I can’t stop staring at the blood seeping into a tube stretching from the bandaged wound on the little girl’s head as she hands me her drawing. Dressed all in pink, she watches with saucer-like black eyes as I run my fingers over the crudely coloured flag. She points at the blocks of red, white and black and explains, in rapid Arabic, that it’s the flag of Yemen, the war-cursed place where she suffered catastrophic injuries in an explosion last year.
Using the international language of smiles and silly hand gestures, I tell her how brilliant the picture is while a team of plastic surgeons from Médecins Sans Frontières (MSF) whisper nearby about the next phase of treatment needed to rebuild her badly scarred face.
Her younger brother, who almost never leaves her side, is also bound for the operating table and needs a prosthetic ear to replace the one he lost in the same blast.
A grizzled Iraqi man shuffles up and pushes another picture into my hand. It’s black, red and white too, but he didn’t draw it. It’s a photograph of his mangled arm, taken minutes after he was caught up in a bomb attack last year. The image is all black scorch marks, white bone fragments and blood. But that was then. Now he holds up the arm with a smile. The bomb’s impact remains painfully evident but, as he tells me, at least he still has most of the limb. If it weren’t for MSF, it would have been lost.
The French section of the Nobel Peace Prize-winning NGO occupies one floor of this Red Cross hospital in the Jordanian capital Amman, where it performs reconstructive and orthopaedic surgery on victims of conflicts across the Middle East.
Such is the enduring nature of the violence that MSF is building its own hospital in the city later this year.
When MSF opened its Jordanian mission a decade ago it was primarily to help the war-wounded from Iraq, Yemen and Afghanistan. But as the broken-body count from these countries started falling slightly in 2011, an equally bloody conflict erupted 100km away in Syria.
Since the uprising against Bashar al-Assad’s regime began, more than 150,000 people have been killed and countless more maimed. About 2.5 million civilians have fled to neighbouring countries, while almost 10 million have been internally displaced. Almost 200,000 people have simply disappeared.
MSF is bound by its charter to be apolitical to give it better access to all victims, but it still has licence to highlight the horrors it witnesses. It alerted the world to the use of chemical weapons in the Syrian conflict last year and was quick to identify the particularly savage nature of the war. Explosive-stuffed barrels indiscriminately dropping from helicopters, and mortar and shells levelling towns and forcing survivors into desert landscapes pock-marked by landmines, have led to blast injuries on a scale that has shocked many MSF veterans.
And MSF veterans are hard to shock. By any measure it’s a hardcore NGO and one always seen racing towards catastrophes as others flee them. In recent weeks the Ebola virus has spread through western Africa, killing hundreds. But instead of pulling out or restricting its missions there, MSF expanded them.
It is the same story in the Central African Republic, where it continues to run field hospitals as a bloody civil war intensifies. And it was the same in Rwanda, the Democratic Republic of Congo, Haiti, Sudan, Iraq, Afghanistan and hundreds of other black spots where MSF’s people have put themselves since 1971 when a group of French doctors and journalists came together to do something in response to the Biafra crisis in Nigeria.
The first MSF mission I visit in Jordan is in the once-sleepy town of Ramtha, two kilometres from the Syrian border. The town is not so sleepy now. Hours before we arrive, three stray shells intended for the conflict zone landed on its outskirts, and the dull but deadly drone of war is a constant soundtrack. “We can be sitting on the balcony in the expat house having a drink after work when we hear the bombs going off. It’s a real buzz-kill,” one MSF veteran tells me. It sounds glib – even callous – but it’s not. It’s just a fact.
MSF’s project co-ordinator here is American nurse Michelle Mays. She is also in charge of the MSF hospital in the sprawling Zaatari refugee camp nearby and has responsibility for more than 100 medics and logistics experts. It’s a lot to heap on the shoulders of someone in her early 30s, but Mays wears the burden lightly. “You’ve arrived at a very stressful time,” she tells me breezily as we are introduced.
For the next three hours she’s run ragged putting out metaphorical fires, but she stays breezy throughout.
“My family tell me MSF has made me more relaxed,” she laughs. “I think you have to be. You can’t be stressing the little things. This posting is less dangerous than others, maybe because we’re not in the middle of the conflict. But that brings stresses of its own. It’s hard to be outside the conflict. We’re used to going into the field to find the wounded but we can’t do that. We have to wait for them to be brought to us. That can be frustrating.”
Mays is on her fourth mission, having served previously in sub-Saharan Africa and Haiti. What compels her to keep returning to the field? “I studied nursing but didn’t want to play a traditional role. And I had an interest in international conflict resolution so this seemed like an obvious choice,” she says.
“It can be hard to carry on sometimes but also hard to stop. When you go home you love the peace and the quiet and the fact that there are no bombs going off, no calls in the middle of the night, but then you start to miss it. Sometimes I wish I could find an excuse to stay at home.”
The mechanics of medical practice here are simple enough. Syrian field hospitals, staffed largely by MSF’s local teams, treat patients as best they can, with some of the most seriously wounded winding up in Ramtha. They are first brought to an ER run by the Jordanian health department and if they meet MSF criteria they are transferred across a car park on rattling trolleys to its self-contained wing. Broadly speaking, MSF criteria means war wounds from the chest down. Amputations and shattered bones have become a speciality.
On the hospital steps, two staff stand smoking. Maybe it’s the price of cigarettes – a pack costs just over a euro – or maybe it’s the stress, but most MSF staff chain-smoke on mission. These smokers are reminiscing about a man in his 40s they cared for recently. As he recovered from a blast injury, he joked about marrying three staff members. One of them stops suddenly. “Oh but his story ends sadly,” she says. “When he was discharged he returned to his village and was shot dead. I don’t know why.”
They fall silent and finish their cigarettes.
As they do, a little boy is carried past in the arms of a nurse. Both are laughing. The boy’s mother is a few steps further back, carrying a plastic bag of clothes and teddies. She isn’t laughing. Her face is creased with worry. She is bringing her child to their new refugee camp “home”.
The boy has a metal brace attached to one of his legs. It looks crude but is anything but. It is an external fixator and is needed when a bone has been broken into too many pieces for the doctors to set it using conventional methods. Put simply, bone fragments are bolted to the external structure and, given enough time, they should fuse. Half the people in the MSF ward have external fixators attached to one or more limbs. Those who don’t are missing limbs.
Dr Kul Deep is an Indian orthopaedic surgeon working with MSF for a month, as he does every year. It seems like a strange choice for a holiday? He laughs. “It’s different to my regular work. I swap the stresses of my day-to-day job for these stresses once a year and go home with my battery fully charged.” Like many of the medics, he enjoys the challenge of the work and the complexity of the cases.
Luis Eguiluz is chief logistician with the Dutch mission in Amman and oversees staff accommodation, transportation and the medical supply chain. When terrible things happen anywhere in the world, people like Eguiluz are the first on the ground establishing the supply lines needed for medics to do their job. He has been working with MSF for more than 10 years. “The biggest challenge here isn’t supplies but the complexity of the injuries,” he explains.
“It’s not what we’re used to. We’re talking about very advanced weaponry so the level of human destruction is very high.”
Why has he given his life to this? Eguiluz pauses before answering. “I don’t know. As humanitarians we’re dreamers maybe?”
He talks of dreamers, but his world can be a place of nightmares. “It’s frightening sometimes, for sure, but that fear is something you learn to deal with,” he says.
Eguiluz’s wife also works in the humanitarian field and they travel together with their children. He was in the Central African Republic during last year’s coup and managed to get his family out hours before the MSF compound was stormed by militia. He and 15 staff were trapped inside.
“They ransacked the place and I had Kalashnikovs pointed at my head. But it wasn’t the first time for me,” he says without bravado.
“I knew what to do. They wanted our cars so I just told them to take them. This is what you need to do in such situations. My job was to protect my staff. You don’t know the level of anger these guys have and, in many cases, the cost of a human life is nothing. You just have to get them out of the place. So you give them whatever they want. The only thing I asked was that they take the MSF stickers off the cars. I didn’t want them killing people in cars carrying our name.”
They said no.
Ahmed, one of the NGO’s drivers, bounces into the courtyard where Eguiluz sits smoking. “I hope you don’t write about drugs,” he says by way of introduction. “Then you will get killed.”
I look alarmed. He smiles. “You know, like that woman journalist who was shot in your country by the men on the motorbike? She was writing about their drugs. It was a great film.” Veronica Guerin is his only connection with Ireland.
Sharon Mealy has a few more. She is 39 and from Kilkenny, although it has been years since she called it home. She is a supply consultant on her fourth mission. “I like how MSF works and how it stays where it is needed most for as long as it is needed,” she says as she sips black Barry’s tea and cradles rashers that have just been hand-delivered by an Irish colleague. “They’re not illegal here but it’s hard to get good ones,” she laughs.
Then the laughing stops. “This work can get you down sometimes but you have to realise that, if you weren’t here, the lives of some people would be so much worse. We are affecting change on a small level but we are still affecting change. We’re not trying to fix all the problems in the world. We can’t do that. But we can help some people.”
Some of those MSF is helping are on hospital beds in the desert an hour’s drive from Amman. In less than three years the Zaatari refugee camp has grown from nothing into a massive city of barbed wire, tents and tension. There are more than 100,000 people living behind a perimeter patrolled by heavily armed Jordanian soldiers. The MSF car is waved through the gates as new arrivals trudge miserably along the dusty paths leading to the United Nations reception centre. Military jets fly low overhead and the burr of helicopters is constant.
It is midday and the camp is quiet. The dusty streets are filled with children walking home from school with sky-blue Unicef rucksacks on their backs. It is not always this calm. Last month a refugee was killed and dozens more injured in clashes with Jordanian forces. The influence of criminal gangs is growing and aid workers are often confronted by hostile refugees driven to the edge of reason by displacement.
MSF’s hospital is protected by razor wire but, despite the hostile backdrop, calmness reigns. “One of our core principles is to try and restore a person’s dignity, and that can be done through simple things like privacy in the dressing station or a clean ward or something as simple as a basketball hoop,” Mays says as we walk through the unit.
Younis (25) prefers chess to basketball. He challenges me to a game and, as he beats me, he tells his story. “I stood on a landmine. They stopped the bleeding in the field and transferred me to the MSF hospital in Ramtha and then here.”
Younis drums his fingers in the empty space where his left leg used to be. “I worked in construction before and when I’m well enough I want to go home. I hope nothing will change and I can live my life as before.”
It is much the same story with Kassem, who lies in a bed nearby. The 27-year-old was hit by a tank shell on Valentine’s Day. It took both his legs from the knee. “I was working in the UAE in my family’s business. Then my brother went home to Syria to see his wife and was shot dead. My three other brothers were killed at his funeral.”
His voice is flat. “I wanted to go home to see what the situation was.” Days after he did, he suffered the catastrophic injuries.
Which side of the conflict he was on is irrelevant to MSF. “Who we are treating never matters,” Mays says. “There is no due process in the emergency room. You are a patient. The question of who [you are] ends there.”
Rabee is 23 and, like Younis, he stepped on a mine. It happened just three weeks ago so his multiple wounds are still fresh. “The blast blew off my foot and I lost one of my eyes,” he says. Then, unexpectedly, he laughs. It’s a proper belly laugh. “We Syrians are very good-humoured and we love to smile,” he tells me. “I was studying political science before the war and I would like to go back to that once the conflict has ended. If I am still alive.”
Ibrahim worked as a nurse in Daraa, the nearby city where the conflict first started. He is a refugee now and an MSF liaison officer. “When I fled my home 18 months ago, my son was just four-and-a-half and it was too dangerous there for him. I miss everything about it. I lived in paradise, with a nice house, a big garden and a car in the driveway. Now I live here,” he gestures out to the tented city beyond the hospital gates.
“When I came to work here I thought it would be very upsetting but there is a lot of laughter. I think I can learn from the patients.”
Éimhín Ansbro is “living the dream”. It’s just not everyone’s idea of “the dream”. As she was preparing for her Leaving Cert, a little over a decade ago, her biology teacher gave her a book about the five greatest medical advances of the last 30 years. MSF featured prominently. “I already knew I wanted to be a doctor but it was then I decided to work with MSF,” she says.
She is on her second six-month stint with the NGO; her first was in northern India last year, where she rolled out a pioneering malnutrition intensive-care unit. “I don’t think I’m making sacrifices to be here. I get more out of it than I give,” she insists.
At home she works as a locum GP but now she is based in Irbid, a short drive from Ramtha, and is researching the treatment of non-communicable diseases such as diabetes and hypertension among refugees. She works alongside her Spanish partner Fernando, who she met in India. She is medical team leader and he is project co-ordinator. “There are a lot of MSF relationships,” she says. “But I’ve seen a lot of relationships break down too, particularly when one partner wants to give up and the other wants to go on.”
For now the couple is happy to go on. So is Paul Foreman, who heads the Dutch operation in Jordan. He came of age in the 1970s as a self-styled leftie before falling into line with Thatcher’s children and setting up a construction business. He had a big house and a fancy car, but then his business and his life fell apart in the recession of the late 1980s. An ex-BBC friend asked him to travel to Bosnia to serve as a one-man TV crew to document the war.
“I had nothing left to lose so I went. I left England a builder and came back a humanitarian,” he says with a broad smile. “I was exposed to terrible and extraordinary things there and that was my Damascene moment – it wasn’t on the road to Damascus but at least my name is Paul.”
Foreman addresses MSF’s accounts and salary scales in the context of multiple crises that have engulfed the voluntary sector in Ireland. In countries such as Ireland it has a 3-1 rule so the highest-paid employee cannot earn more than three times the lowest paid and the wages of all senior staff are published annually. MSF president Dr Joanne Liu earns €105,103 a year. Her predecessor, Dr Unni Karunakara, did a sponsored 5,000km cycle through India after he finished his term to raise money to pay back his salary. “I can tell you our top people don’t aspire to those roles for the money,” Foreman says.
How have two decades as a humanitarian changed him? "Have I become hardened? The short answer is yes. You get hardened because you have to function and you have to be professional. That is what drives us. My first year in Bosnia was extremely emotional and very difficult. Some of the most awful things I saw there have come back to me in recent days when I see what is happening in Syria. But we must stay professional. The main fear is the fear of failure, the fear of not getting it right."
Médecins Sans Frontières is the only medical humanitarian organisation in Ireland providing emergency medical care to people in war, disasters and epidemics. Donate at msf.ie or call 1800 905 509