More thoughts from the MS1 Global Health selective. Last Tuesday we welcomed Dr. Emilie Calvello, who talked about her work in emergency disaster relief following Haiti’s devastating earthquake and the evolving response to the rapidly spreading cholera epidemic. She shared some of the difficulties of working in conditions of such great and urgent need but limited resources and insufficient infrastructure and organization, and the ethical dilemmas that she faces when deciding to care for one patient over the many others who seek help. Yet in spite of the many difficulties and sometimes overwhelming situations that she described, what was most evident was her indomitable passion for the work that she does…
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I really enjoyed last week’s discussion with Dr. Emilie Calvello. It was truly a unique and amazing opportunity for us to get an real view of what actually happened in Haiti after the earthquake and the kinds of roles that physicians have had there at that time and now. There were so many problems that had to be dealt with, especially in a country like Haiti, which had a poor health care infrastructure to begin with. What I thought was most interesting was the idea of triage and how it was applied to the disaster areas. As physicians we’re trained to be empathetic and have connections with our patients, even in busy ER’s. But in a situation like Haiti, you are forced to move extremely fast and sometimes not give the adequate amount of care necessary. Dr. Calvello talked about feeling guilty on multiple occasions because she spent so much time with one patient. She knew that with that same amount of time, 10 patients could have been treated. At times I feel that it’s definitely necessary to focus on one patient and their complex problem. It’s easier said than done, and doesn’t seem too realistic. In these situations physicians are sometimes forced to see things in the big picture and loose importance of each individual life. There is a constant battle between numbers and resources and I feel that it is the biggest problem in disaster settings.
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I took away two main thoughts from Dr. toxoid talk on the humanitarian response to the Haiti earthquake and the assigned readings. First, I left her talk thinking about the implications for the standard of care and the decisions that physicians must make when there are insufficient resources to meet the medical needs of patients. Even as first year medical students, we have already internalized a standard of care dedicated to providing the maximal benefit for each individual patient, and it seems unimaginable to be put in a situation where we must decide which patients will receive medical care and resources and which will essentially be left to die. In the face of an imbalance between medical needs and resources, it makes logical sense that physicians should allocate the relatively scarce resources “for the greater good” of the population, but it also seems antithetical to our moral responsibility to each of our individual patients. I know that decisions about how to ration care are unavoidable in an emergency situation where resources are inadequate to meet the needs of patients (and where the worst possible decision is probably not making a decision at all), but I still do not know how I would personally cope with having to make those decisions as a physician.
Second, I was struck by the extent to which emergency situations exacerbate the baseline health problems of the affected population — for example, the prevalence of tetanus after the earthquake in Haiti because only 53% of the Haitian population had been vaccinated (along with the inability to store tetanus toxoid or immune globulin without a cold chain during the emergency response). Similarly, the problems resulting from weak infrastructure of the Haitian health care system were clearly magnified in the context of the earthquake, making the provision of medical care even more difficult in those circumstances. It underscored for me the importance of understanding the baseline problems of the population when planning for and implementing a humanitarian response to an emergency situation.
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For many, the 2010 earthquake that devastated Haiti is quickly fading into the past as we look forward into 2011. Nearly one year after the earthquake, I was shocked to see how little recovery has taken place. Buildings are still crumbled and destroyed, people are still displaced, and the people and continually being presented with new health challenges. The challenges seem insurmountable for a country that was facing so many problems even before the earthquake. I truly admire people like Dr. Calvello who have stayed with Haiti since the earthquake and are now looking into the future and trying to figure out the best way to proceed. She showed us the many sides of emergency relief. From a clinical standpoint, she reminded us to pay attention to the basic diagnostic techniques because in an emergency setting, most diagnoses have to be made solely from a physical exam. She illustrated the logistical challenges of delivering aid vividly through her example of tetanus infections. When patients came to her with tetanus, she was able to recognize it, but could not treat it because there was no established cold chain. Finally, she showed us the ethical challenges faced by doctors in an emergency relief setting. It is such a challenge to balance a utilitarian view of doing the most good for the most people with the compassion that each human life deserves.
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One of the challenges often mentioned in global health projects is the issue of keeping volunteers safe in foreign countries. While the “safety” of countries varies greatly (and is a controversial issue in itself), this issue is of particular concern after natural and man-made disasters, events that often go hand-in-hand with health crises. In her presentation, Dr. Cavello showed several pictures of the American soldiers stationed around her clinic shortly after the earthquake, and mentioned the contribution of US Armed Forces towards maintaining security at her site. This got me wondering about what exactly would be the “best” way to handle security issues, both for small-scale projects and large-scale disaster response.
From my own experiences, the group I worked with in Central America hired former local police officers as security guards, and stationed us at a base surrounded by a barbed wire fence and armed guards. Given the political instability of the country, and it’s reasonably high rate of violence against foreigners, I thought this level of security actually worked pretty well: to my knowledge, none of the hundreds of volunteers for this organization ever had any violence directed against them in country. Using locals, and specifically former police officers, as guards also helped us interact with the local community, in that the guards often acted as translators, and helped control crowds. On a few occasions, having police officers with us also helped us bypass police and military checkpoints with relative ease. While this strategy worked well for our purposes, I can see a major problem though: police forces are often not as highly regarded and received by the community as they were in our case. I could certainly see how having police officers as guards could actually make global health groups a target in some countries.
As evidenced by Dr. Cavello’s presentation, disasters create and exacerbate security issues exponentially. At that scale, I highly doubt having just a few armed guards or officers would be enough to secure a large clinic or hospital: larger and better-equipped military or paramilitary forces are likely required. The effect of disasters on security certainly aren’t unique to third-world countries either: large numbers of national guard troops were sent to New Orleans following hurricane Katrina. As we discussed in class, there seem to be several main groups that have responded to international disasters: US Armed Forces, UN Peacekeepers/Security Forces, and the military forces of the country in question. Each of these have positives and negatives. US Armed Forces have a strong logistical network, and good training, but are often viewed as an extension of imperialism, and resented by locals. UN forces don’t seem as resented as US forces, since they’re linked to an international organization and not a single country, but can have their own problems (I’m going to avoid going into these specific problems, as I don’t really know enough to comment accurately, and don’t want to open up a can of worms). The effectiveness and local opposition to the armed forces of the country in question can also vary wildly. After looking at the options, I’m not really sure there is a “best” option for securing global health interests in large-scale disaster response. Maybe this problem deserves some dedicated public health research?
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I was intrigued by Dr. Calvello’s description of those doctors who showed up to the main hospital (“where the action was”) and graciously offered their services for a couple of hours. I find this interesting not for the easy shot it allows one to take at a moment of unintentional self-absorbtion, but, rather, for the way it reminds us that we are all human and our reasons for doing anything will always be tied up in the sense we have or ourselves, what we want, and what we want to be. This, of course, is not to say that altruism cannot exist. But it is never simple, and I think Dr. Calvello did a good job of addressing this, however tangentially.
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Similar to Dr. Bollinger from the week prior, Dr. Emilie Calvello shared a tremendous amount of information on the benefits and potential pitfalls of engaging in global health work overseas. But Dr. Calvello’s work in emergency situations and disasters, as opposed to the long-term developmental work that Dr. Bollinger spoke of, added a completely new perspective to the world of global health for me. Learning of Dr. Calvello’s work in Haiti has allowed me to realize that dedicating one’s career to global health emergencies can provide immediate relief to areas ravaged either by natural disasters or man-caused crises (i.e. war). Finally, a common theme from both weeks was the importance of balancing the desire to help in a foreign nation with a realization that foreigners, especially from the United States, are not always welcome – a point that all who plan on working in other countries may want to keep in mind. All of this has helped me learn a great deal more about global health.
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The degree of destruction that is pervasive throughout Port Au Prince is shocking. It has been almost a year since the earthquake, over 1 million people are living in tents, and the recent flooding and cholera outbreak have introduced additional complicating factors. Dr. Calvello’s presentation highlighted the fact that disaster relief requires collaborative efforts between many different foreign organizations and the local community. One of the pervasive themes throughout the last two global health sessions is that the opinions of the local community cannot be ignored and that a consideration in any global health endeavor should be sustainability. Although it is true that the purpose of disaster relief is to address an acute situation, one of the impediments to an efficient response in Haiti is because there is little infrastructure. Even global health workers in disaster relief should devote efforts to developing local expertise and sustainable practices.
