by Damien Brown
Photographs of the three deceased stand on a table ahead of us, falling often as the wind buffets them. There are no coffins, though. The body of Damien Lehalle, the French logistician, has been flown home for a service; Victor Okumu, the Kenyan surgeon, will be buried in his home town in the coming days, although his family are now with us; and the body of Mohamed Bidhaan, the Somali driver of the ill-fated car, remains in his home country.
It’s an outpouring of anger as much as grief, the service. An MSF senior speaks movingly of the sacrifice the three have made, of the senselessness of such an attack, and of how it’s as much an assault on the Somali community, who’ll consequently be deprived of this assistance as MSF reassess the feasibility of the projects. Team-mates of the deceased stand up, sobbing their way through eulogies. The teenage daughter of Victor Okumu has to be helped back to her seat when she collapses despairingly, and his widow is little more composed. But a relative of theirs confronts MSF seniors. ‘How could you do this?’ she cries, standing in front of them. ‘How could you send this man to such a place? And when you knew this country was not safe?’
It’s a painfully awkward moment. The MSF coordinator looks devastated as he weathers the outburst, though I suspect I’d have reacted like the relative had I been in her position. But for me, MSF made no secrets of the security issues during briefings. They’d made it exquisitely clear that the decision to go, and the attendant risk, was mine. A cursory browse of their public websites doesn’t downplay such risks, either. Statements caution that volunteers have been raped, kidnapped and murdered in the past, and off the top of my head I can recall several recent tragedies: the 2004 execution of five MSF volunteers in Afghanistan, shot in their well-marked car; the fatal shooting of a French nurse in the Central African Republic last year, just weeks into her first posting; the kidnapping of two volunteers in the north of Somalia only months ago, since released unharmed; and the seven passengers who’d died near Mavinga in 2002, when the MSF car hit a landmine. If people know nothing else of MSF, in my experience, they know of its reputation for working in dangerous places. Mentioning back home that I’d worked in Angola garners mild interest; saying that it had been with MSF elicits admiration.
Since its inception, the organisation has been active in conflict areas. In many ways it was born of conflict. In the 1970s, a group of young doctors working for the Red Cross became increasingly frustrated with that organisation’s strict policy of silence (specifically with regards to atrocities committed by the Nigerian military during the Biafran Civil War) and argued that to not draw the world’s attention to such acts was tantamount to complicity. Along with a group of like-minded medical professionals and journalists, they formed MSF, and the idea of témoignage—of bearing witness, or speaking out—became central to the new organisation’s principles, along with those of strict neutrality, impartiality, independence, and the observance of universal medical ethics.*
To allow operational decisions to be made free of external influences, the organisation relies largely on private donors rather than governments. The projects they run are varied in scope, and include, among numerous others, general hospitals and community health projects; disease-specific programs such as those for HIV/AIDS and TB; short-term, focused emergency interventions for conditions like cholera, malnutrition or meningitis; and campaigning at a political level for affordable access to essential medicines in poorer countries.
But they’ve always maintained a commitment to assist in conflict areas. The seventy countries they’ve worked in over the last decade include Iraq, Afghanistan, Chechnya, Sudan, Angola, Congo, Liberia, Sierra Leone and Rwanda—a roll call of trouble spots—and in 1999 they were awarded the Nobel Peace Prize.
All of this requires volunteers, however. A constant supply of volunteers. People from a range of professions, often with variable if any experience in such places, and who’re prepared to accept the risks. And I wonder now, as I stand in this park, whether a thirty-year-old health professional from a wealthy country, who has no background in security, international politics, or conflict—me, for example—can make a truly informed decision about any of this. I read the documents. I spoke to people who’d previously been in Somalia, but I still don’t understand the implications of phrases like ‘increasing ethnic tensions’ if I’m to be in the hospital all day, clearly assisting these people. The assumption must be that if volunteers are sent there, the organisation considers it safe enough; conversely, the assumption must also be that any volunteer who’d accept such a position has seriously contemplated the risks—and accepted them. It’d be a fine line, I imagine, between being able to access these areas at all versus taking too big a chance. For me, though, the bubble bursts this afternoon. I stare at the three portraits. The risks are no longer theoretical.
And yet the recently evacuated volunteers are actually keen to go back! I share a guesthouse in Nairobi with a dozen of them, including a Canadian surgeon with a wife at home and a French logistician with a degree in philosophy, and all speak fondly of the Somalis. All deeply regret leaving. All of them miss the staff and patients, and all would return without hesitation if allowed back. And none strike me as ill-informed.
As to whether they will go back, the pressing issue is that of the motive behind the attack. If it’s purely a local problem (a disgruntled businessman, for example) then they’ll return soon, but if this represents a wider threat from fundamentalist groups, there’s no chance. In the meantime, we wait. MSF send a team to investigate, and medical supplies and wages are flown to the Somali staff, who continue to provide a level of health care.
• • •
Being on stand-by in Kenya isn’t without its own problems. Normally a relative oasis of peace in this part of Africa, widespread violence has erupted following the presidential elections in December, just last month. Both parties are accused of electoral manipulation, and members of the president’s Kikuyu ethnic group have become targets of violence. By late January, hundreds of Kenyans have been murdered and hundreds of thousands of others have fled their homes. Camps for these Internally Displaced Persons (IDPs) spring up across the country.
I’m sent to join an existing team in Eldoret, a town in the Rift Valley region further west, to help make a rapid evaluation of the health situation. The scale of the main camp exceeds anything I’d imagined. A vast plain of rudimentary plastic shelters sprawls over a muddy sports ground on which twenty thousand people now live, all sleeping on the dirt or on plastic throw-downs as rain worsens conditions further. These families all fled here to seek protection from their former neighbours, and everywhere in town we see evidence of the unrest: the charred remnants of selectively torched homes and businesses; broken windows and threatening graffiti; and makeshift roadblocks of logs or loose piles of rocks, at which people were dragged from vehicles to an unimaginable fate. The men from these opposing ethnic groups seem pleasant enough, though. They stand around in town as if it were all just a quiet week, and I can’t help but wonder which of them had been responsible for all the violence and destruction. Could they really feel so strongly about an election?
It’s soon apparent that I’m not going to be needed in Eldoret as a doctor, however. The aid response has been huge. The Kenyan government, along with UN agencies and dozens of other aid groups, appear to be meeting immediate needs (our hotel’s car park is packed with white four-wheel drives bearing the logos and acronyms of every aid agency I have and haven’t heard of), and in the larger camps school classes are even being provided for over two thousand children in a series of tents set up by UNICEF.
As for Somalia, security has deteriorated further. No one will be heading there soon. I’m instead offered a position in Mozambique, a country on the south-east African coast, which I promptly accept; and, just two days, three commercial flights and one boat ride after receiving the email, I arrive in my new project.
• • •
Being in Mozambique is like meeting Angola’s happy cousin. The
country has the same national language, a mostly Bantu population and those enticing Afro-Latin rhythms blaring from beachfront bars, although this is arguably the sexier of the two nations. Positioned at a similar latitude to Angola, albeit on the opposite side of the continent, its long coastline is dotted with warm, palm-fringed Indian Ocean beaches that attract a stream of international tourists, yet the history of these former Portuguese colonies is depressingly similar: a thriving slave trade; a violent anti-colonial movement; an almost immediate post-independence civil war; and finally, after fifteen years of fighting, a peace agreement in 1992.
But my posting has little to do with conflict this time. Floods have displaced around fifty thousand villagers along the banks of the Zambezi River, and similar events eight years ago resulted in a large cholera outbreak. MSF are anticipating a repeat of this.
By the time I arrive in mid-February, a dozen volunteers have been assisting communities for weeks. I spend a day with them being shown how to set up a mobile health clinic—essentially a large tent beneath a much larger tree, where short consultations are provided at a plastic table and medicines dispensed—and then head upriver to join a second, smaller team of two expat logisticians and four Mozambicans, closer to the Malawian border.
For the first two weeks we run our own mobile clinic, seeing up to a hundred and fifty patients each day. It’s busy work and none of us have done this before, so we’re all learning on the job. At the same time, flood forecasts change constantly and new health information is phoned through several times a day; our plans are revised often. Then, after two weeks, we’re instructed by coordination to cease the clinics, and to instead conduct a nutrition survey—something I’ve not ever seen, let alone supervised—so by the end of our third week there’s still no semblance of a routine. Except for one thing: no matter what we try, we can’t get away in the mornings.
Or find our staff.
• • •
‘You seen the nurses?’ asks Simon, the thirty-something Canadian log running our group. His physical resemblance to Pascal is uncanny; same woolly Guevara-esque black hair, same wispy goatee. He’s poring over stock lists and a map with torch in hand, the well-worn papers spread over the bonnet of one of the three four-wheel drives we’ve rented.
‘They’re still in bed,’ I reply.
‘Jesus. We’re not going to have enough time out there!’
I agree.
‘And the drivers?’
No idea. We should’ve been on the road half an hour ago. It’s already after five-thirty and the sky’s begun its gentle transition from black to the pale glow of a tropical dawn, yet we’re still waiting in the gravel car park of the guesthouse we’re using, off a side track in our small base town of Morrumbala, to the west of the country’s centre. It’s a four and a half hour drive each way to today’s village, and we’d made it clear: not Local Time again, please people. We have to be back here by sunset, so there’s no room for faffing. Which is ironic, because that’s exactly what our team is best at.
João, one of our three Mozambican logs, soon walks up from the gravel road. ‘Oh, I am early?’ he asks.
‘Late.’
‘But where is everybody?’
It’s the million dollar question. The two MSF nurses are accounted for (in bed, the last time I’d checked), and Kevin, a logistician from New Zealand, is spending the night in another village. But our three drivers and two other assistants are still missing, as too are the Mozambican government nurses we’re supposed to be working with, and it’s this latter issue that’s becoming a problem. The local representative for the Ministry of Health has insisted that two of his nurses accompany us on all visits—‘You are guests in this country,’ he reminded us, ‘and you are here at our invitation, so you are not to run around doing your own thing’—but, yet again, neither of them has arrived. And if they don’t arrive by the time we do finally leave, like yesterday, João will guide us along the winding tracks past nearby adobe homes to look for them. Being presumably unsuccessful in our search—again—we’ll then drive to the government hospital and ask if another nurse can accompany us, because that’s what we’ve been told to do, but the hospital is exceedingly crowded and understaffed and dealing as well with rabies cases this week, so we’ll almost certainly leave without any of their nurses. Then, when we return this evening, we’ll be called back into the ministry offices, again, to explain why we left without the ministry nurses; and when we ask the official in no way facetiously if he’d rather we didn’t run the clinics at all on the occasions they don’t arrive—‘Because, sir, let’s be honest, they never arrive, but if you would rather that we cancelled the program on such days then in all good grace I will inform my seniors that that’s what we’ll do’—he’ll just groan, wag his finger at us, shuffle papers and remind us that we are his guests, and that it is our responsibility to find them.
But where can we find them?
‘And the drivers?’ asks João. ‘Where are the drivers?’
Moments later, one of them makes his way towards us, shuffling from the brick bedrooms across the car park. He looks awful—no shirt, shoulders hunched, almost swaggering.
‘Maurizio? You been drinking?’ asks João.
Maurizio arrives and leans against the nearer car. Blisters of sweat pool on his brow. ‘I think I have malaria,’ he groans. ‘Today, I am not good.’
I put a hand on his forehead; the man’s burning up. I fish through one of the boxes of medical supplies and retrieve a Paracheck malaria test, the same type we’d used in Mavinga, and lay it out on the bonnet. With just a small drop of blood from Maurizio’s finger the test is immediately positive. ‘You do, mate. You had it before?’
‘Not for years. Before, yes, but I have been living in the city these years.’
I hand him a three-day course of artemisinin-based pills from our boxes, good treatment, and escort him back to his bedroom. João brings him food and water, then disappears to rustle up the others. One of our two nurses soon walks over—still in her pyjamas.
Simon laughs.
‘What on earth are you doing?’ I ask. ‘We need to go!’
‘I need to find the laundry girl,’ she replies. ‘I have no clean clothes.’
‘Could you not have done that yesterday?’
‘We didn’t get back until late. Anyway, Katrina’s gone, so we have to wait for her.’
‘Gone where?’
‘Into town.’
Simon folds the map and takes a seat on a large boulder near the edge of the yard. We’re clearly going to be here for a while.
‘Why into town?’
‘To find breakfast,’ she replies; Miranda’s her name.
‘But did you guys not remember? Five! We needed to leave at five!’
‘Yes, but we need breakfast.’
‘We have rolls and drinks here for the drive—like yesterday. And the days before.’
João returns to tell us that the other driver is in the shower.
‘Then I am going to go have a quick breakfast with Katrina,’ says Miranda. ‘If we are waiting for him, I will have plenty of time.’
. . . And on it goes.
Within the hour most of the team have assembled. We decide to give up waiting for the others, and now, just two government nurses and a driver short, we begin our slow journey towards the Malawian border. The driver turns up techno on the LandCruiser’s stereo but like an old man I ask him to turn it down again—six-thirty is a little early for doof-doof-ing our way through African villages, I suggest—but at least the two nurses are now in a great mood—laundry since dropped off, egg rolls scoffed and coffees in hand. The suspension’s long since given out and our T-shirts cling to us as the humidity soars, and João’s telling jokes, all of us jammed together among boxes and equipment like some kind of semi-dysfunctional, multi-racial family, and I find myself grinning broadly. Thrilled to be back in rural Africa once again, and unable to fathom a more scenic trip to work than this, the one
we make each morning.
• • •
The aim of our project here has been to minimise the health impacts for those who’ve been displaced, using a step-wise approach that’s widely applied for population movements and health emergencies. It addresses four basic but overlapping elements—food, shelter, water and sanitation, and health—and is as much a logistical exercise as a medical one. And it’s what MSF reputedly excel at.
Pre-packaged kits covering most disaster contingencies are stocked at their international warehouses, ready to be flown anywhere at a moment’s notice. The order sheets make fascinating reading, with options including an inflatable hospital, water purification systems, haemorrhagic fever kits, and even cars. Several of the cholera kits have already been sent to Mozambique, each one containing everything required to treat six hundred patients, from IV fluids and beds, to stationery and staff clothing. I’d seen them used as I’d left Angola, where large tent-based treatment centres were being rapidly set up, and it’s this—a potential cholera outbreak—that’s been the concern here. Cases have already occurred upstream in Malawi, and without treatment up to half of all patients will die rapidly from dehydration. With treatment (simply the administration of fluids, either oral or IV, for a day or two) the mortality rate is less than one per cent.
In terms of this Mozambique project, two logistics teams have already dug latrines and distributed non-food items (tarpaulins, soap, mosquito nets, blankets, water containers and other essentials), and a water and sanitation engineer has installed water purification systems to supply nearby villages. The World Food Program, a UN agency, has handled food distributions (they were already feeding a quarter of a million people in this region), and some basic health care has been provided by our mobile clinics. Measles vaccination would normally have been of the utmost priority, but cholera is our concern here. There’s still no outbreak in our area, though, so for the moment we’re watching closely and making an assessment of the nutrition situation.