A South African Doctor in Darfur

8 patients who were admitted to our dispensary this month of February died. We admitted more than a hundred and did more than 5000 consultations . approx 20 died in the town, and I have no idea how many have died in the greater Serif Umra locality. So you must wonder why do I spend so much of my time writing about so few deaths and not about the countless we save. Morbid fascination, depressing bouts, enthralled with the bleak, dark curiosity with downfall, powerful insult to a vulnerable ego, compassionate condolence? Not sure, but it penetrates deeper than revelling gratification from saving lives.

Until…… the wizened look on a marasmic infant consuming every simple thing in sight as a few designed meals beef him up;  that when he smiles and uses his teeny weeny fingers to grip your finger with all might summoned, it imprints his memory into mine forever, ever.

5 dead on arrival. All littered with gunshots. Examining a cold, hard cheerless body leaves you cold, hard and cheerless. 4 of the men shot were relatives to our guards. Abaker, one of the guards, is big man. In many ways. he is towering figure with a deep ravenous voice that keeps u awake when he is on duty at the expat house. He has equally deep dimples that liquefies all malevolence. He is a big guy. Today he shrunk. I think it might have been the first time I have witnessed someone wilt when their loved one has died. Maybe because he lost 3 in one shot so to speak. Usually I get to observe families members when we come bearing bad news and overarching grief strikes most in the form of shock and disbelief and then a deluge.

I have never visibly seen someone wither down as he did the night he came to identify the body of the now immeasurable loved ones he has lost since the conflict began.  I have little to offer in times like this. For another gentleman I break all taboos and stroke him tenderly to commiserate. I felt so charged to sympathise, that when I saw some men outside the morgue sitting, I went over to… you know just try to say something. Nothing came out of my mouth of course.

I noticed the men were sewing together pieces of material for the burial rites, using the edge of the material as thread, making gloves for the body. Now you must be let in on a secret, a man sewing (and daddy caretakers), turn me to mush. More so in a dense patriarchal society as this one. All I mustered was ”moomkin?” meaning possible?  Pointing to the carpet asking permission for lady doctor to sit beside them. Solemn nods of approval. I watched and dropped my head each time someone came over to greet preparations were halted and the offering of their palms up to the heavens in prayer. Every 30 odd times. In a raw second, I catch the eye of the gentleman I hugged earlier. His eyes caught mine and I think he’s saying with a sense of stoical forgottenness he feels the world owes him nothing, nobody is watching and none of his pleas to bring back his relative is heard. I’m sure when we lose a loved one all we want is to replace and restore. I think all I have to offer him is the hope that owing and watching each other is a priceless surrogate.

Where does this brave reservoir of mine reside? It reveals itself like a seductive dream you can’t help feel like you remember when you awake. The dream you are sure of just between the aphasic phase and denial phase of the new day that awaits you beyond the bulky blanket. Sometimes though, I have the swaddle resembling an elephant with a toothache in need of a root canal. The life in the desert immediately anaesthetises me and I’m then left juggling the numbness and inflammation. The harsh environment provokes emotional masturbation. Inescapable. On reflection this is par for the course – this initiation and rite of passage in Sudan, I had it in South Sudan and now North Sudan seems to hold no special mystery otherwise in this respect. In other ways it is incredibly special. Here you will walk the ambidextrous path leading you to all the philosophical quandaries. You think you heading for the Nile instead you feel you are just in the middle of nowhere. But nowhere is somewhere for someone!

Last night a woman with a previous caesarean section and prolonged labour kept me awake till she delivered at 6am. Why do they always come in the middle of the night? The call to maternity during the wee hours of the night takes me back to those days of protracted humiliation as a medical student, and those ghastly days of community service, and that shows me up again. For one, obstetrics always gets my knickers in a twist, I can’t seem to act quick enough, I panic deep down and (as usual) in the end you do just fine. But it makes me feel completely inadequate because you always feel like the life and death issue so much more urgent here. And it beats hands down the purity of fighting the social injustice when you do paediatrics. So after my doctor skills get called into action and question at 2am, my focalising eyes are also evaluating the electricity and the carpentry work and my heads spins as I walk away during the full mooned night not just a stress ball of emotions but also notes to self for logistics and pharmacy and more and more and more and more and my heads spins so I don’t sleep.

I fall asleep when I get called again to the ward for 2 babies who just arrived, both facing their first 6 months of life. The odds were against these babies. One had a bulging fontanelle, fever and was having seizures. I put on the works with heart numbing speed trying to halt the ticking hand and left eye but it was just a brief sojourn. My heart fell. The caretakers of the other Baba’s sighed in unity. I refused to give up and eventually the seizures abated and I added the antibiotic and then rushed the other triaged with the poorest of prognoses. He, and I say this with a whimper in my voice, was gasping for something and air I suspect was not it. His gasp was his farewell words to his parents and his limp decrepit senile seen-it-all grandfather who had that look in his eyes, as he joins in the fight for his lineage that shows he himself has not yet plateaued.  This little one too had the signs of severe complicated meningitis clinically and so I threw all in my arsenal right at him, dextrose, anticonvulsant, antibiotic, steroid and some analgesia. Pain is a killer too. In his case it had something to do with him being born in the vast stretch between here and the next health centre. Both too far outta reach. We need to go to him I guess. His parents assure me they tried everything to get him here, but in Darfur I’m doubtful the Donkey going to get you more than water from the water pump or a head injury, and a car that drives by is probably not going to stop for anything other than that – a drive by shooting! Our referral car has been shot at, the roads are not safe and the number of viable vehicles is not available for ambulances, even makeshift ones implored for by parents of a dying infant. So meningitis rears its ugly head again.

In MSF, in the meningitis belt from Ethiopia to Senegal across 20 countries I find myself inhabiting, it is not the isolated disease you isolate as you would in a Danish hospital. No. Here you get the cases, you spring into action. 700,000 people have succumbed in the last 10 years to it. No time to waste then. You check your stocks of drugs, you make sure your staff know the protocol, make a plan to get specimens to the nearest laboratory 3 hours away by plane, you track the cases and you evaluate the cold chain for vaccines in case of outbreak. Cold chain… Ha! In the desert with no electricity, no open road to get gas… Ha Ha! Some life saving force makes me hold my tongue and not laugh out loud. I just get to work. I check my darling of a person with meningitis who takes five days to smile and something deep within me resonates that there is indeed something precious to hope for sometimes and its this that dissolves away all angst and muddy reasoning.

1kg baby born at our facility to a mom with an illness, which triggered the untimely arrival of simply nothing less than a fighter. She stayed alive for 10 days while I asked repeatedly the mom to hop upon the makeshift ambulance to the bigger health centre south of us and stayed alive while her mom refused to bop due to incalculable contingencies. Encumbrances, hardship, burdens, brutal realities ALL SORROWFUL WORDS. When premature her finally succumbed to the intraventricular haemorrhage she had an appointment with and I was present to witness her painful farewell, I ponder how I cannot feel responsible for not fighting more, for not plainly forcing her mom to go? How does she walk away bearing the blame and denouement, and how do I walk away bearing culpability? No sun shining. No moon out to play. Darkness drowns us. I don’t have the answer and I especially don’t like the question. However I’m the contestant in this quiz show and the prize is elusive.

I grieve for the little one. I lament for the future her lost. For the loss of her running her perfect fingers down someone’s thigh, for her walking with one sleeve rolled up, for her drinking coffee sneaking a smoke reading a newspaper, for her looking at her toes when she dances, for her laugh at her own jokes, for her chance to carry her niece or nephew on her back, for her loss to ever look intently into some man’s eyes as if he were her world, for her outlook at the world with smiley eyes, for her never sweeping a dust off a dust floor, for her loss to eat good food with her fingers. I grieve trying to see her try to pin the flavour of a good drink, to see her sing along to a tune only she knows, see her while she draws, see her while she makes minute little structures, see her at a typical Friday family lunch dish, see her when she smiles in her sleep, see her howl, see her try, see her dream, see her in the spotlight, see her just laugh, see her in her private universe, see her climb an apple tree, see her run for shelter in the rainy season, see her take pleasure in someone’s 47 flavours, see her mellow her mind, see her say goodbye, see her ask why, see her ache a little, see her in spring, see her sing about it, see her tap your feet and roll her fingers, to see her long to eat banana pancakes, see her cling to her dreams, see her behold a schoolboy, see her watch night fall, see her whistle. I crave to see her tired out, see her reach down for the sweet stuff, see her in side street howling Kawaga, see her higher than the moon, see her needed, see her needing someone, see her marvel at a set of rosary beads, see her review her future job description, see her try to escape the tsetse fly, see her forget to tell herself something, see her tell herself something, see her waste time, see her making coffee, see her listen to dogs barking at the break of dawn, see her go through a metal detector, see her plunge into a cool river. I miss her already. I pine to see her again, to see her believe in the future, see her kiss a daisy under a dust storm, see her go to doctor to heal her brokenness. I grieve for the passing of her chance to kiss, to be faithless, to be thoughtless, to be lucky as one can be, to dress up in a dress, ah to see her in a dress and headscarf when she 3 years old. I guess she will never be sad, never be too late, never get to fan a bee, sit on a bees knee, be the bees knees, she’ll never have someone see her when no one is there, never have a wedding day, never win the lottery, never scratch a itch, never ponder the marvel of non-smoking signs, never hem her socks, never play with tools like a fool, never touch with the finest gesture of tenderness you can find. She is not anymore. They say the blind and seeing are equal but I guess the live and the departed are not.

What’s new in Serif Umra? Not much except a bureaucratic hurdled permitless team confined to the daily trip between the dispensary and the eating dish for conversation. The dispensary holds its own. Yes, Darfur is in the news, not just of its neighbouring presence to Chad but to its historic presence in Chad. Chad is about 110 km to the West of us, thousands of refugees are fleeing at this very moment and here in SU, it’s the daily grind. We held more than 6000 consultations in the month of January and treated severe cases from a wide array of diseases. We tried to have the insight to treat first and refer when necessary. We are now trying to analyse where these beneficiaries of our service come from so we can go to them. We ought to go to the hardship and not expect them to endure any more.

Responsibility has been on my mind a lot recently, called into question often, when I feel like fighting all the time to the end for the life that belongs. One of the essences we sometimes meet in primary health care is the responsibility of the individual to take care of himself: eat right, exercise, be diligent. What is the responsibility of the parent and mine then in the case I encountered this week?

Petite pineapple of 12 months came in with a sudden onset history of severe difficulty to breathe. Began the night before. The mom is not sure if he had inadvertently inhaled some pip or pop. He was well before. No cough fever etc. She took him in the morning to the traditional healer who duly amputated his uvula (that little dangly tongue-like thing at the back of your throat). Uvelectomy here is the norm. Trying to dissect this would take an anthropologist so I will shy away. She came to us directly afterward. When I trip upon him in the ward, because the alarm bells are out for service, I survey swiftly the blue babe-in-arms. Differential diagnosis is an emergency with an upper airway obstruction either due to acute epiglottis or foreign body inhalation. Now it’s about 6pm in the evening. Night time brings with it the threat of more than nightmares. But I think for this chubby there will be no limits. So radio call to the log to ask for the car for referral to the other MSF project. Some logistic glitches to overcome. Log team to the rescue and voila! Ready to go. Dilemma: the dad insists he needs to go with the mom and baby to Zalingei. We however have a policy of one caretaker per patient in the car. We inform him so but he refuses then to send the child. How to disentangle this one?

I instinctively say ok. Let him go and be done with it, I’m not spending any more wasted moments of this child’s chance of survival on a matter of rule. However the team engage in a discussion about responsibility of the parent here. If he says no, we cannot do more. He needs to accept that it is his responsibility ultimately and must accept it as such if his child dies. Alas, I voice my dissention at the decision thereafter he is duly informed again of the rule and if he not abiding….no go.

He abided. Case made. I lost and of course feel slighted. I more than feel slighted because this exact point is illustrated in dissecting my responsibility I bear for the death of another child with somewhat similar circumstance.

After I put the phone down to one of my sweet thang dearests…I felt naturally dull and displaced. So I went to find a moment’s breathe on my bed, in the dark, since the generator was not yet on, before I joined the rest at the dinner dish. My eyes fall upon a stick hanging on the wall beside the head of my bed. In a slowly evolving instant I realised the sweet, exquisitely kind though absurdly stable and unwavering field co who now by definition attains adored chum status and thus to be named and he goes by the one of Daniel, on our therapeutic walk through the market the day before bought the stick, which I had just assumed was for some log construction thing. But in fact it was him concealing his plans under a camouflage of mapping and actually constructing a lamp for me made from the organics fibre reed woven pot covers that I use to decorate my room and a hanging stick. Interestingly, the same cover was one I had placed silently in his room as a gift. Altruistically he returned it but redesigned to be a bedside lamp. A great deal of meticulous work was poured into it, a lot of sneaking behinds one’s back, drillings of holes etc. Of course in the head space I’m in, I didn’t notice it until 24 hours after it had been installed. So silly but it made me smile in the way that it makes you close your eyes. Of course all I needed in that one moment was to feel cared for especially after talking to my finest and it proved a fitting substitute.

This week is positive reinforcement week for the staff. That’s right. Instead of day-to-day, we decided to up the stakes. I don’t cheat when the stakes are high. I might bluff but no cheating. So as an alternative to the weekly medical meeting being about me niggling them about some or the other problem we decided to do something fun. We held a quiz show to introduce the new banderols that all caretakers of patients should wear to distinguish them. We split the group into 3 and then surprised them with a flurry of mixed medical and general knowledge questions to the ridiculous. What’s the new protocol for the treatment of meningitis? What’s the age of the new nurse? Name the 9 countries bordering Sudan? What’s heavier 500mls of dextrose or 500mls of plasma? Normal temperature? Who is the French president? What’s the major cause of maternal mortality? Etc. they responded with childish giggles and whispered guesses. I flirted between groups trying to instil a sense of importance and a sensation of wonder fused with wit. We crowned them with the banderols like princesses in a beauty pageant and then at the end gave the prizes of sugar coated Twinkies to the winners, one packet of Plumpy Nut to the runners up for a few extra micronutrients and a soap bar to the last to clean up their act. We all has fun. They even turned the tables by making the expats answer the question: when was the last MSF team on ground evacuated (15 July 2006 FYI). They shared their cookies and took their pride home to return the next day infused and soaked with novelty. What fun in Serif Umra!