Band-Aid for a Broken Leg

by Damien Brown

  We move on to see the eight other patients in the women’s ward. The presumed diagnoses, left to right: typhoid fever, gonorrhoea, a severe skin reaction to an anti-leprosy drug, undifferentiated abdominal pain, period pain, back pain, and a kidney infection. And this young woman—Maria, a twenty-nine year old with breast cancer. Her tumour is ulcerated and has a foul-smelling discharge weeping constantly from it, and there’s a large abscess in her armpit that’s likely associated with a metastasis. Yesterday we drained the abscess. This morning, says Manuel, her blood pressure is seventy.

  ‘Seventy? You sure?’

  Sabino double-checks the chart over Manuel’s shoulder. He’s a tall health worker with a wide gap between his front teeth, a black leather baseball cap shadowing his boyish face. ‘Yes,’ he says, sheepishly. ‘It says so here.’

  ‘But she’s in shock then—this is severe! Why did no one start treatment? It’s been like this since yesterday afternoon, according to the chart. Who recorded it?’

  ‘I did,’ admits an enfermeira.

  ‘You must tell someone, though, Veronica. This is an emergency—there’s no point writing it down and just leaving.’

  And then, as IV cannulas and bags of fluids are hastily gathered, the finger-pointing begins. ‘I wrote it on the front of his chart, in red,’ opines Veronica. ‘The clinico should have seen it.’

  ‘Look at the time it was written,’ Sabino defends. ‘I was at lunch then. Carlos was in charge.’

  ‘I was in charge of the whole hospital then!’ cries Carlos. ‘Every-one was at lunch. There were sixty-five patients, and that man in Intensivo was going crazy. Why didn’t the night-shift clinico see this?’

  ‘Because he sleeps,’ quips the nearby cleaner.

  ‘No, because he admitted four patients,’ defends Therese. ‘Ask Novo Doctor—he came for two of them.’

  ‘But Novo Doctor,’ sighs Sergio. ‘You are in charge of this hospital, no? We have had this conversation. You must check these things.’

  They’re all fair points. And they’re largely the result of differing backgrounds, I suspect. While I was being guided through eighteen years of structured, formal education, these people were surviving war. Many health workers have also been promoted quickly, well above their level of training, in a region where literacy and numeracy skills are an advantage shared by few.

  But all of this needs to be addressed. I’ve got only five months left, although I’m confident that if we concentrate on the common medical conditions, consistently and repeatedly, with clearly allocated responsibilities on the ward, there’ll be at least some benefit to patient care. I’m not the first to try—an office folder bulges with the handouts from lessons given by previous expats—but if I’m to be the last volunteer doctor here, it’s essential that this hospital soon runs at a competent level, and independently. Our aim as volunteers, in my mind at least, should be to make ourselves redundant: to leave self-sufficient, sustainable facilities when we pull out.

  First thing to address is those malnourished children, by far the most fragile patient group. Beneath the battered metal scale that we weigh them in each morning, three treatment protocols sit, dog-eared and smeared with high energy milk. Two are in Spanish, one in Portuguese, and all are different. So I work on summarising a single up-to-date guideline, then translate it with Tim’s help.

  Next, I plan some formal sessions with the health workers. Easy enough: an MSF handbook outlines standard treatment policies for key illnesses in all projects. All I need to do is to learn Portuguese. So I watch Dominga massage onion into goat legs after morning handovers for the following days, running through some phrases with her. Then, with Tim’s help, I script a first teaching session. I rehearse it, practise it again, and review it with Dominga.

  And now, just days later, on this third Friday, I take my place in front of the health workers in the larger Outpatients room. It’s a tough crowd. The twenty or so Angolans stare silently, but I’m quietly optimistic. I did exactly this in Thailand, and it became the watershed moment of my stay. For hours, forty Burmese health workers had sat cross-legged on a hard floor, peppering me with polite questions and asking when I could give the next lesson—‘Maybe two more this week, Doctor?’—and there’s no reason Mavinga will be any different. We’re going to all work better because of this, I think to myself. Patients will benefit, health care will improve and morale will soar, because all that’s been missing from this project is the enthusiasm and fresh-eyed approach of a young, inexp—

  ‘Does anyone know what Novo Doctor is saying?’

  ‘I’m saying that—’

  ‘We cannot understand you well, Novo Doctor,’ says Sabino, looking to me sympathetically from the front row.

  ‘What if I speak more slowly?’ I try.

  ‘No,’ says Sergio. ‘This will not work. We cannot go through a whole lesson like this. We just cannot. No way.’

  I run to Maternity to find Andrea to translate, but she’s dealing with a premature baby who’s hypothermic, wrapping it to mum’s chest with a silver-foil blanket. ‘We’ve got twenty-something women waiting for antenatal clinic,’ she apologises. ‘I’m going to be here for hours.’

  I jog over the road to find Tim, who’s working on a letter to the Angolan Ministry of Health. ‘Sounds too interesting to miss,’ he says, and as we walk to Outpatients I explain that I want to address a therapy that’s both medically inappropriate and a waste of resources. Tim nods. Now, back in front of the health workers, firmly in position on my pyre at the front of the room, I throw the match: ‘So really,’ I say, ‘we need to stop this use of antifungals for all diarrhoea here.’

  The flames erupt.

  ‘What is he talking about?’ shouts Sergio, as Tim translates.

  ‘Why?’ asks Senhor Kassoma, the partially hoarse director of Outpatients. ‘Why is he saying this? This makes no sense!’

  Hands are thrown in the air. There’s a snort of incredulity from the back. Roberto shakes his head, and I see now that I’ve made a huge mistake—it’s far too soon for me to be telling them what they should or shouldn’t be doing. We should’ve just revised a straightforward medical topic, but the damage is done.

  ‘He doesn’t know what he’s talking about,’ says Kassoma, eyeing the room from behind his far-too-large corrective glasses. ‘He has no idea! We have been doing this here for years. He does not know our diseases.’

  How to get out of this? I look over at Tim but he just shrugs, no longer translating. I run back to our compound and return carrying several textbooks, opening them to the relevant sections of each. ‘Look,’ I try. ‘Here: diarrhoea in children, and there’s no mention of antifungals.’

  The din is now a low roar.

  ‘And this one,’ I say. ‘Manson’s. It’s the bible of tropical medicine. And look—forty pages on diarrhoea and there are no recommendations for routine antifungal treatment.’ I thumb through others, hold up tables, show charts, but it makes no difference.

  ‘None of these books were written about Africa, Novo Doctor!’ states Senhor Kassoma, who actually looks offended. Who’d have believed that this was the same elderly man who’d whisked Andrea around that dance floor so gracefully? ‘And besides,’ he adds, ‘you haven’t worked in Africa before!’

  I point out that two of the books were written about Africa, and a third has an African editor. He doesn’t miss a beat.

  ‘Well, none of the books were written about Mavinga!’ he says.

  ‘That is true, Senhor, but they are written about tropical Africa. And we are in Africa, and in the tropics, not so?’

  ‘No! We are in Mavinga! It is not all just the same. Maybe to you Brancos it is. For us it is very different. You cannot tell me that a man from Zambia will have the same illness as a man in the Congo. Things are different here in Angola. The war has changed things. And besides, Doctor Lorenzo who was here last year—he was happy for us to use this drug. He was a very good doctor, and a very experienced doctor.’


  The rest join in, jumping onto this newly assembled bandwagon. ‘Mavinga is different,’ agrees Senhor Calvino, one of the four Outpatients clinicos. He’s a large man, the only obese person among our hundred staff members. ‘It is not like other places anymore,’ he says.

  I should’ve known that there was another expat behind this treatment. Why should they now believe me? As they talk, my mind torpedos back to those testimonies I’d found, and I recall reading elsewhere that the battle for Mavinga had been one of the most violent confrontations of the entire war; and here I stand, not even two decades later, picking an argument over diarrhoea.

  A few health workers get up to leave. Tim asks me what I want to do, and in a fit of desperation-induced inspiration I make a proposal: we could conduct a demonstration for a few weeks. All children admitted on certain days will be given the antifungal treatment, while all children admitted on the other days will receive only fluids, as per the guidelines. We’ll alternate the days to keep things balanced, monitoring recovery times to see if there’s any difference. Tim’s intrigued. He translates, though perhaps he shouldn’t have.

  ‘Now he wants to do experiments on our people?’ shouts Kassoma. ‘Absolutely not! Nunca!’

  ‘It’s a demonstration,’ I say, ‘not an experiment, Senhor. And the books say that what I’m suggesting is safe and effective—I’m not doing anything dangerous.’

  The room simmers with conversation.

  ‘And if any of the children get worse on my treatment,’ I add, ‘we’ll stop immediately.’

  Kassoma leads the discussion among the clinicos. Interesting to watch the dynamic of them all together like this; Kassoma’s clearly the leader, Roberto deferred to as well, but I’m not too sure about Sergio.

  Kassoma turns back to me. ‘And if our children recover quicker,’ he asks, ‘we will keep using antifungals?’

  I hope dearly that this isn’t going to backfire. It’s far from rigorous. ‘Okay,’ I say. ‘But if there is no difference, we stop using it altogether. Deal?’

  Excited deliberations take place. Roberto and Sergio are opposed, many others just amused by the afternoon’s turn, but Kassoma seems to be for it. He stands up to face the group. ‘No, what Novo Doctor is suggesting is interesting,’ he says. ‘Let us try this for a short while. Let us prove that he is mistaken.’ He turns, and with pointed finger he cautions me. ‘Because you will see this, Novo Doctor,’ he says. ‘You will see it. And you will understand that Mavinga is different!’

  • • •

  Saturday’s a half-day. Outpatients closes at lunchtime, but the wards keep us busy until late afternoon. By early evening, patients’ families begin lighting cooking fires around the yard, just a few of the hundreds being lit all over the region, and the soft haze of smoke that characterises these chilly evenings blankets the town. Blood-red sunsets are a welcome consequence, although walking for a little fresh air seems an ironic pursuit after work: the smog is at its thickest by then. But distractions remain few, a stroll to the river supreme among them. It’s not to be missed.

  ‘We delivered twins today,’ Andrea tells me, as we head left onto the main street. Tim and Pascal have chosen instead to stay home and finish their game of cards. ‘First I’ve delivered in ages,’ she continues. ‘It’s crazy—you have no idea there’s a second baby until you’ve delivered the first. I thought I could feel two bums through mum’s belly, but I really wasn’t sure. Always quite the surprise!’

  I’ve come to look forward to these debriefings with Andrea after work. Pascal tells me they’re poorly disguised attempts at flirting; either way, she’s the only other medical expat, a valuable source of support. Having previously spent a year working in an orphanage in Brazil, she’s a confident Portuguese speaker, and her competence in the maternity section is an asset to the hospital. Together with the Angolan midwives she looks after all the obstetric services in the hospital and community. Their morning antenatal clinics are my favourite—a wonderful spectacle: the heavily pregnant bellies of a row of expectant mothers bulge beneath bright dresses as they sit side-by-side on the wooden benches, looking like vibrantly coloured fruit ripening on a branch. Unfortunately though, due to the distances travelled, many of these women will never reach us in time to deliver, instead going into labour at home. That’s an extremely risky thing to happen out here: one in thirty mothers will die from pregnancy-related complications in their lifetime. Now that the war is over, giving birth is the most dangerous thing a woman here can do.

  We fill each other in on other patients as we pass the school building (just look for the ‘Escola’ sign on a pockmarked façade, no roof above, and broken pieces of blackboard glued to the front wall), where a handful of boys are playing with wooden tops—crudely carved cones that they spin on a point, flicking them with a strip of linen to maintain the motion. Meanwhile, the evening rush hour weaves past us on the main street: the last of the day’s hundred and twenty thousand litres of clean water, sloshing about in tubs balanced on heads; a handful of roosters, scuttling neurotically between bald yards and steering wide of the crudely constructed pig pens; thin goats, skittish and nervous, nibbling at any object (mostly thorny scrub, although a discarded truck tyre has the attention of one); a group of young girls who’d like to please touch Andrea’s blonde curls; three policemen, still with no car; and two oxen, guided by a young boy who’s whistling instructions from atop the wood cart they’re dragging, the truck axle beneath it squeaking to the plodding rotation of its wheels.

  But what we mostly see is kids. Dozens of them. Hundreds, even. And really, this is the highlight of evenings here: children own the town at this hour. They account for half the population anyway, more than double the proportion in my own country, but now, with adults having gathered around fires or settled against the crumbling walls of their huts, the kids lay an even more conspicuous siege to the township. No track is devoid of a group of girls skipping, singing, or chasing someone around, while boys, if not being chased, push cars made of soft-drink cans and plastic containers, or kick footballs—often a tight bundle of paper or plastic—where space allows.

  We turn right. Down a deeply rutted track, past the market, and we soon arrive at our destination: the mighty Cubia River. Two metres wide and knee-deep at best, it’s a silty, lethargic and slightly funky stream, slowly dribbling its way towards the Zambezi River, which ultimately traverses the continent to discharge off of Africa’s east coast. The unimpressive-looking stream may be the only water source for the town, but to dismiss it as mere water supply would be to horribly belittle its role: the very heart of Mavinga. Just five minutes here, and any doubts as to what I’m doing in this town disappear.

  The Cubia’s banks are the hub of social activity, a place where people sit and chat about the weather and who knows what else. It’s the town laundromat, where teenage girls scrub garments over smooth boulders, eyeing the teenage boys who bathe in the shallow pool upstream, behind the reeds. The far side is a favoured fishing spot, where simple rods made of a stick dangle hooks into a small pool that yields the occasional tilapia fish; the dating spot, where young men come to flirt with young women, and the malaria-laden mosquitos do the same with their kind; and I suspect it’s also the sometime-latrine, the I really hope that kid didn’t really just do that in there place, although the cattle wallowing in nearby stretches surely don’t observe toilet etiquette anyway.

  It’s all of these things, this murky stream, and it’s my favourite spot in town. Just don’t ask me to put a foot in the water. Those hooked eggs we see in stool samples? Schistosoma—a parasite that comes second only to malaria in affecting millions of people worldwide. Itchy red bumps is all you may notice in the days after bathing, at which time the parasites, having now penetrated your skin, will migrate towards your lungs. Next stop, the heart, then the liver, where they’ll pair up with a like-minded partner to mate. Herein, the real trouble: pregnant females will either stay put or migrate to the intestines, and they’ll
begin laying several hundred eggs each day; some of these will be shed in faeces and end up back in the river, but others will lodge where they are, leading to potential complications like bloody diarrhoea, bowel scarring, cirrhosis, even liver failure. Another brand of this parasite will do much the same, only to the bladder instead. So I marvel at the water, but don’t dare touch it. And I ignore the hookworm larvae burrowing into bare feet and seated bums, the clouds of malaria-carrying mosquitos, and the million other things out here that penetrate, bite, infect, or adhere to various body parts.

  ‘Onde vais?’ I ask a young boy, who’s filling his two yellow jerry cans from the edge—Where are you headed?

  ‘Lá!’ he smiles—There!—pointing to the snaking track that heads south to a group of huts, then Namibia.

  ‘Está longe?’—Is it far?—but the walkie-talkie beeps before he can answer. I turn up the handset—something we’re required to carry whenever outside the compounds. ‘Sim?’ I ask.

  It’s the guard. There’s an emergency in the hospital.

  We run, no idea what towards. The guard won’t say or doesn’t know. Last call was for a broken ankle, before that it was Pascal wanting me to pick up six Castles. Could be nothing. Could be a disaster.

  We leg it, past boys driving a large herd down the main street, around the corner, where the guard waves—‘In here,’ he points, ‘it’s a child’—and ushers me into the first room, where a large group of people stand back. A young girl is lying on the assessment table, the urgent heaving of her chest in violent contradistinction to the rest of her body, which is drowsy and weak. She’s panting and gasping, a little sprinter who’s just run a big race. I grab a stethoscope and can hear that her lungs are full of infection.

  ‘What’s the history?’ I ask Carlos, who’s inserting an IV cannula into her hand. ‘How long has she been sick?’

  The mother says nothing. She’s singing quietly as she strokes the girl’s cheek, oblivious to the rest of us in the room, oblivious to the rest of the world. A lone bulb casts severe shadows around the room from where it hangs above, the only light source we have to work by now, and even in this light and despite even her dark skin, the young girl looks pale and sallow.