Along Poland’s border with Ukraine there is Hrebenne, a bustling pop-up community in a parking lot with a patchwork of canopy tents and trailers. People busily criss-cross the scene, some in bright volunteer vests, others in camouflage or religious habits. There are portable toilets and even a bank machine.
In the middle of it all, a tiny blue medical tent is encased by a large, white party tent.
Along this section of the border, foreign NGOs and unaffiliated solo volunteers gather, without oversight, to provide aid to thousands of Ukrainian refugees forced to flee their homes. While the volunteers’ intentions are lauded by many, witnesses and experts in humanitarian response are criticizing the coordination among them as “non-existent,” exposing the danger of poorly regulated humanitarianism.
Kirsten Johnson, a Montreal physician and expert on humanitarianism, says unco-ordinated humanitarianism can lead to negative impacts.
“You have human trafficking, lack of child protection, there can be spread of COVID,” says Johnson.
While the World Health Organization maintains a strong presence in Poland and Ukraine, its focus has been on health infrastructure and medical evacuation across borders, not on providing health services. As a result, providing medical aid to refugees has been left in the hands of local governments.
“The WHO said, ‘We’re not really needed here; Poland’s got a good handle on things,’” says Valerie Rzepka, executive director for the Canadian Medical Assistance Teams (CMAT).
Providing medical aid to Ukrainian refugees
As a physician volunteer for non-profit CMAT, I landed in Poland on March 13. Invited by the Polish government to provide medical services, but not assigned to a particular site, the CMAT team was left to decide where to work.
Our team’s first stop was the Polish border crossing of Hrebenne, where up to 3,000 Ukrainian refugees enter Poland every day. Just a day earlier, Rzepka had assessed it as a site of high need. Julien Auger, a physician who had arrived solo from Saint-Jérôme, Que. in early March, had been the only medic there for days, treating Ukrainian refugees in his tiny blue tent. He was set to leave on March 20 and needed backup.
“I am appealing to Canadian physicians with primary and emergency-care skills … For the moment, I am the only doctor in Hrebenne,” Auger wrote on Twitter in French.
We arrived shortly after dusk to mayhem. Overnight, unbeknownst to Auger, his tent had been engulfed by a larger white tent and relabelled a “Mercy Hut” by the Knights of Columbus, a non-medical Catholic charity founded in the United States.
Instead of medical professionals, however, the Knights of Columbus tent was staffed by several volunteers who had shown up to Poland alone with no clear credentials or plan.
“They wanted to take control of [the medical tent] themselves but only had one paramedic — and nobody to back him up,” says Rzepka.
One of the American volunteers, a young man with a buzz cut, was sitting inside the medical tent wearing a bright orange vest over camouflage. His role was not immediately obvious to me, so I asked him about his medical training.
“I’m not sure how to answer … I have some tactical training,” he said.
As I examined a woman with abdominal pain, the man with the buzz cut stayed in the tent to listen. He then made eye contact with me and waved a box of antacids in the air, as if to suggest she had heartburn. She didn’t.
“The ‘rogue medics’ show up and … in most cases it’s fine, if they’re skilled and have legitimate credentials. [But] how can we verify?” Rzepka asks.
Standards are needed for medical volunteers
In countries facing disasters, the general rule is governments have to invite people in, explains Johnson. He is the CEO of Humanitarian U, an organization which trains and certifies humanitarian field workers.
One gold standard in disaster medicine, says Rzepka, is the “emergency medical team” (EMT), developed by the World Health Organization and first used in the Philippines during Typhoon Haiyan in 2013. This program verifies the training of doctors, nurses and other first responders and has strict requirements for who is allowed to provide medical attention in crisis zones.
These requirements include ethical and logistical standards, such as self-sufficiency and the ability to deliver specific services. For example, a “Type 1” EMT must be a mobile clinic whose staff sees at least 50 patients a day, are able to manage basic trauma and infections and know where to refer those requiring further care.
Humanitarian workers wary of ‘disaster tourism’
And what about those who show up alone to a disaster? Johnson says the practice is called “disaster tourism” and she strongly discourages it.
“I got at least 10 text messages from colleagues asking, ‘Should I just go (to Ukraine alone)?’” she says. “You really need to go with an organization or you’re not necessarily effective.”
Rzepka says even licensed health-care providers can be complicit in disaster tourism. Doctors with good intentions show up to these clinics but have little knowledge of how they operate. They also need to be housed and fed, “a burden to an already suffering society,” she says.
More physicians isn’t necessarily better, as they often cannot work effectively alone, says Johnson.
“[Doctors] need nurses and a whole infrastructure that provides for us. Just because you have a skill set doesn’t mean you can employ it,” she says.
Historical consequences of unlicensed medical aid
Both Johnson and Rzepka witnessed the same historical example of humanitarians’ potential to cause harm: Haiti.
In 2010, an earthquake struck Haiti, killing about 220,000 and injuring 300,000.
“There were over 3,000 organizations that deployed, a lot of them hospital teams sent on private planes. People felt they had to do something,” says Johnson.
Rzepka says the vast majority came uninvited: “They clogged up the airport, compromised the supply chain … For a lot of them, it was their first time responding [to a disaster].”
Johnson says one university in the United States sent junior medical trainees with little experience to Haiti to perform emergency surgery, including amputations.
Another group set up a field surgical hospital for three months but disappeared one day without notice, leaving Johnson to deal with their patients’ surgical complications.
“You can’t just put hardware in these people’s legs and not fix them. How does it ensure continuity of care?” she asks.
Planning ahead for the next crisis
To prevent scenarios like this, Johnson suggests aspiring volunteers should go with a group with logistics in place — ideally one that respects international humanitarian standards. If their rosters are full or they require training, volunteers should be patient and follow protocol.
Secondly, Rzepka says if the WHO is not involved in the coordination of sites such as Hrebenne, it should be up to local-level governments to decide who’s allowed to work there — and prohibit those that aren’t.
“Good intentions are not good enough,” she says. “You need good planning.”
Anthony Fong is an emergency physician who recently provided medical aid to refugees in Ukraine. He is a clinical assistant professor at the University of British Columbia and a fellow in global journalism at the University of Toronto.
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