Saturday, May 19, 2012

May 19th, 2012

I'm sitting in the airport terminal at the Juba airport, preparing to return to the US after my first stint working as a teacher of junior doctors at Juba Teaching Hospital. As I watch expatriate aid workers arrive on the incoming flight from Nairobi, I feel like a seasoned veteran. And yet I've only spent two months here. Sixty days. Barely any time to even get acquainted with a place. Eight short weeks. In some ways, though, it certainly seems like it's been longer.

Working at the Juba Teaching Hospital has been challenging. Lack of essential medications, equipment, and skilled manpower makes taking care of very sick patients even harder than it should be. Certainly, some patients present too late to be saved, even if they were cared for in a first-class institution like Massachusetts General Hospital. But many patients present very sick, yet early enough that they have a chance. Unfortunately, many that should make it do not.

Our goal is not to bring MGH to Juba. That is neither possible nor a good use of time or funds. With diligence, patience, and a cooperative attitude, we hope to raise the level of care to one that is expected of a national referral hospital in Africa. This is feasible. This is necessary. But it won't be easy.

There is so much work to be done. When an elderly patient admitted tp our ward with diarrhea and weakness, unable to care for herself, receives no nursing care for 24 hours, or when a lecture I worked on for several hours is attended by less than half of the junior doctors expected, I feel disheartened. When a patient dies because there is no IV tubing to give medications and fluid, or when a patient with severe anemia fails to get the prescribed blood transfusion because no one walked the 25 meters to the lab and brought the blood to the patient, I feel like the challenges here might be too great after all.

Yet we get up the next morning, and we try again. We encourage the nurses again to clean the patient in need. We work with visiting pharmacists to address the myriad of medication issues plaguing the hospital. We bring in expert nurse instructors to coordinate between the ministry, hospital, and the school of nursing to improve nursing care. And we work side by side with the young physicians that are charged with caring for one of the most impoverished and traumatized people of the world.

Jeff Pierce, MD

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Thursday, May 3, 2012

May 3rd, 2012

Dr Rae Wake teaching on the Emergency Medical Ward, Juba Teaching Hospital

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May 3rd, 2012

Since starting work as a consultant on the Emergency Medical Ward in January I have had my fair shares of ups and downs. But what makes the inevitable frustrations of working in such a resource limited setting as South Sudan worthwhile, is the hope I see in the people we are here to train and support. In this blog I will try and share some of these day to day stories whether from our ward, the classroom or from the many people we meet every day who are also striving to improve the health care system in this brand new country.

This week I gave blood. There is an unreliable blood supply at Juba Teaching Hospital. A family sized fridge, with a fickle power source supplies blood transfusions for over 500 patients including elective and emergency surgeries, paediatrics and obstetrics – a major need when it comes to emergency transfusions since bleeding in pregnancy is the most common cause of death. MGH has set up a ‘Virtual Blood Bank’ and now over 100 internationals in Juba are signed up to give blood at short notice for patients who do not have family members to donate or to keep a small emergency supply for when every minute counts. Since November, the blood bank has always had enough to supply transfusions for these critical cases. As the lab technician Ahmad set me up for my donation, I asked him how things were before the VBB existed. ‘It was terrible working here before’ he told me ‘there was always a demand I could not meet. I remember once there were 4 children who needed urgent blood at 3 in the morning. I came in, put a needle in my own vein and donated enough blood for them all.’

One of the many big challenges we’ve faced on the emergency ward is a very poor capacity to deal with ‘emergency’ cases such as diabetic ketoacidosis (DKA). This often affects young people, is a life-threatening condition and in well resources settings with adequate nursing care is relatively easy to manage. I can think of four young lives that have been wasted on the ward due to DKA so it’s been a focus of our training sessions with both nurses and junior doctors. Residents Ne and David developed a protocol during their month long rotation which simplifies the management in recognition of the situation – little ability to measure blood sugars, urinary ketones, no fridge to keep insulin in, no nurses capable of managing an insulin infusion etc. And we have started to see the management of DKA turn around. The junior doctors are carrying these protocols around in their back pockets. They stay on the ward until late in the evening making sure patients get the right treatments. There is still a long way to go I realized when the head nurse told me there is no way that drugs can be given hourly on this ward. But today I found a house-officer sitting with this nurse, explaining the protocol and the importance of hourly insulin doses. So much better when it comes from the South Sudanese doctors.

One of the most rewarding groups to teach that I have worked with so far are the Clinical Officer Students. These guys have 3 years training before they work in some of the most isolated areas – often as the only medical personnel in a health facility dealing with every kind of problem imaginable. The students are bright, enthusiastic and super dedicated to the ward – the first ones there in the morning, coming in on their days off to check on patients, coming to all our teaching sessions and asking hundreds of questions. I had a ‘heart-sink’ patient today. An emaciated lady who had travelled from far out of Juba, unable to communicate with anyone on the ward in her local dialect, dehydrated and malnourished with horrible bed sores and no money to pay for any tests or treatments. Godfrey, one of the students stepped in to save the day. ‘She really needs to be washed and have the sore dressed’ he whispered in my ear, ‘I will go and buy her some things’. And off he went, visiting 3 private pharmacies to find the right stuff, refusing to take any money from us, instructing the nurse how to care for her. I can only hope this student keeps this incredible sense of justice and compassion as he enters in to the real world of work in a years time. 

- Dr. Rae Wake

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Monday, January 30, 2012

SOUTH SUDAN: Building a blood bank

JUBA, 25 January 2012 (IRIN) - A small fridge in the corner of Juba Teaching Hospital’s laboratory is the only blood bank in South Sudan, the world’s newest nation with some of the worst health statistics in the world.

Health workers say a lack of blood is the main cause of mortality at the country’s main but extremely under-resourced hospital, and they face the anguish of having to watch patients who could be saved die.

“Sometimes they bleed until they die and we cannot do anything about it,” said Wani Mena, head of the hospital.

“The first cause, the major cause, of maternal mortality in our department is bleeding,” said Chuol Kuma, an obstetrics and gynaecology consultant.

While the rest of the hospital is sometimes left for days without power due to frequent cuts, capacity to keep more blood is hampered by only having a small fridge in the laboratory - the only room with a back-up generator.

“The blood bank we have is a very small refrigerator. It only takes around 50 units of blood. This is not enough,” Kuma said.
A 20-year-old mother of two recently died after suffering complications from a late miscarriage. “She needed an immediate blood transfusion and she needed blood and then she got the blood late and died,” he said. This woman, like many others who enter the hospital, was already anaemic. “The need for blood is so great in this place because of injuries. Anaemia is one of the most common presentations to our hospitals, both of women who are pregnant and for those who have malaria... and sometimes they die from it,” said Mena.

Fight for blood

But most of the time, the small amount of blood in the family-sized fridge cannot be touched even in emergencies, as it has been donated for specific patients due for surgery. “Currently the system that exists is that somebody gets sick, relatives come and donate blood. That is not a good system. We should have a stock of blood that we can give to any patient in need of it, and immediately,” said Mena. Cultural taboos and a lack of awareness about the risk-free benefits of giving blood also mean that getting relatives to give blood to save a life is often a struggle that staff do not win.

“In some tribes, somebody cannot, for example, give blood to his in-law, or somebody cannot receive blood from a foreigner, things like that,” said lab supervisor Charles Stanley Mazinda. Other staff say families avert their eyes or want to know their loved one will make it before committing themselves.

Amin Gerald, a nurse at Torit Hospital, about four hours’ drive from Juba, said he had come to give blood for his wife. He understands the importance of giving blood, but would not do it for a stranger. Gerald says he often comes across people who believe that giving blood will make them ill or weaken them, or that blood should never be mixed as it could kill the patient.
But Mazinda said that when there is an emergency, people rush to the laboratory expecting blood, only to find it cannot be touched.

Photo: Hannah McNeish/IRIN
"There’s just not a lot of cultural education about giving blood and still being healthy"
Fighting fear

Technician Charity Ritti said the laboratory used to divert blood to emergency patients whose relatives promised to donate afterwards, but when they did not come back, staff faced a backlash from donors. “The owners of the blood will come and quarrel and sometimes they even want to beat us,” she said.

Ritti is concerned that often the bank only has one unit of key blood types, such as O-negative, but says changing people’s mindsets to build up reserves is extremely difficult. “They are afraid of donations - we have people coming here from Kenya, Uganda and Khartoum [Sudan] and giving blood... but our people here cannot face free donations,” she said. “Sometimes we screen them, then we say go and have breakfast and they never come back,” she said.

Changing attitudes

Hospital staff say awareness campaigns and better medical education are needed, among the huge challenges facing a nation where only 16 percent are literate and very few have access to health facilities. Even local doctors admit they too are scared to donate.

“There’s just not a lot of cultural education about giving blood and still being healthy. I think in the US and UK and Europe we are very educated about that,” said Matthew Fentress, an American doctor working at Juba Hospital. In addition, Mazinda said getting people to the blood screening stage was a challenge, as people feared finding out they were HIV-positive. “Sometimes we screen some blood donors, and when they are [HIV-]positive, we tell them to go to the VCT centre down the road, but some of them don’t reach there [and flee],” he said.

Bridging the gap

The government is planning to build a national blood bank here this year that will hold up to 200 pints (113 litres). Meanwhile, doctors from the Harvard Initiative in Massachusetts have set up a “virtual blood bank” to try to beat storage and power problems. The bank is made up of a database of pre-screened volunteer donors who are willing to come in and replace a unit of their blood type.

Fentress said this would free up blood for emergencies and when the hospital cannot get blood from patients’ friends and families. “Right now we’re really focused primarily on foreigners, as their attitudes are already changed,” he said. The hospital is advertising on the internet and in community centres, such as churches, until a government campaign hopefully ensures South Sudan’s first “real” blood bank is filled.

“It is just the beginning and I hope it will succeed. But I think they need assistance from the communities. There must be medical education or health education for the communities so that they accept to come and donate freely so that we may have enough blood in our blood bank,” said Kuma.

** Matthew Fentress is a Fellow with Ujenzi Charitable Trust


Theme (s): Conflict, Health & Nutrition,

[This report does not necessarily reflect the views of the United Nations]

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Friday, January 20, 2012

Home more dangerous for S. Sudanese women than war

South Sudanese who fled the recent ethnic violence listen as a woman describes the attacks, in Gumuruk, Jonglei state, January 12, 2012. REUTERS/Hereward Holland

Katy Migiro

NAIROBI (TrustLaw) – The greatest risk South Sudanese women face is in their own homes, despite the more obvious dangers posed by continued fighting, according to a new report by the Small Arms Survey.

South Sudan became independent last July following two decades of war with the Sudanese government in Khartoum. But nationhood has not brought peace, with over 325,000 people forced from their homes in 2011 due to a surge in fighting between the army and rebels and between rival ethnic groups, according to the U.N.

“The main threats to their security come not from traditional external sources, such as militia groups or armed conflict with Sudan, but from within their own homes,” the report said. "In the home, the place where they should feel most secure, women face numerous threats.”

Gender inequalities, rooted in culture, are often to blame, as well as chronic poverty and a lack of development.

Child marriage and domestic violence are socially accepted norms.

“I was 11 years old when I was promised in marriage,” said one 24-year-old interviewee, describing how she used to run and hide from her future husband when he came to visit as she only wore underwear at home.

“I didn’t want to marry him, but I didn’t have any choice. I had so many brothers who needed cattle [for marriage] and this man came with 30 cattle, so my father forced me to marry him.”

In South Sudan, as among many traditional pastoralist communities across Africa, the bride’s family receives a dowry, or bride price, from her husband’s family as a symbol of their appreciation for agreeing to the marriage. This is usually in the form of cattle.


Domestic violence is endemic in South Sudan, the report said.

The majority of women interviewed accepted domestic violence as a normal part of married life.

Two interviewees said their friend, who was four months pregnant, had been kicked in the stomach by her husband and admitted to hospital the previous day.

“Although they said she clearly hated and feared her husband, she was forced to return home with him,” the report said.

“Her friends explained: ‘Where else will she go? What will she do? She cannot divorce him; her family will not accept it.’”

Divorce is rare. Aside from the family pressure to remain married – as divorce would force the woman’s family to return the dowry cattle – mothers fear losing custody of their children.

Under customary law, children who have stopped breastfeeding should live with their father if their parents divorce. In some communities, they may stay with their mother up to the age of seven.

“The risk of losing their children forces many South Sudanese women to remain in abusive marriages,” the report said.


Statistically, the greatest threats to South Sudanese women’s survival are pregnancy and childbirth:

  • Maternal mortality rates are the highest in the world.
  • One in seven South Sudanese women will die in pregnancy or childbirth, often because of infections, haemorrhaging or obstructed births without access to medical care.

All of the women interviewed said they wanted to have as many children as possible. “There is no limit; if I can have 15 or 20, then I will,” one female interviewee said.

During the independence struggle, childbearing was encouraged as part of the war effort.

Married women are expected to have children every three years until menopause.


However, the majority of women interviewed perceived hungeras their biggest threat.

South Sudanese women eat whatever food is leftover after the men and children in the house have finished.

  • One in three South Sudanese are either moderately or severely food insecure, according to the U.N.
  • Prices of staple foods, such as maize and sorghum, jumped by 100 to 250 per cent between 2010 and 2011.
  • Hunger is expected to worsen in 2012, with the U.N. predicting a 40 to 60 per cent drop in cereal production.

The report draws on interviews and focus groups conducted in South Sudan in 2010 and 2011.

It calls for a more people-centred approach to security, rather than the traditional military notion of state security, to safeguard women’s lives in South Sudan.

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