October 1, 2004
Matthias Hrubey, MD, is a general practitioner who runs the Doctors Without Borders/Médecins Sans Frontières (MSF) primary health clinic in Kass, South Darfur, a town whose population has swelled to an estimated 77,000 with the influx of approximately 48,000 people displaced by violence in the region. The MSF clinic opened in mid-July and Dr. Hrubey and a Sudanese doctor see 120 to 200 patients per day. MSF also runs a therapeutic and supplementary feeding program for malnourished children in Kass.
I am a "country" doctor in Germany. This is my second mission with Médecins Sans Frontières (MSF). My first was in a post-emergency project in Sierra Leone from 2002 to 2003.
When I first learned that I might go to Darfur, I thought it could be very interesting to work in an emergency project and I knew there were great needs. I was well prepared to find real chaos and difficult security and living conditions, and certainly a high amount of suffering.
I was told that I would be in charge of setting up a clinic in Kass because the health system was very limited and unable to deal with the huge numbers of displaced people who had arrived in the town over the past year. MSF already had a therapeutic and supplementary feeding program set up, but there was a real need for a primary health clinic.
When I first arrived in Kass, I was quite impressed by the set up of the town. The displaced people here are not living in big camps like they are in some parts of Darfur, but are all mixed up with the residents. They are crowded together in small camps and others are living among host families. There are close to 80,000 people living here, but it still looks like a town of 20,000 because people are all crowded together in the town.
Many people are living in small shelters built out of nothing more than sticks and plastic sheeting. When I arrived there were some camps where people had shelters covered with plastic sheeting, and some people had nothing more for shelter than a one-meter square of plastic sheeting. Whole families of seven, eight, or nine were living in the space of a tent that would hold one or two people in Europe. The living conditions are still very basic.
My first impression was that people were very afraid and concerned about their future and what was going to happen. Everyone seemed to have a story of how they had been forced to flee their home village.
Most of the displaced spoke of how one day or night their village had been attacked, their homes destroyed, women raped, and many men and others killed. People were forced to flee with more or less nothing. They talked about how they had found safe haven in Kass, but were still very worried about how long they would be able to stay here, whether they might be attacked here in town, and how they could manage to get enough food and the few things they needed to survive. People from the same village tried to stick together as they fled and now the camps in Kass are named for the villages that the people living in them came from. It gives them some sense of security to stay together in the semblance of a social structure that they know.
BUILDING THE CLINIC
Getting the clinic set up was a challenge. We started preparations as soon as I got here by identifying a site for it and then designing and building a structure with local materials. We ordered the medicines and supplies we would need and began hiring staff in preparation for opening. The biggest difficulty wasn't building the clinic, but trying to find the qualified medical staff and translators we would need to run it. We decided to start small by building just one local-style stick and straw structure called a rakuba. We opened with this one building, some tables, benches, and mats, and a small pharmacy.
People were so desperate for health care. Everybody was asking for us to open a clinic as soon as possible. They had watched us building the clinic and everyone in town knew that we would be providing medical treatment, so on the first morning that we opened in mid-July there were about four or five-hundred people waiting outside the door. We had a very difficult time controlling the crowd because everyone was so desperate for medical treatment. It took us quite some days to come up with a system for controlling the crowd and organizing the flow of patients into the clinic. We even had to close for a half day because the crowd was so big that people were beginning to step on each other.
We opened the clinic for everyone. Internally displaced people, residents of Kass. We treat anyone who comes in. After a bit of time, the message began to get around and we started to see people coming in from as far as 20 miles away for treatment and more and more people from the host population.
In the first weeks we saw up to 200 or 250 people in a single day. There was just a local doctor and myself at the time. We worked ourselves to the limit each day, but still we have been forced to send as many as 200 people home at the end of the day. At least if you work your hardest, you know you've done the best you can even if you still have to send people away. It is not a good feeling when you have so many people waiting that it is even difficult to be able to pick out the sickest so you always know that among those you are sending away are some really sick people who may have waited two or three days just to see a doctor. We've had people lining up at two or three in the morning just to be in front of the queue when the clinic opens at eight in the morning.
After working for a few days, we realized that we didn't have enough space, so we constructed more rakuba and reorganized the clinic to make the flow of patients more efficient. We're still constantly working on improving our services and every day there is something more to do.
It was clear very early on that we needed an observation area for patients to stay in during the day so that we could give them injections and intravenous drips and keep an eye on them. At first they were just lying on the floor between the consultation rooms, but now we have an observation rakuba with 9 beds as well as areas for doing dressings and administering oral re-hydration salts. We've also set up two rooms for use by a new midwife who has arrived to set up an antenatal program as we have seen many pregnant women with problems, but were previously not able to offer them many services. Now we will be able to.
FEARING THE NIGHT
The biggest challenge at the moment is that we don't have any overnight facility and have to send patients home at the end of the day. There is a ten o'clock curfew in all of Kass and the security situation still makes it too dangerous for us to stay in the clinic overnight and our staff is still too limited.
So, we have no choice but to send patients home at the end of the day, even if they are very sick, without any supervision and hope that they come back the next day. Unfortunately, they don't always come back and it is terrible not knowing what has happened to them. Sometimes we hear later that they have died or they didn't have the money to pay for a donkey cart to bring them back to the clinic.
For example, we had a 16-year-old boy who was very ill with cerebral malaria who arrived at the clinic in a comatose state at 3:30 in the afternoon. All we could do was to give him injections and send him home not knowing what might happen to him. His family was not from the town and they had to stay with friends who had some shelter. It was a great relief to see him in the clinic the next morning sitting up. Three days later he could walk and eat again. That was a very positive outcome, but it is not always like that.
We also had the case of a one-and-a-half year-old child who had severe pneumonia and had stayed the whole day in the clinic in a very critical state. Still we hoped that he would make it overnight. But the next day when he didn't show up, we started to suspect that something might have gone wrong. The next day his mother came and asked me for a death certificate. The child had gone into convulsions and died at two in the morning. Because of the curfew, she was unable to call anyone or go anywhere. You never know, but if we had been able to keep the child overnight and give him a glucose drip, he might have made it. I am almost sure that he would have. Unfortunately, this is not the only example I have like this.
PREPARING FOR DARFUR
In Germany, I work as a general practitioner in a country village. I think it has prepared me well for the work I am doing here with MSF in Darfur. Even in a village at home you have to have a broad medical knowledge and be able to do everything, diagnosing mild to severe problems and even doing small surgeries. The big difference is that at home, there is always the possibility of referring a patient to a hospital or a specialist when you don't know what to do anymore. That is something that you just can't do here. You have to deal with all the problems that come your way. You have to improvise all the time. You don't always have the drugs or equipment you need, but you still have to treat every patient that comes to see you the best that you can.
On a typical day, I get up at seven to be in the clinic at eight o'clock to take care of some administrative duties and then begin doing consultations right away. Now we are usually seeing about 150-180 patients per day. If I do only consultations all day, I see about 70 patients myself, but now with the observation area I also see the very ill emergency patients who come in. Usually we work straight through until five or six in the evening. Only this week did we start to have the time to take a short lunch break which was just not possible before.
We treat a range of problems from aches and pains to really life-threatening conditions. The most common ailments we see are diarrhea, respiratory infections, and also a lot of stress-related diseases like gastritis. There are also a lot of old wounds, skin infections that have gone untreated, as well as chronic illnesses that have never been treated.
Today a little boy came in who was severely anemic and in such great pain he could barely sit on the bench in the consultation room. His mother told us that he had suffered from severe attacks of pain that lasted from three days to a week several times a year. I believe that he has sickle-cell anemia. In Germany, a child in this condition would go straight into intensive care in a hospital, be given a blood transfusion and special medicines to reduce his pain and build up his blood. But here all we can do his see him for ten minutes, give him some medicine to get him through this attack and then send him back home again. Maybe we will see him again, maybe not. His mother told us this was the first time he had received any treatment at all for his pain.
SCREENING FOR MALARIA
Now that the rainy season is ending, we are seeing more and more cases of malaria. There are sometimes children who have been waiting outside in the line who we can pick out when we do our screening because they have a high fever and diarrhea and are very sick. Often they can't breast feed or eat any more. We do a quick test and in ten minutes we can tell if they are positive for malaria or not and start them on artemisinin-based combination therapy (ACT), an effective treatment immediately.
I know from my past experience in Sierra Leone that in three or four days they can be very normal children again, playing and eating. But if you didn't treat them they would have a high chance of developing cerebral malaria and dying in a few days.
From what people tell us, the biggest challenge for people at the moment is that they still feel very insecure and don't know what will happen tomorrow or even next week and this really puts a lot of stress on them. Our feeding programs and the general food distributions have at least improved the food situation a bit, but knowing that everyone is fully dependent on outside food and assistance, it is hard to tell what is going to happen and the situation is still very fragile. The hygienic conditions are also still very poor although we've managed to make some improvements here by building latrines and setting up safe water points, but it is still very basic.
It is sometimes difficult to tell what is troubling a patient because of the cultural differences in the way people here express their feelings, but in addition to many severe medical problems, I think we are also seeing a lot of health problems and complaints that are related to the stress that people are under. People are extremely worried and often depressed about what will happen to them in the future and I believe that this can really affect their health.
Without a translator it would be very hard to do a good job because I didn't speak any Arabic at all when I arrived here. And then there are many people who only speak the tribal language Fur. I've picked up enough words of Arabic to do a basic consultation, but I would still be at a real loss without a translator. Right now I have a very good one. He lives in Khartoum, but his family is originally from Darfur. When he heard the news about what was happening in Darfur, he decided that he wanted to come here and help and that is how he ended up with MSF. We have a great rapport and he is totally dedicated to the work we are doing. He tells me every day how important it is that we are here.
People really appreciate MSF being here. Many people tell us that this is the first time that they have been able to see a qualified doctor and receive treatment without regard to their origin or ability to pay. They also feel very strongly that our being here is important for their security. A lot of people have told me that they don't know what might happen to them if we weren't here and there were no international witnesses to what they are going through.
The people here are extremely friendly and very open, so it is very nice to work with them. It is very sad to see that often the atmosphere is quite depressed and you hear only from stories that people tell us of how it was before the war; how they liked to sing and dance. But at the moment there is nobody singing or dancing. But when people open up a bit to you, you can feel how lively they would be if they didn't have so many worries.
At the moment I am living in the pharmacy with about thirty boxes of medicines and sharing a room with a visitor and some mice. It is quite difficult because you really lack any privacy and you can't find a place where you can just sit in quiet. At the beginning it was big problem to find food in the market and every day we ate the same thing and were even eating high-energy nutritional biscuits from the feeding center when we were really busy. But we've been improving the living conditions little by little.
My original plan was to stay here for six months until the beginning of January, but I might extend for a couple of months. When you build up something from the beginning, it is especially hard to leave it. The work is very interesting and although it can be very frustrating at times, it is also very motivating. You can see everyday that it makes a real difference that MSF is here.
© 2013 Doctors Without Borders/Médecins Sans Frontières (MSF)