Dr. James Knox slings his medical kit across his back and begins the 10-minute walk to the tiny health center in Cuimba, in northern Angola. Just past the market, the building comes into view on the left. When the electricity is working, the 10 or so beds of the inpatient ward are illuminated by a solitary light bulb. Today they’re lit only by the afternoon sun, which enters, along with the flies and malaria-toting mosquitoes, through the ward’s two glassless windows. A mild breeze struggles in vain to vanquish the smell of unwashed bodies. Knox sits down on an empty bed to get a closer look at a newborn baby who was admitted for malnutrition a few days earlier. The mother, who can’t be older than 18, was having difficulty breastfeeding, so she walked for two days from the town of Serra da Kanda, more than 30 miles to the southeast. She looks relieved as the doctor explains in Portuguese that the baby is gaining weight and is now out of danger.
Tall and slender, with black hair and expressive eyes, the 28-year-old Australian physician is three weeks into his first mission with MSF. Knox studied medicine in New South Wales, then took a three-month course in tropical medicine in Liverpool, England. After being accepted by MSF, he learned he would be doing his first mission in Angola, took a crash course in Portuguese, and by mid-2003 was in Cuimba, caring for the 25,000 people expected to pass through on their way home from the Democratic Republic of the Congo, where they fled during the most recent outbreak of war.
Knox knows that some people look on aid work as heroic, as though he had selflessly sacrificed his career and put his life on the line to help the poor and suffering. The reality is hardly that simple. MSFers are commonly asked why they do aid work, and the query annoys most of them, not only because of its tiresome frequency but because motivations are difficult to distill into a concise answer. They also worry they might disappoint the questioner, who has usually assumed that aid work is a hair shirt — an act of self-sacrifice. As one doctor puts it: “People hear about MSF and say, ‘You’re going to be nominated for sainthood,’ and it’s not at all like that. I consider myself a person after his own self-interests. It’s rewarding to bring medical care to these people, but I’m doing it because it makes me feel good, and I like it. I’m not doing it for them — I mean, I am, but I go there because it feels right for me, not because I think I’m helping the world.” A desire to help people motivates almost everyone in MSF on some level. But the degree to which that plays a part varies dramatically, even in the same person over time. The drive to do that first mission is rarely the same as the one that prompts a fifth or sixth visit to the field.
Admittedly, delivering humanitarian aid can be dangerous in a place like Angola. During Knox’s mission, MSF set a few rules that suggest there are potential risks, even in peacetime Cuimba: no overnight stays without a vehicle and driver on standby; no walking alone in the village after dark; and always carry $50 “security money” in case of extortion or kidnapping. Everyone also gets mine-awareness training, and drivers are told to follow the tracks of other vehicles and never leave the main road. If you must stop to relieve yourself during a long drive, you do so behind the car, never in the bushes at the side of the road.
Following these security rules is hardly a guarantee. On November 29, 2002, two MSF vehicles were traveling from Cunjamba to Mavinga in southeastern Angola, returning from a small village where the occupants had spent the day giving measles vaccinations. They had driven the same road that morning, but this time the back wheel of the first Land Cruiser, jam-packed with 13 people, hit an anti-tank mine. Seven were killed — four Angolan MSF staffers, two ministry of health employees, and a baby boy.
MSF’s policy for road travel in most African countries is clear: if you hit a person or an animal with a vehicle, you keep driving, returning only after you’ve notified the authorities. You don’t stop to help, even if you’re a doctor. It sounds cold-hearted, but an incident on March 9, 2003, showed why it’s necessary. Rachel Stow, a British physician working in MSF’s project in Malange, was returning from Luanda with driver Aderito Augusto and an assistant when the vehicle struck and killed a young girl. When they stopped, a mob dragged Augusto from the driver’s seat and brutally beat him to death. Stow narrowly managed to escape in the Land Cruiser while the assistant fled on foot.
As Knox speaks, a full moon high in the southeast casts its sheen on the sleepy village, and it’s easy to feel far removed from these horror stories. Here in Cuimba, Knox lives with one other expat in a small but comfortable house made from sun-baked bricks. There’s no running water, and the electricity works for only a few hours each night, so he charges portable solar-powered lights during the day so they’ll be ready for late-night trips to the outhouse, which is equipped with a standard MSF-issue squat plate. Entertainment is simple: paperback novels, a few CDs. Knox has brought his guitar, and in a pinch the logistician can scare up a drum from the local church. The beer is warm, but the one guy in town with a generator will sell you a cold can for an extra 10 kwanzas, about 18 cents.
Despite the potential danger of some missions, MSFers will tell you that working in a place like Angola is a rare privilege, particularly for a doctor who hasn’t yet turned 30 and would otherwise he holding down a junior hospital position. “There probably are people who do this for purely altruistic reasons,” Knox says, “but I haven’t found one yet. I mean, you’re helping people, but it’s not exactly altruistic if there’s something in it for you as well.”
Many MSFers can recall the moment when the idea of humanitarian work crystallized in their mind. For family physician Andrew Schechtman, who has done missions in Guatemala and Liberia, it came in a university library, where he was procrastinating instead of studying for an undergraduate test. “I picked up an old book on the table next to me and started looking through it, and it turned out to be one of Albert Schweitzer’s books about the jungle hospital in Lambaréné, in Gabon. It just hit home — the type of work he was doing, where he was the only doctor in that hospital, taking care of people who had no other access to care. That clinched my idea to go into medicine, and it also planted the seed of wanting to do overseas work further down the road.”
Growing up during the Cultural Revolution in China, pediatric surgeon Wei Cheng was inspired by a different medical icon. Cheng’s childhood hero was Norman Bethune, the Canadian surgeon who assisted the Chinese during the Japanese invasion in 1938. In November the following year, Bethune, operating without gloves, pricked his finger and contracted septicemia. Without antibiotics, he died from the infection and was given a hero’s burial, with Mao Tse-tung delivering the eulogy. “People of my generation still respect him very much,” says Cheng, who in 2000 became the first Hong Kong surgeon to work with MSF.
Vincent Echave, a Cuban-born surgeon in his early 70s, also grew up during a Communist revolution, where he first came face to face with suffering in his own country. “Then, traveling around the world, I realized that a doctor’s mission is not only to cure people and make money here but to give something of his time and knowledge to poor people. It’s a deep conviction of mine that it is essential for any human being, but especially a doctor, to give part of his time to humanitarian work.”
Even if most physicians share Echave’s sentiments, 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 nonmedical 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.
Whatever their age, doctors who go into the field with MSF don’t all fit the same mold. Some manage to interrupt their practices to do emergency missions for a few weeks each year. Others devote most of their careers to aid work, most comfortable caring for patients largely forgotten by others. In addition to her work with MSF, family physician Leslie Shanks has treated tuberculosis in the Canadian Arctic, worked in remote Native communities, cared for federal prisoners, and worked in a clinic in the heart of Toronto’s gay community. “A nightmare for me would be to work in a standard suburban practice, talking to people about their ill-fitting orthotics and treating sore throats,” says Shanks. “That, to me, is my worst nightmare. I’m extremely fortunate to be in the field that I’m in because, as a family doc, I have all kinds of opportunity to do interesting things where I actually feel like I’m contributing something — usually not a lot, but a small bit. Working in an area that is overserviced, I just couldn’t do that. I have no patience for it.”
For others, the push comes later, when they begin to look for new challenges after practicing in the increasingly specialized world of Western medicine. 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.”
MSF tries to match its medical staff to the needs of each project, but circumstances sometimes mess up those plans. In the Liberian hospital where Schechtman worked, the local surgeon disappeared for a month and left him on his own. One of his first patients was a woman in labor whose baby had become stuck. “There was no alternative other than to try and get this baby out. I did a Cesarean section, and she had a ruptured uterus that I couldn’t repair, so I had to do a hysterectomy also. I was definitely in way over my head. I had done maybe fifteen Cesarean sections in residency, six years before, and maybe five hysterectomies, but always with a senior physician standing across the table and telling me where to put my scissor and how deep to cut. It was really stressful, but the only other option would have been to just watch. She ended up doing well.”
One motivating factor is particularly acute among American doctors: lawsuits. “The biggest thing I found when I first went overseas was that there was this huge load lifted off my shoulders — all this malpractice threat that Western physicians, particularly in the US, have to work under,” says one surgeon. “That constant threat that every time you make a decision you’re looking over your shoulder for a lawyer. I was immensely relieved that was gone.”
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 is an understanding that you’re not going to get involved with too much individual patient 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.”
Nurses, too, find that MSF gives them far more responsibility than they would get in a typical Western setting. “I couldn’t give Tylenol without a physician’s order,” says Kathleen Bochsler, a nurse who worked in a remote northern Canadian community before going to Kandahar, Afghanistan. “Technically, at three o’clock in the morning if my patient needed Tylenol, I had to phone a physician and wake him or her up. That’s just ridiculous. We’re supposed to be intelligent enough and trained enough to make life-saving decisions, yet I can’t give Tylenol? It’s very frustrating, especially if you’ve worked independently, without a physician, and you’re making some important decisions on your own, to have to go back to working in an environment where your opinion is always secondary.”
Nonmedical people, too, are attracted by the promise of challenge. Remembering his first mission in Somalia, an MSF administrator says he got to sit in on meetings with UN and military staff, handle about $40,000 a month in cash, and do much of the radio communications with Mogadishu and Nairobi. “It was a great job for someone in their mid-twenties. Every day was different, and there were some days that were absolutely incredible. I was doing a lot of things I never imagined I could do.”
Massimiliano Cosci worked in construction his native Italy, and later in Brazil with a Catholic NGO before he joined MSF in his early twenties. Those jobs could not compare with the exhilaration of working in a war zone like Liberia in 2000. “At that time we had only one project up in the north, near the border with Guinea and Sierra Leone, and shortly after my arrival we had to close the project because it had been attacked and looted by the rebels. They took everything, and they killed one or two of our national staff, raped some of the patients, and kidnapped one of our drivers. This was at the beginning of my career with MSF, so I was very excited. I was much younger than now, so I was fascinated to be part of all of these activities that I had only seen in the movies or read about in books. Suddenly I found myself part of it, and I was proud of myself. During my first four years with MSF, I would come back to Europe, stay a couple of weeks, and then leave again for another mission, because I really needed it. Like we say in Italy, the soil was burning under my feet. I was in Liberia for one year and it was hard — to be away from your culture, your family, your friends for a year has an impact on you. And yet I left immediately for another mission that had an even stronger emotional impact on me.”
That next mission was in South Sudan, where Cosci was the field coordinator for a primary care project that was close to the front lines. “We were taking care of the war wounded — gunshot wounds, blast wounds, landmines — and also illnesses in the community that were not necessarily related to the war.” Cosci had an opportunity to be part of a genuine sans frontières operation. “You have to cross the border into Sudan illegally. You arrive in Kenya and get your briefing in Nairobi, and then you pass through Lokichokio, which is on the border with Sudan. Finally, after a week of briefings you leave for the field. We took a small transport plane with a private company, sitting on the boxes of drugs. After two-and-a-half hours we landed in the middle of nowhere, in the savannah. And the Sudanese people said, ‘OK, we’ve arriving in the town.’ When I got out and walked around I said, ‘Where is the town? There is no town, there are just a few huts.’ The people are walking around almost naked, with ash on their faces to protect themselves from the mosquitoes and the heat. Then you go to the MSF camp, and they have tukuls there, made with mud and excrement of cows. The difference between the temperature inside and outside is about 10 degrees: outside it’s 50 degrees Celsius and inside it’s about 40, which feels like fresh air. That was really something — you cannot believe that in 2001 people could live in those conditions.”
MSF was also running a project several hours away, and the day before Cosci arrived, that team had to run from the Janjaweed, the government-backed Arab militia. “The Janjaweed had arrived there, but because it was at the end of the rainy season they could not cross the river with their horses, so they decided to camp on the far side. The population saw them, and they came to the MSF camp and said, ‘The Janjaweed are here, we have to leave immediately.’ The team left that night, just after sunset so they wouldn’t be seen, and hid in the bush. They spent the night there, and the next morning they had to leave at sunrise. The Janjaweed were able to find a passage across the river, and they attacked our camp and burned our hospital. They destroyed it completely and killed a nurse, a watchman, and a woman who cleaned the hospital, along with her child. She was running while holding the kid, and the bullet passed through her back and also killed the baby.” The fleeing team arrived in Cosci’s project the next day and told their story. “Our team came to my camp and said that the Janjaweed are behind us. And the Sudanese people said to us, ‘We will stop them, don’t worry, we will kill them, they will never come here, you’re safe with us.’ They started to set up machine guns. This was all very difficult for me, because I had just arrived — it was my first day.”
Later in that same mission, Cosci’s job included visiting a remote project by plane once every 10 days to see how it was functioning. “They would give us twenty minutes to unload everything and then the airplane had to leave. The plane would then go land in a safe place, and two or three hours later it would come back and we would have another twenty minutes to load everything and get in. If you didn’t have enough time, they would leave you there. One time I went to visit some patients with a doctor and a nurse. When the airplane came back to pick us up, the pilot said, ‘Let’s go, let’s go, we have to move.’ At that moment we heard a noise and I looked up to see an Antonov coming. These are transport planes and they have no guns, but they can drop a bomb on an airplane that’s sitting on an airstrip. Once we took off we would be fine, but our airplane was vulnerable when it was on the ground. We left all the luggage and got inside the plane, and when I went to close the sliding door, there was a woman there with a small baby. She said, ‘Please, take my baby.’ I said, ‘Look, I cannot take your baby. Where would I bring it? It needs its mother.’ The pilot said he only had enough fuel to go another twenty or twenty-five minutes, and he didn’t have enough for another passenger, so we couldn’t take the mother. He came over and locked the door, and said he didn’t want this bullshit.
“We could hear the noise of the Antonov again, and then we were really scared. The doctor was not talking, the nurse was not talking, plus we were carrying a few patients with gunshot wounds that we had to take back to the hospital. The pilot went to start the engine and suddenly one of the rebels walked in front of the cockpit with a Kalashnikov and aimed at the pilot. The window was open so we could hear the soldier say, ‘If you move from here, I will shoot you.’ And the pilot said, ‘Look man, I am going to start this engine. And if you don’t move out of the way, the propeller will cut you to pieces. If you want to shoot me, fine, because we are already dead if we don’t leave here.’ He was very firm, so the soldier didn’t know what to do. Finally he decided to step out of the way and the pilot started the propeller, and we took off. I still remember the silence when the pilot said, ‘We are already dead.’ That time I was scared.”
Though Médecins Sans Frontières prides itself on having remained small relative to development agencies like CARE or World Vision, it’s hardly the ragtag group it was in the 1970s. Yet it has always struggled to stay close to those roots, beginning with the French reluctance to expand to Belgium and Holland in the 1980s. In his Nobel Prize acceptance speech, James Orbinski, then MSF’s international president, went so far as to say, “MSF is not a formal institution, and with any luck at all, it never will be.”
In mid-October 1999, there were small but boisterous parties all over the world, as field staff toasted the announcement that MSF had been awarded the Nobel Peace Prize. There were celebrations in the European and North American offices, too, of course, but also uneasiness. “I remember the day we received the Nobel Prize I was really worrying about the effects it would have,” says Jean-Hervé Bradol, past 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 worried that MSF would be thrust onto the stage and asked to speak out on issues that aren’t directly related to humanitarian medical assistance. “If you have a meeting about an issue that you are not really involved in — for instance, the death penalty — you will have people saying, ‘An organization like MSF, with the Nobel Prize, should have a public position on that.’”
Bradol and most other MSFers have since made peace with the prize — if nothing else, adding “Nobel Laureate” to its stationery has been a godsend for fundraising. However, Kenny Gluck of MSF-Holland recognizes that it has had a lingering effect on recruiting. “Different kinds of people join us now that we’re big and famous. When you’re little, scrappy and rebellious, different kinds of people come forward to be volunteers.”
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 aid workers. 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-timers 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.”
As an organization — those who share Orbinski’s hope prefer the term movement — MSF is relatively nonhierarchical (except in the field, where a chain of command is essential) and egalitarian. Everyone is invited to join the national association — there’s one in each country with an MSF section — which allows them to vote for board members or to run for a position on that board. And unlike many UK and US charities that are chaired by the gentry or by captains of industry, MSF boards are composed of former field workers, many of them doctors. “We try to structure the organization so that everyone owns it,” says Austen Davis. “So if it’s not performing well, they can’t just complain about the boss. It’s their responsibility to speak up and say where MSF should go in the future, and to get a personal sense of ownership and commitment in the work they’re doing.”
Field workers are paid a small stipend, and the organization picks up all travel costs and health insurance, but expats pay for their own food and most other expenses in the field. Even MSF’s office staff is paid modestly, and equitably, compared with private companies. At MSF’s New York office, for example, the ratio of highest to lowest salary is not more than three to one, with the executive director making about $100,000. When hiring local staff in the field, however, MSF’s tendency is to pay slightly more than the going rate among other NGOs.
Because even the top jobs aren’t going to make you rich, MSF attracts many people who are congenitally uncomfortable amid the affluence of the West. Martin Girard has done missions in Colombia, Sierra Leone, the Democratic Republic of the Congo, and recruited for MSF’s Montreal office. “There’s no way I could work in the private sector, unless I was totally broke and I needed a job that pays more,” he says. “But I’m not attached to material things. I’m forty years old and I don’t have a car. I don’t have the money for it. My mother and father paid for the washer and dryer in my apartment, because I didn’t have the money for it.
“If I sent my CV to the UN tomorrow morning, I can assure you I would have a job, at perhaps five thousand dollars a month,” continues Girard, who has a master’s degree in political science, is fluent in three languages, and has traveled in more than two dozen countries. “But I know that I would be losing part of my soul in a big political organization, having to make compromises in the field that I can’t accept.”
Girard has little patience for people who romanticize humanitarian aid work. “I’ve had one or two yuppies come into my office, saying: ‘I’ve made all my money, and I’ve got my big house. My life is a total wreck, and I think I would find meaning if I went on a mission with you.’ I ask them, ‘Would you be happier if I sent you to a genocide? Do you think you’re going to come back and smile at the sun every morning? Do you think that’s the recipe for happiness? The expats we sent to Rwanda in 1994 are still seeing the shrink once a week.’”
No one really knows what to expect on that first mission. Pediatric emergency doctor Joanne Liu remembers reading a book about MSF when she was 13 years old and dreaming of doing humanitarian work when she grew up. “I did my first mission when I was thirty — that’s a long time to carry a dream. Of course, I was doomed to face disappointment, because my expectations were so high. I could not believe the bureaucracy of humanitarian aid work. I just could not understand it.” Liu did her first mission in Mauritania, where refugees were getting set to return to neighboring Mali. She says a UN official there was trying to move the refugees during the rainy season, just to make himself look good by getting them closer to the border. “Of course, he didn’t order enough plastic sheeting, and the people ended up living under the rain for another two weeks. We had increased mortality, diarrhea, upper-respiratory infections. I could not believe that because this person had an agenda, he was willing to put the health of forty thousand refugees at stake. I was really naive, and my head of mission told me, ‘Joanne, wake up. Welcome to this world, honey.’ I remember writing letters to my parents and my significant other, saying I cannot believe this, and I can’t believe MSF is not fighting it. I was so disappointed and I didn’t think I’d ever go again. I’d been dreaming about this for seventeen years, and this is what I have to deal with?”
After four years practicing law, followed by an MBA, Patrick Lemieux had a dream of his own — to find a job where he could get some real sense that he was helping others. “I was in Barcelona at that point, so I contacted MSF-Spain, and it was very quick. I did two interviews and I was off to Kosovo. I took care of finance, logistics and administration, and while I was there, the team decided to close down the entire mission. So in six months I shut down two projects. It had nothing to do with the feel-good work I was hoping to do. I was freezing my balls off in Kosovo, spending Christmas by myself, firing people, arguing about contracts, and liquidating assets. I did enjoy the experience of being in that area, and obviously you develop relationships with the national staff. Definitely some nice moments, but it wasn’t what I thought it would be.”
What’s surprising is not the ingenuous notions of first-timers, but their willingness to persevere. After her disaster in Mauritania, Liu has done more than a dozen missions with MSF, and Lemieux is into double digits, too. 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 health centers in a war-ravaged country, a single feeding center in the midst of a famine, a drug distribution program in a tuberculosis clinic. It’s rare for a returning field worker to rave about how successful their mission was — more often they’ll grudgingly admit they helped a few people, saved a few lives. “I felt useless,” says nurse Carol McCormack, who worked in a war zone in Burundi. “I didn’t change a thing. A few little things, maybe. Acute problems. But I couldn’t change those health centers in the time I was there.”
It’s not false modesty; it’s genuine frustration. Rather than sleeping well knowing they’re doing good, aid workers are more likely to be kept awake by what’s left to do. “I have people say to me, ‘Oh, you work for MSF, that’s so noble,’” says one, who reacts to that notion by raising her middle finger. “Seriously, you have no idea. It’s not noble; it’s an attempt. People say, ‘You must feel so good at the end of the day,’ and I’m like, ‘Jesus Christ, do you know what happened today?’” That’s why so many veterans insist they’re not being selfless. As they see it, it’s easier to be in the field, getting their hands dirty, feeling involved, than it is to be sitting at home watching the world’s crises unfold on TV. And, after that first mission has opened their eyes, sticking their heads in the sand is no longer an option.
Peter Lorber, who did several stints as a logistician, had a profound ambivalence during his tenure, hating many of the things he saw but feeling drawn inexorably back into the lifestyle. “When I was working missions, I really felt alive,” he says. “The highs are really high; the horrible things are really horrible. It’s not a humdrum life. Even in parts of the missions that are very boring, there are rare, special things that you get so much out of.
“I was in Nigeria when MSF received the Nobel and had a fun time at a quiet reception in the French ambassador’s residence. We brought a bunch of local women who were working on our Lagos slum program — I loved watching them camp out next to the buffet, clean off one chicken leg after another, and toss the bones on the carpet. I had the opportunity to eat pepper soup and pounded yam, to drink palm wine and ogogoro [a local gin], to get malaria twice. Nigeria is about corruption elevated to a national pastime, sizzling late-night dance clubs, fierce national pride, unimaginably vast oceans of poverty, crime and suffering dotted with islands of obscene luxury and wealth for the fortunate few, mile after mile of windblown trash caught in branches and barbed wire. God, I hated Nigeria. God, I’d love to go back.”
After leaving MSF in 2002, Lorber has struggled to feel that vibrancy again. “I don’t think I’ll ever live like I lived when I was in MSF, including the awful stuff. When MSFers get together at the end of the night and have a party, it’s really the best of times. Hard-working people who are crying, getting drunk together afterward. That’s really living.”
Certainly one of the biggest motivators is the opportunity to visit remote places and experience other cultures. Vincent Echave recalls taking a break from his surgical work in Rwanda and going into the mountains, where he came face to face with a family of gorillas. “There were babies trying to play with my tennis shoes. The male was so big when he stood up, it was unbelievable. What struck me was that I was seeing so much brutality in the cities — in Ruhengeri people were killing each other — and this gorilla was so peaceful.” In northern Sri Lanka he watched Tamil villagers walking on fire, and experienced the most bizarre incident that’s ever happened on his rounds. “There was a man in the hospital saying he had this pain in his belly. I started talking to him, and he told me he was a snake charmer. I said, ‘Oh, that’s very interesting, it must be a dangerous profession. Who’s taking care of your snake now that you’re here, your wife?’ And he said, ‘No, no, the snake is under the bed.’ He got out of the bed and pulled out a basket with some clothes on top, and then he took out a flute, and this king cobra came out of the basket. He started playing with the cobra right in the ward in front of everybody.”
Even when those cultures are confounding, there are moments of magic. When nurse Christine Nadori worked in South Sudan — which many MSFers say is close to being on another planet — she remembers running a feeding center among the Dinka, whose culture is centered around their cattle herds. “They don’t even tell time in a lot of ways. And you’re trying to run a therapeutic feeding program for three hundred to six hundred kids, trying to teach a group of Dinka staff to schedule six milk feedings per day and dole it out in a calculated way to every kid. You lose your mind. But at the end of the day, the sun is going down, the fires are sparking up, a long day closes and the heat starts to abate, women are lining up to get their rations for their kids, the light is gorgeous, and you’re laughing. That’s when the fun begins.”
There are dozens of reasons people go on mission with aid agencies, and some are the wrong ones. Michael Maren, in an interview following the publication of his book, The Road to Hell, pulled no punches when asked about the people this work can attract. “There are some really good people out there doing aid work, but I have to say — and this mostly comes from experience as a journalist — that without a doubt, some of the most sanctimonious assholes I have ever met in my life, some of the worst people, and I mean really bad people, work for charities and aid organizations on the ground … You walk in there and you have life-and-death power over people’s lives. And all of a sudden you have a twenty-two-year-old aid worker telling twelve thousand refugees to get over here, to get in line. It gives you a real sense of power.”
Maren wasn’t talking about MSF specifically, but no organization has a flawless recruiting record. Like any agency that sends its people to far-flung places and gives them a lot of responsibility, MSF has hired expats with colonialist attitudes who have abused national staff, misfits who will never be comfortable in their home societies, and those simply looking for a refuge from problems at home. One head of mission jokes that whenever a new team member arrives, she asks, “So, what are you running from?”
MSF is wary about its cowboy image, which persists in the aid community, despite the organization’s claim that it has outgrown it. “We’re very careful not to recruit the Rambos, as we call them — the people who want to do war tourism and catch bullets,” says an HR manager. “Those people are the most dangerous of all to a team. If you get a sense that someone’s going into this for kicks, that’s really not the kind of person you want.” MSF’s human-resources staff also look for people with more than one language — French or English is essential, since one or the other is the lingua franca in the field — as well as experience working or traveling in developing countries. (“Don’t tell us if you did Club Med, because that doesn’t count.”) Field workers need flexible lifestyles, since they may be asked to leave for weeks or months on short notice.
MSF also wants people who can work in small groups. “What makes or breaks a mission is the team you’re with,” says Patrick Lemieux. “You could be in a wonderful country, doing wonderful work, but if you’re with a shitty team, you don’t have any fun. Or you can be stuck in a compound, not able to stick a finger out, but be with an excellent gang of people and you enjoy your mission.”
It’s impossible to predict how people will react in the field, however. Teams can include as few as two expats or more than a dozen, and the environments range from quiet villages to all-out conflict, from hot water and cold beer to sleeping on the floor with rats. A logistician who was in South Sudan during a famine spent his first three months living in a tent that was half-submerged in a swamp and infested with mosquitoes. “There had been a long period of dry spells, which had caused the famine, followed by heavy rains,” he explains. “We had our living compound on one patch of ground, the supplementary feeding center on another, and then about twenty minutes’ walk away was the therapeutic feeding center. During the height of the rainy season we were wading through chest-deep water to get there. You were always wet, you were always cold.” It wasn’t until after they built a new compound on dry ground, however, that the friction got to them. “After those first three months, I can honestly say there were more grumpy people. When the conditions are worst, your team jells much better. You actually have more team-dynamic problems in programs that have been running for a while. Then you have those personality clashes that are a problem in all NGOs.”
Nothing brings team members closer together than having the living daylights scared out of them. While Carol McCormack was in Burundi, the town was hit with a mortar attack, leaving her and two young female doctors huddled in the hallway of their house. “It made the bond stronger because we had shared something like that,” she says. “We were three people who might not have been friends in another situation — we have nothing in common, and they’re both a lot younger than me. They were twenty-eight, and I was thirty-nine. When you’re living in very close proximity, and you’re stressed, and you’re working too hard, and security is bad, there can be spats and difficult times. But then you break loose, and you go and dance your little heart out until two a.m.” Often the friendships happen quickly, since there’s little time for the rituals of drawing people out of their shell and into the fold. “The pressure is on when you arrive in the team,” jokes an administrator with seven missions under his belt. “You better show that you can hang now. Either you drink a beer with us, or you don’t. If you don’t, you’re branded for life.”
Before sending rookies on a first mission, MSF puts them 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. (It’s also an opportunity for recruits to bail out if they’re having second thoughts.) Much of this prep course focuses on getting along in the field. Nurse Kathleen Bochsler did hers in Amsterdam before heading to Afghanistan. On her first night, she and the other first-timers found themselves in the middle of a Dutch forest at 10 o’clock at night. “They divided us up into groups and gave us maps. Then they piled us into a Land Cruiser, took us out into the woods, dropped us off, and gave us a big tarp and some wooden poles. They said, ‘OK, good luck. You have to find this red dot on the map and build a latrine there. We’re not telling you where you are, but here’s a compass.’ Five o’clock in the morning was when this whole fiasco ended. We had found our red dot, built our latrine. The whole time you’re learning how to communicate by radio. Of course, they haven’t taught you how to communicate before this; they’ve just given you an idea how frustrating it might be in the field trying to reach somebody.
“At the time, we didn’t have any clue what the purpose was. It was just long and brutal, and we were suffering from jet lag. The next day, you sit down and talk about group dynamics, what problems you had, how you solved them, and what role you felt you played. And that was the most valuable part of the activity, because you’re stuck with strangers, you’re tired, you’re cranky, and you haven’t actually made friendships yet. In a lot of ways it’s like being on a mission, because you do have to solve problems with people who have totally different ideas. 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.”
If there are frequent fights on mission, there’s also a lot of making up. Inside jokes about what the initials MSF really stand for range from Meses Sin Follar — Spanish for “Months Without Fucking” — to the less colorful but more accurate “Many Single Females.” Take a group of mostly young, strong-minded, unattached people and drop them into an emotionally charged setting far from home, and you’ve got a recipe for matchmaking. But it’s not just opportunity and fewer consequences that bring so many MSFers together. Amid the flings, one-night stands, and missions shortened by pregnancy, long-term relationships form, often lasting for years or for life.
“It’s not just that you have a bunch of like-minded individuals, because people join for a thousand different reasons,” says Canadian nurse Leanne Olson, who’s married to Rink de Lange, a Dutch logistician she met in Bosnia in 1994. “You’ve got people with different languages and different cultures. There are so many differences it really shouldn’t work. But there’s an overriding passion for this job among the people who take it seriously, who aren’t looking on it as a paid vacation or just an adventure. If you legitimately put something of yourself into the work you’re doing, you end up seeing people at their most vulnerable.” Olson and de Lange did several missions together and saw each other at their best and worst. “When things go bad, you really see how someone’s going to behave. You get to know a person far better, in a short time. You might have friends for years and never really know them, because you’ve never seen them under pressure, under the stress of these situations. How often in real life are you in a hostage situation or at a dangerous checkpoint with a gun to your head? How often do you see someone get shot in front of you or witness a massacre? With MSF, something along those lines happens in every mission. And then you see how the people on your team react to that. Do they fall apart or do they get closer together? You get to see this aspect of a person’s character that’s very raw. That’s when you see what this person is really going to be like. It makes the process much faster. There’s none of this ‘Let’s date for six months and go out for dinner.’
“I don’t have to worry, because one day, if I have a crisis in my life, I know exactly how he’s going to behave. With MSF, you know before you ever put on a ring and say ‘I do.’ I don’t have to explain to Rink why I’m watching coverage of the war in Iraq and bawling my eyes out. I don’t have to explain to him why, in the middle of a beautiful afternoon in Toronto, when there’s an African band playing and everybody’s dancing, I’m standing there crying. I don’t have to waste any time saying, ‘It reminds me of …’
“You’re in that same little boat, and that’s where you stay.”