Dr. Geelhoed journal entry 18 Feb 2011: MSF Obstructionism

*NOTE: 17-FEB-C-1 INDEX to the FEB-C-Series on TR’s mission to South Sudan can be found here.

Series: 11-FEB-C-2

FEBRUARY 18, 2011

And here we are! We are sitting under a neme tree, along the banks of the river that cuts through PiBor and in a hot and poor village with elaborately decorated women gracefully strolling along and bringing their kids in for treatment. I saw the Bor Airstrip from the air as we went to pick up Dr. Ajak and the medical supplies we had carried form Werkok by vehicle to leave our CAR and PiBor kits at the Bor airstrip as Ajak went to find the Murle who had been planning to come along with us and deliver the Peace Bonus for the Murle. But the banks would not open until 9:00 AM and we could not wait so Jon Hildebrandt will pick up this money on Monday when he comes through to deliver Tim Williams and the contractor for repairs at MCH. This means we had some last minute changes right on the Werkok airstrip.

First, Jacob’s wife was unable to go to Loki from Werkok since he is going with us and his wife would have to go there on her own as he will be in PiBor with us. Further, since we had put all our kit over at Bor, we had little extra weight beyond the five of us residual TR members and Jacob, so Jon told the three TR members who would be going back to Loki to get their stuff and add them to our takeoff load from Werkok to Bor, only four minutes away. Therefore we were five of us plus Jacob plus three plus pilot in taking off from Werkok which we did with room to spare before the VR at only two thirds of the runway strip. Four minutes later we saw the elevated crown of the hard packed strip of Bor that the UN had improved during the wars and its aftermath. But it is there that the King Air of AIM had landed along the runway avoiding a puddle and hit a run off groove bending the strut and snapping of the gear. The insurance company totaled the plane and wrote it off for the salvage which has had the plane standing on the runway for eight months getting slowly stripped of parts.

We picked up Ajak and his minimal gear and left from Bor toward PiBor. Jon and I talked along the way as he has seen a few of my email postings and is aware of the success of the Mission to Heal Peace Initiative, and may send over the AIM media man on our last night in Mayfield Guest House before returning via Addis to Washington.

We touched down on PiBor’s strip and rolled to a stop as I punched my GPS (again) for the marking. PIBOR =SALT= 06* 47. 68 N and 033* 07.91 E. It feels good since it seems about twenty degrees cooler largely because of the overcast. It is unusual to have cloud cover so early in the dry season and it was reported that it has been raining all week in Nairobi. It cleared and within a few minutes got noticeably warmer, even hot. We met Rev Oruzu, who had been unable to reach us by cell phone or the radio on the plane but heard our aircraft approach. He has a pickup truck and we loaded all the medical packs. We said goodbye to teammates Dan Fong (who said “Thanks for the Once in a Lifetime Experience”; I added, “Well, let’s get back soon and have such experiences three times per week!”) KP Samy is on his way home to secure his match list according to his wishes to go to UCSF or another good transplant program and is hoping that he can get me to support him among the friends of mine form the transplant programs including Nancy Asher and Larry Way at UCSF. And Kirtus, who is eager to get back to his two year old and three month old, but is going to miss this experience which was a real highlight of his life, since he had never been to Africa and now had seen it all as we had discussed it with the tutorials each night and then immediately gone to see and do it, as with the Leprosy Camp which made a tremendous impression on all involved. I believe we are getting a lot of hits on the web site particularly as William McNulty has posted my journal on a separate part of the web site so anyone can read what we are doing in real time as it happens.

We were taken to SALT= Center for Serving and Learning Together—a great name that I had admired the last time I was here a year ago. There is a two week training course of teachers for all over the region which is being concluded as we arrive. We offloaded our personal gear into a thatched tukul and went right to the clinic—a new facility in a very old building right on the river bank. I call it the PiBor River but it is really the Lily River, which has water running through it even in the dry season and is crossed by a ford. I saw four boys wading across the river dragging a fishing net. One looked like a regulation drag net, but the other I had recognized as one of our insecticide permeated mosquito proof bed nets.

Tall and graceful young women are walking along with or without a bump on their back. On their forehead is an elaborate decorative colored yarn that is starched to look like a box in an uncomfortable position but it is for the cover of Vogue so any beauty fashion state is worth the hazard. I have taken many photos of each of the women coming in full Murle costume and admired their pointilated facial markings. They are quite different from the Dinka in their facial markings and quite distinctive in their costume –and rather photogenic.

Almost immediately we were impressed into service and the clinic chief Juono was more than eager to have me take over but I insisted I not sit in his chair but aside it and help him in the review of patients. There were scores of them coming in slowly and demonstrating their “all overs.” The same phrase I had first heard in Nigeria is a standard line over the four decades since then “My Whole Body Pains Me.” Some had specific lesions we could diagnose—such as DJD (Degenerative Joint Disease, or osteo arthritis. There were several cases of GI distress that were diagnosed as Amebiasis, and one (incorrectly, I believe) as typhoid. The ones most alarming were a woman with a six month history of coughing up blood (hemoptysis) and night sweats and fever and weight loss. No diagnostic dilemma, this is classic straight up TB in all its untreated and most infectious stages. I asked him about MDT (Multi Drug Therapy) using DOTS (Directly Observed Therapy System) and he agreed with it all and wrote out a prescription for a month of daily streptomycin injections. When I suggested he add INH and Carbamazole for a period of six months he agreed with that too and cheerfully wrote the script on a scrap of paper.

Then I started to wonder. After prescribing on the same scraps of paper, which we continued until he ran out of the small scraps of paper. I then had them confirmed when I had several other women with the scourge of the area—the STD’s (Sexually Transmitted Diseases) which sterilizes most of them so that they have the 78 % infertility rate. So with treatment for BOTH syphilis and GC in the woman who presented with ulcerative genital disease was written correctly—but the women kept standing around despite the pharmacy being open and without a queue at the window. IN fact the women with their elaborate “phylacteries” on their forehead were all at my window leaning in over my shoulder. It made for interesting candid over the shoulder shots. Then it dawned on me, yes we have seen, diagnosed and treated each of the patients with a small scrap of paper—but none of them would ever get any kind of treatment whatsoever since none was here. I saw the pharmacy which was full of boxes and full bottles of some few medicines NNE of which we had written for. The majority were out of date by a few years as well. But they had all agreed shaking their heads and said—well, if you want them treated then you will have to supply these medicines since none of these drugs are available to us.

A woman in obstructed labor is told to make her way to Bor from which we just flew in forty minutes at 145 knots. On a good day and only in the dry season that drive is a torturous eight hour drive to a hostile reception. It is no wonder that they are Leary of promises and nonfulfillment.

MSF Belgium has started up a hospital here, it is said, but it could not use the bombed out hospital we had sought to get rehabilitated last year. But the MSF has also announced a pull out by the beginning of the year. They are still here, but as Rev Oruzu said to me, MSF has good facilities but very poor care since no one there knows anything about the treatment of the kinds of disease these people have. I told him that this is an ideal vacuum for us to move in to fill. We diagnosed one strong strapping fellow with a left inguinal hernia this morning in a lengthening and drowsy hot tropical clinic in which we were always seeing the “very last patient”. As long as we were still here, of course, there would be still more patients streaming in and sitting outside the door, oblivious of the falling blood sugars and filling bladders of the team who has got up early and flown in to what the patients considered, clearly, to be a nonstop clinic to be run around the clock by the visitors. Several pre-op patients had been selected by the team which included a nurse named Moses and another fellow who was the pharmacist, and the chief CO, but they were nowhere to be seen, and it would be hard to tell them to come NPO after midnight to be operated tomorrow. SO, we scheduled the young man for a hernia repair under spinal anesthesia tomorrow morning in the MSF facility which we still have not seen nor set up in, and will simply takeover since we understand that that facility is good but not being used to anything like its potential. At the same time there were patients coming in for big ticket operations in this falling down riverbank stultifying clinic where we were falling asleep in the drowsy hot breezes off the river. One man came in with the suprapubic catheter in place. It had been put there by the MSF in their allegedly good facility and now referred it to us to do the definitive operation of prostatectomy in a thatched tukul on the river bank without any meds or nursing care. Ours, of course, is free, so it outcompetes other sources in which this might be done such a Juba or Khartoum which are theoretically open to them. There may be less official hostility in other parts of the Jonglei state than there might have been during the civil war with the north, but there seems to be more fear. I had hoped to break that down by having patients we found brought back done to Werkok at MCH for operation with the surgeon, who would be doing it such as Dr. Ajak/

THE “IV TREE”= AS AN ELDERLY MAN STAGGERS IN WRAPPED IN A ROBE HAVING SEVERE RIGORS AND A SHAKING CHILL

Enough of the niceties; Rev Oruzu said it best: “This one is suffering!” He surely was. He came in on his stick and was quaking so badly that he had shivered his clothes off his shoulders. He had his “neck brace” a wooden cradle for when he should lie down as if to protect his hairstyle. It is akin to the neck pillows they sell long distance air travelers but it is not soft. He collapsed under the tree on the packed earth and shivered violently as he grasped his clothes over his shoulders and covered is face. If even anyone needs to see a shaking chill or “rigor” of hemolysis in fulminant plasmodium showering of his blood stream here it is. I feared for his kidneys figuring he would have red cell ghosts casting up his kidneys and he would be in renal shutdown, so I ordered an immediate IV and Zach had a go at it—five times. Each time he got the IV in it would infiltrate and blow up in a hematoma as he quaked. The sixth time was a charm, and we poured quinine into him and almost immediately it stopped the rigors. We gave him a full bottle of fluid and he peed which made me happier about his kidneys.

Around the tree were bodies circled in a rim as if—pardon me for referring back to a cartoon I remembered as a child—Little Black Sambo. I remember the tigers, I believe they were, that raced around the foot of the thorn tree as Sambo was up in the tree and he got down after the bodies all turned to butter. One of the bodies stirred and an old grizzled man reached up his hand to shake mine—a recognition that we share the human condition even if one of us was prone and the other upright. I saluted him for his spirit as he was clearly in a recovery mode. There were a half dozen around the tree and another four in the nearby grass shack, in the unlikeliest setting for an IV infusion port imaginable, but there they all were plugged in to IV;s for malaria for quinine or diarrhea of salt containing fluid or for pneumonia and antibiotics. It seems like we have a dozen all told who are getting therapy “under a tree.”

We had a woman who wants a hysterectomy, and, of course, under a tree on the banks of the River Lily might be a quite cost effective place to do that, but it may not meet JCHAO standards for high option reimbursement. I believe it is absurd for people to continue to come in after we had exhausted our supplies, but much of medicine is predicated on the magic that all this seems to conjure up, with a huge benefit at no cost. Another woman came fully expecting to get a cataractectomy or some other simple small operation under a tree. It is good that they expect much of us, but we are working on getting a realistic and good base of further development but it will not be like Khartoum Teaching Hospital any time soon.

I have learned a bit more about the “phylacteries” of the women. They are engagement signatures, and according to the color and the position they are perched on their head, they are more and more committed to a given suitor. The odd part of this is the women I saw wearing engagement headgear also had babies on their back or on their breasts. It is probably an insurance policy against the awful plague of infertility to have a pregnant or mother as a bride. The continuing theme of the clinic complaints were of infertility.

Four young women—and they were all young women—had chronic seizure disorders, two of them sisters in law. It seems one of the ways that a young girl can rebel against a marriage already fixed by the negotiations over her virginity as bride wealth is to make herself unmarriageble. I had one such young woman who was a chronic seizure expert, since she has never had an unobserved seizure but would wait until I passed by at Duk in the market or at Church so as to stage an elaborate real fit—compete with falling to the ground and clonic tonic seizure motions but without ever becoming incontinent, or injuring herself, or biting her tongue or vomiting or aspirating, in fact not even getting her dress dirty. She was doing her best to keep from being married off. Everyone always scrambled to get her an IV and then the diazepam IV which she never minded since it kept going for a long time possibly long enough to make her alleged suitor hang it up.

Four of these young women were here, and I mentioned to the father of one of the fifteen year olds that she was a very beautiful young woman and we were sorry she had this problem. He had this translated through Arabic with Ajak and Ajak concurred saying at least forty cows. The father was distressed saying that “yes, that is what I had expected, but now the number of cows I had hoped for is steady dwindling and is getting to be more like twenty than the sixty to seventy I had hoped for.” She actually had bit her tongue during one seizure so it may be real but she has been doing it for every other month for ten years. IT may represent a neurocystocercosis in her instance, but certainly not a febrile seizure of childhood since she is no longer a child. We found we DO have phenobarbital as an agent after our diazepam had been exhausted from our CAR backpack kits which now turn out to be the principal drugstore for all of PiBor when we had packed 150 kgs of surgical kits for our doing many surgical cases in the next two days.

As we were doing our clink the pickup truck came around the corner in a cloud of dust to deliver—what else—a fourteen year old girl who is making high pitched whining noises in little groans although she has no difficulty breathing and is aware of our presence and follows us with her eyes when she decides to increase the volume of the grunting whine. She seems to be aware of our presence, for making us aware of her distress, and when we leave her for a moment she increases the woman makes louder noises then gives up if she cannot see us. It seems the classic “hysteria” = the “wandering womb” and is a specific complaint here that afflicts young women. But we do not want to miss the occasional real seizure disorder which we cannot workup nor treat appropriately with diphenylhydantoin.

They would have to go—Somewhere—and certainly not to Bor, the Provincial seat, to which we have already been and can clearly see from the very look of the bombed out hospital that is so eager to attract outside funding sources and has done so four times over, with no improvements, and it is a testimonial as big as life to show up corruption. There is a “County Medical Director” assigned here, but he lives in Juba, since life is easier, and he can spend his allotment on an easier life surrounded by Tusker beer. His goals are as clear as most others here in any advanced position to be in on the ground floor of government dole—to maximize life style and minimize troublesome service. So, the drug supplies which are supposed to come over from Bor to PiBor is an example—their “regular drug deliveries” are a few months past due, and this is the best time of year when the roads are passable. There is NO supply line in the rainy season. So the methods they had pursued today with our help, is the NORM. The charade of making the correct diagnosis and writing the correct prescription for them to “go get whatever they can” is impossible under these guaranteed-to-fail circumstances. IT could then attract some outside help, like the MSF Belgium which it has, but they have announced already their sunset as they are supposed to have pulled out at the beginning of this year.

GOALS OF OUR LIMITED TIME MISSION HERE IN PIBOR

Our goals were not to fail the promises made –on TV coverage—of the paramount chiefs and the sub prefecture chiefs and the District Commissioner and Rev Oruzu all exchanged on our last visit. The promise of peace was made and has been kept, so we are coming through on our end of that promise. Now, the redevelopment of health care here is a longer and much more complex process. They seem eager to have it accomplished, but the intermediate level people assigned to carry it out in any official GOSS government position have an interest of milking the poverty and shock value of their constituents to get outside and lucrative supporting contracts, which they will expend in WHO conferences in Geneva or New York and live in the “new capital” of Juba to have a rather elevated life style supported by the very misery of their people that is so “salable” to NGO’s and multilateral agencies.

Even as we are sitting in clink as I was watching the young boys seining for fish, and the women washing clothes or bathing themselves. Or kids pooping and peeing in the water that was being scooped up in Jerry cans for a long parade of yellow plastic bidons being hoisted on top of stately women’s heads to be carried back to their tukuls. One small boy was carrying a plastic Coke bottle from the river and drinking from it. It looks like cafe au lait with about five centimeters of sediment even as he is shaking it on the toddling run from the river. I am looking at an “epidemiologic perfect storm” as the kids with hematuria of schistosoma hematobium are peeing in the river, and the others are bathing drinking and carrying it home to their tukuls—with a guaranteed encyclopedia of tropical pathology in every bidon. But, we are still a long way back on the public health education here in PiBor, since the war had literally and quite actually bombed this infrastructure back to the pre-industrial era and like the plagues of European Dark Ages, they are self-sustaining.

A Chaos pattern of self-organizing is happening before our eyes as if by evil intent instead of simple ignorance. It would take very little sophistication to institute major changes for little or no money, and since it is the big money projects that are of interest since they are far more siphonable, there will be continued negotiations for big ticket items rather than the simplest of latrine public works, water purification systems, run off of wastes, and simple hygiene –there is no place to wash hands or pee or otherwise even in the newly established “Clinic” where we have just worked for six straight hours in the heat of the overhead sun. A college student could make more inroads for health than a neurosurgeon in PiBor and we need such an incorruptible change agent, and not own who is interested in climbing a ladder of self-advancement OUT of this environment but improving it from WITHIN. There are few such left after all the turmoil in the South Sudan recent history. What is even more important is that even our peace initiative is almost derailed by fears and self-fulfilling prophecies of “There is really nothing we can do for these people, so we certainly should not put ourselves in harms’ way in a position of endangerment”. We now have a mixed team of five US citizens and TWO Dinka Lost Boys who are here for a short time (I hope somewhat longer for the indigenous Sudanese among us so as to assume “ownership” of the peace initiative and the health care redevelopment models as a bridge to that peace.) Let’s go see what we can do here and now in the reality of PiBor as we give it a try.

THE PERFECT STORM OF BUREAUCRATIC OBSTRUCTIONISM AND FRUSTRATION OF ALL THE PEOPLE IN THE FIELD BEING DIRECTED BY A CENTRAL “CYA” BUREAUCRAT FROM MSF-BRUSSELS IN JUBA

It is everything one could wish to have as a worst case scenario. We all launched our diplomatic visit to MSF in its compound of superb facilities, and like the Chad trip to MSF HQ we came into the bureaucratic nightmare of all that the leadership can do to frustrate those who are on the front lines in caring for people. It’s not the MSF Way. Full Stop. All was well until the Director in Juba announced by phone “No Way.” His name is Rob Mulder. I said, “Do I detect a Dutch accent?” He said yes I am Dutch. I said to him, “This is Dr. Glenn Geelhoed Professor of Surgery, and I have done a lot of instructing of surgery in its techniques indications and risks in many parts of the world and including several parts of Jonglei State”. He said, “Your parents must have been Dutch.” I said, “What do you mean? I am as Dutch as you are.”

“No, you may not use any MSF facilities and may not train any of the locals to do any operating since all such surgery is emergency and must be transferred to Juba or Bor”. I said to him, “For a woman in obstructed labor, I know that the eight hour ride to Bor is not survivable, and besides, I know the skill level and facilities in Bor once she arrives. And, you are telling me that in the rainy season which is most of the year, you simply say all such emergencies as you term them are simply going to die since no one is allowed to indigenize skills when we have people and supplies here right now who are both willing and eager to help these people”. “It is not the MSF way”.

Yes, I am familiar with the MSF way. It is like any other “CYA” bureaucracy. All this was after a very warm reception from the field personnel here who were eager to see us and had looked forward to our visit, saying this is exactly what we should be doing. The field station manager was a Nigerian and we swapped jokes about the Agage Motor Road and Ibadan, the physician, is a Kenyan and he said it would be wonderful if he had both skills and equipment to treat surgically rather than just “suggesting these very seriously ill people find their way somewhere to get help.” We all were in accord after several rounds around the table over the first cold water I had had in this area, and they thanked us for having been here before and having launched the peace initiative which they are well aware resulted in no deaths among the Dinka Bor/Murle front whereas there are casualties everywhere else. They said they were 100% with us but that any such decision had to be made at the Juba level of the Director. I said, “Let’s phone him up now so we can begin tomorrow.” That is when the discussion developed. First with our designated leader Dr. Ajak who then referred him to me. I talked for some time as he had had his conclusion from the company line before I began. As a bureaucrat I would have been embarrassed to be telling a professor of surgery with considerable experience in the very field he is supposed to be overseeing about the risks and the contraindications to any surgery anywhere within the range of the MSF which—as Rev Oruzu had said before we left to our visit there: “they have very good facilities and have essentially no services to help the people.”

It is like the UN, which has a huge presence in transplanting entire civilizations and its infrastructure to take care…of the UN! It has A/C hospitals to wrap sprained ankles of Indian soldiers seconded for US dollars to Kardugli when they injure themselves playing volleyball, as bodies may accumulate in front of them on the roads outside their fences and they are instructed to “notify the local authorities” who may have been the ones who cause those bodies to accumulate. Their rules of engagement are first of all ”make no waves” and retire comfortably after drawing a UN salary as an international in US dollars for a limited period in which one is to minimize any contact with the locals.

So we have made our overture to a very receptive end forthcoming group of otherwise bored field staff in the PiBor MSF compound as they were watching a soccer game and the Al Jazeera news from Bahrain where hundreds of bodies were piling up in the emergency rooms from protestors gunned down by the autocrats in power in Bahrain. Perhaps we should send in the UN or MSF.