Dry season

Dry season--hot, dusty and smoky.  We ride to work every morning on dirt roads through great clouds of dust every time we pass another car.  We die of heat if we don't open the windows and choke on dust if we do. The side of the road is either charred or burning.  Everyone burns everything in sight so "there will be new grass for the animals".  Most of the trees survive but apparently they also manage to burn houses and electrical poles (fortunately we have our own generator as the electricity around here was off for a week).  For awhile it was hotter during the day and colder at night.  Now it is hotter during the day and hotter at night--a bad combination.  At least the cold showers are now a welcome respite from the heat. The most comfortable place is outside in the shade so we spend most of our free time sitting on our porch (as opposed to the dorm which is like an oven).  Sunday afternoons we retreat to the air conditioned pharmacy to watch movies.  At work I find it hard to move in the afternoons except for when emergencies come in. The things we are seeing in the hospital have definitely changed.  There are far fewer children with malaria and many more dehydrated from gastroenteritis.  Skin infections and abscesses are common. There has been a huge outbreak of chicken pox in the camp and we see many cases everyday in the outpatient department.  There was also an outbreak of Rubella (German measles) but that seems to be dying out. Chicken pox has not been much of a problem except for a mother who delivered with it and we were quite worried about the baby.  We only had the medicine for the baby in pill form although IV medication would have been better.  The nurses crushed the pills to give to that baby and another 2 week old baby with chicken pox.  Both did well.  I took care of a 6 year old boy with a hugely swollen hand from an infected rat bite.  He had been chasing and trying to capture rats which is a game he and his friends play.  In the bed next to that boy was a girl with a snake bite she got while playing behind her hut. A five year old child was brought in who had been hit by a motorcycle and had a femur fracture. We splinted her and sent her to the hospital in Adjumani--a bumpy one hour ride.  At Adjumani they are not able to do traction and tried to send her on to Kampala.  At that point the parents just picked her up and left saying they were taking her to Juba in South Sudan for treatment.  Not an easy trip for the child. 

Malnourished child in recovery 

The dry season has caused a small increase in the number of SAM cases (severe acute malnutrition).  The ones that are sick with additional problems are hospitalized, started on therapeutic milk and eventually transitioned to Plumpy Nut, a peanut based paste.  Most of them seem to really like the Plumpy Nut which they eat right out of the packet. When they are doing well on that they are discharged with a weeks supply and come back weekly to be weighed and pick up more.  Once their weight has risen to the normal range for 3 weeks they are discharged.

In the afternoons when it's quiet the staff will often tell me about life in Northern Uganda and South Sudan.  The translators have lots of stories about escaping from the rebels and traveling south to Uganda. Another popular topic is wives.  Most of the South Sudanese expect to have 2 or 3 wives.  Many of the Ugandans, at least in the north, also expect to have 2 or 3 wives or a wife and a girlfriend.  The translator in the picture is 24 and working on his third wife.  The first was at 19 and not really a wife as her older sibling hadn't married yet and they couldn't marry until that happened. While waiting for that she had his child but met a man from Nairobi and moved to Kenya.  The child is with the mother now as he has allowed this but the child belongs to him. When she gets older he will claim her. The second wife is one he inherited when his brother died and she is still in South Sudan with an infant.  He is looking for the next wife, the one that will really he his.  In the meantime if things quiet down in Sudan he will try and go back to the University where he was studying economics.  

Ugandan nurse, South Sudanese translator and me

I find it interesting that how well dressed we are seems to be inversely related to our circumstances. The refugees that live with no running water or electricity look the best, then the national staff, who also lack running water but some have electricity,  while we just wear MSF t-shirts and scrub pants.

Refugee Food Distribution

Line for sticker needed to get food

Getting thumb printed and receiving the sticker 

Last week I had the chance to visit the refugee's monthly food distribution site.  Jacob, one of our South Sudanese surveillance officers who lives in the refugee camp, offered to show me around.  The surveillance officers visit every household in the camp, (~16,000 people) over the course of a month looking for malnutrition and illness, and documenting home births and deaths.  The food distribution takes place in a large field with some temporary structures on the edge of the camp. There were long lines of people and groups of people everywhere.  Each family is given a refugee registration card at the transit camp they are taken to when they first enter the country and it is used to get food. The lines are all organized by family size with a separate line for each number from 1-7 and another line for those with 8 and above in the family. At the head of the line there are a couple of people examining documents, collecting thumb prints and handing out the food sticker.
 Once they have the sticker there is another line to get the food--10 kilograms per person.  This month they were given sorghum,  CSB (corn soy blend) and cooking oil.  After spending several hours under the hot sun collecting food they are now faced with trying to carry the food home.  Some package it in smaller quantities and make several trips.  Others pay someone, with part of their food, to help them transport it.

Food!

Party (Ugandan style)

We were invited to the Christmas party put on by the District Health Officer for all the Ugandan health clinics in Adjumani district—about 35 small centers and a 200 bed hospital (staffed by 3 doctors who do all the surgery). The party was held in the courtyard of a bar/night club in Adjumani with chairs set up for the staff  in rows (~150 people) and chairs for the dignitaries set up in a U in front.  The invitation was for 3 o’clock.  The two Africans on our staff said, "we will go at 7 or 8 to avoid most of the speeches."  We arrived at 8, tried to sneak in and sit in the back, but were taken to the dignitary area up front where speeches were still going on.  The guest of honor, a member of parliament, arrived just after us.  The speeches went on for another two hours before dinner was served! For dinner there were two buffet tables—one for dignitaries and another for everyone else.  Before the buffet table there were hand washing stations with soap and water—a woman sitting pouring water over your hands from a jug.  The food, roasted goat, kasava and rice, was served on a plate and everyone ate with their hands.  From a western perspective it was quite odd to see women in fancy gowns eating with their fingers. After dinner there was drinking and dancing although we had to work the next day and left by midnight.

For our staff end of the year party we took over a “bar” in the nearby little town of Dzaipi.  The bar consists of a small shack where drinks can be purchased, a large fenced outdoor patch of dirt for dancing, sound system and stage. We gave all our staff (~100 people) 2 tickets for beer and 2 for soda, and provided dinner—roasted goat, rice and salad.  Having meat to eat is quite important for any special occasion here.  (I was told that only if you were very poor would you not eat meat on Christmas).  The most serious of my clinical officers at work turns out to be the funniest of MC’s and agreed to be MC for the party.  We tried hard to avoid speeches and were pretty successful—just a couple of short ones. The expats prepared a dance to one of the popular songs here which we did up on stage much to everyone’s amusement.  The first part of the evening was similar to a talent show—a lot of staff wanted to sing, dance or lip sync up on stage.  I tended bar for a couple of hours and then danced until I was exhausted. A big crowd gathered just to watch our party.  They sat, in the dirt, for several hours happily watching everything going on on stage and the dancing.

Football, Fire and Fireflies

My elder son seems to think I don't work much as he hears more about the fun stuff.  I have assured him that I am working plenty hard--5 and 1/2 days a week and on call the rest of the time. I have "formal" teaching duties with the clinical officers where I prepare handouts, discuss cases etc in addition to daily rounds.  I also consult in maternity which is generally fun.  The maternity structure is about 25 yards away from the hospital and the midwife supervisor calls me when they have any non-pregnancy related problems with their patients.   Hasn't been too much work until the last couple of weeks when we had 5 cases of neonatal sepsis, 1 of meningitis and 1 of congenital syphilis. Last week the midwife told me there was someone about to deliver if I wanted to catch a baby.  I ran over but missed the delivery. As I walked in the translator fainted and was heading for the floor so I caught him instead.

Waiting for the game to start

As far as entertainment goes here it is pretty much a make your own situation.  A couple of weeks ago we decided to have a staff football (soccer) game as football is quite popular. On the way home from work everyday we pass a group of young boys playing soccer on a dirt field with sticks tied together for goals and all barefoot. When we get closer to home there are a couple of other fields with older kids/young men playing on them where we were able to borrow a field.  The idea was to have one team from health staff and the other from folks that work on the compound and drivers. Well the idea was a huge hit.  Everyone at work was talking about our team--we got interrupted during rounds to make sure our goalie would be off that day. I got asked over and over what position I was playing.  They even put me on the roster which was quite a joke as our real team was young 20's men. I told them after they ran up the score I would come in. People discussed the upcoming game on the way to work, during work and on the way home.  I have to smile at  how little it takes to make people happy sometimes.  On the day of the big match we walked over to the mostly dirt field with goal posts, but no nets, and a herd of cows grazing on one side.  We had decided that one team would wear red and one white.  Not enough people had the right color shirts so players coming on and off the field had to change on the run.  Most of the staff came to watch and even more people from the village next to the field showed up. Many players were barefoot and very impressive runners. My team won 1-0 and everyone celebrated with a beer or soda after the game.

Dry season has arrived and with it very dusty roads (sometimes it is like thick fog). Tall brown grass is everywhere. The practice here is to set fire to the dry brush so new shoots will come up for the animals to feed on.  It's a bit uncontrollable what actually burns so I'm told it's not unusual for houses to be burned as well as grass. In addition to dust in the air now there is often smoke as well.  The other night the guards alerted us there was a nearby fire burning out of control parallel to the side of the compound where there is an above ground fuel tank.  We all left dinner to go watch the flames leap into the sky.  Every once in awhile there would be loud crackling and sparks as a tree exploded in flames.  It reminded me of brush fires in Malibu.  Fortunately it passed by without turning our way and eventually died out. I miss the daily thunderstorms and amazing cloud formations!

I'm not enjoying the various bugs that seem to come in waves but I did have one nice bug experience. I went to bed (under the mosquito net) and read for awhile the other night.  When I turned out the light there were fireflies all over the room but outside the net.  It was a magical light show until I fell asleep!

Murchison Falls

Mud challenge on the way home--
he's about to hit the deep mud hole

My fellow MSFers

After a crazy couple of days at the hospital (seemed like there was a new seriously ill child every time I turned around) eight of us set off for a weekend at Murchison Falls National Park.  As we approached the park we were going up a hill and suddenly saw a big truck and a car side by side, both stuck in the mud, completely blocking the road.  There were many men working on getting the car out which they finally were able to accomplish.  Our driver took a look at the situation and said we should all get out of the car but he thought he could make it through.  It was crazy to watch and at one point it looked pretty dicey but he made it!  At the park we had to cross several streams covering the road, which turned out to be good for washing all the mud off the car, and exciting as water splashed up on the windows!


In the park we took a boat ride up the Nile, which was quite broad and serene at the starting point. Hippos were everywhere standing in the shallow water, and we also saw a couple of crocodiles and a few elephants. Towards the base of the falls they let us off on a trail and we hiked up to the top.  The views on the way were spectacular when I wasn't gasping for breath trying to keep up with the young folks!

We spent the night in the park at a place where hippos come up from the river to graze on the grass at night making walking back to your hut after dinner interesting.

Murchison Falls

  Early the next morning  we took a ferry across the Nile to the area where there are "game drives" (higher concentrations of animals). Beautiful animals everywhere!  We left to come home at noon but the way we came in was blocked by flooding (rain during the night) so we had to go back the long way through the park to another exit.  On the way home we again got out of the car to watch the driver go through the deep mud patch. We made it through but a bit later had a flat tire.  Got the tire fixed and then there was a torrential downpour...  Eventually we made it home.

New roof

New hospital roof--bamboo poles, plastic sheeting and grass

This week they decided to redo the hospital roof as it was leaking during some of the torrential downpours we have had lately.   We had to move patients out of the area they had unroofed and at one point we ran out of beds and had patients on the floor. Many of them bring mats and sit on the floor anyway so they were unfazed by it. The first day they took off part of the roof we had an incredible wind in the morning which is very unusual.  All of our papers went flying making work difficult.  Later in the week we had an afternoon downpour with a different section of roof off flooding that area and much of our covered space as well.  Definitely more challenging working conditions than I'm used too!
As it is late in malaria season the kids seem to be sicker when they get here due to repeated episodes of malaria. Many are very anemic and we did more blood transfusions this week than all of last month despite rain, wind and space!

Nyumanzi Transit Camp

I finally got together a few pictures of refugee life.  When they arrive by bus from the South Sudan border they are taken to the Nyumanzi transit camp where they are given housing by UNHCR (United Nations High Commissioner for Refugees) and MSF provides medical services. Within a couple of months they move to one of the more permanent refugee camps which are mostly divided up by tribe.
Ayilo 1 and 2 are the two refugee camps where MSF  provides medical care for the refugees living there, as well as any Ugandans living nearby that want to come.  Each family group is given a plot of land big enough for a structure or two, a latrine and to grow some vegetables.  The water supply is often a ways away so people carrying water containers is a common site.

Ayilo1 Refugee Camp and women carrying water home

Every month WFP (World Food Program, another UN agency) provides the refugees with beans, sorghum and cooking oil.  Some months salt or soap are also provided.  The distribution is done on a different day for each refugee camp but still involves thousands of people and tons of food.

Women coming back from WFP monthly distribution.
Dinka's are tall and thin!

Most of our food at MSF is purchased by our cooks locally and once a month some is ordered from a store in Gulu 2 hours away.  The food chain here is a bit more direct than at home.  Coming home from work Saturday we pulled over to the side of the road, bought a live goat, put the goat in the back of the SUV and drove home.  Goat showed up on the menu for our evening barbecue with our friends from UNHCR that evening.  Similarly the cooks buy chickens that run around the yard for a few days and then turn up as dinner.  The food here is good, all homemade bread, with very little that is not cooked from scratch. The oranges and grapefruits are green and a bit less sweet. Avocados, bananas and pineapple are wonderful!  Can't wait for mango season.

November

Have been busy compiling statistics for the monthly report that we send to Kampala. After they have reviewed it there they send it on to the Paris office where all decisions about this project are ultimately made.  There are five MSF operational centers in Europe and all MSF projects throughout the world are run by one of these centers.  Currently only MSF Paris and Epicentre (MSF's epidemiology division) are operating projects in Uganda.

One of my jobs is running a weekly hour long educational program for everyone who works at the health center.  This week I asked our visiting epidemiologist/MD, who is a world expert on sickle cell disease, to give us a talk. He gave a good presentation and got everyone in the audience wondering about their genetic status.  Uganda and the west coast of Africa have the largest concentration of people with sickle cell disease and most of the kids that have it here die by age 2.

Some of my patients this week:

-3 kids with severe acute malnutrition (SAM)

-a snake bite—did ok without anti-venom which we have

-toddler with burns on his chest, back and thighs (we get a new one of these every week due to the cooking being done at ground level)

-severe malaria (many cases, and a 17 month old that died from it after poor treatment at a drug shop)

-pneumonia (many cases in kids under 5)

-stroke in an old man (anyone over 40 is old here!)

-8 year old with a huge lump on the side of her cheek.  She's supposed to get surgery in Kampala but the United Nations agency which will pay for it is out of money until January

-2 young boys with broken arms

-women with a miscarriage, malaria and severe anemia (I typed and crossed the blood with the midwife and transfused her)

-adults with asthma with acute attacks from being out of drugs

-9 year old girl with malaria that had had cuts made on her upper arms and forehead to “heal the fever”

-possible TB in HIV+ woman

-child with large abscess under her chin
-1 week old with a large breast abscess

Happy baby recovering from pneumonia

Child with asthma in our "playground"--the dirt

During rounds one of the caretakers of a 5 year old with malaria started crying.  We asked her what was wrong and discovered that at age 14 she had been left to care for 5 younger siblings while her mother went back to South Sudan.  

It's getting hotter here.  Spent Sunday afternoon playing trivial pursuit and watching a movie in the air conditioned pharmacy.  When it cooled off around 6 we had a badminton tournament.  I was paired with our French logistician and we won!