Ruby in the Philippines

Ruby is currently writing about her work on our emergency response to typhoon Haiyan on our Philippines blog. Read her blog plus first-hand accounts from other MSF team members here.

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All talk and no action

We breakfast on hot sugary tea and fried dough balls (a bit like beignets but without the sugar). I completely associate these with Chad. Just like the barbequed meat (cow? goat?) from the roadside grills that you dip into a paste made out of a local curry powder and lemon juice. Yum!

I’ve resigned myself to the mosquito onslaught. No matter how much deet I spray on myself, the mosquitos find a gap. I even have bites on the soles of my feet! Every day I’m taking a concoction of malaria tablets, vitamin pills and antihistamines (for the mosquito bites). All washed down with Castle beer. I’m probably a physician’s nightmare.

The only respite is when I’m under my bed net. In fact, we would all rush to our rooms after dinner to sit under the protection of the nets. I’d like to invent one that I can walk around in, protecting me 24-7. Eating and drinking might be a problem, but I’m working on it!

malaria Chad MSF

Waiting for health care © Ruby Siddiqui

 

Bed nets are very effective at protecting against mosquito bites, especially now that they’re impregnated with long-lasting insecticide. This means that even if the net develops a few holes, the insecticide will still protect you from the mosquitos. And the insecticide lasts for at least three years as long as the net is not washed too frequently.

So bed net distributions are one of the main intervention strategies used in the fight against malaria. The Millenium Development Goal is to achieve universal coverage – one bed net per two people – in malaria-affected countries by 2015. We want to find out what the current bed net coverage is in Am Timan so we’re going to carry out a survey in the coming weeks with our Ministry of Health (MoH) partners. The results will help guide bed net distributions.

MSf malaria Chad

Abdul Aziz (MoH) and Jean-Claude (outreach-nurse) © Ruby Siddiqui

 

The long drive is made bearable by the tunes spilling out of the car radio. Wherever you are in Africa, you’ll hear Congolese music. It’s loud, fun and makes you want to dance. Our driver is clearly a fan. But he also has some Ethiopian shoulder-shaking tunes and Indian bhangra beats and the odd European classic like ‘Barbie Girl’. It’s an eclectic mix!

Chad malaria MSF

The long drive © Ruby Siddiqui

 

We finally arrive in N’Djamena. I already know that my chances of making it to Tissi are slim. The plane can’t land due to the rains and the replacement helicopter is being repaired. There are a number of people waiting to get out and in! But the team seem to be coping with the large number of malaria cases in the refugee camp (more than 500 per week).

Besides I might be needed elsewhere. I’ve analysed the latest data coming from SW Chad. We’re seeing a huge rise in malaria and alarming mortality rates in Kelo. We propose to send a small team (a doctor, a nurse, a logistician and me) to Kelo hospital to support the staff with drugs, tests and training. It seems to take an age to hear the decision. Everyone has an opinion. The medics generally support the idea and the non-medics don’t. It’s the traditional tussle you see in the field. And rightly so. The medics see the need and want to respond. The non-medics see all the potential problems, logistic difficulties and security issues. We have to find a balance.

Chad malaria MSF

Roger (CERU-nurse) and Marie Claire (Deputy-medical-coordinator) © Ruby Siddiqui

 

In the end the decision is to send Roger, our emergency nurse extraordinaire. He is part of the Chad Emergency Response Unit (CERU) and has vast experience in responding to sporadic outbreaks all over the country. He knows exactly what to do and has proved effective time and again. I’m disappointed but it’s the right decision. I’m the least useful person on the team. It’s time for the medics to take over and do their thing, diagnosing, treating and caring. They get all the action.

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What are baby goats called?

The return journey to N’Djamena is all about the animals. We see three types of monkey, camels, new born donkeys, horses and goats and even a deer. Of course each time I tried to take a photo, the animals disappeared. The lakes are beautiful, different shades of pink and green, covered in lilies or flocks of birds. And there are huge hills made of striped boulders. Even the people look stunning against this backdrop, particularly the women with their layers of bright bold colours.

We see a baby goat (what are baby goats called?). It’s limping. Slow and helpless. Its vulnerability transports me back to the intensive care unit at Am Timan hospital, full of children with malaria, all of them so weak and frail, each with a concerned mother at their bedside, willing them to get better.

malaria Chad MSF

Malaria and malnutrition © Ruby Siddiqui

 

There’s a little girl with severe anaemia, her breathing rapid, linked to a tube supplying blood. Malaria is a parasite that has part of its life cycle in the blood. This is the stage that causes the clinical symptoms of malaria. Parasites multiply rapidly in red blood cells and burst out, killing the cell and each infecting a new red blood cell, multiplying again. This huge loss in red blood cells can lead to anaemia, often severe in young children. And unlike many countries in the West, hospitals struggle to maintain a blood bank. We often have to ask family and close relatives to donate, to save the life of the child.

MSF Chad malaria

Severe anaemia © Ruby Siddiqui

 

Another child lies in a coma. Her skinny body unable to cope with the overwhelming disease. The worry is etched on her mother’s face. It feels wrong to take a photo but all the mothers want me to take photos of their children so that people will know what’s happening.

MSF Chad malaria

Coma © Ruby Siddiqui

 

But luckily many of these children will get better with effective clinical management and intravenous artesunate. And the ward next door is proof, full of children on the road to recovery, screaming and eating and doing all the things kids should do (that’s what baby goats are called!). We just have to find them early enough.

Which is why our additional mobile malaria clinics are so important. In addition to supporting the Ministry of Health Clinics, MSF is currently running its own malnutrition and malaria clinics in areas that do not have a health centre. We are detecting large numbers of malaria cases and treating early with artemisinin combination therapy (ACT) to prevent them becoming severe. But for the severe cases, we are transporting them to Am Timan hospital either in our own vehicles or fuelling MoH ambulances to transport them, saving precious time. But additionally the Ministry of Health and MSF treat these severe cases with pre-referral rectal artesunate. Studies have shown that in situations where parenteral medication is not possible and travel to a hospital is expected to take more than six hours, using a single dose of rectal artesunate reduces the risk of death or permanent disability (as long as this initial treatment is followed up with appropriate parenteral antimalarial treatment in the hospital).

MSF Chad malaria

Bednets and PlumpyNut © Ruby Siddiqui

 

And on top of this we have outreach (community health) workers visiting the communities, raising awareness about the symptoms of malaria and the availability of free treatment, monitoring deaths likely due to malaria and referring malaria cases to the clinics and hospital. It’s exhausting work, involving walking or cycling large distances, in tremendous heat or rain. But the outreach teams are hard-working and enthusiastic about their work, they realise how important it is right now.

MSF Chad malaria

Me and the community health workers © Ruby Siddiqui

 

We are doing as much as we can in Am Timan but there is still so much to do. We are seeing an increasing proportion of malnourished children that are positive for malaria. Both conditions in the same child can be mutually exacerbating. We need to administer early ACT and a course of Plumpynut™, a peanut-based nutritional therapy that we have found to be highly effective in treating malnourished children.

MSF Chad malaria

Gobbling up PlumpyNut © Ruby Siddiqui

 

It’s great being surrounded by all these tiny children gobbling up Plumpynut. And it’s all about the kids.

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Emergency response to astonishing rise in malaria

I’m being eaten alive. We’re outnumbered and the mosquitoes are ravenous! Every inch of skin is covered in bites. I’m one big allergic mess.

I’ve arrived in Am Timan, the main town in Salamat region, SE Chad because of a staggering rise in malaria. They have reported more than 15,000 cases so far this year, almost twice the number seen in the whole of 2012. Malaria is a parasitic infection spread by mosquito bites. It causes waves of debilitating fever and at its most severe it can lead to jaundice, severe anaemia, coma and death. It is generally infants that suffer the severe consequences of malaria.

MSF malaria Chad

The MSF car always draws a crowd © Ruby Siddiqui

 

So I’ve been dispatched to investigate this unusual outbreak and help support an exhausted team. After landing in N’Djamena, the capital city, at 4am, I’m allowed two hours sleep before being given a quick briefing by the medical coordinator at the same time as having my passport taken for various authorizations at the same time as being piled with documents, forms, insect repellent and malaria prophylaxis and finally being stuffed into a car. I have a two day drive to catch up on my sleep!

The journey is stunning. The last time I was in Chad it was barren and dry, but with the rains come lush green countryside, spontaneous lakes and beautiful migrating birds. And a hair-raising ride in a narrow boat loaded with all our malaria drugs and kits. The road is somewhere under several feet of water. With the rains come business opportunities (for anyone that can build a boat)!

MSF Chad Malaria

Crossing the Road © Ruby Siddiqui

 

And we finally arrive in Am Timan, just in time for lunch and to meet the large MSF team. Denise is Swiss with an American accent and is usually in charge of finances and administration but is currently acting Project Coordinator. Bienfait is the Medical Team Leader and part of the jovial Congolese posse that includes Guy, the TB/HIV doctor, and Jean Claude, the outreach nurse. Judith, Karla, Andreas and Andreas, the midwife, paediatric doctors and logistician, are the talkative Germans and calm Vincent (lab technician, Kenya), quiet Jeremy (Obstetrician, Australia), bubbly Louise (Pharmacist, Ireland), dapper Richard (Logistician, Liberia), reliable Miet (Nurse, Belgium) and fun Prosper (IEC officer, Burundi) are the sole representatives of their countries. We could almost have a mini-Eurovision Song Contest here!

I waste no time in interviewing Bienfait, Prosper and Jean-Claude. They have implemented Phase 1 of their malaria intervention plan including:

  • creating a malaria tent at the hospital to diagnose and treat the overwhelming numbers of patients arriving at the hospital
  • providing intensive care for severe malaria cases,
  • upscaling the mobile malnutrition clinics led by Jean-Claude to include malaria diagnosis and treatment
  • creating a mobile malaria team led by Prosper that delivers rapid diagnostic tests and drugs to health centres
  • as well as training and information, education and communication (IEC) advice to the health centre staff and community.

It’s an impressive response that owes its success to a close collaboration with the Ministry of Health. Abdel Aziz, Idis Kas and Dr. Mahamat Abakar the district surveillance, district and regional chief health and representatives recognised the issues and worked alongside MSF to support an overwhelmed health staff.

MSF Chad malaria

Malaria Rapid Diagnostic Tests © Ruby Siddiqui

This astonishing rise in malaria has caught everyone off guard. The health centres quickly ran out of rapid diagnostic tests which are needed to confirm a malaria diagnosis and malaria drugs to treat the disease. Am Timan hospital was simply too far for some of these patients to travel. In addition an inability to pay for the usual health care costs might have meant some people did not seek health care. We heard of increased mortality rates in the communities. But with this joint Ministry of Health-MSF response, the tests and drugs are reaching the people that need them, the health centres have increased their staffing and opening hours, and with our IEC campaigns people are coming forward for free treatment at the first signs of fever.

Chad MSF malaria

Stuck in the mud © Ruby Siddiqui

 

The work involves long drives to hard to reach places (of course when I joined we got well and truly stuck in the mud!) but it’s moving to see the health staff light up at the sight of our cars and to hear that their consultation rates have increased because people have heard our health education messages. The only thing left to do is increase our coverage of the Am Timan population, including those cut off by the rains and to fill gaps in bednet coverage (an effective protection against mosquito bites and therefore malaria). We make plans for a nurse and logistician to help with the former and another epidemiologist to help with the latter.

Next stop Tissi, where MSF supports a refugee camp on the border with Sudan (Darfur). We’ve observed increasing malaria there too. But rains are preventing any flights from landing there at the moment….

Posted in Chad, Epidemiologist, malaria | Tagged , | 7 Comments

Day 30 – leaving South Sudan

Randra or Suby? The team are trying to decide what acronym they should use for me and Sandra, along the lines of Brangelina and Tomkat. Sandra and I have been inseparable. We work together, we share the same tent, we’re basically with each other 24/7. I find myself looking for her when she’s not around. And I’m going to miss her now that I’m leaving. It’s been great working with her. She cares about the refugees and our outreach teams just as much as me. She could discuss the challenges, debate the limitations and problem-solve our activities and although we have very different styles (she’s much more patient, gentle and diplomatic than me), I think our combination worked well for our outreach workers too. I feel a bit out of sorts.

Leaving a mission is always hard but this is particularly difficult. There’s so much more to do. This crisis is far from over. We’re just starting to scratch the surface of the true extent of health morbidities in this population, we’re starting to identify patients before its too late and we’re catching patients before they drop out of our programmes. But there’s still more that we could do.

We had to remove the pregnant women component of the MUAC surveillance due to the staff strike. We still need to investigate the main diseases affecting this population and we need to do more qualitative research (semi-structured interviews, focus groups and non-participant observation) to understand the refugees’ attitudes, perceptions and behaviours around water and hygiene. So maybe it’s appropriate that my boss is coming to replace me. I am joking with Tara, the emergency coordinator, also leaving the mission (and with whom I would work again in a heartbeat), about how we’re both being replaced by our bosses. Clearly we’ve set the bar so high only the highest level of MSF is qualified to take over (ignoring the fact that it’s the summer so finding staff is a lot more difficult!). But Phil is an infectious disease expert with years of field experience in MSF. I’m relieved to be handing the project over to someone that can move it on to the next level.

And I leave behind a team of fantastic people. The large Kenyan contingent like Johnstone the WatSan technician and all-round flirt, Janet the shy midwife, Soloman and Steven the supply logisticians that never complained about my demands and Peter my favourite OPD nurse who never looked phased when we brought in lots of patients from the camp and always prioritised their care. And the Sierre Leone posy; Daniel the outreach nurse that would travel through hell and high water to get to his patients, John the passionate nutrition nurse who was just as determined as us to trace every defaulter from the nutrition programme to ensure they were not forgotten and Sheik, the medical team leader with a gentle but determined approach who has been without his luggage for almost a month and hasn’t complained once. And the rest of the team; Richard, Andrew, Neil and Robin, the dependable logisticians; Estoban and Joachim, the coordinators that I last met in Haiti, shortly after the devastating earthquake of January 2010; Laura, Sabrina, Katherine and Erna, the medical staff that care about every patient. And Martha, Matt and Rink, our formidable WatSan team, still battling to supply enough water to the camp.

I put my bags in the car and suddenly Jilail appears at my shoulder. Jilail is the eldest of the Outreach team and I’ve always looked out for him, worried that all this walking might be too much for him, making sure his team support him. He lost six members of his family in the Blue Nile bombings. Six. I think he’s telling me to hurry back, in his quiet gentle way. I don’t know how to tell him I’m not coming back so I nod OK and quickly turn away. A huge lump in my throat.

And as our car pulls away Vanessa, our medical coordinator, suddenly appears, running after the car. I feel the most guilt about leaving her. I’ve known her remotely for a few years, supporting her from my office desk in London. But this is the first time we’ve worked alongside each other and I’ve loved watching this dynamic woman motivate her teams, having advice and an opinion on everything. We have used each other as sounding boards, bouncing ideas off each other to address the health needs of this population. It’s a bad time to leave but she gives me the biggest hug and I know I’m forgiven.

And then I see Rink, our star WatSan technician, running after the car. We arrived together. He was the one that re-routed the MSF plane over river beds and unused runways, igniting the adrenalin in all of us for our important missions. We became fast friends and I’m sad that I might never see him again. And then Anur comes running after the car, one of our lovely translators. We’ve decided to make him and Timoty outreach supervisors. They’ve accompanied me and Sandra every step of the way and know exactly what needs to be done to maintain a robust community surveillance system. The project is in safe hands until Phil arrives. And hopefully the small increase in salary means they can go back and complete college one day.

I’m now a blubbering wreck and the journalists and other expats leaving the mission are tired of stopping the car, keen to get out of this camp. But I see it differently. As we drive away in the morning light I only see the beauty of the Ingassana, a proud mountain people suddenly finding themselves living in a swamp. The change must be such a shock, but they are stoic, and determined to survive this hideous chapter in their lives.

And our MSF team, living beside them, demanding that their voices are heard, and doing what we do best, mounting a response in that critical early phase of an emergency while others debate what to do and providing medical care to people at their most vulnerable. I can’t think of anything more worthy.

MSF plane

The MSF plane Photo ©Ruby Siddiqui/MSF

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Day 29 – the things you remember

She wrapped her arms round my neck and I never wanted to let go. This little girl, as light as a feather, dressed in her best frock.

It’s my last day. I have been bumped off countless flights but tomorrow I will be on a flight out of here. And it seems apt that I’m working in Pudurubel, the village where we started the mortality surveillance 4 weeks ago. I’ve come full circle.

I’m working with Team 4. Benjamin the carpenter, Asha the nurse, Amna the cleaner and Daniel the dispute resolver! Sandra has been chatting to each of the outreach workers individually to find out more about their skills and experience and what they would like to do. We want to ensure we are maximising their skills and capacity-building as much as possible. So Asha and all the former nurses will be talking to Sheik, our medical team leader, tomorrow. Amna will talk to Laura, our Irish nurse, who is also managing the hospital. Benjamin will hopefully join Richard or Robin, our construction logisticians, and cheeky Daniel will stay with us, his skills best suited to working in the community.

The staff strike is over. At the same time as asking them to work incredibly hard for us during this refugee crisis, we suddenly stopped the staff shuttles that brought them from Jamam Town to work, about an hour’s walk. We simply didn’t have enough cars and it was impacting on our activities. So they walked out. After a couple of days, the situation was resolved and we agreed to morning and evening shuttles but would no longer do the lunchtime shuttles. That was a tough couple of days for our teams, especially the hospital staff, but many of our local staff had actually started trickling back anyway, realising that the shuttles didn’t affect them.

So now we could restart the MUAC surveillance. And we are finding so many children in Pudurubel with red MUAC plus an infection. We need to get them to the hospital. Why is it that even when you are telling a mother that her child is seriously unwell, she still has to spend ages getting ready? This is a trip out of the village and they need to look their best. One woman decides to have her hair braided, another gives her little boy a bath and the final one needs to find a pretty dress for both her little girl and her new baby. We often see children become malnourished when a new baby comes long, the mother’s attention being focussed on the new arrival. Hence this little girl, standing in her pretty dress, severely malnourished with a fever. I scoop her into my arms and she rests her head on my shoulder, two mud stains on my thighs where her little shoes gently tap them. But other patients are presenting themselves to us. The old lady with probable malaria, the young teenager with vomiting and diarrhoea and the little boy with jaundice. We will have to do two trips.

And it’s such a fantastic feeling to find the little girl later, gobbling up a packet of plumpynut, the peanut-based high-calorie food supplement that we give to malnourished children. Children with red MUACs have often lost their appetite and we have to try more drastic means to re-nourish them. But this little girl is sticking her finger into the packet, trying to pull out every last dreg. I want to give her a big hug, relieved that she’s going to be OK, as long as she stays in the programme.

Girl with Plumpy Nut, a peanut-based high-calorie food supplement that MSF give to malnourished children. Photo © Ruby Siddique/MSF

Girl with Plumpy Nut, the peanut-based high-calorie food supplement that MSF give to malnourished children. Photo © Ruby Siddiqui/MSF

We pile everyone back in the car to drive them home, all of them diagnosed and receiving the appropriate treatment. I notice the little boy with red MUAC was supposed to receive a bednet. We give bednets to all pregnant women and children under the age of five that attend OPD as they are more likely to suffer the severe consequences of malaria. But his medical card says we’re out of stock. I remember I’d requested a new bednet after breaking mine. I’d actually fixed it (in a lopsided fashion) so I rushed back to find the spare bednet. The mother looked surprised and grateful that I’d gone to such effort.

Field work is exhausting, tensions can rise in such a large team trying to share tents, bathroom facilities and the internet. I can’t remember the last time I had fruit or vegetables and I’d do anything for a bottle of coke.

But you never remember that stuff. You remember days like this, days when your surveillance has picked up sick people, days when you might have saved a life. Its days like these that give you the biggest high.

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Day 28 – pressure

Maram* is not the answer to everything. We can use it to build new roads, to create stands for bladder tanks (huge 10,000L water distribution vessels) and even to absorb swampy lakes outside tents (!) but it can’t be used to build water towers, as can be demonstrated by the collapsed rubble at the end of our shower stands. We all stare in wonder at what on Earth that person was thinking! Then we go back to our queues.

Our team has expanded to over 60 people (+visitors and journalists). This creates some pressure on our 2 shower stands and 2 toilets. Every morning I queue for the toilet, then for a bucket (what’s happened to all of our buckets?), then the tap to fill the bucket, and then the shower stands to take my bucket shower. Then it’s a mad scramble for whatever is available for breakfast (less and less each day) and then the usual bedlam around the cars.

Everything we do is dependent on the availability of cars. If we need to set up a clinic, we need a car, supply ORS points, we need a car, drill for water, we need a car and supervise our outreach teams… we need a car. And of course, all of us think our work is important. So it’s down to Cool as a Cucumber Canadian Andrew to satisfy our automobile needs. He’s just been handed this job (I suspect because nobody wanted it and he was the newest). The poor guy doesn’t flap easily but after 4 days, he looks like he’s had enough.

And this is made no easier by the fact our staff have walked out, disgruntled that MSF has stopped the staff shuttles morning, lunchtime and evening to Jamam town. Suddenly we had few drivers, no radio room staff, no guards and worst of all, hardly any hospital staff.

How were we going to run our hospital wards, OPD clinics, feeding programmes, 3 mobile clinics and 15 ORS points with no staff? We stared despondently at the stream of patients flowing in, soon becoming the usual sea of faces and the 3 expats that would have to handle this alone.

*Maram is a type of grass

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Day 27 – silent children

It’s the silent ones that you notice. In an outpatient’s department (OPD) full of people and screaming children you notice the ones that are quiet. It might mean something’s seriously wrong. The hospital is seriously swamped after we start our nutrition screening in the camp. All of our teams are referring children based on MUAC (mid-upper arm circumference). MSF has created special bracelets, colour-coded green (for safe), yellow (for pay attention), orange (for moderately malnourished) and red (for severely malnourished). Anybody can be trained to wrap this bracelet round the arm of a child and assess the severity of malnutrition.

A red mid upper arm circumference measurement indicates that a child is severely malnourished

A red mid upper arm circumference measurement indicates that a child is severely malnourished Photo © Ruby Siddiqui/MSF

 

And our outreach teams have been finding a lot of malnourished children. The OPD has become a sea of children’s faces, each carrying a white outreach referral slip. The hospital staff are blaming me. But I know they’re just as pleased as me that we’re identifying these kids before they’re beyond medical care. And our outreach workers are enjoying helping kids to live rather than asking families about who died.

But as I wander around OPD, tears come to my eyes. I have never seen children this skinny and weak. Imagine an upper arm, so far in the red zone that it’s basically just a bone, wrapped in skin. It’s heartbreaking to see children suffering this way, a shadow of their former selves, unable to muster a smile. And on top of that some of them are hot to the touch or incredibly dehydrated. Malnutrition makes the child more susceptible to infections such as respiratory tract infections or diarrhoeal diseases (that can lead to dehydration). How much more can a child take?

So we have to be super-vigilant in triage and pay particular attention to those kids that are not responding. And it’s such a relief to hear a child cry. It means they’ve still got some fight left in them.

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Day 24 – Happy Independence Day

Happy Independence Day South Sudan! And what festivities there were, even in Jamam camp full of non-citizens. There was music and laughter until the early hours and a military procession along the only road passable at the moment. We of course were in lock-down. Familiar enough in recent days with the unpredictability of drunken soldiers. But it was great to see our national staff looking so happy and proud, watching their soldiers pass.

So yesterday we took advantage of our last day of movements to drive around the camp and take geographical coordinates. With all this rain, the villages are moving around, looking for higher ground, which makes all of our maps out of date. And we were on our way back when we noticed a cluster of tents that we hadn’t seen before. Eager to find out more we trundled towards them. And our driver Joseph thought he was being clever by avoiding the water-logged road and heading into the grass. Within seconds we had sunk. The law of averages meant it was our turn to get stuck in the mud.

So the village came to us! Some of the local men came to dig us out. Turns out they had only been there a couple of weeks. They had split from the village Soda to form a new village called Soda Amol. They invited me to meet the new sheikh. So I left Joseph and Sandra to wait for the rescue vehicle (Sandra weirdly knows far too much about 4-wheel drives) and waded through the mud, to squeals of laughter from the local children, and sat with the village elders.

The Ingassana people are organised into 4 tribes (Soda, Bau, Kukur and Kulak), each having 2-3 sub-tribes led by umdas. Each umda leads 5-25 sheikh villages. The refugees have naturally reformed these structures here in Jamam camp, assisted by ACTED’s policy of ‘Organic camping’-encouraging the refugees to decide how and where they will live. However the hierarchy made these decisions before the recent rains and the tribes have ended up becoming dispersed, fragmented and even separating with some animosity.

But maybe they will all come together again. UNHCR have responded to calls from several corners and announced that some of the tribes will be moved out of the Jamam swamp and transferred to Batil refugee camp. It’s a relief to the storm-battered refugees. And the move will happen one tribe at a time.

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Day 22 – standing in line

Kowaja! Kowaja! Kowaja! Or the mouse shuffling round the tent at night. Or the dahl every…single…day! I’m trying to list all the things I WON’T miss about Jamam. It will make leaving easier. It somehow feels like you’re abandoning a project when you leave it but in reality I’m no longer needed. I came to carry out the mortality surveys and to set up community surveillance.

Now the international media are quoting the results of these surveys and, thanks largely to Channel 4, this crisis is finally getting the international attention it deserves. And Sandra is more than capable of taking full control of the epi component of this mission. In fact she’s turning into a great asset.

And even the outreach teams are sick of saying goodbye to me. Half suspecting they’ll see me again a couple of days later. We trained them for another ambitious project today, screening every child in Jamam camp for malnutrition. We plan to carry this out in only 1 week and really get on top of what we suspect is a large-scale problem in Jamam. We’re even going to include the pregnant women in the screening after anecdotal evidence that some of these women are malnourished. If an adult is malnourished, it indicates the severity of the food security situation as adults usually have natural coping mechanisms so it takes a long time to become malnourished. And if pregnant women are malnourished that can have extreme consequences to the developing foetus. I’m really pleased that we’re including pregnant women and I’m gutted I won’t be here to support that part of the survey.

So I’m back to making my list. But it’s a bit of a struggle. I could talk about the lake outside my tent every time it rains but Richard, one of the logisticians, has piled maram around that part of the compound so any water is almost completely absorbed. It feels a bit weird, like walking on the moon, but better than wading knee deep through swamp water.

And to be honest I love the kids shouting out Kowaja (‘white person’) to us. It’s so cute. I’m not white but there’s no point in arguing the point. Actually the kids have made up a song about how getting the ‘Kowaja’ water means standing in line, getting the ‘Kowaja’ food means standing in line, getting any ‘Kowaja’ stuff means standing in line. Hilarious.

Line for food distributions

Line for food distributions © Ruby Siddiqui/MSF

 

And I love dahl. It’s the one food I could eat every day. This one could do with a bit of spicing up though.

But the mouse is doing my head in. It appears every night and scurries around the tent. I immediately wake up, flash on my torch and spend the next hour looking for it but at the same time frantically ensuring my bed net is tucked in. I’m so paranoid that it will crawl all over me I can’t sleep. It even managed to get past our ingenious taping of any tiny gap in the tent’s zips. I’m desperate for a good night’s sleep, yet Sandra manages to sleep through the whole thing, oblivious to this tiny monster. How does she do it?

 

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