Humanitarian medicine: one person at a time

There were times when the suffering surrounding us was almost unbearable. I remember the bombing of a town and its civilian population in northern Afghanistan (1997); the endless stream of refugees seeking protection and assistance after having been attacked in their camps in the Guéckédou region of Guinea (2001); the hollow eyes of a malnourished child joining hundreds of others in one of our feeding centers in the bush of southeastern Angola (2002); the woman with a terrible machete wound in her neck after by chance surviving an attempted decapitation in Bunia, Democratic Republic of the Congo (2003).
The humanitarian identity of Médecins Sans Frontières is rooted in medical assistance to "populations in danger." But we never intended to care for entire populations, which from a medical point of view is impossible anyway. It's much simpler, more humane - and a lot smaller! We care for people - one person at a time. Our humanitarian identity puts the individual human being - with all his worries and concerns - at the center of our attention. Through the discovery of our patients, and the recognition of the individual human being and his suffering, we may render the medical act truly humanitarian. It's the most vulnerable who need the most attention; they are at the same time the most anonymous and forgotten. It's the sick, the wounded, children and elderly persons, the aggressed, the poor, the unprotected. Human beings in acute distress need other human beings to get back on their feet and the hand held out by the medical doctor won't be refused. As much as in the Western world, patients in developing countries - and even more so in war contexts - need more than a prescription and a cold handshake. They expect attention, time and an encouraging word - this is only human! Technical knowledge and competence are important to treat people correctly, but insufficient when we want to care for human beings. If we keep this in mind, the medical act becomes not only a way to cure a patient of a given disease. There's a lot more to it. It's the discovery of a person and the context she or he is living in; it's a confidential, intimate relationship; it's a glimpse into the past of a suffering individual - and, hence, offers the possibility to preserve or restore the human condition, which frequently is affected by more than just a physical "health problem." Crisis situations in general, but especially those characterized by extreme levels of violence, have a disastrous effect on the self-respect of affected individuals. Being confronted with violence can be a depersonalizing, even dehumanizing experience. In crises like those in Ituri (Democratic Republic of the Congo) or Liberia, human life is too often degraded to mere survival. The local communities have only very limited resources to react to this unimaginable extent of human suffering. The individual is frequently left alone to overcome injuries, hunger, fear, diseases and the terrible feeling of having irrationally been attacked by other human beings. Aid actors, politicians and today's media frequently reinforce the proliferating anonymity of human suffering when trying to draw attention to a given crisis situation. That's why we have to constantly remind ourselves that behind the empty eyes, the hungry faces and the infected or wounded bodies, there is the universe of an individual human being with his own perceptions, ideas and dreams and, thus, specific needs. Physical presence makes all the difference Although I have always tried to do my best to save lives and alleviate suffering during my years working as a medical doctor with MSF, I have lacked, now and again, the means to do what could have been done in Western hospitals, where I learned my profession. In the field we are frequently confronted with situations in which we would feel a lot more comfortable if we had an additional laboratory exam or a more efficient drug. We have all experienced moments when decisions were based on medical knowledge and common sense rather than on sophisticated diagnostic equipment. And at one stage or another most of us have lost a patient because the next surgical facility equipped to save a multiple trauma patient was too far away to be reached in time. There were times when the suffering surrounding us was almost unbearable. I remember the bombing of a town and its civilian population in northern Afghanistan (1997); the endless stream of refugees seeking protection and assistance after having been attacked in their camps in the Guéckédou region of Guinea (2001); the hollow eyes of a malnourished child joining hundreds of others in one of our feeding centers in the bush of southeastern Angola (2002); the woman with a terrible machete wound in her neck after by chance surviving an attempted decapitation in Bunia, Democratic Republic of the Congo (2003). However, the intense frustration we felt in these situations originated more in the uselessness of human suffering than in our limited capacity to respond to the horrendous consequences or the underlying causes. We did what we could and lives were saved! Moreover, our mere presence in combination with swift and professional action generated a spark of hope where there was only despair before. In these situations, I have realized, it's our physical presence, our closeness to the people we assist and our solidarity with them that makes a difference. It has always been difficult to individualize assistance in extreme crisis situations. When tens of thousands are suffering, it is, indeed, hard to devote much time and attention to individuals - especially when resources are limited. According to the needs, aid actors - MSF included - have to distribute food and shelter, ensure the constant supply of drinking water, install latrines and hygiene facilities and prevent epidemics - frequently in very difficult and unsafe circumstances. In my opinion, however, medical assistance cannot be provided successfully if a minimum of personal contact isn't present. In this respect it is preferable to keep a project and, thus, the number of "beneficiaries" smaller in order to devote more time and energy to the individual human being. Or we have to make sure we bring in enough medical personnel to provide human and effective care for larger numbers of people. We can't save everybody - we have to make choices. We also have to provoke other actors to take up their responsibility to act, thus expanding the number of people who can be cared for. The humanitarian avalanche (which we have seen rolling over many recent crisis situations) can bring in a lot of drugs, medical equipment and logistical supplies, but not necessarily the human resources necessary to spend time with patients. Indeed, donor agencies are rather reluctant to finance personnel whereas they are more than happy to give huge amounts of money for aid supplies. In the end, "humanitarian coordinators" are discussing in air-conditioned rooms, driving around in comfortable 4x4 vehicles and planning how to best distribute all the material and supplies they have at their disposal. The distance between these people and those they came to help is palpable and the assistance provided unsurprisingly mediocre. This tendency, which we have also experienced within MSF, needs to be countered if humanitarian action is to remain meaningful. Public health - a humanitarian cul-de-sac? In 1999, I was sent by MSF on a mission to Madagascar - as a public health manager, not a medical doctor. I contributed to the introduction of a cost-sharing scheme, set up an epidemiological surveillance system and trained health workers who, ill-paid, were ill-motivated. Contact with patients was not a priority - human suffering was all around us, but did not figure in our "action plan." We cared for the national health policy and not for patients. It took me a while before I realized to what extent I was drifting away from my humanitarian convictions. Like all policies, national health policies are influenced by societal needs, economic capacities and, sometimes, nationalist sentiments. They do not aim to bring rapid relief to a suffering individual, but set conditions for a given society to become "healthier." Yet they are undoubtedly necessary, and thus it is understandable that states, health ministries, development agencies and public health experts insist that MSF get involved and concentrate its efforts on these "common and public objectives." Although valuable, it's simply not humanitarian to design national health policies. Their elaboration and implementation should be left to politicians and development experts. Public health policies do not cure patients. For a human being in distress it's the here and now - the physical connection and the act of healing, or at least trying to, which makes a difference, and not ambitious ideas outlined on pieces of paper, destined for the future. Keeping the individual at the center of our work also means that we can approach overwhelming or unimaginable problems without despair. The AIDS epidemic is one example. Forty-two million people living with HIV/AIDS is an overwhelming public health problem; a 22-year-old woman with AIDS is a human being who can inspire compassion, who can be listened to and known. She can be treated, and her life possibly made better. The "overwhelming" problem can be approached. In 2001, I met Josefina in Nairobi, Kenya. Due to AIDS, she was simply too weak to care for her four children. All her financial reserves had been spent on treatment for opportunistic infections, diseases contracted because of her weakened immune system. Her life seemed to be doomed, and the lives of her children too. In 2002, I met her again. In the meantime she had been enrolled in an antiretroviral (ARV) treatment program, gained at least 15 kilograms and restarted her work as a tailor in order to send her children to school. She radiated a touching joy of life during our last meeting - something which had been unimaginable a couple of months earlier. However, only a minority of Kenyan AIDS patients have access to ARVs and political and economic considerations seem to impede a rapid change in the national health policy. In 2002, during a field visit to Angola, I saw a ten-yearold boy, Avertino, suffering from severe malaria at one of the health posts surrounding Menongue. He didn't react to the chloroquine treatment he received (not from MSF) at the health post. Resistance of the malaria parasite to chloroquine and other standard anti-malaria drugs is developing rapidly in sub-Saharan Africa. Luckily, I had some tablets of the very effective treatment ACT (artemisinin-containing combination therapy, drugs readily available and widely used in Western hospitals) in my emergency box and started treatment immediately. Three days later, the boy was able to leave the hospital - cured and laughing. It is true that the treatment which saved him is - compared to chloroquine - expensive and, thus, does not form part of the Angolan malaria treatment standard. But as a medical doctor respecting medical ethics, I had no choice but to "violate" the national malaria treatment protocol, in order to provide the best possible treatment and, thus, give the suffering boy in front of me the best possible chance to survive and recover quickly. If both Josefina and Avertino had been seen from a distance simply as anonymous members of a large category of patients (AIDS sufferers, malaria patients), it might have been tempting to accept that at the moment they would not have access to the treatment they needed, because the country, the system wasn't ready to provide it (lack of funds, or a protocol not yet in place). But when we see them as suffering individuals, we cannot accept the application of second-class medicine. And by insisting on effective treatments in our programs we may induce change and, thus, ultimately have a positive effect on an entire society. Violence - a particularly devastating "disease" Violence in all its forms can also be considered as a "public health problem." Millions of people suffer direct and indirect consequences of violence each year, leading to physical and psychological trauma in its most severe forms. Integrating this fact into public health planning is certainly necessary, but it can't be done to the detriment of action when it is most needed. And, beyond the fact that lives can be saved, a spark of hope may be lit. In a Burundian regroupment camp (forced regroupment of people during conflict in an attempt to cut off supply for rebel groups is a well-known military strategy in Burundi), a soldier went berserk and discharged his machine gun into the crowd, which resulted in the death of seven persons and serious injury to another six (Ruyaga, 1999). As the authorities claimed initially that the rebels were at the origin of this deadly aggression, no organization, institution or anyone else wanted to rescue the injured. Despite possible security constraints, MSF decided to act. When we finally arrived in the camp, hundreds of people were gathered around the small health post. As soon as our ambulances were spotted the crowd started to cheer and applaud. While living through a nightmare for hours, the sudden realization that others do care generated hope. All six patients survived after being evacuated to Bujumbura; this morning in Burundi remains engraved in my mind as one of the most striking examples of effective medical, humanitarian action. While public health experts would have registered six more deaths on a sterile epidemiological surveillance sheet, MSF saw these six specific people as humans who needed independent humanitarian assistance, thereby saving them and comforting hundreds of others who were there. Considering our patients as persons - one at a time - ultimately helps us to bring truly humanitarian aid to people who are victims of wars and other kinds of violence. Millions of people battered by war and conflict can provoke only feelings of helplessness; caring for some among them and bearing witness to what they are suffering can not only restore health and dignity to the injured, but also reinforce the caregiver. Humanitarian action may be a small remedy given the magnitude of useless, global suffering. However, it can make a huge difference, if we can avoid pretending that we will change the destiny of entire populations. Once we start shifting our attention from individuals to groups, societies, or populations, we risk adopting an approach which inevitably neglects the individual. If this happens the foundations of humanitarian action start to crumble. "Humanitarian medicine" - an ambiguous term During my years with MSF, it has become clear to me that to offer truly humanitarian medical assistance, proximity to our patients and their suffering is fundamental. This is especially true where respect for human life is endangered or has already been destroyed. But being with our patients is one thing. We must also strive to offer them the best possible care and treatment, although (and because) our working environment does not always permit us to reach the necessary quality standards to cure all individuals seeking our assistance. This kind of humanitarian medical action not only provides a chance to offer the most humane care possible, but also gives us the credibility and opportunity to point out and influence the root causes of their problems. If "humanitarian medicine" is a synonym for medical, humanitarian action as described above, it can and must exist. However, where public health imperatives, manipulation and greed reduce medical action to a lowquality, few-resources approach in a worldwide charity business, the individual patient, while slipping into anonymity, will perceive the presence of a third-world, second-class medicine, which far too often claims to be humanitarian. MSF vehemently opposes this. Medical, humanitarian action goes beyond the mere analysis and repair of physical disorders; it offers choices where there were none; it provides a human touch in an inhumane environment and it may ultimately help reestablish human dignity. The medical act, the contact between doctor and patient, this closeness to human suffering remains crucial if we want to remain humanitarian in act and spirit. Humanitarian medicine is medical practice according to universal medical ethics based on a moral concept, which values human life and dignity - the human condition. And this is not utopian; it's very realistic...and desperately needed.