Doctors Without Borders volunteers risk their lives to battle disease and despair in the world’s worst places
The Maclean's Excerpt
BORN IN THE BLOODY Nigerian civil war of the early 1970s, Médecins Sans Frontières (Doctors Without Borders) has become the most famous—and contentious—medical relief group in the world. The recipient of the 1999 Nobel Peace Prize, MSF is denounced by some in the international aid community for its political outspokenness, and praised by others for the same reason. In Hope in Hell, Canadian journalist Dan Bortolotti profiles it and its volunteers and—in a time of growing danger for aid workers—details their stories of life and death in the field. An excerpt:
Outside Kandahar a tattered white flag emblazoned with the red and black Médecins Sans Frontières logo marks the entrance to the basic health unit at Zhare Dasht camp for internally displaced people (IDPS). About 40,000 uprooted Afghans live in the tents and mud-brick huts of Zhare Dasht, which means “yellow desert” in Pashto. On this day in August 2003, the temperature hits 111° F.
(In winter, it can plummet below zero.) Shade offers some relief, but even indoors it’s impossible to escape the dust that squirms its way into the eyes, nose and mouth.
Inside the supplementary feeding centre for children, nurse Kathleen Bochsler is just getting used to the challenges of being a woman in Afghanistan. Bochsler and the other female expats have to keep their heads, legs and arms covered whenever they leave their Kandahar compound. Between her sunglasses and sandals, she’s pulled an MSF vest over a blue and white salwar kameez— the loose-fitting cotton pants and tunic worn by locals—and topped the motley outfit with a burgundy head scarf. “This is a fashion crisis,” she joked before leaving for the camp
that morning. “It’s more than that,” answered colleague Hernán del Valle, the resident wit. “It’s a humanitarian emergency.” Bochsler, a Canadian who looks younger than her 30 years, is just four weeks into her first mission, but she’s no stranger to delivering health care in difficult places. After graduating with her nursing degree, she worked on a native reserve in northern Ontario, then in a small rural hospital near the British Columbia-Alaska border, and most recently on a reserve in Manitoba with an unsavoury reputation. Although MSF looks for volunteers who have worked in developing countries, it appreciates this kind of Canadian experience, too. “It’s isolated and you’re dealing with not having support services and equipment,” Bochsler says. “Patients may have to be flown out, so there’s a long delay in care. You have to learn how to manage stress, solve problems. I think they liked me for Afghanistan because I was from a violent reserve, so I was security conscious.” Adjusting her head scarf, Bochsler heads to an area of the camp where dozens of MSF national staff have spent the day inoculat-
ing 1,200 people for diphtheria. It’s a disease that neither Bochsler nor Dutch doctor Bertien van Gijssel had ever seen before—vaccinations have eradicated it from Western countries. There have been about 50 cases in the camp in the past month, however, and MSF is relying on Afghan doctors and nurses, who have experience diagnosing and treating it. The disease can produce a toxin that’s fatal in about 10 per cent of cases.
A barefoot boy approaches the car, his face covered in scabs. “It looks like impetigo,” Bochsler says, “which is very common back home, especially in First Nations communities.” Here, she explains, the only treatment she’s seen is gentian violet, which is
ineffective in advanced cases. “When you see it to that degree at home you’d always put them on oral antibiotics.” Delivering health care in Afghanistan means not only having the right drugs but convincing a sometimes reluctant population to use them. Afghan doctor Syeed Mahboob Shah says that during the diphtheria vaccinations many patients refused the needle. “There are rumours that the vaccine causes infertility.” In other cases, though, Afghans have proven fond of injections, which most believe are superior to oral medication—especially white pills, considered useless because they all look the same. The rule of thumb when it comes to tablets, says van Gijssel, is “the
bigger the better, and the redder the better.” Following the U.S.-led attack on the Taliban that began in October 2001, hundreds of thousands of Afghans scattered, some to other parts of the country, others to neighboring Iran and Pakistan. While the rights of refugees are enshrined in international law, internally displaced people—who may number 25 million worldwide—inhabit a grey area. They are, strictly speaking, the responsibility of their own governments. But whether refugees or IDPs, the Afghan families in these camps face the same med-
ical predicament that comes from cramped conditions, exposure to a harsh climate, inadequate water and sanitation, and despair.
In several of these camps, and in many others around the world, MSF provides basic health care for months or years and intervenes in acute emergencies, such as outbreaks of disease. A refugee camp provides ideal conditions for all manner of pestilence. One of the most rampant is measles, which kills almost a million people each year in developing countries, most of them children. In an overcrowded refugee camp, where people may already be weakened by inadequate nutrition, measles outbreaks can be swiff and deadly. Measles vaccination
is priority No. 1 when setting up shop in a refugee camp, and MSF tries to make sure that all the children between the ages of 6 months and 15 years are immunized.
The camp’s most serious diphtheria patients are sent on a one-hour drive in a bouncing Land Cruiser to Mir Wais Hospital in Kandahar. Because of limited space there, many patients are sheltered outside in tents, where small electric fans are outmatched by the stifling heat. The fact that diphtheria patients are here at all is something MSF had to fight for, says Bochsler. When the first reports of diphtheria came in from the camp, the Afghan ministry of public health and the WHO asked MSF to stop referring patients to Kandahar. “They said it was putting the city at risk for diphtheria. They said they’d build a little hospital at the camp. Well, in theory, that’s wonderful. But if there’s an emergency, like an anaphylactic reaction, they’re an hour away from Mir Wais. If it’s anaphylaxis, they’ll be dead.”
Besides, the antitoxin used to treat diphtheria can’t be given in extreme heat—the temperature must be below 95 °F, and at Zhare Dasht the mercury can reach 120. “At least at the hospital, we have fans and water coolers,” Bochsler says. So MSF did what it usually does in these situations: it refused to work on terms it found unacceptable. “We said to the WHO and the ministry, unless you can replicate what we’re doing in the city, we are not going to support your building a little hospital in the camp, and we said if they didn’t meet certain criteria we wouldn’t send our patients there. That made us very unpopular. However, after we put that all in writing and submitted it, they changed their mind.” As a rookie, Bochsler admits to being surprised that MSF won this argument. “I’m still trying to get my head around the fact that if we don’t agree with something here, we don’t do it.”
THERE’S STILL a Taliban presence in and around Kandahar, says Mattias Ohlson as he sits in the inadequate shade a dozen yards from the compound’s bunker. The 31-yearold Swede is on his third mission with MSF and, as the project coordinator, it’s his job to keep on top of security. The UN and coalition forces are supposed to advise NGOs about any potential dangers, but they don’t always keep pace with the word on the street, Ohlson says. “We also send the local staff to the bazaar to talk to taxi drivers and things
like that.” Conditions keep the MSF team under virtual house arrest. “Many times we are invited to the homes of national staff, but we can’t go because they live on narrow streets and we can’t park the cars there,” says van Gijssel. “We are not allowed to walk around the streets—we’re always getting into the car inside our compound and getting out in the compound of another NGO. You really feel quite locked up.”
While the MSF medical team travels in a clearly marked Land Cruiser, red crosses and other humanitarian logos no longer offer protection in this region. In fact, NGOs may as well paint targets on their vehicles these days. Indeed, in Chaman, the MSF team travels in un-
marked vans and flies no flag over its compound. No aid worker had been killed in Afghanistan since 1998, but everything changed on March 27,2003, when Ricardo Munguía, a Salvadoran water engineer with the Red Cross, was stopped with his convoy by armed Taliban in Uruzgan province. According to a witness, the gunmen called their mullah on a satellite phone
for instructions. The reply: kill the foreigner. The gunmen pumped 20 bullets into Munguía. (To add a cruel twist, the mullah who ordered the execution uses an artificial leg provided by the Red Cross.)
But it was in the northwestern province of Badghis, ironically one of the safer places in Afghanistan, that MSF’s luck ran out on June 2, 2004. A Land Cruiser carrying five staff was ambushed by gunmen, believed to be Taliban fighters. Whether words were exchanged or warning was given, no one is ever likely to know, as the team never checked in by radio after setting off around 3 p.m. Later that afternoon the car was discovered—it had been shredded by gunfire, and shrapnel indicated a grenade had exploded. It was a heinous murder of five unarmed aid workers: Belgian project coordinator Hélène de Beir, Dutch logistician Willem Kwint, Norwegian doctor Egil Tynaes, their Afghan translator Fasil Ahmad and their driver Besmillah. Just weeks before the slaying, while de Beir was taking a break in Italy, she told a friend, “I am exhausted, physically and emotionally.” The friend asked why she was going back. “Because I have to,” the 30year-old replied. “It’s what makes me happy.”
On July 28, MSF pulled all of its teams out of Afghanistan, citing insecurity and dissatisfaction with the investigation surrounding the killing of its staff. They had been working in the country for 24 years. 171
Abridged and reprinted by permission of Firefly Books Ltd. Copyright 2004 by Dan Bortolotti.
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