Guéri par miracle

“Netherworld” by PT Russell

Content Note: This piece discusses sexual assault and medical procedures for sexual assault survivors.

There is no direct translation in French for “cope.” 

I want to say “I'm coping.” Instead, I just say, “Ça va un peu.” I am okay a little. 

On one hand, if you brag that you are doing quite well, the belief is that God will trip you. On the other hand, you don’t want to just come out and say that Congo has you on your knees.

There is no direct translation in English for prise-en-charge. 

I usually write “Plan” at the end of the medical note. But prise-en-charge encompasses more. It covers all the factors that should be taken into consideration. It lays out any legal, social, psychological and medical steps for a population, a community, or a single individual. 

A few times a week, I conduct the prise-en-charge for rape cases.

I work with Mama J, a Congolese mental health nurse for the Ministry of Health. I work for Médecins Sans Frontières as a midwife. With me, Mama J speaks well-enunciated French with the preserved alveolar trill that comes with receiving a primary education fifty years ago in this remote place where twenty years of war and unrest has kept things, such as the colonizer’s language, in the original. In contrast, I learned French during a stage in northern Quebec at the height of Quebec nationalism, providing me with neither a pleasing accent nor the relevant vocabulary for this work. Mercifully, I don’t need to talk much. With the victims, Mama J speaks Swahili. 

In the prise-en-charge for rape, we conduct the interview, document it, conduct the physical exam, document it, provide tea and biscuits, administer the meds to prevent pregnancy and infection, complete a referral form for the fistula hospital if needed, and complete the official legal document to be signed and stamped by the Chief of Staff of the hospital. Then we give the victim a bar of soap and a length of new fabric called a pange. The women and girls can use this for a new skirt or dress. I don’t know what the men do with it. Then we explain how to take the medication for the next twenty-eight days, and explain that the victim should return at three and six months for booster vaccinations. We send the stack of official legal forms in a hand-delivered envelope to MSF’s office in the capital. The documents are kept safe because one day there will be a reckoning. In Congo.

In all the medical and legal documentation we prepare, the word rape does not appear. 

Mama J tells me that Swahili has no direct translation for the word “rape.” When the UN declares that Congo is the rape capital of the world, the news outlets headline uses the word “ubakaji.” 

Ubakaji is perhaps derived from bakua, meaning to rob or to plunder. Or maybe it's derived from baka, meaning a mark on the body like a birthmark or scar. 

The word rape has a legal definition and we, Mama J and I, complete the forms using only medically defined terms. We describe what orifices were penetrated with what body part or tool. We describe what wounds are where on the victim’s body. Thus the only time the word rape would appear in the document is if the victims themselves use the word, and we transcribe it verbatim. 

But the victims never say the word rape. 

***

Our boss is called Co-ordinateur de terrain, or “Charlie Tango” in radio lingo. He calls me Ahh-NAH. He says I shouldn’t go out at night for beers with national MSF staff, for security reasons. I consult the security protocol and point out to him that I can, in fact, go out at night for beers with national MSF staff. Then he says I appear more argumentative than usual, more irrational. Is it the work? Then he suggests I take a break from rape, as if I’ve been merely dabbling in a bit of recreational crack that we can all see doesn’t agree with me. 

Me? It's not me who needs a break from rape. 

I ignore the insomnia. I’ve mastered the chest pain. But finally, when my eyes fill with tears, when I learn we’re out of foley urinary catheters, I admit that I am not even ça va un peu.

Mother Nature got almost everything right when it comes to the human body—but Mother Nature did not account for Congo’s rape problem. The bladder is regretfully positioned next to the epicentre of reproduction and rape. The bladder is tough. It can stretch and bob to avoid damage. But it has a limit.

The woman is curled up on the exam table. In short: term pregnancy, rape by multiple aggressors, contractions start after the rape, delivers a stillbirth in the bush following a protracted, obstructed labour. 

When a labour is obstructed, the presenting part of the baby is stuck in the vagina, cutting off blood supply to the surrounding tissue. For this woman, damage caused by the rape and/or labour resulted in damage of the wall between her vagina and bladder. The telltale sign of rank urine hits me when I walk into the exam room. The urine collecting in her bladder leaks out of her vagina.

We give her pain medication so she can tolerate the exam better. Mama J holds my cell-phone light while I negotiate the pediatric speculum, gently tilting it to get my bearings. Nothing in my training twenty years ago has prepared me for this. I finally locate what I think may be the remnants of her cervix. From there, I locate the hole between her bladder and vagina and estimate its location relative to the cervix and the size of the open window of dead tissue on the anterior wall of the vagina. I use a long clamp to push her cervix to one side, and then the other, to see if there is damage further up. 

The woman holds her breath and instinctively tries to close her legs. Mama J pats her knee and reassures her that we’re almost done, raising her eyebrows in my direction. I confirm I’m almost done. I remove the speculum and explain that I'm going to insert my fingers inside her vagina. The cervix is tender when I move it. Her uterus is boggy and about the size of a cantaloupe. And when I bring my fingers out, I palpate along the posterior wall of the vagina, and I note her rectum is full and blood oozes from her anus. The whole time, I'm breathing through my mouth to prevent myself from retching.

We give the woman tea and biscuits so she won’t vomit the meds. I tell her she can rest here while we make a plan for her care. She doesn’t want to stay on the exam table, declines the couch, and takes her tea and biscuits to the corner of the room, easing herself down to crouch on the floor. The pain running through her whole body distorts her face.

Mama J and I sit down. We both know we’re preparing her for a referral to Panzi Hospital in the capital. Congo has an entire hospital dedicated to putting women’s reproductive organs back together.

The pregnancy test is negative. We think, because of its size, that her non-pregnant uterus may be full of menstrual blood that can’t exit through the damaged cervix. Instead, the blood is leaving through her anus, via a fistula between her uterus and rectum. The fistula between her bladder and vagina is obvious, and because of its estimated size, has a fifty-fifty chance of being reparable. The cervical motion tenderness is likely due to an infection that has climbed up to her uterus.

Who knows, I’m just making it up. I don’t know what I’m doing.

Okay, we’re just going to puzzle this out. I take a minute to organize my thoughts and write key points on four corners of a piece of paper—“infection prevention,” “bladder care,” “uterus/vagina trauma,” “rectal trauma?”—and in the middle of the page I write “pain.” Mama J files all our handwritten notes for each case. They have random titles like “closed vagina,” “under 30 kilos,” “5 years later,” “festering rectal abscess,” and “fresh labial wounds.” I don’t make notes for the straightforward rape cases. She manages those on her own now. We move from each point, making an immediate plan for care, and draft what we’re going to write in the referral letter. I’ve found the more detailed and intelligent the referral letter, the better her chances of getting accepted as a fixable case.

In the first part of the plan, we have antibiotics, vaccines, pain meds, and an indwelling foley catheter to keep her bladder empty so it can start to heal; we write a referral letter to Panzi Hospital; and then wait for her to be accepted. 

We have everything in the exam room but the foley catheter. We are low on these. The night before, I had taken one from ICU for use in a cesarean for a woman with an obstructed labour who walked/was carried thirty km, fully dilated, with a dead baby trapped in her vagina. 

But there isn’t a single foley ... anywhere. I’m incapable of making a Plan B. 

***

A couple of weeks go by, and I’ve lost track of the case. I don’t want to know what happened to her. I’m attending the morning meeting in the MSF office before heading out to visit a village health centre. I’m not listening to the drone of project updates. I’m thinking about how I don’t need my boots today and I wish I had worn my Converse. I should have another coffee. I should pee before leaving. I should do a malaria test—I feel like shit.

Charlie Tango says he’s planned International Women’s Day. We won’t be doing the annual soccer match between men and women. Everyone looks disappointed. Instead, he tells us, “We’ve organized a viewing of a documentary film for the female staff. It’s a difficult film. We’ll stop it after each section and have a discussion.”  

We’re going to watch a film about rape. In Congo.

I try, but I cannot contain my anger.

“Maybe I’ve misunderstood [your haute français, I think to myself], but the women here?” I say, “The women here know rape. Maybe the men can spend their afternoon discussing the film, and the women can go play soccer.”

We’re dismissed. 

“Courage à tous,” he says out of habit.

I follow Achilles, one of the MSF drivers, out to the motor bikes. He’s the only person I work with who says my name the way I say it.

Over the months and many beers, we’ve acted as each other’s cultural interpreters. I’ve described to him the concept of taxes to pay for something called universal healthcare. I state the inarguable truth that donating blood is a civic duty. He explains the difficulty for war-traumatized people to understand civic duty when government institutions have failed them. He explains to me the meaning of the expression “Article 15,” namely the state will not help you, you do what you must do to live. One evening, he enthusiastically takes my hand and asks me to explain again the concept of credit cards and cloud-sharing. I don’t let go of his hand. I want to give him everything to prepare him to leave here one day.

At the motor bike, he doesn’t say anything when I put my left shin guard on my right shin. He just crouches down and rips the velcro and switches them. He takes my radio and clips it to his gilet. He takes my cell-phone and puts it in the zip pocket of my bag. Before he puts on my helmet, he puts his hand on the back of my neck and pulls me towards him. He gently touches my foreheads with his. He takes me by the shoulders and turns me toward the bike. Once he starts it, he pats the seat behind him and smiles.

 “Panda,” he tells me. Get on. 

The road is dry and smooth. The forest arching over the route gives us cool shelter as if we’ve just entered a cathedral. With him I feel safe. I wrap my arms around his waist and rest my head on his back. I love these visits. I love this health centre. It’s the one furthest away, in a hamlet high on a hill. The midwife there works her ass off. She does the equivalent caseload of nine full-time midwives back home. She is completely committed to this community. I love her. Someone should make a film about her.

***

I have to fly to the capital to renew my visa. I deliver a stack of official stamped documents to the MSF office that do not mention the word rape. 

I am summoned to meet with the MSF Head of Mission.

The Head of Mission welcomes me as Ahh-NAH, and motions for me to sit. He wants to profit from my visit to the capital. He wants to explain to me, or as he says it, “impress upon” me the same message Charlie Tango has been trying to instill in me: This is Congo.

The meeting feels important, though maybe it’s because he speaks oh-so formal French. Perhaps it’s because he doesn’t seem to breathe when he comes to the end of a sentence. Perhaps I’m too tired to understand the nuances he shovels after too many subjunctive verbs.

He gives an example from Somalia. But if this is Congo, this is not Somalia. So what he means is, this is Africa. This is Black Africa.

Here, a Black African man cannot be involved with a white foreign woman. “People” are “talking.” “People” have concerns that I'm “going native.” He repeats more than once that it’s for my own protection. He’s referring to Achilles, a national MSF staff of ten years. Since arriving, I could sense it. Now I suddenly get it: MSF is us, not them. In Congo.

***

My time working with Achilles has taken on a contracted intensity, like dog years. By motor bike, we’ve criss-crossed the region. In a day, we experience more together than most people. Someone dies or is injured, food shortages make us both cranky (usually me), crappy communication network leads to one of us stranded (usually him). He often sees the positive; me, not so much.

At the health centre high on the hamlet, thunder starts and pewter clouds you could mistake for mountains lumber towards us. The midwife shoos me out the door. She says she’ll text me a list of supplies she needs, but I must leave before the storm. The nurse who is returning with us is doing the drug inventory slowly. I give up pestering him when he starts recounting each ibuprofen. Achilles calls me over and tells me to chill out. There’s a kind of limbic reassurance that takes place when you hear your name said in the familiar way.

We wait under the gazebo and watch the storm move closer. I’m grateful I did not wear my Converse. He brings up the musician Papa Wemba again, still struck that I’ve never heard of him. This conversation takes on some gravitas because with the storm approaching, we’re using this time to talk about Papa Wemba and not taking steps to save ourselves. Finally the nurse is done. The storm cloud is over us and the rain starts, without a patter, but with torrential force.

We get on the motor bike and edge to the start of the route at the top of the hill. The path has morphed into a river.

“What?” I can’t hear what he’s just said. He laughs and repeats himself louder.

“It’s The Benediction of Our Marriage!” he jokes.

***

When my meeting in the capital with the Head of Mission is over, I have to rush to catch my flight back to the project. I load my bag into the Landcruiser and defer shotgun to the new European nurse, who will probably vomit on the winding route to the airport. The driver instructs me to put on my manky MSF identity daycare vest. I don’t. I climb into the back and put in my earphones, swiping to the new Lumineers song on repeat. 

We have to stop and pick up counter-referrals. These are people we referred from the project to the hospitals in the capital who are now guéri (cured). They have with them their bins of pots and food wrapped in a cloth, and usually more than one has a urine-soaked infant. The driver stops and opens the back door. I don’t move. I don’t help load. 

A woman climbs in and sits across from me. The driver tells her in Swahili to put on her seat belt. I don’t move to help her navigate this foreign strap. She keeps looking at me, and I turn up the volume on my iPod. When we pull out, she taps my knee. Then again, more persistently. I take out one earphone, indicating that my attention is temporary. She lifts her wrap skirt and shows me the inside of her thigh. There’s nothing there except for some bits of leftover surgical tape. I shrug. I put my earphone back in. She taps my knee, placing her hands in a V at her crotch. She smiles. She taps the inside of her thighs with the back of her hands. I have no idea what she’s pantomiming. I ask the driver to hand me the counter-referral forms. I flip through the sparse information and then reach the last page. I read the prise-en-charge in my handwriting.

I look at her again. I have no memory of her face, her hair, the way her lips part as she smiles. I take out my earphones. I motion for her to lift her skirt again. I only remember the scar on her right calf. And the speculum exam. The rank smell of urine. And feeling inadequate and useless. And then feeling blind, tearful rage when I couldn’t find a foley. She’s the fifty-fifty woman—guéri par miracle.

 About the author

Ann Montgomery has been a midwife for the past 20 years in conflict zones, post-disaster settings, and Canada's Arctic. She has a PhD in Epidemiology that focused on preventing maternal death in low-income countries. Her creative nonfiction piece "Papaya Abortion" is forthcoming in Long River Review. When not working, she lives on a sailboat on the ocean with her partner. 

About the artist  

PT Russell is a Bahamian Creative based in Ontario, Canada. Most recently her artwork has appeared in The River Magazine, and NonBinary Review's Apocalypse issue. Contact her on IG: @ptrussellwrites