Sudan Update 1
“Magical – it is truly magical.” Magical was the only word that worked; the only word that adequately described
the entire experience: the view, the sights, the sounds, the emotions. Believe it or not but sometimes I do
wonder why I do what I do, however; at that moment standing on the banks of the Nile, everything seemed to
make sense. It was the end of my first day in Malakal, but all that mattered were the orange streaks
accentuating the indigo hues of the clouds, darkness slowly descending after the sunset, and the almost
palpable silence.
Across the river, a flat plain extends for miles, little grows and there are no houses or signs of activity; it looks
like a no man’s land. On our side, the Eastern bank, a beehive of activity is slowly continuing. Long metal
canoe-like boats discharge their passengers or bound-up brown, taupe and khaki bundles of bamboo, balsa
and thatch - the building materials throughout the region. The piles are stacked and stretch in random patterns
along the shore; traders and passengers amble slowly by, some climb into smaller boats and head further up or
down the river to neighboring villages. Malakal, the city where I will stay for the next two to three months, is
considered the gateway to southern Sudan. It is the capital of the Upper Nile state and home to more than150,
000 people. With a peace agreement reached last year between the North and South, a civil war that raged for
more than two decades ended. Daily more and more former refugees return to the south seeking jobs and a
way to rebuild their lives. They also return to untold numbers of landmines.
But at this time of day the Nile is quite. Masses of green and brown reeds and other debris; small floating
islands - some only a few inches in diameter, some many yards across, float rapidly northward – downstream.
Flock of heron or other such birds fly in V-formation. Occasionally a goat saunters by uttering a strident
“beeehhh;” interrupting the quiet. A few teenagers approach and practice their limited English skills; they smile
and are eager to hear a response. “How are you?” they cry with heavy accents. One shows off his knowledge
with a hearty “Good morning, teacher!”
On the way back to the guest house we pass the back of the hospital and the office of MDM: Médecins du
Monde. (For those of you like moi who are rather francais challenged - Doctors of the World) They are a
humanitarian assistance organization, founded in 1980 by former MSF-Doctors without Borders folk. (I figure
there’s got to be a good inside story, but as of yet I haven’t heard anything too entertaining). It is MDM for
whom I am currently working.
The mission in Malakal is to improve the surgical services at the Upper Nile Teaching Hospital: a 100 bed
government-run facility originally built by the British in the early 1900’s. It is the only government hospital
providing surgical services to the inhabitants of three states: Upper Nile, Jonguli, and Unity. Funding for the
project was provided by the French Embassy in Khartoum. The scope of the project includes building new
operating rooms, providing new surgical equipment and supplies, and developing a training program to help
improve the knowledge of the local surgeons, anesthetists, gynecologists, and nurses.
My responsibilities will focus primarily on working with Dr. Mamoun, the local Sudanese general surgeon, and
his surgical assistants. I must admit, on my first day I was rather impressed. Now remember, I have a fair
amount of this third world type experience, and I’m sure many of you would be horrified by what I saw, in fact in
some ways, Kamuzu Central Hospital in Malawi looks a bit like the Mayo Clinic in comparison, but remember the
context. Malakal was smack dab in the middle of a twenty-plus year civil war. Sure things are better now, but if
anything, the financial situation for obtaining supplies has deteriorated. So the issue is what are they doing with
the limited resources they have? And what is the out-come? Well, that is where I was really impressed. For
January 2006 they recorded doing 237 cases. Alright, 96 were appendectomies (which is a whole other story
for another update), but they also did 8 thyroids, 6 gallbladders, and two prostatectomies. In addition, post-
operative wound infections are almost unheard of; although I did see two while making ward rounds. Basically,
they are doing a great deal of great surgery with very minimal resources. My role will be to help them improve
on what they already have.
As for the success of the surgical services, I really give Dr. Mamoun a lot of credit. He is in his mid to late 40’s
and has been in Malakal for three years. He was trained in Khartoum. We discovered an amusing connection
(at least for me) after I mentioned having worked in Malawi. He remembered that for his final surgery
examination one of the external examiners was from Malawi. He didn’t remember the name, but when I said
“Jimmy James?” He said yes that was it. Dr. Mamoun then recounted a story from his examination about how
Jimmy grilled him on a patient with intestinal obstruction presenting late in the evening. When asked what he
would do, the response was order electrolytes and other labs. Jimmy’s response supposedly was on the order
of “horsefeathers! I’ve operated on hundreds of cases in Africa all without checking electrolytes and they did
fine.” The questioning continued and the patient ended up being operated on that night. After the exam upon
hearing he failed that question, Mamoun asked why. The response was that it is more important to resuscitate
the patient and have a fresh theatre team. That advice was used last week when a very sick young women
presented late at night with intestinal obstruction. Dr. Mamoun waited, resuscitated her, and operated in the
morning. The patient had an ileo-colic intussusception, underwent a resection, and is now doing just fine.
After finishing rounds we went to casualty to check on a new admission. Luckily we were free, unluckily,
however; because all elective operations were cancelled due to a lack of sterile drapes. The reason, from what
I understand, is that city electricity only runs during the evening from 7 pm until about midnight, but since there
had been no city power the night before, the drapes and gowns could not be sterilized. Ah, life in Africa. But
fortunately we and the theatre team were free. The patient admit to casualty was a young man, maybe 19 or
20. He was lying on the floor of the small room and hordes of people were crowded around. A number of men in
uniform stood around soundlessly. On close inspection the soldier’s head and what was left of his hands were
wrapped in bandages: it was a type III landmine injury.
Despite the fact that Malakal was near some of the fighting, relatively few landmine victims have been treated at
the hospital. I guess that this is due to most locals knowing to stay away from the minefields. On rounds we had
also seen a small girl who had lost a leg after stepping on a landmine. With more and more people returning to
Malakal, areas which were previously avoided are now being used and explored. It’s a sad fact that this is a
common occurrence after the cessation of hostilities in many areas around the world.
On a different note, with all my experience in operating throughout the third world, and all the cases that I have
done and all the surgeons, clinical officers, and assistants whom I have trained, this case may have been the
most important. The surgeons here have almost no experience in War Surgery, and although I certainly have
less experience than some of the guys I trained with who have recently been working in Iraq, I felt as if I truly
made a difference. I have to give credit to people like Robin Coupland and others at the ICRC who recorded
much of the data on civilian landmine injuries and wrote extensively about the best ways to manage these
horrific wounds. Here in Malakal these were lessons that were eagerly and truly learned. I am saddened,
however; because I believe that this is just the beginning of a significant landmine injury epidemic.
But after sunset on that first night my thoughts were on more magical things, floating islands, and boats, and
the Nile.
Best to all and I will try to get out other updates if possible.
Sudan Update 2
Cholera, yellow fever, HIV, landmine injuries and...appendicitis; sounds like one of these things is not like the
others. For the non-medico types I’ll just explain that while the other diseases are commonly thought of as
developing world conditions, the classic teaching is that appendicitis is not really found in theses areas but is a
disease of the developed world. Well, if that’s the case try telling that to the folk here.
But first off, cholera; there is a severe outbreak centered around the cities of Juba and Yei a few hundred
kilometers south of here. So far reports indicate 1000 cases in Yei and 700 in Juba with hospital admissions
numbering 100 per day and fatality rates on the order of 2-5%. Cholera is transmitted from person to person in
contaminated drinking water and usually results in severe watery diarrhea. Those affected lose upwards of 10
liters or more of fluid a day and death is from the resulting dehydration. Cholera is completely treatable if
enough fluids can be replaced either orally or by intravenous infusion. Usually Cholera Treatment Centers are
set up with special beds covered with plastic sheeting and holes in the center so that buckets can collect the
massive amounts of diarrhea from the often incapacitated patients. Currently there are no reported cases here
in Malakal and hopefully we will not be affected, however; people are vigilant and a task force of various
Ministry of Health and NGO personnel has been formed to address this potentially devastating problem. But as
they say in Arabic, enshallah, “god willing,” everything will be alright.
As for yellow fever, well, there is a group of let’s say, persons, near Malakal, and a number of them have
developed “yellow jaundice;” two or three have died. Blood samples were taken from a dozen or so and one
reportedly came back positive for yellow fever. Now luckily for me, I have had my yellow fever vaccination (and
the proof is the yellow card I always carry with my passport.) However; for the local population this has the
potential to be an even bigger problem than the cholera. These infected persons need to be kept isolated and
under mosquito nets (yellow fever is transmitted by mosquitoes) a fact which no one is really certain of at the
moment. Next if the other cases are also confirmed as yellow fever then the way to deal with this would be a
massive vaccination campaign of upwards of 100,000 people or more; a massive logistical nightmare, not even
talking about where all the vaccines will come from. But again various Ministry of Health and NGO personnel
are working on it; hopefully as they say in Arabic, ma fi muskala, “no problem.”
So, HIV; luckily this isn’t too much of a problem for the moment here in Malakal, we think. The data that I have
heard is a prevalence of about 2-3%, a far cry from the 15-20% in Malawi. But most people here are assuming
that the rates will increase. Although many of the returnees are from the North, others have been in refugee
camps in Kenya and other counties bordering Sudan. It is likely that these populations have a higher HIV rate.
We were hoping to get some idea of the prevalence of HIV in the surgical population because many of the
cases we operate on are for peri-rectal conditions. Patients frequently present with anal fissures, hemorrhoids,
and fistulas. I am worried just thinking about what will happen if the HIV rate rises as these conditions can be
quite difficult and dangerous to treat in the face of a low CD 4 count. I don’t think the future in this direction
looks very bright, but we can prepare and hope. Enshallah.
In terms of other not so favorable conditions, I mentioned the problem of landmine injuries in the last update.
Well it looks like things may actually be worse than I had imagined. The entire eastern section of Malakal is
considered one massive minefield; an area stretching for perhaps 10 kilometers. To make matters worse, this is
the only place where land is available for returnees to settle. Now that it is the dry season, the ground is quite
hard and many of the mines are literally trapped in the ground. In speaking with the head of UNMAS (United
Nations Mines Action Service) here in Malakal, he feels that once the rains begin and the ground softens there
will be a significant increase in the number of landmine injuries. So far in the past two months there have been
7 victims brought to the Malakal Hospital. I have operated on two: the soldier I wrote about last time (whose
thumbs I was able to save), and a six year old girl that required an above knee amputation, a third child is also
on the ward recovering from injuries she suffered after playing with a UXO (unexploded ordinance). I was told
the other victims were very severely injured and died soon after admission.
To understand the landmine situation more clearly I have also spoken with the UNMAS folks about making sure
that the victim data is incorporated into the IMSMA database. For those of you who don’t know, IMSMA is a
global standardized database to collect information on landmines and minefields; it also has a victim
component. In addition I am hoping to get a better hospital surveillance program on victim data established and
have also written a proposal to get a stockpile of surgical consumables in place for if and when we begin to
receive large numbers of landmine victims. Data shows that landmine victims utilize vast amounts of hospital
resources and we need to be prepared for such a disaster.
So, after all that you may be wondering what the heck am I actually doing in southern Sudan. The answer is
general surgery. As I wrote in the last update, the most commonly performed operation is an appendectomy.
Now this is not a routine appendectomy for acute appendicitis, but rather an appendectomy for chronic or sub-
acute appendicitis. I can already hear the surgeons in the audience getting uncomfortable. I know that back in
the US we don’t really recognize such an animal, but, it appears that here it is something different. Dr. Mamoun
told me that when he arrived three years ago he was reluctant to operate on most of the patients with right
lower quadrant pain that were referred for appendectomy. He refused; a small number perforated, but more
significantly a larger number continued to return on a regular basis complaining of constant right lower
quadrant pain. He looked at stool and urine samples, and tried whatever examinations were available locally,
with no success. On questioning the hospital administration and the OT nurses he was told that
appendectomies were always very common in this area; still he could not accept this. He reviewed OT records
and discovered that the surgeons working in Malakal in the 1970’s and 80’s did indeed do large numbers of
appendectomies; he finally broke down and started doing more and more. To his surprise, the patients did well
and the pain disappeared.
Two years ago Dr. Mamoun began a study along with the University Hospital in Khartoum where they would
examine appendix specimens; but unfortunately they ran out of funds and the study was never completed. We
are in the process of rewriting a proposal to study this condition. The plan will be to first obtain histological
examinations of 100 consecutive appendectomies to see if a diagnosis can be confirmed. If these samples are
confirmed as normal then other diagnostic studies will be entertained and other treatment options will be
explored.
As for me, it’s been the usual fun/torture of operating in suboptimal conditions. A few cases had to be cancelled
due to lack of enough sterile drapes and gowns. We occasionally have cautery, sufficient clamps, or forceps
with-teeth. However; I am told that a batch of new surgical instruments is being sent down from Paris in a week
or so - the supplies will certainly be welcomed. In addition, work on the new operating rooms is proceeding
nicely and they will hopefully be completed within the next two weeks. This lack of supplies or a new OR has of
course not really limited our operating; we managed to do numerous appendectomies and hernias, a few
cholecystectomies, thyroidectomies, a burn contracture release and skin graft, a bunch of hemorrhoidectomies,
and the drainage of a psoas abscess. I have also instituted a formal class room teaching session two days a
week and have been going over various surgical topics. So on the surgery side, as they say in Arabic, mumtaz,
“excellent.”
Cheers,
Sudan Update 3
Saturday night while walking to our favorite grilled goat restaurant I was informed about another landmine/UXO
accident. I immediately went to the hospital and discovered four nine year old boys who had literally been
playing in a minefield (about 100 yards from their houses) and who had detonated a UXO (unexploded bomb).
One was dead on arrival; a second only suffered a few scratches. The other two had more severe injuries.
One was yelling in pain, had a large chunk of his cheek missing, and burns over his front, backs and arms,
probably from his shirt catching on fire. The last had a penetrating wound to his left flank.
Now the prospect of getting an operating room team together at 7 p.m. on a Saturday night in a district hospital
in south Sudan didn’t initially seem like an option, but to my surprise and delight, Dr. Mamoun was able to rally
the troops and by 10 p.m. we were exploring the abdomen of the child with the flank injury. We did the entire
operation under ketamine anesthesia. The only injury was a hole in the descending colon – we recovered a 1
inch piece of shrapnel. We mobilized the splenic flexure, exteriorized the wound, and created a colostomy. All
three boys are currently doing very well.
Other than that in the OR we have done a few more thyroids, a common bile duct exploration for stones, a
number of hernias, and of course a whole bunch of appendectomies. On a positive appendectomy note, we are
starting to collect clinical data on the patients and will try to get a proposal together to get funding to study the
actual pathology.
Also cholera has arrived, at first it was only by barge. A number of people left Juba with symptoms and the boat
was stopped by the local authorities. One case of cholera was confirmed and that person was isolated and
treated. Today, however, 21 other cases were reported with one death. Hopefully things will remain under
control.
On a totally separate note, below is something I wrote about an assessment mission I went on a few weeks ago,
thought some of you might be interested.
Cheers,
Nile Assessment Mission:
Sure it was kinda cool. We were speeding down the Nile in a motorboat; however, the reality was more like
being in a large metal shoebox moving quickly over an enormous washboard. But really I am not complaining. It
had been a fantastic day. Rozenn (our field coordinator), Axelle (the emergency assessment doc), Paul (the
local admin guy), and I had spent a full day traveling up and down the Nile. MDM is looking into the possibility of
staffing mobile health clinics to assist villages along the river. That day I was able to join the team in conducting
health care assessments in villages destroyed during the civil war but which are now being rebuilt and
repopulated. We left early in the morning to reach the village furthest up steam; it took about three hours.
During the journey I first noticed the beauty of the abundant reeds and grasses along the river banks. Coming
right down to the water’s edge the vegetation was a mixture of green and yellow. The grasses reached about 4
feet high, there were few trees or other sights, and mostly the view of the flood plains was obscured.
Occasionally we would pass a village with a name I could barely pronounce. Some of the villages were small
with only a few dozen structures; others stretched for kilometers with what looked like hundreds of the round
mud brick huts with conical thatched roofs. Local villagers gathered on the river banks heartily greeting us with
friendly waves. We passed a number of dugout canoes; occasionally various birds would alight as we
approached. Once I saw a wooden structure used to draw water from the Nile – surprisingly I recognized it from
a model in the Hall of African Peoples at the American Museum of Natural History in New York.
As it is now the dry season, the Nile (and for the record, around Malakal I am talking about the White Nile - not
to be confused with the Blue Nile which begins in Ethiopia. By the way, the two rivers both flow north and merge
in Khartoum and then become the Nile which snakes its way through Egypt and ultimately to the Mediterranean)
is low and divided into numerous channels bypassing low grass covered islands. The major route was at times
only a hundred or so yards wide. Mostly it was smooth sailing (or boating) except for when we reached the
mouth of the Sobat River or when two larger channels would join together; the resulting mix created waves that
would rock our two boats (hence the washboard effect). We traveled with two boats for security reasons. If we
encountered any trouble it would be easier to get back to Malakal. (Luckily we didn’t have any problems.)
In this region fishing is a major source of food and income. On smaller channels numerous fishing nets stretch
across the water and it is impossible to maneuver around them. One’s travel time is severely limited by
constantly having to lift the outboard motor and cross the nets.
On this assessment we stopped at two small villages and one larger town. The villages were being helped by
another NGO. Interestingly, little information was available about this region from the coordinating offices in
Malakal. We later learned that many of the NGOs still get their supplies from Kenya. Despite the peace
agreement between the North and the South some organizations are reluctant to deal with the government from
the North. We were told that many groups had feared working in the “garrison towns.” These had been areas
such as Malakal which had remained under the control of the Khartoum government during the war.
The town we later stopped in was a few kilometers walk from the banks of the Nile. This long distance was
needed to assure that the town remained dry during the rainy season when the Nile swells, sometimes reaching
as much as 5 or 10 kilometers in width. We headed first to the local government office and met the office
manager for the District Commissioner. He helped us try to understand the local situation and even the
Sudanese political structure. The bizarre thing is that this region of Sudan is part of the Shilluk Kingdom, so
they have a King. (I was also told he has 30 wives.) Well, the King appoints a premiership, or actually he
nominates two or three candidates and then the people elect one, or rather they all gather in front of the King
and then sit by the candidate that they want to be appointed. This guy is then the contact person over the chief
of each village who is chosen by the local villagers. Now to make things more complicated, and again in these
situations it can be difficult to get a clear picture, we were told that all these positions were in place parallel to
the official Sudanese government. The government of Sudan is lead by a President, and under him a President
of the South, and then there are Governors for each of the States, Commissioners for each of the Counties,
and Executive Directors for the smaller municipalities down to the village level. To be honest, I’m not sure
exactly how or even if the system works. To emphasize this fact, I swear we must have woken up the office
manager, and of course the Commissioner was nowhere to be found.
But we managed to get the information we needed; despite the many problems that are usual when doing
assessments such as this one. These problems often include language barriers, differences in local customs, a
desire not to reveal information, and occasionally down-right ignorance, not to mention the physical stresses.
What I mean is…and first, picture the scene. It’s literally over 100 degrees and we just walked about two
kilometers from the river; the town is a muted brown-gray with a layer of dust; it is a series of single storey mud
brick buildings and grass huts scattered over many hundreds of square yards. We amble toward a building
painted white, a Sudanese flag flutters nearby. Under a tree a man greets us and we ask him to see the person
in charge. He goes inside the structure and emerges with another man who shakes our hand and invites us into
the one room building. The room has a desk and a few chairs; the only light is provided by the open windows
and door, there are no screens. Michael, we are told is his name, and he speaks English, sort of. We begin to
ask questions about the town and the health status of the population, what their needs might be, and if there
are other NGOs working in the area. Everything is going well until we ask about the number of people in the
district. Michael hesitates to tell us. He seems reluctant to divulge any numbers; it’s hard to tell whether it is a
language problem or something else. We ask for a rough approximation but have little success. When we are
told that he doesn’t even have a rough estimate I figured he just doesn’t want to tell us, maybe for security
reasons, maybe because he really doesn’t know; but after taking us on a tour of the village, he managed to
produce on a small slip of paper the population statistics both from before the conflict and the current levels.
Once again I was reminded of the need for patience when working in Africa.
An amazing thing about the towns and villages is the fact that the land is so bad. Sure they are located within
close proximity to one of the world’s greatest rivers; but the fact remains, the land stinks. It’s dry and cracked
and often there is a constant dry hot wind blowing dust and dirt everywhere. You walk around with a layer of
grime that seems to stick to everything. The wind, however; did make the 100+ temperature slightly more
bearable.
We toured the town and stopped by the local health center. The facility unfortunately was closed because the
only nurse had traveled to Malakal in search of medicines and other supplies. We passed a new structure
being used as a school to replace the building destroyed during the war. As we walked around, we were tailed
by a small horde of children between the ages of about 5 and 10. Their clothing was old and worn and they
wore no shoes; but they were certainly curious about the three white people in MDM t-shirts and vests. They
spoke a little English and would also parrot words and phrases, “hello”…”hello,” “how are you?”…”how are
you?” “goodbye”…”goodbye.”
We briefly cruised through the market, had a cup of tea, and then returned to the boats.
It was another good day in Africa; and a nice break from the work in the hospital.
Sudan Update 4
First the good news. UNMAS, the United Nations Mine Action Service, has agreed to fund (to the tune of US$
13,000) our proposal to stockpile enough surgical supplies to treat 100 landmine victims. Due to the change in
funding sources for the local Ministry of Health from Khartoum to Juba no one is certain that the current hospital
stocks will be replaced. I was excited to hear that the project was approved as a QUIP (quick impact project),
and it was quick - approved within two weeks of writing the proposal. The supplies should be delivered within
ten days.
The less good news. People are building homes closer and closer to the minefield. Last week there were two
more landmine victims. Two young girls were slightly injured when a goat detonated a landmine close to where
they were…squatting. Their wounds were dressed at the hospital and they did not require an admission. On an
additional landmine/absurd note, two of the commercial demining personnel hired by the UN told us that while
they were out doing a survey of one part of the minefield they came across an un-detonated landmine on top of
which someone had defecated. To be honest I am not really sure what to say about that one. But what was
even more disturbing was the guy who walked into the demining compound with an active landmine, presented
it to two of the expats, and then began banging it on a table. Luckily for some reason it did not detonate.
Everyone is dealing with the aftermath, and although no one is sure why the guy did it. The local police have a
warrant out for his arrest.
The bad news. Cholera is here - BIG TIME. The cases started arriving a week and a half ago and so far over
500 patients have been treated at the MSF Cholera Treatment Center (CTC.) After we were notified about the
arrival of numerous cholera patients, we stopped by early Thursday morning to see if MSF needed any help;
they stated that they were desperate for more medical personnel. So, being a medical personnel myself, I
offered my services (with the approval of MDM.) For four days, or actually 3 days and one night, I worked in the
MSF CTC. Let me tell you it was certainly eye-opening.
The CTC is set up in the local soccer stadium, a large expanse of dusty and dry cracked ground. The entire
area is enclosed by a corrugated metal fence which is helpful in keeping people away from the infected
patients; however, there are four entrances to the stadium and people and goats continue to enter despite the
armed police stationed at the entrance. In the stadium there is a groomed earth playing field and to the south of
that is a mass of tents and plastic fencing. A CTC is divided into four zones; one for observation, one for
recovery, one for hospitalization, and one for the staff and supplies. Sprayers are posted at the entrance and a
central point in order to spray everyone’s hands and feet with a dilute chlorine solution in order to limit
contamination.
In theory the medical care for a cholera patient is fairly easy and basic. Patients are admitted with severe
diarrhea and vomiting and evidence of dehydration. The way to treat them is with fluid, lots of fluid, and then
more fluid, and then when you think they have had enough and are beginning to drink you make sure they are
getting more fluid. Now when I say fluid what I mean is Ringers solution, an electrolyte mixture given
intravenously. Most guidelines say about 6 to 10 liters per patient.
So, it all sounds fine and dandy, and not too difficult; there are local nurses to assist with the majority of the
work and the doctor merely supervises. Well, the problem is we are in Sudan, which for those of you who
forgot, is in Africa, where things never really go as planned. An additional problem for me is that I don’t speak
Arabic or the local languages of Shilluk, Dinka or Nuer. This lack of communication adds to the frustration of
working in over 100 degree heat in the middle of a hot dusty stadium in tents filled to overcapacity with patients
with non-stop vomiting and diarrhea. Sure there are beds with large holes in the center and buckets placed
under them, but often they do not collect all the fluid. Patients, especially little children, vomit on the beds, on
the floor, and occasionally on the staff.
The language barrier prevents me from effectively communicating with many of the nurses, the patients, and
the caretakers of the children. Sure I am learning some phrases, and although they were helpful in the tents, I
will probably never use them again. Let’s face it, outside of a CTC when am I ever going to need to say “Kam
isshal?” “How many times have you had diarrhea?” It is probably an even less useful phrase than my second
Spanish dialog in High School which taught me to say, “Vamos a las carreras de perros,” “Let’s go to the dog
races.”
Aside from the difficulties in communication, the job entails only some minor doctoring and nursing skills; but
then also some medical coordination, administration, and heavy lifting. When I started we had about 20 patients
with one 8 bed tent and another 20 bed tent that was partially full. The second tent filled rapidly and luckily a
third tent was erected. On my second day as the number of patients continued to increase a third and finally a
fourth and then a fifth tent was erected. Today there are approximately 100 beds, when the census was over
100, patients were kept on the floor. To date, the maximum number of patients admitted in one day was 71.
In the hospital portion of the CTC, the large tents work well with only 20 beds and a wide central aisle, but
unfortunately this rarely happened. Beds were placed along the center making it difficult to walk, clean, and
properly assess the patients. Initial assessments are for level of consciousness, dryness of mucosa, pulse, and
other physical findings along with the number of times they vomited and number of watery bowel movements.
The bowel movements of cholera are described in the medical text books as rice water stools, well to really get
the idea, imagine taking a bowel of unprepared rice and filling the bowel with water. Swirl the rice around a bit
and then discard the liquid - viola, the perfect color and consistency of cholera excreta. Not pretty, but at least it
matches the textbooks.
The shifts at the CTC were from 8 to 8. The first day was long and stressful; the second day was long and
stressful; the third day was almost unbearable. That third day I was assigned to the third big tent which only had
two patients when I arrived. More and more patients were brought in during the course of the morning and I had
to make and carry in the cholera beds myself and set up the tent. We had few supplies and those too I
collected. Initially children presented with IVs and the nurses were able to start IVs on most of the other
patients, I assessed the new patients and filled out the one page charts for each new admission. As the day
wore on, it got increasingly difficult, the number of patients began to increase, we were flooded with new
admissions, some barely conscious, some barely alive. I tried to continually reassess the patients’ status. There
were no nurses who spoke English. They did not understand my requests and they did not understand how to
care for the patients. I was on a treadmill that was getting faster and faster; I was constantly moving from bed to
bed, reassessing the hydration status of the patients, trying to remain calm with the futility in trying to convince
the caretakers to give the children electrolyte solutions to drink. As my stress increased I realized that not only
were the nurses not continuing IVs, but when a bag finished they would discontinue the entire drip. Patients
who needed more than five liters of fluids were receiving only one. I kept running to the boxes of Ringers and
hanging the bags myself. This continued throughout the shift, but things went from bad to worse as multiple
severely dehydrated children were brought to us without IVs. We struggled to get access. Other local doctors
and nurses were recruited to the effort and I was continually running between the single large tent and the two
smaller tents which had just been set up. I started an interosseous IV on one child. Another Dutch doctor came
to assist us, and I took a much welcomed break. For such a supposedly straight forward and simple medical
job, the stress of the nearly dying children, the heat, the inability to communicate, the interfering of the nurses,
and the apathy of the caretakers was actually almost too much to bear. I must admit, it was by far one of the
most horrible days of my life. But as all days eventually do, it finally ended. On another note, however, I am
sure that whoever put the words Love and Cholera in the same title of their novel never worked in a CTC.
I did not return to the CTC until the following evening for the night shift, however, by that time we were all aware
that the cholera crisis was beginning to overwhelm the MSF site. Rozenn (our field coordinator) had been in
contact with the MDM headquarters in Paris and a decision was made to send an emergency team to Makalal
and set up a second MDM CTC. Monday was spent going around town trying to get support and material for
the second site. As the surgery project is so small our available resources and personnel are severely limited.
In fact we only have one vehicle. And yes, it is white with the MDM logo on the side as all NGO vehicles should
be.
Luckily offers of assistance readily came to us. ICRC gave us a 10,000 liter water bladder, UNICEF promised
buckets, cups, chlorine and plastic sheeting, UNHCR gave us blankets and plastic sheeting, OCHA and UNMIS
lent us a vehicle and the Indian Army helped to dig latrines. We got the names of local staff from the Ministry of
Health and hired nurses, medical assistant, cleaners, cooks and sprayers, all the staff that was needed to run a
CTC.
A site was located and we began to set up; a team of logisticians and nurses arrived from Paris. The only things
missing now are some logistical supplies that got held up in customs in Dubai and medical supplies including
plenty of Ringers which has been held up in Khartoum. We are hoping to be operational within the next day or
two. Luckily for all, the number of cases has decreased a bit and the current situation is manageable.
While all this has been happening I have not been operating. Dr. Mamoun is quite capable of functioning on his
own, although both he and I are eager to continue with the trauma lectures and get back into the OR, especially
since the rehabilitation is finished and the new OR is fully functional. I also received a copy of an ICRC
landmine training video and will plan to show that some time next week.
The only case I operated on in the past week was when some local employees of an international NGO were
shot while traveling in the evening on the west bank of the Nile. The story is that they were attacked by Shilluk
Royal Police who were drunk. Two of the seven passengers in the car were injured and one required a
debridment of his wounds. But basically they were both very lucky and should do OK.
Best to all; and just for the record, even though we are working hard, I am still having a great time.
“Magical – it is truly magical.” Magical was the only word that worked; the only word that adequately described
the entire experience: the view, the sights, the sounds, the emotions. Believe it or not but sometimes I do
wonder why I do what I do, however; at that moment standing on the banks of the Nile, everything seemed to
make sense. It was the end of my first day in Malakal, but all that mattered were the orange streaks
accentuating the indigo hues of the clouds, darkness slowly descending after the sunset, and the almost
palpable silence.
Across the river, a flat plain extends for miles, little grows and there are no houses or signs of activity; it looks
like a no man’s land. On our side, the Eastern bank, a beehive of activity is slowly continuing. Long metal
canoe-like boats discharge their passengers or bound-up brown, taupe and khaki bundles of bamboo, balsa
and thatch - the building materials throughout the region. The piles are stacked and stretch in random patterns
along the shore; traders and passengers amble slowly by, some climb into smaller boats and head further up or
down the river to neighboring villages. Malakal, the city where I will stay for the next two to three months, is
considered the gateway to southern Sudan. It is the capital of the Upper Nile state and home to more than150,
000 people. With a peace agreement reached last year between the North and South, a civil war that raged for
more than two decades ended. Daily more and more former refugees return to the south seeking jobs and a
way to rebuild their lives. They also return to untold numbers of landmines.
But at this time of day the Nile is quite. Masses of green and brown reeds and other debris; small floating
islands - some only a few inches in diameter, some many yards across, float rapidly northward – downstream.
Flock of heron or other such birds fly in V-formation. Occasionally a goat saunters by uttering a strident
“beeehhh;” interrupting the quiet. A few teenagers approach and practice their limited English skills; they smile
and are eager to hear a response. “How are you?” they cry with heavy accents. One shows off his knowledge
with a hearty “Good morning, teacher!”
On the way back to the guest house we pass the back of the hospital and the office of MDM: Médecins du
Monde. (For those of you like moi who are rather francais challenged - Doctors of the World) They are a
humanitarian assistance organization, founded in 1980 by former MSF-Doctors without Borders folk. (I figure
there’s got to be a good inside story, but as of yet I haven’t heard anything too entertaining). It is MDM for
whom I am currently working.
The mission in Malakal is to improve the surgical services at the Upper Nile Teaching Hospital: a 100 bed
government-run facility originally built by the British in the early 1900’s. It is the only government hospital
providing surgical services to the inhabitants of three states: Upper Nile, Jonguli, and Unity. Funding for the
project was provided by the French Embassy in Khartoum. The scope of the project includes building new
operating rooms, providing new surgical equipment and supplies, and developing a training program to help
improve the knowledge of the local surgeons, anesthetists, gynecologists, and nurses.
My responsibilities will focus primarily on working with Dr. Mamoun, the local Sudanese general surgeon, and
his surgical assistants. I must admit, on my first day I was rather impressed. Now remember, I have a fair
amount of this third world type experience, and I’m sure many of you would be horrified by what I saw, in fact in
some ways, Kamuzu Central Hospital in Malawi looks a bit like the Mayo Clinic in comparison, but remember the
context. Malakal was smack dab in the middle of a twenty-plus year civil war. Sure things are better now, but if
anything, the financial situation for obtaining supplies has deteriorated. So the issue is what are they doing with
the limited resources they have? And what is the out-come? Well, that is where I was really impressed. For
January 2006 they recorded doing 237 cases. Alright, 96 were appendectomies (which is a whole other story
for another update), but they also did 8 thyroids, 6 gallbladders, and two prostatectomies. In addition, post-
operative wound infections are almost unheard of; although I did see two while making ward rounds. Basically,
they are doing a great deal of great surgery with very minimal resources. My role will be to help them improve
on what they already have.
As for the success of the surgical services, I really give Dr. Mamoun a lot of credit. He is in his mid to late 40’s
and has been in Malakal for three years. He was trained in Khartoum. We discovered an amusing connection
(at least for me) after I mentioned having worked in Malawi. He remembered that for his final surgery
examination one of the external examiners was from Malawi. He didn’t remember the name, but when I said
“Jimmy James?” He said yes that was it. Dr. Mamoun then recounted a story from his examination about how
Jimmy grilled him on a patient with intestinal obstruction presenting late in the evening. When asked what he
would do, the response was order electrolytes and other labs. Jimmy’s response supposedly was on the order
of “horsefeathers! I’ve operated on hundreds of cases in Africa all without checking electrolytes and they did
fine.” The questioning continued and the patient ended up being operated on that night. After the exam upon
hearing he failed that question, Mamoun asked why. The response was that it is more important to resuscitate
the patient and have a fresh theatre team. That advice was used last week when a very sick young women
presented late at night with intestinal obstruction. Dr. Mamoun waited, resuscitated her, and operated in the
morning. The patient had an ileo-colic intussusception, underwent a resection, and is now doing just fine.
After finishing rounds we went to casualty to check on a new admission. Luckily we were free, unluckily,
however; because all elective operations were cancelled due to a lack of sterile drapes. The reason, from what
I understand, is that city electricity only runs during the evening from 7 pm until about midnight, but since there
had been no city power the night before, the drapes and gowns could not be sterilized. Ah, life in Africa. But
fortunately we and the theatre team were free. The patient admit to casualty was a young man, maybe 19 or
20. He was lying on the floor of the small room and hordes of people were crowded around. A number of men in
uniform stood around soundlessly. On close inspection the soldier’s head and what was left of his hands were
wrapped in bandages: it was a type III landmine injury.
Despite the fact that Malakal was near some of the fighting, relatively few landmine victims have been treated at
the hospital. I guess that this is due to most locals knowing to stay away from the minefields. On rounds we had
also seen a small girl who had lost a leg after stepping on a landmine. With more and more people returning to
Malakal, areas which were previously avoided are now being used and explored. It’s a sad fact that this is a
common occurrence after the cessation of hostilities in many areas around the world.
On a different note, with all my experience in operating throughout the third world, and all the cases that I have
done and all the surgeons, clinical officers, and assistants whom I have trained, this case may have been the
most important. The surgeons here have almost no experience in War Surgery, and although I certainly have
less experience than some of the guys I trained with who have recently been working in Iraq, I felt as if I truly
made a difference. I have to give credit to people like Robin Coupland and others at the ICRC who recorded
much of the data on civilian landmine injuries and wrote extensively about the best ways to manage these
horrific wounds. Here in Malakal these were lessons that were eagerly and truly learned. I am saddened,
however; because I believe that this is just the beginning of a significant landmine injury epidemic.
But after sunset on that first night my thoughts were on more magical things, floating islands, and boats, and
the Nile.
Best to all and I will try to get out other updates if possible.
Sudan Update 2
Cholera, yellow fever, HIV, landmine injuries and...appendicitis; sounds like one of these things is not like the
others. For the non-medico types I’ll just explain that while the other diseases are commonly thought of as
developing world conditions, the classic teaching is that appendicitis is not really found in theses areas but is a
disease of the developed world. Well, if that’s the case try telling that to the folk here.
But first off, cholera; there is a severe outbreak centered around the cities of Juba and Yei a few hundred
kilometers south of here. So far reports indicate 1000 cases in Yei and 700 in Juba with hospital admissions
numbering 100 per day and fatality rates on the order of 2-5%. Cholera is transmitted from person to person in
contaminated drinking water and usually results in severe watery diarrhea. Those affected lose upwards of 10
liters or more of fluid a day and death is from the resulting dehydration. Cholera is completely treatable if
enough fluids can be replaced either orally or by intravenous infusion. Usually Cholera Treatment Centers are
set up with special beds covered with plastic sheeting and holes in the center so that buckets can collect the
massive amounts of diarrhea from the often incapacitated patients. Currently there are no reported cases here
in Malakal and hopefully we will not be affected, however; people are vigilant and a task force of various
Ministry of Health and NGO personnel has been formed to address this potentially devastating problem. But as
they say in Arabic, enshallah, “god willing,” everything will be alright.
As for yellow fever, well, there is a group of let’s say, persons, near Malakal, and a number of them have
developed “yellow jaundice;” two or three have died. Blood samples were taken from a dozen or so and one
reportedly came back positive for yellow fever. Now luckily for me, I have had my yellow fever vaccination (and
the proof is the yellow card I always carry with my passport.) However; for the local population this has the
potential to be an even bigger problem than the cholera. These infected persons need to be kept isolated and
under mosquito nets (yellow fever is transmitted by mosquitoes) a fact which no one is really certain of at the
moment. Next if the other cases are also confirmed as yellow fever then the way to deal with this would be a
massive vaccination campaign of upwards of 100,000 people or more; a massive logistical nightmare, not even
talking about where all the vaccines will come from. But again various Ministry of Health and NGO personnel
are working on it; hopefully as they say in Arabic, ma fi muskala, “no problem.”
So, HIV; luckily this isn’t too much of a problem for the moment here in Malakal, we think. The data that I have
heard is a prevalence of about 2-3%, a far cry from the 15-20% in Malawi. But most people here are assuming
that the rates will increase. Although many of the returnees are from the North, others have been in refugee
camps in Kenya and other counties bordering Sudan. It is likely that these populations have a higher HIV rate.
We were hoping to get some idea of the prevalence of HIV in the surgical population because many of the
cases we operate on are for peri-rectal conditions. Patients frequently present with anal fissures, hemorrhoids,
and fistulas. I am worried just thinking about what will happen if the HIV rate rises as these conditions can be
quite difficult and dangerous to treat in the face of a low CD 4 count. I don’t think the future in this direction
looks very bright, but we can prepare and hope. Enshallah.
In terms of other not so favorable conditions, I mentioned the problem of landmine injuries in the last update.
Well it looks like things may actually be worse than I had imagined. The entire eastern section of Malakal is
considered one massive minefield; an area stretching for perhaps 10 kilometers. To make matters worse, this is
the only place where land is available for returnees to settle. Now that it is the dry season, the ground is quite
hard and many of the mines are literally trapped in the ground. In speaking with the head of UNMAS (United
Nations Mines Action Service) here in Malakal, he feels that once the rains begin and the ground softens there
will be a significant increase in the number of landmine injuries. So far in the past two months there have been
7 victims brought to the Malakal Hospital. I have operated on two: the soldier I wrote about last time (whose
thumbs I was able to save), and a six year old girl that required an above knee amputation, a third child is also
on the ward recovering from injuries she suffered after playing with a UXO (unexploded ordinance). I was told
the other victims were very severely injured and died soon after admission.
To understand the landmine situation more clearly I have also spoken with the UNMAS folks about making sure
that the victim data is incorporated into the IMSMA database. For those of you who don’t know, IMSMA is a
global standardized database to collect information on landmines and minefields; it also has a victim
component. In addition I am hoping to get a better hospital surveillance program on victim data established and
have also written a proposal to get a stockpile of surgical consumables in place for if and when we begin to
receive large numbers of landmine victims. Data shows that landmine victims utilize vast amounts of hospital
resources and we need to be prepared for such a disaster.
So, after all that you may be wondering what the heck am I actually doing in southern Sudan. The answer is
general surgery. As I wrote in the last update, the most commonly performed operation is an appendectomy.
Now this is not a routine appendectomy for acute appendicitis, but rather an appendectomy for chronic or sub-
acute appendicitis. I can already hear the surgeons in the audience getting uncomfortable. I know that back in
the US we don’t really recognize such an animal, but, it appears that here it is something different. Dr. Mamoun
told me that when he arrived three years ago he was reluctant to operate on most of the patients with right
lower quadrant pain that were referred for appendectomy. He refused; a small number perforated, but more
significantly a larger number continued to return on a regular basis complaining of constant right lower
quadrant pain. He looked at stool and urine samples, and tried whatever examinations were available locally,
with no success. On questioning the hospital administration and the OT nurses he was told that
appendectomies were always very common in this area; still he could not accept this. He reviewed OT records
and discovered that the surgeons working in Malakal in the 1970’s and 80’s did indeed do large numbers of
appendectomies; he finally broke down and started doing more and more. To his surprise, the patients did well
and the pain disappeared.
Two years ago Dr. Mamoun began a study along with the University Hospital in Khartoum where they would
examine appendix specimens; but unfortunately they ran out of funds and the study was never completed. We
are in the process of rewriting a proposal to study this condition. The plan will be to first obtain histological
examinations of 100 consecutive appendectomies to see if a diagnosis can be confirmed. If these samples are
confirmed as normal then other diagnostic studies will be entertained and other treatment options will be
explored.
As for me, it’s been the usual fun/torture of operating in suboptimal conditions. A few cases had to be cancelled
due to lack of enough sterile drapes and gowns. We occasionally have cautery, sufficient clamps, or forceps
with-teeth. However; I am told that a batch of new surgical instruments is being sent down from Paris in a week
or so - the supplies will certainly be welcomed. In addition, work on the new operating rooms is proceeding
nicely and they will hopefully be completed within the next two weeks. This lack of supplies or a new OR has of
course not really limited our operating; we managed to do numerous appendectomies and hernias, a few
cholecystectomies, thyroidectomies, a burn contracture release and skin graft, a bunch of hemorrhoidectomies,
and the drainage of a psoas abscess. I have also instituted a formal class room teaching session two days a
week and have been going over various surgical topics. So on the surgery side, as they say in Arabic, mumtaz,
“excellent.”
Cheers,
Sudan Update 3
Saturday night while walking to our favorite grilled goat restaurant I was informed about another landmine/UXO
accident. I immediately went to the hospital and discovered four nine year old boys who had literally been
playing in a minefield (about 100 yards from their houses) and who had detonated a UXO (unexploded bomb).
One was dead on arrival; a second only suffered a few scratches. The other two had more severe injuries.
One was yelling in pain, had a large chunk of his cheek missing, and burns over his front, backs and arms,
probably from his shirt catching on fire. The last had a penetrating wound to his left flank.
Now the prospect of getting an operating room team together at 7 p.m. on a Saturday night in a district hospital
in south Sudan didn’t initially seem like an option, but to my surprise and delight, Dr. Mamoun was able to rally
the troops and by 10 p.m. we were exploring the abdomen of the child with the flank injury. We did the entire
operation under ketamine anesthesia. The only injury was a hole in the descending colon – we recovered a 1
inch piece of shrapnel. We mobilized the splenic flexure, exteriorized the wound, and created a colostomy. All
three boys are currently doing very well.
Other than that in the OR we have done a few more thyroids, a common bile duct exploration for stones, a
number of hernias, and of course a whole bunch of appendectomies. On a positive appendectomy note, we are
starting to collect clinical data on the patients and will try to get a proposal together to get funding to study the
actual pathology.
Also cholera has arrived, at first it was only by barge. A number of people left Juba with symptoms and the boat
was stopped by the local authorities. One case of cholera was confirmed and that person was isolated and
treated. Today, however, 21 other cases were reported with one death. Hopefully things will remain under
control.
On a totally separate note, below is something I wrote about an assessment mission I went on a few weeks ago,
thought some of you might be interested.
Cheers,
Nile Assessment Mission:
Sure it was kinda cool. We were speeding down the Nile in a motorboat; however, the reality was more like
being in a large metal shoebox moving quickly over an enormous washboard. But really I am not complaining. It
had been a fantastic day. Rozenn (our field coordinator), Axelle (the emergency assessment doc), Paul (the
local admin guy), and I had spent a full day traveling up and down the Nile. MDM is looking into the possibility of
staffing mobile health clinics to assist villages along the river. That day I was able to join the team in conducting
health care assessments in villages destroyed during the civil war but which are now being rebuilt and
repopulated. We left early in the morning to reach the village furthest up steam; it took about three hours.
During the journey I first noticed the beauty of the abundant reeds and grasses along the river banks. Coming
right down to the water’s edge the vegetation was a mixture of green and yellow. The grasses reached about 4
feet high, there were few trees or other sights, and mostly the view of the flood plains was obscured.
Occasionally we would pass a village with a name I could barely pronounce. Some of the villages were small
with only a few dozen structures; others stretched for kilometers with what looked like hundreds of the round
mud brick huts with conical thatched roofs. Local villagers gathered on the river banks heartily greeting us with
friendly waves. We passed a number of dugout canoes; occasionally various birds would alight as we
approached. Once I saw a wooden structure used to draw water from the Nile – surprisingly I recognized it from
a model in the Hall of African Peoples at the American Museum of Natural History in New York.
As it is now the dry season, the Nile (and for the record, around Malakal I am talking about the White Nile - not
to be confused with the Blue Nile which begins in Ethiopia. By the way, the two rivers both flow north and merge
in Khartoum and then become the Nile which snakes its way through Egypt and ultimately to the Mediterranean)
is low and divided into numerous channels bypassing low grass covered islands. The major route was at times
only a hundred or so yards wide. Mostly it was smooth sailing (or boating) except for when we reached the
mouth of the Sobat River or when two larger channels would join together; the resulting mix created waves that
would rock our two boats (hence the washboard effect). We traveled with two boats for security reasons. If we
encountered any trouble it would be easier to get back to Malakal. (Luckily we didn’t have any problems.)
In this region fishing is a major source of food and income. On smaller channels numerous fishing nets stretch
across the water and it is impossible to maneuver around them. One’s travel time is severely limited by
constantly having to lift the outboard motor and cross the nets.
On this assessment we stopped at two small villages and one larger town. The villages were being helped by
another NGO. Interestingly, little information was available about this region from the coordinating offices in
Malakal. We later learned that many of the NGOs still get their supplies from Kenya. Despite the peace
agreement between the North and the South some organizations are reluctant to deal with the government from
the North. We were told that many groups had feared working in the “garrison towns.” These had been areas
such as Malakal which had remained under the control of the Khartoum government during the war.
The town we later stopped in was a few kilometers walk from the banks of the Nile. This long distance was
needed to assure that the town remained dry during the rainy season when the Nile swells, sometimes reaching
as much as 5 or 10 kilometers in width. We headed first to the local government office and met the office
manager for the District Commissioner. He helped us try to understand the local situation and even the
Sudanese political structure. The bizarre thing is that this region of Sudan is part of the Shilluk Kingdom, so
they have a King. (I was also told he has 30 wives.) Well, the King appoints a premiership, or actually he
nominates two or three candidates and then the people elect one, or rather they all gather in front of the King
and then sit by the candidate that they want to be appointed. This guy is then the contact person over the chief
of each village who is chosen by the local villagers. Now to make things more complicated, and again in these
situations it can be difficult to get a clear picture, we were told that all these positions were in place parallel to
the official Sudanese government. The government of Sudan is lead by a President, and under him a President
of the South, and then there are Governors for each of the States, Commissioners for each of the Counties,
and Executive Directors for the smaller municipalities down to the village level. To be honest, I’m not sure
exactly how or even if the system works. To emphasize this fact, I swear we must have woken up the office
manager, and of course the Commissioner was nowhere to be found.
But we managed to get the information we needed; despite the many problems that are usual when doing
assessments such as this one. These problems often include language barriers, differences in local customs, a
desire not to reveal information, and occasionally down-right ignorance, not to mention the physical stresses.
What I mean is…and first, picture the scene. It’s literally over 100 degrees and we just walked about two
kilometers from the river; the town is a muted brown-gray with a layer of dust; it is a series of single storey mud
brick buildings and grass huts scattered over many hundreds of square yards. We amble toward a building
painted white, a Sudanese flag flutters nearby. Under a tree a man greets us and we ask him to see the person
in charge. He goes inside the structure and emerges with another man who shakes our hand and invites us into
the one room building. The room has a desk and a few chairs; the only light is provided by the open windows
and door, there are no screens. Michael, we are told is his name, and he speaks English, sort of. We begin to
ask questions about the town and the health status of the population, what their needs might be, and if there
are other NGOs working in the area. Everything is going well until we ask about the number of people in the
district. Michael hesitates to tell us. He seems reluctant to divulge any numbers; it’s hard to tell whether it is a
language problem or something else. We ask for a rough approximation but have little success. When we are
told that he doesn’t even have a rough estimate I figured he just doesn’t want to tell us, maybe for security
reasons, maybe because he really doesn’t know; but after taking us on a tour of the village, he managed to
produce on a small slip of paper the population statistics both from before the conflict and the current levels.
Once again I was reminded of the need for patience when working in Africa.
An amazing thing about the towns and villages is the fact that the land is so bad. Sure they are located within
close proximity to one of the world’s greatest rivers; but the fact remains, the land stinks. It’s dry and cracked
and often there is a constant dry hot wind blowing dust and dirt everywhere. You walk around with a layer of
grime that seems to stick to everything. The wind, however; did make the 100+ temperature slightly more
bearable.
We toured the town and stopped by the local health center. The facility unfortunately was closed because the
only nurse had traveled to Malakal in search of medicines and other supplies. We passed a new structure
being used as a school to replace the building destroyed during the war. As we walked around, we were tailed
by a small horde of children between the ages of about 5 and 10. Their clothing was old and worn and they
wore no shoes; but they were certainly curious about the three white people in MDM t-shirts and vests. They
spoke a little English and would also parrot words and phrases, “hello”…”hello,” “how are you?”…”how are
you?” “goodbye”…”goodbye.”
We briefly cruised through the market, had a cup of tea, and then returned to the boats.
It was another good day in Africa; and a nice break from the work in the hospital.
Sudan Update 4
First the good news. UNMAS, the United Nations Mine Action Service, has agreed to fund (to the tune of US$
13,000) our proposal to stockpile enough surgical supplies to treat 100 landmine victims. Due to the change in
funding sources for the local Ministry of Health from Khartoum to Juba no one is certain that the current hospital
stocks will be replaced. I was excited to hear that the project was approved as a QUIP (quick impact project),
and it was quick - approved within two weeks of writing the proposal. The supplies should be delivered within
ten days.
The less good news. People are building homes closer and closer to the minefield. Last week there were two
more landmine victims. Two young girls were slightly injured when a goat detonated a landmine close to where
they were…squatting. Their wounds were dressed at the hospital and they did not require an admission. On an
additional landmine/absurd note, two of the commercial demining personnel hired by the UN told us that while
they were out doing a survey of one part of the minefield they came across an un-detonated landmine on top of
which someone had defecated. To be honest I am not really sure what to say about that one. But what was
even more disturbing was the guy who walked into the demining compound with an active landmine, presented
it to two of the expats, and then began banging it on a table. Luckily for some reason it did not detonate.
Everyone is dealing with the aftermath, and although no one is sure why the guy did it. The local police have a
warrant out for his arrest.
The bad news. Cholera is here - BIG TIME. The cases started arriving a week and a half ago and so far over
500 patients have been treated at the MSF Cholera Treatment Center (CTC.) After we were notified about the
arrival of numerous cholera patients, we stopped by early Thursday morning to see if MSF needed any help;
they stated that they were desperate for more medical personnel. So, being a medical personnel myself, I
offered my services (with the approval of MDM.) For four days, or actually 3 days and one night, I worked in the
MSF CTC. Let me tell you it was certainly eye-opening.
The CTC is set up in the local soccer stadium, a large expanse of dusty and dry cracked ground. The entire
area is enclosed by a corrugated metal fence which is helpful in keeping people away from the infected
patients; however, there are four entrances to the stadium and people and goats continue to enter despite the
armed police stationed at the entrance. In the stadium there is a groomed earth playing field and to the south of
that is a mass of tents and plastic fencing. A CTC is divided into four zones; one for observation, one for
recovery, one for hospitalization, and one for the staff and supplies. Sprayers are posted at the entrance and a
central point in order to spray everyone’s hands and feet with a dilute chlorine solution in order to limit
contamination.
In theory the medical care for a cholera patient is fairly easy and basic. Patients are admitted with severe
diarrhea and vomiting and evidence of dehydration. The way to treat them is with fluid, lots of fluid, and then
more fluid, and then when you think they have had enough and are beginning to drink you make sure they are
getting more fluid. Now when I say fluid what I mean is Ringers solution, an electrolyte mixture given
intravenously. Most guidelines say about 6 to 10 liters per patient.
So, it all sounds fine and dandy, and not too difficult; there are local nurses to assist with the majority of the
work and the doctor merely supervises. Well, the problem is we are in Sudan, which for those of you who
forgot, is in Africa, where things never really go as planned. An additional problem for me is that I don’t speak
Arabic or the local languages of Shilluk, Dinka or Nuer. This lack of communication adds to the frustration of
working in over 100 degree heat in the middle of a hot dusty stadium in tents filled to overcapacity with patients
with non-stop vomiting and diarrhea. Sure there are beds with large holes in the center and buckets placed
under them, but often they do not collect all the fluid. Patients, especially little children, vomit on the beds, on
the floor, and occasionally on the staff.
The language barrier prevents me from effectively communicating with many of the nurses, the patients, and
the caretakers of the children. Sure I am learning some phrases, and although they were helpful in the tents, I
will probably never use them again. Let’s face it, outside of a CTC when am I ever going to need to say “Kam
isshal?” “How many times have you had diarrhea?” It is probably an even less useful phrase than my second
Spanish dialog in High School which taught me to say, “Vamos a las carreras de perros,” “Let’s go to the dog
races.”
Aside from the difficulties in communication, the job entails only some minor doctoring and nursing skills; but
then also some medical coordination, administration, and heavy lifting. When I started we had about 20 patients
with one 8 bed tent and another 20 bed tent that was partially full. The second tent filled rapidly and luckily a
third tent was erected. On my second day as the number of patients continued to increase a third and finally a
fourth and then a fifth tent was erected. Today there are approximately 100 beds, when the census was over
100, patients were kept on the floor. To date, the maximum number of patients admitted in one day was 71.
In the hospital portion of the CTC, the large tents work well with only 20 beds and a wide central aisle, but
unfortunately this rarely happened. Beds were placed along the center making it difficult to walk, clean, and
properly assess the patients. Initial assessments are for level of consciousness, dryness of mucosa, pulse, and
other physical findings along with the number of times they vomited and number of watery bowel movements.
The bowel movements of cholera are described in the medical text books as rice water stools, well to really get
the idea, imagine taking a bowel of unprepared rice and filling the bowel with water. Swirl the rice around a bit
and then discard the liquid - viola, the perfect color and consistency of cholera excreta. Not pretty, but at least it
matches the textbooks.
The shifts at the CTC were from 8 to 8. The first day was long and stressful; the second day was long and
stressful; the third day was almost unbearable. That third day I was assigned to the third big tent which only had
two patients when I arrived. More and more patients were brought in during the course of the morning and I had
to make and carry in the cholera beds myself and set up the tent. We had few supplies and those too I
collected. Initially children presented with IVs and the nurses were able to start IVs on most of the other
patients, I assessed the new patients and filled out the one page charts for each new admission. As the day
wore on, it got increasingly difficult, the number of patients began to increase, we were flooded with new
admissions, some barely conscious, some barely alive. I tried to continually reassess the patients’ status. There
were no nurses who spoke English. They did not understand my requests and they did not understand how to
care for the patients. I was on a treadmill that was getting faster and faster; I was constantly moving from bed to
bed, reassessing the hydration status of the patients, trying to remain calm with the futility in trying to convince
the caretakers to give the children electrolyte solutions to drink. As my stress increased I realized that not only
were the nurses not continuing IVs, but when a bag finished they would discontinue the entire drip. Patients
who needed more than five liters of fluids were receiving only one. I kept running to the boxes of Ringers and
hanging the bags myself. This continued throughout the shift, but things went from bad to worse as multiple
severely dehydrated children were brought to us without IVs. We struggled to get access. Other local doctors
and nurses were recruited to the effort and I was continually running between the single large tent and the two
smaller tents which had just been set up. I started an interosseous IV on one child. Another Dutch doctor came
to assist us, and I took a much welcomed break. For such a supposedly straight forward and simple medical
job, the stress of the nearly dying children, the heat, the inability to communicate, the interfering of the nurses,
and the apathy of the caretakers was actually almost too much to bear. I must admit, it was by far one of the
most horrible days of my life. But as all days eventually do, it finally ended. On another note, however, I am
sure that whoever put the words Love and Cholera in the same title of their novel never worked in a CTC.
I did not return to the CTC until the following evening for the night shift, however, by that time we were all aware
that the cholera crisis was beginning to overwhelm the MSF site. Rozenn (our field coordinator) had been in
contact with the MDM headquarters in Paris and a decision was made to send an emergency team to Makalal
and set up a second MDM CTC. Monday was spent going around town trying to get support and material for
the second site. As the surgery project is so small our available resources and personnel are severely limited.
In fact we only have one vehicle. And yes, it is white with the MDM logo on the side as all NGO vehicles should
be.
Luckily offers of assistance readily came to us. ICRC gave us a 10,000 liter water bladder, UNICEF promised
buckets, cups, chlorine and plastic sheeting, UNHCR gave us blankets and plastic sheeting, OCHA and UNMIS
lent us a vehicle and the Indian Army helped to dig latrines. We got the names of local staff from the Ministry of
Health and hired nurses, medical assistant, cleaners, cooks and sprayers, all the staff that was needed to run a
CTC.
A site was located and we began to set up; a team of logisticians and nurses arrived from Paris. The only things
missing now are some logistical supplies that got held up in customs in Dubai and medical supplies including
plenty of Ringers which has been held up in Khartoum. We are hoping to be operational within the next day or
two. Luckily for all, the number of cases has decreased a bit and the current situation is manageable.
While all this has been happening I have not been operating. Dr. Mamoun is quite capable of functioning on his
own, although both he and I are eager to continue with the trauma lectures and get back into the OR, especially
since the rehabilitation is finished and the new OR is fully functional. I also received a copy of an ICRC
landmine training video and will plan to show that some time next week.
The only case I operated on in the past week was when some local employees of an international NGO were
shot while traveling in the evening on the west bank of the Nile. The story is that they were attacked by Shilluk
Royal Police who were drunk. Two of the seven passengers in the car were injured and one required a
debridment of his wounds. But basically they were both very lucky and should do OK.
Best to all; and just for the record, even though we are working hard, I am still having a great time.
| Medical Challenges in Sudan August 2006 |