Too Many Guns

Unpredictability – Profiling ‘Aisha’ – Numbers – Kids

These past two weeks have been full of action, and as share some this with you now I should apologise in advance for the bits of blood and gore. You can avoid this by jumping down to my profile of Aisha, a delightful mother of one of my favourite little patients, or to my inspired ponderings on being a child. Enjoy!

Unpredictability
Hours after I emailed off my last letter home things got pretty hot here. The sporadic shooting accelerated and spread throughout town. A government spokesman later explained to the press that their soldiers had entered one of the IDP (internally displaced persons) camps to retrieve weapons after an alleged assault on one of their officers. I would say much more, except I can’t – but here are a few of my scattered pictures of what I saw.

- Our logistics coordinator presenting up to work to tell in shock of having two dozen bullets become lodged in his mud-brick home. Dozens of other staff from that IDP camp with similar stories and shock and fear.
- Hundreds of defiant IDPs marching through the streets holding banners and sticks aloft shouting out chants of protest. Eventually going home after told in no uncertain terms what would happen if they did not.
- Jeep-loads of reinforcements roaring into town loaded with boys, bullets and big mounted machine guns. Seeing them haunt the town for the next week ‘maintaining order’.
- Bullets in chests, and abdomens, and necks, and legs… Fortunately only two patients that made it to the hospital died. One miracle man had a bullet course right through his neck without destroying any vital structures!
- Feeling the whiz of bullets fly over the hospital and sharing looks of fear, resignation and disbelief with the other patients and staff. Then feeling really uncomfortable realising that if things got worse I would be on a UN helicopter getting out of here – they would not!

Then stranger still, everything just returned to normal. Market day came and went, the roads re-opened, kids rode to school, and we resumed all of our activities (we had closed everything but the hospital). In the days following I would walk to work and look around wondering if I had just dreamed it all. But I slowly realised that everyone here has seen this before. Not always this violent and bloody, but the same forces at work, the same powers and threats and insecurity. And before I knew it things felt like normal again for me too.

As if that was not enough drama for the fortnight, this week finished with a bloody crash too. I was just about to leave the hospital yesterday when the army jeeps started rolling up. Half a dozen jeeps, 13 bloodied bodies. Not war injuries this time, just a damn big motor vehicle accident!

Profiling ‘Aisha’
Aisha Abdallah Adam, 26 year old new mother of baby Heemdan (who is in hospital with pneumonia).

Aisha is a nomadic woman who lives far from Niertiti with her husband and their extended family. She has the striking beauty, shiny dreadlocks, and strong eyes that typify the nomadic women of Darfur, and her lighter coloured skin reveals the ancestry influence of Arabs from the north. Her family depend on their herd of cattle for their livelihood, and their nomadic lifestyle is dictated by finding pasture and water – an increasingly scarce commodity in these parts. This competition for resources underlies the conflict that has existed for decades between rival nomadic clans and between these clans and the settled agriculture based Fur villages.

Every week Aisha travels in to Niertiti for market day. Market day is a big affair in Niertiti, with people coming from miles away to sell their produce in exchange for other necessities. On this day the town becomes its most multicultural, with Arab nomads, Fur villagers, town residents and traders from the larger cities all coming together to exchange goods. Aisha sits with other brightly dressed nomadic women selling the milk and meat from her family’s herd. They are highly valued commodities and Aisha knows that so long as they have healthy cattle her family will survive.

Market day is also the day when Aisha can go to the MSF women’s health centre for her antenatal checkups – a service that has been very readily embraced by her and many other women. However, like many women who live far from Niertiti, her actual delivery was completed at home with the assistance of a traditional birth attendant and a birthing kit from MSF (with soap, a cloth, sterile razor blade and string for cutting and tying the umbilical cord). The availability of pregnancy care and birthing kits have made a big difference to women and their babies here, but we still regularly see the complications from prolonged labour and neonatal conditions like tetanus from the use of dirty knives in cutting the cord.

The reason Aisha sits in hospital now is because her 30 day old baby has pneumonia, which sits alongside diarrhoeal disease as the biggest cause for hospital admission (and death). But today he looks great, and I tickle his tummy while I tell Aisha that he just needs a final dose of antibiotics before she takes him home. Five days in hospital is a big deal for Aisha, as it means five days away from her work and livelihood. So Aisha smiles happily when I give her the news, and her husband and mother beside her share the relief that he is well and they can now go home. Her mother (an older image of Aisha) who jokes that it looks like I want to keep him for myself. I am tempted (-:

Numbers
1 hospital, 60 inpatients, 120 admissions/discharges per week
1 expat doctor (me), 4 Sudanese doctors
1 expat nurse (currently vacant), 14 nurses/nurse assistants
14 births per week, 1 expat midwife (currently vacant), 5 midwife assistants
3 outpatient clinics (including a mobile clinic, and remote clinic)
7 medical assistants, 1800 outpatient consultations per week
1 inpatient feeding centre, 30 kids, 10 admissions/discharges per week
3 outpatient feeding centres, 150 kids, 20 admissions/discharges per week
1 expat Field coordinator, 1 expat Logistician, and a big team of administrative and support staff.
Kids
Every day I walk slowly to work and pass dozens of kids who wave and call out ‘khawadji’ (roughly translated as foreigner). Some of them are filling up water bottles from the bore well, jumping up and down and using all their little weight to pump the handle. Others are playing with marbles on the ground, or arranging sticks into little houses. Some kids race down the dirt road using a forked stick to role the lid of a tin can along the ground. Others are walking or riding to school dressed in neat uniforms and carrying their books protectively under their arms. When they see me they wave energetically or come over to say ‘salaam’ (peace greetings) and shake my hand. Sometimes one child will take my hand and walk along with me (this is followed by a dozen other kids running up to hang off my arms). I am told that the Persian mystic Rumi always made a point of greeting and blessing children, seeing them as particularly sacred. I like this idea. Imagine if every adult greeted every child with the respect and attention that they greet other adults with.

In the hospital one of the best parts of my job is looking after the sick kids and seeing them get well. It is also the hardest part when they don’t get better. So I was excited to find out last week that I have been offered a job at the Royal Children’s Hospital in Melbourne next year. It also made me think what a different life kids here have compared to the kids I will see next year. It will be nice to work in a place that has such a high quality of care – specialist doctors, all the blood tests, X-rays and scans imaginable, no worries about running out of essential medications. But will I also resent the fact that there is so much excess and waste in Australia? I don’t just mean seeing the bloated bellies of malnourished kids here replaced by the bloated bellies of obese young Australians. But also all those little every day excesses in the home, at work, in the hospitals. Those unnecessary things we convince ourselves are ‘needs’.

Children are one of the world’s great reminders of what is valuable and necessary in life. Things like nutritious food, clean water and sanitation, schooling, safety, shelter and time to play and just be kids. There are dozens of reasons why children here may not enjoy these things that most Australian kids take for granted. Conflict, famine, population displacement, child labour, child soldiers, deceased parents, child-headed household, family illness, poverty…

These are all big, complex issues. But they are also all issues that we in the rich ‘west’ can help to relieve (or perpetuate). From the individual level up to the level of international policy, diplomacy and economics, we can all do something. Maybe it is simply donating to MSF or other relief and development organisations. Maybe it is signing a petition to make essential drugs more accessible to low income countries. Maybe it is lobbying for greater awareness and action on the food crisis being exacerbated by international economic stressors. Maybe it is writing to your member of parliament urging stronger action on alleviating poverty among the neighbours of our global village. Maybe it starts by picking one issue to become better informed about.

The west will not be able to ‘fix’ these problems (indeed, the west has done much to cause and perpetuate them through colonial, economic, social and political misadventure). Real change and development is always indigenous. But there is so much more that can be done to empower disadvantaged communities around the world to make this change. So before I step off my soapbox I unashamedly challenge you to find one small thing you can do to contribute before we reach the end of this year.

Heart of Africa - Darfur

Normalisation - A Day in the Life (2) – Profiling ‘Ali’ – Rich Africa

Normalisation
I have been here in Darfur for almost two months now and continue to experience a crazy mix of exhaustion, exhilaration, frustration, anticipation, despair and hope. But things have also become very ‘normalised’ (a psychological coping strategy that I am sure all humanitarian workers experience). So, when does normal become extraordinary?

-Malnourished child with sepsis and severe dehydration = Normal (give fluids, antibiotics, supportive care – next patient).
-Four such children, one dies = Crap week (review case, look for improvements, keep trying).

-Eating dinner and then hearing gunshots = Normal (pass the pizza please).
-Machine gun fire continuing after the pizza is finished = Hmm, unusual (keep radio and satellite phone handy, call UNAMID, inform HQ).

-Pregnant lady dying from Hepatitis = Normal.
-Three deaths from liver failure (including one child) = Bad week (wish we had more investigations, could have done more, stay alert for epidemic).

-Two doctors for the whole hospital and outpatient referrals = Normal.
-One doctor for the hospital, feeding centre and >200 outpatients = Damn, not again (work overtime, take shortcuts, turn patients away, coerce a medical assistant to work their day off).

-Government officials delay arrival of staff by weeks = Normal (cover job by other staff, be patient).
-Our only nurse, midwife, lab technician and other doctor denied entry = only in Sudan (stretch staffing, trim activities, keep sweet-talking authorities).

Working here is a huge balancing act just trying to do the best within our limitations. I am frequently reminded that we can only do so much, we cannot save the world, and that without us there would be no access to health services at all. It is very true! But it can also be used as an excuse for the rich world neglecting their moral obligations to the less fortunate - a way of making ‘universal human rights’ selective and relative.

A Day in the Life (Part II)
Last letter I began to describe the nuts-and-bolts of daily life as a medical humanitarian aid worker. I left the story at the end of the hospital ward round, so will pick it up from there now.

…By the time the ward round is finished it is early afternoon. Usually I take a lunch break, but it is the fasting month of Ramadan now so I convince my translator to skip his break and promise we will finish up early. By now there is a line of patients waiting outside the doctor’s consultation room who have been referred by the medical assistants in the outpatient department for review. I admit a child with pneumonia, a man with hepatitis, and a woman with pyelonephritis. Another child comes with suspected appendicitis, so I arrange for him to be transferred by taxi to Zalengei hospital, 2 hours to the west. I lance a big boil on a boys leg, review a couple of nasty wounds, and find the other referred patients can be treated without needing admission.

After reviewing a few of the sick patients from the ward round I handover to the other doctor and collect together all the patient files to collate for the statistics. Today I am pleased to handover by 3:30pm (usually it is closer to 5pm) and get back to the office to start on the stats. As the expat doctor (the other 4 doctors are all Sudanese) it is my job to do the stats and medical reports (as well as organise medical education, look after staff health and supervise the hospital, nutrition program, outpatient department and mobile clinics). This is a time-consuming and mundane job, but I do get a geeky thrill out of seeing all the morbidity trends and looking out for epidemic trends. Maybe one day I will bore you with some of the results (-:

I try to get all this finished by 6, though today we have the end-of-week team meeting that stretches a bit later. This last week has been particularly busy as we are short-staffed and my big reports were all due. So I have been burning the midnight oil to push out a 75+ hour week (finishing each night in the dark as the generator switches itself off at midnight). This is certainly not something I plan to make a habit of! I promise myself no paperwork tonight and a full day of rest on Friday (our one-day weekend).

I return to the living quarters throw down my gear, have a wash and do some cooking (we have cook who prepares our evening meals, but I usually like to cook something extra myself). Sunset is around 7:30pm, and during Ramadan I have made a habit of joining the other non-local Sudanese staff (who live in the same compound as me) for the evening breaking of fast. We kick back, eat, drink tea and chat - I hear all about upcoming marriages, how life is away from family, which villages they are from, and what their plans in life are. It is always intriguing to hear common human aspirations and life experiences presented with their unique cultural and individual expressions.

By the time we finish chatting it is after 9pm and I am ready to wind down and go to bed. So after my evening exercises, reading and meditation I duck under my mosquito net and drift to sleep.

Profile: “Ali”
In response to my last email, a friend has asked me to tell the story of one person “so we can juxtapose their situation with our own”. He commented that many Americans/Australians/westerners want to “hide behind the notion that they are ‘middle-class’, not really wealthy, forgetting that they are fantastically wealthy in comparison with the majority of the people in the world”. Very true! So, in an attempt to personalise the experiences of Darfuris I offer the stories of some of the extraordinary ordinary people I have had the privilege to meet.

Ali Abdullah Musa, 35-year-old father of 6, husband, and my extremely talented translator (English/Arabic/Fur).

Ali grew up in a small village in west Darfur – a self-sufficient agricultural community who lived in simple mud huts without piped water, electricity or any other ‘modern’ amenities. After finishing school he worked as a teacher, got married, started a family and was planning to go on to university. In 2003 his village was pillaged by a group of armed militia he (and other IDPs) calls ‘Janjaweed’. While he and his family got away safely, many of his neighbours have never been seen again. They made their way to Niertiti as part of the first big influx of IDPs (internally displaced persons).

Ali is one of the most motivated, positive people I have met and tells me passionately of his future plans “when there is peace in Darfur”. Like the thousands of other IDPs he has had to put the past behind him to create a new life for his family here. However, unlike most of the other IDPs, he does not seek to forget this past and has written down his own story and recorded the stories of dozens of other IDPs (a growing manuscript that would make an absolutely fascinating book!).

In the 6 years since arriving here Ali has done so much for himself, his family and the community. His self-constructed ‘house’ now has three rooms, a separate cooking area, and a small courtyard that is full of pot-plants and a steady flow of visiting neighbours. This small, mud-brick, thatched roof hut is one of the most homey, welcoming houses I have ever been in. Water is collected from a hand-pump around 100 metres away, and they share a toilet facility with three neighbouring households. His salary goes to support both his household (wife, 6 children, mother-in-law) and assist his extended family and neighbours.

Ali started work with MSF (Medecins sans Frontieres) as a ‘Home Visitor’ when MSF first set up in Niertiti in 2004. [HV’s are the key link between the community and MSF, providing communication on security, health, environmental, logistical and cultural issues back and forth.] After doing this job for a few years he began acting as a translator and is undoubtedly the most fun and talented translator I have ever worked with. Employment with MSF has ensured Ali a secure income and given him a relatively comfortable life compared with most of the other IDPs. [Most IDPs depend on UN food handouts and self-employment (doing such things as collecting wood, making baskets) with most of the more profitable and skilled occupations dominated by the original Niertiti townspeople.]

Ali is a daily reminder for me of the human capacity to find hope and direction in the worst of circumstances. In many ways he is a poster-boy for what an intelligent and educated person can do in tough circumstances with motivation and a bit of luck (and yes he has been much luckier than many of the other IDPs here). It is also a good reminder of the capacity of the ‘poor’ to create a future for themselves - and how the ‘rich’ can play their part in helping them realise it.

Rich Africa
A friend reminded me by email of the richness of life in Africa – “a richness not defined in dollars, cents and possessions…”. It is a blessing to be working in such an environment (and without the unnecessary necessities of my car, house, mobile phone, career, shares, technology etc.). And perhaps it can also be a reminder to all of us about what is truly important and necessary in life.