A South African Doctor in Darfur

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!

Today, as I promised I would, I had a good day. I was disarmingly charming. I made some child come alive with the sweet cocktail of 50% dextrose for her hypoglycaemia and her parents thought I was a magician. Not a skilled doctor of course. So after we did what we needed to do for her, I decided to play a game we all know all too well. Called ‘telephone’, you whisper conspiratorially into an ear and sees what comes out the other end. Today I decided to explain to the nurse what the numbers on either side of an infusion bag of fluids meant. First, admittedly quite wicked on my part, by testing them endlessly to see who knew the answer. Then the playful part which meant they had to each pass on the info to the next shift and three shifts later, I would have the pleasure to check on my morning ward round what came out the other end, so to speak! Discover if the infusion numbers meant how much in the patient and how much left in the bag or if one of the exasperating Medical Assistants wore red women’s knickers.

Well well, no surprise there, the message was not passed on. Why am I not surprised? Silly optimism. Optimism is the fool. Naïve at best and harebrained at worst.

Today, Friday – the one precious day described candidly as weekend, I found in it a few extra hours of sleep under the progressively lighted night sky and stingily cold night, awaking to a considerate phone call from Khartoum and a good earnest discussion about some of the project concerns, then making the trip to the ‘mushtashfa’ to see ”hows evvverrything”. I’m greeted by the herds of visitors to patients and the sweet nurse who accompanied the gunshot victim yesterday to Zalingei. The nurse took my hand, led me the only 5cm of shade to be found, preparing to spare me the knock he was about to deliver. He died. The gunshot victim who exsanginuated out of his bleeding kidney died. He died. He died. He died. How can anyone feel inspired or thrilled when we surround ourselves by impracticalities. Death is an impracticality really. Which any dimwit would agree with, well except a deranged serial killer. I guess this posting is really trying to convey and grapple with the fatigue that creeps and resultant disillusionment that comes with expenditure of vast amounts of energy, but also how I’m trying to climb beyond it. I’m so tired of feeling tired that I want to end it now. I’m prone to the turbulent ruminations about everything, I know that. I know that also I’m a really cool chick. I know how to have fun, I know how to sneak into people’s spaces they stash for special ones, I know well how to cheat at card games and I can be intuitive and silly simultaneously. Today I decided to be faithful to all I am.So I cheated at cards and stroked my geriatric patients cheek when no one was looking.

When I returned to the expat house, I finally completed what I have been putting off for ages. Finishing the novel I’ve been reading for just too long a time. It’s written in the voice of a 55 year old man, who is ridiculously witty, intelligent, equally bewildered by life and insights are downright honest and admittedly doubtful. So in these strange circumstances of isolation, I’ve been enjoying the relationship that’s now so amplified, I felt at a wits end to let go of. I also transferred all things lost, by the way of many lives lost here in Darfur (the stories of 2004 from the staff are frightful) to the loss of my night time author companion. The loss strikes so hard when I close the book and think of the young man who died today that I weep. Both chapters closed. But after this outpouring, I open another book and look forward to another new-fangled spell. To conclude this long recitation: I feel like tomorrow I’ll be better. What I will do is make the medical meeting into an exercise of dissecting what we did right for this guy and what we can improve the next time someone comes in. Motivation comes when we feel inspired and if I don’t feel the kick and buzz, I can’t let that trickle down to the staff, they are in need of it as much as I am and they need it desperately.

For 14 minutes, uninterrupted, I stare at the sweet offering of a box. It has my name and the ultimate destination: Serif Umra. It’s from the far off land called Canada. Its contents offer less than its surprising unforeseen materialisation. A care package from an MSF ‘familial’ colleague. Pure joy seeps from the corners of my lips that slowly give away what I am actually not all hard to disguise: unimaginable happiness.In the lonely confines of the field, it’s terribly unfortunate that what can constitute to happiness is the manifestation that someone you left behind cares. Of course it’s also the chocolates and silly other small things compacted to make best. That’s what we try to rekindle, but never reach match is it? With e-mail, I mean. It’s not the same as handwritten postcard or the carefully crafted care package. The package holds for me the fascination for my own intensity with which I experience each moment, well for these 14 minutes of moments of pure stuffed exhilarating anticipation.

I experience the arrival of the offering with as much zeal as the disappointment that the staff have weak internal alarm bells for sick children as for the man with an accidental gunshot through his right kidney as for the piece of most perfectly barbequed camel meat. The feisty sometimes riotous brooding I have for this life’s imperfections makes all moments longer than they should be. It also makes the ever growing ulcer fed by copious amounts of chilli and cigarettes but on a respite from alcohol for 6 months, an impending threat to my greater wellbeing. The mind however is harder to erode than the fragile lining of the ceaseless call of the stomach. The mind’s nutrients come from resources you have hard to concoct as well as from the simple most easily available of nature’s offerings. So life in the field is not always the story about the kid we waited to feed until it was starving, or the providing the basics we consider essential to human dignity for those who have had to flee their lives in fear. It’s also about keeping sane and healthy ourselves to persevere. It’s about being inspired and thrilled and when these become scarce, to dig deep to find it.

Rashida, our Medical Assistant, an incredibly beautiful woman with some grace, arrived in 2005, with her husband (a soldier) who was posted in SU. He now lives in EL Fasher where he is studying to be a Medical assistant himself. She is markedly different from the locals by the sheer manner by which she is able to contend with her scarf. She is never having to tackle the challenge of wearing a 3 meter piece of material in a strange contorted swirl that means you have to keep your arm close to your chest wall to keep it from falling off. So striking Rashida remained here in Serif Umra with their five kids. The smallest one called Waly (Walydeen actually) who accompanies her to the dispensary daily as she has no one to look after him. The rest of the kids are in school but they are alone here, no family and it seems no friends. No one she can entrust with gorgeous apple cheeked Waly. Of course I can see why she would not let him out of her sight. He is just simply cute. He is also now a permanent fixture in the dispensary and ward rounds. He opens the gate when the pick up approaches and always shakes your hand with his snot soaked hand of his. His snotty nose impels me to make a passing mention that I’m doubtful the dispensary, itself soaked with as much disease you can find pretty much anywhere else, is the perfect playschool for him. Although for me it does. She agrees on both accounts and feels hard pressed to reiterate her loneliness and lack of a chaperone for him. So we think that a good alternative is that he waits with the guard or someone while we do the ward round.

Took about 6 minutes into the round when we heard his wails and I, not Rashida, gave in and ended doing the round with him wrapped around my non-existent hips. He snotty soaked lips kissed me at the end and gave me the two eye wink he’s been perfecting and I knew I was walking down the treacherous road of having my heart lacerated and unalterably tattooed.

The staff and I laugh together about my unrelenting search for yogurt. I’m always soliciting it. The local version in Serif Umra is extremely acidic and so I look to our neighbour in Birka Sera for their softer version and if I’m lucky I get the factory version from far away. However, trying to make a bid for it is not so easy. On one occasion I implored our driver to try and get some in Zalingei when he was done with the referral, he came back with box cream cheese. I asked the other driver to please take some of our local baklava to the other MSF project as a small gift, but instead he brought me the baklava from Zalingei. So apart from most gone astray in translation it begs for my Arabic to be finer tuned. Yogurt seems universal though. So does New Year’s Eve for that matter.

I always regarded New Year’s Eve with an inkling of suspicion. Christmas’s weak twin sister. So this year I thought that maybe the four expats could muster up a small party. In vain. I was called at 10pm and saw in the New Year in the dispensary debriding a gunshot wound on the sole of the foot of my midwife’s treasured son who made his way to town for a celebration. I also spent the night with the survivor of a gang rape… She too looking to welcome a New Year. She had to swallow her pride as well as the noxious cocktail of prevention – meant to deter an unwanted pregnancy, sexually transmitted disease and HIV. She came and that means something in a place we struggle to get women to present to us early, if at all. We need to understand it more closely, but usually women cannot come on their own; they have to report it and the family has to bring them and here they go to police first. Impediments galore. But when my staff cry at her story, unbearable circumstance – I wonder, are their hearts just a muscle that’s been well exercised for compassion? How close are they to it really? Whether they too know this moment long past… they are not young and nothing changes the past. Does the consoling hand sliding across the melancholy girl’s head mean anything? The hair on my neck stand to attention. How amazing is empathy. Is empathy enough? Is it worth anything? No dry eyes in this house this eve that beckons a New Year. The past behind, the future of little concern. I’m all for sadness. Now I’m beginning to be all for an off-license.

The gargantuan spectrum of disease makes me wonder how am I, a single doctor, to know about all the possible afflictions for a population of 135,000 that we serve, including the outlying areas, that is. How am I supposed to train our local medical assistant to recognise the myriad of maladies? Last week I had a 5-year-old boy presented to me with his left eye ball protruding from his skull and very, very ill. I referred him urgently and later found out that he had died from a tumour- Neuroblastoma. His adolescence lost.

This week I had a classic case of Acute Pulmonary Oedema (water in the lungs I guess makes good translation). It constitutes a Medical Emergency. I get the history from the 80-year-old Shahib’s son, do an examination and when he confirms my suspicion by coughing pink frothy sputum into the makeshift handkerchief, I spin into action as the diagnosis is now textbook. The medical assistants inform me the next day that they have never heard of pulmonary oedema or water in the lungs! Alas… how many other Shahibs got an antibiotic instead; at least now he had peed himself dry of all water that hunted gravity and can breathe again, and today even faked a smile for me – and at least our medical assistant can try to make a good diagnosis next time. Both cases clearly demonstrate that I only know some conditions, I read every day to learn more, but I will never know everything in medicine (probably its most attractive quality) and here we expect the these medical assistants, 50% of whom are Shahibs themselves, to save lives. Incredible that we do at all. Odds are against us constantly.

I think that the apparent security I mentioned earlier is a dangerous pretext to letting down your guard and then making a mistake. The reality I want to present and remind myself of, I guess, is that there are just too many guns about. For a while, before some incidents this week, we were walking around Serif Umra like it’s just downtown. The guy on his bicycle and his gun on his shoulder crosses paths with the 5 odd soldiers popping in for some smokes, there is a car parked with 10 odd armed forces–and nobody really flinches. Nothing out of the ordinary. What is noticed is a lot of new faces in the market. What is noticed is that SU is fast becoming a ‘rich’ town – camel market, gun market, crops and sugar market. So it is important for me to remember, I’m in Darfur. It’s not normal to see guns and not tingle. This is the reality here. With the odd gunshot we hear nightly, I feel like I’m witnessing the conflict, in the most subtle ‘non-alarming’ way. The thunder of gunshots starts to feel as if it’s nothing out of the ordinary. Weekly I have a gunshot victim in the ward; some minor, some major. The major gunshot to the head of the salt and peppered gentleman that I told you about remarkably missed his brain and this week he was discharged from our referral hospital. Somewhat intact. Unscathed enough to make it home to his family for a few more precious moments.

Oddly you’d think that being in Darfur with its potent conflict and our presence here, one could believe that things have merged, where everything is a part of something else, we are all part of the world where all seems fluid and seamless; but sometimes I feel the converse to be true for me. It’s as though I live in a small world that’s all our own here, one I share with the population and that we know of no one else, and no one knows of us. We go about our days. Instead of living in a linked world we just live all of life, all the time, in obscurity. Not the truth at all, is it? Not when there’s an imminent war 200km to the west of us on the Chad-Sudan border.

Even though we find comfort in thinking that our actions protect us here, I realised the way to the heart of the Darfurians is not treating their coughs and runs, or awaking at 3am to tend to the breathless newborn or breathless geriatric – both extremes of life, when air seems particularly vital. It’s certainly not from shoving numerous medical equipment down orifices to get fluids into the woman, who bled out from an unclamped umbilical cord after she delivered at home, 50km away from the nearest clinic, or getting out urine from the old man whose prostate is too hefty and has not passed any in 5 days. Nah! It’s by calling the old man ‘Shahib’. So simple. I called my dad ‘old man’ when I was growing up and over the years it’s been the term of affection I use for the few men who make my world. So when I enter the ward and find the adorable pudding of a geriatric with asthma who I have been trying, desperately, to have air again, and the first thing that comes to mind is ‘old man’, and when I cry out Shahib, everyone in eavesdropping distance smiles and laughs – amused as they lap it up like no other action of mine. No other action of mine has yet convinced them that I’m here and happy to be and that they are significant and valuable. When he eventually was meant to be discharged, he asked especially to see me to give me a hug. A hug for the locals from a man to woman is frowned upon so this meant something extraordinarily special, my nurse reminds me. I think he also knew that he had a long trip ahead to an area far outside Serif Umra and who knows when our paths will cross, who knows if he arrives, who knows if he gets to plan his day or brood about the woman he loved for years but never got his head screwed on straight about – the important stuff.