Six Months in Sudan

by Dr. James Maskalyk

  We already know what to expect. Dissatisfaction. When Ajak briefed us before the meeting, he told us this. The community wants us to do more. They are unhappy that we want to focus on the hospital and on secondary care. We either transfer people too much, indicating that our hospital resources are too thin, or we don’t transfer enough, a sign that our transportation options are too few. Some want a helicopter, others an operating room. We heard that many are unhappy being told to go to GOAL for treatment of their non-acute problems.

  We struggled with this. No matter how many days in a row we worked, it felt like we were getting further from being accepted. It had surely happened more often, but I can only clearly remember one patient’s approval. I had taken a piece of glass from his foot, and when I apologized for the discomfort it was causing, explaining that local anesthetic in the sole is painful and often ineffective, he shook his head at me and fixed me with a broad smile.

  “I am from Darfur. In Darfur, there is no one. No hospitals. No medicines. You are doing a good thing. I am a very lucky man.”

  We are not naive. We expect few accolades. The Dinka are a strong people. They have resisted incursions on their soil and on their culture for centuries. Through these last decades, because of the long conflict in Abyei and ascendancy of the NGO as the arbiter of the world’s philanthropic wealth, they have become used to people driving up in Land Cruisers and asking what was needed. We should expect their chiefs to advocate for their people, to ask for as much as they could get even if they might receive a fraction. I would do the same. And after decades of former friends burning down their homes, they will be cautious about trusting new ones.

  Tim and I sit down. As soon as we do, others stand up, queue, and begin to heap their plates. The food is similar to what we eat at compound 1, or find in the market. Oil-drenched okra, black beans, ground goat mixed with pasta or potatoes. There is a round piece of oily white gelatin in the center of the table that survived Tim’s and my pass intact but is being whittled away by the Sudanese guests.

  The paramount chief, for his part, has stayed seated and still. His chair is made of large pieces of strong wood that suit his mighty frame and booming voice. Next to him sits Ajak. Ringing the room on rickety chairs are the rest of the attendees. Between the district chiefs and their emissaries, our MOH staff sit across the room from us. When we arrived, Sylvester came over and shook our hands. The vaccine officer, the one with the office at the back of the hospital, didn’t meet our eyes.

  The paramount chief brings the meeting to order and everyone sits down. He welcomes us to his house, thanks us for our kind patience in waiting for this important meeting. He throws a meaty arm around Ajak, says he is sad his cousin is leaving so soon, but how good it is that he came.

  He starts to make introductions.

  “Majak Atem Atem, chief of Gumbial. Arop Atem Deng, chief of Abienton …” Each name leaves me as soon as I hear the next.

  “We are each grateful that you have taken the time to come here. We know the hospital is very busy,” he says. “It has been a long time since we have sat together, MSF and us. We hope this is the first of many such meetings.”

  Tim shifts uncomfortably beside me. Next to him, Marco smiles at the chief, nods.

  “Many people in the community are unhappy with what MSF has done in the hospital ….”

  And so it goes. From one person to the next, we are roundly reminded of the things we do not do. As one chief runs out of words, starts to pause, the man to his side starts.

  Someone is describing the ire of a patient sent away without treatment, a patient who had some sort of hysterical paralysis that even the local nurses in the hospital called Abyei Syndrome. I interject.

  “How many times do you hear from people who come to stay in the hospital? The very sick people?”

  The chief dismisses this, shakes his head, and continues on. We slump lower in our chairs. The vaccination officer smirks.

  It is an hour later. I glance at the rest of the team. Paola is looking at her feet, Tim leaning forward with his chin in his hands. Marco is trying to remain engaged. Across from him, one of the chiefs who has spoken his piece is leaning his head against the pole behind him, snoring softly.

  The paramount chief looks at his watch. He has another meeting. He calls this one to a close. We stand, dejected, dizzy from the contrast between how hard we are working and our perceived performance.

  We step out into the bright noon sun. Ajak decides to stay behind. He has more family to see. Tim, Paola, Marco, and I start back to compound 1. The road is rutted from the recent rains, but has dried in the morning heat.

  “So?” Paola says to Marco. “What do we do about that?”

  He looks puzzled. “What do you mean? Nothing. We do what we are doing. We work in the hospital like before. Until I hear something different from Geneva.”

  It is rare that we are this deep in the market at this time of day. Store owners glance up at us. We stop to buy some water. A group of children start to trail us, giggling. We walk on, and as a team, we lighten. That we are misunderstood, that our efforts seem unappreciated, makes the long hours seem even more virtuous.

  “Hey, Tim,” I say, pointing at a grass-lined compound and a hanging broken bulb. “Sheeshaashooo …” He laughs.

  By the time we pass through the metal gate of compound 1, together, we feel tighter.

  11/05: paradise now.

  this is the part of the story when the character begins to get tired. when he walks his daily route, one that is so familiar he can do it with his eyes closed, he does it with his eyes closed.

  yesterday, on the walk back from the hospital, a monkey loped past me. he cast a brief backward glance, then took a sharp left into the market. he was wearing the most amazing pair of sunglasses.

  my morning run has been suspended recently so that i might concentrate more fully on smoking. unfortunately, i woke up over-early this morning, and could find no excuse to avoid it. my usual route, over a flat wide flood plain, has been made impassable by the rains. all that was left was to run along the red road that leaves town, and look over my shoulder for overfull trucks. i took it to its first junction, and turned south. it was very early and i could see a corona form over the fields, much clearer than on other mornings, no refracting dust. in an instant the sun blazed, burned my eyes. people walked from the trees towards abyei over the cracked ground that drained rainwater like a sieve, and their white robes were silhouetted by the sun, morning ghosts.

  everyone in our mission smokes furiously. msf. part of the reason is the isolation, the idle minutes. as it has been said in many languages, when you have a cigarette, you always have a friend. the other part is that in the face of all the sickness and early death, one’s health falls from constant focus. you look around at the other passengers, and from all accounts, if it looks like the plane is going down, smoke ’em if you got ’em.

  I AM IN THE LAND CRUISER, on its plastic back seat. Marco is sitting in the front, Anthony is driving. We are grinding slowly past the tire at the corner, but instead of turning right towards the hospital, we drive straight.

  In a few hundred meters, we are somewhere I have never been. We begin to pass half-finished tukuls ringed by a railing of thin sticks. A woman drops a bundle of grass from her head to the ground beside her tukul. It will be used to make a roof, or a fence.

  This must be where the new returnees are settling.

  We pass the last tukul and bump across an open field. Hundreds of plastic bags, bleached white by the sun, flutter on the rough ground.

  “That’s not getting any better!” I shout over the chatter of the car.

  “What?” Marco shouts back.

  “The plastic! All those bags!”

  “I can’t …” He shrugs, smiles.

  “Later,” I say, wave my hand. I turn back to the window.

  This is my second time in the land that surrounds Abyei. The first time was when I did a mobile clinic a month earlier,
to see what it was like. I had been a vocal opponent of mobiles. In my months in the hospital, I had watched the Land Cruiser return at the end of a long day with an exhausted team, and only once or twice had it carried an emergency. I worried that patients who were truly sick might delay attempts to find transport to the hospital if they knew we were coming in a few days. I struggled with the possibility that one day, because of the rain or the fighting or because we had closed the mission, the service would be stopped. Those people may have stayed where they were, farther from Abyei, because we helped them resist the tide of urbanization.

  Further, I knew the type of medicine that was practiced. Pills were given based on the patient’s complaint, often in the absence of a physical exam. At my mobile clinic in Cambodia, I found myself sifting through dozens of patients to get to a sick person. On the way, I would dole out pills that would be traded between patients. Two yellow for one red, my antibiotics for your paracetamol. After a few days, I gave out mostly vitamins.

  Last month’s mobile was the same. Queues of women and children, a few men, all mostly healthy. Of the forty or so patients I saw that day, I diagnosed a girl with a possible urinary tract infection, a young boy with a superficial eye infection. To everyone else I gave either paracetamol or vitamins.

  Anthony turns onto a wide road, a proper one, and speeds up. The rippled clay rattles my teeth. It is too loud to speak.

  We have three sites. We are on our way to the one deepest in the forest. We discovered the population shortly before I arrived, after we received a few cases of hepatitis in the hospital and found that they were from the same area, Bayom. Bev went with the first doctor, the one I had never met, and came across several hundred people, a mixture of soldiers and civilians, all desperately poor, living in the middle of a scrub forest, far from a main road. They had lived closer to Abyei once but, because of the war, had settled here. They had little access to food, less to medicine. It was difficult for them to get to us. We decided to get to them.

  I am told that they have a local doctor, someone who has some official training, but we don’t know what type. I am going to meet with him or her. I am going to get the fuck out of Abyei.

  Anthony points out the window.

  “Bricks!” he shouts.

  On the side of the road, stacks of gray clay bricks, formed by hand. They will be fired in a wood kiln and turn red with the heat. The only people who can afford them are NGOs and the government. Local huts are plastered with clay.

  The scenery changes back to brown scrub, the land flat and austere. No bricks, no birds, no animals, fast glimpses of an occasional hut. Trees flick by. The sameness is hypnotic. We drive for miles. Flick. Flick. Flick.

  The Land Cruiser slows down. To our left, a small dirt track appears, so faint that I would have missed it. We turn. After a short distance, we see that it will not be passable in the rain. The soil is loamy, and the path dips below the water table in several places. Once the daily rains start, these people will be on an island.

  We wind on the path for an hour, scraping between trees, scattering occasional troops of monkeys. After an hour or so, I see a hut. A few more. Roofs of grass held up by walls of grass, and inside them, beds of grass. No clay. Families stand to watch us pass.

  “Bayom,” Anthony says.

  It is my first real glimpse of the larger world that surrounds Abyei, one where many of my patients live. The other mobile I did was just off the main road.

  All this space.

  When I said I was interested in being somewhere remote, this is what I imagined. Not Abyei, its generators, its military rallies, its roving UN vehicles.

  We climb a ridge and see huts scattered on gently sloping hills. At the top of one is a large tree. Underneath it sit several men.

  As we get out of the Land Cruiser, they rise and step towards us. They shake our hands eagerly. One of the men, my age, is introduced to me as a doctor. We smile at each other, then sit down. There aren’t enough chairs for everyone. Two of the men remain standing.

  The chief begins to speak in Dinka and the doctor translates.

  “First, to our guests, thank you for coming such a long distance to meet with us.”

  Marco nods.

  “You have brought medicines to these people who have suffered so much because of the war, and without them we would have none at all. We are glad you are here, to sit with us, because we are worried about the rains.”

  Their worries for the rainy season are the same as ours. Not only will it choke their access to the larger world, it means disease. Malaria, cholera. When the rain starts and before things grow, the chief explains, his people have no food. They eat grass and it gives them diarrhea, and some of them die.

  Please, could we bring them food? A box of medicines? Could we build a proper school? Dig a water pump?

  Marco listens carefully, nodding throughout. When the doctor is done translating, he answers with the only thing we can do: we will drive on an increasingly muddy road until the truck will go no farther, and once that happens, we will turn around.

  The chief nods solemnly. Our limitations must seem like refusals. Marco speaks again.

  “Someone told us of another road, one that goes to Bayom but from the other way, from Twich. Do you know that road?”

  The doctor translates and the men begin to talk excitedly.

  “Oh yes. Another road. A very good road. Someone was on it with a car like yours the other day. It is this way, down the hill. Past those tukuls. I will show you. It is very very good,” the doctor says.

  The meeting is nearly over. I ask them if there are any particular illnesses they are seeing right now. Diarrhea, hepatitis, measles. The doctor answers that there are only a few cases of malaria, nothing else. We stand to shake hands again, and Marco talks to the chief. This time Anthony translates. The doctor and I step towards each other.

  “Michael, I’m glad to meet you,” I say. “It must be difficult to work here. I find it difficult to work in Abyei, and I have a hospital.”

  “Yes. It’s difficult,” he says. “I have no medicines. Sometimes I can go to Abyei and get them, but mostly I have to tell people what they need and let them find it.”

  “Where did you go to school? Are you a medical doctor?”

  “I am a nurse.”

  He did two years of training in Ethiopia, and once his certificate was done, he came to help during the war. That was four years ago, and he’s been here since. He’s not from the area. He is from near Juba, the capital of South Sudan. He wanted to help his people.

  “I have a small clinic. It’s on the way to the road, just down there.” He points down the hill. “You will pass it, just before you get to the road.” He glances over my shoulder. The chief needs him to translate something to Marco. He excuses himself.

  I move back under the tree. Most of the men have left, carrying their chairs back to their homes. A few are still sitting and smoking. We look at one another and with no way to say it, have nothing to say. They start talking to each other.

  The edge of the hill is rimmed with patches of scrappy acacia trees. Underneath a large one, I notice three families standing, looking in our direction. I watch another woman walk towards them, a baby balanced on her hip. They must have heard the car and think we are here to do a mobile.

  Marco and the chief are finished. Michael and I go back to the Land Cruiser. We discuss Bayom’s people, about how poor they are. I don’t ask how much he charges them for his consultation. We shake hands a final time, and I climb in.

  Michael speaks with Anthony, and then the engine roars on. We circle around the tree, away from the way we came, and past the waiting women. Anthony shouts something to them in Dinka, and when I turn around, they are walking back through the brush.

  We pass Michael’s clinic. It is made of grass. I ask Anthony to stop, and jump out. Its entrance is made of thin sticks, designed to form a series of hallways, like a cattle gate. Inside it is cool and dark. The ground is cover
ed in grass. There are two chairs, nothing else.

  I get back into the Land Cruiser, and Anthony finds a road that stretches north. On it, we can see a pair of tire tracks. Huts flank it at first, but as they disappear, so does the road. It changes from a road to a bicycle path. Several times we are blocked by trees and must reverse, retrace our route to the previous fork. We push through the brush for an hour. The sky starts to darken.

  “Do you think we should turn around?” I ask Marco.

  He looks at Anthony, who shakes his head.

  “Are there any landmines around here?” I ask.

  Marco looks straight ahead. I shut up. Anthony picks up the radio to call compound 1 to give them the hourly update on our location, then sets the handset down. We don’t know where we are. The prospect of getting lost becomes more real. I start to get excited.

  We enter a wide clearing, and in the center of it is a large grass tukul. A man, having heard our approach, stands outside. A pair of children’s eyes peek through the gaps in the wall.

  “Twich?” Marco asks.

  The man points north. We drive on until we find another hut, another man.

  Twich? That way. Twich? That way.

  The path finally widens. Underneath a tree, four men are talking. One of them has a bicycle.

  “Twich?” Marco asks.

  The man with the bicycle answers in English.

  “You’re not far. Just that way.” He points north.

  “The road. This road. In the rainy season. What is it like?” Marco asks.

  “Water. All water.”

  “Oh.”

  “You should build a proper one.”

  Anthony puts the car into gear and we drive on. One can interpret these requests in two ways. The first, that these people expect others to do everything. The second, that they believe that we can do anything. If we can drop food from the sky, why not knock down a bunch of trees, push some dirt into a road.

  We enter more clearings, pass more tukuls. The walls are no longer grass; they are clay. We must be getting close to the main road. Like the dry riverbeds I saw from the plane, green trees on their banks, roads spill energy from their sides. The man on the bicycle is right. Of all the ways we could help Bayom, a road would be the best.