Lauralee in Lankien

Several weeks ago I met a doctor who had worked in Lankien. He described it as remote, “Think about the farthest place you could go”, he said, “and then go further”. But strangely Lankien does not feel remote to me at all. My idea of remoteness is the vast expanses of Canada’s unpopulated north where I worked as a young doctor, places like Iqualuit, Pond Inlet, Pangnirtung and Moose Factory. Lankien feels very different; it is bursting with life, people talking, singing, laughing, babies crying, animals calling; the constant buzz of life in progress. Remote for me is the Pond Inlet I remember from 1984, not Lankien in 2008.

One of my favorite places here in Lankien is under the Kala Azar tree. The Kala Azar tree is a large spreading tree in the hospital compound, near the Kala Azar tukul, of course. It is the place where I sit, with one of MSF’s national staff, to admit new patients to the Kala Azar treatment program. We usually do this in the afternoon between 4 and 7 pm, when the air is starting to cool down and light changes.

Kala Azar’s official medical name is Visceral Leishmaniasis. Kala Azar (KA) is actually a Hindi word that means “black fever”. In India, another hot spot for KA, patients with the disease develop darkened skin, ergo the name.

The word Kala Azar has stuck and it is used commonly in the medical literature and in spoken language. Everyone here calls in Kala Azar, and everyone knows about it.

Kala Azar is a tremendously satisfying disease to treat. Without treatment it is fatal in 95% of cases; with treatment, most people recover completely.

KA is transmitted by a tiny, hairy, sand fly, which lives in the black cotton soil of southern Sudan. During the dry season the ground is hard and the cracked; the sand flies live in the cool cracks. We are in the ‘Kala Azar Belt’ that stretches along the eastern part of Sudan and northwest Ethiopia. Pockets also exist in Uganda and Kenya. There is KA in other parts of the world, South America, the Mediterranean and particularly India, but the species of parasite, sand fly and reservoir animal varies. I have yet to figure out what the reservoir animal here, perhaps cattle.

The parasite that causes KA in southern Sudan is Leishmania donovani. It lives in the gut of the sand fly and is transmitted when the sand fly bites a susceptible victim. The parasite invades the liver, spleen, lymph nodes and bone marrow.

The patient has fever, wasting, and an enlarged spleen. She has been sick for several weeks and has walked a long way for treatment. She has several risk factors for death from KA: severe weakness, anemia, malnutrition and advanced age (she is only in her late 40′s). Because of her fragile state she will receive a second line drug called Ambisome, more expensive that the standard treatment, but with fewer side effects.

Enough about Leishmaniasis for now.

The flies and the heat and the frustrations are finally getting to me.

This morning I couldn’t get the email to work and I felt like bursting into tears. I do not normally burst into tears, in fact I can hardly remember the last time I cried, but this morning when the email wouldn’t work, I felt like retiring to my tukul for a good cry.

This mission is very tough. I have heard of volunteers who decide to go home within weeks of arriving. The challenges are many; cultural and language barriers, difficult living conditions, different food, very sick patients, patients who die, long hours of work, being on call frequently, dealing with situations for which you may not feel prepared. And of course there is the heat. Our new thermometer reads 49 degrees C. I have never been anywhere this hot before. Ironically, winter is my favorite season, I love everything about it: snow, skating, snowboarding, Christmas, my birthday. So what am I doing in the tropics you might ask? Today, I am wondering the same thing.

He is still with us. He is even a little bit better. But he is only one of many.

There seems to be more children with pneumonia, diarrhea and dehydration than when I arrived three weeks ago. However, my impression is purely anecdotal, we will know for certain later in the month when the number of cases is tallied. But it is the end of the dry season when children are traditionally malnourished and susceptible to infection, so an increase in the number of cases would not be surprising.

The baby is severely dehydrated. Even in the darkness of the tukul I can see the sunken eyes and the depressed soft spot on her head. When I pinch the skin on her abdomen it is like dough and remains tented for several seconds.

The mother is afraid of the intravenous; she knows that an intravenous is often inserted just before a baby dies.

Pneumonia is one of the top killers of children under five years in the developing world.

The baby is using every once of his energy to breath. The muscles between his tiny ribs suck in and out. His shoulders heave up and down and his nostrils flare; he grunts with every expiration. His mother sits on the floor of the tukul and cradles him in her arms. It’s dark in the tukul even in the middle of the day and I wish for the 100th time that my headlamp hadn’t become defunct on my second day of the mission.

We are doing everything that we can for the baby. Antibiotics, IV hydration, a ventolin puffer with a delivery apparatus fashioned out of a hard plastic IV bag. At home the baby would be in the Pediatric ICU. He would have a tube in his trachea and some kind of mechanical ventilator would be breathing for him. There would be a suction machine sucking up reams of mucous from his chest. But this is not home.

We are doing everything we can; he will have to do the rest. He struggles on.

Tonight I am on-call, but I am very tired and I hope no one comes in to the hospital. The hospital is a collection of tukuls. There is the ICU tukul (it is the ICU tukul because it has a light), the kala-azar tukul, the STD tukul, the antenatal care tukul, and a handful of other ‘general ward’ type tukuls. At home, we always talk a lot about beds; we never have enough beds, we have patients who ‘block beds’, patients are shipped to the US because ‘we don’t have any beds". There is no such problem here. Patients lie on blankets on the mud floor; there is always a spot to spread another blanket.

The therapeutic feeding center is filling up as the dry season grinds on. It is the time when there is a shortfall of grain, when last season’s stores have run out and next season’s have not yet been harvested. I am told it is also the season for potential epidemic outbreaks, measles, meningitis, and cholera.

Another day, another group of hot, dehydrated, babies.

Today I incised and drained a lymph node in a child’s neck. I extracted some fluid from the distended belly of a one year old. I aspirated a tuberculous lymph node from the back of a child’s knee. I debrided a third degree burn on the hand of a four year old, explored the exit site of gunshot wound, aspirated fluid from a swollen knee and extracted the remains of a miscarriage.

During my training I had to line up with the other interns and residents to do anything. Here I am in the front of the line, even when I don’t want to be.

Tonight the moon is a perfect round globe; it floods the compound with light and shadow. The nights are full of weird sounds: donkeys braying, cows mooing, reggae dance music, roosters.

I am wishing for a fresh salad, with delicate leaf lettuce, fresh tomatoes and slivers of red onion. I would put a little pressed organic olive oil on it and then drown it in fine balsamic vinegar. Maybe I would throw on a little Greek feta and Kalamata olives, then top it off with freshly ground black pepper.

People on a mission start to crave the things they took for granted at home. New arrivals are expected to arrive with treats. The usual requests are cheese, chocolate, fine spirits and glossy magazines. I purchased my offerings in the airport in Amsterdam, three round mounds of gouda cheese, multiple bars of Toblerone chocolate, a large box of Siroopwafelen, (Dutch caramel waffles), a People magazine and a Vanity Fair. I dragged the bag from Amsterdam to Nairobi. I took it to the hotel in Nairobi and brought it with me on the plane to Lokichoggio. In Loki I put it in the fridge so that it would not melt in the 40-degree heat. I almost lost the cheese in Loki airport when I dropped the bag and the discs of cheese rolled out. I packed it onto the plane from Lokichoggio to Lankien…And this is where things went wrong. We landed in Nasir first, another MSF project. I was so blown away by my first sight of the tall, beautiful Nuer people of southern Sudan, and the rows of tukuls right beside the airstrip, that I neglected to notice that my cheese, chocolate, magazines and Sirropwafelen got off the plane in Nasir without me. It wasn’t until I got to Lankien that I realized I had fumbled the ball in the homestretch (excuse the mixed sports metaphor). An urgent call was put into the Nasir mission. Where was the cheese? The chocolate? The Siroopwafelen? The cheese had been very nice we were old; they would put my remaining goodies on the next plane to Lankien.

I am feeling better tonight after my illness and I am suddenly ravenous. I polish off a dark chocolate Toblerone, single handedly.

I have only seen three cases of active syphilis in my career, despite working in an STD clinic for seven years. In Canada, that makes me an expert, because at home the infectious forms of syphilis are rare. Today, I saw a case of primary syphilis in a woman, something I have not seen before, a single painless genital ulcer. Syphilis is a bit like TB: it presents in many myriad forms, it is a very old disease that has shaped history and culture, and it affects marginalized and poor populations around the world.

Syphilis and other sexually transmitted infections accelerate the spread of HIV/AIDS. Inflammation and open sores, anything that interrupts the integrity of skin and mucous membranes, allows the HIV virus to gain entry into the body.

The prevalence of HIV/AIDS in southern Sudan is quite low in comparison to the surrounding countries. During the war, many people from southern Sudan fled to neighboring countries of Ethiopia, Kenya and Uganda, all countries that have higher rates of HIV than southern Sudan. Now that the peace accord between the north and south has been in place for more that two years, the Sudanese refugees are beginning to filter home. Migration of large groups of people is a potent catalyst for the spread of HIV/AIDS; I fear it bodes tragedy for the people of southern Sudan.

Back to Lankien today and back to work. I am looking through the medical library. I find myself hoping that the textbooks will be old editions, written by clinicians who remember treating TB in the first half of the 1900′s. The irony of this does not escape me. At home a textbook is deemed to be out of date in a few years. New textbooks are full of the latest diagnostic tests and treatments, but they grow thin on the clinical signs and symptoms.

The natural history, the experience of advanced TB, has been lost in developed countries because it is so rarely seen. I want to know, for example: How long does it take, on average, for a tuberculous lymph node to form a fistula with the skin and start to drain pus? Are there early subtle changes in the configuration of the chest before a gibbus appears over the spine? What does abdominal TB really feel like on examination?

Today there is a merciful breeze. A few people wear toques on their heads.

"It is very cold today, doctor."

"Yes, very cold."

It is probably somewhere in the mid-thirty’s Centigrade. I feel better than I have felt in days. I hope it stays ‘cold’. But I know it won’t. It is coming up to the end of dry season and the month of March will be even hotter than February. The thermometer in Lankien is broken, probably better not to know.

I had my mosquito net washed, no longer will a rain of dust descend on my head when I unwind it at night, at least for a few days anyway.