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Peter A Hakewill
Working on the front line in humanitarian crises can be challenging and satisfying but, at times, fraught with ethical dilemmas
MJA 1997; 167: 618-621
Introduction - Crisis assessment - Medical interventions - Why interventions may not work - Ethical dilemmas - Doctoring at its best - References - Authors' details
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Introduction |
The modern era of humanitarian medicine began almost three decades
ago with massive calamities on opposite sides of the globe: the Bengal
crisis, which saw some 10 million refugees flee to India;1 and civil war in the Nigerian State of
Biafra, which led to a catastrophic famine.
A group of doctors working on the front line in Biafra witnessed the diversion of food aid and the abuse of human rights, perpetuated by both sides in the conflict. Finding themselves unable to influence these events on their own, they later founded a new aid organisation with two objectives:
They wanted the values and ethics of impartial medical care to become universally respected, so they called themselves "Medecins Sans Frontieres" -- doctors without borders.2 They barely had time to write their charter before the next crisis came along. Medicins Sans Frontieres (MSF) has since become an international movement, with field volunteers from some 45 nationalities working on emergency and development projects in about 70 countries. The nature of humanitarian crises has become more complex but also better understood.3 Aid carries with it so many ambiguities and paradoxes that MSF now finds it necessary to publish almost annual analyses of the situations its volunteers are dealing with.4-7 Skills and techniques for the medical and logistical side of relief programs have also been refined to the point where humanitarian medicine can be considered to be a subspecialty of international public health.8 However, as in clinical medicine, if the condition of a patient is sufficiently desperate, better knowledge of cause and pathological process does not necessarily influence the outcome: for example, mortality rates among refugees in Goma, Zaire, during the Rwanda crisis in 1994 were among the highest ever documented.9 |
Crisis assessment |
Protocols now exist for rapidly assessing the needs and resources of a
population in crisis.10 The
groups most at risk of dying are children, the elderly, the
malnourished, unaccompanied children, and households with no
father. Aid workers must act rapidly, for most deaths occur during the
first days and weeks of an emergency situation.11 Counting deaths is an important
tool, not only for evaluating the baseline condition of the
population and how well a relief action is progressing, but also for
advocacy purposes. A graph showing death rates is often an essential
tool for convincing aid bureaucrats that action is urgently needed.
Mortality is measured in terms of deaths per 10 000 population per day,
and empirical benchmarks have been developed.12 For example, the average daily
crude mortality rate in Australia is of the order of 0.25/10 000 per
day; in a non-emergency setting in an average developing country it
may be 0.6/10 000 per day. In a well-managed refugee emergency, it may
reach 1.5/10 000 per day before falling to a baseline of around 1.0/10
000 per day or less. However, in the Katale camp near Goma at the height
of the epidemics of cholera and dysentery in 1994, the average daily
mortality was 41.3/10 000 per day,9
and age-specific mortality rates among unaccompanied
infants in some care centres reached as high as 817/10 000 per day.13 In non-emergency
situations an infant mortality rate of 10/10 000 per day would be
considered very high.
|
Medical interventions |
The medical interventions needed to save the lives of refugees or
displaced persons are few and relatively simple. The major causes of
death are usually diarrhoeal disease, acute respiratory
infections, malnutrition, malaria, and measles.11 Each of these can in some measure be
prevented by attention to the basic vital needs of a population, and
treated by simple means when they do occur. The vital needs include
adequate food rations (average, 2100 kcal per person per day), clean
-- or at least chlorinated -- water (20 litres per person per day),
sanitation (at least one latrine for 20 persons), and shelter (at
least 3.5 square metres per person).14,15
Mass immunisation against measles, prophylaxis with vitamin A, intensive therapy for severely malnourished children, and basic curative care are the medical interventions that must likewise be set up during the first days of a refugee influx. A large portion of potentially fatal cases can be managed by minimally trained health workers wielding oral rehydration salts, an antimalarial, and a simple oral antibiotic. This is fortunate, since the sheer volume of the caseload in an outpatients clinic in a large refugee camp would otherwise overwhelm the capacity of the doctors and nurses available to do the work. Indeed, medical staff need to reorient their thinking from a purely clinical approach to a constant preoccupation with public health interventions. Probably the most important contributions to knowledge in this field have been made by an Australian medical epidemiologist, Dr Michael Toole. |
Why interventions may not work |
If these simple and effective techniques of emergency intervention
work, the crisis may never hit the world news, and the situation may be
handled without major loss of life by relief agencies working in
concert with the local ministry of health, usually under the
coordination of a lead agency such as the United Nations High
Commissioner for Refugees. If, on the other hand, the interventions
do not work, it is usually for one of three reasons. Firstly, as in Goma,24 personnel with some
relief agencies may be inadequately trained or have insufficient
experience; secondly, as happened also in Goma, the conditions in
which the refugees find themselves may be so appalling that a
catastrophe cannot be prevented (800 000 persons arriving in the
space of a few days on a wasteland of volcanic rock); or thirdly, and
most commonly, there are political obstacles to effective aid
delivery. These political obstacles, which always stem from needs of
the State taking precedence over the rights of human beings to
survival and health, can only be understood in the context of recent
changes in international and national politics.
Warfare has changed since the time of our grandfathers when battles pitted soldiers of one nation against those of another. Most wars in the 1990s are internal national rather than international affairs, and most of the casualties occur among non-combatants. Thus, the plight of civilians in war-torn countries has tended to worsen rather than improve. Furthermore, with the fall of the Berlin Wall, guerrilla movements have lost the ideological and material support of one or other of the superpowers and, instead of laying down their weapons, have sought new ways of financing their wars: notably, predation upon civilian populations, and accessorily upon relief aid; and criminal exploitation of local resources such as opium, gold, gems, and valuable timbers.2 |
Ethical dilemmas |
Humanitarian aid cannot escape the ambiguities inherent in such
situations.25,26 Doctors
working in emergencies cannot afford to concentrate only upon their
patients, nor even only upon broader public health concerns. They
must be aware of both the background of the crisis and the factors that
prevent its resolution.7 It
should be the responsibility of each aid agency to encourage
reflection, debate and vigilance among its field volunteers.
Without this vigilance, they risk being drawn into ethical dilemmas
of three major types.2
A recent example of this alibi phenomenon occurred in Bosnia. For the first two years of the conflict the Blue Helmets of the United Nations were mandated to protect aid convoys but not the civilian populations of threatened enclaves. A second example was the Rwandan crisis of 1994. The international community sat back and watched for 12 terrible weeks while genocide took place, and then rushed its crack troops to Goma, in Zaire, to assist aid agencies in their struggle to save the refugees. It was almost as if this belated enthusiasm could efface the guilt of having done nothing to stop the massacres. Ironically, these refugees were not fleeing the genocide, but, rather, fleeing punishment for having perpetrated it. The second dilemma is that humanitarian aid may confer power and legitimacy upon persons who then use it to the detriment of the population. Many people may remember the Ethiopian famine of 1985: massive aid arrived, and the regime of Colonel Mengistu lost the status of international pariah. Mengistu used the logistics of the aid effort and the weapon of withheld food to force whole swathes of the famine-weakened but rebellious population to relocate. Tens of thousands of unnecessary deaths ensued. Alone of all the aid agencies, MSF denounced this "ethnic cleansing" and was ejected from the country. Ten years later, MSF took a similar ethical stand in the Rwandan camps, and withdrew rather than continue to deal with the Hutu extremists who held the population in their sway.6 Primum non nocere: in both cases, the field volunteers decided that their presence by the side of the civilian population was, on balance, cau sing more harm than good. The third dilemma is that humanitarian aid may prolong a conflict. For example, in Liberia during five years of civil war from 1990,7 humanitarian relief was the nation's major industry. The warring factions extorted relief food from the civilian population. Some factions starved their own population in order to attract aid to their stronghold. Vehicles, fuel and radios were also stolen. These unwilling contributions of aid helped the various factions to prosecute their wars. The answers that MSF teams have found to this kind of dilemma have included negotiating endlessly with warring parties for the right to bring medical aid impartially to all civilians, and feeding people in mass kitchens rather than giving them food to take away, on the principle that what was already in their bellies could not be stolen. |
Doctoring at its best |
In the face of such difficulties, why would anyone wish to go doctoring
beyond frontiers? The answer seems usually to run along the lines of
"because it is simply one of the most passionately interesting ways to
practise medicine". There are few naturally occurring situations
that give the same adrenaline rush as battling night and day against
the ravages of an epidemic of cholera; or toiling with the infinite
patience and persistence that is called for in a feeding centre in
order to bring hundreds of malnourished children back from the brink
of death. This is the kind of medicine many of us dreamed of on the
benches of our lecture theatres. And one old surgeon once said to me,
"This is doctoring at its best".
Since opening its Australian branch in 1994, MSF has received overwhelming support from the profession, with hundreds of doctors manifesting their interest in working overseas and thousands of others supporting the work with donations. None of these colleagues seeks public recognition, but their commitment is emblematic of how the profession as a whole tends to work: quietly, methodically, and with an unassuming dedication to the higher good of those we serve. The Australians who go beyond frontiers to use their skills in solidarity with populations in danger do credit to us all. |
References |
|
| Doctors recruited by MSF need to have current clinical experience of a broad type -- general practice, hospital residency or general surgery. They need to be able to work well in an international team and in a cross-cultural setting. They should be prepared to come back having learned new things about humanity, about doctoring, and about themselves. |
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The first ethical dilemma is the humanitarian alibi. Aid can be a fig
leaf for States lacking the political will to address the root causes
of an emergency. Relief is highly visible, low risk, and, compared
with military intervention, cheap. Aid workers may be used as tokens
in games they only vaguely apprehend, and it takes courage to resist
such manipulation. The dilemma lies in deciding whether to risk
perpetuating an untenable situation, or to refuse to collaborate and
risk losing access to a population in dire need.