Six Months in Sudan

by Dr. James Maskalyk

  We drive from yard to yard, and finally bump onto a red road. I look at the odometer. Twelve kilometers. Two hours. And with the rains, no chance.

  We drive back to Abyei deep in the afternoon, and watch the clouds stack. As we turn into town, raindrops start to spatter the windshield.

  13/05: mother’s day.

  one of the members of our team is approaching the end of her mission. she has been here for five months. i have watched her go through some of the same stages i have, some i have yet to approach. right now, she is stifling the excitement she has for going home, trying to save it for when she steps onto the plane, for when she will be able to believe it. marco was talking about what it is like when one’s mission ends. you leave from khartoum and step off the plane in geneva, and the world you left … collapses.

  i am not surprised. we completely inhabit it, focus our entire energies on it, but as soon as you queue up in the airport to get a starbucks latte, it will seem as far away as the moon. but that is why i am writing this. to convince us all that it is not.

  of course, i can’t bring you here, as much as i would like to. as such, much of the perspective gained is mine, and i might only realize it for a split second as abyei disappears into the horizon of my memory.

  part of the secret to being here is to think not of the future, nor the past, but to imagine the day only as it folds into the next. every thought that starts about my vacation, or how much i miss careening around toronto streets on my bicycle, i let out what little air my happiness holds, like a balloon.

  but, if i could be anywhere else today, i would be in alberta. i would be driving down the country road to my home, the one i left more than a decade ago, the only one i have ever really had. i would pull into our driveway, and drive slowly up it, stones popping from beneath the tires. i would stop, shut the car off, and hear only smooth silence. i would open the door, then the trunk, grab my bags, unlatch the gate, and go inside.

  almost tough to type that, i can imagine it so clearly. and as clearly, the delight on my mother’s face. mine would be just as strong, but i have learned to hide it. it burns brightly, but under the surface. hers burns like a star. she is the most famous person in the world. trust me. if you met her, you would see it too.

  “WHY DO YOU PUNISH YOURSELF?” Marco asks me, a piece of bread in his hand.

  “What?”

  “The book. Why do you punish yourself?” He points at the thick copy of Ulysses that sits beside my morning coffee. Each morning when I don’t run, I pull it from the wall of my tukul and sit down to read five pages. After three months, I am a few hundred pages into the annotated edition. I left the SparkNotes in my tukul. I use it to read about what I just read.

  “No, it’s good. Well, okay, I can’t say I like it, but it’s worth it. It changes the way I think about thinking.”

  Marco shakes his head and disappears into his tukul, returns with a book. He sets it down on the plastic table.

  “This is better for you. If you are a writer.”

  I look at it. Paul Auster, The Invention of Solitude. Seems to fit.

  “I’ll take it, but I can’t start it. If I do, I won’t read this. I’m looking for an excuse to stop.”

  Marco shrugs and walks away towards the shower. It is Friday and our day off. Our cook’s too. Our day to starve. I tried to ration the almonds Sarah sent me from home by only taking a small handful in the morning. A small handful in the midmorning. One after lunch. Another just before dinner, and then one just after. They lasted three days.

  I push my chair back from the table, and it scratches in the sand. My coffee cup wobbles on the brown plastic table etched with scattered grooves. I grab it and look in its bottom. Coffee grounds. Cardamom.

  Why do they do that here? Cardamom. That’s an Indian spice. It comes in pods. I saw some in Zanzibar. I have that picture, the one with my guide with a red bindi dot on his head from the ink of a flower. I wonder if the spices began in Africa and were brought on the spice route, or vice versa. Probably vice versa. Why does food suck here so much? I don’t get it. Instead of just boiling a chicken, why doesn’t someone just chop it up and fry it with some onions and some cardamom? Must be a poverty thing. Either you don’t get the chance to sit around and come up with creative ways to cook, maybe risking a meal because the next one might be tough to come by, or it doesn’t matter that much, you just want food and it all tastes good. Could be a taste bud thing too. But Zanzibar had a wealth of spices. Wonder why they didn’t make it this far.

  I wonder what happened to that girl I met there, the one working for the UN. She was in Sudan, I think. Or Chad. She was cool. Oh shit. I sent her a poem. That’s right. Jesus. Why would I do that? So embarrassing. I didn’t even know her.

  I put the coffee cup down and turn my book over.

  The gazebo is completely different after we sawed those legs off that table. Now it looks like a coffee table. It’s funny how something so small can change the whole vibe. More comfortable. Those metal chairs are shit. I don’t understand why we don’t just throw them all away.

  I fish for my sandal with my right foot.

  What am I going to write about today? I should write something. What did I write about last? Mother’s Day. Sunday. Do they have Mother’s Day in Europe? I should have reminded Tim. I don’t remember him mentioning his mom. I think he has a family. I hate when you do that.

  I fish with my left.

  What the hell am I going to eat today? I hope someone else makes something. I haven’t cooked once since I have been here. I wonder why. I don’t even care about it. Oh, I made some eggs. A while ago? Bev was here. We made them together. I cracked one, and its yolk fell out pink. The next one too. Then the third. I cooked the shit out of it anyway. How are you supposed to tell if an egg is bad? The yolk falls apart, I think. These ones smelled like metal.

  I’ll work out after breakfast.

  I’ll work out, then I’ll write and then … I’ll clean my tukul. Maybe I’ll go to GOAL and check my email.

  I walk to the kitchen.

  I can’t believe those bags of dirt are still there. They should just be a garden, then I can tell Grandpa I planted a garden. I should write about him. Like when I told him I was going to work in Cambodia, he didn’t say, “Don’t go, it’s too dangerous,” he said, “Don’t go. It’s too far.” That’s funny. Or how when he was a kid he would put on those skates, those double skates, and just after the lake froze and the ice was thin, skate around with an axe handle and try to stun muskrats through the ice as they swam underneath, bubbles in their whiskers, streamlined smoothing under the clear black ice, and then whack, a star of cracks. He would sell them for pocket money, for candy.

  Grandma’s brother is deaf from measles. I think she had a sister die of it. Maybe I can come to it that way.

  Wow. Our water tank is filthy. Everything is square. The clothes washing sink and that stupid metal table. Was that worth the fight? The cleaner hates me because I took it into my tukul without asking. It was MSF’s table. Whatever. Should just smash it.

  I wonder when the foundation of the new office is going to be finished. It looks like a mosquito farm. Can’t they clear the dirt away? It just makes mud. Last week with the hole in the kitchen. Dust was everywhere. Oh, look, someone stacked dirt to make a little ramp. The satellite antenna is crooked. Tim and I …

  I step into the kitchen. The guard has delivered our morning package of bread in newspaper, the pieces on the outside black from the ink.

  A piece of bread. I wonder if that ink is bad for you. Not as bad as cigarettes, so who cares. I wonder if there is some Nutella left. I wonder whose it is. Everyone eats it. Sarah sent me some. That’s a mess. Don’t think about that.

  What am I thinking about? A billion things at the same time. A billion blind pathways.

  Quiet.

  I open the lid of the freezer.

  An orange. One left. So what. I’ll get another later. Nutella. Sarah. No. Bread. Cigarette?
No. Yes. After lunch. See if it tastes good. Maybe I’ll stop.

  I take the Nutella from the rack at the top of the freezer, grab the orange with my other hand, let the freezer door slam shut.

  Ants in the sugar. Shake them out. Wonder if their brains live on glucose like ours. Probably.

  I unscrew the Nutella jar, and take a spoon from our cutlery can. Beside it is a sink full of dishes, dashes of blue wash powder by its edges.

  They use that powder for clothes. I wonder if it’s safe to eat. So slippery. I should do the dishes. Corrugated metal roof. Hot in here. No breeze. Plastic over the windows. Tear a corner open.

  I pick up the jar of Nutella, the spoon, the orange, and sandwich a bottle of water under my arm.

  Why do I always need to make one trip? I wonder what that means about me. Something. Beer bottles with candle wax on them. We’re supposed to take those back. Should we? We said we would. I wonder what they do with them.

  I step out of the kitchen and onto the flat ground. The compound is quiet.

  Where is everyone? Plants. Wish the generator was off. What am I supposed to do? Cigarette. No. Write something. Shoulda washed my hands.

  I walk back to my plastic table, set my food and water down. The orange rolls off the crooked table and lands lightly in the sand.

  I pick it back up, blow it off, and start to peel it. I turn Ulysses back over and notice that its binding glue has melted from the heat and pages are coming loose from the spine. I tug at one and a section fifty pages deep slides free.

  With satisfaction, I stand up and walk the thick book over to the garbage can and drop it in. I return to the table, peel a section of orange, tilt back my chair, and look up at the sky.

  14/05: half.

  at this point in the story, the character’s eyes are closed nearly all the time. despite the fatigue, sleep eludes him. he is replaced with a half-ness, a part of him awake, part of him not. at night he sleeps in fits. he approaches dreams, but never arrives.

  this morning, while walking to work, at the corner, the one with the half-buried tire, the character saw a mini cyclone pick itself up off the road. it whirled dervishly in widening ellipses, then blew itself into a closed green door, opening it. his eyes met those of the man seated behind it who calmly stood from his chair and closed it again, as if cyclones came knocking all of the time. the character thought to himself, who needs dreams when days are so extraordinary?

  i am more than halfway through my mission, and am overdue for a break. though my time in ethiopia was more about tuberculosis than rest, it did allow me to step away from abyei. so i delayed a vacation partly because i wanted a true experience, to spend my full time in the field, to arrive at all the important points in the mission so that i could better understand them. i have discovered that fatigue, however, is like the personal experience of illness. though being sick is valuable, particularly as a physician, because it increases one’s empathy, only a fool would court it. so too exhaustion.

  but, here it is. a halfness. i remember talking with friends about how i could manage to work, during my residency, 30 sleepless hours in the hospital, leave it to sleep, then return. i explained that the last thing to go was my capacity to perform medical duties. i could sort out a high potassium at five in the morning. what i lost was my ability to offer the patient something beyond the task. i would walk in, inject the proper drugs in the correct amounts into their iv, mumble something neither of us understood, then stumble out to do something else.

  the tiredness i feel now is different. it has been a slow erosion. bits of sand have ground me down. i can still recognize the best things in the day, but am just not able to participate in them fully. half.

  some members of my team have suggested that i not take call, that we have enough staff to make it possible. i have thought about it, but i think i would miss it. often, it makes up the best part of my day. i get to meet someone, someone new, listen to their story and feel their anxiety. i get to touch their child’s forehead, then quietly listen to his heart. and sometimes, i get to put my hand on the father’s shoulder, tell him that everything is going to be all right, and i get to feel the coolness of his relief.

  one of my friends told me that once, when she was having a personally difficult time (someone in her family was sick and her relationship was crumbling), she poured herself into her general practice. the more she worked, the more patients would stop on the street and say “hello, doctor soandso,” the more they would send flowers. not only was she caring, she was being cared for. of course, in the end, this was not an equitable relationship, not the true contact someone needs to feed their bruised spirit, and after several months, she burned out.

  i will not, though i can feel the heat. i can understand it better. i am due for a break in 16 days. i started counting yesterday.

  MOHAMED AND I ARE sitting beside Aweil, watching her play. The woman who has unofficially adopted her, a relative of a child who was in the feeding center, sits close by wearing a new necklace. We have been paying Rebecca to stay in the hospital with Aweil and she seems to be spending the money wisely. I have never seen her drunk and Aweil is wearing a new red polka-dot dress. It is likely she has some children at home, and is using some of the money for them. I don’t care. Marco has agreed to continue the arrangement for now, and each time I suggest to Rebecca that Aweil could probably continue TB treatment at home, she says her home is too far away. I never press.

  We have sent word about Aweil to the military area where we last knew her father to be. So far, we have not seen him. Our discussions about her care have been exclusively with this woman, and we are reluctant to complicate things any further. Mohamed and I are in no hurry to take her from our daily routine.

  To our other side is a mother with her starving child lolling in her lap, his eyes half open, hands taped over so he cannot pull at the feeding tube in his nose. He probably couldn’t manage the strength anyway. Today he hasn’t been able to muster anything but a thin cry.

  His story is typical. Already malnourished, his mouth last in line for whatever small amount of food the family could afford, he got diarrhea. What little energy he had left, to tug at his mother’s skirt, to cry from hunger, to hold his head up to be fed, was washed away.

  Her child mewling and taped, tubes in his nose and his arm, the mother sits embarrassed. I’m not sure if it is because it marks the tenuousness with which her family is hanging on, ten hands scrabbling to find purchase, or if it makes evident her necessary neglect of this child in favor of the others. I wish I could talk to her, I wish Alfred’s English was better. When I walk past and she looks at the ground, I could say, “I know what you were trying to do. I do. You were trying to save as many as you could.”

  We can’t know how many children die in the mud tukuls because the family cannot afford to bring them to the hospital. The only thing we know is how difficult it is to get them better once they do. Diarrhea is a killer. It runs children dry. The work it takes to keep their machinery turning with the desert outside and the one inside becomes too much. They creak to a stop.

  I don’t have the necessary investigations to determine what the terminal cascade of events is. Could be a problem with potassium. They lose it in their diarrhea, become hypokalemic. Or their kidneys fail from having to work so hard with such little fluid. Could be acidosis, the pH of their blood so low that the proteins in it unfold, their cargo bobbing uselessly a million cells away from where it is needed. Could be all three. Or none.

  Aweil shakes a rattle of beads at me. I try to take it, but she won’t let go. She grins.

  On rounds earlier today, I pulled down the boy’s lower lid. It was white from anemia. I remembered talking with someone in Ethiopia (a month ago, two?) about how many malnourished children they saved with transfusions. Today we are trying it.

  The mother agreed to donate. Ismael drew some blood from her this morning, and we are trying to drip it into a small vein in the back of her son’s hand. We are runnin
g it slowly. If we give the blood too quickly, it can overwhelm his homeostatic system, the extra volume filtering into his lungs.

  I hand Aweil to Mohamed, stand up, and dust off my scrubs. I take the small bell on my stethoscope and put it on the boy’s chest. His mother stares. I feel the taptaptap of his heart before I hear it. It’s the size of a cherry. I listen to his lungs. Clear.

  I unwrap the cool towel that we have wrapped around the blood bag and look at the drip set hanging below it. A thick clot hangs from the filter.

  This is the second time today we have tried this, the second time it has clotted. I went over the process with Ismael after the first failure, made sure he added the correct amount of anticoagulant. He did. I went back at lunch to try and find an answer in a book. Ismael did the same. We found none. Brian is gone. We’re unlikely to get a response from Geneva in time.

  Shit. Maybe the intravenous is too small. Or it’s too hot outside. Perhaps it affects the heparin. If we store it somewhere too warm …

  The boy’s breathing is getting faster. I’ve seen it this way a dozen times by now. If you do something as simple as put in an IV, worse an intraosseous, sometimes if you even turn the kid over to wipe at the diarrhea, they spiral. They cry, and that withdrawal of energy, from the pain and the distress, puts them into debt and they die.

  I stop the IV. The mother looks up at me.

  “Mohamed, can you tell her that the blood is too thick, that it won’t flow?”

  While he is translating to her, I go to the front to find a nurse. I find one hunched over the desk trying to read our orders, then drawing up medicines into unlabeled syringes that litter the desk.