Six Months in Sudan

by Dr. James Maskalyk

  Jean shows up, his hands covered with dirt. Sandrine is beside him. “Sorry, everybody. Fuse went in the hospital.” He sits down.

  “Okay, everybody. We’re late, so let’s get this started.”

  The first few chugs of our generator, then clackclackclackclackclack. Bev raises her voice above it.

  “First, today is Sandrine’s last day. She flies out in an hour, so if you haven’t already said goodbye, now’s your chance.”

  Bev continues, reciting the schedule for the week ahead. Mobile clinics, measles monitoring, car repair, changes in military activity. My presence is not given a mention. It seems, after three days, I am a fixture. The machine, and its exchangeable parts, keeps moving forward.

  The meeting finishes. Bev asks for questions. There are none.

  “Now, why does no one ever have any questions? Am I that good? I guess so. Mohamed, question? No? All right, then. Off you go.” She stands up.

  There is no movement. Now, a little shuffling. Someone puts his hands on his knees, pushes himself up. Slowly, the rest of the group, about ten in total, does the same. Sandrine suggests a photo, and everyone starts to queue. I leave them and go to the kitchen.

  I put my dirty coffee cup down in the sink. On the small propane burner, a large pot of water boils beside three metal water filters. There are a few pieces of fresh bread left on the counter, their outer edges black from the newspaper they were wrapped in. I take one. From the small fridge in the corner, I grab a warm bottle of water, then reach around to plug the fridge in. It begins to strain. I step back outside.

  Everyone is still taking photographs. I will defer teaching until tomorrow.

  I leave compound 1 on my own. I know the route. Right, tire, cannon, duck, left. The sun is already hot. Children pass me on donkeys; soldiers walk by with guns drooping over their shoulders and their caps pulled firmly down. A teenager on a bicycle talking to his friend sees me at the last second and swerves.

  At the hospital the dusty MSF flag dangles from its short pole outside of the gates. Patients already line the hallway, waiting to be seen. I walk past them and into the nursing room, gather up all the paper patient charts, and start to go through them one at a time.

  23/02: r&r.

  friday was the traditional muslim day of rest and the day off for this msf project. however, there is little distinction between the work and any life outside of it. at 7 p.m., we are still talking about the day that passed, at 8 p.m., our plans for tomorrow. it is our last word before sleep, and our first on awakening.

  of the patients that i saw on my first day, the ones thrown like match-sticks from the back of the truck, we transferred one to another hospital for an x-ray, and i have since been told his pelvis was fractured. i saw another, his arm casted, driving away from the hospital, his loose camouflaged sleeve flapping behind him like a flag.

  the thing that has worried me the most so far is not the political situation, nor the risk of getting ill, nor the remoteness, nor the lack of hospital resources. it is that, on fridays, our kitchen staff has the day off, and we must cook for ourselves. cooking is easy in kensington market. you can barely find the jamaican allspice for all of the organic lemon-grass. here in the local souk, well, there are tomatoes. onions. goat. um … i’ll let you know.

  MOHAMED AND I ARE making our rounds. Two families, both from Abyei, both with young boys infected with measles, occupy the same veranda. They are the two sickest children in the hospital. We must keep them separated from the rest of the patients and hope that the hot wind scatters their virus into the empty sand rather than into the feeding center.

  I’ve seen measles a few times. The rash is particularly hard to recognize on black skin. You have to let the light hit the fine bumps tangentially to appreciate the random pattern the virus draws over the torso. If you close your eyes and run your fingers over the child’s back, you can feel it, a million soft points.

  The other signs are more obvious. Red eyes rimmed with yellow glue, the shaking cough, the high fever you can feel before your hand reaches the forehead.

  “Why is it,” I am saying to Mohamed, “that they are all getting antibiotics?”

  “Because of their cough.”

  “Yeah, but measles is a virus. Everyone gets a cough. You know, ‘cough, coryza, conjunctivitis.’ Measles.”

  He is silent. When I sat with my team the first time, I said that they had more to tell me about medicine in Sudan than I could teach them. Our job would be to learn from each other. Sandrine has been gone for one day, and already I am doing things differently, repeating discussions from a week ago.

  “I don’t think it’s a good idea. At home, I only treat bacteria when I know where they are. Otherwise they develop resistance, right?”

  He nods. We cross amoxicillin off the list of medicines, increase the dose of paracetamol. The mothers sit on separate beds and ask no questions. Underneath the beds are two empty bowls wiped clean of beans. I take my hand from the boy’s back and stand. Beside him is his little sister, about nine months old. She wasn’t there yesterday. I shake my head. We have only a few doses of measles vaccine.

  “Mohamed, can you tell them again that no children are supposed to come visit unless they have had measles? They’ll get sick, like him. And the little girl should stay here now too.” A little boy comes barrelling around the corner, wearing only a T-shirt, and runs into my leg. “And who’s …? Shit.” This isn’t going to go well.

  Two more patients left to see.

  We walk to the back of the hospital, to the only private room in the place, an empty closet. A wheelchair with one of its front wheels missing sits propped outside of it.

  Mohamed greets Mansood in Arabic. He is an old man for Abyei, perhaps in his fifties. He is Dinka, tall and thin, his feet callused from years and miles. On his left knee is a thick bandage soiled with pus. Beside his bed is a long walking stick. He takes it and pushes himself into a sitting position.

  How is he feeling? All right. Weak. Still not hungry.

  “He used to be a strong man,” Mohamed says. “Even when he came in. Now he’s like a baby.”

  We unwrap his knee. It is swollen and warm. Below the kneecap is a small area of broken skin and from it leaks a pale brown fluid.

  “Has anyone stuck a needle in his knee?” I ask Mohamed.

  “No. We were treating him for skin cellulitis.”

  “I think we should stick a needle into the joint. If there is pus, we’ll try to take out as much as we can, then irrigate it. Have you aspirated a knee before?”

  “No.”

  “I’ll show you. You put some local anesthetic in, then put your needle in an 18-gauge here.” I point at a spot two o’clock to his kneecap, just under its lip. “Direct it this way, pull back on the syringe. Easy. We’ll do it after lunch.”

  “Okay.”

  I tuck Mansood’s chart under my arm. One left, the boy whose fever remains unbroken. I changed his antibiotics the day before to target different bacteria, to expand the coverage. On my arrival at the hospital, the first thing I did was check his temperature: 101.3 Fahrenheit.

  He is lying on his side in the same position Mohamed and I left him in yesterday, his thin chest moving quickly up and down. I put a hand over his ribs. He’s hot. I turn to the nurse.

  “Has he been getting his paracetamol?”

  “Yes.”

  “What about his antibiotics? Were they given?”

  “Yes.”

  “Is he eating?”

  “Not much.”

  The boy starts a staccato cough.

  “He’s malaria-negative … maybe TB? But this all started post-measles. That’s a pretty big coincidence.”

  Beneath my hand, his ribs feel like a wooden accordion, pulling apart, coming together. I motion for him to sit, mime listening to his lungs. He pushes himself up and leans forward.

  “Sounds are way down on the right. Could be an abscess or empyema. We should stick a needle in. Or a chest tube.
He needs an x-ray. And some parents.”

  Mohamed says nothing. Yesterday we confirmed that the boy had no family, that he lived in the market, begging.

  I look at my watch. “Maybe we should do this now. If you take these charts to the nursing room, I’ll get set up.”

  Mohamed nods.

  In the operating theater I find a syringe, a couple of needles, antiseptic, and local anesthetic. Mohamed returns with some sterile gloves. Together, we carry the boy into the operating theater and sit him on its table.

  “Mohamed, explain that we have to put a needle in his back.” What is he, ten years old? “Tell him it won’t hurt that much. He’ll feel just a pinch at first. And tell him that when we ask, he has to breathe out slowly, okay? That’s when I’ll take the needle out. We do that so he doesn’t take a big gasp as the needle is pulling out, right? He could suck in a bunch of air through the hole, and collapse his lung and all that.”

  We clean his back. The white gauze comes away black with dirt. I listen to his back again, thump one of my fingers with the other until the sounds goes from hollow to dull, then make a mark with the hub of the needle. I inject a few cc’s of anesthetic into his back. It raises his skin up in a wheal.

  “You always have to go above the rib, right? Not below. That’s where the neurovascular bundle runs. You can hit an intercostal artery.”

  I take a large syringe and put on its tip an 18-gauge needle.

  “So landmark like this, just over the top. Is he doing okay? He’s okay? All right, he’s thin so we don’t have to go very far … You can kind of feel the lining of the lung pop as the needle enters it, then pull back on the syringe, and …”

  Blood.

  Shit.

  “Okay, tell him to breathe out.”

  I landmark one rib below, put in some anesthetic, get another needle, push it through, pop, pull.

  Blood.

  Damn.

  “Tell him to breathe out.”

  I’m sweating now.

  Why the blood? No way I hit a vessel twice. Maybe he bled into his abscess, or has an infected hemothorax … I don’t know. TB?

  “Okay. Tell him one more time. One more. Good. Great. And …”

  Blood. Dark blood.

  “Breathe out.”

  I empty the syringe into the garbage in a thin red stream. It hisses as it hits the plastic.

  “All right. I can’t find any pus. I don’t know. I think we should probably put in a chest tube. Basically, he’s going to get septic and die if he’s got pus in his chest and we can’t get it out. But we’ve got to try to find someone. A friend, an uncle. If it doesn’t work, we can’t transfer a ten-year-old to a hospital alone.”

  The boy sits stoically, three raised targets on his back, dried blood at their center. We wipe him clean, put on a dressing, then carry him back to his bed. He rolls over and faces the wall.

  Mohamed and I agree to meet in the afternoon to aspirate Mansood’s knee and try the chest tube. As he leaves to find lunch at compound 2, I return to the veranda that holds the measles patients. I smile at the families, and motion for the charts that are tucked again under their plastic mattresses. They give them to me. Beside “Amoxicillin,” where two hours before I wrote “Stop,” I write “Restart.”

  26/02: today.

  today, i woke early, determined to run out of town and find a bit of space in the flatness that surrounds abyei. at 6:30 a.m., the sky was still dark. as i ran, past the trucks and buses leaving for el obeid or khartoum or juba, full upon full of beds and blankets on top of beds and blankets, dawn happened. but the sun never rose. not past the meniscus of dust along the horizon. a windstorm had lifted the sudan sand, and it covered not only my tukul and abyei, but the wide sky. by 8 a.m., the sun was only a gauzy ghostly hole, the color of beeswax.

  today, when i was doing rounds, and i was figuring out what to do with a young boy who developed a fever after a run with measles, a boy in whom i had already stuck a chest tube and three needles to try and drain a large collection of bacteria, as i was deciding whether to stick more things into his chest or send him to another hospital or if he was going to die, and heard from my translator that this boy, already ghostly, had refused food that morning, i looked down and beneath his bed was a butterfly struggling to right itself on the floor but instead, spinning in circlescirclescircles, its wings tracing round grooves in the dust.

  today, a whole rash of measles. i had it as a child. so did my brother. i have no memory of it. all i have are pictures showing how miserable we both were. i doubt they are in memoriam of this special time; more likely we just sat still for 30 seconds. people sit still with measles because they don’t want to move. their eyes get infected, their skin flakes, their fevers are severe. measled. miserabled.

  today, a baby died about ten minutes after coming into the hospital. she was dirty and covered in grass. the family came from far away, and asked if i knew somewhere nearby where they could bury her. i said i did not. they thanked me and left.

  when i ask people in the hospital where they are from, they answer in days. “three days away,” some say.

  i admitted a girl from two days away. her mother had died in the hospital two months before, and she was her only child. her father was a soldier with other wives. a neighbor found her lying on the ground and hitchhiked to abyei to deliver her to our door, an orphan. she was so severely dehydrated that when i listened to her heart, she tried to suck on my stethoscope. she could drink, but no one gave her any water. today she is better. she gained a kilogram in 24 hours. from 5 to 6. the man who brought her said he can’t stay, doesn’t know her relatives. her problems are ours now.

  there is a little boy here who the staff is so fond of that i think they are delaying discharging him because they would miss him too much. he is always between your legs, and crawling onto your lap. if it comes to me, i am never discharging him either.

  I AM SITTING ON A PLASTIC STOOL. Kneeling beside me, a young girl heaps spoonful after spoonful of sugar into my tea. My two new Arabic words, to bring the ringing total to three, are “sugar” and “separate.” I said them when she showed up with the tea, but must have mispronounced them. I am too shy to say them again.

  Tim sits beside me, smoking. It is just dusk, a little late for us to be in the market. We’ve been told to avoid it after dark. Though alcohol is not sold openly here, it exists. I’m not sure if its visible absence is because of expense or a remnant of sharia law. Either way, as the day winds on, one can watch the soldiers’ eyes become glassier.

  My days, so far, all seven of them, have been of the compound-right-tire-straight-cannon-left-hospital variety. I got home late this afternoon. The gazebo was full with a meeting. I tried to lie down on my dusty bed, but the heat was stifling. I ducked into the administration tukul to find Tim, and a few minutes later we were walking on the rutted road towards the market.

  Beside us a group of Dinka men sit talking, resting their long arms on their knees. A donkey ambles past. The air is hot and still and on it, the smell of burning garbage. The girl leaves my side and puts her hot tin can back onto the coals.

  “So, it looks like they are going to send in the emergency team from Geneva,” Tim says.

  “Yeah, I heard,” I say, and stir my tea, swirling the thick layer of sugar.

  There are about twenty patients with measles now. One day there were two, the next day four, then seven. I have been keeping track of them, where they are from, when they started to get sick. Whenever there are more, I tell Bev and she talks to Brian. We were waiting to see if the numbers would cross the threshold to qualify as an epidemic. They do.

  Tim lights a cigarette.

  “Those things are killers. Seriously, dude,” I tell him. “Killers.”

  He holds out his package. I take one.

  “I thought doctors didn’t smoke.”

  “I don’t smoke. If I did, I would have cigarettes of my own.”

  “Oh, right. Sorry.”

&nb
sp; He hands me his lighter.

  “That’s okay. So …” I take a long drag from my cigarette. “How’s life in the admin tukul?”

  “I can’t complain,” he says.

  “Bev seems stressed.”

  “Yeah. Seems that way. She’s off, or on. Mostly on.”

  “Does she sleep?”

  “Can’t say. Not much.”

  I pick up the small glass of tea by its rim and take a sip. Ow. Too hot.

  “When did you get here again?” I ask.

  “A few weeks before you. When was that?”

  “A week ago.”

  “Jesus. Seems longer.”

  “Tell me about it.”

  I lean back on my chair. Generators start to clack madly in all directions. It’s almost dark now. The girl throws some incense on the coals and the scent of frankincense swirls on the smoke. In the sky above Tim’s head, the minaret of the town mosque glows from within. A young boy in ripped brown shorts walks by barefoot, two goats tethered behind him.

  “You got a girl back home?” I ask.

  “Yeah. You?”

  “No. Not really. You miss her?”

  “No. Not really.”

  I laugh. Tim lights a cigarette with the end of his last.

  “We’re going to see how things are when I get back.” He exhales.

  “One of those.”

  “Yeah.”

  “That’s tough,” I say.

  “No. I mean, yeah. It’s just … it wasn’t that hard to leave, but it’s … you know … hard to figure things out.”

  “Tell me about it.” I’ve been letting Sarah’s emails hang in the in-box. Too heavy.

  “I mean, who knows. Do you ever know?” Tim asks.

  “I don’t think so, not really. I think your mind keeps on fucking with you. I remember an ex-girlfriend of mine. She was an occupational therapist, you know, helped people recover from strokes or accidents or whatever. Taught them to dress themselves again, make toast, stuff like that.”