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.

It’s hard to contemplate Bunia without MSF. Bon Marché (the MSF hospital) is truly an institution – everyone I meet has either worked there or been a patient there – usually both.  The community was initially devastated to learn that Bon Marché would be closing, and the fact that we will be here for some years supporting the General Hospital has softened that blow to some extent, even though no one in the community quite understands what that support will entail. And I have to acknowledge that we’re not all that sure either, because here we are being pulled out of our comfort zone – from responding to humanitarian crises – into the unfamiliar world of development aid.

Our disengagement strategy has evolved through a series of stages, governed (as these things are) by political, financial and cultural factors, as much as by experience as to what works in practice. The complexity of ‘integrating’ what are essentially a series of specific and focused MSF programmes (Paediatrics, HIV, Women’s health) into a very general health system is baffling, involving everything from assuring the availability of ink for printing surveillance charts, to advocacy at national and international level for provision of anti-retroviral drugs. To make matters more confusing, each of the numerous partner organisations has its own way of working, its own timetable, and its own agenda – and sensitivity to this is a prerequisite for effective collaboration.

The fact that I am reflecting on all this does not mean (unfortunately) that I understand it. I am only just beginning to get a feel for the landscape, and to identify the points where we may be able to have an influence.  As a doctor I feel like a fish out of water, knowing that there must be many people who could do a better job of this than me. But I remember my father saying that there’s always someone out there who’ll do a worse job of it, and this gives me some reassurance.

So, to return to the original question, can we conceive of life here without MSF? For Bon Marché is not just a structure, an employer and a community service; it implies a way of working, an ideology, even a particular relationship with the community –which won’t be possible to replicate as we move from one hospital to the other. This does not have to mean giving up on such ideals – but it means weaving those ideals into reality, such that the difference between the two ceases, eventually, to exist.

When you are accustomed to living in closed compounds, you develop a long-distance stare; a meditative gaze you adopt automatically when left to yourself. This abstracted state serves two purposes – it allows you to take a little break, to escape for a moment without physically leaving the property; and it helps you overlook the razor wire that charmingly adorns the walls of this and other MSF compounds around the world. This time round, though, my view is a little different – beyond the wire, climbing roses and clumps of deep-green foliage adorn a backdrop of billowy hills.

Perhaps Congo is the closest thing there is to that romanticized image of Africa we have created in the west – tropical forests, gorillas (and guerillas, of course), exploitation, civil wars, dusty road, and lots of dancing. I have numerous preconceived notions of the Congo, all based on novels or historical accounts written by westerners who came here to conquer, enslave or make their name through ‘adventure journalism’.  Then there are those (such as King Leopold) whom we associate with the Congo but who never actually set foot here; and those (Conrad) who experienced the cruelties of the Belgian Congo so vividly that they could only write about what they witnessed in metaphorical terms.  I’m trying to be conscious of these preconceptions so I can let go of them at some point.

Here, for the first time, I will be leading a project. Although there is nothing inherently intimidating about this role, I find myself thinking wistfully about the solid simplicity of the medical roles I have taken on up until now.  We will be closing down Bon Marché, the flagship MSF hospital in Bunia, and transferring all activity to the regional MoH facility. This will involve a lot of negotiating, HR management, and security assessment – and yet I will still be heavily involved in the medical aspects of the programme, in terms of quality assurance before and after the transfer. The role is something of a poisoned chalice, as such changes – with all the HR implications – are inevitably demoralizing for the staff. The next 6 months will undoubtedly be taxing and stressful, but could nonetheless be satisfying. I think.

Thankfully my office is in the hospital grounds, and when I step into the hospital wards I breathe a (paradoxical) sigh of relief, as if somehow I am coming home.  Instead of slippers I put on my stethoscope, and suddenly everything feels familiar and logical. The children are thin and frightened, the mothers care-worn and tired, the nurses are eating their lunch….and all’s right with the world. But then a voice whispers in my ear that the budget revision is due tomorrow, and I reawaken rudely to the reality that I am now a bureaucrat, albeit in doctor’s clothing.

Since 2007 I have been working as a doctor with MSF in Somalia, Kenya and Niger, and am currently Project Coordinator of the MSF Hospital (Bon Marché) at Bunia, DRC.

I am writing this blog for family and friends, for those interested in the work of MSF (or in working with MSF), and for myself, to help me process everything that’s going on here. I’m sure there are many who would identify with the feelings I’ve expressed here, and I would be happy to hear from anyone who has any reflections to share.

Please note: the opinions expressed in these pages are my own, and do not necessarily reflect those of Médecins Sans Frontières.