9. WHAT APPENDIX?

In the whirling, dusty wind that blows through town these mornings, hundreds of people gather at our compound entrance.

‘I want to make sure we are clear,’ states Pascal, addressing the log team assembled near the gate. ‘We need to keep this line moving. There are far more here than we planned for, so remember—each person gets one blanket, one bucket, one piece of soap, and a packet of high energy biscuits. And only the widows, elderly, and disabled. Okay? No one else receives anything. No exceptions. There won’t be enough to go around otherwise.’

We’d only recently planned this handout. An excess of certain items had been found during a stock-take by Pascal, and we’d decided to arrange a free distribution rather than give it to the local Administration when we leave. And so it begins. The gate opens and barefoot elderly people, those with old injuries, and single mothers with children wrapped to their backs like surprised little starfish begin filtering through, taking away the packages one at a time. The poorest of the poor, in a country where more than half the population live on less than a dollar a day. The first wheelchair I’ve seen in Mavinga passes by, too—a man with no legs being pulled backwards in it by his friend, the wheels long since having shed their tyres—and by late morning the heat is oppressive, the crowd no smaller, yet still they stand quietly. Still they trickle past the front of our storage tent, one at a time, and carry off their packages.

‘The people thank you!’ says the King of Mavinga, who’s seated in a plastic chair at the end of the table. I’d not met him before (I didn’t even know Mavinga had a King!) and the man couldn’t be further from the stereotypical image of an African leader. Not to my mind, at least. Dressed in off-white sports jacket and grey pants, he’s a diminutive, grey-haired elderly man, speaking softly and smiling to all as they pass him. Toyota says he’s a genuinely respected leader, democratically elected to the role by the sobas, the traditional heads of all local villages, and is empowered to deal with traditional issues like land and livestock disputes. The appointed Administration, on the other hand, representing the MPLA government in this UNITA town, are nowhere to be seen.

But the King, affable as he is, is unwittingly adding to some sense of guilt I’m feeling about this. ‘I thank you, too,’ he says, ‘for what you are doing in Mavinga. The people are very grateful’—which frankly embarrasses me. Because please: a bucket? A scratchy blanket? There’s little doubt that our gesture is token, we know this, but what worries me is the faint whiff of neo-colonialism: wealthy white people handing out freebies to impoverished Africans.

Our living conditions have previously prompted discussion of this issue among us expats. Ours is a relative island of wealth out here, a bastion of laptops, generators and imported food, and Pascal believes strongly that we should eat only what locals do. Tim doesn’t. He’s spent enough time on these missions, he says, having turned his back on a lucrative career in business, to accept that a little luxury is small recompense considering what we’ve given up to be here. Andrea and I are inclined to agree with him—if frozen chicken, South African porridge and a few chocolate bars are what it takes to keep us happy, so be it.

As for this distribution, we’d all rather be teaching or providing health care than giving handouts, but I’ve seen inside the local huts. A pot, water container, several blankets and straw baskets are the sum total of most people’s assets, and few here have the capacity to earn money. The hundred Angolans employed by this project are almost the only group of salaried workers in town, so far be it for me to scoff at these packages.

The crowd gets no smaller. For every one person who comes through, two more gather in the distance. By midday, young men begin to force their way in. ‘Why do we get nothing?’ they shout. ‘Why do you ignore us?’

Our outreach nurse is at the gate, allowing entry only to those on the lists made by each soba. He grabs the megaphone and re-explains the criteria as the organisation’s obsession with strict impartiality becomes clear to me. A few of the men arc up.

‘This old man is not even Ovimbundu!’ yells one. ‘Why are you letting him through? He is Nganguela! Is this not an Ovimbundu area? What of us?’

‘It is based on necessity,’ repeats our outreach nurse. ‘Not tribe. We are here for those that need it most.’

But the criteria are largely redundant. Everyone here needs it most.

‘My mother is too sick to walk to your compound!’ declares a muscled young man, ‘so why can I not take one for her?’ Another pushes his way to the front, shows the long scar on his chest. ‘This is an injury from the war! I too have an injury, so why can I not come through? Just because I am not missing a leg like that man, I cannot get help?’

The prospect of fighting seems possible. Ethnic tensions exist in the region, though this is the first time I’ve seen direct evidence of it. (Only months before I arrived, a person had been killed here when riots broke out over political differences.) For now, younger men become more agitated, and faces of those who’ve clearly already received goods begin to reappear. The team at the registrations table shuffle confusedly through their loose sheets of paper, but no one has any identification—

‘Are you Joseph Lumumba, from bairro Seixta-Feira?’

‘Yes, I am him!’

—so people say what they want anyway. Verifying it is impossible. Those most in need are getting pushed to the back, while those most aggressive will get their goods, one way or another. The logs soon abandon the criteria and hurriedly give out everything, and I wonder now what will happen when we shut this hospital, retrench a hundred staff, and try to fly out equipment when all these people watching it have nothing left to lose . . .

A fortuitous time for me to have to return to the hospital.

• • •

A complete change of scene over the road. The front hospital yard is unusually tranquil (most are at the distribution), but I hear moaning from the small room that Roberto and Agostinho use as Surgical Outpatients. It can mean only one thing. The Mavinga Dental Clinic is open.

‘Morning, Agostinho,’ I say, stepping past a handful of anxious-looking patients near the door. ‘Everything okay?’

He looks up. He’s standing behind a young man, leaning over him with one hand gripping firmly across the patient’s forehead, the other prying out a tooth with dental pliers. Hard to tell who’s sweating more.

Sim,’ he replies, stopping. ‘Why would it not be?’

The patient looks immensely relieved by this sudden reprieve. Somewhat dazed, he explores his mouth with a finger; disappointment washes over his face as he discovers the offending tooth still in place.

‘No reason,’ I say. ‘Just taking out the one tooth?’

‘No,’ he replies, and continues pulling, forearm trembling with effort. ‘A few,’ he groans.

‘Has he had local anaesthetic?’

Novo Doctor,’ laughs Agostinho, stopping again. ‘I do all of the dental work in Mavinga. What do you think?’

A half-empty vial and clean syringe sit on the nearby tray, so I presume so. I only hope it was an adequate dose because Agostinho now ups his effort, straining hard, and something’s going to give—pliers, tooth or Agostinho’s shoulder, I can’t yet tell—and I wonder what the group of patients sitting outside are thinking. I’ve seen none running into the distance on any of these Dental Clinic days, so I suppose they’ve accepted this as the price of free treatment.

‘You seen Roberto this morning?’ I ask.

Sim.’

‘Where?’

‘At the steriliser. Preparing for surgery.’

My stomach knots.

‘Why do you look so worried, Novo Doctor?’ chuckles Agostinho, and I only smile, shake my head unconvincingly, and lie that I’m not. But really I am, because I recall the roosters wandering out of theatre this morning, the car battery, that suction pump, the anaesthetic, the—

‘Why do you look so worried, Novo Doctor?’ chuckles Roberto, standing before the iodine-bronze belly of the young woman in the theatre only an hour later, and I only smile, shake my head unconvincingly and lie that I’m not. But really, I am, because—

‘Sir, you will need to take that hat off,’ Roberto tells the woman’s husband, who’s sitting in the far corner. (Which is a part of the worry, Roberto.)

The man shuffles outside, returns a moment later.

‘We ready?’ asks Roberto, clinking his surgical instruments into arrangement.

The husband nods.

‘Veronica?’

Veronica nods, nudging her foot-pump into position.

Novo Doctor?

I grimace.

Roberto then grasps his scalpel and neatly divides the layers of her abdominal wall; skin, fat, muscle; then gently snips the pearly-blue peritoneal lining of her abdominal cavity with scissors. Air gushes into her belly as he stretches the opening. ‘We should train you to be a surgeon, Novo Doctor,’ he says, reaching for retractors.

‘That would be good,’ I say, rivulets of sweat already tracking their way down my back. A surgical gown over thick cotton scrubs make this small room unbearably stuffy.

‘Tell me something,’ he says, peering over his mask. ‘We have been wondering about this. What kind of doctor does not know how to operate?’ He pauses as Agostinho ties off a bleeding vessel—a time-consuming process, with each oozing vein or spurting arteriole having to be carefully closed with dissolvable sutures. A diathermy machine would cauterise the same within seconds back home.

‘The others sent here could operate?’ I ask.

‘The good ones,’ he says. ‘Not all. But the good ones could.’

‘Most doctors in my country can’t operate, Roberto.’

‘No?’

‘Not at all. Only surgeons. Most of us use only medicines.’

Roberto chuckles. ‘And how then is a doctor to cure his patients if he cannot operate?’ he muses.

‘We see different diseases, Roberto,’ I say, explaining that we’d have used scans and blood tests to diagnose this woman’s condition well before surgery, and that we’re usually able to treat patients adequately with medications or less invasive procedures.

He opens her abdominal cavity further, sliding his right hand into the incision.

‘We’ve also never had a war,’ I go on, hoping that the Portuguese coming out of my mouth correlates with what I intend to say. I frequently have to stop and try to find a different way of explaining something. ‘In our hospitals we see mainly older people with problems like heart attacks, diabetes, or emphysema,’ I tell Roberto, and as we talk it strikes me that I’ve not seen a single person here with these conditions. My medical background would have to be the complete opposite to Roberto’s. His, an education during the war by South African military surgeons, dealing largely with severe, acute problems in fit young patients, a large proportion of whom would urgently have needed surgery; mine, an education in the context of chronic illnesses associated with affluent lifestyles and an ageing population. For all that I’m learning here, there’s little I’ll be able to apply to an urban Australian hospital. I’m going to be wholly out of touch when I return.

‘So, O Novo Doctor works in emergency centres?’ Roberto asks.

‘I do. Emergency departments.’

He looks again at Agostinho as he fishes around the patient’s pelvis. ‘An emergency doctor,’ he notes in a playful tone. ‘Imagine that: a doctor for emergencies, but one that can’t operate in emergencies!’ He ponders this as he shakes his head again. ‘Never mind, Novo Doctor,’ he says, sifting through loops of bowel. ‘You do work well with the children here, this is true. And the adults’ ward is doing fine. Sabino tells me too that things are changing in the malnutrition ward, that you are writing clearer protocols—and in Portuguese? I like the idea of this. You know that I was not a big supporter of this antifungal business you pulled—Eh! To experiment on our people!—but the children are doing okay. This is a good thing, Novo Doctor. And this chest tube you put in the other night? This I don’t do.’

It was another dramatic night call. A man had arrived with a punctured lung and dislocated ankle following the first road traffic accident I’d heard of here: a cart rollover at the riverbank. The ankle was easy enough to clunk back into position, but his chest was the bigger issue. To allow leaking air around the injured lung to drain (necessary for it to re-inflate) I inserted a plastic tube via a small incision between two ribs at the side of his chest wall. This I’ve done in Australia—although not without an X-ray, and never without familiar equipment. So we improvised. As per instructions in an old textbook, I cut the finger of a surgical glove at both ends, then fixed one end over the end of the chest tube, the other hanging free. The collapsible lumen of the free end of the finger has the effect of a one-way valve, allowing air to escape but not re-enter his chest, and had worked perfectly well. At least until we found a better solution in the pharmacy the following day.

Roberto looks to Agostinho. ‘You have done them?’ he asks.

Agostinho mumbles something, but I struggle to understand what the man says. With or without his mask.

Roberto chuckles. ‘I dare say that you did it well, Novo Doctor,’ he says. ‘Like a doctor should. But still, we are going to need to train you to be a proper doctor before you leave—a doctor who can operate on his patients. One who can really treat people.’

The others nod.

‘Now, Agostinho. Let O Novo Doctor tie the vessels. We must not delay his teaching any longer. Pass him the sutures!’ Roberto locates the patient’s ovaries and pulls them to the surface, ending our conversation, heightening my unease.

The issue of surgery continues to remain problematic here, particularly decisions about which patients we should operate on. Our mandate is clear—that we’re to operate only for life-threatening conditions that we can realistically manage—but a significant confounder remains. Namely, how can we know whether a condition is life-threatening if we can’t diagnose it? It’s a classic Catch-22: the only way to be sure in many cases is to open patients up and look, yet the only reason to open them up is if we’re relatively sure of what the condition is.

We’ve performed two operations since that appendicectomy, a below-knee amputation and an emergency Caesarean, and in both patients the need had far outweighed the risk. Often though a woman will present to the hospital with non-specific pains and actually insist on surgery—the Rolls Royce of medical care, by public perception. The probability is that their condition is benign, although we can’t always be certain. No less when the patients say that they’re getting worse, and the family insist that they’re dying, and partners get upset, and the rest of the ward rally around them to say that we must operate immediately. How then to be objective? I can’t reassure them with a scan. And opening them up to look, with the risk being that they then succumb to any of a thousand complications, is clearly unjustifiable. As is waiting too long—they could then deteriorate. It’s immensely difficult, a balance between being cruelly hesitant versus dangerously over-zealous, so Roberto and I debate each case (albeit a little more amicably these days). That said, the issue remains the bigger difficulty on the wards.

—But right now an ovary is demanding attention, glistening under the glow of the lamp; car batteries and ketamine will not last forever.

‘You see this?’ Roberto asks.

I nod. Two abnormal cysts blemish the gonad’s milky surface. One’s about a centimetre in size and filled with blood; far from a life-threatening condition, but we at least have a likely explanation for her pain.

‘You happy if I remove these cysts?’ asks Roberto.

‘You happy to remove them—?’

‘Sir,’ he calls to the husband. ‘Come here, please.’

The husband gets up and peers over, the affected ovary held up for his scrutiny. Another non-squeamish relative!

‘We will take out these two problems,’ says Roberto.

The husband nods.

Roberto neatly excises the two cysts and sutures closed the raw surfaces. He leaves the rest of the ovaries untouched and carefully reintroduces them to the cavity, then demonstrates her appendix.

‘We can take this out as well now, okay?’ he asks me, in what sounds suspiciously like a rhetorical question.

‘Uh, why?’

‘We always do,’ he replies.

‘It looks normal, Roberto.’

He shrugs.

‘Do we agree?’

He rolls his eyes towards Agostinho.

‘Let’s leave it in,’ I say.

He sighs. ‘Novo Doctor, listen to me. We always take it out. In Mavinga, always.’

This is probably true. Surgeons routinely remove the appendix once they’ve opened the belly, even if it looks healthy, to avoid future confusion from the scar. But this woman’s appendix is normal. More importantly, the clunk of the suction device has begun as the patient’s saliva accumulates; Veronica’s leg is working hard. Better to finish up, I tell Roberto.

He’s not convinced. He mumbles irritatedly to the others, perhaps seeing this as an affront to his skill. Turning to the husband, he makes a somewhat loaded query. ‘Sir, would you like us to take her appendix out? If we don’t, she could get a severe infection.’

Replying that removing it seems like the best thing, the husband is sold. I’m not—and I’ve told them about not ambushing me in front of relatives.

‘Roberto, the husband is not the one responsible for that anaesthetic right now.’ I dig my heels in. ‘Explain to him that the appendix looks completely healthy. Let’s just close her up.’

Novo Doctor—’

The theatre door opens suddenly. A clinico puts their head into the room. It’s Sabino, and he’s looking flustered. ‘We need you in Nutrition, Doctor,’ he says. ‘Quickly.’

‘Now?’

‘Yes.’

I pull off my gown and follow him out, turning back to Roberto as I leave. ‘Close her up please, Roberto. Leave that appendix!’

Sabino leads me to the Nutrition ward, where a new admission is battling away. We insert a drip and initiate treatment, stabilising her before moving her to Intensivo. The surgical patient should already be in here as well, starting to wake up, but she’s not. No one has seen her.

There’s a problem.

I run back to theatre. She’s still on the table, unconscious. The team are around her.

‘What happened?’ I call.

Roberto looks up suddenly.

Novo Doctor,’ he says, looking startled.

‘What’s the problem? Is she all right?

He holds my gaze with a surprised look. There’s no movement for a few seconds.

‘Roberto?’

I step closer. I can see the oximeter. It’s still beeping, and her chest is rising.

‘Roberto?’ I ask again.

There’s dead silence. Veronica shuffles awkwardly but Roberto says nothing. And really, as I look around, it’s clear he doesn’t need to. A pink object dangles from the surgical clamp he’s holding.

‘That an appendix?’ I ask.

The slow, acknowledging nod of the indisputably guilty.

‘I presume it’s her appendix?’

The nod continues.

‘Probably not much point in asking you to put it back, is there?’

Only a shake this time, as they ponder whether I’m serious.

• • •

Tim takes holidays in early August. Pascal covers his job, soon discovering the trials of dispensing monthly salaries in a region with no banks. Most of our hundred staff are paid different amounts (a hundred and eighty dollars per month for a junior guard, up to three hundred and fifty dollars for the older clinicos) so cash requirements must be anticipated, flown in, and securely stored beforehand. Small-denomination US dollar bills are insisted upon, although certain years of production won’t be accepted due to high rates of counterfeiting. For two days Pascal sits surrounded by stacks of bills, checking each one, re-counting, then paying the workers one at a time in the office.

‘But this dollar bill is 1982, Chefe,’ says one of the guards, opening his envelope onto the table. ‘And here. This five-dollar bill is 1997. I cannot take it.’

Another re-enters the office. ‘All my ten-dollar bills are from 1996,’ he says. ‘They will not accept this in the market. And this, look—this dollar bill is a little torn. This also I cannot use.’

So Pascal, who’s dealing as well with a faulty water pump and lack of spare parts for it, is worn. Andrea and I also have a difficult run—two stillbirths and the death of two children from malaria within ten days—and with only two others to look at during mealtimes, cabin fever sets in. In a telling indictment, a light-hearted debate turns into a days-long argument between Pascal and me over whether glass is structurally a solid or a liquid. Meanwhile, Andrea, whose experience in Brazil was nothing like this, and who can still neither manage to get Dominga to use less oil nor the midwives to check on the newborns regularly, wonders aloud what she’s signed up for. Conversations grow old. So too the food. Someone’s going to crack. I see Pascal sprinting back from the airstrip one afternoon, breathless, ranting in half-sentences as I leave the hospital. Seems he’s the first.

‘YOU OKAY?’ I yell.

He shouts back, waving his arms.

‘WHAT?’

He yells something about a flight.

‘PASCAL?’

‘THE MISSION!’ he screams. ‘FOR THE MISSION . . .!’

He arrives at the gate, babbling about a plane.

‘What plane? Our delivery’s not due until next Tuesday, no?’

He’s ragged and wide-eyed, now gushing about Europeans.

‘What do you mean, Europeans?’

‘That group—visiting the mission,’ he pants back. He says a plane landed while I was in the hospital.

‘What—when?’

‘Before. The far end. They’ve gone to town. But they’re coming here soon. We need to change! Fuck—we must clean!’

I laugh at his suggestion and steer him towards the dining room, reminding him that Tim said this would happen. It’s been over two months since any of us have kissed anyone—hell, hugged anyone—and it’s adding to the strain. There’s no end to it in sight either, because relationships with local women are out of the question. Other than being of dubious ethics given that we’re the largest employers, and perhaps also seen as the only prospect of a ticket out of here, cultural idiosyncrasies make it difficult—and dangerous: unwittingly inviting an ex-soldier’s love interest back for coffee presents a security risk to the entire project.

Pascal’s insistent. He says there were four blondes on the planes. A few others, maybe, and some guys, too, but definitely four blondes. I laugh and tell him we’ll take the night off—he’s clearly been working too hard—but he’s anxious, pacing restlessly, and before I can say anything more the guard leads them in, four blondes, My God, late twenties, fair-skinned and

I can’t speak. Connections between brain and mouth dissolve as high concentrations of disbelief and hormone flood through me. Pascal and I try to find chairs, to straighten our T-shirts, to not—

I stand. Then sit. Then stand again. I shake their hands—is that what you do these days?—but they’re European so I opt for a kiss on the cheeks instead. No–they’re English. I shouldn’t have done that! The English aren’t like that! They introduce themselves one at a time but the names fail to register, their lips move in slow-motion as my eyes zoom in tightly, their Vaseline Lip-Care SPF30 looking like Max Factor’s sexiest lipstick ever and now the lights of our dining area dim as one embraces me, and we embark on a dizzying whirlwind of passionate dancing, laughing, carefree, just a couple of crazy kids in the night . . .

Get a grip.

Pascal talks. Accommodation is offered for indefinite periods of time. Tours around the compound are insisted upon, countered by better offers of a ride in the mine-proof car. Wait—the river! Jesus, Pascal—wait until they see a sunset down there! They’ll melt when they see that sky, those ox carts and the kids playing, and we can show them what we call Oxford Street, that short stretch of road where the stalls sell chewing gum and biscuits and batteries—they’ll love it! And my mind darts back to that European poll I’d heard of years ago in which being an MSF doctor had been ranked as the sexiest role on earth, and admittedly it may just be a myth propagated to recruit volunteers but this could be my chance to live it! Right now though Pascal and I are all over the place, two sixteen-year-old boys at a first high school dance, deliriously excited but far too nervous to do anything about—

Andrea walks in. Composed. A little surprised, but sane. She plays the attentive hostess and offers them drinks and invites them to stay for dinner. Pascal and I excuse ourselves to find Vasco, our guard, and ask him to build a bonfire and kill a goat for dinner, which he obligingly does, and I ransack my bedroom for a T-shirt that’s remotely presentable, but the search is futile—everything hints of some or other incident at the hospital. We beg Dominga to stay late and make some salad and rice, and not long afterwards we all gather at the fire, carry our dining set-up outside and place it under that veil of stars. It couldn’t possibly get more romantic.

‘How long are you guys around for?’ I ask, as we fill our plates with goat. The girl across from me smiles coyly (coyly!), runs a hand through her hair as she tilts her head and smiles. Is she flirting? A thousand shudders run down my spine.

‘For a few days,’ she says. ‘Actually, for four days near Mavinga, but we have two weeks in Angola.’

Four days of this! Pascal and I can’t stop beaming as we try to make small talk with them. Tim will never hear the end of this—what a time to have taken his holidays! We go on, delving a little more into each other’s backgrounds.

‘And exactly which organisation are you here with?’ asks Andrea.

‘A Christian aid organisation,’ replies one.

Pascal looks up sharply.

‘Uh . . . and what do you do with them?’

‘Oh, we’re spending some time with the mission we support near Mavinga,’ says the girl opposite me. ‘Documenting their work, interviewing people, that sort of thing.’

‘You’re not staying in Mavinga, then?’ I ask. The mission is where our burns patient, José, came from, and is about an hour’s walk from town.

‘No. Just with the mission.’

It’s not ideal, but things are still salvageable. We’re not permitted by MSF to use the road that heads towards that mission, but our guest’s organisation allows them to use their project’s four-wheel drive. They can visit us.

We talk a little more of their work. I ask how they got into this field, and finally drop the burning question—burning for Pascal and me, at least: ‘Do you have to be a, uh . . . a Christian to do this sort of work? I mean, to work for your organisation?’

Pascal’s stopped chewing. His eyebrows hover somewhere near his hairline.

‘You do!’ comes the answer. ‘I mean, it’s not a written rule, but all of us here are committed to the Church,’ says the girl who’d been flirting. ‘We’re Born Again, actually.’

Andrea kicks me under the table. The irony of three men being stuck for months with only one woman, who’s both attractive and highly dateable yet far more interested in the Church than any of us, is not lost on the team. Nor the fact that the issue has just repeated itself.

‘My fiancé is actually working for this organisation too,’ adds the one beside Pascal.

Andrea suppresses a laugh.

‘And my husband used to work for MSF as well,’ adds a third. ‘In fact, that’s how we met.’

Andrea’s lost it. Pascal takes a renewed interest in his food. ‘Fascinating,’ he lies, and we instead go on to spend the night chatting of approaches to development, the weather in London, and various other things. Not an unpleasant night by any means, although not how we’d have scripted it. And in fairness to the women, I’d also have professed to be both engaged and born again if I’d found myself in the company of Pascal and me in our present state. Our deodorant ran out weeks ago, razors not long afterwards.

So it seems then that fabled stories of passionate love affairs in the field are to remain just that: fabled stories. Unlike others in town, my mosquito net is to witness no romance beneath it, but some respite is ahead. In two weeks I fly out for my holidays, so the prospect of at least some change in this routine looms large. It’s not a moment too soon, either. The tensions born of living on top of each other are building, and I need to not be on call, to not talk about MSF, and to sleep through just one night without waking at least once, worried by the prospect of being summoned to watch yet another child taking its last breaths.

I need a break.