Managers Without Borders, Too

On any given MSF project, it seems to me that at least 50% of the upper-level people are non-medical – logistics experts, administrators, human-resources managers. We got a taste of why that is, and of the sometimes absurd situations they have to finesse, in our last days in Juba.

The clinic where MSF set up the emergency surgical program was, you may remember, originally run by a different NGO, and the plan all along was to turn it back over to that NGO once the acute surgical cases were dealt with. Thus, on Saturday morning, Dr. Dave arrived at the site prepared to do a detailed “rounding” with the other NGO’s surgeon, so that this man would have a clear understanding of each of the patients he would be providing ongoing care to.

I was in the operating room out back, “mixing up the medicines,” as Bob Dylan might say, when Dave came in to tell me that we would be able to start sooner than planned. As he was rounding with the new surgeon, the manager of the refugee camp had arrived and said that the new surgeon and his organization were not welcome on the base, and that – by one account – if he did not leave immediately, they would shoot him. So – rounding over; time to start operating.

Here’s the back story: For some reason, the camp management had decided at some point that they did not like this other NGO. According to MSF’s head of South Sudan operations, this has happened before – a local group, for whatever reason, goes borderline, and decides the people they liked yesterday are now the enemy today. In this case, I have a feeling that it had to do with a perception of difference in quality of care. Basically, MSF had done its job too well – the camp management could see how well cared for the patients were when we were there, and did not want to go back to what they perceived to be the inferior care provided by the other NGO. (And in this they may unfortunately have had a point. Dave later reported to me that, as he prepared to leave the site for good early this week, he heard screams coming from the operating room. He stuck his head in to see what was going on, and saw the new surgeon doing a dressing change, on a man with a deep, deep wound, with no anesthesia….)

From MSF’s point of view, however, this isn’t what we agreed to. From the very beginning, we had made it known that our plan was to exit the project as soon as the major work was done. Dave was needed back at his original project up north, and my replacement was needed in Aweil. Our director felt, very clearly, that what was going on was that the camp management was trying to create a fait accompli – basically, to make it so that no one else was available to take care of our patients, so that MSF would have no choice but to stay on. Beyond not having the human and other resources to do this, the director did not appreciate what he took to be an attempt to manipulate MSF, and did not want to cave in to it and create a precedent.

For most of Saturday and Sunday, it was unclear what was going to happen. Would we leave as planned – stay on for a few more days – stay on indefinitely? The MSF director stayed firm, though, and I imagine that once the camp management realized that we weren’t going to give in, they decided to make their peace with the other NGO and let them back onto the base. Dave was able to finish his “handover” rounds with them, and on Tuesday, only one day late, MSF disengaged and turned the project over. With silent apologies, no doubt, to the screaming patients.

One thing the director was able to do first, however: He managed to move the little girl with the amputated arm to a different facility, where he had more confidence in the nursing care. He has to be a pretty hard-nosed guy sometimes, but let no one think he doesn’t have a heart.

In Praise of General Surgeons

An interesting aspect of the work in Juba was that our patient population was finite. In Aweil, there is an essentially infinite number of potential malaria and malnutrition patients (and I’m sure my colleagues there sometimes feel like it IS infinite – they are apparently completely overwhelmed at the moment, more so than in any recent year). The program in Juba, though, was set up for one purpose: To treat people with injuries related to the flare-up in communal violence in early-mid July. Since the flare-up was relatively quickly contained, and has not, happily, recurred, our pool of potential patients was “capped” a few weeks ago at a limited number. I think, in the end, we treated between 50 and 60 people.

This meant that, when I arrived, the surgeon (“Dr. Dave”) already knew all the patients, each of whom had by now had his or her initial intervention (wound cleaning – bullet removal – initial stabilization of broken bones – etc.). So we had a very clear idea of the exact work remaining – what everyone needed before we left and turned to program back over to our partner NGO.

The list included 3 skin grafts, 3 “ex-fixes” (pinning of thigh fractures that would otherwise have to spend 6 weeks in traction – see my previous post, “Bones”), one exploration of an infected abdominal wound in a woman whose bowels had been destroyed by a bullet but who was hanging in there way longer than anyone had thought she would, and many cleanings of deep, infected bullet, machete, and grenade wounds. (The little girl with the injured arm I have often mentioned was a special case. She was injured not in the July flare-up, but in early August, when some soldiers having a disagreement had the brilliant idea to start shooting at each other (don’t get me started on the idiocy of filling your country with ill-trained, irregularly paid, undisciplined young men with lethal weapons). She arrived literally a couple of hours before we were due to leave the compound for the last time and turn over care to the other NGO. We ended up taking care of her just because there was no one else who would.)

The greatest pleasure of the week was simply watching “Dr. Dave” do his work. He was an Army surgeon for 24 years, which probably prepares you for anything. Also, it must be said, surgeons in general are just very skilled people. Whatever the problem or need, skin graft or pus-filled wound, abdominal exploration or pediatric amputation, Dave dived in and did it, with what seemed to me exemplary authority, speed, efficiency, and thoroughness. “I tend to be a somewhat more aggressive debrider than the surgeon working here before” he remarked, reaching deep into a thigh wound to pull out pieces of dead bone which, left in place, would have prevented the site from ever healing. “Ex-fixes are fun,” he said, screwing a long metal rod into a femur. Two of the skin grafts had to be done with a particularly medieval instrument – essentially, a cross between a cheese slicer and a carving knife. You put it on the “donor” site, usually the person’s thigh, and just – start sawing away! The thin layer of skin to be transplanted comes out between the blade and a metal guide, just like a slice of Havarti. Dave wrestled with it until he had the grafts he needed. I will give myself a small shoutout here, for managing to keep the people on whom this was being inflicted comfortable – but to be honest, once I’d gotten the spinal (so EASY in a land where almost no one is obese!), my only real job was keeping them schnockered enough on ketamine that they didn’t look down at what was being done to them and start freaking out.

Dave also spent the week being a sort of logistical mastermind – when I arrived, there was no more “ex-fix” hardware at the site, and one of the skin grafts he had to do was just too big to manage with our 1^st-Crusade-era equipment (it would have taken many, many hours). Over the next few days, Dave, our pharmacist, and one of the OR nurses scoured other MSF projects and arranged transport, by car and by plane. By Friday, we had both enough ex-fixers AND an electric dermatome (skin-graft-harvester), and were set up to finish all the planned major surgeries before the Monday-morning handover.

Which we did, by early afternoon Sunday. Learning just afterwards that the girl with the shot-off arm had arrived. The next morning, while I was getting ready to fly out, Dave and my replacement operated on her, too, managing to remove all the damage before it spread into her shoulder muscles (extremely good news). I can’t say how she will fare in the long run, but by the time they left on Tuesday, she was as well as anyone could have imagined, as anyone could have made her given the condition she arrived in, and had a real path to recovery. More good work from Dave.

Let That Be Your Last Battlefield

Remember the Star Trek episode “Let That Be Your Last Battlefield?” It’s the one where Gene Rodenberry, or whoever, made his plug for civil rights. The Enterprise has encountered a planet where the people are divided down the middle, one side of them colored black and the other white. Two of these people are on board the ship, one expressing unmitigated loathing toward the other. The crew is puzzled (I was, too, as I remember): Why do they hate each other so much? But one of the two-toned people clues them in: “Don’t you see?” he asks. “I am white on the left side, and black on the right, but he! He is white on the right side, and black on the left!”

I thought of that episode when driving into the POC, the refugee camp inside the UN compound where Nuers have been fleeing to escape Dinka violence since 2013. I have no real qualification to talk about this ethnic conflict (which, to be clear, goes both ways – in predominantly Nuer areas, Dinka have had to flee for their lives). I have no deep knowledge of the roots or content of the tension. All I have are the perceptions and reactions of an outsider. But, then, as with the emperor and his clothes, there may be times when that’s not useless.

All I can say, as an outsider, is that it is impossible to see any difference between the groups. To me, the patients I was treating in Juba (Nuer) look exactly like the patients I was treating in Aweil (Dinka). The kids you drive past on the way to the Quonset hut look exactly like the kids who used to hang out outside the “Maternity gate.” I gather that names are different, and that, if you know what you are looking for, you can tell the difference based on the patterns of scarification on people’s faces and bodies. But if the dissention comes down to things as tiny as that, it makes the Star Trek episode seem even more a propos.

Of course, this is oversimplified. If you asked an anti-Semite why he doesn’t like Jews, I doubt the first response would be “because they look different.” He would seek to justify himself based on some verdict about values and behavior and goals and loyalties – and I’m sure the same applies here. But – I don’t know – when you think of all the killing, all the patients we’ve been patching up, and then you drive into that compound and see people who look exactly like their “enemies,” it’s hard not to think, “What the fuck??”

It hit particularly hard regarding the little girl whose arm we had to amputate. Apparently, she was shot a long way from town. When her family managed to get her to Juba, they were not far from a medical facility. But, as one of my colleagues put it, they couldn’t go to it because “they don’t treat Nuer there.” When you hear that a five-year-old girl in desperate need of medical attention can’t get it because she belongs to the “wrong” group, it makes you think, just what is WRONG with people??

In the end, from one point of view, it’s not “my” problem. I can just fly away, as I did on Monday. But it’s gotten me thinking, naturally, about bigotry in the US. And not necessarily in the way I might have expected.

Sad though it is, I think there is something salutary in realizing that this kind of hatred is universal. As a white American, one of the things I think is unhelpful in the discussions of racism here is any tendency to treat it not as a universal aspect of power struggles and power relations, but as some particular pathology of white people. I don’t think this is a conscious belief of many people (although it is of some – remember Leonard Jeffries, the City College professor from the early 90s, with his condemnation of the pale “ice people”?). More, it’s a kind of vague, potential background assumption that some people, both white and non-white, may slide into making. And it moves the focus away from understanding, taking responsibility, and changing, mucking it up with a guilty and resistant defensiveness.

This isn’t to say that there aren’t historical differences that inflect the problem in critical ways. Thus, in most of the world, white people have, for centuries, been the ones on the “winning” end of racism, the ones benefiting from it, the ones inflicting it or tolerating it, the ones actively seeking to maintain it. And, in America, more than anyone else, black people have been the ones suffering from it, in ways enormous and small, violent and laughable. So it’s not like “we’re all equal” in this. My point is just that seeing the universality of it helps clear away some unhelpful emotional baggage, so we can more clearly (and perhaps with more hope) focus on fixing it.

Or maybe I’m just looking for a silver lining in what is, however you look at it, a sad reality.

First Trip to the POC

Wednesday, 8/10: We head out early – 7:00 – on my first trip to the POC (the Protection of Civilians camp – basically, a refugee camp inside the UN compound in Juba). We have a full roster of surgeries to complete before 3:00, including a skin graft and an “exploration” of a post-surgical abdominal wound that is looking pussy and bad.

As I have been told, and will soon come to agree, the worst part of the day is the trip to and from the POC. Thirty minutes plus, out towards a sort of volcanic hill on the outskirts of town, some of it on paved roads, and some of it on the most god-awful, pitted, rutted, washed out dirt roads imaginable. One of the things you pick up rather quickly in Juba is that no one is 100% certain of the security of anyone there, including expats and aid workers. Members of one of the MSF groups in town were pulled from their vehicles and beaten in mid-July, and NPR just ran this horrific story: http://www.npr.org/2016/08/15/490112607/western-aid-workers-among-those-attacked-by-soldiers-in-south-sudan). So I find myself wondering – if some threatening situation arises, what, exactly, are we expected to do? I mean, you can’t go more than about 5 miles an hour on some of these roads! Kind of does away with any extra measure of security you tend to feel that being in a vehicle gives you….

Our way leads, first, through town, on routes lined with apparently bustling businesses, mostly in low-slung stuccoed buildings. We pass the University, which I gather is still operational, and presents a bit of an oasis behind its rock fence (Tennis courts! Playing fields!). We then have two possible routes: one that goes through a central market but, on the other hand, also goes by the grandiose, unfinished concrete gate fronting the main SPLA (army) barracks – not necessarily a place you want to be if tempers flare. And the other that may be the worst thing calling itself a road I have ever driven on. Either way, we head out past the little statue of the man with a bow and arrow and into less developed parts of town. It took me several days to notice it, but at some recent date this appears to have been a new, rich suburb. Although the land all around is scrubby and overgrown, there are a number of very large, expensive looking “villas” along the way, and even something that looks not far from a Southern California subdivision – although whether these are inhabited or not is hard to say. A favorite spot along the route: The bent and rusted sign of the Juba County Recreation Center. In front of what appears to be a derelict fuel station. We remind ourselves daily to make sure and get a membership.

At last, signs of the UN base come into view – razor-wire-topped fences; beefy white people out for a run. We are greeted by a large contingent from a private security force, who check everyone’s ID, log in the vehicle, do an undercarriage examination for bombs, etc. – a more serious check-in than one often gets at these “security posts.” Then it’s through the extremely heavy, presumably truck-proof gate, into a garden land of tidy apartment blocks and lawns and bungalows with screened porches, the residences of the various UN personnel. (Well, except for the very large contingent of Chinese troops. They appear to live in a village of shipping containers. With air conditioning, at least!)

We’re not staying here, however. A 100-meter drive brings us to yet another gate, this one flimsy, made of two-by-fours and chicken wire. Beyond it is the POC, an expanse of white-plastic-tarpaulin huts squeezed together between narrow dirt lanes. As I understand it, its administration is more or less independent of the UN. Troops do come in to take up defensive positions in the many foxholes and bunkers whenever unrest is in the air (the POC is pushed up against a long section of the perimeter fence, and thus fairly vulnerable to people outside). But decisions about the daily functioning of the camp appear to be made by a separate governing structure, as we will later find out.

The history of the POC, as I understand it, is this: In mid-December 2013, fighting broke out among troops in Juba that, from the beginning, had an ethnic (Dinka vs. Nuer) cast. Almost immediately, the fighting spread from the barracks to the streets, with (as Juba is a majority-Dinka area) Dinka groups going around actively looking for Nuer, soldiers or civilians, to kill. The accounts are harrowing, with people hiding under beds for hours or days, and the streets littered with corpses.

During this time, anyone who was able to apparently started moving toward the UN base – not because it was set up as a refugee camp, but simply because they thought they might have some measure of protection there. And – although the UN has not always been effective in protecting civilians, in South Sudan as in the former Yugoslavia, etc. – the fleeing people were allowed onto the base where, in short order, a refugee camp of tens of thousands of mostly Nuer people sprang up. It has been there ever since, and was the place to which, during the violence in July, many Nuer again instinctively fled. Thus, it was a good place to find and treat injured Nuer people, who may not have found a welcome at other health facilities (more on this in a later post).

The camp we are headed into is “POC 1.” Not by any means the only refugee camp on a UN base, either here or elsewhere in the country. One of the other camps here – POC 3 – is actually situated next to but outside the base (I got a glimpse of it one time when we took a drive around the compound). This must make it even harder to protect, and, indeed, I gather there were cases of attacks on POCs during the July violence, where both civilians and UN personnel were injured and killed.

We drive past the flimsy chicken-wire gate, and past the some of the ubiquitous trucks that deliver water to the POC, onto the road along the camp’s perimeter. Wherever people are, can commerce be far behind? One long stretch of the road (Dave calls it “Rodeo Drive”) is lined with what I guess are shops – mostly full of (very good-looking) vegetables, but also including some other items. How, exactly, people bring the stuff in, to this fairly fortified camp, is a mystery to me, but there you are. We also see things suggesting that at least some of the (many) children are able to go to school, and certainly see evidence of the sorts of sanitation and hygiene problems that must plague any camp like this. All in all, though, and from this road that runs along the outside (I never have occasion to go any deeper in), it looks ramshackle but solid – not pleasant, but not destitute or chaotic or frightening, either. (Perhaps I have arrived at a good moment – I think there were serious food shortages a month ago, and, certainly, a lot of women were assaulted when they left the compound to look for food at that time.)

We pull around, in a long “U,” to the second in a line of three Quonset huts. One of our crew starts the generator, and Dave and I head to the back, along a corridor running through the wards housing the surgical patients, separated off from each other with the same white plastic tarps. Here, we change into scrubs, abandon our shoes for OR clogs, and I head into the corner of the tent that holds the operating room. My home for the next five days.

Down to Juba

Tuesday, 8/9: I've sat down to my tasty breakfast (one fresh pita with eggs, one fresh pita with butter and jam – hard living, I know), when I notice, out in the yard in front of me, Thomas (the medical head of the project) talking animatedly with someone on the phone. A minute later, he says “Okay, I understand,” hangs up the call – and walks straight over to me. Hmmmmmm – this could be interesting.

In short order, he tells me that the anesthetist in Juba has gotten sick, and that they need to send me down there as soon as possible to take over on the project started about a month ago to tend to people injured in the recent political violence. “Today?” “Well, that would be ideal, but it’s probably too late to get you on a flight – and since there is no flight tomorrow, it probably means Thursday. But get your things packed so you’re ready to go, and wait to hear more from me.”

To tell the truth, I was still kind of pissy about the theft the previous week, and I think more stressed than I realized by the confined and unchanging work/life situation up there, so I had a very brief thought along the lines of “Yeah? Well what if I don’t wanna?!?” But I said yes – not being willing to go to any more-or-less normal place they want to send you seems contrary to the whole spirit of the work. And, besides – in a minute or two, I realized how nice a change might actually be.

I went and threw my stuff into my suitcase (given the shampoo I had used, the treats I had eaten, and the stuff that had been stolen, I had plenty of room), then headed in to work. A standard-issue day of changing children’s dressings – although, in something I will have to remember the next time I do this, the very short fuse I found I had that morning was a clue that I need to figure out good “mental-health activities” on jobs like these. (I tend to think of myself as stoic and imperturbable, but I think in fact I may be rather more prone to stressing out than the average person.)

Around 10:00, however, we got a call from the OB – the woman with the ruptured uterus, who had never recovered from surgery, for reasons the OB could not figure out, was coming back. She had gotten sicker and sicker over the week, and he wanted to look in her belly again as a kind of shot in the dark, a last-ditch, desperate attempt to see if there was anything there he could fix or improve. We started setting up for this delicate, probably unstable patient (happily there were three of us that morning), and had her in the room when the OR supervisor said someone in the hallway wanted to speak with me. And there was Thomas, with the news that, indeed, they had managed to get me a ticket on the flight out, and I was leaving in an hour.

After confirming with Nicola and Hassan that they were okay taking care of the ruptured-uterus patient (so nice to have good colleagues!), I changed and ran out to the car, which took me to the compound, where my suitcase was already loaded into another vehicle. I said a quick goodbye to whoever was there, turned over my “security money” (the stuff you always carry with you to have something to give to someone if they want to rob you), and jumped into the new car. And that was the last I saw of the Aweil compound or any of its denizens.

Half-hour ride to the air field through the beautiful-but-unattractive (well – to me) South Sudanese countryside – bright green and clay red, but unremittingly flat, scrubby, and monotonous. Brief horn-locking with the official who wanted to know why I was there 20 minutes before the flight, not two hours (he did not make me put my carryon in the little measuring box, however). Short flight to Wau, where we had to disembark for three hours as they waited for connecting passengers. Hideous, humid waiting room whose essence combined a little of the sauna and a little of the urinal, and neither of whose large and promising floor fans worked.

We were told we could leave for a little while if we wanted to, and, as I was ravenous, I headed out across the neighboring dirt patch to what appeared to be a line of shops. I wasn’t sure what MSF policy said about this little foray, and, as I walked along, in addition to the normal stranger-in-a-strange-land apprehensions (Will I be able to identify what they are serving? Will I be able to make it understood what I want? Will I be able to find out what it costs? Will people stare at me the entire time I’m there?), I had visions of being kidnapped and held for ransom. However, as almost always happens, it turned out to be lovely. Largely because when I got there, I ran into Moses, the guy responsible for biomedical equipment at the hospital in Aweil, whom I had seen several times but never actually met. He is one of those people who, quite literally, the moment you lay eyes on him, you feel “I am in good hands.” What is it? What information are we picking up in those split-seconds, and is it in fact accurate? (And does it have anything to do with the fact that he is rather shockingly handsome?) He stood me to a delicious meal of beans and bread (wouldn’t hear of me paying, despite the fact that my annual salary is probably about three orders of magnitude higher than his), and we were back on our way, in much better moods.

The flight from Wau to Juba is longer, and I spent much of it listening in on the conversation of a bunch of “lifer” aid workers sitting in front of me. I think they were all associated in one way or another with FAO, the UN food organization. Such a lesson/reminder of how anything can become normal if you do it for long enough, of how any of our conversations can be cruelly turned into a bunch of clichés by a bad-natured outsider, and of why I never wanted to do this full time. Yes, Mary is in this boarding school – it really is the best one. No, we were in Rome then, it must have been some other time that I saw you. Yes, yes, but was that before or after we had to evacuate Mogadishu? They say that someone who was a total mediocrity in Brussels could go to the Belgian Congo and suddenly become a king. I know NOTHING about the skills or qualities of my fellow passengers, but – it’s always seemed to me that one has to work very hard not to more or less repeat that process today, in the modern age of aid.

Finally in Juba. Funny, when I first came through, it looked like a dusty and disordered frontier town, and now, after Aweil – why, it’s the metropolis! Once I’m settled in in the guesthouse, I get a detailed briefing from the medical director and from Dave, the surgeon I will be working with. More or less as I understood it: Many people were injured in the flareup of violence in early July – mostly gunshot wounds, but also the odd machete slice or RPG gouge. And medical care was scarce or undependable, especially – a point I will come back to in a later post – if you happened to be Nuer instead of Dinka. Meanwhile, the International Medical Corps (IMC), another NGO, already had a medical center in the Protection of Civilians (POC) camp inside the UN base, where Nuer have been fleeing for safety since the start of the current hostilities in December, 2013. So MSF “borrowed” one of IMC’s Quonset huts to set up a surgical hospital to deal with all these wounds. Everyone has already had their initial, stabilizing surgery; now we just need to finish up as many of the additional surgeries as we can before turning the whole ward back over to IMC on Monday (8/15).

The situation is, in fact, a good deal more controlled and predictable than Aweil, largely because MSF has decided that we must be out of the POC by three o’clock, at the very latest, every day. (I ask why that time, in particular; apparently, it is a compromise – any earlier, and the day becomes unworkably short; any later, and the concentration of “drunk soldiers” on the street becomes unworkably high.) So we are NOT on call, which – even though the work in Aweil, where I was on call 24/7, was never overwhelming – is surprisingly relieving to learn. Also, Dave already knows all the patients well, so what we have to do each day is defined. And in some way satisfying, too – setting bones that we expect to heal, covering huge open wounds with skin grafts that, if everything goes well, will give the person back more or less normal function. Aweil was often a holding pattern – we can’t actually do a skin graft to close this huge burn wound, or massive snakebite necrosis, so we’ll just try to keep the wound from getting infected while the body does it’s months-long work of closing the wound off with scar tissue. You were never sure the patient was getting better. It was vital work, as far as the kids were concerned – a large number of them would almost certainly have died without it – but doing something where you can actually envision the arc of healing – there is something about it that, for me, anyway, is more immediately gratifying.

Dave, an ex-Army surgeon (but not at all in the macho mold that I – not, in fact, knowing anyone in the army (!) – assume for the military), strikes me as super, awe-inspiringly competent. I’m looking forward to the next day.

The Theft, 'N' Things

Okay, first of all - before going any further - may I say that, incredibly weirdly, although I am opening this window on someone else's computer (naturally, since mine was stolen - see below), I didn't have to log in to get here. That is, I just put in the general, everyone's-blog website name, and it took me directly to my pages. Hmmmmmm. Magic? Looking at the layout of the page, I'm thinking this must be a Google site, and so the fact that I signed in on Gmail from this computer may explain it. Othewise - they're reading our minds!!!!

So - as many or all of you know from Facebook, I was robbed two nights ago. I was tired from a late-evening C-section of a woman who may have been bleeding out from placenta previa. It's hard to know for sure - her first two blood pressures when we got her into the OR were something like 57/28 and 58/30 - i.e., much lower and your heart stops, very consistent with heavy blood loss. Also, she was SWEATING, which is kind of a marker of "Oh shit!" in your body (people sweat when they're having heart attacks, for example). On the other hand, with pretty moderate interventions from me, she climbed over the next couple of minutes to a normal blood pressure, making me wonder if the first two reading were "artifact" - i.e., equipment-related. Don't know. All I do know is that, after a lot of "resuscitation" - three liters of fluid, half a liter of "colloid" (something meant to better stay in the bloodstream and not just go into tissues; roughly equivalent to 1.5 liters of fluid), and a unit of whole blood - she was stable at the end of the operation. And the baby lived, too! So it felt like a good outing, a successful night.

As usual, I got in bed with all my "devices" - computer for checking political news (can't stop!), IPad for reading book; phone was actually on the table being charged, but when I got up to pee around 2:30 I brought it into the bed, too (it's my morning alarm). 

Then, about 5:00, I woke up to pee again (it's NOT prostate problems! I've ALWAYS had to do this!). I reached for my phone, to see what time it was - and couldn't feel it. Then I reached around for the computer and IPad. Couldn't feel them. Then I got out of bed and turned on the light. And did all that "This CAN'T be right!" stuff (looking under the bed, as if everything could have fallen there - looking under the pillow - looking around the room). Until I finally noticed that my bag was missing, too, along with the local cell phone they give us. 

I still had the idea that, you know, maybe some of my colleagues were playing a TRICK on me (one had just gotten back from vacation and there was a lively party in her room all evening - perhaps they, you know, got up to some HIGH-JINKS!). But that idea didn't really have much conviction. And, ongoing resistance notwithstanding, I kind of had to concede that theft was the likely explanation when one of the TWO guards (um - I do have some question about why the guards didn't succeed in, you know - guarding), whom I had alerted to the theft, found my bag outside in the street, half-dumped-out, but with everything except an envelope of money (only $15) still in or around it.

Back inside, the guards had found a place where the razor wire that tops our compound wall had been pushed up to a height that would let someone slip through. I am in the first "tukul" (hut) you arrive at if you've entered the site that way. I've wondered if it might have been an inside job - I have never hidden my computer when walking around, and I've always slept with my door open for ventilation, which anyone who worked here and paid attention would have noticed. Also, no one else was robbed. But maybe it was just that they got to me first, and happened to get lucky.

In any case, it's amazingly brazen, isn't it? I am a deep sleeper, but what kind of person would come into someone's room, have a look around (I assume in the dark) to somehow figure out where things of interest were, then assume they would be able to lift my mosquito net, reach over me, pick up three electronic devices, grab my bag and local cell phone for good measure, all without waking me up? Whatever else I may wish to say about them, they do appear to be very good at their job. Oh - and very creepy, too.

Anyway, at this point, I was just grumpy and PISSED. Took a shower; went to the kitchen area and tried to read the one book I had left (which is contemporary political history in French - not exactly easy and relaxing reading for the stressed!). Waited for everyone to wake up, so I could inform the relevant parties.

Once I'd done that, we decided/I realized 1) that we would file a police report (unlikely they'd find anything, but worth a try); 2) MSF DOES have insurance (though someone told me tonight it may have a maximum of $500, ha, ha - if that is the case, I sure think they should tell us that before we come out here - but I have found that communication of the actual situation is not entirely their strong suit!); and 3) I would need to come home a couple of days early to replace all the stuff before leaving NY again (can't do it on line - variety of questions re: phone contracts, whether the Apple Care I bought for the new computer 6 months ago can just be applied to a replacement, etc.).

So we got all that rolling. The visit to the police, which we all had assumed might take a couple of hours, was amazingly quick (<10 minutes), although, since the police report was written in Arabic on what appeared to be a piece of previously used scrap paper, I am not sure it will be of much value in the insurance-filing process. When I finally went into work around 10:30, I discovered that my local colleague Nicola was just planning to do all the cases that day (he'd heard what happened). Very sweet - and, as it turned out, really important. I just went home and hung out and rested. And felt really weird - violated, vulnerable, wanting but unable to be weepy. I just didn't feel part of the normal world; I think having to do a normal, skilled task would have just been hard that day.

And since then - I've felt a bit like I've been going through the Five Stages of Grief, or whatever they are. Maybe not literally, but - there was definitely about 15 minutes of denial; there's been quite a bit of grumpy anger. Don't know about bargaining or the next one, but I can sort of see myself heading towards acceptance. As everyone keeps writing to me, nothing really important was touched, and, in that case (and maybe in worse cases, too?), the new situation just sooner or later becomes the new normal. Good thing we can do that, I guess.

(It doesn't hurt that the OB has been INCREDIBLY generous letting me use his computer, and, today, we realized that if I pretend to be in his "family," I can load all my books onto his Kindle, which he's not really using right now. So in fact not that much has changed! I'm sort of wondering if I should in fact NOT borrow his stuff, if I'm missing a chance to be "unconnected" and feel what that's like for a while. Not playing ball with fate?)

And people have been so nice. One of the snooty French people just came by at lunch and looked me in the eye and asked me how I was doing - made me feel very taken-care-of. And in the OR today, all the staff had heard about it, and so everyone asked me, and were very generous with their condolences. One guy was talking about how the situation in South Sudan makes this kind of thing happen more than it should; he said he had had a mattress and sheets stolen recently (which, in fact, is probably much more of an actual blow to him than losing all my stuff will be to me). I think it made me feel less - I don't know, dissed; like a sucker. His sharing that he'd been taken advantage of similarly. Seemed very sweet to me, a generous solidarity.

But the most recent chapter brings up other "questions." So, what do you think? This afternoon, I realized that one of the wonders of the world-spanning Apple (who's CEO just held some big Republican fundraiser, BTW) is that they now have all these security options that let you make anything that has been stolen essentially unusable, if and when the person tries to go on line with it. I already knew I had to shut down the phone (South Sudan in not on AT&T's international plan (imagine!), and the charges would mount up rather quickly), so I did that. But then there was the bigger question: Do I make all the devices as unusable as possible, or do I say "Eh - they're no use to me now anyway - let someone get some value out of them"? 

I was a little surprised by my conclusion - actually, I was more surprised by how strongly I came to it. I shut 'em all down! Partly, but importantly, it's that I don't want to encourage this as a profitable activity. It sucked that it happened to me, and I'd rather not promote it's happening to somebody else. But I guess I also - lecturing well-off person alert! - don't think stealing is really a great way to get along in the world, and don't want to encourage it. And I also think encouraging it, by allowing the thief to profit from it, would be kind of insulting to the MILLIONS AND MILLIONS AND MILLIONS of people who don't steal. It is one of the things I've been most amazed, and impressed, and oddly humbled by, in all the work I've done all over the developing world. People almost NEVER steal from you. Again and again, early on in doing this kind of work, I'd misplace something, and, you know, tell the hotel front desk that I thought someone has stolen X or Y. They NEVER had. It was always me - I had misplaced it. I know, I know, some of it is that I am by definition a powerful person in most of these contexts, and so stealing from me may be perceived as dangerous, etc. But I truly think it is more than that. A friend of mine once accidentally left $400 in plain view in her hotel room in Burkina Faso. She lived in Senegal, and told me that, absolutely no question, 100%, in Senegal the money would have been gone (Senegal is known for being one of the more money/businessy oriented places in West Africa). The person might lose their job, etc. (or might not), but it would be worth it to get, what - 2 years' income? Well, there in Burkina, a MUCH poorer country (4 years' income?), the money was right there where she left it. I just think it has SOMETHING to do with dignity and honor. And I'd like to honor that, and not the lack of those things. 

So - whoever has my devices will be able to watch my 5 movies over and over again, and look at my pictures, and read all my FASCINATING documents. But the minute they try to use any of the devices on a network, the devices will lock themselves up and display a message asking the person not to buy or use stolen goods, and to call MSF to return them. 

And I feel just fine about it (though I'm sure some of it is the more Trumpian satisfaction of feeling that I've stuck it to the people who stuck it to me). What do you think? Would you have shut everything down, or said more, well, if I can't use it, let someone else, then? I'd really love to hear anyone's ideas about it.

So that's my story today. I had wanted to say something about how I'm beginning to feel better about the power/"colonialism" issues that had been bothering me (basically, some of it is just people learning to work together, with all the associated bumps; we're not always 100% "nice," but something good comes out of it anyway). But that seems kind of extraneous at this point. I'll leave it there - except to say that I am REALLY happy to be coming home in a little over a week. It's interesting to see what these jobs are like, and I do think I'll do them again. But the whole thing is not easy. I'm ready to be done, back in my world and among my peeps.

Trigger warning

I don’t know if it’s interesting to others, or more just a sort of morbid fascination on my end, but – in the same vein as my recent post re: how hard life can be w/o modern medicine - I’ve been thinking about the incredibly weird (for a Westerner), sad, and frankly gross stuff you see, sometimes, here. This post is going to discuss a couple of them, and, at the very bottom, there are some photographs. So – if you don’t want to read about gross medical things, and especially if you don’t want to see them, either skip this post, or stop scrolling when you get to the end of the text. I’ll leave some space between there and the pictures so you won’t be taken by surprise.

So, the first – um - interesting malady I wanted to mention is not something I have actually seen, though one of my colleagues has. It’s called bot fly, and it is truly worthy of a horror movie. (In fact, I actually saw a movie once where this happened, and it freaked me right out – the memory is still powerful.) What happens is this: The fly lays eggs in some way as to bring them in contact with your skin. I have heard that one of the things it likes to do is lay the eggs on clothes hanging on a line at night, which is why they iron all our laundry here, and why you’re supposed to take anything you’ve hung up inside before it gets dark. Anyway, when they contact your skin, the eggs are able, on their own, to burrow into it. And, once there, they hatch. So that a little while later, you develop what looks like a pimple. Except if/when you squeeze it, AN INSECT COMES OUT! Well, a larva comes out. But, from the point of view of grossness, that seems to me a distinction without a difference.

I guess I’m being a little light about that particular parasite because – well, I’ve never actually seen it, and I don’t have the impression it is rampant, in any case. Plus, though it sounds repellent, presumably the damage done is relatively superficial. (Also it’s so weird and nefarious, what can you do but laugh?) I can’t joke about the next one, though. I see it regularly, and I still don’t know WHAT is going to happen to the kids afflicted by it. It could very well end up costing them legs and feet.

I’m talking about snakebite.

It’s interesting to me how many things we sort of think we know about, but, in fact, really have no idea. Reminds me of what European explorers in the Arctic found when they asked local people to describe/map out the local geography. Apparently, people were able to give remarkably precise and accurate maps of any area where they actually lived/worked/hunted, but when they started talking about areas they didn’t usually go to, their accounts became fanciful. There are a lot of “hinterlands” in my mental landscape – places I’ll happily describe to an interlocutor which turn out, upon investigation, to be figments of my imagination. (Doctors may be particularly good at this. I remember my first college friend who went to medical school telling me, during his residency, how most of what a doctor can tell you is what you DON’T have. He said when he saw a doctor venturing beyond this while talking to a patient, he could tell when the doc “just started to make stuff up.”)

Anyway – to the extent I’ve ever thought about snake bite, I guess my image has been “Snake bites you – something bad happens – you die.” As if what snake venom does is strike directly at some central body system, and it is all over quickly. And, of course, there are snakes like that – mambas, as well as little tiny coral snakes, have a venom that paralyses your respiratory muscles, and that’s it. Can’t breathe – die.

But a great many snakes have more insidious venom, that does things like thin your blood, or break down your cell membranes so that what was once differentiated, functional tissue becomes a kind of egg-scramble of inactive organic molecules.

We frankly don’t know which snakes are biting the kids we see – I don’t even know what snakes live in South Sudan. But bite them they do. One of my OR colleagues said that you especially see it around this time of year, the rainy season. The rains fall, the grass gets tall, the kids go out and play, as kids do, and the unseen snake feels molested and strikes.

In theory, if the kids could be treated immediately with antivenin, they might have only minor problems (although that isn’t actually certain…). But often, we don’t see them for days – over a week in some cases. The problem may be distance from the hospital; in addition, the OR staff tell me, people may go first to traditional healers, which also costs time. Giving the poison – here, it seems to be primarily that cytotoxic (cell-killing), egg-scrambling venom I mentioned above – lots of time to work.

By the time we see them, large areas of skin around the bite have either blistered up or fallen off, and underneath, there are expanses of dead, liquefied, pussy tissue. (Since I’ve already given you the trigger warning, I guess I can say that, sometimes, you can smell these wounds all the way down the hall.)

When they come to the OR and the technicians begin to debride the wound, whole areas just dissolve and fall off. And what is scarier to me – often the entire layer of tissue above the tendons and muscles – the skin, the subcutaneous fat, the connective tissue; half an inch of the stuff that makes your leg rounded rather than wiry – is dead, over a large part of the leg. One girl we are treating now had a kind of fissure that went from her lower leg up past her knee to her thigh; over the past few days, the fissure has opened up, revealing dead areas halfway up to her groin. And about half the cutaneous tissue of her lower leg has already fallen or been cut away, allowing everything – muscles, tendons, ligaments – to be plainly visible. It is like looking at an anatomy textbook, or even something bionic.

But isn’t it nice that they made it to us eventually? Well – yes. In the sense that they now probably will not go septic (get a blood infection) and die. But the fact is, we do not have the means to treat these kids. I don’t think they would be cured by skin grafts – for those to work (and we don’t do them here, and they are very iffy, in any case, in any situation where you can’t maintain absolute sterility), there has to be something to graft the skin to, and I don’t think muscles and tendons qualify. My sense is that, in the West, these would be cases where the survivor, or his/her family, would regale the curious years later with stories of how it took “12 surgeries to repair!” Grafts of muscle and fat, watched over scrupulously for days to ensure they maintain their blood flow and don’t choke off and die; skin grafted, and possibly grafted again. We can’t even do the first operation, let alone all 12.

At this point, I simply do not know what our plan is for these kids. I’ve asked my Medical Director if we can clarify what we are doing, and I think we may send the photos to a “surgical referent” in Paris who can give us some idea of what the options are (remember – none of us on this project is a surgeon!). But in the absence of any suggestions from higher up, I can only see two possibilities: Keep cleaning the wounds and changing the dressings every couple of days, which is not in any way a solution – merely a holding action that, hopefully, if we’re lucky, will prevent new infections, but without actual healing. Or amputation.

I saw a young woman with one leg the other day, making good time on crutches in the market. Maybe, in the scheme of things, it wouldn’t be so bad. But what disability (and what, I don’t know, devaluation in the marriage market, leading to “spinsterhood,” dependency, and maybe abandonment in old age – as I say, I don’t know).

You can see the other shore, of cure and safety and wholeness. But the river is flooding, and there is no bridge, and you can’t get there.

Here are the promised pictures, of the sequelae of three different bites. Scroll down a bit; as I say, I wanted to separate them for anyone who doesn’t want to see.