Pré Avis in the Congo

Photo: Grant A

When MSF opened the Dubie project in May of 2005, things were very different then they are now.

The Congo was slowly starting to emerge from five years of bloody war that cost the lives of around 4 million and displaced millions more.  A fragile peace blanketed the country that had slowly deteriorated under a 30-year dictatorship.   All services had essentially ceased to exist and the Congo was characterized by a dysfunctional health care system, a complete lack of roads, a high level of corruption and a population facing a humanitarian crisis where all health indicators (including mortality) were much higher than what MSF would class as a typical “emergency”.

MSF Dubie Opens

It was under these conditions that MSF opened Dubie.  During the first year of operations, the Congolese army launched a massive offensive in an area still controlled by Mai-Mai militia and MSF saw over 20,000 internally displaced people (IDP) arrive at our doorstep. Following the surrender of the Mai-Mai chief Gedeon in 2006, the security situation has continued to improve and the majority of these IDPs have since returned home.  We have slowly seen an increase in the presence of Ministry of Health staff in all of our supported health facilities and there has been a gradual shift from a humanitarian crisis to a developmental one.

Photo: Grant A

While war continues to rage in the Eastern part of the country (in the North and South Kivu provinces), there is no longer war in Katanga.  Everyone is poor, no one has access to health care and we seem to be providing a service that really should be coming from the government.  I now have a hard time explaining why we are only operating in Dubie and not in the next heath zone.   Through an intensive drilling program, the water and sanitation situation has improved and we haven’t seen cholera for over 2 years.

So MSF is left with two choices here in Katanga.  We either have to expand our operations – and our Mandate! – and venture into what could only be described as developmental activities; or we stick true to the mandate of MSF as a medical organization that provides emergency humanitarian relief and we handover our activities.

In the end, we have decided to go with the second option and are in the process of preparing the handover to our two project partners; the Congolese Ministry of Health and the Catholic Sisters.

The Catholic Sisters have been present in Dubie for over 50 years and have been running the local health center and maternity for just as long.  They also have a huge convent, a beautiful church and the largest schools in Dubie.  While our mandates do not necessarily align, it is safe to say that the Sisters are motivated (and now well trained with a fully function health center), have the confidence of the local villagers, some access to funds and will be around for a long time.  With all things are considered, they are a pretty good handover partner.

The presence of Ministry of Health (MoH) staff has been slowly increasing over the past few years and MSF has invested a lot in both their facilities and the development of their staff.  While the presence of staff is a big first step, the government still lacks the means to purchase drugs, has difficulty getting the drugs to the field and does not always have the means to pay their staff.  In our case, the MoH will take over most of our current operations – in cooperation with the Sisters – and only a few of our services (our feeding center and HIV programs) will be dropped.

MSF will donate most of our equipment and will also leave a 3 month drug supply to help get our handover partners up and running.  Regardless, both partners will install a cost recovery system and while $2 for a delivery and $30 for a C-Section doesn’t seem like much, it will surely exclude the most vulnerable populations from access to health care.

Photo: Grant A

Nothing is Perfect

This is the reality.  MSF opens a project knowing that at some point we will eventually pack up and go home.  Knowing when to open is pretty easy.  There is some sort of crisis – war, displacement, outbreak, disease – that results in an increase in mortality to a point that is seen as unacceptable for MSF.  If the numbers are there, we open…regardless of how hard with think it may be to close down the road.

While present, we provide the best care that we possibly can for each patient that comes to our health centers and hospitals.  We do this in the name of medical ethics, knowing all too well that the overall level and ultimate access to care will drop after the departure of MSF.

Deciding when to close is always less clear.  The medical needs are often still present and our operations still have a meaningful impact.  However, it is no longer an acute humanitarian crisis, the security situation is stable and other actors may be present and able to take over.

Photo: Grant A

Dubie is no different.  The medical needs are definitely present and our medical teams save lives each and every day.  But there is no war and the IDPs have all gone home.   People are poor and access to health care is limited, but the health indicators are getting better and poverty alone is not enough to justify an intervention.  The Sisters are here and ready to take over.  The Ministry of Health is moving in the right direction and needs to step up and start taking full responsibility for the health of the nation’s population.

…nothing is perfect and closures are always a bit messy but it is time for MSF to move on to where our operations are more in line with our mandate as an emergency humanitarian relief organization.

As part of my briefings, I spent a few hours with the expat Doctor on her morning rounds of the intensive care ward. 5 beds, a few drip stands, emergency reflective blankets and an oxygen concentrator. That’s about it. And this is in an MSF hospital where we provide the best kind of care around. Man, that was a tough morning and it really reminded me how different it is to run a hospital out here in the bush…

This is how I met Molaw. He was just sitting patiently on an empty bed waiting for his turn. He looked tired and, more than anything, sad… like a child who has too many responsibilities when he should really just be at school and playing with the other kids.

Examination

Upon closer look, you can see that his face is a bit too round and there seems to be some sort of growth on his left cheek. The doctor tells me it is cancerous, common in children and that it could be treated by a simple course of chemotherapy. Unfortunately, we don’t have the resources to do this in the bush so we are left trying to reduce its size, slow its spread and to treat the side effects.

Molaw comes in once a week – Tuesdays – to get his weekly supply of pills. He’s an orphan and living with a great aunt so he comes in on his own and just waits. He is slightly malnourished so he also gets a weekly ration of Plumpy Nut to help him out.

The doctor does a brief examination. Feels his cheeks, looks inside his mouth, listens to his breathing, asks about side effects. Molaw says – through a translator – that his head really hurts and that sometimes he sees double. The doctor tells me that it is the same every week but that he is doing much better then when he first showed up in intensive care.

Too much responsibility

This week, she decides that his treatment needs a slight change…so she has to tell a 10-year old boy that he now needs to take the little white pills 4 times a day instead of just 3. He nods his head slowly to show that he understands. She writes out a new prescription for a pretty powerful cocktail of drugs and off he goes to get it filled in the MSF pharmacy.

It just doesn’t seem right that no one is there to hold his hand and tell him it will be OK…or to at least go to the pharmacy and pick up his drugs and to tell him which ones he needs to take and when. That is such a weight to bear for a 10-year old. Although he had stopped going to school because his head hurt too much, he is feeling much better now and has started going again. The reality is that this will only last as long as MSF is here…but how do you tell that to a 10-year old!?

Humanity

On a basic human level, this is what MSF is all about. We can’t do everything and we can’t be everywhere. We don’t pretend to solve the greater problem or to offer sustainable solutions.

…but, wherever we are, we do everything possible for each individual patient. For now, that means Molaw has a chance at a normal life: fewer headaches, clearer vision, and maybe even school. I had to hold back tears, though, when I realized that “everything possible” is likely not enough in the long run.

Photo: Grant A

Drums echoing through the Sunday morning air.  Feeling a bit like a “Rockstar” as you drive through small villages where everyone waves and the children rush to the road yelling “halo halo” with huge grins on their faces.  Warm greetings from fellow expatriates as they try to feel out the newest member of the team.  The chalk-like chunks of manioc drying in the sun and the memories of the bitter aftertaste it leaves in your mouth.  The constant and comforting hum of a generating.  The realization that the so-called national highway is still nothing less than a glorified footpath.

These were some of my thoughts as I made my way back into the remote corner of the southern Katanga province of the Democratic Republic of the Congo.  It’s true, I have been here before!  From December 2008 to June 2009, I was working with Medécins Sans Frontières (MSF) and was based in the village of Shamwana, a long day’s drive away.  As the project logistician, I was responsible for supporting the operations of a 60 bed-hospital and 6 surrounding health centers.  I also kept a blog for those 6 months and, if you’re interested, you can find my archived entries on the MSF Canada webpage. (http://blogs.msf.org/granta/)

Photo: Grant A

It’s different this time

Things are a bit different this time.  I have a new position, a new program and even a new base.  While I’ve returned to south DRC and am still proud to be working with MSF, this time I arrive as the Project Coordinator responsible for facilitating the handover of our operations in the “cité” of Dubie.

And our operations here are significant!  The latest bed count in the hospital was 102 and includes the following services: maternity, pediatrics, surgery, nutrition (feeding center), emergency treatment, an intensive care unit, TB ward, an HIV treatment program and laboratory.  Besides the hospital, we support 7 surrounding health centers and have extensive water and sanitation and mental health programs.  To make it all happen, there are 9 expats, around 100 Congolese staff and at least another 100 Ministry of Health staff receiving incentives from MSF.

Photo: Grant A

Wow…when you put it on paper, it really is A LOT for which I have just become directly responsible!! Managing operations of this size and diversity may seem fairly daunting, especially for a first time Project Coordinator.  However, my role – at this time and in this project – is less about managing all of these different and complex services and more about facilitating the process of handover.  My job is to make it the least painful as possible for the expatriate team, for the national staff we manage and, most importantly, for our patients and the communities were are all here to serve.

Welcome!

Since you’ve already found this site, I assume that you are interested in MSF and learning about our operations in the DRC.  I hope that my writing will help you get a sense for what life is like working as an expat for MSF.  As my overarching goal is the handover of operations to the Congolese Ministry of Health, I also hope you also gain a better understanding of the complex issues surrounding project handover, the true mandate of MSF and the ultimate gap left when emergency humanitarian relief organizations make the incredibly hard decision to leave.

I gave my first “Pré Avis” letters to staff this week and handover is scheduled for May 31, 2010.  The coming 5 months promise to be full of challenge, intensity, disbelief and awe…and I would like to welcome you along for the ride!

Grant  Assenheimer

Photo: Grant A