Fieldset
Goodbye Lankien

It is difficult for me to believe my nine months have nearly come to an end. It is now wet season again…although perhaps this year they should call it damp season.

It is difficult for me to believe my nine months have nearly come to an end. It is now wet season again…although perhaps this year they should call it damp season.

Rains have not been frequent enough nor hard enough after planting season and as a result most crops have been scorched or will produce a meagre harvest. Still, some of my patients have been eating maize in their hospital beds. It is nice to see the fruit of their labour and their appreciation of South Sudanese soil and not so nice to see they throw the cobs on the floor of the hospital wards when done.

The soil here is surprisingly fertile. Although it looks like nutrient depleted soil in the dry season, our small garden in the compound has produced okra, squash, lettuce and basil with very little work.

There was and is a lot of talk about South Sudan being the potential bread basket of Africa when peace and effective governance can be attained. The once brutally dry terrain and leafless trees of dry season have morphed into a beautiful collage of greens. Similarly, the airstrip requires some serious rain boots and a partner that is willing and strong enough to drag you out when the quick-sand like mud puddles suck you in.

With the inconsistent rains, malaria season decided to get an early start. In January of 2015, at the height of the previous malaria epidemic, it was common to have more than two infants die in a day from severe malaria in the hospital, often related to uncontrollable low blood sugar (hypoglycaemia) and low blood levels (anaemia).  

As well, there seems to be a slight increase in kala azar patients in the last two weeks, perhaps just a fluke [kala azar is a parasitic infection spread by sand fly bites]. Last year, the worst kala azar epidemic in history, started showing an increase in June.  It is likely to be a more relenting Kala Azar season this year. 

As the country has had enough trouble, hopefully this will be one less burden on the people of South Sudan. The seasonality of communicable diseases, especially vector-borne infections, is one of the reasons providing healthcare in South Sudan is so multifaceted.

Tyson left three months ago and I have transferred to working as an inpatient supervisor in the inpatient department (IPD) of Lankien’s hospital. My Nuer is improving and I take pleasure in getting to know my patients and their families. Nearly all of the people I began my mission with have left. I am eager to do the same, but will miss Lankien and my work.

One of our new admissions delivered a healthy baby at home the day prior to admission. Her mental status, according to her family, rapidly deteriorated after giving birth. When we admitted her, she had mild jaundice (yellow sclera) and decreased level of consciousness with intermittent agitation.  

These are all typical signs of a liver disease, but with a recent delivery and the sudden onset, nothing could be ruled out.  While any patient suffering and only getting worse is heart-breaking, to know that the baby may never know its mother was weighing on all of our shoulders.

My best efforts at crowd control with the particularly large family were failing. Even the guards couldn’t understand why seven family members eating lunch all around the bed of a critically ill patient in the intensive care unit would be an issue. So, with frequent re-positioning of her head to re-open her airway and even more frequent crowd control of her family and friends, we debated how to try to treat her. Being two days short of leaving, my patience was running thin.

In the isolation room, not far from her bed, a young man, appearing to show signs of improvement, remained confused from his unknown liver disease. Meanwhile, we ruptured on hepatitis E tests one week ago. While there is a current outbreak in Bentiu, no patients have tested positive in Lankien for over four months and both these patients were not showing some typical symptoms of Hepatitis E: fever, vomiting and diarrea.  

Finally, on my last day of work in Lankien, the MSF plane arrived. No rain for the last two days allowed for a much needed shipment of medical supplies and increased hope that I will get to leave Lankien in the near future.

Now, with Hepatitis E tests, we got the results back from the lab a few hours later….Both positive! 

Needless to say, the doctor and I were very, very surprised.  Sure, we had been hand washing and wearing gloves, but after spending half the day managing her air way, providing suctioning and encouraging the grandmother to manually express milk for the baby, all of us were concerned about spreading the infection to other patients, caretakers and co-workers.  

Despite my personal concerns, I had an entire ward to sanitize, organize and educate, all as soon as possible.

Hepatitis E is most typically seen in developing countries with a low level of water sanitation allowing for faecal contamination of water sources, but there is also human-to-human transmission. Some strains of Hepatitis E have a zoonotic component, swine in the Democratic Republic of Congo and Uganda, donkeys in Sudan and goats and cattle in Egypt are suspected. 

The typical incubation period is three to eight weeks. Hepatitis E, like Hepatitis A, spreads through the oral-faecal route. It is fatal in approximately 2% of cases. With pregnant women it can be fatal in 20% of cases, and more dangerous during the third trimester. Additionally, most studies suggest that clinical infections are higher among young adults.  

Before knowing the causative agent, likely outbreaks were first documented in the mid-20th century. At this time, Hepatitis E was referred to as non-A, non-B hepatitis. Laboratory diagnostics became available in the 1980’s and currently about half the countries in Africa have had confirmed outbreaks.  Treatment is only supportive.

Back in Lankien, we began giving the three-day-old baby formula and sent her home with the grandmother.

The woman sadly passed away later that night. 

As soon as we instructed the caretaker of the male patient, on the now stricter visitor policy, special hand washing and glove wearing rules, she snuck in the pregnant daughter-in-law to visit and locked the door from the inside. There are plenty of moments where screaming and stomping my feet in frustration, total two-year-old-tantrum-style, seems like a sane and helpful response…this was one of them. A few days later, the man improved and was discharged home.

Putting in place Hep E precautions in coordination with water and sanitation, logistics and the medical team leader,  with one of the patients being too critical to put in proper isolation during the last few hours of my nine-month assignment… is… well... typical of MSF work actually. 

In a strange way, that is exactly what I will miss about being in the field: the sudden opportunity to be an instrumental part in the implementation of something you never imagined ten minutes prior.  

I will miss these people, all the hours sweating in my MSF shirt, all the opportunities to learn and be frustrated with a similar goal in mind, and most importantly to provide healthcare to those who need it. While I have ended many days shaking the bugs out of my hair, covered in dust and frustrated at patients, staff and myself, it was all worth it. 

Goodbye Lankien and thank you.

I hope someday your country will be at peace and MSF will no longer be needed.