100 years on, ICRC nurses face greater challenges than ever before

11-05-2012 Interview

Exactly 100 years ago, the Florence Nightingale Medal was instituted by the ICRC. It is the highest international distinction that can be awarded to a nurse. Philippa Parker, a long-time ICRC nurse in the field and current head of the health unit at the ICRC, describes the challenges facing nurses today in countries afflicted by armed violence. She evokes the increasing lack of security that plagues the delivery of effective health care. Philippa is also working closely on the ICRC's Health Care in Danger project, which aims to reduce threats to health care in armed conflict and other emergencies.

Why do you think Florence Nightingale is still spoken about today, over a century after her death?

I would say that it is her humanity and her conviction that she had to do something for the wounded soldiers, because nobody else seemed to be doing particularly much for them. War is a pretty awful thing and just to know that there's somebody around who cares means a lot.

As there was little nursing training at the time, Florence was virtually self taught. Her deep sense of caring and humanity is what inspires me and I think a lot of people in the nursing profession. Her body of work improved the status and training of nurses and indelibly linked nursing with deep and sustained caring for a patient, and recognition as to how important this role is, especially in situations of armed conflict and other emergencies.

Take Khalil Dale, for example (an ICRC nurse with 30 years of humanitarian service who was supervising the Weapon-Wounded Assistance Programme in Quetta, Pakistan, when he was kidnapped, held for four months and recently killed). Khalil was someone, like Florence Nightingale, who simply cared deeply about other people.

Another example of caring comes from our hospital in Peshawar (Pakistan) and Mirwais hospital in Kandahar (Afghanistan), as well as many others around the world. We can't measure it, but the caring aspect of our work in those hospitals has a huge impact. Let me illustrate this point.

A man from the FATA area of Pakistan brings his wife and kids in who have been wounded and stays in the hospital in Peshawar for two weeks. Why do they come to our hospital? Well for one, our hospital is free, but more importantly, we provide post-operative care. We don't have the high levels of equipment that they have in some of the hospitals in Peshawar. But we provide 'after-care', and that man sees people who really look after his family. He goes back to his village and he has a better understanding and respect for us (the ICRC) than he had before.

We even have some hard evidence of this. The ICRC did a small reputation survey in the border region between Afghanistan and Pakistan in 2003. And what was the ICRC remembered for? They all remembered us for our hospitals in Quetta, Peshawar and Karte Seh.

You received the Florence Nightingale medal in 1993. What does this recognition mean to you?

I have to say that I think it meant more to my parents than it did to me (laughs).

But in all seriousness, it was recognition for the work that I had been doing since 1984. By 1993, I had been at the Thai-Cambodian border conflict for quite some time, in Afghanistan, Pakistan (Peshawar and Quetta), and Berbera in Somaliland (Somalia). It meant that somebody saw that I had done something beyond what a nurse normally does.

What was also important to me was to have it recognized that a nurse can bring caring to a patient that often no other member of the health team is able to do. Because you’re the patient's advocate, you're always with the patient. Whereas the surgeon does his operation and off he goes, the anaesthetist the same, the physiotherapist sees the patient for let's say, the left leg, and we, the nurses, hopefully see the patient as a whole and develop a relationship with them.

I think the Medal helps to give this caring role the credit it deserves, as it plays a huge part in looking after patients. So we don't perform the surgery. Nonetheless, our role is extremely important. It's the one-on-one humanity role.

In my view, I didn't have exceptional courage; I simply loved what I was doing. I loved that I was really helping and able to do something that had a direct impact on people.

What are the greatest challenges facing nurses and nursing aides today working in countries afflicted by armed violence?

The main challenge facing ICRC nurses directly is a lack of security. Whether you're in a hospital or out in the field, trying to carry out vaccination campaigns, or whatever, it's the lack of security that is the biggest challenge. From there stems a lack of personal safety, lack of security for the patients trying to get to you and sometimes lack of security right in the hospitals or health centres. Often there is a lack of infrastructure and supplies due to the general lack of security.

For national staff nurses or nursing aides living and working in the country, the challenge comes also from all the other things that they have to contend with in life just to survive and hold a job at the same time. They're worried about their family, have we got enough food, do we have to collect water. It's a challenge to be able to commit to the job when you have all the outside challenges to deal with.

Another challenge particular to some of today's internal conflicts is that the front lines and parties to the conflict are not clear, which was not the case in the days of Florence Nightingale. It is much harder to show that you are a neutral, independent humanitarian worker in today's conflicts compared to the past, because the conflicts are many-layered and complex, and this increases the dangers.

Let's take certain contexts in which we work today. If I'm working in one particular area, the risk can be that I'm considered as part of the group that controls that area. If I move to another area, I can be considered as part of the opposite side. And control of the areas changes on a daily basis. One day ICRC medical staff can go to a place and the next they can't because it's been taken over by the opposite side.

Can you recall an event from your own experience or an example of work done by nurses in situations of armed violence that marked you?

First of all, people should understand that the extent and brutal nature of the wounds in situations of armed violence shocks all the health staff, particularly when they first start.

In Kabul (Afghanistan) in 1989, I remember being in town. The shelling's started, you go in the shop, you come out again, you see all the windows of the car (ICRC land rover) have been blown out and you're thinking 'oh, I'm going to be in trouble now'. There are clouds of dust all around and you look down the street, and there are bodies, and you look up the street, and there are bodies. While you're registering what's happened, there are about eight people, all bleeding and hobbling towards you, and of course they want to get in the car and go to the hospital. So you get them in the car and you take them to the hospital.

But I never looked at those people that were lying up and down the street. Now, I would probably look at the ones in the street but then, I didn't, and I never thought right or wrong about it. You were frightened, you already had enough patients to more than fill up your car. You didn't know what was going to happen next so you just took the patients to the hospital. But you know we (the ICRC) teach first aid, we teach triage (the sorting of patients to determine medical priority). The reality is that in these extreme situations you cannot, or for whatever reason you do not, follow procedure; you simply do the best you can.

How do you see the link between Florence Nightingale's vision and legacy and the ICRC-led "Health Care in Danger" project?

The objective of the Health Care in Danger project is to assure the security and delivery of effective health care in armed conflict and other emergencies. What Florence did has laid a path towards the delivery aspect of this objective and has emphasized the neutral and impartial aspect of caring for the sick and wounded.

You look after the wounded and sick no matter who they are, or what side they are on. Period.


Philippa Parker (middle), in the ICRC hospital for weapon wounded in Peshawar, Pakistan 

Philippa Parker (middle), in the ICRC hospital for weapon wounded in Peshawar, Pakistan

Kandahar, Afghanistan. An ICRC teaching nurse examines a child in the paediatric ward of Mirwais Hospital. 

Kandahar, Afghanistan. An ICRC teaching nurse examines a child in the paediatric ward of Mirwais Hospital.
© ICRC / M. Kokic / af-e-01196