Saturday, January 22, 2011

Refugee Medicine

The medical care of refugees, which often (though not always) takes place in a low-resource setting,
has its own fellowship at Massachusetts General Hospital. Named for Dr. Thomas Durant, who won the Humanitarian Award from the United Nations in 1995, the Durant Fellowship in Refugee Medicine promises its fellows a "full and rewarding hands-on experience in the field," caring for victims of "war, disease, drought, poverty, or politics."

Please note the honesty in the brochure's wording. People who help disaster victims do it in part because it feels so rewarding to do so. But that fact should not detract from hard questions about whether what they are doing is right in the great scheme of things, and I don't see evidence in the Durant Fellowship's online materials that it teaches participants to ask those questions. (To be fair, I haven't interviewed Durant Fellowship leaders to learn more about its aims, so consider the following words to apply to humanitarian efforts in general rather than to that particular program.)

I am lucky enough to know firsthand that it feels great to help disaster victims. Last year I went off to Haiti a few months after the earthquake to work in a field hospital, and there I was surrounded by fellow volunteers who were intoxicated by the goodness of what we were all doing. It was a tremendously good experience, and we bonded over it like kids at summer camp.

Yet there were definite downsides to what we were doing. I recall diagnosing a woman with diabetes and giving her a supply of antihyperglycemic medication, only to realize that when it ran out she might not be able to access any more. Nor did I have anyone to refer her to for long-term care. There were homeless children at the hospital who bonded week after week with new volunteers, only to dissolve in tears when it inevitably came time for the volunteers to go home.* And we were doing absolutely nothing to overcome the poverty, bad leadership, and environmental devastation that made Haitians so vulnerable to disaster in the first place. Perhaps that isn't our job--but the thought should humble us a little.

I recently read Linda Polman's book The Crisis Caravan, one of a number of books that brings a critical eye to bear on the humanitarian enterprise and argues that under some circumstances humanitarian aid can actually do more harm than good. Dambisa Moyo, a World Bank economist and native of Zambia, also criticizes the effects of foreign aid on Africa. There are a number of other books in the same genre that I look forward to reading. I don't know enough about most humanitarian aid organizations to know what kind of response they have made to these criticisms, if any. But I do know that people feel a certain romance to racing off to help the poor victims, a sense (reinforced by others around them) that they are really good people for coming all this way to help--and that that emotion can be misleading or even dangerous if it remains unexamined.

Anyone who wants an international disaster-aid experience should skeptically evaluate their proposed actions, and refrain from assuming that because they are headed off to help the sick and injured, they are heroes and immune from criticism. Too often, we doctors believe we're unambiguous warriors for good--what parent doesn't approve when their kid wants to go to medical school? who doesn't look with awe upon the intrepid Doctors Without Borders?--but I'm not as sure about that as I once was. For instance, if, as Polman argues, humanitarians are sometimes played off against one another by strongmen, then their presence in a war zone might perpetuate a tyranny rather than ameliorating its effects. Are doctors** thus turned into tools in the hands of leaders who use amputation as a war strategy? Does the organization they propose to work with have thoughtful leaders who are prepared to recognize and react to such a situation? There are other hard questions. Does their organization mishandle funds, elbow out more effective groups, or duplicate the work of other organizations? Does it engage in self-evaluation to see if its work is effective? Does it make mistakes like failing to provide for follow-up care after plastic surgery? Do the doctors help to train locals (capacity-building) so that expertise remains in place once they leave? And how, if at all, will their efforts prevent future disasters?

I would never argue that people with the power to help the dispossessed should refrain from doing so. Indeed, justice for everyone is one of humanity's highest goals, and it gives me hope for our species that we feel good when we pursue justice for others. But we must question our methods. We need to weigh the evidence about whether what we're doing will achieve the goal of well-being for all, and not reflexively accord too much weight to the rush we all get when we help.

* One, I'm happy to report, was adopted by a volunteer, and now lives happily with his new family in Ohio.
** I use the word "doctors" as shorthand for all professionals, including physical therapists, nurses, social workers, logisticians, architects, and anyone else who chooses to work or volunteer on behalf of disaster victims.

1 comment:

  1. On the same subject: