Friday morning, and a small milestone: I’ve made it to two weeks out here.
I leave the hospital and cross back to the expat compound, doing my best to avoid our resident wildlife. Lurking behind my towel, a hamburger-patty of a spider in the bathroom shed. I freshen up quickly. In our courtyard, one of the storage tent cats is crouched behind a bush, dreamily eyeing a rooster at least triple its size. I step past them, into the kitchen, although even this room is not for the faint-hearted: the hind quarters of a goat are poking from a plastic tub on the bench—hoofs, hair, flies, and attendant smell—at a little after eight in the morning.
‘Pequeno-almoço?’ I ask Dominga—Breakfast?—and she giggles.
I light our gas stove and fill a pot of water to boil as she fishes out the first of the limbs, laying it on the uncovered wood table, then pull out my Portuguese flashcards to practise phrases with her. We’ve been doing these drills daily this second week. Dominga’s our cook and cleaner, a sturdily built Angolan grandmother, and she’s turning out to be the mother figure of our compound. In every sense, a large woman: expansive mood, broad smile, wide hips, gleaming round Krugerrand eyes, and ample bosoms that jiggle wildly when she laughs—which is frequently. I’d known a similarly proportioned African woman years ago, who’d delighted in wearing a far-too-small T-shirt with the print, stretched across her chest, boasting: ‘All this, and brains too!’ I’d like to think it was made with Dominga in mind.
Dominga asks me how the hospital’s going. Her neighbour’s child is currently in Intensivo with pneumonia, but I report that she’s a little better this morning. ‘And you?’ I ask. ‘Como vai?’
‘Muito frio!’ she smiles—too cold. It gives her back pain, she says of the chilly weather (the consequence of our elevation on the Central African Plateau, over a thousand metres above sea level), so I promise to bring her some paracetamol. She nods, then looks to the flashcard in my hand. Ignoring the half-carcass between us, I read out the first phrase.
‘Bom,’ she says, massaging onion onto the meat—good. She’s not quite so sure about my next attempt, though. ‘Eh?’ she asks, leaning over to follow the card with her pink-wet forefinger. ‘Não! é assim!’—It’s like this—and corrects my pronunciation, which is my real struggle with this language. Vocabulary I’m okay with; memorising lists of relevant words isn’t too difficult. It’s the understanding and being understood where I come unstuck. People here don’t say words, they eat them. Each word rolls into the next before it’s completed, and a strong nasal twang muddies things further. What’s written seems to bear little resemblance to what’s spoken, so I’ve created lists of simple, closed questions for the ward rounds. If I can get people to answer me with only a Yes or No for the remaining five months, I’ve decided, I may just be fine.
Dominga listens as I try another phrase, and another. Nonchalantly, she thumps a cockroach as it scuttles across the table, then flicks it, wipes her hand on the apron over her green dress—all the while listening—and resumes rubbing salt into the goat meat. The source of my frequent latrine visits lately? Quite possibly. I’ll be sure to ask Tim to bring up food hygiene with her when he passes on those new recipes. Not that I’m being lazy in avoiding the issue directly with her. It’s just that Tim’s the overall staff supervisor, and for the moment I’d hate to spoil this dynamic between Dominga and me. Because this mother to seven children, grandmother to two more, is the only Angolan I’m getting to know outside the hospital. And unexpectedly, her presence is prompting a torrent of long-forgotten, warmly pleasant memories of my South African childhood.
It’s not just Dominga, though. There are other things out here, too, seemingly unremarkable cues that prompt film strips of memory when I least expect it. The beers we drink in the evenings, the only brand sold by the little stall near the market, are Castle, ‘Premium South African Lager’, driven in from Namibia and last seen by me in the door of our fridge in Cape Town. The heavy cast-iron pots in which women boil maize flour here, set over evening fires, are the same black poitjies we’d used for traditional stews, brewed slowly over a barbecue on Sundays. And the earthy smell of these huts evokes strong images of the labourers’ cottages on my grandfather’s hobby farm in the north of South Africa—little brick buildings in which a handful of workers lived, the surrounding landscape of yellow grass and dry soils itself not unlike corners of Mavinga. But none stirs my memories as much as Dominga. So I sip a coffee, ignore the cock-roaches, and take my time as I practise Portuguese in her bizarrely familiar, strangely comforting presence.
• • •
Tim’s in the office. Cigarette in hand, he’s trawling through the slew of daily emails forwarded via our satellite link with MSF in Geneva. His job confines him here for most of the day as he handles the work contracts, staff salaries, communications with various MSF offices and the Angolan government, and develops strategies for the project’s future. This morning there’s a warning about possible unrest following Angola’s loss to Portugal in the football World Cup, he tells me, and a message from my ex-girlfriend. (Our email is communal—we can’t access the internet here, only an MSF-based account in Geneva—and there are no passwords.) ‘You like me to read it out?’ he smiles. ‘Because if I have to read another bullshit forward from head office . . .’
Andrea looks no more impressed with her job. She’s at the plastic medical desk, immersed in a pile of stock lists as she tries to put together our next pharmacy order. ‘They’re in four languages,’ she says. ‘Look at this. These lists are all over the place. Urinary catheters: French, Italian, Portuguese, and here—English! And none of the numbers add up.’
I’ll take the travails of the hospital any time over trying to manage that pharmacy. Just yesterday a large amount of medical stock was flown in, and this next order should’ve been emailed off already—it’ll take the supplies three months to be shipped here from Europe. Compiling it is no easy task, though. The pharmacy is a warren of shelves in a large brick room behind our storage tent, stocked to the roof with an impressive range of supplies. Antibiotics, painkillers, surgical kits, obstetric sets, catheters, drains, tapes, pens and even blank medical charts fill the space, but layout is haphazard. As well, numerous requests from the hospital dispensary arrive on her desk daily, creating an almost full-time job in itself.
My bigger worry this morning isn’t the late drug order, though. It’s the semi-conscious twenty-year-old man lying in Intensivo. He arrived yesterday, and we’ve since performed all the tests that we can—a malaria check and lumbar puncture—but both were negative. Or at least the lumbar puncture appeared to be when I held the sample up to the sun, about the sum total of what we can do with it. So for now I’m checking the textbooks again, which is how I spend most of these mornings between the handover and longer ten o’clock ward round. And, much like Andrea, my tasks are also often hampered by linguistic issues, our three shelves of medical references filled with books from various countries. Cholera outbreak? Here’s a yellow guide covering every aspect of management, from building the treatment centre to diluting chlorine for disinfecting the bodies; problem is I’ll need to learn French to read it. Same too for obstetrics, although Spanish is what I’ll need for paediatric surgery. But it’s the tropical medicine books I’m after, and they’re fortunately in English. I pull them out, along with the nearby Medical Resources folders I’ve not yet browsed, and squeeze onto the desk beside Andrea.
The files are an interesting distraction. A mixed bag: medical reports from 2002; guidelines for a haemorrhagic fever outbreak; someone’s team photographs in a plastic wallet; a review of malaria; and a thick document, containing what looks to be transcriptions of an interview. I flick through it for a moment.
‘Tim—you seen these things?’ I ask.
‘Which things?’
‘Testimonials, I think. Taken here after the war.’
‘Oui. I have. You should read it, but sometime when you’re in a very good mood. It’s heavy stuff.’
I nudge Andrea, but she’s only up to Ampicillin ampoules on her encyclopaedic list, so a little distracted. I nudge her again. ‘You seen these?’
She shakes her head.
‘Listen for a second.’ I read the first entry, that of a middle-aged civilian:
A friend warned me that [the government MPLA forces] were going to come and lock me up, and so I left. I hid in the forest with all my family. I started to teach my children in the forest. We went all the way to Mavinga. From 1977 until 1979 I walked, for two years. I bought food, or exchanged my clothes for it. We got to Mavinga and stayed until 1992 . . . It was an area controlled by UNITA and there was a school there. After, I went to [my previous home]. In 1994 my house was destroyed by the bombs so I fled. I had a good rest . . . the aeroplanes didn’t come as far as there. Then a bomb fell on my new home. We set off again, at random, running always from the bombs that were just behind us. We walked and walked, to the right, to the left, always in the bush. We passed villages empty of people . . . During the whole time we slept in all of our clothes, afraid that we would have to flee without being able to take anything. I even slept with my tie on.
‘That was taken here?’ asks Andrea.
Tim nods. ‘MSF do it after many conflicts or big disasters, part of the whole témoignage process,’ he says, referring to a French term that translates roughly as ‘bearing witness’. It’s one of the organisation’s core principles, along with impartiality, neutrality, and the upholding of universal medical ethics. ‘But I’m telling you,’ he adds, ‘this is heavy stuff. Read it when you’re feeling very happy with life, not when you’re about to start three hours of ward rounds. Believe me.’ He gets up and heads outside for a moment, but I’m too absorbed to stop. What I’ve read of the war has been mostly in drier briefing documents, but this is from people here, some of the stories told in our hospital. I read on.
This from a young mother:
If UNITA attacked one day, then you had to expect the [government] to turn up the day after. Most of the time we hid in the bush while UNITA pillaged our houses, and then we stayed there throughout the [government] offensive. Sometimes we stayed two weeks in the bush. We lived like animals. We led that life for many years, but in 1998 we couldn’t continue any longer. My two nephews were forced, on pain of death, to join UNITA’s army. Around that time the [government] gave the order that people must get into their trucks unless they wanted to be killed. So we did. We’ve been crammed [into a disused factory] for two years now. People are dying like flies. We used to have everything . . . a small piece of land which gave us onions, sweet potatoes, sometimes tomatoes.
And another young woman:
I was captured when they attacked our village. I came to Mavinga. I studied in the high school [at the UNITA base]. Life was just suffering. They put us in the houses of the grown-ups, the officers. There, we had to work, washing the clothes, but they didn’t give us anything, no clothes, no food. Some of the officers raped the young girls, so they ran away. My parents were also captured. They were taken to the [food supply] base in Mavinga, where they farmed. My husband had to go to work and he never came back. The [government] attacked us. I ran and hid in the bush, there was a big group of us. We were just running all the time. The pregnant women were also running, but if they couldn’t keep it up they handed themselves to the [government army] . . . My child fell ill in the bush; he had malaria and diarrhoea and we had no medicines, so the nurse gave him some roots. He died. A lot of children died, every day three or four died. A lot of children were also lost when we were running away and were never found again.
Such testimonies go a long way to explaining the nonchalant response of our staff to that fatal explosion four days ago. My attempts to initiate a debriefing session the next day were met only with confused looks. ‘We were not hurt,’ they’d replied, ‘so why would we want to talk about it?’
Why would they? They’d have dealt with far worse. Not so for us expats, though, who’re running on adrenaline for days. In two years of working in Australian hospitals, I’d not ever come across a gunshot wound, let alone the victims of an explosion. And for all the political unrest during my time in South Africa, the most harrowing incident I recall is having a gun pulled on me by a white businessman when my friends and I sprayed his sports car with water pistols: ‘You ever point a gun at me again,’ he’d threatened, ‘plestic or not, and I’ll fucking shoot you.’
So then, are we safe here? I think so. I take heart in Tim’s reassurances that no staff have been killed since that 2002 explosion, and that there’s never been an accident in areas that the HALO Trust have cleared. Guns don’t seem overly prevalent, either; extensive disarmament took place after the war, and only police and soldiers seem to carry them.
The bigger question for me, though, after my reading, is how I can possibly go back to work and pull staff up over trivialities, such as the treatment of diarrhoea, when this was happening four years ago—
To kill our thirst, when there was no water, we chewed on leaves. For two months we would eat one day, then not eat for two days, like that.
As I read on, it worries me what role some of the people here, the men, may have had in the events described. Because UNITA, which in Mavinga had an almost exclusive supporter base, and for which many of our staff worked, was clearly no innocent participant.
. . . it was like someone had just slaughtered goats, blood everywhere and all the people lying dead, right there in the middle of the road. It was just women and children that lay dead in the middle of the road with blood everywhere.
For years, UNITA was considered a viable political party by outsiders. Their leader, Jonas Savimbi, was an articulate, charismatic man who’d begun studying medicine in Portugal before switching to political science, and who was deemed a great political thinker by many. He dined at the White House and was openly supported by the CIA and the South African government, portrayed as the archetypal African freedom fighter. As for the MPLA, the current government, they were led for the first years of the war by Agostinho Neto, an acclaimed poet who’d also studied medicine in Portugal, and who was widely respected across Africa as an anti-colonialist hero. Hard then to reconcile that idealism with all this mayhem.
. . . I was woken up by the sounds of shooting—fway, fway, fway!—and bombs: Bwow! I just ran. Some this way, some went that way, others went that way. I ran . . . Then I started to look for my family.
I can’t finish. It serves me better not to think too much about what has taken place here. About who was a victim, who may have been a perpetrator, and that some of these people—on either side—could be on our staff. The hospital is just metres away; through the office window I can see a group of kids kicking a semi-inflated football near Pascal while he works on the fence; and I think: this could’ve been them just four years ago. So I stop at these last words as I close the file. Words from a nine-year-old orphan, interviewed during her treatment in the feeding centre in Mavinga.
My family is dead. I ate sand. What will I do now?
• • •
‘It is very hard for us clinicos to work like this,’ laments Sergio, addressing the group of staff. It’s later this same Friday, and the weekly meeting with the heads of the various departments is being held. ‘We cannot work properly,’ he goes on. ‘Not like this—not with someone who cannot speak our language. It is very difficult for us all.’
This last point I don’t doubt.
‘And let me say that this language thing, Coordenador,’ he continues, as a dry breeze coughs hot air at us, ‘that this is just part of the problem. Because it is also the work. For example, we have had a very sick woman these last two weeks. And before, we have operated on such patients. Many times we have helped them. But now—’ he stops as he looks around the open-walled hut, here in our expat yard, eyeing the dozen staff seated on wooden benches around the circular shape, ‘—this Novo Doctor won’t let us do this!’
‘Move on, Sergio,’ says Tim. ‘This is not the place.’
‘I disagree, Coordenador, because this concerns everyone. Our hospital is not good at the moment. Novo Doctor questions things he does not understand. And let me please just say this one thing.’
On he goes. I’d almost enjoy his speech if I wasn’t the topic. He’s remarkably dramatic, gesticulating, pausing, staring, pacing, contemplating, and shaking his head ruefully, enunciating each point. Andrea interjects with whispered translations from my left, but they’re largely unnecessary. The gist is clear.
‘Two weeks ago we had a nice mother arrive,’ he continues, describing the case of the woman with cancer, ‘and we did nothing. Roberto wanted to operate, but still we did nothing. And just yesterday, this woman died! With still no treatment from us. How can this be?’
The woman had held on far longer than I’d imagined, although she’d been unconscious for much of this second week. I arrived for work yesterday morning to find her children clinging to her body. The husband said nothing, just quietly wrapped her in a blanket and carried her out the gate, two young sons in tow.
‘Novo Doctor?’ calls Sergio. ‘Tell us. Tell us why we did nothing for her!’
He takes his seat. There is nothing I can think to say. The Angolan staff look just as uneasy; Sergio’s a senior, technically their boss, and as MSF expats we’re the employers. Most look away in silence. Next to Andrea sits Senhor Kassoma, the head of Outpatients, who’s for some reason making notes on all this in his diary. Beside him are Pascal, Tim, and Toyota—still dressed in his blue overalls and thick gumboots; Vasco, our head guard—who’s more likely to charm someone out of entering the compound than physically prevent them; Theresa, the forty-something head of nursing, with whom Andrea’s been having her own run-ins; Jamba, our affable driver, who’s afflicted with an unfortunately large goitre; Nene, the head of midwifery, today outfitted like a West African queen in flowing blue dress, matching headscarf and large hoop earrings; and Roberto, who’s not missed a day of work since his injury. Also present are the heads of cleaning, water distribution, and the hospital dispensary.
‘Sergio, I’ve made this clear before,’ says Tim. ‘These are not medical meetings. This is not to happen again.’
‘Excuse me, Coordenador,’ interrupts Roberto. He stands slowly, leans his crutch against the wall of the hut and straightens his checked business shirt. ‘It is not just Sergio,’ he says. ‘Okay, I do not think it is fair to suggest that Novo Doctor caused the death of this woman. She was very ill, and I think this is unfair. But I could have tried to help this woman. This is the thing: we could have tried. It is what her family wanted. But O Novo Doctor— who has been here for what, two weeks?—he has been refusing such things. And now there is another young girl on the ward—’
‘The point’s been made, Roberto,’ says Tim. ‘The four of us can meet afterwards.’
Sergio’s back on his feet. ‘But must we go through this every time a new doctor arrives?’ he asks. ‘Always, these new questions, these different rules. What if this new patient dies as well? What if she—’
‘Enough!’ calls Tim. ‘We will talk afterwards. Now—Pascal, logistics issues this week?’
I need to seriously question the reality of staying in Mavinga. This is absurd. How has it all so quickly deteriorated into this? There’s a deep irony in my having left the Thai clinic to come here, too—maybe someday I’ll appreciate it. The difficulty of working there had been in getting the mild-natured, soft-spoken Burmese to actually speak up to me at all!
Pascal fills us in on stock issues, and as I watch him speak I want to trade places. Having previously spent a year in Angola with a women’s development agency, he’s a fluent Portuguese speaker, and gets along effortlessly with his team. And what a job he has. Just yesterday our six-monthly logistics order arrived spectacularly in a giant, Russian-built cargo jet, an event overseen by Pascal. The sound of the ageing Antonov bearing down on our dirt runway, just metres from the hospital, was almost apocalyptic as it screamed its reverse thrust into the quiet African morning, the scene equally surreal: a marvel of twentieth-century engineering parked on the dirt as an ox-drawn cart trundled past. A group of local kids quickly gathered to inspect the plane, giving the tyres a firm thump with a fist, whacking the fuselage with a small branch. The logistics team meanwhile unloaded and inspected the tonnes of supplies—fuel, chlorine, medical equipment and maize, and the sundry other items including wiring, cement, sand and bricks for new projects: every conceivable thing we’re likely to need in coming months—and it’s this logistical aspect of the project that I find most fascinating. That here, in the midst of The Land at the Edge of the World, a bubble of modern infrastructure has been created, allowing the hospital and water system to function at a level not otherwise possible. All the technical aspects fall under Pascal’s responsibility, and when not dealing with flights he can be found tinkering with the generator, adjusting the satellite communications equipment, fiddling with plumbing, or getting driven around in the mine-proof vehicle. So I also want to be a log, I’ve decided. I want Pascal’s job. An organised one, with quantifiable, visible results, and a team of light-hearted Angolans to boot.
‘Anyone else with something to add?’ Tim asks.
‘Yes, Chefe,’ begins Sergio. ‘There is now another patient—’
‘Right,’ Tim interjects. ‘Meeting’s over.’
The others leave. Only Tim, myself, Sergio and Roberto remain. We stay on our benches at opposite sides of the hut.
‘This is a huge problem,’ begins Tim, sitting forward. He runs a hand through his dark, close-cropped hair, and asks the two clinicos to explain their sides of the story. For a quarter of an hour the duo speak passionately. It’s a bitter pill, listening to their complaints as Tim relays them. ‘We do want to get on well with the doctor,’ Sergio concludes. ‘We need a doctor to lead the team. But this situation . . .’
‘Thanks for your honesty,’ says Tim. ‘Now for my input. You know that I’m not a medical person—my background is in project management—so it’s not for me to give a medical opinion. But I know that our doctor has been speaking with the surgeon in Geneva, and he’s following the advice he’s been given. Advice also from the medical coordinator. These people are my bosses, too, so if they suggest that we don’t operate on certain patients, then we don’t.’
Roberto glances my way. Sergio stares off into the distance, looking bored. I’m still not sure what to make of these two. I was told in briefings that several of our staff were formerly UNITA seniors, but senior what? Health workers? Politicians? Teachers? Or military commanders? Christ—were some of these guys involved in what I’d just read about? Responsible even for such acts? Am I quibbling with people who ran guerrilla armies? I know I shouldn’t entertain such thoughts. I understand that in circumstances like those everyone was a victim, people were forced into situations to survive and did what they had to, and all are equally deserving of care—it’s the very premise of this organisation. Our staff seem well respected by the local people, too, which must count for something, and I can only assume that MSF looked into their backgrounds before employing them. I’d ask Tim, but I’d rather not know.
‘I don’t want to have to get involved in clinical issues,’ Tim finishes up, ‘because it’s not my job. But if this goes on we’re going to have to lay down clear rules via the medical advisors. You all have to work together for another half year, so you need to please find a way. Any more issues, you come straight to me. Okay?’
Sergio and Roberto get up and leave the compound quickly. I stay where I am.
‘Having a tricky time, huh?’ smiles Tim.
‘I expected to be pushed a little, mate, but seriously . . .’
‘You should have a good read of the old medical reports in the office,’ he says. ‘Sergio’s been like this for years. He’s very good with coordination staff, but in his mind this is his hospital. As for Roberto? Well, he has a background in war surgery, and you don’t. You also look very young, my friend!’
I ask him how the previous doctors managed.
‘The one before you was good with surgery and obstetrics,’ he says, ‘so she spent a lot of time on that side of things, maybe less on the general wards. I never met the other doctors—I’ve only been here a few months—but I can tell you that it’s not uncommon for new staff to get tested when they arrive. I even saw local staff strike in another project once, just because they refused to work with certain expats.’
We walk the few metres to the dining area and grab Castle beers from the vaccine fridge, slump into plastic chairs. The mechanical drone of the generator begins. It feels out of place here, an unwelcome intrusion, but the most delightful sound can still be heard coming from just behind our fence, where children from the nearby huts are playing. Hands clap, little voices sing, and through our open door I can see the sky, blushed with streaky pinks where a setting sun slid past only minutes ago. The softer side of Mavinga. Sitting before us, though, cubes of this morning’s goat, suspended in a puddle of orange.
‘You have to put yourself in their shoes,’ Tim continues. ‘These guys get a new doctor every six months, sometimes more often, and all of you try to change things when you arrive. After a few months the next guy arrives, and he does the same. I’ve seen that list you carry, too, my friend . . .!’
Touché. It’s now a small booklet of issues I’m hoping to address.
‘We are all guilty of this,’ Tim laughs. ‘The thing is, this project has been going for years. Staff are close, and you’re another outsider. But you need to be on those wards all day.’ He stops, takes a long sip and stares quietly out the window. ‘You know, this is a difficult time for them. In six months we’re handing this hospital to the government. The MSF presence in Angola is ending. All projects are closing, and the health workers may well be working on their own after that—if they’re working at all. This is the last few months of formal support they’ll have from MSF, maybe the last time they’ll have a doctor, so you need to teach. And find the problems. So stand your ground with Sergio. Do what needs to be done. As for Roberto?’ He leans across and clinks beers with me. ‘Good luck with him.’
Pascal bounds through the doorway, covered in dust. ‘Fucking hell!’ he declares. ‘Listen to this. Okay, so Jamba is in the tent just before, working through this big order. It’s going to take us days, by the way, this thing. Big fucking mess, lots of stuff missing.’
‘Stolen?’
‘For sure. Some boxes were cut open and resealed, almost perfectly. Only the expensive items are missing—lots of medicines. But anyway, this is for tomorrow’s problems. So, Jamba opens this box and he looks closely inside for something, his head down—he’s concentrating hard—but Toyota comes up from his side, quietly, like this . . .’
Tim and I laugh as Pascal mimics Toyota creeping, but before he can finish the story, a distraction occurs, a comprehensive derailment of thought: three heads pivot in unison like carnival clowns, mouths agape, because, wrapped in only a figure-hugging towel, Andrea has just stepped out of the shower and she’s making her way across the yard to her bedroom.
(‘Fucking hell!’ notes someone beside me.)
It’s going to be an interesting few months.