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FROM SUDAN Michael and Christine Shanahan are a husband and wife team working in the Kalma IDP [Internally Displaced Persons] Camp, South Darfur. Dr Michael Shanahan is a doctor who works as a physician at a Sydney hospital and Christine Shanahan is a nurse. They have both previously been on mission together in Uzbekistan, this is their second mission.
At first look the girl was like others in the shelter. Four had a nasogastric tube in place for controlled feeding so she wasn’t alone. She was lying very still, on her side. Thin, very thin. Severe malnutrition. Obvious at a glance even before you saw the measurements. But she was the only one who had been like this for 3 weeks straight, despite being in our hands; no weight gain at all in that time. Every bit of oral intake is refused. The stomach is fed with the NG tube but empties with periodic vomiting. The usual bit of fever at night; usual green malnutrition stools; the usual “had the measles 3 months ago”; just like the children lying beside her. Has had all the standard Vitamin A, folate, anti-worm therapy and broad-spectrum antibiotic; anti-malarial therapy, all no effect. Physical examination gave no help and showed “just” the signs of malnutrition. HIV and TB could look like this but we could not test or investigate, and the clinical clues for those were missing. So I started again at the beginning; knelt beside the mother and asked her how all this began, and when. “Two months ago. She has been like this ever since her father was shot. He was holding her in his arms”. So there it was. Not just the body in trouble here but a 4-year-old girl emotionally traumatised by the upheavals in Darfur. This is beyond our power as a physician and nurse and Médecins Sans Frontières has made first steps towards mental health care for these cases. In some ways this was one of the worst cases we have seen because there was so little we could do. She stood out amongst the others, and in the last 2 months we have seen so many severely malnourished children. Our role has been in Kalma IDP camp and we were on the ground when Médecins Sans Frontières opened the therapeutic feeding centre in mid-May. Médecins Sans Frontières was the first aid organisation to become operational in Kalma and the pent-up need for help was enormous. In the first 3 days we were swamped and the 4 expats (1 Ugandan doctor, 1 English nurse and Australian doctor and nurse) and partly trained national staff had 150 severely malnourished children in our hands. We were not in control for about 4 days and kept finding tiny children half hidden under their mother and too often we could not help them. There were so many deaths in those first days, too many children admitted in haste to get at least some feeding going as quickly as possible. We are much better organised now, and the staff more experienced, and less often do we find sick children unexpectedly. But you can’t trust these little malnourished ones. About 4 times recently there have been children we assessed, admitted and prescribed treatment and feeding for and thought they were stable, only to be called urgently to see them 2 or 3 hours later with very acute deterioration that led to death within minutes. We now take a more aggressive approach to avoid hypoglycaemia and hypothermia in these children who have no body fat and are often less than 60% of the median weight for their age, and the death rate has continued to fall. A disease we now hate with a passion is measles, the common childhood infection we no longer get to see in Australia. In these weak children with vitamin deficiency there is reduced immunological function and an attack of measles is the last straw. First the cough, then the pneumonia. The diarrhoea gets worse and the breathing gets faster and they fade before our eyes. Then there is a sobbing woman, a quiet man and in about 10 minutes he is walking from the feeding centre carrying a small bundle, a black babe wrapped in white cheesecloth. These people seem so strong. Witness to death of family and friends, bombed and burned out of their village, lose their farm land and now living in a shelter made of sticks and vegetation and covered with a plastic sheet. Perhaps there is a trench latrine near the shelter, but usually not. Last count is 1 latrine to 100 people. Women and children carrying water for half a kilometre or more. That simply means that the camp management and organisation, and even international NGOs, have failed the displaced population. The issue of simple primary health care for the camp has been difficult. We opened a therapeutic feeding centre for severely malnourished children aged 6 months to 5 years and once the child is in the system we look after any and all of the medical problems they throw at us. But what do we do when the 3-year-old in our programme has a sister aged 7 lying beside him, with malaria? Well we treat her of course, but what if the mother says the 2 other children at home also have fever. Because of the absence of effective health care elsewhere in the camp we could easily allow ourselves to be swamped if all we did was treat people who were ill and needed someone to help them. This was an ethical dilemma and we used a sort of clinical yardstick. If the situation we were given was clearly immediately life-threatening then it was easy, so we have resuscitated women with post-partum haemorrhage and post-partum sepsis and today arranged to transport a woman with obstructed labour. We have intervened in 10-year-old children who have collapsed at our gate with dehydration from severe diarrhoea but have politely and firmly turned away from those with chronic and mild complaints and are irritated when our guards let them in and distract us from our specific mission. But we are relieved that Médecins Sans Frontières, Medecins du Monde and IRC have at last opened primary health care clinics in Kalma camp. There are so many effects of the Darfur conflict. Today we interviewed two IDPs who had come to our gate looking for work as nurses. Neither had finished the last weeks of nurse training because their village was attacked and they fled with family (one had 2 wives and 5 children). But with incomplete training and unregistered they can not be used as nurses and we will use them as nurses assistants; they will be good and work hard for their people and national staff like these are the backbone of our mission. We have 4 or 5 expats in our feeding centre but perhaps 80 paid IDPs ranging from senior storeman and best translator to cleaners and guards. The site of Kalma IDP camp is interesting. Why was the land vacant? Why had no-one farmed there? Why no buildings? We found out when the rains came. It turned into a big billabong; might have looked pretty if 60,000 people were not trying to live in it. We saw floating latrine walls and just over our fence the latrines overflowed. Now we await the malaria and the diarrhoeas. And this camp has grown from 20,000 in just 6 weeks. Why do they come here? Because Kalma camp is the best there is. Michael and Christine Shanahan, South Darfur » Find out more › We have compiled an index on the latest news + updates from Darfur, Sudan
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