Lauralee in Lankien

It is so dry and parched. The wind whips up the sand and dust and deposits it on everything. Even the water tastes dusty. Yesterday the mercury hit 50 C.

There were a few drops of rain yesterday; I dreamt that it transformed the land overnight. Everywhere it was lush and green. Plants sprang up through the cracked earth; there was a vegetable garden and bright pink flower blossoms.

And of course it was deliciously cool, in my Garden of Eden.

The compound cat is called Zimbabwe. She is a thin, miserable cat who howls in the middle of the night and seems unable to catch the resident mice. Normally, I like cats, but Zimbabwe scares me and I do not want to pick her up; she rubs herself hopefully along my shins, perhaps sensing my conflict and pity.

Zimbabwe apparently has competition now. There is another cat in the compound that I have not yet seen. A name has been suggested for this new cat, Toxoplasmosis, Toxo for short.

There is a mosquito buzzing around my ear. I turn on my flashlight and try to smash it between my hands. Normally, I take a Gandhian approach the killing of animals and insects, but here in southern Sudan, it’s kill or be killed.

Mosquitoes are the insect vectors for many nasty diseases: malaria, dengue, yellow fever, and of course, West Nile Virus, the infection that has given mosquitoes such a bad name in North America in recent years. But here in southern Sudan, and indeed in the rest of Sub-Saharan Africa, malaria is by far the most important disease carried by mosquitoes. I finally succeed in squashing the mosquito between my palms. Too late, it’s full of blood, probably my own. I tuck my bed net in under my mattress a bit tighter and reassure myself that I did take my malaria prophylaxis on Saturday, my malaria day.

There are 300-500 million new cases of malaria every year in the world and 1-2 million deaths, of these, 90% occur south of the Sahara.

She gave birth to her 3rd baby 4 days ago. Two days ago her baby died. She gave birth at home, probably on the floor of her tukul. Perhaps the village midwife attended her, or her mother or sister. Maybe no one was there. It is almost certain that her attendant had no formal education in midwifery and that there were no clean instruments to cut the cord. It is an absolute certainty that there was nothing available in case of an emergency, no drugs, no intravenous, no cesarean section. She delivered her baby the same way that millions of poor women deliver their babies every second of every minute of every day, completely without the advantages of even the most rudimentary advances in midwifery, medicine and technology.

The mother is anemic and malnourished and her baby was probably small and weak. The baby had the odds of survival stacked against it, even before its birth.

The baby’s death will never be recorded in any registry; the cause of its death will never be identified. There will be no Grand Morbidity and Mortality Rounds. Its death will largely go unnoticed by the world.

Before coming to southern Sudan, Ketamine was a drug that anesthetists used. I remember getting it for the extraction of my wisdom teeth, a pleasant memory where I was dissociated from my body and floated above the operating room. Here in southern Sudan we use Ketamine for many minor procedures: draining abscesses, debriding burns and wounds, dilatation and curettage, aligning broken bones.

He is about 8 years old and he was fighting with his friend. During the fight, he tried to break a fall with his hand; that is how he was injured. His left elbow is very swollen over one side and he is unable to completely bend his arm. He doesn’t want anyone to touch him. We start an IV and give him ketamine and a small dose of Valium. The child drifts gently off to sleep. I can now examine the elbow and try to reduce the fracture. I feel for the bony landmarks of his elbow, for deformity or the crunch of broken bone. Suddenly, there is a ‘clunk’ and I feel the fracture re-align to its normal anatomy. We cast him with some Plaster of Paris.

The woman is pregnant, maybe 7 months. She has the most beautiful face. Her baby is lying sideways instead of head down or bottom down. If the baby is still in this position at the onset of labor, the woman will need a Caesarian Section to save her life and that of her baby.

But this is not the problem today. The woman has severe anemia; her hemoglobin is only 3 g/dl. Normal hemoglobin would be about 12 g/dl. The inside of her lower eye-lid is almost pure white; the palms of her hands are pale.

If she enters labor with hemoglobin of 3 g/dl, she will probably not survive. She will die of hemorrhage or heart failure.

Anemia in pregnancy is a huge problem for women in developing countries. The causes of anemia are protean: iron deficient diets, malaria parasites that destroy red blood cells, many pregnancies without a sufficient interval between them.

Without a blood transfusion, this mother’s prospects are grim. We start the process of finding a blood donor among her relatives.

I have a new respect for blogging. I used to think of it as a narcissistic, navel gazing, somewhat exhibitionist endeavor. So it is ironic that blogging is starting to feel like my lifeline to my husband, family, friends and the larger world. The experience of working for MSF in southern Sudan is so huge and complicated, that I feel I can only convey it in small increments, revealing little bits of it over time in the hope that one day it will hang together as a larger whole.