The roar of the plane, and Andrea’s suddenly looking worried. Not without reason. I’m off for holidays, which leaves her as the sole medical expat for ten days.
‘And that woman with the breast cancer?’ she asks, as we race to finish an early ward round.
‘We’ll have to put a bed in the tent for her,’ I say. ‘Or move her to Intensivo.’ The other patients on Maria’s ward have been complaining about the smell of her ulcerated breast tumour, and she wants to get away from them.
‘And Manuel? What am I going to do about him?’
A good question. Manuel’s on a roll this morning; he gave two litres of IV fluid to a young child for reasons unknown, and hasn’t written any legible notes. He’s all over the place lately, despite the extra time we’re spending together.
‘Keep him off nights,’ I say. ‘And out of Intensivo. And the kids’ ward. Don’t let him start treatment on anyone without calling you. Wait—maybe you should keep him out of the hospital altogether. Get Sergio to adjust the roster and give him time off.’
‘And the guy with the burns—?’ she asks.
The pilot’s waiting. I need to go. I feel bad leaving Andrea as the only medical expat here; she’s in for a week and a half of sleep deprivation covering this place alone, but there’s no alternative. Of some consolation, she’ll take holidays right after me.
I run home to grab my bag and say goodbye to Dominga. Tim and Pascal are already unloading food and mail on the airstrip, the paediatric ground crew buzzing excitedly around the plane. ‘Don’t let the team down,’ warns Tim, who only recently got back from holidays in Cape Town. ‘Make sure you do us proud. Did you email the Red Cross girl?’
I nod.
‘Don’t you dare come back without stories,’ he says.
‘Yes,’ says Pascal. ‘We need stories. Good stories.’
I promise nothing as I farewell them, joining the handful of de-mining technicians in the cabin of the twenty-seater World Food Program plane that’s passing through town today. The propellers soon roar, high fives are exchanged and a warm Castle lager passed around, and everyone’s thrilled to be taking a break from Mavinga. No matter the destination.
• • •
Luanda is mine. The Angolan capital, sprawling along a picturesque stretch of foreshore in the north-west of the country, that strikes me as a poor, rundown version of Havana: a steamy tropical city with a distinctly Latin flavour, its waterfront Marginal lined with coconut palms on one side and tired colonial-era buildings on the other. Spared much of the fighting during the war, the old buildings of this once-beautiful colonial outpost, dubbed The Paris of Africa in its heyday, crumble from neglect rather than mortar damage these days, while new ones are hoisted skywards by the cranes of Chinese construction companies.
It’s a huge city, and as big a paradox. Hemmed in by vast, crime-ridden shanty-towns into which half of Angola’s twelve to sixteen million people are crammed, and through which street kids and stray dogs pick at decomposing mounds of rubbish, it’s an impoverished, dilapidated metropolis; yet at the same time it’s ranked as the world’s single most expensive city for expats. Rent is around ten thousand US dollars per month for an average house in a reasonably central suburb, and all but the most basic foods need to be imported. Trendy nightclubs exist, too. Plenty of them, not far from the slums, situated along white sand beaches that overlook a horizon sparkling with deep-sea oilrigs, behind which those show-stopping tropical sunsets glow. Inside, sheer hedonism: well-heeled oil-workers and foreign advisors rub shoulders with attractive mulatto prostitutes over fifteen-dollar cocktails; outside, the larger reality: a rabble of scruffy kids will watch your car for a few cents, while os mutilados—Angola’s disabled, known literally as ‘the mutilated’ and estimated to be about ten per cent of the population—pass by with their crutches, prosthetic limbs, or various other injuries. Two days is enough for me.
Unable to leave Angola due to visa issues, I take a commercial flight to Lubango, a smaller city in the central highland region where MSF recently ran a cholera treatment centre. Granted, that’s not a traditional selling point for holiday spots, but the town is tranquil and picturesque, nestled among the first hills I’ve seen in months and possessing as well two supermarkets, a dozen restaurants—and grass! Lush, green lawns—something I’d entirely forgotten could exist. This was once the heart of Angola’s lucrative agricultural region, and in the early 1970s more Portuguese migrants lived in town than Africans. However, along with the rest of Angola’s half-million European residents at that time, almost all fled at the outbreak of war, mostly for Portugal, Brazil or South Africa.
I drop my bags at the MSF guesthouse and head immediately to find Stephanie, a Red Cross delegate I’d met on my way to Mavinga. Her house is on the outskirts of town and is a paradise compared with the MSF offering, possessing a satellite TV, hot shower, and a toilet that goes whoosh—all the persuasion I need to wander no further. Not that Stephanie herself isn’t reason enough. She’s a brown-haired Austrian woman who heads a team working to reunite Angolan families separated during the war, travelling the country to create databases to help match people with their families, then arranging transport when confirmation is made. And she’s beautiful. And great company. She shows me around, swaps books and cooks wonderfully, and for my last weekend arranges a camping trip.
In two LandCruisers we head off with a group of de-mining friends of hers, driving down the steep face of the Serra de Leba, where the high plateau of Angola’s centre drops to kneel suddenly at the strip of coastal desert that runs the length of the country. Driving south-west across flat gravel plains, we pass heavily eroded sandstone cliffs and rocky bridges, and arrive finally on a long, desolate honey-coloured beach that merges further to the south with Namibia’s famous Skeleton Coast. Our accommodation for the weekend is three tents on the sand, and our nearest neighbours are the residents of a small fishing village, where salted fish are laid to dry on wooden racks, and where the features of the children, who’re noticeably whiter than their landlocked compatriots, hint at past stops by foreign sailors.
It’s a blissful couple of days. We do little; stroll along the beach, make a fire, sip wine under the night sky. Not surprisingly, the de-miners make for interesting company. Two are middle-aged Italians who’d done time in the military, and the third, a younger Brit, is a professional opera singer who’d once read an article on de-mining. ‘Never even touched a gun before,’ he says, but he’d thought that this would be a great way to contribute. It sounds like it. They tell me of the thousand known minefields still awaiting clearance, and of the hundreds of suspect roads. After another bottle of wine they begin talking of backfiring detonators, of individuals who’ll re-mine a strip and extort money from drivers before revealing the location of the device, and I find it hard to believe that three months ago I was in Melbourne discussing interest rates. How to explain all this when I get back? Or any of it, for that matter.
Andrea contacted me via Stephanie’s phone last week. I took the call with some trepidation (sprawled on the couch at the time, an entire box set of DVDs to still get through), no less when she told me they’d had a rough few days in the hospital. She needed advice, she said—there were big problems with the man with burns, and now a premature infant as well—and as she spoke, reminding me of it all, I actually found myself missing the place. I’ve now had the sleep-ins and hot showers I wanted, and spoken to other people. I’m ready to return.
Which is just as well: two days after the beach trip, the little Cessna bumps me back towards the airstrip again; and this time, as I regard the somnolent bustle of this dusty little town from above, three months since the first time and my Portuguese now at the vastly improved level of a six-year-old native speaker’s, I feel none of the fear I’d known previously.
Just contentment.
• • •
‘Hey Novo Doctor,’ exclaims Sabino. ‘You are back!’
Seems then that this Novo Doctor tag is here to stay. Three months, no signs of its waning popularity.
‘Where did you go for your holidays?’ asks Senhor Kassoma, who’s passing by as I join the ward round. Everyone’s keen to know how things are going in the cities—many have relatives in Luanda.
‘So you didn’t visit your family?’ asks Sabino as I describe my trip, and I tell them that Australia is too far. I’d likely spend a week just flying there and back.
‘Impossible, Novo Doctor,’ laughs Kassoma. ‘Nowhere is that far!’
I sketch a rough map on the back of a patient’s chart, explaining the six flights via three continents it took to get me here. They laugh. ‘I do not understand,’ chuckles Kassoma, drawing a straight line between Mavinga and Melbourne, ‘why you would not just do this.’
So it goes. A pleasant digression as we stand outside Intensivo barely an hour after I landed, covering house prices in Australia (‘Eh!— they don’t believe it), the beach I’d camped on (‘Fascinante!’—they’ve never seen the ocean), and the dolphins I’d seen off their coast (‘Quê?’—they’re not sure what I’m talking about).
And the good feelings continue as we begin the round when Marco, a young boy on the kids’ ward, waddles clumsily to us in the yard. He’s now two months into his six-month course of treatment for TB, and clearly no longer malnourished. In fact he’s almost a little overnourished. His face is different, almost unrecognisably so, his hair even thicker and darker than when he’d arrived. He’d been another late-night call when his mum first bundled him in, his eyes half-closed in that frightening pre-terminal state of fatigue, so I decide that from now on Marco will be my poster-boy for why this can be the best job at times. It’ll be sad to finally discharge him. Not that there’s been any shortage of discharges lately; ‘Where’s that other patient,’ I ask the team, as we continue. ‘You know, the man in bed four?’
‘Oh, we sent him home,’ the reply. ‘We sent a few patients home while you were away,’ say the clinicos. ‘We did a little clean-out, because you sometimes keep people here too long, Novo Doctor, no offence, and people will just stay here forever if it is up to them. So if we didn’t know what was wrong, and they were not very sick, we sent them. But do not worry—they will come back to Outpatients.’
No discharge for Toto, though. He’s still here, still sitting beneath the floppy canvas door of his tent, not far from a patient who should definitely have been discharged: a man who thinks he may be in his eighties, who’s not sure but who definitely looks it, and who’s waving to us from the edge of the concrete steps. We’d inserted a suprapubic catheter—a rubber tube to drain his bladder, via a small incision into his abdominal wall—in order to bypass his blocked prostate, but that was well before I left. ‘Why’s he still here?’ I ask the clinicos, who reply that Our Old Father (a respectful title for the oldest person seen here these months) would like to stay a little while. He likes the food and the company, they say, and he’s not ready to walk home. So can he stay? And when we go over to say of course—hell, Toto’s been here for four years!—he proudly straightens his brown suit, holds up his bag of urine and smiles a toothless grin.
‘Look!’ he says, his face crumpling into a thousand little stories. ‘Look at this! The stuff just keeps coming!’—which is great because it’s both funny and touching, yet a little disgusting at the same time. And behind him the kids’ wards are running well, the protocols we’ve worked on for common conditions still on the wall, clear, being followed for the most part (I’m really getting a buzz on these rounds) and soon Senhor Kassoma calls me to see some patients he’d asked to return today.
Kassoma leads me past the two dozen people waiting for malaria tests near Outpatients (at least half of whom will likely test positive for falciparum, the more severe of the four strains of malaria), and into his office. We squeeze around the small plastic desk, alongside the first patient.
‘He has had this rash for many years,’ begins Kassoma, who two months ago rarely called me. He opens our dermatology atlas to a photograph. ‘I think it is this one here: onchocerciasis,’ he says. ‘This man lived in The Congo during the war. We do not see this in Mavinga, but maybe he got it there?’
The patient’s amused by the fact that we’re comparing him to photographs, which is great—I’d be frankly worried were I in his place. But we find a match. I agree with Kassoma that it’s the likely diagnosis, so we send the patient to our dispensary with a script.
Kassoma brings several other patients through over the following hour, a young infant being the last. The diagnosis is unmistakeable: hydrocephalus. An excess of fluid in and around the child’s brain has caused significant enlargement of his head, so much so that he can no longer hold it up. Mum cradles him gently. There’s nothing we can do for the condition; neurosurgery is the only option, and his mum looks devastated when we say as much. I ask Kassoma to explain that in Luanda or Namibia they may find treatment, but that they’d have to pay for it.
‘Not possible,’ he replies. ‘These campesinos could never afford that. No way.’
So, yet another patient passes through who would’ve been okay if they were born elsewhere, or with more money. But I’ve long had to accept that we’re in the business of providing the greatest good for the greatest number. This hospital already costs a million dollars each year to run; flying out specific cases for expensive treatments is not within our scope. A justifiable decision in principle, but a hard one to swallow at times.
I return to the wards, where a man with HIV/AIDS is our next patient. Paradoxically, as devastating as the war had been, the isolation imposed on this region has partly protected it from HIV. Fifteen per cent of neighbouring Namibians and Zambians are HIV positive, twice that number again in Swaziland, yet Angola has an estimated prevalence of only two per cent. This man is the first case I’ve seen here, but the relatively low rate means that there’s no treatment available in our region.
‘There are charities in Luanda that can help you,’ I tell him, in private.
‘This is too far.’
‘Can you get to Namibia?’
‘I have a card for Zambia,’ he says. ‘I lived there for years.’
‘Then you’ll have to go there.’
I apologise and write him a letter—a referral to no particular clinic in an unknown town, somewhere in another country. We give him antibiotics to treat opportunistic infections, and a box of condoms. I explain the importance of using them.
‘They are uncomfortable!’ he laughs. ‘I do not like these things.’
‘Do you understand what will happen if you don’t use them?’
He shrugs.
‘Listen: you’ll infect your wife. She will get this illness, and she will be sick too.’
He looks away sheepishly.
‘I’m telling you—you need to understand this. And if your wife gets ill, she may pass it to your children. Is that enough reason to use them?’
‘But having sex with these things is not good,’ he laughs. ‘It is like eating a sweet that is wrapped in plastic! It is not fun.’
‘Fun sex is not your priority at the moment. Their health is. Yours too.’
‘But she will know something is strange if I use them.’
‘Then tell her you can’t afford to have another child. Make up a story. But listen to me—use them! You have an obligation to protect your family.’
He takes the box, reluctantly, and wanders off to another country.
Things come unstuck after this.
• • •
Mid-morning, and we stand in the small side room that comes off Intensivo: previously a storage area, now the hospital’s only private room. I swallow the smell; José, the man with the severe burns, is lying naked on his back. His injuries are the result of a seizure that flung him into a cooking fire weeks ago (he’s an epileptic and has no treatment), and we’ve since removed the charred skin, exposing instead large patches of red-raw flesh. What he must have thought when he regained consciousness on that fire, I can’t imagine.
His wife is crouching in the far corner, and smiles solemnly at us. (They’re a strikingly handsome couple: she, big eyes, luminous coffee skin and fine, sculpted features; he, a young, bearded Denzel Washington). Roberto and Agostinho are changing his dressings. They pull gently at a piece of gauze, and José grimaces.
‘What are we giving him for pain?’ I ask.
‘Paracetamol.’
‘And?’
‘Sometimes ibuprofen.’
‘Nothing else?’ I ask. I’d use the same for a mild headache.
‘We tried the Tramadol when you were away,’ says Roberto, ‘but he had more seizures from it. And here—look—he scraped all of this open and was in more pain. So now we give a little diazepam as well.’
The combination would make him mildly sleepy at best. ‘What about the pethidine?’
‘We have ten doses left,’ says Sergio. ‘Andrea says to keep it for emergencies. She said he would use it too quickly.’
She’s right.
Roberto pulls at another piece of gauze. It’s stuck. He wets it with saline, tugs gently at it with forceps and it finally comes free. The pain relief isn’t cutting it, though. A quiet tear runs down José’s cheek. He never does ask for anything, just lies naked in this stifling cell of a room, smiling warmly whenever we come past. I usually put my head in a few times during the day to say hi, and no matter my protestations he’ll always insist on sitting up—no easy task with raw thighs and buttocks, and weeping genitalia that stick to the sheets. To help, Toyota rigged a wood frame at the foot of his bed with a rope attached so that José can pull himself up, but it still requires Herculean effort. Once upright (he refuses help), José lifts each leg in turn, below the knee, swinging it cautiously over the bed, and sits on the edge (naked, because he can’t tolerate clothing over the wounds), and only then will he shake our hands and talk with us. I gave him a handful of the news and gossip magazines that my parents occasionally send, so that he’d have something new to look at, but that was a month ago. They’re still here. Still beside his bed, wrapped neatly in a square of old cloth—the only items, aside from a candle, on the wooden stand that Toyota had also made for him.
‘We need more dressings,’ Roberto says to me. ‘We are using boxes of it. Look how much it takes to cover all this.’
I tell him I’ll email Luanda.
José’s fortunately beaten the infection that Andrea had phoned me about, although another one is an inevitability in these conditions. I’m not sure if he’ll survive all this. Meanwhile, Roberto pulls at another sheet of gauze on José’s groin. José winces. He’ll need to endure these dressing changes every forty-eight hours, though, and for weeks to come.
‘Thank you,’ he says softly, as we turn to walk out.
Intensivo is no more uplifting. Kidje, the young man who’d become progressively more delirious before my holidays, is now completely unconscious.
‘He still getting the same medications?’ I ask.
‘We’ve changed nothing,’ says Sergio. ‘We give him the TB tablets and a little milk twice a day by this tube. Andrea crushes them. And now we have started the IV fluids.’
All I can suggest is to turn him regularly, and to pad the bed with cushions. I apologise to his brother. The boy’s not ever left his side since he carried Kidje here, except to cook himself a meal near the fence.
Our last stop is the tents, where we share a happy, semi-imaginary dialogue with Toto. He seems well. As do the blind albino woman and her demented mother, although they now have room-mates—Maria, the young mother with the ulcerated breast cancer, and her husband and daughter.
‘Is she showering?’ I ask the team. Maria’s not here, but her young daughter’s sitting alone on their bedding. She’s maybe ten, and smiles meekly when I greet her.
‘Sorry, Novo Doctor,’ says Sabino, pulling me aside. ‘There was a problem. Maria died last week. For now, the little girl is still sleeping here. The father is at home. They are from another village, a day or two away, and the father does not know yet that Maria died. But we have sent word for him. Is it okay if the girl sleeps here until then?’
• • •
A lengthy staff meeting fills the afternoon. The weather’s noticeably muggier, and through the fibreglass window of our dining room this evening I see a handful of woolly clouds, their bellies seared orange by the setting sun. Still no rain, though. Just three men, an attempt at cheese fondue in an old coffee can on coals, and the predictable grilling.
‘You didn’t get laid?’ cries Tim. ‘But you stayed with her!’
‘Wait, it wasn’t—’
‘And you know you’ve got more than two months out here—two more months without sex,’ Pascal reminds me, confident in the knowledge that he’ll soon meet his girlfriend on holidays. ‘You will go crazy.’
‘How did you manage this?’ asks Tim. ‘This is unheard of on a mission!’
‘It wasn’t like that,’ I defend. ‘We got on great. She’s really nice, just not that kind of—’
They laugh. ‘Everyone’s that kind when they’re on mission. We’re all stuck in these places for months. Everyone is in the same boat.’
‘That’s the problem,’ I say. ‘We got on really well, but she said she’s tired of all these guys from the field hitting on her. She says it’s a cliché, that she’s tired of—’
‘Tired of it?’
I attempt to shift the focus of the conversation, but with little success. It’s a pleasant enough change following the afternoon meeting, anyway, time spent mostly discussing the looming handover of the project—a topic that’s becoming a sore point for all. The move is an inevitable one given that Angola is now stable. Our presence as an emergency humanitarian organisation is no longer justifiable, not now that the emergency is over. If we were to stay here indefinitely, why not then open projects in the thousands of other African towns with equal needs? I agree with the decision. Handing over health care to the government is the right thing to do. In principle, that is.
In reality, Tim can’t get the Administrator to meet with him. The town’s new hospital was built a year ago by Namibian contractors but still sits empty, with no water supply, beds, or medical equipment. We’ve offered to complete it for them—the log team will do it for free, no strings attached—but we get no answer. We’ve also offered to donate a three-month supply of drugs and move our own staff and equipment there, but again, no answer. Tim meanwhile struggles in the middle of all this, caught between being necessarily diplomatic yet appropriately pushy, and dealing as well with our team’s growing frustration. We’ve asked MSF coordination to push for action at a higher level, but for the moment dozens of emails just fly backwards and forwards within the organisation, CCed to everyone who’s remotely involved with Angola. Seems that being strictly apolitical can be a highly political process in itself.
‘What else did she say?’ asks Tim.
‘Just that she’s tired of guys passing—’
‘Stop! I can’t believe this. You are single. She is single. You are both staying together—end of story!’
‘And tell me this,’ says Pascal, with an air of contemplation, as he dips bread into the can of lukewarm cheese. ‘What are you going to do with all those condoms they gave you in the briefing? That entire box, Novo Doctor—what will you do with them?’
I excuse myself after dinner to check on a patient in Intensivo. I cross the yard and step into the assessment room, stopping suddenly. The scene is frightening. A clinico is standing beside the bed, swaggering as he tries to guide a syringe into the buttock of a young child lying prone. The brown plaid shirt is unmistakeable.
‘Manuel?’
He swings around unsteadily. ‘Ohhhh! Boa noite!’ he slurs. ‘You are back? Eh, I did not think you were back!’
‘What are you doing?’
‘Just treating this child, Novo Doctor.’
To a near-death experience, perhaps. I can’t believe it. The real cause of his increasing ineptitude and fidgety demeanour is now revealed to me, the evidently un-astute doctor and supervisor. Manuel’s an alcoholic.
‘Put that syringe down, Manuel.’
‘Yes. I will just give the injection,’ he says, pivoting to face the child again, his arm arcing wildly.
I step closer. His breath is thick with alcohol fumes. He looks over and relaxes his arm, averts his eyes in resignation. A heavy silence follows.
‘Go home,’ I tell him.
He can explain, he says. ‘I had the day off. Okay, yes, I had a few drinks, but I was not working for hours, you see—’
I take the syringe from his hand and guide him out the door. The patient’s family watch. I ask the guard to please find another clinico to do the night shift, but Manuel won’t leave the gate. He stands. Begs. Holds my arm and cries, says that he’s the only wage-earner in his entire family and he’s never done this before, and I think, What a pitiful sight: a fifty-year-old survivor of war with no other job prospects, being reprimanded by a privileged white man half his age who’s threatening to leave him unemployed.
I tell him to return in the morning. I’m not sure what we’ll do. Tim will be obliged to fire him if he knows the extent of this, so maybe we can bend the story a little, play down the drinking and make it more of a competence issue. There’s simply no way we can allow him to treat patients; maybe we can keep him on the payroll as an attendant with no clinical duties, and I’ll insist that we deal with his alcohol abuse.
Was it really only this morning that I landed back here?
I head home, help finish the cheese and climb into bed. But how does one fall asleep after all this . . .?
Surprisingly easily. I refuse to keep going in circles. For months my mood has ebbed and flowed according to our failures or successes, but not anymore. I can’t keep wondering whether what we do makes any difference, whether any of this is actually worth it, so I don’t. I light a candle. I grab a book, tuck my mosquito net in and ignore the termites, and remind myself of our successes—and there are many.
The reality is that work here is boring at times, although it’s taken me a while to work out why: most of what we do is easy, and most of the health workers do it well. While I’m distracted by the minority of cases with serious conditions—the Kidjes with encephalitis, the Josés with burns—the clinicos quietly manage the majority of in-patients, and almost all of the two to three thousand outpatients, each month. Cases of malaria that are treated in time, cured with three days of tablets; children with mild coughs who are given antibiotics, long before they become the three o’clock night call with pneumonia; and many hundreds with simple gastro, brought into the hospital hours after it begins, and managed adequately with advice and a few cheap sachets of oral solution.
Even our water system quietly prevents untold cases of illness. I’d go so far as to say that by running it, Pascal and the logs save far more lives than we health workers ever have. And from what I’ve seen, this is the reality of medicine in developing countries: people die of preventable conditions that are easy to treat, or even prevent. Of the millions of children who won’t survive the year, most will succumb to one of six things: poor nutrition, pneumonia, diarrhoea, malaria, measles, or a lack of basic neonatal and maternal health care. All of these are easily managed or prevented. None of it is rocket science—or expensive. Here, the death rate in our little hospital is remarkably low (four or five of the three hundred inpatients a month), not because of the occasional operation or clever diagnosis we make, but because the clinicos plug along every day, treating easy-to-manage conditions, with cheap drugs, over and over again. A fact that I find immensely empowering, yet equally heartbreaking that such a situation exists.
And for me, this is the thing about Mavinga overall. These powerful contrasts, these glaring dichotomies, that make working and living out here what it is: a confusing, intoxicating, frustrating, heartbreaking, inspiring, disillusioning and life-affirming blend of all the best and worst things. Every day, all at once. I don’t think I’ve really started to make sense of it, but I’m not sure one could.
So for now I don’t even try. I blow out the candle, shut my eyes, and do what I do each night: try to picture something good. Like Marco, that young boy admitted with malnutrition and who’s now almost overweight, except that another image keeps appearing . . . What’s this? . . . An old man, I think, and he’s sitting on concrete steps, his deep-brown suit soaking up the morning sun as he grins a toothless grin, triumphantly waving . . . Is that—?
It is. A golden bag of pee.
Hardly the image I’d hoped for, but it’ll do nicely under the circumstances.