Jason Wong, MD, a family physician from Seattle, Washington, recently returned from a three-month medical mission in Darfur, a region in western Sudan where more than a million people have been displaced by war. He treated severely malnourished children, as well as children and adults stricken with diseases like malaria and shigella. The following is a diary of his Doctors Without Borders/Médecins Sans Frontières (MSF) mission—his second with MSF.
El Geneina, July 23, 2004
El Geneina translates into "The Garden," but I have difficulty envisioning a less likely paradise. It is a desolate and bleak center of commerce ruined not only by war, but also by the unrelenting arid heat. The donkeys here grow thin without a trace of grass to be found. I watched a horse literally starve to death over the course of a week, as he stood rooted in place, too tired to move until he collapsed and died. Our modest efforts with water and a big syringe proved unsuccessful, as he would not take it. I feel sometimes so far removed from the world I know here with the sands, the thatch and mud huts, the camels, and the donkeys' howls.
Eat, sleep, drink, and bathe - came the repeated warnings from experienced volunteers. After a couple of weeks here, I have come to appreciate that remembering to do all four requires conscious effort.
Drinking is the easiest because an unquenchable thirst stays with me all day and all night long, but it is almost getting to the point where I don't notice anymore. Upon my arrival in El Geneina, the capitol of West Darfur, I saw a thermometer indicator flush to the top of its glass prison, which topped out at what I would have previously thought an erroneous high at 50 degrees Celsius (122 degrees Fahrenheit). My glasses are virtually useless, as I can't seem to generate enough friction to keep them on my nose. Sweat drips off me in a near constant stream.
Sleep is the tough one. There is so much to do. Our hospital consists of a feeding center and pediatrics ward. There are approximately 130 kids, almost all between newborn to five years old, spread out in tents and one permanent structure. We have an intensive care unit/general pediatrics ward with cases like sepsis, rheumatic fever, respiratory and gastrointestinal infections, two isolation tents for our three cases of measles and our one case of suspected meningitis, a nutritional phase 1 tent for readapting the body to feeding after severe malnutrition, and then three nutritional phase 2 tents for concentrated weight gain. We have about 10 nutritional related admits a day usually of the marasmic type (skinny, muscle wasted, dehydrated) and occasionally of the kwashiorkor type (swollen edemas, protein deficient).
Inpatient TFC in El Geneina. Photo © Jason Wong
The idea is to establish ambulatory feeding centers in at least three of the largest camps. Feeding programs are kind of the bread and butter of MSF. They do this extremely well and have lots of experience. So, while days are spent in the hospital, nights are spent planning for the next phases. We built a structure to house our first ambulatory center and have been training staff. We will open it tomorrow. The goal is to have these centers open so that kids who are malnourished but doing well otherwise can just come in twice (or maybe even once when running at optimum efficiency) a week for a medical check up, weight monitor, and food distribution. We can then also unload the inpatient center and make the care there that much better by reducing volume.
Alaska native super nurse/field coordinator, Jehn Pahl, measuring MUAC in ambulatory TFC in El Geneina IDP camp, Ardemata. Photo © Jason Wong
Nights are interesting here with wicked winds picking up out of nowhere to whip through the house. Doors and shutters rattle and slam while winds howl down the open corridors and mini sandstorms rise in every room. Prayers heard from the loudspeaker at the nearby mosque echo throughout the day, most noticeably at 5 in the morning. Donkeys also seem to get more vocal come nightfall, contributing an eerie braying to the nocturnal sounds. The team here is excellent. For now, I am working with 2 other Americans - Jen, our very experienced nurse/field coordinator, Jonathan, a pediatrician also on his second mission, Guenaele, a French nurse on her second mission, and Benoit, a French first mission logistician. It is a young team that just gets along great. Everyone inspires each other. I plan to be here for another few days. Once the ambulatory TFC is good to go and a model for the next two, I'll move on to Nertiti to help open up a program there that will include a hospital, clinic, and feeding center.
Sleep doesn't come easily when business always seems unfinished.
Niertiti, July 30, 2004
Niertiti, sitting at the base of Jebelmara Mountain, is beautiful - green and lush with a temperate climate. It remains misty frequently through the morning. The area is best known for its excellent citrus fruits - mainly sweet oranges and humongous grapefruits. Niertiti means, "shattered into many pieces." Apparently, long ago when the first inhabitants of the village came, it was particularly cold and there was a layer of ice underfoot causing the sandy ground to appear fractured.
Abandoned village between Zalinge and Niertiti. Photo © Jason Wong
The name is a fitting one. This was a small village of 6,000 inhabitants in mostly thatched huts dotted along both sides of the river. The war brought IDPs currently numbering around 30,000, which have formed into two camps at the north and south ends of the village. The once picturesque village is now a sprawling overcrowded area with temporary structures and lost-looking people. These people have absolutely nothing. MSF initially came here in March because of a measles outbreak. It was a difficult area to access. Once that calmed down, MSF maintained a small presence with an ambulatory feeding program and mobile clinic that commuted from Zalinge.
As the work goes on, it has become clear that that effort is not enough, so a full program will open. Now we have the pleasure and pain of starting up the program, which is fascinating, challenging, and incredibly frustrating. We dug a hole for a toilet but still haven't had the time to build walls around it. We boil water over charcoal, and try to work through the wee hours of the night by flashlight and candles.
The team is great - Norah, a French nurse/field coordinator, Jerome, a French logistician, and Eric, a Belgian doc. Our projects include an inpatient hospital, an outpatient clinic, as well as ambulatory therapeutic and supplementary feeding programs. It is ambitious, but doable. For now, we are working in tents and semi solid structures including a school. The building is well under way and we should have a more solid base within a couple of weeks. For now, Eric and I are doubling as nurses as we don't have any. We have about 20 inpatients, a clinic with 150 visits/day, and a feeding program with 700 or so patients.
Our IPD (Inpatient Department) is filled with concerning trends including increasing severe malaria and bloody diarrhea. The common concern is the perceived threat of a shigella outbreak. I'm not so sure what makes this opinion so uniform, but it is true that a shigella epidemic could break us. We are not yet ready for it. For the time being, I'm guarding my tiny supply of ciprofloxacin like a greedy hoarder of precious things, slapping away grasping hands while offering helpful alternatives. My mission yesterday was to teach our medical staff the art of intravenous access. I don't think I was successful yet, but it was a good start.
I leave the hospital relieved but worried because we still have no staff to cover the IPD at night. With the curfew, it means that the patients are on their own until morning. But my walk home is generally pleasant. I get followed everywhere I go by laughing and chanting children. At first I was so impressed by their manners and courtesy when every child I saw yelled out, "How are ya?" but I was recently informed that they are in fact saying, "hawaja" which basically means, "white guy."
Niertiti, August 7, 2004
The nice thing about opening an emergency mission is immediately seeing the magnitude of the needs and relatively quick results.
Mother with her child in the TFC being fed by nasogastric tube. Photo © Jason Wong
I've now met almost all of the 1,000 plus kids in our ambulatory feeding programs and feel convinced that the medical activity here has saved countless lives already. We have a therapeutic feeding center (TFC) twice a week for severely malnourished kids (kids less that 70 percent of the average weight for their height or with a mid-upper-arm circumference (MUAC) less than 110 mm).
First they get weighed and measured and registered. Then, they sit in the first observation room where we observe them eat and drink as well as provide health education mostly regarding hygiene and nutrition. They eat their staple food here called Plumpy Nuts, which is basically a fortified and enriched peanut butter. When satisfied that the kids can or cannot eat and drink, they move to the individual check up. Many protocols help us here including the assumptions that all these malnourished kids are deficient in vitamin A, folic acid, zinc, iron, have worms, and have underlying bacterial infections. Other than doling out these standard treatments, we go hunting for additional underlying pathology. Then the kids pass to the pharmacist where they receive their first dose of medication under observation and instructions for the rest of the course.
If there are lingering concerns, we can keep them in a second observation room for as long as we need to help us decide if an admission to an inpatient setting is warranted. The last step is a stop at the supply counter where they receive Plumpy Nuts (2/day). They also receive a 5kg of corn/soy mixture and 1L of oil, which is meant to supplement the whole family. It works pretty well, but it is a big departure from the traditional inpatient TFC where all patients are hospitalized and receive specially enriched milk 6-8 times a day.
The SFC is basically the same thing but for moderately malnourished kids (between 70-80 percent weight for height and MUAC between 110 and 120mm) except without the Plumpy Nuts. But soon we'll be replacing the SFC with a blanket-feeding program in which every child less than five years old will receive a ration of food every 10 days enough for a family of five. We're doing our 1st distribution later this week, which is supposed to be a marvel of organization and logistics.
The flip side of opening a mission is the Spartan living conditions. We still don't have a generator, anything electric, no doors for our latrines and showers, and rain proof roofs. Our log is so busy with the medical structures that our home is going somewhat neglected. Every night we play musical beds trying to position ourselves away from the raindrops that find their way through our thatched roof in different spots every night.
Niertiti, August 11, 2004
There is still no generator, no computer, no buildings or even temporary structures to move our activities into, minimal medical supplies and no medical books at all. It has been difficult trying to train the staff. All teaching has to be done de novo with handwritten instructions and protocols made from memory or my own personal experience. On the one hand, we could say that the mission was probably opened too fast, but on the other, the needs here are real and any delay in opening would have meant more disease progression and mortality. So we struggle on with what we can.
Niertiti, August 12, 2004
I saw myself in the mirror the other day for the first time in weeks and did a double take. It is strange to go so long without seeing a reflection. My hair is growing out. A colleague, who has known me since my nearly bald days, commented that were my hair green, I'd look like a chia head. Though I didn't appreciate the comment, it was kind of true.
Jerome is a super log put into the nearly impossible position to set up an emergency mission single-handedly. He is grace under pressure and has the perfect disposition for an emergency type situation. I'm reminded nearly everyday why I prefer the pace of a clinic visit to an ER thrash. On one of my first evenings at the hospital, I found myself nearly alone when a young boy was brought in seizing in status epilepticus. I ran to the pharmacy and was horrified to find it padlocked. This was early on in the mission when we had some obvious bugs to work out, including a pharmacist who kept all three copies of the pharmacy keys in his pocket even when he went home for the night. I'm not sure what I did, but I may have screamed. In any case, Jerome came running. After heatedly explaining the situation to him, he asked, "So you need to get in here?" "Yes." "How badly?" "Badly." "Like life or death badly?" "Like death imminent in minutes, badly!" He shrugged, pulled out a hammer from his back pocket and knocked the lock off, pushed the door open, and bowed gallantly toward the now open path to healing. I gave the patient a whopper of a dose of Valium and a treatment for malaria and he recovered nicely. I think it was a febrile seizure rather than a case of cerebral malaria, because I have never seen a case of cerebral malaria resolve so easily.
Niertiti, August 13, 2004
Today, I met a man who had been held captive for two weeks and was beaten with whips, iron rods, hot coals and other things he cannot identify because he spent much of the time unconscious. The horror stories are starting to come out now. I've treated a child who was shot while in his mother's arms. The bullet shattered his right humerus to the point where after a month of hiding without medical attention, he has no function below the fracture point due to a massive infection and non-union healing. But what makes the story tragic is that the bullet continued on its trajectory into his mother, killing her quickly, though not instantly. She lived long enough to imprint an image onto her husband's memory forever, which he describes as a look not of pain or suffering, but of utter, inconsolable sadness. I met a teen-aged survivor of a gang rape who cried mixed tears of relief and despair when told that her ongoing normal menstrual period indicated that she was not pregnant.
Eric, who grew very attached to this one. Photo © Jason Wong
Evening rounds are a pleasure because Eric and I can go over all the cases together. While we share the responsibilities of the medical activity in different locations, we typically try to come back to the inpatient tent in the evenings to bounce ideas off each other. Eric is Belgian from Brussels and is also 29. Fortunately for the team, his mother keeps sending big packages of Belgian chocolates that seem to arrive just as we finish off the last batch. He tells me that he has a wild streak in him with more than his share of youthful indiscretions. He considers himself lucky that he only had to repeat one year of school. He was a jock in his youth and when he wasn't contemplating a career in vagrancy, he was considering becoming a PE teacher, but his mother discouraged him. So he began thinking about medicine and everyone from his friends to his teachers and family either laughed at him or tried to talk some sense into him thinking that he'd never make it. It cemented his determination and he became a general practitioner. He's calmed down quite a bit and I have a hard time imagining his reckless youth. This is his second mission, the first being in Iran when he happened to be well placed to answer the December earthquake. He has a strong training and different enough style from me that makes for interesting discussions. Another plus is that he is a worthy chess partner, and though we don't really get to play much, we've found a suitable distraction.
The heat is unbearable with the tent feeling like a greenhouse and the fly situation is out of control. Due to the close proximity of the IDP camps and the poor sanitary conditions, the flies number probably in the thousands. I sometimes have trouble examining my patients because I can't see through the flies. There are just so many that it is futile to try to move enough to keep them off. I have to keep my eyes squinted and talk like a ventriloquist all day long. At the end of the day, my face muscles hurt.