Government agencies generally did large-scale disaster responses, but Team Rubicon has grown, becoming verified by the World Health Organization as a regency medical team that can be deployed to sudden-onset disasters globally. In this episode, Dr. David Callaway discusses veteran-led disaster response and humanitarian organizations currently working in Ukraine. Dr. Callaway is a US Navy Veteran and Professor of Emergency Medicine at Carolinas Medical Center. He serves as the Chief of Crisis Operations and Sustainability, the Director of the Division of Operational and Disaster Medicine, and the Medical Director of Carolinas MED-1. He shares how a disaster response team works, the types of medical work that can be done in areas of conflict, and how you can help.
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The Crisis In Ukraine With Team Rubicon's Dr. David Callaway
Please keep in mind that the content of this episode does not constitute medical advice but is purely for the purpose of education. Our guest is Dr. David Callaway from Team Rubicon. Dr. Callaway is a US Navy veteran and Professor of Emergency Medicine at Carolinas Medical Center, where he serves as the Chief of Crisis Operations and Sustainability, the Director of the Division of Operational and Disaster Medicine and the Medical Director of Carolinas Med-1.
Prior to his position, he served as a physician supporting the United States Marine Corps and was a Chief Resident at the Harvard Affiliated Emergency Medicine Residency in Boston. In 2008, he was awarded a Zuckerman Fellowship from the Center for Public Leadership, Harvard Kennedy School of Government, to study leadership, national security and disaster response. Dr. Callaway is the Chief Medical Officer for Team Rubicon, a veteran-led disaster response organization, and the Cofounder of the Committee for Tactical Emergency Casualty Care, a best practices R&D group charged with translating battlefield lessons learned to civilian high threat prehospital medicine.
Dr. Callaway has extensive civilian and military overseas experience in Iraq, Kuwait, Dominican Republic, Haiti, Burma, El Salvador and throughout Africa. In 2012, the World Economic Forum selected David as a Young Global Leader based upon his innovative work in disaster, humanitarian and crisis medical response. His areas of interest are high-reliability operations, innovation in disaster response and crisis zone medicine. Welcome, Dr. Callaway.
Thanks. I appreciate the time. I should have given you a short bio.
No, I think all of that was important.
The curse of the academic life.
There's a lot there. Your expertise is appreciated. Tell me a little bit about Team Rubicon. What is Team Rubicon? What do you do?
Team Rubicon is a veteran-led international disaster response and humanitarian organization. Team Rubicon, we go by the short acronym of TR. TR was founded in 2010 after the Haiti earthquake when a group of combat veterans looked at their experience that they had in Iraq and Afghanistan. They thought some of their skillsets would be relevant in these emerging disaster zones and complex humanitarian emergencies. Over the last several years, we've grown from 8 volunteers to about 120,00 to 150,000 volunteers on our books.
In the last few years, we've moved to become verified by the World Health Organization as an emergency medical team that can deploy to sudden-onset disasters globally and coordinate with both the WHO and host country ministries of health. We work mostly in sudden-onset disasters but have been prepping the processes and the people to be able to work in conflict zones over the last few years.
Team Rubicon has grown, but I think the field of disaster medicine, particularly as a branch of emergency medicine, has grown as well. Can you talk a little bit about how that's developed and become more of an agreed-upon specialty or solid specialty?
Be realistic about what your constraints are. Understand that there'll be significant discomfort, significant variability.
I'm going to use this as a general timeframe, but prior to 2010, the large-scale disaster response was generally done by government agencies. In the US, you can think of the DMAT teams or USAR teams or they're done by large Non-Governmental Organizations, NGOs, like Doctors Without Borders or the International Federation of Red Cross. After 2010, what we found is there were a lot of people who were interested in this type of work, but it was uncoordinated, often well-meaning but with unintended consequences. Many groups, including the American College of Emergency Physicians, started to increase our effort to professionalize disaster response.
Everything from standardizing curriculum for post-graduate fellowship training to including it in residency training to work by the WHO to standardize what a response team looks like. We've seen some very good work to professionalize the specialty, some good, unique, innovative work to try to figure out how we capture these areas. Especially in emergency medicine, some were perhaps left out in prior models and how do we get top-level care to communities in need at their time of greatest need.
Now, Team Rubicon is working in Ukraine. Can you tell me a little bit about the types of care your clinical teams are providing? Is it trauma, hygiene, transport? What are you guys doing?
This is, again, a very important question because in the US, in particular, if you watch the news, all you see are the bombings of Kyiv and Dnipro and the Far East, where there are lots of trauma. This is what people think is going on in Ukraine. That's the only problem. A lot of people raise their hands, “I want to go do that,” not understanding the complexity of the problem but also not understanding the depth of the problem.
What's happened in Ukraine is there are a couple of different medical problems. One is the trauma in the Far East, which is largely being managed by the Ukrainian health system. There is the displacement of over 10 million people. About 3.7 million refugees have crossed international borders, and another 6.5 million or so are internally displaced. It's like if you took Chicago and Phoenix and moved them to Southern California and you said, “Health System, start managing that,” or if you took Charlotte and Chicago and moved it into Mexico and be like, “Start handling that.”
What our teams have been doing because we're an American NGO and it'd be foolish of us to be anywhere near the conflict zone, we've been focusing on how you care for these internally displaced people and how you care for refugees. Much of that has been chronic care. Much of it has been urgent care and primary care, but some have been basic emergency care like we would see with any population of 3 million. They're going to have heart attacks and women in labor. We've been providing these mobile camps with care from emergency medicine physicians, pediatricians, and primary care doctors in Hungary and in Western Ukraine.
Often with these massive displacements of people, you see a decrease in hygiene and an increase in many types of infectious diseases. Have you guys noticed that at all? Is there any plan in place for working through that?
There are two distinct questions and they're both super relevant. Number one, Ukraine had a functioning health system prior to the war. Now, there are significant issues in terms of vaccination. They had low vaccination rates for measles. COVID vaccination rate was like 35%. HIV and multi-drug resistance, TB were big problems, but the system was working on those issues. When you displace people for the first 1 or 4 weeks, you're not going to see a lot of these issues emerging because the health system structures are still in place. They're just being strained.
Now, we will start to see these issues pop up, probably starting 5 or 6 weeks into the conflict into 3, 4, or 5 months as these critical health maintenance activities are not performed anymore. Kids aren't getting vaccinations. People are not getting their HIV meds. Cancer patients aren't getting their chemotherapy. This will start to create a complex strain on the system in Ukraine and also in the surrounding countries. That will emerge and continue to emerge as a big problem in this region if not addressed.
There are a lot of people who are chronically ill. You mentioned cancer patients who may have difficulty being transported out of the country. Have you guys assisted at all with the movement of these ill patients to places that are a little bit safer?
That is a gap that has been identified. Our organization is working with other NGOs, then working with the WHO and the Ministry of Health of Ukraine has been working on ways to help augment and improve that process. This is classic emergency medicine. There are patients who are mobile, who need services and need to be linked in with the right services instead of being at a level one trauma center community and trying to figure out, “Do I go to the coronary care or tertiary care? Put them in a helicopter or in an ambulance.” We're in Ukraine. It's, “Do they need to go to Poland? Do they need to go to Hungary? Is there a system in Western Ukraine where they're already plugged in? Where do they have language skills as well as the medical needs?”
The answer is yes. That is an identified challenge that this coalition of partners is working on. It’s an interesting problem that’s also exceedingly complex when you have multiple nonprofit, non-governmental organizations. You have international organizations like the World Health Organization and you have sovereign nations like Ukraine, Poland, Hungary, Moldova, who have their own health systems or own laws, rules, regulations, trying to solve this issue.
It is, again, what I would say is a classic emergency medical problem, which is why it's so great to have smart emergency medicine doctors and nurses on our teams over there who understand the complexity of it. They don't have an answer but they understand not to ask the questions, bring the right stakeholders to the table and always keep the patient front and center in everything we do.
It's a lot to balance. There are so many different systems involved. I can imagine the complexity, bureaucracy, and logistics become an issue over time.
We can either continue to be cynical and cruel to each other or say, "Enough is enough." We want to create an environment or communities that counter this type of aggression and hate.
If you're not aware of it and not used to the complexity of a network, then it can be very frustrating as you try to make rapid decisions. As emergency physicians, we're able to balance making rapid decisions with also respecting the fact that there is a complex bureaucracy there. It doesn't matter that we don't know the intricate details of this particular bureaucracy. We understand it's there. We understand we need to engage it and that we need to partner to solve the problem.
Again, that's critical to any response like this, where an organization like ours partners with local hospitals and local ministries of health to help augment their response. It's critical because we never deploy without a specific ask from the country, the ministry of health, or a health system representative. It would be irresponsible and unethical for us to show up in a country and start practicing medicine.
We don't do that. It's important when we start thinking about how do you engage in and how do you respond to events like this that people who are interested in helping find a vetted organization, make sure that they're following the rules and make sure that they're abiding by the structure that's out there. If you're ever wondering what to do, think about, “Would we ever accept a foreign doctor coming into Iowa or North Carolina and all of a sudden starting to practice medicine?” The answer is no. We should have the same respect with any other country that we're working with.
You also made a great point about the uncertainty in this type of situation and how emergency practitioners are great at working in areas with no definitive answer. There's not necessarily all of the diagnostic information or all of the information about how something will work or end up. Emergency practitioners excel in being able to look at a situation and make fast decisions based on limited information to inch things closer to a good resolution.
You're right, and the flexibility to pivot where the need is. You asked what our teams are doing. Our teams have been providing this mobile care to different internally displaced refugee camps, but we've also gotten asked to help with point of injury, trauma training and basic emergency care, even chemical, biological and nuclear response capabilities for hospitals. The ability to say, “I thought I was going there to practice clinical medicine, but now I'm being asked to train.”
Being okay with that is something that we pride ourselves on at Team Rubicon to find the mission, find the expertise, partner with local organizations and make sure you're caring for people in their greatest time of need. That may be training, transportation support, direct patient care, or to serve as a convener to help bring partners together that otherwise would have spoken.
You answered this question a little bit, but can you tell me a little bit about what a typical day might look like on the ground for your personnel?
Now, we have a type-1 mobile emergency medical team in Western Ukraine. That's a team that's verified by the WHO to meet a certain standard of capability. That capability is the ability to provide urgent and primary care for 100 patients a day and self-sustained without being resupplied with food, water or medical equipment. A typical day for our team now would start the night before and would start with conversations with local partners about what a perceived need or perceived gap is. We’re generating what we call an operational order for the next day so that our support team in Poland and back in the United States knows what our plan is for the next 24 hours.
It could be everything from deploying mobile teams in the internally displaced camp to assessing whether there is a need there to provide care. We may split the team. One part of our team goes to provide care. Part of our team went and did training at a local hospital. Our team is up. They’re mobile. They're usually based out of a partner facility. We try to move around to both assess needs, deliver care and deliver training. They've been in and out. mobile teams in the internally displaced camp to assessing whether there is a need there to provide care. We may split the team. One part of our team goes to provide care. Part of our team went and did training at a local hospital. Our team is up. They’re mobile. They're usually based out of a partner facility. We try to move around to both assess needs, deliver care and deliver training. They've been in and out.
The one unique thing is that everything's interrupted by air raids, probably at least 2 to 4 times a day. Russians either fly a plane into Ukrainian airspace or launch a missile. The air raid sirens go off and our teams have to find a place to shelter until the air raids are over. That is a significant disruptor of all operations. Our team has been pretty resilient. We have both veterans and civilians who never served on our teams and they recognize what this is. They have a pretty good support mechanism to ensure that people are not getting too anxious about it. We have very good safety protocols to ensure that our teams are all safe.
I can imagine that being extremely disruptive to the process of trying to accomplish whatever that day's goals are. I know once, in the emergency department, all of the power went out. It was very short. It was for a couple of minutes, but it disrupted care. I can't imagine what multiple disruptions like this a day would do to the plans. To your point, you have to be able to pivot quickly and understand the current situation and how to regroup and change based off of that changing situation.
This might be one of the areas where the lack of sleep hygiene of emergency physicians might be a strength because it's much like being on-call. The sirens are at random times, but there's almost always one at night sometimes. This ability to wake up, not be angry and frustrated, move down to a bomb shelter, fall back asleep, get back up when it's over, go back up your bed, and function the next day is critical in an environment like this. We always try to think of what are the positives to the negative things in our career, but the ability to function with poor sleep hygiene is important in this environment.
As medical providers, we often want to do whatever we can to help. However, in areas of crisis, medical volunteers can sometimes show up and try to provide assistance in maybe a disorganized manner. What advice do you have for volunteers or individuals thinking about going to Ukraine to help medically?
Number one is to make sure you're a good provider. I'm going to speak to doctors because it will make it easier. The first thing is to be a good doctor or a PA. You need to be good at your job before you do anything else. The second is to be realistic about what your constraints are. Understand that there'll be significant discomfort and significant variability. You may not have great food and water. Be realistic about that. The third is to find a vetted organization. Do not show up on your own. Do not form an NGO out of the blue and show up because you're going to put yourself, other NGOs, and patients at risk. If you're serious about it, use this as an opportunity to learn about disaster medicine, humanitarian response, and start to become a student of the game.
The respect for humanitarian aid and the neutrality of humanitarian workers has started to erode.
You don't have to become an expert right off the bat, but if this has inspired you to get more engaged, go find some online courses or an NGO, start doing some volunteer work, get the skill set, get the experience and be ready for the next appointment. Finally, what we all can do as humans is to be good neighbors and good people. This is a war that's threatening our humanity. We can either continue to be cynical and cruel to each other and fight about stupid things at home or we can say, “Enough is enough.” We want to create an environment or communities that counter this type of aggression and hate. Maybe we come out of this stronger in the US.
That's such a great point because when you see war, you see conflict. It gives people a sense of uncertainty. That uncertainty sometimes can lead to behavior that maybe isn't following the golden rule, not treating your neighbors as kindly as we could in a situation like this. I love that you have brought that up. One way that we can combat anything like this is with kindness and by sharing kindness in your daily life.
When I say this, please know that I'm not being moralistic because I struggle with it too. It's hard not to be filled with rage when you see injustice. It's hard to act with kindness and love but if you also apply it to your daily life in the emergency department. Think about those moments where you get frustrated with the person that comes in the emergency department all the time, or you feel like they're using services inappropriately.
Perhaps use this to reflect on how good our lives are and the responsibility with which we've been tasked to be standing there on the front lines, either in Ukraine or in your emergency department, caring for people in their greatest time of need. That's part of why I do this work. It's a constant reminder to try to be a better person and doctor.
Some reports of physicians have been attacked and killed while providing medical assistance in Ukraine. Do you have any concerns about this for the teams working there now?
As a chief medical officer and one of the operational leaders, my first job is to make sure that our teams are safe and to make sure that there's a mission, they're providing the right care. We have a duty to care to make sure that our teams are protected. If you get closer to the conflict zone, you're at a greater risk in general but the troubling thing here, much like we've seen in other conflicts in many years that have been non-state after conflicts is the respect for humanitarian aid and the neutrality of humanitarian workers has started to erode.
The specific targeting of the humanitarians has been growing threat. What's more concerning to me here is that this is the first time you've had an actual state actor specifically who is part of the system, whether it's the UN Security Council or these other international humanitarian law guiding bodies who appears to be specifically targeting health workers. The answer is yes. It means we have to do things like talking about operational security, how we use our cell phones and how we create convoys, how we communicate. Whether we should or should not be wearing red crosses and marking our vehicles, which historically has always been something you do. These things are on our minds all the time.
We have a very good team in place, some good expertise. At the same time, when you go into a complex humanitarian crisis like this, randomness cannot be controlled. It's a factor that you have to accept. All you can do is prepare and plan as best you can, but there are some things that are going to happen if you put yourself in higher-risk environments. That weighs on my mind and on the mind of every one of our operational leaders every single night.
We talk to our volunteers before they are deployed. We talk to them once they've agreed to deploy and before they leave. We talk to them again when they get into Eastern Europe before they go into Ukraine. We give them multiple opportunities in private and as a team to say, “I know I said okay at the beginning, but now I'm a little concerned.” We give them multiple opportunities to change their minds without consequence or penalty because we understand what we're asking of these volunteers.
Especially over the last few years with the COVID pandemic, you've seen medical providers put their lives at risk to help people. That's the reason a lot of us went into the medical field. We wanted to be able to make a difference and help in times of struggle, whether that's a personal struggle or a global struggle. I am so grateful for what they're doing. I appreciate that you guys are out there and working to help everyone.
We appreciate it. I would agree with you. Partly why you go to medicine is to help people and why you are going to emergency medicine because you have this sense of a willingness to stand on the raggedy edges of society and care for people who have been disenfranchised or marginalized. One of the things that I've seen in the last few years of COVID is people have stepped up. They stepped up for a long time and they're tired. Oddly, even though there's a tremendous amount of work, it's recalibrated a people’s sense of purpose and meaning.
What we've seen with this is COVID was a long strain. This crisis in Ukraine, in particular, is an acute need. What we've heard from some of our volunteers is it's a lot of them again to find a sense of purpose and the morass of all that's gone on the last few years and focus on something discreet and tangible that set laws and to say, “I'm doing something now to preserve humanity and to focus on my oath as a clinician, to provide care to the people who are being again marginalized.” It's interesting to listen to the stories of these people who have been on the frontlines of COVID for a few years, for now going and doing this and how they process both of those complex problems.
What is one thing that you or the teams on the ground think would want everyone to know about what's going on in Ukraine now?
The real crisis is being missed or the displacement of people. Of those 10 million people I talked about, the vast majority are women, children, and the elderly. I would say, as EM physicians, we know that human trafficking is a massive problem. We know that women and children are highly vulnerable, specifically women. They've been displaced from social support networks. My fear, both as an EM physician and a father of two daughters, is at the crisis will miss is what's happening to all these women and children as it gets displaced.
When you go into a complex humanitarian crisis like this, randomness cannot be controlled. It's a factor that you have to accept.
That's not hit on the cover of The New York Times or the Washington Post or Fox News. It's talked about within professional circles, but I don't know that it's getting enough of a highlight. I don't think it's getting enough resources to proactively prevent this from happening. Our teams would say they're seeing mostly women and children. They're worried about what happens after we give the child with a fever Tylenol. What happens to them next? What happens to them a week from now when they're seeing a shelter in another country where they don't speak the language? That's probably one of the things that our team would want people to think about and be aware of.
Is there any way our audience, both in and outside the United States, can provide assistance to Team Rubicon?
I appreciate the ask. TeamRubiconUSA.org. If you go to that website, you can donate. You can track some of the work we're doing. We're also on social media so that you can track our progress on all the social media channels. I'm an old guy. I don't know what they all are, Twitter, Facebook, Instagram. Whatever the cool one is now, our team is on all of them. Consider signing up as a volunteer.
If you'd signed up, the likelihood of deploying to Ukraine is lower unless you have very specific skill sets because we've got a pretty deep bench, but we also respond. We were in Mongolia and Papua New Guinea and Uganda doing COVID operations in 2021. We've got tons of work on our plate. We need qualified, passionate individuals who are crazy enough to think that they can change the world. Volunteer, donate and please pass the word. Continue to support Team Rubicon.
Thank you so much. Any final words before we wrap this up?
Thanks for the time to chat. I appreciate all my emergency medicine colleagues who’ve been supporting Team Rubicon and continue to do good work on the front lines. Keep it up.
Thank you. We appreciate that you joined us, especially knowing that you have so much going on now. That's it for this episode.
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About Dr. Callaway
Dr. Callaway is a US Navy Veteran and Professor of Emergency Medicine at Carolinas Medical Center where he serves as the Chief of Crisis Operations and Sustainability, the Director of the Division of Operational and Disaster Medicine, and Medical Director of Carolinas MED-1. Prior to his current position, he served as a physician supporting the United States Marine Corps and was a Chief Resident at the Harvard Affiliated Emergency Medicine Residency, Boston.
In 2008, he was awarded a Zuckerman Fellowship from the Center for Public Leadership, Harvard Kennedy School of Government to study leadership, national security and disaster response. Dr. Callaway is The chief medical officer for Team Rubicon, a veteran-led disaster response organization and the co-founder of the Committee for Tactical Emergency Casualty Care, a best practices R&D group charged with translating battlefield lessons learned to civilian high threat prehospital medicine.
Dr. Callaway has extensive civilian and military overseas experience in Iraq, Kuwait, Dominican Republic, Haiti, Burma, El Salvador and throughout Africa. In 2012, The World Economic Forum selected Dave as a Young Global Leader (YGL) based upon his innovative work in disaster, humanitarian and crisis medical response. His areas of interest are high reliability operations, innovation in disaster response, and crisis zone medicine.