THE DAY BEGINS WITH MY PRE-DAWN RUN DESPITE A BAD URI ALONG THE DESERTED ROADWAY TO RETURN IN TIME FOR A MAJOR MEETING WITH ALL THE MCH STAFF AND THE FORMAL INTRODUCTION TO THE COMMUNITY WITH OUR FULFILLING THEIR PROMISE OF TWO ITEMS WE SEEK TO LEAVE BEHIND TO HELP THEM: THE CONTAINER THAT CROSSED THE BORDER AT JUBA THIS MORNING AND MORE IMPORTANTLY THE SKILLS WE HOPE TO INDIGENIZE AS ILLUSTRATED BY JOHN JOCH IN HIS CAPABLE REPAIR BEFORE EITHER THE PLANE OR THE CONTAINER ARRIVED; WE SET UP THE CLINIC AND TUTORIALS FRONT END LOADED FOR THREE RETURNEES WHO WILL NOT BE GOING FORWARD TO PIBOR WHERE EXPECTATIONS COULD NOT BE ANY HIGHER
FEBRUARY 8, 2011
I began as I hoped I would this mooring, against all odds. I was awake a good deal of the hot dark night since I was gurgling in secretions from the URI I have carried forward from Philippines. I was not sure I could, but got up pre-dawn with both my headlamp with which I operate having gone sour so it would not turn on last evening after the abrupt sunset which I captured during its two equatorial minutes, and then in the middle of the night I spotted this glow under a pile of clothing which seemed to be a resting place for glow worms. Since I have not assumed my shirts should have thermo luminescence, I got up to find the headlamp not only on, but also having breathed its last in the effort, so it is time to enlist backup.
THE FIRST RUN—BEFORE FIRST LIGHT, AND HANDICAPPED BY PHILIPPINE MOUNTAIN BRONCHITIS
I walked out in the still dark night and started out along the road I know well, except that it has been subject to the worst flooding in memory the past months so the usual ruts are now big enough to swallow ATV’s—i.e. i if a were here—one of the things that they have been hoping for, a mobile floating six wheel drive duck blind-type ATV for evacuating patients during the rainy season.
I ran cautiously and alone. The only notices I got about my presence being known was the barking of the dogs which in one of my earlier visits was called Bashir the unruly cur being named after the sitting president of the GOS northern Government of Sudan)–a fellow hoping to have his indictment by the International Criminal Court lifted by his accepting the result of the Secession referendum vote to be announced on Friday while we are still here. The worries about unrest and actual civil war breaking out prompted all NGO’s to pull out people who were ex-pats to be returned only if there was some relative stability. It has actually happened that there is more stability now than at any other time of my visits, so there is a net inflow of expats again as everyone returns to work.
Despite my bronchitis causing a few sneezing and coughing fits along the run as it had been the case all night, I was able to make it out ten kilometers before the dawn starting limning the few clouds in the dry season began extinguishing the few planets that were visible at the start of my run I turned and returned the same ten kilometers “negative splitting” since I could now see my feet and the ruts. I saw a pair of kites swooping down and hitting the road way just beyond where I had stopped to see a column of army ants marching by –and I made no attempt to interfere with this inexorable force of ten thousand grasping mandibles. The kites swooped down and caught something on the roadway, which I only recognized as they made a climb to altitude over the horizon in front of the pink-tinged sunrise eastern sky—a snake! In the course of their struggle, one of the kits lost a big wing feather from its “flight control surface” and it fluttered down, and I picked-it up to carry back to present it to our photographer Brittany Smith, the only woman on our team.
As I came back to get showered—sure enough, there was no soap and as much as John had encouraged me to throw out all the hotel-furnished miniature soap bars that had collected in my Dopp kit which had got such a trashing in the Dubai security hyper search, I gathered them up and carried them in the insect repelling bags in which the new TR logo clothing had been soaked, and carried them with me so that I was able to go back to the room and get one of them to use and leave in the shower stall– a brisk experience a bit like the Tabu bucket dumped over my head in the Philippines which may be part of the reason I was coughing and stuffy all night.
THE GOOD, THE BAD, AND THE UGLY, AT THE GET GO IN SOUTH SUDAN AS WE COMMENCE OUR MISSION AMID HIGH HOPES
At a brief breakfast and briefing I reported to them the good, the bad and the ugly and made the assignments for the day, putting Dan, Kirtus and Kannan in the fore since they will be leaving on the 18th and cannot be going on with us to PiBor where all the high expectations are (more “”excited about our coming visit than they had been about the referendum voting” is one of the way it was described to me!)
The good news is that the Container has crossed the Ugandan border at Juba and is on its way toward us perhaps arriving as early as Wednesday, a perfect timing for us and the dedication service for its use. Our welcome reception here is a big event. The fact that we are about to have a “recreational sporting event” held on Saturday to which the Governor, MOH and District Commissioners are all invited is astounding, since it is a friendly competition among competitors who may have been shooting at each other as they were just last year at the time of my most recent visit. This is the “First Ever Jonglei Marathon” (as described to me in the run from one significant landmark in Bor to another, such as the police station for which we are commissioning them as water stops. I hope of bottled water rather than Nile River water from the adjacent Nile along which we will be running) and may measure as much as fifteen to twenty kilometers. But, who is measuring? After all, it is a big deal just to be staging this first ever event, far bigger than the super bowl which I heard only on departing from Mayfield had been won by Green Bay.
Next, the BAD: There are three parts to a Charlie Foxtrot here to be annoyed about:
One: At Derwood John Sutter had come to visit me and we had gone through the most high priority items to be carried here and among them were the spinal anesthesia kits of which I had packed over a hundred. The other items included sutures of critical usability and a few items such as ceftriaxone and others which I put into a big SCI Safari Bag and John said he would be sure it went into the TR Storage Locker in Alexandria where they would be picked up by the team coming eastward as they stopped for the Dulles layover to connect with Air Ethiopia, A special trip was made to the storage unit and despite all the alleged arrangements, it was locked up and no one was on call to open it for us; consequently the most critical supplies I had packed for pickup as John and I were on the far side of the world were inaccessible and never carried.
Two: we are giving a graduate course in sonography, and the Interson Probe that had been relayed back to Grand Rapids to Tim Williams to be returned to InterSon and exchanged for a probe that worked never happened. He saw me as I was “book signing” at a distance and only for three seconds, so no transfer of the bum unit was accomplished which was subsequently express mailed back to InterSon through the agency of Betsy Hall and Gene Wright and the West Coast Team was to carry the replacement forward—but never did—meaning we cannot give an ultrasound course for laptop use OB and abdominal imaging. I asked if they could use the BGAN to send back a message to have it forwarded from Marc Fine of InterSon to Tim Williams (his arrival on the Feb 18 flight that carries us on toward CAR, but it will only just BE here if that happens, without any instruction to those who are hoping to use it and later get a probe for their own hooked up laptop downloaded InterSon programs in several locations. This includes Bor, John Mchol (East Jonglei) Juma in Duk Payuel, as well as the hopefuls of PiBor.)
Three: I had packed across country to San Diego two SCI Blue Bags with stuff to be distributed, and with the objective of packing them here with the vital supplies we had hoped to leave at PiBor and to carry forward to CAR. When I asked Zach at Mayfield where the blue bags were, he said, “the blue bags are no more.” He discarded them, either unaware of their value as a Humanitarian Service Logo or because of it, since he was eager to re-pack the stuff into Patriot bags—but those will not be left behind to carry on in our absence.
I must plan now to do some re-packing since a number of the items we will need to carry to PiBor and on to CAR should be carried along with two and possibly four personnel to Bor for our departure date on Feb 18. Three of our members will be returning to the US: Dan. KP and Kirtus, and we might pick up Ajak (who would be the medical director of the PiBor project along with Jacob Gai who is just now over the awful road to Juba and just now carrying back Kathryn and Aaron after they had brought their luggage to Wilson Field to put it on our flight, exercising care to sneak around me since they had directly called Jon Hildebrand to check on how close we were to our maximum weight).
The Werkok Air Strip is short for the 208 which needs 700 meters to achieve VR (rotation velocity for the pickup lift) and fully loaded it cannot be done with fuel and passengers aboard. We burn a barrel an hour of Jet A fuel and have to use that in going forward from PiBor, and we have supplies to go to CAR and to leave at PiBor. These should be carried forward with us to the Saturday race in Bor so as to be picked up there on the 1500 meter landing strip. If we can extend John Mchol and Juma’s leave to the three days of PiBor on the 18th, we might leave them there since they would be several hundred jarring road miles closer to Duk Payuel. If we can get Ajak and Jacob to extend there beyond our visit, first of all Jon Hildebrand would not need to return them by air to Werkok; second they could monitor our follow up patients, and third that would make an important statement: we would have Dinka Bor and Dinka Jonglei caregivers (a bitter and often hostile rivalry in and of itself) collaborating in the care of the arch rival Murle, and without the hand of any white man present from “off a plane” from America. This is the “way it is going to be” from here forward in the new “Republic of South Sudan.” in this Network of Mission medicine that I hope to keep supporting here, the continuing education and consultation will be Sudanese teaching Sudanese, as we had done on the last visit here at Werkok.
OUR COMMUNITY AND MCH STAFF OFFICIAL WELCOME AND THOROUGH “BUYING INTO” THE “MISSION TO HEAL” PLAN FOR PEACE AND DEVELOPMENT LED BY SUDANESE ACROSS THE HEALTH BRIDGE
We had a very formal and thorough introductory session after breakfast, with Ajak leading an appropriate devotional and each of us giving a speech translated alternately by chaplain Peter and Medical Director Ajak to the helping staff of MCH and to the elders and community representatives, including a chief and the two police guards assigned to us for security—their uniform being the AK-47 which is the ubiquitous weapon of this part of the world. There had been cattle for millennial and only in the last twenty years does it seem to have become necessary to have every fourteen year old on up armed with the ubiquitous and indestructible “Original” AK-47’s to “protect the cattle” from the non-existent threat of predation by any but rival clans. “Automatisch Kalashnikov-1947” was a thirty caliber automatic weapon that has to be one of the most resilient pieces of machinery in modernity, since those originals which may have been tossed into the murky Nile last year and can be fished out and used on full automatic a moment later.
THEY ARE ALL PAST HAPPY TO SEE OUR RETURN IN FULFILLMENT OF THE PROMISES OF THE LAST MISSIONS, AND APPROACHING ECSTATIC AT THE PROSPECT OF PEACE WITH NEIGHBORS OVER A HEALTH CARE BRIDGE IN WHICH THEY EACH PROMISE TO PLAY A CRITICAL ROLE
Each of us gathered in a big circle for a two hour welcome and introductory ceremony that included chiefs, cooks cleaners, security personnel, and the clinical officers—John Juma CO of MCH, Juma Co of Duk Payuel, John Mchol CO of Duk Payuet, and the community leaders who all remember me and are happy with our return.
John Sutter, MD Medical Director of TR and my veteran of at least eight foreign missions since his first with me as GWUMC freshman Medical student.
Kannan P Samy University of Toledo Senior Medical Student who was with me in Tanzania where he did his first ever operating with me in Tonga Province and is now matching for a surgery residency
Dan Fong, Paramedic pre-hospital scoop and fire department medic form Denver Colorado
Joshua Webster US Army medic and specialized in retrieval of casualties with several tours in Afghanistan and a litany of special course form jumping to white water to helicopter resuscitation
Zach Smith, paramedic fireman in South California and TR’s West Coast liaison and who was responsible for most of the heavy lifting after I got the entire container full into Toledo to its successful entry into GOSS today.
Kirtus Kreiglow, fireman paramedic and the one who managed most of our order retrieved from the Nairobi pharmacies by orders at a distance.
Brittany Smith, Zach’s sister and our media person doing still and video photography in place of all the professional media who went missing when the events in Egypt caused diversion of everyone from LA Times to Nat Geo and others.
I have been scrambling to pack a kit for both PiBor at which the surgical volume will be higher and at CAR where it is higher still—as I work on Kannan Samy to skip his return and come along with us. I have already recruited Juma and John Mchol who are going to go with us to PiBor, via our aircraft, thus being several hundred miles closer to Duk Payuel return and a comfortable hour and a half ride as opposed to sixteen hours of road trip misery before still having to go by road further to get to Eastern Jonglei.
The acclaim that met our introductory speeches much of which has been taped, included ovations often and vigorous head shaking as I reminded them that the North vs. South Islam vs. Christian was a thing of the long past now, and the CPA and referendum had buried it in distant memory. But what was altogether too well known to them has been the cattle culture raiding between Christian brothers which has resulted in a higher body count including the experiences I had on my last visit here and they had then agreed could not continue. I reminded them that now was the time to collaborate with their brothers even if they had different clans or allegiances, since I was more than willing to support the collaborative network of mission hospital dealing with the health concerns of all Sudanese through the Sudanese caring for and teaching Sudanese with only a behind the scenes supporting role for us as visitors. But that interaction did not include stealing young women or cattle raiding which was a sure way to keep themselves embroiled in a very unhealthy war as they already knew from time out of mind.
I told them that the lesser of two things we had hoped to leave behind were the supplies of a forty-foot container that had crossed the border and was on its way here perhaps as soon as Wednesday. The greater of the two was the indigenized health care expertise and continuing education that would now be continued among the Southern Sudanese under Southern Sudanese leadership as we were working our way out of this job. I pointed out that the day of our arrival a difficult delivery was done and a repair of a vaginal tear by a fellow who tied the first knot of his life at the time of our training him on the last visit—and this remarkable success had occurred BEFORE the arrival of either our PLANE or the CONTAINER. Such are the marks of success we seek.
It was clear to all that this was for all and not for one or another clan or tribe or country—both supplies and education and they were accountable for the promulgation of both. They all stood and applauded and prayers were uttered by several representatives—Peter our chaplain, Rebecca our cook and Zach for TR.
Then we started to work as Ajak left for Bor and I floated over the consultation rooms as each of three teams saw patients that they will present for discussion tonight in the post-dinner tutorials.
A young woman who had heard about me stopped by from Samaritan’s Purse Canada, named Karen Daniels, an she asked me to consider coming to Juba at some point in the future to help them re-develop medical education in the University of Juba which had its last year’s in the clinical facilities of Khartoum now moved back to Juba with input from Harvard and mass General.
AND, NOW, THE REALITIES OF BAKING HEAT AND A HACKING COUGH AS I RETREAT TO MY BAT-FILLED ROOM BEFORE OUR EVENING TUTORIAL AS WE ARE READY TO BEGIN THE EDUCATIONAL REVIEWS
The bats are flying around the baking oven of my room at the height of mid-day when only mad dogs and Englishmen are in motion, as I am coughing out my bronchitis and the bats are being disturbed by the noise. A young kid was led by a robe cheerfully past us as we were on our way to clinic and I invited each to make a brief acquaintance without lunch, as it was shortly rendered into and it took a re-application of the one vital hygienic item I insist everyone carry—dental tape. I have sucked down four liters of fluid so far today since my morning run and have not felt any urge to pee, perhaps because my highest output continues to be from my now and upper airway. I hope this is resolving rapidly in order for me to fulfill the greatest fears of each of our teammates and even including the Governor of Jonglei State, the Commissioner and the MOH—all of whom are invited to the first ever Jonglei Marathon on Saturday—that they will be whipped by a senior citizen, a crotchety white man from far away with a hacking cough, which may cause them to lose Great Face, as we complete the Mission to Heal Race on the Banks of the Nile at Bor, Jonglei’s capital.