Jo Grimshaw, medical coordinator based in Malakal, South Sudan
I have now been here for 2 weeks and feel quite settled. We have a nice house, although I was a little alarmed when I first arrived to hear the muezzin loud and clear from my room but I was assured that he doesn't call the faithful to prayer during the night, so I felt quite hopeful until the next morning at 05.00 when he and the cockerel got going at the same time. No chance of sleeping beyond five then, but anyway I have an early start because I am goingto work at the mobile clinic at Pajur tomorrow and the next day. The temps are getting up to 44° in the middle of the day and during the afternoon now, so it promises to be a very uncomfortable. (...)
Today was my first day at work, Pauline and I went to see the UNMIS Sector commander, he phoned last night and asked to see us. There was a security incident 2 weeks ago at a nearby town called Korfulus, about 30 people were killed and a displaced population of about 5,000 moved over the river to a village called Pajur, about 20 minutes from here, an emergency meeting was called and NGOs were asked for help. Thomas the site co-ordinator was at the meeting and offered a mobile clinic for up to (and no longer than) a month. Since then an DOW mobile clinic has visited Pajur daily Monday to Friday.
I think I am going to enjoy this mission, I'm going to build in some hands on time. And Diana has told me that I can deliver a baby, so that's great!
Yesterday and today were great days. I certainly got my fix of "hands on" enough to last a while. I went out to Pajur with the mobile clinic crew, they consist of Jackson a Sudanese Clinical Officer (very good and professional worker), Barnaba (nurse) and Rossman (nurse), the rest of the team are IDPs living in Pajur, Ochate a nurse who has moved into the clinic to guard it 24 hours a day, and various translators and 2 cleaners. There have to be quite a lot of translators because three languages are involved, mostly Arabic, Nuer and English. The clinic is in a big white tent with the DOW logos on the side. Jackson and I did the consultations while the nurses did the dressings, pharmacy and registration and observations. I really enjoyed it. Generally the health status of the IDPs is better than in Darfur. I didn't see any really desperately ill people, but there were some really awful old war wounds gone wrong, dating back to the security break down the year before last.
Sadly we had to close the clinic this afternoon, which felt like a betrayal, but we have made sure that there will be another health facility there next week, the UN, but the IDPs aren't happy about that. We would be spreading ourselves too thin because we have an accelerated EPI (expanded programme of Immunization) in Tambuong which will take 3 days. (...)
Sophie admitted a baby to the children's hospital yesterday and I visited him today, to take some equipment. He needed IV antibiotics and when we went with him yesterday they were threatening not to take him, because the mother didn't have enough money for a cannula and the drugs, so we negotiated with the staff that they should take the child but I would replace the cannula today and take the drugs to complete the course. He looks better today. I don't have the energy tonight to describe the paediatric hospital. But will tell you about it one day. It really is grim.
In Malakal I am further removed from the patients and therefore I am getting a bird's eye view of the mission and the context, which it was difficult to do working every day in the clinic in Darfur. So in that respect this job is possibly less immediately satisfying, because I can't come home every day and say "today I made a difference to my patients" and you could certainly do that EVERY day in Darfur. But this job is satisfying in a different way, because I am responsible for co-ordinating the medical part of the mission, so there are opportunities to do things on a larger scale and make a difference for more people that will also be more lasting. South Sudan is in a transitional phase and our mission is to support the government in rehabilitating health facilities, in the face of quite large constraints, in particular the shortage of good quality staff at all levels. It means that the expats are doing no substitution work and are really setting up systems within the existing health facility, supervising the local staff and offering training in order to create a sustainable facility that will be able continue to run well without us. The health centre in Tonga that DOW is supporting is now running well, with all local health care workers' posts full at the moment, although some of them still need a lot of supervision and the expat midwife is doing training for the village midwives. The various departments of the clinic are housed in tukuls, but some of them probably won't stand up to the rainy season. The logistics team is building a new clinic building, which we hope will be finished before the rains come. (...)
Let me describe the team, there are 7 of us now. Pauline is the administrator, she is about 29 and she deals with all the budgeting and human resources. (We employ quite a large national team of guards, cleaners, community mobilisers, vaccinators and assistants to the admin and logisticians). Antoine is the site co-ordinator, he pulls the whole programme together and is in charge of security, he and I work closely together and share an office. Nicolas is the Malakal logistician, responsible for stores, warehouse, maintenance and maintaining supply lines. Pauline, me, Antoine and Nicolas make up the Malakal team.
The Tonga team consist of Sophie, Diana and Bruno. They are all based in Tonga during the week, they leave for Tonga late morning on Mondays and return in the afternoon of Fridays. Sophie is the Doctor, her role is mainly supervision and training at the clinic. Diana is the midwife, her role is supervision and training, Bruno is the Logistician, he is head of security there, is responsible for maintaining supply lines and is also building the new clinic (...)
At Phom they have an EPI manager and someone who appears to be a deputy manager and an army of vaccinators, but no actual EPI programme. DOW had borrowed the vaccinators for the first round last month and we are borrowing them again for the 2nd round. They are very keen to be used, because they don't get paid unless they are working, and because Phom doesn't have an EPI programme, they aren't working very much, if at all. Only when there are National Immunization Days or Mass measles campaigns. (...)
The clinic is a huge old colonial style building built around a (now overgrown and rubbish strewn) courtyard and with a covered porch bordering the courtyard on the inside of the building. When we arrived there were the 2 members of staff that we were coming to see sitting on the porch and bunch of unruly little boys were playing around the courtyard and nobody else in the place at all. It echoed with the sound of the little boys playing.
We had our meeting and then we asked if we could see around the clinic. It was, as expected, grim. Completely empty, but with signs of recent patient occupation, filthy beds and abandoned IV drips hanging from the ceiling in the delivery room. A pile of empty vaccine cold boxes in the EPI room. The consultation rooms were locked as was the pharmacy, but there was a window into the pharmacy and the person who was showing us around said "come look, you can see some drugs", so we looked and there were a few bottles of antibiotics (favourite medicine here) on a table and absolutely nothing else in the room. It was sad really, it wouldn't take much to get this clinic renovated, it was in a good state of repair, just very neglected and dirty. The real problem here is good quality staff, we are going to consider a proposition that we will put to Stephane when we have a telephone meeting with him tomorrow. The propostion being that we support the County in getting the EPI programme up and running again. Goodness knows they need one. We would like to do more for them, but it would be very difficult, Phom is in Jonglei State, but Bor, the capital of Jonglei, is really difficult to get to from Malakal, it would take about 2 days to get there. We would need to have frequent access to the State Ministry of Health, because for a project like this, contracts and agreements need to be negotiated and signed and frequently reviewed. We could probably manage to support an EPI programme at County level, but not a whole clinc. The main reason is that these projects have to be sustainable and that means that the MOH have to take responsibility for the salaries of the local staff. We couldn't support a whole clinic at County level, because County does not have the money to pay that many staff. Usually the county just takes responsibility for a few cleaners and guards, all the clinical staff should be paid by MOH. Anyway we'll see what comes out of the meeting tomorrow. (...)
After breakfast we walked down to the "harbour" (actually a muddy bank) to wave good bye to the EPI team. Sophie and Diana with about 6 of our National Staff set off down the Nile in the boat to pick up the Phom vaccinators, they were laden with everything they would need for 3 days of doing vaccinations in the African bush including tables and chairs. They looked like early explorers. I will be doing the 3rd round in a month's time and I'm really looking forward to it. (...)
I spent today in the Malakal Paediatric Hospital trying to sort out the treatment for a little boy from our clinic, who has Visceral Leishmaniasis (Kala Azar) and severe malnutrition. We transferred him last week, but when I visited him on Monday to check that he was getting his treatment, it transpired that the 2 centres (therapeutic feeding and Leishmaniasis) are on 2 different sites and they hadn't worked out a way of ensuring that he would receive both treatments, they originally told me that he would get the treatments consecutive. He had been referred to the Kala Azar ward, where his progress through the system had ground to a halt. He was receiving one treatment a day in the morning and hadn't even seen the feeding centre where he should be receiving treatment every 3 hours. It didn't make sense. So I have arranged for him to be warded in the feeding centre and visit the Kala Azar centre daily.
They do their best in very under resourced conditions and for the most part the staff are dedicated and knowledgeable. The hospitals themselves are dilapidated ruins, damaged during the war, filthy and not weather proof, as I discovered today when I was caught in a violent cloud burst while I was there.
The patients generally abandon their beds in favour of sitting outside under one of the many trees in the grounds. It sounds nice, but it isn't, the ground that they sit on, is dried mud, which quickly becomes sticky black mud, when it rains. Dogs, cats and other livestock, mainly goats and sheep wander freely around doing their business. You really have to be careful where you tread.
It is hot here, though it hasn't reached the 50's yet. High 40s (48 to be precise) and in fact Sudan was the hottest country on the planet the other day. Official!
But we are heading for the rains and this week we had a cold snap, it went down to the mid 30s! I am well and busy, enjoying the mission, in spite of the many difficulties, it is satisfying and fulfilling - most of the time anyway.
A couple of weeks ago we did the 3rd round of our accelerated vaccination campaign in Tambuong, an isolated village about ½ hour down a tributary of the Nile.
On the first day at about 7.15, I set off with Diana, one of the expat team, from our house in Tonga (Tonga is a town about 3 miles up the Nile from Malakal where we live most of the time. - we are developing a Primary Health Care Centre there) We went down river for about ½ hour to Phom el Zeraf to pick up a team of 6 vaccinators, then back up river and along a tributary of the Nile towards Tambuong. A journey of another ½ hour. We disembarked with all our equipment, 6 tables, 20 chairs, 3 trunks, 2 dustbins, a load of orange plastic fencing to create our compound and a large mat to create a waiting area. (...)
I then selected 7 daily workers from among the community, 5 of whom were to be registrars and therefore had to be able to write English and 2 women to be cook/cleaner for the 3 days.
We were vaccinating children under 1 year with BCG, Children over 9 months and under 14 for measles and children over 6 weeks and under 5 with DPT and polio. DPT and polio have to be given 3 times each dose separated by one month; hence the 3 rounds of vaccinations in an accelerated programme. Women of child bearing age (15yrs to 49yrs) and pregnant women get tetanus toxoid.
The compound was arranged with a table at the entrance so that the health cards could be checked as they entered, or new ones could be written if the patient hadn't been before. (...)
They started coming for their vaccinations at about 10.00. And the extraordinary thing was, that many of the children came alone. Tiny little things, some as young as about 3 or 4, emerged from the bush clutching their blue child health cards and marched bravely up to the compound. Most of them had been through it all before in the previous 2 rounds, so they knew exactly what was going to happen. The little lips would start to quiver as they approached the table and there would be a terrible screeching as their time came. The moment the injection was finished the noise would stop and they would then come to the registration table to have their vaccinations registered.If they had completed 3 rounds of DPT they were given a mosquito net. It is marvelous to see the expressions on the faces of children who have nothing, when they are given something like that. It certainly drove away the tears and there were lots of Kodak moments. One little boy of about 4 set off towards to bush with his big packet containing his mosquito net and dropped it on the ground. He picked it up and carefully brushed the dust off it, before setting off again.
The first day was very quiet, but we managed to distribute a few nets and overnight the word must have got around, because when we got back the next day, there was a huge crowd gathering. It was very busy all that day.
At about 1.00 we got word that a lady in a nearby tukul was in premature labour, so Diana (the expatriate midwife) set off with an interpreter and her midwife's bag.
An hour later we broke for lunch and there was no sign of Diana, so I went find her. She was sitting just outside the tukul. The mother was inside the tukul and the baby had been delivered. From Diana's description I think it must have been about 16 weeks gestation. A sad little bundle at the back of the tukul. But there was another complication, she had a retained placenta and had stopped contracting, we were concerned that she would start to bleed. It was over an hour from delivery and couldn't leave it any longer; we rummaged in Diana's bag, found some oxytocin, phoned Sophie on the satellite phone to ask her to look up the dosage.
While Diana was preparing the oxytocin infusion I went into the tukul to see how things were and assess her veins. Which in the event I could hardly see, because it was so dark in the tukul.This particular tukul was a little mud hut, with a mud floor and a tiny circular door, the family really didn't seem to grasp the seriousness of the situation and kept wandering in and out, everytime anyone entered or left, they completely obliterated what little light there was. When it was possible to see anything she was lying on (what had been) a plastic sheet, part of a clean delivery kit from Diana's bag, but there was blood everywhere.
Anyway I got the IV equipment ready, offered up a prayer and got the line in first time. By feel almost, because it was so dark.. We gave her dextrose and oxytocin and within 15 minutes she had a contraction. I supported the mother, while Diana did a manual removal of an intact placenta. Result!
We gave her antibiotics checked her the next day and she was fine. No bleeding, no signs of infection and she was smiling.That was an experience of a lifetime. It was sad that it resulted in a dead baby, but at least it resulted in a live young woman. And that's something.
And then we got on with the vaccinating!
When I analysed the figures of the overall campaign, I found that we had a lot of defaulters between the 1st and the 3rd DPT injection, so we are going to do a 4th round in two weeks time. I enjoy getting out into the field and am looking forward to doing the next round. In the meantime, I am now back in Malakal, we are planning a vaccination facility in a clinic about 2 hours up the Nile from here, in a neighbouring State called Jonglei. (We are living in Upper Nile State). Training of the local team takes place next week and then the facility opens at the beginning of May. Vaccination coverage in Jonglei is terribly low (a dismal 3%). I had an e mail from the someone at the ministry of health who was very happy to hear that we are planning EPI (Expanded Programme of Immunization) in Jonglei.
The locals here call me "Mama" !!!!
So love to everybody from Malakal Mama (...)
So what have I been up to since I last "spoke" to you? Oh yes our new vaccination facility in Phom el Zeraf has opened and is doing really well, the local team who we recruited to work there are really nice, motivated and doing a great job.
We completed the accelerated vaccination campaign a couple of weeks ago we ended up doing a 4th round because at the end of the 3rd round we found that we had "lost" a lot children who didn't complete the course of vaccinations
The 4th started well and at one point I really thought that we would reduce our loss rate almost completely, it would be too much to expect to get it to zero. By the end of the 2nd day we had distributed 70 mosquito nets to children who had received DPT3 and there were 60 more to go, so I decided to tackle the problem strategically and asked the community mobiliser to target the areas where those children were registered, he did a thorough job, visiting the villages with his megaphone in the evening and the following day. (...)
When we finally reached the site (and it took a lot more time and energy to get there than usual) there was no-one there waiting for vaccinations. Eventually people started coming, but unfortunately few returnees, I can only assume that children who started the course in the earlier two rounds, have moved away from the area. I think they are quite a mobile community.
I analysed the figures this week and we actually did a lot better than I had thought; so I feel quite pleased about that. There were less defaulters than I thought, I just wish there hadn't been any. (...)
I don't know if I told you about the little boy that we transferred from Tonga to Malakal Hospital. His name was Doctor Diang, he was 6 years old and had severe malnutrition and a horrible illness called Kala Azar (or Leishmaniasis), I visited the family in the hospital and arranged food for them from WFP, because they had no means of support in Malakal. The poor little boy became sicker and sicker, his condition was very complicated. He might have survived in a good hospital.
But he died. I met the mother on the way to the office to tell me.
Doctor had been buried the previous day, apparently some people from her tribe had turned up and helped her with the burial. She wanted to go back to Tonga with her remaining 4 children, so we took them with us in the boat when we left on Monday.
I marvel at the stoicism of the women here when they lose a child. In the face of her tragedy she alternated between disciplining the little ones, smiling at their antics, occasionally laughing at them and then gazing off into the distance or sitting with her hands over her eyes.
The children were, as usual delightful. The little ones were too young to appreciate the mother's agony and continued their antics. The baby charmed everyone with huge gummy grins and was handed around so that we could all have a turn at baby dandling. (...)
I have become concerned about our management of children with malnutrition in Tonga, at the moment, children who have been diagnosed with moderate malnutrition are referred to the medical assistant who advises the carer and sends them home. Children with severe malnutrition are transferred to Malakal, where it seems they don't do well. Doctor's demise and the current lack of progress that 2 little twins are making has brought this home to me.
In the TFC (Therapeutic Feeding Centre) the families live in close proximity with other families and the conditions and the facilities are of a very low standard. Often the children develop other morbidities such as diarrhoea or other infections.
Also, being so far away from Tonga they are isolated from their usual support network and often don't have any means of financial support while they are away from home and then we have difficulty persuading them to stay in Malakal.
So I have written a report, which I will present to WFP, UNICEF and ACF which will form the basis of my proposal that we do community based feeding programmes, in Tonga.
I need to elist them as partners in this programme, because we will need food rations, (corn soya blend) from WFP for the supplementary feeding programme for moderate malnutrition.
UNICEF supply formula feeds and RUTF (Ready to Use Foods - such as plumpynut) for therapeutic feeding programmes for severe malnutrition.
I have spoken to ACF and they have said that they will train one of our local staff to take charge of the programme.
The other issue at the moment, is cholera. There is an outbreak in Juba, so far 134 cases and 3 deaths, it is possible that it has been contained, but we have to be prepared, so this week we will start moving all the cholera equipment up to Tonga, starting with the tents, fencing for the compound and the chlorine and sprayers so that the logistics department can start preparing a choleral hospital. We have a cholera warehouse in Malakal full of 1000s of litres of Ringers Lactate and ORS, IV equipment, buckets, ladles, sprayers, Chlorine tablets. I'm going to get in there tomorrow and do an inventory to make sure that it is all present and correct before I start transporting it. We also have to start identifying local staff for the cholera hospital and training them.
Lots to do!
I finish my mission in about 3 weeks, I don't know if this will be the last letter or not, I will be very busy trying to finish the things that I have started.
