Violence Against Women

What’s New? – Profiling ‘Aziza’ – IBM Language – Garbage City

I have just returned to Darfur after enjoying a week of rest and rejuvenation in Cairo, Egypt. My ‘holiday’ was nice – I visited the pyramids, camped in the desert, made new friends and avoided becoming a road trauma statistic - but I am very pleased to be back to work in Niertiti.

What’s New?
Returning to the field after my break I was surprised how much news there was to catch up on – good, bad, quirky and frustrating. Construction of a new sheltered area in the hospital courtyard is complete. Built from tree branches and grass it now gives a cool shaded area for patients and their families – and room to triage patients when there are influxes of trauma patients (e.g. war casualities). A new doctor and medical assistant had arrived, as well as the new expat midwife and remote clinic doctor – finally giving us an almost full medical team. Unfortunately the remote clinic doctor will be kicked out of the country next week after only 2 weeks in the field due to a bureaucratic paper issue. It is eternally frustrating for humanitarian aid workers to be delayed and rejected by unwelcoming official procedures when the local population is so wanting for services. But in places like Sudan it is the sad reality.

Security around Darfur has deteriorated for aid organisations, with car-jackings occurring every couple of days and bandits becoming disturbingly disinhibited in their operations. Our vehicles are locked up in the compound and we resort to donkey cart for all internal movements. Our mobile clinic has been closed for one month and remains so indefinitely. The remote clinic is functioning but all travel is done with caution (especially since a nearby MSF team was evacuated after their Landcruiser was ‘borrowed’ to chase and shoot some rebels in the mountains). No personnel have been at risk, but the last thing we want is for our humanitarian resources to end up being directly involved in perpetuating the conflict!

Thankfully there have not been any big shooting incidents since I left. But there are still sporadic assaults and deaths due to local social and political disputes (including the death of a local MSF staff member who was confused with someone else by the gun-toting guys who came to his home!?!). Despite all this I am amazed at the motivation and hope people have after half a decade of insecurity and conflict. In the midst of all this they go about daily activities consistently and regularly talk of their plans for themselves and their families “when there is peace”. When there is peace!

Profiling ‘Aziza’
Aziza Abakar Musa, 16 year old girl from Niertiti who comes to the Women’s Health Centre.

Aziza was 12 years old when she fled her village with her family and came to live in a camp here in Niertiti. She remembers the farm and what village life was like, but for her younger sister life in the camp is all she really knows. Her father disappeared in the raid, and her only other brother recently left to join the rebel fighters in the mountains. So now it is just Aziza, her mother, her sister and her aunt’s family living together in a huddle of mud-brick huts.

Every day Aziza helps her mother with the household chores. She collects water in buckets from the bore-well and brings it home for drinking, cooking and washing. She takes bundles of clothes to the river to wash them and dry them on the rocks. Aziza doesn’t go to school often as there is so much to do at home, but she does have a pencil case and notebook, which she treasures dearly. She accompanies her mother once a month to pick up food rations – grain, pulses, oil and salt. Sometimes she can trade some of these in the market for vegetables, fruit, or even milk. Aziza likes these jobs, they keep her occupied, and give her plenty of time to chat with other local women.

Aziza’s least favourite job is collecting firewood from the forest. It might sound like a simple job, but for young women and girls like Aziza it is a huge risk. And last month, Aziza met with this risk in a very ugly way. As usual she went with three friends to collect wood one afternoon, making sure they had plenty of time before it got dark. On their way back home they suddenly heard the beat of horses and were surrounded in a cloud of dust. Looking up they saw two men on horses with guns hanging from their shoulders yelling at them to stop and lie down. But Aziza and her friend fled, all running in different directions to get away.

It did not take long before one of the men caught up with Aziza. He threw her to the ground and assaulted her, brutally and intimately. Then his companion arrived and he took a turn as well. They dragged her back to their camp, finally releasing her in the early hours of the morning to walk through the desert back home.

I met Aziza the next day when she arrived with her uncle at the Women’s Health Centre. They were both distraught. I sat with her and the female medical assistant and we did our routine medical and psychological assessment and treatment. For Aziza this assault was not only a personal abuse but will haunt her socially for the rest of her life, making things like marriage especially difficult. Unfortunately, her experience is all too common for women in Darfur, who are particularly vulnerable in the context of dislocation and conflict. Rape is a weapon of war, and here in Darfur it is terrifyingly effective. In my desk at work I have hundreds of medical reports for girls like Aziza – and these are just the ones who seek medical attention. Most hide away out of shame and fear.

Two weeks later I saw Aziza for review. She gave me some surprising news. Although initially reluctant to report the assault to the police after a few days she decided that is what she wanted to do. This must have taken extreme courage, knowing that the authorities here have a record of bias towards the perpetrators. Then she told me something even more surprising. The men had been caught, thanks to the efforts of the sheik of their tribal group who heard about the assault and personally tracked them down. They are now locked up behind bars. Realistically, no one expects them to come to trial – but just the fact that they were apprehended is a first for us here!

I check Aziza over and find her bruises and cuts are healing. Her eyes look a little brighter and she gives me a shy smile as we talk about her family. For sure, her life will never be the same again, but she is strong and maintains hope that there is a better future ahead. I hope with all my heart that this is true!

IBM Language
There are three words in Arabic that visitors to Sudan cannot avoid – insha’allah, bukra, malesh. Sometimes it seems that entire conversations can be based around this IBM vocabulary. I was at the airport the other day and arrived at check-in to find my flight cancelled. “Malesh” the attendant sympathised (or gloated!?!). When will the next flight be? “Bukra - insha’allah”, and off I went to return the next day. So for anyone planning a trip to the Arabic speaking world, learn these.
· Insha’allah means ‘God willing’ and is a disclaimer for any future plans.
· Bukra means ‘tomorrow’, which is when most things will happen (insha’allah).
· Malesh means ‘sorry’ or ‘too bad’ (or ‘shit happens’) and is usually said with a big grin when something has just gone wrong.

In Darfur this language carries a deeper meaning and conveys a fascinating mixture of hope and fate. People here are faced with huge challenges, frequent disappointments and never know what tomorrow might bring. A mother sitting beside her dying son looks up at me when I explain we are doing all we can and says insha’allah, reminding me that despite our best efforts ultimately he is in the ‘hands of God’. Our car slides down a muddy bank into a river and the driver smiles malesh, then we all pile out to drag the car back onto the road. My assistant tells me of the raid on his village and how difficult life is as a displaced person, then startles me with his dream of resuming his study bukra, when there is peace. In this case bukra still seems a long way off.

Garbage City
I will finish this letter with a brief tale from Garbage City, an amazing part of Egypt’s capital, Cairo. Cairo has a population of over 33 million and there is no official waste collection for the tons of waste produced by residents and visitors every day. But 85% of waste is recycled – all thanks to the residents of Garbage City. I met one of these residents, Hanna, when I visited a school for working children run by a local NGO (non-government organisation). Hanna took me back home to meet his family and see Garbage City first hand. Like half its residents Hanna’s family is Coptic Orthodox, and as garbage collectors occupy one of the lowest rungs on Cairo’s social ladder. And seeing a glimpse of his life left me absolutely intrigued.

The first thing that hits me as I reach the outskirts of Garbage City is the smell – a potent mix of burning plastic, rotting paper and animals. The alleys are crowded with enormous bags of plastic, paper and metal. The tiles underfoot are buried in the same and I notice a big rat lying stiffly on its back. Despite the dirt and rubbish everything is impressively ordered. I meet Hanna’s sister squatting in a pile of plastic sorting it into piles. After being sorted, cleaned and bundled they will be sold to neighbours who turn it into plastic coat-hangers, cutlery, cups, bowls and plates.

Inside Hanna’s house it is clean, nicely furnished and bright – a stark contrast to the world outside. He takes me up to the roof of his apartment building to show me a solar hot water system made completely from recycled material. For the past year he has been building these with the assistance of a Canadian engineer and donor funding. A few dozen units have been built and distributed to local schools and families. As I watch the sunset over the top of grey buildings, plastic bags blowing around, dust saturating the air and the persisting smell tickling my nose I know I will never look at rubbish quite the same. And I will certainly take more notice of those nondescript people bundling rubbish on the city streets.

Village Clinic

Mobile Clinic – Profiling ‘Aladeen’ – Parties

I am half way through my mission here in Darfur. I have learnt so much about Darfur, the world and about myself. I have had the opportunity to work with amazing people who, in the face of gross injustice and abuse, refuse to be passive victims and instead find the strength to work for a better future. Today I would like to take to on a journey to our mobile clinic and introduce you to a few more Darfur locals.

Thur Clinic
It is 8:30am and the morning sun has risen from behind the Jebbel Marra mountains to cast an orange glow across the country. Today is my weekly visit to Thur, about 30 minutes drive to the southeast, where MSF runs a clinic three times a week. As I walk into the office to pick up the money and travel documents my driver calls out a cheery ‘salaam’ while polishing the windows of our Landcruiser. Joined by my translator and a medical assistant we load the car with boxes of Plumpy Nut (a peanut-based nutrition supplement), a cold-box full of vaccines, sterile equipment for the dressing room and various other medical bits and pieces. In Thur we will meet the local team who do the actual day to day running of the clinic and are already very well set up.

As we leave Niertiti we check in with the local police and wait while our travel documents are scrutinised (even short day trips like this requires authorisation in advance). I look around to see lots of bored young men in khakis lounging around with rifles slung over their shoulders. We get waved through and start bumping along the road to Thur. In the midst of such tight security I love the drive to Thur as it is the only regular chance I get to leave Niertiti and see some of the beautiful Darfur countryside. Today we pass a herd of camels which cross the road in a cloud of dust. A young nomad boy is perched high on one of the camels and he turns to give us a wave before cracking his whip and moving on.

We slow down every kilometre at the unofficial checkpoints. They are manned by Arab militia (many barely in their teens) who make their living holding up the passing trucks. These are the guys known as ‘Janjaweed’ (devils on horseback) by the other Darfur tribes, including those who have lost family and homes from their raids. It always seems strange to stop and chat, swapping cigarettes and jokes, with guys who may well be responsible for the violence and abuse happening in Darfur every day. But it is also a reminder that we are all humans with the potential for ‘radical evil’ as well as ‘radical good’ (to use Emmanuel Kant’s phrase). And if it had been a different group given the arms, money, power and permission the balance of power could be reversed.

Arriving in Thur we weave through the market day masses to our clinic. As we unload and set up there are already dozens of people waiting and our 15 local staff are busy doing registration, taking vital sign, weighing children, doing dressings, pregnancy check-ups and nutrition reviews. Today I begin by seeing the guys doing nutrition screening and the nutrition assistant who manages the outpatient malnutrition program. We are currently seeing a very high rate of malnutrition from this area and the nutrition program has blown out to over 100 children. This is bigger than any of our other nutrition programs and is ringing alarm bells for me so I need to make sure all the screening and treatment is being done correctly. I find that the screening is accurate with particularly high rates of malnutrition in an area a few kilometres south (which has been particularly affected by bad harvests). With the nutrition assistant I work out some areas the treatment can be improved, then leave him to see the kids and give out lots of Plumpy Nut.

The rest of my day is spent doing consultations – malaria, typhoid, scabies, diarrhoea, coughs and colds, pneumonia, complicated malnutrition, pregnancy complaints, urinary tract infections, STIs… At 4:00 we rush around making sure the sickest patients have been seen then have to turn the others away so we can make it back by curfew (any later and we risk being victim of car-jacking by the militia). We pile back into the car, taking with us a few women and children needing admission to hospital – two infants with diarrhoea and dehydration and a girl with severe malaria.

The return journey is without incident and as we arrive back in Niertiti I join my colleagues is breathing ‘Alhamdulillah’ (thanks/praise God) for a safe and productive day.

Profiling ‘Aladeen’
Aladeen Abakar Suliman, 18 month old boy who attends our Thur Nutrition program.

Aladeen lives with his family in Kass, a village about 15 kms southeast of Niertiti. They have been in the area for generations and are among the lucky ones who have not been displaced by the current conflict. But this does not mean they are unaffected. Like most families in the area they rely on agriculture for a living. Good agricultural land has always been scarce and the land has become increasingly degraded since an earthquake 10 years ago the main river flowing from the Jebel Marra mountains. Recent conflict has not only limited the areas they can farm (due to security) but also seen hundreds of additional families relocated into the area. While most of these families stay with relatives who are already in the area it means the already scarce resources need to be stretched even further. And it because of this background of food insecurity that I meet Aladeen and his family.

Aladeen first came to the MSF mobile clinic one month ago. His limbs and face were wasted, his legs swollen, his skin peeling and he stared listlessly at me as I examined him. These are the classic signs of severe malnutrition – signs I had never seen outside of textbooks before coming to Africa but which now confront me every week. We brought him back to the hospital and he was admitted to the TFC (therapeutic feeding centre) for intensive nutritional care. In addition to high-energy, high-protein food, children are also given vitamin supplements, measles immunisation, de-worming treatment, tested for malaria and treated for any other medical conditions. Within two weeks of intensive nutritional care he was looking like a new child – inquisitive eyes, grabbing hands, and glowing new skin.

On my last visit to Thur, Aladeen was ready to be discharged from the program. He should now have the strength to make it through the rest of the childhood risk period and grow up healthy and strong. Of course, the underlying causes of his malnutrition remain (conflict, environmental destruction, poverty…), and until these issues are addressed we will continue to see more children like him come to our clinics.

Parties
It is not all work and no play here in Darfur, and the last couple of weeks I have been invited to a couple of parties. It was a goodbye party for a local UNICEF worker who was leaving to get married and it seemed like everybody came by to wish him well. There were plenty of sweets, loud music and typically restrained Sudanese dancing (except for one young boy who really ripped up the dance floor!). Everyone was decked out in their finest clothes, with the men competing against each other for the biggest turban and flashiest walking cane. I had my hand painted with henna – and the orange stain is still giving the locals a laugh as they ask me who my new bride is.

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.

Humanitarian Aid Worker

Living the Dream - A Day in the Life (1) – Happy Birthday

Living the Dream
Once upon a time, being a medical humanitarian aid worker was just a distant dream of mine. As a medical student I would read books about doctors who had dedicated their lives to improving health in communities as far-flung as Ethiopia, Uganda, Burma and Haiti (e.g. Catherine Hamlin, Albert Schweitwer, Fred Hollows, Paul Farmer). I would imagine myself one day living a similar life - walking in the African sun, squatting by malnourished kids, treating tropical diseases like malaria, and saving lives with basic health treatment and education.

Yesterday, as I ambled down the dusty road to the hospital yesterday morning I noticed the hot African sun on my head and realised how disturbingly similar my life here in Darfur is to my student fantasies. It was a surreal realisation that this exciting fantasy was now the routine of my every day. Of course, for every similarity between my life here and my student fantasy there are a million things I could never have imagined. So today I thought I would try and give you a nuts-and-bolts picture of my life as a humanitarian aid worker. Enjoy!

A Day in the Life (Part I)
At 6am I wake to hear the call to prayer echoing from one of the mosques scattered around town – “Allahu Akbar, Allahu Akbar…ashadu Allah illaha ilallah…heya ila salat…heya ila falah (God is Greater, God is Greater…there is no God but God…come to prayer…come to worship…)…”. After hearing this daily benediction called in the deep, rich tone of the African voice, blessedly welcoming the dawn (just as it has been done for centuries), my day becomes more mundane - squat over the long-drop toilet, cold shower, breakfast of bread and fruit. Then, decked out in my MSF shirt I am ready to start the day.

First stop is to check the vaccine fridges, ensuring the mandatory cold-chain is maintained (3-8 degrees Celsius). Tick the boxes, and hope there are no generator troubles that will cut power and threaten our store.

A short walk down a dirt road leads me to the ‘hospital’ where I get a handover from the doctor who has been on overnight. A couple of admissions, the death of a lady with liver failure, a soldier with a minor gun-shot injury (and another who was taken away dead), a malnourished child with malaria looking better overnight, one woman in labour… – and yes he had managed a few hours of sleep.

During the day there are usually two doctors on duty and we start the ward round together in the ‘ICU’ (not really an intensive care unit – but it at least has one oxygen concentrator, a 1:8 nurse:patient ratio, and the resuscitation gear). Today there are a couple malnourished kids from the TFC (therapeutic feeding program) who are sick with malaria and pneumonia, a premature baby with hypothermia, a low birth weight neonate with poor feeding, a couple of babies with severe Pneumonia, a child with diarrhoea and dehydration, a pregnant lady with hypocalcaemic cramping, and a lady with probable complicated Typhoid fever. We move from patient to patient, my translator by my side (translating between English, Arabic and the local Fur dialect), questioning, examining, explaining and adjusting their treatment.

For many patients this is their first experience of allopathic medicine, and it still carries a strong aura of ‘magic’ to it – reminding me that we really do take things like antibiotics, rehydration salts, vaccination and other basic medications for granted in Australia. This means that patients are always impressed and grateful for the results and will do anything the doctor asks. But it also leads to expectations that there is a medicine that will fix every complaint, and difficulty understanding that sometimes it doesn’t work that way (either because they don’t need medication, we don’t have the medication indicated, or because there is simply no cure).

After ICU I move on to the Paediatric/Women’s ward while the other doctor sees the Male ward and Isolation (where we treat patients with dysentery, tuberculosis, hepatitis etc.). Today I find the ward looking quite orderly with about 20 patients – frequently the beds are packed in like sardines with up to twice that number. I greet the nurse and nursing assistant and we get started. In addition to the many cases of childhood pneumonia, diarrhoeal cases, today I see children with malaria, glomerulonephritis, facial trauma after a donkey bite, severe scabies, complicated urinary infections, burns, rheumatic heart disease, sickle cell crisis, and possible lymphoma. I see women with kidney infections, typhoid fever, pancreatitis, breast abscesses, deep foot infections, severe post-natal depression, and bleeding peptic ulcers. I work my way around the ward slowly, noting down cases to discuss with the other doctors.

The next ward is the TFC (therapeutic feeding centre), which is the inpatient nutrition program for severely malnourished children. These are the kids with marasmus and kwashiakor that you will remember from television coverage of famines across Africa – skeletal frames, sunken eyes and often with oedematous swelling of their feet, face and bellies. In the TFC these children receive intensive feeding until the oedema resolves, they are putting on weight and are able to eat the oral nutrition biscuits. This usually takes a few weeks, after which they are followed up once a week as outpatients. The transformations are pretty remarkable! The TFC is run by a nutrition team and I generally just see the complicated cases or those that are not responding to treatment. Today there is another malaria case, and a child with persisting watery diarrhoea who is looking dehydrated again.

By the time the ward round is finished it is early afternoon – and since this letter is getting rather long I will leave the rest of this story until next time…

Happy Birthday

Thanks to everyone who has sent birthday greetings. The staff here found out after a call on the satellite from my parents, and threw a little party for me in the evening. No balloons or party hats, but plenty of food, drink, cake and music. The best part was being sung happy birthday not only in English, but also French, Spanish, Arabic, and a couple of local African dialects. Very memorable indeed! I was also given a full traditional Sudanese dress, complete with handmade shoes and a funky cap. They will make their debut for the Eid celebrations at the end of Ramadan next week.

Villages Burning

Beauty – Among the Rebels – Burnt out Villages – Hope

Seeing the Beauty
It is a beautiful sunny Friday in Niertiti, my one free day for the week, and I have just returned from a stroll along the river. In the midst of the Darfur chaos, it is so essential to take time out and observe the peace and beauty that surrounds me. It is a particularly impressive time of the year now, with regular rain keeping the rivers and waterfalls flowing and the hills covered in green vegetation. As I meandered along the river dozens of men, women and children were bathing and washing clothes, the rocks covered with bright dresses, shawls and shirts drying in the sun. Smaller children splashed and jumped around in the pools, and made a particular effort to show off when they saw a khawadji (foreigner) walking past. Their smiles and laughter never fail to amuse me, and I had had more than a passing thought to throw of my shirt and join them under the waterfall today!

Among the Rebels
Earlier this week I headed out into the Jebel Marra mountains to visit two of the remote clinics that MSF is supporting. It was a great opportunity to see the area, as well as to better understand the complex social and political situation that exists and what it means for civilians from day to day.

The Jebel Marra region is home to the Sudan Liberation Army (SLA), the Darfur resistance movement, and almost all the towns in this area are under their control. So as we bumped along the dirt track towards the mountains the Government of Sudan (GoS) checkpoints were soon replaced by SLA checkpoints, all manned by guys toting big guns and big smiles as they waved us on through. To this point I have been very impressed with the cooperation from both sides for our work here, and the SLA are well aware that without international humanitarian aid their people would have no health care at all.

It was market day in Kulin, one of the many small villages we passed through, and hundreds of people had loaded their donkeys and trekked to Kulin to trade and catch up. It was great for us, not only because I could procure some spices for cooking, but also because it meant we could sit down with the SLA administrators and community Sheiks (leaders/elders) to touch base and ensure their support. As we discussed our activities, the current security situation and various mundane issues of logistics and transport, I looked around and realised how surreal the whole situation was.

To my left was the SLA humanitarian affairs coordinator, a young local guy who could speak passably in Fur, Arabic and English and was constantly on the phone to representatives from various NGOs and UN groups. Beside him was an old Sheik, decked out in the traditional Sudanese white robes, a turban atop his head and an aura of respect surrounding him. A respect that had no doubt been earned in the toughest of situations – a regional resistance against far superior national government forces. Alongside him were a couple of younger guys, and a sheik from another village. My interpreter and Field coordinator completed the circle. But perhaps most surreal was looking over my shoulder to see who was providing the security. Two boys in SLA camouflage gear were perched on rocks and cradled guns that were almost as big as they were. Child soldiers! I noted how shiny the hair was, falling in plaits down the sides of their faces, and wondered what it would be like for kids like these growing up and only knowing war. War, bloody war!

Burnt out Villages
One of the enduring images of my trip into the Jebel is seeing the remains of burnt out Fur villages. Mud brick walls of houses still stand, without roofs and charred black from fire. They tell a dreadful story and my mind filled with images of raiders sweeping through on horseback, villagers fleeing, women raped, blood sprayed, bodies falling and the whole place going up in flames. The villages are now mostly overgrown with weeds, and rumours of Janjaweed ensure the villagers don’t return.

As we drove through these ghost villages my driver pointed out houses where various local MSF staff members and their families used to live. “That is Ibrahim’s uncle’s house”, he said, pointing to some domestic remains. Ibrahim told me later of his family’s flight from the Janjaweed in 2003, and how he ended up getting work with MSF to help other IDPs like his family. It is a familiar story, with most of the local MSF staff coming from the IDP communities themselves, having fled similar incursions on villages all over Darfur.

Here in Niertiti there are around 24,000 IDPs (a relatively small camp), and most IDPs arrived here in 2004 after the first big wave of violence. However, attacks have continued all over Darfur, and the last big influx to Niertiti was as recently as December 2007. In the whole of Darfur, over 2.2 million people have been displaced – accounting for more than one quarter of the world’s refugees and displaced persons! These numbers are way too big for me to comprehend. But seeing the numbers translate into real people, that is something even more mind-blowing!

In Hope
Equally incomprehensible is how people here manage to do so well! After all that they have been through and the daily struggle of survival, the astonishing thing is that people don’t just give up. Maybe it is an innate survival instinct, maybe it is the hope that things will improve, or maybe it is just the fact that they all have children/parents/friends who continue to give life meaning and purpose. I don’t know, but for this hope I am extremely grateful and very humbled.

I realise that this letter I have completed neglected the medical side of what I do here. Most of my time is spent consulting with patients, supporting the medical assistants and keeping the medical side of things running smoothly. In the past 3 weeks I have seen things ranging from the bizarre to the tragic, from donkey attacks to kids dying from renal failure, from obscure tropical diseases to the pussiest abscesses imaginable. But more on that next time…

Thank you to all of you who have written, and I am sorry I cannot give you the replies you deserve. But I do love hearing from you, so please don’t think your letters have been ignored!

p.s. You may have heard reports last week of clashes between the SLA and GoS soldiers in northern and eastern Darfur. We had varying reports of tens to hundreds of SLA, GoS soldiers, and civilians killed and many more injured. That was all on the other side of the Jebel Marra mountain range, so we have not been affected and do not have any more information than would be available to you.

Doctor in a Refugee Camp

Inside a Camp – Reality Check

It is now one week since I landed in Niertiti. I am still finding my feet here, and this letter will no doubt betray the fact that I have teetered on the edge of being overwhelmed by the situation here. There are three obvious reasons for this. Firstly, the clinical side of things is insane and the resources so very limited. Secondly, this is Darfur and the recent (and ongoing) atrocities are evident everywhere. And thirdly, perhaps most significantly, I have a warm home and secure life to return home to in 6 months time regardless of what goes down here. For the 33,000 internally displaced people (IDPs), the ‘security’ of the camps here and the skeleton services provided by humanitarian organisations is all they have – and even that could be ripped away at any minute. This stark reality was beaten into me on day 1 and I don’t think I can ever really reconcile how these two worlds can co-exist.

Inside a Camp
I’d always wondered what it would feel like being inside a refugee camp. Sure, we have all seen the pictures on TV, but what is it really like. After touching down in the helicopter one of the first things I did was walk through the camps with a local MSF worker, an IDP herself. This was not only informative, but a encouraging start to my mission!

The camps are rather haphazard, poorly defined affairs, emerging from the edges of the town itself and extending out into the plains. Most residents have been here for at least a few years so the dwellings are quite impressive little mud-brick homes, with an average of 8 or 10 people staying in each (somewhat more crowded than UN/WHO recommendations). The pride the people take in their homes is impressive and I was really amazed to see how liveable such a situation could be made. I ducked into one residence and was introduced to the four generations housed within. The feisty great grandmother pulled me inside to point out her small wood-fired cooking pit and the jumble of pots and blankets that constituted their entire estate. There was no shame; and nothing to hide; just smiles, openness and profuse thanks for being there (not that I had even done a single thing for her to thank me for yet).

Bore wells have been installed at points throughout the camp with communal clothes washing areas alongside. Pit-latrines are shared, one between about half a dozen households. At the edge of each ‘block’ is a kinda carpark – only it is for donkeys not automobiles. And from what I can see donkeys are driven hard, being the grunt behind the transport of everything from food rations, to firewood, to families.

As I left the camps I felt really uplifted and affirmed, as the world had just confirmed to me that this is exactly where I was meant to be!

Reality Check
The next morning seriously brought my elation down to earth. Overnight there were gun-shots in the camp north of town and I awoke the next morning to find the bullet-ridden corpses of two young local men lying in the hospital morgue. Apart from the personal horror of murder, this shooting within the IDP camp itself shook the whole community – who have all left villages to escape precisely this wort of insecurity. I am assured that this is a rarity, but as I lay in bed the following night thinking of the crowded mud brick houses of the camp residents I realised what it meant to be truly vulnerable.

Since then I have seen dozens more reasons for both elation and dismay. If vulnerability is the defining feature of displaced persons then their response to this surely shows the depth of the human capacity to survive. So while my hospital round each day is full of kids and adults who have tipped over the edge of vulnerability; it is also full of survivors against all odds. I see seriously sick kids and adults make amazing recoveries, and know that this is mirrored in their families and communities who seem to bounce back from almost every assault.

I suppose as a fresh medical aid worker this paradox is the most important thing to hold on to. To see both the suffering and the joy; the trials and the survival; the sickness and the life. I will no doubt need regular reminders of this, so pray that in another few months I will not be either calloused or broken.

Destination Darfur

Darfur Intro - For You to Do - Contact Details - More Info

Darfur Intro
Darfur. You know the place - that god-forsaken desert area of western Sudan. You have seen the pictures on the news - poverty-stricken refugees terrorised by the Janjaweed militia. You have heard the stats - 200,000+ dead, 2.2 million displaced and now fully dependent on humanitarian aid for survival. Fours years after the genocide in Darfur began, the situation in Darfur still remains the world’s No.1 humanitarian crisis and I am joining thousands of international aid workers in playing our humble parts to help the millions of affected Sudanese people.

I’m writing this from Paris, having completed my briefings and about to step on a plane to Khartoum, Sudan’s capital. Over the next 6 months I will be living and working in a town called Niertiti, at the foot of the Jebel Marra mountain ranges in western Darfur. It is a town of 30,000, most of whom are refugees (or more correctly IDPs - internally displaced persons). This is small compared to some of the other refugee camps but will keep me and the Medecins sans Frontieres (MSF) team very busy! From everything I have been told this is a great mission. It is a typical MSF refugee scenario, working with excellent local and international staff. The Darfuri population are resilient and strong, and treat the visiting MSF workers with warmth and generosity. It will be a privilege to spend time on their land! I am excited and can’t wait to finally get there!

For You to Do
As friends of mine, you are invited to join me on this journey. I will share with you some of the stories behind all the stats and news bulletins. And hopefully these will enable you to inform your own response to the situation of the people of Darfur (and indeed others like them around the globe).

In return I would ask three things of you.
1. Remember me, the MSF team, and most importantly the people of Darfur in your thoughts and prayers.
2. Talk to your family, friends and colleagues about the situation in Darfur (and feel free to pass my emails along - just don’t give them to the media!)
3. Choose a book from my reading list below and read it sometime during the next 6 months (see also the films and websites listed below).

Thank you to all of you who have wished me well, and I apologise for not being able to return all your emails and letters individually at the moment. Please feel free to email or write to me in Darfur (contact details below) - particularly if you have any questions for me.

Email - hamish_hammer_graham@hotmail.com

More Info
There is tons of information about Darfur around (of varying quality). Don’t be overwhelmed, just pick one of these to get started (-:

Books
‘Not on Our Watch: The Mission to End Genocide in Darfur and Beyond’, by Don Cheadle (actor in Hotel Rwanda) and John Prendergast.
‘Heart of Darfur’, by Lisa French Blaker about her experiences as an MSF nurse in Darfur during 2006-2006.
‘Darfur Diaries: Stories of Survival’, by Jen Marlowe (and others) who collected testimonies from many survivors of the Darfur genocide.
‘What is the What’, by Dave Eggers following the story of one of the ‘lost boy’ refugees from Sudan through refugee camps and finally to the USA.

Films
‘The Devil Came on Horseback’
‘Darfur Diaries: Message from Home’

Websites
http://www.msf.org.au/
http://www.savedarfur.org/
http://www.darfurolympics.org/
http://www.reliefweb.int/
http://www.alertnet.org/