FINAL CHAPTER FOR BOOK ON DELIVERING MEDICAL & SURGICAL HELP IN A HOSTILE OR CONFLICT ENVIRONMENT

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“HANDBOOK OF CONFLICT MEDICINE”

Chapter 24

“AND, FINALLY – WHEN YOU COME HOME.”

Author:

Caroline Kennedy

Leonard Cheshire Centre of Conflict Recovery – Royal Free & University College Medical School, London

This final chapter of our book is divided into two inter-related sections. In Part 1, the author is concerned with the immediate aftermath of a mission as it impacts on the individual volunteer.  She has tried to convey the contrasting feelings of exhilaration, guilt and, sometimes, hopelessness, often experienced by aid workers or deployed medical personnel on their return home. It also aims to give a short glimpse, in general terms, of what countries in the “post-conflict, post-disaster phase” can expect to suffer.

In Part 2, the author concentrates of what may be termed the conflict recovery phase.  She gives a personal account, complete with lessons learnt, of her recent experiences setting up a long-term medical aid and academic study programme in a country devastated by war with an uneasy peace agreement in place. In the final section of Part 2, she offers helpful advice to others embarking on a similar long tern recovery and reconstruction mission.

Part I:

AND FINALLY – BACK HOME

by Caroline Kennedy

Introduction

And finally – you’re back home. You’re safe, you’re warm, you’re relaxed. You feel good – and so you should. You have done well.  You have played a very important role. During your time overseas you have helped many vulnerable people. If you are medical you may have treated their illnesses, dressed their wounds, vaccinated their babies or set their broken limbs. If you are non-medical – a logistician for example – you may have built their shelters, provided their food and water, documented their stories or, simply, played with their children.  Whatever you have done, whatever part you have played, no matter how small, you have the right to feel good.

Gradually, though, as the initial thrill of recounting your experiences to friends and colleagues back home begins to fade, doubts will inevitably creep in.  Some of these doubts are listed in Box 1.

Box 1.

  • Did I do as much as I could?
  • Could I have done more?
  • What will become of the people I left behind?
  • How will they fare?
  • Will I ever see them again?
  • Did I make any difference to their lives?
  • Did I raise their hopes too much?
  • Would they have been better off if I hadn’t gone at all?

These are all typical reactions. What you must believe, must convince yourself is, that by helping a few you have raised the morale of many.  You must constantly reassure yourself it is only normal to worry about them and to fear for their future. After all, you are back in the comfort and familiarity of your own homes, surrounded by your families and friends. And they, if they are refugees or displaced people, may be forcibly separated from their families and friends, either temporarily or permanently, and may never even see their homes again. They may stay in camps, or be shunted from transient shelter to transient shelter all their lives. They may well remain pawns in ethnic struggles or territorial conflicts for years to come.

The Aftermath

For everything is not over yet, conditions do not abruptly improve, miracles do not transpire overnight, just because the war, the emergency or the disaster is over. Whether the cause was flood, famine or ethnic conflict, children will still starve, hospitals will still be wrecked, homes will still be razed to the ground, infrastructure will still be ruined, agricultural lands will still be destroyed and countless lives will still be devastated.

This, for the victims, is now the phase of conflict recovery and will be discussed in more depth later. . This is the period when many aid agencies pull out, the cameras turn their attention elsewhere and compassion fatigue sets in. This is the unglamorous, seldom recorded, very often neglected period – a period, what’s more, that can last for several months, years or, even, generations. Local governments may change in the meantime, economic confidence may grow, foreign capital may be attracted back, houses may be rebuilt, infrastructure may be repaired but the plight of the numerous victims is often everyone’s very last concern.  

If you enter a hospital in almost any country in the conflict recovery period what can you expect to find?   Some examples are listed in Box 2.

Box 2

  • Demoralised staff, academically isolated and, more often than not, unpaid.
  • Wards either overflowing with patients requiring urgent attention or totally vacant, depending on the cause of the conflict.
  • Medical equipment, very likely unreliable, dangerous, broken down or destroyed.
  • Inappropriate medical equipment and medicines from well- intentioned donors
  • Drugs and consumables, either non-existent or only available at exorbitant rates, far beyond the reach of the majority of the population.
  • Intermittent or non-existent power and water supplies.
  • Communications degradation or failure.

In other words, the local health system, which was once, perhaps, a flourishing or, at least, adequately run, service has all but collapsed. And what other ancillary problems may be faced with in the long term?

These may include:

  • Possibly hundreds of patients requiring emergency treatment or surgery.
  • Neglected cases of everyday illnesses, such as cancer, diabetes, hernias,

renal disease, epilepsy and severe tonsillitis, to name just a few, with a

chronic shortage of drugs, or no drugs at all, with which to treat them.

  • A complete breakdown of family units and community structures.
  • Severely reduced transportation, due to unserviceable roads.
  • Non-productive agricultural lands.
  • Environmental hazards, contaminated air, soil and water.
  • Long term psychiatric problems such as depression, boredom, malaise, anger, suicide and other related post-traumatic stress disorders.
  • Women recovering from violence, including rape and domestic violence.
  • Adult and child soldiers needing to be reintegrated into society.
  • Stunted growth, blindness, goitres, severe malnutrition and mental disorders induced by vitamin, iodine and food deficiencies. 
  • Chronic unemployment leading to increased frustration and a rise in crime.
  • Dangerous territory due to landmines.

There are many more factors that need consideration. But it’s beyond our remit to discuss how to deal with them here. We mention them simply to give the reader an idea of the scope and variety of problems that could be found in a conflict recovery scenario. In Part 2 of this chapter the author will write about her own experiences, the pitfalls, the failures and the successes while setting up an humanitarian medical programme in a country devastated by conflict.

And what now?

What can reasonably be done in such a country to improve in the following areas?

  • Mother and childcare
  • Education
  • Health and rehabilitation
  • Food security

Always bear in mind that most humanitarian/medical agencies cannot aim to improve these conditions dramatically, at least in the short term.  Long-term objectives will be to help return a society to its pre-conflict, pre-disaster state. In some countries this may be a return to a sophisticated western model – Bosnia and Kosovo, for example In other societies the pre-conflict/disaster state may have been poorly developed – Rwanda and Afghanistan are examples. It is the job of the aid agency to decide what level of improvement is necessary or, indeed, appropriate. And, more importantly, whether, under the prevailing conditions, it is even achievable.

Remember, too, that in a conflict recovery environment, agencies are no longer dealing with the phase or urgency or crisis. By now many of the disaster response agencies will have pulled out. And what is left to deal with are the chronic problems, very often requiring long term, complex and expensive solutions.

When faced with such a challenge whose help should you seek, whose collaboration is vital?  In other words, who are the important players you should you be dealing with as a aid worker or aid organisation?  The more important are grouped in Box 3.

Box 3

  • Government and local government officials
  • Health ministry and local clinic staff.
  • UN organisations
  • Church or other relevant religious organisations
  • Local and international NGO personnel.
  • Peacekeeping forces

Firstly, individuals and even large organisations cannot act independently. Like it or not, you will need the approval of and, preferably, collaboration or partnership with the current government. Without their support nothing is likely to get done. Doors will not be opened, personal security will not be assured and obstacles will constantly arise.

Government representatives (the higher up the chain of command the better) can arrange introductions to local government officials, health ministries, religious leaders, educators and local hospitals or clinics. Apart from these necessary introductions, a supportive government official can help in several other ways, by:

  • Registering your organisation as an humanitarian organisation, if

required.

  • Guaranteeing your security throughout the country.
  • Discouraging harassment by Customs officials, military and  police.
  • Enabling your programme to run smoothly.
  • Alerting you to any political or social crisis or danger.
  • Explaining local history, religion and customs.
  • Providing all relevant information and statistics.
  • Providing transport when necessary.
  • Exempting your organisation from any local taxes.

But beware! There are pitfalls. In many countries you or your organisation may think you are dealing directly with the Prime Minister, the Chairman of the State Customs or the Minister of Health who should, you would think, be able to make their own decisions. But, very often, this is not the case. Every decision, no matter how trivial, might need to be referred for approval or authorisation by the Head of State, Prime Minister or President. This can take days, weeks or, even, months.  So, despite enthusiastic verbal support by government ministers, be prepared for many hours of frustration. It would be naive to assume that government collaboration automatically means things will run smoother, faster or, even, succeed at all. Far from it, it simply means that you may just be paying a handful of people to get things done, to acquire the right stamp, or obtain the relevant signature, rather than paying everyone.

Remember, bureaucracy does not run smoothly at the best of times. Patience, humour and persistence are requisite characteristics, if you are to survive!

Summary – Part A

Thus far, the author has described the early aftermath for the individual (much of this is discussed in detail in earlier chapters – For editor ?Cross ref a particular chapter) and discussed, in general terms, the aftermath for the afflicted society or country.  In Part 2, the author focuses on an on-going long-term recovery programme in a typical post conflict/conflict recover setting – the Republic of Azerbaijan.

PART 2:

A ONE COUNTRY STUDY OF CONFLICT RECOVERY

Background:

The Leonard Cheshire Centre of Conflict Recovery (LCC) is a small university based academic unit with the task of studying medical and allied effects of conflict in an attempt to move care towards an evidence base and to describe good practice.  It is not an Aid Agency in the accepted sense of the term but inevitably involves itself, in part, either alone or in partnership in the provision of assistance.  Conflict countries in need do not readily tolerate statisticians, number crunchers or data collectors.  LCC and similar organisations have quickly learnt that the quid pro quo for access to data with one hand is to render assistance with the other – An important lesson for any enthusiastic researcher hoping to join an aid mission!

In this section, the author describes its on-going combined study- assistance programme in Azerbaijan.

Mission Aim:

For the Centre, the main aim at the outset was to conduct a study in partnership with existing aid agencies and not to become embroiled in aid delivery- a naive ambition as will be seen.  The broad principles governing the aim were to first; ‘keep it simple’ and to recognise von Clauswitz’s aphorism that “The plan does not survive the first contact with the enemy”.

In 1994, little was known about the medical and allied problems facing Azerbaijan.  The first part of the aim therefore was to gain a ‘broad brush’ view of the state of medical provision for the population, but particularly for the over 1 million internally displaced persons and refugees.  The second part of the aim was then to focus on specific problems such as the virtual absence of a referral system to get patients to hospitals.  LCC’s parent organisation, Leonard Cheshire, with its emphasis on enabling the disabled, wished to know the numbers of disabled in the country and what provision was being made to care for them. 

This then was the position at the outset.  Thing’s changed rapidly, and what is known as ‘Mission Creep’ took over.

Before proceeding, a brief summary of Azerbaijan’s recent history will give useful background to readers.

Azerbaijan – A Brief History

Over the centuries Azerbaijan has enjoyed only brief periods of independent statehood, in between longer periods when it was incorporated into the Persian, Muslim Arab, Turkish Seljuk, Mongol, Ottoman and, finally, Russian empires. The modern republic of Azerbaijan is formed from northern territories ceded to Russia by Persia in 1828. Thus, today over half of historic Azerbaijan still lies within Iran’s northern borders and 30 million Azerbaijanis form part of Iran’s population, while the current population of the Republic of Azerbaijan itself is only 7.5 million, comprising 70% Shia Muslim and 30% Sunni Muslim.

In recent years Azerbaijan has been plagued by an unresolved conflict with its neighbour, Armenia, over control of the Nagorno Karabakh region. After a bloody conflict lasting almost ten years Azerbaijan was heavily defeated. The Karabakh Armenians declared independence and proceeded to occupy the “Lachin Corridor”, a wide strip of land linking Nagorno Karabakh with Armenia proper. This corridor represents 20% of Azerbaijan’s territory and its loss resulted in almost 1 million refugees and displaced people seeking refuge within their own country.

At around the same time, in January 1990, Soviet tanks were brought into Baku, allegedly to prevent pogroms of Armenians that had been taking place in the city. This exercise, in the course of which more than 100 people were killed, was actually aimed at restoring pro-Soviet Communist power in the new republic. In this respect it was, initially, successful but, in the long term, the episode proved decisive in turning the majority of the Azerbaijani populace against Moscow.

In 1994 a Russian-brokered accord with Armenia brought the fighting in Nagorno-Karabakh to an end, but reports of armed clashes along the ceasefire line continue and there is little sign that a lasting political settlement will hold. In the aftermath of this prolonged conflict and following its newly-acquired independence, Azerbaijan has experienced a precipitous decline resulting in a devastated economy, wrecked infrastructure, catastrophic environmental conditions and an underpaid, underemployed and despondent workforce. On top of that almost 1 million refugees and IDPs are living in camps, disused buildings and discarded railway wagons all over Azerbaijan with little or no prospect of ever returning home.

Planning & Initial Assessment

After several meetings with the Azeri Ambassador and Embassy personnel in London, it was decided the initial visit should be directed towards gathering medical intelligence within a small but representative group of refugee/IDP camps and then to report back to decide on the next priority. The initial team consisted of experienced Health Visitors and Nurse Practitioners and included LCC personnel with previous experience of working with refugees.

The embassy arranged in-country introductions on arrival in Baku, with the Deputy Prime Minister.  He welcomed the group warmly and, in turn, introduced us to other officials and departments who could be useful to the programme. With the help of these officials and their interpreters we acquired the following;

  • Accommodation – An apartment, which doubled as office space, in Baku.
  • An Interpreter – Employed on a full-time basis.
  • Access to NGOs 

(NB. NGO organisations, some of whom had been working in Azerbaijan for several years, gave a comprehensive account of IDPs, refugees and locations of camps and settlements.)

Readers should note here that NGOs are extremely territorial. At first they exercised great caution and a polite indifference to us. This later changed as, in their eyes, the team earned our spurs by facilitating the provision of surgery to those refugees who needed it. This was an example of a service their organisations were unable to provide and, thus, the team were filling a gap, rather then duplicating their work or treading on their toes.

From the NGOs point of view it was important for them to be able to establish that  ‘new boys on the block’, particularly a university based research group would:

a) Not attempt to invade and take over their territory

b) Not promise the earth and fail to deliver

c) Fill a gaping void

d) Collaborate and co-operate to become a useful ally.

The aim in the preceding paragraphs has not been to attack well-established and organised NGOs.  They have bitter experience of ill-advised missions mounted by enthusiasts that fail and cast a shadow over all aid activity.  They are quite right to adopt a cautious approach when faced with new arrivals.

Reconnaissance

Armed with maps, our interpreter and advice from all the above sources the group travelled three hours south from Baku, by local transport, to a cluster of large camps, near to the Iranian border, known as the Southern Region Camps (Map 1). A government official had telephoned ahead to inform the regional Mayor of the impending visit.

As is usual in post-conflict countries many aid agencies, specialising in immediate aid, had already pulled out leaving behind empty buildings suitable for NGO use.  On our arrival in the local town, Saatli, the group reported directly to the Mayor’s office where the official in charge of refugee welfare set us up in such available accommodation, at no cost to LCC. This official proved immensely valuable not only as a source of local history but also by the Mayor’s introductions to other local officials, medical personnel and camp leaders and, most importantly, by establishing an immediate rapport and trust for LCC within the refugee community. This made LCCs task much easier.

(NB: Sadly, this official was replaced a year later by a greedy bureaucrat who, on discovering we had no intention of providing money or aid to his own family and friends, actually went out of his way to obstruct our programme and the excellent relationship we had established with the IDPs and refugees. Fortunately, by this time, our credibility was confirmed so his crusade was doomed from the start.)

Initial Survey of Camps:

A previous survey of the area found us in a region supporting at least 12 camps of varying sizes. These we marked on our local map, with our accommodation acting as the focal point.  We decided that it would be practical to select a camp for the following reasons:

a) near to our base, for ease of access.

b) where the camp managing agency (in this instance, the IFRC) was

also near to our base.

  • Camp Managing Agents:

As each camp was visited we accessed the NGO responsible for its welfare.

In that particular area the main ones were: the IFRC, Medecins Sans Frontieres, Medecins du Monde, Relief International and Umcor, to name a few. The effective NGO regional headquarters were then visited and it was here that vital links were forged with Regional Directors and Medical Directors. Many of these personnel spoke of their constant frustrations due to lack of provisions, bureaucratic delays and overwork. They happily provided us with  information but remained cynical.

“People promise, but seldom keep them!!” they kept repeating. As the IFRC Regional Headquarters were very close to our base and we swiftly established a rapport with their local medical director,  we selected one of  their camps for our pilot project.

(NB: Our one big mistake here was to assume that if the local IFRC Medical Director was happy with our presence in his camp, then his superiors in Baku would feel the same. This was evidently not the case as, some weeks later, we found ourselves the victims of an unexpected verbal assault from the IFRC Country Representative. It took several meetings to soften his misgivings but, eventually, we were accepted and welcomed.)

  • Need:

This becomes obvious just by visiting the camps. In Azerbaijan camp doctors and nurses are drawn from the local population and from within the refugee community itself. Despite their genuine desire to care, their medical training, knowledge and expertise, on the whole, are minimal, so it is wise to exercise caution in applying Western standards to such titles as doctors and nurses.

The IFRC were providing primary health care but no organisation was  providing surgery. Neither doctors nor refugees had money for fees, drugs, hospitalisation costs or anaesthetics, etc; – all these, plus substantial tips, were expected to be paid by the patient.

Our First Case:

This need was identified by members of our medical assessment team and provided a stark example. It came to light as a result of a request from an IFRC camp nurse to visit one of the mud huts in Saatli refugee camp. There the team discovered an 8 year old boy, Mushvig, lying in the dark on a bare mattress. His mother told us he had been lying there for over 4 months suffering extensive second degree burns to his right leg. The leg was found to be green, putrid and necrosing. Mushvig had received no medical help since his family could not afford it. All they could do was watch him as slowly he succumbed to necrosis and septicaemia.

Confronted by this credible evidence the case for some form of surgical intervention was overwhelming. Time and again it was explained to us that refugees without money, requiring surgery, simply die. This proved a hard fact to grasp at first but we later witnessed several such incidents. Mushvig, however, provided us, not only with the real chance of a medical programme but, more importantly,  with a real chance to save his life. To put this programme into action, we networked every useful contact we had

made since our arrival. We borrowed a van and driver from an NGO whose officials cried at the sight of Mushvig’s photos. We begged a Professor of Surgery in Baku to handle Mushvig’s case without charge and we convinced the selected hospital and nursing staff to waive their fees. We had no dressings and, thus, improvised by wrapping Mushvig’s leg in cling film for the three hour journey to Baku.

Meanwhile, we had asked the Professor of Surgery to obtain permission for this operation both from his own Medical Director and from the Minister of Health. We had no wish to offend anyone by not obtaining the required signatures for such a venture. The urgency of this case had necessitated circumvention of the established state and regional procedures which usually encompassed regional referrals to a major hospital.

(NB: This clearly demonstrates the importance of the early meetings.)

  • Limitations and Capabilities:

Following Mushvig’s case, a team of four medical assessors (all volunteers drawn from UK hospitals) were dispatched for two weeks to take medical profiles of over 3600 refugees in two IFRC camps, with a total population of approximately 9000. This health survey presented a broad picture of the incidence of certain diseases and other conditions. As has been mentioned before, the IFRC could only offer primary care and medical problems, such as

the following, were found to be rife.

malaria (treated)

diabetes

respiratory

GI and GU diseases

cardiac

epilepsy

burns

 trauma

fractures

congenital abnormalities

gynaecological

surgical cases

4. ASSESSMENT: 

Strengths:

Our team was predominantly surgically orientated, having access to UK surgeons and anaesthetists who would readily accept one to two weeks secondments to teach and interchange their skills in Baku. Nurse practitioners could also be used to diagnose surgical cases on site, to be vetted later by the admitting surgeon.

Weaknesses:

From such data it was obvious we would be overwhelmed if we agreed to treat every case that presented. Spread too thinly such attempts would prove futile. Economy of scale was also governed by finance, a major factor.

5. ESTABLISHING THE PROGRAMME:  “Fast Track” Referral System:

a) The “Policy Document”:

The successful outcome of Mushvig, the burns case, spread throughout the camps.  We needed to capitalise on this by formulating a “policy document”.  It was evident that without an official document, with the correct signatures and stamps, no cooperation would be given and no programme could be established. Officially, the document was required to state that for all cases diagnosed and admitted for surgery by the Leonard Cheshire Centre (LCC):

  • LCC would be responsible for transport, food, dressings, anaesthetics and drugs.
  • Free medical treatment and surgery, by named Azeri surgeons and other hospital personnel, had been agreed.
  • Free hospital accommodation for patient and one relative had also been agreed by the participating hospitals.

Having drawn up this document, four copies were required to be signed by

the following:

i. The Minister for Health

ii. The Deputy Prime Minister

iii. The leading Professor of Surgery

iv. Senior Medical Representative of LCC.

(NB: No procedure is straightforward. Expect to meet many seemingly insurmountable hurdles. For instance, even though we had the verbal agreement of the Ministers involved, it still took four and eight hours, respectively, of waiting doggedly outside the offices of the Deputy Prime Minister and the Health Minister before we finally received their signatures on the document.  (Determination, as proved here, does, win through in the end! )

From here on, this document was to be our “passport”. It meant we were now credible in both the eyes of government and the regional authority officials. And, as word of our successful programme grew, more hospitals asked to participate.

b) Parameters:

Surgical cases only.

  • Orthopaedic
  • Trauma
  • Hernias
  • Burns
  • Thyrodectomies (toxic only)
  • Undescended testicles
  • Contractures
  • Fibroids
  • Tonsillectomies (recurrent)

With this simple list we believed the programme was viable, sustainable and effective.

(NB: It is important to stick religiously to defined parameters. It is so easy to veer away from them when presented with such obviously needy cases, such as invasive melanomas, etc; We found, to our cost, it is impossible to sustain the open-ended expense of oncology or other chronic cases. )

In camps registering 8,000-10,000 people we diagnosed approximately 30 refugees requiring urgent surgery, i.e. 1:300. With this in mind we effected a procedure.

c) “Fast Track” Referral Procedure:

  • Forewarn the camp doctor to have all possible cases ready for an LCC “clinic” at a preordained time. Communications can be made via the local NGO office.
  • “Clinics” are then held by senior A & E RGNs.

(NB: These “clinics” are held either outdoors or, if more privacy is required, in the camp clinic or camp mosque. When held outside the danger is that many other patients will show up and demand treatment)

  • Cases are then sifted and, approximately, 75% have proved to be medical and, thus, not eligible for our “Fast Track” system.
  • Surgical cases are diagnosed and prioritised.
  • Patients are then given bus fares and put on a specialist hospital list for a future admission date.
  • Back in Baku the relevant operating surgeon is informed the week before of any LCC admissions to his hospital.
  • Any problem cases are discussed with medics back in the UK by email.

Admission to Hospital:

  • Most arrive by bus on their given admission date.
  • Our full-time Baku-based representative (usually a Post-Graduate volunteer) meets them, with the admitting surgeon, at the receiving hospital. Here diagnosis is confirmed, money sorted out and introductions given to the ward nurses.

(NB: It is vital to maintain regular visits encompassing meetings with nursing and medical staff to supervise all treatments and to ensure no problems or abuses of the scheme arise.)

Monthly visits are, thus, maintained by UK-based RGNs, surgeons, nurse practitioners, doctors and anaesthetists.

6) Sweeteners:

“Familiarity breeds expectation.”

There is no doubt about this. In a “post-conflict” country everyone,

surgeons, nurses and other professionals alike, earn a mere subsistence allowance, if they are fortunate enough to be paid at all. Thus, you are bound to receive requests such as, the hospital director enquiring what is in it for his hospital to hints or, in some cases, blatant demands from staff and even some patients’ relatives requiring some form of remuneration. This is understandable but must only be answered with a firm, resolute and diplomatic “NO!” 

Never, never give money, for any reason.

Regular visits by senior UK medical staff can swiftly dispel such awkward situations. This interchange of medical personnel is invaluable.

7) Lessons Learned:

The Recce:

It is worth mentioning again here how essential it is for any organisation deploying overseas not to duplicate established in situ practices, however menial. This may sound obvious and simplistic but it so often happens, mostly as a result of poorly researched, inaccurate or incomplete intelligence.

A short reconnaissance visit, therefore, is vital.  And, to extract the greatest benefit from such a visit, you will need to organise a meeting, prior to your departure, with a Senior Consular Official or the Ambassador, at the host embassy. Secure from him the following:

  • A letter of introduction to the relevant government ministries,

particularly the Minister at the Department responsible for refugees

and humanitarian relief.  For instance, if it is a medical programme

you wish to establish you will require a letter to the Minister of

Health.

  • If necessary, a visa.

(NB: If you or your team members will be travelling regularly, you will need to request a multiple entry visa, preferably at no cost to your organisation.)

Armed with these, on arrival, you have the basis for networking.

IN COUNTRY:

Things you need to do on arrival:

  • Find an hotel.
  • Visit the government offices and make contact with the Health and Humanitarian Departments; using the letters of introduction for access. Don’t give up, this may well take a few days. 

(NB: The British Consulate may speed this up if a problem persists.)

  • Gather information from them and explain the mission clearly.
  • Arrange meetings with NGOs based in the capital.
  • Obtain a map of the refugee and IDP camps.
  • Sort out transport and find a local to act as interpreter,

(preferably one with a car!)

All these points must be met before going “up country”.

(NB: It is worthwhile noting here that accommodation near camps and settlements can invariably be suggested or secured by NGOs or government officials prior to departing the capital.)

Do not forget to ask the government official to telephone the regional mayor of the district to inform him of your plan to visit his area. Such an official can be an invaluable source of local information and networking.

UP-COUNTRY:

  • Keep your interpreter with you at all times. He will also be able to fill you in on local customs and traditions, including etiquette, dress code (particularly applicable to Muslim countries), forms of address, sensitivities, etc;
  • Meet the Mayor and the official in charge of humanitarian affairs.
  • Meet the NGOs
  • Find a base (see later information)

IDENTIFY:

  • Identify camps – population and health statistics.
  • Identify camp management agency – i.e NGOs, IFRC, Umcor, etc;
  • Identify need – existing healthcare provision – which void can you fill ?
  • Identify – your organisation’s capabilities and limitations.

You have now executed a successful mission analysis. What next?

Evaluate your data and start by running a simple pilot scheme in one camp.

It sounds simple, doesn’t it?

letters of introduction

mayoral meetings

interpreters

transportation

communications

NGOs

maps

accommodation

Yes, we finally achieved all this in Azerbaijan, but only after a few hard lessons and only  at great cost to our patience, sanity and time. In reality setbacks were numerous and incredibly frustrating.

However, in order to succeed in your mission, any failure, stonewalling or corruption must be challenged with intractable tenacity and stubbornness. If you stick by the rules, success, in the end, will automatically follow.

Communication was, perhaps, the most important issue for LCC staff in Azerbaijan. At times, due to constant power surges or failures, computer breakdowns and faulty telephone lines, we were unable to maintain regular telephone / fax and  email links, not only in-country, but with our own headquarters back in the UK. This led to many hours, sometimes days, of frustration waiting for answers or approval from our local officials and our superiors in London and this, in turn, led to severe delays in operating on the people requiring emergency surgery.

As has been shown, we also learned from bitter experience to keep everyone, at every level, informed about our activities at all times, from camp leaders to NGO officers, from government ministers to UK bosses.

Disseminating your plans and your progress will help to ensure success and provide a solid and trustworthy base for a positive and supportive collaboration with other agencies.

We have learned hard lessons this way. Diplomacy is the name of the game.

8) And, finally……..Remember!

  • Remember, there must always be an end point. Plan to withdraw

    leaving something in place for your successor.

  • Remember, after you have made a decision, don’t hesitate, always execute it.
  • Remember, never promise anything you cannot deliver. Credibility, always hard fought for, is easily lost. To give false hope is immoral.  Respect is gained by action only, not words.
  • Lastly, never forget YOU ARE A GUEST IN THEIR COUNTRY!

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