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Healing, Distance & Harm

The following is a short lecture presented at the inaugural Hungry for Change Gala at the University of Western Ontario on 30 April 2008.

I was asked to speak to you tonight largely because I spent most of last year working in Cambodia. In the next 15-20 minutes I want to share some of my experiences and reflections with you.

One of the most important lessons that I learned in practice was this old one that most of you, I imagine, are familiar with:

    Our potential to harm others is rarely as great as when we are trying to help them.

It applies to healing interventions aimed at populations as much as it does to the healing of an individual. It applies no matter what the form of intervention. Of course this risk of harm does not mean that we should give up on foreign aid or global health, any more than the risks of harm in our day-to-day work prevents us from caring for the sick. It just means that we have to engage in this work with special vigilance and mindfullness. This is true not only of the people who physically carry out the work but also for those who support them, spiritually, financially or otherwise.

Often, even with the best of intentions, we can be undone, and I want to share some ideas on how we can guard against this, and hopefully trigger your imagination to come up with more.

Cambodia was a great place to learn about this because, amongst many things, it is a museum of good intentions gone wrong, often reminiscent of the old adage about the paving on the road to hell. In Phnom Penh, the capital, for example, many poor communities are being forcibly evicted from their land with little compensation so that condos can be built for the ever growing numbers of foreigners, most of them so-called aid-workers. The presence of this group, which I was a part of for 8 months, and their demand for resources has contributed to a near 10-fold increase in land prices over the past three years, which has had catastrophic consequences for many farmers. So much for “First do no harm”.

But I want to talk about a more personal side of this. So here is one story from my first week working in Calmette Hospital, the largest teaching hospital in Cambodia.

I was working in the emergency room. My supervisor, the chief of emergency, was working elsewhere that week. On my first day he introduced me to the unit staff and left, which made for an interesting situation. The staff were trained in French, the patients spoke Khmer, and in my state of culture shock & confusion I could barely speak English. I could understand some French, and could speak Khmer at the level of an average 2-year old, which is to say I could make a few two-word sentences from my vocabulary of about a dozen words.

~

I was there with a year of clinical experience, with hungry eyes, wanting to experience medicine for the poor, wanting to help, wanting to assuage my guilt for being so privileged and using far more than my fair share of the earth's bounty, wanting to learn and understand another way of life, wanting to do good.

As per the requirements of my academic institution, I had rather detailed plans for how I intended to execute this good. Most of these plans it turned out had been based on gross misinformation and had collapsed within days of my arrival, leaving me even more disoriented.

So here I was now, in the emergency room of Calmette with some of the noblest intentions I have ever had, but also preoccupied with my collapsing plans and the like.

I did my best to make it clear that I was a student with very limited clinical experience, but it was still obvious that I was being taken far more seriously than I should have been. This wasn't new, but it still made me very uncomfortable. My initial reaction was to be extra polite and respectful, for example, by always using the forms of greeting used with a senior regardless of who I was speaking to. I later found out that this itself was often interpreted as either a sign of disregard for convention, or evidence of low intelligence.

All of this made for a mentally exhausting routine. Every act of communication required a huge amount of effort. It seemed best to just watch and absorb for a while. It was in this state I came upon the nameless and unmoving person at the centre of this story.

I don't remember his name. I remember reading it on his chart several times, but everything about it was strange to me, and my memory had no idea what to do with it.

He was a farmer brought in by his wife. He wore the traditional black pants and loose white shirt and looked much older than the 65 years on his chart. He had a strong stout build, and the wide well-worn feet very characteristic of Khmer farmers. He was burning with fever. He was delirious. I learned later that his family's decision to bring him to the hospital, and the hospital's decision to accept him as a non-paying patient implied that both his family and the hospital triage thought that he was beyond saving.

He seemed very ill and no one was paying him any attention, despite the place being full of interns and staff. So, with some help from one of the medical students who spoke some English I reluctantly started to get a history and examine him hoping that any point one of the staff would join me and help correct the inevitable misunderstandings and cover my social improprieties, but no one came.

Luckily (for me) it was a rather simple diagnosis. I had only been working for three days but I had already seen much the same scenario before. It looked very much like an infection (probably malaria) that had reached the brain. We had to confirm the cause of infection and that required a lumbar puncture.

I had also noticed some signs of a potentially serious contraindication to the test, namely increased pressure within the skull, but I failed to connect these pieces of information together. If the pressure was in fact increased a lumbar puncture could result in parts of the brain being squeezed out through the base of the skull, which is not the kind of outcome I have been taught to aim for.

This kind of situation is why people like me are generally kept on a short leash and not allowed to do much without running their harebrained plans by someone with a bit more gray hair first. So I made my case to the attending physician.

Two things were obvious. First, that neither he nor anybody else shared my sense of urgency. Second, I strongly suspected that I was not making myself understood. When I was done he just nodded and didn't correct anything I had said. He just asked me what kind of needle I wanted. He gave no hint of whether or not he agreed with my assessment and he hadn't examined the patient himself. I reminded him of my phytoplanktonic status on the food chain. He didn't seem concerned.

I noticed that he had already ordered a CT scan which for a non-paying patient would involve many hours of waiting as administrators decided whether there was enough money to cover the scan. Meanwhile I felt that precious time was being lost when this man's only hope for survival was rapid treatment of the infection.

I was comfortable enough performing the test itself, but I was also acutely aware of my own inexperience and rather wide (to put it politely) margin of error in clinical judgment. I tried to get the more senior staff to assess the patient and confirm my plan but no such luck. There seemed to be great and widespread hesitation to disagree with anything I said.

What should I do? Why was no one else in any rush? Was I over-reacting? Maybe this wasn't really an emergency? Or maybe they had seen this too many times before and knew that it was already too late? Maybe he was a poor, sick elderly farmer in a place where younger, healthier people die of even simpler things? Should I just do my best however bad that best might be? Would I be putting this man in even more danger than he already was?

Then there was my growing suspicion that such patients, poor and given up as lost, were often brought in for training purposes and that I would be allowed to do almost anything I wanted to. This impression became stronger when about a dozen medical students lined-up next to his bed and all took turns performing an uncomfortable exam. Neither he nor his wife were ever acknowledged.

Now in all this confusion one very strange thing struck me about my own reaction. I believed that this man needed urgent help which was available in that hospital but which he was not receiving. I had no idea how to get him the help he needed, and I didn't trust my own clinical judgment enough to act on it without support. I knew all this, was deeply troubled, confused and agitated, but I was, mostly, emotionally unmoved.

The prospect of his dying was unpleasant, something I was trying to avoid, but I was not, for example, nearly as distressed as I had been the day before when a Belgian tourist came in with a serious, but not life-threatening knee injury from a motorcycle accident. Then I felt an immediate camaraderie with my patient, and actions flowed more naturally.

I felt numb. I wondered to myself if this is what being a sociopath feels like.

Someone had to stand up for this man. But I was too worried about respecting unknown social norms, not wanting to disrupt a system I did not understand, not trusting my own perception or judgment. I wasn't going to be that one.

In retrospect I was seeing him in exactly same way as those around me were: he was poor and beyond hope, a cheap life destined to die of for the lack of a few dollars timely medicine. I did not see this dying man as my equal, as my brother. Despite standing next to his bed with my hand on his shoulder for over an hour agonizing about how to do good for this man, my heart was very far away.

I needed air. So I went for a walk to clear my head. I felt guilty, cold, confused, like a coward. To add to it I, just then connected the pieces together and realized how close I had come to putting his life in even more serious danger. In the end, after long hours, the CT scan showed nothing and the man was transferred after being given some antibiotics, though his condition was never properly diagnosed. I don't know what happened to him. The last mention of him in my notes from that day just states his temperature: 40 degrees Celsius.

~ ~ ~

This happened very early on during my time in Cambodia but it stayed with me because its essential elements would come up again and again throughout my time there, not only in the clinic but also in my day-to-day life and research. Months later, after my return I came across this passage from Henry David Thoreau

    "There is no odor so bad as that which arises from goodness tainted. It is human, it is divine, carrion. If I knew for a certainty that a man was coming to my house with the conscious design of doing me good, I should run for my life, as from that dry and parching wind of the African deserts called the simoom, which fills the mouth and nose and ears and eyes with dust till you are suffocated, for fear that I should get some of his good done to me, -- some of its virus mingled with my blood. No, -- in this case I would rather suffer evil the natural way. A man is not a good man to me because he will feed me if I should be starving, or warm me if I should be freezing, or pull me out of a ditch if I should ever fall into one. I can find you a Newfoundland dog that will do as much. Philanthropy is not love for one's fellow-man in the broadest sense."

Personally I find Newfoundland dogs frightening so I can't share that last sentiment. But Thoreau is making a fine distinction here. To him the Good Samaritan is not "Doing a Good Deed" so much as acting spontaneously and naturally. He sees the stranger by the road as his own and behaves in the way most of us do when our loved ones are in need. In such a situation we don't act out of guilt, or some explicit principle of being good, but spontaneously and out of compassion. In my case, I had guilt, I had explicit principles. I had the capacity for compassion, but it did not materialize.

A few years ago an interesting experiment was done at the Princeton Seminary. A group of divinity students were told that they were going to be giving a practice Sermon. Half were given the story of the good Samaritan as their topic. The other half got other random topics. They had some time to prepare and then, one at a time, they were told to go to a room in another building and give the sermon. On their way they would each encounter a man bent over and moaning, clearly in need in of help. The question was: would the people who had just been thinking about the Good Samaritan story be more likely to stop and help than the others? The answer: No.

The fact that an individual had spent the last 10-15 minutes contemplating the Good Samaritan story had no effect on their behaviour. So what does make a difference? why does my compassion run short in some situations and not in others? I have spend quite a bit of time looking for an answer to this and here is some of what I have found so far.

Consider the following two situations.

Situation ONE: I am driving along and I see someone severely wounded and bleeding on the side of the road and I am quite certain that if she doesn't reach a hospital soon she will die. I am about to stop, but then I think of the time and the mess. I press on the gas and speed past.

Situation TWO: I get a letter from a reputable charity that I trust, asking for $50 or $100 to provide emergency care to victims of a massive global food shortage. I look at it then ignore it.

Think about how you feel about the my actions in these two situations. Why is it that in the first case I seem like a monster, but in the second situation, when I could have probably saved more lives with less resources, my actions seem less bad, even permissible?

Ariel Garten, who I stole this example from, relates this to the research on the neuroscience of morality. We seem to have hard-wired mechanisms for altruism towards other members of our local group, people who are familiar to us and whose distress we see and feel. A situation like the first one with the bleeding person in front of us, triggers those mechanisms in our brain. Statistics about numbers of people dying of famine or under-5 mortality tend not to. They can distress us in other ways, but they don't elicit the same guttural response, and physical urge to help. So when we toss away the letter from the charity we are not being immoral in the neurological sense, and the fact that all this suffering can go on in the world without a dramatic response is not necessarily a reflection of a general lack of morality, but rather a feature of the mechanisms of moral behaviour.

The thing that seems to make the most difference is distance.

Distance comes in all forms: space, time, culture, language, age, gender, money, power, goals ...

In the case of the old farmer, space, time and gender were not at play but all the rest were: culture, language, age, money, power, goals. With the Belgian tourist there was far less distance.

In the clinic we are at greatest risk of harming those whose lives and illness we least understand. The further away that someone else seems, the bigger the lack of mutual understanding, the more ineffective is the healing and the greater the potential for harm.

The greater the distance between us and the person in need, the less emotionally moved we are to help, The less we understand the problem and the less effective and more dangerous our potential solutions.

Think for example of a situation when you were in need of some help. Now imagine a very dedicated and passionate person who does not speak your language and knows very little about your culture and personal history directing people and resources from half-way around the world to come to your house and help you. Would that not make you a bit apprehensive? Wouldn't it be better to have a compassionate neighbour who just gets to know you and then acts as a compassionate individual naturally would?

We need to find ways to close the distances involved, to make the far away other real to ourselves so that our compassion can come in. In that experiment at the Seminary, the biggest thing that determined whether someone stopped to help or not was how preoccupied they were and how much of a rush they were in. Their preoccupation kept them from closing the distance. In my own case, culture, language, age, money, power, and my preoccupations with my own place and role created vast distances between me and the man I was trying to help.

Statistics are useful in lots of way. This isn't one of them. We need to know the other's stories, myths, art and ethnography, in short, all those things that reflect the qualities of the other way of life rather than quantities. Cultures, for example, that have managed to close the time gap, who naturally take into account the past and future generations in every decision, are often aided in closing that distance by their myths and religious stories, that help them see that distant ancestor or descendant as real as their own parents and children.

How do we get these stories? We can read them. We can go to that place, without an explicit agenda and be a compassionate neighbour. Or we can send young adventurous emissaries to go and bring stories back.

In Italo Calvino's book, Invisible Cities, Kublai Khan, the aging emperor, saddened by the corruption and horrors of his empire listens to the traveler Marco Polo who describes to him the cities he has visited on his travels, both their marvel and their sufferings.

At one point near the end the Emperor says:

    "It is all useless, if the last landing place can only be the infernal city, and it is there that in ever-narrowing circles, the current is drawing us."

    And Polo says:

    "The inferno of the living is not something that will be; if there is one, it is what is already here, the inferno were we live every day, that we form by being together. There are two ways to escape suffering it. The first is easy for many: accept the inferno and become such a part of it that you can no longer see it. The second is risky and demands constant vigilance and apprehension: seek and learn to recognize who and what, in the midst of the inferno, are not inferno, then make them endure, give them space."

We have compassion, education, life experience and some of us, deep pockets. For us to be able to make a positive change, we need all of those. It takes our money our minds and our hearts to close vast distances and see the stranger as our own. Without this we are dangerous.

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Notes:

1. I would like to thank the organizers the gala as well as Rebecca Draisey, Thon Buntheoun, Chor Nareth, Jim Gollogly, John Howard, Michael Rieder, John Scott-Railton, Toni Palombi, Tarek Loubani,
Jessica Lefort, Thivian Vandeyar, Ariella Helfgott, Maggie Rebel, Francis Chan & the MD Management Student Line of Credit.

2. The Good Samaritan experiment at the Princeton Theological seminary was presented by Daniel Goleman at the TED conference in 2007 and can been viewed at http://www.ted.com/talks/view/id/200.

3. Ariel Garten's thought experiment was presented at a TV Ontario Big Ideas lecture which is available through their podcast feed at http://www.tvo.org/TVOspecial3/WebObjects/TVOMedia.woa?bigideasVideofeed

Comments

Yeah, baby!! Well spoken, I hope well taken and understood. Bravo!!