And new beginnings

September 2nd, 2010 by Kiran Jobanputra

The closure ceremony was a great success – 350 people, traditional folk musicians (with the real one metre long Vuvuzelas, not the little ones we saw at the televised world cup matches), and the opportunity to remind the community of MSFs new role here in Bunia.

The hospital Bon Marché exists no more – except for the Women’s Health service, which will be taken over by a local association in the coming weeks. So we will still be in Bunia to ensure that this new Women’s Health / Sexual Violence service gets up and running. We will also continue the process of skill transfer and capacity building at the hospital and 7 health centres, to ensure that the transfer of pediatric services that has already taken place is fully successful – that the quality is maintained, and that the health facilities can meet the population’s pediatric health needs autonomously. And the same for HIV – we will continue our support to the hospital to try to ensure that quality of care and availability of medications continues after our departure.

It’s a challenge to guide a team through this stage – with 100 people laid off, and all our work (as we knew it) at an end, we are all liable to feel a little lost and deflated. So we’ve made the effort to elaborate our vision for the coming months, and to generate objectives that we review periodically. It’s an interesting transition – the move from traditional MSF style hi-tech substitution healthcare, to fully integrated, resource-limited, sustainable healthcare. We just have to keep telling ourselves that this change represents an interesting opportunity for creative collaborative working – and is not just a half-hearted attempt to delay our final adieu to Bunia.

I am optimistic now. At times, with threats of strikes and the total absence of medications I thought that we would never get there. Yet now we are already there – the quality of care is more than acceptable, and a huge number of obstacles have been overcome. Now it is just a question of figuring out how to stay at this level in the years to come!

Closure

August 25th, 2010 by Kiran Jobanputra

I suppose the last few weeks have turned out more or less as I had imagined. As we have ceased to admit new patients or transfers (all are now managed at the general hospital), the wards have become emptier, the staff more melancholy, and the atmosphere a little strained. Project closures are not reputed to be easy – one undertakes this sort of work expecting to be treating patients, yet at this final stage the goal is to avoid treating patients. This can obviously be demoralising, and I have found that I have spent much of the last few weeks chatting with taciturn staff reminding them of all the good things they have done here.

For my own part, it does feel sad to be closing down a hospital that has offered hope to so many over the years, that has been one of the few neutral facilities that has bound the different ethnic groups together. I am also conscious that I have hardly worked here, having arrived just 4 months ago – and it feels a little rich to be giving the closure speech for a project which I only know from the testimony of others.

In these last weeks we have to keep going, to maintain a longer term perspective on the value that a well-conducted transfer can have on the community over the coming years – and not focus on the fact that Bon Marché hospital now has just 2 patients. And we must use the closure ceremony to celebrate with the community the successes of Bon Marche; but also to remind ourselves that the closure is a fine thing, because it reflects a collective confidence that the war is in the past now.

Targets and indicators

August 19th, 2010 by Kiran Jobanputra

Yesterday I transferred a 3 year old boy from the General Hospital to 
the MSF hospital (Bon Marché) – although most of the paediatric care
 now takes place at the general hospital, we have retained Intensive
 Care at Bon Marché for the time being. The boy was gasping, and had 
that familiar terrified stare that one sees in cases of severe anaemia 
which are starting to decompensate. (Malaria tends to destroy the red
 blood cells, resulting in anaemia; up until a certain point the body
 adapts to this loss by diminishing its level of activity, but there is 
a critical threshold beyond which the body cannot survive without 
supplementary oxygen and a blood transfusion). I sat opposite the
 mother, whose tired expressionless face suggested that she was 
prepared for the worst. But within 5 minutes the boy was on oxygen,
 and that night, following a transfusion, he was sitting up and eating 
his porridge.

Now, we must acknowledge that under current circumstances this child
 would not have survived had he stayed at the general hospital. Yet
 such deaths are avoidable, with the use of commonly available tools 
and medications. We cannot think about leaving until the hospital has
 the capacity to manage cases like this.  But shouldn’t we be focusing 
more on the health centres, such that they are able to treat the
 malaria early enough to prevent it getting to this stage? And if we go
 one step further…what of the (unknown) number of families who cannot 
afford care at the health centres – can we conceive of leaving in the 
knowledge that huge numbers of people have no access to care at all?
 What of the charter of MSF – what population can be more in distress
 than a population that has no access to healthcare?

Of course, we have to accept the fact that our interventions will 
never reach everyone. Particularly at these transitional phases, where 
we are moving from a model of care that prioritises accessibility, to 
a model that prioritises sustainability.  We have to choose indicators 
and set targets that at first may seem modest, but ultimately are
 realistic. When we achieve these targets we will know that we are ready to pull out. But all of this is difficult to consider when one 
is faced with a child in extremis.

Sometimes I think that such doubts are a sign of fatigue – when we are
 full of energy, we can remain convinced that the strategy will work,
 and we retain a philosophical outlook in the face of individual 
losses. And yet we must not stop voicing these doubts, because at some
 level it is never acceptable that children (that anyone) should die
 like this; and we must keep expressing this if we want it to change,
 and if we wish to avoid losing our humanity amongst all the targets
 and indicators.

Motivation

August 2nd, 2010 by Kiran Jobanputra

Once again I find myself wondering what drives us to undertake this sort of work. I remember my friend Daniel saying that there are 4 motivations for working with MSF – escape, adventure, money and idealism. In talking of escape, he was referring to the fact that many undertake this sort of work when they are trying to put their past behind them and move on, or even literally escape an uncomfortable situation back home. Undoubtedly the promise of adventure and challenge is attractive to many, and for some even the modest salary is a draw.  Finally on Daniel’s list is idealism…tacked onto the end as an afterthought…. as if to suggest that such motivations are rare amongst people working in the humanitarian sector.

I love the honesty of Daniel’s analysis. And I agree with the theme…that we carry an emotional baggage that influences our motivations and behaviour. I think most of the international staff working with MSF show an escapist tendency, and a search for adventure goes hand in hand with this. But is this it? Is idealism just the gloss that we apply to our heap of emotional baggage? Can we say with confidence whether we are motivated by idealism? And does it matter, if the results are the same either way?

Of course it doesn’t matter… is the immediate response I am tempted to make. The humanitarian industry runs on funds not idealism, and this is a good thing, because the sector needs level-headed economists, not uncritical idealists. The well-known line from Yeats’ poem comes to mind : “The best lack all conviction….the worst are full of passionate intensity.”

It’s easy to be convinced by Yeats’ statement because we have all experienced this, and because the words sound valid. Yet if we make an effort we can all recall people who have bridged this gap, who have bought their ideals, their humanity to bear, without sacrificing their pragmatism. James Orbinski, in his writings on his experience with MSF, shows a untiring humanitarian spirit, an appreciation of humanity, which is nonetheless set within a pragmatic public health perspective. I think we all remember individuals who have influenced us (and reassured us) in this way.

So does it matter whether or not we are idealistic? It depends on the outcome we are looking for – simply achieving the objectives of the current project…. or going further, hoping to influence those around us, to express our personal vision, or perhaps to empower others to express theirs. We all influence others – we all make a statement -  whether we like it or not; and thus perhaps idealism can be redefined as taking responsibility for this, and consciously choosing the manner in which we influence others, to advance our ideals.  

So to return to the first question: it is not so hard to say whether we are idealistic. I do feel that I have a vision… not a very original vision, perhaps a vision that almost all of us share… and I allow that vision to influence the way I interact with others. Perhaps this vision is not always very salient, perhaps my motivation flags at times; but it is always there, peeping through amongst the emotional baggage, at the origin of my desire to do this work (I believe), and not just a gloss I have applied as an afterthought.

Reflection

July 30th, 2010 by Kiran Jobanputra

At first I felt that one of the risks in this job was that you can spend too much time talking.  At present I feel as if there’s not enough time to talk.

It’s currently time to reflect, to identify how far we have got in achieving our objectives for the year, to identify which objectives are still to be met, and then making modifications to our activities to achieve those objectives. To do this, it goes without saying that we need to attain a shared vision that each member of the field team ascribes to – which involves a lot of talking – and we then need to bring this vision before the coordination team, to establish a vision that they too share. Yet in parallel this vision needs to be compatible with that of our partners – the local health authorities, the NGOs and development organisations that are also involved. Unless we manage to elaborate a vision that everyone shares, implementation will be extremely difficult. The challenge is to make enough time to talk with everybody.

So yes, as it turns out my role is that of a full time talker! My medical activities are peripheral, and security research can be done in the evenings. Most of my time is spent chatting, reflecting and philosophising. As a student this would have sounded like the ideal life. But now that I am aware of the stakes, of the responsibility this entails, I have to acknowledge that talking is easy as long as you’re not worried about the content or outcomes. Being a professional talker is tricky, because it requires you to rethink and relearn an activity that is essentially automatic and unconscious.

So, I’m sure I made piles of mistakes at first, perhaps negotiated some things inelegantly such that I had to redo the whole process over a beer in order to reassure my collaborator. But this is happening less and less. Finally the partners are starting to have confidence in me. I think it takes about 6 months to reach this point….which is the average length of a mission with MSF!

Good work

July 23rd, 2010 by Kiran Jobanputra

Each day brings an unpredictable variety of events. Last Sunday I woke to the news of an outbreak of viral hemorrhagic fever, which by lunchtime had turned out to be a false alarm (a snake-bite, I think). I spent the afternoon in a plane carrying out a medical evacuation, and the evening at an (informal) security meeting. This weekend, by contrast, has been spent in relative hibernation, in view of political events in the province that have resulted in a somewhat tense atmosphere in town (and a general heightening of security measures). At the same time we are immersed in contingency planning, in preparation for a strike at the General Hospital that could come any day now.

I do feel I am lucky to be here, lucky to have work that is varied and interesting, to work for an organisation that makes a significant positive impact on people’s lives, and has their esteem as a result. It could be said that it is the benevolence of the donors that effects this work, and in that case it is a privilege to direct the application of this benevolence, to be the instrument of reconciliation between the ‘haves’ and the ‘have nots’.  Or to go one step further, to be the expression of the conscience of the west.

I wasn’t intending to be so prosaic – but I wanted to recognise that our project, and my presence in it, exists in the context of an array of historical links, economic interactions, and cultural exchanges. As much as Bon Marché has been a response to a humanitarian crisis – and now, in this exit phase, an attempt to build local heath care capacity – it is also the manifestation of a relationship (socio-economic, cultural, humanitarian) between societies. It is a relationship that is complex, and sometimes uncomfortable, since all humanitarian interventions run the risk of disempowering/disenfranchising the beneficiaries. But when I feel positive about this relationship (which is most of the time), it feels hugely rewarding to be part of it – to feel that you are expressing your feelings and your wishes for the world through the work you are engaged in.

So yes I am lucky, and I think I will keep feeling this way until next weekend. For the one downside of having a job that is varied is that (logically) you will sometimes have to do things that you are not so interested in, and that you might even fear. The week after next it’ll be time (once again) to tackle the budget revision.  That is why I am trying to enumerate all the good things about the job, to get through the dark times ahead!

Complexity theory

July 15th, 2010 by Kiran Jobanputra

I remember a public health colleague once saying to me “Know what it is that you do, and be able to sum it up in 1 minute when asked”. Yet the report I submitted this month was 19 pages long, and I’ve just not been able to cut it down any further.

Basically, the programme has three main elements: Paediatrics, HIV and Women’s Health; but each is going through a transition of one kind or another.  In paediatrics we’re in mid-transfer from the MSF hospital (Bon Marché) to the Government Hospital. As regards the HIV, we’re working on building capacity in the hospital and trying to procure reliable drug supplies, whilst tailing off our own programme.  And for women’s health, we’re reducing certain activities whilst setting up a new programme offering comprehensive care for victims of sexual violence, which will ultimately be delivered by 2 local NGOs with technical support from MSF at the inception phase.  Combine this with the security reports, the construction of a new paediatric block and installation of a water supply in the hospital, the administrative workload involved in laying off 120 staff, and the occasional medical evacuation – and 19 pages feels scarcely sufficient.

These 19 pages reflect 2 characteristics of our programme that are much less salient in the work of a doctor – scale, and complexity. (Yes, I tend to compare everything to the work of a doctor, because this is my reference point, the work I know best). Having to deal with several hundred staff and several thousand patients may not seem a challenge to a public health worker, but as a clinician I never see more than 10 staff and 40 patients a day. And although people, and medical consultations, are not easily predictable, with time one tends to develop an approach – a way of being, communicating, and reasoning – that allows one to take each new consultation in one’s stride. The process of taking a history, examining, making a diagnosis, and formulating a treatment plan is more or less universally applicable. Here, by contrast, we are dealing with complex systems – structures with so many variables (so many of which seem unknowable) that it seems impossible to predict what will happen next, which partner will suddenly see a cut in their funding and have to pull out, how political factors will influence the turn of events. And since every event, no matter how subtle, has the potential to change the system, a report must logically cover everything there is!

So, I congratulate our team on writing this concise 19 page report. For it represents a brave attempt to sum up complexity in (just over) a minute.

The right to intervene

July 7th, 2010 by Kiran Jobanputra

On certain days I ask myself if we were right to get involved in Bunia in the first place. There are hundreds of NGOs here, many of whom are now thinking of leaving. Since 2003 this temporary community has built hospitals, reunited families, dug wells, and completely overturned the economy. People have given up farming, or their original trade, to work for much higher wages as drivers or store-keepers for the NGOs.  Now the war is over, and the honeymoon period is coming to an end – and as the population take stock of the situation, they understandably start to question the ethics of NGO intervention.

This is not to say that the population disapprove of the NGOs. The majority remain hugely appreciative of the work of MSF, but there is a perception that we have undertaken these dramatic interventions without ever considering the long term effects of our actions. A Congolese colleague from another organisation said to me “You (MSF) have broken a health system that functioned adequately before hand, and now that you are leaving, the population will be left worse-off than they were before”. To some extent this reflects a very human tendency to forget what things were like beforehand – the fear of an unknown future causes us to romanticise the past. But whether or not there is any truth in his observation, the fear of being left without healthcare is widespread amongst the community. It is essential that we acknowledge and address this fear, because the transfer we are trying to achieve is not just a transfer of medical activity, but also a transfer of the community’s confidence to a new health structure.

I guess I do believe short-term humanitarian interventions can have some lasting benefit, as long as we accept the responsibility of assessing their potential impacts from the start, so that we can try to maximise the positives and minimise the negatives. But in such unstable situations the future is very hard to predict– the original Bon Marché project was expected to last 3 months, and here we are 7 years later. Could they have envisaged that this intervention would reveal a huge unexpressed demand for paediatric care, ultimately requiring a doubling of the capacity of the hospital’s paediatric service? We start these interventions on the basis of imperfect information, and then have to constantly reshape our goals according to the findings that emerge. If at least we do this with transparency, in genuine collaboration with the community and partners – with an awareness of those unmet needs and unexpressed fears – we stand a chance of building something that the community will wish to maintain.

50 children

June 28th, 2010 by Kiran Jobanputra

The Congolese give their children the most wonderful names – Dieu-donné (God-given), Dieu-Merci (Thank you, Lord), Glorieuse (Glorious), Desiré (much-desired). And usually everyone knows why they have the name they have. Dieu-donné, for example, may have been born 15 years after the previous sibling, such that the mother believed she could not conceive again, making the birth something of a miracle. It seems a shame that we, the Jonathans and Freds of the world, are unlikely to have such a special relationship with our names.

In the course of one such conversation, I learnt that my colleague Deo-Gracias is the 50th child of his father. Thankfully not all of the 50 were born of the same mother, but if I remember rightly the mothers numbered just 4, such that each one had raised at least 10 children. When I asked Deo-Gracias about this he told me that it’s not as difficult as it sounds, because the older siblings look after the younger siblings, and so after a while the mothers can just take it easy (presumably not before they reach the menopause though).

There is definitely a ‘more-the-merrier’ attitude to child-bearing here, which contrasts quite vividly with our fashion for one or two-child families. It’s clear though that desired number of children is (partly) a function of gender: my female colleagues want fewer children, whilst my male colleagues are more expansive in their outlook, which is unsurprising given that the father performs a fairly hands-off role once the baby is born.

I have to acknowledge though that Deo-Gracias seems a very happy and well-adjusted fellow, and does not obviously lack as a result of the limited quality-time spent with his father. After all, he had what every young boy really wants – a reliable supply of siblings to play football with.

Cows, beer and chocolate eggs.

June 14th, 2010 by Kiran Jobanputra

I have now discovered a little circuit that I walk each weekend. It’s not much to get excited about – I walk from the compound to the MSF hospital, then to the General Hospital, and then home again. In some ways it can be a bit repetitive – particularly the predictable conversation with the motorcycle taximen, who ask me (every time) why the MSF staff never use the moto-taxis (I invent increasingly elaborate reasons on each occasion – often our creativity flourishes when our repertoire of activities is limited). But the route is pretty in places, with its crops of palm trees and fish ponds; and the highlight is a little river that is forded by a slippery log, providing a few moments’ excitement in an otherwise unremarkable promenade.

On the slippery log bridge

On the slippery log bridge

Now, I wasn’t really planning to talk about the walk in such detail – it is the little river that I wanted to get to. And before I get there, I should say a word about the rivers here. No matter how diminutive or dirty or inaccessible a river may be, it will always be the site of frenetic activity of one sort or another. Women will be washing the clothes of numerous children; numerous children will be playing nearby (and getting their clothes dirty again); and the men will be polishing their beloved motorbikes, or (occasionally) killing a cow.

This latter task is undertaken only on special occasions – indeed, it was back on Easter Sunday that I chanced upon this activity taking place. Everyone was in a good mood, and eager to chat. We started discussing Easter celebrations around the world – I told them that in the UK we hide chocolate eggs for the children, whilst in the Czech republic (according to one of my colleagues) the young men chase the young women across the town, attempting to whip them with birch twigs, whilst the women frantically bake cakes in an attempt to appease the men. I asked them how Easter was celebrated in Congo, and they told me that they kill a cow and then spend the day drinking beer. I asked them if they hide chocolate eggs, but at this point the conversation broke down due to linguistic and logical barriers (why do we hide chocolate eggs?).

After graciously declining the offer to participate in the cow killing, I headed back to the compound. I stopped off briefly at the moto-taxi stop to discuss our non-utilisation of the moto-taxis, and then at the corner store to see if chocolate eggs were available. They were not, so I picked some birch twigs, headed home, and tried to persuade my colleagues to celebrate Easter the Czech way.