Southern (Asian) Hospitality

My Voinjama doctors and I had the most scrumptious meal at the Pakistani Battalion last night:  Roasted chicken, minced spicy beef, potato salad (universal necessity), chicken curry, garbanzo bean, corn and cilantro salad and sweet rice, all enveloped in warm chapatti.  After being worried sick that my Pakistani doctor could not possibly survive the remoteness of Lofa—a place where one can’t find canned tomatoes let alone a strong Skype connection-- I discovered that Dr. Khan, who supervises half of IRC’s hospitals and clinics, has practically become the mayor of Voinjama, where at least a third of the population is comprised of UN peace-keeping forces from the very town of Chitra from where Dr. Kahn comes.  It is Dr. Kahn who chaperoned us “white” colleagues into the compound for dinner.  The guards at the entrance gate looked confused as they shone their flash light beam through the wind-shield at first onto the face of the Liberian driver, then onto mine.  We squinted like lizards about to be squashed. But down came the passenger side window and out came Dr. Kahn’s head.  I don’t speak a lick of Urdu but Dr. Kahn’s exchange with the guards sounded like a handsome treble clef of rolling phrases and voicing which lilted upwards at the end of each sentence to glide ever so gently down.   The guards motioned us forward and our car revved in. 

The 14th Pakistani Battalion compound is fifty acres in size.  It contains features one might expect from a military base:  a collection of square tin-roofed barracks, parking lot for jeeps and tanks, gravel road bordered by sturdy scraggly bushes with an occasional lost flower, wooden guard towers supporting a barbed wire periphery and thousands of soldiers in light tan camouflage outfits.  The analogy starts to fade when you add on the full size cricket field, slanted tennis court, large laminated posters of mountainous scenes from the home country decorated with strings of Christmas lights, two fish ponds with landlord toads, roving bands of ducks, goats and hens with their lines of obedient chicks, and an officers mess hall with a special side room consisting of twelve lazy boy recliners in front of big-screen one hundred channel TV.  The Pakistani Battalion, or Pak-Bat for short, has been in Liberia since the end of the Liberian Civil War 2006 along with about 15,000 other UN peace-keeping forces.  The arrest of Charles Taylor in the Ivory Coast and the election of Ellen Sirleaf to the Presidency certainly led to a period of stability in Liberia, but like the genocide in Rwanda and in the former Yugoslavia, the world’s inability to act quickly to prevent the slaughter of millions was followed by a never-late-than-ever strategy of keeping the peace so long as the fragile peace was proffered without much strain.  Thus, there is no fighting any more in Liberia, maybe because of UNMIL (United Nations Military in Liberia) Force patrols, maybe not.  But the UNMIL performs other important non-military roles including handling traffic court disputes, fixing the country’s horrible roads, transporting non-UN workers such as ours to and from hard to reach destinations if there’s room in its airplanes, and even supporting the Liberian economy. 

By the time Kahn, Kalisa and I walked into the officers mess hall, fifty of so officers were already seated around a large rectangular table consisting of many smaller rectangular tables pushed together and covered with an enormous white thick starched table cloth.  Senior officers, who looked older and sat on sturdier chairs, were seated on one side.  Junior officers were seated to their right, left and across from them.  We were a sight:  Kalisa is Ugandan, I am Taiwanese-American, and Kahn is a petite Pakistani.  Two weeks ago, the 16th battalion from the South began replacing the 14thbattalion from the North and few of the new contingent knew us as neighbors, who occasionally come for a civilized meal for the price of four bucks.  I looked a little dirty because I was dirty.  I had spent the day sweating it up with a drug supply consultant determining what exactly she had done for two months.   Also, I had been preparing Kalisa, who runs our Tellewoyan Hospital project, for a visit from our Swedish funders who want to see how things are going at the disaster, which is the Tellewoyan project.  I wore jeans, hiking boots, a short sleeve button down shirt and my IRC picture ID hanging from a black and yellow lanyard around my neck.  Kalisa and Kahn in contrast were dressed in long sleeve shirts, shoes and slacks.  Thank goodness for Kalisa and Kahn.   

Waiters who are part of the food service company seated us apart and for a moment I felt as if we were being isolated for the interrogation.  But then came the plates, silverware, food and drink and chapatti and more main course, more dessert and like that, the awkwardness went away.  A junior officer next to me with bad teeth but cilantro breath started up a conversation.  He explained how he and the others chose to come to Liberia as part of Pakistan’s stable army.  The company had been together for more than two years in rough Northern Pakistani terrain.  We did not talk Al Qaeda.  By coming to Liberia, the officers could rise faster in their organization.  Also the officers got paid $900 a month salary which paradoxically was much of the reason why the officers came but “not enough” relative to the sacrifice of leaving their families.  I thought how Dr. Kahn knows too well this sacrifice.  The soldiers stay for a year at the Pak-Bat without vacation at which time they earned 2 months of leave.  The guy asked me how long I would be in Liberia and I said a year and a half.  He asked by how much I made in salary and I lied.

After dinner, we were just about to sit down for some proper tea with two officers known to Dr. Kahn when a tall muscular man in traditional black robe rushed through the door.  The man looked worried and determined.  He was breathless and had beads of sweat on a furrowed brow.  He was the Pak-Bat medical officer and asked for help attending to a soldier who was sick.  I was going to just send Dr. Kalisa, who is an internist, but in finding out that we were all physicians, the medical officer named Khuran insisted we all come.  We left the mess hall, crossed the duck pond, and walked up the gravel road towards the compound entrance and into the collection of trailers to the left of the entrance gate that served as the compound medical facility.  Outside the weather was unseasonably cool and chilly—so nice.  There were a lot of bugs obsessing over bright spotlights, which now illuminated the posters of Pakistani scenes.  The expansive black sky was lit unsuccessful by a million pinpoint stars.  In one of the medical rooms, we found a slim well appearing man also dressed in a black one piece cotton robe, sitting up staring straight.  He was mute and unresponsive.  He wouldn’t respond to anything though his vital signs and his physical exam were normal. With this normal physical exam, I was tempted to give the man a severe knuckle rub to the sternum but I didn’t.  The man continued to simply stare straight ahead, blinking sometimes.  Around him at least fifteen of his friends and senior officers debated and watched in worry.

The man was being treated for malaria—quinine, which often causes ringing of the ears, but not mental status changes, though certainly severe cerebral malaria can make you unconscious but not in this way.  Because he had a high fever, the man was being given Tylenol and because he had felt nauseas, he was given intravenous antihistamines (strange), which can make you drowsy or agitated but never mute.   I asked if the man had suffered any trauma, had any recent events, had taken any drugs, had a history of psychosis but to all of this, there was no affirmative. Not knowing what the diagnosis was, the medical officer proposed to bring him to our hospital in Tellewoyan and as Kalisa was nodding in agreement, I instead suggested we keep the man where he was.  It was not that I knew what was happening to this man, but I knew what kind of services he would get at Tellewoyan.  One thing I have learned working hospitals in Sub-Saharan Africa is to avoid the fiction of a medical transfer, which gets rid of the problem on one side, but does little for the patient on the other.  The implication is that you move patients to facilities where they can receive a higher level of care, but the reality is that this higher level of care either doesn’t exist or can’t be purchased, so people transferred die en route, waiting or on the ride back.  Tellewoyan has an x-ray machine and ultrasound but we needed a CT scan and probably not even that.  Another rule in medicine is that never do a test that doesn’t change the management of the patient.  The man’s physical exam was normal.  What would we expect to see in a head CT?  Or, even if the man had suffered a stroke and the CT showed densities indicative of bleeding, in Liberia there would be no anticoagulants to give, no thrombolytics.  Simply put, normal vital signs and a normal physical exam don’t lie.   Do no harm even if you are not sure what you are dealing with—the night’s final medical rule.  I convinced the team to watch and wait and I gave Khuran by cell phone number in case there were problems during the night.

Before seeing us go, Khuran insisted that we have Chai tea.  It was kind of strange but so too I guess are Pakistanis in Voinjama.  There, we discovered that Khuran was a junior medical officer.  He had just graduated from medical school last year and this was his first post.  He had worked for a year without incident.  He was going home in 4 days and was worried about this brand of karma on a clean work slate.  While we were waiting for the tea to arrive, suddenly there was a commotion from the room where we had come and out opened the door and in came the man who had previously been immobile and mute.  The man walked unassisted, had a wry smile and was followed by the original large now cheery entourage.  The man was led to a bed in the corner of the room and the man having being placed on the bed with his many friends and comrades basically started to party.  The Chai tea came.  People told stories.  Someone began playing music.  I made a few people laugh describing that this was perhaps the most interesting consult I had ever done.  While in the U.S. you might return home from work despondent having been unable to improve the lives of your patients, at the Pakistani Battalion you celebrate your failures while your patient miraculously gets better in the company of community and friends.  What a deal. 

We stayed in the medical room for two hours.  It was kind of crazy.  Chai in substitute for beer, brotherhood in substitute for women, medical infirmary in substitute of bar.  We all exchanged cell phone numbers.  People asked us to stay.  We promised to return.  I offered up lodging to those who would ever get to Monrovia.  When we finally moved to leave the compound, it was quite late.  Our vehicle was delayed because the ducks with their ducklings and goats with their kids refused to move out of the way.  Who would have guessed that Galapagos had moved to Northern Liberia?  Kalisa had to get out of the car and chase the animals away and even then the animals moved unmotivated as if there were no real threats in this world.