Six Months in Sudan (10 page)

interesting times. we have made it part of our campaign to screen all the children we vaccinate for malnutrition. because the population of abyei has tripled in the past year, there is a food shortage. there is one harvest a year, and it happens at the end of the rainy season. that will
be in september or october. abyei is about to enter its food gap, and starvation will worsen. if we vaccinate 35,000 children in the next few weeks, and we find 1% severe malnutrition (a local ngo estimates it at 3%), that will mean 350 children, perhaps 1/2 under 5. we will offer all transport to the hospital. if 1/2 are under five, and 1/2 refuse, we still might end up with 80 more children in the tfc. right now we have ten. interesting.

so, that’s what we talk about over lunch, and that is why there is reason to be nervous. 80 children. it would double our current census, measles patients included. what about latrines? showers? kitchen? where would they sleep? who will take care of them?

right. the max capacity of latrines is 20 people per. we have five. we can build more. we’ll send a car for more gas and stoves. build another shower. we shouldn’t put children at the front of the hospital because they would be vulnerable to fighting or the chaos of a big accident. so they go in the back. away from the tb patients and the measled. ok. we’ll set up a tent. no, they don’t like tents. too hot. they like recubras. fine. big hut, back of the hospital, put starving kids in it. more latrines, a shower or two.

this could start tomorrow. wednesday. ok. maybe we’ll get there and everyone will be so fat they can’t even waddle to the front of the vaccination line. so let’s wait and see. then move fast if we have to.

our logistician spoke up. “well, maybe one thing. those y-shaped sticks, you know the ones we use to make the recubra? they are hard to find. people have to travel to get them. we should go to the market right now and buy as many as we can so we are not scrambling tomorrow if we need them. i’ll do it after lunch.”

we’ll sort it out as we need to. except for the y-shaped sticks. today it’s all about the y-shaped sticks.

logisticians make things happen. if it wasn’t for them, the rest of us would be standing knee deep in dust, waiting to get started but not sure exactly how to begin. we add things to their lists, and put request forms on their desks. yesterday i put one on jean’s desk for “world’s largest emerald.” he didn’t mention it today, so i guess it is on its way.

“W
HERE’S HE GOING?
” I ask Tim.

“Who?”

We’re sitting at the table in the gazebo, eating our lunch.

“The emergency-team log, what’s-his-name. He just went into our kitchen and took our kitchen knife.”

The emergency team has been here for a few days. They are here to run the vaccination campaign and help take care of the infected measles patients. Right now, we have about forty in the recubra next to the cement fence. With their families, nearly one hundred people sleep there, hospital on one side of their buttressing wall, soldiers on the other. One noticeable effect is that, since we started flanking the soldiers with the infected, we have not seen them sneaking in to use our latrine.

The emergency team, thus far, has cut a wide swath through our normal activities. Three new people in our compound, five or six in compound 2. There are so many people there now, we have started to call it camp 2, because the number of people sharing a latrine exceeds the WHO standard for refugees. Our showers are flooded, our drinking water disappears from the fridge.

“I don’t know where he’s going,” Tim answers.

I charge after him. I find him in one of the emergency tents, cutting open boxes.

“Bro. What? That’s our kitchen knife. There’s gotta be a better option.”

“I need to open these. The ice packs.”

“I can appreciate that. But that’s our kitchen knife. It’s our only one. It’s already so goddamn dull. I’ll help you find something else.”

I take it out of his hand and feel instantly like an ass. Him chastened and me sorry, we walk to the logistics tukul to find a utility knife. I leave him there.

Tim is sitting, eating an orange. I set the knife down on the table.

“I’m a dick.”

Tensions are high everywhere right now. We rarely eat together. Paola has retreated into her tukul, and if she’s not there, or at the hospital, she is at the World Food Programme compound visiting her boyfriended friend. During the day, Jean is working hard to push forward a planned borehole. At night, he visits a friend of his who works for the UN. On top of her role as field coordinator, Bev has assumed that of vaccination campaign coordinator. I catch glimpses of her barreling past me in a Land Cruiser a couple times a day, cigarette in her hand, handset to her mouth.

I am at the hospital, mostly, and when I’m not, I’m trying to sort out the TB register, or make sense of the statistics. If the hospital is quiet, every couple of days I will sit in my tukul and write. The gazebo is full of bullhorns and maps.

The hospital is crazy. I think even more than usual. To this point it has been a controlled, smoldering chaos, full of unmet needs and slow revolts by patients and staff. As more people arrive at Abyei, as more people come through our doors, as the word spreads farther, the busier we become.

I was on my way home yesterday, hoping that there would be some food left. I had spent my lunch hour talking with the man who had brought the orphaned girl Aweil to us. He had intended to leave several days ago, to start school, but each day I try to persuade him to stay until she gets better. I found him that morning, his books bundled with a leather belt under her bed. She was still febrile, not eating. I convinced him to stay at least one more night. I was just turning right at the cannon.

“Dr. James for hospital.”

Come on.

“Hospital, go ahead.”

“Move channel 6.”

“Moving. Channel 6.”

“Dr. James, we need you at hospital.”

“Why?”

“…”

“Hospital?”

“Dr. James, please come to hospital.”

“Affirmative. Over and out.”

Halfway home, I turned back. Outside the gates were two Ministry of Health vehicles.

The Abyei hospital is, officially, a Ministry of Health hospital. Though an MSF France section worked in Abyei during the war, it left as fighting slowed. This mission opened last year with the dual purpose of treating a growing number of returnees and watching for war. When we arrived, the hospital was so overwhelmed that there were dead people in the rooms. The few people who were working in the hospital couldn’t keep track of who was alive. We signed a memorandum of understanding with the Ministry of Health. We would share their space and provide what resources we could to make the hospital function. We provided drugs, equipment, staff. We sourced a generator. We planned a borehole.

There were unavoidable problems. Some of the staff are MOH: a percentage of the nurses, all the cleaners. Their salaries, when they are paid, are lower than MSF’s, so we decided to top them up. Though we pay them, we cannot discipline them. They are not our employees. If they miss work for a month, all we can do is withhold their incentive.

There is a skeleton administration, a director, a vaccination officer, and a hospital administrator. They each have their own offices in the hospital, but their salaries are as erratic as their colleagues’, and their power to effect change small. They have neither a phone nor the right numbers.

Our flag hangs outside the gates. The hospital, however, is deeded to the MOH. In whose name were we working? In countries like Sudan, the government relies on NGOs, and at times leans on them. If there is any ethical imperative for a central administration to assume some responsibility for the health of its people, it is tempered by our presence. The people are getting free care. Why hurry? The presence of a Ministry of Health, from the North or the South, becomes a political game.

As I passed the MOH cars, I wondered how the hospital was being played. I already knew that the vaccination officer was unhappy with
our campaign. We had called in the emergency team, trained vaccinators, and organized the vaccines, all on our own. By doing so, we removed the chance for others to make money from the endeavor and receive what they considered their fair share.

The guard was inside the gate, feet up on his small plastic desk, fiddling with the thick rubber antenna of his handset. As usual, not a lot of guarding going on. A guard’s position is the lowest paid and least enviable. In a land of guns, we give them a walkie-talkie and then we rely on them to pass it to someone who can understand what we are saying. The other day I saw a group of guards underneath the tamarind tree looking at a blackboard easel with the alphabet written on it, practicing.

“So?” I asked him, shrugging.

He pointed lazily at a group of men walking towards the measles area. I ran to catch up to them.

“Wait a minute! Wait! Stop!”

They turned around.

“Have you guys all had measles?”

They had. I introduced myself. Together we walked through the measles area, row on row of infected children and adults, flat on plastic beds. Often, three or four children from the same household, at different stages of the illness, lay like puzzle pieces, their mothers fanning their fevers.

I explained to the MOH delegates how our team was out right now, north of Abyei, mobilizing the communities for the upcoming campaign. I told them that of all the patients so far, we have had only two deaths. Both under five, both showed up late, with a secondary infection.

“Are you sure of the diagnosis?” one of them asked.

I leaned over a small boy and pulled his shirt up.

“You can see the rash. Here, look from this angle. Little raised bumps, patches. After you see a few, you can spot it at twenty yards.”

They murmured their agreement. One of them wrote something down in his notepad.

“Do you mind if we take some blood from some of them? Just to confirm?” he asked.

“I … um … I guess you had better ask them.”

The patients, of course, would not refuse. I doubt they recognized their right to do so, the idea of autonomy in the face of authority as unfamiliar as everything else in the hospital.

I started to ask what had brought them to Abyei from Kadugli. A nurse grabbed me by the elbow.

“Dr. James. A woman in the emergency. Bleeding. Pregnant.”

I left the ministry officials beside the little boy’s bed and crossed the courtyard to the hospital. I stopped where the orange fence, used to separate the hospital from the measles area, had been loosened, stepped through, pulled it taut. A little girl, on the veranda, watched me.

“You didn’t see that,” I said.

In the emergency room were a woman and her husband. She had started bleeding that day.

“How long has she been pregnant? Is she cramping? Has she passed any tissue or clots?”

A nurse at my arm.

“Dr. James. Please come to the nursing room. A boy. Breathing problem.”

I left the woman and her husband, their answers still in their mouths, and walked to the nursing room. Breathing before bleeding.

The child, about four years old, could barely draw a breath. Every few seconds, the muscles in his ribs would flicker and his stomach would pulse. He was unconscious.

“Vital signs?” I asked.

None had been done.

“Okay. Heart rate, temperature, oxygen saturation, and check his blood sugar. All of those. Grab that mask. No, that one. The small one. Give it to me. And the bag. Watch. Hold it like this. Like this. Just so his chest moves. No. Too big. Small. Good.”

I hurried to the pharmacy and grabbed the oxygen concentrator. It was new, still in its box. I cut the top off and pulled it out, foam beads spilling onto the floor. I removed the plastic, kicked the pharmacy door open with my foot, and wheeled it past a queue of admiring inpatients who had gathered to watch.

“Out out out. Everyone.” One of the nurses had taped an oxygen saturation monitor to the child’s finger. It read 70%. Should be closer to 100%. He had a fever. His sugar was okay.

I unwrapped the plastic from the concentrator and threw it on the ground. I found a pediatric mask and affixed it to the boy’s face. I turned the machine on.

The oxygen saturation crept from 70% to 90%. I looked down at his ribs. Flicker. Pause. Flicker. Pause. Pause. Pause.

His mother sat on the edge of the bed, looking from my face to the flashing numbers on the monitor.

The child couldn’t breathe on his own any more. His ribs and diaphragm were too tired. He needed a machine to do it. We didn’t have one. I removed the face mask.

“Michael, start bagging again. That mask. Yeah. Right. Like that. Perfect.”

I grabbed a handset off the nursing desk.

“Brian for Dr. James. Brian for Dr. James.”

“James, go ahead.”

“Brian, I’ve got a kid here who needs to be intubated or he’s going to die. Likely pneumonia. He’s got a fever. I just don’t know if I should do it. We have no ventilator. Over.”

He would be right there. Sweet.

I returned to the pharmacy and fumbled through its shelves in the dark, flashlight in my mouth. I still haven’t figured out where the light is.

What size of tube? Age over four, plus four … a 5. Suction … where is that? Here. Laryngoscope. What size blade? One miller, I guess.

By the time I got back, Brian was in the nursing room.

“Yeah, I agree with you. He’s not really breathing. How long has he been this way?”

“Mother says he was fine this morning, but I doubt that. He’s going to die any minute.”

He looked at the laryngoscope and tube in my hand.

“I say go for it. We’ll call a nurse from compound 2 and she can bag him.”

“For how long?”

“I don’t know. How long do you think he’ll need it?” he asked.

“He’s not going to turn around in an hour. Not if it’s pneumonia. It would have to be at least overnight. Maybe even longer.”

“Overnight, then.”

Brian called on the handset to compound 2 and asked for our best nurse. I sat down with the mother.

“Your baby’s not breathing very well. See? He’s only breathing small. Not good. We need to help him breathe. Put this tube down his throat to push in air. I think if we do not do it, he will die. Even if we do, he might die. I don’t know. It’s the only thing I can do.”