Suddenly…Sudan.

in the airport, finally on my way. i have been waiting for a beginning for some time, not knowing where or when it would come. it’s here. it starts now.

in my mind, i thought it would start three months ago. i went to germany to train with médecins sans frontières (msf) last october, and during that time, colleagues were getting phone calls: “can you do nine months in northern sri lanka? immediately?” many of them had missions coming into the training session. i assumed that i would be off like a shot, the day i said i was available.

i wasn’t. i have been waiting. for the beginning. i packed up all my things, and without a place to live, took myself to brazil for november. no word. came back to toronto, convinced close friends to take me in, and worked in the ER over christmas. still no word. two weeks into the cold canadian january, just as i was reconsidering both my plan and my sanity: word. word up.

i knew as i was waiting that i would realize at least two important things. first, that the time would be fonder in my memory than it was to experience. true. and it will become even more so. i have spent hours with people i care about most in the world and fully participated in every moment because i never knew when the next one would come. i am grateful for each. thank you.

second thing. “be careful what you wish for because you just might get it”. wise words. i said i would go anywhere, that i wasn’t afraid of being isolated, that i had a wide complement of medical skills and can do a little of everything. i could work in a small team with little back up, and improvise if necessary. that if there was any time in my life where i could go to a place what required close attention to security, now was that time. no wife, no kids, no debt. no one waiting for me to get back.

so, i wished, and then got it. i am off to sudan. a small town in the middle of the country, right on the border between north and south. for those with a grander memory of the struggle there, you will know that it has been at war for many years. much of it is between the south and the north. it is a conflict about resources. and allegiances. and history. darfur has become a media story, particularly in the past two years. and there the war rages on, and the fighting is vicious. but sudan has rarely been at peace since its independence in 1956. it has more people displaced from their homes, because of conflict, than any other place in the world. many of them are from southern sudan where war still smolders. they feel deeply the effects of chronic conflict. it’s like a chronic disease. one wastes away from thousands of tiny insults.

the place that i am going is called abyei. you can check it out on google earth. it looks like a smudge in the sand. it sits at the troubled crossroads between south and north, in an area claimed by both sides but owned by neither. tensions, i have been told, are high. i will be working in a small hospital with a small team. aside from that, i know little else. i will find out more this week, in geneva.

boarding now. i learned something else these past few months. that one shouldn’t think with certainty about the future. it has helped. right now i don’t know how long i will be away, nor what my days will be like. i will let you know as i do and send word when I can.

change can only happen, in the world as in ourselves, with some amount of insight. i hope that during these next six months that i am afforded some about sudan, as a part of our world that is happening right now this very second even now. if I am lucky, maybe i can explain it well enough that i might understand.

that’s it for me. boarded. wine service. better take it when i can get it. soon, suddenly, sudan.

james.maskalyk.md@gmail.com

feb 13 day 2 of briefings in geneva. my passport sits with the Sudanese embassy. there is a 90% chance I will have permission to travel by Friday. a midwife from italy, destined for the same mission, has had her visa with the embassy for weeks and still has no approval. it is important for me to get to sudan as quickly as possible. the doctor I am replacing is due to leave soon, and our paths must cross. she needs to give me the crib shit for abyei, about how to make things work.

I have learned some more about abyei. 60,000 people. it sits neatly on the border between north and south sudan, and is one of the areas where tensions are highest. a peace agreement signed in 2005, the Comprehensive Peace Agreement (CPA) has allowed this area to be governed under “joint” rule by the two signatories, the Sudanese People’s Liberation Army (SPLA) and the ruling National Congress Party (NCP). some claim that the CPA’s Achilles heel is that it focuses to squarely on the division of resources between two groups. there is a referendum in the future that will determine whether areas like abyei will be governed by the north or the south. some suspect the peace will not hold until then.

there is much more, but I want to try and keep these short. the situation in this area of sudan, like in darfur, is very complex. it is msf’s policy to be completely independent. already there is some concern that we are being perceived as partisan. to ensure access, and for safety, it must be clear that we side only with the sick.

to the sick. I saw an outline of the hospital. and a breakdown of patients seen. lots of malaria. some malnutrition. no meningitis yet, but an outbreak is consuming the south. kits have been ordered but haven’t arrived. there was some wounded brought into the hospital a couple of weeks ago, and I have been asked to make sure there are contingencies to treat a large number at the same time, if necessary.

though I saw the outline of the hospital, i still can’t see it in mind. when I try to imagine what my day will be like a week from now, I don’t succeed. every time I try to stare at it, I ricochet off to after the mission to those familiar feelings of return. about how straight everything in geneva will seem. and square. and clean.

I have a few briefings tomorrow, and have to visit the hospital to get a final check up. I’m anticipating that it will be done in some type of amazing hi-tech 007 medical lab where anything is possible. i am going to ask to be made taller. if they refuse, I am going to ask for super hearing.

feb 14. the doctor’s appointment went well. it was just as i imagined, very secret, lots of lasers. they couldn’t (or refused) to make me taller, and all they had in cybernetic enhancements was super taste. so i got it. i am tasting things that i had three months ago. jack, i had forgotten how delicious that stew you made for thanksgiving was. amazing.

still waiting to find out if my visa will be ready by friday. apparently it requires one more signature. if it is ready, i will travel to khartoum very early on saturday morning. since the day of rest in sudan is friday, it will be the equivalent of arriving at the beginning of the week. i am hoping to get to the field as quickly as possible so that i might get handover in abyei.

the midwife had her visa refused. she is on her way back to italy. apparently the government is happy with the quality of deliveries and feel that there is no need for any further expertise. wait until they get a load of me. the red carpet will stretch all the way to italy. i do have a few tricks up my sleeve. one of them is that trick with the fake hand, where you greet the woman and say “hi, i’m doctor maskalyk” then turn away leaving her holding the hand. i use it to try to scare them out of labour. it rarely works, but is worth a shot.

i have delivered about 30 babies in my time, and will be delivering a few more in abyei. it has been a while, though. a straightforward delivery is as easy as falling down. the biggest issue is how to deal with obstructed labour, when a woman needs an urgent c-section, or continues to hemorrhage after delivery. luckily, there is a surgeon a few hours away. to this point, the field has orchestrated a few transfers a month for maternal problems during delivery.

i had hoped i would get to khartoum every six weeks or so, for a couple of days of R & R, and to send some pictures of abyei, but i have been told it is too far. i will see what i can do.

a friend sent me a link describing canada’s recent pledge to begin the repair necessary in south sudan. sweet.

feb 16. my visa has come through. i am going to pick it up in a few hours, at the end of the day. i leave tomorrow at 5 am for khartoum.

i thought the beginning was last week. now as i get closer to africa, and closer to abyei, i realize that it won’t begin in earnest until i lay my suitcase down in the small room i will have in abyei, and take from it the few things i brought from home. some clothes, some books. pool table.

trying to laugh because i am a bit nervous. it is a similar anxiety that i felt when i did my first overnight shift after graduating from my emergency residency, when i realized that i would be the only MD in the emerg, that i was responsible, and anything could happen. after a while the feeling faded. i realized it was better just to walk into the emergency and not even look how many people were waiting, or how crazy it was. it didn’t matter. just do what you can and work through the night until it is time to go home and sleep.

so i’m working on that right now. i’ll just do what i can. and just like the evening before that first night shift, all that i can see in my mind are the challenges, and none of the rewards. and there will be many. by the time i am done, and i will remember to report on it, i wager that they will far outweigh any hardship.

this morning, half asleep, i stumbled into the hallway of my tiny hotel
and ran headlong into a man my age holding a toothbrush. “dentifrice?” he asked. i returned to my room and found him some toothpaste. we chatted. he was with msf too. most of us in this place are. it’s like a halfway house. we are either halfway gone, or halfway home.

he is a logistician. he was on his first mission in guinea conakry, but was evacuted a few days ago, after only two months in the country. guinea is at war with itself. the government has recently imposed a 20 hour curfew to deal with increasingly violent protests. MSF treated 275 wounded in the capital over the weekend. i remember sitting in on a meeting earlier this week, as the office talked about various projects. guinea came up. there was positive news. msf would be allowed to move around the capital from 10 am to 6 pm if they flew their humanitarian flag. i don’t know what has happened since.

[More Info: For an update on Guinea and MSF's action there, click here to read the full news release]

he turned towards his room to brush his teeth and to pack for home. “what now?”, he said, “no plans. no idea. good luck to you.”

just do what you can until it’s time to go home.

i will send word from khartoum. have a lovely weekend.

feb 19. i arrived in khartoum two days ago. the air temperature when i stepped outside was 30 Celcius. i have been told that we are about to be entering the “hot” season, where temperatures in khartoum climb to 50 C during the day, and cool off to 30 at night.

i haven’t seen much of khartoum. the MSF office is not far from the guesthouse, about a ten minute walk. well, ten minutes unless you assure the head of mission of your impeccable sense of direction and insist that you can find your way without using a driver. in that case, the walk is approximately one hour.

my day has been full of details. i have received a more refined account of the social and political environment of abyei, discussed security procedures in the field, and today, am receiving a more specific medical briefing.

in brief. well, depending on one’s definition of it. abyei sits in a political vacuum. it is mentioned in the comprehensive peace agreement, but its final division, between north and south, is yet to be determined. at present, it is home to primarily two populations: the masseria from the north, and the dinka from the south.

the town itself has increased in population from 5,000 to 25,000 in the past ten months or so, mostly dinka. with cessation of conflict has come an opportunity for people to return home. the influx of people is less than anticipated thus far, but it is expected to continue. and with it, an increased need for medical care and a potential for outbreaks.

i have been told that there is a measles outbreak in the abyei area, and that we need to mobilize a vaccination campaign. further, we are anticipating that the meningitis outbreak [More Info: Meningitis Definition & Treatment] in the south will soon find its way north. i am asked to be vigilant with case finding, for there may be a need to organize mobile meningitis vaccinations. there is also a problem with the water supply in town, and for the hospital. there is enough, but it is not clean. we are hoping to get a water and sanitation expert to visit the town next month. some here are surprised that we have avoided a cholera outbreak thus far [More Info: Cholera Definition & Treatment].

much of my work will take place in the small hospital. jean, the medical coordinator with whom i just met, says of it: “it’s what you would expect of a rural, remote hospital in africa. not much. but still pretty good.” no x-rays, a small lab, direct blood transfusion (from family to the patient), about 30 beds.

there are two referral hospitals three hours away that have a surgeon. one is built by the oil companies in the area, and the other is managed by an NGO. if i receive a woman with obstructed labour, and can’t manage her in abyei, we transfer her to one of these centres. similarly if i receive any gun wounded, or traffic accidents, that need an operation and can survive a three hour ride. for those that cannot, or need more sophisticated operations on their head or their chest, there is nothing that can be done.

it is dusty here. and windy. not a cloud. i am having trouble sleeping. not just from the heat, but because my head is full and my mind too active. i wonder about things i cannot know, like how i am going to recognize my first case of kala-azar, or how i am going to arrange transfer for half a dozen injured patients that i may never see. i have gone from not thinking about the future to completely inhabiting it.

i leave on wednesday, on a world food program plane. i am told that i can bring 15 kg of luggage, including carry on. i think i have 15 kg of peanut butter. i might have to leave my bowflex in khartoum. crap.

off to lunch. i need to winnow down my peanut butter stock.

feb 20. i leave tomorrow for abyei. i will be flying on a world food program plane at 9 am, and arrive shortly after.

most often when i mention that i am going to abyei, people are not familiar with the area. i am hungry for someone to say “abyei? wow, great place. you’re lucky.” once or twice this has happened. it made things a bit brighter. easier to see.

today, when i was registering at the canadian embassy, the woman answered “abyei? they are talking about abyei this week, in the government. they are going to discuss the borders. again.” i suspect consensus about boundaries will be difficult to reach, and hope that the agreement on peace is easier.

the office is being locked and with it, my instant connection to the larger world outside sudan. i am anticipating it, and the focus it will provide, with my entire spirit. the story starts in earnest.

peace be with all of you.

[More Info: Sudan: Abyei Boundary Commission report]

bio: James Maskalyk is an emergency physician and, when not in the field, lives and works in Toronto.  He was stationed with MSF in Abyei, in a small hospital that sits on the contested border between North and South Sudan.  This was his first field mission with MSF.

feb 22. made it.

i left yesterday morning, very early, to board a UN plane at the domestic airport. i was told to pay attention to the shouted arabic boarding announcements because worthier souls than I had been left behind holding 15 kg of carefully chosen luggage.

the luggage restriction proved not to be a problem. while I checked in my essential bag, I asked my driver to stand behind me and hold my equally heavy second bag which was never weighed. I had a small fleeting fear that the undeclared kilos might send us hurtling towards the ground in a thin metal airplane shell, gasless, just because I wanted to haul Ulysses around the world for the fifth time. still, we made it. my copy of Ulysses now sits proudly on the window sill of my tukul, fully confident that it will leave it as it came, its spine strong and unbroken.

there were six passengers in a plane that held twelve. as we left
Khartoum, and banked sharply over the turbid water where the blue and
white niles meet, the airport looked like a UN parking lot. so too El Obeid airport where we stopped to refuel. I am told that the MSF mission in Sudan is the most expensive in the world. I suspect the same is true of the UN.

the landscape from the sky was austere and beautiful. the earth was
flat and red and cracked. i could follow the paths of rivers only by the stubborn trees still clinging to dry banks. it seemed they were living only on the memory of the energy that once flowed to them. bits of nitrogen from dead grass, or bugs, or dropped seeds. their persistence was admirable because again, the sky was only blue and clear. I saw one small embarrassed cloud on the horizon, but it didn’t stay long.

I had the distinct pleasure of sitting and talking with a Sudanese woman
who was visiting abyei to talk to the community about how it might, one
day, own its own resources. she was born in sudan but spent many years in Saskatchewan. we laughed about coincidences; not only we were Canadians, but prairie folks. She returned to Khartoum in 2003, with her 10 year old daughter. “either you will love sudan, or you will hate it. it is a difficult place to love. but I do.” when I asked why she came back, why she left Canada for she loved her life there too, she answered “…in my heart, I am a nomad.”

[More Info : Plus des renseignements sur Soudan par MSF Suisse - en français seulement!]

we talked about sudan, and about peace, and about living. when we had finished, when neither of us had any more to say, I turned to look at the red ground below. as I watched it pass, criss crossed with dry rivers and camel paths, I had a moment of realization where I recognized that my understanding of the world I live in went up by an exponent. she helped me distill a complicated crisis in a complex country into a story. it was like crystallization of a super saturated solution. I want to talk more of it later, but have neither the space nor the time.

the rest of the flight was silent. abyei snuck up beneath me with no warning. then it was gone. “ I think we missed the landing strip”, a passenger said. “I think they were checking it for cows”, I answered. it turns out we were both wrong. it was goats.

a dirty, dusty, rumbling landing, and I was there. here. for those who don’t know exactly where abyei, sudan is, I will draw a map. the X marks it.

right in the middle.

I will spend some more time later talking about my hut, its 5 x 5 metre cement walls and its straw roof, how it captures heat so well, and… actually, I don’t think I will spend any more time on it. that’s pretty much it.

I will talk more about the hospital, because I just finished my first day. I am getting handover from the departing doctor, amina. she is excellent. my last question to her today is “is everyone always this sick?”.

she has left for the hospital again. the last patient she and I saw, a
child, is not breathing well. his oxygen saturation is 50%. if there was a hospital we could send him to, to put him on a ventilator, we would. the nearest is 3 hours away and the roads are not safe at night. she is one of three patients I saw today who would have been cared for in an intensive care unit in Canada.

but, more about that later. and about the team here, and how they seem the best kind of people. and how it´s so dry that one doesn´t need to towel off, he just needs to wait 30 seconds. and of ali, the sudanese doctor, who i like already, and how he takes pictures of the moon.

and more about abyei, the town. its braying goddamn middle of the night donkeys and barking middle of the night damn dogs. its lovely people,
and dustdustdust. and, importantly, how despite its innocent shy surface, it offers us the best lens to look at the prospect of peace in sudan. it’s a supersaturated solution. but, I guess that’s one of the reasons msf is here. it’s sure not the middle of the night damn dogs.

p.s. the subject heading is an excellent book by a white zimbabwean about the war she lived through. bracing, and beautiful in equal turns. read it if you can.

[More Info: the book that James mentions is a personal memoir by Alexandra Fuller who grew up during the Rhodesian Civil War, and post-colonial Zimbabwe. Fuller went on to study at Acadia U in NovaScotia. The book is called "Don't Let's Go to the Dogs Tonight : An African Childhood" and is available through commercial and online book retailers]

feb 23. today, Friday, is the traditional muslim day of rest and the day off for this MSF project. however, there is little distinction between the work and any life outside of it. at 7 pm, we are still talking about the day that just passed, at 8 pm, our plans for tomorrow. it is our last words before sleep, and our first on awakening.

today, on my day off, I was woken by the nurse, andrea, from Switzerland.

“james? james?”

I throw the mosquitoe net from my face, and abyei rushes in.

“yes.”

“you have to go the hospital. there has been an accident. six or so casualties.”

“alright.”

I had spent much of the night in the latrine or lying on the ground outside of it. my head was banging and unclear. I grabbed some water and tried to drink some on the way to the hospital.

within three minutes I was at the front doors, and pushed past the large crowd gathered around them. inside was no better. the difference was I was surrounded by men in military uniforms. one of their trucks had crashed into a car, then rolled over. six people were hurt, one of them run over by the wheels of the truck. another was badly injured by the glass. every time I tried to move from one room to another, to get some idea of how many patients we had, I had to negotiate a dozen shouting men and women.

the situation was quite tense. there were other injured people, from a different tribe, and a different area. at one point, I am told, someone pulled a knife. I didn’t see it. I was too busy examining and stitching and being dizzy. at one point, I found myself alone in a room with some of the militia who were insisting that their injured soldiers needed to be transferred to Khartoum. by airplane. I started to explain the difficulty, about how we transfer only if it is life threatening, and never to Khartoum. we simply can’t. they did not accept my explanation. I was well out of my league. thankfully, my field coordinator, fran, entered and assumed the role of negotiator, taking the heat off of me. I went back to splinting and sewing.

I returned back to the compound several hours later. I have just heard that the military has taken two patients from our hospital, and were taking them elsewhere. unhappily.

I am here now, typing in my tukul. it is 39 C in the shade, hotter in here.

I have been here for 2 days.

the girl I spoke of yesterday, the one with the noisy breathing, who sounded like each breath was her last, she is getting better. she breathes silently. when I waved hello, she ignored me. she is ten. that is normal. yesterday, she wouldn’t open her eyes.

the thing that has me terrified the most, since I received my briefing on my arrival, is not the political situation, nor the risk of getting ill myself, nor the remoteness, nor the lack of resources. it is that, on Fridays, our kitchen staff has the day off, and we must cook for ourselves. cooking is a thrill in [Toronto's] Kensington market. you can barely find the Jamaican allspice amidst all of the organic lemongrass. here in the local souk, well, there are tomatoes. onions. goat. ummmm… i’ll let you know.

I found out that an NGO nearby has wireless access, and that i can go sit in a car on the road, and use it. I hope it works. if it does, I encourage you to send me word if you can. it has been nice to hear from some of you through the blog. all the comments are forwarded to me. again, as usual, you can email me at the MSF satellite here in abyei.

may you all find some quiet this weekend.

feb 26.today, i woke early, determined to run out of town and find a bit of space in the flatness that surrounds abyei. at 630 am, the sky was still dark. as I ran, past the trucks and buses leaving for El Obeid or Khartoum or Juba, full upon full of beds and blankets ontop of beds and blankets, dawn happened. but the sun never rose. not past the meniscus of dust along the horizon. a windstorm had lifted the sudan sand, and it covered not only my tukul and abyei, but the wide sky. by 8 am, the sun was only a gauzy ghostly hole, the color of beeswax.

today, when I was doing rounds this morning, and I was figuring out what to do with a young boy who developed a fever after a run with measles, a boy who I had already stuck a chest tube in his side and two needles in his back to try and drain a large collection of bacteria, as I was deciding whether we should stick more things into his chest or send him to another hospital or if he was going to die, and just as I was hearing that today, already looking like bones glued together, today he started refusing food, I looked down and beneath his bed was a butterfly, white wings with black mosaic, struggling to right itself on the floor but spinning in circles and circles, broken.

today, a whole rash of measles. twenty patients in the last week or so. I had it as a child. so did my brother. I have no memory of it. all I have are pictures about how miserable we both looked. I have no idea why we have these pictures. perhaps in some kind of memoriam of how sick we were, but more likely, we just sat still for more than 30 seconds. people sit still with measles because they don’t want to move. there eyes get infected, their skin flakes, there fevers are severe. measled. miserabled. that’s how my brother looked in the pictures, and that’s how these patients look. but we make most of them better. and we are organizing a campaign to vaccinate thousands. they are some of the sickest people in the hospital. you learn early on in the refugee business that if you have thousands of people together, the first thing you do, before plastics sheets and protein, the first things is to vaccinate against measles.

today, on our rounds, stopping by the miserabled, we found two girls who came in on the same day: achol kwol, and his friend, kwol achol. though we set up a measles tent for this latest surge, people refuse it because it is too hot. sudan sleeps outside these days. achol and kwol were not exception, but by moving around, they had lost their hospital cards. “which are you? achol or kwol? achol? no? kwol? which? achol kwol? the other?” by the time we were done, they were as uncertain as we were.

today, a baby died about ten minutes after coming into the hospital. she was dirty and covered in grass. the family came from far away, and asked if knew somewhere nearby where they could bury her. i said I did not. they thanked me and left.

when people I see in the hospital talk of where they are from, they answer in days. “three days away”, some say.

people here make small cuts in their childrens faces, and as they grow, their scars form elegant angles. they look beautiful. and severe.

I admitted a boy from two days away who had such severe dehydration that he tried to suck on my stethoscope as I listened to his heart. today he is better. he gained a kilogram in 16 hours. from 5 to 6.

there is a little girl here who the staff are so fond of that I think they are delaying discharging her because they would miss her too much. she is always between your legs, and crawling onto your lap. if it comes to me, I am never discharging her either. her mother stays happily too, as thrilled as we are to have someone so delighted so close by.

there is a falcon that sits on my tukul and pierces the afternoon with his high whistling cry. before they knew I was coming, they fed him bits of meat and named him james.

I must return to the hospital. already, it is a well worn path. I am going to take some pictures in the next few days, and send them so you can see what I am talking about, of abyei and some of the miserabled if they agree. if not, then of the hospital.

I am sorry I haven’t updated in the past few days. trying to find the time is occasionally difficult, as is sitting inside when it is 44 C. I believe that you can sign up for RSS feeds that tell you when something is new.

and, of course, if someone is reading this, tell me if something is new with you. no details are too banal. I am hungry for them.

Feb 27. That is not far from the truth. Today I have seen and admitted six cases. The tally would have been seven, but the family of a young patient lived just a bit too far away, and he died from measles complications before I got to the hospital this morning.

(Lizard in my tent. In fact, there are several. I can hear them rustle in the straw when I am in bed.)

The miserabled are exceeding our capacity to hold them, certainly to isolate them. Until yesterday, they occupied the veranda of one hospital ward. Yesterday, they started spilling onto the lawn. They ignore the tent we have set up for them because it magnifies an already aggressive sun. Yesterday I baked a cake in the tent. I made it from nutella. It was delicious.

Sporadic measles cases have popped up in other inpatients. Families mix freely in the hospital and it is not uncommon to have the patient share his bed with three relatives, sometimes more.

I am often asked why I ended up choosing MSF from an armada of medical NGO’s with whom I could work. For many reasons, but none more compelling than this one. At our morning meeting, I wondered aloud to the rest of the team about our space problem. A decision was made to do something about it. By 2 pm, there were six men in the corner of the hospital compound, and by 5, they had built a shelter that would house 20 patients. We also decided to find a nurse, hire one if necessary, and devote him or her to measles care. Within the day, the will was found, the money, and the hands. We did not need to add it to the agenda of another meeting, nor to a paper pile of requests on an administrative desk. Within hours, it was hammers and nails.

(Bilal call to prayer. Five times per day, I think. The first is at 6 in the morning. I think there are two competing mosques. They battle with volume. It wakes me, but somehow, it is not so bad.)

Unfortunately, as much as we like hammering things into place, sometimes nails are tough to come by. In this case, it is vaccines. My head of mission is in the next tukul with my updated measles register, trying to convince Khartoum that there is an epidemic. The curves certainly suggests it. And we have mobilized a dozen people, three cars, , bought bullhorns, hired translators, pored over maps, made site visits to places even closer to the middle of nowhere than abyei, been refused by broken bridges, and turned back by soldiers. Vaccines. Release the vaccines. Abyei has learned all that measles has to teach. Me too. Neither of us need to learn more hard lessons about life, death, and preventable disease. We get that one.

[More Info : Basic Guide to Measles and MSF vaccination programs]

My radio crackles beside me. I am on call to the hospital tonight, and am responsible for it all nights. And all days. I thought I left this call business well behind me, that I could just carry it around as a kernel of pride. “oh yeah. 30 hour shifts, I’ve done that. It’s not so bad.” It was bad, OK? I admit it. Didn’t like it at all. Uncool.

But, speaking of uncool, and its opposite, the coolest…..here is the real reason I work for MSF. Radios. The coolest. I really, really get to say almost every day: “Roger. Good Copy. Over and out.” It’s amazing.

Pictures. By Friday evening.

Feb…wait…March. the first of March.

We are so fragile when we are new. Something in our physiology or our spirit isn’t convinced that the outside, so cold and bright, is worth the breathing.  After the first seven days, most of us find something to like and our breathing gets easier.  But those first seven days. We sit on the fence and a breeze can knock us down.

So much more true in places like Sudan.We die commonly, from infection, or because we are too early, or because the mother is as far from a hospital as you and I from mars. If one cares to look at infant mortality rates, you can see that western Europe, North America, Australia and, somehow, Cuba fight for the lowest at around 5 per thousand. Poorer countries like Mali, or Mozambique, suffer with the highest. The latest data I have with me shows an infant mortality rate of 181 for every 1000 babies born in Sierra Leone. Nearly one in five babies doesn’t make it.

This afternoon, as I was gathering some motivation to take a young boy to our operating theatre (it sounds more grand than it is) and remove some of his burned skin, I was pulled aside. The nurse pointed at a woman sitting on the ground. So what. People sit on the ground here all the time. Most of the time I don’t know who they are, and assume they are one of eleven necessary relatives that accompany most of our patients.

“She was seen at the outpatient department. I think it is her baby. It is two days old and not breastfeeding. She was told to go home, and to come back another day if it didn’t improve. But she says she is too tired.”

I walked over. The woman was very tall, her forehead marked with sloping scars. I asked her, through my translator, what the problem was.  She handed me an outpatient card. It read: “Breastfeeding Problem”. Beside it was a temperature: 37.8. It was unclear if it was the mother’s, or her child’s.

“how many children has she had?”

“this is her fifth.”

That is the most important question you can ask a mother who comes to
you with child problems. New mothers are, well, new. Everything is a cause for concern. A woman with four babies does not walk for hours to find simple answers.

I asked to see the baby. Pale. Sleeping.

“Has it been sleeping like this all day”.

It had. I listened to his heart. It was beating too fast. About 190 times per minute.  His breathing was too fast. And every now and again it would stop. One one thousand. Two one thousand. Three. Four. Five. Six. Sev… He was swaying on the fence, trying to decide.

I went into the nursing station and asked the mother to follow. I asked for the nurses to start an intravenous, and prepared to put a cannula in his shinbone if it failed. They succeeded. I took saline and glucose in a syringe and pushed it in slowslowslowly. While I was doing it, for the first time, he opened his eyes. He looked into my face as best he could with new retinas, and slowly closed them again. The odds, in my estimation, fell.

Oh. Must go. Radio. Hospital. Writing time over. Over.

Fragile when we are new. I was called to a complicated delivery. The baby was presenting with her hand over her face, in a premature swoon, an “oh great, what have I gotten myself into this time” pose. She delivered before I arrived. But she has a brother or sister not far behind. Twins. He/she is coming out foot first. If they live, I wonder if they will get along. Already they seem so different.

I think they are too new. This first one was small enough you could fit her comfortably in a lunchbox. She has the most tiny, perfect fingernails. Her heart, no bigger than a cherry, tapped in her thin chest. You could feel it.

Time will tell for her. And for her twin, who will be making his first appearance in the delivery theatre.

Next week, on delivery theatre, the triplets of abyeiville.

I will let you know how all three do. For me, though I would like to write more, I am going to bed. It is my day off tomorrow, which means I start work an hour later. Sweet. Night. Lights. Out.

this is my tukul. there are many like it, but this one is mine. it’s door is four feet high. i have made it part of my morning routine to clip my head on the frame on my way to the shower.

march marches.

“may you live in interesting times” is one of the greatest curses. the measles vaccines have arrived. 43 000 doses. they sit in…wait, they should be in the fridge. so too the diluent. we must get on that.

while we were setting up traditional “recubras” for our measles patients, we were setting up tents for a vaccination campaign command post. three large tents. one for equipment, one to house the extra team members flown in from Geneva, and the other to plaster with maps and strategies. a plane arrived in Khartoum on Saturday carrying 4000 kg of cargo for the measles emergency. they arrived by car in abyei last night.

I just ran into the MD in charge of coordinating the vaccination effort. I asked him if he wanted some of our peanut butter based salad, or if he preferred the peanut butter spaghetti sauce. “no, I can’t eat. I am too nervous. if I do, I’m going to be sick.”

all week we have had members of the ministry of health, UNICEF, the World Health Organisation, Save the Children, and more, tour our compound, our measles HQ, and the measles patients. there were concerns about our data, our assessment of the problem, and our plan to intervene. some from members of our own team, some from the other NGO’s. perhaps we should delay. “no, we start on Wednesday.” but… “Wednesday.” what if… “Wednesday.”

tomorrow is Wednesday. interesting times. we have made it part of our campaign to screen all the children we vaccinate for malnutrition. one of my responsibilities (in addition to supervising the hospital and all the patients in it, being on call for emergencies 24 hours per day seven days a week, running the tuberculosis program, keeping statistics, and training staff) is the therapeutic feeding centre. the TFC. because the population has quadrupled in the past year, there is a food shortage. there is one harvest a year, and it happens at the end of the rainy season. that will be in September or October. abyei is about to enter its food gap, and starvation will worsen.

if we vaccinate 35 000 children in the next few weeks, and we find 1% severe malnutrition (a local NGO estimates it at 3%), that will mean 350 children, perhaps ½ under 5. we will offer all transport to hospital. if ½ are under five, and ½ refuse, we still might end up with 80 more children in the TFC. right now we have ten. interesting.

so, that’s what MSF talks about over lunch, and that is why there is reason to be nervous. 80 children. it would double our current census, measles patients included. what about latrines? showers? kitchen? where would they sleep? who will take care of them?

right. the max capacity of latrines is 20 people per. we have five. we can build more. we’ll send a car for more gas and stoves. build another shower. we shouldn’t put them at the front of the hospital because they would be vulnerable to fighting or the chaos of a big accident. so they go in the back. away from the TB patients and the measled. ok. we’ll set up some shade netting. no, they don’t like. they like recubras, the huts. fine. big hut, back of the hospital, put starving kids in it. more latrines, a shower or too.

this could start tomorrow. Wednesday. ok. maybe we’ll get there and the other NGO’s data will be crap. everyone will be so stuffed they can’t even waddle to the front of the vaccination line. so let’s wait and see. then move fast if we have too.

our logitician spoke up. well, maybe one thing. those y-shaped sticks, you know the ones, that we use to make the recubra. they are hard to find. people have to travel to get them. we should go to the market right now and buy as many as we can so we are not scrambling tomorrow if we need them. I’ll do it after lunch.

that’s MSF. we’ll sort it out as we need to. except for the y-shaped sticks. today it’s all about the y-shaped sticks.

we are overflowing… with people running from place to place, so nervous they can’t eat, but so too our showers. compound 2 has 20 people staying in it. one latrine. the WHO maximum, per latrine. today we starting calling it “camp 2″. we mentioned all this to our logistician this morning and he added the requests to an already long list.

logisticians make things happen. if it wasn’t for them, the rest of us would be standing knee deep in dust, waiting to get started but not sure exactly where we should begin nor how we would get there. we add things to their list, and put request forms on their desk. yesterday I put one on Gilbert’s desk for “world’s largest emerald”. he didn’t mention it today, so I hope it is on its way.

I am on my way. to a meeting about the feeding centre. here is how I am going to start it off: “so, what the hell are we going to do?”. I’m going to use the “y-shaped sticks” idea that I stole from Gilbert at lunch as my contribution then shake my head disappointingly at other ideas. all md’s secretly want to be logisticians.

march 4. wow. yesterday was crazy. while trying to find some time to rest, just away from everything, a moment to myself the radio called me to the hospital. the ministry of health was touring and they wanted to see our measles program. i rushed to the hospital and showed them our wooden hut that stretched for a hundred yards, full of the miserable measled. i talked about coinfection, mortality, the ease of prevention. the audience was sympathetic.

as i was finishing, i got pulled aside. “could you see this woman who is bleeding? she is pregnant…” i did. she was miscarrying. as i was finishing, pulled aside. “could you see this boy? he is not breathing?” i did. they were right. high fever, poor respiratory effort, unconscious. he had fresh wounds on his chest from traditional treatment.

i am careful to not say to myself, or out loud, “in canada… .” but sometimes i do. in canada, in case you don’t know, i can offer you the world. though we complain about the inefficiencies in our health system, our waiting lists and crises in rural care, when i walk into the room of a sick child i can say to the family, with confidence, “we will give your child the best care on the planet. the whole planet.” In sudan, in abyei’s tiny emergency room, i can only say “we will do what we can”.

what can we do. the child needed to be on a ventilator, that was clear. his intercostal muscles and his diaphragm were too fatigued or acidotic to last. often, at home, i have a team of qualified nurses devoted to the care of these types of patients. in abyei, as well intentioned as they are, emergencies have a different meaning.

i asked the nurse to bag the child, to assist his breaths, and i went to the store room to find an oxygen concentrator that had arrived the day before. i set that up, wheeled it past a queue of curious and admiring inpatients, and gave the boy some oxygen. his saturation improved from a wincing 70% to close to 100%. but his breathing was erratic. too shallow. the question before me was to intubate him, to breathe for him through a tube in his trachea.

we have no ventilator. and we cannot travel the roads at night. if we could, i am not sure where we would go. the nearest hospital 3 hours away, and they have two ventilators, but perhaps they are in use. i couldn’t know. what i have learned through experience is that .

luckily for me, my head of mission is visiting abyei to help prepare for our emergency measles campaign. i called him to the hospital. it was clear that if we did nothing, the child would die in hours. maybe minutes. we talked briefly.

it is so difficult in cases like this, to fight each battle. the war is going to be long, and the field littered. it is easy to say, “there is nothing we can do, we don’t have the resources”, and then work with resolve towards the day when we might. but i think, with msf, it seems we fight each battle when we can. we will try to convince each severely malnourished kid that we find on our measles campaign to get in the car, and to come and be fed until they are better. and we’ll track down that patient with tuberculosis that left, frustrated, half way through his treatment and try to convince him to come back. even though the countryside is full of tuberculosis patients who we will never see, and one case will not tip the balance sheets of epidemiology towards a brighter TB-free future. to the world, it probably doesn’t matter that much. until you remember that it means the world to the patient. one exact world. per patient.

so, i intubated the child. we called in an exhausted nurse from home, and she sat with him and pushed the ambu bag 12 times per minute for 12 hours. in the morning, she was spent. i removed the tube and for now, the child is breathing on his own. 12 hours later. at this point, as people here are fond of saying, insh’allah. it is in god’s hands.

i would tell you about being pulled aside again, about a melee and the soldiers, or about the gunshot today, but i will save it. things are heating up, just in time for the hot season.

for the patients i spoke of before. the butterfly boy with the tube in his chest is improved. he is eating, and wants to go home. i will let him. while i was attending to the boy above, the baby who had been breastfeeding poorly, died. i watched the mother cover his face, then walk out. of the twins, the first one, the drama queen with her hand over her face, is alive. despite being so premature, she is feeding well. today she went home. her brother, sadly, was too new for the world.

one last thing. i have only this satellite to connect to the rest of you through. eventually, i get the comments you leave sent to me by msf. i read them all, and am so, so grateful for each. if i do not respond, it is because i haven’t the resources. do keep them coming. so much better to have a dialogue. the work, as worthwhile as it is, can make one feel far away.

time for dinner. oh, for those who are considering sending me something, please cross peanut butter off the list. there is a 4 gallon pail in the kitchen. we go through them rather quickly. i am shocked to say that i may be losing my taste for the peanut.

this is my hospital.  there are many like it, but this one is mine.  460 paces.  200 or so from here…..

and just inside, to the side, are the measled.

march 8. thursday. day two of the measles campaign. we are hoping for some bounce from the undetermined electorate, particularly the hard to reach 5 year olds. you never can tell with them. they play their cards close to their chests. will they vote measle?

passed some of the queues on my way to the hospital yesterday, families standing outside in the hot sun, voting measle. we had some late night drama the night before with our newly trained local vaccinating team. they demanded more money. our field coordinator had played this game before. “those who want to leave can…we’ll pause the campaign, tell the community you don’t want to do it, and train others. no problem.” yesterday morning, they were all sweating with the patients, jabbing thin arms.

the malnutrition screening is not going as smoothly as we would like. it is difficult to incorporate. all of them have their upper arms measured. if they fall below a certain range, they are weighed (screaming) and then (screaming) measured in a larger version of the slide rule that the shoe store guy uses to measure feet. the severely malnourished, less than 70% their minimum weight for height, are brought to hospital and fed. 71% and above, no.

there are so many children, it is sure we are missing a few. yesterday i admitted only three for feeding. today might tell a different story. on the brighter side, we have the necessary y-shaped sticks.

last night the emergency team was disheartened. the day was chaotic, crowd control was a problem, we had brought water for the staff but forgot to bring some for the patients and families in the long lines. one needs to be efficient and careful in the execution of such a massive endeavour because if you lose the favour of the community, your numbers fall off.

I told the team, as far as i was concerned, it was already a success. hundreds of kids will never, ever get measles. sure, some of enthusiasm is altruistic, but some is purely selfish. we don’t need 100 cases of measles in the hospital. so whether it happens in an orderly way, people in rod straight lines with smiles and sleeves rolled up, or if you have to run around in the middle of the market vaccinating everyone you see using some type of rapid fire blow dart scenario, it will be a success.

the coordinator still isn’t eating. i told him if he doesn’t, i am going to put him in the feeding centre and feed him plumpYnut.

this morning, at 630, i woke up for a run. it is my only oblique entry in an otherwise linear day. my path is from the compound to the hospital. 460 paces to it in the morning, 480 on the return (so hot). i have seen very little of the countryside. i have been to the local souk three or four times for hibiscus tea, or to buy some soap. it is lively, full of white robed men and children careening on bicycles, the chants of the bilal, mounds of beans on mounds of beans. i need to spend more time there. need to fall in love with this place.

as it is, security remains high. our compound sits directly between 4 disparate military groups. our hospital abuts one. until recently, we had soldiers barracks on our property. only last week, we built a fence to ensure we are separate. it is a priority for us to be neutral. for the sake of our patients, so that they feel safe whether they are dinka or misseria, soldier or civilian, nomad or farmer. but not just that. for our security as well. already all accuse us of aligning with the other side. as i have mentioned before, abyei is the canary in the mine shaft. or perhaps, more aptly, the oil well. it is the point in bridge to peace that must bear the entire load for it to happen. i don’t know. for now that means i must have a radio with me at all times, and cannot be out past 8 pm in the market. armed drunken soldiers are three words that are uncomfortable enough to put together in a sentence let alone at the dead end tof a wrong turn in a dark market. we try to make sure our staff represents all members of the community. and, sadly, we are not allowed to go to the UN social club. completely non-partisan, we stay independent and sweat in our tukul.

off to the hospital. 480 paces. i am a bit fatigued. i am trying to schedule a meeting with the dog that lives behind our grass fence. i am going to try and explain that whatever point he is trying to get across, all night every night, is as clear as it is going to get. insistence will not help me, nor anyone else, understand it. perhaps a different approach, maybe with only an occasional bark, would provide more effect.

march 9. so far, at this point in the day,
twelve noon, i am having my first day off. well, i went to the
hospital, but only to check on a baby i admitted yesterday who was so
dehydrated that you could see his fontanelle from twenty metres. he was
sleeping soundly, his mother beside him. she has two oblique scars on
either cheek. like this:

O    O
// ^ \\

last night the “abyei jazz band”
(and i use the already loose term “jazz” so loosely that one of the z’s
just fell off) played all night at volumes that greatly exceeded my 32
dB rated earplugs. one of the rewards i had hoped to find this far from
somewhere was a night full of quiet stars. no.

beside me, on
this plastic tukul table, sits the card from the newborn i wrote about
some days ago. it says “poor breastfeeding”. the baby died two days
after. i have cleaned this table a dozen times since but can’t bring
myself to throw it away.

families here don’t accept little
children as full members of their family until they are two or three.
if there is not enough food, it goes to the older children, and the
younger starves. he or she is still too close to the fence. my head of
mission said that when he came to this part of sudan for the first time
he saw a two year old left in front of a tree next to the hospital. the
family had moved on.

i am trying not to smoke, and mostly succeeding.

the
shower has been fixed. it no longer looks like cholera culture medium.
it is one of the highlights of the day, to stand under the loose pipe
and get clean. sure, the clean lasts for about three minutes, but it
gives us some memory of what it is like. by the time we see each other
around dinnertime, we are all smeared with dust.

there is no
electricity in abyei. everything runs on generators. ours runs for
about 12 hours a day and charges batteries that provide us with some
energy for the rest of it. not enough for fans, however. next door, the
world food program has a huge generator that runs all night and powers
air conditioners.

more returnees arrive every day. mostly dinka.
they are asked to build a tukul for themselves and one for another
family of returnees. i can’t get a straight answer about who is asking
them. last year, the population was 5,000. a few months ago, 65,000. i
am not sure what they are going to eat.

i spent the morning
writing a response to a journalist who asked why i am doing this. two
reasons, i said. one is personal. it provides a narrative to my time
here, and it allows me to feel that i get to talk with the people in
the world i care about, and who i miss with my whole soul. second, i am
bearing witness. like i was on a stand. i have to believe that the
biggest problem in moving towards an easier world for two year olds is
not the indifference of those who can effect change. it is distance. if
i didn’t believe that, i would have moved to fernie long ago. maybe,
for some who read this, it doesn’t seem that far now. it isn’t for me.
it’s right here. i’m touching the dirt with my feet right now, leaning
my head against the warm wall. you guys are all here too. thank you for
that.

at the door in the emergency room. the child is not nearly as pleased as his mother.

severe acute malnutrition. look at the skin folds on the buttocks. i will send pictures as he gets better.

this is everyone’s favorite patient. that isn’t even his mother.
people just take turns holding him. he is a celebrity.

the infamous y shaped sticks i spoke of a few days ago.

one of the measled. and the recubra now stretches three times as far.

march 11.

I have just returned from the hospital.  for the moment, it
is quiet.  as my last order of business, I assessed a woman in
labour.   with my fingers I examined her cervix.  she
was 5 cm dilated.  I struggled to feel the baby.  oh.
there it is.  tiny fingers.  no, too short.  tiny
toes.  yep.  there’s the heel.  footling breech.  a
bit farther though….that’s the head.  yeah, I can feel the
sutures.  definitely not a bum.

so, one of two possibilities.  some type of crazy somersaulting
acrobatic compound presentation with the foot coming out just over the
head, or there are two fetuses.  I guess there is a third.  I
can’t tell my heads from my asses.  the unfortunate part is that
neither deliveries are straightforward, and it is late, and we cannot
drive to find a caesarean section at this time of night.  and i would prefer not to do one on my own.

I am mulling this over as I sit and watch the sun fall into the deep
red African sunset.  whenever I see the sun come up in africa, or
go down, I think the same thing: it is easy to believe that life
began here.  there is so just so much of it.   the
spectrum of light that runs from red to violet, from long to short, is
proof.  as the starting and finishing days rays pass through the
atmosphere tangentially, cutting across the dusty plains and the deep
jungle instead of directly down, the smaller bluer rays are picked out
by water vapour, or a piece of sand, or a tiny buzzing beetle.
the reds and the oranges bend around, careening through.  each
morning and each night, a collision of these, and a phoenix.  when I
run in the morning, I can look directly at the sun until it is well
above the thick horizon, thanks to the sand and the blinded buzzing
beetles.  it is the most perfect circle.

there is so much life here.   not just humans, of
course.   insects, lizards, birds, bats, babboons, spiders
(as large as my fist, in my tukul, yes indeed), big cats, loping
giraffes,  and with them a legion of viruses, parasites,
bacteria.  it seems no mystery that most of the rest of the world
had its start nearby.

and, perhaps, so will two new twins.  but perhaps they are too new.
in some ways it is easier to be a spider here than a new human trying
to make it out with your brother’s foot in your face.

back to work for me, for you, for us.   good night.