Tag Archives: humanitarian medicine

Stuart Kinmond reads the CMAJ Humanities Encounters article "He was a boy with a name". The article is written by Dr. Nicholas Batley, associate professor in the Department of Family Medicine at the American University of Beirut Medical Centre in Lebanon.

The article tells the true story of Dr. Batley’s encounter with a young Syrian refugee on the streets of Beirut. The patient’s name and personal details have been changed to protect his identity.

Full article (subscription required): www.cmaj.ca/lookup/doi/10.1503/cmaj.160530

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D_BDavid Benrimoh is a fourth year medical student at McGill UniverDr. Cecile Rousseausity

Dr. Cécile Rousseau is a professor of psychiatry at McGill University, working with refugee and immigrant children

 

The Syrian Civil War has become the greatest humanitarian crisis since the Second World War, creating over 4 million refugees. These refugees have, in large part, taken up precarious temporary residence in countries such as Egypt, Jordan, Turkey, Iraq and Lebanon. They are unlikely to find permanent residence there because of local integration policies, and so are left to either wait until the conflict in their homeland is resolved, or to apply to attempt to resettle in another country. It must be understood that those living in refugee camps face difficult conditions: sexual violence, trafficking of women and children, and lack of access to healthcare and education.

Because of poor conditions and limited opportunities in camps, many refugees try and make the move to another country. We have all seen reports of refugees drowning by the hundreds while trying to cross the Mediterranean, and the EU has been paralyzed by indecision with respect to who should take how many refugees. Canada has committed to taking in 10,000 refugees by year’s end ...continue reading

Bryant_MSF_cropSimon Bryant is a Canadian Physician currently volunteering with MSF in the Mediterranean

Editor's note: This piece combines two of Simon's blogs published on Médecins Sans Frontières' staff blog 'Moving Stories' on April 26th and May 4th respectively.

Since I arrived in Malta on April 18th over sixteen hundred people have drowned in the Mediterranean, and it's sadly starting to look like the deadliest year ever for trans-Mediterranean crossings. European politicians have scrambled to respond and the "Triton" program, consisting of naval and coast guard ships patrolling Europe's maritime frontiers, has just seen its funding tripled. Still it seems their objective won't be specifically "search and rescue" (SAR) benefiting those near death and close to the Libyan coast, but rather "wait and see" much, much farther north. ...continue reading

Patrick_ODonnellDr Patrick O’Donnell is a Clinical Fellow in Social Inclusion at the Partnership for Health Equity, a pilot project of the the University of Limerick’s Graduate Entry Medical School in Ireland

It was a one of those endless days in the medical library in my third year of studies that I had an epiphany. I had become pretty disillusioned with my life as a medical student and I was starting to doubt my reasons for choosing this path. I remember leafing through a fairly dull journal when I came across a series of reports on student electives to far-flung impoverished parts of the world. My attention was immediately seized and I quickly set about finding out how I could become part of the wave of idealistic students who go abroad every summer to help people less fortunate than themselves. To be able to marry my passion for travel with an interesting medical experience seemed like an incredible opportunity.

This was the start of a journey that led me to India, the Solomon Islands, Haiti and Nepal to take part in IHEs (international health electives) over the next four summers. They were all very different experiences, but I returned with the same positive feeling; “I have helped in a meaningful way”. These were experiences I could not have gotten at home, I felt. These were making me a better person and hopefully a better doctor in the future. The feelings they created in me and the reactions of those I told about my experiences on my return made me feel like I was definitely making good use of my knowledge and skills.

Looking back, I doubt I made a difference at all, as a recent CMAJ editor’s blog suggested. I was ill prepared and very naive. Language was a barrier to being any way useful in all four of the countries I visited. Often a member of staff (usually a qualified nurse or doctor) was assigned to translate for me as I chatted to patient in the clinics. This ‘baby-sitting’ was a waste of skilled professional time in services that were often overstretched to begin with. I didn’t know very much about the common conditions in these far-flung parts of the world, and often the little I did know related to advanced tests and expensive treatments unavailable in the countries I visited. I brought with me some old textbooks, antibiotics and some surgical supplies to donate to clinics. I had done a little general research on each country I visited, but still managed to encounter civil unrest in both the Solomon Islands and Haiti. I had no plan B, no formal emergency contacts and my medical school did not know anything about my exploits.

Don’t get me wrong, I had the time of my life, and the experiences I had and the people I met have moulded me as a person and a doctor.

That medical student worldwide are attracted to IHEs electives is not surprising. A recent study in Ireland on the attitudes of university students to global development reported that 83% of those surveyed felt it was important to do something to improve the world in which we live and 81% felt that traveling abroad to volunteer is the most effective action to take.

It is not surprising then that bright, enthusiastic medical students act on these impulses. I know I certainly felt as a medical student I had much more to offer on a developing country elective than my colleagues studying arts or business. I also know, however, that as a medical student I was less inclined to examine my reasons for travelling, my activities while away and the effects of my trip with a critical eye. I had never been to a homeless shelter or an addiction service in my own country, yet I was delighted to fly half way around the world to meet similarly marginalised patients in distant places.

I now have the benefit of age, experience and a higher qualification in global health and yet I am still conflicted on the issue. Do IHEs serve a purpose? What do students actually gain from them? Do they cause harm? Are they safe? Who is ultimately responsible for the students and their welfare while on IHE? These are some of the many difficult questions generated by the phenomena that are IHEs.

One area that is beginning to be looked at is the ‘host’ experience of these IHEs and their effects on health services in the developing countries visited. The studies that have so far been published do show despite all the expected problems with IHEs; such as cultural incompetence and language difficulties, there are benefits (Bozinoff et al. 2014, Kraeker and Chandler 2013). Most of the positive gains reported relate to improved partnerships between developed and developing country academic institutions and that concept of reciprocity that is often mentioned, but very hard to achieve in this context.

There are now a huge variety of resources for students to encourage practical preparation and that provide thought provoking scenarios that focus on the inevitable dilemmas faced on IHE. Many medical schools now have modules on global health and cultural competencies. Post-exposure prophylaxis kits for HIV exposure are much more widely available. Students are a lot better informed on world news and issues in foreign parts. Communication with home and emergency contacts are easier. All of these factors should make for better informed, safer and more knowledgeable IHE students.

Whether IHEs are truly successful as a life changing learning experience, however, rests with the attitude of the students themselves.

In addition to those mentioned in the previous blog, some international resources include:

The Ethics of International Engagement and Service-Learning (EIESL) project from UBC, Canada
Elective guidelines from the UCL Centre for International Health and Development
• Ethical scenarios on the Responsible Electives website
General advice and actions for volunteers

Dr Patrick in action as a newly qualified physician working in an obstetric unit in rural South Africa

Dr Kirsten Patrick is Deputy Editor at CMAJ

Last week I was fortunate enough to be invited to a great workshop, organized by the CMA’s Public Health division, aimed at developing a unified policy and advocacy platform for humanitarian medicine. As the background reading material pointed out, many Canadian physicians are interested in participating in humanitarian medicine initiatives and work or volunteer abroad at different stages of their life and career. The problem is that many such activities are ad hoc, not optimally planned, fragmented, and undertaken without due consideration of their impact. The CMA hopes to co-ordinate efforts in Canada to explore and delineate best practices, and to optimize the way that global health activities are coordinated among NGOs, physicians, residents and medical students.

I’ve had some experience with developing guidelines for best practice during short term experiences in global health. In 2010 I was part of a group led by Jeremy Sugarman, professor of bioethics and medicine at Johns Hopkins, and John Crump, a professor at Duke’s Global Health Institute, that produced the first Open Access guidelines on Ethics and best practice guidelines for training experiences in global health. The first decade of the new century saw an explosion of global health programs that would send students and graduates for short term experiences, usually from a developed country to a less developed country (without much traffic in the other direction). To quote Sugarman, we now have a “stunning  prevalence  of  initiatives covering  a  broad range  of  activities,  institutions,  and  countries”, offered by “Governmental, Non-­‐governmental, Religious, Humanitarian relief, Academic and Professional [organizations].”

In the early 1990s, as a medical student in Johannesburg, South Africa, I spent some clinical rotations in Baragwanath Hospital in Soweto. There I met many foreign medical students (mainly German and British) who came to get 'developing world experience' (mostly of performing surgery that they would not get to perform at home). If they were keen and hung around long enough sooner or later they’d get to do an appendectomy, or a circumcision, or excise a lipoma the size of a baseball. Ethically sound behavior? Mmmm. Not so much.

But it isn't just students. Trained physicians from wealthy countries also go to less well developed areas to offer their skills. Historically the pattern was for physicians to pack up their lives and go to live and work in an under-served area for many years. Yet in the last few decades the ease with which air travel and temporary accommodation can be arranged has changed this pattern. Now the opportunity exists for physicians to keep their ‘developed world lives’ relatively intact while taking a short trip to ‘do good’ somewhere else.

Do they do good? That's the million dollar question. While they may be motivated by good intentions there is no clear evidence that such activities are beneficial in an enduring way to the host countries. An oft-quoted paper points out that there IS benefit for physician who goes abroad for the brief stint, both for that physician personally and for his/her home country (because such people are more likely to work in under-served areas back home in their future careers). Trainers from leading humanitarian organizations acknowledge that one thing we DO know for sure is that there is always some harm that comes from even the most well-intentioned of humanitarian missions (see list of resources below).

Some of the ethical considerations and potential negative consequences of short term global health experiences were outlined in an influential 2008 JAMA article. The cynical term ‘voluntourism’ is perhaps a realistic descriptor of such activities, given their clear benefit for the traveler and much less clear benefit for the receiving community.

I think there is a particular difficulty for many who are fired up by the noble desire to ‘do good’ or ‘make a difference’ to stop and think about potential negative consequences of their well-intentioned behavior. Because how could giving up one’s time for the good of others be bad? Yet it is probably ‘placebo’ at best as some have argued “don’t go”. But realistically, without some Icelandic volcanic ash scenario in which all airplanes out of North America and Europe are grounded, physicians will continue to go abroad on global health ‘missions’. The only thing that we can do is increase awareness of ethical concerns, encourage physicians and students to think about scenarios ahead of time and endeavor to educate, educate, educate…. in the hope that the harm done by people going on global health experiences and humanitarian missions can be minimized.

The CMA meeting’s participants were top notch, representing all the main stakeholders leading the way in humanitarian activities and global health electives in Canada and some international players, perhaps with the notable exception of experts from countries who receive medical humanitarian missions and voluntourists. The CMA will produce an official report at the end of the process. In the mean time here are some educational and support tools that may be helpful to those who are thinking of going abroad to ‘do good’ in a medical way.

  • The Johns Hopkins Berman Institute of Bioethics collaborated with the Stanford Center for Innovation in Global Health to produce an excellent case based online course on Ethical Challenges in Short-Term Global Health Training. [This course is based on the guidelines on Ethics and best practice guidelines for training experiences in global health I mentioned earlier; it is widely understood that case studies are the best tools to teach applied ethics…best for pre-departure training, but also useful as an in-field resource and to assist debrief after return.]
  • HumEthNet, a website that developed out of empirical research on the ethical dilemmas faced by humanitarian healthcare professionals working in humanitarian crises, disasters or areas of extreme poverty.
  • The McGill Humanitarian Studies initiative, which offers the Canadian Disaster and Humanitarian Response Training Programs that range from an introductory course to an advanced program that includes simulation training.
  • The 53rd week, a non-profit organization that aims to maximize the benefits derived from short-term volunteer initiatives using innovation, education, and research.