SUNDAY, OUR DAY TO BEGIN THE FULL WEEK AT WERKOK WITH THE ARRIVAL OF SOME INTERESTING CASES FOR EXPLORATION
FEBRUARY 13 2011
I met a fisherman who came to the pond that is dug out behind my cabin and was carrying two metal tipped spears, pointed but without barbs. He waded in to the thick and stagnant water. A short time later he returned to sell us the products of his efforts which I ate as part of dinner—three catfish that looked like the kind that can actually breathe through their skin and also walk on their bony pectoral fins when the pond dries out, which it is well on it way to doing. Next to them were five thick and tasty tilapia. Does this represent the “aquaculture” I have been trying to start at Werkok and had discussed with Matt Frackelton and his colleagues as well as with the EWB (Engineers Without Borders) at GWU? No. These are the kinds of native fish that were swimming in the hospital compound and were being caught in the road in front of the hospital and leading to it. They just had to swim away somewhere when the waters receded leaving havoc behind in the roadways and they hung around in the pond—nature’s way of re-populating various ponds with a variety of species, at least in the greatest wetland on earth.
I have often run by the similar side-of-road puddle turned pond before we get to Werkok and its pond (the “Wer” of Kok) and each of the last years I have been here there has been water in it at the start which has run out by the end of my stay. In the early days of my dawn runs each visit, I see hammerkopf and ibis wading in the water with cattle egrets and occasionally the grey necked herons (which I noted have built large dried grass nests at the water tank up on the platform over the compound)—our source of water thanks to a contribution of Grand Rapids Kiwanis Club. I imagine right now, as I have seen the water level disappear from that shallow pond out to a puddle, that it is “summer time and the fishing is easy!” I should see the backs of the tilapia as have the wading birds and other predators, even those without a spear which I hoisted in the air as a salute to this fisherman’s prowess.
We are settling in to a routine here as the container is expected almost any time. Juma is going to visit his family in Bor and taking John Mchol with him. Ajak is seeing to some further paperwork that had dealt with the Jonglei Marathon and will return on his motorbike. We have the potential for a couple of bigger cases to be done in the course of this week here or in Bor. We have not heard further about the potential prostatectomy in Bor Hospital.
But a fourteen year old pre-menarche girl came on an eight hour walk with her father to see us in order to have the presence of a tender mass in her abdomen evaluated. She had a similar episode of abdominal pain in November which seemed to resolve spontaneously. She has had the recent onset of a similar pain, and it is located just to the left of the midline. It is associated with a tender mass which is about five cm in diameter and is easily palpable. She has not been febrile or particularly sick. She is not aware of the sensation of a mass moving around in her abdomen. It is too high to be adnexal and she has no GI symptoms. It could be an ovarian neoplasm at her age, likely a cystic teratoma which might have become symptomatic when it twisted, the kind often found to contain teeth and hair. We have no X-Ray, but we do have the next best ideal machine to help differentiate this.
The sonography probe shows an almost fetal skull like shadow with relative echoic consistency within it. I just happen to have the Study of Surgery here which I had prepared to differentiate just such a mass. So, she has fallen in at the right time to be studied and fixed and she has come a very long way to go back without help. SO, we will arrange for her to be operated here at MCH.
HEALTH CARE IS THE SHORT TERM: LONG TERM EVERYONE HERE RECOGNIZES THAT THE TRANSFORMATIONAL POWER OF EDUCATION IS THE ONLY WAY UP AND OUT OF THE CURRENT STATUS OF STAGNATION CYCLE AND “ENTROPY INDUSTRY”
I think the phrase is a useful one: “Entropy Industry.” It means that almost every developed system passed along from the first world breaks down without maintenance and is sent to the graveyard here of the developing world where it cannot be resurrected without the parts and expertise of the developed world mind set. Therefore, a major enterprise in developing world arenas is “breaking down” whatever has been sent from the developed world that is no longer functional and reducing it into parts small enough to send back to get recycled back up the scale into something useful for value added. This is why the people along the roads in Zambia are pounding apart the rubble of the walls and structures which have crumbled and perhaps salvage a few bricks, and if not, make for the kind of gravel that might be component parts of cement. This is why there are salvage crews wandering through the deserts of the Horn Of Africa looking for broken down vehicles that have been abandoned, or—as seen in Asmara Eritrea, a whole military hardware graveyard, where carcasses of war machines that have been strafed, blown up and the human “consumables” have been burned away, and the scrap metal may be useful as some kind of salvage. This is also why Pakistan, without any iron ore, limestone or coke, is one of the leading steel producers and exporters in the world since it carefully searches “Jane’s Book of Ships” to check on the aging fleet of freighters and purchase the whole of any ship and its cargo to buy and then ram it up on the beach of a suburb of Karachi and peel it away layer by layer in “Ship Breaking” to create an iron and steel export industry from foraging among the scraps of the developed world to send back to them the used and recycled parts after they might otherwise be sunk as artificial reefs.
Here, the dumping of developed world fancy health care systems such as the notorious anesthesia machine which has never been made to work despite whole teams being sent here to salvage the lemon sent here at great cost—and a handsome writ-off to the donor (a featured item in “Gifts from the Poor.”) Now sitting outside the container depot here is the twisted remains of the hydraulic operating table. Three of my trips ago, we thought we might put several of our mechanically gifted folk to work on this hydraulic table which raises, lowers and is set to different positions as it might accommodate several specialized operations. While part of our team worked on it for several days, jury-rigging hydraulic lines to substitute for those that had been bent, and doing whatever might be ingeniously substituted, the rest of us operated on multiple cases side by side on the gurneys which do not have any flexibility in position but were good enough to get the job done. Finally the repair team conceded defeat—there was no way that this special purpose OR table could be made to work, so it has been sent out behind the container depot to sit through the rainy seasons and dry seasons until someone decides that one of its parts will make an effective boat anchor. Meanwhile, it has a single function—it is one of the weed clogged covers under which the cat who begs scraps from us caries off her kittens each night to spread them out in different locations to prevent the total disaster of some predator discovering the intact covey of all her brood in one spot. Divide to survive is her motto, and that is one of the themes of “Entropy Industry” as well.
Making use of “found parts” also as a wonderful French term “bricolage” and the artisan who can do that is the “bricoleur.” Cobbling together the pieces of another world ad making use of them for more fundamental purposes here in this world is a bricolage of the first order in survival skills—like using the infant bed nets impregnated with insecticide to fish for carp in the Nile River—eat today and worry about disease tomorrow. Immediate gratification is the spark to fuel all such attempts just to get through another day.
Now, the next phase of that is the reaction of those with whom we work. Clearly they are caught between two worlds with an envy of the lifestyle and power achieved even at much lower social levels in the own society than in the other. They see, quite clearly, that the single most useful thing they might achieve to help in their own personal mobility through the strata of each society is education. So, each will be eager to sit through our tutorials which have been quite good. Our participants from Team Rubicon have had many courses taught by the Special Forces or by at least ten graduate programs in my case, and the power and potential of such knowledge is quite attractive—to each. Several of our team mates have expressed an interest even if quite wistful—“if only”…(I did not already have a wife and kids, or a job, or a life style that requires me to be making a good living rather than getting re-encumbered with a lot of debt, or if only I could get support, etc.)
Now, with almost identical yearning, the indigenous folk have come to me, most recently Gabriel, one of my trainees from last year. He had to drop out of MCH as one of my more able surgical trainees in order to achieve his primary school certifications. He cannot go further in any application process until he had this out of the way and at considerable expense and support he did get that accomplished in in the past year. Remember the embarrassment this caused the Lost Boys on arrival in the USA when they were first brought in. Here they were under the assumption that they were at least eighteen—many had no idea how old they were but hastily assented to that as their age, when as tall as they were they might have been fourteen at that time. They were going to start a new life in the USA and wanted to get into such as Junior College. But first, this twenty plus year old must fold up his six foot six inch frame in a school room chair to study the three R’s to get advanced into placement for a secondary starting school. It is embarrassing enough to be the only black man in class, but then to be twice their height and half their speed in the take up on the primary school lessons?
But those who did, also found it was hard. It is difficult studying the supposed trivia of any discipline when one might have visions of returning as the “Jefe” of the village. Many envisioned an “entry level” return job as, say, Minister of Health. I have all the tickets punched and credentials passed counting and still would not think I could walk in with immediate acceptance as the Director of a national budget on any large program—which they figured was going to come to them as a matter of course. After all, they were to the manor born, they were sent abroad to take up this responsibility, and they wanted to get started since they were already advanced beyond the ages that these jobs would be taken up since they had squandered a good number of years, not studying but wandering the bush at night in fear of predation by wild animals and wilder tribes, and strafing by day from Antonov’s. They hoped to get “advanced Placement” from this “Post Graduate Equivalent Experience.’ But clearly they would not be competitive in such a role against the applicants from another world who had not had these impediments. “Affirmative Actions” as we have already discovered, has its drawbacks, and puts a lot of pressures on those it is designed to help. Many cannot take that heat, and most have some weaknesses in confronting their expectations against their capabilities.
My longest conversations with John Dau have been about the current status of his education and what he must do when the inevitable already-told story becomes yesterday’s news. As compelling as his life story is, he is not alone in it, and it has already been told. If he wishes to equip himself to lead any kind of redevelopment, he cannot expect all of the power and responsibility to come to him from having led smaller boys across rivers into Ethiopia, when his completion will be carrying PhD’s and technical skills more useful in the modern world. But, he is now the “President of the John Dau Sudan Foundation” and going back for this lifestyle of jetting from one tony hotel to another and TV Interviews and public appearances to sitting in an classroom doing declensions of some common languages is not something to consider. Especially since he is already acknowledged as a Big Man. After all he has a wife, purchased at a great cost in cattle. And now has several children. This is a rule with many of the applicants such as Gabriel who came by last night to say hello and to pose his plight.
He has received the special training with which I had helped Francis the Nuer at Old Fangak; he is qualified to do the trachoma lid eversion procedures. This skill is limited but valuable to certain small segments of populations who need it. Can he parlay that into the next level and become a CO Clinical Officer, like John Ajok her or Juma at Duk Payuel? Well, that is what Kathryn had proposed and come close to promising. At the time the CO School—the only one in South Sudan would cost six thousand dollars a year, and she pledged to see what she might do to raise such funds. Almost immediately Zach said “Well, TR could help!” Wait. The current tuition is $19,600 per year to get to be CO, and that certificate is not assured from that investment in the training. That is not a sure thing that making that investment will get the outcome anticipated by the donors, since there may be a couple of different agenda involved in the applicant’s efforts to matriculate. If one considers Gabriel a “student” remembers that a number of the would-be students that had always followed me through Africa from the Horn of Africa and from Assa Congo and from Malawi and Tanzania to name a few, come along with a few “impedimenta.” Like at least one wife and in Gabriel’s’ case, four children. Living expenses therefore are usual cumbersome. And using Juma as an example, he is the CO of Duk Payuel and BECAUSE he is the CO, members of his extended family have re-appeared from out of Ugandan Refugee camps and claimed their dependency upon him, including the five children of the niece of his dead father’s third wife—close enough to claim total dependency. SO, once one is “in for a penny,” the donor is in for an infinite number of pounds, Sudanese.
Besides, advocacy means there is one such person standing before us when there are hundreds—no, probably every single one of the developing world’s citizens, standing right behind the one being advocated with every bit as legitimate a request. As stated in “”Out of Assa: Heart of the Congo” the fundamental principle is irrefutable: “If I had all the advantages you have had, I could be YOU!”
We have already promised support in US $100.00 bills to Jean Marco for support of his daughters to get to be nurses. After all, I had once previously left money in a check to support just such education and it was allocated to other sources of aid every bit as urgent I am sure, but unknown to either JM or to me. And it would be far cheaper than trying to support someone already further upmarket such as Gabriel who already has finished his primary schooling now and even has some medical skills imparted by me on the last trip and through the entropion repair skills he had achieved on prior visits. Whom should we support and at what level, when there are so many with needy claims for help?
Jacob and I had had a discussion that he has been working hard as the manager here, and is rather poorly compensated and needs a break from the continual demands upon his time and talents. (See following as to the next chapter in the saga of the Container and its mishaps in making its way from Derwood to Werkok, and how Jacob has been called out each time to make the killing repeat trip to Juma to re-do the already accomplished “slam dunk” of clearance of the container and its load of donated supplies.)
Jacob is a Lost Boy who is a Michigan resident, which is how he has become affiliated with PCC Sudan. He is a graduate of Grand Valley State University. Given that fact, he might apply for support for the next level of skills enhancement—he has sat through several of our tutorials and considered that he might be capable of doing some of the things we are involved in and has expressed an interest to me of getting an MPH. OK, this is a good idea. But, now, from what pot are those resources withdrawn to support this objective and to what end? How that investment would pay off is easily apparent if considered from the perspective he brings to one such view, his own, but how does that forward the cause for the MCH of PCC it inevitably becomes to regardless of the pledges of better and more for Sudan? He could return as an effective representative of MCH, but, as seen in all the ministrations for the container, he is already doing that and the eighteen months minimum subtraction from that post would absent him form such work. Then, if he came back even to do the very same job, it is expected that his skills so enhanced would require a higher compensation, and already all the PCC Sudan MCH workers are functioning on a cutback in their salaries by 25% with the fall off of the charitable support for PCC Sudan among all other charities in the USA with the Recession that has hit them all. So it might be interpreted by some that the investment in further training of a worker already employed would lead to a NEGATIVE return and a good deal of frustration for the advance which would not necessarily be forthcoming and an almost guaranteed departure.
If the help that each seeks as a way to advance is not intended UP FRONT to be the “Ladder Up and Out” it inevitably becomes so regardless of the pledges of better and more faithful service to the sponsoring institution by more capable employees in the future post-graduation. Indentured servants do not make very contented employees, and their very ambition and resourcefulness will cause them to seek much greater opportunities than the limited scope of an organization which in itself has a sunset provision for the next phase in its development, that is a transition into the local and traditional way of doing business, which the outside help has elevated in a qualitatively and quantitatively higher demand.
Most organizations in the field deal with only one or a few charitable targets and the universe becomes one of advocacy for the narrow and often parochial base. I cut across all of them being a member or dependent of none of them so I can see that some get more yield and effectiveness than others. As some mature they get very sophisticated in their fund raising, if not in their effective delivery of services. They do not count on donor fatigue and expect that every subsequent fund raising period will be outstripped by more and better resource support. If they are effective, should they NOT be phasing out and requite less, rather than more support? My statement about that is that it is a series of very short steps from Advocacy to Agency to Ownership of a people and their problems which then entails a vested interest in failure to perpetuate the program for taking on a life of its own. I see that the fund raising of any programs that becomes a major source of support to the DONOR always get more shrill and parochial and brand named as they are less connected to the solution of a peoples’ problem and get more vested in a security system as an employment agency for both first and third worlders.
I have just spoken with several who are riding a crest of popularity often associated with a book or media event—the John Dua movie and the Greg Mortenson book being examples of each, and the presence of the principle fund raiser on the platform seems to be the barometer of their fund raiding effectiveness, with “air time” exceeding “on the ground” programmatic time. The fund raising frenzy leads to feast and famine without any sustainable and long term transitional plan toward local development. Much is foolishly allocated when times are flush and much is cut back with all the local frustration when the inevitable lean years come. Popular support in donor aid is a very fickle platform on which to build a future, when such a future might include another tsunami, or Haitian earthquake, or 9/11 or cholera outbreak, or subprime mortgage debacle—all of which are going to be considered much more important than the project already underway when the “Next Big Thing” happens along.
This then becomes an “advocacy niche group” and who screams louder for support from constituencies already worked over by others. The sub-differentiation starts to occur—“We are building a Tiv Reformed Seminary” (from my earliest experiences in Nigeria) or the “SP Evangelicals are re-building the churches bombed away by the Islamic Northern GOS” (from my earliest ventures into Sudan a decade ago during the war before the CPA) which appeal to smaller groups which have to ante up in greater numbers than a general appeal across a wider range in flusher times for the common good of many more who are disadvantaged. Doing Good Carefully is not easy.
AND, NOW, ABOUT OUR STAR-CROSSED CONTAINER TRUCK, WITH JACOB ATTACHED TO IT AFTER CLEARNACES AND COUNTERCLAIMS ENROUTE IN TRIUMPH TO WERKOK—WHEN IT BREAKS DOWN: THE MISSING PART AND A MECHNANIC CANNOT BE FOUND IN MONDIR NEARER JUBA THAN BOR WHERE IT IS NOW STRANDED, AND BOTH ARE BEING FLOWN UP FROM MOMBASSA, DELAYING REPAIR, AND ITS NOW-POSTPONED ARRIVAL IN WERKOK WHERE IT IS AWAITED WITH A CEREMONY STILL PENDING MULTIPLE PARTICIPANTS’ POSSESSION
Nothing is simple. This is Africa, after all, and we are dealing with all the imponderables and immoveable forces and the law of entropy in its purest primitive form. The truck broke down. After all the good news of Jacob’s having made hand delivery of the same letters of clearance and exemption that were already present with the driver but had gone missing in the hopes of private profit in impeding the forward progress, the truck made it out of Juba and on its way to Bor. The LAST place I would like to have the container stranded is in proximity of the clutches of those who have already expressed a preference for their own more evenhanded distribution of the precious resources as favors within their own patronage. But the container, contrary to first report, did NOT make it to Bor, but got to a village called Mongir, where the truck itself broke down. They made it back to Mongir to seek out help from mechanics which, of course, are not in abundant supply scattered through the bush between Juba and Bor. Most all “long haul over the road trucks” in Africa (which happens also to be the chief vectors in the spread of HIV, by way of our information in the tutorials) are moving parts depots. Except in this case, the missing part is not available and the mechanic’s skill is not present either. Remember, we own the content but not the container. Our leasing the truck (which we also do not own) is along with an insurance policy on its breakdown, part of the nearly $20,000 fee to get it here. So, the owners of the truck and the container box itself are at risk for the down time as well as we, so they called down to Mombasa where it is home ported and they said they would send both the part and the mechanic to repair it. If this were to be by road it would be months, but their down time is going to have to prevent that, so that the truck owners are going to fly the unknown part and mechanic to repair the truck—just where they will rendezvous with it and those details are sundown, but the long estimate on the timing of the truck’s eventual arrival is five days now, which puts it at the outside limit of our visit here.
Of course, this is subject to change without notice, as have each of the prior changes. Faithful Jacob is going to return by some other road transit to get back to Werkok. We will go about our clinical activity as if the arrival of the container eventual will be an unplanned surprise windfall into our schedule. And all of this proceeds through our educational program of nightly tutorials which seem to be very rewarding for all those who participate which has been everyone who is here. That excluded D. Ajak who was still in Bor last night. It excluded John Mchol and Juma who were also on our van to get to Bor early yesterday morning for the Race (which I have just heard has elicited interest from ESPN!) but they are visiting the family and dependents that Juma is supporting from his employment at Duk Payuel. He had received a note that Dan Reid was one of the people who would be coming to Duk Payuel but long after any of the referendum election unrest was expected to peak, and insisted Juma be present on February 26 since there would be a session on Ultrasound technique. Juma could report back he has just had that session and is loaded with the software on his laptop having already used the U/S probe in practical applications here at Werkok.
The nightly tutorials have been good. The topics covered are those I have done every time I have visited any of the stations, but I was the one who gave all such discussion in the past, and then I assigned one or two to the participants who had traveled with me. Last year I made a point to be transitioned through from me on the first days, to half of the topics given by the other visitors on the next days and by the last week, 100% of the topics were by Sudanese teaching Sudanese. This time we have started with a mix, (since all other travelers are first timers except John with me) and last night’s topics were HIV, Hepatitis, and STD’s with each given by Kirtus, Dan, and John respectively since we were short all but John Ajok from the Sudanese team. By the end of the week, everyone will have gone through the whole curriculum and have presented at least twice, in time to have all the presentations left with the Sudanese for the “Network CME Program“ which I envision to be all Sudanese teaching Sudanese and convened and run by Sudanese here at MCH with only backup support and materials supplied by anyone from outside.
ACTIVITIES OF DAILY LIVING
With baking enervating afternoon overhead sun temperatures in the proximity of a hundred degrees Fahrenheit, not much is happening in mid-afternoon. It has been remarkably cool in the evenings and mornings and we ran the race in probably the only overcast morning in which it was not insufferably hot by ten o’clock so we used up a lot of our luck yesterday during the run. Nonetheless, we each drank in two liters and never peed until return.
The dry season plague is “flies in the eyes.” This is a real annoyance for Europeans, but Africans hardly blink. The source of any moisture for these pests is the eyes, ears and nostrils of adults, as well as kids who often have several other moist orifices exposed for the flies to cluster around (which is why they fit in the “Five F’s of Trachoma: Fingers, Flies, Feces, Families and Fomites”). A scorpion wandered in and scurried between stomping feet at the tutorial night before last. The ever-watchful raptors here, the kites, swoop over head at our dinner time and last night one made several close passes to inspect and try to clear our plates of any of the goat that had been slaughtered the day before to be turned into our dinner with the beans and bread. It is necessary to guard the foodstock from predation by animal life around here including the cat that is always carrying around a litter of kittens, spreading them out to avoid having them all in one place overnight. I saw another civet cat on this morning’s dawn run. It was a solo run since none of the others were up or out, presumably since they had already made their one exhausting run for the week. The bats that are thick as fleas in the hospital like especially to hang out under the cloth covers of the instruments and get scurrying around whenever anyone enters. They should be doing a better job of catching the pesky flies so we would not have to blink so often.
But, mosquitoes have not been a major problem. In this middle of the dry season there is very little standing water, and what is around has been so concentrated it is virtually mud. Wading birds include the hammerkopf and cattle egrets and the grey necked heron (filling the same niche as the Great Blue Heron and looking like it at the same size.) Both Sacred and Hadeedah Ibis are flying over in V formation at dawn and dusk, and all day long the cooing of the African Mourning Dove is heard. It is not unpleasant as a breeze is rather constant making one unaware of the heat unless one is out of the shade and in the overhead sun, which, of course, only mad dogs and Englishmen ever do so.
It is easy to get lulled into the mid-summer leisure, even by a team which has come here ready to “DO IT.” But today’s discussions distilled many of the topics from the tutorials and I could hear them all coming to the same metaphysical question every first time visitor in such a trip to Africa starts to ponder: “What on earth am I doing here? Any intervention is moral and has all kinds of consequences, both good and bad. If I save a life” what then becomes of it and haven’t I caused more problems in doing so for which I will not be present in the future to address?” etc, etc We will discuss the “Demographic transition” in our later public health discussion and talk then about what role an outside agent has in supporting development from mainly education as opposed to dropping in and Doing Everything to his or her own satisfaction, and then leaving—creating as much frustration and setting back progress of indigenous development by the extravagant outlay of resources in a few beneficiaries while frustrating so many more. These are the big questions for which I am going only to sharpen the inquiry without furnishing the answers—which will stay forever elusive out ahead of them no matter how many return tips to Africa they might make.