From the Sheraton to raw onions

Time here seems to be moving so fast and somehow it has been a few months since I last wrote anything.  A wise friend commented recently about how quickly you can adapt to any setting and the totally abnormal can become a new normal.  As I have settled in here, events that in most other places would be highly unusual and disturbing simply form the back drop to “ordinary” life.  As things seemed more commonplace, so the impetus to write about them seemed to have diminished for a while.

However, coming back from a holiday and being thrown into the biggest spike of malaria and malnutrition cases ever seen in Aweil has reminded me that the reality here for ordinary people is far from “normal” as we would see it.  As the fragile peace process in the country flounders, the situation for the average family becomes unimaginably tougher week by week.  Fighting in the capital Juba last month and elsewhere in the country has resulted in thousands of people being displaced from their homes and living in the bush or in UN protected sites. South Sudan currently has the highest level of inflation in the world and prices for the little amount of food there is in the market are unaffordable to many.

Having a holiday and a break from the field, gave me some time away from the day to day immediacy of these issues and allowed for some reflection.  I was lucky enough that my first break coincided with an Australian nurse who also works here and so we went to Ethiopia together.

First stop on any trip out of here is a flight from Aweil to Juba.  The small UN World Food Programme plane is often delayed, but was even more so on this occasion. The head of the army was also flying out of Aweil, with a distinct lack of military-precision time-keeping. His helicopter was waiting at the airstrip as we arrived but evidently he was not.  Over an hour later, scores of military trucks laden with armed young men sped up to the airstrip.  Then some time later, a second convoy with an armoured car and the army chief had arrived.   A large military presence always make for an uneasy time in a country where tensions remain high and violence can flare quickly, but the helicopter left without incident and the many trucks of armed men sped away from the airstrip as quickly as they had arrived.

The refreshment/ duty free options at Aweil airstrip are limited, but we did manage to get a cup of hibiscus tea to drink whilst sitting doing crossword puzzles and waiting for all the commotion to die down.    Our plane arrived around 5 hours late and we were off on holiday.

We spent an evening in Juba, catching up with some friends working elsewhere in the country who were also passing through, over passable gin cocktails and almost pizzas.   Then a trip back to the utter chaos of Juba airport in the morning.  A new attempt at a queuing system quickly descended into a farce and it was elbows out and push again.  Who knew that many hours spent trying to get nearer to the front of tightly packed crowds at Glastonbury would come in so useful? An added twist to the general discomfort was the addition of gastroenteritis in an airport with only one terrible toilet.  No lock, no light, no water, no paper. Fabulous.

Flying into Addis Ababa was like arriving in a different would. Compared to Juba, it is an incredibly developed city. A short trip to our hotel and we had arrived in luxury.  Never have I been so excited to have a duvet, an on-suite flush toilet and warm shower!  As a result of tiredness and illness our first Ethiopian meal consisted of chips and a cup of tea. A rock-and-roll evening watching BBC news 24 in bed followed.  This all proved to be the perfect medicine and we were both feeling much better and ready to explore the next day.

A visit to a friend who works in the British Embassy provided a glance at how the other half live.  The embassy compound is extremely luxurious, with beautiful gardens, tennis courts, a golf course, stables and a club house with a swimming pool.   A swim in the pool was extremely welcome.  Unfortunately, I did not run into James Bond as had been the hope of my colleagues in Aweil.

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Rock church in Lalibela

After Addis, we visited several other parts of the country. In Lalibela, there are stunning churches carved into the rock face plus a surprisingly excellent Ethiopian-Scottish fusion restaurant. The biggest highlight was walking for 3 days and camping in the Simian Mountains National Park. With very limited options to walk around in Aweil, to be out in the fresh air and surround by space and beautiful scenery was wonderful.   A traditional coffee ceremony in a hut in a small mountain village finished off a great three days.

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Gelada monkey in the Simian Mountains National Park

Back in Addis for one more day on our way out meant we just had time to stock up on all of the essential to take back to the field (Pringles, jelly, chocolate, shampoo).  Then one final holiday treat with breakfast and a swim at the Sheraton Hotel.  Words cannot do justice to how incredible the breakfast buffet was – an eye watering array of food from around the world including a waffle station, omelette station, juice station, Ethiopian, Asian, Middle Eastern, European food, pastries, cold meats, fruits, yoghuts etc etc.

Three hours and 7 courses later we finally left.   An incredible and indulgent morning, but as we headed back to the airport, the irony was hard to ignore.   This breakfast was far more food than the average family will have to eat for a week back in South Sudan.

Even going away for a short time meant that I saw a difference in poverty levels when I returned. The hair of malnourished children can take on an unusual orange tinge and the prevalence of this in the town has been far more noticeable.  Prices of basic food items have more than quadrupled in the same time.   Walking through the market this week, I saw a street boy steal an onion from a wheel barrow and eat it raw, straight away like an apple.  None of this is normal.

And the mosquitos are here. Very much so. We are seeing an unprecedented rise in the number of admissions to our hospital with severe malaria.  The reasons we are working here have never been clearer.  However busy we are, there is an immense amount of job satisfaction and so much still to learn and to do.

But for now a poker night awaits ……

south sudan

 

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From the Sheraton to raw onions

The Cost of Care and Hawks who like Pus

As predicted, being the doctor for the paediatric intensive care unit (ICU) and the neonates (babies under 1 months old) has made for a challenging few weeks.  Looking after premature babies weighing little over a kilogram is not something I ever expected to be doing that is for sure!

Working in these wards means I get to be involved in the care of the most unwell and complex patients in the hospital.  This is challenging and stimulating but can be emotionally draining at times.  Particularly in ICU, where all of the sickest children end up and therefore where almost all of the deaths in the hospital occur.   I try and remind myself that the vast majority of the patients we treat get better and leave the hospital, but this can be difficult on some days where all you seem to see is children dying.   Despite this, I remain overall very positive in my work and surrounded by an amazing team of people who all support each other.

The extreme poverty of many of our patients is starkly evident – when one of the experienced expat midwives who has done many missions for MSF all over the world says she has never seen poverty like this it really makes you think.

Each patient who is admitted here comes with a caregiver. A caregiver is a relative of the patient (usually but not always the mother) who stays in hospital with them and performs many of the roles that a nurse or nurse assistant would provide in the UK or elsewhere.  They provide all personal care for the child, collect food and feed the child and even care for and give milk down nasogastric tubes – a tube inserted through the nose into the stomach to allow feeding for children who are unconscious, too weak to feed or in the case of premature babies not yet able to suck or swallow to breast feed.   This would be the role of a trained nurse in the UK, but there are simply not enough nurses and too many unwell patients here, so the parents end up being highly involved in the medical care of their children.

MSF gives each patient/ caregiver a mosquito net, a blanket and half a bar of soap when they are admitted.  I had not given a second thought to these items, until a child had to be moved suddenly from the admission ward to ICU as their condition deteriorated.  The caregiver seemed to trust us to look after the child but was extremely concerned that her bar of soap was not lost in the move, highlighting how very few possessions people here have and how a small bar of soap is precious, even when a child is critically ill.

Another sobering example of poverty and its impact on healthcare is the cost of transport.  While we provide all treatment free of charge, we do not provide transport/ cover transport costs, except in the case of referral to other facilities.  Earlier this week, we were looking after a child who was extremely malnourished and very weak with severe dehydration from diarrhoea.  As is typical here, they presented to the hospital very late in the disease process and in a critical condition, potentially at least partly due to the cost and difficulty of reaching the hospital. Severe dehydration in acute malnutrition is a very difficult situation to try and treat.  It is important to give enough fluid to the child to replace the losses from diarrhoea, but due to the malnutrition giving too much fluid can overload the heart very quickly and cause it to stop.  We were dealing with this difficult balancing act and were unsure if the child would survive, given the severity of the dehydration and the advanced state of malnutrition (at aged six the child weighed under 7 kilograms – the weight of an average  3 month old in the UK).

We managed to stabilise the child during the day but they remained severely unwell.  When I came in the next morning, the child was not there and I asked the medical assistant (MA) from the night what had happened, assuming the child had died.  He informed me that the father had taken the child home against medical advice very early that morning. I was very puzzled by this, as I could not understand why you would go to the great trouble of bringing the child the long distance to the hospital and then not wait to see if the treatment work.  The MA patiently explained to me that the father had decided the child would probably not survive even with medical care (he may well have been right) and needed to take the child home before they died in hospital.  Apparently, it costs much more to take a dead body on public transport than a live person, however critically sick, so the father was trying to ensure he did not have to pay to transport a dead body.  This was a very sobering reminder of just one of the truly incomprehensible and intolerable decisions parents face in this country.

The next day, a child with severe pneumonia and malnutrition died in ICU, despite all the attempts of the staff to resuscitate the child. I explained to the mother via a translator that the child’s heart had stopped and we were unable to restart it.  I asked if she had any questions, expecting medical related ones, why had this happened, was there nothing more we could do etc.  Instead, again the harsh reality of life here was made apparent to me.  With no time to grieve, the mother was already trying to deal with the practical, rather than emotional, aspects of a dead child.  She asked if we were able to help her with transport home, as it was a two day walk and she was here alone.  I apologised profusely and haltingly tried to explain that we were unable to help with transport costs.  I offered her my phone to use if she needed to phone anyone to come and help her.  The translator explained to me that no one in her village owned a phone so my offer was useless.  The mother stoically picked up her child and said she would walk then and sleep overnight on the road.  At a loss of what else to do we filled up a water bottle for her and gave her some food for the journey.   This seemed like such an underwhelming gesture in the face of her suffering.

Despite these episodes, I have been reminded on numerous occasions this week of how lucky I am to be working for MSF and thus able to at least give free health care to people once they arrive at the hospital.  Reading blogs from friends working in other hospitals in Africa and around the world, I am struck by the added level of difficulty and emotional torment they face in situations where patients must pay for their healthcare and so decisions on which medicines to use and tests to conduct are not only clinical but financial.

To highlight this, for the last 5 days, I have been treating a patient with Visceral Leishmaniasis (also known as Kala-Azar).  This life-threatening disease is common in parts of Sudan, South Sudan and the Indian Subcontinent but is rarely seen elsewhere. Left untreated it is almost always fatal.  It is a protozoan parasitical disease spread by sand fly bites.   As the parasites build up in the body, they can affect almost every organ system, causing devastating systemic illness.  Parasites in the bone marrow prevent blood cells developing, leading to severe anaemia, lack of platelets and therefore inability of blood to clot properly, and a lack of infection-fighting white cells.  With no white cells and also with a massively enlarged spleen, patients become immunosuppressed so are also at risk of other infections such as pneumonia and tuberculosis.   Parasites in the liver can lead to liver enlargement and jaundice.

It is fascinating to be putting the theory learnt about this condition from my tropical medicine diploma into practice (although I must confess I cannot remember the lifecycle that a few months ago I could draw out from memory.) The patient I am treating is a 2 year old child with a severe form of the disease, causing massive liver and spleen enlargement, jaundice and weakness.

Most of the treatments for Kala-Azar are very old fashioned and have toxic side effects.  Because only a few, resource-poor countries are affected by the condition, there has been no financial incentive for drug companies to develop more effective and less harmful treatments.  However, there is one treatment called Liposomal Amphotericin B, that while still having serious side effects, is far less toxic and more effective that the other options. Of course this means it is also considerably more expensive.  I feel very lucky that we are able to give this treatment to the patient and give her the best possible chance of a cure, based purely on clinical need, not whether the family can afford the treatment.  In this case the treatment will cost several hundred dollars and this would be far, far beyond the means of almost all of our patients.

As I have said, the vast majority of patients that we treat get better and go home and it is always extremely rewarding to see a very sick child get better.  When I first arrived, one of the other doctors was treating a child with pulmonary tuberculosis and severe complicated pneumonia on top of this.  His infection was so severe that he developed something called an empyema, which is essentially a lung full of pus.  In this case, not only did he have a lung full of pus, as well as the tuberculosis, part of his lung had also collapsed meaning there was air in the wrong place in his chest. It is not possible to treat this type of infection/ lung collapse with antibiotics only, it is essential to let the pus and air out and allow the lung to re-expand.  If this sort of complex pathology was seen in the UK, the child would be treated in an extremely specialist thoracic surgery centre. Here they get us.

As the person with the most experience in inserting chest drains (a tube into the chest cavity to let the pus and air drain out) due to my time in South Africa, it fell to me to try and correctly drain the air and pus.  Despite being the “most experienced” I had never placed a chest drain in a child and was a little nervous about the size difference.  Although mostly a straightforward procedure, occasionally they can go very wrong and end up causing damage to vital organs or catastrophic bleeding. And this child was very unwell and emaciated from the tuberculosis.  Luckily, the procedure went reasonably smoothly, with the only major complication being my failure to predict how explosively the pus and air would be expelled once the drain was inserted and therefore covering a considerable part of the operating theatre in foul smelling pus, much to the disgust of all concerned.

An added, unpredictable complication occurred when we were transferring the child from the operating theatre to the isolation ward.  One of the prevalent large South Sudanese “hawks” (I think they are actually kites) swooped down and tried to pick up the chest drain tubing. Whilst we have become used to having to shield our food from these bold scavengers when eating outside, one having a taste for plastic and pus had not crossed my mind!

With copious amounts of pus and air draining from his chest, high fevers and an ongoing cough producing large amounts of foul smelling sputum, the child spent several weeks in a critical condition.  Given the state of emaciation he was in to begin with and the seriousness of his illness, we all felt that he was unlikely to survive.  However, against all the odds, he began to improve.  The pus stopped draining, the fever and cough settled and he started to sit up and ask for food.  He was discharged from intensive care last week.  This week he has been up, smiling, playing and putting on weight.  Yesterday we were able to discharge him from hospital to complete his TB treatment at home.  He was here so long, we all spent time looking after him and it felt like a real team win for him to walk out of the hospital.

Social activities also continue, giving a welcome respite from work, with a party last night to celebrate several birthdays at the base – Team Taurus.   Many hours spent juicing fruit and trying to keep drinks relatively cool proved successful and a range of cocktails were on offer as a welcome change from Tusker.   As well as strong birthday trousers.

birthday

Now, as the temperature rises above 40 for the rest of the afternoon, I am going to spend some time in the luxurious swimming pool here at Aweil Paradise.

swimming pool

{Disclaimer: This is not an official MSF blog and the views expressed do not necessarily represent MSF.}

The Cost of Care and Hawks who like Pus

Measles and Dust

It has been a busy and dusty few weeks here in Aweil.

We officially have a measles epidemic in the town and surrounding area.  We started seeing suspected measles cases turning up the hospital several weeks ago, with the numbers being large enough to cause concern.  Samples sent to the WHO (World Health Organisation) reference lab confirmed multiple cases of measles and we have been working hard to try and contain the problem.

Measles is a viral illness that is entirely preventable by vaccination and so is rarely seen now in higher income countries.  However, the vaccination coverage is very poor in South Sudan (and many other low income countries) and so this, and other vaccine preventable diseases, are seen much more frequently.  Measles is highly contagious, with 90% of susceptible (i.e. un-vaccinated) people becoming infected if they are in contact with the disease.  It can be a self-limiting and benign illness for some but can have serious and life-threatening complications in others, particularly in those under 5 and those who are malnourished – meaning a large number of the population here.

We have set up a measles isolation ward in the hospital for children with complicated measles- for example if they have measles plus severe malnutrition, pneumonia or encephalitis (a potentially fatal inflammation of the brain).  We also have a separate isolation centre to send children with uncomplicated measles, in an effort to contain the disease and stop it spreading rapidly amongst families.

MSF responded very quickly to the epidemic and we completed a mass vaccination campaign a fortnight ago.  To put things into context, it normally takes 2 weeks minimum to organise a mass vaccination campaign.  Ours was organised in 3 days, such is the potential seriousness of a spreading epidemic here, with so many malnourished, un-vaccinated and vulnerable young children.

Experienced staff flew in from the co-ordination team in Juba to help with the planning and implementation of the campaign.  Planning included drawing maps of the town areas (strongly resembling the incomprehensible maps from the public health section of out Diploma in Tropical Medicine) and identifying which locations to set up vaccination posts, in order to maximise the vaccine coverage.  [Diploma friends may be interested to know that the statistics for working out vaccine coverage were not done using LQAS – other methods do exist!]

Once sites had been identified, then a representative from MSF went to meet the chief of that area, to ask for permission to conduct the vaccination and ensure they would help publicise and encourage people to come and be vaccinated.  This stage is essential to a successful campaign – without the approval of the area chief few people would attend.

Other stages involved in the planning of a campaign include identifying and training local staff to act as vaccinators, recorders and social mobilisers.  Ensuring the supply routes for all vaccines and equipment is also a massive logistical challenge. The vaccines have to be kept cool at all times, so in >40oC heat the maintenance of the “cold chain” (i.e. ensuring the vaccines are either in a fridge or a specialised cool box for a limited amount of time) is essential and complex.

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Social Mobilising – publicising a vaccination campaign by megaphone. In a society where many people do not read or write, word of mouth is crucial.

Luckily, the people leading things were highly experienced and so got things moving very rapidly. It turns out however, that there is a reason it normally takes longer than three days to organise such a large campaign, with people working 18 plus hours a day during both the planning and implementing phases and all of us needing to pitch in and help out.

So, I spent my “day off” supervising two vaccination sites in the town.  Setting up a site involves arriving at the re-arranged location in the morning and asking to meet the chief again to confirm that all is still well and the day can proceed.  Next on the agenda is acquiring tables and chairs to set up the site – apparently this is the norm rather than bringing your own with you! After a range of slightly wonky plastic chairs and a small table had been brought from one of the houses, then the site was set up, with orange netting to contain things and try and maintain the flow of children.  This ran smoothly at one site. However at the second, after setting things up, the chief decided that he would prefer the vaccine site to be in a different location (for reasons I will never understand!) and so we had to pack up and start again.  Despite this false start, both sites ran well throughout the day, with hundreds of children arriving to be vaccinated.

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Setting off from the hospital first thing in the morning to get to the vaccination sites. Large numbers of staff are required for a mass vaccination campaign.

The aim of this campaign was to vaccinate as many children as possible between 6 months and 5 years (the most vulnerable group to the disease).  After setting up the site, social mobilisers (local people with megaphones) would go out into the village and publicise the campaign and encourage people to bring their children to be vaccinated.  At each vaccination station, children are registered and given a vaccination card.  Vaccinators work in teams, with one person preparing the vaccine and the other injecting it, to ensure things move along rapidly.  Children are then screened for malnutrition (using a special measuring bracelet that measures the diameter of their upper arms) to try and provide us with an overview of the levels of malnutrition in the town.

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Vaccination station under mango trees

After three extremely busy days, we are optimistic that the campaign will have been a success.  Over 18,000 children were vaccinated and this hopefully represents around 90% of the target population.  This estimate is unfortunately impossible to verify as background population statistics are non-existent or hugely out of date.

A party was arranged at our “local” – the grandly named Africana Style Palace – to thank all of the staff for their hard work during the campaign.  The bar consists of an outdoor space with a few tables and chairs ringed by a rattan fence, as well as a speaker that has seen better days (and better music choices!).  Whilst not actually having its own beer to serve, the enterprising owner is happy to send someone on a motorbike to obtain (very warm) Tusker from somewhere. Despite this, at least here we are able to socialise with our national staff and try to integrate a little outside of work.  We had a great night with lots of dancing despite the heat and everyone was a lot sweatier but happier at the end.

After all of this crazy work, a dust cloud decided to settle over Aweil for a week.  This left the air tasting like sand and the world looking like a sepia picture.  No planes were able to land at the airport, so all of the extra staff from Juba were stuck here, as were three people due to go on leave and one person due to go home at the end of their mission.  This left a very crowded and pretty fed up team of people for a while.   Luckily, things have now cleared up, planes are flying again and the normal level of hot and dusty service is resumed.

One of the doctors who eventually managed to go on her leave once the dust disappeared was the only actual paediatrician left here, the other having completed her mission several weeks ago, with no replacement having yet arrived.   So somehow, I have now become the neonatal (babies under 1 month) and paediatric intensive care doctor for the next few weeks!  The learning curve just got a fair bit steeper…….

{This is not an official MSF blog and the views expressed do not necessarily represent MSF}

Measles and Dust

Hospital Life

{This is not an official MSF blog and the views expressed do not necessarily represent MSF}

Week 3 has come and gone here in hot and dusty Aweil Paradise (44oC this week).  I am slowly getting to grips with the hospital set up and as I spend at least 6 days a week here I will try to give you a bit of a picture of life in the hospital.

Aweil main street

{One of the main roads in Aweil Town and the road from our compound to the hospital. Don’t be fooled by power cables – there has been no mains electricity in South Sudan since independence and all power comes from expensive and noisy generators.}

The hospital – Aweil Civil Hospital – is run by Medicines Sans Frontiers in conjunction with the South Sudan Ministry of Health. It serves around 1.2 million patients in Northern Bahr el Ghazal, the poorest state in one of the world’s poorest countries.  The Ministry of Health look after outpatients and adult in-patients.    MSF are in charge of paediatric in-patients and all obstetric care, as children and pregnant women are the most vulnerable sections of society in health terms so this is where MSF concentrate their resources. South Sudan currently has the highest rate of maternal mortality in the world and is 13th worst for Under-5 mortality.  With over 50% of the population thought to be living officially below the poverty line and with huge difficulties accessing healthcare, the need for affordable and good quality health care provision is very plain to see on a daily basis.

For paediatrics, there are 4 expat doctors here, supporting and training South Sudanese Medical Assistants (MAs).  The MAs have 2-3 years of training (compared to 5-6 years of university followed by 2 years of internship/foundation training for UK doctors) and carry out much of the work that a junior doctor would do in the UK.  They are generally very good at managing the things they see every day, such as malaria and malnutrition, but are less confident in more complex or unusual cases, as they simply have not had the level of training.   They are very keen to learn more and improve their skills, so it is very rewarding working with them.

For obstetrics, there is one expat obstetrician/gynaecologist and two expat midwifes, again supporting national MAs and midwives.  The obstetrician is on call for emergencies 24 hours a day, 7 days a week the entire time they are here, so they only undertake short missions of 5-6 weeks, whereas the paediatric doctors are all here for 6-9 months.  We work 6 days a week from 8.30 – until 6pm ish.  In addition, one of us is on call overnight for all of the wards, usually around twice a week. Luckily, the MAs are able to manage most things so we don’t get called in that often.

Paediatric patients are first seen in a triage area.  Any patients who are life-threateningly unwell get taken straight to intensive care.  The remainder are admitted to the admission ward IPD1 (In-Patient Department 1).   Despite being relatively simple to implement and proven to be life-saving, it is unusual to see a working triage system in many low resource settings and so it is a testament to the training, education and resources that MSF bring to the project that the system here works surprisingly well.

The “intensive care” ward has 10 beds.  Intensive care here means there is oxygen and slightly more nurses. It is certainly nothing like intensive care at home and we have no facilities to ventilate patients or give any complex circulatory support. Next to intensive care is the neonatal ward, caring for those under one month old, often born prematurely or suffering from infections and other complications.

I am mainly based in the admissions area (a corridor) and IPD1. IPD1 is a 40 bed ward (plus as many extra patients on mats in the corridor as needed).  Luckily, as it is a permanent brick structure, it is slightly cooler then the sweltering ward tents at the back of the hospital. It is a very fast paced, with lots of new admissions and discharges throughout the day and night.  There are a wide range of conditions, which makes for very interesting days – and a lot of reading and asking specialist friends for help in the evenings!   Severe, complicated malaria accounts for a significant part of the admissions, despite the fact is in not even peak malaria season yet.  There are also a wide range of unusual (at least to me!) tropical diseases, dehydration due to diarrhoea, trauma and surgical cases, severe acute malnutrition plus the usual range of conditions such as diabetes, asthma etc that you would see in the UK.

IPD1{Part of IPD1, the admissions ward where I am based}

At the back of the hospital are a selection of semi-permanent tent structures housing the rest of the patients.  IPD2 has children who are stable or have chronic conditions and are going to be in hospital for a prolonged period of time – for example those patients needing prolonged intravenous antibiotics for meningitis or collections of pus in the lungs or muscles.   Sadly, there are also a large number of diabetic patients with very difficult to control disease who end up spending a long time in here. The lack of education and home blood sugar testing equipment means we are only able to use very old fashioned types of insulin.  This, combined with food insecurity and erratic meals, means that these patients have blood sugars ranging from dangerously high to life threateningly low, sometimes both in the same day, and getting this under control is extremely difficult.  Having any form of chronic disease here is a pretty serious issue and diabetes seems particularly problematic.  Despite our best efforts, the long term prognosis for these children is really not good.

IPD 3 houses the “surgical” patients.  There is no MSF surgeon here, so our surgical patients mainly comprise burns patients having dressings (extensive burns are common in an environment where cooking is carried out in the open and children are often nearby boiling water), abscesses and orthopaedic patients.  It is mango season currently and we are seeing lots of children falling out of trees having tried to get at the fruit.  Some suffer fractures, which we do our best to set back in line and put in casts, but others are less lucky still and suffer severe head injuries. There is no neurosurgery anywhere in South Sudan so there is little we can do in these cases except keep the child comfortable.    For any patients requiring abdominal or complex orthopaedic surgery, we have to transfer them to the nearest available surgeon, a two hour plus car journey away to a town called Wau.  Unfortunately there have been tensions on the road and reports of sporadic check points being set up and we are not always able to transfer patients if there are security concerns.

Next to IPD3 is the In-patient Therapeutic Feeding Centre (ITFC).  This swelteringly hot tent houses children admitted with Severe Acute Malnutrition (SAM). Another acronym to get used to – at first I thought Sam was just an unusually popular name in South Sudan! Food insecurity is a huge problem here and the rates of malnutrition appear to be increasing. The “hunger gap” – time between harvests – has not even hit yet and this tent is full and spilling out into other wards.   We only admit those patients who are severely malnourished and also have another complication (for example diarrhoea or pneumonia) or are so malnourished that they do not even have the energy or appetite to eat. The remainder are discharged with “ready to eat therapeutic foods” – essentially a fancy, nutritionally-balanced type of peanut butter paste – and followed up in out-patient feeding centres.  This cheap and easy treatment is literally life-saving to the hundreds and thousands of children who receive it every day.

There are two further large tents that we can open in peak malaria season (which I am reliably informed will increase our workload exponentially) or if large scale famine hits (which is a huge and realistic concern).  We also have two isolation areas, one currently housing patients with pertussis (whooping cough) and the next a number of patients with complicated measles.  We have seen a worrying number of potential measles cases over the last few days and are waiting on blood results being processed by the WHO (World Health Organisation) to confirm if we are entering an epidemic.  Measles is particularly dangerous in children under 5 and especially malnourished children, so an epidemic would be devastating here and would require a huge mobilisation of resources to try and contain it.

But it isn’t all work. We manage group yoga twice a week and volley ball on Sundays.  This week we had an “Africana” night in the compound on Saturday, with all of us dressing in our best African clothes (our tailor in the market did a good trade in new clothes in the preceding week).  Food included Ugali, pepper soup, goat stew and a combination of other African staples cooked by our ex-pats from Kenya, Congo and Nigeria.  All washed down with copious amounts of luke-warm Tusker and accompanied by the ubiquitous top 6 Nigerian songs on repeat.  Until next time all together now – Chop my money – I don’t care, I don’t care.

Hospital Life

Aweil Paradise

{Disclaimer: This is not an official MSF blog and the views expressed do not necessarily represent MSF}

From Juba to Aweil

Hello from Aweil Paradise!

I have been in Aweil for a week now and this is my first day off and chance to write down my first impressions of South Sudan.

Landing in Juba [the capital of South Sudan] airport is an eye opening introduction to the state the country is in.  The airport is only open 5 days a week and has at most one international flight a day.  The rest of the activity is made up of humanitarian and non-governmental organisation (NGO) flights to various parts of the country.  There are hardly any tarmacked roads outside of the capital and no long stretches linking any settlements, so travelling by plane or helicopter is really the only way to transport goods and people over long distances.  So instead of an airport with the usual rows of planes from international companies, there are rows of small planes and helicopters belonging to the UN Humanitarian Air Services (UN HAS), World Food Programme (WFP), Medicins Sans Frontieres (MSF), International Committee of the Red Cross (ICRC) and a whole host of other acronyms and organisations.  It turns out the humanitarian work is second only to medicine for the number of new acronyms to learn!

After landing came a pretty disorganised immigration hall with a variety of different lines and seemingly no real queuing system. After getting to the front of the wrong line and having to start again in a different queue, I made it to the correct person.  I presented my MSF ID, passport, letter of introduction and entry permit along with a $100 bill, clean and unfolded, dated later than 2006, as carefully instructed by MSF in Paris, to buy my visa.  Despite taking all of the advised precautions to keep this $100 pristine (apparently problems with counterfeit dollars mean they are very strict with what they accept), a small pen squiggle on one side meant they categorically would not accept it whatever my protestations.  And would not accept $100 in smaller notes. And would not let me leave the immigration hall until I had bought this visa.  And my UK phone did not work to try and call anyone from MSF. Luckily, a very helpful women working for Save the Children was able to swap some of my smaller dollars for a new and acceptable shiny $100 bill, so about an hour after landing I was officially free to go and pick up my bags from the jumbled heap on the floor (no baggage belts here).   Welcome to South Sudan and a classic example of African bureaucracy at its finest!

Luckily the MSF driver was waiting to pick me up and didn’t seem at all surprised by the length of time it had taken me to get sorted.  We drove from the airport to the MSF compound in the centre of the city. A 20 minute drive, mainly on dirt roads full of ruts and holes, so even in the capital tarmac is a rare luxury.   Then time for more briefings – about security rules, an orientation to South Sudan and more detailed medical guidelines.  I met one of the logisticians from Aweil who was passing through Juba on his way back from his holiday.  He persuaded several of us to go out for lunch to a cafe that had ice cream.   The length of time lunch took and the rules meaning you are not allowed to walk anywhere alone meant I was late back for my afternoon meeting – unfortunately with the Head of Mission for the whole of South Sudan – however it was definitely worth it for the last ice cream I am likely to have for several months!

Next day up at 6 to get to go back to the airport.   However chaotic it was landing, checking in was ten times worse.  There was a big mass of people waiting outside the airport for it to open and a lot of pushing as soon as it did, people with sacks of rice, televisions, lab equipment and goodness knows what else creating quite a scrum.  Then more pushing and shoving when inside to get to the World Food Programme/UN Humanitarian Air Service check-in desk and the very strict weighing of bags – 20Kg only for all things. Lots of arguing from people who had a few kilograms over and were made to take things out.  After this strict weighing was done we went through to the one small room that serves as a “departure lounge.” Despite there being nowhere to get food/drink and only one toilet (with no light or water) there was a small duty free shop selling bottles of spirits, yoghurt, red bull and shampoo – all the essentials for months in the field.  It also turned out you could buy as much as you wanted here – very much making a mockery of the weight limit!  After purchasing several bottles of rum and whisky (apparently there is no tonic – catastrophe! – so gin is off the menu) we sat around waiting for our flight.  It turns out the time of your flight departure is only a rough guide and you just wait until the UN man shouts out your flight destination.

So two hours later than scheduled it was our time to go.  We boarded a small UN plane and took off for a town called Rumbek and then on to Aweil.  Sadly, it turns out there are no in-flight snacks or entertainment on humanitarian flights but it was only a 45 minute flight to Rumbek.  Here, we had to get out to allow the plane to refuel and then wait for a herd of goats to be shooed off the airstrip before taking off again for Aweil.   Another 45 minute flight and then a 10 minute drive from the airstrip  to the MSF compound and here is my home for the next 9 months– Aweil Paradise.

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[The central communal area of the compound in Aweil]

The project in Aweil is quite big by MSF standards and so there are a lot of staff.  MSF run all the paediatric and obstetric in-patient services for the hospital here – serving a very large area and population with a huge need of medical care.   They also run outreach programmes into the community to find out what needs there are and to provide health education.  Aweil is a relatively safe and for now stable part of the country, although extremely poor.  The people here are almost exclusively from the Dinka tribe, so there is little of the tribal, ethnic tensions still seen elsewhere in the country.  Soberingly, 2 national MSF staff were killed yesterday, along with 16 other people, in a flare of ethnic violence in the Malakal Protection of Civilian site in the north east of the country.  This is a reminder that although things may be peaceful here, huge tensions remain in other parts of the country and despite a supposed truce in the civil war, violent flares are still occurring.

We live in a relatively large compound with huts (tukuls) surrounding a central communal area and kitchen.   There is electricity and wifi most of the time, slow but good enough for emails etc.  Importantly, there is a semi-working freezer that acts as a reasonable fridge so we can have cold (ish) beer. Hurray!   This is particularly important as the temperature has been well above 40OC all this week and it is apparently going to be hotter next week.

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[One side of the compound with tukuls (living huts)]

There are currently around 20 expats living in the compound – doctors, nurses, an obstetrician, anaesthetist, logisticians and admin staff – from the USA, Austria, Ireland, Russia, The Democratic Republic of the Congo, Lebanon, Nigeria, France, Iran, Sweden and elsewhere in South Sudan so it is a varied and multicultural group.  Everyone is very friendly and many people have worked for MSF for years in a wide range of different countries, so have plenty of stories to tell.

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[Inside my home for the next 9 months]

Well that is two pages long and I haven’t even mentioned the hospital yet, so I will save that for the next instalment. Suffice to say it is big, hectic and full of sick kids. But I am enjoying both the work and being here in general very much so far.  Bye until next time!

Aweil Paradise

Bananagrams, the world’s thinnest guidebook and the little people

{Disclaimer: This is not an official MSF blog and the views expressed do not necessarily represent MSF.}

Hello from Paris! Not being a natural linguist (and actually actively disliking writing anything!), it may seem like a strange idea to have decided to try and write a blog whilst I am away this year.  The motivation comes from some of the many inspiring people I had the privilege to meet whilst I was studying for the Diploma of Tropical Medicine and Hygiene (DTM&H) in Liverpool.

I initially saw this diploma simply as a step needed in order to fulfil my goal of one day working for Medecins Sans Frontiers (MSF). However, it turned out to be the most incredible, hectic and enjoyable three months, which I can only describe as a combination of university first year social life condensed and amplified, combined with fascinating, challenging, world class teaching. I learnt about a vast array of previously unknown topics and I have been itching to put them into practice since.  The diploma also provided the opportunity to meet many similar people who I know have already become lifelong friends, some of whom started blogs whilst in Liverpool and many more who have done so now we are scattered across the world (alright mainly Africa, alright mainly Zambia and Malawi!)  I have enjoyed reading about their travels, challenges and triumphs so much that it only seemed fair to give it a go myself. (However this does not mean that however much I like receiving Christmas cards, I will be starting writing any this year or ever. You have been warned.)

For those of you who don’t know much about them, MSF (also known as Medecins Sans Frontiers or Doctors without Borders) are a large non-government organisation (NGO) founded by a group of  doctors and journalists in 1971.  MSF is founded on the key principles of providing independent, impartial medical humanitarian aid to those most in need.  A further and defining characteristic is that of “Temoignage”, a French term which roughly translates as to “bear witness”.  Speaking out for those who do not have the voice to do so for themselves and ensuring that they are not forgotten by the world.

Since my first – of many as it turns out! – gap years in Kenya as an 18 year old, I have had an interest in humanitarian work and the possibility of one day being involved myself.  Taking time out from UK medical training to complete the DTM&H and then getting accepted onto the MSF field register for deployment were the first steps in this.   Speaking to friends who had worked in the field for MSF before, I expected a bit of time twiddling my thumbs in the UK then a hectic time preparing for a mission and I wasn’t disappointed in this respect!

The phone call from the MSF UK office came whilst I was at work (locuming in the tropical medicine hot-bed of the elderly care ward of Cheltenham General Hospital).  Could I be ready to go to South Sudan in …… 4 days?? After a bit of negotiating and the realisation that it was going to be nearly impossible to get all of the required vaccines and paperwork done in this time (nothing to do with the Six Nations Rugby ticket the week after. Honest.), 4 days was extended to 10.

Cue a lot of frantic and moderately unorganised paper work, vaccines, dentist, medicals etc and phone calls back and forth from the UK, Paris and New York MSF offices.  What I was going to be actually doing in South Sudan remained rather vague but I would be going to a town called Aweil in the Northern Bahr el Ghazal state in North Western South Sudan.  Google earth revealed a pretty desolate and dry looking settlement, but Wikipedia assures me the highlights include a railway station (however no functioning railway currently), an “airport” (but with no airlines other than UN type-chartered planes), the offices of Aweil Town Council, the Aweil Rice scheme and a Soccer field.  So it’s pretty much a metropolis!  Also temperatures are consistently in the high 30s, sometimes up to 50oC – and I don’t really like the heat!  However, further research has revealed that South Sudan does have a brewery and makes a selection of beers (tasting notes to follow from the field), so not all bad news.

A week before leaving came the bombshell to eclipse all others – my project would be only ….. paediatrics (CHILDREN!) Anyone who knows me will attest to my at best lukewarm feelings towards the little people and I have not done any medical paediatrics since medical school.  I felt pretty overwhelmed and extremely anxious for the next 24 hours but have come to terms with the idea and am now quite excited by the challenge.  I have been spending every spare minute (well at least some of them) reading multiple paediatric guidelines and trying to refresh the knowledge I know must be in there from medical school.    I am also extremely grateful to have been welcomed as an honorary  member into the “Paediatric Heroes” Whatsapp group of fellow diploma graduates, including a consultant paediatrician, so will have people to turn to for advice (when the internet works!)

My main role in the project will be looking after paediatric in-patients.  The hospital serves a large population with no other health facilities to access.  After years of brutal civil war, the region is relatively peaceful but people remain extremely poor and food insecurity is a major issue.  The El-Niño phenomenon has been playing havoc with the weather patterns and there is a real concern that the crops will fail.  So far this year, there have been a far higher number of children admitted with Severe Acute Malnutrition and needing therapeutic feeding than is normal for this time of year, so it looks like I will be kept busy.   Then the rainy season starts in May and this leads to a surge in children admitted with Severe Malaria and other infectious diseases.

So after getting my head around this extra challenge, came the attempts at packing for 9 months – with the combined total of hand luggage and main luggage of only 20 kilograms.  Despite the restrictions, I have ensured I have Bananagrams, a (miniature) rugby ball, a radio, cheese and even a (very very thin) guidebook to South Sudan.

Then came a whirlwind of emotional goodbyes, several delicious “last” meals, a lovely trip up to Edinburgh (don’t mention the rugby result) to say goodbye to my family and a flight to Paris.  After some more briefings in Paris, I am flying out tomorrow. 20kg of my luggage plus an extremely awkward shaped piece of lab equipment (I hope it’s not fragile!) to transport from Paris to Vienna, Vienna to Addis Ababa, Addis Ababa to Juba and then finally Juba to Aweil.  I can’t wait!

https://hazelsouthsudan.wordpress.com/

Bananagrams, the world’s thinnest guidebook and the little people