Final Call from South Sudan

Nine months have passed since I first arrived in South Sudan and it’s almost time to go home. It seems I have have spent the last few days constantly typing – staff evaluations, January’s medical report, a handover report for the project’s new doctor. We also had a small going away party in the clinic for me and one of our nurses who has just left Bentiu. I was delighted to receive many gifts including traditional shirts, bracelets, a spoon for eating wal-wal (a traditional local food) and a Nuer spear.

I have tried to spend a few moments reflecting a little on my time in Bentiu. Since May last year the weather has changed from searing heat, to torrential rain, to the relatively cold nights of the early dry season when temperatures can drop below 20 and now back to dry, dusty and very hot with daytime temperatures in the 40’s.

I have also seen many changes in Bentiu. When I first arrived the population were recovering from recent aerial bombardment of the town. Then in the rains I saw the people struggling to get even basic commodities for their families with food shortages, high prices and the town almost cut off from the outside world due to roads being flooded. Later as access became easier and crops were harvested the situation became more ‘normal’ and with prospects that the nearby border with Sudan may be opened and that oil may finally again flow from the nearby oil fields the people can look forward with some hope.

Many humanitarian challenges remain in Bentiu and South Sudan however. The security of the population is threatened by inter-tribal cattle raiding and violence as well as on-going tensions with Sudan. South Sudan is host to hundreds of thousands of refugees many of whom are fleeing violence. Many people are returning to the country after years and decades away from their home land. Basic infrastructure is almost non-existent. The majority of the population live in severe poverty and access to even basic health care is very limited. The work of MSF in South Sudan will continue.

Tomorrow I begin the long journey home via Juba, Nairobi and Amsterdam. Finally in a few days I will hopefully arrive back in the west of Ireland. Many memories of South Sudan will remain with me forever. Sad memories of seeing first-hand the dire circumstances many people have to endure or of witnessing the death of a small child. Disturbing images like seeing a small boy play with an imitation AK47 possibly trying to mimic his father or other men. But mostly happy memories of seeing a mother’s joy when her child gets better, the appreciation of our staff for training and coaching given, the surprise on people’s faces when I talked to them in my few words of Nuer, of working together with the rest of the team and of the beautiful sunsets.

I would like to thank all the people from all over the world that I have had the privilege to work with over the last nine months. I want to thank also all of the staff in the Bentiu project and all of the patients and their caretakers for welcoming me into their community. I want to thank my family, girlfriend and friends for all of their support. Thanks to everyone who has read this blog and to all who have left comments of support and encouragement. In difficult moments it was good to remember that so many people support our work. Thank you especially to the people from all over the world who make donations to MSF. Without you there would be no MSF.

Until next time.

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The Traditional Way

I have only a few weeks left on my mission in Bentiu. Numbers in our nutrition programme have decreased over the last few months, which is a good thing. Nonetheless, the team are still busy as our project is set to undergo major change, handing over our nutrition activities to the ministry of health and other NGOs and also planning the start of a full TB and HIV programme here in Bentiu. This will provide a much needed life-saving service for the people of Bentiu and northern Unity state whose only previous access to TB treatment was in MSF’s hospital in Leer south of here, an arduous journey and one that is not even possible for a few months during the rains each year.

I am also trying to cram in all the things that I wanted to do but never got around to before because of being too busy.  One that I really don’t want to miss out on is a visit to a local traditional healer. Like almost everywhere else in the world many people here resort to traditional and alternative treatments for a variety of reasons such as cultural beliefs, traditions,  lack of access to mainstream medical care or dissatisfaction with the care they have received.

After a bit of arranging I find myself accompanied by two of our national staff nurses sitting outside a traditional tukul dwelling having a conversation with James*, a renowned local traditional ‘bone setter’ (there is no actual word for James’ line of work, people just refer to it as traditional treatment). It’s a relaxed atmosphere. James is open and friendly and has no issues with me taking notes and pictures and writing this piece. There is no traditional garb or chanting. He is wearing western clothes but somewhat disconcertingly is waving a hack saw blade in his hand for most of our chat.

James hasn’t had any formal training. He did not go to school or study. His father practiced the same methods and he learned from him growing up. He doesn’t profess to have any magical powers saying only he learned the trade from his father. He focuses only on fractures and bone problems. There are an array of other traditional healers to deal with other problems. Throughout our conversation he expresses absolute confidence in his methods saying “I have never come across a case that I cannot manage and I enjoy the work.”

I am interested to know what exactly James does and he has a case on hand to show as an example of his work. A 15-year-old boy is brought forward. Wrapped around his right leg are a collection of random pieces of material acting as dressings. These are covered by a lattice of sticks obviously serving as a kind of splint. When I ask what happened to him I am told he suffered a gunshot wound to the leg in a crossfire two years ago. He had been to the hospital where he was told the leg needed to be amputated. Rejecting this offer, his family had brought him to James.

James explains that the boy had a big wound and a fracture but now “he has become good” thanks to his treatment. He says that the sticks are used to splint the broken bone and not allow it to bend. They are left on for three weeks only. Also he has given the boy injections of antibiotics including penicillin and erythoromycin. The boy can carry the leg a little alright but even from a distance it looks very swollen and multiple flies are circling over one area of the dressing where I suspect a festering wound lies underneath.

I ask James what type of treatment he has given the wound. He assures me he dresses the wound regularly using iodine as an antiseptic. Also, he says he washes it with warm water “to make the movement of the blood OK”. The use of warm water seems almost a universal treatment here for everything from diarrhoea to rashes. It sounds harmless but I have seen children with burns following parents pouring boiling water on their skin in the mistaken belief there would be some health benefit.

When I ask James if any particular sticks need to be used to make the splint or if they come from a particular tree the question is greeted by rapturous laughter. This type of traditional medicine at least is based only a partial understanding of mechanics and not on any magical beliefs. I also get a look at some of James’ ‘instruments’ –  fairly old looking scissors, a new-looking artery forceps and a few other items. He explains he uses the hacksaw for cutting parts of protruding bone from open fractures.  He shows me the solution he uses to disinfect the instruments – a bottle of ‘Tetol’ (no not a typo!).

While the word ‘traditional’ is used to describe this treatment, it doesn’t come cheap. It can cause harm to people’s finances as well as their health. The course of treatment costs 1,000 South Sudanese Pounds (about €250) per person. Whilst James comes across as a modest man he is known to have four wives and very many cows, clear signs of wealth in South Sudan. He is busy, he says, claiming that he does not even have enough space in the tukul to accommodate all his cases. I am told by one of our nurses that during the war there were even more cases coming here.

Before I leave, James proudly shows me one of his other ‘success stories’. He shows me a young man who had sustained an injury to his upper arm and shoulder. He is happy and smiling and seems pleased with the treatment. However the head of the humerus (upper arm) bone is quite obviously dislocated from the shoulder joint. He has limited movement of his arm.

Bentiu does not have a specialist orthopaedic surgeon. James himself says he would like to have some cooperation with the ministry of health,  perhaps so he can refer cases there or maybe because he wants to get some medication supplies from the ministry. These type of  ‘traditional’ practices will continue until a proper health infrastructure is in place and probably even beyond that. This is certainly a public health challenge. Part of the solution may involve working with people like James, perhaps training them as community health workers, though such work would certainly not be as lucrative.

Of course there are many different types of traditional healers here in South Sudan, and elsewhere in the world, of which James is only one. For many people their treatment is highly valued and respected. It’s definitely good to learn more about people like James and get a better understanding of what they do. I thank James and head back to the ‘conventional medicine’ world.

*Name changed to preserve anonymity


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Kala azar and the long road back to Bentiu

From the air South Sudan looks calm, peaceful, almost empty. Even now after the rains have finished much of the flat countryside looks green and lush, being taken up by the vast swampy wetlands of the Sudd. There are few signs of habitation visible partly because the traditional tukul homes of thatched roofs are difficult to spot even from the low altitude of the small aeroplanes that ferry aid workers from the capital, Juba, to the interior.

After six months I feels like I have seen so little of the country beyond my daily life in the malnutrition clinic in Bentiu. A couple of shorts stays in the capital Juba (a bustling town frantically trying to grow into a capital city to accommodate the government officials, UN agencies, NGOs and entrepreneurs that have flowed into the new country) and these glimpses from the air. So after a much needed in holiday in Ethiopia I ask to spend a few days in MSF’s project in Leer on my way back to Bentiu.

When I arrive the team in Leer ask if it is possible to stay a little longer to cover for one of their doctors who is sick. A few days turns into two weeks. Leer is a small town about 125km south of Bentiu. MSF run a hospital there providing a broad range of services including inpatient and outpatient medical care, antenatal clinics, maternity services, a malnutrition clinic, TB treatment and emergency surgery. It’s a busy place, there are few other health care providers in the area and this is the only facility in Unity state that can offer TB treatment so patients come from far and wide, including many from Bentiu and beyond. In one week during my brief period over two thousand patients were seen in the out patients department.

I try to grapple with the workload in the medical ward there, trying to review most of the 60-70 patients every day and thereby dealing with babies, children, young adults and elderly patients, seeing pneumonia, malaria, kala azar, TB and many other complex and difficult cases. Kala azar in particular provides a big workload for the team in Leer.

Like malaria, kala azar is a parasitic infection. It is spread by the bite of a tiny sand fly, people (such as those in southern Unity state) living in or near to forested areas are particularly vulnerable to sand fly bites. The sand fly is so tiny as to be able to get through the mesh of a standard mosquito net. Over 400,000 people get kala azar worldwide every year with one in ten of these dying. This is one of the worlds ‘neglected diseases’ for whose sufferers MSF are one of the few organisations to treat and act as an advocate for wider treatment. They didn’t teach us about kala azar in medical school.

Kala azar usually develops slowly with fever, swollen glands and an enlarged spleen. Many patients don’t present to the hospital in Leer until later in the disease when there is severe wasting, anaemia and often other infections due a suppressed immune system. Left untreated most case of kala azar are fatal.

There are many challenges in treating this disease. The drugs needed to treat it are extremely expensive, they can have serious side effects and some need to be kept in the ‘cold chain’ (between 2 and 8 degrees Celsius at all times) which can be a challenge in a country like South Sudan. Treatment takes from two weeks to over a month of daily or alternate day’s intravenous or intramuscular injections. Many of the patients need treatment for other infections, some need blood transfusion for their severe anaemia and all need nutritional support. While I was in Leer almost one hundred patients were receiving kala azar treatment in the hospital.

I enjoy the challenge in Leer but after the two weeks of hard work and having a pigeon laying an egg in my tukul it was time to go back to Bentiu. Strange as it seemed to me I was looking forward to going back particularly after not seeing my colleagues for a month.

The journey is an opportunity for me to see some of the country from the ground and also to get an idea of the kind of journey some of the people have to make to get to Leer including the patients I have sent from Bentiu to get TB treatment. During the rains and up until a few weeks ago the dirt road north from Leer was virtually impassable. Now it has dried out and left behind is a bumpy fissured surface with many huge craters several feet deep left behind from trucks trying to struggle through in the rain. Not far from Leer there are two towns but from there on there is little or no habitation. Further along we pass over a swamp area, the road is raised a foot or two above but has obviously sunk considerably from its original height. Along the way we see few vehicles, a couple of trucks (one broken down) and the public transport from Bentiu (a clapped out old pickup with several dents, a cracked windscreen and too many people crammed in the back).

The MSF land cruiser from Bentiu meets us half way. Here I swap cars and three children from our clinic in Bentiu with TB and severe with kala azar are transferred to the Leer vehicle. From here to Bentiu the road widens and has a gravel surface, there are less bumps, we can cruise along at a pacey 40km/hr. The landscape becomes drier and more arid.

When we finally reach Bentiu I am glad to be back. The 125km journey has taken four and a half hours, I am sure the public transport that the people here have to rely on takes a little longer.


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Christmas in Bentiu

As Christmas drew close I began to wonder what it would be like here in South Sudan. I thought it wouldn’t be a big deal in a place where most people live to day-to-day and can’t afford to make elaborate plans for the future.  I wondered if Christmas would be just like any other day

Christmas wasn’t just like any other day in Bentiu. In the days leading up to the main event various church groups started playing music and drumming through the night. Then on Christmas Eve many stayed all night in the Church praying and singing. On Christmas morning I went along to a Church service. The service had been moved outside to open ground behind the church, there was a small stage and two makeshift shelters with shade provided by mats supported by sticks, behind that there were some seats, then masses of people standing. There were three entrances to control the entry and exit of people, many ushers and organisers, and I would estimate about two thousand people of which I seemed to be the only foreigner. I only stayed for about an hour to get a small sample of proceedings. By that stage standing at the back and barely able to hear the music or see anything and with the sun getting hotter I think I had had enough.

After that it was on to our nutrition clinic to see the children remaining as inpatients for the Christmas period. Some of the children and their mothers had got new clothes and most people were happy wishing each other a merry Christmas. Thankfully all of the patients were fairly stable so there was not too much clinical work. After that I got to work on my side of the preparations for Christmas. I tried to cook 11.5kgs of rice (for which I discovered you really need a very big pot). My colleagues prepared the rest of the food at the expat house – delicious beef stew and greens. With plenty of help from the clinic staff and some of the mothers I decorated one of the tukuls in the clinic with balloons and arranged tables and benches for lunch. Then we had lunch in the clinic with the staff, the children and the mothers. Accompanied by some soft drinks, music and dancing. Everybody seemed to have a good time and hopefully could forget about their worries and concerns for one day at least.

In the evening we got the chance to enjoy some ‘Christmas goodies’ which we were able to order for our supply flight before Christmas. These were dispatched on the MSF plane from our supply base in Lokichogio in Kenya from where almost everything we need for the project is supplied, from medicines to logistical supplies to mosquito nets and blankets for the patients. So we enjoyed grapes, red wine, cheese, broccoli (strangely for me the biggest treat of all) and sliced ham. We even had turkey – a single slice of turkey (I am sure the team in Loki packing that for the flight had a good laugh). Unfortunately we were unable to source any additional turkey locally in Bentiu. So we enjoyed Christmas evening with more music, good food and good company. I even did a ceremonial carving of the slice of turkey so the six meat eaters among us could at least get a taste each.

It was a really enjoyable day though of course it is always lonely spending Christmas far away from family and friends. I hope all MSF staff all over the world and all of the people who support our work had a good Christmas.


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No home to go to

Kaderia* doesn’t know how old she is. As she tells me her story I try to guess her age, she looks about fifty but perhaps her difficult life has made her age quicker. As she talks her face betrays a life of difficulty and anguish but also a look of pride and defiance.

Kaderia was born in a village she calls Ogulu in the Nuba Mountains which is in the state of South Kordofan in Sudan. She was born in that village, grew up there, got married and lived all her life there until May of this year but now she says she will never return:

My village was a very good place, except this war when people came and destroyed everything and chased the old people until we eventually escaped and came to a safe place. The whole village was burned down.’ She says a lot of people in the village died in the attack.

Kaderia explains that nothing like this had happened in their village before this year. ‘I don’t know why these people did this, maybe they wanted to take the land from us’ she explains.

Kaderia’s difficulties didn’t just begin in May this year, she has lived a hard life. Her husband died shortly after they got married. She remarried to a soldier and he was killed in the conflict in the Nuba mountains. Before May she says she and many of her villagers spent more than five months trying to hide in caves in the mountains.

After they fled their village Kaderia and her people spent two days walking until they reached Yida refugee camp, located in northern Unity state in South Sudan. ‘Yida is a big area and it is good’ she says as she explains she has no desire to return to the place where she has lived all her life. ‘I don’t want to go back as fighting might erupt again, we will stay in Yida’.

Kaderia has no children of her own. She was brought from Yida to Bentiu by another NGO to act as a caretaker for a relative’s child who needed to be transported for surgical care. The child is now recovering in our clinic. I had presumed before our conversation that this was her grandchild such is the level of care and attention she gives to him.

She also has her own health concerns. When fleeing from the village she fell and injured her back. She is still experiencing pain. She looks tired but I wonder if her life will be any easier in the refugee camp or how long she will be able to remain there. Her only shoes, a pair of plastic flip flops, are worn to almost non-existence. She explains they are very old but she can’t afford a new pair which retail for about €3 in the markets in Bentiu.

Her story is only of the hundreds of thousands of refugees and displaced people in South Sudan. They face huge challenges in coping with a new environment difficult living conditions in camps and trying to integrate into a new community. Kaderia has however been through tough times before and I am sure if anyone can survive such a trauma she will.


*Names changed to preserve anonymity

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Nuoih – part 2

I have been trying to get an idea about people’s beliefs on the reasons for malnutrition here in South Sudan and having already asked  the clinic staff for their opinions, I ask some of the mothers in our clinic what they feel. I often get the impression that many of the mothers are in a state of denial that malnutrition is the problem with their child; they seem to think that the only problem is diarrhoea or malaria or cough. Maybe this is partly because of the Nuer characteristic of being a proud people.

The first lady I ask is not from this area and the conversation is in Arabic. Her two year old carries all the features of severe marasmus (malnutrition) that you read of in a textbook – wiry hair, thin ‘old man face’, loss of fat resulting in lose ‘baggy trousers skin’. She recognises that her child has malnutrition. She says he has been sick for a long time and they had no means to attend a health facility as until recently her husband had been posted in an isolated area and the family were with him. She however denies it was because of food shortage ‘I don’t even know,all I know is that he was very sick and it was not because of food shortage’. When I question her about the type of food she was giving the child she says she was only giving sorghum as nothing else was available. The lack of protein in the boy’s diet may well be the root cause of his malnutrition. She adds that her husband salary is paid irregularly ‘sometimes our husbands don’t get the money, and then when they do they run away, he also has another wife to support’.

For the next few mothers we are back speaking in Nuer ‘I think my child does not have a problem with malnutrition he is just sick with diarrhoea and vomiting’ offers one mother whose child is currently receiving therapeutic milk through a naso-gastric tube because of poor appetite related to malnutrition. Another soldier’s wife offers ‘we don’t have enough food for all the family, my husband is a soldier and sometimes will not be paid at the right time, it will be delayed for two to three months’. The next lady I try to ask is from the Dinka tribe and speaks neither Nuer nor Arabic and none of the staff around today are able to translate. This reflects the variety of people as well as views we have in the clinic.

In another tukul, I hear different stories. One woman tells me that her child is now malnourished because he was born during a time of insecurity. She is a widow. ‘We were attacked by a militia group (in April 2011), my husband was killed, all our crops were destroyed, our personal belongings were looted, we stayed two months without any food, the children got sick’. The woman explains that she is not from Unity state but a member of the Pojulu tribe. She has not yet received any pension from the government but says she has survived from the generosity of the local Nuer people.

Cows are a big deal around here, a sign of status and also important in settling disputes and matrimonial arrangements. One woman feels a lack of cows is somewhat to blame. ‘In this country people are living different ways of life, some have a lot of cows and food. For us we lack food. If you have a cow children will be drinking milk and be ok’. Maybe this faith in milk is part of the reason for trust in our inpatient programme where we off the special therapeutic milk. Of course cow’s milk can be healthy for children once it is safe and not given to young infants.

I hear one final story in explaining individual reasons for malnutrition. One lady, Elizabeth,* in our TFC stands out. Whilst many of our mothers are teenagers or in their early twenties, she looks much older. Her nine month old son Diew* has Down’s syndrome. This is not the first time he has been admitted to our clinic. It is impossible to know what the future holds for him, none of the facilities a child with his needs should have are available here. Elizabeth* is also a widow. Her husband passed away last year from a sickness she was told was typhoid fever.

Elizabeth* used to live in Khartoum and earned a living there cleaning houses. She moved back here because ‘we were informed by an international organisation that we should go home to vote, that is why we came here’. With her husband dead and her three oldest daughters married off as teenagers Elizabeth* has to provide for the three youngest children. ‘My duty is only to go and collect firewood which I will then sell in the market. Sometimes I will get ten South Sudanese pounds per day (about €2) if I am lucky, other days between three and five. I use the money to buy sorghum and milk for the children. I cannot afford meat, oil or beans’. When she goes to collect the firewood she leaves Diew* in the care of her six year old daughter. She also cannot provide safe water for her family. The water they get is from the river, she filters it through a clean cloth. The nearest supply of clean water is over an hours walk away and most days she does not have time to reach there. ‘This year also I planned to cultivate but my child was very sick so I could not’.

There seems to be many causes of malnutrition here and solving the problem will require many answers. For now in our clinic we continue to see and treat those most severely affected and advocate for broader action so that the situation will improve in time.

*Names changed to preserve anonymity

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Nuoih – part 1

The reason for our work here in Bentiu is to decrease mortality and alleviate suffering caused by an on-going malnutrition crisis. According to our statistics this year we have already ‘cured’ over 3000 children from malnutrition.

This is a concept I am very uncomfortable with. Sure we have improved the nutritional status of these children, treated any inter-current disease, our programme has probably saved many lives this year but how can we say we have cured their malnutrition without thinking what the causes are?

A few months ago a Belgian film crew visited our clinic as part of a story they were doing on the anniversary of South Sudan’s independence. They were very professional and courteous in their approach being sure to get proper consent before filming and following correct procedures. When asking about our work in the clinic they press me about the causes of malnutrition. They angle a little regarding the problems with the border dispute with Sudan and whether this is the reason. I think, how am I supposed to know? I am only here to treat the children and help them get better, before giving some politically correct response that the causes are ‘multifactorial’.

One afternoon I ask some of the staff in our clinic why they think there is malnutrition here. I get a wide variety of ideas. The Nuer have their own word for malnutrition – Nuoih. Most staff refer to a lack of food and also the fact that illnesses such as malaria and diarrhoea lead to malnutrition rather than being a consequence of it. There are other theories ‘lack of food, sickness, in addition South Sudan is a new country and has had a long war so a lot of things are destroyed’ offers one of our nurses.

So is the malnutrition problem is a new one? No; one of our paramedics informs me that before MSF opened a nutrition programme in Bentiu another NGO had run a programme from 2000-2008. Indeed he adds that since the 80’s people have been depending on the UN, the WFP and other organisations for food drops and feeding programmes.

Some staff seem to think it will just take some time for South Sudan to get on its feet. “It will take a long time with this new mechanism (independence), change will happen when security is stable because then people can cultivate and raise cattle, conflict causes displacement like with those of rebel militia groups which are fighting with the government.’

Since gaining independence from Sudan last year the border has remained closed and this has added to difficulties. ‘The border (being) shut down is also a problem, we do not produce a surplus, South Sudan depends on foreign aid. We have the land, we have the resources, we just don’t have the instruments – tractors and bulldozers – to develop.

The abundance of resources and potential here has been obvious to me since I arrived. The countryside is now a sea of green after the rains. The sun is warm, the potential to grow large quantities of food is there and this country is not over populated.

Weather conditions also seem to play a part ‘This malnutrition happens during drought which causes a food gap which will cause all children to be malnourished, even the adults.’ Too much rain can also be bad and some of the staff are not hopeful for the year ahead ‘this year will be a bad year, the people who went for cultivation (to grow food) their crops have been destroyed by floods’.

Another view expressed is that lack of access to healthcare and timely treatment leads to poor appetite and malnutrition. Others blame the geographical situation of South Sudan ‘We are landlocked here so we cannot get food from neighbouring states, also the road to Juba has been blocked by the rains.’ When I ask how come Uganda which is a landlocked country doesn’t have the same malnutrition crisis the answer is that ‘Uganda has a lot of traders, money, big farms they make their own food.

On-going insecurity also appears to be a factor which disrupts people’s way of life and traditional reliance on wider family and community. If you don’t have food yourself during insecurity you will not be thinking to go out to get food from somewhere like your relatives’.

So maybe my answer to the film crew was right, that the causes of malnutrition are multifactorial. I am also interested to see what the views of the mothers and caretakers in the clinic are.

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Difficult Choices

Nyakor* is back in our clinic, again. Her appearance is pitiful; thin, short wiry hair, tattered old clothes. She says she is about 23 years old, her son Chiang* is 4 months old and is losing weight again so needs to be readmitted to the clinic.

Nyakor has had a difficult life. She was born in nearby Mayom County. When she was 15 she was married off to a soldier in return for 40 cows for her family. Her husband was much older than her and his profession involved a lot of moving around. They moved to various places in South Sudan in addition to Uganda. Together they had three children. Last year her husband was killed in a battle here in Unity state. She was nearby at the time. After her husband’s death she was told by one of his relatives that his family would not provide for her and that she should go and search for someone else to look after her financially. A widowed woman with young children and no means to support them would be very vulnerable here. Normally the husband’s family would care for her or his brother would take her as a wife. She faced a difficult choice.

Pragmatically she says ‘So I left to look for somebody else and I found someone, he is a distant relative of my husband, Chiang is the first born child [from that relationship]’. She says she doesn’t know if that man will come back to her or remain with his first wife.

Nyakor says that before she met this man she was healthy but after she became pregnant she became sick with diarrhoea, fever and weight loss. ‘I am thinking for that lady now [the man’s wife], that she is sick also, and that I am better off as I have come for help’.

When Nyakor first came to our clinic over two months ago she was even more desperately thin than now, little Chiang was just 2.2kg and clinging to life. Thankfully over a few weeks he got stronger, put on some weight, started to smile.

During that admission I took Nyakor to the government run Bentiu hospital for voluntary counselling and HIV testing. Her result was positive and she is now on antiretroviral medications. ‘I am becoming stronger, with the medicine though I can get heartburn, nausea, constipation’ as she describes some of the side effects common from HIV medication. I previously worked in Zambia, a country with one of the highest HIV prevalence’s in the world. There, whilst a diagnosis of HIV is always devastating there would be much hope for Nyakor. She would probably have access to a well run HIV programme with guaranteed medication supplies, trained staff, adherence councillors, access to a laboratory to monitor her bloods.

Here things are entirely more difficult. The hospital HIV programme is run by a very hard working counsellor. He works out of a single room and has a limited laboratory he can use. He only has access to one regimen of medications, if the patient has treatment failure or severe side effects he has no alternatives. Supply may not always be guaranteed and he has no medications for children. The only well resourced HIV programme in Unity state is run by MSF in our hospital in Leer, 100km south from here. Road transport between the towns can be difficult to impossible, especially during the rainy season.

With Nyakor’s positive result I was obviously worried for Chiang. Diagnoses of HIV in infants cannot be done with the standard rapid tests used for adults. Thankfully I was able to send a sample for testing to Nairobi and the initial result was negative. But then came a difficult decision. In settings like here women who are HIV positive would ordinarily be advised to exclusively breast feed their child to six months. But given Nyakor’s illness and subsequent poor milk supply Chiang needed supplementary feeding to survive. Mixing formula and breast milk in a young infant increases the risk of HIV transmission so I had to advise Nyakor to take the difficult decision to stop breast feeding.

When Chiang got stronger a few weeks ago, he and Nyakor were able to leave the clinic. She would have to fend for herself in Bentiu, find food to eat for her and the older children (one of whom is now being treated with plumpy nut in our outpatient clinic) as well as provide formula milk for Chiang. It’s no surprise that Chiang has lost weight again though I think if he makes it to six months so he can start solid food he will be OK. Nyakor has a limited amount of insight into her illness and how she contracted it. ‘I just know I have a virus in my blood, that I got through sexual transmission’. She hasn’t fully grasped yet the lifelong nature of the condition and the medications ‘Now I feel strong, maybe I will need to take the medicine for two more months then I can stop’. Thankfully she has developed a good relationship with the counsellor in Bentiu hospital and hopefully in time will begin to understand more fully ‘I feel this may kill me in the future, but from the date you discharge me I will always go for review’.

Nyakor doesn’t have any grand plans for the future. Her dreams are of survival only and she will make whatever difficult choices she has to make to provide for her children. ‘All I want is to build a shelter and try to protect myself, my children and my food’.

*Names changed to preserve anonymity

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Before departing for a first mission with MSF people have to complete a PPD (Preparation for Primary Departure) course. This involves eight days of intensive preparation on issues such as team building, management skills, cultural and security awareness as well as more specific medical and logistical topics. As well as helping me prepare for working with MSF it was a great opportunity to meet over twenty people from different countries and backgrounds. We have managed to keep in touch since then through a Facebook group. Shortly before I departed for South Sudan I had a look at a few of the posts and one in particular struck when one of my PPD colleagues responded to a general question, how those already posted to a mission were finding the experience. Her response simply read ‘passed through all emotions you can imagine’

I am often reminded of this post when during any given week I can pass through emotions ranging from amusement when some of the mothers laugh at my attempts to speak Nuer, frustration at the difficulty in doing basic things in South Sudan, joy at seeing a child recover and marvel at the simple sight of bubbles, to despair when a child dies. Sometimes you can feel overwhelmed by emotion and it’s difficult to find somewhere to escape given long hours at work and the daily routine of compound-clinic-compound.

To try and get a little escape one Sunday morning I decide to accompany George our ATFC (Ambulatory Therapeutic Feeding Centre) supervisor to a local church service. It’s an opportunity to see some of Bentiu life outside the TFC and to remind myself that there is more to life here than childhood malnutrition. The service takes place in a simple, small church comprised of mud walls and a grass roof supported by sticks. There are no grandiose religious artifacts. Nor are there any dreary or serious people. It’s a joyous occasion where families have come together to pray and also to sing, play music and dance and socialise.

A few days later over some tea I chat to George and wonder how Christianity can mingle with local traditions. George is very much Nuer. He bears the scars of six straight lines across his forehead which were made with a knife whilst still a teenager in keeping with tradition. These are called ‘Gaar’ in the Nuer language. These marks are used to distinguish Nuer from other people. Some people say they have originated from colonial times when colonists wanted to easily distinguish between different tribes but others believe they are more ancient than that. George also has had his four lower front teeth removed when he was just eight years old, again another traditional custom. He has two wives and six children. Unlike many Nuer he is not particularly tall but he is proud yet kind. I ask George what it means to be Nuer. He mostly talks about a code of life involving not stealing another’s cows or wife. He also tells a story about the origin of the Nuer people.

‘Long ago some people were gathering in one place and they took a gourd which had been cut into two pieces to make a bowl. Then they called themselves and each one put his own saliva into the gourd. When they saw the gourd was full of saliva they got soil and mixed it with the saliva. Then everybody drank out of that gourd. Then they made rules and laws and if you broke these you will be punished or die, and that is where the Nuer people come from’

George goes on to tell me that the Nuer people live in Northern part of South Sudan and some even in neighbouring Ethiopia. He explains the welcoming nature of the Nuer saying that ‘if you live among us in my house for one year I will share my food with you and even give you some cows so that you may marry’.

Life is hard for many of these people now with many struggling to feed their families, access to health care and education poor and the ongoing risk of further insecurity. Add to that the previous centuries of domination by various groups. It puts my own emotions somewhat in perspective.  George doesn’t recount much history of times past but does say that during 1997-2004 ‘I witnessed a very severe time with a lot of fighting and a lot of death’ Talking to people like George helps put the difficulties I perceive as facing into perspective.

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Happy Birthday South Sudan

As seems to be the norm here in South Sudan there were a lot of different predictions going around about what the 9th of July, South Sudan’s first birthday would bring. There were rumours that the government were going to announce five days of public holiday as part of a nine day celebration. There were rumours of movements of rebel militia groups to the north of Bentiu. There were fears that over indulgence might lead to rowdy behaviour among some sections of the large military presence in the town.

As a security precaution a decision was made that our international team would spend the day in the compound with no movement outside and only maintain contact with the clinic via radio. I was very much against this decision but I am the doctor not the security responsible and those that make these decisions have much more experience of working in similar contexts than I. In any case I wasn’t feeling the best and needed the rest so the Sunday and Monday were the first two days since I arrived that I did not go to the clinic.

Thankfully the day passed off peacefully, reportedly there was a parade in the town with music and military display. There were no reports of any trouble. Sensibly the government decided on just two days public holiday. On Tuesday it was back to work as normal in the TFC (Therapeutic Feeding Centre) so it seemed a little bit to me like independence celebrations did not happen at all. A brief look online at news stories related to South Sudan’s celebrations revealed plenty of negative headlines such as ‘Juba’s bitter anniversary’ from the Guardian or ‘Viewpoint: South Sudan has not lived up to the hype’ on the BBC.

I feel this is overly harsh on the ordinary people of South Sudan, yes while there are many challenges but at least now the people can hope for a brighter country. Also it’s very quick to write off South Sudan as a ‘failed state’ after just one year. I wonder what the media were writing about Ireland in 1922 when shortly after independence the country was in the grip of a civil war?

There are huge problems in South Sudan. In Jamam and Yida in massive refugee camps MSF and others struggle to provide water, food, shelter and healthcare in dire circumstances to almost 200,000 refugees from Sudan. Throughout the country access to education and basic healthcare is limited. Inflation is high and the economy, which is almost entirely dependent on oil revenues, faces huge challenges. Corruption is also reportedly a big problem and even the president Salva Kiir has admitted that $4bn may have been misappropriated since 2007. Inter-tribal violence mainly arising from cattle disputes is also a huge problem in parts of the country.

However many of the people I meet here are happy and almost all are proud of their new country and proud to call themselves South Sudanese. To help get a better perspective than the headlines a few days after the anniversary I try to get a snapshot from a few people in the clinic about what independence means to them:

‘Because we get our right to be a new nation….also because for us to work hard to defend and develop ourselves as a new nation’ John, nurse

‘I am happy because we have a new nation’ Freeda, mother

‘We have our new government without obstacles in South Sudan, but we are still weak because we don’t have anything, we need some help as we are like a newborn baby we need help to raise us up’ Janes, father

‘It’s fine for me, you help us to treat our children, as our government is still yet weak, until our independence becomes strong’ Nyalada, mother

‘We are happy , we were even brought here by the international Organisation for Migration, here in our new-born independent South Sudan. We hope to get help from other countries because we are independent country’ Nyamen, mother and recent returnee from Sudan

‘If the government becomes strong our children will be ok, it is now new’ Elizabeth, mother

‘We are happy because we are in our new country, even though it is weak we thank those who help us, we will continue until we become strong’ Nyaboth, mother

‘Independence is good for freedom and fairness and also people will help develop a good society, because before we didn’t have any good services or prosperity’ James, nurse

It is clear that these people are happy and proud of their new nation whilst accepting the problems and the need for outside help. So let us wish them well on the first birthday of their new nation and hope for a brighter future.



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