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Letter Home from Cote D'IVOIRE
A New Zealand medical doctor from Christchurch, Emily Gill, writes about her impressions of her first month on mission in the west of Côte d’Ivoire, where Médecins Sans Frontières (MSF) has a primary health care clinic and a therapeutic feeding centre (TFC) in Guiglo. The mission begins After a fantastic Christmas and New Year’s with family, I finally landed in Abidjan, the capital of Côte d’Ivoire. After one night in Abidjan, we started the seven-hour road trip 500 kilometres west to Guiglo. The road was paved, straight and wide enough for all the trucks, NGO vehicles and private cars to safely share. The countryside is dusty still (rains starting in the next few weeks), but surprisingly green. Guiglo is a town of 40, 000 people, situated next to a large river that appears to be more of a slow-moving swamp surrounded by jungle and dense bush. ‘Le Base’, the MSF office and my home, is in the industrial part of town, so no great scenery, but rather has the advantage of being central and among the townsfolk. I arrived in the early evening to be greeted by the usual crew that mill around the place at the end of the work day. . .the ex-pats, local staff and other acquaintances. It was a warm welcome, followed by a truly refreshing shower and then to bed. The following day was busy exploring the two medical facilities we operate. Daily RoutineWork here is most notably different from my last three years of work in that I have at least one hour lunch break a day! The day starts at 8am when I leave ‘le base’ for either the clinic or the malnutrition centre (TFC - Therapeutic Feeding Centre). There are three of us doctors and we rotate weekly so that two of us are at the clinic, while the other is at the TFC. We work until around 4pm and then take turns being on call for after-hours work at the TFC. I spent the first 4 weeks at the clinic. It’s basically a walk-in GP clinic that’s super busy. The clinic is a dirt square compound that has a building at one end with two consultation rooms, paediatric observation room and a dressing room. The pharmacy, vaccinating room and the nurse’s consulting room are in a building running along the other side of the compound at right angles to the first building. The remaining sides of the square are taken up by triage and waiting room areas, where initial investigations are done such as temperatures and a finger-prick rapid malaria test (‘Paracheck’). The whole system is incredibly well organised and efficient with very competent local staff, most of whom have no formal medical training but have learned through their work with MSF. So, when we arrive, there are often some emergencies for which we either can start infusions and treatment on site, or we send them to the local hospital. The bulk of the day is spent sitting in the consultation room seeing the patients, around 5-10 minutes per patient. At the TFC, the routine is a little less hectic. The day starts with visits with each of the kids to monitor progress and decide when kids can go to the next stages (to start eating Plumpy’nut*) or if additional medications are needed. This usually takes 1-2 hours to see the 10-15 kids in the initial stage. On Tuesday to Thursday, a team of us drives to various villages to hand out food rations and follow-up with the kids who have left the TFC. Kids are kept in the nutritional program (including these visits and food rations) until they have been two consecutive weeks above their ideal body weight, and have no other medical problems. *Plumpy’nut is a ready-to-use-foodstuff (RUTF) made from a peanut milk-paste enriched with nutrients. On my first such visit we travelled about 60 kilometres west of Guiglo on Thursday, towards the Liberian border, and the landscape was beautifully arranged with the occasional granite rock hill, with impressive rock faces standing out against the green of the forest and jungle. Around 4pm, we all return to the base. The following few hours are always filled with sorting out medical emergencies (MSF supplies surgical kits for some patients), having meetings about how the clinic or the TFC is running, sorting out the pharmacy, reading up on medical issues, and finally, around 6pm we have a lovely shower and unwind. Medical Work At the clinic, the most commonly treated condition is malaria, followed by lower respiratory infections, gastroenteritis and then a whole range of both familiar and exotic conditions. My focus so far has been on learning to appreciate the subtle early symptoms of malaria and typhoid that are potentially so serious and yet are hard to pick up in the early stages with limited diagnostic capabilities. In general, there are so many potential nasty infections around that even if the symptoms are nonspecific, it’s necessary to treat aggressively. Certainly there are plenty of nasty cases that do present in fulminant disease to justify this! I never thought I’d feel so many spleens or see such classic presentations of bacterial pneumonias. So my challenge is to have a higher level of suspicion for the weird and wonderful, while still trying to treat rationally, in a context where follow-up is difficult. Fortunately, the two other doctors here are very competent and are great to bounce ideas off when deciding on a course of action. This past week I began working at the TFC; I suspect this is going to be my preferred medical activity. Malnutrition is a medical condition I knew nothing about until I arrived. Essentially, it’s a total body disease that happens when the body stops absorbing adequate nutrients. This may be due to lack of food, but here is more commonly a result of a series of infections that play havoc with a young child’s ability to absorb food. For instance, the combination of a diarrhoea and/or vomiting illness, with malaria and perhaps a lung infection thrown in, are usually present for a week or so before the kid turns up malnourished. Of course, social factors such as early access to medical care in the early stages of such illnesses and/or the family’s ability to ensure additional nutritious food during an illness contribute to why some kids end up malnourished. And so, due to this total lack of nutrients, all parts of the body are affected from the brain to the liver, to the immune system and to the heart. People are prone to this problem from six months to five years as this is the stage where the body requires a lot of nutrients to develop and grow (this is why kids need more than just breast-milk from six months onwards). So, all this to say the TFC is full of agreeably aged kiddies, which makes work pleasant. Furthermore, especially for kids where the malnutrition is recent, treatment is very effective, with obvious improvement over just a few days! Here’s an example from last week. A father arrived one afternoon with his seven year old boy, reporting he’d become all swollen over a few days and had been having fevers with some gastroenteritis for the last one to two weeks. He indeed was quite swollen, unhappy and tired. Since he was older than the kids at risk of being malnourished, we wondered whether it was another medical problem (a kidney problem to be precise). But, the urine sample that would indicate this was fine so we decided to treat him as malnourished. This means he could only drink fortified milk until his swelling went down. Naturally, the poor kid was upset as he wasn’t allowed to eat as he wanted to, but now, one week later, his swelling is gone, he’s starting to eat Plumpy’nutTM, the high-energy food given to malnourished kids, and he’s now smiling and looking like a normal kid! It really is a privilege to work in this area of medicine where results are so tangible. Read other articles on Côte d'Ivoire
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