Outreach has been great the last couple of months. As my focus to date has mostly been on the OPD handover to the Ministry of Health I only get to go out with the team one day a week, but it is a day I seriously looked forward to.
Outreach for MSF can vary hugely from project to project – from running whole medical clinics, to antenatal services, immunisations, health education – you name it, it’s been done. And there's variation in how you get about too – bike, donkey cart, boat, flying… Currently in this project we content ourselves with travelling in the rather more prosaic Land Cruiser, with the occasional boat trip.
There is a focus on childhood immunisations, but coupled in with that the team take health education materials out with them, screen for malnourished children and actively refer sick people and pregnant women back to the MSF hospital services. One week was mental – 84 children vaccinated in one morning – I had to dash back to the hospital for more vaccines!
It’s rather beautiful to watch the women and children criss-crossing the vast dusty expanses toward the tree or tukul you have set the clinic up under. Nuer people are tall and thin– and I mean really tall – and so long-limbed and slender! Women range from 5’ 8” steeply upwards and men often get well over the 6’ mark. At 5’7” and built decidedly on the curvy side I look positively stumpy stood beside them. And the women’s posture is perfect – a lifetime of carrying firewood and water containers on their head has given them balance and deportment flawless enough to make Kate Middleton weep and turn in her tiara. The day South Sudanese people decide to learn ballet is the day the whole of Covent Garden can hang up their pointe shoes in despair. The terrain underfoot here is a crazy-paving patchwork of mud plates that have cracked and fissured apart as the flooding from the wet season has receded. I gracelessly trip and traipse my way across, never able to take my eyes from the ground for more than a few seconds at a time, but even when bearing heavy loads, the women here walk erectly and evenly, almost gliding, their long bright sarongs fluttering around their legs.
And it’s not just food and fuel they carry on their heads – when I first got here I was at a loss to explain how women carried their very young babies here as I hadn’t seen any of the sarong slings across women’s backs that I had semi-expected, but even babies are carried largely hands free, balanced on their heads… No safety nets, no seat straps, no fancy carseats here! The women weave long reed baskets with lids which they line with blankets and carry their babies inside. Balanced atop their heads I find it heart-stoppingly precarious. Their gait even with this precious cargo aboard is stately, unworried, unhurried. I’ve never once seen a woman trip on the rough ground, or even falter. Once they reach our vaccination station the baskets are lifted down and the lids untied - nestled inside you will find a newborn infant, or sometimes twins, like so many little cocoa-coloured Moses’s snug in their reed cradles, lulled to sleep by the gentle swaying walk of their mothers below them. We vaccinate children under five only, but often if mum is busy you’ll get a shy and leggy nine-year-old walk up in lieu of her, trailing a reluctant chain of smaller siblings behind her all clutching their tattered vaccination cards.
Malnutrition screening worldwide for children is done using a simple tool which measures round a child’s arm – Mid Upper Arm Circumference, or MUAC for short. A traffic-light-colour-coded arm band is used; Green = chubby and healthy; Red= refer for urgent inpatient treatment; anything in between is referred to the OPD Ambulatory feeding center. It’s a well-established and astonishingly reliable indicator of nutrition status, as it can be used on any child between the age of six months and five years old. Currently the early part of the dry season season is the fat time of year in South Sudan so there are a delightful amount of chubby children around, and at the end of the day our MUAC tally recording sheet is reassuringly dense on the “Green” side. Lean season will start soon though and will run til June/July time. In the hunger gap between crops it’s not unknown for the attendance of the inpatient and ambulatory feeding centers to increase fourfold or higher from then on. But for now, it’s great to see the children healthy and well fed on the milk from the family cows.
MSF staff conducting MUAC assessments for child malnutrition in refugee camps, Upper Nile State, South Sudan. June 1012 © Louise Roland-Gosselin/MSF
In that vein however, it was a tad unnerving on my last trip downriver with the outreach team to see a diminutive toddler of no more than 18 months old pottering about amongst the cows tethered in the village, his pudgy form wobbling between the legs and bodies of these comparatively massive beasts while the unconcerned mother sat calmly with her back to him milking another heifer. And I guess I haven’t seen or heard yet of a single cow related injury at the hospital, so I know that child was safe, but it did rather put my heart into my mouth to watch nonetheless!
A more arresting sight still was when I spotted the woman milking get up, go around to the rear end of the cow, lift its tail and placidly proceed to plant her face firmly into the cows backside and blow hard not once, but several times, into its vagina, before resuming her seat and continuing milking again. Once I had unfrozen with horror I managed to dredge up some memory of hearing about this technique being used for stimulating more milk flow from the udders. Had never seen it in practice though. Rather puts the apparent bother of having to pop down to the corner shop for an extra pint when the fridge is empty into perspective! Could you imagine having to do that every time you wanted milk for your morning cuppa? Nope, me either.
The Nuer tribal culture here centres almost entirely around cattle. They are their livelihood, their diet, their security and their identity. No major life event is separate from them – deaths, marriages, court settlements and many other events all involve strict traditions of purchasing, exchanging and killing cows. They are an integral way of life and there are always cows and calves visible, tied up outside every home tukul in the villages. Herds and their grazing needs determine the ebb and flow of population and seasonal migration of the tribes all across South Sudan, and blur our conventional political borders into the surrounding countries too. Here, wealth is measured in how many cows you have.
Put quite simply – here currency is cattle.
To such an extent that the introduction here within the last century of Western paper and coin currency was initially viewed with not-immoderate suspicion – and quite reasonably so when you stop to consider it. When you know no banking system, no investments; when there are no stocks, shares or interest to be earned, money in its physical self is an inert, lifeless, loveless thing. As a quote from a Neur man in a book on the culture here beautifully expresses “…There’s something I don’t understand about money. Money is not like the cow, because the cow has blood and breath and, like people, gives birth. But money does not. So tell me do you know whether God or man created money?”
Give to Caesar what belongs to Caesar indeed.
There is a quite lovely symbiosis in the relationship between man and beast here, and one that I don’t think I’ve ever seen so close, so dependant, so umbilical before in any other culture I’ve been close to. And yet if you tried to take the monetary value of a heifer – about USD$800 – and imagine a parallel closeness between the people and the paper bills – well, you just can’t. Despite the multitude of problems here and the poverty, there is something very beautiful and organic in the relationship that cold hard currency could never and I hope will never replace.
Children look on as cows head home for the evening in Nasir, South Sudan. April 2012. ©Brendan Bannon/MSF