Doctor in a Desperate Land

Tom Catena, an American missionary doctor, has been living since 2008 in the Nuba Mountains of Sudan, a land of horrors where families sometimes cower in caves to avoid aerial bombings by the Sudanese government. Rebels of the Sudan People’s Liberation Army-North (SPLA-N), who are fighting for greater autonomy from the government in Khartoum, control much of the countryside, while government forces occupy the towns and prowl the skies. Hundreds of thousands of civilians have fled.

Villagers who remain scatter at the sound of Antonov cargo planes. From these aged aircraft, Sudanese air force personnel drop crude bombs through open hatches, hoping to hit something below. Catena treats the wounded, as well as the sick and the malnourished. Patients walk for many days to get to his overcrowded Mother of Mercy Hospital. He is the only trained doctor in a rebel-controlled area roughly the size of Austria.

Recently, “Dr. Tom,” who got his medical degree at Duke University, was on a very rare home leave to the United States. We met for lunch at a sandwich shop on Second Avenue in Manhattan, where Catena seemed overwhelmed by the number of soft drinks and juices on offer. In college, he played football and weighed 230 pounds. Now he’s a gaunt 48-year-old, weighing 155 pounds. Over chicken paninis and apple juice, he spoke about life in one of the most isolated and troubled regions on the planet.

FP: Foreign Policy: You wake up in the morning in the Nuba Mountains. What do you see, smell, hear?

Roosters. I stay on the hospital grounds in a Catholic guesthouse, a little cinderblock building. I don’t have an alarm, but wake up around 5:00 or 5:30. The roosters are crowing. We’ve got chickens all over the compound. Sometimes donkeys are braying and cows are mooing.

We have a couple of priests living there and they say mass everyday at 6:30. So I get up, walk out of the back gate of the compound, cross a dry riverbed to the fathers’ compound where there’s a small chapel. Usually a couple of the sisters are there, maybe a couple of the people from the area, and we have a mass from 6:30 to 7:00. When mass is over, the sun is up a bit. We have a very small breakfast, maybe some coffee and bread. Then I go to the hospital at quarter-past-seven and start the rounds. 

FP: People in the West might have an idea in their heads of what a hospital is, and it might differ from what you’re talking about. 

It’s one floor, shaped like a U, made of hand-carved stones from a quarry in the hillside. We have about 300 beds, and distinct wards, but with the overflow of patients now there are beds in the corridors, beds outside on the veranda. We have beds in a large tent, and in other makeshift tents, spread out all over the place.

We usually have 350 patients, two to three children to a bed. When I left last week, we had 124 kids in the children’s ward alone, in maybe 50 beds. There is never enough bed space. 

FP: Does the hospital have electricity and running water? 

During the day we run solar. We have maybe 12 solar panels and 16 solar batteries. We run the day-to-day operations off that solar bank. As a backup, we also have a 25-kilowatt generator. We’re already on our second set of batteries [in four years], and they’re expensive. About $8,000 for a full set. 

 FP: Water? 

We have two hand pumps: One is in the back, used by patients. One is in our compound, which we use. We also have a borehole with a solar-powered pump that draws water up to two storage tanks on the roof. That comes down and feeds the hospital and our compound. So we have running water in the hospital. 

FP: So the area you are serving, how big is it? 

Maybe about two-thirds of South Kordofan would be our catchment area, and before the fighting, the population of South Kordofan was about two million. The area we serve now has probably 500,000 people — in the SPLA-controlled areas of South Kordofan. 

FP: How many other clinics or hospitals are in this area? 

We are really the only hospital in the Nuba Mountains. That’s it. About an hour away from us is a large clinic, run by the German Emergency Doctors. There’s no doctor there. Besides that, just small clinics scattered about. Sometimes they have drugs, sometimes they don’t. 

FP: You are the only trained doctor in the whole rebel-held area? 

Yeah. 

FP: So tell me about your patients. How do they get to you? 

Some take seven days to walk, some five days, some three days. Some will start walking, find a passing vehicle [to give them a ride]. It’s very difficult: There’s no public transportation anywhere [and none of the roads are paved]. 

FP: Are there many cars in Nuba? 

Very few. There aren’t really any NGO vehicles left. There’s us, the German Emergency Doctors, and Samaritan’s Purse. Everyone else is gone. There’s no regular transport. [The rebel forces have vehicles.] 

FP: So who are your patients? 

Very few can read or write. During the five or six years of peace, when there were functioning schools again, kids were going to school. But that’s all stopped. Most of the schools have closed. When patients sign a consent form for surgery, almost everyone has to give a thumbprint. Very few can sign their names. Our medical staff can read and write English a little bit.

Probably 99 percent of Nuba are subsistence farmers. They have maybe two or three cattle, a few goats. Now there are food shortages, so they’re very thin. But traditionally, they are very strong and muscular. They grow sorghum, okra, a bit of corn, some peanuts. If they need money, they’ll sell one of their animals or sell some sorghum.   

FP: Malnutrition has been a problem. There have been reports of people eating leaves and roots, or whatever they can forage. 

Before the fighting, we always had malnourished children coming to the hospital. What often happens is that a mother who has a young child conceives, and she stops breast-feeding her baby — who is maybe a year old. Her belief is that she can’t breast-feed when pregnant. So she stops breast-feeding the child, and starts giving the kid poor nutritional food; the kid gets diarrhea, a bit of sickness, and starts the cycle of becoming malnourished. We’d often have five or ten children in the ward in this kind of scenario. Now, in the past two years with the fighting, we see older children and adults malnourished because of lack of available food. Last year, we had people lining up: They would come in the morning and ask us for food in exchange for work. They’d say, “We’ll cultivate some of your land, collect you some firewood,” whatever. That was something unusual.

We had some extra food. But we had only planned to have enough sorghum for our patients and staff. So it was very difficult. We managed to give them something, at least. Now it’s starting again. Whatever they harvested in September is running low. 

FP: A recent Human Rights Watch report says the government has imposed a de facto blockade on humanitarian supplies to rebel-held areas. 

In August, the Khartoum government signed an agreement to allow humanitarian access to the SPLA-controlled areas of Nuba. I’m still not sure what is going on. There are supposed to be [international] monitors coming in to report back on the situation. I haven’t seen anybody. I haven’t seen any monitors, I haven’t heard of any monitors coming. The Khartoum government is expert at this kind of game. They know how to hide facts, how to hoodwink people, how to tell half-truths, how to obfuscate. 

FP: You told me previously that you grew up in a large Catholic family, and that a large part of your motivation was to emulate the life of Christ. Can you tell me a little more about what inspired you to spend the past four years in the Nuba Mountains, and the last two years within a half-mile-square compound there? 

Well, certainly it’s a religious motivation. I’ve always wanted to do mission work with the poor. I was influenced very much by St. Francis of Assisi, whose idea was to radically live the gospel. He was not a priest, or even a brother. He was a layperson. His whole concept was to emulate Christ through the gospels, and to live it in a radical way. That has always resonated very much with me: Not to just live it half way, or live it from a distance, but to really enter into that reality. I can still get out if I want to, but I have no desire to do that. I want to continue this line of work, living this kind of life.

As a Westerner, as an American, you never fully enter into the reality there — to know their mind, their way of thinking. But I try to do it as much as possible, given my limitations. 

FP: There’s been a lot of criticism of the Western aid community in general, that Western aid or “white saviors” from afar are doing more harm than good — promoting corruption, dealing unrealistically with situations, making matters worse. What do you make of that kind of criticism? 

I would agree with a lot of it. It’s very difficult, because most everybody involved in humanitarian work is well intentioned, I think. The trick is: How do you do it in a good way, without making people dependent. My approach is to enter into this work with the people, and to work along with them. We do it in a low impact way. We don’t come in with 20 doctors, take over a hospital, and do all the work ourselves. The whole thrust of the church and diocese is that we want the hospital and infrastructure to last for 50 or 100 years.

In a lot of cases, NGO’s have a project with money for two years, and they come in and run an emergency clinic. When the money [for that project] dries up, they pack up and they leave — move on to the next crisis. That’s not our idea. The church is part and parcel of the people there. Our goal is that local people will eventually run the place. We tell them over and over: This is your hospital.

It actually helped a lot when [some Kenyan and Ugandan staff, including a pharmacist and a midwife] got evacuated in 2011. That June 16th, I had a meeting with the staff and I looked at them and said, “The expatriates are gone; you’re left with myself and a couple of sisters. You need to pick up the slack. You’ve got to do the job now.” And they did it.

The criticism is valid, however. We always have to ask ourselves: Are we doing the right thing? Are we creating dependence or harm? If you don’t do that, you can make a mess. 

FP: There are some people who will say, well, you have a Christian agenda. Just by virtue of the fact that you’re on a Christian mission, you’re an outsider who is coming in and trying to influence the ideology of the people. You’re a foreigner with a foreign mission. How do you respond to that? 

Well, I would say yeah, it’s a fair criticism. But first off, the Nuba Mountains are mixed: Maybe 40 percent Christian, maybe 40 or 50 percent Muslim, the rest are animist. We as a church, the mission of the church is to be available to the people. Myself as a missionary, I’m trying to present to you a face of Jesus in what I’m doing. I don’t preach, I don’t say you’ve got to be Christian or else we won’t take care of you, or you’ve got to be Christian or we won’t treat you as well. This is how I believe Christ would react to this situation and I try to emulate that. The Nuba people can see how I’m behaving, good or bad. 

FP: You see a lot of horrors on a daily basis. Has your faith ever been tested? Have you had cause to look upwards and think, “Where the hell are you?” 

Yeah, where is God in all this when you see children being maimed and slaughtered and dying? Sometimes I wonder, why does God allow this? And in the end, the only conclusion I can come to is: There is so little I know about the world — the here-and-now and the hereafter. My role is not to question everything. It’s just to be of service, to do my best in this earthly realm. Perhaps after I die, I’ll know a little bit more. There’s a lot that we as humans have no idea about. Somehow, all this stuff makes some kind of sense in the end. This is a temporary existence. 

FP: On the other hand, you look into the face if a child, and regardless of what will happen after or what happened before, that child is in excruciating pain. 

The only thing I can think of is: whatever suffering we have in this life, the afterlife is so much grander than anything that we can imagine, all the suffering, all the chaos is overshadowed and forgotten and goes away. Maybe the suffering has some redemptive value. I don’t know. [tears well up briefly in Catena’s eyes at this point, and he removes his glasses.] Watching a kid die, hearing that mother wailing, for me is so excruciatingly painful. It’s excruciating. Those are the only times I feel, I’ve got to get out of here. Hearing that screaming. 

FP: Tell me about patients who have really stuck with you, that can’t get out of your memory. 

There was one kid who was hit by shrapnel from an Antonov bomb. I can’t remember his name; he was about 12 years old. He came about a year ago. The bomb exploded and the shrapnel just tore his face apart. Anyway, he went to some clinic somewhere, a few hours from us, and had some crude surgery. They stitched the wound and you don’t want to do that; it traps the bacteria and bugs. He was a total mess. There was pus and stuff oozing from his wounds. We took the sutures out, and inside his wounds was dirt and grass. We cleaned it out and packed the wounds.

He was doing okay for a couple of weeks. The wounds were healing. But every time the Antonov would come overhead, and we’d hear it, he’d just put his face into the wall and moan. He was terrified. Then we saw him one morning and he was going rigid, and we thought, oh no, he’s getting tetanus. So we put him in isolation and put a feeding tube down, and started our standard tetanus treatment. He was spiking high fevers, so we put him on antibiotics. And after a couple of days, he just up and died. And it was excruciating.

He was recovering from his wounds. He was doing fine. I discussed it with one of the Comboni Sisters who was in charge of the children’s ward. We talked and talked about it. She said, “What can we do? Maybe it was God’s will. He would have suffered the rest of his life.”

Then there’s a guy named Daniel, who is still alive. Daniel was hit by an Antonov. He’s 14 years old. The Antonov came over, and he fell to the ground and wrapped his arms around a tree. The shrapnel hit him and severed both of his arms. He came in with spaghetti arms, you know? So I had to take off both of his arms.

To amputate somebody’s arm is not a nice operation. A leg is better. If you take off a leg, there is a possibility of giving him a prosthesis so he can walk again. But take off somebody’s arms, particularly a kid like that, you are screwing that kid. He’s left to a life of constant dependency on somebody else.

We just set Daniel up with a program to get him prosthetic arms, but they’re cosmetic arms, like a mannequin — non-functioning. We’re hoping we can later give him some kind of a claw or latch [that can grasp things]. But he’s depressed now. He needs to have somebody help him pass his stool, to help him wash his butt. He can’t eat. 

FP: How many patients do you get who have the flu or other more common problems? 

We get everything: rabies, tetanus, back pain, a simple fracture, diarrhea. 

FP: Your hobbies before going to Sudan included scuba diving, bicycling, and basketball. You can’t do any of that anymore. What do you do when you’re not working? 

If I get some time, I lie in bed and read a bit. My dad sends magazines that get there eventually. Books. The work is pretty much all encompassing. I’ve thought about getting a mountain bike and bringing that in. 

FP: Do you ever think that if you continue leading this kind of life, you won’t have a family? 

Yeah, I’ve thought about it. I have. Because it is isolating… Marrying a local person is a possibility if I stay long term. There’s certainly a culture gap. But to get a Western lady to go there, it would have to be somebody who has the same mission. I could not meet somebody here in the U.S. and bring her along. It’s too isolating. She would independently have to have the desire to work in that missionary field. Otherwise I’d make somebody very miserable.

I really feel that I’ve been given everything in this life. I was born to this incredible family, very supportive. My parents have been married 50-some years and I’ve never heard them fight. I got the chance to attend great universities and medical school. I’ve had everything. I don’t think I’ve had any adversity. I mean, yeah, I studied hard in school but that’s not adversity. Everyone in the Nuba Mountains has faced incredible adversity, every single one of them. Just to finish primary school is an incredible challenge. What the heck?

You asked about God. I wonder why God gave me all this stuff and gave them the short end of the stick. I don’t understand it. I feel I have some obligation to even the score up a bit.

Photo: Jeff Bartholet