MSF Holland

by Jeremy Shoham

My interview with Saskia van der Kam from MSF Holland didn't start well. I turned up at the offices I had been visiting in Amsterdam for over 10 years only to find it wasn't there. It took a while to convince myself that it really wasn't there and that MSF had in fact moved since my last visit. After some judicious use of the mobile phone and a couple of calls back to the office I managed to find out the new address. Saskia, who I have known for years, met me at reception to tell me that they had in fact moved offices over a year ago. I made a mental note to read my emails properly in future.

Saskia joined MSF H in 1994 as assistant to Kurt Ritmeijer who was the nutritionist at the time. Prior to this she had been working for the MoH in Burkina Fasso seconded by WHO. She began working for MSF Holland on an hourly basis doing a range of work from analysing surveys to preparing briefing papers. She was effectively on call. During Kurt's tenure as nutritionist there was a lot of internal discussion over whether MSF should remain a predominantly medical agency or broaden activities to include linkages between health and nutrition. Fortunately, Kurt's view that 'sick people needed food to get better' prevailed. When Kurt became the health advisor it was natural for Saskia to replace him as the nutritionist. For a period, Saskia was joined by another nutritionist - Austin Davis, who later went on to become Director of MSF Holland.

Saskia explained that MSF H and MSF Belgium were set up as 'an independent clone' of MSF France in 1984. Their first mission was a joint MSF H and MSF B programme in Chad. This was followed by an independent MSF H programme in Darfur. MSF Holland nutrition activities basically started in the form of nurses obtaining as much food as they could and handing this out at feeding centres to starving children. More formal selective feeding programmes were implemented in Khartoum in 1988 for the IDP camps. The first really professional and protocolised selective feeding programmes were probably implemented in Somalia in the late 1980s and early 1990s.

Air drop damaged grain sacks

Saskia identified a number of key learning points in MSF's nutrition programming history. The large number of severely malnourished adults during the Somalia civil war (1991/2) were a real shock to the agency and forced them to think through a new set of nutritional protocols for adults. A year later in Liberia and Sierra Leone MSF H were forced to implement large SFPs and TFPs in open situations. These programmes "really honed MSF staff professional and management skills". The 1998 famine in southern Sudan led to the realisation that perhaps MSF were too focused on individuals at the cost of the family and that MSF needed to consider "larger amounts of food aid programming", i.e. blanket SFPs and GFDs. The experience taught them that waiting for advocacy to work may not always be a good strategy, i.e. WFP may not come up with the food in time. Saskia also remembered Wau in southern Sudan in 1998 as the occasion when MSF had to come to grips with extensive adult malnutrition. The technical expertise of Andre Briend, Mike Golden and Steve Collins were instrumental in dealing with the problem. During the Afghanistan crisis, MSF learned that nutrition surveys based on MUAC measurements cannot be used as an advocacy tool and that outsiders expect more nutrition and health linkages in programming. Also, the blanket supplementary feeding strategy as a stopgap measure needs to be reviewed as general ration food aid cannot always be relied upon, i.e. it is out of MSF's control.

According to Saskia the work of Briend, Golden, Collins and Warterlow has shaped much of MSFs thinking in the nutrition field while initiatives like NGO-nut and Field Exchange have also been vital for lesson learning.

A critical issue for MSF has been the tension around general ration provision. The lack of control over GFDs with implications for the success of SFPs and TFPs has fuelled much internal discussion. The three main MSF sections have disagreed about this. MSF H have always been reluctant to get into large scale food aid in the belief that they would not have the capacity to do a good job preferring instead to focus on assessment and advocacy. MSF France on the other hand set up a unit specifically to implement GFDs. However, the few experiences of MSF France did not turn out well. Saskia identified the lack of expertise and capacity on the food security side, i.e. inability to undertake detailed food security assessments, administer GFDs or other food security interventions, as a major weakness of MSF Holland. "Implementation of family rations for children in feeding centres was a compromise for MSF and an easier type of programme to handle".

MSF H feeding programme

Current thinking within MSF H is that there is a need to strengthen medical /nutritional progammatic linkages and that the technical backup for this is weak. Key areas are AIDS/TB, Kalazar and malaria programming. MSF plan to develop the nutritional and curative side of treatment in tandem. A lot more can be done with nutrients during treatment of HIV and TB while drugs for malaria will work more effectively with well nourished children. MSF UK are currently supporting MSF H in their efforts to develop nutritional protocols alongside anti-malarial combination therapy. MSF are developing nutritional protocols as they go. In a Kalazar programme in Wau MSF applied TFC protocols with severely malnourished adults (Kalazar leads to substantial wasting). It worked well amongst this pastoral population who were used to consuming milk while in Ethiopia the same approach was not so successful. The emerging view in MSF is that normal or slightly modified diets respecting local habits should be used for this type of programming.

Saskia stated that while MSF are an emergency organisation they do work in long-term crisis situations like southern Sudan. "Is this still an emergency?" she asked. Also, as a medical agency MSF is now moving towards viewing HIV/AIDS endemic areas as emergency affected.

While MSF sections work closely together in developing policies and approaches through meetings and discussion their operations are separate. Saskia reckons that there are substantial differences between MSF France and MSF Holland. For example, MSF France employ a large number of doctors and nurses so that their programmes are essentially curative, while MSF Holland has a more 'public health' approach. In terms of agency culture "the Dutch are more formal in meetings (a bit like the English!) - they want action points". "The French are more emotional, are reactive and always find a solution. They just jump in and work it out as they go while the Dutch tend to be more cautious, analytical and less vocal. There are pros and cons with both approaches".

MSF H supported camp

A unique feature of the MSF organisation is that 50% of funding comes from the public with 50% from major donors. Public money, although dwindling of late, is raised through the lottery and churches, etc. This allows a lot of autonomy and the ability to start a programme when MSF wants to start it. This is one of the reasons why MSF is often the first to arrive in an emergency. However, the common misconception that MSF 'goes it alone' is not really fair as MSF nearly always work with appropriate government ministries. Another feature of MSF is that humanitarian values are at its core and that it is decidedly non-political. MSF will not denounce parties unless humanitarian interventions are being compromised. Advocacy is based on 'temoinage' or witnessing and reporting. Lots of other agencies make political statements but MSF will go out of its way 'not to blame'.

I asked Saskia what have been the turning points in 'her' professional life. She found this question quite hard. After a while she singled out her experience in Wau where she had never witnessed anything like the level of adult starvation. She said that she had to consciously "turn off" in order to keep working. She also cited her experiences in Liberia, Darfur and Afghanistan where the bravery and self-sacrifice of local staff never ceased to amaze and move her. In Liberia health staff literally came 'out of the bush' having experienced appalling deprivation and suffering themselves to start to administer to others. In Darfur local staff were at particular risk from militia but continued to work. The same was true in Afghanistan where under the Taliban people risked their lives by collaborating with MSF.

Over the years I have known Saskia as a tireless worker for MSF and as someone who will always take time out of her demanding schedule to attend meetings and workshops in order to move thinking and practice forward. Her contribution to this process has been substantial.