February 5, 2006
I had heard the expression 'dressed in rags,' but I had never seen anything like I saw in Dubie. The tattered remains of shirts and pants dangled from children's bodies. I didn't even know how they stayed on their bodies.
I was dispatched to this town in the Democratic Republic of Congo's Katanga province in mid-December to improve the water-and-sanitation situation for more than 20,000 displaced people who had fled fighting near their villages and were now crammed into the town's school house, market, and streets. Doctors Without Borders/Médecins Sans Frontières (MSF) had been running a clinic in the town for more than a year prior to the arrival of the newly displaced people in December. The situation was extremely dire now and there were no other aid agencies around to help. We were on our own.
I was struck by how few old people were among the displaced. You got the feeling that they just never made it to the town. Their makeshift camps were very clean for the simple fact that there was nothing to waste. The displaced families that were fairly well-to-do were eating manioc—a starchy, native tuber that needs to be leeched of cyanide before it's edible—and the really desperate ones were surviving on manioc peels.
In contrast to what I had seen on my last assignment in Darfur, Sudan, where the people had been violently displaced but relatively healthy, these people were chronically malnourished. They had already been in a bad situation for many years before fleeing this most recent bout of violence.
Three-and-half inches between life and death
My first responsibilities were to extend the existing waterline in the town out to the camps and start constructing the latrines. More than a decade ago, the Order of Franciscan Sisters living in Dubie had tapped into a water source deep in the jungle hills some three miles away from the town. I met with the local water committee to discuss the steps needed to extend this system to the camps that my team members were now helping to construct on the town's outskirts.
Given the influx of people and the limited number of water taps available, there was only enough output for five liters of water per person per day—little more than drinking water. In an emergency situation, you would like to have at least 15 to 20 liters to allow people to maintain basic hygiene, which is essential for preventing outbreaks of cholera and other diarrheal diseases. In contrast, a typical US resident uses 368 liters per day, according to the US Environmental Protection Agency.
The previous water-sanitation engineer had assessed the town's water source, but I decided to hike up to it to check it out for myself. The only thing separating the displaced people from life-threatening dehydration was a three-and-half inch diameter, exposed pipe that was snaking through the jungle to the town. Imagine the drainage pipe attached to your kitchen sink and you will begin to picture what was sustaining these people. It was a purely gravity-based system.
It was an extremely tenuous supply. Any interruption in it could precipitate a crisis where people would become desperate within 24 hours. And mining run-off from upstream has rendered Dubie's local rivers undrinkable. With those kinds of pollutants it is nearly impossible to quickly purify the water. We needed to increase the water capacity as quickly as possible.
"You can't even buy a nail"
We immediately set about digging trenches to run the pipes that would extend the water system out to the three different camps, and therefore decrease the distance people had to walk to reach the water taps. But you have to understand you can't buy anything in the town. You can't even buy a nail! The market has nothing in it. They have no beasts of burden—just bicycles.
Everything needs to be brought in either on MSF's weekly air caravan or truck. And I didn't believe roads could be so bad until I got to Katanga province. We carried tools with us in order to reconstruct the roads along the way. After the rains, the roads would wash out. It was really slow going—less than 10 miles per hour. The MSF trucks coming from Lubumbashi, the provincial capital, roughly 200 miles to the south, take a week to get to Dubie.
In about three weeks, we were able to install 2000 feet of pipe and add 5 new water tap stands (with 6 taps per stand) that were much closer to the outlying camps. This increased the daily supply of water to 10 liters per person per day. But I am really concerned that the source may dry up after the rainy season ends.
Preparing for cholera
With cholera endemic in the area and MSF responding to several outbreaks in other parts of Katanga, I helped put together a cholera contingency plan. You need to respond within 24 hours of a cholera outbreak otherwise people can start dying very quickly. With the logistical constraints we faced in Dubie, we had to assume that we'd be on our own for at least a week before receiving any outside help.
First, we determined the inpatient bed capacity needed for the cholera treatment center, which amounted to 100-beds given the size of the population. We also identified an open field where the center could be established. It was isolated from the three camps but close enough that patients could be easily moved there in the event of an outbreak. We ordered all the supplies to establish the center (oral rehydration salts, intravenous fluids, antibiotics, and chlorine solution to disinfect). We also had national staff working in the camps to promote the proper use of the 300 latrines that we were constructing. They were our eyes and ears in the camps to look out for disease outbreaks, including cholera.
Meeting basic shelter and medical needs
In between working on the water-and-sanitation system, I helped the teams distribute non-food items like jerrycans, buckets, and plastic sheeting for shelter to the more than 20,000 displaced people. The medical team ran mobile clinics in each of the camps. They were treating malaria and other illnesses, screening children for acute malnutrition, and vaccinating all the children against measles, sometimes as many as 600 in one day.
By the time I left Dubie in early February, I couldn't help but think how much these people had lost and how it remained uncertain when it would be safe for them to return home.
© 2013 Doctors Without Borders/Médecins Sans Frontières (MSF)