Lauralee in Lankien

The vast majority of women here in southern Sudan deliver their babies at home. So when a woman presents to the clinic for a pregnancy related problem, it is usually serious. These are my thoughts as I walk the short distance from the compound to the in-patient tukuls.

The patient delivered her baby at midnight, but at 7 am this morning the placenta is still not out. In medical jargon it is called a ‘retained’ placenta. Sometimes a retained placenta is stuck firmly to the wall of the uterus and its removal is difficult and bloody. Fortunately for the woman (and for me) this placenta has already separated from the uterus and is sitting in the vagina. I clamp the cord and apply some ‘gentle traction’ (doctors and midwives never ‘pull’ on a cord) along with some counter traction against her uterus. The placenta slips out easily.

The baby, by the way, is a beauty.

I return to the compound in time for breakfast and the company of my fellow missioners. The day is starting out well.

I am starting to see how I might survive. It comes in little flashes, small epiphanies throughout the day. When I first arrived in Lankien, I seriously questioned whether I would make it to the end of my contract. 9 months seemed like a very long time. I wasn’t sure I could do it. And even now I feel this way, but not all of the time. One MSF volunteer compared this mission to a marathon: you must pace yourself, drink plenty of water, and hope that you don’t hit "the wall" too hard.

Occasionally now I feel quite light. For example last night, I tucked myself into my outdoor bed under a perfect African night sky and for a brief moment I felt.. well.. deliriously happy! Imagine that.

By blind good luck, I was born in a country that the UN ranks as the 4th best country in the world in which to be woman. Canada was beaten out only by Iceland, Norway and Australia. I discovered these not so surprising facts from the on-line edition of the Toronto Star, published on March 8th, International Women’s Day. The article goes on to list Sudan as being one of the 10 worst places to be a woman, along with Afghanistan, Democratic Republic of Congo, Iraq, Nepal, Somalia, Mali, Guatemala and Pakistan.

Several years ago, UNICEF published a much-quoted study that found that girls in southern Sudan were more likely to die in pregnancy and childbirth (1 in 9) than to finish primary school (1 in 100). This means that one out of every nine southern Sudanese women will die as a result of complications of pregnancy and childbirth. In contrast, the lifetime risk for Canadian women is 1 in 2,800. One in 9 versus one in 2800!

More recently, a Sudan Household Survey (by the MoH/GoS from 2006) estimated the maternal mortality rate in southern Sudan to be over 2,000 per 100,000 live births. This is the highest maternal mortality rate in the world! The medical causes of death are bleeding, infection and obstructed labor. The health system problems are a lack of trained midwifes and little or no access to emergency obstetrical care. On a broader level the culprits are poverty, women’s low societal status and the legacies of a prolonged civil war.

So, to the women in Canada: Thank fickle fate for your blind good luck!

In Season 3, Episode 16, Edie Britt suddenly has to take care of her 9-year old son Travers. "His father is going to work for Doctors Without Borders in Kenya," Edie tells Carlos, her voice dripping with sarcasm and loathing. I found this line uproariously funny and so did the other MSF volunteers who were watching the DVD with me. Why? Because like most satire and lampoonery, there is a painful grain of truth hidden in the humor. The seemingly selfless act of working for MSF is not always so selfless. People volunteer for MSF for a variety of reasons, altruism being only one of them. In some contexts, working for MSF can be a supremely selfish act.

I am back in Loki, Kenya, for Easter weekend. Another fever, this time more of a respiratory infection, no doubt I caught it from some poor child who does not get to come to Loki to recuperate. I am better though, and will go back to the field on Tuesday.

“You should eat those vegetables,” my father, Regis, said one night in the late 1960′s. “The little children in Biafra would be happy to eat those vegetables.” With that comment, the idea that there might be starving people in the world crept onto my radar. But it wasn’t until many years later, during the 1984-85 famine in Ethiopia, that I really sat up and noticed. So did the rest of the world. Pictures of starving children assaulted our senses every night through our television sets. The world was outraged.

Like most people, I loved Band Aid and Live Aid. I am embarrassed to admit that I still tear up when I hear “We Are the World” and “Do They Know It’s Christmas”-almost unbearable. Yes, the world was outraged and people tried to help, but outrage is a simple, often fleeting, emotion and famine is a complex, recurring, problem. It was many more years before I realized that famine is also about politics and that the simple equation of drought=famine was reductionism in the extreme.

Here in southern Sudan, food security is so fragile that even a minor drought can cause a severe food shortage. A poor harvest can mean the death of many children. We are currently in what is known as the ‘Hunger Gap’, essentially at the end of the dry season when the food stores are running out and before the next year’s harvest. The ‘Hunger Gap’ occurs every year in Lankien to a greater or lesser extent. There is no concert, no celebrities, no feel good lyrics. We Are The World? Indeed.

"Obstetric Fistula is the single most dramatic aftermath of neglected childbirth."
— WHO

Try and imagine what it would be like to be continuously incontinent of urine or stool. Imagine how uncomfortable and embarrassing it would be, how it would affect your social relations, your livelihood, your self-esteem.

This is the reality for approximately 2 million women in the world who suffer from obstetric fistula; it is most prevalent in Sub-Saharan Africa and Asia.

An obstetric fistula is a hole between the vagina and another pelvic organ, usually the urinary bladder, sometimes the bowel. It develops from an obstructed labor when the baby is too big or poorly positioned to deliver normally and when there is no access to an assisted delivery or Caesarian Section. The baby, usually the head of the baby, presses down against the mother’s pelvis, sometimes for days on end, cutting off the blood supply to maternal tissues. The tissues eventually die, leaving the woman with a hole communicating the vagina with the bladder or bowel. Fistula often causes women to become divorced and socially outcast in their communities.

Almost right away I noticed the urine running down the young girl’s legs below the hem of her skirt. She noticed that I noticed, and she looked away, embarrassed. I felt badly that I had let my eyes drift down. About six months ago she went into labor with her first child. She had pains for the better part of 5 days; the traditional birth attendant in her village tried to help her but there was nothing she could do. At some point the baby stopped moving, and the pain became constant. Her family finally carried her on a makeshift gurney all the way from her village to the MSF hospital three hours away. There she delivered a stillborn baby boy. The loss of her baby was, and still is, compounded by the loss of her own health, family and community.

"Yes, your name is on the list for the fistula clinic." I hear myself saying, referring to the fistula repair clinic that MSF helps to organize. She nods and smiles, temporarily reassured that she is not forgotten and that there is still hope. Her smile tugs at my heart. She lingers for a while, then finally turns and starts the long walk back to her village.

Finally, some weather I can relate to, thunder, lightening and rain. Yesterday, we could hear the raindrops tapping on the roof of the ICU tukul while we were doing rounds. We came out of the tukul to suck it up. Wonderful. It then rained off and on for several hours. When I suggested to the Sudanese staff that there was a lot of rain, they laughed. Apparently, compared to the rainy season, this little rainfall is nothing. I am told that during the rainy season, it rains in great torrents for hours on end, a deluge, until the land is an inaccessible expanse of mud and water.

We are in the so-called “African meningitis belt” in southern Sudan. The belt stretches from the eastern part of Ethiopia, across southern Sudan, southern Chad, Nigeria, Niger, Burkino Faso and Mali, to Guinea and Senegal.

The area is subject to regular, explosive epidemics of meningococcal meningitis caused by the bacterium Neisseria meningitidis. Epidemics occur in vaguely periodic patterns about every 8-10 years. I am told that the time is ripe for an out-break. MSF carefully monitors cases of meningitis, a kind of early warning system.

The boy is about 6 years old. He has a fever and is unwell. His neck is rigid and he cries miserably when I try to lift his head off the examining table. The lumbar puncture is positive. We start him on high doses of an antibiotic called Ceftriaxone. Within 24 hours he is eating and sitting up; I have to check the chart and make sure I have the right child.

This boy is younger, about 3 years old. When he arrived at the in-patient department he was already semi-comatose. We think he has meningitis; he dies as I am positioning him for his lumbar puncture. The mother is frantic, talking loudly and angrily. I suspect that I am being blamed; the interpreter does not translate for me.

I was the last holdout. One by one my MSF compatriots dragged their beds out of their hot tukuls to sleep under the stars. Finally, it was either join them or spend another restless night marinating in my own sweat.

It was glorious, a cool breeze, moonlight. I listened to my music (to block out the sound of the Zimbabwe crying) and looked at the stars. I even imagined I saw the Big Dipper but I think that is not possible from where I am. Obviously, I know nothing about astronomy. I would google “Big Dipper, sky, equator” or something like that, but we have no Internet.

The spleen is a small organ about the size of a fist; it sits up under the diaphragm in the left upper quadrant of the abdomen. In temperate climates, like Canada, the spleen does not figure prominently in general medical practice. It is of interest mainly in patients with lymphoma and leukemia and in teen-agers with infections mononucleosis.

Here in the tropics, however, the spleen is paramount. It becomes enlarged serving its primary function, which is to protect the body from infectious agents. In malaria, kala azar and schistosomiasis, the spleen can become massive, stretching from the upper left part of the abdomen to the pelvis. It can also be enlarged in brucellosis, typhoid and even tuberculosis.

We were taught in medical school to start examining for the spleen in the lower part of the abdomen. The technique is to work your way upwards towards the chest, all the while asking the patient to take deep breathes. If the spleen is enlarged you will be able to palpate it with your fingertips as the patient inspires and the diaphragm pushes the spleen down. Sometimes, you can see the spleen with your naked eye, especially if the patient is very thin, and the spleen is very large.

Here in Lankien, spleen palpation is a refined art.