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Beyond Borders (2003), or the human side of medicine

Patricia Maria Rabelo Annes

Facultad de Medicina. Universidad de Salamanca (Spain).

Correspondence: Patricia Maria Rabelo Annes. Rua Coronel João Batista do Rêgo Barros, 21, Macaxeira. Recife - Pernambuco. Brasil. CEP: 52071-350

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Received 23 May 2007; modified 3 August, 2007; accepted 27 August 2007


Summary

Beyond Borders (2003) reflects on the human side of people and the wish to help those most in need, special emphasis being placed on the medical profession. It also reflects the main outcomes of armed conflicts on the health of the populations affected by the strife and the difficulties encountered by those interested in helping out. The frequent denouncements (such as that made in the film) have not changed the penury of refugees and internally displaced persons, who remain with no definitive solution to their problems, despite the efforts of many, such that it is crucial to attack the root causes themselves instead of trying to minimise the horrific consequences generated by armed conflicts.

Keywords: Humanitarian medicine, Humanitarian aid, Armed conflicts, Refugees.


The weirdest, purest thing, suffering

Technical details

Title: Beyond borders

Country: USA and Germany

Year: 2003

Director: Martin Campbell

Music: James Horner

Screenwriter: Caspian Tredwell-Owen

Cast: Angelina Jolie, Clive Owen, Teri Polo, Linus Roache, Noah Emmerich, Yorick van Wageningen, Timothy West, Kate Trotter, Jonathan Higgins, John Gausden, Isabelle Horler, Iain Lee, Keelan Anthony, John Bourgeois and Kalyane Tea.

Color: Color

Runtime: 127 minutes

Genre: Drama, Romance

Production Companies: Mandalay Pictures, CP Medien, Camelot Pictures and MP Film Management UNLS Produktion GmbH and Co. KG

Synopsis: Sarah Jordan is an American who lives in London and is married to a wealthy Briton. At a fund-raising event, an English doctor who works voluntarily in a refugee camp in Africa –Nick Callahan- makes a protest about the social indifference to the problem of starvation on the African continent. This arouses in Sarah a powerful desire wish to help the less fortunate, and this is to change her life forever. The film ends in tragedy with the brutal death of Sarah, again reflecting the constant threat under which tens of thousands of people live in zones of armed conflict.

Through bloody images within the setting of a romance, Martin Campbell shows us the struggle against hunger and extreme poverty in which people in refugee camps worldwide still have to live1 as a result of fratricidal armed conflict. The director also shows us the difficulties faced by medicine in these emergency situations, such as widespread epidemics (cholera, measles, typhus, diarrhoea due to cholera and other diseases, tuberculosis, pneumonia,….), malnutrition in its most extreme forms, and the physical consequences of armed conflict (amputations due to antipersonnel mines). We witness all of this in a setting coloured by the lack of even the most basic human and material resources. In sum, the film emphasises the need to help the less fortunate and underscores the valiant work carried out by non-governmental humanitarian organisations (NGOs) worldwide.

Her role in this romantic drama led Angelina Jolie to collaborate with UNHCR (High Commissioner of the United Nations for Refugees) in favour of refugees, which culminated in her being nominated good-will ambassador by this organisation in August 20012.


The film

The wide diffusion and huge attraction of the cinema for mass viewers make it very suitable for health education. Its main advantages are the possibility of offering facts with great reality and its capacity to expand images that are not usually captured by the naked eye3.

Beyond Borders (2003) confirms the above quotation in the sense that it provides an impacting view of three contemporary conflicts that have degraded the human condition: namely, those occurring in Ethiopia, Cambodia and Chechnya. The film addresses delicate issues deriving specifically from those armed conflicts. It portrays the crude rawness of the refugee camps set up in N. Africa during the eighties, the precariousness of the health system in the fight against disease, and ravages of malnutrition and the lack of drinking water. It tells us how the food provided by humanitarian relief is sequestered for military ends; it hints more than strongly at the cruelty and corruption of the combating groups and it realistically portrays the difficulties encountered by NGO’s in maintaining their independence. Thus, the movie transmits a message of solidarity in situations of social exclusion, injustice and poverty and highlights the crucial work carried out in this context by those involved in humanitarian aid, in particular in the field of medicine.

The film tells the story of the North-American Sarah Jordan (Angelina Jolie), married to the Briton Henry Bauford (Linus Roache), with whom she enjoys a more than comfortable life in the British capital. On the twentieth anniversary of the “Aid Relief International” organisation, the British doctor Nick Callahan (Clive Owen), then a volunteer in Ethiopia, interrupts a fund-raising ball accompanied by one of the children from the camp where he is working (Figure 1) and delivers an impromptu speech denouncing the indifference with which hunger issues in Africa are being dealt with; the organisation he works for has withdrawn its funds for political motives. What a paradox! While some enjoy themselves and stuff themselves with food at gatherings aimed at collecting funds for the needy, these die of hunger and thirst behind the confines of camp walls. After hearing Dr. Callahan, Sarah decided to go to Africa to see for herself the crude reality of the situation, just a jet flight away from her own very comfortable existence.

On the way to the camp in Ethiopia, Sarah is confronted by the horrifying images of this reality of penury and determined that she must become personally involved in succouring the needy. Sarah’s presence upsets Nick, although he tries to treat her with indifference despite her insistence on helping as much as she can. The doctor later comes to realise her good intentions when he witnesses her desperate attempts to save a child that he knows has very few possibilities of survival (Figure 2 and 3) and she somehow awakens in him a feeling that he has not felt before. After a time Sarah returns to London, but her thoughts dwell on the camp and her heart becomes enraptured by her passion for that man who is so completely devoted to his work.

Some time later, now in a foundering a broken marriage and working for UNHCR, Sarah travels to Cambodia on a relief mission upon a request by Elliot (Noah Emmerich) (Figure 4), Nick’s best friend and an important member of his cooperating team.

There, constantly threatened by combat groups, Nick and Sarah become closer and closer in their shared desire to help others and, after Elliot’s brutal murder, in a love that neither of them can deny, even though she had been tricked by both to act as facilitator (in her UNHCR capacity) in the transport of a consignment of medical supplies that also contains weaponry. Nick soon realises that while she is with him Sarah will be exposed to huge risks and decides that they should separate.

The time passes and Sarah, without knowing Nick’s whereabouts, traces him to Chechnya, where he was last sighted. There, she finds out that he has been captured by rebels. Desperate, Sarah endangers her own life to save him but is killed, resulting in a tragic ending to a dramatic love story that occurred between 1984 and 1995 (Figure 5).

The passion that glues the characters together –the will to help the needy- is also what separates Sarah and Nick. Movingly, this romantic drama shows us the force of the human side of medicine. In the film Nick facilitates the arms deal to allow medicines to be transported to their rightful destination. In view of the difficulties Nick and his team members face he tells her that to cure people we have to break the rules, and he does this by collaborating, although for a noble cause, with the ignoble men themselves responsible for the armed conflict. Regardless, the fact of saving lives by sacrificing others is not justifiable.

The tragic ending to this story makes it clear that the endendes not justify the means. Sarah’s death in the midst of an armed conflict is a true irony of destiny in comparison with regards Nick’s own involvement in arms trafficking.


Images of Humanitarian Medicine

Faced with calamitous situations due to armed conflict, governments are powerless to look after their citizens and even profit from their misery, as is well documented in the film. Apart from their ideologies, if indeed they have any, the guerrillas combating corrupt government forces have no qualms about stealing food from the hungry populace: “They fight for the people but rob them of their food” (Figure 6) and are even prepared to kill their own citizens regardless of their ideology.

In contrast, the governments of prosperous nations pay little heed to these conflicts unless there is something in it for them. They even use them as business partners in the trafficking of arms to the combatants, as we are realistically told in the film.

Thus, the desperate need of food and health supplies lies in the hands of NGO’s, religious organisations and their missionaries, and some UNO agencies. In Beyond borders, we see the NGO that Nick and his team belong to and the UNHCR, who is eventually nominated representative for Great Britain. The resources of NGOs are very limited and in the film we witness two events related to this circumstance. One of them is when funds are withdrawn under the suspicion that they are destined for some kind of communist-run agency, and the other -nightmarish- is when Nick’s own NGO becomes involved in arms smuggling in order to transport food and drugs.

The poverty and precariousness of health resources and for subsistence in displaced or refugee populations running from war provide an especially favourable setting for outbreaks of severe epidemics4, as shown many times in the film. Even before the introduction of humanitarian relief, infectious diseases are already responsible for huge numbers of deaths in such zones and armed conflict only exacerbates this. In both instances, infectious diseases are the result of inadequate or absent medical facilities, the lack of water owing to persistent drought, the lack of hygiene, unhealthy housing, poor nutrition…5. All this is brutally and extremely realistically reflected in the film in the scenes showing Sarah’s arrival at the refugee camp in Ethiopia.

As is always the case, it is the children who suffer most. We see this when Nick arrives in London with the boy he has saved from his misery in Africa and who eventually dies in a first-world setting that is completely beyond his understanding or control.

Beyond Borders shows horrific scenes of severe malnutrition (PEM- Protein Energy Malnutrition) (Figure 7) among displaced populations fleeing from conflicts. The most acute forms are characterised by a rapid loss of weight (fat and muscle) and they affect all age groups6. In children, “PEM is associated with an increase in mortality” owing to secondary infections6; measles is benign in children under normal nutritional conditions but is mortal in the undernourished7. The treatment of PEM is based on a very slowly-administered diet of high nutritional value, and demands intensive surveillance (this is seen in the film when Sarah is taking care of a malnourished child using “TL” (therapeutic milk), feeding him drop by drop. Although it is recommended to immunize children against measles6, the efficiency of this strategy is affected by the nutritional status of the child and it only prevents infections passed on through contact5. Measles is particularly dangerous in children living in these situations. In the film, there is one scene that shows children being vaccinated in Cambodia. Regarding the risk of contracting this disease, Nick orders that vaccination should begin with the youngest children, then passing to the older ones in chronological order until they run out of vaccine; again, the scarcity of health resources .

Hunger, thirst and infectious diseases lead to consultancies overflowing with patients and a high mortality rate. The cadavers, piles of them, are buried at dusk so as not to alarm the remaining population, who must struggle on in their day-to-day lives.

The lack of resources is also seen in the lack of anaesthetic in the operation performed by Nick on the wounded mother of the malnourished child whom Sarah is taking care of. The operation is carried out under deplorable conditions and the scene shows us how under these conditions doctors must somehow tackle everything thrown their way: there are no specialists in these deplorable circumstances.

The scarcity of water is another important problem in these situations, considered “zones with a high population density and subject to a high risk of fecal contamination”, and water “should be considered the foremost priority in complex emergency situations”, especially when it becomes necessary (starting from scratch) to install a completely new water supply. In this context the “participation and collaboration” of the victims is indispensable if the job is to be carried out quickly and efficiently. We see this in scenes showing the drilling of a well in the Ethiopian refugee camp (Figure 8), which fortunately does provide water (this is not always the case). The health care received by the victims depends directly on a suitable water supply, such that sources must be protected with a view to preventing diseases related to contaminated water8.

In the case of cholera, emphasis should be placed on the relationship between this disease and living conditions with poor hygiene (5), both characteristics of the context of poverty in which refugees are forced to eek out their meagre, isolated lives. In epidemics, any case of diarrhoea should be considered a potential symptom of cholera9. Like medical treatment, appropriate management of such situations is of utmost importance during an outbreak or before one starts5.

In this context, the main challenge of humanitarian medicine is to provide suitable health care, using the scant material and human resources available as efficiently as possible. To accomplish this, it is crucial to have some kind of standard as regards medical decision-making and the establishment of treatment protocols. Unlike normal clinical practice, where the patient with the most severe prognosis receives priority, in emergency situations, such as in epidemics and refugee camps, treatment of patients with the highest likelihood of survival is put to the front (triage), owing to the greater number of lives that can be saved10, as we see in the case of Nick. However, this criterion is not free of ethical constraints.

Moreover, the reduced availability of experts demands the training of locals, such that health care is provided “by” the population instead of “for” the population10. This is clearly seen in the film when we witness several scenes portraying the locals actively collaborating with the medical staff.

Finally, this kind of setting demands one essential element (often absent) from medical practice: “humanitarianism”. Humanitarian medicine deals with the “sick person” and not the “disease”. That is, it considers the sick to be included within a social, political and economic environment that will affect their health. This must be taken into consideration when attempting to provide the necessary medical-health care.


Consequences of conflicts on the health of the civilian population

In the past decade, conflicts have become a problem of public health as a resulting of the population being considered as a military objective and the use of weapons or military tactics that cause severe harm to the population, infrastructures and the natural environment11. One of the most serious consequences of armed conflict is the displacement of whole populations, such as occurs in a large part of Sub-Saharan Africa, where countless camps shelter hundreds of thousands of people4. Martin Campbell describes all this very realistically.

The huge number of victims of armed conflicts overloads public health systems, decreasing their efficiency. Also, the expense of militarization and the diversion and use of food and medical provisions for military ends continue to run rampant4. This is also seen in Beyond Borders.

For an idea of this, The Department for Disarmament of the United nations has estimated that current military expenses in the world run to some 1.9 billion dollars a minute, whereas during that minute 30 children die of hunger, from a lack of vaccinations or the absence of other basic health needs12, making humanitarian aid a crucial component in the survival of these people.

The use of antipersonnel mines in conflict zones also raises the number of wounded, as if the suffering and misery caused by guerrilla rebel groups, with enormous power over populations even though the conflict has ended4, were not enough. The mutilations caused by such mines are shown in the film in the scenes referring to Cambodia.


The role of Humanitarian organisations

Beyond Borders is a call to society about the situation of displaced refugee populations, at the same time praising the efforts of those dedicated to humanitarian aid, with special emphasis on medicine. The experience of humanitarian organisations in different emergency situations has provided sounder knowledge about the main consequences for the victims and their needs and the care of the affected persons has improved marginally4.

Despite the constant denouncements, even in the cinema – as we see in Beyond Borders- the problem of refugees and displaced persons continues unresolved. This is the case of Darfur, where the greatest humanitarian operation in the world is now ongoing; 14,000 humanitarian aid workers are involved. According to Gonzalo Istúriz, the person responsible for the Spanish Red Cross projects in Chad, a country bordering Sudan, what is most worrying is that there are millions of people who survive thanks to the efforts of humanitarian agencies, above all because the lack of security is ever increasing. Women are now unable to walk for a few kilometres without risking some kind of attack13.

Nevertheless, although the work of humanitarian organisations is essential for the survival of the victims of armed conflicts –the displaced, among others- it is also true that there are cases of corruption within the sphere of such aid. This is also denounced by our central character in the film, in the scene where he paralyses the fund-raising gala celebrating the anniversary of the “Aid Relief International” at the beginning of the film. The truth of the matter is that armed conflicts and internal displacements are indeed the fruit of political and economic imbalances across the world and those who most suffer the consequences are the populations of developing countries. Unfortunately, those involved in humanitarian organisations are not immune to the temptation of corruption when going about their affairs.

In general, aid in emergency situations is usually based on “policies designed on a charitable impulse inspired by critical and urgent care”12.

Against the concept of charitable medicine, one sees the concept of the provision of integrated care within a broader context of “humanitarian action”. This term encompasses a series of principles based on justice and on the respect of human rights, among which access to health care is included14. Thus, health cannot be considered a question of charity but of justice. Furthermore, it is necessary to act at the very roots of the problem and not on its consequences; in the specific case of displaced persons and refugees, such action should seek to redress the actual causes of armed conflicts.


References

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  2. UNHCR. The UN Refugee Agency [homepage on the Internet]: UNHCR Goodwill Ambassadors [cited 2007 Jul 30]; [about 1 p.]. Available from: link
  3. Salleras Sanmartí L, Oromí Durich J, Canela Arqués R. Métodos y medios de educación sanitaria. In: Gálvez Vargas R, Sierra López A, Sáenz González MC, Gómez López LI, Fernández-Crehuet Navajas J, Salleras Samartí L, et al., editors. Piédrola Gil. Medicina Preventiva y Salud Pública. 10th. ed. Barcelona: Masson; 2000. p. 233 – 241.
  4. Bolúmar Montrull F, Torres Cantero AM, Hernández Aguado I. La violencia como problema de salud pública. In: Gálvez Vargas R, Sierra López A, Sáenz González MC, Gómez López LI, Fernández-Crehuet Navajas J, Salleras Samartí L, et al., editors. Piédrola Gil. Medicina Preventiva y Salud Pública. 10th. ed. Barcelona: Masson; 2000. p. 993-1001.
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  7. Colimom KM. Fundamentos de Epidemiología. Madrid: Ediciones Díaz de Santos, S. A; 1990.
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  9. Ure BM: Feldkrankenhaus für Cholerapatienten unter Katastrophenbedingungen: Leitfaden für Betrieb und Management.Herausgeber. Colonia: Komitee Cap Anamur - Deutsche Not-Ärzte; 1994.
  10. Ure BM. Problemas específicos de asistencia sanitaria. In Bunjes R, Gebler A, Krumme BA, Munz R, Guha-Sapir D, Ure BM, editors. Medicina, Salud Pública y Ayuda Humanitaria. Bilbao: Universidad de Deusto; 2000. p.85-98.
  11. Ugalde, A, Richards P, Zwi, A. Health Consequences of War and Political Violence. In Kurtz. J editor. Encyclopedia of Violence, Peace and Conflict, vol. 2. San Diego: Academic Press; 1999. p. 103-121.
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Figure 1: Nick Callahan at the fund-raising gala

Figure 2: Extreme hunger

Figure 3: Nick and Sarah meet at the refugee camp

Figure 4: Elliot, Nick’s best friend

Figure 5: The tragic ending to the love story of Sarah and Nick

Figure 6: They fight for the populations and steal their food

Figure 7: The vulture awaiting death

Figure 8: Looking for water

American poster with Nick and Sarah in the foreground