Monthly Archives: February 2011

On the Ward: Referendum Aftermath (part 3)

In my blog, I have seldom yet taken the opportunity to actually talk about, or describe, the medical work we do here. I am slightly sceptical of emotive ‘aid images’, so have maybe shied away from too many ‘MSF t-shirts on doctors’ photographs. And in this sense, it has been good that images are so hard to email over the Satellite Phone Link here. For some reason with text there seems less chance for misinterpretation or misrepresentation. Call me old-fashioned, but I think the camera often lies. And I should know, having spent a career in Film and TV, creating these illusions which the viewers often do not realize are ‘posed’.

Morning is always the busiest time of day, when I have to organise my team, my daily workers, and the guards, as well as trying to get onto the shared computer to pick up any emails from the outside world. Today, though, Dr. Hanna offered to take me on her daily ward-round, and I decided to make some time. It was really grounding to be part of such an everyday routine, rather than the helter-skelter variety of Logistics.

The wards of Intensive Care Unit, Inpatient departments 1 and 2 (IPD1 and IPD2) are long barn-size buildings, made from sticks plastered with mud, but with corrugated zinc roves rather than the local thatch. Peoples’ personal belongings and food plates, as well as tribal accessories like sticks, robes, smoking-pipes (usually women), and water-gourds abound. There is an ongoing campaign to prevent food being cooked inside the wards. Yes, people have often lit fires on the cement floor between the beds, and still will try, if not watched. There is also the ongoing patrol, for which we have to employ a man full-time, to prevent open defecation around the outside of these wards.

So when you walk in, there is a smell which I can only describe as ‘Nuer’. It is something between the smell of a horse stable and good, clean tropical sweat. It is now a long time since I have really smelt it, as one becomes acclimatized quickly to the smells here. But I remember it hitting me well when I first arrived. The first person we meet is a woman with suspected Kala-Azar. Kala-Azar is a disease which only appears in developing countries. It has no value to western pharmaceutical companies, so comparatively little research has been done. I am not a medic, but from what I remember, it eats the body up from the inside-out. It attacks the immune/glandular system in the same way that HIV does, from what I can tell. I often see the results of it in its late stages as I am fussing around the oxygen machine, where the most boney living corpses you can imagine, lie on mats on the floor, hooked to the oxygen generator for survival.

Visually, these victims could put some of the hardest famine photography to shame, but remarkably many recover on the treatments of Ambisome and other drugs here. We are just coming to the end of an outbreak here in Lankien. I believe we may be the project with the biggest numbers left, here in Africa.

The next patient we see is one of the most dramatic in the hospital at the moment. She looks like a terrible leper, but in fact is the victim of a massive burn to her face. Although she looks ghastly, Hanna assures me that she is nearly healed, and has made a really good recovery. I get called away at this point, as somebody has asked me to fix the lights in IPD2 while I’m at it. I get my electrical hands, Malo onto it, show him how to test, how to use the multi-meter, and leave him to replace the necessary socket. When I catch up with Hanna, she is in the interim wards, a stained (but sanitary) trigano tent. This tent is one of my tents set-aside for ‘Sudden Influx of Wounded’ scenario, but is being used as a ward, not because we don’t have space – Kala Azar numbers are on the decline – but because people prefer to sleep in a tent, on the floor, rather than in formal hospital beds.

In this tent, from what I can see, are two patients and their families. I immediately spot one of the really fun children of IPD, who is always to be seen carrying her little brother around, and, with a friendly smile, introducing herself to ‘Kawais’ like me. We have a lot of fun, and I greet her. It turns out she is the daughter of the daughter of the patient, and old woman with a gangrenous leg. As we are visiting her, I get to touch her lower leg, which, just like those wax models you dare to touch as a kid in the London Dungeon, is just like wood. Or at least, the skin is just like cardboard. I heard and read a lot about the smell of gangrene when studying the history of medicine at school, and had smelt some new smell when I came through the flaps of the tent. She will be ‘greenlit’ out of here (flown on the plane), as we do not have an Operating Room in which to do the amputation. Despite the tent being old and stained, I have evaluated it closely, and have supervised chlorination, and the ‘ward’, with its mud floor covered in a plastic sheet, is actually a pleasant, clean, and relaxed area. I can see why some Nuer prefer it to the big ward. At least it’s not trying to be something it isn’t…

We see one other patient, and then Hanna walks over to a scrunched-up blanket on a mat in the corner. There is the most tiny, skinny, frail old woman under there! I had had no idea that she was there, and was relieved I hadn’t stomped over what I thought was the empty bed. At that point, I got called out again, to find that two of the three walls of a new Oxygen Room I am building were leaning and twisted like a snake.

That was my first experience of a regular ward-round. At night in most wards, the beds will be empty, with the patients who can move, going either under their beds (they fear the height from the floor!), or outside to sleep. Every morning, order is restored and the beds are re-occupied, but I remember the first time at night heading into IPD to check some light, and the place resembling a little festival – bodies lying around in the moonlight, low murmurings of patient and caretaker.

Evening found me sitting in the back of our expat compound with an African tribesman pressing a razor-blade against my jugular vein. This was not an abduction, or outbreak of clan violence which so often happens with spear, club, or AK47 in this part of Africa. Thomas Chuol Wiector, one of my finest carpenters, fabricators and, it has to be said, dandies, was giving me a ‘Nuer’. A haircut. At the start, I was thinking: ‘Hang on a minute, it feels like you’re just cutting along my head with the pair of paper scissors I just got for you from the office. Then I felt the back of my head, and found that to be exactly what her was doing. I had asked for a ‘trim’. I quickly resigned my self to the local buzz-cut, and am now actually really pleased with it. Like all things that are done well here, this was done extremely well.

It was just funny, looking forward, tilting your head, all the things you normally do at the barber except for the ‘Going anywhere nice on holiday this year?’ conversation. I chuckled silently as he walked round me, sizing-up what he had done, like the pro he is. A lizard scuttled across the mud wall of the Tukul in front of me. I looked at the chunks of hair on my lap that had been butchered from my scalp, and wondered for the umpteenth time at the bizzarreness of the evening, as he came at me one more time with the razorblade-on-the-back-of-the-comb, to finish off what transpired as a really good (really short!) short back and sides.

My First Delivery: The Referendum Aftermath (part 2)

One of the abiding memories of Christmas for me, from amongst the chaos of Cargo, Air-Traffic Control, and Security Management, was my first delivery. Ever since being once denied the chance, I have always wanted to witness a birth, and when I first came, Sheila was very keen that I come and be there one time, in the delivery room. One night, between Christmas and New Year, I was roused from bed by a guard, needing me to supply water and 230v light to the anti-natal clinic or ANC (12v light-bulbs still on the way from Amsterdam…). This request came into my sleep through the African night:

‘Rufa, Come-On: Miss Shielie, Piu, Light Kalas. ANC.’ Sheila had a Mama birthing in the ANC. I had to come, to turn on the Water Tower, and something was wrong with the lighting of the Delivery Room. It was urgent.

After I’d seen to the necessary, I went to check-up on Shiela, and hung-around, shy and bleary-eyed, by the door, whilst the Mum, with no screaming or swearing, went into the final mechanisms of giving-birth. It being the first time I had seen this miracle, I was amazed by how it happened as it was meant to. I wondered at how the baby boy could come from such a slim frame, and, sizing him up afterwards, could swear he was bigger across than the mother who had carried him. But it happened, as I say, with a neatness and order which dumfounded me. Obviously, it was not ‘easy’, but walking back to the Tukul under the vivid blanket of stars, I had that sense of ‘Species’, that fatalistic, inevitable perspective on the human condition which provokes so much thought and philosophy.

Good friends in Spain emailed me today some photos of themselves holding, with barely-concealed glee, their newborn baby girl. Sheila the midwife and me looked at the lovely pink bundle of sterile, clean baby, no dirt, dust, flies anywhere to be seen and wondered. I haven’t been here that long, but already whiter-than-white, cleaner-than-clean images like this a part of some different world.

Today, another massive change happened to Lankien. The UN turned up. There are now four cars (Four Wheel Drive) in the village, and it feels like an invasion. We are still cut-off by truck, but I am told that supply is only a matter of weeks away. It is too risky to travel and assess the impassable part of the road ourselves, so all information is composed from local sources.

New Year: The Referendum Aftermath (part 1)

Thank you, everybody who has replied to this blog. Times here recently have been full of uncertainty. Things for me, if I’m honest, have been tough. It has been so frantic with E-Prep (Emergency Preparedness), and everybody being on leave, that time has flown, and I have been completely frenetic.  I am hoping to return to the discipline of blogging in order to remind myself, as much as anything else, where I am, and what I’m doing. Now that at least the initial period of the referendum is over, the atmosphere may un-tighten.  The singing is back at night, at least, after a lull of several weeks.

But maybe I can rewind a bit, first, to Christmas. I didn’t write, in the end, what actually happened. The run-up to Christmas was insane. We were in the full throes of supply, ordering ‘buffer stocks’ of medicine and logistics, for the hospital, the patients, and us to survive any ‘instability’ which may have occurred over the period. Potentially, we were ready for being cut-off for a month.

I guess I finally stopped for Christmas when I switched off the generator, which may have been on the morning of Christmas Day, after it had been needed overnight for Oxygen. We had already had a plan that it would be nice to go to one of the churches to mark the day, and so we walked in the general direction of drumming and singing, through the scrub on the other side of the airstrip. Church is a huge outdoor affair, it seems, which goes-on all day inside a sorghum-fenced compound, with a big drum, choirs dressed in gowns, with male and female parts who soing and dance, and an ‘MC’ with a megaphone, controlling the activity and prayer. We were ushered-in and, embarrassingly, seated amongst the Elders out-front.

Central Lankien

We had gone along simply for personal reasons, and when inevitably called to address the crowd of several hundred people, each of us were very careful to give a neutral and non-political message of goodwill. I was pleased with myself that I was able to deflect the occasion by telling everybody about what my family at home would be doing, and how it would involve being together, eating, and singing. That seemed to go down well, but we were extremely relieved when we were able to duck-out of the seemingly never-ending event, and get out into the bush. It was nice to see a couple of our staff kicking about as we walked back, though, and there was much hugging and backslapping to be done. I never really see my guys out of the workplace.

After that, and a quick walk around the market, which was quiet, we came back, and had a light lunch.

Rope and Boreholes

In Lankien, life is very very busy. Being TechLog means that one can rarely leave the confines of the Clinic Compound, as generators, water pumps, and everything else depends on constant attention. None of us ex-pats get out more than once a week, except to go to the airstrip and receive a plane, or for the morning jog up and down the runway. This is quite different from the kinds of project work I am used to, where I tend to explore and liaise under my own steam, research and co-ordinate within the community itself. We probably walk miles and miles every day within a radius of about two hundred metres, but because of the various security issues, and the fact that we are ‘in the community’ every minute in the workplace, the inclination is to withdraw from it in downtime, and seek peace and solitude.

We have to hold back the kids as they pelt onto the runway to dance in the slipstream of the plane when it takes off.

I’m sure medics will tell you the same story of ‘voluntary incarceration’ in hospitals the world-over, but it was a great treat when WatSan advisor Matt came from Amsterdam HQ, to walk around the outside of Lankien ‘Payam’ (district), touring the twelve water boreholes. It’s amazing how much you can know a place from within a compound, and vicariously through the hundreds of people coming to the Clinic.

Part of me was reluctant to take the time to go with Matt. I was so caught-up running supply and Admin as well as Technical Logistics for this project and our two Outreach Projects, but I’m so glad I did. Matt and I got on like a house on fire, and I really enjoyed having somebody to bounce technical ideas around with, and also a fellow British person to have a beer with. The provision of Water and Sanitation to a population is at the very heart of all services provided by MSF. Although the technical intricacies of the methods of this provision, i.e., how to fix a generator which powers a pump, which provides water to a plumbing system, which supplies water to an Operating Room might seem ‘Logistical’, it says a lot that WatSan has recently been handed over entirely to be managed by the medical side of MSF in each project. Functionally, of course, it relies on TechLogs on the ground, as most doctors don’t do mechanics, but Medical Service without Sanitation is like a bath without a plug. And a great deal of preventative care in our mission countries is simply the provision of Hygiene. It is a strange situation in many ways, and a field in which, like no other, Logistics and medicine are completely interdependent.

Walking around the different boreholes in each different hamlet around Lankien gave a great demographic overview. There was a borehole by the huge abandoned WFP tents, one in the area used as barracks, one called ‘Church’, lying next to the catholic church, one in the market, a few in rural farm, or as they say ‘garden’ locations.

Duba Tropic, MkII handpump and borehole. The village municipal capital!

Duba Tropic, MkII handpump and borehole. The village municipal capital!

At each place, a gaggle of girls and children were crowded round the ailing pumps, squeezing-out the cup-fulls of ground water from (way-too) deep in the ground, frenetically pumping, the water trickling into stained, faded and battered vegetable oil drums and jerry-cans. It is sparse bruchland here, and the dry season can be seen physically advancing every day.

The mechanics of boreholes and the pumps used as standard were, until recently, pure theory to me. Sure, I have built a sewage treatment system in my house where there was none, and the same goes for the very effective plumbing system, but I have never taken apart a deep borehole handpump. This week just gone, I have ended up following on from Matt’s work, supervising the strip-down and rebuild of one of these pumps, and getting the submersible electric pump in the Market Borehole, fitted by some long-departed NGO, working again. It was a classic bit of cobbling-together for the test-run. A very rough-looking Chinese generator, coupled to a very dodgy control panel which emitted electric shocks, which was then connected to an unknown electric borehole pump, positioned about 180 feet underground, and intent on pumping shovelfuls of the earth’s core up with every load of water. But it worked, after I had figure-out why the panel kept tripping. The ropey old borrowed generator, with its bare wires, was knocking-out about 330 volts, way more than the 230 volts it was designed for. A few words with the alcohol-soaked owner to ‘turn down the volume’, and we had it ticking-over nicely.

Shame, of course, that it was only a test which revealed several issues. I have had it before, where a whole load of people think that you have solved their problems when really the solution is a long way-off, so I tried to slope-off quietly after pumping a few gallons of water, amidst excited congratulations from villagers. But one day soon it will really be working, and then the ‘Water Messiah’ attitude of these friendly folk will not leave such a bad taste in my mouth…

These people come from a culture steeped in herding. Everything from the songs sung by moonlight to the large staffs carried makes one think ‘Cowboy’. Many times I have gone away, leaving instructions for something to be built, and come back to inactivity, confusion, or something completely wrong. But it is simply the concept of permanence which is alien, not only because of recent years of unrest, but deep in the culture of the nomad. There is a lovely expression used by Riek a few times when he beams as he at last understands something I have asked him to build. ‘You have a big mind’, the first times, and then: ‘I understand you; my mind is joined with yours. Our minds are joined in these (shelves, latrine design, etc.)’.

But generally it seems a Nuer from Lankien would as soon understand the idea of a tradition of construction standards, or a fixed workshop, complete with tools which are permanently there, as a Londoner might understand washing-up after eating in MacDonalds. But when it comes to halters, harnesses, goods for herding, there is a magical door opened into the Nuer world.

One of our old Kapirs, tirelessly friendly, and determined to teach me Nuer through sign language and his not one word of English, can be seen all day at his post, with his big toes through a carefully splices loop in a polythene rope he weaves from ruined woven food aid sacks. His work is beautiful and intricate, and when he has finished weaving, he has made a noose-tether for a goat. The other day, as I have decided to sure-up our fences around the compound ready for any ‘events’ that might occur in the near future, I paid-out several hundred Sudanese Pounds to my Log Assistant, Moses Makuach. Moses is one of those super-lean local Nuer, who, to fit with his current position in the MSF team, will often turn-up for work in a three-piece suit. He knows everyone, and is known around the area, and seems to foster many a waif and stray in his down-time out of hours. I trust him, and he brings in supplies for building, and helps me to run the jobs in-hand.

So I was closing-up the workshop for Christmas, and last thing before closing the door, my eye was caught by what looked like a figure, huddled in the corner. A flash of the torch revealed not a person leaning into the wall, but the most gigantic hank of rope I have ever seen. Makuach would have purchased it with the construction money I gave him. But it was not so much the size of the hank, but the fact that it had been custom made, woven from Savannah Grass. A six –foot bale, beautifully wrapped around itself, like some kind of exquisite exhibit, or an improbably crafted part of a classic yacht.

Beautiful handmade cowboy rope Beautiful handmade cowboy rope against a wall

It put me in mind of that D.H. Lawrence quote about ‘Things Men Have Made’, which I love so much:

“Things men have made with wakened hands, and put soft life into ?are awake through years with transferred touch, and go on glowing ?for long years. ?And for this reason, some old things are lovely ?warm still with the life of forgotten men who made them.”

Today is Referendum Day

Southern Sudan has fought on-and-off for the last century both amongst its own tribes and over issues of North and South division. Today is a very quiet day both in the Hospital, and in Lankien in general. There has been no drumming, singing, or dancing, none of the usual Sunday parades. It is a bit eery, thinking about it. Today, history of some sort is being made. Last night, we had our annual staff party, and the staff themselves organised it. It was complete with wonderful dancing and singing, and a cow was killed, but there were certain organisational elements which left me wondering, with so little ‘organisational culture’ embedded in the national identity, how will the new South Sudan be run? Certain basic things were overlooked, or ‘expected’ from the outside world (i.e. MSF), and one wonders how ready this country is for catch-all centralised self-governance.

‘As ready as any of the other African countries were at Independence’ – is, of course, the answer. And it is true.

Meanwhile, in the Hospital, we await the new world order, ready, and with open arms, and hope we are prepared enough to deal with the demands of this new era. We have stocks of medicines, and space for overflow. Our staff each have a day-off this week to vote, and I have tried my best to prime the staff which I supervise how to deal with changes and difference in workload and work-type.


There has been a change in the air, of course, for some time, and perhaps this is best expressed through changes in our working environment. Our print-server laptop ate one too many gusts of dry-season dust, and had to be put on a rotation back to Loki. To be overhauled. All of a sudden, my laptop became the print-server of sorts, as an independent machine upon which I was allowed to lodge a downloaded driver . So everybody was coming to my laptop by the printer and putting files on there to be printed. Everything office-wise is by hook or by crook, but the MSF protocol is that we must not interfere with MSF standards. So I am looking through my desktop, and it gives me some kind of a demographic. Files called things like ‘Dehydration’, ‘Guard Schedule’, ‘Outreach Worker Interview – A.N.C.’, and ‘Interview Announcement’ documents appear. But most prevalent of documents of topical concern right now are ‘Returnees’, and Returnees 2’.

I am already slightly relieved that there are often one or two more people every couple of weeks in my Monday-morning worker-pool who speak some English, or know how to mix cement, or how to impress a work-boss. Many people have now returned from the North. Every day has some kind of tale about some family member stranded halfway home. People are making their way back often generations later, to the homes (read: ‘Territories’ – they are herders) of their forefathers.

Music is everywhere, in multi-register singings undertaken by workmen, to sweet tunes of washerwomen at work, scrubbing fists together under the tree, and the dramatic voices of church singing through the compound fence. It isn’t a performance, though; it is a consciousness. ‘Rupert, did you hear the song of the Car?’ (when the first car turned-up in the village since last dry season, or ‘I think the machine (electric saw) is Kalas (broken), it’s song has changed’….

The first ‘stereo’appeared in the village some three weeks ago. I heard it, playing some old soft-rock and modern R ‘n’ B, and caught myself mildly appreciating that change from tribal tunes and drums, when the owner switched to some Jamaican soft Reggae mix. But this evening caught me wondering about the ‘Returnees’, who are bringing back this music, especially hearing a stereo go past tonight playing some more Eastern, almost Bollywood music.

I have been here for only two months, but that is long enough to take some solace in the mono-culture of the simple old herding drumming-tunes, the church songs blended from ‘bible musicals’ and tribal spirit songs, the words to which everybody – bar none – seems to know the words. The night entertainment here has, until very recently, been wholly organic.

I have noticed my Log Team’s diligence of late in taking the free English Language classes we offer in the compound at lunch. This has stepped up very noticeably. At the same time, soldiers and politically engaged people in the village will confront a Kuwai with their clear dislike of all things ‘Arab’. It must be mildly terrifying to start hearing these influences eclipsing the more usual sounds, with no real reason to feel afraid of them – a bit like growing up, as I did, with a background fear of Japanese or Russian product because of the cold war propaganda.

But to hear it here is more than just media study. Electrically-produced sound is happening in Lankien, is coming to this village, for the first time in history, ‘on my watch’. A strange acceleration of evolution, amongst many others. I can’t help worrying whether the days of strange tribal leaping-dances en-masse on the airstrip are somehow numbered. There is a strange loss of innocence in the air. And I know I am sounding ‘colonial’, but it is the only way I can find of describing it. And it is a very demonstrative transition.

New Years Eve saw us all gathered around the table here in the compound, waiting with a bottle of champagne which had been flown in as a gift from OCA (Operations Centre, Amsterdam). As we compared notes on different ways of wishing Happy New Year (Russian, Welsh, Italian, English, Dutch, German), Sheila the midwife was called away. Two minutes to midnight, saw us all heading towards ANC (Delivery Room) with the Moet under our arm, mugs in hand. When the shooting started, we all expected it, of course, as a celebration, but sometimes it was so close, through the frail grass perimeter fences of the compound, that we couldn’t help wondering about the odd stray bullet, with so many shots, and basic laws of probability, as well as Newton’s Law, that ‘What goes up – must come down’. Reluctantly, we snuck sheepishly through the dark back to the safe-room, and waited for Sheila to finish.

Men here are mainly named after their father, using the prefix ‘Gat’. My name, then, is ‘GatKuwai’ – Son of a the Kuwai (white man). All women here have a name prefixed with ‘Nya’. So NyaKuong would be the daughter of Kuong, and one of our National Staff has the beautiful name NyaKuoth – Daughter of God. All a bit ‘Handmaids Tale’ and patriarchal, but children here – like in many developing countries are often named topically, not just after their menfolk. Gatkuoor, my driver, has named his new baby boy ‘Reuben (easier to say than Rupert) Demarcation’, as he was born the day after Referendum, and came out right-hand first, as if voting! One of our expats has even met a child called ‘MSFCompound’.

To get back to the story, when Sheila came back from having delivered the New Year Baby amidst the torrent of gunfire, we all speculated that the little girl may well end-up being named ‘NyaPangPang’, after these particular birth conditions. It wouldn’t surprise me in the least, except for the fact that most little girls less than one year old and born in MSF Lankien are called ‘Sheila’!

The Nuer language is something which I am being forced to pick up by the multitude of requests and communications which are lost in translation, resulting in no water for delivering babies, shelves being built in wrong places, etc. It has many charms, and the idioms already fascinate me. ‘Maleh’ (‘How is it?’ is the standard greeting here, but it can be augmented, in response, to ‘Maleh Ma Gwah’(It is Good’), Maleh Ma Chum-Chum’(It is Tasty’), ‘Maleh Ma Lim-Lim’(‘delicious’) etc. ‘Gwah-Lun’ is ‘Very Good’. A lot of fun can be had with these additions. There is a lot of Arabic used, too; ‘Shukurum’ being reminiscent of the Turkish ‘Teshukur’ – no word in Nuer for ‘Thank You’, and I believe the word ‘Kapir’(‘Guard’) is Arabic, too. ‘Kawai’, as I mentioned, means white/foreign person – said of other black Africans as well as Europeans, equivalent to the Swahili ‘Mzungu’ across the rest of this part of Africa.