Road Tripping

There has been a long hiatus between the last blog and this, partly due to a lack of internet access for 5 weeks combined with the fact that the original version of this failed to publish when I wrote it some time back. Here is round two in a briefer form, you will probably be relieved to hear.

The painted sign on the bus bumper read ‘Relax, Jesus is in control’. This seemed like a good thing since the grinning glazed-eyed gentleman behind the steering wheel did not inspire confidence. However just a few miles into the trip it dawned on me that Jesus is probably usually chauffeured around and that would certainly explain the erratic driving on the wet potholed road to Torit.

That’s right, we were on a road trip in South Sudan; the first of a couple to see the other health facilities outside of the capital to get a feeling for the different facilities available in the various states and to see the differences between a state-run and government-run hospital.

Road-trip 1

Torit is in the South East of South Sudan, a small town en-route to North Western Kenya. The town was quiet and friendly and it was easy to pass days with our American colleagues in the roadside tea houses. The hospital was a state-run place and surprisingly quiet. There are no tarmac roads here so road trauma is sparse and the busiest ward was male medical filled with liver disease. The paediatric ward had the obligatory ‘child fallen out of mango tree’: the mango season contributes hugely to child trauma as when stones fail to knock down the succulent fruit the rascals head up the tree themselves, often with friends still firing up rocks! The only female patient had been chopped by her husband with a knife.

Road-trip 2

Yei is in the South West on the road to the Democratic Republic of Congo. Two of my junior doctors had left Juba hospital to work down there as they felt they were treated better in this busy State-run unit. Yei is the second largest city in South Sudan and often described as the most beautiful. It certainly was a stunning place to see; the rough dirt road that took us there became a deeper shade of red the closer we came and palm-nut trees started to rise up from the bush as the scenery became more Central-African. Describing it as the second city is a big claim as it is tiny in comparison with the rest of East Africa and would constitute an average-sized town elsewhere. There are a couple of tarred roads in the city centre which are always a pleasure to see. The hospital was very busy and we were toured round by Joseph who worked with us in Juba. Here the junior doctors do everything- medicine, surgery, obstetrics and gynaecology and paediatrics. The accommodation was good in private houses a short walk from the hospital and free use of a 4x4 motor!

Road trip 3

Not exactly a road trip as a plane trip. After calling in some favours we landed ourselves a flight to Malakal in the north of South Sudan where up until recently there has been heavy fighting. This is the 4th largest city and is the base of one of the three medical schools. We climbed off the plane and fell directly into a swamp. After wading to one side we soon realised that the whole place was a swamp- and we arrived after a dry couple of days! First problem: accommodation. The recommended hotel was a simple one storey structure habituated by a large force of the SPLA (army) and in the reception was a crowd of grenade launcher-wielding troops waiting for their Commander. The rather steep $325 USD price tag for a room for the night saw us quickly vacate the premises.

Then began the long trudge in the blazing sun looking for a roof to cover us for less than the price of a kidney sold on the black market. This was to prove impossible until we stumbled across the International Red Cross who have established a trauma unit in the hospital. We were hoping to meet them to discuss the state of the hospital and they were aware of our arrival having been warned by our ICRC friends in Juba. Immediately we were accommodated, fed and toured round the hospital. Their kindness was amazing, and a huge relief after our wanderings in the sun, stumbling across drunk soldiers at check points and obstructive security guards in some of the very few cars in the town.

The hospital was basic and not particularly busy- generally a bad sign in a place with so many people, though you could see how hard it might be just to get to the hospital with no roads. They did, however, have doctors, which is at least something.

All in all an interesting time, and a great opportunity to see what is outside of the bubble of Juba. You very quickly realise just how well served the people of Juba are compared to some of the surrounding states.

Sorry the pictures are out of order.. starts with Malakal:

The view of the Sudd on our way to Malakal

Self explanatory I think!

A view of the river Nile behind the hospital

Theatre

The Surgical Ward

Swamp!

More swamp..

Onto Torit..

Now Yei..

The road out of Juba - so this is where the rubbish goes, depressing

Some interesting public health signs all over Yei hopsital in particular

Not Art for those non medical readers, but Anti Retroviral Treatment (or HIV centre)

Theatre

Medical ward, note the mosquito nets (not in any of the other hospitals, including Juba)

Joseph on the left and Stephen on the right

An Inspiration

Completely unrelated to this blog, but us enjoying a drink after our tour of the only brewery in South Sudan (Corlia, Louis and their son)

Braving the boda bodas

With our time in Juba drawing to a close it is worth mentioning the medical students again, for they have earned a full blog to themselves.

We arrived with intentions to teach the junior doctors but were unfortunately bowled over by indifference and disinterest. After writing talks and lectures only to deliver them to an empty room (or the occasional nurse specialist) we were rapidly losing enthusiasm. This was, however, thankfully short lived as the first four medical students came strolling into our lives.

Some recent history:
Back in the depths of time, before the civil war, the medical school in Juba thrived. Teaching was done in the Government hospital (I believe it has retained its name from this time) and doctors emerged to serve the sick of Sudan. During the conflict the three medical schools based in the Southern part of Sudan: Juba University, Upper Nile University and Bahr el Gazal University medical schools, were relocated to Khartoum in the North, the capital of the country, for safety. The students were still a mix of people from both the Northern half and the Southern Half of the country but as time passed the lecturers of Southern origin vanished leaving University staff of almost entirely Northern origin. The University infrastructure, equipment and all other teaching tools were basically owned by the North. With the Comprehensive Peace Agreement (CPA) signed in 2005 to end the war work began to build a Southern Sudanese State and eventually an obvious part of this would be the relocation of the medical schools. When term ended in November 2010 the three Southern University Medical schools were officially shut in the north but since then there has been no sign of them opening in the south. It takes no mathematician to work out that this is now a whole year with no formal education. The fact that the medical schools have yet to open is not a huge surprise since there are few lecturers, few buildings and no teaching aids. There has been fighting in Upper Nile as recently as the last few weeks, and when we visited the hospital a couple of weeks back there was certainly no way it could accommodate students and despite its enthusiasm Bahr el Gazal still needs a lot of work to provide adequate pre and post clinical training. If the closure continues there will be serious repercussions for healthcare in this emerging country. I have yet to hear anyone sound concerned that there will be no new doctors graduating this year at all. That means no house officers at all. Nil. None. In a country already short of doctors this is a disaster. My biggest fear is the tragedy of a student trained for 5 years of his 6 year degree but unable to finish due to university closure and then starting his carreer somewhere else. Perhaps he (there is a good mix of men and women in medical school so I use the male sex merely for ease) will be pouring bottles of beer for the multitude of expatriates every evening lamenting how he almost graduated medical school as the disbelieving faces gaze through him, if not believing not really caring anyway. The problem for the medical school is that with medical students and doctors, in the ‘aid world’, you don’t get much bang for your buck. Midwives, they get cash, and this is good news especially in a country with the highest maternal mortality on the planet. But it is much much cheaper to train a midwife than a doctor. But a healthcare system cannot function without doctors.

I must add here that clearly it is not a bad thing to be pouring beers for a living, just that 5 years of medical school prepares you for something different.

But that is the rant over, though I hope it gives you a little more understanding as to what has been happening here behind the scenes. So what of us? I take you back to those four keen and resourceful souls who pitched up on ward 4 medical and asked Heidi and me if we would teach them. We said yes, and not because of us but because of them, something amazing emerged.
Those few joined rounds, talked to patients and presented them to me on the wards. Once a week we did formal classroom teaching on examination skills and every week all of them were there. And yes, by ‘all’ I mean 4, but this is four students who have chosen to turn up. They travel in from their homes on their own savings from part time jobs in the bars or laundry houses. If they were running late they would call and beg us to hold on for them. In the classroom after the lecture while we had them examining each other under our critical eye they took the criticism and advice and, most rewardingly, remembered it the next week. And all this when it did not count at all to their formal training. It got them no closer to a medical degree; no closer to becoming a doctor. But they came.

After a few months of this the numbers started to swell. We gradually increased our sessions from one day a week, to three and finally four, as we stopped all attempts at teaching the junior doctors to focus on this remarkable group of students.

By May our numbers had reached 10, by June 30 and by July 40. Our tiny office was chocablock. Having finished the examination skills we were now on to generic skills such as interpreting the chest X ray, Abdominal X ray and the Electrocardiogram and more specific topics such as triage, airway skills, diabetes and stroke. The list could go on but at the risk of boring you we’ll move on. However the new arrivals had heard about the examination skills sessions and asked for them to be repeated. We agreed and to ensure the small group nature of the sessions Heidi divided them up into groups of 14 and we ran evening classes. By this time we were working during the day at the military hospital (but that is another story) so the classes ran from 5pm until 8pm and again the turn out was extraordinary. And again, it counted (officially) for nothing.

The evening classes were awesome, sharing cokes and seven up that we picked up on the way over, eating ground nuts and prodding abdomens or listening to hearts (I even got my hands on some ophthalmoscopes for the eye exam and otoscopes for the ears but the less said about that the better). One evening our room was open because some decorators had been in to paint. The temptation for them had been too much and they had drunk the case of softies we had left in the cupboard. They denied it but their room full of empty cans gave it away. And who could blame them? Its bloody hot and they work from 6am til 7pm and sleep on the ground at the site to earn single figure dollars to send back to their families in Uganda. We picked up an extra crate for them the next time and asked if they would leave the ones in the room for the students: and they did!

Anyway, with our time coming to an end we could not help but worry that it would ultimately all be in vain. The university does not look like it will open soon and there was no one willing to take up the training. No one, that is, until Harvard Medical School with Massachusetts General Hospital stepped up. After stumbling across a group of preclinical students doing biochemistry on a step using a stick in the sand they had already started some physiology lecturing informally. They then flew out some trainers to run a full six week course covering all the basics that we had done plus more in hired classrooms and we topped the whole thing off with a written exam and practical exams (OSCEs) with Heidi and me involved in the examinations. The advertising brought in 170 students from outside of the city (Heidi and I alone were clearly not enough of a draw!). The whole event ended with a huge ceremony attended by the vice presidents wife and certificates were awarded for attendance and academic achievement. It was an amazing day filled speeches and photos but to see them actually walking away with a signed certificate endorsed by ‘Mass Gen’ was sweet as a nut. Sure, the university has not opened, and sure they are still no closer to becoming doctors, but this came as some reward for the hard work to this point that has not gone unrecognized. Their hunger to learn, their tenacity to improve things for themselves and not simply accept the hand they were dealt and resilience to the hardships that would break most others and to do all this without bitterness or resentment should be an inspiration to us all, especially those who like me have had education handed to them on a plate, in a world where surviving is, quite simply, easier.

This is a tribute to them, though not one will have this blog address, and an invitation to us to make the most of everything we have been given.

The OSCE exam

Some of our hardcore - Bol, Wani, Nyuiping and Chol

The ceremony

Mori receiving his certifcate with Michele one of our American colleagues on the edge.

UNMISSable

UNMISS is the ‘UN Mission in South Sudan’ (prior to July 9^th it was UNMIS: ‘UN Mission in Sudan’). Hence the staggeringly entertaining title that came to me while sipping ‘cacaday’ (that is how you say it but probably not how to spell it) or ‘hibiscus tea’ to us English speakers.

We met the military medical team at the Bangladesh level 2 hospital some months ago purely by chance. We bumped in to them when they were touring Juba Teaching Hospital in March and they were particularly keen on meeting Heidi because she could act as a back-up anaesthetist in their surgical unit if Parvez (their anaesthetist) became incapacitated. From then on the relationship grew and we spent time teaching the Sudan Peoples Liberation Army (SPLA) Cardiac Life Support with them and starting up the joint clinical meetings between Juba Teaching Hospital and the UNMISS hospital which started off very well, allowing both an educational and cultural exchange between the South Sudanese and the Bangladesh doctors.

The first joint session with BANMED and JTH

Us at Iftar

The SPLA house officer training

The panama amongst the berets outside of the teaching room

James entertaining the troups during the training

From then on a great friendship blossomed and we have been back many times and always been met with such warm hospitality and over-whelming generosity that time spent there has been nothing but a pleasure. Within seconds of walking in a spiced tea is in your hand and Bangladesh cuisine is soon to follow, anything from a snack to a full blown meal. I certainly never thought that I would come to South Sudan but learn so much about Bangladesh.

During August they were fasting for Ramadan and invited us to a big Iftar celebration one warm Saturday evening when they had invited all the Bangladesh community with the UN to breakfast. After arriving and sharing what appeared to be a full meal the whole party headed back to the mosque to pray, leaving Heidi and I alone to discuss how great the meal was and how full we were. Moments later they returned and announced that now we were to enjoy the main course! While this was enjoyed we sat down to a history video on the Qur’an.

The Bangladesh group donating some drugs to JTH

Dr Robert and Charity enjoying the food after the second joint meeting

Famous at last!!

A visit some weeks later was to celebrate the return of the Bangladesh troops from the border hostilities. A hall was packed full of the soldiers all cheering a band with bag-pipes playing at the front (yes, the Bangladesh army use bagpipes!) and what followed was a full cultural show- and we were escorted to sit in the sofas at the front with the head of UNMISS and other guests of honour.

The cultural show a comedy sketch

Us in our seats of honour with the hardworking soldiers behind

Evidence of the bagpipes, a kick back from colonial days!

We have met some wonderful people here that have shown real hospitality when things were tough and this is really just a tribute to one of those groups that has helped shape our time here through both their kindness and their willingness to share their lives with us. It has also given us another holiday destination for the next year.

Gift exchange (don't worry we didn't just give them a book!)

The lovely drivers that often took us back and forth