Sunday, June 30, 2013

Security / Camera

South Sudan is the newest country in the world, and will be 2 years old in a couple of weeks. As everyone knows South Sudan came into existence after a referendum in the south of “old” Sudan and a huge majority voted for independence from the north, which is still called Sudan. There’s a long history of violent civil and intertribal war which continues sporadically even now, but in parts of South Sudan and Sudan itself which are quite remote from Aweil. However there is a legacy of this prolonged violence that lingers even here,  firstly I am told by a general state of post traumatic stress, a wariness and hesitancy about engagement with all but your own. This explanation certainly made sense to me, because it is hard to get a smile from anyone, life seems to be pursued with a grim and self  contained determination, and joy seems in short supply, even among children. Whereas a walk from the hospital in Ethiopia inevitably attracted throngs of kids who would call out and come running, here they watch silently as you pass. In Ethiopia it was possible to engage with patients and their carers but here that seems less common. – we do good, I am sure they know it and appreciate it but there is little in the way of feedback. This is my impression after only a week, so it may change as I get to know and understand their ways better, and perhaps, they, mine.

A further legacy of the wars is a nighttime curfew in the town from 11pm to 7am. There is an MSF rule that after 7pm we are not allowed out of the compound except for work related activity, and we area not to walk anywhere but use a car and driver. If we need to go to the hospital during curfew the ambulance has to activate the flashing light.

A final reminder that security remains a major issue in the country is the prohibition on Photography, and is the one that affects and annoys me most. How strictly such a requirement is enforced I couldn’t say, but I took a few pictures in Juba, and when I arrived here , and nobody seemed to object. However at my first briefing in Aweil it was made very clear that I am not here as a Tourist but as a representative of MSF, and taking photos in the streets and of people and scenes generally, let alone of public buildings or military or policing subjects, was simply forbidden. There were one or two photos on file in the Office Computer that I could use, and of course I could take photos within the compound or, with the permission of the subjects, of work related activity, but my habit of always having the camera in one pocket has had to be scrapped. I will post what photos I can but sadly many scenes, colors faces and events that I witness will have to be recorded in my head and nowhere else.

Saturday, June 29, 2013

The Hospital at Aweil

So far I have only been into the wards of the hospital that are staffed by MSF. Maybe I will get to see the others later. These are the typical Florence Nightingale arrangements, namely long, even very long rooms with beds side by side along both sides and doors at each end, and lining the corridors to and from. I would be surprised if even in Florence Nightingales time there were so many people crammed into the in-patient wards, children and babies and their caregiver families crowding the beds and the narrow spaces between them, the heat and smells, the noise, the dust and dirt, a feeling that the place must be on the edge of collapsing into complete chaos such is the apparent confusion of noise and crying and talking and push and shove. The MSF doctors that work here work incredibly hard all the time – their patients are all kids and babies, and unlike maternity which also gets chaotic and mad, but gets quiet sometimes with a little lull in the floods of women coming in to give birth – there is an unending flood of kids with disease, and injuries and worried parents and complicated problems to unravel.  And they have to do this with almost none of the resources we are all used to back “home”, things like comprehensive laboratory services, radiology, microbiology and pathology services, not to mention the hierarchy of colleagues in other sub branches of medicine with expertise in dermatology or rheumatology, cardiology,  and endocrinology, people we are all used to having on hand to get second opinions from.  In our ward we have a tiny portable gadget that gives a rough estimate of a persons hemoglobin concentration – in other words it tells us if they are anaemic or not and by how much, but the device is very basic.  We can send blood to the lab for a result which I took to be obtained from a more sophisticated machine but found out today their machine is the same as our one! The medical doctors are always last in for lunch and dinner.

The maternity service here delivers more than three thousand babies annually, so its very busy. There are several tiers of worker, from Medical Assistants to midwives, nurses and nurses assistants. Almost all of them are men. On our ward round the other morning I discovered we also have an Interpreter – he  explained this to me after I asked him to discuss the clinical state of the patient in the bed in front of us, much to everyones amusement. Some of the staff can be identified by the colour of their work clothes, which makes it easier for me, because they all seem very eager to help out, but some are well trained medical assistants while others barely trained at all. At least three are called Joseph, just to add to the confusion, and they are supposed to wear name badges to help me out but most often they don’t.

The long maternity ward itself has 10 beds for pregnant women at one end with problems like miscarrriages and malaria, then a small area for Triage where women sent in from elsewhere are assessed and then either admitted or sent home depending on what the problem is, then  further along still there are 5 Intensive Care beds, and on the other side of them ten beds for women who have given birth, and then beyond them and through a door another ten beds for women in labour. When their babies are about to come out they transfer into an adjacent birthing room where there are four birthing tables in a line against the wall. There is absolutely no provision made in almost the entire place for the sort of privacy we are used to in the west. You may be naked and giving birth on one bed while another woman arrives or is bleeding and being resuscitated beside you or also giving birth or having a miscarriage in the adjacent one on the other side. There arent even curtains. 

A word about the intensive care beds : to us westerners, “Intensive Care” conjures up vision of hi tech beds that cost more than a car, banks of machines and instruments with figures flashing on screens, oxygen outlets and suction hoses and monitors – well you can forget about all that – Intensive care beds here are just ordinary clapped out old beds like the others, theres no space age technology, no flashing light alarms or oxygen monitors, nothing. Its just that the really sick or potentially really sick patients get put in this little group of beds together to make it easier to keep an eye on them – so its intensive observation more than anything else.

This whole ward is usually also packed to the rafters with patients and their families, so is noisy and busy.  At times I am told they will run out of beds and people will sleep on the floor. Fortunately once the babies are born the mothers only stay a few hours before going home, so the postnatal beds  empty out often but then steadily refill. It is quite a wonderful place to pass through, as many of the women and their visitors, now smiling and relieved are dressed in exquisitely coloured flowing clothes and often have colourful scarves around their tall heads. The local women are Dinka, a race of very tall men and women who are often more than 6 feet tall and tower over me. They are never overweight, indeed most are probably underweight, but they are slender and strong with high cheek bones, very black smooth skin and are often remarkably elegant. There are also women from other Sudanese regions as well as Uganda and even Ethiopia.

These are our patients. Like women everywhere, they are phenomenal.

Thursday, June 27, 2013

The Walk to Work

The hospital is a lazy ten minute wander down the road that passes in front of the compound.  I have no idea what the daily temperatures are but they must be well over 30 most of the time, because its much hotter than Darwin where 32 was often the daily maximum, so unless walking at a very gentle pace, soon enough perspiration drips down your face and into your eyes, your shirt sticks to your back and you long for shadows, clouds or a breeze. I’m told – and accept – that things are cooling down compared to 3 months ago, as the rainy season approaches – in fact its overdue – but more heat than this must be almost intolerable. Rain of course will turn everything to mud and create new problems one of which is dramatic increases in malaria.

The road is wide and dusty with huge potholes to be negotiated at intervals, and after recent overnight rain many are filled with muddy orange water. It is possible to drive to the hospital down this road but it takes as long as walking, because the vehicle weaves all over the place around the holes and if it goes any faster than walking pace bounces about so violently people can damage their spine.  At Juba I met a women being sent home early because of exactly that.

The first part of the walk is past roughly walled housing compounds containing numerous dwellings grouped around grey dusty spaces littered with stuff that looks like junk and rubbish but which might not be. There may be clothes on a line, naked or near naked kids sitting about, women working on a struggling garden or washing or cooking on an open fire. Houses would not be the right word to describe these mostly dilapidated mudwalled huts with pointy thatched roof, or else low shelters with a sort of bamboo-like screen for walls and sagging roof. Large trees here and there are the only greenery, apart from small front yard stands of corn, and everywhere is dust and plastic junk, old bags and containers, piles of rubbish and dead leaves, sticks and paper. Dragging himself around in all this on the roadside is a sad paraplegic in rags, using old thongs  to protect his hands as he hauls his useless legs about, he is apparently also deaf, and his only language appears to be meaningless noises and groans when people pass. He doesn’t seem to be begging and I haven’t seen anyone ever give him anything so I have no idea how he survives. When I passed him this morning he was asleep in the shadow of a wall, as gray as the dust, dribbling mouth open, and I thought what a relief it must be for him to be asleep and maybe dreaming about anything but this reality. He must hate waking up.

Further on, the road to the hospital crosses a main street which is sealed.  Pedestrians are the main traffic on it, but there are a few Tuk-Tuks, motorbikes and lorries, and of course NGO Landcruisers but traffic is very light – most of the time it would probably be safe to wander across without looking to left or right . An occasional horse or donkey drawn cart goes by.

On the other side, within its own walled and nicely gated compound is an impressive brick catholic church, almost the biggest building in the town. Yesterday, Sunday, inside its compound an open sided enclosure facing the church was full of believers who presumably couldn’t fit inside for Mass.  The majority religion is some variant of Christianity, other indigenous belief systems and also Muslims, whose curious little sand coloured mosque and green minaret is crammed in among the shops and commercial activity of Aweil Central. Thankfully the MSF compound is far enough away that the 5 am call to prayer is barely audible. We are not encouraged to go to Mass or other religious service, but if we must, for personal reasons, we are requested not to wear our MSF T-shirts, to preserve our neutral secular status. In a place like this you really do wish there was a God and therefore some point in going to church, because people like that poor man on the street could sure do with one. For me the policy of not wearing an MSF T-shirt to church will not be a problem.

The potholes and mud continue past merchants, tiny low roofed shopfronts  and flimsy stalls on both sides, and the road seems narrower, because their wares are displayed on boxes and carts and benches out front.  Here to avoid walking in mud you  might have to wait your turn to step between two puddles. It’s the usual limited variety of mostly chinese made plastic and cheap metal consumer junk, plastic shoes, locks and nuts and bolts, torches, hinges, twine, batteries and cosmetics, as well as tinned milk and fruit, biscuits and rice and a few other food items. Clothes are also on sale. I haven’t seen but have certainly smelled a merchant who deals in dead and dried fish.  This street is not the main street but runs parallel to it – on the main street there is a slightly better range and quality of merchandise, there are a couple of  “restaurants” and somewhere I can get some sort of a haircut, and “Bookshops” which sell dusty very old text books, books about Nelson Mandela and about English language, and not much else. The main street has some nice shady trees, an area used to park donkeys and horses and their carts, and is quite bustling.

Finally you come to a T-Intersection and the hospital is right in front of you, through its own half closed double gates, another rocky and dusty walled enclosure at least as big as a football field, and a collection of long low buildings connected by covered walkways. Some of them are staffed and managed by the local Ministry of Health , and others , by MSF, and they function more or less independently of each other, though together, cover most of the possible medical needs of  the local population. Essentially MSF provides all the medical services needed by babies and children to age 15, as well as women giving birth or with complications of pregnancy. Obstetric care therefore includes provision of anaesthetics and operating theatre staff and equipment.  In addition there is an MSF Feeding program for malnourished children – these are kids who are literally starving to death, and the ward is full. Hunger is common here. How embarrassing it would be for us if they knew how many millions of tons of good food are thrown out every day in the west.

So that is the trip to work I shall be making at least twice every day for the next six weeks. 

Monday, June 24, 2013

Aweil, South Sudan

Aweil Suburbs

I finally made it to Aweil on Friday afternoon. It took an hour and a half on a United Nations Humanitarian Air Service flight. We had a very smooth trip – the lone cabin attendant gave us water in plastic cups, but there was no movie or airline Magazine to read.

This air service exists entirely for aid workers in Africa, and here in South Sudan there are aid workers and NGO’s and foreign charities of one sort or another on just about every street corner. There are even several different MSF’s, as the organization is structured in such a way as to prevent it becoming one massive bureaucracy, with all the attendant inefficiencies and potential for waste. Each “MSF” operates more or less independently of the others and is responsible for its own projects and regions but they have shared procedures and protocols and the hierarchical structure of each part is identical. There are something like 26 MSF projects in South Sudan but only 3 are the responsibility of MSF France.
At first this might seem like unnecessary duplication of multiple layers of bureaucracy but its obvious that at each level what is focused on is the practicalities of getting aid to where its needed rather than struggling with  structures and processes as these have already been worked out. Each sector is identified by where its main head office is so there is MSF France, MSF Spain, MSF Holland, MSF Belgium and so on. I have been recruited from Sydney but its not MSF Australia but MSF France that I am working with – actually there is no MSF Australia or MSF USA or MSF Japan even though people are recruited from all these places. At Juba when I arrived the other day the first MSF T-shirt I saw was on someone from MSF Spain but they weren’t waiting for me or in the least bit interested in taking me to the MSF France base. It took me a while to find the right MSF guy.
Arriving in Aweil
It was much easier on arrival in Aweil. The airstrip is unsealed orange soil. I noticed a wrecked plane off the side of the runway identical to the one we were landing in but and there are no terminal buildings, just a sort of car park with people and vehicles scattered about.  A group of 5 people, some with MSF T-shirts approached me and I had a brief chat to the woman I was replacing.  In lieu of the planned 24 hour overlap between my arrival and her departure, lost because of my failure to arrive the day before, she gave me a report and some written hints and tips and suggestions about how the place was running – and then with two others of my “welcoming party”, headed for the plane and ultimately, in her case for home in the USA. The rest of us headed into town and the MSF compound in the regulation white Landcruiser with MSF Logos on the side and a large flag at the front.

As usual the compound is behind a big guarded sliding steel door and the perimeter is a high wall with razor wire on top. Inside there are lots of small buildings, offices and huts and uner a huge leafy tree a central open sided dining and socializing space with  tables and chairs,  filtered water supply, a bookcase, freezer and basic lounge furniture with large cushions scattered about to relax in.  Wifi has been set up in that area, and theres a sound system. Nearby was the kitchen, where except for Sundays, all our meals are prepared by three local women. I was shown the fridges and storeroom where food is kept, the offices and latrines and showers (cold), the laundry and finally Apartment 13, which will be my home for the next six weeks. It’s a 5m by 5m concrete room with a shuttered and screened window front and back, a couple of plastic tables and a chair and bed with mosquito net, an electric fan and a 3 shelf storage cabinet covered with wire netting. What more could I need?

Friday, June 21, 2013

Are we there yet?

I left Australia for Aweil, South Sudan on Monday evening, and three days later I am still not there.

The flight over was an ordeal – they had me on an aisle seat, so lots of disturbances from people and trolleys going past, and no views, and being one row back from the bulkhead meant more disturbances from the child crying and howling in the cot. MSF paid for the tickets this time – which was nice – but then, I didn’t get a choice of where to sit. The Emirates Airbus 380 had a crew of 26. The food was good. Twice I got to the Million Dollar Question on Who Wants to be a Millionaire and both times picked the wrong one.

At Dubai 15 hours later I was in a transfer bus for about 20 minutes going from Terminal One to Terminal Three on the other side of the runways. The air was so polluted planes were invisible before they had cleared the runway. Terminal One looks like a huge striped slug, and inside it’s  very poorly designed, with vast empty corridoors and halls but hopelessly tiny check-in areas where one has to squeeze and jostle to go from one side to the other, and toilets that  would be slight overkill for a busy Petrol station but for a terminal that has something like 60 million visitors a year, and in a city that flaunts its massive wealth in obscene excess at every opportunity they are ridiculous. Only at Dubai have I ever had to join a queue that started outside a toilet !

Terminal Two is  much smaller and even more cramped and crowded – I ordered a smoothie which was very refreshing and then I was off with FlyDubai Airline for Juba, a four hour flight that went right over Addis Ababa. Looking down  from 35,000 feet I felt real affection for  that chaotic and scruffy but friendly city, for all my Ethiopian friends and their homeland.

Two hours later we landed in Juba, capital city of the worlds newest country. It is the start of he rainy season so it was cloudy and grey. They are building a new Terminal and they certainly need one – the “arrivals” area, baggage claim, customs and immigration are all crammed into one room that was literally standing room only. To get anywhere you had to push and shove and squeeze, and be pushed and shoved and squeezed in return by mostly black men, perspiring and panting in the smelly congestion. In desperation I climbed over a counter instead of going through a sort of funnel of scores of people trying to squeeze through a gap in a partition wide enough for one person at a time. When I got to the Immigration window to pay my $100 in US notes, the person in front had his notes rejected because apparently they were too old.  He kept submitting alternative bills and they also were rejected so in the end he squeezed his way back past me looking for a friend who may have had newer money - Mine were criso and unused : No Problem. I finally dragged my luggage outside to a covered over shelter and found the MSF driver - It had taken an hour and a half to get through .

It was only a short drive to the MSF Main Office, secured behind a high steel gate.
I met many friendly MSF staff and was given briefings about security, about my Mission, and about Juba, they gave me a mobile phone  and my “per diem “ – which is  my daily allowance of about  $15, and took me to the Accomodation building a few km up the road, also secured behind a high wall. It was a new building with shiny tiled floors , a big living area with a satellite TV and each room had an en suite – but no hot water, no power during the day and depending on demand the room could be shared.  Local people are employed as cleaners and cooks, and dinner was going to be available at 6. Predictably, my short pre-dinner nap ended well after midnight because I had been awake most of the previous 36 hours.

The next day, Wednesday I would have flown to Aweil, my final destination , but the one flight was already fully booked. There was little to do and  wandering the streets was discouraged for security reasons, though there seemed to be no significant history of violence in the town. However for lunch I arranged for a driver to take me to the Juba Bridge Hotel and had grilled chicken. That evening there was a lively gathering of dozens of ex-pats at the  accommodation place, apparently a weekly thing for everyone to catch up and have some beer. I met more lovely people with interesting backgrounds and stories, most had completed many missions with MSF, most seemed to smoke, and everyone was very welcoming .

On Thursday morning I was up and packed early, and back at the airport at 7 for my flight to Aweil. Again there was horrendous congestion , standing room only and mud everywhere because it had been raining. I was directed to a queue and after 40 minutes got to the counter and was told this was the wrong queue! The correct queue that I was directed to was thankfully very short – but this was because the flight had been cancelled! I would be rebooked for Friday!

The plan had been that I would arrive in Aweil and have a day with the person I was replacing so I could be shown the ropes. Now I would have to get a quick “Handover” at the airport, because the plane I will be going on will be bringing the departing Doctor back.