Daniel Flecknoe is a Specialty Registrar in Public Health and a senior tutor at Leicester Medical School with over a decade of emergency nursing experience across the South of England and overseas. He worked with a mission team for Médecins Sans Frontières (MSF) in Northern Darfur between 2008-2009 at a critical time prior to the retrospective identification of this zone by the International Criminal Court as a genocide situation.
While there he was also involved in health education, teaching and training for the local nursing team which demanded making information context appropriate. For instance, one of his most memorable teaching sessions discussed the differences between sympathy and empathy and he relates the satisfaction of finding a common inter-cultural understanding of these concepts with the local staff via an Arabic interpreter.
How can MSF communicate and deliver aid with integrity in hostile and complex humanitarian situations? By extension, when does one identify that a field mission and its aims have become untenable?
Fundamentally MSF is a non-partisan organization which operates for the benefit of all those affected by conflict and emergency situations. But not taking sides can cause it’s own problems in maintaining safe access to those who need medical care. For example, the MSF Kunduz hospital, which was recently bombed by coalition forces treated wounded Afghan Government fighters, wounded Taliban fighters as well as sick and wounded civilians, Treating enemies can be a very tricky affair, and working on a shifting frontline makes it hard to keep the service running, let alone to stay in all sides’ good books. Unfortunately, the rules of war regarding the rights of injured combatants to treatment are not always respected, and humanitarian organisations can become a target. It is getting harder and harder for humanitarian groups to operate in places like Syria, Afghanistan, Iraq, because the warring parties do not abide by their obligations under international law to let them do so safely. This is a matter of very serious concern.
My current interest is in the primary prevention of armed conflict, and how healthcare professionals can get involved in this effort, but it is very clear to me that MSF and similar NGOs will always be required. Somewhat like A&E departments, however much we all agree the demands upon them need to be reduced by prioritising preventative health measures. Even if we get much much better at the primary prevention of armed conflict, there will still be a global need for humanitarian work.
When to withdraw from a situation is always going to be a bit of a judgement call, and often a very traumatic one for people who have put their heart and soul into a project. You have to consider the way things are trending, so a one-off event such as an armed robbery may not be enough in isolation, but cumulatively, as part of a general escalation in violence, it may warrant the withdrawal of an NGO from the area. Of course gradual change can be difficult to detect, so it is sometimes easier to assess the situation with external or fresh eyes. MSF capital teams take on the role of wider security and contextual surveillance while the project teams on the ground focus more on the situation in front of them.
Some people think of humanitarian aid work as a wholly positive endeavour, but there are situations where it is possible to unnecessarily endanger yourself, or to do more harm than good. Prospective aid workers should be aware of the necessary compromises and contradictions, issues of wrongly imposing our own values, culturally-relative medical definitions, advancing the interests of Big Pharma, and confronting White or Western privilege, which may be brought up by the experience of working overseas with an NGO.
In terms of being heard, how can indigenous care providers best receive coverage and credit for their work?
Their stories definitely deserve to be told, and their hard work recognized. Unfortunately I don’t think that such stories would sell very well in the Western media, because we (as a media-consuming population) are generally more interested in stories about people like us doing things that we would not normally do. […] Unfortunately this means the amount of column inches that someone will get does not correlate to the amount of good work that they have actually done because they don’t fit the right demographic to generate media interest. I don’t think this is really a racism issue; it’s like the prioritization of stories that you see in local news […] we are all drawn to narratives that pertain to us in some way. Nevertheless it remains an injustice, in terms of media coverage, done to a lot of indigenous aid workers who do a lot of difficult and dangerous work.
NGOs don’t always do enough to promote the stories of their indigenous staff because their priorities include, of course, fundraising. Personally I consider myself as an international volunteer for MSF to be much more useful on my return from missions in terms of spreading the word and raising awareness, and for me that definitely includes representing my brave Darfurian colleagues.
One of the supposed changes between the Millennium Development Goals and the Sustainable Development Goals is the role of UN member state or country level actioning of goals. But what about those goals that require cross-country efforts? How should these be coordinated?
The public health experience on behaviour change at both the individual and the population level seems to show that giving people information, especially when it is unpleasant information often doesn’t work. People tend to block it out […] and not identify with it. We are pre-disposed to accept pleasant information, which is congruent with what we already believe or how we already behave, and reject the unpleasant information. The “Nudge” concept in public health takes a different approach, by incentivising positive health behaviours and de-incentivising negative behaviours without banning or limiting or criminalising anything. This makes it easier, cheaper and more appealing to make healthy choices, and the technique may also have some wider democratic applications. For example, as citizens it is possible to make global health and human rights into political priorities through our votes and democratic engagement. We all have the power to incentivize political change in our countries towards peace, equity and positive health care policies through democratic action, and I would encourage everyone to consider how they can contribute to the goal of making their country not only a better place to live, but also a more ethical actor on the world stage.
What do you think is the priority of the sustainable development agenda?
The most pressing imperative for me right now is promoting and also reinforcing the responsibility of warring parties to prioritise the health needs of the civilian population […] Whenever that doesn’t happen I think it is deplorable, because while it is easy for political actors to get bogged down by their own priorities, the health and safety of the civilian population should always be paramount [… They] have a right not to have their health impacted because of political goals being pursued by violent means, however pressing those goals may be.
I don’t mean that humanitarianism is automatically a pacifist philosophy. Prioritising humanity does not necessarily exclude supporting military interventions sometimes. There are circumstances where you could advocate a military invasion on humanitarian grounds. It’s not unthinkable.
You said preventative medicine should be the focus of future MSF work. What does this mean in practice?
I’m not sure that this is a job for MSF. MSF has its own sphere of competence and expertise, and as Jose Bastos recently said, humanitarian action is a visceral impulse, motivated by outrage and empathy. That is not at all the same as primary prevention.
I could use the analogy of parenting (and bear with me here, because I am not a parent). Obviously as a parent you would be motivated to reduce the risks to your children, to forbid that dangerous playground or this unsafe skate park. That’s primary prevention, and it’s incredibly important work. But you would also be driven to hold them on your lap and give them caring first aid for the wounds they have already received, which you cannot prevent because they have already happened. That’s humanitarianism, and they are two separate fields, which I happen to have a dual interest in.
Primary prevention in this case requires tackling the root causes of armed conflict – stopping them before they get started, in other words. MSF is focused upon the tertiary prevention of armed conflict – minimizing the collateral damage. But either way, it’s important for healthcare professionals to have a voice at a political level, and to advocate for the universal right to health and security.
So why public health rather than global health?
I don’t think that there necessarily needs to be a distinction. Public health in the UK already has to cross inter-professional boundaries, and we have to engage with people across the spectrum of disciplines if we are to tackle the root causes of health problems. For instance, in the case of TB coming back into high prevalence in some parts of this country [UK], it isn’t just about screening immigrants, it is about housing, deprivation, overcrowding and other social and political issues not traditionally within the domain of health […] As public health professionals we have to get involved across the spectrum in order to address the problem.
Just raising our focus from the local, we can see the same interconnectedness requiring a broader view and engagement at the global health level. Climate change, armed conflicts, political instability, infrastructure breakdown – all of these things, which predominantly directly impact on other parts of the world, will also have an effect on the health of the UK population if they are not addressed. Whether through mass population movements, interruption of food supplies, exported diseases, we will feel the effects here. There were incredibly pressing humanitarian reasons to fight the Ebola outbreak in West Africa, for example, but there were also selfish reasons, because we live in a globalized and interconnected world where you can’t just close the doors to your own country and expect to stay safe. Western countries had to get involved with tackling Ebola at the source, because they couldn’t afford to let it spread further. I would prefer that the humanitarian motives were more dominant, but if self-interest ultimately motivates the right course of action then,… well, I’ll take what I can get!
It’s commonly and rightly said in my profession that “there is no health without mental health”. It’s very true, but I would also say that in the longer term there is no local health without global health either.
What key learning from operational work with MSF could you pass on?
It’ll probably be different than you expect. It’s not a rescue mission. The main goal of Western aid workers, as I see it, should be to learn as much as possible from their local colleagues who have far more experience and who know the culture and context better than we ever will. Our job is to support them as best we can, and to come to terms with the fact that we may be of more assistance to them and their struggle once we return from the field. While you’re out there, you can definitely be useful, applying and sharing the medical skills and knowledge that you’ve been lucky enough to gain through your education. You also demonstrate solidarity with them and their cause, which is a valuable and important thing. However, once back home you can bear witness to what you have seen, and be involved in raising awareness and money for their ongoing efforts, and in some ways that is the best thing that you can do for them.
At the moment I am professionally focused on my public health training, although in my own time I can also pursue projects which have an international and conflict-prevent slant. I would also like to work with MSF again in the future because it is an organization that I really love and respect. I get very uncomfortable with simplistic portrayals of aid workers as saintly and selfless altruists, because that’s not really me, and I’m sure many of my colleagues in the field would also dismiss such one-dimensional stereotyping. People are complicated, and we do this work for a variety of reasons […] There are certainly many reasons why I want to do it again, some of them selfish and some of them less so. But working with MSF was one of the most satisfying things that I have ever done, I benefitted from it enormously in terms of my personal resilience and capabilities, and I think with the benefit of my public health experience I’d probably be better at it now too. Maybe I also want to have some good stories to tell my grandchildren!’.
Going back to MSF may also help me to clarify my ideas about a possible synthesis of humanitarianism and primary prevention, which at the moment seems to me to be an interesting and important area of work to get involved with.
Fundamentally, aid work is about coming to terms with what you can do and what you can’t and what you might have to sacrifice along the way […] It is like fighting massive forest fires with buckets of water. It absolutely has to be done if you’re going to save even a few houses from the flames, and it can look sort of heroic while at the same time being massively inadequate to the scope of the problem. As a species, it is incredibly important that we devote more energy to preventing these fires from burning out of control in the first place.