(This article first appeared in The Hindu)
Dr Bhavna Chawla, a surgeon, recently returned from her first mission with MSF 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 told myself. The tukuls, though basic, looked as charming as a print ad for an au-natural rural resort. It’s another thing to sleep with 10 different species of insects in huge numbers stridulating all night long. But this letter is not about the rhythms of the swamps nor is it a study of the culture in Lankien, South Sudan.
The surgical facility in Lankien
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 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 gun-shot wounds everywhere - extremities, chest, abdomen, head. We had an inflatable operation theatre (OT) set up with one fully functional OT and one minor OT. Patients kept coming in scores every day. Triage had become a function of habit, prioritising and re-prioritising every few hours. The only prayer on my lips, “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 for taking 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 goes to OT. In 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 on stretchers, made out of bamboo, wood and rope, by their relatives. 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 bare minimum clothing and no way to communicate to 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 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.
There were many such stories. When I would take rounds of the ward I would often wonder, “What about the war wounded in my 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?” [i]
MSF rises to the occasion
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 that were fit for discharge 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 to come. Once more MSF rose to the occasion in negotiating with the civic authorities and roping in neighboring humanitarian agencies to resettle the discharged patients. MSF set up camps for them to stay and provided NFI (non-food items) kits while other agencies catered to food requirements.
The only thing that kept us going without getting fatigued was the patients getting better and being eventually discharged. The surgical team worked as one body with complete synchrony, the sole 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 off the pressure. Besides keeping up with the routine work of the hospital without compromise, almost a hundred war wounded were treated over a span of few days.
Moments such as these lit sparks of joy in our hearts during the days that followed. Some patients would come back to the ward even after discharge 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…maybe.
The experience if anything at all is humbling. I may never find some answers. Meanwhile, there is work to do.
[i] 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.