In the line of fire

IF HOLLYWOOD were to make a film about humanitarian aid doctors, there would be guns, lots of them, and plenty of blood too, no doubt. There would be border-crossings at night with a local guide, life-saving operations in a dusty cave lacking in the most basic resources, and a rock-hard floor on which to steal a few hours’ sleep. Meanwhile, helicopters would rain down rockets and bombs onto the surrounding area, the explosions punctuating conversations among the medical staff.

And despite Hollywood’s reputation for hyperbole, this would not be an exaggeration. Indeed, this is exactly what has been happening in the recent conflict in Syria, where surgeons from the humanitarian charity Médecins Sans Frontières (MSF) have been working under the most extreme conditions to treat the horrendous casualties of a modern war

But there are other types of care going on too – perhaps less dramatic, certainly no less important – in this organisation of 25,000 people providing emergency aid to the needy and dispossessed around the world, including eight million outpatient consultations and over 70,000 surgical procedures a year. And whatever the circumstances, be it a conflict situation, a cholera epidemic or a devastating earthquake, the requirements for medical staff are usually the same: medical know-how, of course, but also an ability to keep a cool head when all around are losing theirs and the best-laid plans are going wildly off-course.

Facing danger

Dr Angeline Wee, a GP from Singapore, has done two missions with MSF, one of seven months to post-earthquake Haiti and one of nine months to the conflict-torn Democratic Republic of Congo last year. In both cases, events took a turn for the unexpected.

“Haiti was meant to be a fairly simple, stable first mission,” she says, “but it turned out to be quite complex, because this was just before cholera hit, before the elections in December and we were also preparing for the coming hurricane.”

Her regular duties involved delivering care from a bus-cum-clinic in a camp controlled by gangsters and also working in a clinic set up on a golf course owned by the actor Sean Penn (later, she would move to a primary care clinic attached to the paediatric hospital). But events meant she was suddenly involved in setting up a new cholera treatment centre in Port-au- Prince, as well as a number of 24-hour emergency centres, first ahead of Hurricane Tomas and then again in preparation for the anticipated electoral chaos.

“It was a difficult time – a lot of the surrounding NGOs were pulling out because of the deteriorating security situation, so people started coming to us.”

In the Congo, Angeline was in charge of an outreach project supporting two clinics in the mountains near Kitchanga. Based just 50 km away, her weekly three-day visits would nevertheless involve a six-hour road trip taking medical supplies and a small supervisory team to the clinics.

She had got used to dealing with the associated security issues – “I had never spoken to anyone holding a gun before” – when the conflict suddenly escalated, and the subsequent displacement of people raised the medical stakes further.

“In one of the areas there was a refugee camp of about 20,000 people, so we had to set up a cholera treatment unit. There were cases of measles as well. I had never even been part of a measles vaccination campaign and suddenly here I was in charge of one! It was really intimidating.”

Political resistance

By contrast, the intimidation encountered by Dr Johann McGavin, who is now a trainee GP in Brighton, during his nine-month mission to Zimbabwe was of a different nature altogether. There, he was working mainly to provide HIV and TB care to a group of 25,000 patients who had been displaced through a deliberate government policy called ‘Operation Murambatsvina’.

Meaning ‘Clean out the Trash’, the policy had displaced 250,000 people from Harare to an area with no water, no electricity, a very low employment rate, little food and shelter, and a lot of crime and sexual violence.

The Zimbabwean government was not particularly keen on the presence of NGOs. “It was like walking through treacle,” says Johann, who, unusually for an MSF volunteer, was working with his fiancée. “We had a lot of challenges with the local hospital because we were made to do a three-month introductory period under supervision and that included a lot of paperwork and obstruction. It was challenging in a rather insidious, undermining, quiet way, not like in other countries.”

Upon arrival they had been briefed to be very careful about what they said. “I felt very oppressed being there, not being able to really vent, to my partner at any volume, to my friends, certainly not to any Zimbabweans and not even over the phone to my parents in England, in case that was being listened in on.”

The experience brought him very low and he even considered giving up. “But then you remembered that if you gave up because of frustration with the government, it was the poor people who were going to suffer.”

Johann developed a survival toolkit to help him get through the difficulties with the authorities and those arising from treating a steady and insistent stream of 500 adult and paediatric HIV patients a day between one doctor and 14 other clinicians in a hugely under-resourced facility.

Called HOPE, it stood for humility and humour; open-mindedness; patience and pragmatism; and expectation management. “I think the most important one was expectation management, which was the cure for frustration, disappointment and burnout,” says Johann.

Johann underwent this first mission at the age of 28, after his foundation training, which is the earliest possible with MSF, whereas Angeline, who went to Haiti at 31, was further along in her career, already working as a GP after switching from respiratory medicine.

Careful planning

Despite the differences in their experience, both discovered that a lot of the work required from the 4,000 MSF international volunteers, who are sent in to support 20,000 locally employed nationals, is supervisory.

It is something that Liz Bowen – an MSF human resources manager in charge of field staffing – is keen to emphasise. “It’s important to understand there is a strong supervisory and training element,” she says. “It’s not that you won’t do any hands-on work – sometimes you have to, because there aren’t any other staff there – but you’ll always be managing some staff and they deserve to have somebody who has an idea about managing groups.”

Typically, among refugees, those most at risk are children and young people, closely followed by pregnant women. For this reason, says Liz, young doctors looking to get into this kind of work should get as much exposure as they can to paediatrics, obstetrics and gynaecology. “Pregnant women refugees have a really, really hard time,” says Liz, who has done missions as a nurse in Sri Lanka and Sierra Leone.

A diploma in tropical diseases is a prerequisite, languages – particularly French and Arabic – are a definite advantage, and MSF prefers international staff who can commit to 9–12 months per mission.

Planning is essential, then. As Angeline Wee says: “It cannot be an impulsive decision. All in all, I had been planning this for nine years. You really need to know what you’re getting into and pick up the necessary skills. From what I have seen, people who are more experienced and with management skills tend to do better. It’s not easy for someone coming out of medical school – you really need a steady head.”

And then there’s the question of security. Volunteers may not all be flying into a war zone, but a mature attitude to risk is indispensable, says Liz Bowen.

“We want people who are considered and thoughtful. What experiences have they had of being in an insecure situation and how did they manage it? And what is their thought about where they’re going? Obviously the media portrays a certain angle, but often it’s not that exciting at all. But they are unstable contexts, so they might change. If we get people who say I only want to go and work somewhere stable then we wouldn’t accept them.”

The reverse is also unacceptable – and here the Hollywood version might well diverge from the reality: “You don’t want somebody who’s completely gung-ho, thinking ‘Oh I don’t mind about danger.’ We would reject a person like that immediately.”

Adam Campbell is freelance writer and regular contributor to MDDUS publications