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.

Change of Pace

Perhaps you remember that I said, a few posts ago, how there wasn’t really enough work for me, so I had to go looking for other things to do? Well, the past five days have shown why it is they need someone like me here, even if I’m sometimes twiddling my thumbs. In my first almost 3 weeks, we had a grand total of 2 C-sections (plus 2 other very unusual emergencies). In the past 5 days, we have had 8 obstetric emergencies. Mostly C-sections, of varying degrees of urgency - but this morning, we had the first case I have ever seen of a ruptured uterus. Which is just what it sounds like – the woman is in labor, and the uterus, in contracting, literally tears itself open. Usually, as in this case, it requires an emergency hysterectomy; it is potentially very dangerous because of blood loss. There were 15 minutes there when I thought we might be going downhill, but some blood (which the bank happily did have!) and some epinephrine (not something you generally use outside of heart attacks and surgeries on very sick people) brought her back – her vital signs were like yours or mine at the end of it all. Cannot bear kids anymore (which may be a stigma here, I don’t know), but she is alive, which she definitely would not have been without us. Feels good!

In general, I would say that I am learning “how it is done here." Partly just internalizing all the new things – the layout of the operating room; where the drugs are stored (so I can be more and more efficient when called in for an emergency); what happens to kids when they are sedated on ketamine (a drug I have rarely used before now). Partly coming to better terms with that thing I fret over, the awareness of not being perfect, the guilt that there is a learning curve. The last few days – where I have seen myself actually move forward on that curve – have been helpful in that regard. 

It is strange how very hard it is for me to give up on the ridiculous, and not even very interesting, idea of being perfect….

It's all a longer, and to me very interesting, conversation, but I'm not quite ready to go into it here.

Anyway, the more familiar I feel with everything – and I imagine the more open and generous, the less worried and tight, I manage to be, too – the more at ease I am, and I begin to really enjoy it. I’m past the halfway point, now, and I AM happy about that (I’m sure that plays into the enjoyment, too). But the time remaining doesn’t, tonight, feel like a penance.

As for life in general – well, Movie Night this week was “Point Break.” (Hey, at least that one is directed by a woman, albeit the woman who made “Zero Dark Thirty.”) So, no, not much has changed. But I’m getting some reading done. And there is a new OB, a Spanish guy who has lived in the States for a long time. And today a nerdy German electrician showed up. (Do I get along with both of these guys partially because they are about my age? I’m guessing the answer is yes.) And I’ve begun calling out the snooty French people who won’t speak French with me even though my French is MUCH better than their English, which gives me a certain negative satisfaction (!). And – I feel like, if any Trump voters are convincible, the Democrats this week actually did what they needed to do to convince them, which is SUCH a relief! So, for the moment, life outside work is pretty darn good, too.

Oh, and, yes – I’m not sick anymore. Cipro turned out to be the right drug to pick (the problem could have been parasitic, in which case it would have been the wrong drug). It did it’s magic in a couple of days. In retrospect, I think I had a mild infection almost from the day I got here – these last few days have been the first time I’ve felt more or less normal, stomach wise, the whole time. Life is so much better when your stomach is good isn’t it? It’s so CENTRAL.

People

So, you’d think writing about the people I see and have met and treat here would be one of the first things I’d do (you would, that is, if you didn’t know what an introverted curmudgeon I can sometimes be). But, you know – it’s hard. As I think I’ve said before, of all the places I’ve worked except, perhaps, Vietnam, Africa (and perhaps eastern and southern Africa in particular?) is the place I feel I get to know people the least. I know some of that is my problem. The history of Europe/whites in Africa is so fraught with horrors – I can remember the first time I went on a work trip to Kenya, I found myself thinking, “My God, I can’t believe these people will even talk to me!” And then, as this summer continues to show us, the sequelae of those horrors are far from played out. So maybe that makes ME stiff – self-conscious – a little guilty and earnest – in a nutshell, a little blocked and not good at communicating.

I think it’s more than that, though. As a contrast: In India, I have the sense (correct me, those who think this is crazy!) that there was a certain consonance between colonizer and colonized. Meaning that the Mughal state was a large, integrated, stratified, bureaucratic state, and so was England – in some weird way, they “got along.” Plus, England was messing around there for a LONG time, starting at a time when the technological pre-eminence of the “West” wasn’t quite as strong as it later became. So I feel a bit like the Indian substrate and the European overlay kind of grew together, to the point that now, in cities, anyway, what remains is a culture that is different but not alien, that speaks an English you can understand, that has entry points but is still unequivocally “local” (it’s one of the things I LOVE about India).

But I feel like Europe came at Africa when it had guns and steamships and railroads and mining equipment, technology that gave Europe power WAY beyond what Africa could muster. And it came at Africa with centuries of contempt for its people, and with more or less one objective – to profit (oh – and maybe to convert, too). So that I feel like what happened in the places where the Europeans came and lived and worked is that they simply pushed African cultures aside, wished them away, made them go into the background and underground. The result being that, often, in many places in Africa, you can go to a supermarket, or a gas station, or in some places a downtown, and it feels rather dully familiar. But to make the jump from this simulacrum of the West and enter, even a little, into how people actually live must take time, and patience, and a kind of commitment.

So, anyway – I don’t feel like I have much of a sense of the actual lives of the people here (beyond certain physical conditions which I can observe). But here are some impressions:

English is now one of the official languages of South Sudan (it used to be Arabic, when it was part of Sudan proper, a scant 5 years ago), but most people speak it in a way that makes us fairly mutually uncomprehending. I frequently have to ask the guys I work with in the OR two or three times what it is they are trying to tell me, and sometimes I have the sense, with me, that they just kind of give up and make assenting noises, though they don’t really know what I’ve said. This does not make for easy conversations! On the other hand, there are these wonderful bits of music that come along with the way English is spoken here that make me smile. For example, “even” as a modifier always seems to go at the beginning of a phrase – so it’s not “You can even wash it,” but “Even you can wash it.” (That just cracks me up!) And “that” does not appear to be enough to indicate an antecedent; it has to be “that one” (the way in Romance languages you often have to use an object pronoun where it is understood, in English?). “You can use that one;” “That one (speaking of my IPhone) is very nice!” It is subtle (they are not saying “that IPhone in contrast to other IPhones,” they are saying “that IPhone”), but unmistakable when you hear it. Gives the sentences a little catch in their step.

There is a certain interest in American politics here – people have even asked me about Hillary’s e-mail problems! And there seems to be a widespread belief that, after 8 years of a Democratic president, a Republican has to be elected, and vice-versa. (I have made it clear I very much do not want this to come true!) It actually makes 100% perfect sense when you think that the people I have talked to who hold the belief a) are all pretty young and so know no Presidents before Bill Clinton, b) live in a country where power-sharing seems to be the only hope for avoiding intercommunal bloodshed, and c) may very well not have experienced “elections” as having much to do with their actual choices. They’ve asked me about Trump, and I’ve told them what I think – I can’t get much sense if they have an independent opinion (I remember arriving in India in the ‘80s and being amazed how many people LOVED Reagan!), since I sort of think they just agree with me out of politeness. When I ask them about the situation here, they – like the Irish people I talked to during the “troubles;” like most people in most war-torn places, I imagine – shake their heads and tell me “what South Sudan needs is peace.”

People come in all shapes and sizes, as you might imagine, but there does seem to be something along the lines of a “classic” Dinka physiognomy. VERY thin, VERY tall, with purple-y black skin (think “classic” Dutch physiognomy but thinner and a whole lot darker!) I think I am below-average height among the OR personnel, which doesn’t happen to me very often, and I have run into women who are taller than I am. And the men’s hips are stunningly narrow; they are like humans as bright gesture, a brushstroke in the air. One of the “techs” is about 6’3” and I think he weighs, max, 130 pounds (and I don’t think he is malnourished, although maybe deficits in early nutrition contribute - ?). Some Dinkas also do traditional things with their teeth – removing the lower incisors (one of the letters in their alphabet is actually kind of hard to say if you have lower incisors) and, it seems, intentionally cultivating buckteeth in the upper incisors – although I have met many people who have not done this. You also see very delicate scarification patterns (on the face, on the torso), which, apparently, make people’s ethnicity instantly recognizable – during the civil war, having “Nuer” scarifications in a Dinka area could apparently be deadly – but I truly know nothing about this.

As so often everywhere, men tend to look a lot shlumpier than women – t-shirts, random pants. Although – as far as I can tell, almost all the clothing stores (er – stalls, rather) in town sell used clothes, arrived here by whatever Byzantine route, and it is impressive how sharp some of the guys can make a second-hand button-up look. The women, by contrast, wear all sorts of colorful clothes, ranging from things that look like a suit you might see (or have seen 15 years ago) in a suburban office, to dresses indistinguishable from those on sale at NY summer street fairs, to – most commonly – something that looks to me like a sari (apologies to those who know how a sari is actually wrapped!): Tight undergarments of some kind swathed in a wrapping of colorful fabric, usually with a tie of the same fabric covering the head. My favorite, however, goes one step further: Many women (and I wonder if it has something to do with religion? we are very close to Sudan proper here, and I hear the call to prayer every day) continue the wrap of cloth so that the end of it sort of wraps and piles onto and floats over their head, like a kind of colorful cloud. I’m not sure where I’ve seen photos of this style before, but something about it seems classically Saharan. Picture it: A tall, thin, dark woman, with a nimbus of bright orange fabric winding about her body and face, perhaps walking along with a bundle on her head. I don’t want to exoticize, but it looks very – exotic! And beautiful. (Not to leave the men out completely: The other day, I saw a guy dressed entirely in white, his head topped with a white cowboy hat, peddling along on a white bicycle. He looked like he should be an important person in the community; I wonder if he was?) Men basically all seem to wear their hair cropped close to the skull; women – any manner of braid, weave, extension, what have you, you can imagine.

I think that – like many places on earth – there may be a formality in public intercourse here that makes swearing not like at home – makes it a VERY serious matter (we could probably use a dose of that in the States, no?). I actually said “fuck” in the OR yesterday (not AT anyone, nothing like that, but it was still totally stupid – me getting worked up over something that turned out not even to be a problem), and I had a subtle feeling I might really have offended people. More, that I might have lost some respect, in their eyes. I did my best to apologize, clearly and more than once, and everyone has been very nice since, so maybe it wasn’t as bad as I thought, or maybe they accepted my apology (or maybe they are just nice).

Well – hmm – that’s all fine and good, but I’m not sure I have anything more intimate to say about the folks who live here. People are usually friendly when you say hi on the street, although, as I’ve said before, they also (especially patients in the hospital) often look at me like I’m from Mars – either a potentially dangerous life form that must be carefully negotiated, or an irrelevance. Though, you know, I think some of that is probably me overinterpreting the serious look of someone who has to be in the darn hospital, for Chrissake. Today, I had to get a woman to bring her child for a lumbar puncture, then take him back to his bed, and we wordlessly communicated just fine – I wondered whether there might even have been the little hint of a smile.

Little kids NEVER seem to tire of yelling out “khawadja!” (“white person!”) when we walk by, even though we walk by every morning, and they are the same kids every morning. Lauren, I don’t know if you are reading this, but it always makes me think of a story you told me one time in the basement of Foley House – how, when you were in Spain in the late 70s or early 80s, people would sometimes point at you and yell “negra!” and you wanted to yell back at them “I know!!” Makes me smile to this day.

There are street kids at the hospital gate who will follow you around asking incessantly for money, bringing up all the issues that one is never satisfactorily resolving – why shouldn’t he have some of my money; but it might sow conflict if he gets some and another kid doesn’t; and isn’t it demeaning to be put in a position to beg, and to encourage it; and, anyway, what happens when I go in a few weeks and no one’s giving him money any more – on and on. All coming down to the ineluctable fact that, for some reason that doesn’t make any actual sense, things being left as they are, I get to be comfortable and he doesn’t (unless he’s a Zen master, which, who knows, maybe he is).

Some of the babies seem a bit freaked out by white people, but there was one yesterday – maybe 6 months old, doing great after a bout of croup, about to be discharged – whom I got some great baby smiles out of while we were hanging out by his bed. (I love the occasionally bobbing, uncertain carriage of the head at that age!) His mother seemed happy, too.

And maybe I’ll leave it at that.

Except to say that – I’m sick! I’m sick! My stomach has NEVER been right since I got here, but I’ve actually felt pretty okay except when I eat (!). And my eyes have been burning, and then I started to get a cold a couple of days ago – but I still felt basically okay. Today, however, still feeling fine, I passed a colleague at the hospital and she asked “Are you okay? You’re looking a little peaked there.” And, wouldn’t you know it - she was right. Within a couple of hours I started to have that light-headed sick feeling, and this afternoon – well, lets just say I’m losing a lot of WATER, through the LOWER (not upper, happily) orifice. Still light-headed and headachy; maybe a little fever – but, hey, actually, it’s not that bad. I started taking antibiotics this afternoon (I’ve had many bouts with bacterial GI stuff, and this feels like it might be that), and am all ready with my anti-parasite meds if I’m not better by tomorrow (Giardia has been a bit of a problem here…). Drinking my oral rehydration salts mixed with Emergen-C (not bad, actually). Expect to be able to report a full recovery…sometime soon. (Tomorrow is my day off, wouldn’t you know it? Well, probably better to have it as a day to recover rather than feel this way in the OR.)

Have a good weekend, everyone – talk with you soon!

The Raw and the Cooked

I plead guilty to being one of those people who can fall into romanticizing an imagined “earlier time.” And I don’t think it is entirely crazy (although it may be entirely fruitless)– the rapaciousness of our technology does seem to have the potential to make the earth unliveable; the balance between the constructed human environment and nature does seem to be off; the scale of killing in the conflicts of colonialism and the twentieth century is truly monumental and unheard of in the past; consumerism does seem rather poor at giving meaning to life – etc. But one thing being here reminds you of over and over again: Life without the health and safety measures we have developed over the course of the past few thousand years is no picnic. The skin infections, the funguses, the blindness, the withered limbs, the burns that lead to contracted, barely useable legs, the pus-y abscesses, the insect-borne diseases, the diarrhea, the inability to drink water without risking getting sick – man, it is hard. It’s possible that subsistence life prior to contact with a market economy was a little easier (population density was smaller, nutrition better, and meaning-systems presumably more intact), but I doubt it made a lot of difference, regarding this sort of thing. It reminds me of the impression of peasant life you get from late 19^th- and early 20^th-century Russian writers – destitution, squalor, and few if any options. Very often, I can’t tell if the woman sitting with a child is his mother or grandmother – she seems to be the mother, but she looks so old. The wear and tear of life that leads to that – it’s not something that anyone reading this is likely to have even tasted.

Although…a little voice in my head points out that some (certainly not all!) of the above reaction probably has to do with a good old American fear of – dirt. What do you think – if you’ve never had a daily shower, do you miss having a daily shower? If you’ve never had a house with a door that keeps the dust out, do you mind having dust in your house? Certain issues are objective (do you have the resources to keep a wound clean? Can you keep domestic animals out of your water source? Is your air clean enough that you don't get serial respiratory infections?). But beyond that – is there anything objectively unpleasant or unhealthy about not being able to keep things to the cleanliness standard of an American suburb? Is distaste for dirt more akin to a habit? I honestly don’t know. I can tell, however, from the frequency with which I reach for words like “squalor,” and from my discomfort with the judgment such words imply, that at least part of my sense of how hard life is here comes from a squeamishness about “uncleanness.” Which may largely be beside the point (?).

Okay – next time I'll get to the promised musings on the people I'm meeting!

IPD-1

My role here is a little strange – they have to have someone like me as an insurance policy for (rare) emergencies, and yet there generally isn’t enough work to actually fill up my day. So I’ve started rounding with one of the general MDs in the most acute pediatrics ward, to see if there is anything I can do to help them out with their (huge) workload.

So far, I’m not sure I’ve actually been that much help – but it has been fascinating for me. First of all, just getting used to the place, and to how it works. From my description of the hospital a few days ago, you can probably already imagine that the ward is – intense. Each bed is filled, not just with the young patient but also always with a caretaking family member, usually but not always the mother. The kids are sick and hot and bored, so the ones with enough energy may very well be crying. And though there are a fair number of fans, the air is hot and steamy. And has a particular smell – sharp and sour, some combination of urine, sweat, and dust. For someone not familiar with it, the first impression is of alarming chaos, a cul-de-sac off of one of Dante’s circles of hell.

But within an hour or two, you begin to see how it works – how the patients are being looked after, what the mechanisms are for making sure the sicker ones get more attention, the pathways for moving them along toward discharge as they get better. As I’ve mentioned a few times, malaria season has arrived in earnest, and most of the patients in this ward have it. (There is still an overflow of malnutrition patients, too, but they are in a different ward.) Each patient goes through a pretty standard protocol – malaria testing; evaluation of the severity of the malaria, including whether or not the child has “cerebral malaria” (in brief, very dangerous malaria that causes brain swelling and seizures); testing of hemoglobin and blood-sugar levels (since malaria can cause severe anemia and hypoglycemia). Treatments are based on results: if it is just plain malaria, a three-day course of treatment usually cures it. If cerebral malaria is suspected, antibiotics are added “empirically” (doctor-speak for “without first waiting around to confirm that the treatment is necessary, since by then it might be too late”) to treat possible meningitis (the two are hard to tell apart). If the hemoglobin is too low, the child gets a blood transfusion. And hopefully, after a couple of days, he or she is well enough to be moved to a less acute ward and, later, back home.

The devil is in the details, however, and the details are different from anything you might see at home. Take the matter of blood transfusions: A normal hemoglobin level is somewhere between 12 and 17. For some fragile patients in the US, anything below 10 can prompt consideration of a blood transfusion, and, informally, anything below 7 is often considered a “hard” indication for the same. However, many, many people here have anemia all the time, and your body is amazingly good at adapting to it. So our cutoffs are 5 (if the patient has severe symptoms or complications) and 4 (our “hard” floor). But you can often see kids with hemoglobins under 4 – a level that would prompt US hospital staff to run, not walk, to the blood bank – sitting around looking fairly un-distressed.

Then there is the matter of where to get the blood. It appears that the idea of giving blood, as a kind of general gift to some unknown recipient down the road, just doesn’t work, culturally, in South Sudan. (I can kind of imagine why – it’s weird to give a bag of your blood to someone, isn’t it? What if they take too much – or take it all…?! And isn’t it in some way like giving away your “essence?”) So, usually, if a kid needs a transfusion, we have to get a family member to go to the blood bank right then and give some. Which, happily, most seem willing to do. Of course, being a family member does not necessarily mean you will be a match – but the blood bank does have a small stock of various blood types; if the parent doesn’t match, the bank can dip into that small reserve and save the family member’s blood for someone else. Apparently, at the height of the malaria season, about a third of the kids who are admitted end up needing transfusions – so it’s a really good thing that there is a system that more or less works, different though it may be from what we do at home.

We expats, on the other hand, have been told we cannot give blood. The explanation seems to be 1) that they don’t want us getting anemic and exhausted, and 2) that if our blood is used and something happens to the patient, we might be blamed, and it could get ugly. Apparently, though, on our last day we can give some – we can sleep on the plane home, and I guess if the patient doesn’t make it, we’ll be too far away for mob vengeance to reach us - ! So I’ll try to leave a little of my A-negative behind – actually, a relatively valuable contribution, since apparently EVERYONE here is positive. You can’t give positive blood to a negative person – so, on the off chance that a person arrives who does happen to be negative, my blood will be useful.

It’s nice to watch the ward doctor (an expat) doing his work – the principle really seems to be that this is the LOCAL PEOPLE’S hospital, and so it is the local staff who should triage, evaluate, make decisions, prescribe, update the plan as necessary, discharge. The local practitioners – called COs, or Clinical Officers – have different levels of training, from basic nursing up through MDs (albeit MDs earned in systems that are not necessarily up to what we might expect in the US). So some of them need more teaching, help, and support than others. The expat doctor provides guidance as needed, but the discussion today really was more like one between colleagues than like the outsider telling the local what to do. I’m glad it can work like that sometimes.

Hey, and check out the latest fashion - scalp IVs! EVERYBODY'S wearing' 'em! (This guy was just about to have his out - he was going home.)

The Town

I’ve given you some sense of the hospital environment, so I thought I should also describe the town.

Aweil has an official population of somewhere around 35,000 (a little less than that in the 2010 census, but, what with population movements caused by the war, it’s hard to be very exact right now). As those of you who have spent time in developing world towns will suspect, however, it “looks” – to the eyes of a westerner – much smaller. At first blush, in fact, it looks much less substantial to me than, say, Shelburne, Nova Scotia, a town where I spent many summers as a child, population 1,600. I’ve always explained this to myself (and I think it makes sense) in terms of resources – if you are rich enough to build (or rent) a big house, with a yard, and drive a car to stores that are stocked with lots and lots of things that only rich people (relatively speaking) can buy, etc., etc., well – your one life just has a bigger footprint than one life over here. So that 1,600 of you can end up looking like more than 35,000 South Sudanese. (We talk a lot these days about the relatively abstract “carbon footprint,” but it’s interesting how physical – how visible – it actually is.)

The town has one paved road and is otherwise arranged around a network – more or less gridlike – of red-dirt streets which, in the absence of any regular grading, often have undulations and holes as large or larger than a car, and sometimes two or three feet deep (after a rain, these are called “lakes”). We often ride to and from the hospital in cars because of security requirements, but negotiating these streets means the car trip is only minimally shorter than walking.

It appears to me that more than half of the structures in the town – in fact, maybe 80% of them? – are mud-walled and grass-roofed, the grass being set out in tiers rising to a little witch’s-hat peak – quite attractive, although most of the roofs are a bit bedraggled. The remainder of the buildings – mostly in the market area, but also the hospital and a handful of others – are stuccoed brick or cinder-block. Their predominant pattern, seen throughout the market, is a long one-storey building, divided linearly into rooms or shops, with a concrete porch in front covered by a corrugated metal awning held up by rough 4 by 4s. The stucco is painted varying shades of taupe and yellow, with also quite a lot of sea-green scattered around. The rooms are generally closed with metal shutters, which are often painted royal blue with a yellow star on each panel. The town is very colorful, in other words, if also always smudged and smeared (as are we) with red dust.

Apart from this, there are a few buildings of the linear, market type that have a second storey, though it often appears to be unfinished and/or unoccupied. And I’ve seen two three-storey buildings. One is a bank; the other is of unknown purpose, but everyone thinks that it – like everything around here that smacks of greater-than-subsistence living – belongs either to the government or to the military.

The main (paved) road is lined with huge green trees, also dusty, but pleasant and attractive. And the town – or, at least, the market area, which is the only area I see with any regularity – is bustling with people. In the morning, and again in the early afternoon, there are troops of children in their blue school uniforms heading off to and then home from class. And throughout the day, there are shoppers, merchants, street children, motorcycle-taxi drivers, auto-rickshaw drivers, mothers with babies, sharply dressed young men moving with purpose, town drunks and lunatics, you name it, ambling or occasionally hurrying around the market.

Speaking of schoolchildren – it’s nice to see that, here at least, the basic education system appears to be functioning. Although last week, a dispute over the management of a school led by some strange chain of events to a policeman shooting a teenager in the back. NOT what you want to have happen in a country already on edge. For a short while that afternoon, there was an absolute ban on movements (we couldn’t even go to the hospital), and we were required to stay inside our huts. But nothing else happened, it all settled down quickly – and the kid, pretty amazingly, is doing fine.

One final observation: As I also noticed, again and again, in Ethiopia, the largest, cleanest-looking, most attractive building in town is the (Catholic) church. Maybe familiarity makes it look particularly nice to me: You could pick it up and plunk it down in Boston or Philadelphia (or, probably, somewhere in France) and no one would look at it twice. A waste of resources in a hungry country? Or an excellent investment in a place that relies on spiritual sustenance to get it through the times when material sustenance is lean? You make the call!

I want to start giving you some impressions of the people I’m seeing and working with here, too – I’ll do that next time.

Security Briefing

We just had a briefing on the security situation in the country, and I’ve also been listening to what some of my colleagues have to report about what they are seeing in the hospital.

It sounds like Juba (the capital, where the violence recently flared) is in a pretty scary state, even though the active shooting stopped several days ago. MSF has actually started a surgical program there to deal with all the gunshot wounds. Meanwhile, cholera has also appeared – if that gets out of control, it will be a huge problem. And, finally, rape. Apparently, there is not enough food in the UN compounds and other protected enclaves people have fled to. When women leave the compounds to look for food, though, they are being attacked. So barbaric. Did everyone see Zadie Smith’s New Yorker story a couple of weeks ago? It illustrates alarmingly (eerily) well my worst fears here.

There are other problems, too, that one might not immediately think of. For example, the synergy these three things: 1) Many of the aid organizations on which, for better or worse, the country depends have pulled out since the violence flared; 2) The insecurity means that cross-border traffic (and road traffic in general) has come to a halt; and 3) There was a lot of random criminality during the unrest, including the looting and destruction of markets and UN warehouses. The result of all this being that there are shortages of many necessary items, including food, and that inflated prices are being charged for whatever is available. So you don’t necessarily need to be ill or injured to be desperate. (The inflation – which was a problem before the unrest, as well – affects even relatively peaceful places like Aweil. Today, one of the drivers was talking about the impossible prices for sorghum and sugar, and it seems like the South Sudanese pound has lost something like a quarter to a half of its value in the past week.)

The head MSF office (located in Juba) has responded to these and other problems by trying to expand healthcare activities in the most affected areas, using whomever they can pull from existing programs. My colleague, the local nurse-anesthetist, was sent to the new surgical program in Juba three days ago. My workload is completely manageable, however; the bigger problem is in the wards, where they are apparently starting to get malaria admissions at a rate similar to the worst period last year. In a perfect world, we would open more wards – but I don’t know if the present staff can take it. It’s almost 7:00 here, a time when, usually, everyone is getting dinner. However, after the briefing, a large number of folks went back to the hospital to finish their backlog of work.

And then there is the little matter of getting out of here! Truly, it is rather far down on the list of problems, in this particular time and place. But, as a first-missioner, I suppose I can legitimately claim ignorance as a partial excuse for having put myself in a position to be concerned about it. In brief: I would not say that anyone really, truly made it clear to me how fragile the transportation network can get when there is unrest. For several days last week, neither commercial nor humanitarian airlines were flying – if I’d been scheduled to leave then, I would just have been out of luck. And even now, they are trying to keep the number of people coming through Juba to a minimum, to make security easier. Which means that the lovely “logistics” guy – essentially, the guy who keeps the physical plant of the hospital running – who has been here for 9 months and just wants to go HOME, was informed yesterday, the morning of his planned departure, that, no, he would have to wait a little longer. In the briefing, they said he might get out on Thursday, which wouldn’t be SO bad. But, then again, he might not.

I’ve got a whole life planned for when I get back, including a nice visit with my sister (hi, April!) and, it seems, a nice new money job. I really, really, REALLY don’t want to be stuck here for an additional week, or two, or six. It’s not up there with getting raped, getting shot, or getting cholera, but, in my little life, it would really suck. So I will make sure and do a little plotting and investigating over the next few days to see if I can at least minimize the possibility.

On a brighter note, we are very near a huge swamp, so there are lots of cool birds here (see the two herons in the top of the tree?). In the evening, along with the herons, flocks of long-necked black ibises sometimes fly by, and you see trees full of white ibises, too. And of course the LOUD tuxedoed crows that are everywhere. And the huge (wingspans of several feet?) fruit bats. They come out at dusk, and look more like birds when they fly than I would have thought possible (no feathers!). The best way to tell them apart? Birds: Back ends have tails. Bats: Back ends have little rodent feet!

Have good days, wherever you are.

Grumble, grumble

Well. I certainly have been Mr. Grumpy these last couple of days.

I’m inclined to believe that a lot of it is just the ebb and flow of energies across a project like this. At first, there is the excitement (fear?) about all the new stuff you are suddenly exposed to and asked to do; this gives you a bit of an “up,” tinged, perhaps, with anxiety. What may have been going on during this, week 2, is the subsequent settling in to a new normal, with its realizations and frustrations about things that don’t work so well.

That said, here are the more specific causes of my darker mood – some of which are, indeed, troubling.

The main one was having a patient – the mother of 4 young children – die on the operating room table about 6 minutes after we started doing surgery on her. In truth, no matter what had happened in surgery, it was very likely she was going to die (her colon had ruptured, spilling its contents into her abdomen – in other words, a horrid mess). But that doesn’t make the experience any less upsetting – it happened yesterday morning, and hung over the whole day.

The fact that certain limitations in the care we can provide here contributed to her death makes it even sadder, and points to another of the things bothering me this week: A sense of medical aid as a colonialist enterprise. Now, I recognize that that is quite an extreme phrase, to the point of being distorted. We unequivocally do manage to help individual people with real, sometimes life-threatening problems, and send them out better equipped, physically, to meet the challenges of their lives. I’m talking more about the background to what we do. On the one hand, it’s knowing that some aspects the care my patient received here would simply not have been tolerated in, say, the US, or France. So why are they tolerated here? Why is it okay here? That is exactly the question that Paul Farmer, the head of Partners in Health (the organization I went to Sierra Leone with) is continually asking, and I admire him greatly for it. I don’t know this, but my guess is that Partners might have made no pretense of offering any surgical services for years (thus leaving patients like mine to possibly die for lack of surgery), during which time Partners would have been building, and developing local staff for, something like a modern, well-equipped hospital with a full range of services (so that at the end of those many years, the people here could expect care at least resembling what a US person could expect). It’s a different model, and it seems to me a good one – but the cost of it is not treating people you could treat here and now. From what I’ve seen here, MSF has chosen to offer the care it can now, even if in some ways it doesn’t equal what you’d get in the west. Is one approach clearly better than the other? 

My bigger question about “colonialism,” however, has to do more just with impressions that rankle. We drive around in big SUVs; most people here walk. We have three big meals a day; most people here are not sure of getting enough calories. We make very little money (by Western standards, one of the things I love about MSF) – but it’s still WAY more than we pay our staff, and we get upset when they ask for more. We talk amongst ourselves about how you have to watch the local staff or they’ll just sit around all day, about how “hopeless” their skills sometimes are, about how we’ve warned them they could be fired if we find them on their cell phones when they should be working (NONE of us ever does that, of course) – etc. Is it really that different than the bwanas sitting around in their pith helmets tsk-tsking about the “natives”? Again, I don’t have an answer – most westerners would find how we live unacceptably Spartan, as it is; and it’s true, sometimes the local staff DOES seem to work slowly or reluctantly, and DOESN’T have what seem like basic skills. It’s just the whole setup seems – like something that should be questioned. My father once wrote a book about Albert Schweitzer; I know shockingly little about him, given this, but my impression is that he actually lived WITH the people he cared for, for YEARS. Is that the only acceptable model for “Western aid?” Or is it okay to be somewhat piggish and occasionally condescending outsiders, as long as we do some good in the process?

Okay – frustrations with care, frustrations with the enormous economic/class/power differences between us and the people we work with. What else was bugging me this week?

Well – um – how to put this – the fact that this kind of work seems to attract certain TYPES of people? With certain PERSONALITIES? As I’ve said again and again, I really admire (and often am in awe of) the skill and dedication of my colleagues. But, back at camp – well, a certain atmosphere prevails that reminds me of, I don’t know – freshman week? Summer camp? A fraternity? An image: “Movie Night” a few nights ago was Top Gun, a movie I find so repellent I really can’t even enjoy it as camp (I know – I’m a supercilious a-hole). The evening, fuelled by a great deal of alcohol, was roundly enjoyed by all (or most). Loud, joshing camaraderie seems generally to take precedence over quiet, thoughtful conversation. There is a French literary magazine lying around, but I seldom see people actually reading. The morning after the Nice attack, no one had anything to say about the world situation (or about the attacks at all), despite the fact that there are I think 6 French people here. I could continue, but I think you get the idea. Basically, the work seems to favor action over contemplation, and the group over the individual. There’s nothing wrong with this – I just happen to not be like that. Never have been, for as long as I can remember. I think I manage not to be too much of an insufferable prig, in response – I just kind of go my own way and enjoy those (many) interactions that I do over the course of a day. But I feel a bit like a sore thumb. Or, actually – like the new kid in high school. Amazing that I can still feel that way, at my age! Obviously, it doesn’t sting like it did back then, but – I guess on top of everything else, I’ve been feeling a bit isolated and lonely.

So there you have it, the sources of my ill-humor, from the sublime (or, well – the serious) to the ridiculous. For some reason, though (partly the writing it down here?) I’m already through this round of it. In terms of the more serious questions, about the care we provide and the sociopolitical context we provide it in, what it comes down to is it isn’t perfect but we do what we can, and we can (and I think most do) keep asking questions and noticing things and making choices that will help us do it better (or change how we do it). And in terms of the social situation – obviously, it’s a pretty minor concern in the scheme of things (though it may have some bearing on the choices I make around this kind of work in the future).

After all of which we are left with just – the state of the world! Oy vey. I don’t think I’ve ever in my life felt so worried about what I read in the newspaper every morning. But let’s leave that for another post, shall we?

I hope you’re all having good weekends, wherever you are!

Waves

A couple of dramatic things happened on recent nights. There is a lot in them that bears on the essence, or one of the essences, of “doctoring” (that is, of being trusted, for variable lengths of time, with a person’s fate). I don’t want to go on and on about that right now, though (I think I already did in Sierra Leone). More just to tell you about them.

Three nights ago, I was called back to the hospital (after a nice evening socializing with a Swiss borehole team) for a C-section on a woman with twins. Despite my still-unfamiliarity with the room and the equipment here, everything went fine – spinal in fairly quickly (one of the upsides of no one here being fat), worked well, woman stable and comfortable. When the first baby came out, though, I could see she was floppy and grey. I went over to help the people at the warming bed. But nothing we did brought her back. By the time the second baby was delivered, she had no heartbeat at all. 

That had never happened to me before. Without, as I say, going on and on, let me just state that one is never perfect in one’s work, and one is even less perfect in things one has never had an opportunity to practice. That was the first time I had ever been faced with resuscitating a newborn, and I KNOW I could have done it better. I don’t know if it would have made any difference – she might have been dead from the moment she was delivered, and her brother – whom we did manage to revive – died a couple of days later. But I do know I could have done a better job. It is sad, and hard. 

(Sadder and harder for the mother, of course. But, even without the spacesuit I had to wear in Sierra Leone, I often feel like I am from Mars here – a visitor from an irrelevant, alien world with whom people do not share their inner lives.)

Then, last night, there was a woman in maternity who was at only 25 weeks, but had been feeling bad for a few days and so came to the hospital. Her abdomen was distended, and getting hard (bad). Her x-ray showed that her large intestine was stretched and inflated. But the only surgeon here who might know how to deal with it (not an MSF employee) was already at home. Cell phone reception was down on the network we use (no one has a land line), but I found someone with a phone on the other network, called the surgeon, and luckily he answered. Security concerns made him hesitant to come back to the hospital, but he said that if we could transport him (he is from Ethiopia, and they don’t give their people fleets of cars), he would come back and evaluate the woman.

Shortly thereafter, we took her to surgery – where we found the most blocked, bloated large intestine I have ever seen. She had a “volvulus” – a twist in her intestines, blocking all movement through them. All the poop and, more importantly, gas that is produced down there had been backing up for days. If we had not been able to operate, at some point her intestine would have literally burst (or, if not that, would have necrosed – died – from all that pressure blocking its blood supply). She very likely would have died, last night or not long after.

She still has a hard road ahead of her. She had a miscarriage a few hours after coming out of surgery, and some of her intestine may still die, requiring us to operate again. But last night, at least, we gave her what she needed.

So. Makes me think of The Waves, the Virginia Woolf book where she manages to re-create the entire world in 250 pages. Love and hate; life and death; inner and outer; together and alone – we move back and forth between them, rising and falling like waves in the sea. Success and failure, too.

And I said I wasn’t going to get philosophical.

The Hospital

Someone asked me the other night why I couldn’t go back to the hospital if the heat, humidity, dust, mud of our living “compound” got too much for me sometimes. Which made me aware that I should probably give you a basic description of what the hospital is like.

The short answer is that it may not be like anything you have ever associated with the word (unless you’ve seen hospitals in poor countries – it’s exactly like many of those). The environment inside is not more agreeable than our hot, muddy, fly-beset compound, but considerably less so. (But this makes sense, right? Wherever it is you live, would you rather be in your house – or at a hospital?) It is not air conditioned; it is not modern; it is not sparkling. What it is is a collection of five or six long, painted cinderblock buildings with screened but not glassed window openings, most of them set up as open wards full of dented iron bedsteads supplied with waterproof (think: not breathable) mattresses, each maybe two or two and a half feet from its neighbor. Or, at least, that’s how the original part is. There is also an extension made of four industrial-size rubberized tents (think, again: not breathable).

It is a government hospital, and I believe (?) that outpatient services are available to everyone in the community, provided by the state. However, the large majority of the inpatient hospital serves two populations: pregnant (or peripartum) women, and children. This part of the hospital is effectively run by MSF, and all the staff – “expat” and “national” – are MSF employees.

There are pregnancies all the time, of course, but at least a couple of rhythms govern the pediatric caseload: The “malnutrition season” and the “malaria season.” You can probably figure the latter one out for yourselves: it’s the rainy season now, and, as I have learned even at my New York apartment basically every time it rains and the temperature is above maybe 40 degrees – rain=standing water=mosquitoes. The last term in the equation, here, being “mosquitoes=malaria.”

The malnutrition season is a little more puzzling. On the face of it, it has to do with the rains – by the end of the dry season, not much has been growing for a while, so subsistence farmers run out of food and their kids get malnutrition, up until it has been raining long enough for new, harvestable food to grow. The thing that makes it a little more puzzling is the fact that South Sudan is for the most part a pretty fertile, well-watered place. So you’d think you might be able to put up a sizeable surplus every rainy season, to last through the dry. (I should say that I know absolutely nothing about farming, especially of the subsistence variety.) Possible explanations that I’ve heard or thought of for why this is not so: The Dinka are VERY identified with cattle herding and see farming as a bit beneath them, but the money economy has given them incentives to concentrate their cattle near market areas, leaving fewer in the hinterlands to feed the people there. The money economy (and perhaps food aid??) has, in general, distorted incentives, inducing people to rely on store-bought food even as their access to the money needed to buy it is highly variable. Civil unrest/war has disturbed agricultural patterns. Storing a surplus is not easy in a very hot, very poor country. The population is larger than it used to be. The climate is changing. When it rains, it rains too much, and you can’t grow food in a swamp.

Whatever the explanation(s), there is apparently a spike in pediatric malnutrition admissions that continues well into the rainy season, and a spike in malaria admissions that grows as that same rainy season progresses. Which means that we are in the place where both conditions are spiking – right about now.

I tell you all this to underline that the pediatric wards are FULL (as, in fact, is the maternity ward). All the beds are full, and there may sometimes be two or even three kids per bed, with others on mattresses on the floor.  So, to continue outlining my picture of the physical space we work in – imagine these buildings and tents, filled with people, with either an occasional fan or nothing for ventilation, with patients coming in and out after walking over red earth that is, variably, mud or dust, when the outside temperature is often in the 90s (the 100s in the dry season). The wards are inevitably dusty, grimy, sweaty, smelly places, despite the fact that the staff seems to do a great job of keeping them basically clean. Happily, it seems like the plumbing, though rudimentary, works: though I won’t say there is never the tang of urine in the air (!), the key principle of not pooping where you eat (or drink) seems to hold.

But, you know – at bottom, though it isn’t the sort of squeaky-clean place we associate with the word in the States (well – ha! – sometimes), it seems to me to basically work. I can’t imagine it is fun, fun, fun to be there – but, again, have you EVER seen a hospital (aside maybe from the out-of-pocket vanity suites that all big NY hospitals now seem to have) that was? Basically clean, basically orderly, sterile when it needs to be. We could, in fact, probably afford to be a little less obsessed with sterility in the States, with little cost to patients and significant savings of money.

So, no – it is not a place I would go to escape the heat and dust of the compound! But it isn’t badly run, and once you get over the shock of a hospital looking “like that,” you see that, in lots of important ways, it gets the job done.