Saturday, June 2, 2012

Level Two Threats and Threats of Unknown Magnitude

South Sudan’s recent appearance in the news prompted me to post this series recounting my experience operating on the Nile riverbank in 2007.

Arriving in Sudan from Kenya, I was greeted in the tiny airport by a young man called Lazarus. The whole airport was a single crowded cement room serving as receiving terminal, immigration, baggage claim, and customs. A stern man smashed my passport and South Sudan travel pass with an inkless rubber stamp. Lazarus then asked for my passport and disappeared. Meanwhile, I was subjected to the post-flight security check. As the same rubber-stamper man was rummaging through my luggage and asking questions, I realized I had no idea what I was carrying.  The Belgium office had given me an overstuffed sportbag to deliver to the mission.

"What is here?" asks security man, in Darth Vader's voice.

"Gifts," I bluff. "Medical supplies."

"What gifts?"

"Books. Mumble, mumble. Sweets. Murmur." He opens a box I'm sure contains hand grenades, and finds a few paperbacks. Bored, he sticks a dime-sized sticker on my luggage and points outside. I exit the sweaty building and find no sticker checker and no Lazarus with my passport. I act cool, standing among soldiers and a dusty tumult as if I own the place. Soldiers? Wasn't there a peace accord? It was in my briefing papers, which I read on the plane. I put on my sunglasses, wondering how one acquires news in the Sudanese bush.

Lazarus returns and shoves me into the back of a Rangerover festooned with mission logos and decals bearing a cartoon AK-47 with a big red circle-slash. No weapons! is the message. But for whom? Volunteer surgeons? Water/sanitation volunteers? Hitchhikers?  Armed bandits on the road?  Sorry, we didn't see the sticker. Please proceed.

Lazarus drives me a hundred yards - back to the airstrip I'd just landed on. There I await a pilot to shuttle me into Bor Town, my destination. Surrounding the strip are cows, mud huts, tall bushes, and soldiers. More soldiers. It looks like the opening scene of Platoon with a hundred or so troops filing into the bellies of monstrous white personnel carriers.

This is the uncertainty part - the unsettling business of seeing heavily armed men and wondering what their orders are, their alliances are, and hoping they understand my express neutrality. Where are they going, to my village? (Yes, stay tuned for upcoming episode)

When I land in Bor and pile into another Rangerover, our path is immediately blocked by another group of armed men. This group is more rag-tag than the airport soldiers. Their truck is swerving and bouncing toward us, camouflaged boys overflowing, clinging outside the truck, their machine guns aimed skyward. We let them pass on the one-way road and sit silent as they brake and unload in a tumble behind us. Hoots and howls. Laughter. A commander jumps down from the truck cab, shouts a few words, and gathers the boys. He waves us on and my heart re-starts.

I laughed at a persistent mosquito buzzing outside my net all night. In the morning, there he was on my pillow, too bloated to fly, smiling like after Thanksgiving dinner. Later that day I'm operating and feel a bite on the back of my neck, but am unable to address due to my sterile hands. During the case, I also feel the typical warmth of blood against my lap--nothing unusual for a bloody case. After the case, though, I realize my operating gown is not waterproof, but simple cotton. My boxers are soaked and I'm blood-stained from navel to knees. Maybe I should've worn a condom? How do you practice safe surgery around here? I shudder, and tell myself the HIV rate here is probably lower than in Kenya, since the Sudanese are all returning from twenty years in refugee camps. Wait, would that be higher risk? Thank goodness I got my Hep B updated. I assure myself that intact skin is an effective barrier to disease and I throw away my underwear and wash off my blood-soaked knees. Under dried blood I see scabs I'd acquired boarding a Rangerover.

In the mess tent at lunchtime, I enter to find the water-sanitation volunteer shooing a bat out the door, nudging it with the front of her sandal.

"He seems tired," she says. "I don't want to hurt him, but I don't want him in here while we're eating."

"Tired?" I say. "The f**ker has rabies, are you out of your mind?" I fling him out with a stick and drop a cinder block on him. I stuff him in a cigarette box coffin and chuck him in the latrine. Now I'm thinking about all the wildlife in our compound, the cats in my tent, the rats from the table cloth. I'd been vaccinated for rabies, but not for plague. I'm wondering if the flies in the latrine will carry bat saliva to the frogs. Would we be the first mission evacuated for rabid frogs?

[Wilderness medicine lesson for readers: a live bat on the ground in daylight has rabies until proven otherwise.]

 I was only in Sudan for a month, camping, operating, and periodically fearing for my life. Imagine living there your whole life. Camping, fearing, your whole life. I learned yesterday that MSF evacuated from Darfur due to attacks and injuries, and I felt sick while trying to get the details. I thought of the Sudanese I'd gotten to know, the OR crew, nurses, and medical assistants, our cooks, my patients, who so readily befriended me - who protected me! (See level three.) Where do they go if we abandon our mission? Back to the refugee camps where they've lived most of their lives?

Most of my patients arrived at the hospital on foot. The only patients I recall arriving by wheels were a busload shot by road bandits (there's only one road out of Bor) and a group of civilian gunshot victims hitching with soldiers.

One woman started her two-day walk after being shot in the back and elbow during a raid on her village. Her two young children were abducted by the raiding tribe. On her walk to the hospital she came upon her infant child, killed, and left behind on the footpath. The exit wound of her gunshot was in front - a broad opening you could put your head in. Her intestines were gathered in a cloth strapped around her waist where they bounced for two days on her walk to us. I unwrapped them and tried in vain to return them to her abdomen. I had to sew a saline bag over them to keep them contained. I did not bother with her elbow.

In the middle of the previous paragraph I mentioned that my patient was shot then saw her dead child shortly after. In the sentence following, I moved on and gave technical details. That's how I handled these horrors in real time too. I'd never conceived so much pain and loss in one place. At home I'd ruminate one patient tragedy all month. Here I spent a few minutes fixing what I could before the next misery out-did the one before.

I have photographs I can barely look at, and one memory I can barely re-tell, of another woman who walked days for hospital care. She started walking the day after failing to deliver a baby boy who was sideways in the womb. Family members had tried mightily to deliver the boy, but all that came was an arm.

But I also have photographs of parents protecting their children against bad odds. Of loving brothers and sisters. I lost my direction in the middle of this piece when I learned of the mission evacuation, so I'd like to show some nice pictures: 

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