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.
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.