From Bunia

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!

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!

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.

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.