Letter from Old Fangak 1st November 2009

written by Ann Evans, clinical nurse helping Dr Jill Seaman in Old Fangak, South Sudan

Today marks my tenth day in Old Fangak, arriving in the midst of a deadly kala azar outbreak. In July and August there were 15 cases each month; by September the numbers grew to 60--a 4-fold increase; we closed October with 345 cases in treatment--more than an additional 5-fold increase! Boats arrive day and night, ferrying patients from outlying areas. In a country where only a third of the people have any access to health care, this place is well known. Dr. Jill Seaman refuses to charge for the care or the medicines. Some say she should charge those who can pay; Jill says few can afford it and it seems inherently unfair to charge at all. So they come here--young, old and in between. One man came from the city of Malakal, a large city in Sudan, miles and hours up the river--a place where there are many more resources and lots of hospitals; but he couldn't afford his TB medicines there, so he came here to get the treatment he needs.

It is also 8 days since a WHO representative, the State Minister of Health and the Minister of Pharmacy arrived to assess the kala azar situation. There was a huge festive gathering in the village. The women put on their finest clothes and danced for the guests in the arena in front of our humble hospital. Small church groups paraded with drums, many wearing some vestment to associate themselves with the church. There were a number of speeches from the visitors, telling the people that they know about the kala azar problem and have come to see for themselves and to take action. One of the administrative people had married a woman from this village; he donated a cow. Another donated 4 cows. A modest sum of money was also given to be used as needed--a small 'local option', as it were. The administrators needed statistics; these were given, even using the special format requested. A meeting was held in Juba a few days later; information was forwarded to many other people and groups.... We wait for results....it's like waiting for Godot. Jill, wise and experienced from many years of working in this area, knows there is only so much that can be done and knows who can generally provide what. I, in my ignorance, would have asked for 'every thing' we need; but Jill requested blankets and high energy food--like 'plumpy nut' and special milk formulas for malnourished children. We are gradually using up the regular milk powder and sugar that Jill purchased. Still, no blankets and no high energy food for the infants. I wonder just how long cold and hungry people should have to wait for a blanket and food...? And I'm, glad that donations from our friends will bring in milk this week when our Alaska friends arrive to help with the infrastructure here.

Last week one of the donated bulls was sacrificed to stop the kala azar outbreak. Several men gave long speeches to the gathering crowd of villagers, and to the bull too, as it stood patiently in the hot sun, flicking flies with its tail. The old men pulled dusty green grass from the ground and slapped it on the bull's backside, all the while gesturing with a long stick and a metal headed spear. It was important that the bull urinate as we watched, to show that it was healthy; it dutifully obliged. In the background I saw Jill hurry from the storage room to the inpatient room. A little later, as the speeches droned on and I continued to stand, rather foolishly, in the sun, Jill summoned me. A child was dying; she was trying desperately to keep it alive. Her rush had been to get a blood transfusion set to infuse her own blood into the child.

As requested, I made a photograph of the dying bull, the great sacrifice; a copy was later sent to the donor. I returned to Jill and the small child lying in its mother's arms, and watched as Jill gave mouth to mouth resuscitation--so kindly, so gently. Yet all the measures were to no avail, and like the bull, the child too died. Jill stopped the blood, quietly telling me she would have to infuse it back into herself, for it might be needed for another child. Although the bull provided a little additional protein for some of the villagers, the kala azar outbreak continues, undaunted by the sacrifice and ceremony.

Our inpatient room with its 12 open air beds is now full, the beds often shared with the mother and father, and even siblings. The beds are metal with large wire mesh. Only a few have mattresses and some of those are so past their appropriate life time of use that it feels indecent to offer them to human beings. Three days ago a 12 year old arrived in his father's arms. He had been sick for two months; now he was in shock, just barely alive. The father laid him down gently, his son's wasted body against the hard wires. When we only had a paper box to initially cushion his head, Jill had me bring a small blanket of hers. The father managed to locate a mat and some sort of cover. Jill started an IV right away in veins that were hardly there. That night, after we saw our last clinic patient around 10 PM, we spent well over an hour trying to bring the boy out of a coma. We gave him more antibiotics, steroids and glucose through his IV; Jill placed a nasogastric feeding tube, feeding him our powdered milk and sugar. I sat on the side of the bed, trying to coax him awake. Yesterday the child died.

Jill and I stayed up late one night, watching the Pete Seeger 'Power of Song' CD, with guest appearances by many of our greatest peace and justice singers, musicians like Peter, Paul and Mary, Bob Dylan, and Joan Baez. It was wonderful to hear the familiar songs and revisit the dream of a world that cares and shares, that fulfills the teachings of Jesus, the Koran, Buddhist writings, humanists and other good, decent, open-hearted people who dream of a better world. Then I settled into my small screened tent under the acacia tree with the stars and moon lighting the sky. The experiences of packed-full days flooded my mind, as if seeking escape from days too full to think, too full to write. The events and images are vivid, rich, sad, happy, touching--so real, yet so unlike my decades of working in health care, and my life of so many comforts. A feeling of gratitude arises, gratitude for the privilege of being here right now in the midst of this epidemic with a friend I so admire and from whom I can learn so much. Still, I laugh when I recognize my feeling of 'gratitude', realizing others might not feel the same.

Although it is sad that three children died during the past ten days, please be assured that so many more people are escaping death. Between 1989 and 2005 MSF treated more than 60,000 cases of kala azar in Sudan, and had a death rate of 7.5%. Jill is one of the world's leading experts on this deadly disease. I am positive that her presence, planning, bull-dogged commitment, and her love for these people has spared so many lives during this epidemic. I think our death rate is even less than 1%--quite amazing. Please continue to spread the word about the kala azar epidemic in Old Fangak and the work being done here, which is ongoing and much more than 'just' a response to this epidemic. Donations made through crosscurrentsinstitute.org, under the 'Current Programs' of 'Sudan Medical Relief Project' go completely to this work. One can also go to the website of sudanmedicalrelief.org; contributions through either of these avenues flow to this project. It seems that surest way to get what we need and to guarantee delivery is to purchase it and fly it in ourselves. There is no mail system here; but thank you to those who have offered to send things directly. Prayers, blessings, good wishes are all welcomed; and thank you to those who are contributing to this work, and to all who pass these letters on. I know there are many good people who will help, if they just know about the need and how to go about it. Namaste and God bless you all.



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