Tatiana Zhelezniakova interviews Dr Damien Brown who recounts the challenges of medical humanitarianism, working for MSF and returning to First World medicine

4th year Medical Student
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Images by Richard Roche

(MSF), or Doctors Without Borders, as it’s known in English, remains one of the biggest organisations in the field of medical humanitarianism. It’s the go-to name for an aid NGO, the ultimate aspiration for any medical professional interested in international volunteer work. However, behind the scenes, it’s not just a smoothly run operation – while the successes are undoubtedly worth celebrating, there are many difficulties that arise while working for agencies like MSF. From trying to reconcile tolerance of human rights violations with the permission to remain on site to provide aid, to risking your own safety and health to help others, MSF missions are anything but straightforward.

Damien Brown is an Australian doctor and author of the book “A Band-Aid for a Broken Leg”, an incredible narrative of his time spent with MSF in Angola, Mozambique and South Sudan. Here, he has helped to provide an insight into how to get involved with agencies such as MSF, as well as to untangle some of the complexities of working for a humanitarian aid organisation.

At the end of “A Band-Aid for a Broken Leg” you’ve started working in rural Australia. What have you been up to since? Any plans for another book?

I’ve been trying to find the most effective way to straddle both worlds: keeping myself employable and skilled in Australia, while still being equally skilled enough in ways best suited to overseas work – and having the job flexibility to do both. It’s a work in progress! After I had finished writing, I undertook a masters at the London School of Tropical Medicine (I can’t recommend a diploma in tropical medicine at a place like that highly enough). I then came back to Oz to work with the Flying Doctors Service for a couple of years, mostly in Aboriginal Communities, and complete my fellowship training.

'As a doctor, you’re granted such privileged access to other people’s lives and worlds'

Last year I worked with MSF in Amsterdam as an advisor, and this year I’m back in Australia doing a year of anaesthetics. As far as another book goes, I’m very tempted to try to paint a little portrait of some of the people I’ve met in Aboriginal communities. It’s a difficult topic though – but fascinating. As a doctor, you’re granted such privileged access to other people’s lives and worlds.

There are marked cultural differences between many countries, what did you find particularly difficult to adjust to during your time in Africa?

The way that women are treated in some of the places I’ve worked. Without a doubt. That’s not to suggest that this is how it is in Africa in general, or anywhere in general for that matter, but it was highly confronting among some of the cultural groups I’ve worked with. For me, it presents a jarring, difficult clash between my role as a physician to do the right thing for my patient, first and foremost, versus other significant considerations – things such as the security of the team (it’s a high priority to not offend local customs or clan sensibilities). The reality is that you’re there to work with, not against, the communities and cultures you’re in; but their values can clash strongly with your own, and with the best interests of the patient. It’s a difficult thing to reconcile.

In many English-speaking countries, people are often very complacent about learning additional languages. What’s the best way to get a language crash course in adulthood, and which languages do you think are the most useful for a career with agencies such as MSF?

Start learning now! Immersion is the key. Do your weekly evening classes, but then go spend a couple of months in your term breaks in a French – or an Arabic-speaking country (you’ll never have as many holidays again as when you’re a student!). French and Arabic are incredibly handy.

As a student, what do you think is the best way to shape your studies and extracurricular activities in order to be a desirable candidate for MSF (and, perhaps, other international agencies)?

Learn a language. Read widely. When you are a junior doctor, do as broad a range of rotations as you can – A&E (lots), Paediatrics, Obstetrics and Gynaecology, etc. Do a diploma of tropical medicine (3 months in length), and maybe chip away at an MPH (Masters of Public Health), if you have time as a student.

'they’re looking for someone who knows what they’re about to sign up for, and who are likely to cope – and to be effective doctors and sane colleagues'

Also, travel to low-income countries, and try to get a position as an observer at a hospital or an elective student somewhere – NGOs are looking for people who are going to be comfortable living in the field, and comfortable dealing with other cultures and difficult situations. Having been there before demonstrates that you have a somewhat realistic notion of what you’re getting yourself in for. My experience is that they’re not looking to hire someone who wants to be a hero or change the world: they’re looking for someone who knows what they’re about to sign up for, and who are likely to cope – and to be effective doctors and sane colleagues.

Do you think there’s a ‘celebrity’ factor drawing people to MSF as opposed to other aid agencies with perhaps just as much of an impact?

Yes. I’ve heard many people say that they want to ‘get MSF on their CV’, as opposed to saying that they’d like to just volunteer, whatever the organisation. I’m guilty of being lured by the MSF brand myself; I started with a very small organisation, and then stepped away to volunteer with MSF. I loved the smaller organisation, but there are advantages to MSF that I wanted to see for myself – they’re big, they have great resources, and they’ve developed many of the industry guidelines.

They also cover all costs (some organisations don’t, but some actually pay a decent salary), and it’s hard not to like MSF’s principles. Their supply chain is impressive, which, as a doctor, means you’ll have the drugs and essential equipment you need – for the most part – wherever you are. This is a huge thing. As is staffing. It’s one thing being a doctor in the field, but if you don’t have the backup of logisticians, water engineers, administration and coordination people, among many others, you’re not going to be particularly effective. Overall many people swap between organisations though, coming and going both ways. All have their various pros and cons; I’m yet to hear about or encounter the perfect organisation.

One of the key differences MSF holds over other agencies is the principle of témoignage – the promise to ‘witness’ and to bring abuses and intolerable situations to the public eye, rather than continue to provide medical aid regardless of the atrocities seen in countries of operation. However, it’s been the cause of much debate over the years. How do you feel about aid organisations getting involved in more than humanitarian relief?

'What do you do if you know that speaking out on behalf of victims, who otherwise would have no voice, may lead to you being expelled from the region?'

This issue creates a lot of debate within MSF. (They’ve previously published a book, ‘Condemned to Repeat’, that recounts some of their past experiences with this. I should also note that I don’t currently work for MSF, so I’m not answering this on their behalf.) There’s no single way of applying this principle that works for the many troubled contexts in which they work. In my opinion, the principle of speaking out usually meshes well with, and often supports, the medical and humanitarian objectives; at other times, it can cause difficult dilemmas. What do you do if you know that speaking out on behalf of victims, who otherwise would have no voice, may lead to you being expelled from the region? And, therefore, no longer be able to provide help to these same people? Speaking out may well raise local and international awareness of atrocities and lead to pressure against the perpetrators, but your expulsion from the area will, in the meantime, result in a lack of medical care for the victims you’re ultimately trying to assist. Speaking out may also compromise the security of the teams who’re trying to provide assistance. Which are the more compelling needs, and how do you triage these?

For those who choose to leave the MSF, what is the main push factor? The strain of the work, the emotional hit, the frustration with the way the agency runs its missions or something else entirely?

Almost half of all volunteers only undertake one mission, and the attrition rate is about the same again for each subsequent posting. For many, I suspect that professional and life commitments intervene: mortgages, relationships, family commitments, medical training, and so on. In my experience, the medical work itself isn’t usually the most difficult aspect; it can definitely be wearying (I left one of my projects burned out and exhausted from endless on-calls due to staff shortages); but I think most volunteers step into that arena expecting to be challenged and are prepared for as much. The medical work is incredibly rewarding at times, and invariably immensely stimulating.

It’s the social aspects of living in a project that can be the real challenge: spending 6-9 months with a small group of passionate, opinionated, usually single strangers is like a season of Big Brother on steroids. I had some great teams, a highlight of my time, but I’ve seen some pretty dysfunctional groups. (Medics, Missionaries, Misfits, Mercenaries, and Madmen – so they say of the five types of people who end up in these places. And you ain’t seen awkward team dynamics until 3 overlapping love triangles exist at the dinner table of just 11 people, you trying to work amicably among them all.) The living conditions can also add to the difficulty. Falling asleep inside a mud hut, just beside a river in South Sudan, is amazing – the first fifty times. It’s far less romantic when the hot season hits and you have no ventilation, and have to leg it for the latrine a half-dozen times in a night for your third bout of diarrhoea that month, or wake up to see the cook washing breakfast dishes with dirty water (which presumably accounts for one’s diarrhoea). And then of course there are the cultural aspects – usually a hugely wonderful thing to be introduced to, but that can also create some significant difficulties (see above example re: the way women are sometimes treated). And the bureaucracy and administrative inefficiencies – these can be maddening.

What was the hardest thing about going back to practising medicine in a resource-rich country?

'The cliché is that coming home is far more difficult than going to the field. It’s true.'

 The inordinate resources, and the expectation that this is how it just should be. Like the UK, Australia has universal healthcare. I’m working in theatre at the moment (doing some anaesthetics), and no expense is spared: 80-something year old patients having cardiac bypass surgery, morbidly obese patients having joint surgery when weight loss alone would probably have helped considerably, and so on. I don’t begrudge it: it’s a level of healthcare I want for myself, and my family. But having seen women in their early thirties palliated overseas because their breast cancer simply cannot be operated on – ever; and having sent 20-something year old patients home to die from renal failure, because the nearest dialysis machine is two borders and a lifetime’s income away, I wince at the disparities sometimes. (And don’t even get me started on doctors here complaining about not being paid their 45 minutes overtime last week…!). It’s a difficult transition. The cliché is that coming home is far more difficult than going to the field. It’s true.

It seems that often it’s easier to enjoy privilege when you don’t know any different. Do you ever wish you hadn’t got involved with medicine outside of the First World?

No. And a little bit yes. But overwhelmingly no! Working in these troubled places has without a doubt been the most rewarding and fascinating aspect of my life as a doctor, and the biggest of learning experiences. The downside is that it sets you up for that reverse culture shock on coming home – every time you come home. There are times when I think it’d have been easier to become an inner city specialist, make my fortune and reputation and then go do something like this when I’m retired, rather than move back and forth like this. But, to paraphrase an aid worker I’d heard years ago, I’m quite sure I get far more out of these experiences than I’d possibly give back to my patients. It’s immensely enriching. And a huge privilege. And it can surely only make one a better doctor all round – wherever one works. (And perhaps also a more broke, more single doctor).