Portal de Periódicos da CAPES

Emergency medicine goes global: Specialty steps up humanitarian role

2006; Elsevier BV; Volume: 47; Issue: 4 Linguagem: Inglês

10.1016/j.annemergmed.2006.02.016

1097-6760

Éric Berger,

Disaster Response and Management

IntroductionAnnals News and Perspective explores topics relevant to emergency medicine, in particular those in which our specialty interacts with the political, ethical, sociologic, legal and business spheres of our society. Discussion of specific clinical problems and their management will be rare. By design, it will not be a “breaking news” section with the latest (and undigested) developments, but instead a reflective investigation of recent and emerging trends. If you have any feedback about this section, please forward it to us at [email protected] Annals News and Perspective explores topics relevant to emergency medicine, in particular those in which our specialty interacts with the political, ethical, sociologic, legal and business spheres of our society. Discussion of specific clinical problems and their management will be rare. By design, it will not be a “breaking news” section with the latest (and undigested) developments, but instead a reflective investigation of recent and emerging trends. If you have any feedback about this section, please forward it to us at [email protected] David Lanier flies in to a remote village in northern Pakistan to treat victims of a suspected cholera outbreak in the aftermath of a killer earthquake. Joel Selanikio choppers into coastal Aceh, Indonesia, his helicopter surrounded by desperate villagers struggling to survive in the wake of the Asian tsunami. Barbara Burke struggles to treat a patient dying of Lassa Fever in Sierra Leone. They join the growing ranks of emergency physician volunteers with non-governmental organizations (NGOs) providing desperately needed care in global health tragedies. “My opinion is that emergency medicine doctors are really ideally trained for this kind of work,” Lanier said. “Most of the cases you’re going to see in any developing countries are going to be your bread and butter emergency cases: diarrhea, respiratory problems…. Most of the work we do in the United States is similarly low-tech and hands on, so more than any other specialty you just have a level of comfort.” Before the end of the Cold War, American doctors, usually surgeons, internists and pediatricians, provided most humanitarian medical aid to the Third World. But when the United States emerged as the only remaining superpower, a global polarizing effect began to threaten the safety of Americans abroad, even on humanitarian missions, said emergency physician Frederick “Skip” Burkle Jr. Added to that, managed care has led to time constraints. “Managed care doesn’t tolerate its physicians leaving on long-term missions,” said Burkle, director of the Asia-Pacific Center for Biosecurity, Disaster & Conflict Research at the University of Hawaii. “Our medical system doesn’t promote international missions.” Emergency medicine, by virtue of shift work, schedule flexibility and broad clinical training, is becoming an ideal source for NGOs seeking physician volunteers. Dr. Rachel Moresky conducted a survey, published in Prehospital and Disaster Medicine in 2001, finding 45% of NGOs send emergency physicians to the field. “There’s an increasing role for EPs, and I think that’s being realized,” said Moresky, Director of International Emergency Medicine Fellowship starting this year at New York-Presbyterian, the University Hospitals of Columbia and Cornell. “I think it’s changing. There’s definitely a shift.” Doctors Without Borders, the US branch of Médecins Sans Frontières (MSF), sent about 210 American volunteers overseas this year, more than ever before. And more NGOs offer short- and long-term opportunities abroad. Selanikio, an American emergency physician who volunteered just days after the Asian tsunami in late 2004, recalled the travails of reaching victims in coastal Aceh, Indonesia. The villages were only accessible by boat or helicopter, and most marine docking facilities were destroyed by the waves. After several days, the International Rescue Committee secured transport from the US military, which took Selanikio and other support staff to one village not yet visited a week after the natural disaster. “It was kind of a scene out of a Vietnam movie, that was the kind of thing where I remember … wondering what have I gotten myself into,” he said. “We found a field of tall grass in which to land, and people were just running at the helicopter. They clearly were just desperate for some kind of medical care.” As the co-founder of the DataDyne Group, a small organization that supports public health in developing countries, Selanikio has worked in foreign countries for both NGOs and the US Centers for Disease Control and Prevention. In the last decade volunteerism has become more professional, he said, and that has led to organizations requiring longer commitments. Lanier volunteered for a mission with MSF to Pakistan last year, after the devastating 7.6-magnitude temblor shook the country’ s northern provinces in early October. The quake killed about 90,000 people, and injured about 70,000, according to the United States Geological Society. Tens of thousands of buildings collapsed, and many of the injured lived in rural towns settled in narrow valleys. Lanier, along with a couple of other doctors, a logistician and a translator, boarded a helicopter to fly into Gangwal shortly after the quake. Five children with watery diarrhea had died, and health officials were concerned cholera might be spreading in the region. “We just basically landed in the middle of a cornfield, in a valley,” he said. “It was the end of human habitation, shortly beyond there nobody lived, it was too mountainous, rugged and cold. When we set down people started streaming around us, hoping we would distribute materials.” As Pashtuns, the villagers were assumed to be at least nominally sympathetic to Al-Qaeda, Osama bin Laden’s network of terror. The MSF mission director told Lanier he would have to agree to identify himself as a Canadian. MSF officials deny this is policy, but concealing one’s nationality does raise philosophical issues, said Richard Stoll, a professor of political science and associate dean of social sciences at Rice University. “If American doctors identify themselves as Canadian, then it does not help to build goodwill for the United States,” Stoll said. “But there are some places in the world where I think it is reasonable for individuals to make their personal safety the highest priority. “Also we should keep in mind that although it would be nice if others saw that Americans can be helpful and caring about people they do not know, the most important thing is to actually help people. If an American doctor has to claim to be a Canadian in order to help people, this seems like a small price to pay.” US doctors who have traveled to the Third World generally say the populations they visit separate Americans from the US government. They may be intensely curious about the US, and question why the government does things, but they don’t tend to hold individual citizens accountable. That is not always the case, as Burkle, who has escaped 3 attempts on his life, can attest. According to State Department figures, 2003 was the deadliest year on record with 76 NGO workers killed, most in Afghanistan and Iraq. Once considered neutral, State Department Humanitarian Affairs Analyst Dennis King wrote, humanitarian workers are now seen as “soft targets” with little protection, and doctors have been no exception. (See table for list of doctors killed while working for NGOs).TableDoctors killed while working for non-governmental organizations, 1997-2004.⁎Information gleaned from news reports and NGO bulletins collected by the US State Department.June 2, 2004 – Dr. Egil Tynaes, MD, Norwegian, Médecins Sans Frontières, in Afghanistan by small arms fire and grenades.October 5, 2003 – Dr. Annalena Tonelli, Italian, shot at close range on the grounds of a tuberculosis treatment center she founded in Borama in Somaliland.November 8, 2002 – Un-named Afghan staff doctor of Mercy Corps International, died from a bullet wound after being shot during a visit to a project community.March 4, 2002 – Dr. Khalil Sulieman, Head of the Palestinian Red Crescent Society Emergency Medical Service (EMS) in Jenin, West Bank.November 20, 2001 – Dr. Kassi Manlan, the World Health Organization’s representative to Burundi, found shot on the shore of Lake Tanganyika.September 15, 1999 – Dr. Ayub Sheikh Yerow, a UNICEF doctor, shot and wounded in a north Mogadishu, Somalia, hospital. Died the next day.September 30, 1998 – Dr. Sheptim Robaj, International Red Cross, killed when his car hit a landmine in Kosovo. Another Yugoslav doctor identified as Ilir Tolaj was seriously injured.Jan 19, 1997 – Dr. Manuel Madrazo, Doctors of the World, when his compound in Ruhengeri, Rwanda was attacked. Information gleaned from news reports and NGO bulletins collected by the US State Department. Open table in a new tab “You have to pick and choose,” said Burkle, who teaches emergency medicine fellows at the Harvard Humanitarian Initiative and Johns Hopkins’ Center for Disaster and Refugee Studies. “You need to know what kind of program they (NGOs) are bringing to the community. Do they give people training or do they just show up? It’s terrifying for some people….You really have to be wary. You need to do your homework…. You really need to be mature enough to research this well enough that you’re not getting yourself or others into trouble.” MSF, which carries the gravitas of a 1999 Nobel Peace Prize, has strict requirements for doctors who apply; they must commit to a 6-month mission initially, with the possibility of shorter trips after they acquire more experience. The organization covers travel, visa and immunization expenses. It also provides housing in the host country, and per diem based upon cost of living for necessities and food. Beginning volunteers also receive a minimum stipend of about $800 a month. However, MSF may see the American government as “part of the problem,” and American involvement may be seen as a threat to the neutrality of the organization, Burkle said. That neutrality has allowed MSF to operate in theaters where other NGOs fear to tread. The president of the American arm, Doctors Without Borders, is a family physician, and an internist sits on the board. The International Rescue Committee’s health director is Australian Emergency Physician Richard Brennan, and Robert Simon, chair of the Department of Emergency Medicine at Cook County Hospital in Chicago, is the founder and chair of the International Medical Corps. Emergency physician Jennifer Leaning is a board member and founder of Physicians for Human Rights, which shared the 1997 Nobel Peace Prize as part of the steering committee for the International Campaign to Ban Landmines. Emergency physicians’ role is expected to continue to grow with the formal fellowship training grounds springing up at academic centers around the country. The Society for Academic Emergency Medicine lists a dozen international emergency medicine fellowships on its website (http://www.saem.org/services/fellowsh.htm#inter), and more are in the planning stages. Moresky notes that fellowship benefits both emergency physicians and NGOs by allowing time for long-term relationships and projects. These programs, which require 1- to 2-year commitments, represent the most comprehensive training for emergency physicians interested in humanitarian medicine. Most offer master’s degrees in public health, considered the “union card” for NGO work abroad, Burkle said. “You have to understand how emergency medical care fits into public health priorities,” Burkle said. “What we’re trying to do is develop this more into a profession. We train them heavily in the epidemiology, to look at things very evidence based and look at outcome indicators. Did it have an effect on morbidity or mortality? “One of the things we’ve learned is it takes more than achievement indicators – parachuting in and setting up a clinic, and counting how many MREs (meals ready to eat) did we hand out, how many blankets. Do these things really actually mitigate and have a positive effect on morbidity and mortality? They do create good will, but they probably benefit the health care providers by giving them experience more than anything else.” This sort of “big picture” thinking can lead to some heart-wrenching moral and ethical dilemmas, and it is often antithetical to the patient-centered medicine taught in the Western world. For instance, in eastern Africa, female circumcision is commonplace, as are its sequelae, mostly wound infections, tetanus and other pathogens. Despite criticism that they are facilitating mutilation, some NGOs have handed out tetanus shots and sterile scalpels to make infection less likely. Conversely, some times arguably the best course is inaction, a bitter pill even for seasoned veterans, which is illustrated by the thousands of amputations performed by Western doctors in war-torn Somalia, Burkle said. Most died of infection because there was no follow-up wound care. Burkle also witnessed an example of the best intentions gone awry in Rwanda, where doctors ran a full code on a child dying from cholera, including intra-cardiac epinephrine. After 3 cardiac arrests, the child died, but there were no resources left to treat the mother stricken with the same disease. She died soon after, while her remaining children stood outside the tent. “Now you have a dead mother, a dead child and 2 orphans who ain’t going to make it in that culture,” Burkle said. “There are a lot of very difficult decisions you need to make. The decision to doing anything is based on a lot of things, not just medicine.” Emergency physicians must prepare for cultural clashes as well. Burkle recalled several instances of being unable to treat patients because of obdurate tribal elders, and Lanier’s attempts to evacuate a young woman with spinal fractures were thwarted because the family could not spare a chaperone. At a minimum, emergency physicians wishing to do humanitarian work in developing nations should attend training sessions, such as the one-week course at the Cleveland Clinic or the 3-week Health Emergencies in Large Populations course offered at Johns Hopkins. Physicians abroad work in a range of conditions, and veterans stressed the need for flexibility and strong physical exam skills. Some locations may have no electricity or even running water, and equipment will be limited to intravenous catheters, fluids and antibiotics. “You’ve got your eyes, your hands, your ears,” Burkle said. “Do you have the expertise to practice the science and the art of medicine without all the bells and whistles that you are used to? That’s the shock.” Others, like a Kenya hospital where Dr. Scott Sasser worked, may have reasonable facilities and serve 100,000 patients a year. But such conditions may be no easier. Sasser, an assistant professor in the Department of Emergency Medicine at the Emory University School of Medicine who has worked in and out of Africa for the last decade, says his Kenya post wore him down. Just half a dozen physicians handled the patient load. Sasser assumed responsibility for not only the emergency department, but about 70 patients in the pediatric ward. And he lived at the hospital. “It was a 24-hour-a-day job,” he said of the Kenya assignment, where he was sponsored by World Medical Mission, the medical arm of the faith-based organization Samaritan’s Purse. But at the same time, as an American physician, Sasser said he never felt more free. A lot of the headaches of a US practice, liability, insurance and paperwork, simply didn’t exist. Instead of high-tech diagnostics, the doctor-patient relationship was strictly hands on. “There’s a certain freedom that’s wonderful,” he said. “You’re only taking notes to help you take care of the patient the next day. It takes you back to the roots of what it’s like being a doctor. You perform the exam, there’s no expensive test. So you get more human contact, you rely more on your senses; it feels like what you’ve been trained to do as a clinician.” Doctors seeking just 2- or 3-week rotations in foreign countries should generally seek smaller, faith-based efforts, but it can still take months or more than a year to prepare. Ben Busch, an emergency medicine resident at Doctors Hospital in Columbus, Ohio, collected medicines and supplies from hundreds of doctor’s offices in Columbus for victims of the Asian tsunami. But he didn’t reach Sri Lanka until March last year. After contacting several organizations, he finally found the faith-based group MercyWorks which helped sponsor the trip. Busch, involved in international relief efforts since his medical school days at Michigan State University, shares the view that growing numbers of doctors are interested in traveling abroad to offer care in developing nations. The interest especially exists, he said, among younger doctors. More medical schools are offering their students international opportunities simply because the young doctors-in-training are demanding it, he said. “I think people have a better cultural awareness because the world is so small these days,” he said. “The desire probably comes from the fact that today’s young doctors have grown up in a more global culture. We see all this terrible stuff going on around the globe, and we want to make a difference.”