It was a humid summer morning at the Therapeutic Feeding Center (TFC) that served five over-crowded refugee camps in Sierra Leone. The Center was a complex of large tents populated by over a hundred severely malnourished children (ages 1 month to 5 years), their mothers, grandmothers, and/or siblings who helped attend them. The newest children where those in the worst condition (phase one) and they stayed in a special tent where local nurse-aids could do more frequent monitoring. It was in this tent, separated by more than six hospital beds (approximately fifteen meters) that nurse Frida Aronsson and her colleague Dr. Nina Vandyke (pseudonym) were each working to resuscitate a child using ambu-bags.

They had no time to carry the children into the adjacent ten-bed ICU where there were normally 2-3 working light bulbs to help them see in the dim tent. Neither the ‘special’ tent nor the ICU had any monitoring or life support equipment, but the advantage of the ICU was a few working light bulbs and a bit more privacy. That being said, the electric generator had been broken all week anyway and privacy was a luxury Frida and Nina had learned to live without. A few minutes earlier the two expatriate medical professionals had been making their early morning rounds together when Umaru, a 4 year old malnourished boy, had stopped breathing. His condition was probably a result of herbal intoxication although it was impossible to say for sure.

Mothers regularly brought their children to the TFC only after the herbal treatments of the local shamans (traditional folk medicine practitioners) failed to deliver the promised results. The shamans typically prescribed (and sold) strong herbs to treat severe malnutrition. Attempts by TFC personnel to negotiate new practices with the shamans in the area had been unfruitful.

Often by the time the child was brought to the TFC it was already too late. Frida and Nina’s perspectives of the shamans were, in a way, on different ends of the spectrum. One was a little belligerent towards the shamans while the other maintained hope that the shamans would one day cooperate with the TFC. But they never did. Interesting enough, many developing countries have integrated traditional folk medicine into modern medical practices (WHO 1978; Xiao 1991), but such a merger has yet to occur in most of Sierra Leone (Lebbie & Guries, 1995).

Fortunately Umaru still had a pulse. Frida and Nina had worked to resuscitate Umaru for about five minutes when a mother, encamped next to her child’s hospital bed, cried out that her three-year old daughter had stopped breathing. Nina left Umaru with Frida and dashed off to assess the second child. Two minutes later each of them was working independently on a different patient. Distressed, Umaru’s teenage sister began to wail remorsefully, apparently less hopeful than the medical professionals that her listless brother would recover from this latest setback. But Frida and Nina reckoned that both kids still had a chance to survive… if but a small one. Even though less than 20% of the malnourished children who went into respiratory arrest came back; Frida and Nina were not ready to give up. It took two hands to operate an ambu-bag. One to pump the air and the other to keep the mask sealed around the child’s nose and mouth. Frida monitored Umaru with her eyes…stopping the resuscitation every 2 to 3 minutes to check for a pulse. They were prepared to keep at it for twenty to thirty minutes…and barely ten minutes had passed so far.

The distance separating them and the noise in the ward made it impractical to communicate with each other verbally. Even at this early hour the TFC was buzzing with activity. Besides the patients and relatives, the local nurse-aids and staff employed by the project were busy with their own duties on the ward. From time to time Frida and Nina would make a quick glance to each other across the tent to check the status and offer a look or nod for mutual support and encouragement.

In spite of the medical intervention and feeding therapy at the TFC, children died every day. One dark week last month seven children had died in a single day. Over the past few months the TFC had grown from a 60 bed to a 190 bed therapeutic feeding center in response to the famine created by the brutal civil war in Sierra Leone and neighboring Liberia. And no matter how many times Frida witnessed a child’s death it was always hard. She never got use to it (and she hoped she never would). She found some comfort in knowing that hundreds of children, who would otherwise die from malnutrition, were being saved because of the TFC where she and Nina played integral roles. This certain knowledge served like a salve on the daily heart ache…but now was not the time for personal reflection… Umaru needed her full attention.

Frida and Nina were both serving six-month assignments as medical volunteers with Medecins Sans Frontieres (MSF or Doctors Without Borders) the Nobel Peace Prize winning international humanitarian organization. Frida is a 27 year-old Swedish intensive care (ICU) nurse with five years of experience working in Swedish hospitals. In order to join the Swedish branch of MSF she was required to take leave from work so she could attend a 3-month university program on tropical medicine. As a child Frida lived in the Congo and Zaire for six years where her parents had done church work. She speaks fluent French and English in addition to Swedish. Before Frida left Sweden, she received different information packets from MSF about her project assignment. She found the discussions of project history, culture, policy, etc. very useful. On her way to her assignment Frida made stops at the MSF international headquarters in Brussels and then at the MSF country office in Freetown, the capital of Sierra Leone. At both locations she received 5-10 hours worth of briefings about organizational protocol and project issues. She arrived at her project location four months ago, the same week as Nina, a 31 year-old Dutch family physician, to start her assignment. Frida benefited from the fact that she arrived one week before the Australian nurse she was replacing returned to Sydney. But none the less, it was still like being thrown in the deep end of a swimming pool…success was not to drown, but often Frida felt she was drowning. Upon arrival, Frida learned that she was responsible to supervise nearly 80 local employees at the TFC, including cooks, security guards, maintenance and cleaning staff, administrators, and nurse-aids. She was called to deal with everything from conflicts among the kitchen staff, demands for higher wages, and employees who didn’t show up for their shifts. She had never supervised staff in Sweden nor realized the extent she was to do so at the TFC. Her learning curve was long (five and a half months by her own reckoning) and full of frustration and stress. On the bright side, Frida and Nina worked well together and a strong sense of professional camaraderie developed between them and the two other expatriate medical professionals on the project.

This morning Frida and Nina were the only expatriates in the crowded TFC. And now Frida was working alone to resuscitate Umaru, in a struggle between life and death. The local nurse-aids were also trained to use the ambu-bags, but because resuscitation took so long and they were needed to attend all the other critically ill patients on the ward, the job of resuscitation usually fell to the expatriate medical staff. Now, sometimes a situation can go from bad to worse…and that seemed to be happening. Just then a nearby nurse-aid signaled for Frida. The nurse-aid was signaling another code blue in the adjacent ICU tent. Hawa, an emaciated 5 year-old girl had stopped breathing. Hawa had been brought to the TCF by her grandmother several hours earlier. There were three children needing resuscitation and only two available people (and two functional ambu-bags). Frida tried to make eye contact with Nina, but her line of sight was now obstructed by a cluster of relatives standing by the bedside of another patient. The thought “Only in Africa!?” flashed through Frida’s mind. But there was no time to lose; a critical decision had to be made and fast. So Frida made it…

… two months later…

Frida didn’t realize that a long line of people were waiting near the 1994 Toyota pick-up to see her off. Her most intensive work/life experience had now come to a close. She would be driven to Freetown where she would catch her flight to Dubai and then on to Stockholm, where after a month holiday she would resume her nursing job in Sweden. As she emerged from the tent that had been her home for the past six months African drums began to beat and scores of women began to dance and make a high pitched clucking sound from their throats to honor their esteemed nurse who had supervised them for the past six months. Hugs, tears, kisses, gifts, and other expressions of affection were bestowed upon the departing nurse. Frida looked at the crowed of TFC staff which in time she had grown to love and appreciate. Her eyes swollen with tears, she thought, “Only in Africa.”

[Note: I collected most of the details for this story from two 90 minute interviews with my niece, Frida Aronsson, shortly after her return from Sierra Leone. All other names used in the story are pseudonym of real people. Frida’s story is extraordinary but not extra ordinary for those serving in the humanitarian aid sector. I wrote it as a narrative case study. ]