Dr. Bhavna Chawla, a surgeon, recently returned from her first mission with MSF (Médecins Sans Frontières) in Lankien, South Sudan. In this letter, she recounts her experience of delivering emergency surgical care in a conflict situation.
In the beginning, my struggles were different. A strange, but extremely resilient, people for whom cattle is riches, and you can only marry if you have cattle. A strange language and an even stranger, hard-to-decipher body language. I couldn’t make out if people were laughing at me or with me. “But then, isn’t it the same everywhere?” I asked myself. The tukuls, though basic, looked as charming as a print ad for an au-naturel rural resort. It’s another thing to be with 10 different species of insects in huge numbers and stridulating all night long. But this letter is neither about the rhythms of the swamps nor is it a study about the culture in Lankien, South Sudan.
Bhavna ChawlaThe facility
South Sudan, the newest country of the world. The euphoria of independence would be disrupted soon and the country would break into turmoil less than three years after its independence. The team in Lankien showed extreme reserves of courage and resourcefulness when the war-wounded started coming in, initially on their own and later brought in by other medical actors in planes. In a matter of hours, the surgical facility, which consisted of 25-odd beds, expanded to more than 80. And we were ready for more.
There were gunshot wounds everywhere — extremities, the chest, the abdomen, the head. We had an inflatable operation theatre (OT) set up with one fully functional OT and one minor OT. Patients kept coming in by the score every day. Triage [the evaluation and categorisation of the sick or wounded when there are insufficient resources for medical care of everyone at once] had become a function of habit, prioritising and re-prioritising every few hours. The only prayer on my lips was this: “Oh God! Please don’t let them die once they reach us. Help me and my judgment!” For my judgment is all I had to depend upon besides my extremely capable team. No fancy investigations, not even X-rays. In the beginning, there was no time to investigate a proper clinical history or the history of events. We had to assess the injury and the anticipated damage within minutes to decide when the patient went to OT. On the evening rounds, most of the male patients appeared angry and the female patients upset. They had been evacuated from other parts of the country to Lankien as it was the only functional, resourced and safe surgical facility left. Some of them had walked with assistance or had been brought by their relatives on stretchers, made out of bamboo, wood and rope. One wounded patient, who sustained an injury to his hip joint, had crawled for eight days in the bushes to reach us. They were without money, food or caretakers and with minimal articles of clothing and no ways or means to communicate with their families left behind. No wonder they were angry. The women, some shot by accident and some intentionally by the perpetrators, had either lost all their loved ones in indiscriminate shooting or had no way to know who among in their family had survived.
The crickets and their ‘relatives’ in my tukul didn’t matter anymore, nor did the bats or the threat of a flooded OT. These seemed minor inconveniences as compared to the physical and mental agony of the wounded patients.
“I was in my tukul with my older sister,” said a 20-year-old girl in the sixth month of her third pregnancy. “They made us all lie on our bellies on the floor — me, my two children, my sister and her three children — and shot us all in the back, shot us all to death. I pretended to be dead and was later found[by medical aid workers],” she recalls.
The deeper questions
There were many such stories. “What about the war wounded in my ward?” I would often wonder when I was on my rounds of the ward. They must have also committed acts like these! So, who am I treating? The victims or the perpetrators? Can I even begin to understand why this is going on? Do they understand why this is going on?”
These questions always faded into the background. There was work to do. And that’s all that mattered. As the patients got better, more questions arose. How and where would they go after being discharged? There are no roads from Lankien except muddy trails. The patients fit to be discharged still needed follow-up but we couldn’t keep them in the hospital for long. We needed to economise our resources as there was news of another influx of patients. Once more, MSF rose to the occasion in negotiating with the civic authorities and roping in neighbouring humanitarian agencies to resettle patients who were discharged. MSF set up camps for them to stay and provided non-food item kits while other agencies catered to food requirements.
The only thing that kept us going without getting fatigued was patients getting better and being eventually discharged. The surgical team worked as one body and in synchrony, the goal being doing whatever was best at whatever given hour, with whatever resources we had. Every single team, be it logistics, security or the medical team, contributed to easing the pressure. Besides keeping up with the routine work of the hospital without compromise, almost a hundred of the war wounded were treated over a span of a few days.
Moments such as these sparked off joy in our hearts during the days that followed. Some patients would come back to the ward, even after getting discharged, to spend the night in the ward. It was their sanctum — a cozy bed, friends in the ward, food and extremely caring nurses. I wouldn’t want to go out into the world outside if I were a war survivor.
In a few weeks I saw the worst and the best of mankind, the ones who would kill for reasons that are difficult to understand and the ones who leave the comfort of their families to do something for those that no one cares for. What do they seek? What do we seek? Gratification? The cost of staying away from our families to seek gratification for our service is too high a price to pay. Gratitude? To be able to help someone, for the lives we have, to be able… may be.
The experience, if anything at all, is humbling. I may never find some answers. Meanwhile, there is work to do.
(MSF offers assistance to people based on need and irrespective of race, religion, gender or political affiliation. We give priority to those in the most serious and immediate danger. Our decisions are not based on political, economic or religious interests. MSF does not take sides or intervene according to the demands of governments or warring parties.)
(Dr. Bhavna Chawla is a surgeon.)
Keywords: South Sudan, Médecins Sans Frontières
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