The drone of the motor from our small plane is soothing. Tyson and I are returning from another busy and productive week of outreach. From up here, South Sudan seems almost uninhabited. The greens and browns (mostly browns) of the swamps and trees stretch endlessly, pancake-flat, in every direction.
Trails wind through the bush connecting one small collection of mud tukuls to another, narrow tracks through thickets bristling with cattle and thorns. During dry season these trails cover craggy, ankle-twisting mud baked hard by the sun. They are the closest thing to roads most people have here in South Sudan.
MSF in Lankien has attempted to shorten the distances patients in Jonglei state need to travel by operating small satellite clinics in the surrounding area. As the outreach team, Tyson – a fellow expat – and I are responsible for managing them. The largest of these clinics is in the village we just left, the village of Yuai. It had taken me nearly three months to finally make the trip out to Yuai because of security concerns and scheduling conflicts, but it felt exciting and rewarding to finally meet and work with the staff there.
I had known them previously only by their names and voices as we spent endless hours exchanging data (each attempting to understand each other’s accents) with a poor connection over satellite phone. With only three community health workers they are relied upon to treat a wide range of often-serious illnesses and injuries with minimal direct support.
While kala azar numbers are consistently lower in Yuai than in Lankien, burns, malaria, respiratory infections and injuries are comparable if not higher. While working there, I found myself constantly turning to the national staff for treatment suggestions. Living in South Sudan they have had limited opportunity for professional education and have even more limited diagnostic and treatment options, but they have enormous practical knowledge and dedication. They are eternally resourceful.
Life in Yuai is different than Lankien. Yuai has even less vegetation than Lankien, so families do not build sorghum-stock fences around their tukuls. This makes watching the sunset a bit more accessible; bright oranges and pinks blaze above the smoke of cooking fires. It puts the entire village on display as the residents go about their evening activities. Neighbours greet neighbours in a near endless recitation of the traditional greeting: Maley!! Maley Magoa!!
There are a few other NGO’s at work in the village and we occasionally visit with their staff during lunch hour for interesting conversation. These conversations often revolve around what food their NGO sends them, seed distributions, vaccination campaigns, medication ruptures [disruption in supplies of medicine], local news, attempts at gardening in the compound, borehole construction, and lately… bees.
Honeybees are a force to be reckoned with in South Sudan. This may sound a touch dramatic, but the truth of the matter is they have no interest in accommodating the activities of local NGOs or anyone else. Only a few weeks back in Lankien, a celebration ended in a matter of minutes when a child threw a stick at a honey-bee nest. All I could hear from inside of the hospital gates was yelling and then silence as the rally dissipated; weeks of preparations wasted.
Disappointingly we arrived in Yuai to find a massive nest had been constructed beneath our shipping container we use to store ready to use therapeutic food. This explained the inconsistencies in the inventory reports. Locally referred to as ‘lub lub’, Plumpy Nut is a peanut buttery goo full of vitamins, minerals, protein and 500 calories per sachet. Along with BP 100 biscuits (300 calories), Plumpy Nut is given to malnourished patients and all patients with kala azar. It is a critical resource in South Sudan.
If you need to feed malnourished children, housing bees under your storage container is a Big Problem. A neighbouring NGO with a similar problem had recently made the mistake of disturbing a honeybee nest in the door of its broken down 4x4. During the ensuing bee storm they lost four chickens and the compound had to be vacated for two days. Needless to say they will not be eating eggs for breakfast or fixing their 4x4 any time soon. When I asked our water and sanitation logistician (Wat-San) and tech-logistician over satellite email how to resolve the issue, they simply suggested bottling and returning to Lankien with the honey. Really funny guys… hopefully this issue will resolve quickly and safely!
In our three month absence there have been other problems with the clinic compound as well. With the past season’s winds and rains came the deterioration of the buildings and destruction of our perimeter fencing (for security, and for keeping out marauding goats and donkeys). Rainy season had brought its usual torrent of termites, who over the course of months had happily eaten most of our usable fencing. When we arrived in Yuai, the compound was in desperate need of a makeover. As it is now dry season (Tukul rebuilding season), we decided to make some repairs. Luckily, a national staff member skilled in construction had recently moved from Lankien to Yuai and he agreed to help with the project.
Tyson and I (mostly Tyson) spent the week purchasing various types of construction supplies – wood, rope, bundles of sticks, and hiring local workers to re-mud the clinic and re-build the fences using the traditional method: sorghum stalks and rope of woven fibre. I spent the week trying to learn as much as possible; construction has never been part of my skill set as a nurse but that is about to change. I also worked on trainings, learning from my national staff colleagues, and visiting the other healthcare NGO’s to better understand the services they provide in the community. NGO’s in South Sudan are constantly in transition; medication ruptures and employee transfers are frequent. Other NGOs often offer important services we don’t in Yuai, such as refrigeration for storage of vaccines, and trained midwives. Knowing when and who to refer can be life-saving.
Diagnostics are limited in Lankien, but we do have a basic chemistry machine, centrifuge, microscopes for blood slides, and haemoglobin machines. We also have rapid diagnostic tests (RDT’s) for syphilis, pregnancy, malaria, kala azar and urine dipsticks. In Yuai, we have only the RDT’s. I now have a better appreciation of why there is such a push for RDT development in public health. In a clinic like Yuai, without electricity or highly trained lab technicians, RDTs can make the difference in a patient’s treatment plan and prevent the incorrect usage of antibiotics.
A few patients I examined had already been to the clinic multiple times before our arrival. I could see from their worn treatment cards and progress notes they’d been given multiple courses of antibiotics. Antibiotic resistance is the first thing that comes to mind, but realizing that when someone is only getting worse and there are no test results nor scans to guide their treatment plan, a different antibiotic becomes the only glimmer of hope.
One young girl around the age of seven was already tested for kala azar and malaria (both negative), completed treatment for TB a few years back (the father responsibly carried in hand the small laminated card to prove it), and was the most malnourished human being I have ever seen. Everything inside of me wanted to hold her like a new-born. I could palpate a small mass in her abdomen, even through her swollen and protruding belly, but there was little else to guide her care and diagnosis.
Her father was so tender and caring with her, which is something I see regularly here; it’s not a mothers only club for raising and loving children in South Sudan. The second I handed her Plumpy Nut she devoured it only to be in pain later from poor digestion. In other countries she would have received every scan and blood test possible. Here in South Sudan I could only treat her for dehydration, diarrhoea, and do my best to put her on our flight back to Lankien.
We would likely start her treatment for relapse of extra-pulmonary TB as a last effort, and that made my heart sink. I realize that people suffer at every end of the spectrum from inadequate and over-aggressive healthcare, but that child’s suffering was just plain unfair. Nobody should have to look so frail and helpless, and still be able to smile in appreciation of insufficient care.
For the moment our airplane ride is without turbulence. I hope it remains that way. While I am thankful for my time in Yuai, I am looking forward to being back at our big compound in Lankien. The seven-year-old and her father are on-board with us. Both are captivated by the view from the plane. I realize that if the hospital in Lankien cannot make her better we have now separated her and her father from their family which always gives me a mixed-bag of guilt.
I force my thoughts to drift, and I realize I’m excited for our return home to Lankien because there is usually something fun happening and the gossip and camaraderie gives some variety to the emotional and physical grind at the hospital. We come from all over the globe, so experiencing life together in Lankien is a multicultural collage.
A few weekends ago our tech log jerry-rigged strobe lights for our Saturday night dance party. Our HR log managed to get someone coming back from holiday to bring butter and she whipped up an amazing carrot cake with frosting. Carrot-cake-with-butter-strobe-light-dance-party with Kenyan, Korean, Pakistani, and Italian dance music.
A small group of us also have gym time four to five days a week. All the squats, sit-ups and creative use of stretchy bands, TRX bands, and jump ropes help to keep us active and give us a mental vacation from the constant talk and work of running the hospital . . . And suddenly, there it is: Lankien’s dirt airstrip growing on the horizon. It’s been another eventful week, as most weeks are, but we’re almost home.