Targets and indicators
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.