The fine line between do no harm and do nothing

On a particularly sultry day in a hospital of the Peruvian Amazon, I found myself with the task of telling a group of parents that their babies, who had been waiting in the hallways for days without eating in preparation for surgery, would not be able to have their cleft lip and palate fixed. We, a group of American doctors and medical staff offering this procedure free of charge to a population without access to a plastic surgeon, had overbooked our week out of eager hopefulness and now had to cancel the cases that we couldn’t fit in before our flight home. Nobody else from our group could do this job. They didn’t speak any Spanish; nobody among our Peruvian counterparts wanted to do this job. They didn’t have the heart to deliver the news.

Lo siento, I said, limited by not knowing another way to apologize in Spanish, por favor regresa el proximo año. Please come back next year. Mothers cried, asking did I know how long a year is in the life of a baby. Fathers quietly and politely explained how far they had come, most families traveling for days in boats and canoes from deep in the jungle. I again could not say much more than Lo siento mucho. The Spanish phrase for “I’m sorry” literally translates to “I feel it (with you),” and I did.

I use the term “we” loosely, as I was not originally a part of this group, although by the end of the week everyone, especially I, had forgotten that. We met by serendipity during my last week in Iquitos, Peru, where I was working for a month in the pediatrics department as an observer and experiencing the different levels of care (PICU, pediatrics, NICU, emergency room) for possible long term collaborations with American hospitals.

My integration into the surgical mission was automatic; the group did not bring a pediatrician and collectively spoke no Spanish. After three weeks of clinical immersion in the most resource-scarce region of Peru, rejoining my fellow American practitioners, most of whom live and work within 30 minutes from my program back home, was a reverse culture shock. Suddenly, I had to transition from learning a new system (what anthropologists call participation-observation) to putting the tinted glasses of my own culture (American health care) back on and trying to bridge the distance.

I would never have signed up for this mission on my own. Shaped by my undergraduate background in anthropology, I was deeply wary of international medical missions; practitioners from wealthy nations air dropping into a poor region to deliver temporary medical care without regard or respect to the local context, leaving behind handfuls of antibiotics and no real change to the health care infrastructure. I was bothered by the questionable ethics of inflating one’s altruistic ego at the price of potentially disrupting a community’s efforts towards sustainable progress.

In other words, I would never have found myself facing the parents’ anguish that day if chance hadn’t intervened. Strangely, instead of feeling vindicated in my rejection of the genre, I realized something important from being a part of something I did not previously believe in.

Our oath begins, “Do no harm,” which I think might be the most crucial and most difficult part of the pledge. But to scrutinize the opening, even more, it begins with the word, “do.”

Action and theory need to co-exist for progress to take place. I am reminded of my first struggle with this dichotomy when I traded pursuing a career in journalism/anthropology for medicine in order to follow up observation with more immediate action. In the area of global health, theory and cultural mindfulness form the foundation of do no harm, but the theoretical complexities led me to a mentality of inaction that was just as prohibitive. It is possible, and in fact necessary, for social science and clinical practice to build upon each other in global health. After careful participation-observation, there comes a point where one must jump in and do, even if the doing begins imperfectly. Otherwise, there is no path to improvement.

My Spanish is far from fluent. I looked up different ways to apologize later that day and immediately forgot them again. But the important part was to jump in and try, stumble and get back up. The surgical group is raising funds to turn the trip into an annual project, and I hope to return with them next year. I am glad we did certain things poorly, so we can use this year to reflect, refine, refocus. And, of course, to practice Spanish.

Amy Fan is a pediatric resident who blogs at her self-titled site, Amy Fan, MD.  She can be reached on Twitter @AskDrAmyPeds.

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