Aweil hospital: Aweil, Northern Bahr el Ghazal has some of the highest maternal and infant mortality rates in the world.
I always wanted to do something that involved working with people. I liked the idea of the variety and portability being a doctor offered, as well as the opportunity to work in less well-resourced areas. Médecins Sans Frontières (MSF), with its reputation for high quality projects and good security, was an obvious choice.
The state hospital in Aweil, South Sudan, where I went for my first field assignment, has a catchment area of 1.2 million people. MSF runs the paediatric inpatient departments, providing a capacity of up to 175-beds for children under 15 years of age in three inpatient wards, a neonatal unit, intensive care unit (ICU) and an inpatient therapeutic feeding centre (ITFC). While I was there our paediatric triage team assessed a minimum of 300 children per week and we admitted approximately 75% of those.
My role was as the paediatric ICU and neonatal doctor.
The hospital itself is very basic and the intensive care unit resembled nothing I had ever seen back home. In this case ‘intensive’ simply means that we can put the patients on oxygen and monitor them a bit more closely due to an increased nurse-to-patient ratio. No fancy equipment. Given our limited resources, the number of lives we manage to save there is staggering.
When I first arrived in Aweil the malaria season was ramping up and the vast majority of the patients we were seeing had the disease. The most common presenting complaints were coma or seizures, fever, or difficulty breathing. The malaria medicines work quickly, and I got used to the almost miraculous recoveries of children who were critically ill. But too often they arrived too late, with complications that were too severe to reverse.
We also began to see an increase in severe acute malnutrition, or SAM. Food security was deteriorating in the region, partly due to a very short rainy season but also resulting from conflict and population displacement. Malnutrition came with many complications and children were being admitted with infections which, although normally easily treatable in well-nourished kids, were often life-threatening due to SAM-related reduced immune functioning.
With food so scarce, the arrival of the mango season brought relief with fuller bellies, but also many accidents. Children were falling from the trees, and coming to the hospital with fractures, abdominal trauma and head injuries. These diagnoses made up a significant part of our morbidity and mortality.
However the patients who will always stay with me are those from the neonatal ward.
To me, the very presence of this neonatal unit was quite amazing for the region. The unit offered care to preterm babies as small as 1.25 kilos and to sick neonates, children who simply might not otherwise survive. Mothers and their babies would stay for a long time – anywhere between four to eight weeks – and it was easy to form strong bonds.
We had one pre-term that was with us in the unit for a very long time. Her name was Miriam.
Miriam’s birthweight was only around 1.45 kg. She was small. And, like quite a few of our preterms, she had Necrotising enterocolitis (NEC). This occurs sometimes after beginning to feed a premature infant due to an immature intestinal tract, causing damage and infection. Globally, NEC affects a significant percentage of infants who weigh less than 1.5 kg and leads to problems later in life and even death.
Treatment for NEC consists primarily of supportive care including bowel rest, gastric decompression, fluid repletion to correct electrolyte abnormalities and prompt antibiotic therapy. Many babies with NEC will require surgery, and even in a high-tech hospital with access to specialist neonatal surgeons, the baby could die and will often have life-long medical complications. Here in Aweil, the greatest danger was that Miriam’s bowel would rupture, the outcome of which would certainly be fatal.
So we stopped Miriam’s feeds, treated her with antibiotics and then very gradually reintroduced the feeds. And she didn’t die.
But Miriam did stay very unwell. Her blood count dropped, a condition called anaemia, which was severe enough to require a transfusion. Anaemia itself is not unusual in premature babies, but it becomes serious when complicated with other medical issues. Unfortunately, two days later, her red blood cell count had dropped again, much too quickly. Although I wouldn’t think of it immediately back in Australia, this pattern made me think of congenital syphilis; by this stage I had seen a number of classic presentations, which I had previously only ever read about in the textbooks. I now suspected mother-to-child transmission of syphilis.
Nearly a million pregnant women worldwide are infected with syphilis annually, resulting in early fetal loss and stillbirth, neonatal death, low-birthweight infants and serious neonatal infections. Normally, infections should be picked up by routine serological screening during pregnancy, and treatment with penicillin is simple and cheap. But the reality is that many women in South Sudan have only very limited access to antenatal care. Combined with the lack of diagnostic tools adapted to these poor-resource settings, it means a significant number of pregnant women with syphilis go undiagnosed.
Miriam tested positive so we extended her course of antibiotics, and gave her supportive care with IV fluids, oxygen and repeat transfusions until her red blood cell production recovered. We made sure her mum was referred to the maternity unit for treatment as well.
Over the next few weeks we managed to get her through her various acute illnesses, continued to increase her feeds and just watched and waited as she gained weight. Eventually she reached our discharge weight of 1.8 kg. She was breastfeeding beautifully and her red blood cell count, whilst still on the lower side of normal, had stabilised. After 55 days in hospital, Miriam was ready to go home.
I found it very hard to say goodbye.
Field work has really helped me hone my clinical skills. We didn’t have much in the way of diagnostic facilities so I had to think about my diagnosis and base it on a combination of history, examination and the findings in front of me. I think it has helped make me a better clinician.
And then there is the exposure to the pathologies. I had a Master of Public Health and Tropical Medicine under my belt and had read a lot about malaria before I arrived in Aweil, but I had never seen it. I let the national staff teach me a lot and took my lead from them. But after a week I’d seen so many cases, I began to feel more comfortable.
Another skill I developed was simply being able to deal with whatever came in.
I had received little exposure to trauma in my training so far and in Australia, whenever a case arrives, we have a whole trauma team and a host of specialists to refer to. Now whatever the trauma, at least I now know where to start. I have an approach.
But perhaps the most rewarding part for me was the clinical education and capacity building. I had a lot of opportunities to work with the national staff who were almost universally motivated and dedicated. In a country with such low literacy rates, they have had to fight for opportunities to learn and education is highly prized.
My opportunities to learn from the national staff were endless. Not only did they share their knowledge of the things that we just don’t see in Australia (malaria, malnutrition, measles, tetanus), but they would also sit me down and teach me about their culture, politics, life in the village, and their language, supporting me to stumble through some sentences in Dinka.
Learning the best ways to convey information and how to work differently with different people was also exciting and rewarding. There’s nothing quite like running a training session and then seeing that newly acquired knowledge or skill being applied in practice.
The experience has definitely had an impact on my career decisions. I am leaning more towards doing paediatric emergency medicine or acute care, which I’d never considered before.
And I will definitely work with MSF again. Working in resource-poor settings was something I loved. It suits me.