Outgoing MSF chief on a rapidly changing South Sudan

JUBA, South Sudan — After 11 years of working on and off in South Sudan, Liz Harding, the country’s head of mission for Médecins Sans Frontières says she wishes she could have done more.

“I always feel like we should have gone into that place quicker or been more responsive or should have seen that coming,” the British native told Devex. Ultimately, Harding says you have to “work with the information you have at the end of the day.”

After 14 months at the helm of one of MSF’s largest operations worldwide, Harding is handing over the reins. In her only one-on-one interview on the record, Harding speaks exclusively with Devex about the challenges she’s faced and insights she’s gained working in one of the world’s most challenging aid environments.

South Sudan is MSF’s second largest operation globally, having spent 84.5 million euros ($98 million) in 2016, following the Democratic Republic of the Congo’s 107 million euros expenditure. The South Sudan mission employed the largest number of staff — with 3,923 people, including expats and nationals — for the organization last year.

A seasoned aid worker, Harding has worked with MSF in Ethiopia, Somalia, India, the Philippines, and Myanmar, and says South Sudan stands out due to its complex and dynamic context, one where the “need is so much in your face.”

In this exit interview, she opens up about her experience coming to South Sudan as a nurse in 2006, one year after the signing of the Comprehensive Peace Agreement that put the country on track toward independence — and what’s it’s been like watching the young nation spiral into war.

What’s going through your mind now that you’re leaving?

It’s quite a separation. This has been so much a part of my life for two years that it’s hard to leave the work and our staff. I also know that I need to be fresh and have a rest and someone else can take over for now. My heart wants to stay but my brain’s saying, no you need to rest.

How do you know when it’s the right time to leave a job like this?

It’s always quite hard to gage how long you should stay. I don’t want to leave with bad feelings or feeling too stressed and you kind of have to feel ok when you leave and not push it too far. I want to continue with MSF, and so this is my lifestyle and you also have to be a little bit sensible as well.

How does an organization like MSF evolve in a conflict zone with restricted access and attacks against humanitarians?

You just have to respond to changing situations. For example, right before I came in 2015, our hospital in Leer, in Unity State, was looted and we had to evacuate. Then we went back trying to set up some secondary health care and it all went wrong again. The sad thing is that it’s not safe for us to open a hospital again in Leer, so we’ve had to use a much more community approach. This means that we have our national staff out in different areas around Leer and Mayendit counties, providing basic nutrition and health care. They provide the care for where the population actually is and they can move if the people move or due to insecurity.

It means that those who feel safe in certain areas don’t have to go to an unsafe place to get health care. The painful thing is that we can’t do it with secondary health — overnight, in-patient care. With secondary health you need a fixed location and it’s a bigger operation, and it’s just not safe right now to be able to set up that kind of facility. You can’t do what the population needs, but you still remain engaged with them in providing some basic health care. It’s hard choices.

How do you keep up with the changing pace?

Our [MSF] independence is not just a nice philosophy; it’s actually the way we do things, so we have the privilege as well to be able to respond when we want, to places where we think it’s important for us to be there. I know other organizations don’t necessarily have that privilege and I think that’s the key to making us effective. It’s about always thinking: What is the situation today that the population needs? Even if you just planned a beautiful intervention, things can change overnight, and you have to be willing to change your approach and your priorities and just keep always on your toes.

How does South Sudan compare to other places you’ve worked?

This is a very dynamic context both from a security and context point of view, but also from a medical point of view. It’s a country that has so many endemic tropical diseases and not just cholera, but you have ups and downs of kala-azar and malaria. Initially when I was here as a nurse and I’d just finished my diploma in tropical nursing at the London school, you’d see everything that you’d been taught.

Then there’s the logistics required to get the operation going. The fact that you have to fly most things in, and there’s many months a year when it’s all wet. So for example, when we had to open up the cholera treatment center in Lankien and the cholera treatment unit in Pieri, that was at a time when we were fortunate that the rain hadn’t come too much. Imagine having to do that in the middle of a big rain when you can’t actually get anything in when things aren’t land-able.

How do you combat the logistical challenges?

You try to always have some prepositioning in the projects so you can always have a way to respond. A lot of it is trying to plan ahead, so knowing that it will be malaria season and making sure you have enough drugs in the country and that you’re always prepared. We know roughly times of year when the diseases should happen, but if you have displacement on top of that, you have added complications and suddenly you have things like cholera. We had this in Bentiu. It started last October but didn’t finish until halfway through the dry season, which is unusual for cholera. Sometimes due to the situation it changes the dynamics and you can have certain diseases when you wouldn’t actually expect them.

What is the biggest challenge you face here?

Having to react all the time to changing either context or diseases or population movements. It just becomes part of your regular work life, and you think, “OK this is happening in this project so we need to send more stuff in.” Even now we’re looking at the dry season and we’re looking to see how much stuff we can actually preposition in the projects to be prepared for the next rains when they come. It’s a constant challenge, but it’s the most amazing people and you can really see the effect of what you do every day.

What’s one story or moment that has greatly impacted you?

When I was a nurse in Leer in 2007, if I think now of some of those staff I was working with at the time. Some are in the internally displaced person’s camp in Bentiu and they’ve been there for three and a half years and still aren’t sure when they can go home. Having met them again in Bentiu, nine years later and having talked to them about what they’ve been through and what it’s like to live in the camp and the things they’ve seen, they can’t go back to a normal life. They’ve all lost so greatly and that’s really impacted me a lot, because it’s people that I knew from previous, more stable times and then met them again in different circumstances. Our staff is amazing the way they cope and adapt. It puts our adaption to shame.

How do you feel watching the country go from what it was after independence to what it’s become now?

It’s really hard, particularly knowing that there was so much hope at one time, and it’s tough to deal with. But the toughness I deal with is nothing compared to the toughness our population and our patients and our staff have to deal with. I just feel that we still have a big job to do in this country making it a little better for the population and our patients, and that helps. With the way that we’re able to do things in areas that we’ve been working in for a couple of decades, that also helps us to remain here. Of course you have your days of huge frustrations as in why am I doing this, but overall it’s actually quite positive and I’ve really enjoyed my time here.

MSF has said “we’re doctors, not politicians.” Is it hard walking that line in such a charged context and how do you balance your public responses?

We try to tell the story of what it’s really like, particularly for our patients on the ground. It’s telling their story — whether it’s in a cholera outbreak or if they’ve just been displaced and had to walk three days to the protection of civilian site. Those are the stories that we really need to focus on as they’re quite often not told as much.

In general, we stay away from the politics, but it’s a very hard line to walk as you also don’t want to dilute what’s happening and you don’t just want to brush over the politics either. Whether it’s politics, context, or natural disasters, there are always as many causes to the situations where we find our patients in. It’s very hard to say who did what to whom. In this country, it’s particularly complex and that’s why, personally for me, I stick more with what’s actually happened. For example they’ve just been displaced and they’re in an area and there’s no services and no health care, no food, children are getting malnourished — these kinds of stories have a really big benefit.

What advice would you give another head of a mission in a similar context?

Be as reactive as possible. Plan for what you know might happen and then day-to-day prioritize as much as you can. Set priorities, as in “these are the things I really want to respond to.” So for example, displacement due to conflict is one of the top things on our list and keeping that in mind is important.

On a pure human side, make sure that you take your time off because some days you can feel like you’ve done a week’s work in a day. Take the calmer days when they happen, as it’s not crazy every single day, but is most days. I always tried to take a day off a week and I managed most of the time. If something can wait for Monday morning it can wait till Monday morning.

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