Doctors without borders

Dr. Amber Alayyan & Massimiliano Rebaudengo
Deputy Cell Manager (Medical) & Technical Consultant for Operations
Medecins Sans Frontieres (MSF), Doctors Without Borders

The Focused Sun team was able to connect with Medecins Sans Frontieres (2021) through Dr. Amber Alayyan, Deputy Cell Manager in the Medical team’s Paris headquarters, and Massimiliano Rebaudengo, the MSF Technical Consultant for Operations.  

For more information about the USA operation of MSF, Doctors Without Borders (2021), and to learn more about their Partner Program, visit https://www.doctorswithoutborders.org/support-us/explore-donation-options/join-partner-program. 

References:
Doctors Without Borders. (2021). MSF partner program. Medecins Sans Frontieres - MSF. https://www.doctorswithoutborders.org/support-us/explore-donation-options/join-partner-program. 
Medecins Sans Frontieres. (2021). MSF. Doctors Without Borders - USA. https://www.doctorswithoutborders.org/. 

1. Tell us about the technical requirements at MSF (Energy, Power, Heat)

The leadership and operations of MSF (2021) rely heavily on their global logistics supply chain, in which Dr. Alayyan is responsible for finding ways to get supplies to where they are needed in advance and at the lowest cost possible.

What is the process for setting up a remote clinic?
The only power supply solutions that are readily available in remote clinics are non-green options like generators running on fuel.  Because of the lack of infrastructure, that’s pretty much what you’ll find in a remote clinic or hospital with Doctors Without Borders.

If clinics are not totally remote, MSF is able to utilize the grid in the country and extend it with regulatory approval.  Generators, on the other hand, require relatively little approval and are regulated more by the microeconomic buyers, sellers, suppliers, and technicians than any government agency. 
 
While remote medical aid is starting to use solar panels and batteries for energy storage to heat and cool clinics and hospitals, they are still viewed as expensive.  Pharmacies and ORs with Surgery (in Operating Rooms or Operating Theaters depending on the nationality) require a higher level of power supply and reliability.  Pharmacies must keep certain medicines refrigerated and treatments cool, while operations may require more electricity with longer procedures.

Because of their expense, Solar Panels with batteries, when used, are still often supplemented with generators.  Solar is not ideal for powering humanitarian medical aid as the electricity in photovoltaic panels is only produced when the sun is shining.  As we learn about the Focused Sun microgrid, it’s clear that the oil used with concentrated solar to store heat can be a versatile and low-cost solution to alkaline and chemical battery storage.

Reference:
MSF. (2021). How we work. Doctors Without Borders - USA. https://www.doctorswithoutborders.org/who-we-are/how-we-work. 

2. What are the problems to solve applying medical aid where it's needed most?

In addition to logistics and the operational challenges MSF faces, the answers to questions about solving problems where humanitarian medical aid is needed feed into the Principles shared by the American Doctors Without Borders organization (MSF Ethics, 2021).  This includes their commitment to political neutrality, as well as a growing commitment to environmental protection that can reduce health risks associated with generators.

Among the leadership at MSF, there is a green movement in the Humanitarian Medical Aid environment.  Starting with the number of planes doctors and field workers take, there is a lot of interest in becoming more environmentally friendly.  The logistics warehouses, described by Dr. Alayyan as “an IKEA warehouse for drugs”, are located across Europe in Amsterdam, Bordeaux, France, and Brussels, Belgium, among other places.
All medical supplies are shipped by boat or flown by cargo flight, but as mentioned with MSF leaders reducing the amount of flights they take, planes are frowned upon despite their convenience.  Import options are increasing and the movement is slow to pick up, but there are creative ideas circulating to improve medical supply lead times while reducing the cost and the ecological footprint at the same time.

There is a Green Team in Paris headquarters working on this, the effort to reduce the costs on the triple-bottom-line of planet, people, and financial figures. To the question, all of these problems to solve in providing medical aid are looking for innovative solutions that may allow improvements that were historically unattainable.

Operational Support for MSF in Bordeaux will know specific technical requirements for a remote microgrid module like Focused Sun’s.  The Focused Sun regional factory model would be useful for these technical requirements, as the ability to fabricate the parts on site will reduce uncertainty and shorten lead times for power supply as well as other medical equipment that can be made from these FSMicrogrid factories.

Sweden, where Focused Sun CEO Rene Francis serves the local government and runs his own international humanitarian efforts, has an MSF innovation unit where many of these technologies are researched and discussed.  While the process at MSF moves at a pace that reduces risk and uncertainty, the technology landscape is evolving quickly to provide solutions like the Focused Sun Microgrid for remote heat and power at low cost and with versatile implementation. 

Reference:
MSF Ethics. (2021). Principles. Doctors Without Borders - USA. https://www.doctorswithoutborders.org/who-we-are/principles. 

3. How much electricity, heat, power, clean water, and cooling do remote clinics use?

To experience what we learned from Dr. Alayyan and Mr. Rebaudengo, readers of their response to questions about remote clinics may wish to watch one of several MSF Documentary programs (2021), where viewers can perceive first-hand the challenges doctors face in these remote clinics, hospitals, and pharmacies, each with its own unique energy needs. 

While clinics run from 7 am to 5 pm in daily operations, a neighboring pharmacy must be cooled overnight and run 24 hours a day, 7 days a week.  When these energy demands are met by using a generator, the generators must be refueled, which often occurs at night.  The noise and exhaust of the generator are troublesome, and the refueling requirement adds cost and pollution.  Each remote site will use multiple generators in different locations, so refueling is time-consuming and cumbersome as the number of required fuel increases.

Hospitals run 24/7, along with their pharmacies, with both the large and small hospitals in the MSF network.  The figures on consumption in clinics are about one-third that of the hospitals, with the 8-hour clinic schedule compared to the 24-hour hospital schedule.

An average US hospital uses 31 kilowatt-hours ( kWh ) of electricity and 103,600 Btu of natural gas per square foot annually (Snohomish County, 2021).  Remote hospitals may be in the ballpark of 20 kWh per year, putting each remote clinic at about 7 kWh per year. (Snohomish County, 2021).

References: 
MSF Documentary. (2021). Access to the danger zone. Doctors Without Borders - USA. https://www.doctorswithoutborders.org/who-we-are/films-about-msf/access-danger-zone. 
Snohomish County. (2021). Municipal Healthcare and Hospital Energy Usage. Business energy advisor, E-Source Companies LLC. https://snopud.bizenergyadvisor.com/article/hospitals.

4. What opportunities do you see with renewable energy in global medical aid? How about in rural areas? At what capacity?

MSF serves in the area of Humanitarian Medical Aid, which requires Emergency and Long-term Development of infrastructure.  Not just MSF, but many organizations work in this space:
Save the Children, Action Against Hunger, CARE, International Community Red Cross (ICRC), Unicef fund the work, World Health Organization (WHO) funds governments, and also there is the Relief International and the International Rescue Committee (IRC).

MSF is one of the only purely medical organizations, MSF and ICRC, whereas IRC and the others are more general, covering water, sanitation, etc.  “Multi Sectorial” is the term used to describe these other organizations, while MSF is medical only in nature.

Long-term, how much can we use renewable energy?
We may need to change the mindset from one of accepting the system currently in place to a willingness to make bold decisions.  The renewable energy MSF chooses to replace generators will have lasting impacts on the economy, and this is a part of the ongoing internal discussion of operations and logistics.  MSF can certainly use renewable energy in this changing mindset.

Do we know about grant opportunities for renewable energy sources?
From generator economics in Africa to European nuclear and German PV, all energy sources come with their own complications and each is received into various regional limitations.  Development is longer-term direct assistance that starts to change the other variables.  While increased spending is not a guaranteed solution to problems, development certainly helps.  The capacity for energy infrastructure must be aligned with the local economy for energy use, and this is a slow process to shift, as anyone can relate in their own countries transition to renewable energy sources.

Are there grants for doctors and hospitals to install and fund clinics?
MSF funding for these projects would mostly come from private donations, where the topic of renewable energy and private sector funding has evolved over time.  Governments and development agencies focusing on environmental issues are popping up.  There are funding opportunities for these technologies in Humanitarian Medical Aid, which can come from private as well as public sources in certain regions.

What are the sources of funding available for remote medical aid?
Financial aid is provided privately, medical aid by doctors, the technology is delivered by MSF.  All of these networks are governed by the central MSF body with local representatives, and the allocation of resources goes through a rigorous process to ensure funds are allocated properly.

5. What issues do you face with electricity?  Downtime if any? What temporary solutions did you use? How was it solved?

Authors have pointed to the challenge of accurately reporting on humanitarian medical aid (Grais, Luquero, Grellety, Pham, Coghlan, & Salignon, 2009).  The study of Grais et al. (2009) points to the importance of this interview with Doctors Without Borders (MSF), specifically when it comes to the accuracy of reporting the electrical needs and solutions available in the field.

Electricity issues are a part of everyday life at MSF.  There is a daily failure of electricity in most countries MSF serves.  The shortages can happen at random or come as scheduled outages, planned to conserve electricity.  Power cuts for electricity can happen one hour at a time, but this becomes problematic when power usage for lights and refrigerators continues even at night.  

Reference: 

Grais, R. F., Luquero, F. J., Grellety, E., Pham, H., Coghlan, B., & Salignon, P. (2009). Learning lessons from field surveys in Humanitarian Contexts: A case study of field surveys conducted in North Kivu, DRC 2006-2008. Conflict and Health, 3(1). https://doi.org/10.1186/1752-1505-3-8 

6. How is the cost of renewable energy viewed in your industry of Humanitarian Medical Aid?

Humanitarian medical aid organizations treat a number of medical issues (2021), and each medical issue has particular needs with various equipment and logistical processes.  While MSF runs clinics that operate one 8-hour shift during office hours, they also run hospitals requiring 24/7 care.  As we discussed in Question 3, annual remote power usage may average 20 kWh per year in a hospital and 7 kWh for a clinic, with 103,600 Btu of natural gas per square foot as an annual figure for each independently.  County-run Public Utility Districts often publish this data for their local constituents, which can be used to plan scenarios and register the costs associated with various energy sources (Snohomish County, 2021).

The fact that renewable energy is less available is the biggest challenge
Importing solar panels is possible but it requires an extra step and a mindset shift
When a generator is running and it works, doctors have other problems dealing with
The entire team of doctors, nurses, logistics, administration, security 
Also project coordinators and a massive staff of expatriates

The whole team just wants to have electricity 
Does it work?  The generator works and is less of a priority
Embassies in foreign countries will need to source their energy 
Consulates and embassies clustered in countries as an energy showcase for MSF field operation

References: 
Medical Issues. (2021). Medical issues MSF faces. Doctors Without Borders - USA. https://www.doctorswithoutborders.org/what-we-do/medical-issues.
Snohomish County. (2021). Municipal Healthcare and Hospital Energy Usage. Business energy advisor, E-Source Companies LLC. https://snopud.bizenergyadvisor.com/article/hospitals.

7. What barriers do you have to adopt renewable energy?
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While barriers to renewable energy adoption are not listed as the challenges faced in the MSF list of frequently asked questions (MSF FAQ, 2021), the increasing issues of climate change tied to polluting fuel sources is related, which ties to the organizational concern of “Having the necessary reserves to allow us to respond to new emergencies as they occur”.  While financial reserves are explicit, energy reserves from renewable sources are implied.

In addition to their effect on global warming, fuel sources emitting carbon into the atmosphere also harbor direct negative health impacts.  Protective gear is required for people working around generators to avoid inhalation of fumes as a part of their daily work.  The road to improvements and replacements is long, and this lengthy process feels like the biggest barrier to adoption.  While the time to adopt is a challenge, there is a change happening and the willingness is there.  MSF is committed to the process of improving renewable energy.  

Part of this discussion concerns whether MSF will position itself at the center of a global debate about green energy.  The core principle of political neutrality allows MSF to operate with relative autonomy in the various regions where humanitarian medical aid is being delivered.  This conservative risk aversion comes from a concern of maintaining political neutrality.  Having conversations to making progress has always been a part of the MSF process.

Dr. Alayyan plans budgets for countries on the supply side, where the common question her team answers is “Are we shipping or flying materials to the aid site?”.  It sounds like an easy question, but there are several variables that make it hard to strike a balance between the triangle of speed, cost, and environmental impact.  Flying is fast, expensive, and has greater environmental costs.  Shipping takes longer, is cheaper, and the environmental and economic costs are lower.  When it comes to saving human lives, where do you draw the line on how fast you need supplies, what it’s worth to spend, and when the environmental costs are too great? 

This leads to the question of, “OK, do we put in the standard list of solar panels to power our existing buildings, or build new buildings to improve the infrastructure? We can only do one at a time.”  Solar panels are suggested as an item to add to the list of materials, and we are seeing more of them being installed.  The current number of barriers is fewer than it was in the past.

Reference:
MSF FAQ. (2021). Frequency Asked Questions About Our Work. Doctors Without Borders - USA. https://www.doctorswithoutborders.org/what-we-do/faq-our-work.