Living in Emergency: Stories of Doctors Without Borders
Directed by Mark Kaplan
Produced by Mark Kaplan, Naisola Grimwood, and Daniel Holton-Roth
Red Floor Pictures
Living in Emergency, which will be in U.S. theaters on April 17, tells the stories of four developed world physicians who have worked on Médecins Sans Frontières / Doctors Without Borders (MSF) aid missions in Congo and Liberia. The documentary feature offers a somewhat confused but still fairly engaging look at MSF's work in these war-torn nations. Of course, the film is an advertisement for MSF, but it is admirably frank about tensions between foreign and local staff, the stress of confronting widespread suffering in dangerous areas, and the despair that critical resource shortages can cause. The film even offers some insights on foreign aid work. But it mostly ignores MSF's local staff, and completely ignores its nurses and logistics officers, all of whom play key roles in the Nobel Prize-winning group's work. Although nurses are the most numerous MSF health professionals, this film is almost entirely about physicians, who do virtually all of the talking and acting. Viewers learn what the physicians do, what they think, and how they feel. Other MSF staff may flit across the screen, unidentified, but they are portrayed as peripheral to the stories that matter: those of the casually heroic physicians who provide all meaningful care to these populations in great need. In the end, the distorted film's treatment of emergency aid mirrors that of MSF's name: it's a physician thing.
Living in Emergency has received a good deal of attention. It will have a theatrical release April 17, 2010 in the United States, but it was already screened simultaneously in hundreds of theaters across the nation in December 2009 as part of a special New York-based event that featured the ABC News "20/20" anchor Elizabeth Vargas and some of those involved with the film. The film was short-listed for 2010 Oscar consideration, but did not ultimately receive an Oscar nomination.
The film is structured around the largely distinct stories of the four physicians, though two of the stories do intersect for a time. The film weaves its stories together with extensive voiceovers from the physicians, and by following their interactions with other aid workers and patients. The physicians make clear that the work is rewarding but also maddening; some of them seem to spend considerable time pondering how long they can stand to continue doing it.
Tom Krueger is an unassuming, thoughtful surgeon who has practiced for 20 years in Tennessee, but who has grown tired of the "big business" of the U.S. health care system. He seems to be looking for a new way to contribute and a new adventure. He finds it. His first MSF mission takes him to Liberia, where the long-running civil war ended in 2003. His segment shows how he copes with the new environment in Monrovia, where his decisions in a setting with few resources can have especially grave consequences. Krueger displays an unusual level of understanding when he notes that helping others helps him, so it is in a sense still "selfish." In the end he seems to bear up pretty well, as the film epilogue notes that he went on to MSF missions in Darfur, Nigeria, and Sri Lanka. Krueger appeared at the live New York screening of the film in December 2009.
At the other end of the spectrum seems to be the Australian Chris Brasher, an MSF veteran who has been away from his home nation so long that he considers himself to be "homeless." Brasher began to feel burned out working in sometimes apocalyptic conditions while in Liberia in 2003. The film finds him in Congo. There, the articulate physician muses at length on issues like why people go on the missions in the first place (e.g., to run away from home), and how he prefers helping poor people who care about each other to helping well-off people who don't. Still, the epilogue notes that Brasher ended up practicing in Paris; no word on how much the Parisians care for each other.
Another MSF veteran is Kiara Lepora, an Italian physician who serves as MSF's head of mission in Monrovia. The film mostly shows her trying to manage problems with the local and international staff. At one point, she tries to mollify a Liberian MSF physician who, though not a young man, says he is tired of being treated like a "boy" by the international staff. We also see Lepora meeting with the Liberian Minister of Health (a physician). Lepora offers observations about the work, for instance noting that people need to have a lot of sex on MSF missions because they face so much death. When it is time for her to leave Monrovia, there is a farewell event, at which one local staffer notes that the aid group is not about individuals, and all the expatriates eventually leave, so it's best not to get too attached to them.
One local who does not seem to be in danger of getting too attached is the sole nurse identified in the film. She is a "head nurse" who speaks up at a large farewell gathering for Lepora not so much to thank her as to complain bitterly that she was not consulted about who would replace her as head nurse. The film never explains this--why she is being replaced, or why she would expect to weigh in on her own replacement, which would seem to be an unusual thing. So the audience is left with this awkward scene as the only one in which a clearly identified nurse has done anything in the whole film. In any case, the epilogue says that Lepora was later promoted to "Emergency Coordinator," whatever that means, and that she went on to establish MSF's mission in Somalia.
The last physician profiled is Australian Davinder Gill, whose first MSF mission goes very differently from that of Tom Krueger. Gill is working in a more remote part of Liberia, where, he says, he is "the first doctor who's lived here for over 15 years." Gill struggles with drastic resource limitations, and with the local staff; he remonstrates with one about missing supplies and a lack of familiarity with patients. Some of Gill's efforts to help patients are frustrating. One child with a swollen face seems to have kidney disease; his mother actually removes him from MSF's care because there is apparently little they can do for him. At another point, an injured girl is distraught because both of her parents have died. A couple of Liberian MSF workers try to comfort her, and they briefly explain her grief; they might be nurses, but they are not identified. Eventually Lepora, the head of mission, travels to see Gill, apparently because he is having so much trouble. They have heart-to-heart discussions about accepting the limitations of their role in the nation, but it's not clear that Gill's outlook improves. The epilogue notes that he is now a pediatrician in Australia and has no plans for further MSF missions.
The film focuses far more on the MSF staff than on the patients, but the story of the stressed-out aid worker with conflicting motives and emotions is naturally compelling, and a good vehicle to convey something of the basic situation to a developed world audience. The film also mostly skips the deeper issues that play into the poor health of these nations. But that may be understandable for a film about a group that, after all, does not seem to do international development or holistic public health work, and is instead essentially a large-scale emergency care provider. There is no real discussion of broader programs for health education, vaccinations, or any other initiative that might have a broader long-term impact. (The physicians might not be ideal public health ambassadors anyway, since two of them smoke constantly.) These physicians can offer isolated interventions, but it's sometimes unclear how long a patient will survive after a relatively difficult intervention has saved the person from immediate death. The film does acknowledge that MSF can do little to address the "normal" situation in these poor nations, and that the decision to leave when there is no longer an "emergency" can be a wrenching one.
It is unfortunate that the film focuses solely on the international staff rather than the local staff who presumably do most of MSF's work. Couldn't at least one of its four profiles have been about a local worker? This flaw is ironic since the film candidly reveals the resentments of local MSF staff who feel disrespected. What would the Liberian physician who did not want to be treated like a "boy" say about the failure to give any attention to the local staff's work?
And of course, there's the lack of nursing. Although nurses are the most numerous MSF health professionals, this film is utterly physician-centric, telling its stories almost completely through the eyes of its four stars. Only they provide voiceover narration, and in doing so they spend a lot of time pondering what it means to be a good physician, or any physician, in these challenging circumstances. They discuss their backgrounds, their frustrations, their plans. We do occasionally see other MSF workers, especially in a few clinical scenes. But these scenes focus only on what the physicians are doing, and only they reveal health expertise. Nurses are virtually never identified, they speak very little, and their perspectives are never explored or even explained. It is possible that if nurses had been included in the film, there would have been a little more of a holistic perspective on MSF's work and the larger problems that confront its patients. There might even have been some patient education; there is almost none here.
But wait! Nurse alert: If you watch the closing credits closely, you'll see that there is a long list of everyone who has appeared at all in the film. We counted 17 physicians and 9 nurses! Presumably the real nursing role in MSF's work is such that even in a film that tries as strenuously as this one does to highlight only physician activity, nurses will be more than a third of the health professionals who appear. But of course, no viewer will come away from the film thinking that nurses play any significant role at all in MSF's health care, much less that they do a third of it, since viewers hear absolutely nothing about the nurses' work, or their perspectives--except, of course, that they demand the right to have input on who their replacements are.
Please write to MSF and ask that them to improve their public outreach activities, including that of their name--so that the public understands that plenty of nurses deliver life-saving care under the banner of "Doctors Without Borders" and that nurses deserve public credit for their work.
Reviewed by Harry Jacobs Summers
Nursing Editor: Sandy Summers, MSN, MPH, RN
Reviewed March 23, 2010
The views expressed herein do not necessarily reflect those of the Board Members or Advisory Panel of The Truth About Nursing.