the end.

I decided that this book should start at the end. It is the place I am trying most to understand.

This is it. I am standing in a field watching sparks from a huge bonfire float so high on hot drafts of air that they become stars. It is autumn in upstate New York, and the night is dark and cool. Wedding guests huddle together, white blankets loose over their shoulders. They murmur, point at the fire, then at the sparks.

I am standing by myself, swirling warming wine. A man to whom I had been introduced that night, a friend of the bride, rekindles our conversation. He is talking about an acquaintance, a nurse, who worked during an Ebola outbreak in the Congo years before. He recounts her story of how, after days of watching people die of the incurable virus, she and her team decided that if there was nothing to offer those infected, no treatment, no respite, they would give them a bath. They put on goggles and masks, taped their gloves to their gowns, and cleaned their sick patients.

Before he can go on, I stop him. I can’t talk about this.

“I’m sorry. No, no, it’s okay. It’s nothing you did. I’m going to go inside. Glad to have met you.”

I had been back from Sudan for a month. I had worked there as a physician in a small overwhelmed hospital run by the NGO Médecins Sans Frontières. I returned to Toronto sick and exhausted but convinced I was going to make the great escape. I was working in emergency rooms again, surrounded by friends. Things would be like always.

In this field of cold grass, where hours before my friends had been married, I heard ten seconds of a story, and during them realized there were things I had not reckoned on.

It was the taping of the gloves. The whine of the white tape as it stretched around their wrists, forming a seal between their world and the bleeding one in front of them. I could imagine the grimness with which it was done, could see the flat faces of the doctors and nurses as they stepped into the room.

As he was talking, I cast back to the measles outbreak that was just starting as I arrived in Abyei. One day we had two patients with measles in the hospital, the next day four, the next nine, the next fifteen. The rising tide of the epidemic soon swept over us.

I rewound to a film loop of me kneeling on the dirt floor of the long hut we had built out of wood and grass to accommodate the surge of infected people. I was kneeling beside the bed of an infant who was feverish and had stopped drinking. I was trying, with another doctor, to find a vein. The baby’s mother sat helpless on the bed as we poked holes in her child. She was crying. She wanted us to stop. Small pearls of blood dotted his neck, his groin. We failed, his breathing worsened, and he died. I stood up, threw the needles in the sharps container, and walked away to attend someone else. Behind me his mother wailed. I can see my flat face.

Who was that person? I am not sure if I know him, not sure that I want to.

People who do this type of work talk about the rupture we feel on our return, an irreconcilable invisible distance between us and others. We talk about how difficult it is to assimilate, to assume routine, to sample familiar pleasures. Though I could convince myself that the fissure was narrow enough to be ignored, it only took a glance to see how dizzyingly deep it was.

The rift, of course, is not in the world: it is within us. And the distance is not only ours. We return from the field, from an Ebola outbreak or violent clashes in Sudan, with no mistake about how the world is. It is a hard place — a beautiful place, but so too an urgent one. And we realize that all of us, through our actions or inactions, make it what it is. The people I left behind in Sudan don’t need us to help them towards a health system that can offer immunizations — they need the vaccine. Fucking yesterday. Once that urgency takes hold, it never completely lets go.

Just as our friends wonder at our distance from their familiar world, we marvel at theirs from the real one. We feel inhabited by it. We plan our return.

I have done this work before, but I have never looked back. Now I will. I am going to wear that flat face again, toss and turn in a tangled bed. But I also will feel, for the second time, the cool relief when a child I had bet everything on started to recover, to stand close to the young soldier who volunteered to give blood to a woman he didn’t know, to visit again the members of my small team. Some of the work in repairing the world is grim; much of it is not. Hope not only meets despair in equal measure, it drowns it.

This book started as a blog that I wrote from my hut in Sudan. It was my attempt to communicate with my family and friends, to help bring them closer to my hot, hot days. It was also a chance to tell the story of Abyei, Sudan, a torn, tiny place straddling a contested border in a difficult country. Mostly, though, it was where I told a story about humans: the people from Abyei who suffered its hardships because it was their home, and those of us who left ours with tools to make it easier for them to endure. It is a story that could be told about many places.

The blog became popular. Part of me wants to believe it was because of my writing, but that’s not it. It is because people are hungry to be brought closer to the world, even its hard parts. I went to Sudan, and am writing about it again, because I believe that which separates action from inaction is the same thing that separates my friends from Sudan. It is not indifference. It is distance. May it fall away.

So, this is where I stand, at the end. In the dewy grass, sparks stretching to the sky. It is cold away from the fire, and I shiver. In the distance I can see light bursting from the farmhouse door. Inside, people are dancing. I thrust my hands into my pockets and walk across the field, away from the end, towards the beginning.

the beginning.
It was my mistake. The beginning was not that clear. It fooled me again and again. It was like preparing for a marathon. You think it starts on the day you decide to do it, when you lace up your shoes for the first time, step outside, and look at your watch. But soon it is the day of the race, and that is the beginning. But no, here you are shuffling to the starting line with a thousand others, high with anticipation. This must be it. Then, the shot.

The real beginning of Sudan, for me, was when I dropped my bags into the dust of compound 1, looked around me, and saw no one. That was the moment, that was the starter’s pistol. Go.

The larger story, the soft bookends to my time in Sudan, began when I was twenty-three years old, a medical student between my first and second year. Most of my friends were taking vacations or were busy in Canadian hospitals, trying to add lines to their CVs, when I stepped onto a flight to Santiago, Chile. I had received money to support a six-week international rotation and was looking to impress my older girlfriend. It was my first time anywhere that was somewhere else.

On my first day of work there, I hung off the back of a bus headed towards a public hospital and reluctantly handed my fare to the person next to me. Minutes later, my change and ticket were returned, passed hand to hand through the crowd. It was at that hospital that I saw a man whose fingers were so heavy with gout, so knotted, that he couldn’t pick up a coffee cup. I was working with a cardiologist who spent his days employed in a public system where families tried to find someone with a credit card to finance their grandfather’s angioplasty. At nights, he travelled to private hospitals to consult on the health of the wealthy so he could send his children to university. I went home convinced that if I was being trained to take care of the sickest, they surely were in other places.

For my residency, I chose emergency medicine because it would give me the widest set of skills, and wouldn’t require me to have a patient practice. I would leave no one in a lurch when I left Canada for weeks at a time.

The story started in rural Cambodia four years after Chile, when I spent a month alone, as a new medical resident, conducting medical clinics in the morning and a needs assessment in the afternoon, trying to understand the health needs in a group of recently surrendered Khmer Rouge. I arrived at the Phnom Penh airport with a backpack full of donated pills, and a letter from the commander of the valley guaranteeing my safety. I drove south with a borrowed translator in a borrowed Land Cruiser and found fourteen thousand people who had exchanged one struggle for another. Instead of fighting the government, they were fighting to carve rice fields from the jungle. It was there I ate my first meal surrounded by starving people, there I saw a woman whose breast cancer had pushed through her skin and to whom I had nothing to give but acetaminophen, there that I walked out of my guest house to find food and stumbled over the feverish body of a woman nearly dead from HIV left at my door, like a cat would a mouse. Overwhelmed and alone, I first discovered my helplessness in a world beyond my control.

I returned to Cambodia two years later to set up a university project that would introduce new doctors to the medicine of poverty. I looked at a heaving shelf stacked with reports on reports of how Cambodians should address their own health and realized that as the one with the resources, it was my privilege to waste them. I set up a meeting with a Cambodian health official and asked what he would have me do.

After I graduated from my specialty training, I heeded the advice of a teacher who told me not to let my lifestyle expand to accommodate my potential income. I rented a small apartment in Toronto and rode my bicycle to the emergency room. I made it six months before leaving for Bolivia, then to southern Africa, to write about the neglected diseases Médecins Sans Frontières was treating. I found a community of people carrying dusty bags with whom I shared sympathies and space. I learned that the larger question of these diseases, whether HIV or Chagas, was not how best the world could help those affected but whether we would appreciate our capacity to do so. No matter how many hollow zeros were added to the death toll, my family and neighbours could not understand what the numbers measured because they could not feel the consequences. The response to the tsunami was profound because the size of the wave could be measured by the height of the boat in the tree. If I presumed to work on distant problems, and to write about them, that’s what I had to show.

The story started when I was standing in a customs line, waiting to board the plane to Germany for pre-departure training with MSF, when my friend Matt called and asked why I had decided to go. I told him I wanted to see who I was when everything was taken away, when all the insulation between the world and me was removed.

It started when I arrived in Germany and shared my room with three African men. We stayed up late and talked about what we looked for in women and laughed at how different our tastes were. Later that week, we sat and calculated how much plastic sheeting we would need if our team found a hundred thousand refugees on our doorstep. And in a classroom in Bonn, with thirty others bound for different places, I was told for the first time that I could expect to come back different, that my friends wouldn’t want to talk about the things that I would, that I would have less in common with them than ever before.

I was sitting on the hard plastic chair outside my friend’s office in Toronto, waiting for him to get off the phone. My cellphone buzzed in my pocket and I looked at the display. It read “MSF Toronto.” On the other end was the human resources officer asking if I would accept a mission in Darfur, a mission with only men, a mobile one with security risks. I left the building, got on my bicycle, rode through leaf-filled alleys, and asked myself what I was willing to lose. I got home, read the Joan Didion quote that appears at the front of this book and decided that I might as well risk it all.

Two months after the Darfur mission fell through because of security concerns, deep in the Canadian winter, about to make other plans, I checked my email during a lull in an evening emergency shift and saw a subject line that said only, “Sudan?”

I read the profile:

MEDICAL DOCTOR
ABYEI project - MSF - SWITZERLAND
Southern Kordofan — SUDAN

Requirements
• Special knowledge:
— Reproductive health and minor surgery highly recommended.
— Tropical Medicine
• Special qualities:
— Psychological strength
— Interest to work in remote environments

It started when I sent back the message “yes.”

I stood on the porch of the house where I had been allowed to quietly come and go over my last few uncertain months in Toronto waiting for a mission, and shared an uncomfortable hug with Steve. He was leaving on a vacation, and we wouldn’t see each other until I returned. He walked towards the fence and before he reached it, spun around and took a few steps back. “It’s like the last days of disco,” he said, turned, and clattered the gate shut.

My final night in Canada, I walked through a skiff of new snow, my arm laced with Sarah’s. Though I’d been home the last few months, my heart was not. I wanted no ties. My departure seemed like a convenient breaking point for us, at least to me. We arrived at a bar full with my friends gathered for a birthday party. “So when are you going?” one of them asked, as uncertain as I was from my flightless holding pattern. “Soon,” I said. I lingered by the bar, sipping a beer, and after a few minutes, caught Sarah’s eye. We spent a last night together in my borrowed home.

I woke up alone. I could hear Sarah. In the shower now, now on the stairs. The door creaked open, paused. Creaked shut. Gate clattered. I swung my feet onto the cold hardwood floor. The house was silent. I got dressed and walked downstairs. My packed bags were by the door, and I moved them to the snowy porch. I turned the lock for a final time, then dropped the keys in the mailbox. I had no home. I was free.

The story started when I was sitting on the plane, flying from snowy Canada to snowy Switzerland, my backpack wedged in the luggage hold below me, writing a letter.

12/02: jet plane.

in the airport, finally on my way. i have been waiting for a beginning for some time, not knowing where or when it would come. it’s here.

of the many lessons i thought i might learn with this, i knew one would be: “be careful what you wish. you might get it.”

i said i would go anywhere, that i wasn’t afraid of being isolated, that i had a wide complement of medical skills and could do a little of everything. i could work in a small team with little backup, improvise if necessary. if there was a time in my life where i could go to a place that required close attention to security, it was now. no wife, no kids, no house, no debt, no one waiting for me to get back.

so, i wished, then got it. i am off to sudan. a small town in the middle of the country, right on the border between north and south. for those with a grander memory of the struggle there, you will know that it has been at war for decades. much of it is between the south and the north. it is a conflict about resources. and allegiances. and history.

darfur has become a media story, particularly in the past three years. there the war rages on, and the fighting is vicious. but sudan has rarely been at peace since its independence in 1956. it has more people displaced from their homes, because of conflict, than any other place in the world. most of them are from southern sudan where war still smoulders. the people there feel deeply the effects of chronic conflict. for a nation, it is like a chronic disease. one wastes away from thousands of tiny insults.

the place that i am going is called abyei. you can check it out on google earth. it looks like a smudge in the sand. it sits in an area claimed by both sides but owned by neither. tensions, i have been told, are high.

i will be working in a small hospital with a small team. the patients will be regular size. the mission is a new one, and there isn’t much infrastructure. aside from that, i know little else. i will find out more in geneva.

boarding now. i learned something else these past few months: one shouldn’t think with certainty about the future. it has helped see me through.

that’s it for me. boarded. wine service. better take it while i can get it. soon, suddenly, sudan.

I arrived in Geneva on an overnight flight and stood sleepless, blinking under bright lights. I hefted my two bags from the circular parade of black cases and looked at the clock. I was overdue at the MSF office with still a train to catch.

This is the way it works in MSF as a volunteer: you are either in or you’re not, you buy it or you don’t. You take public transit and stay in hostels. You brief sleepless and fly economy. An unnecessary dollar spent on you is one less for the field.

I put my backpack on and tightened the straps until it felt snug and weightless then stopped at a kiosk to get a train schedule. Minutes later, the Swiss countryside was blurring beside me.

I walked from the train station, with my backpack on and my suitcase rolling behind. The office was twenty minutes away by foot. Geneva was temperate, its streets bare of snow. Taxicabs slowed beside me and honked. I waved them on.

On a final corner sat a building draped in scaffolding, and behind bright metal bones a banner shouted: “Malaria!” I pushed through the glass doors and into a hallway lined with posters. One showed a pill set like a jewel into a gold ring; another decried rape in the Congo. People walked past them, talking loudly, papers under their arms. A woman with a large backpack on edged past me and out the door. I walked to the front desk. The woman behind it hung up the phone to have it ring again. I smiled and waited.

On a whiteboard beside her was written a list of names and countries: people leaving on mission, people coming home. Mine sat misspelled in the “Out” column and, beside it in brackets, “MD – North Sudan.” When she was done, I pointed at it.

“That’s me.”

She looked down at her busy desk. On it was a piece of paper with names and times: my briefing schedule. She handed it to me. At the top was: “James Maskalyk MD (Sudan) – Stay in Geneva: 12.02.07 to “???”

She showed me to a room where I could store my things. It was full of luggage. People leaving, people coming home. The walls were lined with rows and rows of grey plastic boxes, on their mouths written “DRC” or “Mozambique” or “Myanmar.” Inside some were letters, or small bound parcels making their way to the field. They were grouped together geographically. I traced my finger from Asia to Africa, from South to North, and next to “Tschad” sat a box labelled “Northern Sudan.” I shook it. It was empty. I stepped from the room and closed the door.

I sat in meeting after meeting, sleep headache bunched behind my eyes, and tried to concentrate. Facts that were meant to illuminate my days, the course of my months, were laid out before me. I was told about life on mission, how one should behave around alcohol, around drugs, about the perils of sleeping with one’s team members. I was given the layout of the hospital, the pattern of pathology, the hierarchy of responsibility. I was told about the diseases I would see, ones that my medical training rarely touched, ones I had encountered mostly in textbooks. Malaria, tuberculosis, guinea worm. In my satchel was a sheaf of papers I had already printed off, some on leishmaniasis, some on leprosy.

I would have no access to x-rays in Abyei, no basic lab tests. The nearest surgeon was three hours away, and the road to him was not always safe. I would be expected to birth babies and handle trauma. I was asked if I would perform an abortion if it was medically necessary. I said that I would.

I was responsible for the Sudanese people in the hospital, but so too the expatriates on my team. I was told that the doctor I was replacing was leaving after only three months to pursue a master’s. I wondered how many master’s started in March.

During my last meeting of the day, I learned more about Abyei. The project was the crucible where North meets South. In a peace agreement signed two years before, the one that ended Africa’s longest, bloodiest war, it was agreed that the Abyei question would be settled later. Soldiers from each side faced each other across an invisible divide and between them sat the hospital. And our compound. And soon, me.

Everything around Abyei was a vacuum built by twenty years of guns. One that both sides, South and North, were trying to get people from all over Sudan to fill in preparation for a referendum that was to determine Abyei’s fate, and with it, the destiny of Sudan.

There were a few other NGOs in the area, and a large UN mission. Together we were in the middle of nowhere. Us and thousands of Sudanese people returning to make a home where there was none; canaries in a coal mine.

I shook my head clear. I was in the security briefing with the operational director. This was important. I should write this down.

Where’s a pen?

“All right. Well, I guess the biggest risk is full-scale war. Not very likely at the moment, but it can change quickly. Okay?”

“Okay.”

“Things in that area are very tense. It is a very important area for both sides. Historically, but mostly because that is where most of the oil fields are, okay?”

“Okay.”

“I haven’t been there. Not yet. It’s still pretty new. So far there has been no real fighting. A few small skirmishes, some gunfire, nothing too hectic. The North and the South take this place very seriously, and are very much in control of the militia. Not like Darfur. You’ll be given more specific details in Khartoum.”

“Okay.”

I looked at what I had written. “War” and “oil.” That should be helpful.

In Germany during my pre-departure training, I had watched colleagues get phone calls or emails (“I’m going to Sri Lanka!” or “They offered me Myanmar!”), and silently crossed my fingers for a place at war. I took French lessons so that I might end up in Congo, or Chad. I read books about Sudan.

The country was at war, and had been for years. The conflict had not ended, it had shifted fronts. Currently it was Sudan’s western province of Darfur that was on fire. In Abyei, for now, the fighting had stopped, and in its place was a shaky truce. I was going to where I wanted to be. Close to war and its consequences.

Pushed by the sharp thrill of being somewhere new and rare and exciting, pushed towards that free feeling where anything can happen. Pulled because I wanted to understand. I understood the blind actions of large companies because they were a multiplication, a millionfold, of a greed I knew, stripped of accountability. I appreciated the wisdom of the Red Cross’s silence because I have, at least briefly, known patience. I valued MSF’s vigour and indignation because I understood outrage at injustice. But war, I didn’t know it. Not yet. Not well. But it’s in me somewhere.

I think there is at least one other reason I wanted to be in its way. As a new medical student, I was in the hospital one afternoon, sitting in a small, windowless room with a man and a woman, my teacher behind me. We had discovered a tiny tumour in the woman’s brain. It had spread from a cancer in her lung she didn’t know she had. It was incurable. I was going to tell her. Minutes before, my teacher and I had sat at an Arborite desk in the nursing lounge as he explained how best to deliver bad news.

“I have some serious news. You have an aggressive form of cancer,” I said. “It is very advanced. It must have spread quickly. We’ll do everything we can, but at this point there seems little chance of cure. I’m so sorry.”

I watched the colour wash from her face. Her husband sat beside her like a stone. And I, for the first time, understood that though I was living, I was also dying. I have never forgotten it.

Because of that, part of me wants to walk towards it.