Darfur, Sudan letter: 'Maybe there is just too much real grief here'

"Days in the MSF clinic can veer between hectic - seeing hoards of outpatients; over 4,000 a month) and unreal - truck upon truck of patients with gunshot wounds arriving within hours of each other.

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 totally 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 4,000 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 all this 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."

"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 two days ago.

A 45-year-old lady had a huge stroke and died.

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."