1. Freeman, Anna MPH, RN

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In 2008, I packed my bags for my first-and what I thought would be my only-field assignment with Doctors Without Borders/Medecins Sans Frontieres (MSF). I had expected this to be simply a good opportunity to see the world while using the nursing skills I had honed during 3 years of critical care pediatric nursing in the US. Ten years and eight countries later, I am still involved with MSF. This organization opened my eyes to the challenge of delivering high-quality healthcare in extremely difficult circumstances and to the reward of offering care to people who otherwise lack access to even basic medical services.


I have been involved in managing hospital-based nursing services in rural Democratic Republic of the Congo, running a cholera treatment center in posthurricane Haiti, providing emergency obstetric care in South Sudan, and managing mental and primary healthcare services for refugees in Iraq, Kurdistan, and Greece. No matter what the setting, my colleagues and I strive to provide care that is both clinically sound and adapted to the specific needs of the populations we serve.


The differences in healthcare needs, sanitary conditions, and available clinical services in these countries are vast. Volunteers might be assigned to care for patients with war-related injuries and illnesses; set up isolation and treatment facilities for patients with infectious diseases; coordinate an operating theater and inpatient maternity services; or run clinics to address the health needs of refugees. Although the settings and daily tasks are always different, the nursing mission remains the same-to provide competent and compassionate care to all patients.


A bleak reality

When I look back at my fieldwork experiences, one stands out as an example of the importance of nurses in humanitarian crises. In 2013, I was working in the Central African Republic (CAR), a country that has struggled for decades to develop and thrive after independence. Although the country is rich in natural resources, most people living in CAR are extremely poor. Health statistics in the country are dismal: life expectancy is only 51 to 54 years; the maternal mortality ratio is 882 per 100,000 live births; and mortality for children under age 5 is 128 deaths per 1,000 live births.1-3 These statistics are grimmer than those for other countries in the region and countries of similar wealth around the world.4 This bleak reality worsened in 2013 when a coup d'etat sent the country into a civil war.5


As a nurse manager, I worked with a team of CAR and international staff in a referral hospital north of the capital of Bangui. The hospital, located in the town of Sibut, was surrounded by rebels leading an attack on the capital. Outside the hospital fence, the rebels lived, strategized, and celebrated their victories with local beers, sometimes firing their guns into the air.


At the hospital, we cared for pregnant and laboring women as well as children with malaria, pneumonia, diarrheal diseases, and malnutrition. Our hospital census fluctuated depending on how safe it was for people to come to the hospital; we could anticipate fewer admissions when the fighting increased and people were forced to hide out. As the rebel group advanced on and then retreated from the capital, we triaged and treated mass casualties with our limited surgical resources.


One day, a family was admitted to the pediatric ward. Two babies had become ill: a 1-year-old with malaria and a 2-month-old with pneumonia and failure to thrive. The mothers of these two babies were "sister wives," meaning both women were married to the same man. We admitted the babies and started their treatments. The two children shared a bed in our small inpatient room, and the mothers slept on a mat on the floor next to them. One of the mothers, the second wife in the family, was very young and extremely frail. Her sister wife cared for all three of them, fetching water and preparing food. The younger woman stayed on the mat and held her baby, nursing her and napping with her.


Over the following days, this young mother also started showing signs and symptoms of pneumonia. Her condition quickly deteriorated. We treated her with antibiotics and supportive therapy, and her sister wife patiently spoon-fed her porridge and nursed both babies. We learned that both wives and their husband were HIV-positive, but the younger wife had not started antiretroviral therapy (ART). The ongoing war prevented delivery of ART to rural areas, and we had none to offer: The Ministry of Health Hospital where we worked was supposed to have antiretroviral drugs, but the hospital had recently been looted and most of the medical supplies, including the antiretroviral medications, had been taken. We could not send our patient to the capital, as the journey was too dangerous.


After a few days, the physician and I were called to the unit where the family was being treated. The young mother was in shock. She was hypothermic, delirious, and in respiratory distress. We knew her death was imminent.


Her sister wife diligently and gently tended to her and the babies, and the pediatric nurse and I wrapped her in a survival blanket to keep her warm. She would regain partial consciousness, then try to pull out her I.V. catheter. We gave her an anxiolytic agent and tried to give them privacy as a family despite the shared room with other patients.


Shortly after, the young wife died. The pediatric nurse helped the sister wife to clean her body, then we watched the babies while the husband and sister wife buried her body next to the hospital.


Proud to serve

Being with her family at the time of this patient's death was a powerful experience, one that has stayed with me. I can still acutely feel the frustration of being able to do so little for her, and the sorrow of her early death, leaving such a young baby behind. But I am proud of what we could offer her in her final moments, working with her family to make her as comfortable as possible, giving them precious final moments together, and helping them to prepare her burial in a way that aligned with their culture. After her death, the patient's family stayed in the hospital while the children recovered before being discharged together. The older wife cared for the younger wife's baby as her own.


Working in CAR during this tumultuous period was one of my most challenging assignments. I witnessed the horrific effects of conflict on the health of a population. Working as a nurse in this context is both gratifying and frustrating, as the needs are often much greater than what any one individual or organization can address. The story of this young mother's life and death is a common one in countries experiencing political instability and violence, especially when access to healthcare is limited. But these experiences have shown me that no matter where I am, how few resources are available, or how dire the circumstances, as a nurse, I can still offer compassionate care to all my patients.


MSF is an international medical humanitarian aid organization. MSF provides medical assistance to populations in distress, to victims of natural or manmade disasters, and to victims of armed conflict. Each year, in almost 70 countries, around 3,000 international volunteers work alongside more than 30,000 locally hired staff to provide lifesaving medical and technical assistance to people who would otherwise be denied access to basic human rights, such as healthcare, clean water, and shelter. MSF's care is free of charge and is provided irrespective race, religion, creed, or political affiliations.


To learn more about working as a field nurse with MSF, please visit




1. World Health Organization. Central African Republic. 2015. [Context Link]


2. World Health Organization. Maternal mortality in 1990-2015: Central African Republic. 2015.


3. World Health Organization. Global Health Observatory country views: Central African Republic statistics summary (2002-present). 2015. [Context Link]


4. World Health Organization. Central African Republic: WHO statistical profile. 2013. [Context Link]


5. Pouambi JR, Callimachi RC. African Republic hospitals looted after coup. Associated Press. 2013. articles/2013/03/26/rebel-leader-dissolves-cafrican-constitution?s_cid=related-links%3aTOP. [Context Link]