Targets and indicators

19 August 2010

Yesterday I transferred a 3 year old boy from the General Hospital to 
the MSF hospital (Bon Marché) – although most of the paediatric care
 now takes place at the general hospital, we have retained Intensive
 Care at Bon Marché for the time being. The boy was gasping, and had 
that familiar terrified stare that one sees in cases of severe anaemia 
which are starting to decompensate. (Malaria tends to destroy the red
 blood cells, resulting in anaemia; up until a certain point the body
 adapts to this loss by diminishing its level of activity, but there is 
a critical threshold beyond which the body cannot survive without 
supplementary oxygen and a blood transfusion). I sat opposite the
 mother, whose tired expressionless face suggested that she was 
prepared for the worst. But within 5 minutes the boy was on oxygen,
 and that night, following a transfusion, he was sitting up and eating 
his porridge.

Now, we must acknowledge that under current circumstances this child
 would not have survived had he stayed at the general hospital. Yet
 such deaths are avoidable, with the use of commonly available tools 
and medications. We cannot think about leaving until the hospital has
 the capacity to manage cases like this.  But shouldn’t we be focusing 
more on the health centres, such that they are able to treat the
 malaria early enough to prevent it getting to this stage? And if we go
 one step further…what of the (unknown) number of families who cannot 
afford care at the health centres – can we conceive of leaving in the 
knowledge that huge numbers of people have no access to care at all?
 What of the charter of MSF – what population can be more in distress
 than a population that has no access to healthcare?

Of course, we have to accept the fact that our interventions will 
never reach everyone. Particularly at these transitional phases, where 
we are moving from a model of care that prioritises accessibility, to 
a model that prioritises sustainability.  We have to choose indicators 
and set targets that at first may seem modest, but ultimately are
 realistic. When we achieve these targets we will know that we are ready to pull out. But all of this is difficult to consider when one 
is faced with a child in extremis.

Sometimes I think that such doubts are a sign of fatigue – when we are
 full of energy, we can remain convinced that the strategy will work,
 and we retain a philosophical outlook in the face of individual 
losses. And yet we must not stop voicing these doubts, because at some
 level it is never acceptable that children (that anyone) should die
 like this; and we must keep expressing this if we want it to change,
 and if we wish to avoid losing our humanity amongst all the targets
 and indicators.