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that have taken action to be more inclusive of persons with disabilities.
Interview with members of the diversity and inclusion working group in MSF UK on the importance of diversity and inclusion, the grassroots engagement that provokes change, and new ideas for nurturing inclusion in MSF offices and policies.
Burj el-Barajneh is a refugee camp in the south of Beirut, Lebanon. It was created some 70 years ago by the League of Red Cross Societies in reaction to the influx of Palestinian refugees. Since then, the camp’s population has expanded continuously with the arrival of refugees from Syria, Egypt and Iraq, and of Lebanese migrants. Today, Burj el-Barajneh is Beirut’s most densely populated area, with over 18,000 people living in a space of one square kilometre. Médecins Sans Frontières provides there mental health and reproductive health care as well as health promotion activities for patients facing traumatic experiences, difficult living conditions and barriers in access to medical assistance. The barriers in access to health care in the camp are particularly strong for persons with disabilities, while many refugees suffer from chronic diseases, reduced mobility, injuries due to conflict, and mental health issues. To respond to these needs, MSF has chosen inclusion of persons with disabilities as one of the strategic objectives of construction of its new family centre in Burj el-Barajneh.
When the MSF-project in Swaziland was faced with hearing loss in 40% of its drug resistant tuberculosis (DRTB) patient group as a consequence of the treatment, the project responded by creating an environment that is inclusive to patients with hearing impairments. The long-term benefits of their actions have had a positive impact on the general accessibility to health care for the deaf community in Swaziland.
Although the course of action taken by this project has a more vertical scope than the mainstreaming efforts that we, through this TIC-project, are encouraging you to implement – there are several aspects making their experience highly relevant, which are highlighted in the text below. Continue reading to learn about how this project was developed and what lessons you can bring to your project.
Interview with members of the diversity and inclusion working group in MSF UK: Elisabeth Stodel, Stewardship and Campaign Officer; Romelia Anthony, Office Manager; Patrick McConnell, HR Manager Field Staffing; and Iain Bailey, Senior HR Business Partner – on the importance of diversity and inclusion, the grassroots engagement that provokes change, and new ideas for nurturing inclusion in MSF offices and policies.
What inspired you to start working on inclusion in the MSF UK office? What was the trigger?
Elisabeth Stodel (E.S): I thought that we were reasonably inclusive to begin with – but then we did the OCA training on diversity and inclusion, and we suddenly realised that many things could be done better. The training brought the idea of diversity and inclusion to the forefront of people’s minds. It empowered our staff to speak out about the areas where we might become more inclusive.
How is your work around diversity and inclusion issues organised?
E.S.: We started holding the diversity and inclusion training quarterly. As more and more staff attended, more and more suggestions were coming out of these workshops – ideas of what we could do to make our office truly diverse and inclusive. There was nowhere to channel them, no one to action them. That's why a few people who attended the training and felt passionately about the issue put together a working group. It is completely grassroots and comprised of 20-30 members. We try to make sure that every department is represented, and that we have link members from the management team and HR Field qnd Office to cover all the bases. We took the suggestions we kept receiving after trainings, and started using them as catalysts of change. Without implying that the working group alone can introduce all these changes, we strive to make aware the key people who do have the power to change things.
Romelia Anthony (R.A.): Having a working group has been a brilliant platform to get the conversation started. Before we began doing the training, and before we had the group, there was no real conversation about diversity and inclusion. Now it has become an important aspect of how we work and of the kind of organisation that we want to be.
So the working group relies on grassroots engagement rather than on any top-down process.
E.S.: Exactly. Even the training is done by volunteers from the working group. Anyone can apply to become a facilitator, we have terms of reference for that, and we encourage people to try and further contribute to the movement.
How does one become a facilitator?
E.S.: The original facilitators had the training of trainers in Amsterdam. It is quite intense, focused on being aware of what people might be saying and how they might be feeling, because the training can get personal and sensitive, and we have to be mindful of that. In the next couple of months, we are going to run the training of trainers for new facilitators here in London. You need to be trained to become a facilitator, but we also want anyone in the office who is interested and passionate about it to have such an opportunity.
Are your diversity and inclusion trainings only for the MSF UK staff, or do you include colleagues from other sections?
E.S.: Including colleagues from outside the MSF UK office is a new idea. We had someone join in our last training, from MSF Greece – and this has encouraged MSF Greece to run its own diversity and inclusion workshop. We suddenly realise that this is a simple and effective way to spread the word and inspire other sections. We have decided that in each training, we will hold one place for somebody from another office or from the field. Although not everything will be completely relevant for them, as the training is designed around the UK office, participation may inspire them to organise their own training, tailored to the local context.
Do you see a connection between fostering inclusion in our offices and in the field?
Patrick McConnell (P.M.): We appreciate that there are differences between the two, but at the root, the impetus is there for both the field and the office. Through this year, within our annual plan, we want to have diversity and inclusion much more prominent in our activities, and not just in day-to-day work and in recruitment, but also in different training courses: leadership trainings, welcome days – induction and orientation, and any other touchpoint where we can create awareness.
Does this increased focus on field workers as catalysts of diversity and inclusion translate into changes in field recruitment? Are we ready to be more inclusive in this domain?
P.M.: There is a need to review of our processes and activities, to get a better idea of inclusive practices, of what is feasible and what is ideal, and to examine our recruitment within the diversity and inclusion framework. As recruiters, we have done courses on unconscious bias, but how we put it into practice is something we want to review. We can certainly capitalise on what we are already doing with the diversity and inclusion committee to improve our recruitment.
What about the diversity and inclusion perspective in recruitment of office staff and in a broader HR perspective?
Iain Bailey (I.B.): There are gaps, but also opportunities for improvements. Our recruitment process is not anonymised, which risks unconscious bias at the shortlisting stage. We have no formal policy that would ensure having gender-balanced interview panels. Managers are trained in interview skills but this is not mandatory; mandatory training would help fill this gap. MSF already has an equal opportunities policy, and new starters are encouraged to read it. This could be formalised by requesting that every new starter sign a document confirming they have read it. Ensuring that the diversity and inclusion training captures all new starters would further support understanding and implementation of the policy. We could also improve our learning and development opportunities. They are offered to all staff, but there is no checklist to ensure that all groups can access them equally. Simple adjustments, such as holding courses at times that are accessible for part-timers or making sure that the location is disability-friendly, are potentially a quick fix.
What would it take to incorporate reasonable adjustments into our recruitment processes in a more systematic way?
I.B.: MSF already asks shortlisted candidates if they need any reasonable adjustments before an interview. However, there is a lot more we can do. The HR department has recently worked with Leonard Cheshire, a leading UK disability charity, ahead of possibly accepting an intern with disabilities in the summer months. We were involved in an assessment-centre day for the recruitment of interns, and we aspire to incorporate lessons learnt into our existing practices. This would enable us to integrate reasonable adjustments in a more systematic way at very little cost. Feedback from exit interviews, from colleagues with disabilities, could inform future good practices and policy changes to ensure that reasonable adjustments are made. We could request such feedback from successful candidates at the induction stage.
Are there any specific topics within diversity and inclusion that are a priority for your office, or any pressing needs to address?
R.A.: One of these topics is disability. We had a disability audit done for the office last year; it was given to us with recommendations and suggestions of changes. We are looking at them now, and the plan is to get as much done this year as possible, to make the office more inclusive for people with all kinds of disabilities. There is always going to be challenges with older buildings, especially in London, but we will try to make our space as disability-friendly as possible.
E.S.: Another topic that we are focusing on is socioeconomic inclusion: we want to make sure there is access to work at MSF for everyone, whatever their background might be.
What has changed in your work environment since you launched your inclusion efforts? Are there any milestones you would like to discuss or share?
E.S.: We carry out an annual survey, asking for staff’s feedback. One of the questions is if they feel represented in terms of diversity and inclusion in the office. We have seen considerable improvement in this dimension. What has gone really well, and is simple enough to introduce elsewhere, is themed events. We have organised Black History Month, Women’s History Month, themed events on LGBT and men’s health. There has been a lot of engagement around these events. They have further increased the number of staff suggestions regarding diversity and inclusion in the office and, even if not everybody has been interested in each specific topic, they have inspired thoughts on other things.
R.A.: We have had the diversity and inclusion group for about ten months now. Because we are all involved in it on top of our day-to-day tasks, we need to be realistic about how much time we can dedicate and how much we can do. After a period of testing the waters, we have quite a robust idea and an annual plan, so we can propose something that is much more focused and streamlined. It has been a very useful learning curve.
Do you think there is a need for MSF to create positions focused specifically on diversity and inclusion, or would it be counter-productive, as fewer people would engage at a grassroots level?
E.S.: I think that you need both. You need grassroots, because otherwise, people would stop being so engaged, but it is also difficult to have enough time to do everything we would like to do. We have one member of the working group who is part of the management team. Our chair of the board and our executive director have attended the diversity and inclusion training. They are on board with what we are doing, and it would be challenging to carry on without this kind of support.
In your perspective, what is the main value of inclusion for organisations such as MSF?
E.S: I think we have a moral obligation to be inclusive. We are a humanitarian organisation, we go where the need is greatest, and to ignore or marginalise some people would be against everything that MSF stands for. It is also about adequate representation of those we serve.
From an operational perspective, there is a bulk of research showing that if you have a more diverse workforce, you achieve more. It is a good business case to be inclusive.
Do you have any advice for those who would like to develop similar initiatives in their setting?
E.S.: Change can come from anyone, but it has to start from within. If you feel passionately about diversity and inclusion issues, speak up and do not give up – keep speaking until things change. We invite anyone in the movement to join our training; we always keep one space open for colleagues from other sections and from the field. We are also happy to share our experiences, and advise on how to set up your own working group.
Burj el-Barajneh is a refugee camp in the south of Beirut, Lebanon. It was created some 70 years ago by the League of Red Cross Societies in reaction to the influx of Palestinian refugees. Since then, the camp’s population has expanded continuously with the arrival of refugees from Syria, Egypt and Iraq, and of Lebanese migrants. Today, Burj el-Barajneh is Beirut’s most densely populated area, with over 18,000 people living in a space of one square kilometre . MSF has been working in the camp since 2008, providing mental health care and basic medical services to patients facing traumatic experiences, poor living conditions and difficult access to medical assistance. Barriers in access to health care in the camp are particularly strong for persons with disabilities, while many refugees are affected by chronic diseases, reduced mobility, injuries due to conflict, and mental health issues. To respond to these specific and often unaddressed needs, MSF in Burj el-Barajneh has chosen inclusion of persons with disabilities as one of the strategic objectives of the construction of its new family centre. Dr Laura Rinchey, Project Medical Referent, and Harald Lognvik, Construction Focal Point in the South Beirut project, explained why and how it had happened.
A challenging setting
Moving around Beirut can be difficult. There are broken narrow sidewalks, cars parking everywhere, dirty streets and uneven surfaces in the city’s few green spaces – many challenges for wheelchair users and for any person with reduced mobility. In Burj el-Barajneh, suitable buildings are scarce, and MSF clinics operating in the camp have only been accessible by stairs. The clinic specialised in chronic diseases is also four flights of stairs up, even though most patients are elderly or experience reduced mobility. Only one stairway has handrails. We are located next to a school. At times, patients get caught up in a swarm of children – a frightening experience for anyone with reduced mobility.
An eye-opening encounter
One day, a pregnant woman with a disability was referred to MSF. Years before, she had been in a car accident and had become paralysed and a wheelchair user. She knew that MSF offered antenatal consultations in Burj el-Barajneh, but was too ashamed to come to the clinic. Now she was in the ninth month of pregnancy and urgently needed financial resources for the delivery of her child. She was very distressed and only chose to come to us as her last option. Crowd controllers carried her up four flights of stairs. In the waiting area, other patients had to stand up or move their chairs to let her pass. By the time she reached the consultation room, she was crying of embarrassment. It was heart-breaking to learn that she had not sought care earlier simply because of the lack of access to our clinic, and to see her experience such a humiliation at the time when she should have been happily waiting for her new baby.
Provisional accommodations in the project
In MSF clinics in the camp, staff would often assist patients walking up to seek help. Doctors and nurses would also often descend the stairs to see patients outside, in their cars or in the alleyway. While there were about 50 patients with limited mobility in the project, the staff had become used to the existing barriers and had strived to respond to the needs without changing the whole set-up.
Seeing needs plus seizing opportunities equals triggering change
“When the project started planning its new family centre that would integrate the current sexual reproductive health and maternal health services with development of the maternal health component, I saw it as an opportunity to adapt the set-up and have a ground floor clinic”, said Dr Laura Rinchey, Project Medical Referent.
Initially, the idea was simply to move our women’s health clinic to Burj el-Barajneh from the nearby Shatila refugee camp. The team envisioned a quick and straightforward move, but the available buildings did not fulfil the requirements, neither medical nor logistical, and we chose a more important construction effort. The objective was to become more family-friendly, and to include as many people as possible.
One basic requirement was that all services should be available on the ground floor, so that medical staff could assist patients with disabilities and chronic diseases and treat them with dignity and confidentiality. Maintaining one multifunctional room on the ground floor would make it possible to move staff to the patients for whatever service they may require.
Due to the layout and levelling of the building, with its tight confined spaces and many different floor levels, this turned out to be an important challenge. It was necessary to restructure completely the area around the reception and the stairs. Doorways and hallways leading to the clinical multifunction room and toilet had to be widened and the entrance area cast with concrete slab and levelled with a gentle incline to be accessible for wheelchair users.
It is about extra consideration, not extra costs
Wheelchair access means thinking in very different terms when it comes to construction. It is necessary to consider how the floor is levelled, what dimensions the doorways and the rooms should have. We have to think about patient flow and the overall layout of the clinic. This means a greater need for change, adaptation and compromise – but it is absolutely worth it. Such a process forces the team to think twice and thrice about every decision, which in turn makes it more likely that you will end up with a design that will better serve all patients, both with and without disabilities.
Barriers to lifting barriers?
Other than the planning itself, the project has not faced real barriers in adapting the centre to the needs of people with disabilities. It is tempting to think that inclusion requires too much effort, time and money. In reality, this is not necessarily the case. In the South Beirut project, except for the extra consideration put into the planning, the cost and the efforts needed have been negligible.
The family centre is now operational. The services continue to include sexual reproductive health, mental health and health promotion, among other activities. The active cohort of the reduced mobility clinic for non-communicable diseases is 72 patients. The medical follow-up in the room at ground floor level is operational one day a week. The patients have been happy with their access and the ability to also see a social worker, a psychologist or a pharmacist who can all give direct support and advice if needed, instead of passing messages through family members.
In South Beirut project, MSF also runs a home-based care programme working with patients suffering from chronic diseases. The team has been consulting occupational therapists about how to improve the functional mobility of patients within their own homes as well, and is trying to approach disabilities from several angles to increase mobility and access for all .
Many patients at the Matsapha Clinic, a comprehensive MSF clinic offering various medical services in Swaziland, suffered from hearing loss due to DRTB-treatment. Patients that had previously been fully able to hear and communicate freely, became partially deaf or completely lost their hearing.
Despite being fully informed about the possible side effects, the patients were not prepared for the sudden hearing loss. Not only did the affected patients isolate themselves socially from their families and communities as a result, but they also found going to a medical clinic problematic, as they could no longer communicate with the nurses and doctors.
Actions taken by the clinic
With this training, the patients were able to interact and have a conversation with others again. Clinic staff were able to communicate with the patients with ease, and to intervene with confidence based on the patients concerns. As the patients were trained with their relatives, they were also able to interact at home, with the ones they spend most of their time with after completing DRTB treatment. With the acquired skill, they went from having secluded themselves from social life due to their inability to communicate, to being more expressive and open again.
With the switch to new drugs without damaging consequences on hearing, the number of new patients that could benefit from the training quickly decreased.
Core impact on Inclusion
Beyond the positive influence on the quality of life and health care of the initially targeted patients, the impact of the actions taken by MSF Swaziland remains important in terms of accessibility to health care for patients with a hearing impairment in Swaziland.
Unexpectedly, awareness about the staff’s Swazi sign language skills was raised across the deaf community, which led to an increase in the number of deaf patients seeking care at the clinic for services unrelated to DRTB. These patients informed MSF staff that they had had negative experiences of impatient staff members at public health services.
Because of the training, the Matsapha clinic – a comprehensive clinic offering various medical services – had become accessible to deaf patients.
Key lessons learned
• MSF projects are normally overwhelmed by needs and other priorities. The needs of people with disabilities are often not taken into account. MSF projects could zoom in more on people with disabilities as they could be excluded from access to health or social life because of their handicap.
• Learning a new skill takes time and patience, therefore participating staff have to be motivated to take the training. Learning sign language is challenging and requires consistent attendance and practice, not everybody is sufficiently motivated to keep up the effort. (Initially there was a high attendance from the staff, patients and relatives, but with time, the attendance rate slowly decreased.)
• Including health care workers from all departments in the sign language training ensured accessibility to health services for all deaf patients.
• The training would not have been a success without the involvement of the patient’s relatives. The aim of the training was both to enable communication with clinic staff for medical care, but also to reintegrate the patients into their families so that they did not isolate themselves.
This text is based on a report by Fundzile Msibi, Psychosocial Coordinator, and Kees Keus, Medical Coordinator at the Matsapha Clinic, MSF Swaziland (Eswatini).
Drug-resistant forms of tuberculosis (DRTB) are hard to cure, involving ineffective, long, painful, toxic, complex and expensive treatment regimens. Current recommended treatments include drugs (Kanamycin, Amikacin and Capreomycin) given by injection. They can induce irreversible hearing loss in up to 40 % of the patients, in addition to nausea, joint pains, gastro-intestinal problems and psychosis.
MSF is involved in research on two new drugs (Bedaquiline, Delamanid) that are less toxic, and do not give the patients hearing loss. MSF Swaziland is currently applying them - but they are still not implemented as standard treatment for DRTB. MSF is pushing for broader implementation of these drugs.
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