Off the beaten path… PNG

I woke up in the middle of an intersection, feeling a motorcycle’s tread marks over my body, a car whizzing past me. I blink a few times, and my sight focuses on holes in the ceiling. Ceiling? I look around. I am lying in a single bed, in a narrow, over-priced hotel room in Amsterdam, and the cars are outside, their crescendo-decrescendo acoustics invited in, silence denied by the thin window and walls.

The night before I drifted to sleep after discovering that there is only one thing more annoying than America’s Next Top Model…Holland’s Next Top Model. I’ll spare you.

I venture out onto the streets of Amsterdam under the siege of crimson and yellow hues of the fall. I meet Simon and Ingrid, whom I met a couple of weeks ago at the MSF training, for lunch. They are in Amsterdam for their Finco training. As ketchup is finding its way from my hamburger onto my t-shirt, one of their Finco colleagues asks me why MSF is sending me to PNG, since there is no real emergency situation there. No war. No genocide. No refugee situation. Hmmmm. Whatever happened to small talk. I rather he ask me who should be Holland’s next top model. The tall, skinny one, I would have answered.

What is an emergency? I am an emergency doctor so I should know. In medical terms, it’s an acute episode that threatens life or limb.

Emergency; an unexpected, dangerous situation requiring immediate action.

Take this scenario. A woman with a pale, opaque appearance to her skin, the tinge of cancer, presents to my emergency department a few months ago. She does not know she has cancer. I do. I have learnt to recognize the look.

She is sick, and has been getting sicker over the span of a few months. She is in pain and vomits after meals, her eyes betray bewilderment that her body is being so cruel to her. I look at her records, and see that she has been seen by a slew of doctors before me. She has had multiple blood tests, biopsies, a number of CT scans, has been seen by a surgeon and a hepatobiliary specialist, and none of them have been able to confirm a diagnosis. The situation is not uncommon. Medicine is imperfect, and nature has a way of revealing itself to us at its own pace despite our best tests and brainpower at work. She has been discharged home on multiple occasions. Now her daughter has brought her in, tired, exasperated, heartbroken that her mother is withering away at the hands of some unknown entity.

I have 5-10 minutes to assess her. I have to decide if her case is an “emergency” and what to do next, because around the corner there lurk other emergencies…the heart attack, the broken bone, the asthma exacerbation.

She does not qualify as an emergency. Her condition is chronic. She is sick from it, but it’s been there for months now. It is not threatening life or limb at that very moment. Technically, I could have sent her home with the right medications to be seen in follow-up by her specialists. Part of me wanted to. I knew I wouldn’t.

I called her surgeon, who refused to accept her as a patient. “I will see her in follow-up in my clinic”. But she is sick, really sick. “This is not an emergency,” she tells me. I call her hepatobiliary specialist. “I’ll see her in follow-up”. And so on.

If she had come in that day with the very same symptoms for a day or two she would have been admitted. She would have been considered an emergency. But because her symptoms had been present for months, she did not qualify as one. Enough time lapses and an emergency is not an emergency anymore.

Strange, isn’t it? What is the definition of emergency? I should know. I am an emergency doctor. But sometimes I get tangled in my own answer.

“Language is determinant. It frames the problem and defines response, rights, and therefore responsibilities,” from Orbinski’s acceptance speech for the Nobel peace prize awarded to MSF.

The mission in PNG has created a significant amount of controversy amongst MSF staff. It’s been debated in many circles. You see, there is no active conflict in PNG. It is a violent place, but there are no boy-soldiers doped up on crystal meth killing civilians. It is not prey to a hegemonic ethnic group. The sexual violence has been escalating slowly, chronically. The government has been unable to avert the situation. Now two thirds of all women, and often children less than five, have been subjected to sexual violence.

Isn’t that an emergency?

I can’t help wonder why it is that a bunch of men running around killing civilians, oppressing their rights to safety and basic needs, is considered a conflict zone, an emergency, but a bunch of men running around raping their victims on a consistent basis, oppressing their rights to safety, is not?

Is it a matter of semantics? Or is it because the sexual violence in PNG is inflicted by their people and not by another ethnic or religious group trying to subordinate their race? Or is it because rape and sexual violence are seen as an inevitable entity in our society, an evolutionary remnant of our past? Or is sexual violence simply too covert to make it into our agendas as an emergency situation?

MSF Holland has decided that it is an emergency, a chronic emergency. I spoke to a MSF staff member who was one of the first people to assess the situation in PNG. He has done multiple missions including one in Rwanda during the 1994 Genocide that has left its psychological fingerprints all over those that witnessed it. He deemed the situation in PNG so dire that he considered it a necessary intervention by MSF. As I watched his body shift positions in his chair every split second, a pantomime of the events that have stormed his life over all these years, I was moved…by his dedication and empathy. He tempered my fears about embarking on this mission.

Let’s rewind back to the female protagonist of my ER scenario. I had her admitted to the ward under another doctor. The next day, nature revealed herself; she was diagnosed with gallbladder cancer, and went on to get the right treatment for it. Other battles I’ve lost, to myself, to others. This one I won.

I won’t be leaving to PNG until the end of November. I found that out today. No concrete date. And now what??

I have handed over my passport to custom agents on a number of occasions in the last few weeks. Custom agents are a tedious bunch, cloned around the world to spew the same humdrum of questions…

“What is the purpose of your trip?” Wha….wawawawawawawawa?

Never…“Are you new in town? I know this great bar you should check out.”

A passport is 8-10 pages of expensive paper bound together with a code-bar, a photograph, a few identifying features. Hardly worth the fuss. Yet we fuss over it. You check and recheck that you have it in your purse before you set out on a trip. A tinge of anxiety creeps in as you hand it over to the custom agent. You feel all grown up when your parents trust you with it for the first time. Your heart sinks as you realize that your passport is hostage at a reception desk in a coastal hotel in Corsica as you are about to embark on a boat to Sardinia.

A 24-year old boy from Iran ended up in my emergency department a few months ago after being toppled over from his bike by a car. Cars always win. He was tight-lipped, and would say very little when asked questions. The nurses worried he had sustained a brain injury. But he had not. Except for the shiny, bloody abrasions on his face and arms, he did not even break a bone. As I was suturing his cuts, I asked him what he was doing in Canada.

“School. Work.”
“You’re from Iran?”
“Yes.”
“Where?”
“Ahwaz.”
“Why don’t you have a health-card?”
He pauses, sizes me up. “I am here illegally”
That’s when I pause. I am familiar with the situation. The stamp of the Islamic Republic of Iran on a passport, as shiny as it may be, denies you visas to most countries. It creates the delusion that you are up to no good, a terrorist or unworthy of a passage to the USA, until proven otherwise.
“How did you get out?”
“I bought a fake passport”
“How much was it?”
“$10,000.”

Passports. We’ve made them worth the fuss. They can be your ticket to a new life, to travel and work opportunities. Without them you might be prey to systemic violence, isolation, and despair. That is the predicament of countless displaced people in our world, an official estimate placing them at 40 million. Palestinians. Rohingya refugees from Myanmar caught without refugee status in Bangladesh. Those displaced by the waging wars in the Central Republic of Africa, Sudan and countless other countries. Those flocking into Dubai for subsistence, forced away from their homes by constraining living conditions.

“Where you scared?”
“No. I did not care. I had nothing to lose.”

These millions live at the periphery of our “civilized” world, “living off our waste”. Some have no access to shelter, food, or health care. Most of us know of their existence and we rather not think about them. However, no matter how hard we try to remain oblivious, they eventually make it into our backyard, as the Rwandan refugee that comes into the emergency department haunted by the image of her slain mother, or the friend at a dinner party that shares her memories of fleeing from Vietnam on refugee boats. Someday we might end up living at the periphery of civilization. You might think that seems farfetched as you stare at your computer screen, toying with your coffee mug. But history toys with us all.