I had just come back to my room after the morning meeting, and was preparing myself to go to the hospital, when I heard footsteps approaching. Our new project coordinator (PC) entered my room, took a shallow glance at me and quietly said, “Hemant, you are being medically vacuated to Nairobi and you have to pack your stuff. We have to move you to the airport as soon as possible because the plane has already landed.” I was like, “WHAT? I beg your pardon, but what did you say?”
My first mission had been in Somaliland. Although it was a short one, I had an opportunity to understand what MSF is and how it works. But soon it was time for my second mission, which was in South Sudan – Malakal for nine months, as a tropical medical doctor focused on kala azar. I was briefed in the capital, Juba, and told that my handover would be with the previous interim doctor. After I reached the field the handover process, introduction and briefing were given to me by the previous doctor and then he left.
My first impression of the kala azar ward was like “not so good!” Since MSF was running only the kala azar programme in the government hospital building, how come that building was worse than the other hospital buildings in terms of infrastructure? The nurses’ skills and knowledge about kala azar and other diseases was not sufficient to give good nursing and medical care to their patients. Together with the clinical officer and the nurses, we started doing ward rounds. We started talking and sharing ideas and opinions about how we could give better healthcare to the kala azar patients coming to the kala azar ward. Everybody was pointing at the bad infrastructure. I thought, how can infrastructure come in the way of providing good healthcare and nursing care? Well yes, infrastructure does affect your working conditions, but the infrastructure in Malakal was not the worst I have seen. If you are willing to give your best and work hard, rather than neglecting your patient, they can do well under these circumstances. But they said, “Dr Hemant, wait and you will see”.
On top of the goats, dogs, cats and cattle entering the ward, the rainy season started. I made my way to the hospital with my gumboots and raincoat. When I reached the hospital, the nurses were standing outside, laughing and looking into the ward. The head nurse pulled my hand and said, “Hemant, come and look: our whole ward is flooded and it looks like a swamp. All the patients left. Some are staying in the MSF tent and some of them went back home without completing their treatment. How can you expect us to work in these conditions and give the best from our side?” She was right, the roof was leaking everywhere, and the whole ward was filled with water and God knows what kind of tiny creatures. We decided this had to change.
When we raised the issue of renovating the kala azar ward, our project coordinator stated that it was a very challenging task given the extreme remoteness of the project.
When I first arrived in this project, the people working there were all at the end of their missions and everybody was on the verge of leaving. Within 15 days of my arrival, there were only three people left in the field: a nurse, a technical logistician (log tech) and me. There was no PC, no administrator (log admin), no medical team leader (MTL), no outreach nurse. The log tech was asked to handle the PC position; the nurse was doing the kala azar outreach documentation, handling the pharmacy, the store and so on; and I was busywith hospital issues.
One of our kala azar outreach sites was running out of supplies and was calling us every day by satellite phone asking us to bring more supplies and do an assessment over there. This place differed from the other outreach sites, because it was being run by MSF-trained non-medical staff, and the only mode of transportation was by air. We talked amongst ourselves and decided that two of us – the nurse and I – would go to visit the outreach site while the log tech handled the project. The clinical officer in the hospital would manage the hospital.
We left with supplies and a plan to stay there for a week, with the intention of supporting the staff over there, without knowing whether it would be possible to be back in a week or whether it would take us a month. It was rainy season and we were heading for the middle of a jungle, where the airstrip was muddy and dangerous.
Once there, I started pushing myself. Since there was nothing much to do, I involved myself in other activities such as managing the drug store, training the staff, fixing the doors and windows and trying to renovate the place with the help of the assistant log tech who flew out there with us. Every day we worked together, with patients and with renovating the building, so that by the time we left it would be easy for the MSF-trained staff to continue from where we left off. Luckily, after one week, it was possible to leave for Malakal.
Over the course of two months, our team had slowly expanded. People were arriving and finally we had a complete team with a PC, Log Admin, hospital nurse, outreach nurse, Log Tech, MTL and medical doctor (MD). The PC and the Log Admin were people I knew from before, as we had worked together in a mission in Nepal, and they were nice people. The team was perfect. It’s important to have good chemistry within the team otherwise, if you have a difficult team, it makes survival more challenging.
The PC was asking me to take a holiday and have some rest because it was already more than five months since I arrived, but I said I would think about it. Since the mission in Somaliland had been short, and I didn’t have any trouble doing that one, I kept thinking that maybe I could do the same in South Sudan and continue working without taking a break for six or seven months. I had been told in my briefings that I had to take holidays on time, and had to learn when to stop and take some rest, but I kept on going, thinking I could do it. The PC was worried and she was now pushing me to take a holiday as soon as possible.
It appeared that somehow we had managed to make the people in Juba and Amsterdam see the need that the kala azar ward in the hospital had to be renovated. It had been approved and the work was going pretty fast. We shifted all the patients into tents. We also started training the nurses in how to deal with kala azar and malaria, plus nursing and medical care. They were really interested and everybody was coming to the training sessions.
The hospital director was impressed with what we were doing with the ward. Everything was finally taking shape and we were creating very good relationships with the ward nurses as well as the hospital administration.
One early morning I felt like I could not move my neck; when I tried to do so it was extremely painful. I told my PC that something was wrong. She told me that it was because I was completely burned out, exhausted, although I had never noticed it. She asked me to go on holiday as soon as possible, this time without making excuses. After six months of working in the field with no rest, I was leaving for my holidays finally. Leaving it so late was my biggest mistake, and things would never be the same again.
After two and a half weeks of holiday back home with my family and friends, I returned to the field. The ward renovations were now complete and the new kala azar ward was much, much better than before. Everybody was happy to work there. The nurses, who used to quarrel and not follow the advice given by the doctor or clinical officer, were trying their best to give the best possible nursing and medical care to their patients; and the hospital administration and medical director were supporting us in every possible way. It was an awesome feeling to see everybody working and supporting each other like that.
But something was not right with me. I felt tired, lazy and unable to concentrate on my work, although I had just come back from holiday. The PC was worried, and continually asked me not to push myself too hard and to take rest whenever possible, because sometimes I used to go to the hospital even on Sundays when it was our day off.
There was a turnover in the team since people were coming to the end of their mission and leaving one by one. Within a week there were new faces on the team. The new team members were nice, easygoing people. But I was still facing the same problem: every morning it was so hard to wake up. It felt like, “Oh God, I can’t do this anymore”. I guess my team mates noticed this burned-out, exhausted, irritated, trying to stay alone and not talking much phase. So they were always asking me to have a rest and were as friendlyto me as possible.
The end of my mission was approaching: I had only four weeks left. I was trying my best to take it easy and not to get stressed out. I was doing OK with day-to-day activities at the hospital and thinking that soon I would manage to finish the mission. One night I started vomiting and had a headache. The new PC was worried. She asked me, “Is everything alright?” I said, “Yes, it’s ok, it’s just the heat and the humidity; if I have some rest I will be fine”. She visited me again that night to see how I was doing.
I tried to persuade her that there was no need for a medical evacuation and that I was going to be fine. She said, “Hemant, I cannot take the risk. It seems like you are completely burnt out and stressed. Although you are trying your best, you are not able to concentrate on your work. And now you are having other problems too: you are vomiting and you have a headache.”
She was doing what she thought was right for me at that time, and I respected her decision. Everybody helped me to pack my belongings and within half an hour I was in the air, flying to Nairobi, escorted by the MTL.
We went to the hospital the next day and every possible investigation was done. The doctor in Nairobi discharged me, saying there was nothing to worry about and I just needed rest. I hoped that after this assessment I would fly back to the field, but instead a French doctor was waiting to escort me back to Nepal.
More than four months have gone by and I am now looking forward to my next mission. When I look back, there are certain things that I have to learn. I think the biggest mistake was pushing myself to work continuously for six months without taking any rest or holiday. People in Amsterdam while doing my preparation for primary departure (PPD) course, my HR colleagues in India, and the PC in the field all told me that proper rest and holidays at the right time are essential to withstand these long missions. Otherwise the work makes you exhausted and your body gives up. Initially I thought, “What difference does it make whether you take holidays or not? You are there for work, and you should take your holidays after you are done with your work.” I was completely wrong, and they were right, and I definitely have to learn this. The only thing that still bothers me is that I never got the chance to wave goodbye and say thank you so very much to those wonderful nurses and clinical officers and to the hospital director and the administration, whose tremendous efforts made that kala azar ward a bearable place for their patients.
– Dr Hemant Bogati
