Perth – Sydney – Doha – Geneva – Amsterdam – Dar es Salaam. After transiting through six cities across six time zones in six days I boarded a 6am flight in a light plane to Kigoma, Western Tanzania to start a six-hour Land Cruiser journey to my new home for six months. I guess good things come in sixes? This would be my first time working in a refugee camp. Although I studied refugee health in my Master’s degree, nothing had quite prepared me for this bustling city-sized microcosm of semi-organised chaos and activity.
My first week in the camp was a whirlwind of emotions, and I was astounded by the vastness of the project and the job at hand. Despite this, I rapidly settled into life in the field with an incredible team of Burundian, Tanzanian and international staff, in a project covering everything from emergency cases and trauma, to severe malnutrition, childhood vaccinations, maternity, primary healthcare, mental health, non-communicable diseases and tropical medicine.
Nduta, unlike other regions, is not in drought, meaning that many trees provide shade, and the weather (when it’s not rainy season) is very tolerable as it lacks the extremes of nature’s climate forces. Sadly, due to the original unrest in nearby Burundi, many people in the camp have been there for a few years already.
The majority of refugees are sheltered in tents. Others have been there so long that they have started building more solid structures by laboriously hand-making their own mud bricks from the camp’s deep-red earth, in an effort to protect themselves and their families from the elements and to provide at least some stability in a very precarious context. I’ve now met many refugees who fled to this same camp in the previous Burundi civil war between 1993 and 2006, only returning home for a few years before having to flee again when the most recent unrest occurred.
The size of the camp had doubled from 60,000 in September 2016 to more than 120,000 refugees by March 2017. My colleagues on the ground before I arrived had done an incredible job, trying to maintain essential services for all despite the massive surge in the camp’s population and the heavy burden of the peak malaria season.
Quickly, my life becomes routine. We live about an hour away from the camp, so there is a lot of travel time to and from work each day. This time is spent in a variety of different ways depending on the person and their level of fatigue: sipping a thermos mug of coffee and trying not to spill it on the bumpy road, reading over MSF guidelines or trying to jot down a schedule in your diary for the million and one tasks of that day. I’m amazed at how quickly I have become accustomed to reading whilst travelling sideways in the back of a Land Cruiser at 60km per hour along an insanely bumpy unsealed road, without even the slightest hint of motion sickness. Next level adaptation goals: achieved!
Driving into the camp every morning, often the first sight is of refugees walking or hitching a bicycle ride the long distance to the market on the outskirts of the camp to get supplies. After sunrise’s gentle quietude, I notice the families huddled closely around their fires. The flames sometimes burn dangerously close to surrounding tents (and to playful children), the smoke rising from the embers fanning out between the trees in the cold air, fracturing the early morning light. They create a beautiful but eerie luminous show, that sadly just heralds the beginning of yet another day for these people in prolonged exile, distanced from their homeland and far from the comfort of having an actual home as shelter.
I arrived to the project in Nduta just after the rainy season ended, expecting the malaria rates to have started dropping. But to my surprise we saw another surge of malaria after the peak time. Although I was prepared to see many cases of severe malaria and was well versed in the emergency management of these cases, it was quite overwhelming to see the number of admissions we had on the wards, the outpatient area absolutely overflowing with patients and many of our Burundian staff succumbing to the disease.
The worst of the cases are tragically usually children. Our paediatric ICU was filled with kids with such complicated cases of malaria that they were having convulsions and haemorrhaging blood in their urine, requiring blood transfusions and intensive emergency care. The most severe cases, even if they survive due to treatment, often have long-term secondary effects that can haunt them for life such as brain and other essential organ damage. Seeing kids on the ward in this state was gruelling to say the least.
Malaria is a truly awful disease that is hugely prevalent across the world: approximately 3.2 billion people (nearly half of the world’s population) were at risk of malaria in 2016, and approximately 445,000 people die from malaria each year. Some 90 per cent of those deaths occur in Sub-Saharan Africa, and 70 per cent of those deaths are in children. Here in our project it is one of the most common illnesses that we treat, yet still one of the biggest challenges to prevent as it requires a combination of public health measures such as health education, insect control, distribution of mosquito nets, and early diagnosis and treatment.
Meanwhile, back at the MSF house, I feel very lucky indeed, taking my anti-malarial tablets every day and sleeping soundly under the protection of a mosquito net. Refugees, however, do not always have access to these precautions. Malaria traps people in an unfair cycle of suffering and illness. Huge efforts are required to ensure that people have access to health promotion messages, adequate insect control measures and mosquito nets, but these interventions are costly and difficult to sustain in an ongoing crisis. The nets need frequent distribution as they get damaged with time, and many families I meet are currently living in tents without them.
Recent food ration cuts are also starting to take a further toll on the people here. The lack of adequate food is a very significant concern in the camp, so we are keeping a close eye on the nutrition rates of the community. Malnutrition affects all systems in the body including the immune system, making people much more prone to infectious diseases, which can further compound the risk of malnutrition. Because of this we frequently admit malnourished children and adults with concurrent chronic diseases such as HIV and tuberculosis.
Tired and desperate families often wait out in the open for long hours to pick up their rations, and if there are long delays or if the distribution points run out of food frustration and anger can rapidly rise. The despair of the hungry people here is intense.
For now, a few months after the peak, the malaria rates have dropped temporarily. But with another rainy season rapidly approaching us yet again, we are already in preparedness planning mode and bracing ourselves for the next waves of malaria to hit our little hospital.
The Médecins Sans Frontières project in Nduta refugee camp includes maternal health care, nutrition, emergency and inpatient care for adults and children, immunisation activities, sexual violence care, mental healthcare and health promotion. MSF also provides support to the operating theatre of Kibondo Ministry of Health Hospital with human resources, material and equipment, and with technical advice on water, sanitation and hygiene.