Independence Day

The Flag of South Sudan : Red is for Blood

Today, July 9^th 2013 is Independence Day in South Sudan, now 2 years old. It is a public holiday and apparently leaders from many African countries have arrived in Juba, the Capital, for celebrations. Here in Aweil, celebrations are apparently going to take place in Freedom Square, a large open space of gravel and dust at the edge of the main market area. Theres nothing special about Freedom square  - maybe in the future it will be upgraded with paving or flag poles or something but for now its just a wide space which I think was once an airstrip.  However, something extraordinary happened there last week during a football match – the sky darkened as a storm approached, huge drops of rain began to bounce off the gravel as a tropical  rain squall approached, and then in an instant a man was killed by a lightening strike. I had been there watching a different football match, got soaked in the rain and saw lightening but it wasn’t until much later when the storm had passed and I saw a very dense crowd packed together in a different part of the square, and asked what was going on that I found out. I was also told that tradition has it that the deceased is buried where he was killed, so a crowd remained there for hours, presumably digging a grave and burying the poor guy.

Today however the crowds gathering will be much happier. Already – its 10am – there is a rising swell of crowd noise drifting into the compound from all directions, shouts, trumpet blasts, and occasional chanting and ululating of women, increasingly frequent clusters of happily animated laughing and shouting people hurrying past the compound walls with Flags and music, increased numbers of bikes and motorbikes, a sense of building excitement and anticipation. I am not sure what exactly has been planned for the Square but  peering over our razor-wire topped wall I saw a cluster of men jog past wearing tiny leopard skin sort of skirts, some crude white body paint, long poles in their hands and chanting as they ran, so I daresay there will be lots of local colour, traditional dance and song.

Unfortunately, all this excitement and nationalistic fervor is seen by our MSF leaders as representing an increased threat to foreigners. We have all been confined to Barracks since yesterday, and forbidden to walk outside the compound for any reason. When we need to go to the hospital we have to be driven there, and the route has been changed so we don’t go anywhere near Freedom Square. Its thought there may be an influx into the hospital of  accident and trauma victims, and if people move into Aweil from surrounding towns we may even have some extra babies to deal with.

To be excluded from participating or even witnessing all this of course is very disappointing , but its easy to understand why such a risk averse policy is so rigorously applied: there is a long sad list of MSF workers worldwide who have been beaten, kidnapped and even killed while in places like this, doing humanitarian work. Right now two MSF  workers remain hostages somewhere in Somalia, and this very week threats of murder have been made against MSF right here in Aweil!  These were made by a local person formerly an MSF employee who was dismissed when found to be a thief. Similar threats were made last month by another disgruntled former local employee who tried to set fire to our compound, and drew a knife when tackled in the very act of sprinkling petrol about the place!

The brutality and horror of civil war is very fresh in the minds of the people here, and violence, for so long a part of everyday life still seems to be close to the surface even now. No doubt there are still many guns around, many knives, many unsettled scores, grudges and grievances. I have spoken with people who have personal experience of atrocities and war crimes, some committed by the notorious “Koni” who operated out of neighboring Uganda and also in Southern Sudan, not too far from Aweil which apparently at one time was in the centre of much of the appalling violence. A lovely woman on the hospital staff told me  a horrifying tale of how she came to be raising her brother and sister-in- laws children – the children’s parents were murdered in random violence – the grisly details are too ghastly to repeat, but  believe me they would make you shudder.

So I can easily understand why today must be a day of huge celebration for everyone, the miracle of Independence, the end of so much horror and uncertainty, a chance to make a future and to be at Peace. Never-the-less, Independence Day is also a reminder of what went before, and for many it must be a day of very mixed emotion. Hopefully they wont get out of hand.

Every Day

For me there is no weekend or days off in Aweil. I am on call and go to work every day, and every day is much the same as the one before. This is how it goes:

I usually wake before six when its still not light, having had a horrible night on top of a sheet which is damp with sweat and all wrinkled from my tossing and turning in the heat. I may have been woken by a few cats on the wall behind my concrete cell, snarling and growling, or by the barking and howling and yelping of packs of dogs that fight and wander the streets at night, and aken for ever to get back to sleep. The heat makes me have vivid dreams, sometimes disturbing dreams of confrontations and conflict, I started dreaming about Sue again. I am always on call but have been woken to go into the hospital in the middle of the night only a couple of times so far, but its an eerie deserted scene except for the dogs in the unlit road. The stalls and streetside merchandise are all packed away there is no advertising or neon, no streetlamps, just the rubbish and the muddy potholes remain as we bounce and weave our way past, it all looks abandoned. The light on top of the Landcruiser flashes and illuminates everything momentarily as we pass with its orange beam. Outside the church an old man and a young boy sleep under a scruffy heavy old piece of plastic sheet, which they fold up and sit on once daylight comes, begging.

But in the morning, once I am awake, I go for my shower. It’s a cold one and I have to brace myself for the shock, stepping under it and shuddering at first, but then within a minute the cool water feels good. I then suffer as usual this awful itchiness on my legs and arms and back for half an hour, I dress in jeans and clean shirt and take the laptop over to the main compound where I have some horrible instant coffee and check my email and news on the internet. The connection is slow but we used to think dial-up speed was amazing so its not a problem. It just takes a bit longer. I usually then have some cereal and maybe  some fresh locally made bread, a sort of Pita bread, round pockets which are very tasty with nutella or some of that French processed cheese brand “La Vache qui Ris” . The others all appear at intervals, mostly preoccupied with their own waking thoughts and breakfasts and emails, and then  I go back to my room and brush my teeth, and head for the hospital. Usually I go with Maura , the ex-pat Midwife who has been here since February. By now, 8.30, the streets are busy again and all the stalls are opening up and the wheelbarrows of merchandise are back on the street.

At the hospital we have a quick look in Labour ward and then I do a round of all the patients. It is supposed to be a learning opportunity for the staff , but few seem to attend the round, and those that do often disappear and return at intervals. I am taking things slowly and not pushing the staff too much at he moment as I am still learning their names and their roles, but soon enough I shall start insisting on attendance because I am discovering how much they need to learn. The round usually takes a couple of hours. After that, there are usually particular people to sort out, scans to do, notes to sort out and a steady stream of new patients arriving to be sorted out, some for admission, some for sending back home. Most of this work is done by the local staff.

Eventually I return to the Compound for lunch -  its usually really hot by now, our faces are all wet with perspiration just from walking, our MSF T-Shirts  sticking to our backs. For lunch ? - well today we had barbequed chicken with rice and chopped up tomatoes and onion, chips and lots of cups of cold water – in other words Chicken and chips – and its apparently a regular on Wednesdays.

Afterwards I might check my email or read some of the news on the Sydney Morning Herald  website – there’s been lots lately with the sad ending of Julia Gillards term as Prime Minister. She has been replaced by the man she replaced three years ago, the populist and treacherous Kevin Rudd for the purely pragmatic and sole reason that he is immensely popular with the Australian voters.  She of course was not and the Labor party was headed for a massive thrashing at the election due in a few months. The fact that the same Labor party under Rudd, with the same history and more or less the same Policy platform has now made a huge gain in the opinion Polls demonstrates how much the Australian electoral environment has  degenerated into a Popularity contest between personalities rather than a contest of ideas. How sad. The positive for me is the possibility that the very unpopular opposition leader who was sleep-walking to an electoral landslide win while Gillard was the PM may now remain Opposition Leader after the election. That result is not widely expected but it is at least a possibility now. I dread the day Australia is led by a man who thinks the science of climate change is “crap”.

At some time in the afternoon I walk back to the hospital and see whats happening and check to see that all the plans we made for the patients in the morning have been acted on. Surprisingly they often haven’t been – theres a degree of disorganization bordering on chaos at times in the ward which all the people preceding me have been attempting to improve but it still needs work. There may be new patients to sort out as well.

Around five I walk back again, the stall holders and merchants are packing up , everyone is heading home, the sun is close to setting by 6, the air is starting to cool down a little , and back at base I open a cold  can of African beer, Tusker. A beer at the end of the day has never tasted so good.

Security / Camera

South Sudan is the newest country in the world, and will be 2 years old in a couple of weeks. As everyone knows South Sudan came into existence after a referendum in the south of “old” Sudan and a huge majority voted for independence from the north, which is still called Sudan. There’s a long history of violent civil and intertribal war which continues sporadically even now, but in parts of South Sudan and Sudan itself which are quite remote from Aweil. However there is a legacy of this prolonged violence that lingers even here,  firstly I am told by a general state of post traumatic stress, a wariness and hesitancy about engagement with all but your own. This explanation certainly made sense to me, because it is hard to get a smile from anyone, life seems to be pursued with a grim and self  contained determination, and joy seems in short supply, even among children. Whereas a walk from the hospital in Ethiopia inevitably attracted throngs of kids who would call out and come running, here they watch silently as you pass. In Ethiopia it was possible to engage with patients and their carers but here that seems less common. – we do good, I am sure they know it and appreciate it but there is little in the way of feedback. This is my impression after only a week, so it may change as I get to know and understand their ways better, and perhaps, they, mine.

A further legacy of the wars is a nighttime curfew in the town from 11pm to 7am. There is an MSF rule that after 7pm we are not allowed out of the compound except for work related activity, and we area not to walk anywhere but use a car and driver. If we need to go to the hospital during curfew the ambulance has to activate the flashing light.

A final reminder that security remains a major issue in the country is the prohibition on Photography, and is the one that affects and annoys me most. How strictly such a requirement is enforced I couldn’t say, but I took a few pictures in Juba, and when I arrived here , and nobody seemed to object. However at my first briefing in Aweil it was made very clear that I am not here as a Tourist but as a representative of MSF, and taking photos in the streets and of people and scenes generally, let alone of public buildings or military or policing subjects, was simply forbidden. There were one or two photos on file in the Office Computer that I could use, and of course I could take photos within the compound or, with the permission of the subjects, of work related activity, but my habit of always having the camera in one pocket has had to be scrapped. I will post what photos I can but sadly many scenes, colors faces and events that I witness will have to be recorded in my head and nowhere else.

The Hospital at Aweil

So far I have only been into the wards of the hospital that are staffed by MSF. Maybe I will get to see the others later. These are the typical Florence Nightingale arrangements, namely long, even very long rooms with beds side by side along both sides and doors at each end, and lining the corridors to and from. I would be surprised if even in Florence Nightingales time there were so many people crammed into the in-patient wards, children and babies and their caregiver families crowding the beds and the narrow spaces between them, the heat and smells, the noise, the dust and dirt, a feeling that the place must be on the edge of collapsing into complete chaos such is the apparent confusion of noise and crying and talking and push and shove. The MSF doctors that work here work incredibly hard all the time – their patients are all kids and babies, and unlike maternity which also gets chaotic and mad, but gets quiet sometimes with a little lull in the floods of women coming in to give birth – there is an unending flood of kids with disease, and injuries and worried parents and complicated problems to unravel.  And they have to do this with almost none of the resources we are all used to back “home”, things like comprehensive laboratory services, radiology, microbiology and pathology services, not to mention the hierarchy of colleagues in other sub branches of medicine with expertise in dermatology or rheumatology, cardiology,  and endocrinology, people we are all used to having on hand to get second opinions from.  In our ward we have a tiny portable gadget that gives a rough estimate of a persons hemoglobin concentration – in other words it tells us if they are anaemic or not and by how much, but the device is very basic.  We can send blood to the lab for a result which I took to be obtained from a more sophisticated machine but found out today their machine is the same as our one! The medical doctors are always last in for lunch and dinner.

The maternity service here delivers more than three thousand babies annually, so its very busy. There are several tiers of worker, from Medical Assistants to midwives, nurses and nurses assistants. Almost all of them are men. On our ward round the other morning I discovered we also have an Interpreter – he  explained this to me after I asked him to discuss the clinical state of the patient in the bed in front of us, much to everyones amusement. Some of the staff can be identified by the colour of their work clothes, which makes it easier for me, because they all seem very eager to help out, but some are well trained medical assistants while others barely trained at all. At least three are called Joseph, just to add to the confusion, and they are supposed to wear name badges to help me out but most often they don’t.

The long maternity ward itself has 10 beds for pregnant women at one end with problems like miscarrriages and malaria, then a small area for Triage where women sent in from elsewhere are assessed and then either admitted or sent home depending on what the problem is, then  further along still there are 5 Intensive Care beds, and on the other side of them ten beds for women who have given birth, and then beyond them and through a door another ten beds for women in labour. When their babies are about to come out they transfer into an adjacent birthing room where there are four birthing tables in a line against the wall. There is absolutely no provision made in almost the entire place for the sort of privacy we are used to in the west. You may be naked and giving birth on one bed while another woman arrives or is bleeding and being resuscitated beside you or also giving birth or having a miscarriage in the adjacent one on the other side. There arent even curtains. 

A word about the intensive care beds : to us westerners, “Intensive Care” conjures up vision of hi tech beds that cost more than a car, banks of machines and instruments with figures flashing on screens, oxygen outlets and suction hoses and monitors – well you can forget about all that – Intensive care beds here are just ordinary clapped out old beds like the others, theres no space age technology, no flashing light alarms or oxygen monitors, nothing. Its just that the really sick or potentially really sick patients get put in this little group of beds together to make it easier to keep an eye on them – so its intensive observation more than anything else.

This whole ward is usually also packed to the rafters with patients and their families, so is noisy and busy.  At times I am told they will run out of beds and people will sleep on the floor. Fortunately once the babies are born the mothers only stay a few hours before going home, so the postnatal beds  empty out often but then steadily refill. It is quite a wonderful place to pass through, as many of the women and their visitors, now smiling and relieved are dressed in exquisitely coloured flowing clothes and often have colourful scarves around their tall heads. The local women are Dinka, a race of very tall men and women who are often more than 6 feet tall and tower over me. They are never overweight, indeed most are probably underweight, but they are slender and strong with high cheek bones, very black smooth skin and are often remarkably elegant. There are also women from other Sudanese regions as well as Uganda and even Ethiopia.

These are our patients. Like women everywhere, they are phenomenal.

The Walk to Work

The hospital is a lazy ten minute wander down the road that passes in front of the compound.  I have no idea what the daily temperatures are but they must be well over 30 most of the time, because its much hotter than Darwin where 32 was often the daily maximum, so unless walking at a very gentle pace, soon enough perspiration drips down your face and into your eyes, your shirt sticks to your back and you long for shadows, clouds or a breeze. I’m told – and accept – that things are cooling down compared to 3 months ago, as the rainy season approaches – in fact its overdue – but more heat than this must be almost intolerable. Rain of course will turn everything to mud and create new problems one of which is dramatic increases in malaria.

The road is wide and dusty with huge potholes to be negotiated at intervals, and after recent overnight rain many are filled with muddy orange water. It is possible to drive to the hospital down this road but it takes as long as walking, because the vehicle weaves all over the place around the holes and if it goes any faster than walking pace bounces about so violently people can damage their spine.  At Juba I met a women being sent home early because of exactly that.

The first part of the walk is past roughly walled housing compounds containing numerous dwellings grouped around grey dusty spaces littered with stuff that looks like junk and rubbish but which might not be. There may be clothes on a line, naked or near naked kids sitting about, women working on a struggling garden or washing or cooking on an open fire. Houses would not be the right word to describe these mostly dilapidated mudwalled huts with pointy thatched roof, or else low shelters with a sort of bamboo-like screen for walls and sagging roof. Large trees here and there are the only greenery, apart from small front yard stands of corn, and everywhere is dust and plastic junk, old bags and containers, piles of rubbish and dead leaves, sticks and paper. Dragging himself around in all this on the roadside is a sad paraplegic in rags, using old thongs  to protect his hands as he hauls his useless legs about, he is apparently also deaf, and his only language appears to be meaningless noises and groans when people pass. He doesn’t seem to be begging and I haven’t seen anyone ever give him anything so I have no idea how he survives. When I passed him this morning he was asleep in the shadow of a wall, as gray as the dust, dribbling mouth open, and I thought what a relief it must be for him to be asleep and maybe dreaming about anything but this reality. He must hate waking up.

Further on, the road to the hospital crosses a main street which is sealed.  Pedestrians are the main traffic on it, but there are a few Tuk-Tuks, motorbikes and lorries, and of course NGO Landcruisers but traffic is very light – most of the time it would probably be safe to wander across without looking to left or right . An occasional horse or donkey drawn cart goes by.

On the other side, within its own walled and nicely gated compound is an impressive brick catholic church, almost the biggest building in the town. Yesterday, Sunday, inside its compound an open sided enclosure facing the church was full of believers who presumably couldn’t fit inside for Mass.  The majority religion is some variant of Christianity, other indigenous belief systems and also Muslims, whose curious little sand coloured mosque and green minaret is crammed in among the shops and commercial activity of Aweil Central. Thankfully the MSF compound is far enough away that the 5 am call to prayer is barely audible. We are not encouraged to go to Mass or other religious service, but if we must, for personal reasons, we are requested not to wear our MSF T-shirts, to preserve our neutral secular status. In a place like this you really do wish there was a God and therefore some point in going to church, because people like that poor man on the street could sure do with one. For me the policy of not wearing an MSF T-shirt to church will not be a problem.

The potholes and mud continue past merchants, tiny low roofed shopfronts  and flimsy stalls on both sides, and the road seems narrower, because their wares are displayed on boxes and carts and benches out front.  Here to avoid walking in mud you  might have to wait your turn to step between two puddles. It’s the usual limited variety of mostly chinese made plastic and cheap metal consumer junk, plastic shoes, locks and nuts and bolts, torches, hinges, twine, batteries and cosmetics, as well as tinned milk and fruit, biscuits and rice and a few other food items. Clothes are also on sale. I haven’t seen but have certainly smelled a merchant who deals in dead and dried fish.  This street is not the main street but runs parallel to it – on the main street there is a slightly better range and quality of merchandise, there are a couple of  “restaurants” and somewhere I can get some sort of a haircut, and “Bookshops” which sell dusty very old text books, books about Nelson Mandela and about English language, and not much else. The main street has some nice shady trees, an area used to park donkeys and horses and their carts, and is quite bustling.

Finally you come to a T-Intersection and the hospital is right in front of you, through its own half closed double gates, another rocky and dusty walled enclosure at least as big as a football field, and a collection of long low buildings connected by covered walkways. Some of them are staffed and managed by the local Ministry of Health , and others , by MSF, and they function more or less independently of each other, though together, cover most of the possible medical needs of  the local population. Essentially MSF provides all the medical services needed by babies and children to age 15, as well as women giving birth or with complications of pregnancy. Obstetric care therefore includes provision of anaesthetics and operating theatre staff and equipment.  In addition there is an MSF Feeding program for malnourished children – these are kids who are literally starving to death, and the ward is full. Hunger is common here. How embarrassing it would be for us if they knew how many millions of tons of good food are thrown out every day in the west.

So that is the trip to work I shall be making at least twice every day for the next six weeks.