by Damien Brown
She really was serious?
• • •
My second-ever marriage proposal occurred on this ward as well—just last week, and from an HIV-positive patient, too. Nyawech is the woman. She’s the mother of Breast Man and his two older sisters, and for almost six months has been living in a bed in the isolation area, a small, semi-partitioned space at the far end of the medical ward. She’s unfortunately not doing well.
As well as late-stage HIV/AIDS, Nyawech is suffering from Kalaazar, the illness caused by the Leishmania parasite that’s transmitted by the bite of infected sandflies. It’s almost always fatal without treatment. Twenty-eight days of injections with an old, side effect laden drug will usually cure it (the two tents behind the surgical ward currently house eight patients receiving it) but Nyawech has relapsed twice. The HIV makes it difficult. An expert in Amsterdam is advising us and we’ve now got her on a combination of expensive second-line drugs, but she’s still not improving, battling with high fevers, severe anaemia, marked weight loss and worsening diarrhoea.
This morning there’s no more talk of marriage. Only a forced, crack-lipped smile from her, and an apology that she’s not good. Just weak and achy, she says, and asks if she can have some Plumpy’nut, the oily, peanut-based high energy supplement we give the kids in Nutrition, because she loves the taste and can’t eat anything else. We really shouldn’t give it—if the rest of those on the ward see us we’re going to be stuck handing out Plumpy’nut until next Wednesday—but we do. We sneak a box from Nutrition and slide it under her blanket, only the younger paraplegic woman crumpled in the opposite corner sees us and she’d also please like some. So we fetch a few more sachets and give them to her, discreetly, as if it were an illicit substance we were trying to sneak past Customs, only now the old lady with the swollen belly beside her sees it and wants some, and the man in the first bed of the main ward pokes his head around—
‘Jesus, Mark! Hide it!’
—and he does see it, and now we’re in serious trouble because he makes it known to everyone else . . .
• • •
This third week has been mercifully easier. Not without problems, though. We’ve had a few deaths, and the medical ward remains full—partly because I still struggle to send home patients who’re desperate to stay for the food, the attention, and the respite—but it’s been a better week nonetheless.
The workload remains heavy, but from an academic point of view this place is unparalleled, these wards a master class in tropical diseases. Cases seen just this morning, on the left side of our unit: brucellosis—a disease contracted from the consumption of unpasteurised milk (or from blowing into a cow’s vagina, according to my reference book, as a practice that alters their fertility); HIV/AIDS, with extensive skin lesions; Kala-azar, requiring blood transfusions; leprosy, with severe nerve complications; pneumonia, with the affected child receiving oxygen via our small oxygen concentrator (a noisy, compressor-like device); typhoid fever, the patient recovering well; acute paralysis of the legs, highly suspicious for polio (the boy is being moved to a tent); a snakebite to the ankle, with marked swelling; probable exposure to rabies, the third such patient this week following a spate of dog attacks; and two older women, each with a litany of non-specific symptoms and a hankering for Plumpy’nut, and who’ve been diagnosed with, according to Joseph’s notes, Generalised Achings. Notable is the absence of any malaria, although the rains will likely change that.
Contrary to what I’d expected, staff here have proven relatively easy to work with. Their medical knowledge is poor but they’re aware of this, and for the most part are keen to learn. Teaching sessions are a delight; attendance is good, questions asked, notes taken and future sessions planned; but the issues in Nutrition, and of the frequent night calls, continue to be significantly troublesome.
Language is another major challenge. Less so for me because I get to speak English all day, but the health workers need to make themselves understood, often regarding complex presentations, in a tongue they hear only at work. I empathise wholeheartedly with them; I know well the frustrations of trying to make yourself understood to a bewildered audience, and they handle the difficulties with patience. That said, the confusion does lead to amusing exchanges.
‘Chest pains,’ says The Professor, presenting a patient a few beds down.
‘The baby?’
‘Yes.’
‘But she’s four months old. How can she have chest pain?’
‘She told me.’
‘Oh?’
‘Yes.’
‘This four-month-old girl told you she had chest pain?’
‘Yes. Before.’
‘The thing about chest pain, Mark, is that—’
(The baby coughs.)—‘There!’ he says. ‘She did it again!’
So I learn this morning that chest pain, at least in our little hospital, means ‘to cough’.
Later in the afternoon, Peter and I meet to do a round of the TB village. Within minutes we’re mired in a fine example of the difficulties of translation, this time involving three of us.
‘How’s her pain?’ I ask Peter, as we review an elderly woman in one of the huts. She’s now in her fifth month of treatment for pulmonary TB and looking well, but every time I visit her she complains of an ache. And every time I ask, the ache is somewhere different.
‘Yes?’ asks Peter.
‘The pain. How is it?’
He speaks with her in Nuer. She gestures with her hands as she replies, and Peter asks another question. She then embarks on an animated monologue for several minutes; after a while I ask what she’s saying. ‘Not much,’ replies Peter, and they continue. More questions and lengthy explanations follow, all in Nuer, and if the woman’s facial expressions are anything to go by she’s recounting something truly remarkable—what seems to be a journey of sorts, certainly something evoking a range of emotions. It’s fascinating to watch, the people so delightfully expressive when they talk.
Peter turns to me when she’s done. ‘Yes,’ he says. ‘She does have aches.’
‘What else did she say?’
‘Not very much.’
‘Anything?’
‘No.’
‘Hang on—you spoke for five minutes! She looked like she was giving you her life’s story, Peter. She must have said something else important.’
‘Not really,’ he laughs. ‘Because, she is just talking about things.’
‘About the pain?’
‘No. Not very much.’
This happens frequently. Particularly in Outpatients, health workers will have lengthy discussions with patients and summarise it all back to me in a sentence or two. Not that they’re being lazy—I’m sure the patients digress, or explain concepts for which there is no direct translation, or perhaps the health workers don’t know the right English word—but there’s little doubt it leads to errors.
I look back at the woman. The confusion now ramps up a level. I ask Peter where the ache is. He asks her, and she points everywhere. He asks her something else, but she again points everywhere. He questions her gently and she raises her voice, and when he tries politely to interject she shouts at him.
‘Because, this is the problem!’ he laughs, rolling his eyes. ‘She is never making sense. So many of these peoples, always, they point everywhere!’
She does seem to be favouring her left knee as she waves around, though, so I examine this. It seems normal. I examine her more generally but find nothing of note. I explain to her that nothing serious looks to be going on, and that we’ll keep a close eye on her and in the meantime prescribe gentle painkillers. Peter relays this, and an argument ensues. The woman’s unhappy. She shouts at Peter, but he just looks over at me and throws his hands in the air, and I can’t help but laugh. The guy’s over two metres tall—the hems of his surgical scrubs would dangle well over my feet, yet they hover well above his ankles—and of the most jovial, soft-natured disposition. To see someone scold him is quite unexpe
cted.
‘She giving you a hard time, Peter?’ I ask.
‘Because, she says we are not finished examining her yet,’ he says. ‘She is crazy. She says you have not listened to the knee.’
‘Listened to it?’
He points to my stethoscope, dissolving into hysterics. ‘Listened,’ he hoots. ‘She wants you to listen to the knee!’ Between fits of laughter he explains that the previous doctor used to do this (I can only hope it was to appease the patient, rather than for any perceived medical reason), and Peter says that he’s now been trying to tell the woman that it’s pointless. We’re clearly not getting anywhere, though, so I do it: I crouch down, place my stethoscope on her knee, and pray that no one walks in. And after a long moment I smile and give her the thumbs up, which pleases her no end.
Not all is as light-hearted in this little village. Peter and I continue through the huts—tin-roofed, poorly illuminated, wet-hot spaces—and by the end of the afternoon we’ve seen only half the patients. Most of them are recovering well from pulmonary TB and will go home cured, but many others won’t. Like the paraplegic man with a twisted spine, for whom we can kill the TB bacilli in the bone but do nothing for the nerve damage—if it’s TB that he’s suffering from; or the elderly woman with the swollen belly, who may actually have cancer instead; or the handful of others in here with unclear diagnoses. So why then admit them? It’s a difficult decision. Like many diseases here, TB can present in unusual ways, so treatment becomes a balance between committing someone to six months of potentially unnecessary therapy with powerful, side effect causing drugs, versus missing the only opportunity they may ever have for a cure—even if that possibility is small. And the patients are almost always desperate to try anything. It never ceases to amaze me when we tell someone about the therapy. ‘You will need to live here,’ we say. ‘You will get free meals, free blankets and free tablets, but you must stay for the whole period.’
‘But I have children.’
‘They can stay as well.’
‘And my wife?’
‘She’s welcome too.’
‘Okay.’
No arguments. No debates. (Ignoring the young man who’d walked out for a night.)
It’s a fascinating place, this little village, as if all the challenges of practising medicine in the developing world had been compressed into these dozen huts. For the kids, it’s a thrilling rabbit warren of a playground; for the patients, their last ever hope. Many are touchingly grateful even though we do little more than give them medications and see them weekly; others complain about their persisting symptoms, or the heat, or the lack of space. In the corner of a hut, an eight-year-old girl has done up her family’s dank little patch, placing a little throw rug—a piece of white plastic—on the dirt, sweeping it neatly with a bundle of sticks as we come past; in the opposite bed, an old man clambers up and spits lightly on my head, in what Peter assures me is a sign of respect. You can’t possibly come through here and not be moved. And you can’t come through here and not be humbled, having to tell people sorry, that the tablets should hopefully work, but if not there’s little more we can do.
Sometime after I’d got home from Mavinga, a friend had asked me if aid workers had a ‘God Complex’. If we thrived on the responsibility of life-and-death decisions, of being in control of such large numbers of patients and staff in difficult situations—a degree of responsibility we’d never have at home. If we delighted in being flown to places where we’re ostensibly important, highly regarded and very much needed. Narcissists, even. To which, I’d said that some may. I can’t speak for them. But if they do, then what I’d suggest they have, above and beyond a God Complex, is a complete lack of insight. Because walking around this village, as with everywhere I’ve worked, I’m conversely overwhelmed by the scale of needs. And by my inability to do anything much lasting about it.
• • •
Marina leaves in the fourth week, still no replacement surgeon found. Most of her patients are fortunately stable, and Thomas, the head surgical health worker, knows them well, as does Heidi, so managing the ward is relatively straightforward.
Then the acute cases begin arriving. No Roberto-like clinicos here, so Heidi and I take the smaller things to surgery—a few large abscesses, a badly broken arm (from an alleged police beating), and a partially amputated finger (from an accidental gun discharge)—and when a man arrives with appendicitis, we arrange a plane to fly him to the other MSF hospital with a surgeon. So far, so good. The lack of a surgeon here adds significantly to the workload, but I’d be lying if I said I didn’t like the variety. Until a week later.
On a Sunday morning in late May, the victims of a gunfight are bundled in. Two of them this time. Both men, and both with significant limb injuries. Others were also injured at the scene, but they’ve since died. (My fears about having to deal with severe abdominal and chest injuries were partly allayed by Marina, who’d explained that nature does the triaging here; critical cases generally die en route, so if someone makes it to the hospital they’re likely to be relatively stable. The mainstay of our treatment is the debriding, cleaning and dressing of wounds, rather than any complex surgery.)
The morning the two men arrive, I take them to theatre to clean up the wounds, then admit them for antibiotics and dressings. Again, so far so good, but things get suddenly more complicated when a third man is carried in—this time by the opposing clan. Word spreads quickly. Much commotion ensues as men from both clans gather outside our gates. Police arrive and our guards watch the wards, and Thomas says there’s no way this third patient can stay here. He’s a security risk to everyone. Whatever his injuries, he needs to go. Zoe makes phone calls, and within hours a plane arrives to transfer him.
Three days later, a fourth man is carried in, a victim of the same fight. For reasons unknown he’d chosen to treat his wound at home, but the delay may cost him his life. His lower right leg has an extensive, gaping wound that’s about fifteen centimetres long at the front, and that involves bone; shards of his tibia adhere to the dressings as I pull them off. The surrounding tissue has already become grey-green with gangrene, and he’s showing signs of sepsis, or ‘blood poisoning’. He urgently needs an amputation.
I call for a plane, but our airstrip is currently a kilometre-long puddle. There’s no chance of a landing in this rain, no other transport options, so I pull out the surgical books and brush up on my anatomy, then take the patient to theatre with Heidi and one of the Sudanese assistants. There, I cut away large sections of green, putrid flesh, working around the shattered ends of his tibia and going as close to arteries as I can safely go. None of it will save his limb or cure his sepsis, though. By debriding this and giving fluids and antibiotics, I’m merely trying to buy time until the plane can land.
On day two he’s worse. The plane still can’t land, so we repeat the process—and hope desperately for a change in the weather.
On day three he goes into shock. The airstrip’s fractionally drier but still not safe, so there’s simply no choice: if we don’t amputate, he’ll die. His dozen companions on the ward don’t see it that way, though.
‘Three days,’ says one of the men, standing a foot from me, a pair of sunglasses hiding his eyes. The smell of millet beer is strong on his breath and he’s becoming agitated. ‘Three days, and still this is not fixed!’
We’re going in circles. Thomas has been speaking with them for half an hour, but the man, who’s the patient’s older brother, refuses permission for the amputation. The others crowd behind him and agree. I explain the options once more and Thomas translates, but voices are raised. Their decision remains. No amputation. ‘He is a herder,’ says Thomas, who’s himself a tall, well-respected Nuer man. ‘They say he cannot lose his leg. They say this is a hospital, and they want it fixed. I have explained this is not possible, but they do not believe it.’
I fetch gloves and take down the dressings, hoping the sight of the leg will convince them otherwise. The smell f
ills the room. A woman cries out, but the men are unswayed. ‘Not acceptable,’ says the brother. ‘Look at all this! All this mess! We want it fixed. Now.’
Thomas speaks with him at length but the shouting starts up again. ‘No way for an amputation, Doctor,’ he says, looking flustered. ‘No way. They will not allow it.’
It’s an aspect of this place I’m growing to seriously dislike, this machismo, or bravado, or plain aggressiveness, or whatever it is. In as much as the people here are open and expressive in their warmth, it holds true for the opposite: if they’re unhappy, they’ll be sure to let you know. There’s no holding back. Last week I was severely reprimanded by a man for draining his daughter’s neck abscess, a quick, easy procedure, because I did it with only his wife’s permission: I’d undermined his authority. And twice now I’ve been threatened; once by Gatwech, one of our Nutrition health workers, when I pulled him up for not attending teaching (‘You ever tell me what to do again,’ he’d stammered in a rage, ‘and I will kill you!’); and on another occasion by the parents of a child who’d died on our ward, accusing me of giving the wrong medicines. Both were obviously empty threats—Joseph had reassured me as much at the time, and I’m still here—but I found them deeply unnerving. Expats have been evacuated following such incidents in the past. In the Somalia briefing, I was told that a threat means the end of your placement—or worse. So how then does one know which to take seriously, which to laugh off? Seems to me that it’s a retrospective assessment: if you don’t get hurt, they probably weren’t serious.
What I’m struggling even more with, though, is this culture of gunfighting. I’ve tried my best to understand it. I finished that book about the Nuer and I appreciate the significance of cattle and the cultural factors behind these raids. But what I read, and what I see, are two different things.