Hope in Hell: Inside the World of Doctors Without Borders

Dedication

For the people of Port-au-Prince,

who gave me a glimpse of their lives

before they were so suddenly taken away.

Introduction — Fixing Up the Humans

Chapter 1— Stand and Deliver

Chapter 2 — Biafra and the Bumblebee

Chapter 3 — We Don’t Need Another Hero

Chapter 4 — Doc in a Hard Place

Chapter 5 — In the Yellow Desert

Chapter 6 — Ugly Realities

Chapter 7 — How the Other Half Dies

Chapter 8 — Best Performance in a Supporting Role

Chapter 9 — New Fridge Syndrome

Chapter 10 — You Can’t Stop a Genocide with Doctors

Ours Is Not a Contented Action

Author’s Note

Notes on Sources

Glossary

Photo Section

Credits

Like all great cultures, Médecins Sans Frontières has its own creation myth. The story is based in historical fact, but it’s related and remembered differently by the people who were there. In the standard version, a group of young French doctors goes to work in a Red Cross hospital in the breakaway Nigerian state of Biafra in 1968. They are appalled by what they see — hundreds of thousands of children dying from malnutrition — and believe they are witnessing a genocide. Although the Red Cross demands the utmost discretion from its volunteers, the French doctors, led by the charismatic Bernard Kouchner, cannot remain silent. They angrily tear the Red Cross armbands from their sleeves and denounce the Nigerian government. On returning to France, they organize a committee to raise awareness of the genocide and, later, a group of doctors devoted to emergency medical aid. Around the same time, a Paris medical journal publishes a call for volunteer doctors to help the victims of earthquakes and floods. The two groups eventually come together in 1971 to form Médecins Sans Frontières. Twenty-nine years later, the organization accepts the Nobel Peace Prize for being emergency aid rebels who blazed new trails in international humanitarian work. In his 2002 book, A Bed for the Night, journalist David Rieff, who has covered wars and emergencies around the globe, calls this group the most important humanitarian NGO in the world.

Médecins Sans Frontières — also known in North America as Doctors Without Borders, and universally as MSF — is the world’s largest independent medical humanitarian organization. In 2008, it ran projects in 65 countries, requiring more than 26,000 staff in the field. While it is best known for its high-profile projects in conflict zones, refugee camps, and countries hit by famine, MSF also runs smaller programs outside the media spotlight: supporting rural health clinics, providing antiretroviral treatment for people with AIDS, and bringing fresh water and sanitation to remote villages.

To understand the work of MSF, it’s important to clarify some of the terminology used in the aid community. To begin with, aid groups make a distinction between development and relief. There’s an old adage that says, Give a man a fish and you feed him for a day; teach a man to fish and he can feed himself for life. Development agencies concentrate on the latter goal: their projects are usually long-term, focusing on building local capacity, always with a view to sustainability. Many development programs are foreign aid projects funded by Western governments. Non-governmental organizations (NGOs) that do development work may have a religious bent (World Vision and Tearfund, for example) though many others (Oxfam, Save the Children) do not.

Relief organizations, by contrast, are primarily concerned with aiding populations in acute crises, such as war or famine, epidemics or natural disasters. MSF has always been in this category, with a focus on the medical needs of the people it serves. Members may work in an area for several years, but addressing the underlying causes of the emergencies is not part of their mandate. MSF operates feeding centers for starving people, but does not supply shovels and seeds to grow crops; it brings health care to poor areas, but does not try to eradicate poverty.

There is also a fundamental difference between humanitarian and human-rights organizations, and it’s a distinction that is often missed. Both types of groups uphold international law (as set out in the Geneva Conventions, the Universal Declaration of Human Rights and other codes), but human-rights organizations tend to be more activist, with lobbying at the heart of their work (Amnesty International is the most familiar example). Humanitarian agencies, on the other hand, must remain neutral in order to get access to victims on all sides. MSF is foremost a humanitarian organization — neutrality is enshrined in its charter — but from its earliest days it has wrestled with the knowledge that, in cases of extreme brutality and oppression, neutrality may be tantamount to complicity. While not a human-rights group per se, MSF often has a toe in the same waters.

When MSF emerged in France in 1971, nothing like it had existed before. There were other aid agencies, of course — Save the Children was already more than 50 years old, Oxfam almost 30 — but the International Committee of the Red Cross (ICRC) was the only group bringing significant medical relief to the victims of war and natural disaster around the world. But as conflicts in the late 1970s displaced millions of people, the new private organization soon found a niche in the refugee camps of Southeast Asia, Africa, and Central and South America.

From the beginning, MSF’s reputation exceeded its actual impact in the countries where it worked. Its early emergency projects were small, often poorly coordinated, and modest in their success. Yet with the flamboyant and media-savvy Kouchner at the helm, MSF gained a reputation for going into the most dangerous areas just as other aid agencies were fleeing. Newspapers carried pictures of the fearless and heroic doctors riding on donkeys into Soviet-occupied Afghanistan, trekking the jungles of a newly independent Angola, and tending to Cambodians in the shadow of the Khmer Rouge. Among the French press and the public, Médecins Sans Frontières became known as medical mavericks, the cowboys of emergency aid, a reputation that clings to them — for better or worse — to the present day.

Inside the organization, however, tensions were simmering between the founders and a younger generation of doctors that was growing weary of Kouchner’s media stunts. In late 1978, as thousands of boat people fled Vietnam, Kouchner announced a plan to send a rescue ship (and television crews) to the China Sea, an operation most of the younger MSFers felt was naive and futile. Bitter arguments ensued, and within a few months Kouchner and his allies were gone, forced out of the organization they had created.

During the 1980s, MSF added offices in Belgium, Switzerland, Holland, Spain and Luxembourg, each with considerable autonomy. Its reputation continued to grow, and so did its outspokenness: MSF criticized Pol Pot’s regime in Cambodia in 1980, then was expelled from Ethiopia after it took Colonel Mengistu to task in 1985. Now well funded by UN agencies, European governments and private donors, MSF became admired for its logistics and its frugal use of resources. As its teams moved quickly and efficiently by plane, Land Cruiser, canoe and on foot to deliver medical aid to the most perilous and remote places on earth, MSF acquired a paradoxical image. On one hand, it was an informal movement with a culture of debate that prevented it from knee-jerk actions, while on the other it was hailed for its decisiveness. It was an organization of swashbucklers with technical expertise who spoke with equal parts brazenness and sophistication.

The 1980s has been called the golden age of humanitarianism. Western governments had not yet co-opted humanitarian aid as a tool to win the hearts and minds of people in occupied countries. The Ethiopian famine that began in 1983 sparked Live Aid and countless other fundraisers, and money poured into the coffers of aid agencies. Being an aid worker now carried cachet, and by the end of the decade, when French citizens were surveyed about their ideal job, a third of them said they wanted to be a médecin sans frontières. Without Borders suggested a gatecrashing fearlessness that appealed to those who were tired of the timidity of the United Nations, and perhaps even the neutrality of the Red Cross.

During the 1990s, MSF became a global organization, adding sections in the United States, Canada, Japan, Hong Kong and Australia. But as it did so, the golden age of humanitarianism gave way to an unprecedented period of soul-searching in the aid community. People shed their innocence about the impact of aid, realizing that it can create a culture of dependency and even exacerbate conflicts. The crises of those years dramatically revealed the moral ambiguity of relief and intervention: in Bosnia, where UN peacekeepers failed to stop the massacre of 7,000 people in Srebrenica; in Rwanda, where aid poured in to help Hutus who had just perpetrated the worst genocide since the Second World War; and in Kosovo, where the perverse term humanitarian bombing was born in 1999. That same year, Médecins Sans Frontières received the Nobel Peace Prize, largely for its leadership during this difficult period in the aid community.

The first decade of the new millennium brought new challenges, from the post–September 11 war on terror, to the horrors of Darfur and neighboring Chad, to the famine in Niger. MSF has continued to evolve as an organization: adding new partner sections in predominantly Muslim countries; expanding its offices in South America, Africa and Asia; and giving more and more responsibility to its local staff.

Through it all, MSF’s doctors, nurses and other workers continue to grip the imagination of the public. People are captivated by the drama of surgery in war zones, the idea of prosperous professionals who leave behind comfortable lives for deprivation in the field. That’s part of the MSF story, but the big picture is far more complex — and thankfully so. A nuanced portrait is far more compelling than a caricature.

Dr. Wendy Lai was accustomed to watching women deliver babies in unusual places. Since arriving in Port-au-Prince in September 2008, the 33-year-old family doctor had seen mothers give birth in the stairwells, the bathrooms, and on the ground outside Jude Anne, the maternity hospital operated by the Dutch section of Médecins Sans Frontières. But even Lai was surprised when a guard fetched her one Friday in late October to say a woman had delivered dans le carrefour — in the intersection.

Before Wendy Lai arrived in Haiti, she worked in a Toronto hospital doing low-risk obstetrics. That meant uncomplicated vaginal deliveries in a well-equipped facility, with a gynecologist always available as backup and lots of experienced labor nurses to assist. Her job in Haiti was a world away. The mother who gave birth in the intersection was among the lucky ones; at least she was within a short walk of free, high-quality medical care, a rarity in this Caribbean nation of nine million. By any measure, health care in Haiti is a disaster, particularly for women and children. The country has the highest infant mortality and maternal mortality rates in the Western hemisphere. For every 1,000 babies born here, about 60 won’t see their first birthday (compared with five or six in the United States, Canada and the UK), and about five mothers will die, a rate at least 50 times that of developed countries. While a wealthy minority can afford good quality care in Port-au-Prince’s many private clinics and hospitals, as many as 70 percent of the population has no access to health care at all. Not surprisingly, the life expectancy of a baby born in Haiti today is less than 61 years, ranking it number 181 among the world’s 224 countries. Those are numbers that MSF is hoping to change.

Maternal care in Haiti is supposed to be free. In March 2008, the country’s health ministry launched a program called Soins Obstétriques Gratuits, designed to provide every expectant mother with four prenatal consultations, delivery in a public hospital — including a caesarean section if necessary — one postnatal visit, and any necessary medications. Under this program, public hospitals are expected to give care for free and then submit a claim to the World Health Organization for reimbursement. A year after it debuted, MSF found that many women were indeed able to deliver for free, but they were still being asked to pay for drugs, and in a country as poor as Haiti, even a $5 regimen is hopelessly unaffordable.

It’s little surprise, then, that expectant mothers flooded Jude Anne as soon as it opened in March 2006. By the time Lai arrived two-and-a-half years later, the 65-bed hospital was averaging more than 50 deliveries a day, with the busiest days approaching 80. The overcrowding was particularly acute in October 2008; during that exhausting month, three of the five government-run hospitals were on strike, including Isaie Jeanty, the public maternity hospital. One day when I was on my way to work the driver had the radio on, Lai says, and I heard the Minister of Health telling the public not to go to the general hospital because there was essentially nobody working there. I remember the moment I found out the maternity hospital was on strike, too. One of our gynecologists came to find me because he was working in triage that day and he said, ‘Isaie Jeanty is closed and I don’t know what I’m going to do. I’ve got patients I want to transfer, but there’s nowhere to send them.’ He said he felt like he was going to have a heart attack. It was horrible.

The other reason for the dramatic increase in deliveries during October is rather less mundane than work stoppages. Like many Caribbean countries, Haiti celebrates Carnival in February or March, a three-day extravaganza of music, parades, costumes, dancing, and uninhibited sex. Nine months later, a wave of Carnival babies arrives. When Lai first heard the story of Haiti’s reproductive peak, she thought it was an urban legend. But when she tested it on a pregnancy wheel — a tool that can be used to determine a baby’s due date based on a woman’s last menstrual cycle — she discovered that the math works out. For someone who’s ovulating during Mardi Gras, their last menstrual period would be around the first week of February. I fiddled with the pregnancy wheel and looked at the expected due date for a full-term pregnancy, and lo and behold, it fell bang on in October. February and March are pretty quiet at the hospital, and in April and May we start seeing spontaneous miscarriages and people who’ve tried to induce an abortion. Women will also start to come in with the complications of early pregnancy, such as ectopic pregnancy. Around the summertime we start seeing the premature babies, and then in October, everyone is delivering all over the place.

Wendy Lai’s Haiti mission was her second with Médecins Sans Frontières. Born in Newfoundland, she earned an undergraduate degree at McGill University in Montreal and attended medical school at the University of Western Ontario, graduating as a family doctor in 2003. Though she studied sciences at McGill, she didn’t originally intend to become a doctor. Most people decide on medicine pretty early. A lot of doctors will say they have always wanted to be a doctor since they were a little kid, but that certainly wasn’t the case for me. When Lai was in high school, she was active in social justice and human rights. As the editor of her school newspaper she also learned the power of advocating for people by bringing their stories to a wide audience. Even though my undergraduate degree is in biochemistry, I was thinking I would become a human-rights lawyer. As my undergrad wore on, though, it occurred to me that I could use medicine to get at the same kinds of issues. Being a doctor doesn’t mean you have to be in some suburban practice, treating hypertension and whatnot. I realized it could be an interesting way to provide something real and concrete to people, and to get to know their stories really well.

Lai knew that a mix of medical expertise, a passion for social justice and a willingness to shout from the rooftops is at the heart of MSF’s work. Curious about the organization, she decided to ask for advice from someone who knew MSF as well as anyone. James Orbinski, the former president of its International Council and the man who accepted the Nobel Peace Prize in 1999, worked in the same Toronto hospital where Lai was doing her residency. Orbinski, also a family doctor, had joined the group in 1992 and been at ground zero for some of the world’s worst humanitarian crises: the famine and civil war in Somalia, the Rwandan genocide and the refugee crisis it spawned in neighboring Zaire, and the 9/11 attacks in New York. When I was seriously thinking about this, Lai says, I wandered down and asked, ‘So James, what’s it like?’ He is a very philosophical person, so the answer he gave me was a good one. I’m not sure it was the answer I was looking for, but it was accurate. He said, ‘It’s like nothing you’ve ever done before. You will find yourself doing things you didn’t know you could.’

MSF usually requires doctors to have two years’ experience after their residency, but the recruiters were impressed enough with Lai that they accepted her with only one. In August 2006, she shipped off to Shabunda, a region of South Kivu in the Democratic Republic of the Congo. About 15,000 to 20,000 people live in this remote, densely forested area that can be reached only by landing a small plane on a tiny airstrip. As Orbinski had warned, it was like nothing else Lai had experienced. Some MSF efforts are highly specialized, targeting malnutrition, treating a cholera outbreak, or providing trauma surgery in a war zone. Shabunda, on the other hand, had everything. There was a general hospital in town where we did obstetrics, surgery, internal medicine. We had a pediatric ward, we did tuberculosis, malnutrition, HIV. When I was there we had a measles epidemic, so we were doing a vaccination campaign, too. We were also supporting half a dozen primary health clinics out in the bush, several hours’ travel, so we would send a mobile team into the jungle on motorbikes.

As in most MSF projects, the organization’s role in Shabunda was not to run the whole show but to support the work of local health authorities. One of the public’s biggest misunderstandings about medical humanitarian aid is the belief that it’s done largely by doctors and nurses from developed countries. In fact, while these foreigners — or expats — attract the most interest in the West, the work in the field is done mostly by locally hired medical and nonmedical personnel, called national staff. (In 2008, MSF had almost 22,000 full-time national staff positions in its projects, compared with about 2,000 positions filled by expats.) In some cases, expat doctors and nurses do little hands-on work, concentrating on supervision, training and administration.

Indeed, a project’s success often comes down to the caliber of its national staff. Even in countries where medical training is suspect, local health workers can be the organization’s greatest asset. National staff understand not just the local political context, but the medical context, too, says Lai. I certainly learned a lot from the national staff in Congo. Malaria is rampant in that part of the world, and what do I know about malaria? Not a lot. I had the basic theory, but when it comes to the variety of ways in which malaria can present itself, I had no experience with that. Tuberculosis, typhoid fever, measles — same thing. National staff are much better at diagnosing and treating those things than I am.

At the same time, many MSFers admit that differences in culture, skill level and attitude can drive a wedge between expats and national staff, sometimes compromising the entire project. In Africa, and in Haiti, a long colonial history has made people suspicious of foreigners who act like they know best and want to change local practices. Certainly there was that tension in Congo, where I often felt like I couldn’t push too hard or say too much, because they didn’t want to hear it, and they didn’t put much value in the perspective that I had to bring, Lai says.

In her Shabunda project, most of the hospital staff were employees of the Congolese health ministry whose salaries were being topped up by MSF. There was a power imbalance, because we were bringing in the drugs, we were trying to insist on protocols, and there was this question of neo-colonialism. I understand that, but it made the work very difficult. One of the struggles I had was trying to get the nurses to take a full set of vital signs two or three times a day. They would take a temperature and wouldn’t do anything else — no pulse, no blood pressure, no respiratory rate. I know blood pressure is harder because you’ve got to find a cuff, but pulse? I failed at it. I was there nine months and I still wasn’t getting a full set of vital signs. When I left I didn’t feel I had accomplished much. I was exhausted and stressed, and I felt like I had done the most difficult thing I had ever done in my life, but I don’t know what has really changed there.

The dynamic was much different during her work in Port-au-Prince. Lai found the Haitian medical staff were well educated, and they fully embraced Western medicine. If I say ‘evidence-based practice’ to the doctors in Haiti, they get what I’m talking about. We can talk about research. It’s a little difficult, but we’re speaking the same language.

As 2008 wore on it became obvious to everyone that Jude Anne was simply too chaotic to function as a maternity hospital. It wasn’t just that it was too crowded. One of the most common complications of pregnancy in Haiti is preeclampsia, which made up about a quarter of the caseload at Jude Anne. The treatment for preeclampsia, a condition that is potentially life-threatening for both mother and baby, includes rest in a calm and quiet environment. The hospital, situated on a busy street amid the incessant honking of car horns and powered by rumbling generators, hardly fit that description. When it became clear that MSF was going to need a new hospital, they looked to Lesli Bell.

Less than a quarter of MSF’s field workers are physicians, and almost half are nonmedical staff, including project coordinators, financial coordinators and administrators. Then there are the logisticians — rhymes with magicians, Wendy Lai points out — who are routinely asked to do the impossible. On a given day they may be expected to fix a generator, install a satellite phone, track down hard-to-find medications or, in the case of Lesli Bell, take an empty warehouse and turn it into a fully functioning hospital.

Bell, the logistics coordinator for the Haiti project, knows something about building hospitals, though her career path was different from most MSF logisticians. She was born and raised in Bermuda, spent time in the US and Canada, and later moved to Australia, where she currently lives. (Bell is also unusual among MSF veterans in that she has two teenaged children, with whom she keeps in touch through email and Skype while on mission.) She earned a degree in fine arts, spent 10 years as a professional photographer and is an accomplished wildlife painter who has done contracts for Earthwatch and Greenpeace. When I was doing a painting job for Greenpeace in Australia, I started doing logistics and realized I was good at it, says Bell, who has also worked for Oxfam. Her first MSF mission in the Democratic Republic of the Congo included overseeing the construction of a new health center. She also built a cholera treatment center in Congo-Brazzaville, and just before arriving in Haiti she helped start a domestic and sexual violence project in Papua New Guinea. But opening a new project is one thing; moving an existing hospital that’s chock full of very sick patients is rather more difficult.

I was told that the project was an emergency obstetrics hospital, that it was very crowded, and that I need to find a place for twenty more beds, Bell recalls during a smoke break at one of the MSF houses in Port-au-Prince. "So from the airport on my way here, I stopped at the hospital just to have a look. First of all, I couldn’t get through the gate because there were hundreds of people, patients, families, standing outside. Then I came into the waiting room, which was actually an outdoor area with a tin roof, and it was complete chaos — women in labor screaming, yelling. A baby was born in a woman’s hands right in front of me. She was sitting on