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BY: DAVID G. ADDISS, MD, MPH

Illustration by Carole Hénaff

Compassion is never more important — or more difficult — than in disaster situations. Disasters trigger a deep sense of vulnerability. In the face of sudden, profound loss, we experience grief, disorientation and disbelief. All that we had leaned on and taken for granted is stripped away. Structures and routines that provided meaning no longer support us. In such moments, we depend on the compassion of others.

In their recent book, Compassionomics, Stephen Trzeciak, MD, MPH, and Anthony Mazzarelli, MD, JD, MBE, review the available scientific evidence on the power of compassion in health care settings. The results are striking. Not only does compassionate care result in a higher quality patient experience; it also enhances healing and immune function and leads to better clinical outcomes.^1-4 Compassion provides measurable benefits to patients, health care workers and health systems. Comparable scientific data on disasters are lacking, but it is hard to imagine that the benefits of compassion in disaster settings would be any less important.

AWARENESS, EMPATHY AND ACTION
Compassion is more than a desire to help. Psychological research, neuroscience and multidisciplinary scholarship have yielded fresh insights into the nature and mechanisms of compassion. In general, these findings point to three main elements: cognitive awareness that suffering exists; emotional resonance (empathy); and a commitment to alleviate the suffering (action). Disasters pose challenges to all three elements.

Cognitive Awareness
Recognizing the presence of suffering in disaster settings is not difficult: the reality of suffering is everywhere. However, disasters typically are marked by chaos and confusion. The sheer volume of suffering can easily overwhelm our capacity to respond. Stability of mind and critical thinking are essential skills for effective, compassionate action in these settings.⁵

In addition, disaster response is characterized by frenetic activity, particularly during the early rescue phase. Time is of the essence. Responders are exceedingly busy, highly focused on the task at hand. While this is both understandable and necessary, an experiment at the Princeton Theological Seminary offers a cautionary note, with implications for compassion.⁶ Seminary students were assigned to hear either a talk on the parable of the Good Samaritan or an unrelated topic. They were then told to proceed to another building on campus for their next assignment. Some of the students were instructed to take their time, while others were told that they needed to hurry. Both groups of students had to pass by a man (an actor), slumped in the alley and shabbily dressed. Overall, 40% of students stopped to offer help. Surprisingly, this proportion was not significantly greater for those who had heard the parable. However, only 10% of students who were told they had to hurry stopped to help, compared to 63% who were time-relaxed. In disaster settings, urgent, highly-focused activity — itself motivated by compassion — may preclude responding to other invitations for compassionate action.

Empathy
Responding to suffering with compassion requires some degree of empathy, or emotional resonance: the ability to feel or imagine the pain of the other. But the magnitude and intensity of suffering in disasters can easily lead to empathic overload and personal distress. When this happens, rather than attend to the suffering of others, we become fixated on our own distress, retreating into a pattern of fight, flight or freeze. Alternatively, we may busy ourselves with activities (often subconsciously) intended to alleviate our own distress, which may or may not address the suffering of others. In the presence of intense suffering, emotional regulation is essential for compassion. The ability to remain present to suffering, to feel the pain of the other but not be overwhelmed by it, is a skill that is taught to chaplains, but not very often to public health or humanitarian workers.

Action
Action distinguishes compassion from empathy. Disasters focus the mind and demand urgent action. In disaster settings, the tools of compassion vary. For example, in the search for survivors amidst the rubble of an earthquake, the most effective tool of compassion — the means through which compassion is enacted — may be a bulldozer. At other times, compassion may best be expressed through human presence, sitting in silence and holding a hand of someone who has suffered incalculable loss. Wisdom is required to discern the specific action(s) that will best serve.

Thus, in complex disaster settings, as elsewhere, compassion "devolves into" millions of specific actions. In this sense, compassion is "comprised of non-compassion elements."⁷ Each of these actions is, at the same time, both an essential component of compassion and an expression of the compassionate impulse. Whether a specific act is compassionate depends both on the act itself and how it is performed. Turning on a computer in an office setting is not inherently an act of compassion. But it may undoubtedly be considered such if it is done with the intention of approving the shipment of life-saving medications, or drafting a proposal for a community health project, or writing an email to support a colleague going through a difficult time.

The multiplicity of compassionate actions is also described by "recipients" of compassion. In a study by Shane Sinclair, MDiv, PhD, and colleagues, palliative care patients were asked how they experienced compassion from their health care providers.⁸ Their responses revealed a rich, nuanced understanding of the term. Patients did experience compassion through specific actions taken to attend to their physical, emotional and spiritual needs. But they also experienced compassion from providers who expressed interest in understanding them and their disease, or whose demeanor, affect and behavior communicated a capacity and willingness to be in relationship with them. Health care providers whose presence embodied particular virtues, such as love, honesty and kindness, were also seen as compassionate. Thus, from the perspective of these "recipients," compassion is comprised of a multitude of specific actions, as well as attitudes, capacities and virtues.

CRITIQUES OF COMPASSION
By way of better understanding compassion in disaster settings, it may be helpful to explore what compassion is not. There are many possible responses to suffering. The opposite of compassion — also known as its "far enemy" — is cruelty. Compassion is usually — although not always — readily distinguished from cruelty. Other responses to suffering, such as pity, may masquerade as compassion, but they are, in fact, its "near enemies." Compassion arises from a sense of shared humanity, from solidarity, respect and a profound awareness of interconnectedness. In contrast, pity is characterized by a sense of separation or distance between ourselves and others; it is a form of condescension. Compassion requires self-awareness; it demands that we be honest about our motives, needs, projections and distortions. Pity thrives on lack of awareness of self and other. It primarily seeks self-gratification. Like the Pharisee in Luke 18: 9-14, pity declares, "I am glad that I am not like that unfortunate person." In global health, humanitarian or disaster settings, pity may say, "I feel good when I help these poor people."

Three critiques of compassion in global health and humanitarian work are relevant to relief work in disaster settings. They shine a light on the "near enemies" of compassion and call us to critically examine our motives and expectations.

Expression of superiority
The first critique is that compassion is an expression of superiority. This view is articulated most poignantly by French anthropologist and sociologist Didier Fassin, MD, PhD, who argues that compassion "always presupposes a relation of inequality … When compassion is exercised in the public space, it is thus always directed from above to below, from the more powerful to the weaker, the more fragile, the more vulnerable."⁹ Essentially, Fassin is describing pity rather than compassion. Further, people most severely affected by disasters are vulnerable and fragile in that moment — which is precisely why they are in need of compassionate action. Nonetheless, Fassin's critique serves as a useful reminder. Are we acting from a place of solidarity, interdependence and compassion? Or can we detect subtle strains of self-gratification and superiority seeping into our work?

All about us
A second critique is that what passes for compassionate action — especially in short-term medical or humanitarian missions — may have much more to do with the experience of the "giver" than benefit to the "receiver." Short-term missions have become big business. Often with little preparation, no knowledge of local culture or language, an absence of coordination with government health officials, and no plans for long-term follow-up, students, medical teams and church groups descend on hospitals or communities to "help." Terence Linhart, PhD, conveys the essence of this critique in the title of his paper, "They Were So Alive!: The Spectacle Self and Youth Group Short-Term Mission Trips."¹⁰ Exactly who benefits from such adventures — or how — is not always clear. To address this problem, the Catholic Health Association has developed a suite of excellent resources for promoting self-awareness and critical reflection among church groups, medical teams and others interested in international service.¹¹

At issue here is not the desire to help, but the a priori unquestioned assumption that one knows, without asking or further investigation, what will serve, as well as the over-identification of the ego with the role of "the helper." In her book, The Need to Help, anthropologist Liisa Malkki, PhD, explores how Finnish International Red Cross professionals wrestle with the complex motivations that drew them to, and sustain them in, their work.¹² They acknowledge a strong innate desire to help and to be useful, and they admit to feeling "fully alive" only when engaged in humanitarian missions. But they also eschew heroic narratives and reject the notion that this work somehow makes them special or confers self-importance. Their experience suggests that self-reflection, humility and honesty regarding one's needs and motives can help to insure against ethical blind spots and errors in judgment that arise from over-identification with humanitarian and global health work.¹³

Unstable emotion
The third major critique of compassion in global health and disaster settings is that ethical decision-making, particularly in matters of public policy, must be rational, evidence-based and devoid of emotion. Emotion, particularly compassion, can introduce distortions that can interfere with equitable allocation of resources. Compassion privileges the few whom we can see. We are more likely to care about — and devote resources to helping — identifiable individuals or coherent groups of people in predicaments that are vividly described (or shown on television), a phenomenon known as identified person bias.¹⁴ Massive resources and extensive media attention are focused on the plight of a few boys trapped in a cave, while those same resources could save the lives of thousands of unidentified children if invested in primary health care.

Disaster situations highlight the challenge of identified person bias, particularly when triage is necessary. With triage, scant resources are allocated to those who will benefit most, rather than to those who are likely to die, even with help. Triage is equitable only if pre-established rules are followed. A recent Radiolab episode featuring New York Times reporter Sheri Fink illustrated how excruciating it can be when those rules demand that life-saving treatment be withheld from an individual one cares about.¹⁵ But to do otherwise violates the principle of equity. Thus, some argue that compassion has no place in public policy.

However, humanitarian and global health work becomes oppressive and untenable when stripped of compassion. Dr. Abhay Bang, MD, MPH, a physician-researcher in Gadchiroli district, India, reminds us that, "Global health decisions without compassion become bureaucratic, they become impersonal, they become insensitive. Global health operations without compassion may become autocratic."¹⁶ The answer to identified person bias is not to banish compassion from decision-making in resource-limited settings, but, rather, to expand the scope of compassion to include all persons, including those who are unidentified — the "multitudes" to whom the Gospel writers refer. Even triage, as emotionally and morally wrenching as it can be, does not negate the need to extend compassion to all persons as much as one is able.

PRACTICING COMPASSION
In disasters, many of those affected depend on compassion for their very survival. At the same time, people who work in disaster relief are motivated and sustained by compassion. The inclination to move toward, rather than away from, suffering, or to stand firmly in its presence with the intention of transforming it, must be cultivated and practiced. Mature compassion requires attending to and developing the requisite cognitive, empathic and action-based skills and capacities that together allow compassion to naturally emerge and flow in the presence of suffering. Mature compassion also demands self-awareness, critical reflection and honest appraisal of our motivations, rewards and expectations. These practices serve as guardrails that prevent us from sliding into the distortions of compassion highlighted by the three critiques: pity, self-absorption and preferentialism. Finally, mature compassion requires an acknowledgment of our own suffering and an openness to receiving compassion from self and others.

For those who wish to deepen their journey of compassion as followers of Jesus, many resources are available to provide support and guidance. Compassion is a major theme throughout the Bible, especially in the writings of the prophets, the Psalms and the Gospels. Studying compassion in the life and work of Jesus, which compelled him both to heal individuals and feed multitudes, can yield invaluable insights for us today. As noted above, CHA has developed materials to guide individual reflection and collective discernment regarding international short-term missions. Frank Rogers, PhD, and Andrew Dreitcer, PhD, at the Center for Engaged Compassion, Claremont School of Theology, have developed contemplative-based compassion training that is particularly accessible to Christians.^{17, 18} Such training helps to cultivate cognitive and emotional stability in the face of suffering. It also helps us to recognize the interpersonal assumptions and distortions that are inherent in the roles of "helper" and "beneficiary."

There are hopeful signs that global health and the humanitarian sector are rediscovering the "precious necessity of compassion."¹⁹ For example, the World Health Organization, with its new emphasis on people-centered health services, now considers compassion as essential for quality universal health coverage.²⁰ The Federal Ministry of Health in Ethiopia has identified compassion as a core pillar of its national health sector transformation plan.²¹ The CHS Alliance, a network of humanitarian and development organizations, is engaged in a deep exploration of compassion as a fundamental value linked to the core humanitarian standard.²²

In summary, compassion is essential for quality disaster relief as well as for quality health care. But for both areas, more work is needed to realize the power and potential of compassion. On the one hand, we need to recover our compassionate impulse and commit to nurturing it at the individual, organization and systems levels. But we also need to awaken to and appreciate the myriad ways in which we are already participating in the work of compassion. The need for this awakening, and for setting ourselves on a pathway toward mature compassion, has never been greater. We live in a world that paradoxically is more globalized and more polarized than ever before. For the foreseeable future, the frequency of disasters will continue to accelerate. Being able to respond to those disasters with compassion, wisdom and skillful means will make all the difference. As Roshi Joan Halifax, PhD, so rightly noted, "We live in a time when science is validating what humans have known throughout the ages: that compassion is not a luxury; it is a necessity for our well-being, resilience, and survival."²³

DAVID G. ADDISS is the director of the focus area for compassion and ethics, Task Force for Global Health. The Task Force is an international nonprofit working to improve the health of people most in need, primarily in developing countries.

NOTES

1. Stephen Trzeciak and Anthony Mazzarelli, Compassionomics: The Revolutionary Scientific Evidence that Caring Makes a Difference, (Pensacola, FL: Studer Group, 2019).
2. Jorge Fuentes et al., "Enhanced Therapeutic Alliance Modulates Pain Intensity and Muscle Pain Sensitivity in Patients with Chronic Low Back Pain: An Experimental Controlled Study," Physical Therapy, 94, no. 4 (2014): 477-89.
3. Simone Steinhausen et al., "Short- and Long-term Subjective Medical Treatment Outcome of Trauma Surgery Patients: The Importance of Physician Empathy," Patient Preference and Adherence 8 (2014): 1239-53.
4. Stephano Del Canali et al., "The Relationship Between Physician Empathy and Disease Complications: An Empirical Study of Primary Care Physicians and Their Diabetic Patients in Parma, Italy," Academic Medicine, 87, no. 9 (2012): 1243-49.
5. Joseph Albanese and Jim Paturas, "The Importance of Critical Thinking Skills in Disaster Management," Journal of Business Continuity and Emergency Planning 11, no. 4 (Summer 2018): 326-34.
6. John M. Darley and C. Daniel Batson, "From Jerusalem to Jericho: A Study of Situational and Dispositional Variables in Helping Behavior," Journal of Personality and Social Psychology 27, no. 1 (1973): 100-108.
7. Joan Halifax, "A Heuristic Model of Enactive Compassion," Current Opinion in Supportive and Palliative Care 6, (2012): 228–35.
8. Shane Sinclair et al., "Compassion in Health Care: An Empirical Model" Journal of Pain and Symptom Management, 51, no. 2 (2016): 193-203.
9. Didier Fassin, Humanitarian Reason, (Berkeley: University of California Press, 2012), 4.
10. Terence D. Linhart, "They Were So Alive!: The Spectacle Self and Youth Group Short-Term Mission Trips," Missiology: An International Review, XXXIV, no. 4 (2006), 451-62.
11. Catholic Health Association, International Outreach Overview, https://www.chausa.org/internationaloutreach/Overview.
12. Liisa H. Malkki, The Need to Help: The Domestic Arts of International Humanitarianism, (Durham, NC: Duke University Press, 2015).
13. David G. Addiss, "Spiritual Themes and Challenges in Global Health," The Journal of Medical Humanities 39, no. 3 (2018): 337–48.
14. J. Glenn Cohen, Norman Daniels and Nir Eyal, eds., Identified Versus Statistical Lives, (Oxford: Oxford University Press, 2015).
15. "Playing God," Radiolab, reported by Sheri Fink and produced by Simon Adler and Annie McEwen, August 21, 2016, http://www.radiolab.org/story/playing-god/
16. Task Force for Global Health, Compassion in Global Health, Richard Stanley Productions, (2011) https://www.youtube.com/watch?v=ydn0H60K3Nk.
17. Frank Rogers, Practicing Compassion (Nashville, Tenn.: Upper Room Books, 2015).
18. Andrew Dreitcer, Living Compassion: Loving Like Jesus (Nashville, Tenn.: Upper Room Books, 2017).
19. Joan Halifax, "The Precious Necessity of Compassion," Journal of Pain and Symptom Management, 41, no. 1 (January 2011): 146–53.
20. World Health Organization, WHO Global Learning Laboratory for Quality UHC, https://www.who.int/servicedeliverysafety/areas/qhc/gll/en/
21. Federal Democratic Republic of Ethiopia Ministry of Health, Health Sector Transformation Plan, October 2015, https://www.globalfinancingfacility.org/sites/gff_new/files/Ethiopia-health-system-transformation-plan.pdf.
22. CHS Alliance, www.chsalliance.org.
23. Halifax, "The Precious Necessity of Compassion," 152.