On-line version ISSN 2078-5135
SAMJ, S. Afr. med. j. vol.100 n.8 Cape Town Aug. 2010
ISSUES IN MEDICINE
Natural disasters and acts of terrorism demonstrate a similar critical need for national preparedness.1,2 As one of a team of volunteers with a local South African NGO who recently went on a medical mission, I would like to share glimpses of our experience and reflect on the mistakes - and also to state the obvious: that we do not learn from our mistakes. A simple literature search has shown that the same mistakes happen repeatedly. 'Humanitarian disasters occur with frightening regularity, yet international responses remain fragmented, with organizations and responders being forced to "reinvent the wheel" with every new event.'3 This is the result of an obvious lack of preparedness.
The recent catastrophe in Haiti demonstrated major deficiencies in the international response to disasters, particularly from the USA government and the NGOs involved in providing aid that have become an industry in their own right. More than 3 million people were severely affected by the earthquake, of whom over 2 million needed regular food supplies. Over 1.1 million people were rendered homeless, and at least 300 000 people were severely injured.
Pure intentions and realistic expectations
Training and working in South Africa, we develop such knowledge as 101 uses for Elastoplast. From strapping to fixing Boyle's machines in theatre, we sometimes think that is enough to save the world. On 18 January, with a backpack and a prayer, I met up with the group of 10 medics for the first time at Johannesburg Airport international departures. Only individuals can confirm their true intentions, but the actions of our group remained humble throughout the mission, and we were shocked at the attitude and behaviour of other NGO volunteers and staff who were perfect examples of disaster tourists.
In a disaster of such a scale, there can be no hero, and one needs to face the fact that, if you are a volunteer, you need to be a jack of all trades and master of none. One cannot remain within a single job specification in such an environment. Every effort contributes to the bigger picture. A medic needs to be willing to pitch tents, hold amputees' hands as they take their first steps, and change bandages, knowing that every act of service and simple human kindness contributes to the healing of a nation in ruins.
Not only are realistic expectations required but also knowledge of the actual situation on the ground. Media frenzy and arbitrary security zones imposed unilaterally on innocent individuals do little to assist relief efforts.
Knowing the facts before entering a disaster area can help to alleviate fear. Fear is self-perpetuating and, if you enter a disaster area radiating fear and isolate yourself, you will offend the majority of people who are really the primary reason why you are there.
Were we brave or stupid? Humanitarian missions, even with planning and an extremely cautious attitude, can expose volunteers to serious diseases, accidents, assaults and even death!
Our humanitarian mission was within the first week of the earthquake, and we did not even think of the dangers we would face in the disaster area; these ended up including infectious diseases, aftershocks and looting - to name just a few. Having worked in medical evacuations, travel insurance and even being exposed to Lassa fever, you'd think I would be wiser to reality.
Arriving with limited support, communication and supplies, it was hard not to think of ourselves as just extra mouths to feed using precious resources like fuel, water and food that would be better utilised by the victims. All we could do was hope that none of us would be exposed to injury or illness - although we did take medical supplies for our personal use. One can only imagine the logistical nightmare of a medical evacuation for a team member during the mission.
Volunteers also need to take responsibility and cannot assume that the NGO or even a governmental organisation will take all precautions for the personal safety of all volunteers. Again, coming from a country where the HIV rate is high and most of us carry a personal antiviral starter pack, it still evades me why none of us thought that the same might apply in a disaster area where the chaos would add to the risk. Immunisations should be up to date and, on the ground, precautions should be taken.
To be truly independent, volunteers need to arrive at a disaster area fully self-sufficient with food, drinking water, sanitation and medical supplies for the group in addition to equipment and supplies to meet the group's objectives. Bearing in mind the need to blend into the local surroundings, it would be cruel to arrive and live in luxury while the victims surrounding you have nothing.
From reading existing literature, there are extensive pre-written lists of basics that need to be packed and taken on humanitarian missions.
A mass disaster requires individuals with integrity and honesty to volunteer, and one would like to think that the best of mankind will come forward. In such unco-ordinated efforts, no one regulates the medical profession and the scopes of practice. We experienced first-hand individuals coming to Haiti to practise on vulnerable individuals without any worry of consequences.
However, one should bear the following in mind: 'Ethical norms do not change during disasters - professionals remain obligated to providing the best care reasonable in such circumstances'.4
There were many cases where our ethical and moral consciences had to be subdued to assist with relief efforts. But if one cannot complete consent forms or case notes and work in ideal circumstances, the basic principle of 'First do no harm' should always be foremost in one's mind.
'Number of cases performed should not be allowed to trump patient safety and proper monitoring. One good rule is to offer the types of procedures that are minimally invasive, to relieve immediate discomfort, and that require little follow-up care, especially for missions that are short-term.'5 If you cannot assist, rather refer, look for expertise, relieve pain but never compromise your ethics.
Post-traumatic stress in volunteers
In an effort to co-ordinate preparedness, we need not only to focus on pre-disaster training of volunteers in clinical skills, communication and team building but also to prepare for their integration back into society after the medical mission. After 2 weeks' reflection, it has not been easy to ease back into the normal routine of life. One cannot begin to describe the events and emotions that we felt in Haiti, and it's difficult to explain since the actual scale of the disaster was simply overwhelming. I don't think the human brain can comprehend such a mass casualty and the reactions of the victims. As many as 40% of the people directly affected by disaster develop mental health conditions such as depression, post-traumatic stress disorder and substance abuse. And this can be extrapolated to the volunteers, as we were in the middle of relief efforts and exposed to similar stressors as the victims.
Debriefing, team building and preparation have been shown to decrease the incidence of post-traumatic stress.6 Having been part of a South African team who were already exposed to pre-hospital medicine, working in extremes and being accustomed to trauma was definitely an advantage. But we did not personally debrief nor make any effort to have a formal debriefing among the group members. Debriefing sessions are not formalised in any medical curriculum, but all medical personnel would benefit from formal training and applying it in day-to-day practice. There is also a stigma attached to mental health, but its importance cannot be emphasised enough.
I am not shy to disclose that I attended a trauma debrief session - but it was not easy sharing with a stranger. Individuals who share the experience have a special bond and friendship that will last a lifetime. Such a relationship can be used to assist with mental health by providing group support. Practising working in teams, debriefing and a good support structure would really benefit volunteers and assist their re-entry on arrival home.
The way forward
The Haitians will require long-term commitment from a unified international response that will benefit the victims not only in the short term but also offer a long-term solution. In keeping with the theme of preparedness, I believe that not only the victims' but also the volunteers' mental and physical care should be planned.
I also believe that the South African medical fraternity can lead by example. There is nothing stopping us, and I know that we have the willingness, resources, expertise and - now - the experience to lead a unified response.
1. Institute of Medicine. Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report. Washington, DC: National Academic Press, 2009. [ Links ]
2. Agency for Healthcare Research and Quality. Altered Standards of Care in Mass Casualty Events, Bioterrorism and other Public Health Care Emergencies. AHRQ Publication 05-0043. Rockville, MD: Agency for Healthcare Research and Quality, 2005. [ Links ]
3. Krin CS, Giannou C, Seppelt IM. So you want to help? BMJ 2010; 340: C562. [ Links ]
4. Gostin LO, Hanfling D. National preparedness for a catastrophic emergency: Crisis standards of care. JAMA 2009; 302(21): 2365-2366. [ Links ]
5. Welling DR, Ryan TM, Burris DG, Rich MR. Seven sins of humanitarian medicine. World J Surg 2010; 34(3): 466-470. [ Links ]
6. Walsh DS. Interventions to reduce psychosocial disturbance following humanitarian relief efforts involving natural disasters: An integrative review. Int J Nurs Prac 2009; 15: 231-240. [ Links ]
Dr Docrat is a product physician at Pfizer South Africa, in the neuroscience and pain portfolio. She has an interest in aerospace medicine, is still active as a practising medical doctor on a locum basis, and is involved in medical mercy missions.
Corresponding author: F Docrat (email@example.com)