Behind the Land Cruiser and Stethoscope

The idea of MSF and the work that we do is a pretty strong one in the world. The photos of the white land cruisers, the principles of independence and neutrality, the pictures of operating rooms setup in conflict zones, or workers in suits treating patients with Ebola.

The idea of MSF and the work that we do is a pretty strong one in the world. The photos of the white land cruisers, the principles of independence and neutrality, the pictures of operating rooms setup in conflict zones, or workers in suits treating patients with Ebola. The medical work and the patient care is always front and centre, as it should be. Often times people forget about the positions that are not front line medical that work in MSF (half of the positions are non-medical, such as logistics, HR, and finance). This side of MSF is rarely thought about and if these positions are easy to forget about, let me tell you the part that is NEVER thought about or promoted is how all of this amazing works comes to be. Enter the extensive and exhaustive planning processes of MSF…..  

Yes, this is what happened in the project this week. We had our Autumn Control and Planning (ACP), our Country Management Team meeting (CMT), and the budget for next year was due. Basically, this means that the general plan for 2018 had to be nailed down and explicitly stated in terms of the project goals, our mandate, and our expenses. There is always wiggle room, but we are not operating willy nilly and somebody, somewhere needs to be responsible for articulating that before it gets sent back to Amsterdam for approval. It’s not glamorous, no reporter is going to come and write a story about the amazing budget proposal that was done, but it’s a huge part of the MSF process. We are given donor money, and we have to use it responsibly. So there are no pictures this week and no exciting stories to share, because the somebody, somewhere happened to be our team this week. The outcome of the annual planning actually had a huge impact on the project moving forward.  

The discussion of the alcohol use disorder (AUD) component in the project took some time, as it is starting up and is in the development phase. In my last project, the project was more or less established and running, so my job was to continue that and there were not a lot of changes to the overall picture of the psychosocial department. In this project, a large focus moving forward is how to mitigate the harm of alcohol use in the context of adherence to TB drugs. And since this has not been done before, it’s got to start somewhere. A comprehensive plan of alcohol supports is needed for next year and this had to be included in the project planning, but getting there takes time. The process starts at the field level, with meeting, discussions and assessments with stakeholders. The project comes up with the proposal, and this is taken to the Country Management level. This is further discussed and, once approved, sent to Amsterdam for final thoughts and approval. For our meeting this time, we had 13 people from coordination in Moscow, the project in Grozny, leadership in Berlin, and the Minsk project – and me. 12 heads swiveled towards me looking for answers about next year. Or at least that’s what it felt like. “Tell us how to move forward, Hilary, give us your recommendations. Give us a starting point.”  

After the fear subsided, I realized what a unique opportunity this is. I have spent the last 5 weeks assessing the situation with regards to alcohol support, determining the gaps, and then developing a plan about how MSF can support those gaps. Then I got to propose what I thought would work, and my supervisor basically told me to shoot for the moon. As we received feedback from the Minsk Ministry of Health partners that they were interested in working with MSF around addiction, the proposal grew and grew to accommodate. So, I shot for the moon. I recommended: 

  • Anti-craving drugs need to be supplied and offered as part of MSF treatment, a first
  • Increasing the foundational knowledge of addiction, harm reduction, and patient centered care through a pretty significant training program
  • A full time person who will plan and deliver a range of addiction supports within the TB hospital and other facilities where we work 
  • An intensive outreach team consisting of a nurse and counsellor working 6 days per week (likely 2 of each position with a rotating schedule) to support the most complex patients to adhere to treatment 
  • An addiction referral specialist to work with those TB patients that would like addiction support, and to help them navigate the existing complicated system of alcohol supports in Minsk 
  • An addiction physician to oversee detox and support TB physicians that we work with 
  • Initiating medical detox within the TB facilities   

And the answer back so far was positive. It’s now sitting at the Amsterdam level for the last round of approval and discussions. I was pretty pleased and the feedback was overwhelmingly positive about my proposal. MSF is supporting me to come up with a comprehensive plan around addiction support in the project. Sometimes MSF is about the direct, immediate treatment of those in front of you, but sometimes it’s about the bigger picture and planning to change higher level policy. Bringing in anti-craving drugs for the first time into Belarus would be a game changer for the addiction field. Integrating care of TB and addiction so that TB patients can access psychosocial supports in a TB hospital would be a long term sustainable change for patients.   

Addiction is a complicated disease that clearly affects health outcomes in other areas; however, the level of understanding is lacking within the medical community. Even within our own project, there was a goal of “treating 12 people with alcohol use disorder”. What does that even mean? Once I explained that alcohol use disorder doesn’t fall into a medical model like diabetes or high blood pressure, things started to make sense. You can “treat” diabetes – there is a recommended blood sugar level to stay within – and you can even “treat” alcohol withdrawal symptoms until they abate, but you can’t “treat” alcohol use disorder in the same way. There is no fixed endpoint, or range to stay within. You might say 10 drinks weekly is too much, and I might say 2 drinks is too much, but we both get to work daily, pay our bills, and function well, so how do you explicitly measure one against the other? From a medical perspective, we might recommend abstinence, so that does that mean if a person is not 100% abstinent they “failed” at “treatment”? What if this person doesn’t want to stop drinking, but really wants to be adherent to TB drugs, or HIV drugs? Is that not a success if they identify and reach that target? Where does the patient’s voice fit in? There are WHO recommended guidelines for alcohol intake and Canada certainly has guidelines around safe drinking that we want all patients to follow; however, alcohol use doesn’t fit into the medical model in a nice, neat way that cancer, heart disease, kidney stones, or broken bones do. It’s not measurable in the same way, it’s not “curable” in the same way, and the interventions are not delivered in the same way, yet it affects our health in such a profound fashion.

If alcohol use doesn’t fall within the neat boxes of the medical model, “treatment”, or as I prefer to say alcohol supports, need to operate outside the boxes of the medical model as well. That led me to my proposal and the go ahead to start moving in that direction. As with any new project, I anticipate areas to be evaluated, not working quite as well as initially planned, and need adjusting but we can deal with that when we get there. But providing a comprehensive addiction treatment model within the context of disease management, in this case TB, is exciting and the right step forward in the bigger picture of treating DR TB. It still doesn’t make the planning, budgeting, and what feels like attempts at predicting the future any easier (try predicting the amounts of drugs that should be ordered for an entire year, that have never been used in the project and have no previous baseline to work from). If anybody has a crystal ball I can borrow, please send to Hilary c/o Minsk City.