May 04, 2012

South Sudan 2012 © Cédric Gerbehaye

A father and his malnourished son at the MSF hospital in Gogrial, Warrap State, South Sudan.

Dr. Ana Maria Guzman, a physician and clinical researcher from Maryland, recently returned from six months overseeing medical activities at MSF’s clinic in the town of Gogrial, in South Sudan’s Warrap State. Below, she talks about her time in Gogrial, where MSF has worked since 2009 as the sole organization serving the medical needs of nearly a quarter of  a million people in the area.

The Clinic
I was an MFP, the medical focal person, so pretty much all of the medical activities were under my responsibility, including supervision of about 15 expats and 80 to 90 national staff. I had clinical responsibilities as well. Then one of the midwives resigned, so I had to perform another job, which was supervising maternity, which was kind of exciting because I am trained in obstetrics. I was also in charge of some of the emergency room, so any case the clinicians were not able to handle I went and helped. The hours were very long because if you have any coordination position, you’re on call, and if you’re medical, you are the back-up of the back-up. There is no rest. Every day I would walk around the primary health center to see how many patients came in. Then I’d go to the inpatient department, check the situation, see anybody in critical condition, then go to maternity. Then we’d start the morning briefing with the staff on duty, and then we’d have our own medical briefing where I’d give a summary of the activities that people needed to accomplish.
In rounds I made sure that everything was okay and that the national staff was learning at the same time. We are there to make sure they are able to handle things once we leave. Whatever I did, I made sure that somebody was looking at what I was doing, so that when I left somebody would be able to take over. The idea was to implement some things every day, making sure things get done but also that we’re seeing as many patients as possible, and providing good quality of care.
There was also the matter of putting out little fires if people sometimes didn’t show up, because in South Sudan that’s a big issue with human resources. So you have to find ways to cover all the services if people don’t come.
The Patients
You see a lot of spear wounds, bullet wounds, stabbings with knives. There are also traffic accidents. And a lot of people were coming in with cutaneous anthrax. We reported this to the Ministry of Health (MOH), and the MOH had to report it to WHO [World Health Organization], but we didn’t see them doing anything about it, so we went to investigate on our own in a village about two hours away. It turned out that the cows had started dying but people still ate the meat. Afterwards they just threw the carcasses in a pound near their village, which was probably why the animals kept getting sick and why there were all these cases of cutaneous anthrax. The cows in South Sudan are very precious. When we told one of the elders in the village that they had to burn the carcasses he was not happy and said that was a waste that they could not afford.
I had one very bad maternal case, too, one of the most difficult cases that I have dealt with. It was a woman who came all the way from Khartoum. She had been in the MOH hospital in Kuajok for about 10 hours and then they just dropped her. The ambulance from Kuajok drove to Gogrial, which is about one hour and a half if the road is good, and they just dropped her, basically just opened the door and told her to get out. Obviously there was no referral, and we had no specifics on how long she had been in labor, what she was she given in the MOH hospital, nothing. So we started putting fluids in her, making sure vital signs were normal. Everything was okay for about 20 minutes and then she started crashing.
 Unfortunately, the baby and the mother both died. It turns out she had been in labor for about 14 hours and had only been given saline in the MOH facility. This was her eighth baby, which put her at greater risk.
Looking Back
There’s no question that there is a need for MSF to be in Gogrial. But while I was there, I wondered if maybe we are creating a gap in the health system, because it seemed like the MOH relied completely on MSF for vaccination campaigns, for anything that it had to do en masse for the community. Of course the project will have a lasting impact for a lot of the patients, but I don’t think the authorities consider the fact that MSF will not stay there forever.
It was a very, very difficult mission and I think I was surprised on every level. I was surprised in a nice way by how the international staff that I worked with became more confident and also the national staff, once we started implementing a lot of the changes and making sure their work situation improved, how thankful and how willing to do the work they were.
Now I’m back at work in the US. It was kind of hard going back to normal life. It’s very difficult to describe how different it is. It just makes you realize how lucky, lucky, lucky we are. I think South Sudan is one of the hardest missions that MSF has, and I think everybody who has worked in those missions deserves a lot of credit. It is a very hard context and there are so many times you want to say “Okay, I’ve had enough.” But once you leave, you will never forget South Sudan.

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