|Courage and conviction|
|Friday, 02 March 2012|
Professor Tony Redmond has spent three decades delivering medical care in dangerous situations around the world. Here he discusses his experiences and how best to use emergency medicine in an international crisis
It was in 1988 that my team, the South Manchester Accident Rescue Team (SMART), was asked to respond to the earthquake in Armenia. This had a profound effect on me; never before had I been exposed to so many hundreds and thousands of injured people and so many dead bodies. The terrible tragedy of this huge earthquake provoked an outpouring of sympathy and teams were mobilised from around the world. Our pre-hospital trauma team linked up with the fire brigade and formed the British response to the earthquake.
This sudden influx of people without proper coordination and preparation caused as many problems as it sought to resolve and, therefore, the UN Disaster Assessment and Coordination Team (UNDAC) was formed. The original team had 20 members and I was one of the founding representatives from the UK. Eighteen of the first 20 members of UNDAC had been in Armenia. The lessons learnt then are as valid today – if you want to be effective and help people, only go if you are asked; if you go uninvited you will become another refugee, who will drain the resources of an already compromised society.
Improving local response action
We were not in Armenia very long and on my journey home I was determined to do things better. I had only been home a matter of hours when I received a call about the Lockerbie Air Disaster. Within an hour or so of it occurring, we were mobilised with the RAF to the scene at Lockerbie and I spent 36 hours in Lockerbie helping identify human remains and supporting the local community.
"Too many of those who turned up uninvited at Haiti provided no proof of medical qualification, made no medical records and went back to their countries and are now untraceable and unaccountable – this is not acceptable"
These two experiences made me determined to improve the response to large scale disasters and we trained with fire and rescue and the ambulance services to make the South Manchester Accident Rescue Team much better prepared. In 1990 when we responded to an earthquake in northern Iran at the request of the Iranian Red Crescent Society we knew from experience to go first to where the casualties would have been evacuated to and later to the scene to treat those less severely injured and not transferred to hospital. Because of the good relations we had established with the authorities in Tehran once again we were invited to Iran in 1992 at the time of the Kurdish Refugee Crisis. We provided medical services to over a million Kurdish refugees on the Iran-Iraq border and stayed there until the Red Cross Red Crescent Society were able to get there to follow on our work in establishing a more permanent facility.
Functioning in conflict zones
By the time Bosnia came it was clear a national team was needed and so UK-Med was formed and drew teams from all over the UK who went out on a rolling basis to support surgical services, particularly in Sarajevo. Because Sarajevo was under siege, water and electricity were often turned off by the Serbs and in the middle of the winter we had to put a domestic fire into the middle of the operating theatre and run it from a diesel-powered generator. On one occasion, the Serbs had fired an anti-aircraft shell into the hospital’s intensive care unit, which went through one wall and out another, thankfully without exploding. Snipers would shoot to maim rather than kill in an attempt to demoralise the population –shooting at the spine to produce paralysis or both thighs to produce bilateral high amputations. We met with our Bosnian colleagues at the end of the war and I asked them what was the single most effective thing we had done throughout the war and they simply said, ‘we came’.
We then moved on to Kosovo and I was medical director of the hospital in Pristina following the NATO invasion. There I saw for myself a middle-aged woman who had been machine gunned by the Serbs and was so frightened that the Albanians in the hospital would kill her if she had an operation that she came armed with what looked like a grenade and said that if we attempted to operate she would activate the grenade and kill us all. The problem was she was clearly bleeding out and very soon she would not be able to hold onto the grenade and we would all be killed. We took the decision collectively to operate and she was gently sedated while the grenade was removed from her by the Army (it turned out not to be active), surgery was carried out by an international team that I put together and she was transferred safely to Belgrade where she made a good recovery.
The Haiti crisis
We responded to the earthquake in Haiti with a core surgical team, supported by emergency physicians and nurses and logistical support from the UK NGO, Merlin. Haiti was already extremely vulnerable. Six months before the earthquake, the mayor of Port-au-Prince had said 80% of the buildings were about to fall down, so when the earthquake occurred they simply crumbled. Moreover, the UN already had a heavy presence in the country, and more than 200 UN workers, including the head of mission, were killed in the earthquake and so international support had to start from scratch.
We sent a small team out first and found a good spot to pitch our tents in the grounds of a disused hotel which we chose because it had running water and working toilets. Working with Dr Louis, a local doctor, we established a working hospital in a former tennis court with a waiting room, emergency room and dressing clinic. The type of surgery you can carry out in these circumstances is largely determined by the follow-up facilities and surgery is also dictated by the provision of oxygen – once you have a good supply of oxygen then you can perform much deeper sedation and anaesthesia and this allows more complex and more prolonged surgical procedures. Dr Louis told us that the Brazilian Army had a good supply of oxygen and we secured the supplies and set up our surgical service.
When a crisis hits
The UNDAC team will respond very quickly and, if more international help is required, will post their findings within hours on their website. As a doctor you need to determine if it is medical or non-medical help that is needed, and is it people or equipment that is needed. It is important to recognise when considering medical interventions in humanitarian crises that medicine is only part of the response; it is other needs that need to be met first. The most important being the supply of clean water and sanitation, and then the supply of food. The provision of shelter and safety, particularly for women and children, is also a priority. So it is important that those who provide medical help understand where medical help fits in the list of priorities.
When I’m asked by the public how best they can help when a major disaster occurs I say that by and large it is always best to send money rather than supplies. I have found only limited evidence for things getting to the country itself or to the people for whom they are intended. If you give money to the Disasters Emergency Committee you can be pretty certain that it will be spent appropriately.
The most common natural disaster I have responded to is an earthquake. Foreign medical teams dealing with earthquakes will not be treating severe head, chest or abdominal injuries as patients will have either received life-saving treatment already or will have died by the time you get there. Those who survive can have spinal injuries, limb injuries and in some cases amputations must be carried out.
The hidden casualties of war
One often thinks of women and children being the most vulnerable in war and they often are, but the hidden causalities of war are the old, the already ill and the mentally ill. It is particularly hard to summon international aid to treat the mentally ill. In Sarajevo we had a small number of chronic schizophrenics who couldn’t get their medication because of the siege and it was extremely difficult for their families to manage a paranoid schizophrenic when the city was being shelled and snipers were at work. Diabetics were vulnerable without their supply of insulin. It was very hard to get patients evacuated to other countries. There was a political and legal process to go through and then it became even harder for countries to take people with chronic diseases, particularly with the elderly.
It might be said that there are in fact no "natural" disasters. There are natural phenomena but the disaster is often a failure of prevention or mitigation. An earthquake itself doesn’t kill you – only falling buildings. But people are forced to live in earthquake prone areas in poor quality buildings. This is related to poverty and is therefore a product of politics and economics and these can be changed if we have the will.
"Delivering aid to conflict zones brings its own special problems. There is the obvious danger and one must think very hard about going and understand and accept the true nature of the risk. Also one must consider the concept of neutrality and is it always achievable. By taking aid to the most vulnerable you will be seen as partisan by the rest. If you spread your limited aid equally between all sides, the most vulnerable will get less. Florence Nightingale no less raised similar issues with Henri Dunant the founder of the Red Cross for his notion of a neutral third party giving aid to the wounded of war.
This she said relieved the responsibility for the consequences of their actions from the warring factions, leaving them free to wage war without hindrance. It’s a complicated world and these arguments still play out today when giving aid to the besieged might prolong their resistance but thereby increase their dead. However in my experience human beings can value some things more than their own life but also the lives of others. Dealing with the dead
It is a myth that epidemics follow earthquakes and it is very important that people understand this. Dead bodies pose little risk to health even when there are many of them and they are decomposing. The ignorance surrounding this leads to, as in Haiti, the burning of bodies in the street and mass graves. The problem with mass graves is that people can never find their loved ones and be sure that they have died which brings psychological, social and legal problems. Dead bodies are only a risk when the person died of certain infectious diseases such as viral haemorrhagic fever and also cholera. In these circumstances body fluids remain infected for some time after death. But in an earthquake, where people were well and died suddenly from injury, there is no risk to health.
Accountability for action
Foreign medical teams need to work alongside local colleagues and ensure that they have provided adequate follow up for their patients when they leave. External fixators provide a good example. When we returned to Pakistan some months after the earthquake, we found in the more remote areas external fixators on legs that had been put on by foreign surgeons but with no means of removal the limbs were now infected.
After the Haiti earthquake, amputation rates varied between 1 to 47%, however because of the paucity of medical records made by foreign teams, we do not know the reasons why the amputation rates varied or were so high. What is required urgently is a minimum, uniform data set on reporting and an agreement to share information so we can bring emergency surgical practice after earthquakes and natural disasters into mainstream practice. This would allow proper audit and more peer reviewed publication. Sadly too many of those who turned up uninvited at Haiti provided no proof of medical qualification, made no medical records and went back to their countries and are now untraceable and unaccountable - this is not acceptable. Any doctor that goes to an emergency overseas must first ask themselves whether they are licensed to practice medicine in that country, and if not they must make themselves accountable to the local ministry of health and/or appropriate authority.
How to help
I now work at the Humanitarian and Conflict Response Institute that studies the responses to these events in order to improve our knowledge and the aid given to the victims of these disasters. We have established the UK International Trauma Register and now anyone in the UK who would like to respond to a disaster overseas can register with us (www.uk-med.org) - it is inclusive, everyone is welcome. We will look at a medic’s experience and advise what further training is necessary. We also provide field training opportunities in Africa and India for those who have not worked in that type of environment.
We are now working with the Royal Colleges to develop a specialist training course for those who will respond to these types of disasters. I also chair the other Foreign Teams Medical Group at the World Health Organisation in Geneva, which is aiming to get an international code of practice, a registration of teams and the sharing of information, again to improve accountability and effectiveness. Even though terrible things happen and people suffer greatly, there are more resilient people than vulnerable people. The capacity for mankind to cope with these disasters never ceases to amaze and the altruism of those willing to help lifts my heart much more than the cruelty of people in wars can sometimes make it sink.
Professor Tony Redmond is Professor of International Emergency Medicine, Lead for Global Health at the Manchester Academic Health Sciences Centre and Deputy Director of the Humanitarian and Conflict Response Institute at the University of Manchester