Six Months in Sudan

by Dr. James Maskalyk

  For now I am sitting in the gazebo, watching the sun fall into deep red sunset. Whenever I see the sun come up in Africa, or go down, I think the same thing: it is easy to believe that life began here. There is just so much of it. The spectrum of light that runs from red to violet, from long to short, is proof. As the day’s starting and finishing rays pass through the atmosphere tangentially, cutting across the dusty plains and the deep jungle instead of directly down, the smaller bluer rays are picked out by water vapor, or a piece of sand, or a tiny buzzing beetle. The reds and the oranges bend around, careening through. Each morning and each night, a collision of these, and a phoenix. When I run in the morning, thanks to the sand and the blinded buzzing beetles, I can look directly at the sun until it is well above the thick horizon. It is the most perfect circle.

  There are so many living things on this continent. Not just humans, of course. Insects, lizards, birds, bats, baboons, spiders (one in Paola’s tukul the size of a fist), big cats, loping giraffes, and with them a legion of viruses, parasites, bacteria.

  I look at my arm. Bites march over it, and over these a series of small pimples from the bacteria that cover my bed, my sheets, my tukul, me. Perhaps, like the rest of us, the new twins will get their start here. But maybe they are too new. In some ways it is easier to be a spider in this place than a new human trying to make it out with your brother’s foot in your face.

  Bev rounds the corner.

  “Hey, Bev.” I start cleaning up my plate.

  The last time I saw her was this afternoon. She sped up in the Land Cruiser, pulled me aside, and pointed at two young children in the back seat.

  “Two more measles cases, from Akur,” she said excitedly, and sped off.

  They weren’t. Just regular rashes. I sent them both home.

  “Hi.”

  She sits down, reaches for the ashtray in the middle of the table, pulls out a package of cigarettes. She takes one, then slides the open package towards me.

  “Thanks.”

  We smoke.

  “How are you doing?” I ask, finally.

  “All right.” She looks worn.

  “You’re not sleeping much.”

  “The measles team. It’s busy. First emergency mission for all of ’em. Fuckups all around.”

  “How’s the coverage so far?”

  “Can’t really tell. We don’t really know how many people there are around here. All we have is GOAL’s data, and I don’t know if it’s any good.”

  The handset crackles on the table between us. We both look at it. It remains quiet.

  “Hey, I wanted to ask you something,” I say.

  “Shoot.”

  “Um … have you ever heard of … This is going to sound kind of weird, but … uh … Ever heard of someone adopting a kid while on mission?”

  “Like, is it possible? Or is it against the rules or something?”

  “It’s not a good idea, James.”

  “There’s a girl in the hospital, in the TFC. The orphan. Aweil. Did I tell you about her?”

  “Yeah. Her mom died from malaria or something a couple months ago, right? Here in the hospital. Dad’s a soldier. It’s a bad idea.”

  “Think so?”

  “Definitely bad. It wouldn’t be a popular move. You would make a lot of people angry.”

  “’Kay.”

  “I get it, James. ‘If I can’t save them all, why not one?’ Right? Everyone goes through it. Wait it out.”

  “’Kay.”

  Pause.

  “What about money? Are we allowed to give money to particular people? Like is it okay to give her some of my per diem? Or just some money so she can go to school, or whatever? Not even now. Later.”

  “People do it. But it’s not a good idea.”

  I am half finished my cigarette. It tastes black. I put it out.

  “Okay.” I stand up, stack my plates together, and turn towards the kitchen.

  “There’s some beer in there. It’s probably not very cold, but grab one if you want.”

  “Sweet.”

  I leave my dishes by the side of the sink, look into the fridge. Pushed to the sides are people’s personal food reserves, each wrapped in a separate plastic bag, or labeled with tape. It seems odd not to share, but to one side, my bag. In it, a can of pineapple I bought for 60 cents.

  To the side of that, 500 milliliters of beer. From Kenya. Warm as hell. Once the fridge is unplugged and opened, it quickly assumes the ambient temperature. Today it is about 104 Fahrenheit. I plug the fridge back in, and it sparks, then hums alive. I stick two glasses in the freezer.

  A few days ago, I showed up and the man with the books was gone. I’ve since watched Aweil shuffle from one mother’s lap to another’s in the feeding center. She never smiles. Everything else about her seems normal for an infant. She will pick at things with her forefinger, track my movements. But she won’t smile, as if in the ten months she has been around, she has only seen things worth mourning.

  She remains sick. And listless. Yesterday, after everyone left the hospital, I went to her bed and sat down. She was lying alone, half turned over, blinking slowly. I touched her bare back. She had a fever. I turned her, pulled her up to my knee. She drooped.

  “What’s wrong with you, huh? Why all the fevers?”

  I looked at her chart, as I had done that morning, and studied it. Her weight was falling again. I’d treated her for everything. Malaria, all the bacteria I could think of, intravenous, oral, all. I posited to Mohamed today that it might be HIV.

  “How did her mother die?”

  “Meningitis,” he said.

  “Did you see the spinal fluid?”

  “No.”

  “Could be HIV. Crypto. Or TB. Dad’s a soldier.”

  “Possible.”

  “So maybe Aweil’s positive.”

  I left it at that. We don’t routinely test for HIV unless we have a program. She’s ten months old. To whom would I provide the counseling about what a diagnosis means? Or the possibility of lifelong treatment? We can’t test CD4s, liver function, nothing.

  But I put the thought in Mohamed’s head, hoping that he would test her without my permission.

  I open the freezer. The glasses are a little cooler. I take the beer from the fridge, pour a glass for myself, one for Bev.

  Maybe she is right. Maybe I want to do it because I want one small island of control to cling to. But it isn’t that simple. I don’t want to only save Aweil, treat-her-malaria save her. I want to take her home with me, put her in school, let her decide who she will be. I think I might love her a little bit. I can’t help it. It’s bigger than me.

  Could I do it? I would have to quit, particularly if she doesn’t get better. Get to a hospital where she can be diagnosed. I would have to get a new place. Mine’s too small. I would have to commit to Toronto, or move back to Alberta. Commit somewhere. No more MSF. Who would babysit for me during my night shifts. Steve? Greg? Jeff? No way. I would need a nanny. What if she is positive? Could I watch her die?

  I leave the kitchen, beers in hand, and Bev is gone.

  14/03: good news.

  “whatever you do tomorrow, do not go to akur riang from where you will be. there are mines along the road. it doesn’t matter what anyone says.”

  that’s the conversation that is going on beside me right now. measles team talk. they are blanketing the countryside with vaccines. they leave at 7 in the morning, and are finished loading the vehicles by 11 at night. they are improving. at the beginning of the campaign, one week ago … wow, it seems longer … at the beginning, they were nerves on nerves, tracking back on the themselves, just unprepared enough for things to fray by the end of the day. now they are moving like a machine.

  the other night, the foot-in-the-face twins, delivered by one of our midwives. one lived. one was too new.

  i received the best news today. well, two good pieces. the first is that my mother is sending me a battery powered fan. if i am lucky, someone
will be coming to khartoum, and have the space to bring it, luckier still if that someone drops it at the msf office in sudan, and even more when someone brings it as part of their 15 kg of luggage to abyei. in the meantime, i sweat. it is 10 p.m., and 100F in my tukul. it was 115 this afternoon. the only recourse one has is to minimize the surface area of his body in contact with the bed. for instance, the side-sleeping knee-elbow maneuver. or the scapula-butt pillow wedge.

  the second piece of good news, if not enabling my sleep, will allow me to lie contentedly awake. a child i’ve grown fond of is not improving as well as i would like. last week, as i was sweating asleep, a dark thought crept in. “maybe hiv.” could be. the fevers, and the weight loss. i hoped not. i held my breath.

  while i was away from the hospital today, she was tested. negative.

  i spent months traveling africa in 2005 writing about hiv, but i never understood how truly important it was to prevent and treat the disease until i felt that cool relief today. good news. may it happen more and more often to more and more people.

  THE DAY IS ALMOST DONE. I have checked on Aweil. She was lying on the plastic mattress in the courtyard. No one was around, so I picked her up and held her. Her head lolled to the side, to the back. I leaned her forward, let her hot forehead rest in the crook of my neck, and listened to the breath whistle through her nose. I sat there for fifteen minutes. I set her down when one of the nutritional assistants came around the corner. I didn’t want to show any proof of my investment, that on this one, I am betting everything.

  I have one more thing to do today and I am waiting for everyone else to leave. Last night a nurse pulled me aside and told me that a friend of one of our cleaners was raped a month or so ago and is now pregnant. And sick with fevers and pelvic pain. Probably gonorrhea or chlamydia. She wants an abortion.

  Nyanut is in her forties, and well known in Abyei’s small community. She often comes to the hospital to bring the nurses tea. She does not want anyone to know about this. In the curious twist so common here, rape is the woman’s crime. We spoke briefly this morning about her symptoms, through a translator, under the guise she is not pregnant, but only having abdominal pain. I asked her to meet me here this afternoon.

  There she is, over by the emergency room, talking to one of the nurses. I want to catch her eye, to gesture her towards the operating theater. It’s private there. I can lock the door.

  Good. She sees me.

  I walk into the dark hallway that leads to the small operating theater and pass two women lying on beds. One is about to give birth, the other did this morning. Her new infant is lying beside her, uncovered and ignored, mewling. I came across an article on the medical computer about the importance of “kangarooing” the newborn infant, and mean to start encouraging it, get the midwives on it. I haven’t. It sits at the end of a long list.

  I remove the padlock from the door and enter the theater. On the surgical bed, I put a plastic sheet.

  The windows are open to the outside. Through the mesh I can hear the chatter of the mothers in the feeding center, and behind the hospital the splash of someone washing themselves. It is almost dusk, and the generator remains off. I don’t ask the guard to turn it on. There’s enough light for now.

  Nyanut raps on the door. I gesture for her to come in, to sit on the bed. I pull up a chair.

  “Baby?” I say, and point at my belly, tracing a pregnant abdomen. Nyanut knows some words of English. She doesn’t want to use a translator for this.

  “Baby,” she says.

  “How many days ago, last period, last bleeding?” I ask.

  She counts back on her fingers.

  “Twelve January.”

  I count on mine. Sixty days or so.

  “Pain?” I ask.

  “Pain,” she says, pointing to her pelvis.

  “Blood?”

  “Tch.” A shake of the head. No.

  “Do you want to have baby?”

  “No. No baby.” She waves her finger. “Cannot. Bad man. Think friend but friend no. Sex, afraid, no.” She holds up three fingers. “Me, many children. No husband. Husband die. Cut. Muslim. Pain.” She points down towards her groin.

  I nod. I take her pulse. Normal. I touch her forehead. It’s warm. I put a thermometer under her arm and wait for it to cool. Her temperature’s okay. I gesture for her to lie down, then place a sheet over her legs.

  I push on her abdomen. I can feel the edge of her uterus jutting above the hard brim of her pelvis. It feels firm, not boggy. She winces a bit. I push a bit harder and let go quickly. I look at her face. No grimace, no peritonitis.

  I sit her up.

  “I’m going to look inside with this.” I show her the bright metal speculum. “I look for infection. Okay?”

  “Okay.”

  She lies back down and spreads her legs. I remove the sheet and pull up her gown.

  Her labia are scarred together. The introitus is tiny. Perhaps big enough for one finger. The speculum would never fit. I reach to my side and unwrap a pediatric one. It is much too large. I pull her labia apart and do my best to look inside. I can see green pus. I pull her gown back over her knees and sit back. I’m silent.

  What the fuck.

  She must have been cut, her clitoris removed, and her labia sewn together. Again after her children. Torn open, sewn back together. Infibulation.

  She sits up. “Small small,” she says.

  For the first time, a hard hot kernel of anger burns in me. We have patients who refuse to treat their contagious tuberculosis and leave the hospital coughing, families with malarious children who disappear when our backs are turned, and we make sense of it. They might not appreciate fully the choices, or their consequences, or maybe there’s something we don’t know. But this. It seems deliberate, irrevocable, unforgivable.

  “You need to take medicines. For infection. Okay?”

  “Okay. Baby?”

  “Yes.”

  Her eyes widen.

  “Oh, I mean yes, pregnant. But we can stop, okay?” Whatever it takes to help you, I want to do it.

  She nods.

  I’ve never done this before. I think you use prostaglandin to relax the cervix. I’ll look it up. I’ll ask Brian. He’ll know.

  “All right. If you wait outside, I’ll get some medicines, okay? Wait outside, okay?” I point.

  “Okay.”

  She leaves through the blue wooden door, and its hanging lock bangs as she shuts it.

  She’s getting to the end of the effective period for medical abortion, I think. We can still try, but if it doesn’t work … I guess a D&C … dilate the cervix, scrape out the uterus. Might have to do it anyway if the infection worsens, or she could die. I would have to ask Mohamed for help. He’s done more than me. The secret would be out then. We would have to cut her open in order to get the tools in there. Use ketamine, cut open the scar tissue with a scalpel. There’ll be a ton of blood. Then sew her together. Might heal wrong otherwise. Chronic pain.

  I know we don’t have the right meds in the pharmacy. Maybe in the market, but I doubt it. I’ll look. If not, I’ll find a way to get them from Khartoum. Maybe I can send some from Ethiopia. Addis. It hangs like a diamond in my calendar, a breath away from this place, the handset.

  I’ll need to give Bev and Nyanut clear instructions about how to use the pills, how to watch for infection. And when to tell Mohamed if things go wrong.

  I shut the wooden windows tightly against their jambs, put the plastic sheet in the washbin and the speculums beside it. I close the door and lock the small padlock. The baby is still mewling beside his mother. I pick him up, put him on his mother’s chest, and cover him with a blanket.

  I leave the hallway and the hospital is quiet. No outpatients to be seen, all the visitors have gone. Nyanut lingers near the front gate. I hold up my finger. One minute.

  I walk towards the pharmacy to gather her antibiotics, picking my way between children on the increasingly crowded floor of the feeding cente
r.

  15/03: dream.

  i had a dream last night that i was finished my mission. i was sitting at a table, surrounded by friends. one said “wow, that went so fast!” i agreed.

  i woke up to the sounds of the muezzin at 5 in the morning. i lay in my bed, smelling the dust.

  i left canada more than a month ago. it seems longer. i have seen and learned so many things, lived one hundred stories.

  i wrote in my first post that i had anticipated one of the lessons i would be taught. “be careful what you wish for, you just might get it.” part of my motivation for coming here, to abyei, was to test my resolve. i didn’t anticipate it would be tested so well.

  in the pre-departure training, we are told of the well-worn personal trajectory we will likely follow in missions like this one. we arrive to the project full of nervous excitement. there are so many new things. new faces, new routines, roles, and rules. we are frenetic, and overwhelmed, but buzzing with energy.

  this fades after a couple of weeks. the reality of the days starts to thicken like cement and initial momentum slows. new things become old ones and the weeks of work stretch ahead. we realize that this is not an exciting dash to a spectacular finish; it is a marathon. our mood ebbs. one day of work bleeds into another.

  days become weeks. soon the midpoint of the mission approaches. after three months of working seven days, we are allowed to rest for a week. our mood improves. where are we going to go? we start planning tickets and departures. excited, we leave the country, lie on a beach, and sleep. we return somewhat rested, and take another blow to our enthusiasm. back here again. back in no(middle)where, treading water.