Honeymoon in Chad

The Irony

I fear I am getting fat.  It is always a danger on a MSF mission, where you have little control over food, little opportunity to exercise, and mealtime is the main social activity. And of course, where you rely on Pringles as a stress-management strategy.  It’s ironic, though, as Grant is under the exact same circumstances and it seems to have the opposite effect on him.  So unfair!

Even more ironic is that I am currently in one of five nutrition projects we have here in Chad.  So as I indulge in a mid-afternoon dunk in the Nutella jar (a rare but cherished treat), we have thousands of malnourished kids under 5 lining up each week for their supply of Plumpy Nut – the high-energy, protein-rich, fortified, peanut-based power bar that will hopefully put some meat on their bones.

Women and children, waiting to be screened for our feeding program.

The Facts

According to the MSF nutrition webpage, 195 million children suffer the effects of malnutrition every year, 90% of whom are in sub-Saharan Africa and South Asia. Malnutrition is a factor in 1/3 of all deaths of children under 5, exacerbating the effects other illnesses.  While the vast majority do not die from malnutrition or associated illness, they do suffer physical and mental delays that will shape them through to adulthood.  This damage occurs largely before their second birthday.

How’s that for my paragraph of hard-hitting statistics?

The Response

This year was particularly bad in Chad as there was drought in 2009, wiping out huge tracts of the 2010 harvest.  Between March and August,  MSF opened 12 emergency nutrition programs across the country and integrated similar activities in its longer-term projects.  As of December, we have treated more than 30,000 children for severe malnutrition.  And counting.

In addition to running nutrition projects across Africa and Asia, MSF has launched a multi-media campaign called “Starved for Attention” to bring attention the issue of malnutrition.  Not only are they advocating for increased aid money to address the issue, they stress that the type of assistance given must change.  Typical food aid is in the form of fortified cereal blends of rice and soy, which do not meet basic nutritional standards for infants and small children.  MSF is advocating for the provision of food supplements that target the specific nutritional needs of these most vulnerable.

You can learn more about their campaign and sign a petition at www.starvedforattention.org.

More Irony

There has been a lot of baby talk around me lately as friends and family members pop out baby-buntings in quick succession.  Lots of researching and discussing different child-rearing techniques and trends, including detailed menu planning for babies as they transition from liquids to solids, avoid potential allergens, and have the perfect balance of different colours on their plates.  I eagerly take notes for my own future reference.

But I can’t help but contrast this to the women who arrive at our feeding centres, with a baby slung on their back, a toddler at their side and older siblings waiting back home in their mud huts.  Their diet is based on millet and maize; soupy and sweet in the morning and boiled into a big ball for the evening.   Hopefully a bit of goat meat or some beans, for the older children at least.  Maybe some peanuts and sweet potato?  What, of that bounty, will make its way to the two-year old’s tummy?

Written by Grant…

Old Story with a New Twist

Did you know that some girls here in Chad are expected to be married and out of their father’s home by the time they have their first period!?  Imagine.  Actually, it isn’t something I can even come close to imagining – and I see it every day.   So don’t feel bad if it seems a distant story to you, unrelated to your world of Boxing Day shopping and family ski trips.

Plus it is usually an arranged marriage.  Plus it is often to a much older man.  Plus it is likely that this man already has a wife or two.  That often puts them pregnant with child number one before they are 15 years old.

One of our community health workers is 23 and has 7 children.  You do the math.

While I am caught up in the social and psychological consequences of this all, our doctors and midwives see the medical consequences of young pregnancies.  The girls’ bodies are not fully developed and are not ready for pregnancy, let alone delivery. This puts them at higher risks of complications, including obstructed labour, fistulas, and ultimately, miscarriage.  There was a recent delivery of twins at the hospital.  It was the mother’s 11^th pregnancy, of which 6 were stillborn….

…but the real kicker is that, according to our midwife who actually delivers their babies, THEY ARE HAPPY!  The girls seem thrilled to be having their first child at 14 and to officially become a real women.  Wouldn’t want anything else.  Somehow they don’t seem to mind the fact that they go from child to women and miss the whole being a girl part.

In my mind, I have this picture of Muslim men making their wives cover up, keeping them from going out, forcing them to have more children.  Yet it is a whole, complex social system that somehow makes it not only OK, but truly the norm.  And, in the end, it is not the men but the WOMEN who directly enforce this strict code.  The grandmothers and mothers and sisters.  It seems it is not only accepted by the women themselves, but also DESIRED by them.

Too young to be mothers?? Depends on your perspective…

So while I always thought those other things were so appalling – the older man, the arranged marriage, that they are so so young – it is the fact that, for the most part, these girls seem to be HAPPY to be having this first child at 14 that is so hard for me to swallow.

How can I even comment on the situation, or pretend that “my” way is better, or to even start to understand how things work in this context when it is so far from my ability to grasp this one thought?

Meanwhile….Dancing in Am Timan

Yesterday, we held a party to mark the departure of two of our expats.  There was a Medics vs. Logistics soccer match, followed by a dinner of roasted lamb, dates and your choice of orange Fanta or beer.  Of course there were a few speeches and a bit of music, but mostly people just come for the free food and any change from the ordinary.

Being new to this Muslim context, I had no idea how things would work but definitely didn’t expect there to be much dancing.  Wrong again.  Our cook, the quietest and reserved female staff member that we have, led a charge to the dance floor with some high-pitched yelping, 10 seconds into the first song.  Suddenly that awkward pause where the dance floor is huge and no one is willing to be the first was no more.

Our cook, hard at work in the expat kitchen.

Later in the evening, an Indian-type song came on and another of our female Chadian staff jumped into action.  Although she dresses well, every time I’ve seen her she has always been completely covered – everything but hands, feet and face.  Yet there she was, alone in the middle of the dance floor in a tight-fitted pink top, her wrap left discarded on her chair, her hands high in the air and her chest pumping in and out in a frantic rush to keep up to the beat.

Two and Two Together

The 23 year old community health worker with 7 children wants 5 more.  That makes 12 in total.  She is one of the best from our team of twenty…loud, outspoken, intelligent.  She knows how to laugh and has bright eyes that always seem to shine.  Nothing at all seems wrong in her world.

…and I am left asking myself just how does it all fit together!?!?

So, two months into my 5^th mission with MSF and you have a glimpse into what is bouncing around my head these days.  It is only once I am able to rationalize these ideas that I will be able to properly coach the other expats and guide the programs here in Am Timan.  Not there yet, but working on it.

Grant told me I have to write about something positive for the next blog.  No more vomiting cholera patients or corrupt shopkeepers.  So the most positive thing I could possibly think of is R&R  [rest and recreation]!  A long weekend in the capital city (N’Djamena), promised to each expat after 6-8 weeks in the field.  R&R is particularly wonderful for Grant and I as we actually get to see each other!

There is a hotel in N’Djamena that epitomizes exactly what an R&R is and should be.  It is one of the nicest hotels in the city (and by default,  in the country) and has a full-size, outdoor, clean, swimming pool, complete with lounging facilities, a snack bar, and showers that have both HEAT and PRESSURE!  The shower alone is worth a visit, after weeks of cold bucket showers in the bush.

It costs 10,000 francs, or about 20 dollars, to use the pool.  10,000 francs is the largest banknote available in Chad and equivalent to 3 days salary for our well-paid unskilled daily workers, facts that quickly fade from your mind as you slide into a padded lounge chair and beckon the waiter for a fresh pineapple juice, on ice.   ICE!  They have ice!!!!

At the pool you will find a collection of NGO workers, bush pilots, oilmen, off-duty international soldiers, and a licorice all-sorts equivalent of UN and other diplomats.  If one were to generalize, one could say that the bush pilots are a friendly bunch with little pot bellies and salt and peppered hair; while the soldiers travel in packs and collectively display an impressive portfolio of tattoos.  The NGO/development crowd seems the largest, youngest, and most female-dominated, making for an interesting pool-side mix.

You can tell those who have office jobs in the capital and are regulars at the pool from those who sweat it out in the bush and are just here on R&R.  The former have beautiful, bronze tans from head to toe, while the latter have beautiful, bronze tans from the elbow down and the neck up.  I also have the classy bandana tan across my forehead.

This particular day, all the women are in bikinis.  I seem to be the only one in a one-piece – a sensible speedo at that!  Here, apparently, men wear speedos, not women.  Quite a contrast to the world beyond its walls.  I feel like a bit of a prude, but just wait until I pull out my swim cap to do some laps!  Not to mention hairy legs.  Fortunately I need only to impress Grant and he is already sun-burned and obviously no pool-princess either.

We had an amazing day of relaxing, swimming, snacking, reading, vacation planning, and just being together.  And for the first time since we arrived in Chad, we didn’t once think about…..what organization is it that we work for again???

Well, 4 weeks later I am still in cholera country.  What were originally instructions to “go check it out for a few days to ensure the watsan components are in place” has turned into a month of building fences and latrines, setting up tents, negotiating with donkey-cart owners for water transport, choking on fumes as I distribute chlorine powder to health centers and trying to win over hygienists so they will clean vomit buckets on their own initiative.   Not all has been successful….but overall I can say that things are now pretty much “in place”.

Over the last month, I have had to make a lot of random local purchases….kerosene, buckets, beds, wood, brooms, etc.  And of course,  I always need a receipt so that our administrator can balance the books.  Usually, after asking for a receipt half a dozen times and receiving a seemingly positive reply but no actual receipt, the driver intervenes in Arabic.

Sometimes, for example the flasks of kerosene set up on the side of the road, the concept of a receipt is so foreign that I just scribble my purchase and the date on a blank page in my notebook and rip it out at the end of the day to give to our administrator.  Often, the less-than-entrepreneurial merchant searches around and pulls out a dusty old receipt book.   In some cases, he fills it out and gives it to me, as would be expected.  More often than not, though, he hands it to me and I fill in all the details, presumably because he cannot write French (or at all???).  He then very officially, distinguishably and dramatically, signs and stamps the receipt, having no idea what I have written.

Local kerosene enterprise. No receipt.

In one case, after haggling and bargaining and arriving at the still-inflated price of about $60 for some water barrels, I asked for a receipt and the storekeeper asked me what amount I would like him to write on it!!!  Am I a fool to think that he should write $60?

I have to be honest. Writing a blog is hard sometimes.  There seem to be a few traps.

First of all, there is the danger of reinforcing stereotypes.  We are all guilty.  We seek out our preconceptions and our stereotypes and look to validate and reinforce them as truths.  We immediately pull out our cameras when we see what we think is the “real Africa” or the “real” country X, Y or Z.  When we see the World Vision infomercial in living colour right before our eyes.  When we see the tribal women on the donkey.  The cute naked children playing in the dirt.  The lone mango tree in the sunset.  The kicker is that these stereotypes do originate from some grain of truth.  And these images do exist so they must be true.  But, they are partial and over-simplified truths; and partial and over-simplified stories are so much easier to tell.

Another danger is always being negative, because, well, we are sent to war-torn, under-developed desperately poor places.  With, often enough, an epidemic of some sort thrown in for good measure.  Sure, there are laughing children and a perseverance of spirit which serve to inspire.  But these things often exist in somewhat of a depressing and hopeless context and stand out only because of their stark contrast with what is the norm.  Even if that is not always the case, it is easy to feel that way when you are working long hours, drinking warm water all day and have a multitude of insect bites.

Do I ever notice laughing children in Canada?

There is also the danger of superficiality.  While the complete overtaking of our compound by hideous toads serves as valuable comic relief, it is at times too tempting to skirt the more complex issues and incessantly lament about how hot it is here and how my sweaty forearms stick to my paperwork and smudge the ink.

So, in the blogs that follow, please forgive my narrow presumptuousness, any cynical tendencies, and the odd lapse into the superficial.

While Chantelle has been busy exploring the world of Cholera in the southwestern corner of Chad, I have immersed myself in the increasingly complex project of Am Timan.  It has been intense, to say the least, and after 7 weeks in country I am only today enjoying my second full day off!

Regardless, I am learning…learning lots and fast and continuously!  Learning about my staff, the programs we are running or hope to start, the history of MSF in the area, the Muslim religion, local politics, security management.  Although questions often lead to more questions and answers can be somewhat conflicting, I am slowly getting a feel for how things work around here.

Nice and Easy

Take, for example, our nutrition program.  When we opened in February of 2010, we used nutrition as our entry point with the ministry of health.  This is one service that was not being provided by the ministry of health and we showed up in their hospital with the idea to treat whatever small number of malnourished children could be found in the area.  From there, we would get a better idea of the current condition of the local population and the capacity of the ministry of health in their provision of care…and we could go from there.

The first month, with all of the staffing and supply problems common during a project startup, we admitted 34 malnourished children under 5 years old into the program. 149 in March. 211 in April.  By the end of May we had 401…and it just kept growing and growing!  To date, we have treated over 3000 children for malnutrition and still have more than 500 kids coming each week to receive their bag full of PlumpyNut or what can best be described as a high energy, nutrient enriched peanut butter paste.

In Am Timan, we go through 60,000 sachets of PlumpyNut each and every month!

Receiving Care at our treatment center.

What’s Going On?

We were shocked by the numbers!!  Remember that Am Timan is located in what is called the “Granary of Chad” and is known for its consistent and plentiful production of millet, sorghum, corn and beans.  Yet we kept finding huge numbers of malnourished children and we weren’t even really looking.  So much for a quick and easy entry point with the ministry of health, as suddenly we were running a full blown nutrition program!

Mothers waiting to have their children’s weight and height taken, as part of their weekly trip to the MSF nutrition center.

In the end, it seems that even this rich agricultural area was not spared by the lack of rains consistent across the Sahel region of Africa over the past 2 years.  In Am Timan, these drought-like conditions reduced harvests and farmers had to dip into savings to plant for next season and to feed their families.  While the rains improved and things were looking up for 2010, there was huge and unprecedented rains in September that led to widespread flooding and practically wiped out what was looking to be a very promising harvest.  Less food, more debt and definitely more skinny and hungry kids.

The list goes on.   A general lack of hygiene, zero latrines outside of Am Timan and very limited clean drinking water leads to what could be considered endemic diarrhea.  And, as you can only imagine, it only takes so many days of constantly running to the bush to shit before malnutrition sets in.  Men also have to pay a significant dowry to get married (roughly 9 head of cattle per wife!) and this is often only managed by borrowing money.  With the September crops all but destroyed, farmers will have a hard time making good on their pre-sold grain contracts this year as well.

It’s pretty simple.  Bad harvest = less money = more debt = less food = more malnutrition.

Fish Season Brings Temporary Reprise

During each rainy season, torrential rains fill the otherwise dry and sandy ‘ouadis’ and, in this granary of Chad, they always overflow to cover vast flood plains with live-giving water.  The rains normally end in September and the waters recede, leaving behind enormous fields of nutrient rich soils that are rapidly and completely planted with millet for next February’s harvest.

As these gigantic ‘rivers’ shrink (some can grow to more than 50 km across!!!), bottom feeding sucker fish become concentrated in smaller and smaller areas and it is literally like fishing for trout in a stocked pond.  Fish flood the market – cheap, meaty and delicious – and it really is “la grande fête”.   Boxes of fish are sent to relatives in N’djamena.  There is a real buzz in the market and around tea stands.  Even the expat team got our fair share!

Deep Fried Goodness

Unfortunately, this “fish season” only lasts 1 month as the ouadis are bone dry once again and will remain that way until the rains start again next June.  For now, this short burst of protein has led to a slight decrease in the number of patients in our feeding programs.  However, with the September harvest largely destroyed by floods this year, we are expecting our numbers to peak in January as people hungrily await the harvest of their recently planted crops.

…and so we ramp up our nutrition programs accordingly and help then wait it out.

In theory it makes sense, but man oh man, in practice – it has the potential to be a real circus.

For example, we have tents set up in essentially an open field, with plastic sheeting floors.  Have you ever tried washing a plastic sheeting floor in a dirt field with patients and vomit buckets all around you, and chlorine foot baths that everyone has to dip their feet into before entering the site?  Using a bucket of water and a squeegee.  Guaranteed chaos, right there.  Worse even, have you ever tried to coordinate someone else to do it, when you don’t quite speak the same language, linguistically and otherwise?

Rehydration bags hanging on fence posts.

But everything seemed to be going smooth with numbers of new patients going down.  Our treatment centres had only 4-7 patients in them by now.  Then the water pump in one village broke and everyone started drinking from the river.  Hello oral-fecal contamination!  Boom – 21 new cases the next day.  13 new cases 2 days later.  We only have maybe 10 beds!  So, patients are literally laying on the ground, on a mat, on a plastic woven grain bag, on a flattened cardboard box.  Or directly in the dirt, which is now pretty much mud because we just tried cleaning the plastic sheeting floor with more-than-instructed amounts of water.   And we haven’t quite finished the new laundry platform so women are washing clothes and dumping the water in the dirt.  Again – a three-ring circus in the cholera ward!

The IV rehydration bags are everywhere!  Massive bunches of  bags hanging from tree branches, from fence posts, or held up limply by the patient’s care giver.  The nurse can now barely keep up in replacing them as each patient goes through about 7-8 per day!

A patient laying on the ground (beside the latrine) vomits on one side, rolls over, and 15 minutes later vomits on the other side.  The superstar hygienist rushes over with his chlorine spray solution and pulverizes the ground where the vomit is, and on his way back to his post at the main entrance sprays the backside of patients with continued diarrhea.

Hastily fashioned cholera beds.

One phrase from the MSF Cholera Guidelines kept flashing through my mind: “Cholera treatment centres can become main sources of contamination if hygiene and isolation measures are insufficient.”

Fortunately, our circus was fairly short-lived.  We quickly found more beds, finished the laundry platform and revamped our floor-washing techniques.  Oxfam is now busy distributing chlorine to households and has repaired the well.  We asked the Ministry of Health for more nurses (paid partially by MSF), and hired more hygienists.  I just wished we had those buttons that read “In training – thanks for your patience.”!

We first heard of cholera cases in neighboring Cameroon in August and we began monitoring the situation in the corresponding border areas of Chad.  By September there were cases reported here, but it seemed the Ministry of Health, with supplies from UNICEF and WHO and logistics support from Oxfam, were managing and the case numbers were stable.  Then there was a spike, with 40 new cases per day in a single health centre!   Enter MSF!

We sprang into action, but even so, the response may not be as springy as you might think.  We need to first receive the information and make a decision to intervene.  Then, we are a day’s drive away, need to load trucks with supplies and treatment and somehow round up enough bodies (preferably an MSF nurse or 2, a doctor/coordinator and a logistician, plus several Ministry of Health counterparts) to actually deliver treatment to patients.  While MSF does essentially have people “on stand-by” for this type of situation, they are essentially standing by in Europe or at best, in the capital city.  But, three days after the first sign of a major peak, we were on the ground, in action.  Not bad, I’d say.  As for myself, infection control is paramount in a cholera epidemic, involving fairly involved protocols for disinfection. That is where the watsan comes in!

We are now supporting 4 different Ministry of Health health centres, by operating a cholera treatment centre (CTC) at each.  Oxfam, WHO and UNICEF continue to participate in the response as well.

Our CTCs are basically a torrent of plastic sheeting, IV rehydration bags and chlorine.  Everything from fences to patient tents to latrines to medical “offices” are made from very expensive, high quality plastic sheeting from Europe.  Precious stuff and after any MSF intervention you are bound to see scraps of it throughout the neighboring villages, patching a leaky roof, providing a ground sheet to dry beans/maize/peanuts/millet, serving as a sleeping mat, or even a bicycle seat cover.  Somehow acquired.

Entrance to plastic sheeting Cholera Treatment Centre. Wastezone on the left and Oxfam water bladder in front.

Ringer lactate is the be-all and end-all of cholera treatment.  It is a simple saline solution given intravenously to moderate and severe patients – up to 8L per day for 3 days.  So, loading the truck to send medical supplies is quite a task if each patient needs 24L of treatment, and there is a peak case load of 40 new patients per day.  You do the math!  One patient who arrived at the CTC only inches away from death received 6 litres in one hour!  Dripping furiously into both wrists and his groin.   He was amazingly discharged 48h later.

And my personal favorite – chlorine!  While medical treatment is easy, infection control is more complicated.  We need 0.05% chlorine solutions for hand washing stations; 0.2% for foot baths at the entrance to each room and for spraying beds, clothes, floors, showers, and the like; and then 2% for dead bodies and when anyone produces “rice water” (vomit or watery feces).  Each bed has a hole in the middle with a buck underneath to catch as much as possible.  If you can actually make it to the latrine, you’re almost cured!  In addition, each room (observation, hospitalization, recovery, and neutral area), should be isolated from the other with separate pathways, latrines and disinfection facilities.

Spraying hands and feet with chlorine solution at entrance to CTC.

Oxfam did most of the plastic sheeting, the medics handle the IV bags and I am pretty much in charge of chlorine and disinfection control.  And my bleached out pants can attest to that!

My "cholera pants"

Greeting!  Chantelle here, reporting live from my first ever cholera outbreak.  Infection control is paramount in cholera epidemics, and where there is chlorine, there is always a watsan nearby!  So, myself and my national staff counterpart were sent to Fianga, where MSF has been intervening for the past few weeks.

I wish I could search the internet an tell you how many people unnecessarily die from cholera every year, corresponding directly to how many people have no access to clean water or a shitter of some sort; but alas, those are hoop dreams in an imperfectly connected wireless world and I am left only quoting from the MSF cholera guidelines and reporting what I see here.  If you have followed the events in Haiti or previously in Zimbabwe, you have a sense of the potential scale of mortality if conditions permit.

I quote:

“Cholera is an acute enteric disease characterized by the sudden onset of profuse painless watery diarrhoea or rice-water like diarrhoea, often accompanied by vomiting…”

Yup – I can vouch for that.  “Rice-water” is pretty accurate.

“…which can rapidly lead to severe dehydration and cardiovascular collapse.” “In severe forms (a patient can lose) more than 10 to 20 litres/ day”

Wow!  Didn’t measure, but I can believe it.

Cholera can cause as high as 20 to 50% mortality if case management is not adequate. Conversely, the death rate can be less than 2% if well treated.”

Easy to get, easy to cure.  Simple oral and IV rehydration for the majority of cases, with antibiotics for the most severe cases.  Really just a matter of pumping them with fluids.  IF they can get to a health centre and IF that health centre has supplies. Therein lays the kicker.

WHO cholera information brochure. Don't be fooled though, the discharged body fluids are rather white than red.

When we were told that we would be going to the city of Am Timan, we were quite impressed that it actually appeared on the map.  Forth largest city in Chad, apparently.  We were certain that if nothing else, it must at least have one dingy restaurant that sells deep-fried chicken and fries, served with warm orange Fanta.  Sign us up!

Am Timan is a provincial capital with a population of about 50,000.  As a capital, it is home to all the government and military officials, housed in crumbling brick compounds, thatched tukuls, or under the mango tree, depending on rank.  It has wide streets filled with grazing goats and tethered donkeys, and a bustling market area that from a distance is a kaleidoscope of colour as women flutter about their business.  And of course, the ever perplexing presence of a cell phone tower in the absence of running water or electricity.  Where does everyone charge their phones?

Kaleidoscopic market place in Am Timan

MSF began operations in Am Timan in February, 2010.  We work with the Ministry of Health in the main reference hospital for the district, responsible for pediatrics, maternity and a large feeding program.  If you have a soft spot for cute little black babies, our side of the hospital is the place to be.

Am Timan reference hospital

As MSF projects in the notorious eastern border region of Chad are in constant threat of evacuation or closure due to the precarious security situation, the original strategy for Am Timan was to establish a long-term project in a more stable, adjacent location.  While maintaining minimal operations here, we would then be able to provide medical, logistical and human resources to any emergency that sprang up, either along the border or elsewhere.

Well, with over 600 malnourished children, 60 cases of severe malaria and 100 newly birthed babies in a single month, that strategy has since been scratched.  The medical needs in this region have proven far greater than first anticipated and all available resources have gone into meeting them.  Because the region is stable, we are now able to expand our operations into health centres outside of Am Timan as part of an outreach program.

Since it is a longer-term project, there are plans to extend our services to include tuberculosis and HIV programs, with the aim of enhancing existing national programs.  With this comes the operation of the laboratory and extensive testing and counseling services.  So now that our original programs are well established, but many needs still uncovered, we are set to grow, kicking into high gear.  New construction, expanded medical orders, more expats and national staff, and even a few more piddly Jimnies painted bright pink.

We have been here in Am Timan for a couple weeks now.  No sign of a deep-fried chicken joint, but exciting times at the hospital nonetheless.