How do doctors operate in warzones?

What are some of the operational challenges faced by doctors working in some of the world’s most dangerous active warzones? Natalie Roberts is the executive director of Médecins Sans Frontières UK, which is also known as Doctors Without Borders...

Natalie - The first stage of emergency response is really trying to get into somewhere and try and work out what's going on. So we do that through a sort of specially trained group of people. We send them in to try and first of all, just spend a day or two really understanding what's going on, talk to the people who are there and try and work out the first steps of what we should start doing and how we could be most helpful. So it can be a little bit chaotic because you go into places where maybe you don't already have any team members, maybe never been there before, you might not speak the language. You have to, first of all, start by finding translators, finding somewhere to stay, finding some cars to drive around in, and then working out who you need to talk to to understand what's going on. So those first stages of emergency response are really about trying to understand the situation as best as you can.

Chris - There must be some things which are commonalities. It doesn't matter where you go to, a conflict or a war zone, you are always going to expect the same sort of things. Generally, what are they?

Natalie - The first worry you have wherever you go anywhere is - this is a war zone. It's very dangerous. You're going into a dangerous place. You're usually going into a place where people are leaving or trying to leave. First of all, you have to start thinking about, well, how can I make sure that I'm as safe as possible? Maybe I need to not go straight into the heart of the conflict. Maybe I need to start off a little bit further away. But you're trying to balance that with the fact you know that there's a conflict, there's a war going on, that people need you to be there and you don't want to take too long getting there to help them, because every day that you're delayed in choosing where to go and what to do, that's a day that maybe you could have spent saving people's lives or at least trying to to help them in some way. So really it is about balancing those considerations about, this is uncomfortable and this is dangerous, and what risks am I taking, versus how can I do this as quickly as possible to be useful on the ground?

Chris - What sorts of medical problems do you end up trying to solve?

Natalie - They can really vary from place to place. So for example, I went into Ukraine with this idea that really I needed to be setting up surgical units to treat people with war injuries. And what you always find anywhere is that you're never alone. You're not alone with just a bunch of people around you. There are always other doctors, or there are always other healthcare workers who are already working there. And in Ukraine, it actually wasn't the war injuries that were most important. It was actually the elderly people. It was cold, it was winter, suddenly their electricity had been cut off, they couldn't move around anymore because of the war going on around them. A lot of the people that would normally look after them had fled and so they were left behind. And so in some place you have to change your opinion immediately of who you're trying to help. The other, you know, extreme is somewhere like northeast Nigeria. which is also an active war zone where again, it's not necessarily about treating wounded people, it's more about the children that are in that space who maybe are struggling to access the right type of food and the right type of healthcare. And you have to immediately start thinking, who are the people I'm here to try and help? It is very challenging to even understand that in the first place.

Chris - Do you find yourself worrying about yourself when you're there, or do you put all that to one side or do you continuously think, how am I going to get out of this? How do I get home? Am I going to get stuck here?

Natalie - Anyone going through that situation needs to worry about themselves. If you're not worrying about yourself, nobody will be worrying about you and something we have to learn is we're not there to sacrifice ourselves. We are there to try and be useful, but you can't be useful if you can't work, and you can't be useful if you get injured, if you fall sick. So you need to look after yourself and you need to worry about yourself. There's a moment when you're in that situation, you start thinking, 'oh, I feel fine now. I'm used to this, this is normal.' That's the moment you should start thinking about taking a break and seeing if somebody else should come in and replace you.

Chris - How do you prepare for all that kind of thing though? Is that something that MSF trains you for, or is it literally a case of being mentored by someone on the ground and really finding out the hard way. How to do this, do this safely, protect yourself, look out for your own interest, but also look after the people that are there the best way you can.

Natalie - You don't always know how you're going to react in that situation, but MSF and other organisations do prepare you to start thinking about where you're going to be, how you're going to cope with that. They also do quite a careful selection procedure, recruitment procedure to decide who will work with the organisation. You go on a special training, I did mine for about 10 days in the German forest, which is a scenario where you're supposed to kind of think what this is like in reality. So they do test you a little bit so you're aware of the realities, but there's only so much they can test you before you go. What I found quite useful actually was working in the National Health Service in the UK because if you think about working in the emergency department, if anyone's ever been to A&E, you get all these different patients coming in all the time. You're constantly having to, to think about what you're doing and what's going on. And while you can't equate that to a war zone, if you've learned to deal with that and the stress that comes with that, that gives you this idea that you probably can cope with some elements of stress. Then I think that idea of mentoring, of going with somebody who's maybe experienced something similar before when you're going for the first time to somewhere like that so that you can just talk to them and just cross check, not necessarily what you're doing in terms of your work, but more about how you're feeling and how to cope with the situation that's around you.

Chris - Do you find though that it's tricky sometimes because there are things that you think, if I were in my, well-funded, relatively speaking, NHS job, I could solve this in the blink of an eye and I don't have access to this piece of equipment, this drug, this course of therapy, which could rescue this person and I'm going to have to give them less good care. Do you end up with that conflict?

Natalie - Absolutely. It can be at times really frustrating, really tricky. You have to think on your feet the whole time. You know, you go somewhere and you're maybe seeing diseases you've never seen before. I'd never seen Diphtheria or Ebola in the National Health Service. And so not only are you trying to think, I don't even know what I'm doing here, I've never seen these types of diseases or injuries before, but I'm also not sure I'm well equipped to deal with them. You've got those two uncertainties of seeing something you're not familiar with and not having all the equipment that you would have normally at home, and it can be really uncomfortable. In some ways the way to deal with that is to think of everything as a challenge. Think about how you can be creative, think about how you can maybe innovate, you know, try different things out. And particularly if you're working with local staff, with doctors and nurses and other healthcare workers who are from there who have to work in that situation all the time, they've often got really good ideas about things you could do when you are kind of more used to having your laboratory tests or your X-ray machines and they're kind of saying, well there's this trick and I can teach you this, and you actually learn an awful lot that way.