It was recently my immense privilege to work in Lebanon with Médecins Sans Frontières, meeting some of the health needs of the vast number of Syrians that are living in Lebanon with chronic, non-communicable disease.
My role was coordinating and providing technical advice to a multidisciplinary team delivering care to over 2,000 chronic disease patients across two clinics in northernmost Lebanon. The clinics treat patients with coronary artery disease, hypertension, diabetes, epilepsy, asthma, chronic obstructive pulmonary disease and thyroid disease.
These are complicated diseases with multifactorial aetiology, requiring various medication regimes and often significant lifestyle optimisation. Imagine the challenge of this in a complex humanitarian emergency, living in a tent, with minimal finances and limited control over diet and daily activity.
Janine was eight weeks pregnant when I met her. A type one diabetic in her late twenties with two healthy children from pregnancies managed with self-titrated insulin and Endocrinology support in Syria, Janine presented sweaty and very thin. Throughout this pregnancy she had experienced persistent nausea and hyperemesis, and as a consequence her food intake was now inadequate for her known insulin regime.
In Syria, Janine effectively used a glucometer to monitor her sugars but the strips for the glucometer were prohibitively expensive in Lebanon. Her husband explained he was buying some, but was at times doing so in lieu of other basics, including adequate food. As a General Practitioner, a Psycho-Social Education & Counselling (PSEC) Program Counsellor and I listened with deepening discomfort, Janine’s husband explained that at nights he was unable to wake her from a sweaty, restless state that he assumed was sleep. I wasn’t so sure and suspected she was teetering on dangerously low blood sugar levels as she slept, having taken insulin but not food.
Our strips did not fit Janine’s machine. We gave her one of ours, reduced her insulin markedly, engaged with the PSEC counsellor for education and support, referred her to our midwife for onward Obstetrics referral, sent her to a local Endocrinologist for further opinion, and ultimately reflected more on the challenges of providing clinical care to pregnant diabetic women in complex humanitarian emergencies.
Adnan had had a STEMI one month previous to me meeting him. I nearly fell off my chair when I was handed a beautiful ECG showing a significant cardiac event. Adnan had faced prohibitive challenges accessing hospital care at the time the ECG was done, and had decided to go home and await his appointment the following month. I was dumbfounded. He sat there smiling at my widening eyes as I looked from the ECG to him and back again.
Through a process of involving the Médecins Sans Frontières social worker to negotiate what is in any country a complex web of communication events to access secondary and tertiary care services, Adnan went on to have an angiogram a week after I met him. Communication, education and support made all the difference, just as they would in a clinical setting at home.
Jamila was in a wheelchair, being cared for by her intellectually challenged son. He was doing the best he knew how, and was as distressed as the nursing staff to see that his mother’s diabetic foot wound was breeding maggots. Our chronic disease nurse and the dressing care nurse worked carefully with Jamila’s son to educate him about wound care. Over the next two months we saw resolution of infection and the skin starting to heal.
There are many, many more stories, some of them much more complex again. The goal of telling you these particular stories is to show how context is potentially everything. What might be a relatively simple medical problem to manage becomes potentially life-limiting in a resource-poor setting. Small investments in good chronic disease care can make an immense difference.
As a clinician, possibly the aspect of Médecins Sans Frontières I adore most is its self-reflection and adaptability. The ethics and structure of an organisation for which you choose to work is important. Understand the organisation’s goals, core principles and established values, for they translate to practical outcomes.
There is no medical college for Disaster and Humanitarian Medicine. There is no training pathway; no prescribed textbook or clinical rotation list. But there is some great information available.
It is essential to consider both the personal and the clinical aspects of how to progress to being able to be of value as a clinician in frontline, fieldwork settings.
Medical practitioners working with vulnerable populations need to have robust clinical skills, have the ability to make decisions, function well within a team and ultimately be able to make a contribution to the population they are working with. Yes, absolutely you will learn an immense amount from the patients and your local colleagues, but this must not detract from the ethics of going to each position to contribute.
One of the greatest frustrations of my years of work post-medical school was just how long it takes to really establish a generalist skillset and thus be in a position to undertake a career in Disaster and Humanitarian Medicine. Yet working now in the field I am immeasurably grateful that I did stay in Australia and systematically gain those experiences.
I’m grateful for the breadth of experience, for the rotten days in the middle of nowhere putting one more foot in front of the other, for the communication challenges at all levels of medicine and the skills you subsequently develop, and for the opportunity to work at a senior level, teaching and supervising others and facilitating others’ clinical decision making.
There are many ways to formulate a Specialist Generalist career. The path I took to develop clinical competence for generalist medical positions with Médecins Sans Frontières was as follows:
Many, many years ago, when I started out at medical school, I printed out a list of requirements for doctors from the International Committee of the Red Cross’ website. This particular list has now been superseded but you will find variations online. I stuck it on the wall, and worked towards it. Absolutely life got in the way and detours occurred, but over time, slowly the list was ticked off.
I completed Fellowship of the Australian College of Rural and Remote Medicine with Advanced Specialised Training in Emergency Medicine, and worked as a Senior Medical Officer (Emergency Medicine) in Australia. I have Specialist General Practice registration. Starting in medical school I enrolled in a Masters of Public Health and Tropical Medicine, and through experience and publishing gained Fellowship of the Australasian College of Tropical Medicine.
I worked in rural, remote, regional and urban settings, with Indigenous Australians, in the detention centres on Christmas Island, and in mining towns. I ensured at all times I was seeing a broad spectrum of patients, from primary care to resuscitation and trauma, from neonates to geriatrics. In particular, I am quite purposeful about not losing reasonable skills in Paediatrics and basic ones in Obstetrics.
The Australasian College for Emergency Medicine is another great pathway for a generalist career, and there are many other ways of obtaining Tropical Medicine and Public Health skills and experience.
With patients, with colleagues, there are thousands of moments that, for me, make every sacrifice and challenge worthwhile.
If you’d like to know more about MSF’s program in Lebanon with Syrian refugees, you can read my blog here along with those of my colleagues from around the world. They explore a number of issues that are outside the scope of this piece but may be of interest.