“When I arrived in Lankien, there were many patients who had undergone surgery some months previously, but were still waiting for MSF to fly them back home. People injured in the war had been flown here from other parts of South Sudan. As the violence spread and hospitals were destroyed or evacuated, MSF’s surgical team moved to Lankien and so did its patients.
MSF has been trying to adapt to a new reality in South Sudan. It has shifted from addressing the huge medical needs of a people with generally no access to healthcare, to addressing the huge medical needs of people trapped in an armed conflict. Resources, as always, are limited – so how do you make decisions about those resources? As ceasefire attempts fail time and again, as hunger looms and tropical diseases like kala azar erupt, our strategies have to be re-examined. Do you attempt to save the greatest number of lives? Or do you prioritise resource-intensive surgical programmes that focus on the relatively few? It’s a dilemma, since every human life matters, but decisions have to be made.
We’ve decided to maintain a surgical programme here, but we no longer fly war-wounded from across the country to Lankien for lifesaving surgery. One exception is patients in the surrounding area, where MSF runs clinics, who need to be admitted to hospital to save a life or a limb. As we have cargo and staff going there by plane anyway, we will bring patients back with us on the clear understanding that, after discharge, they will have to make their own way home.
But walking in South Sudan is not exactly unusual. This is a pastoral nomadic society and people walk for days and weeks at a time. An estimated 2 million people have been displaced since the conflict started more than a year ago, and they have walked halfway across the country and into other countries to escape the violence. There is no reliable public transport in this part of South Sudan while air travel inside the country is mostly reserved for the military and NGOs.
But what could I tell the surgical patients who asked me when they were going to be flown home? All I had was a policy that had changed with the context. The hospital was full of patients who were already discharged but had nowhere to go, so we continued to house them. But knowing that people walk everywhere here, I did my best to send the young and now healthy on their way. What was harder was those who had been flown here from great distances, across what were now front-lines in the conflict or across rivers. What about the very vulnerable – amputees, children, women with infants, the disabled – who faced a journey of several weeks?
I got lucky when another organisation offered to help get this vulnerable group home. The first group returned to a village that had been burned and looted and was just starting to be re-inhabited. After a few more flights to other destinations, the numbers went down enough for some of the surgical ward tents to be removed. One week a flight was called off at the last minute when fighting broke out nearby. When I heard of a plane going to an area where I knew some of our patients were from, getting them home was always on my mind. But flight plans in South Sudan are always changing, even in the dry season.
One week we had a team travelling to a place where there was an outbreak of kala azar, and I saw a chance to take a paraplegic man and his caretaker there at the same time. It was all arranged but, at the last minute, he decided he wanted to stay and continue his care at our hospital, apparently scared his wound might get infected before healing completely. It seems that whenever someone needs convincing, it’s the project coordinator’s job to do it. So I tried to convince him that there was medical care there (not as good as ours, he said) and that there would not be another flight that could take him. A reason I did not share was that if Lankien came under attack, he would be extremely vulnerable and would be much better off with family, who could help him escape into the bush. Having reassured him that his dressing changes were not difficult, and that he would have to leave the hospital in any case, he decided to go.
One day, while walking through the hospital, a 12-year-old girl called Nyapur took my hand and asked me why everybody else was going home but she was still here. Nyapur had arrived some months previously, weighing only 13 kg and with an abdominal fistula that required surgery. Now her fistula was repaired and her weight had risen to 28 kg. I told her that I was working on it and that I hoped I’d be able to get her home soon. In fact, there were plans for a flight later that week, but since it had been cancelled before, I didn’t want to raise her hopes too soon.
The day before the flight, I was able to tell her that we had a plane to take her home. She smiled and said, ’But I will miss you!’ I went to look for the other patients who would be going back with her to their village. One was an amputee called Tor, who had lost an arm and a leg above the knee. Several weeks previously, he’d pleaded with me to send him home to his family. At the time I could only say that I was working on it. I’d heard he’d become so depressed that several men in the ward had taken to watching him at night, afraid he might take his own life in despair. He was sitting on his bed when I arrived to tell him he was going home and we both smiled.
The last patient was a woman who had been seven months pregnant when she came in with a gunshot wound to the head. She’d sustained some paralysis on one side, but could still walk, dragging her leg. Her baby had been born in the hospital, and she managed to care for him with her good arm. She was sitting on her bed in the maternity ward, her now four-month-old baby sleeping by her side, when I told her that we finally had a plane to take her home. Her eyes widened and she smiled shyly, turning her face into the crook of her arm. She said she was very happy, and I told her I was glad there was a way to get her home and that she should be ready by 10 the next morning.
There is so much of this job that is hard and heartbreaking: the frustrations, the misunderstandings, the requests that you can’t fulfil, the endless needs. So I was determined to see my group of travellers off at the airstrip. They were waiting with their stuffed plastic bags around them as the plane was unloaded in a cloud of dust. When it was time to board, I helped them up the few steps, gave them all embraces, made sure that Tor was secure, and gave one final wave. They were off, but their delight and joy stayed with me as if it were my own.”