I miss our monthly staff meeting because I am in the field visiting two sick patients that I am worried cannot wait. When I return to the office, I am greeted by a smiling Marielle. Marielle is a brilliant and experienced French nurse and as she has spent twenty years working in England, including for the Health Protection Agency, we are tuned-into each other’s sense of humour. ‘Looks like we’ll be together in Shumanay,’ she blurts out, ‘they announced it in the staff meeting!’
So, my fate is sealed: I am opening Shumanay.
Up until now, my position in the Karakpakstan project has been as the doctor in the Khodjeily district. I took the baton in the short run-up to our handing Khodjeily back over to the Karakalpakstan Ministry of Health (MoH). Already by the time of my arrival, things were running pretty impressively in Khodjeily, and at times I have felt frustrated that there has not been a great deal for me to do. All of the hard-graft had already been done by my predecessors: doctors Jan (from what I can ascertain, some kind of Canadian medical God) and Johanna (an organisational guru). So, by the time I arrived in Khodjeily there was little left for me to do. No heroic lifesaving. No stamping my mark. No making a gigantic difference to rapturous applause. Great for the programme. Great for the patients. Khodjeily is a real success story. But for me, working in Khodjeily has always felt akin to sleeping with someone else’s husband.
In the car, in between clinics, I tell my translator Murat of my frustrations. He replies by quoting Abraham Lincoln: ‘Give me six hours to chop down a tree and I will spend the first four sharpening the axe.’ I am increasingly coming to view Murat as a Mr Miyagi or Yoda figure in my life. And so during the day I undertake my supervision duties in Khodjeily and in the evenings I pour over the TB literature, learning and preparing as much as I can. I sharpen my axe.
And now my time has come: I am handing-over Khodjeily and opening the district geographically beyond. Shumanay is virtually uncharted territory for us: I believe MSF last ventured there in 2003. How many cases of TB will there be? How many will be drug-resistant? What is the state of TB-care in Shumanay? I am granted an MSF dream team for the job: joining Marielle and I will be our national nurse, Sarbinaz, and counsellor, Koral, both of whom are industrious, kind and capable. We will be starting from scratch. Shumanay will be our baby.
We travel the hour and a half to Shumanay for the first time and survey the environment. It is similar to the rest of Karakalpakstan – flat, barren and parched plains without undulation as far as the eye can see, small shack houses and Lada cars kept just about road-worthy since Soviet days. But it’s even more remote, rural and sparsely populated than I have previously experienced. I can practically hear the untreated mycobacteria TB bacilli singing to me from the houses. This is a fine land.
My pocket vibrates as my phone receives a text: ‘Welcome to Turkmenistan, roaming charges apply…’ We are right on the border.
Marielle catches me grinning and laughs at me. I tell her I love Shumanay and that when I get home after my mission I’m going to buy a kitten and call it Shumanay. “Lets talk again in a month and see if you still love it,” she chortles and then does an impression of an exasperated me, pulling out my hair, screaming ‘I hate Shumanay!!’ But I don’t hate Shumanay, I already know that I heart Shumanay.
I meet for the first time one of the three MoH TB doctors in the region, Tileubergen. He has olive-green eyes, a striking contrast to his handsome dark Uzbek features, and he smiles a lot. He is the Karakalpak George Clooney. He takes me to see a few patients he is worried about. One patient tells me in the local language, via Murat, that he is on 25mg of amitriptyline for depression. “That is a pretty old-fashioned drug and too low a dose,” I comment to Murat. “I know,” says Tileubergen, ‘but we do not have mirtazapine available locally and that is the dose the psychiatrist wanted to start. I know it is too low.’ Bingo! My MoH doctor speaks some English AND he knows the correct dose of amitriptyline. I told you Shumanay was a great place.
I take Murat and Tileubergen for lunch at a café and we wolf-down dishes of hamburger patties with runny fried eggs on top (I pray to the God of salmonella to let this one slide, given the momentous nature of this occasion), all washed down with lemon-tea. Then, pen in hand, before I’ve even swallowed my last mouthful, I start to grill Tileubergen about the current TB resources in Shumanay. I ask Tileubergen how he feels about MSF entering his district. He replies: “we have been waiting for this time to come.”
Over the following days, my MSF colleagues and I perform our assessments to evaluate exactly what state Shumanay is in so we can start rolling out comprehensive TB care. There are no second line drugs, no proper DOTS corners, no infection control, no staff training on treating drug-resistant TB, no capacity to culture sputum or perform drug-sensitivity testing. The radiological provision for the entire district is one portable X-ray machine in a room less sturdy than a shed. They have an inpatient ward brimming with cases and over 300 ‘chronic’ TB patients in the community they cannot cure, presumably because they are infected with drug-resistant strains. Staff have been rationing a handful of respiratory masks between them, reusing them over months. Where to start? It’s a mammoth task. It’s huge. This will have me working round the clock… I am itching to go. My colleagues tease me for my enthusiasm and start addressing emails to me with ‘Dear ShuEmily…’
I Skype with my partner, Pete. He tells me he found a song called ‘Pompeii’ by a band called Bastille that he has taken to listening to, because its lyrics sum up his predicament since I left him for my MSF mission: ‘How am I going to be an optimist about this?’ And in many respects the line sums up how I cannot help but feel on so many occasions about our plight against MDR-TB. The problem is just so vast, so complicated, so without obvious solutions. The TB epidemic here is out-of-control, we have hopeless drugs, insufficient global regard for our cause and the threat that our work will collapse as soon as we try to leave. How on earth am I going to be an optimist about this? But for now I have Shumanay, my new cause, a new hope. And I heart Shumanay.