RSM Global health and human rights film club: Living in emergency

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The RSM’s Global health and human rights film club launched on 8 September 2011 with a screening of director Mark Hopkins’ Living in Emergency.

Filmed in the war-zones of Liberia and Congo it follows four volunteer doctors providing emergency care under the aegis of Doctors Without Borders/Médecins Sans Frontières (MSF).   The film’s urgent title is borne out by its content.   The doctors work in chaotic overcrowded clinics, there is limited diagnostic equipment and often they have sole responsibility for the lives of all the patients they treat.

The stress of this situation runs through every frame and every line of dialogue.  “The demand is pretty much infinite” says Dr Christopher Brasher.  “It’s just a matter of choosing what you can do”.  The film shows that the inadequacy of what MSF’s doctors can offer is in direct contrast to the enormity of the task with which they are faced.

Brasher, a veteran of several conflicts, wants out but wonders where he should now call home.  American surgeon Tom Krueger works in Monrovia’s only emergency hospital and is on his first assignment, having grown disillusioned with the contribution he could make at home.  He appears to cope the best, but struggles to live with his inevitable mistakes.

Davinder Gill, 26 years old and working in remote bush, is overwhelmed and exhausted by his responsibilities.  His irascibility makes him the most compelling character, his frustrations leaving him unguarded in front of the camera.  Perhaps inevitably Chiara Lepora, the head of the Liberia mission, compares him to Conrad’s Kurtz, driven mad by the insanity that surrounds him.    Like the majority of MSF doctors who never make it beyond one 9 month mission, Gill is unlikely to volunteer for a second time.

When conflicts end, healthcare needs remain and the film sensitively shows how difficult it is to leave.  Also here are the gore, personal conflicts, and difficult compromises that day to day MSF work entails.  This is no recruitment film for MSF, but a forceful character study of people close to their emotional limit.

It’s a shame that couldn’t have gone a bit deeper, as its subjects’ back stories remain untouched.  A more serious omission is total lack of any local viewpoint on MSF interventions or volunteers.  Without this, their suffering becomes a mere backdrop for the disillusionment of Western idealists.

Living in Emergency press page for further reviews

Also published on BMJ blogs

(reviewed June 2018)

Anyone curious about Kurtz can either read Heart of Darkness or listen to In Our Time

Metaphors in medicine

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Illness as metaphor on

Metaphors are widely used by both healthcare professionals and lay people when talking about matters of health. Despite this their role is largely unrecognised. This is a shame, I feel, as they can have a powerful effect on the practice of medicine and the experience of illness.

A metaphor is a way of understanding and experiencing one kind of thing in terms of another. Many complex concepts are understood in this way and they are integral to the way we understand things.

The essayist Susan Sontag was one of the first to identify the widespread use of metaphor in relation to certain diseases. She wrote Illness as Metaphor whilst being treated for breast cancer and visited the topic again in 1988 with AIDS and its metaphors.

Sontag argued that metaphors attach themselves to certain diseases and these metaphors exert influence on patient and public attitudes. With both HIV and cancer Sontag argued that metaphors introduced an unhelpful emotional dimension when a more detached scientific approach was required.

Two main sorts of metaphors have been suggested. “Biomilitary” metaphors represent disease and the body’s response to it in terms of “attack” and “defence.”  By contrast with “bioinformationist” metaphors the body, in both health and disease, is seen as a communication system with “receptors,” “transmitters” etc.

Particular diseases attract metaphorical description more readily than others. Biomilitary metaphors are pervasive in discussions of cancer. By contrast heart disease is discussed almost exclusively in terms of the mechanical metaphor of plumbing.

Arguably metaphors don’t merely describe similarities; they create them. As well as illuminating they can also conceal. It can be hard to think of cancer in a way that is not biomilitary, but wars honour battles which can make the transition to hospice care problematic. Mechanical metaphors for heart disease are also limited as they hold no place for lifestyle modification. I don’t agree with Sontag that metaphor should be eliminated from the discussion of medical illness. In fact I don’t actually believe that it would be possible to talk about disease without them. But they have a hidden power that should be understood.

If you choose a metaphor, choose it wisely.

Also published on BMJ blogs

BMJ: first despatch


This, published on BMJ blogs

Last Wednesday I joined the BMJ as the Roger Robinson editorial registrar. This is my first despatch from the frontline of medical publishing.

The registrar role has been running for 22 years and is named after the late Professor Robinson who was an associate editor at the BMJ for ten years. It’s for one year and allows the post holder to take a break from clinical practice and develop skills in medical journalism and editing. This sounded like an excellent opportunity to me as I’ve been interested in writing and publishing since medical school.

Although I’ve been in the job less than a week, I’ve already been put to work and have written my first news article. In the process I’ve learnt that news requires short paragraphs and quotes are vital to lend a sense of currency. BMJ style strongly discourages the passive voice. I also helped select letters from amongst the BMJ’s many rapid responses for inclusion in the upcoming issue.

I’ve not worked in an office for over ten years and there are lots of differences to my previous NHS foot soldier job. Clearly I’m not seeing any patients at the moment, which is a shock.  Another big change is how central the BMJ’s offices are – I’m used to working in the far reaches of the capital (where the riots are). It’s not been a complete culture change though, as amongst many medical journalists there are also plenty of medically trained staff. I find it quite exotic that a lot of people at the BMJ work remotely, some as far away as Sydney and Boston USA. At any meeting several people join us by phone.

I’ll save further details of how the journal is put together for future despatches. As a final reflection, unlike stereotypical journalists I detect no evidence of a habitual heavy drinking culture here, but the coffee in the canteen is tasty, keenly priced, and frequently very strong.

(June 2018 – broken links removed)