THE TOO SWEET CALLS OF THE PEPPER-BIRDS WOKE HER BEFORE DAWN. ASLEEP, JULIA HALF heard the chattering and whistling of the other birds, of course, but it was the fluty, chirping, melodic pepper-bird call that Julia recognized as she lay on her cot in the District #4 Health Center consulting room. She had come out with Sister Martha, her favorite nurse, and with her driver and guard, the previous day just before dark, twenty miles down a rutted one-track road into the middle of nowhere, across bridges that were unstable, and through miles of thick dark jungle. There was a war on, and although it was said to be far away, people like Julia moved about only during the daytime, and even then only with a driver and a guard, because of what was said to happen in the bush at night.
Of all the places she loved and the ideas that moved her, the grand romantic notions about healing the world and making it a safe place for all its children, Julia Richmond loved the District #4 Health Center most. She had only just come to Liberia, after stints in Haiti, Rwanda, and Bangladesh. She came to Liberia when Bill Levin, her friend and mentor in the U.S., forwarded an e-mail describing the position and the need. Liberia, after fourteen years of civil war, was among the most desperate places Julia had been and its people the most distant and afraid. Julia loved desperate places, the places where there was nothing and where the people had no one, so they took her for who she was, as she was, and didn’t ask her the questions she couldn’t answer for herself.
Julia also loved the softness of the light—the muddy browns, tans, and ochres of a place where you couldn’t really see the corners or down the halls, where you could hear and smell people and things before you saw them. There was no electricity in the health center, so the light filtered in through the larger windows, one per room. If you wanted to read or see clearly, you stood or sat by a window, even at midday. Inside, the hallways and the larger waiting rooms were shrouded and warm. When you walked from room to room, the hidden life of the place was revealed, so it felt like you were discovering an unknown truth just by moving about.
The health center was in a village without a name. It was built on a rise. Rows of wooden benches lined its broad porch, benches that had been polished over many years by the bottoms of people who came shortly after sunrise and might sit there most of the day waiting for a doctor, a physician’s assistant, or a nurse. The red dirt road emerged out of the jungle on the far side of a field that lay next to the health center, which meant if you were sitting on the porch you could see who was coming down the road from the jungle and who was going away. There were two clusters of huts near the health center—one behind, a little further up and over the rise, and one further down the road. Julia heard voices among the huts, murmuring and indistinct except when a baby cried or a child called out. She heard the crowing of cocks and the clucking of chickens, and she smelled the warm bitter smell of wood and charcoal fires, which reminded her of Arab coffee and burnt toast.
The first morning light fell on the health center before it came to the village on the other side of the rise.
Julia had been awake for a moment in the middle of the night. She heard muffled moans and then a cry. A newborn. They hadn’t called her. The child must have been okay. The labor room was at the far end of the health center, and the nurse and the community health workers assisted at births.
Torwon and Charles, her driver and guard, slept in the village. Sister Martha, a Carmelite nursing sister from Burundi, slept on a cot in the dispensary. Yesterday they did a vaccination clinic and the big belly clinic as soon as they arrived, working until they lost the light. Today there was a sick clinic. Then they would hurry home down twenty kilometers of one-track road that led to another twenty kilometers of county road that was wider but not better, scarred by potholes and ruts cut by runoff water from the evening rains. They would be back in Buchanan before dark. They had to be back in Buchanan before dark.
The six-bed infirmary had four overnight patients—two malarias, a dehydration, and a typhoid. The nurses and community health workers cared for those people without Julia’s help. Some nights they awakened her when there was a crisis, but by the time they called her it was usually too late. So Julia had taken to seeing each patient just before dusk. It didn’t matter. There were still often empty beds in the morning where there had been a sick patient the night before.
There was a latrine out back, built with Julia’s patient instruction over many months, but no one else in the health center or village ever used it. Water came from the village. Each day they filled two ten-gallon jugs and carried them up the rise from the village pump.
Julia Richmond was thirty-two. She was from Mill Valley, and then Stanford and Brown, and could have worked anywhere, so God only knew why she loved this godforsaken place so much. She was trained in both Pediatrics and Emergency Medicine. She had green eyes, black hair, and pale skin that had tanned in the equatorial sun. In her own mind, Julia was awkward and insubstantial despite the letters after her name and what everyone said about her looks. Here she never had to judge herself against the standard of too many others like her, and here there wasn’t a crowd of people just like her, so she didn’t have to look at herself reflected in the hollowness of the culture that stamped out people who were all alike, again and again.
Julia heard footsteps. Then she heard murmuring and the creaking of wood as people climbed the stairs and settled themselves on the polished half-log benches. They came from the village and from the bush, one or two at a time.
She went into the clinic room to wash. The water jug was near empty.
I’ll go to the village, she thought, to the pump, and wash myself properly. And check on Carl’s pump at the same time.
She did not think about Carl himself but didn’t not think about him either. She thought about Carl’s pump and thought about how the water would gush from the spigot when she pushed down on the handle and about how she would splash the cool, clear water over her neck and face and use it to wash her eyes, and she thought about how alive she would feel as the water flowed over her and brought her from sleep to life.
They started the sick clinic just after eight. Sister Martha, a short, proper woman with dark skin, who dressed every day in the same white blouse, brown jacket, and brown skirt despite the heat, came to the consulting room just after Julia arrived. Sister Martha walked out to the porch to see who was waiting for them and to see if any of the clinic staff were walking from the village to the health center. Julia sat at an old wooden desk with a window behind it.
The first patient was a young man with a cut on his leg. He sat in front of the window in the pale yellow light of early morning. He was about nineteen, thin and wiry, with dark brown skin and brown eyes. Sister Martha stood next to the window.
There was an open cut in the man’s calf the size of Julia’s hand that ran deep into the muscle and was covered with white-green pus.
Julia held out her hand. “I’m Dr. Richmond. Let’s look at that leg.”
“Halloo,” the young man said. He took Julia’s hand. His grasp was warm but weak. “Sundaygar,” he said.
“When did you get that cut, Sundaygar?” Julia asked.
Sister Martha waited a few moments. When Sundaygar did not reply, she began to speak in Kreyol. When Sundaygar did not look at her, Sister Martha switched to Bassa and began again.
The man now looked at Sister Martha, not Julia, and answered her.
“He got it in a palm tree. One week,” Sister Martha said.
“How did you cut it?” Julia asked.
Sister Martha translated the question. Sundaygar answered in several long sentences. Sister Martha asked more questions, which the young man answered as well.
Julia dropped to one knee. She took Sundaygar’s leg in her hands and turned it from side to side in the light.
“It cuts with machete. He is cutting palm nuts in the tree,” Sister Martha said.
“When was your last tetanus shot?” Julia asked.
“He has not tetanus. The clinic has not tetanus,” Sister Martha said, without translating the question.
“Let’s get some Betadine and water and debride a little. I want to see the tissue,” Julia said.
“The clinic has not Betadine today,” Sister Martha said. “He wants to sew, to make stitches.”
“I can’t sew it. It needed to be sewn within twenty-four hours,” Julia said.
“He is two days walk.”
“Do we have Silvadene?”
“The clinic has not Silvadene,” Sister Martha said.
“Any antibiotic cream?”
“Not cream today. Bottles amoxicillin liquid and pills, Bactrim.”
Julia bit her bottom lip.
“There is no indication for oral antibiotics,” Julia said. “He needs a tetanus shot and surgical debridement. Otherwise it’s going to leave a big scar. Or get infected, in which case he loses the leg or dies. Maybe he can get by with a good topical antibiotic and twice a day wound care. Maybe.”
Sister Martha did not answer.
Julia turned to the patient.
“You should go to Buchanan, to the hospital. Otherwise big big scar or infection. Okay?”
Sundaygar looked at Sister Martha, but Sister Martha did not speak.
Julia bit her lip once more, and then continued. “Maybe it’s too late to sew,” Julia said. “You need good wound care. Dressing changes twice a day. Infection is starting to creep in. If this gets infected, you could lose the leg. Or you could die.”
She paused, waiting for Sister Martha. Sister Martha still did not speak.
“Let’s do this,” Julia said. “There are no signs of bad infection yet. Just surface infection. Take the pills that Sister Martha will give you. Keep the wound clean. Try to wait a few days before you walk far or work, and let it heal. It will take three or four weeks to heal—maybe longer. Come back if there are streaks of redness on the leg, if it gets more tender instead of less tender over time, or if you get a fever, the hotness of the body. Bactrim BID for ten days.”
Sister Martha translated.
Sundaygar stood. He said something to Sister Martha, while Julia made a note on one of the dog-eared green cards, and Sister Martha walked Sundaygar to the dispensary.
“He is walking to his village now. He is climbing tomorrow,” Sister Martha said, when she returned.
“Let’s bring tetanus and Silvadene next trip. For the physician’s assistant to have when we are not here,” Julia said.
“Buchanan Hospital has not Silvadene. The health center has not refrigerator,” Sister Martha said.
Julia looked away for a moment. Then she turned to see who was next.
The next patient was a twenty-three-year-old with burning on urination (an antibiotic and a talk about safe sex, perhaps translated, but probably not.) Then an eight-month-old with a cough for two days (clear lungs, normal weight for age, no fever—watch and wait, and come back for difficulty breathing, loss of appetite, or if the cough isn’t gone in a few days. Perhaps translated. Perhaps not.)
Then Sister Martha brought in a young woman carrying a baby. A limp baby. Eyes open but dull. Breathing fast. Way too fast.
This was trouble. Julia didn’t need a stethoscope, a thermometer, or a blood test. Bad trouble. Respiratory distress secondary to severe anemia. Anemia caused by malaria. Goddamn malaria. All these kids had it. Julia could spot it from a hundred miles away. Sick. Incredibly sick. Could die at any moment sick. Drop everything and run for cover sick.
The child would die soon—in an hour or in a day—if somebody didn’t do something. Do something fast. Will die. If Julia didn’t do something now.
The baby was a girl, six months old but barely eight pounds. She was not moving anything other than her chest. She didn’t whimper. Her chest moved in and out twice as fast as a person’s heart beats; in and out, in and out, in and out, the breathing without sound or obstruction but so fast that the skin between her ribs was pulled in with each breath. The mucous membranes were dry. There was no wheezing. The chest was clear. The fontanel was closed. The muscle tone was not good. The baby was breathing way too fast.
The child’s mother was in her early twenties, a country girl. She was small, bony, and Bassa-speaking. The mom wasn’t frightened enough. Her matted hair was wrapped in plain mud-stained green cloth. She had a small nose and mouth, and she looked away as Julia looked at her baby in the soft morning light.
Sister Martha spoke. There were four other children at home. The mother carried this baby for three hours. She walked with another woman, her mother or an aunt. They must have known how sick this child was. They had to know. The baby had been sick for days, maybe for weeks.
Julia pulled the child’s lower eyelid down with her thumb. The conjunctiva, the red-pink lining of the eyelid, was white, not pink. To Julia, eyelids that pale meant severe anemia. The child didn’t have enough red blood cells in her veins and arteries to sustain life. Malaria attacks and destroys red blood cells. This was malaria, as severe as it gets.
The child in front of Julia had severe malaria complicated by severe anemia and her heart was beginning to fail. Severe malaria in the bush, where most severe malaria occurs, kills a million African children a year. But maybe not this one. Maybe not.
“The child must to go to hospital. We leave now. Right now. We bring you and the child to Buchanan,” Julia said.
Sister Martha translated into Bassa.
“Torwon. Charles. We are leaving,” Julia said, loud and clear so her voice could be heard out of the room. Torwon and Charles were waiting in the main room, chatting up the ladies. “We are leaving. Now.”
Torwon and Charles came to the door. Torwon was thin, young, and intense. Charles was a big dark-skinned man in his early forties, a big jovial man who loved to tease.
It was against the regulations to carry patients in the Land Cruiser. Sister Martha waited for Julia to change her mind, to vacillate as Julia often did. But Julia did not look at the faces of her colleagues. She stared only at the child, and the others could see that her mind was made up.
Then Sister Martha translated. They were leaving. Now.
The child’s mother spoke in a quiet voice. She had other children. Buchanan was too far. She was afraid of the hospital fees. The child was not that sick. She needed only the pink medicine.
“Walk with me,” Julia said. “Bring the baby to the Land Cruiser. Now.”
Julia worried for an instant about blood for a transfusion. The hospital in Buchanan didn’t have a blood bank. If you needed blood, you had to find a friend or relative to donate what is going to be transfused. Perhaps the mother would refuse. But Julia could give blood herself. This child would be dead by nightfall if she was not transfused.
The child’s mother kept her seat.
“Tell her the baby will die in a day or two if we don’t go to the hospital today. Tell her,” Julia said, “that we have to go now. Today. She has to go today.”
Sister Martha said a few words.
The mother stood. She went to get her mother or aunt, who waited outside on a worn wooden bench and wore a yellow Port Angeles Dragons tee shirt over a green and blue lapa, a skirt made of brightly colored African cloth.
So it was they left the District #4 Health Center, breaking all regulations, and traveled twenty kilometers down a rutted one-track road through the bush in a Land Cruiser with a green Merlin insignia and the red silhouette of a machine gun with a red circle over it and the words “this vehicle carries no weapons” stenciled just beneath the silhouette of the gun on the driver’s door and the back doors, with a child who was dying in her mother’s arms.
In America, there would have been an ambulance, its lights flashing, its sirens blaring, driving seventy-five miles an hour in the left lane of a superhighway, as they called it in over the transponder, and the trauma center at the hospital emergency department would have assembled a team that would have been set up and ready to go the moment the baby was whisked through the ED doors. In Africa, in Liberia, there was a red dust–covered dented white Land Cruiser nosing through potholes still filled with the runoff from the previous night’s rain, hoping against hope that the child might survive the trip, that the Land Cruiser wouldn’t slide off the road or break down, that the hospital would have some blood on hand, that there was IV tubing to use to give the blood, and that the hospital hadn’t run out of antimalarial medicine yet that week.
There is no malaria in America.
They drove as fast as the road would allow. They drove over an unusable log bridge that they should have gotten out and walked over. The Land Cruiser jolted into each pothole and sometimes bottomed out with a jarring bang.
At the end of the one-track road, they turned right, toward Buchanan, and climbed a hill.
They hit a rut. There was a jolt.
The Land Cruiser sagged to the left, and Torwon stopped it on the side of the road.