But the night won’t end.
I lie in bed, and for hours there’s absolute silence—a sound disconcerting in its own right. No traffic, no voices; no hint of any life. Then the roosters start. Then the donkeys. And then the soldiers, performing their drills on the airstrip; but anything’s better than silence, and their singing is somehow soothing. I may yet drift off. Only now the sun’s rising, cleaving a shelf of bright dusty light below my wood shutters.
I get up. I search my room for a distraction, but pickings are slim. Two pairs of pants, some MSF T-shirts and a few other clothes sit on a metal rack beside the window, and my laptop gathers dirt on a plastic desk. On the cold concrete floor, underwear; on the blue-grey walls, nothing. The only other objects of note are the half-dozen books stacked beside a candle on the cardboard box I’m using for a bedside table, but they’re exactly the wrong books for a day like this. References on African history and tropical medicine, a novel set in Afghanistan, and an account of the Rwandan genocide. I’ve got no idea what I was thinking when I packed.
Back to bed.
Andrea begins to stir in her bedroom, to the right of mine, then heads out for a jog. The others are likely still sleeping. A relative silence descends again, and in it I hear termites rustling softly, gnawing at the crudely hewn poles of the roof frame above me. An almost imperceptible mist of wood dust drifts down, creating a brown residue on the mesh of my mosquito net—the supporting structure of my shelter being chewed, milligram by milligram—and I imagine it won’t take much to bring the remaining honeycomb down. A few days of rain in the wet season, perhaps, or the rumble of another cargo jet landing. Or a bird. One of those large, big-bellied, waterbirds. They’d weigh five or ten kilograms; this thing could hold maybe one. Not that there’s much chance of large waterbirds flying past here, though. The war decimated wildlife populations. They say that thirty years ago one could find black rhino, elephants, lion, buffalo, giraffes, buck and zebra roaming the area, but domesticated animals and small birds are all I’ve seen since arriving. A cruel irony given we’re in a designated wildlife reserve.
The desperate search for food during the war led to these animals being eaten out of local existence. Even the country’s national animal, the black sable antelope, was hunted almost to extinction, although elephants suffered a more senseless fate: rather than for food, entire herds were slaughtered by UNITA troops (at times with machine guns, in coordinated attacks from helicopters) for ivory, which was then sold on to Asian markets to help fund the war. It’s understandable then that the earlier leopard attack, as dramatic as it was, had actually been viewed as a positive sign by many: native fauna are finally returning. Hippos are known to wallow in downstream pools, and I’ve heard our staff mention that elephants have been spotted further south. But still, nothing in Mavinga.
A door flings open loudly to the left of my bedroom. It’s Pascal’s.
‘We need to do something about this!’ he says, uncharacteristically animated for this hour.
‘What?’ calls Tim, from the other end of the compound.
‘THESE FUCKING DONKEYS!’
‘I’M IN THE SHOWER,’ Tim yells.
Pascal goes on, complaining to no one in particular. ‘CAZZO! THEY HITCH THESE ANIMALS BEHIND OUR FENCE, AWAY FROM THEIR HOMES, RIGHT NEXT TO OURS. HOW CAN WE SLEEP WITH THIS NOISE? EVERY NIGHT, RIGHT OUTSIDE MY—’
‘I’M IN THE FUCKING SHOWER!’ Tim calls again, but Pascal’s on a roll now. ‘VAFFANCULO, PEZZO DI MERDA—’ he goes on, which I find amusing because he does it so frequently, and so passionately, about the most benign of incidents.
As for Tim, he’s likely to be in the shower for a while yet. He appears to actually enjoy the freezing water, singing in a rich baritone as he flirts with hypothermia in that little shed. Pascal and I do no such thing. We’ve deferred instead to the heat-a-pot-to-splash-yourself technique for the moment—best undertaken during the warmer afternoon hours. Andrea puts us all to shame, anyway. She showers straight after her dawn jogs, long before the rest of us have contemplated rising, then once more at night, long after even Tim’s deemed it too cold.
Not that I’m taking an active interest in the living habits of my workmates. It’s just the unavoidable reality of living in close confines. Proximity, squeaky doors, single-brick walls and poor insulation have long negated any illusions of privacy, and we already know well each other’s personal oddities—and on a level I’d even find uncomfortable at this stage of a torrid romance. Andrea, for example, whose Germanic obsession with neatness is rivalled only by her team-mates’ lack of it, wears sandals to go to the latrine during the night. I know this because my bedroom window faces the latrine, its shutters an inch smaller than the opening they’re meant to cover. Pascal, however—who makes it through most of the day on Nutella and cigarettes, and whose resemblance to Che Guevara goes beyond the mere physical (had he been born thirty years earlier, I’m confident he’d have swapped his MSF T-shirt for the uniform of a freedom fighter)—wears no footwear to the latrine, and is usually the culprit for leaving the pit’s lid open. In contrast, Tim closes the toilet grate. He also speaks in his sleep, snores heavily, and, since his previous breakup, no longer believes that love exists . . . which is all just the tip of the iceberg. Who knew we’d be each other’s relationship counsellors, career advisors, political sounding boards, and private audience—willing or otherwise—to tales of sexual misadventures? Living on top of each other like this can’t be underestimated.
As for my insomnia, the donkeys had little to do with it. The death of that young girl unnerved me. I’ve not seen a child die before, and I’ve never seen people react like that. Not to anything. I’d expected that deaths would be an inevitability out here; one in four Angolans die before their fifth birthday, probably more in places like Mavinga; and as a doctor, I’ve dealt with death. I’ve certified bodies of patients on the wards in Australia, and been called to open bags in the morgues of regional hospitals in the small hours of the morning. I’ve made phone calls to relatives and heard their sobbing on the end of the line, and been a part of discussions with families regarding end-of-life decisions. It’s always sad. But it’s never been like this. Never children. This is different. And the intimacy of it all, being there to watch that family grieve like that . . .
I heard crying early this morning as news spread around town. The family carry the body around afterwards, I’m told, and a funeral procession will snake its way towards their village today. So now I wonder: did we make a mistake with her care? Did she even have a chance at all out here, with or without our treatment? I can see no way to objectively assess this. As with so many of the patients on the ward, I’d give anything for a senior medical colleague who understands this context to come out here, just for a day, to guide me, correct me, even to reprimand me if needed. Because I’ve read the medical guidelines many times, and the theory I’m okay with. It’s the application of it that’s not so straightforward.
Patients here often present late, in advanced stages of illnesses that aren’t seen back home, and that crutch of Western medicine that I normally rely on is absent: abundant tests. It’s as if we’re practising medicine in the nineteenth century. To determine a patient’s haemoglobin level, I pull down their lower eyelid and gauge the colour (we have a lab test, but it’s rudimentary), and to check a foetal heart rate, Andrea listens to the mother’s belly with an empty cone-like device, a Pinard’s stethoscope, as if eavesdropping on a conversation in another room. Fevers present a particular problem. The causes are infinite, the cases many and the only tests we have are kits for HIV, syphilis, malaria and hepatitis, as well as that little microscope and devices for blood grouping. So I trawl textbooks for clues I’d not ever needed in Australia. If it’s typhoid, for example, the pulse will be unusually slow; in neonatal tetanus the baby won’t latch onto the breast properly. If it’s Borrelia the fever will likely recur, and in measles you’ll see telltale white spots inside the mouth. Such signs can be subtle and easy to miss, though. Yet even diagnosing things as ostensibly straightforward as broken limbs is not without difficulty. A conversation with a soldier last week, who’d fallen on his arm during training—
‘How did you break it?’ we asked.
‘So it is broken?’
‘Possibly. Does it feel broken?’
‘What does broken feel like?’
‘Good question. Is it very sore?’
‘Yes.’
‘Did you fall hard?’
‘Yes.’
‘And what if I wiggle it a little here?’
‘AIEEAH!’
‘Sorry—let’s assume it’s broken. We’ll plaster it, and you’ll need to wear this for four weeks, okay?’
Then again, even having a clear diagnosis doesn’t always make things easier. Days after we saw the soldier, a young boy presented with a significantly deformed forearm—undoubtedly broken. How then to assess it? Good painkillers and a firm feel along the fracture line, pushing hard enough to feel through the swelling. Were there two fragments of bone in there, or more? Who knew. Had he suffered any damage to nearby nerves or blood vessels? Didn’t seem to be the case. So we gave even stronger painkillers, took a breath, then pulled, bent and massaged the arm back into shape, all of which contradicts my every instinct as a Western doctor regarding certainty. Who would do such things in a litigious, resourced society? My experiences in Thailand had certainly been challenging, but there we had a modern hospital to refer people to.
So I’ve taken to contacting anyone I can for advice. The MSF surgeon in Europe graciously replies to my many emails, and I frequently query specialists in Australia. Last week I called the switch-board of Melbourne’s Royal Eye and Ear Hospital from our satellite phone and spoke to the on-call ophthalmologist about a young man who’d been carried to us from the Christian mission, an hour from town, having gone suddenly blind. Their advice was excellent; people are always keen to help, the problem is that we seldom have the equipment needed. Drugs we’re usually okay for—I’ve not yet needed a drug and not been able to find it in the pharmacy, or at least a suitable substitute—but equipment is the issue.
So yes, I need an experienced colleague. And while they’re here, I’d ask them kindly to take one of the nights on call for me, because this enduring sense of dread regarding a call to the next disaster, every day for the foreseeable future, is draining in itself.
Indulging my self-piteous wallow, I called my girlfriend last night—or ex-girlfriend, or whatever we are at the moment because we’ve been emailing each other a lot so I wasn’t really sure where we stood. She was. ‘I can’t be your support,’ she said. ‘You left me to go there. I need space.’
(Sofia was right: you do need someone to think about out here.)
My parents fortunately didn’t need any space. They were thrilled to hear from me and encouraging of this whole experience, something I desperately needed to hear because I wonder at times whether massaging arms in one needy village out of the thousands on the continent will make any difference at all, no less if we’re going to leave soon anyway . . . But parents are good at smoothing over that stuff. (And, at only four dollars a minute via satellite, I was treated to an update regarding the family dog, the latest rugby scores, and progress with the new kitchen flooring. A nice taste of home—a home that’s already starting to feel strangely unfamiliar, even though it’s only been weeks since I left.)
Anyway, there’s no point mulling over what happened yesterday. I can’t change it. And today of all days is not to be squandered with introspection: it’s Sunday. Our day off.
‘Hey, Damien,’ calls Tim.
‘Yeah?’
‘You up?’
He sounds like he’s in the office, next to the shower at the hospital end of our compound.
‘Still in bed,’ I call back.
‘What?’
‘IN BED.’
‘YOU HAVE AN EMAIL FROM SOMEONE NAMED ANNA ON HERE,’ he shouts.
‘THANKS.’ I’ll read it later, I decide. She’s an old university friend.
‘I DON’T REMEMBER YOU TELLING US ABOUT AN ANNA,’ he says, and now the door on the other side of my bedroom swings open again.
‘Anna?’ asks Pascal. ‘You definitely did not mention Anna. TIM—IS HE KEEPING THINGS FROM US?’
That thing about living together? Yet again, any notions of privacy are shattered.
‘AND YOU HAVE ONE FROM A NICOLLE,’ calls Tim. ‘JESUS, WHAT HAVE YOU BEEN DOING ON THE INTERNET, NOVO DOCTOR?’
‘SHE’S MY SISTER!’ I shout back.
‘IF YOU SAY SO. PASCAL AND ANDREA, A FEW HERE FOR YOU. AND MERDA! DAMIEN—ANOTHER ONE FROM THE EX! DID THIS THING NOT END?’
I bury my head under the pillow.
• • •
Spending a day off in Mavinga is not without its challenges. A walk around town is the norm, and we’ll make one together, although not until the daytime heat wanes this afternoon. Dominga is off, too, so one of us will have to prepare lunch and dinner—no pleasant task in that dingy kitchen. And we’ll need to do some exercise; a jog on the airstrip, or maybe set up the badminton net we found in the store room. But even doing all of this, everything we can think of—twice even—will leave at least twelve hours to spend with the others. Or in the hospital. Again. So really, there’s no rush to get out of bed.
We lounge around our bedrooms for much of the morning, taking turns catching up with correspondence from home. Reading fills in a little more time. By midday I’ve shaved, checked emails, cooked porridge, reviewed the handful of sicker patients and been thrashed by Pascal in a game of chess. Andrea’s busy in the kitchen, where, in a fortuitous turn for the rest of us, she’s embracing a personal stress-management technique benefiting us all: baking. We three meanwhile kick a football in the back yard, an activity that’s cut short when the ball’s thumped far over the fence—
‘You go.’
‘Fuck that!’
‘No chance! No way am I going that far.’
—because we’re not entirely sure about the ground where it’s ended up. The airstrip to our left is free of mines, the collection of huts further along is fine, and we can see no Perigro, Minas! signs in the foreground, but our map on the office wall has this area marked as being off-limits. We think it’s safe; to the north of the airstrip are the bulk of those de-mining grids I’d seen, and we’re now to the south. As well, bridges, water collection points and fruit trees are more likely to have been danger areas, but there are none of these features ahead of us. And none of the donkeys grazing here seem to have any injuries, either, but before we can agree on who’s going to retrieve the ball a group of young kids have run over anyway—‘CUIDADO!’ we yell, ‘BE CAREFUL!’—and had a kick of it among themselves before kindly throwing it back.
By mid-afternoon we’ve exhausted all extracurricular activities. Paperwork is what we’ve defaulted to. And it’s now, with the temperature rapidly dropping, that it’s best to head out.
As with previous days off, the market will be our ultimate destination, even if Toyota was right: there’s little of interest to buy. People-watching is the real reason we go, because the same piles of donated clothing and cheap goods (candles, batteries, soap, cigarettes, handheld radios, hair beads and Western-styled wigs) clutter the shelves of the three dozen ramshackle stalls, while the town’s meagre food supplies, sold on the outskirts, are a sobering sight. Here, women and girls kneel behind paltry quantities of stock spread on cloths before them—little mounds of maize, dry biscuits, small piles of okra, a few tubers, maybe some oil or cans of fish. How the town feeds itself with this we’re not sure. Ironic then that the only other goods we’ve come across being sold, aside from beer, are diamonds. As fanciful as that sounds, we’ve now been approached twice by men offering handfuls of the uncut gems, taken presumably from the large alluvial deposits to our north. The stones look merely like broken glass, but there’s every chance they’re genuine; the trans-border trade is still thriving in the region, although the prospect of time in an Angolan prisão has so far kept us from investing in it.
So the market it is. I charge my camera. Put a few Angolan kwanzas in my pocket, change batteries on the walkie-talkie and let the hospital guard know. We’ll leave in fifteen minutes, we decide, except that Sergio’s at the office door right now, describing what I suspect will be my alternative arrangements. Surgery.
• • •
For three weeks we’ve not taken a major case to theatre here. Potential candidates have been managed medically, albeit not always with Roberto’s agreement, but Sergio now leads me to see a young woman who unequivocally needs an operation. This worries me greatly. Not so much her condition—likely appendicitis. More, the conditions under which we’re about to operate.
The theatre is a small brick room attached to Maternity, where the only hints of modernity are a handheld pulse-oximeter and halogen lamp. A car battery powers the latter. Two shelves of medical supplies, a steel operating table and a curtained window account for the rest of the fittings, and a crack in the wall allows for some ventilation.
I enter and find the anaesthetist setting up in the room. Veronica’s her name. She normally works with Andrea in the pharmacy, sometimes also on the wards as an enfermeira.
Veronica looks a little nervous.
‘Have you done this before?’ I ask her.
‘A few times,’ she says, meekly.
‘What training have you had?’
‘One of the other doctors showed me,’ she says. ‘And I use this chart on the wall.’
‘What anaesthetic do you use, Veronica?’
‘Ketamine.’
‘And what else?’
‘Just ketamine,’ she says. ‘We only have ketamine.’
This is a problem. I’ve given the drug in emergency departments as a sedative and painkiller for minor procedures, and vets use it widely for surgery on animals. It’s an illicit party drug, too; Special-K, it’s called, taken for its dissociative and hallucinatory effects. But for use as the sole anaesthetic, in open abdominal surgery? I’m not convinced.
Roberto’s here. Sergio had called him earlier and now takes me to see him. He’s squatting in the doorway of a small shed behind the adults’ wards, watching something simmering over coals at the centre of the space. He looks up.
‘Novo Doctor,’ he notes unenthusiastically. He returns his attention to the coals.
‘How are you, Roberto?’
‘Bom.’—Good.
‘Good. Have you seen this woman?’
He nods, watching the coals.
‘And?’
He thinks it’s appendicitis, he tells me. I tell him I agree. He says nothing.
‘So what now?’ I ask.
‘We will take it out.’
‘Okay.’
He stares quietly at the coals.
‘When?’ I ask.
‘Soon.’
‘Okay.’
Another awkward pause. Sergio walks off.
‘Uh, have you done many of these appendicectomies before, Roberto?’
He stares at me, saying nothing.
‘Is that a yes?’
He continues staring. I take it as a yes.
‘Good,’ I say. ‘So, do we do it now?’
‘As soon as the steriliser has finished,’ he says.
‘Sim. Okay. But what steriliser, by the way?’
‘This one.’
‘Which one?’
He nods towards the large pot simmering above the fire.
‘That’s the steriliser?’
‘An autoclave, Novo Doctor,’ he corrects me. ‘Sim. This is an autoclave.’
Jesus Christ! Our steriliser is a pot on top of a fire?
My anxiety levels ramp up as he asks me how I thought we’d cleaned the instruments, but I really hadn’t considered it at all, hadn’t needed to until now. But that’s the least of the issues, just the start of it, because an hour later we’re standing in theatre, scrubbed and gowned, only an iodine-bronze square island of the young woman’s belly visible below us and the rest of her covered by a sea of sterile green drapes, when Roberto turns to the woman’s husband—the husband’s in theatre, too!—to ask him for permission to proceed.
‘Sir,’ Roberto says. ‘We are going to start cutting now, okay?’
Sofia had forewarned me about this, although seeing it is no less surreal. The patient’s husband is sitting not far from us, on a wooden stool; a farmer, dressed awkwardly in green surgical scrubs, about to watch us open his wife’s belly. ‘It’s a security thing,’ Sofia had explained. ‘It’s important the family know exactly what’s going on in theatre, in case something goes wrong. They won’t operate without the relatives there.’
Four others are crowded into this room, too. Veronica and her enfermeira assistant; Agostinho, the surgical assistant; and Andrea, who’s kindly offered to help me.
The husband smiles, nodding his permission to begin.
Roberto lifts a scalpel from the tray of steel instruments to his side, then re-examines her belly and feels the anatomical landmarks. Satisfied, he makes a firm, straight, midline incision below her navel. The layers of her abdominal wall cleave neatly under the pass of his blade; black skin, yellow globules of fat, beef-red muscle, each in turn. Roberto pauses briefly to allow Agostinho to tie off oozing blood vessels, then opens the abdominal cavity itself with a pair of scissors. I feel a little easier about my decision. He seems to know what he’s doing. Gently, he slips the gloved fingers of his right hand into her abdomen and feels around for a moment. He removes his hand and extends the incision slightly, then re-explores the cavity and retrieves a loop of bowel.
‘Her appendix,’ he states, pointing out the finger-like diverticulum. He reinserts his hand. Kissing noises fill the air as moist organs slide against each other, sloshing and slurping while he probes. ‘Her ovaries,’ he declares next, pointing to the relevant structures.
I nod in agreement.
‘Which ones do you want us to take out?’ he asks, voice somewhat muffled by his surgical mask.
‘Sorry?’
‘Which of these, Novo Doctor, do you want us to take out?’
‘Say what, Roberto?’
‘Her appendix, Novo Doctor, or her ovaries? Which would you like me to remove?’
Did I just hear wrong? I look to Andrea, who’s standing beside Veronica, but she’s equally wide-eyed, which only confirms it.
‘You serious, Roberto?’
He is.
My low-grade sweat of background unease shifts gear into a full-scale tropical deluge. ‘You’re the surgeon,’ I stammer. ‘This is your decision, no?’
It traditionally is.
‘I’m not a surgeon,’ he says. ‘You know this.’
‘Are you kidding me?’
‘I’m a surgical clinico. I do the cutting. You are the doctor, so you must decide what her diagnosis is, and what is normal or not normal in her belly. Now, are you happy with her appendix and ovaries?’
The words resonate in my head like a guilty verdict being delivered in a bad courtroom drama. Roberto drops a clamp back onto the tray; it clangs, bounces, echoes like a judge’s gavel and I can’t believe what we’re doing in here. Christ, it’s hot in here—Andrea, is it hot? This surgical garb is killing me. I want to adjust my mask, I need a little air. My God, Andrea, what the hell are we doing in this town! I glance around the room and try to gather my thoughts as I look to the husband, his face one of simple humility as he stares back, implicit in his expression the enormous trust he’s placed in us. Beside me is Agostinho, comfortable, relaxed, adeptly tying off oozing vessels; watching me from across this open belly is Roberto, wearing the confidence of a man relieved of the burden of decision-making for the time being. To my right, Veronica’s sweating as she corrects the position of the simple plastic Guedel device in the patient’s mouth to help her breathing—like a big plastic straw, really—but the patient begins to gurgle so Veronica tries again, then introduces a suction catheter to the patient’s mouth to clear the airway secretion, and now she’s hopping—Andrea, she’s fucking hopping!—and a loud clank commences beneath the table so I drop my head to look below and see her stomping energetically on a small metal foot-pump to generate suction for the tube. This is utter insanity! I want out, we need to close this woman up as soon as possible but gleaming ahead of me on a bronzed belly is the soft whiteness of her two ovaries . . .
‘Uh, my God, Roberto,’ I stutter. ‘Her ovaries look completely normal. Let’s leave them in.’ I’ve assisted and watched enough operations to know what normal looks like, and her ovaries look fine.
Roberto agrees. ‘Then we will just remove the appendix,’ he states.
What—we’re bargaining for body parts now?
‘Hang on, Roberto. Let’s look at it again.’
He gently returns the ovaries via the incision and isolates the appendix. Although rupture is not imminent, it’s definitely inflamed. I agree with Roberto—we should remove it. He nods and turns to address the patient’s husband, who’s still sitting on the stool against the back wall. ‘Come here, sir,’ he says. ‘But do not touch anything.’
The man approaches and peers over Roberto’s right shoulder. Roberto lifts the small, finger-like structure as the husband regards the tissue with a detached fascination, not in the least bit squeamish. I’ve seen medical students faint over far less—and this is his wife! The husband nods his approval.
‘Good. You can take your seat again, sir,’ Roberto tells him, and that’s where the man stays: on his stool, quietly, in his scrubs, watching two strangers debate the fate of his wife’s organs over her open abdomen.
Roberto then performs an appendicectomy—not the fastest, but more importantly a competent one. I’m immensely relieved. The three of us assist with closing each layer of the abdominal wall, then dress the wound and carry the woman to Intensivo. The ketamine wears off quickly.
The husband’s thrilled with our work.
‘You did the right thing, Novo Doctor,’ says Roberto, as we head to the side room to get changed.
I nod, still rattled by what I’ve seen.
‘You did,’ he repeats.
I sincerely hope so. More, I hope that the young woman recovers. And that we never, ever, have to operate on someone again.