Canada Day

It is the 1st of July and I am back home in Canada having returned a while ago from my first mission with MSF.

I would like to thank so many of you for following my blog from South Sudan; for the many helpful and encouraging comments you made, and for helping me to understand that there is a big world of people out there wanting to know more about the rest of the world and MSF’s work in it. I did not have time to answer each of you individually but I read every comment and it was so lovely to be cheered on by you, especially when the going was tough.

Canada Day. This is a very special day for me; a day to celebrate the wonder that is this awesome country of Canada, and a day that was a very special day for my Dad, an immigrant from a country with far less opportunity for him than Canada has offered his children and grandchildren. It is what I think of when I ponder the way families everywhere, in every country and corner of this amazing world, always try to do the best they can do for their children. I am awed by the mothers and fathers who have walked for days, and sometimes weeks, carrying their children to safety, away from the conflict or the famine or the natural disaster that has overtaken them. It is what I think of now when I read the blog by Ruby, the MSF epidemiologist, who has been working in the refugee camps of northern South Sudan. We all just want to look after our families, and to do that people sometimes need help.

I have been home for a while now and am only able to begin to process the experiences, the good and the not so good, of working in South Sudan, and my return from this struggling, fragile country. Sometimes MSF works in confusing and inexplicable ways, frustrating and annoying ways and it can be difficult to reconcile your expectations, the reality of life in the field, and returning to life at home. Sometimes things don’t go at all as you had planned, or as you had hoped, or just at times, don’t go well at all. It can be a challenge to pick yourself up, dust yourself off and figure out what is next. This is what I have been doing with myself since I returned home. Dusting myself off. And thinking about things.

For now, every time that I go to the grocery store (and I always move first to the fresh fruit and vegetables) I am overwhelmed by the amount of food and the choices I must make about what to buy. Initially I would get a little ‘tachy’ (medical talk for having a very fast heart rate) and have to take a big breath and walk over to the canned food section to calm down. I knew I was not going to face any choices there because I was not buying anything out of a can for a while, if ever again. Then, I would head back to the fresh food, pick out what I would like to eat and always, always head home with far more than I could eat before it started to rot. Then I would have to figure out a way to eat it, because really it was not possible to waste food. That would simply be too wrong.

It certainly does take some time to catch your breath, to look around at your world here, to think about the world there that you visited for a while, and to appreciate – really appreciate – the choices that come along with the privileged spot I was lucky enough to have been born into.

I read about the recent kidnappings and rescues from Dadaab, a refugee camp in northeastern Kenya, and I am so sad for Blanca and Montserrat, MSF workers from Spain who were kidnapped at the start of my mission last October and are still being held captive. I wonder what to do about myself and my decisions about returning, or not. I know that about 50% of 1st mission MSF staff do not return for a 2nd mission. There are so many individual and institutional reasons for this, and I wonder what is being done, and what more could be done, in such an amazing organization to understand the reasons field workers choose not to return after their first mission. I still wonder what I will do.

For now, I have tried to come to terms with the things I did not like about my first mission, and think about the things that I really loved; to decide if they are enough to compensate and allow me to consider a return. I have joined the MSF Association, attended the amazing Annual General Assembly, met a whack of interesting, engaged and enthusiastic people, as well as heard a few more difficult stories of missions that did not go as well as hoped, inexplicable decisions made that are difficult to comprehend, behaviour that was inappropriate and unacceptable and sometimes dealt with appropriately and quickly, and sometimes not.

I have spent time with my wonderful and supportive family and have felt the worry they had for me when I was sick and hospitalized. I have returned to what feels like an alternative universe of medical work in North America. Today I am enjoying a day beside a beautiful northern Ontario lake, watching the fish jump, listening to the loons calling, and thinking, thinking…. and thinking some more.

Thank you for listening to my thinking. It helps.


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Field science

I have just spent a cold and rainy Canadian Sunday indoors, watching the 9th annual MSF UK Scientific Day, streamed online for the very first time, for the entire world to see. (You watch the videos here)

967 people in 5 continents, including many current field workers, were able to watch the remarkable presentations about research done in the field by MSF. From recent changes in Malaria treatment (which I learned about in South Sudan, when I was told I would be responsible for instituting the brand new malaria treatment, keeping all the statistics, and sending in all the data), to research into the use of satellite mapping to assess populations in emergency situations, to surveys done to delineate horrific sexual violence in Guatemala, to questions concerning how to balance priorities in a world with so much needing attention, it was a day guaranteed to make one think and wonder.

An amazing talk by Paul Conneally about ‘Digital Humanitarianism’, in which he makes it clear that MSF can choose not to be “an analog organization in a digital world”, was guaranteed to make everyone rethink how we as an organization will harness the benefits and the risks inherent in the ongoing explosion of technology that is upon us. One of the most remarkable statistics I learned is that there are now more people in Africa with cell phones than electricity. As was made clear in this keynote presentation, humanitarian organizations need to be in the forefront of research into how this technical revolution affects how we do our work. Humanitarian organizations “need to understand how people are using technology in communities and countries where they are working, and how this will affect ‘community driven development’.” The digital world is going to revolutionize humanitarian work, and the message presented is that we must prepare ourselves by researching the best way to use this to the advantage of the populations we work with and our organizations.

With only one mission under my belt, I was awed and my brain was tired by the end of the day, and I was just sitting on my couch, watching the presentations with a glass of lovely Chilean vino keeping me company. I did not realize the breadth and depth of the medical research done by MSF, and watching the conference online allowed me to have a much better understanding of the organization I work with. The presentation about using Teleradiology to accurately read radiographs done in the field was particularly poignant to me. I was chastised in the field for questioning another clinician’s diagnosis of TB from what appeared to me to be a normal x-ray of a very sick child. It became very clear to me that good research into how to appropriately assess and diagnose difficult cases would help our patients and our field workers, and in this case, a protocol for diagnosis would have been very useful to me.

Particularly impressive to me were the questions presented: should MSF focus on the greatest good for the highest number of people; should there be more singular and focused investigations into specific problems; what is the best way to allow access to the research done by MSF, and how to appropriately assess the research being done and be comfortable that the work is not just heading out into cyberspace, where it may not be effectively assessed, analyzed and utilized.

As a returned field worker, I would like to know about these things while I am in the field. This is where our need to understand how the new digital world and the research being conducted is affecting the work I am doing would be helpful to me. It would be good to know in the midst of my daily chaos, that there is much thought and work and analysis going on behind the scenes. With the ability to reach almost everyone almost everywhere, at least part of the time, this would be one way to make very good use of the new approaches to Humanitarian Work that will be inevitable in the coming years.

As a fitting end to the day, consider watching the trailer for the as not yet completed movie ‘They Go To Die’ presented by epidemiologist and new filmmaker, Jonathan Smith, which brought the reality of the work with and the research of MSF to a palpable spot in my heart. (You can watch the trailer here)

Posted in Doctor, Kala Azar, South Sudan | Tagged , , , , , | 1 Comment

Hard Hearted Woman

I am entering my second week here in Leer. The team found out they missed my birthday, and last night, we had a birthday cake, made from scratch in the homemade outdoor oven, and Happy Birthday songs and cool beer (there is no fridge in the compound, just ice packs and a cooler). It was a lovely evening, talking under the stars and sitting in the coolness of 32 degrees. It was a respite from the hard work for everyone, for a night. It was a chance to relax as a team, and get to know everyone a bit better. It was so nice.

I am really enjoying the challenge again, for sure. It is so good to have some success stories. Often, at home, people would ask me why in the world I was heading off to such a remote area, to volunteer for such a long time, to eat tinned food, to work such long hours and my answer, the easy answer, was I was looking for a new challenge.

Without trying to explain the intellectual and emotional intricacies behind the desire to volunteer in such a difficult environment, I would say simply that I was looking for a new challenge, something different from my day to day normal life. So, when the challenges threaten to take my breath away, I try to remember; this is why I came.

My favourite patient right now is little Joseph. Nuer children usually have 4 names, and it takes a while to get used to them all. Usually the first is a western name, then a Nuer name, then the name of the father and then the grandfather. For this blog,I have used Western pseudonyms, worried that I will get the Nuer names wrong, even as pseudonyms. It is a complex naming system.

Joseph is a severely malnourished child, previously treated in many places for many illnesses, and not getting well and recently transferred (meaning a note was written from the outlying clinic, and Joseph’s mother was told to walk to Leer Hospital).

I was asked to see him in consultation on my 2nd day here. He had already received treatment for every disease it was thought he might have, and he was dying despite all the previous treatments. I looked at this shrunken child, his malnourished state, his obvious severe anemia, his swollen belly, and then I examined him.

He stayed so very still while I poked and prodded him. He did not acknowledge my presence. All his tests for Kala Azar (my specialty disease, remember, the disease I know so much about now) had come back negative, all the tests negative, done twice. But…. his clinical exam showed all the signs of having Kala Azar; fever, lymphadenopathy (enlarged lymph nodes), conjunctival pallor indicating anemia (low blood HB (hemoglobin) levels), peripheral edema (swollen legs and feet), and his abdomen contained a large liver and hugely swollen spleen.

Your spleen should barely be palpable under your ribs. His stretched all the way across his abdomen to his umbilicus and down to his pubic bone. I had worked with Kala Azar for the last 3 months. I knew, even if all the tests said no, that this child had Kala Azar.

I immediately transferred him from the Feeding Program to the ICU and started our most aggressive Kala Azar treatment. He was so sick. It was questionable if it was possible to bring him back from the brink. But slowly, and with a few terrifying setbacks, he sat up, he ate, he smiled and then he walked. Not far, but then he started to play with his sister. He was better. I was happy. I am enjoying this difficult job. It is what I wanted when I applied to MSF. I feel settled, finally.

Something I have learned, but haven’t written much about yet, is just what kind of a team is needed to run MSF’s medical programs. We, the Medics, the doctors, nurses, nutritionists, midwives, lab technicians, and pharmacists simply cannot do our job without the Team.

In ‘the field’, as a simple basic need, someone has to get the right medicine to the right place at the right time in the right amount in order for any medical work to happen. All the equipment and supplies that are needed to run a hospital or clinic need to arrive also.

And we must have a place to live and communication equipment and vehicles and computers that work and food for the team…….and in the city, there is a whole other crew of people, making sure that airplanes arrive on time, that medical evacuations are done when needed, that human resources are attended to, that finances are sorted…. so we can do the medical work that we do.

The non medical team members ‘in the field’ don’t often get a close up look at the fruit of their labour. They are far too busy doing their job to be able to see the medical work on a day to day basis. And the MSF staff ‘in the field’ but who work in the capital city, who are in charge of the bigger picture, often don’t get any chance to see the effect of their hard work I, personally, think this would be so difficult.

To work so hard for a medical humanitarian organization, and never really get to see the medical side of the work seems like it would be disheartening. But, perhaps, that is just the medical side of me coming out. Perhaps the FinCo (Financial Coordinator), and the electricians and mechanics really would rather be away from the more colourful (think blood and guts) side of MSF!

But, I would like to, formally and publicly, acknowledge and say thank you for the awesome work done behind the scenes so I can do medical work. Shukran, Gracias, Merci, Danke, Asante, Chezu ba, Dank je.

So, back to the job I am now doing, supported by all those folks.

Today, I think about how this job has changed me in a profound way, which I think is good, but I wonder. I pronounced 3 people ‘passed’ or deceased, in one day. The first was a baby, brought straight over to the ICU, referred from the OPD to the ED and immediately to me because she was so sick The charge nurse told me there was a new sick patient, and I went in to see.

A new mom, sitting with a bundle on her lap, sat on the bed, and I went over to examine the baby. I smiled at the Mom, she smiled back, and I unwrapped the baby. She was warm. But she was dead. There was no heartbeat. I listened and I listened and then I looked at her Mom, and said Malish, Malish Sorry Sorry. She died on the walk from the Emergency Department. It’s about 150 feet, 50 meters. She died walking across the hospital compound, after walking so far to get to the hospital.

And then I got up and went to see my next patient. I worked for many hours that day, and pronounced 2 more people, one a young boy, trying to stay cool in the 40 degree weather, who drowned in a small brackish collection of water, left over from the rainy season.

The last one was a soldier, injured in a gun battle. We operated to repair the terrible damage that closely fired semi-automatic bullets do to a human body, but he died. His family was all there. The women screamed and ululated (an amazing sound like a musical instrument or a scream, depending on the context) and fell down and cried out, and the men stood to the side, quiet and stoic, and I, once again, moved on. I did all this, I looked after so many sick people and I went home to dinner and a beer, and wondered if I am getting too callous, or if this is what must happen to be able to continue in the work.

I don’t know.

I discharged many well people that day also. We sent them home healthy again. I do know that our new treatment for malaria, introduced on my very first day here, seems to be working so well. Children that are deathly ill when admitted are sitting up the next day and smiling and on their way home the day after that.

MSF is instituting this new treatment in our hospital as one of the first sites, and there is paperwork to fill out and forms to complete so we can know, does it work better, are there worrisome problems with it, is it too difficult a treatment regime to be instituted in places that are more remote than we are here? It is good that we do this, but it is much more work for the nurses and the medical staff that I work with on the ward. But, it is good. Malaria is deadly. I like that I am a small cog in the wheel of research to see if this treatment is better.

What I don’t like, but accept as part of the job here, is the fighting, the war, the seemingly senseless ongoing skirmishes that result in spear and gunshot trauma. I just want to be mad, to get upset and not to attend to the perpetrators of another seemingly senseless act of aggression But I don’t know who the perpetrator is when a body is lying on the ground in front of me covered in blood. I cannot judge, and even if I could, I am here to provide medical care, to any and all who need it.

There are so many people simply caught in the crossfire, children who were in the wrong place at the wrong time, and I am here to work, and to witness and to accept that humanitarian care means providing assistance to all, regardless of the origin of or the reasons for the injury. I am working on this. I am growing into this job, I am learning in ways I never, ever imagined, what I am capable of.

I usually I like it very much, but not always. There are days of frustrating confusion and days of great accomplishment. Usually, I go to bed, in my tukul, (with my companions, the bats and the ants and the mosquitos and hopefully no snakes), with the feeling that this is the right place for me to be right now, and I look forward to the next day.

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The dusty Yellow Brick Road

It turns out the Yellow Brick Road is just Dust. Hot. Hot. Dust everywhere and in everything. I do wish I had Dorothy’s red shoes sometimes. Just for a moment, a respite from the dust and the heat and the sweat. Especially the sweat, that runs in your eyes and down your chest and gives you a terrible rash.

Tap my red shoes, and I have 10 minutes on the top of a ski hill in Canada, looking out over a white winter wonderland, crisp, cold air that tickles your nostrils, and the thrill of the wind going by as you fly down the mountain….. Yes. Back to South Sudan.

My new room in my new tukul has a cover over the shelving unit. It takes me a couple of days to figure out that that it is there to keep the dust off of everything you own. Sometimes I am not too swift; it can take me a while to sort simple things out and I have to shake my head at myself. My kids rag me about that; make fun of me and ask me how I ever made it through medical school if I can’t figure out how to program the TV remote. I don’t have an answer to this question.

I have been at my new job for a while now. I am settling in. It is a new team. It is a very different place. It is an entirely different job. I finally have my own room, and I have put up my photos, and have a sense of ownership of my small little tukul, a sense of place that has been missing in the past few months, as I travelled here and there and it seems everywhere.

It has been a good experience to see so much of South Sudan, but I am so happy to have a place of my own. I feel settled. The job is not what I originally signed up for, it is much more challenging, it is a bit overwhelming at first, but it is good.

I am in Leer. MSF runs a full hospital here. It is huge. There is no other medical care of this calibre anywhere near here. We have a huge IPD (In Patient Department).We have an ICU (Intensive Care Unit), although this means a much different thing here than it does at home. We do OB (Obstetrics) and we have a delivery room.

There is an OT (Operating Theatre), an HIV/AIDS (Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome) program, providing ART (Anti-Retroviral Therapy), a TB (Tuberculosis)program, a KA (Kala Azar) ward, an ITFC (Inpatient Therapeutic Feeding Center), where the severely malnourished children are cared for an OTFC (Outpatient Therapeutic Feeding Center) where the less malnourished children are given nutritional supplements, and we run an OPD (Out Patient Department) (like a medical clinic) and an ED (Emergency Department) and an Outreach Program, consisting of MSF staff that travel far and wide, supporting the local clinics so far away that they are run by our National Staff.

I think that is all. It is a huge undertaking, and it takes a big team. We have a good team here There is not as much dancing, but there is just as much camaraderie. It is now officially 39 degrees in the shade, and getting hotter every day. It is too hot for dancing anyway.

And I have gone back to worrying, again, that I don’t know enough. It really is hard to know something about everything that walks in the door. I am responsible for the full medical and emergency departments, and there is no way to prepare for the incredible variety and severity of the illness that I am now seeing. The national staff, nurses and Clinical Officers, are incredibly helpful and always point me in the right direction when I am not sure what to do next.

And, I am so lucky to have a really experienced MD, who is running the HIV/TB program, to help me. I can just slide over to her side of the compound, ask for her advice on a patient, and head back to my area, comfortable with her pleasant guidance and willingness to lend me a hand, no matter how incredibly busy she is. I know how fast I will learn, and how I will soon be really enjoying the new challenge. I better learn fast. She is leaving for vacation soon, and I will be very busy.

But, tomorrow is my birthday, and no-one here knows it. I am new, and I really don’t want to draw attention to myself. But, it has been a tough day; I am missing home. Another day I should be celebrating with my family, and I am on my own, with the team, but it is different.

I was called tonight to the IPD (In Patient Ward) to see a very sick newborn, only 2 days old. The baby was hypothermic (very low body temperature) and not breathing well. After a quick assessment, trying to get a temperature, pulse and oxygen saturation, none of which were able to be registered, I went to the maternity ward to get our makeshift cardboard box incubator (made by our awesome TechLog (Technical Logistician) with the tin foil walls and 100 watt bulb inside I found another baby already in it, born yesterday, prematurely.

As I tried to sort out if that babe was well enough to give up the box for the evening, I went back to my patient, and found that she had ‘passed’ (as they say here in South Sudan). Attempts at resuscitation were not successful. I looked at the mother, said how very sorry I was, and sadly walked to the nursing station to do the necessary paperwork.

After about four minutes, the incredibly amazing nurse in charge of the ward came to ask me to see another seriously ill child. As she led me to the child’s bed, I realized that it was the bed of the child who had just died, having been already vacated, and filled with the next critically ill infant. I felt such a sense of utter hopelessness, for just a minute, and then I looked around our ‘ICU’ (Intensive Care Unit) and tried to accept that there were six children who were still alive because MSF is here, and moved on to my new patient.

It is not easy, this work.

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Medevac (Medical Evacuation)

Day 90

And then it was Christmas.

We had a wonderful Christmas Eve party with other NGO’s (Non-Governmental Organizations) that included presents, turkey, stuffing, lots of dancing and getting to relax curfew and stay over. Slept on the balcony in my mosquito net tent and woke up Christmas morning feeling all was ok with me, if not with the world. It almost made it acceptable to be so far from family and friends on this special day. But not quite. I was looking forward to a Skype call to my family on Dec 28, when my whole family would be gathered together for their Christmas dinner. But a peaceful Christmas was not to be.

We received a disturbing phone call late Christmas morning, while we were enjoying our day off and the camaraderie of our fellow volunteers. We were advised to expect a large number of wounded civilians with GSWs (Gun Shot Wounds), some extremely serious (I would have thought any gunshot wound was serious). They were being transported for hours in a boat down the Nile to our hospital from an area where we had an outreach clinic and local MSF staff who ran the clinic. I had never seen a gunshot wound before. We don’t have many of them where I live in Canada. We were informed that the injuries had occurred the previous evening, in a church, on Christmas Eve. People were gathered for the service, and then, there was shooting.

We solemnly gathered up our mattresses and our leftover turkey and our Christmas gifts that we received in our Secret Santa festivities on Christmas Eve. We climbed into the Land Rover and headed back to our compound. On the way we passed so many families, out dressed in their Christmas best, on their way to church, or off to visit their friends and families on this special day. The little girls had their hair plaited and bows to decorate their beautiful hairstyles, and wore gorgeous satiny sparkling dresses in pink and blue and lavender. The boys were outfitted in serious suits, pants and ties and polished shoes. Their mothers were dressed in the stunning colourful outfits that African women wear with such statuesque style. And the men, looking serious, chaperoning their families, dressed to the nines in their dark suits in the midday sun.

There were parades and drums and musical instruments and dancing. Everyone looked so happy and the contrast between watching all the families, looking so wonderful and enjoying the holiday, and us, missing our families, and heading back to the hospital to deal with unspeakable horror, was so difficult for all of us. We were very quiet on the drive back. We were wondering what the rest of Christmas Day would bring us and how we would cope.

Christmas afternoon, we waited. And waited some more. We sat in the shade of the building that houses the Operating Theatre, and we talked. Some smoked. I’m still not smoking. Yet. We talked about why we were so far from home on Christmas, and how bad things happen for no good reason everywhere, not just in South Sudan, and what exactly we were expecting, thinking about and afraid of.

Finally, at suppertime, Dec, 25, they arrived. The boat pulled up to the harbour on the Nile, and the badly wounded were lying in the bottom of the boat. The rest had been sitting, leaning on each other for support, in the sun for hours, with little water or food. Our National Staff worker, an amazing Clinical Officer (akin to a Dr. in Africa) had assessed and bandaged and given antibiotics to prevent infection already. He had not slept all night. He is amazing.

We triaged. We took the most seriously wounded patients to the OT (Operating Theatre) on Christmas night. And then we went home and collapsed into bed and I got up the next morning and went back to the OT and we operated all day long.

The next day I finally rested. I really rested. And I wondered about guns and violence and war and innocent civilians and children caught in the crossfire and the reasons MSF is where it is and the reasons why I am where I am. It really was a good day for me I felt, not contented, but accepting in some way, and felt that I had managed to do a good job in a very difficult situation. We all did. We were a good team.

And then….that very night, hours after I fell asleep well, I woke up in severe pain, so suddenly, violently ill. Not able to walk, I had a fever, nausea, vomiting, diarrhea and an abdomen that was acting like it wanted to have its appendix out There are no high tech investigation here, no xray, no CT, no ultrasound. And so my MSF colleagues, the wonderful doctors and nurses that I had been working with, looked after me, started antibiotics, an intravenous, gave me pain medication and my PC (Project Coordinator) arranged a plane, which picked me up four hours later and took me for investigation and medical treatment far far away from where I was, and where I knew no-one. There was no Christmas Skype call to my family.

At the very moment I should have been chatting with my kids, I was, instead, writhing with pain inside the CT (CATScan/Computerized Axial Tomography) machine in Nairobi Hospital. I would much rather have been Skyping.

It was a very lonely time; in a strange city, with no team to support me, very ill and so sad to be so alone during the Christmas season. But here, (MSF really does teach you, simply by observation, to always look on the bright side, to realize that things could always be different, could always be worse), I would receive excellent treatment and recover from my illness, catch my breath and, once fully restored to good health, eventually go on my much desired and needed vacation. I relaxed on the beach, I ate food not out of tins, I had salad(!), I ordered a mixed drink, and I had time to think and swim in the beautiful warm salty Indian Ocean, and rest some more and then I realized I had the time and the energy and the inclination to finalize the writing of these blogs

And then, recovered, on to my new job, in a place I passed through once already, on the way to the Kala Azar assessment. I liked it then and am excited to go back. I have been given the JP (Job Profile). It seems the previous doctor left abruptly. The job just wasn’t right for him.

MSF asks if you are willing to take on a job and tries to be sure you know what you are agreeing to. There really is no pressure to accept a job you are not comfortable with. Although after a while, you realize that there is no job you will be completely comfortable with, ever. And sometimes, you think a job will be ok, but once you arrive, once you see the enormity of the need and the challenge, you may reconsider.

I had read the JP; asked many questions about the new responsibilities. I had spoken on the telephone to the MTL (Medical Team Leader) about whether my medical qualifications qualify me to do this new job (I was pretty sure the job profile was actually for three physicians). This job is not Kala Azar-related. This job is being the responsible physician for the medical ward, including the ICU (Intensive Care Unit) and ED (Emergency Department) of a huge MSF run hospital. I feel like I’m Dorothy, going on the Yellow Brick Road, not to Oz, but to Leer. I’m told there is a book to read, called ‘Emma’s War’, that will help me better understand the history and politics of South Sudan, and that Emma is buried in Leer, so I think I will go shopping, before I go back to where there are no shopping possibilities. Except, perhaps, onions.

The Yellow Brick Road……to Leer and a brand new job

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The Good, the Better, and the Bad

Day 50

So, they say, you can go to Pagil. Soon.

But first we would like you to assist on an Explo (exploratory mission). It seems that there is an outbreak of Kala Azar in a place where it was not expected. There are reports from Leer, a town with a very big MSF hospital, that most of their patients with KA are coming from elsewhere, from a remote village many hours of walking away; a place with little medical care available. Would you be willing to go there? You will assist the MSF Kala Azar Coordinator with the assessment. Sure I say.

I said in the beginning I would go where I was needed.

So, a new experience, flying in very little planes, up and down and up again and down (luckily no motion sickness for me), and are we where we are meant to go yet? It is a supply run, as most flights are here, and we go where the plane goes until we get to where we want to go. I’m learning. A vast expanse of brown earth and tukuls and cows is all I can see from the plane. Now that I have met and cared for the people that walk these distances to get to medical help, I am stunned into silence. I have no idea where I am, I couldn’t find a map before I left. I was told the project’s map drowned in the recent flooding of the house during the rainy season.

So I go, with an awesomely experienced MSF’r, to test hundreds of people for KA, and see if it would be appropriate for MSF to set up a clinic there. She is the leader, she points me in the right directions for setting up the clinic, and getting there safely. Where we are going is near the oil fields, near the controversy, near where there is recent conflict and some of the roads are off limits, and so we need to detour and travel in convoy and contact each other and home base by satellite phone, giving our GPS coordinates so they always know where were are, and the remote possibility of land mines, or the much more likely possibility of being stopped by soldiers at checkpoints and still I say ok. “To assist people in need in areas of conflict. “ I did say yes.

It is an amazing few days. We find many sick people with minimal medical care available, and a level of Kala Azar that is high, but I’m not sure what the decision will be. That will go up the chain of command, and decisions will be made about the needs in this isolated village.

Day 60

And so, happily and finally, to Pagil

At last, I have arrived. I have finally landed, via the MSF plane, at my destination. I am so excited and happy to be here. Exactly 2 months after I left home to come to volunteer with MSF, I am finally in my very own tent, on my awesome bed, under my pop up mosquito net. I am listening to the cicadas and the drumming and singing from the small village of Pagil which is just a 3 minute walk from our compound. With no electricity and no generator and no running water and no internet and no phone service (except for security communication) and no ability to get out of here except by plane, (the roads, such as they are, are all under water), I think this mission fits the definition of ‘remote”. I have met some of the people of the village, who are very pleased that the MSF team has returned, and I can only wonder at what my time here will bring.

And then I found out:

The first three days were so difficult.

1st day, a patient, severely ill, carried in a blanket for 2 days by her family through the bush, who was treated aggressively for typhoid/dysentery/sepsis, and I have been told, died a few days later. Her family did not bring her back for further care, and the rumour in the village is that it was because there was a decision made that, due to a suspicion of incest and her illness being the result of a transgression by someone of some sort, she was not allowed to be given any further treatment.

2nd day, a woman, walking from her home, far far away, with a spear wound through her left hand. It is massively infected. Her hand is swollen to the size of a football, her arm is not usable. We give pain medication, debridement (cut away the dead tissue) and massive amounts of antibiotics. We dress the wounds and we inform the family that the patient needs surgery. We cannot do it here. We can only treat Kala Azar, and some of the co-infections that are part of the disease. We tell the family that they must continue to walk, and explain where they should go, a 2 day walk further, and give more pain meds and more antibiotics to take on the journey. I watch her family help her walk off with a heavy heart. A very heavy heart. I have read that the Nuer people (the tribe that predominates in this area) believe that the liver is most important in matters of emotion, and not the heart, and so, I think, they would have a heavy liver. Sounds wrong, but I am learning a different way of thinking here, already.

3rd day, a newborn, critically ill, arrives at the door of the compound after dark. 6 days old. Likely neonatal tetanus. IV’s are started, everything given that we have, urgently, in the dark, by headlamp. We are told the baby died in the morning. My liver now hurts.

This was what we did as we treated the Kala Azar patients, and the villagers sick with malaria, pneumonia and diarrhea. The cases of Kala Azar were many and most were cured by the treatment we were able to provide. The look on a child’s face, when told that was the last of the painful buttock injections, is worth every minute of the difficult and stressful times. And then, there were the lessons that came out of nowhere…

There is a disease here, a common and serious disease, called brucellosis. It is contracted from the milk and meat of infected cows, and the cows of the village are sacred. Cows are currency; they are wealth and they are essential to life. They are what you pay for a bride, or for a debt, or as punishment for a crime. They are everywhere, and the young boys look after them, out in the wilderness where the acacia trees and the black sand is. This is often where they are bitten by the sand fly that gives them Kala Azar. The younger children collect the cow dung, and make ‘patties’ with it, to use for fuel, or for construction. Then, with their hands covered in cow poo, they come up to you smiling, to shake your hand, and say Maale? (How are you?). If you are distracted, you shake their hand and receive an unwelcome surprise, and then your answer is not Maale midit (I am well). Your hand is covered in cow poo.

There is a tradition here called cow blowing. I had heard of it, but I didn’t know if it was still done. It seems, women will kneel down behind a cow, and blow into the vaginal/vulvar area. This is supposed to stimulate the cow to give more milk. It also puts their mouth very close to the cow’s mucous membranes, and it is thought may be a significant way to transmit brucellosis. Well. I was walking to the clinic one morning, in the serene quiet of the early dawn, and heard a strange sound. I looked toward it and yes, this is exactly what was happening. I couldn’t tell if the cow was enjoying it, because the theory I heard is that if the cow is stimulated to orgasm, it will produce more milk. It really never occurred to me that cows have orgasms, but how ethnocentric of me. I just stood there, astounded, and then turned and walked on to the clinic. Brucellosis can be effectively treated. The difficulty is how to approach changes in culture and tradition; how to reduce the transmission rate. These things I ponder as I watch so many behaviours that are different and confusing to me. Tradition. Disease. Cultural differences. I have so much to learn. And not just about culture and medicine….

And then…….all hell broke loose.

All is not well in the Pagil compound. Our team is having difficulties. We are absolutely not getting along. As part of the preparation training, you learn that one of the things that cause the most problems in a project is the interaction, in often very stressful situations, between team members, living in close quarters, 24 hours a day, with nowhere to go for a break, with no respite from each other. We are having trouble. We are working hard to sort it out, but it is so difficult. We are not enjoying ourselves in this team here. I like the work, I love the place, but the team interactions are taking a toll on all of us. We try, we all try, to sort out the differences, to come to some resolution, to see if there is some way we can resolve impasses, and sometimes it works, and sometimes it really does not. I am tired of the disagreements. At the end of a long day in the clinic it is exhausting to come home to the compound to acrimony and disagreement. Obviously, everyone thinks that someone else is the crux of the problem, and it is a difficult thing out here, in nowhere, to try to look at your own behaviour, and try to think how to change it to effect positive change for the team. We are struggling.

I realize there has been a profound change in me since I came here. I am again lying awake at night, worrying. Or I am hiding out in the corner of the compound, looking at the stars, the awesome black sky and the stars that are profound in this incredible darkness, and worrying. But, I am not worried about my patients or my abilities. I have grown comfortable, not always accepting, but more able to cope, with the fact that I cannot know everything, but I now know a lot. I cannot fix all the ills, but I can fix many of them. I feel I am doing a good job medically. Now, instead, I am worrying about the team. I don’t like sleepless nights. I never have insomnia. But I have it here.

And then, we are suddenly, very suddenly, surrounded by soldiers. In a town of maybe hundreds, there are, we are told, a thousand or more soldiers setting up camp. They are everywhere. They have guns and rocket launchers over their shoulders. They are GOSS (Government of South Sudan) soldiers, and they are very respectful toward us. Their commander comes to the compound for a visit. He, and all his associates, take off their guns and don’t wear their uniforms for this visit, (as is required before entering an MSF compound) and we talk, in a friendly and not upsetting manner, about why they are all there, so suddenly. It is, we are told, a normal troop movement. This country was so recently at war, and there is a fragile peace, and this peace is maintained, as well as can be, by the new government. This movement is a normal part of the peace process. I have so much to learn, and it seems, much of it is not medical.

And so, my time in Pagil comes to an end, our mission to assess the program here is completed, and we head back to the bigger team. We talk and we debrief and we talk some more and we miss the place and we are glad we are out of there. So many emotions. The questions that we were sent to answer we have. The National team (the locally hired MSF employees) that run the clinic when we are not there are happy we came to support them, to bring supplies, to teach, and to let them know, that in the middle of their so difficult work, we appreciate what they do, and we could not run the program without them. We have determined they can run the Kala Azar program without the need of an MD, and I have been told that I will have a new placement. I will be going to a new place, and I am excited, once again, about the new challenge.

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Hard Lessons Learned

Day 45

My patients…..Tabitha… (all names are changed)

She is such a cute little girl. 5 years old. Often her mom is not here at the clinic where they have been living for so long. The other mothers watch out for her. Make sure she gets food from somewhere. There is supposed to be some food supplied for patients, but often…. we really aren’t sure how much they eventually receive; we are not in charge of the food distribution. Tabitha’s Mom is off trying to find some way to make some money, in the market, or down by the Nile, weaving baskets, trying to catch fish? I don’t know, really, where she is, because there is so much about the customs and the way of life here that I know nothing of. Tabitha makes me think of my niece, back home in Canada, who has everything a Canadian little girl has to her advantage. A world of things Tabitha and her family cannot imagine. Tabitha has Kala Azar. She has been treated for months, much longer than it would normally take to cure her. For some reason, her tests keep coming back positive. She still has this deadly disease. Our medicine is not working.

And John, who also has Kala Azar (remember, this is the disease I came to treat, but we also diagnose TB, leprosy, pneumonia, HIV, brucellosis, typhoid…. I could go on and on). This disease can be similar in presentation to HIV because they both severely affect the immune system, and the body’s ability to fight off other serious illness. My patients often have a few of these other diseases, so it is a challenge…

I met John and his Mom on one of my very first days here at the Malakal Teaching Hospital. I didn’t know much about anything then. I barely had my feet planted on the ground, and not at all firmly. I was just starting to learn. John was on medication, and he was much better, so the nurses told me. But the day I met him, when they called me to see him, late in the day, just as I was about to head home to the compound, he couldn’t walk, he was vomiting, he had diarrhea, he looked absolutely terrible. I didn’t know how he had looked before, and people really do look so sick here; he didn’t look much different from so many of my other patients.

I ordered the (few) tests that we have available, added some intravenous fluids, more antibiotics, really, just hit him with everything we have, ordered some extra Plumpy Nut, the food paste that we give all our patients, to try to get some calories and nutrition into them, and went home for the day. When I came back on Monday, John was almost comatose. I ordered everything else I could think of, and went on to the next sick patient.

Kala Azar, or visceral leishmaniasis, is a disease I did not learn about in medical school. It is considered one of the ‘Neglected Diseases’ and there are conferences in places like London, or Shanghai, or Buenos Aires, where all the folks who know get together to discuss what to do about it, and the many other diseases that so many people here have (people with no money to pay for a cure or a treatment). Part of the significant issue with the neglected diseases of the world is that they are not neglected because few people have them, or they are not serious illnesses. They are deadly diseases. Generally, they are neglected because there is minimal profit to be made from finding a treatment or a cure, if no one has money to buy the finished product.

A weight loss pill, or a sexual enhancement product has millions of wealthy buyers in the West lining up to pay many dollars per pill for a medicine to make you prettier, or feel sexier. Tabitha and John’s families don’t own much, they live in a mud tukul, they share a cup and utensils with the other patients. They have no money for medicine. So, if the research departments of the pharmaceutical companies choose to focus on these illness, there must be a financial incentive. It’s a fascinating look at how the world works and why I can only think of these things in my reflective moments; for now, let’s return to the disease and the patient sitting in front of me.

Kala Azar comes from the bite of a sand fly, and it travels in waves; an epidemic will break out in an area, the population can be decimated with so many deaths, and the next year, it will begin in a totally different area. In the past, there have been villages where 90 % of the populace has died. It is difficult to predict where it will go next.

This is the disease I came to treat, and the unpredictability of the disease is why they made it clear to me that I may not ever go to the place I signed my contract to work in. Treatment is difficult. Imagine, a tiny emaciated 5 year old getting IM (intramuscular) injections of a very painful medicine into her buttocks every day for 17 or 30 or 60 days. Usually, the children are stoic. They often put up with pain that would be unheard of at home. But these, these injections, they hurt. They really scream. They whimper while they are waiting in the lineup for their turn. I can’t stay near where the injections are being given for too long without starting to get teary myself.

The national staff nurses (the MSF employees that live here in Malakal) give all the injections, and I marvel at their ability to do the job, day after day, and comfort each patient as they receive their injection. I am trying hard to be able to stay around, but I’m not there yet. I am trying to learn, buck up and move on, there is more for you to do than stand around worrying about how painful an injection is.

So, from knowing absolutely nothing about this disease, to being able to feel comfortable being responsible for the OPD and IPD (out and inpatient departments), has been a challenge. But I am slowly getting there. But yesterday, I learned a hard lesson. I’m learning, sometimes by absorption, and sometimes, it just hits you in the face. It is painful, and then, sorting out the best way forward is also a valuable lesson.

First, Tabitha.

My colleague (The marvelous Kenyan nurse that I told you about before) thought that it was a bit strange that Tabitha’s tests kept coming back positive. We, and other NGO’s, had been treating her Kala Azar for far too long. So she sat down with Tabitha’s mom, and spent an hour with her (precious time in this land of far too many patients), and discovered the true history of her disease and her treatment. And we discovered that what we (and others) had been doing was confused by the difficult history; treated in many different places, each offering a level of care different from the previous. And then, with this history, I was able to use the amazing power of the internet to email our Kala Azar advisor in Amsterdam and ask for advice. Within a few days, I had a response, and suggestions of what to try next in this very difficult case, and was able to move forward with significantly more aggressive treatment, that made me a little nervous, but I took the advice of the expert, and moved on to…


So, the next day, on ward rounds, when we arrived at John’s bed, he was no better. I felt terrible. His mom was, as usual, waiting for us. She was always the one to help all the other mothers on the ward; helping other people’s children who were vomiting, holding the pail and their foreheads, or getting a cold compress to put on the body of the 6 month old in the bed next to John with the temperature of 41 degrees. Late one night she helped me and two nurses carry the body of a young mother, across the hospital compound, to the morgue. There was only the 4 of us available, one on each corner of the stretcher, under a beautiful African starry night, to make that lonely walk.

Today, I was doing rounds with my South Sudanese colleague, a man that had been treating Kala Azar for a very long time. I outlined the symptoms that John was having, and the things I had done to treat them, and he very softly and very carefully and considerately, said ‘Do you think that these symptoms could be a side effect of the Kala Azar treatment that we are giving John?”. Oh my. Lesson learned and sleepless nights. So we changed the medicine.

I never got to actually see what happened with my two patients. I had to leave, sent elsewhere, before I knew if they lived or if they died. And so, it was with marvelous relief I heard, from the MSF staff that continued after I moved on, that Tabitha’s tests eventually came back negative and she was considered cured. And John. After much worry and intervention (so many antibiotics, a change of medicine, new other medicine, a blood transfusion and many weeks of daily meticulous care (mostly by his marvelous mother), he turned the corner, started to sit up, to eat, to smile and then to actually make jokes with the nurses.

We sent them both home, well.

But, then, the husband of the woman that I told you about before, the woman who smiled at me, over and over, every time I went to see her in the TB (tuberculosis ward, where she went after we treated her Kala Azar), her husband came up to me, and in the universal language of grief, let me know, with no words at all, that his wife, the mother of his children, had passed. Just then. He wanted to let me know. And he said thank you for all I had done. And he asked for some money, so he could make the boat trip home to tell his children. He said (through my amazing translator) he would return to get her body, and take it home. I said Malish, malish Sorry, sorry again, and again, because I don’t know enough words in his language, to express my sadness.

I am learning, slowly, with the help of my African MSF colleagues, to cope with this. They are supportive, they let me lean on their shoulder when I need to, and they show me how to move forward and continue the work despite my wish to hide away and not do this anymore. They have the experience that I do not have, despite my previous African work history, to really accept that which I cannot change, and to move on to the next patient that I can help. It is hard and exhausting work.

So, it is interesting to watch yourself adapt. To accept that this Saturday night, it is ok to celebrate a birthday, to wish someone farewell as they finish their mission, to dance and to dance some more. I think it is good for coping. It is fine, it is acceptable, it is crucial, to enjoy in the midst of this incredibly difficult work. To really accept that your best is all you can do, and head back the next day rested, restored, and maybe with a headache from a beer too many. At least (so far) I haven’t started smoking as a stress reliever. Many do.

And then, suddenly, my PC (Project Coordinator, the boss of me) told me that I could go to where I wanted to go. Pagil.

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One night of solitude

Day 40

I am having my first real night of solitude since this whirlwind began. My roommate (a wonderful Canadian nurse), is ‘on outreach’, and sleeping in one of the villages where we have our medical clinics that are primarily run by our South Sudanese ‘National Staff’. She is a remarkable breath of fresh air; much younger than me and a spirit that makes me happy to share my (her) bedroom with her (me), despite the lack of privacy. She is our party planner, puts together the Sat night dances and pizza parties and makes coming back to the compound a welcome end to the day.

My other roommate has been sent elsewhere, and I am sad, very sad about that. She is a Kenyan nurse, and knows everything about all the things I know nothing about. She has nursed in Africa for as long as I have doctored in Canada, and has been teaching me so much in the couple of weeks I have been privileged to work with her. She helps me when I am uncertain what to do next in a medical situation, and she knows when I need some guidance in order not to do something that is culturally inappropriate. I have depended on her in more ways than I had realized, and now MSF has sent her off to work somewhere else where there is need for her expertise and amazing skills. I will be lost without her, at least for a few days, and then I will have to get my bearings again.

So, I have my own room for the first time for a few days, and I am enjoying the quiet. Solitude is a difficult thing to come by in this land of hope and turmoil and quiet desperation. A land I know so little about that I am ashamed not to have done more research into the country, and not just the diseases, before I came. 20 years of war, 5 years of unsteady peace and 6 months of being a brand new country have left a population just waiting to see what will come of the unpredictable changes now occurring. Players are jockeying for power in the new political climate here. Old scores are still to be settled. There are rivalries that endure despite reconciliation, and borders are drawn on paper, but some are still being debated in the meeting rooms and fought about on the ground.

I hear the stories of fighting and trauma in other areas of South Sudan, but where I am now, the gunshots are usually just singular, in the night, someone playing with their Kalashnikov, or celebrating a birth. I am learning from my fellow MSFr’s how to tell the difference between ok gunfire and bad gunfire. At least my bedroom is the ‘safe room’, the place where everyone goes, with the supplies stocked under the beds, to hide out for a while, if we hear the bad gunfire.

My first born child gave me a letter to open once I arrived in the field. In it she said, (and I will have to paraphrase, because it has become one more thing lost on this journey), that she is so proud of me, and that she knows there will be challenges and there will be days when waking up to face the day will be difficult, but to try to remember that ‘tomorrow is another day‘and that the tribulations that are difficult are what make you strong, and the events that occur, although they may be overwhelming at the time, will make a mighty fine story once I am home. I have raised pragmatic children, I think. I am trying to absorb her wise words, and go forward into tomorrow with some confidence, a little anxiety, and retain the good anticipation that I want when I wake up each day.

To do this, I need to remember the success stories we have in the Clinic. I need to acknowledge that the events that dig deep into my brain and make me doubt everything are the ones that keep me awake and wondering and worrying at night. The events I don’t dwell on are the children who go out the door with their mothers, with a smile and a wave and a thank you in one of 10 languages, off to walk for 2 days to get home, but this time healthy and well. I need to remember that the oh so terribly painful 10% of my job is much less than the wonderful 90% of my job. I will tell you about ( not their real names), Tabitha, a beautiful 5 year old little girl, and John, a strapping and now healthy 17 year old boy/man.

Next time…

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The work and the play

Day 30

One month. Exactly one month since I left home. 30 Days. And the staff meeting tonight was as frustrating as is possible to be. Just like staff meetings at home. Over 2 hours of meeting and a totally unsatisfactory outcome for all the players. I am in a tug of war with a hospital clinician over procedures there and am wishing so hard that things would settle and I could go to Pagil, where I am originally contracted to be. I should be working in a small clinic with a small team in the middle of nowhere with no bureaucracy to deal with. But no… the security issues are not settled and I am living in a large town/city, full of mud and chaos and soldiers with torrents of rain, but no water in the taps, in a house designed for far fewer people than are here, in a room shared with two or three others, depending on who is passing through (MSF does say that whenever possible, you will have your own room). The market has nothing but onions and the security here means you can’t go out alone, you must always have a radio, and you cannot go out after dark (6:30pm) except in the car and you must be home, but not necessarily tucked into bed, by 9:30 pm.

Well, that was certainly a rant, but it does feel good to get it out and off my chest. MSF tells you that you need a way to relieve ‘stress in the field’. They suggest perhaps yoga or exercise or meditation. I prefer drinking beer, or blogging, it seems

The good things are that we have music and we sometimes have cold beer and we seem to have dancing most Saturday nights and we have a team here that works well together, despite the challenges. I think that perhaps MSF should include dancing, really really dancing, as a way to relieve stress. We have an awesome sound system and music, fantastic African music, courtesy of the African expats, the people who now work for MSF as international staff (like me) but who started out as National Staff, working for MSF for years in their home counties.

They come from every part of Africa, (Congo, Kenya, Cote D’Ivoire, Sierra Leone, Ethiopia, Eritrea) and bring an incredible amount of experience with them. I really had no idea how much MSF promotes education and development of skills among their staff, but more of this later. Our Saturday night parties are energizing, and people from the other NGO’s (Non-Governmental Organisations) in town always come because they have later curfews than we do.

One of the things they stress in the PPD (remember, if you are following along on this journey, Primary Pre Departure) week long session, is just exactly who it is ok to have any kind of ‘relations’ with (aka Bill Clinton, Past President of the US of A) while on your mission. It seems that other NGO staff are ok, (thank goodness, I haven’t broken any rules yet), MSF expats are ok, (but beware the challenges when you break up and you still have to work in close quarters in the middle of nowhere with guns firing all around for 6 more months), but National Staff (the amazing South Sudanese employees of MSF) and the local population and our patients are definitely not ok.

There are many good reasons for all these rules that concern the same things that make it not ok to be involved with someone inappropriately at home (you are their boss, their teacher, their professor, their employer, their doctor, or have an unequal power relationship) but when the ……… well, you know.


there is work for me here and the reason I joined MSF was to work where I was needed and so, now, back to the non-stress relieving activities of my day. Let me tell you about…..

My patients…

who often arrive critically ill, after a boat trip on the Nile that may have taken days. I am only starting to feel that I am ok, that it feels right to be here, that I have the ability and the knowledge and the tools to do a good job, and then today happens. A woman arrived on our doorstep, folded up in a blanket, carried by her husband for 2 days, having left four children at home to care for each other. The oldest was 12. The last born, as they say in Africa, was 4. The rest had already died or lived somewhere else or could not be contacted.

We think she was about 46 years old (ages are generally unknown here) and she weighed 48 lbs or 22 kilos. Yes. 22kg. Her BMI (Body Mass Index) was 8. I had seen hungry and sick people before in Malawi and Zimbabwe, treating HIV/AIDS, but…

We had to measure her height the way we measure a baby; lying down because she is unable to stand. Her husband had to hold her and we had to subtract their combined weight from his to get her weight. We included the weight of the blanket.

Body Mass Index is a way of judging how close to normal a person’s weight is. This is needed to correctly calculate the dose of medication we should prescribe. Normal is between 18 and 24. My BMI was 24 when I left home, and even now, with the weight I have already lost here, I am over 100 lbs /45 kg more than my patient. I am about the same height. I have to step back and take a big breath before I can start to examine the form wrapped up in the blanket. And when I did, she opened her eyes, looked up at me, and she smiled. She smiled at me. I did cry.

A BMI of 8 means that when I tried to listen to her chest, to see if she had pneumonia or perhaps tuberculosis, I couldn’t get a seal on my stethoscope so I could not hear her heart sounds or her breathing. Imagine the ribs of a skeleton you have seen in the museum, and try to place a stethoscope and listen. I finally figured out how to angle the chestpiece of the stethoscope so I could sort of fit it between 2 ribs.

It’s hard not to look too shocked, not to be certain that I will be unable to offer her the medical care she needs. But I have seen people with AIDS gain 30 lbs/13kg in just one month on ART (Anti-Retroviral Treatment) and come back to the clinic looking healthy and well. Perhaps, since Kala Azar is a disease similar to HIV/AIDS, in that it attacks the body’s immune system, the medicine we have for KA will work that well for my patient. Today, I can only start the IV lines and the rehydration and the antibiotics and the food supplement and the investigations into her illnesses, and wish and hope. And move on to the next patient.

Last week I had a patient with a HB or HgB (Hemoglobin) of 2.7. The previous lowest HB I had ever seen in a conscious person was 4. Every time I think I will never see illness more unmanageable, a patient with a more astounding problem comes in the door of the clinic. And sometimes they are even walking! And have been walking for days to come to the MSF clinic to get help. Normal HB should be above 10 or 11 in women, and up to 16 in men. Hemoglobin carries the body’s oxygen. How a person can walk for days with their circulatory system working on such overdrive, already sick with a disease I haven’t yet diagnosed, overwhelms me. Sometimes, the end of the day can’t come too soon, and I can go home to the team, the people that make my work possible.

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Into South Sudan

Day 0

We are leaving for South Sudan today. Me and MSF. Me and my things. 18 hours and counting. Many of my things are not actually leaving. They would like to come, and I would really like to have them with me, but they are way over the awesomely light weight limit (20 kg including carry-on) suggested by MSF, and they have been set aside, like a long ago lover. There are many things you so wish you could take on a journey such as this, but as you sort and resort and sort again, you start to realize how much you don’t really. need.

The reason for this weight limit is because once you are off regular commercial airlines, and flying about in very small planes and helicopters, there’s not much leeway in the amount of extra weight that can be carried. The guidelines tell you that you don’t need to bring 6 months of supplies; that you will be able to buy things like shampoo and tampons, but really, my mission is in the middle of nowhere, living in a tent in a village only accessible by plane, where there is not even a market. How much shampoo should I bring? How much does a bottle of shampoo weigh anyway? And how long does it take for me to use one bottle? These are things I never really thought about before. It is strange that this is what I am fretting about.

I think it is much easier to worry about the inconsequential things, the things that will turn out to be totally irrelevant, than to focus on the worrisome things running through your mind before you leave on your first mission. Will I have the skills, the fortitude, the interest, the stamina and the desire to do this after the first couple of months? Am I really capable of going and treating a disease, Kala Azar, that I had really never even heard of before?

It has another name. Visceral Leishmaniasis. That registered in my brain from long ago in medical school, but just a distant memory. Have I done enough reading and studying to not look like an absolute idiot on my first attempt to be the responsible MD? What should I bring for looking up the diseases that I will see that are not Kala Azar, diseases that I may have never seen before? And the snakes they warned me about. We don’t really have deadly snakes in Canada. Perhaps I can look that up on the plane. I know nothing about so much. The medical books are heavy, and most of the ones I want are not available on the internet. Oh dear, what to do? I will start with tearfully saying goodbye and getting on the plane and hopefully, leave all the worry behind.

Day 21

It has taken me 21 days to feel that I can write anything at all here in this brand new country. The Republic of South Sudan has taken me in, twirled me around like a tornado, and spit me out. I am trying to land on my feet. What a 3 weeks. I know, from previous experience working in Africa, that it is necessary not to make any big decisions, judgements, or formulate any definite opinions until you have been ‘in country’ for a while, and have had a chance to get your sea legs, as (I think) they say in the boating world.

It’s called culture shock, and it does lessen with each trip, but for me, it is still there each time I return. So, there has been some 2nd guessing, some wondering what in the world I was thinking, but mostly I am trying to accept that things are often not what were expected when you are working in a volatile situation. This is a new country, that has been at war for 20 years, that is struggling to make it work, but it is going to be a rough and rocky ride for the country, and for me, I think.

The flight, Toronto, London, Nairobi was long and exhausting. There was no briefing in Amsterdam, and I flew straight to Juba, the new capital. First impression is hot and wet and dusty at the same time. It is the end of the rainy season. In Juba, I was finally briefed, and told that, due to unforeseen circumstances concerning security issues, I would not, right now, be going to the place I am contracted to work. As a matter of fact, they had just pulled out the team members that were already there, in an emergency helicopter evacuation. It seems the airstrip was too wet to land our plane.

So, despite the preparation course in Amsterdam and the knowledge that you have, indeed, signed up to work in a potential area of conflict, it is disconcerting to be told on your very first day that you can’t go somewhere because they are worried for your safety. But, turn this around, and it is comforting to know that MSF will monitor security and spare no effort in evacuation by whatever means possible if a situation becomes potentially dangerous. I was clearly advised (by both my HOM (Head of Mission) and PC (Project Coordinator) before I accepted this placement that it could be unpredictable, and I am just right now taking things day by day.

So, after a fitful night of unsleep under my mosquito net, I finally get on the plane the next day to go to the north of South Sudan, near the new border with Sudan, to a wet and rainy town to await the next decisions about where I will be going and what I will now be doing. Flying over the land that will be my new home for the next 6 months is daunting. There is nothing below me but miles and miles of scrub land, few trees and water, which by the time I leave, will be nothing but bone dry arid tundra. There are many mud homes, with thatched roofs, and cows, the currency of the people. I am told the houses are called tukals, and if I am not living in a tent, I will be living in one of these. For now, I join the team already in Malakal, who are very crowded because we, who are supposed to be elsewhere, will be living with them. Introductions are made, names are forgotten and once again, I collapse into my bed in my crowded room. They seem an eclectic group, and what a surprise, there is cold beer here. This is a good sign.

And so, after much anticipation and with significant trepidation, I start the work of treating this deadly disease. For now, I am working on the Kala Azar Ward in the Malakal Teaching Hospital. The hospital is run by the Republic of South Sudan Ministry of Health, and MSF supports the Kala Azar ward with funding and staff and support to help treat the victims of this epidemic. I am learning from the current MD who is stationed here, and the South Sudanese nurses and Clinical Officers. The learning curve is steep and I often feel overwhelmed with my lack of knowledge, but having worked in Africa before, I know this feeling of total incompetence will be replaced with some confidence and relief as my skills and my knowledge base increases. The current MD will be leaving on vacation soon, and I will suddenly and soon have a brand new job as the senior medical staff person.

And so now, finally, I am caring for patients. My patients. The people who look at me and hope that I have the skills and the medicine and the ability to do what needs to be done in a desperate situation. The mothers that can only hope that I will have the knowledge needed to do the right thing for their sick baby. But, and so importantly, this job is obviously about the medical work, but a critical part of the MSF mandate is ‘temoignage‘, witnessing the events you are involved in, and letting the world know. So, I will try to let you know, and you can bear witness with me.

Please, wish me and my many patients well.

Posted in Doctor, Kala Azar, South Sudan | Tagged , , , | 21 Comments