Dear Darfur…

What’s in the wadi?

I think the dust is settling a little bit here in Darfur for the time being. MSF is able to access the displaced populations and attacked communities to determine a strategic way to address the needs of the population. Almost everyday I go to and from work on a helicopter… it beats the office any day. It is very difficult to assess a community in 4-5 hours — but we are getting better at it with every Rapid Assessment.

My role is to systematically visit families and assess their demographics, living structure, and general health condition using rapid assessment techniques. The problem is my rapid assessments are neither rapid nor quick enough. As a nurse I am in the habit of focusing on holism rather then numerical data. Plus, I am always concerned that I am going to miss something by being too direct. A few days ago I was assessing an internally displaced persons (IDP) community and I came across a family who were making Alcohol! I think one of the grandmothers was offering me some but my translator would not participate in the situation and kept me focused on health status — maybe she was teaching me how to make it.

Being my translator is a difficult job, I ask too many abstract questions, I try to speak Arabic, and sometimes I get into trouble. One of the questions on the questionnaire involves the availability and use of a latrine. My translator initially answered for the IDP family, instead of asking. When I insisted that he ask, I learnt that all the families were using the riverbed (wadi) as a latrine that is the same place where they get their drinking water. Typically health education should be participatory, community driven, and non-punitive. Health teaching programs are also implemented after the assessment, but in this case I could not wait. I told every family: “Don’t use the wadi as a latrine or you’ll end up drinking each others pooh!” — That phrase had to be translated by someone through my walky-talky radio. The kids thought it was hilarious hearing such vulgar language come out of the small speaker in my hand. Was I condescending? Could I have treated people the way I would have liked to be treated given the situation? Perhaps I did not know what it was like being an IDP without a place to go to the toilet.

It wasn’t until I arrived at the next house that I learnt my lesson. During the interview my stomach started to cramp, I was notably in distress. Sitting with the 10-person family, with a crowd of on-lookers I was starting to make a scene. I confided in my translator telling him that I needed to use a latrine. He brought me to a small exposed ditch assuming I had to have a “short-call”. Dancing on the spot and moaning I told him I ate poorly prepared food from the market – he then pointed me in the direction of the wadi. I shook my head in disagreement but it was the only place where I could attain some degree of privacy. Looking at the tears in my eyes my translator instructed me to run! “hurry!”

The on-looking crowd: the military, children, cattle etc. watched me off in the distance being the ultimate hypocrite as I received my dose of poetic justices. I returned to the family I was previously interviewing – embarrassment is not an exclusion criteria. The very next question was: “Do you use a latrine?”

There are plenty of factors that cause a population to behave in a way that is contrary to their usual health habits. There is nothing more discouraging then being relocated from a “prosperous” community to a dusty desert strip of land – the security situation can make it a prison. With family members missing or dead, building such things as latrines may be too far on the list of survival activities. During this visit, I came across some situations where people’s most basic survival activities could not be performed because of grief alone. In three particular cases the head of the household could not answer the questions of the rapid assessment – they were too consumed with the tragic events of the last week. They would describe the events with their faces swamped with tears. I think I was the first person removed from the situation whom they were able to tell their stories to, and had the time to listen. Their children and other family members would stand around and watch the explosion of grief and frustration. The systematic rapid health assessment did not have an area where I could document this crucial requirement – mental wellness. To perform the activities of daily living when life seems impossible, mental wellness is essential.

A dodgy Internet connection allowed me to catch a glimpse of psychiatrist Steve’s blog about MSF mental health treatment programs on the Sudan-Chad boarder. Please take advantage of your technology and read it thoroughly since I only got a minute or two of viewing.

The helicopter approached the burnt and abandoned town of Seleia. The MSF team exited the fuselage on the rocky pad and watched the helicopter take off. It was a strange feeling landing in this community without curious greeters, no vehicle to load equipment into, no animals, no local colleagues… just the wind as the sound of the helicopter fading away. I think it was especially strange for those of us who had spent a significant amount of time in the community. Three months ago when we were evacuated, I expected to return to a more stable community still full of life, happiness, “industry” and fun. In stead we carried our medical equipment through evidence of dwellings, and yards looted and burnt to the ground.

As we approached the town center we found two local women who had returned from being refugees in Chad. Each of them had a baby on their back. The MSF medical assistant spoke to them and learnt that everyone was staying around the military base for safety. On the way to the confined Seleia camp I noticed some holes in the ashes where people likely retrieved the food which they buried- for most this was not the first time they have been attacked and forced to leave everything valuable behind.

The returnee sample of Seleia resettled with only woven grass walls for shelter, a few items for cooking and something to collecting water- some of which I recognized as our medical equipment. I’m glad some medical items ended up in worthy hands. The small grass walls were huddled together for protection, exposed to the open desert, nestled next to the military base. Knowing what this population had been through, I was too impressed with their resiliency and innovation to pity them. I don’t think anyone from a western lifestyle can comprehend what it is like to start again in this way.

Approaching the living area people seemed too busy or perhaps tired to yell out the usual comments that every foreigner to Sudan hears. The population was mostly women and small children; apparently it was too unsafe for many men to return. As we started to settle a clinic area around a tree people approached, then crowded around. It was so great to see some familiar faces again. A few of our staff had returned: One of our guards, the woman who used to clean the operating theater, her infant who would ride on her back while she cleaning, and our translator. As expected they were not themselves. There was not enough time, and too much going on to catch up with them as we set up a table under a tree for medical consultations. Dr. Eric typically works in the emergency department of a teaching hospital in Iowa – this old school desk under a tree in the desert could not have been a bigger contrast. I left Issag and Eric to see the patients and I made my way back into town to inspect the medical facility and the MSF living area.

The only items left in the inpatient area were 2 intravenous poles with the solution bags, and tubing. No beds, no tables, and no one really knows what happened to the patients. The tent part of the operating theatre was missing- medical equipment and waste was spread all over the place- there was no point in collecting an inventory. I could not find a single item to contribute the makeshift clinic in progress. Items I didn’t know were valuable were taken such as: light sockets, hinges, and doors, screening… everything. Jean the logistician was able to find a biohazard container that we were able to use. Jean stayed in the compound and burnt all the medical records and hazards, then later joined me at the clinic set up.

Beside the consultation table I sat on a plastic mat, cleansed and dressed some of the physical wounds of the population. As time went on people acted out their story to me and explained what happened in their local dialect. I was able to pick up a few grim details of what they told me, I wish I had a translator. Though there were some serious wounds, I think a lot of people just wanted recognition, to be listened to, and maybe reassured. One elderly lady was listening in as I was trying to teach the patients about wound care such as what to do with the dressing material, cleaning, etc. Later she declared that it would be her role to teaching people (in a way they could actually understand) how to care for their wounds so that I could continue with the dressings. This woman also went through the crowd and brought a few people to me who needed attention.

I wanted to stay, I felt obligated to become part of this welcoming community again but it was too unsafe at night. The afternoon was coming to an end and we soon had to close our clinic table to return to the landing area. I went through the crowd to determine if there was anyone who was too ill to wait for our next visit. I thought I found everyone such as the women laying on the ground, the baby with the fever, but other sick people still presented themselves to the clinic table, as we had to leave. I hope we were able to attend to all the serious needs.

I watched the burnt town of ashes get smaller out of the helicopter window. Strangely, I felt a sense of reassurance that people were still functioning, being progressive, and doing everything they could to regain themselves. Again, people like me should not mistake the optimism and resiliency of a community with the reality of their troubled state.

I used to be a little baffled by the psychosocial interventions MSF would initiate. I thought that psychological interventions were more of a developmental, rehabilitation project. It was comforting to read the blog of the Canadian psychiatrist Steve who is working on the Sudanese/Chad boarder (sorry I don’t have the specifics, my internet access is few and far between). My Seleia friends who are still refugees need all the motivation and clarity they can get- it is easy to loose faith in outside parties. The more displaced populations I visit, and burnt villages I assess, it becomes clear that it is not so much the NGOs that get a community functioning again- it is more the human spirit.