Just after 7am, with the temperature already nearing 100°F, about 20 international staff members of MSF’s project in Aweil, South Sudan, assemble in the shade of a mango tree for breakfast. The tree sits in the middle of one of two small living compounds that face one another across a dirt road on the edge of town. Each is surrounded by high cement walls and has a number of mud-brick huts known as tukuls that the staff uses as sleeping quarters. There’s also an office, a kitchen, a supply shed, and showers and bathrooms. But when it comes time to gather and the weather allows, everyone usually gravitates towards the mango tree.
These people have come from the United States, Democratic Republic of Congo, France, Korea, the United Kingdom, Nigeria, Ivory Coast, and other countries to be here. Over a simple spread of locally baked bread, jam, and cereal, they discuss the day ahead, the patients they will examine and treat, the cases they need to follow up on, the supply orders they’ll need to place and fill — everything they and their South Sudanese colleagues must do to provide high quality medical care to any and all patients they see at Aweil Civil Hospital.
Aweil is the capital and largest city of South Sudan’s Northern Bahr El Ghazal state, which borders Sudan. Despite brutal fighting elsewhere in the country and perpetual tension — and occasional violence — between the Dinka and Nuer ethnic groups in the area, Aweil itself has remained relatively calm. The team members can walk from their compound to the hospital, for instance. They must walk in groups, and at least one person has to be wearing an MSF t-shirt or vest, but even that wouldn’t be possible at most MSF projects in South Sudan or other conflict zones around the world.
MSF’s program in Aweil dates back to 2008, when the organization took over the hospital’s maternity and pediatric services. Now, roughly 350 South Sudanese and 20 to 25 international staff members run the hospital’s three inpatient wards — neonatal, maternity, and an intensive care unit — along with its inpatient therapeutic feeding center and a tuberculosis ward. There are also three areas where they can erect additional tents during disease peaks, which often come during a rainy season that brings torrential downpours, widespread flooding, and potentially deadly outbreaks of malaria.
Though mornings at the compound can seem unhurried, the team members know that days at the hospital are usually anything but. South Sudan, the world’s youngest nation, is also one of its least developed. Health indicators have long been horrible and health care options few. And that was before a civil war broke out between competing political factions, making everything worse. Even in places like Aweil that have avoided the worst of the fighting, it’s hard to understate the scope of the needs.
Knowing they have a busy day ahead, the staff members clear the table, gulp final mouthfuls of coffee, and fill their water bottles before filtering out of the compound for the short trip across town to the hospital. Whether they walk through the city center or climb into white Land Cruisers adorned with MSF’s logo, everyone is headed to work.
THE NEEDS OF NEWBORNS
Shortly after Hazel Morrison gets to the hospital, the 30-year-old British doctor heads to the inpatient wards to start her morning rounds.
“How’s my dream team today?” she asks brightly as she enters the neonatal ward. Walking fast and talking faster, she greets her colleagues in both English and the Dinka she’s picked up over the past few weeks.
The facility itself — several large cement buildings arranged around a central courtyard — was built in 1954, and it survived the decades of civil war in Sudan that resulted in the birth of a new country, South Sudan, in 2011. As the only full-service maternity and pediatrics hospital for the million-plus people living in Northern Bahr El Ghazal, MSF’s Aweil project is almost always at or near full capacity. Today is no exception: mothers and children occupy all the beds in the ward. Others lie on mattresses on the floor between them. Hazel’s first order of business is to assess the patients to determine if any can be discharged to make way for newer, sicker admissions.
Even early in the morning, the hospital is a noisy place. Voices echo off the ward’s high ceilings — the cries of children and the chatter of conversation between mothers and family members. Large ceiling fans spin overhead and smaller oscillating fans nod back and forth in corners, adding to the din.
Though she practices adult medicine back in the UK, Hazel oversees pediatrics here. This means managing the care of the numerous malnourished children on the ward, many of whom are also being treated for related complications. She sees a lot of children with skin rashes and general sepsis as well.
Her first patient on this day, however, is a prematurely born baby. Setting her water bottle on a shelf, Hazel follows Ugandan medical officer Masereka Ronald to a bed where a young mother is resting with the child. “One of the risks of prematurity is that the newborn’s intestines and stomach aren’t developed properly, so if you feed them too fast they get an infection of the intestines,” Hazel explains as she examines both the woman and the infant. “It’s called necrotizing enterocolitis, or NEC. It’s not very pleasant, and it’s common in neonates here. You have to stop feeding them, give them everything by IV, and reintroduce feeds very slowly. Some babies survive it; some don’t.”
She bends to examine the child more closely. “This baby has had that infection for a long time, but now things seem to be settling down. We’re trying to reintroduce feeds slowly, but we don’t want to give it too fast or we might go backwards.”
Nearby, another child is recovering from congenital syphilis. “It’s a really big problem here,” says Hazel. “Antenatal care is pretty patchy in the region. They don’t test for syphilis, so we have a lot of babies who are born with it. It’s quite a nasty disease for a newborn — it causes the blood to break down, so lots of anemia. It causes infections and skin rashes, too.”
She checks the child’s skin. “This baby has done really well. The mother and her partner have been treated, too. The baby had a horrible rash all over her body when she was born, but now she’s looking really good. The rash is gone, she’s gaining weight. They have to have ten days of antibiotics, so they stay for a while. But she looks good.” If mother and child stay well they will soon be discharged, in time to make room for the bed’s next occupants.
FROM AND FOR THE COMMUNITY
Those occupants, whoever they might be, will first meet with nurse Peter Akot at the triage table outside the ward before being admitted. Though he’s only worked in triage for one month, Peter has 11 years of experience as a nurse. Originally from Akuem, South Sudan, Peter now lives in Aweil with his wife and five children. “I applied for a job with MSF because [they were] helping the children and the mothers,” he says.
Trained as a nurse by MSF in Akuem, he is proud to put his skills to work to help his community. “If MSF was not here, then these children would not survive,” he says. “I know many people who have received care from MSF. Even my children!” His second son, now six years old, was brought into the hospital when he fell ill with cerebral malaria. “My child was convulsing; he was brought in unconscious,” remembers Peter. “He was treated here, and he’s now OK — he’s in school.”
As Hazel and Peter examine patients, 38-year-old nurse supervisor Scovia Morris meets with a group of South Sudanese nurses and medical officers. Originally from Juba, Scovia has worked with MSF since 2013. “I was originally contracted for a cholera program in Juba,” she explains, but a need for qualified nurses brought her to Aweil. She was later promoted to nurse supervisor and is now a fixture in the inpatient wards. Twelve hours a day, five days a week, Scovia makes sure that her team of nurses, nurse aids, and medical assistants keep things running smoothly.
Scovia has a hand in nearly every aspect of care in the inpatient wards. Over the course of her long shifts she interacts with patients and staff alike, checking vital signs and dosages and providing guidance to less experienced members of the team. The hours are long and the work can be difficult, but Scovia is upbeat. “MSF is doing a lot for the community,” she says, “not only in this area, but in the whole of Northern Bahr El Ghazal State . . . MSF provides food for the patients, they provide blankets and soap, and free medication.”
In a region with very few economic opportunities, she and her team members have benefitted from the hospital as well. “I joined MSF as a nurse, but they promoted me to supervisor,” says Scovia. “I can now pay tuition fees for my children, I can rent a house on my own, I can feed myself. I would love if my children joined MSF, so they could be members [of the organization] in any country in the world.”
AN AGONIZING CHOICE
Meanwhile, over in the maternity ward, Scottish midwife Róisín Gormley and American OBGYN Kim Roe conduct a private consultation with a patient behind a small divider. “She came in yesterday, 20 weeks pregnant, with pain, leaking some thick fluid,” Róisín explains. “We need to determine where it’s coming from. Thrush [a yeast infection] is my first guess.”
The cries of a woman in labor emanate from the delivery room as a South Sudanese staff midwife attends to her. Four-hundred twenty-four babies were born at Aweil Civil Hospital in February 2016 alone, and each mother needs care as well. Some cases are very straightforward. Some are not.
“It’s very confusing,” Kim says about the woman she and Róisín are examining. “The patient was admitted overnight with what they say is a sexually transmitted infection, but there’s no history or laboratory investigation to back that up. It appears that her water has broken, but there’s very little fluid. She’s dilated, complaining of leaking fluid, history of rupture . . .”
Working together, Kim and Róisín use an ultrasound machine — a rare piece of equipment in this part of South Sudan — to examine a young woman who looks to be in her twenties. They confirm that her water has indeed broken, but at just under 20 weeks the baby is not nearly old enough to survive outside the uterus.
“Babies seem to survive here at a younger gestational age,” Kim explains. “But to get there is a minimum of probably nine weeks from where this baby is. We’d love her to get to 34 weeks, but that’s forever. We cannot wait for that
Having made their diagnosis and determined what they think is the most appropriate action, the two women must now talk it over with the patient so she can make the decision for herself. It’s a terrible choice. Kim and Róisín recommend induced labor, to ensure the woman’s survival. “Getting the baby delivered is preferable, before infection sets in,” says Kim. “Most of the time we don’t know why the water breaks early; sometimes it’s infection, sometimes there’s something wrong with the baby.”
Speaking through a translator, the midwives talk to the patient about her circumstances and options. In cases like this, it can be extremely difficult to frame such a wrenching decision in terms that can be understood across the divides in language, culture, and medical knowledge. “You always want to give people autonomy,” says Kim. “You want to give them options, but at the same time, the understanding of health can be very limited.”
After a few more minutes of discussion, the young mother nods, her mind made up. Róisín sighs. “She’s decided we need to rescue her, so that she can be there for her family.” she says. “She wants to go ahead with the induced labor. She needs to be alive.”
Back in the parking lot of the compound, Congolese MSF team member Joel Kambale meets up with Marko Akech, a South Sudanese driver and interpreter. So much goes on within the hospital, but there’s important work to be done outside it as well.
It is one thing to set up a medical facility. It’s another to ensure that the local community knows about it and the services on offer, free of charge. Northern Bahr El Ghazal State is a desolate place, too. There are no paved roads. The terrain is harsh, arid scrubland dotted by patches of charred vegetation that residents had set aflame to make charcoal.
Outreach is therefore essential, which is where Joel and Marko come in. As outreach coordinators, they serve as ambassadors for MSF, charged with spreading the word about the hospital, dispelling fears and superstitions about diseases and treatments, and meeting with local leaders to ensure that MSF is well accepted.
Outreach takes many forms in MSF’s operations around the world, from posters to leaflets to radio broadcasts to public performances. MSF has been running its programs in Aweil for nearly a decade, so most people in the region are aware of its existence. Joel and Marko therefore often find themselves gathering information as much as dispensing — surveying the area for outbreaks of epidemic diseases, like measles; taking stock of the nutrition situation in the region; talking to people about what they can do to look after their own health; and, occasionally, collaborating with other nonprofit organizations, as they will be doing today.
Several international NGOs operate in Northern Bahr El Ghazal, but MSF is the only one running a hospital. Our teams are therefore uniquely positioned to identify patients who might otherwise fall through the cracks. But staff must then figure out how to get them where they need to go. That can be complicated. To this end, MSF often coordinates with other NGOs to refer patients to the proper facilities for treatment. Joel and Marko, for instance, are headed out to assist Samaritan’s Purse, another international humanitarian group, with their work for young patients suffering from cleft palates.
MSF’s surgical team at Aweil Civil Hospital is not equipped to perform cleft repair operations. Samaritan’s Purse has a hospital in Juba that is. Joel and Marko plan to follow up with children MSF staff thought were good candidates for referral. They need to confirm their addresses and inform their parents of when and how they would be brought to the capital.
That’s not as simple as it sounds. Outside of Aweil, locating specific dwellings can be difficult. Settlements and village spread for miles, linked only by rutted dirt roads. Homes, most of which are one-room tukuls, don’t have addresses to speak of and rarely appear on maps. Joel and Marko will have to use their knowledge of the area to match what they know — phone numbers, town names, descriptions — with what they find.
Marko, 27, grew up in Aweil and still lives in town. He knows his way around the region and has helped bring Joel up to speed. Their first stop is a tiny settlement known as Udhum about 20 minutes outside the city center. Boys and men loiter at the entrance of the settlement’s lone shop as Nigerian pop music blares from a blown-out speaker. Marko leaves the Land Cruiser running and hops out to ask a few questions.
He also buys credit for his phone, which he uses to call a prospective patient’s family. After a few tries, they answer and explain that their home is not far away. Figuring they’re better off on foot, Marko parks the car, Joel grabs his clipboard, and they set off down some abandoned train tracks that years ago carried goods and people north to Khartoum. Following a ten-minute walk past rusted skeletons of long-forsaken train cars, they reach the settlement they’re looking for, a handful of huts situated a few hundred feet off the tracks. With Marko translating, Joel asks the first residents they meet about the patient’s family. Word is sent, and soon after, the child’s mother emerges from her home carrying a tiny girl, just nine months old.
As it happens, she’s too young for the repair surgery. Joel explains to her mother that they’ll need to wait another six to nine months, until the child is strong and healthy enough to undergo the procedures. Then they can arrange to fly the mother and child to Juba for the operation. The young mother’s face remains expressionless as the two MSF workers explain the process, but she nods to show she understands and thanks them as they leave.
The two men spend the rest of the afternoon on the dusty roads that crisscross Aweil’s outskirts, following up with the cleft palate patients on their list. Joel’s responsibilities are many and varied — the next time he and Marko team up for outreach, they might be investigating a potential epidemic, checking on patient follow-up care at a facility run by another NGO or the South Sudanese Ministry of Health, or even assessing the living conditions of people displaced by violence elsewhere in the country. “We need to know where our patients come from,” says Joel. “We look for the explanations.”
Fred D’Alauro got an early start today, going for a run with some colleagues soon after the sun rose. After a quick shower, he dressed in his tukul, donning his MSF T-shirt ahead of the walk to the hospital through Aweil’s already-busy streets.
When he arrives, Fred, an anesthesiologist, joins up with the rest of the surgical team. Their unit is small but it’s one of only two air-conditioned buildings in the complex (the other is the lab). Once inside, Fred starts preparing alongside the operating theater technicians, Simon Malao and William Kiir. Both are from Aweil and both are MSF veterans — Simon has been with the organization for eight years, and William for four.
Most mornings, they put on pale green surgical gowns, gloves, masks, and head covers and start with minor pediatric surgeries. They are on call to assist with more major obstetrical surgeries when needed as well. “The majority of the cases we see here are abscesses and burns,” says Fred. “Sometimes tropical diseases that can cause abscesses when they progress further than they would in a place like the US. Some of these people have to travel long distances to reach this hospital.”
Inside the operating theater, an oxygen monitor beeps rhythmically. Fred moves methodically, laying out all the tools he and the techs will need over the course of their shift. “We start with new drugs each day,” he explains. “We usually have a combination of ketamine and a little bit of narcotic — morphine — and a drying agent. One of the side-effects of ketamine is it causes a lot of secretions, so the drying agent, atropine, dries the mouth out to help prevent that.”
When the room is ready, Fred walks to the waiting area to meet with patients. The first is a six-month-old baby girl with a large abscess on her jaw. Clearly uncomfortable, she wails as another technician, Victor Akech, also from Aweil, gently lifts her from her mother’s arms. She goes quiet once she’s inside the operating theater and Fred carefully administers the anesthesia. Simon inspects the abscess closely, then cuts into it to drain the infection. Without surgery, it might have eventually killed her. Here, though, the team thoroughly cleans it and packs it with iodine-impregnated gauze to ensure the infection doesn’t return.
When the surgery is complete, the young patient is transferred next door to the recovery room, where Victor will watch over her. She’ll be able to go home later today. It’s the happy confluence of groundwork done at several levels — the medical work the teams at the hospital do, the outreach that lets members of the various nearby communities know what services are available, the human resources work that helps attract, train and retain qualified medical professionals, and the logistical work that ensures everyone has what they need to get the job done.
It’s no small undertaking to keep any hospital running, much less a hospital in South Sudan. But Gordie Hatt, a Canadian logistician who has completed nine MSF missions in the past three years, embraces the challenge with enthusiasm as he oversees a team of supervisors, maintenance workers, cooks, security guards, and others who are collectively responsible for keeping Aweil Civil Hospital operating as efficiently and safely as possible.
Stepping out of an MSF Land Cruiser after it enters the hospital grounds, Gordie says hello to members of his team then heads off to do his version of rounds. First on the list: checking on the two generators that provide the entire project with electricity. “Most of what I do here is supply electricity and water,” he explains as he walks past the main facility towards a garage-like shed that houses the generators. Bought locally and serviced by MSF, the massive machines run 24 hours a day, alternating back and forth to allow for maintenance.
“They’re running at about 50 amps each, so we’re supplying a lot of power right now,” Gordie says.
Generating enough power to run a hospital of this size takes a lot of fuel — the team keeps as much as 12,000 liters of diesel on hand. “That sounds like a lot, but it’s not,” he notes. “The generators burn a minimum of 6.5 liters an hour, all day, every day, 365 days a year. We also have to be prepared for the rainy season when the fuel truck can’t arrive. I’m starting to order a little extra every time now, to build up our supply.”
Supply is not the only issue in Aweil. “The dust kills everything here,” Gordie says. “This is the dustiest place I’ve worked as a logistician. Even Jordan wasn’t this dusty. At one point we had a five-day span where three different peoples’ cameras stopped working — lenses got stuck halfway out — a computer power supply died, and two or three keyboards died.”
More evidence of the dust’s destructive power can be seen in the small graveyard of broken oscillating fans near the generator building. It costs money to keep replacing them, but they’re indispensable inside the wards, where often feverish patients must be kept as cool as possible.
Water — its delivery, sanitation, and safe disposal — is another priority. Luckily, despite all appearances, water is not terribly hard to come by in this region if one has the right tools. The hospital draws its water from a nearby well.
“We generate about 1.2 million liters of water per month for the hospital,” Gordie says. “The water table is strong here, it’s only four to five meters down, so if we ever have to drill another well it’s not the end of the world.” Once extracted, the water is treated with chlorine to ensure it is safe to use and stored strategically in a series of huge tanks located across the hospital grounds. “Our main tank is a 30-cubic-meter tank,” Gordie adds. “By the time we come in in the morning it’s almost empty. We turn it on and it pumps for five to six hours to fill.”
Disposing waste water is more of a challenge, and the team has come up with a novel solution to the problem.
Gordie points to a small stand of banana trees behind the hospital. “They’re called ETAs, evaporative transpiration areas,” he says. “What they really are is a form of septic system; it’s a gravel bed with pipes running through it, a collection system that takes waste water from the hospital and runs it through a grease trap to keep grease and soap scum out of there. It’s like a septic tank, but without the black water — that stays in tanks underneath the latrines and gets pumped out periodically with a truck. The banana trees have an amazing capacity to turn water into leaves, and pass it back into the air again.”
This small grove is just one of several ETAs on the hospital grounds. Some are filled with banana trees, others with mango or sorghum trees. It’s an elegant solution to handling waste water, and the fruit from the plants is safe to eat.
“The plants deal with the water,” says Gordie, “and someone gets free food. It’s always a race to see who the first person will be to harvest a bunch of bananas.”
On the outskirts of town, inside the cavernous MSF warehouse, supply logistician Robert Reiss and his team unload a shipment from a recently arrived trailer. The warehouse, a ten-minute drive from the hospital, is the size of an airplane hangar. Voices echo inside as locally hired laborers unload heavy metal bars and corrugated metal sheeting from the truck — building materials for a new shed at the hospital complex. Motes of dust drift lazily in the dim light filtering down through the building’s windows.
The warehouse is meticulously organized, with boxes, crates, and shelves of supply materials stacked in orderly sections.
“We had 1,213 boxes come in just today,” says Robert as he takes inventory on a clipboard. “That’s 30 tons of supplies. Everything from galvanized pipe to electrical cables to buckets to toilet paper to coconut milk. I have to check everything in. The inventory system is complex and very, very well organized. Everything is assigned a specific number within a family, then every family is broken down even further. It works a bit like UPC codes.”
The supplies are ordered through MSF’s coordination office in Juba. Some are bought in South Sudan, others are shipped from MSF’s logistics warehouse in Bordeaux, France. The ordering process is just as carefully managed as the warehouse inventory, Robert explains.
“There are very strict ways to order, process, and receive receipts. If I go to the market here in Aweil and spend a dollar on a lightbulb, I have to ask that the vendor sign a receipt. Administration is very strict on that, which is the way that it should be.”
ALL IN A DAY’S WORK
The sinking sun does little to mitigate the oppressive heat as team members leave the hospital at the end of the day. Most international staff return to their compound across town around 5:00pm, although many of them remain on call for emergencies. Some South Sudanese staff stay later into the evening and through the night so that we are assuring patient care 24 hours a day, seven days a week. Others head home to their families.
The sound of dogs barking and tinny strains of dance music drift on the hot evening breeze as the last Land Cruiser enters the MSF’s residential compound and the gate is closed behind them. Everyone gathers once more beneath the mango tree for a simple dinner of stewed chicken with tomatoes, fresh greens, and rice.
This is just one MSF team, a few hundred of the 30,000 or so MSF staff members that are currently working to provide care all over the world. From triage to logistics to outreach to surgery, each team member is an essential component of the work that allows the hospital to deliver urgently needed care to the people of Aweil. The work can be taxing, both physically and emotionally, but the staff recognizes the importance of their roles. As triage nurse Peter Akot said, “There are a lot of challenges here, but we manage.”
And tomorrow, they will do it all again.
All photos © Adriane Ohanesian/MSF