Men in yellow protective suits. Doctors Without Borders between Ebola and the machine gun

28 May 2019

From a distance, humanitarian mission service often seems to be a heroic task: a brave, masked doctor treats people in the most dangerous parts of the world. It is not just lonely heroes who go there, but ordinary office workers as well. Nikita Bulanin is of the latter. He has been working for the international organisation Doctors Without Borders (MSF) for more than 10 years. An AIDS.CENTER reporter asked him about his work in crisis-stricken countries, about how to negotiate with rebels and community elders, and learned why office work is just as important as "field work".

Why did you start working with Doctors Without Borders? Was it because you used to read a lot of adventure books as a child? 

My mother taught Russian as a foreign language to students from very exotic countries at the Polytechnic University: Bangladesh, Nigeria, Cyprus, Guyana (a country in South America), India, Palestine. She occasionally took me to her work, and I would sit in the back of the classroom and observe the classes.

And at home, in the corridor, my parents put up a map, so I learned the capitals of all countries. Then my godfather brought a book by Miklouho-Maclay from the library to me. It couldn't be bought back then, it had been out of print since the 1950s. Its paper turned yellowish, and the book had the unique scent that only old library books have. It contained drawings of huts made by Miklouho-Maclay, his thoughts on Papua New Guinea, the story about his life with the Papuans and his travels, and about him collecting anthropological and ethnographic items. It was then that I began to wonder: why not become an ethnographer? As a result, I joined the Faculty of Ethnography. This is how it all started.


Nikita Bulanin in Myanmar. Photo provided at the courtesy of the Doctors Without Borders press service

And how did you start working? With what position did you start?

My first job was Head of human resources and accounting. I was responsible for all financial and personnel issues, such as recruitment, job descriptions, interviews, teamwork, salaries, taxes, insurance, disciplinary procedures, and dismissals. At the same time, I prepared monthly budgets, made sure the money was spent in accordance with it, and that all the documentation was in order.

Regular office work? 

Yes, but meanwhile you are in an African hospital. I was working on the top floor, and downstairs there was a pediatric ward, a centre for children with malnutrition, a maternity ward, and a surgical post. Every day, as I was going upstairs, I would see patients.

Over time, my dream came true - I became a project manager, evaluated the context, understood where the local MSF could help. My last field missions were to lead vaccination campaigns.

What do you call projects, and how are they different from missions?

A project is a basic operational unit. A country where it is deployed, is called a mission. It might host several projects. For example, Burma (Myanmar): we had a project on the treatment of drug-resistant HIV, AIDS, and tuberculosis in the "Kachi" Hospital situated in the capital; we implemented HIV treatment and primary medical care in Shan State. There are 48 clinics scattered around the State in the western part of the country (populated by the Rohingya people, who have now fled to Bangladesh). The Rohingya were forbidden to move from one village to another, and in order to provide people with medical care, it was necessary to create as many clinics as possible. They were small, with two or three employees.

I was responsible for two HIV treatment clinics and one primary medical care centre located in the mountains. But I could not even get there - they did not give me permission.  And in Liberia, the project was a hospital with a department to assist victims of sexual violence.

So, a project can be of any scale?

Yes, Doctors Without Borders had a very large hospital in Haiti, in Port-au-Prince, with 600 employees. And only 20 people work in the project for the assistance to migrants in Serbia. They are psychologists and social workers.


Gedeo, measles vaccination of children, 2015. Photo provided at the courtesy of the Doctors Without Borders press service.
Measles vaccination campaign, Yida refugee camp, South Sudan. 2015. Photo provided at the courtesy of the Doctors Without Borders press service.

But in any case, are your projects temporary?

We have nothing permanent, and this is a part of the idea - we are a crisis organisation. Fortunately, the crisis is not constant, although there are countries where it lasts for a very long time, like Sudan or Congo - there it has been present in various forms for 50 years, and, accordingly, the projects are also long-standing.

There are projects that are launched after natural disasters that are supposed to last for only a few months. For example, after the earthquake in Nepal, we were there for about eight months. Medical assistance makes sense in the midst of a crisis, when people are being removed from under the rubble with broken arms and legs, when all structures are destroyed. Then we come and help. But when everything has been gradually restored, when the development stage begins, other organisations come and say: "We will be supporting this hospital for 20 years." While we come to fill this gap.

In which countries did you work?

I had long missions in Liberia, Northern Sudan, Ethiopia, Myanmar, and South Sudan. When I was in South Sudan, the first year of its independence was being celebrated. Then I went to short missions to Lebanon and India. But since then, I have no longer worked "in the field", I am now based in Denmark.

Why did you stop going "in the field"? Got sick and tired?

My wife and I decided to stop because we had our children born. She also works in Denmark, at the hospital, and she really likes it. She is now “civil” - she left Doctors Without Borders, and I am still “in the family”. 

Darfur refugee camp, South Sudan, 2010.. Photo provided at the courtesy of the Doctors Without Borders press service.

And what do you do now? 

I am a recruiter and career coach. The main task is to look for non-medical specialists in Denmark. I do recruiting, interviews, tests, and prepare staff for the trip "in the field", I support them when they are there. We have a big support system. If you are confronted with a difficult situation and want to talk to someone, you can always call and get advice. People call a lot. I also teach at our internal and external courses, as well as at the University of Copenhagen as an MSF representative. I reached a  career level where I can create and make decisions a lot. But I sometimes dream to be back "in the field."

And you no longer work “in the field” since the birth of your children because you have been in dangerous situations?

I have. In some countries, we were taken for interrogations by rebels. If the military appear on the same road, you find yourself between two lines of fire. Once we were halted while our mobile clinic was operating in the desert. We heard shouts, thought they were shooting into the air. Then they found a hole in our car - it turned out, they were shooting at it. But we saw it only when we arrived at the destination. The other day we woke up because of the shooting - the rebels attacked our town, and we saw shining bullets. It was really scary.

In one of the places where I stayed, they were constantly shooting - mainly during weddings and other holidays, but the rebels were also in this city, and from time to time we would hear the sound of bombardments, everything was shaking. I was not under direct fire, but all of this influenced me greatly. It was a short mission, but in terms of security it was very unpleasant.

In one of the places where I stayed, they were constantly shooting - mainly during weddings and other holidays, but the rebels were also in this city, and from time to time we would hear the sound of bombardments, everything was shaking.

What security measures do you have to follow during missions?

For example, in Venezuela we are talking about a terrible crime rate, and in that part of Ethiopia where I stayed, - about an armed conflict. Accordingly, the security measures are completely different. In Ethiopia, if you have an expensive watch, nobody cares, and in Venezuela you immediately attract attention. There is no general list of rules. But in all countries we are trying to explain to people what we are doing, why and how, that there are no political interests behind us, we try to understand what they need.

And how is security organised?

There are three security strategies - acceptance, protection and deterrence. Acceptance is when the population accepts you as their own, as a very important and valuable part of the community: “If we get sick, if our arm is broken, we go to the Doctors Without Borders hospital. If there are no Doctors Without Borders, we have nowhere to go. As a result, the population is our main advocate, it will take care of us. The protection strategy is the protection itself. For example, there is a fence around most of our residences.

And there are not even guards with guns?

There is security, but it is not armed. Rather, they are watchmen - a person sits at the entrance and asks: “Whom do you want to see? What kind of help do you need?” The guards were unarmed even in truly dangerous countries at that time, for example, in South Sudan, in the part of Ethiopia that was experiencing a conflict. This is part of our message, we have stickers “Weapons are prohibited” everywhere. 

Another security measure is using common sense. Taking photos of the military during an armed conflict is a bad idea, getting a phone from your pocket at the entrance of a roadblock is bad too, being rude to an armed person or walking around Caracas at night alone is definitely not worth doing. In places where soldiers shoot or where criminals appear on the streets after dark, you cannot go out at night.


Coordinator of a mobile clinic, Abacoro, Ethiopia, 2010. Photo provided at the courtesy of the Doctors Without Borders press service.
Vaccination at Degehabur Hospital, Ethiopia, 2015. Photo provided at the courtesy of the Doctors Without Borders press service.

But countries differ, each has its own context.

There are security protocols for everything, they depend on the specifics of the country. But there are general principles too. Acceptance is everything for us. Plus some protection measures. Addis Ababa, a city which is safe both during the day and night, is one thing. Another thing is a region of Somalia where there are roadblocks and armed people on the roads. I saw them shooting there - not as a joke, but for real. And there are 700 kilometres between the two.

A part of the project coordinator's work is to assess risks using a special formula and propose measures that minimise risks for employees. 

How do you explain to people unfamiliar with medicine and science what kind of help they need and why?

I personally did not do this. But we have trained people to translate complex ideas into simple language. Many of them have an anthropological background, they are specialised in medical anthropology. They find necessary allegories and words. I usually work at the level of elders, who are, as a rule, more progressive. Elders are not only elders because of their age - they are respected people. At my level it was not hard to explain, but anthropologists face a difficult task.

I remember that in one country we carried out a vaccination campaign, and the population told us: "If you vaccinate us, you must pay us." Of course, we did not pay them. Sometimes you get rebuffed, and it seems like everything is lost. In fact, very often, by telling the same idea in different words, you can explain your position.

Do you persuade?

Persuade is the wrong word. Informed consent is important so that people understand what is happening to them. After all, vaccination is some kind of invasion to the body. If you do not want, we cannot force you to have it, but we must convince, give arguments. For example: “Look, this boy was vaccinated and didn't get sick, and your son got sick. What will you do with your daughter?” In Ethiopia, we often travelled with mobile clinics to isolated nomadic communities, came and talked with the elders, and explained why we prioritise women and children. By doing so, you enter a certain traditional world, which looks at things in a completely different way, appealing to some facts that are significant for these people. 


Leitchuor refugee camp, Ethiopia, 2016. Photo provided at the courtesy of the Doctors Without Borders press service.

Without an agreement with the elders you cannot work, right?

No, we cannot. We drink tea for a long time, talk about life. They know that there are non-governmental organisations, but their idea of what we can do is vague. For them, the UN and Doctors Without Borders are the same. They will begin to tell: “We have dirty water here, children are sick, we have no schools” - they talk about all the problems. Just talking is not enough. You need a team of doctors who conduct basic consultations to create a medical picture.

The idea of communicating with the elders is to understand the needs, to explain that we are not agents of some kind of intelligence, but work out of humanitarian motives. By listening carefully and explaining everything, you get that acceptance. But if you come and build a white European hospital in the middle of the desert, without asking anyone for permission, it will stand empty, no one will come in. Maybe it is not even needed there.

Have you faced rejection from the local population?

"In one country, we conducted a vaccination campaign, and the population told us: "If you vaccinate us, you must pay us"

Yes, we have. I believe that the main cause of conflicts and misunderstandings is insufficient and incorrect communication. If they, the local population, did not have a complete picture of the situation, or if there was a rumour that vaccination leads to autism, they could be worried.

When the Ebola virus was rampant, doctors worked in yellow protective suits. Imagine: some creature comes in such a spacesuit, takes a person, and the likelihood that they will not return is 50 percent. Who is guilty? The spacesuits! Before they appeared, there was no Ebola in Nigeria, Sierra Leone, or Guinea. They simply did not know what it was. For locals, this is a straight-forward association: a person appeared in a yellow spacesuit - part of the population dies. If people interpret this as a direct connection, they will be very unhappy. Therefore, in West Africa many anthropologists worked with us to explain what was happening, to find a certain balance between traditional culture and science.

And how did you overcome the language barrier?

I only worked in one country where English was the official language. What is more, it was a local version - pidgin English with simplified grammar, local words and very heavy pronunciation. In the first month I had to listen very carefully to understand what my assistants were saying. Then you get used to it and you start adding local words and expressions to the language.

In other countries, qualified staff who work with us usually speak English. But, for example, there were no professional interpreters in Ethiopia. I remember how I was looking for a paediatrician: a lot of candidates came to the intake. The doctor would ask: "Tell me about yourself!”, and the interpreter would nudge the HR manager with an elbow and ask in Somali:  “What is she saying?”. 

Barnesville Junction Hospital, Liberia, 2016. . Photo provided at the courtesy of the Doctors Without Borders press service.

What are the strangest ideas about medicine and health you have encountered during missions?   

My wife is that very paediatrician who was looking for an interpreter. At the time we had only just met and we were sitting in Myanmar at a Chinese restaurant (there is a fairly large percentage of the Chinese population). A mother with a baby was sitting nearby. The baby began to cry, the woman tried to calm him down, but she failed. Then she took a Coca-Cola can and started rubbing the baby's back with it. According to a local belief, it calms children down. The child began to get even more annoyed and screamed - she rubbed its back with a can at a breakneck pace! My wife simply could not bear it, and we left. At the same place, on the local market, in the Chinese medicine section one could see claws, hides, bones, and other body parts of various exotic animals. All of it was used for "treatment."

And finally: what is your own motivation?

I decided to work for charity a long time ago. At first, I had a desire to get into a respected international organisation. But now a stronger motivation, to know the world, other cultures. Helping people has always been a must for me as well. At this job I saw people in very vulnerable situations. When you see what you can do for them, it makes a very strong impression.

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