Band-Aid for a Broken Leg

by Damien Brown

  For a long time he stares at the page and says nothing. He tracks the text with his finger as he sounds out each word, slowly, determined to find the dose, and I want to crawl into a hole suddenly because look at me, what a big man I am right now: berating a young, semi-literate, junior health worker who’d grown up in a war. When did I cross this line? I’ve seen behaviour like this in some others in the past. I’ve seen it in volunteers, even among the local staff, and I loathe it. I caught myself doing it in Mozambique, too—a large group of people kept pushing into our tent, crowding it, and I repeatedly raised my voice to tell them to stay back or we’d have to leave; in the crowd I no longer saw individuals, just a wall of demands.

  I take the book from Deng. ‘I’ve just had a bad week,’ I tell him. ‘I’m sorry, mate. It’s not you. I’m just being an arse. I’m tired. I’m really sorry.’

  His reply disarms me. ‘The doctor here is like a father,’ he says, graciously. ‘We respect them very much. But for us, it is very hard. Sometimes the doctor will not like it if we call. Sometimes they get angry if we do not. I am sorry for calling you.’

  I tell him he needn’t be. Wake me whenever, I say.

  And I go back to bed.

  And bury myself under my mosquito net. Deeply, horribly embarrassed.

  • • •

  But embarrassment is the least of it by the next afternoon, now my eighth since coming back. I’m more unnerved: the TB boy has died. He’s the ninth patient to die during this past week. Our catchment area is huge; one hundred and sixty thousand people, we think, making it well over five times Mavinga’s, and the team here see forty thousand outpatients a year and admit five thousand others. Even so, this number of deaths is worrying.

  In the afternoon, myself, Heidi, Marina, and Zoe (who’s an experienced nurse, although working non-clinically in this project) all meet to talk about it. We gather at our outdoor table in the shade of a large tree, where we spread out the patients’ charts and try to find a pattern to these deaths. Are we doing something wrong? Overlooking something obvious? I find myself getting defensive as we go through each of the cases: what if the underlying problem is me?

  I tell the others that I’ll tabulate the patient data, looking closely at how and when the patients died. I’ll talk with Joseph and the nutrition guys, go through all the protocols they’re using and make spreadsheets, and I keep talking because if I stop I’m either going to cry or fall asleep. But Marina’s great. She assures me it’s been a far busier week than normal, and reminds me that we’ve all lost patients—not just the ones under my care are dying. And the thing to do, as I’d learned well in Mavinga, is to focus at times like this on the positives. So I do. I think of the fifty-plus inpatients, the forty TB patients, the twenty-two malnourished children, the dozen HIV patients, and this week’s thirteen hundred outpatients who’re currently doing okay.

  In aid of such reflections, Marina fetches cold Ethiopian Bedele beers. We lean back in our chairs as we sip on them, regard those smoky dung-fires and the sun that’s dropping slowly behind our fence, but I see sudden movement at the gate.

  I cringe.

  I can’t possibly deal with another emergency.

  I look over hesitantly.

  The guard?

  It’s not the guard. It’s a little boy who lives in the TB village, and who I only ever see wearing beads—a white string around his waist, red around his neck and not a stitch of clothing—and he’s standing with hands on hips, watching us. He waves hesitantly when I do but otherwise just stands, completely still. Regarding us. Concentrating and contemplating, his podgy belly out and little eyes squinting, and his head tilted just slightly.

  I’d give anything to know what he’s thinking.

  18. AIRBORNE REMINDERS

  Like highways, these dawn skies. I stand at our fence watching thousands of bats return from their nocturnal food hunts to settle into the few trees on the far riverbank. They chirp noisily as if swapping stories from last night, jostling and crowding upside-down in dense clusters where they’ll hang like fat black plums from the broad branches and sleep the day away. Then it’s the water birds—herons, we think; hundreds of them flying in almost perfect arrowhead formations, off to some mysterious swamp somewhere. They’ll return this evening in much the same manner, too: a single bird at the front, the others trailing neatly behind. No bird ever strays. Periodically, the leader will drop to the back, the next bird momentarily picking up his pace to assume the role of guide as they plough on, the whooshing of their collective wings audible even from inside my tukul. A glorious sound to wake up to.

  It’s late in the second week and I’m up earlier than normal. The rest of the team are still in bed but Paul’s already busy, cutting long beams for the new nutrition ward with hand tools before the sun climbs. At our front gate, the best-dressed MSF employee I’ve ever met—European offices included—has meanwhile arrived for work: our guard, who’s this morning back on day shifts, wearing a full black suit with neat business shirt and tie. ‘Hi, Dennis,’ he smiles, and I smile back: two weeks of cajoling, and we’ve just moved on from Shamiane.

  The main hospital yard is still. Nothing like what it’ll be in an hour. For now only a few kids play near the fence, and a handful of women are boiling water in the communal fire-pit behind Nutrition, using pots that look like relics from the British colonial era (and that may well be). Beside them, the hospital cook is stirring the patients’ breakfasts—mud-brown sorghum, bubbling in a large pot like thick lava—with a length of wood that looks suspiciously like the oar of an old rowboat (and that also may well be). I stop to greet them; then, avoiding the wards entirely, head straight for the main entrance, where David, the watch-tapping health worker from Outpatients, is going to meet me. He’s promised to show me his home before rounds.

  David and I stroll north, away from the river, and head against Nasir’s morning traffic—a single UN LandCruiser, two trucks from the military compound, hundreds of people walking towards the market, and the groups of kids who’re hopefully off to one of the schools. A few bicycles are around, too, and even some taxis—also bicycles, these ones adorned with bright plastic flags or boldly painted signs, and whose riders will give you a lift on the back rack for a few Sudanese pounds.

  ‘My house is not a very big house,’ David apologises. He shows me into a grass-walled enclosure, one of a small cluster of compounds about five minutes from the hospital. Within it, three tukuls and a plastic-roofed shed are arranged around his dry yard, a few goats wandering about. Unusually for an African village, there are no fowl—the Nuer don’t eat birds.

  David leads me inside the first tukul (two single beds, a table and some chairs provide the furnishings), and I’m immediately impressed. They’re clearly not easy to build. The wall is circular and mud-covered, but the roof reveals the intricacy of the inner frame—a latticework of thicker sticks bent carefully into shape, dozens of smaller wooden ribs tied across them using natural twine, and thick straw woven over the top of it all. The shape conferred from the outside is that of a giant, grass-coloured Bacci chocolate; the larger tukuls, used as cattle byres, reach over four metres in height. Seeing hundreds of these near-conical structures on a barren moonscape, all silhouetted against a red sky each evening, is quite other-worldly.

  A group of kids jostle in the doorway. ‘These all your children?’ I ask David, but he laughs. No way, he says. He has only five children to two wives, all of whom live in this compound. He points out his three younger ones and explains that the older one is in Juba, and another son with the herd. ‘These other ones, they have come to see you. I think they have never seen a Khawaja [white person] so close before.’

  I’m inclined to agree. I’ve become used to the startled reactions of some children to seeing me these past years—the fleeing, the screaming, the transfixed staring or the more adventurous patting and prodding of my skin—but these kids take the prize. Three kneel down and pull gently at my leg hairs. Two of the you
nger boys have taken instead to rubbing my forearm, and as my arm heats up they rub it more vigorously, faster each moment, and I wonder what on earth they’re doing. One of the boys stops to cool his hand with spit but immediately resumes rubbing, even faster this time, and it dawns on me that perhaps they think I’m also black—that beneath a layer of white, firmly adherent dirt, I too have the same wonderfully dark complexion as them.

  David shoos the kids away and shows me proudly around the rest of his compound. ‘But it is not like your home,’ he says. ‘I am sure your home in America is big, yes?’

  ‘In Australia,’ I reply. ‘I’m from Australia. Do you know it?’

  He turns. ‘Oh—Melbourne, or Sydney?’

  This I didn’t expect. I tell him Melbourne, and his face lights up.

  ‘Oh! My friend is living in Werringbee.’

  I stop dead. Blown away!—that this man, who’s surely not ever been out of the region, can name a suburb in Melbourne! I ask him if he’s been there, and he says no.

  ‘But many Sudan peoples went to Australia,’ he says, which is a fact I’d discovered inadvertently while working in a small coastal town a few years ago. Several Dinka families had been resettled there as part of Australia’s intake of twenty thousand South Sudanese over recent years, creating a small but highly conspicuous group in an otherwise very white town. What they must have thought when arriving in a rainy, affluent coastal town in the throes of a southern winter, having been recently ushered from a hot, dry, crowded refugee camp, I can’t imagine.

  Nor can I imagine what the town’s people would have thought. Because even having spent time in Africa, I find the Nuer remarkable looking. Take David as an example: six-foot three with long, thin limbs and utterly black skin; a soft, handsome face; and the distinctive dentition of many of the adults here—the absence of his lower front teeth and two upper canines due to ritual extraction during childhood. (These teeth, the Nuer believe, make people look like hyenas.) And then there’s the gaar—those six prominent scars across the forehead, the incisions having been made so deeply that it’s said that marks can be seen on skulls found in the region.

  David nods vigorously when I ask if he remembers having it done. He was about fourteen, he says. ‘It is when a boy becomes a man, and he must not cry. It is a shame to cry. And he must not move. If he moves, it will not be straight, and everyone will know forever that he was not brave.’ He was very much awake at the time, he explains, the procedure having been performed with a sharp knife by the Gur, a ceremonial leader, following which—ensuring a truly memorable afternoon—the initiates were circumcised. But it’s a proud moment, David tells me, and the point at which a man will be given his first head of cattle.

  What I’d really like to ask David though is about the war, and more specifically how he’d survived: Nasir was the scene of some of the worst of it. For decades the northern government armed and encouraged horseback-mounted Arab militias, known as djellabas (not unlike Darfur’s infamous janjaweed), to conduct raids on southern villages. Homes were torched, women raped and children taken into slavery, with many thousands of others killed. As well, the region was bombed extensively by government planes; in Nasir alone, the crowded hospital and UN feeding centres were hit on more than one occasion, a fact to which the twisted beams of metal in the corner of our compound still attest.

  Things took an even worse turn here in the early 1990s, when the southern forces—the SPLA, or Sudan People’s Liberation Army, a group ostensibly formed to defend the people here—split into two factions: a Nuer faction, and a second, Dinka-based faction. Now, Southerners were pitted against each other along tribal lines, and a war-within-a-war ensued—a conflict every bit as devastating as the north–south war, which meanwhile continued. Both tribes attacked the others’ villages. Both were responsible for rapes, kidnappings, and the burning of essential crops. And both continued like this for almost a decade, until an agreement between the respective southern leaders in 2002, just three years before the north–south war ended.

  As in all these conflicts, though, it wasn’t just violence that caused deaths. Starvation and disease took a greater toll. When MSF first arrived in 1988, a parasitic illness called Kala-azar had killed a hundred thousand people near Nasir—around one-third of that area’s population. My briefing documents described volunteers coming across villages that were either deserted or filled with bodies. And then there were the food shortages. In 1988, a quarter of a million South Sudanese starved to death. Barely three years later, another food crisis resulted in thousands dying along this riverbank, with individuals so desperate they were seen to be digging in search of any grain stored in ant nests. In 1998 the region was again on the verge of another catastrophe, and an international aid effort named Operation Lifeline Sudan was set up, carrying out widespread food distributions (mostly by air drops, using Lokichoggio as a base) that at its peak cost donors over a million US dollars a day—the largest effort of its kind since the Berlin airlift.

  Perversely, the manipulation of this food aid was a feature of the war, and perpetrated by all sides. The north threatened to shoot any plane it didn’t expressly authorise, and southern rebel leaders frequently dictated where and how the aid was to be delivered. In a more extreme example, the leader of the SPLA in Nasir was suspected of deliberately keeping twenty thousand people in a state of perpetual starvation nearby so as to bait further deliveries.

  Yet walking around here, as in Mavinga, I find it hard to reconcile such stories with what I see. The kids are still with us (they sneak back within moments of David shooing them away, jostling to hold my hand, one of the smaller ones happy enough with just a thumb), and the oldest would be no more than ten. When I was last in Loki, a colleague had lent me two memoirs, both being the first-hand accounts of young boys who’d fled fighting during the war—boys of about the same age as these kids now with us. These children, having survived the raids on their villages, and being unsure as to whether their families were alive or not, walked for months across Sudan in the late 1980s, arriving in Ethiopia like ‘walking skeletons’. Camps were set up to accommodate them, and more generally the growing numbers of Sudanese being displaced from all over the south, but Ethiopia’s own security situation deteriorated and they were forced to move again, this time south to Lokichoggio—on foot. Many spent their next decades in the refugee camps nearby.

  More than twenty-five thousand children made this journey overall, either alone or in groups, and became known collectively as the ‘Lost Boys of Sudan’. Few girls set out. Boys survived the militia raids because they were tending to cattle away from their villages when they occurred, whereas girls were either killed or taken into slavery; and of those boys who did escape, at least one in five died travelling. It goes without saying then that the accounts of their journeys are heartbreaking. Of an aerial bombing raid, for example, one boy wrote that there was a plane standing above the trees, pouring fire on them; another boy noted that during the walk he’d envied those who had a cup of urine to drink, and that the journey had become a game where the object for him was to go as far as he could before dying. I did manage a smile, however: on being given milk and butter as part of his rations in an Ethiopian refugee camp, one boy pondered how the UN could possibly own enough cows to produce such quantities of dairy.

  So, could David have been in this group? Very possibly. As too could Joseph, Peter, John, Gatwech, Deng—any of our two dozen health workers. Almost all are men in their thirties and forties, the same demographic as the Lost Boys, and all had to have learned English somewhere. A refugee camp is as likely a place as any. (Birthdays are a giveaway for someone having spent time in them: a significant number of our staff and patients list theirs as being January 1st, a date conferred by unimaginative registrations staff at the camps.)

  But I ask David about none of this. I’d hate to upset him. He looks delighted showing me around. And I’d previously tried to ask staff about such experiences, and it hadn’t gone well.
I’d asked Roberto about the Angolan war, sometime towards the end of my time there when we’d started to banter a little in the afternoons, but he just looked away, said only ‘Confusão,’ and stayed quiet. It killed the conversation. And I see the consequences of mental stress often enough in this hospital to know that it’s an issue here. Since I’ve arrived, we’ve admitted a dozen patients, usually women, whose conditions are almost certainly a manifestation of psychological trauma: pseudoseizures—atypical, non-epileptic seizures that tend to respond promptly to a placebo; extreme states of hysteria, including the transient inability to speak, dramatic outbursts followed by a collapse, or other unusual neurological symptoms; or just inconsolable crying. All of which seem to improve with a night on the wards, some reassurance, and the doting of loved ones. (And I wonder as well, with regard to the men, whether these gunfights aren’t another expression of trauma—or at the least a result of desensitisation to violence, given a lifetime of exposure to it.)

  David looks at his watch. ‘Already eights,’ he says: time to get to work. I’m not quite ready to head back, though. This is what I didn’t get to do enough in Mavinga, just spend time with staff, and I’m quietly intrigued by him, his kids, and really all of these Nuer people. That some of them show symptoms of post-traumatic stress disorder isn’t what surprises me—it’s that not all of them do. Maurice was right. These people are tough.

  David’s tapping his watch now. I know, I tell him, but I remind him that he did also promise to show me the fish market.

  ‘Yes, but we will be late,’ he says.

  I shrug. He laughs; the fish market it is.

  • • •

  Carol, our midwife, returns the week after walking out. She still doesn’t want to talk about it although she at least seems rested, and things have generally settled this week—no more gunfights, fewer deaths, and what I assume is the more normal routine has set in: busy mornings, a long lunch break (staff go home at one and return at four to avoid the hotter hours), and late afternoons spent in the hospital again; and, if we’re lucky, pleasant, lazy evenings at the outdoor table, or sitting on the riverbank, or watching DVDs in the room with the bats. Morale seems okay even if people are tired, and there’re enough of us here to at least allow for some social variety.