From Bunia

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.

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.

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.