Going Away Lunch

It's my Going Away lunch, where I have invited the entire logistics department out for lunch. Ten out of the 40+ people show up, which suits me just fine, since I'm not a big socializer, I don't like awkward goodbyes, and there is not enough place for forty people in this small restaurant. It's a quiet gathering at first, but eventually we spark some conversations about family, our lives outside of work, and what it's like in the USA.

One guy jokes he wants to sell his son. We all laugh at his stories. He says how bad the boy is, and how he gives even his grandmother a really hard time. He's a terror and he hits his mother. I ask how old the child is. Two. Two years old, and already labeled a bad child. The father wants to give him away, and will pay someone to take him. We laugh. I can't help but notice someone asks him later what his serious price is, though.

A military officer overhears one person bad-talking the military. My staff member is saying how government or army officials will keep the pay of dead soldiers instead of search for their next of kin. He gets yelled at by the military officer for quite some time. The staff member is not at all timid, and is not intimated by the officer. They shout at each other for a while. I understand enough Arabic to know he is giving my staff member a hard time about talking bad about his country to a white person. Not patriotic. The staff member says it's not over, he will hear more this evening, when the officer will find him at his house and continue the conversation.

We talk, we laugh. I explain the distance I will travel to go home. Everyone is astonished I will travel 13 000 km. "How many days?" "Three, more with a stop in New York." That's how many days it takes to get to the capital, 800km away. We talk about the roads in the USA, how I once drove across the country from one coast to the other. I explain the distances involved, and 5000 km of roads stretching across a continent. "Tarmac? Is it all tarmac road?" they ask immediately. When I say yes, they talk about how 5000 km of tarmac road would change the face of South Sudan. They are all jealous of the one theoretical road across the US. I can't find the words to explain that it's a multilane superhighway, ten times bigger than any 'highway' here in South Sudan, and part of a network of similar highways lacing throughout a continent.

Home

I've been in Wau Town for three months. I'm nomadic, so I'm used to referring to wherever I am sleeping that night as "home." But for the population here, many of whom have become displaced because of recent fighting, home was a house they built with their own hands, with hard-won possessions and family ties. Home was a place where their roots had grown. Now, many people huddle in a protection camp just outside of the UN base.

It was incredible to watch the camp be constructed. The area went from an open field to a city. Women dig post holes for the poles men bring back. Children scavenge bits of rope to tie a shelter together. A family builds a shelter, and gets on with life. People lounge in the shade, do laundry, prepare meals. Children run wild, exploring the many nooks, crannies, facets and forbidden zones of their new home.

These displaced people are already setting down roots. Two months in a place and their claims of ownership are shifting. What happens if another family wants to build a shelter right in front of their shelter? What are the claims of ownership of this land? Will one family say, "don't build there, that's our yard"? Do these people still claim their homes in town, as well as a small parcel inside the camp? Where do they come from? Where do their children come from? Where do they say that they live? I can see how conflicts come up when this question of territory and temporality is expanded to a country-wide scale.

Pithy travel quotes tell of going on a journey and never being able to go back, because even if you find your starting point again, you will have changed. How your place doesn't change but you do so that it's no longer comfortable. True--the journey leaves you homeless. Not homeless, because you can make a home, but origin-less, perhaps. No one has your story, no one has a shared history. The closest you get is someone with a similar Venn diagram of experiences, and you skip from overlapping area to overlapping area, finding a common history. Or the least disparate history. How do you answer where you are from, unless you start recounting a story of years spent on this continent, trip duration in this mountain range, wars survived in this country. The flag of your home becomes a patchwork quilt with some familiar landmarks, maybe a pattern or two emerging. No one else will fly this flag. Maybe patterns will echo each other, but if the journey is your home, then no one is from your village.

Tableau

Ground into the dirt and faded by the sun, the three disparate elements of NGO label tape, bullet casings, and looted drugs tell the whole story. 

We are at a health center about an hour and a half by pitted road from the the main town. It is our first time visiting this place with our mobile clinic, although we have passed through twice before in the last two months. We sent someone yesterday to tell the population, who is hiding in the surrounding wilderness, to come for free medical care today. No one is around. The health center stands eerily looted, forlorn and silent. 

I reflect on our luck that this still life of three conflicting elements is not splashed with another difficulty. There is no rain soaking in to the soil, no rain keeping potential patients away from life-saving care, no rain turning the clay soil to mud to trap our vehicles. There is no blood dotted among the debris on the ground, no evidence of life force bled out on this site. 

We clean for an hour as first one, then three, then 10 people show up. By the time the first sick child arrives, we have swept, cleared, and mopped all of the rooms except the pharmacy. The pharmacy is 30 centimeters deep with looted drugs, all destroyed. Hundreds of dollars of drugs ground to dust in a country in desperate need.

Six hours pass in their usual blur of mobile-clinic-activity, and by the end, we have some patients left waiting. "Tuesday, inchallah" is all that we can tell them. Hopefully. Hopefully we come back Tuesday. 

We pay the cleaners, water carriers, watchmen, and translators for their work with us, and their faces light up. Most of them cannot sign their name, but they clasp our hands and say thank you. Yes, we have treated over 100 people with free medical care today, but we also gave a dozen people a job and a cash payment. I allow myself to daydream how the cash influx will change this old woman's life, or feed this man's family. Maybe this young woman will only tell her husband about half of it, and keep some money for a rainy day fund. 

We say goodbye, and I hope to see every one of the staff next Tuesday.

A Day In The Life: Mobile Clinic

The Ramadan call to prayer filters into my consciousness. It's too early to get up, but only barely. This is a day in my life on mission in Wau, where we are establishing a new project, hopefully for only 3 months, to assess the situation and provide help to a population displaced by local fighting.

We leave at 7am today, and my alarm is set for 6. I submerge back to sleep after the call to prayer, and am startled awake by my alarm. It's still dark. 10 minutes later, after hitting snooze, it's still dark too. Sigh.

Members of the team progressively join the breakfast table, until we reach our 7am start time. The drivers have checked the cars and all our equipment was loaded the night before. We call our contact in the opposition forces (whose territory we are going into today) to confirm the security situation is calm. We get the green light, and head out. I hand the satellite phone to the project coordinator, confirming that he will be the one sending location updates at each town we reach. I'm going in the car with the HF radio, and I want to check if we can reach the neighboring projects by radio.

The sun is just coming above the trees and haze over Wau town as we roll out. It looks like it will be a beautifully clear day. We stop by a health center to see if a nurse that usually works in Ngesa is around. We couldn't contact him by phone, so we hoped the word had reached him that MSF is going to Ngesa today. He's not around, so we ask the watchman to let him know we stopped. We will make do with whomever we find in Ngesa.

The road is in good condition, with very few water puddles and almost no mud. We make good time, covering the 20+ kilometers in one hour. We roll over erosion channels and weave our way through holes. I reflect that these road conditions have become normal, even exceptionally good, in my recent experience. There is a piece of tarmac road that runs through the center of Wau town, but it's edges are slowly cracking away, so it's only about one lane wide. It's still used in two directions, just each car has one tire in the tarmac and one on the hard pack dirt.

We reach the abandoned health center to find no one waiting for us, but everything clean and open. As soon as we pull up, a woman bicyles up with her baby. She sits down on the nearest bench. Our first patient. We discuss set up with our new medical team leader, who has not been here before. We use a couple of 'patient flow' tricks that we learned from trial and error at other sites and this one in the past, and we redesign a system. We put the waiting area and first registration under a couple trees at the other end of the yard, then pass patients to another tree for vital signs. We have a rapid diagnostic test station in the hallway of another building, a bit out of the line since patients may go there after registration or after a doctor's consultation. The three rooms of a low building are perfect for our two consultation rooms and our dispensary. The shade from the vital signs tree makes a good waiting area for the pharmacy until about 11am. After that, we have to move the bench back every 10 min to keep it in the dwindling shade.

As we set up, people appear. By the time we have a registration table ready, there are 10 people waiting. We start registering before we are fully set up, building the infrastructure moments before our first patient hits each step.  By the time the first patient finishes the consultation and goes to the drug dispensary for her medicine, there are 40 people waiting.  We iron out the gaps, snags, and shortages, and local staff trickle in to start helping in their roles.  A midwife shows up at the rapid diagnostic test station, and explains to me in either Arabic or Balanda (I can't recognize any words, so I can't be sure which one it is).  The universal language of gestures let us communicate.  She has been here before, she will do the RDTs.  Great.

She immediately reorganizes her RDT area, and has everything under control.  A cleaner has come with her, so I head to a hand wash station and explain to the cleaner (in gestures and one or two words of Arabic) that all patients need to wash their hands before vital signs.

We realize we have forgotten our scale, and quickly lament about the need for a global packing checklist.  I have a logistics checklist, and medical has a drug checklist, but we found a sliver of a gap between the two.  Our scale seems to have fallen in that gap.  We hang a small 25-kg scale on the tree, and weigh the kids in a harness.  The driver who is taking vital signs asks me how to read the scale, after he has registered 10 patients.  At least he asked.  I explain the hand of the scale, and counting the small tick marks.  He gets the hang of it right away.  It's funny to teach him to read a scale as he competently reads people's vital signs with a pulse oximeter that he attaches to each patient's finger.  He's got O2 saturation down, but needs a refresher on weight.

I float around a bit, checking on the medical team leader, who is plugging gaps where ever he needs to.  I ask if he wants to me relieve him so he can walk around, and we switch off in a couple of areas until the local nurse shows up and plugs the last gap in registration line.  I check on the last few sanitation and hygiene items on my mental checklist, but the project coordinator has already seen to them.  I settle into the pharmacy for drug dispensation, which is the area that is always backed up.  I narrow my vision and dive in.

I've never worked in a medical context before MSF, so everything medical is new for me.  I've learned to analyze bed occupancy rates, to ask for the percentage of positivity for rapid diagnostic tests, to speak in epidemiological weeks, to discuss morbidities and to do rapid nutritional screenings.  I have never done mobile clinics before, so this mission is the first time I'm taking blood pressure, temperature, and weighing patients.  I learned to get a blood sample and run a rapid diagnostic test for malaria.  Just this week, I learned to dispense drugs.

And I love it.

Being in the drug dispensary at our mobile clinics is a whirlwind experience combining elements of being a short-order cook and a poker dealer.  I have been neither of those things, but this is what I imagine.  Dispensing is our biggest roadblock in patient flow, so the time pressure is always hanging over your head.  But it is very important to have patients get the right drugs and to understand how to give the drugs.  I work with the medical team leader, who speaks conversational Arabic, so he gives instructions to each patient.  Rapidly, we take a translator from the local population ("Does anyone here speak English?") and have him tell patients when and how to take drugs.  Mothers are walking away with 4 or 5 health cards and bags of drugs for their whole family.  We brainstorm how to quality control our drug instructions...  That's next on the list for improvement.

My time passes in a blur of pharmacy orders, selecting sachets of pre-prepared drugs in the right doses and quantities, and assembling bags of rarely-prescribed drugs for special prescriptions.  I yell over the wall to the doctors who are in the other rooms whenever I have a question.  "This 19 year old man is prescribed ACT 100mg 1x1x3.  Shouldn't he get 2x1x3 instead?". "Can I give 1x3x5 Ibuprofen 200mg instead of 1x3x2 as prescribed?" "What's cloxacillin?" "We are out of mycodrin cream, or whatever this says here.  We gave the last one away. What should I do?"

Registration of all waiting patients has finished by 12:45.  Everyone who was waiting has been registered.  That's a first, at this quantity.  When mobile clinics are small and only 80 people come out, we have seen everyone.  This time, we have two trees' shadows worth of people waiting.  The end of the line trickles through vital signs.  About this time, we see we are running low on RDTs for malaria.  We have had a stunning number of malaria-positive patients.  The medical team leader picks out the 65 remaining patients who need the test the most.

An hour later, all patients are registered and we pack up the registration areas.  I'm still head-down in the pharmacy when I hear that we are out of RDTs. We make a call to Juba to ask for authorisation, and we get the green light to prescribe malaria drugs to all remaining patients with malaria symptoms.

At this point, 4 doctors are consulting the remaining patients, and the line for people waiting for drugs explodes.  It's been at a constant 2-10 people waiting for a few hours, and now it stretches to 20.  After checking all the cards, I see many patients with RDT results but without prescriptions from the doctors.  They get shuffled to a new line to see the doctor again, and my line is back to a manageable 5.  Then the wave of patients from the additional 2 doctors hits (we have had 2 doctors consulting all day).  The line swells to 40.  Time blurs.

I am dimly aware that the rest of the team is packing up.  The local doctors come in to the pharmacy to start explaining drugs to patients.  I prepare drugs orders in a blur.  Our team goes to collect the prescription cards directly, and I don't leave the pharmacy.  ATC, paracetamol, ibuprofen, amoxicillin.  Pick, pack, cross off, "order up!". Next.

I'm out of bags!  I'm out of adolescent ATC!  Someone searches for resupply in our boxes, then it's the last card.  Never mind, never mind!  We made it, we are OK.  The last adult ATC and paracetamol go out, and I take a deep breath.  Wow.

I blink around at the 5 people inside the tiny room, and the deserted yard outside, with patients happily chatting and wandering away.

The team leader reminds me to pay the daily workers, and I leave the medical team to pack up the pharmacy.  The drivers have already packed up everything else, and are starting to load the pickup.

I sit down with the project coordinator to make the list of all of our workers and the hours they work, then calculate their payment in a convoluted and bureaucratically-necessary process that takes a calculator and a meditative trance.  One by one the workers come in, return their MSF ID that we have slapped on them throughout the day, and sign for their payment.  There is a brief question about the cleaners who have cleaned the health center before we arrived, and we haggle out a solution.

As the drivers finish tying down the load, I grab a drink of water and a hand full of dates.  We make contact, both via satellite phone and radio, for a final time here (we have been doing hourly check-ins), and hit the road.  I find I am exhausted.

I let my thoughts wander on the way back, but remember that I need to sketch out a 3-month budget for the project.  It's due tomorrow, so I should think on that.  I run through our budget codes in my head and make notes on an estimated envelope for each line.  Some are wild guesses.  I'm glad for the admin who will clean up my conjecture and chicken scratch to make a real document. 

We get home to find my assistant and a loader waiting for us, so the drivers hand over their keys, and the 10 questions from today's activities at the base are pressed upon me.  I examine the construction in our compound (we are building a fuel store, watchman shelter and generator shelter).  There are some electrical and plumbing problems with the house, so this is never ending. 

I grab lunch/dinner, and we sit down to debrief the day and check in with the whole team.  Some good ideas, solutions, questions and observations come up, and we plan next week's schedule, as well as strategy.

Time to hit email, but the internet connection isn't working.  There is a land cruiser pickup outside that is waiting for a mechanical check to see if we would rent it, found by our sister project in Aweil.  I check it without seeing the email, and call the log ref up in Aweil.  We discuss supplies, movements between our project, the price of the car, and the decide to talk again on Monday.  It's 7pm on Saturday, everything is stable for the weekend.

Having just eaten lunch at 5:30, we all agree to go out for a beer to get our minds off work and to change the scenery.  As it starts to rain, we climb in the car and head to the hotel that we lived in for a couple weeks.  A beer and some french fries are a nice closure to the day, and we stay out until our 9pm curfew.  I check the internet connection, which is still flighty, and try to get an email off with a draft of next week's schedule.

Someone produces a bottle of Amarula, and we all take a night cap, but the party ends soon as we droop off to bed.  Tomorrow is Sunday, and I swear the drivers to silence and stillness.  I give out keys and bread money and instructions, and I hope to not hear from anyone until tomorrow afternoon.

Goodnight.

Malesh

In front of me is a chubby little baby sitting on her mother's lap.  She grins back at me after I give her a smile.  She doesn't understand me at all, but the grin is universal.

"Are you going to be a brave girl, just like your mother?"

I select a finger.  Thumb and forefinger are for you, I'll pick the next one.  She drools a bit and offers a small amount of babble.

"Malesh," I say.  I'm sorry.

I stick her finger with a pin prick, and the pain takes a moment to settle in.  In the calm before the storm, I watch her blood well up into a tiny red bead.  I hope for more.

The screaming hits.  She has realized that she is hurt.

"Khalas," I say.  Finished.

That doesn't make her feel any better.  Now the thrashing starts, but I'm ready for it.  My firm grip on her hand doesn't let that slowly-growing red bead get dislodged.  A bit more pressure, almost like milking, results in a sufficient sized droplet.

She is making the most noise of anyone of the hundreds of people here.

I swoop in quickly and siphon up the blood into the pipette, nodding to the mother to press the alcohol pad to her daughter's fingertip.  I turn away and disappear from the little girl's world, to insert the blood sample into the rapid diagnostic test, add the reagent, prepare the next test, and stick the next innocent child waiting on this bench in this particular health center in this corner of South Sudan.

I'm at a mobile clinic, as the field logistician for this activity, which at this point in the day means supernumerary.  Contrary to being just a face in a crowd, I am a free agent.  In the last hour, I have been drafted to take blood pressure, purify water, subdue fights, direct patients, administer medicine, and recruit translators.  Everyone calls me 'doctor.'  Right now, I am screening patients for malaria after they have been consulted by our team's doctor.  I change my gloves because the old pair is bloody, but the new pair sticks and is really hard to get on.  I'm sure there's a trick to putting on gloves with sweaty hands, but I will figure that out on my second day.

Views of the Interior

In Burundi, the rest of the country outside the capital is referred to as "the interior."  Despite having bought every single thing needed for the coordination team, and for the opening order to get the field project started, I haven't set foot outside of the capital.  I've been in plenty of neighborhoods, plenty of districts of Bujumbura.  I've been in markets that were bombed hours after my passage, I've been in intersections that were fought over the night before.  I've been in workshops for welders and carpenters, I've been in offices for phone and internet companies.  I've searched for lock boxes, copies of keys, beds, coffee machines, bananas, light switches, hammer drills, buckets, voltage stabilizers, and a whole laundry list of other things.  But I haven't been outside of the city, into the interior of the country.

Until now.

I hired a truck and loaded the first two project orders for the field.  It was me and the new water and sanitation engineer, who just flew in 4 hours earlier.  "Welcome!  Can you help me lift this freezer?"  I sign the contract and the truck driver hands over the keys right around 5pm.  We have a little over an hour of daylight left, and about 1 metric ton of material to load.  I check off items on the list and the watsan packs, but we are both carrying things to the truck from the various corners where they had been shoved.  In 40 minutes, we're done.  Everything's checked off.  We lock down the truck with some pieces cut from an inner tube, and head inside.

The next morning, we're on track for a 7:30am departure.  The truck driver comes (almost) on time, miraculously, and I give the last instructions to the driver who will stay behind with our city car ("hey, can you buy three sacks of cement for me?").  The watsan and I climb into our pickup truck, and the truck driver revs the engine.  We're on the way.

After 50m, we determine that the pickup should be in front, due to the unacceptable amount of exhaust coming out of the truck.  Turns out we can't get in front of the truck until a kilometer later, but the cancer won't set in for another few decades.  I'll have long forgotten about this day by the time I get my diagnosis, I'm sure.

We're headed to the city in between the two locations; the capital and the field are separated by about 4 hours of tarmac road and several mountain passes.  We'll meet in Kayanza, 2 hours from each base.  We'll transfer the watsan into their car, then turn around and come back, while they return to the field with the truck in convoy.  It's called a kiss movement, because the land cruisers come face-to-face, like they're kissing.  Actually, it's much easier if they go side-to-side, for the transfer of material, but I guess hand-holding movement was too long to say.  It's still called a kiss in any language you work in, so many francophones think it's an acronym.  Just anthropomorphizing our conveyances.

We roll up and down huge hills, winding our way up a few switchbacks.  The road is in good condition, and the traffic is light.  Bikers benefit from slow-moving trucks climbing the hills to catch a free ride.

We get to the kiss location about half an hour early, and stretch our legs.  Kids run up and stare at us, then the police comes to warn us to look out for thieves.  They indicate that the kids will probably try to climb in the truck and steal everything.  People slow down and gawk at us, or come up and ask for money in several languages.  The other car gets there, there's a smoke break, then everyone piles back in and we head our separate directions.  I had no need to be here, but I wanted to get out of the capital.  I have 6 days left in this mission, and I couldn't have told you what a Burundian meal is like.

On the way back, we hit a cloud that has covered the final mountain before the descent into Bujumbura.  It's eerie and calm in the fog, which is so thick that driving slows to a crawl.

Then we're through it and we see the city spread out below us.  Home sweet home, at least for the next week.

Security

Sometimes I catch myself doing domestic, responsible tasks, and I feel grown up.  When did that happen?  I draw the curtains closed and check all the doors are locked before going to bed.  I'm the last one up at night, usually, and I collect random glasses, turn off the printer, and straighten up.  I feel like a parent after the kids have gone to bed.  A touch of normalcy in a nomadic life.

Some of what I'm doing is due to my role, since the logistician is responsible for hygiene and security.  But the log is not a maid, and it's not necessarily me who is up latest at night.  I'm locking doors because I'm a responsible adult.  The logistician part comes in as I call a network of contacts to localize that last grenade blast, as I ask the watchman for a translation of the local radio announcement that tells the route of the anti-Rwandan protests being organized every weekend, as I label the security lights deterring theives from jumping the barbed-wire-topped walls.

You know, everyday adult things.