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The transition from acute to chronic in medicine and in the humanitarian work of the ICRC

20-03-2008 Feature by Marion Harroff-Tavel

How do humanitarian workers in a country emerging from war, and doctors practising medicine in Geneva, experience the transition from an acute to a chronic problem – from saving lives to supporting patients suffering from a long-term illness? This was the subject debated by doctors, patients and ICRC managers in Zinal, Switzerland, in March 2008. The author of this text is a political adviser to the International Committee of the Red Cross, responsible for the analysis of future trends. The text reflects the author's opinions only and does not necessarily correspond to the views of the ICRC.

   

   
 
A village is attacked. The population escape through what their attackers deem a “humanitarian” corridor but which they in fact exploit to kill, wound or extort money from those fleeing through the checkpoint. The elderly – exhausted, terrified and frozen – travel across a snow-covered mountain pass. The doctor at the dispensary who meets them practises emergency medicine and has no time to consider his patients’ emotional state. The ICRC delegate, meanwhile, is busy distributing food and blankets and driving back and forth in his Land Cruiser transporting the dying.

  One year later, a ceasefire is in force. It is time for reconstruction to begin. The same doctor no longer spends his nights extracting bullets, amputating limbs and resuscitating the dying. Most of his time is dedicated to caring for patients suffering from a chronic illness, such as diabetes. Patient support has now replaced emergency surgery. As for the ICRC delegate, his job is now to support the health system or repair a water-supply system. The stage of distributing water by lorry is over.    
     
 How do humanitarian workers in a country emerging from war, and doctors practising medicine in Geneva, experience the transition from an emergency to a chronic problem?  This iss ue was at the centre of a debate that brought together ICRC delegates and members of the medical profession, in particular specialists in therapeutic education for diabetes patients, in Zinal, Switzerland, between 1 and 5 March 2008. The debate took place under the auspices of the Fondation de Recherche et Formation pour l'Éducation des Patientsguidelines for ICRC work in countries in transition (the foundation for research and training in patient education) and the International Committee of the Red Cross, at the instigation of Professor Jean-Philippe Assal, a member of the ICRC Assembly and a diabetologist. I had the opportunity to attend this meeting, after having previously been able to participate in ICRC activities during periods of armed conflict and post-conflict, and help produce the from armed conflict to an often fragile peace.

This is what humanitarian workers and doctors in Geneva had to say about emergencies and chronic situations:

  • First of all: there is no clear-cut distinction between a crisis and a chronic situation. Chronic illness is often uneventful, but can also involve acute crisis periods that need to be treated as emergencies. Humanitarian work during a post-conflict period also involves unexpected crises. For example, we may suddenly have access to an isolated region which was previously cut off from humanitarian aid during fighting. This is one of the reasons why using the continuum between emergency and development as a framework for analysis has long been called into question.
       
 
  ©ICRC/T. Gassmann/sd-e-00215    
 
  Darfur. The ICRC surgical team at work in Zalingei hospital.    
   
 
 
  • Second point of agreement among the doctors and ICRC delegates: in acute situations, that is, during a crisis, "doing" takes precedence over "being". To save lives, we must act quickly and work as a team. Action is more important than listening, even though listening should always be part of a doctor’s work or part of an assistance programme for people affected by armed violence. In chronic situations or as soon as the crisis is over, attitudes and perceptions become more important. The patient asks us to " be " as well as to " do science,” even though that is still necessary, of course. He needs to talk about his illness or about his distress at the destruction of his environment by the conflict. He needs to confide his loneliness, his feeling of abandonment, his fear of permanent disability, his fear of death.
     
    The patient, as a survivor of armed conflict, will feel unable to confide in someone who he perceives to be overly preoccupied with the technical quality of his work. If a doctor hides behind impenetrable scientific and rational details or if an ICRC delegate accords an exaggerated degree of importance to the rigorous implementation of what appear to be bureaucratic procedures, he loses all warmth as a human being. In other words, he should be ready to listen to people who want to talk about their suffering and not be afraid of showing that he is affected by it.
     
    For anyone who comes into contact with human suffering on a daily basis, maintaining the right distance from the other person and knowing when to close that gap is a challenge. Emotion is frequently hidden behind reserve or held in check for fear of losing control, because it is contagious. Emotion can throw us into utter turmoil but it can also be a positive experience. Sharing emotion allows us to step outside our roles and everything associated with them. Of course, the ICRC has to remain neutral and cannot express a judgement on the cause of the suffering. However, this is about experiencing a genuinely intimate moment in which the unspeakable can be expressed.
     
     

  • Third comment: being entrusted with the suffering of others is a burden and it takes time – and knowledge – to process what has been heard and transform it into positive energy. The doctor as humanitarian worker is often overwhelmed by feelings of powerlessness and by his inability to respond to the scale of the tragedy. He is brutally confronted by death. The head of a medical team at a hospital, like the head of delegation, must remain scientific and rational and must look after his team. He does not always seek out their support as he may see management of the team in hierarchical terms, meaning that he has to take difficult decisions alone. Being able to recognise the warning signs of burn-out and therefore prevent it is both an individual and an institutional responsibility.
     
    Once the crisis is over, both the doctor treating a patient with a chronic illness and the humanitarian worker need to know how to provide support, that is, how to withdraw into the background.   This transition is not easy, as it involves a loss of control. It is no longer about managing a patient's treatment or providing humanitarian aid quickly and independently and taking decisions on behalf of the other person based on an assessment or diagnosis. It is no longer simply a question of informing the family. It is about helping that person take control of his future once more, regain his independence and, despite the scars in his life, make his own decisions. He needs to be supported within his family or community, who may also need help. This can take time. There may be some loss of effectiveness, given the distress experienced by someone who has to rebuild his life and who has been unable to mourn his friends and relatives and all that he has lost. It is not easy to become fully operational immediately.

   
  ©ICRC/B. Heger/sd-e-00215    
 
Farchana refugee camp, eastern Chad. An ICRC delegate talks with a mother whose baby daughter suffers from a serious eye affliction. The child will be brought to an ICRC field clinic where she will receive appropriate care.    
     

The doctor will teach the diabetic patient to manage his dependency, pass on his knowledge and provide the patient with psychological support. The humanitarian worker will respond to the needs of those who have survived the war, as they define them. He will build capacity locally, and, if needs be, increase the capacity of the National Red Cross or Red Crescent Society. He will be open to learning new things and will be enriched by this.

I remember when we consulted the residents of a village in the Balkans after peace was restored. Our survey revealed that the villagers wanted trees to be planted in the cemetery to protect the elderly from the blazing sun as they mourned their lost relatives, the traffic passing in front of the school to travel more slowly to avoid accidents, and the clinic to be rebuilt. We dealt with the third request and informed other international agencies about the others. That is the essence of a participatory approach.
 
 

  • Fourth line of thought: the work of those who dedicate themselves to crisis, to emergencies, is valued more highly and receives more recognition than the work of those who deal with chronic problems, in both hospitals and humanitarian organizations. There is an “aristocracy” of people who deal with acute problems. Emergencies, according to a doctor in Zinal, encompass heroic moments, they receive recognition. An operation is successful. A patient is saved and expresses his gratitude. His relatives celebrate. Dealing with chronic situations does not attract the same recognition from others. For the rest of his life, the patient must be helped to manage his dependency or the scars left by the crisis. Sometimes the doctor asks himself: “Am I making a difference?“
     
    It is the same story at the ICRC: operations are very highly valued. The organization is proud to have deployed to a conflict zone within four days. It announces the number of wounded who have been treated. But how often do we talk about the success of a delegate who has distributed seeds and tools and shown a farmer how to use local vegetation as fertilizer (provided, of course, that he hadn’t already known about this since time immemorial)?
     
    In conclusion, there are limits to comparisons, but interdisciplinarity is a way to learn. A diabetic patient in a hospital in Geneva and someone left temporarily vulnerable by armed conflict naturally have different identities and problems. Analogies between medicine and assistance during armed conflict (both food and non-food) do not necessarily apply to other areas of work. That said, the doctor and the ICRC delegate (who may also be a doctor) can be of great help to one another if they share their thoughts on the transformation that must take place during the transition from crisis to post-crisis.

As far as the ICRC is concerned, optimizi ng this transition involves being aware of development and reconstruction requirements as early as possible in the crisis. On a local level, the organization’s humanitarian work may help to piece together the social fabric that has been torn apart. The human quality of the men and women it employs are the true richness of a humanitarian organization.

  The author of this text is political adviser to the ICRC. The text does not necessarily reflect the views of the ICRC but rather those of the author.