Chicago, Illinois, USA
While not the clinic where this story took place, this very rural health center in a developing nation highlights the challenging environment in which health care is provided by dedicated, hardworking staff.
“Rebecca, can you help me with a dressing change?” Clarence, the nurse and secessionist fighter, asked from the doorway of the room where we were being held. He made it sound like a request, yet the tall, lanky fighter flanking him with the hunting rifle casually pointed in my direction put me on notice that it was not a choice.
“Sure,” I smiled weakly, pushed myself off the metal cot, and followed him to the front of the health center, past the group of young men gathered on the porch watching the grey drizzle with their guns slung over their shoulders, and into the “dressing room.” I entered the small cinder block room lit only by limp daylight filtering through the window overlooking the lush tropical forest encroaching on the clinic.
Clarence turned and pointed to the patient perched on the wooden chair, his back to the door. His right leg rested on a second chair and his right arm was laid out on the wooden table holding the basic supplies for a dressing change — gauze, normal saline, forceps, iodine, a kidney dish, tape. Glistening pink tropical ulcers were exposed on his smooth brown skin.
I recognized the wounds before I saw the General’s face. I knew that there was a third wound high up on his buttock near his right hip. I had first seen these wounds two days earlier when he methodically unwrapped them one-by-one as his opening gambit of the final chaotic interrogation session.
That day had begun when our seven-member team was welcomed to a remote village at gunpoint by secessionist fighters. We were then passed over to the local commander, then the colonel, next to a General who advised the Commanding General, and finally to this man, the Commanding General, who used his three festering bullet wounds as justification for kidnapping, interrogating, beating, and threatening us. In the same rambling speech delivered in his calm, quiet mix of English and pidgin, he explained how despite the black magic that prevented him and his fighters from getting hurt or killed, he had sustained these wounds back in February. On that July night, he explained, “It took 1,000 bullets from hundreds of men to hit me here, here and here!” He brandished these bullet wounds as his boys brandished their guns to demonstrate his power. These wounds were just one source of his quiet rage. He wanted us to look at these wounds as proof of the violence visited upon the people he was defending. He displayed them to inspire his boys to defend his and his people’s honor, to fight for their independence. And then he sat back and watched his boys brutally interrogate us to ferret out our real identities as spies.
We were not spies. We were humanitarian workers coming to their village at the invitation of local leaders in order to collaborate to provide access to primary and secondary health services.
By the time I saw these wounds again, the General had provisionally accepted that we were not spies. He had agreed to release us so that we could go back to our base in the city to gather supplies, as well as additional health care providers, and return to provide care to the populace in his base deep in the bush surrounded by banana and palm oil plantations. We had agreed to these conditions, although there was an unspoken understanding among our team that we would not be coming back anytime soon. We could not risk our lives. I would not risk my life or those of the rest of my team again.
Meanwhile, there were patients to treat at the health center. Clarence had given me a tour the day before. He introduced me to the two other health care workers who had fled from marauding government forces to this secessionist zone for safety. Clarence showed me their neatly arranged and well-stocked pharmacy. I surmised that these supplies were from the two Ministry of Health trucks hijacked by secessionists a few weeks before. I had heard about those trucks from our Ministry of Health counterparts who worried about how to maintain the supply chains to the few functioning hospitals and clinics far from the cities and towns controlled by the government. Clarence told me that they had purchased the supplies.
The day before, I had helped Clarence and the other nurses take care of several civilian patients. Overnight, we treated Joy, a three-year-old girl who came in shivering with malarial fever. I consulted on a woman who had been diagnosed with appendicitis three months prior; I thought she had an ovarian cyst. We reviewed their registry book and discussed their protocols. We talked about what type of support and training my team could provide to Clarence and the rest of the staff when we came back. They were thirsty for the knowledge, asking me about some of the pharmaceuticals they had and about our protocols for severe malaria. And while I was relieved to be able wear my mantle of a nurse, I could not forget that we were there against our will. The clinic was overrun with gun-toting secessionist fighters dressed in second hand jeans, t-shirts, and track suits. Clarence was unable to touch Joy because “the oil on her body will ruin my protection, my magic power.” He needed to maintain that power as he was foremost a fighter and a nurse only when he was not fighting. I wondered aloud how we would manage that conflict of interest when we returned; Clarence looked at me impassively instead of responding.
I stood staring at the wound on the General’s forearm. It looked remarkably good considering the lack of supplies and expertise and the tropical climate. I knew that back home these wounds would warrant grafts or a wound vac to facilitate healing. I picked up the General’s wrist to look more closely at the wound.
Clarence looked at me tentatively and asked, “How do they look?”
“Honestly, they look very good. You are doing a great job taking care of them.” Clarence beamed. “Although,” and here I paused for a moment before turning to the General, “it will still take a long time to heal and likely you will not regain full use of your arm.” It felt good to say that. Not only because it was the truth, based on my clinical experience, but because I was glad that he would not have full use of that arm ever again, just like my colleague Charles, a driver, would likely not have full use of the thumb that was sliced open by the General’s boys during our interrogation session and inexpertly stitched closed by Clarence.
“Show me how to dress it,” Clarence commanded.
“But you know how to do it. You have been doing it. And very well.” I was resistant to dressing this man’s wounds. The nursing code of ethics requires me to establish relationships with my patients and set aside any bias or prejudice. All individuals deserve health care, transcending any difference. Yet this man was also a murderous secessionist fighter who had kidnapped, threatened, and tortured me and my colleagues.
“I want you to teach me how to dress it better. I want to know how you would take care of it,” Clarence insisted and, considering my position, I assented. I glanced toward the crowd of people huddling in the doorway gaping at the White nurse taking care of their General. It felt close in that room — the tropical humidity, the crowd pushing through the doorway, Clarence pointing at the supplies, the General holding out his arm towards me. I knew that the government forces had harassed and arrested health care providers based on mere rumors that they had done what I was being commanded to do. I took a moment to look at the General’s wounds again and at the supplies. I needed that moment to push my memory of that interrogation session aside, to re-focus on the wound in front of me and not the jagged, oozing cut on Charles’s thumb, to reconsider who the General was and to turn him into my patient.
Inhale, 2, 3, 4.
Hold, 2, 3, 4.
Exhale 2, 3, 4.
Hold, 2, 3, 4 and I fully inhabited my role as a nurse. The General was now my patient.
I pulled on gloves and picked up the forceps and some gauze in order to clean the wound. As I did so, I matter-of-factly explained to Clarence our protocols for wound care. I focused on the wound in front of me, on the arm in front of me, attached to the patient in front of me. After cleaning and dressing the patient’s arm, I directed Clarence to clean the other wounds while I supervised.
“See one, do one, teach one,” I chimed when he protested that he wanted to watch me clean the other wounds as well. I gave him some tips, passed him the clean gauze as needed, and cut the tape and handed it to him.
After the wounds were dressed, I stepped back and looked the General in the eye. “Thank you,” he mumbled. I nodded. In the space of that nod, the General was once again the man in charge of my life and that of my colleagues. He was no longer my patient.
Inhale 2, 3, 4.
Hold, 2, 3, 4.
Exhale 2, 3, 4.
Hold, 2, 3, 4 as I watched him limp out of the room and on to the porch of the clinic accompanied by his people.
Photo taken by Rebecca Singer, May 2008, at a health center in South Kivu, Democratic Republic of Congo.
REBECCA SINGER, DNP, ND, RN, teaches population health at the University of Illinois College of Nursing drawing on over a decade of experience in global health and community partnerships. In her work with humanitarian and development organizations, she focuses on responding to victims of violence, emergency preparedness, and community-based cancer prevention. Formerly the Director of Healthcare Services at an interdisciplinary center for torture survivors, Dr. Singer provided intensive healthcare case management to asylum seekers and refugees.