Final Entry: Who’ll Stop the Rain?

September 4th, 2008 by lauraleem

The rain has just started. It sounds like artillery fire on the metal roof of the logistics building. If it continues much longer, there will be no plane tomorrow. Everyone is here, taking refuge from the storm. No Woman, No Cry issues thinly from someone’s laptop. No one speaks, they are all intent on their reports and paperwork.

Tomorrow I fly to Loki, then Amsterdam the following day, then home. I debrief in both Loki and Amsterdam, then the long and all-important debrief at home as I reflect on my mission.

I am seriously at loose ends having already completed my handover to the new doctor and cleaned out my tukul. I thumb my way around my ipod and settle on something that seems apropos for the moment: “Long as I remember the rain been comin’ down. Clouds of mystery pourin’ confusion on the ground. Good men through the ages, trying to find the sun. And I wonder, still I wonder, who’ll stop the rain?”

I examine the pictures in my digital camera, hundreds and hundreds of them, all the pictures I could not show you: a malnourished baby with big eyes, an old man wasting away from Kala azar, a boy with a twisted TB spine, a child contorted with tetanus, a young man with a stump where his right leg should be. I come to the picture of a young woman who died of Kala Azar, I cannot bare to look at her.

I try to do a video with my digital camera. I go from person to person and get them to say hello. But the logistics room is dim, lit only by one light bulb and the glow of the computer screens. The video is too dark, my MSF family just a series of disembodied voices and self conscious, flashing smiles.

The rain intensifies. It streams off the corrugated roof in discrete rivulets; the ground below the overhang erodes into a series of identical puddles. It is becoming more and more obvious that there will be no plane. Once the airstrip morphs into a sea of mud it sometimes takes days to dry out. Isaac leans on the doorframe of the logistics room and stares balefully out at the deluge; he is due to leave for R and R tomorrow.

Of course, the plane will come eventually, if not tomorrow, then the next day or the next. For now I am content to stay here, I am in no rush. I will have at least one more night to say good-bye.

Below: My MSF Family: Zak, Helen, Fredoh, Lauralee, Geke and Isaac (missing: Leanna and Francis)

Zak

September 1st, 2008 by lauraleem

Zakaria Mwatia is our base nurse. He is from Kenya and has worked in Sudan, Kenya and Somalia. He is deeply committed to his work and will always go the extra mile to do the right thing for patients. I often see Zak going back to the hospital after hours to check on this or that patient. He works with unfailing good humor, quiet diplomacy and is always willing to help me learn in this new environment where innovation and adaptation are the watchwords of survival.

Here are just some of the things that I learned from Zak:

1. How to successfully incise and drain almost any pocket of pus.
2. How to make a cast with an open window in the plaster designed to permit wound dressing of exposed fractures.
3. How to make an inhalation mask out of a hard plastic IV bag.
4. How to rig up skin traction for fractures using a pulley and a bag of stones.
5. How to successfully use an old style fetal stethoscope that is made from metal and shaped like a trumpet.
6. How to pack a gun shot wound.
7. How to debride a burn without wasting a scalpel blade.
8. How to reduce a child’s rectal prolapse and dress it so that it does not recur.
9. How to recognize and avoid scorpions, sand flies and tsetse flies.
10. How to kill a snake

Thanks Zak.

Below: Zak at work in Tukul 1

Zak

Kala Azar, MSF and Francis

August 27th, 2008 by lauraleem

And there they were, right under the microscope lens, just the way I had seen them in books and prepared slides in my tropical medicine training. Amastigotes, the tissue form of Leishmania donovani, the parasite that causes Kala Azar (KA) in southern Sudan. Sammy, our lab supervisor, had prepared the slide from a patient suspected of having a relapse of her disease. I had aspirated the tissue sample from her spleen with a small needle. Clinically suspected first episodes of KA are diagnosed using a rapid blood test (rK39, Optileish), a quick, easy test compared to spleen aspirate and direct visualization. The results of the Optileish test are confirmed using another blood test, the DAT (Direct Agglutination Test). Blood tests remain positive after a first episode of KA and therefore cannot be used to diagnose relapsed disease.

The treatment of KA in countries like Sudan has many challenges: access problems for patients, logistical problems related to diagnostic tools and therapeutics, lack of trained staff to administer treatment, just to name a few. Our first line treatment is sodium stibogluconate (SSG) given in a series of daily injections over 30 days, with a shorter duration of treatment if combined with a drug called paramomycin. But SSG, a drug first developed in the 1930’s, has its problems: painful injections, long treatment regimens, parasite resistance, cost, potential toxicity and lack of effectiveness in patients with other infections. Ambisome is an alternative treatment used for more serious patients but it also has some potential toxicity and is very costly.

Below: SSG, first line drug for KA

 SSG - first line drug for KA

Below: Ambisome, drug for KA, used for seriously ill patients

 Ambisome - drug for KA, used for seriously ill patients

MSF has a long history of treating KA in southern Sudan and has been an advocate for better, less expensive KA drugs (see link below). Over the last 20 years, MSF has treated thousands of patients. Francis Gatluak, our KA/TB specialist, has worked with MSF for all of that time, using his knowledge and experience in the management of KA, TB and other health problems. I think of Francis as the heart and soul of the Lankien project. He is both a valuable medical resource and an important link with the community. Cheers Francis and best wishes.

Below: Francis at work admitting a patient with KA

Francis at work

This is a link to MSF’s Campaign for Access to Essential Medicines.

Alumni of the January 2008 PPD in Bonn

August 23rd, 2008 by lauraleem

MSF provides first missioners with an introductory course prior to going to the field. It’s called the Pre-preparation Departure Course, PPD for short; I did my course in Bonn, Germany in January this year. The course was multidisciplinary and included people with diverse backgrounds in medicine, logistics, administration and finance. The course was run in English but the participants were multi-national with attendees from Holland, Germany, France, Italy, Finland, the UK, India, Bangladesh, Zambia, Canada and the USA. The goal was to orient people to the organization and its operation. Most participants were yet to be assigned to a mission but several in the group were already working in MSF projects: multi-drug resistant TB in Uzbekistan, obstetrics in Sri Lanka. Since January, the alumni of the PPD course have been assigned to various projects, a refugee camp in Chad, a KA/HIV project in Ethiopia, an HIV mission in Zimbabwe, and yes, projects in Southern Sudan. I am fortunate to have two people from my PPD right here with me. Leanna Hutchins, our log admin in Lankien, and Andrea Hewitt. Andrea is from the UK and is our Financial Coordinator for the mission. She is part of the Country Management Team and works out of Loki. It has been wonderful to see a familiar face in Loki and share some time with Andrea.

Below: Andrea Hewitt, at work in Loki

 Andrea

Below: Leanna Hutchins does radio call in Lankien

 

Below: Andrea and I in Loki

 

The Nuer People of Southern Sudan — Part 3

August 21st, 2008 by lauraleem

Cow’s milk and sorghum (millet) are the staples of the Nuer diet. Maize (corn), okra and sesame are also cultivated. Milk is viewed as necessary for children; families temporarily without milk can usually get it, or a lactating cow, from a relative. In areas closer to rivers, fishing helps to bridge the hunger gap at the end of the dry season. The Nuer also eat the meat of their cows but not as much as you might think, slaughtering their cattle more for ritual and religious ceremony than for food. They are highly adapted to their environment. I run the risk of romanticizing the Nuer, but I have to say it: The Nuer are tough, resilient and highly resourceful. They would have to be, to survive for thousands of years in this harsh environment.

Below: Sorghum, a Nuer staple

Sorghum

Below: An elderly woman prepares sorghum porridge. The bowl is a hollowed out gourd.

Below: A mother and her child stand on their homestead, amidst their maize (corn) crop.

Mother and child, amidst maize crop.

Below: The flower of the okra plant.

Flower of the okra plant

Below: Babies and small children are carried in baskets weaved by their mothers.

Babies carried in baskets

Below: Women sweep the ground every morning with straw brooms. 

 Women sweep the ground every day

Below: A very popular game (that I can never remember the name of). Photo Credit: Negar Adib

Babies carried in baskets

Below: Homemade Splint

Home-made splint

Below: The Nuer are exceptionally tall, even the children are tall. This is the only bicycle I saw in Lankien.

The only bicycle I saw in Lankien

Below: Coke can car: Child’s toy made out of an empty coke can.

Child's toy make out of a Coke can

Below: Tukul under construciton, a marvel of engineering using local resources.

 Tukul under construction

The entry I wanted to make way back on Mother’s Day

August 19th, 2008 by lauraleem

The mothers of Lankien, like most mothers, work incredibly hard. In addition to caring for their children, they spend hours carrying water, preparing food, and working in their gardens. What would it be like to be a mother here, where looking for food and water can be a full time job? Where your child can starve if there is just one crop failure? Where medical care for a sick child is hours and hours away. What would it be like to know that at least one of your children will probably die before the age of five?

And what would it be like to know that your own existence is heavily dependent on your ability to be a mother, in a place where there are few other roles for women?

These are pictures of our national staff and their children, and my own mother, Eda. I think the faces of pride and happiness speak for themselves.

To the mothers of Lankien, my own mother, and all the important mothers in my life: A Very Belated Happy Mother’s Day

Below: Mary and Nyanen

Mary and Nyanen

Below: Elizabeth and Fina matot

Elizabeth

The entry I wanted to make on Mother’s Day

August 19th, 2008 by lauraleem

The mothers of Lankien, like most mothers, work incredibly hard. In addition to caring for their children, they spend hours carrying water, preparing food, and working in their gardens. What would it be like to be a mother here, where looking for food and water can be a full time job? Where your child can starve if there is just one crop failure? Where medical care for a sick child is hours and hours away. What would it be like to know that at least one of your children will probably die before the age of five?

And what would it be like to know that your own existence is heavily dependent on your ability to be a mother, in a place where there are few other roles for women?

These are pictures of our national staff and their children. I think the faces of pride and happiness speak for themselves.

To the mothers of Lankien, my own mother Eda, and all the important mothers in my life: A Very Belated Happy Mother’s Day

Below: Mary and Nyanen

 Mary and Nyanen

Below: Elizabeth and Fiona matot 

 Elizabeth

When you educate a woman

August 18th, 2008 by lauraleem

"When you educate a man you educate an individual; when you educate a woman you educate a whole family."

— Robert Morrison MacIvor

Education, like health care, is (at least it should be) a basic human right. Levels of education are low in southern Sudan. It is one of the big challenges that MSF faces here. In particular, we have problems hiring women because they lack the necessary facilities with reading, writing, math and English. We do have female staff, but they are generally in cleaning and cooking capacities and not in paramedical positions, where we would like to have them.

Once a week, MSF has hired a local teacher to spend an hour with our female national staff to teach them basic literacy. He teaches them in their native Nuer language. This program has been a great hit. The women attend in high numbers, studiously keep their notebooks and seem to enjoy the class. One hour is, of course, not very much time, but it is a start. This simple but great idea is one of many from our project coordinator, Geke Huisman.

Below: Women’s class under the Kala Azar tree

Women's class under the Kala Azar tree

Geke is a committed, passionate advocate for the rights of women and children. She has worked as a nurse in diverse MSF projects in the Ukraine, Darfur, and Zambia and brings her health care background to the position of project coordinator. Geke has been a great support to me. She was incredibly kind to me when I was sick and she held me together in the sleepless, Larium crazed days of June. Thank-you Geke.

Below: Geke Huisman, Project Coordinator

Women's class under the Kala Azar tree

The Nuer People of Southern Sudan — Part 2

August 17th, 2008 by lauraleem

"A people whose material culture is as simple as that of the Nuer are highly dependent on their environment. They are pre-eminently pastoral, though they grow more millet and maize than is commonly supposed. Some tribes cultivate more and some less, according to conditions of soil and surface water and their wealth in cattle, but all alike regard horticulture (agriculture) as toil forced on them by poverty of stock, for at heart they are herdsman, and the only labor in which they delight is care of cattle. They not only depend on cattle for many of life’s necessities but they have the herdsman’s outlook on the world. Cattle are their dearest possessions and they gladly risk their lives to defend their herds or to pillage those of their neighbors. Most of the social activities concern cattle and cherchez la vache is the best advice that can be given to those who desire to understand Nuer behavior."

"The Nuer" — E.E. Evans-Pritchard

This was first published in 1940, a long time ago and much has changed, but much has also remained the same. Indeed it is hard to overstate the importance of cattle in the lives of the Nuer. Before I came to southern Sudan I was told to buy a book on Canadian cattle, as a way of opening up lines of communication with the Nuer. At the time, I found this suggestion outlandish. Now, eight months later, I realize I should have made space in my backpack for such a book.

The Nuer are primarily cattle herding pastoralists and their lives are closely intertwined with that of their herds. Traditionally, the Nuer are a migratory people moving in rhythm with their environment and the needs of their cattle. It is the wet season now, when the White Nile and other rivers flood their banks and turn southern Sudan into a huge swampland. Flooding forces the Nuer to seek higher ground in villages like Lankien, places where they and their cattle are protected and where the Nuer can cultivate crops. When the rains cease and the land becomes parched during the dry season, they will move their cattle back to ‘cattle camps’ situated closer to rivers and other water sources.

Below: Cow on the Airstrip

Cow on the airstrip

Below: Cattle mix freely with people in the market

Cattle mix freely

Below: Byre (barn) for cattle

Byre (barn) for cattle

Below: Young girl with milking gourd

Young girl with milking gourd

Below: Cattle Camp from the air, dry season Photo Credit: Negar Adib

Cattle from the air, dry season - Photo : Negar Adib

Immunization and Maternal Health

August 16th, 2008 by lauraleem

In 1983, when I started to practice in Ontario, Canada, the routine schedule of immunization covered only a hand-full of infections: diptheria, tetanus, pertussis (whooping cough), polio, measles, mumps and rubella. Twenty-five years later there is now funding for vaccines for Hepatitis B, meningitis, pneumonia/otitis media, chicken pox, influenza, and most recently, cervical cancer. Globally there is ongoing research and development for vaccines against a great number of other infectious diseases, many of which predominately affect the poorest people in the world.

Despite the good news, the situation on the ground in Lankien is grim. No one knows the proportion of children who receive vaccination. What we do know is that we see patients with vaccine preventable diseases: large epidemics of measles, meningitis and pneumonia, neonatal and childhood tetanus, cases of whooping cough, mumps and chicken pox, life threatening forms of childhood tuberculosis, cervical and liver cancer.

The Centre for Disease Control in Atlanta called vaccination, the greatest public health achievement of 20th century America, but all over the world children still do not receive even the most basic immunizations. In Lankien, MSF immunizes against the six vaccine preventable diseases covered by the World Health’s Organization EPI (Expanded Program of Immunization); they are diptheria, whooping cough, tetanus, polio, measles and tuberculosis. Recently, we have successfully achieved a large increase in the number of children being immunized, the result of a simple change in our triage plan and led by Helen Galla, nurse midwife, and Francis Gatluak.

Below: Helen Galla immunizes a child in the EPI program

Helen Galla imunizes a child in the EPI program

The immunization area is simply some chairs and a table protected under a plastic canopy. It is next to the Ante-natal Care (ANC) tukul where Helen and our national staff see pregnant women. In addition to the usual routine clinical exam, MSF provides women with iron tablets, multivitamins and medication to prevent malaria. We also test and treat for syphilis, an infection that causes serious abnormalities in newborns. We vaccinate all women against tetanus with the goal of protecting the newborn infant from this lethal infection. In addition, we provide bed nets and clean delivery kits.

Helen has extensive experience working in Sudan, particularly in the practice of remote area obstetrics. You can’t learn obstetrics for places like southern Sudan in places like southern Ontario. And this leads to one of my regrets as I approach the end of my mission: I will not have more time to spend with Helen.

Below: Helen and newborn

Helen Galla imunizes a child in the EPI program