Lauralee in Lankien

It’s the end of the month and the Medical Monthly Report, MMR for short, will be due in a few days. The MMR summarizes, both quantitatively and qualitatively, the medical activities of the project. It is a gold mine of interesting numbers. The most interesting part of this month’s report is the burgeoning number of malaria cases, the result of a rather dry wet season. Intermittent rains allow mosquito larva to develop undisturbed; they do so in vast pools of water in the seasonal swamp that is southern Sudan.

I look forward to doing the MMR every month, a chance to do some math, look at disease patterns and work more closely with our data collector, Isaac. Isaac has the rather daunting task of collecting and preparing all the data from the various departments; he does so every month with patience, diligence and quirky good humor. The MMR is a collaborative effort, Isaac supplies the numbers and the medics supply the interpretation.

MSF volunteers are expected to be versatile and are called upon to wear many hats. Isaac is able to do this well, filling in for our technical logistician and our logistician administrator when the need arises. He is also good company, in what I have come to think of as my MSF Family (more on my MSF Family later).

Cheers, Isaac

Above: Isaac at work in the logistics room.

Above: Helen, Zak and Isaac at work on the Medical Monthly Report, a collaborative effort.

I am rummaging around in the Store Room where we keep our drugs and other medical materials. It’s dark and I have to squint closely at the shelves to see anything; I am sure I saw some drugs for leprosy in here. The old, sweet tempered storekeeper doesn’t understand what I am looking for but tries to help anyway. Finally I find it, MDT-Combi it says on the box, Multi Drug Therapy for Leprosy. It hasn’t even expired, my lucky day.

There is only one person receiving treatment for leprosy in our project. He is waiting for me to give him his second month of drugs and authorize his food ration. There could be many more people with leprosy in this part of southern Sudan; probably nobody really knows the scale of the problem. Social stigma, difficulties with diagnosis and limited treatment opportunities make leprosy a hidden scourge.

Leprosy is a ‘Disease of Poverty’ as is malaria, TB, HIV/AIDS, measles, pneumonia, diarrhea and complications of childbirth. These diseases/conditions disproportionately affect the poor. The association between leprosy and poverty is a two way street. Poor people get leprosy because of overcrowding, malnutrition, and lack of care; leprosy makes people poor because of social stigma and chronic disability.

The patient with leprosy is an emaciated old man. His face is riddled with thick nodules and the cartilage of his nose is collapsed, the hand he proffers for his drugs is a claw that is missing most of its fingers.

“He says he doesn’t have enough food,” the Community Health Worker informs me. I explain that our protocol allows him only one week’s food ration per month, a strategy that is meant to improve adherence to treatment. But I feel mean and stingy as I speak. No sooner is he gone than I start to think that this is probably one of those instances for which the rules were made (i.e. to be broken).

There is always next month.

My husband and several of my friends are passionate naturalists. They would never dream of killing a snake; my husband, in particular, was disturbed by my description of how to kill a snake (See Snake Bite 1) and, I admit, the entry was rather brutal in its choice of words. But conserving the lives of dangerous animals, especially ones that show up next to the place where you sleep, seems, in this instance, to be a ‘western’ luxury. There is no one to call, no SPCA, no nature conservancy that will come and take the frightening thing away!

 
This snake showed up in our compound one Monday night in July. He was curled up next to a tukul, not far from the path to the shower. One of my colleagues would have tripped right over him if it were not for the light from a large solar panel. I was told that this is a black cobra, a very dangerous snake.
 
So, Erik, Don, John, Brenda and Brian, I am sorry, but we bludgeoned this one to death too.

“Male (Greetings)," I say.

“Male madit (Big Greetings)," she says.

“Male me-goa (Good Greetings)," I say.

“Male me-lim-lim (Sweet Greetings)," she says.

“Male me-chum-chum (Sweeter Greetings)," I say.

“Male poindu (Healthy Body Greetings)," she says.

I am defeated. I don’t know any more “males” (pronounced ‘maalae’). I have this exchange at least half a dozen times a day, mostly with little girls and old women, occasionally one of the men wants to play. I have come to think of it as the “battle of the males” and I never get the last word.

“Be sure to remind him to boil his milk and not to blow into the cow’s vagina.”

It is morning rounds. I am squatting on the floor in the overflow tent, shuffling through a tattered water stained chart. The patient is a young man recovering from Brucellosis. He has already been here for two weeks receiving gentamycin injections and oral doxycycline. He will receive four more weeks of doxycycline to complete his treatment. Today he is being discharged to finish his treatment at home.

Brucellosis is primarily a disease of animals. In southern Sudan it is transmitted to people by the ingestion of unboiled cow’s milk. A less common mode of transmission though, is the practice of “cow blowing”, forceful blowing into the cow’s vagina in order to increase milk production.

Brucellosis has a worldwide distribution but is most common among rural people who live in close contact with animals. It typically presents with a swinging fever, hip and/or back pain, and difficulty walking. A young person with a walking stick is an easy give away. MSF uses an antibody test to confirm clinically suspected cases and treats most cases with Gentamycin and doxycycline; children and pregnant or lactating women receive trimethoprim-sulfamethoxazole instead of doxycycline.

The paramedic/translator is sharing a giggle with the patient.

“Ask him if he understands,” I say.

“He understands ,” returns the paramedic.

More giggles.

I don’t ask.

1965, St. Wilibrord’s School, Chateauguay, Quebec

“But it’s not fair,” I said to my grade 3 teacher Mrs. Ducey. I can’t even remember what my 8-year-old self was complaining about. Though I will always remember the response.

“If you are looking for fairness,” she said, sounding uncharacteristically angry and exasperated, “you are on the wrong planet!” The moment was pivotal for me; I was shocked and shaken. What if it were true? What if the world was not a fair place? The idea conflicted with my childish schema of how the world worked.

2008, Southern Sudan

For every 20 babies born, 1 dies during the first 28 days of life.

Of 1000 babies born, 150 die before their first birthday.

One in four children die before the age of 5.

45% of children under 5 years old suffer from chronic diarrhea.

1 in 9 women dies during her lifetime of a pregnancy related cause.

For every 50 deliveries one mother dies of a pregnancy-related cause.

Only 5% of births are attended by a skilled attendant.

The adult literacy rate for women 15- 24 years is 2.5%.

Life Expectancy at birth is 42 years!

Mrs. Ducey eventually died quite young of a brain tumor, proving her point. And I eventually came to accept that the world was indeed, not a fair place.

"Do you like camping?" my recruiter in Toronto asked me. At the time I did not understand the reason for the question, but now, 7 months later, I totally get it. In many respects, this mission is like a nine month camping trip!

I have been told that the living conditions in Lankien, and in other MSF missions in southern Sudan, are particularly difficult. Of course, no matter how harsh they may be, they are still infinitely easier than those of the general population. Yes, we live in tukuls with mud walls and thatched roofs, and yes there is no running water and limited power. But we do have a reasonably nice pit latrine, a shower, and a combination of solar and generator power in the logistics room and the TV tukul. (Yes we have a TV tukul where we watch DVD’s, the latest being Heroes and all of Denzel Washington’s movies.) We have staff to cook, carry water and wash our clothes. It is a rather upscale camping trip I would say.

Above: The shower from the outside.

Above: The shower from the inside.

Above: The latrine from the outside.

Below: The latrine from the inside.

Below: The new kitchen tukul under construction. 

Below: The view from inside of the TV tukul.

Below: The logistics building gets decorated.

Below: My tukul.

Below: Leanna’s tukul.

Below: The back gate.

"Tell him that I think he has cancer," I say to the paramedic who is acting as my translator. He looks at me blankly. "It’s when a cell…..ahh…is out of control," I fumble around for the words that will bridge the language and knowledge gap between us. The conversation eventually ends with confusion all around.

As far as I can tell, not only is there no Nuer word for cancer, there seems to be no conceptual understanding of it. Cancer, the great bogey man of aging millions in "the West", is off the radar in southern Sudan. It’s not that cancer doesn’t exist here, I’m sure it does, along with other chronic disease such as heart disease, osteoarthritis and chronic lung disease. Cancers of the cervix, breast, liver, nasopharynx, esophagus, and lymph nodes all occur in southern Sudan. But cancer, in the main, is an age related phenomena. It occurs more and more frequently as people move into their 50′s, 60′s and beyond. Since the average life span here is only about 50 years old, most southern Sudanese do not live long enough to develop cancer!

If I had been born in southern Sudan, I would already have reached my full life expectancy of 50 years, anything after this would be a bonus. Since I was born in Canada, I can reasonably expect to live for 30 more years. But Canada has already completed the so called "Epidemiologic Transition", and southern Sudan is only getting started. "Epidemiologic Transition" is a conceptual theory dear to the hearts of demographers, medical geographers, epidemiologists and those interested in international health. Simply put, it is the change in the pattern of disease from acute infectious disease to predominately chronic non-infectious disease. It occurs as countries climb the development ladder and life expectancy increases. With economic development, women have fewer children and more of those children live into adulthood. Consequently there are more old people and, with the benefits of improved living conditions, better nutrition and modern medicine, those old people start to live longer and longer. But development can be a double edged sword. In economically developed countries people are exposed to more risk factors for chronic disease, in particular smoking, obesity and sedentary life styles, ergo the increase in chronic disease.

Since the 2005 peace accord that saw the end to the civil war between north and south, places like Lankien have started to show slow signs development. There are more traders that come here and the market has more products. There is paper currency now, something that was not the case only a few years ago. But the transition is in its early stages and could easily be derailed by war, violent unrest or a large HIV epidemic.

July 1984 — About 3 degrees south of the Arctic Circle

"Do you want the vacuum, doctor?" the small Inuit nurse asks, really more of a suggestion than a question.

"Uhh, the vacuum?" I say, hesitating. "Yah….OK, sure". It was the kind of exchange that occurs when a kindly experienced nurse meets a young inexperienced doctor.

We were in the delivery room in Frobisher Bay, North West Territories, before Frobisher Bay was renamed Iqaluit in the new territory of Nunavut. The patient was a very young Inuit girl having difficulties trying to push out her first baby. I remember that the baby she eventually delivered was a huge healthy boy; he had lots of straight black hair falling in a wet curtain over his forehead. The vacuum that the nurse handed me that day had a soft plastic cup that fit onto the baby’s head. It was attached to a hand pump with a pressure gauge and a release valve. This was one of my first jobs as a doctor and I had never heard of a vacuum extractor before. In medical school and internship we had only used forceps, vacuum deliveries being out of medical vogue at the time.

July 2008 — About 8 degrees north of the Equator

TThe baby is already dead. The girl is only 16 years old and she has been in labor for 2 days. She has a fever and is leaking thick, green amniotic fluid. Initially, we were able to locate the fetal heart, but that was four hours ago and we haven’t been able to find it since, despite numerous attempts. The young girl is exhausted and ill and cannot push any more. The vacuum I use today is a hard metal cap; otherwise it is just like the one I used in Frobisher Bay. I am praying that I can deliver the baby with the vacuum, otherwise the only thing I can do will be a destructive delivery. I have seen one done during a short mission in Ethiopia, but I have never done one on my own. I remember the feeling of revulsion as I watched the Ethiopian doctor insert a long metal instrument into the soft spot of the baby’s head, trying to decompress the skull and allow its passage through the pelvis. I also remember that this didn’t work and he then had to dismember the baby and deliver it piece by piece into a bucket.

I pull and pull with the vacuum. We are only trying to save the mother now. Finally the head delivers. I ask Zac to deliver the rest of the baby because I don’t have any strength left in my arms.

But nothing is easy tonight. The cord rips off the placenta; I remove the placenta manually. She bleeds vigorously for a few minutes. I massage her uterus through the abdominal wall and the bleeding slows to a trickle. It takes me a long time to sew up the episiotomy; the light has faded and I cannot see. Someone goes back to the compound to get me a head torch. The blood has attracted the flies; they swarm about the perineum. I sew, then wave the flies away, then sew some more.

Someone wraps the body of the baby in gauze and places him on the table next to the girl. She is flat and expressionless. Spent. The girl’s parents thank us. They know that this is not the worse outcome; at least their daughter is still alive.

When I finally look up from my work, someone has already taken the baby away.

The rainy season has brought some spectacular sky gazing: frothy cumulus clouds, black thunderheads, beautiful sunsets. Leanna, our multi-talented logistician administrator, suggested that Paul Simon had it right. I would tend to agree.

Joseph’s face was black as night
The pale yellow moon shone in his eyes
His path was marked
By the stars in the Southern Hemisphere
And he walked his days
Under African skies
This is the story of how we begin to remember
This is the powerful pulsing of love in the vein
After the dream of falling and calling your name out
These are the roots of rhythm
And the roots of rhythm remain

"Under African Skies" — Paul Simon