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.