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Book Review: Hope in Hell: Inside The World Of Doctors Without Borders by Dan Bortolotti

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Hope in Hell is a look into the world of Medecins sans frontieres, the renowned humanitarian agency focused on providing medical care in countries that lack the infrastructure to do so whether because of unrest, disaster or extreme poverty. Unlike many other aid organizations, MSF also takes on the role of advocate. Though they go in to countries as a non-partisan organization, they actively seek the attention of media, governments and the UN in acknowledging crises around the world. Most recently, MSF has been vocal about the costs of AIDS drugs in Africa (the subject of a previous Fourth-Rate Reader) and rape as a war crime in Darfur, Sudan.

Bortolotti’s book looks into the lives of the doctors, nurses and non-medical volunteers who work with MSF in places around the world. The book debunks the idea that all volunteers are doctors (in fact, most aren’t; the majority of volunteers work on administrative and logistical tasks), and deemphasizes the glamour of the work that is done by medical staff. Often, doctors do very little hands-on work, instead training local members of the community to provide the care, in the spirit of teaching a man to fish. In one case, a doctor stood by watching as local staff attempted, repeatedly, to insert an IV in the veins of a dehydrated baby. By the time the staff succeeded, the baby had moved from wailing to stoicism, but the doctor did not intervene, because local staff needed to be able to do this procedure.

For Western doctors, the pace of the work takes a toll. Accustomed to working in the controlled chaos of Western medicine, they find themselves plunged into uncontrolled chaos, without the luxuries of technology. Says one doctor:

General surgery training is famous for 120-hour weeks, every other night on call, but this was every day on call without relief, no backup, no blood, just the basics — and on top of that, the language barrier. Other things begin to wear on you as well — the food, the lack of sleep, the noise when you’re trying to sleep. You end up being pretty ragged, and you’re not as good as you could be.

Most of what MSF does is basic medicine, including immunizations and treatments for malnutrition and dehydration. There are also a plethora of diseases that have been eradicated in the Westbut still plague MSF-visited countries. Borolotti talks about the toll of these diseases, that are viewed by those in the developed world as diseases of “historical curiosity,” particularly malaria.

SARS caused fewer than eight hundred deaths worldwide in 2003, while malaria kills about the same number every six hours.

Treatment options for these and other ailments (sleeping sickness, typhoid, etc) are limited because drug companies don’t see profit potential in researching medications.

From news reports, the life of MSF volunteers can seem extremely dangerous. Aid workers can be killed by landmines, in accidents, and sometimes even deliberately targeted for violence.

In Iraq, where both the UN and the Red Cross offices were targeted by suicide bombers in 2003, many in the aid community believe that agencies — even the rigorously neutral Red Cross — are being targeted because they’re seen as tools of the occupying coalition army. And they believe this image is the result of a deliberate strategy by the US and British governments. When Colin Powell talks about NGOs being “such an important part of our combat team,” and Tony Blair says that “this war has three dimensions: the military, the political and the humanitarian one,” they reinforce the idea that aid organizations are their partners rather than independent actors.

Governments seeking legitimacy by associating their work with that of aid organizations do so at great potential cost to those who are working for independent humanitarian relief efforts. MSFers tell of places where soldiers have begun adopting the habits of aid workers—driving the same vehicles, dressing in the same style of clothing—leaving aid workers and soldiers indistinguishable to the eyes of local residents.

The experience of seeing disease, corruption and disaster can make the transition back to “normal” life extremely hard for the organization’s volunteers. Do you tell people about the horrible things that you’ve seen or do you spare your friends from the trauma of the gruesome tales? And how do you handle the inevitable “fridge” conversation, where you talk about your experiences in a ravaged landscape and someone follows up by telling you that they bought a new fridge. Many volunteers find that it’s easier to be away, easier to be with people who understand, than to try and explain to people who haven’t experienced what they have.

Bortolotti relates the MSF history and experiences in a readable, workman-like way. Reading the book, you have a sense of the kind of service that MSF provides and why, and a hint at the motivations of the people who are involved. The book is eager to disabuse MSF’s reputation as a “cowboy” organization, while emphasizing its independence as compared to other aid groups. It provides a solid overview of the organization without going into details of particular missions. Finally, the book serves as a reminder of the larger goal of humanitarianism, sometimes overlooked in an era that demands quantification of results, reminding us that is enough that humanitarianism is a “compassionate response to suffering [and that it] doesn’t need to be justified by science.”

(This review originally appeared on Fourth-Rate Reader.)

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