BMJ  2006;332:244 (28 January), doi:10.1136/bmj.332.7535.244

reviews

Personal views

Do doctors who volunteer their services in disasters overseas do more harm than good?

Recently we returned from the area in Pakistan affected by October's earthquake, having provided care to people suffering in its aftermath. Nothing could have prepared us for the distressing scenes we saw. Whole generations have been lost; millions of people have been left homeless and thousands of children orphaned.

Should there be a system for checking the background of care providers in disasters such as the Pakistan earthquake? Credit: TOMAS MUNITA/AP/EMPICS

 

As in all recent natural disasters there was an outpouring of charity from the public and a rush to the scene of scores of emergency relief organisations. These ranged from recognised, regulated official organisations to unregulated and ad hoc groups.

Many individual overseas medical professionals volunteered their help and inundated the afflicted areas. However, although well meant, their help led us to question whether volunteer doctors do more harm than good.

We were alarmed at the number of patients who had received some form of care but were then neglected

We found several issues of concern. Firstly, it was notable from the outset that there were numerous foreign doctors operating makeshift clinics in camps for the survivors. Many were unable to communicate with patients because of language barriers and, surprisingly, were even reviewing patients without translators.

We were alarmed at the number of patients we saw who had received some form of care but were then neglected, with no follow-up plans, which resulted in many patients suffering avoidable complications. We saw patients who had been immobilised in plaster for weeks because of uncertainty about possible fractures and for whom no review had been arranged. Most of these patients had no clinical indication for a plaster cast and had now, as a result of the immobilisation, suffered subsequent muscle atrophy and joint stiffness. A medical director of one camp had his concerns about a particular team that had arrived: it was obvious that some members of the team were learning plaster techniques and applying plasters when a clear clinical need wasn't apparent. Unfortunately, because of the obligation felt by the overburdened local staff all help was gratefully received without question. It was horrifying also to hear from some local people that "doctors were using us as guinea pigs." Sadly this seemed in some cases to be not far from the truth.

We saw other examples of woefully inadequate and dangerous care when reviewing patients on our rounds in the camps. Medical notes were non-existent or, if available, inadequate. Many patients were left with complications after surgery done by inexperienced surgeons and lacked any follow-up.

We were surprised that at no point during our mission were we asked for our credentials. It was assumed that the members of our team were all senior doctors from Britain. It was disturbing that we found that several consultants and specialists working at the camps were shown, on further simple inquiries, to be junior doctors, and in some instances nurses and physiotherapists passed themselves off as doctors.

At one camp two medical students who supervised the daily medical care of several hundred patients were left frustrated at the continual influx of volunteer doctors who had varying management plans that changed as frequently as the doctors. In another camp we found many patients who had been given a cocktail of analgesics and antibiotics for indeterminate periods, prescribed by different volunteer doctors— giving rise to concern about adverse events and antibiotic resistance. Another shocking example of dangerous care was when a volunteer doctor prescribed aspirin for a child with epigastric pain who had already been prescribed diclofenac, ibuprofen, and mefenamic acid by another volunteer.

What we experienced made us question the competence of some volunteer doctors and to ask whether there is or should be a system for checking the background of care providers in such disasters. The examples we saw also raise the question of whether we should, when we volunteer, allow the level and quality of care that we provide in our home countries to be compromised in such environments.

Despite the best intentions of volunteers, it would surely be better for all concerned if they attached themselves to the various well established and regulated bodies that organise the provision of care in such large scale disasters. This would, we hope, eradicate the well intended but unregulated and uncoordinated care provided by medical volunteers. Unregistered organisations should be discouraged from organising and sending medical personnel to disaster areas under their auspices.

All the recognised aid organisations should make more of an effort to communicate with each other better and to coordinate their efforts to provide a structured relief effort in such harsh environments.

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Academic Rheumatology and Osteoporosis Unit, Whipps Cross University Hospital, London hasan.tahir{at}whippsx.nhs.uk

Carlton House Surgery, Enfield

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