Contagious Conversations / Episode 11: Humanitarian Aid Beyond Borders
Creating a safe space for patients in conflict zones
Obstetrician-gynecologist and physician Dr. Rasha Khoury shares her experiences with Doctors Without Borders: a international humanitarian organization that provides medical aid where the need is greatest, and the recipient of the CDC Foundation's Fries Prize for Improving Health.
Below: At "Even War Has Rules," the October 2016 remembrance event for the bombing of the MSF Kunduz trauma center, Dr. Khoury exchanges the microphone with deputy field coordinator Salamat Khan.
Transcript
Pierce Nelson: Hello, and welcome to Contagious Conversations. I'm your host, Pierce Nelson. Every episode we hear from inspiring leaders and innovators who make the world healthier and safer for us all. Contagious Conversations is brought to you by the CDC Foundation, an independent nonprofit that builds partnerships to help the Centers for Disease Control and Prevention save and improve more lives.
Joining me today is Dr. Rasha Khoury, a physician in the Bronx, New York with a focus on global maternal health. Dr. Khoury has completed six Doctors Without Borders surgical missions in Afghanistan, Iraq, Lebanon, Cote d'Ivoire and Sierra Leone. She also serves on the organization's U.S. board of directors.
In this episode, Dr. Khoury shares her experiences with Doctors Without Borders, a humanitarian organization that provides medical aid where it's most needed. Doctors Without Borders is the recipient of the CDC Foundation's Fries Prize for Improving Health presented at the American Public Health Association annual meeting. Welcome, Dr. Khoury.
Rasha Khoury: Thank you so much, Pierce. Thank you for having me.
Pierce Nelson: So, Doctors Without Borders, as I mentioned, recently received the prestigious Fries Prize for Improving Health and that recognizes the organization's incredible work doing the most good for the most people across the globe. Doctors Without Borders is an organization many people have heard of but may not know much about its work. What would you like for people to know about Doctors Without Borders?
Rasha Khoury: You know, one of the things that defines Doctors Without Borders as an organization and is often not known by the general public is that we're an organization made up of its members. We have an associative model. And that means that each one of our staff members, no matter where they're working, has an equal say and an equal voice in the organization.
This really helps us shape our medical aid to be both high quality and to be accountable to the communities that we serve. We work in more than 70 countries in the world and we're really responding to medical emergencies that are absolutely based on need and not based on government call or request from a certain group.
Our principles, which define the organization, and which the organization is very committed to, really allow us to continue to work with integrity. So, the main principles I think that people might know about, principle of medical ethics, independence, neutrality and impartiality are really what allow us to remain financially independent, financially healthy in order to serve some of the most vulnerable people around the world.
It helps us be very reactive and adaptive. It helps us really learn and be iterative in our service delivery. And I think it's what keeps us honest and person-centered in the care that we deliver.
Pierce Nelson: That's great. I'd actually read that these principles are actually one of the things that attracted you to Doctors Without Borders in the first place. And you've now done six missions with the organization and sometimes I know that missions are in uncertain or even dangerous circumstances. Can you tell me a little bit about what moves you to serve as a physician with Doctors Without Borders and putting yourself at risk potentially?
Rasha Khoury: Yeah, absolutely. And I should say that I am, in many ways a minority in the organization. The organization is primarily made up of people working in their own countries, in their own communities, in their own context, serving their own society in many ways. And we make the differentiation between national staff and international staff; and upwards of 85 percent of our staff are, or sometimes 90 percent of our staff, are national staff working in their own community.
So, as an international staff and as a doctor, I remain a minority in the organization, which is primarily made up of many, many, many allied and support staff that allow our projects to exist and function.
But I actually went to medical school because I wanted to be a medic with Doctors Without Borders. I was introduced to the organization growing up in the Middle East, and what fascinated me about them was their nonviolent focus. So, we are an unarmed organization.
Everywhere we work, even in the highest places of instability and conflict, we don't have any weapons and we don't allow any weapons in our facilities. One of the main logos that people know MSF by the no weapons logo on our vehicles, on our hospital buildings and clinic buildings.
And this idea of serving people in the most precarious contexts in a nonviolent way, in a nonviolent space, and creating a safe space for patients, regardless of what side of a conflict they're on, really attracted me a great deal. The idea that you could be in solidarity with people who are living in really frightening and unstable spaces and not shying away from that out of fear. I wanted to be part of those teams and in those groups of people.
So, I went to medical school knowing that I wanted to work for Doctors Without Borders and when I eventually joined sometime after my medical training, it was really a dream come true. I always was drawn to the part of medicine that treats some of the most vulnerable populations and that's what drew me to women's health, and especially women's sexual and reproductive health.
And so, I work for MSF, or Doctors Without Borders, as an obstetrician-gynecologist, and most of our work is really around emergency obstetrics. When I'm in the field in a project, that's primarily what I'm doing. It just so happens that in areas of widespread epidemic like Ebola, or war, or displacement, like Afghanistan and Iraq, some of the highest needs are the needs of women and children, women and newborns.
And so there is an abundance of work in these kinds of projects. And often, when you're in these projects, it's not that you forget about the war, the conflict that's going on, but you're so focused on delivering excellent care and really helping people survive and thrive, and survive, certainly, a critical illness or a critical pregnancy event, that you feel bolstered by that service and also bolstered by the team that you're working with.
And so, I can't remember a time that I was physically afraid in these contexts. And I think that's what helps you, the sense of solidarity, is what helps you take on that risk, certainly among many other coping strategies.
Pierce Nelson: That's fascinating. And I know that you were in Bo, a city in Sierra Leone in 2014 when the Ebola outbreak started. What can you tell us about your time there? What you saw, and then, how you reflect back on that time today.
Rasha Khoury: Yeah, that's a time I will never forget. It was my first mission with Doctors Without Borders. And I had previously been in many resource-restricted settings in various capacities. But that was the first time where I was the specialist being sent there to work with the team. Sierra Leone, as you may know, is one of the most dangerous places to give birth in the world, and maternal mortality in our project in Bo was quite high, consistent with the country numbers.
So, I think in my very short time there, which was almost two months, we had nearly eight maternal deaths. And that's a staggering number.
Pierce Nelson: Yeah.
Rasha Khoury: I was sent as an emergency obstetrician in a maternity and pediatric, one of our largest maternity and pediatric centers, that has since closed because of Ebola. It was at the start of the epidemic, and as the epidemic approached Bo and really started to affect the community, it was a very big challenge for the facility and the team to continue to deliver excellent care because it became a challenge, in terms of triage and identifying cases of Ebola, in reaching out to the community to educate about Ebola signs and symptoms and the need to really have people in isolation centers where they're receiving appropriate care, but also protecting their family members from becoming infected.
As you can imagine, emergency obstetrics, where there's often a lot of bleeding and hemorrhage, it can be complicated to tell whether somebody has Ebola or doesn't have Ebola, and complicated to treat them in a way that is dignified, but that still protects the staff from becoming infected.
It was a very trying time and it was very difficult for the team, for the community, for the organization, to decide what to do. And ultimately, we decided that for the safety of our staff that we really needed to transition from an emergency obstetric and pediatric facility to Ebola treatment.
Not evacuating or forsaking the community in any way, but really transitioning to Ebola detection and treatment and doing a lot of community outreach. At that time, my emergency obstetric services were no longer required, and so, I was sent home. But when I think back on that, it was a very frightening time, certainly, for many of us.
You think about sometimes Doctors Without Borders, you think about war and conflict and very visual threats, and Ebola is something that's, in many ways, stealth, undercover, is impacting communities without communities really knowing about it. It was quite frightening.
Also to feel responsible for a team, a team of midwives. It's a team of nurses, of housekeepers, and to think, "Okay, how can we keep people safe while at the same time not forsaking patients in any way?" It was a very, very big challenge and I think we learned a great deal from the 2014 epidemic, and are using much of the lessons we learned in order to serve the current epidemic in the DRC.
Pierce Nelson: Yeah, I think there's so many organizations that learned quite a bit during the last Ebola outbreak in West Africa and I know it must have been difficult as well because so many diseases actually look like Ebola, but they actually may be something else and, how do you discern between that? That makes it very difficult as well.
In addition to Sierra Leone, I know that you were also in Khost in Afghanistan, which is not far from the border with Pakistan, working with women and performing deliveries for pregnant mothers. And I believe that your team performed more than 23,000 deliveries in one year alone with four maternal deaths. That 23,000 number is really a very large number. And can you talk about the challenges that your team faced in delivering children and caring for pregnant women in this part of the world?
Rasha Khoury: Yeah, absolutely. I would say Khost, Afghanistan is one of the projects I'm most proud of that we operate in MSF. It is in the eastern province of Afghanistan, as you mentioned, on the border with Pakistan, which is a quite porous border. It's a very large Pashtun community. And the only reason I mentioned the porousness of the border is people are coming back and forth across between Pakistan and Afghanistan.
It's a quite rural area and it's quite arid. Interestingly, in the last few years, it's been heavily impacted by, not just war, but also climate change, a drought. And so, we've seen a lot of displaced people due to that and it contributes to the very large population that we serve.
You mentioned 23,000, and just to put that in context for people who might not be as familiar with obstetrics, in most U.S. hospitals, on average, deliveries are about 2,000 per year and in Khost, we were doing approximately 2,000 deliveries per month. And MSF was one of the only existing, what we call comprehensive obstetric and newborn care facilities. So we operated a blood bank, an operating theater. We had 24/7 service delivery with midwives, obstetricians, or doctors with obstetric skills, pediatricians.
And so, we were able to receive people at any time of day or night that they arrived, and in any state that they arrived, and we were able to deliver life-saving care. We cooperated a lot with the local provincial hospital, which was designed to be a comprehensive center but often was lacking in staff, supplies, and certainly did not always offer free care. Just to mention to the audience, MSF delivers all care for free and that's one of the ways to eliminate barriers to access.
We also, in Khost, did a lot of support of community health centers and a lot of collaboration with the public health sector and education to the private health sector and that was a way for us to really intervene across the province. Khost has about 13 districts and around 1.5 million people inhabiting the area on average.
And so, we were able to support the peripheral centers that might have been closer geographically to people where it might have been unsafe to travel, to get to the MSF facility. We equipped them with supplies, with training of their midwives, often with solar panels and generators, and safe water and waste disposal stations, so that women who arrived there were able to also receive safe delivery. So, on top of the 23,000 that we physically cared for, we supported around between 200 and 300 deliveries in some of the community health centers and that was a huge contribution to the community.
Pierce Nelson: Wow, that's really amazing and I would imagine in your experiences with Doctors Without Borders, I know that you've been through some difficult, and I'm sure, trying circumstances. I'm also imagining that there are experiences where you really felt joy for a patient and for the work that you were able to do. Can you share one of those experiences?
Rasha Khoury: Yeah, absolutely. The joys are more than the pain. Of course, the sadness of losing a patient, or losing a neonate, or really having a patient who suffers a complication, are things that never leave your mind or your heart, but the joys are daily.
And I will say one of the stories that never leaves me, I just recently came back from Afghanistan, after a seven month stay, and that was my second time in Khost. I'd previously stayed for about six months a couple of years ago. And something happened that had never happened to me before, which is very unique in a humanitarian setting. But I cared for a patient in 2016 who was a mother of five children and had had a home delivery because she couldn't safely travel by night to arrive at a facility.
And after her home delivery, she bled a great deal and was brought to us around five in the morning, to the MSF hospital in a critical state after suffering a hemorrhage and being in a state of shock. We needed to operate for several hours and transfuse her almost 15 units of blood.
Ultimately, we had to remove her uterus to save her life and she spent around two weeks with us recuperating in the hospital and the first few days were very much critical and there was a lot of family meetings to update and reassure. And then, she started to turn the corner and really gained back her strength, was able to walk in our garden, to eat our food, to be excited to go back home to her baby.
I have a beautiful photo of her that she allowed me to take on the day of her discharge where she was sitting with her mother-in-law who had helped care for her. And two years later, when I went back to the project, I was in the caretaker area, which is the area where we really interact with families and are able to give updates.
And I saw her in the crowd and she recognized me, came over and gave me this enormous hug and she was a female caretaker for her sister-in-law who was delivering with us. And to be able to see somebody who you saw near death, and then, help them recuperate, but you never really know, after a patient is discharged, what happens in their life. And to be able to see her healthy and smiling and know that she was well two years later, it was really an indescribable feeling and an indescribable joy to know that you helped somebody really thrive and not just survive.
Pierce Nelson: What a great story. Thank you for sharing that with us.
We'll be right back with Dr. Khoury.
Since this is a show about Contagious Conversations, we want to hear from you. Each episode we ask you a question and this episode's question builds on the work of the committed team at Doctors Without Borders. Have you ever worked in another country to help address a local health or humanitarian need? If so, share with us your experience. Just email info@cdcfoundation.org to answer. That's info@cdcfoundation.org. And if you share your thoughts with us, you'll have the chance to win some CDC Foundation merchandise.
And now, back to our conversation with Dr. Khoury.
I want to take a little bit of a turn here because we've talked about the work that you did out on the front lines, out in the field. And now, you're actually a board member for the U.S. operations for Doctors Without Borders. Do you see the organization differently now that you're on the board versus being on the frontline and, if so, can you talk a little bit about that?
Rasha Khoury: Yeah, absolutely. So, I joined the board in May of this year and it's the board of the MSF USA section. We're actually one of the largest sections in the movement. And just to explain that MSF is a global organization, obviously, with staff and members all over the world, but also offices in different parts of the world, mainly European centers, although there's a very big movement now to diversify and decentralize our operational centers.
The MSF U.S. section is really a huge motivator of funds and fundraiser for the movement. We contribute around a quarter of the budget for global operations, and I joined the board because I was looking for a way to contribute to the organization now that I have to be physically in New York for some time and I wanted to be able to continue to meaningfully contribute.
It's absolutely a very different lens. It's much more of a helicopter lens to the organization. It's much engagement with the budget and the finances, and I think one thing that makes MSF unique, in terms of the financial independence, is also that most of our fundraising really comes from private individual donors, and these individual donors are people we cannot feel enough gratitude towards, but we really work hard to be accountable to the spending of these funds.
More than 90, 89 to 90 percent of the fundraising is spent on programs, so on service delivery to beneficiaries and patients. And this is a huge, very important point of how the organization operates. And one of my main functions as a member of the board is to remain accountable to our donors and accountable to our beneficiaries.
I think it's interesting to be a very recent field worker who's on the board because you bring a different perspective and I appreciate that people are interested in that perspective. We're really working hard to diversify the board, in terms of age, race, ethnicity, gender, and I think that makes us also unique in many ways.
It's also nice to be part of the thinking on strategy and direction of the organization. We're a quite large organization and, how do you maintain your adherence to your principles, but also, how do you keep your patients in focus, and how do you amplify the voices of patients and the voices of staff all over the world? And I really enjoy being part of those conversations.
Pierce Nelson: Yeah. So, you mentioned that you are in New York for some time and also serving on the board of Doctors Without Borders. Do you see yourself going back into the field at some point?
Rasha Khoury: Yes. Absolutely. I think I'm a field worker in my heart. I absolutely see it as part of my professional life for a very long time. I usually tell people when I do recruitment sessions for MSF is, I really see MSF as part of your life cycle. There are going to be times in your life that you need to support elder family members or children, and maybe you can't physically be in the field, and then, there are other ways to contribute.
And then, there are other times where you're much more free to move. I have now done six missions, and so, I have more flexibility, in terms of the timing of the missions and the length. But absolutely, I will be back in the field. I think, especially as an obstetrician, my skills are needed. Being a female obstetrician and being multi-lingual makes me a bit more versatile in the field, in terms of where I can go.
I also appreciate that when I'm not in the field I can really be contributing actively besides the board. I serve on the telemedicine specialist platform, which is a huge service we provide to the field. So, it's access to all sorts of different kinds of specialists that exist all over the world. And almost every day, just today I was consulted on a case from Kandahar, from Afghanistan, from Somalia, from Bangladesh, and it's teams in the field asking for practical, and real, and real-time advice on patient management.
And it's a way to really bolster the quality of the care, and also to be in solidarity with the team when they may feel stuck with a certain clinical problem and looking for advice. So, what I love is feeling constantly connected to the field and knowing that I will be back.
Pierce Nelson: So knowing that, are there any areas where you're particularly interested in going? Either returning to places you've already been or additional areas where you have an interest?
Rasha Khoury: Yeah. So, places I haven't been that I aspire to go are the Democratic Republic of Congo and the Central African Republic. And those two locations, because they're very precarious contexts where women are suffering disproportionately to other parts of the population, where there's a huge burden of pregnancy complications from either unintended pregnancy, unsafe abortion, and where there's a skilled workforce that needs further capacity-building.
Those are both contexts where our teams are quite large and where they really benefit from having specialist skills available in order to further guide, to build skills, to ensure that there's an evidence-base and protocol-following in order to deliver the best care to patients.
There are also two contexts that I haven't been in and I'm always searching for more opportunity to be humbled by the situation, to learn, to grow in different ways. I am partial to the Middle East and I would also love to go back to Iraq where I was in Mosul. So, there are definitely many, many different places that I'd like to still participate in.
Pierce Nelson: What advice would you give to someone who has an interest in serving with Doctors Without Borders? Is there any type of advice or guidance that you would offer to them?
Rasha Khoury: Yeah, absolutely. I think one of the main things to say to people interested, please know that you don't have to be a physician or a doctor to work with Doctors Without Borders. We're always in search of nurses, midwives, pharmacists, architects, water sanitation experts. And so, our team is made up of a really multidisciplinary group of people. So, don't shy away if you're not a physician.
I think it's very important to have really done a lot of self-reflection and introspection on why you want to work with Doctors Without Borders. I think the people who do best in the organization are people who are really driven by the social mission, and not by alternative motives, but also I think a deep sense of humility, of respect for the populations that we're serving, of commitment to really the highest standard and quality of care.
The importance of acknowledging people's humanity and dignity when we're in the field and really thinking, this is not an organization where people are cowboys. It's really a place where we're working as a team and there needs to be a cohesiveness in the field.
So, for example, when I'm talking to medical students or midwifery students, I'm always encouraging people to have as many experiences as possible outside of their comfort zone, in their own training, in their own professional life. Whether that's working in... things I did in medical school, for example, working in a clinic, a jail clinic, for women, working in a homeless prenatal clinic, working in a refugee and asylum seeker clinics.
I also spent time working in South Africa and am MDR HIV joint treatment facility. I think really trying to go outside of your comfort zone, whether culturally, professionally, from a socioeconomic and class standpoint, because I think it helps you build the skills you need to really be a value-added in the field with an organization like MSF.
Pierce Nelson: One of the things that you said there that really stood out to me is this idea of respect for the population. Not going in necessarily with all the answers, but going in with expertise, and then, being able to really apply that into the situation that you're in. That's a great point to make.
So, based on your work and experiences that you've had, both with Doctors Without Borders and beyond that, can you discuss the role of collaboration and how that's made a difference in your view in improving the health of patients who are addressing a tough health challenge?
Rasha Khoury: I think you can't underestimate the importance and the value of collaboration. So, really moving away from siloed care delivery. So, the mistake of much of the international humanitarian and NGO community is to really come in and have a preset template and try to deliver that care in an area without collaborating with places like the ministry of health, or like local NGOs, or other local actors.
I think when you do things like that, it takes away from how much you're learning about the community and it also takes away from your sustainability, and from the sustainability of your intervention. So, for example, in Iraq, and in Mosul, we collaborated very strongly with the department of health and, of course, it depends on the precariousness of the situation and what kind of population you're serving.
And you certainly don't want to exclude anybody with medical need because of political status. That's one of the mainstays of impartiality and neutrality. And so, you want to collaborate smartly with organizations where you maintain that you're addressing the medical need of all people who have that need.
But working in strong collaboration with existing health structures, I think, also gives you more legitimacy in the community, can help people see that when you're no longer there as an organization, that their needs are still going to be met in a real way. In Mosul, we ended up handing over our maternity and trauma facility to the department of health and they continued that work and much went into that collaboration, and to support the maintenance of their supplies, and their staff, and their salaries.
In Ebola context, we're working very strongly with, not just local, but international NGOs and other responders because if you don't do that, you lose the ability to really analyze the context to understand other barriers that people are facing.
Patients also are beneficiaries in certain localities. They can't always tell the difference between who is MSF, and who is ICRC, and who is a local NGO. Often, you're hiring local staff, and so, you really need to make sure you're collaborating with people so that you're one front of medical humanitarian aid to patients, and people feel safe to come to any one of these facilities.
In a lot of our projects we're focusing more and more on outreach into the communities and not just remaining bunkerized in our, whether there are basic or comprehensive, hospital facilities, but really going out, sending teams out to do outreach, to do health promotion, to do sensitization, whether that's about how to detect Ebola, or whether that's about danger signs in pregnancy, and the importance of recognizing these signs and bringing people to care when that care is needed.
And I think, without collaboration, there's no real way to do that kind of outreach. In Afghanistan, for example, we collaborate a lot with community elders, with religious leaders, with village schools, mosques, health centers, and it's a way also to have visibility in the community and a way to a bit demystify the objective. So, to be very clear that the objective is serving a medical need and not a religious or political influence in any way.
I think that more and more we're understanding the value of collaboration and exchange. Also, the ability to share skill-building. For example, in Afghanistan we did a lot of training for public health staff, came to us from Afghan hospitals and health centers. And that was really a way to also invite people into our facility and show them what kind of care we provided and how person-centered care and dignified care can be done, even in places where we might not have a lot of resources. And I think that's very important.
Pierce Nelson: I think a message that I heard coming through from you, and while you didn't use these words exactly, is this idea of collaboration and using that as a way to strengthen systems for the present and for the future. And that's something that we at the CDC Foundation, and our work with CDC, feel very strongly about is the idea of, in the work we do, being able to go in and work collaboratively and leave systems stronger for the future. That's something that's very important to us. And it sounds like that's something that's also important to you and the team at Doctors Without Borders as well.
Rasha Khoury: Absolutely. And it's also a way to maintain institutional memory, in many ways. You become accountable to your collaborators and to your external partners. You're maintaining a certain set of service delivery, or a package, and people are holding you to that. And I think that's a very good thing, that it's not dependent on an individual being there or not being there. But it's really, as you say, the system and the team.
Pierce Nelson: Well, Dr. Khoury, thank you so much for joining us today. It has been a real pleasure speaking with you.
Rasha Khoury: Absolutely. Thank you so much for having me, and thank you for the support to the organization.
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