by Damien Brown
• • •
Joseph’s examining a patient when I enter the ward.
‘Any news about the new woman?’ I ask.
He finishes what he’s doing and looks up. ‘Not yet. The families is still making problems.’
We walk to the far corner, where Carol’s crouched beside a new patient, a pale, quiet twenty-something woman. The patient’s brother is standing on the opposite side of her bed with a handful of other men. I ask how she’s doing.
‘Weak,’ Carol says. ‘Very weak.’
‘Has the brother decided?’ I ask.
She shakes her head, looking flat. ‘He’s still refusing.’
‘He won’t even let us screen for a transfusion?’
Carol shrugs. ‘What can I do? I have told them everything. They know how serious this is.’
The woman was carried in just hours ago, having gone into premature labour during the night. But rather than delivering a foetus, she’s been passing numerous small cysts, the consequence of a molar pregnancy—a rare, unviable type of pregnancy where clumps of poorly formed embryonic tissues develop instead of a baby. She bled heavily at the time and her haemoglobin has fallen to forty—three times the lower limit of normal, a life-threateningly low value—and she’s still bleeding. She urgently needs a blood transfusion and the removal of the remaining tissue in theatre, both being straightforward procedures that would fix the problem. But the brother is refusing both. Why? He won’t say. As for what she wants? She can’t say. The men have forbidden her from speaking.
In anticipation of a transfusion, we’ve screened a few staff members for compatibility (as usual we have no spare stocks in the fridge—people generally won’t donate unless it’s for a close family member) but haven’t yet found a match. The brother has refused to give blood or allow his companions to do so, but the situation’s becoming critical. We ask again.
‘No,’ they say.
‘What if we just try among the staff once more?’ I ask. ‘Would you be happy for one of us to give a unit?’
Joseph translates, but the brother looks uneasy. No one is to do anything until the husband arrives, he says.
‘But where is he?’
They’re not sure. But someone is out looking for him, he says, so not to worry.
The morning wears on and I become more impatient. She’s bleeding to death. Theatre is set up and ready to go and I could have performed the procedure a dozen times by lunch, but the men continue to forbid us from doing anything.
I try to explain the situation again. I explain it patiently, and simply, but they say no. I explain it with a little more urgency, and they say no. I ask them to step outside, and I tell them bluntly that they’re going to be responsible for her death. ‘Do you understand that?’ I ask. ‘She will die while you just stand here wasting her time. It’s that simple.’
The brother remains adamant, if nervous. Not until the husband is here, he says. Only he can decide.
‘And the woman? What if we get her consent?’
‘No,’ he says. ‘It is for the husband. Only he will decide.’
Meanwhile, here she lies, seeping away into a sheet.
I try to get on with the day. I take a few minor cases to theatre—abscesses, wounds, all small things—and make my way through the rest of the ward, then the Kala-azar tents. Sometime mid-afternoon I get called back to the medical ward: the husband is here. I run over. The man’s tall, six-foot five at least, wearing dark glasses, nice business shoes and a pair of silk pyjamas, top and bottoms, and his expression suggests he’s very serious.
Joseph, Carol and I go through the situation with him. We explain what we need to do and how simple it will be, and what will happen if we do nothing.
‘No,’ he says.
I couldn’t possibly have heard right. Joseph speaks with him again at length.
‘No.’
‘But do you understand that if we don’t do this, she is going to die?’
He again refuses.
My heart thumps. Maybe they’re misunderstanding me. I talk with Joseph and he again translates, but the husband reiterates his answer. The brother and four other men stand behind him.
Fuck them, I think, and ask the woman what she wants. Why should the men have a say in this at all? I crouch beside her where she’s lying on her back in a long green dress, covered by a sheet that Carol changed not long ago because the previous one was bloodstained. Her eyes are too white—dangerously anaemic—and she’s too weak to reposition herself. She looks away from me and up at her husband as I speak, abdicating all decision-making as she puts her life in the hands of this man, and I wonder if she’s more scared of speaking against him than of just bleeding to death on this mattress. I watch them both. He regards her for a moment. They don’t touch, and he doesn’t speak with her. He looks irritatedly back at me.
‘I’ve said no.’
Jesus, maybe it’s me? Maybe I’m explaining it all very badly. Maybe it’s my manner; I’m being too forceful, I look too young. I leave Carol to speak with him in private for a few minutes, hoping he’ll be more persuaded by an older person’s take on this. But she walks out a few minutes later and tells me again, No.
I call Thomas from the other ward to try. Thomas is used to consenting patients for surgery. He knows the ins and outs of theatre far better than Joseph so maybe he can explain it better, spin it and deal with whatever misconceptions the rest of us may be oblivious to. But the husband again says no.
Why?
‘He is giving no reason,’ says Thomas. ‘Just, “No”.’
I try bargaining with him. I ask him if he’ll allow only the transfusion for now; he can decide later about whether to allow me to do the curettage. I offer to show him the theatre and the instruments we’ll use, but as calmly as if declining an offer for coffee, he again says no.
Christ! This makes no sense! My hands begin shaking and I lose any self-restraint and step closer, and I find myself shouting with pointed finger that he’s about to murder his own wife, and I wonder if maybe she’s brought shame on him or frightened him for having borne this unsightly complication instead of a healthy child, because bearing children is a woman’s most important role out here—no marriage is complete until the woman has had at least two children for her husband—but I couldn’t give a damn about cultural considerations at this moment because hers is one life we can actually save.
I ask Joseph to tell him that she’s going to die soon because of his decision and that we can’t just stand here and watch it happen, so the husband has three options. One, we take her to theatre and fix this; two, we just give her the blood, Christ—our blood if he wants; or three, we do as he says and don’t treat her, but in that case he’s to stay beside her all day on this ward. He’s to sit here and attend to her, and he must watch the consequences of his decision play out. He doesn’t get to walk away. Not from this. Not from his wife.
The ward is silent. I’m trembling. The man glares and I’m hot-wet with nerves. Joseph’s unsure of what he should translate but I tell him all of it, every word, this man is to understand the gravity of his decision, and in this moment I feel more anger towards a person than I’ve known before. I hate this man and what he represents; what these women, these children and so many other men have to put up with because of people like him, the strongman, the self-righteous minority of men who impose their wills on the rest. The Administrator in Mavinga, the gunslingers in our market, the bombers in Somalia, the post-election gangs in Kenya—the mentality is just the same.
The woman lies quietly. My eyes meet hers and I don’t know if I’m more heartbroken for her or outraged with him.
‘He will takes her home,’ says Joseph. ‘He says if she dies, that is God choosing. Not him.’
A wave of heat runs through me. Jesus Christ, I want to grab the man, I’ve not ever lost it like this before and I step closer and point angrily at him and raise my voice and I couldn’t give a fuck right now if he or his posse threate
n me. ‘Make it very clear to him that God’s got nothing to do with this, Joseph. If she dies at home, it’s the husband’s doing—he’s doing this. He’s responsible.’
The men talk for a moment. The husband pauses. He puts on his sunglasses, and his shoulders relax. He talks with Joseph more softly now, and I ask him what they’re saying.
Joseph shakes his head and speaks quietly. ‘He is wanting to borrowing something,’ he says. ‘Something to carry her in. He wants us to gives him a sheet, so he can carry her home.’
I’m speechless.
Carol walks out.
Joseph gets a sheet.
And the husband just waits, looking as unfazed as when he’d first walked in, still in his business shoes and patterned silk pyjamas.
A ridiculous-looking prick.
• • •
The sky’s unchanged when I step outside—heavy, gloomy—but my watch tells me it’s evening. I’d like to keep walking; past the compound, the fuck out of town and away from this entire volunteering thing, try to remember why I wanted so much to do this work in the first place.
Amos is at the outside table when I return to the compound. Today’s the birthday of Maya, the office assistant, and Amos is opening a box of cask wine, wrestling the plastic tap through the little cardboard door. A moment later he fills an old coffee mug and swirls it under his nose, inhaling deeply like a sommelier. ‘Yessss!’ he laughs. ‘Very nice!’
‘That good boxed wine, Amos?’ I ask. ‘You look very impressed.’
‘My friend,’ he says, a smile igniting his face, ‘in Africa we say that a lion that cannot find meat, he must sometimes eat grass to survive!’ He throws his head back and laughs—that big, deep, African belly-laugh the way that only they can do—then offers me a glass.
The rest of the team gather around the table, about a quarter of our stock of candles providing mood lighting. The bugs fling themselves at us and the cask wine flows, and the Ethiopian beers are chilled; not a bad evening. On top of it all, I’ll be out of here in thirty-six hours, off for my scheduled break.
I go to bed early. Just before dawn I’m called to attend a breech delivery with Carol, seeing in the new day by repairing an episiotomy by the light of my headlamp. Afterwards, I steal another hour of rest—a fitful, sweaty, uneasy sleep—and when I get up the clouds have broken for the first time in days, and two new patients have arrived: a gasping infant and a comatose young girl. We do what we can. The infant hangs in there, but the girl’s serious.
‘Meningitis,’ I tell the worried-looking parents. Her neck is arched, her back as stiff as concrete.
‘Is it serious?’ they ask.
‘Very. I’m sorry.’
We start treatment for the girl just as Mark, The Professor, walks in. He’s usually quite the clown on the wards but today looks solemn, and he says I must come to isolation. I follow him to the little room, to the corner where Nyawech lies.
She’s dead.
I go over to the bed. Breast Man is next to me. The child clearly doesn’t know, or doesn’t understand; he wants me to pick him up and throw him, and while I listen in vain for his mother’s heartbeat, he sits on my hip, clinging to my T-shirt with all the dexterity of a little monkey. I wonder where his sisters are. ‘There’s not a father, is there?’ I ask Mark.
‘No,’ says Mark. ‘He is dead. But the grandmother is coming back soon. She can maybe look after them, Doctor.’
Three more kids orphaned by HIV/AIDS. Three more to add to Africa’s growing generation of them.
We pull Nyawech’s blanket up, over her face, but she’s too tall. Her feet peer out. I cover them with a separate piece of clothing. The paraplegic woman in the corner drags herself over to see, and she shakes her head, and Elizabeth looks from around the corner, and she begins to cry. The two had become friends. They’ve lived together in here for months.
But Breast Man’s still oblivious.
I tell Mark that I’ll be back soon. I’m just going to have a quick drink, I say, because I need to get some air, wash my face, fucking breathe a little, but an irritated young man yells to me as I step past.
‘Hey!’ he says, lying bare-chested on his bed. ‘I’m not any better!’ He points to his IV. ‘This thing does nothing. I want to go home.’
He arrived yesterday, and he already seems a lot better to me. I pick up his notes and show him that his fever’s down. Mark explains this to him.
‘I get no attention here!’ he says. ‘I want to go home!’
We explain that fluids and antibiotics are running constantly via the IV, but he becomes more agitated. ‘Take this out,’ he says, gesturing at his IV. ‘I’ve had enough. You are doing nothing for me.’
Mark talks with him, but the man still wants to go. ‘Take it! I’ve had enough!’
So I pull his IV out. Right here. I slap a piece of gauze on it, don’t even bother with the tape. ‘Go home then.’
Fuck off. I’ve also had enough.
I storm across the yard and into the living compound but I can’t find Heidi. Zoe’s going through paperwork on the outside table. I tell her I need to talk as I take a cigarette from the box in front of her and pull up a seat.
‘I’m losing it,’ I say to her.
‘Huh?’
I tell her about Nyawech’s death and having just kicked that guy out, and that I’m not dealing with this stuff like I should.
She shakes her head. ‘Are you serious, Damien? Jesus, how do you think you should be dealing with all this? It looks to me like you’re doing well under the circumstances. Don’t you start beating yourself up, too. This is a tough place, and you’ve had a bad run—and we’re down a surgeon. MSF don’t give us more holidays here than most other missions for no reason, you know. And you’re off when—tomorrow? Honestly, I was the same as you before my last holidays.’
It’s not just fatigue, I tell her. I fill her in on my conversation with that woman’s husband yesterday, the one who’d refused treatment, and explain that I’m losing my patience with people. I can’t help but wonder if the outcomes would’ve been different if I’d handled these cases better. ‘It’s hardly the ideal work manner for a doctor, Zoe. I know I should be the last person to judge these people. We’re guests here, I get that, and I know I shouldn’t take this stuff to heart all the time and expect that they ought to act like I would. I mean, aren’t we humanitarians supposed to be these unconditionally compassionate, caring people?’
She smiles slightly. ‘Ideally.’
We talk for another hour. Daytime confessionals, beneath the berry-eating birds that shit constantly from the big tree above. I hunch in my chair and admit to her that I’m scared, that these guns and increasing clan movements frankly worry me; two of the other projects have been partially evacuated this week. I tell her that I’m tired from all the on-call, from the bouts of diarrhoea and the constantly broken sleep, and that I suspect I’m going to make a major mistake—security-wise, or with the management of a patient: either would be disastrous. And on top of it all, I confess that I’m losing my desire to be here, to do this work, or to even care about anyone else anymore. Compassion Fatigue, indeed. What a pathetic term.
Zoe listens quietly.
I ask her what the end-point of all this is. Do we all spend the rest of our lives flying around, trying to visit these thousands of impoverished towns, spreading ourselves so thin as to be almost useless at times? And at what personal cost? And why should this be my battle, anyway? Wouldn’t the more sensible thing be to get on with life at home, to at least take full advantage of the opportunities that I’ve been given? Why then this burden of white middle-class guilt we all seem to have?
Zoe’s silent. I look up, watch the birds quietly.
‘I’m not sure I’m the right person for this anymore, Zoe,’ I tell her.
‘I disagree. But what are you saying?’
‘I’ve been away for six months already, and I’ve got six more in Sudan. I can’t do it. Two to three mont
hs is all I’ve got left. I’m really sorry. Please ask them to start finding a replacement.’
• • •
My last day before holidays passes quickly. A fill-in doctor will fly in tomorrow to cover for me, but there’s a ton of loose ends to tie up.
Joseph and I review all the medical patients once more; the new infant who’d arrived gasping this morning is looking much better, managing to breastfeed a little, but the girl with meningitis is as rigid as a pole, still unconscious.
I visit the TB village with Peter, who, incidentally, is getting an office renovation, and by a work crew unlike any I’ve seen. Four Nuer women are delicately patting handfuls of mud and chopped straw onto the wall frame—two mud-patters and two mud-mixers, all in dresses—and they’re only too delighted to pose for a photo. Afterwards, Peter and I pass through all the TB tukuls, following which he lodges a request for annual leave.
‘What? Tomorrow?’
‘Yes!’ he says.
‘Really, Peter? Tomorrow?’
‘Yes. Because, after from today.’
‘But why are you only asking me now?’
‘Because my brother, he is only telling me the other day he is getting married again, next weekend.’
‘He only told you the other day?’
‘Yes!’ he laughs.
‘So can’t you hold off until that weekend then? It’s going to be impossible to get one of the other health workers to replace you by tomorrow, no?’