Six Months in Sudan

by Dr. James Maskalyk

  “We want to buy some beer. Tusker. Forty.”

  The last party Abyei had, at an NGO near us, ran out of beer. MSF has a reputation to live up to. Back at the compound, we have taken the vaccine freezer from the hospital and plugged it into our generator. It has been running all day to freeze the ice packs.

  Tim is fiddling with his headlamp, turning it off and on. I try to take in the shadowed surroundings. I can see a candle flicker inside one of the tukuls, little else.

  The man stands up, disappointed the visit is purely business. “How many?”

  “Forty Tusker,” Jean says.

  “No Tusker. Only pilsner and extra ale.”

  “That extra ale nearly killed me last time. It’s terrible,” Tim says. “I vote pilsner.”

  “Okay, as many pilsner as you have, and the rest extra ale.”

  The man’s back fades into blackness.

  Tim smiles at me.

  “This is fun,” I say. “Jean, getting beer is going to be so boring a week from now. You’ll just have to go to the corner.”

  “I’ll manage.”

  “What about extending your mission? Tim, can you get on that?”

  “Oh, I’ve already started. You’ll just need to sign some papers.”

  Jean laughs. To this point, there is no one to replace him and no one due. An MSF water and sanitation expert is being sent to Abyei to work on the borehole. We each secretly hope he will help us fill the gap Jean is leaving behind. While the hospital can work without me as long as Mohamed is there, if the radio fails in the desert, and there is no one there to fix it, no sound.

  The man returns with a bottle of pilsner and hands it to Jean. It is covered in dust. He blows it off.

  “Can you clean the rest of them? Too much dust.”

  Jean hands the bottle to me. I turn on my flashlight and look at the label. Its best-before date was last year. Whatever. I hand it back to our host and he leaves with it.

  Jean looks at his watch and shakes his head. People will be arriving in a few hours, and the beer needs time to cool.

  We can hear only the faint drone of the market generators. From behind one of the tukuls, I can see the shape of three children, looking at us.

  “Hey, check it out.”

  “Hey, you guys, come here. Don’t be shy,” Jean says.

  The first, the little girl we saw tending the fire, comes slowly, shyly, towards us.

  “That’s a pretty dress,” Jean says. “What’s your name?”

  She smiles, continues to look at the ground. The other two inch forward. Younger. Sisters. They stand behind the eldest and peek around her.

  “We’re going to have a party tonight, with our friends. Dancing and music. You know, doooodooodaaaaaa …” he sings tunelessly, shaking his shoulders.

  The girls all laugh. The youngest ones come closer.

  “Dooooodooooodaaaaaa …”

  The three of them are now standing between us and the fire, grinning.

  “Doooodadoooodaaaaa …”

  The oldest one starts to sing.

  “Sheshashooooohh …”

  Jean joins her.

  “Sheshashoooohh … sheshashooooohh …”

  Her sisters start to dance, moving their shoulders and hips. They can’t be more than six or seven. Soon they are singing too.

  “Sheeeshashho … sheshashooohhh …”

  We can see their silhouettes, and when their faces turn towards the fire, their bright smiles. They are looking into each other’s eyes, laughing.

  “Sheeeshaaashoooooohhhhhh …”

  We’re all singing now, we’re all smiling now. The girls dance.

  After five minutes of the same refrain, the father returns with a crate full of beer. We stand up. He returns with a second.

  Tim pulls out the sheaf of dinars we donated from our per diems, counts them, then hands them to the man, who does the same. Satisfied, he smiles.

  We each pick up a handle and carry the two crates between us.

  “Thank you. Goodbye, girls.”

  They smile, continue to sing. We move away from the fire, towards the black road and from there to our car.

  We load the clinking crates of beer into the back and climb in. Jean starts the cruiser, turns it around, and we inch our way back.

  “Sheeeshaaaashoooo …” he sings.

  15/04: glass.

  once, when i was fly fishing in the rockies, pushing through brush and over rocks, hoping my luck at the next spot would be better than at the last, a mallard started following me. it wasn’t easy work for either of us, all thick trees, all upstream, but he stayed with me the entire afternoon. i would turn to look for him every so often, and he would be there, treading water, pretending to mind his own business, waiting until i moved. at the end of the day, as i started back downstream, he flew off.

  i ran yesterday morning. as i left town, a soldier ran from between two tukuls, and kept pace two steps behind. i looked over, and he looked straight ahead, minding his own business. we ran together, me carrying my heavy handset and him with army boots and jangling pockets. when we reached the tree in the middle of the flat landscape outside abyei, i stopped and turned around. he slowed to a walk and continued on.

  the team is changing. jean, the logistician, left today. he is returning to khartoum, and from there to london. our new field coordinator, marco, is arriving. he is italian. this means with the italian nurse and midwife, tim and i are surrounded. the food has improved.

  tim and i were talking, just now, wondering what we were doing here. not simply as two men the same age, with friends left behind and a future on hold, but as humanitarians. as msf. there is no conflict, and though perhaps we are too immersed to notice small signs, things seem peaceful. there are no refugees. the returning population is not huddled together under plastic sheets, sharing latrines with 19 others. the hospital needs attention, so much attention, but isn’t that true of nearly everywhere?

  the memory of the precise chemistry behind supersaturated solutions sits fragmented like much of my premedicine studies. i think the founding principle is one of entropy, that as one adds energy to a system it increases its randomness. what it allows is for one to add much more of a certain salt to a heated quantity of water than it would bear otherwise. it requires a completely new and clean beaker full of pure distilled water. as one adds heat, and chaos, he also adds salt. it dissolves, and he adds more. and more heat. and then more salt. the salt dissolves into its constituents, and the heat makes sure that the molecules ricochet faster and faster, knocking other ones loose. soon, all the salt has been added, and it is all in parts that are flinging themselves against the glass borders of the beaker. if one removes the heat, and allows the beaker to cool, the disorder lessens. the ions slow down. they spend less energy bouncing off of one another, and in fact would form crystals again if they could, but they can’t. there is no solid substrate. you are left with a beaker of clear water sitting on your lab bench, full of molecules waiting to precipitate, but none of them have anything to hang on to.

  now, take a glass rod, and just touch the inside lip of the beaker. a small piece of glass dust flakes off, so small you can’t see it, and falls into the water. in an instant, the water becomes a crystal. completely solid. the molecules are at rest.

  i think, for me, that is the reason why we are here, to be that piece of glass. it doesn’t matter if you are from the north, or the south, or a christian, or a muslim, or dinka, or misseriya, or soldier, or civilian. we deliberately don’t care. our intention is to make a place that is safe and solid for everyone in abyei. and it is not just about medicine; that is only our tool. the hospital is not just a place to treat the dinka infant with meningitis or the little misseriya girl with malaria, but a place where their fathers can reach for the water barrel at the same time and say to the other, after you, no after you. and maybe, two weeks later, when they pass in the market, they will nod. and perhaps, two years from now, they might stop and talk.
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  I’M WALKING TOWARDS the pharmacy. I am going there, officially, to start looking through the supplies to treat a large number of casualties. I meant to do it a month ago, but haven’t yet. Unofficially, it is the only cool, quiet place in either the hospital or the compound. Unofficially, I am going there to sit in the dark.

  The pharmacy door clangs shut. I look at the wide hole above it. I had mentioned it to Jean shortly after my arrival, and twice before he left. It remains open, and through it, cool air pours out.

  I look for something to put in the space. An old box. That’ll do. I take some scissors from a shelf and cut the box into pieces, fit one of them into the hole.

  It is nearly black in here now. Shadows of pill bottles and equipment surround me. It is Paola’s drowning task to keep things organized, a task made even more difficult by my grabbing armfuls of medicine, scribbling down approximations on loose pieces of paper, and leaving the scraps behind.

  I reach down towards a box near my feet. It holds about 100 energy-dense biscuits called BP-5. They do not have as many calories as BP-100s, not as fatty. They’re quite sweet. I like them. My translator said he ate so many when he was living in a refugee camp that their smell makes him vomit. I open one. Paola’s job gets worse.

  I start thinking about the feeding center. I am having a tough time with it. Some of the children don’t seem to be gaining weight well, particularly the youngest ones. Paola is trying to improve the procedures, to train the staff. To this point it has been neither easy nor successful.

  I’m not sure how to help her. I’m not sure if she wants help. She hasn’t asked me for any, nor have I asked her. We have developed a system where we work separately in the hospital on our own important pieces. We pass each other several times a day, hurrying from one to the other.

  Her tasks are broader than mine, less specific. I suspect, sometimes, she doesn’t know where to begin. When I arrived, she was trying to take care of the outpatient triage, sorting the round crowds that sat at our door from dawn into straight lines, sickest at the front. On my way to the inpatients, I would pass her scribbling vital signs on outpatient cards, shuffling them into order, then with frustration trying to rearrange patients.

  I haven’t seen her there in a while. The triage system is once again working on momentum. The loudest patients get seen first.

  We see, six days a week, a maximum of forty outpatients. This is a number that was decided on before I arrived. From these forty, I or one of my team sees the most ill. The others are seen by Sylvester, an MOH medical assistant. He has been in Abyei for decades. He told me that during the height of the war, he would not leave the hospital for months at a time. Since we arrived, he works a few hours most days, prescribing pills for patients I never hear about.

  He seems interested and careful. Beyond that, he seems a good man. I don’t agree with his frequent use of antibiotics, or his choice of them sometimes, but am not his supervisor. I treat him like a colleague. In turn, he treats me like a consultant, asking me to comment on difficult cases.

  It is our mandate to practice secondary care, to focus on acute illness. We see the forty outpatients mostly to appease the community’s hunger for contact. In an ideal world, we would have a sign on the door that said “EMERGENCY” and would turn people away with minor or chronic problems, sending them to the one other health clinic in town, run by GOAL, another NGO. Already, in an effort to refine our forty patients to the sickest ones, we turn some away.

  Word has filtered from the community, through our staff, that there is growing dissatisfaction with our project. The community wants more.

  We cannot provide it. Between the triage system that is now forsaken, tabled for another time, to the feeding center and its flat children, to the patients with contagious tuberculosis that refuse to be hospitalized, to the missed doses of medicines, to the children shitting in the yard, Paola and I can’t keep up with the things that need to change. We suffer from not having a medical coordinator to help us focus. Both of us are reluctant to bother Brian much. We know Darfur is higher on the list of priorities.

  In truth, no matter how unpopular our approach happens to be, it appeals to me. It has the same merit as working in the emergency room. I get to deal with emergencies. Everything else, no matter how important, is not my business.

  It is the contrast between relief and development. We put fingers in the dam until the water goes down or someone comes along to repair it. We are not here to improve the community’s ability to thrive. We are here to save lives that would otherwise be lost. That’s our expertise. When we are asked what we are going to do about unaddressed problems, we say: “We’re going to do what we’re doing. The question is, what are you going to do?”

  I finish my BP-5. It’s been two weeks since I discovered the supply and I can feel my stomach starting to turn.

  I look at the boxes around me. Two of them are labeled “EPREP” emergency preparedness. I stand and open one. Inside are dozens of liters of Ringer’s lactate, dressings, intravenouses. I try to lift it. Too heavy. Would make more sense to have five boxes, each for five patients. I start to unpack it.

  Knockknockknock.

  “Yes?”

  “James, it’s Mohamed. I brought the girl to the operating theater.”

  Oh yeah. The girl with the burn. We have to change her dressing. I open the metal door.

  “Okay. Do we need anything from here?”

  “I think the ketamine is expired.”

  “I’ll grab some. See you in a second.”

  I put the bags of saline back in the box, get a flashlight, and move past the rows and rows of medicines. Towards the back, I see the bottles of ketamine. I take two and stop just before the door to write on a scrap piece of paper: “April 18 ketamine × 2 JM.” I tuck it under the calculator, and click the lock behind me.

  22/04: open.

  the hospital is slowly filling again. today, i turned the corner to the tfc, and couldn’t find a route between all the families lying on their mats.

  last night, i could not leave the hospital. i tried. but each time i put my stethoscope in my bag and washed my hands, clapped the nurses on the shoulder and said “bukra … tomorrow,” another worried family opened the gate. they carried an infant with pneumonia, a woman with a spike of metal in her foot, a teenager with a kidney infection. one family walked for six days to bring an old man who could not walk on his own. i saw a child i discharged one month ago, the one i promised not to when i arrived, and didn’t recognize him. he was 55% of the proper weight for his height. he had lost all that he had gained in hospital and with it, his bright curiosity. he couldn’t lift his head to look me in the face.

  i found myself leaning against the door frame of the nursing room, waiting for the results of a malaria test. the light was fading. the patients had pulled their beds away from the walls and their radiant heat and were scattered like dominoes on the ground. the air was heavy and still. i think it might rain, i said, to no one.

  i leaned there, on the door frame, and waited. around the corner, below the blue water barrels in the middle of the courtyard, came achol. she was running like toddlers do, a little off balance, listing to one side then the other, using her fat arms as ballast. she came into hospital a month ago, thin and feverish. we fed her and i treated her for tb. tonight, as always, she was running. her mother scooped her up, and she screamed with delight.

  i turned to look for clouds. none. i caught the eye of a parent of a child in the feeding center. she smiled brightly at me. i don’t think i have shared one personal word with her, though i see her child every day, examine him every day. but whenever our paths cross, it is always the same; nothing but the widest smiles.

  an unfamiliar feeling started to seep in. what was it? foreboding? no, nostalgia. melancholy. no. unfamiliar. wait … is that … fondness? for this hospital? for … abyei? with all its hard, sharp edges, dustdustdust, heatheatheat. no way. really?

  the nurse picked her way t
hrough the beds littered on the ground and handed me the sheet with the malaria result. negative. i turned from the door and set it on the table. a gust of wind blew in, and scattered all the papers. outside, it whipped through the courtyard. i felt the sting of sand on my face, the grit in my eyes. an unattended mattress flipped end over end past the door of the nursing room. the soft dusk light disappeared. sandstorm.

  i saw two more patients, and walked home in the dark, squinting through my fingers. still, even though the desert tried to cover it up, i am pretty sure fondness is what i felt.

  “WHAT’S HIS HEMOGLOBIN?” I ASK.

  “Six,” Mohamed says.

  “Six? Shit.” I look down at Manut. His eyes are wide and worried. Today is the day we have to change the dressing on his leg. We’ve done it every couple of days since the grenade accident earlier this month. I was hoping that we could do this one under general anesthesia, using ketamine, so I could fully explore his wound, dissect some of the torn muscle away and see if his bone is intact.

  A hemoglobin of 6 is too low for me. If he vomits and inhales it, or if he gets laryngospasm from the ketamine, a rare complication, the oxygen level in his blood will fall, and there’s not a lot of hemoglobin in him to keep it up.

  We had tested his mother as a possible blood donor shortly after he arrived. She has hepatitis C.

  We tested Manut too. I looked at his result and could see a few clumps of antibodies near the margins of the test’s blue circle. Weakly positive. He likely received the virus from her during delivery.

  I asked his mother if she knew of anyone nearby who would be able to donate. She did not. The boy’s father is far away, and she tried to send a message to him, but heard nothing. No one else in Abyei was willing.

  People here fear giving blood, believing that once it is given, it is gone forever. I explain that it will grow back, that it is like their hair, but cannot convince them.