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Physician, Nurse, and Truth debate merits of New York Times Banda Aceh story

New York Times logoJanuary 20, 2005 -- On January 6th, the New York Times ran Jane Perlez' "For Many Tsunami Survivors, Battered Bodies, Few Choices." The lengthy front-page piece described care in Indonesia's Aceh province as being provided almost exclusively by physicians, and with its reliance solely on expert comment by physicians, the Truth argued in an analysis that no one could possibly come away from it thinking nurses or other health care workers are doing anything of significance in the stricken province. See the Truth's full analysis of the Times article here. Since our analysis appeared, we have received messages from several of the physicians profiled in Perlez' piece, and one of their nursing colleagues who was ignored in the piece. The messages took us to task in vigorous (and at times personal) terms; some suggested, inexplicably, that we had faulted the work of the nurses Perlez ignored. We post below two messages that reflect some understanding of our analysis, followed by our response.

Physician Paul Luckin, who was featured in the original Times article, responds:

I was interested to see the article on your website regarding nurses and their work in Banda Aceh, and the apparent lack of recognition of their work.

The handful of nurses in Banda Aceh worked unbelievably hard, and did an incredible job. They worked very long hours in apalling (sic) conditions, with little equipment and a huge workload - as did every member of the team. They are a credit to themselves and to their profession.

The article by Jane Perlez in the New York Times was accurate, for a number of reasons. First, there were no nurses in the operating rooms at the hospital we worked in, other than the three operating room nurses in our own team. The local nurses were largely either dead or unaccounted for, as were the majority of their doctors, ward staff, other health care workers, and general staff. The last estimate was that over 80% of their nurses had been killed. The rest were mostly missing; we were told that very few were in the hospitals. Of 300 local hospital doctors, 150 were dead, 130 plus missing; 17 were at work in the hospitals.

During our operating times the operating room in the hospital principally described by Ms Perlez was staffed by 5 doctors, three nurses, and one ambulance paramedic, all members of our Australian team. Sometimes we were assisted by Indonesian staff, although as far as we knew none of them were nurses. Lifting and carrying of patients was done by the paramedic, our one male nurse, doctors, occasionally Australian soldiers (both male and female), or any helpful Indonesian hospital worker we could find (- none of whom were nurses.) A surgeon mopped the blood and pus on the floor, while the nurses cleaned the few surgical instruments we had and prepared for another case as fast as possible. As far as I know the Malaysian and Indonesian teams had no nurses in theatre while they were operating, because there were none surviving.

The article correctly describes Dr Schumack as tending to a dying patient, because he did. You may well "wonder about who was more likely to be performing such an important act, nurses or senior surgeons," but you would not wonder if you had been there to observe for yourself. There were no nurses in our "recovery room", if you care to call the floor in the entrance corridor a recovery room. Dr Schumack looked after the patients waiting to go into theatre plus the post-operative cases largely by himself. It is very easy to be an armchair critic, less easy to stand the reality of an operating theatre in Banda Aceh six days after a tsunami. The four hospital volunteers who carried Novi's body to a small bus were untrained civilian locals, willing to do anything they were asked to do. All of the members of our team helped with every task, not one of which was pleasant or easy. Our nurses worked beyond any reasonable limit, as did every member of the team. They had nothing to do with infections and wound care, not because they are unable to but because we could not spare them to do so - their skills were needed in the operating room, and they worked only in the operating room. You appeal for fairness, and accuse Ms Perlez of bias, yet feature photographs showing clean, uniformed, relaxed nurses - I do not know where those photographs are from, but they are not from Banda Aceh post-tsunami. (Truth's note: they are from Thailand and India post-tsunami). I did not ever see a single uniformed nurse, or a clean one, or a relaxed one. I saw a lot of haggard and exhausted workers, mostly people who had come to Banda Aceh to help.

To answer your headline question; yes, nurses were doing something of importance in Aceh - but there were so few of them that most of the activities which are generally the province of nurses were done by others, as described by Ms Perlez. Ms Perlez did in fact observe carefully, and her article was both accurate and balanced.

The articles' acid comment that Ms Perlez "neglected to mention how physicians are rebuilding all the structures of Banda Aceh by hand and serving bowls of soup to every living resident" does not reflect well upon your writer or your publication. It also fails to uphold the dignity and standards of nursing professionals everywhere. It trivialises the apalling (sic) death and suffering in Banda Aceh, where over 100,000 of a population of 300,000 are dead. Most importantly, it does not reflect the very high standard of professionalism that we associate with our nursing colleagues.

And from a later message Dr. Luckin comments:

Sandy, you are in a wonderful position to raise awareness of the terrible problems nurses in Banda Aceh will have during the recovery phase - probably the next ten years, and to garner support for them. Their infrastructure has been destroyed; there will be no nursing teachers left, few resources, no money to provide them. This is an opportunity for people who care to help provide the basis for an assistance programme for nurses and nursing in Banda Aceh. The political and religious differences will require very diplomatic handling, but the need is huge.

Sincerely,

Paul Luckin

Nurse Liz Cloughessy, who was ignored in the original Times article, responds:

How sad and disappointing to read the commentary regarding the role and value of nurses, especially as the comments are coming from a centre that claims to be nursing advocates. As the nursing leader of the Australian team and an emergency nurse with over thirty years experience, I am appalled that some nursing circles still have to resort to the very tired doctor / nurse debate to try and raise the profile of nurses. A team of 28 highly qualified Australian practitioners which included nursing, paramedics, firemen, public health, infectious disease, emergency, anaesthetic and surgical specialists were deployed to Banda Aceh to contribute and support our Indonesian colleagues to the best of their ability. Not one member of the team went to Banda Aceh with media recognition or public acclaim as their top priority. Never at any time did any member of the team say, “it’s not my job” or “I don’t do that”. All of the team were sensational and worked so hard in difficult conditions to do the best that they could and I feel privileged to have worked along side each and every one of them.

Do not devalue the team or what was accomplished for sensationalism.

As we worked, we were all under constant pressure from the world media to make comment and as you are no doubt aware, journalists will ask specific questions and then are at liberty to edit to meet their own agendas.

The four emergency nurses and four operating room nurses were fantastic, but so were the rest of the team.

Please let us focus on the real heroes, the wonderful people of Aceh and the enormous task that they face in trying to rebuild their community, our Indonesian nursing, medical paramedical, police and military colleagues who worked tirelessly along side us, and the Banda Aceh dedicated volunteers, who having lost many of their family and friends turned up every day to work as interpreters for us.

To my colleagues at the Centre for Nursing Advocacy, please continue to be advocates of nursing and promote loudly the skill, expertise and diverse roles of nursing, but let us not devalue our professionalism, standards or integrity by criticising another profession.

Liz Cloughessy


The Truth replies:

We salute Ms. Cloughessy, Dr. Luckin, and the other physicians who wrote to us for their work in Aceh province, and we thank them for providing important information about the work of nurses there that Jane Perlez' New York Times piece unjustifiably failed to provide.

Because some of the responses do not seem to reflect understanding of the basic point of our analysis, we will start by restating it: Our main point was that Perlez' Times article ignored the work of nurses, and gave readers the impression that only physicians were providing care of any significance in Aceh province, and by implication, elsewhere in the tsunami disaster zone. We did not criticize the actual care provided by anyone. The title of our piece, "Are nurses doing anything in Aceh Province?", was rhetorical. The Truth About Nursing at times uses devices like this to make our points more powerfully. Of course we know that nurses are working in Aceh province and are saving and improving many lives. As for physicians, they deserve credit for their own work, but not for the work that nurses or others really do. They do not deserve to have a team composed of five different types of professionals described as a team of physicians.

In light of the global nursing shortage, this matters a great deal. When the real contributions of nursing are ignored, the world--including health care decision makers and potential nurses--remain convinced that only physicians matter. When society does not know that nurses save lives, that nursing is a distinct and autonomous science that is vital to global health, nursing is undervalued and underfunded in practice, education and research. These factors lead to understaffing, which drives nurses from the workforce in a vicious cycle. In the US, only half of 1% of the national health research budget goes to nursing research. For this to change, the world must learn what nurses really do. And that starts with media coverage. In most of the media, if a nurse or other health worker does it or says it, it's not news. For physicians, the reverse is true. Extensive research and analysis bears this out, as a glance at our web site would confirm. (Given this state of affairs, we commend Dr. Luckin and the other physicians for taking what we say seriously enough to attack it; too often, physicians feel comfortable simply ignoring the concerns of nurses.) Research has shown that the media has a significant effect on health-related views, including those that affect nursing. The nursing shortage, to which the mass media regularly contributes through biased accounts, has cost thousands of lives and is one of our most urgent health crises, especially in developing nations like Indonesia, as a recent report by the International Council of Nurses (pdf) made clear.

Despite Dr. Luckin's claim that Perlez' piece was "balanced," our main point--that the piece ignored the vital nursing contributions Dr. Luckin himself describes--remains unanswered. Dr. Luckin says that his particular team was composed of five physicians and three nurses, but Perlez' description of their work was not 5/8 about the physicians. It, like the rest of the piece, was 99.9% about the physicians (the word "nurse" does appear once, in the phrase "a team of Australian doctors and nurses"). The Perlez piece carried multiple quotes from Dr. Luckin and his physician colleagues and discussed their activities extensively. Of course, we never questioned whether the events Perlez described actually occurred; we questioned the physician-centric bias in what she chose to describe and how she described it. And though we appreciate the information from our Australian colleagues about the nurses' work in Aceh, such notes to the Truth do not quite have the same impact as a lengthy, front page, above the fold story in what is perhaps the most influential newspaper in the world.

As for the surgeon who held a patient as she died, we understand Dr. Luckin's point that this kind of thing occurred perhaps in part because there were too few nurses left following the tragedy. But our point was about the impression this kind of account, in isolation, will leave on readers. Of course, Perlez is not required to scour the disaster zone for examples of nurses doing what are generally nursing tasks. But we can't help but note--it's our job to note--that the Times ran such a major piece featuring a surgeon doing this kind of thing, and we have yet to see anything comparable from the paper about a nurse--and obviously nurses are doing it. We also understand the point about the absence of local health workers, but again, our point is about what the Times chooses to present. Since this piece, the Times has run at least one piece about the heroic exploits of a surviving Sri Lankan health worker--perhaps needless to say, it was a physician. (Also see another Times piece about a Thai physician.) In any case, the Perlez piece failed to note or explain the absence of local health workers or nurses generally in Aceh. It simply focused on the exploits of foreign physicians as if it were self-evident that only they mattered.

Of course, the New York Times is hardly unique in its physician-centric approach to coverage of tsunami relief. We note that a January 8th Sydney Morning Herald article about this same team of Australian health relief workers is eerily similar to the Perlez piece in giving the impression that only physicians matter--with extensive quotes only from physicians, and descriptions of what "doctors" would be doing, as if they were acting alone--despite including a photo of Ms. Cloughessy.

It's not hard to see why Dr. Luckin and the other physicians would defend Perlez' piece so aggressively. Their good work was presented to the world in the piece, they had direct contact with the sympathetic journalist in the midst of a desperate situation, and they apparently relied on her translator. And as Dr. Luckin remarks, it can be easy to be an "armchair critic." However, we note that it can also be easy to resort to misdirection and self-righteousness when you don't like what someone has said but have no real argument to counter it. Dr. Luckin, who does not appear to have a nursing degree, asserts that the Truth has not acted in accord with the "dignity," "standards" and "professionalism" of nursing. And we note with interest Ms. Cloughessy's virtually identical criticism a short time later (she also throws in a swipe at our "integrity"). Our view of nursing standards does not include unquestioning reverence for powerful media entities and physicians, and meek acceptance of disrespect that ultimately harms patients. Frankly, we are saddened but not surprised that a nurse has quickly appeared to support Dr. Luckin's position and effectively endorse her own relative obscurity; nursing's traditional virtue script calls for just that kind of self-negation. But strong patient advocacy is central to good nursing, and when we advocate for nurses, we're really advocating for our patients. They are depending upon nurses to strengthen their profession so that they may receive the care they need. Increasing public understanding of nursing is the most basic prerequisite in creating a stronger nursing profession.

We take seriously Dr. Luckin's claim that we have "trivialised" the suffering of the tsunami victims with our comment wondering facetiously why Perlez did not describe the physicians providing all services of every kind, since her piece gave the impression that they were providing all the health services. But our comment, though satiric, was deadly serious, and it spoke only to Perlez' conduct. It clearly said nothing about the suffering of the victims. However, we do have to question Dr. Luckin's explicit use of that same suffering in a misguided effort to excuse the Times' blatant physician glorification.

We encourage Dr. Luckin to follow up on his concern for the future of Indonesian nursing by advocating for fair treatment for nursing--in words and resources. And we invite Ms. Perlez and the New York Times to see if they can find any nurses in the enormous disaster zone whose work merits the laudatory treatment given to Dr. Luckin and his physician colleagues.

See our original piece on this item: "Are nurses doing anything important in Aceh province?" regarding Jane Perlez' article "For Many Tsunami Survivors, Battered Bodies, Few Choices" in the January 6, 2005 edition of the New York Times.

Please send your comments to Jane Perlez at perlez@nytimes.com

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