South Sudan: One Week In

Where to begin? Aside from the ungodly heat for which it is famous, South Sudan is the worlds newest country, having gained it’s independence from Sudan in 2011 after a 22 year civil war, one of the worlds longest civil wars. There has been turmoil in this region for decades and it is basically one giant humanitarian aid project. This is evident immediately as you descend into Juba International Airport with a view of rows and rows of every kind of aircraft imaginable sporting logos of every humanitarian assistance program imaginable, including UN, IRC, MSF, RCRC, ICRC, WFP, USAID and on and on.

At independence, South Sudan was grappling with at least 30 humanitarian emergencies. Parts of the country were engulfed in increasingly fierce intercommunal clashes, and there was renewed conflict in border areas with Sudan. Despite the challenges, the first years in the post-independence period were a time of optimism and it was a period of relative peace for most of the country. 

However, by December 2013 – less than two years after independence – the country had rapidly imploded into a new civil war, exposing the fragility of the newfound independence. The conflict is estimated to have led to over 400,000 deaths to date, many the result of ethnically motivated targeting of civilians, including children and the elderly. Sexual and Gender Based Violence (SGBV) has been used as a weapon of conflict.

Some of the most extreme violence was conducted in places of refuge and sanctuary, including state hospitals, where patients and people seeking shelter were killed in a series of brutal attacks. Millions of people have been displaced, often multiple times, inside and outside South Sudan. This includes hundreds of thousands of people who sought shelter in Protection of Civilian (PoC) sites, inside the bases of the United Nations Mission in South Sudan (UNMISS). 

I am currently in a PoC camp with a census of 108,000 at last count. Our hospital serves this entire community and although there are other organizations providing healthcare, we have the highest level of care which includes a surgical unit, NICU, TB isolation ward, COVID isolation ward, and all the rest, like maternity and general medical wards. We currently have about 160 patients admitted.

Our compound has roughly 30 expat staff from around the world and we live right next door to the hospital. This means at night I can sleep in my own bed and the maternity staff can call on my radio and I can be in maternity in under 2 minutes. There are about 500 national staff, all of whom are IDPs themselves and they live in the camp.

Surgery is available 24/7 and we have one surgeon. For this reason, the expat surgeons have short assignments – 6 to 12 weeks usually – due to always being on call. Although the surgeon can do Cesarean sections, our rate is about 5-7% given the month and for maternal indication only, so our section rate remains low. The maternity is a referral center and patients have to meet a high risk or emergent criteria to be here. They are referred from other clinics inside the camp or from other MSF projects in South Sudan, and flown in. What this means is, that regardless of how many patients we have at any given time – usually 8 to 10, most are quite sick and/or high risk. There are occasional patients that shows up as self referrals in labor and if they are too far into it, we keep them. Otherwise we send them to a nearby clinic because we don’t have the bed space for patients who are not critical.

We do not do any kind of antenatal care, so we don’t have the usual line up of women waiting to be seen. Anyone in outpatient (OPD) is there because they are pregnant and unwell. We do not do postpartum care beyond the time they are hospitalized, they go back to their primary clinics for that. We treat a lot of malaria in pregnancy and most of those cases are outpatient. I manage 15 midwives and of these, about half are men. There are usually 2 midwives on shift, 2 in maternity and 1 in OPD during the day. There are 2 that manage everything overnight. There is a midwife in our family planning/SGBV/ToP clinic. She is stationary and manages the sexual violence cases, and all family planning. I support her as well. On weekends when she is not working, I manage those cases that come in along with one of the maternity midwives due to the language barrier.

NICU is a separate ward across the corridor and I have no staff in that ward but I am responsible for helping in emergencies, referring babies from maternity to the NICU and collaborating with them on care of the babies that are admitted. There are no babies past 6 weeks in that ward. This week we have had 3 preterm babies born.

In less than a week I have experienced and managed a great deal. There have been 2 pregnant women with hemoglobin of 2.3 and 2.7 respectively. One was second trimester and the other 3rd. Each were transfused. The one is still pregnant and the other gave birth to a stillborn male at about 24 weeks gestation. He came out into my hands completely encased in the caul with the placenta attached, a perfect oval package. There was no bleeding whatsoever and the demise had been very recent.There are 2 patients with polyhydramnios and one is quite severe. Her gestation is 21 weeks and her baby is hydrocephalic and has other facial anomalies. The other is 26 weeks with an anencephalic baby – so both babies have anomalies incompatible with life. Both are being treated this week and I will write about those cases in a later post.

There have been 3 cases of gestational trophoblastic disease (molar pregnancy). All were about 16 to 20 weeks. After termination, we follow these cases for a year due to the risk of the GT turning into choriocarcinoma. Gestational trophoblastic disease at an advanced gestation like 20 weeks, which all of these were, is very rare, but not uncommon in environments such as these when prenatal care is often not sought or is not received until far into pregnancy.

Currently, there is a patient with gestational gigantomastia. She has a very small frame and I cannot imagine the pain of having breasts the size of watermelons with virtually very little in the way of treatment options. Another patient is 4 months pregnant and being treated for wounds on her thighs and buttocks from a beating sustained from her father.

We saw several cases of SGBV this week, as gender-based violence is quite common in places like refugee camps due to the extreme stress and crowded conditions. The stories are quite disturbing and often it is intimate partner violence for which not much can be done to keep the woman safe in the future.

Because there is no obstetrician or gynecologist on staff, I guide the staff in management of all difficult cases that present. There is nowhere else for the patients to go, so this is how it is. I will write more in the coming weeks about specific cases and the challenges surrounding them. I have already seen some of the most challenging cases of my 32 year career and I am more and more grateful for my time in Afghanistan and all I learned there because this is going to rival that but in a much lower resource environment with less support staff. It requires patience, creativity and more than a little tenacity.