21 Oct, 08 | by BMJ
“By far the most dangerous foe we have to fight is apathy – indifference from whatever cause, not from a lack of knowledge, but from carelessness, from absorption in other pursuits, from a contempt bred of self satisfaction”
William Osler (1849-1919)
Dominique Jean Larrey was strongly affected by the misfortunes of others. He would often describe how serious disasters afflicted his soul, filling him with profound grief. Late into the eighteenth century the skilled but sensitive physician was assigned to be divisional Surgeon-Major in the army of the Rhine. It was enough for him to observe the poor medical organization of the French army, and its intolerable toll, for a revolutionary concept to form, that would alter military surgery forever. This is, of course, the Ambulances volantes (“flying ambulances”), an efficient medical unit for the speedy evacuation of the injured during the battle and precursor of the medical vehicles used by present day armies. Largely ignored, however, are other brilliant contributions made by Larrey. His amazing pioneering goes as far as introducing the concept of the triage and improving the sanitary organization of the army.
Larrey greatly contributed to various other medical issues, from the effective control of hemorrhage in the battlefield and the drainage of empyema and hemothorax, to non-surgical observations, such as controlling infectious agents in hospitals. For all those creative innovations, some less known than others, Larrey was considered a model military surgeon in his time.
Nevertheless, I was stunned to reveal one astonishingly-modern contribution he made, much ahead of his time, that resides in a few dusted textbooks only: Larrey, to my amazement, collected injured soldiers of the enemy and treated them as best he could. His moral principles were outstanding and exceptional, even when evaluated by today’s standards. The rules of medicine and humanity were of a higher priority to him than those of the war.
During my white-coat ceremony, I could not help pondering the Savior, Larrey’s nickname among his troops. How did Larrey manage to permeate my thoughts at that festive moment? That is because of a saddeningly sharp clash between words and deeds. Excitement pervaded the dignified ceremony, while semi-biblical words of the Israeli version of the Hippocratic Oath electrified the medical students.
We then made a collective vow to help any diseased person, be it a foreign, despised or respectable one. I felt bad about myself, even some guilty feelings. I was fully aware of the severe humanitarian crisis on the other side of the border, and I had not even tried to make a difference in the horrible daily scenario faced by the citizens of Gaza.
What crime did the 1.5 million Gazans commit that would make them the major victim of a bitter and deadly conflict with Israel? Do they deserve to suffer the complications of untreated chronic and sometimes fatal ailments? In just a few days tens of innocent Palestinians died, and the condition of many others was aggravated dramatically. And all this catastrophic mess and unnecessary loss of human lives was the result of attempts by Israel to deter rocket attacks by militants.
To that end, Israel limits supplies of fuel, which results in a lack of electrical power. You can imagine yourself a hospital director forced to make the choice to either cut electricity in the operating room, heart surgery department or in the neonatal unit. You save one life on the second floor, and lose one in the ward next to it.
You deprive chronic renal failure patients of their vital dialysis treatment, and make use of precious fuel in intensive care units, right? I used to think, not so long ago, that electricity was all about leisure, a non-crucial supplement to modern life. Something that was primarily meant to give us 12 extra hours of light each day, or to enable us to enjoy a hot shower in the icy winter. I never learnt of megawatts as potent silent killers. But it turns out that epidemics may occur when hypowattemia spreads, contagiously moving between the sick. It is an acute hypowattemia, with replacement therapy not a beneficial option: even hospital generators cannot operate effectively due to the severe fuel shortage.
Moreover, medical equipment is malfunctioning, and there are restrictions on the movement of medicines and other supplies, further denying the Gazans access to appropriate medical care.
Global emergencies do not shout for help; they wanly tell their stories. And when they do so, we have to delicately tune our logic, and to do it fast. Because the plea for help is gradually weakened as time goes by, interfered by blurring foreign sounds.
The almost-fictional reality experienced by the Gazans must offend us, particularly because the energy crisis in Gaza leaves a considerable mark on the health care aspect. Isn’t the right to medical care the most basic, vital and existential, each and every person possesses? That is what I was taught. Isn’t that a person’s prerequisite for a productive and wholesome life?
In southern Israel Qassam missiles are falling, leading to further tightening of the restrictions imposed by Israel, which paralyze life in Gaza and enhance retaliatory actions by terrorist organizations. And missiles are again the answer. Any way out? The political arena does not seem to produce desirable results, and meanwhile cemeteries are filled with more tragic stories. The cat and mouse play has a much-too-long half-life time. Wait and see is not an option.
There is an interesting theory in science, commonplace in medicine. Some call it the “Synergism Hypothesis.” A simple example may be the beneficial substance (table salt) that is formed from two toxic materials (sodium, chloride). This combination produces a synergos (in Greek: cooperative) effect. That “magic of nature” can be used by us. In fact, societies have used it for centuries. You can see it in factories, where thousands of workers each perform specific tasks, together creating a larger-than-sum effect. There is something unique about the joining of many separate parts of nature.
In the same manner, a vision shared by and endeavored by people whose conscience bothers them, may transform a tiny spark into a huge noticeable flame.
I suggest a first-time hospital, to be built on Israel’s side of the border with Gaza, with as many nations as possible lending their hand. It may be named “Larrey’s Flying Hospital,” in recognition of Larrey’s marvelous idea of ambulances. The optimal location may be a few minutes’ time from Gaza, in a place where medical operations and emergencies can be performed with minimal disturbances. A committee will make sure that supplies of drugs and anesthetic agents, as well as number of beds are appropriate so as to enable proper medical treatment in all the units. Doctors from other countries may spend a few weeks’ time at the hospital’s wings, benefiting from an exposure to a form of medicine that, unfortunately, becomes increasingly common in our days. Medical students in Israel will train and gain knowledge at the institution, as an elective during their studies.
But the real value of a hospital of this type may be much greater. It will serve as a precedent for the creation of similar hospitals in other stricken areas across the globe, where there is an urgent need to medically intervene. Building a hospital is indeed a formidable and lengthy task, but many facts are encouraging. One is the prolonged innate nature of humanitarian crises.
Take a look at Darfur, if you are skeptical. Their significant length should, by no means, deter the nations of the world from doing their utmost to return normalcy to the region in early stages. The second is the inherent vulnerability of such a place to collapse in that point of time or another. You know a certain place on the globe needs reinforced facilities and manpower. You can feel it in your bones. And another thing – when a military conflict ignites, a domino-like loss of souls is on the way. Prompt volunteering is the name of the game. Therefore, the type of hospital I propose will expand the abilities of the medical community to better manage such situations and the grave perils involved.
At the historic battle of Waterloo, Larrey was overtaken and sentenced to death. By a stroke of luck, however, the order was never carried out. In fact, it was Larrey’s service to a higher authority that permitted him to evade death. Because it happened that in a previous campaign, in Austria, Larrey saved the life of the son of no other than the Prussian Marshall. Therefore, Larrey was treated with respect, offered food and money, and allowed safe passage to France. The obstacles Larrey strived to overcome are miles away from those of present day doctors and human right activists. Nevertheless, his story may serve as a final motivating reason for us: we must follow Larrey’s footsteps, and translate his devotion to the common soldier into a joint effort to relief the suffering of vulnerable populations.
Ohad Oren is a fourth year medical student, Bruce Rappaport Faculty of Medicine, Technion – Israel Institute of Technology, Haifa, Israel.