I am here on my first mission, working in the busy, sometimes chaotic, but always interesting and rewarding, paediatric admissions ward at the Aweil Civil Hospital.
The hospital is run by MSF in conjunction with the South Sudan Ministry of Health. It serves over a million patients in Northern Bahr el Ghazal, the poorest state in one of the world’s poorest countries.
We see a huge variety of cases every day, including acute malnutrition, meningitis, pneumonia, severe dehydration due to diarrhoea, complicated malaria and a wide range of other tropical diseases. As well as diabetes, asthma and other conditions you might see anywhere in the world. We also see trauma cases including burns, fractures and severe head injuries.
We work alongside local medical assistants, who have a variable level of training and experience. They admit these complex patients efficiently, asking for help and advice with the sickest or most unusual cases. As MSF doctors we are here to support them in their work, provide them with training and improve their clinical knowledge and skills.
One issue frustrates us all on a daily basis – the need for blood. In keeping with much of Sub-Saharan Africa, South Sudan does not have a national blood bank or donor system. Any patient who needs a blood transfusion is required to provide a donor who can give blood prior to them receiving a transfusion.
In paediatrics, the most common reason here for needing a blood transfusion is malaria. Malaria is extremely common in South Sudan. Although it can, and does, infect people of all ages, children under five are the most severely affected. They have not yet built up enough immunity to protect themselves against the most devastating complications malaria can cause.
One such effect is to cause severe anaemia (a lack of haemoglobin – the essential oxygen carrying component of blood). Malaria parasites replicate inside of red bloods cells and then burst out of the cells when this cycle is complete, destroying the cells in the process.
Our patients often have low blood levels to start with, due to chronic bleeding from intestinal parasites and a lack of iron and nutrients in the diet needed to build healthy red blood cells. This means that an infection with malaria can quickly tip them into critically low blood levels, with symptoms including severe difficulty breathing, chest pains and reduced conscious levels. These children urgently need a blood transfusion to save their life.
If a patient is in a critical condition and there is blood in our blood bank, we will transfuse them as an emergency and try to persuade a family member to donate afterwards. If a child has low enough blood levels to need a transfusion but is otherwise stable, we talk to relatives to persuade them to donate blood first so that we can perform the needed transfusion.
There are many barriers to donation here. Usually the person who has brought the child to the hospital is the mother. If she is pregnant, exclusively breastfeeding a child or is anaemic herself, she will not be able to donate. Even if the mother is able to donate or if a relative is found who would be a suitable donor, people are often very reluctant to do so. They are afraid of the consequences and often have no understanding that their blood will replenish itself with no lasting ill effects.
Already I have had many long and frustrating conversations with family members who are simply too scared or unable to understand how essential and safe blood donation is. Despite this time spent in conversation with the help of our excellent and patient translators, in some cases we are just not able to find or reassure a suitable donor. In these cases again, we must make the agonising decision – is this very ill child unwell enough to justify using any of our vanishingly small stocks of emergency blood or do we need to save them in case an even more unwell child or bleeding mother comes in today? It is an impossible decision.
I have been really lucky to see the incredible work of Joel, our Congolese outreach nurse in the last few weeks in trying to increase awareness and education amongst the local community with regard to blood donation, reinforcing the need for it and the safety for healthy donors.
Along with a local man who has previously donated blood and one of the national staff who work in the blood bank, they have been attending the town mosque and a variety of churches to provide information and answer any questions or concerns people have.
I attended the talk at the local Catholic Church and the passionate speeches from the previous donor and our blood bank worker were incredibly powerful, receiving a very loud round of applause and stimulating a lot of discussion.
I am promised by Bene, the South Sudanese blood bank worker, that he is producing a jingle for the local radio station to further spread the word. This integration into the community and attempt to deal with an issue nearer to its source, rather than wait until a child is critically ill, are an impressive use of MSF resources.
And whether it is a coincidence or not, the following week I overheard a very encouraging conversation. One of the expat midwives was having a conversation with the relative of a woman needing a Caesarean-section for obstructed labour.
“I am responsible for this women” stated the man, “So I must give blood if it is needed.”
Roisin patiently explained that a Caesarean-section is a major operation and blood may be needed but not definitely. She also explained that if he were to donate blood and it were not required by his relative, then we would use it to save the life of a severely unwell child.
The man took this on board and went off to donate. He returned a few hours later – it turned out that he was not a suitable donor due to chronic high blood pressure but instead he had phoned his village and now had three young men here who were healthy and willing to donate. He explained that each of them was willing to save their relative or a sick child.
Happily, the woman had a successful operation and did not require any blood. The generously donated blood of these three men will replenish our blood supplies somewhat and help make the next impossible decision just that little bit easier.