The MSF Community-Based Model of Treatment

I have always admired the humanitarian organization Médecins Sans Frontières, or Doctors Without Borders (www.msf.org), without knowing the details about what they do on the ground. We had the privilege of touring an MSF treatment center being constructed at a school in Kissy, Freetown (there were no patients there yet).  Since school is closed right now, they are using the school grounds for the center.  Fernanda Falero with MSF Spain gave us the tour.  Fernanda is a humanitarian anthropologist with a specialty in Ebola. MSF has been responding to VHF outbreaks since 1995, and Fernanda started in 2006. As an anthropologist she does her best to make the treatment processes transparent and participatory. Her initiatives, she hopes, help to clear up misconceptions about Ebola, make treatment more accessible and acceptable, and involve community members in prevention (see below).

We have not visited other centers, so we are not sure if these efforts are unique to MSF. Sierra Leone has treatment centers around the country that are being run by different groups, including the Sierra Leonean government,  Partners in Health, Save the Children, the British Military, and the Chinese, Canadians, Nigerians, and Italians.  Each one of these groups comes with their own protocols, logistics, data and staff.   There is even a debate among some of them about whether to provide IV therapy to Ebola patients (http://www.nytimes.com/2015/01/02/health/ebola-doctors-are-divided-on-iv-therapy-in-africa.html?_r=0). From a patient and community perspective, interaction with the centers likely varies depending on which group built a center close to them.  I bet that not all centers employ the kinds of community outreach that Fernanda and her team do.  Also, it's no surprise, given all these NGOs, that people here perceive that internationals are profiting from this epidemic (more later).

From what we learned today, MSF seems to have a thoughtful model that reaches beyond medical treatment and into the community. And the fact that MSF hired Fernanda, an anthropologist, to work with their team may be unique and useful.  It would be great to someday see the MSF model formally evaluated.  Here are a few of the ways in which Fernanda and her team intend to employ transparency and community participation in their work:

1. The treatment center is open to the community as much as it can be.  On the perimeter, the center is surrounded with open chain-link fencing so that community members can see inside. This is in contrast to some centers that put up opaque walls on the perimeter. Community members are invited to visit the center. Family members are invited to visit patients, and if the patient is very sick, one person from the family can wear PPE and go inside to visit the patient.  MSF is also producing a video that shows the entire process of detection to treatment to survival that they will show to the surrounding community. 

 2. 150 community members, both skilled and unskilled workers, are being paid to construct the center.  Fernanda believes that this increases buy-in of the community for the center. We met the Member of Parliament whose constituency is in this community.  He said that as a politician people always ask him "What have you done for this community?" and now he can say he has done something, which makes him proud.  He also said that this center brings resources to the school, which will be good for the school once it reopens.

3. The family will be allowed to visit their sick loved ones in the treatment unit. Family members can wear PPE and visit their sick loved ones. This is important because people have not wanted to send their loved ones to treatment centers because of fear that their loved ones will be mistreated or will never return. The patients who are well enough to walk can meet their family members outside the sick (red zone) tent. Patients and their family members are instructed to sit two meters apart during the visit. Below is Fernanda with the poles indicating the two meters distance.  Family members can bring anything to a patient (food, etc.), knowing that whatever goes into the treatment center will not come out. MSF also provides confirmed patients with phones so that they can communicate with their loved ones while they are in the treatment center.

4. Once a patient dies, MSF will consult the family on what to do with the dead body.  It is critical for the family to believe that their loved one has received a dignified burial. Fernanda explained: "When the body is prepared for burial, the family is allowed to come in and have a moment with their loved one...the best way to do this is to sit down with the people and talk. You explain the protocols and why the body cannot be manipulated because of the transmission of infection. Then we ask them  'Do you have any alternative [ritual other than touching the body] that your heart and your soul will feel fine with?' Because it’s a special moment. I did burials in other outbreaks and it worked fine. It’s just you need to take that time to listen.... And then when it comes from them, then it’s fine because they accept it."  

It seems so logical when Fernanda says it, and it seems like this process would help allay people's fears in Sierra Leone that dead loved ones won't make it to the afterlife. We wish this consultation with family members would be the usual procedure. We have heard stories of a corpse either left on the ground for hours or days until the ambulance picks it up or the family buries the corpse themselves, which puts them at tremendous risk of infection. 

5. MSF hired health promoters from the community and is training them to talk to their community members about prevention. Below are some health promoters who were just being trained.  This woman is a teacher who has not been working because school has been closed due to Ebola. She was not afraid, but rather excited to have a job and talk to people about prevention.  As Fernanda said: "[The prevention work is] what needs to be done at the level of the community. We have to close the tap. We don’t want more transmission, we don’t want more cases. But.. we cannot reach that tap from here (the treatment center). We need to empower people to be part of the solution to their own problems." We have heard that health promoters have made a difference in reversing the tide of this outbreak and hope to see them in action soon.