July 24, 2001
A CONVERSATION WITH / DAVID KUHNS
Rx for War Zone Workers
By JULIE FLAHERTY
Like many children of the 60's, David
Kuhns dreamed of joining the Peace
Corps right out of high school. And like
most teenagers, he didn't have any skills to
offer. So he studied to become a physician
assistant, and in 1994 applied to go
overseas with the aid group Doctors
Founded in 1971, Doctors Without Borders
sends some 2,000 volunteers to 80
countries each year, often directly to the
world's most notorious war zones, including
Beirut, Afghanistan and Sarajevo. Mr.
Kuhns landed in Somalia during the
country's civil war, not long after an
American helicopter was shot down in
Mogadishu, the capital, during a raid on a
warlord's forces. The loss of 18 troops led
to a recall of American forces.
Mr. Kuhns was sent far from Mogadishu to
Somaliland, where he was the medical
coordinator for a 200-bed hospital and 10
countryside clinics and supervised an
expatriate staff. He spent six months
surrounded by poverty, famine and gunfire.
Returning home to Maine was not as
comforting as he had expected. His former
employer, a hospital, no longer had a job for
him. He had trouble talking with friends and
co-workers about what he had seen. Like a
soldier returned from battle, he showed
signs of post-traumatic stress disorder.
After returning from a similar assignment in Afghanistan, he discovered that
other relief workers faced similar difficulties after they came back.
Some were overwhelmed by the traffic, the crowds at malls, the choices and
the luxuries. Their friends and families treated them as if they were the same
as they had been before they left, but they saw themselves as profoundly
Four years ago, Mr. Kuhns sought to break the isolation by helping to
organize a Peer Support Network to open communication among the
hundreds of Doctors Without Borders volunteers in the United States. He
and about 20 others volunteered as re-entry counselors, helping newly
returned doctors, nurses and nonmedical staff through their first months back
in the United States.
On a break from his new job as epidemiology consultant in infectious disease
for the Maine Bureau of Health, Mr. Kuhns spoke about why these
volunteers often needed help themselves.
Q. Was your time in Somalia with Doctors Without Borders what you
expected it to be? A. I didn't know what to expect. It was a couple of
months after the whole blowup in Mogadishu.
The first couple of nights we were staying in a house right in the center of
town, and there were AK-47 rounds going off all the time. One night it was
just literally outside the wall. We could hear them loading the gun; it was that
At the hospital compound, there was an armed guard at the gate. There were
bullet holes and shrapnel holes in the ceiling. There were beds, but if a patient
wanted a mattress, that came from home. There was no running water. You
could literally step onto a pile of goat manure and then walk right into the
operating room. There were used needles and syringes lying around on the
I was just stunned. It was the load of losing reference points. My
predecessor was a Dutch surgeon who had been working in Africa for years.
I said, "How can they call this a hospital?" And she said, "This is a good
hospital; I can take you to some bad hospitals."
In the end, it seemed futile. The hospital we were working in was overrun
and looted. We were frustrated because we had been trying to improve
things, and that all disappeared quickly. Q. What was the first sign that
coming home after serving in war zones was going to be difficult? A. Patti,
my girlfriend, had come to pick me up at the airport in Boston, and she had
to stop at the supermarket on the way back. I walked in with her, took
about five steps, and froze, just absolutely overwhelmed. After seeing people
in conditions that were just so very difficult to describe ― malnutrition, war
wounds and disease ― seeing the excess that we have floored me. I felt
angry that we were so wasteful, that we would have 15 different varieties of
cat food while some people just need the basics. Q. How did returning from
your stint with Doctors Without Borders affect your personal relationships?
A. I wanted to talk to people and tell them, "Look, you've got to know
what's going on out there." But trying to sit down with them and tell them
what six months was like in a couple of minutes is impossible. They would
just kind of glaze over and say: "So what was the food like? Did you eat
bugs and grubs?" And I finally got to the point where I would say there was
a lot of good, a lot of bad and a whole lot in between.
It was very hard connecting after being gone. There was stuff that I had seen
that I didn't want to talk to Patti about. And she was my outlet at the time.
Some people wind up having relationships in the field that they don't want
anyone back home to ever know about. Other people are going to have a
hard time with the trust issue, being gone so long. In the first six weeks in
Afghanistan I didn't have any communications with Patti. I couldn't get out to
call. It can be rough on loved ones as well. Q. Did Doctors Without Borders
warn you of the stress you would face coming back? A. I flew back through
Amsterdam, where they have had a re-entry program for a number of years.
They offered a debriefing to me, but I was so hurried I just wanted to get
home. I said, "That's O.K., I don't need it." Q. How difficult was your
transition to life in the States after being surrounded by poverty and gunfire
abroad? A. I got back in March, and a couple of months later I was coming
out of the hospital parking lot on the Fourth of July. Someone set off a string
of firecrackers and I literally drove up on the sidewalk and ducked down
thinking that they were shooting at me.
I started realizing that there was more to it than just the day-to-day stress.
You're gone for six months, your finances are screwed up. All those things
kind of added up. At times I would go into work and I would have a hard
time with the patients. They would come in for some relatively benign
process that felt life threatening for them, and I'm going no, no, no, you don't
understand! Q. Did you seek professional help in adjusting to life after your
time with Doctors Without Borders? A. I did what a lot of folks do. I went
back to the field. I went to Afghanistan, and I found myself more at ease
there than I had been over the past eight months. Q. How did you begin your
Peer Support Network for returning volunteers? A. When I came back from
Afghanistan, I did a lot more talking in Amsterdam. I came back in May, and
in June we had the first meeting of the Return Volunteers Network, a social
gathering in New York. It became apparent there that what we needed was
to develop something along the lines of what Holland had been doing and
what Canada has started. In the fall of 1997, we had a joint training for the
Peer Support Network volunteers in Toronto with the Canadians. Q.How
does your Peer Support Network for volunteers returning from overseas
work? A. It starts with the debriefing by the Human Resources Department
when a volunteer comes through the New York office. The P.S.N. gets
involved after the volunteer is back home. Basically the P.S.N. is there to
listen. We want to contact the return volunteers at one week and four weeks.
From our own experiences, those are kind of the hard times. It's a month or
so later when you come back and reality hits you in the face. It's all the same
stresses that we have on a daily basis, but they are magnified by being so far
removed from our family or normal support structures. We find it is easier to
share some things with people who have gone through similar circumstances.
Q. Do all volunteers seem to go through the same pattern of problems when
they return from difficult and dangerous overseas assignments? A. It varies
from individual to individual. It also varies because of the country they go to.
Somebody who goes to a relatively stable environment might not experience
the same things as someone who goes to Chechnya and is threatened.
Because they do short missions of a month or so, surgeons are sometimes
better off than the rest of us who are in the field for six months or a year.
Over there, the surgeons might work seven days a week, operating 14 hours
a day on patient after patient. Yet that's not that far removed from what they
You have to kind of feel the person out as you're talking to them. We are not
doing formal psychological interventions, but we've been trained to pick up
the signals of depression, or alcohol or drug abuse. We tell them what they
are experiencing is normal, and there are other support services available if
they want to make use of them. Q. Do you have to convince the returning
volunteers that American life is not as vulgar and distasteful as it seems? A.
No. People know that. It helps that we're only doing short missions, six
months to a year. But for many people, it has opened their eyes, perhaps to
the failings of the system. Q. How common is post-traumatic stress disorder
in volunteers for Doctors Without Borders? A. We don't know how, but
that's something I would like to find out. We need to be able to collect that
information. Q. Have you and your girlfriend, Patti, been able to work out
the problems created by your return? A. She's my fianc*e now. She is a
physician who works in the intensive care unit of a hospital, and she wants to
come with me next time. Given the opportunity, I would be back in the field