This weeks feature : Médecins Sans Frontières Australia

February 2007

Still violence, still suffering

As envoys from the United Nations and the African Union arrive in Khartoum and depart after another round of talks, the conflict in Darfur rumbles on. The humanitarian situation in this troubled western region of Sudan remains appalling. In the first few weeks of 2007 Médecins Sans Frontières (MSF) continued to witness outbreaks of violence, displacement of civilians, and despair and perpetual fear of the 2.5 million people trapped in camps around Darfur.

Read letter from MSF medical doctor Joe Jacob - “Maybe there is just too much real grief here”

Read interview with MSF nurse Ineke Swaans - “I can still see them standing there, waiting”

Civillans are targets

Sporadic fighting in numerous areas across the region, combined with the switching allegiances amongst the many forces involved in the conflict, is complicating what is already a labyrinth for aid agencies to navigate. Today there are more than a dozen separate rebel groups, local militias in addition to plain banditry. Each area seems to have its own unique line-up. The conflict is increasingly splitting the population along ethnic lines, prompting attacks on villages or camps for the displaced, making direct targets out of civilians without any relation to the military.
According to the United Nations, over the past six months, 30 non-governmental and UN compounds have been attacked by armed groups while more than 400 staff have been relocated 31 times from different locations throughout Darfur. Médecins Sans Frontières has been far from exempt. The level of violence and associated risks are so high that it is increasingly difficult to sustain the assistance.

Injuries from violence

Despite this, MSF teams are working across the region, for instance in the south Darfur town of Muhajariya, where severe fighting recently displaced around 50,000 people. In 2006 Médecins Sans Frontières performed surgery on 574 persons with violent injuries in Muhajariya. Due to the fighting in the area, access to the hospital became more difficult towards the end of the year. The overall number of patients dropped and the percentage of emergency related surgery went up to 96 per cent. The situation in Muhajariya remains difficult and people with violence-related injuries continue to pour into the hospital: in January another 24 persons had to undergo surgery.
‘In the past month I've seen terrible injuries, scores of gunshot wounds, parents whose children have just died, auto-amputations and assaults, but only one person over the age of five has cried audibly,’ says medical doctor Joe Jacob. ‘Maybe there is just too much real grief here and too much energy that would be expended were it to be expressed in full every time.’ [read Joe Jacob’s letter from Muhajariya here]

Reliant on assistance

An estimated 14,000 of the displaced sought refuge in Seleah, a town 40 kilometres to the south. Médecins Sans Frontières provided for distribution of plastic sheeting, blankets, jerry cans and soap and started running a clinic with a small nursing department, that conducts 300 to 400 consultations a week. In addition the team vaccinates children against common illnesses and provides treatment for malnourished children.

In the village they have made shelter from sorghum stems covered by a plastic sheet. “For some displaced it is only seven kilometres back to their village,” says nurse Ineke Swaans, who recently returned from Seleah. “But if the women return to harvest the crops, they run the risk of being raped or killed, or having their crops stolen.” [read the full interview with Ineke Swaans here]

People who have made it to the displaced camps like those in Seleah, are totally reliant on waning external assistance for up to four years, there is little hope of good news in sight. MSF medical and logistical staff working in Darfur often find it hard to see any positives. Unless the political environment changes rapidly, the tragedy will go on.

Letter from MSF medical doctor Joe Jacob - “Maybe there is just too much real grief here”

“I am writing from a town called Muhajariya, population 36,000, a significant proportion of whom are displaced refugees within their own country. Here we run a clinic where we are the only medical and surgical referral centre in this region, attending to the needs of a wider population of 200,000 people. Life is far from easy here, but the happiness and sheer enjoyment of living today that envelopes and dissipates the ever-present fear here, would certainly make you think otherwise.”

Abnormal lack of fear
“I can't really talk about the clinic without telling you first about the people of Sudan. They are such a conundrum. On meeting them, you'd be astonished by their generosity of spirit and open heartfelt welcome. If they see you enter a restaurant, they have no hesitation in buying you a drink, even if they barely know you. And this isn't just a perk reserved for foreign doctors, it's an ingrained custom.
“But smothering all this kindness is the total senseless killings that are happening all around. No-one would dare steal from you here, but militias drive around town with rocket launchers hanging off their shoulders on the back of converted land cruisers. As you sit under the tea sellers' tree, outside the hospital, a man armed with a machine gun and belt of bullets will sit in the seat next to you and smile a greeting as he sips his hibiscus tea, his eyes hidden away by sunglasses. Men armed with swords and AK47's are so common, they barely merit a second look these days. In fact it’s only writing this now that I realise how abnormal my lack of fear really is. I guess you do get used to anything given enough time.”

Biggest challenge
“Days in the MSF clinic can veer between hectic (seeing hoards of outpatients - over 4000 a month) and unreal (truck upon truck of patients with gunshot wounds arriving within hours of each other). But the staff we work with here, who have unfortunately seen this all before, carry on with such continued compassion and determination that one can only feel strengthened by their example.
“The biggest challenge I've faced so far has been with the acceptance and stoicism of the people of Sudan. Recently I saw a boy of 13, with a horrendous dilated cardiomyopathy (disease of the heart muscle) who I could only encourage to go home and enjoy what remained of his life. The difficulty came after the consultation when he stood up and smiling bravely shook my hand and thanked me, as did his slightly older brother. So many people here have suffered so much, they take everything life throws at them and just carry on. I wish at times they would just scream and shout with the unfairness of it all, but in fact they probably do this as well, though surreptitiously, via complaints of chronic backache, loin pain, chronic headache or night fever irreproducible during daylight hours.
“I hope the above doesn't sound too negative because some of the things we have done here have been truly amazing. Last week, I had to use a pinnard stethoscope to listen for foetal heart sounds on a lady who was experiencing an obstructed labour, for only the second time in my life. All the women here are circumcised and this often leads to difficulty for the baby when negotiating the birth canal. Thank god I heard a heart rate of 140, and the surgeon went on to do a caesarean and deliver twin girls. I can only hope the rest of my time here see this luck hold out.”

Silent tears
“In the past month I've seen terrible injuries, scores of gunshot wounds, parents whose children have just died, auto-amputations and assaults, but only one person over the age of five has cried audibly. Plenty have shed silent tears, but for a sound as natural as laughing, its absence only became apparent 2 days ago. A 45-year-old lady had a huge stroke and died the next day. Undoubtedly a cultural phenomenon, the mourning daughter, whose uncontrolled wails made us all stop our activities, and my hairs stand on end, was quietly ushered away. Whilst laughter here is as unrestrained and enthusiastic as I've ever seen, the polar opposite holds true for grief and sadness. Children's eyes will glaze over and slow salt-water drops will be the only evidence of pain as an abscess is drained without anaesthetic. Maybe there is just too much real grief here and too much energy that would be expended were it to be expressed in full every time.”

Interview: MSF nurse Ineke Swaans - “I can still see them standing there, waiting”

“It’s happening to people who have lived in the village for years, they are being shot at, attacked, chased away. Now they’re concentrating on surviving in the place they've been brought to and from which they can't leave. Ineke Swaans is back from Darfur where she worked as a nurse for Médecins Sans Frontières in the town of Seleah. Since November 2006, some 14,000 people have arrived there after being forced out of their villages.

“At this moment, the established militia and armed groups are splitting off, sometimes it seems like a new militia appears every day. Each group controls some areas, forcing out people they say don’t belong there because they belong to a different ethnic group. Some of the displaced living around Seleah told me that people said, ‘Pack your things and start walking. Go, you don't belong here.’ They are afraid to return and some areas have become a no man’s land. Nobody dares to trust anybody anymore.”

Sheets and sorghum stems
The town of Seleah has a population of about 6,000 people. When thousands of people from the region around Muhajariya sought shelter there, an MSF team travelled there immediately to offer assistance.“We provided blankets, jerry cans, soap and plastic sheets. The people used the sheets and sorghum stems to make some shelter. For some of them it is only seven kilometres back to their village: if the women return to harvest the crops, they run the risk of being raped or killed, or having their crops stolen.”
“We run a clinic with a small nursing department that conducts approximately 300-400 consultations a week. In addition, the team vaccinates children against common illnesses and gives “home-based treatment” for malnourished children. At first there was only one place to get water, then another aid organisation drilled a second water hole.”

Unbelievably strong
“In the beginning especially there were a lot of gunshot wounds. I started working there in the middle of December and I treated five such victims myself. Wounds made by an exploding (dum-dum) bullet make a small hole when they enter the body but cause a great deal of damage inside. They also use bullets that make a small hole when they hit
the body and a big one when they leave it. With these, you really have to search to follow the bullet’s destructive path. I’ve seen everything: wounds caused by a grazing shot to a gunshot wound that completely destroyed the hip and buttocks of a 10-year-old boy. There have also been wounds made by machetes and axes that were just thrust into someone’s head.
“Whole families have been forced to move, everyone from young to old. However, these are incredibly strong people who live under extremely difficult circumstances without complaining. They sit in their ‘little huts’ with only one blanket during very cold nights. They just keep going with what they have. If I think back, I can still see them standing there, waiting by the water pump. When there was still only one pump, they had to wait up to 24 hours, day and night. You almost can’t imagine it.”

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