Epicentre

In 1986, MSF France’s General Assembly voted to create a structure in charge of training MSF volunteers. This association, called CIREM (Centre d’Intervention pour la Recherche et l’Epidémiologie Médicale/ Intervention Centre for Research and Medical Epidemiology), had three objectives: public health training, provision of scientific support to MSF missions, and scientific networking.

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General Assembly Flash, MSF France, 18-19 April 1986 (in French)

Extract:

Il) Training

To improve our international credibility and the effectiveness of our field work, the training effort initiated in 1985 should head in several directions: funding of training courses in France and abroad and creation of a training unit specific to Médecins Sans Frontières. This training centre must create specific learning programmes, with priority given to MSF staff, but also available to anyone seeking better training in our focus areas. Médecins Sans Frontières will provide grants to help MSFers participate in these courses.

The centre will initially be funded by Médecins Sans Frontières and will then seek institutional funding with the aim of gradually becoming financially independent.

The committee would also like the centre to publish articles in national and international journals to publicise the results of our work in the field.

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Minutes, MSF France General Assembly, 1987 (in French)

Extract:

Despite everything, a long road lies ahead of us in this area, as noted during the last General Assembly. The “MSF and training development” committee had recommended two measures to improve MSF’s effectiveness. The first was to create a special status for field staff designed to encourage the medium-term commitment of experienced individuals or those with specific expertise. The second was to set up MSF’s own training centre and provide study grants for specialised training courses directly related to our field work. […]

The training centre, known as CIREM [Intervention Centre for Research and Medical Epidemiology], is currently being developed. In October, 25 trainees took part in an intensive three-week session at which they learned practical nutrition and sanitation skills and epidemiological assessment techniques. The instructors came from a variety of backgrounds, including the ICRC, Oxfam, FAO [Food and Agriculture Organisation], Tropical School of Medicine, CDC [Centers for Disease Control and Prevention] in Atlanta and, of course, MSF.

I believe I speak for everyone, both trainees and instructors, when I say that this first course was a real success. The course received two-thirds of its funding from the Caisse des Dépôts et Consignations [a public financial institution].

Three key objectives grew out of initial discussions about the centre’s role. The first is training in public health, which has moved beyond the design phase now that the first course has taken place. Other than the subjects already addressed, this training should also discuss, among other essential issues, disaster epidemiology, diarrhoeal disease control, health planning and perhaps the training of community health workers.

The second objective is to provide MSF with scientific support, which includes, for example, investigating epidemics and monitoring malaria and drug resistance. This goal can become reality only if MSF teams themselves perform the work, with CIREM playing a support and advisory role.

The third objective is to develop scientific relationships by maintaining contact with various specialist centres, by accessing databases, and by publishing articles and manuals – all things we already do but that are insufficiently systematic.

These are, of course, initial objectives, which will be supplemented or revised based on experience.

Treatment manuals based on an updated list of essential medicines and on behaviours practiced in the field have already been published. Because WHO officials found these manuals, as well as some of our emergency kits, to be of value, they are now being used by both the UNHCR and WHO, with credit given to MSF, of course.

Specialist sectors should be added to this policy, each consisting of one to two people who combine field experience with additional training. These sectors are hospitals, nutrition, vaccination and sanitation, with most work taking place in the field in direct contact with staff and unresolved problems. The sectors’ managers also draw up technical documents and guidelines and, if necessary, attend international conferences (for example, the vaccination meeting in Africa).

Lastly, they conduct specialised training courses, like the one on EPI [Expanded Programme for Immunisation] in January and another one on nutrition that is currently being developed.

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When we worked directly with the UNHCR or the ICRC, we could see that their reports were prepared by the CDC [Center for Diseases Control, based in Atlanta, USA] or Johns Hopkins [department of Hospital Epidemiology and Infection Control at the Johns Hopkins Hospital, Baltimore, USA], by outside parties – always American and always well-organized. It was really irritating when they would always manage to outsmart us or, at best, lectured us.

I had the idea of saying that we were going to send MSF volunteers for training in public health or epidemiology in the US – at Tulane [Tulane School of Public Health and Tropical Medicine, New Orleans, USA] or Johns Hopkins – so that when they came back, MSF would have people who knew the area well and had respect and recognition.

That’s how we founded CIREM – the Centre d’Intervention de Recherche et d’Epidémiologie Médicale.

I also thought that, based on all of our missions, we could do epidemiological and statistical research because we dealt with many cases in lots of countries, involving illnesses that people didn’t know much about and in isolated places. It developed gradually, but steadily. CIREM was transformed into EPICENTRE, a real epidemiological centre with a real strategy – but epidemiological.

Dr Francis Charhon, MSF France President 1980-1982, member of MSF France management team 1982-1992 (in French)

In the following years, CIREM strengthened its support to MSF missions, and its scientific networking. In 1988, it was renamed ‘Epicentre’ so that its name better specified the epidemiological orientation of its activities.

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Annual report, MSF France, 19 November 1988 (in French)

Extract:

Epicentre training

Training, a key reason for our effectiveness in the field, is still growing at a rapid pace. In addition to courses on vulnerable populations, nutrition, vaccination, sanitation and the cold chain, we have now added new modules, including ‘Investigating an Epidemic’, ‘Information Systems’ and ‘Administrative Management of Missions’, amounting to 22 weeks of training per year. The ‘Training the Trainers’ and ‘Health Programmes Management’ courses, which have already been developed, will soon be added to the list.

Consolidating all training programmes from the different MSF sections has given a European scope to this practical instruction in international health, which we are planning to expand beyond the organisation and export to other countries. Our primary goal is to provide very practical training at different levels and in a variety of fields; the training supplements a traditional university education and can be immediately applied in the field.

Instruction is coordinated by Epicentre, MSF’s research and scientific observation arm. In addition to providing training, Epicentre, which succeeded CIREM, evaluates our field work, provides technical support upon request, encourages the publication of medical articles and develops contacts with scientists worldwide. One of Epicentre’s basic assessment principles is to involve doctors returning from the field work on their own mission. This gives its studies an operational character that makes them all the more valuable, while also resulting in articles with the same asset; examples include a study on cholera in Malawi, intensive feeding centres in Niger and Malawi, and a disease surveillance system in Honduras.

Two software programs have been developed on the basis of a needs assessment exercise conducted in the field. One program supports our surveillance of diseases in the general population and the other the surveillance of the Expanded Programme on Immunisation.

Lastly, close work contacts developed with the WHO, the Centers for Disease Control and Prevention in Atlanta – the famous CDC – and the training and consultation agreements entered into with a US university serve as powerful incentives as well as offering opportunities to move beyond the image that we are simply nice guys that we’re still stuck with in certain quarters.

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Annual report, MSF France, 23 June 1990 (in French)

Extract:

Epicentre has experienced rapid growth, currently employing 10 full-time staff, although six of them are working on a temporary basis.

The organisation has been providing an increasing number of consultants – to the EEC [European Economic Community], WHO [World Health Organisation], UNICEF [United Nations International Chidren’s Emergency Fund ] and, of course, MSF – in close cooperation with its Belgian counterpart, AEDES [European Association for Development and Health], whose activities are highly complementary. In full collaboration with MSF experts, Epicentre is in the process of publishing many articles in international scientific journals and has been giving an increasing number of presentations at conventions.

While we have completely resolved the few problems we had experienced dividing up roles and responsibilities between MSF and Epicentre, we still need to collaboratively develop therapeutic strategies, particularly regarding one-dose treatments and malaria research.

In-service training has maintained its high level of 32 weeks of courses per year, while sales of turnkey modules have been growing, including to Vietnam, Guinea, the Ecole de Santé Publique in Rennes and the Institut Pasteur. The latter two clients purchase modules on medical information technology.

And it is through Epicentre that MSF offers an interuniversity public health diploma, together with Bordeaux and Tours universities and the Fondation Mérieux.

In 1994, the Epicentre General Assembly voted in favour of a motion for progressive autonomy that would lead to complete independence of the satellite from MSF France.

Epicentre, 42% of whose activities were with non-MSF clients, wished to strengthen these relations with outside entities while keeping a special link with MSF.

For their part, the MSF executive team and board of directors were in favour of Epicentre being autonomous, though overseen by MSF.

The motion was rejected, but the composition of the Epicentre’s board of directors was reorganised. Though still controlled by the MSF board of directors, it would be opened to representatives of other MSF sections and of the scientific community.

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Minutes, MSF France board of directors meeting, 30 September 1994 (in French)

Extract:

Relations between MSF and its satellites: Epicentre and MSF Logistics

Philippe Biberson [President of MSF France] notes that discussions have been taking place over the past few months on restructuring the relationship between MSF and its satellites, Epicentre and MSF Logistics. With regard to Epicentre, the last two meetings that addressed the subject issued inconsistent recommendations:

- The Epicentre GA [General Assembly], which was held on 21 April 1994, recommended that the satellite become gradually autonomous, with a long-term objective (without specifying a time frame) of complete independence from MSF.

- The MSF management seminar that took place in Royaumont on 2 June 1994 decided to keep Epicentre within the MSF ‘group’, making it an autonomous entity overseen by MSF. The points of agreement are as follows:

- a mutual desire to remain close;

- the need to separate ‘customer–supplier’ relations from a partnership type of relationship by creating a technical committee for managing orders (consulting, training, research, etc.);

- the opportunity to make Epicentre’s daily operations more autonomous in areas such as accounting, facilities, human resources management, etc. […];

Epicentre had been created as a non-profit satellite, but the idea of future profitability had been discussed from the beginning.

Since then, the budget has soared, rising from 1.5 million francs in 1988 to nearly 8 million francs in 1994, due to the growth of activity both within MSF (58%) and outside the organisation (42%).

Epicentre is also well known for working closely with MSF rather than independently of the organisation.

Epicentre wants to maintain a community of interest with MSF while also developing projects of wider scope that is no longer simply fulfilling MSF’s requests and immediate needs, but developing contacts with other sections and organisations in order to diversify funding sources and creating field jobs.

The goal is to maintain a working environment that fosters creativity and motivation, while introducing risk-taking and contributing further to establishing the direction of Epicentre direction and guiding its move toward autonomy.

The entire Epicentre staff approves the following Epicentre GA conclusions of April 1994:

- separate the two MSF functions of administrator (oversight) and client;

- enable Epicentre to gradually move toward independence.

To that end, Alain proposes a seven-member board of directors consisting of four members from the MSF France board and three external members. The president and treasurer would be chosen from among the external members. The director would be appointed by the board. The director would set salaries based on guidelines drawn up by the Epicentre board. The Epicentre board would decide how to use any surpluses. There would be two committees responsible for managing the Epicentre–MSF relationship. The first would be a committee with members from both MSF and Epicentre, and MSF would audit and evaluate Epicentre services. The second would be a technical committee, also with mixed MSF–Epicentre membership, that would regularly audit and evaluate research projects conducted by Epicentre.

The Epicentre staff wants, at all costs, to maintain its special working relationship with MSF but would also like to have control over its decisions.

Alain [Moren, Epicentre director] would like to see the board majority of four MSF France members gradually move toward a majority of four MSF International members.

He does not want members from MSF headquarters to serve on the Epicentre board to prevent any conflict of interest and to avoid the development of hierarchical relations and a blurring of roles.

In response to the following question by Frédérique Laffont [MSF France board member]: “Why isn’t Epicentre master of its own destiny right now?”

Alain [Moren] and Valérie [Schwoebel, MSF France board member] answer that MSF headquarters currently oversees Epicentre. The Epicentre board does not have any real authority, with MSF taking all the decisions. For example, the treasurer does not play the usual role of treasurer; instead, the MSF budget committee decides how to use any Epicentre surpluses. As a result, the Epicentre treasurer decided to resign this year.

Bernard Pécoul [MSF France general director]: The satellites have satisfactorily met MSF’s expectations. It’s a good idea to talk about the two satellites at the same time; moving from one to the other helps us better understand both the differences and similarities and the issues that should guide our discussion. Before presenting his proposals for the two satellites, Bernard had some preliminary comments:

- The two proposals aim to keep the satellites within the MSF group, i.e. to develop a policy framework that would avoid any risk of rupture in view of the common interests currently shared by MSF and its main satellites. MSF needs its satellites and the satellites need MSF. We hope to avoid a rupture and the disappearance of this community of interests, which would require MSF to create a new network of consultants.

- The two proposals aim to provide an extremely high level of management autonomy (and development autonomy for Epicentre) for each entity as part of a pre-established policy and ethical framework permanently guaranteed by the board of directors. MSF Logistics mainly started out as an annex at rue Saint Sabin, with almost no autonomy; the move to Bordeaux gave it significant management autonomy even though the situation has room for improvement.

Concerning Epicentre, we have yet to resolve the issue of management autonomy due to the close working relationship and the fact that the services that MSF provides to Epicentre make the latter dependent on MSF, such as accounting and payroll. Such autonomy is still to be developed. Epicentre also needs development autonomy for its research and field work activities.

- The difference between the two proposals is related to the fact that MSF’s current dependence on MSF Logistics for its operations requires it to set development goals for MSF Logistics that are compatible with MSF France’s operational requirements.

Proposed MSF/Epicentre relationship:

Policy control would be exercised by the Epicentre board of directors. The MSF France board of directors would have majority control of the Epicentre board, but representatives from other MSF sections and the scientific community would have a significant voice.

For example, a seven-member board comprising:

- 4 MSF board members

- 1 representative from other sections

- 2 members from outside the organisation

The board of directors would be responsible for:

- Establishing a policy and ethical framework

- Appointing the director (setting a salary)

- Approving its development policy

- Voting on its budget and annual results

The board would meet twice a year and at the request of the Epicentre director.

Relationship with the client, MSF:

A more technical decision-making body should manage the MSF–Epicentre relationship.

Creation of a technical committee within MSF, with one representative from management team (chairperson), one from Operations, one from HR and one from Finance, with responsibility for:

- Determining the annual order for consulting, training and research projects (for the latter, plan for medium-term projects, i.e. three to five years).

- Evaluating Epicentre’s services on an annual basis.

- Regularly monitoring the decision’s state of progress and revising as necessary.

Need for regular follow-up (four to six times/year) by the committee and Epicentre management.

In both cases, we need a board of directors that meets regularly, which is not the case at present.

Bernard Chomillier: MSF Logistics

His proposals are similar overall. Logistics has no intention of leaving MSF. The main question raised before talking about autonomy is figuring out what type of control MSF wants to maintain. What will it control and at what level – revenue, development, human resources? Our operations overlap and there’s a lack of clearly defined roles.

When we determine the exact type of control that MSF should exercise over MSF Logistics, we’ll be able to discuss the board and its composition as well as a technical committee. This should be a joint effort.

Philippe comments that there are almost no areas of agreement in the two proposals. No one questions the value of the satellite organisations.

The important thing is for MSF, MSF Logistics and Epicentre to understand what’s behind this desire for independence or for keeping the satellite within MSF. The issue here is the importance of deciding whether to grant future independence – an independence that could negatively affect MSF.

A discussion then ensued between those who support management autonomy – and even independence – for the satellites and those who oppose independence for the satellites.

Proponents of autonomy or independence:

In the opinion of Alain Moren [Epicentre general director], independence doesn’t mean separation. Epicentre wants to continue working with MSF. Independence means being open to a degree of risk-taking to improve management while still maintaining ties.

Epicentre feels that belonging to MSF France prevents it from working with the other sections, blocks access to donors and hinders development of large-scale projects.

Francis Charbon [member of the MSF France management team]: the two satellites are expressing the same malaise. These two entities were originally targeted for growth, so we can’t blame them now if they have their own ideas and want to expand. Their capacity for growth needs to be based on policies defined on an annual basis.

Valérie [Schwoebel, MSF board member] emphasizes the importance of risk to autonomy and independence; people work harder if they know they’re going to be evaluated.

She’s not worried about a rupture. Firstly, it’s in Epicentre’s interest to remain in the MSF movement given its humanitarian objectives. Secondly, there are not that many organisations willing to fund projects such as those conducted by Epicentre, which are not always profitable. For these reasons, Epicentre needs MSF as a client. Epicentre and MSF share the same objectives.

Brigitte Vasset [MSF France operations director] believes that independence would be healthier for the organisation because the satellites are costly to headquarters compared to field operations.

Renaud Tockert [MSF France board member] thinks that the main issue is trust. Epicentre has staff members who previously worked for MSF. Good relations will depend on trust rather than oversight. How can we expect people to feel appreciated if we limit their opportunities?

Jean Rigal [deputy medical director, MSF France] and Karim Laouabdia [deputy medical director, MSF France], who both advocate independence for Epicentre, focus on the ambiguous relations between Epicentre and the Medical Technology department. We’re putting curbs on Medical Technology. With respect to trust, the people at Epicentre need this level of freedom. In any case, the bonds between MSF and Epicentre will not be broken. MSF will have a better understanding of Epicentre services and negotiations will be healthier.

Loïc Flachet [Epicentre]: Epicentre only needs autonomy to develop its projects. Epicentre is a unique experiment in Europe that allows MSF sections to find a project to carry out while remaining within the humanitarian movement.

It would be a good idea to determine MSF’s goal for Epicentre and Epicentre’s goal for MSF. We could develop useful projects for MSF as well as other development organisations.

Opponents of independence

Frédéric Laffont [MSF France board member] is surprised that the satellites are asking for independence at a time when everyone agrees that things are working out.

It’s too easy to succeed, then leave the MSF fold while saying we’ll always love you.

This line of argument is incompatible with independence.

For anyone who starts working at Epicentre without any experience at MSF: what will it mean for them to say “I’ll always love you”?

For them, independence can only be seen as a total break [with MSF]. We run the risk that people from outside MSF could take control of the satellite’s board.

In that case, why not create a marketing satellite?

It’s very much in MSF France’s interest to keep its satellites within the fold because they make us more professional.

JF [Jean-François] Alesandrini [MSF France communications director] thinks that the three years requested by the Epicentre GA will be a forced march toward independence. It’s either independence or staying in the group, but not a solution for an ambiguous, evolving autonomy.

MSF has the same needs it had when creating Epicentre.

Does that mean that each time an entity works well, it then has to leave MSF; what’s going to happen if we create a nutrition unit?

Marc Gastellu [-Etchegorry, MSF France deputy operations director] thinks that Epicentre cannot survive without MSF. A certain degree of independence is important for conducting research, but close interaction remains necessary.

Brigitte [Vasset]: We can’t demand autonomy then ask MSF for money.

Alain Guilloux doesn’t see any reason for an independent board – for either MSF Log or Epicentre – because it doesn’t resolve either of the two issues that it raises: MSF’s ethical and policy oversight, and the customer–supplier relationship.

Independent entities generate problems such as duplication of jobs, conflicts and constant tinkering.

Philippe [Biberson, MSF France president]: If we separate powers, as proposed by Bernard, then we should eliminate ambiguities and conflicts without raising the issue of complete independence.

Sylvie [Lemmet, MSF France finance director] is disturbed that the two proposals are too similar yet embrace different goals.

Above all, we should make a joint effort to determine which decisions are up to Epicentre and which are up to MSF.

We shouldn’t delude ourselves that we’re going to resolve the issue of general oversight when we decide on a structure.

She has doubts about whether we have the resources and capacity necessary to oversee and evaluate Epicentre.

We do, however, have what’s necessary for MSF Logistics.

To be continued …