Thursday, March 28, 2013

Saad Gishra Musings

Everything one wishes for in life.

I went to Sa3ad Gishra last weekend to get a few things fixed. For those who don’t know, Sa3ad Gishra is sort of our local shopping center. It’s basically a few hundred shops and tents set up and named after some guy (Sa3ad Gishra) that sell and fix everything and anything for a wide range of prices. I don’t buy stuff from there (or anywhere else in Sudan) because I can’t haggle with sellers. The negotiation usually goes something like this:
Me: how much is that??
Guy: 100. (The thing looks like it costs not a dime more than 15)
Me: I’ll take it for 45.
Guy: Yefta7 Allah ya okhot.
Me: MA DAYRAHO ZATO. (storm out of the place and end up going home empty handed. Every. Single. Time.)
Anyway. I had a handbag I bought ages ago from Oman and the zipper had broken, so I thought I might as well get it fixed there because it was a nice and relatively expensive bag and I wanted to use it for the Port Sudan trip. So I drove down Africa Road, past the airport, over the railroad tracks, past the ginormous government and army buildings, crossed over the 100+ year old bridge to Bahri, stopped at the roundabout that gets renovated 6 times a year, where a traffic officer named Nimeiri has been stationed for the past 18 years, and whose lungs I’m pretty sure are as black as the carbon he inhales from car exhaust day in day out forever. Down Alinqaz Road, cross over to Almazad road, then again to Alma3ouna, and finally park in front of Sa3ad Gishra. I am immediately approached by an elderly man who asks me if I want to wash my car, and I decline. If the man knew how much money I had in my wallet, he wouldn’t have bothered to ask me anyway. I know the people who fix things are at the back of the market, an area I haven’t been to before, and I head there directly. I locate one small shop, am told that my bag cannot even be looked at before tomorrow, and am then director to another shop, where I find a man surrounded by old and broken bags, suitcases, shoes, and other unidentifiable objects. He’s sitting in front of a sewing machine and is fixing something or another. He doesn’t even look up at me and looks so bored and uninterested he isn’t even breathing. He looks at my bag with half an eye and tells me it can’t be fixed. I insist that he try, and after nagging for a while he finally looks up, looks around and calls to some other guy to have a look. The other guy comes over, and says something about finding a zipper somewhere, and stalks away with my bag. After waiting for some more time, he shows up with a different coloured zipper, and motions me to sit down while he and a third person fix my bag. I watch them for a while as they push and pull and crimp and oil and do all sorts of things to the zipper. The first man is wearing an old torn shirt, has dirty hands and finger nails and is wearing a sifinja. The other man is better dressed, with shoes and socks. I’m not sure if they both work with the shop keeper or are just friends or have some agreement going on. What I do know is that the bag they are fixing costs more than what all three of them make in a month, and don’t know what to make of this piece of information. As they go along with their job, I look around me. There are tailors and carpenters and people with high tables on which are objects for sale. Dozens of people walk back and forth, into and out of shops, everyone is talking or complaining or laughing or working. An old lady appears carrying a low table that she gives to the carpenter and disappears. Another lady, much younger, pulling her daughter behind her, passes in front of us in one direction then again in another direction. The little girl, who looks about 5 or 6 years old, has black shiny henna on both her hands and feet, in a zig zag design that matches her mother’s. I regret not having my camera at that moment to photograph the matching pairs of feet walking away from me. An old man who looks Egyptian walks past, carrying horrible sculptures of eagles and mountains and other things, and I wonder who on earth would want to buy something so hideous to put in their homes. He looks tired and annoyed and sweaty. I wonder if he managed to sell anything today, and how heavy the sack of sculptures are, but also carefully avoid making eye contact so that he doesn’t spot me in the midst of all those men and tries to sell me something. I look instead at a group of men collected in front of a shop a couple of meters away. They’re all leaning on each other and looking at something on the ground, deep in discussion. I try to see between their legs but can’t for a while, then someone moves and I see the cards. Is it a poker game? It must be, since everyone seems so interested. I don’t see any money though, and no one in the immediate 100 meter radius looks like they can afford their next meal, let alone bet on a poker game. The old lady appears again, picks up her low table that has been fitted with some extra limbs, and walks away. She must be a tea lady. I can’t see the henna on her feet because she’s wearing black socks. As she walks away between the shops, I catch sight of the Egyptian man again. He’s standing against a wall smoking a cigarette. I look away, irritated that someone so hard off he has had to leave his own country and come to Sudan, of all places, to sell eagle sculptures, is wasting precious money on a stupid cigarette. Then I notice that he is standing next to a couple of boys who are seated on the ground. Shoe shiners. In the midst of his misery, the Egyptian man is smoking a cigarette and getting his shoes shined. I wonder at humans and their primitive needs: at their lowest times, the need to satisfy their hunger for food, drink, smoke, and the need to look good, stand out. Reminds of something my friend once said about a woman who was begging on the side of the street, but whose face had the tell-tale colour of whitening cream.
Anyway. My bag is getting mutilated by the 2 men, but the zipper is finally in place. They slowly pull it back and forth a few times, and pronounce the bag fixed. I am delighted, and take the bag to try the zipper myself. Less than a minute later, its stuck, and the men are back at square one. They blame me for pulling it too hard, too far, too everything, and I silently thank God that I pulled it too hard and too far before paying my money and going home. As they go back to pushing and pulling and crimping and oiling and doing all sorts of things to the zipper, a young boy standing next to me catches my attention. He’s talking to a man who is sitting on the ground and fixing his sleeves for him. The boy has 6 long fingers on each hand and no thumbs. He looks about 12, and I wonder he manages on doing anything with his hands. The kids probably tease him endlessly at school, and he probably walks around with his deformed hands in his pockets to hide them from view. However, looking at the boy’s badass stance and confident posture, as he stands on the side of the narrow street with his hands open at his sides, I then wonder what hedoes to the kids at school, and laugh to myself at his cocky attitude. He doesn’t look bothered at all. I look back at my bag and see that the guy who looked so bored he would drop dead any minute has gotten up, walked around the table and came to have a look at the troublesome bag himself. A short while later, the man in the sifinja gets up and walks away, having given up. The shop keeper goes back to his seat, and the man with the socks gives me my bag back, unfixed. I don’t get charged anything, and I get up and walk away, down the narrow streets with shops and shacks on both sides, filled with men with and without educations, supporting families of one or a dozen, with rough hands and unshaved faces. Men who have no health insurance and who cannot guarantee that their children will not grow up to a better future. Who joke with each other and ask about sick relatives, tease small boys selling mineral water and sponges, complain about the government but do nothing about it, and who may or may not be satisfied with their lives. 

Wednesday, March 27, 2013

The Insect's Toenail Goes To Port Sudan

I am currently involved in an interesting project that seems to be the answer to Sudan’s health problems. The ministry of health has decided to conduct a complete overhaul of the current healthcare system, and to choose a state in which to run a sort of pilot for the reform initiative. The Red Sea State, home to Port Sudan, was chosen for several reasons, and negotiations resulted in the writing of a proposal and the kick off of the project. I took over the work from Ahmed and am now sort of in-charge of the technical work in the institute that I currently work in.
This post is not about the reform initiative, although that in itself is quite an interesting topic and one that gives us hope for the future of health in the country. Past experience has showed us that not everything we are promised actually happens, but let us for once be optimistic. The post is about my visit to Port Sudan, and my first experience of a government freebie.
Nice hotel, but the napkins were burnt and the room service only once every 2 days
I now know that I wasn’t really supposed to be included in this visit. It was mainly the undersecretary for the ministry of health (a very important person in the ministry, second to the minister himself), the director of primary health care in the ministry (also a very important person in the ministry), the consultant to the public health institute (my boss and also a VERY important person in the NCP and the ministry), a representative from the national health insurance fund (a not so very important person as a person, but a very important person for what he represents), and finally director of emergencies in the ministry (a very important person in the ministry, and the daughter and granddaughter of 2 major chiefs in Port Sudan and more or less related to the entire state). And then there was me. A not important person at all, who doesn’t really represent anyone, whose name no one knows (except for my boss and recently the head of emergencies), who isn’t related to anyone in the state, and who is too skinny and too short to stand out in the crowd of big people I was engulfed in for most of the trip. I had known and planned for this trip for the past 7 months as the whole reform initiative is something I am quite interested in, as well as the fact that I had planned to carry out my masters dissertation in one of the reform areas. However, the afternoon of the travel, I came to the ministry for a final meeting and was approached by a guy with a grey moustache, asked if I was Reem, informed that there was ‘some confusion’ with the travel arrangements, and given the general idea that I was not cleared for travel. After the meeting with my boss I informed him of what I had been told, and he immediately got up and left the room, and came back a couple of minutes later to inform me that indeed there had been ‘some confusion’ and that he had cleared things up.
The only interesting thing about the flight was that it was my first experience with flying first class. Yes, the plane was tiny, the seats and services were basically economy with bigger arm rests, and I was too scared of us falling out of the sky the entire length of the flight to appreciate this fact, but still, the fact remains that I had finally flown first class. So there.
We were received by a group of important looking people who would be our escorts for the entire stay in Port Sudan. I later came to know their identities as the state director of health (equal to undersecretary), the director of the health insurance fund in the state, the state minister of health (who later met us at the hotel), the director of preventive medicine (a short chubby lady) and a few other people. We chilled in the VIP lounge and were then whisked away in big shaded cars to the Hilton, where we were received by the state minister of health himself. It was quite an affair, and the Hilton was very nice and bright, and I felt a surge of pride in the fact that it was my aunt who had designed it. There was an issue with the room as the first one we were taken up to had some maintenance work but the second one was fine. We dropped off our bags and were whisked away once again to a dinner invitation. I was distressed. I had brought an outfit along just for the dinner, and I didn’t want to go in the plain clothes I had worn for the trip, but there was no time to change. However, when I saw the club where the dinner was held, I didn’t feel so bad. And when I saw the dinner, I was downright happy I hadn’t wasted my time and changed into anything fancy. The dinner was foul, eggs, liver and chicken. We all shared plates and bread and it was not fancy at all.
Anyway. Back in the hotel lobby, the state director of health walked up to me with an unpleasant look on his face.
‘Inti mino?’
‘Reem mino?’
I didn’t know who this person was and didn’t like the look on his face. I couldn’t tell if he smelled something bad or had an itchy nose or if that was just the look he carried around on his face. He then informed me that he had received a call that afternoon from the ministry’s office that a 6th person who had not been previously included, was now included in the trip. A person named Reem. Reem mino?
‘Who knows?’ was the answer he had gotten. Which was why he was wondering who I was and why I had been included in the trip. Do I have a presentation as well? Yes, I said. At this point I wonder why I hadn’t asked him who he was and what business was it of his who I was, but I didn’t. Anyway, this guy was like a nail in my eye for the entire trip. He continuously carried that look of disdain on his face, was always in my way, always blocked me at the door, and kept making stupid comments on things like when I took pictures. When me and the lady with me were about to enter a room, he would stand to the side and say ‘ladeez ferist’ to let the other lady pass, but then step in front of me and walk in ahead. When we were shown around the new renal centre and were standing in a small backyard with nothing more than pipes and back windows, he would turn to me and tell me I could take a picture if I want, since that’s what I do, isn’t it? When we were introduced to an official, I would be left out. On the day of the presentation and 20 minutes before we were to meet the wali, he kept me back to download mine and everyone else’s presentations on his flash disk, then left. By the time I had finished and picked up all my things, he had disappeared. And so had everyone else. I found myself standing on an empty street in front of the building, while he and everyone else had gotten in the cars and driven off to the wali’s office, the most important man in the state and the main reason of our whole visit. I was livid. I was so upset I almost cried. I called my boss and in my distress I couldn’t even tell him off for leaving me behind, but just told him that I could just stay behind if it didn’t matter that much. Anyway, he called someone who came rushing down and brought a car that drove me to the wali’s office. I then joined everyone in the waiting room, and found the guy sitting in the middle of crowd, looking as smug as a bug in a rug. I gave him the dirtiest look I could but he didn’t even look at me. Eventually we were called in to see the wali, and entered a huge office with spot lights and plants and blinds, in front of which sat one of the most interesting men I have met. Again, I was kept out of the introductions, and sat on a chair at the end of the office, seething and cursing the man and everyone on his team who were going out of their way to treat me like the insect that I felt like. Not an insect, but an insect’s toenail. I felt that bad. This whole government freebie thing was losing its shine fast. The whole first class tickets and staying at the Hilton on the state government’s dime apparently showed people as the cheap gits that they are. They gave their smiles and suck-up speeches to the important people but people who weren’t people to them were a waste of money. Anyway. The undersecretary gave his speech, and my boss gave his speech, and the health insurance guy gave his speech, and then the wali gave his own speech. The whole affair was quite interesting, but something else kept my attention. It was the waiters’ activity. There was a whole group of extra people in the room: 2 photographers, 2 waiters, 2 people who had just appeared with us out of nowhere (I think they were taking notes or something), one guy from the ministry back in Khartoum (who had been in charge of arranging the visit and who had said ‘who knows’ who I am to the other guy) who had apparently flown in that morning just for the visit, and finally a small man who had been following us around the whole time and who I think was the state minister’s assistant. This man was a local, who had small hands and feet, who didn’t look very bright, and who was wearing a weird coloured shirt. It looked kind of curry or turmeric coloured. What annoyed me was that he was sitting ahead of me in the office, while I sat in the end. I was already annoyed by the rude treatment of the director, and this little man annoyed me even more. As the waiters brought in the drinks and coffee, I carefully followed their movements looking for any cold treatment from their side as well. However, I got my karkade and coffee just the same as everyone else, and even before most people in the room, being the closest to the door. The ‘who knows’ guy was sitting next to me, and as the waiter passed in front of him he motioned to him for some coffee. I then noticed that he hadn’t been given a drink. I then looked around the room again: none of the extra people had gotten drinks. Neither the photographers, nor the note takers, nor the guy in the turmeric coloured shirt. I was unpleasantly surprised. I didn’t worry too much about the photographers since they were probably attached to the office, or to the local TV channel or newspaper or something, and were only passing through. I had no idea who the note takers were, but I later found out that they too were reporters or something. I didn’t bother at all about the ‘who knows’ guy sitting next to me. He eventually got his coffee. It was the turmeric shirt guy that broke my heart. He had looked at everyone else getting drinks, has waited patiently for his own, and hadn’t gotten anything. He wasn’t just an insect’s toenail, he was lower than that. And it wasn’t something that was new to him like it was to me. It was most likely something that he went through every single day of his life. I tried to read the look on his face but couldn’t decipher it. He was someone who wasn’t anybody important, who no one introduced to anyone, who no one even bothered to give a drink with everyone else. I then remembered my own stupid behaviour towards him: I was upset that he, a no body, had sat down near the middle of the room while I was right at the end. My earlier feelings of hate and 7agarra that had been consuming me suddenly disappeared, and were replaced by a very uncomfortable and ugly feeling: shame.
Our return tickets were economy class, free seating (dafoori bas), and I tripped on the stairs climbing to the plane, a combination of high heels, too many bags, and a skirt that is too big and too long for me. I learnt a number of lessons from this trip: that only stupid people are rude to people they think are unimportant; always wear comfortable shows NO MATTER WHAT; and that I need a backpack for a laptop bag instead of that stupid thing I have now. And that if the wali of Port Sudan ever decides to run for presidency, he has my vote.

Tuesday, March 12, 2013

How To Die In Sudan

Keep your city clean and throw your heads in the garbage.
I am currently staying in the Armed Forces Hospital (Alsila7 Al6ibi) with my grandfather and today is day 7 of our stay. This isn’t the first time we’ve had the bad luck of staying here, but no matter how much I brace myself I am still blown away by the stupidity, ignorance, and downright cruelty of the system. The last time we were here my grandfather was undergoing renal dialysis, and it was so bad that we actually had to go knock on the nurses’ door to tell them that it was time for his session and can we please go, instead of THEM coming to remind US. The only doctor assigned to insert the dialysis catheter would have to be hunted down and begged to please insert the catheter today so that we can dialyse. The nurses would hang an IV fluid bag that needed to be changed every 4 hours, but they would disappear all night without even bothering to wonder about the bag they had hung up. And the doctors? Let’s not even go there.
Or no, actually, let’s go there.
Secondary to his renal failure, my gramps has had to have an indwelling urinary catheter to be kept forever. Urinary catheters are known to cause recurrent infections, and indeed he had been running a fever and getting more and drowsier for a few days, and we came to the hospital last Tuesday night with a full-blown urinary tract infection, which was so bad he was draining frank pus instead of urine. Admitted through the emergency room, we were kept in the emergency wards which are meant to keep patients for the first 24-48 hours of their stay, after which they are either discharged or admitted into the hospital itself. From the first minute of our admission, the only 2 questions we were asked over and over again were: which doctor saw him last time (because that would be the doctor to whose unit he will be assigned to), and what is his military rank? My uncle was in the army and died in the war with the South in 1996, after which he was awarded the second highest rank in the military. Being a military hospital, patients are assigned to wards according to their ranks; lower ranking officers are not allowed near higher ranking officers’ privileges. Since there was no room available for his rank, we were kept in the general men’s ward, where for the first night I slept sitting up at the end of the bed, and the second 2 nights I slept on a mat on the floor. There was no bathroom in the ward so I had to change and bath him on the bed and go upstairs to the female staff’s rest room to take care of myself. 3 nights later we were informed at midnight that a room was empty, and I went up to see it. There was already another male patient in the room with his sons. I told the nurse that we were 2 women staying with him and could not share a room with 3 men. She told me that I could take it or leave it, and naturally I left it, miraculously avoiding punching her impudent face in. No one cared about when his last meal was. No one bother to check that his medications were entered correctly. I don’t even know who entered the medications in the first place, and wonder if that person was even remotely related to the medical profession. We were in a constant war with the security because only one attendant was allowed to stay with him, when it took 3 people to lift him for bathing and changing. As for his medical treatment, it was a disaster. In a nut shell, the following potentially fatal mistakes were made:
1.       Full dose IV antibiotics were prescribed despite his renal failure (half dosing is required so as not to kill what remaining kidney is left)
2.       Oral iron prescribed despite his peptic ulcer (iron is very irritating for the stomach and large doses can cause bleeding and ulceration even without a pre-existing ulcer)
3.       Calcium prescribed once daily (should be given 3 times a day)
4.       No fluid charting: this was probably the worst issue, since he was a) very sick and strict fluid control is need to maintain hydration of the cells without overloading, and b) he is already in renal failure and can very easily overload anyway
I kept my own careful charting of his input, and on requesting the nurse to please empty the urine bag, I was informed that I was the one who would be doing so. How? Don’t know, don’t care. There was a basin of some sort shared between all the wards that I would have to go around looking for, and in which I would empty the urine bag, and then carry the basin full of urine to the men’s toilet and flush it down. He was drowsy and very difficult to wake up to feed, and even when awake he would sometimes keep things in his mouth and fall right back asleep again and could choke on them. A nasogastric tube was advised to be inserted, and a couple of young doctors showed up at 3 in the morning to insert it. I requested that it be postponed a few hours since he had just been fed and had fallen asleep, and they left, never to return again. The whole following day I went through the exhausting procedure of lifting the bed, propping up on pillows, padding his face with wet cotton, shaking, tickling and calling, in a futile attempt to wake up him, and then feeding half spoonfuls of fluids over hours, all the time worried sick about him choking and aspirating the food. On questioning the nurses about the tube insertion, I was informed that only doctors are allowed to insert tubes, and so we would have to wait until someone was kind enough to show up. They did eventually show up: 3 different teams of doctors, all passed by, but not to check up on their patient and complete their treatment plans, but only to inform me that it will not be their team that will take care of him, because someone else’s name was written on the card. But that someone else had not seen him last time, he had only supervised the dialysis. Don’t care, it’s not us, or the other people, or the third team. So who in God’s name is taking care of him then? Don’t know, don’t care.
Basically, if I, as a medical doctor and able bodied person, had not been by my gramps’ side, he would have died in the first 24 hours of his admission for one of a number of causes: fluid overload, renal failure, aspiration, ruptured gastric ulcer, or simple starvation. On the third day after we complained to the higher authorities, and my one of my late uncle’s friends who had come back alive from the war continuously harassed the hospital director, one of the teams reluctantly agreed to take over his care. Only then was a feeding tube inserted and his medications corrected and his fluid intake and output charted. At 1:30 am we were woken up by the sight of around 10 doctors with their consultant coming to do their rounds, and on the 4th day we were finally moved to a proper room with a bathroom and a second bed. Better late than never.
I wish that was the end of it, but it wasn’t.
Due to the prolonged lying down and lack of a feeding tube, my gramps then developed aspiration pneumonia, which is a chest infection caused by choking and breathing in particles of fluid and food; a particularly nasty form of pneumonia and one that plagues elderly and bedridden people. I went to work on Sunday morning but was informed on the phone that he was breathing with much difficulty and had been making all sorts of sounds all night and morning. A doctor was called for several times, but showed up only once and advised physiotherapy and nothing else. At one point the nurses hooked him onto a an oxygen mask, but that was it. It took me over an hour to wrap up some things, get in my car and drive all the way from one side of Khartoum to Omdurman, and all this time not a single doctor showed up. By the time I got there he was in severe distress and getting more and more exhausted by the minute. I asked for the doctor, any stupid doctor, and was informed that the team was on their way. What about the on-call? Unreachable at God knows where. I started a nebulizer but that was all the nurses would do for me; it had to be their own doctors who would order the medication. Lucky for them, the team finally trudged in at 2 in the afternoon. They cruised into the room, asked their regular questions, auscultated his chest, and announced the obvious diagnosis of a chest infection that would need antibiotics. They very kindly asked the chest physician to please come and see the patient right now, at which point an equally young looking doctor came and again announced the obvious diagnosis of a chest infection. After much discussion, we (meaning I) put the first proper plan for management; including a select of antibiotics, regular steroids and nebulisers, regular suction, chest physiotherapy, positioning, and controlled fluid management. So again, if I had not been around, and had experience in managing critically ill patients, my grandfather would have died of any number of reasons: suffocation, overwhelming chest infection, simple respiratory exhaustion, or a cardiac arrest that would have whisked him away to the land of no return where he would be forever at rest and away from the torture of this system.
This post is not a nag about how bad our healthcare is and that we should all leave because we hate it so much. It’s a note that there is so much more to be done. The military hospital is very clean and very well equipped. The problem is that the people working here are the same people working everywhere else in the country: people who may care about patients and may have some knowledge about how to take care of them, but for some obscure reason do not portray this care or knowledge. The attitude they carry around is one that I can never understand. My gramps is doing dramatically better al7amdulillah, but I shudder to think where he would be right now if he was like most other patients who do not have the luxury of a medical doctor as an attendant. However, we still have 2 or 3 days more to go in this hell, and one can only hope that we are left alone and leave through the front doors on our feet and not in a body bag.