Dr. Andreas Steiner Photo by David Blumenkrantz

Incident In Ankoro
1-13-87 Ankoro, Zaire
(Journal entry)

By David Blumenkrantz

Sure enough, we had a magnificent lightning storm last night. The warm rain came, and the entire horizon lit up, defining impressive clouds with intermittent bursts of energy. . .

We were in living room of Dr. Steiner's brick Ankoro home. It was Kisimba and I, along with a local friend of his called Angelina. Steiner was resting in his bed after a full day of consultations and operations. Raphael was in the small kitchen preparing Steiner's spaghetti dinner. There was a knock on the door. A harried looking middle-aged man dressed in ill fitting, dirty clothing entered nervously. He spoke urgently to Kisimba in Kiluba. Kisimba rushed in to get Dr. Steiner--it was a woman at the hospital-- an emergency. That was all I could tell, but I grabbed my camera gear, preparing to see the doctor in action at night.

But he didn't go. "The baby is already dead-- Dr. Kabwe will take care of it."

We jumped in the Land Rover and picked up Dr. Kabwe, who was waiting in the dark rain along the road in front of his house. "Good evening, how are you?" he asked me in his usual polite manner, oddly incongruous under the circumstances, I felt. We hurried down the road to the hospital, accompanied by lightening and thunder, passing several people walking down the road, their pace seemingly unchanged by the weather. Kabwe was painfully polite-- "You like the jungle?" He seemed surprised and bit amused that someone from California could find the bush conditions so agreeable. I told him so.

In a few minutes we pulled up at the hospital. I jumped out to open the wooden gate. As always there were people around the building-- mothers with children, sitting around under the overhang, calmly talking amongst themselves.

Photo by David Blumenkrantz

Into the maternity room we barged. Nothing I'd ever seen, read or heard about could have prepared me for this situation. On a stark wooden table a middle-aged women was lying naked on her back, surrounded by a small group of attendants and nurses. She was in intense pain, moaning as they administered to her. Between her legs hung the blue-black head of her dead unborn child. Partially severed arms, white from blood drainage hung limply alongside. I felt an ominous weight descend upon me, and was numbed by the tragic sight, but proceeded to snap off a few frames. This was to be one of those situations where you are glad to have a camera to hide behind . . .

The woman, who had delivered twelve children in her life, lived in the village of Mukale-- about 25 kilometers of bad road away. An ignorant "Red Cross Soldier"; a Zairian outfit about which Dr. Steiner scoffed "know nothing about medicine, but have nice uniforms," had attempted a hackneyed delivery. It was a stillborn, and in his ill-conceived attempt to remove the child, had cut away at the arms and umbilical chord-- severely puncturing the uterus and causing vast internal bleeding.

Zairean Red Cross Photo by David Blumenkrantz

Dr. Kabwe seemed a bit lost. He discussed the situation at length with his staff, hesitant to take action. Meanwhile, the woman had been transported the twenty-five kilometers (I'm not sure how, most likely on a makeshift stretcher) with the baby in its present condition. In an adjacent bed, another women lay staring straight ahead, with dull, yellow eyes. It was all too nonchalant for me. Kabwe at one point turned to me as I was taking photos, and said in his deadpan English, "Delivery is not easy. This is one of the problems of tropical medicine."

The king of the Zairian understatement at last decided to consult Dr. Steiner.

Outside the maternity room, the husband of the woman was standing. He too was dressed in tattered, filthy clothing. Kisimba said he was foolish for not bringing her to the hospital. I asked Kisimba to hear the man's explanation. He said he had been in another village fishing when he was summoned. He seemed disturbed; Kisimba told me he was deranged. He spoke angrily, growing more agitated as the hospital staff gathered round to listen. As we left I put my hand firmly on the man's shoulder. He returned my gesture with a blank stare.

We rushed back to get Dr. Steiner, and found him enthusiastically eating his spaghetti dinner, complete with a good bottle of Spanish wine he had brought along. He apologized for having started without me. His calm was strangely reassuring. He realized that what I had seen was "horrible, it's horrible." He explained that he didn't go at first because Kabwe had to learn to handle these things, as he is usually the head doctor in Ankoro. I barely touched my dinner, though swallowing a few large glasses of the wine. Steiner prepared to go to the hospital, explaining in his best Swiss-German accent that Kabwe should have just reached in, and "popped zee baby out." He thought Kabwe was "perhaps frightened."

Such are the normal occurrences of tropical medicine. People are hesitant to use the hospitals, particularly because of the distance. It is ignorance, I was told; and there are still the natural healers, or medicine men whom many people in the bush still prefer to trust. Stillborns are common in these remote villages, but this case was extreme.

As Steiner went to the hospital, I stayed at the house, thinking the emergency was over. Steiner returned shortly, but the night was far from over. He had indeed "popped ze baby right out," but the maneuver was tricky and in doing so had inadvertently gone through the existing hole in the uterus while digging out the last of the baby, and tore some of the bowel cavity intestines. As a result, severe bleeding ensued. A nurse came to the door, and the doctor had to go back, this time to operate. I went along to record the operation.

Photo by David Blumenkrantz

At the hospital I immediately donned the sterilized mask, hat and rubber beach sandals. Scrub nurses, wearing African dresses under their smocks prepared the instruments and table. In the hallway outside the operating room, two of the attendants pleaded with me to take their photograph. I was used to these requests. The novelty of my camera had secured as many fast friends as it had driven people away. But at a time like this? I took one, and others wanted theirs. It became ridiculous, with the attendants acting as though they were walking importantly down the hallway, then they would laugh hysterically and give me the thumbs up sign as I snapped the shutter.

They brought the patient in on a stretcher, and laid her down in the hallway, while final preparations were hurriedly being made behind the double doors. More photo requests. "Kazi kubwa!" (Important work!) I insisted. They took this as a sign that I wanted them to pose working. Five of them crowded around the suffering woman, pointing at her or feigning medical care. It was straight out of the Marx Brothers, except this woman was bleeding to death. Into this madness came a shirtless Dr. Steiner. He ordered the staff into action authoritatively. The patient was put on the table, anesthetized and attended to intravenously. As the doctor was helped on with his smock and gloves, the woman lay there, naked, her insides bleeding profusely, her bloated stomach glistening. From her half-parted lips came soft, resigned moaning.

At 9:30pm the stomach was cut open, a "midline incision," and the operation began. The generator, which normally brought electricity to the otherwise powerless village hospital from sundown till 10 each weekday would stay on late this night. Steiner worked swiftly, deftly, almost frantically. He accepted no hesitations or mistakes from his staff, as he pulled out the uterus, the remains of the child, and finally about two feet of small bowel intestines. It was a horrific site. ("It is horrible, just horrible," Steiner had reminded me as we entered the hospital. "Just horrible.")

The patient's eyes were closing, rolling up. Blood was filling the drainage bottle beside the operating table, which was surrounded by the two doctors and a half-dozen sets of dirty, sandaled feet and the semi-sure hands of a homegrown staff of trainees. For me, it was a photographer's field day-- adrenaline pumping as it never had before. I photographedrelentlessly. It was too grim for pauses or contemplation. I used all my lenses, and shot from every angle. Steiner once had to warn me not to lean on the patient for risk of infection.

Photo by David Blumenkrantz

Finally Steiner announced that he had stopped the bleeding. Still the pace was frantic, and the accomplished Swiss surgeon became increasingly impatient with fundamental mistakes. Brow furrowed permanently, he implored Kabwe in French, "Sil vous plait, le doctuerrrrr," drawing out the last syllable for emphasis. Indeed, Kabwe was comparatively a trainee alongside Steiner, a fact not lost on either of them. This woman would surely have died had Steiner not been in Ankoro that night.

The operation lasted more than 90 minutes. Near the end, Steiner announced "It was a run for life for a while there." He worked swiftly to close up the stomach. The atmosphere lightened up a bit. The staff all laughed when Steiner berated an assistant for cutting both sutures instead of just one, forcing him to start anew. A giddiness returned to the camera hams, who were standing on footstools behind the doctor, monitoring an I.V.. They started signaling again for me to take more photos. I was astonished at the indifference, the seemingly complete lack of concern for the significance of this life-saving operation. (When I questioned Steiner about this the next morning, he shrugged it off, explaining, "they do the job they have to do, but very few get personally involved with the patient.")

I could understand the average Zairian villager becoming accustomed to suffering and death, but I expected medical personnel to display at least a semblance of a humanitarian, altruistic motivation. A solid argument could probably be made to trace the blame for this phenomenon back to the hollow leadership of the Zairian government, which has done virtually nothing, (save for a few sweeping statements) to promote a sense of responsibility to millions of people needing just that. In fairness, it must also be pointed out that the few attendants who had raised my ire are not representative of all medical personnel, and certainly not of the others present at this operation, who worked serious professionalism.

When the last stitch was in, Dr. Steiner sat down in a small storeroom to fill out the report. I looked back in on the patient. The operating room was a disaster. The floor was covered with bloody cloths, cotton, wrappers and hoses. There were dozens of dirty tools. The patient lay alone under the bright
operating lights, naked but for the bandage on her stomach, which convulsed irregularly-- a sign of life.

Such a frantic effort, to safe the life of an ignorant villager. This was my introduction to tropical medicine; this was the third world. Survival or a horrible, preventable death, dealt out by the hand of fate. Patchwork medicine, and operations that the people's own government does not provide. I thought of the American public, and refused to accept the notion that they only care if confronted with photographs of starving children with doe-like eyes. And I wondered about the spirituality of it all, this conflict that seems to be ever-present, the conflict between Christian morality and African tradition. Steiner himself had been beleaguered in the past by local Methodists for his "unexemplary" lifestyle. What was it that Steiner had said to me that first evening in Ankoro, sipping cold beer as approaching darkness engulfed us?

"I consider myself a Christian, but not a fanatic. What we are doing here you could probably call Christian. If a man drinks, or loves a woman, this is not so bad; it's what he does overall that counts." Whatever has drawn Steiner to this remote, self-contained existence, he has come to grips with himself as a self-motivated individual, blending his better instincts with his more selfish ones. Another of his remarks comes to mind. "When I am about to operate on a dying person, they do not ask me, 'how many women are you sleeping with?'"

THE AFTERMATH
I was overcome with emotion as I finished that last entry. I went to my room and closed the door, and for the first time since I arrived in Africa, I wept. I felt sadness, shame, and confusion at the sudden feeling of powerlessness one experiences when confronted with such a realization; that underneath the surface of a romantic notion, reality is waiting in the form of darkness, pain, death and sorrow. I think of how the next time I walk down these dirt roads, the children will smile and wave, and the adults will acknowledge me as politely as ever. Do they ever wonder if I've reached this point in my awareness of their plight, or am I merely a symbol of all mzungu's past and present that have come here seeking business or pleasure?

And where is the justice? Dr. Kabwe, as the medical authority of the Ankoro Health Zone, will arrest and imprison the ignorant Red Cross Soldier. As I look out my window now into the sun-bleached afternoon, a lone boy walks down a humid path. Is the Red Cross soldier really any guiltier than this boy? How about the medical assistants who bugged me for photographs? Not even Dr. Kabwe was prepared to handle yesterday's catastrophe. The only guilt I can sense right now is for humanity. For the Mobutu regime, certainly-but also for the non-humanitarian actions of global neighbors who continue on their paths toward enlightenment through the pursuit of wealth, while allowing situations like this to further deteriorate.

I'm sure that I'll feel like myself again soon, and will be able to laugh with Kisimba and the others as we attempt to transcend our cultural barriers. The difference is that now I know what Dr. Andreas Steiner has known for a long time, probably since he took over the stewardship of the Albert Schweitzer Hospital in Gabon. Every family I see, crouched on their crude porches or in front of small fires in some simple village, demands the same care as the woman resting now in the Ankoro Hospital. If and when she returns to her village, it will be without a uterus or ovaries. Worse for the wear, she will live out her life with the same spirits lifting her as before.

Link to Zaire photo gallery (b&w)

Link to Zaire photo gallery (color)