Working on the edge

Interview with Harriet Roggeveen

At the office of Médecins Sans Frontières (MSF) in Amsterdam, we meet up with Mrs Harriet Roggeveen, 54 years old and working for MSF as a paediatric advisor since five years. Even though she always had the drive to work in tropical medicine and started her career with a yellow fever-project with MSF, she chose to specialize in paediatrics first. But after having worked happily as a paediatrician in different settings in the Netherlands, she didn’t hesitate to apply for the position of paediatric advisor in 2011 to follow her lifelong dream. In this personal interview, Harriet introduces us to her work with MSF.

The public health point of view

From the beginning of our conversation, it is clear what motivates Harriet most in her work: the full picture, the broad view on paediatrics. Her role as advisor varies from providing medical advice on specific patient cases to indicating areas for improvement of paediatric care in a setting of limited resources.

As an example, she explains the situation in Haiti, where MSF started a project to reduce the high maternal mortality. As a result of many high-risk pregnancies, many premature and small-for-gestational-age babies were born, which had resulted in the development of very advanced neonatal care. ‘The first time I was there, I noticed they provided Continuous Positive Airway Pressure (CPAP) and had incubators, but basic care and hygiene were inadequate. Babies of 33 weeks old were discharged even though it was uncertain whether breastfeeding would succeed, while at the same time little ones of 1000 grams were put on CPAP in an incubator.

That did not make sense! Children with good chances of surviving should be given adequate care before organizing expensive specialist care for the ones who are less fortunate, not the other way around, even though from an ethical perspective you would want to care for each individual as they come to you.’

Harriet then explains how they tried to take a step back from advanced care so as to ensure that a more basic form of care could be provided, for example by implementing kangaroo care. But she also knows how difficult that can be, especially when local staff is more interested in advanced care. ‘We ran into major problems with hygiene, resulting in nosocomial infections with resistant pathogens. In order to try to control that, we appointed an infection control manager and introduced the technology to do cultures. But then again you move towards advanced care and ask yourself

‘COULDN’T WE BETTER PUT THIS MONEY INTO CHILD VACCINATION?’ THESE ARE DIFFICULT QUESTIONS, BUT THESE KINDS OF PUBLIC HEALTH QUESTIONS ARE ALSO WHAT MAKES OUR WORK SO INTERESTING.

Emergency aid or building sustainable healthcare systems?

As we continue to discuss the work of MSF, we soon come to the next challenge. Is it better to focus on providing emergency aid or on building a sustainable system of healthcare? ‘Because MSF often works in so-called ‘failed states’ with poorly functioning healthcare systems, cooperation with the local government is often not possible. In an emergency setting that is acceptable, but from a development perspective that might not be the right way to work. And even though the core business of our organization is emergency care, in reality many projects continue for over 10 years, so should we then play a role in development. How sustainable should the work of MSF really be? Should we put more effort into training local staff and working with local ministries of health? Or should we focus on delivering emergency care and leave development work to other organizations? Of course, that influences the type of care we give and determines whether or not, for example, we engage in vaccination programs. Such questions keep my work interesting!’

An illustration of how MSF sometimes does focus on long-term care comes up when we discuss malaria, one of the biggest problems in paediatrics in tropical areas. ‘In many countries, for example Congo (DRC) or South-Sudan, the burden of malaria is increasing, and then it’s simply not sufficient to provide secondary, hospital-based care. In our long-term projects, we try to shift towards community-based primary health care. That is not always possible in areas where it is unsafe for our medical staff to go into the community, but sometimes it works very well, for example in one of our projects in Congo. In the community, you can provide more integrated care, treating diseases like malaria, pneumonia and gastro-enteritis at an earlier stage. It’s not very sophisticated, not rocket-science, and not very new, but it works!’

Medical specialists or generalists in the field?

Emphasizing that it’s her personal opinion, Harriet explains the importance of having both specialist and general health expertise: ‘I think basic care should be the first priority, and generalists like the Dutch tropical doctors are generally very competent to do that. If there were many specialists, the care would probably become too technical. But general doctors need the input of specialists, like paediatricians, especially because the under-five population is often huge. Perhaps paediatrics should be given more attention in the training program for tropical doctors, even though western paediatrics is very different from the tropical version.

‘Doctors who are not trained in paediatrics are often a bit afraid of it, especially of neonatology. But knowing that 44% of the mortality in under-fives happens in the neonatal period, you realize it’s a very important area. And a lot can be achieved with relatively simple interventions, without CPAP or incubators. The best practical advice I can give to tropical doctors with no paediatric training is to make sure they know how to resuscitate new-borns by providing Neonatal Life Support (NSL) and know how to recognize and treat neonatal sepsis, hypothermia and hypoglycaemia. They should also use the training materials available from WHO (www.who.int), which describe various evidence-based, uncomplicated interventions. They will then be better prepared and better able to train local staff.’

And a final request

At the end of the interview we thank Harriet for her passionate and inspiring story, at which point she asks us to use this opportunity to send a message to our readers. ‘At MSF, we are looking for medical doctors, especially people who would like to work with us in long-term assignments. Having experienced staff is very important for us, and MSF is a great organization to work with!’