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Margaret Bell, an Australian nurse from the Blue Mountains in New South Wales, has just returned from Darfur, in western Sudan, where 1.5 million displaced people have sought shelter and protection in regional centres, and where international aid agencies can provide assistance. Margaret was sent to Mornay camp (near El Geneina in West Darfur) for Medecins Sans Frontieres on a three-month mission. She provided her letters and photos and we are publishing them as a retrospective in two parts, detailing the highlights and the lowlights of delivering babies, treating malnutrition and tuberculosis. September, 2004 It’s been a very long time since I’ve written – I think two months in fact and I may even be home before you all receive this but better late then never. I actually finished my three-month mission at the end of August. My replacement arrived two weeks prior to my departure so we did a few days handover of the Inpatient Department (IPD) and pharmacy, and I then spent about 10 days focusing on the midwifery and women’s health. Over the past three months I tried to give the local midwives as much support as possible but that was very limited with my work in the IPD and the TFC (therapeutic feeding centre). It became quite clear to me that they needed a lot of education and support and the mission also needed a midwife to deal with the complicated cases, support women who were victims of sexual violence and set up a proper women’s health program. So about two and half weeks ago I returned to Mornay much to the wonderful surprise of the local staff who thought I’d gone forever the first time. I don’t know if there were more tears on my return or on my previous departure.
MIDWIFERY TRAINING Before I left the first time I set up contacts with the midwives who worked for another organisation in the Mornay camp. They have three clinics around the camp and see women antenatally and do home deliveries. They refer any complicated cases to us. They also have greater access to women who have been sexually assaulted due to their proximity in the camp. They encourage women to come and see me – often a few months too late unfortunately, when they discover they are pregnant. The community midwives tell me they still hear reports of rape and violence occurring despite the fact the camp now has a very relaxed, almost stable atmosphere. Certainly people are wandering a lot further from the centre of the camp to fetch wood and grass - you even see the children playing quite a distance from the camp. This was not happening a month ago. VIOLENT MEMORIES In contrast to all this it never ceases to amaze me how people in the most desperate of circumstances still find something to smile about. They all greet you in the street when you go by, the children running after you screaming ‘kawadja, kawadja’, as if they have never seen us before. We now walk to work every morning and home again for lunch and in the evening. The children never miss coming out to greet us each time with as much vigour as you would greet a long lost friend, or someone you haven’t seen in a very long time. And it is the simplest handshake, touch or a smile that they seem to love. The children appear to be like any other child as far as their desire and ability to play and have fun. It’s wonderful to see that ability children possess to forget where they are, what they or haven’t got, and lose themselves in play. Perhaps it’s a coping mechanism but at least it gives them some time of pleasure. There are legacies of being a child in this situation, some of which they won’t even know themselves until much later. When they hear gunfire they react immediately and not because it’s a loud noise, as often it’s way off in the distance. You can see their reaction is from familiarity, you can see the momentary fear in their faces, which is only relieved when they see their parents oblivious to the sound and continuing their business. TRIPLETS AND TWINS
My biggest challenge was to convince the parents to let us put a feeding tube into their stomachs so we could feed them regularly. They were too little to suck so this would be the only thing we could do to give them a chance at life. The parents agreed and it was quite humorous the first few days trying to show the mother how to express her milk and feed the babes. She learnt quickly however and soon became an expert. Miraculously they had no other complications, which was amazing considering their size. This made me more determined to do everything we could to help them survive. I should have realised however that in this culture and in this situation, survival of the fittest is what it’s all about. After two weeks the parents had enough and wanted to go home. There were other things to be done and no matter what I said I couldn’t convince them to stay any longer. So the tubes came out and home they went. I asked her to come back a week later but I never saw them again. If they survived it would be a miracle. They weren’t sucking at all well when they left. I’m sure the parents probably wondered why I was making such a fuss over two all babies when they were so used to a culture where at least two or three of their children die in the first years of life. Another women came in with premature twins who were three years old. One was very sick and the other OK. She agreed to let us feed the babies with a tube but that afternoon the sick one died so she was convinced the other one would die also so she left the hospital. No amount of reasoning could persuade her otherwise. She may have been right - it probably would die but was it not worth trying? TRAUMATISED CHILDREN In the first two months I was there if a plane came over it would take a while to calm people down. There were no UN planes back then so a plane was something very odd. If we heard or saw one some would say it was a plane to bring weapons for the militias. Since July though, there have been quite a few UN planes or planes carrying various important delegates like the French ambassador. People are now getting used to the air traffic and the increased presence of the UN coming and going has certainly made a difference to the feeling of security. HAFIZ FAMILY
We have another beautiful woman named Khartoum, who is paralyzed from the waist down - no one seems to know why. She came to us with a huge pressure-sore on her buttocks from being in the same position for so long at home. She also has her father looking after her and he is just divine. She is incontinent and totally debilitated and he is so wonderful with her. They will both be with us for who knows how long as we don’t know what to do with them. They would die if they go home to a grass hut with little food or sanitation. The men here, like in South Sudan, are wonderful carers. They are very attentive to their wives, children, mother, brother and whomever - they do a lot of the hands-on care. It amazes me when I talk to women who think they may be pregnant and I ask them when was their last period and they usually have no idea and say, ‘ask my husband’. How many husbands in Australia would know when their wife's last period was? The practice of prayer is interesting. They have to pray at certain times during the day and no matter what is going on they just leave to pray, even in the middle of an emergency. It becomes quite amusing after a while as you turn around to talk to the nurse and there’s no one there. I found it difficult at first or more frustrating really, but you get use to it and work with it. We provided the staff with a praying area so at least they don’t have to go too far. HEPATITIS E OUTBREAK The logistics team responded very quickly after the first few Hepatitis E cases presented and confirmed after sending specimens to Khartoum. Basically they had to increase the chlorination in the water at all the source and the water points. A lot to organise but very effective once it’s done. We did however have a high mortality rate from Hepatitis Encephalopathy as a major complication of being infected with Hepatitis E. Most people will recover reasonably well however Hepatitis E has a 20% mortality rate with pregnant women, so we had a lot of pregnant women dying. Many died at whatever stage of pregnancy however most of them sadly were six months or more in. Therefore the baby would often be alive when the mother was very sick and comatose, so it was very tragic if she died as of course her unborn child died with her. It was a terrible few weeks for a while. Thank goodness we have not had a huge amount of severe malaria cases and now the malnutrition rate is increasing also. FOOD It’s quite amazing to watch as you see around 8,000 children a day in about three hours. The logistics team organises it and it’s incredible to see that many people behaving very orderly. I think they know there is enough food for everyone so they don’t need to rush or get out of control. To make sure no child cheats and comes back for seconds their mouths are plastered with gentian violet so you’ll see kids walking around with purple mouths for days…it’s a great anti-bacterial agent too. So that was then, now I find myself sitting here at El Genina on my way back to Paris as I had a very silly accident three days ago. I cut my thumb with a surgical blade whilst trying to cut the lid off a plastic bottle and in the process severed my tendon. Within an hour of doing it the team had me evacuated to El Genina where there was a Médecins Sans Frontières surgical team waiting to repair it. That was a little scary as El Genina hospital is very basic and my last view of their theatre when I arrived in Darfur was seeing a clothesline with surgical gloves hanging out to dry. But the team had it all organised - sterilised all the instruments and had a fantastic Sudanese surgeon to do the repair. I’m fine and my thumb will be OK, it is just a shame that I had to leave early without saying goodbye to everyone. At least I got to do that the first time three weeks ago and I was given a huge farewell party and lots of wonderful gifts and kind words. » Read Margarets earlier letter
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Sudan
