Hope in Hell

Hope in Hell
Author: Dan Bortolotti


This book is a comprehensive account of the history and work of Medecins Sans Frontieres (MSF) – ‘the world’s largest independent medical humanitarian organization’. The author chronicled its emergence and rapid rise to prominence because ‘it was a brash and fearless group that went where others would not go’. The book not only provides revealing insights into the work MSF does in dangerous places, but it also uncovers the group’s impassioned internal and external politics. Its thorough portrayals of the visionary founders and the successive leaders of the organisation also provide a background to understanding the defining impact it has made – a globally transformative impact that won it the 1999 Nobel Peace Prize. The content covered the spectrum of MSF activities, from its conventional humanitarian work in conflict-ravaged areas, to its relatively recent involvement in improving access to important drugs for neglected diseases (page 56, 155-162, 172-189 and 21-22).


By AdventSource – Adventurer Club, CC BY-SA 3.0, Link


Although the author traced the birth of MSF to ‘a Paris boardroom in 1971‘, he showed that the remote spark for the group’s conception was the involvement of gastroenterologist Bernard Kouchner in the humanitarian fallout of the Biafran Civil War in 1968. He depicted Kouchner as a charismatic, flamboyant, and media-savvy man ‘with a fire in his belly’, illustrating his defiant nature with the example of how, when working with the Red Cross at the time, he defied their rules and wrongly denounced the Nigerian government for purported genocide. The book further depicted Kouchner as ‘blunt, abrasive, impatient, disorganised, opinionated and quick-tempered‘, but suggesting that these were the qualities that enabled him pursue his humanitarian vision. The author chronicled how Kouchner teamed up with another group lead by Raymond Borel to form MSF, describing the rifts that emerged shortly after over the issue of the organisation’s political neutrality. The author documented the eventual falling out that forced Kouchner out of MSF and led the way to a ‘new breed’ led by Tony Brauman and Claude Malhuret. The book also charted the growth of the organisation to the stage where it now has 19 semi-autonomous branches with its headquarters in Geneva (pages 11-12, 41-54 and 63-66).

CC BY-SA 2.0, Link

The book painted a comprehensive picture of the type of work MSF does, explaining the factors that it considers before it engages in any humanitarian crisis. The organisation typically carries out its relief work in refugee camps because these provide ‘ideal conditions for all manner of pestilence‘ such as measles and cholera. In view of this, immunisation programmes are central to the organisation, although the author highlighted the challenges of this strategy in places such as Afghanistan where field workers had to convince ‘a sometimes reluctant population to use them’. On the other hand, the peacetime humanitarian work of MSF usually focuses on the management of child nutrition, and the author illustrated this with the example of the high protein food supplements it dispensed to malnourished children in the Zhare Dasht region of Afghanistan. In carrying out this type of activity, the author explained that MSF would typically set up therapeutic feeding centres within the camps, but it also exceptionally distributes food outside camps during famines, and this is illustrated by the group’s work in Sudan in 1998. In remote areas afflicted by natural disaster such as floods and volcanic eruptions, the author said MSF undertakes the riskier activity of providing mobile clinics, but this is only after an exploratory mission has gone ahead to ‘assess medical needs and judge whether an intervention is necessary‘. The author noted that such missions which provide medications and other emergency supplies may take place in schools or mosques, and even ‘under a shady tree‘ (pages 111-119 and 131-134).

MSF tent on the Kabo site. hdptcar on Flickr. https://www.flickr.com/photos/hdptcar/2299342261

A major theme of the book relates to the stories of the people doing the ground work for MSF in different parts of the world. An example of such anecdotes was that of James Knox, a doctor from Australia who spent 9 months teaching and supervising the staff of a rural clinic in peacetime Angola. His story reflected the challenges of working without the appropriate diagnostic tools, with no regular water supply, and with a major language barrier. Another doctor who worked in Angola was surgeon Wei Cheng who carried out operations – the ‘highest profile‘ work in war zones – and who saw such conditions as ‘a man with deep machete wounds on the side of his face which was designed not to kill but to send a warning‘, and a man ‘with a stab wound four days old, with a section of bowel hanging out’. The author stressed that most MSF volunteers are motivated by high altruistic ideals, and MSF itself looks for volunteers who can adopt flexible lifestyles, work in small groups, and preferably to speak a second language. He however also pointed out that there are some who volunteer just to experience variety and challenges, using MSF as an ‘opportunity to visit remote places and experience other cultures‘. He also asserted that some volunteers are driven by mundane reasons as ‘simply looking for a refuge from problems at home’, and wanting ‘to do medical tourism‘ (pages 17-29, 91-93 and 70-83).

MSF Headquarters CC BY-SA 4.0, Link

A running theme throughout the book is the physical risk that accompanies the type of work MSF does. The book illustrated this hazard with graphic examples such as of MSF health centres coming under arms fire, both intentional and by ‘random bullets‘, and attacks on travelling teams such as occurred when the Taliban ambushed and attacked an MSF Land Cruiser in 2004 with gunfire and grenades, killing five aid workers in the process. Another example was the ambush of the vehicle carrying MSF logistician Stephanie Courteheuse in Somalia in which the driver was killed ‘by five bullets to the head’, and Stephanie was shot in the chest and spine, leaving him wheelchair-dependent. Another alarming risk the author narrated was that of abductions, as happened to Kenny Gluck, the MSF head of mission in the North Caucasus in 2001. Other hazards of the work the author explored included the risk of contracting infections, and the danger of injury and death from landmines and plane crashes. A less evident risk for the workers is psychological, and this may be so overwhelming that it may ‘threaten to burn them out in a matter of weeks’; the author illustrated this with the example of previous MSF President James Orbinski who developed prolonged post traumatic stress disorder after he witnessed the Rwandan genocide (pages 102, 128-129, 149, 213-222, 26, 103, 96-98, 159-160 and 232-239).

Rwanda genocide 1994. Gil Serpereau on Flickr. https://www.flickr.com/photos/gil_serpereau_photographe/23783589798

Whilst the profile of MSF the author painted was generally positive, in several places he highlighted what he perceived were the organisation’s shortcomings. For example, he criticised the group’s rigid stand of refusing government funding – a principle that maintains its neutrality but restricts its fund-raising capacity. He also questioned the limited impact of the short-term nature of many MSF emergency missions, the group’s involvement in resource-intensive natural disasters, its refusal to release statistics of its casualties, the inadequate welfare support it provides its volunteers, and the image it projects to other aid organisations that its members are ‘arrogant, self-righteous troublemakers‘ who assume they know what’s best for the populations they help. The author also reviewed criticisms that the organisation’s politically controversial concept of ‘without borders‘ is a policy it uses to transgress political boundaries when convenient (pages 135-136, 146-154, 200, 230-231 and 241-244).

CC BY-SA 4.0, Link


This book provides a very useful insight into humanitarian medical work generally, and of MSF specifically. The research is detailed and it is supplemented by field interviews which provided a realistic atmosphere of what humanitarian work entails. The content is enhanced by the numerous, often graphic, photographs the author included. The writing is rather journalistic and occasionally poorly focused, and it often gets mired in the mundane. There was also a sense that all the chapters were formulaic, following a standard template applied to different parts of the world. The book also suffers from the absence of depictions of practical medical work, such as surgeries, and this is probably because of the author’s non-medical background. The book is however comprehensive and it provides a very objective assessment of the principles and values of an organisation that has made a major impact on global humanitarian work.

Overall assessment

This book has done an excellent job of highlighting a little appreciated dimension of medicine, particularly spotlighting the motivations and the dangers involved. It also emphasises the major medical problems humanitarian missions address. The book’s exploration of the history and politics of the organisation is also helpful, as is its depiction of the protocols and risks of the field work. The book addresses a fundamental health concern in many parts of the world, and I recommend it to all doctors.

Book details

Publisher, Place, Year:  Firefly Books, New York, 2006
Number of chapters: 10
Number of pages: 304
ISBN: 978-1-55407-142-5
Star rating: 4
Price: £11.25

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