Seriously sick in South Sudan - Part 1

Juba from above

In the last few weeks I have ended up in South Sudan on a fairly regular basis. Most will be aware of the terrible civil war and of its recent divorce from Sudan in 2011. Obviously its partner in the north has been the news considerably more frequently recently in regard to the humanitarian crisis in Dafur. Unsurprisingly for this region of Africa, bordering the Congo and Somalia, South Sudan is not an exemplar of peace and equality since its hard fought separation but it is working on it so I'm told. Both sides in that conflict were responsible for horrific slaughter and human rights violations during the civil war and then there is always the continuing tension with the north about the contested region of Abyei slap bang in the middle of the two.

Juba from the ground

The two nations maintain their prickly symbiotic relationship with a flow of oil and other mineral resources. South Sudan is rich with resources and no good way to export them, whereas Sudan is relatively poor in mineral wealth but has access to a massive port and maintains the pipelines from the oilfields in the south. I do wonder what will happen if Kenya makes good on President Kenyatta’s recent pledge to build pipelines across to South Sudan from their northern coastline. A bit of competition will be interesting (possibly about as interesting as kicking a hornets nest) but I would be surprised if it actually happens.

Anyone who has been to countries in this area will be starkly aware that, no matter their huge mineral wealth, very little of this trickles its way to the ordinary man on the street (if there is anything resembling a street). That applies particularly to healthcare. The only reasonably functioning healthcare facilities I’ve visited have been private clinics in the capital Juba (which seem to mostly serve foreign technical staff, businessmen and diplomats) and missionary hospitals out in the sticks like the town of Yei.

I’ve picked up some extremely sick patients from Juba, mostly European nationals. The medical staff there work extremely hard and do a great job despite the limitations. When the stars align correctly we are probably minimum 4 hours from call-out to bedside in Juba and considerably more to the smaller airstrips. There is very little critical care equipment and expertise, so getting seriously ill in South Sudan has a pretty high mortality. Despite our vaccinations, prophylactic medication, alcohol cleaning gels and ‘health and safety’ culture, we foreign nationals seem to get ill or injured quite a lot in these places. One thing I have noticed is we often do some pretty stupid things. Perhaps this is because we lapse into a state of false security and stop doing things because they are not routine practice in the cultures we find ourselves in; like wearing seatbelts or helmets, not drinking and driving, taking malaria prophylaxis, practicing safe sex and so on. Or decide that South Sudan is the perfect place to learn how to ride a motorbike. Enough said.

 

Yei airstrip

In the rural town of Yei I was called to evacuate a poor young lady who was being cared for by the inspirational doctors and nurses working at the Harvesters ‘Bet Emin’ maternal and paediatric hospital. It is a missionary hospital and is doing some remarkable work for the local population. This lady was not pregnant but had been cared for there as she had links to the charity. She had developed the relatively rare condition known as Guillain Barre’s syndrome. It is a classically post infective autoimmune, demyelinating, ascending polyneuropathy. It’s classically associated with outbreaks of Campylobacter Jejuni gastroenteritis or certain viral respiratory infections which are nasty enough in their own right, but then, just when you thought you were getting better, you start losing feeling and strength in your legs. Then your arms become effected and it starts to creep towards your core, potentially getting so far as to effect the nerves operating your heart rate, your lungs and your ability to control your own swallow. It shouldn’t take a medical degree to work out that, unless you do something for someone whose own immune system has rendered them paralysed, unable to breathe or swallow, they will not be long for this world. Luckily in the vast majority of cases, they don’t get to that stage or if they do, they recover eventually as the little supporting cells that surround their nerves start to grow back. I’ve seen three cases requiring intensive care and ventilator support back in the UK and from what I understood of the medical report, this lady was going to be my forth. But as often happens with aeromedical cases, the case had considerations far more complex than the underlying pathological process.

 

The funding for her treatment was coming from a charity and I did not know whether they were at all clued up about the potential length of her ICU stay. If these patients need ICU, it’s often for a long time. Like our long stay patients with critical illness polyneuropathy, they can sit on the unit for weeks, even months. Patients and their families luckily do not need to consider that in the NHS but they do here. It is not an infrequent occurrence for a patient to ‘stepped down’ prematurely from the ICU to the ward because the policy will no longer cover or family can no longer pay the bills.

 

Downtown Yei

Also this lady was Sudanese with poor English and no passport. We had got clearance for her but her husband’s clearance was more problematic. Our window of opportunity was closing fast and we could not reliably establish whether these things had been taken care of before we starting loading the plane. The worst case future scenario we could consider was of a poor lady paralysed on a ventilator without her spouse, unable to understand those around her and eventually passing away in a foreign country as her funding ran out.

 

Where are we going?

Fortunately we got word as we touched down on the dirt airstrip that the charity was committed to the care no matter the length and her husband would be joining her. This was so far the most rural setting I had visited since being with AMREF and it was remarkable. The pictures do the experience more justice than I can. But at that time, with every pothole and twist of the track, I was more concerned about how I was going to safely get this lady on a ventilator all the way from the mission hospital to the plane. Fortunately she had improved and had enough strength and vital capacity to cope with the trip on only oxygen. Dr Edwards dodges another bullet.

While we assessed and prepared the patient for transport, the doctors at the hospital gave me a quick tour and even tried to pick my brain on a few cases. Given these were either post-partum or paediatric cases (not exactly my forte) I’m afraid they got slim pickings but I suppose it’s always nice to discuss a case with a colleague. The current medical director Dr Graham Poole originally trained in Tazmania, has been doing some incredible work there and kindly took me to see one of his success stories.

 

I was taken to see a 9 year old lad who had arrived with them out of the bush about a month ago. Even for a child in one of the poorest regions on the planet he had his cards stacked against him. His father had died, his mother was an alcoholic and his frail grandfather was looking after him. Then he became ill with an expanding growth exuding from the left side of his face. It had reached the size of a mango by the time his grandfather took him to seek help. Burkitt’s lymphoma is the most common childhood malignancy in Africa but you may have never heard of it. From what I remember a combination of genetic factors in equatorial Africans and environmental factors chronic malnutrition, malaria, Epstein Barr Virus and HIV, make it extremely prevalent. It responds well to chemotherapy but that’s in rather short supply in East Africa. His grandfather was told nothing could be done and, I forget the details, but the boy disappeared. After a while when he couldn’t be found and given the severity of his illness, it was assumed that he had died. In fact they even had a funeral for him in his village. But news of his death had been greatly exaggerated and, after what must have been days of walking, he arrived alone and weak at the Harvester’s hospital in Yei.

With little hope of a good outcome given his general condition, Dr Poole started treating him and a few months later the growth has completely receded and he is slowly regaining his strength. The picture shows the facial damage the lymphoma has left in its wake. His grandfather visits frequently, overjoyed that his grandson managed to make it to someone who could help.