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Letter From Sudan

February 15, 2008

Driven in part by the activities of the Bill and Melinda Gates Foundation and the Clinton Global Initiative, private support for public health and development initiatives in poor and developing countries has become big news.

Predictably, as media coverage of those efforts has grown, so too have questions about their effectiveness. In November, I wrote about an online "conversation" hosted by the John Templeton Foundation on the topic of whether money will solve Africa's development problems. And last month we noted Bill Gates's call for a kinder, gentler capitalism at the World Economic Forum in Davos, Switzerland. The Microsoft chairman's remarks were widely discussed in the blogosphere and mainstream media and were also the subject of a fascinating lunchtime panel discussion at the Hudson Institute's Bradley Center for Philanthropy and Civic Renewal on January 30.

Most of the discussions of this topic that I come across are substantive and well meaning. At the same time, there's often something academic and bloodless about them. A week or so ago, my brother-in-law Dave Reed, an upstate ER doc, traveled to southern Sudan to spend a month in a medical exchange program. Dave's a great guy and a wonderful letter writer, and I thought it would be interesting to share his on-the-ground experiences in a typical rural African village with you. I've cleaned up the typos and fixed some of his punctuation, but otherwise the words and observations are his.

Dave writes:

Duk Payuel -- 12 February, 2008

I want to pick up from my last letter and focus, from a medical perspective, on what I see in Duk Payuel. There are so many new experiences and sights that I am finding it hard to articulate it well in writing. 

First a reminder about what the setting of this clinic is: we flew out of Nairobi in a small plane and for hours traversed dry barren wilderness scarred by dried riverbeds, creeks, and salt sink holes which illustrate the brutal divide between the wet and dry season in Sudan. The locals know with confidence that there will not be any rain for several months because it is the hot season and currently 105 F in the shade. But we are fortunate to have a brisk wind blowing, even though it makes it feel a bit like a blast furnace; I would prefer not to consider the alternative.

I am sitting in my tent over the lunch break -- it's too hot for anyone to work -- with goats and cows lying on the ground around me. The animals run freely and always seem to know where they are going, except for the goat that was roasted yesterday in our honor. Remarkably, we are quite comfortable in our tents despite the lack of electricity (except for when we run the generator to pump water from the well -- that's when I charge the computer battery and can fire off a quick email on the donated Internet satellite dish).

There is no running water, and of the three wells in the community there is only one nearby, so the women and children all come with two-liter bottles or big gerry cans to try and get some water when we are pumping. How do you say no to a pregnant mother or a small kid who has been holding a place in line just for the chance of getting two liters of well water?

There is a wedding in the village today that has been the talk of the town, and we just learned that they settled on 35 cows and about $1,300 for a dowry, so the wedding will proceed over the next couple days; should be interesting, especially as it is a union between members of two different tribes.

Perspectives on the Medical Experience So Far:

I woke at 4:00 a.m. this morning thinking about how we take immunizations for granted in the United States, a reality that has profoundly reduced mortality of diseases that we now only see in medical text books. In this part of the world there are NO immunizations. Contributing causes include lack of electricity and refrigerators to store the vaccines, lack of trained staff, and lack of money to fund these efforts. It is frustrating for me that these are all achievable but lacking. As a result, young children here die of measles, pertussis, pneumococcal pneumonia, and meningitis. Last year, an estimated 7,000 children died of meningococcal meningitis. No one is immunized against tetanus.

We have a lab tech, a pharmacist, a nurse-midwife, one Kenyan doctor, and a nurse working together. Our patients sit stoically in the sun, waiting for a chance to be seen (part of the reason we stop our activities in the middle of the day). As I said, diseases that are routine here are things we only read about in textbooks during medical school. Between today and yesterday, we have seen the following:

Five patients with trachoma, a very treatable water infection that affected many members of the community during the height of the wet season last year. Initially signaled by a defect of the eyelid, trachoma rapidly progresses to scarring of the eye which will continue to injure the cornea until blindness is complete; one of the greatest gifts an ophthalmologist can offer these people is cataract repair, which in the course of a day literally restores sight to the blind.

I saw a man with a gunshot wound to the upper arm that had occurred two weeks ago, but he had just come in from the bush. Unfortunately, he has a radial nerve injury that will permanently cripple him.

Malaria is common, and the local people can't imagine that the average doctor in the United States will never see or treat a single case.

Giardia and other water-borne intestinal infections are very common, and it becomes obvious why that is so as we watch people forage for water wherever they can find it, putting it into whatever container they can get their hands on. Fortunately, we are able to diagnose these kinds of infections quickly with a microscope.

A seven-year-old boy came in after badly injuring his hand when a grenade exploded. I suspect he found it and was playing with it.

Syphilis is prevalent here, and we are fortunate to be able to diagnose it with an inexpensive lab test. I saw three patients with syphilis today. Exacerbated by polygamy and the lack of regular screening, STDs have a significant impact on the local women, who don't have access to the kind of care we take for granted in the U.S.

Today I was asked to evaluate three women who were brought in by their husbands to determine whether they were infertile. Generally, the male speaks for himself and his wife and typically will express concern that the new wife he had invested so much in financially is not able to bear him children. One of the cases involved a new eighteen-year-old wife (one of four) who was a married to a man of sixty or so. I raised the possibility that men, as they get older, can become less fertile, too. In addition, we have seen several children with Down's syndrome, and a theory held by the local staff is that this is related to the advanced age of many of the men fathering children with young brides.

There are no ambulances, referral centers, or even a hospital within a reasonable distance -- unless a person has the kind of wealth that would allow him to charter a medivac flight to a large city. Of course, no one here has that kind of money. At least there's a clinic here thanks to a returning "Lost Boy of Sudan" and the generosity of committed supporters of the American Care for Sudan Foundation.

Allow me to end on a philosophical note: It is remarkable to me that people here seem to find more joy in life than those who live in relative wealth in the United States; they laugh, sing, and dance, go to bed soon after the sun sets, and start their days early to beat the midday heat. They smile despite being the survivors of a civil war in which their village was burned to the ground and as residents of an environment so tough and challenging that two out every five children are likely to die before the age of five. You can't help but be inspired.

-- Dave

I hope Dave keeps e-mailing us about his experiences in Sudan, and if he does I'll be sure to pass them along.

-- Mitch Nauffts

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