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A RETROSPECTIVE LETTER FROM SUSAN THOMAS Susan Thomas, was a nurse on her second mission with Médecins Sans Frontières in Ibba, South Sudan when she wrote this letter. Susan had completed one previous mission with Médecins Sans Frontières in Uganda, and is now working and living in Sydney. Hello to everyone again and many thanks for all your mail and even those few packages which are hugely appreciated. Things here have been moving along rapidly as seems to be the Médecins Sans Frontières norm. We are frequently on the go and still have visitors from other missions and from Europe dropping in on short notice. I spend as much time as I can on the ward with the nurses and patients but much of my job takes me on the road and to integration meetings and training sessions. A few weeks ago we admitted several Sudanese refugees. They frequently travel across the border to a town in the northwest where they can be transported by Médecins Sans Frontières vehicle to Omugo for treatment. They come in groups, bringing with them their pots and plates and cups and blankets. Often they are thin and weak and the disease is usually advanced. They look rather dramatic with their decorative scarification on their faces. Madonna has yet to exploit this fashion trend....This time we admitted a family with a 12 year old girl, Lorna (not the Sudanese name you'd expect). She was to receive treatment first while her mother was her attendant. Unfortunately Lorna was also suffering from a parasite common in Sudan called microfilaria. It is a nasty wormlike thing that you can see actually moving under the skin and maybe if you are very unlucky, swimming across the eye! It causes river blindness and is also called Onchorsociasis. If I ever get that....I will require heavy sedation followed by intensive psychotherapy not to mention immediate treatment including a complete blood transfusion and anything else going! But here it's business as usual, all in a days work. This parasite seems to precipitate the dreaded Arsobal Reactive Encephalopathy, characterized by high fever, cerebral edema and hemorrhage with convulsions...and at this stage the prognosis is pretty poor. In the evening Lorna's temperature rose to 38.4. All seemed quiet until the early morning when she began to have convulsions. The nurses started the protocol, giving IV dexamethasone for the inflammation and valium. This was followed later by phenobarbitol for seizures, lasix for fluid accumulation in the lungs, antibiotics for aspiration pneumonia and hydralizine for hypertension. She fell into a coma. An airway was inserted and we suctioned her, using a foot operated suction machine...like a treadle sewing machine. In the open ward, all the other patients were subdued. Her mother and sister looking on, children and attendants gathered near the doorways and watched and waited in silence. All efforts were in vain and despite heavy sedation, Lorna died a rather gruesome death that night with the seizures continuing until the end. While Lorna's mother and family were obviously distraught, the pressing problem of what to do with the body was foremost in everyone's mind and had to be resolved on the spot. Taking her back to Sudan was out of the question due to transport and time constraints. There is no refrigeration, no morgue, and no funeral parlors. It is hot and humid. Burial requires land ownership and the family owned none in Uganda. A general meeting was held in the nursing station with the mother wailing on the floor and the sister crouching at the entrance (this is a position of respect I have come to observe). Another Sudanese man acted as a translator and it was decided that Lorna's body would be taken to the nearest Sudanese Refugee Camp where a relative lives. She would be buried there, far away from her home and her family. Her mother and sister must now stay behind and undergo the same dangerous treatment-anything else is certain death but how they must feel we can only guess. Poverty and its hardships have a way of overshadowing emotions we in developed countries are free to indulge in, like grief. You just have to get on with it. I have been listening to the stories of people around me, ordinary people whose lives have been directly affected by violence, corruption and poverty. Many families have lost a few men in wars and rebel attacks and women in childbirth and babies and children through illness or accident. It is not uncommon for people to just die suddenly, or after a short acute illness that goes undiagnosed. There is no equipment for X-ray or ultrasound and no pathology. Even if there were, there is virtually no treatment available. Diseases like Diabetes or Epilepsy go undiagnosed and untreated. Medication is in short supply, and hugely expensive and supply is unreliable. Sometimes I wonder why people bother to come to the health centre as they just languish on a mat outside, receiving care from their attendant only. Either they get better or they don't. Maybe there is a belief in the healing vibe radiating from the building? We met a man in Moyo on the street who was suffering some sort of mental disturbance but knew a lot about helicopter mechanics and military operations. Turns out he was based as a military mechanic in Texas, later captured by Tanzanian rebels and tortured, later rehabilitated, then retrenched and now wanders the street, dressed in rags with an old tie. He has a pension though and people were kind enough to him. I have also met many people displaced by fighting and war, moving from country to country wishing mainly for an education or a job. The army is always well paid and well fed here while people have limited access to health care and education. You can see it all around you. These are some of the stories I have been listening to lately, as I get to know people a bit better and they tell me a few things. Beside theirs, my travel log seems frivolous and rather silly. Still, all my impressions will mix and blend together and are shaping up to be a most interesting and rewarding experience. So, on that cheery note I will end this lengthy letter. Susan Thomas
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