By this time we had established our workflow, so in the morning after breakfast Alex and I, The Butterfly Boys, joined the surgical team for pre-op evaluations. In the meantime, Lazaro rounded with the inpatient house officers. Alex and I had a probe and a walkie-talkie each, which meant anyone needing input from the ultrasound could reach us throughout the morning. Again, the Kyangwalinomas kept coming in bizarre forms. The first case we saw was a woman with a complicated mass on the side of her face.

I was coming into the tent and walked behind the curtains to find Alex and Julie next to the patient. She was a woman, probably in her forties or early fifties. She looked comfortable, but right around the base of her mandible below her left ear she had a big irregular mass. Julie had asked us to scan it in order to get more information.

‘Can you determine what it is or where it’s coming from?’ she said.

Alex was holding the probe in one hand while I held the tablet and we looked at the images.

‘I am not going to be able to tell you what it is,’ he pointed out. ‘But I can tell you it’s heterogenous and appears distinct from the bone.’

‘Fair enough,’ she said. ‘Could it be a parotid gland mass?’

‘Your guess is as good as mine when it comes to that, I can only tell you what it looks like,’ Alex said. ‘I don’t think its parotid gland based on how far back it is? Can’t really say.’

I’ll add that later that day, the surgeons resected a large tumour consistent with parotid gland tissue from the side of her face. So it goes.  

Alex got called away to the ward and I stayed in the tent to assess the next patient. She was a lady coming in with a bulge in her abdomen from pelvis to below her sternum. It was fluctuant and mobile, meaning the thing could be wobbled from side to side. It was unlike anything I had ever seen before, and Susana agreed. Pradeep, in his time spent in India seeing more bizarre and wonderful things, had his suspicion that this woman had a mesenteric cyst. The mesentery is a fold of tissue that wraps around the front of the intestines, sealing the entrails away from the fatty tissue under the skin. If a cyst evolves out of the mesentery, it typically tethers to the front of the abdomen and not the back, which is why it can move from side to side when manipulated with two hands. This woman had been dealing with this mass for many years, making her look pregnant and causing significant pain and discomfort.

‘Can you scan her?’ Pradeep said. ‘I think it’s a mesenteric cyst. I just want to confirm that it’s a simple collection and tethered anteriorly instead of posteriorly.’

‘Sure can,’ I answered. Direct instructions are always well received by Dr Bozo.

I confirmed that she wasn’t in active pain and slid the probe up and down her abdomen. I could see nothing but black, which meant it was simple fluid so deep that I couldn’t see all the way through it. Sliding the probe to the patient’s flank, I could see the kidneys beneath, and the spine. 

‘Definitely no loculations or heterogeneity to the collection,’ I said. ‘I can also see the retro-peritoneal structures. Does that answer your questions?’

‘Yes, excellent,’ Pradeep said.

‘Any reason why we can’t just drain the fluid collection? Or does the whole thing need to come out?’ I asked.

‘When it’s a large mesenteric cyst like this, draining them carries a degree of risk and also recurrence. You have to resect the whole thing,’ he answered.

‘Cool.’

Between the cases and a few other small errands, we had come up to 930ish and went back to the midwives for more teaching. The numbers now were larger than the day before, with word of mouth spreading about our session. Alex and I set up and got everyone to do some scans. Again, we reviewed the basic anatomy, and gave everyone a chance to use the probe. They brought us patients of different gestational ages, which gave us the chance to do early and late pregnancy scanning. Already, by day two, we were seeing some show an affinity for the probe, jumping in to assist others when troubleshooting certain positions or taking measurements. I was floored by the initiative and engagement we saw. Wrapping up around two hours later, we still had time to join the tail end of ward rounds, so Alex and I bopped across the path to the inpatient side.

We caught Lazaro and Dr Brian midway through rounding on the last female patient; she was probably in her late forties or fifties and had been admitted with an episode of depression with psychosis. She had a history of depression with psychotic features for a long time, and it sounded like she was in the midst of another episode. I missed the details, but as they were discussing the plan, I was reminded of the dearth of mental health services commonplace in medicine. This woman was a refugee from the Congo and was accompanied by her husband at bedside. Brian and Lazaro talked and talked about her plan right next to her as if she was hardly there. Dr Brian then turned to me.

‘For Depression, you think an SSRI or a tricyclic is better?’ he asked. He was referring to two classes of anti-depressants. SSRIs are some of the most commonly prescribed drugs in the world, think of Prozac, Lexapro, and Zoloft. Tricyclics are an older drug class that was more common in the 1950s and 60s, coming with more addictive properties and risk of overdose. Tricyclics still have their role in other diseases but are rarely used in depression anymore, especially not as a first option. He was asking me about these two classes because that was all he had.

‘For depression SSRIs are the most commonly used option, although their efficacy has been called into question recently,’ I said. ‘This woman has undoubtedly lived through severe trauma as a refugee. I don’t know how much she will respond to medication alone. She needs support services far outside what we will be able to provide.’

‘So I will prescribe an SSRI,’ he said. He then darted away to write the prescription.

I remember just standing there, looking at this woman and feeling like we were falling so short in her care. We have such a vacuum in the accessibility of mental health services in high income countries like the US and Canada, imagine what it’s like in the middle of a refugee camp in Africa. This woman had undoubtedly lived through circumstances that I cannot even fathom, with a complex and layered social history that the language barrier prevented me from breaking down. She was unlikely to ever get a shred of talk therapy to unpack her trauma. I met a psychiatrist in Ireland with mission experience who told me that in some central African tribal communities, a diagnosis of schizophrenia is like a death sentence.

‘Witchcraft superstitions and an inability for communities to manage the burden means that some of these patients wind up locked away or sent to wander into the savannah,’ he told me.

I stood facing another reminder of how cruel the world could be. She would get a box of tablets and send her on her way, and I was reluctant to look her in the eye knowing this. Someday I’ll have to find a way to help fix this, I thought to myself. The more I thought about this the more I felt like the obstacles to changing the circumstances were insurmountable. Where would I even start?

Ward rounds wrapped up and Alex and I ate near the van before Justus drove us to the school to continue the health screening. There was only one problem: we had no kids!

The rain that fell overnight had flooded many of the distant communities in the camp, which meant that attendance on the day was poor, even though the rain had stopped by morning. Alex and I sat idle for a while as only a handful of children trickled in through the afternoon. By around 3pm, with no signs of much action, Alex, Neda, and I decided to go for a walk into the camp through the markets.

Just outside the school were a slew of local vendors, many of them selling root vegetables, fruits, and fish. It wasn’t a terribly robust selection, but there was action. This was effectively downtown Kyangwali. Many of the vendors were women, and I met one guy walking around selling blankets. He offered me his goods, and asked me more about my story. He spoke good English.

‘I am from the Congo,’ he told me. ‘Before this, I studied physics.’

The energy from the people in the refugee camp was different than what I was used to as a white person in Africa. In Ethiopia I felt eyes on me everywhere, walking in a park, on the street, getting coffee, or going to the cash machine. People asked me for money every time I stepped outside. Even though I never felt unsafe, I was always a target, and it was impossible to shake. In Kyangwali it felt different. Yes, heads still turned when the van of white people drove through, but it was always smiles and waving hands. The children in particular, always grinned from ear to ear. I felt like a dog wagging my tail with them, eyes wide and beaming.

‘Mzungu mzungu!’ they would shout jumping up and down.

‘Jambo sana!’ I’d reply.

Even the adults would wave.

I took the opportunity to jambo sana every human being I could as we walked up the main road. We passed kiosks and the odd tire shop on either side. At one point we came to a path opening to the right towards more shops. There was a big truck unloading glass bottles. Alex and I had wanted to buy some beer to enjoy at the guesthouse, so we asked if we could strike a deal. Several men unloading crates led us across the path and we came into a small bar.

It was one rectangular room, with a dirt floor and plastic tables with chairs, all oriented facing the TV above the bar at the front. There were a handful of patrons, all men, sitting in pairs and not saying much. I can’t remember if there was music or not, I think there was but it wasn’t loud. At the front was a counter and a barman behind it. He had a big Coca-Cola fridge next to him with five shelves of different beers. After some broken translations and finger pointing, he started bagging a bunch of beers. While he did this we sat down next to a nearby table. There was a guy sitting there drinking a beer, he spoke decent English, and we started talking.

His name I can’t remember, but he began telling me his story. He was a refugee, like so many others from the Congo. From what I understood, he told me there had been a local election in the days that we arrived, for a refugee spokesperson/representative to sit on an advisory board for the UN High Commisioner for Refugees (or something along those lines). I had heard about it when we arrived. This man told me he had put his name in for the election, and he had a lot to say about the role. It was ornamental he told me, with the elected member having no choice but to promote whatever narrative is given to them. Make too much noise, he said, and it reflects poorly on the structures in power at the camp. This meant that speaking about poor conditions or bringing attention to deficiencies would spur them to accelerate the refugee placement process to quickly ‘relocate’ you somewhere in Europe. He was a businessman in the Congo, and told me he had previously applied to positions at the camp and health centre but got no attention. I didn’t really know what to say other than nod along. This was maybe one of the few times in my life I was lost for any meaningful way to contribute despite being genuinely interested in exchanging ideas. I just couldn’t fathom the circumstances of his world and anything coming out of my mouth would be pure ignorance. After some time spent talking, our beers had been packed and I said my farewell. I wasn’t in a position to do any favours for this guy, so I left the bar without exchanging information; to do so felt like a false promise. Also, I was only hearing one version of the story.

I enjoyed the bar, it felt like a window into another world. A world that perhaps I had no place to be in, and yet I felt compelled to explore. Later at the guesthouse, we mentioned it to Tayseer. He really liked the idea of us going as a group to get a drink there, a suggestion that was immediately met with apprehension by the local partners.

‘No no, you cannot go there,’ they said. ‘It is too dangerous. People are desperate and this can lead to uncomfortable situations.’

I was disappointed to hear this. I queried about it a few times over the next few days, but they didn’t budge. I didn’t press them on it either. We would have to make do with our purchases in the daytime and no more. I could only imagine what it would have been like to watch a futbol match in there amongst the African lads. Tayseer for one, was in agreement with me.

‘I think if we were not in this big group, and it was up to me, I would go to this bar,’ he told me.

I grew to find a tremendous amount of admiration and respect for Tayseer. The man was truly committed to service for those in the deepest and darkest corners of the world. That night, him and I sat down over those beers. With crackers, cheese, and drink between us, I probed him. I think in very little time, he caught a glimpse of who I was and saw some elements of himself in my craving for both service and adventure. I think any honest humanitarian will tell you, some part of this is the thrill: a window into places deeper and more flawed than a tourist could ever hope to see, the excitement of experience, the humanity of dirt roads, radios, and cold showers. He had seen and served in areas of immense grief, active conflict, and things in between. He even worked as an Oncologist is Paris, which didn’t last long. He told me a lot of things that night that greatly impacted me even if he didn’t know it.

‘I will be done my training in June, and I looking for work,’ I said to him, like a kid with a teacher or a parent. ‘I know this is what I want to do, but I don’t know who to trust, or where to dedicate my efforts. You have worked with all of them, Tayseer, are there groups I should avoid? Have you got advice for me?’

‘The thing is Jwan,’ he said, tapping ash from a cigarette and choosing his words carefully. ‘There is an unfortunate truth. If you are going to be a true humanitarian, you will die broke, sad, and alone. I wish it was not like this, but it is. I do not want this for you Jwan. Every time I come here I ask myself if what I am doing matters, if anything will ever change. I don’t know that it ever will. I have to believe we are doing good work, but I think of this sometimes. I am not sure.’

‘If I think of what is the best way to do this,’ he continued. ‘I think something like what Alex is doing is best. Have your nice house, have your wife, have your beautiful children and make your money. Then if you want to travel, to do good humanitarian work, take your month or two months a year if you wish, but once you have done this for good, you cannot go back to that world. It is impossible to carry on. I had a patient in France, a ninety-two year old lady with cancer. I remember discussing her case with the team. Go and order a PET CT scan for her, they told me. PET CT? I said. You guys are crazy! I realized in that moment I cannot do this anymore. You look around and see how things are here and then to go and order a PET CT for a ninety two year old, you simply cannot.’

‘I think the best advice I can give you right now is see as much as you can,’ he added. ‘See as many different places in as many different ways with different groups if you can. This will help you decide where to make your niche. We can talk about individual projects, but this is where I would start.’

I thought a lot about what we talked about afterwards. I think it was the first time I felt like I was hearing from somebody who knew the world that I sought to find. His words slightly shifted my feelings in several ways. I always felt deep down that I had something to prove to myself in giving life in the field a chance, almost as if in order to be taken seriously as a humanitarian I had to cut my teeth clinically in the trenches. I still feel that way to a certain degree, but I took his advice seriously. Over the past several years I have edged closer and closer to the brim of a plank overlooking this great beyond. All my life and career has been signposted with checkpoints, first it was to finish with good grades in high school to get into a good school for undergrad, then it was to secure medical school, then residency, I just kept chasing the next signpost because it gave me some direction, but now the train tracks end, and I am dropping into a world so big and directionless it’s like an abyss that could swallow me whole. I have so many different lives that I passed up thinking that when I got to this point I would be confident this was what I wanted, but as it comes closer I have started second guessing, wondering if I am really making the right choices. Was it really the right choice to forego a fellowship? Was it really the right choice to end my relationship with someone that made me happy because she didn’t like the jungle? Is it right that I want to leave my family behind to chase something so far away I’ll see them twice a year, potentially risking my life in the process? I think about my parents and how much I love them, my friends back home, and all the life events I’ve missed. I come home to an empty apartment every night and likely will for many years. I think of every email in Philly from a job recruiter with a gig paying 300k a year goes in my deleted pile as I steal cold leftovers from the hospital to bolster my savings for the trek ahead. Sometimes I don’t know either, Tayseer. I don’t know if I am doing the right thing. I am happy, yes, but sometimes I wonder if I should be happier with all of the decisions that I’ve made.

‘Home will always be here,’ my Dad told me once. When my degree was coming to a close in Ireland and I debated whether to come home early or enjoy my last month in Dublin in the happiest phase of my life, he told me not to worry, to enjoy my time abroad, because that life would come and go, but home would always remain. In these moments of reflection I realize that when I strip away everything I am so lucky to have so many people in my corner, in so many places. Even when I feel alone, the truth is that I never truly am. I have the type of friendships that some can only dream of. I am the luckiest motherfucker in the whole goddamn world. If I died today at age 29, I have loved, been loved, and lived with a degree of joy, wonder, and belonging that most never will. There are so many out there with real suffering that will never know this kind of love or happiness. It’s not fair. God has been immensely good to me, and I am keen to repay the favour for those who never got a shot.

‘Of course I have to try,’ I told Tayseer. ‘I want to help.’

‘Very well Jwan,’ he said.

‘Let’s talk.’