By Dr. Unni Karunakara, International President, Médecins Sans Frontières/Doctors Without Borders (MSF)

In February, during a visit to Bolivia, I had the opportunity to tour the Chagas diagnosis and treatment project that Médecins Sans Frontières/Doctors Without Borders (MSF) runs in Narciso Campero province, located in the rural area of Cochabamba, which has one of the highest prevalences of Chagas in the country. During my visit, I talked to both patients and MSF staff and they confirmed that, despite the challenges, diagnosis and treatment of people living in areas far from urban centers is possible.

Paraguay 2012 © Seamus Murphy/VII

Unfortunately, the experience in Narciso Campero is just a drop in the ocean when you consider the actual impact of Chagas disease: it is estimated that there are between eight and 10 million cases worldwide and that the disease causes the death of 12,500 people every year, making it one of the parasitic infections with the highest mortality rate in the American continent. In Bolivia, it is estimated that up to one million people are affected, and more than 3.2 million people are exposed to the disease in endemic areas. The situation is even more difficult for those patients who have developed heart or digestive complications due to the disease, since palliative care in these cases is expensive.

Changing this scenario is only possible if governments of endemic countries commit to closing the significant gap between the number of people living with Chagas and those who receive treatment. Latin American states are facing a historic opportunity, more than one hundred years after the discovery of the disease, to finally begin transforming the reality of Chagas patients.

In recent years there has been significant progress. The Drugs for Neglected Diseases Initiative (DNDi) has developed a pediatric formulation of the drug used for the disease, leading to improved treatment for children. The International Federation of Chagas Patients, which allows for those affected to have a platform from which to make their voices heard, and International Chagas Day, which we commemorate today, were recently created. The World Health Organization (WHO) and the Pan American Health Organization (PAHO) have both adopted resolutions recommending the diagnosis and treatment of Chagas be integrated into primary healthcare centers (ie the clinics and hospitals that are closer to the community), and the supply of the existing treatments strengthened with the aim of making access universal in the future. But much remains to be done for these resolutions to be translated into concrete actions.

In this sense, Bolivia can play a key role as a regional leader in the fight against Chagas. Although it is the country with the highest Chagas endemicity, it is also the one treating the largest number of patients, and it has some of the strongest laws regarding the disease. Act 3374 of March 23, 2006, for example, declares as a national priority the fight against Chagas and its prevention in all departments. If, under the leadership of the President of the Republic, the Health Secretary and provincial governors, the country achieves to turn into a concrete reality what the decree proposes, Bolivia can become a role model for the continent.

The great barrier existing today for patients’ access to diagnosis and treatment is the lack of human resources and a sound primary healthcare infrastructure that includes raising awareness and educating both the population and medical staff in charge of providing treatment. Simpler diagnostic tools and better treatments, tailored to the contexts, are needed. New drugs have to be developed to accompany this process; meanwhile WHO and PAHO should support the efforts of governments, ensuring that the necessary drugs are available in all concerned countries. Since 1999, MSF has been working on Chagas, serving more than 7,000 patients in different countries of Latin America and proving that it is possible to provide treatment. Of course, it will take time, work and commitment from the authorities, but the moment to start transforming the lives of millions of patients with Chagas is now.

by Stephen Cornish

Executive director for Médecins Sans Frontières in Canada

Earlier this month, Minister of International Cooperation Julian Fantino visited Burkina Faso. The visit dovetails with the government’s current matching funds program to raise aid money for the Sahel region of Africa. These efforts, laudable for their aim of helping people in need, unfortunately give an emergency-style focus on what in reality is a chronic crisis that needs long-term solutions.

This year, across the Sahel, one million severely malnourished children are expected to receive lifesaving nutritional and medical treatment. This is the largest number in the history of humanitarian interventions. Malnutrition in the Sahel, however, has not simply spiked overnight resulting in a nutritional emergency. What we are witnessing is the recurrence of a usually silent and recurring annual crisis.

Chad 2012 © Catherine Robinson/MSF

Countries in the region such as Burkina Faso, Niger and Chad, face a yearly hunger gap, a period in which last year’s grain stores are spent and this year’s harvest is still a few months away. This situation compromises the nutritional and health status for millions of people across the region. What is different now is that for the first time all concerned governments reacted early, calling for cooperation and international assistance. This has allowed donors and aid organizations to roll out relief efforts in time to maximize their lifesaving impact. In Niger alone, more than 229,000 severely malnourished children have been treated through these efforts.

Significant challenges remain. With the onset of the rainy season, several areas have become inaccessible and recent floods have increased the incidence of malaria, affecting many people in a context where vulnerability is already at its peak. Political instability and insecurity in parts of Mali, Niger, Chad and Nigeria further complicate the delivery of assistance.

In Niger, the government, humanitarian organizations and donors developed preventative programs to ensure community supported nutritional care for infant children before their family’s resources dried up and the children’s weight plummeted to the point where they would require urgent and expensive medical treatment just to save their lives.

Lack of access to health care is a key component of this recurring crisis. Cost-recovery strategies long pushed on developing countries by the World Bank as part of structural adjustments to decrease social spending by developing nations governments mean that families with even the most modest incomes have to pay to access health care. During the lean period, people’s scarce resources are used to feed their family. There is nothing left to pay for medical care. This leaves children more exposed to opportunistic infections and seasonal malaria. Ensuring access to free health care and including ready-to-use food supplements containing proteins and micronutrients as part of the health package provided to mothers and children is essential to treat and prevent diseases. It will reduce the burden of malnutrition.

Burkina Faso 2012 © Aurelie Baumel/MSF

It is difficult to compare the impact of malnutrition from year to year, and particularly difficult when the comparison involves such a diverse group of countries, as well as external contributing factors. But we do know that hundreds of thousands of children are at risk of death every year, caught against their will in this predictable cycle of recurring starvation.

We must rethink the meaning of “normal” and “crisis” in the Sahel.

The good news is that the scale of the problem of malnutrition — which was previously under-estimated and even hidden — is finally visible. Developing nations, donor countries and humanitarian organizations are ensuring this year that more and more children are accessing lifesaving care.

Médecins Sans Frontières/Doctors Without Borders (MSF) has expanded its ongoing long-term programs across the region and stepped up its emergency response efforts. Between January and June, more than 56,000 severely malnourished children were treated by MSF in the Sahel region – more than 36,000 in Niger alone. MSF teams are also currently working in northern Mali, Niger, Chad, Burkina Faso and Mauritania to assist people displaced by the conflict in Mali.

While the emergency response underway in the Sahel is vital to help people in the region bridge the hunger gap until this year’s harvests come in, it cannot alone solve the “permanent emergency” of malnutrition in the Sahel. We must enact long-term solutions to change this chronic situation. Donor governments and developing nations must help to expand access to free preventative nutritional and medical assistance via local health ministries and aid programs. Such an approach will be more cost effective in the long run. It will save countless lives and will also help to pull families out of the vicious cycle of hunger and dependence on emergency aid once and for all.

by Fasil Tezera
Head of mission for Médecins Sans Frontières in Zimbabwe

June 6, 2012

In Zimbabwe, there are at least 66,000 people living with HIV who face the prospect of losing their current access to lifesaving antiretroviral (ARV) treatment because of a dangerous shortfall of international funding for local treatment programs.

To make up the shortfall, various segments of the Zimbabwean health sector proposed that certain HIV patients pay for their ARVs themselves. But what might initially appear as a cost saving measure will actually carry far greater costs – both in money and in lives – because it will undermine treatment adherence, quality and outcomes, as well as efforts to prevent more people from contracting the virus.

2011 Zimbabwe © Brendan Bannon
Seven-year-old Brian Tom, pictured above, is patient in the HIV/AIDS program run by MSF in Epworth, Zimbabwe.

Médecins Sans Frontières (MSF), which supports treatment for more than 228,750 HIV patients in more than 20 countries, is deeply concerned by these and similar proposals that involve shifting the financial burden of buying ARVs from state budgets and donor funds to HIV patients themselves. This idea is being aired as international donors continue to retreat from previous funding commitments on ARVs, thus cutting off access to lifesaving treatment for patients in resource poor settings.

Countries are struggling more than ever to find additional alternative sources of funding in order to avoid a return to rationing treatment and undoing much of the progress that has been made in HIV care over the past two decades. Interrupting treatment will also contribute to the growth of resistant strains of the virus.  

In Zimbabwe, ARVs are not currently covered by the Health Transition Fund (HTF), which creates serious problems. Until the end of 2011, a pool of funds financed by the UK, Sweden, Norway, Ireland and Canada paid for ARVs. This year, the HTF, absorbed this pool, but purchasing ARVs was no longer part of its mandate.

This means that some 66,000 patients already on treatment do not know where their ARVs will come from, to say nothing about people waiting to begin treatment. If  donors such as the United States, European member states or the European Commission through the HTF, do not mobilize to cover the gap, the next opportunity for additional funding would be a grant from the Global Fund to Fight AIDS, Tuberculosis and Malaria. The earliest that would happen, however, if it happened at all, would likely be in 2014.

The funding shortfalls have sparked much debate and calls from UNAIDS and others for countries gripped by the HIV crisis to step up domestic efforts. It is certainly true that national governments and ministries of health must make both political and monetary commitments to treating HIV. But passing the burden on to the patients themselves is not the answer. That would mean expecting people who are already vulnerable to pay for treatment that should be free; it also jeopardizes the gains and results treatment programs have made.

2011 Zimbabwe © Brendan Bannon
The pharmacy at the MSF clinic in Epworth, Zimbabwe. MSF provides patients in the HIV program medication and care free of charge at the clinic.

The World Health Organization – backed by medical evidence – holds that guaranteeing ARVs free of charge is crucial to maintaining good treatment outcomes and to slowing the spread of HIV. Most people accessing ARVs in high-burden countries through government healthcare, as in Zimbabwe, are already impoverished because they have lost income due to the disease and are shouldering ancillary healthcare costs. The majority of patients in Zimbabwe and similar low-income countries often live below the poverty line and already struggle to pay costs related to care, be it for drugs to treat opportunistic infections, registration and hospitalization fees, X-rays, laboratory tests, or transport to clinics or hospitals. A study carried out by MSF in Kenya in 2007 compared retention in care among HIV patients with access to free ARVs, to patients who had to pay a fee of approximately $7 per month, while all other elements of care were the same. The result was that offering ARVs free of charge reduced the risk of loss to follow up by more than 56.6 per cent.

To make vulnerable patients in poor resource settings pay for ARVs goes far beyond reasonable expectations. What’s more, fees collected from patients in a country where 80 to 90 per cent of the population is not formally employed will not amount to much. And we know from experience that patients with unpredictable incomes may start rationing their ARV intake, taking less than the recommended dosages of pills in order to make drug supplies last longer. This leads to added complications, drug resistance and interrupted virus suppression – all of which would further increase the cost of care, wiping out any savings generated by the imposition of fees. In turn, it would increasingly burden health services, discourage health workers, and, worst of all, deter people from coming forward for testing and treatment.

A great deal of progress has been made in the fight against HIV/AIDS in Africa, but the emergency is far from over and the successes to date are far from assured. Any domestic funds that can realistically be raised in low resource settings now will not be sufficient to cover treatment for all people in need –  the number of people infected is still too high. . Zimbabwe alone has one million people living with HIV.

Economists estimate that most low-income countries will have to remain reliant on external support for the next 20 years if they are going to ensure an effective HIV response that meets the needs of their populations. Zimbabwe’s national HIV and AIDS levy, which channels  domestic resources to the HIV response, is an effective model that shows the country’s increasing commitment to generating domestic financing for HIV, but international funding still is and will remain critical. The funds raised at home should be used to put more patients on treatment, rather than to fill gaps left by retreating donors.

Therefore, MSF urges donors to make sufficient funding available for free and effective HIV treatment to all who need it. Domestic resources must be augmented with consistent and continued international involvement. Only then can we curb the HIV epidemic in Zimbabwe and similar high-burden, low-income contexts.