“I can appreciate that. But that’s our kitchen knife. It’s our only one. It’s already so goddamn dull. I’ll help you find something else.”
I take it out of his hand and feel instantly like an ass. Him chastened and me sorry, we walk to the logistics tukul to find a utility knife. I leave him there.
Tim is sitting, eating an orange. I set the knife down on the table.
“I’m a dick.”
Tensions are high everywhere right now. We rarely eat together. Paola has retreated into her tukul, and if she’s not there, or at the hospital, she is at the World Food Programme compound visiting her boyfriended friend. During the day, Jean is working hard to push forward a planned borehole. At night, he visits a friend of his who works for the UN. On top of her role as field coordinator, Bev has assumed that of vaccination campaign coordinator. I catch glimpses of her barreling past me in a Land Cruiser a couple times a day, cigarette in her hand, handset to her mouth.
I am at the hospital, mostly, and when I’m not, I’m trying to sort out the TB register, or make sense of the statistics. If the hospital is quiet, every couple of days I will sit in my tukul and write. The gazebo is full of bullhorns and maps.
The hospital is crazy. I think even more than usual. To this point it has been a controlled, smoldering chaos, full of unmet needs and slow revolts by patients and staff. As more people arrive at Abyei, as more people come through our doors, as the word spreads farther, the busier we become.
I was on my way home yesterday, hoping that there would be some food left. I had spent my lunch hour talking with the man who had brought the orphaned girl Aweil to us. He had intended to leave several days ago, to start school, but each day I try to persuade him to stay until she gets better. I found him that morning, his books bundled with a leather belt under her bed. She was still febrile, not eating. I convinced him to stay at least one more night. I was just turning right at the cannon.
“Dr. James for hospital.”
Come on.
“Hospital, go ahead.”
“Move channel 6.”
“Moving. Channel 6.”
“Dr. James, we need you at hospital.”
“Why?”
“…”
“Hospital?”
“Dr. James, please come to hospital.”
“Affirmative. Over and out.”
Halfway home, I turned back. Outside the gates were two Ministry of Health vehicles.
The Abyei hospital is, officially, a Ministry of Health hospital. Though an MSF France section worked in Abyei during the war, it left as fighting slowed. This mission opened last year with the dual purpose of treating a growing number of returnees and watching for war. When we arrived, the hospital was so overwhelmed that there were dead people in the rooms. The few people who were working in the hospital couldn’t keep track of who was alive. We signed a memorandum of understanding with the Ministry of Health. We would share their space and provide what resources we could to make the hospital function. We provided drugs, equipment, staff. We sourced a generator. We planned a borehole.
There were unavoidable problems. Some of the staff are MOH: a percentage of the nurses, all the cleaners. Their salaries, when they are paid, are lower than MSF’s, so we decided to top them up. Though we pay them, we cannot discipline them. They are not our employees. If they miss work for a month, all we can do is withhold their incentive.
There is a skeleton administration, a director, a vaccination officer, and a hospital administrator. They each have their own offices in the hospital, but their salaries are as erratic as their colleagues’, and their power to effect change small. They have neither a phone nor the right numbers.
Our flag hangs outside the gates. The hospital, however, is deeded to the MOH. In whose name were we working? In countries like Sudan, the government relies on NGOs, and at times leans on them. If there is any ethical imperative for a central administration to assume some responsibility for the health of its people, it is tempered by our presence. The people are getting free care. Why hurry? The presence of a Ministry of Health, from the North or the South, becomes a political game.
As I passed the MOH cars, I wondered how the hospital was being played. I already knew that the vaccination officer was unhappy with our campaign. We had called in the emergency team, trained vaccinators, and organized the vaccines, all on our own. By doing so, we removed the chance for others to make money from the endeavor and receive what they considered their fair share.
The guard was inside the gate, feet up on his small plastic desk, fiddling with the thick rubber antenna of his handset. As usual, not a lot of guarding going on. A guard’s position is the lowest paid and least enviable. In a land of guns, we give them a walkie-talkie and then we rely on them to pass it to someone who can understand what we are saying. The other day I saw a group of guards underneath the tamarind tree looking at a blackboard easel with the alphabet written on it, practicing.
“So?” I asked him, shrugging.
He pointed lazily at a group of men walking towards the measles area. I ran to catch up to them.
“Wait a minute! Wait! Stop!”
They turned around.
“Have you guys all had measles?”
They had. I introduced myself. Together we walked through the measles area, row on row of infected children and adults, flat on plastic beds. Often, three or four children from the same household, at different stages of the illness, lay like puzzle pieces, their mothers fanning their fevers.
I explained to the MOH delegates how our team was out right now, north of Abyei, mobilizing the communities for the upcoming campaign. I told them that of all the patients so far, we have had only two deaths. Both under five, both showed up late, with a secondary infection.
“Are you sure of the diagnosis?” one of them asked.
I leaned over a small boy and pulled his shirt up.
“You can see the rash. Here, look from this angle. Little raised bumps, patches. After you see a few, you can spot it at twenty yards.”
They murmured their agreement. One of them wrote something down in his notepad.
“Do you mind if we take some blood from some of them? Just to confirm?” he asked.
“I … um … I guess you had better ask them.”
The patients, of course, would not refuse. I doubt they recognized their right to do so, the idea of autonomy in the face of authority as unfamiliar as everything else in the hospital.
I started to ask what had brought them to Abyei from Kadugli. A nurse grabbed me by the elbow.
“Dr. James. A woman in the emergency. Bleeding. Pregnant.”
I left the ministry officials beside the little boy’s bed and crossed the courtyard to the hospital. I stopped where the orange fence, used to separate the hospital from the measles area, had been loosened, stepped through, pulled it taut. A little girl, on the veranda, watched me.
“You didn’t see that,” I said.
In the emergency room were a woman and her husband. She had started bleeding that day.
“How long has she been pregnant? Is she cramping? Has she passed any tissue or clots?”
A nurse at my arm.
“Dr. James. Please come to the nursing room. A boy. Breathing problem.”
I left the woman and her husband, their answers still in their mouths, and walked to the nursing room. Breathing before bleeding.
The child, about four years old, could barely draw a breath. Every few seconds, the muscles in his ribs would flicker and his stomach would pulse. He was unconscious.
“Vital signs?” I asked.
None had been done.
“Okay. Heart rate, temperature, oxygen saturation, and check his blood sugar. All of those. Grab that mask. No, that one. The small one. Give it to me. And the bag. Watch. Hold it like this. Like this. Just so his chest moves. No. Too big. Small. Good.”
I hurried to the pharmacy and grabbed the oxygen concentrator. It was new, still in its box. I cut the
top off and pulled it out, foam beads spilling onto the floor. I removed the plastic, kicked the pharmacy door open with my foot, and wheeled it past a queue of admiring inpatients who had gathered to watch.
“Out out out. Everyone.” One of the nurses had taped an oxygen saturation monitor to the child’s finger. It read 70%. Should be closer to 100%. He had a fever. His sugar was okay.
I unwrapped the plastic from the concentrator and threw it on the ground. I found a pediatric mask and affixed it to the boy’s face. I turned the machine on.
The oxygen saturation crept from 70% to 90%. I looked down at his ribs. Flicker. Pause. Flicker. Pause. Pause. Pause.
His mother sat on the edge of the bed, looking from my face to the flashing numbers on the monitor.
The child couldn’t breathe on his own any more. His ribs and diaphragm were too tired. He needed a machine to do it. We didn’t have one. I removed the face mask.
“Michael, start bagging again. That mask. Yeah. Right. Like that. Perfect.”
I grabbed a handset off the nursing desk.
“Brian for Dr. James. Brian for Dr. James.”
“James, go ahead.”
“Brian, I’ve got a kid here who needs to be intubated or he’s going to die. Likely pneumonia. He’s got a fever. I just don’t know if I should do it. We have no ventilator. Over.”
He would be right there. Sweet.
I returned to the pharmacy and fumbled through its shelves in the dark, flashlight in my mouth. I still haven’t figured out where the light is.
What size of tube? Age over four, plus four … a 5. Suction … where is that? Here. Laryngoscope. What size blade? One miller, I guess.
By the time I got back, Brian was in the nursing room.
“Yeah, I agree with you. He’s not really breathing. How long has he been this way?”
“Mother says he was fine this morning, but I doubt that. He’s going to die any minute.”
He looked at the laryngoscope and tube in my hand.
“I say go for it. We’ll call a nurse from compound 2 and she can bag him.”
“For how long?”
“I don’t know. How long do you think he’ll need it?” he asked.
“He’s not going to turn around in an hour. Not if it’s pneumonia. It would have to be at least overnight. Maybe even longer.”
“Overnight, then.”
Brian called on the handset to compound 2 and asked for our best nurse. I sat down with the mother.
“Your baby’s not breathing very well. See? He’s only breathing small. Not good. We need to help him breathe. Put this tube down his throat to push in air. I think if we do not do it, he will die. Even if we do, he might die. I don’t know. It’s the only thing I can do.”
The nurse translated and the mother agreed.
I put the flat blade of the laryngoscope past his tiny white teeth and pushed his tongue to the side. I lifted the blade until I could see his vocal cords. They flickered with each breath. I pushed the tube past them, into his trachea, then attached the bag to it.
His oxygen saturation improved to 100%. His chest rose and fell with each small squeeze of the bag. I hoped the MOH delegates would walk by, but they never did.
Muriel arrived from compound 2. She’s young, was trained in Khartoum, and worked with MSF for years in Darfur. She is interested and competent, the best we have.
“Okay. Like this. Just a gentle push. Watch his chest. In … and out … in … and out. This is the suction machine. You work it with your foot, like this. You’ll need to suction him every hour or so.”
I addressed the other nurses. “This is a hard job. You will have to help her. You too, Mom. She can’t stop. If she does, the baby won’t be able to breathe and he will die. Okay?”
We left them, Muriel pushing on the bag, twelve times per minute, 720 times per hour.
I wonder, in cases like this, if the battle is worth fighting. The war is a long one, and the odds are stacked so heavily that perhaps energy is best conserved. Maybe it’s best to use likely defeats to increase our resolve to work towards a day when they will be easier to win. But then there is the other tack. Battle, every time, with everything you have. Do the best you can for the person in front of you. Persuade the family of every malnourished kid to get into the truck, to come to the hospital, to be fed until they’re better. Track down each TB patient who left, frustrated, halfway through his long treatment and try to get him to come back even though the countryside is littered with tuberculosis patients we will never see and one case will not tip the balance sheet noticeably towards a TB-free future. To the world it doesn’t matter that much. Until you remember that it means the world to the patient. One exact world, bright and full of sounds, per person. That’s what is lost.
I attended to the woman I left in the emergency room. She was miscarrying, but not hemorrhaging too much. If she continued to bleed, we would do a D&C on her tomorrow.
I checked on Aweil. She was sleeping on the floor beside another child. One of the mothers was watching them both.
In the nursing room, the boy’s saturation was still 100%. I went to the gate.
“Driver?” the guard asked.
“No, I’ll walk,” I said, and mimed legs with my fingers.
The night was thick, moonless. I made my way slowly back to the compound, trying not to trip into someone coming the other way. It was late by the time I arrived, and everyone was in their tukuls. There was some food left on the stove, and I ate a few spoonfuls standing over the sink. I crawled into my sweaty bed and called the hospital. The child was still alive, saturation 100%. I told the hospital to call me if anything changed, and left the handset crackling beside my head.
This morning, when I got to the hospital, Muriel was still pushing the bag. She had not taken a break all night. The mother was lying down on the bed, her hand resting on her child’s chest, feeling its rise and fall.
I relieved Muriel, and she stumbled from the nursing room towards the waiting Land Cruiser. I explained to the mother that we needed to take the tube out, to see if her child would breathe on his own. I suctioned his small mouth, removed the tape from around it and from the tube. I stopped bagging.
He was breathing. A little. More than a flicker, more than last night. I pulled the tube.
On my way home for lunch today, I got a call from the hospital. His breathing was getting worse.
“Put him on oxygen,” I said. We couldn’t intubate him again. We didn’t have the resources or the trained staff. Fifteen minutes later, they called again. He was dead. I sat down to lunch.
And now I am looking at this dull goddamn knife. Useless. Better for cutting boxes than tomatoes, that’s for sure.
I am not going to intubate anyone else.
08/03: bounce.
so far, at this point in the day, twelve noon, i am having my first day off. well, i went to the hospital, but only to check on a baby i admitted yesterday who was so dehydrated that you could see his fontanelle from 20 meters. he was sleeping soundly, his mother beside him. she has two oblique scars on either cheek. like this:
last night the “abyei jazz band” (and i use the already loose term “jazz” so loosely that one of the z’s just fell off) played all night at volumes that greatly exceeded my 32 dB-rated earplugs. one of the rewards i had hoped to find this far from somewhere was a night full of quiet stars. no.
it is day two of the measles vaccination campaign. we are hoping for some bounce from the undetermined electorate, particularly the hard to reach 5-year-olds.
passed some of the queues on my way to the hospital yesterday, families standing outside in the hot sun, voting measle. we had some late-night drama the night before with our newly trained local vaccinating team. they demanded more money. our field coordinator had played this game before. “those who want to leave can. we’ll pause the campaign, tell the community you don’t want to do it, and train others. no problem.” yesterday morning, they were all sweating with the p
atients, jabbing thin arms.
there are so many children, it is sure we are missing a few. yesterday i admitted only three for feeding. today might tell a different story. on the brighter side, we have the necessary y-shaped sticks.
i told the team, as far as i was concerned it was already a success. hundreds of kids will never, ever get measles. some of my enthusiasm is altruistic, but most of it is selfish. we need another 100 measles cases in the hospital like we need someone to crank up the heat. so whether it happens in an orderly way, people in rod-straight lines with smiles and sleeves rolled up, or if we have to run around in the middle of the market vaccinating everyone using some type of rapid-fire blow-dart scenario, it will be a success.
this morning, at 6:30, i woke up for a run. it is my only oblique entry in an otherwise linear day. my path is from the compound to the hospital. 460 paces to it in the morning, 480 on the return (so hot).
BRIAN HAS GONE BACK TO Khartoum. The measles team remains. Roberto, the Spanish coordinator of the measles effort, sits in the small recubra we built for him, typing out a growing catalog of measles patients. He eats only bread and jam, drinks mostly grape soda. A hummingbird.
I am just back from the hospital. For the moment, it is quiet. As my last order of business, I assessed a woman in labor. With my fingers I examined her cervix. She was 5 cm dilated. I struggled to feel the baby.
Oh. There it is. Tiny fingers. No, too short. Tiny toes. Yep. There’s the heel. Footling breech. Wait … that’s the head. Oh yeah, for sure. I can feel the sutures. Definitely not a bum.
So, one of two possibilities: some type of crazy somersaulting acrobatic compound presentation with the foot coming out just over the head, or there are two fetuses. I guess there is a third possibility. I can’t tell my heads from my asses. The unfortunate part is that neither delivery would be straightforward, and it is late, and we cannot drive to a hospital that could do a caesarean section at this time of night.
Brian told me that he did his first when he was in South Sudan, sweating over a book, his heart in his throat. I went through our surgical tools before I left today, and we have the right ones. As I locked the door, I imagined myself standing there, Mohamed beside me, sweating over a book, the woman flat on her back, her abdomen draped with the cleanest cloths we have, twins waiting to get out into the world, Mohamed showing me the book, then again, finally taking the scalpel and drawing it smoothly through the skin of her abdomen, blood quickly blooming into the yellow crevice, “suction … suction …” My heart’s in my throat.
Six Months in Sudan Page 8
