Lauralee in Lankien

I have been remiss in not writing more about the Nuer people themselves. When I started the mission I was quite uninformed about The Nuer, my head stuffed to overload with tropical medicine, public health and MSF protocols. No doubt my current knowledge is spotty, so I apologize in advance for errors or omissions.

The Nuer people, who call themselves the Naath (human beings), are one of the biggest ethnic groups in East Africa; they are located in southern Sudan and western Ethiopia. In southern Sudan, they form the second largest ethnic group; the Dinka are the largest. Jonglei province, where we are, is also home to the Shilluk and the Merle. As a result of the protracted civil war in southern Sudan, many Nuer have emigrated to Kenya and other countries. Thousands were also resettled as refugees and currently live in Canada, the USA and Australia.

The Nuer are well known in anthropology as the subjects of a famous ethnographic study by E. E. Evans-Pritchard. The trilogy he wrote is considered a classic example of social anthropology. It starts with The Nuer, published in 1940, and is followed by Kinship and Marriage Among the Nuer, published in 1951, and Nuer Religion, published in 1956. More recently the Nuer have been studied by anthropologist Sharon E. Hutchinson, her findings are described in Nuer Dilemmas: Coping with Money, War and the State, published 1996. I bought The Nuer and Nuer Dilemmas from Amazon when I was home in June. My husband sent them to me in a care package that never arrived; perhaps they are still in transit somewhere between Toronto and Lankien. I hope someone eventually reads them.

Despite the hardships, it is a privilege to be here and work with the Nuer, a group that has been isolated by war for most of the last 50 years. Few people have this opportunity and I am one of the lucky ones. The Nuer always seem willing to tell me about themselves and now, as I am approaching the end of my mission, I wish I had asked more questions. Of course, asking questions and penetrating the language barrier takes time and energy, something that always seems in short supply. And the language barrier can be very dense, the accuracy of translation often tenuous. Those who speak English are usually the young men who went to school in the refugee camps of Kenya and Ethiopia. Very few women speak any English, and communication with them is usually filtered through the biases of a translator.

I know close to nothing about electricity, power generators, high frequency radios, house building or car fixing. When the auto mechanic at my local repair shop holds up a piece of rusted metal and tells me he had to replace the whatchamacallit with a thigamajig, he could be showing me a part from an old washing machine for all I know. Fortunately for me, and everyone else, the fore mentioned areas are not part of my job description; these responsibilities, among others, fall to our technical logistician, Fredoh Macharia.

Fredoh brings a wealth of valuable experience from other MSF projects where he has worked. He is a whirlwind of activity, tearing down old structures and building new ones, mending fences, re-organizing our triage area, etc. Most recently he has torn down the old decaying kitchen tukul and replaced it with, by far, the most beautiful tukul I have ever seen. It is large, light, airy and painted blue, my favorite color. Thank-you Fredoh.

Below: Fredoh on the roof of the old kitchen tukul, planning its demolition Photo credit: Leanna Hutchins

Below: Sammy and Fredoh, kitchen tukul under construction

Below: The New Kitchen Tukul completed

Southern Sudan has one of the highest concentrations of Neglected Tropical Diseases (NTD’s) in the world. The NTD’s are a group of infectious diseases that traditionally receive little attention from governments and donors. Their victims are some of the poorest most marginalized people on earth, people who have no economic or political voice, people who live under the conditions where NTD’s thrive: unsafe water, poor sanitation and little or no health care. In contrast to the Big Three (TB, malaria and HIV/AIDS), the NTD’s suffer from a lack of international awareness and funding for research and development.

To my knowledge, with the exception of Chagas disease (American sleeping sickness or American trypanosomiasis), which occurs exclusively in Latin America, all of the NTD’s are present in southern Sudan. The list of diseases covered by WHO’s Neglected Tropical Diseases department is long: Buruli ulcer, Chagas disease, cholera and other epidemic diarrhoeal diseases, dengue, guinea-worm, yaws, African sleeping sickness, leishmaniasis (including kala azar), leprosy, lymphatic filariasis (elephantiasis), onchocerciais, schistosomiasis, soil-transmitted helminthes (worms), and trachoma (a blinding eye infection).

Neglected tropical diseases suffer from the 10/90 Gap, a term first coined to describe a statistical finding of the Global Forum on Health Research. In 1990, it estimated that only 10% of all the money spent globally on health research and development was devoted to the problems of the poorest 90% of the world. Conversely, the other 90% was spent on the richest 10% of the world. Although these estimates are old, the term 10/90 Gap still persists to describe the mismatch between resources and need.

The World Health Organisation’s Neglected Tropical Diseases:
http://www.who.int/neglected_diseases/

Global Forum for Health Research:
http://www.globalforumhealth.org

Drugs for Neglected Diseases Initiative:
http://www.dndi.org

The team I joined will not be the team I leave. The composition of the expat team is constantly changing as the contracts of volunteers begin and end in a staggered fashion. This is good and bad. It allows for continuity in the project, transfer of knowledge between team members and variety. But it also means that we often find ourselves saying good-bye, sometimes to people we have come to cherish. The expat team lives and works together and the interaction can be very intense. We become more or less like a family, sometimes a happy, efficient family and sometimes a miserable, dysfunctional family. This is one of the great challenges of working for MSF, how the team works can ‘make or break’ your mission and how it works is both within and outside your control.

I have already said good-bye to more than half of the original ex-pat team. The Good-byes can be tough, the conversation populated with Maybe I will see you on another mission, Let’s get together in Toronto, I will see you in Amsterdam, etc. And perhaps you will, but it will never be the same.

Good-bye again friends, Jodi, Jackson, Fiona, Lindsay and Uriah

Jodi Pipes, Outreach Nurse. Photo Credit: Lindsay Farnsworth

Jackson Lochokon,Technical Logistician. 

 Fiona Gillett, Nurse Midwife. 

 Lindsay Farnsworth, Logistician Administrator. Photo Credit: Trish

Uriah Morgan, Outreach nurse.

Some medical problems can be notoriously difficult to diagnose early in their clinical course: ectopic pregnancy, meningitis, pulmonary embolus, pancreatic and ovarian cancer. The clinicians among you will undoubtedly want to suggest others. Even with the benefits of advanced diagnostic tools, these problems can be difficult to diagnose. Often as the disease progresses in its natural history, the diagnosis declares itself. Inevitably, the last doctor to see the patient looks like a genius. “It’s easy to diagnose a pumpkin in October, try doing it in May,” I like to remind my specialist colleagues.

In Canada, patients tend to seek medical care early, a blessing of our universal health care system. Not so in southern Sudan. Here, patients often present only in advanced stages of disease. But late presentation does not always make diagnosis easier, particularly for ‘Western’ trained physicians more familiar with seeing early disease.

In the end, the patient had a “chronic” ectopic (tubal) pregnancy. She had been sick for weeks with pain, vaginal bleeding, and a large midline mass in her lower abdomen. I had trouble making the right diagnosis, not because she presented so early but because she presented so late. In my defense, we have no ultrasound, no blood tests for pregnancy and certainly no laparoscopy. I was thrown off by the large pelvic mass, which turned out to be the ectopic pregnancy itself, made huge by repeated internal bleeding. Ultimately, the patient was transferred to Nasir for surgery, where the diagnostic mystery was solved and the patient received a successful operation. As for me, I chalked it up to experience and another lesson in humility.

“The neck looks fuzzy,” says Leanna, training her binoculars on a large marsh bird in the distance. I am flipping back and forth through The Birds of East Africa trying to find the section on storks and ibises.

“There’s something here called a Wooly-necked Stork?” I offer. We switch roles. Leanna takes the bird book and I look through the binoculars.

Sunday is the closest thing to a day off in Lankien, and Leanna and I are on a bird walk. We are hoping to make it a tradition, an effort to unwind, see the world outside the compound and indulge our mutual interest in birds. Leanna Hutchins is our talented logistician administrator and like myself, this is her first mission with MSF. I have watched Leanna apply her considerable skill to master the tough, steep learning curve presented to every first missioner. Leanna is also the only other Canadian currently in the project and as such, we happily share the bonds of culture and language. I am very lucky to have her here.

“Yes, it’s the Wooly-necked stork!” says Leanna enthusiastically, snapping some photos. She is surrounded by a group of children; they hang off her arm and demand to see the camera. She laughs, shows them the pictures and asks them their names in Nuer. They are thrilled.

Below: Leanna and Friends, Birding at the Airstrip

 Below: Lauralee and Children at the airstrip

Below: The Wooley-necked Stork. Photo Credit: Leanna Hutchins.

Gunshot #1: The bullet ripped through his mother’s forearm, shattered the bones and left bits of cloth from her sleeve peppered throughout the wound. It then entered the cheek of his infant sister as she slept in the crook of her mother’s cradled arm. It was a mistake of course. He’s only six years old and didn’t intend to hurt anyone. He got hold of a loaded gun; that is the way it happened. Underneath all the blood, his baby sister had only a superficial wound; it will heal with a scar. His mother however, will always have trouble with her right arm.

Gunshot #2: It happened during a cattle raid. Someone tried to steal his cows and shot him in the process. A single bullet went through his left ankle, touched the inside of his left thigh, brushed the skin a centimeter below his scrotum on the right side, then entered and exited his right hip. I spent a few minutes trying to figure out the path of the bullet. He said he was sitting on the ground with his left leg outstretched; his right leg, bent sharply at the knee, was tucked tightly into his body.

Gunshot #3: Another cattle raid and another young man barely out of his teens. The bullet entered his back, just to the right of his spinal column. It narrowly missed his spinal cord, traversed his right lung and exited his right shoulder.

When I first got to Lankien, I marveled at the luck of many of the gunshot victims, although they had serious injuries, they did not die from their wounds. Of course this was all a mirage. It takes a long time to get to the clinic; the victims of lethal wounds never get here.

Click here for a high resolution version.

It’s the end of the month and the Medical Monthly Report, MMR for short, will be due in a few days. The MMR summarizes, both quantitatively and qualitatively, the medical activities of the project. It is a gold mine of interesting numbers. The most interesting part of this month’s report is the burgeoning number of malaria cases, the result of a rather dry wet season. Intermittent rains allow mosquito larva to develop undisturbed; they do so in vast pools of water in the seasonal swamp that is southern Sudan.

I look forward to doing the MMR every month, a chance to do some math, look at disease patterns and work more closely with our data collector, Isaac. Isaac has the rather daunting task of collecting and preparing all the data from the various departments; he does so every month with patience, diligence and quirky good humor. The MMR is a collaborative effort, Isaac supplies the numbers and the medics supply the interpretation.

MSF volunteers are expected to be versatile and are called upon to wear many hats. Isaac is able to do this well, filling in for our technical logistician and our logistician administrator when the need arises. He is also good company, in what I have come to think of as my MSF Family (more on my MSF Family later).

Cheers, Isaac

Above: Isaac at work in the logistics room.

Above: Helen, Zak and Isaac at work on the Medical Monthly Report, a collaborative effort.

I am rummaging around in the Store Room where we keep our drugs and other medical materials. It’s dark and I have to squint closely at the shelves to see anything; I am sure I saw some drugs for leprosy in here. The old, sweet tempered storekeeper doesn’t understand what I am looking for but tries to help anyway. Finally I find it, MDT-Combi it says on the box, Multi Drug Therapy for Leprosy. It hasn’t even expired, my lucky day.

There is only one person receiving treatment for leprosy in our project. He is waiting for me to give him his second month of drugs and authorize his food ration. There could be many more people with leprosy in this part of southern Sudan; probably nobody really knows the scale of the problem. Social stigma, difficulties with diagnosis and limited treatment opportunities make leprosy a hidden scourge.

Leprosy is a ‘Disease of Poverty’ as is malaria, TB, HIV/AIDS, measles, pneumonia, diarrhea and complications of childbirth. These diseases/conditions disproportionately affect the poor. The association between leprosy and poverty is a two way street. Poor people get leprosy because of overcrowding, malnutrition, and lack of care; leprosy makes people poor because of social stigma and chronic disability.

The patient with leprosy is an emaciated old man. His face is riddled with thick nodules and the cartilage of his nose is collapsed, the hand he proffers for his drugs is a claw that is missing most of its fingers.

“He says he doesn’t have enough food,” the Community Health Worker informs me. I explain that our protocol allows him only one week’s food ration per month, a strategy that is meant to improve adherence to treatment. But I feel mean and stingy as I speak. No sooner is he gone than I start to think that this is probably one of those instances for which the rules were made (i.e. to be broken).

There is always next month.