The good doctors in Haiti
February 2010 -- Countless news reports have described efforts to provide emergency health care to survivors of the tragic January 12 earthquake in Haiti. The vast majority of the reports have focused only on the work of physicians, and consulted only physicians for comment, ignoring nurses' expertise and central role in responding to such mass casualty events. Some reports suggested that few nurses had arrived on the devastated island in the early days after the quake, and that many initial foreign aid teams were mostly physicians, which itself suggests a tragic undervaluation of nursing, given the many thousands of nurses worldwide who volunteered to go. In any case, many nurses were already working for NGOs like Médecins Sans Frontières and Partners in Health (which had 600 nurses on the ground in Haiti when the quake struck, along with about 100 physicians). And surely hundreds of nurses were aboard the USNS Comfort when it arrived on January 20 with a crew of more than 1,000. Yet even reports on those efforts generally focused only on physicians. CNN commendably devoted many resources to the story, but it was also a notable source of physician-centric distortions. Consider a couple pieces built on the cable network's reporting whose physician-centrism cannot be linked to any absence of nurses on the ground. A January 13 CNN report by Madison Park explored the grave effects of the quake in a nation whose health system was already fragile, relying solely on physician experts, and implying that only physicians were involved in directing responses to the crisis. And Rahul K. Parikh, M.D.'s January 18 piece on the Salon web site was a love letter to CNN "medical correspondent" Sanjay Gupta, M.D. (above), who had apparently single-handedly saved the lives of some badly injured Haitians by caring for them overnight after a group of U.N. workers were ordered to evacuate. Oh, some unnamed Belgian U.N. nurse did "accompany" Gupta, and Parikh allowed in passing that she had the "chutzpah" to disobey the evacuation order. But that did not stop Parikh from telling readers over and over that the heroic Gupta alone was responsible for the patients' survival. On the whole, the U.S. media's reporting on the quake offered a relentless vision of post-disaster health care in which nurses play no significant role.
The perfect storm
Madison Park's January 13 piece report was "Haiti earthquake could trigger possible medical 'perfect storm.'" The article explores the major risks in the immediate aftermath of the quake, including untreated trauma and the risk of malnutrition, infections, and disease, in a nation that lacked a strong health infrastructure in the first place and was "already struggling to fight rare tropical and infectious diseases, health experts said." The piece relies on three such experts.
Dr. Peter Hotez, "head of the department of microbiology at George Washington University," explains that the displacement of people from their homes could lead to crowded conditions in which respiratory infections can spread. Hotez says the situation is a "perfect storm of infection," with potential sanitation breakdowns exacerbating the existing "high rates of infections and neglected tropical disease." Hotez points to the risk of diarrheal infections and diseases from contaminated water and food. The piece also consults Hotez about the quake's effects on existing public health initiatives. It introduces the topic this way:
Some doctors worry that the major, long-term health initiatives to treat preventable diseases in Haiti could be upended.
Hotez says the quake will be a "big setback for public health control measures," and he advocates "something equivalent to a Marshall plan for Haiti. ... You go to Haiti, it's like you go back in time 500 years and see incredible neglected tropical diseases that don't need to be there."
The report quotes Dr. Tamman Aloudat, "senior health officer with the International Red Cross in Geneva, Switzerland," mainly on the likely immediate aftermath of the quake. Aloudat explains that after such disasters, people not only have injuries like fractures and amputations, but what the piece calls "extreme physical and mental shock." He notes that the vast majority of casualties after major earthquakes happen in the first 3-4 days, and he also points to risks from bacterial and mosquito-borne diseases like malaria. And he says the Red Cross will monitor "outbreak epidemics" and "deploy stocks of non-food relief items."
And the piece relies heavily on Orlando (FL) pediatrician Ted Kaplan, who has formed a network of clinics and health organizations in Haiti called Cap Haïtien Health Network, which the piece says "tackle[s] preventable diseases such as diarrhea, malaria and malnutrition." Kaplan explains:
In Haiti, if you have a serious injury or illness, if you're lucky, you can make it to the hospital. ... The situation now is there's no ambulance. If you don't get to the hospital, you don't have an orthopedic surgeon, you don't have a CT scan -- there's no equipment to deal with the injury.
The piece explains:
The lack of a safety net means that if left untreated, minor injuries or fractures can become life-threatening because they're left open to bacterial infections such as tetanus, doctors said.
Kaplan says he has to hope "this situation may lead to improvements, because it's bringing lots of attention and help to the area."
This report gives readers a good sense of the severe health effects in the immediate aftermath of the earthquake, but it also reinforces the false idea that only physician views and actions matter. Most obviously, why would the piece casually note that "doctors" are worried that long-term health initiatives in Haiti will be disrupted and that "doctors" say untreated injuries can lead to bacterial infections? Don't any other health workers have those concerns, like, say, the nurses who provide much if not most of the skilled health care in such initiatives and in treating those with infections? Is the piece suggesting that only "doctors" have significant health care expertise, so only their concerns are worth reporting? Well, of course it is.
The report's choice of expert sources tells readers the same thing. All three are physicians, even though many nurses have a great deal of expertise in these issues. What might be different if we heard from nurses? Consider Kaplan's comments about what will happen to the injured now. His remarks suggest that it's all about physicians and machines: no ambulance, no surgeon, no CT scan, no equipment. Notice anything missing? A nurse would be more likely to explain the full range of health care that patients lack when they can't reach health professionals. For instance, skilled post-operative nursing care can be just as vital to patient survival as the surgery itself. And ambulances and CT scans don't actually operate themselves.
For a broader perspective on post-disaster emergency care, the piece consults a U.S. research physician whose specialty is microbiology and tropical health, and a Red Cross physician in Switzerland. These physicians are certainly qualified to give relevant information, but many nurses with vast experience in tropical and post-disaster care could also have provided useful comment. In general, nurses are trained to focus more directly on such holistic, community health issues, and many of them have a great deal of experience in doing so, including in Haiti. For instance, nurses are the most numerous health professionals who work for Médecins Sans Frontières, and some have been leaders in the organization, despite its name. Carol Etherington, a Tennessee nurse who once directed MSF's U.S. board of directors, is a recognized expert in developing community health programs to address just the kind of post-disaster "physical and mental shock" Aloudat describes. Fiona Genasi (right), a Scottish nurse who is President-Elect of the International Society of Travel Medicine, develops policy in travel medicine and international health for the Scottish government, and she has worked extensively around the world. And Johns Hopkins nursing professor and pediatric nurse practitioner Elizabeth Sloand, RN, PhD, CRNP, (below) who managed to get to Haiti on January 27, "has spent considerable time in Haiti over the past 10 years as clinician, researcher, and teacher," as a Hopkins release notes. "She is extremely knowledgeable regarding the capabilities and limitations of its infrastructure and health systems."
Of course there are also many physicians qualified to comment on these issues. But the media's consistent practice of consulting only physicians reinforces the damaging social view that only they have relevant health expertise. That matters because it feeds the sense that only physician practice is worthy of significant investment from the public and private sectors. (See our FAQ "Just how undervalued and underfunded is nursing?")
Rahul K. Parikh, MD (right), writes commentary on health care practice and policy for the Salon web site. His pieces often present a vision of health care that includes only physicians, and clearly suggest to readers that physicians provide or direct all important care. Parikh does not just focus on physicians because that's what he knows; he makes statements that strongly reinforce assumptions that when it comes to health, only physician views and actions matter. His January 18 discussion of CNN correspondent Sanjay Gupta's admirable work "Sanjay Gupta, the good doctor" in Haiti is no exception.
Parikh finds the U.S. cable news networks "generally insufferable," but in tragedies like the Haiti earthquake, "amid all the ruin and hopelessness, cable personalities emerge as something like heroes." One such person is CNN's "chief medical correspondent, neurosurgeon at Emory University and the man-who-was-almost-surgeon-general Dr. Sanjay Gupta." Parikh describes Gupta's "gripping dispatches," such as a clip of him "treating a baby on the Haiti streets," and says Gupta has special influence because he appears to be "the only physician-journalist down there right now, so he offers a unique perspective on what medical personnel and patients face." Parikh goes on:
As someone who is smart, articulate and affable, Gupta is one of CNN's best assets, as far as I'm concerned. He may not be a transformational figure in American medicine (unlike, say, Atul Gawande, whom you'll meet shortly here in Salon). But as a physician myself, I think Gupta takes his responsibilities as a reporter and health educator seriously. And as someone who shares his South Asian heritage, I'm gratified by how he's represented my culture.
For more on all that, see Parikh's gushing February 2 Salon interview with Gawande.
In the January 18 piece, Parikh focuses on a particular "drama" in which Gupta was reporting from a United Nations "medical camp" near Port-au-Prince with more than two dozen critically ill patients, some recovering from surgery. Parikh explains:
The site was staffed by a team of physicians from Belgium, who only earlier that day had gotten the place up and running.
Really? The site was staffed solely by physicians, and the physicians alone had "gotten the place up and running"?
But as night fell, Gupta explained to Anderson Cooper that the United Nations ordered these doctors to pick up their medical supplies and leave. (A claim the U.N. later denied.) Gunshots had apparently been heard nearby, and there was concern about an outbreak of violence.
So "the medical team," which we again hear was composed entirely of physicians, packed up and left the patients behind.
That left Gupta, there as a reporter, the last doctor standing. And so he did what good doctors do. He assumed responsibility for those sick patients with a stethoscope and some bags of IV fluids left behind by the Belgians. A camera crew followed as he moved from sick patient to sick patient, accompanied only by a single nurse from the Belgian group who refused to leave. That night he tweeted, "345a. pulling all nighter at haiti field hosp. lots of work, but all patients stable. turned my crew into a crack med team tonight. #proud." (See Jan. 16, 2010,12:49 am tweet.)
So Gupta was "the last doctor standing," and he had to "do what good doctors do": "assume... responsibility for those sick patients," apparently all by himself. But wait! After we mention his camera crew, there is something else, someone...oh yes! Gupta was "accompanied by a single nurse from the Belgian group who refused to leave." Of course, the nurse does not get a name, and even the description of her role suggests she did nothing but follow Gupta around, maybe holding things for him. Actually, "accompanied only by a single nurse" manages to turn what the nurse did into a kind of Gupta achievement, like she was some ill-suited tool that the good doctor MacGyvered into service. In fact, an experienced nurse would be too busy caring for the critical patients on her own to spend time just "accompanying" Gupta. Nurses are the ones who give patients IV fluids, and in general, they have far more skill in monitoring and keeping lots of sick patients stable over extended periods; that's what nurses do, and they don't need physicians to tell them how to do it. Gupta's tweet is pretty special too. Apparently, he was able to turn his crew into a "crack med team." So critical care must be about physicians and their helpers, who can be trained overnight. And some people think it takes years to train a nurse!
Parikh says the Belgian team returned the next morning, and the finger-pointing began. He notes that he will not be among the cynics who may call Gupta's action self-promoting:
I believe those lives were, literally, in Gupta's hands, and he responded. In addition to the 25 patients dropped in his lap, Gupta also stabilized a few more patients who trickled in during the middle of the night. None of them died on his watch. That's good, hard work, and he deserves praise for it.
"His hands," "his lap," "his watch": only Gupta "deserves praise," because those lives were in his hands alone, only he did the hard work, only he stabilized and monitored them, and only he saved them. But of course, that wasn't the only desperate scene in Haiti that week. Other heroic physicians were single-handedly taking charge and saving lives too.
Gupta isn't the only lone doctor taking charge -- one Haitian doctor took 100 patients into his own home to care for them. Another American physician, who was in Haiti as the earthquake hit, found herself in a similar situation to Gupta's. "It was overwhelming," she told a CNN reporter. "Several people bled to death while I tried to treat them. One girl's skin was ripped off her hand and forearm, and you could see all the muscles and tendons. Then a father handed me a baby who was minutes away from dying, and I had to say, 'I'm sorry, there's nothing I can do.'"
But were these physicians really alone, or were they just "lone doctors" in the way Gupta was--alone with one or more nurses? Readers will never know, because nurses register 0.1 on the Parikh scale.
Parikh sees a kind of upside to all this tragedy: It may restore Americans' faith in "doctors and the medical establishment," which apparently has been shaken in recent decades. More Parikh:
Gupta's actions (as well as those of the other two physicians) are a refreshing reminder that a physician's altruism, skills and knowledge still matter. Of course, the exit of an entire team of doctors (with their precious supplies) while patients lie in agony is enough to kick up that familiar suspicion and mistrust. (And the additional story of the nurse with enough chutzpah to defy orders probably makes someone want to sue for malpractice.)
So here is that unnamed nurse again, getting credit for "chutzpah," kind of a feisty, stubborn quality, generally positive, but not really courage, and of course, nothing like the "altruism, skills, and knowledge" that physicians like Gupta have.
But let's focus on courage and professional integrity. Does Gupta really deserve so much more credit for those qualities than this unnamed nurse does? Here is a wealthy international media star and surgeon, with a full crew of who knows how many people and a major television network behind him, providing care in this makeshift camp, contrary to no one's orders and with no adverse consequences other than lost sleep, indeed with every expectation that he will rightly be considered a hero for it. And there is the nurse, doing the same thing, but with none of the above power or esteem, and in doing so defying her employer's "orders" in a way that could get her fired from a job that may well be the only one she has. Did she really just display "chutzpah" as compared to Gupta's "altruism"? It's not that we want the nurse to just be considered noble and virtuous, which might reinforce the unskilled angel image, but we do think she deserves at least as much credit as Gupta does for toughness and professionalism (and skill).
Then there's Parikh's bizarre reference to the nurse's defiance of "orders" possibly inspiring a "malpractice suit." Is he suggesting that when nurses defy physician "orders," that's a red flag for bad care? Or just that people like those evil trial lawyers might wrongly think so? We suppose it's possible to read the comment more broadly, simply to mean that any health worker defying a superior might raise suspicions that something is amiss. But given the obvious social assumptions, most readers will probably assume Parikh means that normally nurses are expected to follow physician "orders" without question. That is false. Nurses are legally and professionally obligated to resist any care plans that they believe are not in a patient's best interests, and more broadly, to advocate strongly for patients. This nurse was meeting her professional responsibilities just as Gupta was, but at far greater risk to her own welfare.
Parikh goes on to describe his own brief experience working in India, which he concedes could not have been as difficult as the desperate conditions health workers in Haiti faced after the earthquake. He speculates about how hard it must be in such insecure conditions:
Should it be any different for doctors, even though we take an oath to care for our patients? According to the lead physician of the Belgian team, a request was made for security details to protect the doctors and patients. Had it arrived, he says, they would have stayed the night. ... Doctors are not immune to getting caught in the crossfire. Early last year, an army doctor in Iraq was killed by mortar fire. Last April, Somali gunmen kidnapped two physicians working there for Doctors Without Borders. My own opportunity to help out in a relief situation, in Sri Lanka after the 2005 tsunami, was called off after reports of increasing violence trickled back to us.
So determination and altruism are muddied by uncertainty and self-preservation. It's an impossible decision in an impossible situation. It's also one that doctors in this country have faced before. During Hurricane Katrina, floodwaters rose so rapidly that doctors in New Orleans hospitals had to literally decide between life and death for the patients in their care. The result was that some patients' deaths were hastened using medications, so others could be brought to safety. While two doctors were initially arrested for this, a jury refused to indict them, and no new charges have been brought despite similar admissions by other doctors.
Yes, yes, but how do all these terrible situations affect doctors? And we certainly hope the Belgian U.N. team was finally able to get a security detail to protect the "doctors and patients," as Parikh describes those who were in harm's way (that accompanist nurse probably has enough "chutzpah" to protect herself!). In fact, though, nurses were also arrested for their decisions during the horror of Katrina, and though most of the media paid far less attention to them than it did to the physicians, some pieces did at least mention the nurses. Not Parikh. More generally, since nurses are often more numerous than physicians in the kind of emergency settings that Parikh describes, working for groups like MSF, nurses are more likely to be the targets of the kind of aggression Parikh describes, just as nurses are far more likely to be abused in both developing and developed nations than physicians are. Nurses are the main targets because they provide the majority of skilled care patients receive. And nurses endure physical insecurity in many places suffering from armed conflict around the world. For instance, in the years following the 2003 US-led invasion of Iraq, hundreds of Iraqi nurses were killed or wounded, and thousands were driven from their jobs or overseas. But to acknowledge any of that, you have to see the nurses in the first place.
Want to read more about physicians and the medical miracles they pull off pretty much by themselves? Just check out Gupta's 2009 book, Cheating Death: The Doctors and Medical Miracles That Are Saving Lives Against All Odds.
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