“…visceral and immediate…” – British Medical Journal

A place where dreams turn to dust

A daily blog from an aid agency medic in Sudan, now an insightful book, dashes the romantic notion of achieving medical miracles in basic conditions, finds Jonathan Kaplan

From a distance it seems easy, signing up to a humanitarian mission. Most doctors, at some stage in their training, dream of working somewhere extreme, applying their skills to alleviate the suffering of those caught in a disaster, a conflict, a refugee crisis, some place where a little doctoring goes a long way. There is the romantic notion that with basic equipment and idealistic resolve, medical miracles will be achieved. But the journey is vastly more complex, the rewards far less definable. All of us who return from these places leave something of ourselves behind.

James Maskalyk was a young, recently certified emergency medicine specialist in a Toronto hospital when he accepted a six month assignment from Médecines sans Frontières (MSF) in 2007 to be a doctor in the contested town of Abyei, right on the fracture line between North and South Sudan. He did so because he wished to help, but also because he wanted to explore that particular self realisation that is acquired through hardship and abnegation; because, as he admits, he wanted to be close to war and its consequences. His discoveries might have remained personal ones, but Dr Maskalyk chose to make them generally accessible. In the face of some resistance from MSF—like all NGOs, mindful of its image—he elected to write a blog of his daily experiences in the field. Those writings, visceral and immediate, form the core of Six Months in Sudan.

As medical literature this book excels; as an insight to that exhilarating, life changing step into chaos—walking towards death, Maskalyk calls it—his account can hardly be bettered. The consequences of his decision form the start of the narrative, in a first chapter entitled The End. Back home in North America, at a happy wedding party, Maskalyk finds himself suddenly overwhelmed by memory, starkly aware of the “irreconcilable invisible distance” between himself and those who have never embarked on such a mission. “Though I could convince myself that the fissure was narrow enough to be ignored,” he observes, “it took only a glance to see how dizzyingly deep it was.”

From that point he moves to try to understand The Beginning; the steps involved in volunteering. These require the incremental extraction of the self from conventional aspirations, from friends, from—as he comes to realise—the shared moral framework of structured society. It is necessary to shed expectations about certainty for the future. He is taking his idealism to a place where order has collapsed: subsistence replaced by starvation, trade by banditry, schooling by armed militias. An aircraft lifts him to the place where he will be working, across vast tracts of desert. How many good intentions had these pilots ferried over the sand, Maskalyk wonders, how few brought back. One of the choices he has made, just before departing from MSF’s Geneva base, is to buy cigarettes, a self destructive act but one that ends up making perfect sense in the loneliness of his posting; “When you have a cigarette, you always have a friend,” Maskalyk will write in his blog after two months in Sudan, “everyone in our mission smokes furiously.”

A further, essential adjustment is the realisation of the limits of what can be achieved. This is not the place for those who need reassurance that they are doing the right thing, or even the evidence that they are making a difference. The work is not easy, he observes, and it never ends. Rather, it is an exercise in patience, knowing that the war is a long one, that not all projects will go forward or interventions succeed; that it will be difficult enough sometimes to simply do the best you can for the person in front of you.

After Dr Maskalyk has been working in Abyei for some months, the community arranges a meeting though the paramount chiefs to complain that the hospital is not doing enough for them. Some want to be able to get treatment for minor, non acute as well as emergency conditions; a full surgical service; a helicopter for transfers to other hospitals. Their expectations are unmeetable. When factions in Abyei start shooting at each other, the hospital becomes a point of conflict. Armed men demand treatment for their wounded, post mortems on their dead. Playing the only card they have, the MSF team withdraw their services until the guns depart.

Yet at the same time their work is about much more than medicine. It is a catalyst, a nidus around which the structure of a new, tentative society might coalesce. “The hospital is not just a place to treat the dinka infant with meningitis or the little misseriya girl with malaria,” reads Maskalyk’s blog, “but a place where their fathers can reach for the water barrel at the same time and say to the other, after you, no after you, and maybe, two weeks later, when they pass in the market, they will nod. And perhaps, two years from now, they might stop and talk.”

And therein lies the hope and beauty of this rare medical experience.

Cite this as: BMJ 2009;338:b1489