Category Archives: MSF Work

Franco and the Plumpynut Bandits: Mad Max Revisited

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OK, I think we are all agreed here: the dry season is starting. For fun, we got the thermometer out today. 110 in the shade. Nevertheless, we are still cut-off from supply by – incredibly – water! Most of my time now is taken-up with water management. Whether it be trying to get my guards to stop marauding villagers running the hospital borehole dry, or lobbying and supporting the Local Commissioner to take responsibility for the town borehole, we are the only organisation in this part of the ‘New South Sudan’ with expertise and tools to create and maintain water supply. It is deeply ironic, then, that on the one hand water is our holy grail, and in the story that follows, is our enemy.

When Laraine, the other Logistician here in Lankien was on leave, and I was in charge of all the Logistics here, I ended up requiring several Cargo plane flights. There was one day, when a truck had been sent over-optimistically from Loki with Cargo for us. In desperation, we ended-up using a bush Cargo Plane to shuttle it from the other side of the swamp to here in episodes. This is an account of it which I wrote at the time:

Cargo plane at Lankien International

…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. Meanwhile, Aeroplanes remain our lifeline. When a plane comes, and after it has been meticulously packed with all the supplies, which first have to be ordered four months in advance, then picked from a stock across the border, then loaded according to urgency versus weight, we receive a ‘Flight Schedule’, ‘Flight Manifest’, and ‘Packing Lists’. These should correspond with what we have requested, give or take. Then, at dawn, I have to check the Airstrip, and report to our Flight Co-ordinator in Loki, who will then allow the plane to take-off. We then have to keep the airstrip clear of dogs, donkeys, cattle, random NGO equipment, and rubbish. The plane lands, we offload, check-of all the cargo, and the plane can go. In theory.

Miraculously, the dog survived.

On the first day of Dornier flights, there was a flight from an MSF plane from another project, to refuel from our stocks here. This used-up the fuel we had left – two drums of ‘JetA1’. This flight took off. Minutes later, the Dornier arrived with four new drums of fuel. These were the beginning of the stock from the stranded truck.

On the next Dornier load-up, another MSF plane had already turned-up – the scheduled regular rotation. As the Cargo unloaded, the MSF one taxied through the human faeces, shreds of old mosquito nets, piles of plastic waste, tumbleweed and dust, and over the dried-out mud, turned at the end, and started to build-up speed for take-off . It was at about 50 knots, I suppose, when my eye was caught by Riek running after one of the many wild dogs that haunt that end of the runway where they slaughter animals. The dog ran out, straight for the plane, and I have two fantastic photos of the plane, cloud of dust behind, with a dog running literally for its undercarriage. It was a heart-stopping moment. There were MSFers on board, too, but the plane was able to stop, turn, and have another go.

It is now one month since that time, and guess what: we are STILL waiting for the road. The area between us and the supply route is cut-off by swamps, and, although usually dry by now, it was ruined by some ill-advised civil engineering over rainy season, which seems to have done more harm than good. An MSF truck and trailer waits the other side of the swamp, with essential supplies – pipes to plumb the ever-growing Out-Patients Department, propane to run the Laboratory Fridge and cook, Cement to keep-up with the Latrines construction in the fight against cholera outbreaks, and Plumpynut (nutritional food supplements) for the malnourished and recovering Kala-Azar and Tuberculosis victims. This is cargo which our supply centre are reluctant to put on the planes all the way, because of its weight. It has taken two weeks to travel up from our ‘remote’ HQ at the Kenyan border.

It is always a battle of the budgets. There is a price applicable to every Kilo in weight that is brought to our project, and this ‘Transport Surcharge’ is massive. It took me a long time to be convinced to work with MSF. I had seen how Aid worked in countries like Liberia where I worked during the build-up to that infamous civil war for a different Relief Project, and it was only the fact that MSF is guaranteed to commit at least 75% of funding to field operations that made me, after 20 years of consideration, apply. But that commitment shows. There is no wastage here on the ground.

So on Tuesday, when we walked into the market in search of a place to have tea, and a huge six-wheel drive Russian Ural lorry appeared out of the dust like some kind of Out –of-Place, tattered Cold War Juggernaut, it took a moment to register first, that there was a vehicle in the market, and second, that this was the first moment of a huge opportunity.. Absent-minded for a moment, I lapsed back into traffic mode immediately and for a second carried on walking. Then it struck me. Today, this big commercial ‘Mad Max’ style truck, coming, it turned-out, with news of our MSF truck stuck in the swamps, was not to be missed, our biggest chance of supply. We are days away from running out of Diesel for the generator, and are out of propane for cooking food. Latrines will overflow before long, and it may be weeks and big bucks before we can get the stranded load ferried by cargo plane. I started running through the dust after the disappearing ragged hulk.

The driver, ‘Franco’ was friendly, and the first thing I said to myself, with unconcealed glee, was ‘He speaks English!’. I knew I had to try to make arrangements with this driver to retrieve our cargo, bit by bit, across the muddy swamps of Central Africa. But Communication across borders and deserts is painstakingly slow, and there is a list of challenges. Different accents, hell, different languages – Swahili, Arabic, Nuer and English; bad Sat-Phone reception and long-distance HF ‘Bush’ Radio. It is frustrating to know, from our supply and ordering system, that Unimogs are approved MSF standard (huge Mercedes-built ‘Go-Anywhere’ machines). I have used these Unimogs in the ‘swamps’ of West Wales, and if any project ever needed one of these, it was us.

But it is what it is. By the next evening I had managed to co-ordinate between the key players: Field HQ in Loki (Kenya/Sudan border); our Contracted Truck Company in Nairobi (Kenya); their driver at the flooded bridge over the swampland at Pathai; the 6×6 Truck owner in Bor (Sudan), and his driver here in Lankien. Payments between two transport companies across two countries had been co-ordinated, with me in the middle, and the MSF system was working like clockwork.

There is a long queue of NGO vehicles lined-up there in Pathai, waiting to come back in to South Sudan now the Referendum is over, but I persuaded him – with a bit of backslapping/handshaking, some major ‘Truck Admiration’, and a cup of tea – to do a deal with me! MSF remains the only organisation with any active presence in Lankien, so maybe this also helped to persuade all the right people to have all the right conversations with each-other. The biggest struggle was getting hold of his boss in Bor. We had to call a taxi-driver friend of his on Sat-Phone, who drove to the yard and found him. There is much more mobile phone technology than water here (although not in Lankien), but there is no electricity infrastructure in place to charge them. Landlines, of course, don’t really feature.

This is the kind of work I thrive on in the film world – making difficult things happen on film locations, finding the man who can, getting amongst the community – but I do not usually have to do it ‘blind’. All of the places I talk to are imagined to me. I have never visited them. In three months since arriving, I have not gone more than 500 metres from this compound for security reasons. So I have to guess at what is – and what isn’t – possible in these ‘Outside World’ locations around me. As I write, the truck is on its way through the bush to do what it does best. Its tyres are ragged and hissing with air, the front wheels splay apart jauntily, but it is the essence of Red Army ruggedness, and is well-capable of wrenching our MSF truck and its vital load through the mud. Spirits are high.

On the Ward: Referendum Aftermath (part 3)

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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)

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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)

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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

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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.”