Daniel Flecknoe is a Specialty Registrar for Public Health in the East Midlands and a Registered Nurse with ten years’ experience of emergency nursing, trauma & orthopaedics and overseas work. In 2008-09 he worked as a medical team leader for Medecins Sans Frontieres in North Darfur.
Everybody should travel. Travelling expands your horizons and gives you the chance to see scenes of amazing beauty, make new friends, learn new languages and understand more about the world & cultures foreign to your own. But along with the pleasures can come some painful shocks – the overwhelming poverty, ethnic divisions, oppression and helplessness inherent in the lives of many of the people you encounter, usually not too far off the well-trodden tourist track. This sort of thing can have a profound effect on your outlook. I can still clearly remember the shock of crossing from Israel into the West Bank in the late ‘90s, soldiers patrolling a border gate that seemed more like a time machine transporting me from the modern world into a miserable pre-technological past. I recall just as vividly the experience of reporting a theft to the local police while travelling in Borneo and then having to sit through the terrible noises that were made as they beat a confession out of a luckless suspect in the next room. I’m sure I am not the only white middle class British kid who only noticed the realities of massive economic inequality, state corruption and police brutality on leaving my own country, where all of those things also do exist (although not in equal measure to elsewhere in the world). Why is it so much more common for people like us to immerse ourselves in the cultures of South-East Asia or South America than in those of the most deprived parts of our own country? That was a lesson I didn’t learn until much later. But what I did notice was that by the time I had shed my early complacency about the conditions which a distressingly high proportion of the human race have to endure on a daily basis, travelling outside of Western Europe seemed to become a much more morally problematic affair. You might start to wonder if there’s anything that you should be doing about it.
There are obviously a good deal of things that can be done to further the cause of social & economic justice without leaving your own country, or even, in the internet age, your own armchair. However, I used to be an A&E nurse, and in general we are a group of people who like getting our hands dirty (both metaphorically & literally, although in the literal sense we’re also strongly committed to washing them between patients), so the idea of aid work appealed to me. From various bits of reading on the subject, I decided that Medecins Sans Frontieres (MSF) was the organisation that I wanted to work for on the basis of their reputation for independence, competence and neutrality.
Different aid organisations will all have slightly different entry requirements, but in general for nurses they are looking for several years’ experience at Band 6, preferably in an acute specialty, and either a Tropical Nursing Diploma or significant experience working in a resource-poor environment. I guided my early career with these requirements in mind, so that by the time I applied in 2008 I had done four years of A&E nursing (two at D Grade, back when that was still a thing, and two at Band 6), an expedition with Raleigh International and the Diploma in Tropical Nursing at the London School of Hygiene and Tropical Nursing. These were all intensely rewarding experiences in themselves, so I didn’t undertake any of them reluctantly, but I did definitely have my eye on my long-term strategy all the while. It’s always worth checking out the person specifications of dream jobs for which you are not even remotely qualified. That way, you can find out what you’ll need to do to MAKE yourself qualified for them.
At the same time I applied for six months’ unpaid leave from my A&E job. All NHS Trusts should have a policy on the different varieties of leave available, so it’s worth looking up in advance if you are thinking about doing this kind of thing. Having a job to come back to afterwards is quite nice, as I learned a few years earlier after returning from a period of travelling (for which I had quit my D grade job). Between the application, interview, police checks and HR processes I had to wait nearly four months before I could start my next A&E job, and stacked shelves in a local bookshop to earn my pennies in the meantime. Hopefully the majority of managers understand that the experience of working overseas will benefit your practice in all sorts of ways, and (if the alternative is losing you altogether) will be likely to authorise your unpaid leave. On the other hand, maybe you want to get out of your current job, but at least be brighter than I was and join an agency before you leave.
Having been accepted by MSF, I was sent on a ten day pre-mission training course in Barcelona, meeting other novice aid workers from all over the world and learning the basics from the brilliant team at MSF Spain. Shortly afterwards I was offered a position with a mission in North Darfur. You don’t exactly get to choose where you are sent, but you can of course decline an offered location. Keen to get my hands dirty, I accepted.
Darfur doesn’t lend itself to neat one-paragraph summaries. It is a huge region of Western Sudan, roughly the size of Spain, which has been the battleground for independence struggles and insurgency for decades. Tensions flared up in 2003 into a conflict between local armed groups and government-backed militias which the International Criminal Court has described as a genocide, and which continues in a low-level form to this day. Something like 500,000 people are estimated to have been killed and close to three million displaced by fighting, often forced to travel hundreds of miles from their homes. These persecuted and often traumatised exiles have grouped together for safety in makeshift “Internally Displaced Persons” (or IDP) camps all over the region.
My time in Darfur was an eye-opening experience. I worked primarily at an established medical facility located between two huge IDP camps. What is not at all apparent from most media coverage of aid work is the usual ratio of local to international staff. Virtually all MSF projects run a ratio of roughly one international to every ten local staff. Over 90% of the people who have been heroically working to control the recent Ebola epidemic in West Africa have been local people – West African doctors, nurses, pharmacists, engineers, builders. From most media accounts of these endeavours you could very easily get the impression that White people are single-handedly saving the world. The kindest interpretation I can put on this apparently literal colour-blindness in aid work reporting (which aid organisations do not always try very hard to correct) is that we tend to be more interested in stories about people who are in some way “like us”. It’s a pity though – an inaccuracy and a disservice to a lot of non-Western staff who do difficult and dangerous work.
It occurred to me while I was in Darfur that the local staff must regard me in rather the same way as I have (before and since) regarded a brand new SHO/F2 who has been rotated into my A&E department. I mean sure, he’s keen and hard-working but by the time he’s learned enough to be competent and useful here it’ll be time for him to leave! And if we’re unlucky he’ll be one of the arrogant ones who thinks he’s better than us and reckons he knows it all to begin with. I am sure that many others can recognise that feeling. Having realised this (fortunately quite early on) I did whatever I could to learn from and support my phenomenally competent and dedicated Darfurian colleagues on the project, and tried to avoid giving myself airs. Harder than it sounds when you’re doing something that you’ve been working towards for the last five years and are secretly quite proud of, but I did my best.
Our team of approximately 110 MSF staff (nurses, doctors, logisticians, drivers, guards, cooks – only four of us from outside of Africa) delivered nutritional and vaccination campaigns, mainly aimed at young children and pregnant or breastfeeding women, inpatient, outpatient, antenatal and maternity services, with community health workers and mobile clinics providing outreach into the camps and outlying villages. Most of the medicine we practiced was preventative, because in a resource-scarce environment that is basically all you can do. We had no imaging, no surgical facilities, only the simplest blood tests and a mere fraction of the formulary you would find in the most basic NHS ward. When I taught emergency first aid to the community health workers (at their request) we discussed the concept of chest compressions, but I explained that I didn’t propose to teach it. We were over 70miles from a defibrillator in any direction, so there didn’t seem to be much point. Training was one of the highlights of the whole experience for me though. It was great being able to pass on some of the medical education I have been privileged to receive, but really, I’d say that until you’ve watched forty people in flowing desert robes putting each other into the recovery position while studiously ignoring the intimidating buzz of helicopter gunships overhead, well, you’ve hardly lived.
The maternity side of things was also very satisfying at times. Our local midwives were a great bunch of characters who knew the limits of what we could and couldn’t manage. In cases of obstructed labour, from which mother and baby were both likely to die without intervention, we would undertake the strangely un-medical procedure of hiring a guy who owned a truck. We would then put a mattress in the back of the truck, put the expectant mother on that mattress with some friends for company and they would be driven for four or five hours (over very unsafe roads) to the nearest hospital capable of performing a c-section, which MSF would also pay for. More often than not, the next day we would hear over the radio “Mother and baby both doing well”, and feel that our presence, however low-tech, was ultimately justified.
Trying to deliver healthcare to a population of about 40,000 can be a tricky business when it is sometimes too dangerous to leave the compound. There were attempted raids and armed clashes nearby, and government planes would sometimes bomb rebel positions close enough to feel through the soles of your feet. There were times when I felt intensely angry about the way that the conflict was both harming the civilian population and also frustrating our efforts to help them. There were other times when I felt very scared indeed, but it was reassuring to be working for an organisation with enormous experience and well-rehearsed exit strategies. Twice we had to evacuate because of armed clashes in our town or direct attacks on our compound, and each time I was grateful for the smooth organisational competence on display.
MSF was definitely a life-changing experience for me. It got me interested in population health, which led me to do an MSc in public health and ultimately guided me towards my current job, which I enjoy very much. I do have the occasional withdrawal symptoms though, twinges that make me itchy to drop my established UK life and join a team of inspirational people working much too hard somewhere over that horizon. People who reject the idea that the right to health, and to a decent quality of life, somehow ends at the borders of certain countries. This isn’t a rescue mission – it’s offering solidarity and whatever help we can give to people who are already working to lift their own societies out of the hardship, conflict and misery which are usually the direct legacy of colonialism and the plundering of multi-national corporations. Many would argue that this is the least we can do.
All photographs courtesy of Daniel Flecknoe