How MSF maintains neutrality in conflict zones
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Welcome to the Medicine Science Podcast from the BMJ. I'm Cameron Abassi.

This week we're at the World Innovation Summit for Health where we are a media partner and the meeting is focused on conflict, equity and resilience. In that vein, we're joined by Christos Christou, head of Médecins Sans Frontières, to talk about attacks on healthcare staff. Even if we are taking care of your enemies, we are not your enemy. That's how we interpret neutrality.

Aradazi, surgeon, executive chair of the WISH Conference and author of the recent review of the NHS, also joins us to talk about another area of his focus, which is antimicrobial resistance. One in five deaths below the age of five is attributed to AMR.

And finally, we'll move to the US and hear about new research into adverse events during surgery. 25 years since the original Harvard Medical Practice study, and many interventions have been put in place in terms of improving safety, but we wanted to see how much things have changed. But first, conflict and health. In last week's podcast, we heard from WHO about attacks on healthcare, where it's happening and why it's unacceptable.

Today I'm joined by Christos Christou, President of Médecins Sans Frontières, who work in conflict zones and are known for their impartiality. How is it possible to retain that sense of neutrality when you're seeing the extent of violence, damage, death and deprivation of basic human rights that you're seeing in Gaza?

That's an excellent question. That's a new question. It's a question that keeps bothering us, I would say, since the beginning of this organization. And we found ourselves in several different contexts where we posed this question to ourselves.

As a medical humanitarian organization, we are driven by the medical ethics and we have guiding principles. As you mentioned, neutrality being one of them, impartiality and independence. When you are independent, which is extremely important, and thanks to all the support by our supporters, millions of them, you can impartially assess the needs of the people.

And then be there, be that a conflict or a tricky situation and say I'm here for everyone, I don't take sides, my hospitals are neutral, the patients are patients, they are not combatants, we don't have weapons inside the hospitals. And we see that medical staff many times treat even people that they may have attacked or killed their families.

So we know that we are the doctors and we should not be seen as enemies. Even if we are taking care of your enemies, we are not your enemy. That's how we interpret neutrality. But at the same time, which is very important,

Our two main pillars are medical action that comes first and "témonias" bearing the witness, telling the stories of the people, carrying the witnesses of them, the testimonies. So neutrality in MSF and in all these contexts means a lot of things, but neutrality does not mean silence. That's really interesting. So what you're saying is that

The neutrality, of course, applies to giving equal care and support to people from all sides that are involved in any crisis or conflict situation that you're trying to help. But then you're also bearing witness. I want to talk a little bit about that in a minute. But one thing, one way that people interpret medical neutrality is that they believe, certainly several medical organizations that I can think of,

think of it as they cannot then be critical of any of the parties in that particular conflict.

And to my mind there's a distinction there. Would you agree with that? Yes, I see your point here and I wouldn't disagree of course because every time when, as I said before, you come with the medical action first, you need to negotiate access. How are you going to access these people that they need you? And we treat this with countries that they want their sovereignty. They want to tell you how and what to do.

So this is an ongoing negotiation. Sometimes you may compromise of how much critical you may be, but bearing the witness and actually telling the stories of your patients is something that to at least themself sounds like a moral obligation. Okay, and in terms of bearing witness, I think that might be something listeners aren't as familiar with, but it sounds very, very important. In what ways are you doing that?

That's an excellent question, because there are plenty of ways, and I understand that sometimes there is a blur zone between being medical but also defending human rights, and I know how they intersect.

However, we are medics. We are doctors. We have medical data. And our reports have medical data together with patient stories. So we establish a narrative there, which says clearly what we see in our emergency rooms and what we also hear by the people when they are saved and they want to go back to their home and what they tell us.

Yeah, so you're combining narratives with the data that you're collecting. Medical data. Yeah. And all our advocacy is based on the medical data. Okay, okay. And what we're seeing in Gaza is destruction of healthcare facilities, deaths of health professionals and civilians, which are in breach of Geneva Conventions and humanitarian law. Yeah.

This is not an isolated example, of course. You know, we've seen it's a common theme of conflict everywhere. It just seems to be getting more and more a feature of conflict. How do we stop this from happening? How do we hold people accountable? How do we make sure that the existing laws and conventions are adhered to?

As you said, it's not just Gaza. Gaza is a small and very intense place and there of course we see the magnitude of the problem.

As I mentioned before, our reports from Gaza and our reports these days and what happened and has been happening in Sudan for more than a year now tell more or less the same stories. There are severe atrocities happening, violations of the international humanitarian law, attacks on the hospitals. And I understand that

At this moment, we suffer by this impunity. We should not accept that, we should not tolerate that, we should not use these different standards because what we say as MSF is exactly what we said in Ukraine, and this is what we say these days in Gaza, and we want to tell also in Sudan. So having had a different approach by the international community in Ukraine,

Nothing in Gaza. How are we supposed to be lecturing, if I am allowed to say so, the warring parties in Sudan on respecting the ISL? Yes, yes, yes. That's in practical what happens. Yeah, yeah. It's a hypocrisy, isn't it? It is. It is. And...

You asked the right question. I think that's why MSF is also here and why MSF will be joining any kind of alliance of goodwill, any coalition that will try these days to show that...

An IHL should be respected. There are laws of war, and these are the only framework that enable us to work in all these places. And we want the states to hold themselves and the others accountable. We are not there, but we should not start reinventing the wheel. We are...

We don't need more statements and other commitments other than just the strong alliance and willingness by all of them to hold itself accountable. Yeah, so you say you're bearing witness, you're collecting the narratives, you're collecting the data. We have existing regulations, we have existing laws and conventions that should be adequate.

in this setting, but clearly they're not at the moment. What is missing? Well, this is their political will, is that right? Exactly. I mean, you're asking me the question, but it's really to say to you is that, you know, there are kind of billions of people, I guess, around the world that are very grateful for the work your organization, similar organizations do in places like Gaza and Sudan and elsewhere.

But I think there's a sort of sense of frustration and disbelief and lack of sort of hope in the system that we have will move from the narratives that you gather, the data that you gather, to actually implement those conventions and laws and that there will ever be the political will that's required. Do you sense that...

that might change? And if so, what is the mechanism for that changing? And I know you're not a political organisation, but this has to stop. Yes, and I'm usually reluctant to respond to these kind of

political questions because I really don't have all the analysis, but we are so much involved in this at this moment and we have been so much impacted and affected by all this. I follow the discussion on the failure of the multilateral system itself. And I do believe that we have just to strengthen it, but we need also to reform it, to look at it again. It was established almost more than 80 years ago.

As it was said this morning in one of our panels, that time more than 40% of the world was still colonized. Is it fit and designed for today's reality? Maybe not. But we should not...

you know, just leave it and look for something else. We should strengthen that. At the same time, I think that we should count more and more in the civil societies and the massive movements outside there because, as you said, they are frustrated but they also have expectations from

All of us, not only civil society organizations, but also their politicians, to go back to the basics, to go back and defend humanity. And this is what is missing. And that's where an organization like MSF wants to focus in defending humanity with the basic language of that.

That it is not right to see civilians not be protected. That it is not right to see children dying, either killed by bombs or by famine in Darfur these days. And it's not right to have people in hospitals being attacked so massively and disproportionately. Yeah. Okay. I mean, we're here today talking at the World Innovation Summit for Health in Doha.

Have you, and conflict has been one of the themes of this conference, are you coming away with any hope, any kind of new directions following the conversations here?

I still hope, but I would like also to come out from this room with some more optimism, which I have not gained yet. I count a lot on these days' discussions, those in the round tables, and I want to see if this kind of coalition of strong will really can be spread. I want to take something that will enable me tomorrow in my negotiations

negotiations, gaining access to this population and also gaining the basic safety, some guarantees that we can move. We can go back to those places that we had to suspend activities in Darfur. We can go back to Northern Gaza. We can go in all these places around the world that they need us. I don't have them yet. And I don't think that wish will give us the magic bullets for this to happen, but at least

We are in a place where we have so many leaders, policy makers, we have recommendations, we have WHO. Let's make something very practical for us on the ground for tomorrow. Christos, thank you for talking to us and thank you for the work you're doing. Thank you so much.

Now let's turn to antimicrobial resistance. So I'm joined by Lord Ara Darzi, who is Executive Chair of the Fleming Initiative. Welcome, Ara. Thanks for joining us. And we're speaking at the World Innovation Summit for Health Conference, where you've just...

launched a report on antimicrobial resistance. And I'm going to read a paragraph from a piece you've published in the BMJ with us about your work and about the report as well. And it begins pretty strongly. It says, antimicrobial resistance, AMR, is one of the starkest public health challenges of our time.

As bacteria evolve and develop resistance to treatment, antibiotics and other drugs become ineffective. This poses a threat that could reverse a century of medical progress. Without urgent action to keep antibiotics working, AMR could claim 39 million lives over the next 25 years. Now that's pretty stark.

That shocked me. I mean, we had some figures of around 1.2 million people dying a year and potentially 10 million dying by 2050.

year, but this is the cumulative impact if we don't do anything about it from now by 2050 we want to have 39 million of cumulative deaths that is a shocking number. Yeah, one of the first things I did when I started the BMJ a long time ago in 1997 was put together a theme issue on antimicrobial resistance and when I look back at that now we could almost republish that in the BMJ and

and just update a few of the numbers. But the problem still exists. It is that issue, that point about activating. The extent of the problem is well mapped and documented. The solutions are spoken of. It's getting that kind of, you know, getting action from the global community at every level. Absolutely. You know, citizen activation is the most important driver here.

This is not different than climate. No. It took 30 years, three decades to get to where we are today. And I think there's still a lot of work needs to be done on the climate. Yeah. This is so much well behind climate. And we need to engage in the public. We need to activate citizens. We need to engage kids in schools. We need to engage senior citizens. Actually, in fact, if you look at the mortality rates, the biggest areas or age groups is usually the elderly or the young. Hmm.

One in five deaths below the age of five is attributed to AMR. Globally. That is a tragic figure. Yeah. And certainly on the senior citizen side. So, yes, we should do that, but we're well, well behind. Okay. And in your paper that you wrote for us, and I think in the report as well that you've written for this conference,

You talk about three areas of focus, one of which is funding. Then you talk about diagnostics. And the next one is building a global movement. I think there are opportunities in the science, but it's very important to underline this. Science alone is not going to fix this problem. But science is critical in helping us get over socialization.

some of the big challenges facing us. One of the areas of science is the opportunities we have when it comes to AI and artificial intelligence. We hope it will enable quicker diagnostics. It will enable new drug discovery. It will enable more precise prediction based on the genotype and phenotype of the host and the bacteria in tailoring the right antibiotic with the right dose and the right time. So there is plenty of opportunities there.

The second one is diagnostics. We need point of care diagnostics. These technologies are available. They could be in clinics. We need to disseminate those innovations. If you go back to 2019, 20, 21, it was the test. It wasn't the vaccine. The vaccine got us out of COVID. But we lived for two years during COVID by a simple test. And we could do, you know, we're not short of innovations to do exactly the same.

point-of-care diagnostics for urine if you have UTI symptoms, sputum to make sure that you'd have a viral or bacterial infection. That, I think, from a scientific perspective, would be transformative. That's the bit that's difficult, isn't it? You know, when we say you've got to be careful with how many antibiotics you're prescribing, it's managing that situation where someone's worried about themselves or about a child or a family member, and they think they need an antibiotic.

but they don't get one. And you say, well, come back in a few days or whatever the situation is. And that's what makes it very difficult to implement. I agree with that. And I think that would make me anxious too, if I have a five-year-old who on a Friday afternoon, and I take the child back home without actually knowing whether they have a bacterial viral infection. But

innovation technology is here we can we can actually have a diagnostic test that could give you the results immediately yeah is there anywhere people are using diagnostics in the way that you're describing yes and where's that in many clinics outpatient clinics in europe us have that potential technology available to them actually in fact it's not the technology you go and speak to the syphilis

Danaher's, the big diagnostic companies, they have the diagnostic tools. But I think it's a historical thing. We spend 90% of our

budget on purchasing budget of medicines and diagnostics. 90% goes on medicinal products and 10% goes on diagnostic. That ratio has to change. Okay, in terms of funding in your piece for us, you say that the UN Declaration which you refer to, which recently was made in September, calls for a hundred million dollars to achieve a target of at least 60% of countries having funded national action plans on AMR

by 2030. Now you mentioned Covid. When we think back to Covid, that seems like a very small amount of money. Tiny amount. Tiny amount of money. So why is it a problem getting it? It's commitment. It's commitment of governments to invest in this. It's, you know, that's essentially the challenge because if we don't, if we don't at a country level have a very clear set of actions that is owned

locally and execute it locally, none of this is going to happen. Yeah, okay. But $100 million. Globally, it's a small amount of money. Absolutely. And we're talking about mostly oil and metal. But what you're speaking to is a problem that we're facing

You mentioned climate, you mentioned COVID. We could talk about conflict in the same sentence around this, which is getting people to think in a way that's outside their own political or national interests and think, well, here's a global, here's one of the major global health risks that we're facing in the 21st century. And we need to act together. What you say here, many countries facing the greatest threat from AMR.

may remain unsupported. Because of the constraints on the money. It's as simple as that. I mean, the problem here isn't just the diagnostic test and what you can do. We're talking about many of the lower middle income countries in which there is no physicians to prescribe. So you're essentially dependent on a patient going to the chemist

and with a set of symptoms and given probably no more than one, four antibiotics available, which are mostly generic, and they have access to one of them. And most likely, there will be some percentage of the population will have resistance to all of the four. So that's the situation you are dealing with. And so what can you do about that? Again, would you have a day where, I mean, remember the old

GE came up with this frugal innovation of a portable ultrasound that could tell a mum

whether the baby is breech or not. And if they are, they should get into an ambulance and go to a proper hospital. We might come up with technologies like that that might be able to tell you something about the sensitivity and even whether you are resistant to the, which could be done at the chemist. And why not? This is not as challenging as climate.

We can actually shift the needle here significantly. We'll link to the WISH report on antimicrobial resistance and Ara Darzi's BMJ opinion piece in the podcast notes. Ara, thanks for joining us.

Our final item is about research we've just published on bmj.com. In 1999, a landmark report by the Institutes of Medicine in the US referred to the Harvard Medical Practice Study from 1991, which set out the scale of medical harm in the United States.

3.7% of patients in their sample were harmed by treatment and 48% of those harmed were surgical patients. The new research we've just published on bmj.com looks at how things have moved on since then and whether anything has improved. Navjot Lada, the BMJ's UK research editor, finds out more.

So I'm Antoine Duclos, I'm an epidemiologist and I work with David Bates on this study while I was a visiting professor in Boston for a year but I'm used to work on patient safety since a while too.

I'm David Bates. I'm a professor of medicine at Harvard Medical School and the PI on this study. Thank you so much for joining us to talk about your research paper, which is in the BMJ and it's looking at surgical safety. And the results are fascinating, which we'll come to. I just thought perhaps we could start with a little bit about the background and why you felt this was important to study.

Yeah, we did the safe care study because it's been approximately 25 years since the original Harvard medical practice study. And many interventions have been put in place in terms of improving safety, but we wanted to see how much things have changed. And just for maybe our listeners who aren't familiar with that original Harvard study, what did that show?

The original Harvard study found adverse events in 3.7% of the patients hospitalized in New York State. And at that time, that figure was quite shocking. Okay. So can you tell us a little bit about the methods and what you actually did to study this, Antoine?

It was mostly based on an observational study design with the aim to provide a true description of surgical adverse event rates in Massachusetts Hospital. And then for that purpose, we used a randomized sample of a representative cohort of patients who underwent a surgery. And then they also had a rigorous evaluation and analysis of their medical record by nurses and physicians. Okay, so having done that, what did you actually find?

So there are two main reasons. The first one is that when we try to quantify the occurrence of these adverse events, so one third of patients, operated patients experience an adverse event during their inpatient stay. And almost half of those adverse events were classified as major adverse events.

and the majority were potentially preventable. And the other information we had from this study is that adverse events in surgical settings occur not only in operating room, actually, it's also occurring outside and mostly outside operating room, especially in hospital care units.

So these adverse events are also involving not only surgeons, but also all professionals involved in the patient care during their inpatient stay, which means nurses, residents, or others. So overall, it tends to suggest that efforts to improve patient safety should not only focus or be limited to operating with surgeons, but really encompass all the professionals involved in patient care during their inpatient stay.

Right, because I guess the things like the surgical safety checklist and that kind of thing have been a real focus of attention. But I guess from what you're saying, it needs to be more holistic than that. I think that one other key is that this is higher than the rate for all patients. The rate for all patients was about one in four. And the rate is even higher in this population and the types of events that people had were more serious.

Right. I mean, it's a really quite shocking and alarming figure. As you were going about the data collection and doing the analysis, what was your reaction to seeing these figures?

So I was not so surprised personally because I'm also working on other datasets in Europe and especially in France, and we are quite the same rates of adverse events in French institutions. So it's not so surprising at least the overall occurrence of adverse event rates because you don't necessarily have the preventability of those adverse events which require a very in-depth analysis of medical records that you don't have in routine practice.

David, can you tell us a little bit about the setting of the study? There are several hospitals in Massachusetts that we'd consider to be world-leading and the creme de la creme. Is that fair to say?

This was actually done in a representative sample of hospitals in Massachusetts. So it included some very big, well-known hospitals, but it also included some smaller hospitals. And we felt it was pretty important to include the full spectrum in this evaluation. Yeah. Did you look at different types of surgery? So was this elective surgery, emergency surgery, all kinds? Antoine?

So because it was a randomized sample of patients operated in those institutions, then it included both elective and urgent surgeries in many different specialties. We observed that the rate of complication is not necessarily the same from one institution

to another, which means that for a digestive surgery or for cardiothoracic surgery, the rates of a reverse event may be higher compared to orthopedics or urology or gynecology. But overall, in all those specialties, there was a pretty high number of complications. Yeah. And can you speak a little bit about the preventative

preventability because that to me is also one of the more interesting aspects of what you studied the fact that you can comment on the preventability how did you study that and what do you make of those findings as well?

So we had two independent physician reviewers review each case, and we looked for how much agreement there was. And again, 20% were definitely preventable, but there was an additional large amount that were rated as possibly preventable. And what we found over time is that when we evaluate adverse events,

Often things that we didn't think were preventable at one time have been preventable when we come up with new and different interventions. So given what you found, there's this high level of adverse events in surgical patients, many of them potentially preventable. Let's talk about some of the implications. David, what do you think are the key takeaways for clinicians?

So I think first of all you should consider whether or not to do surgery in the first place. In most instances it's clearly indicated but I think this represents an important call for tracking how many adverse events are occurring, making that information available to patients and then putting in place things to try and prevent these in the future. And then maybe you can talk a little bit about what actions policy makers should consider.

Yes, I think it's important to have better approaches for tracking these adverse events and then making the rates of adverse events publicly available so patients can understand what sort of risks they're taking and whether, for example, one institution is doing better than others in this regard. Yeah. Clearly, this is something that will need monitoring and ongoing study. Are there any advances that might help with that?

The way that this should be done in the future is to go through the electronic health record and look for things that suggest that an adverse event may have taken place. Most of these are recorded today in the electronic health record, and we have not used that as well as we should to find adverse events. But that is increasingly becoming possible, especially with tools like large language models.

You can capture a lot of information with the information already available in the hospital data warehouse. The question is maybe about the validity of those information and the signal detection. Is this a true or false signal when you have a higher or lower rate of adverse events?

But we shouldn't necessarily only focus on the metrics. Metrics is just a pretext to be interested about patient safety. It is very important, definitely. But then if it's not the perfect metrics, if it's close to the perfect metrics, it's still usable and interpretable to detect some signals for improvement. And that study, Safety of Inpatient Care in Surgical Settings, is available on bmj.com.

That's it for this week. I'll be back next week with David Miliband, President and Chief Executive of the International Rescue Committee, which was originally founded by Albert Einstein. Subscribe to our podcast so you don't miss out on that. Until then, I'm Cameron Abassi. Thanks for listening.