Responding to the Humanitarian Crisis in Ukraine

At 5 AM on February 24,
there was a massive explosion.

My family woke up, and I said,
"Let's evacuate. The war's started."

We visited several of our friends
today in Mariupol and relatives.

And we saw in different parts of the city
places where explosions happened.

On the 24th of February 2022, Russia invaded Ukraine.

Attacks throughout the country have forced countless numbers of Ukrainians to flee.

To date, over 10 million people have been displaced.

Médecins Sans Frontières, or MSF, known in English as Doctors Without Borders, immediately started emergency activities in Ukraine.

Christina, did you have your contacts?

They are at the border ringht now. Can I across with the first one?

Yes.

The international NGO supports people affected by conflicts, disasters, and poverty.

By early April, MSF Japan had dispatched an emergency physician and two logistics specialists to Ukraine.

Also in April, Dr. Yuko Nakajima was appointed the new president of MSF Japan.

While working as an emergency physician at a hospital in the United States, she has provided medical and humanitarian aid to people in conflict zones and poverty-stricken areas,

including Syria and South Sudan.

The most important thing is to put
yourself in the patient's shoes.

To be there for them.

You must also work with people
familiar with the local culture.

This is very important and
it's something we're doing well.

Working both behind the scenes and on the frontlines, she plays a key role in Japan's MSF activities.

She joins us today to talk about MSF's work in Ukraine.

In April of this year, Dr. Nakajima bacame the new president of Doctors Without Borders Japan.

The war in Ukraine has put a new spot light on the activities and contributions of Doctors Without Borders.

Our dialog today will focus on these activities and on the possible roles that Japan may play in a days to come.

Dr. Nakajima, nice to meet you.

Thank you for having me.

You've just been appointed the president of the Japan office of MSF.

Thank you for taking time out of your busy schedule to join us today.

It's my pleasure.

Ukraine is now in the midst of a serious humanitarian crisis.

When reports about the situation started to come in, tell me what were some of the things that were going through your mind?

I was in Iraq at the time, in Mosul.

It's a region which is now struggling to rebuild after years of terrible conflict and destruction.

When I heard the reports about Ukraine, my first reaction to the shocking news was probably similar to that of other people.

I wondered, why was this happening again?

Why is there no end to such conflict?

But at the same time, I knew that MSF would waste no time in launching emergency activities.

And I wanted to be a part of that and to do whatever was possible on my part.

Since Russia's annexation of Crimea in 2014, MSF has been a major presence in Ukraine.

They've been responding to the needs of patients with HIV, tuberculosis, or other diseases.

And in addition to that, for the last few years, MSF has also been fighting the pandemic.

Since the end of February, I understand MSF has switched gears and gone into crisis mode, and that they are now providing emergency aid to Ukraine and neighboring countries.

Could you tell us specifically about what MSF is currently doing on the ground and the scope of its activities?

MSF is providing an emergency response in both Ukraine and neighboring countries.

Currently, we have set up about 20 facilities on the ground.

In terms of staff, we have already dispatched an international team of over 100 people.

And this team is working with over 200 local staff members.

From Japan, we've dispatched an emergency doctor as well as two logistics specialists.

When putting together a team of multinational staff, what sort of decisions need to be made and how do these teams actually operate?

So, projects are overseen by operational centers.

We have five of these centers in Europe, and one in Cote d'Ivoire in western Africa.

These centers determine what kind of teams are needed for the different projects.

In other words, they determine the profiles of the people they need and then recruit them accordingly.

MSF has 26 partner sections around the globe.

The centers find appropriate personnel from these partner sections and match them up.

After that, they send a team made up of members from various parts of the world to go and work together alongside local staff.

That's basically how it works.

Since the start of the Russian invasion in February, MSF has set up clinics, assessed needs, and provided medical supplies to people in Ukraine and the surrounding area.

We, as MSF, right now are providing emergency medical supplies to hospitals in Kiev.

We are doing that very much in cooperation with the Ministry of Health.

The way it works is we keep trains that actually goes to Kiev, wait the emergency medical supplies that you can see behind me.

And then they have been taken over by the employees of the Ministry of Health, and those're then distributed to the hospitals in Kiev where actually need them.

MSF has also outfitted a medical train.

It's being used to transport trauma patients over 1,000 kilometers from southeast Ukraine to hospitals in Lviv.

I'm Dan Schnorr, an emergency doctor with Doctors Without Borders.

We're here in Lviv, our flooding patients who we just been evacuated from Zaporizhia.

We had patients on boarded and their family members who left Mariupolis and had multiple traumatic injuries.

They were stabled during the transfer, and now we are making a hand over to a hospital in Lviv.

Can you tell me about the nation's state?

The patients are all traumatic injuries, blast injuries, abdominal trauma, post-surgicial, multiple fractures, and facial trauma.

Also family members with them.

All them having escaped some pretty dire circumstances.

And they are relieved to be here now.

The focus is reducing the burden on hospitals on the frontlines, and providing patients the best possible care.

Many of the patients that are brought to us, including a large number of children, are in serious condition.

So in order to coordinate the transfer of such patients to better-equipped hospitals, MSF worked with Ukrainian Railways to outfit a medical train.

The key factor here is to determine whether a patient is stable enough to withstand the journey.

We want to transfer the seriously wounded to hospitals where they can receive better care.

But they need to be stable enough to be transported.

So it's important to evaluate the patient's condition and make sure they can survive the journey.

We have to balance those two concerns.

I understand that MSF has also set up mobile clinics and temporary medical facilities that are located in subway stations, where people are taking refuge from airstrikes.

Right.

MSF is committed to providing immediate assistance wherever it is needed.

So, we tend to work on the frontlines.

But by cooperating with other organizations such as the Red Cross, we believe it's possible to do even more.

So we're always thinking of ways to provide better assistance.

Families, including children, have been forced to flee their homes and live in evacuation centers or makeshift shelters.

But according to various reports, shelters and children's hospitals have been targeted by airstrikes, resulting in the deaths of many civilians, including children and the elderly.

No matter how intense the warfare, hospitals and facilities where children congregate are never supposed to be attacked.

That's something that's been decided under international humanitarian law.

As we have witnessed firsthand the violations that are taking place in Ukraine...

MSF has been speaking out at the United Nations and other forums...

And we will continue to advocate for the victims and provide more testimonies to violations.

But it's difficult to truly make a difference.

Therefore, in addition to our main activities providing medical support in the field, we also intend to emphasize advocacy and testimonial activities.

We hope to raise global awareness and act as watchdogs.

That's one of our goals for the future.

As of March, MSF Japan has dispatched three nationals to Ukraine.

Dr. Shusuke Monma is an emergency physician who worked in Ukraine for several weeks from late March.

He was part of a multinational team of 20.

Dr. Monma was dispatched to a clinic in Dnipro where he treated evacuees from warzones.

A man who had fled from Mariupol complained of pain in his toes.

- He was hiding in the basement for a week.
- I couldn't take off my shoes.

Wash, wash, wash.

OK?

Dr. Monma administered first aid to prevent the man's injuries from worsening.

Please come to Mariupol someday.
It's a warm coastal city.

Someday. Yes, yes. Thank you, thank you.

The main mission for Dr. Monma and his team was to provide training on how to respond to the influx of mass casualties.

On this day, he's training the medical staff of a university hospital in Zaporizhzhia in southeast Ukraine.

There was an explosion while
transferring patients.

Many people were injured.

This is a procedure called triage which refers to the assignment of priority levels when dealing with mass casualties.

Triage is essential for providing efficient treatment as fighting intensifies.

Then Doctors reserve it as kind of greeting, so it's gonna be fine.

OK.

They didn't know what's fair than good advancing.

Can you tell me what kind of support is being provided by the Japanese medical staff in Ukraine?

What is unusual about the situation in Ukraine is that most of the medical treatment is being provided directly by local doctors.

The multinational doctors deployed by MSF are playing more of a supportive role, and are involved with providing mainly technical support and medical supplies.

That has become their primary role.

On their own, doctors would be unable to act in the field.

They need the support of professionals who are able to create an environment that allows medical personnel to do their work.

We can't provide medical support without the help of our non-medical staff and our administrators.

Without them, it simply wouldn't be possible to carry out medical aid.

With all of that considered, I think that one of the real strengths of MSF as an organization is that we can rely on our own personnel to handle everything in-house.

All of are team members are expected to be flexible and consider the extent of what they can and cannot do and to provide as much support as possible in each situation.

The most important thing, of course, is to put yourself in the patient's shoes.

You have to do the best you can in the situation you're in, and to be there for them.

Naturally, MSF teams dispatched to Ukraine come with their own experience and knowhow.

But it's imperative that they work alongside people who are well-versed in the local culture and understand the local environment.

I think that this is something we're currently doing quite well.

What kind of support do you think is most needed in Ukraine at the moment?

Personally, I believe we're providing exactly what's needed.

I think the most important thing is simply to provide medical supplies.

That's what's needed the most right now.

Also, to provide training on how to handle and prepare for an influx of mass casualties and other situations which people would normally not be familiar with.

This includes psychological as well as medical care.

This kind of support is very much in need in Ukraine today.

And I think MSF has the capacity to meet such demands.

Dr. Nakajima is currently based in the United States, where she works as an emergency physician while also taking part in MSF's activities.

Her first mission as a member of MSF was in Nigeria in 2010.

Since then, she has worked in Syria, South Sudan, Yemen, and other conflict-stricken parts of the world.

She has been deployed to a total of seven countries and regions.

You have experience working as a member of MSF in many different countries.

I'm sure you have found yourself in situations where there was a shortage of the necessary medical supplies and equipment.

In the face of challenging situations like that, how were you able to cope?

It depends on the project.

As you say, there were times when we lacked the necessary equipment and medical supplies.

But as long as you have basic medical knowledge and skills, I've found that you can somehow get by in these situations.

When I was working as an anesthesiologist, there was one time where I had to administer anesthesia without the necessary equipment.

But I did have a portable respirator and ventilator.

Although I couldn't find an anesthetic apparatus, I was able to find a gasification unit used to deliver anesthetic gases so I used the two in combination.

There were times when I gave an anesthetic via IV drip.

So, even without the appropriate anesthetic apparatus, I've had to somehow come up with ways to administer a general anesthetic.

Doctors with different languages and religious backgrounds must go to the frontlines of conflict zones and work together as a team.

I'm sure it's difficult to overcome various language and cultural barriers when providing support in the field.

Have there been any particularly challenging situations, especially with regard to religious taboos?

Yes.

My very first mission was to Nigeria.

I had to treat patients who were suffering from severe injuries, including fractures that needed to be stabilized with external fixation.

But wounds would get infected to an extent that the limb required amputation, which would be standard procedure in the United States or Japan.

Amputation?

Yes, the limb needed to be removed to keep the infection from spreading throughout the body.

There were a number of patients with such life-threatening injuries.

But cutting off a limb was considered to be a taboo in the local culture, something really negative.

If someone in the family had to undergo amputation, the entire family would be regarded suspiciously.

An amputation might mean they would be looked down upon by the rest of the village, regarded unfavorably.

Because of this cultural background, there were patients who insisted they would rather die than lose a limb to amputation.

In such cases, you can't use any amount of logic to sway the patient.

There's just no way you can get them to agree to the procedure.

So in cases like these, it's important to go into the field with a good understanding of the local culture.

Doctors, including yourself, take a leave of absence from their regular jobs to go on MSF missions.

Does their experience in the field have an impact on the way they do things when they return home, or vice versa?

If so, could you share some examples?

Yes.

For example, we've found ultrasound machines to be particularly useful in the field, so MSF is putting them to use in many projects.

Even in situations where it's difficult to take an X-ray or CT scan, it's possible to take a scan using a portable ultrasound.

They're becoming smaller; you can even attach some units to your smartphone.

Amazing.

So, it's possible to apply our training and experience with handling such devices at home when we're out in the field.

There are also cases where experience gleaned from MSF missions has helped improve emergency medicine in the United States.

One of the first things that comes to mind is the drug ketamine.

It's used widely by MSF in the field today.

It's a very useful and versatile drug that acts as a painkiller and sedative.

It can also even be used as a general anesthetic.

Doctors who have been on MSF missions know how safe and effective the drug is, and this has helped to raise awareness of ketamine and lead to widespread usage in the US.

It's used in emergencies that require sedation and by medics en route to hospitals to control agitated patients and to relieve pain.

MSF doctors are used to using ketamine.

So this is an example of useful knowledge gleaned from the experience of working with MSF.

Working in the face of devastating conflict and poverty, Dr. Nakajima says she has drawn strength from the words of a Japanese surgeon.

I understand that your mentor once told you: "Cultivate the ability to remain detached."

You've taken this advice to heart.

How has it helped you in the field?

What are some of the situations where it was necessary to remain detached?

I'm often reminded of his words, which have kept me going through many difficult situations.

You're often confronted face to face with extreme, severe cases in the field.

But at those times, you have to be able to detach yourself in order to do what you were sent to do and fulfill your mission.

If you empathize too much with the patients and their families, you become emotional and lose the ability to work efficiently.

So at times you need to be able to step back and take a more objective view of the situation.

You have to detach yourself in order to keep going.

Also, while I enjoy working in different environments with people from different countries, there are times when it can be rather stressful if you let it get to you.

So I remind myself of my mentor's words and do my best not to worry about the little things.

His advice has proven to be really important in maintaining my cool so that I can do what is expected of me.

May I ask what compels you to keep on working as a member of MSF?

MSF has a charter that underlines the principles of neutrality, independence, and impartiality in providing ethical, medical, and humanitarian assistance.

This is at the heart of all of our activities and it's what attracts people who believe in these principles to join MSF and become members.

I would say, for me, this charter is the top reason.

As a doctor, I totally believe in the importance of maintaining neutrality, independence, and impartiality in my work.

MSF's stance really appeals to me, I strongly identify with it.

And the organization itself is very active.

It's highly flexible and very responsive to all kinds of situations.

When I was in Syria, working in a very dangerous environment, I saw many seriously injured or ill patients.

It was truly a heartbreaking situation.

But in the midst of this chaos, two little boys came asking for help.

They were brothers who I think were probably about four and seven.

The older brother said his little brother had stuck a marble in his nose and couldn't get it out.

We were so accustomed to dealing with life and death situations that his request to remove the marble came as a pleasant surprise.

The older brother acted like a parent, keeping his little brother calm while we took the marble out.

We were able to remove it, and everyone was happy.

Afterward, we watched the brothers holding hands as they made their way home.

It was very gratifying to know that the brothers, those little boys, believed that we could help them, and that they were willing to visit our clinic to get that help

even in the midst of all the fighting.

That's such a happy memory for me.

Experiences like this on the frontlines are what keep me going.

We asked Dr. Nakajima to write a kanji character that symbolizes her life and her work.

The kanji she selected is "kyo" or "tomo" which means "together."

Why did you select this particular kanji, which can be read "kyo" or "tomo?"

Both the medical staff we dispatch overseas and our office staff are all working together as one to provide assistance to those in need.

So despite the gravity of the situation we're facing today, it's important for us to persevere together and continue our work.

My vision is to dispatch more and more Japanese staff to projects overseas.

I want to provide support for those efforts.

And in addition, I also want to play a part in developing a system that will allow for the provision of more medical support on a global scale.

I hope to be able to contribute to creating an environment that will make it easier for more Japanese doctors, nurses, and other medical personnel

to be dispatched to go on missions overseas.

That's how I hope to contribute.