by Damien Brown
‘She’s had a cough,’ says Carlos. ‘For a few days. Now a high fever and lots of diarrhoea. It took them most of the day to carry her here.’ He runs to get a malaria test while I draw up saline and antibi otics from supplies on the shelf and give it to the enfermeira to inject. Carlos returns and pricks her finger, but it’ll be minutes before a result comes so we give her antimalarials anyway. Next, IV glucose in case her blood sugar is low—we can’t test for it—and we call for the lab worker to check her haemoglobin.
We repeat the fluid bolus but the girl remains drowsy. We set up a fluid infusion, then carry her to Intensivo, where mum cradles her. The girl needs oxygen but we’ve got none, and Carlos volunteers to stay late as the rest of the staff get on with the evening handover. We reassess her frequently and adjust her infusion. We stay beside her. We give her another bolus, double-check the handbooks, and after an hour she’s still chugging away, hanging in there, but her eyes are tired. I step outside to radio Pascal about the generator because we’ll need the light for hours yet, and while I’m there I hear a cry.
I run back in. The mother’s up, walking in circles. She looks back in disbelief with her hand over her mouth. The four men draw closely around the bed. I squeeze past and can see the girl’s stopped breathing. Christ. Carlos grabs a rubber bag-and-mask from the cupboard and hands it to me to ventilate her. I place the mask over her mouth and begin resuscitation but there’s surely no point because it can’t possibly work, not out here, so I wrestle with my conscience while the mum paces behind me: Is it crueller to give the parents another few minutes of false hope than to just call it like it is? The girl’s chest rises with the deflation of the bag but it means nothing. There’s no pulse. The family are silent. Do they think she’s breathing?
Carlos begins chest compressions. I ask the enfermeira to get a vial of glucose and adrenaline and we give both. The families of the three other patients in this ward come over. There are too many people and I don’t know what to do so I keep ventilating her body while Carlos continues with the chest compressions. How or when are we going to stop this futile exercise? What do the family expect? I whisper the questions to Carlos and he says they hope we will still save her. I say softly to him that it’s over and he nods, says he knows, and I wonder if the family will sleep better for getting their child to a hospital where a foreign doctor could try to save her.
‘Tell them the infection is too severe,’ I say to Carlos, still inflating the bag. The bed squeaks like an old tumble dryer under the compressions of her little chest, and a conversation in a local language follows behind me. The mother looks at me and tears well in her eyes and she covers her mouth again and starts to cry into her hand. ‘I’m sorry,’ I say. ‘I’m very sorry.’ A word I’m using too often on these wards. I stop ventilating. Carlos stops the compressions. The mother starts screaming.
It’s clearly not the Africa of newspaper articles and TV documentaries where people just accept tragedy.
Mum falls to the floor. She pounds it, pounds her chest, holds on to the leg of a man standing nearby. People begin wailing. Women come in from outside and see the body and go back out crying. Men cry and gather around the father. Big, powerful-looking men, and they raise their hands and yell and seem to question something, and like a deer caught in headlights I don’t move. Are they angry? Do I apologise and attempt to console this sea of waving and pounding arms? They carry on for what feels like an eternity until Carlos wraps the body in a blanket for them and then they lift it up, a crumpled little package, and they go wailing out of the compound, into the dark. Carlos heads home and the enfermeira wipes the bed, and I don’t know what happens now, I have no idea, so I go home to play cards with Pascal and Tim.
I don’t know what else to do.
7. BARGAINING FOR BODY PARTS
But the night won’t end.
I lie in bed, and for hours there’s absolute silence—a sound disconcerting in its own right. No traffic, no voices; no hint of any life. Then the roosters start. Then the donkeys. And then the soldiers, performing their drills on the airstrip; but anything’s better than silence, and their singing is somehow soothing. I may yet drift off. Only now the sun’s rising, cleaving a shelf of bright dusty light below my wood shutters.
I get up. I search my room for a distraction, but pickings are slim. Two pairs of pants, some MSF T-shirts and a few other clothes sit on a metal rack beside the window, and my laptop gathers dirt on a plastic desk. On the cold concrete floor, underwear; on the blue-grey walls, nothing. The only other objects of note are the half-dozen books stacked beside a candle on the cardboard box I’m using for a bedside table, but they’re exactly the wrong books for a day like this. References on African history and tropical medicine, a novel set in Afghanistan, and an account of the Rwandan genocide. I’ve got no idea what I was thinking when I packed.
Back to bed.
Andrea begins to stir in her bedroom, to the right of mine, then heads out for a jog. The others are likely still sleeping. A relative silence descends again, and in it I hear termites rustling softly, gnawing at the crudely hewn poles of the roof frame above me. An almost imperceptible mist of wood dust drifts down, creating a brown residue on the mesh of my mosquito net—the supporting structure of my shelter being chewed, milligram by milligram—and I imagine it won’t take much to bring the remaining honeycomb down. A few days of rain in the wet season, perhaps, or the rumble of another cargo jet landing. Or a bird. One of those large, big-bellied, waterbirds. They’d weigh five or ten kilograms; this thing could hold maybe one. Not that there’s much chance of large waterbirds flying past here, though. The war decimated wildlife populations. They say that thirty years ago one could find black rhino, elephants, lion, buffalo, giraffes, buck and zebra roaming the area, but domesticated animals and small birds are all I’ve seen since arriving. A cruel irony given we’re in a designated wildlife reserve.
The desperate search for food during the war led to these animals being eaten out of local existence. Even the country’s national animal, the black sable antelope, was hunted almost to extinction, although elephants suffered a more senseless fate: rather than for food, entire herds were slaughtered by UNITA troops (at times with machine guns, in coordinated attacks from helicopters) for ivory, which was then sold on to Asian markets to help fund the war. It’s understandable then that the earlier leopard attack, as dramatic as it was, had actually been viewed as a positive sign by many: native fauna are finally returning. Hippos are known to wallow in downstream pools, and I’ve heard our staff mention that elephants have been spotted further south. But still, nothing in Mavinga.
A door flings open loudly to the left of my bedroom. It’s Pascal’s.
‘We need to do something about this!’ he says, uncharacteristically animated for this hour.
‘What?’ calls Tim, from the other end of the compound.
‘THESE FUCKING DONKEYS!’
‘I’M IN THE SHOWER,’ Tim yells.
Pascal goes on, complaining to no one in particular. ‘CAZZO! THEY HITCH THESE ANIMALS BEHIND OUR FENCE, AWAY FROM THEIR HOMES, RIGHT NEXT TO OURS. HOW CAN WE SLEEP WITH THIS NOISE? EVERY NIGHT, RIGHT OUTSIDE MY—’
‘I’M IN THE FUCKING SHOWER!’ Tim calls again, but Pascal’s on a roll now. ‘VAFFANCULO, PEZZO DI MERDA—’ he goes on, which I find amusing because he does it so frequently, and so passionately, about the most benign of incidents.
As for Tim, he’s likely to be in the shower for a while yet. He appears to actually enjoy the freezing water, singing in a rich baritone as he flirts with hypothermia in that little shed. Pascal and I do no such thing. We’ve deferred instead to the heat-a-pot-to-splash-yourself technique for the moment—best undertaken during the warmer afternoon hours. Andrea puts us all to shame, anyway. She showers straight after her dawn jogs, long before the rest of us have contemplated rising, then once more at night, long after even Tim’s deemed it too cold.
Not that I’m taking an active interest in the livi
ng habits of my workmates. It’s just the unavoidable reality of living in close confines. Proximity, squeaky doors, single-brick walls and poor insulation have long negated any illusions of privacy, and we already know well each other’s personal oddities—and on a level I’d even find uncomfortable at this stage of a torrid romance. Andrea, for example, whose Germanic obsession with neatness is rivalled only by her team-mates’ lack of it, wears sandals to go to the latrine during the night. I know this because my bedroom window faces the latrine, its shutters an inch smaller than the opening they’re meant to cover. Pascal, however—who makes it through most of the day on Nutella and cigarettes, and whose resemblance to Che Guevara goes beyond the mere physical (had he been born thirty years earlier, I’m confident he’d have swapped his MSF T-shirt for the uniform of a freedom fighter)—wears no footwear to the latrine, and is usually the culprit for leaving the pit’s lid open. In contrast, Tim closes the toilet grate. He also speaks in his sleep, snores heavily, and, since his previous breakup, no longer believes that love exists . . . which is all just the tip of the iceberg. Who knew we’d be each other’s relationship counsellors, career advisors, political sounding boards, and private audience—willing or otherwise—to tales of sexual misadventures? Living on top of each other like this can’t be underestimated.
As for my insomnia, the donkeys had little to do with it. The death of that young girl unnerved me. I’ve not seen a child die before, and I’ve never seen people react like that. Not to anything. I’d expected that deaths would be an inevitability out here; one in four Angolans die before their fifth birthday, probably more in places like Mavinga; and as a doctor, I’ve dealt with death. I’ve certified bodies of patients on the wards in Australia, and been called to open bags in the morgues of regional hospitals in the small hours of the morning. I’ve made phone calls to relatives and heard their sobbing on the end of the line, and been a part of discussions with families regarding end-of-life decisions. It’s always sad. But it’s never been like this. Never children. This is different. And the intimacy of it all, being there to watch that family grieve like that . . .
I heard crying early this morning as news spread around town. The family carry the body around afterwards, I’m told, and a funeral procession will snake its way towards their village today. So now I wonder: did we make a mistake with her care? Did she even have a chance at all out here, with or without our treatment? I can see no way to objectively assess this. As with so many of the patients on the ward, I’d give anything for a senior medical colleague who understands this context to come out here, just for a day, to guide me, correct me, even to reprimand me if needed. Because I’ve read the medical guidelines many times, and the theory I’m okay with. It’s the application of it that’s not so straightforward.
Patients here often present late, in advanced stages of illnesses that aren’t seen back home, and that crutch of Western medicine that I normally rely on is absent: abundant tests. It’s as if we’re practising medicine in the nineteenth century. To determine a patient’s haemoglobin level, I pull down their lower eyelid and gauge the colour (we have a lab test, but it’s rudimentary), and to check a foetal heart rate, Andrea listens to the mother’s belly with an empty cone-like device, a Pinard’s stethoscope, as if eavesdropping on a conversation in another room. Fevers present a particular problem. The causes are infinite, the cases many and the only tests we have are kits for HIV, syphilis, malaria and hepatitis, as well as that little microscope and devices for blood grouping. So I trawl textbooks for clues I’d not ever needed in Australia. If it’s typhoid, for example, the pulse will be unusually slow; in neonatal tetanus the baby won’t latch onto the breast properly. If it’s Borrelia the fever will likely recur, and in measles you’ll see telltale white spots inside the mouth. Such signs can be subtle and easy to miss, though. Yet even diagnosing things as ostensibly straightforward as broken limbs is not without difficulty. A conversation with a soldier last week, who’d fallen on his arm during training—
‘How did you break it?’ we asked.
‘So it is broken?’
‘Possibly. Does it feel broken?’
‘What does broken feel like?’
‘Good question. Is it very sore?’
‘Yes.’
‘Did you fall hard?’
‘Yes.’
‘And what if I wiggle it a little here?’
‘AIEEAH!’
‘Sorry—let’s assume it’s broken. We’ll plaster it, and you’ll need to wear this for four weeks, okay?’
Then again, even having a clear diagnosis doesn’t always make things easier. Days after we saw the soldier, a young boy presented with a significantly deformed forearm—undoubtedly broken. How then to assess it? Good painkillers and a firm feel along the fracture line, pushing hard enough to feel through the swelling. Were there two fragments of bone in there, or more? Who knew. Had he suffered any damage to nearby nerves or blood vessels? Didn’t seem to be the case. So we gave even stronger painkillers, took a breath, then pulled, bent and massaged the arm back into shape, all of which contradicts my every instinct as a Western doctor regarding certainty. Who would do such things in a litigious, resourced society? My experiences in Thailand had certainly been challenging, but there we had a modern hospital to refer people to.
So I’ve taken to contacting anyone I can for advice. The MSF surgeon in Europe graciously replies to my many emails, and I frequently query specialists in Australia. Last week I called the switch-board of Melbourne’s Royal Eye and Ear Hospital from our satellite phone and spoke to the on-call ophthalmologist about a young man who’d been carried to us from the Christian mission, an hour from town, having gone suddenly blind. Their advice was excellent; people are always keen to help, the problem is that we seldom have the equipment needed. Drugs we’re usually okay for—I’ve not yet needed a drug and not been able to find it in the pharmacy, or at least a suitable substitute—but equipment is the issue.
So yes, I need an experienced colleague. And while they’re here, I’d ask them kindly to take one of the nights on call for me, because this enduring sense of dread regarding a call to the next disaster, every day for the foreseeable future, is draining in itself.
Indulging my self-piteous wallow, I called my girlfriend last night—or ex-girlfriend, or whatever we are at the moment because we’ve been emailing each other a lot so I wasn’t really sure where we stood. She was. ‘I can’t be your support,’ she said. ‘You left me to go there. I need space.’
(Sofia was right: you do need someone to think about out here.)
My parents fortunately didn’t need any space. They were thrilled to hear from me and encouraging of this whole experience, something I desperately needed to hear because I wonder at times whether massaging arms in one needy village out of the thousands on the continent will make any difference at all, no less if we’re going to leave soon anyway . . . But parents are good at smoothing over that stuff. (And, at only four dollars a minute via satellite, I was treated to an update regarding the family dog, the latest rugby scores, and progress with the new kitchen flooring. A nice taste of home—a home that’s already starting to feel strangely unfamiliar, even though it’s only been weeks since I left.)
Anyway, there’s no point mulling over what happened yesterday. I can’t change it. And today of all days is not to be squandered with introspection: it’s Sunday. Our day off.
‘Hey, Damien,’ calls Tim.
‘Yeah?’
‘You up?’
He sounds like he’s in the office, next to the shower at the hospital end of our compound.
‘Still in bed,’ I call back.
‘What?’
‘IN BED.’
‘YOU HAVE AN EMAIL FROM SOMEONE NAMED ANNA ON HERE,’ he shouts.
‘THANKS.’ I’ll read it later, I decide. She’s an old university friend.
‘I DON’T REMEMBER YOU TELLING US ABOUT AN ANNA,’ he says, and now the door on the other side of my bedroom swi
ngs open again.
‘Anna?’ asks Pascal. ‘You definitely did not mention Anna. TIM—IS HE KEEPING THINGS FROM US?’
That thing about living together? Yet again, any notions of privacy are shattered.
‘AND YOU HAVE ONE FROM A NICOLLE,’ calls Tim. ‘JESUS, WHAT HAVE YOU BEEN DOING ON THE INTERNET, NOVO DOCTOR?’
‘SHE’S MY SISTER!’ I shout back.
‘IF YOU SAY SO. PASCAL AND ANDREA, A FEW HERE FOR YOU. AND MERDA! DAMIEN—ANOTHER ONE FROM THE EX! DID THIS THING NOT END?’
I bury my head under the pillow.
• • •
Spending a day off in Mavinga is not without its challenges. A walk around town is the norm, and we’ll make one together, although not until the daytime heat wanes this afternoon. Dominga is off, too, so one of us will have to prepare lunch and dinner—no pleasant task in that dingy kitchen. And we’ll need to do some exercise; a jog on the airstrip, or maybe set up the badminton net we found in the store room. But even doing all of this, everything we can think of—twice even—will leave at least twelve hours to spend with the others. Or in the hospital. Again. So really, there’s no rush to get out of bed.
We lounge around our bedrooms for much of the morning, taking turns catching up with correspondence from home. Reading fills in a little more time. By midday I’ve shaved, checked emails, cooked porridge, reviewed the handful of sicker patients and been thrashed by Pascal in a game of chess. Andrea’s busy in the kitchen, where, in a fortuitous turn for the rest of us, she’s embracing a personal stress-management technique benefiting us all: baking. We three meanwhile kick a football in the back yard, an activity that’s cut short when the ball’s thumped far over the fence—