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Being Present

Sometimes the suffering in the developing world seems too intractable, too overwhelming, to dispel it, even a small part of it. But far away from home—about as far as he could get, in the Afar region of Ethiopia—one DMS alumnus concludes that just being present, fully present, may be enough.

By Robert M. Rufsvold, M.D.

The hottest year I ever spent was my first week in Galaha, in the Afar region of Ethiopia. It was the fall of 2006 and I was on a mission with Médecins Sans Frontières (MSF), an organization known in the U.S. as Doctors Without Borders.

Upon landing in Addis Ababa, I headed for the northeastern desert, home of the Afar people, with whom I was scheduled to work for the next six months. As our Land Cruiser wound its way out of the relatively cool central highlands, the temperature rose with each passing kilometer. I couldn't help but think of the famous quip (apocryphally attributed to Mark Twain) that "the coldest winter I ever spent was a summer in San Francisco." As it happens, I had spent the last five years in San Francisco, and my body, used to its cool summer fogs, was now rebelling.

I was grateful for the two-liter, burlap-wrapped, plastic water bottle between my legs. A local MSF administrator had given me the bottle before I left Addis, promising that it would quickly become my friend. Indeed! It soon went everywhere withme, since 10 to 12 quarts of water a day barely kept me hydrated in midday temperatures that reached 110 to 120 degrees Fahrenheit. It was little consolation when other staff in Galaha would say, as they frequently did, "You should have been here two months ago, during the hot season!"

As we rolled along, I reflected on the news I'd received only a few days before, in Paris, that the MSF project in Galaha would soon close. A dam was being built downstream on the Awash River, and Galaha would be under water within six months. The people in the village would be relocated, but there was no plan to rebuild the MSF clinic, hospital, or TB treatment center.

This word put a whole new perspective on my assignment, and I had a lot of questions and few answers about the continuity of care for the Afar people. The closing of the project would be a huge loss to the region. There were virtually no

An early-morning view of the Afar village in Galaha. Smoke rises from cooking fires in the daboytas—huts made of straw mats laid over interlaced sticks.

other primary-care services within a 104,000-square-mile area—the size of Colorado—that was home to about 1.3 million people. Yet I was fretting over matters about which I had little knowledge and no control, I soon realized. So I turned my attention to the stark beauty unfolding around me.

The heat, the harsh terrain, and the isolation were merely discomforts to which adaptation was possible—discomforts that paled by comparison to the suffering I would witness in the ensuing weeks. The Afar, perhaps Ethiopia's oldest ethnic group, have occupied their inhospitable homeland for at least 2,000 years. Nomadic pastoralists, they suffer from chronic malnutrition, episodic famine, and a list of endemic diseases that could fill an infectious disease textbook. Brucellosis, malaria, meningitis, cholera,

schistosomiasis, tuberculosis (TB), and kala azar (a parasitic disease also known as visceral leishmaniasis) are common. HIV/AIDS is taking an as-yet-unknown toll on the populace. Even everyday respiratory infections can be life-threatening to a people whose overall health status is so dismal. Two out of five infants don't survive to their fifth birthday, and Afar life expectancy is less than 50 years.

This is their story. And the story of just one organization among many, just one project among many, seeking to address the growing burden of chronic poverty, disease, food insecurity, and conflict that afflict a majority of the world's people.

The drive north to Galaha was a nine-hour, 350-mile trip. I was tired but couldn't sleep. Not only were we moving into an oven-like climate,

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Rufsvold is a 1979 graduate of DMS. He practiced family medicine in Lyme, N.H., for 18 years before moving to California in 2001 to be the associate director of the Institute for the Study of Health and Illness and the director of Finding Meaning in Medicine, based at Commonweal, a nonprofit institute in Bolinas. After the trip to Ethiopia about which he writes here, Rufsvold returned to the Upper Valley and is again living in Lyme. He took all the photos included in this article except the larger ones on pages 2 and 5; those were taken by Dr. Nancy Tsai. Rufsvold received permission to take these photos from everyone who is pictured.

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