Much of the work that we do out here is focused on the final act: the prenatal exam, the psychotherapy session, the assessment, diagnosis and treatment of disease, supplements and monitoring for the malnourished. In a very real sense, the good people in Berlin and Amsterdam support the administrative Country Management Team (here in Abéché), who in turn support the logistics arms of the many projects all along along the eastern border of this godforsaken land. And they, in turn, support the medical people. Us nurses, doctors and midwives are left with the task of patient care, pure and simple. Food is on the table, pantries full, land-cruisers to transport, medical centers running triage, pharmacies stocked, electricity flowing, water delivered.

Organizing anything in Chad is no mean feat. This is a place where no opportunity for misunderstanding goes unexercised. Where negotiations often start with a stalemate or a threat and progress from there. Where everybody is needling and clawing for money and kickbacks. Where the security situation hangs over you like a thundercloud in the distance; you never know when it’s going to break.

I wrote a couple of weeks ago about the murder of Pascal Marlinge, the Head of Mission for Save the Children (StC). That day, all NGOs stopped providing non-essential services and retreated to the safety of their respective compounds. StC, understandably, never resumed. Within a week it was unofficially known that they would, again understandably, suspend all their activities and most likely leave the country. This left Breidjing Camp, with 30,000 refugees and 12,000 local IDP Chadians with no organization providing medical care. A vacuum.

This is the story of how MSF took over services and within two weeks, were up-and-running at full capacity.

People. Jochen, our mobile clinic nurse with many years of field experience, stepped up to the Project Coordinator position (PC). With a solid handle on both the medical and logistics side of things, he hit the ground running and hasn’t stopped since. Jean-Marc, the technical logistician also stopped on a dime and headed that way, as did almost all the national staff on the mobile clinic team. Ivan, our PC here in Farchana (but he basically likes to do everything, and would if given half the chance) got to planning. Since ground transport has been declared unsafe, Breidjing would need an airstrip. Ivan called up Karline (our Head of Mission in Abéché) and asked for authorization to build one. On the phone, at that moment, she said yes, and within two days 159 local workers had been hired and were on the job. Within six days the first flight landed and took off, notably bringing Ivan back to Farchana.

A full complement of staff were hired and given contracts. Stock rooms were inventoried and new medications and supplies ordered. Endless meetings with local authorities, and long conversations into the night about what to to the next day. It was, as Ivan calls it, “E-team mode,” which stands for Emergency-team. If there are locks on doors and you can’t find the keys, you cut the locks. You don’t think of overtime costs for national staff, you just work till the day ends (although notably none of the staff even asked for extra pay). Administrative authorization lagged behind implementation. Often. The lines of communication were open throughout, but decisions were made on the ground.

Notably absent from this story is the call for funding. In most organizations, it would take months of proposals and oversight to fund a project that effectively costs about a million Euros a year to run. It’s an onerous, paper-heavy task, leading to what could best be described as administrative fatigue. MSF, however, is independently funded. This means that beforehand they do not need to knock on government doors, UNHCR doors, or whomever, to ask for the means to provide health care. There is minimal lag. The airstrip, which incidentally had been “in the planning” for three years, and was built by Ivan et al. in five days, cost about 2000 euros. This is the cost of doing business out here. Health care for a population of 42,000 people for a whole year. Fantastically reasonable. In my view, administrative fatigue is rather low in this organization. Every cent is accounted for, of course, but money in MSF, at least from my vantage point, is not a “power-grab,” it’s just grease. My guess is that everyone over the age of six knows how rare this is. It likely would not escape the purview of an astute six-year-old, either.

I include the numbers because they interest me, and I figure others may want to know as well what things cost. Money is important.

This is a proud moment. (I was on vacation, so I feel justified in beaming without seeming the least bit self-congratulatory.) On the day that Pascal was killed, Ivan, Jochen and Edith (our logistics administrator) sat under the mango tree and spoke about what it meant for them to work out here. It hit them hard. But the conversation went from personal reflection to planning. What if StC left Chad? What would need to be done to keep primary health care services in Breidjing. It had to be MSF. Literally, nobody else could do it, given the administrative fatigue of other operations. They sat down with paper and pencil the next day and started mapping it out: a proposal to make it happen ASAP, for about two to three months, until a long-term solution could be found.

Group identification is a funny thing. I hear people all the time saying of their favourite football, hockey or basketball team that succeeds: “we won!” This is absurd. In the words of Chris Rock, a comedian, “no, six black guys, who would hate you if they knew you, won.” This is not absurd. But it does highlight the extent to which people ignore every register of class division and common sense to feel associated with something winsome. All of a sudden my friend who works in a bank, from a sheltered, privileged and rather sanitized petit-bourgeois childhood is character-identifying with Shaquille O’Neil. “We won!” Pointing out the absurdity does not mean it shouldn’t happen. Personally, I don’t care one way or the other, it’s mostly just amusing. But it does tell us something. That we want to be a part of something bigger than us, a community, a team, a movement that means something, that does something of which we can be proud. People buy products because some pretty face or talented athlete endorses them. And even the humanitarian world is on this: I see the faces and read the words of cinema- and rock-stars on the plight of those suffering oppression and its hardships all over the world. And why? I’m not arguing that it’s not pragmatic, but it’s strange, too.

I see many faces of MSF, but for me, this week, it is Jochen, Ivan, Edith, and Jean-Marc (three of whom, incidentally, are Canadian). They did not win a football match, nor have they been shortlisted for an oscar nomination. But they did work non-stop for two weeks to fill the vacuum, to enable the provision of emergency health services in a large refugee camp in Eastern Chad. No newspapers picked up the story, of course. Can you imagine what would happen in Montreal if medical services were stopped for two days? What about two weeks? It would topple governments. It would be a national state of emergency. Well, it’s an emergency here, too, but look who did something about it. My team.

“It’s not the mountain that wears you down, it’s the rock in your shoe.”

It has been brought to my attention, most unceremoniously, that I have kept the blog more descriptive than personal, more playful than ranting, more academic than grit. That I’m telling the stories of others more than telling my own, and am committing the error that every shrink hates to make, but invariably does: I ask everybody else what they feel about this or that, and am not asking myself this question (or at least not writing about it). Point well-enough taken. How am I doing? Right now I’m starting to feel better, but last week I felt mostly flat, tired, and shitty.

The rest of my body is, at times, not so thrilled either. After being here a month or so I got some odd rash on my palms, which I was told was probably from the harsh soaps or maybe dyshydrotic eczema (from sweating too much). Either way, over the following couple of months the skin hardened and then peeled off, but I was just glad that it wasn’t itchy anymore. Some problems with bed-bugs, a painful tooth (for which I went to the capital to see a French dentist who never arrived, so I just came back to Farchana), and some back pain rounds out my list of gripes. No, add the large spiders (like the size of your fist), the fact that a few weeks ago my computer broke (hence no pics on the last few blogs), that the MSF-provided shared computer has a screen that flickers epileptogenically, and that my blog is being censored in ways I don’t understand, and you get some sense as to the frustration. If I were back home, I’d get the computer(s) repaired, take a long walk, catch a movie, rant in-person to the censor, read a dour blurb in The Economist and promptly forget about it, partake of a soul-soothing smoked-meat Schwartz’s combo, paint, and sit across from a good friend or two and, while a smile and beer endure, sing the blues.

For the first time since arriving, I felt tired in my bones last week. It’s been three months here, and I have since mostly marveled, but I recently found myself wanting to not have a 6pm curfew, not live in a 43ºC-in-the-shade dust-bowl, eat some standard fare, crap normally, and otherwise read for a week. I awoke one morning and felt *hesitant* about going into the camp and seeing patients. The crush of suffering was daunting, and I just wasn’t sure if this would be the day that I’d lose my grit and have to go back to the compound, or, dare the thought enter, just leave altogether. Worse still, that the empathy buffer was too thin and I’d show frustration with my patients or colleagues. Everybody has parts of their job that are uniquely hard, and for me it is working with children. It’s a cliché, I know, but the children save you out here (followed closely by your team and patients). I spend a lot of my day playing with tykes who initially yell out “ok!”, “ca va?” or “donne-moi un cadeau.” But when they’re mute and catatonically frightened after some horrific incident, it stays with me in a way that other patients don’t. Images of Fatna sitting on the mat with a perplexed and curious disposition still arrive in my sleep, when I walk from one health center to the other, or sit down to eat; her story, and so many like it, of the sticks and death, isolation and fear, are present.

I’ve always felt that it is a good thing to follow dreams, in part because they’re inspiring, but mostly because they never give you what you think they will, and you get a whole lot else in the bargain. Sometimes good things, sometimes less so, but it’s definitely good to figure that out sooner rather than later. This isn’t a nod to jadedness… it’s just what one finds when you pay attention to the appearance of things. And so it has been coming out here, to Chad, to Farchana. Last week, in the icy clarity of a protracted and jittery malaise, I started to recognize the pleasures that have been earned by the boys playing soccer with long-destroyed balls or the frustration in the eyes of an old man who knows his children will not be brought up in a political state that could in any way be confused with a meritocracy. Hope is an emotion that operates in accordance with the law of gases: it will expand to fit any container in which it is put. Last week I felt it to be thin, and I wondered, selfishly and somewhat ashamedly, how I would survive in this rarefied environment. If hope is some ether of self-preservation mixed with motivation, it is icy clarity and rage that focuses it like a lens. This helps… to know in that vital way that things here need to get better. It counters the adaptive instinct that can bring with it a well-intentioned but eventual complacency. Well, that and another course of antibiotics that hopefully will get the bug that ails me:)

Inshallah.

About 5 years ago I was living on the plateau in a cavernous unfinished loft on St. Laurent, a couple floors above a bar/billiard hall called “Le Swimming.” The place comfortably slept five; at that time there were seven. The plumbing had been done by my buddy and loft-mate Adam who was a master of approximation and invention when it came to fixing things around the apartment. But with all the engineering capacity at his non-negligible disposal, the plumbing in the bathroom needed a better system than the rusty nozzles and showerhead. So we hopped into a beat-up MG that had recently had it’s entire bowels removed and put back in, and head off to where we could exchange money for said necessary product. The guy at the store showed us some pressure-balanced gizmo that adjusted hot and cold water in one nozzle—I’d imagine almost everyone reading this has one. But myself being a first-year psych resident, and Adam being in the throes of an interminable PhD in biomedical engineering (he recently finished, incidentally, and is off to MIT for a hopefully less-interminable post-doc), we decided to hit the hardware store and make do with a cheaper, non-rusty but still-crappy system. This is when the guy in the store, overhearing our conversation, said “don’t buy anything that’s not pressure-balanced, you won’t be happy with it.”

Fast forward to last Tuesday in the mobile clinic, about 25 miles southwest of nowhere, 7 pm, pitch dark on one side of the starry-night horizon, and opposite the last remnants of a faint under-lit glow just visible behind the mountains in the West. The shower was, as are most things here, built with an economy of resources and time as much as plastic sheeting and irregular-shaped bricks and crumbly mortar. So there’s the shower, a pillar of bricks in one corner of an open-roofed, plastic-sheeting-enclosed space slightly bigger than a phone booth. A black jerry can with a refilling hole cut out of it’s top sits on the head-high pillar, and a 2L plastic water bottle has been grafted onto the side of the can, with a rudimentary plastic spigot to adjust “water flow.” The water still hot from the day’s heat, I found myself wondering if the skin on my arms was dark because of the sun or the layers of dust and sweat and more dust. I think it was the best shower that I ever had.

When did I forget this? That it’s not some fancy nozzle that makes a good shower. It’s being dirty after an honest-days work. If but only to learn that again I would have come back to Africa. Tomorrow is Monday… a new week and I’m happy to be here, but I suspect that I’ll also be well ready for that vacation that’s coming at the end of the month.