Notes from the field: South Sudan (part I)

It was a hot and sunny day when we started out across the only bridge on the White Nile for over a 1000 km. The banks of the river were bustling with people bathing, washing their clothes, fishing, and off loading goods from small boats. After we crossed the river we headed down a dirt road toward our first destination: a Primary Health Care Center (PHCC) staffed by a trained community health worker (CHW). The old adage that “It’s the journey that matters and not the destination” held true as we flew like bats out of hell down the dirt road narrowly missing goats, long horned cattle, and small children and women carrying water containers and wood on their head. At one point in the road we noticed a traffic jam with various NGO land cruisers, minibus taxis, moto-taxis, and curious onlookers piled around a beer truck stuck in a muddy crevasse in the road. Men with shovels surrounded the beer truck desperately trying to dislodge the vehicle and its precious cargo. Apparently a church was being inaugurated in a village down the road and many dignitaries were attending, as it was the home village of a political bigwig. Eventually the combined testosterone, need for beer, and growing crowd of annoyed onlookers managed to push the beer truck to the side and we proceeded onward in our mach 5 fashion. On the way, we passed the village where the church was being inaugurated and it was crowded with people sitting around in plastic chairs listening to a parade of speakers, visiting dignitaries with a mini-battalion of security forces (You do NOT mess with SPLA folks- Sudan Peoples Liberation Army- as they are battle hardened after decades of fighting and armed to the teeth), and small children running around. Two and half hours later we reached the PHCC.

The PHCC was situated on the slopes of a hill surrounded by a village and borehole. It recently had an upgrade and I was told that it was one of the better PHCCs in all of South Sudan. As I was guided through the building, accompanied by two colleagues, both doctors, we met patients lined up on benches waiting for the CHW. The trained CHW system came out of the decades of civil war in Sudan when most of the trained medical staff, many of which were from the north, fled the south for safer pastures. The CHWs were given basic medical training, along the lines of a trained medical assistant, and staffed outlying health outposts. Many of the CHWs received additional training from NGOs when they fled the south with their communities and settled into refugee camps. The CHW in this PHCC led us around to the dressing room, a room where they dressed wounds and “sterilized” instruments, the drug dispensary and storage room which was over 35C (most drugs, even heat stable ones, need to be stored below 30C), delivery room, and laboratory (a microscope, some malaria test kits, and urine testing strips). In one of the patient rooms a third trimester woman lay weakly on a bed, she had a rapid pulse, shallow breathing, and we were told she was severely anemic (malaria is endemic here and is a major cause of anemia in women) and potentially had hepatitis. We realized that she had to be transported rapidly to the referral hospital and we were the only source of transport at this point. One of the small boys ran off to a distant village to tell her family to come and prepare her for transport as we sat down and talked to the Village Health Committee (VHC), local traditional birth attendants (TBAs), and village elders. We used a mix of English, Arabic, and Dinka to discuss some of the health care issues in the community. In the group of local people was one notable elderly TBA named Maria. Maria was tall and thin, as are most Nilotic people in this part of the world, with a small turban, flowing dress, and a plastic rosary around her neck. Her eyes spoke volumes: decades of conflict, refugee camps, returning home to rebuild, and the stories of hundreds of women that she had assisted in giving birth. It was her dry sense of humor as she told us that “I know women are pregnant before they know” and the respect, tinged with some fear, that the village elders held her in made me understand why we do this work and how important it is to involve women like Maria who are the gatekeepers to women as well as “walking archives” of information on maternal health, cultural norms, and local politics.