Managers Without Borders, Too

On any given MSF project, it seems to me that at least 50% of the upper-level people are non-medical – logistics experts, administrators, human-resources managers. We got a taste of why that is, and of the sometimes absurd situations they have to finesse, in our last days in Juba.

The clinic where MSF set up the emergency surgical program was, you may remember, originally run by a different NGO, and the plan all along was to turn it back over to that NGO once the acute surgical cases were dealt with. Thus, on Saturday morning, Dr. Dave arrived at the site prepared to do a detailed “rounding” with the other NGO’s surgeon, so that this man would have a clear understanding of each of the patients he would be providing ongoing care to.

I was in the operating room out back, “mixing up the medicines,” as Bob Dylan might say, when Dave came in to tell me that we would be able to start sooner than planned. As he was rounding with the new surgeon, the manager of the refugee camp had arrived and said that the new surgeon and his organization were not welcome on the base, and that – by one account – if he did not leave immediately, they would shoot him. So – rounding over; time to start operating.

Here’s the back story: For some reason, the camp management had decided at some point that they did not like this other NGO. According to MSF’s head of South Sudan operations, this has happened before – a local group, for whatever reason, goes borderline, and decides the people they liked yesterday are now the enemy today. In this case, I have a feeling that it had to do with a perception of difference in quality of care. Basically, MSF had done its job too well – the camp management could see how well cared for the patients were when we were there, and did not want to go back to what they perceived to be the inferior care provided by the other NGO. (And in this they may unfortunately have had a point. Dave later reported to me that, as he prepared to leave the site for good early this week, he heard screams coming from the operating room. He stuck his head in to see what was going on, and saw the new surgeon doing a dressing change, on a man with a deep, deep wound, with no anesthesia….)

From MSF’s point of view, however, this isn’t what we agreed to. From the very beginning, we had made it known that our plan was to exit the project as soon as the major work was done. Dave was needed back at his original project up north, and my replacement was needed in Aweil. Our director felt, very clearly, that what was going on was that the camp management was trying to create a fait accompli – basically, to make it so that no one else was available to take care of our patients, so that MSF would have no choice but to stay on. Beyond not having the human and other resources to do this, the director did not appreciate what he took to be an attempt to manipulate MSF, and did not want to cave in to it and create a precedent.

For most of Saturday and Sunday, it was unclear what was going to happen. Would we leave as planned – stay on for a few more days – stay on indefinitely? The MSF director stayed firm, though, and I imagine that once the camp management realized that we weren’t going to give in, they decided to make their peace with the other NGO and let them back onto the base. Dave was able to finish his “handover” rounds with them, and on Tuesday, only one day late, MSF disengaged and turned the project over. With silent apologies, no doubt, to the screaming patients.

One thing the director was able to do first, however: He managed to move the little girl with the amputated arm to a different facility, where he had more confidence in the nursing care. He has to be a pretty hard-nosed guy sometimes, but let no one think he doesn’t have a heart.