In this interview with editors Tanja R. Müller and Gemma Sou, Tony Redmond
reflects on his long career as a professor and practitioner of international
emergency medicine and founder of UK-Med, an NGO that provides international
emergency humanitarian medical assistance and which hosts the UK International
Emergency Trauma Register (UKIETR) and UK International Emergency Medical
Register (UKIEMR). He questions the usefulness of prioritising innovation in
medical humanitarianism and advocates aiming for the same duty of care that one
would offer in one’s everyday practice at home. In this, Tony is also
critical of the term ‘humanitarian space’, as it by definition
proclaims an imagined geographical entity where normal rules should not
As an academic and practitioner for more than forty years, we asked Tony for his take
on innovation from a personal perspective and how this might have changed throughout
his career. Tony has worked with medical emergency teams in a range of disasters and
conflicts including earthquakes in Armenia (1988), Iran (1990), China (2008) and
Haiti (2010), conflicts in Bosnia (1991–96), Kosovo (1999–2000),
Sierra Leone (2000) and Gaza (2014), a super typhoon in the Philippines (2013) and
outbreak responses in Sierra Leone (2014–15) and Bangladesh (2017).
The interview took place in Tanja’s office at the University of Manchester in
Tony Redmond: My responses refer specifically to the medical field,
where I don’t think there has been much in the way of true innovation. And I
think that is a failing. You can look at, say, plumpy’nut, for feeding
children – that was a great innovation. Peanut butter, high calorie: the kids
love it, it is simple and it has been a game changer. There have been some issues
around who owns the rights to it, I understand, but it has been really innovative
and really quite simple.
But in terms of medical teams, medical support in a humanitarian emergency, there
hasn’t been much innovation in the delivery of care. And I think the
humanitarian healthcare workers are at fault. I sense there is a reluctance to
transfer innovations in everyday medical practice to humanitarian work in the field.
It seems to me a cultural, a psychosocial block.
If you talk about surgery, for example, in a humanitarian setting,
immediately among many NGO workers their antibodies will rise. They will say,
‘That’s terrible, you can’t allow that Western, too high-tech
surgery; it is inappropriate.’ But then if you say, ‘So, what about
obstructed labour and interventions to save the mother and the child?’, then
they say, ‘Oh, that’s fine,’ but that is
surgery. It is a conceptual thing. But safe surgery can have an
impact on a community as great, for example, as a vaccination programme. So, you
might think, ‘That can’t be right: vaccination programmes are as cheap
as chips and you can get them out to lots of people’ – yes, but your
target audiences are not economically active, so this may sound very
consequentialist or whatever, but that’s the fact; they are not the most
economically active people. People from 18 to, let’s say, in low-income
countries, late forties, early fifties, they would be helped to some extent by
vaccines, but they will usually succumb not to infections but to injury,
road-traffic accidents, violence and, in women, complications of labour – and
there is a surgical fix to those.
I think the innovations in medicine may need to come conceptually and in the way
things are presented; in order to understand that you should really focus on
outcome. It is a philosophical approach: whether or not you should just do it or
because it really needs to be done. The humanitarian principles are based largely on
just do it; whereas there is another way of looking at it,
where you can say, ‘Well, but what about the outcome?’ Given that
resources are limited, and will always be limited, no matter what situation you find
yourself in, choices need to be made. So, you should look at the consequences and
the biggest impact of what you do. I think that is where innovation needs to happen.
In addition, one needs to remove the idea that what you do in everyday practice
cannot be applied to a humanitarian emergency. I think you need to get rid of that
idea. It might be difficult and you might not be able to apply all of what you do in
every practice; but you should not see medical practice in a humanitarian emergency
as something fundamentally separate.
Tanja R. Müller: That is one reason why we wanted to interview
you for this issue on innovation, because I know this has been one of your
long-standing issues, that people tend to treat humanitarian situations as
TR: Yes, it is a conceptual thing. The humanitarian space is proclaimed
to exist separately; does it?
TRM: Where do you think this comes from, historically?
TR: Separate to International Humanitarian Law, the medical humanitarian
space may in part have also evolved from religious missions.
Medical teams when doing global health can still talk about a
‘medical mission’. I think it’s the view that you are doing
good above all else; you are delivering charity, that may have driven this
separation from daily medical practice; that there is a separate space where people
suffer and people in that space should be grateful for what they get – harsh,
perhaps, but I think it has been a factor. People perhaps will be very offended by
that, and I am not saying it to shock or offend. I am just trying to tease out why
medical practice in a humanitarian emergency or humanitarian setting becomes viewed
as distinct from everyday practice and its accepted standards.
There is also the other question: why does it persist? It is a lot easier if you
don’t have to do the same things you do in normal practice. Unfortunately,
many people find that attractive. Medicine is highly regulated, more and more
regulated, more and more accountable, and in a humanitarian setting you hear people
saying, ‘I just want to go and treat patients in need’ – OK,
but if you have to be accountable in this country, you have to be accountable
everywhere, full stop. And I think that’s a problem.
You might just think it’s semantics, but I don’t think you should ever
alter the standard of care that you deliver; I think you should always give the
highest standard of care you are able to. However, if you have limited resources and
you have a large number of cases, then you will have to adjust the
level of care that you give to a person, to people, in order to
maintain a high standard of care to the people.
So, you balance the level of care against the overall standard of care when you have
limited resources. But limited resources are not always inevitable, and this begs
the question: if you are in an emergency team, why don’t you take enough
stuff with you? What did you think was going to happen? There is obviously a limit
on how much you can carry, but, still, you must be prepared. And if there are too
many patients for your team, why are there so few of you? So, you just
shouldn’t accept these things as inevitable – which they are not. That
is why you have heard me say a lot of times, I don’t like the phrase
‘natural disaster’, because that implies nothing
can be done about it, whereas, in fact, there are natural phenomena that occur, but
an associated disaster, I would like to challenge people to think, is always
Things happen, yes, but it is usually the poor who suffer the worst. Whether it is in
a typhoon-prone or earthquake-prone area, look where the rich people live and look
where the poorer people live and see who lives in the most vulnerable areas and the
most vulnerable buildings. The British Medical Journal banned the
word ‘accident’, as most injuries and their precipitating events are
both predictable and preventable. So too are disasters, and ‘natural’
can usefully be discarded as an accompanying epithet.
I have begun to worry about the word ‘humanitarian’ on similar grounds.
The phrase ‘this is a humanitarian mission’ first and foremost implies
the inherent goodness of the mission; but there is no automatic reason to assume
that. It is a funny word. On the one hand, should not everybody try to be
humanitarian, try to be humane? I appreciate adherence to humanitarian principles,
but people use the word as though it’s a thing in itself – and, when
it’s a title that has been given to something, as a reason, consciously or
subconsciously, to not do all the other things that would be done in a
non-humanitarian setting. It is also used to distinguish emergency
from development aid. In practice, I have tried to do more in
training the people in the country so they can respond themselves, though
it’s easier to do the initial response than it is to do the more difficult
longer-term response in countries that have very complex social set-ups –
poor, weak, sometimes corrupt governments that could thwart anything you do.
It’s easier to just move your thinking into humanitarian mode – to say
to yourself I am just doing the humanitarian part and will not think about long-term
You know the buzz phrase at the UN at the moment is ‘the humanitarian and
development nexus’. Well, OK, but the fact that we need to come up with a new
phrase that joins the two areas together is part of the problem. The thinking
shouldn’t have separated in that way in the first place.
Gemma Sou: So, you think less of a technological innovation, more a
different conceptualisation to change the way things are?
TR: The technological advances are going on, so we don’t have to
do those; they are in the shop. We just have to go to the shop and get them –
for example, electronic medical records, that’s all done, using tablets to
record and report, using a closed-circuit Wi-Fi-system. The technology is all there,
doing points-of-care testing at the patient’s bedside; there are tests for
everything, and they come in tiny handheld devices – even an ultrasound
device, they are hand-held – but none of those have been developed by the
humanitarian community. They are all being developed in established medical
settings, so we should just draw on these technologies. It is the application and to
know that you can use the technology in a humanitarian setting that is the problem;
I know professionalising the humanitarian sector is again another issue that poses
problems for some people about what is meant by that. Well, I would like to think
that you could combine professionalism and humanitarianism. There should not have to
be a separate career in doing medical humanitarian work. It should all be part of
your general medical career. You could then move from different environments
throughout your career more easily and not separate them off in this way. Because if
you do separate it out – in particular, say, in relation to surgery –
how would you ever maintain the skills and keep up with new developments, if you
worked predominately in a humanitarian setting? Well, with difficulty is the answer;
I am sure some people do, but it is really difficult, whereas if you can move more
freely between humanitarian and general medical practice, I think you would also
more readily apply in humanitarian settings the technological innovations that are
TRM: That is what UK-Med tries to do, right, taking people working for
the NHS who are trained in care as we deliver it in this part of the world and take
TR: Yes, and the difficulty we face is how to get them released from the
NHS to do this, and here again the innovation needs to be conceptual. First of all,
and again coming down to consequence, there is enlightened
self-interest for our country to let their medical staff do this type of work. Of
course, there is the feel-good factor as well, and people feel very professionally
enriched when doing humanitarian work, which is good, and they also feel good about
themselves, so you do actually retain people in a mundane or routine NHS job if you
allow them to do this work. Overall job satisfaction goes up and they can tolerate
routine better – no matter how exciting you think your job is, at some point
it becomes routine, but you can better tolerate this routine when you have more
opportunities to do something out of the routine, so there is that element to
But there is also the experience and the technological experience people get by
working in a more difficult environment. If you look at management of major
incidents and even terrorist attacks and so on, those people who had experience
working in difficult emergencies overseas responded better; they understand how to
deal with those crises.
The NHS, and if you look at UK-Med specifically, has a cadre of people who are all
trained in major-incident management, who are all trained in field exercises where
they have to work as a team in difficult circumstances, and we have a large cadre of
people trained in outbreaks of dangerous pathogens like Ebola and this kind of
thing. They are all trained in how to protect themselves and how to treat patients
in that environment. The overseas humanitarian work feeds right back into practices
here. You also want is to build capacity, use your experience, and in many ways it
is no more than that, because the people have skills; it is more a question of
resources and finance, to support them in being able to respond to these things
In Uganda, for example, they now have huge experience with managing Ebola. In my
professional lifetime, I have seen the capacity of disaster-prone countries increase
enormously. The need, certainly around earthquakes and trauma responses, for teams
from Western Europe to go to disaster-prone countries has clearly gone down and is
going down as it should. If we look at the Nepal earthquake, there was very little
need for outside aid, and the response was very good because it was a Nepali
response. But a lot of NGOs had also worked on preparing the country for the
earthquake that they knew was coming. And the Nepali government worked hard, and
they had very good surgical expertise. So, the capacity has increased.
GS: How has UK-Med innovated over the years?
TR: UK-Med’s biggest innovation is in setting up an application
of standards that try to mirror the standards of UK practice.
GS: In relation to standards of practice, is this something that other
organisations are also doing, following in UK-Med’s footsteps?
TR: Yes, other organisations are following UK-Med and the work of other
teams, such as MSF, Red Cross, ICRC and so on. This all led to the WHO Emergency
Medical Teams initiative, which has codified a set of standards that are there for
people to see what they should aspire to. These are minimum/core standards and mimic
the general way that medical practice develops before you’ve got the complete
evidence for what you do. You first get a consensus view and you say these are the
agreed standards, and if people say, ‘No they’re not! That’s
terrible!’, you ask them ‘Why are they not?’ and draw out from
them their evidence. Usually you’ll find that if you get the right group of
people then their standards are not way off each other. With common standards, you
can then start gaining some meaningful data. That’s been a huge innovation.
So, we’ve got the standards and people are keen to work to those standards
because they see it as a kite mark. The next stage now is to get
the data and review what we’re actually doing. This might show that
we’re having minimal impact; it might show negative aspects of the work; and
it might point out what the good things are.
The measurement of outcomes in and of itself is an innovation, because these
practices never used to be measured. You could simply say that it is great that
people are helping others, but we need to understand and we need to know the
consequences. Certainly, with some surgical interventions, such as limb salvage, I
don’t know whether the pendulum has gone the other way and if I am
responsible. I was looking back on papers I wrote thirty years ago saying people are
not amputating enough or early enough. And I’m saying the opposite now.
Practice has changed, but I think you’ve got to get the evidence and the
data. The innovations from these measurements that will have the biggest impacts
will not be technological: they will be process-driven.
GS: Did any innovative practices emerge later in your career that you
wished had arrived earlier?
TR: Yes, the point-of-care testing. The handheld devices for testing.
So, you can test for malaria, for example. And the big one is the handheld
ultrasound. You can hold the handheld ultrasound and you can diagnose an awful lot
of things with that. Obviously, you can look inside body cavities to see if people
are bleeding, and even run them over bones to see if they are fractured.
TRM: Since when have they been around?
TR: In common practice in the last ten years. But the more portable ones
were coming in the mid-1990s, but you still had to wheel them in. Then they got
lighter after that, and now the technology is very good, to the extent that
it’s become part of your examination in the emergency department that the
physician will run a scan over you.
GS: What would happen before you had these technologies?
TR: Well, in clinical practice in the UK you would do a physical
examination, which depends on how experienced you are. You ask what does it look
like, what does it feel like, see if it’s tender; you listen; you percuss to
see if there is air. But it’s a guesstimate. An ultrasound
can cut a lot of that out; you can manage very well with a portable ultrasound. So,
in the past people could have had unnecessary operations. And in a context where
infection control is difficult you want to reduce the number of operations that you
do. So, being able to look at those things is really important.
GS: Have you seen any new practices or technologies that were
TR: Yes, doing too much surgery. Doing surgical techniques that require
too much follow-up. One of the problems is that if you focus just on the technology
and not on the human support that is required for that technology to work, it will
fail. For example, doing tissue transfers for a terrible wound that you need to
close: you’ve got a lot of tissue missing, you can move a whole muscle
– say, your latissimus dorsi. You can move that with its
blood supply, cut it out, put it over the wound, and under an operating microscope
you connect all the blood vessels so it can now live there and it will cover the
wound. But it requires specialist post-op nursing care to make sure it
doesn’t become infected. So, first you need an operating microscope, which
you’re not going to take with you, plus it’s complicated, and you need
specialist nurses for the post-op period.
So, many years ago I worked in Sarajevo, where they had a plastic-surgery centre.
Sarajevo was a leading plastic-surgery centre and lots of war wounds needed
attention. But in the war they didn’t have all the specialist staff to look
after the patients. So, some teams would go in and there would be an operating
microscope to work with, but there were no staff to look after patients after their
complex graft surgery, so the operations failed. People still ended up with a wound
but also the loss of the muscle for no advantage, whereas you could have just done a
more straightforward procedure – just a skin graft, say, that would have
More recently, internal fixation. So, most fractures now will be managed with
internal fixation. So, you open them up and line the bones together and put in a
piece of metal and screws and join them together. Or you put a nail down the middle
of the bones. The problem is that you’ve got metal, which is a site for
infection, and you’ve got circulating bacteria that will lodge on those
places. But if you have a good sterile hospital with antibiotics, you would hope
that, by and large, they don’t get infected. But if you’re doing that
in a tent where you will not have the same sterile operating environment as you
would in an operating theatre, and again you don’t have the specialist
post-op aftercare, it will more likely get infected.
Saying this, MSF will use internal fixation, I understand, but that’s because
their field hospitals can be so sophisticated that they have a proper lamina flow,
just like in an operating theatre in the UK, to the extent that it does match the
technology that they would have in a more established hospital.
TRM: Is it only MSF that has this level of sophistication?
TR: No, the UK-Med operating theatre has one. The problem is that it
just adds to the weight and bulk of things that you are taking on deployment. And
the MSF field hospitals are often established quite a long while, so you only need
to carry stuff in once. So, it is possible.
TRM: Thank you so much Tony. Is there anything you would like to
TR: Yes, I want to clarify the idea about the humanitarian sector
adapting, which I talked about earlier. To me, that sounds like
a business statement. For example, if you were running a business and you wanted to
keep the business going, that’s the sort of thing you would say. But why do
we need to maintain the relevance, reputation and impact of the humanitarian sector?
I would hope that its relevance fades as local capacity increases. We’re not
there yet. But it’s another conceptual thing that the aid industry is looking
for something to do and place itself in, when, in fact, it shouldn’t be about
that. It should be responding to a clearly identified need. For instance, we get
people who want to volunteer with us and they so want to be deployed; but we say you
might not always be needed. This might be difficult for them to hear because they
just want to go. When I was fit enough to deploy, and I didn’t, people would
say, ‘Oh, I didn’t expect to see you here, as there’s been a
disaster,’ and I’d say ‘Well, they’re not asking for
outside help’ – ‘Oh, they don’t need you
anymore,’ they’d say to me. I’d think, ‘Well, actually,
no they don’t.’ But there’s this idea that you’ve got to
go, and as it’s become more industrialised and competitive, it’s very
hard for agencies not to go when others are getting the publicity.
GS: It seems as though there should be some sort of planned obsolescence
in the humanitarian sector.
TR: I think there should be, yes, and you can see it’s starting.
Look at China. China is an exporter of emergency medical teams, and it’s only
ten years ago that there was an import, after the Sichuan earthquake. It would be
unthinkable now. They have an institute for it, they have a higher number of
verified emergency medical teams than any other country, and you can see that other
countries will follow.
Also, before we end, I want to say that the humanitarian response needs to be led by
local people. And it must be needs-driven. There’s been great improvement in
that, but it’s still not always needs-driven; it should not simply be driven
by what we did before. There will often be a response that follows the line of
‘this is what we do and this is what we’ve done before’, but
there hasn’t been enough attention to what people’s needs actually
are, and the response needs to be focused on those needs.
This article explores the actions of Médecins Sans Frontières
during the 2018–20 Ebola outbreak in Nord Kivu, in the Democratic
Republic of Congo. Based on the experiences of practitioners involved in the
response, including the author, and on the public positioning of MSF during the
first year of the epidemic, it argues that although the actions of response
actors were usually well intentioned, they could rarely be described as
lifesaving, may have exacerbated disease transmission as much as limited it and
had the perverse effect of fuelling corruption and violence. The article
documents and analyses contradictions in MSF’s moral and technical
positioning, and the complicated relationship between the organisation and the
international and Congolese institutions leading the response. It argues that
the medical and social failure of the response was the result of an initial
belief in a strategy designed at a time when the only realistically attainable
outcome was to relieve suffering, and of the later inability of the organisation
to convince the authorities in charge of the response to adjust their approach.
It suggests that for future success new protocols must be elaborated and agreed
based on a better social and political comprehension and a better understanding
of the tools now available.
Despite a concerted international effort in recent decades that has yielded
significant progress in the fight against HIV/AIDS, the disease continues to
kill large numbers of people. Although there is still no definitive cure or
vaccine, UNAIDS has set an ambitious goal of ending the epidemic by 2030,
specifically via its 90-90-90 (‘treatment cascade’) strategy
– namely that 90 per cent of those with HIV will know their status, 90
per cent of those who know their status will be on antiretroviral therapy and 90
per cent of those on antiretroviral therapy will have an undetectable viral
load. These bold assumptions were put to the test in a five-year pilot project
launched in June 2014 by MSF and Kenya’s Ministry of Health in Ndhiwa
district, where an initial NHIPS 1 study by Epicentre (MSF’s epidemiology
centre) in 2012 revealed some of the world’s highest HIV incidence and
prevalence, and a poor treatment cascade. Six years later, a new Epicentre
study, NHIPS 2, showed that the 90-90-90 target had been more than met. What
explains this ‘success’? And given the still-high incidence, is it
truly a success? MSF Deputy Director of Operations Pierre Mendiharat and
physician Léon Salumu, Head of MSF France Kenya programmes, discuss the
political, scientific and operational challenges of the Ndhiwa project in an
interview conducted by Elba Rahmouni.
The COVID-19 pandemic has exposed multiple fault lines in the performances of
health services at every level – from community to national to global
– in ensuring universal, equitable access to preventive and curative
care. Tragically, this has been to the detriment of those who have suffered and
died not only from COVID-19, but also from the myriad other ailments affecting
people around the world. Of those, we wish to highlight here some key categories
of diseases that have caused a greater burden of illness and deaths as a
consequence of the policies and political decisions made in relation to the
COVID-19 pandemic. In our view, these should be considered epidemics or, more
accurately, syndemics – the clustering and interactions of two or more
diseases or health conditions and socio-environmental factors – of
Two experimental Ebola vaccines were deployed during the tenth Ebola epidemic
(2018–20) in the Democratic Republic of the Congo (DRC). The first, the
Ervebo vaccine manufactured by Merck, was used as part of a ring vaccination in
the epicentre of the epidemic in North Kivu. In 2019, the prime- (Ad26.ZEBOV)
and boost- (MVA-BN-Filo) vaccine manufactured by Johnson & Johnson
(J&J) became the second vaccine against Ebola, deployed by the DRC-EB-001
vaccine trial in Goma, North Kivu. There was international debate as to the
value and ethics of testing a second vaccine in an epidemic context. This
article examines how this debate unfolded among actual and potential DRC-EB-001
trial participants in Goma. Drawing on ethnographic observation, interviews and
focus groups, it explores how the trial was perceived and contested on the
ground and situated in broader debates about the ethics of clinical trials,
especially during the COVID-19 pandemic. We illustrate how debates around the
ethics of clinical research are not simply centred on bioethical principles but
are inseparable from local political dynamics and broader contests about
governance, inequality and exclusion.