South Sudan Journal, Parts 7, 8 & 9 (of 29)

Message #7 October 11, 2003


Hello Mom and Dad.

Today was a big day. The Buffalo couldn't come yesterday, but was able to come today after all. I think someone in Loki is cashing in some favours.

So, the day started at 0530. We have to give a confirmation that things are fine here, before the plane will leave. So, I woke up, got a lantern, found a guard to walk with me to the airstrip, and paced the strip one more time. It was still soft in parts, and hard in others, but to my (expert) opinion, it was land-able.

To my horror though, in the south there was lightening off in the distance, and a wind blowing from the southeast. After conferring with Sammy (the team leader, and the real airstrip expert) we asked Loki to send the plane, but quickly.

In the following 2 hours, I had an extreme interest in this storm, and it's path. Without the presence of anything taller than a hut (well, the occasional tree), the sky is pretty large. This storm got closer, and bigger, and whiter and darker, and it passed without visiting. At one point a small drizzle of rain started, but that stopped before long.

So, at 0820 I got a call that the plane was 15minutes away, and we headed to the airstrip. "We," included all the expat staff, and all the healthy relatives of the patients. Usually, it takes the better part of the day to unload 8000kgs and bring it 250m to the compound, so we even stopped the clinics, until the load was in the compound.

We gathered at the airstrip, eyes in the sky. This community depends on the airstrip, and they know what a rain can do to it. Then a guard pointed to the sky, and there it was, the Buffalo, the beast of burden. It did a fly-by, turned and landed. The landing was a little rough, and muddy, but these planes can stop in no distance, very impressive. Once it stopped and opened up, many people swarmed the plane, to unload it. Fun stuff, tons (8) of maize, unimix, and other specialty nutrition foods were pouring out of the plane, and I got to direct it, and get the right people to watch it. (Note on watching food coming off a plane. Our outreach team was evacuated today from Pultruk. WFP did a food drop there. There was something like 96,000 kg of maize dropped. A fight broke out between two people, then the community hit the drop zone, and half of that food was looted very quickly. This type of event can lead to violence, so the team was pulled out.)

Anyway, after it was all off the plane, and piled nicely at the side of the airstrip, the plane started up it's engines, and blew over all our nice piles. It was really something, many boxes were sent down the airstrip, and the piles of 50kg bags of maize (4 high) were knocked over. I was also standing there, and I felt like my skin was, "exfoliated" a little more than my liking.

Then came the fun part. The crowd around us, filled with curious people, opportunistic people, and helpful people too, were just waiting there. With the help of some others, we counted it all again, and decided to space ourselves around in the line from the strip to the compound (to limit losses), then I gave the word and the madness began. Some men, many women and many children grabbed what they could and started off to the compound. I will take a photo next time; it is impressive to see 50 people walking with all sorts of different sized things on their heads.

The most impressive part was after all the small things were taken, many 50kg maize bags remained. I was ready to take one, and it is harder than it sounds! However, when I was returning, I started seeing a stream of women (some weighing 50kgs) carrying these bags ON THEIR HEAD!!! I couldn't believe it. Not only were there women carrying 50kg on their heads, but also as hard as I tried, I couldn't get any men to carry them! Through the day, I heard the reason, it is women's work, and men mind the cows. Damn! Anyway, these women are incredible! 50kgs on their heads! Not by the strong one of the town, but by many of them!

Well, within an hour, it was all in the compound and I was pretty damn happy with myself, but happier with everyone else. Before I believed, "many hands make light work," but now, I will start preaching that. Less than one hour, 8,000kgs, 250m!

Well, that went well, and I think I got some good respect points by heaving the heavy ones too, and cheering on the ones beside me in my best Nuer. (Lim Lim, Lim Lim, and boom boom, boom boom, seem to work well.) There was a lull in the work after that, and being Saturday, I tried to have a lazy day. Actually, most positions have between 12:00 and 16:00 off, due to the sun; so that helps the lazy day work.

After lunch I had a rest and started thinking about the day, and about some of the differences... I can't believe where I am.

Imagine you get sick. After some days, it is unbearable, and you need to make that 1-25 day journey to the clinic where you heard there is medicine to help you. You get there and are admitted after some tests. You learn that it is Kala Azar, and you will need to stay in the clinic for the next 17-31 days. (You look over the fence and see the TB clinic, and count your blessings, because they stay for up to 7 months!) You receive a mosquito net, a cup and 0.5kgs of salt. If you are malnourished as well, you get a plate and spoon and a blanket right away (otherwise, you get a blanket after your friend/family member brings in a bundle of wood in as payment). Your group location is pointed out to you. This is the tukel, or space in front of it, where you will get examined and receive your shots and milk (don't lose the cup!) once a day. There are no private sleeping rooms, or dorm rooms for that matter. There is some space on the ground between the group tukels, and there are some shelter tents that can hold about 15 mosquito nets worth of people. Your privacy was left at the door. You even get a wrist band to identify yourself as a patient, and the guard with the stick will let you in, should you walk outside for a while.

So, there you are, one of 250 Kala Azar patients, 'sleeping under the stars,' in an MSF clinic in South Sudan. There isn't just one child crying through the night, there are many. In your sights are the different clinic tukels, there is a fenced off area, called the TFC (Therapeutic Feeding Centre), there is a tukel called "special care" where more people are carried out (one or two a day), than walk out, there is a disgusting area in the back, called the "latrines" where you are told to crap in a hole and there are these white folks (fat as legends!) walking off to a corner behind a fence where lots of boxes labeled, "expat food," go.

You start to get a little hungry. But the hospital food here isn't that great. Once a week, each patient receives 4 kg of maize, 0.5kgs of lentils, 0.5 kg of unimix (high protein powder), 0.25litres of corn oil, and a bar of soap. (You got the salt on admission, remember.) The people in TFC get daily food, until they are bigger, but still malnourished by Canadian standards. Over the past few weeks, there has been lots of rain, and as such, stocks ran low, and the maize and unimix were cut from your rations. Life is rough, and luck is not always with you.

One morning, the clinics are closed, and there is a bunch of excitement around the place. Some strong words of encouragement are being shouted, and crowds of people form in the wake of the vocal authorities. A plane flies over, and it is clear what is going on, food has arrived and help is needed to bring it to the clinic. And those that can, get up and walk to the plane and carry what they can. (Except for a lot of the men! Those lazy bastards!)

Besides the 250 in Kala Azar, there are 68 in the TB clinic and another 130 in the TFC. For those 450 people, there are two doctors (right now just one though), two nurses and a bunch of other health workers. Unless you are dying, you don't get a daily 30minutes with "your" doctor.

It is a professional operation going on here, with measurable significant impacts on the quality of healthcare in this area, as well as important work in preventing large epidemics. However the biggest impact for me is a personal one. What greater differences can there be, than the black and white contrast of this health care system, and the one back home in Canada? I'm glad to see the public push for improvements to the health system, but I also find little weight behind statements like, "our health system is in the gutter." The biggest impact for me in doing this work is the realizations I have (daily) of how fortunate I am. I am glad to be able to share that with you, and I am happy that many of you are enjoying it too.

Well, the night is quiet today. I'm a little tired from a big day, so I'll say goodnight.

Cheers,

Steve


Message #8 October 19, 2003

Hello Mom and Dad and all.

Things are going well here, still getting into things. Tonight’s insight is into touching things. I don’t mean physically, I mean observing the consequences of a single action, and it’s ripples. A couple of things have happened that I find incredible how related it all is. Enough preamble.

A week ago, or so, I was in ‘special care’ talking to Lindsay the Nurse there. Special care is the tukel for the most sever patients with Kala Azar or mal-nourishment. 1 to 2 people die there a day. It isn’t a pleasant place. Lindsay told me she was just changing a dressing on a patient, when a clump of dirt fell into the wound. That sort of thing happens when your ICU is in a mud tukel where the roof is slowly being eaten by termites, and the result is little bits of roof, and termite waste fall down. Anyway, she asked for something to help out, and we agreed some cotton cloth nailed to the roof would help a little. We had the cloth, it was a technology implemented elsewhere in the clinic, (mostly the office and kitchen), and we had the cotton, so why not? (What an infinitely valuable question!)

Within a couple of days, the special care tukel was emptied, and the roof was being lined with cotton cloth. After two days, 20 bars of soap and 20 bags (500g) of salt labour payment, the special care tukel was (mostly) dirt free. The very next day, one of the milk ladies from the TB clinic came with a translator to demand that cotton cloth be put into her tukel. It seems that her, and many others, are unsure how they ever worked before with such an unacceptable work condition, and cotton cloth should be put in all the tukels.

Similarly, we provide uniforms to our staff when they are hired. After the uniforms rip, tear, wear, etc, it is an expectation that they are replaced. We are calling it, raising the bar. Last year, the TFC (therapeutic feeding centre) was only in tents, no tukels. Now, after much building by my predecessor, there are many tukels for all the phases of the TFC, except one. The TFC has grown considerably, and as such, we made another group recently and only had a tent for them. In the mid-day sun it is hotter in there than the other tukels, and the team almost refused to work there. It was agreed that the whole TFC was better off than before, but the issue was, they were the only one’s without a tent.

Similarly, people want the broken items like locks, buckets, jerry cans, etc. But even if I say, “if I give you one, I will have to give everyone one,” and refuse, the waves of people still come on. It is tricky when it comes to things that we need people to have, and cannot regulate. Guards need flashlights, but you cannot regulate if they are using the batteries for their radios, or not. Log laborers need matches for the burning of waste, so they are seen as receiving matches, but then others ask for matches and are refused.

Anyway, I feel it is like trying to place some food coloring dye at the bottom of a bucket full of water, without coloring the water; you make one mistake, and you’ve tainted things for a long time. It is tricky, when I would love to give these people fancy things, like a pack of matches (every month) or maybe a new pair of gumboots, but the ultimate question that limits our spending, is, “does that add to the medical intervention we are doing here?” Many times the answer is yes, but sometimes it is, “no, but it is a damn good cause anyway!”

Example damn good causes: there is a little boy, Peter, suffering from some sort of skin disease. It covers his body with puss-filled sores, and it won’t get better with our program, (we treat Kala Azar TB and malnourished people). CMA, the medical NGO across the way, treats everything else, but they don’t have the capacity to treat him. With some misplaced medications, we could treat him, and take his standard of life, up a considerable notch. Do we do it? Tricky stuff to sleep on in the evenings.

There are many questions like this that come up with regards to EVERYTHING here. The boots that we gave to a staff member for their work were stolen, do we replace them; the uniform that was stained so badly with blood it wasn’t dark green anymore, do we replace that and what about all the uniforms that were stained, but to a lesser extent; do we give a cup of kerosene to a guard knowing he will use part of it to light his own tukel at night, etc

The thing about all these questions that I question even more, is, “are we raising the bar and creating more problems for ourselves and those we serve here?” Really, that is it. I see the more I have, the more my goals and desires are expanding, and similarly here too; the more we give out, the more is expected of us.

This place is pristine in some many ways. Nothing from here pollutes the environment (except for all the fires they have), but there are no plastics, wrappers, oil spills, cans, glass bottles, one-time-use bags, etc, only what was flown in by us. The ladies don’t cry out in pain during birth, (sympathy doesn’t exist here.) Sharing is quite common I find too.

But I see what we are doing here may impact that. People we employ here have never worked in their lives before, for someone else. To instill in them views that your family/cows/leaking home/etc have to wait, it is 0800 and you have to be at work now, is a foreign concept, (pushed by… foreigners of course.) We give them cloths of such quality that they have never seen before, as if it grew on a tree, or picked from the sky; and boots too. Then we refuse them for a request of similar magnitude, can I have a pen? Then they are naturally disappointed by the refusal. Did we teach them the feeling of being disappointed? What about desire, did we develop that feeling, and what about jealousy and envy?

Well, there is good to what we do, I’m just exercising my ability to pick up the negative parts of the things I’ve noticed here. We do have in our care around 450 people, all sick of diseases that will kill them. Most of those people survive because of the work that we do. So, despite all the other questions I have at night, I do manage to sleep.

So, that is the extent of my philosophical inner dialogue right now. Charlie is in the kitchen cooking up the loudest of our chickens tonight along with some Ojalee (Kenyan starch of choice). The sounds of Chicane, (recorded and produced in the same world this laptop comes from, but definitely not this world) are playing in my ears. And some of the medical staff are doing statistics on the patient records (for predicting what is going to happen next, but also reporting back to the donors that fund us.) It is a Wednesday night, and all is as it should be.

Have a good night, love,

Steve

P.S. I forgot to mention, food has finally come from WFP! On the morning that we were expecting a small plane (caravan) with some more expats, a buffalo arrived. I was standing there with the log from CMA, and we were both saying, “no, that’s not mine, it must be yours.” Well, it stopped, turned around, and opened the back door. The pilot mouthed, “MSF HOLLAND!” and guess what, we had 8000kgs of maize, and a plane that wanted to get going back to Loki ASAP! I love surprises! Well, it worked out again, but again, these men are very lazy, and would not help carry anything to the compound, again it was all the women from the clinics, carrying 50kg bags on their heads! Impressive.

Message #9 Sunday October 19, 2003


Hello Mom and Dad.

Well, never a dull moment here.

It is Sunday afternoon, the lazy part of the week. Everyone is writing reports, sitting in hammocks, listening to music, or enjoying just one more cup of tea. Just 5 minutes ago, as I was sitting down to write, and there was some shouting outside the compound. It was some women, maybe 50 women in total, celebrating the election of another 2 people for a women’s collective. It apparently is a newer thing here, organizing women together; but based on the excitement of the group, it is well received. This organizing will be a parallel to the organization of the clans and sub-clans. If women have concerns, they will no longer need a man (husband or family member) to voice them, but rather through their ranks the concern will be raised higher and higher, and finally from their leader to the Chief.

I wonder if this celebration is what it was like in North America in monumental times of women’s rights. Did our Mothers and Aunts lift up their newly elected leaders on their shoulders, cry out in excitement, sing at the top of their lungs at their achievement so far, and of optimism of times to come? What hardships and victories are there in the future for this collective? Did a gender revolution (peacefully) just arrive here? Didn’t they hear the news before? (Oops, forgot, no TV.)

Today I had a very pleasant talk with Francis, our Sudanese Senor medical staff member. Francis is from Western Upper Nile, a little to the west of us. He has been working with MSF for quite some time now, and lives in the compound with us. It is a pleasure to have him here; his input is infinitely greater than any of ours, when dealing with issues related to the community, population, or other cultural issues. Today we talked more about marriage, customs and traditions.

It started when the daughter of our cleaning lady (the one that left on a plane halfway through doing the laundry) came in to do the work of her mother. (It is common, in the labour positions, that if you are sick someone from your family comes to do your duties while you are away.) We talked about how she was pregnant, but not married. “How can this happen Francis?” I inquired. Our talk followed roughly as such.

Fr: “If a man takes a woman, but doesn’t have the cows to pay for a marriage, or does not want to marry, the family takes the woman back. When the child is older, 1 or 2 years and a boy, the father can take the child and raise him, otherwise the uncle (mother’s brother) will raise the boy. There will be some payment (in cows) to the family of the mother, since she is not as wanted, but she can marry another man.”

SD: “What happens if the man dies before he takes the child?”
Fr: “He doesn’t have to pay cows.”

SD: “Is divorce acceptable here?”
Fr: “A man can divorce a woman, or a woman can divorce a man. If a man is beating a woman, she can ask for a divorce. First, she would go to his family, second, she would go to her family, and after that if it is not resolved, she would go to the ‘head man’ and a court would decide. It depends on the reason for why he beats her. If she is not feeding the children, it is one thing, but if it is because he is drinking, that is not allowed.”

SD: “Who is the ‘head man’ and how are the clans organized?
Fr: “In charge of the Clan, is a Chief. Depending on the size of the clan, there are sometimes 3 or 4 sub-Chiefs. Under the ‘Sub-Chiefs’ there are 3 or 4 ‘Head Men’. Under the ‘Head Men’ there are people like policemen that will carry out tasks, like bringing someone to the Chief, or passing messages.”

SD: “Are there taxes?”
Fr: “Sometimes, 2 or 3 times a year, the SPLA asks the Chief for some food, (goats or cows) the amount depending on the amount of people there. The Chief divides that amount among the Sub-Chiefs, and they divide it among the Head Men. Then the Head Men sit with their community and decide who will give what. At that level, there will be 2 or 3 cows, and it will be decided who can give what.”

SD: “Are people ever over taxed?”
Fr: “Explain please.”

SD: “Does the SPLA ever ask for more than the people can give?”
Fr: “Everyone knows how many cows people have. You can’t ask for more than people have. Plus, most of the time, the soldiers are part of the community, and sometimes a cow that is given to someone may have come from their father.”

SD: “Tell me about the scarring on people’s faces.”
Fr: “It is decoration.”

The scarring I am referring to is the decorative scar tissue that is found on most (but not all) people’s faces here. On the men, there are horizontal lines cut across their foreheads usually from above their ear on one side, across the front and to above the other ear. On the females, their faces are usually decorated with little spots in very beautiful patterns, accenting the corners of the eyes, circling the cheeks, or lining the lips. It is quite beautiful.

SD: “How old are people when they get the scars? How old were you?”
Fr: “It varies. I was 17 years old when I got mine.”

SD: “Did it hurt?”
Fr: “It is really quite painful, they are cutting those lines!”

SD: “And the patterns?”
Fr: “It changes from area to area, you can tell if someone isn’t from around your area.”

SD’s inner dialogue: “Like it is written on their forehead.”
Fr: “That is the reason some of the young people aren’t doing it anymore. With the war, lots of people are moving around, and traditions are being lost. If you go to the city (Khartoum) people will know you are not from there, and they may fight with you. If you go to another village, people may also fight with you, if you have different markings.”

Francis is a very calm collected man. His family is staying in a refugee camp across the border in Kenya. He has some medical training, and has worked with ICRC before MSF. His Mother and a Sister live in Western Upper Nile (WUN), but there will have to be peace before he can return there. The Government of Sudan (GoS) holds his town, and as such, men cannot walk freely there, without being thought of as a spy, and killed. He has been able to send messages to his Mother, but not seen her for quite some time. He used to own many cows and goats, but with the war, they were taken. He told me with the peace, he hopes to bring his family back to WUN to be with his Mother and Sister. If peace holds for some time, he will again buy cows and maybe start growing crops again.

So, the weekend (Sunday) is here. It is 1500, the morning slipped into afternoon without anyone noticing. Another busy week will be here before long. I anticipate this week on being my busiest yet. Last week, some medicines went missing again. We have two storekeepers, and as such could not isolate blame. As such, the medical store and pharmacy is now under my supervision. The time allowed to do things in the day, just reduced a little.

Running the pharmacy is pretty easy, just a little legwork. 4-5 times in the day someone brings a request to me for some medicines. I get them, sign them out and get back to my work. Since I am also in charge of ordering that stuff (around 200 different medical items) it is a good chance for me to learn what all that stuff is.

Another problem with the storekeepers is their math, and initiative; they are both pretty low. I have been on them quite a bit in the last two weeks about actually counting the stock when they do “Stock Checks”, about questioning their calculators when 1000 minus 10 gives them 9990, and when they notice stock losses, to alert me so we can find the problems. I think this issue (poor storekeepers) was in mind when people were telling me, “don’t get frustrated at the level of education, initiative, etc here.”

Also, on Saturday, John, my assistant who runs EVERYTHING, came to me when I was in the pharmacy. (Note on John: In the mornings we talk briefly on what the log labour staff should do, what water ladies are out sick (due to whatever reason) and to approve replacing them, what guards have what complaints, what wheelbarrows are missing, etc. John does everything!) So he came to see me, and he wasn’t looking too good. He told me he wasn’t feeling too good, and I asked him what else there was for him to do for the day, there wasn’t much that couldn’t wait, so we talked of him going home at that time. He mentioned he had a fever, so we grabbed a thermometer and tried his temperature; it was high. He started slumping down and down and looking less steady and shaking a little. We decided to find a medical person and sort it out. Fortunately, when one of our staff are sick, we can use the ‘back-door’ approach, and see someone right away. Lindsay became free enough to give a little look, suggested malaria and give him the test; she was right. Damn, John has malaria. Malaria is one of those tropical diseases that can last three days, or can kill you. Depending on when you start taking medication, (and depending on some other things that I don’t know about just yet, as I am still not a Doctor.) John came back in the afternoon, looking surprisingly better, so hopefully he will only need a week or so.

A week or so, without John, or the storekeepers running the pharmacy sounds like a busy time. It will be an excellent opportunity to exercise my delegation muscles, and watch out for not taking too much on myself that should be shared with others instead. I will be looking to see who steps up to the challenges, ‘a lack of John,’ brings, and maybe there will be promotions afterwards. We’ll see.

One thing is for sure, there is never a dull moment here… yet.

(It is a couple of hours since the mob of singing dancing ladies moved on, now the grunts and groaning of 40 odd cows passing by is filling the air. That sound is nothing I would call pleasant, and in fact it is a little unsettling when a loud one cries out. Good thing for volume control on my portable CD player. Sundays are the only time I really feel comfortable enough to take this CD player out of my hiding place in my tukel. On Sundays, the compound is not filled with other people, so I don’t have to explain how the musicians fit into my headset, or raise desires for my possessions. Speaking of music. THANK YOU to all the musicians out there, your service to humankind (and my life) is huge. Whether it is the distant drumming of the churches here, or the music I have brought with me, it is very nice to have, and also essential to my nightly (and Sunday) escape from South Sudan.)

One last thought, and question. We have been discussing, and not solving, the issue of having a national staff member in charge of the medical storeroom. The question is, “Are we providing too much temptation to leave that amount of stock in the control of a national staff member?” To give you an idea of size, let’s use money as the unit of measure. The two things that are most important to the debate, are: 1) the med store has about $30,000 of medical supplies in it. 2) the average salary for a storekeeper is about $45 a month.

Simple math tells us, $45/mth = $540/year = approximately $30,000 in 55 years or one lifetime’s salary, just sitting there. Now putting that into Toronto terms, would I be able to hold steady against temptation if more than $2million dollars were under my supervision? What if my children started to get hungry in tough times, or my house was knocked over in the last storm and I needed to build again? What if my son was crippled and wanted a wheelchair to get around? I think one of the storekeepers did take the vials of medicine, but no one here blames him one bit.

Another frustration that has hit me is the asking for things here. “Can I have a pen?” (Asked by Simon, a schoolboy that I’ve grown to appreciate. Every time I see him out of the compound, he shows me his recent math test, and I give him a couple of math problems for next time. He wants a pen.) From an older medical staff member, “You are like my son. I am cold at night. Please my son, can you give your father a blanket to keep him warm at night.” “Can I have an empty pop bottle for carrying water?” “Can I have a paper so I can practice writing?” “My tukel is open all day when I am here. People can steal my things, can I please have a lock?” “Can I have some oil, so I can oil my wheelchair?” “Can I have some matches?” We have a policy here: don’t give anything. I agree with it, for the two times I have stepped outside the guidance of that policy, I have unleashed a flood of wishes, and reference to the two times I folded to the pressure. But damn it is hard to resist. I did sneak some oil to the staff member with the wheelchair that had a fused chain, but even that was very risky. I want to buy everyone in the community a pen, but what fighting will that start. (The team in Pultruk was pulled out after some fighting started when WFP dropped some food last week.)

There are frustrations popping up left and right all over here, but there is nothing to blame, no focus to direct unpleasant thoughts towards. As a friend simply pointed out to me a few years ago, and it has been making more sense ever since, “It is what it is.” It is South Sudan, nothing more or less, no right or wrong, it is just South Sudan the way it is. Maybe not the way it always was, but the way it is now, and that’s all that matters; “it is what it is.” (Thank you Heather.)

Well, time to go, hope all is well at home, lots of love,

Steve

P.S. It is still hot and humid, but the mosquitoes are less and less at night. Soon we will be eating outside at night; that will be nice.