Doctors Without Borders or Psychiatry venturing into terra incognita
This article was translated into English by Jessica Dutse. Many thanks to her!
Agnes, you joined Doctors Without Borders (DWB) as a psychiatrist, working first in Iran and then in Iraqi Kurdistan. It was a courageous decision: not everyone can decide to travel, to a “terra incognita” as you did, and especially in psychiatry, which is still a rather unique field. Why did you make this choice?
Ever since I was a child, I always wanted to pursue a career in humanitarian medicine. DWB was a childhood dream for me... I'm adventurous! I definitely considered a career with DWB, but after working these two shifts, I realized that going on a mission from time to time would be much more suitable for me.
How old were you when you left? Can you tell me a little bit about that first humanitarian experience?
When I did my first mission with DWB, in Iran in 2013, I was 30 years old.
I'm French but I lived in Brussels, Belgium for nine years and that's where I studied medicine. I have been living in Geneva, Switzerland for 9 years now, and this is where I started my internship in psychiatry; I had been working for almost 3 years as an intern in psychiatric hospitals (especially in prison and in the emergency room) when I left with DWB. I applied for DWB France rather than Switzerland because there were more mental health missions with them, at least back then.
Did you personally pick the countries for your missions? Were there places you didn't want to go? How long did each mission last?
No, I was open to all countries, and in any case, DWB decides where to send you. You have the right to refuse, of course, but after one or two refusals, you run the logical risk of not getting asked anymore.
All in all, I spent a year and a half with MSF: 6 months in Iran and 3 months in Iraqi Kurdistan, with some (usually very long) time between missions, mental health missions being rarer.
I was scheduled to spend 6 months in Iran, after which I recruited a local psychologist. DWB proposed I stay a little longer, but I refused due to issues related to hierarchy in the field.
However, by the end of my 3 months in Iraq, I would gladly have stayed longer because the expatriate team there was nice, but the replacement schedule had already been set.
Back then it went like this: during the first 12 months of your mission, DWB would recruit you as a volunteer with a very low compensation salary, then you became an actual employee with a salary close to the minimum wage. You were only paid for the actual time of your mission so if you had no other source of income, it could very quickly become tight, especially since you had to be ready to travel at any moment (the salary policy may have changed since then). I would've been unable to cope if I didn't financially rely on my partner.
You were relatively inexperienced as a psychiatrist, you're young and you're a woman. Did one or more of these three aspects cause you any problems during your missions, either with your colleagues or your patients?
It didn't cause much of a problem because up until then I had always worked very autonomously and in difficult environments, including prison and closed psychiatric wards where mentally unstable [editor's note: out of touch with reality] patients were treated. In addition, I had worked night shifts as a nurse in closed psychiatric settings as a medical student.
What exactly was your mission in Iran? What was your daily life like?
I was deployed to a DWB clinic located in the very deprived areas of southern Tehran, meant to provide care for sex workers and drug addicts. My mission was to assess whether this population needed mental health care, and if so, to provide it. In practical terms, I would see these women in my consulting practice, and at the same time, I had to think about which concrete actions to carry out, such as awareness-raising activities in the area, or organizing training sessions with my colleagues at the clinic.
I started by identifying the existing organisations in Tehran, be they closely or remotely linked to mental health or to the target population of our clinic. I could then position DWB in this ecosystem and decide what the NGO (Non-Governmental Organization) could offer in terms of mental healthcare in this neighbourhood. In the end, since the answer to the question "is there a need for mental health care in this clinic" was that a psychological consulting practice was necessary but not a psychiatric one, I recruited an Iranian psychologist to replace me.
And in Iraqi Kurdistan, what was your mission?
I worked in two DWB general health clinics, this time in two large Syrian refugee camps. The camp was open to all Syrian refugees, but as it was in Kurdistan, the refugees were mainly Kurds.
A psychologist had been there for 6 months, but she was a bit overwhelmed because she was the only one providing mental health care without the local support of a psychiatrist. So, I was sent there to take over from her at the end of her mission.
What were the challenges in the refugee camp?
Honestly, the refugee camp was a complete mess; with the media coverage of the Syrian conflict, many NGOs were getting involved, because it was quite easy to raise awareness and collect donations. So much so that there were virtually a million humanitarian organizations all eager to help the Syrian refugees, but it wasn't clear exactly what it was that a good number of them were actually doing there! This obviously caused coordination difficulties, which the UNHCR (United Nations High Commissioner for Refugees) was actually responsible for. As a result, we regularly had double medical follow-ups, sometimes with harmful consequences on the health of the patients, especially in terms of mental health.
In the end, after 3 months I was replaced by an Australian psychiatrist, who was very competent. He had both clinical and interpersonal skills, which I feel was essential in this type of setting. I guess such skills can be acquired with age, with a certain maturity or through a certain intelligence -- but obviously not everyone has these abilities.
I wasn't surprised to learn that he later became head of the mental healthcare sector at DWB in Paris!
It was you who ended your missions with DWB. Can you tell me why?
Because I started my master’s degree in International Relations at Sciences Po, where we met!
Ultimately, what were the positive aspects of your experience with MSF?
I really appreciated the diversity that comes with the job: it's not just a job as a psychiatrist in an office or even in a hospital, because you do everything yourself in terms of training, coordination, recruitment... and also in terms of strategizing beforehand. Another aspect is the context and the audience you interact with, which is obviously stimulating. In fact, it can sometimes prove dangerous when you have to pick up a patient in crisis in his camp tent yourself! Furthermore, depending on the country, the laws and customs are not the same: outside the Western world, often the family is very involved and the State isn't much, and this must absolutely be taken into consideration.
You still contribute to the relief of people in great difficulty; a bit like in prison, these are very precarious, very complex situations.
And the negative aspects?
First of all, living in an expatriate community can be very difficult, depending on your personality: you often have to share your room, work 6 or even 7 days a week, you have very little privacy, very few opportunities to be alone... I'm a real introvert, and I imagine that not everyone has the same needs.
Hierarchically, I sometimes found the organization a bit rigid. For example, your position or your salary was determined by your time spent there (as an employee, not taking into account your training or previous experience), though perhaps that has changed since then.
And then, in the humanitarian field, you meet great people, that's for sure... But you also meet temperamental people, with problems, with whom you might encounter harassment issues. Of course I think the difficult living conditions and the whole overcrowding thing don’t make human relations any easier.
Do you think you'll take up missions with DWB again? Would you recommend this experience to other psychiatrists, young or old?
Although I don't plan to work with DWB after graduating from medical school, I would be happy to go back on a mission, yes.
As for recommending the experience, yes, I think I would. But you should know that only 50% of people go on a second mission, and among them, only 50% go on a third one. Having said that, in my opinion, knowing what to expect lets you appreciate the next experience better, because you already know what you can get out of it in a positive way, and because you learn to (re)act in difficult situations.
A humanitarian experience is a great human experience and I would recommend it. However, in humanitarian work, you should do it for yourself rather than believe that you are going to save the world.
Plus, you can meet a lot of interesting people! I go back to Iran every year since I completed my mission there, because I made some true friends there.
What lessons did you learn there, for yourself, for people being cared for in psychiatry, for the world?
This experience led me to ask myself many questions about the impact and meaning of humanitarian actions, both in the local and global political contexts, and in relation to other health actors present in the field. This is a question that I hadn't asked myself during my practice in Europe. That's why I decided to do a master’s degree at Sciences Po afterwards: to adopt a more global point of view, because that is necessary if you want to be able to act in the right way.
On a clinical level, I've been wondering whether using Western psychiatric classifications for certain pathologies and in certain cultural contexts is the best way to go about it. This is where culture and morals come into play: I have observed that certain behaviours are more frequent and better tolerated in some cultures than in others. Having said that, in psychiatry we often talk about a continuum and we put the cursor of the pathology in a certain place; hence, for certain pathologies, in certain cultures, the cursor could potentially be moved a few degrees.
Do you mean that basically, what defines a psychiatric disorder is that the behaviour deviates from the norm, instead of a psychiatric disorder being defined by the behaviour itself?
It depends on what type of behaviour and what type of pathology we're talking about. In some cases, yes, it does; and what really defines a psychiatric disorder and allows a diagnosis to be made is the fact that it causes difficulties in daily life.
It doesn't really matter in the end whether a behaviour is regarded as normal or not.... The question is, does it cause difficulties for the person who is experiencing it, be it socially or personally, or both, obviously. And that's where culture and morals come into play: certain personality traits are going to be problematic in one place and perfectly accepted in another.
There is a school of thought in psychiatry that develops this way of looking at things: it's called transcultural psychiatry. I'm not particularly familiar with this approach, but it's true that my experience with DWB has led me to ask myself questions along these lines. I continue to explore all these questions with my patients today and it's exciting!
- A peer reviewed international journal that publishes original research and reviews articles on cultural psychiatry and mental health
- An article (in French only) by a French NGO on the why and how of transcultural psychiatry
- A 2016 WHO (World Health Organization) study on the mental health of migrants and refugees