Suddenly…Sudan.

this morning, during breakfast, a loudspeaker blared thick
Arabic.  today was a clean up day in abyei.  everyone was to
clean the space outside of their tukuls, or face consequences.
tonight the air is full of the sharp smell of plastic.  fires line
the road.  as you walk down it, you can see the black shadows of
people tending them flicker and dance.

on the way back to town after my run first those weeks ago, I saw a
cloud of smoke moving across the horizon.  it bunched on itself,
then came loose.  as it grew closer, I saw it was a flock of a
thousand birds.  un marriage du ouiseau.  they landed in one
tree, all one thousand, and sang.

within twenty minutes of landing on wednesday, I was stopped and
hassled by soldiers then told I had to attend the hospital because a
child found a grenade and pulled the pin.

welcome home.  to the place with no face.

noone knows who abyei belongs to and noone comes from here.  no
face.  yet  more arrive each day.  the future is being
decided even now, but I can’t see it.  I am too close to the
centre, and today, I can only see smoke.

there are soldiers from four different groups, and I can make no more
sense of them than I could when I arrived the first time.  my
field co starts talking about recent tensions between acronyms, and I
lose the plot.  thankfully, my job is in the hospital, the radius
of my life 480 paces.

the measles is settling.  in shala. god willing.   two
admissions yesterday to add to fifteen sweating in the
recubra.    the feeding centre has grown.  the
families of  thin children spill out of rooms onto mats.  the
girl I wrote about before, the “now you see her, now you don’t”,
is still in the hospital. I talked with ali as he waited for the wfp
plane to take him away, and he told me he saw her laugh for the first
time. I was glad to see her.  I will tell more about her another
time.  I’m on call today, and need to return to the hospital.

it was 46 today.  people keep on saying the hot season is coming
with straight faces.  I’ve started to sleep outside.

old
home.
new home.

old
roof.
new roof.

flower
bike.
agok.

march 29.
the abyei night is black like thick ink. as you walk down the road, you
(not me, you) push your face into it, trying to gain a centimetre or two
of perspective, and it almost meets a soldier’s leaning over his
handlebars doing the same. you both recoil like surprised fishes at the
black bottom of the ocean. he swerves, and the flowers on his
handlebars brush your (not my, your) arm.

people fix flowers to the handlebars of their bicycles in bunches. roses, carnations, impossible pink flowers in rows. even soldiers. daisies pour off the front, a machine gun hangs from the back.

when an organism enters a new environment, with time the new stimuli
elicit diminishing responses. as it inhabits, it habituates. in a
conflict setting, for expatriates, it is called “immersion”. at first,
every soldier is registered, every weapon noticed. after weeks, in a
new normal, one sees mostly daisies.

for years i was blind to flowers. it took a friend to show me how easy
they are to love. in the hot morning, they hang for water. an hour
after, they are bright. when i leave the feeding centre, i think about
flowers each time.

i will write more when i find some minutes. they are so slick with
sweat here. five things you meant to meet in your day somehow slip
right by.

go to www.youtube.com and search for “reno balloon race”.  beautiful.

the speaker above me clicked on.

“ladies and gentlemen, we have started our descent towards
Khartoum.  we ask you to ensure that your seats and table trays
are returned to their upright position and that your luggage is stowed
in the overhead bins or safely under the seat in front of you.
the weather in Khartoum is …um…blowing sand.   the
temperature is 32 degrees celcius.  Local time is 150 am.”

I am once again in the land of blowing sand.  I am sitting in the
msf office, five minutes away from the guest house where I stay, just
past the garbage mound, and down the road.   there is a small
desk near the entrance.  it is surrounded by boxes of drugs and
equipment destined for the field, but there is just room enough for
me.  I can hear the squeal of the HF radio as it picks up signals
from abyei or darfur.  I wonder what they are saying.

addis ababa is behind me.  it was, as I hoped, a welcome
respite.  I spent a week learning about tuberculosis from some of
the most experienced people in the world and sitting beside colleagues
from all over the world.  some, like me, were visiting from the
field.  others were waiting for missions, or on their way
home.  each had their own story and their own reasons why it met
ours at this point in it.

on our last night in addis, some of us went dancing.  there were
about ten of us who became fast friends.   we shared a
similar enthusiasm for what we were learning about TB, but also about
what there was to learn about addis.  after the long days, we
discovered Yemeni restaurants, king meliniks old castle, got lost in
africa’s biggest market, found traditional music, and little holes in
the wall just down the road.  we were dubbed “the addis ababa
explo mission”.

the last thing we found was the dancefloor late on Saturday
night.  I was surrounded by people I had come to know, respect,
and like.  every hour our number would dwindle as someone left for
the hotel to pack for rural Ethiopia, or Mozambique, or
Geneva.    I was talking with my friend, maria, an
Argentinean doctor who had last seen me throwing my backpack on top of
a crowded bus in Zimbabwe the day I finished with msf last time.
she said she often wondered what happened to me.

“james, answer me something.  this life, where you get to meet
people and know them, and become friends, and then in a few days or a
few weeks, either they leave or you do…we say ‘well, that’s msf’, but I
don’t know.  is it worth it?”

I am not sure.  I think so.  maybe having your heart broken a little bit like that is what keeps it open.

now maria is back in Buenos aires.  mohammed ali (the great) is in
mozambique.  Anthony in Uganda.  all blown like sand.

I am looking at the departure and arrivals board.  on it names,
destinations, and dates are scrawled in felt pen.  mine is
there.

James  KRT ?  AB  28/03/07

but there are others.   my field coordinator is returning to
Khartoum on the day I arrive in abyei.   she is exhausted and
needs a break from the field.  on the same plane is the other
abyei MD, ali.  who is also taking a break.  when I left from
abyei, I shared the plane with one of the two Sudanese medical
technicians that work in the hospital and who, with ali and me, make up
our four person medical team.  I learned today she is not
returning to the project. the doctor who I replaced left after three
months.

my field coordinator is leaving in two weeks, and there may be someone
to relieve her.  our logistician is leaving at the same time, but
as of yet, there is noone to take his place.  in Khartoum, there
are similar problems.  we have been without a medical coordinator
for several weeks.  I saw our logistical coordinator in Ethiopia
and he told me he resigned.  our head of mission wants to be gone
by the middle of april.  no news on their replacements.

I mentioned earlier that the mission in sudan is the most expensive in
the world, for both the UN and for MSF.  talking with my colleague
about their different projects and countries, it seems that it is also
one of the most difficult.    the departures board
speaks to this truth.

I hope for the people of abyei and darfur that we find a way to work as
long as possible in the country.  i will contribute as much
resolve as I can.  i think i will need it all.

I will send word from abyei.  love the spring for me.

p.s. for each of you that posts comments, my gratitude.  I get
them forwarded to me by msf every now and again, and they are a source
of comfort.  thank you for them.

you need a visa to go to brazil.

you do.  trust me.  if you don’t have it, you will be sent
back home on the TTC in the snow.  this is a public service
announcement.

earlier this week I spent most of my day in the Sudanese embassy trying
to get a visa to return to the country.  one needs a visa to enter
the country, another to travel within it, and one to leave.  on
occasion, people have waited weeks in Khartoum for an exit visa.

I arrived to the corrugated metal gates of the embassy to a queue of
100 young Ethiopians hoping for a visa to go work in sudan.  most
of them were muslim.  the ones I asked explained their prospects
for work were better in Khartoum than in addis.

being a gringo has its advantages.  I was moved to the front of
the queue and within minutes, I was inside.  I walked to the
chair  in front of the visa window and sat down.  I
waited.  soon the small waiting room was full with people pushing
from one line to another, papers being passed over and around me,
guards pointing people to different offices.  i waved one of them
over, showed them my documents, and was pointed to another line.
after half an hour, I asked the same guard and was pointed to another
line at the front of which people were being weighed.  I could not
fathom the reason.  being a gringo has its disadvantages.

after two hours of shuffling from place to place, getting various
signatures, I found myself at the visa window, face to face with an
indifferent official.  he didn’t look up, only reached through the
window to grab my passport and msf contract, and walked away without
saying a word.   the Sudanese were sorely overestimating my
desire to return to their country.  after all, it wasn’t brazil, a
country for which you also need a visa, even if it is the middle of a
Canadian winter and you had planned the surfing trip for months.

I stood at the window with that butterfly of anxiety that one has when
someone takes your passport without discussing its return.  I
pushed my face against the iron bars of the window to try and see the
next step in the visa process.  it was the “taking tea”
step.   during it, people came and rapped on the door of the
visa office and noone in the office flinched.  he started to work
his way through the passport pile.  mine was on top (gringo
advantage).  he looked at my passport, then my contract, then up
at me.  he stood and walked to the window.  I pulled away
from it, linear bar impressions on my forehead.

“abyei?”

“yes.  I work in abyei..”

“abyei.  it is where I am from.  I have family near there.”

the butterfly settled, and its place, a small hope.

“ it’s a nice place”

“yes.  ok.  come back this afternoon.  I’ll have your visa ready.”

“who can I pay”

“it’s gratis.  abyei is my home.”

after three hours, an abyei advantage.  I didn’t realize there were any.

I left the embassy, and organized someone to return and pick up my visa
the next day.  she tried.  “come back the next day”.
she did and queued for an hour or two, then got it. I saw her afterwards, at lunch.  she looked shaken.  she had
my visa, but while she was waiting, she saw a man beaten  by
the guards.  she didn’t know the context.

“here’’s your visa.  better you than me.”

I leave addis tomorrow.  I will be in abyei in a few
days.   I must confess it is something I am steeling myself
for rather than anticipating.  i will leave Khartoum from the
domestic airport, trying to find anyone in the chaos who can tell me
when the WFP plane for abyei will leave, then standing up every five
minutes to scan the runway.   the plane will take off, bank
over the nile, and head south over the desert and brush.  we will
climb to 10000 feet in the thin air, and the cabin will rattle.
the hot desert wind will push us from side to side, and drop us like a
stone for a few hundred feet and I will think “is this the end for
batfink?” and turn up my ipod to distract myself.   we will stop in no less than
three increasingly small airports, and fly for miles over land whose
only sign of humans is a pipeline built by the Chinese and shared with
the Sudanese government.  it is powered by rolls Royce engines,
and is the only straight thing for miles.

abyei will come up swiftly.  we will buzz the landing strip once
in an attempt to frighten the nonplussed livestock, then land on
the second pass.  the doors will open, and I will step out onto
the dry, cracked runway and smell the dust, and feel the harsh
unflinching heat.   a cloud of approaching sand will turn
into an msf landcruiser, and I will throw my bags in the back, and
return to my world.  compound 1.  the hospital.

but for now, addis.  last night the moon, my favorite moon.
just waxing.  like someone had taken a pencil and poked it through
the black cellophane of the night sky, letting in only the
smallest sliver of the bright light that lay beyond.  it was
surrounded on all sides by clouds but it stayed there in the centre of the sky, in its gray frame,
for hours.

allow me to apologize for the running pestilent theme of the blog these days.  i am not always this way.  i have outside interests that run deeper than disease.  two months ago, the only thing that prevented me from talking even more about the abysmal state of hiphop, particularly the lack of mc’s with skills, was that my fake mustache was starting to slide off.  for the time being, my life is a bit different, and so too my days.  and so too this blog.  that said, for me, irreverence is my highest form of worship, and I will remember to add it when I can.

for this post at least, i will write a bit about health.  i think that when one does, statistics are best avoided.  1 in 4 with hiv, 40 million infected, 200 billion dollars needed.  what do these mean?  numbers just numb us.  we can’t place them in proper perspective, even worse when they describe a world that we can’t inhabit.

it is better to provide a narrative.  a description of someone with whom we can empathize.  a woman who lives with hiv, and now has to care for her two children to whom she passed it.  that is the unit of our understanding: the story.  that is why there was so much philanthropy after the tsunami.  we could see the boat in the tree and understand the size of the wave.  so too the recent attention to Zimbabwe.  it took the black eye of tsingivrai for the world to appreciate the black eye Zimbabwe has worn for years.  a bruised man is an easier symbol to understand than a life expectancy that has declined from 73 to 35 in the past decade.

but as much as i try to avoid them, today i was astounded by two statistics. i’ll tell them to you. first, guess the percentage of people who live in africa.

thirty?

forty?

how about ten. ten percent.  i was shocked. there is so much disease here. most of the HIV, all of the sleeping sickness, leprosy, kala azar.  and most of the NGO’s. the MSF data that I have shows that 70% of our global budget is devoted to this continent.

i see it as a sign of great hope, linked in part to what i spoke of in the last post.  we are better able to understand our world, even parts we will never visit.  and once we do, we respond. perhaps not fast enough, or in a scale commensurate to need, but we do.  we are.   in an important way, our treatment of this continent, the birthplace of all of mankind, is a litmus test of our ability to empathize with our fellow man.  about how much we care about the plight of innocent people whose lives will not intersect with ours, and for whom we can make easier lives without making ours any more difficult.  it is an interesting and important question.  and i think we are answering it.

i will discuss the second statistic at length in another post, lest this one gets too long and you get disease fatigue.   i’ve increased my tolerance through regular doses.   but this one is as astounding.   1 in every 3 people are infected with tuberculosis.  what?  for most of us, it is a disease more
properly placed in the dirty cities of the industrial revolution, more george orwell’s “down and out in paris and London” than in our world of paris hilton.  untrue.

it is increasing, mostly on the rising tide of hiv infection.  a marriage of inconvenience.  you should know that though there are millions infected with the HIV virus, none will die of it.  most will succumb to tuberculosis.

alright.  again, sorry for the all disease all the time radio.  tune in soon for a discussion about how nice rakim was on the microphone, how his use of alliteration and internal rhyming, though having little impact on tuberculosis, made the prospect of surviving the disease that much more attractive.

lucy.  we can only hope we look this good in 3.2 million years.  sunscreen is the secret.

our nearest ancestor, in the background.  160 000 years old,  he doesn’t look a day over 30.

i arrived to addis ababa late last friday night.  my flight was delayed because of a sandstorm in khartoum so thick that it blocked the sun from the sky, and for several hours, our plane.  i shared
the flight with a sudanese colleague, yassir, our assistant medical coordinator in khartoum.  we waited for our luggage on the carousel, and together walked out into ethiopia for the first time.

we shared a taxi to the hotel with a colleague who was attending the workshop from mozambique.  it is a strange but certain phenomenon that when you identify a stranger as someone who works for msf, you welcome them into your fold of friends.   perhaps family might be more apt.  you may not get along, nor agree, but there is a common ground and with it, some forgiveness.  at least you know
that the person wearing the msf shirt who stole the last cold pepsi has been through a metafilter, that they could be working somewhere else, somewhere easier, closer to their friends and family, for a hell of a lot more money.  so, you just grab the warm pepsi, and sit back down.

though i landed in africa more than a month ago, i didn’t feel like i had arrived until i found myself, the next day, crammed into an ethiopian minibus with 15 other people.  it was so full i had to lean over two rows of passengers, and brace myself on the back of the drivers seat.  the cross hanging from his rearview mirror swung left, then right, as he angled his way through a thick mix of cars, goats, and pedestrians to pick up more people, reggae music bumping from under his seat.   it is no wonder that the largest single cause of morbidity for expatriates is road traffic accidents.   i am sure the same is true of goats.

I visited the Ethiopian anthropological museum.  ethiopia’s rift valley is one of the richest sites in the world for fossils. several years ago, they excavated a nearly complete skeleton of our oldest ancestor, “lucy”.  she is 3.2 million years old.  her bones lie in the basement of the museum here in addis.  I believe an older fossil has been found, an even grayer relative of ours, but I don’t think the skeleton was as complete as lucy’s, and at the least, isn’t just down the road from my hotel.

so there she was, a pile of old bones.  3 200 000 years ago, she walked in the mountains I can see from my window.  there’s no way to know if she had any children, nor what type of food she preferred,
nor how she died.  we can’t know if she had a ringing laugh, or if she was afraid of the dark.  we can tell that she walked, and that her brain wasn’t much smaller than ours.  she represented an important advance.  once she was an adult, she walked on two legs for her entire life.  some scientists suspect that it allowed her to search the savannah for prey or enemies.  others believe it was a step towards being able to throw and catch a Frisbee, the most perfect manifestation of human ability.

it is somewhat different for most humans now.  rather than responding to our environment, we change it to suit us.   we don’t grow more fingers, we build tools. I wonder how we are evolving now that we can see our enemies on google earth.

I believe some of it is an evolution towards collective consciousness, and with it a recognition of a shared human condition.  it began, perhaps, with the first morse signal, from there to radio and
television, and has been made manifest with the world wide web.   the perspective it provides properly places us in the world and offers a clearer understanding of our role in it.  in that way, the internet is not an infinite series of portals, it is a mirror in which we can see ourselves reflected more perfectly than ever before.

lucy can be forgiven for not caring about what lied on the other side of the mountain.  she could not have known.  one hopes that if she did, she would make the walk.

I do not think that is a naïve hope.  I am sitting in a room with 32 people from 22 countries who have made it to stand on common ground.  there is room enough for more, for all of us.

there is little choice but to tell the story again, better, to more people.  about humans and war and disease and fairness and success.  and we hope that if we do it well enough, people will respond with whatever tools they have available.

everyone has a collection of their favorite
travelling malapropisms.  beauty saloons are mine.  they
abound here in addis, and in other places in africa.  when i see
the sign, i can’t help but think of a dusty beauty saloon in
arizona.  the swinging doors burst open.  people look up from
washing hair and peek from underneath hair dryers.

“must be the wind.” someone says.

just
then you here the tack….tack…..tack of high heels on a parquet
floor.  a middle aged woman with a beehive hairdo and wearing a
pancho turns  the corner,  a curling iron hanging
dangling loosely from her right hand, the business
hand.  everyone is silent, watching.  the only sound is
the drone of an upright hair dryer.  she fixes it with a steely
glare and it whines off.

“i don’t suppose anyone here knows anything about a straightenin’ hair….”

“umm….ma’am…ah do…..” says a stylist crouching behind the washing sink.

people
breathe a sigh of relief, the dryer goes back on, and
the beehive woman collapses into an old barber chair, dusty
and relieved.

arrived to ethiopia yesterday.  have
successfully avoided any beauty saloon trouble.  the weather is
mercifully cool.  i needed some time to regroup from abyei, and
will find some.  i am grateful.

i am not sure who
noticed, but the picture of a girl i spoke of, one who was abandoned at
the hospital dehydrated and motherless, was taken down.  my
colleagues at MSF communications called my attention to it, and rightly
so.  after posting it, i felt uneasy, and looked to take it down
myself, but was unable to access the web.  luckily they were one
step ahead, and removed it  until they could discuss it on monday.

it
is probably better down.   on matters like this, it is better
to err so far on the side of caution, that the chance of harm is
zero.   when i speak of patients, i am careful to make them
unidentifiable.  when i send pictures, i spend considerable
amount of time discussing possible consequences with each
family. i try to make them understand that others will
see their pictures, and one day might recognize them. of course that
will likely never happen. few of you will go to sudan, fewer still to
abyei, fewer still  cross
paths with anyone here.   it remains my duty to
explain it as best i
can.  when i travelled africa last time, with a photographer, we
were exhaustive with our consent forms because our subjects were people
with HIV, and the stigma towards the illness is
strong.    no matter how well we did,  it
is likely that they never fully appreciated their right to
refuse.   a similar criticism is often levelled at clinical
studies in developing countries.  we speak in our language, from
an insoluble position of power.

i have been meditating on the the picture before it was
brought to my attention.   both because it made me
uneasy, but so too to better understand my reasons for posting
it.  it was obvious that this one patient had been occupying my
thoughts.  she typified a problem that i did not have the tools to
address.  i can’t properly explain why it was her when there
are five children a week whose positions are as
tenuous.   the best i can come up with is that when there are
so many battles, one can choose only a few to fight
completely.

i compromised a bit.  i gave him enough money for transportation,
and a good, long dose of antibiotics in case he decided to keep the
money.  he did, and survived the appendicits without
surgery.  i saw him two weeks later in the fields.

the truest piece of advice offered to aspiring writers is this: put ass to chair.

some times are easier than others. often, i sit in my hot and dusty tukul at the end of a long day, and try to coax a sentence, one measly measled sentence, from a thousand things that happened. once i do, it sits there lonely and bored, with no friends, and no help at all. more rarely, the story can’t tell itself fast enough. it’s like a clear radio signal where there is usually only static, and i just have to transcribe what i hear. those are easier days.

today is not one of those easy days. but my ass is in the chair. it is in a chair because i am in the khartoum airport departure lounge. i am leaving for addis ababa, the capital of ethiopia where i will attend a TB workshop. after my time in abyei, ethiopia seems, in my mind, as sweet as canaan.

some abyei news. the measles campaign may finish sooner than we anticipated. the ministry of health is encouraging us to stop the campaign so that they can begin one of their own. i will reserve comment. i am wondering if the Spanish emergency team leader feels any pangs of guilt, because i am sure given the chaos of last week, he was praying that the end
would be soon. actually, we all were. it was a chorus of prayers.

i have been a bit troubled about some of the things in the hospital, and have been perseverating on the feeding centre. i couldn’t understand why some children would not gain weight. and why, in particular, was it the sickest and the skinniest? the ones who are so starved, they have lost their taste for food and need to be fed by a tube in their nose?

I will talk about severe acute malnutrition another time, because it is
interesting and worth knowing about. suffice it to say, we calculate calories very carefully and provide exact amounts. too much, too soon is little better than too few. we treat infections even if they children manifest no signs because the body is so shut down, it can’t even rub sparks together enough to start a fever. but, once you treat them, and you feed they, they grow. that is why it is such a wonderful place to work. sick child + food = healthy child. it is the best piece of math i know. but some of ours wouldn’t grow. they lied listless in their mothers arms, tubes taped to their ears, while we plotted their weekly weights… “6.7 kg, 6.7, 6.7, 6.7, 6.7….”

after some sleuthing, i think i’ve got it. the ministry of health
staff in the hospital is on strike. they have not been paid in months. msf is, in effect, running the hospital alone. the measles outbreak has
doubled the work, and the strike has halved the staff. our nurses are running from place to place, and the nutritional assistants have to cook for a hospital that needs twice as much beans as one month ago.

some of our nurses have been too busy and not recognized the importance of the night feeds. our tfc staff have not been checking to see if they were
administered. of the eight meals, the skinniest have been getting seven, sometimes six. not a big deal for you and i, but when a child is one or two meals shy of his calorie count, he is in debt. in essence, one begins to run a starvation centre.

so, I changed the regimen this morning. six meals, more calories in each.  if that won’t work, five.

then I stood on the cracked dirt strip that is abyei’s airport and
waited for the world food program plane to take me towards khartoum. we took off two hours late, missing the donkey below by about four feet.

pic 1.  runway
donkey
pic 2.  planespotters.

after several delays, a broken fuel pump (”ummm….excuse me? isn’t that important?”), three different routings, three different airports, i arrived. my impression of khartoum had changed. on my first way through it, towards abyei, it seemed a backward place. archaic. now, with abyei eyes, it is one of the most cosmopolitan places i have ever seen. what is that stuff? concrete? amazing. lights? spectacular. fan? this is heaven. perhaps we did hit that donkey. maybe i should walk towards the lights.

outside there is a haboub, a sandstorm. it is so thick, you can not see the sun. people are holding their hats, and covering their eyes.

will send further word once i am in ethiopia. rest well.

i had a dream last night that i was finished my mission.  i was sitting
at a table, surrounded by friends.  one said “wow, that went so
fast!”.  i agreed.

i woke up to the sounds of the muezzin at 5 in the morning.  i lied in
my bed, smelling the dust.  i was still in abyei.    still here.

it has been going fast.  i left canada more than a month ago.  it seems longer.  i have
seen and learned so many things.  it feels like i have been told one
hundred stories.

i wrote in my first post that i had anticipated one of the lessons i
would be taught.  “be careful what you wish for, you just might get
it”.   part of my motivation for coming here, to abyei, was to test the
limits of my resolve.  i didn’t anticipate they would be tested so well.

the medicine is difficult, so too the hours, so too the isolation, so
too the climate and the culture.   outside of work, the pleasures are
few.  one has to look for them under every heavy tile of his daily
routine.  there are some.  that half an hour  of cool silence in the
morning before the generator starts, the…..ummmm…..

in the pre-departure training, we are told of the well worn personal
trajectory we will likely follow in missions like this one.  we arrive
to the project full of nervous excitement.   there are so many new
things.  new faces, new routines, roles and rules.  we get to use the
radio (the coolest).   we are frenetic, and overwhelmed, but swimming
with all of our might.

this fades after a couple of weeks.  the reality of the days starts to
thicken like cement and initial momentum slows.  the new things become
old ones.  the weeks of work stretch ahead and seem insurmountable.  we
realize that this is not some exciting dash to a spectacular finish.
it is a marathon.  our mood ebbs.   one day of work bleeds into
another.

days become weeks.  soon the mid point of the mission approaches.
after three months of working seven days, we are allowed to rest for a
week.  our mood improves.  where are going to go?  tickets, and
planning, and departures.  excited, we leave the country, lie on a
beach, and sleep.   we return somewhat rested, and take another blow to
our enthusiasm.  back here again.  back in no(middle)where, treading
water.

that feeling does not last long.  days somehow find weeks again.   soon
we realize that we have have an opportunity to make a lurching step
towards progress, towards a better TB program, or a bigger feeding
centre, or having borehole finally dug.  but what we don’t have is much
time.  we become frenetic again, and as the end draws nearer, we wish
it were further away.   but it isn’t.  and here comes someone else,
full of nervous energy, and a new world rolls over him.

for the time being, for me, there is that half hour of silence before
the generator starts.  the sun is still down, and the roosters newly
up.   we leave our tukuls, walk quietly past one another, whisper
“morning…morning”.   we go to the kitchen and boil some water, grab a
piece of warm bread, and sit on the brick wall of our communal gazebo
and look at the sky.  for a few minutes, the world seems to stretch
wide, much wider than the grass walls of compound #1.    for a minute,
we are who we are.

the clatter of the generator starts, and we stand up.  “right.”  we
gulp our last bit of coffee, walk to our tukuls to put on our MSF
shirts, and grab our notebooks.  the first of the people start to
arrive for the morning meeting.   with them, the day rushes in headlong
and washes over us with so many things that we spin, breathless.

feeling a bit out of breath today.  i will find it tomorrow.  in that half an hour, before the generator starts.

march 13. “whatever you do tomorrow, do not go to akor riang from where you will be. there are mines along the rode. it doesn’t matter what anyone says.

that’s the conversation I overheard as I was checking the satellite email for news just now. measles team talk. they are blanketing the countryside with vaccines. they leave at 7 in the morning, and are finished loading the vehicles by 11 at night. they are improving. at the beginning of the campaign, one week ago…wow, it seems longer…at the beginning, they were nerves on nerves, tracking back on the themselves, just unprepared enough for thing to fray by the end of the day. now they are moving more like a machine. and staying well away from the mines. that makes me glad.

it has been a test to have a new team glued to this one. the quarters  were close enough by ourselves that we needed to watch for each others toes. but now, there are so many of us, you can’t move without stepping on some. shower lakes, empty fridges, no water for drinking in the mornings. we hold our breath and remember that their job is no easier than ours. and that they are holding theirs too until the job is done. once it is, I am sure they will wonder if it ever happened.

the other night, twins. they are fine.

i received the best news today. well, two good pieces. the first is that my mother is sending me not only a fan, but cookies. they will travel to Geneva, then wait in a plastic box labeled “northern sudan” that sits beside “southern sudan” that sits near “tschad”. it is a wall of such plastic boxes, each bearing the name of a country, and most holding packages for the field. if I am lucky, someone will be coming to Khartoum, and have the space to take my fan and cookies. luckier still if that someone drops it at the MSF office in sudan, and even more when someone takes it as part of their 15 kg of luggage to abyei. in the meantime, I sweat. it is 10 pm, and 38 C in my tukul. it was 46 C this afternoon. there is not enough power in the compound for fans. the only recourse one has is to minimize the surface area of his body in contact with the bed. for instance, the side sleeping knee-elbow maneuver. or the scapula/butt pillow wedge.

the second piece of good news, if not enabling my sleep, will allow me to lie contentedly awake. if you remember a couple of weeks ago, I wrote about a child who was brought into the hospital so dehydrated, she tried to lick my shirt when it fell across her face. she was willing to drink. no one was willing to take the time to offer her anything. her mother had died weeks ago, and her father was uninterested. a neighbour took pity and brought her in. he didn’t stay long.

she was ours. a mother in the feeding centre offered to care for her, but her son improved, and yesterday she left with him. another mother has adopted her temporarily, but her son will also improve. none of the mothers, nor their children, would be there if they had enough food. another mouth takes more than they can give. these arrangements will not be a lasting success.

I have grown very fond of this girl. beautiful, and quiet. I would take care of her if I could. I cannot. i don’t think I can. no. I cannot. But I want to.

she is not improving as well as I would like. occasional fevers, not gaining much weight. listless. last week, as I was sweating asleep, a black thought crept in. “maybe HIV”. could be. how did the mother die? why the fevers, and the weight loss. I hoped not. I held my breath. I didn’t mention it to the other staff. in absence of consent and counseling, and particularly in the absence of treatment, we don’t test.

while I was away from the hospital today, she was tested. negative.

I spent months traveling Africa in 2005 writing about HIV, and I never understood how truly important it was to prevent and treat the disease until i felt that cool relief today. good news. may it happen more and more often to more and more people.

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.

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 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.

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.

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 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.

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.

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.

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.