Stars in the Sea

One night in the Mediterranean

I stood next to the large blue shipping container on the bright foredeck of Aquarius. I observed five regional prosecutors, four of whom wore white decontamination suits under their blue tunics with the words “POLIZIA” embroidered in large white letters. Face masks and surgical hats made them look professional but detached.

One stood to the back, wearing nineteen-eighties traffic-police type sunglasses, immaculately groomed hair, tight navy bomber jacket, slim-fit dark jeans and rough brown boots. While the others scurried to open the triple-wrapped body bag sealed with duct tape, he stood on the periphery, directing whilst saying very little. Tapping his thick brown cigar he observed the scene, a trail of ash blowing into the sea.

The face of the dead woman was uncovered from beneath the soft orange blanket we had wrapped her in. Immediately I froze. It was not the image of the young woman’s face that caused me to react, but the strong stench of the petrol which had contributed to her death. The events of last Saturday night, which I had blocked from my mind, now shot into my consciousness.

In 2017, Doctor Conor Kenny spent three months working on board MV Aquarius, a search and rescue vessel jointly operated by Médecins Sans Frontières and SOS Méditerranée.

Night rescue

© Guillaume Binet

I am part of the Médecins Sans Frontières (MSF) medical team on Aquarius, located in international waters, around 12 nautical miles from the coast of Libya. On the boat we work with SOS Méditerranée, a non-governmental organisation that rescues people in distress on the Mediterranean. On Aquarius, they use two high-speed rigid-hulled inflatable boats, or ‘RHIBs’.

Photo credit: Kevin McElvaney

Photo credit: Kevin McElvaney

That Saturday night, at around midnight, we had been directed to a position by the Maritime Rescue Coordination Centre (MRCC) in Rome. A boat full of people had been spotted. It was a relatively rough night with a south-easterly breeze generating a reasonable sea swell. By 2.30am, three more boats, each with around 120 people on board, were stricken in the water.

"In seas like this, every wave hits you like a punch in the stomach"

When the search and rescue team radioed requesting my support, I immediately descended the steps of Aquarius on the starboard (right-hand side) ‘landing area’. The landing area consists of two large orange poles which the RHIB crew can secure their boats to, in order to maintain contact with Aquarius.

Photo credit: Guillaume Binet

Photo credit: Guillaume Binet

I could see the RHIB crew calling but their voices were drowned out by the sound of the engine revving to keep it in position alongside the ship. The waves began to rock the RHIB from side to side which meant I couldn’t get a firm grip to climb on board. Instead, assisted by the rescue crew, I leapt on to the large flat foredeck. The ropes were unfastened and we departed into the dark.

Photo credit: Guillaume Binet

Photo credit: Guillaume Binet

It was pitch black and stormy, with a reasonable swell making our journey to the distressed rubber boat particularly challenging. The spray from the sea rained in on the boat. In seas like this, every wave hits you like a punch in the stomach – whilst blindfolded. Remarkably the lifeboat team had been doing this for almost three hours before they radioed me, and continued for three more.

© Marco Panzetti \/ SOS Mediterranee

© Marco Panzetti / SOS Mediterranee

Through the wide bright beam directed from Aquarius I could see the hapless grey rubber boat 150 metres away. Bobbing in the rough sea, full beyond capacity, people leaned over the port side as we began to approach. It was deflating rapidly. They were clearly scared, screaming loudly. Many were crying – begging for mercy, with the palms of their hands pushed together and fingers pointing to the sky. They looked to us for help.

With the lead of the SOS Méditerranée rescue team, we assessed this tragedy. We identified two vulnerable people in the middle of the crowd, which was now moving in unison back and forth, people’s movements dictated by the waves. You make your decision based on instinct, subconsciously processing the facts you observe, in the context of the overall situation. There is little time for discussion.

I could justify prioritising any one of these 120-plus people screaming at us. Sadly, I am acutely aware that my decision-making is biased. Despite all efforts, I observe only the fittest – the top 90 percent who can make themselves known in the midst of a sinking ship. I know there are people on the floor of this rubber boat – most likely women and children – who, if mass panic ensues, could potentially be asphyxiated in the fuel-laden water which lines their craft.

© Kevin McElvaney / MSF

With remarkable leadership, strength, tenacity and courage, the rescue team calmed the people on board.

Facilitated by the goodwill of some on the rubber boat they pluck two of the sickest from the crowd without triggering a capsize. A sudden movement in precarious situations like this can lead to the death of everyone on board.

The first was brought aboard the bow of the RHIB. He landed on his front, knees and elbows flexed, lying prone for a moment with right cheek against the black platform.

I could see he was tall, wearing no shoes, a white vest and brown trousers, breathing and making sounds. Signs of life. Pulling him off the platform towards the back of the RHIB, initially by his sturdy black belt, then by his shoulders, I dragged him to a safe space and made way for the second boy.

This time, the patient had a smaller build and appeared malnourished. Again he was breathing but not responsive. I immediately pulled him by his shoulders, sitting him up on the floor. The shock of the sudden movement appeared to jolt him into life.

We sped back to Aquarius.

Emergency on Deck

© André Liohn

As we approached the ship, my radio generated incomprehensible muffled sounds. I thought I could hear my name.

Again a second call.

We were getting closer to Aquarius. I could see the deck crew wave their hands. Then with metres left to the gangway, I could hear on my radio, “Doctor, medical emergency on back deck. You need to get off the lifeboat.”

Whilst we had conducted our rescue of the two boys, the second RHIB crew had rescued an unconscious woman. They had bravely started CPR on the exposed front deck of their small boat, despite the rough sea, and had got her aboard Aquarius.

I leapt to the front of the lifeboat as it made contact with the gangway. Climbing the ladder before the black ropes were secure I could see four of my team doing CPR under the bright lights of the floodlit back deck.

"There are no other options, there is no Plan B"

I quickly processed the scene, aware of the contrast of 20 people who were lining up for registration next to a woman fighting for her life. Surprisingly there was no chaos. No bystanders. Cool, calm and collected, the code was being run by the team.

Her thick, wet, gasoline-soaked clothes were difficult to remove as I tried to place a device which would allow fluids through a vein now obscured by her bloated skin. With my knife I eventually ripped through her sleeve.

In the background I could hear the mechanical voice from the automatic external defibrillator: “Non-shockable rhythm, continue CPR”. The team on chest compressions diligently exchanged positions as I called out “x minutes, adrenaline, one milligram administered”.

Round after round after round we continued.

The toxic smell of gasoline the patient was soaked in contaminated the air. Five of us continued to fight. I could hear the heavy breathing and see the sweat lining the hairline of my colleague as he methodically delivered compressions. As time went by secretions related to her drowning emerged from her mouth and nose. We wiped these away. We warmed her up with blankets.

"It soon felt like a war zone"

Sometime later, news filtered back from witnesses on the boat that she had been unresponsive for just over half an hour before we commenced CPR. It was becoming obvious that our attempt to resuscitate her was futile. I felt as if I were failing. We rigidly followed the protocol for running cardiac arrests. There is little room for experimenting or variation. The confines in desperate situations like this feel incredibly frustrating. Here modern medicine reaches its limitations. There are no other options, there is no ‘Plan B’.

Eventually I announced my thoughts to the team. The deck of the ship was becoming crowded, more and more sick people were climbing on board. Dehydration, hypothermia, fuel burns, exhaustion, more stretchers being requested. It soon felt like a war zone, every 10 minutes a RHIB would ferry more victims from the ‘frontline’.

“Our attempts here are futile. I want to stop CPR in the next round if we remain unsuccessful. Please let me know if you disagree and want to continue.”

The team agreed. CPR was discontinued on the next round. We paused for a number of seconds, on our knees on the cold metal floor of the back deck, where a small pool of dark blood had emerged from the venous catheter and begun to dry. Life continued around us. People boarding, children playing, women laughing.

© Patrick Bar \/ SOS Mediterranee

© Patrick Bar / SOS Mediterranee

I felt a certain sense of relief. The trauma of the chest compressions we were inflicting on this young woman ceased. She had left in the middle of this Mediterranean graveyard. She looked peaceful, but disturbed. Braided black hair, the skin on the right side of her face had dissolved in the fuel, which now exposed a dark red, raw, moist interior.

"The burn on her face extended the length of her chest. Clearly she had been face down in the fuel lining the base of the rubber boat."

The burn on her face extended the length of her chest. Clearly she had been face-down in the fuel which had leaked into the base of the rubber boat. A horrific way to drown. I wiped her face with a cloth and with the assistance of two others transported her to the right side of the boat, wrapped in the orange blanket.

Members of the woman’s family had been located. I found a safe space to break the bad news, sadly complicated by the language barrier. Through the cultural mediator I explained that we had tried everything.

I am sorry.

There is nothing more we could have done.

The family followed me to her body. The passageway where it was temporarily located was for once empty and quiet. Here the wind was cold, cutting, raw. Sitting at her head, I showed them the young woman’s face so they could be sure it was her.

They immediately broke down. On their knees, screaming, tears streaming. I felt useless, on the wrong side of the young woman’s body in this narrow steel passageway which links the front and mid portion of the ship. To them a sister, a friend, a character. To others a statistic, one of the 14 who would die that day. One of the 98 who would die that week. One of the 5,000 who will die this year.

"We sat together for an indefinite amount of time and nothing was said. We just held each other"

I stepped awkwardly to the side of the body and over to one of the relatives. I embraced her, holding her tight around her shoulders as she wept and wailed.

My friends say I can be cumbersome with embrace. For once it felt natural. I hope she derived some comfort from this. My colleague held the other relative.

All the time I whispered, “I am so, so sorry” whilst the pit of my stomach dropped to the floor and any remaining adrenaline-fuelled energy I had drained away. What else could I say?

We sat together for an indeterminate amount of time and nothing was said. We just held each other. With time one of the relatives opened up. He said they had left Libya on the boat at 11.30pm, and had seen the lights of Aquarius in the distance at around 2am. I began to feel sad – it was just 35 minutes later that we were performing CPR on her.

In the background I could see the maritime drama unfold. The ship’s search light was no longer beaming on the boats at sea. Instead, crafts could be identified only by bright torch lights, resembling white stars in the distance. Occasionally glistening in the black sea these provided a beautifully perverse backdrop.

With time, more rescue boats travelled back to the Aquarius. The two orange poles on the landing area now symbolised a nautical Arc de Triomphe. Those who passed through them had been victorious in this high-stakes game of chance. As the stream grew, I knew this also meant my time was needed elsewhere and within a minute I was back in the clinic.

There were others to attend to.

Morning

Photo: Guillaume Binet

We eventually finished at 7am. It was breakfast time. My team and I were shattered, up for 24 hours and looking forward to a two-hour power nap before we re-opened the clinic.

Later that day I took a break from the clinic to clear my head. I had just finished dressing a fuel burn which covered the back of a young boy’s lower limb, blisters cruelly extending to his perianal region. Pain relief had been complex. My mind was racing in a sort of caffeine-fuelled, over-fatigued haze that followed the previous night’s events as I sat with Tony, a 21-year-old man from Gambia.

Photo credit: Guillaume Binet

Photo credit: Guillaume Binet

Tony was of moderate build, six foot in height, wearing a black nylon hat, a thin navy tracksuit and white socks we had issued him during registration. He was sat, eyes closed, facing the sun as he leant against a small pillar on the starboard side of the foredeck to shield from the cool northerly wind.

“Why the hell did you get in a boat? Last night of all nights, you could easily have died”

I was still quite emotional from the night before, whether it was the two hours’ sleep or last night’s death on board. I probably should have been more empathetic in the language I used. I asked him if he knew about the 240 people who had died in the same spot less than three days earlier. He said he did.

“So why the hell did you get in a boat? Last night of all nights, you could easily have died.” I was immediately mortified. After what he had been through only hours earlier, he had to heed this insensitive diatribe from me. I apologised.

“Sorry, what I meant was…” and began to ask the question again – this time I hoped, in a more diplomatic tone. I need not have bothered. He interrupted, more through his now stiff body language and eye contact then any verbal response. I expected anger.

Once our eyes connected he brought my attention to his right lower leg, pointing to the bullet wounds (entry and exit) as well as whip marks on his back which he had obtained from his employer who would not pay him.

“I just want a future. My future is not Libya”

“Because the Arab man beat me. We are afraid to go out in the street. If we walk on the street we are seen as gold and treated like slaves. I have been kidnapped twice. They call my family and make them pay ransom. If we do not pay they beat us and kill us. I have seen two friends die – husband and wife. They do not pay us and beat us if we try to run away.”

I was interested to read some weeks later the International Organisation of Migration report which corroborated his account: clearly outlining the forced labour culture that exists in Libya.

I looked at the floor and paused for a minute, momentarily regretting having come out on the overcrowded deck for a break. Taking a deep breath, I said “I’m sorry, I shouldn’t have.” He softened in both tone and body language, looked me in the eye and said “I just want a future. My future is not Libya.”

Thirty hours later I stood at the front of the boat with the police, next to the body of the woman who had died. Drowning in a few centimetres of petrol was the presumed narrative I’d written in my medical report. She was rewrapped in the orange cloth and placed back in the body bag. I requested the corpse was carried through the right-hand side of the ship in a bid to avoid traumatising those gathered to have their asylum claims processed on the left-hand side.

While raising the body high enough to slip through the narrow gangway on the left of the ship, I could see the large crowd of rescued people, NGO and Ministry of the Interior staff pause. Those we had rescued had been queuing for hours. The sideshow I had hoped to avoid now became the main event. There was no way of shielding them from it.

We lowered her into a grey plastic coffin placed on the floor a few meters away. Despite staring at the ground I could see in my peripheral vision people gathered onshore. In particular I noticed an elderly nun, dressed in different shades of navy blue. She was holding rosary beads, blessed herself and appeared to say a prayer under her breath. I smiled – a rare piece of consideration afforded to this woman cut down in her prime.

In port

The following day we moved to a different, more industrial, port city for resupply. That evening I took the opportunity to go for a run. I needed some space. The concrete jungle of this large port complex is in stark contrast to the beauty of Sicily. Running on the road surface which dissected the port felt boring. The man-made 10-foot-by-10-foot octagonal boulders spanning the length of the port jetty, protecting it from sand shifts, provided a nice alternative challenge for me to navigate.

Occasionally I would pass an elderly fisherman, sitting peacefully next to his tackle box and long line anchored between his legs. At the most southerly point I stood next to a large white beacon emitting a green light to direct ship traffic into the port and away from danger. To my right, the bright orange sun was beginning to set on the horizon, through the occasional wispy cloud. The cool breeze was welcome relief.

"Nine boys we rescued 20 days ago with moderate hypothermia would be dead had we found them two hours later"

Thoughts still raced through my mind; it was hard to ignore the fact that it had been a challenging month. Last week we carried 946 people, many seriously unwell and rescued from nine boats, to safety. Our capacity is 400. Twenty days before that incident we rescued nine boys with moderate hypothermia, two hours later they could have been dead. One hour sooner and this woman could have lived….

When my thoughts settled, I started to wonder what the point in me being here is. So far I have been involved in the rescue of over 2,300 people. My team has tried everything to alleviate suffering and give the people we rescue a basic level of dignity which they wish for and deserve.

© Nick Owen\/MSF

© Nick Owen/MSF

Sometimes however, I feel that despite all efforts, life and death in the Mediterranean is something we have little control over. From what I have listened to in my medical clinic, I feel death is determined by a cold, cruel alignment of stars. At one end of this configuration, people escape poverty travelling a perilous journey through the Sahara only to end up in Libyan detention after being sold, arrested or kidnapped.

The beatings and near starvation which result from this imprisonment drive exhausted people to a precarious sea journey in a rubber boat. From what I have witnessed, the search and rescue capability – which in the overall context is hopelessly insufficient – is the major deciding factor in life and death here. It is this cruel alignment of stars that means every day the Mediterranean claims more than 10 people to its depths.

Increasingly we hear about the degradation of human life in Libya. An unrelenting and remarkable human spirit understandably drives increasing numbers away from this abyss. Ultimately this leads to more deaths. The current European intervention to saving lives is failing. We are cotton wool in this crisis when a stiff tourniquet is needed.

Listen to Conor on our Everyday Emergency podcast