A South African Doctor in Darfur

The gargantuan spectrum of disease makes me wonder how am I, a single doctor, to know about all the possible afflictions for a population of 135,000 that we serve, including the outlying areas, that is. How am I supposed to train our local medical assistant to recognise the myriad of maladies? Last week I had a 5-year-old boy presented to me with his left eye ball protruding from his skull and very, very ill. I referred him urgently and later found out that he had died from a tumour- Neuroblastoma. His adolescence lost.

This week I had a classic case of Acute Pulmonary Oedema (water in the lungs I guess makes good translation). It constitutes a Medical Emergency. I get the history from the 80-year-old Shahib’s son, do an examination and when he confirms my suspicion by coughing pink frothy sputum into the makeshift handkerchief, I spin into action as the diagnosis is now textbook. The medical assistants inform me the next day that they have never heard of pulmonary oedema or water in the lungs! Alas… how many other Shahibs got an antibiotic instead; at least now he had peed himself dry of all water that hunted gravity and can breathe again, and today even faked a smile for me – and at least our medical assistant can try to make a good diagnosis next time. Both cases clearly demonstrate that I only know some conditions, I read every day to learn more, but I will never know everything in medicine (probably its most attractive quality) and here we expect the these medical assistants, 50% of whom are Shahibs themselves, to save lives. Incredible that we do at all. Odds are against us constantly.

I think that the apparent security I mentioned earlier is a dangerous pretext to letting down your guard and then making a mistake. The reality I want to present and remind myself of, I guess, is that there are just too many guns about. For a while, before some incidents this week, we were walking around Serif Umra like it’s just downtown. The guy on his bicycle and his gun on his shoulder crosses paths with the 5 odd soldiers popping in for some smokes, there is a car parked with 10 odd armed forces–and nobody really flinches. Nothing out of the ordinary. What is noticed is a lot of new faces in the market. What is noticed is that SU is fast becoming a ‘rich’ town – camel market, gun market, crops and sugar market. So it is important for me to remember, I’m in Darfur. It’s not normal to see guns and not tingle. This is the reality here. With the odd gunshot we hear nightly, I feel like I’m witnessing the conflict, in the most subtle ‘non-alarming’ way. The thunder of gunshots starts to feel as if it’s nothing out of the ordinary. Weekly I have a gunshot victim in the ward; some minor, some major. The major gunshot to the head of the salt and peppered gentleman that I told you about remarkably missed his brain and this week he was discharged from our referral hospital. Somewhat intact. Unscathed enough to make it home to his family for a few more precious moments.

Oddly you’d think that being in Darfur with its potent conflict and our presence here, one could believe that things have merged, where everything is a part of something else, we are all part of the world where all seems fluid and seamless; but sometimes I feel the converse to be true for me. It’s as though I live in a small world that’s all our own here, one I share with the population and that we know of no one else, and no one knows of us. We go about our days. Instead of living in a linked world we just live all of life, all the time, in obscurity. Not the truth at all, is it? Not when there’s an imminent war 200km to the west of us on the Chad-Sudan border.

Even though we find comfort in thinking that our actions protect us here, I realised the way to the heart of the Darfurians is not treating their coughs and runs, or awaking at 3am to tend to the breathless newborn or breathless geriatric – both extremes of life, when air seems particularly vital. It’s certainly not from shoving numerous medical equipment down orifices to get fluids into the woman, who bled out from an unclamped umbilical cord after she delivered at home, 50km away from the nearest clinic, or getting out urine from the old man whose prostate is too hefty and has not passed any in 5 days. Nah! It’s by calling the old man ‘Shahib’. So simple. I called my dad ‘old man’ when I was growing up and over the years it’s been the term of affection I use for the few men who make my world. So when I enter the ward and find the adorable pudding of a geriatric with asthma who I have been trying, desperately, to have air again, and the first thing that comes to mind is ‘old man’, and when I cry out Shahib, everyone in eavesdropping distance smiles and laughs – amused as they lap it up like no other action of mine. No other action of mine has yet convinced them that I’m here and happy to be and that they are significant and valuable. When he eventually was meant to be discharged, he asked especially to see me to give me a hug. A hug for the locals from a man to woman is frowned upon so this meant something extraordinarily special, my nurse reminds me. I think he also knew that he had a long trip ahead to an area far outside Serif Umra and who knows when our paths will cross, who knows if he arrives, who knows if he gets to plan his day or brood about the woman he loved for years but never got his head screwed on straight about – the important stuff.

I guess the stuff that really makes me know why I’m here, is the laughter. I laugh a lot with the patients, staff and expats. And so despite the language barrier, cultural gulf and the fact that no one can know what’s really lost in translation, we share the joke.

What’s no joke though is the handsome salt and peppered young man who came in this week with a gunshot to the head. An entrance wound between the forehead, the bullet makes it way through toward his right temporal area and exited beside his right eye. About 10mm away from a lucky miss. Skull fracture, pupils blown, not reactive to light. In our beautiful blistering tent, amidst a gallery, we stabilized him and sent him immediately to the nearest referral Hospital in Zalingei. There we have other MSF teams supporting the hospital and they kindly accept the cases we cannot handle that need surgery. He is one of the many this month that have come in with a gunshot, but his misfortune is at the hand of another. Most others just wobble in because they have shot themselves accidentally while cleaning the killing machine. Accidentally does not make it less violent, does it? Just silly I guess. There are just too many guns about. An incredulous ridiculous reminder lest I forget that I’m in Darfur.

What’s really concerning though is the epidemic of falling off donkeys. Not so funny at all I promise. My not so funny stories are endless! The woman who has 9 kids still alive after 12 previous pregnancies comes in on Friday after being in labour at home for far too long. She not progressing well in labour and her ‘whip thin’ uterus needs help to contract. I can’t give her the magic potion of oxytocin in case she ruptures that well worn womb that bears a new child. So I send her too to Zalingei, in a rented car on a rough and rutted road. That’s surely a recipe for her to deliver on the road. However it’s the same brutal, grueling road trip that protects us here in the dulled spotlighted Darfur. The population of Serif Umra know well that we do what we can at the petite dispensary and acknowledge our own cognisance of needing to do a bit more (even if it is the deserted desert) by sending patients further down the tortured road for a life saving intervention. We do what we can here, everyday I try to push the envelope but I guess neither is the answer. The answer is to balance being here for the population of Serif Umra and trying to support the staff here to always be here for the population.

I visited the shantytown here in Serif Umra, which is where approx two-thirds of the IDPs (Internally Displaced People) live.The others have makeshift reed tukuls in their resident relatives’ brick house back yard. The population in the town is 60,000. It’s densely populated. The conditions are appalling, no real shelter, big families, overflowing latrines, and donkey and goat droppings in the living/cooking area. We came across a mother who had defaulted TFC (Therapeutic Feeding Centre) visit. When the home visitor asked her why she didn’t come, she looked at him with such disdain, surveying her surroundings as if pleading with him to follow her eyes and telepathically revealing that she does not care when she has one malnourished child on her breast, five snotty malnourished desert roses as kids, one frail severely malnourished gran and a fat patriarch. The obvious blinding inequality and destitution turns my stomach.

Through our medical activities, we can witness a degradation of the nutritional status of the population. The conflict ensured that long-term prospects are grim, so I wait with bated breath for the moderates to flood soon. It is harvest season now, but that holds no hope for IDP’s who only work on the farms but don’t own the crops. Traditional livelihoods have been dismantled all over Darfur, and are currently being remodelled.I wait for the moderates as I watch school-less children and overly burdened women carry out all the labour that happens in this town. I know it means something that shiny tasty plumpy packet (plumpy nut). This week I sit in ATFC (Ambulatory Therapeutic Feeding Centre) and see the scared look on the baba, try to make her laugh but to no end. End of consult, perched on hip, she sees the shine of plumpy and smiles. So simple this moment that I melt. They don’t even make it 10 meters out of the dispensary gate when I find her cosy up in the enclave of her mom’s dress sitting in the sand in the sun eating her plumpy.

The dispensary consists a 27-bed in-patient department, ANC, ATFC (230 children in the program), out-patient department (between 4,000 and 5,000 consultations per month with three Medical assistants, which means 50 odd consultation per day per consultant). Half of all consultations are IDPs. An isolation unit with 3 rooms. The dispensary has no lab, no possibility for blood transfusions, there is no resuscitation unit, no thoracic drainage tube, no surgical scalpels, not a single piece of equipment for a surgical procedure.

It’s true it’s my choice to be here, alone – medically speaking, only doctor on call 24 hours a day and seven days a week. I should rest today, my one-day weekend. It’s Friday, but I’ve been at the hospital looking after a sick child. I’ve decided today that I will work on training the national staff and together with my team find a strategy to motivate them, so that I don’t lose my mind. This is really the hard part.

I feel scared today after our referral car narrowly escaped the group of armed men on the road to Zalingei. I dream of hiding in my wash basket and in my bed I close my eyes, the mosquito net has a strange protective aura and for a second it allows me to fall asleep again. If there is fighting – I’m useless. I can’t go the dispensary as it is about a 200m walk from the house. I can’t offer refuge to anyone in the compound. Access for our patients who need referral and surgery are my prime concern. It’s just not safe. How do I possibly put our midwife in that car? How do I possibly put the pregnant women unaccompanied? What do I do when I just cannot send them?