Crossings

by Jon Kerstetter

“I know, but it just seems too risky. What if you’re hurt over there?”

  “It’s the same as if I were hurt over here. There are no guarantees.”

  We discussed how long I would be gone if I went and the logistics of emergencies at home and how I would respond from Africa. I assured her all of those things would be made clear before I left and that if she felt certain I should not go, then I would not, but that we would be missing a great opportunity to reach out to people who needed us. She tentatively agreed subject to getting more information. Over the next days I phoned the hotline set up by the International Red Cross. They referred me to the United Methodist Committee on Relief (UMCOR), a humanitarian group that provided medical care and relief for refugees worldwide. UMCOR gave me detailed information, which I discussed with Collin. She finally, but reluctantly, agreed that helping would be a good thing. I notified the ER staff at the hospital and they adjusted my shifts to allow for the time off. I also enlisted some local churches and charities to raise money for a shipment of medicine. Within a week I was on a plane to London to meet with the team from UMCOR. I was the only doctor in that particular first-response group.

  We flew from London to Nairobi, Kenya, the staging site of the United Nations mission to Rwanda and the surrounding area refugee camps. From Nairobi we took a small two-engine prop plane to Bujumbura, Burundi, where we stayed one night in a hotel. From the open windows of our rooms, we could hear distant gunfire coming from the border of Zaire. In the morning we hired a private convoy of three vehicles to take us into Uvira, Zaire.

  As soon as we passed the border checkpoint, I wondered if I had made a mistake and should have listened to Collin’s warnings. Soldiers wearing tan uniforms and maroon berets lined the road, belts of ammunition slung over their shoulders. They wielded machetes and wooden-stock rifles, which they waved at our driver as they halted our convoy and demanded money for our passage. They threatened to confiscate our passports and our boxes of medicine. The convoy leader negotiated a payment, and after a tense hour we were finally allowed to pass. On the road into Uvira, we saw soldiers beating people with the butts of their rifles, demanding payment for passage. When we arrived at our final destination, a mission hospital less than thirty miles from Bujumbura, we were frazzled and worn, hot and scared.

  I stayed in the home of a doctor named Wanume who had escaped the regime of Idi Amin in Uganda. Dr. Wanume established a mission outpost hospital with the support of the United Methodist ministries. His twenty-bed hospital was built of wood and white stucco and had one operating room and a five-bed section for cholera patients. Together, we treated war injures, tropical diseases, and delivered babies. We cautiously treated one patient dying of a hemorrhagic fever we thought was Ebola. An attached twelve-by-twelve-foot pharmacy had run out of medicine three weeks prior to my arrival, and I offered boxes of the medicine we had brought from the States. Wanume said it would keep him stocked for about a month. I gave him a book of current perspectives on infectious diseases, and he was so grateful he almost wept when he turned the pages.

  “I have not had a medical book for five years. I left all my books in Uganda when I escaped,” he lamented. “I shall read this book every day.”

  We stayed with Wanume for just two weeks before we moved north to Bukavu, Zaire. That had been our plan, to spend time supporting outpost doctors where we could, but also to spend time in areas that had no medical services. In the northern camps, and generally in most of the camps bordering Rwanda, tensions ran high. Hutu militia members leveled charges that Tutsi infiltrators were spying on refugees. They even accused aid workers of spying for the United Nations in order to bolster a hidden agenda. One group spread rumors that medical aid workers were doing experiments on Hutu refugees. There were daily incidents of violence, rape, and even murder. There were no adequate UN security forces to quell the violence, so aid workers proceeded cautiously to their respective camps.

  We had been assigned to assist at a medical camp near the Panzi Refugee Camp, bordering Bukavu. Our first day at the camp started at 7:00 a.m. with a drive from the central part of Bukavu, where we stayed in a run-down hotel and guest houses. The drive took more than an hour. Mud and ruts from the constant rain made the road nearly impassable. Along the roadside, literally hundreds of children scampered to the sides of our vehicle, and our drivers swerved to avoid hitting several of them.

  The scene on the way was nothing short of horrifying. Thousands of blue tarps, which the UN had distributed, one per refugee family, lined the road and the nearby fields. It looked like a sea of twelve-foot-by-twelve-foot shelters with campfires spread about, giving off a gray smoke that hung in the air. Some families didn’t get tarps. Instead, they made do with sticks and pieces of wood and canvas. Between the rows of tarps and lean-to shacks I saw only mud and puddles and refuse. Some of the blue shelters had been trampled by the thousands of refugees. In many cases we saw naked children with open wounds standing near their mothers. We wanted to stop and help, give medicine and clean water, but if we did, the action risked setting off a chain of violence because we did not have enough to give everybody. We had been instructed to stay on the road and proceed to the camp at Panzi.

  What I saw, I could have never prepared for. I was fully prepared for the practice of emergency and disaster medicine. In many ways, that kind of doctoring came easy to me. But Rwanda was far more than a disaster, even more than a genocide. Its near millions of refugees, its countless numbers of wounded and ill, and its malaise of camps and bodies scattered in the mud all coalesced into a heavy feeling that humankind had become lost and unredeemable. The greatest health risks were not germs or injuries or bleeding, but people. And that realization gave way to sadness and emptiness.

  When we arrived at the medical camp, the scene was similar to what we had seen on the drive in. Hundreds of small tents filled the surrounding open land as far as we could see. Two large medical tents had been set up adjacent to a Catholic missionary grade school atop a slight hill with a graveled road. Our arrival created quite a stir of curious patients, some of whom had bandages on their legs and arms and heads. Some of them walked alongside and greeted us in Swahili or French. A few had makeshift crutches made from tree branches. Many of the wounded had faces devoid of any expression.

  “Do you bring medicine?” one man said, his arms reaching toward me. “Do you bring food?”

  “Yes, I have medicine,” I responded tentatively, not knowing how and if I could help these patients. The translator explained that we were the first medical team to arrive and the patients were desperate to see us.

  I wanted to get into the medical tents to make an initial assessment, so I asked for the translator to accompany me. There was some discussion between him and a person who seemed to act as the informal spokesperson for the patients. They had not expected us to arrive that day and they said they needed time to prepare.

  “I don’t need any preparations,” I said, urgency creeping into my voice. “I just want to see the patients and get an idea of how to proceed.”

  The spokesperson addressed me in fair to broken English. “Sir, I am Sergeant Nkunda. I am chief medic of the hospital. Welcome.”

  I was surprised that I was speaking to a soldier, much less in English.

  “Sergeant, I am Major Jon Kerstetter of the National Guard. Where did you learn to speak English so well?”

  “Fort Sam Houston, Texas” he said, grinning. “I had training there as a medic three years ago.” He turned up the flap on his khaki shirt pocket. Sewn onto the underside was a U.S. Army Expert Field Medical Badge, earned by less than 10 percent of all Army medics.

  I couldn’t have been more surprised. He went on to explain that the Rwandan Army had sent their best medics to train at U.S. Army medical facilities under a training agreement. At the camp he had been doing emergency amputations and whatever else needed to be done as he waited for medical help to arrive. Apparently, I was that help. Doctors and medicine were in short supply or simpl
y not available.

  Nkunda showed me into the main tent. The smell of infection had saturated the air and it was nearly overwhelming. I could sense the despair that seemed to permeate the air as well. The tent had been set up by a UN crisis response team two weeks prior to my arrival. It had a dirt floor, no ventilation, and no separate area for contagious patients with cholera or tuberculosis. The camp provided no surgical facilities or pediatric beds. The water supply had been contaminated by cholera. Sanitation facilities overflowed. The adjacent school building served as the operating room where Nkunda performed amputations. Wounded child soldiers and a mix of older civilians lay in rows like stacked cordwood ready for burning. Some of the patients with field amputations had infected stumps that lay open to the air. Flies laid eggs in the necrotic tissues.

  I was no stranger to field medicine through my training in the Guard, but I had never seen the near-death certainty of refugees in the aftermath of war. I had come prepared to make a difference, as if I could just drop in and save lives. When I saw the conditions of the camps, I considered my efforts weak and paltry at best and that whatever I did there represented nothing more than a temporizing measure before a bleak and tragic outcome.

  On that first day I went from patient to patient with Nkunda. The tents held close to three hundred injured and ill. I made a list of priorities. We needed to separate the cholera patients from the others immediately. The rest of the UMCOR team went to work on setting up a cholera tent where infected patients could be isolated and treated. By midday we had selected about twenty patients for isolation. I expected half of them would die within a few days. And when that happened, the rest of the patients feared being selected because it meant almost certain death. Nkunda explained to them that if they stayed in the main tent, everybody would die of cholera because of contamination.

  That afternoon I operated on a boy who had been shot in the chest. Infection had eaten away at his chest wall until it eroded through his ribs and skin. I showed Nkunda how to drain the infected area by cutting into it and removing the dead tissue.

  “I expect he’ll be dead in a few days,” I said to Nkunda. “We don’t have enough antibiotics to treat his infection.”

  “But at least we tried,” Nkunda replied. He looked resigned to the reality of our patients dying for lack of supplies.

  I was surprised that the boy was still alive two days later, since we had only a limited supply of antibiotics and not the appropriate ones for his kind of infection. The team made arrangements to transfer the boy to a different camp where a Swiss humanitarian group had pediatricians on their staff. We transferred him but never heard if he survived.

  The same day, I treated an injured young Hutu woman whom Tutsi forces had shot as she carried water up the steep embankment from a nearby river. She had been sitting and sleeping on a two-foot-by-five-foot grass mat in the main tent for five days before I arrived. When she stretched her legs or tried to lie down, her feet settled on the dirt floor of the tent. She leaned her bare back against the center twelve-foot tent pole. Her breasts were exposed to the air. A ragged tan skirt covered her knees. She wore no shoes or sandals. Flies lit on her legs, arms, face, and chest—and on the baby in her lap. She did not brush them away. Systemic infection had set in. She had not received surgical intervention or antibiotics.

  I smelled pus as I approached her mat. Sweat dripped from her face. It collected on her chest and ran into the wound on her breast. Her right arm hung limp and its motionless, swollen hand lay in her lap. She had a finger-size entry wound in her deltoid and a corresponding exit wound in her armpit. Between the entry and exit wounds lay a shattered humerus and a severed axillary artery. She had a secondary wound that pierced her chest wall and split a rib. The rib apparently changed the course of the bullet, causing it to travel through the base of her right breast, where it carved a tunnel and exited near her sternum, carrying with it fragments of bone, breast fat, and milk glands. I put my entire gloved hand into that tunnel to remove debris and pus. She felt no pain. Her breast was dead.

  As I examined her right arm, she held her baby girl to her good breast with her other arm and rocked slightly. I had left my own children in the care of their mother, fully sheltered, safe, with ample food and extra money for weekend entertainment while I was gone. They would survive with barely a ripple in their routines and perhaps barely a notice that I was gone. The mother and child before me were hours to days away from their deaths. I became desperate to save them, to show them that I valued their lives.

  The baby tried to suckle a parched nipple. It could not latch on and the mother could not make milk. She was dehydrated and lacked adequate nutrition. Her lips were cracked like the heels of her feet. I told her through my translators that she needed to have her arm amputated and her right breast removed because infection was killing her.

  “How can I care for my baby with one arm and one breast,” she asked. Her barely audible voice wavered. A translator told me she was afraid surgery could kill her, and she refused to die before her baby. “If I die first,” she said, “I cannot give milk.”

  I explained that her breast and arm were already dead and that surgery was the only way to save her baby. She refused by simply and softly saying hapana, no, as she clutched her baby to her chest. I gave her as many oral and intravenous antibiotics as I could find. She died on her mat three days later, her feet coming to rest in the dirt, her head askew against the tent pole. A nearby patient had covered her body with a bloodstained blanket. We took her baby to a nearby pediatric camp where nurses bottle-fed her special formula. I did not have time to follow up. I presumed she died from malnutrition or dehydration. I hoped I was wrong. I also hoped I was right and that she died quickly.

  In the days following the mother’s death, I felt numb and incapable. The aftermath of genocide and its atrocities had torn limbs and lives, had killed fathers and mothers and left their babies starving and sick. I could not save them, the mothers or their babies, and that was a curse, watching them die, knowing I had the skills but not the power to heal, knowing that war had blown apart any reasonable chance that a doctor from Iowa could save an innocent mother from Rwanda. People died every day. The despair was palpable and I had to look beyond it or risk becoming useless. And that was the hardest part, to portray the strength of a doctor in the midst of a plague, to move with the wisdom and confidence that advanced the power of healing.

  I performed amputations on several refugees whose legs had been severely injured and were infected. Some of them had already received field amputations, Civil War–style, performed by their own medics. A few were missing limbs hacked off by crazed attackers. I performed the operations on a wooden table in the nearby grade school. Between taking photos, a Belgian photojournalist from the Belgian Standard batted flies away from the surgical incisions and instruments. Flashlights and sunlight served as the operating room lights. We didn’t have an anesthesia machine or an anesthesiologist, so I administered intravenous anesthetics myself. When the patients began to stir or wake, I asked one of the team members or Nkunda to administer another dose. “Just squeeze half that syringe into the IV,” I would say. After the patient stopped moving, I would continue. After the amputations, I gave each patient ten Tylenol tablets and told their tent mates to give them two tablets every four hours or so, or in between if they moaned in pain.

  I had four cases of Army MREs (meals ready to eat) that the Iowa National Guard had sent with me. I handed them out to post-surgical patients to aid in their recovery: one surgery—one MRE. Two weeks after I arrived at the camp, a patient who was older than the other refugees, probably in his late forties, and who likely weighed less than one hundred pounds, asked me to amputate his arm in exchange for an MRE. I refused him both.

  “An amputation must be medically necessary,” I said, trying to sound objective and unemotional.

  Using a mix of Swahili and English words, he told me it was. “Doctare, you cut.” He held up his arm as if to offer it
to me and drew an imaginary line across the middle of his right forearm with his left index finger. I told him I could not and turned away to attend other patients. The next day I saw him leaning against the back corner of the classroom where others had received amputations. He was staring out at the jungle. I knew he was on the verge of hopelessness. I felt guilty that I had done nothing of substance to help him, but I also knew that nothing I could give him would have enough substance to save him. I expected him to die like the boy with the chest infection, but when I saw him there alone, hungry, I decided to do something anyway. I sneaked him one MRE and a packet of multivitamins. He smiled and said, “Asante sana,” Swahili for “Thank you very much.”

  —

  Africa was my first war zone experience. There would be more. I spent several months in two consecutive summers working in the Zenica Hospital in Bosnia, teaching emergency medicine and treating patients from the ongoing war. The injuries there were typical war wounds from small-arms fire, rocket-powered grenades, and mines. During the summer a group of five boys waded into the Bosna River for some summer fun. They were hit by an IED attached to a balloon floating downstream. The boy closest to the balloon bomb died of a head injury. Two other boys had shrapnel injuries to their chests and abdomens. The boys nearest the shore had penetrating injuries to their arms and faces. On other occasions, landmines injured or killed members of Bosnian families out gathering mushrooms or wood in the surrounding mountain meadows. The mines spared no age group and had a predilection for inflicting civilian injuries.

  I made a similar trip to Albania in the late spring of 1999 and worked in collaboration with humanitarian organizations attending to Albanian refugees from Kosovo. At the peak of the refugee crises, the United Nations estimated the number of refugees at over six hundred thousand. Approximately two-thirds of them fled into Albania. I joined the team of World Medical Missions at the Hamallaj refugee camp about twelve miles north of Durres, Albania, next to the Adriatic Sea. In our makeshift clinic/hospital, which was nothing more than a twenty-man, green Army tent with a smaller supply tent attached, I examined patients on a plastic folding table. A camp generator supplied power to a string of overhead lights that, all added together, might have been the equivalent of a single 120-watt bulb.