by Damien Brown
On he goes. I’d almost enjoy his speech if I wasn’t the topic. He’s remarkably dramatic, gesticulating, pausing, staring, pacing, contemplating, and shaking his head ruefully, enunciating each point. Andrea interjects with whispered translations from my left, but they’re largely unnecessary. The gist is clear.
‘Two weeks ago we had a nice mother arrive,’ he continues, describing the case of the woman with cancer, ‘and we did nothing. Roberto wanted to operate, but still we did nothing. And just yesterday, this woman died! With still no treatment from us. How can this be?’
The woman had held on far longer than I’d imagined, although she’d been unconscious for much of this second week. I arrived for work yesterday morning to find her children clinging to her body. The husband said nothing, just quietly wrapped her in a blanket and carried her out the gate, two young sons in tow.
‘Novo Doctor?’ calls Sergio. ‘Tell us. Tell us why we did nothing for her!’
He takes his seat. There is nothing I can think to say. The Angolan staff look just as uneasy; Sergio’s a senior, technically their boss, and as MSF expats we’re the employers. Most look away in silence. Next to Andrea sits Senhor Kassoma, the head of Outpatients, who’s for some reason making notes on all this in his diary. Beside him are Pascal, Tim, and Toyota—still dressed in his blue overalls and thick gumboots; Vasco, our head guard—who’s more likely to charm someone out of entering the compound than physically prevent them; Theresa, the forty-something head of nursing, with whom Andrea’s been having her own run-ins; Jamba, our affable driver, who’s afflicted with an unfortunately large goitre; Nene, the head of midwifery, today outfitted like a West African queen in flowing blue dress, matching headscarf and large hoop earrings; and Roberto, who’s not missed a day of work since his injury. Also present are the heads of cleaning, water distribution, and the hospital dispensary.
‘Sergio, I’ve made this clear before,’ says Tim. ‘These are not medical meetings. This is not to happen again.’
‘Excuse me, Coordenador,’ interrupts Roberto. He stands slowly, leans his crutch against the wall of the hut and straightens his checked business shirt. ‘It is not just Sergio,’ he says. ‘Okay, I do not think it is fair to suggest that Novo Doctor caused the death of this woman. She was very ill, and I think this is unfair. But I could have tried to help this woman. This is the thing: we could have tried. It is what her family wanted. But O Novo Doctor— who has been here for what, two weeks?—he has been refusing such things. And now there is another young girl on the ward—’
‘The point’s been made, Roberto,’ says Tim. ‘The four of us can meet afterwards.’
Sergio’s back on his feet. ‘But must we go through this every time a new doctor arrives?’ he asks. ‘Always, these new questions, these different rules. What if this new patient dies as well? What if she—’
‘Enough!’ calls Tim. ‘We will talk afterwards. Now—Pascal, logistics issues this week?’
I need to seriously question the reality of staying in Mavinga. This is absurd. How has it all so quickly deteriorated into this? There’s a deep irony in my having left the Thai clinic to come here, too—maybe someday I’ll appreciate it. The difficulty of working there had been in getting the mild-natured, soft-spoken Burmese to actually speak up to me at all!
Pascal fills us in on stock issues, and as I watch him speak I want to trade places. Having previously spent a year in Angola with a women’s development agency, he’s a fluent Portuguese speaker, and gets along effortlessly with his team. And what a job he has. Just yesterday our six-monthly logistics order arrived spectacularly in a giant, Russian-built cargo jet, an event overseen by Pascal. The sound of the ageing Antonov bearing down on our dirt runway, just metres from the hospital, was almost apocalyptic as it screamed its reverse thrust into the quiet African morning, the scene equally surreal: a marvel of twentieth-century engineering parked on the dirt as an ox-drawn cart trundled past. A group of local kids quickly gathered to inspect the plane, giving the tyres a firm thump with a fist, whacking the fuselage with a small branch. The logistics team meanwhile unloaded and inspected the tonnes of supplies—fuel, chlorine, medical equipment and maize, and the sundry other items including wiring, cement, sand and bricks for new projects: every conceivable thing we’re likely to need in coming months—and it’s this logistical aspect of the project that I find most fascinating. That here, in the midst of The Land at the Edge of the World, a bubble of modern infrastructure has been created, allowing the hospital and water system to function at a level not otherwise possible. All the technical aspects fall under Pascal’s responsibility, and when not dealing with flights he can be found tinkering with the generator, adjusting the satellite communications equipment, fiddling with plumbing, or getting driven around in the mine-proof vehicle. So I also want to be a log, I’ve decided. I want Pascal’s job. An organised one, with quantifiable, visible results, and a team of light-hearted Angolans to boot.
‘Anyone else with something to add?’ Tim asks.
‘Yes, Chefe,’ begins Sergio. ‘There is now another patient—’
‘Right,’ Tim interjects. ‘Meeting’s over.’
The others leave. Only Tim, myself, Sergio and Roberto remain. We stay on our benches at opposite sides of the hut.
‘This is a huge problem,’ begins Tim, sitting forward. He runs a hand through his dark, close-cropped hair, and asks the two clinicos to explain their sides of the story. For a quarter of an hour the duo speak passionately. It’s a bitter pill, listening to their complaints as Tim relays them. ‘We do want to get on well with the doctor,’ Sergio concludes. ‘We need a doctor to lead the team. But this situation . . .’
‘Thanks for your honesty,’ says Tim. ‘Now for my input. You know that I’m not a medical person—my background is in project management—so it’s not for me to give a medical opinion. But I know that our doctor has been speaking with the surgeon in Geneva, and he’s following the advice he’s been given. Advice also from the medical coordinator. These people are my bosses, too, so if they suggest that we don’t operate on certain patients, then we don’t.’
Roberto glances my way. Sergio stares off into the distance, looking bored. I’m still not sure what to make of these two. I was told in briefings that several of our staff were formerly UNITA seniors, but senior what? Health workers? Politicians? Teachers? Or military commanders? Christ—were some of these guys involved in what I’d just read about? Responsible even for such acts? Am I quibbling with people who ran guerrilla armies? I know I shouldn’t entertain such thoughts. I understand that in circumstances like those everyone was a victim, people were forced into situations to survive and did what they had to, and all are equally deserving of care—it’s the very premise of this organisation. Our staff seem well respected by the local people, too, which must count for something, and I can only assume that MSF looked into their backgrounds before employing them. I’d ask Tim, but I’d rather not know.
‘I don’t want to have to get involved in clinical issues,’ Tim finishes up, ‘because it’s not my job. But if this goes on we’re going to have to lay down clear rules via the medical advisors. You all have to work together for another half year, so you need to please find a way. Any more issues, you come straight to me. Okay?’
Sergio and Roberto get up and leave the compound quickly. I stay where I am.
‘Having a tricky time, huh?’ smiles Tim.
‘I expected to be pushed a little, mate, but seriously . . .’
‘You should have a good read of the old medical reports in the office,’ he says. ‘Sergio’s been like this for years. He’s very good with coordination staff, but in his mind this is his hospital. As for Roberto? Well, he has a background in war surgery, and you don’t. You also look very young, my friend!’
I ask him how the previous doctors managed.
‘The one before you was good with surgery and obstetrics,’ he says, ‘so she spent a lot of time on that side of things, mayb
e less on the general wards. I never met the other doctors—I’ve only been here a few months—but I can tell you that it’s not uncommon for new staff to get tested when they arrive. I even saw local staff strike in another project once, just because they refused to work with certain expats.’
We walk the few metres to the dining area and grab Castle beers from the vaccine fridge, slump into plastic chairs. The mechanical drone of the generator begins. It feels out of place here, an unwelcome intrusion, but the most delightful sound can still be heard coming from just behind our fence, where children from the nearby huts are playing. Hands clap, little voices sing, and through our open door I can see the sky, blushed with streaky pinks where a setting sun slid past only minutes ago. The softer side of Mavinga. Sitting before us, though, cubes of this morning’s goat, suspended in a puddle of orange.
‘You have to put yourself in their shoes,’ Tim continues. ‘These guys get a new doctor every six months, sometimes more often, and all of you try to change things when you arrive. After a few months the next guy arrives, and he does the same. I’ve seen that list you carry, too, my friend . . .!’
Touché. It’s now a small booklet of issues I’m hoping to address.
‘We are all guilty of this,’ Tim laughs. ‘The thing is, this project has been going for years. Staff are close, and you’re another outsider. But you need to be on those wards all day.’ He stops, takes a long sip and stares quietly out the window. ‘You know, this is a difficult time for them. In six months we’re handing this hospital to the government. The MSF presence in Angola is ending. All projects are closing, and the health workers may well be working on their own after that—if they’re working at all. This is the last few months of formal support they’ll have from MSF, maybe the last time they’ll have a doctor, so you need to teach. And find the problems. So stand your ground with Sergio. Do what needs to be done. As for Roberto?’ He leans across and clinks beers with me. ‘Good luck with him.’
Pascal bounds through the doorway, covered in dust. ‘Fucking hell!’ he declares. ‘Listen to this. Okay, so Jamba is in the tent just before, working through this big order. It’s going to take us days, by the way, this thing. Big fucking mess, lots of stuff missing.’
‘Stolen?’
‘For sure. Some boxes were cut open and resealed, almost perfectly. Only the expensive items are missing—lots of medicines. But anyway, this is for tomorrow’s problems. So, Jamba opens this box and he looks closely inside for something, his head down—he’s concentrating hard—but Toyota comes up from his side, quietly, like this . . .’
Tim and I laugh as Pascal mimics Toyota creeping, but before he can finish the story, a distraction occurs, a comprehensive derailment of thought: three heads pivot in unison like carnival clowns, mouths agape, because, wrapped in only a figure-hugging towel, Andrea has just stepped out of the shower and she’s making her way across the yard to her bedroom.
(‘Fucking hell!’ notes someone beside me.)
It’s going to be an interesting few months.
6. MAVINGA IS DIFFERENT
Another windy morning. The red and white MSF flag sketches colour into a burned-out sky above the hospital entrance; below, one of our guards reclines in his plastic chair, struggling to light a cigarette. I pass him at the gate but a young girl stops me.
‘Tire uma photo!’ she says brightly, a phrase I’ve come to know well from walks into town. She wants me to take a photo. Her older sister chimes in as well. ‘Por favor, Branco,’ she begs—Please, White Man—leaning on a wooden crutch that she’s long outgrown, her left leg hanging limp and withered—polio, I suspect. The disease still occurs out here, and she’s old enough to have caught it during the war. A time when an entire generation would’ve missed out on vaccines.
I tell them I don’t have my camera with me. I pat my empty pockets to prove it, but bashful little eyes peer back from bowed heads, and soft voices go up a pitch. No choice now. I fetch my camera from the office and return to a waiting chorus of squeals and little jumps on the spot, only the other half-dozen children nearby are just as excited, nudging and pushing each other to be at the front.
I ask the other kids to wait. First the sisters, then everyone else, I say, but it’s impossible to compose a shot with even just two of them. They’re in constant motion, wriggling forward incessantly, stopping only when their faces are almost on the lens as if it’s a peephole they desperately need to see through.
I inch back.
They inch forward.
‘O que e isso?’ I ask, trying to ready the shot again—What’s this?—because the younger girl’s cradling a brown bottle, holding it between the two of them for the picture. She hands it to me gently. It’s a bottle of Windhoek Lager, another Namibian export. ‘What on earth are you doing with beer?’ I laugh.
‘Não é cerveja,’ she replies, shaking her head earnestly—It’s not beer. But it definitely was beer, only now it’s empty, a tuft of coarse, black hair jammed into its top.
‘Why this?’ I ask, pointing to the woolly clump. ‘Porque este?’
She smiles, takes back the bottle, and with all the dignity of a little princess—a princess wearing a torn, shapeless dress, the colours long since massaged out on the riverbank—she replies: ‘É a minha boneca.’ It’s my doll.
I’d laugh, if only she wasn’t serious. It’s like that wedding gift we’d been advised to take. Or the way that people here salvage everything—bottles, plastic bags, old cloth; or the pieces of twine they’ll fashion into jewellery and the lengths of wire they’ll use as a belt. Poverty this extreme can’t be quantified. It’s a state of existence. Hollow cheeks, four skinny limbs and a belly swollen with parasites; patches of ringworm causing bald spots all over these kids. And it’s why I’m here, I’ve decided. For the sister that should never have had polio. For this young girl, proud as punch with her hairy, eyeless beer-bottle doll. And for the countless others, sleeping on cowpat floors in smoky huts, for whom the hospital represents the only hope when their kid gets malaria or their partner develops TB.
So fuck it: I’m not about to be bullied out by a chubby health worker. Nor his non-chubby, highly imposing, war surgeon of a colleague, although I’ll be honest that he does frighten me. So I step in, this third week, and confront my accusers on the ward. Because surgery isn’t the only issue here.
• • •
‘To see the doctor,’ says Manuel, the clinico looking after the women’s ward today.
‘That’s the management plan?’ I ask.
‘Yes.’
‘Nothing else?’
‘No.’
‘You’re not giving any medications?’
‘None.’
It’s an often-had conversation as we review new patients on these lengthy mid-morning rounds. ‘But what’s the patient’s diagnosis?’ I ask. ‘What’s her actual illness?’
Manuel loosens his lab coat, tilts his head and scratches the skin under the collar of his brown plaid shirt. It’s the only shirt I ever see him in. ‘The notes don’t say a diagnosis, Novo Doctor,’ he says. ‘Just: to see the doctor.’
‘Yes, but that’s what the Outpatients clinico wrote,’ I say. ‘You’re looking after her now, Manuel. What do you think the problem is?’
‘Uh . . . not so sure,’ he replies. The three enfermeiras and five other clinicos stand patiently behind him, shuffling on the stained concrete floor. ‘Her malaria test was negative, and she does not have a cough.’
‘Okay. So it’s probably not malaria, maybe not a chest infection. But she’s got a fever and it’s got to be coming from somewhere, Manuel, so we need to look for a source. What other infections could it be?’
‘It could be anything, Novo Doctor. Anything at all!’
He’s right. It really could be: bacterial, viral, fungal, parasitic—most infectious diseases I’ve come across in the textbooks seem to exist in this part of the world. Thousands upon thousands of unpronounceable, obscure, hard-to-diagnose rari
ties I’ve not ever seen, if heard of.
‘I agree, Manuel. So it’s important that we take a proper history and examine her from here,’ I say, pointing to the patient’s head, ‘to here,’ pointing to her feet, because mime is now an integral part of my communication strategy on the ward. I have my vocabulary sheets on hand, too, and Andrea’s usually available when I get stuck. ‘So you need to examine everywhere, Manuel. Did you do this?’
‘No.’
‘Why not?’
‘Because she is waiting to see you, Novo Doctor.’
‘I know this, but you can still examine her, Manuel.’
‘But there is no point—the plan is already here.’
‘Where?’
‘Here.’
‘There isn’t a plan there!’
‘There is.’
‘Where?’
‘Here: To see the doctor.’
And it’s not because staff are incompetent that this happens. Many of the clinicos have years of experience. Sergio, for all his bluster, is very clinically astute, as are many of the older health workers. They’ve dealt for years with illnesses that I’ve never seen at home. The real problem is this . . .
‘Manuel,’ I say, ‘we talked about this yesterday. I want you to assess these patients,’—and now I run to get Andrea to help explain these next bits, because a gallery of querulous eyebrows meets me as I try—‘because you are health workers, not paper clerks. You are not here to just write what I say. You have medical knowledge and medical experience, no? You must use it, Manuel. I want you guys to come up with the diagnoses and suggest plans, and then we can discuss them together afterwards. Okay?’
It’s not okay.
It’s all too confusing, the clinicos lament. Another doctor wanted them to make the decisions only after hours, not during the day, but the doctor before that forbade them from initiating any treatment until she’d seen the patient. Then there was the doctor who forbade them from prescribing for children, but not for adults. As well, this lack of continuity has clearly led to a lack of accountability: who is actually responsible for the patient?