Suddenly…Sudan.

the HF radio crackles beside me. a guard is resting his head on the desk in front of it. every minute or so, he lifts it and calls into the mic:

“mobile, mobile for alpha bravo, over… mobile for alpha bravo, over…”

we have sent a patient, urgently, to the nearest surgical hospital 3 hours away. when they arrived, they were told that there would be no surgical cases accepted, and suggested another hospital, 4 hours away. it is well past dark, and outside of a hospital in northern sudan, in the back of a car, a woman in labour and in need of surgery is waiting to see if they change their mind, or if she will have to drive in the black night 4 more long hours on a dangerous road. we are sitting by the HF radio waiting for the same news. there has been no contact recently from the driver. we are not sure how to interpret this.

“mobile, mobile for alpha bravo, over…”

we were talking the other night about the msf life. country to country, crisis to crisis, six months here, two there, on and on and on. there are a few of us who are doing our first mission with MSF. others have done several. maurizzio, our field coordinator, is of the latter group. he said that when he was proposed the mission in abyei, his second in sudan, he was doing some research and came across my blog. after reading, he decided not to come. he recognised too many things from his previous mission. thankfully, for all of us, he changed his mind, and relented.

he was speaking the other night that after you do one mission, and you go back home, you are ruined. there is a distance between you and others that is irreconcilable, things that you cannot share. when you try, the people you talk to either cannot place themselves there, or they realize they don’t want to know after all. the larger the rift becomes. you arrive home, exhausted, longing for familiar comforts you thought you missed, but after a short time, no matter how hard the previous mission was, you feel the pull. if at least to be around people who have known a similar world.

i have just returned from the hospital. i was called in a few hours ago.

“doctor james? this is hospital. we have sick child. girl. 5 months. high fever. diarrhea. breathing problem.”

“alright, hospital. can you do a paracheck, give the child 80 mg of paracetamol, and some cool cloths… do you copy? …good… is the child drinking?”

“no.”

“ok, start a cannula, …weigh the child and write the name down. …and i will be there in a few minutes… do you copy?”

“doctor james… i… ummm… i use bag for breathing now…”

“i’m coming. over and out.”

where is the driver? no driver. i grab my stethoscope, and jog 480 paces. i arrive through the gate, people are standing in front of me, waving outpatient cards. i brush past them to the nursing room. a young mother wearing a bright yellow veil is holding a limp 5 month old child whose eyes are sunken, and half open. her small chest rises and falls with last breaths. two nurses are bent over one tiny, dangling arm that has a latex glove tied above its elbow, poking needles through soft skin, looking for veins.

they can find none. no veins, no intravenous. (mohammed, can you use the bag again… no, like this, smaller breaths… no… do you hear that sound? it means there is no seal… you know what… i’ll do it… tell the guard to start the generator for the oxygen machine). no gas for the generator. (ok, prep the leg, the left one. with betadine. perfect. great. ok, take the bag. smaller breaths. push when she breathes. no, make a seal…). i open the intraosseus cannula, landmark a little less than a cm below the tibial tuberosity, on the flat part of the shin just below the knee, twist and twist and twist until it pops through the thin shell of bone. marrow flows back freely into the clean water of the syringe and i flush it smoothly back. the fans in the nursing room start to spin. i ask for fluid, and antibiotics. the child’s head hangs loosely on my knee. she vomits, and breathes it in. (suction please.)

last breaths are like this:

………hu…………..siiigghhh………..hu………..siiiigghhhh…………hu……………………….hu………………………………

so, instead, i am blowing in tiny, tiny breaths through a tiny, tiny mask. i barely have to squeeze the bag, her lungs are so small. small, and full of crackles. three times my stethoscope dangles down and touched my knee, and three times i feel a small pearl of hope, thinking it was her hand. i looked down, her arm hangs loosely by her side. i stay there for three hours.

i think i would still be there if her breathing didn’t worsen, but it did. she was tired, her muscles burning and inefficient from the lack of oxygen, full of lactic acid. when i would stop, instead of taking a breath, all she could manage was a grimace, a shrug of her small shoulder.

i placed an oxygen mask over her cheeks and pulled it gently snug. i put my stethoscope on her chest, and heard her heart count quietly down.

5………(hu)……4………(hu)……3………(hu)…………2…………………………….1……………..

i don’t think that i will end up ruined, but there are certain things that are going to be tough to share. things that would make poor dinner conversation (hey, have you ever heard an infant’s heart stop? don’t you think it is like the silence must be after a train wreck, deep in the forest? once the metal has stopped creaking? like all this activity, and then this final vacuum in place of all the sound?). i can imagine meeting people on the street, and being asked how my “trip” was. (……you know the feeling, when you are confined to the compound, and you and your colleagues are sitting underneath a tin roof, listening for the cracks of gunshots, but all you can hear is the rain, and then someone decides to make an apple pie, and how happy you all feel for something else to anticipate?).

it was fine. it all was fine.

i cleaned up the emergency room, the nursing room, watched the family close the baby’s mouth with gauze. i saw some outpatients. i took a seed out of a little girl’s nose. i walked back to the compound alone. i went to the kitchen for a glass of water. andrea, the nurse, came in to see me.

“is everything ok at the hospital? is the baby ok?”

“ummm… no… she’s dead.”

“are you ok?”

“yep, i’m good.”

“you know, you don’t have to keep everything right here,” she said, and pointed to her sternum.

“i know,” i said.

usually, as a doctor at home, it is rare to have one of these experiences, but when you do, you often bear it with others. another doctor, or nurses whom you know. you sit, and talk about it. it doesn’t make it go away, but it diffuses some of the weight. so, just now, from the kitchen, i walked over to the log tukul, and started typing this. instead of keeping it here, in my sternum, i am going to put it right here:

.X.

still no news from the car. we are all quite anxious.

i don’t mean to burden anyone unnecessarily, but this is what happened tonight, just now, i am freshly back. the part of me that normally edits these stories out doesn’t want to do it today.

i am grateful for this forum. not only does it allow me to place X’s, but it also means that when you meet someone you know on the street, and they have just gotten back from something like this, and you say, “so, how was it?”, and they say “fine. it was fine.”, you will know. good night.

with the first rain came a blanket of buzzing bugs in all forms. small ones that fit through your mosquito net and circle your headlamp casting tiny orbits on the pages of your book. larger ones who have bodies like an ant’s, but longer, and who can stand on their back legs and survey the huge landscape of the dining table for sugar lodes; lucy’s homologues. praying mantises made from sharp green seesaw angles fold and unfold themselves on our kitchen counter. and on the first night, an insect that seemed a fragile, colorless cousin of the dragonfly. they lay waiting in their dry coffins for the water to wash them free. when it did, after thoughtless months, they took to the night air and carpeted abyei. in the morning, all that remained from their short, glorious season was their wings. they littered the ground like fall leaves and blew and swirled with the wind.

most of us in the project have contracts for six months. some are shorter, none are longer. though mine is only a few months through, it feels like many. my team member, reto, and I have decided on a slogan for this project: “for those who think life is too short… come to abyei! it feels like it lasts forever!”

I think in some way, we all distract ourselves to avoid the true experience of time because it is uncomfortable. I think that is why many of us dread going to the dentist. it is not because of anticipated pain, there is little of that. I think it is because we are never more vividly awake, never more focused on the present, never experience a longer minute, then when someone has their hands in our mouth.

in the same way, we find it better to rent a movie than to sit quietly outside for two hours. if we could, I suspect we would amuse ourselves from sunrise to sundown, Christmas day to Christmas day, beginning to end. I am no exception.

i think some of the reason the time feels differently here is that there are few distractions. it is something I looked forward to when I read in the job profile: “must have interest in living in remote locations”. there is no morning paper to read while we eat our breakfast. after dinner, there are no concerts to go to, nor a walk to go on. we sit quietly, and the moments stretch. it is uncomfortable, and only after time, do they bring with them peace.

the rest of the reason is the tumult of daily experience. one’s emotions are cast through their full register. the delight of receiving a package and a letter from home is followed immediately by the anticipation of your Thursday night meal being carpet-pulled from beneath you when you get called to the hospital to see a woman who has been raped. the world never lets go, and we are tossed about by its circumstances.

like the first rain. with no protection, we feel more acutely its true weight.

when people say life is short, I disagree. it is long. it seems like forever. it seems like a million years ago, not ten, that I stood uncomfortably on the lawn outside calgary’s medical school, waiting to make small talk with my new classmates. a hundred since I worked in Cambodia, tracing a maze of ox-cart paths to find new villages, not five. and it has been at least a decade since I threw my dusty backpack down in compound one, having hitched a ride from the landing strip with the UN, forgotten, and wondered where the hell everyone was.

short? no. too short? perhaps. I’ll figure that out later.

I wonder if those bugs, the dragonfly cousins, sat with the dawn dew weighing heavily on their wings, grounding them, and marveled at the majesty of their long life, how the night lasted, and lasted, and lasted, until it seemed like the dawn would never come.

abyei is underwater. well, much of it. the cracked fields that stretched from its sides are filled. in the middle of these lakes sit poorly placed tukuls from which women walk, balancing buckets on their heads, lifting their dresses to keep dry. trucks lie stranded, their wheels spinning. it seems that either none of us were prepared, or we were waiting for the beginning to begin. our compound of dust is now one of mud, and we are watching for the first signs that cholera has found abyei’s thousands of returnees in their new, wet land.

I mentioned that one of our plans is to draw the hospital, to imagine it differently. I have been here too long, and can only see it as it is, immutable. once we draw it, I will post it. as it is, one enters through a common gate into the chaos of our outpatient department. people lie on floors or fan themselves with their registration card until they are seen. emergent cases, if recognized as such, are seen more quickly and passed to me or the other MD. if admitted, the patient is loosely placed near one of our wards. pediatric (consumed entirely be the TFC), the male ward (full), a the female ward (full), measles (empty and leaking), tuberculosis (full). earlier this year, in january, the hospital held twenty patients. we now have 20 in our TFC alone, 50 in total. malaria season is yet to come.

I am not sure if you can glean an idea of the hospital structure from the short video I posted. likely not. there is brief shot of the feeding centre. because of our increasing numbers, we made it on the open ground between two buildings. we covered the space above with shadow net, and on top of that, heavy grass. it has been one of the greater challenges here to convince women to stay in the hospital to allow their children to complete treatment. they often have four others at home, equally as deserving and, for all I know, just as hungry. we look for solutions, reason, beg, compromise, do anything to make it possible, or easier. the shadow net provided some respite from the sun, and was working well.

with the rains, of course, it is not. water leaks through and when I looked at last night, the wet grass was causing the shadow net to sag. a quick image of thin, broken needles in a wet haystack, and we knew a change was necessary. the only space we have to use is the emergency tent we have been reserving for mass casualties. the most common mode of transport in and around abyei is to ride standing in an open convoy with 20 other passengers and watch the landscape pass by, or if you are unlucky and the truck turns over, watch it hurtle toward you.

(wait … I heard something rustle… there has been a frog in my tukul for two days… he is very small, very fast, and somehow, smarter than I am… i am going to try and catch him ……………………………………………………… and, finally, no.)

so, anyway, ground hurtling, hurting, 20-people tent, now a proposed home for starving children and their reluctant families. some of the women agreed, others refused. the rains have continued all day, and they have been heavy. the tent leaks at its seams. when I went to the hospital this evening, only three families had made the transition. the others sit, crowded, on top of each other, in two small hospital rooms. I will see how many remain in the morning.

some follow up. the woman with the rash, no response to antifungal treatment, and I have asked her to come back for a biopsy. the lab technician returned today on what may be the last flight to land on the dirt strip in agok. from now on, we drive 12 hours to the nearest tarmac. I will ask him if he can look for filiria.

last night, at 5 am, I woke to the sound of thunder. above me, there were none of the familiar stars. I moved quickly, rolled my sheets and pillows into a ball, tucked the foam mattress under my arm, and dashed to my tukul as the first drops fell. I lied on the ground and listened to rain tap, staccato, on the grass roof. it didn’t last long. a second warning. beware. act fast.

the morning was cloudless. 42 C by noon. lunch brought a few tall, white stacks. by 2 pm, the team huddled in one corner of our meeting space as the rain fell in sheets, heedless.

i called over to andrea, our nurse, from the medical tukul. “TFC!” i yelled. she smiled at me. the rain drowned my voice. “TFC!”, i said again, and traced the letters to her. her eyes widened, and she covered her mouth.

i called to the hospital. the women and children were crowded into two rooms. dry for now. measles? the one family was tucked into a spare corner.

the rain slowed, and we mucked our way to the hospital. the recubras we waterproofed after the last rain were soaked. so too the TFC. dirty water pooled on their plastic sheeted floors. a live wire sparked near the measles area.

the recubras wouldn’t do. tents? maybe. containers? none to spare. we walked around the hospital, looking at structures, and roofs, and walls. knock this one out. move people to the veranda. does the lab need to be there? why not here?

we covered the wire, and resolved to sit down with a pen and paper tomorrow and reimagine our too full hospital as a different place.

for now, the skies are a smooth, calm gray. our TFC patients have been moved to an emergency tent. we have been warned twice. it’s at least one more than we deserve. we sorely need a logistician to inherit this puddled clay kingdom.

a tiny blue breasted bird is tapping the post, just outside my door. if i can read his expression, he is very pleased with this latest meteorological turn. for everything there is a season.

last night, I could not leave the hospital. I tried. but each time I put my stethoscope in bag and washed my hands, clapped the nurses on the shoulder and said “bukra…tomorrow”, another worried family opened the gate. they carried an infant with pneumonia, a women a with spike of metal in her foot, a teenager with pyelonephritis. one family walked for six days to bring an old man who could no not walk. I saw a child I discharged one month ago, the heart listening celebrity and didn’t recognize him. he was 55% of the proper weight for his height. he had lost all the weight he had gained and with it, his bright curiosity. he couldn’t lift his head to look me in the face.

I found myself leaning against the door frame of the nursing room, waiting for the results of a malaria test. the light was fading, changing into amber sombre shadows. the patients had all pulled their beds away from the walls and the radiant heat and were scattered like dominos on ground. the heat has returned and it has been merciless. the air was heavy and still. like the sky was drawing in a slow breath. I think it might rain, I said, to no one.

I leaned there, on the door frame, and waited. around the corner, below the blue water barrels in the middle of the courtyard, came achol. she was running like toddlers do, a little off balance, listing to one side then the other, using her fat arms as ballast. she came into hospital a month ago, thin and feverish for all her life. we fed her and treated her for TB. tonight, as always, she was running. her mother scooped her up, and she screamed with delight.

I turned to look for clouds. none. I caught the eye of the parent from a child in the feeding centre. she smiled brightly at me. I don’t think I have shared one personal word with her, though I see her child every day and ask how he is. but if our paths cross during the day, it is always the same, nothing but the widest smiles.

an unfamiliar feeling started to seep in. what was it. foreboding? no, nostalgia. melancholy. nope. unfamiliar. wait… is that… fondness? for this hospital? for… abyei? with all its hard, sharp edges, dustdustdust, heatheatheat. no way. still, it feels a lot like it.

the nurse picked her way through the beds littered on the ground and handed me the sheet with the paracheck result. negative. I turned from the door and set it on the table. a gust of wind blew in, and scattered all the papers. outside, it whipped through the courtyard. I felt the sting of sand on my face, the grit in my mouth and eyes. an unattended mattress flipped end over end past the door of the nursing room. the soft dusk light disappeared. sandstorm.

I saw two more patients, and walked home in the dark, squinting through my fingers from the sand. but still, even though the desert tried to cover it up, I am pretty sure that’s what I felt. fondness.

I returned to the hospital twice more last night, leaving it for a few hours of sleep at 2. now it is the next day. it is dark, and the generator clatters in the background. I am several hours short of sleep, and have missed dinner. time to find both.

one last, important thing. I want to congratulate my friends at Open Medicine [www.openmedicine.ca]. they launched a free, independent, medical journal last week. for their tireless effort and principled dedication they have my admiration, gratitude, and loyalty.

in writing, it is better to show than tell. instead of “people were sad”, better to write “a woman wept”. so too in the world. instead of saying that we, each of us, deserve a world where information that affects us is both free from influence and ours to use, open medicine has shown that it is possible. I believe it deserves the widest support. congratulations.

the hospital is slowly filling again. today, friday, I turned the corner to the TFC, and couldn’t find a route between all the families lying on their mats.

I cannot explain the surge. it is possible we are entering the months of the food gap; the time where crops from last year are the lowest, and the harvest is yet to come. it is also likely that as the measles tide ebbs, we are seeing the consequences of illness on a population whose health is already tenuous.

the emergency measles months were difficult for the project. not only on the sanity of our staff, but also with our relationship with the community. the speed with which it was necessary to act meant that toes were run over. I suspect that some members of the community, both abyei and the NGO one, were irate at our urgency. for me, as the ex-pat physician in the hospital when the numbers started to swell, first 5 patients. then two days later, 10. by the end of the week, 20 … we couldn’t vaccinate fast enough. there are still cases trickling in, but without the campaign, the hospital would have been swallowed.

the rains have left for now. it was as gentle a reminder as one finds in sudan. our measles area is water-proofed, and so too our TFC. we have unloaded the mosquito nets, and are digging trenches. we are grateful for the time.

the rainy season brings life to abyei. it has little to do with humans. rain forms puddles, and then ponds. husks of mosquito larvae start to hatch, and frogs crawl from their dry tombs. birds fly from the Congo, from Kenya. snakes uncoil themselves and move from their dust bed. tress leave and plants flower bugs, and bats, and scorpions and centipedes. and malaria, and typhoid, and cholera. all of them waiting for the rains, and their season.

so much life, just sitting under the sand, under abyei’s skin. I have asked some local people which they prefer, this hot one or the wet one that follows. most favour the green of the coming fall. one person did caution, however, “for me, the rainy season… the only problem is that everything is trying to eat you.”

it is a truth that in places like this, humans are not arbiters of the food chain, but links. and not the strongest ones. one of the members of our team has lost 15 kilos. i am holding steady at 5.

it is friday, and our cook’s day off. I am looking for prey. I have offered my left arm to whichever insect would have it. I am not above playing my part. what I need in return is to have a roast duck take perch on my tukul, and then fall off in delicate, delicious pieces. or a smoked, candied salmon to trace its way across the desert with a bagel on its back, leap over the fence, work its way to my desk, and gently nudge my foot. waiting. still waiting. hey, I thought we were a chain here.

I am trying to paint a picture of abyei, but all I have are hurried, infrequent strokes.

Yesterday, after dinner I was sitting in the open space of our compound. Our night is again moonless. Ink. Overhead a flock of white birds flew, fluttering in the black night like pieces of paper. They landed in our tree, and noisily settled in for the night.

I made my bed under it. The shuffling wings mixed with the voices of my neighbours and the tinny music playing on their radios. The air smelled of dust, and the sharp odor of burning plastic.

I woke at dawn, too tired to run. The birds were gone. The sky was cloudless. I folded my mosquito net, and shook the dust from my sheets. The smell of plastic still hung in the air.

On my way to the hospital, 480 paces away, I passed children on donkeys and men on bicycles. I answered them, fine, how are you. I am fine. Plastic bags blew by with the gusts of wind and were carried into the open field nearby where they fluttered, thousands strong.

I passed two sisters. The youngest, ten, was dressed in a white dress, frills on the shoulder. It was torn and it’s white choked with dust. Still, no princess ever looked more important.

I am somehow sick again. I returned from the hospital for lunch, and was in the middle of a feverish dream (organizing something, again, what, again), when I was called to the hospital. A woman had been run over by a car. I opened the door to the emergency room, and saw the piece of white bone pushed from her leg glistening brightly.

Later, a large truck pulled into our road, and backed up to our gates. They carried from the box a stretcher with a woman and her new baby on it. Twins, we were told. One delivered, the other not. We took her to the delivery room and removed the blanket. Between her legs, an arm. A tiny blue arm. I touched it, and the skin came loose. How many days ago was the delivery. Six. Six days. Six days ago, a baby was born, and her brother, almost. He made it to his shoulder, and finding nothing to hold onto, went no further.

I saw a child in our feeding centre, our TFC, whose mother carried with her two pieces of wood. What for, I asked. Well, my translator explained, when she was born, there were three. Now she is the only one. So her mother cut two pieces of wood and said, these, these are your brothers. How long will she keep them, I asked. Forever, he said.

It is later that same day. Near dusk. I am sitting in the compound, in our only covered area. It is hot. Generators clatter and donkeys bray. Soon the call to prayer. Still the sharp smell of plastic.

Just to my left, our nurse is giving our logistician a haircut. Our midwife has just handed me a mirror to inspect my own sorry state. I need both a haircut and a shave. I look tired.

The radio just crackled beside me. I am on call. Now, I will walk to the kitchen (…call to prayer…) and eat what I can, then make my bed. I will shake my sheets, tuck in my mosquito net. And once I am done with whatever night business the hospital has in mind, I will fall asleep. 24.

Once, when I was fly fishing in the rockies, walking through brush and over rocks, hoping my luck at the next spot would be better than the last, a mallard started following me. It wasn’t easy work for either of us, all thick trees, all upstream, but he stayed with me the entire afternoon. I would turn to look for him every so often, and he would be there, treading water, pretending to mind his own business, waiting until I moved. At the end of the day, as I started back downstream, he flew off.

I ran yesterday morning. As I left town, a soldier ran from between two tukuls, and kept pace two steps behind. I looked over, and he looked straight ahead, minding his own business. We ran together, me carrying my heavy handset and him with army boots and jangling pockets. We reached the tree in the middle of the flat landscape outside abyei, and I stopped and turned around. He slowed to a walk and continued on.

The team is changing. Gilbert, the logistician, left today. He is returning to Khartoum, and from there to London. Our new field coordinator, Maurizzio, is arriving. He is Italian. This means with the Italian nurse and midwife, Reto (our swiss administrator) and I, are surrounded. The food has improved. Each team, particularly if a small one, has its own personality, and it changes with each iteration. If one is lucky, enthusiasm and camaraderie are in large supply, and at the end of his mission he finds himself saying goodbye to friends. If not, then he counts days, and leaves with few words. I am curious as to what this next iteration will be. Today we said goodbye to a friend. Someone will arrive to take his place. MSF is a treadmill.

The nights in Abyei afford little distraction. There are no restaurants, nor movie theatres. We are not allowed to travel by foot after dark, which proves little problem as there is nowhere to go. We sit on our veranda, smoke, and talk.

We try our best to not talk about the project, or sudan, but little else seems real. None of us has seen a new movie in months, nor know the latest headlines. After a few merciful minutes of respite, work edges its way into the conversation.

The one I just left hanging outside was an important one. Reto and I were wondering what we were doing here. Not simply as two men the same age, with friends behind and a future on hold (treadmill), but as humanitarians. As MSF. There was no conflict, and though perhaps we are too immersed to notice small signs, things seem peaceful. There are no refugees. The returning population is not huddled together under plastic sheets and sharing latrines with 19 others. The hospital needs attention, so much attention, but isn’t that true of nearly everywhere? We “offer assistance to populations in distress, victims of natural or man-made disasters, and victims of armed conflict”. Development is not our strong suit.

We both agreed that if MSF left the hospital, and took with us all of our resources, our oxygen machines, and our pills, our nurses and our feeding centre scales, what would remain is a house of cards that wouldn’t survive the next stiff wind. And we agreed that for the people we passed in the market, as for the ones building tukuls on the outskirts of town, the war was still fresh. And here, on the border between north and south, it would be years, maybe generations, before anyone will believe it is far away.

The memory of the precise chemistry behind supersaturated solutions sits fragmented in my hippocampus, like too much of my premedicine studies. I believe the founding principle is one of entropy, that as one adds energy to a system it increases its randomness. What it allows is for one to add much more of a salt, like potassium permangranate, to a heated quantity of water than it would bear otherwise. It requires a completely new and clean beaker full of pure distilled water. As one adds heat, and chaos, he also adds salt. It dissolves, and he adds more. And more heat. And then more salt. The salt dissolves into its constituents, and the heat makes sure that the molecules ricochet faster and faster, knocking other ones loose. Soon, all the salt has been added, and it is all in parts. Parts that are flinging themselves against the glass borders of the beaker. If one removes the heat, and allows the beaker to cool, the disorder lessens. The ions slow down. They spend less energy bouncing off of one another, and in fact, would form crystals again if they could. But they can’t. There is no solid substrate. You are left with a beaker of clear water sitting on your lab bench, full of molecules waiting to precipitate, but none of them have anything to hang onto.

Now, take a glass rod, and just touch the inside lip of the beaker. A small piece of glass dust flakes off, so small you can’t see it, and falls into the water. In an instant, a second of a second, the water becomes a crystal. Completely solid. The molecules are at rest.

I think, for me, that is part of the reason why we are here. To try and be that piece of glass. To help build a place in a community that is not a community, for everyone. It doesn’t matter if you are from the north, or the south, or a Christian, or a muslim, or a civilian, or dinka, or misseria, or soldier, or civilian. We deliberately don’t care. Our intention is to build something lasting for the people in abyei with the people of abyei. Not just a place to treat the dinka infant with meningitis or the little misseria girl with malaria, but a place where their fathers can reach for the water barrel at the same time and say to the other, after you, no after you. and maybe, two weeks later, when they pass in the market, they will nod. and perhaps, two years from now, they might stop and talk.

I am sure there are tiny pieces of glass like this in abyei, and all over sudan, and all over the world. But, this is ours, and it is one of the reasons we are here, and I would do well not to forget it.

the other morning, I was in the measles recubra, our house of straw, and looked to sky. the clouds whose lightning flashed on the horizon the night before were mounting in the east. I called our logistician on the handset.

compound one for james… yeah, bro, have you looked up? I think we need to cover the recubra and the tfc… i know, not for another month, but… just look up…

he did. he thought it would be ok. we were all told that the rain would not find us until the middle of may. but still. the clouds were dark. they looked unhappy.

I continued on my rounds. the miserabled measled. so sick. it takes so long for them to get better. as I mentioned before, both my brother and I had measles. we missed some school. my father had it as a child too. but my grandmother, living in northern Alberta before vaccines and antibiotics, lost one of her brothers when measles spread through their family.

I had seen half of the patients when the chart blew out of my hand, and a burst of hot air swept sand through the recubra. I left and looked at the sky. it looked unhappy. approaching fast and unhappy.

I called on the handset.

yeah, I think we have a problem.

I felt a first drop, then the rain started in sheets. it quickly soaked the straw roof, and started to leak onto the beds. there was nowhere to go. the patients were quickly drenched, so too their beds, their clothes. they gathered in a corner. I couldn’t take them into the hospital. too contagious.

help soon arrived. we placed a piece of plastic against the wall and braced it with a y-shaped stick and moved the patients under it. they huddled together, a tangle of soaked women and sick children.

the rain was heavy. it was pooling on the beds, and forming puddles on the plastic floor. we hauled more plastics sheet from a nearby container, and pulled them over the roof. the drips slowed. there were pockets where one could stand, and not get wetter. the patients moved from their corner.

the rain lasted for an hour. the ground was puddles. the beds were wet, and the children were cold. the rain lashed us, unprepared.

and so too the tfc. and so too our compound. it was a month early. we erased our list of logistic priorities, and moved “rain preparation” to the top. it seems sudan has no middle ground.

with the rains, the heat will break. and, I am told, from the cracked earth will come the snakes, and the scorpions, the mosquitoes and the malaria. we will walk around in rubber boots, and the roads will be rutted mud. there will be no sleeping outside, and no morning runs. again, and again, the lesson…”be careful what you wish for…” is repeated.

but today, two days later, it is like it never happened. it is 11 am, and forty degrees. it is Friday, our one day off. I am on call, and will walk to the hospital soon. I will step out of my tukul and the the sun will punch me, and I’m not going to say a word.

one short word to the people who have commented on the woman whose rash I showed. your responses have been wonderful. I will let you know what I do. unfortunately, a skin biopsy will not be helpful. there is no way to look at it. in areas like this, as much as I loathe to do it, one is left with trials of therapy.

To compare health between nations, one most often uses statistics. When
I was working as an editor at a medical journal, I asked for an article
on common indicators. I asked my potential author to explain what they
really meant. Numbers are meaningless. What lies beneath under 5
mortality rates? What shortens a country’s life expectancy? What does
maternal mortality really mean? Why do the mothers die, what is the
human cost? He wrote the article, and answered some of my questions.
More have been answered in the past few months.

Last night I was on call. I was asked to come to the hospital to see a
woman with a severe headache. As I was walking through the hospital
gate, I heard the handset crackle with a call to Tina, our midwife.

“Tina….there is a woman here who delivered a baby at home two days
ago….she has a high fever and it feels like she has another baby
inside….i can feel a part. Can you come to the hospital?”.

She would. I walked into the hallway that leads to our delivery room. A
young dinka woman was lying flat on her back, her eyes closed. Her new
baby was on another bed, crying. He appeared healthy. His mother was not.

She had been losing blood since the delivery. I felt her abdomen, and
could feel the bulk of her uterus through her hot skin. It was so
swollen it came nearly to her chest. I reached for the pulse in her
wrist, but could not find it. When I moved the sheet back to feel for
one in her leg, I saw the umbilical cord hanging limply between them.
The placenta was still inside, infected. She was both septic and
profoundly anemic.

Tina arrived, and together we carried the patient to a delivery room
bed. She could not walk. I asked for the national midwife to put a
cannula in place, and called on the handset for our lab technician. The
woman would certainly need blood, and we needed both her blood group and
to screen donors. Tina and I finished our examination. We agreed there
was little choice but to remove the placenta manually and risk the
hemorrhage. I left to gather the necessary anesthetic drugs, antibiotics
for the infection, and ergotamine to help the uterus clamp to itself and
staunch the bleeding. While I was in the pharmacy, I threw two vials of
adrenalin in my pocket and grabbed a bag and mask. I can recognize last
breaths when I see them.

By the time I returned, she was worse. She was unconscious and her
breathing was becoming noisy. I started to assist her breaths. A cannula
had been put in place. I looked at the intravenous bag. It was running
too slowly. I didn’t trust it. We needed another IV. Better two. The lab
tech arrived, with the other Sudanese doctor. I asked, do we have blood?
No. Are you O negative? No. You? B. You? B.

Someone take over for me….no, like this…..fingers under here, squeeze
the bag like this….here, give me a cannula…an 18…. and a syringe so I
can get some blood for cross match. Someone go and ask the relatives if
they will donate.

The veins were tough to find. They were flat, and slipped one way or the
other. The other MD was working on the other arm. Couldn’t get it. No
central line. I felt for her femoral pulse. None. Her neck?. Barely. Her
breathing was becoming intermittent, agonal. It stopped.

Ok, keep bagging. Yup, like that. Faster. About ten times per minute.
Don’t stop.

I laced my fingers together, felt for the hard flatness of her sternum,
and started compressions.

Now, someone take over for me. Like this. Push like this. One, two,
three, four, five, breath…one, two, three….

I took a glass vial of adrenalin from my pocket and snapped its top off.
I drew up a milligram in the syringe, and pushed it into the slow, first
intravenous. I reached for her neck and felt for the carotid pulse.
None. I took the second vial of adrenalin, snapped the top and drew it
up. I pulled back her sleeve. HerI arm, above the cannula, was a
balloon. The fluid was trickling slowly underneath her skin, not into
her vein. No intravenous, no fluid, no blood, no adrenalin, no breathes,
no pulse. No more. I checked her pupils. No response.

No more. Stop.

Fifteen minutes. That’s what it took, from the first crackle of the
radio to no more.

No death is easy. If it starts to become that way, one should change
professions, for his job has gotten the better of him. This one was more
difficult than most. The four of us stood for a minute, then bent
silently to clean up the ground of scattered, useless intravenous lines
and tossed pieces of gauze. We cleaned her body of lines, and wiped the
tiny bullets of blood that were scattered on her arm from all of our
attempts. We did not meet eyes.

I left the room. The baby was lying on the bed, crying. A man with wide,
wet eyes looked at mine, and he knew. Malesh. I’m sorry. Sorry I can’t
speak Arabic or dinka and about the intravenous and the baby and your
wife and the fifteen minutes and the no more. So sorry.

He wanted transport to the graveyard. I told him we don’t do that, that
we can’t. That we couldn’t save his wife, and that we can’t move her
body. He asked, what am I to do, hire a car, where, the market, where? I
don’t know. Malesh. Sorry. For so many things.

When I arrived back to compound one, there was a meal prepared for the
departure of a member of our team. They were waiting for me to begin. I
ate quickly and moved to my bed under the tree. I saw clouds for the
first time yesterday. They hung around the horizon, lurking. They were
still there. I could see their flickers of lightning. I lied there for a
long time, watching the flashes, and finally fell asleep. When I
returned to the hospital this morning, the body was gone.

Today, the rains arrived to Abyei one month early. They lashed us,
unprepared.

I was on call last night. I left the hospital at eleven, and was not called. still I woke every hour with a “was that the radio?” thought that somehow slivered into all of my dreams. I was up at first light. sleeping in is for inside.

it was 630 am and the compound was quiet. with a sleep headache behind my eyes, I laced up my running shoes and ran out of town. it is an important anchor in my day, to reach open space and find there the wide horizon. this morning, over the cracked flat earth a few kilometres north of abyei, the sun and the moon shared the sky with
dawn birds.

here in abyei, outside my hospital and in it, I am witness to the most beautiful things. yesterday I was walking in the measles recubra with a child from the feeding centre in my arms. measles had once again swept through our hospital and infected his mother. she was too sick to care for him, too sick to care for herself. I was
hoping to find a mother to help feed him until she was well. I looked at the beds, and saw a woman take the most
gentle care to offer her child water from a plastic cup, watching intently so that not a drop was spilled. the child refused, and the mother offered softly again and again. it was such a beautiful, intimate act of love. I asked the women in turn if they could feed this child along with theirs, even if just for a day, even if they did it in turns. they roundly refused. no. I will care for mine. I pressed, and they resisted. the fittest survive. here beauty and the hard truth of nature share the same recubra. like somewhere a butterfly fold her wings once, twice and take off on her jittery way, and as she does, a swallow swoops in, eats her, then wheels away.

I spent the morning at the tree I spoke of last week, in my letter to Samantha. we arrived early, and there were no patients. I walked out into a field nearby and a million birds flew by. the flock pulsed and changed like smoke. when I turned back, I could see bright flashes of clothing moving through the woods as people approached.

msf tree.
waiting room.

i saw a woman with this rash. if anyone has particular tropical disease experience, I am curious about what it is. she has had these diffuse plaques for four months, involving mostly the extremities andd sparing the palms and soles. it is pruritic. otherwise, she is very well. doesn’t appear HIV related. onchocerciasis? fungal?

it is now midday. most of msf has the day off for easter. the temperature is 49 C, by my thermometer. I don’t see james the falcon on my tukul anyore. but high above, the falcons drift on hot drafts of air. some move so high that they become dust, then disappear like an untethered helium balloon. the other night, my field coordinator fran and I were talking about how we would like our ashes to be reanimated. “falcon”, I said.

annie dillard once offered her opinion on whether birds fly for pleasure. she found her answer when she watched, from her window, a barnswallow fall from his nest in the loft, like a stone. just as he was about to hit the dirt, he spread his wings, skimmed the ground, and flew out of sight. of course they do.

it is easter. in lac la biche, Alberta, my family will be sitting together and watching cold ducks test the ice of the lake. they will have an afternoon meal and talk about the things they are thankful for. being grateful is a lesson I was taught well. it is one that the world keeps repeating. each of us is lucky to be alive and to be surrounded by people we care about. there are a thousand million ways it could be otherwise. but somewhere
an opaque reason met an impossible chance, and we are all here at the same time. it’s such a lucky thing, it’s hard to believe.

I wanted to add some easterness to this email, so that I could participate with my family, and my family of friends. I sit here, in my tukul, 49 C, sleep headache and all, content with the calm certainty that of all the luck in the world, I have been given the most. thank you for being the proof. all my love.

april 6.

most writing about Africa touches on its heat. touches on it, then jumps back with its burnt finger in its mouth. though I was determined to avoid the cliché, today I cannot. today, it is smothering. but at least it’s a dry smothering.

last night, at the omega point of my blackest most dreamless sleep, I was woken by someone shaking my mosquito net.

“doctor….hospital…..handset.”

I sleepwalked to the landcruiser and found my lab technician in the passenger seat, his head bobbing with microsleeps. together we rattled to the hospital where a three year old girl was taking her last few breaths. I have become an expert in these breaths. I recognized them as soon as I walked in the room. they weren’t real. they were a disguise. as soon as we nudged her, she would fall from the fence she was sitting on. the nurse turned
her over to administer antibiotics, I prepared to put in an intraosseus line, and she fell.

“malesh”, I said to the father. I’m sorry. I’m sorry you lost your daughter, I’m sorry that the rule here is that we arrive just a little too late rather than in the nick of time.

I walked from the emergency room. my lab technician had his head on the front desk. macrosleep. I tapped his shoulder and we got in the landcruiser. twenty minutes after I was called, I was back under the tree looking at the moon. it has been good company. we watched each other for a while, drifting.

I must remember, this isn’t a story about another three year old fallen from the fence. I should spare you that. those last breaths are my job, not yours. this is a story about heat.

I woke up this morning, underneath my tree, grateful for my thin sheet. it was dawn. roosters shouted. murmurs of morning voices carried through the thin grass wall of my compound. I lied there and listened. I was covered in sand. I could feel its grit in my mouth. a breeze lifted a corner of my mosquito net that had come free.

the day brightened, this day, the one right now. it brightened, and I moved the sheet from my body. the breeze started to blow warm. sweat started to bead on my neck. within minutes of lying and listening, I needed to move. it was too hot to continue. I lifted the mosquito net, shook the dust from my sheets, and bunched them in a ball at the foot of my bed. i walked to the kitchen, to find coffee, to find an orange.

by 9 am, i couldn’t sit in the sun. by ten I had moved into my tukul. I decided to write before I walked to the hospital on this, my day off. and here I am. it is 1039 and 40 C in the shade. it will climb to almost 50. I am typing with pieces of tissue underneath my wrists because sweat pools on my computer. I have taken my headphones off because it affords me another fraction of uncovered body surface area.

I will soon leave my tukul and walk to the hospital. I will step out into the sun, and touch the top of my head where I have just clipped it on the doorframe. my hair will be hot even after these few seconds. i will look down at my scrubs, and see dark sweat at my knees. I will walk 480 paces under a cloudless sky, walk it in zig zags, looking for any piece of grey shade, no matter how narrow. fence, lightpost, piece of barbed wire. anything to break the sun’s insistence. the last 100 metres is across a dry courtyard, and the wind will sweep across it, gusting heat like bellows, into the hospital.

I will walk through the different wards, each hanging with their different smell of sickness, the hot wind stilled by the walls. mothers in the TFC will fan their babies, and the man in the back room, the one who I can’t decide what is wrong with him, why he is wasting away, he will lie on his back and stare at the ceiling. of the 51 patients, I will see the sickest ones. I will walk back, sometime in the afternoon, through the courtyard and its hot wind, down the road, then left, and enter compound one. I will walk to the kitchen and drink a litre of warm water from the freezer that was just unplugged. I will leave because I can’t stand the heat. I will walk to the shower and turn it on. the water will flow from the pipe, and warmed by the white sun, it will be almost too hot to bear. I will stand in the doorway and towel my hair, and by that time, the rest of me will be dry. I will return to my tukul, take the thermometer that is hanging by my plastic desk, and take a photograph of it. I will then post it here.

you feel the heat like a real thing, something you must push against when you open a door. in other places, it seems like it comes mostly from the top. here it comes from all sides. you leave the doorway, and it presses firmly on the back of your neck, moving you towards the ground, like it was scolding you. you walk past the metal gate, and it hits you like punch. you bend to pick up a cold box left in the sun, and touch the metal handles and get burned. all sides.

that is my final word on the heat. my tissues are soaked through. forgive me this digression, but now i can resume with other things. like my vision of last breaths, the telling is an exorcism. perhaps with it I will be able to stop thinking of the white shock of diving head first into icy mountain streams, or sitting on a surfboard at sunset swinging up and down with the swells, or the clear silence before the snowboard lands ten feet below into a white cushion of dry snow that stings your face in a million tiny points.

but I doubt it.

Samantha wrote:
Hi my name is Samii and i’m in grade 6. I’m doing a speech on MSF. I think the stuff you do is amazing. You’re helping people who really need you. What could I say to help my classmates understand what MSF is really all about? We had people from MSF come to Kenora, in the fall. My mum told me about the presentation that they gave and i’ve read through the blogs and the website. Is there something that you would like to say that I could pass onto my classmates in my speech?[31/03 13:08:37]

samantha.

first, let me apologize for taking so long to write to you. i don’t
have much chance to use email here in rural sudan. i hope i am not too
late.

i am impressed that you are going to give a speech about médecins sans
frontières (MSF). it shows that you already know more about the world than i did in grade 6.

what is msf all about? so many things. perhaps it is best to start at
the beginning and explain where we are from. we were started about 35
years ago by a group of doctors and journalists, some of whom were first
working for the red cross in nigeria, a country in africa, others who
were working in bangladesh. up until this point, the red cross was one
of the only organizations that provided medicines and help to the worlds
poorest people.

because the red cross wanted to work in as many places as possible and
reach as many patients as they could, they thought it was best to not
speak about political things. they were afraid that the governments of
the countries where they worked would be angry, or make them leave. they believed that this silence was in important part of being neutral,
of not taking sides.

the people who started msf did not agree. they knew that the famine in nigeria was caused not by the weather, but by a war. they also believed
that the world needed to know, so that other countries could work towards a solution for the real problem. the nigerian people who were starving because of the war could not tell their own story. they were too poor, and too hungry. most of them had left their homes. the doctors and journalists who started msf in 1971 believed that in addition to giving medical assistance, they had a responsibility to say what they had seen, that they must speak for people who had no voice.

there are many more parts to the story, but for me, this is the most
important. it is where we get our name from. “sans frontières”.
“without borders”. we work all over the world, providing care for
people who otherwise would be forgotten. it is to these people that we
feel our responsibility lies.  we think about borders mostly when they
get in our way.

i have visited a few countries with msf. i went to bolivia where there
is an msf project to treat a disease called chagas. i hadn’t heard of
it either, don’t worry. but several million (million!) people in south
america are sick with it. the problem is that is the poorest, the
people with no way to get medicines, and no way to tell their story. the ones with no voice. the first day i arrived i had to cross a river
on a horse to get to one family, to teach them how to avoid it. it took
most of the day. for just one family. i visited some places in africa
where many people are infected with hiv, and most are so scared they
don’t want to know if they are. there msf teaches them, tests them, and
gives them medicines. they get stronger, not just from the pills, but
also with the knowledge that hiv can be treated and prevented. they
tell two people, who tell two more, who tell two more.

the other day, in sudan, hot hot sudan, we did a clinic far away, under
a tree. people came from all around, some even on donkey. there were
no schools nearby, and little water. some mothers had six children or
more, and some of these were very thin. because we had many patients
with measles in the last month, it had been a long time since we had
been back to this area. the patients were happy to see us. one of the
mothers said, “we were afraid that you were not going to come back. we have no government, and no schools. without this, we have nothing.”

i am not sure if i have done a good job of explaining what msf is about. it is about all of the things above, but it is about this too, this email, this blog, and your speech to your class. it is about a greater understanding of the world, and a greater respect for people no matter where they live. a recognition that people who suffer from borders the most don’t get a chance to draw them.

maybe one day, some of the people in your class will work for msf, or an
organization like them.  it’s not easy work. one thing it has taught
me, the more i know about the world, even the hard parts, the more i am
able to love it.

i hope you have learned something about msf, and maybe even about
abyei. the next time i visit the tree, i will tell that woman that a
girl in canada, samantha from kenora, all the way around the world, is
telling her class about sudan. i think it will make them feel less alone.

thanks, samii. good night.

James takes us on a personal video tour of the MSF compound in Abyei, starting from his original tukul home, to the new home under the stars…

http://www.youtube.com/watch?v=cg5ac6lB23w

if you are a dinka child, say, 13 months old and have around your waist
a circle of beads looped twice, mostly white ones but every fifth is a
blue like the dawn sky,  and you are naked and lying on the
cracked black plastic of a hospital bed in the abyei emergency room at
ten pm, and you are surrounded by your mother and father a nurse and a
midwife who is trying to blow air into your lungs with a mask twice too
big, and it’s not working, and the Canadian doctor arrives in time to
watch you take your last ten breaths, and you stop, and you die, then
this is what happens.

your mother screams.  your family outside of the emergency room,
an impressive number of aunts, uncles, and their friends, start to
wail.  your father sits down on the other bed, impassive.  he
puts his face in his hand and looks through his fingers.  your
mother leaves, and the emergency door shuts behind her.

a nurse puts one hand over your eyes, and uses the other to close your
mouth.   he holds them both closed until a piece of cloth can
be placed over your face.  through it, he keeps your eyes and
mouth fast.  another nurse begins to wrap gauze around your head.
again and again and again, until they are sure your mouth and eyes are
closed and safe.  the midwife removes your intravenous and cleans
your skin of blood.  someone takes a small piece of string and
binds your large toes together, to keep your legs closed, then wraps
your feet.  your hands are placed grasping the other, and your
thumbs are bound.    your fingers sit like piano keys,
folded neatly next to the other.  your hands and your wrists
are covered with gauze. last, you are lifted onto a piece of coloured
cloth, and wrapped a final time.   the door is opened, and an
older woman (your grandmother?), comes and takes you from the room.

from there, where?   this is where I lose you.  this is
part of the story I can’t tell.  my story goes on at a thousand
miles an hour,  different things in all directions, so many I
don’t know where to begin.  but yours is done, and there is one
bit of it I don’t know.  this tiny, final mystery is yours to
keep.