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The Humility of Expertise

Tags: public health

Ed note: Today we welcome Junaid Nabi back to the blog. For more about Junaid, please see the bottom of this post.

Photo by Margarida CSilva

 

The following is adapted from a speech that was delivered as one of the Undaunted talks at the 2018 Aspen Ideas Festival.

In the Spring of 2013, on a warm, sunny afternoon, I was working in a government hospital in Dhaka, Bangladesh. As a Fellow in a foreign-exchange physician program, I was training to learn how surgical care can be delivered in a low-resource setting. As I prepared to leave the hospital, I received a call.

On the other line was my friend — usually a chatty and upbeat guy — who, in an anxious voice, asked me if I could take a few days off from work, and meet him immediately in a town called Savar. Savar is a small town on the outskirts of capital city of Dhaka which houses a large number of garment factories that support Bangladesh’s economy. My friend informed me that minutes earlier, Savar had witnessed the largest industrial disaster in the country’s history.

You see, medical care is an enterprise of individual heroism. From the very beginning, medicine teaches us that individual doctors must be the protagonists in every episode of healthcare delivery. And this is why I studied medicine because I have always been comfortable working on my own. And this was never an issue in clinical practice, as I always dealt with an individual patient at a time. After that call, however, I was asked to take care of hundreds of patients at a time.

As I reached Savar, I was greeted by a wind of a familiar, noxious smell. This smell was rustic and metallic; the kind that would burn your nose if I inhaled for too long. It was the smell of dried blood — one that I instantly recognized from my time in the preclinical anatomy labs. This smell still lingers in my nose. This smell exuded from the hundreds of lifeless bodies of garment workers who were crushed to death from the collapse of the 5-story garment factory. That day, the factory could no longer stand the vibrations from hundreds of stitching machines.

Once at the site, I was expecting to be greeted by a medical coordinator that would assist me in triage, or, direct me towards sites that need attention. But none of that existed.

Instead, I witnessed volunteers from schools and colleges who were using hammers and plastic ropes to extract survivors from the cement rubbles. With an absent coordinated medical effort, I realized if I wanted to save lives, I had to abandon the individual hero mindset and work collectively to train these volunteers in basic surgical care such as bleeding control, fracture stabilization, and infection control.

And that is what I did: I assembled my compatriots. Given the passion of these volunteers, it took merely a few hours before they had understood how much pressure would prevent bleeding from large blood vessels; how many pieces of gauge would be required to maintain oxygen supply to a wound; how tight a fracture bandage needs to be; and, how to lift an unconscious person without injuring their cervical spine.

Hours later, while we were working at the site of collapse, some Red Crescent volunteers pulled a garment worker from the sheaths of cement. Unresponsive and not breathing normally, he was initially presumed dead. After checking his carotid pulse in the neck, however, a feeble pulse was noted. Armed with my freshly trained health workers, we attempted to assist this survivor. You could immediately see the power of collective effort: One of them used first aid gauge to control bleeding from puncture wounds, the other one stabilized an arm fracture using sticks and ribbons, while I stitched some of the open wounds.

For far too long, within the space of global health care delivery, especially surgical care, the narrative has almost always been that of a heroic surgeon who flies in from a wealthy nation and slays the dragon of disease single-handedly. But we never stop to think: Is this a sustainable model? Would this approach suffice the unmet need of safe and affordable surgical care in low- and middle-income countries?

5 billion people around the world lack access to safe and affordable surgical and anesthetic care. It would be remiss of doctors to think that an individual approach can address this unmet need. Instead, we will need to focus on collective effort and recognize the limitations of individual expertise in global health. It will not be individual heroic acts, but continuous incremental changes that can address intractable problems in global health.

What we need is to train and empower allied and community health workers in order to increase the overall capacity of surgical care. Task-sharing, a public health approach that distributes workload among different segments of the health system, may address this need.

So, there I was, with cement on my face, squatting on a large pile of cement rubble, working with young passionate individuals trying to save a life. Within minutes, as the bleeding and injuries were being taken care of, the color started to return on the face of that garment worker and his pulse rate started to stabilize.

On that day, collectivism triumphed individualism. It was only through working together, we were able to bring that survivor back to life.

About the author

Junaid Nabi, MD, MPH, physician, public health researcher, and a medical journalist. He is a Fellow in Bioethics at Harvard Medical School, Boston, and a New Voices Fellow at the Aspen Institute, Washington, D.C. Twitter: @JunaidNabiMD

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