AAMC Reporter: January 2005

Physicians Risk Lives to Work in Conflict Zones

Mary Ann Hopkins, M.D., has volunteered with Doctors Without Borders in Sri Lanka and Burundi

When Mary Ann Hopkins, M.D., released her patient, the 9-year-old girl in Sri Lanka was healthy and recovering from a simple operation. A few days later, the young girl returned to the medical outpost, sick and dehydrated. The solution was simple: start an IV and pump fluids into the little girl's veins.

Medical reality, however, is rarely that simple. The girl was so dehydrated that the nurses could not insert the IV, and because of a cultural hierarchy that prevents lower level nurses from talking directly to doctors, Dr. Hopkins was the last to find out. Dr. Hopkins finally rushed the girl into the operating room and managed to start an IV, but the girl's heart failed, and she passed away.

"Losing a life is so painful as a doctor if you think something could have been done," said Dr. Hopkins, an assistant professor of surgery and director of the surgical clerkship at New York University Medical Center.

But her desire, sparked in college, to improve public health in impoverished countries overshadowed the emotional and professional stumbling blocks and led her to volunteer with Doctors Without Borders, the world's largest independent emergency medical relief organization. Through this organization, she became one of the first female surgeons to serve patients in Sri Lanka and later Burundi.

Volunteer doctors in rural locations face more challenges than their urban counterparts, Dr. Hopkins said. Not only are beds in short supply, but medications and supplies are also scarce, sometimes forcing nurses and physicians into the agonizing task of prioritizing patients. Such trying circumstances required Dr. Hopkins to treat patients more likely to survive instead of using supplies on those who were likely to die.

Tragic Cases

Burn victims of homicide or suicide attempts are common in Sri Lanka. Yet even patients with moderate burns who would easily survive if treated in an American hospital can die in medical outposts because of inadequate resources.

Patients who do survive, however, offer a glimpse into how resilient the human spirit can be, even in the face of horrific atrocities, Dr. Hopkins said. In Burundi, she treated two victims of a guerrilla machete attack, and even though their injuries were not life threatening, both had lost toes, fingers and ears. She treated both men and was surprised by what she saw the next morning.

"The next day, the two men joked with each other, cooked food for the patients, and helped clean the children," she said. "They kept begging me to let them go back to their village. It's the first time I think I've seen true courage."

Despite the risks involved, the work completed by doctors with Doctors Without Borders is vital, Dr. Hopkins said, because the organization is apolitical and treats everyone in conflict zones equally. The organization is also one of the few groups with enough doctors to make a significant healthcare change in an affected region.

"To go and heal is so important," she said. "What we do is much more important than economic aid. We show that everyone is equal and entitled to healthcare, that it is a human right."

Every year, roughly 100 physicians from the United States and other countries travel to some of the most strife-ridden areas around the globe through the relief organization. In addition to Sri Lanka and Burundi, doctors have served in the Darfur region of Sudan, Côte d'Ivoire and the Gaza Strip.

Volunteer doctors need diverse professional experience, preferably as a family practitioner or an emergency medicine doctor. Medical outposts have limited space and must maximize the efforts of every physician on the mission.

Jason Wong, M.D., a family physician from Seattle, fits the profile of a typical volunteer. As a Doctors Without Borders volunteer, Dr. Wong worked in both Côte d'Ivoire and Sudan for several months at a time and focused much of his energy on treating children.

Limited supplies also forced Dr. Wong to categorize patients, and he treated all children first before attending to adult patients. However, prioritizing patients did not help when unforeseen problems arose, such as tuberculosis or hepatitis E. Without the proper medications, Dr. Wong said he was unable to provide much relief.

Self-Reliance

Jason Wong, M.D., feeds a malnourished Sudanese child by nasogastric tube

In addition to language difficulties with French in Côte d'Ivoire and Arabic in Sudan, Dr. Wong was, for the first time, working as the only practitioner in the community. In Côte d'Ivoire, he worked without an immediate supervisor or advisor, relying solely on his own judgment for diagnoses and faced problems he never encountered during his residency at the University of Washington.

"In Côte d'Ivoire there's no local doctor with enough experience in treating diseases, so I really had to rely on my books," he said. "I walked from patient to patient with my books open to see what symptoms corresponded to what diseases. It was also difficult because I'd never had a pediatric patient die on me before."

There were not enough medical team members in Sudan either, and Dr. Wong recruited others from the local areas to help him in the outpost. He needed help taking temperatures and administering medications but had difficulty training unskilled people to do the work properly.

Although these obstacles and limitations affected his medical mission, Dr. Wong pointed to his obstetrics work as some of the defining moments of his experience abroad. Each time he delivered a baby, he said, he was amazed that new life continues to flourish in areas beset by war and misery. He also left his own imprint on these families — his name.

"Traditionally, the one who delivers the baby names it, but I tried to convince the mothers to name their own children because I didn't think a lot of kids should be running around with stupid Western names," he said. "But I found out much later that everyone had named their child after me, so there are a lot of Jasons over there."

Trauma Counseling

In addition to traditional medical assistance, many people need psychological aid to conquer the fear, insomnia and depression that conflict fosters. For these situations, Doctors Without Borders sends clinical psychologists like Michael Machilik, Ph.D., from Rockford, Ill.

During his eight months in the Gaza Strip, Dr. Machilik helped families living in the most violent areas cope with situations that they could not control. Often, he said, he could only provide encouragement to accept their current limitations and teach them to focus on day-to-day activities that they could influence, such as cooking or doing homework.

Dr. Machilik's main challenge was building trust with his Palestinian patients. Counseling sessions were sporadic because he never visited a family if fighting was too intense near their home. In addition, women were never comfortable without a male family member present, so Dr. Machilik sometimes altered his schedule. Language, the use of a translator, and limited eye contact at the beginning of the relationship made developing trust even harder.

Once he established a working relationship, Palestinian families openly discussed their fears and concerns, and children often treated him as a force of stability and peace in their neighborhoods.

"One little boy once asked me to stay the night in his house. I told him I couldn't, but I had to ask why," Dr. Machilik said. "He said, 'When you're here, the soldiers know you're here, and it's quiet and I feel safe. If you stay, I know I'll be able to sleep tonight.'"

Although the missions are sometimes dangerous, sending American physicians into conflict zones to see the problems and health effects first hand is crucial to understanding the lives of those caught in the midst of fighting, Dr. Machilik said. Physicians volunteer their time because they believe they have something to offer the innocent people who suffer across the globe.

"We receive no combat pay. We believe in what we're doing and want to provide care for others," Dr. Machilik said. "We have a responsibility to do it because we're concerned for their welfare and want to help them as much as we can."

-Whitney L.J. Howell, whowell@aamc.org

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