In 2016, Courtney Bercan, a nurse from Vancouver, Canada, worked with Doctors Without Borders/Médecins Sans Frontières (MSF) on a search-and-rescue boat in the Mediterranean, the Dignity I. In December 2018, MSF was forced to stop operations of its last rescue boat in the Mediterranean, the Aquarius, due to political pressure from several European countries.

This news triggered harrowing memories for Courtney.

Years later, I still don’t want to think about it, let alone type it out. Three children, babies practically, dead before me. Their parents, dead beside them.

It is now two years since I was on a Doctors Without Borders search and rescue vessel in the Mediterranean and it’s been a slow path to find healing and peace for the things we saw and experienced there.

As my life back in Canada settled into a predictable rhythm, the memories started coming out of the blue and with intensity. They demanded attention.

The process of finding closure for a patient’s death, while not always easy, is not usually this difficult. There are mitigating phrases to help you along the way:

“They were elderly and had had a good life.”

“We did everything we could.”

“At least now they are out of pain.”

As health care professionals we rely on these phrases to keep us sane. But what do you tell yourself when none of them apply?

Those three children were the littlest bodies we recovered that day; their lives were short. Their time in Libya would have been characterized by deprivation and fear. Their parents would have agonized over whether to board an overcrowded dinghy with no life jackets, no realistic chance of making it to Europe, and little guarantee of rescue if they didn’t.

The trip would have been terrifying, uncomfortable, and exhausting. The sun beating down on them. Their throats parched after having run out of water. Fuel sloshing around the boat — stinging and burning their skin. I find it difficult to think about the flash of hope they must have had when they saw our rescue boat on the horizon.

But then someone slipped into the water, destabilizing the boat and the collective psyche. Panic ensued. The flimsy dinghy started to collapse, and the women and children in the middle and those sitting along the edges would have been among the first victims.

It’s impossible to piece together the exact sequence of events for many of those who drowned.

But what struck me about these babies when they were brought, lifeless, onto our ship was how plump they were. They were healthy and filled with potential until they drowned, just moments before we reached them.

They didn’t even have a chance.

There are no pat phrases in this scenario. No comforting words.

I have one specific memory that I had been suppressing. I rarely let my mind form a full picture of it. When I do, I am watching it from above — like it wasn’t really me there experiencing it. I try not to get too close to it.

I definitely can’t think about the cold skin, the tiny fingers, the wet clothes, the smell of gasoline… the fuel blisters. I really can’t handle the blisters.

I comfort myself with the thought that anyone who has worked with Doctors Without Borders has got to have these no-go zones in their mind, right? This is normal… right?

But the truth is, I knew it was time to go there because, months later, whether on a busy bus or an idyllic hike, this memory, among others, kept returning.

Podcast: "Good luck, my sister"

The memory felt identical to that moment on the boat: a rock of sadness making my chest so tight it’s difficult to breathe. A rapid pulse. A lump in my throat so big that I had to bite my cheeks to keep down. My squeaky voice replying, “I’m fine,” to a colleague who knew I clearly wasn’t. I knew they weren’t either. How could they have been? And finally, the reverberations of energy in my heart as I carefully cleaned the bodies of those babies while silently chanting: “I’m sorry. I’m sorry. I love you. I’m sorry”.

I’m learning to make space for these memories and how they fit into my normal, very privileged life, but there are certain things that I struggle to reconcile.

Nothing I do can make up for, or even begin to fix, the incredible injustice of the fact that this happened in the first place. There was no memorial for three small children who died 80 years too young, a few hundred kilometers from safety. No possibility of conveying to the parents how sorry, how desperately sorry I was, since their parents were lying in body bags next to them.

In that moment there was mainly, I’m embarrassed to admit, startling numbness and a desire to run as far away from that ship as I could. And part of me has been running ever since.

So how do I, years later, find a way to honor those little lives the way they would have been if they had had the fortune of being born with the “right” color skin or the “right” passport? How arrogant am I to even hope that I could?

I wish I had an answer to this question — an easy one, a hard one, an incomplete one… I’d take anything. But nothing makes the deaths of these children less brutal, painful, or unfair.

And perhaps truly accepting that is the only option.

After months of processing, I am starting to feel power in the pain these memories bring. In the tears that are flowing down my cheeks as I write this, and in the nausea and lightheadedness that wash over me with waves of sorrow and rage. Time after time the same phrase comes to me:

I was there with them.

There WITH them.

We were there.

In the end, all we could be was present.

And for the first time I see a small shard of light in the dark moments I spent with these kids: I may not have been a witness to their beautiful, short lives, but I was a witness to their deaths, and the pain of it lives in me.

It’s not enough — not even remotely enough. I don’t kid myself. I cannot know their names, their favorite games, or even where they were from, but I know that they were. I have the incredible honor of feeling the sorrow of their deaths.

The pain is not pleasant, but I wouldn’t change that we were there — if only to bear witness to the fact that these children existed and the injustice that they no longer do. And if pain is the price we pay for that, the price we pay for knowing and acknowledging the intrinsic value of the thousands of lives that continue to be lived and lost on the Mediterranean, then I will cherish it. I will not run from it.

Rest in Peace to the tens of thousands of people who have lost their lives so senselessly in Libya and on the Mediterranean while European leaders stood by and watched.

We will not forget you and we will not be silent.

Mediterranean: MSF rescue ship Aquarius forced to terminate operations

I Was a Witness To Their Deaths was originally published in MSF Passport on Medium, where people are continuing the conversation by highlighting and responding to this story.

By Dr. Dan Schnorr

Two rescuers pull people from the boat up the ladder and onto the main deck, where many of them immediately fall to the ground in a mixture of relief and exhaustion. Our team helps them to their feet, takes off their life jackets, and encourages them onward to make room for those that follow. One of the medics from Doctors Without Borders/Médecins Sans Frontières (MSF) triages them, looking them up and down in search of urgent medical conditions.

MSF then hands them a rescue kit containing clean clothes, a blanket, a bottle of water, and food, and says, “Welcome on board. You are safe.”

I finished training in emergency medicine in Oakland, California, in 2015. Shortly after graduating, I did my first assignment with Doctors Without Borders/Médecins Sans Frontières (MSF) for six months in South Sudan. After that, I moved to Los Angeles with my wife, where I currently work in a combination of community and academic practice settings.

My second assignment with MSF was for three months on the search and rescue vessel Aquarius.

This blog was inspired by the migrants that I met while working on board.

When I first sat down in the ship’s medical clinic to listen to these people recount the circumstances that brought them there, I could not believe what I was hearing. I wanted to relay some of the stories that stood out to me in as straightforward a manner as possible, while still preserving the patients’ privacy.

Everyone is entitled to their own opinion on how they think the world should respond to the migration crisis centered in Libya, but I think their opinions should be informed by the reality of the people that live it.

The Aquarius

The search and rescue vessel Aquarius has a crew of 30 people. There is the marine crew, which includes the captain, officers, engineers, and cooks. There is the search and rescue team, run by a European NGO called SOS Mediterranee. And then there is MSF. All responsibilities are shared, but mostly SOS performs the rescues, and MSF cares for the rescued people once they are aboard.

One of my responsibilities is to ensure the health of the entire crew. I take confidential medical histories on my colleagues and do my best to balance the duality in that relationship. I am also responsible for planning a helicopter medevac for any of them should the need arise. I want everyone to be healthy; because that’s my job, because that’s the only way that we can be successful at our mission, and because these are my friends.

With the support of the rest of the medical team, I train the entire crew in basic life support and mass casualty scenarios. There are many interesting considerations in preparing for these types of situations at sea, like how to move patients on stretchers through steep and narrow staircases, and how to prepare people with no medical background to assist in patient care and resuscitations should resources become overwhelmed.

Lastly, I am responsible for the health of the rescued people once they are on board. The main emergencies we are prepared to handle are hypothermia/exposure and drowning. We even have a ventilator (breathing machine) on board. We see patients in our two tiny cabin clinics. If a sick patient requires respiratory isolation or admission for observation, we are down to only one cabin.

There have been few true medical emergencies since I took over this job two months ago. But even still, once we have rescued people aboard, the medical team works non-stop. Virtually everyone we rescue has at least one medical complaint, and with good reason. They have been traveling for months from various countries in Africa and the Middle East, most recently fleeing horrific conditions in Libya by piling into severely overcrowded boats and risking their lives at sea. Most have not seen a doctor in years, if ever.

The Aquarius can safely transit the Mediterranean with 300 rescued people during the winter and 500 during the summer. They might be aboard for as little as 24 hours before arriving in Europe, which leaves time to treat only the most serious medical cases. We also have to screen everyone for infectious diseases like tuberculosis and scabies, which are naturally of particular concern to Italian public health authorities.

The task would be wholly impossible without the participation of the entire crew. Each crew member has his or her unique experience and responsibilities, though our duties always overlap, and we can only function when we work as a team.

MSF Sea on Twitter

Over the past few days the #Aquarius #MSF medical team did over 100 medical consultations. They typically see violence related injuries from people's journey into #Libya, injuries & conditions from their time in captivity & chronic diseases worsened due to lack of medical care.

The ship has seen an average of two mass casualty events per year since commencing operations in 2016. The last occurred a month before I arrived when many people were pulled from the water after being found floating face-down and lifeless. Resuscitation efforts began on our two fast rescue boats and continued uninterrupted until the patients arrived to our floating micro-hospital on the Aquarius.

Nine resuscitations were performed during that single rescue and six of them survived: a remarkable percentage. It’s not a miracle, but rather a testament to the foresight of those who planned this mission and the training and preparedness of the entire crew on board. I hope that nothing like this happens again, but if it does, I hope our team is ready to handle it. As much as anybody can be prepared for such a situation, I think we are.

First Transfer

The first transfer of rescued people onboard the Aquarius, was something I will never forget. Here’s the back story:

A merchant vessel had been working the oil fields off the Libyan coast when it suddenly found itself in the middle of two desperate situations. First, a wooden boat carrying 51 people started to break apart during the night and 21 people drowned. The merchant vessel happened upon the remaining 30 people the next day and took them aboard.

Later, they came across an overcrowded rubber boat carrying about 120 people, but the Libyan Coast Guard arrived on scene at about the same time. Determined not to be intercepted and returned to Libya against their will, 42 of these people swam for and were rescued by the merchant vessel. Those who remained on the rubber boat were picked up by the Libyan Coast Guard and brought back to a detention center in Libya, resulting in the separation of many people from their families.

Many feared that they would be taken back to Libya, and possibly punished for having fled.

Enter the Aquarius, the ship where I work as the doctor on-board. The Aquarius was tasked by Italian authorities with taking the rescued people on board and bringing them to a port of safety in Europe.

We met up with the merchant vessel in the middle of the night and launched two rescue boats to dock with them. The first boat contained the search a rescue coordinator, his deputy, an Arabic translator, and me. I was brought along to triage the rescued people so that if anyone was critically ill he or she could be transferred first.

I boarded the ship and found the 72 migrants sitting in single file, deathly quiet, waiting to find out what their fate would be. The crew of the merchant vessel had not told them anything about what was going on. Many feared that they would be taken back to Libya, and possibly punished for having fled. These were the people who saw others drown the day before and others captured and brought back to Libya.

I looked them all over and asked a few questions to see if anyone was ill. They all seemed fine. Then the deputy search and rescue coordinator announced that we were from a humanitarian organization and that we would be taking them aboard our ship and then onward to Italy. “Don’t worry. You are all safe now,” he said, and then it was translated to Arabic. The outpouring of emotion and relief was completely overwhelming.

People fell to the ground crying and shouted prayers of thanks into the sky at the top of their lungs.

There wasn’t a dry eye on the ship.

Once the rescued people were aboard the Aquarius, where they felt safe and their basic needs were attending to, many of the awful consequences of their ordeal began to bubble to the surface. One man from the shipwrecked boat told me that he saw his brother fall off the boat and disappear into the sea during the previous night. Another informed us that he had been separated from his 10 year-old son when the Libyan Coast Guard intercepted half of the people on his boat.

Through contacts in Libya, an MSF team member was able to arrange an emotional conversation from the Aquarius between this man and his son, once the latter had arrived at a detention center in Libya. We also traced another child, 7 years old, who was separated from her uncle in the sea wreck and brought to the same detention center. However she later disappeared, and to this day we don’t know where she is.

Pulled from the Sea

The people we rescue are amazing individuals.

They come from dozens of countries throughout Africa, the Middle East, and Asia. Many are fleeing war-torn and lawless lands in places such as Syria, Yemen, Afghanistan, Eritrea, Somalia, Sudan, and the Occupied Palestinian Territories.

They frequently start their journeys having been tricked into abusive contracts.

Many have been the victims of religious persecution and extortion by extremists and thugs. Their family members have been killed. They carry the financial hopes for entire communities on their shoulders, often traveling alone as young as 14 years old.

They frequently start their journeys having been tricked into abusive contracts. They might pay a few thousand Euros with the expectation of delivery to a place of safety or financial security, but once in a smuggler’s hands find that they have surrendered all control over their destiny. On the road many are sold as commodities and forced to work for free. Many are raped or forced to pay for passage or freedom with sex. They are held captive by the smuggling and trafficking networks, tortured by beatings, burning, and electrocution until they can convince a loved one back home to send more money.

I know this because the victims of these atrocities have told me so directly.

Untold numbers die en route. Those who make it to Libya are often detained arbitrarily. Many are held for months without adequate sanitation or food. Torture and rape become a part of daily life. Scabies eats at their skin. Infectious diseases like tuberculosis spread easily. Pregnant women give birth unattended in these unsanitary conditions.

Having survived all this, many refugees and migrants feel they have no choice but to risk their lives by piling into a unseaworthy and overcrowded boat to cross the Mediterranean. Their smugglers wait for good weather, and then send the boats out at night so that they have a chance of reaching international waters at 12 nautical miles from shore by daybreak. Most of the time they have no food and very little water.

Many become seasick.

An increasingly large proportion of them are intercepted by the Libyan Coast Guard and returned to Libya.

But if we find them first, they are given a life jacket and pulled into our fast rescue boats, which ferry them to the Aquarius.

Two rescuers pull people up the ladder of the boat landing and onto the main deck, where many of them immediately fall to the ground in a mixture of relief and exhaustion. Our team helps them to their feet, takes off their life jackets, and encourages them onward to make room for those that follow.

One of the MSF medics triages them, looking them up and down in search of urgent medical conditions. MSF then hands them a rescue kit containing clean clothes, a blanket, a bottle of water, and food, and says, “Welcome on board. You are safe.”

Some are concerned that we will return them to Libya, but once they are satisfied with our trustworthiness, many start to celebrate.

They get a welcome speech: “You may be here a few days. The bathrooms are over there. That area is for women only. This is when food is served. That is where you can refill your water bottles. Also there is a doctor on board. If you are sick, come find one of us or wait on the white bench to be seen.”

One of the MSF medics triages all medical complaints on the deck. Many are dizzy or nauseous or complain of general body pain. Low-risk complaints can be treated on the spot on the deck with oral rehydration, Tylenol, or sea sickness medications. Those with more serious complaints eventually make it back to the clinic, away from the commotion and noise. The door is shut behind them and they have a private space, likely for the first time since they started their journey many months ago. Someone is paying attention to them, taking their vital signs. I sit across from him or her wearing a white vest and a stethoscope around my neck.

I shake their hand and ask how I can help.

Medical Ship’s Log

For many of the medical conditions I encounter among the rescued people on the Aquarius, we have a ready treatment available. For instance, a bacterial skin infection can be treated with oral antibiotics. Hypothermia in winter months may require only a change of clothes, but we also have heat packs and warmed intravenous fluids should we need them. Seasickness can be treated with oral or intramuscular medications.

Some conditions are unique to the Aquarius, such as fuel burns. These occur due to a chemical reaction between salt water and engine fuel. When the unseaworthy rubber boats inevitably take on water, some fuel spills out and burns the skin of those crowded into the bottom of the boat. These burns can be deep and are always very painful.

The most extensive burn I saw involved deep blistering over 13 percent of the woman’s body surface area. She told me that she had been burned so badly because she had positioned herself to protect the pregnant women on board from the fuel. Her pain was so intense that she had to be sedated into a light coma in order to change her dressings.

We screen for fuel burns as soon as rescued people board the Aquarius. If there is one, there are likely to be many, and if we can act fast to wash off the fuel before it eats away the skin, we can avoid progression of the injury. Thanks to the logistical ingenuity of our predecessors on board, we have a deck shower system that can be started within a minute or so via a clever pulley system.

We also see a lot of infected scabies. I see uncomplicated scabies very frequently in my work in emergency rooms in the United States, usually among homeless populations. This is an infestation involving mites that burrow under the skin to lay eggs. It is benign and easily cured but causes intense itching.

A feared consequence of untreated scabies is “bacterial superinfection” or simply “infected scabies.” The mite’s burrowing and the patient’s scratching cause breakdown in the skin, allowing bacteria to enter and form abscesses. This can be disfiguring and in some instances can lead to life-threatening infections if the bacteria enters the bloodstream.

For men, the most common site for infected scabies is the genitals.

I see this most frequently among East African migrants, such as those from Eritrea or Somalia, because they generally endure the longest detentions in Libya. When I try to put myself in these patients’ shoes, I find that I can’t imagine sitting in a detention center day after day for months or a year as this type of infection is allowed to progress untreated. Certainly some die and others are permanently scarred from the bacteria. All suffer immensely. I am thankful to be a part of the team that can finally offer treatment to these people. For infected scabies, all that is needed is a shower, oral antibiotics, and local wound care.

MSF Sea on Twitter

These two brothers from Sierra Leone were evacuated from yesterday's rubber boat, along with many other children, pregnant women and vulnerable cases. #MSF's Doctor Dan is giving them all a medical check up. Photos: Yann Levy

Our diagnostic capabilities on the ship are limited. We see patients with unexplained bleeding, fevers, or weight loss, and I hope that by referring them for further evaluation in Europe, they may find a diagnosis and eventually a treatment. But even when the diagnosis is clear, there are many conditions that we can not treat. Often these are the result of violence endured along the migration route or in Libya.

There are broken bones that have already healed incorrectly.

There are hernias resulting from forced labor that will require surgery.

There are lacerations that are too old or infected to repair.

There are traumatic brain injuries, skeletal injuries, and scars from burns and electric shocks that will never fully heal.

We provide whatever psychological support we can. Often there is no proper space to do this, and it has to be done on a corner of the deck or sitting down on the floor in the storeroom.

One woman had been pregnant when she arrived in Libya, but her captors wanted her to work as a sex worker, which she refused. She was beaten and coerced into having an unsafe abortion, which involved forcing her to sit in scalding water, leaving deep, disfiguring scars throughout her legs and pelvis. She had also developed an internal infection in the abdomen that had eroded through the skin. This infection had been allowed to fester for seven months, and the woman was nothing but skin and bones when she arrived on board.

With intravenous antibiotics and supplemental nutrition, she started to improve in just the three days we had her in our care, but she would likely require multiple complicated surgeries before the wounds could heal. And she would likely never be able to conceive again.

Seeing this woman’s condition and trying to understand the circumstances that had allowed this to happen took an emotional toll on the entire medical team. I wondered how many women had undergone similar ordeals but did not survive.

MSF International on Twitter

Sometimes I think about what these women have gone through & I find it very difficult" Pregnant #displaced women & girls are a very vulnerable group attempting to cross the #MediterraneanSea. Listen to #midwife Jonquil's full story here: https://t.co/r5OgGiRwHA #IWD #IWD2018 https://t.co/in3KNZKOZt

There are many victims of sexual violence. We generally get to them too late to administer emergency contraception or medication to prevent HIV infection, both of which should be given within 72 hours of the assault. But we can treat them presumptively for other sexually transmitted diseases and refer them for further testing and treatment in Europe.

We provide whatever psychological support we can. Often there is no proper space to do this, and it has to be done on a corner of the deck, or sitting down on the floor in the storeroom. And often we have just a few minutes free before other responsibilities and other patients call. But we do still try to provide psychological first aid, as we are told that it can make a big difference. It is part of our mission on the Mediterranean to restore human dignity.

Medic on the RHIB

For my third three-week rotation on the Aquarius, it was my turn to be the “medic on the RHIB’s.” RHIB stands for Rigid Hulled Inflatable Boat. Built for speed, maneuverability, and buoyancy, these are the vehicles of choice for maritime search and rescue teams worldwide. I was excited to venture out of the clinic to provide the first-line medical assessment at sea. In this role I would assist with rescue operations where needed, but my main responsibility was to perform the initial medical assessment and triage of the people aboard a boat in distress. I would also resuscitate any critically ill patients while transporting them to the Aquarius.

The word “triage” is derived from “trier,” the French word for “to sort.” There are many tested strategies available to aid medical first responders in sorting the sick from the non-sick, so that time-sensitive interventions and preferential transport can be directed toward the most ill. All strategies involve assessment of some combination of the mechanism of injury, exam findings, vital signs, and patient characteristics, such as age and underlying medical conditions.

I pondered which strategy I would use, but soon learned that these types of methodical assessments are impossible when approaching an overcrowded rubber boat. These are meant to hold 40 people but are typically packed with 110–130. The hull is a flimsy inflatable rubber tube, and the floor is a slab of rubber with a few wooden beams laid across. Lucky people get seats straddling the tube, and the rest, including women and children, are made to stand in the middle.

Once at sea, the floor very quickly sags under their weight, so that the heads of those standing in the middle only reach the height of the feet of the people sitting on the inflatable hulls. The two sides of the boat are pulled towards one another and the people in the middle are squeezed together. Water enters to varying degrees, reaching anywhere from the knees to the necks of those inside. Mothers may need to hold their children above their heads to keep them out of the water. This mass of rubber and flesh is pushed along by a 40 horsepower engine, generally reaching a speed of no more than two nautical miles per hour.

Thousands of people have died trying to cross the Mediterranean in these types of boats. Some boats succumb to the weight of the passengers and sink. Those in the middle of the boat may be crushed or drown where they stand. Again and again though, rescued people tell us that they would rather risk dying this way than stay in Libya.

If the boat does not collapse, it is only by some miracle of coordinated weight distribution. If anything were to throw off this balance, say by the shifting of people provoked by an approaching rescue boat, the homeostasis is disturbed which could spell disaster. That is why we are taught that the first approach to a rescued boat is the most dangerous period of the rescue.

A cultural mediator stands at the bow of the RHIB and does his or her best, with words, body language, and tone of voice, to convey a sense of calm. Once that message is conveyed, we start distributing life jackets, and that’s when I am supposed to perform my assessment.

MSF Sea on Twitter

MSF's Cultural Mediator Hassan makes sure everyone is calm before today's rescue. On board now are 164 men, women & children from 12 different countries - including 49 unaccompanied minors & one pregnant woman. Photo: Anthony Jean

The first time I did this, I thought, “My job is pointless. These people are dehydrated, crammed together, soaked, vomiting. They all need evacuation as soon as possible. The order doesn’t matter.” But I tried to do my job as best I could, because for some sick person, a few minutes’ delay to medical care could make a huge difference. Of the many parameters typically taken into account in triage protocols, the only ones that I could see as applying here were:

1. general appearance (who looks sick or weak on a snap first impression)
2. age (extremes of age are more vulnerable and likely to get sick quicker)
3. self-reporting (just ask the people, “Is anyone sick?”)

The last one is the most reliable

In the case of my first rescue, they informed me that yes, one man is very sick. Then from the bowels of the boat, from underneath a mass of people where I could not even see, they produced a young man who seemed lifeless and handed him over their heads toward the RHIB. Two rescuers hauled him in and lowered him to the deck where he collapsed limply. He appeared very sick, so we made immediately for the Aquarius. I called over the radio that we would need a stretcher to meet us at the boat landing.

As we sped over the waves, I found thankfully that the man was breathing and had a faint pulse. With some vigorous shaking, I got him to produce an audible mumble. He wasn’t dead. He was just severely dehydrated from sea sickness, sun exposure, and lack of water. Once on board the Aquarius, he made a full recovery. But after seeing the condition of the rubber boat, I was surprised that we didn’t have many more patients presenting similarly.

Passengers waved at us to help, but we were ordered by European maritime authorities to stand by and not rescue.

The Human Toll of Being Caught in the Political Crossfire

As the migration crisis in the Central Mediterranean becomes more an issue of political concern to Europe, governments have started mounting barriers for Non-Governmental Agencies (NGOs) providing humanitarian assistance at sea. It is frustrating when government agencies stand between medical professionals and their patients, or between a search and rescue ship and a boat in distress. MSF’s charter states that that our organization “observes neutrality and impartiality in the name of universal medical ethics and the right to humanitarian assistance and claims full and unhindered freedom in the exercise of its functions.”

At times during my assignment the medical team has been called upon to speak up when political barriers prevented the Aquarius from helping those in need of care. The first such instance occurred when we spotted a rubber boat in distress. Its passengers waved at us to help, but we were ordered by European maritime authorities to stand by and not rescue. Control of the rescue was given to the Libyan coastguard, so that the people could be taken back to Libya instead of onward to a port of safety. However the Libyan coastguard was nowhere in sight.

It was only once our nurse on the RHIB (Rigid Hard Inflatable Boat) spotted a 16-day-old baby on board the rubber boat, and the medical team advocated that the newborn be evacuated immediately, that the authorities gave us the go-ahead to disembark the baby, along with her family, and any other medical cases. One could argue for all passengers on such a boat to be classified as “medical cases” since they are trapped in a position that is unquestionably hazardous to their health. But in this instance we were allowed to take only the most vulnerable and obviously ill, which ended up being young children, pregnant women, people with chronic medical conditions, and their families.

After we had evacuated the medical cases, we were instructed to leave the scene. At which point the Libyan coastguard arrived and took the remaining people back to Libya.

This was a morally wrenching situation for everyone involved.

Mediterranean: MSF's Search and Rescue Ship Aquarius Evacuates 39 Vulnerable People from Boat in Distress | Doctors Without Borders - USA

We tried our best to keep families together, but one woman was separated from her husband. It was difficult for our cultural mediator to keep everyone on the rubber boat calm, knowing himself that most of them would be returned to Libya after we left. I questioned that by rescuing only some people from the boat, had we actually done harm? Would the correct response have been to leave a newborn in that situation? The newborn’s mother had given birth unattended in a detention facility. Once on board the Aquarius we found that she had bled so severely during delivery that she would require a blood transfusion. What would have happened to her if we did not evacuate her?

Another notable event occurred after a small search and rescue NGO performed a rescue of 105 people. Due to the size of their ship, they were unable to transit the Mediterranean with rescued people on board, and the Aquarius met them at sea with the intention of transferring them to our ship. However the maritime officials refused to authorize the transfer, saying that they had not authorized the rescue in the first place. The other NGO followed us for a full day as we continued search and rescue operations and waited for authorization to make the transfer.

Finally in the evening, the ship called with a report that a child on board had begun vomiting blood. They requested that I visit their vessel to assist their doctor with this potentially life-threatening situation.

I arrived to find a crowded small boat and, as the weather deteriorated, many rescued people becoming sick. Their doctor had done a remarkable job of treating everyone in the helm room that doubled as her clinic, but her capacities were quickly becoming overwhelmed. And indeed, one child had been seasick for three days and was now vomiting blood, likely the result of a tear in the lining of his gastrointestinal tract resulting from sustained retching.

I described the situation to our project coordinator via radio, and eventually the authorities relented to the sustained pleas of both the Aquarius and the smaller NGO, and allowed us to transfer all rescued people aboard the Aquarius. We were happy with the result but frustrated that it required a child to deteriorate into a potentially life threatening situation in order to reach it. Once he was aboard the more stable Aquarius, and treated with sea-sickness medications, the child stopped vomiting, his blood levels stabilized, and he recovered completely.

Hundreds of people left adrift by political standoff in Europe

A TB Patient at Sea

We had a few critically ill patients on the Aquarius in my three months there. One patient I first noticed as we disembarked him from a wooden boat. He was very thin, so much so that the muscles on the side of his forehead had atrophied, a finding that we medical people call “temporal wasting.” There are many conditions that cause this. In Africa the two most important are AIDS and tuberculosis. Unfortunately, in the context of search and rescue of persons fleeing Libya, we must also consider forced starvation imposed by human traffickers and kidnappers as a possibility.

I was amazed that someone in his condition could make the journey.

However, in the next few days, as we got to know the predominantly Eritrean population from this wooden boat, it started to make sense. This group had been detained together for nine months. Their community was strong. They looked out for each other. Some of the wiser or more educated among them had assumed de facto leadership roles. One had training as a paramedic and had cared as best he could for the sick among them during those months, earning the nickname “Doc.” He helped me to identify people needing care who otherwise might have fallen through the cracks when we had more than 500 people on board.

When the rescue of this wooden boat was nearly completed, I boarded an RHIB heading back to the Aquarius along with 12 rescued people. As we approached the ship, the rescued men I rode with could see the hundreds of other rescued people onboard, smiling and cheering. They knew then that they would be safe. One of them suggested to the others that they offer a prayer of thanks, and they sang a beautiful hymn as we approached the boat landing. The next day was Sunday, and these Eritreans held a Mass on the deck. There was one leader and everyone else sat packed side by side and sang song after song in perfect unison. I imagine that this type of community and faith must have been a great comfort and sustaining force for them throughout the months of captivity in Libya.

I am convinced that it is only because of this strong community that the patient I described above was able to survive. This ill man is technically a boy; he gave his age as less than 18 years old. He had been traveling with one other boy his age. He told me that in the detention center in Libya he started to cough, and eventually developed nighttime fevers and sweats and weight loss: classic signs of tuberculosis. When he got to the Aquarius he could barely support his own weight and needed help to walk. As soon as he hit the deck, our nurses recognized that he was in critical condition, and diverted him from the other rescued people to our “pit-stop” area where they could take vital signs and a blood sugar level to make sure he was not in imminent risk of death. A day under the sun on a packed wooden boat without food or water could be enough to push someone in this condition over the edge.

We gave the boy oral rehydration salts and admitted him as an inpatient in order to watch him closely. Every night his temperature spiked and his heart raced and he appeared so weak. When he became febrile he could barely muster the strength to speak. We started antibiotics in case there was a bacterial infection underlying this syndrome, but predictably his fevers continued. We gave him special food designed for malnourished people, but he had little appetite, which is an ominous sign. When his blood pressure dropped, I became very worried. We had to start intravenous fluids, which is very risky for a malnourished individual.

On the night prior to our arrival in Sicily, I prepared a disembarkation report to hand over our medical referrals to the Italian public health authorities. I alerted them that among the more than 45 individuals whom we were referring for medical follow-up on land, we had one emergency case that would require an ambulance to meet us at the port for immediate transfer to a hospital. I also informed them that in addition to this one critically ill patient, we had three others who required respiratory isolation for suspected pulmonary tuberculosis.

When we arrived at port, as always, the doctor from the ministry of health was the first to board, along with four medical assistants, all donning full personal protective equipment including face masks and jumpsuits. I led them to our back clinic, where we had our respiratory isolation room.

The doctor immediately recognized the patient as a critical case and agreed to take him directly to a hospital. He asked if we needed a stretcher, and I was inclined to say yes, but when I asked the patient, he said no. He got out of the bed on his own, and then, supported by the other patients in the clinic, with whom he had been detained and grown ill in Libya, he walked down the long corridor to emerge into the sunlight on the main deck. Here he got his first glimpse of Europe. He was helped down the gangway as the cameras of the press that had gathered on shore swarmed in his face. And then his friends helped him into an ambulance and he was taken away.

I was moved by this scene. Having arrived in Italy, this boy would receive good medical care and would likely improve and survive his illness. It was fitting that those countrymen of his, with whom he had suffered for so long, and through whose support (quite literally) he managed to cross the Mediterranean, were the ones to finally deliver him to safety.

Thoughts After Coming Home

While at sea, the MSF team does our best to identify those needing medical care or those qualifying for special humanitarian protection. We know that once they are disembarked in a port of safety and we have handed them over to the Ministry of Health and other NGOs, we will no longer be able to follow their cases.

On shore their fate rests with various European security agencies, Italian health and human affairs authorities, and a smattering of NGOs that try to advocate for this population and fill some of the gaps left by an overstretched infrastructure for processing refugees and asylum-seekers.

It has been a pleasure to work with the Italian health workers who met us in port during my period on board. Despite the politicization of the migrant crisis, these individuals value the standing of medical professionals as non-partisan caregivers. They do their best to perform their own triage of the hundreds of rescued people, including dozens of medical referrals, we bring to them with each port call. They too have to decide how best to marshal scarce resources to benefit the sickest and most vulnerable. And I know that the decisions are not always easy.

Some rescued people will be granted asylum or protection to stay in Europe. Depending on their home country and individual circumstances, others will quickly be instructed to leave Italy, or may be deported. Many more will spend months or years in limbo in processing centers and reception centers, neither expelled nor granted the legal standing in Europe to start building a new life.

But the mission of the Aquarius ends with the delivery of people in distress to a port of safety. Our objectives are to prevent the loss of life at sea, provide medical care, and to restore human dignity. Within that narrow mandate, I think that we have been successful. We had no deaths in my three months on the boat, neither during rescues nor during transit to Europe. 1,359 people were pulled from the sea, and 1,359 people were delivered safely to port. We were very lucky, but also well-prepared.

One rubber boat that we approached was taking on water very fast, and looked about to collapse. The MSF team aboard the Aquarius prepared for a mass casualty event, by converting the shelter that usually serves as the sleeping quarters for rescued women into a makeshift trauma hospital. We were prepared to receive many drowning and trauma victims, however the SOS MEDITERRANEE search and rescue team was able to quickly and calmly offload the distressed passengers onto rescue rafts before anyone was injured. The only sick patient from that rescue had moderate hypothermia and recovered quickly.

Another time, the Aquarius transited the Mediterranean in rough weather with almost 300 people on board. At around midnight on the night prior to arrival in Sicily, I was finally finished treating patients and was going to sit down at the desk in our clinic to type up the disembarkation report detailing the medical conditions of the people on board. Just as I placed my coffee on the desk, the ship lurched violently to port, and everything in the room went crashing to the floor. Cabinets full of medical supplies were thrown open. I cursed, and wiped up the spilled coffee, but left everything else on the floor where it had fallen.

The waves outside had reached six meters. I had to type my report while standing because the only way I could keep myself steady over the keyboard was by constantly shifting my weight from side to side. This paled in comparison to the difficulties faced by those working outside. It was impossible to move on the deck without being knocked over. The logistician had fixed tight ropes running horizontally a few feet off the deck, so that rescued people could make their way to and from the bathroom. Large waves came crashing down on the rescued people, completely soaking them. The deck team had distributed survival bags to keep them dry.

No one slept until the weather subsided. But the next morning the sun rose over clear skies, and everyone made it to port in one piece. We can’t end the wars, conflict, instability, or oppressive circumstances that drive these people from their homes. And there is no easy counter to the trafficking networks that abuse them in this most vulnerable state. All we can do is try to treat people humanely within our capacity, and regardless of the political currents of the time. I think it is the right thing to do.

For the latest updates on our search and rescue activities, follow @MSF_Sea on Twitter

MSF Sea on Twitter

All 141 people rescued from #Mediterranean by #Aquarius 5 days ago have been disembarked in a safe place. https://t.co/ITcRy80xUv https://t.co/BdDqgLCz88

I worked onboard the Aquarius search and rescue ship earlier this year. was originally published in MSF Passport on Medium, where people are continuing the conversation by highlighting and responding to this story.

Dr. Rasha Khoury worked in a Doctors Without Borders/Médecins Sans Frontières (MSF) trauma facility in April and May 2017.

Disclaimer: The location of the project has been withheld to protect MSF patients and staff. Although abortion for medical reasons is legal in the country where the project operates, it is still a very sensitive issue.

My handheld radio crackled under my long dress. “Cars are leaving in 10 minutes.” I cursed under my breath. I needed to stabilize this patient before we could leave.

I radioed back, “Can we hold the departure time?”

The field coordinator finally texted: Ok, but keep me posted.

Delaying the Doctors Without Borders/Médecins Sans Frontières (MSF) medical convoy inside the city was always a risk. Ongoing fighting meant that we had to leave the hospital by late afternoon each day. Our local colleagues remained overnight to keep medical activities functioning 24 hours a day.

The patient was anemic and bleeding heavily. She had risked her life to reach MSF’s trauma center.

She was pregnant but unsure how far along the pregnancy was.

When we had examined her, she complained of shortness of breath and her belly was unusually ballooned. She had not felt fetal movement for several days. We performed an ultrasound and determined that she was around seven months along. We also saw that the amniotic fluid level inside her uterus was too high — a medical condition often associated with fetal abnormalities. The dangerously high level of fluid was likely worsening her shortness of breath.

We transfused her as fast as possible with blood from our blood bank but I anticipated further hemorrhage after she delivered. I sent our ambulance to local hospitals — which were still only partially operational because of the conflict — to look for fresh frozen plasma (FFP).

I took a breath and noticed the patient’s mother pacing. The patient was crying in pain and squeezing the midwife’s hand; my colleague was calm and soothing. I refocused to place a second IV cannula and provide more fluid for resuscitation. Someone ran over from the operating theater with a medication that helps to control bleeding.

Time was moving in slow motion, but every second was critical. My clothes were drenched in sweat.

Out of the corner of my eye I saw the field coordinator in the hallway, then heard the radio, “Convoy on hold for medical emergency.” I felt relief.

The fetus had heart activity but lacked brain structures. This condition is called anencephaly — a fatal fetal abnormality that causes death in utero or almost immediately after delivery. The condition is directly linked to folic acid deficiency.

Anencephaly puts the mother at high risk of hemorrhage both before and after delivery — a preventable complication, but one of top five causes of maternal mortality each year.

Conflict makes this anomaly — a rare deficiency in countries like the United States — considerably more common when people cannot access folic acid fortified foods and supplementation, family planning, early pregnancy diagnosis and treatment, and affordable health care services.

During my time in the trauma unit, I saw pregnancies affected by anencephaly multiple times a week but in my 10 years of training and practicing obstetrics in the U.S., I have only seen this condition a handful of times.

It is dangerous for women carrying a fetus with anencephaly to go into labor while at home, especially in times of instability and conflict.

Had we not been able to provide this care to the patient, it is quite possible she would have died from the obstetric hemorrhage at home, or in another medical facility that may not have had all the resources she needed.

Our patient had travelled several days to reach our facility. If I had sent her home without inducing her labor, it is unlikely she would have made it to a functioning health facility in time to receive the care she needed to survive.

Explaining the diagnosis to the patient had not been easy; the accumulation of suffering was visible everywhere on her face.

Her husband and three of her five children were killed in the fighting. But knowing the risk she faced if we sent her home, and knowing her fetus would not survive, we offered to induce her labor to end the pregnancy safely in our facility. Here I could attend her delivery and she would have access to an operating room and blood bank should she need those services.

This care would be free of charge; in keeping with our principles, MSF provides free care to everyone regardless of race, religion, or political status.

Minutes later the patient delivered. It took an hour to stabilize her with all the medications we had available to make the uterus contract back to its usual size: four units of blood, two units of FFP, many liters of normal saline, a urine catheter, and continuous uterine massage. The midwife smiled proudly as the patient’s mother kissed her hand.

We were able to save her life and avoid performing a hysterectomy — two outcomes that are rare for patients in her condition.

Had we not been able to provide this care to the patient, it is quite possible she would have died from the obstetric hemorrhage at home, or in another medical facility that may not have had all the resources she needed.

"There is No Abortion Here"

Safe abortion care plays a vital role in reducing maternal morbidity and mortality. MSF is committed to offering safe abortion care services if needed. How we provide these services depends on the specific context and is tailored to keep patients and staff safe.

Unsafe abortion is one of the five main causes of maternal mortality worldwide, together with hemorrhage, eclampsia, sepsis, and obstructed labor.

It accounts for 13 percent of maternal deaths around the world, according to the World Health Organization. MSF’s priority is preventing the consequences of unwanted pregnancy and unsafe abortions.

Doctors w/o Borders on Twitter

MSF OBGYN Veronica shared her thoughts on the #GlobalGagRule and maternal mortality #TomorrowNeedsHer #IWD2017 https://t.co/UL7cw2cywe https://t.co/U0Ak4beUuX

Wherever MSF works, we must navigate different value and belief systems, taking social norms and laws into account without allowing them to inflict further suffering on vulnerable groups. MSF stands behind safe abortion care as a medical necessity and argues for it from a humanitarian and evidence based perspective.

She remained hospitalized overnight for observation; most women insist on going home within hours of delivery.

The following day I found her waiting for our MSF convoy to arrive so she could say her goodbyes. We talked with her about what she had just been through and provided her with contraception, iron, and a high dose folic acid supplementation to prevent this happening again if she were to unexpectedly become pregnant in the future.

When we think of insecure environments and conflict, we often think of direct injury and death, food and shelter shortages, or perhaps we think of the spread of diseases. The countless people with indirect injuries leading to death or near-death experiences, like this patient, remain mostly invisible.

Dr. Rasha Khoury will be speaking as part of our panel talk on #NoGagRule June 6th, 2018:

• What's So Scary About the Global Gag Rule? - WEBCAST
• Is the Global Gag Rule Truly Pro-Life?

What Safe Abortion Care in a War Zone Looks Like was originally published in MSF Passport on Medium, where people are continuing the conversation by highlighting and responding to this story.

Dr. Javid Abdelmoneim recently returned to London from the Syrian city of Raqqa, where civilians were caught up in a major military offensive by Syrian Democratic Forces and US-supported Coalition forces to oust the Islamic State group last year. He spent a month working in a clinic set up by Doctors Without Borders/Médecins Sans Frontières (MSF) in one of the few houses left standing in the city. Although the fighting had stopped, he found the war still taking a terrible toll.

You arrive, and of course, it’s not just a drive into town. There are bunkers, there are blown-up vehicles, there are blown-up bridges, there are ‘Danger’ landmine signs everywhere.

There are checkpoints along that whole route once you’re into Syria. You get the feeling that you are far away from anywhere… in a zone that has clearly seen a lot of destruction recently. It’s a little bit eerie.

It reminded me of Haiti after the earthquake . . . that level of destruction, that many buildings lying in rubble across an entire expanse of a city. It’s just that much more sinister because it’s much more complete, the destruction of Raqqa, compared to what I saw in Port-au-Prince. It was much more complete, and not a natural disaster.

Raqqa has been mostly destroyed, with vast swathes of the city razed to the ground. Residents trying to rebuild their city are being wounded and killed all the time by explosive devices.

I’m an A&E [Accident and Emergency] specialist in London, and I’m used to dealing with major trauma cases: car crashes, stabbings, the occasional gunshot wound.

But in just one month in Raqqa, I treated more severely wounded people than I’ve seen in the past three years in A&E.

MSF opened an emergency room in Raqqa within three weeks of the end of the offensive. It’s just an ordinary house with a few rooms, but we’ve been inundated with patients. During the first fortnight, about 55 blast victims arrived in the small emergency room each week — that’s almost eight a day.

The blast victims ranged from people with shrapnel wounds to people whose arms or lower limbs had been blown off.

Our job was to stabilize the patients: to stop the bleeding, wash their wounds, splint their broken bones, give them strong painkillers such as morphine and ketamine, and start them on antibiotics to control infections. This is all with the aim of transferring them to our hospital in Tal Abyad, two hours’ drive to the north, where we have full trauma surgery services.

There were usually six of us in the room — two doctors and four nurses — working on patients in three beds. We were a mix of Syrian doctors and nurses and international staff, all working together as a team.

In all my years with MSF, I’ve seen nothing more impressive than the work of that clinic in Raqqa.

The main reason there were so many injuries was because the city was littered with improvised explosive devices, many of them quite sophisticated, with heat and motion sensors and trip wires, operating on time delays.

They had been planted in houses, in cupboards, under beds — everywhere you could think of. There were also huge amounts of unexploded ordnance and remnants of war.

Doctors w/o Borders on Twitter

The number of patients injured by landmines, booby traps and explosives in parts of northeast #Syria doubled between November 2017 and March 2018. "The girls didn't see it... how can a child know what is a mine?" #DemineNow https://t.co/SkPAH0AAtl

We heard stories of men returning to their homes in Raqqa to prepare them for their families. They’d enter the house, trip a time-delayed device without knowing it, and then, three days later when their whole family had arrived, the device would go off.

The former residents of the city are coming back in waves — an estimated 90,000 people have returned so far. With only one organization doing the brave job of demining, it’s clear there are going to be many more casualties.

90 seconds to save a life

I remember one man was brought to us who had had one leg blown off at thigh-level, while the other one was attached just by skin and muscle. He had multiple open wounds and fractures and had lost nearly all his blood.

We couldn’t even feel a pulse, there was so little blood. He was taking his last breath.

In trauma situations like that, you’ve literally only got about 90 seconds. You need to work together as a team, and you need to do everything at once.

We opened two IV lines, grabbed the blood from the fridge, gave him six units of blood and three litres of fluid. We applied tourniquets to stop the bleeding and provided the patient with painkillers.

There were nine of us working on him at that point. And it was amazing, because when you’ve taken over someone’s breathing because they’ve stopped breathing for themselves, they’re basically dead. But we managed to save him.

We got his blood pressure back to the point where he was agitated and fighting us, which is a great sign. It wasn’t good for us as we tried to hold him down, but it was great for him.

We stabilized him to the point where we could transfer him for surgery. Apparently, he needed a further 29 units of blood products to stay alive.

Car accidents, broken limbs, and burns

While I was there, about 40 percent of our patients were blast victims and the other 60 percent were what we called “ordinary” emergency room patients. They were far from ordinary, however.

I’d see someone with diabetes, but because they’d not had a regular supply of insulin for years because of the war, they’d have catastrophic diabetic complications: deep leg ulcers, high blood sugar with high acid levels, which all needed emergency treatment.

We’d see pregnant women who had received no antenatal care with uncontrolled high blood pressure that was causing them to have seizures. The only treatment was to deliver the baby ASAP.

As the city is mostly rubble, with plenty of uncleared roads, we saw a lot of car accidents and children falling off motorbikes. We also saw a lot of people falling off roofs with the most awful broken limbs. And a lot of burns from stoves running on diesel, as that’s the only fuel available for heating.

After the Gas and Bombs: The Health Crisis That's Killing Syria

We did our best to patch people up, and either send them home or send them on to our hospital in Tal Abyad. It was important, lifesaving work.

In all my years with MSF, I’ve seen nothing more impressive than the work of that clinic in Raqqa. It’s the right work at the right place at the right time.

The people of Raqqa — and of Syria as a whole — have been through so much, and it’s not over yet. A city of this size needs maternity care, surgery, treatment for chronic diseases and mental health services, among other things. We’re one of the only medical organizations working in that area, and I’m proud that we’re there, playing a part.

Donate to Doctors Without Borders

Saving Lives in the Rubble of Raqqa was originally published in MSF Passport on Medium, where people are continuing the conversation by highlighting and responding to this story.

Nurse Tatiana Chiarella spent most of 2017 working in Doctors Without Borders/Médecins Sans Frontières (MSF) trauma facilities in Iraq and Yemen.

For the past week, I’ve been in California working as a guide with our Doctors Without Borders traveling exhibition on the global refugee crisis.

All day I speak to school groups and members of the general public, about the various reasons millions of people around the world are on the move in search of safety.

I tell them that just a few weeks ago I was working in Yemen — a war zone, where the health system has collapsed and where people are trapped and at high risk of dying from violence of war, or the indirect consequences of war such as malnutrition, epidemics, or simply the inability to access healthcare facilities.

The war is not over and the violence continues. It feels endless. But someone has to do something, and even if I don’t know when it is going to end, I have to keep hope that one day it will end — otherwise I could not do this job.

In Yemen, electricity is sporadic, water is hard to find, the sewage system is a mess, and tens of thousands of public sector health workers across the country haven’t been paid for more than a year. I asked why they continue to work with no salary. They see no other options, if they leave then who will do it? This is their home, their families, their community, so even if they don’t receive a salary they know that somebody has to do it. So, they sell their belongings and start business on the side, just to get by.

Public hospitals have run out of resources, so even though care is meant to be free, patients are asked to go to the market and buy their own medicines. MSF provides free care, but we can’t treat everyone.

It’s really difficult to turn a patient away because we don’t offer the type of care they need. I have no neurosurgeon, for example, so I refer the patient to a hospital that should have a neurosurgeon. But often what happens when they go to that hospital for the surgery is that the hospital doesn’t have the materials they need for the surgery, or the patient needs certain medications, but the hospital has no medication. I never know if they will actually get the care they need.

We have a saying in Brazil, secar gelo, for when something feels useless. In English, it translates to dry ice. Trying to dry ice is pointless; you dry it, but it continues to melt, no matter how hard you try.

Despite these obstacles, MSF and national staff in Yemen continue the work. This past year, MSF responded to one of the largest cholera epidemics in history — a direct consequence of the war, and a sign of a system that has collapsed and a population greatly in need.

أطباء بلا حدود-اليمن on Twitter

Since the salaries stopped being paid,nurses have continued their work as a national and humanitarian duty." #1year0salary https://t.co/CJNRmZIGpt

Unexploded landmines and grenades scatter the streets where children play; we treated many for missing limbs.

At the hospital where I worked, in Aden, we received a family of five who suffered severe injuries from a grenade explosion. The mother and aunty had treatable shrapnel wounds but the father and uncle did not survive. Both had severe wounds requiring emergency surgery; the father died before reaching our facility and the uncle passed away two days later in the intensive care unit.

The fifth family member was a three-month-old baby girl. Both of her feet had been crushed during the explosion. When the mother saw the grenade, she jumped to protect her baby, unwittingly crushing her feet. Although our surgeons saved the baby’s feet, the mother blamed herself and her guilt was crippling.

While the baby was receiving care, we referred the mother to multiple sessions with one of our counselors. Mental health care is such an important component to the care we provide anywhere in the world; sometimes it can be more lifesaving than physical care. The mother’s mental health improved quickly, and after a few follow up consultations, she was smiling again.

Large metal plates across every window block even a sliver of natural light from entering the MSF trauma hospital in Aden. These serve as a reminder of the days when the facility was near the frontline and it was too dangerous for staff to go home. One of my Yemeni colleagues lived in the hospital for nine months, not meeting his newborn daughter until she was three months old.

We have a saying in Brazil, secar gelo, for when something feels useless. In English, it translates to dry ice. Trying to dry ice is pointless; you dry it, but it continues to melt, no matter how hard you try. I sometimes think of this saying when I am treating patients in conflict settings like Yemen. I treat patient after patient after patient but the wounded keep coming and coming and coming.

The war is not over and the violence continues. It feels endless. But someone has to do something, and even if I don’t know when it is going to end, I have to keep hope that one day it will end — otherwise I could not do this job.

This week in California I tell these stories to people who might never know about Yemen or some of the other conflicts where I’ve worked. It’s a way to educate people and help them see what I’ve seen. It’s also a way to continue my work, even when I’m far from our patients and staff.

Join our message: Stand with people #forcedfromhome who risk their lives for a safer future. #standwithrefugees

Read on the latest updates from Yemen:

Yemen: Blockade by Saudi-Led Coalition Hindering Medical Aid

Doctors w/o Borders on Twitter

Yemen UPDATE: For the past 12 days, MSF has not received authorization from the Saudi-led coalition to fly into Sana'a, which is ESSENTIAL to bring medical aid. Read the statement: https://t.co/PJO85IcPpu

Just a few weeks ago I was working in Yemen. Here’s what I witnessed was originally published in MSF Passport on Medium, where people are continuing the conversation by highlighting and responding to this story.

During my recent visit to Kasai, I went with our teams to a rural part of the region that has been particularly affected by violence. Villages and fields have been burned, and several mass graves have been discovered. A man approached us and said very simply, in a composed manner, “the violence was so terrible here that we didn’t hear the birds sing for days.”

Yet, when I first arrived there, I got the impression that nothing had happened. Kananga is a fairly typical, bustling Congolese town of around 750,000 people. The markets were full and loud music played from the small shops.

This was certainly not the situation that my colleagues discovered last March, when silence filled the town. Not a single school or shop was open. Fear was everywhere. In the end, I realized that the normalcy I was witnessing in the town was similar to the experience one has of visiting the site of a loved one’s grave a year after their burial, when the grass has started to grow over the tomb. Life has taken hold again.

There are other images from this visit that have stayed with me. I remember seeing a teenage girl laughing and running after other children along the hospital corridors. It was as if nothing had happened to her. But several weeks before, her sister had been decapitated in front of her eyes. The armed men took her away and kept her tied up on the floor for ten days. They raped her so many times, it was impossible for her to say how many. “If you speak, we’ll cut your head off like we did to your sister,” they told her. What is clear is that the people of Kasai have lived through so much, it’s hardly imaginable.

The crisis in Kasai started a year ago, but it’s taken a lot of time for us to realize its magnitude. During the worst months, no humanitarian aid arrived there — now it’s still extremely limited. Why did communities not ask for help sooner? A village elder replied: “When you are lying on the ground and people are shooting at you, you can’t get up and run.” We at MSF only started to work in Kananga in March — very late, too late, surely — and today we are still conscious that we are just scratching the surface of the problem.

Afterwards, it’s always the same three questions that come up: how can I earn a living, feed my family, rebuild a home?

The wounds of the patients who MSF treats tell us about the extreme levels of violence that the people of Kasai are facing. Out of fear, some grievously injured people have waited days or weeks before trying to see a doctor. For example, one of the patients our surgical team treated had had his hand cut off. He hid in the bush for several weeks, afraid of being found and killed, treating his stump with traditional medicines. By the time he arrived at our hospital, an abscess had formed and a serious infection had developed in the bones of his forearm. His chances of avoiding a further amputation are slim.

If our mental health teams ask what has happened, our patients never tell us who has inflicted this violence — the fear is always there — but they tell us their stories, invariably awful: your husband decapitated in front of your eyes, your wife raped in front of you and your children while you are tied up, forced to watch. But they only tell it once. Afterwards, it’s always the same three questions that come up: how can I earn a living, feed my family, rebuild a home? What is my future?

The crisis in Kasai is like a forest fire during the driest summer months: one spark in August 2016 has ignited the whole region. Millions of people have been caught in the trap of militia attacks, army repression, and even localized conflicts that had nothing to do with the initial spark, but exploded due to the chaos that reigned. And if today Kananga is returning to normal, very worrying noises are still coming from other places in this region the size of Italy. The lack of access to the area due to security problems makes it difficult to tell the difference between rumour and reality. What is for certain is that, even if from the outskirts it seems as if nothing has happened, a human tragedy has unfolded — and is still unfolding.

MSF’s work in Kasai Province

MSF independently manages the 49-bed trauma wing of the Kananga General Hospital in Kasai Central province. The team has rehabilitated the operating theatre and offers free care for victims of violent and accidental trauma. MSF also runs mobile clinics in the countryside around Kananga to provide free health consultations.

Since June, MSF has been supporting three health centers and one general reference hospital in different areas of the city of Tshikapa with a focus on providing assistance to children under 5, pregnant and lactating women, people with wounds, and violence-related emergency cases. In July, the teams expanded activities to surrounding rural areas.

Even the birds had stopped singing in Kasai was originally published in MSF Passport on Medium, where people are continuing the conversation by highlighting and responding to this story.

I first joined Doctors Without Borders in 2011, when my baby girl was just one year old. As a mother of three it was a difficult decision to leave my family for six weeks, but I knew my skills could go a long way in an area like southern Sudan.

It was easier for the little ones, they don’t really have a sense of time and just accept it as my job. But to my 15-year-old, six weeks was a long time, so it was a good chance for us to talk about the issues that girls not much older than her face in this context — it gave her the opportunity to be supportive on a different level.

South Sudan became the world’s youngest nation while I was there but it is also one of the least developed and health care options are few. Ninety-nine percent of all maternal deaths occur in developing countries; South Sudan has one of the highest maternal mortality rates in the world.

Everyone loves their baby as much as I love mine, I just do it in a completely different context.

Every day, women die from causes related to pregnancy and childbirth — severe bleeding, infection, pre-eclampsia — that can be prevented with treatment provided by trained medical personnel.

My husband is completely onboard. He says it is worth all of it, worth missing me, worth the angst that comes from me being away. Since my first assignment in 2011, I have been twice more to South Sudan and once to Nigeria. Before I leave, I cook a cauldron of spaghetti sauce. It is one less thing for my husband to worry about, but for my kids, the way their mom cooks is special. On the weekend, it’s mommy’s food: you only have to do that four or five times and then mommy will be home.

The last time I was in South Sudan, in February 2016, I lost a 19-year-old patient and her baby.

She was the same age as my eldest daughter.

Having the discussion with her mother about the complications was hard. It was her only daughter and the baby would have been her first grandchild; the joys and excitement that come with that — even in the middle of a civil war — translate across the board.

As a mother, I am constantly contrasting in my mind: the differences are stark, but the similarities are strong. It is important for me to take a step back and notice the joy. The culture is different, the context is different, but the joy of a new little loved one, of deciding who the baby will be named after, of taking a new baby home — it’s the same. Everyone loves their baby as much as I love mine, I just do it in a completely different context.

When I am in the field, I am often the only OBGYN in the project. I am on call 24–7, I even shower with my radio on.

Most nights I am called in, but some nights are so quiet it is scary. Perhaps it means everyone had a safe delivery and went home, but often it means road blocks, check points, instability, poor weather — or worse.

Before I leave, I cook a cauldron of spaghetti sauce. It is one less thing for my husband to worry about, but for my kids, the way their mom cooks is special. On the weekend, it’s mommy’s food: you only have to do that four or five times and then mommy will be home.

It is hard to tell when it was just a quiet night or if there are women bleeding on the side of the road that were unable to access care when they most needed it.

Doctors w/o Borders on Twitter

As a parent, as a women's health practitioner, I hear the same: moms and dads doing what needs to be done for their babies. @ForcedFromHome https://t.co/X3neKxMY9X

In contexts like South Sudan, where access to health care is limited, the health and the safety of the mother is what decides the health and the safety of her children. In the field you have to understand the consequences of your decisions within the context you are in. I must always consider what the risks and consequences of surgery will mean not only for the mother, but for her children at home.

Sometimes this means deciding that a C-section is not a viable option. That is one of the things that makes me go home and say, “I’m never doing this again; I’m never going to listen to a baby’s heart beat just fade away,” knowing that in a different context I would not have had to make that decision.

But, I always go back. It will always be a pull and tug, but as long as I can do what needs to be done then I will keep going back. I don’t need to do anything else except wash my hands and operate.

Work with us:

Obstetricians / Gynecologists

Dear Kids: there’s homemade spaghetti sauce in the freezer! See you soon, Love Mom was originally published in MSF Passport on Medium, where people are continuing the conversation by highlighting and responding to this story.

For the past 2 years, we’ve been asking them to lower the price of their #1 selling vaccine–the pneumonia vaccine–because too many kids are dying from this preventable disease.

We’re essentially asking them to transform their bottom line from valuing profits to valuing kids’ lives. Not the easiest thing to do.

To me, this is a creative challenge. How do we design content and actions to raise awareness in order to mobilize a community behind this cause?

We explored new mediums, tried different approaches, and enjoyed getting to work together with our supporters. When we made a call to take action, you guys showed up, and together we’ve made progress. So on most days, my job is pretty fun.

Today is not one of those days.

Today we attended Pfizer’s annual shareholder meeting. It brought us face-to-face with their CEO and board members.

There, it was very clear what Pfizer’s bottom line is: maximizing profits for the company.

It’s hard not to feel discouraged after seeing this up close and personal. But I continue to believe, because we’ve seen firsthand that when people come together, change is possible. After all, the companies have already agreed to a significant price cut for humanitarian organizations like us.

We need to start speaking in terms that the companies care about (aka money talk). So that’s where you come in... yes, you.

You see… if you have a 401K plan or some kind of retirement fund, then you are likely to have money invested in Pfizer and or GSK.

Here’s how it works: You put money away in your 401K plan. Then your provider invests that money into a mutual fund. The asset manager of that fund choses which companies to invest in, and that could include Pfizer and GSK.

If Pfizer or GSK is in your portfolio, then you effectively have investments in the company. It may seem small and insignificant…

But if everyone in your fund comes together, then collectively, you actually hold a significant percentage of shares.

That’s not something Pfizer or GSK can easily ignore. So find out here if you have money in these companies, and please speak out: http://afairshot.org

Let’s use our investments to save for the future AND save children’s lives in the meantime.

I need your help pushing this mountain. Join me? http://afairshot.org

Vivian

The hidden power you didn’t know you had was originally published in MSF Passport on Medium, where people are continuing the conversation by highlighting and responding to this story.

The fighting continues in Libya, a country fragmented by a multitude of power centers. Since mid-2014, the humanitarian situation there has deteriorated due to the resumption of the civil war and the political instability it brings. Millions of people across Libya are impacted, including refugees, asylum-seekers, and migrants. Dr. Tankred Stoebe spent the month of January 2017 in the country, coordinating a medical assessment with Doctors Without Borders/Médecins Sans Frontières (MSF) that took him from Misrata to Tripoli. Here, he describes what he saw.

Misrata

Ismaël and Masjdi were 19-year old students when the revolt began in Libya in 2011. Like thousands of others, the two fervent idealists took up arms against the Muammar Gaddafi regime with no training or understanding of military strategy. The two young men, who both narrowly escaped death, met much later in Malta.

During the fighting, Masjdi sustained wounds to the face and was blinded, while Ismaël was paralyzed and can only move his right hand. They became friends from the moment they met in the intensive care unit. Separated during their convalescence, they kept in touch and now meet up in Misrata whenever they get the opportunity. “We’re like brothers,” they told me in chorus. Masjdi pushes his friend’s wheelchair and Ismaël reads to his blind friend.

Misrata is steeped in history. Strategically located on the Mediterranean Sea, the city is known as much for its pride and independence as its traders, smugglers, and pirates. Subjected to heavy fighting between February and May 2011, Misrata is a sandy and dusty, but bustling desert city. Economically and militarily powerful, its hospitals are well equipped and its health system better organized than in the east. Compared to Benghazi and Tripoli, Misrata is — for now — relatively safe, so this is where we decided to set up a base.

Every day, we saw sub-Saharan Africans, each with their own agricultural or construction tools, brushes, and drills, stationed at the city’s crossroads, looking for work as day laborers. Few are arrested, but some get caught at police checkpoints and interned in camps before being deported back to their home countries.

There are around 10,000 migrants in Misrata, mostly from Niger, Chad, and Sudan. Fearful of arrest and deportation, when they fall sick they usually go to pharmacies and buy the often high-priced drugs they are advised to take. For more serious problems, they prefer private medical facilities because, although expensive, these are not required to report undocumented patients.

When they have a chronic illness, their only choice is to go home. When I asked them if they didn’t want to get on a boat to Europe, they smiled and shook their heads: “It’s too dangerous,” they said. “We don’t want to die in the sea.”

Between Misrata and Tripoli

Living conditions and hygiene are truly appalling in the detention center in a small town halfway between Misrata and the Libyan capital, Tripoli. Intended for 400 refugees, there were only 43 detainees, 39 of them women from Egypt, Guinea, Niger, or Nigeria, who’d been there for a month with no contact with the outside world, including their families.

Most of them had come from Nigeria and they told me their homes there had been bombed. The Libyan coastguard had intercepted their inflatable dinghy near the Mediterranean coast and they were sent to the detention center.

Rooms in the center were small, dirty, and jam-packed with mattresses. As we entered the hall, there was a putrid stench.

We walked through puddles of urine. There were no showers, the toilets didn’t flush, and the women had to relieve themselves in buckets.

They used a little of their drinking water to wash. They were utterly desperate and begged me to help them get back to Nigeria.

When I told them I was a doctor, they didn’t believe me at first, but then they accepted the treatment we offered them. Their average age was 22 and almost all of them (93 percent) had health issues. Many had scabies (58 percent), for which we gave them prescriptions, and some had various aches and pains (48 percent).

Other non-specific ailments were due to emotional trauma — or at least that’s what we deduced from the stories they told us about their flight, and from their almost palpable fear.

When I asked them if they thought they would try to get to Europe again, they replied, horrified, “Never again!”

Sirte

Our visit to Sirte was a real eye-opener. Close to the oil fields, the town is known for being the birthplace of Muammar Gaddafi, who died in October 2011. In the spring of 2015, the so-called Islamic State, which controlled around 185 miles (300 kilometers) of the country’s coastline, made Sirte its stronghold in Libya.

It was only in December that militias from Misrata succeeded in retaking the town with help from the U.S. Air Force. The battle lasted seven months. Many fighters died and more than 3,000 people were wounded. Ten ambulances were damaged and three rescue workers were killed.

Armed with a special permit and a police escort, we managed to enter the coastal town. Reduced to rubble, not one building has been left intact. Sirte was subjected to a brutal war that left a trail of total destruction. A deathly silence hangs over the town that, from an historical perspective, was probably most unique.

We went to Ibn Sina hospital in Sirte. Relatively unscathed by the bombs, it had been ransacked. Abandoned over a year ago, the hospital was once a modern, 350-bed facility equipped with several operating theaters, an intensive care unit, an MRI scanner, a cardiac catheterization laboratory, and 20 practically new dialysis machines.

It’s completely destroyed, with ripped up, flooded floors, smashed windows, and sagging ceiling tiles*.

Tripoli

When we reached Tripoli, I was stunned by the towering heights of the ruins. MSF colleagues were in the capital, providing assistance to people spread among seven detention centers.

Most of those wanting to cross the Mediterranean to Italy are from sub-Saharan Africa — Nigeria, which is mired in conflict; Eritrea, governed by an authoritarian regime; and Somalia, a country embroiled in a civil war.

People flee north to escape poverty and terror. To reach the Libyan coast, they have to pass through Chad and Niger, both particularly poor countries. According to the International Organization for Migration (IOM), more than 300,000 people crossed through Chad and Niger last year. However, there are no precise figures on how many have died of hunger or thirst, or from falling off a truck along the way.

According to most estimates, at least as many people have died crossing the desert as those who have drowned in the Mediterranean Sea — the statistics on people who drowned are more reliable. Be that as it may, survivors are insistent that the desert is by far the hardest part of the journey.

The number of dead migrants also pose a problem. We went to hospital mortuaries overflowing with unidentified corpses, some that had washed up on beaches. Many have been there for months. As the authorities don’t have the resources for DNA testing, it’s impossible to identify the dead and ship them back home or bury them.

Note: This story is based on personal experience in January 2017. Please note that due to volatile context, the situation changes quickly in Libya. *As of April 21, 2017, the Ibn Sina hospital in Sirte is expected to re-open soon.

Between Towering Ruins and Detention Centers: A Look Inside Libya was originally published in MSF Passport on Medium, where people are continuing the conversation by highlighting and responding to this story.

Emily is a Doctors Without Borders project coordinator who recently returned from the Democratic Republic of the Congo.

I felt strange when I got back from DRC. Going by the other times I’ve come home after a mission, it’s normal to feel a bit weird when you come back, but this time it was different.

I came back in mid-December. It’s always difficult to come back to Christmas after being away. The expectations, the intensity that surrounds Christmas anyway, the stark difference between coming from a place where people have next to nothing and arriving in a place where it’s all about presents and over-eating. To compound it all, we had a death in the family just two weeks before I left DRC and so I came back to a funeral and a grieving household. But that wasn’t it.

The difference was my reaction, or rather lack of reaction, to it all.

Of course I was sad about losing my relative. I knew I was, but it was very internal and didn’t display itself as it usually would. I knew certain members of my family needed support and love but I didn’t have anything to give. I had limited words to say and not much comfort to provide. The best I could do was spend time with them being “normal” — going shopping, going to cafes, watching television.

I knew I should be doing more but I physically and mentally wasn’t able to. I had lost feeling and the ability to empathize. I was told by people that I was being insensitive and that I didn’t care.

I know the signs now and looking back, I should have seen them developing years ago.

I did care, I knew I did, it’s just that I couldn’t feel it or show it. In that respect, I felt numb.

I also felt anger. So much of it.

My immediate reaction to everything I didn’t agree with or like the sound of was to boil up inside. It took a lot to not show my mad responses to people and sometimes I did. A few angry outbursts broke bridges over the weeks. But I couldn’t work out what was wrong and decided it was nothing and just the adjustment period that you’re always faced with when you get back from the field.

After a few further weeks went by and more bridges were broken, I went to the doctor.

“Symptoms?” I was asked.

“Anger, cynicism, detachment, feeling down, not sleeping, unable to concentrate, anxiety, negativity…” I had all of these, and others, though all to varying extents. After mulling it over and asking a few more questions, the doctor looked at me.

“I think you have burnout.”

I didn’t believe her when she told me this and I dismissed it quite rapidly. It’s a term that I think is bandied around so frequently and easily in this line of work that even the slightest tiredness can be attributed to burnout.

For me, burnout was in someone who literally could not function anymore, which wasn’t me — I was functioning, just not as I used to.

I was told to look up the symptoms. Apart from the ones listed above, there was depersonalization, tick; loss of enjoyment, tick; isolation, tick. The list went on.

For physical symptoms, chest pain, dizziness and headaches were some of the common ones I had every now and then in the field, but which I had dismissed at the time as run-of-the-mill stress.

Although it took a while to acknowledge I may have burnout, once I had, it gave me a direction. At least now I had something to work with.

The most difficult for me, apart from the anger and inability to empathize, was the isolation, loss of enjoyment, and impaired concentration. A ‘people person’, highly motivated, and very organized are three traits I am known for. However, on coming back from DRC, I found myself wanting to avoid meeting new people and also socializing with people I knew well.

I also remembered how hard I found it to get daily tasks done towards the end of my mission, and to write a handover for my successor in the project — something I usually spend a long time doing to ensure it is well structured and covers all details. I just couldn’t bring it all together in my head.

It’s also true that I haven’t been able to read a book or watch a film for months. I have started about seven different books in the last year and not finished any of them, and my attention span only lasts as long as a 20 minute sitcom.

And the worst: I couldn’t even write a to-do list.

The pessimism and lack of enjoyment extended to working abroad again. The thought of going overseas and being faced with another difficult place and a ton of responsibility sounded really uninspiring to me. In fact, just getting up for tomorrow I lacked enthusiasm for. I had no excitement left.

I read somewhere that burnout occurs when passionate, committed people become deeply disillusioned with a job or career that has previously provided them with identity and meaning. This work has defined me for nearly a decade.

I have spent my entire working life chasing after opportunities, jumping into new job after new job and spending a lot of time in difficult places with significant responsibility. Stuck on a base, often working late, an early evening curfew, and sleeping just a few metres away from your office, you have no choice but for this to become your life. As a result, your personal life back home suffers and, as it can feel, your sanity.

There’s no ‘cure’ exactly, for burnout, but the good thing is it can take just a short time to recover if you put the right things in place.

It’s just a matter of taking time out and removing yourself from the stress triggers that have been identified. It requires a lifestyle change. Counseling can also help, I’ve been told.

For me, getting out of DRC was already a step in the right direction, and once I was home, moving back into my own flat to have my own space and live on my own timeframe was another.

I ordered books and read articles online to try and become a master of my madness. Apart from that, I had an overwhelming urge to be part of a community, part of somewhere I belong.

“What do you want?” someone very close to me asked when I was at a low point.

After a few days of thinking this through, I could put it into words: “I want my world to become smaller.”

So using this, I have deliberately narrowed my world considerably. I, maybe selfishly, don’t want to think about the grand scale of things and everything going on out there (especially at the moment) — I just want to concentrate on my immediate surroundings.

My life and world exists now between London zones one and two. I now take part in the weekly park runs near my flat, and every now and then I volunteer at them. I’ve joined the gym: a membership of a local establishment! And I go to the classes a few times a week: exercise and community.

Exercise, by the way, is another move in the right direction.

I also try to set myself some kind of routine: breakfast, coffee, part-time low-stress work in the morning, gym and friends in the afternoon and evening.

I read somewhere that burnout occurs when passionate, committed people become deeply disillusioned with a job or career that has previously provided them with identity and meaning. This work has defined me for nearly a decade.

I don’t need to worry about the problems across the globe if I don’t want to. I don’t have to think about negotiating access with armed groups for tomorrow’s follow up visit to our health post; I don’t have to worry about a potential imminent security threat from ethnic based conflict that we could get stuck in the middle of; and I don’t need to worry about whether my actions have an immediate impact on someone’s life being saved.

I just have to get up, carry out my few tasks of the day and then come home. No drama, no fuss, and surrounded by fun and like-minded people.

People can think burnout is just about over-work. I certainly did.

But it turns out it’s not.

There are a lot of ways of defining it. One of my favorites, and to simplify it, is it can come from any situation where we put in our everything. It can come from having to deal with a lot of high stress things at the same time.

For me it’s likely been cumulative: a mixture of working for a number of years in difficult places without much break in between, the heavy workload and high responsibility combined with the constant exposure to difficult situations and the want to make as much of a difference as I can but without that always being possible. Plus difficult working relationships that can crop up, joined with the constant feeling of not being safe or not knowing if you’re safe, so that even when in reality you are, you start to doubt it.

This, combined with various stressors in my personal life over the past 18 months gradually added to the blocks of pressure falling on me bit by bit until my brain and body could no longer handle it.

Burnout crept up on me without me being aware. In fact, almost no one saw it. On the outside and to people who didn’t know me, I seemed fine — I put on a good show. Even the most experienced people who had been in the field for years and had probably come across burnout multiple times, didn’t spot it — they just thought I was a bit irritable and short-tempered.

Only those who really knew me well suggested something was wrong.

And I, myself, who had heard of burnout before and assumed it was a term reserved for severe cases, had no idea.

I was a slow burner, it seems.

Working for MSF, our focus is always on the people we are working with: our patients and their communities. It always will be. It’s why we do it. To continue to do that, we need to look after ourselves too — something many of us neglect.

MSF Field on Twitter

'70-80% of our patients test positive for #malaria' Emily loads the van for another emergency clinic > https://t.co/GC5xooVGby

It’s been over two months since I got back and by having this break, by putting a simple change of lifestyle in place and with the help of MSF, I feel more ‘normal’ again.

My to-do list is finally back and growing by the minute. MSF is a great organization when it comes to looking after its staff. There can be stigma attached to issues like this, which is why I wanted to write this blog, but at MSF I don’t feel that.

I’ve learned a lot through this process. I know the signs now and looking back, I should have seen them developing years ago even. Instead, I ignored them all and kept going; mission after mission, stressor after stressor.

Although they say there’s no cure for it, they do say that burnout demands that you listen. I, now that I am aware, am listening and will continue to listen hard, ready to spot the signs in myself and others I may come across in a similar situation in the future.

Read more of Emily’s posts from the field.

If you are an MSF field worker and think you may be experiencing burnout, remember there is support available. Contact your human resources officer or the staff health unit in your home office or OC.

Burnout in the Field was originally published in MSF Passport on Medium, where people are continuing the conversation by highlighting and responding to this story.