Six Months in Sudan

by Dr. James Maskalyk

  “We’re done, right?” I look at my watch. With Mohamed away, I have all the patients in the hospital, save those with measles. The emergency-team MD leaves in a few days, and when he does, the measles patients become mine too. Brian sent word that we might be able to borrow a Sudanese MD from Darfur. I am glad.

  “No. One more. Mansood,” says Alfred, my translator. He’s new. Our previous translator quit last month.

  “Oh, right.”

  We move to Mansood’s room at the back of the hospital. His walking stick sits beside his bed in the same place it was a month ago. He has stopped eating normal food. We have tried to give him Plumpy’nut, a nutritional supplement we usually reserve for children. Two of the foil packets lie near his head unopened. He is flat on his back on a plastic mattress, his head inclined towards the small mesh window at the back of the room. On its ledge sit a half-dozen bottles of apple soda, their bottoms littered with flies. It is the only thing he will drink.

  When Mohamed and I aspirated his knee joint, the fluid was clear. We have treated him for conventional bacteria, and tuberculosis, but he has not improved.

  “Mansood,” Alfred says, stepping into the room before putting his hand over his mouth and nose, and stepping back out.

  “Mansood!” he shouts again, one foot on the threshold, the other outside.

  A slow turn of the head, and he lifts a thin hand. I walk into the room. It smells of urine and feces. I gag. I put my hand over my face, grab the chart wedged underneath his mattress, and move back out.

  He has been tested for malaria, hepatitis B and C, and HIV. The only other test we can do is a hemoglobin, but that will tell us nothing about his sickness, and blood is not the cure.

  “What are his vital signs?”

  The nurse leans over my shoulder and scans the chart. They haven’t been done. Nor did he get his medicines yesterday. Forgotten by everyone except Alfred.

  I feel his pulse. It is normal. He doesn’t feel warm. I look at his eyes. No jaundice. His knee remains swollen.

  “Mansood.”

  He raises his thin hand again, turns his head slowly towards my voice. His eyes are thick with cataracts, dull pearls.

  He’s probably uremic. Kidney failure. Can’t confirm it, but seems that way. From what? Hypertension? Diabetes? His sugar was okay. Maybe he got a bunch of gentamicin or something before I arrived, wrecked his kidneys. I check his chart. No. Well, if he is uremic, then he needs dialysis. He’s not going to get it. He’ll be dead soon, and I won’t know from what. No one dies from old age. It’s always something.

  “Why is he lying in his own urine?” I ask the nurse.

  She shrugs.

  “He’s not dead yet. We can treat him better than this. This is not a way to die.”

  “Dr. James, we have no time for this. There are not enough of us. At night, we are busy trying to give medicines, and there are not enough nutritional assistants, and …”

  I know. Some of the MOH staff are unreliable, our MSF nurses are haggard. We need one full-time in the measles area. Muriel has left the project, requesting to return to Darfur. Those who have worked there all prefer it to Abyei. Others have been talking of going back.

  “We’ll hire someone, then. But until we do, I want him cleaned. And I want someone to help him get up and sit in the wheelchair. I know it’s broken, but we can just have him sit outside. Okay? This is bullshit.”

  I’m angry. I can’t stop.

  “Just because he is from far away, just because he’s old, doesn’t mean we can’t care for him, does it? That’s our job, no? Sick people. No matter what, or who, or where, or when. Right? It’s not easy, but sometimes that’s the way it is. If they can’t bathe, we have to bathe them. If they can’t eat, we feed them. Okay?”

  She nods. I take the chart from her hand and look at it one more time. I can think of no more medicine to add, none to remove. I close it, hand it back to her, and turn away.

  I am standing in the courtyard, in the hot sun. Patients line the halls, trying to find shade. Alfred lingers nearby, glancing nervously at me, seeing if he should step closer or effect some kind of retreat.

  “Alfred, come with me,” I say. “I want to talk to you.”

  We walk towards the front of the hospital and past the laboratory’s open door.

  “Hey, Ismael.”

  Ismael looks up from his microscope, grunts hello. Alfred and I sit down on a bench outside his door.

  “Okay. I’ve been meaning to have this conversation with you for a little while. I’m sorry it’s taken me so long.”

  He fidgets.

  “I know you are new. How long have you been working here with MSF?”

  “Two weeks.”

  “All right, very new. Now. For me, you have the most important job in the project. I can give people medicines, and do many things for the patients, but I can’t talk to them. And they can’t talk to me. Without that, it is almost impossible for me to find out what is wrong with someone. We say in medicine, the story is 90 percent of the diagnosis. And even if I get it right without one, I can’t tell them. I am useless.”

  “Okay.” He looks at me with a small bit of pride on his young face, in place of his nervousness.

  “So I need you very much. Now, I also need you to understand something else. First, you must translate what I say exactly. All my questions. If you don’t know what they are, I don’t mind. Ask me. I can explain it again in a different way. It is very important.”

  “Okay.”

  “The second thing is this. I know I get frustrated sometimes. But I am not frustrated with you. I am frustrated with me. It is difficult to not be able to talk, or to understand. This is not my country. I can’t meet someone in the market and make a friend, I can’t make a joke with my patients. So when I seem frustrated, it is not with what you are doing. I promise. It is because I feel helpless. Okay?”

  “Okay.”

  “I’m sorry I haven’t said that before. I meant to.”

  “Thank you. I worry about my English.”

  “I know. I’ll try to remember to speak more slowly, more simply. We’ll help each other. The translator before you used to write down words, and we would go over them together. I have a medical dictionary and we can start with easy things.”

  “Oh yes, that would be very good. Very-very good.”

  “We’ll decide on a time at the meeting tomorrow.”

  I am hungry. It is lunchtime soon. Alfred is long overdue for his. The Sudanese eat no breakfast, taking their first break at ten. Despite our best attempts to shift their schedules to ours, the hospital empties for an hour at this time. My translator sits and waits for me, stomach grumbling.

  “All right, enough of that. Let’s go for lunch.”

  We move together towards the gate of the hospital and out onto the hot red road.

  “Where did you learn English?”

  “In a refugee camp. In Ethiopia.”

  “When did you come back to Abyei?”

  “Only this year.”

  We duck at the cannon. Across the flat flood plain, men in white robes walk between market stalls.

  “Are you married?” I ask.

  “Yes. I have two children. Two girls. Are you married?”

  “No.”

  He laughs. “But you are very old! And rich! You should have many wives.”

  “Maybe I’ll get one while I am here. A Dinka woman. So my children will be tall. How many cows do you think it would take me?”

  “For a rich man like you, maybe twenty cows.”

  “Twenty! Would she be tall?”

  “Oh yes, for twenty cows, you can get someone very good.”

  “Back home we have only one wife. We think that is enough.”

  “Oh yes. Even one is too many sometimes.”

  I laugh. “Why did you come back to Abyei?”

  “Because it is my home.”

  I look around. To my right the barbed wire of the military compound, soldiers
sitting idly in a covered house. To my left, the potholed path to the market. We turn down it together.

  “Is Abyei better than before?”

  “When I left many years ago you could not walk at night. Sometimes you would wake up and your neighbor would be disappeared. Soldiers would stop you and take you away, beat you for no reason. Maybe kill you. These days it is safe at night. For now.”

  We are drawing closer to one of two food stalls in town. This one is at the very start of the market, on one of the two paths that lead to my compound. I rarely take this one. Some of our nurses and drivers are sitting down and eating pieces of fried goat with their fingers, breaking off pieces of bread.

  “Will you join me for lunch?” Alfred asks.

  “Oh, no, thank you. Mine is waiting for me at compound 1. I have to talk with Tim about getting a helper for Mansood.”

  “Please, it would be nice for me.”

  “There are some things I have to do. Next time. Thank you, Alfred.”

  He frowns for a second, then shakes my hand. Some of the nurses look up. I wave. They smile.

  “Well, I’ll leave you to it. See you back at the hospital. Take your time.”

  I stop at a stand. I have been stealing Tim’s cigarettes mercilessly and decide I should buy him a couple of packages. I pocket my change and look back at my translator. He is smiling and laughing with the others.

  I turn around and walk towards my compound.

  01/04: new normal.

  this morning, during breakfast, a loudspeaker blared thick arabic. today was a cleanup day in abyei. everyone was to clean the space outside their tukuls, or face consequences. tonight the air is full of the sharp smell of plastic. fires line the road. you can see the black shadows of people tending them flicker and dance on the grass walls behind.

  people fix flowers to the handlebars of their bicycles in bunches. roses, carnations, impossible pink flowers in rows. even soldiers. daisies pour off the front, a machine gun hangs from the back.

  when an organism enters a new environment, with time the new stimuli elicit diminishing responses. as it inhabits, it habituates. in a conflict setting, for expatriates, it is called “immersion.” at first, every soldier is registered, every weapon noticed. after weeks, in a new normal, one sees mostly daisies.

  for years i was blind to flowers. it took a friend to show me how easy they are to love. in the hot morning, they hang for water. an hour after, they stand tall. when i leave the feeding center, i think about that.

  THIS IS WHAT HAPPENS if you are a Dinka child, say thirteen months old, and you have around your waist a circle of beads looped twice, like Aweil’s beads except some of yours are blue, and you are naked except for these beads and lying on the cracked plastic bed in the small emergency room of Abyei’s only hospital at ten at night surrounded by your mother, father, a nurse, and a midwife who is trying ineffectively to blow air into your small lungs with a face mask that is four sizes too big and lets all the air slip out of the sides, and the Canadian doctor arrives just in time to watch you take your last ten breaths, and then they stop and then you die. This is what happens.

  Your mother screams, turns, and leaves the room. The metal emergency door clangs behind her. Your family outside the emergency room, an impressive number of aunts, uncles, grandparents, and friends, start to wail.

  Your father sits down on the other cracked plastic bed, puts his face in his hands, and looks through his spread fingers.

  A nurse puts one hand over your eyes and uses the other to close your mouth. She holds them like that until a clean cotton cloth can be placed over your face and she puts her hand over that.

  The midwife takes long strings of gauze and slowly wraps them around your head, again and again, until your mouth and eyes are closed fast.

  The nurse removes the intravenous and cleans your skin of blood.

  Your father takes a small piece of string and binds your large toes together, to keep your legs closed, then wraps your feet. Your hands are placed grasping each other, and your thumbs are bound. Your fingers sit neatly folded together like piano keys. Your hands and wrists are then covered in gauze. Last, he lifts you onto a piece of colored cloth and wraps you a final time.

  Someone opens the door (your grandmother?) and takes you from the room.

  I stand there useless, and once the emergency room empties, I am alone. I pick up the gloves off the ground, square the edge of the cracked plastic bed with its metal frame. I loop the padlock through the drug cupboard and click it shut.

  I take my time. I secretly hope that you and your family are gone when I step out into the night air. I don’t know what to say. I’m sorry? That after the tenth time, it is not getting any easier at all? I just want to walk home alone, eat my dinner leaning over the stove, and go to my tukul and not see anyone.

  They’re gone. So are you. To where? I don’t know. Here, for me, your story ends. Mine goes on, rushes away from me in all directions, so many things in it I don’t know where to begin.

  I finish with the last of the outpatients and walk towards the gate of the hospital.

  “Call driver?” the guard asks.

  “No. I walk. Cigarette?”

  He gives me one. The package has a picture of a soccer player on it. He lights the cigarette for me.

  I start walking home. The night is moonless and black. The cigarette tastes terrible. I throw it on the ground. I strain forward against the dark and a soldier almost barrels into me.

  08/04: easter.

  the abyei night is black like thick ink. as you walk down the road pushing your face into it, trying to gain a centimeter or two of perspective, it almost meets a soldier’s leaning over his handlebars doing the same. you both recoil like surprised fishes at the black bottom of the ocean. he swerves, and the flowers on his handlebars brush your arm.

  this morning, a sleep headache behind my eyes, i laced up my running shoes and ran out of town. i wanted some open space; no people, no cars, no zigzagging chickens, only the wide horizon. a few kilometers north of abyei, the sun and the moon shared the sky with dawn birds.

  here in abyei, outside the hospital and in it, i am witness to the most beautiful things. today i was standing in the measles recubra holding a child from the feeding center in my arms. measles had once again swept through our hospital and infected his mother. she was too feverish to move. paola was giving her a sponge bath, and i was hoping to find a mother to help feed her son until she was well. i watched a woman take the most gentle care to offer her child water from a plastic cup, holding her hand under the rim so that not a drop was spilled. the child refused, and the mother offered softly again. it was such a beautiful, intimate act of love.

  i asked the women in turn if they could feed the child i was carrying along with theirs, even if just for a day, even if they did it in turns. they roundly refused. i pressed, they resisted.

  the fittest survive. here beauty and the hard truth of nature share the same recubra. like when you watch a butterfly fold her wings once, twice, then take off on her jittery way, and a swallow swoops in, eats her, then wheels out of the frame.

  i spent the morning on a mobile clinic about an hour from abyei. we arrived early, and there were no patients. we hadn’t been there for weeks because of the measles epidemic. while i was waiting, i walked out into a field and a million birds flew by. the flock pulsed and changed like smoke. when i turned back, i could see bright flashes of clothing moving through the woods as people approached.

  it is now midday. most of msf has the day off for easter. the temperature is 120F, by my thermometer. i don’t see the falcon on my tukul any more, but up above, some drift on hot drafts of air. a few move so high that they become dust, disappear like untethered helium balloons. the other night, bev and i were talking about how we would like our ashes to be reanimated. “falcon,” i said.

  annie dillard once offered her opinion on whether birds fly for pleasure. she found her answer when she watched, from her wind
ow, a barnswallow fall like a stone from his nest in a barn’s loft. just as he was about to hit the dirt, he spread his wings, skimmed the ground, and flew out of sight. of course they do.

  it is easter. in lac la biche, alberta, my family will be sitting together and watching cold ducks test the ice of the lake. they will have an afternoon meal and talk about the things they are thankful for. being grateful is a lesson i was taught well. it is one that the world keeps repeating. each of us is lucky to be alive and to be surrounded by people we care about. there are a thousand million ways it could be otherwise. but somewhere an opaque reason met an impossible chance, and we are all here at the same time. it’s such a lucky thing, it’s hard to believe.

  “ANTONIA? FUL?”

  She looks into the red plastic bowl of beans Paola is holding and frowns. “No. Absolutely not.”

  Antonia arrived earlier this week. The last time I saw her, she was sitting beside me in Geneva, grumpy from having her visa refused. Brian must have convinced Geneva that a midwife was important. I am glad. The “maternity hallway” that lines the entrance to the operating theater is the event horizon of an obstetric black hole.

  Of a half-dozen midwives, a number that seems to shift with the week, there is only one that has any specific training. The others are traditional birth attendants. They are all larger than me and make an intimidating bunch. Antonia, though a third their size, is a force of her own. She is Italian, in her late thirties, and has worked everywhere. Within twenty-four hours of arriving she had distributed to all of us our own laundry buckets. She called our habit of throwing the clothes we needed washed on the tops of our tukuls “filthy.” Two nights after she arrived I heard the whir of a fan coming from her room. I was amazed. When I asked her how she persuaded Jean to let her have one, she looked at me like I was from another universe.

  “Let me? It’s 120 degrees.”

  I liked her immediately.

  “Salad?” Tim passes her a bowl with onions and cucumbers in it. She looks at it and wrinkles her nose. He sets it down.