Farchana Nights

Much of the work that we do out here is focused on the final act: the prenatal exam, the psychotherapy session, the assessment, diagnosis and treatment of disease, supplements and monitoring for the malnourished. In a very real sense, the good people in Berlin and Amsterdam support the administrative Country Management Team (here in Abéché), who in turn support the logistics arms of the many projects all along along the eastern border of this godforsaken land. And they, in turn, support the medical people. Us nurses, doctors and midwives are left with the task of patient care, pure and simple. Food is on the table, pantries full, land-cruisers to transport, medical centers running triage, pharmacies stocked, electricity flowing, water delivered.

Organizing anything in Chad is no mean feat. This is a place where no opportunity for misunderstanding goes unexercised. Where negotiations often start with a stalemate or a threat and progress from there. Where everybody is needling and clawing for money and kickbacks. Where the security situation hangs over you like a thundercloud in the distance; you never know when it’s going to break.

I wrote a couple of weeks ago about the murder of Pascal Marlinge, the Head of Mission for Save the Children (StC). That day, all NGOs stopped providing non-essential services and retreated to the safety of their respective compounds. StC, understandably, never resumed. Within a week it was unofficially known that they would, again understandably, suspend all their activities and most likely leave the country. This left Breidjing Camp, with 30,000 refugees and 12,000 local IDP Chadians with no organization providing medical care. A vacuum.

This is the story of how MSF took over services and within two weeks, were up-and-running at full capacity.

People. Jochen, our mobile clinic nurse with many years of field experience, stepped up to the Project Coordinator position (PC). With a solid handle on both the medical and logistics side of things, he hit the ground running and hasn’t stopped since. Jean-Marc, the technical logistician also stopped on a dime and headed that way, as did almost all the national staff on the mobile clinic team. Ivan, our PC here in Farchana (but he basically likes to do everything, and would if given half the chance) got to planning. Since ground transport has been declared unsafe, Breidjing would need an airstrip. Ivan called up Karline (our Head of Mission in Abéché) and asked for authorization to build one. On the phone, at that moment, she said yes, and within two days 159 local workers had been hired and were on the job. Within six days the first flight landed and took off, notably bringing Ivan back to Farchana.

A full complement of staff were hired and given contracts. Stock rooms were inventoried and new medications and supplies ordered. Endless meetings with local authorities, and long conversations into the night about what to to the next day. It was, as Ivan calls it, “E-team mode,” which stands for Emergency-team. If there are locks on doors and you can’t find the keys, you cut the locks. You don’t think of overtime costs for national staff, you just work till the day ends (although notably none of the staff even asked for extra pay). Administrative authorization lagged behind implementation. Often. The lines of communication were open throughout, but decisions were made on the ground.

Notably absent from this story is the call for funding. In most organizations, it would take months of proposals and oversight to fund a project that effectively costs about a million Euros a year to run. It’s an onerous, paper-heavy task, leading to what could best be described as administrative fatigue. MSF, however, is independently funded. This means that beforehand they do not need to knock on government doors, UNHCR doors, or whomever, to ask for the means to provide health care. There is minimal lag. The airstrip, which incidentally had been “in the planning” for three years, and was built by Ivan et al. in five days, cost about 2000 euros. This is the cost of doing business out here. Health care for a population of 42,000 people for a whole year. Fantastically reasonable. In my view, administrative fatigue is rather low in this organization. Every cent is accounted for, of course, but money in MSF, at least from my vantage point, is not a “power-grab,” it’s just grease. My guess is that everyone over the age of six knows how rare this is. It likely would not escape the purview of an astute six-year-old, either.

I include the numbers because they interest me, and I figure others may want to know as well what things cost. Money is important.

This is a proud moment. (I was on vacation, so I feel justified in beaming without seeming the least bit self-congratulatory.) On the day that Pascal was killed, Ivan, Jochen and Edith (our logistics administrator) sat under the mango tree and spoke about what it meant for them to work out here. It hit them hard. But the conversation went from personal reflection to planning. What if StC left Chad? What would need to be done to keep primary health care services in Breidjing. It had to be MSF. Literally, nobody else could do it, given the administrative fatigue of other operations. They sat down with paper and pencil the next day and started mapping it out: a proposal to make it happen ASAP, for about two to three months, until a long-term solution could be found.

Group identification is a funny thing. I hear people all the time saying of their favourite football, hockey or basketball team that succeeds: “we won!” This is absurd. In the words of Chris Rock, a comedian, “no, six black guys, who would hate you if they knew you, won.” This is not absurd. But it does highlight the extent to which people ignore every register of class division and common sense to feel associated with something winsome. All of a sudden my friend who works in a bank, from a sheltered, privileged and rather sanitized petit-bourgeois childhood is character-identifying with Shaquille O’Neil. “We won!” Pointing out the absurdity does not mean it shouldn’t happen. Personally, I don’t care one way or the other, it’s mostly just amusing. But it does tell us something. That we want to be a part of something bigger than us, a community, a team, a movement that means something, that does something of which we can be proud. People buy products because some pretty face or talented athlete endorses them. And even the humanitarian world is on this: I see the faces and read the words of cinema- and rock-stars on the plight of those suffering oppression and its hardships all over the world. And why? I’m not arguing that it’s not pragmatic, but it’s strange, too.

I see many faces of MSF, but for me, this week, it is Jochen, Ivan, Edith, and Jean-Marc (three of whom, incidentally, are Canadian). They did not win a football match, nor have they been shortlisted for an oscar nomination. But they did work non-stop for two weeks to fill the vacuum, to enable the provision of emergency health services in a large refugee camp in Eastern Chad. No newspapers picked up the story, of course. Can you imagine what would happen in Montreal if medical services were stopped for two days? What about two weeks? It would topple governments. It would be a national state of emergency. Well, it’s an emergency here, too, but look who did something about it. My team.

The ground moves here.  It may look like a patch of dirt, rubble or cracked concrete, but it you crouch down and just wait a few seconds, it starts moving.  Tiny ants doing reconnaissance, larger ones lumbering through, smaller red insects that look like pin-point spiders everywhere. Long things with many legs, beetles, and others start to circle and weave along some hidden meshwork that is beyond the understanding of humans.  Or maybe it is just random, chaotic radiation, turbulence, Brownian motion.  Scurrying like white noise.  There are no straight lines in Africa.

I write “Africa” in the sense that most people that I have met use it here. Chadians will refer to themselves as Africans, as will Sudanese, Tanzanians, Kenyans, Congolese and so on.  It does not escape the Chadian pastoralist that he has a vastly different language and life-way than his neighbour in the next town, the village up, or over the lake yonder.  The word “Africa” resonates as a whole for the people who use it, and this is remarkable.  A few words of Arabic or Kiswahili, and millenia of trade, land rights, marriage arranging, brotherhood brokering, animal husbandry and herding, water-balancing.  These forces stretch a continent.

Shift ahead a few days.

A small place called Bwejuu.  South-East coast of Unguja, the main island of the Zanzibari archipelago, itself just off the coast of mainland Tanzania.  It was a seaside town, that forgot to close down, and moved at about that pace.  I’d arrived in the trough of low season, but met a few similarly wayward travellers nonetheless.  By day three I felt that if I was any more relaxed I’d slip into a coma.  Which was nice.  My mornings were spent snorkeling through the fringed coral reefs, and I awoke to the sound of small yellow birds that make small teardrop-shaped nests in the trees all around my bungalow.  Jeremiah, one of the Masai fellows working at the small guest house at which I stayed, asked me if he could take my motorcycle (250cc of Honda Baja glory) to the beach and ride it.  He had the energy and smile of a gleeful person, which struck me as a strange quality in someone carryone no fewer than three concealed blades under his flowing red garb.  As we went out to the beach, I realized that he had never ridden a bike.  But hell, neither had I until a week ago.  The problem came in trying to explain what a clutch is with twenty shared words!

Zanzibar is called The Spice Island, which is a misnomer. Sure, it may have once been the hub for trade in cardamom, lemongrass, nutmeg, chili and peppercorn, among others, but the food is of the blandest I’ve ever eaten.  Luckily this is well made up for, among many other things, by the spectacular views.  I had not bought a new camera by then, so I’ll just have to describe the scene.  Rough-hewn locally made tables on a white-sand beach.  Low-light candle in a corner.  The sun sets quickly and leaves a blotted underbelly of fiery reds and purples on the clouds.  It looked like hell upside down, and from a safe distance.  Lateen-rigged dhows are off in the distance, small wooden fishing boats that have a triangular shaped sail with a scythe-like curve that is masted close to the front of the sliver of a vessel.  Every image was charmed… that kind of a place.  I looked over to the right of me while I was sitting out there and saw about eight other people on the beach, seven of whom were taking photos.  This is a well photo-documented generation.  It struck me that it may be the case that more photos were taken of sunsets that one day than in all of the 19th century.

My days on the island were coming to an end, though, and I had to run back to the capital, Stone Town.  This is, incidentally, also not really a meaningful moniker.  I suspect that it would have been more accurately called Smelly & Cracked-Concrete Town, but alas, that did not track well with focus groups.  The point, though, is how it is that one finds their way around this island, back to the capital.

These were the directions: “Turn right at the T-junction, then left at the second round-about, past the big “Foma” detergent sign, and when you’re close to town, you’ll see an intersection that looks like a platypus… turn hard left there…” and so on.  I was becoming a bit frustrated… the lack of street signage makes it difficult to know where you are, and where you should be going.  Over the past week, with no real destination in mind, this had bothered me none.  I had my rented dirtbike, miles of road and beach, and, of course, throngs of people everywhere to ask directions along the way.  And this is when it struck me… that image.  The one that comes at 5am, wakes you up, and just sits there.  You know the type, no?

Back a few nights.

Imagine a hard flat surface like a book or open hand slapping forcefully against another surface, that of a placid body of water.  Scale is unimportant.  Look at the streams of water that are jetted out from the sides, shooting outwards but connected by small tendrils, some thick and goopy, others impossibly thin.  A viscous crown of molasses-like mesh, curving in all directions.  Like in networks of veins just under the skin or on a leaf.  Patterns on wind-swept desert sand.  The mesh of a sponge.  The petrified pith of trabecular bone.

This was the road back to stone-town, and the people were the network along which I would wind my way.

It started to rain, and I pulled over under the metal sheeting of a small hut where kids were selling fruit.  My clothes were soaked through, but it was warm enough to ward off the chill.  I bought a large papaya and ate the reddish-orange pulp while chatting with the kids in some broken pidgin of English and my ten Swahili words.  The boys were fascinated with the multitool leatherman that I had used, and took turns over the next two hours passing it among them opening and closing every knife and screwdriver.  Despite the rains, lots of bikes, motorized and not, whizzed by.  I waited for the rain to stop, pointed in one direction and said “Stone Town?”  To which the boys smiled and nodded yes, trying to curve their hands to the left, which was what I had to go on.  There are no straight lines in Africa.  But with a belly-full of papaya and the hot sun drying your clothes, this seems less important.

The day that I left Chad a text message arrived an hour before hopping on a plane for my holidays (I write this from idyllic-but-obviously-not-too-distant Stone town, Zanzibar). The text message said that a fellow named Pascal Marlinge, the Head of Mission for an NGO (Save the Children, UK branch) had been shot and killed in a car heist a short drive from Farchana.

http://news.bbc.co.uk/2/hi/africa/7378304.stm

http://www.reliefweb.int/rw/rwb.nsf/db900sid/ASIN-7E8QNG?OpenDocument&rc=1&cc=tcd 

It left me sad and a bit numb; I write this with heavy hands.  I found myself trying to make sense of it. How could this have happened? And, inevitably, why did this happen? Why would someone shoot a clearly unarmed person exiting a clearly marked humanitarian vehicle with his hands in the air? And this is where my mind has gone while sitting in airport terminals, eating street food in the grungy Escape-from-New-York backdrop of Dar es Salaam’s Kariakoo district, and watching the waves foam up on shore.

The word that I keep coming back to is "power." Several years back, one of my mentors in psychiatry casually said "there is only one type of power." I am not sure if he’s right, but he’s the type of person that you listen to, and figure out how they came to that conclusion, even if you’ll disagree with it eventually. Over the years I’ve muddled around with the question of what it would be, this one power, if there was just the one. And what I’ve come up with is this: power is the ability for one entity to set the viability conditions for another. That is, one entity can effect a gross difference in the capacities, choices, and mortality of another entity. For humans, this would include, for example, a parent or state feeding their young so that their bodies can grow and learn; teach skills leading to more vocational choices; or the provision of basic health care so that a premature death doesn’t cut this potential all to shreds.

It is also, notably, the power at the end of a rifle, an apron string (families excommunicating members), an emotional outlash.  Images of tyrants always come to mind whaen I think of "powerful" people. Mussolini, Mugabe, Stalin, Pol Pot, Mao Zedong, Nikolai Ceausescu, Saddam Hussein. Basically what these guys did was whatever the fuck they wanted, and nobody could say otherwise. They were, and are, barbarians. 

Lust, gluttony, avarice, sloth, wrath, envy, pride. These are the seven deadly sins, which may as well be a laundry-list of the manifest entailments of 20th century Western success. "Get rich or die trying." Envy was used in the sense of "malice" in the fourteenth century, as in "creating equality" be taking or destroying that which someone else had… the vulgur side of jealosy: hate someone for havng more or being more.

But this is here it gets complicated. I think that most of my cohort can rally against the despots, but what of the seven sins? It may be schlocky, but I think that TV is a sophisticated barometer of an ethos. While practicing up in the Canadian North, I had too much free time and a satellite connection, so I watched all seven seasons of The Sopranos. Hellava good show, and to my mind, there has not ever been a character as complicated as Tony Soprano. Somewhere along the way (maybe in the second season), I realized that this guy was a simmering psychopath (however pro-social). Enter "Dexter," another TV character, who is a blood-lusting psychopath who "uses his evil powers for good," killing "bad" psychopaths. Brilliant premise, but can you imagine the pilot being pitched twenty years ago? Not a chance. For 50 years, the bible of broadcasting was the Production code of motion pictures, and for 40 years or so up until the late 60s, it stated that:

"No picture shall be produced that will lower the moral standards of those who see it. Hence the sympathies of the audience should never be thrown to the side of crime, wrongdoing, evil or sin."

You couldn’t even watch someone pretending to be evil!  As if just the perishing thought could shift the balance to the dark side.  I remember being timorous in medical school when I asked patients if they had ever hade ideas of suicide or self-harm (a standard part of the psych exam, and for good reason). It was hard for me to ask the question, as I did not know what I’d do with the answe, or worse, that I’d throw their symathies to such an act.  It’s kind of absurd that someone’s going to say "wow, suicide, great idea! Never thought of it, but you’ve been a great help, doc." I needed to gain experience with the idea of suicide in the same way that I have needed, in Chad, to become more familiar with ideas of genocide, mass displacement, and wanton violence the likes of which I had only read about, but never seen.

But what do we do, then, when we character-identify with Tony Soprano in some way but are also revulsed at the mindlessness of actual wanton destruction and death? This is not a rhetorical question. We talk about it, and the dialogue makes it more real. There is no answer, of course, but exploring it carefully may lead to a better ability to balance the essential urges of war and peace that wage their quotidian battles in us. Maybe we’ll even gain a better understanding of what power means to us, and use some of those superpowers for good.  

So what, then, would be the luminescent side of power… how can we counterpose and salvage the beauty in wilful and benevolent expressions of it? It would then be the exercise of might in capacity-building, the prolonging of life and heightening of health, all in the service of preserving the right for people to choose what they want to do. If freedom is some waffly continental breakfast, options and choice are the sustenance that sticks to your ribs.

MSF came out with a position paper of sorts called "The Chantilly Document." It starts with a single line, before getting into two pages of text: 

"The overall purpose of MSF is to preserve life and alleviate suffering while protecting human dignity and seeking to restore the ability of people to make their own decisions."

In my opinion, Pascal was doing this. He was working away from his wife and two children, in an inhospitable place, quite likely for less pay, less stability, and higher job-related anxiety than he could have found elsewhere. Like so many people that I’ve met out here, they hold it together for some reason or another so that, in the long run, others will have more options. This character trait I call integrity, the exercise of which is strength.

It is apalling the abuses of power that I have seen in the past several months. The stories, the lives, the wounds physical and psychological. They track closely with the absence of wide, transparent, and consensus-driven means for accountability. With no accountability, it seems that power prevails over strength.

In the end, Tony Soprano got punted by his Shrink.  Strength prevailed after seven seasons:) I hope that Farchana does, too. We’re in our fifth year, now.  

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sorry, no pics.  My camera broke.  The fellow at the repair shop said "There is a lot of dust in here, where have you been?"  

    "Chad, four months."

    "oh." 

Note that none of the following pictures contain patients, and all parties have signed written consent to have their pictures included in this blog.  Of course, parents signed for les petits.

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Not sure what it was that helped me turn the corner, but after a couple of feverish nights and a loose string of, well, phlegmatic days, some energy returned!  Whether it was the anti-parasite medications, a few long walks under the mango trees, good days at work, or the regime of sun salutations, vitality creeped back in.  You need it here, too.  In the same way that it’s hard to remember the summer heat on your skin in the dead of winter, after a trudge through the dregs I’d lost sight of the joy in many little things out here.  So I thought that this is what I’d write on, or just show.  The things that you do that make this place fun…

My good friend Jerry sent me a few care-packages of junk food and sundry, which included a bag of ring-pops, some original star-trek cards (odd), bubble gum tape, pez, and nerds.  This is a picture of Patrice, eating nerds for the first time.

Jochen brought a slack-line from Swabia, and we’ve been practicing our tight-rope walking on weekends.  Seriously, you you make this up?

Make a Ouaddai-tini:  
1) Go to Eastern Chad, in the Ouaddai region of the Sahel
2) Find hooch (locally called “diable” or “demon”)
3) Mix it with home-made Hibiscus juice
        
Walk pretty much anywhere and get accosted by jovial screaming tots 

Play soccer with them

Kidnap a wee malnourished goat, nurse it back to health for a couple of days, and set it back out with it’s kin.  Be told by one of your staff to never touch local animals because the rules of Chadian ownership of animals is “more complicated than sex between ducks.”  Look confused.

Relearn the extent to which necessity is the mother of invention

Read while listening to Ivan playing guitar under the mango trees

Say hello in the morning to Fatima, a worker at the Nutritional Center, and her twins, Safi, and Safia

Say hello to Habib and Hamra, some of our MHS staff

 Wonder after unfortunate abbreviations

Say hello to the theatre group.  This week they presented a little ditty on “family planning.”  Later I learn that Zakariah has three wives and 19 children.  He looked disappointed when he learned that I had none of neither.  You either laugh or cry.

Uh, hello-moto?

Walk through the camp and happenstance upon a volleyball game.  Be given a prized seat and asked if you want to help officiate.  Politely decline.

Hang out with Bienfait in the Health Center.

Eat some lunch with the boys

Greet the new sheriff in town

Keep on providing good health care for free

Wipe dust off your computer screen when you post blog entries