July 20, 2008

MSF nurse practitioner Deborah Van Dyke helped run a medical program in the remote village of Pibor. Here she describes the experiences that affected her the most.

Sudan 2006 ©Gloria Chan/MSF

People wait to receive consultations in MSF’s Pibor medical compound.

FIELD JOURNAL

Deborah Van Dyke, a nurse practitioner from Vermont, was in the village of Pibor in South Sudan’s eastern Jonglei State from January to April 2008, overseeing all of MSF’s medical programs there. She also trained locally hired staff to take on increasing responsibilities, responded to medical emergencies, and prepared a mass trauma triage system for an area where, three years after the official end of the North-South civil war, health structures other than MSF’s do not exist and peace cannot be taken for granted. Here, she describes her experience.

In addition to running the main medical facility in the village of Pibor, we also ran two clinics that were located in opposite directions from the village. To support the staff working at these outposts in Gumuruk and Lekongele, a nurse and a logistician would leave Pibor to visit them weekly, driving an hour and a half over a rut-filled road that was difficult to navigate in the dry season and impassable in the rainy months, when MSF used a boat instead. Some patients always traveled with them, so in the morning, I got everyone ready and made sure they were boarded, along with the necessary drugs and vaccines, to be on their way by 7 A.M.

The people of Pibor didn’t seem to mind the horrible state of the roads. They walked where they needed to go, but the lack of infrastructure made supply transport difficult, and basic health care was beyond people’s reach, except where MSF offered it.

I spent the mornings on medical rounds at the main compound’s inpatient department. Then I would survey the tuberculosis program and the outpatient department, which included a therapeutic feeding program for malnourished children. We saw twice as many cases of malnutrition this year, compared to last, because it had been a particularly bad harvest. At any given time, about 100 patients were in the program.

It’s hard to describe my work in Pibor because telling it day to day doesn’t give the sense of all the details involved and everything that’s happening at once. We were constantly training staff; I was reorganizing the pharmacy; and then there were the medical emergencies.

“Human love in the face of great challenges”

We had many ordinary success stories of malnourished babies gaining weight, good pregnancy outcomes due to timely referrals, and patients treated for malaria, tetanus, or snake bites. To me, though, the most memorable patient stories are not always those with ideal outcomes, but those that demonstrate human love in the face of great challenges.

I think of an eight-year-old girl brought to us too late, already with brain damage possibly caused by meningitis. During her month at our facility, we treated her with antibiotics and taught her father how to exercise her limbs to prevent contractures. He never showed discouragement or loss of hope. He spent the days putting her limbs through the motions, holding her all the time, carrying her to the latrine, and tube-feeding and washing her. Eventually we took them back to their village near our outreach clinic, with her feeding tube still in place. They will need to continue the same care at home for the rest of her life.

We admitted a boy, about the same age, to our inpatient department with an enlarged liver, wasting, and a bacterial disease called brucellosis. He required a blood transfusion, and his mother was the only relative nearby. The others lived an eight hours’ walk away. To make sure that he had two possible blood donors, someone left in the late afternoon to notify the family, and another relative arrived by morning. He had walked through the night to help save this little boy’s life.

Preparing for the Worst Scenario

During my time in Pibor, we received patients wounded from violence no more than a few times a month, but we can’t take this measure of stability for granted. When I left, Pibor was surrounded by armed Sudan People’s Liberation Army (SPLA) troops, and a disarmament process was looming.* In other towns, disarmament has led to heavy fighting, so we could receive hundreds of wounded if it happens there.

For that reason, we set up a mass trauma system, so that staff will know what to do if that happens. We did a run-through so that the person following me as the next medical focal point could see it in action. I divided the medical staff into color-coded teams; and the cooks, cleaners, and logisticians played the role of patients and patients’ families. I told them, “I’m going to assign you a problem, and you need to be very realistic, acting like it’s your problem; and all the family members need to be unruly.”

Everyone really acted his part and it went great. The new medical team leader and I did triage, giving colored cards to all the so-called patients. Stretcher bearers brought them to different places in the hospital, and medical staff laid the supplies on the bed of each patient, to see if they had everything they would need. In the following days we filled small gaps in the plan. For example, there were many fractures in the practice and the local staff realized they didn’t know how to do casting, so we trained them.

The future of the project just depends on what happens in southern Sudan in the lead-up to the referendum between the North and South, now set for 2011. In the meantime, we can continue to train staff and prepare for what we can.

* Disarmament began on June 4, and at the time this story was published, there was no resultant violence.

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