Lauralee in Lankien

There is a joke that goes around MSF: You go off on your mission and you come home. You are sitting at the dinner table with your family and you want to tell them everything about your mission: the poverty, the diseases, the deaths, the happy things, the sadness. Eventually, someone will look at you blankly and say, "Hmm that’s wonderful. Did I tell you we got a new refrigerator?"

Nothing like this happened to me when I got home. There was no ‘New Fridge Syndrome’. I had the feeling that people had a pretty good idea of what it was like. I think it is because they have been reading my blog.

I dream about Lankien every night, about climbing mountains, about the work. Not bad dreams, but more as if I am cataloguing, consolidating.

I have Tanzanian shillings, Kenyan shillings, Sudanese pounds, English pounds, Euros, American dollars and Canadian dollars. My pockets and money belt are overflowing with bits of different currencies. The only currency I do not have is the currency of Lankien. Cows. The Nuer people of southern Sudan are mainly cattle herding pastoralists and livestock has historically been their most important form of capital. A man’s prestige and wealth is measured by the quantity and quality of the cows he owns. This initially seemed very strange to me, but when you think about it, in an area with no formal banking system, cows are probably as good a currency as anything.

I am thinking these thoughts during my sleepy layover in Heathrow airport. Yes, London Heathrow. I am going home. To hell with the jet lag. It is my long break, almost half way through my mission. I need to go home to see my husband, family and friends. I need to regroup.

I took an overnight British Airways flight from Nairobi to London. I found three empty seats, popped an imovane, stretched out, and slept for 4 hours. I am bleary eyed with fatigue and a hangover from the sleeping pill.

It is raining cats and dogs in London. In another hour I will be on my way
to Toronto. I sit at the gate, stare out at the rain and contemplate my rapidly expanding environmental footprint.

Lately, I seem to spend all my non-working time lying in my tukul, sweating. I don’t read; I don’t listen to my ipod; I don’t do anything except stare at the inside of my mosquito net and wait to be called back to work. My mosquito net is old and sagging, like me. It is patched with duct tape in various spots. The bed sags too. I wonder how many other MSF volunteers have lain here, mindless. Sometimes a bat hangs from the ceiling; I can get a really good look at it with my binoculars. It really does have red eyes and looks like a flying rat. 

This time the placenta is really stuck; no amount of ‘gentle cord traction’ will make it separate from the uterine wall. The patient had a stillbirth during the night and was brought in because the placenta has not yet delivered. She requires a ‘manual removal’ or her placenta. This is exactly what it sounds like. A gloved hand is inserted into the vagina, past the cervix and into the uterus; you then sweep the blade of your hand around trying to find the plane between the placenta and the uterine wall in order to cleave the placenta off the wall of the uterus.

The problem is that we don’t seem to have any long sleeved gowns, and the latex gloves only cover my hands and wrists. So we cut the fingers out of several gloves and arrange them in overlapping rings up my forearm, trying to cover all the exposed skin. I insert my right arm up to the elbow, and grip the uterus through the abdominal wall with my left hand. The placenta is free at the back but is still attached anteriorly. I am getting blood on my forearm where the rings of latex have slipped. I remove my arm, de-glove, wash the blood off, cut the fingers out of several more gloves, re-glove arranging the bands of latex up my forearm, and try again. This time it works and I can feel the placenta shear off the wall of the uterus; it now slips out easily. I de-glove and wash, no blood.

The room is full of men all talking at the same time. I have to look from one to the other to find the patients. There are three patients, each with a gunshot wound. The wounds are fresh, only a few hours old. The men are all young and from the same clan. The circumstances of the shootings aren’t clear to me, except that retribution for past events is involved. We have to work quickly; more wounded men will be arriving from the other clan involved in the shootings.

The first patient has a single small entry wound into his left scapula, no exit wound. The second has a small entry wound on one side of his ankle and a huge exit wound on the other side. Fragments of bone are clearly evident in the exit wound. His foot wobbles independent of the rest of his leg and the pulses in his foot are absent. The third patient has a gunshot wound to his right arm, his humerus is shattered and the arm flops uselessly at his side. The exit wound is also full of pieces of bone and dying muscle.

Since coming to southern Sudan, I have seen at least 20 gunshot wounds. Tragically, decades of civil war and cattle raiding have left southern Sudan awash in guns. Cattle raiding has a long history here and is often the source of armed conflict. In the distant past, arrows and spears wound be used for raiding, now it’s automatic rifles.

We finish attending the three young men and wait for more wounded to arrive.

We are two medics now in the project and one of us takes call every other night. Most nights we are called back to the hospital to admit patients. There is a sign made of aluminum foil that marks the tukul of the person on call. The guard comes to get us. First there is the sound of the gate opening, then the clop clop of his gumboots, then the flashlight pans around the compound looking for the aluminum sign. More clop clopping as the guard approaches your tukul, then “IPD, IPD” except it sounds like “ITB, ITB.” Sometimes you are awoken out of a deep non-REM sleep, but most of the time you are still awake….. because, to be frank, it is just too damn hot to sleep!

I am getting tired. I can tell because I have heart-sink whenever I hear the gate opening. Also, my patience during the day on the wane.

Lankien does not exist on Google Earth. In fact, it does not exist on any digital map that I could find on the Internet.  I did find a map with Lankien on it at the infamous Yaya Centre in Nairobi, so I do know where I am. However, to give a clearer picture, I added Lankien to the following map.

Sudan is the largest country in Africa . It is about a quarter of the size of Canada but has more people, 40 million compared to Canada’s 33 million. It shares borders with no less than eight other African countries and the Red Sea. Lokichoggio, MSF’s base of operation for southern Sudan,  is tucked into the north-west corner of Kenya.

Lankien is east of the White Nile. The White Nile and the Blue Nile join each other at Khartoum, then the Nile proper flows north to Egypt and the Nile delta. Most of the water of the Nile comes from the Blue Nile and its source, Lake Tana, in the Ethiopian mountains. The water of the White Nile gets lost in southern Sudan in a huge swamp called the Sudd.

In the north, Sudan is mostly desert, but southern Sudan is a huge, clay plain. There are no major mountain ranges to break up the weather which is dominated by a dry north east wind from the Arabian Peninsula and a wet south west wind from the Congo Basin. It is this wet south west wind that is beginning to drive the weather in Lankien.

As you can see from the map, we are between 5-10 degrees north of the equator.

We are seeing many children with pneumonia, small children, most of them less than 2 years of age. Today, we did rounds in the overflow tent, where almost every child had pneumonia.

Pneumonia kills as many children in sub-Saharan Africa as malaria, but it gets less attention from researchers and international donors. In Sudan, pneumonia is responsible for between 20-25% of deaths in children less than 5. Of course, pneumonia occurs everywhere in the world, in both temperate and tropical climates, but illness and death from pneumonia is much more common in poor countries like Sudan. The reasons are poverty, malnutrition, over-crowding and lack of access to health care. The two main bacterial causes of childhood pneumonia are Streptococcus pneumoniae and Hemophilus influenza. There are also viral causes of pneumonia, such as the Respiratory Syncytial Virus and the Measles virus. In developed countries, we have vaccines against both of the bacterial causes, but of course these vaccines are not available here, where many children do not even receive basic  immunization against measles, tetanus and whooping cough.

 

Rounds in the Overflow Tent 

The book I am looking for does not exist. If it did, it would be called “A Field Guide to the Birds of Southern Sudan”. It’s not really surprising, a country with a civil war for most of the last 50 years is not the place to do bird counts or construct range maps.

When I knew I was leaving for the Sudan, I went to ‘Open Air’ bookstore in Toronto to look for a bird book. I found several large tomes: “The Birds of Africa”, “The Birds of East Africa: Kenya, Tanzania, Uganda, Rwanda, Burundi” and “Birds of Africa South of the Sahara”. I looked for birding books on my R and R as well, but found the same array of choices.

So I am still without a bird book.

I have been watching this little green bird for three months. There are many in our compound. They are gregarious birds that nest in the ground and sit out on branches to feed. They will fly out to catch an insect then return to the same branch, similar to the flycatchers.

10 pm. The child arrives in his father’s arms. He has been comatose for 4 hours already. Maybe 11 or 12 years old, he is handsome and well nourished, on the cusp of adolescence. His father said a snake bit him while he was swimming.

“The red one,” the father says shakily in English.

“Cobra,” says our Sudanese staff, a chill in his voice.

The child is struggling to breath. His respiratory muscles are becoming paralyzed by the snake’s venom. I can see him trying to expand his lungs using the muscles of his abdomen. We start an IV and decide to hang snake anti-venom. It takes us at least 30 minutes to get organized. The snake anti-venom is back at the compound, in the locked fridge, in the locked logistics room. We don’t bother with the oxygen; it hasn’t worked for a few weeks. His respirations become shallow and we try to help him breath with a mask and bag. The mask fits over his nose and mouth and is attached to a rigid rubber bag that is squeezed by hand. There is no equipment to insert a tube into his trachea or to ventilate him by machine. We do this for….how long….I don’t know. The men of the family stand around the examining table, quiet. When the boy’s heart stops, it becomes clear that our efforts are futile. His pupils are ‘fixed and dilated’, the medical equivalent of ‘no real hope’.

I don’t think I have watched a child die before. At home we would call ‘a code’. We would have a team of doctors and nurses who would come running with the crash cart. The feeling of impotence would be camouflaged by a flurry of activity, the actual process of dying lost in sea of lines, tubes, monitors, drugs and electrical shocks. “Clear….” And the flat ECG miraculously jumps to life.

Afterwards I say, “Malesh, malesh.” (Sorry, sorry.) The father nods.

The men gather up the boy’s body. The father asks if he can borrow a lamp, and the MSF shovel.

“Of course,” I say. “Of course.”