Healers without borders

Médecins sans Frontières
Médecins sans Frontières

In early 1995, the Dutch branch of Médecins sans Frontières or Doctors without Borders had just celebrated its tenth anniversary. It had projects in a wide variety of countries ranging from Afghanistan to Georgia, Peru and what was then known as Zaire. MSF had just been in the headlines because it and other non-governmental organisations had threatened to suspend their work in the Rwandan refugee camps in and around Goma, Zaire. They said they would pull out unless the United Nations took action to break the stranglehold which Hutu militants exerted over the hundreds of thousands of Rwandans in the refugee camps. The French branch did withdraw. MSF Holland stayed.

Producer: Eric Beauchemin

Broadcast: February 15, 1995


Radio Netherlands, the Dutch international service, presents “Healers without Borders”. The programme is produced and presented by Eric Beauchemin.

Médecins sans Frontières has been created as a result of the Biafra war. At that time, some French doctors – Bernard Kouchner who was the former minister of humanitarian affairs in France was one of those doctors, and MSF was created because the international organisations had no access to the victims because the humanitarian organisations were obliged to work on both sides, and if one of the parties did not agree, you had not the right to intervene. And on the other hand, the humanitarian organisations were not supposed to witness on what they saw. So from that moment, MSF always witnessed when there is a systematic and huge violation of human rights in a particular situation. The moment we see that our humanitarian aid has hardly any impact given the massiveness of the problem, then we react, and that’s nothing new.

Jacques de Milliano, the director of the Dutch branch of Doctors without Borders, better known by its French name Médecins sans Frontières. MSF, with branches in France, Spain, Switzerland and the Benelux countries sends medical and logistical staff to assist people in conflict zones around the world. The Dutch branch, which recently celebrated its 10th anniversary, runs projects in a wide variety of countries ranging from Afghanistan to Georgia, Peru and Bosnia. Since the collapse in 1989 of the Berlin Wall, MSF – perhaps more than other humanitarian organisations – has regularly been in the news, not only because of its humanitarian work, but also because of its scathing criticism of governments for not taking their political responsibilities and acting to end conflicts. Bosnia is a case in point, as was Rwanda, where UN peacekeeping troops withdrew at the beginning of the genocide last spring. MSF was again in the headlines late last year when it and other non-governmental organisations threatened to suspend their work in the Rwandan refugee camps in and around Goma, Zaire. They said they would pull out unless the United Nations among others took action to break the stranglehold which Hutu militants exert over the hundreds of thousands of Rwandans in the refugee camps. The French branch did withdraw. MSF Holland stayed.

MSF in Zaire has different programmes.

Anita Jansen is MSF’s country coordinator for Zaire.

It goes from drug supply programme for the Zairean population in the whole province of Kivu where we also do some maintenance of solar equipment. We have an emergency preparedness programme for small emergencies that come up: measles, cholera, dysentery, epidemics like that. So MSF Holland has been working in Zaire for a couple of years now. We started because of the total lack of health care for anybody in Zaire or in this part of Zaire, which has always been a very problematic part. Then about a year ago, we started working with refugees in south Kivu, which is in the area neighbouring Burundi because there were Burundian refugees. And then of course in April, the first Tutsis came across the border, followed in July by a massive amount of Hutus who fled the war in Rwanda. So at the moment MSF Holland on this emergency project is running the health care and water sanitation in two different camps: one is a smaller camp which is 15,000 people, and the other one is a big camp. It’s Katale with 200,000 people.

EB: I’m in the inpatient department, which is basically the hospital in Katale with Lucy Wikam who works for MSF Holland. What is this right here? The inpatients department is the hospital. It is the field hospital. I look at it from the logistical point of view. I can’t tell you much about the medical side of things. We have here the morgue: bodies get put into body bags and put in here as and when they happen. Another organisation picks up bodies from here on a daily basis, and all bodies get transported to Goma to the mass graves because there is no cemetery in the area which we can use and the ground is so difficult. As you can see, the lava, it’s really difficult to make individual graves. EB: It smells of chlorine here. What is that? This is the beginning of a drainage system we’re building. The chlorine you can smell it because they do all the washing of clothes and washing of blankets again just next to where we are now standing. Everything gets washed every day. And they wash obviously in chlorine solution for the disinfection. We spend most of our lives upsetting this hospital by trying to build things around them. This has all recently been extended. This line of tent has recently been shoved back, and we’re actually going to extend again when they put this new road into the southern section because you’ve got 200 beds here of very sick people. These are the sickest people you get. People start at the OPD, the outpatients department, the clinics, if you like. EB: The hospital consists of around how many tents? About 10, 15 tents? Well, it’s 15 double tents. 15 tents, 11 metres long. I think there’s 18 beds in every tent at the moment. EB: Who is the staff inside? They’re all MSF people? Yeah, all local staff. The medical side is run by two expatriates: Daniel and Danny, medical doctor and a nurse.

EB: What type of people work for MSF? Very interesting people, that’s for sure. They are coming from all different types of backgrounds, different religions, different countries, different nationalities, different continents. They’re in general very, very interesting, and they all have something to contribute to the well-being of the refugees.

I started off as a civil engineer or started studying civil engineering, got kicked out, went to work as a diver and after that joined a multinational. I worked in petroleum and diving industries for about five years.

My background is MBA. I did some market research for some big companies, found out I didn’t want to work for multinationals, so came to MSF.

I’m an anthropologist. I work as a researcher at a research institute in Holland, and I’m on unpaid leave for a while.

I did personnel management, afterwards retail marketing, alternative trade.

I’m actually a theologian and did your job for a while. It was very nice to do, but it was time for something different, and somehow you end up in MSF and that’s a real rewarding job to do.

I’m a paediatrician. This is my fifth year in Africa and I’ve had specific experience before with other NGOs, and I sort of knew that I could maybe do a better job at MSF. Yeah, that’s happened.

I’m a general practitioner, and I’m trained in tropical medicine. One year, I do that one thing and the other year I do the other thing.

EB: What are they doing here? It’s a wall. I would have thought that’s fairly obvious. It’s a kitchen, a kitchen for the diarrhoea treatment centre. EB: Lady Ganaka (?) is also working for MSF Holland. Where are we exactly in the centre? Right at the bottom of the diarrhoea treatment centre, opposite the morgue. It’s just quite a good thing to show you because you try to sort of dignify it by the fact that the truck backs up there, and it’s quite nice that it’s not a sort of open effort. Do you want to walk around? EB: Sure. These are the showers. There’s a water supply, which I like. Toilets. It’s really quite neatly done. EB: Is the site fairly clean? Oh yeah, we’ve got a group of people that come. There’s one over there. They clean the place, and then the tents are cleaned twice a day, in the morning and the evening. Because it is a diarrhoea treatment centre, cleanliness is sort of one of the main things.

I’m Dr. Lee, John Lee. I’m from Canada. I’ve just accepted a six month contract here in Zaire to care for the Katale refugee camp. EB: Why is a Canadian working for the Dutch branch of MSF? It’s just the way the infrastructure of MSF world international works. MSF Holland has branches in the UK, Canada and Germany. EB: And what are you doing here in the DTC, which is, once again, remind me. Diarrhoea Treatment Centre or Dysentery Treatment Centre, whatever your choice of. I’m here to supervise it and help run it. This centre is running very well. I guess the census is going down in terms of the number of patients, which is a good thing. EB: Are a lot of these people very, very sick? There are other underlying conditions which make for some very sick patients. You have quite a few that have diarrhoea. The criteria for coming here is diarrhoea, but that can be due to anything from malaria to severe malnutrition to HIV infections or tuberculosis. Just an example: we have this one child here, is 1 year old girl who was admitted for diarrhoea. Soon after being admitted, developed a rash, which is very consistent with measles. She is actually quite ill, with a very productive cough. She’s got pneumonia. She’s quite dehydrated, thus requiring an IV hydration. She has quite profuse diarrhoea. She has not been able to keep anything down, so her condition is quite severe, but we’re hopeful because she’s not too malnourished, and hopefully with any luck, she’ll make it through. EB: Is the work quite depressing? Do a lot of the patients die or are you able to save a lot of them? The standard treatment that we institute for most of the patients, the fact this is here, I think there’s a lot of lives being saved. Obviously if this wasn’t here, we’d be losing a lot of people. There was a cholera outbreak not that long ago, and the morbidity and mortality rate was extremely high. So in that sense, yes, in sheer numbers, I think we are making a difference, but it is frustrating because we’ve kind of reached that transitory phase in the project where they’ve been here for six months. We’ve brought the medical care level up to a certain point. Now, how much further do we go? We have to be sensitive to what kind of medical facilities were in the surrounding area for the Zairean people because we can’t obviously surpass them or that’s going to breed a lot of resentment. EB: So how are you dealing with this dilemma? I’ll give you an example: whether to treat TB right now, tuberculosis, which is an age old problem. I gather there are quite a few patients here who I suspect have TB. Now the problem is that they need six months’ treatment at the minimum, and we really don’t know whether this camp is going to be here for six months. So is it fair to start something where we may end up losing them in the move back to Rwanda or if they are displaced somewhere else? It’s a difficult debate. I see it on a one-to-one level. I see this patient. I see this patient can benefit from TB medication, but the powers that be, the higher forces have to make the decision whether you are going to basically save lives and whether it’s cost productive. There’s been experiences in refugee camps with TB programmes where they’ve had so many people default, basically not follow through on the treatment that that can also cause resistance to the antibiotics that we use, the medication we use, and it can worsen the problem. EB: So how do you deal with this dilemma on a personal basis? Basically, I didn’t come here with high expectations or need to fulfil my ego just to save lives. But I just wanted to do the best I could for the people, given what materials and the conditions were here. Maybe I could be accused of putting on the blinders a bit, but I think in this case, that’s enough for me.

MSF is an organisation where professionalism and amateurism are combined. Like you go to a job and you have a certain skill but you come there and you need about 10 skills, and you only have one. The other 9, you don’t know if you can adapt to what’s going to happen. But they give you the freedom to do so. You always find out that some skills you don’t have and you will never get, but at the end, you have sometimes more than what you think. EB: In other words, it’s a challenge. Yeah, it’s a challenge.

In general, I would like to work for an organisation which offers people the possibilities I had in Holland or in Europe. And why MSF? Because it’s a very pragmatic, efficient, short-term, and another reason is that it’s very basic. So we provide water, a place to sleep, health, a place to shit, very, very basic.

I think it’s really a great challenge. You get a lot of freedom to do things the way you want, and you work very closely together with local people, and that’s what I really like very much.

I like the idea of hopefully encouraging people to use the resources available to them in the country that they are in.

What I also appreciate is the fact that MSF accumulates and keeps a record of the experiences and information that have come out of many different situations all over the world. So the whole process of learning how to deal with the medical and other needs of people in emergency situations is a growing one, an evolving one, and one that is continually under analysis. And I really appreciate and value that, and I’ve learned a great deal through being associated with MSF.

For me, it’s a challenge. I’m a medical doctor and I like to put my skills in this type of extreme situations. And what I like also very much with MSF is that you work a lot with local experts, and many times you are more a facilitator and give them the possibility to solve their problems, their own problems. That’s very rewarding.

I’m in charge of the sanitation programme, says Jean de Dieu Ngaraya, a Rwandan refugee who works for MSF Holland in Katale camp. We began by building family latrines because in Rwanda, families have their own toilets. We haven’t built latrines for everyone, but since the ground is volcanic and it’s extremely hard, we provide material and equipment to those families who want to dig a hole. We also build public latrines. All the waste is picked up every day by six trucks. We divide the waste in separate categories. We collect about 120 metric tonnes every day.

EB: So now we’re walking up to where they dump the excrements. And the Rwandan here is warning me about the pungent perfume that will be emitted by these big plastic containers which they dump into this big hole. So he was saying that before they bring the waste here, they treat the waste so it doesn’t smell, and he was also emphasising that there are no flies whatsoever here. The waste is actually quite clean in essence. In essence, that’s very true. They have chlorine in the buckets. We’ve got lime in stock. Originally the intention was to put lime on top, but so far it hasn’t been necessary. As you can see, there’s no problem with flies at the moment, although we are thinking about putting some baits around the edges because obviously there’s going to be a lot of maggots down there and if they come out, they can get to sort of bait and hopefully die. But at the moment, there’s no problem. It’s working very, very well.

The thing that makes it so difficult here in Zaire with the refugees from Rwanda is this whole genocide aspect and the fact that there are amongst your population, your target population, there are many people that probably have been killers and they might be killers again in the future. EB: MSF France pulled out a couple of months ago because of that and also because of violence within the camps. How do you feel about MSF Holland here? MSF Holland has a task to perform here. I don’t think we are the only ones. With us, there are many organisations. We still reach our population, and the population is very mixed. It’s a lot of children. It’s a lot of unaccompanied minors. It’s a lot of women. It’s a lot of female-headed households which have a difficult time, and it’s also a lot of men. I think that as long as we feel that we are reaching the weakest, we should stay.

OK, base, I’m turning off the handset for about half an hour. If there’s anything with security, you can go to Yolo, over. OK, Anita, that is all copied. So you are in a meeting now, over? Well, kind of yes, over. OK, that’s well copied Anita. Thank you for the information. I’ll do so. Anything else, over? Negative, over. OK, well copied. OK, I’ll see you later. Base out.

EB: Carol, you are one of the radio operators here. We’ve got a board with all the names of the people here in Médecins sans Frontières. What are you doing? I’m just completing the board about the transportation of some local staff and from problems of security in the compound. So when there is a car going outside, I’ve got to write it down because I can remember easily where somebody has gone and so I can just tell the information to people who are looking for the information about the transportation. EB: So you know at all times where everybody is. That’s affirmative. Yes. That’s correct. I’ve got to know at any moment where somebody is. EB: And it’s because of the security situation in and around Goma. Yeah in Goma and in the camp and in the base. If there is a problem happening downtown, I’ve got to take the information and dispatch it, to tell people to be careful and to not move in town.

In general, safety is very relative. Of course, there are grenades and you hear things. But I think as long as you have the feeling that you are well informed and that you have more or less all the information you need to make a good decision whether to stay or to leave, till that point I think that there is no problem.

I think that the security issues are related to expectations as well, and that’s why you almost join MSF because you know that you are going to be in situations that may not be particularly comfortable. The comment about being well informed is very important. You make the rules up as you go along with that incoming information.

I always find that it depends on who you are here for, if you are here for yourself or if you are here for the people that you are supposed to help. In that respect, it’s always difficult with all these problems. If you look at the people that are in need, then you know exactly why you are here. And as long as they are in need and there’s people suffering, it’s a reason for me to stay here.

Yes, H2, go ahead, over….

 We think that the crisis situation that the world is in at the moment, like the Rwanda crisis, which is a real genocide, that we should really tackle those crises at the roots, and that’s to prevent a genocide and not only to react on genocide by humanitarian action. What we saw in April and in May in Rwanda was a huge genocide, and the international community reacted by withdrawing those people, UN forces, who could have protected the people being threatened. So those people were not protected by the international community, and a few weeks later, we saw a huge humanitarian response in the sense of giving assistance to the refugees. Giving humanitarian assistance is very necessary but preventing a genocide from occurring is more important. So this development is a cumbersome development for us as humanitarian aid workers being in the frontlines of crisis situations. We think that this development is a bad development that the international community has only the political will to respond in a humanitarian assistance-like way and not in a real political way to prevent crises.

EB: I’m now in another part of the camp with Andrea McFean. We’re in front of this hut that is being built. What is this? It’s actually called a tukal. It’s an African house. We’re hoping that we can use it as a sort of mini community centre for the mums and kids that come as guarde malade for the sick children. EB: Why do you need a place like this? Can’t the women and children just stay in tents? They could do, but it’s not the best. It gives them a bit of a respite from the tents and the continual air of sickness around. It gives them a bit of a break, and they get a chance to congregate and perhaps we can do a bit of health education with them, and moms get to discuss what’s going on outside their tents. EB: Is it also very important for you and for the people working at MSF to actually improve the living standards, to make life more enjoyable for people here, despite the horrible conditions? Well for sure. Everybody wants a bit of stability in their life and I think if giving them an opportunity to sit around as they perhaps do at home and discuss what’s going on and to get on with sort of everyday living, it’s good.

EB: How do you feel about the fact that MSF, Doctors without Borders, is increasingly taking a stance in conflicts or in zones where you are working? By doing the job, I think we are speaking out. You don’t have to speak out verbally to say what you feel.

I agree with you that it appears that MSF is more and more politicising in that direction, but the discussion is certainly not finished. The feeling here in the field is probably that doing your job and signing to the charter of MSF, it implies in certain cases that you do speak out or you don’t speak ou or you speak out by your presence. The discussion about if this has to be kept implicit or more open is not over yet and I don’t know which direction it’s heading.

Personally, I feel that in some cases, MSF really should speak out, like the forgotten areas of the world. In some cases, our focus could be mainly health.

Well, if I speak for myself personally, I sometimes find it difficult not to be able to speak out and take a stand, but I was part of the former team and we had lots of discussions about this thing, much more I think than now is the case. But also in the old team, there was a part of the people who said we should speak out more clearly. But mainly the things came from the office in Amsterdam who always sort of pushed us. In one way that was alright. Once you work here, you stop thinking. You just work. You’re so close together with the people here, so you forget what is also going on, and the information that came from the office, that used to make us think again and ask questions about what we’re doing here, and I thought that was really good but it was sometimes quite difficult ‘cause sometimes I’d like to speak out and say I think something has gone wrong here, but I know that can also be dangerous for us as a team and especially for the people in the camp. So it’s ambivalent.

I think it is not a duty of the humanitarian organisations to be unbiased. Our main role is to try and serve and to be close to the victims and to have a real impact on the victims. Even if we have to lose a bit of our neutrality in the strict sense, neutrality that we should not speak out and only do our daily humanitarian work, if we are following that line and if this has not enough impact to the victims, then we should look for other ways to serve the victims. And therefore MSF has chosen – it’s not really a new development, it’s only we are strengthening this course – is that MSF has always added to its humanitarian assistance the part of putting forward the context within which it is giving assistance. The moment when there is genocide, I think we cannot only respond by sending medicines, food and other material assistance. So we have also a duty to put the political side of the problem on the table because if we do not do that, our humanitarian aid can be misused, in the sense that we become an alibi for political paralysis in conflicts.

EB: Has the medical situation improved considerably over the past couple of months? Yes, we can actually show you graphs down there, showing you the malaria drop in frequency, drop in bloody diarrhoea, non-bloody diarrhoea. Most of the vital statistics have improved considerably since August.

EB: Some people have said that you can work for MSF for about 5 years and then you get burned out or you have to move on to something else. What does the future hold after MSF? Is it you’ve gained a lot of experience and this has profoundly changed your life or is it simply you go back to your old job? I work in Holland normally so I have my job there. I think it has personally changed me and I might not go back to my old job. It doesn’t mean I will continue working for MSF but do the same sort of work, yes.

My job is MSF at the moment, and the work you do for MSF does change your life. For me, it’s like an open end. Perhaps I will work for MSF for 5, 6, 7 more years. But I don’t know yet, and I think you can’t really predict the future in terms of what situations you will be in, and especially in those situations, there might be one day one incident which really affects your life in a very heavy way and you might decide to do something completely different.

Since I still like it, I will stay with MSF. The moment I think I have to move on to whatever it may be, I will. Also because of MSF, a lot of things can change. A year ago, I was working in Bosnia and suddenly I got married very happily I can add, and that’s already a big change I would say.

It’s definitely changed my life in that I don’t think I can go back to what I was doing before, simply because it has broadened my horizons, and I’ve met some really wonderful people nationally and internationally, apart from my husband, but…

EB: The cook guaranteed that the food would be good. Is it good? It’s wonderful. Absolutely. Oh yes, it’s fantastic. Fantastic!

You know that it’s a team and that you’ve got to work together and support each other. Though that might sound quite sicky actually, I don’t mean it like that at all. I just mean that your relationships tend to be very, very close, very intense, especially in these kinds of surroundings when you are living with 20 people and you get to know, sleeping, eating, normal habits plus work habits. I think that’s maybe another reason why you do join MSF because you do feel able to find your way through that.

I think that we’re also aware that the people we’re helping to heal or to improve quality of their lives are living in much, much worse circumstances than even we are on our very worst days. So, that sort of puts it back into focus, as well as the team spirit and the sense people here are very like each other in many ways. It’s the same kind of spirit that brings people to Africa to do this kind of work. So there is a kinship in this community that can be developed.

I think that being in such a situation is at times so challenging or so adventurous. You are in a different country, you can make various trips, so there is also the possibility of relaxation. The arrival of mail is always a big event. But I think that home sickness is not really seen very much, no.

It’s the fact that there is no pub around the corner. There is no telephone cell. There is nothing actually. So what you can do is work and have a good time with each other. So that it doesn’t feel like you miss something because your whole world is doing the same. Sometimes of course the situation is difficult, but I still feel very privileged to be here. The situation is miserable. We work in a refugee camp. People live in awful situations, but still there are beautiful people. We have a beautiful nature around here. There is beautiful music. There is so much to enjoy here. There is so much to learn from those people.

“Healers without Borders” was produced and presented by Eric Beauchemin.