It was a funny story that Hans Rosling told at last week’s scientific day of Médecins sans Frontières (MSF) in London.
Rosling’s message to the audience: If, as a humanitarian response, you do something perfectly, you have taken a resource away from somewhere else where it could have been used. Listen to the people who are affected and give them what they need, rather than aiming to be the “perfect” humanitarian aid worker. You don’t want to leave a place in a situation where your intervention is not sustainable. Don’t burden underfunded health systems with white elephants.
Even if the example itself is literally a limping one (by any standard, a foot should point forward rather than sideways), Rosling’s position is highly debatable. MSF creates “islands of excellence in seas of under provision”, and gets criticized for that, not only by Rosling. The “islands of excellence” criticism originates from the debate about HIV programmes. Critics argue that these vertical, disease-oriented programmes do not contribute to developing the health care system in (African) countries.
Much has already been said about HIV in this context and I won’t go into that now. But what does Rosling’s position mean for humanitarian medical aid in general? MSF is a medical humanitarian organisation, driven by medical ethics. MSF strives to provide the best health care possible for populations in need, whatever the context. And I agree. As a doctor, I have difficulties to treat my patients by standards that are far below of what I have learned to be good medical practice. Good medical practice also means: respect the patient and respect the culture you’re working in. Cut ’n paste health care creates white elephants. But there is a difference between smart adaptation of good medical practice and accepting mediocre health care. No population and no individual should be exposed to the latter.
Rosling’s message worries me. Putting sustainability first stifles innovation. A lowered standard of HIV care in resource- and/or security constrained settings would never have lead to the scale-up and access to antiretroviral medicines in resource-constrained settings that we witness today. Accepting that ARV’s are far too complicated for Africa, that malaria should be treated without a diagnostic test, that diagnosis and treatment of multidrug-resistant tuberculosis is technologically too burdensome for countries like Uzbekistan or Myanmar, that monitoring hepatitis C treatment for side-effects is not possible for patients in India or Ukraine, will get us nowhere and leave patients empty handed. The gap between medical needs and access to good health care in the world has proven to be too sustainable to worry about sustainability.