The hospital buildings at Aweil are arranged around a huge central open rectangular space of gravelly dirt and dust and three huge mango trees. During the day visitors and carers and mobile patients gather in colourful groups under the trees talking, sleeping, even boiling water on small fires and cooking food and kids play and roll around in the dust and filth. An enclosed verandah looks onto this space and links all the buildings, the ones used by MSF at one end and the rest, at the other end constitute the Ministry of Health Public Hospital (The MOH). The MOH is supposed to cater to all adults except for women who are pregnant - they are looked after by MSF which also looks after all babies and all children, up to the age of 16.
The other day Maura, the MSF midwife I work with all the time, took me to see a woman in the Public Hospital. It was thought she might have an ectopic pregnancy, a dangerous complication of early pregnancy where there is internal bleeding which can be lethal. We went into the crowded ward to find an obviously very ill young woman lying on the stained and grubby thick sponge of a mattress whose vinyl covering had long since been ripped and damaged and thrown away. The bed sank alarmingly in the middle. The woman could barely move or talk and her face was shining and wet with perspiration. A crowd of onlookers, patients and their carers from adjacent beds moved in close to find out what was happening.
With the help of the translator, who accompanies me to see just about everyone, we learned this woman had been on that bed since the day before. Her abdomen was so painful she could barely move. She had not received any treatment because the hospital had run out of drugs to treat her, and no one in her family could afford to buy her any. Her Blood pressure hadn’t been recorded because there was no BP recording equipment. Her temperature had not been recorded because here was no thermometer. Nothing , absolutely nothing, not even her name had been written in her chart except for the names of some drugs on a scrap of paper. This was the list the family was supposed to fill. A pregnancy test hadn’t been done because there were no pregnancy test kits.
Thinking about it later I wondered if the health worker who asked us to see her had suggested the possibility of her problem being a pregnancy complication as a way to get around the rules which state adults are not seen by MSF unless they are pregnant. Her care up to that point could better be described as neglect, and she was going to die if that was allowed to continue.
We found a catheter and I inserted it and we got back a tiny amount of very concentrated urine and tested it – she wasn’t pregnant. Technically therefore she was not our problem , but she desperately needed help, and apart from resuscitation with intravenous fluid, and huge doses of antibiotics for the fever that was burning her up, she needed surgery because upon examining her abdomen it was obvious she had peritonitis. I wanted to get help for her from MSF – a surgeon had joined our team the very day before – but how was I to get around the rules? I decided to pretend that her peritonitis might have spread from a pelvic infection – though for various reasons I felt this was unlikely, but the people I needed to persuade weren’t surgeons or gynaecologists.
Time was ticking by, and she lay there waiting while I argued her case back at Base for MSF to accept her. A week before I had leaned on our medical manager to get one of my patients transferred to an MSF programme in a town 3 hours away because she had a bowel obstruction and might have needed surgery to relieve it. I had said she could die without surgery and now I was saying it again “That is what you said about the woman we sent last time but she didn’t die” he said, and it was true. Maybe I was overstating the case? “At least come and see her first” And he agreed. Meanwhile she just lay there.
Eventually when he saw her I think he was shocked by her condition but still he felt MOH should be taking care of her. “If we look after her then all the people here will want us to look after them “ he said. “She is not our patient”
“ But now she is MY patient” I said in reply. “I HAVE to give or get for her the best possible care I can. The rules are not my concern – they are yours and you will have to make her an exception. At least get the surgeon to come and see her, and see if he agrees with me that without surgery she will probably die”
And thankfully he agreed, and later still the surgeon saw her and was also shocked. She clearly needed antibiotics, she clearly needed fluids, and she was almost certainly going to need surgery. At last it was agreed - she would become an MSF patient – so I hurried off to get all the supplies she needed, set up the fluids, gave her all the antibiotics she needed and wrote it up in her file. I explained again and again to the nurse there exactly what I wanted done overnight – it wasn’t difficult – all the drugs and fluids were there in a box by her bed - they just had to connect them – and when I returned in the morning they were all still there! Now, apparently they had decided she was an MSF patient and therefore not their responsibility.
Fortunately the patient was still there too, still very sick and when our surgeon reviewed her with me at 9 am he agreed she must have surgery, and before lunchtime, she did. What we found surprised us – no burst appendix, no pelvic sepsis, no perforated bowel but an inflamed kidney abnormally positioned in her pelvis on her left side and a fine sticky film of inflammatory exudate all over the bowels. We removed the appendix anyway, washed out her abdomen and sent her to recover in the MSF part of the hospital. She was not yet “out of the woods” and was going to need intensive post operative care, something that was obviously not going to be provided by the MOH.
Today she is still very sick.