Working in the red zone: the crucial role of paramedics in providing access to care in difficult situations

It’s not often that an academic, instead of writing a journal article, decides to create a documentary. But that is exactly what Leanne Brady, a CHESAI colleague and Research Fellow, Health Policy and Systems Division, University of Cape Town did in creating the documentary Red Zone Paramedics.

Nikki Schaay, a colleague at the School of Public Health, University of the Western Cape sat down with Leanne and asked her about her motivation for making the documentary and how she thinks the medium of film contributes to health policy and system research (HPSR).

 

Red Zone Paramedics is a documentary film about an ambulance crew working the night shift on New Year’s Eve in Mitchells Plain, an area of Cape Town with high levels of gang-related violence. Long granular shots winding through darks streets while navigating the visceral complexities of delivering healthcare in a city of complex contradictions – this is a film about the everyday experiences of life on the road.

 

Watch the documentary

RedZone

 

NS     What is the back story to this documentary: what was your motivation for making the documentary and why did you focus on this issue specifically?
LB    

It all started while I was doing a documentary film course at the Centre for Humanities Research at the University of the Western Cape in 2016. I wanted to learn how to use film as a way to tell stories from the health system, and still hope to do this as part of my PHD.

We all needed to make a film for the course, and so I contacted the director of Emergency Medical Services (EMS) to get permission, and then started riding around with ambulance crews. Although I had worked in the health system for a number of years, I was always on the other side (in the Emergency Room), and had never actually been inside an ambulance – which meant I had a lot to learn about what it meant to work on the road!

In many ways, paramedics are the community health workers of emergency care – they are the first point of contact to the health system, when people need care most urgently. But, despite their vital role, paramedics are often not seen as a part of the formal health system (where hospitals and clinics take centre stage). So, one of the goals for the film was to shine a light on the important role paramedics play in the health system. I took an ethnographic approach to the film, spending many evenings and weekends with ambulance crews learning more about the complexities of delivering emergency medical care in Cape Town. One of the stories that emerged is: Red Zone Paramedics – a film about navigating the night shift and the complexities of continuing to deliver emergency care in an increasingly violent context, and what it meant to negotiate the ‘red zone’ policy at the front line.

In areas of Cape Town demarcated as high risk (red zones), ambulance crews are required to be escorted by police officers when attending to patients.

       
NS     Why the choice of the medium of film specifically? 
LB     Film is a powerful way for researchers to be part of a conversation that reaches beyond traditional health research audiences. It is an audio-visual story-telling feast for the senses that can help us connect more deeply to human experience through the window into the granular realties of life that it offers us. Red Zone Paramedics invites you to spend the night shift with Mr Martin and his crew. It is filmed almost entirely from the inside of the ambulance and hopes to give the audience a taste of what it’s actually like to work on the road. The film also tries to help us engage with violence, a very complex social issue, and how it impacts the health system.
       
NS     How long did it take to conceptualize the story, share the idea with colleagues within the provincial health department, obtain the necessary permission/approval from government, and then shoot and edit the movie?
LB     It took about 18 months from conceptualising the story untill the final edit was done.
       
NS     In what ways do you think the use of film complements the more traditional way one produces HPSR – in other words, what does a documentary offer the field of HPSR that a peer-reviewed journal article, publication or policy brief could not quite get to? I understand that the film has been screened in a variety of settings including the 2018 Encounters Film Festival in Cape Town and Johannesburg, and that it will be screened internationally at the Global Symposium on Health Systems Research (HSR2018) in October 2018. Was your initial idea one that you wanted to communicate with a range of different audiences?
LB    

Well, I never expected the film to travel this much, and never expected so many different audiences to engage with it, in so many different ways. At the last screening in Tafelsig (the neighbourhood in which it was shot) the post-film Q&A highlighted the tensions and contradictions between top-down policy initiatives and how they play out on the ground. It allowed for a robust discussion between the director of EMS, front-line health care workers and the community they serve. A peer reviewed article or policy brief could never have opened up that conversation.

Many health workers who attended the event remarked that the film screening and poetry performance changed the nature of the conversation – stating that it opened up a public dialogue that allowed for connecting on a much more human level.

In addition to reaching beyond the HPSR audience, the film has also reached many more people than a journal article would have. It has been used for teaching, has been presented at a number of university engagements, has been used by the Department of Health in a variety of ways, and has screened at a number of film festivals in South Africa, Kenya and America. In October it will be screened at HSR2018 in Liverpool as one of the multi-media submissions at the symposium.

       
NS     Can you tell me a little about how this documentary connects to the other HPSR you and colleagues are continuing to explore in relation to the EMS and everyday resilience of the health system? 
LB     The film has set the scene for the PHD work, and has been an important vehicle to build relationships with EMS staff, and deepen understanding of the issue. It also connects to the work we have been doing as part of RESYST
       
NS     What have been the responses from these different stakeholders to the story? I am particularly interested in finding out how the first responders themselves, and their colleagues working in the EMS, have felt the movie has portrayed the context in which they work and some of the issues they deal with daily as public health workers?
LB     Good question, and people have responded differently. Overall, it seems to be a story that resonates with first responders. We have done a number of post-film Q&A’s together, and they feel it portrays the situation thoughtfully and accurately. It has also been a platform to start a conversation about the issues they face and response to these.
       
NS     And what about community members – those who face similar levels of violence, and are collectively trying through, for example, the local community policing forums to resolve some of the challenges related to access and safety?
LB     The Tafelsig screening was deep. Over 300 people attended and it was a platform for some really difficult conversations between people living and working in the neighbourhood, including the community policing forum, the ward councillor, paramedics, and a senior EMS manager. It was the beginning of a conversation and while some really important points were raised, more engagements allowing for frank and open conversation are needed.
       
NS     Were there any specific production challenges or obstacles you faced in making this documentary?
LB    

There always are! But one of the lessons from the film class was related to the Lars Von Trier & Jorgen Leth film The Five Obstructions which basically demonstrates how to use the ‘challenges’ or ‘obstacles’ you face to your advantage – and that these ‘obstructions’ can push you to make creative choices that ultimately make for a better film! So, that is what I tried to do in this film.

So for example, an ‘obstruction’ could be the space constraints in an ambulance resulting in the decision to make a very intimate film. Or, the importance of filming ethically and never revealing anyone’s identity resulting in shots that add to the mood of the film. It was never intended to be a sensationalist take on EMS, and I tried to use these ‘obstructions’ to add to the intimate, slow-paced, reflective nature of the film.

It’s also important to note that the role I play in the health system (as a doctor and now researcher) opened up a lot of doors that would have probably been more difficult for a non-health care worker.

       
NS     What camera did you shoot the movie on?
LB     I used an iPhone 6S with a plug-in Rhode microphone, a GoPro and a drone.
       
NS     How many other people worked on the movie with you and what was their role?
LB     Ambulances are small, and they already have crew! So, I was director, cameraperson and sound. The fantastic editor was Khalid Shamis.
       
NS     How much did it cost to make the movie? Where you supported in any way with this funding?
LB    

It cost much less than usual because I was a one wo(man) crew making the film without a budget in order to learn. Towards the end, I received a grant from the SARCHI Chair in Health Systems, Complexity and Social Change, which allowed me to bring an amazing editor on board (this improved the film significantly) and organise a community screening.

The cost for editing and post-production was R30 000.

       
 NS     Since making the documentary in late 2017, have things changed in relation to the crises: for example, have the number of demarcated ‘red zones’ been reduced, has there been a set of interventions that has reduced the level of risk faced by the EMS teams, or increased access communities have to paramedics in such zones?
 LB    

Hmmm…not really. There has been a slight decrease in terms of the of attacks, but nothing significant and it remains a very complex issue that is difficult to address. It has, however, become less news-worthy, so any perceived decrease in incidents is mostly likely due to that.

The Department of Health remains committed to finding solutions and there are are a number of initiatives being introduced to this end. One such initiative is paramedics training local community members to provide first aid while waiting for the ambulance to arrive (as they are often first on scene). This kind of initiatives has benefits beyond providing emergency care and also strengthens relationships between paramedics and the communities they serve.

       
NS     And to switch perspectives a bit: what about documentaries as an aide in HPSR teaching? What key ideas/reflections can you offer the facilitators of HPSR training programmes as to how they can best incorporate the use of documentaries into their teaching practice?
LB    

The film has been used for teaching in a range of different ways, including the UWC Winter School's Health Policy Analysis course, the UCT MPH Complex Health Systems course and the LSHTM Global Health Executive Leadership course.

One advantage is that is very quickly allows all members of the class a shared expecience to discuss – in the MPH class that led to people discussing the challenges Mr Martin faces as if he was their uncle!

       
NS     And lastly, this is a more personal question – and one that I am particularly interested in as an advocate of the power I believe they have in being able to transform the way we think and feel about critical health and social justice issues. What documentaries or documentary film makers have served as an inspiration for you or have influenced or shaped your craft as a docmaker?
LB     Oh wow, there are so many! Hard to choose – but my top 3 would be Khalid Shamis who is currently finalising The Colonel’s Stray Dogs, Nadine Cloete who made Action Kommandant and Kurt Orderson who made Not in My Neighbourhood

 

HSR2018 in Liverpool

  • Red Zone Paramedics will be shown as part of the 5th Global Symposium on Health Systems Research, and can be viewed during this session: Sustaining community health systems: Wednesday Oct 10th (10 – 12:30) in the ACC Room 11B.
  • On Wednesday 10th October (4 – 5.30pm) in the ACC Main Auditorium, Leanne will also be chairing an organized session entitled Using media to facilitate bottom-up accountability, health system responsiveness, and participatory decision-making processes: the role of citizen journalists, social activists and the media. Follow #media4healthsystems on twitter to join the conversation!
  • You can find out more details about this and other CHESAI-facilitated sessions here. In addition, the Teaching & Learning thematic working group is having a satellite session entitled Strengthening Capacity for Teaching and Learning in Health Policy and Systems: Practical Issues for Educators and Learners on Monday 8th October (8am — 12pm) in the Exhibition Centre room 24. Many exciting topics will be discussed, including the use of audio-visuals in teaching.
  • You might also want to follow the CHESAI twitter feed to keep up to date with some of the proceedings of HSR2018.

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