Global Health and Humanitarianism

Delivered by Joelle Tanguy, U.S. Executive Director, MSF, at Stanford University

Good Afternoon,

It is a great pleasure for me to be here at Stanford University, especially here at the Business School. That’s where I started the oddest carrier path in the MBA class of '82, from the Silicon Valley to Doctors Without Borders. I left the Bay area after engineering a sabbatical leave from my software product management job and volunteered with Doctors Without Borders, more than 10 years ago. It’s great to be back here, meet old friends, rediscover the campus, the new GSB building—it has changed so much!—and reach out to you!

VOLUNTEERING

I started with Doctors Without Borders after the Armenian earthquake of December 1988. It was supposed to be a short volunteer assignment. Some temporary parenthesis in a busy life. But I eventually found myself living five consecutive years of a nomad life—with nothing but a blue sports bag to hold my possessions—from crisis to crisis. From Armenia to Uganda, from Zaire to Somalia, from Sierra Leone to Bosnia.

I was not a caregiver, since they don’t teach basic medical skills at Stanford Business School, but I progressively came to enroll the support of medical volunteers and coordinators, and I came to direct emergency and refugee operations involving primary health care support, acute nutrition programs, epidemics control, refugee assistance and war surgery, often amidst political turmoil. I made friends of all cultures around the world, from the ruins of Armenia to the war-torn streets of Mogadishu. It had become my life; it was the best I could have ever dreamt: it reconciled my soul with my work, my values with my personal challenges.

Everyone volunteers initially for a different reason. It can be the search for new challenges or new meaning, or the accomplishment of an old dream, or the need to serve, or the appeal of traveling, of meeting new faces, of feeling part of the planet's humanity.

One of my Argentinean colleagues once said something that really made sense to me. He said, " I am not trying to do anything cosmic, like saving the world. I believe one can help with little steps, a small grain here, a small grain there". This is so true, every single person you help, every life you save, every suffering you alleviate, makes the trip worthwhile. And it's important that they'd be people willing to travel 6000 miles from their homes to tie bandages, it's important because it shows respect for life and humanity, without discrimination. You live for yourself and you discover other people in the process.

The grand ideas and the altruistic but distant feelings for that other half of humanity that we might have before we leave are completely transformed by working in the field. You develop a sense of proximity and solidarity to those who suffer on this other side of earth, now your neighbor, and thrive on the challenges you have to face to bring relief to the most endangered, the most destitute. Landing a relief plane in Eastern Congo can be an even sweeter victory than a wildly successful IPO! And being deprived of first-world comfort can be taxing but it can also raise a hot shower to the level of an ecstatic experience!

You also have a new fire within yourself: outrage and a sense of urgency.

For example, as a volunteer you would see the devastating injuries to children from landmines. When there's more, when you’ll see the "made in USA" stamp on them, you’ll be ashamed and outraged, and you'll be a campaigner to ban landmine all your life, when you return to your family medical practice or your business in San Francisco or Oakland!

So let me make a first pitch right here: As of May 24, 1999, the Mine Ban Treaty had been signed by 135 countries, and ratified by 81 nations. In the Americas, only the United States and Cuba have not signed the Treaty. The other recalcitrant nations, including Russia, China, Iraq, and Iran, continue to hide under the shadow of the non-signature of the United States. It is crucial to the effort to universalize the ban on landmines, and I invite you all to support the organizations pressing the U.S. government to shift its current position and to agree to join the Mine Ban Treaty now!

Since we’re transitioning from the personal to the global, I want to bring our conversation to a different plane. First having a look at global health, focusing on access to essential medicine, and moving on to the challenges in civil wars and the state of humanitarianism.

DISEASES WITHOUT BORDERS

When Médecins Sans Frontières was established almost 30 years ago, the medical community was setting for itself the ambitious goal of the eradication of disease and the rise of life expectancy worldwide. "Health for All, 2000" was the slogan by the end of the seventies, when humanity was triumphantly announcing the eradication of smallpox.

Similarly, the optimism was pervasive in economics and development circles, and in the Bretton Woods institutions claiming that sound economic modernization would improve health status in developing nations.

These ideologies did not pass the test of time. Instead we must realize that while the gap between the have and the have-nots is expending rapidly, we also re-entered the era of "disease without borders". That’s how Laurie Garrett chose to label our new era where "every day one million people cross an international border, and as people move, unwanted microbial hitchhikers tag along. Geographic sequestration was crucial in all post-war health planning, but diseases can no longer be expected to remain in their country or region of origin. Even before commercial air travel, swine flu in 1918-19 managed to circumnavigate the planet five times in 18 months, killing 22 million people, 500,000 in the United States. How many more victims could a similarly lethal strain of influenza claim [now], when some half a billion passengers [a year] board airline flights?"¹

The reemergence of infectious disease and the growth of scope of the refugee crisis, are two lethal factors whose combination were well portrayed by the cholera crisis in the Rwandan refugee camps and to some extent by the Ebola and Marburgh scares in recent years. But another factor, changing the profile of the challenges awaiting international medical teams, is the growth of the urban population worldwide. Whereas 23 million people were displaced in 1994 by social unrest or war, another 30 million moved from rural to urban areas within their own country. There are new tremendous challenges lying in the actual heart of the developing world’s exploding cities.

By 2025 more than 5 billion people, i.e. 61% of the world’s population will be living in cities². Meanwhile, from Cairo to the Bronx, from Kinshasa to Moscow, public health systems are collapsing under the new influx in population, in particular the primary health-care system, which is the most important gateway for the control of infectious diseases. From onchocercosis to TB, from Guinea worm to Yellow Fever, from Polio to AIDS, it is striking to realize none of us believes anymore in inevitable eradication process as we did 10 years ago, and instead see the challenge is ahead.

And there are serious obstacles on the way. Some of them lie right here, in our backyard! The policies of US drug manufacturers so far translate directly into a deadly diagnostic for millions of people, enunciated as " you’re dying of market failure". Let me explain.

YOU’RE DYING OF MARKET FAILURE

Treatable communicable diseases such as tuberculosis, meningitis, and pneumonia are still the leading causes of death in the developing world.³ In fact more than 90% of all death and suffering from infectious diseases occurs in the developing world.

Millions are dying because of several reasons—lack of research and development for neglected diseases, and lack of access to lifesaving medicines for known diseases.

LACK OF RESEARCH

Research for neglected diseases has ground to a virtual halt. Little research is being carried out on tropical and other infectious diseases like malaria and sleeping sickness that largely affect people in poor nations, because drugs for such illnesses are not profitable for pharmaceutical companies. Out of 1,223 new drugs brought onto the market worldwide between 1975 and 1997, only 13 were for tropical diseases.

Access to medicines for these communicable diseases is critical, infectious diseases kill 17 million people a year and in Africa for example, infectious diseases account for more than 60% of the deaths. Yet, there is no money for research as research dollars focus on the lucrative lifestyle drugs for the profitable developed world markets.⁴

LACK OF ACCESS TO LIFESAVING MEDICINES

Even when effective treatments exist, as they do for diseases like multidrug-resistant tuberculosis and many AIDS-related infections, when lifesaving medicines are available, they are simply too expensive, due in large part to patent protection and pricing strategies aligning on the wealthiest markets. A lucrative market for lifesaving drugs addressing infectious diseases simply does not exist in the developing world despite the fact that more than 90 percent of all deaths and suffering from infectious diseases occurs there.

In summary, "Our patients are dying, not because their diseases are incurable, but because as consumers, they do not provide a viable market for pharmaceutical products. Clearly, market forces alone are not enough to address the need for affordable medicines or to stimulate research and development for neglected diseases. This market failure is our new challenge."⁵

Our intuition was that progress would come from a confluence of efforts: public mobilization, public-private partnerships and regulation. Two years ago, at Doctors without Borders, we initiated a campaign to develop "Access to Essential Medicine", partnering with activists groups, academics, philanthropic institutions, corporate interest groups (drug manufacturers and associations), the media and governmental institutions such as the World Bank to stimulate development and appropriate pricing of drugs for the developing world. Together we must ensure that trade of essential medicines is regulated in the interest of public health. We are not questioning the importance of patents in stimulating research and development, but rather we are insisting that a balance be found between protecting intellectual property and ensuring individuals’ access to medicines. And we are seeking to provide an impetus for both policy development and practical solutions to specific access problems.

The progress is very encouraging. In civil society circles, activist movements have taken on the cause. Academics and economists such as Jeffrey Sachs have registered the urgency and scope of the problem and are brainstorming for solutions. On the political spectrum, Al Gore and Bill Clinton, after having erred with policies that supported the US Trade Representatives bully of developing world governments on behalf of US pharmaceutical companies, turned the official US policy around. On the corporate horizon, a few drug companies are finally moving forward towards practical, responsible partnership, finally freed from regressive rhetoric. We are not far enough yet, and we could use all the help to convince such firms as Pfizer and Bristol Myers Squibb that to price out of live saving medicines entire generations of men and women around the world is neither more nor better business in the short and in the long run. But at least, with a few, we’re beyond good PR for charitable donations, we’re entering at last—and hopefully for good—the realm of corporate responsibility. What the world essentially needs now is not so much more charity as more responsibility for structural change.

WAR ZONES: UNCIVIL CIVIL WARS

Most of these public health crises, where Doctors Without Borders operate, occur in poor countries. When I say poor, I never know how my Silicon Valley friends understand it. The frame of reference here is so warped. Did you know that the wealth of the world’s 3 richest individuals is greater than the combined GDP of the 48 poorest countries, a quarter of the states on the planet?

That among the 100 largest economies in the world, 5 are corporations, not countries? That 3 billion people—half of the planet—live on less than 2 dollars a day? That many mothers in stable but poor areas of the planet can only feed their children erratically, sometimes only two, three meals a week, and the rest of the time have the children would suck sugar cane or whatever could help alleviate hunger?

It is in these same poor countries that the most uncivil civil wars are being waged. Sometimes rich in natural resources, always rich in culture, these countries have failed in the modern political economy. Failed redistribution, failed accountability and the cycles of exclusion, denial of rights, and aggression escalate.

In a world where conflicts have less to do with territory than with economic control and identity of a nation, civilians have become both pawns and targets for the belligerents.

Our volunteers are witness to the fact that the toll on civilians is extraordinary. In 1990, civilians represented 90% of war casualties, almost half of them children. Civilians have become the prime targets of opportunistic violence, raiding, looting by militias and military troops. Even worse, they have become strategic stakes in these wars. Forced displacement, sieges, starvation, indiscriminate bombing, massacres and even maiming campaigns and rape, have become frequent tools of war.

Forty million people are displaced by conflicts, most of them resourceless and traumatized. Eighty percent of them are women and children. Displacement easily leads to 30 fold increases in mortality. The children under 5 are the first to die. Their elders, if they stay alive, are often stripped of their dignity and rights. Surviving on humanitarian assistance is no great solution. In public health terms, being a refugee in a camp, being dependent of food aid, is a most precarious condition that often leads to excess mortality and morbidity. In human terms it’s unbearable. Some of our patients, children and adults alike, the most traumatized, cannot face their fate, cannot even ask for help, cannot even receive help, they sit and stare and let themselves die.

ON HUMANITARIANISM AND MSF

Humanitarianism occurs where political processes have failed or are in crisis, leading to such situations as war, community violence, or the marginalization of a minority group. Our task is the short-term relief of the suffering caused by political failure seeking out the most vulnerable first. It is an impartial act out of human solidarity provided on the basis of need alone, regardless of ethnic origin, gender, creed or political affiliation.

The Nobel Peace Prize Committee singled out the work of Doctors Without Borders/Médecins Sans Frontières not only for its relief operations but also for its will to bear witness, call public attention to humanitarian catastrophes and point to the causes of such disasters thus helping form bodies of opinion opposed to violations and abuses of power.

This is an essential, defining feature of the organization, grounded in its birth in the Biafra crisis. We have a commitment bear witness for massive violations of human rights and humanitarian law. We espouse a new concept of vocal impartiality, definitely taking distance from the humanitarian dogma on neutrality that made the Red Cross a silent witness of the Holocaust.

Keeping frontlines and militia checkpoints open to relief teams to operate on all sides of the conflict while bearing witness when aid is no longer enough is a challenging exercise. To ensure our capacity to do so we had to secure total independence from political, economic and other interfering agendas. To maintain its independence from political interference, Médecins Sans Frontières built, worldwide, a pool of individual and private supporters who guarantee that the majority of the organization’s funds is independent of governments and other organized interests. This private funding also gives us the freedom to respond to the greatest needs as fast as possible.

We are hard-pressed to make sure that in this confusing and unkind world, at least humanitarian teams can reach populations in danger, assess independently the needs, deploy assistance impartially, and monitor the impact of their work to make sure it helps the most vulnerable. That’s what we call ensuring "humanitarian space" at the heart of the conflicts.

At the beginning, the organization was just a couple of doctors, a suitcase and a dream. Today it is the largest private emergency medical organization by the sheer size of its operations, number of its volunteers, presence worldwide. We’ve built hundreds of guidelines, conceived protocols of intervention, worked with the best of the world’s epidemiologists to certify the quality of our work, trained thousands of volunteers. We’ve had to deal with political, military, economic realities and technical challenges that stretch our capacities in a renewed fashion at every major crisis. But we’ve refused the temptation of hyper professionalism. Our actions are and will still be carried out by volunteers. Trained volunteers yes, qualified doctors and nurses, supervised by a cadre of experts, but still, at heart, volunteers. They help us question again and again and revisit anew the old ethical debates.

"Our volunteers and staff live and work among people whose dignity is violated every day. These volunteers choose freely to use their liberty to make the world a more bearable place. Despite grand debates on world order, the act of humanitarianism comes down to one thing: individual human beings reaching out to those others who find themselves in the most difficult circumstances. And they reach out one bandage at a time, one suture at a time, and one vaccination at a time. And for Médecins Sans Frontières/Doctors Without Borders, this means also telling the world of the injustice that they have seen. All this, in the hope that the cycles of violence and destruction will not continue endlessly.⁶

Ethics and humanity are of the essence, and there is no guideline, no textbook for this. It is a fragile group dynamic that needs to be sustained daily. That’s what will keep the humanitarian movement alive.

That’s where the human adventure is too.

1. Laurie Garrett, The Coming Plague.
2. Source: United Nations
3. 90% of death and suffering from infectious diseases occur in the developing world where there are no local resources nor lucrative markets to attract them. Infectious diseases kill 17 million people a year. In Africa, infectious diseases account for 60% of all deaths
4. A single of these neglected diseases, Sleeping Sickness, alone threatens 60 million people. As ins the case with many tropical diseases, research targeting this diseases halted after the de-colonization.
5. See Nobel Peace Prize address, James Orbinski, MSF
6. i.d.