Quotes from Hope in Hell, by Dan Bortolotti


- ‘Medecins Sans Frontieres – also known in North America as Doctors without Borders, and universally as MSF – is the world’s largest independent medical humanitarian organization. Every year it sends more than 3,000 volunteers to some 80 different countries. Its most noticed projects are in conflict zones, refugee camps and countries hit by famine, though MSF also runs smaller programs outside the media spotlight – supporting rural health clinics, providing antiretroviral treatment for people with AIDS, bringing fresh water and sanitation to remote villages.’ (12)
- ‘[MSF] almost invariably works closely with health ministries and trains local staff, and may work in an area for several years, though it does not attempt to address the underlying causes of the emergencies. MSF operates feeding centers, but does not supply shovels and seeds to grow crops; it brings health care to poor areas, but does not try to eradicate poverty.’ (12-13)
- ‘The group runs several hundred projects a year, and most are not on the front lines of conflict. The medical teams may simply train locals rather than treat patients, and most of the volunteers are not sacrificing lucrative medical careers – three-quarters are not even doctors. That’s not to say that the truth is more mundane, only that it’s more complex, and thankfully so. A nuanced portrait is always more interesting than a caricature.’ (16)
- ‘Though he examines some patients himself, James Knox spends the bulk of his time supervising the work of the local nurses and giving informal presentations in the jangu – a gazebo-style shelter outside the hospital.’ (24)
- ‘Not all of MSF’s work is in active emergencies – in addition to war zones and refugee camps, it also works in peaceful but remote corners of the world, where people have no other access to health care. Often teams will come and go for years, but that’s not by design. Once the epidemic has passed, or the government has been prodded into caring for its people, or the work has been handed over to another aid agency, it’s time for MSF to pull out. ‘But,’ says Knox, ‘to an extent you do want to leave something behind.’ ’ (25)
- ‘One of the biggest misconceptions about MSF is that the organization is primarily doctors. In fact, only about a quarter of the volunteers in the field (to say nothing of those who staff its international offices) are physicians, and more than 40 percent are nonmedical staff, including project coordinators, financial coordinators, logisticians and administrators. Although expats are the ones who attract the interest – and the donations – from the Western public, the work in the field is done mostly by locally hired medical and nonmedical staff like Andre and Pedro. In 2002, MSF had almost 15,000 national staff in its project, compared with fewer than 3,000 expats.’ (27)
- ‘ ‘Over the years,’ Daglish could still write in 1998, ‘employees of MSF have become inured to the sight of UN employees and their families standing in long lines in airports around the world with their suitcases at their sides, at the very moment MSF personnel are arriving to begin their emergency work.’ ’ (61)
- ‘In 1989, a group of pollsters asked the French public to name their dream job, and the most popular answer – 32 percent – was to work for MSF. The organization still had a low profile in English-speaking countries, however, and that would remain so until the new decade.’ (61)
- ‘MSFers in the field are still overwhelmingly European, however. Of the 3,000 or so who go abroad in a typical year, roughly 800 are citizens of FranceBelgium (a country of only 10 million) sends about 400; Holland and Spain, 200 each; and the United Kingdom about 150. Australia contributes about 110, while Canada had almost 140 in the field at the end of 2003. The United States, despite a population that’s double that of MSF’s five operational countries combined, and ten times that of Canada, sent 135 expats on mission in 2003. (One reason for these disproportionate numbers is that francophone Canadians – almost half the volunteers are from the province of Quebec – slip easily into MSF’s culture. Another is that American volunteers may be more difficult to place in parts of the world where the US military is active.)’ (64)
- ‘The sections have also evolved their own specialties – Holland tends to focus on conflict zones, for example, while Belgium has the most experience with AIDS programs.’ (65)
- ‘Other aid agencies – particularly those that rely on child sponsorship programs, such as Save the Children, World Vision and Plan International – may give the impression that they rely heavily on donations from the public, but in reality they are far more dependent on government agencies. MSF was, too, until it made a movement-wide goal to get away from it. The organization feels that dependence on UN and government donors is a trap – it forces aid agencies to become institutionalized, too bureaucratic and too unwilling to bite the hands that feed them. Other agencies, not surprisingly, are not impressed with the implications of that argument.’ (66)
- ‘It was a strategic choice by [CARE] as an organization to be very big [with government funding, and it was a strategic choice by [MSF] to stay small but be independent [of government].’ Kenny Gluck (67)
- ‘To the extent that the military are there, or UNHCR is there, or ECHO is there doing a great job, we’ll work alongside them. But we will not subsume ourselves to their project.’ Austen Davis (67)
- ‘The drive to do that first mission is rarely the same as the one that prompts a fifth or sixth visit to the field.’ (70)
- ‘MSF’s keenest challenge is finding enough doctors. The organization requires one or two years (depending on the section) of clinical experience, so freshly minted MDs aren’t eligible, let alone the medical students who often inquire and are surprised to find that MSF doesn’t take all comers. For many young doctors carrying enormous debts from their student loans – especially in the United States, less so in Europe – humanitarian aid work can seem like a luxury they can’t afford. For more experienced doctors with thriving practices, the inability to find locums during their absence can be just as prohibitive. First missions usually last six to nine months, since the learning curve is steepest for newcomers. Those who make subsequent trips to the field may stay for shorter periods. The average age of MSF expats is 37 years, but that’s misleading. If you visit a field project, you’ll find that most non-medical people, in particular, are considerably younger, so the overall mean is probably distorted by older doctors doing short missions. Humanitarian aid work mainly attracts single, childless people, so, by their late 30s, those inclined to start a family have usually found less adventurous employers or, if they stay with MSF, exchanged field missions for office jobs.’ (71)
- ‘ ‘With so many experts available to their patients, general practitioners are far more likely to give a referral than to try an unfamiliar procedure, which is good for the patient but less rewarding for a doctor. For their part, specialists may be looking to add some variety to their own experience. ‘There’s huge appeal to the scope of medicine you get to practice,’ Schechtman says. ‘I had to do things I really wasn’t trained to do, but there was nobody better to do them. It was sort of a MacGyver situation, where I had to just do my best with the training and tools I had. It challenged me as a doctor to push myself to the limits, and I learned a lot because of that.’ ’ (72)
- ‘While surgeons are an exception, many first-time doctors and nurses are surprised to find that an MSF project may involve little direct treatment of patients. ‘The thing we’re looking for among medical people in an understanding that you’re not going to get involved with too much individual patients care,’ says an MSF recruiter. ‘You’ve got to get that out of your mind, because it’s not going to be as hands-on as you think. You’re a lot more effective using ten local health-care workers than trying to do it all yourself. That’s a bit tough for people, because you’re suddenly entering management, computers, statistics, reports, and that’s not always what doctors want.’ ’ (73)
- ‘ ‘I remember the day we received the Nobel Prize I was really worrying about the effects it would have,’ says Jean-Herve Bradol, president of MSF-France. ‘I thought there would be a danger of taking ourselves too seriously, of trying to play in the courtyard of the really big players on international issues.’ Bradol was worred that MSF would be thrust onto the state and asked to speak out on issues that aren’t directly related to humanitarian medical assistance.’ (75)
- ‘Even before the Nobel Prize, MSF tried to ensure that at least 30 percent of its expats were first-timers, to guard against attracting too many complacent career volunteers. Gluck admits that ‘everyone else in the humanitarian movement makes fun of us’ for this policy, which can lead to inexperienced people being overwhelmed by too much responsibility. But even second-time volunteers admit that nothing compares to the urgency of a first mission, that baptism of fire in a hospital on the edge of a war zone. ‘There’s a shock of transition between the shiny clean urban hospital and one where there’s trauma you’ve never seen, where health care has abominably low standards. That shock is a driving force in the organization. It also allows a person to tell an old fart like me, ‘I don’t give a damn that you’ve seen twenty places that are worse than this. This offends me, and I want to do something about it.’ That’s what we try to institutionalize as a check against our own cynicism, against the thick skin we develop.’ ’ (75-76)
- ‘All volunteers are invited to join the association – there’s one in each country with an MSF section – which allows them to vote for board members or run for a position on that board.’ (76)
- ‘With experience, humanitarian aid workers grow to understand and accept the limits of their work, well aware of how small their projects seem in the big scheme of things – a few tiny clinics in a war-ravaged country, a single feeding center in the midst of a famine, a drug distribution program in a tuberculosis pandemic.’ (79)
- ‘Before sending volunteers on a first mission, MSF puts its rookies through a training program to introduce them to the organization’s philosophy and teach them practical skills, such as how to use a VHF radio or change a tire on a Land Cruiser.’ (85)
- ‘In an organization like MSF, you have a lot of people who are used to being leaders. You throw a bunch of leaders into a group and it’s usually chaos.’ (86)
- ‘When I got home, people would ask me how it was, and I would just say it was incredibly intense. I never had to experience a month like that in my life. It just went on endlessly, day and night. General surgery training is famous for 120-hour weeks, every other night on call, but this was every day on call without relief, no backup, no blood, just the basics – and on top of that, the language barrier. Other things begin to wear on you as well – the food, the lack of sleep, the noise when you’re trying to sleep. You end up being pretty ragged, and you’re not as good as you could be. That’s why I’ve always limited my missions to three or four months, because after that I need to get back to my own reality for a while.’ Bruce Frank (99)
- ‘When security gets dodgy, MSF headquarters in Europe, or the head of mission in the field, can order an expat team to evacuate, but the volunteers themselves are given leeway to determine how much personal risk they’re willing to take.’ (103)
- ‘I’ve done recruitment, so I’ve tried to alleviate people’s fears about being chucked into the deep end without any resources. We don’t ask a nurse to be a doctor, or a doctor to be a surgeon, but you do expand your range of what you can do.’ Christine Nadori (105)
- ‘In post-Taliban culture, male doctors cannot give females a full examination – they listen to the heart and lungs through clothing, something even through a burqa, the heavy garment that covers the bodies and faces of many Pashtun women. What this means is that doctors have to make guesses, so they tend to overprescribe antibiotics. In other cases, they may underestimate conditions like abdominal pain or gynecological problems because they don’t have enough information.’ (115)
- ‘Measles vaccination is priority number one when setting up shop in a refugee camps, and MSF tries to make sure that all children between the ages of 6 months and 15 years are immunized. These campaigns may also include a vitamin A distribution, since a deficiency of this nutrient can increase the measles mortality rate.’ (119)
- ‘Left untreated, cholera can be fatal in up to 50 percent of cases, but a simple course of rehydration, either orally or intravenously, can bring a quick turnabout.’ (119)
- ‘Many patients show up with headaches, body pains and other complaints that have a psychosomatic cause, not unusual in a population that has endured years of stress and hardship.’ (120)
- ‘Before the Taliban was ousted from this area, kite-flying was outlawed, along with such other vices as music, public laughter and white shoes.’ (123)
- ‘ ‘You’ll pick your drop zone in the driest area you can find, and then you have a lot of national staff keep the area clear, because as soon as people know a food drop is going to happen they congregate in the area. When the Hercules comes over, it slows down, the back comes open, and the pallets just roll out of the plane and free-fall onto an area about the size of a football field.’ Cederstrand says only 6 or 7 percent of the bags break, and almost nothing is wasted. ‘When security lets the people come in, you have thousands converging on the drop zone with their little gourds and their little bowls, scooping up dirt or mud just to get ten pieces of maize.’ ’ (132)
- ‘There are few sights more heart-rending than a starving child, but those who are admitted to a TFC [therapeutic feeding center] in time can recover within 30 days. In the critical first phase, the child receives six or more feedings a day of therapeutic milk that includes oils, vitamins and sugar and is designed to kick-start the metabolism.’ (133)
- ‘The first step in most of these projects is an exploratory mission, or explo, which involves sending a small team into an area to assess the medical needs and judge whether an intervention is necessary. These short-term projects measure mortality rates, morbidity rates (the local prevalence of disease) and the level of malnutrition in a population. The medical team may set up sentinel surveys, which monitor the rate of measles, malaria, diarrhea or cholera at selected sites and quickly identify an outbreak when it occurs. An explo will also look at the medical infrastructure to see if the local health ministry has things under control. It will determine whether other NGOs are planning to work in the area. And if MSF decides to intervene, it will find out who is in charge and get permission to work there.’ (134)
- ‘In acute emergencies, medical aid can save hundreds of lives in days or weeks. In rural health projects, however, success is far less dramatic. And while outbreaks of disease can be brought under control, doctors doing primary health care in places like Ogaden have nagging doubts about the long-term prospects of their patients. From the beginning, Ouimet wondered just how much good MSF was doing in the area. ‘Our project didn’t make much sense, and I thought it wasn’t worth taking such high risks for something that had absolutely no impact.’ ’ (148)
- ‘ ‘In an ill-equipped health clinic with no lab, where the only diagnostic tools are your eyes and hands, it’s easy to feel you’ve been cast adrift. ‘The first thing you realize is that the people who are going to save you are your staff,’ says nurse Leanne Olson. ‘There are nursing schools everywhere in Africa. All of the nurses I worked with were trained, they had their degrees, they had studied, but we underestimate their diagnostic capacities and their ability to treat people, and we do that at great risk. They’re perfectly capable of taking care of their own people – much better than I can, because they know the diseases, they know the parasites, they know what schistosomiasis looks like inside and out. They can tell me whether this is a surgical emergency or not. I learned so much stuff by working with and understanding my medical staff.’ ’ (149-150)
- ‘Then you try to put that plan into action, and it’s impossible. Every day we would go out and try to fix things, try to make the health centers better. At the beginning, people would tug on my sleeve and I would say, ‘Leave me alone, go see the other nurse, I’ve got to organize your immunization plan.’ Then one of our managers said to me, ‘You know, you have to deal with the patient who’s in front of you. You can’t fix everybody, you can’t fix the injustices and the disease, but you can help that old lady who’s pointing to her son who’s going blind because of Vitamin A deficiency.’ That really helped me get through the last few months of the mission.’ Carol McCormack (152)
- ‘Following an earthquake, up to 60 percent of adults and 95 percent of children may suffer from post-traumatic stress disorder, so MSF sends psychologists to counsel victims and, more often, train local counselors to deal with the aftermath.’ (155-156)
- ‘Tropical illnesses are killing people because ‘life-saving essential medicines are either too expensive, or not available because they are not seen as financially viable, or because there is virtually no new research and development’ into new treatments. ‘This market failure,’ [James Orbinski] declared, ‘is our next global challenge.’ And so it was. Along with the Nobel gold medal and diploma, MSF picked up a check for 7.9 million Swedish crowns, equivalent to just over a million US dollars. It wasn’t the largest donation MSF has ever received, but it packed more symbolic punch than any other. MSF decided to use the money to kick-start the Campaign for Access to Essential Medicines.’ (161)
- ‘Sleeping sickness, or human African trypanosomiasis, is carried by the tsetse fly in sub-Saharan Africa and is also treated with a decades-old drug that faces growing resistance – it’s so toxic that it burns when injected, and it fatally poisons up to a tenth of those who receive it.’ (161-162)
- ‘This is something that’s very difficult to do with child soldiers in Sierra Leone. These kids are ten years told, drugged or drunk, trigger happy all the time. How do you control a thing like that? How do you reason with a kid like that at a checkpoint? You do it very politely. You treat him like a four-star US general. If I had a cold chain of measles vaccines worth two hundred grand in my two trucks, I had to be polite. There are moments where you really can communicate with these kids. They’re very special moments, where for a few seconds they kind of go back to their nice childhood and forget about their guns and say, ‘You’re a nice guy, you treated me well.’ ’ Martin Girard (196-197)
- ‘ ‘Corruption is not just an evil little footnote,’ says Lorber. ‘In lots of places in the world, corruption is the economy.’ ’ (205)
- ‘Techniques for coping with stress are covered in the prep course taken by first-time volunteers, and senior field staff get further training in stress management, including recognizing the signs in others. In addition to teams of professionals that respond to serious incidents in the field, some sections also have less formal ‘peer support networks’ made up of experienced volunteers who are matched with first-timers. They’ll talk on the phone before the mission and again afterward, as often as needed.’ (228)
- ‘You need time to reflect on what was good, as well as what was bad. Because if you don’t get rid of the bad before you go on your next mission, you take it all with you.’ Leanne Olson (230)
- ‘ ‘You do see people who stay too long,’ Cederstrand agrees. ‘They think, ‘I’m past that point, I can’t settle down now, I can’t have children, so I’ll just keep doing this.’ And you can see people are burned out, tired, who should not necessarily stop doing the work, but should stop doing it is the field. Some people realize it too late. People have mental breakdowns, and agencies don’t like to talk about it.’ ’ (231)
- ‘One might think that home, around people you care about, is exactly where you would want to recover from field-induced stress. On the contrary, most volunteers say it’s much easier to leave for a mission than it is to come home.’ (232)
- ‘I’d get home and I really couldn’t relate. I was not nice to be around for weeks and months after some missions. I’d get on my motorcycle and take a sleeping bag and a few books and I’d go away for six weeks and learn a little bit of civility in the process. I got back after Somalia and I was just a mean bastard – I hated everything around me.’ Peter Lorber (232-233)
- ‘It’s those reactions from family and friends that are often the hardest for MSFers to deal with. Everyone at the party wants to hear their stories and see their photos – for a few minutes. Soon the listener’s eyes have glazed over and he’s thinking about the shrimp cocktail that just went by. ‘One of the things you miss when you come back,’ says physician Leslie Shanks, ‘is that you’ve been working with a group, all of who are focused on improving the health of the population, improving the situation. And then you come home and nobody cares. Even though when you’re away you’re missing your family and your friends, it’s very difficult to come back because people don’t understand – some people don’t want to understand, other people can’t understand. There’s also this sense that it’s too much for them to hear. It’s difficult to be in this space where you can’t share your experiences because of the traumatic effect it’s going to have on the listener.’ (233)
- ‘Some returned expats are burning to share their stories and raise awareness in their own countries. But they soon realize that people don’t want to be told how lucky they should feel, how minor their own problems are. When they flush the toilet, they don’t want to be reminded that some refugee in a faraway land doesn’t get that much water in a day. There’s a danger, too, of giving people the impression that you think their whole lives are self-indulgent and frivolous.’ (234)
- ‘Everything seems insignificant. You’re listening to the complaints of your best friends and you’re like, ‘Yeah, so?’ You hear a telephone ring and it upsets you. You do become almost antisocial in that respect, at least by Western standards. But that wears off. Then you learn to live your next mission less emotionally.’ Patrick Lemieux (234)
- ‘The bad days are when I feel that the things people around me see as significant are quite a lot different from what I’ve done with my life. People construct their identities around what they consume. And everyone’s getting married and buying a house and a car, and I’m not. You start to wonder, ‘Am I supposed to be doing that? Am I supposed to be getting mutual funds?’ You just start to panic, like, ‘Oh my God, I’m doing this wrong.’ ’ Chris Day (235)
- ‘When I see a kid with a sprained angle, I don’t say, ‘What the hell are you doing here? If you were in a refugee camp…’ What does that mean? It’s totally irrelevant. You have to get over it.’ Chris Day (236)
- ‘One MSFer remembers an overzealous head of mission he worked with in Columbia, a ‘stupid cowboy’ who talked about going to the media with a list of human rights violations he witnessed. ‘The local staff turned white and said, ‘If you do that they’re going to kill my family tomorrow.’ ’ (243)
- ‘In extreme cases, where MSF publicly denounces a regime, it must withdraw from the country – as it did in Ethiopia in 1985, and more recently in North Korea in 1998. The population it had been serving, however imperfectly, may then be left with no health care, which is why denunciation is a last resort.’ (243)

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