Suddenly…Sudan.

I am to fly out today. i will drive to agok, 30 km from abyei, and wait by the cracked landing strip with a few other desperate travellers each scanning the sky for a plane. the first thing we will hear is a thin drone. we will move from our landcruisers into the harsh light, shield our eyes, and look for a spark of sunlight glancing off the white metal frame of the WFP plane. the drone will grow louder (there it is, someone will say), and we will watch the plane approach, circle, make a pass at the airstrip to frighten animals and look for errant bricks or logs, circle, then land in a dust cloud. as the engine whines down, two pilots will jump from the small cockpit, light up cigarettes, completely unimpressed with this, already their third stop in a brown, scrub town, in the no(middle)where. one will start to scan the manifest as the other walks behind the plane, hand on his hips, and opens the luggage compartment. we will grab our bags from the car, and walk out onto the strip, acting nonchalant while secretly trying to beat the others to the pilot in case there aren’t enough spaces on the plane. we will hold our torn paper tickets to him, which he will ignore.

“name?” he’ll ask.

“maskalyk.”

“masaly?” he’ll say.

“sure.”

“get on the plane.”

i will. i will hook the seatbelt over my lap, and ignore the uncomfortable bar of metal under my sacrum. I will listen to the sparse instructions, a promise of turbulence, and cram my bag under the seat. the props will twitch, then turn, then blur. the plane will jerk to a start, turn around on its heel, bump along over the dry ground, gaining speed, and lift smoothly from sudan. agok, and abyei, will fall from all sides.

in sh’alla. WFP, in addition to its correct acronym as the World Food Program, is also known as “where the f is the plane?”. our nurse, andrea, finished her mission on sunday, and left for agok in a flurry of hugs. two hours later she was back on the veranda, lying on the couch her bag beside her, unable to catch up with the rest of her that had already collapsed on her bed in Geneva, exhausted. as such, we temper our expectations. we will leave if we do, if like everything in sudan, it is god’s will. I will be in the sky, hanging on as the plane drops like a stone through an air pocket, if I am. if not, I will be back here, hanging on until I fly.

shamefully, in a week full of important news, this post has avoided it all. I will write more from Khartoum. in sh’allah.

at the entrance to compound one, there is a white board on which all of our movements are recorded. it has room for 2 weeks of Mondays through
Sundays. when a week runs through, it is wiped off the board and replaced with seven more days. it flips through time like those old
clock radios did numbers. I watch people arrive from two weeks away, and from days back, watch them leave. underneath may 30, in scrawled felt
pen, sits my name. “Out: Dr. James – R&R”. like a marathon is a 20 mile jog to a six mile race, so to this latest push. one foot in front of
another, one day at a time, and on may 30, I will meet my felt self leaning against the plane window pane, and I’ll fly away.

as I have said before, I would write about other things in my life if there were other things in my life. for now, there are only these.

a woman in the single room at the back, a cursed room that no one leaves, is wracked with tuberculosis. she walked for days to come here. this
week she delivered a baby prematurely. he was no bigger than a bird. I showed up in the morning and looked into the room and saw two stacks of
breathing bones hanging onto each other. skin and angles.

I need to tell you other things. I don’t want this to be too much for you once, when I was walking through MoMA [Museum of Modern Art, New York], I watched a man lead a woman around by her arm. he would stop at a painting and say, “this one… this one is… modern. abstract… it is a large canvas, perhaps 10 feet wide and six tall… the background is yellow, and there are thick blue strokes carrying away from the centre that fade to grey as they near the edge… in the bottom left is a thin circle of white… ” she would pause, imagine, then touch his elbow. they would move to the next.

there are snakes in the hospital. every few days you can see a cleaner carrying one to the waste area, draped over a broom handle, beaten
flat. earlier in the week, we found one on the bottom tray of our delivery room trolley. our midwife nearly picked it up, thinking it was
a rag. the next day, they found one in the single room at the back, beneath the bed. the baby died later that day. cursed room.

I visited Pablo Neruda’s houses a decade ago, in chile. in the one in Valparaiso, you can see the ocean from every window. in Santiago, the
china cabinet in his dining room was a secret entrance. when he had new guests for dinner, he would enter through it, surprising them all, and
calmly sit down. at the door were a pair of shoes twenty times larger than a man could wear. he bought them from a cobbler who made them to
hang above his store.

today a boy came from “far away” to the hospital, accompanied by his father. his leg was full of holes from an infection that had festered for two weeks. he was thin from it, all angles. I lifted his leg off the bed to look at the other side, and it came apart at the knee.

last year, I went camping with my friend jehan. we paddled for hours to find our own lake. we set up camp, and the next day, in my hammock,
after a cup of strong coffee, I ate a plum for half an hour.

our new nurse arrived yesterday, full of nervous energy. she toured the hospital and saw her first starving child. she told me about it.

“yeah, I saw him too… he probably will die,” I said.

“I don’t know how I am going to get used to that,” she answered.

“you don’t,” I said, “you just accept it.”

when I was in Bolivia, in Copacabana, I got lost. I was looking for a restaurant with a hand drawn map I could make no sense of. as I gave up,
I caught the faint strains of a violin. I couldn’t place where it was coming from. I turned down one street, then another, walking further and
further, following the music. I finally arrived to the edge of a valley, outside the town. across it, on the other side, light poured out of a
large house, and with it, the sound of an orchestra blared, echoing strings, horns, piano, thick drums. the moon was fat, full. in yellow
light I sat down on the top of the cobblestone stairs that lead into the valley, and listened. an orchestra. here? a music lover. this late?
here? the movement finished, and I stood, dusted myself off. I turned to walk back, full of thoughts, a witness to a beautiful mystery. I saw a
man standing at the door of his small house, holding a baby in his arms. “que pasa?”, I said, and gestured back to the valley.

“ella esta muerta,” he said.

she has died. of course. a dirge.

a few days ago, I was standing over a boy whose leg was wrapped in bloody bandages. I asked him what happened. my uncle found a grenade,
and he was pulling at it. I told him to stop, but he didn’t. his uncle’s body was lying in our tent, a hole in his stomach, through and through.
the boys leg was badly fractured by the explosion. we took him to the operating room, but his hemoglobin was too low to give him general
anesthesia. the sedation and local anesthesia we used was ineffectual, and as we cleaned the shards of bone, he begged us to stop in a
language we did not understand.

last year I was working at st. mike’s hospital in downtown Toronto and walked into a room to tell a man that he had a badly broken jaw. “what happened?” I asked, “…if you don’t mind telling me.”

“well, I’m not from here, you see,” he replied in a thick native Canadian accent, through clenched, broken teeth. “I came from the nort’. looking to get a job as a counselor. I don’t got any money, and don’t know anyone in the city, at least not yet, so I’m staying at a shelter. it’s not good. lots of drugs. so tonight I saw someone, a brother, selling. I walked up to him and said, ‘what are you doing? you’re poisoning us, you’re killing your brothers and sisters. don’t you see that?’”

“they got angry and chased me, then I guess they broke my jaw. but I’m not done with them, doc. I’m just getting started.”

he is the only hero I have ever really met.

six days. now it’s a race.

it’s not just a jane’s addiction song.

tired.

the sky looks like it will fall. after a dozen cloudless mornings, blueblue afternoons, and sweltering starred nights, heavy black clouds
hang above us, looming, ready to crash down. the wind has whipped up sand, and as we rush to close our tukul doors, we can feel the tiny
stings from the whipping grains. never a middle ground.

with the change in weather, so too our moods. we are grateful for any texture in our days, even more for the respite from the heat, a chance
to lie in our beds and listen to the soft patter of rain on our grass roofs. the rainy season has been slow to come this year. we wake up each
morning and with all of abyei, scan the horizon for clouds.

the atmosphere is different on the ground too, in town. tense. waiting for the change, for the sky to fall. there was a fight this afternoon, and someone was stabbed. i was in the hospital when it happened. I left the operating theatre, and found a crowd of people outside of the emergency room, huddling around its closed steel door. every so often it would open, a nurse or doctor would enter or leave, and close the door behind them. what’s going on, I asked my translator who was leaning against the wall. hitting… with knife, he said. I pushed through the crowd and rapped on the metal door. it opened a crack and an eye peered out at me.

as I walked in, people from behind tried to push past me, to enter theroom. I held them back, moved them gently back into the throng, and closed the door. the room was full already. it was difficult to move. three nurses, soldiers, relatives, another medical doctor. “ok, everyone out. except staff and one relative. please. everyone. you. you. you. out.” reluctantly they left, one by one. as they did, others tried to push back in, removing their hands from the closing door only at the last minute.

a young man was lying on his back, eyes wide in terror, his shirt red with blood and so was the bed. two IV’s, I said, 19 gauge, and open them. call the lab technician for a blood group, and ask outside for a donor. blood pressure?

this was the medicine I do at home. like waking. I examined the patient, and his wounds. there were two, one was definitely superficial, but the other I couldn’t tell if it went into his chest, or possibly his abdomen. his stomach was soft, his breathing clear. that’s good. I put on sterile gloves and poked my little finger into the hole. it didn’t pass through to his lung. I could feel a spicule of bone, as fine as a tooth on a comb, that the knife had sheared off, but I couldn’t feel the thin tract of the blade underneath it. perhaps the knife had bounced off of it, continued on a harmless path.

we decided to go to the OT and explore the wound. I opened the metal door, and the crowd outside had grown. at least 30 people, more arriving
through the gate. 2 women had thrown themselves on the ground in grief, wailing, rolling. someone tried to push past me. no. he stood fast. so
did i. there were too many people for us to navigate a stretcher through. the little courtyard was nearly full, tilting towards chaos.
please move, I said, stand at the gate. I will come and talk to you soon.

some of our staff arrived from the compound and helped push the crowd back. we closed the gate, and people leapt over it. we started from the
ER with our stretcher, people trying to follow from all sides. i ran interference where i could. we blocked the entrance to the OT, and went
inside.

we prepped his chest, and cleaned the wound. I tried to pass forceps through to his abdomen or chest, but it appeared the track went
underneath his skin instead of inside. so lucky. both of us.

I left the other doctor to close the wound and went back outside. most people were now at the gate, their backs turned to the hospital,
watching a fistfight across the football field, half a mile away. I spoke with them.

I walked home an hour later on my worn path, with my translator. today is a difficult day, he said, I don’t think I will make any movements tonight. I agreed. a good night to be quiet at home.

but, he said, you know, abyei is better than before. two years ago, no one left their homes. the market would close early. everyone was too
afraid. you could wake up one morning and step outside and see a dead body. it wasn’t safe for anyone. well, it seems much better now, I said.
oh yes, much better, he said. safe. now there is peace.

peace. after so much war. i hear that word all of the time, use it all of the time, but never did it sound so correct, it’s meaning so obvious. the difference between then and now was complete. like the change in the sky.

it is one of the reasons MSF is here, of course. not simply to show solidarity with a population torn by war, but to encourage peace. we do
it by being neutral, siding only with the sick. we make a place, the hospital, where everyone can find respite, regardless of which tribe
they claim, or which border they cross to get here. but we also did it when we first put up our flag, already brown and frayed. we needed, from
the beginning, to guarantee the safety of ourselves and our staff. the local authorities work, in part, to keep the roads safe because if they
are not, we will not be able to move. the hospital must be safe or we will not be able to work.

the rain is starting. i am to bed. a good night to be quiet, and i hope the people of abyei agree.

that boy, the one whose bone we drilled into with an hypodermic cannula, the one who i used as an example of our small therapeutic successes, the one who came to life after lying dry, drooping in his mother’s arms, he died. i was told the next day. the cannula had stopped working, but he was drinking. an hour later, when the nurse next went to check, he was dead. a husk.

diarrhea is a killer. i see it nearly every day. it kills children, turns them to husks. the work it takes to keep their machinery turning
with the desert outside and one inside, is simply too much. they cave in, exhausted, and creak to a stop.

this past month has been difficult. brief spates of rain provide groundwater, then the clear, hot days that have followed have allowed it
to stagnate and teem with bacteria. the mothers, themselves undernourished, supplement their childrens milk with unpasteurized cows
milk. they develop diarrhea, and water falls out of them faster than it can be put in.

several children have died this month. it weighs heavily on me. dying of dehydration in the hospital seems an unforgibable crime. we have water.
water, water, everywhere. plain water, boiled water, filtered water, chlorinated water, oral rehydration solution, resomal, intravenous
ringer’s lactate, normal saline, dextrose 5%, dextrose 10%. everywhere.

so i have been watching carefully. my team, the nurses. i sit with the mothers of the children, watching the drips, the sips.

when a child is conscious enough to drink, we allow him to replace his own fluids, helping out intravenously only when necessary. we give the
mother a syringe, and a cup of oral rehydration solution. we ask her to give the child enough to replace the losses from the diarrhea, and a bit
more to replace what has already been lost.

i was on call last night, and watched a mother help her child, around 10 months old, drink. she took the cup of ORS, and held it to the childs
face, and poured it into his mouth. he drank greedily, pulled the cup closer, and she poured. he started to cough. she stopped. he gestured
for more. she poured, he coughed. and coughed. still coughing. he grabbed the cup. more. pour. cough. more. pour. cough.

this mother, perhaps 20 years old, watched her child slowly cave in for days. she watched, and hoped the diarrhea would stop and he would be
whole again, that he would laugh and cry and grow. when he didn’t, when he was so dry he could no longer lift his head, she tied him to her
chest, bundled what she could and stacked it on her head, and walked for three hours through the hot afternoon to abyei. there is a place in
abyei, she was told, where sick people go.

so she left her home in the brush and came here. it was not easy. she has 2 other children at home. her neighbour reluctantly agreed to watch
them (“but only until tomorrow! i have four of my own.”). the town is different than hers. noisy, dirty, so many things at the same time. the
people are different too. faster. she knows noone. she walks to the main road, and works up her courage to speak to a man waiting to board a
rusted bus. my child is sick, she says, there is a place? over there, he half points over his shoulder, indifferent. no, over there, someone
behind her says, and takes her by the elbow and turns her around. there.

she arrives through the front gate of our hospital and it is chaos. people are lying on floors, others are pushing to get them registered.
someone jostles past her with a bag full of bright pills. she takes the bundle from her head, and sits beside it on the floor, her dry baby tied
to her chest. she cleans the diarrhea from her dress, from his buttocks, and she waits.

after an hour, the crowd begins to thin. a nurse walks by and asks her what she wants. my child, she says, is sick. diarrhea. she uncovers him,
and holds the drooping boy, his eyes half open, up to the nurse. did you register, the nurse asks. what? nevermind…..come with me.

her boy is taken past all of the patients, directly to the nursing room. she follows, wiping embarassedly at her stained skirt. the nurse lies
the child down and starts poking in his skin to find a vein. he finds one. a doctor is called, and an infusion is started. bright, clear water
drips into her child’s limp arm. after some minutes, he stirs.

now, the nurse says, handing her a cup of ORS, your child is dying of dehydration. he needs this water. he doesn’t have enough. it is from the
diarrhea….if it continues, and he doesn’t get enough water, he will die.

she is taken to a bed on the ground. she sets her bundle beside it. she sits down, picks up the cup, and holds it to the childs lips. he drinks
greedily. cough. more. pour. cough. pour. cough.

it is obvious that he is aspirating. his thirst is so strong, he will take in water until it fills him completely, fills his stomach, his
veins, his cells, his lungs, until it drowns him.

i stand up, and walk over. slow, slow, slow, i say, and take the cup from her hands. i retrieve a syringe from the nursing room, draw up some
ORS in it. i put it into his mouth, and push out a few drops. he grabs the back of my hand, thursts the syringe all way to the back of his
throat, tries to swallow it. i pull it out, and wait. after a minute, i put it back, and he pulls it in, gnawing it with his dry blunt bumping
gums. a few more drops. just small, i say to the mother, small small.

i ask the nurse on duty about the child last friday. did he die coughing? yes, i think so.

just small small, i tell him. little bits at a time. like our successes.

closing time.

girl at the door.

walking boy.

hospital bed.

looking up.

blue ward.

light switch.

hospital room.

water.

emergency room fan.

sunglass graveyard.

I have been in sudan for over three months, but I have yet to fully arrive. I wonder at times if I ever will, if it is even possible. it seems part of me remains in canada, watching my friends and family through a thick glass wall, unable to hear them or touch them. another part of me is waiting on the plane, looking at his watch, ready to leave as soon as the rest of me shows up. it is an uncomfortable feeling, one I am not accustomed to, having parts missing.

at home, I spend as little time as I can in the past. the parts that I need I carry with me. I rarely look at photos. I have a box in which, out of habit, I throw in all the cards and letters I have received over the years. I have never opened it. I broke my rule last night and went through a series of old emails. Halloween plans, last minute trips to brazil, new york tips, party invitations, love letters. each memory that they revived seemed embedded in a nostalgia like in ancient amber, static and irretrievable, varnished with a sad certainty that would never again be alive.

this morning, I opened the honey jar, and inside floated an ant. I held the jar up to the sun, and his wire frame swayed gently. for an ant, the sweetest of deaths. amber.

I also work on avoiding the future because I will never catch up to that part of me that is already waiting on the plane. when I make it there, he will already be through customs, and on the cab ride home, he will already be having a glass of wine on the roof, watching the sun set, surrounded by friends. if I spend my time running to catch up, I find myself only running.

so, I work on here. 11:09am, Friday, May 18, 2007, in my tukul, compound one, abyei, sudan. the sky is mercifully cloudy. a bird is tapping for termites on one of my posts. a small lizard poked his head around the corner, and just now, ran underneath my clothes trunk. a larger one, a foot long or more with a yellow head and tail, is clambering up the brick wall of another tukul, and is doing push ups, peering around the corner, looking for locusts.

every now and again, it rushes in. not just for me, but for all of us. we arrive, completely, even if for a short time. we sit in the middle of our compound, reading, and the donkey boys show up with our water. the glass falls away, and you remember, right, I am in Africa. donkeys deliver our water. a boy walks to the hand pump, waits his turn, grabs the hot, sweaty handle, and pulls up cool water hidden underneath the sand. he collects it in dirty plastic buckets, heaves it onto the back of his donkey, and together they walk to the msf compound, through the gate, to our water tank. there they stand now. such hot work… and someone calls your name, and you are gone.

I lead a medical meeting once a week, and this most recent one, I talked about how I partly manufactured the fatigue that I felt. I explained that some of it was due to a belief that I needed to help this project arrive to a new, better place. that the goal was constant and swift progress. towards what, I didn’t know. for every inch i drew closer, it moved an inch away. but, I recently realized, with some relief, that we are doing what we came here to do. we are putting the correct medicines in appropriate amounts into the hands of people who otherwise would have none. at the end of a day full of frustrations, radio calls and illness, we are doing what we came here to do, and in my opinion, we are doing it well.

i asked them to follow me, and walked into the emergency room. inside was a child who was so dehydrated from diarrhea he needed an intraosseous catheter. earlier that day, I had taken his limp leg and showed my team how to drill the cannula into his bone. the child was so near death, he didn’t flinch. six hours later, he was alive, clinging to his mother.

so, that’s what we are here to do, I said. this is the success, this little boy. if all of our ambitious goals never come true, and in the six months that we are here, we never reach that vague ideal future, at the least we have this boy, and the one exact world he carries inside of him. tomorrow, a little girl. the day after, a woman will deliver twins.

it is a constant work to be where one is, and if one arrives at all, it is never for long. what I know today may be lost in the static of tomorrow’s busy-ness, but, like all things, practice makes practiced.

thank you all for your wonderful words in the past week. I am the lucky recipient of more kindness than I can hope to repay. my sincere gratitude now, and always.

last night, at 4:30 in the morning, I woke to the brrrrrr… brrrrrr… brrrrbrrrbrrr of gunfire. it was difficult to sleep after. I expected a call on the handset, another dead body, or someone wounded. or worse, more gunfire. it never came. I turned on a rusty fan that clacked so loud no brrr’s could be heard above it, and eventually fell asleep. in the morning, I asked my team in turn. no one had heard. my imagination? finally, I asked the guard. he heard. it a birthday celebration, he said.

it hasn’t taken many rains for abyei to dust herself off. the cracked, dry expanse that raced away from us to all sides is now a verdant green. I have been told that the grass will grow so high, it will be taller than a man. right now, the countryside looks like a sparse fairway, every bit of green so new, it is the same size.

we have started receiving more measles cases in the hospital again. the first few arrived earlier this week. I went to the hospital with my field coordinator to see them. from down the hall I said, “yeah. it’s measles”. my field co asked me how I could be sure. I told him we had seen 150 cases in march.

the man had come with his measled sons from north of abyei. they were nomads, and were moving north with the rains when his children became sick. the boys were ill, but they would be alright in a few days. the father was very nervous. he kept on pointing to where the problems were. the rash, their chest, their eyes, their throat. I said, ok. ok. ok. we’ll take care of it. how long will it take, he said? five days. he was aghast. they needed to move. I pressed, said that not only would I need that time to make sure his boys were alright, but the measles would spread, that it would make others sick. he was reluctant. he asked if he could use traditional treatment to put on the rash, and pulled two sachets from the pocket of his white robe. I took them from his hand, and smelled them. fragrant herbs. sure, I said. we shook hands.

the next day, my field coordinator and I went to the area the measled family came from. it is the only the third time in more than three months I had left abyei for the countryside. I have never moved so little in all my life. I watched the ground blur beside the landcruiser and was struck by an overwhelming pleasure to be travelling so fast again. I stuck my hand out of the window into the hard current of air and the world whipped by. we passed by women balancing white buckets of water on their heads. back and forth they went, sometimes for a kilometre or more, balancing. I wondered if they felt a pleasure to be back on ground after stepping out of a car, a relief to resume their familiar cadence.

we made several detours, from small village to small village. in each, we would shake hand after hand in a growing crowd determined to participate in the day’s most interesting event. after several minutes, we would sit down only to stand up to shake more hands. at our third stop we were pointed in the right direction. several people, we were told, were sick with measles, just down the road

we drove where we were told, parked the landcruiser on the side of the road, and walked into a forest. a month ago it would have looked like scrub, but now, the floor was thick with grass, and there were green buds on the trees. through them, we could see families gathered around brightly coloured tents. they were a different tribe than the ones we most commonly see around abyei. muslim nomads, moving north with the rains, likely missed by the measles campaign. their children ran back and forth between their scattered camps and dogs followed them, barking. it was a pastoral scene, sharply contrasted to abyei’s crossroads of cluttered busy-ness.

we went from one tent to another. beside the family’s possessions, all carefully packed and tethered, ready to leave at any time, we often found a sick child. “we’re going to reach Khartoum if we keep on following the measles”, said my translator, surveying the bright swatches of color through the branches.

we offered each family, in turn, transport to the hospital. they all refused. it will pass, they answered. we need to move.

I treated the patients that I could, and we promised to return on saturday, to see if there were more cases. in the meantime, they should isolate the sick patients, make sure that only adults with measles should be in contact with them. I watched the children run back and forth, throwing sticks and chasing dogs. the prospect of them staying still was small.

we climbed back into our landcruiser, and roared back to abyei kicking up a tail of red dust.

at this point in the story, the character’s eyes are closed nearly all the time. despite the fatigue, sleep eludes him. he is replaced with a halfness, a part of him awake, part of him not. at night he sleeps in fits. he approaches dreams, but never quite arrives. this morning, while walking to work, at the corner, the one with the half buried tire, a mini cyclone picked itself up off the road. it whirled dervishly in widening ellipses, then blew itself into a closed green door, opening it. his eyes met those of the man seated behind it who calmly stood from his chair and closed it again, as if cyclones came knocking all of the time. the character thought to himself, who needs dreams when days are so extraordinary?

i am more than halfway through my mission, and am overdue for a break. though my time in ethiopia was more about tuberculosis than rest, it did allow me to step away from abyei. so i delayed a vacation partly because i wanted a true experience, to spend my full time in the field, to arrive at all the important points in the mission so that i could better understand them. i have discovered that fatigue, however, is like the personal experience of illness. though being sick is valuable, particularly as a physician, because it increases ones empathy, only a fool would court it. so too exhaustion.

but, here it is. a halfness. i remember talking with friends about how i could manage to work during my residency, to spend 30 sleepless hours in the hospital, leave it to sleep, then return. i explained that the last thing to leave was my capacity to perform medical tasks. i could sort out a high potassium at five in the morning. what i lost was my ability to do it as myself. to enjoy it, to make the patient feel less afraid, to offer them something beyond the task. i would walk in, inject the proper drugs in the correct amounts into their IV, mumble something neither of us understood, then stumble out to do something else.

the tiredness i feel now is different. it has been a slow erosion. bits of sand have ground me down. i can still recognize the best things in the day, but am just not able to participate in them fully. half.

part of the slow erosion has been due to being on call all of the time. every third or fourth night, i take emergency calls from the hospitals, dealing with new cases or inpatients that worsen. no matter how busy the night is, the next day is a full one. the other nights, i still sleep with the handset. if one of the doctors or medical technicians has something beyond their abilities, they call me. trauma, obstructed labour, sexual assault. it doesn’t happen every night, just enough, here and there, bits of sand. enough so that a hushed voice through a grass wall is a call through the handset, the sharp night crack of contracting sheet metal is the rap of the guard on my door.

i realized, during my long residency, that there is a merit to being on call that extends beyond treating sick patients quickly. one learns not just how to sort out high potassiums when there is noone around to ask, but also how to lose the voice inside that gets annoyed when you are paged at 4 in the morning on the friday of a long weekend after just lying down for the first time all day. with time, that voice that says “so what if mrs. snow is having pain? does she know what time it is? how tired i am? that i haven’t eaten?” fades, and is replaced by, “i’ll be right there”. it is beaten out of ones spirit by thousands and thousands of repetitive beeps. and, with it, that dissatisfied narrator that wishes only that things were other than the way they were, grows quieter in general.

some members of my team have suggested that i not take call, that we have enough staff to make it possible. i have thought about it, but i think i would miss it. caring for someone who is sick is such an incredibly human act. often, it makes up the best part of my day. I get to meet someone, someone new, listen to their story and feel their anxiety. I get to to touch their child’s forehead, then quietly listen to his heart. and sometimes, I get to put my hand on the father’s shoulder, tell him that everything is going to be alright, I promise, that i can’t say such things very often in abyei, but this time i can, and at least today, this child, his child, is going to be ok. and i get to feel the coolness of his relief. i am more at home in the hospital than i am in my tukul and my tangled bed.

one of my friends once told me that once, when she was having a personally difficult time (someone in her family was sick and her relationship was deteriorating), she poured herself into her general practice. the more she worked, the more patients would stop on the street and say “hello, doctor soandso”, the more they would send flowers. not only was she caring, she was being cared for. of course, in the end, this was not an equitable relationship, not the true contact someone needs to feed their bruised spirt, and after several months, she burned out.

i will not, though i can feel the heat. i can understand it better. i am due for a break in 16 days. i started counting yesterday.

one of the members of our team is approaching the end of her mission. she has been here for just over five months. I have watched her go through the stages that I have gone through. I am watching her now try to stifle the excitement she has for going home, trying to save it for when she steps onto the plane, for when she will be able to believe
it. our field coordinator, maurizzio, was talking about what it is like when one’s mission ends. you leave from Khartoum and step off the plane in Geneva, and the world you left, collapses. disappears.

i am not surprised. we completely inhabit it, focus our entire energies on it, but as soon as you queue up in the airport to get a starbucks latte, it will seem as far away as the moon. but that is why I am writing this. to convince us all that it is not. that it is right here, that today is Friday May 11, 10:20 am, and a lizard is crawling around under my feet, that the wall of the tukul is already hot, two tiny blue birds are hopping just outside my door (always in pairs, these birds) and the hospital is just down the road. soon someone will pull up on a donkey cart and carry their sick child into our emergency room because they heard they can get medicines there.

of course, I can only do a small, imperfect job. I have a hurried half an hour to write something in one copy, maybe post some photos. I can’t bring you here, as much as I would like that. much of the perspective gained is mine, and perhaps I will only realize it completely for a split second as abyei disappears into the horizon of my memory.

part of the secret to my happiness here has been to not think of the future, nor the past. to imagine my day only as it folds into the next one. every thought that starts about my vacation, or how much I miss careening around Toronto streets on my bicycle, I let the air out of it like a balloon. I can only be here.

but, if I could be anywhere else today, I would be in Alberta. I would be driving down the country road to my home, the one I left a decade or more ago, the only one I have ever really had. I would pull into our driveway, and drive slowly up it, stones popping from underneath the tires. i would stop, shut the car off, and listen to the calm smooth silence. i would open the door, then the trunk, grab my bags, open the gate, and walk inside.

almost tough to type that, I can imagine it so clearly. and as clearly, the delight on my mother’s face. mine would be just as strong of course, but I have learned to hide it. it burns brightly, but just under the surface. hers doesn’t. it burns like a star. she is the most famous person in the world. trust me. if you met her, you would know.

if anything that I am doing requires strength, none of it is mine. it was given to me by my family. from my mother, and my father, and even from my forever-to-be-1/4-of-an-inch-littler brother. for none of them has life been easy, it seems to me not for even 15 minutes, but never has that seemed the goal. to live and work honestly, to give love and respect freely, to value most the qualities we aspire to most; these are the lessons I have freely received for my whole life. this is why I can bear the things that I do, because I know we are all quietly doing it.

so, mom, for all the things I have been given, offering my love and thanks on this one day doesn’t seem like enough. be sure, though, I manifest it every single day in every thing that I do. i know sometimes you wish you could be here, but of course, you already are.

thank you. love. happy mother’s day.

this is the part of the story when the character begins to get tired. when he walks his daily route, one that is so familiar he can do it with his eyes closed, he does it with his eyes closed.

yesterday, on the walk back from the hospital, a monkey loped past me. he cast a brief backward glance, then took a sharp left into the market. he was wearing the most amazing pair of sunglasses.

my morning run has been suspended recently so that I might concentrate more fully on smoking. unfortunately, I woke up over-early this morning, and could find no excuse to avoid it. my usual route, over a flat wide flood plain, has been made impassable by the heavy occasional rains. all that is left is to run along the red road that leaves town, and look nervously over my shoulder for over-full trucks. I take it to its first junction, and turn south. it is very early and I can see a corona form over the fields, much more clear than before, no refracting dust, and then in an instant the sun blazes, burns my eyes. people walk from the trees towards abyei over the cracked ground that drains rainwater like a sieve, and their white robes are silhouetted by the sun. morning ghosts.

everyone in our mission smokes furiously. msf. part of the reason is the isolation, the idle minutes. the end of a day, and there is no beer, no paper, no telephone, no email, no gym, no plans. as it has been said in many languages, when you have a cigarette, you always have a friend. the other part is that in the face of all the sickness and early death, one’s health falls from constant focus. you look around at the other passengers, and from all accounts, it looks like the plane is going down so you smoke ‘em if you’ve got ‘em. the other night we were talking about when we were going to quit. the question was posed to our admin. “me? when am I going to stop smoking? about here…” he said, pointing to the filter.

last night we had dinner with a man who has been in abyei for his entire life, lived through wars and famines as the only medic in the area. he told us stories of killings, how his friends would be woken up in the middle of the night, taken from their homes for no reason, and disappear. he told us that after the war, msf came to the hospital, and
found its beds full with dead bodies. he had so much work, he could not keep track of who was alive anymore. that was one year ago this month. I am the third msf doctor.

it was the end of a long, difficult day. earlier, a man, well-known in the community, died shortly after arriving in hospital from either botulism or guillan-barre. a young woman who remained feverish and unconscious despite both treatment for cerebral malaria and meningitis, had her blood pressure climb and climb and climb, until her heart
couldn’t bear it and stopped. probably a brain abscess. another severely malnourished child, two, eyes half open, stopped his half breaths, too tired from his last one to start another. I can’t figure out how to save them. look at them the wrong way, and they fall from the fence. these three in the past 24 hours, and at the end of a long, difficult day, I stood at the gates of the hospital with our national doctor. we looked
out at the rough football field. we were talking about paradise. he said that all religions in the world accepted that there was a place after this hard one. he asked me what I thought. I said that I wasn’t sure. that if there was something after this it wouldn’t be a place I could smell, or touch, or taste. in the same way I didn’t know what it was like before I was born, I probably won’t know what it was like after I leave. I said I thought this was heaven. this world. the one here, the one I can touch with my hands, and see move at a million miles an hour in a million directions when I open my eyes, the one that makes me feel so many different things. that somehow, each carbon atom in our body came from a star, and passed through millions of miles of cold space, and in a miracle too impossible to believe that we are here, made from stars, leaning up against this swinging gate, talking in the late afternoon sun.

he disagreed. too many people have nothing. too many eating grass. too many families leaving the hospital on ox-carts with daughters covered with thin sheets. what about them? I said I didn’t know. maybe it’s different things for different people. like a season with food, or one’s short life with his daughter. maybe it’s just that paradise doesn’t last forever, and it’s something we have to work on. he shrugged. we were through. we stepped from the gate and into the fading light. we walked the dusty road, both quiet, both lost in thought. at the intersection, we wished each other good night, and we went our separate ways.

I have been told that some years, in this season, a thin cloud appears on the horizon of an otherwise clear day. It approaches quickly with the wind and minutes later, locusts cover crops, cars, tukuls, and lie floundering in puddles. as I type this, one is doing a stop-motion crawl across my tukul floor. skitterpause… skitterpause… skitter.

last night I lay sick in bed, sweating, plastered to my sheets. I could neither sleep nor accomplish anything. I listened. donkeys braying, calls to prayer, generators clattering. but as I was drifing in and out, at once, above the usual noise, wailing. a chorus of cries from the hospital. another dead body. another throng of people and more, running from town, to join the mourning. I pulled myself up.

we have been having problems with dead bodies recently. not because of their depressing number; this is something the abyei hospital is accustomed to. other problems.

where to put them? we replaced the dusty room at the back of the hospital, a makeshift morgue, with a pharmacy. now when someone arrives to the hospital ten minutes too late, we flounder for space. in the emergency room? occasionally. it does little to instil live patients with confidence in the hospital, nor my skills in emergency medicine. in the tent beside the tfc? once. when the roof crashed in from all the rain (more later), the women refused to move their children into the tent. haunted. on the ground, in the back? too wet. in the room at the front? nope, full… measles patient. in the pharmacy? over my…

dead body problems. they don’t end there. as I alluded last week, we recently suspended activity in the hospital. an important ingredient was the police routine of bringing suspicious deaths to the hospital to confirm the cause. of course, in absence of an autopsy and a pathologist, my medical opinion mostly ends with looking for gunshots. no matter. it is area policy, and it is done. the problem in a place like this, crackling with political and military tension, is that it opens the hospital as a focus for confrontation. in our recent case, this is what occurred. like peace, war sometimes requires only a tiny piece of glass

to become real.

dead body problems. when someone is sick in a village, they don’t come to the hospital straight away. there is no road. transport is too expensive. often the family calls a traditional healer, and they spend their carefully collected money, likely saved for this exact contingency, for treatments that do not

work.. the patient worsens. there is no choice but to spend what money they have left to hire a donkey, or a car, and bring the patient to abyei. they don’t have enough, so they borrow from their neighbours. they use it all to get the patient to the hospital ten minutes too late.

they are grieving, and penniless. it is the middle of the night, and the body of their dead wife, daughter, mother lies covered with a thin sheet on the back of a donkey cart and they arrived to a place that deals only with live ones. there is nowhere to put the body, nor for them to sleep. pleading, they ask for our help to take the body to the graveyard.

they are penniless and heartbroken. we say no.

it is an impossible decision. we could easily take one of our cars, the pick up for instance, and offer the grief stricken family some relief in a day that has been immeasurably cruel. but we don’t. we cannot. we cannot be a hospital and a hearse service. nor when someone knocks on our compound door, his eyes as big as moons, and says “my wife, she is delivering at home, but the baby is stuck, can you take her to the hospital”, can we be an ambulance service. no, we say, you need to find a way, and we quietly close the gate.

they are impossible decisions because their wisdom is easy to see, but they are contrary to one’s spirit. once we start transferring bodies to the graveyard, the hospital becomes their destination. once we become an ambulance service, our resources become taxed, and we may go to destinations that are not secure. further, each time we are a band-aid, we simply cover the problem, and delay the slow work towards a tenable, permanent solution. but when a family comes miles over broken roads, carrying their dying

daughter, and they arrive ten minutes too late, when you tell them that no you cannot help them bury her though you have the means, and they ask you what they can do and you say you don’t know and turn away, the knowledge that you are being wise is poor comfort.

you want to drive each patient where they need to go until you run out of gas, use every last dose of rabies vaccine for the small chance the dog was infected and the child dies foaming, to give the starving family money even if will only feed them for a day, drip all of the blood into this patient, the human (someone’s father, brother, son, best friend )bleeding in front of you even though it means there might be none for the next ten, bbut today you have it, and today is his lucky day, and tomorrow you will worry about tomorrow.

but we don’t. we are measured, and careful. it is what tomorrow’s patients expect of us. and the tomorrows stretch forever more, and today is nearly done.

hospital wall.

hospital food

what hospital food does for kids

her growth chart.

abyei dusk.

one of the most difficult things for me to accept in sudan, among all of its hard edges, is that everyone has better sunglasses than I do. well, not everyone. mostly the old men. in my other life, I live in Kensington market in Toronto. when I am not working or running from once place to the next, I am wandering the streets of my neighbourhood trying to soothe that one hollow part in my spirit that the right pair of sunglasses would fill.

I don’t think this is a sign of inner dischord, representing a broader sense of dissatisfaction with the universe. nor do I think I should be looking for sunglasses inside my own soul rather than in second hand store windows or on the faces of old Sudanese men. I know this because once I found the right pair. i bought them in new york on the street for ten bucks. they were like blue blockers, except orange, and on the bridge, had a swordfish. with them on, the world was better. minty. I took them off only when necessary. last year, on my way to train with msf, sleep deprived and excited, I left them on the seat of a german taxi. as it took off, I felt a familiar ache.

it is a grand leveling that msf, as part arbiter of my sunglass woes, placed me in a country with such a high density of cool sunglasses. I could even begin to forgive their role in the loss of my perfect pair if I could track some down. when I was in Khartoum last, I spent an afteroon with a driver roaming driving from place to place, souk to souk, looking for some. he would pull up to a stand with racks of fake Gucci glasses and look at me hopefully. no, I would say. I want old man sunglasses. confused, we drove on in frustrated silence.

and now I am in abyei. the souk is full of carbon paper stores. the one selling cigarettes, powdered milk, tomato paste, lighters, and biscuits abuts another selling cigarettes, powdered milk, tomato paste, lighters and biscuits. there are two restaurants. at bashir cafeteria, one can take his chances with beans, goat, or if he is lucky, tomatoes. at the other, beans, goat, tomatoes. the worst part is, of course, the old man who takes your money has the best pair of sunglasses you have ever seen, but the market has none. I asked him one time where get them. he smiled, shrugged, and turned away. he could smell my desperation.

all this to say, I needed to write something that was not about my life here. something trivial. my days and nights are imbued with a reality where one has no choice but to lean up against the broken, beating heart of one of the world’s most broken countries, where some people eat grass and others fight viciously. at night, as often as not, I can’t sleep from all the ghosts. and when I wake up, and step from my tukul, the world is reflected in all of its sharp edges, and the light is harsh and unflinching.

hence the sunglasses.

our sites before the road was washed away. we set
off  early, with my field coordinator, along the red road that
stretches south.  we drove for miles, rocked up and down by
ripples in the clay, the din so loud in the landcruiser we couldn’t
speak.  no animals, few birds, only an occasional hut through the
trees.  the scenery was flat and austere.   after an
hour, a small dirt track appeared off the road, so faint that I would
have easily missed it.  our driver turned onto it, and we
disappeared into the bush.

the road was poor.  it was clear after a hundred metres with rain
it would be impassable.  the soil was loamy, the track dipped well
below the water table, and the trees were too thick to negotiate.
I recalled a day I spent in Cambodia throwing sticks on top of sticks,
trying to give purchase to my buried landcruiser.   once the
rains start, these people will be on an island.

we drove on for more than an hour, scattering troops of monkeys.
huts started to appear through the trees.  more.  a few
more.   roofs of grass held up by walls of grass and inside
them, beds of grass.    the families that built them
stood outside and watched us pass.

we arrived at the site of our mobile.  akur.  we found its
population last year while we were investigating a curious outbreak of
hepatitis.  several huts were scattered in an open area, and
underneath a large tree, sat a dozen men, community leaders.  we
had sent a message to the community to anticipate our arrival.

we introduced ourselves, and shook hands.  they offered us chairs, and sat down on plastic chairs, curious company.

they spoke in turn.  they thanked us for coming, thanked us for
giving medicines to people who had suffered so much during the
war.  they too were worried for the rainy season, not simply
because the water would choke their contact with the world, but because
it meant disease.  malaria, cholera.   they hoped that
we would continue to come.  and if not, that we would be able to
send them boxes of medicine.  people have no food, and as the
rains start, they begin to eat grass.  then they get sick.
diarrhea.

please bring us food.  please bring us a water pump.  please
build us a school.  please give us boxes of  medicines.

we told them we could do none of those things.  all we could do is
try to negotiate an increasingly sunken road until the day we could
not. our limitations seemed like refusals.

we asked about a road we had heard about, shorter than the one we just
traveled, one that lead to anet.  what was it like?

it was good.  it was shorter.   much better.  we
could use it during the rainy season.  they nodded.
yes.  definitely.   it is over there.  a car was on
it other day.

we stood up, roundly shook hands, and climbed into the land
cruiser.  nearby, women were gathered underneath a tree, balancing
babies on their hips.  they thought we were there to do a mobile
clinic.  we drove away.

it was not a road.  it was a path.   a bicycle
path.  it wound in fits and start.  it was blocked by trees
here and there, and more than once, it disappeared into a dozen
others.  we looked in vain for signs of a previous vehicle.
none.   for an hour, we pushed through the brush.
occasionally we would come onto a grass hut and a family standing
agape, children’s eyes peeking between cracks in the walls. “anet?”, we
would ask, and they would point east.

we remembered that we needed to call our base, and give them our
location. my field co picked up the transceiver, then set it back
down.  we didn’t know where we were.

the path started to widen.  underneath a tree, a four men leaned,
talking.  one of them was on a bicycle.  “anet?”, we
asked.  the man on the bicycle responded in English.  it was
just over there.  not far.  we asked about the road we were
on, what would it be like in the rainy season?  water, he
said.  all water.  you should build a proper road, he said.

we drove on.  more huts appeared.  their walls were clay, not
grass.  we were getting closer.  soon, the homes were thick,
and found ourselves we driving from yard to yard, and from there onto
the red road.

12 kilometres from akur to the red road at anet.  nearly two
hours.  nearly impassable now, in the rainy season, no
chance.   we turned in the direction of abyei, and started
our rattle home.  we passed a bus, a pickup with five passengers
jammed in the cabin and five more in the back, and a gravel truck
throwing up dust.

I thought of the suggestion of the young man on the bicycle that we
should build a road.  I used to misinterpret these requests, used
to think that they expected foreigners to do it all.  i understand
differently now.  they don’t believe that we should do everything,
they believe we are so powerful we can do anything.  if we can
rain tonnes of food from the sky, use strong medicines to make people
well, bring water where there is none, we can build a road.

of course, they are not wrong.  of all the ways the world has to
invest in its poorest places, in my estimation, roads are the
best.   like the dry riverbeds I saw from the plane, still
green with trees living on the memory of water, they mean
life.    energy spills from their sides. it can turn
grass into clay walls, even into food.

it was deep into the afternoon as we drove back to abyei, and the
clouds started to stack as they have in the past few weeks.  it
started to rain.  people in akur wondered how much time they had
left, and green buds of grass poked through the ground.

the last week has been a tense one. after I sent my last post, sent it through the air (somehow) to a satellite orbiting in the thin atmosphere above Africa that then bounced it to a server (somewhere) that deposited the correct words in the correct order in the MSF office in Canada and from there to a computer screen, after this series of small miracles, I hoped for another: to sleep through the night. it was clear, at 3 in the morning, that I had used my daily miracle quota, and I was called to the hospital. I didn’t sleep until the next evening.

I will not, because I cannot, go into details, but there was a recent spate of violence this week, and it has the whole town on edge. as the dust clears, it is apparent that it will not spill into a larger conflict, that the incidents were isolated and non-partisan, but it made for some tense times. an area wide curfew was enforced from dusk until dawn, no movements allowed. those of us who were on call slept in the hospital in case we needed to receive several patients in the middle of the night, and because we could not move freely from hospital to compound. twice, we suspended activities in the hospital, and gathered in our respective compounds waiting for clearance that it was safe to return. on the first night, a violent storm blew in, first covering us with sand, and then pelting us with rain. the first night, after my sleepless one, we huddled in the centre of our compound, silent, listening for shots above the ratatatat of the rain.

the violence, like the storm, has blown over. the town is slowly returning to normal. the market is again bright with flowered bicycles weaving through puddles, the nights loud with tinny music. but that first night, everyone was sitting, awake and quiet, training their ears above the rain, time stretching like in a dentist’s chair. and for many of us, we realized more deeply the work we had signed up for, that we had anticipated, even excitedly. now that it was closer, as we sat silently wondering if we were going to be in the middle of a chaos well beyond our control, the gravity of this place became heavier, and the reason for our presence more clear. it is, after all, what médecins sans frontières does.

I never did hear about the woman we sent for surgery that night until the next morning. after being refused, the surgeon changed his mind, and operated. after a c-section, her and abyei’s newest baby girl are ready to return home. a home that for the time being, and hopefully forever more, remains sudan’s best place for peace.