Issue 1 • 2022
Humanitarian deployments – what does the future hold?
Responding to disasters through humanitarian deployments has been a staple of the medical community for years. In recent times, specialists around the globe have been involved in multiple deployments for a growing number of disasters, and with the growing impacts of climate change, increased likelihood of pandemics such as COVID-19, and other ongoing unrest, the prevailing wisdom is that these deployments will likely increase.
RACP Quarterly recently spoke to three people involved in various humanitarian deployments to explore their experiences, challenges and the impact of remote medicine. Dr Margaret Young is a public health officer who has spent over three years in resource poor countries; Dr Catherin Tacon, an intensive care specialist who was part of the April and September 2021 deployments to Papua New Guinea and Timor-Leste; and Peter Grzic, an experienced humanitarian who has worked in most regions of the world and is now a freelance consultant, working primarily on training and simulation exercises for humanitarians. Dr Young and Dr Tacon have both been part of Australian Medical Assistance Teams (AUSMAT) deployments. All three have worked on deployments of varying lengths and in different capacities.
Tell me a little more about your deployments and the work that you do.
MY: I call myself a generalist public health physician. I had quite a few years of hospital-based and primary care medicine, then three years of experience in Cambodia. It was really in Cambodia that I discovered public health in a formal sense. I came back from Cambodia, studied a Masters of Tropical Health and did my public health medicine training. I really love public health medicine. I love the mix of policy, strategy and operational aspects, and as such consider myself a generalist. I enjoy disease control, environmental health, protecting and promoting health as well as looking at the strategic opportunities to influence policy both within health and externally.
PG: Most of my work is in the general humanitarian space, rather than specific technical areas. Coordination is my biggest area. To do coordination well, you need to have a broad knowledge of things in each space. I have a decent of understanding of most sectors and areas but I'm not an expert in health or water and sanitation, and so on. Regarding health, I have worked for the World Health Organisation, and for UNICEF - both of which run quite large health programs.
CT: As well as being an intensive care and retrieval specialist, I have always had an interest in medicine in resource poor settings. Before I started my training in intensive care, I worked in Papua New Guinea for a year as a general medical officer and have done a Master of Public Health and Tropical Medicine. I currently wear a couple of different hats. From an AUSMAT perspective I’ve probably been on the database for 10 years or so and deployed as part of their critical care response to the Measles Epidemic in Samoa and the COVID-19 responses in Papua New Guinea and Timor Leste. With my other hat on I'm the co-Vice Chair of the College of Intensive Care Medicine (CICM) and Australia New Zealand Intensive Care Society (ANZICS) Global Intensive Care Initiative and their lead for the PNG and Pacific Region.
Are most deployments natural disaster responses?
PG: Most humanitarian work isn't sudden onset. So called natural disasters, we use that term but there's no such thing as a natural disaster, they're more cyclical and predictable but often it's combinations or what we would call complex emergencies. For example, I was in Ethiopia working, and a large part of our work was people affected by conflict between different ethnic groups. There were also refugees from another country, prolonged drought, and cholera outbreaks, all happening at the same time. And complex emergencies tend to drag on for years on end.
And you work with local governments and people in these complex emergencies?
PG: Often, in the Asia Pacific region nearly everything you're talking about is a so-called natural disaster, which means we're going into it with the aim of supporting national governments and national systems. Basically, anywhere there is not really conflict or significant political issues, the goal is to work as closely as possible with the national government and actually have the national government leading the response. In the example of Fiji, with cyclone Winston, undeniably the Fijian government was leading the response and we were trying to support.
CT: Your job is not to go there and tell people how to do their job. It's about trying to share clinical skills, clinical mentorship and taking the time to understand what barriers they may be facing to put in place whatever change needs to be implemented. Going in there without assumptions about people’s attitudes to healthcare systems is important. You are going in there to work with the team and support them.
PG: Most humanitarian workers are from the affected country. Whether they're working for an international organisation or a local one, they are mostly locals, or what are generally called national staff. They are there long-term and are part of the community. Much of the work, especially public health work, has to be done in the language of the people involved, so it is the people from those communities who will do the work.
How difficult is it to land in the midst of a new emergency?
MY: The first potential chokepoint is entry. Over the years AUSMAT has done extensive work to establish trust relationships with countries receiving assistance and with international organisations. That is invaluable. When I was in Cambodia in the mid-90s, there were over 100 international organisations working in health. It can be a bit overwhelming to negotiate.
PG: It depends, in Fiji, Suva was not significantly affected by the cyclone, so conditions were fine, whereas you know, you've got other people, other humanitarians deploying to really tough conditions such as living in or around the refugee camps in the early stages of the Rohingya crisis.
MY: The next choke point is getting to know people on the ground and establishing a professional connection to identify how you can best contribute to the public health response. I think one of the key personal attributes of any humanitarian being deployed into emergency situations such as a pandemic is to bring a range of skills and be very flexible.
From a coordination perspective, do you think there is enough focus on preparation?
PG: Inevitably there is always more you can do in preparedness. If you look at the picture less as an international humanitarian situation, and more in the way most governments look at it, which is disaster management or emergency management, you start to look at things from a risk management perspective. There are always more measures you can take in terms of preparedness and mitigation, but is that investment worth the payoff? There's a statistic that gets thrown around constantly, it's usually cited to the World Bank. Though the validity is unclear, the idea is right. For every dollar you spend on preparedness you save seven dollars in response.
Do you think that education and system strengthening aspects are going to be a greater part of deployments?
CT: I think it always is. With all the deployments, no matter what they are, we need to work with local clinicians to strengthen the frameworks they already have or help them build their own systems. With COVID not going away anytime soon we need to sustainably develop responses. There's no point in us going to a country for two weeks or four weeks and putting in a whole lot of processes that are never going to be able to be sustained. That's always needs to be the focus for any disaster response.
PG: The Sphere Handbook is one of the main technical guidelines for humanitarian work. There is a chapter on healthcare and if you look at the outline, the whole first section is just on health system strengthening. Health service delivery, health workforce, essential medicines, health financing, health information, that's a huge part, and a lot of that will be through the World Health Organisation (WHO) but also others.
CT: I think upskilling and education is the key for the clinicians on the ground. Clinicians, whether they are medical, nursing or allied health will benefit from this in the long term. By sharing knowledge and helping clinicians develop their skills, regions can strengthen their own training and education, resources and knowledge. This is what can make a difference in the long term.
Do you think the ability for more telehealth, remote access and other technical improvements will change the nature of some deployments?
CT: Telehealth can do a lot but it's never quite the same as being there, face to face. There's always going to be times that you need to have extra bodies on the ground. The main importance of telehealth has been to share knowledge and resources, and support the clinicians in the country.
PG: I don't think we're there yet. Let's say I'm working remotely from Australia, and I want to support a health response in the Rohingya camps in Bangladesh – I have no idea what the conditions are like. I can read reports I can see what's on TV, but I can't go and see it for myself. I can’t sit in the back corner of the consultation meeting with someone translating for me. Maybe there is an element of this, but again we're seeing more and more of these roles, even the technical advisors are coming from these countries that are affected.
MY: The pandemic has helped us transition to do a lot of work remotely, but there will always remain a need for on-the-ground response also. My 2021 deployment with AUSMAT to Fiji was short, with just three weeks on the ground and then two weeks in quarantine on my return to Australia. During that period of quarantine, I was able to participate in daily incident management meetings conducted by the Ministry of Health and other meetings with international organisations, key stakeholders, as well as ministry and divisional health representatives. I know a lot of international agencies have been continuing to provide support to Fiji remotely during the pandemic or with a mix of on ground and remote work.
PG: Also, community consultation directly has to be done by local people, especially when you're talking about health and personal hygiene practises. There are so many cultural elements to that as well, so language and cultural barriers or elements are a massive concern that can’t always be address remotely.
What are things that have stood out in your deployments?
CT: Every country is slightly different so you can’t do the same for each deployment, even if it's the same disease. However, although responses need to be adapted for each situation, I think that infection prevention control needs to be at an absolute forefront for COVID responses. I think a lot of lessons were learned during the past year and ongoing responses will continue to adapt and change.
MY: It was a fabulous opportunity to be part of a multidisciplinary team supporting the response to COVID-19 through acute care and through the systems response. As a public health practitioner, I found that understanding some of the clinical challenges helped me understand how you could fine-tune the public health response.
CT: Just because countries are smaller and don't have the same resources as places such as Australia, doesn't mean they can't do a very effective job. It's about systems and it's about getting those systems in place quickly. To be entirely honest I think some of the COVID-19 responses in resource poor countries have been probably more effective and more rapid than in some more well-resourced places. This is because clinicians in these areas realise they have to be more pragmatic about resources available and make decisions rapidly. It’s about having strong systems, education, and having the right people in positions of leadership to be able to make the decisions.
PG: What does the future look like? My best guess is more situations in places like the Association of Southeast Asian Nations (ASEAN) region and Europe, where you start to see regional cooperation, regional sharing of information and, for those short periods where there is a sudden need for extra capacity then you see arrangements where they share staff.
Helpful tips for going on a deployment We asked our interviewees for travel tips when going on deployments. Here are some of their helpful suggestions:
  • Learn place names. Study a map and learn the districts, especially in affected regions. You will be going into meetings straight away and you don’t want to spend the entire time googling.
  • Make sure you have enough local currency when you touch down. Travel arrangements may vary but if you are heading into uncertainty, have enough to get by for a bit.
  • Plan how to get from the airport to where you are sleeping that first night. A lot of NGOs will send someone to pick you up from the airport but, even then, get the person’s phone number and also a backup phone number.
  • Always carry water purification tablets and gastro stop of some sort.
  • Carry toilet paper in your hand luggage, backpacks, travel bag – everywhere.
  • If you like coffee, travel with a coffee plunger.
  • Bring a good book to read. It isn’t always possible, but it’s important to find a quiet space where you can do something that reminds you of being at home.
  • Bring a travel pillow or a good pair of comfy socks.
  • Make sure you bring a pair of swimmers. Not because you're going to go swimming but if you get stuck somewhere with no privacy and need to wash, at least you're going to be covered.
  • Take a skipping rope. You might not get to use it but it’s a great form of exercise and you can do it almost anywhere.
  • Carry something that helps you remember who you are and what you are doing this for such as a family photo. Sometimes it can be very difficult to stay in touch with family so maintaining some sort of daily connection with home is important.
© 2022 The Royal Australasian College of Physicians