damien's travelogue

Sudan pics

2008-06-18T02:43:00.001-07:00

Top to bottom: Daily workout; check out the mohawk!; my newly-renovated tukul with veranda (until i got promoted to the house); skyline; elderly man; local fish market.

Sudan pics 1

2008-06-18T02:16:00.000-07:00

Top to bottom: Net fishing next to the compound; local "Oakley's"; water-point outside the surgical ward; a beaming young boy who arrived unable to stand or walk - who likely got better in spite of rather than because of treatment, but who cares - check out that smile!; mum's relaxing with kids outside the feeding centre for mlanourished kids.

TB Village

2008-06-18T02:15:00.000-07:00

I’ve just woken from my post-lunch siesta, and I feel all the worse for it. The afternoon heat and humidity is unavoidable, and now I have that groggy, drunken sleeping-in-the-heat losing-half-your-body-weight-in-sweat need-to-peel-the-sheet-off-your-body when you get up kinda feeling. And feeling as fresh as that egg you hid in your old high-school desk was by the end of term, when the lid was chewing-gummed shut and the whole classroom smelled positively volcanic (not that I ever did that)... Back to it.

Outpatients are pretty quiet this afternoon due to the huge storms and flooding yesterday, so now seems like a good time to try and catch up with the 45 TB patients living in the “village” here; I haven’t had time for a couple of weeks.

Out our expat gate, wave to the usually-sleeping guard, left past the new ward being built and then – WHAMMO! – that smell I always forget and am so grateful that I can – past the over-full patient’s latrines to the TB “office”, an oversize mud-hut where Paul, our always deliriously happy TB medic is usually entertaining friends (could it be possible that he’s high on poo-fumes?? Is it like petrol if you sniff it for too long, I wonder…).
Paul, as usual, asks me everything, but waits for nothing. We tap each other’s chests in the Nuer greeting (strangely omitted with women…), he asks (or tell’s me – I can never be sure) about 3 dozen times “You are well, yes… are you well? You are well! Because, eh… you are well…. Are you well?!”
I like it; it makes me laugh, it goes on, and after a couple of minutes no-one is any the wiser about the wellness of the other. But I’ll take what I can get in the way of pleasantries and laughter in this town. Although there’ll be no hand-holding with me on today’s round, I’m afraid! Line’s been drawn.

We pick one end of the village to start from; one of the larger mud-walled and tin-roofed buildings, with many smaller spaces within for the TB patients and their families to make a home for the 6 months their treatment will take (It always amazes me when new patients are diagnosed; So, you will need to spend 6 months here, every day. You must live here. You understand? “But I have three children”. That’s OK, they can stay as well. “OK”. Just like that. Imagine that back home? “Your appendix is pretty screwed up Mr Jones, it’s a real f#*ken mess to be honest. Tell you what: call your wife, tell her to bring the kids on over and we’ll bundle you all into a little unit out the back for, oh, say, 6 months. That suit?! Great. Lets get cracking then…”).

I have never encountered a space on this planet that has more contrasts, more contradictions, or is a bigger dichotomy than the TB village. It’s like a school-yard for intractably happy kids, backing onto the shitty-diseases wing of a large Hospital for Truly Shitty Diseases.
As we approach the first building, the usual gang of kids mobs me; I love these kids the most – they have all been here longer than me, they own this place and I know them all by face and by greeting now. Some want a hug, others want a throw into the air, others want a hi-five (and then a brief game of who-can-whack-the-white-guy’s-hand-the-hardest begins), and one little guy, proudly wearing nothing but a few colourful strings of beads around his waist and neck, just wants to hold my hand for the ward round. Hero.

Then I step into the first room. Village of the damned. A big intra-muscular dose of humility, administered with the biggest f#*ken syringe on the planet right into my arse, on the bit where you sit down. And then a little more on the other side too. Hero to zero.

The scene in the first room: an elderly man with a spine so deformed it would make Quasimodo wince lies on a bed to my left. The drugs we give will kill the TB, but nothing will reshape his spine, or restore the nerves it collapsed on to. Nothing in Sudan, anyway. He greets me warmly. I’m slowly getting to know all the faces. He says he has back pain. I bet you do, sir. I give the first of many “We cant fix it, but we can help it” speeches for the afternoon. Some gentle pain-killers, a shake of hands, and a turn to see the bed alongside his.
This guy is a complete medical disaster, and if you ever wondered how much a human can take, I suggest a visit to this fella. He lies under his mosquito net, which seems crazy as surely it can only be a further impediment to the already minimal airflow in the stifling room (an idea for an oven in the current global energy-crisis: 3 mud walls with a small opening on one side, cover with tin and place under the Sudanese sun for a while). In his twenties, he has a growth the size of his head inside his buttock, and it constantly drains fluid; inoperable according to the previous surgeon. He cant walk, he cant lie on his other side, he cant pee without assistance. He has pain he says. Well, stress not my friend, because here’s the doctor with some paracetamol. And if thing’s get really bad, we’ll give you some nurofen. (Must save the limited morphine stocks for the really severe acute stuff).

Still in the same room, we step past the 8 year old grand-daughter of the guy with the bad back who’s milling the sorghum by hand, in between looking after her siblings. So she wont be breaking the cycle and learning to read and write any time soon then.
But oh, thank God! On the last bed in the room is our little joy of the week – the most gorgeous little 14 month old boy with eyes like almonds, who only 3 weeks ago was floundering in our malnutrition centre, but is now thriving since we started TB treatment. Fan-blood-tastic. Lets continue the round then!

And it goes on for hours, and we only get through half the patients. Twisted spines, hopeless cases, lost causes that probably end up on TB treatment as a “last ditch” effort to try something, but fortunately – and mostly - patients with lung TB that respond fantastically and are happy.
The round can at times seem like an endless sea of people that seem to just want to complain to me: my foot aches, I have a cough, I need more food, my legs are still not working, it’s hot, get back hear and listen to my painful leg with your stethoscope… when I started here, it did my head in, and at certain moments I still have to catch myself to reign in my frustration. I cant solve all your problems! I What more do you want??

But I think I’m getting far better at dealing with that frustration. A sympathetic ear, an “I understand, we will try and help but we cant fix this 100%” goes a long way. People just want to be heard. They see the doctor for a few minutes every week, and the recovery can be slow for a lot of them. Though there’s the occasional bugger that pushes my patience just a little too far – and wants to fight because we wont buy a plane ticket to Khartoum for him, or fly him to Ethiopia to go back to his uncle, or re-imburse his lost earnings while he was receiving life saving treatment. (Though with 20+ years of European agencies handing out things in a place where anything is a bonus, you cant blame them for trying...).

And interspersed in this little microcosm of chronic disease, suffering and at times hopelessness, is that African icon: that ubiquitos presence, and surely the continent’s most valuable resource: seemingly endless numbers of healthy, happy, cheeky-arsed kids with way too much personality (- though unfortunately too-often, almost as much snot, and usually wiped by themselves a moment before they grab my T-shirt or shake my hand with their sludgy, albeit cute little hands).

Note to self: distribute face-wipes next week in the TB village. Or carry hand disinfectant lotion.

A day on call in Nasir

2008-05-18T19:18:00.001-07:00

Saturday 17th May: An actual day on call here

My mobile phone’s alarm goes off at 6.45am, and reminds me that by the way, there’s no reception out here. Among a couple of other things.
Lying in bed contemplating the day ahead (and even possibly how to avoid it… who do you call if you want a day off around here?!), I remember yesterday’s dire “warning” by one of our staff, who approached me discretely, very concerned, outside Outpatients.
“Dr, eh, big problem here in Nasir. We need surgeon back quickly, very ‘portant, or you need help us. There’s outbreak in town – you hear about it?? Many peoples suffering. (Bite of lower lip and shake of head)…. Sufferings….!” Head still shaking.
Fantastic, thinks my selfish brain. Because the hospital’s not busy enough, and I don’t have enough to do…. What’s it now… Cholera? Measles? Meningitis?
He hands me a folded up piece of paper – carefully – and asks me if I know about “thises diseases”.
I unfold the paper many times. Good Lord, which of the biblical pestilences these people present with daily is now going to inundate us…?

There’s only one word on the paper. I kid not: “Haemorrhoids”.

But this morning’s affair is a little more serious. I have to decide by 7am whether or not to divert the MSF charter plane to transfer one of our patients for surgery.
The dilemma: The guys likely got appendicitis. No biggie. But our surgeon’s left (note to self – no more missions before I can do Caesareans and appendicectomies). So I have to make the call (and like all patients here, every time you ask about their symptoms, the story changes completely. Pain for 3 weeks, no 1 day, here, no there. And until the moment they are discharged, most patients have a very melancholic, serious demeanour, which is hard to differentiate from mind-set rather than a severe underlying medical condition…). On top of that, one of his friends is a very powerful figure in town and wants him transferred. Not a bloke you want offside, so a potential security issue. And it’s going to cost a not insignificant $1500 extra just for the plane to land here. Public health issues are raised. But he’s worse for sure, a call is made and MSF divert the plane. Sorted.

I sneak home – about 15 metres from the ward, just behind the TB village - for a quick brekky and tea. Someone’s on pancake duty this morning. Perfect.

Back to Outpatients. By 8am, there are well over a hundred people waiting outside to be seen. Most days are like this, it seems the village must be on a rotation system. Where do they all come from?
“OK, the western half, listen up – its your turn again today. Everyone to Outpatients. And don’t forget – don’t give them a consistent history. If the bald white one asks you where the pain is, point to one spot, then when he goes to examine it, point everywhere. Just everywhere. Confuse the bugger. And if he re-asks you questions, whatever you do don’t give him the same answer. The longer you’re in, the more likely to get prescribed the good stuff.”

The guys are triaging already, and the four health workers have until 1pm to get through all the patients. I leave them there – they call me often enough when they have questions.

A quick office visit to quickly check my emails, before walking across the drive to the medical ward. There are no empty beds left, but I’ll have to come back. Surgical ward is in more need at the moment – no surgeon for a week now, and there are 20 beds of patients with problems I’m not as familiar with. Families and friends are already crowding everywhere; cooking just outside the ward, 4 on a bed “Its going to break – I told you yesterday – off!”, the kid with burns providing the always present background sound of crying-baby, despite pain relief.

The surgical ward is a large corridor of a room, and the right hand side is lined by mostly young guys, mostly in traction devices for broken – usually shot – lower limbs, with one guy that looks like he has an AK-47 stapled to his arm, due to the mass of external-fixation device holding the various remnants of his humerus in place. As the previous surgeon quipped, there’s no ward round here, it’s the “war round”.

Four small cases for theatre this morning. A large thigh gunshot wound that came apart and needs to be cleaned and closed again, a partially amputated finger that needs tidying up, a broken forearm that needs to be pulled straight and a kid with a huge abscess on her neck that needs drainage. No worries. A quick review of the surgical text books (paying special attention to my favourite diagrams illustrating the “DO NOT CUT HERE!” bits of the body), and off to theatre. (I’ll be honest, the procedures I do are small fish. But then when you haven’t spent much time fishing, even catching the small ones can be tricky…).

All goes well, both I and the patient with the battered finger survive my first encounter with the “bone nibblers”. (And I might add – for the first time I understand the real appeal of surgery – theatre must be the calmest, most controlled environment on the continent. And (usually I guess) problem goes in, solution comes out. It all seems so neat!).

Back to the medical ward. Deary me I wish I could have hidden in theatre all day. Some good stories, but the ward is slowly getting bogged down with adults with chronic illnesses we are unlikely to cure. I suck at discharging people, I know, I have to start sending some home. It’s too full. So is my head. An hour of ward round, but that’s a whole other story on its own.

11am, back to outpatients. We go through the usual routine, making a mockery of my attempted teaching sessions (see following blog with some reflections on our health workers). ‘This patient has a fever’. And what else? ‘No, nothing’. Fever since when, what other problems, did you examine them….?? ‘Er, no’. And how long has her eye been bulging out like that with the infection….? ‘Err… I didn’t see the eye’. Of course not. Its not like its staring at you… I’ll come back in half an hour when you’ve examined your patients.

So follows an afternoon ping-ponging backwards and forwards between inpatients and outpatients, trying to put out spot fires before they become infernos. A quick visit to the TB village, where there’s a problem. The health worker is a truly hilarious guy who I cant understand, and he holds my hand in his as we walk gaily to the hut of the problem patient; quite common in Nuer culture and no big issue. Unfortunately the Aussie bloke in me isn’t overly comfortable with this; I opt for a manly pat on the shoulder instead.
We arrive at the problem: a young man, the leader of the ‘food ration rebellion’ where all the patients briefly walked out a few weeks ago in protest of a small change in food rations. He’s finished treatment, and he wants us to pay for a ticket back to Ethiopia for him. He’s insistent and getting testy. Mate, what part of the free drugs, health care, food, accommodation, and you going from the verge of death to the healthy specimen you are now, has caused you to become so angry, I ponder? Oh. So please, take stock of what these guys did, don’t burden yourself with a thankyou to our staff who’ve nursed you these six months, and understand that a chartered flight back to Ethiopia is not part of the standard TB treatment regimen.

Back to outpatients. Young girl with an umbilical hernia that’s stuck, she’s distraught. Quick trip to the theatre, a light anaesthetic and gently push it back in. Too easy, two very happy parents and a groggy child with a normal looking belly. If only it were all so simple.

Back to medical ward; 6 patients waiting for admission. But they’ll have to wait for the staff meeting to finish; yes that’s right; the afternoon sun invites us to swelter beneath it, go through statistics and discuss the numerous issues for the week. I’d rather be on the ward. Or experimenting on my own finger with the bone-nibbler in theatre.

4pm: Find myself standing back on the ward, staring at that all-too familiar sight of a floppy child, with her eyes as yet undecided as to whether they are gazing up to heaven, or still at this world. They always look so peaceful, there’s a resignation in those eyes as they roll back, then re-engage with you, then close. But with some quick initial treatment she picks up, and for a moment I am actually confident she will make it (naïve, overly hopeful or just inexperienced….?). We take her off the drip to weigh her quickly, she stands there, she shits, she sits down on her mother’s lap, and she dies. Just like that.

Another body in a blanket in a cardboard box.
Another wailing family.
Another fuck-up.
Or is it? I have no idea. She’d been sick for weeks and bundled in only now. Probably no chance. We seem to be doing what the books say, what my course said, what I think is right, what I learned at home (But then what if I’m just reading the wrong page of the manual...? And you don’t get kids this sick at home – other than the annual presentation that is this sick, but you can be sure you will be standing in line behind about 10 specialists attending to them). If only to have a more experienced Dr standing next to me to reassure - or reprimand - me.

Anyway. Next admission needs to be done.

____________________________________

On my way back to the compound for a quick dinner, I get accosted by the same rapidly-expanding gang of young kids from the TB village that track me down at least daily. “Throw!” they yell in Nuer. Seems I’ve backed myself into a corner here… my occasional throwing-and-catching of a young kid into the air has now morphed into a daily sport for them… only the numbers are growing, the sizes are increasing (some of these ‘kids’ almost equal my height), and my back is giving out. But I can’t resist, and the contrast with the events that passed minutes ago on the ward are not lost on me.

Nine little briefly-air-born-reminders of why in fact I am here.

A quick dinner and an even quicker half-beer. An episode of Friends on the DVD player. And to chase it all down, a call to Maternity. And yet again I find myself in theatre, yet again an unfamiliar set of tools in my hand (not the fancy ones of the rare Curettes I have done in Australia), Curetting a woman who has retained-products after a miscarriage, and heavy bleeding.

But finally…

She stops bleeding, I stop thinking, and a cold shower washes away the day’s memories. To sleep, to pray, not to be woken by another disaster again tonight.
Or for that rumoured Haemorrhoid outbreak not to strike our over-stretched hospital…

Months of shit food

2008-05-18T19:15:00.000-07:00

Having been here a few weeks, and having walked the river’s edge at sunset (on those rare evenings out of the hospital); watched the thousands of birds fly north on their morning mini-migration, only to return in the evenings as I sit below, awed by the audible swooshing of their thousands of collectives wings beating them across the east African skies; and having jogged through the town at dawn, as families stir in the rapidly waning coolness of the early morning air, I am moved to describe this town, my home for the moment, thus, in the most descriptive prose I can conjure: it’s a dusty shit-hole.

But change is afoot. I will despair not.

Its rapidly becoming a muddy shit-hole.

The rainy season arrived 2 days ago following a sarcastic remark that now appears to have revealed a freakish gift for prophecy; when we asked one of our national staff when the season started, he joked at 2.12am on the morning of the 12th. He was off by a few minutes.
On cue, the storm blew in during the wee ours of the morning, a deluge of rain so grand it was as if the gods were trying to make amends for centuries of drought in a few hours. Meanwhile, I lay with a sheet over my head in my mud hut, reassuring myself that my understanding of the behaviour of materials was obviously wrong, and that the sturdily patted-together walls would surely hold up against the horizontal rain.
And contemplating the cunning design by the hut’s architect whereby the top metre of the walls is left open in all directions – obviously to facilitate that wonderful interplay between expatriate, mosquitos, scorpions, rain and other delights of this region. Like trying to sleep with a garden blower in my face. With a bloke dumping handfuls of sand and leaves in it periodically, just to shit me.
So as from today, gumboots are the official footwear of choice for the coming months. Muddy shit-hole indeed.

This last week in the hospital has been a little kinder to me; just a little. Following the departure of our midwife (fortunately not permanent) and now also surgeon this morning - with no one yet to replace her, I found myself the general attender of all problems large and small; interpreting Obstetric problems by torchlight at night, with ye olde illustrated “Obstetrics for those who’ve never done it!” (unintended pun there) guidebook in my other gloved-hand; and – a profound-sweat inducing time this afternoon – releasing the tightened skin on a young boy’s penis to reduce the damage from swelling after he burned it standing too close to a fire, on top of this morning’s efforts at debriding dead muscle from a bloke who shot himself (accidentally I presume) through the thigh a couple of days ago.

On a massive upside, we have had no deaths in a week now, in contrast to the mayhem a couple of weeks ago. I also survived a now second attempt on my life by the Assassin (“cook”) with yet another night spent in a feverish haze with frequent short vacations to the latrine.

I’m getting to know the local staff in the hospital a lot better now, which has provided for some sobering moments (“no, I would empty about three-quarters of that syringe into the bin first – yup, that’s bordering on a lethal dose you’ve got in your hands there tiger…”), but far more humorous moments.

First, the disclaimer: It must be remembered that these guys grew up in an extremely volatile context of civil war, with a government that actively bombed them, their food distribution centres, and their pets. Contrast this with my government that built pretty squares, argued over a flag, charged the “outrageous sum” of peanuts to go to uni for 6 years, and fined me for doing 111km/h on a highway that you could comfortably land a 747 on. Consequently survival skills are the order of the day here, formal education a luxury available to few, medical education almost non-existent. Suffice to say the standard of most of our health workers is far below what would be encountered in most other countries/settings.

Second: the funny stories. I am acutely aware of trying to not be patronising, but I think as often it is my lack of ability to speak their language (hence 2 and often 3 way translations taking place) and cultural differences that lead to these situations…

One of my favourites is the random guess. Usually in the context of taking a history.
So you said this patient has pain in her abdomen for a month now?
“Yup”
Had she had it before?
Silence. Regards the patient, tilts head to side. Silence continues. I’m waiting for him to ask the patient, but something more profound is going on here… yes… he’s guessing!
“Errrr, no.”
“Could you ask the patient that…?”
“No, it looks OK. I think she hasn’t had it before.”

(This technique is also used frequently with examining patients: How long has that lump been there…? “Oh, it looks like about 7 months to me…” Indeed).

Or the random guess coupled with a whacky diagnosis:
(After being called to see a patient, as usual, with no history or examination by the paramedic): So what do you think this (healthy looking kid sitting on mum’s lap with a runny nose) has?
“Cholera!”
Whooaaaa there buddy!! Just like that?! Never mind that there is no cholera here at the moment… Couple of other issues here.... Firstly, did you ask mum what the problems were?
“No”
Well… (Ensue about 4 minutes of intense conversation between them, boiled down to essentially 2 words for me. I know more was said! The answer lies in all that, but I can never get it out….!).
“OK, she says no vomiting, no diarrhoea.”
OK good. Now did you examine the child? Doesn’t look particularly dehydrated to me.
So could it still be cholera?
“No way”.
Uh huh… do you see why I want you to go through the seemingly pointless and perhaps laborious task of asking but a few questions first….?? And maybe even – God forbid – touching a patient…?

Or a shining example of HR management, and how being the new guy means a few staff are certain to see how far they can push it…
“Excuse me Shamiane… [my name here due to difficulties in pronunciation. Don’t ask.]…. But I need time off”
When?
“Tomorrow. For a week.”
But James, you are the only one doing this ward now, your work-partner is due back from holidays next week… you’ll have to wait. You know this.
“Yes, but I wants it now (smiling). Its very important!”
What’s the reason?
“Er… I’m getting married!”
Tomorrow?? And I presume you didn’t plan this wedding just this afternoon…?
“No, [laughing, vigorously shaking my hand], but I forget to say. What about not tomorrow, but the rest of the week….?”
So you’ll shift your wedding, just like that?
“It’s no problem….”

Hmmm. James, you’re not getting married are you? You’re fishing for days off, wouldn’t you say? (hysterical giggling). Yup, I think that’s a great idea; talk to your ‘bride’, explain that you gave your employer about 12 hours notice about your “wedding”, and I’m sure she’ll forgive you and you can shift the whole imaginary celebration…!

I could go on for weeks. Actually, its going to have to be months…

In the meantime, I’m off to uncover more secrets of this organization and this hospital (This weeks big revelation was finding out what MSF actually stand for: “Months of Shit Food”).

Beaten with the olive branch

2008-05-04T15:10:00.000-07:00

Sudan didn’t extend the olive branch when I returned; it spanked me around the head with it.

It’s been said (that means I can’t remember who said it, or perhaps am making it up) that laughter is the opposite, and often substituted reaction to crying. That may explain then why we were all hysterically giggling last night in the “safe room”, on the back of what is undoubtedly the most overwhelming 2 weeks I’ve experienced.

It was about 9pm and I’d just got out of the shower (ie pipe of cold water that opens above your head in a room I’d be ashamed to lock a cat in – and I hate cats), after another remarkably unremarkable plate of food prepared by our assassin (formally employed as our “cook”). Just when you think it couldn’t get worse – hey! – she pulls out another ripper dish.
It’d been a truly shitty Saturday; I hadn’t slept the night before, up in the hospital dealing with various medical disasters (below). Then that afternoon, as we were getting on top of things on the ward, a truck pulled up outside our compound with victims of the previous nights’ cattle raid, all shot and with significant injuries. Them old cattle raids. Back to it.

So by the time I took the shower, I was truly buggered and with a first class Emirates-reclinable-seat-with-eye-pads-and-earplugs-and-glass-of-red-wine-and-sleeping-tablet-so-you-wont-even-know-what-planet-you’re-on-when-you-wake-up ticket to bed in my hand. Actually not quite, but a lumpy bed after a night like that is just as good.
Strolling across the compound en route to my mud ‘tukul’ (hut) from the shower, I heard gunshots in the distance. Our co-ordinator yelled for us to get in the “safe room”, and being a complete stranger to the sound of gunfire with my heart in my throat, it goes without saying I got there fairly quickly, trying to duck non-existent bullets on the way like a tool. With only my towel on. And the rest of the team in the already crowded room. And me now locked in there as well… And the realisation that I may in fact be the first MSF expat to be evacuated essentially naked… And images in my mind of the live press images after our escape, coming down the stairs of the (preferably aforementioned Emirates first class) flight onto the tarmac, my colleagues in their MSF T-shirts… and me in my f@#ken towel. No dignity in that.

I have felt at times in the last 2 weeks that I may have had a glimpse of the 7th circle of hell. Apparently an exceptionally busy and unusually catastrophic period here (re-confirming my shit-magnet status), its been an exercise in sleep deprivation, questioning and sanity preservation (time will tell how well I do with the latter).

It began when I got off the plane last Saturday, fresh from closing an outreach project that week (ie telling a community that for various reasons we could no longer provide healthcare for them, and the staff of 9 years that they had been great, thanks for coming, try the fish and by the way good luck with the future). Bags in hand, I got ushered straight to the hospital here.

And there I was, bag over my shoulder, in the inpatient department only minutes on the ground, staring at a pair of wide eyes, sunken into an oversized head that appeared to be balancing – just – on a child’s skeleton with skin draped loosely over it. Welcome back to Mars. All those old feelings back - torn somewhere between anger, disgust at the situation that allowed this, and overwhelming pity. But the eyes just stare back at me so pathetically. They look so frightened, but maybe that’s just because the eyelids and everything else on this tiny body is just so malnourished and wasted and dehydrated. I never can tell if they are frightened, desperate, or (hopefully) just vacant by this stage. It’s unsettling. But the kid’s in dire straits, I’m determined not to let it die, and this mum is freaking out (which begs the question why, like so many others, she waited two weeks until the kid was in a big hole before bringing him here... chill, Damien. Education, distances, logistics, 20 years of war…. It’s different).

So we begin the slow, delicate and anxious process of rehabilitating them. Can’t just whack in an IV, her heart is too weak and she’ll likely die of heart failure. So gently, slowly, we begin the drugs and fluids by nasogastric tube and by mouth. But this kid is just so thirsty… every time I take away the syringe of fluid, she cries, and looks at me with those frightened big eyes, and she sucks the plastic of the empty syringe, no its dry, so she picks up a stick and sucks it, no its also dry, so she puts her head towards my shoe. She’d grab the cup of fluid off me if she could, but with 6kg of flesh on her 1-year old skeleton, there’s not much chance of that. It’s pathetic to watch. And she tears strips off my heart with every rapid breath of her pneumonia-ravaged lungs. Every few minutes her bowels just unload a seemingly impossible amount of fluid from her dessicated body, and I vow she wont die, I’m on tonight and I’ll keep a close eye on her (because as sure as shit the night health-worker duty will be reclined and snoring, dreaming of night-clubs and burkhas in Khartoum within half an hour of my departure).
But as time has already shown me, don’t go vowing things like that… cos that night she dies anyway. And this week so did two others just like her, and so did a young boy shot in the stomach, and a man who exsanguinated on the ground outside our compound only hours after I sat chatting with him and his young family, and a young mum with Kala-azar who we had spent so much time with and who now left a young orphan with no breast milk, and a 20kg 10 year old boy with TB… it just goes on.

I’m actually tired of thinking about it today. Perhaps this afternoon I am suffering “compassion fatigue” (as not giving a shit is so pleasantly labelled these days). And fatigue of the usual issues in the field… what if I was wrong, what if I did that differently, what if we had an X-ray and instead of guessing I could actually see something. We had a mortality meeting yesterday to try and sort it out. General consensus is its been an unlucky week with sicker than usual patients coming, and of course some things we could improve around the place. But with 5000 outpatients a month, 300 inpatients, 45 TB patients, HIV patients, malnourished kids, one doctor (yours truly), one surgeon, a nurse and a team of local health workers who struggle with basic numeracy, let alone management of simple illnesses, it’s a little tricky to keep track of everything all the time. Actually, it’s impossible.
Is it wrong to be fantasizing about a week on Zanzibar after only being here 2 weeks….?

So while I look forward to buying the new Nokia 51-Tryhard-Turdmaster with live American Idol updates on my holidays in coming months, these people will continue to struggle for God knows how long. I dare anyone not to be moved at the prospect of human beings dying for lack of simple necessities. (Compassion Fatigue sufferers aside. Its really hard to care sometimes, there’s so much nasty news these days). Although concerningly I am turning into the whingeing turd I vowed never to become, so its time to stop.
And reflect instead on the 50+ inpatients, 44 TB patients, 32 malnourished kids and 1300 outpatients who are doing fine this week. Perhaps I’ll do it over an Ethiopian beer right now…
Only the f@#ken medical report and statistics and stock orders need to be done. Damn it!

Evacuated - medically and literally

2008-04-20T00:00:00.000-07:00

I made it to Sudan. For 4 days. Now I'm out again. After all the delays, cancellations and disasters of the previous few months, you gotta laugh....

Survived the beaches and restaurants of Cape Town for a couple of weeks whilst waiting for another job with MSF. Tough gig, but pulled through. Still jobless, I headed back to Switzerland; already feeling as appreciated as a puppy who just shat on the new suede, the Swiss went a step further and welcomed me back by locking my bags overnight in the offices and giving me a hotel reception floor to sleep on. Au-revoir hommes.
Fortunately the Dutch came through; a brief trip to Amsterdam followed, and 2 days later i was sitting in the MSF compound in the north of Kenya waiting for my flight to south Sudan. With recent trends, it goes without saying that my travel permit didn’t come through, but nothing like a dusty one-horse town with locals as friendly as pit-bulls to kill a week.

So last Friday I finally boarded a plane to South Sudan. Small, rickety, overloaded and with howling winds, clutching my bottle of duty free and once-again becoming a devout Evangelical for the duration of the flight. Fan-bloody-tastic (and always that lingering question - when those kids were swinging off the back flaps when we were loading on the runway, could they have ripped off something? Is that strut supposed to be rusted and bent?!). Landing at my new project, again the flaps providing shiny new play equipment and the tyres a fun object to spank with a stick for the village kids, we received a sat-phone call - the plane is to be diverted, there are some wounded that need to be picked up elsewhere and ferried to the surgical project. An hour later we descend to another dirt airstrip, where an MSF team meet us with a handful of wounded from a big clan-fight that morning.
So about 2 hours after entering Sudan, I find myself straddling a large young man on a stretcher in the back of the plane, battling the biblical clouds of flies feeding off these guys' wounds. He’s got a wound through his chest and neck, and for sure a chest full of air and blood. Not conducive to flying well. Seemed a good time to practice that chest decompression with a needle and syringe I’ve seen so often in the books – bite your bottom lip tiger, this isn’t going to tickle (I must admit I also bit my bottom lip at the thought of being attacked by his mates who saw a white bloke plunge a needle into his chest).

The flight went well, made it to the MSF hospital in South Sudan where there was a surgeon. Weekend spent floating around theatre and the wards. Stoked to finally be back out in the field.
Until Sunday… woke up great, then whammo! Fever, headache, Delhi-belly, the works. Spent the following 36 hours lying in a steaming mud hut sweating myself into the mattress, deliriously watching the coming and goings of the lizards on the wall, with frequent short vacations to the latrine. Sheer joy. And in setting possibly another new record with MSF, I get med-evacuated by a plane the following day. A thoroughly un-respectful 4 days in the field. I defy anyone to beat that!

So here I sit now, in Kenya again, fattening myself up and waiting for my flight back out in a couple of days. Lets see if I can make a week this time…

Email access still in the field – if you write to my hotmail address, it will ping back the new ones.

Mozambique pics

2008-03-09T10:01:00.001-07:00

Top to bottom: transporting goods up the river for a distribution to camps, elderly man weaving straw, crossing flooded land, fisherman with (rather undersized?!) fish, young girls outside the clinic trying to show me how to dance.

a nutrition survey: reflections on faffing

2008-03-09T09:57:00.001-07:00

Morrumbala, Mozambique 3rd March

Its 5am and I am standing in the carpark of our ‘hotel’ here in central Mozambique. We are supposed to be leaving now, and once again, myself and the two logisticians are still waiting for our local staff to arrive. We made it very clear – not African time this time please peoples. It’s a 4.5 hour drive and we have to be back here by sunset, so there’s no room for faffing. Which is ironic, as that’s what our staff seem to be best at.

One nurse is still sleeping. Two of the drivers are not here yet. One reckons he has malaria, and the rapid-test I do proves positive. The nurses promised by the local health department are not here with their promised scales and height measuring tapes. And yet for some strange reason I am actually surprised – despite this being our daily routine (which is not as exasperating as waiting for dinner, which comes between 3 and 4 HOURS after we order it daily). So I find myself gesticulating wildly like an angry Italian to get some momentum, because its hard to be clear when you’re pissed in another language, and my Portuguese doesn’t yet allow for rants, so flailing arms seems to get the point across. No, now is not a time to find someone to wash your clothes for you. Forget the coffee. You need mobile phone credit..? Now….?! Tough! Get in the car.

As we begin the arduously slow drive towards the Malawi border to another displaced people’s camp, I settle into that euphoric dream-like haze that is the morning drives. I fall asleep for a few seconds before the next pothole prompts the window to spank my head and remind me to enjoy the view. The sun’s rising over the mountains in the distance, kids are already walking to school with chairs and books balanced delicately on their heads, mums are out in the corn fields and rice-paddies and men are lugging unbelievably large loads of pretty much everything on the back of their bicycles (which here serve as family wagons, cargo haulers, recreational vehicles and food transport vehicles here – I saw a bloke with a live goat tied from his handle-bars down the top bar of his bike. So I guess everytime the goat sneezed he goes left, and if the goat coughed he veers right…?). Then asleep again for a moment, before the next whiplash-inducing pothole.

We arrive in Jonassi by mid-morning, and are greeted by the usual quorum of dozens of children. They watch as we unpack, they watch everything, and they are the easiest audience you could have – my unco-ordinated attempts to swat a wasp draws laughter, as does a sneaky attempt to pick my nose. Life in a fish-bowl.
Setting up for the days’ screening begins, as we set up crowd and queue control barriers, the tent, and quickly recruit local workers to help. Today we are doing a nutritional screen, and the idea is to file as many kids between 6 months and 5 years as you can through a line where we measure their upper-arm circumference; over a certain level and they leave with a de-worming tablet and a glob of purple ink on their finger (so curious kiddies don’t sneak back around again for another ‘lolly’!). Under a certain level and we measure their weight, height and screen them for medical problems. Malnourished kids are admitted into a program of supplemental feeds and followed up.

It sounds easy. At least I thought so when it was sold to me. It looked so on paper. It’s not. The population we are working with is a very rural population, with variable levels of numeracy and literacy. To get a local worker to read a scale accurately and write down the number is not as easy as you would expect. A significant number of mums don’t have any idea when their kid was born, give or take a year or two. Getting others to interpret graphs of which kids are malnourished based on their stats is equally tricky – either way too many healthy kids are admitted, or malnourished kids are sent home. So everything has to be supervised, repeated, questioned and re-explained (with patience I hope) over and over again… and then one more over again for good measure.

And all this is going on at once. So there’s a line of hundreds of people waiting, its 40 degrees and the humidity is through the roof, and we are all already caked in dust. Adults are getting in line wanting pills for their headaches and two of our local nurses are fighting over which protocol to use. Kids are sneaking through the barriers – curious kids want to be weighed, others want to dip their fingers in the dye, others want to just sit and watch near you. Other kids are screaming bloody murder when it comes to measure their arm, and in true crowd mentality, when one kids starts screaming, they all do - perhaps a kind of sympathetic show of solidarity on their behalf. So it goes through phases – for 15 minutes kids will wander up and grin at you as they thrust their arm into the tape, then one kid will start screaming and everyone behind him will be convinced that we must be ritualistically torturing him, so they all start and are petrified when they get to the white guy. Then it settles after a few minutes and you go through a happy phase again.

The dipping-of-the-fingers-in-dye is another fascinating little insight into child psychology. Like the different approaches to waving at cars (previous blog), there are many variations – there are those that are convinced their finger will dissolve in the cup and will do anything on earth not to let that happen; it’s a little bizarre (and perhaps unnecessary!) to watch a mum and two grown men wrestle a 4 year old’s hand towards a cup, and occasionally it seems the kid just may win. Then there are those that are a a little hesitant, but curiosity overwhelms them and they just cant resist. And finally, those that just dare anyone to stop them, bathe their hand in the stuff and make a grab for the cup to take a sip. And one cheeky little dude who wet his finger in it, regarded it for a few seconds, decided it looked like something that would make for brilliant finger painting and that his mum’s white dress was just the canvas.

So it goes for several hours – a somewhat organised chaos, but we get through hundreds of kids and sort out the malnourished ones. And when we start to pack up, I am once again humbled and floored by the needs of these people. Dozens of people crowd around… please, I need treatment for this, please, my husband is really sick at home, please, my daughter that. A girl who broke her arm months ago but still has the bone poking out of her skin – unbelievable – and surely infected, but she gets lost in the confusion (I curse myself later and vow to head back tomorrow to find her and bring her to hospital). And local health workers pitch in – we haven’t been paid in months, we have no supplies, please give us what you can. And so begins the routine that I was previously familiar with – but had pleasantly forgotten in the last year in Australia – sorry, we don’t have drugs for that, sorry we have to leave soon, yes I promise we will be back soon but I cant say when, sorry, you need surgery for that in the capital which means I may as well just tell you that there’s a clinic on Mars that will look after you.

But our day is done. We have to high-tail it back to our town before it gets dark, and our other Australian logistician (also Damien, also from Melbourne, also bald – so I am “Kangaroo” here) is trying to calmly explain to the nurses who have now ordered goat for dinner from a family that he will leave them here if they don’t get into the car in the next 30 seconds, but they refuse anyway. Our other logistician got given a chicken for our help here, which is too cute to eat I decide. I am dripping wet from sweat, the kids crowd around the car again laughing and smiling and we pull off back to town as I settle into my trance-like state for the ride home, waiting hopefully for the little chubby kid to do his foot-shuffle dance as we drive past.

Addit: the following day, I go to see our driver with malaria. He’s much worse. Take your tablets today? Yup. Last night? Yup. Let’s see the packet… its full! You didn’t take any did you? No. Well, may I hazard a guess then as to why you are worse….?!

Another day in another universe goes by.

2008-03-09T09:28:00.000-07:00

Top to bottom: curious kids in rural Mozambique, fishing - a popular use for a mosquito-bednets, doing nutrition check on a clearly slightly over-nourished baby!, view out the window on the drive to work in the morning, dudes at a swimming hole, where's wally.

Shit-Magnet

2008-03-09T09:19:00.000-07:00

Mopeia, Mozambique, 20 Feb 2008

Within an hour of arriving in the field here in Mozambique, I had firmly cemented my reputation as a medical shit-magnet (although this trend does seem to extend into other aspects of my life as well). This time, unfortunately, literally.

After a dream-like boat ride up the Zambezi river, we arrived on a river bank to be greeted by a sea of inquisitive children, who were even more inquisitive of my apparent inability to be able to walk upright on the mud bank. The boat ride took us past villages of people recently displaced by the floods here, where a river normally at best a few dozen metres wide had now flooded land to be 5km wide. Any risk of the trip being boring for the regular guys was negated by my repeated mini-convulsions as I threw myself across the boat every time – and there were many times – the boat pilot pointed at my arm dangling over the edge and yelled “Crocodilla!!” Standard new-guy gag I’m sure.

After a half-hour walk through some small villages to reach our mobile medical clinic in a clearing, I was introducing myself to the staff, trying to get some sense of the layout having never seen a clinic like this before (in essence, a large tent under an even larger tree where patients can wait in the shade, basic medical essentials, some Mozambican nurses, the all important crowd control dude, and a clueless doctor – me - supposedly supervising the whole thing whilst grappling with the heat and humidity and insects the size of small birds trying to molest me from every angle). Whilst exchanging pleasantries in (déjà vu) bad Portuguese again, three guys ran towards us carrying the limp body of a man lapsing in and out of consciousness. For f@#k’s sake… not even here half an hour. As they lay him on the floor of our tent, I struggled to get an IV into him. Eyes sunken, no recordable blood pressure, I pinched his skin and it just stayed there, twisted, for minute.
Cholera for sure, and he’d undoubtedly shat 10-20 litres of fluid by now. Somewhat short of the 2 litres of IV fluid we had on us. So we spent the afternoon watching this guy trying to die, puking and shitting everything we gave him IV or to drink with interest, lapsing in and out of consciousness, while the boat raced off to get more supplies from our base. Fast forward to the following morning, when he is eating and wants to go home after having had more than 10 litres of fluid, plus more to drink. Another testament to the resilience of the human body (and another gentle reminder for me to bite my tongue when I go home to work, forget all this and reset my threshold for concern, when a 15 year old who has vomited once that morning is brought into the Emergency Department by his anxious parents…)

My time here so far has been ridiculously and overwhelmingly pleasant, and I must confess I feel more than a little guilty enjoying myself so thoroughly on an MSF mission, especially given I should be in Somalia confined to a compound facing the most woeful of crises. Mozambique here is so green, it’s as if a plane carrying all the fluoro-dye for a 1980’s ski-wear manufacturer exploded over the country-side and coloured it. ‘Lush’ would be an understatement. Its safe, and instead of confronting drunken soldiers and avoiding landmines on my evening walks, I refuse offers for a lift on the back of locals’ bicycles. I may also in fact be the first person to come back from a mission fatter than when they left.

Our daily ‘routine’ for the last week has been to hit the road at a sparrow’s-fart with 2 landcruisers of medical supplies, drive out to the selected location for the day (1-3 hours), and see as many people as we can, in the new camps of displaced people.
The drive itself is a highlight, excluding the orthopaedic issues of being tossed around an old landcruiser on bad roads with “anti-suspension” (a sarcasm/irony-based suspension system that seems to exaggerate any of the billion potholes and bumps).

Cotton fields and maze fields dominate the horizon, punctuated by kids chasing down the car and women working on their back problems in the fields (I have noted three types of kids here, as defined by their response to a car with a Mizungu (white bloke) cruising past in it. Firstly there are the startled ones - those that stare wide eyed, as if you had just landed from space. Some run and scream, others remain fixed to the ground paralysed by fear/intrigue. A wave does nothing to disarm them. Secondly, there are those whose day you’ve just made; they are waving so frantically before the car is even in site that you worry they may dislocate their shoulders. They beam, they chase the car, and occasionally (usually a podgy-bellied young boy) will do a little dance on the spot before giving chase. These kids can be dangerous – if you don’t wave back, they may quite possibly chase the car until its next stop demanding an explanation. And the final group – my favourite – fits between the two. They start off in the first group. They look petrified. Then a little hand tentatively goes up to wave. There’s a flicker this way… then that…. Wide eyes…. And then (you wave back)… they erupt. ‘Whooooaaaaa!!! Mizungu’ and off they go chasing us). I could spend a year just driving around the countryside here just watching these kids.

Fortunately the health (so far) of the refugees here is not too bad – food and blankets have been distributed, clean water is now mostly available, and the population seems as healthy (or unhealthy) as any rural group. A fascinating observation (well, I think so) is that no matter where you go in the world, patients will still present with seemingly trivial, well, bullshit. I suppose that a backache or a headache is equally annoying for a patient whether you are waiting in Geelong Emergency Dept, or in a clinic in a refugee camp. So there I am buggered and sweating more than I can manage to drink in the medical tent, seeing kids with malaria, ulcers bigger than the feet they are destroying and other horrendomas, when a bloke sits in front of me and complains – in all sincerity – that his eyes hurt when he stares at the sun. I suggested sunglasses, but he recommended that I prescribe him antibiotics instead. Just be nice. Just be nice… (I did suggest an opthalmology mobile clinic to MSF to follow up on this guy in my weekly report, but as yet no feedback).

The state of health being what it is here, we will be shutting up shop soon, which means I may have in fact grabbed the trifecta of the three shortest missions in MSF history – about 12 minutes for Somalia (made it to the airport hall and briefing), 36 hours in west Kenya (although the umbrella we got sucked into the aircraft propeller certainly made it a worthwhile trip), and now a few weeks here. Lets see if I can break the one month barrier in the next one. Or at least make enough frequent flyer points to fly to the moon with Virgin Galactic.

Umbrellas and propellers

2008-03-09T09:06:00.000-07:00

Nairobi - 6 February

I would like to be able to – at this point of the mission, having been gone for a month – recount stories of lives saved and interventions intervened. Alas, mine is a tale of weeks in the compound in Nairobi, working on my love-less handles in various restaurants, the world’s second shortest field-trip with MSF (48 hours in West Kenya, versus an airport hall only for Somalia), and almost destroying a light plane...

The situation in Somalia has not improved since I last wrote, and despite daily updates from the Somali clinic I am supposed to be at (where there are now NINE HUNDRED children receiving treatment for malnutrition, and overwhelmed Somali staff), it is impossible to go back. An immensely frustrating situation, but potentially currently a game of Russian Roulette regarding security (when the five blokes next to you have already shot blanks, and then hand you the gun).

My trip to West Kenya (Eldoret), where there was some of the worst post-election violence here was an eye-opener to say the least. 20 000 people crammed into the showgrounds in this one town alone, living in makeshift tents, on mud, with the rain season about to hit. Imagine the indignity for a proud father to bundle his family into squalor with a pot and a pair of underwear as your worldly possessions, because your neighbours of 50 years turn around one day and torch your house and take a machette to you. Its unfathomable. You see selective houses burned, you see huge rocks lining the side of the road where roadblocks were set up and people were dragged out of cars to a fate I cant imagine, and then you drive through towns where the likely perpetrators were, and everyone’s friendly, they’re approachable, they’re smiling and buying mobile phone top-ups and selling vegetables and reading papers. So who did this? These guys? And then you go back to one of the refugee (IDP) camps, and all the kids are running around playing football and doing general kid-like things, absolutely oblivious and seemingly unfazed by the whole thing (in fact, possibly even stoked – a playground with 10 000 other kids…!).

On the positive side of these camps, from what I saw they were very well organised, clean, there was adequate water and food, and unbelievably a dozen or so massive tents in one camp where 2500 kids were attending school daily. There was no medical work for me, as the Kenyan hospitals are coping, at least for the moment (but MSF have stuck around to monitor the situation).

On the purely fascinating side, I had my first insight into the petty and ultra-competitive world of aid agencies (MSF entirely excepted from this). Being Kenya, most agencies were present anyway, and they were literally scrambling to get their flag in first, to find some other group of refugees or some other thing they could build. Arguably great for those affected, but financially and logistically ridiculous – at a meeting, groups were refusing to share information with each other, and some actually lied about the location of people/needs in order to maintain the ‘monopoly’. Imagine at least a dozen groups, all in hotels, all with drivers, nice 4WD’s (except MSF – we had ye olde Corolla), all reporting on pretty much the same reports about the morning’s reported changes, calling overseas…. Big money. Monty-Pythonesque moments (popular people’s front sketch); “so, do you look after water systems…?”. “F@#k off!! We look after systems that provide water!”. On my last day there, another agency’s car almost ran us off the road to beat us to a small camp.

On the way back from western Kenya as I boarded the airplane after being recalled to Nairobi, I was wildly frustrated. Nothing could have lightened the mood, least of all climbing into another shit-box plane (if someone glued wings onto the side of a Datsun 120Y I would have been more convinced) to take off into a thunder storm pounding the not-too-distant horizon. Nothing that is, except for the actions of our logistician next to me (a logistician is the general dude-about-town in the group, the Hire-a-Hubby, the Mr Fix-it. They are responsible for all the technical things on a mission, including the seduction of female team-members. So it would seem obvious that if anyone was going to do something stupid on boarding the plane, it would be me, not the ‘log’).

The airline kindly issued us with over-sized umbrellas to walk out to the plane, as the storm was now almost on us. As we queued to climb the stairs, people diligently closed their umbrellas and handed them to staff at the door. Except for our Log.
I remember thinking that it wasn’t a good idea as I watched him place his open umbrella on the ground next to the attendant. As the breeze gently toyed with his umbrella, threatening to send it this way then that, the pilot revved up the prop engine on the other side of the plane. I stood entranced. It wont… yes it is…. No it cant…. But what if it does….?! Ever so slowly the umbrella sailed under the plane toward the engine, my morbid fascination matched only by the attendant’s morbid fear (of loss of job or life I wasn’t sure at this stage)…. And then F@#KING-WHOOOMMF!
An explosion of metal, ribbons and colours maybe a hundred metres into the air… a mesmerisingly beautiful dance of propeller, nylon and umbrella handle. The engine stopped, the pilot rushed out, and passengers followed him. And as we stood in our MSF T-shirts on the runway in a truly fine advertisement, I worried I may actually stop breathing due to laughter (anxiety-driven to be sure). Although the plane was fine, mechanics checked it out, and we were off minutes later.

As expected, the group of expats evacuated from Somalia (fantastic bunch) still stuck in the house in Nairobi started to go slightly mental towards the end. Nudy-swims were swum, tears were shed during “Atonement” (a serious sign of losing the plot), and Kenyans were shown how to really dance by the hip-hop masters that we found ourselves to be (read: unco tools that we were) after a Tusker beer or six.

So…. What now?

With Somalia looking dubious, it’s off to Mozambique in the coming days to help with mobile clinics being run after huge floods there. Could think of worse places to go. Although until I’m actually facing a patient in the clinic, I wont assume anything again...
Let’s see.

PS – sketchy if any internet access in the coming weeks, so if I don’t respond for a while it’s not because I’m recovering from my kidney-harvest after a big night out in Maputo. Hopefully. Photo is an IDP camp in Western Kenya... a mere 20 000 of the 300 000 people.

sticker thieves

2008-02-03T00:47:00.000-08:00

Note for the unwary - this is why you should never turn your back on the sticker supply in an Emergency Department in the Northern Territory. Accomplished thieves clean out Tennant Creek ED....

Nairobbery; 3 Feb 2008

2008-02-03T00:36:00.000-08:00

Finally made it to Africa. Although, as the universe has been yelling at me for the last few weeks, perhaps this is a trip I shouldn’t have made. In light of the news to follow at the end, this is about to be a largely selfish rant, but indulge me anyway.

January was looking good. Summer in Torquay, a wedding, all to be followed by my long awaited and heavily anticipated next mission with MSF (Doctors Without Borders), this one being a dream job in a nightmare destination… a feeding centre for malnourished children in Somalia (which, contrary to some rather misguided questions from occasional people I have met, is neither a surfing nor holiday destination – jihadi’s excluded). Overwhelming needs in a country I had previously sworn I would never visit; ongoing clan rivalries, a gun-toting culture superimposed on a civil war, and recent viewings of Black Hawk Down playing no small part in that decision.

Then things started to unfold. I got a call from the office in Europe to say I needed to be there sooner. This entailed missing the wedding and messing work around, but hey, I’m no stranger to burning bridges at Aussie hospitals (Eg 1: Geelong. Eg 2: Geelong), and this is one job I did not want to compromise getting. So sure, a few phone calls, a hurried move out of a house and cold sore inducing bout of anxiety-to-get-it-all-done-in-time.

Then the problems began…

On the flight to Europe, in a momentary failure of his brain to function, our pilot… “ladies and gentleman, theres been an, errrrr…, problem at Heathrow; we have extra fuel in case… it’s a runway, and…. Uhhhh… a plane, errr… uhhh, we may not land in London. It’s a, ummmm…. Yuh. I’ll fill you in more later.”
What .??!!! You just alluded to a plane crash as we hurtle towards said runway with extra fuel – ie explosive - on board? Why not just take on dynamite? Perhaps a shoe-bomber next time..?
And a poignant moment for those of us on the verge of a complete panic attack as we approached the runway hours later – in the second (and this time thoroughly more complete) failure of his brain to function – the pilot actually pointed out the wreckage of the plane to our right as we landed! Great!! “So, Damien, what was the last thing that went through your mind as your plane careered into the runway at Heathrow?”
‘Well, I’d have to say I was probably distracted thinking about the last thing that went through the people’s minds in the crash just below us…’
Ensue delays, cancellations and tantrums.

Geneva. I walk in to MSF headquarters. Actually, I strut in. Big grin. I’m back baby! Give it to me, here for my next mission. “Allors, Damn, you are here already! No. We were hoping next week…”. Not the enthusiastic Gallic kiss-on-the-cheek greeting I was hoping for, and certainly not after high-tailing it here. Turns out due to various ‘security’ issues in Somalia, my briefing had been pushed back a week. F@#ken brilliant. Could have made a good friend’s wedding, could have enjoyed summer in Oz. So followed 11 days of inhaling entire colonies of dust mite in a two star hotel (overlooking the sewer that overlooked Lake Geneva), Starbucks, CNN, countless hours at the MSF offices waiting for people, and trying not to spend all of my savings (that weren’t misappropriated by the Aussie Tax Office or my intellectually disabled accountant – who I would like to re-iterate should be the one going to Somalia, not me). The shittiness of the prices surpassed only by the shittiness of the weather, Geneva ain’t no place for a less-than-billionaire to kill time.

Monday evening. Ecstatic, I step off the plane in Nairobi – finally en route to Somalia - with a senior MSF guy. He checks his message bank, then says to me, errr, big problem with Somalia. Drive from airport – inhaling Africa (literally – it was a dirt road), absorbing it again. Awesome to be back. My brothers from another mother. Its good. And that feeling decimated in a second at the guest house. ‘You’d better sit down’. Oh really? Well not a lot of good news starts out like this. I presume its not because you’re intimidated by my overwhelming height and/or woolly mass of hair. What up? I’ll play along. ‘MSF staff were killed in an attack in the south of Somalia this morning’. I understand for possibly the first time the origin of the phrase ‘a chill down your spine’.

The devastating thing is that there are so many devastating things. Volunteer workers dead. That seems a wickedly cruel twist of fate for a person that puts themselves out there. The other expats in that mission scarred for life in ways I cant imagine. And as 100 expat staff are immediately evacuated from all over Somalia, millions of Somalis are the ones left to suffer as essentially the only organization providing medical care is forced to leave – in a show of solidarity, hundreds take to the streets in the town where this happened in support of MSF.

Blah blah blah, heard it all before, another shitty African crisis. I get tired of reading about it all myself. But heres (hopefully) some food for thought (potentially poor choice of phrase) – In one small town alone that I am supposed to go to, THREE HUNDRED THOUSAND people (that’s everyone in Geelong or Geneva) are sleeping under sticks with a cloth or two thrown over it, with no latrines, running water, very limited food, the worlds media still obsessed with Darfur, etc etc. The clinic the staff left in that camp alone had 90 severely malnourished children in the hospital at that moment, with 800 malnourished children on outpatient treatment, among other patients (left with local staff and food, certainly not abandoned). That’s ONE camp. There are dozens, not to forget towns and cities.

So then the BIG question… how do you quantify risk, and how much risk is too much? If it turns out that this attack was likely to have been a local issue rather than a widespread threat, MSF will go back in the next few weeks. For the volunteers - courage-of-your-convictions humanitarianism, or blind optimism? Where - and how - do you draw the line between the needs of a population in the throes of the biggest evolving humanitarian disaster around, versus the risk you expose yourself to?

Oh, so the cherry on the cake? All the expat staff are stuck in Nairobi, normally a regional oasis of good restaurants, bars and shopping, only now it’s deteriorating around us. We have been confined to the compound for the most part, as riots step up in town. Caught views of the police helicopter in the last few days, which has apparently been firing into crowds during some protests. A photographer staying with us went to see the protests, and had some rather interesting photos (interesting at least that he could push the shutter-release, although perhaps that was just the tremor overwhelming his camera) – of youths with machetes opening a can of whoop-arse on his car.

So in the meantime, whilst 2 countries descend further into chaos around is, we play volleyball and drink bad Kenyan wine to pass the time in our hotel’s compound whilst the bigger cleverer guys try and assess the situation. I am off to the west of Kenya in a couple of days to help in the new camps there, whilst we all wait for the dust to settle – if it ever does – on Somalia.

On the plus side, the thirty or so expats stuck here are a great bunch. European-with-the-token-Aussie Big Brother Season 7. Perhaps even Fantasy Island if we don’t leave soon. (Ed – that’s a joke mum. I would leave if it got to that. You know I would).

coming home...

2006-11-20T07:11:00.000-08:00

All over. Back in the land of hotmail, hot-meals and hot-pants (Actually, I'm in Switzerland where winter fur coats are more the rage).

Its been a ridiculous ten days... from emotional goodbyes in Mavinga, goodlucks to a population soon to be left to the devices of their apathetic (and officially third most corrupt on earth) government, witnessing the mayhem of a massive cholera outbreak (and helping the new MSF team as an interpreter for a day - full circle or what?!), to boozy dinner parties and nights in trendy nightlcubs in the Angolan capital with wealthy oil-workers, to the most ridiculous sunburn in history attained lying on a beach in Luanda (resulting now in the raw pink patchwork quilt thats is my back - the type that would make a first-time-English-backpacker-to-Oz very proud), to fondues and strolls along Lake Geneva here in Switzerland, contemplating which of the ten-thousand dollar watches takes my fancy.

If i come home confused, you'll forgive me.Will be back in Oz this weekend. Looking forward to catching up with people. I may talk a lot. Its been a while.

More photos at www.dambro2.blogspot.com. (Yup, thats two internet sites. Looking at a Google takeover bid. All in the pipeline).

So in the end it all works out OK

2006-10-26T23:54:00.000-07:00

So in the end it all works out OK. Nothing like some time off to afford you a little perspective (The time off was given to me and Simon here by some mystery fever thing – I went through every possible exotic diagnosis in my head, and entertained images of arriving at Melbourne International Airport with a smile on my face and my car-sized elephantiasis-suffering testicles in a wheelbarrow ahead of me. Joyfully no swelling as yet).
And there it was, on return to the hospital, a wonderful image of a place that actually runs OK, people that were happy to have you back, and the little initiatives you have worked on in the past months actually coming to fruition. Sheer joy. (And somewhat dubious cheers to some of our clinicos, who took it upon themselves to discharge a few of our more difficult chronic cases…. Nice idea, see your point, certainly less work, but ummmm, here’s hoping some of them come back guys).

And add to that those poignant moments since my return, like that cute kiddy who grabbed my knee the other day in malnutrition – OK tiger, I know this game, u want me to walk around with you hanging on?! Whats that?? Good god no…. oh, you didn’t. Hmmm. Seems u did. U just grabbed my leg, smiled at me and squeezed out a turd on my shoe. How about that. Anyone want a pair of runners? White, kinda patchy…?

Outside the hospital, the rainy season has arrived with a vengeance, and Mavinga has been transformed from a dust-bowl to a mud-hole in a matter of days. The entire brown landscape is now a vibrant green, and things just cant grow quickly enough. Our compound has turned into a virtual menagerie as the insects and all other animals here make like a Frenchman living next door to a brothel – they have embarked on a reproductive frenzy. Who knew how many shapes and sizes things-that-bite-you could come in (for the record, way too many). And any notions of manhood acquired were deftly shattered last night, as I found myself squealing (and not with delight) as I climbed into bed to find a scorpion perched on the wall above. You go squish now, scorpion (Simpsons reference there for observant readers).

(And for point of reference, I would define this is a manly: a 30 year old guy who rolled up to the hospital on Saturday night, after 2 days in the bush with severe injuries sustained whilst HE KILLED a leopard that attacked him, with a small knife he managed to find whilst getting mauled. Bugger me mate, what did he do to you?? Oh, no biggie, just clawed out my eye and tore both my arms open…. (the patient then refused pain killers)
Uh huh..? Well, wait until u hear about what I did to this really small scorpion….!)

So… less than 2 weeks to go, and I can wholeheartedly say I will be very sad to leave this place. Some of the new team have arrived, and the handover process has begun. Hard to handover something you have put so much time and effort into, and that has given u so much back (including several infections). Feels a bit like giving up a child (and I mean that in an absolutely non-patronising way), but, as Whacko Jacko said to Billy Jean, “the kid is not my son”. Damn straight. Time to let go.

So there it is. All good. And as I sat typing this email, a heavy storm blew in. Our sat phone is out, hospital got flooded, and I think the internet satellite blew away.
And while I stood outside with my camera making short movies of the storm, three young women huddled together in a hut a few hundred metres from us - and got struck by lightning. An image I will unfortunately never forget…the bodies of two women – one pregnant - slumped over each other, eyes open and looking skyward at a heaven that randomly decided today was their day, and a hundred thousand volts was their way. Heres hoping it was quick. On the upside one survived, she is in the hospital, and doing OK. Because when thirty years of civil war, disease and food shortages just aren’t enough, you need random acts of destruction like that in your life.

And minutes later the kids were out playing in the puddles, two funerals were being prepared, and twins popped out in the hospital….
So on it goes.

A good day

2006-10-05T20:34:00.000-07:00

.... and then days like this when u know why you came, and all the myriad problems pale into insignificance and even if this was the only good thing to come out of your time here, it would still all have been worth it...

Another hot day, 30 degrees by breakfast at 7am. And then during lunch a call to maternity. Never good - they know what they are doing, and if they call me, its bad. So i stand looking at a woman lapsing in and out of consciousness, 38 weeks pregnant who had a big fall this morning. She now has a belly full of blood, a dead baby inside, and a blood pressure thats barely detectable. I don't rate her chances much. But we pull out all stops. We have people lining up to have their blood group tested, while we set up the theatre and find the surgeon-nurse (who by the most amazing co-incidence happens to be walking past the hospital during his holidays, because the truck out of town got delayed today....).

We give 5 litres of fluid intravenously and her blood pressure barely registers a change. But in what must be a new Angolan record she is on the operating table ready to go within half an hour. Sure enough, a belly full of blood, and we have no suction, so it pools around everyones feet. Out comes the baby, dead, but lets worry about mum right now. More blood. The uterus has burst and is a mess. More blood.
Sutures, fluids, a shitty blood pressure, and out comes more blood.

Didnt realise a person had so much inside them. But she still has a pulse, and it must be 40 degrees in the operating room as her family (obligatory that they watch here) and a handful of nurses crowd around the table. Fuck's sake, more blood, our shoes are wet now. But our surgical nurse is great, he does a brilliant job (and if you consider that he, with no medical background, learned during a war to do this with one year of training, it should elevate your respect for these people to incomparable heights...)
Then it's the evening, and you walk over to the hospital, and there is a crowd hovering outside her ward. Turns out she's the pastor's daughter.

And shes having her second unit of blood transfusion, and shes starting to talk, her wound is fine and her blood pressure is good and the bleeding has stopped. She'll be fine. In fact she'll be great. And everyone is stoked and happy and its a joyous moment, and when they thank you you say thanks very much, but the surgeon is the man, and he is there and says no, you are the man, and you all laugh and pat eachother on the back, and instead of being a tough-guy doctor, like a tool your voice breaks and u fight back tears.
And u don't want to leave this place.

Comfortably Numb

2006-09-24T18:50:00.000-07:00

Comfortably numb, though too often at times without the comfort. Or adequate numbness. Flat out buggered. Everyday I wake up and face the hospital with optimism and enthusiasm, and everyday I climb aboard that rollercoaster, sometimes a great ride, sometimes terrifying. Sometimes it breaks down half-way, on that loopy bit, and a chubby attendant yells up that you will be stuck upside down for a while, I’m afraid.

Yesterday I was a witness to a fantastic indictment of “where theres a will, theres a way” - Mavinga 2 weeks ago: no electricity, no running water (except for MSF’s project), maybe 5 cars. Mavinga today: streetlights, 1500 new police, at least a dozen aircraft a day this weekend including private jets, a fleet of at least 30-50 brand new Jeeps. I met senior Ministers, and watched in awe as one told the people here in Mavinga that the new police were here to protect them… but wouldn’t hesitate to kill anyone who caused the slightest problem… this is after all rebel territory. Truly rousing speech. Perhaps something for the next Liberal campaign. Then I watched as fat-cats sat eating lobster and caviar – literally – as hundreds of scrawny kids sat around staring; they may as well have been watching Star-Wars in terms of other-worldliness. Of course all this was airlifted in – our foodmarket is frighteningly barren, and how it manages to feed 1000 people, let alone 30 000, I will never know. Actually, it doesn’t manage.
After, I spent the evening outside our malnutrition ward, mums cooking over fires, kids dancing to the rhythm of a choir of dozens and drums not far off in the distance. Another easy ‘this is why I am here’ moment. Only it was a dying girl that sat next to me, and we watched together. But she was smiling. And inside lay another young girl I don’t seem to have any answers for.

And today on it went… roll on the acutely ill, because I can deal with you: we help you usually, and with spectacular results sometimes, or unfortunately – but fortunately only very occasionally – you succumb. But the chronic, severe ongoing illnesses… can’t you see there is only so much we can do here? I would give anything to have another person here, another doctor, who I could defer responsibility to on occasion. Or another hospital I could bundle these people off to. Because I am tired of having to be the bearer of tragic news, or the giver of token palliative treatment, or dealing with everyone’s, everyday replies (including our apparently healthy staff) to my ‘how are going?’, with ‘not so good actually, I have this pain sometimes….’

For sure the ball-breaker out here. There’s no strength in success, glory. It feels good, in fact it feels great. But it’s the ‘I don’t know and I have no way of finding out’ or ‘its far too late’ or ‘there is no hope at all’ or ‘we cant treat this here… so for you that means this cant be treated fullstop’ that chips away at you. Or some days just flat out assaults you.

So as usual I will try and take solace in our successes (fortunately not infrequent), and defer responsibility to the “that’s just life” rationale for the things that are too hard, and draining, to explain. Or perhaps defy explanation.

And that’s just the patients… lest I forget staff issues, drug shortages, team issues, sand and dust in every orifice everyday, the abscess on my arm, another scintillating bout of Giardia, and that damned big hairy spider in the shower I cant find lately….

Fortunately though my team mates continue to be great, and five minutes of walking around town negates any questions of whether or not this is worth it. Just need that Portuguese-language school for Scandinavian women to open up in town, and we’ll be sorted…

This weeks awards go to...

2006-09-12T23:10:00.000-07:00

And so concludes another “what have I done to deserve this” alternating with “wow, this is cool” week. This weeks awards go to…

The if-u-didn’t shit-on-my-hand-u-would-have-been-the-cutest-patient-i-ever-had award: The 4 year old monkey bought to me, in his little cardboard box house. How cool is that?! My first monkey as a patient. Except he had gastro. Not so cool.

The like-a-fart-in-a-space-suit-you’re-no-longer-welcome award: The white Namibian work crew in town, who arrive drunk daily in the evenings (just when u need a group of drunken middle-aged men like a hole in the head) for medical advice, free medications, to drink our beer and bore us to the point of contemplating suicide (apparently some countries now have a thing called the in-ter-net. Hold on tight). And special shout out to the two who let themselves into our compound this Sunday morning and woke me up for some medical advice re their hangovers.

The here’s-hoping-someone-inserts-a-landmine-up-your-bum award: The “tough-guy” (read: enormous dickhead) who took it upon himself to discipline his wife with a knife. On her face.

The are-you-watching-me-all-the-time-on-CCTV-or-else-how-could-u-posibly-time-this-so-well-everytime award: General population and medical staff. Once again… Saturday night, bonfire is lit, BBQ is ready to go, shhhhh goes the beer as I pry off the lid. And 0.3 seconds later, the radio: Yup, we need the doctor at the hospital right now. Joy.

The I-promised-i-wasn’t-going-to-get-emotional-anymore-about-anything-so-thanks-for-nothing award: This one’s a tie.
Firstly, the grandfather who sat all week with his orphaned 6 month-old granddaughter here in the hospital, for his overwhelming gratitude when we arranged for some supplemental food/milk for the next few months for her out here.
Secondly, to the choir who came and sang this afternoon outside the room of our patient with the most horrific burns here. Seriously guys, would have been a lot easier on us all (and very funny too) if you just sang out of tune instead… something to think about for next time.

And finally, the thanks-for-keeping-me-sane-even-if-some-of-you-are-insane award: My fellow expats out here. All both of them. Also, I must acknowledge the recent food delivery (particularly the 2 jars of olives). Special thanks as well to Friends Season 10 that I managed to score on my ipod… that Ross and Rachael, will they get their shit together already?! Those crazy kids. And lest I forget… ye olde ice-cold shower, for taking my breath away and helping me to forget my worries in seconds flat, and ponder instead what happened to my genitals.

Holidays were going well

2006-09-03T18:10:00.000-07:00

Holidays were going well. I was relaxed. I had eaten until my stomach ached, hot-showered until I was as pink as a lobster, watched dolphins play off the coast – literally metres from where we camped – in the south of Angola, watched hours of satellite TV and made it through the entire first season of “Lost” DVD’s– that’s 25 hours of serious viewing, (not including the bonus DVD). That damn Freckles… why couldn’t her plane have crash landed out here in Mavinga? Oh why…???!!!

And with only a few words, any notion of relaxation and contentment dissolved.
“Don’t panic…” our head of mission told me the day before I flew back to Mavinga. Uh huh. I just did. Now what?
“U heard of viral haemorrhagic fever? Like Ebola…?”.
Yup. You heard of a person running from Mavinga to Cape Town in less than three hours? And so it followed that I returned to Mavinga with a ton of salami, chocolate and new shoes. And a Haemorrhagic Fever Kit. Replete with Space Suit (possibly to protect the suspected patients from me as I soil myself when I see them), blood taking kit and veritable encyclopaedia of how to try and avert a complete disaster (The outbreak is currently only rumoured, and 200km from here, and in all fairness to MSF, if it turns out to be true, there will be a big group of experts with a new hospital here within days. Certainly wont be me making any decisions out here).

Coming back after holidays was great. I hit the ground running, in stark contrast to my initial arrival here, and so much more relaxed. That was 10 days ago. I can now unconditionally say I am exhausted. Our usual expat team of 5 has been reduced to me and one other in the last 2 weeks, and I am the only medical one. In one big “Welcome Back Damien” effort, several of our nurses have converted to alcoholism in the past weeks, we have lost several other staff to various things (not dead!), and our midwife to holidays (Pledge: I will never again give shit to, or disrespect, a midwife). Literally hours after her departure I was doing frequent laps between our office library here and our maternity section. But all’s well that ends well, and so far it all has… fishing out retained placentas (with the lightest sedation – African women seriously take pain tolerance to new heights), twin delivery, haemorrhages, premature deliveries... Should never have resigned from Obstetrics at Geelong early.

I think it’s the contrasts here that make this experience what it is – and what it is I am not sure yet. With all the subtlety of enjoying a warm bath, only to discover moments later that you have just in fact lowered your face not into water but rather Tabasco sauce, Mavinga is sure to keep surprising me, frustrating me, wowing me and testing me until I leave. Three months, and no hint of a routine.

Even the daily wonders of a sunset here won’t conform to normality. The wailing of yet another mother in the distance, as malaria claims another of its million victims for the year. The silhouette of a young fowl tentatively reaching for its next step, all legs at once, all in the wrong direction, not unlike some of our staff here arriving for their shift drunk.” Naaaaooo, eshhhtoooo bemmmm!!” – with shower of spit for good effect. The soul-refreshing sound of the choir practicing, once again a sublime accapella that only Africans seem to be able to pull off, as a young man pulls his friend backwards in a wheelchair across impossible terrain, the shape of his jeans making a mockery of his stumps.

Even the simple pleasure of a (should I confess here?!) twice or thrice weekly shower promises adventure. Which furry – or other – creature will greet me in the outhouse today? That tarantula (big hairy ugly spider that induces occasional sphincter-clenching moments of panic)… where is it now? Why the hell cant I see it now?! It was over there on the door a minute ago, I cant see it anywhere… it couldn’t have gone over to, oh good god no…. my towel! Look away fellow expats, streaker coming through….

But nowhere is the contrast more evident than at our hospital. We are a lot busier now as the malaria season is really kicking into swing. We had our first rains here in over 4 months the other day (how those mud huts are going to hold up..?). Everyone’s workload has increased a lot, and roll on the day when I am no longer on call all the time.

We continue to have our share of successes here. Some small but quite satisfying, like inserting a chest drain (big plastic tube) into an elderly man’s bladder through his abdomen, as he couldn’t pee and we couldn’t get a urinary catheter in. All went well, and he must have passed a litre of urine when the tube went in, about half the quantity of anxiety and effort-related sweat I passed trying not to bugger it up. Or setting someone’s broken arm straight(ish) with some light anaesthetic, no X-Ray, and force.

Some successes are more significant, like watching the incredible recovery of one of our toddlers with malnutrition, who continued to worsen despite weeks of good treatment in our unit, now thrive after starting TB treatment. Or the recovery of almost all of our malaria patients, even the severe ones, on a daily basis. Or the improvement of pretty much all of our other malnutrition patients whose weight reduced while I was away – turns out because milk was being diverted elsewhere, so all the kids were getting overdiluted milk (Hows that for taking nothing for granted? Everything here has to be supervised, checked, double checked. Adds a dimension of policing everything which I don’t really enjoy. Supervising, OK, but policing, no).

And we continue to have our share of failures too. Sobering reminders of the odds stacked against these people. We have this incredibly unfortunate woman who came here with really quite bad leprosy. A few days after starting treatment, she developed the most horrendous drug reaction, and went on to lose a lot of her skin (Stevens-Johnson for the medics, to dapsone, I presume). What are the odds? She has recovered quite a bit now, but still is in a very bad state. Not unlike our burns patients, who is still in the process of losing his skin, as daily we remove more of the charred, dead pieces. Not one for the early morning round.

Then there’s – very fortunately – still relatively uncommon AIDS cases. Same story. Young adults, and you can just see it from the end of the bed. Heard of Namibia or Zambia? Good, because if you want any chance at all of living another year, you better try get there and find treatment.

And then that universal staple: cancer. The patients come too late, and they stay for weeks, months sometimes on the wards. And so I get to be a voyeur and limited palliative care provider, as these patients worsen, ever so slowly. And everyday the clinicos present them to me as if it’s a surprise they are worse, and despite all of the gentle explanation in the world, the patients look back with hope and expectation, as if overnight I might have stumbled across a cure.
And now we have a 13 year old girl who has joined this unfortunate group. There she sits, last patient on the ward round everyday. Another frail ghost of a person. That broad smile, those sunken eyes, the slightness of all her movements as if already trying to conserve all her energy for the final days, for what’s to come. Like she knows. And like the other ones, she taunts me with her smile. Her gratitude. For what? Its not necessarily that they are going to die that really tears at me, although it does. It’s the grace and hopefulness that they face it all with. That endless optimism. Blind faith.
Tonight she was standing alone at the guard’s fire outside the hospital, cloaked in her blanket, and she smiled when she saw me and summoned the courage to come to say hello. Which is touching, because normally she shies away from me (and anyone else) whenever we try and talk to her.

And those are the moments I really cherish here.

….other than if that hottie from “Lost” would roll up….

PS – After 2 months of treatment for TB meningitis, completely bedridden (and I must confess I thought with little hope of recovery), Kidje (of My Brothers Keeper fame – see below), and his friend now sit together at the fire… the guy has done a Lazarus and is unstoppable. The problem now is finding him for his daily treatment!

Mavinga Photos 5

2006-08-10T08:55:00.000-07:00

They let me out to play for a few days in Luanda, the Angolan capital... I never imagined a supermarket, sit-down toilet, newspaper, bed (NOT supplied by Guantanamo Bay Outfitters as i suspect my last one was), and hot shower could bring so much joy....

Photos below are of Mavinga and the projects there.

In order:

the water project, 2 typical scenes of the town here, a 'permanent' patient (an albino woman) with unfortunately common skin cancers who lives in a tent behind the hospital, myself and the rest of the exapt staff pretending to work c/o photoshop (this delighted our local staff to no end!), skyline at night, young girls at the river, 3 kids in the window of the shelled-out old school in town, old bomb in the new market, next 2 photos of patients in the malnutrition ward (mostly their families), me in my trendy new Mu-Mu, our anti-mine car, me in the cockpit of the charter flight out to Mavinga, one of the cooks in the hospital kitchen looking like a rock-star, adults ward at the hospital, fetching buckets of water at sunset with the cart, a Russian cargo plane drops off our supplies (after almost landing on our Co-ordinator - read below), high school in town, the two subjects of 'My Brothers Keeper' below...

Love to hear from home, wherever that may be to you.

Email: msfch-mavinga-sat@geneva.msf.org

Please put subject: damien brown

Mavinga Photos 4

2006-08-10T08:42:00.000-07:00

Mavinga Photos 3

2006-08-10T08:33:00.000-07:00

Mavinga Photos 2

2006-08-10T08:25:00.000-07:00

Mavinga Photos 1

2006-08-10T08:14:00.000-07:00

My Brothers Keeper

2006-08-07T04:06:00.000-07:00

I have a good friend here, although I don’t know his name. And he doesn’t speak a lot of Portuguese either, so we don’t talk a whole lot. But we make up for that with laughter. Not sure either of us really knows what over, but we laugh nonetheless.

I have shared a few sunsets with him here, as he tends to his smokey fire, and I (usually on my way to watch the sunset or go for a run), sit and enjoy the moment with him. His life, for the moment at least, is simple. He does simple things. But he does great things. I wonder if he knows I think he is one of the most amazing people I have ever met.

Metres away, in our “isolation” ward (often used as a last stop for patients with not much hope, a kind of God’s waiting room I guess) his brother lies in the urine and shit-stained bed where he has been for weeks now. The room stinks unbelievably, the sort of smell that forces even flies to think twice before entering.
Kidje has improved a bit recently, and can now make noises and at least sit, albeit with some help. He’s going nowhere anytime soon though.

The room in the isolation ward - other than a bed, a mosquito net and an impossible stench – contains little else. A couple of blankets on the floor, a spoon, a bowl and a burned out candle.

And that’s where my good friend comes in, because that’s where he sleeps night after night, and sits day after day, patiently coaxing bland maize and drinks into his brother, cleaning him after he shits his foul waste all over the bed, again and again, offering nothing in return other than the occasional moan and vacant stare.

And yet everytime I see my friend, he has a smile so big you wonder how he’ll ever tuck those teeth in back back behind his lips. And today when I asked him how his brother was, he just beamed and told me he didn’t have a brother – Kidje is his friend.

Saturday 29th July - week 8

2006-08-07T04:03:00.000-07:00

So its now been 8 weeks i have been here. Thats 8 weeks on call..... I gotta be honest, I'm fairly buggered. This past week, all of a sudden, has been an explosion (bad pun here - see last entry) of young kids with severe chest infections. Every time one comes in (which is getting more frequent, and almost exclusively in the wee hours of the morning, during dinner, or on the "weekend") i am convinced its the worst case i have seen. At least until the next kid is carried in. Its the carrying of them out (usually in a cardboard MSF drug box, but fortunately only a small proportion of the kids) that is getting to me. If only the parents would bring the kids in sooner...

As for life outside the hospital, theres no question about it. We’re living the vida-loca here; enjoying the sort of crazy life that comes with being with the same three people… that’s the SAME three people, all the time (refer to entry to follow re ‘flipping out’). Big Brother aint got nothing. For interesting viewing, I suggest putting together the following people, in a very small area, and adding a dose of frustration, a pinch of tension, a generous serve of B.O., a cup of homesickness, and bake at just the right temperature to allow cabin-fever to develop: a very Swiss-German midwife, a vehemently socialist Italian logistician (who I believe may actually be the re-incarnation of Che Guevara), a Swiss-Italian Co-ordinator with an uncanny ability to go jogging on the landing strip minutes before the arrival of our cargo planes (setting perfect conditions for some Chaplin-esque moments of indecision and panic as he weighs up his options – run towards the landing Antonov, away from it, or step off the runway onto land that’s not officially cleared of mines… highly amusing!), and of course a super laid-back Aussie doctor who is the epitome of being relaxed and easy to get along with, even following a night spent at the hospital (and also has a tendency to be sarcastic, last sentence not excluded).

Of course, with any of the idiots on Big Brother these people would have strangled each other with portable-mic cords by now. But full credit to my colleagues here… cards are still fun, we are wearing the felt off the billiards table and we even had a fondue night last week (more like a fon-don’t actually, but the idea was good!). And even fuller credit to my colleagues here again (English skills waning rapidly… ), because it has taken me the last 2 months to appreciate the scale of what only four people here are actually doing (obviously with a lot of support from MSF offices in Europe).

So (again) we are in the South East of Angola, in former rebel (UNITA) territory which was a major base for Africa’s longest running civil war, which ended in 2002. There is a noticeable shortage of men in town as a result of the war, and most of the medics at the hospital here (sort of MSF trained local nurse-doctors) were former military leaders in the rebel UNITA, some as high as Majors and Generals (As an aside, this puts an interesting spin on giving teaching sessions to the medics here, a big part of my job; I was initially quite intimidated by my lack of Portuguese, but that has been trumped by the knowledge that while I am espousing the importance of adequately treating dehydration, these guys are probably having flashbacks to 30 years of guerrilla warfare, interspersed with images of a young white bloke with a dicky accent standing in front of them talking about Rotavirus diarrhoea….). It’s a war-hardened place, and every remaining brick structure in town bears testimony to this with its pock-marked facades and incomplete walls.

The irony of Angola though, or at least here, is that you would never believe it if you met these people. They are great.

So anyway, MSF has been here four years. The project is truly amazing, and there are over 100 Angolans that work for us here. We have a water system that provides 120 000 litres of clean, chlorinated water to a series of well-maintained taps in town, where literally several thousand people collect water every day in an endless parade of women with buckets in their head. Quite a sight!

Then there’s the hospital and its pharmacy. We have about 300 admissions a month at the moment (quiet season), and see another 2000 patients at least in outpatients. There’s a malnutrition ward (my favourite – awesome to watch a frail kid bounce back in a few weeks), a TB program (albeit a small one), an operating theatre where I have spent some of the more anxious moments of my life, and the usual wards and things that go with a hospital.

The truly amazing thing about it all though is where it is. There is essentially no road access to here, so EVERYTHING has to be flown in. Fuel for the generators, food for the patients, all the drugs, towels, buckets, blankets, spare shiny-things that dangle from the machine-that-goes-ping… its insane. And it’s even a more insane sight to watch an unlikely-looking 100-tonne Russian cargo-plane (think of a turkey, add two toilet-roll cylinders to either wing and build a scale model plane based on that) bear down onto our dirt runway and unload 6 months worth of medicine and fuel (about 20% of which had been stolen).

The staff here are what make the place though, and they are daily the source of my happiness and my frustration in varying proportions. This is the aspect of the job I never anticipated… having to manage over 50 medical staff. They are as diverse a group of people as I have ever known, although consistently fun. Some are the most honest and trustworthy people, and others are downright liars; some are church leaders, and others are drunks. Some have a reasonable knowledge of medicine, and others bullshit their way through everything (sometimes quite convincingly!).
Most respond well to the relaxed “we’re on the same team, lets be mates” approach that I really like, but others abuse this and take you for a ride, and respond to nothing short of being TOLD forcefully and repeatedly what to do – not an approach I am comfortable with or enjoy. (I had to suspend a medic for being drunk at work this week; not the first, but certainly the most brazen – when I took a syringe from him as he swaggered and swayed trying to find the leg of a patient in which to plunge the needle, he offered me a beer!).
So its certainly one of the harder aspects of being out here, but also the most rewarding at times.

I’m off for holidays in a couple of weeks. Cant leave the country, so we will see what Luanda, the Angolan capital (which ironically is more expensive than London for pretty much everything, yet really doesn’t have much) will offer me. My aim is to find a hot shower and spend my 2 weeks under it, with occasional side-trips to the nearest steak outlet.

ONE OF THOSE DAYS:

2006-07-08T09:58:00.000-07:00

Its been one of those days again… one where I need to just sit and write everything down as it happened, to try put it into perspective. And read it back as if it all happened to someone else. And let it all soak in and hope that when it does overflow, its OK.…

Admittedly its not all been like this. In fact last week was very quiet, almost routine. I’ll describe the last 24 hours .

So its Thursday evening. I am on a walk to the river with Miriam, the Swiss midwife here, to get a little air. Although that’s an irony not lost on me everytime I’ve tried to go for a run here – the air is thick with smoke in the chilly evenings, a most welcome consequence of which is the blood-red sunsets. As we near the river, we hear the most soulful noise. A choir of young adults singing gospel in perfect harmony, the most wonderful accapela. The sun is setting, a crazed, over-zealous rooster is gearing up for dawn 8 hours too early, and a group of kids help a farmer struggling with his ox-drawn cart which has become stuck in a dry creek-bed a few metres away. Its too perfect. I don’t even bother taking a photo… it’ll never do it justice.

Half an hour later I am back in the hospital for the evening round. There’s our very unwell male patient now tied to the bed – becoming increasingly agitated and disoriented. The medics used to see sleeping sickness in the past, they reckon he fits the bill. Don’t have the drugs to treat it here unfortunately. Plan B. Next… shit, what a frail young thing. A 2 month old really fighting hard to breathe, starting to look very tired. We’ve given really everything we can, she came far too late. Fingers crossed. Next. 8 month old, weighing 3kg. That’s a new record for me... is it even possible, are the dates right?! Coming along well though. Good… now the malaria wards, all doing OK.

Adults… my two ‘heartbreak’ patients are in here. A great 20 year old guy who has gone totally blind within days. I have no idea. Have been in contact with an opthalmologist who concedes they have no idea either (surely the Melbourne Eye and Ear Hospital’s strangest ever enquiry…. “Yeah, hi, I’m a doctor working in Angola, could I speak to your opthalmologist on call please? No, its not a prank call… just put them in the phone! What’s that….?!… I have a landmine here that says you will get them, and quickly….”). And there’s that beautiful, frail ghost of woman who just smiles at me in between moans as her kids play on her bed and her cancer plays havoc inside her. “She has more pain today doctor. She cant sleep.” For god’s sake, stop telling me that. It rips my heart out. Shes on every drug we have in the hospital, elephant doses of them. Any more and she wont recognise her kids. We up them.

Back to the compound. A beer and a game of pool (yes, tut tut, we have a pool table out here… but don’t scorn MSF. It’s a hand-me-down from the Red Cross!). Not half a beer later… “Doctor, e muito urgente!”. A quick dash over the road, straight to where our 2 month old patient is. Everyone stands back from the kid when I walk in and look at me. Shes clearly dead. Fuck… here we go again. Our second baby dead in a week. So I go through the token motions of resuscitation (token out here), we do our best, as I wrestle with my conscience – is it crueler to give the parents another 15 minutes of false hope than to just call it like it is? Or will they sleep better knowing that they got their baby to a hospital in time where a white doctor could try and save its life? Is that an arrogant thought? Or is this just the Africa on TV where shit happens, so get over it?

No… clearly not. For the 2nd time this week, I witness the distraught frenzy of a family morning the loss of a child, wailing and beating themselves. Will they turn on me? Is that a selfish thought when these people have just lost their baby? So I stand like a deer caught in headlights, just watching, not sure whether to apologise or attempt to console a sea of waving and pounding arms. They take the body and go.

They go to wail on through the night. I can hear them.

I go to finish my beer and game of pool. I have a few beers. I forget about it.

And then I go to bed and I remember. And the questions start.

---------------------------------------------------------------------------------------

Friday morning. Cold again, 7.30 ward round. Same old, but good team on today. The round is enjoyable, and once again we have a few successes, a few not so successes. I am liking this place more.

Fast forward to lunch. The four of us expats once again ponder our reflections in a bowl of oil garnished with a little pasta. And bread… today with ants. Don’t mind them so much now!

And then… FUCKING-THUMP!!!!!!!! Dust and debris fall from the roof, and the plastic windows almost fall out of their panes. What the hell was that?! The walkie-talkies and radios go insane. Clearly not a planned blast. People are screaming. I grab the landmine medical kit and we all run down the road, but before we get 50 meters there’s a crowd of people running towards us, some with injured slung over their shoulders. Fuck. It’s the real deal this time.

I run to the hospital. They pour in, people just dump wounded in the first room. There must be 50 people within 2 minutes… medics, injured, family, police. Theres blood all over the floor. Everyone is yelling. Its full scale chaos. So I join in on the act. I start yelling too. We clear two wards quickly, we forcibly remove relatives. We pick up patients and put them on beds… who’s completely fucked, who can wait a bit, and who can wait ages? OK, good, only two severely injured… bits of jaw missing, a penetrating skull wound. That’s not bad out of over a dozen.

And so it goes for the afternoon… we get there though, no one dies. The team rises to the occasion, the Angolan staff do fantastically, everyone pitches in. Fortunately the governor of this state is visiting town today with the press, so he offers his plane to transfer our two most severe patients tomorrow. The others will be fine.

(And in an absurd irony, our surgeon-nurse here, who fought for over 20 years in the civil war, sustained his first ever injury today! Its minor. He thinks its hilarious!).

So now its just past 6pm Friday night. Simon, our Italian logistician, is frantically yelling for me to come play billiards. We have a fridge full of South African beers to get through…

Roll on weekend.

DISORIENTATION:

2006-06-25T13:14:00.000-07:00

So you wake disoriented… music has been blaring all night, and there was a fight (military again most likely) outside the compound in the wee hours of the morning. So how do you know where you are? On a beach in Thailand? Melbourne? Well, in the unlikely event your disorientation lasts more than a few minutes, a few clues will remind you as the morning passes that you are in fact in the middle of Africa with MSF.

1. Your Sunday ‘sleep-in’ is interrupted at 6.30am. There’s a young woman needing urgent surgery. Not long after, you ponder both your and her situation as you stare intently, and occasionally blankly, at her open belly below you, and the Angolan nurse-surgeon opposite you… he is starting to sweat and look at you. You have already been sweating and looking at him for quite some time now. Where to go next. You have both done what you can, her case is far too complicated for here, so now you close up and explain to her husband that at 30, she will have to take her chances as we wait and watch, although the odds are firmly stacked against her.

2. Its 10pm on a Friday night. You have had a few beers, enjoying a chat with some Red Cross workers who have flown into town for a couple of days, and you get called. An unconscious pregnant woman.

“I’m enjoying a beer here. Check the roster. I was on call last night. And the night before. And before that… Whats that?? Oh, yeah right. I am the only doctor in town. Bugger…”

So you get your stuff, put on beanie and jacket (its seriously cold here at night) and head over the road… to the hospital not more than 5m away (hows that for location location?!). Alright… lets give her some IV glucose. None left? OK, run across to the supply tent/room in the MSF compound. Sort through the boxes (in a very well equipped pharmacy I must add). Got it. Great. Reach in, and …. Instead of a vial of glucose, out comes a dirty big hairy spider. Good one! Call the nurse, because now the doctor needs some IV glucose. And some clean pants.

3. Its Saturday evening, and you have run out of (South African Castle Lager) beers (Hows that for coming full-circle?!). Theres none in the kitchen fridge, but the logistician assures you he put some in the stock fridge. Ahh… there they are… in between boxes of vaccines and HIV testing kits (up there for thinking though – the vaccine fridge has a battery backup, which means that even when the generator is off, ie most of the day, we have cold beer. Seriously. You just cant afford to take chances out here).

4. You come back from the morning round for lunch. Bread from the local ‘bakery’ again. The anticipation is killing me. What will it be today? Bread with ants? Bread with sand? Or bread with hair? Perhaps sandy hair? Or perhaps sand ‘n ants. In the words of Blackadder, Oh, the agony of choice.

5. You sit down for dinner with your (fortunately very fun and mostly sane) colleagues. You stare for the 21st night in a row at the pasta on your plate, and marvel as you watch your reflection in the pasta. She’s done it again… Dominga (our cook) has managed to match the amount of oil in our dinner with the average amount used by a US aircraft carrier in a year. (We are currently in negotiations with the UN World Food Program to see if they can bring in an extra plane of oil a week for us. The little MSF charter cant keep up).

6. It’s a weekday in your third week here, and its 7am (half an hour before the rounds start) and you cant think of a good reason to get out of bed. The head medic is a prick. Your Portuguese is now that of an eight year old with a mouthful of toffee and only a mild intellectual disability (as opposed to a severe disability a week ago). You are getting pressured daily to operate on patients that probably would benefit to some degree from surgery, but cant bring yourself to subject them to the risks of surgery here unless it really comes down to life or death (medics – we have no oxygen, no airway equipment, only ketamine and a bag. Sterility here is a term best used in reference to sperm count rather than the operating room). You are tired of looking at the palliative terminal patients in isolation with their spectrum of funky illnesses, who smile at you daily, as you ponder how much of incredibly fuck-all we can do for them (other than keep them comfortable of course). You are tired of fighting your gag reflex when the stench of dozens of kids with diarrhoeas first greets you in the morning as you walk in to the air-tight paediatrics ward.

But then, you start your round and the medics are pleasant. They seem to be getting to know you, and you open your mouth and accidentally a perfectly intelligible sentence comes out in Portuguese. The kid who was unconscious last night with malaria is sitting up eating, and his parents are stoked. Another kid sees your white face and starts crying (its not just a bald thing, I know, cos it happens to the others too!). But then a handful of scruffy kids smile as you pass them on the ward, and you shoo the chicken away as he follows you on the rounds. Things are looking up. Some more patients improved. Some very happy. And then to finish the rounds… my favourite… The malnutrition ward. In amongst a collection of little fires upon which relatives cook their food, sits the ward of 12 or so beds, where kids who looked like poster-children for a Bob Geldof appeal only 2 weeks ago, sit and play and improve at a phenomenal pace (mostly).

So its only 3 weeks gone. Feels like so much more and so much less depending on the minute. Its been a hard 3 weeks, but I wouldn’t take it back. Things are good here, and we are doing good things. It’s a good place to be…

Hope everyone is well back home. Stay in touch (msfch-mavinga-sat@geneva.msf.org, attention to me). Take care, Damien.

SAM UPDATE:

2006-06-25T13:11:00.000-07:00

Just a quick update on Sam. He had another procedure towards correcting his heart defect, and is doing very well. He was dicharged from Chiang Mai and is now back at the clinic where i met him. The surgeons want him to gain a bit more weight and recover from the previous procedure before they undertake the next one. Most importantly though, he has done well with the first ones, he is gaining weight and he has follow up in Chaing Mai in the coming weeks. So thanks again!

Welcome to Isolation, Sticksville

2006-06-11T15:05:00.000-07:00

As we circled over Mavinga for the landing approach, the sign in the pilot’s room at our departure “airport” (read: shed) seemed a whole lot more poignant: ‘Mavinga airstrip: watch for children, and note stray dog’. “So where exactly is the town? Thought it was next to the airstrip…?” I asked the pilot. “It is...”

Welcome to Isolation, Sticksville. Population: You. And a stray dog…

Another poignant moment occurred about 4 days later, as I was examining a young patient on rounds. There was a huge bang, and the windows shook violently; as I suppressed the urge to squeal like Homer Simpson in the famous “Cobras” episode (which, by the way we have here too – Cobras that is, not the Simpsons unfortunately), my colleagues reassured me. “Landmine. Anti-tank. Controlled detonation probably.” Oh right… that’s OK then. Thought it might have been something scary.

So its now the end of my first week here, and I still don’t think I have even begun to make sense of the overwhelming sights, sounds, smells, issues, emotions…

So if it’s a remote experience I wanted, I couldn’t have asked for a better place. The town itself is said to have 30 000 inhabitants, but I defy anyone to find more than several hundred. We are essentially at the centre of a large collection of very small, very rural villages. The town itself contains no more that a handful of brick/stone buildings (with our house and the hospital being half of them). Everything else is mud huts. There are no shops, just a market. There cant be more than 5 cars in town (and be warned – a drive in one may result in the collapse of dozens of kids as they chase u down!). There is no electricity (we have generators), and MSF supplies the only drinking water in town – literally hundreds of people line up daily to access the dozen taps. There is a small charter flight every 2 weeks into town, and we cant leave by road.

If its an isolated experience I wanted, I probably couldn’t have done much better either (although to be fair we can email via sat phone. Not too shabby). Other than me, there are 4 white faces in town. In fact, only four other non-Angolans in town. And we live together, our office is where we live, and the hospital is about 5 metres across the road. There is a bar, although the lure of drunken soldiers has so far failed to entice any of us over there. So for that special cabin-fever feeling, this is the place to come I am assured. Although to everyone’s relief, we seem to have a great team, the big issue being we don’t have a single common language. There is also no fresh food in town, so that has to be flown in as well.

But… for a genuine “African” experience, I don’t know if I could have done any better. The landscape (desert) is beautiful, add to that daily sunsets that take your breath away, the local school around the corner (riddled with bullet holes and lacking a roof) from where the most beautiful singing can be heard daily, and warm, strikingly beautiful people. And just so open and friendly, with beaming white smiles that would light up the darkest, starriest night here. Heart warming, and food for the soul when you consider how utterly and completely poor they are.

I have been really humbled by the kindness and generosity of the locals towards me so far, and last night we were invited to a local wedding. We arrived fashionably late (it had already been postponed several hours – “You need to understand, this is Africa!!” our host guffawed when we arrived on time earlier that day). Anyway, it turns out the entire ceremony had been postponed pending our arrival. ‘Nos expadriaos’ were also given the dubious honor of first dance… much to the delight and amusement of the locals!

Oh yeah, I forgot about work. Really the reason I am here I guess. The hospital is obviously basic, and fortunately for me has mostly now increasingly familiar cases – malaria, malnutrition, diarrhoea, etc etc. There is a lot of malnutrition, and they are predicting a big problem in the coming months. Another big issue is that there is no referral hospital at all, and no other doctors here. That means that there is nowhere to send the really sick complicated cases, and we have to just do our best here. Big change from Thailand. The major issue for me though is the language. They only speak Portuguese, no English whatsoever (which is ironic really, considering I only speak English, no Portuguese whatsoever… although I am trying to learn quickly, and my Spanglish is helping a bit).

Anyway, I will talk more about the hospital in the future – I am trying not to think about it for an evening; its been an intense week.

Well, that’s probably enough rambling for me for one installment. I will update you as time goes by. In the meantime, take care and stay in touch – love hearing news from home.

Damien. X

Contact details

2006-05-31T10:02:00.000-07:00

These are my contact details for the next 6 months. Please dont send anything to my hotmail account. Please dont add attachment (phots, etc) to any emails - max size 50k.

subject: damien brown
msfch-mavinga-sat@geneva.msf.org

Please put Damien Brown in the subject heading.
I can reply to emails.

Snail-mail can be sent via:

Damien Brown/Mission: Angola Mavinga
c/o Medecins Sans Frontieres
78 rue de Lausanne
CH - 1202
Geneva,
Switzerland

(Will take up to a month to arrive).

Cheers!

Sam Update

2006-05-31T09:50:00.000-07:00

Just to let those interested know - Sam is doing fantastically. He had the first of his procedures last week (called Pulmonary artery banding) and is doing well. They are waiting his response before they schedule further surgery to correct the defect, but will keep him in the specialist hospital in Chiang Mai in the meantime.

As I mentioned to donors before, we have raised enough money to cover ALL the costs of his care! So thanks so much again. Big kiss from Sam. X

2006-04-22T00:56:00.000-07:00

Well, my time at the clinic has regrettably come to an end. There will no longer be a bald white bloke walking around scratching his head as he contemplates yet another quirky patient presentation for the others to watch. That is unless they have access to Japanese TV...! Yes, watch out all you B-Grade stars of reality TV such as Survivor and Big Brother.... there is an even B-er Grader star coming soon to (subtitled) Japanese TV... Me!!
In what was hands-down the bizzarest experience of my life (other than the monkey that beat me at poker in the Amazon), a documentary film crew spent the week at the clinic, filming pretty much everything that went on... except the exciting stuff damnit! They missed me plunge a needle (whilst sweating profusely I might add) into an abscess that had almost completely obstructed someones throat (admittedly a couple of weeks ago), amongst other dramatic events.... Instead they filmed hours of interminable ward rounds, educated guesses, uneducated guesses, and me sitting on my arse drinking Pepsi as the MSF docs arrived to do a round with me (they were hoping for a frenzy of activity and excitement as lives were saved I think. No actually, I know they were, cos after finishing my Pepsi we had to re-enact the "grand arrival" of the MSF team, only this time with frenzy and excitment; I would like to think I gave them frenzied excitement actually).

The reason for my departure is that my previously arranged contract with MSF has come through. I am very torn leaving the clinic and new friends there, as things have really been gaining momentum in terms of teaching and things getting done. There is such a need, but fortunately a very experienced doc has arrived to work on another ward, and can help out a bit where I was.

Hmmm... so reflections on my time here. Reading my previous posts, I still think my description of things here was accurate; what has changed is my response to them. Its frightening how quickly things stop shocking you. Survival mechanism I guess. I dont often come home with that heavy, Oh My God, get-away-from-me-everyone feeling I had in the first few weeks. Except the kids; its the sick kids I really mull over.

I still am moved on a daily basis though; I am frustrated by the constraints of working here, of what I can't do for so many of these people, that I could do without a second though back home. I am annoyed by the medics occasionally forgetting to do simple things that I have asked them, or that they know to do, that really affect the patients wellbeing. I am frightened by the ease with which i find myself saying "There's nothing to do, they will die, send them home", and I am gnawed at by the guilt of uncertainty - what if I was wrong? How could I say that so flippantly? And I am angered by the fact that because these people were born 100m on the wrong side of a river, they get fuck-all access to health care, when the Thai hospital up the road is as good as any in Australia.

But more than all this, I am touched by the numerous displays of love and affection that the condtions there seem to elicit in people; The husband that spends every waking minute at his wife's beside, sponging her and stroking her hair, as she writhes and babbles and stares into another dimension, gnawing off her bottom lip in her encaphilitic stupor. The sons and daughters that spend days just sitting, watching over their sick parents, never asking for anything. The mother who quietly got up, more concerned with her son than herself, after he shat copious amount of diarrhoea on her, as shet just gathered it all up in her skirt and gently moved him. The greatful smiles of the patients, just for being seen by myself and the medics, nevermind the outcome.

And the medics; those wonderful medics, ghosts that don't exist in a land that wont even recognise them as refugees, that arrive for their shifts 7 days a week, 50 weeks of the year, for $30 a month... but always with a smile (ofen full of beetel-nut!), and look after the endless stream of often hopelessly sick people, always eager to learn more or to teach you or to share their story with you.

Crazy world, huh. And only an eight hour air-conditioned flight from the comforts of home...

PS: Sam update. Thankyou so much to all those who have so generously offered money; Sam is going to Chiang Mai tomorrow for further tests, and they will give us a final date for his surgery then. Although we dont have the full amount yet, we should have enough to commit, and the clinic should be able to get hold of the remaining funds. There is an Australian nurse who will look after Sam's case here in Thailand, and I will give her personally all the money, so no middle-men (Or women...)! She has been at the clinic for years and I trust her implicitly. I will let you all know in the coming weeks what happens. Also, if you have pledged money but haven't deposited it yet... just a gentle reminder to please do so in the coming week or two if possible. Thanks!

sam's appeal

2006-04-07T00:31:00.000-07:00

Hi all,

Well, I didnt think I would do it, but I am about to... ask for donations.

There is a 13 month old boy, Sam, on our kids ward who has congenital heart disease which is causing progressive heart failure. Sam was on death's door when he came to the clinic, but now (apart from being a little breathless) he looks great - he is incapable of not smiling at you, and now when we come in he even does a little happy-dance!

Sam's improvement from medicines, whislt dramatic, will be temporary; he needs surgery. He is on his way to Chiang Mai (in the North of Thaialnd) to see some paediatric cardiologists, who are confident from the preliminary information that they can operate and significantly improve his condition - if not, I will be sure to inform you. Anyway, the estimate for Sam's procedure is $5000 - $10 000 Aussie. Thats a ton of money here.

So why am I asking for donations for one kid with a complex, expensive-to-fix problem, in the midst of all the other VERY sick and equally in need patients?

Simple. Sam is young, and his condition is treatable, and he has an excellent chance of a good life following this (the cost covers follow up and medicines). And because we can. We are not in the middle of the desert with no options, and I consider this amount of money not obscene when you compare it to the average cost of a hospital admission in Oz. Other kids in Sam's situation at the clinic have been succesfully treated in the past (we have a young boy who just had a heart valve replaced, doing great!). Unfortunately now the well has dried up in terms of funding for Sam.

So I hate to ask people for money. I dont want to guilt anyone into donating. But if you feel you would like to contribue (through my account), I can guarantee 100% of it will go to Sam, and I will update you (We can arrange tax-free deductions through a charity, but 20% gets taken by them for "processing costs" - what's that?!)

So if you feel you would like to help, be it $10 or $100, please do. This email goes to 100 people; if everyone averaged $10, that's $1000. If everyone averaged a bit more, well....

Thanks muchly. I promise I won't do this often. The circumstances are exceptional, and rather than give money to an intangible giant of a charity, you can give it directly to the person in need here.

Cheers,
Damien

PS - If you would like my account details (Commonwealth in Oz - you can transfer online), please email me at damienbrown3@hotmail.com.

2006-03-26T04:25:00.000-08:00

2006-03-26T03:23:00.000-08:00

The time is just flying now, and Prue and I are in a nice routine of work, swim at the kiddies pool, and gorging ourselves on cheap, oily meals of clispy por with lice - and my personal favourite - the lib eye (Exactly what a 'Lib' is, I can't be sure, but the eye kicks arse. Okay, so i think it may be rib eye. From a horse. Not many cows in town. Come to think of it, there's a lot of dogs disappearing lately... oh god...).

Things at the clinic are going well. I am amused daily to read in the charts (and fortunately, more often than not), that the "patient complains of feeling better" - a complaint I don't mind hearing (its either this, or "patient not good", which is often a significant understatement). A pleasant change from work back home, where more often than not the patient just complains.

This week there has been a plastic surgeon from Canada and an opthalmologist from the UK doing surgery at the clinic. As John grafted skin onto things that desperately needed skin grafted onto them, the opthal team churned through cataract surgery in the most organised, prolific manner (There were 400 patient on Sunday last week that came for assesment). So the clinic has been even more abuzz than normal, with hundreds of elderly blind Burmese people and their families laying siege to the grounds; the kids ward is also doubling as the female monk dormitory this week!

In a slightly disappointing turn, I came to terms with what I had long been told was a reality - that not everyone involved in aid work was necessarily a) sane b) competent or c) has the patient's best interests at heart. So by a bitter, cynical old doctor (who was long ago told to leave the clinic for ever but still "slinks" in out of hours), I was told that I was naive and that my efforts to teach medics were a waste of time (Being the mature person I am, I politely pointed out several objects in the vicinity that could be inserted into him with my assistance).

On a far brighter note, we have continued to have some great success stories with patients, and my twice weekly ramblings on now-hazy medical topics are now attended by dozens of medics (although Prue assures me its the promise of free food and drink that lures them).

Not sure what the coming months will bring, as I have no offers from MSF, an offer to work in Afghanistan (Hmmm....), an offer to work with a missionary group in Kenya, and an offer to lie on my arse on the Thai islands. Stay tuned...

Hope all are well.

2006-03-11T20:16:00.000-08:00

Officially been here a month today. Feels like so much less, but yet so many things feel so familiar already.
Had a crazy day at the clinic today; busier than your average day to be honest, but this week there must be 60 - 70 patients on adults and kids, SICK, and by this afternoon i still hadn't got to see all the patients once since Monday morning. Its also well into the hot season now, and I am somewhat reassured by all the locals telling me how hot it is today. Good. Not just me drinking 3 L of water a day and peeing once by five pm - If i really push hard.

So i will try and describe my day, cos my head is swimming and i think it may help put closure on the week for me. Maybe the month.

8am. Get up. Apply my sticky sunscreen and insect repellent sheen for the day. Bike ride to clinic past the usual rabble of mangy dogs ( - one bugger that chases me at night only, but he's soft during the day, so i ring my bell frantically and ride towards him. Hah! Even the score for yesterday).

9am. Pull into the clinic. My favourite time of day; kids are running around, the morning sun gives everything a warm glow, patient's relatives are cooking brekkie in the communal outdoor kitchen, and the crowds amassing outside outpatients are still chatty and lively.

9.05am. Pull up chair and banter with the medics. They miss half of what i say, and i miss half of what they say, so well all laugh a lot and who cares cos its fun anyway. How's the 9 year old girl who came in unconscious last night? Worse. Fuck it. She had antibiotics? Yes, great. Did you guys do a lumbar puncture? No. OK, we do one now. Right now.

10.30am Lumbar puncture finished; took a while to get it all happening, but things went smoothly. We will get the result tomorrow if we are lucky. Lets start treatment for TB too... Yes, right, we will call (various powers that be and exist purely to obstruct access to timely treatment and really shouldn't be making any decisions about their underwear for the day, let alone a patient's health). We play the game. Make it sound like it's their idea, then we can do it. Great! We can do it. Hooray. Logical really.

10.35am. Rounds. 40 year old woman with meningitis is looking great. Much better. The lady who had a heart attack looking great. Family here, dozens of them, wrapped with us. If only they knew how much I didnt do... (ECG machine unfortunately had no paper. No GTN or morphine, let alone thrombolysis. Mental note: sell ECG to antique shop, must be worth a bit. 1928?).
The alcoholic in withdrawal who was amusing the entire ward with his delirious outbursts is looking like a new man thanks to the elephant doses of valium (I think the others are secretly hoping for it to wear off soon).
The guy we restrained to the bed is now in a deep coma. His lumbar puncture yesterday produced pus - not good. His urine is the colour of cab sav. I wonder if he has ANY chance at all. The medics are doing a great job with him though.
Woman with muscular chest pain. I like her, but shes anxious. Have paid for some tests, and they are all normal. Any problems at home? Husband has HIV, no food for the kids, nowhere to sleep. Oh, right. Ummm... crazy weather lately, huh?
Man with the weird abdo pain for months. Shit, this guys a mystery. Cancer? Hmmm. We'll come back to him later.
Oh - this guy rocks my world! Lets see him. 21 year old, getting weaker for a month, 2 days ago couldnt walk. Diagnosis? NFI. No f@#king idea. Checked all the big textbooks. Doesn't fit. Trial of cortisone - he walked the next day! Lazarus, rise! Now its day 2, he has no weakness (still seems like an unbelievably dramatic recovery to me, but who cares!). Yup, he can go home. Holy shit, i might cry this guy and his family are just so happy. I just wonder how long before his condition (whatever it is) worsens despite treatment...

And on it goes. Until...

1pm. "Doctor, come quickly to childrens ward!" This can't be good. Its the first time anyone said 'come quickly' anywhere here. And kids ward too. Where is he? Oh faaarrrrkkkkk. 1 year old, pale as a ghost, vomiting and shitting blood. Lapsing in and out of consciousness. I try put a drip in his arms, groin, feet, neck.... nothing. Shit. Mum's crying. I haven't seen a mum cry yet here. Prue suggests intraosseous (in the bone), but they don't have the special needle here. Great idea though. Give me a spinal needle, a fat one... OK. Read this in a book before i left. Needle into his tibia bone, right into the marrow. Sorry buddy.... He doesn't flinch. It works!! Small victory. Very small victory. We pump fluid into him. Blood is on its way. We bundle the kid in a car with a health worker and send him to the big Thai hospital (expensive) with mum.... Good luck little buddy. What's that? Aforementioned 'various powers' are now here and wanted to have been consulted re the decision to transfer. Fuck off. Seriously.

3pm. My weekly tutorial to the health workers is on... meningits. Plenty of patients to see and talk about. Very productive, many questions, they seem to remember a hell of a lot. Smart people. Wish they weren't stuck on a sliver of dusty shitty "no-man's land" for their entire lives. God some of them would kick arse at med school.

5pm. Back to guesthouse. "and that's the other thing thats wrong with Burma...". The usual crowd at the guesthouse discuss the usual bullshit conspiracy theories. Spare me. Seinfeld's on cable. That'll do me just nicely....

Addit: Sunday morning (I wrote the above bit Friday night). The guy with the pus in his lumbar puncture died. So too did the young girl we fought so hard and organised the money to get transfered to a big hospital to have the pus drained from her eye abscess (she had been transferred at great expense, but not operated on yet.... Why?) No one can tell us. Mum came to get her stuff, she doesn't want to talk.
The floppy baby with all the bleeding we transferred is still alive in a Thai hospital (we get a phone call if they die).

And - here's the smile for the day - the 9 year old who was unconscious with meningitis yesterday is sitting up eating and drinking! And literally minutes after I turn my back on her, another mother bundles in a floppy child, fever, unconscious.

And on it goes....

bird flu??

2006-03-03T20:25:00.000-08:00

Did an interesting thing a couple of days ago... made the somewhat controversial call of labelling a sick kid as possibly having bird flu (known cases in Thailand and Myanmar). I can only imagine the vast resources and beauracracy that were mobilised minutes after said kiddie was transferred to a Thai hospital with an oxygen cylinder and a piece of paper with the not so ambiguous phrase "BIRD FLU??" taped to him.

Anticipated headlines for the Bangkok Post soon to read one of two things:
1. "Hero volunteer doctor makes brilliant diagnosis and averts pandemic - virus to be named after him" - pages 1, 3, 5 -11
2. "Dickhead foreign 'doctor' fails to recognise simple pneumonia in a child - asked to leave country."

Before the medics amongst you chuckle, i am more than happy to prepare a case report justifying my call. Alternatively, you could use local 'freedom of information' laws and access my testimony from a possible impending inquest....

2006-02-28T06:01:00.000-08:00

Well after almost 3 weeks, Prue and I are a lot more settled into life here. All my tops are permanently sweat stained, I can almost pull a mono on my Chinese made bike-with-no-gears (and optional brakes) - which incidentally has a ripper basket mounted to the front! - and my serum green-curry levels are bordering on toxic. I am also getting quite fond of my new fragrance "DEET-for-men", my Thai-fisherman pants, and my permanent sheen of SPF 30. Yup, we even look local... well, like tourists trying to look local anyway.

Things at the clinic are becoming a little more "normal" as well... well as normal as wanting to cry, laugh, thump someone, rejoice, be broken, be inspired, hug people, not go near the patients with TB, adopt all the kids, hate the Thai and Burmese for the situation here, want to leave, want to move here, rejoice, and be broken again - anyway, as normal as going through all these phases each day can be.

Not a day passes when i am not convinced that i have just seen the saddest thing ever, or that I see a patient that I assure everyone will not make it through the night. And not a day passes when I do not arrive in the morning and eat my words, as the aforementioned "terminal" patient is sitting up wanting to go home, another patient has unexpectedly died, and I see something that just puts a smile on my face for the rest of the day. Its a strange, heady mix of optimisim, hopelessness, inspiration, intense frustration, joy and sadness.

I am the only doctor in adults and kids ward, which have between 50 - 80 patients between them. The health workers look after, well essentially all the patients, because I am the first doctor on kids ward for YEARS (whats with that?), and adults has occasional volunteer docs. The mix of patients is interesting to say the least. We are the oncology patient with no chemotherapy, morphine or anything stronger than paracetamol. We are the appendicitis and general abdominal surgical ward, with no surgical skills or facilities (everyone gets IV antibiotics, and no one has not improved from appendicitis or cholecystitis - docs at home, go nuts! Patients are so bloody hard to damage!). We are the malaria unit, with no bednets (but i must amazing medics at treating malaria in all its forms). We are the urology ward with no leg bags (- "OK buddy. Feels better now that the bladder is drained huh?! So now what u gotta do is walk around for the next few decades with this urine bag under your arm. Uh huh. Think of it like a "man-bag". Seriously, these things will catch on. I'm Australian. We know these things."). We are the respiratory unit, the intracranial bleed unit, the TB meningitis unit, the orthopaedic unit with a three year old patient who's spine collapsed (probably TB...) and now-cant-walk-but-we-cant-fix-it unit (but my god we will try!) The haematology unit (with platelet counts of 6 and bleeding out of mouth, nose and rectum) that gave a dying patient prednisolone and laughed as she walked out a week later absolutely normal.

But, most frustratingly of all, we are all too often just the palliative care unit, with no palliative care to give. I have lost count of the number of patients i have just had to tell to go home, there is nothing we can do. They don't get it mostly. "Oh no, we stay until she is strong again." "No. She will never be. She will die. You must go home so she can be with her family. Do you understand?" "Yes, doctor. Thank you for your help. We will go home when she is strong...."

And here's the killer... there is plenty we could potentially do. Because Mae Sot (this town) has a great local hospital, and the nearest city has an even greater local hospital... for Thai people. Or people with money. And our patients fit into neither of these. And in a cruel twist of irony, thanks to donations the clinic has a small but increasing budget we can access for "special cases". So now I get to sit down with the health workers and decide who of the patients we can "justify" spending (relatively significant ammounts of) money on. Thirty year old with liver cancer from Hep B?.... nope. Too old, poor results. Faaarrrrk.... Thirty??!!! (Fortunately I am MUCH younger than that - 11 months at least). Young girl with eye abscess? Yes, great... hooray, we can pay for her to have her eye removed. Joy! Oh yeah, not necessarily a good thing.

You get the picture anyway. But i must say, i have a new found respect for the resilience of the human body...!

Then there is a prosthetics clinic that runs daily, fitting prosthetic limbs to the numerous amputees here - oh yeah, most of which are done "in the field", ie in the bush by a health worker with a sharp bone saw. (Actually, I had to laugh - the list of daily expects at the prosthetic workshop the other day read... "(patients details... diagnosis) landmine, landmine, landmine, landmine, landmine, FELL OFF TRAIN, landmine, landmine....!" Poor bugger. I dont know of any trains within hundreds of km's around here; how'd he even find one to fall off?!)

And then there is the language barrier, the cultural issues, the new health workers every shift that you have to get to know and who's trust you must earn from scratch before they will consult you about a patient. So it has been a slow process (and will be for the rest of the year) of learning to be patient, be satisfied with small breakthroughs, the little things.... Fortunately, I am enjoying this work more that any work I have ever done (I hope the above doesn't give any other impression!). I haven't even talked about the people, but i will save that for another rambling installment. Suffice to say the Burmese I have met and worked with are just the most wonderful, humble and friendly people. The Burmese could certainly cook with a little less oil, and the Thai woud go well to ease up on the Chilli around here, but all things considered, its a rockin' great place to be. I hope all are well. If you have just woken up dribbling on your keyboard, then you have just slept through another exciting installment of my BLOG... blog.... blog.... (fade out......). Take care, Damien

2006-02-13T05:45:00.000-08:00

Well, today it all happened. I lost my volunteer work virginity; popped my aid work cherry...

For months i have anticipated what it would be like to be staring at emaciated patients, looking at their vacant eyes with my own even-more vacant eyes - vacant of any ideas as to what the hell was going on with them. "Do they have chest pain?" Oh right... they are only 34. "Really? Holy shit. They look a hell of a lot older than that." Better stay out of the sunlight buddy - yup, give the man some moisturiser. "What?.... HIV positive you say". Rightyo then. This one i know. "Lets go some Combivir, oh and better add some Bactrim." Thank heavens for Bill Gates, I would think to myself.... Everyone has HIV drugs now in the developing world.

And then an overture of joyous music would play in the background, and i would have saved another life (Well, a life. Lets be honest, not too many saved as yet back in Oz. Prolonged uneccesarily perhaps. Or even accidentally - I have been known to arse my way through a few iffy situations). On to save the next patient...

OK, so my preconceptions weren't quite as naive as that. But I certainly thought i would have no idea what to do, and that in a country with a reasonable economy like Thailand, with Bill Gates spending some of his fortune on HIV drugs in developing countries, and with the might of MSF only a few hundred metres away, there would be access to drugs. I thought i would be the rate-limiting step in the patients treatment.

Well, as i learned today... Wrong. I have just finished my first day at the Mae Tao clinic on the Thai-Burma border. Its a clinic run by a Burmese doctor that treats Burmese refugees fleeing the random attacks, beatings and rapes commited by the junta over the border (Ironic - "junta" sounds almost cute doesnt it? "Anyone up for a junta down the coast this weekend?" "Hey baby, fancy a little junta after dinner?") . Faced with such exciting job prospects as "human mine sweeper" (position still vacant if anyone interested; apparently there's a high turnover), the Karen minority filter across the border and live as ghosts; they are not recognised as refugees by the Thai government formally, and they have left their country.
So this nice doctor treats them, for free. 60 000 of them a year, in a collection of sheds and rooms scattered over a large area of land and called a clinic; run by local health workers (who do their own amputations and treat malaria but also give aspirin to people how come in with bleeding from their bowels - amazing practical skills, but an understandable lack of theoretical knowledge - in striking contrast to us).

So I found myself today as the official adult and paediatric inpatient doctor. Gulp. They havent had a paediatric doctor in months, and I am the next best thing (a very distant next I might add). Although, much to my surprise, i wasnt the rate-limiting-step. In fact (and i put this down entirely to my tropical medicine course last year, not intelligence), i had a fair idea what was going on with most of the patients. HIV. HIV with TB. HIV with probably histoplasmosis.... HIV with the lot, extra cheese and a side order of fries. All HIV. Sad, but not unexpected. "OK, lets fire up the AZT. What we got? Nothing??!!! Bullshit. Nothing....??? No bullshit???? Oh, sorry... bullshit is meaning what-the-fuck.... yes - you know that one. So seriously - no HIV drugs? None?? Farrrrkkk. How about we give drugs for histoplasmosis. None of them either huh? Hmmm. Moisturiser? Good, great. His skin looks all cracked and shit. Lets get on top of that." (To be fair, they did manage to russle up some drugs later for the above condition, but no HIV drugs; a major bummer given maybe a third to a half (conservative estimate) of todays patients are HIV +. But we can test for it at least...)

So i think that demonstrates my point. Other notables were the 20 year old with renal failure secondary to malaria; cant afford to go to Bangkok for dialysis. Treatable, would probably pass, but without dialysis he will die almost certainly. Bullshit, not while I'm here I tell myself, but seriously, what can we do? Treat the various symptoms and complications as they arise, but essentially buy him time. But I dont get to worry about him too long, cos there's a guy in his late 20's with HIV and fluid around his heart slowly crushing it (probably from TB). Due to various red tape blah blah blah, he doesnt qualify for TB treatment; so we will treat him symptomatically as his heart fails and hope that he resolves spontaneously (I am still up for an aspiration for fellow medicos - nothing to lose right?). Feedback appreciated.

Then over to paediatrics; holy shit... TB meningitis (thank God, on adequate treatment though), an eye popping out because of an infection - oh, doctor you think we should take the eye out today??? Farkkk.... umm, lets try some other things first. Do i want to be responsible for a 5 year old girl to lose her eye just yet? What if the antibiotics dont work and she gets meningitis or thrombosis as well?? What if waiting to see for 2 days costs her more than just her eye? What if it gets infected from the surgery?? (by the way it wont be me doing it - they will transfer her at great expense to a Thai hospital...).

So anyway, this has been a very therapeutic vent for me. I must just say though that the health workers here, at least from what I have seen, do incredible things with an incredible lack of things; they are well respected, and i have no doubt it will be them teaching me far more than i could ever teach them.
Prue is here with me at the clinic, and we have another 2 months here before i run off with MSF. Hopefully these rants will only get shorter, as this stuff becomes the norm and we find our stride here. Its a fun town though, and our accomodation is really nice. Some great expats working around the clinic and around town, and it looks like its going to be a really enjoyable couple of months. The cute kids and local men and woman dressed in their traditional gear provide a magical background to tall this. Off to buy a bicycle tomorrow to become a little more local!

Hope everyone is well.

photo's

2006-02-06T22:51:00.000-08:00

I thought i would post some of my favourite pics that i took over the last year, in the off chance the editor of National Geographic or Lonely Planet Images comes across this blog and offers me that permanent position on their staff.... it will happen. Yes, it will....

Shameless Indulgence

2006-02-06T04:53:00.000-08:00

Well, this seems am ironic way to start a spot on what promises to be an, um, at least very intersting year of volunteer work... I decided that for now at least, the only aid work needed was on my mental state and anemic Siberian-prison-camp like complexion.

And so the 12 hour emergency shifts have been replaced with 12 hour beach shifts on Ko Phangan in Thailand; the broken nights of sleep on call - with every siren and barking dog resulting in a tightening of my foetal position (among other things) as I sob under my sheets -have been replaced with broken nights of sleep in my beach side bungalow, where the sound of drunken Israelis force me to get up yet again, adjust the air conditioning, look out at the moon over the Gulf of Thailand and adjust my silk boxers as i get back into my king size bed (OK, I exaggerated. They are polyester. Well, polyester blend).

"Wasn't it only a few months ago he was charring his buns in Cuba?" I hear people sneer. Well, perhaps. But its not all beer and skittles... the sand here is a lot stickier to wash off, and the cigars suck. And it may only be 50 metres between our bungalow and the beach, but hobble that with a chargrilled frame, and it may as well be a night on call... or not.

Well, i best be off to track down some more Aloe Vera. My body currently bears a striking resemblance to the Canadian flag (from top to bottom) - very red, very white, and very red again, with a random maple leaf of redness where i (well, actually Prue!) missed a spot with the SPF 30.

Take care, hope all are well.