Transcript

MIC CAVAZZINI:                Welcome to Pomegranate Health, a podcast about the culture of medicine. I’m Mic Cavazzini, for the Royal Australasian College of Physicians.

Most of us have, at some point, imagined ourselves in distant lands, providing humanitarian care to people less fortunate than ourselves. But very few of us follow through with this. Life gets in the way and our world closes in to a horizon of more tangible concerns.

Today we’ll hear from two physicians who took the bull by the horns and signed up with Médecins Sans Frontières. Also known as MSF or Doctors Without Borders, it is one of the most-recognised medical relief agencies in the world. MSF has projects in more than 70 countries that might be affected by natural disasters, armed conflict or disease outbreaks. In 2022 over a million patients were admitted to MSF clinics or hospitals, and over 16 million treated as outpatients.

Much of the hard work is delivered by the 40,000 or so locally-hired health staff in those regions, but MSF looks to internationally-recruited medics to provide specialist expertise and clinical leadership. Last year there were 133 assignments filled by Australians and New Zealanders, of which about half were in medical or allied health roles.

On MSF’s high demand list at the moment are paediatricians and paediatric nurses, as well as obstetricians and midwives, trauma surgeons and mental health professionals. At the end of this podcast I’ll skim over some of the eligibility criteria and point you towards application process.

The focus of today’s interview will be the experience of working with MSF. What’s it’s like to ship out on your first assignment and then what kind of responsibilities you’re given as you become more experienced in the organisation. We’ll hear about deployments to conflict zones including Sudan and Gaza, and what MSF does to ensure the safety of its staff. And finally, how do gaps of six months or more affect progression in your day job, and even your financial situation. My wonderful guests were Drs Tasmin Hasan and Josephine Goodyer.

TASNIM HASAN:               So, my name is Tasnim Hasan. I'm an infectious diseases and general medicine physician, an adult physician. I work in Western Sydney at Blacktown Hospital. I'm also a part-time researcher at the University of Sydney and my passion is tuberculosis.

MIC CAVAZZINI:                And, Josie, what about you?

JOSIE GOODYER:              Yeah, so I'm Josie Goodyear and I'm a paediatrician and paediatric emergency medicine specialist currently working in the ACT. I'm also a part-time academic with the Australian National University Medical School.

MIC CAVAZZINI:                Thank you. And to help ask the questions that our junior doctors want answered, I've also invited Dr Aidan Tan. Not only is he one of my most trusted podcast reviewers, but he sits on about a dozen committees and working groups for the college, another dozen with health departments, state and federal, the AMA, the Agency for Clinical Innovation. Tell us about your day job, Aidan.

AIDAN TAN:        Thanks Mic, I'm Adam Tan, I'm paediatric advanced trainee at Sydney Children's Hospital.

MIC CAVAZZINI: Thank you. Okay, let's cut to the chase. Tasnim, you've been on assignment four times with MSF in various theatres that will be familiar to listeners. We'll get into the complexity of some of those later, but tell us where your journey with MSF began. What stage were you at in your career and what were you hoping to get out of it?

TASNIM HASAN:               So I, was always attracted to potentially work for MSF. I actually looked at the application process when I was an intern. So in my first year as a doctor, and they only take people who've had at least a couple of years of experience. So I was decided that, that wasn't for me at that time. and actually parked it and somewhat forgot about it and then I just went through and did what a lot of doctors do, which is go on the train and finish all my, junior training and advanced training, go through all my exams, finished it all and then at the end of six years I was like, I've done nothing in my life but study, what shall I do? And so actually I went to Darwin first so that was my idea of getting out of Sydney and I really enjoyed working in Darwin and working within the remote communities and then at the end of that year I was also like no I'm not ready to return to Sydney, let's look back at the MSF chapter.

I actually applied for MSF but I think they're quite pedantic and I answered some questions incorrectly and I got rejected. I can't remember which ones now but there was at back then there was a job that was specifically targeted towards infectious diseases doctors in Uzbekistan and it was a multi-drug resistant tuberculosis job. So after the rejection of the official process I just applied for that and somehow got in through the back door and that's how I landed in MSF.

MIC CAVAZZINI:                Josie, what about you? How far through your training were you when you packed your bags for Kiribati?

JOSIE GOODYER:              Yeah, I was a fair way through my training when I packed my bags for Kiribati. And the first time I worked with MSF was Liberia, actually, in Western Africa. And I left the country and there was no COVID and then I landed in Liberia and then there was COVID and it changed everything. I was really early in my medical career, I guess, when I thought about working for MSF. So, I'd thought about it as a medical student and somewhat similar to Tasnim had attended some information and sessions as an intern and junior doctor. What changed things for me was the setup between MSF and the Sydney Children's Hospitals Network, which for me really removed all of the barriers that I faced in terms of working for MSF for the first time.

So, a previous paediatric advisor for MSF Australia in the operational centre in Paris was a paediatrician with the Sydney Children's Hospitals Network. And she had established an arrangement whereby instead of doing a six month advanced training rotation within the Network you could apply in parallel for a network position and your first assignment with MSF. And so, for me it removed all sorts of barriers in terms of timing, access to additional supervision—because I was really nervous about working for MSF for the first time despite it being something I thought I would love and I'd always wanted to do—and access to additional leave entitlements and things in an Australian setting. And the ability to leave a job in Australia and return to a job in Australia which for me was quite important. So that's how I got into it, yeah.

AIDAN TAN:        There's a strong public image of MSF as conflict medicine and we'll certainly be hearing about some of that. But Josie, is that an accurate mental image for young doctors to have when they're trying to picture themselves working with the organisation?

JOSIE GOODYER:              That's a really interesting concept, Aidan. In my mind, it was an organization that worked in places where no one else worked. And you saw medicine and you contributed to clinical care and in ways that no other organizations did. The first two times I worked with MSF were not in emergency project settings and were in countries where there was not current conflict, so both in Liberia and Kiribati. In Kiribati it was about climate change, actually. and most recently was in a conflict setting in Sudan. And it certainly does change the nature of a work, but as a paediatrician majority of the time, the need is global and certainly MSF contributes to work in global contexts that aren't only areas affected by conflict.

MIC CAVAZZINI:                Let's go back to those hurdles and benchmarks, Tasnim. These days, MSF only takes doctors who have fully qualified as Fellows or paediatricians with at least five years experience. Can you reflect on the kind of responsibility a new recruit is likely to have on their first assignment with MSF?

TASNIM HASAN:               So, I first worked for MSF seven years ago now and the organization has changed a bit in those seven years. But generally speaking, when you start your first assignment, you're put in a place where you would be put in roles where you'd have less supervisory responsibilities and more clinical responsibilities. And generally, you know, as a medical doctor it would be in clinical settings relevant to the project. So, if you're a paediatrician, as a paediatrician, in my case, I was an ID physician in a tuberculosis project.

I think those requirements of being a specialist have evolved in the last few years. And one of the things I do respect about MSF is that they really do value the locally-hired staff and they really give the locally-hired staff a lot of independence and a lot of ability to work within the clinical environment and I think that that requirement has probably come as a result of you know the recognition that locally hired staff can do the bulk of work and are really the you know are really the wheels of the project and so I think a lot of the international staff now go in at more senior roles. More a supervisory role than a clinical role.

MIC CAVAZZINI: Yeah. Yeah, so bearing in mind that that first experience might differ now, what information do you wish that recruiters had given you then, or maybe be more transparent about? You can both have a go at this one, but you start, doesn't he?

TASNIM HASAN: I don’t really know that there is something that I wish I knew before I went. I don't think I realized that locally hired staff was so important and that's just ignorance but if you think of it from a common sense point of view it makes complete sense because at the end of the day you want to build capacity. But if I give you an example in Uzbekistan, there were 20 international staff and maybe three, 400 locally-hired staff. So, we're a very small portion of the workhouse. But yeah, I don't know if there's information, because I was in a stable setting and maybe Josie has the same experience being in library because it's a stable setting it's an easy way into MSF. I do know people who've probably started off in South Sudan or Sudan and that, you know, the answer may be different if you start off there. But yeah, I don't know that there was, you know, it's a steep, steep learning curve but it's a very worthwhile learning curve.

MIC CAVAZZINI:                Josie, see whether any surprises for you that were outside your…

JOSIE GOODYER:              COVID was the biggest surprise. It changed everything and then decision-making around that in terms of ability to travel home and return to Australia. Some of the advice that I received wasn't from, I guess, the recruitment process, it was from others who'd gone before me and paved the way to an extent.

I think most people are nervous about the clinical medicine, it's what we've trained for a lot of years to be able to provide and it's what we'd like to contribute. Because I felt like it was context and settings in which, for example, I'd be adding into treatment of malaria, but local staff would have far more experience with that—that's their day to day—than what I would.

And so, some of the advice that I received from people who went before me was that it's actually not the clinical medicine that's the hardest part. And it's probably not the part that I'm going to find the most difficult. People had said that the most difficult part is living and working with people on a daily basis and often the living conditions, even in very stable contexts. It's really challenging in some of these areas and in some of these contexts in countries, we really under-appreciate how much of an effect climate change and basic complicating factors like severe storms and weather can have. And some of the really ethical and moral dilemmas that you're faced with on a daily basis and how you navigate that in a culturally supportive way. Because we're there to contribute and also learn and share together.

AIDAN TAN:        Thanks, Josie, and can you describe the kind of preparation you're given before you set out on your first assignment? And what could junior doctors be doing towards this even before they become eligible for recruitment?

JOSIE GOODYER:              So, I might answer the second part first, Aidan. So certainly for paediatric trainees or paediatric advanced trainees, which is really part of the recruitment process and having those years behind you for an MSF context. I think the more experience you can have in terms of critical care, medicine and acuity, the more well established you'll be for what you see clinically on a day-to-day basis. You see extremes of illness and it can be extraordinarily challenging to treat.

You do see a lot of death. It's very different to it in Australian context and the way that that is accepted and part of life in settings in which MSF is present and works again is different and you need to develop approaches to that. I had done a paediatric intensive care rotation before I went and first worked for MSF and that was deliberate and I'd also done at that stage about 12 months or so of work in paediatric emergency departments.

I had also just completed my rural rotation as an advanced trainee, which I do think added to the aspects of retrieval medicine that you do when you work with MSF and thinking about referral pathways, or not, that are present in the context where MSF is present. And all of that, I think, was quite a good founding base.

The pre-departure training that I had for MSF before I first worked for them with this parallel recruitment process was done in person at that stage and it was just the most fantastic experience because it really built a community of practice. And I certainly made friends and established connections in those five in-person pre-departure days that I've maintained throughout my career and across the years that I've continued to work for MSF and that really stood me in good stead. And in the pre-departure days, it's a big mix of everything, but the majority of the information is not about how to treat patients and how to do clinical medicine, because MSF anticipate that you enter the workforce with those skill sets. So, it's more about how do you apply that skill set in completely different contexts and how do you navigate ways of working and living and working together with people that you might not necessarily choose to otherwise live and work together with. And lots of security information and protocols, which was all new for me.

MIC CAVAZZINI: The remit that MSF covers is well represented in its origin story. Nigeria gained independence from the Crown in 1960 but within the decade was fighting a secessionist movement in the south. With covert support from the British, the military blockaded the self-declared Republic of Biafra. The scale of the resulting famine wasn’t known to outside world until the French Red Cross became the first relief organisation to go into the besieged territory. It’s estimated that two million civilians died by starvation over the three years of the conflict.

The doctors who had witnessed this formed a new aid organisation that would provide emergency relief irrespective of political boundaries. Around the same time, another group of French doctors came together in response to a cyclone in eastern Pakistan that killed over 600,000 people. In 1971, the two organisations merged under the name Médecins Sans Frontières.

Fast forward to 2005. Sudan had seen the end of a twenty-two year civil war, one of the longest in history. As part of the peace agreement, a referendum was held which led, in 2011, to the formation of South Sudan as an independent country. Two years after this glimmer of hope, the government was torn apart in a power struggle that fell along ethnic lines. As well as the conflict between the dominant Dinka and Nuer groups, South Sudan is home to another dozen ethnic minorities struggling for representation.  

Medecins Sans Frontieres were present in South Sudan throughout the internal conflict and in 2014 both staff and patients had to flee a hospital in the north after government forces breached a cease-fire. By the time hostilities formally ended in August 2018, there had been some 380,000 war-related deaths and human rights abuses attributed to both sides. A power-sharing agreement has limped along since then but not without accusations of government corruption and violent flareups featuring rebel groups who had rejected the conditions for peace.

From South Sudan’s population of around 12 million, at least 4 million are displaced and more than half of those are classed as refugees by UNHCR. In 2022 Tasnim Hasan went for a six month assignment to the north-eastern province of Upper Nile. This was a time when two thirds of the country’s population was facing severe food insecurity. There was no shortage of aid committed, some $1.4 million dollars per year to scores of different relief and development organisations [according to a UNOCHA]. I asked Dr Hasan how Médecins Sans Frontières worked within this ecosystem of NGOs.

TASNIM HASAN: MSF is a big player in South Sudan and one of the biggest budgetary expenditures of MSF is in South Sudan. So, when I was there, there was 13 different projects in South Sudan. So, there were 13 different locations within the country where a project was up and running that was run by MSF. But the other thing is that I was there almost four years ago and in the last two years the situation has deteriorated further from a conflict point of view. Although there was conflict while I was there.

I was working in Malakal, which is in the north in the Upper Nile region. The area there is quite big, so the population there is big. can't remember exactly how big it is. But MSF also worked in much more remote areas where they were the only health care provider. But where I worked, because it was much bigger, there were actually several different NGOs that worked together. So, there was International Medical Corps, was the IOM, the International Organization for Migration, Norwegian Red Cross, ICRC, the International Red Crescent Society.

So, there quite a lot of different NGOs in Malakal, and each NGO had a different goal to fill. So, you know, ICRC was about helping people who had potential war related injuries. So, any amputations and rehabilitations and issues related to war injuries. And IMC were more the surgical NGO. And so yeah, different NGOs had different roles. We had a big field hospital. We actually had two settings in Malakal. One was a field hospital within an IDP camp where there was one ethnicity and then there was another town sort of area where there was a different ethnicity, where we ran a hospital in coordination with the Ministry of Health and we provided paediatric adult and neonatology care. So, we didn't provide maternity that was provided by another NGO.

I mean, I guess in summary, know, was a MSF is a big player in South Sudan and they do work collaboratively with other NGOs to fill identified gaps and the aim is perhaps to tackle the things that you do well in one place rather than trying to solve all problems which is why we did paediatrics and not maternity and not surgery.

MIC CAVAZZINI:                To avoid replicating the wheel, does one organization build the infrastructure, the field hospitals, another one provides the staff or do you each have your own hub?

TASNIM HASAN:               Yeah, it's different in different settings. in South Sudan specifically, we had each had our own field hospital. But when I worked in Afghanistan, we did work in a hospital where different players or different NGOs were in different parts of the same hospital.

MIC CAVAZZINI:                                Yeah, Josie, you have been in Sudan, which sadly also has a tragic history going back decades. The most recent round of conflict started in April 2019 with protests that overthrew a 20 year military dictatorship. And then bloodshed between the ex-government supported by the Sudanese armed forces and the paramilitary group called the Rapid Support Forces, who are the heirs to the notorious nomadic militia, the Janjaweed.

They're heavily armed and last year they had taken most of the country with the last outpost of the SAF in city of El Fasher in Darfur, just above South Sudan, in fact. More than half of that city's 1.5 million inhabitants are displaced people and the largest refugee camp is known as Zamzam. And 70 km to the west of that is another small town called Tawila, which is where you landed in July last year. Tell us what the situation you found there just before a new round of atrocities claimed as many as 60,000 lives.  

JOSIE GOODYER:              Yeah, so I was, I was in Tawila, so within Darfur or North Darfur state and we were about 60 kilometres from the frontline in El Fasher where there was ongoing daily violence, shelling that we could hear and feel in the ground, drones that were flying overnight in a no airfly space and hundreds of thousands of internally displaced people who were fleeing violence and coming to Tawila, which completely changed the population of Tawila and completely changed the needs of the population and the needs of the surrounding area. So, it was a completely different context for me and it was the first time I'd worked for MSF in an emergency context.

We were, as in MSF, we're established in like a hospital building structure. And then we needed to expand because we didn't have enough beds and spaces for all of the patients that we needed to treat and provide care for. And it was a large project that was doing a significant amount of work that needed to pivot frequently. Whilst I was there, there was a measles outbreak, which I did know about and had information about before I landed or arrived in Tawila. Then in the time that I was there, there was a very large cholera outbreak, which took a significant amount of our resources. Which included things like beds in our paediatric tents.

So, we were trying to establish a paediatric intensive care unit in a separate physical area to what was previously shared with the adults who needed intensive care. And what that meant in this context was a six bedded, cramped, very hot space with just enough space between the beds to fit a single person walking sideways. And we needed more space because we had more patients than what we had beds for so, we were really working on trying to establish a space for a paediatric intensive care unit and the intent was to do that in a tent. And I'd walk out in the mornings and the tent would be there and then I'd walk out in the afternoon and the tent would be gone. And this was happening sort of over a week period. And the reason for that was because our resources needed to be diverted to the very large cholera outbreak and crisis.

The MSF team established a cholera treatment centre which was about 500 metres or so down the road from where we lived and worked and so then that changes our thinking in terms of infection prevention control, staffing, patient flow, all of these considerations. We then, during the time that I was there, sat down as a team to think about and to plan for simulating a mass casualty plan because it had previously been activated, as in enacted, following increasing numbers of internally displaced people who were fleeing Zamzam when that was attacked. And there were lots of learnings from that that the team had wanted to implement and to trial and to simulate.

So, we sat down, I think it was a Sunday afternoon, to have a discussion about this and plan for it within the next 24 hours. And then within 12 hours, we actually activated our mass casualty incident plan because we had increasing numbers of people who were fleeing and trying to flee El Fasher, which continued to be besieged and was under siege for more than 500 days. So, my time in Tawila, I expected and anticipated measles. I expected and anticipated huge amounts of severe acute malnutrition with significant ongoing food insecurity. We were going into malaria peak-season and we certainly saw a significant amount of that. And then the add-ons were a very large and significant cholera outbreak and then activation of our mass casualty plan and the flow-on effects of that and people fleeing violence, which includes things like increasing numbers of premature deliveries and increasing numbers of women who have severe acute malnutrition themselves and then neonates and children with severe acute malnutrition.

MIC CAVAZZINI:                Wow. Aiden, do you want to put that next question to Tasnim?

AIDAN TAN:        Yeah. Tasnim, there must be a sense of frustration or even moral injury in being able to do only so much with the limited resources you have at your disposal. One of the podcast reviewers wanted to ask how you maintain your resilience in the face of such despair and what personal support do you receive?

TASNIM HASAN:               Yes, it's definitely challenging to work in places where resources are quite limited. And it's also very challenging to see a patient who you know can be treated with very, very little resources if you had the resource. You know, like a simple, the availability of a simple blood test could help you diagnose something which could then treat something better.

At the very same time MSF, is actually very very good at having resources which actually do you know which are cheap and have big impacts. So you know, whether or not it's a rapid malaria test and access to anti-malarial drugs so MSF is quite good at having access to the big things that are required to make big impacts but at the same time there are you know things that are maybe rare and you don't have as many resources to tackle those things so it is very frustrating to see people die or become more unwell of things that are otherwise easily treatable when you're back at home.

I think you have to get resilience from the people around you. And when I say that, it is the international staff, it's very, very much the locally hired staff that really give you that resilience and hope and the ability to maybe see perspective. At the end of the day when you're an international staff, you go home. You do your time and then you go back home. Whereas when you're a local staff, you do the same job with the same frustrations day in, day out for years and years and years. Some, you know, some local staff have worked for MSF for 20 years and they have the same issues year in, year out with resources, with mortality, with morbidity. And yet, somehow, they still get out of bed. They somehow still look impeccable. There's never been a mission where I, or an assignment where I have worked where the locally hired staff don't come dressed impeccably to work. So, when you see people who have been doing the work for years and come to work with a positive attitude and an attitude that they can solve whatever they possibly can, I think that gives you an extreme sense of motivation to keep going and motivation to keep striving. And also, wherever I've worked, there is an absolute keen desire to learn. And that degree of determination also gives you inspiration and resilience to keep going. But it is sometimes very challenging.

MIC CAVAZZINI:                Is there anything to say about sort of formal supports, debriefs, counselling, that kind of thing?

TASNIM HASAN:               Yeah, I mean... I think so when you are on the field, you always have a group of international staff and I've been very lucky in the sense that wherever I've worked, the team is quite large. So, there's a lot of people to choose from in that sense. Because there are settings where you can work where there's only three or four international staff. But you know, I think the international staff are a big support because you come home every day and you debrief every single day. So, there's always something to complain about. And that's one thing that's quite unique. You sleep in the same house, you eat the same breakfast, you go to work at the same place, you have the same lunch, and you come home and have the same dinner, and then you continue to talk about work at dinner, and you debrief together, and you do that for six months. And you develop these intense relationships that are completely not comparable with any other situation in life. But they, yeah, the international staff that you go with, really are your support in that way.

And then yeah, and then I have friends back at home who sometimes I will text when I'm away about things that I can't talk to the people that I'm around with where I just need a breath of fresh air. And then MSF of course have within the system itself a staff health support system. Confidential psychological support as well. I never used it in my first three assignments, but I did use it after I went to Gaza. And that's quite a supportive system and a system that allows you know to get help when you come home but also in the long term as well because sometimes it's not just the immediate effect but things that have lasting impact that you may need support from and MSF is quite good at providing that support if required.

MIC CAVAZZINI:                Josie, a part of resilience, I suppose, is maybe having to develop a thicker skin, or keeping a certain distance, or “objectivity”. Is there a risk that this can slide into callousness, maybe, particularly when you come back home to a well-resourced setting where you might think, “what are people complaining about”?

JOSIE GOODYER:              That's the biggest challenge that I have found every time I've worked for MSF is returning home. For me, people who live and work in differently resourced settings and countries in which there is significant emergency need, conflict or disasters or other—patients and their families, I really feel value different things to what is valued in an Australian context. I continue to learn so much from local staff and the local context and really trying to understand as a paediatrician what the family needs and what they want and would like us to try and achieve for them has really been a way for me to, not necessarily develop a thicker skin, but a way for me to try and meet their values and try to provide them with the care that they would like. Because sometimes they would like to take their child home. In the context in Sudan, most families who had children with life-limiting illnesses did not want their children to go home and die. They wanted their child to die in a hospital setting. And that's completely different to an Australian context. And so...thicker skin, thinking about things differently and coming at it in a different way, I guess, has been a way for me to try and develop some resilience around that.

AIDAN TAN:  Just as Josie found herself dealing with infectious diseases in Sudan, Tasnim, you have previously described doing a stint in a paediatric unit in the north of Afghanistan. It strikes me that it's almost like you've both had your specialties flipped. How did you grapple with this change scope of practice?

TASNIM HASAN:               Yeah, so I think one of the things that when I enlisted into MSF many years ago that they tell you and I think it's probably still true is that one of the most important skills you have to have in MSF is flexibility and being able to adapt to any situation. So, before I worked for MSF—and probably to an extent it’s still true, but not as much as before I did—I was terrified of paediatric patients. I was terrified of anyone under the age of 16 because for one, you have to calculate drug doses and who wants to do maths when you're practicing medicine, as well? But the first time I was exposed to paediatrics was actually in South Sudan. So we did have a paediatrician in the project. However, she left and they couldn't find a replacement. And that was the first time I had to cover a bit of paeds. And to say that I covered peds would be an insult to the local staff because I think I maybe walked into the ward and nodded in agreemeny. Sometimes, you know, sometimes they just wanted some reassurance and you nod and agree and say, “I don't know, you know much better than me. But that sounds about right”.

And, you know, and South Sudan was—I did a bit of neonatology when the paediatrician left as well. And after I did neonatology in South Sudan, my belief of neonatology was that—you know, this is a place where there were no resources in terms of NICU or oxygen, there was oxygen, but no other higher resources—but my belief was that to save a baby all you needed was breast milk and kangaroo mother care. And there were so many children who came in at you know a thousand thousand grams and left you know at two thousand grams and I was like, wow neonatology is beautiful and you can save babies with such little resources.

And then I got matched to Afghanistan and my first email back to them was, “Is it really ethical for an adult physician to go and work in a paediatric hospital”. And the reply back to me was it's a supervisory role, it's not a clinical role. And that's true, it was a supervisory role. there were two international paediatricians, but there were 70 local paediatricians who were, each one was absolutely fabulous, and each one was completely capable. But it was where I learned that neonatology in a resource limited setting is not just kangaroo mother care and breast milk and that mortality was 10 per cent to 20 per cent and that neonatology is actually quite terrifying.

But yeah, so I was put into that situation because I was told that I was a supervisor and that was my role. But as someone who loves clinical medicine, I did spend as much time in the wards as I could. And I really do appreciate all the things that I learned from those local paediatricians. And one of the things that I often say about MSF is you actually, sometimes you feel like you gain more than you give when you go. There are so many times that have learned much more than I've been able to give.

MIC CAVAZZINI:                Interesting. And so you're in those supervisory roles, you're….

TASNIM HASAN: Doing rosters!

MIC CAVAZZINI:                Yeah, just bringing that systems thinking from...

JOSIE GOODYER:              And I might add as a paediatrician when you work for MSF, are also in a role as a neonatologist. So it is care of children and babies. Yeah.

AIDAN TAN:        And in settings with such high autonomy, your clinical decisions can carry enormous weight. How long did it take to become comfortable with this, Josie? And how has it affected your confidence back in the Australian setting?

JOSIE GOODYER:              Your clinical decisions do carry enormous weight. Having said that, it's an extraordinarily collaborative context and it's more collaborative than contexts within Australia because you interact with all of the teams who are present on a daily basis. And sometimes there's sort of that physical separation in an Australian context that isn't present in contexts where MSF works. There is always oversight and you do not make decisions in isolation. So, MSF have a telemedicine platform, so for those really clinically complex cases, or often I would find myself using it for some prognostication or diagnostic certainty in terms of working out, does this child perhaps have congenital cardiac disease or do I think it's a primary respiratory illness and point of care cardiac images can be uploaded to the telemedicine platform and it gets sent to specialists globally and so you can receive subspecialty expertise in their field whilst you're on assignment.

There is also always line management and a chain of communication with MSF that we need to work within and understand the context around. And so if you're thinking about those patients who might need resources that you don't have access to in your clinical setting, but you do know that there's a referral possibility or another hospital. Those discussions happen at high level and you can contribute in terms of their clinical knowledge and their expertise, but it's certainly not decisions that are made in isolation, there's lots to be considered. And there was a second part to your question Aidan around autonomy and then an Australian context?

MIC CAVAZZINI: Yeah.

JOSIE GOODYER:              I'm probably sometimes when I first returned overconfident in an Australian setting. And maybe the best example is again, talking about resourcing, and this most recent time, we did not have access to imaging as in x-ray. We had a point of care ultrasound machine when I was in Sudan. And I remember coming back to an Australian context and working in a level 1 trauma centre for a children's hospital. And a junior came to me and they said, “We've just seen this child who had had a fall into outstretched arm” and I said, “Yes, they have a fracture of their forearm”. And they looked at me a little bit oddly and I sort of paused and stopped talking and then they said, “Yes, so we'll wait for the X-ray and we'll probably talk to orthopaedics”. And I was like, “Yes, of course they should have an X-ray”. And it was completely because I'd come from these contexts where we didn't have access to it. And so, if it was significantly deformed, you treated it. If it wasn't significantly deformed, you sort of casted it and got the patient home because that was what was the best outcome for the family.

Especially in an emergency context and coming from a paediatric emergency background making however many hundreds to thousands of decisions within a clinical shift in a clinical day, bringing that back to an Australian context and continuing that pattern of making quick decisions probably does mean that I come across as quite confident. But it does again, it's about, I think that perhaps that question around resilience, and my answer to that in terms of thinking about what patients and families value in different contexts. In an Australian context, families value different things and they value imaging and they value additional investigations. So, sometimes you need to walk it a little bit back when you're back in an Australian context and take things a little bit more slowly.

MIC CAVAZZINI:                I want to ask about, sorry to keep probing about the sort of conflict zones, but Tasnim you returned last year from a stint in Gaza. How does MSF maintain the safety of staff? What are the red lines that they maintain to protect staff?

TASNIM HASAN:               Yeah, so I think my situation itself probably answers, you know, that question if I just explain what happened to me. Gaza was my fourth assignment. So, I felt that I was familiar with MSF and I felt relatively comfortable with the safety procedures that MSF took and I was a relative degree of confidence that they would look after my safety. I left in March of 2025 and I was told so that was a time when we had the first ceasefire in Gaza and I was told in every briefing that the ceasefire would end while I was there. That the end of the ceasefire was imminently coming. And so, I was well prepared for that situation.

I went in to go to the north of Gaza because the ceasefire had meant that the north had opened up and there was a desire to re-establish a field hospital, and so my role was to help set up the paediatric hospital in the north. I was supposed to be in Gaza for six weeks and the idea was that I would learn how the field hospitals were running in the south for a week before I moved north.

And again, it's the locally hired staff who are the wheels of the project, especially in Gaza, who work day in, day out, despite the fact that they are themselves experiencing the bombing, their family members are dying and yet they still come back to work every single day. And entering and exiting Gaza is the sheer product of privilege. The privilege of having a passport that lets you to enter and exit is an incredibly overwhelming thought when you enter and you see complete and utter devastation and destruction.

So, my first week I spent in the South before I was supposed to move North and I went in, probably, I think it was like the 10th of March and the ceasefire broke on the 18th of March. It’s a day that is now etched in my mind for eternity. The bombing started at about 2am and we were all woken up and we were in a three-story building and we moved to the bottom floor. Basically from 2am to 7am there was bombs non-stop. I mean, then they continued for the next several months but in that period, the 24 hours on the 18th of March was one of the heaviest days of bombing in the last sort two and a half years and 400 people died in those 24 hours, which is again one of the days with one of the highest casualty numbers as well.

And it was during Ramadan as well. I was the only one fasting among the international staff. And one of the sheer examples of the resilience of the Palestinian people is the fact that I was the only person fasting in Gaza amongst the international staff. And at 7am, the bombs were still going and at 7am breakfast was still delivered on time despite the fact that everyone else was fasting and despite the fact that it was literally one of the most terrifying nights of my life.

I can't speak for everyone else because some of them have experienced truly horrific things. But back to the question of how did MSF look after the safety? After the 18th of March, we were unable to resume our activities. So, there was a system by which MSF communicated with the Israeli army to notify all our movements. Those movements were acknowledged, and then you would go to the field hospital, basically, and then come back. And in those first few days after the ceasefire was broken that that process was not reestablished and so MSF took the decision not to allow us to move and so I then spent two weeks stuck in the house.

And it's difficult to describe how it feels to be stuck in a house two entire weeks with 15 different people while you listen to bombs day and night. Knowing that you're a healthcare worker, being able to do absolutely nothing with almost nothing to do inside the house and being unable to go outside the house to help within a healthcare setting. Not that me as an international staff, as an infectious diseases physician could have achieved anything, the local staff are far more superior at handling mass casualty situations than I would have been. But the frustration is simply indescribable. But MSF were unable to reestablish the process where we were able to leave the house. And so, we had to downsize. The decision to downsize came immediately given all the processes to take people in and out, it took two weeks before I was able to leave. And so yeah, I guess that process basically, demonstrated the care that MSF took in our safety in trying to make sure that we were looked after when protocols could not be followed to deliver us the hospital safely.

MIC CAVAZZINI: Thank you for sharing that. Another member of our podcaster tutorial group who didn't even know we'd be speaking to you, Tasnim, asked what happens when your access to certain places or resources is restricted? How much can MSF do to advocate for your work while remaining politically neutral?

TASNIM HASAN:               So, it is one of the fundamental principles of MSF to remain politically neutral and it really is what provides safety for MSF as well. And that's really relevant in places like South Sudan, where there are multiple ethnicities and sometimes there's political differences between those multiple ethnicities. So being politically neutral and helping all the different ethnicities is one of the most important ways to continue the work. So that is one of the most important things.

But there's also a principle of MSF to speak out if there is injustice as well. And so that's a very fine balance. I think, you know, in terms of your question about red lines and what to do when you're prevented from working is a very challenging one and it has happened many times throughout the history of MSF and I can't speak to all of them as I'm not as familiar. But most recently in Gaza, the operations of MSF have been seized and they're about to imminently stop working in Gaza. I think at the end of February that MSF has to pull out.

And one of the reasons for this is because the Israeli government have asked for a list of all the staff members, the locally-hired staff members, who work for MSF. And this is not just for MSF, they've asked this for all the NGOs that work in Gaza. And the proviso is that if that's not provided, then the operations cannot continue. And this is really epitomized the debate that MSF have had in terms of the balance between being able to work versus red lines. So, the policy was announced on the 31st of December and on the 24th of January, they did decide to give the names of staff members.

However, the decision really, really caused quite a lot of debate within the MSF community, the NGO community and sort of the global community in general as something that crossed the red line of safety of local staff. And I can't comment as to whether or not the decision initially was the right or wrong thing, because I think the context is so complicated. But I do respect the fact that MSF listened to the debates that held place and then did come to the decision that it had crossed a red so they haven't at any stage handed over that list.

And they took a decision not to give that list and now they will be withdrawing from Gaza, which is a huge, huge, huge loss to the health care system in Gaza. And I still can't comment as to what the right thing to do in this situation is, but I do think that this is a reflection of MSF and a reflection that they do listen and debate and talk and try to do the best.

MIC CAVAZZINI:                                Wow, so in this instance, they're, I guess, making a political decision so as not to set that precedent where they can be forced into compliance with unreasonable demands, but at the expense of the care that will no longer go on.

JOSIE GOODYER:              Yeah, and I think it's around that concept about trying to ensure safety of staff. So that's part of why MSF are no longer working in Zamzam and why they shifted to Tawila. so we were in Zamzam in Darfur and in Sudan for a number of years as we spoke about, Mic, and then the safety of staff in Zamzam for MSF was no longer able to be guaranteed and there wasn't that acceptance with the armed groups within the area. So MSF made the really difficult decision to have to leave Zamzam despite huge ongoing overwhelming need.

MIC CAVAZZINI: You can’t listen to these stories of civilian hardship without feeling moved and the bravery of these medics is certainly inspiring. But how do you fit such recurring assignments of six month or more within the framework of a regular career? What might you have to compromise on? A few members on the podcast editorial group had these kinds of questions. Aidan Tan started by asking whether long assignments were associated with any loss of proficiency in high end clinical skills or organisational processes. Here’s the response from Dr Josie Goodyer.

JOSIE GOODYER:              I think it's one of the biggest barriers and challenges I continue to face Aidan. It certainly does take you away from your day job and it's different for different specialties when you work for MSF. So as a paediatrician, particularly when you go on your first assignment with MSF for many completely understandable reasons, they want you for a minimum of six months and ideally the longer the better to establish those connections and to support the local projects, which is where you're going to contribute. In an emergency context, it's different in terms of what you're exposed to and the resourcing and so often emergency project contexts are shorter, which is why for me, it was about three months or so in Sudan, whereas for Liberia and for Kiribati, I had left the workplace in an Australian context for six months each time.

It takes about 12 to 18 months each time before I work for MSF for me to think through it, have a good sense of whether or not it's the right time for me in my life and my career. And every time I've done it and have taken time out of an Australian workplace to work for MSF, I've given a lot of thought to being able to return to work in an Australian context and trying to maintain that sense of job security. And so, the first time I worked for MSF, as I spoke about, was as an advanced trainee with Sydney Children's Hospitals Network. So, I didn't need to take leave from my training program.

The second time I worked for MSF, took leave without pay from one position and squashed all of my shifts together from another position that I held. So, I didn't actually technically have time away from my contract. And this most recent time I used long service leave and that was advantageous I felt in an Australian context because it meant that the FTE that I have can be backfilled and so it didn't have as much of an impact on disruption to the Australian workplaces that I needed to take leave from.

I'm always a little nervous about losing proficiency as Tasnim has spoken so well about locally hired staff in these contexts are far more proficient and skilled than we are. So, I often find I come back to an Australian context and I haven't done a cannula for six months. And then I'm asked to put a line in children who are the most critically unwell when advanced trainees have had multiple attempts and I think, “Oh it's actually been a little bit of time since I've done this”. So, there's some practicalities around that. The processes in an Australian context and how we communicate and engage with subspecialty teams, again, completely different and some of that autonomy is, it feels different in an Australian context. I won't say it's lost because you always have a degree of autonomy as a clinician, but it feels different and the processes around that certainly are different.

MIC CAVAZZINI: Tasnim, what about you? Has taking this time out had any impact on your career opportunities? Whether it's missing a chance at some promotion because you weren't as visible as other colleagues or conversely making you more competitive.

TASNIM HASAN:               Yeah, look I probably am a little bit different to Josie because Josie mentioned early on that she, was always important for her to come back home. And when I started working for MSF, I didn't really care if I came back home, like I wanted to come home to visit my family. But if I worked in global health, that was okay with me. I didn't mind if I lost the connections here other than my family and friends. But if my career was global, that was okay for me.

The way I ended up the way I am is because I came back during COVID. And then I got stuck. So, you I was an infectious diseases physician in COVID. And then I was working in the public hospital system as a specialist during COVID. And I had no intention to do that, But you have to do that when you're an infectious diseases physician. And I actually took the job, you know, my boss, who's still my boss, hired me saying, “Look, just take the job during the pandemic and then if you want to go off to another place, just do that”. And then the temporary job became a permanent job.

And then I'm very lucky. I have a very, very, very supportive department. And each time I've gone, I have more or less tried to make, I've taken unpaid leave basically each time. And although I took annual leave to go to Gaza. And I've tried to find ways to do roles that will allow the department to hire a locum while I'm gone, because there's a lot of politics of trying to hire a locum and then and then this department's been completely supportive of me going. I don't know if you know in terms of promotions, I don't think it's affected promotions because once you're a specialist I think unless you want to be you know, the head of the hospital or something, most people are pretty happy just to be the specialist working day to day clinical jobs. At least for me that was okay. So, I didn't mind from that point of view.

But I'm actually very, very glad that what happened to me happened. And I'm very, glad that I got stuck in Australia during COVID because, if I am to give advice to anyone who wants to work for MSF now, my advice would be not to get lost in the world and would be to try and have a balance at home. Because I think it's very easy to get lost in the world and become disillusioned with the world. That's possible to happen when you're in Australia as well, but I think Josie and I are probably both very lucky that we have been able to come back and forth. Not everyone can do that. But I am so lucky that I have been able to find a department where I can do that where they support me to do that, because, I think I have the best of both worlds. I bring back skills here and I take skills from here there. So, I'm very, very glad that I was forced to be grounded back in Australia.

MIC CAVAZZINI:                Interesting. And again, there are plenty of inequities to resolve in our country, let alone...

TASNIM HASAN:               Yes, absolutely. And I absolutely love working in the public health system in Australia. Yes.

JOSIE GOODYER:              Yeah. And I think it makes us better clinically. That's part of the reason, I guess, why I always was keen on returning to an Australian context, because I really feel quite strongly that if you're not exposed to, for want of better terminology, gold standard or the forward momentum in clinical care and medicine, and you don't know about the advances in giving sodium bicarbonate in the context of metabolic acidosis, then maybe you don't think about, “How can I apply this internationally gold standard MSF protocol?”—they are excellent—to this cholera outbreak, and do I need to think about giving sodium bicarbonate on a more individualized basis? Is that going to make a difference to our morbidity and our mortality rate? If you're not exposed to that in a high resource setting, it's very hard to provide the stretches of clinical care that you can with the resourcing that you have in lower resourced settings.

TASNIM HASAN:               Yes, I completely agree with that.

AIDAN TAN:        Another question from the podcast review group. No one does this for the money, of course, but if you're paying off a mortgage, raising a family perhaps, what's the remuneration with MSF like compared to a new consultant position or a senior edge?

JOSIE GOODYER:              It is equivalent to minimum wage in an Australian context paid on a monthly basis in Australian dollars. So, on the occasions when I have worked for MSF, I've had to give thought to finances. I have continued to pay mortgages in an Australian context and on occasion rent when I've been working internationally. So, having done it with different access to different leave entitlements for the three occasions, it does make a difference. So doing it as an advanced trainee in a network supported position meant that I could access annual leave from Sydney Children's Hospital's network. And I had that paid out at half pay whilst I was in Liberia, which certainly helped financially. And then this most recent time taking long service leave and that made it a bit more financially manageable as well.

Having said that, I would add in that MSF pays all of your expenses whilst you're on assignment. So you're driven for, you don't have any living expenses. There's a food allowance without going into too much detail and a per diem or a stipend in terms of some additional living costs and some spending money. But there's a huge difference in terms of pay in an Australian context as an advanced trainee or as a staff specialist compared to pay when working for MSF.

MIC CAVAZZINI: Many thanks to Josephine Goodyer and Tasnim Hasan for sharing their confronting experiences for Pomegranate Health. If you think this is for you, there’s lots more information about signing up at the websites msf.org.au or msf.org.nz.

As mentioned at the top of the podcast, Médecins Sans Frontières is in particular need of paediatricians, among other specialists and allied health staff. Among the strict requirements for candidates are at least five years of post-qualification experience. i.e. you’ve started PGY6 and have a minimum of three years professional experience in paediatrics, including neonatal care. Adult physicians considering a role with MSF must already be Fellowed with the RACP, or equivalent.

As you’ve already heard, the clinical remit of such generalists is broad. Paediatricians will often be responding to infectious disease outbreaks and nutritional deficiency. Experience in paediatric or neonatal intensive care is desirable and candidates should be prepared to face high rates of mortality in some settings. Other assignments will be hospital-based, providing perioperative management or outpatient services and vaccination campaigns.

MSF wants people with experience or interest in managing teams, designing protocols and building local capacity. Needless to say, significant experience in remote and low-resource environments is essential and you must commit to practicing within MSF clinical guidelines. Language skills are highly desirable, particularly French, Spanish, Arabic, Portuguese or Russian.

You must be prepared to deploy for assignments of six months or more and to consider a career-long association with MSF. A final requirement of candidates is to respect the MSF charter and a commitment to treat all patients irrespective of gender, race, creed or political conviction.

At the MSF Australia website and YouTube channel there are several more discussions with physicians and paediatricians about what it’s like to work in different theatres. I’ll link to a few of these in the shownotes at racp.edu.au/podcast, then click on episode 143. There you’ll also find links for subscribing to new episodes of the podcast and feel free to send any feedback or ideas to the address podcast@racp.edu.au. Many thanks to the physicians on the podcast editorial group that helped me out with feedback, including Aidan Tan, Stephen Bacchi, Rahul Barmanray, Maansi Arora and Leon Li. I’m Mic Cavazzini. This podcast was produced on the lands of the Gadigal clans of the Yura nation.