Band-Aid for a Broken Leg

by Damien Brown

  But right now we need to leave. Lunch has been served and the healthier patients are sitting on mothers’ laps, spooning fortified maize everywhere—onto hair, blankets, mum, the floor, and occasionally into their mouths—and Sergio’s getting cranky. ‘We also need to eat,’ he complains, as Alberto’s brother listens to the wrong end of his stethoscope. ‘These ward rounds always take too long,’ he sighs. ‘Before, the other doctors were much quicker, Novo Doctor, and we get very hungry . . .’ so Carlos offers him a high energy biscuit. Meanwhile, the girl in the pink dress asks for another hug, Sabino’s got two kids pulling his lab coat, and Manuel’s just been dealt a spoonful of red beans across his lab coat by Alberto’s sister, whose white string earrings flutter as she giggles delightedly.

  Seems all is not bad in Mavinga General, after all.

  • • •

  All is not bad in the compound, either. A Friday night in mid-July, and the four of us gather around a fire in our back yard. We’re doing this a couple of times a week now, buying wood from the kids who sell it from their donkey carts and building these fires to create a little variety. And what wonderful variety; Tim sits forward to stoke the embers, and a hundred little fireflies of glowing ash dance their way upwards, into a sky unlike any I’ve seen. The night is moonless, and as we recline on the sand and gaze up I find it easy to understand why so many ancient cultures were so enthralled with the stars. Unlike the few dozen pinpricks of light visible in cities back home it’s a dense and detailed landscape here, the Milky Way not some nebulous concept you think you can maybe see, rather a luminescent veil spread out above us, a glowing silky cloth of light so real that it beckons you to reach up and try to grab it.

  And far below it, the faint rhythms of Kisamba music crackles from handheld radios in huts near to us, and the conversation still flows around this little fire—somewhat improbably given that we share every evening, meeting and meal together, but there’s no shortage of topics to cover. How Toyota got his name, for example, or plans for a wooden seat over the latrine. So I’m fast coming to the conclusion that I’ve been lucky with this team. Conflict is reputedly common in the field, but we’ve so far had only one disagreement (regarding breakfast cereals, of all things). Not bad for six weeks, four first languages and only three other faces. That said, visitors would be good, just some social variety, although Tim tells us that we’re in luck. A group of Brits will be visiting the Christian mission near town in the coming month, and they may stop here. I look forward to it. And what then of any intimate relationships among the four of us? It seems fate has dealt us an interesting hand there, because Andrea, who turns heads as she leaves the shower, and who could have her pick of the men out here, just happens to be a born-again Christian. Of the strictly No-Flings type.

  Earlier this evening we walked down to the river. On the way back I stopped at the hospital, watched the sunset with the families gathered along the fence line as they stirred maize into their tin pots over cooking fires. We made small talk (mostly asked each other ‘Quê?’ and laughed), and in the background we could all hear the choir practising in the mud-walled church off Main Road, singing Portuguese gospels in the most beautiful acapella. The kids from the Nutrition ward came out, too—they didn’t dare want to be excluded from any gatherings; and as Tim now stirs up another shower of fireflies, and Pascal sings the Italian football anthem for the umpteenth time since their World Cup victory last week, I remind myself that money can’t buy this.

  Whatever this turns out to be.

  9. WHAT APPENDIX?

  In the whirling, dusty wind that blows through town these mornings, hundreds of people gather at our compound entrance.

  ‘I want to make sure we are clear,’ states Pascal, addressing the log team assembled near the gate. ‘We need to keep this line moving. There are far more here than we planned for, so remember—each person gets one blanket, one bucket, one piece of soap, and a packet of high energy biscuits. And only the widows, elderly, and disabled. Okay? No one else receives anything. No exceptions. There won’t be enough to go around otherwise.’

  We’d only recently planned this handout. An excess of certain items had been found during a stock-take by Pascal, and we’d decided to arrange a free distribution rather than give it to the local Administration when we leave. And so it begins. The gate opens and barefoot elderly people, those with old injuries, and single mothers with children wrapped to their backs like surprised little starfish begin filtering through, taking away the packages one at a time. The poorest of the poor, in a country where more than half the population live on less than a dollar a day. The first wheelchair I’ve seen in Mavinga passes by, too—a man with no legs being pulled backwards in it by his friend, the wheels long since having shed their tyres—and by late morning the heat is oppressive, the crowd no smaller, yet still they stand quietly. Still they trickle past the front of our storage tent, one at a time, and carry off their packages.

  ‘The people thank you!’ says the King of Mavinga, who’s seated in a plastic chair at the end of the table. I’d not met him before (I didn’t even know Mavinga had a King!) and the man couldn’t be further from the stereotypical image of an African leader. Not to my mind, at least. Dressed in off-white sports jacket and grey pants, he’s a diminutive, grey-haired elderly man, speaking softly and smiling to all as they pass him. Toyota says he’s a genuinely respected leader, democratically elected to the role by the sobas, the traditional heads of all local villages, and is empowered to deal with traditional issues like land and livestock disputes. The appointed Administration, on the other hand, representing the MPLA government in this UNITA town, are nowhere to be seen.

  But the King, affable as he is, is unwittingly adding to some sense of guilt I’m feeling about this. ‘I thank you, too,’ he says, ‘for what you are doing in Mavinga. The people are very grateful’—which frankly embarrasses me. Because please: a bucket? A scratchy blanket? There’s little doubt that our gesture is token, we know this, but what worries me is the faint whiff of neo-colonialism: wealthy white people handing out freebies to impoverished Africans.

  Our living conditions have previously prompted discussion of this issue among us expats. Ours is a relative island of wealth out here, a bastion of laptops, generators and imported food, and Pascal believes strongly that we should eat only what locals do. Tim doesn’t. He’s spent enough time on these missions, he says, having turned his back on a lucrative career in business, to accept that a little luxury is small recompense considering what we’ve given up to be here. Andrea and I are inclined to agree with him—if frozen chicken, South African porridge and a few chocolate bars are what it takes to keep us happy, so be it.

  As for this distribution, we’d all rather be teaching or providing health care than giving handouts, but I’ve seen inside the local huts. A pot, water container, several blankets and straw baskets are the sum total of most people’s assets, and few here have the capacity to earn money. The hundred Angolans employed by this project are almost the only group of salaried workers in town, so far be it for me to scoff at these packages.

  The crowd gets no smaller. For every one person who comes through, two more gather in the distance. By midday, young men begin to force their way in. ‘Why do we get nothing?’ they shout. ‘Why do you ignore us?’

  Our outreach nurse is at the gate, allowing entry only to those on the lists made by each soba. He grabs the megaphone and re-explains the criteria as the organisation’s obsession with strict impartiality becomes clear to me. A few of the men arc up.

  ‘This old man is not even Ovimbundu!’ yells one. ‘Why are you letting him through? He is Nganguela! Is this not an Ovimbundu area? What of us?’

  ‘It is based on necessity,’ repeats our outreach nurse. ‘Not tribe. We are here for those that need it most.’

  But the criteria are largely redundant. Everyone here needs it most.

  ‘My mother is too sick to walk to your compound!’ declares a muscled young man, ‘s
o why can I not take one for her?’ Another pushes his way to the front, shows the long scar on his chest. ‘This is an injury from the war! I too have an injury, so why can I not come through? Just because I am not missing a leg like that man, I cannot get help?’

  The prospect of fighting seems possible. Ethnic tensions exist in the region, though this is the first time I’ve seen direct evidence of it. (Only months before I arrived, a person had been killed here when riots broke out over political differences.) For now, younger men become more agitated, and faces of those who’ve clearly already received goods begin to reappear. The team at the registrations table shuffle confusedly through their loose sheets of paper, but no one has any identification—

  ‘Are you Joseph Lumumba, from bairro Seixta-Feira?’

  ‘Yes, I am him!’

  —so people say what they want anyway. Verifying it is impossible. Those most in need are getting pushed to the back, while those most aggressive will get their goods, one way or another. The logs soon abandon the criteria and hurriedly give out everything, and I wonder now what will happen when we shut this hospital, retrench a hundred staff, and try to fly out equipment when all these people watching it have nothing left to lose . . .

  A fortuitous time for me to have to return to the hospital.

  • • •

  A complete change of scene over the road. The front hospital yard is unusually tranquil (most are at the distribution), but I hear moaning from the small room that Roberto and Agostinho use as Surgical Outpatients. It can mean only one thing. The Mavinga Dental Clinic is open.

  ‘Morning, Agostinho,’ I say, stepping past a handful of anxious-looking patients near the door. ‘Everything okay?’

  He looks up. He’s standing behind a young man, leaning over him with one hand gripping firmly across the patient’s forehead, the other prying out a tooth with dental pliers. Hard to tell who’s sweating more.

  ‘Sim,’ he replies, stopping. ‘Why would it not be?’

  The patient looks immensely relieved by this sudden reprieve. Somewhat dazed, he explores his mouth with a finger; disappointment washes over his face as he discovers the offending tooth still in place.

  ‘No reason,’ I say. ‘Just taking out the one tooth?’

  ‘No,’ he replies, and continues pulling, forearm trembling with effort. ‘A few,’ he groans.

  ‘Has he had local anaesthetic?’

  ‘Novo Doctor,’ laughs Agostinho, stopping again. ‘I do all of the dental work in Mavinga. What do you think?’

  A half-empty vial and clean syringe sit on the nearby tray, so I presume so. I only hope it was an adequate dose because Agostinho now ups his effort, straining hard, and something’s going to give—pliers, tooth or Agostinho’s shoulder, I can’t yet tell—and I wonder what the group of patients sitting outside are thinking. I’ve seen none running into the distance on any of these Dental Clinic days, so I suppose they’ve accepted this as the price of free treatment.

  ‘You seen Roberto this morning?’ I ask.

  ‘Sim.’

  ‘Where?’

  ‘At the steriliser. Preparing for surgery.’

  My stomach knots.

  ‘Why do you look so worried, Novo Doctor?’ chuckles Agostinho, and I only smile, shake my head unconvincingly, and lie that I’m not. But really I am, because I recall the roosters wandering out of theatre this morning, the car battery, that suction pump, the anaesthetic, the—

  ‘Why do you look so worried, Novo Doctor?’ chuckles Roberto, standing before the iodine-bronze belly of the young woman in the theatre only an hour later, and I only smile, shake my head unconvincingly and lie that I’m not. But really, I am, because—

  ‘Sir, you will need to take that hat off,’ Roberto tells the woman’s husband, who’s sitting in the far corner. (Which is a part of the worry, Roberto.)

  The man shuffles outside, returns a moment later.

  ‘We ready?’ asks Roberto, clinking his surgical instruments into arrangement.

  The husband nods.

  ‘Veronica?’

  Veronica nods, nudging her foot-pump into position.

  ‘Novo Doctor?’

  I grimace.

  Roberto then grasps his scalpel and neatly divides the layers of her abdominal wall; skin, fat, muscle; then gently snips the pearly-blue peritoneal lining of her abdominal cavity with scissors. Air gushes into her belly as he stretches the opening. ‘We should train you to be a surgeon, Novo Doctor,’ he says, reaching for retractors.

  ‘That would be good,’ I say, rivulets of sweat already tracking their way down my back. A surgical gown over thick cotton scrubs make this small room unbearably stuffy.

  ‘Tell me something,’ he says, peering over his mask. ‘We have been wondering about this. What kind of doctor does not know how to operate?’ He pauses as Agostinho ties off a bleeding vessel—a time-consuming process, with each oozing vein or spurting arteriole having to be carefully closed with dissolvable sutures. A diathermy machine would cauterise the same within seconds back home.

  ‘The others sent here could operate?’ I ask.

  ‘The good ones,’ he says. ‘Not all. But the good ones could.’

  ‘Most doctors in my country can’t operate, Roberto.’

  ‘No?’

  ‘Not at all. Only surgeons. Most of us use only medicines.’

  Roberto chuckles. ‘And how then is a doctor to cure his patients if he cannot operate?’ he muses.

  ‘We see different diseases, Roberto,’ I say, explaining that we’d have used scans and blood tests to diagnose this woman’s condition well before surgery, and that we’re usually able to treat patients adequately with medications or less invasive procedures.

  He opens her abdominal cavity further, sliding his right hand into the incision.

  ‘We’ve also never had a war,’ I go on, hoping that the Portuguese coming out of my mouth correlates with what I intend to say. I frequently have to stop and try to find a different way of explaining something. ‘In our hospitals we see mainly older people with problems like heart attacks, diabetes, or emphysema,’ I tell Roberto, and as we talk it strikes me that I’ve not seen a single person here with these conditions. My medical background would have to be the complete opposite to Roberto’s. His, an education during the war by South African military surgeons, dealing largely with severe, acute problems in fit young patients, a large proportion of whom would urgently have needed surgery; mine, an education in the context of chronic illnesses associated with affluent lifestyles and an ageing population. For all that I’m learning here, there’s little I’ll be able to apply to an urban Australian hospital. I’m going to be wholly out of touch when I return.

  ‘So, O Novo Doctor works in emergency centres?’ Roberto asks.

  ‘I do. Emergency departments.’

  He looks again at Agostinho as he fishes around the patient’s pelvis. ‘An emergency doctor,’ he notes in a playful tone. ‘Imagine that: a doctor for emergencies, but one that can’t operate in emergencies!’ He ponders this as he shakes his head again. ‘Never mind, Novo Doctor,’ he says, sifting through loops of bowel. ‘You do work well with the children here, this is true. And the adults’ ward is doing fine. Sabino tells me too that things are changing in the malnutrition ward, that you are writing clearer protocols—and in Portuguese? I like the idea of this. You know that I was not a big supporter of this antifungal business you pulled—Eh! To experiment on our people!—but the children are doing okay. This is a good thing, Novo Doctor. And this chest tube you put in the other night? This I don’t do.’

  It was another dramatic night call. A man had arrived with a punctured lung and dislocated ankle following the first road traffic accident I’d heard of here: a cart rollover at the riverbank. The ankle was easy enough to clunk back into position, but his chest was the bigger issue. To allow leaking air around the injured lung to drain (necessary for it to re-inflate) I inserted a plastic tube via a small incision between two ribs at th
e side of his chest wall. This I’ve done in Australia—although not without an X-ray, and never without familiar equipment. So we improvised. As per instructions in an old textbook, I cut the finger of a surgical glove at both ends, then fixed one end over the end of the chest tube, the other hanging free. The collapsible lumen of the free end of the finger has the effect of a one-way valve, allowing air to escape but not re-enter his chest, and had worked perfectly well. At least until we found a better solution in the pharmacy the following day.

  Roberto looks to Agostinho. ‘You have done them?’ he asks.

  Agostinho mumbles something, but I struggle to understand what the man says. With or without his mask.

  Roberto chuckles. ‘I dare say that you did it well, Novo Doctor,’ he says. ‘Like a doctor should. But still, we are going to need to train you to be a proper doctor before you leave—a doctor who can operate on his patients. One who can really treat people.’

  The others nod.

  ‘Now, Agostinho. Let O Novo Doctor tie the vessels. We must not delay his teaching any longer. Pass him the sutures!’ Roberto locates the patient’s ovaries and pulls them to the surface, ending our conversation, heightening my unease.

  The issue of surgery continues to remain problematic here, particularly decisions about which patients we should operate on. Our mandate is clear—that we’re to operate only for life-threatening conditions that we can realistically manage—but a significant confounder remains. Namely, how can we know whether a condition is life-threatening if we can’t diagnose it? It’s a classic Catch-22: the only way to be sure in many cases is to open patients up and look, yet the only reason to open them up is if we’re relatively sure of what the condition is.

  We’ve performed two operations since that appendicectomy, a below-knee amputation and an emergency Caesarean, and in both patients the need had far outweighed the risk. Often though a woman will present to the hospital with non-specific pains and actually insist on surgery—the Rolls Royce of medical care, by public perception. The probability is that their condition is benign, although we can’t always be certain. No less when the patients say that they’re getting worse, and the family insist that they’re dying, and partners get upset, and the rest of the ward rally around them to say that we must operate immediately. How then to be objective? I can’t reassure them with a scan. And opening them up to look, with the risk being that they then succumb to any of a thousand complications, is clearly unjustifiable. As is waiting too long—they could then deteriorate. It’s immensely difficult, a balance between being cruelly hesitant versus dangerously over-zealous, so Roberto and I debate each case (albeit a little more amicably these days). That said, the issue remains the bigger difficulty on the wards.