Interview with Damien Brown, author of "Band aid for a broken leg: Being a doctor with no borders (and other ways to stay single)"
LONDON (Thomson Reuters Foundation) – The title of Damien Brown's book about his first postings with Medecins Sans Frontieres (MSF) was taken from a conversation with a colleague over a few beers in Nairobi.
It was in the wake of Kenya's 2008 post-election chaos and they were wondering what the point was, what were they doing - and did it make any real difference? Brown's friend, a French logistics expert, a veteran of humanitarian crises, said the job was a bit like sticking band aids on broken legs. It seemed like a fair observation.
Brown says the book, "Band aid for a broken leg: A doctor with no borders (and other ways to stay single)" is his attempt to write the book he wished he had read before being sent to Mavinga, a dusty outpost in southern Angola, where he was the only doctor for miles around.
During his first week in Mavinga, Brown treats a man who has been mauled by a leopard, is invited to a wedding where a mosquito net is deemed the best gift for the bride and groom, and is tested by his colleagues – Angolan war veterans-turned-health workers – who walk out when he decides not to operate on a woman with late stage cancer.
A funny, moving account, the book captures the intense highs and deep lows of working in a hospital that has no oxygen, machines or electronic equipment, in a town so remote it takes three months for medical supplies to arrive by plane and so cut off there's little chance of the kind of sexual adventures promised by "Emergency Sex", an infamous account of life in the field by three U.N. workers.
Both inspired and at times overwhelmed by his six months in Mavinga, Brown, an Australian who grew up in Cape Town, South Africa, goes back to MSF for more. He is sent to Mozambique and what is now South Sudan.
In one pivotal incident, a South Sudanese man refuses to give his consent to a life-saving blood transfusion and operation for his wife, who has suffered a rare molar pregnancy in which clumps of poorly formed embryonic tissues develop instead of a baby. His decision effectively condemns her to bleed to death.
It's too much for Brown, who quits soon afterwards.
The Thomson Reuters Foundation spoke to Brown, now studying for a Masters in International Medicine at the London School of Hygiene and Tropical Medicine, about cultural misunderstandings, compassion fatigue and whether it was worth it.
Q: What compelled you to write this book?
A: Writing was definitely my own personal therapy. I blogged and wrote my own notes as a bit of therapy.
The one thing I noticed every time I came home from the postings was that everyone thought the contexts must have been awful, and there's a whole misconception of 'Wow, you must be so selfless and amazing to go there' – or – 'Jeez, that must have been a tragic, hideous experience'.
The thing I became increasingly obsessed about, struck by or really wanted to communicate was that constant juxtaposition of beautiful, beautiful, beautiful, heart-warming moments and these images of incredible resilience against this ugly, ugly backdrop. I really wanted to convey that because I had read so many books where people were like, ‘I've spent 30 years in the field, it's all bullshit, money goes nowhere’ and I read a couple of things where people overly romanticise. I've tried to write the book I wish I’d read before I went.
Q: The patient who is attacked by a leopard walks for two days to the MSF hospital and then refuses morphine, despite his injuries, saying the pain has gone. Was that resilience very common among your patients in Angola, Mozambique, South Sudan?
A: It was. And it was a big part of what I was trying to get across in the book. Another example that comes to mind was when one of our Angolan staff members, a health worker in his fifties, suffered a leg injury from an explosion in town one day. The injury wasn't life-threatening, but it did leave shrapnel in his leg, yet he refused to take the next day off to recover - instead arriving for ward rounds on his crutches.
So there was this incredible resilience, yes, but I was very wary of romanticising all this too. I remember the first time I saw a child die when I was in Africa ... The family went berserk. There was this incredibly physical outpouring of grief, and that blew me away ... I really thought people would take it in their stride. And that's the kind of image you have - that's life out there, people just roll, they don't even moan in labour. And that's true to some degree. But they also suffer greatly at times. They mourn horrifically for loved ones. Certainly far more visibly than people back home.
People get angry too. Some of our patients in South Sudan got angry, like in the TB treatment village. It would be week three of their six months of therapy, and you go to see them and some of these guys would be upset. 'This is nonsense. I'm not cured yet. What are you doing?' and sometimes they'd yell, they'd want to be better NOW.
So I didn't want to paint it as these people being pitiful, helpless victims, always quietly grateful for the foreign white doctor. They're tough. And they're proud, and I did get the impression that people that I saw didn't see themselves as victims. Seldom did I see any hints of self pity. They just got on with things.
Q: You describe Mavinga as the "most daunting, heartbreaking place you've ever walked into". When you look back, is there anything you would have done differently to better prepare for how daunting it was going to be?
A: I read the books I could find. I read as much as I could about the people. I spoke to as many people there as I could. But I think nothing really can ever prepare you for those first sights and sounds and smells.
I also feel in retrospect - it's important to be shocked or overwhelmed because that's when your impressions are really formed. So quickly - within a week or two - you've got a job to do, you get up and you sort of reset your threshold for what's normal. And that's normal. It's just a busy job.
Q: You're very honest about tensions between expats, who fly in for a few months and leave, and local staff, who have been there a long time. What advice would you give MSF volunteers about how to handle that sensitive relationship?
A: Someone gave me really good advice that I didn't follow because I was young and thought I knew all the answers. The best advice someone gave me was for the first two or three months - this is for a nine month project, mine ended up being six – for the first two or three months of your first project, go to work every day and listen and watch and ask questions and just observe. Obviously don't do nothing, you don't want to be completely hands-off but just understand that you are completely inexperienced.
That was good advice but then I found the big struggle I always had ... on the one hand being super-culturally sensitive and being everyone's mate and respecting that people might arrive an hour or two late, they might not give the medication when they're supposed to - and on the other hand, at the other extreme of the spectrum, I'm officially the manager of this hospital and my obligation begins and ends with patients and their outcomes, and whether these guys like me, whether they think I'm treating them respectfully and culturally sensitively is a very second, third, priority ... I always struggled with that dynamic, right up to the last day.
You just get there, humble yourself, watch and learn. Appreciate these guys may not do things that you've been taught to do, but they have their methods. This is their context, their people, their culture, their town. They grew up with these diseases that for you are exotic and rare. For them it's just childhood diseases.
You come away very often having learnt far more than you've taught.
Q: What did this experience in the field teach you about the rulebook and how important and relevant that is?
A: Just because you've been taught one way to do it does not mean it's the only way or the right way. I always felt it was a cruel irony that organisations, NGOs, generally send out relatively highly trained people - doctors, logisticians, nurses, people who have a lot of formal training and with that comes a very structured way of thinking and you're taught through uni and work to think in a very formalised way and then you have to undo that when you go. It's about realising there are other ways of doing things and letting go, and taking kudos again from the local staff.
Q: Did this experience of working with no X-ray machines or ultrasound and limited resources make you a better doctor?
A: You learn to be adaptable and you learn to let go of your rigid ways of thinking, but I'd be wary of romanticising. People make do there and cope but would I want that level of care for myself, my family? No. And I think we should aspire to something far better. It's the minimum acceptable standard and it's a sorry substitute in many ways.
People often say: medically what did you learn? What surprised me most was how the majority of conditions were incredibly easy to treat. For the most part, we saw really one in four or five things, particularly in the kids who made up most of the patients, and that's diarrhoea, dehydration, chest infections, malaria, and then any degree of malnutrition, TB ... but generally those things accounted for the majority of the work and they're incredibly easy to treat.
It was equally the most inspiring thing I'd done and disillusioning at the same time, because on the one hand you look at the scale of need – replicated in place after place after place - on the other hand, it's incredibly inspiring you can do so much for so little for the vast majority of people.
The vast majority of patients leave the hospital cured.
Q: You write about serious cultural misunderstandings. What examples stand out?
A: Often, with the health workers and the patients, I'd do my Western thing. No matter what you're going to do with the patient, start them on mild medication or whatever, you explain the whole thing to them - the diagnosis, the medication, why you want to do it and generally if you're on a ward round, you consult your colleagues, 'Do you agree with that? Does anyone have any problems?'
At times it was hilarious. (In response to) my very inclusive, democratic approach, these guys were like, 'This guy doesn't know what he's doing. He keeps asking us if we're cool with that'.
Or the patients, so often you would say, 'This is what I think we should do, these are the benefits, are you happy with that?' And they'd just look at you (as if to say) 'You're the doctor, are you actually asking me? Are you insane?'
Q: You were very honest about compassion fatigue and questions you had about whether it was worth it. Was it?
A: That really is the million dollar question isn't it? Is it worth it? Is the money worth it? Is the time worth it? What are we going to achieve. But what price do you put on a life? Who am I to sit in London or in Melbourne to say well, is it worth that amount of effort, that amount of donor funds because all we're doing is curing malaria six months at a time.
Well yeah, of course it's worth it. Those bigger questions are not for me to answer.
If you've got the means - the money and the resources to treat that person in front of you, today, now, I would argue that it's an absolute imperative.
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