From Bunia

At certain moments it feels as if we are walking a tightrope, struggling to retain our equilibrium in the face of a constant barrage of destablising events. Each day poses new challenges for the transfer of activities – a threatened strike by the nurses at the general hospital, the discovery of bats in one of the buildings we wish to use, confusion amongst the public about the new setup (requiring further radio-broadcasts and announcements in the churches). The biggest problem at present is our capacity – we have built a new 42 bed paediatric block in the general hospital, which, in combination with the old 45 bed paediatric building should meet the needs of the population. However, we did not bank on the old building still being ‘under reconstruction’ 2 years later. So we have accomplished the first part of the transfer strategy – the opening of the new block (which filled up in three days) – but yesterday we had 46 children, and only 42 beds.

So, the solutions – we’ve put up tents, only to find that they are immediately filled with surgical patients, soldiers, families of patients. We could use the observation beds in the nearest health centre (300 m away), but would be unable to assure the quality of surveillance of the patients. We can (and do) meet with the corporation responsible for the reconstruction to try to find a solution, so far with little success. And of course (as many suggest) we could just put two patients per bed – to which I am strongly opposed, having seen the potential consequences of this elsewhere.

So we just manage to hang in there. Fortunately work in the surgical ward finished yesterday, enabling us to move the surgical patients out and the bedless children in today. But as soon as there is a further influx of patients we will be back to juggling beds again. There is no slack in the system, no extra space to put up more tents; if a child now comes in with measles or any other contagious disease, we will have to reorganise things again to create an isolation area. And the stakes are high – the lives of the children, and the credibility of the hospital (and MSF) – which determines whether parents will continue bringing their children to the hospital when they are ill.

At times it all seems formidable – we are trying to keep so many plates spinning, all at different speeds, and the tightrope is wobbling – and disaster looms in all directions. But then at times this vertiginous sensation is followed by a wave of serenity, as I recall the comforting words of whoever it was that wrote that book on chaos theory – that there is order within chaos, or that chaos gives birth to order, or something of the sort – and suddenly I am sure that everything will turn out alright.

Demand for health care is not unlike demand for any household service – plumbing for example; we base our choice of provider on numerous factors including cost and reputation, and if the barriers are too high we are quite likely just to try and do it ourselves – sometimes with disastrous consequences.

With this in mind, I have been touring the health centres this week, holding semi-formal meetings with the health centre staff and the elders of the village or suburb. This represents the (almost) final stage in a communication strategy that has spanned several weeks, involving radio messages and meetings with health authorities, mayors and representatives of each community. The aim of these meetings is to minimize the barriers to accessing the health centres we are supporting. Given that the community have used the MSF hospital – which assured free, high quality care – for so long, we must now convince them that the Regional General Hospital is functional once more; that the care will be acceptable, effective and free (assured by the presence of our teams).

So these meetings have felt worthwhile. We have assured the communities that their children will be seen for free at their local health centre, and that if they are referred to hospital the costs will be covered. Fortunately there are various partner organisations involved, such that MSF will only be reimbursing a small percentage of these costs. At the end of these meetings I have the impression that the message will spread, and that the community will at least give the hospital a try.  It now remains to be seen if we can deliver what we have promised.

Why should this be such a challenge? I think it is us – our wishes and expectations – that make this task enormous. The hospital has always been functional to some extent, even when there were no drugs and almost no patients. Now all of the ingredients are there – staff, drugs, patients – albeit in limited quantities. The challenge is born of the fact that we wish to achieve a standard of care close to that which we delivered in Bon Marché – in a hospital that survives on one tenth of the ‘inputs’ that we had at Bon Marché.  So we invest in the hospital, in training, in providing tools for organisation of services (such as the pharmacy), in equipment and in searching for partners to provide the drugs.

The bottom line is that all of this involves a big injection of cash into the hospital. This seems like cheating in a way – we congratulate ourselves that we are improving standards of care, but the biggest difference between us and the hospital is that we have a bigger bank account. And yet it is not at all obvious how to invest this money for maximum benefit – and I hope that we do bring a certain degree of public health expertise to the fray.  If not, what are we doing here?

I just hope the results in two months time vindicate our actions!

It is sad, it never ceases to be sad, working in hospitals. Working with the mothers, their fatigued, careworn faces, the infrequent tears, the resigned, long-suffering poise, concealing hearts that are heaving with sadness. The world feels sad some days, a palpable sadness like a cloud spreading out from the feverish body of the sick child.

Other days the world (my world) is a frenzy of bureaucratic activity. The sudden news of an outbreak of cholera somewhere sets of a chain of phonecalls, of meetings, of running around between warehouse and pharmacy to check that we have the necessary kits in place. And I throw myself into this wholeheartedly, despite the awareness that 9 times out of 10 this will turn out to be a false alarm.

In both cases, there is a feeling of ‘total immersion’ to this lifestyle, as if there is no time to waste, as if what we are doing is very real, very vivid, very important. We may step back from time to time, and recall that we are not indispensible, that the world – this community – will find a way through this without our involvement. But the immediacy of the human suffering we witness pulls us back down to earth from this somewhat abstracted position, such that we quickly find ourselves fully immersed in our work once again.

One consequence of such a lifestyle is this intermittent but overwhelming desire to flee. To escape, if only for a day, for an hour. To forget the suffering and the needs that surround us, and instead to re-experience our individuality, to feel that we are something more than the work we do, that we have a life outside of this work that continues untrammeled. And here, as in many cultures, this ‘escape’ has become institutionalized, and is better known as ‘Saturday night’.

Up until now, a quiet drink and a movie have sufficed for me, allowing me to spend the sunday morning walking or reading. But already I am starting to feel the draw of the saturday night discos, which promise total oblivion, a complete ‘change of head’ as people here say. Of course, this reduces the sunday to a hazy interval between satuday night and monday morning – but after a few months in such a setting one happily forgets that sunday ever existed.

Of course such a means of escape may seem a little unhealthy, yet healthy or not it allows us to achieve some sort of equilibrium.  And the loss of the Sunday represents collateral damage in this Faustian trade-off, enabling us to stay (more or less) sane in these challenging situations.