulation of the problem tells us that, either the problem is AIDS or it is poverty. This interfered with the government's willingness to take any early preventative measures. At the same time he and his Minister of Health, Manto Tshabalala-Msimang, believed that anti-retroviral treatment (ART) for HIV would by itself kill people and that its distribution was, in fact, a plot by the white developed nations against black people. Tshabalala-Msimang even tried to evict Doctors without Borders from the country because they were advocates of ART

With almost no open discourse about the AIDS issue in the poor black communities and no adequate government response, AIDS in South Africa quickly reached a terrifying rate of new infections per year, and most of those infections were among the young adults, those between the ages of fifteen and thirty. More than a third of all black South Africans are under the age of fifteen, and the AIDS epidemic has decimated their parent's generation upon whom they most depended. By 2004, when the government finally approved a plan to make antiretroviral treatment publicly available, the HIV prevalence rate among pregnant women was 27.9%.[2]

Khayelitsha is now home to around a million people. The unemployment rate is high and most of the people live in poverty. The economic poverty of the people is linked to many other hardships. Especially serious is the health situation. Tuberculosis has exploded chiefly because of the AIDS epidemic, and close to a third of the population is infected with HIV/AIDS.

In 2003, the government of South Africa began to get behind the use of anti-retroviral drugs to combat the disease and these programs began to take effect in 2004. But a great deal of damage had been done and in 2005 the prevalence of HIV in pregnant women had reached 30.2%, almost one third of all pregnancies in the country.

Rachel Cohen and Dr. Eric Gomez of Médecins sans frontières in South Africa

The clinics for HIV Treatment in Khayelitsha were begun by Dr. Eric Gomaz, who has been working for MSF in South Africa for 10 years. Last January, Luther, Wendy and I found ourselves traveling there. The road was hot, flat and dusty and led through miles of slum dwellings. We passed through a gate to market area with stalls of oranges, potatoes and clothing items. This is where the MSF clinic is located.  

With courage and strategic planning, Dr Gomaz and MSF, along with the Treatment Action Campaign (TAC) [3], an activist group made up mostly of HIV positive people who have worked hard to address the stigma of AIDS. TAC was started in 1998 by AIDS activist, Zackie Achmat. He would not take the drugs until they were available for all. There was civil disobedience but finally dancing in the streets. Eventually, there were 20,000 activists working for change. Together MSF and TAC have overcome incredible challenges to obtain antiretroviral medications and to get people to take them.

At first, Dr. Gomez tried to start an HIV clinic in Johannesburg; but he could not get any support. But, he didn't give up. TAC helped by putting pressure on the government and, in 1999, Dr. Gomez finally got enough support from the Khayelitsha township and Provincial Government for MSF to start the Mother to Child Intervention Programme.

At first antiretroviral drugs were only available from the brand-name drug companies. They were very expensive (10 to 20 thousand US dollars a year) and the South African Ministry of Health refused to support their use. But in a two-year study done in the Khayelitsha clinic in and in Thailand, activists showed that antiretroviral drugs would save lives; so, because of the advocacy of TAC, the door opened for much cheaper generic production of the drugs and, in 2003, more than 20 years after the first outbreak of the disease in South Africa, the government got behind a program to fund the aggressive treatment of HIV/AIDS. Things have been changing for the better. In 2008, President Mbeki was replaced by Kgalema Motlanthe. Motlanthe, in turn, appointed Barbara Hogan as the new Minister of Health. Hogan strongly supports the use of antiretroviral medication and even has a member of TAC as one of her top advisers.

In 2000, MSF was conducting its work in a one-room office but, by 2003, they had three rooms. That was the year the National Health Act was passed, which now guarantees free health care for all. But, even with the NHA, sufficient resources are still not available. There are some good hospitals in South Africa but not enough. There may be 350 beds in an area with 3 million people. The problem for the poor is getting access to those beds.

This is where MSF's strategy of Task Shifting becomes crucial. In order to get the most medical services to the most people, those with the highest level of training must be placed in positions in which their skills can be used most effectively. So, MSF started using its medical staff, not only to deliver care directly, but also to train new staff to teach those living with HIV how to care for themselves and how to cope with the rather strict regimen the antiretroviral drugs demand. Now, the clinics have been handed over to the government and are staffed mainly by local people.

An "Adherence Counselor" at the Médecins sans frontières clinic in Khayelitsha

HIV treatment at MSF's clinics is organized with a great deal of peer support and coaching by local people. A person who tests positive for HIV and has T-cells below 250 will have three private sessions a week with an Adherence Counsellor who teaches the person about HIV and its treatment. The counsellor uses a list of important points and retests the patient in a discussion the following week at which time she writes notes about possible problems. She continues to see the patient until she feels satisfied that the patient has sufficient knowledge, understanding, and support to be able to take the antiretroviral medications exactly as prescribed.  When she decidess that the patient is ready, she will set a meeting with the patient, the doctor, and herself to start antiretroviral treatment. For the first three months after a patient starts on medication, patients have to come to the clinic every week to get their medications and take part in a two-hour support group (usually of 30 people). The support group model works well because the people involved are all living with HIV. They help each other solve their dilemmas. Those who have been taking the drugs longer and have more experience, help the newer members make the necessary adjustments that the drugs require.

By 2003 thousands of people in Khayelitsha were on antiretroviral medication. At this time, 350 new people are started on medication every month. Now there are 10,000 people successfully started on antiretroviral at seven sites in Khayelitsha. More than 93 percent of them are alive and remain in care. The clinic estimates that there will be 15,000 people on the drugs by 2015.

Doctors without Borders' approach is to address health issues and develop an infrastructure, a delivery system and an overall model that is not only effective, but can also be sustained after they leave. The education of both trained people and lay people is key to this approach. From the beginning, MSF explored the economic needs and resources of the people and of South Africa and discovered what backing and support would be needed. Even though the MSF staff knew from the beginning that South Africa's health care system was not going to become effective without major changes and that they would have to find support from outside the government, they approached the problem as diplomatically as possible. When it finally became clear to all that antiretroviral therapy did save lives, the government began to change its policies. At that point MSF was able to seek government support in funding and to facilitate the process of transition, enabling the government to take over the running of the clinics. MSF was able to step back, look at the big picture, and create a strategy that would deliver health care in the most, timely, efficient and sustainable manner possible given the realities of the situation.

How can one create a strategy that will enable a project to receive crucial support, but still not give up the ideals and practice of effective, culturally sensitive treatment?

The concept of task shifting is the key to effectiveness. The MSF educators spoke to us of their experiences when starting the clinics in Lesotho. There they trained many people who had never had a paying job and could neither read nor write, to become effective outreach workers and health educators. The MSF staff found a way to be a part of the culture in a natural, easy way that was empowering and not patronizing.  They approached these enormous challenges as tough but interesting problems, the solution for which required many different and creative approaches.

Many Susila Dharma projects are working in countries where poverty is extreme, basic infrastructure such as roads, communications, and health clinics is nonexistent, civil society is lacking, and the government has neither programmes nor money to be tapped. In many cases there are even elements in the society or government that are actively opposed to the efforts of the SD Projects. By examining the successful strategies employed by Doctors without Borders, we can learn important lessons about building long-range strategies and relationships for the success of our own projects.

1. Virginia Thomas's report on the schools and clinics in DR Congo, Despite the Hardship, (read the section on Kimpemba Medical School which trains nurses in much the same way as MSF does.)

2. For historical background on AIDS in South Africa, see Avert's website.

3. How TAC Began, News24.com

4. Médecins sans frontières (Doctors without Borders) Luthuthupdates: 2006| 2006/2007 | 2007