Lauralee in Lankien

I am spending the weekend in Lokichoggio, Kenya. Loki, as it is called for short, is a stones throw away from the Sudan border. It is MSF’s base of operation for southern Sudan; supplies are trucked from Nairobi to Loki and then flown into the field. It is a ‘humanitarian town’, originally spawned in the 1980′s as the operational base for a huge aid effort called Operation Lifeline Sudan. Since the 2005 peace agreement that ended the civil war in Sudan, most humanitarian organizations have relocated to Juba in southern Sudan.

Loki is also the place that sick ex-pats go to recuperate. And that is why I am here, recovering from my never-to-be-identified fever. I am almost completely recovered.

Loki has some of the creature comforts that Lankien lacks. There is a television for instance. I surf back and forth between BBC and CNN, between coverage of the unrest in Kenya and the race between Hillary and Obama.

I have a new unblocked, quad-band, GSM cell phone that works almost anywhere in the world, with the exception of southern Sudan, unfortunately. It does, however, work in Lokichoggio. I talk with my husband, Erik, my mother, my father, my sister, one of my nieces, one of my brothers, my sister-in-laws.

It never ceases to amaze me that I can make a call from this remote town in the northwest corner of Kenya to Brampton, Ontario. My husband, family and friends have been excellent about me coming to southern Sudan. I’m quite sure that my husband and mother would have liked to beg me to stay in Canada, but they didn’t, they knew it was important to me.

"I just want to thank-you,
For all of the things you’ve done, I’m thinking about you,
I just want to send my love.
Feel like I’m falling,
Falling off the face of the earth"

— Neil Young, Prairie Wind

I lie sweating in my tukul in the middle of the day. I have only been in Africa for 10 days and already I have a fever. It is 39 degrees C by mouth. I have a headache and nausea. For the first time I wish I were somewhere else. I am told that most ex-pats, as we are called, succumb to some illness in the first few weeks of a mission, our immune systems suddenly bombarded with new infections and different strains of more familiar ones. Our lack of immunity is the reason why Africa became known as ‘the white man’s grave’ during colonial times. If I were at home I would say I have the flu, but in Africa you always have to think of malaria, malaria, malaria (this message has been hammered into my head by every tropical disease doctor I have every met). But of course the odds are strongly against it: 1) I have only had three mosquito bites 2) I am on medication to prevent malaria 3) It takes a minimum of seven days from the bite of an infectious mosquito till the first symptoms appear. I would have to have caught it during the three days it took to transit through Kenya. Dr. Stan Gorski, the outgoing doctor, kindly tells me that he was out of commission for four days with illness the first week he arrived in Lankien. He does a malaria test on a drop of blood from my finger. Of course it is negative. I hope I do not set some sort of record for the quickest return from an MSF mission. I take some tylenol, lie back down and try to gain some comfort from my music.

“Take me to another place she said
Take me to another time
Run with me across the oceans
Float me on a silver cloud
If I could I would but I don’t know how..”

Phish

The outpatient department is a tukul divided into several individual consultation rooms. The ‘waiting room’ is a large piece of ground covered with plastic sheeting and sheltered from the sun by a thatched canopy. Good triage in the waiting area saves lives. Children and their caretakers, usually their mothers, form a line to the left, adults form a line to the right; at least this is the way it is supposed to work in theory. In practice there is much shuffling back and forth between the lines, people coming and going to the lab, people socializing, organized chaos. All children have their temperatures taken. Those with a fever get screened for malaria; those under five years old get screened even if they only have a history of fever. Children between 6 months and 5 years are screened for malnutrition using a MUAC or mid-upper arm circumference. If they are deemed to be malnourished by the MUAC, they are measured and weighed using a sling and a scale that hangs from a nearby tree. The children are generally not happy with the sling, but a good cry is a good sound. All pregnant women and adults with fever are also screened for malaria.

The mothers cover their children with blankets or carry them in baskets. We have to be careful to find all the children who are hidden in the lines or risk missing a seriously ill child. Most of the children have diarrhea, upper respiratory infection, pneumonia or malaria, sometimes meningitis.

A child, semi-conscious and in shock, is identified quickly by the vigilance of one of the staff. The child is rushed to the inpatient area where three people try to establish an intravenous line. The hands, arms, feet, and scalp are all tried. The child does not even flinch. Finally someone succeeds with a scalp vein. A small victory.

My tukul is my sanctuary. It has mud walls and a grass roof; I share it with a hedgehog, some lizards and an assortment of insects and spiders. At night, the bats flap in and out on soft wings. Inside I have a bed, a chair and a mosquito net. Yes, it is hot and dusty.but it is mine. At night, I sleep under the mosquito net and let the cool breezes circulate through an open door. If I have to get up at night I am careful to turn my flashlight on and check the floor and the inside of my shoes for scorpions. I have never seen a scorpion but I am told they are unmistakable.

There are thirteen tukuls in the MSF compound if you count the latrine tukul that is under construction. I saw tukuls in various stages of construction in the village. They start with a square or rectangular wooden frame; balls of mud are wedged between an outer frame and an inner frame.

The gaps are filled in with more mud and the whole surface of the wall is smoothed over and finally adorned with a relief pattern around the doorframe.

In the center of the compound are several large spreading trees with a few smaller shrubs here and there around the periphery. One of the staff is nurturing a banana tree near the kitchen tukul. The birds are beautiful: a small green one with a black eye stripe and a long tail, a small brown sparrow like bird with a blue bottom, a black raven with a white bib.

I worked in Canada for 20 years and only saw two cases of active TB. Since coming to southern Sudan four days ago, I have seen two new cases of spinal TB, a new case of pulmonary TB and several suspected pediatric cases. This is in addition to the fifty patients in the TB village where people live for 6-8 months while completing their treatment. In Canada, TB disproportionately affects new Canadians, First Nations and the Inuit, and those with impaired immunity such as people living with HIV/AIDS. In southern Sudan the lines are drawn somewhat differently, poverty, malnutrition, and lack of health care are the more important common denominators.

Mycobacterium tuberculosis is the organism that causes TB in all its myriad forms. Spinal TB is particularly cruel. It eats away at the bones of the spine until they collapse forming a bump, or gibbus, over the spine. Paralysis usually comes gradually as bone, pus and other infectious debris compress the spinal cord.

The patient is 11 years old. She has had a gibbus for six months. Until last week she was managing to walk with two sticks; now she no longer has the strength to stand up. She is quite lovely, shy and slim. She reminds of my niece, Julia. Ironically she is one of the lucky ones because with treatment she will be able to walk and even run again.

TB is an ancient disease; researchers have even found evidence in 4000-year-old Egyptian mummies! It killed Emily Bronte, Kafka and the poet Keats. Although there has been treatment for more than 50 years, it still kills more people than any other infectious disease, but it kills mostly poor people so it gets less attention than it deserves. I will leave this subject for another day.

Dr. Lauralee Morris is a a general practitioner from southern Ontario. This is her first mission with MSF. The project is located in Lankien,
Southern Sudan where MSF delivers basic health care services, including pregnancy care, therapeutic feeding, and programs for the treatment of tuberculosis and Kala Azar.