August 1, 1998
Southern Sudan: Testimonies of a Human Tragedy (Part 2)

The following are testimonies collected by Samantha Bolton, Press Officer for Doctors Without Borders, during her visits to the organization's feeding centers in southern Sudan in early August. Text in italics is her commentary.

The teams in the field are facing a variety of problems. A real emergency has kicked in. Everywhere adults and children are dying. The teams are keeping track of mortality rates. In Ajiep, there are at least four people responsible for counting the dead and reporting back each day. Doctors Without Borders has also organised a cemetery and for the dead to be picked up as many have no relatives or the relatives are too weak to do anything. Traditionally the Dinka dead are buried in their village compound so that the spirit rests with the family, but because these people have fled their homes and have no shelter, it is not possible for them to do this.

The vast majority of the problems are due to logistical constraints. The missions need a lot of food for the feeding centers. But all of this requires heavy supplies which need to be flown in. In addition, most of the missions were started from scratch, so all the initial building materials, such as water containers, had to be flown in.

"A lot of children are losing weight - some have to walk for four days and many are sharing their ration with the whole family."

— Anthony Ajanga, Kenyan nurse, 29 years old, Ajiep mission

"In the therapeutic feeding center we were feeding the kids seven times every 24 hours: five times during the day and then twice at night. But then we noticed that the kids were not really putting on as much weight as they were supposed to. We were concerned about what was happening at night, as we could not be there to monitor properly, so we cut down to five rations, but still giving them the total calories of the seven feedings. Then they started putting on weight."

"The hardest thing is that I have been here three weeks and the emergency is still getting worse. When you are in it every day it is difficult to see if things are getting better. There are so many logistical constraints.'

"I am responsible for keeping track of the dead. One of the main problems is that people are too weak to bury their own dead so there are a lot of dead bodies lying around. We have arranged a cemetery and they get buried every morning.'

— Carine Daenens, Belgian nurse, Ajiep mission

"Lots of people have died so there are many orphans. Some of the kids who come in the feeding centers are so much thinner than those accompanying them. We have the feeling that some of the starving orphans are temporarily adopted by families so that they get a ration. It reminds me of Somalia, people are really desperate to feed their families and will do almost anything to survive."

"Most of the people here are suffering from marasma which is pure and simple wasting, not from kwashiokor which is a protein deficiency. People are wasting away and simply need to have their strength built up. They don't need complicated diet balancing."

— Marie Jo, French nutritionist, Ajiep mission

In the therapeutic feeding center in Ajiep, long queues of dying, dehydrated and famished people wait to be seen and to be treated for whatever illnesses they have in addition to starvation. Dr. Lou sits in the sweltering heat, in a mud tukul (hut) and examines the patients one by one. She puts the babies on her bare lap against her chest, flicks away the swarms of flies and tries to placate their cries. In the 30 minutes I was with her, two babies urinated on her and one had diarrhea. Dr. Lou just lifts them up and smiles and carries on with the questions. Every question the doctor asks has to be translated by an interpreter. Most of the mothers only answer in general, not in specific terms, for example,"When did the fever start?" "Today/yesterday/few days ago." Time is measured in night and day and days, not hours. Likewise, many do not know how old their children are.

Beatrix and Elizabeth are taking turns preparing the needles and vaccinating the lines of screaming skinny children. Their table is in the shade of a gnarled tree and a watchman makes sure that no one skips the never-ending line and that no one comes back for seconds. Most of the children are so thin that they look like their heads with their little old man faces are too big for their bodies. The skin on their arms and bottoms hangs in empty flaps, making it painful to inject. Some are too exhausted to even cry.

"Right now these people have a big problem because over the last years they had no good harvest and this year the rains were bad. The rains have increased."

"If you sit here all day and work all day you still don't finish. It is difficult to always maintain the high standards we would like because we have to work so fast and do so much."

"Then there is the problem that many of these people have fled the fighting and have lost their vaccination cards, so we are revaccinating them even though some say they have been vaccinated, but don't know against what. Also, it is very difficult to be strict about only vaccinating children under 12 or 5, as many of the children and their parents don't even know how old they are. So we make a visual estimation and are flexible so that we don't miss any."

— Beatrix Opiyom, nurse from Kisumu, Kenya, 40 years old

"It is really shocking. People lack the most basic things in life, but somehow out of their misery they still manage to smile and laugh. I thought it would be hard to come here...sometimes it just feels like a death watch. Everyday we enter the feeding center and there is at least one dead person lying there. Yesterday we had two inside and two outside."

"I had no idea how intolerant people are of the cold. I am relatively well fed and I only need a sheet at night. They need a blanket and then it rains and they get wet and because they are weak and wet and cold so they catch pneumonia and die. Everyone is coming in here with chest infections."

"Where I come from people have no concept about what is going on here. The worst part is when a small child looks at you and points to his wrists and says he wants a malnutrition bracelet so that he can be admitted to the feeding center."

— Lisabeth List, nurse from Dallas, Texas, 30 year old, Panthau mission

After being vaccinated in the shade of the tree, the screaming teary children line up to be measured and weighed. Many of the small ones continue screaming as they are laid on the floor, knees pushed down, and stretched out to be measured. Els is the nutritionist organizing the weighing and measuring.

"I feel terrible about the kids. It feels like playing God. These peoples' lives depend on us, the decisions we take, which depend on what we have, which depends on the planes, which is not enough. We are desperately waiting for more tents and more supplies to open up more centers, but there is a problem with the flights."

"There are at least 3,000 kids in our feeding center who are all under 80% weight for height. So we want to start with wet feeding so that the kids get the full ration immediately instead of getting a partial ration shared between the family. The easiest way to do this is to feed them milk and porridge."

"We are trying to improve the medical care but at the moment we are using most of our capacity to just keep people alive and build up their strength by feeding them so they can survive. Once they have a bit more energy and are not dying from hunger, we can concentrate more on the medical."

— Els Adams, nutritionist from A'dam, Holland, 42 years old, Panthau mission

When we arrived, the team members in Panthau were still trying to clean out their tents and to dry their clothes and belongings. There were huge puddles everywhere and the health centers stood out like islands in a sea - surrounded by slushy mud and water. As the logisticians were busy doing other things, the two Dutch nurses built a wall of sandbags around the edges of the tent and were treating patients.

"It is terrible to have so many malnourished children. At my first job in Africa, I worked in Zambia as a district nurse. I thought rural health was basic there, but here there is really nothing. No health centers, no hospitals, no roads, nothing. It is difficult to believe that a place like this could exist in 1998."

"When you have never been to Africa you can't imagine what it is like. Then you come here and you never want to leave because you realize how much there is to do."

— Linda Van Huis, nurse from Looscrecht, Holland, 56 years old, Panthau mission

"The reason why so many people are hungry is that last year the rains were bad and this year there were no seeds. People were hungry and ate many of the seeds they were supposed to plant, and then they had to survive on leaves and wild fruit."

"So many people have died. In my immediate family, since June, eight children have died and six remain."

— Salvatore Wal, nurse at the therapeutic feeding center, originally from Thier Wet, Sudan, recently fled Wau, Panthau mission

"In my immediate family, nine children and one mother have died and only two remain. We were living in Wau and then the fighting happened and we had to run away. My family is one and a half hours away from here walking."

"In this area, before Doctors Without Borders came here, there was nothing. Sick people had to walk very far. They had to walk all the way to Wau which is eight hours away on foot even just for a health center. People will stay here for a few more months. They depend on what they can find or are given. They have no choice."

— Paul Aken, Head nurse, from Wathmuok, Sudan, Panthau mission

Although most of the missions are emergency missions to deal with the famine, some missions in Bahr El Ghazal, like Mapel, continue to run their long term training and general health programs. Last week, ten nurses graduated in Mapel from Doctors Without Borders nurse training program. Because of the emergency, many of the more experienced international staff from the longer term project are being moved into the more difficult emergency missions. Margaret had just been moved from Mapel to Bararud, the most dangerous mission in Bahr El Ghazal when I spoke to her.

"When I arrived, the impression I got was that this was not a war zone, but a village where people needed primary health care and education. In Mapel there was a higher level of health education than here because there have been more NGOs working there. When we started our training program, we found 40 TBAs (Traditional Birth Attendants) who had some sort of training. We ran a refresher course and still we continue to discuss the problems they face: breach births, bleeding from delivery, first aid needs and so on. It is also very difficult to find women to train to be nurses. To train to be a nurse, you have to have a minimum of education and some basic English. Here most of the women have neither."

"In Mapel, it was very quiet. It is only when I am here that I realize that there is a war. When there is an attack on the village, we get the wounded. If the security is really bad then we have to run into the bush. The only way out of this place is by plane."

"When we get the wounded, we check if they will need an amputation or surgery. Then we stabilize the patient, start them on a course of antibiotics, immobilize them and then radio Loki to see if there is a plane passing by and to see if we can refer the patient to the ICRC hospital in Loki."

— Margaret Kariuki, midwife from Kiambo, Kenya, 40 years old, Barurud mission

"This is my first mission with Doctors Without Borders and I really did not know what to expect when I came here. We have a small but good team, but the living conditions are very difficult. We have no electricity and no light, no music - just the short-wave radio to hear the news-and we have very little supplies. There are very few fresh vegetables or fruit, just lots of pasta and tinned tomatoes."

"Even worse, there are very irregular food and supply deliveries for the patients. We have a small pharmacy in a mud tukul, but we do not have enough to do all the things we need to do. We are always waiting for the planes or waiting for things to get better for the people we are trying to help. There is a lot of energy and willingness to help, but we are blocked by the logistics and by the huge needs everywhere."

— Grazia Marcianesi Casadei, nurse from Rome, Italy, 30 years old, Achumchum mission

"To keep track of the dead, we encourage people to report them by giving them an incentive. When someone dies, they come over and they give us the details and then we give them a food ration. There are a lot of people dying around here. Around 10/10,000 per day are dying and twice as many in the under five age group: 20/10,000 per day. We have around 2,000 children in the feeding program. The children are often the first to die because they are traditionally among the most vulnerable in any population. Just the fact that so many adults are dying is really bad news. The other day I came into the feeding center and there were four dead adults lying on the ground, who had died during the night."

"The first couple of days when you come in and see what is happening here, it is absolutely horrible. But then you get used to seeing it everywhere and just get on with the work and do your best."

"The worst thing is picking out the most starving. They all need help. But we have to help those who need help the most. It is a question of whether they look starving and could last a few days or if they look close to death and have to be helped immediately."

"I saw a kid on the airstrip today and his ribs were only sticking out a little bit and I thought wow, this kid looks pretty good then you catch yourself and realize that your perceptions and criteria are all messed up because of the extreme situation here."

— Karen Kasan, training coordinator, from Tampa, Florida, 37 years old, Panthau mission

"I have been working here throughout the 1990's, and this really is the worst I have ever seen in Sudan. Everyday outside our feeding centers, all the starving and sick people line up. They all need help and are asking for help. They all line up and we have to pick out the worst-those in most urgent need of treatment. But even so, the ones we leave behind look terrible. The worst thing is that in these conditions you really look twice and are shocked when you see a healthy looking kid."

— Stephanie Maxwell, nutritionist and medical coordinator from Dumfries, Scotland. 33 years old

© 2009 Doctors Without Borders/Médecins Sans Frontières (MSF)