Band-Aid for a Broken Leg

by Damien Brown

  ‘Um . . .’

  ‘It is Schistosoma, I think.’

  ‘Oh.’

  ‘Do you agree, Novo Doctor? Do you agree that it is this?’

  I agreed only to get my pathology book from the office and return after lunch.

  For the moment I take a seat with Isabella, below the only tree in the compound, just near the dispensary, and contemplate this growing list of newly discovered roles. It’s pleasant out here, a world away from the austerity of the wards, but it’s not providing the desired respite. Because even this front courtyard, entered via the crooked gate to our right, a No Guns sign tacked above, is unlike anything I’ve seen. Traditional village, grim medical centre, happy child play-centre, last hope for the desperately poor—it’s all of these, everything in between.

  Ahead, a few dozen people sit under a large cloth awning, waiting for consultations with one of the four Outpatients clinicos. There’ll be a hundred such people today. Every other day, too. At the front of this open-air waiting room, two toddlers are suspended loosely in linen harnesses that hang from scales. It looks fun. Just like a big swing, as if hanging there would be enjoyable, but these two aren’t buying it. Not in the least. They’re screaming loudly in protest; screaming at the rows of people on the log-roll benches in front of them—people with coughs, tumours, leprosy, leg injuries, malaria, and a man with a spine that’s bent at improbable angles who’s propping himself up with an old tree branch. Screaming at a young man who’s clutching his belly with abdominal pain, a symptom that may be caused by schistosomiasis from the river in town, or may be due to any of the other thousand viruses, parasites and bacteria that thrive in this part of the world and that are going to necessitate my doing some serious reading. Screaming too at the boys kicking a half-inflated football near the gate and at the dozen people waiting for malaria tests; and at the two of us, Isabella and me, as their mothers and those on the benches chuckle at the pair’s disapproval.

  Unhappy little parachutists, caught momentarily in the weighing-tree.

  ‘You were saying?’ I ask Isabella. She’s been trying to reassure me about things this morning, telling me I’ll pick up the Portuguese. I’m going to have to; she leaves in a few days.

  ‘With all that banter between you and Sergio,’ she smiles, ‘you’ll get plenty of conversation practice.’

  I ask her if I said something wrong on the rounds.

  ‘Don’t worry about it,’ she says. ‘Sergio gave the previous doctor a hard time as well, especially when she started. He’s got quite the reputation around here. I think he’s just trying to—what’s a nice word?—assert himself, to establish his standing in the hospital. And that whole quinine issue was unnecessary. He normally does keep an eye on those things. That was sloppy on their part. But I think he just doesn’t like being questioned, especially because you are new. Just give it back to him, though. Sofia did! She really clashed with him for a while.’

  As we talk, three older women waiting at Outpatients walk over to us. ‘How many children does he have?’ the shorter of them wants to know of me, and then—‘Eh! At his age! Why on earth not?’ So I try to explain that this is normal for a twenty-nine year old where I come from, but the Inpatients clinicos wave to us; and as we join them and enter the women’s ward all levity provided by recent moments is shattered and I feel ill, actually physically ill, because on the first bed is a woman soaked in urine, skeletal, barely—

  Is she even alive? I watch her for a moment. She is. Just. Her face is a grimace, an unmoving paper-thin mask draped over the severe architecture of her skull. Her eyes, open and unblinking, seem untroubled by the flies gathering at their margin.

  ‘She’s been sick for many months,’ says the clinico, speaking with the husband. ‘He just brought her here. She had bad pain in her belly, and she cannot eat. Now the pain is everywhere.’

  Her two children sit quietly beside her on the bed, and her husband leans over to gently wipe the flies from those big eyes. It’s the saddest sight I’ve seen. I ask if I can examine her and her eyes turn to me, and the husband gives his permission so we gently pull up her dress and cover her lower half with a blanket. There’s no need to really even touch her, though. An obvious mass, a firm fist of tissue, is visible low down in her belly, bulging from the deep concavity between her hipbones. Several smaller knuckles of tissue can be felt nearby, too. It’s surely cancer. But whatever the exact condition, she’s in the final stages. We can try to keep her comfortable, little more.

  I cover up her belly and the husband grabs my hand, smiling warmly. The clinicos translate his words from Tchokwe, a local language. ‘He says that he’s grateful to us for helping her,’ says Isabella. ‘He says he knows that here she will become strong again. He knows we will fix her here. His family wait for this day.’

  He can’t really believe this. I ask him to come outside with us so we can speak in private, and in the far corner of the yard I explain that we will help her as best we can. ‘But sir,’ I add, ‘she is already very weak. We can’t ignore this.’

  He nods, eyes downcast.

  I explain that hers is not an illness we can cure. I wait for the translations, give him a few moments, then tell him that I think it’s cancer. He’s not heard of it before. He studies Isabella’s face intently as she clarifies, the clinicos interjecting with explanations in his language. I feel awful telling him all this but he needs to understand. She’s certainly going to die in the next few days; he needs to be prepared. His children meanwhile hold on to his legs, watching me with big smiles as I talk, fascinated by this white person who’s chatting with their father in the yard.

  ‘It’s a very serious illness, sir,’ I continue. ‘A very strong illness. And I don’t think that here, in Mavinga, we can possibly fix this. But I promise you that she will be comfortable while she is here.’

  He speaks with the clinicos and shakes his head. His face softens and he grabs my hand between his, looks at me with eyes that scream hope. ‘That is why we brought her here,’ he says. ‘We know you can help her. God has led us here, and God will show you. She will get better—she will be strong!’

  What to say? Maybe I’m not saying the right things. I ask Isabella how they approach such things here, but she agrees: tell him we’ll keep her comfortable. No false promises. So I try to explain that her recovery is out of our hands, but he excuses himself while the others begin to translate. ‘I must be with her,’ he says, and walks back inside.

  I stay where I am. I’m not entirely clear if I’ve done the right thing. I’d have said the same at home, but one doesn’t see people in this advanced state who don’t already have a diagnosis, or at least some understanding of the nature of their illness. One of the senior clinicos steps forward as I talk with Isabella.

  ‘I can operate,’ he says.

  ‘Sorry?’

  ‘I can operate on her,’ he repeats. Roberto’s his name. He’s a lean Angolan man, a good four inches taller than me. Sofia’s told me much about him. He’s the closest thing we have to a surgeon here—a health worker, trained in field hospitals by military surgeons during the war, who’s proficient with limb amputations and less so with emergency laparotomies. But it was stressed to me that he’s not a doctor. And it was made clear that he’d likely pressure me to operate, but that he was to perform only emergency surgeries—and only with my permission. Looking now at his imposing frame, telling him what he can and can’t do seems somewhat hypothetical.

  ‘I can take out the mass,’ says Roberto.

  ‘That whole thing?’

  ‘Yes. This afternoon. Or tomorrow. When you’re ready.’

  I look at Isabella. ‘Is he serious?’ I ask. She looks at me uneasily, shakes her head and looks back at Roberto. His expression suggests he very much is.

  ‘The husband wants us to help her, yes?’ he says. ‘So what then is your plan?’

  ‘I’m not sure if there’s much we can do, Roberto. There’s no way she will survive an anaesthet
ic in her condition—not in America, not in my country, definitely not here. She’s far too weak. And that cancer, or whatever her illness is—it’s surely spread. We won’t be able to cure her.’

  ‘She is not in your country!’ says Sergio, stepping forward. ‘Or in America. She is in Mavinga. Do not compare us.’

  I’m speechless. Do these guys really think an operation is feasible?

  ‘And this nice family,’ says Roberto. ‘She has young children—did you not see them? How can you just do nothing? She will certainly die without this surgery. And yes, with the surgery she may die too, this is a possibility, but how can we not do something? How can you not at least try? Let us talk with the husband—let us see what he wants. But I tell you now, he will ask us to operate.’

  I’m lost. No one back home would consider such a plan. Surely! Is this how they do things here? Maybe the husband would rather she died during surgery being given a last fighting chance; perhaps to just palliate patients out here is to admit defeat, regarded as weak. Un-African, even. Is it an insult to the husband if we don’t operate, given that he’s carried her here with their two children in tow? I have no idea. I’ll call the medical advisor in Geneva this afternoon, but right now there’s still other wards to see—not least those malnourished children. I tell the clinicos my plan and turn to head back to the wards.

  ‘Novo Doctor!’ Roberto calls out, walking towards me. I stop and turn back. He looks like a military commander as he strides towards me. A man’s man, for sure. Am I really about to get involved in a stand-off with the local staff? On day one? And how am I meant to be the ‘boss’ out here, anyway? These guys are mostly ten to thirty years older than me, yet technically I’m the more qualified. I’d not expected any of this. I’d rather imagined arriving and just getting on with seeing patients, and that on at least some level people would be grateful for my having come here; that I’d learn from them, they from me, and in the process we’d all work as a happy team . . .

  But this—?

  ‘Yes, Roberto?’

  ‘We are not finished talking,’ he says, piercing brown eyes staring through me. ‘You must not forget something very important,’ he warns, voice calm, his face one of annoyance. ‘Do not forget that you are very young, and I am sure have no experience in Africa.’

  ‘Roberto—’

  ‘Am I correct?’

  I can think of nothing to say. I look away, watch patients queuing with bowls in hand for a serving of maize and beans from the kitchen nearby.

  ‘We are from here,’ he continues sternly. ‘This is our home, and these are our people. Our patients. We all have worked here a long time. For years, even during the war. Long before MSF came here, we were looking after patients. And you? You have been here what—not even a week? You have only just arrived! You know nothing about us, about our medicine—nothing even of our language! You need to remember these things, Novo Doctor. Remember all of them when you are in this hospital, trying to tell us how we should manage our people, what drugs we should use, when we can operate on them. And when you do—when you understand and respect these things—maybe then we can work together properly.’

  I stand, frozen, in the middle of the yard. He walks off with the others.

  I’ve got no idea where to begin.

  4. CONFUSÃO

  The week grinds on in the hospital. More sick patients, more debates over management, and there’s no point in heading to our living compound in search of any comforts. I find myself having to bolt at times for the shed in the far corner of our living area, just near the fence, in what’s becoming somewhat of a routine. The flies whoosh past as I open the door, no doubt themselves keen to escape the smell in this little room. A plastic grate with a hole in the middle is its sum total of fittings, the outline of two feet on either side prompting confused users what to do. But I already know: Squat. Squeeze. Flee. You really don’t want to stick around in here.

  I’ll get used to the latrine, Tim assured me, but he also said that our compound is one of the better MSF ones around. I’m yet to be convinced. Our bedrooms—cold, simple brick spaces—are furnished with only a metal hospital bed and small shelf, arranged along the two far sides of a dusty courtyard. Mine, to the left, has the dual luxuries of backing onto the logistics area—site of the recent wedding gift debate, and where our guard slaughtered a goat for the cook two nights ago—and of providing sweeping views towards this latrine. A dining room accounts for our communal space, just across from my bedroom, beside which a cold shower has been set up in a shed. A garage-sized office block takes up the fourth side of the yard. As for our kitchen? Best avoided. So how we’re going to survive the next six months in here, with just the four of us for company, I can’t be sure.

  Mavinga township

  Nor can I be sure how we’re to survive outside the compound. In fairness I can’t imagine a more authentic African experience than living here; there are redeeming features. Problem is that they can all be seen within a fifteen-minute walk—the limits of our security perimeter—and I’ve done so numerous times. Already, in only this first week.

  The airstrip is our northernmost boundary, just behind the compounds, and the river our southernmost, about a kilometre away. Midway between these is the sandy main road—the only safe path we can use, aside from the airstrip and a short track to the water’s edge. To the west, the main road curves between our hospital and expat compounds, then crosses the airstrip and continues north to the provincial capital of Menongue, about two days’ drive away. To the east it flees straight for Zambia; the kilometre of this east–west stretch, between our hospital and the large tree that marks the limit of our perimeter, is the town centre—a barren cluster of two peach-coloured Administration buildings, the grassless football pitch, three metal sheds, and a handful of other buildings in various states of decay.

  Our boundaries are absolute, imposed by MSF in Geneva, but at a glance seem over-zealous: locals appear to wander everywhere, and only to the north of the airstrip have I seen any of the red tape and ‘Perigro, Minas!’—Danger, Mines!—signs that mark uncleared fields. That said, I’m unlikely to go exploring. Photographs on our laptop show the aftermath of an accident four years ago, when an MSF LandCruiser struck an anti-tank mine on a road just outside town. Seven occupants were killed, pieces of the car flung high into nearby trees. And if that’s not deterrent enough, the poster on one of our wards is: How to exercise your stump following a limb amputation.

  So what then of any ‘redeeming features’? They do exist. One need only get up a little earlier, or wait until evening, to encounter them. Times when Mavinga reveals her softer side.

  Hours after confused roosters commence their ill-timed calls, a red toffee-apple of a sun rises and beams down the length of the east–west main road, flinging long shadows behind the groups of children heading to school. Hand in hand, wearing tops that are either far too long or not nearly long enough (an occasional patch of belly smiles through torn fabrics here and there) children walk with friends or younger siblings as smoke curls from cooking fires in dusty front yards. What I’d always imagined was an exaggerated cliché of African people, that they sing beautifully while going about mundane activities, is not so, here. They do sing—and beautifully. All the children. And even the soldiers, carrying out their morning drills on the far side of the airstrip, just hours after they were last heard having drunken brawls in their distant barracks.

  By the time the sun climbs a little and burns off its scarlet hues, the wooden benches at Outpatients will be full. My next ten hours will be spoken for. Meanwhile, children will have set down their blue plastic chairs—it’s bring-your-own furniture at school here—in one of the several makeshift classrooms, either the building with no roof, just opposite the wedding venue, or beneath one of the few trees, nearer the soccer pitch. Women will be hard at work. With goods balanced upon the head and a baby most likely swaddled to their back, they’ll be filling a bucket with water or collecting firewood
on the outskirts, or attending the ramshackle collection of stalls at the market, or perhaps washing their laundry at the river, where cattle will by now be being driven across the knee-deep waters by boys equipped with sticks. As for the men, I’m yet to work out what they do.

  So I do my best to get up a little earlier. And the four of us will certainly wander into town sometime after work; sometime after the sun’s dragged itself across this cloudless vault of a sky, slid behind the cooking fires at the opposite end of town, and resumed its deep blush to the west. Then we’ll head to the river. We’ll sit there for a while on the muddy bank, bask in these images of rural life, and, as I put another disastrous day on the ward behind me, I’ll wish that I could spend the entire week beside that water.

  But right now I need to enter this little shed. And not for the first time today, which makes me wonder if Tim’s comment about getting used to this latrine was a warning rather than any kindly reassurance. Regardless, I again inhale deeply, step inside, and wish immediately I hadn’t; and when I scramble out moments later, light-headed from battling the urge to breathe, it seems an appropriate time to take stock of this first difficult week in the hospital. The lists handed to me minutes ago seem a good way to try. The belated summaries of last month’s presentations, prepared by each of the department heads, as I pull them from my pocket:

  Outpatients

  A neatly ruled table annotated in pencil by Senhor Kassoma, the man first seen whisking Andrea around the dance floor at that wedding last weekend. The numbers are impressive. Two thousand eight hundred patients attended last month, and were seen by one of four Outpatients clinicos. Eight hundred were under five years of age. Malaria accounted for twelve hundred cases—the majority of presentations for children, but less so for adults. Other diagnoses, in decreasing order according to number of presentations: respiratory tract infections, diarrhoea, chronic pain, sexually transmitted infections, skin infections, jaundice, meningitis, and the thoroughly nondescript category, Others.