Arabic lessons, please?

Serif Umra, 2009-01-22

The sun is setting in Serif Umra, bringing closure to a not so restful day off. Friday, prayer day, is the official day off and theoretically the time to recuperate from the events of the week. Obviously, there’s always some glitch to that idea; the morning today was the only feasible day for a confidential talk with my nurse supervisor, and though I indeed had a couple of hours set aside for good-for-nothing activities such as table tennis and tanning in the mid-day, the evening hours were spent dealing with a suspected case of viral haemorrhagic fever. A case like this, potentially highly infectious, where a good understanding of the history of the patient is absolutely essential in order not to put yourself or any of your staff under risk, occurring on a Friday, with no translator present in the dispensary, poses the level of challenge that makes this kind of mission… let’s say interesting.

This child presented with fever and two days of nose bleed and vomiting of blood, which constitutes enough of a warning sign, then add that the information we received indicated that this was the fourth case in the particular village. There is no Ebola in these parts, but you want to make sure you know what you’re dealing with nevertheless. Rather be safe than sorry. Consequently, Mauro, who fortunately speaks a bit more Arabic than I do, was trying to get a better picture and give instructions while I set out to organize some sort of barrier care in the isolation area. It’s no rocket science, but it demands that you take certain measures to prevent contamination of, well, everything.

Much of this knowledge is still lacking among the staff and it has a rather paralyzing effect on the staff in general and the caretakers of the patient in particular when expats dress up in protective goggles and face masks. After much pointing in many directions and many pointless explanations in English, my cleaners speak as much English as I speak Arabic, at least everyone was dressed in proper protective gear. At this point a Medical Assistant who speaks good English had showed up and it became clear that this had indeed occurred before with four people, but within the same family and with several years apart. Hence we were dealing with a hereditary coagulation defect rather than infectious haemorrhaging.

Instantly, the situation became less complicated, but still left the young boy at risk of life. We spent the following two hours trying to stop the bleeding and organizing a blood transfusion. Nobody should have to die from a nose bleed. The situation was under control when we had to leave the dispensary for curfew, tomorrow we will see how it turned out.

So, after another meeting in the evening, the week has come to a close. It started out good; the package with ginger bread cookies, among other goodies, that my parents sent for Christmas finally arrived. We’re now halfway through January and there was never much of a Christmas feeling, but my taste buds don’t care. In the course of the week we then dealt with a large number of wounded after a car accident, I came down with a severe case of homesickness and lack of self esteem, our Medical Coordinator paid us a visit from Khartoum, giving support and closing communication gaps, I recovered from my depression (definitely bi-polar), and finally identified a storage area for the cleaner’s equipment. Every single square meter of the dispensary seemed to be spoken for. Tomorrow the sun will rise (inshallah), and the never-ending list of tasks will be calling my name. At least then I’ll have my translator back.

Al-Soukh

I’ll share an experience with you. Maybe it’ll help you imagine this place and the atmosphere that surrounds us. Fortunately, it is not only the impressions of human suffering that remain with you when looking back on a MSF mission. The smells, sounds and tastes of everyday life in a community so profoundly different from your own make an equally important contribution to a memory. There are a numerous different ways to make these experiences, but some carry more weight than others. Partaking in the celebrating of a wedding in the local tradition is a must, and equally important is dining out.

Serif Umra is the centre point in a bigger locality, and consequently the place to be on a market day, soukh day. Hundreds of craftsmen, camel herders, farmers and men with influence gather to trade, make money and above all make connections. Tuesdays and Saturdays means a significant influx in the movement in and around the market, and are also our busiest days in the clinic.

Today, together with a number of colleagues from the office, I ventured out of the dispensary premises to join in the commotion, a welcome break from the house-office-dispensary routine. We walked the road along the wadi, reduced to a wide stream of sand now in the dry season, towards the market. You must picture the movement around us as we followed the stream of movement to and from the marketplace. Camels, bound together in groups of fives and tens trotting by, men in sunglasses on motorbikes, men with whips on horseback, women in colourful scarfs on donkeys or on carriages and finally big trucks whipping up dust engulfing the moving crowd. We join our assistant field coordinator under a shelter in the meat section of the market. Now, here is a man who knows the circles, truly irreplaceable when it comes to navigating the complicated politics of this place.

Anyway, we assemble among butcher’s benches, cooking fires and tealadies, where the scent of blood and guts is strong in the air. Soon we are guided into the back of one of the butcher’s shops where carpets are spread out on the ground under a shelter. There’s the mandatory hand-washing, thank goodness, and many greetings and handshakes, after which we take our shoes off and sit down, gathered on the carpets around two big plates. This is the way to dine in the Sudan, you eat from one massive communal plate, filled with little dishes from which everyone help themselves, using fingers or flat bread. I make a second experience with camel meat, I expect there’ll be many more, much better than my own failed attempt at a Christmas dinner anyway, and on the side we have tomatoes, fried liver, spicy sauces and bread. I stuff my face and enjoy, there’s something particular about eating with your hands. Someone told me that the real question is why anyone would like to use a foreign, cold, metal object like a fork to eat with when you can use your fingers, which are natural and familiar? Well, I’ll leave that for you to think about. The eating process itself is quite swift without a lot of conversation.

Inevitably, towards the end there’s the whole competition in politeness where the local staff make sure to offer the expatriates have the last pieces of meat and the expatriates in their turn try to respectfully offer back. In the end there’s some sort of a draw and we leave to make room for the next group of diners. We search for a good spot to relax after dinner and finally spread our carpets and ourselves out in the shadow of an old truck.

This is the true moment of communion where you discuss manly matters over a glass of sweet tea while digesting. I learn that marrying is quite expensive these days and that love is complicated also in Darfur. Someone brings and chops up sugar cane for dessert, and hence the conversation stops once again. Looking at this stick in my hand I wonder what in the world to do with it, though I presume it’s somehow for eating. Glancing right and left I learn how to peel one section of the cane at a time with my teeth, chew off the flesh and suck down the sugary juice before spitting out the starch. Imagine us sitting on that carpet with a pile of canes in the middle, piling, chewing, sucking, spitting; a striking picture. Spending time together with your co-workers in this way is precious and probably the best way to remove barriers between staff, not to mention it’s great fun and a nice perk to aid work. It lasts an hour, then we head back towards the office, duty calls.

Inshallah

Today I was bouncing, rather than walking, from the dispensary back to the compound at lunch time. Well, quite a bit after lunch time, actually, as usual. Anyway, this time the balance tipped to our favour and a woman will live to see yet another day. There’s no greater satisfaction for a medic. Equally satisfying is the fact that the tetanus baby proved stronger than the toxin, after weeks in almost constant spasms she’s able to breastfeed again. Glory.           

As mentioned in one of the previous posts, we are providing a very basic level of treatment here, and though we are moving forward and extending the capacity of the dispensary, the provision of treatment for more or less simple conditions like dehydration, malnutrition, respiratory infections and uncomplicated malaria is what’s having the greatest impact on the health of this community. It is becoming exceedingly clear to me that when caught in despair because of one child who came and died in the emergency room, one must remember the dozens or hundreds of patients who came and lived because of the clinic that same day.

You have to play it by ear and listen to the rest of the team when learning to deal with these issues, at least in my case previous experience provided few useful tools for similar situations. At home, there’s almost always something more you can do, more resources to draw from. If there’s a spinal injury, well then somewhere not too far away there is a specialised neurosurgical unit. If there’s a respiratory failure, then there is a respirator around. Generally, the holes in the security net are much fewer and smaller. Here, you can only do what you can do, and the rest is up to luck, fate, or what other force or being you put your trust in.

The of the expression ”inshallah”, meaning ”God willing”, suddenly makes a lot of sense. Before I could dismiss this as a face of fatalism, but here things are put in a different light, especially when compared to western society which in many ways has effectively expelled the need of a divinity from of its system. In Darfur, Allah gives and Allah takes, and to the local population nothing could be more obvious.

A few trivialities to counter the deepness:

-We had grilled camel for Christmas dinner. Quite chewy.

– Crazy Camilla made amazing meatballs, what a way to earn respect from a

Swede!

– My stomach is rather ok, again. We’ll see how long it lasts this time.

– It’s getting nippy here, morning showers (no hot water, obviously) are accordingly refreshing.

Different realities

The Serif Umra dispensary is in a transition phase. Large parts of the activities are still carried out in tents or in structures that were really meant for something else. The  completion of the buildings is long overdue and some of them, though finished, need to have their floors redone, again.

It is, I believe, the sixth time that those floors are broken up and remade, the sledgehammers are never idle. The vision is not only a permanent structure for the present profile of the clinic, but also an expansion of the activities to surgical capacity and a laboratory. This always looks good on paper, while in reality it is a painful process of constructing the necessary facilities, ordering and waiting for the equipment, recruiting the human resources and organising their training. This is Africa and everything, absolutely everything, takes longer time than anticipated. In the meantime, the medical staff soldier on, trying to maximise the use of the present resources while knowing that with the capacity waiting around the corner, more lives could be saved.

One such thing is the possibility of performing blood transfusions. Coming from a haematology (disease of the blood, leukaemia etc.) ward in Sweden, where half a dozen blood transfusions in a work shift is not uncommon, I find this experience very sobering. It is one thing to order whatever you need in whatever quantity from the hospital blood bank and another to, after identifying the need, immediate or prospect, for a transfusion in a patient, having to start from scratch.

Current limitations simply don’t allow keeping a blood bank in Serif Umra. Hence you have to start by checking the blood group of the patient, then continuing with searching for and hopefully finding and interviewing a suitable donor (matching blood group, good haemoglobin and generally healthy), screening for infectious diseases such as hepatitis and HIV (time consuming, despite ingenious rapid tests), taking the blood, cross testing it for reactions with the recipient before finally being able to start giving it. Of course, this constitutes the minimum requirements for safe blood transfusions. It’s neither possible nor desirable to cut corners when doing this, or quality will be compromised. Consequently, this takes time, though necessarily so. Even when, like in this case, you have an experienced laboratory technician, you will probably need an hour for preparations, all depending on how lucky you are in your search for a donor. Then take into account that this still only means one bag of blood and only critical patients are considered for this treatment, sometimes needing more than just that one bag.

This means you need to find more donors, so whatever you do you’ll be fighting against time. The trick is, of course, to foresee an emergency. The other day we thought we did. A young pregnant women came to seek care for vaginal bleedings. The placenta had partly detached from the uterus, causing profuse bleeding. There was no saving the foetus, and the mother needed intensive care. To reach a hospital with anything resembling an ICU you have to travel no less than three hours on dirt roads in an aged Land Cruiser, our grand referral vehicle, and you’d better get there before nightfall. Obviously, only stable patients could be expected to survive the journey. As the bleeding diminished, it was decided we should try and use our new-found ability to transfuse blood and then do the referral in order to give this woman a chance. All good and well, we started looking for a suitable donor thinking we had time, but soon found that the woman’s condition was rapidly deteriorating. The intravenous therapy to maintain the blood volume was result-less, and the blood pressure already critically low. Before long, we are doing resuscitation instead of a transfusion, ultimately out of time. At this stage, our efforts are futile and the husband soon asks us to stop the attempts to revive her. ”It is Allah’s will”, he says. How do you respond to that, coming from a man who just lost his wife?

Death is a part of everyday life here, and for sure I’ve had to give up on patients in Sweden as well, but one can’t help but be frustrated and wonder what could have been done differently, or what it would have meant to have that blood just a phone call away. These are different realities, and you  adjust. In the end, you can make a great deal of difference with small means, and I’d like to think we already do.

Striking a tone

Honeymoon is officially over. Not because reality has efficiently crushed romantic illusions about humanitarianism, mine are still somewhat intact, but simply because there’s a load of work to be done. If in the beginning, that is the initial week, I could allow myself the luxury of being the displaced newcomer, incapable of making any useful contribution simply because I was busy being confused and dehydrated, it is now time to start pulling my load. Laura, the Flying Nut, has taken off with one of the old Russian helicopters that make humanitarian aid in Darfur possible, and all the others in the expatriate team are working their hardest to keep the momentum and direction of the project. Nobody has time to baby sit a Swedish nurse, anyway.

So, game on. The following few weeks will be crucial, as they will determine the spirit in which I will work and by which people here will remember me. Other expatriates have already come, worked furiously, and left their footprints as they took off again. The local staff, creating the backbone of the project here, has adapted to the habits and mood of numerous khawadjat (”white people”, this is what the kids shout when they see us, sticking their thumbs in the air) before, and they’re already embracing me, the next one in line. It is a humbling position to be in, with lots of power to influence for good, but also to set a wrong direction or reverse progress previously made.

The nature of humanitarian work, with international staff carrying resources and know-how into needing, but not incapable, populations easily creates a relation characterised by friction, misunderstandings and expectations wrongly put. Effectively, the opposite is true as well. When such obstacles are properly dealt with and overcome, it can be a productive symbiosis. We will only rarely hear of or understand what lasting impression the local staff have of us, and I can only hope that by the end of my stay here, I will have managed to sow some self-confidence and pride into this crew of workers. In the end, the aim of our job here is to make ourselves unnecessary. Inevitably, MSF will eventually leave Serif Umra, and judgement will be passed on our effort. Did we merely impose ill-fitting solutions and standards on a setting we didn’t bother to listen to, let alone understand, or did we build something vital and independent? Time will tell. What goes for the project as a whole also goes for my own limited stay.

Whether I think it’s an optimal solution or not I’m now the supervisor of a diverse band of workers; nurses, drug dispensers, nutritionists, nurse assistants, cleaners, managers and sterilisation staff, some forty people altogether. It requires a great deal of listening before being able to strike a tone together with this foreign orchestra. Priority number one would be to engage with the pharmacy manager and the nurse supervisor, two central players. The key to a successful mission lies in creating a constructive and trustful relationships with these two. Empower them, and much will be won.

I realise I haven’t introduced the team with which I’m working here, a solid bunch of people indeed:

– Mauro, our Medical Focal Point/Doctor, a pasta perfectionist.

– Camilla, a.k.a. Crazy Camilla, the Midwife and social motor of the team.

– Jon, always in his sunglasses, looking chill. Occasionally he acts the Logistician.

– Raphael, well, obviously I must be nice speaking of the Field Coordinator, runs the business with gentle guidance, very French.

Add a Swedish nurse, the team dish-washer and rookie.

Primary

It’s now five days since the WFP (World Food Program, you may as well get used to the abbreviations) helicopter dropped me off at the airstrip, and the first working week in Serif Umra is coming to a close. Needless to say, the time runs by quicker than you realize. The crew here has graciously allowed me to take my time to aimlessly run around, trying to orientate
myself, learn names and stalk whoever seems to be up to something interesting. In a few days Laura, the coordinating nutritionist, more commonly known as the Flying Nut (really, a title to be jealous of), will leave the dispensary and see to some of the other MSF projects here in Darfur.

The therapeutic feeding centre will then be left under my supervision, and consequently I’m mostly following her to learn how things run. I go about it with much respect. Some three years of nurse work in Sweden has naturally left me with little or no grasp of malnutrition, or even paediatrics. Here,overseeing the work and quality of care for these little ones in the feeding centre will be one of the main responsibilities. So I’m following, taking every opportunity to listen in as Laura coaches the local staff or does the round in the inpatient department. I couldn’t imagine a more profound way ofproviding health care, and indeed, the care for the malnourished and dehydrated children is likely to be the source of both my greatest satisfaction and my greatest frustration during the time here. Lack of food and clean water pulls away the foundation for every other area of life, and while it may seem nothing is easier to address than this, nothing tears your heart like watching a child die from something so easily prevented.

This week I’ve also seen my first case of tetanus in a newborn. Again, tetanus is easily prevented through vaccination and through proper hygiene and care of the umbilical cord after birth. Still, it’s not uncommon here and fatal in almost 80 percent of the cases. Once it hits, it causes spasms in all the muscles of the body, and the only thing you can do in this setting is try to feed the child through a tube to the stomach, then wait and hope for the best. Our little treasure in the paediatric ward is still hanging in there. Maybe we’re lucky enough to see this one wear off. In the meantime, we go about our work to try and provide a basic level of care to this population. If nothing else, this is primary health care.

I feel privileged to be here.

Real

Darfur. The word stands out. It disturbs, if only a bit. Sometimes we recognise it as it sails by in the daily stream of news and information bombarding our senses, and flinch as it fires its guns at our guilty conscience. We know of Darfur, or at least it rings a bell, and it causes us unrest. Some would even give one or two facts about the conflict and sit with wrinkled foreheads discussing the state of the world. Usually it only holds our attention for a little while though. Soon our defence mechanisms kick in and helps us sort the unpleasant reminder into locked cupboards in the back of our heads.

Like with most news of human suffering we find it distant, difficult to comprehend and even more difficult to do anything about. Of course, we can only take in so much information about how people across the world are miserable. Usually we come to the conclusion that it’s sad an all, but unfortunately there’s not much we can about it, and ultimately it’s not really our business. It goes for me too. It was too hard to imagine, and not really my business.

Now I’m here, in Darfur. I’m inhaling its dust, exchanging phrases in staggering arabic with its smiling people and its sand fills my sandals. If it was previously hard to imagine, it’s now as real as a slap in the face and I’m trying my best to figure out how to deal with the impression. It’s a fantastic, rather sobering, feeling to find yourself dumped into reality like this. Ever since getting in involved with Medecins Sans Frontieres (I will use the abbreviation MSF henceforth) ten months ago, I’ve tried to picture what it would actually be like to arrive in the field. Well, this is it.

For some six months I will call this place home. This is Serif Umra, a community on the border between North and West Darfur. Following the conflict it has grown considerably from people seeking a refuge here. There is a small camp in the outskirts, but mostly people have been absorbed by a gradual expansion of the town, now holding an estimated total of 55,000. The population is now composed of internally displaced  persons, in humanitarian lingo commonly referred to as IDPs, permanent residents and nomads from the bigger locality.

For MSF and its team here on the ground, the task at hand is to provide secure access to health care to these people. Though generally covering primary health care, emphasis in the project is put on woman health care and nutrition. It seems women and children will always be the ones to take the hardest blows when the structures and safety nets of society collapse. Every man should ask himself why.

So, I’m here, and I’m only just trying to digest the first impressions and familiarize myself with the structure of the dispensary. It’s not all that spectacular. The reality rarely is. It’s just real.