Posted in Issue 114 - October 2010 Editorial
Earthquakes, among other sudden onset disasters, cause a large number of traumas and disrupt the delivery of local health services. Those services may be locally overwhelmed, leading to long delays before primary care is received by the victims; a situation widely reported by the international mass media.
Is the “immediate” dispatch of foreign field hospitals and medical teams the right solution or is it a media driven response? The debate started in the region in 1976 following the expensive air lifting of a 100-bed US military field hospital arriving too late to have much impact for the wounded in the Guatemala earthquake. For a decade or so, the lesson was learned to be later forgotten. In the most recent disasters, few are the responding countries or agencies not sending field hospitals or medical teams.
In 2003, WHO and PAHO joined efforts and called a meeting of experts to review the situation and prepare guidelines. The objective was to transform an offer-driven automatism into a demand-sensitive response. As shown in the earthquakes in Pakistan and in Haiti, the guidelines are largely disregarded. No technical recommendation or results of needs assessment seemed to influence the international rush to deliver emergency medical care.
What did we (or should we) learn from the medical response in Haiti?
Although arriving far beyond the golden six hours for primary emergency care, the first trauma teams did save lives and prevented serious complications. This has been rarely the case in other disasters. In Haiti, the small size of the country, mere number of casualties and the severe disruption of the poor pre-existing hospital capacity ruled out any hope of national self sufficiency. Indeed, In India national health services were more than capable (if not necessarily prepared) to meet all the needs for health care in Gujarat. In Iran, foreign field hospitals started to arrive long after the last wounded from the Bam earthquake had been evacuated and redistributed over the 13 provinces. In Pakistan (Kashmir, 2005) logistical challenges and a population thinly spread over mountainous terrain prevented timely arrival and reduced the impact of most external medical facilities.1
Quality of services was variable: from the disaster-experienced and organized teams to the publicity-seeking individuals with unproven skills and competence. Unfortunately, offering “medical care” was the most popular entry point or pretext for pursuing other objectives be they personal, religious or political.2
Speed and local flexibility was far more important than technology and sophistication. Small mobile teams from places as far apart as Florida or Europe saved far more lives than the best equipped hospital ships arriving much later.
Collaborating with local structures and integrating Haitian health staff into the foreign teams, an indispensable condition for a harmless exit, was far too rare. The Red Cross Movement spirit of support to the local society is not always emulated by other actors. The progressive integration of Haitian personnel into the pediatric team sent by the Swiss Cooperation and their well-planned handover to the University Hospital was also an exception noted by the health authorities.
If there was an initial acute shortage of medical care, rapidly it turned into an uncoordinated flood of competing initiatives resisting the supervision from an otherwise seriously disrupted local Ministry of Health.
The main lesson is perhaps that the humanitarian community just did not seem to learn lessons! The tendency to call the latest catastrophe as “unprecedented” is a disguised and convenient way to suggest that the excess and failures bear little relevance for the next disaster!
The WHO/PAHO guidelines, however imperfect they may be, were just not heeded.
The main reason is that the problem is not technical (better specifications and norms), it is political. Adjusting medical response to needs will be similar to the arduous selling of the concept of “safe hospitals”: Norms were refined and adopted by experts in a matter of a few years...with little impact on even the construction of new facilities! Pressure had to be built through conferences, high visibility public awareness campaigns and sensitization of decision makers for what they occasionally see as an inconvenient long-term concern competing with their most pressing priorities.
Then what should be done about this dysfunctional medical response?
Reject the fallacy that the Haiti earthquake is so unprecedented that “not too much” should be learned from it! If one thing, the Haiti tragedy confirms how actual the PAHO video on myth and realities remained! A full compilation of observations and systematic documentation of health errors and failures need to be compiled and published. Memories, especially humanitarian ones, are very short.
Review the 2003 PAHO/WHO guidelines on field hospitals. Indeed, some aspects of the impact and response in Haiti were not foreseen and need to be considered in a new version. The scope of the guidelines should also be broadened and include medical teams. Large medical/surgical capacities deployed in Haiti did not consider themselves to be “field hospitals” and therefore not subject to the 2003 norms! This review will be initiated at a meeting of experts in December 2010 in Havana, Cuba.
Widen the debate on key issues such as:
- When is it too late for immediate trauma care?
- Where is the right balance between sustainability and ambitious “minimum requirements” for humanitarian assistance? In other words, when does providing too much medical assistance during a short period of time may become detrimental?
- How to internationally support and enable medical staff and volunteers from the affected or neighboring countries to play a greater role in the medical response? Local or regional volunteers may be more adapted and available but are often marginalized by their lack of the most basic logistic capacity and material resources.
- How to insure quality control of the health assistance provided. Professing to be “accountable to the beneficiaries only” should not be a license to provide substandard care. Registration and accreditation (certification) of potential foreign medical teams is an avenue being explored with the support of DFID and the Swiss government. How to, and who should do this accreditation?3
Mobilize, sensitize and involve political decision makers: It is a global issue that should be approached at global level. The topic should be discussed from the ECOSOC meetings and the WHO Health Assembly to the Regional Committees and national forum. This cannot be done without some participation of the mass media. As for many subjects, it is a too serious matter to be left to the experts or practitioners only.
Let’s hope that reflecting about the errors and shortcomings of the response to recent earthquakes and the tsunami will create this political will indispensable for any collective progress. It is time to transcend the good intentions and mold them into a broader view of the short and long term interests of the affected population that we all serve.
A group of experts, from PAHO/WHO and other agencies, will revise the existing guidelines on the use of foreign medical teams and field hospitals in emergencies and disaster situations at a meeting that will be held in Havana, Cuba, from 6-8 December 2010. We will publish the results from this meeting in the next issue of the newsletter.
1. Simple Cuban “field hospitals” consisting in fact mostly of mobile primary health care teams were more efficient and appreciated than large trauma care facilities from traditional donor countries.
2. Lancet 2010 Editorial: Growth of aid and the decline of humanitarianism. www.thelancet.com. Vol. 375, January 23, 2010.