MALNUTRITION: Southern Sudan

At dawn, an old woman in a bright but tattered dress picked her way along a muddy, trash-strewn path. She stopped at a pile of garbage and carefully removed the remains of a dirty onion. Then she sat and slowly began to eat it for breakfast.
I was in southern Sudan as part of a medical team from Massachusetts General Hospital — my first foray into international medical work. The goal of this pilot project was to teach Sudanese hospital staffs the basics of newborn care and resuscitation.
Southern Sudan has barely emerged from more than two decades of civil war, in which at least two million people died. Since the war ended in 2005, many of the aid agencies that were sustaining education, nutrition and health care have pulled out, and despite the heroic efforts of those that remain, most citizens’ day-to-day existence is shocking. As a tent camp manager in the town of Wau observed, “The peace is killing us.”
Pictures of these war-torn regions do no justice to the physical and emotional realities. It was boiling hot each day as we trekked over dusty, crater-filled streets filled with noisy motorcycles and honking jitneys. After lugging our equipment to the hospital, we were sweaty and exhausted by the time we began rounds in the children’s ward with the sole pediatrician.
The hospital was beyond imagination. Beds were overflowing with infants and children, many of them desperately ill with malaria, malnutrition or viral diseases. Babies with diarrhea wore no diapers, but were wrapped in simple cloths that their mothers would rinse out periodically in the hospital yard.
Patients of all ages were urinating and defecating around the hospital grounds. Water to wash hands was not available in the ward — only outside at a common pump. The smells were overwhelming, and the heat was barely relieved by a single ceiling fan. Flies buzzed around, and persistent tubercular coughs filled the air.
Filled with admiration for the medical teams — and aware that the doctors had not been paid for six months — we offered our meager help. We began our courses with a willing group of medical assistants, nurses and the local pediatrician, who served as translator.
Much to our surprise, we were called one day to practice what we were preaching. A mother who had lost three babies was about to deliver her fourth. The obstetrician asked that we be present in the delivery room.
The baby came out limp and blue, making no effort to breathe. While the medical team watched, we re-enacted the resuscitation we had been teaching all week.
Finally the baby began to cry and then, with great effort, to breathe. We were exultant. Not only had we saved the baby, but the staff could see the value of our teaching.
Such is the smugness of do-gooders. When we visited the next day, our wonder baby was grunting and struggling to breathe. Since there are no intensive care units, he was going to have to make it on his own. His mother looked sad and tired.
Meanwhile, in the next room, a grandmother sat looking out the window while a tightly wrapped premature baby lay on the bed. As I unwrapped the baby, I realized the infant was cold and still. The grandmotherly stoicism suggested that death was a familiar companion.
Southern Sudan is still defined by a tribal culture, with groups living in wood huts with dirt floors. Children are not in school. In Juba, the region’s capital city, garbage is piled high, the stores are empty of fresh food and canned goods are covered with dust. Water is dirty. Toilets are mostly nonexistent, or just filthy holes in the ground.
The challenges of providing health care in this setting were so overwhelming that I found myself questioning the mission. What were we doing there? Whom were we helping? Or were we simply assuaging our first-world consciences? Shouldn’t basic needs — roads, water, food, housing — be met before all else?
The aid groups still stationed in Juba seemed to be a mixed blessing. Many Africans have written about the passivity and dependency spawned by an “aid culture,” and I could see for myself the lack of initiative that seemed to pervade the towns. Trucks of soldiers frequently roared by, bristling with armed militants. Had years of tribal warfare, malnutrition, disease, heat and poverty sapped the will of the once proud Sudanese?
Few would question the inspiring rescue efforts taking place in Haiti. The outpouring of food, dollars and labor affirms our humanity. But when human suffering goes from the acute to the chronic stage, does the strategy need to be revised? Caregivers who have spent years in Sudan suggest that without sweeping changes in government and infrastructure, the misery will continue.
I returned home feeling less happy about our successful baby-saving exercise, and wondering what would happen to that child. Still, I remembered the oft-quoted observation that if you help one person, then you help one person. That is surely better than doing nothing, and I am continually inspired by the many health professionals who selflessly offer their time and expertise to those in dire need.
But I resolved that my future efforts would be more defined. As a neophyte in international health, I needed more direction. Partners in Health, a Boston-based charity that has done pioneering work in H.I.V. prevention and treatment of tuberculosis, has demonstrated that focused, strategic efforts will produce the best results.
My baptism in the world of international health was bewildering and challenging, and I left with many unanswered questions. And while I may not return to Sudan, I hope to return to an area of need where I might make a small difference.
Dr. Victoria McEvoy, an assistant professor of pediatrics at Harvard Medical School, is the author of “The 24/7 Baby Doctor.”
http://www.nytimes.com/2010/08/10/health/10case.html?_r=1