Why care? Lucia Castelli, AVSI Child Protection Advisor at MedConference

The core of the medical profession—the relationship between patient and caregiver—is too often reduced to a mechanical process. The very nature of medical care is at risk because the care of the patient is reduced to the cure of solely his or her physical being.

Accelerated by the pandemic, the culture surrounding medicine is changing. The American Association of Medicine and the Person organized the 2023 MedConference in Minneapolis (USA) to discover or rediscover the beauty in practicing medicine. Among the speakers Lucia Castelli, who joined AVSI as pediatrician and she is now AVSI Senior Child Protection Advisor.

In the medical courses attended in university I was educated to see the reality of the patient in a certain way. During my experience in Africa and around the world, I learnt another gaze.

During the years spent in Africa, the university changed way of teaching, more importance was given to the techniques, exams, specializations increased, even in one field like pediatrics there are many sub specializations and the deepened study of a particular is more important than a holistic overview and approach to the patient.

These are the contradictions and challenges lived from which I learned more about sickness and how to approach my medical profession in general, patients in particular.

I think that each of us, since we chose this profession, has in the deep of his/her heart the desire to “care”, to be useful for the other human being we meet. I expressed my desire to become a medical doctor and to go to Africa to work when I was 10 years old! I am pretty a determined person, sure of what she wants. But in life, to achieve your goals, you do not need only to have desires and follow them, but to merge them with circumstances, events and encounters with people, facts to which you adhere and through which you grow.

My desire to become a medical doctor was accomplished when I was 24. I started as general practitioner then I became pediatrician and worked in a pediatric ward of a general hospital and in clinic for outpatients.

My desire to go to Africa had to wait until I was 38 years old, for the circumstances of my life. And I am very happy to have been obliged to wait, because I started my African adventure with a maturity as human being and as medical professional that I could not have when I was 24 soon after the degree.

The occasion - the event... - was the genocide in Rwanda in 1994. A friend of mine, pediatrician like me, was the President of AVSI, an international NGO, he knew my desire and he had a need: to find a pediatrician for the orphanage of Nyanza, an orphanage run by the Father Rogazionisti, where, during the period of the genocide, many children where left over by their parents to save them from death.

I replied to a question: this is always the right method for a good answer, also in our work. The real issue many times is to understand the real question, to ask where the question is coming from, which is the real need behind the question..this became clear in my first experience in Rwanda.

A friend of mine, before leaving told me: remember that you are not going to Rwanda to save the children, you are going them to discover the meaning of your life…I discovered that the importance of my life and of my work was not in the competence I had but in the presence. I was important for the children because I was there, not for what I was doing. The importance of the relationship with children/with patients came out clearly as the first point to care for them.

The little children in the orphanage were the most difficult to deal with. They didn’t want to eat, they cried all the time. We decided to organize the little houses where children were living and sleeping in a different way, not divided in age groups, as they were, but putting older children with youngers together and giving to the older ones the responsibility of being “mothers and fathers” for the little ones. The situation changes and the little ones started eating and being more quiet! Such a simple thing! Such an important thing! The relationship, the presence of someone caring for you is important in order to recover! The answer to an essential need, like the one of having food, is not given only by the presence of food, but by the presence of a person giving you food!

What was the real need behind the symptoms and signs we see? I realized the importance of understanding what happened in their body, in their mind, in their family and their community.

Together with the friends who were there with me (Giovanni, Annet) we developed a specific psychosocial program of reintegration for war traumatized children, based on the IASC (Inter Agency Standing Committees Guidelines on Mental Health and Psychosocial Support in Emergency Settings, but developed on the “world of the person approach”.

A child 10 years old, living near the orphanage,  was coming to my clinic every day for a bad wound on his head done by the rebels using a machete. I was dressing the wound every day, using antibiotics etc, but there was no improvement. I discussed the issue with my friend Giovanni, psychiatrist, who had started to have groups of therapy for PTSD  with the children in the orphanage and we decided to propose to Eric (not the real name of the child) to have an exercise book and start writing whatever he wanted to tell us and then we invited him to participate to the groups organized in the orphanage. In a short time the wound was healed!

From 1997 to 2012, with some years of go and back from Italy, I worked for AVSI in Uganda, in northern Uganda for the reintegration of child soldiers and then for a huge project for orphans and vulnerable children in Uganda, Rwanda, Kenya and Ivory Coast.

In 1993 AVSI started operating also in the emergency field, to meet the needs of the local population and the Sudanese people fleeing from the war in their country and seeking refuge in Kitgum District, at the border with Sudan^. This is not an acute emergency but it will be a very long one, as it will now happen for many international crises, creating new needs also in the local population. The civil society is completely devastated by massacres carried out by the various rebel groups – Nile Bank Front, Uganda National Rescue Front II, Lord’s Resistance Army (LRA) –who attack the civil population to create terror, plunder the Health Centers, attack villages, shopping centers, refugees camps, the schools and teachers in order to hit young generations, but first of all kidnap children to train them to become “soldiers”. Approx. 60% of the LRA “soldiers” are children younger than 16 years of age. Their strategy is to handle and oblige them with brutality so that, in turn, they can torture and kill other people. The adolescent girls are given to the rebels as “wives”. Local authorities estimate that between 1993 and 2006 LRA has kidnapped over 50.000 children in the four districts of Northern Uganda. Only half of the kidnapped children have been able to escape and go back home. Since June 1997, still supported by Unicef, AVSI started a psycho-social support program in Kitgum District, characterized by a global approach, giving special attention to the needs of the children and the most vulnerable groups. The project main objective is to restore the child’s mental and psychological heath, starting from the assumption that the trauma endured by the children in such situations can irreversibly affect their psychophysical development. The expression activities carried out with the children, singularly or in a group, are essential to reprocess their life experiences, find reasons and reintegrate in a life path. The children can in this way recover self-confidence, self-esteem and awareness of their capacities.

OVC means Our Valuable children. Attention is given to each single child/youngster and his life history, wishing first of all to listen to themand to share (why not) their grieving, conveying to them the confidence in a hope for the future and proposing a reintegration at school or in suitable working activities. The relation that develops among beneficiaries and humanitarian operators in crises situations is therefore fundamental for any action that cares not only to ensure emergency assistance but also to give the possibility of growth and future development.

In Uganda I  continued learning: the importance of “the peace of the mind” for the mental health, and not only, for the health of children the importance of expression of feeling, emotions, desires to a person whom you can trust the importance of relationship, the importance of working on oneself. To start from oneself and to consider own’s needs and desires. To know and discover oneself to be ready to go towards the other

Back in the same hospital where I was working before leaving for Africa, but with all new colleagues, young, skilled, with more competence than me… more technical competence, less human competence. The patient is a body made by pieces... the patient is no more there, there are only the pieces…

In 2016 I went to Lebanon as Manager of one of AVSI’s most important projects in support of the Syrian community: “Back to the future”, financially supported by the regional trust fund of the European Union to respond to the Syrian crisis, the Madad, implemented by a NGOs consortium composed of AVSI, Terre des Hommes Italy and War Child Holland. The project aims at promoting the reintegration at school and supporting the school attendance of refugee and vulnerable children living in the local communities in Lebanon and Jordan. Through this project we were able to establish relations with thousands of families, with their lives and their endless needs in a context that cannot be defined as just a prolonged crisis situation but that seems to be an endless crisis!  I met with persons different than me regarding culture, religion,language, social status... but who had my very same desire to live and have a dignified and happy life.

The project takes care of the children but, since the beginning, starts relations with the caregivers, the parents, the older brothers and sisters who are often responsible for the children, with the extended family. While meeting the educational needs, we cannot forget the family and, first of all, we cannot avoid considering the social context and the environment where families live. Through our relations with adults we are able to take actions regarding children and promote their education and growth.

What I learned working in difficult situations, conflicts, prolonged crises in various countries around the world, is that the most important thing is to be there: accompany people, share part of their destiny, because the worst wound when a person is in great need is the sense of abandonment, to be forgotten.

But, first of all, meeting with persons who have the same needs and dignity we have, who ask to be listened to and to be considered, principally, as persons and be able to be part of a human relation, is what gives them back dignity and hope. The relation is part of HOW actions are carried out. To consider this relation as the “action” that must be mainly cherished when working, means to consider it the successful point of any action. And this applies to every corner of the world.