Sleepless in Dubai

Hi – It’s 5:30 here in Dubai, where I had to spend a night on my way to South Sudan, and – though I slept more than 8 hours on the flight over, and for a good spell at the beginning of the night here – I’ve been up for several hours now. Spent a good while listening to a tape of “The Silk Roads,” a delightful new book about the place of Central Asia in world history – great listening; if you’re bored of where you are, tune in and you’re off to a market town in 1^st century Afghanistan! But, alas, that failed to put me to sleep, either. In these situations, there comes a time when you just have to get up.

I wanted to write, anyway, to give you a sense of the things I’m thinking about, here on the cusp of actually arriving in the country.

1. I think my biggest worry – apparently it happens to everyone on their first MSF job – is, “what if there is a situation I don’t know how to handle?” This is not a completely unrealistic fear – a friend of mine who is mostly an intensive-care doctor had to resuscitate newborn babies and do nerve blocks without any imaging technology. And the last thing any of us wants, after having sold ourselves as bearers a certain level of expertise, is to end up providing inadequate care instead. But the more I learned about the project, the less worried about it I got. For one thing, I did a fair amount of studying of techniques, medicines, and diseases that I don’t usually encounter in the States but that I might here (and made myself a nice book of “cheat sheets”!). For another, I will be working in what is essentially an MSF obstetric and pediatric hospital-within-a-hospital, completely run by the group and staffed with their employees (expat and national). Which means that I will have a lot of people around me whose expertise, approach to medicine, language skills, etc. will be basically familiar – in other words, it will be a supportive rather than an isolating situation. Perhaps less interesting in some ways, but good for a first placement. For a third, it sounds like the local anesthetist whom MSF has hired and with whom I will share the work is SUPERB. And, finally – I’m now two years out of residency. Which is not the same as being five years out, or twenty years out. But – it’s undeniable – you do get better at it the more you do it. I faced some pretty weird situations at the community hospital in the US I was working at last winter, and seem to have figured out how to pull through all of them. It’s no guarantee – but it does make me feel more at ease.

2. I found the death we all had to deal with in Sierra Leone harder than I thought it would be. Hopefully, there will be nothing like that level of death here. But South Sudan does have what may be the world’s worst maternal mortality ratio, and this is an obstetric hospital. I talked to a colleague who worked here a few months ago, and he said that, in fact, he – as an anesthesiologist; I’m sure it’s different for the OBs and midwives – didn’t see any maternal mortality. And the pediatric mortality will hopefully be negligible – for me, it’s a lot of dressing changes for kids who may be badly injured or burned but who, in theory at least, are getting better. The one thing my colleague did say he saw was C-sections where the baby was stillborn. And in general, there will probably be more bad outcomes here than in a hospital in the US, and every time there is a bad outcome, whatever you did or did not do, you feel bad and you wonder. So I probably do have that to look forward to (though I’m hoping not too much).

3. I have some concern about simple psychological distress. Anyone ever read The Sheltering Sky? Or A Passage to India? Remember how the heroines in both cases kind of fell into this situation where, with so much unfamiliar, so much unfamiliar stimulation, so much stress, so much apprehension on their parts, they both decoupled from the world a bit, lost a little track of what was real and what wasn’t…? Don’t worry – I don’t expect my embassy will have to find me in a house down an alley somewhere in the Sahara! But I have always found that being in a foreign place where I don’t know anyone, don’t speak the language (although I have had two Dinka lessons!), where no one knows me, where I can’t be sure of being understood – it can send me into a pretty isolated internal space that is tense and unpleasant. But, again – the situation here seems reasonably well set up to work against that – particularly the fact that I will be living with 20+ other MSF staff in a large compound near the hospital. Hopefully if I start to get too weird and internal, I will remember to go find someone to talk to.

4. Then there is the question of whether all this is futile, anyway. I mean, of course it isn’t, for the individuals we help. But I’m reading a book right now by a former MSF person about how, in some situations, humanitarian interventions might actually make things worse (Fiona Terry, Condemned to Repeat? The Paradox of Humanitarian Action). And however that may be, I certainly have no illusions that what I’m doing will bring better governance to South Sudan, or help reduce the number of weapons circulating, or rebuild interethnic trust. And I think, just on principle, that all of us doing this kind of work should ask ourselves from time to time whether and how much what we are doing might be a sort of disaster tourism, and whether, in fact, we depend on there being disasters out there to give us something to do. I have met a lot of people of whom I do NOT think that is true – people who really inspire me (many of them in Sierra Leone). I will try to be like them.

5. Other worries – political insecurity/violence; disease; transportation disasters – nah, they don’t bother me much. Aweil appears (?) to be an area that has had relatively little violence even at the height of the recent civil war, and seems to be stable now. And although I’m told that some people in South Sudan are ambivalent about MSF because the organization tends to drop in to solve problems and then leave without doing much local capacity building (that’s the way it’s structured), I’m also told that medical people in general are held in high regard, which hopefully translates into security. Re: disease: I’ll take my malaria pills; I have Cipro ready for the stomach problems that I’m told have become very common on this project (!). For transport - it’s the rainy/mud season, so maybe people won’t be driving that fast; and as for plane crashes – what can you do? If it happens, it happens. Seriously – all of these things seem to me both unlikely and the kinds of things you really can’t do much about anyway, so – why worry? For better or worse, I can be very “rational” about stuff like that – it’s the way I’m wired.

So there’s a peek at my mindset as I head into the country. (Of course, there are also lots of things to look FORWARD to – interesting encounters; getting to know people; learning more and more; experiencing another environment and a taste of some other cultures; the simple pleasure of feeling like I’ve helped out. But I tend to focus more on my worries – again, the way I’m wired.) Since I started writing this, I have made my way onto the plane to Juba, whose human cargo strikes me as pretty classic for a country in crisis: Mostly men; some beefy/ruddy military types (humanitarians? mercenaries? who knows…); some folks whose country of origin suggests they are probably working on oil and infrastructure projects; some tweedier looking (and occasionally even female) development (?) people – even a few folks who might be South Sudanese! That the mise en scene is so familiar is mildly depressing – the rote, prepackaged response to a country in crisis? On the other hand, I could see it as encouraging evidence of the world’s ability to place skilled people in a country that needs them. Whichever way it is, on this particular day, I’m a part of it.