Week 4

Anybody who remembers the first Star Wars movie will recall the monster in the sewage-crusher that our heroes got trapped-in. I went to check up on a latrine which we were decommissioning in our ‘TB village’. This is a compound of some twenty tukuls, mainly residential, where patients suspected of having tuberculosis live, whilst being monitored for developing symptoms. I spent a few seconds looking down into the slurry before it was filled-in, and felt that ‘vertigo’ compulsion to look down from a great height. As I was taking my eye away from the effluence, it was caught by a big yellow eye looking back at me. A huge fat lizard-like creature had made its home there, living off the flies. It was at least a foot and a half long, and I wondered if it was a monitor-lizard, or just one of the many four-inch lizards around, which had become massive, gorging itself on the thousands of flies which live down the warm, disgusting hole.

But the other things living off flies here are the chorus of amazingly colourful birds. I do not know any of the species names apart from the African Bee-Eater, but they are a constant blaze of incandescent light at the corner of the eye. It may be that they have found a particular haven in our compound, safe from children I have seen toying with small birds before eating them around Africa. They capture them and keep them by a string around the foot, and it can seem cruel to the western eye. It is hard to imagine that happening here, though; people seem so gentle and dignified. No doubt, all will become clear, but Felix, the compound cat, flea-ridden as he is, does not seem remotely interested in these little birds either, although I did find the wing of what must have been a juvenile African Kite lying around in the dirt the other day.

This week has seen me take over responsibility for all the supply to the clinic. This is done through our HQ in Loki, where half of our stock for the project is stored – along with stock for the other projects in South Sudan. Weight limits for flights, and monthly consumption rates have to be juggled with each 10-day plane flight (‘rotation’). If we get it wrong, anything can happen, from having no UHT milk for tea (local milk risk of brucellosis) to no second booster for a course of vaccinations. ‘Don’t overthink it’ was the best advice I’ve had from Laraine, the LogAdmin going on leave and handing her job over to me. Yesterday we were working til 10.30pm compiling our medical ‘buffer’ order for the next month, when we may have our supply interrupted for reasons to do with the Referendum. Every medicine has an MSF code which must be found, and a weight, and expiry date, all of which has to be taken into account. Confused? I was. All I know is that last night, for a 700kg load restriction, we clocked up a 1250Kg demand. So now I have to request a new flight, or slot it into a cargo flight which I hope will come the day before New Years Eve.

At 3.30am I was awoken by Daniel, Medical Team Leader, saying that the generator, which had been running because a patient was on the Oxygen Generator had ‘passed away’. I have been in increasing contact with death this week, more babies dying, and reports of someone dying from a gunshot wound in our outreach project. When people die, family members waste no time in their burial. At 5.30am, I was again awoken by Bo Gatluak, one of my Logistics team, who needed to bury his brother. It was he who had been on oxygen, and Bo needed a pick/hoe to dig his grave. My heart went out to him, as I imagined the lone soul digging in the gloaming of dawn. I asked if he needed help, and as I spoke I realised that he would have plenty of help from his family and friends.

So many things have happened this week which merit reporting, and which I was saving for the blog, but my memory has been distracted by the panic of the new handover from Larraine, and I seem to have forgotten so much in the daily panic. I will remember, in time, but the helter-skelter at the moment, jumping from one situation into another, without even time to think to myself ‘This is Mental!’ renders me wholly preoccupied with surviving in the job in hand.

As I browse through past postings, I notice some typing errors. This will be due to all the keyboards here being full of dust. In fact, everyday I am filthy with it. People spit in it, and one of my responsibilities, for Water and Sanitation (WatSan), is to supervise the prohibition of open defecation around the clinics. What with the ‘sputum’ from TB positive patients (everybody spits in the dust here as a habit), and the other fluids that end-up on the ground, drying to dust, and then getting blown up by the gusts of wind, and breathed-in, it’s a constant battle against infection. My nose now doesn’t smell the smells it did when I first arrived – the ‘normal’ smells of the In-Patient’s Department, the Kala-Azar Clinic – but I can still smell the carefully constructed pit-latrines, from down-wind. The other day, I tried to have an English-Nuer conversation with Majok, whose job it is to try and enforce sanitation in the Hospital compound. During a ‘translation lull’, I watched absently as one of the lady patients walked over to a newly-built corrugated iron pit-latrine building. These are simple, but with custom-made foot-pads, and well-constructed ergonomics, they are highly effective and familiar to the Nuer people. We put a new one together at least every week, to keep up with them filling.

It baffles me to know what went through her head as she spotted this building, for which everybody knows the use, and how she clearly thought: ’what a great thing to defecate BEHIND’! I realized at the same time as Majok spotting her, and the cry went up to take a crap INSIDE, but with language and culture being so impenetrable, it does sometimes seem two steps forward and one step back…

A Ruby in the Dust: I hope to post more photos than I have on Facebook, but sat-link is very difficult. Then I could show a picture of our clinical laboratory. Sammy, our Kenyan former acting project coordinator, is in charge of the lab. Here he meticulously investigates sputum, blood, and stool, looking for evidence of Malaria, Kala-Azar, Tuberculosis, HIV, and loads of other tropical diseases. It is incredible to see the place where this all happens; a low Tukul (mud-hut), beset by dusty gusts of wind, with stick and rope poking through the mud walls and a bilingual sign saying ‘Laboratory’. It just struck me last week at the team meeting, when Sammy was reading-off his statistics, what an amazing feat it is to achieve reliable laboratory conditions in this environment.

I went looking for a list of data, so that I could go through the long-winded job of ordering new supplies for the lab. I have been in there before, but not when it is in full swing. It was a bit like going into the Tardis. Suddenly, ultra-violet light on desks, lighting-up microscope slides on a squeaky-clean surface. A high-tech microscope glowing with its micro-image, and a technician diligently logging and rechecking his findings. For a moment, it felt like Boots The Chemists, until a glance at the wall above, with thatch sticking through the mud, and a big flat spider scuttling after a termite, reminded me I was where I was. The lab is the closest I come to home.

One of the many areas of my work which I am trying to strengthen is supervision of the guards. Since arriving here, I had, until recently, had no time whatsoever to get to know the names and faces of my Nuer guards. There is little, if any, English spoken amongst them, and they work shifts through night and day. They guard the flow of village people wanting water, and I try to balance the needs of the clinics with the needs of the community for our limited supply of borehole-pumped water. Discipline is something which I am trying to foster, across the spectrum, as it will be our reference-point in the midst of any panic. This has to be done by example, of course, and through a friendly appreciation of mutual professionalism. The other day we took-in a gunshot wound through the leg, but not a critical one, and as I received the soldier at the gate, our guards were very good with making sure that the incoming recognized the ‘No Guns’ sticker which adorns all of our gates, and left their weapons outside.

Of course, certain colleagues wanted to make sure their friend was all right, and so I let them look through the mosquito net gauze and communicate with the sedated man. There is much suspicion of our medical techniques (particularly in childbirth), so it is important to be transparent, but also to be firm that our doctors are doing a professional job, and must not be disturbed from their work.. This seemed to go quite well, and I hoped I was able to enforce a calm and clear respect reciprocation across the language barrier.
It was great to see Doctor Hanna in action. She is a tough first mission medical doctor from Holland, who sends my logistics boys away when they go to her with work injuries, healthily dismissing them as ‘big babies’. Like all the team, she is thoughtful and caring, but takes no prisoners when it matters. Together with Daniel and the other doctors, they are a formidable force, and the man was treated quickly and discharged. We are in safe hands, and our protection is in our impartiality.

‘Temoignage’ is an interesting key part of the ethos of MSF. It goes hand in hand with the medical agenda, and it is interesting for me to be in a position, for the first time in my adult life, perhaps, where I think it important and justified to express my opinion. This is why I dare to write this blog, and what lets me forgive myself for what might seem like ‘talking all about me’. Here is what MSF has to say about Temoignage and Independence:

Witnessing (témoignage) consists of:

  • The presence of volunteers among people in danger, motivated by concern for the fate of fellow human beings and a willingness to be at their side and to listen to them, as well as to carry out medical work among them, and
  • Reporting on the situation and on the fate of these people, which is seen as a duty. Where MSF is present as a witness to large-scale human rights violations, such as forced population displacements, sending refugees back from their country of refuge (refoulement), genocide, crimes against humanity and war crimes, then MSF may ultimately be forced to make public denunciations.


  • MSFs independence is, above all, an independence of spirit that has its roots in an independent judgement and a critical attitude towards the way in which humanitarian interventions are both made use of and abused.
  • An independent spirit is a prerequisite for independent action, ensuring a free choice in regard to where and how to intervene, when to start an operation and when to end it.
  • This operational independence implies an independent organisation. MSF refuses to intervene under pressure from any authority, whether ‘de jure’ or ‘de facto’, or to be manipulated into seeming either to support any such body or to act as an alibi for any of them. MSF therefore maintains the strictest independence from any organisation or de facto authority (be it political, religious, economic, financial or other). However, the search for independent financing must respect certain ethical safeguards and the values held by the MSF movement.
  • This overall independence must be respected by each member of MSF, who must at all times refrain from linking the organisation with their own political and other affiliations.

(Chantilly Document, MSF Guiding Principles)

Remaining a voluntary organisation is an important factor in maintaining and renewing an uncompromising spirit, refusing to be bound by routine and the risk of institutionalisation.

These are the words that made me decide to work for MSF.

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