Six Months in Sudan

by Dr. James Maskalyk

  She wanted to go and find his father herself, but had no money. She tried for days to borrow some but could not. Finally, Mohamed gave her the dinars she needed. She said she would be back in two days. She has been gone for five.

  Traditional beliefs here are strong, and we struggle for legitimacy. There are two health providers in town, both competing for patients with our hospital. One is a medical assistant who charges patients for his services, which, regardless of the problem, include an intramuscular injection of benzathine penicillin, one of quinine, and an infusion of normal saline. Patients believe that intramuscular injections are superseded only by intravenous ones in their potency and are often unhappy when they receive pills from us, and completely dissatisfied if they receive nothing at all.

  The other show in town is a traditional healer. I haven’t taken the time to meet him yet. I would like to. It would be better to have a relationship with him so he knows when to send people to the hospital. As it is, frustrated mothers leave the feeding center because of the slow growth of their children and visit his tukul. He either blesses them and sends them on their way delighted, or keeps them until they fall more and more sick. Near death, they come to the hospital and die, sullying further our reputation.

  “Well, I guess we’ll have to do it with local. You want to grab him, Mohamed? I’ll open the theater.”

  Mohamed lifts Manut up from under his arms. The boy whimpers, terrified.

  I open the lock to the operating theater and lay a plastic sheet on the operating table. Mohamed enters behind me and sits Manut on top of it. He starts to cry.

  “Nonononono …”

  He wasn’t this upset last time. Mohamed tries to comfort him in Arabic, then shakes his head. Manut speaks only Dinka.

  I leave the room to find Alfred. He is sitting at the front desk, arms folded, eyes closed. I tap him on the foot and he starts awake. He follows me into the theater.

  “Alfred, explain to him that we need to look at his leg, and we will be as gentle as we can. Okay?”

  Alfred speaks to the boy softly.

  “Nonononononono …”

  Mohamed and I prepare the necessary dressings and syringes full of local anesthetic.

  “Mohamed, do you know the maximum dose of lidocaine? It’s 5 milligrams per kilogram. This boy is 20 kilograms, so 100 milligrams, right? Ten cc’s. Shit. Is that right?” It doesn’t seem like very much.

  We try to get Manut to lie down. He refuses, wailing.

  “Alfred, tell him there is no choice. You know what, just hold him. Yeah, like that.”

  I remove the splint from his leg and Mohamed pours some sterile water over it, loosening the caked dressing. More crying.

  “What is he saying?” I ask Alfred.

  “Nonsense,” he says.

  I glance through the open mesh window into the feeding center. A feeding center mother is peering through, concerned.

  “Shut that, will you, Alfred?”

  Mohamed starts unwrapping the dressing. The boy sits up, trying to stop him. Alfred thrusts him down.

  “Tell him he is being very brave. Brave like a man.”

  Mohamed has unwrapped nearly all of the dressing. The last bit remains adhered to Manut’s flesh. Mohamed rips it away. Scream. I look at his wound. A hole the size of a golf ball in the anterolateral part of his shin, rimmed with brown, rotting tissue, and at its base, gleaming splinters of bone.

  Mohamed starts injecting lidocaine through the periphery of the wound.

  “Maybe if this doesn’t work, we can try a Bier’s block,” I say.

  The 10 cc’s are quickly used. I try to lift Manut’s leg by his toe. It bends at the wound like a tape measure stretched too long. He screams. Completely broken. No union.

  “Well, he probably needs an amputation. We can transfer him if his mother ever comes back.”

  Mohamed and I set about trying to clean the dead tissue from the wound, but the lidocaine is not effective. Manut begs us to stop in a language Alfred is not bothering to translate. It is clear to all of us.

  We’re almost finished. Manut sits up with tears in his eyes, his hands in praying position.

  “All right. That’s enough. That’s enough.” Mohamed tries to wiggle free an ochre fragment of bone. Scream.

  “Tell him it’s over, Alfred.” I walk around the end of the bed so I am close to his face. I look him in his eyes. “You are a very brave boy. When your father comes I am going to tell him how strong you were.”

  Manut’s lips quiver as Alfred translates. He looks away.

  “Alfred, if you can help Mohamed finish the dressing, I’m going to make a phone call.”

  I leave the operating room and hurry from the hospital towards the compound. The wind gusts dust in swirls. I clang through the gate, duck into the admin tukul. Tim is sitting at his desk.

  “Hey, do you have the sat phone?” I ask.

  “Yup. Here. Who are you calling? I need to write it down.”

  “Your girlfriend.”

  “Oh. Say hello for me.”

  “I’m calling our new medco. He’s supposed to be in Khartoum this week. Finally. And he has tons of tropical health experience. I’m psyched.”

  I punch the numbers into the sat phone. It’s my first time using it. We are allowed a free ten-minute call on our arrival in the field, but I haven’t taken it yet.

  “Hello. Hello? Hey, this is James, the doctor in Abyei. How are you? What is Khartoum like these days? Uh-huh … Uh-huh … Ha. So not much has changed. Hey, you have someone new in the office now, the medco from Geneva, right? Is he in? Can I talk to him? Great.”

  I move underneath the tamarind tree. Scattered empty pods crunch under my feet.

  “Hello, Paul! Welcome to Sudan! It’s James, the doctor from Abyei. Thank you. Trying my best. Listen, I have a question for you. Sorry to hit you with business right away. I just finished debriding the wound of a young boy who probably needs general anesthesia for me to do a proper job. In fact, he probably needs internal fixation or an amputation. Grenade wound. Yeah. Long story short, he’s very anemic. We’ve looked for donors, but the usual, no one will give except his mom. But she has hep C. And so does he weakly positive. Uh-huh. So, my question. My assumption is that he got it from her. Yeah, no scars or anything. If I give him her blood, is it possible that she has a higher viral load or something, or if he contracted it elsewhere, might I be giving him a more virulent strain? Could I be making him worse? You know, ‘First, do no harm.’”

  The generator roars to a start. I glare at the guard and move farther away.

  “Okay … right. That makes sense. They’re both in their latent phase. Cool. Okay. I’ll do it if necessary. Well, I must say, it’s good to have you here. I’ve been figuring stuff out with textbooks, or by contacting Geneva. They’ve been trying, but they have so many different countries and … What’s that? Oh. Really. No way. Shit. Well, I guess you have to do what you have to do. Uh-huh. Well, thanks for talking to me. Okay. Good luck to you too. Bye.”

  I duck into Tim’s tukul and plug the phone back in.

  “Was it good for her too?” he asks.

  “The medco just told me he’s leaving.”

  “What? Why?”

  “I don’t know. Something about the office being a mess, no records. Whatever.”

  “Man. That sucks.”

  “Tell me about it.”

  He holds up his hand and counts on his fingers. “No medco, no logco, no head of mission, no logistician … um …”

  “No admin,” I say.

  “No doctor.”

  We shake our heads.

  “What are we doing here again?” I ask.

  “Sometimes I don’t know.”

  “I mean, why not two hundred kilometers … that way.” I point over my shoulder. “There’s probably a hospital just like this one, maybe even worse.”

  Tim shrugs, turns back to his payroll sheets. I leave his tukul and pass under the tamarind tree. The generato
r shakes noisily behind me and from it, the thick smell of oil.

  Each week we get an email from Geneva with vacant positions around the world. There are always several in Sudan, and lately, many in Abyei. I don’t know why. Perhaps experienced people are fatigued from the long civil conflict, maybe most of them have already worked in the country and know how difficult it is. Or they know something else I don’t.

  I pass through the compound’s open gate and walk back to the hospital. I don’t want the work to be easy. I would feel I was in the wrong place if it was. I just want to know that of the many fights out there, this is a good one.

  27/04: time.

  abyei is under water. well, much of it. the cracked fields that stretched from its sides are filled. in the middle of these lakes sit poorly placed tukuls from which women walk, balancing buckets on their heads, lifting their dresses to keep dry. trucks lie stranded, wheels spinning. it seems that either none of us were prepared, or we were waiting for the beginning to begin. our compound of dust is now one of mud, and we are watching for the first signs that cholera has found abyei’s thousands of returnees in their new, wet land.

  with the rain came a blanket of buzzing bugs in all forms. small ones that fit through your mosquito net and circle your headlamp casting tiny orbits on the pages of your book. larger ones who have bodies like an ant’s, but longer, and who can stand on their back legs and survey the huge landscape of the dining table for sugar lodes; lucy’s homologues. praying mantises made with sharp green seesaw angles fold and unfold themselves on our kitchen counter. and on the first heavy rain, insects that seemed a fragile, colorless cousin of the dragonfly lay waiting in their dry coffins for the water to wash them free. when it did, after thoughtless months, they took to the night air and carpeted abyei. in the morning, all that remained from their short, glorious season was their wings. they littered the ground like fall leaves and blew and whirled with the wind.

  most of us in the project have contracts for six months. some are shorter, none are longer. though mine is only a couple months through, it feels like more. tim and i have decided on a slogan for this project: “for those who think life is too short … come to abyei! it feels like it lasts forever!”

  i think in some way, we all distract ourselves to avoid the true experience of time because it is uncomfortable. i think that is why many of us dread going to the dentist. it is not because of anticipated pain, there is little of that. i think it is because we are never more vividly awake, never more focused on the present, never experience a longer minute, than when someone has their hands in our mouths.

  i think some of the reason the time feels differently here is that there are few distractions. it was something i looked forward to when i read in the job profile: must have “interest to work in remote locations.” there is no morning paper to read while we eat our breakfast. after dinner, there are no concerts to go to, nor walks to go on. we sit quietly, and the moments stretch.

  the rest of the reason is the tumult of daily experience. emotions are cast through their full register. the delight of receiving a package and a letter from home is followed immediately by the anticipation of the thursday night meal, the one where we can stay up a bit later, the carpet being pulled from beneath you when you’re called to the hospital to see a woman who has been raped. the world never lets go, and we are tossed about by its circumstances. like the first rain, with no protection, we feel more acutely its true weight.

  “MMM … EVERYONE … welcome to our first … meeting as a team,” Marco says. “Mmm … I’m sorry for my English … it’s out of practice … Where’s Antonia?”

  We all look around.

  “I’ll go get her,” Paola says, and leaves.

  Marco smiles at all of us and shrugs. “Already, it’s not so easy.”

  He arrived last week. In his luggage he had brought with him, all the way from Geneva, a package for me. It had inside of it a portable fan, several D-size batteries, and a box of cookies. It must have weighed at least 5 kilograms, a third of his allowed baggage weight. When I thanked him, embarrassed, he shrugged. “A package from home is important, no?”

  For three days he was either bent over a map with Bev, reading glasses on the tip of his nose as she spoke in rapid-fire English about the military intricacies of Abyei, or roaring around in a Land Cruiser so he could see for himself.

  He has worked in South Sudan before, but this is his first mission as a field coordinator. He told me that after he accepted the mission, he started reading my blog and changed his mind. Not because this project was any different from the one he had worked in before, but because it was so familiar. In the end, he agreed. We’re lucky. Bev’s lucky. She was hanging on at the end.

  Paola emerges from Antonia’s tukul. Antonia is behind her, brushing her hair.

  “Sorry, everybody. Sorry. Terrible,” she says, and lights a cigarette.

  Marco looks at her closely, clears his throat. “So, welcome. This is our first meeting as a team. James, Tim, David, you are surrounded by Italians. I hope you are ready.”

  David pushes his chair away from the table and stands up. “No. I refuse. When I signed up for water sanitation they told me about the soldiers, but no one said anything about Italians. I leave immediately. Goodbye.” He marches away.

  Marco’s eyes widen. A minute later David emerges from the kitchen, a large bottle of water in one hand, six glasses in the other.

  “He’s French,” I say to Marco, as explanation. David has been here for a week now. He’s a former logistician. No one knew he was coming. We got an email from Khartoum announcing that he would be arriving from the South in few days, then he was here. Officially, he is here to sort out the borehole. Unofficially, he is our new logistician, whether he likes it or not. Luckily he does. He spent today driving around, trying to find the best bricks for the new office Geneva just approved.

  “Already it is not easy,” Marco says again.

  David pours water for himself, Tim, and me, then sets the bottle down, waiting for a reaction. He gets none and fills the other three glasses. Marco sighs.

  I didn’t get David at first. He talked too much. Then, one day, in the pouring rain, we climbed on the slippery walls of the gazebo, fixed yellow plastic sheeting to its sides, and shouted to each other over the storm “up a bit, down a bit.” Now I think he’s the best. Every doctor secretly wants to be a logistician.

  “So.” Marco looks around the table, surveying us all, drawing out a long pause. “Welcome.”

  I pick up Tim’s package of cigarettes. He nods.

  “This is the first of our weekly meetings. We will meet here Wednesday at four o’clock. To talk about our week. Or the problems. Is that time okay?”

  We all shrug. Silence.

  “Okay. Wednesday.”

  The generator clacks on.

  “Before we begin, I would like to start this meeting off with a small game. It’s okay?”

  Paola sighs, Antonia continues to brush her hair. David is expressionless.

  “Sure,” Tim says finally.

  “Okay. Everyone stand up. Everyone. You too, Paola. You don’t like games? Okay. Move to the center of the floor. Good.” He points at us in turn. “Remember your number. One, two, three, four, five.”

  “Why don’t you get a number?” Paola asks.

  “You’ll see in a minute. Now, I want you to start moving around each other. Move. Walk. Faster. Don’t stop. Faster. Try to use as much space as you can. Okay. Now, when I call out a number, that person, you make a loud sound, yes? A loud sound like you are dying and then fall backward. The others must make a catch to you. Okay? Faster … Two!”

  Antonia lets loose a wide yell, “Oh! I’m dying!” and starts to slump to the ground. David grabs her under her arms.

  “Good! Good! Okay, more moving. Move, move. Faster … Three!”

  David gasps, “Mon dieu!” and falls to one knee. Paola and Antonia sandwich him, pull him to his feet.

  “G
ood! Okay. Move … One!”

  I clutch my chest, start to fall backwards. Tim, nearby, stops me.

  “Okay. Well done. Very good. Let’s sit down.”

  We sit back around the table, smiling.

  “Antonia, very good dying,” Marco says.

  “Oh, yes. I am very wonderful at it.”

  “Good. Now, does anyone know what the game is meaning?”

  We look at one an other.

  “Like, a trust thing? You have to trust your team to catch you?” Tim volunteers.

  “Yes, a little.”

  “I know,” Paola says. “It’s about how you fall.”

  “More.”

  “If you make a big sound, like Antonia, people know how to catch you. If you make no sound, like James, no one knows you are going to fall.”

  “And then you hit the ground,” Marco says, smiling at me.

  30/04:. X.

  the long-distance hf radio crackles beside me. a guard is resting his head on the desk in front of it. every minute or so, he lifts it and calls into the mic:

  “mobile 1, mobile 1 for alpha bravo, over … mobile 1 for alpha bravo, over …”

  he is trying to contact our land cruiser. we have sent a patient, urgently, to the nearest surgical hospital 3 hours away. when they arrived, they were told that there would be no operative cases accepted, and another hospital was suggested, hours away. it is well past dark, and outside of a hospital in northern sudan, in the back of a car, a woman in labor and in need of surgery is waiting to see if they change their mind, or if she will have to drive through the night on a dark dangerous road. we are sitting by the radio waiting for the same news. there has been no contact recently from the driver. we are not sure how to interpret this.

  “mobile 1, mobile 1 for alpha bravo, over …”

  marco was saying the other night that after you do one mission, and you go back home, you are ruined. there is a distance between you and others that is irreconcilable, things that you cannot share. when you try, the people you talk to either cannot place themselves there, or they realize they don’t want to know after all. the rift becomes larger.