She is amputating the boy's arm and leg: In a spray of blood and bone chips, the surgeon's saw slices through the devastated tissue. The boy is 14. They have removed his right forearm below the elbow and his right leg below the knee, because a few hours earlier he had with foolish curiosity touched a land mine. Somehow he has managed to cling to life despite the shock and blood loss. Now his severed stumps flop like dead fish over the side of the stretcher as he is carried, unconscious, out of the operating room in Butare Hospital, on Rwanda's Burundi border.
The doctors of Médicins Sans Frontières (MSF)—Doctors Without Borders—are highly skilled in amputations; Rwandan MSFers are especially experienced in the repair of terrible mutilations, since the brutal Interhamwe militia often cut off victims' hands before (or sometimes in lieu of) killing them. “Sometimes I think, What are we doing here?” says a Dutch nurse named Selina. “Are we doing any good when 38 out of 40 children we see will be dead anyway? All this money we spend!” She pauses. “You have to take meaning in the small things. A grandmother whose grandchild died in Sudan didn't have anybody to help bury the child. I took the people from the Feeding Centre with shovels and I carried the dead child through the rain. We were sitting down. The child was lying there dead and the grandmother's slipper was broken, and while we fixed it she took a big knife and cut her toenails! And then we went on. Death is such a part of life here. They dug a hole and laid the child down and filled it up with leaves, and the grandfather said thanks to those who helped, and they went home.”
Humanitarian medicine is more than medical heroics. A woman once asked her for an empty medicine box, Selina recalls, because the cardboard would make a good wall for her house. “I like to do something for people. In these situations, if you are not going to do it, no one will do it—while if I don't go to work in Holland, another nurse will,” she explains. “It's not that we are doing more important things than raising a family or keeping a shop; it's all important. Sometimes I think it would be nice to have a family like my sisters have, but sometimes they think, ‘It would be nice to go everywhere like Selina.’ It's a need for me to do something for other people—but I'm doing it for myself, too.”
As our small team—myself, photographer Greg Locke, and artist Bonnie Leyton—endlessly crisscross Rwanda, we find a Scottish nurse, Julie, in a mobile hospital, a simple van trundling along the road searching for the weakest—“the vulnerables”—among thousands of refugees. She is reluctant to be interviewed; so severe is her discomfort that her face contorts into wooden self-consciousness. But the instant she takes her leave of us, the joy on her face—youthful exuberance, even exultation—returns. Her feet hardly touch the inch-deep mud as she glides from patient to patient.
The slimy mud road to Byumba cuts for miles through the exquisite greens of the terraced, conical Rwandan hills, perpetually topped with black storm clouds in the rainy season. Suddenly, the hospital van pulls onto a side road at the edge of a village; the rear and side doors spring open, a table slides out the back, and staff quickly assume their rehearsed positions. The lame and the halt form a queue behind the van. The first MSF assistant checks for fever by touching each face and chest; an aide hands out oral rehydrants to those who need them. Others await bandaging or a medical interview by the side of the van. Indifferent to the mud and omnipresent rain, Julie and her assistant prepare gauze bandages and antiseptic, watch for symptoms of cholera and malaria. They are utterly focused: There is silence, a calm fusion between medical worker and patient.
We spend the night at a gracious colonial MSF compound, where MSF newcomers brace themselves to meet increasing numbers of refugees. The tension mounts; people fear that the crisis may be too much to handle. Eighteen medical and administrative people will arrive in the next 24 hours; they will need food, mattresses, medical supplies, and instructions. The day after, 19 more will arrive as MSF mobilizes fully for the 1996 Rwandan emergency, dragging European and Canadian volunteers out of comfortable homes and aboard any air transport they can commandeer—23 physicians, 26 nurses, 29 logisticians, 15 water and sanitation experts, 19 administrators, 2 psychologists, and 2 epidemiologists, 116 volunteers in all.
The current best guess is that half a million “returnees” have crossed the Zaire-Rwanda border and are heading south toward us. Many wonder aloud if the returnees will bring the dreaded cholera with them, and if we are in for a repeat of 1994, when—in what has come to be called “the Judgment” for the nation's butchery—Rwandans began to sicken with cholera and to die.
The following morning, we return to the capital to find the emergency team house in chaos. Six Belgian and French MSFers, two Scandinavians, and a Canadian have arrived, exhausted and frustrated. They flew all night from Norway on a Ukrainian-crewed Ilyushin transport plane, its cargo bay stuffed with aid supplies; they slept on a bed of high-protein biscuits and urinated in Coca-Cola bottles.
Here in Kigali, those who have worked together on previous postings recognize each other as old friends. Amidst much hugging and squeals of delight, they grab foam mats and unload their possessions, including gifts of European cheeses, breads, and salamis. Those who plan ahead will briefly scrub their bodies under a cold shower. Together they boisterously depart for a restaurant meal on what will surely be their last free evening for many weeks. The next morning, some will notice that the cheeses are writhing with maggots, their fecundity inspired by the African heat. A press officer laughs. They have a sharp and bitter taste, these maggots.
The essence of MSF work is emergency, and “hospitals” are makeshift affairs at best. “Once a situation is stabilized, we hand it on to other organizations,” says a nurse. At Little Wall Camp on the Zairean border, an abandoned warehouse has been converted into a temporary hospital; its unpaved “floor” consists of lumps of dusty volcanic rock awash in muddy puddles. Outside is the now-empty refugee camp; 16 corpses are pulled from its tents.
An assistant methodically walks up and down each aisle, spraying a cloud of disinfectant from a converted European garden-herbicide sprayer. A 10-year-old girl, abandoned by her parents, will not eat. An MSF press officer says the child “wishes to die,” but he coaxes her until she reluctantly takes a mouthful. He estimates the organization is giving 1,000 oral rehydrations and 200 intravenous drips each day on this short stretch of road.
People regard MSFers with awe —or bewilderment. They see women and men who abandon comfortable sinecures in Canada and Europe to heal the sick, often under savage conditions: tormented by extremes of heat or cold, bitten by poisonous snakes and insects. They calmly go about their business in the midst of Third World genocides, plagues, famines, and floods, dispatching colleagues to new posts with the traditional adieu: “Have fun!” They might have dry toast and coffee for breakfast and a hurried meal in the evening, then sleep for a few hours before returning to work the following morning fueled only by more coffee and toast. All this for an airline ticket, room and board, and a few hundred dollars each month.
The workers are sometimes stricken with malaria or diarrhea, and they run the risk of contracting typhoid and cholera. From Chechnya to Yugoslavia, Rwanda to Cambodia, they increasingly are targets for local death squads, as political factions begin to see them as useful pawns in the political process and as dangerous witnesses to their activities.
It is only natural for us to see people who voluntarily embrace such hazards as heroes or saints pursuing private, perhaps mystical, visions. But MSFers themselves are ambivalent about their image. Frank, a Canadian M.D. who often walked alone and unarmed into the Zairean jungle with his medical kit on his back, remembers being held captive for three hours while drunken militiamen fought over the soap he carried in his backpack. “What am I doing here?” he asked himself. “I'm catching the next plane home.” But as the adrenaline and the shaking fear left his body, so did the desire to abandon his mission. Jean, another Canadian physician, recalled the time she and some other women medical workers in a Kurdish refugee camp in Turkey overheard Turkish army soldiers planning to break down their doors and rape them. The women shouted and made tough, angry noises, she recalled, then added, “Well, they were just going to rape us, not kill us.”
Yet nothing irritates MSFers more than being called heroes. This is no false modesty; their motivations for joining are often quite mundane—unemployment or underemployment at home, rebellion against boredom, a thirst for adventure and meaning. Few seem to miss their other lives, awash in the ennui of dispensing prescriptions, bedpans, and bandages for the largely self-inflicted wounds of an industrial nation's secure, overfed population. Yet there appears to be a private, rarely articulated, satisfaction that engages and sustains them. There must be, since in 1994 alone there were 2,950 MSFers working in 64 countries, from Afghanistan to Zimbabwe. And they return to their posts again and again, sometimes for years.
“There aren't many naive idealists in MSF,” says Leslie, a 33-year-old Canadian M.D. working in Zaire. “I can't imagine doing a run-of-the-mill family practice after this. At home, the shooting and shelling sounds horrible, but here you just deal with it. Look, there are a lot of people who do this because they can't get a job at home, or at least they can't get an interesting job at home. Over here, people in their 20s are handed huge responsibilities: a chance to manage huge budgets, big staffs. Nobody comes here to help ‘the poor and the suffering’ anymore, and I'm tired of people asking me, ‘How can you do this?’ We like this work. We like the lifestyle. It's a culture of its own.
“I find it difficult with my friends in Canada when I go back because they don't follow what goes on in these places. That's why a lot of people in this business sign on for mission after mission—because they find you just can't go home.”
Charles, an emergency team member, needs the adrenaline high: “I tried hang gliding, then skydiving. I want to live on the edge! You're at the border with all those people running toward you; you don't stick to your ‘job description.’ ”
British press officer Amanda thinks many join MSF to escape from boredom: “It's more fun than sitting in an office. After running a hospital and doing surgery, you could never be a nurse in Europe and wear your funny little hat again.” Amanda's “worst nightmare” is marriage, children, and a mortgage: “I love Africa. Here, everything is real, not phony; it's life or death.”
Others' tales mix sentiment with a taste for the exotic. A shambling German giant, Völker, toils as a logistician in bandit-ridden, snake- and scorpion-infested Sudan. Like most MSFers, he smokes constantly; occasionally he sets his mosquito net on fire, shouts his characteristic “damn shit!” and stuffs a sock or two into the hole. He struggles to explain: “When I first came, a boy and all his friends they walked by my side and held my hand everywhere—that's what kept me going.”
Still others express political motivation. Cathy, a Canadian press officer, joined MSF after one stint with an Antarctic ecotourism company and another on a collective farm in then-Soviet Armenia. When I asked why she cared so much, she shouted, “Don't! You'll make me cry,” then bolted to another room to sob. “That was a good question,” she said when she returned.
“That was a good answer,” replied a colleague nearby.
Georg, a Scandinavian physician, talks about the unanticipated consequences of aid agencies' efforts in the Third World. “In fact, our work here has less practical effect than in Norway,” he says. “I don't see this work as being more useful, or productive—it's not that.” What matters most to him flows from his profound, contagious spirituality. “I can take part in a transcultural reaching out of a hand—putting yourself at their disposal as a sign of respect. We don't really know what our impact is, but it's an attitude we want to propagate. We want to break barriers across borders. We are very good at what we're doing, and we are motivated in a way that government agencies will never be because they're paid for it—it's not a commitment to them. That's our real strength.”
“I wanted to come,” says Nancy, a French nurse, sheltered from the heavy rain by a windswept tent in north Rwanda, rivulets of soupy mud swirling at her feet. At first she had mixed feelings about joining MSF: “I wanted to help, but I didn't know what could be done. I'm a nurse. I can have a job in France, not like the logisticians.” She talks to us as she works, feeling foreheads and bandaging wounds. “Your energy has more results here than in France—it's multiplied many times. I like my job in France, but it is difficult to top this.”
Elliott Leyton is a professor of anthropology at Memorial University in Newfoundland, Canada. Adapted from Touched by Fire: Doctors Without Borders in a Third World Crisis by Elliott Leyton with photographs by Greg Locke. Published by McClelland & Stewart, Inc., the Canadian publishers. Reprinted by written permission of the publisher.