Kala azar and the long road back to Bentiu

From the air South Sudan looks calm, peaceful, almost empty. Even now after the rains have finished much of the flat countryside looks green and lush, being taken up by the vast swampy wetlands of the Sudd.

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

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

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

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

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

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

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

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

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

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

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