Port-au-Prince, Haiti. The city spanning valley and mountain, where art and music are wrapped up in culture yet muffled by the battles that rage and the bullets that ricochet through its streets. Here is a recounting of my first trip to the Caribbean, where I worked as a humanitarian project pharmacy manager. This blog aims to showcase leadership that saw an emergency centre team manoeuvre volatile and violent times.

Lay of the land

Haiti in Taíno means “mountainous land.” This nation, the pearl of the Antilles, was the first to be founded by former slaves. With the conch shell taking a surprising role in the communicating strategy, a republic was born that threw off colonial rule. For many of the Haitians I met, victory still beats in their hearts as they continue to speak for their land and for their survival. Their history has been a patchwork of upheaval, and our initial briefings reminded us of this. Upon entering the country, we learnt of the dos and don’ts in the occurrence of hurricanes and earthquakes, road accidents and barricades, stray bullets and kidnappings.

The day-to-day

As in most emergency centres the world over, our one was abuzz with daily medical activity. Each morning, our medics, nurses, pharmacy and biomedical teams surveyed the tasks ahead of us. Each evening, the metaphorical summit was reached as the clock struck end of shift and the curfew hour approached. This was our daily chance to look back at the scene behind us. What happened today in terms of the security context, staffing numbers, medical supply chains, patient care? For a humanitarian medical organisation, providing good patient care despite the circumstances describes all our intents and purposes. The neonate that came in late last night; did keeping them warm and stable give them a chance at life? The child brought in by a desperate mother; did their treatment for sepsis work in time? The passer-by caught in the crossfire; did they survive their bullet wound? The challenge is the context, there too lies the reward.

Living in VUCAT

Humanitarian organisations may use the acronym VUCAT to characterise their working contexts: volatility, uncertainty, complexity, ambiguity, threats – adapted from the more common VUCA acronym. Threats are constantly present, and described as any event that can have an adverse impact on the organisation. Guiding principles, such as the primacy of life over assets, a proportionality between risk and benefit of operations, and defined responsibilities for every staff member, exist to allow humanitarian organisations and individuals to operate in threatening environments. The following paragraphs describe my experience of VUCAT…

All change (Volatility)

During my time in Port-au-Prince, a critical incident resulted in all medical activities coming to an abrupt standby and temporary closure of our emergency centre. As in my previous humanitarian blog, we had to identify the times and adapt to the situational reality. In times of volatility, where the critical incident impacted the day-to-day of all emergency centre staff, I valued clear communication and direction from the medical lead. In turn, I could clearly communicate and give direction to my team as we figured out what ‘temporary’ meant for patients and staff. Our efforts achieved safe patient referrals to other healthcare structures and coordinated stock inventories and deep cleans ahead of the standby period.

When there are few answers (Uncertainty)

The volatility of our context gave rise to peculiar seasons of uncertainty. During the standby period, increased armed group activity in the capital resulted in heightened security. On the days it was deemed safe to venture forth to the emergency centre, I would discuss with the pharmacy team what could be accomplished during this period of standby. I learnt a valuable leadership lesson, to embrace positive risk. With no patients and no regular stock movements and an unknown timeframe for the period of standby, we risked redesigning internal medical flow, reorganising medical stock, and donating upon request much of our stock to neighbouring health centres.

Back on track (Complexity)

A couple of months after the critical incident, answers regarding the emergency centre reopening came, and they came fast. We were given just over a month to restart all medical activities. The reopening had its complexity, requiring a joint effort to improve on previous ways of working, including the adaptation of patient flow to better suit emergency activities, the redefinition of staff responsibilities, the adjustment of supply chain timeframes. Leadership promoted innovation from combining cultures and avoiding inefficiency from clash of cultures. In a multinational humanitarian team, the term ‘cultures’ could easily refer to different nationalities, however more pertinent at this time were professional cultures. I saw teamwork between logisticians and medics to redefine patient flow, knocking down walls to create separate emergency admission and outpatient clinic entry points; administration and finance helped the nursing managers redefine staffing numbers; supply and pharmacy teams coordinated medical stock flow. Visionary leadership and strong collaboration put us firmly on the road to reopening our centre within the specified timeframe.

Another turn of events (Ambiguity and Threats)

Even with a relatively clear path ahead, a subsequent turn of events changed our course. Haiti declared a State of Emergency in the western region, that of the capital. At the time, this created ambiguity, as it could have meant an escalation or de-escalation of the constant threats and ensuing violence. To be best prepared, the decision was taken to reopen the emergency centre a week and a half ahead of schedule. Leadership involved a change in approach, increased pace of activities and, yet again, clear and this time decisive communication. As team leaders, we all aligned our staff to meet the new goal and prepare for what was to come.

Over and out

This experience introduced me to the versatility medical humanitarian organisations muster when dealing with acute disruptions or destabilisations that could result in significant suffering. I valued the knowledge of locally recruited colleagues as they worked within their environment, for their own people, such that lives were saved despite the challenges of the context. As a leader in the humanitarian setting, it was a privilege to help strengthen the resolve of individuals and watch teams collectively innovate and solve issues to promote good patient care.

Author

Eleanor Harvey

Eleanor Harvey is a clinical pharmacist, with experience working in the humanitarian sector overseas. She has worked for the UK Health Security Agency as Chief Pharmaceutical Officer’s Clinical Fellow – part of the FMLM leadership scheme, where she led projects, co-led workstreams and published research on antimicrobial stewardship and infectious disease outbreaks. Currently, she is a critical care and theatres pharmacist at North Bristol NHS Trust and Editorial Fellow for BMJ Leader. She has a keen interest in leadership and management, and in emergency preparedness and response.

Declaration of interests

I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: None.