'In my eight missions with MSF no two have been the same. Yes, I draw on many of the same guiding principles and tools, but there’s always something new to learn.'

How I Got My Epi Training

I got my master’s in public health (MPH) from the department of international health and development at Tulane University School of Public Health and Tropical Medicine. On my visit to New Orleans to check out their program I walked into a class that had begun a few minutes before. The lights were turned off and the professor had started up an old-timey slide machine. I saw a photo of a Land Cruiser with solar panels in the Kenyan desert with a nurse giving a shot to a little boy out of the back of the truck. That was it. That was what I wanted to do. I sat there and listened as the professor talked about the mobile health clinic she had set up for a nomadic tribe in northwestern Kenya and I was completely hooked.

Since it was geared for complex emergencies, my program attracted a lot of doctors who had worked with MSF. In my first group project I worked with a German doctor that had just come back from the Democratic Republic of Congo. I wanted to hear every story he had to tell. We used MSF’s Refugee Health book as our text. I remember reading the chapters that talked about how a measles vaccination campaign was the most important intervention in a refugee camp and how many liters of water per person per day were required during the emergency phase. I hoped I would be able to apply all of that new knowledge to real situations, not just for my final exam. But first, I knew, I’d need some field experience. I’d lived and worked a lot in Latin America but never in Africa. That’s where I wanted to go. I bought a one-way ticket to Nairobi and crossed my fingers.

Two and a half years after that first visit to Tulane, I was riding shotgun in that Land Cruiser from the slide show, helping my professor’s former organization start up HIV testing and counseling for my internship. After six months of that and other research projects in Kenya, I bumped into someone at an HIV conference in Nairobi who seemed very familiar but I couldn’t place. He was the head of HIV/AIDS programming for UNHCR and it turned out he had been a guest speaker in one of my classes at Tulane. He asked for my resume and six months later he offered me a consultancy at the Dadaab refugee camps on the Kenya–Somalia border.

How I Ended Up with MSF

When I came back home, after a year and a half in Kenya, I needed to figure out what to do next. How could I get back to Africa? I lost my keys in front of an office building in Santa Monica. When I looked up from digging around in my backpack I recognized the MSF logo on one of the doorbells—it was the West Coast MSF communications office (which has since closed). It was hard not to feel like it was a sign. I started volunteering there; when the recruiter came I was interviewed and accepted into the pool. 

My First Mission

The first place MSF offered me was Darfur [in Sudan] in 2004. After a lot of soul-searching and family negotiating (the Darfur conflict was in the headlines and on CNN every night at the time), I decided to do it. It was an emergency mission, so my contract was only for six months (usually first mission contracts are for one year), but I wound up extending to 10 months. I was learning so much—such an experienced team and dynamic context—that I didn’t want to leave. At the time it was the biggest project MSF had ever done, so I got experience working with almost all of the services MSF provides, from war surgery to nutrition to mental health. Though my graduate work had prepared me for many of the issues I was dealing with, I have drawn on the on-the-ground training I got working in Darfur during that first mission for all of my subsequent projects.

The Role of the Epi in an MSF Project

One of the most surprising aspects of international health work I learned about in Darfur was the diplomacy required to do something as simple as a measles vaccination campaign. The Refugee Health book said that vaccines are one of the most important things, right? In the book it said if kids aren’t vaccinated you get the supplies and give them vaccines. But what I didn’t hear about in those public health classes was the number of cups of tea you must have with the minister of health over a two-month period before you’re granted permission for a vaccination campaign; vaccines, like many other health interventions, are sometimes more about politics than health. Part of my job as an epi is to help with that diplomacy and political maneuvering, frustrating as it sometimes is.

One particular challenge faced by many epis in the field is that most people don’t know what an epi is. Epi-demi-what? Dermatologist? A doctor? Sometimes you’re the only one who knows who you are and what you’re supposed to be doing there. This can be funny, frustrating, a secret advantage, or all of the above. They really need you, they just don’t know it yet.

Doctors and nurses are often really interested in collecting data about their programs and patients, but it’s hard for them to find the time to develop efficient systems to collect that data, analyze it, and understand what it means. Many will never have used Excel. So much of the data is important for a variety of reasons. Are the patients young? Are they pregnant? Are they from the north? The west? And what are the patterns? Are people sicker with a particular disease now than they were in the rainy season? Has there been a spike in the diarrhea numbers for children under five years old? It’s very hard to do that kind of analysis when you’re in the thick of seeing these patients every day. Clinicians have a good sense of the day-to-day, but it really helps to have someone whose sole job it is to help set up a system to collect and analyze the patient information to tell the bigger story of what’s going on.

Of course you also need to be able to predict the future. I’m kidding. No one can do that. But, you always hope that the data you’re collecting now will help other teams in the future who might be dealing with the same context and outbreak. If we had a cholera outbreak in a camp, how many children in that camp were affected? How many adults? This helps you make projections for the current situation.

The data you’re collecting isn’t just for the doctors and nurses, it’s also for the whole program. For instance, the logistics department needs to know how many might get sick so they know how many supplies to order. The project coordinator will be interested to know how long the epidemic is likely to last for human resource planning.

In my eight missions with MSF no two have been the same. Yes, I draw on many of the same guiding principles and tools, but there’s always something new to learn and a new environment to apply my expertise to. And I use that word expertise broadly. In Nigeria I spent two days taking a printer apart, for instance, because we desperately needed it to print out patient forms for the lead poisoning program. In Zimbabwe, one long hot day, I learned proper notification procedure for what to do when a Land Cruiser hits a goat. That knowledge base is not very typical for epis who work in North America or Europe—but it’s extremely valuable with MSF.

Similarly, if you’re applying to MSF hoping to do all of the cool, sophisticated stuff you got to do at the Seattle Health Department—regression, statistical analysis of breast cancer, et cetera—and you’re sent to a context where much of your time is spent deciphering paper and pencil tallies to determine if 200 or 2,000 children came to the clinic yesterday, you can be very frustrated. It’s not that it’s a lower level of work—it’s almost like a completely different job. It’s the same with clinicians. If a doctor is used to relying on an MRI machine for diagnosis it’s a big transition to go back to only having a stethoscope, thermometer, and blood pressure cuff. It’s not for everyone. For me, it’s a perfect match because I don’t ever want to do just one thing. I love how varied my job is.

Love of the Job

In the ten years of my career that I’ve spent in Africa I’ve had many more profound moments of thinking “this is exactly what I want to be doing” than some people have in their whole lifetimes. Some things get really old—rats climbing the mosquito net, foul-smelling food, and Ministry of Health diplomacy—but for the most part I got exactly what I came for: usefulness, adventure, human connections across seemingly insurmountable language and cultural barriers, and total engagement with the world around me.  

Advice for Epis Starting Out with MSF

In my first project in Darfur, I thought I’d have to turn myself in after two weeks. I imagined going up to the medical coordinator to confess “I’m a fraud, there’s no way I’m going to be able to learn this and actually help you guys with your work. I’m sorry. I’ll go home tomorrow.” Somehow I got through those first days and never had to catch the next plane home. It can be nerve-wracking (to say the least) but if you sit tight for that period of total insecurity and remind yourself that you do know how to learn or you couldn’t have ended up in this situation to start with, it will come together. Because we work in emergencies, the context, team, and project can be very fluid. You’re there to do the best you can for the needs of the people around, and those often change. MSF’s nimbleness is a great strength, but sometimes it can also be challenging to keep up with, especially when you’re new. Staying open-minded and flexible—which is really easy to talk about but much harder to actually do—is essential to keeping useful and sane.

  • Hit the ground running. Read up on whatever you can before you land. Sometimes that means collecting all of the articles, research, and MSF reports about a disease or context and reading through the pile on the airplane. You’ll be glad you did.
  • Be prepared to feel like an idiot. Of course, no matter how much reading you do, you’re never going to be prepared enough or know enough about any context or environment before you get there. That’s fine—it’s the same for everyone. Often the first two weeks are a total haze of confusion. The first 24 hours, in particular, can be brutal.

  • Let go of how it’s “supposed” to be. There’s a reason MSF highlights the need for flexibility so much. A lot can change between the time you are hired and the time you eat your first dinner in the field. Many times I’ve been recruited for a meningitis epidemic and by the time the plane hits the ground a measles and cholera epidemic have broken out. Sometimes I’ve been told that everyone gets their own room and I’ve arrive to a shared tent.

    Because we work in emergencies, the context, team, and project can be very fluid. You’re there to do the best you can for the needs of the people around, and those often change. MSF’s nimbleness is a great strength, but sometimes it can also be challenging to keep up with, especially when you’re new. Staying open-minded and flexible—which is really easy to talk about but much harder to actually do—is essential to keeping useful and sane. 

  • Come with a project for yourself. For some people that means a craft project—a nurse I worked with in Nigeria used to crochet little elephant toys. For others it means a series of books that you really want to work through, or writing songs, or bringing seeds to make a little herb garden. Bring something that connects you to a piece of home, so you can have a couple hours to yourself every week. You’re living and working so far away from anything considered a comfortable context, and having a little corner (even if it’s only in your mind!) of that faraway place that’s your own is really important. Most cases of burn-out that I’ve seen are people that don’t have any tools to keep anchored in their normal life. You’re not going to write the great American novel or finish knitting a really complex button-up sweater, but having something of your own to peck away at is really important.