South Sudan Journal, Parts 26 & 27 (of 29)

Message #26 June 16, 2004,
Hello Mom and Dad.
I'm in Pieri, South Sudan, right now. The team has assembled here to try to fit together a plan to remedy the situation we seem to be in. As I mentioned to Dad on the phone on June 19th, the team was evacuated Tuesday, June 8th. This was the most disturbing evacuation in a long time. This time, there was another killing, of a high ranking official. As such, the village evacuated, anticipating a fight. The team walked to Pultruk, and were picked up there in the morning.
With the community evacuated, the patients were also gone. Approximately 40 TB patients walked with the team to Pultruk. After our team was pulled out, another plane was sent to transfer these patients to another TB project run by MSF Holland in Western Upper Nile. Unfortunately, when the plane arrived, the airstrip was flooded and the plane could not land. Food was dropped, with a message to head to Pieri (3 days walk south) where we would set up a clinic to continue their treatment. More than one week later, no patients had arrived yet.
Flights over Lankien show some disturbing things. The market is burned, there are what look to be papers and other garbage all around, as if the clinics, compounds and everywhere else is looted. We will try to go in soon to see the damage and salvage what we can.
For now, we are in Pieri to build a temporary clinic, until there is a better solution. We have 200 patients in our care, all of which have diseases that will kill them. We are waiting to get our patients back, and depending on the availability of planes, and the cooperation of the rains, to pick them up in various locations.
There is more to do now, I'll head off now.
18-06-04. Today, I believe, was my last time seeing Lankien, my home for the last 9 months. We were able to come up with a plane, a plan and the equipment to do it. All this to get to our patients, take the really sick ones, and tell the others where to meet us. The plan was to fly to Pultruk, where many of them evacuated to, and where many were seen from the air on the unsuccessful trips to get them. If Pultruk was wet, we would land in Lankien, send a team to walk the 14kms to Pultruk to get to the patients and with the remaining team in Lankien, salvage what we could, lock up the rest and go back to Pieri. Omari, Marjan and I were the salvagers, and are back now in Pieri. Jan (my PC) and Mary (a Doctor) went to Pultruk and will stay there overnight.
When we arrived on ground, it was a difficult sight to see. As before, with the fire, fences were down, chaos was throughout and I started to doubt that this was the same place we held clinics, less than a month ago. Of everything we had, very little remained. There were piles of papers (thrown out of binders), drugs (tossed out of the containers), needles and syringes (emptied from the boxes), and little else. Of all our food (patient and other, more than 10 tons) nothing remained. Of all the buildings, no doors, door jambs, door thresholds remained. Of all the large tents, only the metal frames remained. Of all the everything, very little or nothing remained. There are so many things that would be useless to anyone within 100 miles of here, but nothing remained.
I went around and took some photos. These are the same photos I took many times before. The office, when I arrived. The office when it was getting re-thatched. The office after it burned down. The new office tent. The new office as it was being built. And now, the frame and a pile of papers where the office used to shelter us. Other areas of the clinic had similar stories.
As we salvaged what we could, Jan and Mary headed north to Pultruk. Also, the word was spread out to the few people who were there to meet the plane, to bring out the TB patients that remained in Lankien. And so they did.
In the hour and a half we had on ground, we were able to find some patient records (blowing in the breeze), a handful of other useful papers, one vaccine fridge, and some tent frames (for the large shelters). We gathered these up at the plane and started loading. After loading, we had 10 patients (with a whole assortment of children and caretakers, 20 in total), our salvaged gear, the three of us, and the three flight crew.
The captain wouldn't let us take back on the plane the bag of maize (corn) that we brought for any patients we couldn't take with us. So lacking any staff, any patients, or any other adult I knew, I found a trustworthy looking guy who spoke some English. "Can you share this with everyone?" "Yes." "Am I an elephant?" "Yes." Hmmm, English not so good. In my best Nuer, I signaled to the 20 people there that this was for everyone, and figured it was better that they fight over it, than that person take it all.
"We have to leave now, the rains will be here soon," was our Captain's signal to say goodbye and leave. I looked around, and the only one I really wanted to say goodbye to was Banak. He is a 8-10 year old orphan that the clinic kind of adopted. I say, "kind of," because it really wasn't anything, except letting him into the clinic when he wasn't suppose to be and looking away when he stole something. He always came to the airstrip to help unload and carry things, never asked for anything either. Many of the other kids hit him and teased him, and he would run behind us and grab a hand of one of us and the kids would stop. I think he had status through us (or maybe just sanctuary behind us). He never wore anything, partially I think because he is a free-spirit and therefore clothes cramp his style. But also, mostly, because whatever he finds, he trades for food. The more I think of it, I miss that boy. Everyone here knows him well, I hope he makes it to Pieri. I leaned over and took his gritty, sweaty, hand one more time. I said some things, he said some things, as we did many times before. Neither of us understood what the other ever said, this time no different, then I got onboard. As we left, Banak stood at the side of the airstrip, naked as a thin black tree in a clearing, smiling, and waving. To me, Banak is Lankien personified. His parents beat him and orphaned him because he was different. He smiled like anyone else, but he, like Lankien, had a rain-cloud overhead, all his life. I wish things were better for him, I wish they were better for Lankien. That may be the last I see of him and Lankien. Good Luck Banak! Good Luck Lankien! As we took off, for some reason, or no reason at all, tears overcame me.
We arrived in Pieri half an hour later. The patients clapped loudly. Rescued from Lankien by plane, what a day! For all of them, it was their first time flying. For many of them, they will try their best to walk back after they get better, flying was not for them.
We settled them into the shelters we just made, gave out some food, and went back to setting up more store rooms, etc. A lot of work went into building Lankien into what it was when we left. It will take some time to do the same here.
19-06-04. Jan and Mary arrived in Pultruk and found 100 TB patients. That is more than we anticipated. After hearing that, Omari and I set together some more plans to build, build, build! We were able to erect some of the poles from Lankien, covered with some plastic from Loki, to make the equivalent of 5 large tukels. For 100 patients, that is still tight. Also, 100 patients is more than a plane load, in the best of times, with the best of planes. We planned to use the remains of the Western Upper Nile flight today to ferry some to Pieri today, and the same tomorrow. The plane, the plan, and the equipment again fell together effortlessly, after much effort.
Today, we received 5 plane loads of people. It was the small plane, but with low fuel and thin patients, we got approximately 50 patients, and another 30 caretakers here. More shelters went up, more food distributed and now drug programs resumed. Today was a very busy day.
It was a good time to be here. The patients stepping off the plane, like explorers setting foot on new soil. "This will do, I'm staying," many faces expressed as they got their legs working again. People saw old faces in the crowd, and there were smiles, laughs and tears of happiness. This was all muffled while the plane was still running and some of the staff were running with us to get the plane unloaded and off for another run. Walking around town today, there were many people with smiling faces coming up to me saying, "Hello Steve." There was a communal sigh of relief, as one would express coming home after a week away. It was pleasant to be alive in such a place.
This community is really excited MSF is here. Anything that is asked of them, they do. Dig a latrine here, fence here and new tukel here. "Okay, we'll talk with the community and see what we can do." And they do, and it gets done.
At night, the sky has been rumbling a little, as if it is threatening to storm. That could slow this recovery operation down a lot. I think there is a consciousness, or spirit in the environment in South Sudan. Since I got here, I felt like I was in a battle with South Sudan. Days of security, it was hot. Cool days, it rained. Clear days, the staff would give us problems. Days where the staff was friendly, the community would be un-cooperative. When the community was good, fires took out the compound. When the compound was re-built (with good fire-breaks and fire fighting gear in stock) insecurity ruled in Lankien, and all was lost to looting. Each time MSF and South Sudan fought, we got knocked down, and slowly rose again. This time, we are rising again, even if just slowly. Today, we stole a clever victory away from South Sudan with the 50 patients that we brought here. Tomorrow we will try again.
Many people ask me, "Why bother?" I too have asked this same question to myself many times. And today I got a clear answer for anyone, and everyone asking that question, "BECAUSE IT MATTERS THE WORLD TO THESE 50, AND THE OTHER HUNDREDS THAT WILL PASS THROUGH THIS CLINIC IN THE COMING 2-3 MONTHS, AND THE HUNDREDS AFTER THAT! That's why. That's why I bother, and why the heck not?"
There is still much to do. I should get going. Tomorrow, we will receive another 30 patients or so, if the rains hold off. Also, people are starting to come here on foot. Soon we will have 200 sick, hungry, cold patients, all demanding by their condition (illness), drugs, food and shelter. Much to do, much to do.
In all of this, the team and I are fine. It took careful planning and clear communication over the last few days, and the team did that very well. A good test for the coming months will be to try to steal away other small victories from South Sudan.
Take care all. It was great to be home for a short time to see some of you. Sorry I didn't get to see all of you though. But, as before, I'll be back in the fall and will see you then. Lots of love,

Steve

Message #27 July 24, 2004


Hello Mom and Dad,
July 24th!!! It seemed like just last week I was announcing to the whole of South Sudan, at a frequency of XXXX MHz on our HF radio, "GOOD MORNING, AND HAPPY CANADA DAY!!!" The unenthused reply I received, "negative copy, please repeat," alerted me to the fact that I was alone in the celebrations of the day. But with enough patient explaining (and maple syrup from my private, evacuation-proof stash,) everyone was pleased that Canada gained it's independence from the ??? rulers, in the year ???, "can I have some more of the sugar water please?" "The British, we asked the British to leave and they did, and we've been nice people ever since. And it's MAPLE SYRUP!" I have been silent in my writings for a while. Please know this is not a bad thing.

I can fill you in on what has been going on here, (ie. details,) but I think it best to instead just go through the events of a day, actually this day, and all the important things will come through. Feel free to email back here, just know that the email address has changed, ironically to this: XXXXXXLankien@xxxxxxxxx.

~0600, not exactly 0600, but near when the sun starts thinking of coming up... If the people involved had a watch, they wouldn't be up that early. "Hhhhhaaayyyyaaa, blah blah blah....." The local SPLA barracks, full of 4 people, turned out and pledged allegiance to the flag of South Sudan as it was raised, just 50 odd meters from our compound. I can appreciate the ceremony, but would appreciate it more if moments of silence were part of the proceedings too. It was pointed out to the team one day: "Everyone MUST remain still as the flag is raised or lowered!" In fear of disobeying the local SPLA forces, I stayed still in my bed, and a couple more hours of sleep washed over my eyes.

0745, I could hear the team talking about the latest news and local talk. I like how my tent is right next to the eating table. I don't like alarm clocks, and this version of the morning news is not too intrusive on the mind or ears. Plus, when I finally rise up, I am briefed on people's dreams and odd noises everyone 'should have heard' last night. I'm sure my Mother will be proud to hear that I still excel in the strenuous discipline of being a good sleeper.

0757, Time to rise, to make it to the morning meeting. As per usual, the team is assembled, "Morning Steve" comes unanimously from the team, and I head to the office and grab my day planner. As I return to the table to make my tea, (Earl grey, Kenyan style with lots of sugar and powdered milk, in a half litre plastic feeding cup) I sit as Francis' radio plays the theme to BBC Africa's hourly news, and someone's watch beeps. "It's 8 o'clock, and now for the hourly news... click" Good morning, Jan our PC greets the already assembled group, the day has just begun.
0800 Our morning 8 o'clock meetings are a good chance to disperse project information that would be too intrusive at the dinner table. I like how everyone makes an effort to separate work and non-work, and these meetings give us a chance to make up for that lapse of work, work, work. We discuss events over the night such as, there was a very mal-nourished boy the team was dealing with for the last few days. He came in, in a deplorable state. No one here has ever seen an 8 year old boy, weighing 7 kilograms. "The stuff they throw in front of the camera," Mary told me when she saw him, and until I saw him, I thought many things I saw, were the things TV ad's were made of. He died last night, and the other lady (we have been having a rash of deaths from lactating mothers recently) doesn't look so good either.

We also discuss the day's work ahead. Today was Saturday, so that is food distribution day for the patients. I like this day. Not only do I get a math class with a staff member and a patient, but after the distribution to the TB clinic, I talk with the patients.

My work for the day would involve the food distribution, but also meeting with the local authorities about some roofing work in the clinic, hiring a carpenter for a skylight (yes, a skylight! It is really just a void of grass, replaced with a transparent sheet of plastic, but to the unseeing medical staff member inside the tukel, this is technology at it's greatest!), sending orders for more and more stuff, (including "Steve, can we get a ..." "It's dinner, Steve's not working right now, you’ll find him here in morning, or if it is urgent, after dinner"), reply to a few emails about, "how many microlitres do you want for that micro-pipette that was ordered last week?" "What size solar panels do other projects have, and can we borrow them?" and "Where is WFP?"

0830 Radio contact. Sky: slightly cloudy. Airstrip: Wet, unlandable. Security: Normal. People: 7. No messages. From Loki, "There will be a UN plane coming to you around XXXX (time coded)." "I repeat, We are very wet, and unlandable, just like yesterday." "They want to see themselves." "Okay." Then there was a 10 minute pause, as the team gathered by the airstrip to watch the UN Buffalo pass over and over the airstrip. Would have been messy if they tried to land, but after some time, they moved on. Maybe next time they will be curious about what we mean by, "VERY WET, UNLANDABLE."

0900 John and Gatluak came to attend their weekly math lesson. Brief update. We are still in Pieri, and again on a holding operation. The team (including your infinitely patient author) is frustrated by this. There are people we want to hire, things we want to build and patients we want to admit, but we are holding off full operations until the decision to stay or go somewhere else, is made. (We are also slowly getting used to the 43 inch high doorways, living in tents, and general uneasiness in the compound. I think the longer this holding continues, the lesser I will be able to distinguish between a survivable and an unacceptable way to live.)

Being here, on hold, has ment that my Lankien logistic staff of 7-9 labourers, 9 guards, 7 cleaners, 1 storekeeper, 8 waterladies, etc, has been replaced with me, two guards and 'resourcefulness'. I had noticed in Lankien that the Math lessons were EVER-SO-SLOWLY paying off, and as such, with limitation put on any other building project, I decided to build on the people we have. The people we have consist of a limited amount of medical staff, the two guards (Simon and Kouk) and patients. And so, I have started an intensive semi-private math lessons to John (medical staff) and Gatluak (TB patient with passable English).

0901 The math lesson begins. "Okay, let's see the homework from last time." 0902 "If you didn't understand the homework, you could have come to see me anytime during the week."

0903 "If you didn't know you could see me anytime in the week, you could have come to... Okay, let's try this another way." And so my degree at the Beih State, South Sudan Teacher's College of Fine Arts and Infinite Excuses, where I am doing a Major Degree in Patience Studies, has had a surprise quiz. The problem is, we were doing a multiplication matrix. Lining up those damn rows and columns, then to do it all over again for the reciprocal numbers, is a little too much. But, these two have the multiplication skills, just not the speed; as if things like the rapid growth of tomato plants, or the racing of a snails, can be referred to with such swift words like, "speed." If they didn't get 9 out of 10 multiplication questions right, I would give up, but they get it, and so, we try again.

There are a lot of math demands around the clinic, stores, and pharmacy. Also, here there is an incredible lack of those skills. Most people, I think, learn math first with money. Here, there really isn't that much money, and as such, people don't learn the numbers. Also, as a kid, I remember learning some math with the stacking of similar objects, or playing with Lego. Not much to stack here, or for that matter add together to get something; construction is mostly, add some sticks, add some mud, roof it with some grass, and you have built a roughly roundish shelter.

The math lessons focus around the food distribution. There is addition: Number of TB patients plus Number of Kala Azar patients. There is multiplication: 166 patients times 4 kilograms of sorghum each equals? There are realistic checking mechanisms: "Really, 8 kilograms of sorghum will feed 166 patients?" And there are rewards for correct answers: "John got the answer right, maybe it would be best for you to move the 500 kilos of sorghum out of the store and think about how to be right next time." (Kidding, there are no wrong answers, and we help move the items together.)

By 1030, we are done the TB and KA portionings, and the food is heading over to the clinics for distribution on the heads of the women, or under the arms of the men with wheelbarrows (here too, heavy lifting is left to the women, unless it involves a status machine, like a wheelbarrow, then the men get involved, as long as the novelty is there). Over the last month, we have been working hard with the patients and staff that have been distributing the food, to encourage them to stick to the amounts that we provide. They play a game called, "We portioned out the food as you told us. Now all the food is gone, and there are 10 patients without any." It is a game, because they know, we know, that they are playing on our inability to allow someone to go hungry. They are winning, since this is true. We are winning because I am slowly educating them on the portioning side of things, and now, there is no excuse, (except for bad math, or wrong distribution technique) as to why the amounts are not right.

1200, More patients admitted, dealt with the food and relief item distributions. A difficult thing going on here with regard to the distribution of relief items, (Relief items are things like a 1m X 2m plastic sheet to sleep on, a 1 litre plastic bottle for water, a cup, a blanket, a piece of soap, etc) is that the community around the clinic is jealous of the luxuries the patients get. Plastic sheeting, wow! One could put that on their roof, and not have to re-grass it every year, free from leaking! The patients are asking for more, but the gap between our patient care, and the state of the community is growing fast. What good is it to cure TB, if a patient leaves the clinic and becomes mal-nourished?

Email some answers to our purchasers in Nairobi. Had a moment to reflect on how our power supply system was doing in this usually overcast weather ( we only have solar panels here too). Had some lunch, then back to work. Saturdays are a half day. So, we usually work till the usual lunch time, but then instead of taking a siesta (between 1400 and 1500) and working again after that, we work through lunch thinking that if we finish just one more thing, then the day will be over.

1330 The TB patients were done the food distribution. Over the last month and a bit, I have been talking with them at this time in the week, just about how things are going. I think they like the attention, and I find it helpful in solving the logistic problems of feeding and housing 150 people. Also, with 'resourcefulness' as my Logistic Assistant, and no other labour force, it is a good time to share our problems and share the solution. With the difficulties with the displacement from Lankien, there has been a drastic cutting down of any expectation, and the language has changed from things like, "You need to do _____ for me." and "This tukel you put me in is leaking, you must fix it." To discussions like, "We have been using the tools you gave us for cleaning and maintaining the compound. We need some string to do some repairs."

Some of the conversation went as follows:

"Ma-le!" (They always laugh when I speak Nuer. I think they like my accent.)"The food ration as you have told me, is too little. (Translated) But the number of caregivers is close to the number of patients. (Translated) This is getting too much to feed. (Translated, one or two groans.) With too many caregivers, that is less food for you the patients. (Translated) Let us discuss this and find a solution.""It is part of our culture that men do not cook, and as such a man patient must have a wife there to cook for him. Women patients cannot do all the work themselves and they all need caregivers. Therefore, everyone needs a caretaker."

"Right now it appears that we virtually employ 70 people to cook for and care for 96 patients. (Translated) I think I can employ 10 people to do the same work, cooking and caring for the patients. (Translated, much talk now) Is it part of your culture to get food from MSF at all?"
The crowd laughs. I like this part. The things we are discussing in these talks are basic things they are asking for, and trivial reasons why I cannot provide them. Humour at these times keeps the tensions low, and keeps us working together. It is obvious that we are from different worlds. As I look around the group, half the people I see are nearly naked; knees, breasts, or bums sticking through worn out clothing. Some children near my feet are playing with my sandals. Another child in the clearing stops walking, squats and defecates on the ground in the middle of the circle. The caring mother whisks the child away, clears the mess with a couple sticks, and the meeting never pauses, because this is an everyday happening in their home. Cows, children, goats and the local crazy lady all crap in their home. Visitors here have commented that some refugee camps are better provisioned, I believe them.

I constantly fear the discussion being turned to a personal tone, something like, "You try living off of what we eat! It is not enough!" Kees, our medical coordinator told me once, "I tried the WFP ration amounts, for one week." "How was it?" I naively asked. "How the hell do you think it is, at the end of the week you're frick'n hungry!"

I think I have gained a respect with the patients, partially by listening, and partially by finding solutions to their problems, even if it is using their labour. Maybe it is just caring when not many others do. As such, my lifestyle, my luxuries in our compound, my meals, my ability to email home, my salary, my medical insurance, my return ticket, etc, has never been questioned.
We give out an empty 3 litre cooking oil jerrycan (with the other relief items) to every TB patient on admission.

"I just gave birth, I should get another jerrycan."

"I lost my jerrycan in the insecurity in Lankien, I should get another jerrycan.""I'm an old man, I should get one too."

"The large jerrycans we are keeping for new admissions, but I have 25 small ones for you. (Translated) Unfortunately there are more than 25 patients, so we cannot give one to each person. (Translated) I have an idea how to hand them out, but most times people don't want to hear my thoughts."

"Continue." The crowd asks.

"When someone builds a shelter for the clinic, they should get one. (Translated) When someone cleans the clinic compound, they should get one. (Translated) When someone helps unload the plane, they should get one."

"And I just delivered a baby."

"And the new mothers and the ones that lost theirs in Lankien, and the old man with the funny eye and bad leg in the back too, should get one, or someone should share theirs with them. (Translated) but if it were my jerrycans, I would reward the efforts of those helping everyone. (Translated)"

"But they are your jerrycans?" a confused reply came back.

"If they belonged to All of you?"

Lots of talk came from this last comment. In the ensuing conversation it was determined that Choul (a respected patient) and Gatluak (my Math student with decent English) would be the dispensers of the jerrycans, as they felt were appropriate, based on people's participation for communal activities, and a portion would be given to others that couldn't participate, but needed some social assistance. To this, the group agreed.

The group of consisting of approximately 30 people, representing (more or less) the patients in TB, not only agreed on something positive, but did it with such vigor that it felt like a grab of responsibilities at a fire sale. Other momentary examples of inspiring talk haven't amounted to much, before the move to Pieri. Here, with a shake-up of the routines, responsibilities and expectations, I have been moved by other people's energy into the cause I had often felt I had been fighting alone. In Lankien, we had staff strikes, some close discussions about patient strikes, and general discontent for everyone. Here, things are different. After the last heavy rainfall, there were men with shovels and digging hoes clearing the drainage channels from the airstrip. "Can we borrow some shovels," sounds much better on the soul than the previous, "if you are so concerned about the airstrip, you should hire some more people and send them to the airstrip yourself. It is only your planes that land here anyway." (True, it is only our planes that land there. We are the last ones to care about you, and it is wearing thin.)

I guess the biggest thing I like about this group, is that in the lack of anything else I will be able to hand-over to my replacement, I feel I have added, EVER-SO-SLOWLY, to the stuff of the people, the stuff that remains after the fires and through the insecurities. Back to the question, the resonating echo, whispered in every tense moment, and chanted at every victory, "Does it really matter after all?" I still feel, no it doesn't. All the little things and the big ones here to, do not matter, they will all return back to dust. However, with some of this good stuff floating around, life is a little more pleasant in the meanwhile, and that is worth it all.

I think I will leave it there for tonight. Trust that the afternoon was filled and worth living completely as well.

One more note: I see the calendar of the months going by. I remember thinking June was the month, so far in the future, which I have to survive until. Now I look at it as the month I would have prematurely left this place. Still looking at the calender, I look ahead at September and think, I'm not ready to leave just yet. I think I am falling in love with South Sudan, her temper, her stirring moments, her mystery, her simplicity and her beauty. People ask me if I regret extending my contract, especially after the evacuations, the fire and the recent displacement. No, not at all. In fact, I applaud my intellect on that decision, and wonder if the rewards would come to me, if I stood up again and stated, "I'll extend," in the company of the right people. I feel though, as I look around at this mud tukel (our office/lab/pharmacy/log store single room), hearing the termites eating the roof, watching a rat dig away part of the wall and the rain erode other parts, South Sudan will always be here, and what she lacks in style, she makes up for in consistency; she's not going to change! Given time, more than most places in the world, everything standing will crumble, and become the building materials of the next people through the area. For here, I think that the life-cycle is measured in months, not decades. For me, the time is good to return home in the fall, and I'll catch-up with SSudan again sometime, and if not in person, at least in my dreams.

Lots of Love,

Steve