Nurse Anna Freeman is frustrated by the limits of technology when she attempts to advise a Syrian hospital over a shaky Skype connection.

Anna Freeman is a nurse and quality improvement specialist at Médecins Sans Frontières / Doctors Without Borders. She has worked in humanitarian response in ten countries over the past ten years, focusing on refugee health, infectious disease, and quality of care.  Anna is an excellent dancer, an enthusiastic fumbler in any foreign language, and one of the world’s worst surfers.

This story first aired April 6 2018 in an episode titled Science Communication.

Story Transcript

As Paula said, I work in humanitarian aid and I work for Doctors Without Borders, which we usually call by its French acronym which is MSF.  I did my first assignment ten years ago and I was very young.  Like many young people, I was very naïve and very optimistic about what I was going to be able to do.

I went to Eastern Congo and I worked in a trauma hospital for six months.  And when I came home to North Carolina, I was totally devastated by the experience.  I was just so sad and so angry and so frustrated.  Most of all, I was really ashamed by what I couldn’t do in the face of this humanitarian crisis.  I felt like what I could offer was so insignificant and so I thought, “I will never, ever do that again.”

So I started working again as a nurse in North Carolina and, over the following couple years, I ended up doing a couple more assignments with MSF.  I found that with time and with experience, I was able to kind of manage those feelings and do this work that I really loved and I really cared about but also take care of myself.

So I started working full-time for MSF and worked in a lot of different places around the world and in a lot of challenging settings.  Then last year, I got a call asking if I would go to Syria to do an evaluation of a hospital that MSF runs.  I’ll give you some information about this hospital and where it is in Syria.

As I’m sure you’re aware, there has been a multi-year civil war in Syria and in this part of the country where the hospital is located, there are a lot of people who have been displaced.  So they’ve fled their homes because of violence and are living in camps.  So what that looks like is that extended families live together in canvas tents and they have poor access to things like water and electricity.  For cooking, people use basically like camping stoves with unrefined fuel.

Unrefined fuel is very unstable and so it’s very explosive.  And what happens often is that the stoves will explode and cause a fire.  The hospital that I was being asked to evaluate is a hospital that treats explicitly only patients who have burns that come from either these kind of cooking accidents or from things like shelling.

When I accepted to go to this evaluation, what was explained to me was that this part of Syria is very, very unsafe and it’s actually too unsafe for MSF to send international staff there.  So there is a Syrian staff that runs this hospital and then there’s a support team of international staff in a neighboring country in the Middle East that provides support to the hospital.

So they said, “You know, you’re going to go to this neighboring country and you’re going to do your review,” what we call cross-border, so remotely from this other country.  So that’s what I set off to do.

I get there and I find that the team has set all this stuff up for me.  So they’ve hired a translator named Nur who will work with me and there are boxes and boxes of documents for me to use in my evaluation, and they’ve got a computer with Skype, which is the best, most reliable way to talk to the field team.

So Nur, he starts translating all these documents for me and the first thing that I do is I go through the emergency department logbook where all the patients are listed.  I’m thinking that this will help me understand the activity in the hospital, to get a feel for what they’re doing and what it’s like.

What I find is that this logbook actually really gives me an idea of what it’s like to live in this part of Syria because every time there’s an attack in the area, I can see that in the book because there will be a bunch of patients who come with traumatic burns.  Or every time there are new people who come from a different part of Syria who have fled, I can see that in the book as well because there’s a new camp that appears.  So I’m getting this idea of what it’s like to live there.

Meanwhile, Nur and I are talking to the team in the field and setting up interviews with different staff and it’s going terribly.  The connection is so bad we can barely talk to anybody.  We can hardly hear with Skype.  It’s just a nightmare.  

And I’m hit with all of the same feelings that I had when I came back from the Congo of feeling so sad and I’m reading about what it’s like to live there and all I can offer is like the world’s worst phone call.  I mean, it’s a terrible, terrible feeling.  I was so ashamed that I couldn’t do more.

But of course we press on and we’re trying to figure out a way to make this work.  And so Nur and I realized that for us to best communicate with the field team, that we will use this computer with Skype and we’ll have to use earphones to hear.  So he and I are sitting next to each other like sharing an earphone, like this, and it’s connected to the computer, of course, and we’re like making full body contact going on this side, which is pretty uncomfortable in a Middle Eastern context.  So we’re both talking like… you know, it’s terrible.  It’s really uncomfortable.

And Nur has his computer open as well because he has the translation software, since even if his English was fantastic, he didn’t have a phone with that medical vocabulary.  So while translating, he’s also looking words up on his software.  And I’ve got my phone with WhatsApp, which is what I’m using every time Skype fails which is like every five seconds.  I’m texting the team and saying, “Stand by.  We’re calling you back,” or whatever.  So this is what we find we can kind of work with.

And we’re interviewing all these people in the hospital and we start to interview somebody named Wayel who is a physical therapist for the team.  Burn patients, especially people who have really serious burns, they need a lot of rehabilitation.  It can be like twelve to eighteen months’ worth of physical therapy.  It’s a long, long time.  And in order to have that, we’re asking these patients to come back to the hospital two or three times a week.

So I’m talking to Wayel and I’m saying, “How are we making sure that happens?  What are we doing to make sure our patients can come back for all this long-time,” and I’m really pushing him on this subject and I’m basically saying like, “Are we doing enough?  Are you doing good enough to make sure that this happens?”  I’m really pushing him.

Finally he says, “Habibi,” this means like, “my dear” in Arabic, he says, “we’re doing everything we can but we can never do enough for our patients because we can’t take away their burns.”

That comment really sticks with me.  Nur and I, we continue our interviews and the next day we’re interviewing somebody called Jihan, who is the counselor for the hospital.  We’re talking to her and, for once, the connection is actually pretty good so the conversation is flowing and we’re talking. 

I realized that Jihan, like all of our staff, she is living in this area so she’s exposed to all of these same traumas with the attacks and the population shifts and displacement and all of these things that our patients are exposed to, she’s also living.  But then in addition to that, as the counselor, she absorbs all of our patients’ stories all day, every day.  She’s hearing about their trauma and their loss and their grief, and I think that must be so hard.

So I say that to her.  And I say, “Jihan, how do you take care of yourself?  You’re so exposed.  So what do you do for your own mental health?”

And Jihan says… well, Skype froze, and I was so frustrated.  I turned to Nur to say, “Look, okay, what are we going to do?”

And Nur stops me and he says, “I think she’s crying.”

And I realized that he was right.  Skype actually hadn’t frozen.  She was silent because she was trying to compose herself. 

Finally she says, “No one’s ever asked me that before and I’ve never thought about my own mental health.”  

And I realized that talking to Wayel and talking to Jihan, we were just people talking to each other.  Even though we could sometimes barely hear each other, there was the translation, we were just two human beings talking.

Then I got to the end of my evaluation and it was almost time for me to go and I offered to the team to do kind of a debriefing or like give them feedback on my review before I left to go back to the States.  So I asked the nursing director if he could set up a time that we could do this.

So his name is Abdumalik, and I said to him, “You know, this is not mandatory.  People can come if they want to.  They don’t have to come.”

So he's sets this up and we get everything ready to go and he had this good idea.  He took a picture of the room and sent it to me through WhatsApp, because we couldn’t use the video on Skype.  So we’re about to start and I open WhatsApp and I have this picture and this room is just jam-packed with people. 

And I’m thinking like, “Oh God, they probably all felt like they had to come to this evaluation because somebody is here from headquarters that’s reviewing them.”

So I’ve got Abdumalik on the phone and I say, “You know, this is wonderful and I’m so glad everybody is here, but I hope that nobody felt pressured to come.”

And he says, “Well, Anna, for one thing we know, we all want to provide the best care that we can for our patients so we all want to be here to hear what you have to say.”  And then he says, “But more than that, when people like you come and work with us, we know that the world hasn’t forgotten us.”

Thank you.