Monday, August 17, 2009

Medecins Sans Frontieres by James Maskalyk

I sat down with the mother.

"Your baby's not breathing well. See? He's only breathing small. Not good. We need to help him breathe. Put this tube down his throat to push in air. I think if we do not do it, he will die. Even if we do, he might die. I don't know. It's the only thing I can do."

The nurse translated and the mother agreed.

I put the flat blade of the laryngoscope past his tiny white teeth and pushed his tongue to the side. I lifted the blade until I could see his vocal cords. They flickered with each breath. I pushed the tube past them, into his trachea, then attached the bag to it.

His oxygen saturation improved to 100%. His chest rose and fell with each small squeeze of the bag.

Muriel arrived from compound 2. She's young, was trained in Khartoum, and worked for years with MSF in Darfur. She was interested and competant, the best we have.

"Okay. Like this. Just a gentle push. Watch his chest. In...and and out. This is the suction machine. You work it with your foot, like this. You'll need to suction him every hour or so"

I adressed the other nurses. "This is a hard job. You will have to help her. You too, Mom. She can't stop. If she does, the baby won't be abe to breathe and he will die. Okay?

We left them, Muriel pushig on the bag, twelve times per minute, 720 times per hour.

I wonder in cases like this, if the battle is worth fighting. The war is a long one and the odds are stacked so heavily that perhaps energy is best conserved. Maybe it's best to use likely defeats to increase our resolve to work towards a day when it will be easier to win. But then there is the other tack. Battle every time, with everything you have. Do the best you can for the person in front of you. Persuade the family of every malnourished kid to get into the truck, to come to the hospital to be fed until they are better. Track down each TB patient who left, frustrated, halfway through his long treatment and try to get him to come back even though the countryside is littered with tuberculosis patients we will never see and one case will not tip the balance sheet noticeably towards a TB-free future. To the world it doesn't matter that much. Until you remember that it means the world to the patient. One exact world, bright and full of sounds, per person. That's what is lost...

The next morning when I got to the hospital, Muriel was still pushing the bag. She had not taken a break all night. The mother was lying down on the bed, her hand resting on her child's chest, feeling its rise and fall.

I relieve Muriel, and she stumbled towards the waiting Land Cruiser. I explained to the mother that we had needed to take the tube out, to see if the child would breathe on his own. I suctioned his small mouth, removed the tape from around it and from the tube. I stopped bagging.

He was breathing. A little. More than a flicker, more than last night. I pulled the tube.

On my way home for lunch, I got a call from the hospital. His breathing was getting worse.

"Put him on oxygen," I said. We couldn't intubate him again. We didn't have the resources or the trained staff. Fifteen munutes later they called again. He was dead.


  1. Then there is the dead body problem.

    When someone is sick in a village, they don't come to the hospital right away. There is no road. Transport is too expensive. Often the family calls a traditional healer, and they spend their carefully collected money, likely saved for this exact contigency, for treatments that don't work. The patient worsens.. There is no choice but to spend what money they have left to hire a donkey, or a car, and bring the patient to Abyei. They don't have enough so the sell their only goat, or a piece of their land, to their neighbors. They use the money to get to the hospital ten minutes too late.

    They are grieving, and penniless. There is nowhere to put the body, nor for them to sleep. Pleading, they ask for our help to take the body to the graveyard. They are heartbroken. We say no.

    It is an impossible decision. We could easily take one of our cars, the pick-up for instance, and offer the family some relief from a cruel day but we don't. We cannot be a hospital and a hearse service. Nor when someone knocks on our compound door, his eyes as big as moons, and says "my wife, she is delivering at home, but the baby is stuck, can you take her to the hospital?" Can we be an ambulance service. No, we say, you need to find way, and quietly close the gate.

    These are impossible decisions because their wisdom is easy to see but they are contrary to one's spirit. Once we start transporting bodies to the graveyard, the hospital becomes their destination. Once we become an ambulance service, our resources become taxed, and we may go to destinations that are not secure. Further, each time we are a band-aid, we simply cover the problem, and delay the slow work towards a tenable, permanent solution.

    But when a family comes kilometers over broken roads, carrying their dying daughter, and they arrive ten minutes too late, when you tell them no, you cannot help them bury her though you have the means, the knowledge that you are being wise is poor comfort.

    You want to drive each patient where they need to go until you run out of gas, use every last dose of rabies vaccine for the small chance the dog was infected and the child dies foaming, to give the starving family money even if it will only feed them for a day, drip all the blood into this patient bleeding in front of you even though it means there might be none for the next ten, but you have it today, and today is his lucky day, and tomorrow you will worry about tomorrow.

    But we don't. We are measured, and careful. It is what tomorrow's patients expect of us and tomorrows stretch towards forever, and today is nearly done.

  2. In Germany, during our pre-departure training, we were reminded that the nature of conflict has changed. Wars no longer take their greatest toll on combatants, but on civilians. This means that our proximity to the fighting is necessarily greater. As war spreads its wide grasp, it erodes the space in which we work.

    Once, being a humanitarian carried with it a certain privilege: if you declare yourself one, you were not a target, not even on the battlefield. The red crosses and MSF logos no longer provide as much protection. Some don't see them, and to others they look like a bull's eyes, a sign of wealth, of resources.

    We were increasingly seen as part of the conflict, a potential pawn in a larger political game. With one swift stroke, one could drive help away from the enemy, or more likely, from civilian countrymen who might be supporting them.

    The problem is, once this humanitarian space falls away, it cannot be rebuilt. The newer wars will have no memory of it. Those whose only protection is this invisible margin of safety will be left defenseless. It is why we keep our distance from anyone with guns, even the UN, why we cringe when we see soldiers delivering food, or hear the phrase "militarizing humanitarian corridors."

    The space is not only for us. One of the reasons the worn red road between the compund and the hospital is safe at night is that if it were not, we would leave. If the hospital fills up with armed soldiers, if someone refuses to check their grenade at the door, we evacuate. Thus the soldiers and their families also lose the free care for themselves and gain the ill will of the community. We demand the space, and with it comes air for everyone.

  3. In the space beside the hospital road, a group of younger boys is playing their own match. The ball thy are using is nearly flat, likely discarded by their older brothers. One of them kicks it, and it makes a loud 'pock' and careens erratically.

    Smoke is coming from some early-evening fires. High above Abyei on the hot drafts of a rainless day, hawks circle.

    I turn around. Mohamed is standing behind me, watching. We sit down on the hospital step and watch both games.

    "James, do you believe in God?" he asks after a few minutes.

    I think for a second.

    "Not really"

    Mohammad often excuses himself, if we are in the hospital through lunch, to go pray.

    "What about paradise?"

    "No, Not really"

    "Most religions have theirs."

    "I think this is it, Mohamad, Paradise, I mean."

    He shakes his head. No.

    "The way I figure it is that I didn't know what life was before I got here, and if there is something after this, I won't know it either," I continue. "And this world, the one here, the one with that ball being kicked up in the air, and above it those birds, I can touch it with my hands. I can taste it. I can change it. It is the only miracle I know. You and I, sitting here, every bit of us from some distant part of the universe, filtered through a star, and put together just like this." I hold up my two hands.

    "No, I don't think so. Too many babies die here, too many of us are fighting. This is not what God, praise be to Him, wants of heaven for us."

    " You could be right. I don't know anything. It seems too hard. But maybe that's the thing. Maybe we're supposed to make it."

    The game closest to us is winding down. One by one, the younger boys are leaving for home. Now there are only two boys, kicking the wounded ball back and forth.


    Mohamed shrugs, stands, and brushes off his pants. "I am going to walk home"

    "Me too."

    We move step in step towards the compounds, both of us lost in our thoughts. As we draw close, Mohamed stops.

    "I'm going tp pass through the market"

    "Okay. See you tomorrow"

    "Yes, Good sleep"

    I watch him walk, head down, hands in his pockets, until I lose sight of him in the fading light.

  4. "Six Months in Sudan; A Young Doctor in a War-Torn Village" by James Maskalyk, Spegal & Grau, N.Y. 2009

    Dr. James Maskalyk is an assistant professor in the University of Toronto's Faculty of Medicine and a founding editor of the medical journal "Open Medicine"