Leaving Juba

There is a naked man who roams the streets of Juba. He must walk for miles as I see him in at least 2, sometimes 3 different locations a day. The sight of this filthy but seemingly happy young guy striding among the land-cruisers, motorbikes and stray dogs this week reminded me that living in Juba and becoming accustomed to these daily quirks has been a truly unique opportunity. Only in Juba would I have got to experience the bizarre dichotomy of a working day surrounded by filth, stench and heat (the real world) and evenings in clean, cool, air-conditioned compounds, bars and restaurants (the NGO world). In Juba I received the most interesting text-messages. Security alerts warned me to avoid areas with ‘heavy SPLA/police presence’ that I was invariably sauntering through at the time. Then there were messages from the reality TV show ‘South Sudan has Talent’ offering me the chance to text-and-save rap-artist Chol Deng or Mariah Carey coverer Achol Deng. And public health messages reminded me to seek medical attention if I 'complained of a white worm exiting the body'. Daily life was never dull with excitements such as ‘snake-woman’ occurring. This was a woman who actually turned in to a snake after stealing money from her husband. This was to the absolute delight of staff on the ward and our driver (whose brother had a photo of it on his phone) and causing crowds of people to swarm around the police station where she was being kept. Some grumpy NGO-workers thought this a ridiculous story but I was a believer, and you will be too once you see the video on youtube: 

 http://www.youtube.com/watch?v=Fueb6XA-YHI

 (yes, I was also a bit confused by the strange noises and the blonde hair). 

We were relieved to receive the reassuring text-message informing us that snake-woman had been evacuated by a UN helicopter. 

So, there are certainly aspects of Juba-life that I will fondly miss. These don’t entirely exclude working life at Juba Teaching Hospital, although an NHS job has never been (and will likely never be) such an attractive prospect. I have very mixed feelings about leaving JTH. On the one hand I’m relieved to be escaping the daily exposure to levels of suffering and poverty that I have found hard to stomach. On the other hand I feel guilty that I can escape, leaving my colleagues to carry on with little hope of improvements in the coming months. I have, of course, learned a lot. And I can only hope that while I have not had any impact on the real problems afflicting the health system, I may have shown a couple of young doctors how to treat patients in shock or DKA and encouraged nurses to see that saving lives is possible.

When I hit the luxury of pavement-lined streets, cardboard cups of coffee and sitting on a sofa watching Wimbledon it will be with a big sigh of relief. The challenge will be to go on being moved by the need I’ve seen, while living in a world where I will likely forget the reality of life in Juba as it carries on with out me - with its huge health care challenges and a roaming naked man.

Living it up in South Sudan

Tending to the basil plant

White water rafting

Real life

The Ward

The outside ward

New TV screen in the waiting room (What?)

Assessing patients on the floor

Blood tests

Angelo doing his bottle trick again

When healthcare isn’t free…

Of the pitiful amount of Arabic words I’ve learned to use over the last 6 months working in South Sudan, ‘mafi’ is the one that will stick with me for life. It basically means ‘nothing’ and out of the words for pain, diarrhea, vomiting, blood, sorry and ‘may I’, I’ve picked up, it is probably the most commonly used on the Emergency Medical Ward. At first it was a reassuring word: ‘mafi mushkala’ or ‘no problem’ would say a nurse when I asked how the patients were (until I learned that the nurses had no idea how the patients were). Then it became irritating: ‘mafi money’, when I asked for a blood test, or ‘mafi co-patient’ when I asked why someone hadn’t been washed or taken for xray. Recently this word has begun to haunt: ‘mafi antibiotics, mafi IV fluid, mafi bedsheets, and then yesterday, ‘mafi gloves’! I’ve come to realize, it is very difficult to save lives with mafi. Having grown up benefiting from and working in a health care system which is entirely free at the point of care, it is disconcerting to be working with the world’s poorest people and charging for almost every aspect of their care. This feels awful when a patient has relatives, who come from miles pooling the village’s resources to pay the inflated prices for drugs and equipment. When a patient comes on their own, with nothing, it’s worse than awful. A young emaciated girl was brought in unconscious by her brother this week. She had a long history of watery diarrhea, weight loss and fungal infections. She was someone I didn’t need to do an HIV test for to know her status, but when I did the cause of her demise was confirmed. I had just done a teaching session on ‘an approach to a patient in coma’, so started quizzing the young doctors on what they should do. She would need an IV line, a drip set, IV fluid, strong sugar solution, blood tests, a spinal tap, a chest xray, antibiotics, antifungals, anti-malarials, an NG tube and a urine catheter… all of this coming to the equivalent of £18 per day of treatment. The brother slunk away, never to be seen again. Five days later, we’d begged, borrowed and bought some of her drugs, but I realized that no one had touched her but us. Her death was as undignified as you can imagine. Doctors don’t save lives at Juba Teaching Hospital. They help a bit, but what is key to survival is having a wealthy, willing family by the side of your bed to buy and administer your care. Business is booming down the road however. Pharmacies and laboratories are springing up, hoping to benefit from the increasing existence of ‘mafi’ in the hospital. I popped in on the brand new ‘Advanced Laboratory’ that opened this week. Proudly they showed me their price list: liver function tests were on offer! – 200ssp (that’s about £25, and 50ssp cheaper than the one down the road). But although a bit of competition might help bring down the prices, they are still unaffordable to the people that need them most. While slowly slowly, South Sudan will improve its public diagnostic capabilities, its logistics systems and drug supply many patients will sadly lose out without the benefit of some cash in a family-members hand when they arrive to hospital. Meanwhile, I will endeavor never to take for granted the marvel of the NHS; there may not be mafi mushkala, but there is free healthcare, free IV lines, fluid, antibiotics and gloves, free complex imaging, procedures and therapeutics I can’t even remember exist any more, and health-workers who do their jobs 24/7.

Lifeskills

I like to think that living in a one year old country has given me certain survival skills that will equip me for the rest of my adult life. How to clean out one’s nostrils for example, after a day breathing in 60% faecal air. Or how to walk in one-foot deep mud and still turn up to work looking respectable. And how to avoid ingesting parasites in the shower, salmonella in eggs and E.Coli on carefully prepared salad. One of the compound cleaning ladies gave me a good tip on removing weevils from rice. Turns out you just pour the rice on to a plate, leave it in the sun for a day, and the little blighters run for it. Amazing! Then there was the genius suggestion that inspired my underwear washing ritual. Rather than spend my Sundays soaking, scrubbing and wringing out the weeks wear (invariably for 2, me being such a saintly wife), I now simply throw them on the shower floor with some ‘suds’ and trample them underfoot. Dancing improves the effect. Aside from becoming au fait with baby wipes and chlorine tablets, adapting to resource ‘limitations’ in the hospital, is a whole new challenge, often requiring a level of invention and improvisation beyond my well-resourced mind’s experience. Empty water bottles are useful. Cut the top off and you have a commode or portable urinal, sputum and vomit container or a bowl for bean stew. Cut a hole in the end and you create a life-saving device for a severe asthma attack. Spray an inhaler into one of these and breathe through the top and it will have the same effect as one of the fancy nebulisers that connect to the wall and infuse drugs into your lungs in A&E in the UK. When it comes to other procedures – drains for fluid in lungs or abdomens or spinal taps, it is pretty much a case of what needles or tubes happen to be lying around that day. A drip tube held upright with the top cut off replaces the engraved glass manometers I used at home for measuring the pressure of CSF coming out of the spinal space, a urine catheter bag collects any kind of fluid it turns out. Plasters also come in handy for fixing broken equipment such as our oxygen machine – patching together the ‘disposable’ mask which has been used on every breathless patient I have seen in the last 5 months, and the dodgy plug connection which sparks and smokes when you turn it on. Finally, like nowhere else in the world Africa has taught me the art of religious diplomacy. I was deeply impressed by the way the issue of mixed-faith prayer was dealt with on the ultrasound course I am attending in Kenya. Obviously the first thing our Kenyan instructor asked us to do on this completely secular training program for East African health workers was to commit the course to God in prayer. ‘But we are not all Christians’ one of the participants pointed out, ‘there are Muslims amongst us so what should we do?’ Ouch, this is awkward I thought to myself as the instructor looked around for ideas, we’re obviously gonna scrap the prayer idea now, or ask the Muslims to leave and use a ‘prayer room’ like we might do at home. But ‘It’s ok’ another student pipes up ‘we’ll have a Muslim pray for us this morning and a Christian this afternoon’. I looked around to see the response to this joke, but everyone was nodding, relieved at this solution and bowing their heads while one of the Muslims asked for God’s blessing on our day.

10 weeks and 4 days

I must admit that while expressing outrage at having to fly across the world to deal with a minor stationery issue, I am secretly feeling a little relieved at my excuse to have a break from Juba. Maybe it’s the heat, dust, and burning piles of rubbish that make Juba a less than endearing place to live or maybe it’s just my intolerance. But as one colleague put it, ‘Juba seems to have all the problems of Africa, without any of the charm’. Saying this, I know that I have glimpsed some charm in the sights, the people and the querks that I have come across during the 10 weeks and 4 days I’ve now lived and worked in Juba but right now I’m feeling an acute need for some time and distance away to be able to recollect them.

Moments I enjoy are walking through the hospital grounds first thing in the mornings. Every day I take the same route, picking my way among the camped out ‘co-patients’, recovering wounded and recent amputees. They sleep on mats outside the wards, cooking their breakfasts on coal fires and brushing their teeth with bits of wood. Many of them have been there for weeks, waiting for relatives to recuperate or their bones to heal and so they greet the strange kawaga doctor: the young guy with one-leg and the huge smile, the angry woman who tells me which patients I should be operating on and the little bare-chested kids with their round bellies and dinka beads who say ‘moning, moning’ (which I like to believe means ‘good morning’ and not ‘give me money’).

Life on the wards, although tough, also has its moments. I like to make the tired, demoralized nurses smile with my pigeon Arabic (‘Waja? (pain) and point to head, tummy, chest etc.. is my general approach). I like the super keen Clinical Officer students who put the doctors to shame, coming to the ward early, rounding in groups of 10, asking hundred of questions. These guys know how to learn, and they have to learn a lot, quick. After 2 years of training most of them will be the only medical professional covering a majority of health facilities in South Sudan. I like the ward ‘mascot’, Marco who is technically not a patient but seems to like living in hospital and I guess has nowhere else to go so the nurses let him stay. I also like seeing community like I never see at home. Sickness bring people together – huge families gather around bedsides, village meetings are held on the ward to decide if they can pay for patient’s treatments, people travel for miles to donate blood for distant relatives. Although infuriating when attempting to do a ward round among this throng of people, it is pretty humbling to see the meaning of family in this country.

Life is hard in South Sudan. People are so poor they come to hospital without spare clothes, never mind the money they need for tests, drip sets, drugs, and even the ‘public’ toilet. People get sick a lot and come to hospital so late in their disease we don’t get a chance to make a diagnosis before they pass. And sadly people die a lot whether due to lack of awareness, money, expertise, treatments, resources or a simple system failure. My frustrations though are nothing compared to what is felt by my South-Sudanese colleagues. They are the ones seeing their own family suffer (I’ve already attended one of their funerals), who don’t get allotted any leave, who don’t get enough salary to pay the rent and hadn’t been paid since December until they went on strike for 3 weeks. They are the ones who I will leave with the long-term burden of working for better health care in South Sudan. So once I have replenished my stock of cadburys chocolate, earl grey tea-bags and waitrose muesli and have regained a positive frame of mind, I hope I return an encouraging trainer instead of the nagging Kawaga that left them.

Clinical Officer students soaking up every word...

My lovely walk to work

Another burning pile of 'trash'

A rare moment of relaxation

elcome to JTH

It is hard to sum up my first month back in Juba but I thought this lovely bit of tinsel adornation of the hospital conference room did quite a nice job.

Juba Teaching Hospital has welcomed Michele and me to cover the Emergency Medical Ward full time, supervising a (variably small/reliable) team of junior doctors and teaching twice a week. As with the lovely tinsel sign, JTH is broken and lacking in many ways. The broken and lacking resources, systems and infrastructure combined with the bruised morale of under or unpaid health workers and the very often too unwell patients with unfamiliar diseases has made this my most interesting, frustrating, traumatic, rewarding etc. working month in life, so far!

But on to the shiny bits – the highlights so far. It is in the end all about my South Sudanese colleagues who, while I get a taste for how difficult a working life it is here, have a much deeper understanding of the countries hardships, feel the pain of watching their own people suffer, and for whom this is real life, and not just a sabbatical. My favourite moments have been attending an excellent lecture on ECGs by the registrar Stephen (under tinsel sign). Bearing in mind there is no ECG machine at JTH I was amazed at the ease with which he explained concepts consultant cardiologists have never managed to get me to understand at home, and the enthusiasm he drummed up in the junior doctors for interpreting a diagnostic they will rarely come across.

Then there is Angelo. A clinical officer, who does not actually have a medical degree, but stepped up into a senior doctor role during the war and is one of the most compassionate, dedicated doctors I have worked with. He found me tearing my hair out and getting cross with the nurses when a young alcoholic girl was left outside lying on the floor in her own diarrhea with no one to buy the IV lines and antibiotics she needed. He calmly crossed the road to the pharmacy, bought the meds himself, cleaned the girl up and carried her into the ward. He chose not to do the minimum, shrugging shoulders and saying what a pity, but went beyond his job description to sort this girl out. He was rewarded when she was revived back from her unconscious state, sat up and promptly fell out of bed. Although it was a sign of her recovery, it also made me realize why the nurses had kept her on a mattress on the floor.

Lastly I’ll mention Martin, a student nurse who also went beyond his job description. I have been coaxing and nagging my house officers to come to the ward early and clerk the new patients before I arrive. Occasionally they do. I was a little taken aback when Martin began presenting a patient to me on ward round. It was a perfect doctors’ presentation: a detailed consultation, examination findings, impressions and management plan. ‘Thanks Martin’ I said ‘that was a great presentation, I have nothing to add… but which doctor saw this patient?’ I looked round at the house-officers who were looking sheepish – ‘no doctors’ he replied, ‘just me’…

Michele looking happy during a successful ultrasound guided pericardiocentesis (needle drainage of fluid around the heart!!)

Chris perplexed at the random imported goods store

Day 4 Juba Teaching Hospital

The last 4 days have been a whirlwind of dust and heat, feverish comatose patients, quinine, broken equipment and ‘not available’ drugs and diagnostics. In honesty, despite having spent the last 3 months in East Africa, arriving in Juba and promptly leading ward rounds in the major government hospital was a bit of a culture shock and a bit like jumping into the deep end of a pool with not much water in it.

Surreal moments have included: finding myself fixing the only oxygen mask in the hospital with sellotape then deciding which of my 4 hypoxic patients to use it on; realizing I couldn’t hear anything through my stethoscope because the patient’s family had just started a very loud prayer meeting by the bedside; rapidly alcohol gelling my hands to shake hands with the MOH and 50 person suited entourage who trouped through the ward while I was examining a half-naked lady; and finally finding out from the HIV counselor that a comatose patient is positive when they have been waiting for a test for a week.

There are a few challenges here in Juba. On the up side, the basil plant is doing great, Diesel (the kitten) has an incredibly therapeutic way of rubbing my ankles while I make dinner, and I have a very nice room with a fan and the BBC world service. It’s also a bonus to be living with my husband again after 6 months of intermittent skype calls and throwing my phone against the wall.

Operational realities...

There’s nothing quite like maternal and child health to bring home the realities of living in a country where only 8% of GDP is spent on health care. First, there are the numbers. 435 women out of every 10,000 die in childbirth in Uganda compared to 8 in the UK; 88 of 1000 babies die in infancy and many more are stillborn. Second, there’s the experience of the ward. I saw for myself (at close enough range to catch one) what baby production looks like in the National Referral Hospital - the ‘best’ place to give birth in Uganda. The ward had 20 beds, no curtains, and around 30 labouring women with little or no assistance. I will not attempt to describe this picture any further, only to say there is no way in a million years that I would choose to give birth in that room (if I’m ever persuaded to give birth at all).

So what’s going wrong? The deficiencies in peripartum healthcare unfortunately reflect similar problems across the developing world where funding, human resources and infrastructure cannot keep up with the growing population. The average number of children a Ugandan woman has is 6.7 - one hundred babies are born in this labour ward every day. There are 3 midwives on duty, and one doctor. The intern doctors are on strike because they haven’t been paid for 3 months. The SHOs are taking exams but no one is covering for them.

There are a number of factors that might prevent a labouring woman accessing adequate healthcare. First, she delays seeking care because she can’t afford to get to a health centre; then when she arrives there are no doctors and a clinical officer tells her to go home without examining her; she then puts off traveling to a hospital because she can’t afford it (although care is free, she must bring her own gloves, plastic sheets and scalpel for the cord to be allowed on to the ward); if she can get these, the roads may be too bad to use; if she makes it to hospital, there are 20 other emergencies waiting and she is not seen for 4 hours; when she is finally seen, it’s too late. This is the story of one woman I met and sadly I don’t think it’s a one off.

The Diploma in Tropical Medicine and Hygiene has come to an end. It has taught me a lot more than what vectors transmit dengue fever and how to treat leishmaniasis. Although all that stuff has been incredibly fun and rewarding, the real curriculum has been exposure to the operational realities of health care in developing countries. I might have read about it and talked about it a hundred times, but nothing quite prepared me for how difficult things really are for people who happen to have been born on the other side of the world. Or how tough they are for my wonderful, hard working, intelligent African colleagues who work here – not just for a ‘gap year’ or a ‘sabbatical’ but for life. I don’t claim to understand what this is like but I acknowledge the poor working conditions, the inadequate pay, and the frustration of daily seeing diseases and suffering that although you know what should be done, you can’t do anything about.

And now back to Juba (after a good bit of parental sponsored African holiday). I’m pretty daunted by the next few months working in the emergency ward at Juba Teaching Hospital and by my lecturing rota I’ve just received – flip!… But hopefully I’m going this time a bit more prepared, a bit less naïve and with some new friends in high places dotted around the world to call on when I’m stuck.

Austens on holiday - drinking with the locals