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Silent wounds


Understanding the moral challenges associated with humanitarian work

In 2020, the COVID-19 pandemic made visible to the general public some of the many challenges associated with humanitarian work. Suddenly mortality rates, shortages of medical supplies and the difficulty of making hard choices in contexts with limited resources were reported in the media and discussed in social circles across the world. Little was said, however, about the consequences of making those choices on the frontline humanitarian and healthcare workers who witnessed their direct impact.

Perhaps this omission is a consequence of health workers being portrayed as heroes, praised and applauded for putting their lives at risk to care for others. Even the stories which surfaced during the pandemic of harassment and violence against health workers somehow served to illustrate frontliners’ resilience in the face of adversity and to feed the ‘superhero’ narrative. One problem with this narrative is that it does nothing to address the fundamental reasons why our health systems suddenly appeared on the verge of collapse. But most importantly,it is a distortion of reality which completely overlooks the complexity of individual situations and the less-than-optimal choices that had to be made, as well as the impact on those who made them.

Understanding moral discomfort

Humanitarians are often uneasy with being idealised because, in fact, working on the frontline of a medical emergency often means being confronted with our own powerlessness in the face of human suffering. Sensations of inadequacy, meaninglessness and frustration are symptoms of moral distress, defined as the feeling when one “knows the right thing to do, but institutional, contextual or cultural constraints make it nearly impossible to pursue the right course of action.”[1] In humanitarian terms, moral distress occurs when something – a medicine, a vaccine, a medical technology – exists in the world but, for whatever reasons, we cannot provide it in the contexts where we operate.

Ethical issues posed by epidemic emergencies and their impact on the mental health of field teams first generated formal interest at Médecins Sans Frontières/Doctors Without Borders (MSF) during an Ebola outbreak in Uganda in 2009. In 2018, the analysis of moral experiences became a focus of research at MSF’s Operational Centre in Geneva. The ongoing ‘Moral Experiences’ project acknowledges the importance of moral questions in the conduct of humanitarian action and provides staff with a space to share stories and strategies to prevent or alleviate moral distress. Ultimately, the objective is to understand the moral challenges associated with humanitarian work and to develop resources to support MSF staff.

Imperfect choices in times of COVID

Dilemmas associated with humanitarian action are neither new nor specific to COVID-19, but the pandemic brought into a more public forum the moral distress regularly faced by humanitarian workers forced to make difficult choices in resource-limited settings. In the early stages of the pandemic, the scientific uncertainty in the face of a disease we did not know how to prevent or treat limited the care we were able to provide. Shortages of medical oxygen sometimes made it impossible to provide appropriate end-of-life care and to allow people to die with dignity. The exposure of our staff to the risk of contracting the disease was also not specific to COVID-19, but it was rendered more severe by a global shortage of personal protective equipment.

“Where can I be more useful, here with MSF or at home?”

What’s more, COVID-19 created a unique situation where countries in which MSF has headquarters were severely impacted, while many of the contexts where we work in sub-Saharan Africa were less impacted during the first wave of the pandemic. Some international staff asked themselves: “Where can I be more useful, here with MSF or at home?” As borders started closing, decisions had to be made quickly, without having the information needed to fully gauge their consequences.

A collateral effect of airports closing was that international staff on missions were unable to go home. Depending on their country of origin, evacuation planes were organized at different rates, creating feelings of inequity. Finding domestic flights within the African continent, for instance, was extremely challenging. Staff were also torn between remaining on standby, in the hope of being able to board a plane, and supporting overworked colleagues, thereby renouncing quarantine measures imposed by most airlines at the time.

On a larger scale, the increasingly complex work environment created by public health measures such as the shutdown of international travel generated concerns within MSF about our ability to maintain routine programmes and to respond to existing health needs other than COVID-19. A great many internal discussions took place around competing priorities. In some places, we were forced to suspend regular activities temporarily, either to prioritise the COVID response or because too many of our staff were unable to get to work, due to travel restrictions or because they or their families had contracted COVID-19.  

Caring for the carers

The ‘Moral Experiences’ project aims to show health workers as human beings and to raise awareness of the impact of these impossible choices and imperfect decisions on medical professionals’ mental health. It aims to shine a light on the distress that comes from working in sub-optimal conditions, being confronted with only poor choices, and being unable to provide the highest standards of care and of humanity.

Insofar as the decision to join a medical humanitarian organisation is often experienced as a ‘moral choice’, trying to respond to infinite needs with limited resources is not just part of the job, it is the job. What matters is not leaving individuals to carry the weight of difficult decisions alone. As for MSF as an organisation, debunking the myth of omnipotence is a necessity if we are to avoid caricaturing people as either victims or heroes. By rejecting the glorification of humanitarian workers, we reaffirm the basic necessity of protecting them so they can continue serving the most vulnerable.

[1] Andrew Jameton, “Dilemmas of moral distress: moral responsibility and nursing practice”, AWHONN’s clinical issues in perinatal and women’s health nursing, vol. 4 (4), 1993, p.542-51


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