Lauralee in Lankien

And there they were, right under the microscope lens, just the way I had seen them in books and prepared slides in my tropical medicine training. Amastigotes, the tissue form of Leishmania donovani, the parasite that causes Kala Azar (KA) in southern Sudan. Sammy, our lab supervisor, had prepared the slide from a patient suspected of having a relapse of her disease. I had aspirated the tissue sample from her spleen with a small needle. Clinically suspected first episodes of KA are diagnosed using a rapid blood test (rK39, Optileish), a quick, easy test compared to spleen aspirate and direct visualization. The results of the Optileish test are confirmed using another blood test, the DAT (Direct Agglutination Test). Blood tests remain positive after a first episode of KA and therefore cannot be used to diagnose relapsed disease.

The treatment of KA in countries like Sudan has many challenges: access problems for patients, logistical problems related to diagnostic tools and therapeutics, lack of trained staff to administer treatment, just to name a few. Our first line treatment is sodium stibogluconate (SSG) given in a series of daily injections over 30 days, with a shorter duration of treatment if combined with a drug called paramomycin. But SSG, a drug first developed in the 1930’s, has its problems: painful injections, long treatment regimens, parasite resistance, cost, potential toxicity and lack of effectiveness in patients with other infections. Ambisome is an alternative treatment used for more serious patients but it also has some potential toxicity and is very costly.

Below: SSG, first line drug for KA

Below: Ambisome, drug for KA, used for seriously ill patients

MSF has a long history of treating KA in southern Sudan and has been an advocate for better, less expensive KA drugs (see link below). Over the last 20 years, MSF has treated thousands of patients. Francis Gatluak, our KA/TB specialist, has worked with MSF for all of that time, using his knowledge and experience in the management of KA, TB and other health problems. I think of Francis as the heart and soul of the Lankien project. He is both a valuable medical resource and an important link with the community. Cheers Francis and best wishes.

Below: Francis at work admitting a patient with KA

This is a link to MSF’s Campaign for Access to Essential Medicines.

MSF provides first missioners with an introductory course prior to going to the field. It’s called the Pre-preparation Departure Course, PPD for short; I did my course in Bonn, Germany in January this year. The course was multidisciplinary and included people with diverse backgrounds in medicine, logistics, administration and finance. The course was run in English but the participants were multi-national with attendees from Holland, Germany, France, Italy, Finland, the UK, India, Bangladesh, Zambia, Canada and the USA. The goal was to orient people to the organization and its operation. Most participants were yet to be assigned to a mission but several in the group were already working in MSF projects: multi-drug resistant TB in Uzbekistan, obstetrics in Sri Lanka. Since January, the alumni of the PPD course have been assigned to various projects, a refugee camp in Chad, a KA/HIV project in Ethiopia, an HIV mission in Zimbabwe, and yes, projects in Southern Sudan. I am fortunate to have two people from my PPD right here with me. Leanna Hutchins, our log admin in Lankien, and Andrea Hewitt. Andrea is from the UK and is our Financial Coordinator for the mission. She is part of the Country Management Team and works out of Loki. It has been wonderful to see a familiar face in Loki and share some time with Andrea.

Below: Andrea Hewitt, at work in Loki

Below: Leanna Hutchins does radio call in Lankien

Below: Andrea and I in Loki

Cow’s milk and sorghum (millet) are the staples of the Nuer diet. Maize (corn), okra and sesame are also cultivated. Milk is viewed as necessary for children; families temporarily without milk can usually get it, or a lactating cow, from a relative. In areas closer to rivers, fishing helps to bridge the hunger gap at the end of the dry season. The Nuer also eat the meat of their cows but not as much as you might think, slaughtering their cattle more for ritual and religious ceremony than for food. They are highly adapted to their environment. I run the risk of romanticizing the Nuer, but I have to say it: The Nuer are tough, resilient and highly resourceful. They would have to be, to survive for thousands of years in this harsh environment.

Below: Sorghum, a Nuer staple

Below: An elderly woman prepares sorghum porridge. The bowl is a hollowed out gourd.

Below: A mother and her child stand on their homestead, amidst their maize (corn) crop.

Below: The flower of the okra plant.

Below: Babies and small children are carried in baskets weaved by their mothers.

Below: Women sweep the ground every morning with straw brooms. 

Below: A very popular game (that I can never remember the name of). Photo Credit: Negar Adib

Below: Homemade Splint

Below: The Nuer are exceptionally tall, even the children are tall. This is the only bicycle I saw in Lankien.

Below: Coke can car: Child’s toy made out of an empty coke can.

Below: Tukul under construciton, a marvel of engineering using local resources.

The mothers of Lankien, like most mothers, work incredibly hard. In addition to caring for their children, they spend hours carrying water, preparing food, and working in their gardens. What would it be like to be a mother here, where looking for food and water can be a full time job? Where your child can starve if there is just one crop failure? Where medical care for a sick child is hours and hours away. What would it be like to know that at least one of your children will probably die before the age of five?

And what would it be like to know that your own existence is heavily dependent on your ability to be a mother, in a place where there are few other roles for women?

These are pictures of our national staff and their children, and my own mother, Eda. I think the faces of pride and happiness speak for themselves.

To the mothers of Lankien, my own mother, and all the important mothers in my life: A Very Belated Happy Mother’s Day

Below: Mary and Nyanen

Below: Elizabeth and Fina matot

The mothers of Lankien, like most mothers, work incredibly hard. In addition to caring for their children, they spend hours carrying water, preparing food, and working in their gardens. What would it be like to be a mother here, where looking for food and water can be a full time job? Where your child can starve if there is just one crop failure? Where medical care for a sick child is hours and hours away. What would it be like to know that at least one of your children will probably die before the age of five?

And what would it be like to know that your own existence is heavily dependent on your ability to be a mother, in a place where there are few other roles for women?

These are pictures of our national staff and their children. I think the faces of pride and happiness speak for themselves.

To the mothers of Lankien, my own mother Eda, and all the important mothers in my life: A Very Belated Happy Mother’s Day

Below: Mary and Nyanen

Below: Elizabeth and Fiona matot 

"When you educate a man you educate an individual; when you educate a woman you educate a whole family."

— Robert Morrison MacIvor

Education, like health care, is (at least it should be) a basic human right. Levels of education are low in southern Sudan. It is one of the big challenges that MSF faces here. In particular, we have problems hiring women because they lack the necessary facilities with reading, writing, math and English. We do have female staff, but they are generally in cleaning and cooking capacities and not in paramedical positions, where we would like to have them.

Once a week, MSF has hired a local teacher to spend an hour with our female national staff to teach them basic literacy. He teaches them in their native Nuer language. This program has been a great hit. The women attend in high numbers, studiously keep their notebooks and seem to enjoy the class. One hour is, of course, not very much time, but it is a start. This simple but great idea is one of many from our project coordinator, Geke Huisman.

Below: Women’s class under the Kala Azar tree

Geke is a committed, passionate advocate for the rights of women and children. She has worked as a nurse in diverse MSF projects in the Ukraine, Darfur, and Zambia and brings her health care background to the position of project coordinator. Geke has been a great support to me. She was incredibly kind to me when I was sick and she held me together in the sleepless, Larium crazed days of June. Thank-you Geke.

Below: Geke Huisman, Project Coordinator

"A people whose material culture is as simple as that of the Nuer are highly dependent on their environment. They are pre-eminently pastoral, though they grow more millet and maize than is commonly supposed. Some tribes cultivate more and some less, according to conditions of soil and surface water and their wealth in cattle, but all alike regard horticulture (agriculture) as toil forced on them by poverty of stock, for at heart they are herdsman, and the only labor in which they delight is care of cattle. They not only depend on cattle for many of life’s necessities but they have the herdsman’s outlook on the world. Cattle are their dearest possessions and they gladly risk their lives to defend their herds or to pillage those of their neighbors. Most of the social activities concern cattle and cherchez la vache is the best advice that can be given to those who desire to understand Nuer behavior."

"The Nuer" — E.E. Evans-Pritchard

This was first published in 1940, a long time ago and much has changed, but much has also remained the same. Indeed it is hard to overstate the importance of cattle in the lives of the Nuer. Before I came to southern Sudan I was told to buy a book on Canadian cattle, as a way of opening up lines of communication with the Nuer. At the time, I found this suggestion outlandish. Now, eight months later, I realize I should have made space in my backpack for such a book.

The Nuer are primarily cattle herding pastoralists and their lives are closely intertwined with that of their herds. Traditionally, the Nuer are a migratory people moving in rhythm with their environment and the needs of their cattle. It is the wet season now, when the White Nile and other rivers flood their banks and turn southern Sudan into a huge swampland. Flooding forces the Nuer to seek higher ground in villages like Lankien, places where they and their cattle are protected and where the Nuer can cultivate crops. When the rains cease and the land becomes parched during the dry season, they will move their cattle back to ‘cattle camps’ situated closer to rivers and other water sources.

Below: Cow on the Airstrip

Below: Cattle mix freely with people in the market

Below: Byre (barn) for cattle

Below: Young girl with milking gourd

Below: Cattle Camp from the air, dry season Photo Credit: Negar Adib

In 1983, when I started to practice in Ontario, Canada, the routine schedule of immunization covered only a hand-full of infections: diptheria, tetanus, pertussis (whooping cough), polio, measles, mumps and rubella. Twenty-five years later there is now funding for vaccines for Hepatitis B, meningitis, pneumonia/otitis media, chicken pox, influenza, and most recently, cervical cancer. Globally there is ongoing research and development for vaccines against a great number of other infectious diseases, many of which predominately affect the poorest people in the world.

Despite the good news, the situation on the ground in Lankien is grim. No one knows the proportion of children who receive vaccination. What we do know is that we see patients with vaccine preventable diseases: large epidemics of measles, meningitis and pneumonia, neonatal and childhood tetanus, cases of whooping cough, mumps and chicken pox, life threatening forms of childhood tuberculosis, cervical and liver cancer.

The Centre for Disease Control in Atlanta called vaccination, the greatest public health achievement of 20th century America, but all over the world children still do not receive even the most basic immunizations. In Lankien, MSF immunizes against the six vaccine preventable diseases covered by the World Health’s Organization EPI (Expanded Program of Immunization); they are diptheria, whooping cough, tetanus, polio, measles and tuberculosis. Recently, we have successfully achieved a large increase in the number of children being immunized, the result of a simple change in our triage plan and led by Helen Galla, nurse midwife, and Francis Gatluak.

Below: Helen Galla immunizes a child in the EPI program

The immunization area is simply some chairs and a table protected under a plastic canopy. It is next to the Ante-natal Care (ANC) tukul where Helen and our national staff see pregnant women. In addition to the usual routine clinical exam, MSF provides women with iron tablets, multivitamins and medication to prevent malaria. We also test and treat for syphilis, an infection that causes serious abnormalities in newborns. We vaccinate all women against tetanus with the goal of protecting the newborn infant from this lethal infection. In addition, we provide bed nets and clean delivery kits.

Helen has extensive experience working in Sudan, particularly in the practice of remote area obstetrics. You can’t learn obstetrics for places like southern Sudan in places like southern Ontario. And this leads to one of my regrets as I approach the end of my mission: I will not have more time to spend with Helen.

Below: Helen and newborn

I have been remiss in not writing more about the Nuer people themselves. When I started the mission I was quite uninformed about The Nuer, my head stuffed to overload with tropical medicine, public health and MSF protocols. No doubt my current knowledge is spotty, so I apologize in advance for errors or omissions.

The Nuer people, who call themselves the Naath (human beings), are one of the biggest ethnic groups in East Africa; they are located in southern Sudan and western Ethiopia. In southern Sudan, they form the second largest ethnic group; the Dinka are the largest. Jonglei province, where we are, is also home to the Shilluk and the Merle. As a result of the protracted civil war in southern Sudan, many Nuer have emigrated to Kenya and other countries. Thousands were also resettled as refugees and currently live in Canada, the USA and Australia.

The Nuer are well known in anthropology as the subjects of a famous ethnographic study by E. E. Evans-Pritchard. The trilogy he wrote is considered a classic example of social anthropology. It starts with The Nuer, published in 1940, and is followed by Kinship and Marriage Among the Nuer, published in 1951, and Nuer Religion, published in 1956. More recently the Nuer have been studied by anthropologist Sharon E. Hutchinson, her findings are described in Nuer Dilemmas: Coping with Money, War and the State, published 1996. I bought The Nuer and Nuer Dilemmas from Amazon when I was home in June. My husband sent them to me in a care package that never arrived; perhaps they are still in transit somewhere between Toronto and Lankien. I hope someone eventually reads them.

Despite the hardships, it is a privilege to be here and work with the Nuer, a group that has been isolated by war for most of the last 50 years. Few people have this opportunity and I am one of the lucky ones. The Nuer always seem willing to tell me about themselves and now, as I am approaching the end of my mission, I wish I had asked more questions. Of course, asking questions and penetrating the language barrier takes time and energy, something that always seems in short supply. And the language barrier can be very dense, the accuracy of translation often tenuous. Those who speak English are usually the young men who went to school in the refugee camps of Kenya and Ethiopia. Very few women speak any English, and communication with them is usually filtered through the biases of a translator.

I know close to nothing about electricity, power generators, high frequency radios, house building or car fixing. When the auto mechanic at my local repair shop holds up a piece of rusted metal and tells me he had to replace the whatchamacallit with a thigamajig, he could be showing me a part from an old washing machine for all I know. Fortunately for me, and everyone else, the fore mentioned areas are not part of my job description; these responsibilities, among others, fall to our technical logistician, Fredoh Macharia.

Fredoh brings a wealth of valuable experience from other MSF projects where he has worked. He is a whirlwind of activity, tearing down old structures and building new ones, mending fences, re-organizing our triage area, etc. Most recently he has torn down the old decaying kitchen tukul and replaced it with, by far, the most beautiful tukul I have ever seen. It is large, light, airy and painted blue, my favorite color. Thank-you Fredoh.

Below: Fredoh on the roof of the old kitchen tukul, planning its demolition Photo credit: Leanna Hutchins

Below: Sammy and Fredoh, kitchen tukul under construction

Below: The New Kitchen Tukul completed