Emergency Obstetric and Abortion Provision in War Zones: An Interview with Dr. Rasha Khoury from Medecins Sans Frontieres

Interview by Grace Sun '21 with introduction by Amelia Warshaw '21
All photos courtesy of Dr. Rasha Khoury

 

This year’s Women’s Reproductive Health Scholarly Concentration Annual Lecture, Emergency Obstetric and Abortion Provision in War Zones: Notes from Medecins Sans Frontieres Field features Dr. Rasha Khoury, an emergency obstetrician with Medecins Sans Frontieres (Doctors Without Borders). Her focus on providing quality medical care to women at the most risk around the globe has taken her to Afghanistan, Iraq, Lebanon, Cote d’Ivoire, and Sierra Leone.

For those in the AMS community who missed Dr. Khoury’s inspiring lecture or want to learn more about her training, experiences, and what compels her to continue her humanitarian medical missions, Murmur sat down with Dr. Khoury to get the inside scoop.

MSF-Khost Afghanistan 11/2016 Surgical team

1. Please tell us more about your journey in medicine – your process and drive behind pursuing maternal health and eventually humanitarian medical aid work.

I decided to study medicine based on my desire to be a community activist who uses science to improve people’s lives. My parents are human rights journalists and I grew up in the occupied Palestinian territories– where social mobilization for the collective good was at the core of Palestinian liberation efforts in the 80s. My father was a political prisoner for many years and my mother and grandmother raised my sisters and me with a deep sense of equity and justice. In medical school I found women’s health contained the intersection of many things I cared deeply about: empowering a group marginalized by society at best and oppressed at worst.

I learned how I could be instrumental in the movement for women’s sexual and bodily rights and for reproductive justice (when all people have the power and resources to make healthy decisions about their bodies, sexuality, and reproduction).

In medical school, my eyes were opened to how health (and not just the management of illness) allows people to be part of society in a whole way. I decided to do my residency training in obstetrics and gynecology; within this discipline, I was most drawn to the care of vulnerable women (women living in poverty, homelessness, incarceration, abuse). The most empowering spaces for women in my residency were at the San Francisco County Hospital Labor and Delivery Center and in the Women’s Options Center. In these spaces, women were treated with dignity, their values and support systems (or lack thereof) were acknowledged and incorporated into their care, they had an equal voice, and their needs were considered by health workers in the context of their lives.

After residency I decided to focus on abortion and emergency obstetric care, two critical areas where women’s lives can be saved. This led me to my fellowship in family planning and global women’s health at Brigham and Women’s Hospital and Planned Parenthood League of Massachusetts and from there to joining MSF (Doctors Without Borders) as an obstetric and gynecology specialist.

 

2. Why did you choose to join MSF specifically in comparison to other medical aid organizations?

MSF-Mosul, Iraq Operating theater team, nurses, technicians and hygienists May 2017

In fact, I never considered other medical aid organizations. I was familiar with MSF from my home country [Palestine] where MSF has been working since 1989. As a teenager I was drawn to the “no weapons” logo on MSF cars that drove around my town. I always imagined myself one of the medics in those cars. The idea that you could travel halfway across the world to be in solidarity with people suffering in war, displacement, and famine and provide them with quality medical care was exhilarating.

Later when I learned more about the international organization I was attracted to the MSF principles and felt that they aligned with my belief systems: independence, neutrality, impartiality, humanity, medical ethics and témiongage or “speaking out.” I was especially looking for a way to contribute with hands on service and as an obstetrician gynecologist with MSF I get to do just that.

What is harder to capture in words is how gratifying it is to work with teams of people who share your vision and mission driven work ethic, who work in non hierarchical and respectful ways, who create a positive and supportive work environment that allows diverse teams to always have the patients’ best interests in focus, going beyond their job description to help those in need without asking for anything in return.

 

3. I know you mentioned this in your presentation, but for the general online audience, can you tell me more about the missions you’ve embarked on as of date, and your specific role in each one?

With MSF I have worked in Bo, Sierra Leone; Shatila refugee camp, Beirut, Lebanon; Khost, Afghanistan; Katiola, Cote D’Ivoire and Mosul, Iraq.

MSF obstetric projects are divided into BEmONC (Basic) and CEmONC (Comprehensive Emergency Obstetric and Neonatal Care) facilities depending on availability of operating theater, anesthesia, blood bank and preterm neonatal care. With the exception of Shatila, I have worked in CEmONC projects.

My role to date has been as obstetrician gynecologist, along with a few months of filling the gap of project medical referent (medical team leader).

In general, as an MSF aid worker working in stable and unstable contexts you have to be both flexible and humble, taking on responsibilities as the need arises. Primarily I was responsible for women with direct obstetric complications (e.g. antepartum/postpartum hemorrhage, uterine rupture, preeclampsia/eclampsia, extra-uterine pregnancy, abortion with complication and sepsis), operative deliveries (e.g. cesarean section, surgical management of hemorrhage including hysterectomy, complicated assisted vaginal deliveries –vacuum and forceps), ultrasound and ultrasound teaching (specific to humanitarian context), complex contraception and abortion, procedure teaching (e.g. manual uterine aspiration, breech extraction, external and internal version, theoretical and bedside teaching of MSF protocols to nurses, midwives and general doctors with obstetric skill (e.g. labor management, documentation, medical management of bleeding, hypertensive emergencies, postoperative care).

I was also responsible for reviewing patients’ charts to ensure we were following protocols, auditing maternal morbidity and mortality cases, assisting with evaluation of neonatal morbidity and mortality cases and reporting back to the team, project coordination and sometimes MSF headquarters.

One of my favorite jobs was also helping create and share our monthly medical reports and quarterly reports; I was proud of our work, and [enjoyed] being part of the evaluation of our project goals and directions for the future.

 

4. Looking back on your experiences so far, how much of an impact has medical skill provided on your missions, and at what points does medical aid only go so far?

MSF-Khost Afghanistan Operating Theater, teaching a new (Afghan) national staff doctor surgical skills during a cesarean section November 2016

Emergency medical aid absolutely has an impact on the lives of people living through war and displacement or chronic conflict and violence or poverty and famine or epidemics and natural disasters. The highest impact of this aid is on the lives of women and children who are disproportionately affected by the absence or disintegration of primary and emergency health care.

Emergency medical aid of course has limits, with finite resources we are always debating this internally in MSF: when do we hand over a project, open new projects, what services do we provide and which do we make a conscious decision not to provide.

In most projects we are responding to an acute need but of course this gets complicated when war lasts for years and decades, when displaced people are further displaced, when there is infrastructural vacuum or total collapse of a health system and no one to hand projects over to, how do we ethically leave? But if we remain are we becoming a development organization? The lines are unclear.

 

 

5. What are the highest highs and lowest lows you’ve experienced working with MSF on missions in war-torn countries?

The highs definitely outnumber the lows, but the lows are always in the front of my consciousness.

I remember every maternal death; the women’s faces, the scene in the room at the time of their death, the sounds of wailing family members, the cries and tears of husbands and parents, the facial expressions of my colleagues and staff. I still replay many of these deaths in my head years later and question whether we missed something or whether there was more we could have done.

The highs are women walking out of the hospital days or weeks after a near death pregnancy complication because of our MSF operating theater or blood bank or delivery or postoperative care, the kisses of family members when their patient and baby are wheeled out of the delivery room or operating theater safely, the joy of staff when learning and performing new skills, the lifelong friends made on missions.

 

6. What in your experience does it take to make for a “successful” medical mission?

I will refer here to MSF as it is the only emergency humanitarian aid organization I have worked for: A “successful” medical mission is one that serves an acute need for vulnerable groups that are otherwise not served by extant health structures, where services are guided by community needs and are adaptable to changing contexts, are based on high quality evidence and equity, are continuously audited, monitored and evaluated, and when possible are done in collaboration with existing health structures so they may continue well after the end of MSF’s presence in that particular locality.

On a personal level I feel that I have succeeded in my position in the mission when the overall function of the medical team improves, when patient outcomes improve, and when I watch staff grow in their capacity to provide a high standard of care.

 

MSF – Khost Afghanistan Obgyn with Midwife Supervisor on top of MSF water tower October 2016

7. What are some important lessons you’ve learned from your missions and how do you bring your past experiences into future missions?

There are mission lessons that I try to apply even in my medical work outside of MSF:

1) pace yourself (it’s a marathon not a sprint)

2) find ways to stay calm (music, exercise, food, build relationships with your team, sleep when you can) the more calm you are the faster people help you –find ways that help you snap out of panic in the hospital

3) choose your battles (don’t argue over every single thing that is not “right” try to see the staff/patient point of view and decide internally if doing it their way will kill them or not, if not try to let it go) it will help you when big things happen and you need people to act a certain way or do certain things,

4) be malleable (you need to work according to MSF guidelines but if national staff are doing something not exactly how you would do it and it is within the guidelines and causing no harm, try not to criticize)

5) really work on learning people’s faces and names, greet them when you see them and let them greet you, even in emergencies this is important, it goes a long way

6) take time away from the hospital during calm moments, it gives you perspective and makes you more useful when you’re there

7) give staff autonomy while supporting them, and 8) don’t forget to laugh at the silly things and have fun (once I asked a midwife in the OT to support the patient while I did a forceps delivery –she speaks little English- and instead she understood to support me and wrapped her arms around me and pulled me, after the delivery –baby and mother ok –we laughed about this for days…

Every mission teaches you a thousand lessons and they become a part of you in ways you cannot even articulate. What I bring from one mission to the next is humility, adaptability, awareness of resources and acknowledgment of various feelings– both mine and others.

 

8. And now, some fun questions: What is one thing you like most about yourself? What type of shoes do you wear? What is your spirit animal?

I like that I am a do-er. I alternate between my Dansko clogs and CrossFit shoes, my friends and family hate them but my back loves them. My spirit animal…I had to take a quiz to find out: the wolf.

 

9. What advice do you have for medical students (at all stages training) on how they can shape their education if they have an interest in doing humanitarian work?

MSF-Katiola Ivory Coast team member farewell party, (right to left) Obgyn, Lab director, Hygiene and Sanitation Nurse Supervisor, Outreach supervisor, Anesthetist, Pediatrician March 2017

I think a fundamental piece of advice is invest in growing your capacity for empathy, challenge yourself by engaging with situations that are outside your comfort zone, go the extra mile for patients in need on your various rotations, collaborate genuinely with your allied (non-doctor) staff and across disciplines, try to find commonality in health care work rather than boxing yourself early into a specialty interest, seek out experiences in first and second year that expose you to patients across the lifecycle (family health clinic, jail clinic, teen clinic, refugee clinic, substance use clinic, homeless clinic, etc.).

In your clinical years seek out rotations outside your institution whether that is national (National Health Service, MSFC externship, etc.) or international (electives at sites your institution or mentors have relationships with).

All these experiences will help inform your decisions about the type of medical care you want to or don’t want to be involved in.

 

10. How can people help and support MSF right now?

Apply to be an MSF aid worker or encourage others (most MSF aid workers are NOT doctors) here: http://www.doctorswithoutborders.org/work-field

Make a donation or organize a fundraiser: http://www.msf.org/en/donate

Arrange a speaking event in your community: http://www.doctorswithoutborders.org/support-us/events/request-speaker

Apply for a paid internship in the MSF-USA office in NYC: http://www.doctorswithoutborders.org/faq-us/office-internship

 

MSF-Katiola Ivory Coast Postpartum Ward, discussing contraception with a patient who survived a uterine rupture after surgical repair and multiple blood transfusions (otherwise fatal pregnancy complication) March 2017

 

Dr. Rasha Khoury is an emergency obstetrician with Doctors Without Borders (Medecins Sans Frontieres, MSF) and fellow in Maternal Fetal Medicine at Montefiore Medical Center in Bronx, NY. Dr. Khoury’s research and clinical work centers around reducing maternal morbidity and mortality by improving access to high quality, safe abortions and contraception, along with antenatal, delivery, and postpartum care among at-risk populations (including women of color, women living in poverty, and women surviving displacement and war). Her work as a humanitarian medical aid provider has taken her to Afghanistan, Iraq, Lebanon, Cote d’Ivoire, and Sierra Leone.

Grace Sun is an AMS medical student and managing editor of MURMUR.

Amelia Warshaw is an AMS medical student and lead content editor of MURMUR.

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