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Being Present

—a gesture that he reciprocated. Then I kissed his hand yet again.

Strangely, his eyes were filled with joy, a look of peace mixed with exaltation. I believe that he knew exactly what I wanted to say. No sooner had I expressed how sorry I was about his loss, about the fact that we had not been able to save Ayisha, than he offered his own condolences. He said he knew that we'd done everything we could to care for his daughter. She was now in Allah's hands. It was all right. I really wanted to believe him.

We parted, and I later watched Ayisha's funeral from a respectful distance.

As planned, the dam was built. In the interest of "progress," the broad, flat plain between the Mille and Awash Rivers—the site of Afar grazing lands for thousands of years and of the MSF clinic for just over a handful of years—gave way to rising water. However, the irrigation project will not benefit the Afar. Its goal is not food to fill hungry, swollen bellies but sugar cane to distill into ethanol to help fuel a growing military in one of the newest fronts in the war on terror. Once again, human conflict is at the root of human suffering.

A few days after Ayisha's death, just a month into my scheduled mission, a family medical emergency cut my stay short and I had to return to the U.S. Before leaving Galaha, I prepared a draft plan and timetable for phasing out the project. I regret deeply that I couldn't see it through to its end.

My time there encompassed only a few shortterm gains; much loss; and some of the most physically, mentally, and emotionally taxing work I have ever done. The sense of coming up short was pervasive—short of personal, professional, organizational, and governmental resources to do an impossible task in the face of much suffering.

But what I took home from the mission, and continue to learn as I reflect on my

Above, the Mille River at sunset, before the dam. Below, an Afar man sporting a gilé (sword) and AK-47—the reason for the sign on page 8.

experiences there, is that we all face situations where the sense of being or having "not enough" permeates our lives. This is particularly true in medicine, and not just in resource-deprived places.

So perhaps just showing up and being fully present is enough. Perhaps such work, in the words of the 18th-century poet Samuel Johnson, "would in time be finished, though not completed." Perhaps, I have concluded—recalling a poem that I wrote a year before my trip to Ethiopia—poetry is a more appropriate coda than prose for such a saga:

What If . . .
"How do I know when I've done enough?" You ask the question that perennially haunts all who serve at that edge where the pain and suffering of others threatens to overpower and make us wish, sometimes, that the gift of empathy and compassion be lifted from our shoulders, as if it were a burden we no longer have the strength to bear.

Why do we add to our suffering so, tossing and turning and hoping that we might someday know the unknowable? What if this is simply a part of the mystery, just another thought to be held

with all the other unknowables when they take our attention and entice us to inaction or, worse, indifference.

Mitakuye oyasin, say the Lakota. "All beings are my relations." What if, simply, this is enough? What if we could simply live this experience, place our hand on the door, and before entering say, "Use me. Help me to do good work today."

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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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