Sharon Tissell, RN, dreamed of one day helping those around the world without the fortune of growing up in a loving, middle-class family like hers. Tim Harrison, RN, MPH, flew for 10 years with a medical helicopter service and knew he had the right skill set to make a difference. Martina Ford found that she thrived in multicultural settings.
All three of these nurses have found their professional sweet spot, which, at most, pays them a modest stipend and requires them to endure Spartan—and often dangerous—living conditions for months at a time. They are humanitarian medical relief nurses who make multiple trips each year to the very places we see in the news that we are told to avoid.
Places like the Syrian-Lebanese border, which is experiencing the largest exodus of refugees in recent history as Syrians flee their country after a brutal government crackdown and civil war began in 2011. Or South Sudan, Africa’s newest nation where ethnic rivalries have destabilized a fragile government and led to violence, bloodshed, and the internal displacement of tens of thousands. Or the Philippines, where Typhoon Haiyan flattened towns and villages, crippling a country’s capacity to deliver basic services and medical care to its people.
What motivates Tissell, Harrison, and Ford to return to these situations time and again is the opportunity to offer unconditional care, comfort, and compassion to the world’s most vulnerable populations. Across vast geographic, cultural, and ethnic boundaries, their work goes to the heart of what nursing is.
They don’t let politics and war keep them away, although these are often the factors fueling the crises at hand. While fearless, humanitarian relief nurses are hardly reckless, receiving intensive security training from their sponsoring organizations and working on highly coordinated teams where personal safety is valued above all else. Moreover, these nurses hardly see what they do as a personal sacrifice.
“It’s not about you,” says Harrison, a nurse with Médicins Sans Frontières (MSF), or Doctors Without Borders, who lives in Maine when he is not traveling for MSF. “It’s really about the direct connection between donors [of humanitarian aid] and beneficiaries. You’re simply the conduit.”
Wearing Multiple Hats
While nursing can be a satisfying career, it also runs the risk of being repetitious; working internationally can be a “way to break out of the doldrums going into your shift every day,” says Sue Averill, RN, cofounder and president of One Nurse At a Time, an organization that provides information and scholarships to nurses who want to work in humanitarian relief. Averill herself has gone on eight missions with MSF and several others with Medical Teams International (MTI), based in Tigard, Oregon, and with Smile Train, based in New York City.
Averill says experiences in the ER, ICU, surgical, and critical care floors are great preparation, as are courses in public health and tropical diseases such as Dengue fever, malaria, and others rarely seen in the West.
Also invaluable are critical thinking skills that empower you to be resourceful and in situations where supplies, medicines, and equipment are limited. Reorienting yourself to medicines that may be similar to those in American hospitals but with different branding, dosage levels, and packaging is also key.
Being able to communicate crossculturally and understanding cultural biases are as important as having strong medical training, Averill says. For example, a small white pill may be perceived to be inferior to a large white pill or a colored capsule in certain cultures. Local people and medical staff may “imbue [Western nurses] with qualities [they] may or may not have,” she adds. “People believe that simply because you came across the world to help them that you come with something better than they have,” even when that may not be the case.
That’s why it’s critical to have frequent conversations with patients to understand cultural biases and figure out how to work around them. One major strategy is to make sure you and your translator are “on the same page,” suggests Averill.
Relief work also requires nurses to wear multiple hats, she adds: “You’re a human resources person. You’re diagnosing and treating. You’re hiring and firing.” But perhaps most importantly, you’re teaching local people to think critically.
Averill was once tasked with setting up a hospital for Darfurian refugees in an isolated village on the border between Western Sudan and Chad. The endeavor required training local workers, including a woman who said she was a traditional birth attendant. After asking the attendant how many weeks pregnant a local woman was, the attendant said “36,” when the woman was nowhere near full-term. It was then that Averill realized that the attendant was unable to count.
In a similar vein, other workers claimed to know how to take pulses and blood pressures, but in fact didn’t understand how to do either. Another worker wore the same pair of gloves as she screened patients for malaria.
“They were doing these tasks rotely and not understanding what they mean,” Averill says. “That critical thinking piece wasn’t there.”
So, Averill went over the basics, teaching the staff how to take vital signs, the importance of glove disposal and frequent hand washing, and how to do A/B/O typing for blood transfusions. “It was really fun to see the light bulb go on,” Averill says, similar to the one going off in her own head as she stretched her own skill set.
Similarly, Ford had little experience in obstetrics before traveling with MTI to the Nakivale Refugee Settlement in Uganda last year. The local midwives were eager to see a “muzungu,” or white person, to deliver a refugee woman’s baby. So with “no IV, no monitors, no electricity,” Ford says she stepped up to the plate and did it. “It was mind-blowing.”
“When you’re talking to people about going on these trips, many people like the idea of it,” she adds. “But nothing is what you think it’s going to be.”
Having a successful experience as a humanitarian relief nurse also requires emotional fortitude, flexibility, and the ability to think on your feet, says Harrison. Being a medical transport nurse for Boston MedFlight not only gave him a broad skill set in obstetrics, pediatrics, and trauma care, but also taught him the importance of teamwork and maintaining equilibrium in situations that are fluid and unpredictable.
Harrison first encountered MSF in 2004 working on a volunteer assignment in Chad with another medical assistance organization. What impressed him about MSF was its long-term investment in communities lacking the medical infrastructure to contend with disease outbreaks and public health emergencies. He also observed that MSF didn’t do “drop-in medicine” like other relief organizations did, allowing it to have a larger impact; he also admired MSF’s independence from government funding and its neutral stance towards political debates and conflicts. With several international assistance trips under his belt, he decided to apply for a full-time nursing position with MSF.
After a lengthy interview process with MSF, Harrison was accepted in 2008 and left Boston MedFlight with the blessings of his boss. That year, Zimbabwe was being devastated by a cholera epidemic caused by the breakdown of water sanitation and sewage systems in urban areas; the disease spread quickly to the countryside after city-dwellers visited relatives in rural areas.
Harrison’s first assignment was to manage a database that tracked the epidemic as it moved from cities to towns and villages. Later on, he joined a team responding to malnutrition and cholera in prisons around Harare, the country’s capital. Rather than focusing on the prison’s water delivery system, the MSF team focused on chlorinating the water supply, boosting the immune systems of prisoners through antibiotics and nutritional therapy, and getting infected prisoners into treatment.
After six years with MSF and multiple trips to conflict zones throughout Africa, Harrison says the work brings out his street smarts. “I seem to have the mentality that [MSF] can put me some place in the world and I can work out what’s going on,” he says.
At no other time was Harrison’s even-keeled temperament tested more than a harrowing trip to South Sudan late last year. His experience also underscores how rapidly the situation on the ground can change and the importance of staying alert and in contact with team members.
Since 2009, Harrison has made trips to South Sudan, which achieved independence from Sudan in 2011 after a protracted civil war between rival ethnic groups. MSF has had a strong presence in the region since 1983, delivering primary and secondary health care in clinics and hospitals in several major cities including Juba, the capital, as well as Lankien, Bor, Bentiu, and Malakal.
On his first trip in 2009, Harrison went to Lankien to oversee a feeding center for malnourished residents. He spent time training local hospital staff who had little or no medical training. After a brief trip to the region in 2010, he returned to Malakal in October 2013 to see the fruits of MSF’s investment in the local workforce. “You could really see the change,” he remembers. “I had skilled people working for me.”
As with his previous trips, Harrison was assigned to one of MSF’s kala azar treatment centers within the Malakal Teaching Hospital. Kala azar, a tropical disease that attacks the immune system and is fatal if untreated, is transmitted to humans through sand flies, carriers of the leishmania parasite. The disease persists in Sudan despite MSF’s long-established kala azar clinics.
On December 15, 2013, a coup was attempted on President Salva Kiir’s postindependence administration after long-simmering tensions between rival ethnic groups, the Dinka and Nuer, exploded. A Dinka, President Kirr accused Vice President and Nuer politician Riek Machar of instigating the coup. The military began splintering along ethnic lines, and armed conflict began spreading from Juba to other regions.
By the week of Christmas, the fighting had reached Malakal. Harrison and an Amsterdam-based MSF team were hunkered down in their rented house in the middle of Malakal’s downtown marketplace, gunfire and mortars exploding around them. Harrison and others had been staying in touch with MSF outposts in Juba and other cities to get the latest news. “By the time it became obvious something was going to happen, we couldn’t get out,” he recalls.
The group managed to move down the street to a house rented by an MSF team from Spain. Altogether, there were nine MSF team members who had remained in Malakal, holed up in a 12 x 12 room for 36 hours until Christmas Day, when the shooting began to dissipate. By Thursday, the day after Christmas, the teams decided to make their way back to the Malakal Teaching Hospital to assist an International Committee of the Red Cross (ICRC) surgical team with a brand new set of patients: soldiers and civilians wounded in the crossfire.
When he returned to the hospital, Harrison noticed that many of the healthier kala azar patients had simply fled. He quickly switched gears and helped set up a 60-bed triage unit to deal with the sheer numbers of wounded streaming into the hospital. With his experience as a trauma nurse, Harrison jumped in to assist the ICRC surgeons with anesthesia, wound debridement, IVs, and “whatever was needed.”
Harrison’s work continued on like this until mid-January, but what was becoming painfully obvious was the deterioration of the security situation inside the hospital. Initially, the soldiers agreed not to bring their guns inside, but soon, guns and “cases of whisky” could be found on the hospital grounds. Family members of the wounded and refugees from Malakal soon began overrunning the hospital to escape the violence.
“At one point, there were 1,000 people in the hospital,” Harrison says. “It had become an IDP [Internally Displaced Persons] camp.”
What finally convinced Harrison and his fellow MSF team members who had remained in Malakal that staying was no longer an option was when teams in both MSF residences took a hit. The Spanish team was robbed of their mobile phones and laptops at gun-point by an armed group; a drunken soldier burst into the compound where Harrison and the rest of the Amsterdam team were staying and started shooting in the air. The house’s security staff talked the soldier down and got him to leave. The next day, Harrison and the entire MSF team headed to a United Nations compound outside of Malakal and were on a flight out of the county soon after.
Harrison says the decision to leave was wrenching, but one that ultimately made sense given the escalating conflict. The hardest part was wondering whether the work could be continued by the hospital’s local staff, many of whom said that it probably wouldn’t. (By February, MSF had to suspend its activities at Malakal Teaching Hospital, according to a recent MSF report.) Still, the team’s departure weighs on his mind: “How does this look that you’re having to flee? You can always leave. You can always go home. What about the people left behind?”
A Higher Purpose
Tissell remembers clearly what inspired her to work internationally: the National
Geographic magazines her parents subscribed to at the family’s home in Kerkhoven, Minnesota. As she perused stories about hardship and traditional cultures from all over the world, she began to realize that “not everyone had the same upbringing as me.”
Her parents, now in their 80s and extremely supportive of her work with MTI, gave Tissell both a great childhood and self-awareness. “I had a strong sense as a young person that I had a whole lot and [some] people had nothing,” she says.
Ford, too, was deeply affected by the unequal distribution of medical care throughout the world. As a childhood survivor of uterine cancer, Ford pursued nursing because of wonderful care she received at a children’s hospital in Portland. “I have a lot of guilt related to inequalities in medicine and education,” she says. She channels her guilt into providing medical assistance and communicating across cultures through trips with MTI.
With her propensity to help those in need, nursing was a natural fit for Tissell. When her eldest of four children turned 17 in 1999, she decided to join an MTI month-long trip to Honduras to set up mobile medical clinics in remote villages destroyed by Hurricane Mitch. The last two weeks, Tissell’s team packed their medicine and supplies and rode mules into the dense jungles of the Mosquito Coast. “We saw a lot of Dengue fever, malaria, a lot of infections from injuries, upper respiratory infections…and childhood disease that hadn’t be treated with vaccines,” she recalls.
Over the next 15 years, Tissell went on more than a dozen medical trips with MTI. She now works shifts at two different hospitals to accommodate and subsidize her travel.
Through her work, Tissell has provided medical care to refugee communities around the world uprooted by high-profile natural disasters and wars. She has treated famine-stricken Somali families seeking refuge in Ethiopia. She served in an IDP camp in northern Uganda to receive malnourished women and children who had fled the terror of Joseph Kony and his Lord’s Resistance Army. On a trip with Los Angeles-based International Medical Corps, she was treating civilians at hospitals in Libya just days before Colonel Quaddafi was captured and killed. And she was in a tented settlement in Lebanon’s Bekaa Valley in May 2013 providing medical care to the thousands of middle-class families from Damascus and other Syrian cities streaming across the border after President Bashar al-Assad began shelling his own people.
The families, who had left homes and careers behind, weren’t suffering from exotic diseases, but rather chronic illnesses such as lymphoma, diabetes, and heart disease that they were unable to treat without access to medicines and regular medical care. “One woman said, ‘We lived in a nice house, we had three bedrooms,’” Tissell says. “This was a total disruption of what their life had been like.”
Each time she returns to her home in Happy Valley, Oregon, Tissell arrives with photos and memories of the families she has helped. Motivated by a strong sense of divine purpose, Tissell says she is perennially awe-struck by the gratitude expressed by people who have just lost everything—and in many cases, everyone. She says she’ll never forget a Congolese woman she met in Uganda whose husband had just been shot during an outbreak of violence in their native country. When she asked the woman if she thought God had abandoned her, the woman turned to her and said, “Of course He hasn’t. Otherwise you wouldn’t have made it here.”
Archana Pyati lives in Silver Spring, Maryland, and writes frequently on health and science topics.