Band-Aid for a Broken Leg

by Damien Brown

  A sacrifice, being out here?

  I’d swap it for nothing.

  * The referendum was successfully held in January 2011. Almost ninety-nine per cent of voters opted for independence, and on 9 July 2011 South Sudan formally became the world’s newest nation.

  16. EVACUATION

  And when the sun rises just hours later, gleams through the foot-wide opening along the top of my tukul’s circular wall, I’m already awake, thinking too much to sleep, thumbing instead through a book on the Nuer—the tribe who make up almost all of Nasir’s population. A notable paragraph:

  They strut about like lords of the earth, which, indeed, they consider themselves to be. There is no master and no servant, but only equals who regard themselves as God’s noblest creation. Their respect for one another contrasts with their contempt for all other peoples.

  The book was written by a British anthropologist, E.E. Evans-Pritchard, during the 1930s, and eighty years later it’s still in print, considered a classic in social anthropology. The author spent a year living in South Sudan, at times in remote villages and at times here—literally right here, in the brick house we’re using, built originally by the American Presbyterian missionaries who’d arrived a century ago via steamer down the Nile, and who’d set up the first hospital in Nasir.

  What strikes me most as I thumb through the book though is not the descriptions of the Nuer’s complete devotion to their cattle, their lifestyle as nomadic pastoralists or of their traditional absence of any leadership (there are no chiefs or kings, the clans being described as ‘acephalous’ states), but rather the comments about their temperament. Forget Maurice’s subtle warnings. Phrases like ‘derisive pride’ come up frequently, and it’s noted several times that some have a tendency to be easily roused to violence. Two other quotes that catch my eye, as my alarm clock now beeps:

  The ordered anarchy in which they live accords well with their character, for it is impossible to conceive of rulers ruling over them.

  Then, a little more empathetically:

  I again emphasise the crudity and discomfort of their lives. They are very poor in goods and they are very proud in spirit. Schooled in hardship and hunger . . . they accept the direst calamities with resignation and endure them with courage.

  If what I saw yesterday is any indication, it doesn’t seem as if any discomfort has lessened. Maybe even worsened; the civil wars hadn’t begun when this book was written—and there were no guns. Today, two million firearms are scattered among South Sudan’s eight million people.

  • • •

  I take a shower and walk the fifty metres to the surgical ward to meet Marina. It’s just after seven and she’s already standing with a gloved handful of soiled dressings, having begun her rounds. She gives me a quick rundown of the unit.

  ‘A bullet,’ she says, pointing at the man in the first bed. He’s sitting up with a heavily bandaged head, looking a little dazed.

  ‘What—in his head?’

  ‘Si. Through his head.’

  ‘As in, right through?’

  ‘Yes. As in, in at the front, out at the back,’ she says.

  The man stares at us as we talk. He blinks, but says nothing.

  ‘Seriously?’

  ‘Seriously,’ Marina says. ‘We had a few gunshot injuries arrive that day. Here, this man—he was shot through the buttocks. Both cheeks. And this woman, in the thigh. And those two over there, in the arms and legs. But they were the last gunshot victims we’ve had for over a week. It’s been good for a little while, at least until you brought in our friend with the neck wound yesterday.’

  The new patient is sitting on his bed in the middle of the room, leaning against the back wall. His mum’s at the foot of it. ‘He’ll be fine,’ says Marina. ‘He may never speak again, but he’ll otherwise be okay. I put in a chest drain and cleaned this all up a little, but his larynx is quite damaged.’

  I follow her down the rest of the ward, a long, narrow corridor with seven beds against each of the two longer sides, the brick walls painted a deep red. It’s unfathomably humid inside. And hot—far more than outside. Long windows reach high into the walls, their louvred shutters opened wide as if imploring a breeze to wash through, and many patients lie partially naked, draped only in light cotton wraps. Crowds of relatives are milling about, too, seated on beds, the windowsill, the floor, the doorway—

  ‘Thomas, we’re in the middle of a ward round!’ says Marina to the Sudanese health worker beside us. ‘Cazzo! Must we ask these people every day? Tell them to wait outside!’

  Thomas smiles. He’s around six-foot three, and like the other Nuer I’ve met here—our entire staff and all the patients—he looks unlike any Africans I’ve known before. His long, thin limbs contrast starkly with the generally thicker build of the Bantu, and his face is striking: high cheekbones, heavy-lidded, almost Asiatic eyes, deeply black skin, and six deep, horizontal lines of scar that run parallel across his forehead from temple to temple.

  Thomas tells people to leave. Much clicking of tongues and rolling of eyes ensues, but it’s immediately easier to see patients. And Marina would have this down to an art by now. She’s been working in South Sudan for close to two years, and even her clothes have adapted: the sleeves of her MSF T-shirt cut off, the collar trimmed into a plunging v-neck, a piece of medical tape securing the spot where the fabric’s most likely to tear. She runs a tight ward from what I’ve seen. Everything has its place, and the smell of disinfectant is strong.

  We continue on. The majority of her patients have burns, soft tissue infections or limb injuries, and lying in each of the three nearer beds is a young man fixed to a traction device—traction here being created thus: a thick pin has been driven through the end of the broken leg, above the ankle, to which a metal stirrup is attached; connected to this stirrup, via a length of rope, are three bricks, all bundled together in a plastic bag and hanging over the edge of the bed, providing the counter-force to straighten the fracture. It’s much like Toyota’s ‘gallows’ frame in Mavinga, and also requires around six weeks of immobilisation.

  I ask Marina how they broke their legs.

  ‘Shot,’ she says. ‘Through the bone.’

  ‘In the same gunfight?’

  ‘No. All different.’

  ‘Seriously? So this happens often?’

  ‘Yes, Doctor, and you’ll soon get used to it. Didn’t they tell you during your briefing?’ she asks playfully. ‘Here, we don’t do a ward round. It’s a war round.’

  I ask her about the peace agreement, or why the UN don’t intervene.

  ‘This has nothing to do with the war,’ she says, ‘or with the UN. They are here only to observe the north–south peace process. These injuries are all because of raids. One clan steals another’s cattle, then the men avenge it, try to recover the animals.’

  ‘Over cattle?’

  ‘Almost always. Then there’s the ongoing grudges, the revenge attacks, and just when you think it is quiet again, another raid. And the women and children get caught in crossfire. These people here?’ She gestures to last week’s arrivals, three of whom are women. ‘There will be payback for what happened to this group. You watch. There’s talk of escalation between the two bigger clans here. We’ll soon have more fighting.’

  • • •

  I spend the rest of the day trying to orient myself. The other expats kindly show me around their respective units, and on the third morning I attempt my own ward round. What follows resembles nothing like the orderliness of Marina’s.

  Medical Inpatients is where I begin. Outpatients is where I’m called to. But the dispensary is where I end up.

  ‘I look after this as well?’ I ask the assistant, who’s just intercepted me. I trail him to the small room near the front gate, where patients are lining up at an open window.

  ‘Yes,’ he says. He’s one of the three Nuer staff who fills the Outpatients prescriptions. ‘Always it is the doctor we call. And this morning we have run o
ut of the worm tablets. You know these ones? They are red. The blue tablets we have, but not the red. The red are finished.’

  I head to Stores, a series of steel containers behind our offices, to find the two Sudanese logs who run it. ‘You guys keep pills here?’ I ask, and they say No, those are in Pharmacy.

  ‘Thanks,’ I say. But I can’t remember which building is Pharmacy. The compound here is a far larger and more haphazard than Mavinga’s, a collection of mud huts and single-storey brick buildings on a rectangular property alongside the river.

  ‘And Doctor,’ adds one of the logs, pointing out the pharmacy for me. ‘Mr Paul was looking for you. He is sick. He went home, just before.’

  Better look after the other volunteers. I head to the expat compound, at the western end of the block, where our cook is washing dishes in a shallow plastic tub on the dirt in front of the house. I ask her if she’s seen Paul, and she points to the latrine.

  ‘Paul—you in there?’

  ‘Yeah,’ he groans from the small hut near our gate.

  ‘You okay?’

  ‘Sort of. Got the squirts again. Big time. Third lot this month.’

  ‘I think I’m coming down with something as well,’ I say. ‘I was up a few times last night.’

  ‘Yeah, well, welcome to Nasir. Anything you can give me for it?’

  Back to the dispensary.

  Back to find the pharmacy.

  Back to—

  ‘Hey, Doctor! We are still waitings for you,’ calls one of the Outpatients health workers. He’s standing beneath the awning where several dozen patients are waiting for consultations, seated on rows of wood benches. ‘Still waitings!’ he says, tapping his digital watch lest I misconstrue. He’s smiling, but insistent nonetheless. So I sidetrack briefly—‘I’ll have to be quick,’ I say to him, ‘because Inpatients are waiting for me as well’—and I’m shown to a small, plywood-walled cubicle, where a mother with a skin infection is lying. She’s an attractive Nuer woman, short peppercorn hair and deeply black skin, wearing a long, simple, royal-blue dress that’s draped from just beneath her shoulders to her ankles. She smiles when I introduce myself, although her daughter is distinctly unhappy with the idea of me approaching them.

  ‘Ha! She is scared of white peoples, I think,’ says the watch-tapping health worker. ‘Very scared! Wow—screaming so louds. OKAY, DOCTOR, I WILL HOLD HER. YOU LOOK AT THE LADY, OKAY?’

  The three of us risk industrial deafness as the daughter protests my examination of her mother—‘SUCH A SMALL GIRL, HOW ABOUT THOSE LUNGS!’—and I suggest we admit the woman for IV antibiotics to treat her foot cellulitis. She agrees, and we walk her over to Inpatients (daughter trailing at a cautious though audible distance), where I’m informed that I’m now keeping these guys waiting, too.

  ‘We must still see the other side, Doctor,’ the affable Joseph tells me. He’s the senior health worker on the medical ward, and he may well be the only Nuer person shorter than me. He’s been trying to get me to see this other side since seven this morning. ‘You run away too much,’ he smiles. ‘But first, I would like you to seeing this mans. He is very sick. I think maybe he has the HIVs,’ he adds quietly.

  Few maybes about the man’s diagnosis. He’s in his mid-twenties and severely gaunt, and has profuse diarrhoea and a persistent cough. I begin examining him but I’m called suddenly by a female health worker. I quickly follow her to the vaccination tent, just near the office at the northern end of the yard, where an assistant is kneeling beside a motionless body.

  ‘I didn’t even give the injection!’ he says. ‘Look. Here—I only took it out of the packet. But she saw it, then: fwap!—she did this. On the ground.’

  The patient’s certainly only fainted. She’ll be fine. We check her blood pressure, put her legs up and head down, then move her to Inpatients to recover for a while.

  ‘More patients?’ chuckles Joseph. ‘No beds, Doctors. We are already have no beds. But now we can please see the other sides? Maybe we can send some peoples home.’

  I agree. We start and review a couple of patients, but soon there’s a thin giant of a Nuer man waiting quietly just beside me, dressed in a neat business shirt and trousers.

  ‘Yes?’ I ask.

  ‘Yes.’

  ‘Can I help you?’

  ‘Yes. It is me, Peter,’ he says, grinning broadly as he shakes my hand. ‘From the TB village.’

  I recognise him now. He’s the supervising TB health worker—the only TB health worker, in fact—and he’d like me to please come and see a man who’s causing problems. ‘Because, this man is trouble,’ he says. ‘He is crazy. He is shouting with me all the time. He is saying that if I do not call you, he will leave the village.’

  I apologise to Joseph and follow Peter, past the nutrition centre and patient latrines to the back corner of the yard, not far from my own room, where a man in his early twenties is standing in front of one of the dozen mud-walled TB huts. He doesn’t look impressed. ‘He says that if we do not give him more food, he will leave,’ says Peter. ‘He says he will take other patients with him.’

  ‘Leave for where?’ I ask.

  Peter speaks with him. The patient’s bare-chested and standing with arms folded, squinting at me. He’s doing his best to look assertive. It works. ‘His village,’ says Peter.

  ‘What about his treatment?’

  ‘He doesn’t worry about this anymore. Because, he says he is better from TB, but now he will get sick with just this food. He says he needs more food. And meat.’

  ‘Are we giving him what the others get?’ I ask.

  ‘Yes.’

  ‘And we’ve always given this amount?’

  ‘Yes,’ says Peter. ‘For years. Everybody is getting the same. And they get extra for their families.’

  I reiterate this information back to the patient, via Peter. He’s surely calling our bluff—he wouldn’t really walk away from free accommodation, free meals and free treatment for a life-threatening condition, would he? ‘I’ll talk to Zoe this afternoon,’ I say. ‘I’ll let you know, Peter. It’s not my decision, but it seems to me he’s just trying his luck.’

  Peter agrees. I shake the young man’s hand and smile, and tell him I’ll return later. His glare softens. He seems happy enough to have made his point, no less because he’s made it in front of the others who’re watching on.

  Back across the yard.

  Back to the medical—

  ‘Doctor!’ beckons a voice from inside the nutrition centre, just south of the main Inpatient unit. I step into the garage-sized, mud-walled structure.

  ‘Can it wait?’ I ask the health worker. ‘Can I come back in an hour?’

  ‘No,’ he says. Gatwech is his name, and he’s another mountain of a Nuer man, also with those six scars, or gaar, across his forehead. A faded red Chicago Bulls T-shirt hangs from his broad, bony shoulders. ‘I would like to call Nurse Heidi,’ he says, ‘but she is in the operating with Doctor Marina, so I cannot call her. And this little boy will not drink. He will not touch the milk. And his mother will not give it. She is tired of fighting with him.’

  I look at the mother. She shrugs, raising her upturned palms as if lifting imaginary weights; what I assume is a quiet gesture of frustration.

  ‘But if Nurse Heidi gives the milk to him,’ says Gatwech, ‘he will drink it. He is very happy with Nurse Heidi to feed him. But when I try, he does not like it. Watch: I will try.’

  The child definitely doesn’t like this.

  ‘You try, Doctor.’

  The child very definitely doesn’t like this.

  ‘Maybe we should put in a nasogastric tube?’ asks Gatwech, as I towel milk from my T-shirt. ‘And also, he has a fever this morning.’

  We assess the fever, hold off on the nasogastric tube, and prescribe instead antibiotics and an afternoon with Nurse Heidi. And then, ignoring the Outpatients worker who’s signalling for me again, I head to Inpatients and rejoin Joseph—pending the next interruption. />
  The following day is much the same. The plan is for the other doctor to leave on the weekend, but by the evening of my fourth day I become unwell, following Paul’s well-beaten path to the latrine with increasing frequency. Steffi returns to ward duties.

  On the fifth day I’m worse, unable to work at all. Soon there’s a fever and some blood involved, too, at which point I recant everything I’d said about the conditions here being part of the appeal, because between the fever and forty-something-degree temperatures my mattress has become firmly adherent to my back and my tukul smells much like the latrine, and I wonder how the patients survive with their even-higher fevers on those wards. For much of the night I roll around light-headed in a sweat-sodden sheet, and sometime in the afternoon of the next day Steffi comes in to tell me that the sample I gave the lab showed dysentery, and that she’s arranged for a plane to take me back out to Kenya. I’d laugh. Or refuse—I’ve lasted not even a week in Sudan—but I’m too drained to care.

  • • •

  Lokichoggio is where I end up, back at the MSF base. (‘A record!’ quips one staffer.) Within days of starting antibiotics I’m fine, eating well and waiting for the next charter flight back to Nasir. This town is an interesting enough place to spend a few days anyway. An edgy outpost that was featured in The Constant Gardener, it’s located not far from the site of some of the oldest known human remains, and the residents are fascinating. Traditionally dressed Turkana people, many sporting Mohawk-style haircuts, gather beneath trees or the eaves of shopfronts, the women adorned with colourful bead necklaces worn in such improbable quantities, and packed so tightly together, it’s as if they’re wearing a vibrant neck brace.