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 Physician assistants and humanitarian assistance
David H. Kuhns, PA-C, MPH
Mr. Kuhns is Assistant Professor, physician assistant program, College of Health Professions, University of New England, Portland, Me. As the first PA to serve with Médecins Sans Frontières, he was the country medical coordinator in Somalia and Djibouti in 1994 and then a project coordinator in Jalalabad, Afghanistan, in 1995. He is a member of the editorial board of JAAPA.
The tsunamis of December 26, 2004, will long be remembered, first for the vast suffering and loss of life that occurred in the south Asian and Horn of Africa regions. Scores of waterfront communities throughout Indonesia, Thailand, Sri Lanka, India, the Maldives in Asia, and Somalia and Kenya in Africa were literally erased by the towering walls of water that struck with so little warning. The tsunamis took with them, in a matter of moments, tens of thousands of men, women, and children.
The subsequent news reports, and especially the graphic video footage, showed the staggering physical and psychological toll on the faces and in the eyes of the survivors. The loss of everything of value was evident, from their families and loved ones, to their homes, and even to their boats and other means of livelihood. The despair was palpable. In many cases, we could see that for many victims, even hope for the future was lost. Their suffering touched millions of caring souls around the world, and the humanitarian response was swift.
On the front lines, local medical staff and medical facilities were overwhelmed with victims, both living and dead. One doctor at a hospital in Sri Lanka reported having 800 bodies piled up in outpatient departments. The living patients, many of whom suffered devastating trauma, awaited openings in the OR. Patients with lesser injuries, such as lacerations whose treatment was delayed because of inherent access problems, were later found to have cellulitis from contaminated wounds.1
International humanitarian aid agencies already working in the South Asia region quickly mobilized efforts, as did the governments of many nations—including the United States, which made military resources available. (Although it is still too early to know, the first PAs in the region were likely part of those American efforts.)
The images associated with this disaster horrified caring and compassionate people around the world. Charitable contributions in support of the humanitarian relief efforts were remarkable. People everywhere made donations to assist the many relief organizations on the scene. Proudly, we can report that the American Academy of Physician Assistants contributed $10,000, earmarked for the tsunami relief, to the charity Direct Relief International. The Physician Assistant Foundation is continuing a matching campaign of individual PA contributions, for an additional sum of up to $10,000 for the American Red Cross International Response Fund for victims of the tsunami. Despite all the good feelings associated with those contributions, however, scores of PAs around the country have been frustrated during the past weeks—frustrated because they want to help, but can’t.
The international medical relief community
PAs are usually thought of as “can-do” folks. If a patient needs to be cared for or a community needs to be served, PAs will step up to the plate. We do this because of our profession’s commitment to helping others, because of our own professional goals, and, ultimately, for the good of our patients. When we are stymied, for whatever reason, we become frustrated. That feeling afflicted many in our profession when they were rebuffed in their efforts to join directly in the international outpouring of humanitarian aid in response to the largest scale natural disaster we have known in our lifetime.
In the days and weeks that followed the disaster, the network of my fellow PAs who, like me, had international disaster experience were being contacted by other PAs asking how they might help. Online message boards at www.physicianassociate.com were buzzing with queries about how PAs might join their clinical experience with the larger international medical relief organizations.
Regrettably, those PAs ran headlong into a wall. Despite a proven 35-year track record in the delivery of health care in this country, the PA profession is still not yet widely recognized beyond our borders. In the early days of January 2005, international medical relief agencies such as Doctors Without Borders (or the original French name, Médecins Sans Frontières-MSF) and others were deluged with volunteers—doctors, nurses, and PAs—offering to help. While many of the volunteer doctors and nurses did travel to help with the relief effort, we are unaware of any PAs who served with MSF during this time.
 Serving as a PA with MSF is still very difficult because it and other international agencies lack a good understanding of what PAs can bring to the table. In the 10 years since I first served with MSF, hundreds of doctors, nurses, and nonmedical volunteers have been sent to the field—but to my knowledge, there have been just four PAs.
It took me almost 2 years to enter MSF. I was able to join the organization only because I finally connected with the then president of MSF-USA, an emergency physician who worked with PAs and was willing to serve as my advocate. With his help, I made the connections and got a chance to prove myself. Ultimately, I served in a combined administrative and clinical capacity, first in a coordinator role where I was in charge of the international and local staff of our project in Somalia, and then in a clinical role where I operated as the senior medical provider in a cholera treatment center.
The other PAs in MSF served in other ways, ranging from direct patient care to epidemiologic work. Regrettably, because MSF is a large organization whose primary operational centers are in Europe, and because so few PAs have served, there has been a loss of institutional memory of how PAs have functioned before.
PAs remain relative newcomers to the international medical community. Initiatives for PA analogs in the Netherlands are underway with the first handful of graduates last year. The United Kingdom’s pilot programs utilizing American-trained PAs in the UK National Health Service is still very much small-scale. While we are well entrenched in the American health care system (and in the military in Canada), we have a long way to go before we will be able to move easily beyond our own borders.
A call for action
As a profession that is emerging internationally, we must continue to strengthen our relationship with key players. While efforts are underway for a more formal liaison with the World Conference of Family Doctors (WONCA), the AAPA also needs to work with international health organizations such as UNICEF and the World Health Organization to promote the viability of the PA profession. Talks should be renewed with the Global Health Council to explore means through which we as a profession might contribute to improving access to care in other parts of the world.
PAs wishing to become involved in the international medical relief community should become proactive, yet remain patient. Agencies such as MSF and the International Rescue Committee (IRC) require that potential workers be interviewed, usually in person, and that their credentials and references be completely vetted. PAs should therefore not assume they can be sent to the field by such an organization without going through this time-consuming process. PAs who are interested in working with such an agency should start the application process now.
Today’s PA, both in training and clinical experience, is becoming technology dependent. This may be a disadvantage in the international arena—in disaster response, for instance, clinicians need strong “hands-on” skills, particularly in physical diagnosis. PAs can increase their odds of being selected by having a couple of years of primary care or emergency medicine experience under their belt. It is also important to travel outside the United States and have a realistic sense of what is involved in relief work. PAs need to educate themselves about disaster medicine and tropical medicine ahead of time—and they should learn a practical second language.
News of the tsunamis has already started to fade from the evening news, but their impact on the health of millions of people will remain for years to come. Meanwhile, other longterm humanitarian disasters are simmering, for the most part unpublicized, in otherwise forgotten places like the Sudan and Uganda. Unfortunately, humanitarian assistance will be needed for decades. As a profession, we must step up to the plate, educate ourselves on how better to contribute to the efforts of the international medical community, and inform the world about who we are and what we do. Only then will the PA profession be recognized as a global player—and perhaps then we will be able to join the ranks of qualified health professionals providing humanitarian assistance around the world.
REFERENCE
1. Brown H. Treating the injured and burying the dead. Lancet. 2005;365:204-205.
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