South Sudan Journal, Parts 17 & 18 (of 29)

Message #17 December 16, 2003


Hello Mom and Dad.

Boy it has been a little busy since I returned back to Lankien. It seems hard to believe that it has been only one week and a day.

Here is an excerpt from an internal MSF news report, "Over and Out." It reads:

"Sudan: team to Bimbim to fight kala azar outbreak Last Sunday MSF-Holland sent a team to Bimbim in Eastern Upper Nile, near the Sobat River, where there is a serious outbreak of kala azar. MSF has sent a team, since the clinic of ADRA in Bimbim is overwhelmed. In the first two days, 110 people were tested and it is expected that many results will turn out positive. Most of the people tested reported that they had lost at least one family member to the disease. The out­break seems to be epidemic in nature, since it affects all age groups and both sexes. Most people had not been traveling, which indicates that the disease is spreading within the resident population. ADRA also has over 100 kala azar patients in a clinic 8 to 12 hours walking distance from Bimbim. Priorities for the team are now diagnosing, treating and passive case finding. The team will try to evacuate the sickest patients to the better-equipped Lankien clinic, however, as Lankien is in hostile territory for the Nuer of Bimbim, this might be problematic. The start of the kala azar treatment in Pieri and Pultruk, close to Lankien, has been delayed following militia movements in the area. Security in Lankien has been increased."

We sent our outreach team there a little over a week ago, and things looked quite grim. We were sent the DAT tests to complete in our lab, and the daily numbers were a little scary, 42 completed, 37 positive for Kala Azar; 45 completed another day, 40 positive. The team on the ground also couldn't test everyone that showed up, there just wasn't enough time in the day.

After the first night they were on ground, Dennis (a Kiwi Nurse) asked for some blankets (it was cold at night early last week). I asked him how urgent it was (since there is only so much space on the plane). He answered, "the most severe ones are dying at night with this cold, please send soon."

We often hear someone declare, "that was a preventable death," or others shake their heads mumbling, "it's too bad, this is a preventable disease," but I haven't seen it so clearly defined as Kala Azar, in South Sudan. Coming in early, one can get medication and survive. Come in late, or never, and you will die.

In Lankien, we were doing our best to support them, putting together supplies for them to build a clinic, find/train staff and a few things to live off of (shelter, water filters, cooking equip etc.) We have been having flights every couple of days, and that has kept things very busy here.

The community in Bimbim has taken them in fully we hear. There are no issues about staff motivation or lack of people helping out. It is a solid community, with a recognized problem and ambition to survive it. They have been asking for help for a while, and MSF was able to get there to look into things, and fortunately do something about it too. With Christmas coming, a lot of other NGOs are leaving the field for the break. It is sad that we are still here, instead of with our families, but it doesn't feel right to leave at times like these.

By Thursday, all the late nights were getting to me, and I was fully looking forward to the weekend; until I heard the dull mechanical noise that only a certain airplane has. I looked up and a WFP (World Food Program) Buffalo flew overhead it's landing gear coming out.

The Buffalo (WFP has three of them in Loki) is a very impressive aircraft. It can deliver 8 tons of cargo, land in tricky airstrips, and take off with very little runway. The last time a Buffalo "happened by our way" we got a surprise 4 tons of food. A blessing to the hungry, but a thing to be feared by the tired. I was tired, along with the labour staff who had been working pretty hard that week too.

I started off through the clinic to the exit, calling some of the labour staff to call the oth­ers and come for a look. It could be empty, it could be full for someone else, or it could be for us; I was hoping it would be gentle on us, for it was Thursday afternoon, the clinics were empty of caretakers to help us, and there weren't too many hours left in the day for the slow task of moving food to the compound.

Sure enough, it was for us. It was a nice mix of cereals (Shorghum), pulses (lentils) and CSB (Corn Soya Blend) mix; 4.5 tons in total. Again, I got frustrated by the lack of many men to move one muscle to carry this stuff. I would ask, "why aren't these men helping out?" and I would get a laughing response like, "oh, the women like to do that work," or "Oh, ha ha, that is not work for the men."

I recognized that laugh, I occasionally laugh the same way when trying to explain the obvious to them, "Ha ha, you can't just fly in a car into Lankien," or "Ha ha, we can't just buy boots for everyone and have them here tomorrow." Was I not understanding the obvious labour division between the men and women?

Along with the cargo, there was a heavier burden; a WFP man telling me much more food was coming for us tomorrow.

The next day, we received another plane of our own, plus they had news that two more planes were heading our way. By 0900, another buffalo landed and dumped another 4.2 tons for us. The sun was still down low, but threatened that it would be a long hot day.

When big planes come in for us, we close the clinic until the load is brought in by care­takers and staff. It is a dirty trick, but if we cannot get it in by nightfall, we could lose a lot of it. I have problems with this set-up, but there aren't too many alternatives, so like everything else, we do what we can. We have a labour staff that can take care of small loads, but 4.5 tons is another order of magnitude, and we need help with that, so the clin­ics are closed and food distributions stopped, until the food comes in.

The WFP man, George, told me that more food would be dropped in the drop zone, about 1 km away from our clinic. Later on Friday afternoon, a HUGE airplane, (an Illusion) flew by a couple of times, then on one low pass, it tipped upwards and a small load popped out the back and scattered in the breeze like dust off a the back of a model plane. That dust turned out to be 9 tons of wheat.

A lot of the bags spilled out onto the field. Our counterpart (local community liaison) tried to get some people to help gather and transport the food back to the compound, but that was quite fruitless, he also has problems motivating the people. ("Ha ha, don't you understand, no one will move a muscle." I thought of telling him, but declined the opportunity.)

By 1700 nothing had come back to the compound, so we made arrangements to guard the food for the night. A fairly high commander in the SPLA was in town, and he offered his men to guard it overnight, and to our surprise, no problems came up and most of the bags were there in the morning. We get on nicely with him, and I think he personally asked that nothing go missing that night.

The next day was not so nice. It was Saturday (usually a half day of work) but 9 tons of wheat was waiting for us 1 km away. That can feed the patients in the clinic for about 6 weeks. I hate the times when food gets short and we have to cut rations to the patients, so I was quite eager to get it in before losing it. We made a deal that 10 bags would be used as incentive (payment) to porters (after the 2 bags for the gatherers and 1 bag for guard­ing was paid, also a lot of the spilled wheat was spread too thin over the field to be col­lected) and a rough group headed off to the field to start the task of carrying it back. All day the wheat trickled in, slowly slowly. Also, people divided the bags into two, so peo­ple could carry 25kg bags instead of the 50kg. I don't know how WFP decided that 50 kg bags should be used. I think they looked at the breaking strain of a person to carry food, then increased the amount given that the people would carry more if they were hungry (and ignore the fact that they may be weaker if they are malnourished).

There were a lot of loses, some of the bags had holes in them and unnoticed to the porter, a line of wheat was drawn out sometimes. Then kids would run in and collect all they could and head home. I think people here respect that MSF property is not to be taken, except if there is a reason, like it falls on the ground. If something falls on the ground, it isn't MSF property anymore, and you can take it. If something is measured out, and there is extra, it doesn't need to be returned, you can take it, etc. We lose so many things, but I doubt many of them are taken, I think people just, "share" them, or help us get rid of bro­ken things (regardless of who broke them).
So, by late afternoon there was still lots to come, and the porters were very tired. (Porters were all but one, female.) There was a lot of loud talking by the ones supervising (men), and a lot of pointing in the direction of the drop zone. After the yelling slowed, and peo­ple were not moving, I asked what was going on. (I don't like getting involved too much, since I have a hard time understanding the rules here, but sometimes I can't bear the yelling and appearance of a misunderstanding.)

"The women complain that their babies haven't eaten all day, and they want to stop now and feed their babies. They won't carry any more until they can feed the babies. I told them to move, but they refuse." I cannot argue, that is one of the best reasons I can think of not to leave for another load. "Can we feed the babies some of the F100 (special therapeutic milk)?" I asked. There was an angry sounding translation, then the ladies got up again and headed for the field. I handed out the sachets of milk powder to the right people and that issue was resolved. That was just one of the many types of situations that arise here.

Just as the sun went down, the last of the bags came into the compound. In total, we only lost 1.5 tons. The WFP man was telling us how sometimes up to 50% can be lost in the drop. In nearby Pultruk, 40 tons (out of about 90) was looted in less than an hour about 2 months ago, so I consider our loss pretty good. We also agreed that many of our motiva­tion problems came from the situation where the community didn't receive any food this time, only the patient food.

So the food was in the compound, but not in the storeroom, that would be done on Sun­day after church, at 1200, people were just too tired now, and now that the food was somewhat secure, we could rest. (The commander and his troops had left that day, and we no longer could have security for the food overnight in the drop zone.)

But, there wasn't too much rest that night. There was a plane in the morning for Bimbim again. They needed more supplies, so we spent some time gathering the right stuff, and fabricating things if we didn't have them. Also, Charlie, (my Logistic Coordinator who was visiting at the time) said there was another Buffalo coming in the morning. Charlie has a way of joking sometimes, so I laughed and without other comments I went straight to bed, half believing him.

In the morning, our plane came, we traded cargo, and to the disapproving of the staff, I hurried them along with the transport to the compound. Maybe Charlie wasn't joking, I didn't know, but I wanted to secure this load just in case.

Just as the last of the cargo was stowed in the compound, there was that dull noise again, a Buffalo. I was sitting around with the labourers doing a little math in the sand (which has taken on nicely after the weekly math lessons) when this happened. They all looked at me in tired eyes, asking, "is that for us? Please say no." (That's funny, how did Charlie plan to have an empty Buffalo come by to continue on the Joke? What a timely complex joke. Ah that Charlie, funny guy, ha ha.)

It landed and pulled up to the cargo clearing. I hopped in the back and found the pilot. "Who is this for!?!" "It's for WFP!" "Really!?! Not MSF, project number ..." "No!" (Oh, this is good, this is really good, I briefly thought to myself.) "Where is the WFP person?" The pilot asked. "He left yesterday." "Is there anyone from WFP on ground?" "No." I answered as I started thinking of how to slip away from another 4 tons of shorghum. "Let me call and get clarification." (I'll let you do anything you want with your plane, your cargo, your waybill etc. Knock yourself out! I'm going to sleep.)

He talked on the radio for a bit, then returned, "It's for you." I guess when it rains, it pours. WFP hadn't delivered anything for 2 months, and over the last 4 days, we got it all.

On Sundays, we have no clinic, so no caretakers would help. Any community people that felt an obligation to help us were completely spent on yesterday's efforts. The log staff was looking tired too. It was 0930 once the Buff took off, there was a very awkward silence. I didn't know how we would get this load in. It was another 4.2 tons, and I thought we spent all our energy on the other loads. I was lost for ideas; I really didn't know what to do. I asked around (my favorite problem solving tactic,) but only got blank stares. We sat down on the bags and talked a little about other things. That didn't get the pile any closer either.

Occasionally here, I start doing something and wish with all my might that I don't end up making a fool of myself. Like the time we visited the school and agreed to sing a song for them in reply to their many songs; like the times I've practiced my Nuer words in a crowd; like the times hard problems are thrown at me and I come up with a different so­lution; like the times I spend lots of money on building something (and hope it is the right size, location, construction, etc); like the times etc etc. etc. Sometimes I'm right and peo­ple smile, many times I'm slightly off and people laugh, sometimes I'm right off and peo­ple don't say a thing.

In those minutes we were sitting on the load of Shorghum and talking of other things, I was getting over my stage fright, and preparing myself for another one of those moments. Would they smile, laugh or say nothing and watch me head down the lonely path of ridiculous. I got up, declared, "I think it will be a long day," and got Issac (the biggest of them) to help me put a bag on my shoulder, then I walked to the compound.

I was scared to look back, were they laughing yet? To my relief, I heard another bag get loaded on someone and on I walked. When I dumped my load at the other end, I turned around to see a stream of other bags coming in and people saying, "Tall man, tu-boom." (I have been named, "Tall Man" and Boom-Boom means strong, and Tu-Boom means a bit more.) I figured with such a complement, I should summon the strength for another bag, and back I went.

This continued for quite some time. Many pauses, many shoulder slaps and handshakes. "Boom-boom", "Gua-gua", "Gua-long-a-long-a-long" (Strong, good and very very good) yelled back and forth powered us along. My back was getting sore, but I could tell that it was part of the works that brought the food in. If I gave up, they would, and if they gave up, I would too. What a delicate balance.

The last bag came in, and that last person flopped down beside the rest of us. Even though we are different people from a world apart (by geography, culture, technology, etc), I felt more that day than any other, we were the same people.

We hobbled back to the main compound, and to my horror, I spied the pile of 7.5 tons of wheat, just outside the storeroom, ready to go inside that we left the day before.

The eyes came back to me, but I could easily reply this time, "I think we rest now." One mutiny averted!

"When do we load it?" (Oh, don't make me the evil one today please. I thought.) "When do YOU think is a good time?" (I cunningly put it back out.) There were many discus­sions and arguments. I said I would get some water and return to hear their answer. When I returned, they were loading it into the store; I couldn't believe it. One of the guards said, "after we do this, then we rest really good, so we do it now." That was true.

Within a couple of hours, the area in front of the storeroom was clear, and the room was full to the tops of the walls with food. I looked at the walls, noting any larger cracks that would indicate too much pressure inside and tried to recall some of the lectures on foun­dation walls in my soils mechanics courses. My observations were positive.

The Log supervisor took me aside (as he does when asking for something) and said, "I think the staff is tired now." "Looks like it eh." I replied. "I think they should have two days off." "I think so too."

All in all, 19 tons of food came in, around 7.5 from 1 km away, the rest just 150m. That will keep the 300 patients fed for a couple of months. It is good to have it here, but damn we pushed our limits beyond what we thought possible to get it here. I have been impressed by the lengths people here go to, to survive. Patients are carried for 5 days to get here, people eat terrible things, and people live in the harshest conditions, just to sur­vive. I think there is a wide range of conditions that humans will survive in, and I think this place is close to the limit of what is possible. It almost seems comical to hear some­thing like, "it's not fair," for nothing is fair here, so why start counting now, you'll run out of breath.

After the food was stowed, I went to the pharmacy to stow some meds that just arrived, but I was interrupted by Evert the PC. "Here is a tea, in 5 minutes we have to leave." "Are we being evacuated?" (Are you joking too?") "Yes, to the river for a swim. It is 1700, if we hurry we can dip in and be back by night." (Last week the team found a river that is still deep enough to float/swim in.)

I thought we were all too tired to move, but the opportunity to dip in a river (even if it involved a 30 minute walk) uncovered unlimited reserves of energy and we were off!

Well, just a little update to let you know that things in paradise are still not dull. Every­day is exciting, and some days are better than others. I shared in the day off with my staff, yesterday, and that was damn nice. We realize that too much work isn't good for the body, and so we have formalized some ideas on time off in the day and week. Also, X-mas is coming, and we are making preparations to slow down work over that time. We still have 300 hungry-sick patients, but with a little planning there will be times when they are not so hungry-sick and we can ring in the holiday season properly.

Glad to hear things are well at home, take care all, lots of Love too.

AND MERRY CHRISTMAS AND A HAPPY NEW YEAR!
Steve
Message #18 December 22, 2003



Hello Mom and Dad.

Never a dull moment... still. I don't know how a place can stay this exciting for this long, but it does.

The outbreak in Bimbim is continuing. In a couple of days, they will have the same number of patients as we have here. (Just had a radio talk with Dennis there, they now have 220 patients, that is 40 more than us.) Different level of care, but you really don't need much infrastructure to deliver medicine to people (in South Sudan, in Canada it is a different story). They are starting to encounter larger problems in the community and in the workings of the clinic, now that the initial onslaught is slowing, and the numbers are now just rising slowly.

There is only one water pump in Bim Bim, and with the population rising (due to increased patients, caretakers, stretcher carriers, etc) the pump is running day and night. We are looking into ways to get a drilling team there to put in more wells, but that some­times takes time. There are no other options for water there since surface water has all dried up, and ground water is 60+ meters down (a little far for a hand dug well.)

Also, the ground is getting very hard and the waste is much and the dead are many, so other problems are occurring.

A team from Bim Bim set out to investigate another place nearby, where reports of Kala Azar were very high as well. They decided not to start treatments there too, because numbers were too high, and an organized effort would have to be made, and for that we need a little time to really step back and see the problem.

MSF has sent out a press release about this outbreak, hoping to get some other support from other NGOs, but with the holidays, this may have to wait.

Things here are keeping busy, planning the planes to re-supply, and the purchases to fill the planes, and anticipating the needs for the next while is a little tricky. It would be so much easier to do emerg. Planning if there was a Home Depot around the corner. It is getting hard to buy things 2 months before I need them!

As for other things... It is Christmas soon! It feels a little funny, especially all the Christmas songs on our radio, but it is coming together. We planned to have Christmas together (the outreach team and us) but this Bim Bim thing is keeping it from happening, we may do Christmas again in January. There will in fact only be 4 of us here (usually there are around 10) so that is a little odd.

The seasons are changing a little too.

When I got back, the nights were a little cold, (a very little cold) and the day is not that hot. It is windy too. It hasn't rained for the last month and a half or so, and the ground and air is very dusty. The ground is starting to get quite hard and cracked up. This soil is very impressive here. When wet, it is impressively cohesive, slowing a walk to a crawl, but when dried out in the sun for a month, it has a concrete like hardness and appearance, except for the wide cracks that could twist an ankle pretty easily. In fact, it is difficult to distinguish the difference between the dusty concrete that is formed here, and mud which is worked to a nice finish on the floors of most tukels.

There are different bugs and other creatures out too. Some large angular insects, and hundreds of small flies coming out one night, and none the next night. I've seen a couple of scorpions, but only a couple. The mosquitoes are almost all gone, so we can nicely eat and sleep without nets again (I hate these nets!) Also, there was a large lizard a while ago (almost 70cm (30 inches) long). Apparently that is a sign that the snakes will be out soon, but with our home-compound-defense team of 5 cats, we haven't seen any snakes, or rodents that attract the snakes.

Russell, the compound hedgehog has been popular around here. He waddles about at night until someone approaches, then bundles into a ball as people scoop him up in a towel (Russell has many sharp spikes on his back), then once we are done, he waddles off again. A couple of nights I found Russell trapped in a box in my room. I think if it weren't for his spikes, his species would be out-smarted and die off.

Also, all the plant life in the compound has dried up, except for one papaya tree, which gets its water from the shower. It has yielded papayas, (one or two a day) for a couple of weeks (Great stuff). But it is bending in the heat, and I fear any day, it will blow over in the wind like the rest. I hope the remaining fruit will ripen first. They look great! We have sent seeds to the other projects for Christmas; this tree is a good thing to have here.

The team is doing very well, but now there are only 3 of us here, tomorrow there will be 2. People are either out in Bim Bim or other investigations, or a couple are on holiday. Through this emergency in Bim Bim, people have been great to work with, doing what they can, regardless of job description or any other concept that becomes loosely inter­preted here.

On Friday, I went out with the Lankien outreach team (Lindsay: expat nurse, and James and Steven: Lankien Health Workers) to Paak, to do a nutritional survey (a short one) and to investigate Kala Azar and TB cases there. We sent a message the day before, so when we arrived, patients were waiting. We did a little walk about the village with the MUAC (Mid Upper Arm Circumference) measurement tapes, and then spent the rest of the day in the clinic looking at patients and referring some to Lankien.

The MUACing went well. I went with James and the Paak clinic guard one way, and Lindsay, Steven and another Paak clinic worker went the other way. Most of the children were looking good, except for one I saw. He was 1 year old, yet his upper arm was 9cm around (two of my thin fingers or so). He was in our feeding centre when it closed, and now, (a month and a half later) no better off. I saw some other fat kids playing behind his mother, and inquired about the harvest; they said it was good, and they showed me their pile of food, pretty big. I asked them to come with us to the clinic and maybe there would be something we could do there. There are some simple hygiene things that can stop his diarrhea and maybe get him healthier, plus a little food, I don't know, it is pretty difficult for people here, but maybe there is something, so we try.

Back at the clinic, the crowd grew. Lindsay explained why we were there, and that we were looking for signs of Kala Azar, and she explained them. They included fever (we were looking at people with a fever for more than two weeks) and a large spleen. Sur­prisingly, the first person to be reviewed had a fever for two weeks, same with the next one, and the next one too. The spleen is a lot harder to make up, so we screened more on that, and other clinical methods.

I say we, because Lindsay showed me all about the spleen, where it is, how it feels, then she put me to work to screen people. There were just too many to look at for her, and the staff was a little difficult to work with, so on we went. I would find ones with what I thought had good symptoms (fever and big spleen), and sent them on to her. Over the last two years I have been learning many medical things, (seeing operations, managing pharmacies, etc etc) but I haven't consulted patients before. (Everyday something new!) Fortunately for the patients, I didn't turn any away, but rather I just brought the sick ones forward and took histories of the rest.

Taking a history is a difficult thing here. There is no private consultation room or any­thing. We held this clinic under a tree, where people were very open to strip right down and lie down to be examined in front of everyone. The difficulty is, that the history of the sickness becomes a group effort.

Example:

"This lady has TB!"
"How can you be sure?" I reply to the translator.
"She says she has TB, she wants to live with MSF in Lankien."
"Is she coughing sputum?"
"No"
There is a call from someone in the crowd.
"Sorry, she does cough sputum."
"Really, what colour? and please ask her."
There were some words.
"She says she doesn't cough sputum."
More words in the back.
"It is white."
"Really?" I inquire.
Lots more words in the back.
"Actually, she has had a fever for two weeks and a big spleen, she has Kala
Azar."
"Can I feel the spleen?"
"She says it may be small now, but this morning it was really really
big."
"Thank you for translating, you've taugh me lots."

By 1530 we finished and started the 2.5 hour walk back. Boy these guys can walk. If I stopped to drink water, no amount of walking faster would get me back to the group, I would have to jog.

On Saturday, we held a children’s party for the kids of the staff. Simple to organize (no time for anything else) and simple to run was our goal. It was a success. We had about 150 kids in total. We also had a back-up evacuation plan (dump the candy and run) if things went bad. The races were very funny. (WFP sack races, balloon between the legs races, tug of war, etc) It is apparent that we had developed skills from our Western lives,
that do not develop here. One boy in a WFP bag was jumping up very high, but not moving forward at all. The staff really got into it, and now people are hopping around town.

We also had some music later (boy the people love dancing here.) Then we had illusions of letting loose a couple dozen balloons in the dancing crowd for them to play with. In Canada, that would be a cool thing to do at a kid’s party. Here it was different. I call it social experiment 23 (after the 23,000 other social lessons I've learned here.) The bal­loons came out, and the cheerful dancing crowd turned on us, and attacked, we threw the balloons up, and to our horror, fights broke out to get them. It was a bad moment, one of those regretful instances where I wanted to give up trying to do good things, in fear of it being taken the wrong way. I don't do anything, unless I've asked others their opinion and delay by thinking of all the consequences of the action, before doing it, but still it ALWAYS backfires. As the fight went on, the parents sat back, (I think they were hoping the kids would bring a balloon home for them too) and the kids got angry. "How should we hand out the popcorn?" "Should we hand out the popcorn?"

Fortunately with all the fighting, there weren't many balloons remaining, and order was restored and it ended very well, but I appreciate fully the volatility of the people here. Tomorrow I will be handing out the Christmas gift to the staff (a blanket, a pad lock and a bed sheet), I will do lots of preparation to ensure crowd control (one at a time in the storeroom where I hand things out) and also ensure all the locks work. What a pain!

Anyway, things are well here. We are tired, but it is Christmas soon, and we aren't tired enough to have a good day off, and a great rest then too',

Time to go, lots of love,
Steve