Dr. Geelhoed’s journal entries paint a bleak picture of the situation in South Sudan. But there is a silver lining. His medical peace initiative between the Murle and the Dinka has held since January 2010. The two tribes have upheld their end of the promise – to end cattle rustling, bride snatching, and never ending raids and counter-raids – and so Dr. Geelhoed is delivering on his promise to them: to deliver medical equipment and expertise to war-ravaged South Sudan on his “Mission to Heal“.
SOBERING REFLECTIONS ON THE EVENTS OF A SINGLE DAY, FROM DAWN CATTLE RAID TO DUSK REVENGE KILLINGS UNDERSCORING THE URGENCY OF OUR MISSION IN ATTEMPTING TO ACHIEVE A PEACE INITIATIVE USING THE MISSION MEDICINE BRIDGE; WE MAKE ROUNDS AFTER THE SUNRISE RUN, INPATIENT ROUNDS AND CONSULTATIONS, AND THEN PACK THE TEAM OFF TO BOR TO VISIT THE BRIGHT LIGHTS OF THE BIG CITY—THE SHOPPING MALLS, HIGH RISES AND RIVERPORT TRAFFIC (!)
AN EMERGENCY CASE INTERRUPTS THESE MUSINGS, AS A MURLE RIADING PARTY KILLS ONE WOMAN AND ABDUCTS ANOTHER WHO SURVIVES BY FEIGNING DEATH AND BEING CARRIED A FULL DAY LATER TO MCH—FURTHER RE-ENFORCING MY MUSINGS ON CATTLE CULTURE PEACE/HEALTH CARE LINKAGES AND THEIR POTENTIAL OR POSSIBIIITY
January 9, 2010
It should not be made more of than it is, and it should not be ignored or gilded. I was two hundred meters from a cattle raid and killings this morning of an unknown number of Murle predators on the Dinka and their cattle which were repulsed with the loss of an unknown number of casualties on the Murle side. All of this was within easy ear shot and the response from the scrambled lorry-loads of troops from Bor were sent out to capture the raiders with unknown results, other than I witnessed and photographed in the mobilization of masses of firepower by the lorry-load. I did not talk about this with too many people except Ajak and Jacob, and I had told Julie that these were the sounds of antelope hunting as the game would be moving at dawn.
At six o’clock PM, another bit of consternation occurred, this time only one hundred meters from where I sat trying to Spell-Check and send by attachment the events of the day through the fragile wireless connections. These events detailed the extensive on-camera interviews I had with Ajak in speaking about the several different levels of what the mission might try to accomplish under his leadership here—the successful bridal negotiations among the Dinka clans here in this payam; the immediately following overture for peace through an expanded medical mission to the Murle at PiBor the very next day after the wedding feast extending a hoped for armistice and alliance through the Jonglei Province the further medical and surgical education exchange within the whole of South Sudan, beginning with his visit to Old Fangak the following week for further training and teaching what he has already mastered here in my envisioned “Network” of all-Sudanese expertise for internal consultations; and the “International Medical Continuing Education” process I envision with my next promised visit—involving not just Werkok MCH, but the whole of the Payam and “bought into” by the Jonglei Province MOH hosting it in Bor for the didactic and MCH for the clinical application, with participants from Akobo (Michael Pur), Duk Payuel, and Old Fangak, not only, but also from Uganda, Kenya, Tanzania and Ethiopia as I am able to let my friend sin Soddo and Kijabe and Tonga Province Tanzania know of the invitation to TEACH, and TO BE TAUGHT BY, the Sudanese of the envisioned Southern Sudan network. Each of the staff here have already been assigned a topic—they actually self-selected from a list offered along with the audiovisual supporting materials John presented “Malaria” to us, Gabriel just presented “acute pneumonia” to us last night in our “all Sudanese Tutorial” along with Ajak’s annual audit report; Aret is going to present “Malnutrition” on Monday (recognize that these topics are all in the leading killers of mankind on the planet in DAMMM—which we have emphasized every single tutorial, now shifting from our Western focus —I gave all the topics for the first few days of Old Fangak and then assigned each of our team to cover one topic each night of the three that would be discussed, and gradually the team members did two of the three, and then one of the three was done by an indigenous health care worker, until last night we achieved the all-Sudanese tutorial in which they gain the pride and prestige of being the professors teaching US learners how it is that they are able to manage problems here and I am simply the leader of the applause and the summarizer of the good points.
I had been able to access the internet through the Wrights’ small ASUS which I had emailed them as the right one to buy in forwarding to them Chris Tate’s advice to me. I sent on one chapter from Old Fangak, and two chapters from Werkok as samples of the daily activities in this mission and what we hope to accomplish by kicking it up one more order of magnitude to a new plateau, envisioning the medical mission as being an ideal bridge to peace.
[Incidentally, I learned from an email message from Jun Garcia in Manila that “Sorry things did not work out for a return to the Apayao Province of Luna’s Far North Luzon General Hospital & Training Center because of the unrest over the coming election—a surprise to me—but I hope to see you this year.” I immediately emailed him back that I was in South Sudan and rather remote to learn any such news, but still had plans to come forward according to the itinerary I had mailed to him to arrive in Manila on January 17, and would be willing to work wherever needed. Almost before I recognized what was happening, here in the remote South Sudanese bush, that tenuous wireless connection delivered an email back to me from Jun saying he was looking forward to picking me up on the arrival of the Qatar Air flight I had sent to him and we would be working together in the first week in goiter-rich Leyte, where I have often been before—that means I will not only have an even more productive experience there, but will be making my morning run along the Canagao Strait beach to the delightfully-named village of “Arok”—the sound the raven makes while croaking!]
I had just completed the emailing from this miraculous connection in the bush to a well-wired world outside Africa when a great commotion occurred outside. As I went out to take pictures of the huge red setting sun, magnified by the smoky haze of the burning bush, I saw people running from the tukuls just over the road adjacent to the three tukuls built by Peter, our “pioneer” who had been assigned by the Comboni Fathers to come here as a teacher of Arabic due to his separation from the family and interment in Khartoum for much of the war years.
Peter was the pioneer of this compound having arrived in 2006 as the Comboni Fathers had sent him to teach Arabic, one of his skills as he had been in forced residence in Khartoum during the long GOS/GOSS war. Peter had aspirations to be a teacher with the avocation as an evangelist. He had hoped to continue his schooling, and had arranged everything for him to be sponsored to go to India for further schooling which at the last moment failed because of the lack of $200 US. He was then sent down here to the open field adjacent to the few tukuls that were Werkok in 2006, to start up a school program. He was here when PCC-Sudan surveyed this site as a potential for establishment of a medical center and was the first one hired as a translator and evangelist.
Dr. Ajak and his Alberta Canada fellow Lost Boy Doctor trainee Dr. Deng were brought here in 2008 only very shortly before I arrived and was gong to work with them both in helping establish the hospital. It was during my stopover in Duk Payuel that the miscommunication from AIM Air that told us there was no way that we could be accommodated in Werkok and to scratch this site form our 2008 visit—as Drs Deng and Ajak were waiting with cases in theatre and the beds made and our dinner cooling. When they heard we were in Duk Payuel, they asked to get carried in the AIM Air plane that would have carried us to them and they made an immediate visit on a round trip from Werkok to Duk Payuel to meet me and to discuss the association that would have been conducted on site if we had not been prevented from arriving by some interjected miscommunication in our plans.
Peter was, therefore the senior most PCC-Sudan appointee, and the two Lost Boy Doctors were the next two, with a combined Hospital Administrator function absorbed by Ajak until the hiring of Jacob only four months ago. Meanwhile, Deng had received an offer for a local NGO “Medical Care Sudan” in Bor, and left reluctantly from MCH Werkok leaving his colleague Ajak on 24/7 call as the only doctor—this separation occurred immediately before my visit here in January 2009 in what Dave Bowman called the single most successful medical/surgical mission they had ever seen, thanks largely to the very resilient self motivated team of surgical residents and Ob/Gyn and medical students from a very positively re-enforcing team—much like this year’s group. In order to leave for continuing education, Ajak has to call upon one of the two lost boys in practice in Bor to cover him. One is Deng, who had been frustrated since the NGO was blocked and had to go back and forth to Juba to continually seek the clearances to carry out their mission. Only recently have these blockades been lifted and finally after the year since he left MCH will Dr. Deng be able to get back into clinical practice with the NGO which had been otherwise foundering, now rescued by from the political impasses. The other fellow is Dr. Samuel. He is another of the Lost Boys who had made the John Garang sponsored trip to Cuba where they were raised and learned in Spanish their primary education. It was a paradise for them, and they enjoyed the ambience of Cuba but for missing their families and their home culture and they vowed they would return in some capacity to help their people. Ajak had first thought he might try to study law to get into the political resolution of the civil war stalemates. Many of the boys in Cuba were sent back to Sudan where they were immediately put into front line command positions in the SPLA and virtually ALL were immediately killed. This would have frustrated the long term goal that John Garang had envisioned for them to come back to help reconstruct their devastated country which may have made considerable progress against the predations of the north through attracting international attention in the North /South War but was now blown apart by the continuing Civil War between Nuer and Dinka leadership and even more finely drawn tribal disputes such as Murle/Dinka and even the sub-tribal clan wars such as Dinka Bor versus the Duk Dinka etc—which I am growing altogether too familiar with and which will constitute the major stories of this and all other days of our visit and long after we are gone unless some directed action is taken. Perhaps the “Surgery” bridge over these barriers can be the “Surgery and Healing in the Developing World” that is so desperately needed here as you will soon see as you read on.
FROM THE ABSTRACT, TO THE BLOODY CONCRETE, AS WE GET INVOLVED IN THE LETHAL CONTINUING TRIBAL WARFARE HANDS-ON AND UP-CLOSE AND PERSONAL
John, from our compound grabbed the AK-47 and ran along with the crowd and they all stopped about one hundred meters away at the road side right near the hospital—in other words, my regular running route.
There, at roadside, in front of MCH were the bullet-riddled bodies of two Dinka men who were then recognized as the men-folk of the tukuls across the road from us. We knew this from the mournful wailing and ululation that came almost immediately form the tukuls over the road. We did not go out to see, or photograph (!) the bodies—-remember the great disruption caused by the construction team at Duk Payuel who had gone out on such a report while the Duk Lost Boys Clinic was being erected and some members of the team posted on the internet the pictures of a pile of bodies of the Dinka/Murle dead from a clash that had occurred in Duk Payam three years ago. It was such indiscretion that gave rise to a long missive about conduct by outsiders written by a few folk who had never even been to Africa stating that all statements made or photographs taken were the immediate property of the DLBC Board and they had censorship rights over any and everything that would happen there. This is hardly a set of circumstances that would make me an eager volunteer to go there—and probably such restriction is a greater deterrent than the news of nearby violence or the photographic evidence made available to prove that. But, we stayed in the compound, although a number of our team looked on through binoculars.
And, that is not all. About a kilometer down the road toward Bor further along my early running route were two other casualties. These were two young Dinka men who had gone to a church meeting in the large thatched church along the road which is in the classic mediaeval “Cruciate” style complete with nave, choirs and chapels, all under an impressive elephant grass thatching. They were retiring just at the cooling part of the evening in the golden glow of the slanting sun, when even the persistent plague of flies in the eyes was subsiding, and as they walked the road, both were cut down by gunfire from a tree I had frequently passed and had photographed as an example of the ironwood tree growing in association that is symbiotic with a large termite mound. One was killed immediately. The other was shot through the abdomen. He was scooped up and taken to Bor, where Dr. Samuel, who has about the same amount of experience as my freshmen medical student trip participants, was backed into doing an emergency operation. He resected four segments of penetrated colon each of about three centimeters of devitalized tissue on each side of the penetrating AK-47 wounds through the gut. He left two drains in the abdomen and got him out of theater alive and without shock and no other vital injury such as kidneys as the urine was clear. No, the fine points of the surgical procedure (such as the difference between the right and left colon and primary repair, and advisability of doing four segmental colon resections for multiple penetrations—these are subjects for the later tutorials on Monday. But, that he did ANYTHING at all, let alone something that resulted at least in the survival of the young man who will develop complications later in the context of a living patient—this IS the remarkable story. He has not had a surgical residency, nor even a second hand view of what he just had done. But, as he would later tell us, he DID have to DO something, and with no blood transfusion in the makeshift facilities of the still bombed out Bor hospital—the main ward of which still has no roof—he did what was urgently needed—and well.
He did not have long to savor the triumph of his first laparotomy on a survivor. A fellow I would later recognize from the red tee shirt and blue sweat pants he was wearing as he had been going down the road from Werkok was brought in, those same sweat pants and red shirt now bloodied. He was brought in as a casualty from yet another “incident.” In this one he was with a group of young Dinka men, and a shot rang out. The others turned to see their fallen colleague with a highly significant injury. He had been shot through the head, the entry wound being into the right eye. There was no thought about the salvage of that eye which was exploded, but he still DID have vision from the right eye, and he seemed alive and moving all extremities when I saw him later. He was brought in with the remarkable story that here is a young Dinka man with a through-and-through penetrating wound of the head entering through the left orbit and exiting from the right face, with both consciousness and ability to move his extremities—in fact, he was swathed in a head bandage and able to ambulate with assistance!
Now, I knew NOTHING of all this, at the time it was happening, and knew nothing for sure among the rumors that circulated, except for what I had witnessed directly here and that was the gunfire at 6:50 AM that had preceded the other stories which I picked up later in the day as the body count kept rising. I then directly witnessed the recovery of the two bodies within a hundred meters of the hospital at the road side and conducted the evening tutorials against the backdrop of keening wails of mourning family in the three tukuls across the road. To say that things happen fast here in the tropics (against popular misconception of indolent sleepy villages and the events within them) is a true statement since there are but two classes of all life here—the quick and the dead, since in the tropics, the dead do not hang around long. There is no time to send for distant family, no period of grief to go through stages, no embalming no viewing, just a rapid wrapping the body in a blanket and a quick period of the ululation of those who are closest to the event before a burial within the same day, especially if it is in the heat of the day.
That is happening around me at the rate of , by my count, four deaths and five injuries—so far today—but stand by more is yet to come. I am lecturing and demonstrating on saving infants and children from diarrhea and pneumonias to have them grow up healthy for productive lives terminated abruptly by nearly random spear-thrusts and AK-47 gunfire.
IT IS SATURDAY, A WEEKEND DAY, AND A “LIGHT CLINICAL DAY” BY ALL PREDICTIONS—SO STAY CLOSE, ON DUTY!
So, my day was bracketed by killings, fore and aft. The killings were a result of the tensions between clans and tribes and languages and cultural systems, both deeply embedded in cattle culture. It takes a long view to rise above the immediacy of this “background noise” and state that this is precisely the right time to be here and to be making peace initiatives to the Murle who are suffering every bit as much as the Dinka. They too have needs—as Ajak had pointed out in the utter simplicity of the exchange of cattle for a bride after long and very delicate negotiations—“it is in every one’s’ best interests for a resolution based on needs—-I need a wife and they need cattle.” That is true here since there is a very high rate of STD’s seen daily in our MCH Clinic. It is even more true of the Murle who have at least as high a rate of UNTREATED STD’s and the resultant infertility—a desperate feature of the cattle culture which means they might be headed for extinction, a cause of great worry to the tribal elders. One narrow view might be the opinion of one group: “Good! And their extinction cannot come around too soon, so let’s help hurry it along!!”
WHAT IS IT WORTH TO YOU TO GIVE PEACE A CHANCE?
Our overture is based in a biologic needs approach to the potential for a never-ending series of cattle raids and child kidnapping and bride stealing—all of these might have been abstract concepts and far-fetched hypotheticals if it had not been for our first hand observations during the course of multiple trips here to the South of Sudan. There is very little abstract about a pile of dead bodies, or the queue of cattle moving down the road to new owners or the kidnapped woman I had treated from the Duk Payuel area who had been snatched as a young girl and brought up as a Murle with even the addition of the dot-matrix-like Murle facial markings. It was only during the internationally brokered cease-fire that she ran to Duk, where she was seen as a Murle invader until she could describe the hut under at tree where she had been as a girl and tried to return greeting s in Dinka. She had been married of to a Murle during the early parts of the war and had two sons. She had been presented before the chiefs as a wannabe returnee Dinka and the chiefs accepted here even giving her to an understanding and long-suffering charitable fellow who took her as his wife. But, she had had to leave her two sons behind in making her break to return to Dinka and now when I had seen her—with her distinctive Murle facial tattoos standing next to her new Dinka husband with the characteristic Garrh—linear cuts in the forehead of the Dinka—she had a problem. Recurrent PID and infertility had led her to seek help in salvaging the one true value she thought made her a woman, her capacity to bear more children to replace those lost to the Murle. And this is not an abstract story at all. Peace here is not an abstract term. I am going to treat the Murle, as we have the Dinka.
EVEN AS I WRITE THESE THOUGHTS, I AM CALLED URGENTLY TO THEATRE FOR THE RESUSCITATION OF THE SURVIVOR OF TWO DINKA WOMEN WHO WERE ABDUCTED AND BOTH SPEARED IN EXTRACTION OF INFORMATION OF CATTLE MOVEMENTS FOR RUSTLING
Incredible! I am just now writing these thoughts as I am summoned and have just now returned from theatre. The story is as simple and as repetitive as any twice told tale in the South of Sudan, probably a re-run of similar stories told through media like fireside legends long before it was stored in laptop computer chips.
As I ran yesterday morning, the Murle raiders who had made an unsuccessful pass at the Dinka cattle herd adjacent to my running route had fled with unknown losses inflicted by Dinka cattle guards—an old fashioned Wild West shoot out at rustlers in a raid. They DID likely draw blood from the evidence of the drag line I had seen this morning on our run out to the 45 minute turn around point, which we did NOT reach yesterday morning lest I interject two white road runners into the already complex events that included murder among a litany of other lesser crimes against which there were few scruples. This time I had seen where a body of some sort had been dragged through the dust of the bush .
In retreat, and apparently before the Bor-mobilized Dinka troops were trucked out here an hour later, the retreating Murle who had a stronghold further east of us abducted the two Dinka women. They hustled them off toward the forested area around their terrain and asked them if they knew where the cattle were likely to be moved to. The first woman did not know and insisted that she did not—there was no further use for her, therefore, and she was stabbed with a spear with a single thrust through the chest and died immediately and was left to lay where she fell. The second woman, who was the one who became our patient, was carried to their forested hideout as the Bor troops were searching –safely, but ineffectively—closer to the road on which I was running. They asked her repeatedly, and either she told them what she knew or imagined, or whatever of the movements of cattle, which they had been trying to “prod out of her” quite literally with the spear that they penetrated her chest wall in multiple places, and apparently in two sites where they entered the pleural cavity and she sustained pneumothorax, left>right. It did not result in a tension pneumothorax; however, as it did not appear that the lung was similarly penetrated. She alleged to one of her “rescuers” later that she had lost a lot of blood, but that point was unclear and from what source it was lost.
With a final thrust she collapsed to the ground and the Murle moved on leaving her where she fell convinced that she, too, was dead, making for a double kill on rather easy-to-die Dinka women. The Murle moved on and she remained until she recovered and stared to make her way back—an attempt at self-rescue. Only later in the following day—i.e. this morning, when I was out doing my own sunrise run this morning, did the Dinka who were sent out searching for the women who had not retuned to their tukuls as they had been sent out in search of firewood, and she was found collapsed again. She was roused to tell here story, and the circumstances including where it was that she had seen the other woman killed, so they could recover that body as well as get the still-alive one back to the MCH.
This is when I was called. We had already done our rounds and had reviewed the inpatients and gone over the Monday theatre schedule. Ajak was at the hospital and I was typing since the generator had come on for the OT use, particularly the A/C. I arrived as Kathy had already started an IV and had already given the first two grams of cefazolin and Ajak had already evaluated the chest wounds. He had done a good job without any hysterics and had calmly supported her, with a single spokesman summoned who happened to be a brother in law.
I evaluated here as well and noted that she had a pneumothorax, but not a tension pneumothorax. She had hyper-resonance over the left side and subcutaneous crepitus over the left anterior chest. She had reduced breath sound on the right side but had a “tambour” effect on the left yet no distended neck veins and no shift in the mediastinum. We examined her back and found similar wounds which had already been marked on a drawing by Kathy.
Her BP was OK and here O2 Saturation was 84% on pulse oximetry. She had already proven a very effective “stress test” by surviving a day and a half in the bush, and her problems appear to be more closely due to EXPOSURE than TRAUMA. We determined that she be kept warm under blankets and infused three liters of saline and then we would re-evaluate, particularly by pelvic exam since the earliest reports were that she was raped as well—a “red herring” of a story not further substantiated. I had asked if a witness to her report could be found to confirm that after her injuries she had attempted her own self-rescue and a second to ask would be the report of bleeding –form where? It turned out that she had made a fair distance on her own and her bleeding was related only to the superficial chest wounds, and not vaginal or other sites. So, she is being treated now by IV fluids and support with local wound care—exposure more than shock.
I asked the family observers if it would be OK if a documentary team filmed the interview and assurances by Ajak who would continue to manage her and was doing a good job. They agreed so I ran back and got them and they made footage of us in the theater until the theatre suddenly appeared to b e rather crowded with an excess number of bodies clad in bush clothes. So, on camera, I announced that Dr. Ajak was in good control here and I was not needed so I would absent myself and take a lot of the extraneous people with me. The patient was cold in an environment in which we are all warm, so I thought we would NOT use the OT A/C and give her one more bottle of IV fluid and I would stop by in an hour, even as our vehicle was awaiting our transfer to Bor and our lunch here had been canceled,
PEACE IN OUR TIME?
The limits of our understanding always come along with our culture. Gene said to me “I cannot understand petty violence.” The woman whose Petty Violence was experienced on the point of a spear probably did not consider it PETTY, but the pattern of this small scale continuing conflict is accepted in a cattle culture competing for scarce resources—water and grazing being an unceasing demand brought about by having too many cattle. Geoff asked, “Why the need for more cattle? Are they so hard to come by?” I asked him “Why the need for more dollars?” Our currency translates very readily into the other values we exchange them for, such as several barrels of Jet A fuel to bring us here with all the attendant costs involved in moving us from the far side of the globe. Their cattle represent fertility—both as respects the fecundity of the cattle themselves and the fertility of the humans upon which they depend, and the one bride price we know for certain since it will be coming down the road passing MCH this weekend from the relative security of the Abraham cattle camp on the West Bank of the Nile are in direct exchange of r a bride named Tabitha coming up the same road with an entire clan in attendance for the special events we will witness signifying a fair exchange. This was expressed by Ajak as a “NEED” on each side of the deal. After those needs were met, as Mazlow might say, there must be some other value associated with acquiring more—like the arbitrageurs on Wall Street disappointed with their piddlly twenty million dollar bonus deflating their self-esteem. It is easier to see out here than at home as one goes over the net worth balance sheets, but that the real value of cattle is not simply in offspring, or even status, but a direct and immediate worship—like a Mazzerotti is needed for transport to work every day.
WHAT IS PEACE WORTH?
MISSION MEDICAL/SURGICAL CARE AS A BARGAINING CHIP
What price peace? If they do not want it, it won’t happen. If the accommodation of such nearly daily losses in the cattle culture can be continued as acceptance of losses to maintain a life style that persistently worships the medium of exchange, there is nothing we will do that will change that. In fact, they may value our mission medicine, and they are even going to change the outlines of the Bor Payam to make the formerly barren field of Werkok the new county seat and MCH will be the “County Hospital” albeit, still owned—and staffed and supplied—by the Western supporters as a mission hospital. The health system is better served inside such a volunteer organization since the graft tolerance is lower—not absent—but lower.
I can hear already the eager acclamation with which the chiefs who have agreed to meet with us are clamoring for health care for their needy people, but they will agree in lip service to any matter of assuring peace, but have no inkling of how their culture can persist without the continuous cattle wars. How else is manhood achieved and fatherhood procured? If a naïve Westerner enters such a negotiation and accepts the assurances that all peoples served will henceforth live in peace, they have not had any life lessons in reality—in a cattle culture, in Africa, or in the military industrial complex of America for that matter. “I Hate War” is an inscription carved in stone in the memorial for the most war-waging US president in US history and he was admired for his persistence in pursing peace to victories. In South Sudan I have often heard that each side decries the violence inflicted upon them and the cattle losses they have sustained in continuing raids around Duk Payuel I had heard the urgent insistence that all Murle be disarmed. I asked them “”What about dis-arming the Dinka?”
: Never! We need the AK-47 to defend ourselves against the raiding of the incorrigible Murle raiders, and to secure our women and children and cattle from their depredations!” “Wouldn’t they say the same about the losses to their cattle herds from Dinka raiders? And, why do they need to steal your cattle —and would they not have a decreased need if they did not have a plummeting population of infertile peoples that we might be able to address with a medical mission to help treat them?” No, a plummeting population is what they deserve and which we fondly wish and are seeking to complete in a process that is divinely predetermined.” OK, enjoy your wars, but in the absence of our extended offer of volunteer medical/surgical missions assistance.
LATE WORD: A SPECTACULAR RESPONSE TO A SIMPLE TECHNIQUE AS THE SPEARED PATIENT DEVELOPS A TENSION PNEUMOTHORAX RELIEVED BY NEEDLE ASPIRATION
I was in the theatre with Ajak and the team—most particularly Kathy, Adam and Dee, with Adam carrying out his paramedic duties spectacularly as the Dinka woman was carried in as an emergency. It was ironic, since Kathy had so arranged the stores that we had emergency response kits. Included in the set up were IV kits with IV fluids. Adam and Dee were about to perform a training exercise under Kathy’s supervision—they were going to insert IV’s into each other. AN IV access is one of the first and most important responses to anyone ill or injured after securing the airway, and they were on the case as Ajak walked in and asked “What are you doing?” They told him, and he responded, “Well, here is a chance to do it for real!” The woman had been carried in and thanks to the Emergency Response Team being set up as a training exercise, the patient was the beneficiary of the expertise of Kathy and Adam and Dee already exercised in the abstract, and now in the concrete. Adam had trace a ball point pen circle around each penetrating injury so that Kathy had drawn a figure showing the front and back view of each numbered wound so we would be able to find the one that was either blowing bubbles or bleeding, and not ignore any of the others if one or another were addressed primarily. Ajak was on the scene, and evaluating what was possible to find in the absence of any fancy testing such as a chest X-Ray, which anywhere else would hardly be considered a luxury “”Extraordinary “test, but since there is none such available, we now go back to what God gave us in eyes, ears finger tips and the brains to connect them. I had shown the difference in the “tambour” by percussing each side of the chest and hearing a much more resonant area in the left chest than the right had assured them that there was a pneumothorax in the left chest, moreover likely to be a “tension” pneumothorax since the patient seemed to have a large amount of “crepitus” over the left breast from subcutaneous emphysema. It also seemed that she was perhaps shifting her mediatinum left to right, although she did NOT have distended veins in the neck on examination but then she had been over a long period of time in the bush without drinking or eating and was dehydrated on arrival. The IV was useful in pumping in over four liters of fluid and she still had a measurable O2 saturation of about 85% so I agreed with Dr. Ajak that we could watch her at this point and see if she was getting better or worse, the former maybe allowing us to go to Bor as planned, and the latter an indication for remaining with her, with the one thing I wanted to do not available to me.
I had suggested a chest tube. They have no such tube nor do they have any understanding of how such a device might work and save lives. I tried to give them an on-the-spot description of the “Pneumodynmics” of “Chest Tube Physiology” showing them that a sucking “open” pneumothorax is survivable, but a tension pneumothorax, even on one side of the chest, compromises the function of BOTH lungs, and that asphyxia is going to cause death. So, converting a “CLOSED” pneumothorax to an OPEN one is live saving and can be done with a needle or a knife and maintained for a period of further investigation and healing by securing a chest tube to a seal.
They have no “water seal” or “Pleurevac” here—a single package that would be important to carry here for any such emergency in the future which they can re-use indefinitely even though in the Western World they are considered single use disposable devices. But an alternative is a “Flutter valve” in which air can be expelled when the valve is dilated but it collapses in inspiration and does not let air return into the chest cavity. Such valves are commercially made as “McSwain Darts.” (I actually have met McSwain in Louisiana, though I had been using the concept in a low budget application for some long time before he packaged and sold it.) My suggestion is to take a glove, and make a slit in the fingertip and let it expand, as air flutters out in expansion. But in the reverse phase of the ventilatory cycle, the glove collapses and no air goes back into the chest. This is a cheap “flutter valve” equivalent, and may make up for the lack of a water seal. But I will also describe the principle of a water bottle for the chest seal and the differential peruses to be overcome as air is pumped out of the chest, but by Ohm’s Law, would have to overcome a resistance greater than the minimal resistance in the airway, favoring the air flow down the tracheobronchial tree as air is successively bubbled out of the water seal in the chest tube bottle.
Now, about that chest tube. I could carry a few of these on the next trip also, hoping they would not be all used up for some other functions , so that they are not missing when critically needed, but we can make a chest tube right now of other “found parts.” We can use the ubiquitous Foley catheter, even inflating the balloon to retina the tip of it inside the chest. We can use a large bore intravenous (“Intracath”) or with our kits we have something for radiologically (that means ultrasonographically-directed, here) abscess drainage called “Abcession” or Inter-Acess or some proprietary name like that with a pigtail catheter tip to retain it. We will use that if needed. We also have a ureteral urinary catheter that could be used in a pinch.
All of this seems to be a heuristic exercise in improbable intervention events. And then it happened.
On the documentary teams’ camera, I had walked out leading a large contingent of the effusively grateful family, as I said two things—this is a somewhat greater crowd of outside-dressed audience than we should have in theatre and Dr. Ajak is doing a good job in managing this problem; I will take my leave since he is managing it well!”
When I returned, I heard “Stridor” from a distance. I checked and immediately saw that she was extremely restless—a symptom of hypoxia we had emphasized in each of the last several evening’s tutorials. She had shifted her mediatinum to the right. She was using all her accessory muscles to try to get air, in “air hunger” fighting for breath. She needs a chest tube.
In a hurried discussion on the advisability of a chest tube, I again got the many reasons it could not be done here starting with the fact that there is no chest tube and once inserted it could not be managed. SO, I resorted to plan B. I shoed them how the chest was VERY hyper-resonant on the left, compared to the right, a sign that is even apparent to the boom microphone that Glen had elevated over the patient. So I suggested putting a needle in the chest, saying that without a chest X-Ray to confirm the pneumothorax and a shift in the mediatinum, (hardly necessary in this case!) one could simply use a large bore needle on a big syringe. Plunge the needle into each chest pleura and if there is a tension pneumothorax, the plunger jumps from the syringe on the affected side. So, she needed a needle, in absence of a chest tube.
I would not be doing it. I showed Ajak that if one goes immediately over the rib superior edge there would be less chance of going through the neurovascular bundle which runs under the ribs. So, with an 18-guage needle on a 30 cc-syringe and in advance the pulse oximeter was placed on the fingertip. It confirmed what was obvious, that the patient was slipping into extremus, with her stridor and desperate air hunger—the oximetry was 60% saturation.
I directed Ajak to insert the needle. The plunger moved back spontaneously and then he pulled the plunger back for the thirty cc’s of air. I asked that he twist the lure lock off the syringe and leave the needle in place and the hissing air under pressure would be the equivalent of performing an “Open Thoracostomy” without a chest tube. A sucking open chest wound is survivable, interfering with only the long partially affected lung on that, but the “Pendaluf” (a term and concept both obsolete, but a first approximation for understanding what is happening here—for which reason I have NOT used this term or concept here) is lethal if it compromises the other unaffected lung as well—collapsing both!
On the first withdrawal of air by the syringeful, Ajak withdrew the needle as well as the syringe. He re-inserted it and withdrew another syringe-ful and this time left the needle in the chest, and on detaching the lure-lock the needle hissed and sputtered—just as an open chest wound would, to expel air.
Immediately, on-camera, and witnessed by each of the clinical observers—most especially Gabriel, John and Aret—the patient improved dramatically, and the pulse oximetry came up to 95%. Even the subcutaneous air (emphysema felt as crepitus—which I demonstrated to the patient’s mother by moving her hand with mine over the left breast to have her feel it) improved. It was not necessary to tell the family that she was better after this simple maneuver—they began ululating and calling out “Hallelujah!” and grasping my hands—which I diverted to Ajak’s and the teams. As I walked out the informant who had been most helpful in telling us the details of her abduction and injuries and the self rescue, came out to say he would be going home now since she seemed improved and he said –through Aret’s translation, on camera—“She is in your and God’s hands now, and we are very thankful for your being here and saving her life.”
I responded “”You are right in one of those since she is in God’s hands and we will try to do our best to follow His will in caring for her, but she is still in danger since she has a significant injury for which we are not ideally equipped in the circumstances here, but I am grateful for the MCH and Dr Ajak and team that makes it possible to extend her help.” Having so said, we then gathered to go for our brief excursion to Bor, so that the team could be disabused of the preconceived Big City Capital of the whole of the Jonglei Province, the largest province in all South Sudan. The kidding had been about the High Rises, Shopping Malls and center City General Hospital, and they would shortly see the grubby trash-line banks of the Nile river port where the cattle are both watered and slaughtered and kids are bathing and women drawing their drinking water next to the latrine functions. They will get a bigger shock when they see Bor General Hospital, which looks rather like it was 1945 Dresden, or the second most devastated city in WW II history—Manila. And we would see more casualties of a continuing “small scale” war and leave behind here an “innocent non-combatant” in serious condition in the Non-Intensive Care Unit without the single item she most needs—a simple concept and device—a chest tube to water seal for a life threatening tension pneumothorax—attained by a Murle Spear for intelligence about Dinka cattle movements!
OUR FIELD TRIP TO BOR AND TOUR OF BOR HOSPITAL WITH DR SAMUEL AND MY REACQUAINTANCE WITH DR DENG IN AN INTERVIEW LED BY DR AJAK OF THREE OF THE THIRTEEN “LOST BOY DOCS” CLASSMATES FROM SUDAN TO CUBA TO CANADA AND A RETURN TO THE PLACE OF THEIR BIRTH
We bounced over the nearly chiropractic readjustment roads passing vultures clustered over the carcass of a Dinka calf, and a more ominous site ahead. “Here is where the tow boys were shot yesterday evening” Jacob pointed out; “And there is the tree from which they shot them.” A little later we passed a pond. All around the pond are the ludicrously dignified waddling “old men” some with long wattles that look like pendulous double chins, and many spread out like weather vanes oriented not to the breeze but to the sun as they are thermoregulating. These are so-called “undertaker birds.” The large Marabou Storks (their real name) serve the function of cleaning up the dead bodies that have littered the landscape. The dozen or more of the storks are standing wait for their next feast. We do not know of the unrecovered bodies, from the recent day’s casualty list, we find that we know of over half a dozen that WERE recovered, and more than half are dead.
We arrived in “Greater Bor” which does not look too different than the village just left, with the exception that there is a little more trash. In addition there are elaborate hand painted signs, in front of shacks which are—according the signs—“The Addis Ababa Luxury Hotel and Lounge”. “Pay-as-you-go Beer—No Borrowing,” announces one sign. A little later we could see the reason for this policy. A fellow stumbled forward in the noon-day sun, staggering to stay on his feet while kicking up the dust, oblivious of the lorries and Toyota Land Cruisers bouncing by him at close range which he was in no condition to dodge. He was a matador with no reflexes. The reason why cold be seen in his left hand which was a sampler bottle of Gilbey’s Gin, and he had his other hand extended, no doubt begging for cash to supply his children with footgear, or buying bread for his aged mother, or getting an operation that his sister desperately needs—etc. “Khawaja” are the Dinka name for “white men” the Ki-Swahili equivalent is Wazungu. They are all easy hits for those who can put on a good mendicant performance, but I would rank this latter fellow’s appeals as less than convincing to wrench support from this cold-hearted humanitarian.
We made a plan heartily concurred in by our over-eager “tourons” packed in the back of the Toyota Diesel Land Cruiser and tightly wedged enough to prevent being tossed around randomly. I was in the front seat (left side passenger side) along with Jacob as john was driving. Everyone was tossed around, but we needed a large number of stalwarts to make such an excursion since the assembled man power is the “starter motor.” To get the Toyota to start, it needs to be pushed a considerable distance. Even after that it coughs a few times and some mysterious process must occur under the hood. Further there has not been a trip in my experience in which something did not break—often a flat tire. This time was no exception—a left rear tire. When we are all reassembled in what the early slave traders called “Tight pack” we bounced along through the rough ruts. It is occasionally when someone hits the ceiling of the high roof of the Toyota that we call out “Bump!” an announcement as superfluous as it is late, invariably. So, getting there is not quite Half the Fun, but it is for that reason that one must have a good reason for getting to Bor to do something necessary and worth while when there. This is Saturday, and the government offices are not necessarily any more eager to be here and open than they would be in Washington DC on the weekend, and for the sundry meetings they wish me to have with various ministries, there is inevitably the suggestion that “I come back on Monday, etc.” Since I have already done the full court press on Medical Diplomacy, which nearly always consumes a full day, I will delegate the well-wishes to others and continue to work as needed, and will make the formal handshakes to seal the deal as they say in such negotiations as at Copenhagener recently (after the details have been “worked out by lower lever emissaries,” as they almost always are NOT, as was also the case with the Copenhagen conference on dealing with Global Warming.
Everyone thought I had exaggerated the condition of the Bor General Hospital as a wreckage of war. It cannot be as bad as I had described, with the roof gone and the structure a bombed out hollow shell from which the patients have retreated to sleep under the magnificent spreading mango trees. No, it could not be that bad; it is worse. The shock of recognition of the hospital where “Dr Abraham,” father of Ajak, had worked as a physician’s assistant, and Dr. Samuel’s father had worked as well, is only that something must have taken place in this site in better times of which the present is hardly a representative slice. There are patients spread out in scattered smaller outbuildings, with the large tent like structure left behind by MSF which left after the war. It is an oven right now since the A/C went with them, and it is used only for stores. The sign which announces “Operations Theater”’is over a door way behind which is stored charcoal bags as cooking fuels.
We met Dr. Samuel the newly placed Lost Boy Doctor from the group of the thirteen who are in practice in Sudan, all classmates of Ajak. Dr. Deng, who had been his MCH partner for a year before taking on the frustrating job in Bor of leading an NGO which was never functional and was obstructed until its further thrashing through multiple trips to Juba as political deals were struck to get him back into operating as a clinician The two other :Lost Boy Doctors and I would hold an on-camera interview “under the mango tree” and “in front of the bombed to oblivion ruins” of what had been Bor Hospital to point out the contrast between the ruins of the past and the hope of a better future. I identified myself as one of the “Muchachos perdidos” and brother to each, as they tried to work their way through to a resolution of the multiple and complex situations of the current continuing warfare all around them.
When asked by Ajak after interviews with the three of them among themselves in their Albertan Canadian English as well as their Cuban Spanish, and a little Dinka-Bor thrown in, we all agreed that something MUST be better and soon. I pointed out a few hopeful signs despite the strong reality reminders all around us, such as the boy shot through the skull being led along the path behind us for a first dressing change since he had been shot though the left eye. Here we sit in front of the ruins of their father’s era hospital. But here is a new and hopeful generations of the best of the Lost Boys returned. I had asked Ajak to describe for the others the technique he had used to aspirate the first ever aspiration of a tension pneumothorax in MCH. It is simple, without X-Ray or fancy equipment. So is bowel resection for penetrating Gunshot wound, which I had just reviewed with Dr. Samuel. I then pointed out that each of the two of them and only within the last six hours had saved a life without the application of techniques they had learned on site and without ever having seen or performed them before but all around them they were witnessed by a half dozen others now empowered with the concepts and techniques to manage similar problems in the future. So there is hope for the treatment of the casualties of this tragically –afflicted area. Now, if only we can extend that hope into prevention—and we will start that with overtures in the next coming week.
Another point to be made, is that each of these lost boy doctors is in a personal transition of their own in a very important part of their own life in a commitment to stay here and help in reconstruction in the fulfillment of the marching orders given to them as small boys, age eleven by Dr. John Garang—their George Washington of the GOSS and commander in chief when they were rescued as child soldier trainees from the firefight for which they would otherwise have been simply cannon fodder. They are “Saved to Serve” and none are unaware of the contingency of their own continuation.
Both Samuel and Deng are “Advisors” to Ajak in another capacity. Each has been married within the past year. Furthermore, each has a wife who immediately did what Dinka wives are predestined to do. Deng has a three month old baby, and Samuel’s wife is pregnant about due for imminent delivery. That hope and biologic imperative comes as a first order proxy for what they hope is also “abornin” just now in South Sudan under their leadership. How is that for pressure? Ajak reported that each of his advisors counseled him to simply relax at home, carrying no troubles form work to his home, and vice versa, going to work with a freshened hope based in the home base of support. All three are eager to hear of my proposed return next year and a Network that might flourish with representatives from not just all over South Sudan but also from Uganda refugee camps, from Soddo in Ethiopia where the Soddo Christina Hospital might come across the border and join with Michel Pur at Akobo and arrive here with whomever may be representing Duk Payuel at that time and the selected personnel from Old Fangak, perhaps Francis and Peter. The MOH at Bor might take some pride and ownership of the didactic “International Medical Education conference” here for which practical experience will be obtained at MCH especially with the newly enhanced Ultrasonography course to be pioneered by Ajak and his cousin Benjamin who is the new Medical Director of Bor Hospital. I will participate but only under the leadership of the Sudanese who will convene the conference, and will supply each with a topic and supporting materials as requested with a year to prepare. We have already done the dress rehearsals of each of the staff in our evening tutorials which will serve as the model as more and more of the instruction is shifted from me and even the learners from my team to the Sudanese who will gain confidence in being net “exporters” of medical information and wisdom in managing complex problems in larger and more serious volume with far fewer resources than can be taught by Westerners who live in redundancy. Witness just the events of today! These tragedies have given a platform for coping that allows skills to be taught from their own perspective in what can be done with however little in the way of sophisticated specialty support.]
LATER WORD: AS WE RETURN THE FAMILY OF THE SPEARED PATIENT WOMAN IS SINGING “Hallelujah!” AT HER APPARENT IMPROVEMENT AS WE MOVE HER TO THE WARD
As soon as we returned under some pressures to scramble from the Nile river bank with just time enough to photo the Osama Bin Laden tee shirts along with the Bob Marley shirts and the even more numerous Barak Obama shirts, we all got the single sign I had marched them to the Nile river bank to shoot. “Be faithful to your Partner (s)!” The anxiety of Jacob to get back quickly before dusk is obviously based in the last dawn and dusk events at Werkok’s doorsteps and on the road leading to it. Further contingency plans should include the fact that they had to change the tire on the Toyota to allow for the return trip despite a flat. We piled in and stopped only once, with a photo in the slanting rays of the sun of the passengers pushing to re-start the vehicle.
I went immediately to the theatre where our patient was surrounded by a large number of families, each of whom raised their hands high and blessed us with cries of Hallelujah! I had smiled but was worried, since without a chest tube she was still at risk if she blew out a “seal” (by clot) of a lung puncture if the spear thrust in any one of those stabs had gone deep enough. It is like a self sealing tire, and if the “plug” were dislodged, she could again gather air under tension in her pleura. But, it was true. One hardly needs a pulse oximeter to note the patient is doing better if the whole family is praising God and holding their hands high, since they recognize that she was in serious condition, and now is better, at least for this time. It was decided that she might be able to get moved from theater to the ward and we went back to collect for the diner of the evening.
LAST WORD: OUR EFFORTS ARE CALLED OUT AS AN ENTIRE TEAM FOR AN EMERGECNY AS THE PATIENT IS MOVED TO THE WARD AND DROPS HER LUNG IN A RECURRENT TENSION PNEUMOTHORAX AND A FULL RESUCITATION EFFORT FAILS TO RESTORE HER PUPILLARY CONTRACTION RESPONSE
It did not take long. Kathy came over and said almost casually, “I think she may need tapping again.” I asked if she and one of the others might want to do it as a teaching exercise for one of the staff. I regretted again not having a chest tube. It was then that Dee ran over exclaiming that I was to come quick that the patient had arrested.
I got to the ward in a minute, and saw that she was already being pumped with the AMBU bags I had brought last year from the redundant stock of Anne Arundel Medical Center which has come along with the pediatric resuscitation units I had also brought. I heard from Kathy that she had arrested and already had fixed dilated pupils. I said one word: “Knife!”
Plunging the blade into the left chest and forcing through a sharp hemostat which I spread wide to let a large stab wound into the chest gave rise to a sharp billowing of air under pressure. Adam was closest and was near blown away. I threaded through the urologic catheter we had as a substitute for the chest tube she should have and periodically evacuated air by the syringe full then leaving the catheter in place and letting the air blow out as the lungs were expanded with the AMBU bag ventilation.
We immediately organized the team into a rotation around a bed board which we placed under the patients as we did five chest compressions for every one AMBU bag ventilation. We placed the pulse oximeter on a finger and pumped and ventilated. The team did well and rotated so that each one was in the loop for at least five minutes on each task, AMBU ventilation while holding the neck extended as the fingers hooked the angle of the mandible to pull the tongue forward and the spring-loaded AMBU bag allowed ventilation on each fifth pulse beat. She had good peripheral pulses in her soft supple arteries without a trace of atherosclerosis, her heart was not big and flabby as might be the case with the patients with metabolic syndrome in the US and she was conditioned by hard work, long walks and was a previously healthy relatively youthful victim, She would have every good reason to be resuscitatable –such as a youngster who falls through the ice and is submerged for over twenty minutes since hypothermia and youthfulness are good preservatives and indicators of a hopeful resuscitation . So we did the full court press and all out attempt by the whole team each of whom followed in turn most specifically including the indigenous staff. I was the one designated to be “Running the Code” but later I put each of them in that same position. We instilled epinephrine through the IV and pressure infused it. We were amazed at the pulse oximeter which showed a pulse rate of 80 from the chest compression and an O2 saturation of 95%–all viable indicators. But when her pupils were examined with a bright light at thirty minutes into the code, she showed no reactivity. She was still warm as she was when walking around, but had no return in her CNS function
We determined that we would try to continue for an hour with three observers checking her pupils at fifteen minute intervals. I was the first and saw no reactivity. We pumped for another fifteen minutes of three exchanges of team rotations of five minutes each. The documentary crew had been quietly and unobtrusively filming, and I even directed the boomed microphone of Glen’s sound boom to the chest to hear the audible swoosh of air in and out of her sucking chest wound thoracostomy. Her pulse oximetry and pulse and peripheral perfusion remained of viable quality. I asked evangelist Peter to bring in the family members a small number at a time, and each witnessed our rather professional team efforts without making a sound, although I had relayed to them through the translation of Peter that this was a grave circumstance and only the power of prayer and some miraculous intervention would help keep this from ending in a very unfortunate demise. They understood.
The next time in, Momma came to hold her still warm hand and felt her pulse, but shook her head when I opened her eyes to shine in the light. I put my arm around Momma, the one who had been trying to kiss my hand earlier in the afternoon, and nodded gravely with her. Through Peter I said in translation, “Yes, Momma, we think now your daughter is no longer alive. Everything seems to have recovered except her brain, and the will of God that governs us all has told us doctors that we are failing to revive her, and as you can see we will now desist. She nodded in response and put her hand on my shoulder and the translation from Peter was “Thank you from her and all of us.”
I gave the light to Adam who shined it into her eyes at 6:54 PM and shook his head and we stopped the chest compressions pulling the sheet up over her face. There was no sound of ululation from the family that had come to terms with her death, it seemed, at the time she was recovered along with her compatriot wood-gathering partner, so both souls were released in their estimation at the same time.
I let everyone think their own thoughts in silence as we all recognize not only Akew’s, but our own mortality, and the stark limits of medical care to ultimately solve the big issue of life, even if we have been almost clever at several smaller healthcare techniques. It is also clear to all that the CPA has NOT meant PEACE to now the fifth of six individuals of today’s casualties alone, and it seems somewhat futile for me to be preaching about DAMMM, and salvaging children from diarrhea, malaria, and pneumonia to have young women who are such sinister combatants as young men returning from and church service and wives and mothers die on ancient spears and hot rounds from the most indestructible and ubiquitous device of modernity littered throughout South Sudan—the accursed AK-47.
IF FURTHER PROOF WERE NEEDED THAT NOW IS THE TIME AND THIS IS THE PLACE FOR “SURGERY AND HEALING IN THE DEVELOPING WORLD” EVERYONE HERE IS NOW AWARE
NO ONE here is unaware of the mission and the gravity of the cause we are pursuing. NO ONE need be told that “Surgery and Healing in the Developing World” is NOT an unintentional “Double Entendre.”
We are here for a purpose. That purpose grows bigger and more urgent each day, and if this day does not do it for you, you need not read the next chapters since they will most likely seem irrelevant. If you think that a surgeon talking international policy toward peace is stepping beyond the limits of his (or her) expertise, what is the purpose for teaching techniques of health care in a very unhealthy environment for women, children and all growing and learning entities?
This is our “Mission to Heal”. Today the scorecard shows this inning has not been our best but the opposition is scoring rather heavily. There is a response that others have uttered: “There is REALLY NOTHING you can do for these people.” That, of course, is the most self-fulfilling of prophecies. To those of that opinion, I would simply agree—Yes, there is noting that YOU can do for these people from this your starting point. Please step aside, since we are going to re-double our efforts to get this task if not done, at least well begun!
“Mission to Heal.” We have not succeeded. But we have not yet begun to try as hard as we still might. We have a week of work here in a theatre that is as big as MCH today, the Payam of Bor tomorrow, and the Province of Jonglei next week. And we will not stop there.