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Letters from Ann Evans, Old Fangak.3rd Kala-Azar Letter from Old Fangak – November 14, 2009 Ann Evans, FNP, DrPH In the small South Sudanese village of Old Fangak, its tukuls stretching along the banks of the Zeraf River, the deadly outbreak of kala-azar rages on, undeterred by time, cow sacrifice, or the dedicated efforts of the local national staff and the white skinned people from afar. Locals say it is the worst outbreak ever. Medecins Sans Frontieres (MSF) says Old Fangak in Jonglei State, with 275 in treatment, is the “most affected” of all areas. We now have more than 450 in month-long treatment that includes daily injections of heavy metals, and more than 600 cases diagnosed since September. With a disease that is nearly 100% fatal when left untreated, it is a virtual race against time. Success lies in early access and appropriate treatment of both kala-azar and the accompanying inter-current diseases of pneumonia and severe vomiting and diarrhea in patients whose immune system have been weakened by the kala-azar. Those living afar are most at risk of arriving too late to be saved. In one 24-hour period we had four deaths, three of which were emaciated children. Two sleepless nights of tender care and blood transfusions were no match for this raging disease. Meanwhile, boats continue to ferry patients in from out-lying villages; others walk for hours or days seeking care. Mixed with the kala-azar, malaria, and TB patients come the full array of other medical conditions. A young man with a strangulated hernia arrived last night, carried for four days by friends and family, desperate to get him here for care. A young mother of three lingered and died from an unknown cause—too sick to travel, too complicated to diagnose here. The scorpions bites bring wailing children into the late-night clinics for numbing injections to stop the intense pain. Aged patients with myriad concerns sit patiently on the ground, waiting their turn. The nights of uninterrupted sleep are few. Most mornings a patient is standing in view of our mosquito net tents with a pleading look and verbal request, waving their blue-card ‘medical record’. Where else does a patient have such immediate access to their provider? I tell Jill there should be at least one barrier layer between the patients and her; she gives me the look that says, ‘right ‘ and smiles at my silly notions about some order to this chaos. Having breakfast and other meals are a priority for me, just a luxury for Jill. I’ve badgered her about eating to the point of mutual frustration, finally resigning myself to the facts that she isn’t wasting away and I’m not gaining ground. Jill says protein is over-rated, as she spreads oil on local white bread and sprinkles it with a blend of spices. I fix a hot vegetarian meal with a protein complement that can be accessed by mid-day and warmed up later, leaving a more nourishing option on the table, so to speak, and vow to stop discussing nutrition with her. The good news includes the arrival of Solidaritas and their building of 10 latrines in response to the mass infusion of kala-azar patients. It would be nice to have one of the lovely heavy plastic caps with foot stations to bring the expat staff latrine up to the standard of the new ones; but that isn’t possible due to the funding source and current policy, which I find both interesting and disappointing. Bureaucracy thrives in the developing world too. We probably don’t need to lock our latrine anymore---who would want to use ours with its rusty, mostly-open barrel with its too-good view of what lies below? Other good news includes the arrival of two very large bags of milk, some F-100 high energy milk, some rk dipstick ‘quick’ tests for kala-azar, some medicines and the promised one-month loan of two Community Health Workers, salaries paid by the loaning organization; still no blankets. We are rapidly going through the 40,000 syringes purchased by Jill. An assessment team arrived last week to see what gaps need filling and what education they can provide to let people know about the epidemic, so we can get more patients in here sooner… The potential of earlier intervention is good; but more patients here???? We encouraged the team to go to the distant villages and survey the situation there, even set up another treatment center elsewhere. Finally a plan is made for their travel; then our boat goes missing, the bolts undone in the dark of night. A training that we would like held elsewhere is planned for here instead. Our staff is upset that they can’t attend and respond by delaying clinic for two hours. Our camping/cooking area is congested with the additional team. The boat is located and returned; we win some and lose some. In three weeks there is ample opportunity to adapt to less than subtle differences in life—like the chicken under the patient’s bed, the dog with nursing sized teats firmly planted in the open air inpatient area, the two goats that sleep in the MCH room when the door is left open, the monitor lizard who surprised me in our cooking/eating hut, and the list goes on. I think the concept of ‘pet therapy’, though relatively new in the States, is not such a new one here. At the least, the chickens eat some of the bugs, but not nearly enough to suit my taste. The goats, however, leave their waste and the dogs make passages tricky at best. Cows wander through the outdoor clinic area, leaving footpath avoidance deposits. The ‘bat’ house now has a few rats, one cat, and a surprise visit from a 4-foot monitor lizard. A locally purchased chicken for a future meal is held captive by its tied feet, squawked at me as I passed it in the house. The name ‘bat’ house no longer seems to apply; someone suggested ‘zoo’ instead. Spitting, although considered bad manners in the States, is a Nuer way of life, an art form that takes place anywhere and anytime, indoors or out, hospital floor included. It’s done with clear definition and precision, generally missing people’s feet, though not by much—such great accuracy of aim. The covered-cough is still undiscovered or not yet in vogue here. I remember that in some cultures it is insulting to deny another one’s breath. Here the spit and cough seem to be the equivalent of the shared breath. Once when I mentioned to Jill my discomfort about the old woman at my side that was coughing on me, Jill responded with an impish smile and a question about my TB skin test status, clearly demonstrating her insufficient sensitivity to my concern; I made a mental note. Each morning the doves rest on the branches above our tents with their haunting call, “What to do; what to do?” I reflect on the healthy looking children, now completing their month-long treatment, children who would not be alive without the intervention they received, which wouldn’t have happened without the financial support from a growing group of friends who continue to respond. We who volunteer are the fortunate ones, for we see the pressing human need, then the successful results of holding death at bay for so many people. I hope the stories I write help you feel more here, more a part of the success in which you participate. Please feel free to share these letters with friends who may want to join this wonderful project. We are so appreciative of contributions to purchase and ship supplies and to pay the very small salaries of the local staff. Since our expatriate staff and those who administer this project all volunteer their time, 100% of donations go to program expenses. Checks can be made out to "CCI" with notation that they are for Sudan, and mailed to Crosscurrents International Institute On-line banking makes it possible to set up monthly donations, assuring an on-going flow of funds to sustain this program. Or one can contribute online, at sudanmedicalrelief.org; however, Paypay does take a portion of those donations. Contributions, of course, are fully tax-deductible. We thank you and remember you regularly as we go about the work here. Namaste, and God bless you all! |
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