University of Virginia School of Nursing
Last winter, Cunningham - an emergency nurse and professor - cared for Rohingya patients in a the world's largest refugee camp in Myanmar. His essay VICIOUS won Intima's top prize for 2018.

The essay below - by Compassionate Care Initiative director and assistant professor of nursing Tim Cunningham - earned Intima Journal's top prize in its 2018 Compassion in Healthcare essay contest, done in partnership with the Schwartz Center for Compassion in Healthcare.


Abdul’s belly was swollen like the rice fields. It didn’t take much rain to saturate them, the swaths of troughs and ridges, muddy dams and canals near our clinic. Hundreds and thousands of pounds of rice they produced. The growth endless, always water, always mud.  Runoff lubricated the road that bifurcated the camp where we worked. From the deforested hills above where a reported 800,000 Rohingyas live, torrents of water and mud carved new paths towards the fields.  Angiogenesis in the morning. Nourishment at night.  There the water had a place to run. Abdul’s belly, however, was a vault. A monsoon was in his liver—hepatitis, some malignancy. Days prior, the hospital an hour away sent us a report from their lab that his liver enzymes were elevated.  We figured that on physical exam. But why? No further tests we could do, no curative treatment to offer. Palliation was obsolete.

When he was thirteen he started to lose weight. Now seventeen, he was negative space. Bones hung flesh wherein muscle once thrived. Like most of his family—while they lived in Myanmar—he had no access to school or healthcare, but he could work the fields. Though described by many as non-literate because he had no official access to school, he could read the Quran with ease. His recitation of its Surahs was exquisite.

Nawshad kept calm and held Abdul’s hand while I stretched the tired tourniquet. Abdul yelled, “Vicious!” as the 20-gauge needle ripped open his forearm to find a home in a thirsty vein.

Tim Cunningham, assistant professor of nursing, in "Vicious," his award-winning Intima essay

On the darkest night of his life in August 2017, Abdul and his brother fled across foreign rice fields, westward. They were backlit by burning villages and the pierced grief of raped mothers and children-in-slaughter. Their family found a home near Hakimpara Camp, Bangladesh.

The morning I met Abdul, his brother had carried him to our clinic hours before it opened. He lay there, cold, on a bamboo bed.  Because we had no linens, his friends gave him pieces of clothing to use as sheets. Abdul’s abdomen was discordant and quaked a chaotic pace, beats behind his bones.  It was a bowl of water furious to settle while prisoner to the corporeal agitation of disease.  His genocide had shifted internally, an annihilation of his once-healthy cells.

Abdul spoke limited English and we, no Rohingya. We relied on our interpreter, Nawshad. When asked about pain Abdul said, “Everywhere.” When asked about his family, he smiled, “They are well.”  When asked about his home, his response was gratitude.  He lived with his family in a box of bamboo—poles and thin crosspieces upon which an orange tarpaulin was strewn.

“Now we are safe,” said Abdul.

Outside of Abdul’s examination room, I heard the rumble of 120 patients.  Many coughed in the morning air.  Smoke from tents littered cloudless skies. Cook fires in the tents suggested nourishment was available; they also caused chronic cough. Smoke from the fires brought entire families to us suffering respiratory distress. Gentle, yet toxic billows from the tents were the new normal.

Abdul told us he had lost his appetite three days ago. He said he did not miss dahl and rice, mangos and bananas, though he knew that he should. He had not drunk for a day. I unwrapped an IV cannula and Abdul jumped. It was that quiver we see in our chronically ill patients who, for their entire lives, are stuck with needles. Those patients who we assume won’t mind just another shot. But they are the ones who feel the pain the worst as they catastrophize over another stick, their tolerance for that pain significantly diminished. It was as if Abdul, though new to receiving medical care, was an haruspex—a diviner who examines proceedings from animals’ digestive processes—who knew that his own gastrointestinal system would invite the onslaught of frequent injections for the rest of his life. He foresaw years of clinically induced pain.  He winced when I cleaned his arm with alcohol.

Abdul’s fear-cracked groan shook the bed and his left hand made a fist as I sought a vein. The needle was in a void; there was no flash of blood in the cannula’s chamber.  Pause. Let the vessel de-constrict. Let him relax.  Let me relax. Nothing. I moved the needle; Abdul wailed.  Nawshad whispered into my ear, “No blood.” Abdul’s eyes irrigated the borrowed t-shirt that he used for a pillow.  I told him that I would try again. He whimpered, but nodded with soft affirmation. Second stick. Nothing. Abdul arched his back off the mat.

He looked at me and sniffled, “Vicious.”

Saliva stretched from the bottom of his paan-stained teeth to his splintered lower lip.  It was mucilaginous from dehydration but aqueous enough to break and bespatter my face when he, a second time, uttered, “Vicious.” A third and fourth time with swollen vehemence, “Vicious, vicious!”  I set up for another IV. All the while, I imagined places to which we could transfer Abdul that he might receive appropriate care. They would have diagnostics for his hepatomegaly and cachexia. They would have 24-hour staff, teams of nurses and physicians to treat and listen his life-story. The providers would all speak Rohingya. These thoughts were but daydreams. For extraordinary diseases, with extraordinary measures and extraordinary means, there are ways to treat illness.  If you are Rohingya, there is nothing.

An interpreter barged into the room, “Three diphtherias here.”   

We had a makeshift holding unit a few meters away from our waiting area where we sent any patient with symptoms of diphtheria. Diphtheria had followed the trajectory of forced migration across the Naf River, so too, did measles. We waited patiently for cholera.  The diphtheria patients could wait. We needed to get this line started first.

Nawshad kept calm and held Abdul’s hand while I stretched the tired tourniquet. Abdul yelled, “Vicious!” as the 20-gauge needle ripped open his forearm to find a home in a thirsty vein.

“We’re done,” I said and secured the line. I put my hand on Abdul’s shoulder, “I’m sorry I hurt you.”

Nawshad leaned in behind me and said, “He’s fine.”

Abdul whispered, “Vicious.”  

In the waiting area outside of Abdul’s room I heard a shuffle of bare feet.  In haste, a mother kicked off her slippers and rushed towards registration.  She held a three-month-old in her arms. Her arms, the child’s arms, face and head were coated in soot. Her child’s eyes were wide.  With each breath his head tilted backwards. Accessory muscles in the neck teetered his head to pull oxygen into the lungs too congested to breath normally. The mother stood with her anxious child, she said nothing. She knew the breathing was not right. I grabbed bulb suction.

Saline in the nose to loosen the secretions and then the bulb.  Push farther than you think, when the child winces, pull back on your thumb. The child held his breath at this new sensation. His eyes closed tightly, pressure-sealed tombs; they repelled me. His lip quivered.  An open mouth betrayed an imminent cry. No sound though.  Copious, thick sputum was wrenched from his nose. The sound of a ripped paper bag precluded his announcement that he could breath once again. He howled. His mother exhaled. She then laughed a sigh of relief. We taught her how to use the bulb and what symptoms to watch for in the future to suction him at home. I told her that she could handle this. My interpreter said, “Yes, she can.”

Two liters of fluid in, and Abdul looked less pale.  His heart rate had decreased from 150 to 120. Slower was better but not good enough. We called to transfer him to another clinic that could rehydrate him overnight.

The afternoon light shifted the sky. Winter’s golden-red skies gave us two more hours to work. If we stayed in the camp after sunset the military would arrest us. A translucent, brown sheen wretched upwards from the now dry roads. Overloaded lorries, full of bamboo for new non-permanent homes choked the thoroughfare.  The bamboo would be used up by tomorrow.  New tents for a thousand more refugees.

We called for an ambulance, rather a van with a gurney. It had a rusted oxygen tank tied to the back of the driver’s seat with twine.  The mask attached to the tank was clouded with memories of dying breaths. Abdul said he could walk the few paces from the clinic to the ambulance.  He took five on his own and then he leaned heavily on his brother and me. The entirety of his bones and youth was in our hands for the last step as we lifted him onto the stained gurney. I put my hand on Abdul’s hand.  He laid his hand across his abdomen.

One last time he said, “Vicious.”

Nawshad closed the door to the ambulance.

“He really liked you,” said Nawshad with careless confidence. “All day long he sent you wishes."


Tim Cunningham is an emergency nurse, clown with the non-profit “Clowns without Borders,” and an assistant professor at the University of Virginia, where he also serves as the director of the Compassionate Care Initiative. Last winter, Cunningham spent three weeks working with Rohingya refugees who had survived the genocide in Myanmar and who are now living in the world’s largest refugee camp, in Bangladesh.

His essay “Vicious” was chosen as the top essay in the Intima’s 2018 Compassion in Healthcare Essay Contest in partnership with the Schwartz Center for Compassionate Healthcare, judged by Haider Warraich, MD, author of Modern Death: How Medicine Changed the End of Life.