Tuesday, April 3, 2012

Dr. Clarke's amazing medical journal

16 March 2012 
I have not had the greatest experience with or relations with the local medical men, the witch doctors, but I think I heard the lowest today.  A father, a policeman, brought his daughter to us because of swelling in the abdomen for a month.  As a policeman, he has some income, and much of that was spent buying Flagyl in the market.  Though I believe most self-medication results in foolish and needless expense, Flagyl is the drug I probably would have tried on the child had the father brought her to me.  Instead, he took her to a local medicine man who pulled out a needle and syringe that had obviously been used before.  He jabbed that wretched instrument into the abdomen of this sweet little girl and aspirated back some pus.  He then demanded of the father 100 SSP (South Sudan pounds).  When the father declared that he did not have the money, the witch doctor stuck the needle back into the child’s abdomen and pushed the pus back in. 
            I was sick and furious as I heard the story.  I recommended to the policeman that he take the man to jail.  It is bad enough that these men are allowed to practice their evil trade on unsuspecting people and charge far more than any hospital in the area practicing real medicine would think about.  We charge far too little and I suspect that many refuse to come to us because we are virtually free and they have learned that nothing worthwhile in life is free.  But it is a new low for that same quack to jab that fomite of death back into the abdomen and expel the contents. 
            The child did have a relatively large abdominal mass, about 3 x 6 cm, that was somewhat fluctuant.  Even before I had heard about the quack pulling pus out of the mass, I thought it was an abscess and was planning on incising and draining it, particularly after being told that the child had been on the logical antibiotic for a month.  I gave the child some Ketamine and was able to get into the mass and drain out about 7-10 ml of fluid and then placed a wick into the mass.  That would have been sufficient to anticipate a good outcome for this child except for the involvement of the witch doctor.  Did he jab that needle in to the peritoneum and inject the amoebae into her abdomen?  Will she end up with peritonitis because of his actions.  And of course much worse, did he inject her with HIV?  Will she get over this bad infection despite his malpractice, or will she die from a worse infection because of his use of contaminated needles?  Why would anyone take his precious daughter to be treated in such a manner?     

17 March 2012 
As I was driving to Adol, I passed a large number of cow keepers running in the road.  Now Dinkas are typically in pretty good shape: tall and thin.  If there is any obesity, the man is probably in government.  But they do not exercise, per se.  They do not put in a certain number of miles/week or do pushups or jump rope with any regularity.  In addition, Dinkas treasure being cool.  James Dean had nothing on them.  I see cattle keepers walking on the road all the time, keeping their cool intact, but I had never seen them running with their spears in large numbers like this group was.  Deborah was in the car, so I asked her what was going on.  She pointed ahead.  There was a bull, a thon (a real bull, not the castrated variety) running with the cattle keepers around it, pushing it on.  “They will run that bull for two days between Karic and Atiaba, and then they will spear it to death for a sacrifice.” 
“A sacrifice to what?”
“To the spirits of their ancestors.”  When I have said many times in the past that Dinkas love their cows, I must clarify that.  It is not a cuddly type of love.  We are not talking about Wilbur the pig (Charlotte’s Web).  From childhood they hit and drive cattle, but cows are so critical in the Dinka economy, giving status, providing the means for marriage, payment of the dowry.  Admittedly their greatest love of cows does seem to be for the castrated bulls, but they value all cows.  How can they torture and then kill a bull in such a seemingly senseless ceremony?  The reality is that Dinka culture is still held captive by many horrible traditions that need to end.  What they were doing amounts to demon worship.  We need to be sensitive, but there are some things incompatible with a profession of faith in Christ, and we do them no favors in avoiding the subject.   

18 March 2012 
Balang is the payam administrator.  Payam is a division of government below the county level.  There are 10 counties in the Lakes State, which is probably about the size of my home state, South Carolina, which has 46 counties.  Thus the counties in the Lakes State are relatively large.  Payams are therefore important subdivisions of the government tree for handling local matters.  Balang is not a Dinka Agaar.  His tribe is Atuot, a traditional enemy of the Agaar, but he has stayed with us even during the times of unrest and killings between the two sub-tribes.  Balang has been a good friend to the hospital.  He has supported us in several skirmishes when some local personalities and has been a liaison with the SPLA when some issues arose with them.  Though he has not been as active in pursuit of some of our goals as I would like, he has made some progress in setting up committees responsible of the hand pumps, something we have been unable to accomplish before.  Therefore when Balang asked me to help him take some things to his home in Mapuordit because of reassignment, I wanted to help him. I had planned to go after church in the pickup, but the girls approached me about going down early using the LandCruiser so that they could go as well.  “We can go to church there.” 
            The drive down was unremarkable except that it was more pleasant to travel in the relative cool of the morning.  It is a bumpy road during the dry season, and there is always the risk for tire puncture (high) or getting lost (relatively low), but there is none of the fear or excitement of travel during the rainy season.  Part of the reason for going down was to transport Balang’s goats.  Cows are the signs of wealth in the Dinka community, but goats and sheep are of more practical importance.  Cows are slaughtered for special occasions; sheep and goats die regularly to provide meat for guests or celebrations.  The goats were one of the main reasons for taking the pickup.  As it was, Mary and Maria had to share the back compartment with the goats that quickly made you wonder how Noah survived all those months at sea with his charges.  We also had a few others to join the back compartment and enliven the show, but we arrived in Mapuordit unscathed and in time for church. 
            There is an impressive Catholic cathedral in Mapuordit.  Mapuordit is a strongly Catholic town.  The hospital, probably the finest in the Lakes State, is supported and staffed by Italian Catholics.  There are primary and secondary Catholic schools there.  And there is a seminary in addition to the Cathedral.  The Cathedral is new.  I remember seeing the guts of it a couple of years ago, but now it is finished and very nice.  It could probably hold about 300 kawajas or about 500 Dinkas (Dinkas have not accustomed themselves to having “personal space).  The church was packed yesterday.
            The preacher is Dinka (I think), but he preached in English.  I had little difficulty following him, which was a treat.  Rarely do I get a chance to hear a message in English except when I am out of South Sudan.  The International Day of Women had just been celebrated, and so the preacher gave a sermon about treating mothers and sisters well.  It was more than just the Mother’s Day appeal we may get in the US.  He was addressing the Dinka male traditions of leaving most of the work for wives, sisters, daughters.  He called on those who name Christ as their Savior to bear the burdens equally.  He challenged the dowry system from several stand points.  First, he championed the right of women to have some say so in whom they marry.  He addressed the misery of young girls given to old men for marriage against their will, an extremely common practice here.  He challenged the basic underlying principal that anyone should be sold, for indeed that is what the dowry system does.  I typically prefer a presentation from Scripture, but his presenting this took real courage, and it seemed to be received fairly well. 
            Changing a culture is never easy.  It usually requires someone to give up something he is accustomed to think is his right.  And the first step towards that sacrifice involves those with the privilege being challenged as to the validity of their right.  I do not expect to hear of massive changes occurring in the Mapuordit area, but if there is no challenge, there will never be change.  I appreciated what he was seeking to do. 

19 March 2012 
Yesterday before heading to Mapuordit, I made quick rounds and found a little girl about three years old who was stiff.  She had some fever and would not move her neck at all.  She had been admitted the night before with the diagnosis of malaria, but I was convinced she had meningitis.  She looked very ill, she refused to bend her neck, and I did not feel the spleen.  I asked the nurses to start Ceftriaxone with the plan of doing a LP (lumbar puncture, spinal tap) that afternoon.  In the US, we always try to do the tap before starting meds, but that is because we can send the fluid for culture, an option unavailable here. 
            I checked on the child later during the day and she seemed the same: very stiff, very irritable, though a bit more alert.  I did the LP, which was not completely clear, but appeared to be some blood, not truly cloudy, and the cell count was low.  Still, I kept with the diagnosis of meningitis.  Today, the child was a bit better and now she has a large spleen.  She is on both Quinine and Ceftriaxone. 
            The diagnosis for this child is uncertain, but if I had to choose one, it is cerebral malaria.  We used to always say that if all your LP’s are abnormal, you are not doing it frequently enough.  There have been two children this week who clinically looked to have meningitis, but the cells were not there.  We see a lot of cerebral malaria with confusion and convulsions, even coma, but I have not seen this nuchal rigidity (stiff neck) presentation before.  I will treat both of these children for meningitis, but I will probably feel okay about changing over to oral Chloramphenicol rather than going with Ceftriaxone the entire time.  And I am glad that we do have the counting chamber so that we can make a firm diagnosis rather than going just with the clinical presentation. 

20 March 2012 
Jacob came to my room with two books.  It was not a particularly busy day, but there were a couple of patients I had started with and was trying to complete before coming to the treatment room.  The first child was an 8 year old boy who was hopping on his left foot.  He was bearing almost no weight on the right leg.  His right calf was 1.5 times the size of the left (though that still does not mean it was large.  Dinkas are the classic long ankles) and had “woody induration.”  I first heard that term from Primary Surgery, but it is the perfect description.  Induration means thickening, hardening, but only in pyomyositis have I felt this texture.  It feels like skin over old, fairly rotten wood.  The child had started with swelling and fever 3 weeks earlier.  The second child was a 9 month girl with swelling in the right upper arm for 4 days.  She was still nursing well, but she had a large, obviously fluctuant swelling at the transition between the axilla (armpit) and upper arm.  I gave the older child some Ketamine and Promethazine and instilled some Lidocaine into the swelling of the younger child.  It is not that I enjoy hearing little ones cry, but I anticipated 20-40 seconds of fairly intense pain for the baby and then it would be over.  I did feel such pain required sedation because there are always some risks in sedation.  The probing of the older boy, however, would take much longer and he needed the sedation. 
            Neither child would have voted me their favorite person that day.  The younger child did have about 10 ml of pus and a bit of probing was required, but it was quick.  Within 10 minutes the child was nursing contentedly.  The older child was showing some signs of awakening from the sedation by the time I opened his leg.  I incised medial (towards the middle) from the shin and then had to probe fairly deeply, but there was about 30 ml of purulent/necrotic fluid to drain.  The areas of induration were fairly extensive, so I probed a good bit more in this child and then sutured a drain into the abscess bed.  By that time, the child was still “out of it,” but he was clearly feeling some pain.  Fortunately, the procedure ended before the sedation really wore off, but he was still moaning as we took him to the wards to recover and to receive IV antibiotics.  The 9 month old I sent home on oral antibiotics, and except for the bandage, you could never tell she had been disturbed.
            Normally I am much more concerned about younger children.  Particularly in the first year, the younger the child, the more vulnerable to overwhelming infection and to the effects of anesthesia.  The latter is the reason I did not use Ketamine with the younger child, though I would have had the procedure been more extensive.  The younger girl did have the more obvious lesion, but the abscess was superficial.  The older child had a less obvious, but more invasive disease.  My experience is that pyomyositis will take some time to heal, even when properly managed, but the little girl’s disease is virtually resolved and the antibiotics are just for “good measure.”  The pyomyositis requires both the drainage (often multiple times) and aggressive antibiotics.  I had heard of pyomyositis before coming to South Sudan; now I feel as though I am fairly experienced.  I hope this child will benefit from my experience. 

21 March 2012 
The parents said she was four, but she looked smaller.  She came in with a history of cough and diarrhea, but the last day she had high fever and vomiting.  I tried the key trick on her, shaking the keys until she looked at them and then lowering them to her lap to see if she would follow.  She briefly looked at them, but would not follow into the lap.  Then I got a good look at her face.  She had almond shaped eyes and the nose and middle of the face were too small (hypoplastic).  The space between her first and second toes was too large.  I asked about speech.  Though she was four (or at least had been weaned for 2 years, so four was likely), she was not speaking.  She had Down’s syndrome. 
            I have a problem with Down syndrome children, but not the one much of the world has.  Down syndrome (Trisomy 21) is caused by having an additional chromosome, the gene carrying bodies in our cells.  Contrary to what would seem logical to me, having extra chromosomal material is not beneficial.  It results in mental retardation and numerous problems with the cardiac, immunological, and respiratory systems.  The retardation is what bothers many.  In the mistaken guise of concern for the genetic pool, many want to see Down syndrome children die, and many do die via abortion in the US.  I have dealt with many Down syndrome children and have a great affection for them.  They are gentle and loving and often not nearly as retarded as once believed.  My problem with Down syndrome children is their propensity to die.  They get sick very quickly and die with what seemed to be a not so serious illness.  Therefore a Down syndrome child refusing to bend her neck earns a LP (lumbar puncture, spinal tap). 
            I did give her a little bit of ketamine.  Because of the small size of their upper airway (the pharyngeal space behind the nose) and the their general low tone, Down syndrome patients tend to block off their airways, so I did not want this child too out of it. 
            The spinal fluid was cloudy.  In the counting chamber, there were about 80 cells/block.  This child had meningitis.  I believe we were relatively early in the process so I am hopeful that we have started medication in time.  We will see.  For now, I am even more skeptical of Down syndrome children than before.

22 March 2012 
Wailing is not an adequate compensation for acting at the right time.  A large part of my father’s law practice was handling estates.  One man once commented to him, “You never did a lot of criminal law, so you did not seem the unseemlier side of the law.”
“You have obviously not watched families during the reading of the will.”  One of his observations was that the children who were most negligent of the demised seem to make the biggest fuss at the reading.  We certainly see that in medicine.  A son has not seen his mother in 5 years, but in the ICU he is cursing everyone, pushing to get everything done for her even when there is no reasonable hope. 
            Today an 18 month old girl died in our hospital.  The first time I saw her in the hospital, I noted a lesion strongly suggestive of Kaposi’s sarcoma, a cancer almost unique to AIDS, before I found out she was HIV (+).  The mother was also known to have HIV, but she was in Juba (I presume getting therapy).  I strongly suggested at our first rounds on this child that the child needed to go to Mapuordit and get started on ART (antiretroviral therapy).  I knew the sister, Sarah, who was with the child; she had lived at the hospital during the unrest of Jan 2010.  She is much older and has children of her own, but though she could be trusted to care for the child, taking her to Mapuordit was “outside her pay scale.”  I stressed that Nyitor, the child’s mother, needed to be contacted.  “This child has AIDS and will not improve until she gets started on ART.”  That was a continual theme as we made rounds.  “Where is Nyitor?  Can you get permission to take her over the phone?” 
“The network is down” (which was true).  The fever was down and the diarrhea reduced, but the child was not really looking any better.  I stressed again on rounds today the urgency of getting the mother here so this child could get appropriate therapy. 
            When Francis approached me to tell me a child on the ward had died, I was afraid it would be the 4 year old Downs child with meningitis.  I hate to feel relieved at any death, but I did feel that the prognosis for this child was poor, even if we had the ART’s to start ourselves.  The responsibility to transport this child’s body home fell on me.  I ran a couple of errands and then picked up Sarah and the baby.  Sarah was beside herself with grief.  She was not throwing herself down, as many women do, but she was sobbing, particularly when in the view of her relations.  I have no doubt that she was expressing real grief, but I could not help but think that had she used some of that energy for seeking appropriate therapy, this death may have occurred so quickly.  Better to act in a timely fashion than curse your fate. 

23 March 2012 
Dr. Rossi has started a movement that is quickly gelling: going to Paloc weekly.  Actually, our friends and colleagues from Across have also decided to go to Paloc regularly, so I do not think there will be a need to go every week, but we are still working out details.  Peter Malual was behind the movement.  Peter is a great guy.  He really has a heart for the cattle camp people that Justin Culp saw during his time here and got Peter acting as a missionary to the cattle keepers.  Peter is always seeking to help his flock in every way possible.  He was the first to get Dr. Rossi to go to Paloc.  I have been with Peter a few times for clinic and evangelism, but during my visits I managed to escape with only make vague promises (we will come back again, but I am not sure when).  But Rossi’s commitment involved me and this week it was my turn to go, so Peter approached about going to Luel.  Luel is a remote village of cattle keepers significantly beyond Paloc.  Few kawajas have ever been there.  Peter told me they were having a lot of diarrhea and were really suffering there.  Therefore I decided to go. 
            Amazingly, we left Akot at 9:20, almost at the time we wanted.  I decided to go the back way.  There is a road to Paloc that runs right by our hospital, joining with the road from Akot “a couple of klicks” down the road.  There is a new road from Karic to Paloc.   It is actually nice and getting nicer.  But it is the dry season, so there is little chance of getting stuck, and Karic is 15 kilometers away, so I opted for the old way.  It turned out well.  I saw some beautiful birds along the way, and we arrived in Paloc at a good hour.  As we drove up, so did our friends from Across.  As mentioned, we have not worked out all the details of this arrangement.  We would enjoy having clinic with them, but that also means twice the time between visits.  But since our plan was to go to Luel, we greeted them and headed northwest.  In my mind, I envisioned Luel being 5-10 kilometers away.  It was more like 20-30.  The road is being extended in that direction, but it is far from finished.  I saw a cutoff to the right and asked Peter about it.  “That goes to Luel, but so does this road.”  About 5 kilometers later, we found out that the latter statement was wrong.  I think, in truth, the road will be connected to Luel in the future, but it does not at present.  So we retraced over rough roads, took the aforementioned path and came to Luel. 
            My first impressions were unfavorable.  Many of the “barracks” that the SPLA soldiers construct utilize sorghum stalks to get temporary shelter.  It always reminds me of the three little pigs, but there were only a few more permanent looking tukuls in the area.  We set up under a cuie tree.  From Peter’s description, I expected to see half dead skeletons drag themselves to our clinic, and I brought IV fluids and canulae, plus minor surgery equipment.  In fact, very few were very ill, and none were life and death matters.  There were a lot of common illnesses, including some asthma for which I had neglected to bring appropriate drugs, and we did take one malaria patient back for admission, but overall, it was like a normal clinic day in Akot.  As typical of that kind of clinic, there were few initially and then many more as the time went on, so that we left as many unseen as seen, but scanning the group as we left, I do not think we neglected any seriously ill patients. 
            I think my trips to Paloc and Luel are much like a group from America doing short term missions: you are interrupting your routine and going to do something at your own expense, so there are high expectations to make it worth your while.  I am not sure that the journey was worthwhile.  It is likely that the malaria patient’s life may have been saved, but he might have recovered on his own.  Certainly nothing I did required a great deal of expertise.  But it may have opened the door for Peter or someone else to work in that area, set up a church, bring the gospel to bear upon that community.  God ordains both the means and the ends: He calls us to be faithful and obedient.  How He uses our obedience is up to Him.  Besides, I did see a lot of pretty birds. 

24 March 2012 
Francis approached me with an unusual request: “May Elijah and I have next Saturday off?”  The request itself is not unusual; people everywhere seek to have some time off from work periodically.  What was unusual was that it was coming from our nurses.  We have three nurses who rotate through the hospital.  I have been here for close to three years now; Samuel and Francis have been here over five years and Elijah will have been here five years fairly soon.  When they came there was an expectation of having a doctor in charge of the hospital, yet for almost three years, the nurses ran the hospital by themselves.  And since my coming, they have continued a rigorous rotation.  Indeed, because the work in the hospital has increased greatly over the last 3 years, you could forcefully argue that my coming has increased rather than decreased their work load.  They come in for two months at a time and are one every other night.  They cover the antenatal clinic and are responsible for all patients that come outside clinic hours, though Dr. Rossi and I try to relieve that burden to some degree, particularly on Saturdays.  But today they took off for a day of “R&R.”  Before leaving, they gave the morning medications, relieving us of that responsibility. 
I rounded with Rebecca.  We have a fair number of sick patients, though nothing like during the real malaria season.  We have a newly diagnosed diabetic patient.  Though he is 60, he is not at all obese and I suspect he is insulin dependent, though we have not established that fact.  We have a patient with pyomyositis who has responded well to drainage and antibiotics.  We have several cases of malaria still, several with dysentery, several with asthma.  Most were doing well.  Again, I suspect that had there been any really unstable cases, the nurses would have cancelled their day and stayed on to care for the patients.  By the time we finished rounds, there were a number of patients waiting to be seen.  When those were completed, the drain from the patient with pyomyositis needed to be removed.  There were a number of other cases to be seen, but Dr. Rossi saw them in the clinic, thus reducing that burden.  Shortly after finishing the rounds and seeing the walk-ins, we went to lunch, and then it was time for the afternoon medications.  We had to round up the patients, give the puffs to the asthmatics, the Quinine drops to the children with malaria.  Fortunately we did not have to start or hang any drips, but we did have to help force the oral meds down the unwilling throats of the children who at the time comprise the majority of our current census.  I had promised to transport some grasses for Deborah, so I used that promise as a means of shifting the responsibility for the hospital to Dr. Rossi.  I was gone for 2-3 hours and when I returned, he was just completing the evening meds. 
Francis and Elijah traveled to Yirol.  They went to the lakes around that town.  I think they were both burned out and stir crazy.  They live on the ward.  Even on their “off night,” crying babies and other distractions make sure that their sleep is insufficient.  Nursing is hard work everywhere.  Often it is tedious, but it is virtually always relentless.  I have appreciated our nurses, both their hard work and their cordiality.  They have always made me feel welcome and are ready to learn or teach, whatever the situation demands.  I am glad I do not have to try to run this hospital without them. 

25 March 2012 
Gabriel Amat asked me to preach today from Numbers 21.  It is a great passage where both the wrath of God and His grace are made clear.  I approached the subject by talking about manna.  Manna has always fascinated me.  I have wondered about its taste and hope that in heaven we will get to sample it.  One thing very clear about manna is its miraculous nature, even though the people quickly took it for granted.  Manna began 45 days after leaving Egypt, about the time when their supplies from Egypt were exhausted.  Though they were in the desert, dew formed around them every morning.  That in itself is miraculous.  We have no dew here in South Sudan during the dry season.  The dew was limited to the area surrounding the people of Israel.  When they moved, the dew moved with them.  And that dew changed into the bread of heaven that stayed fresh for the day, but was worm eaten if they tried to take more than a day’s supply.  Except on Friday, when they had to take a double portion and that supply remained fresh the next day.  No dew or bread came on the Sabbath.  Despite this continuous reminder of the goodness and provisions of the Lord, Israel continually sinned.  When Moses went up Mt. Sinai, the people gathered in their manna in the morning and that afternoon took off their gold rings, declaring, “Come, make us a god who will go before us” (Ex 32:1).  When the spies went to scout out the Promised Land, they had been eating the manna before seeing the land flowing with milk and honey and declaring, “The people who live in the land and their cities are fortified…we are not able to go up against the people” (Numbers 13:28-31).  But it is in Numbers 21 where Israel rejects the manna (and thereby the provisions of God). “We loathe this miserable food” (Num 21:5).  God, in His anger, sends the fiery serpents to kill them, but then they cried out for mercy, and God instructs Moses to make the bronze serpent on the pole for the people to look upon.  Interestingly, God does not take away the serpents, but all those who looked upon the bronze serpent by faith, though they were bitten, did not die. 
            Jesus identifies with both the manna (John 6) and the bronze serpent (John 3).  He is the bread of heaven, our provision until we reach our Promised Land, heaven.  He is payment for our sin, the hope for those justly condemned by their own sin.  We see both the wrath and grace of God in this story, and we are warned that we will face one or the other.  The call is stark and I attempted to make that clear.  “See, I have set before you today life and prosperity, and death and adversity” (Deut 30:15, one of our readings for today).  We can eat the manna and still die.  It is not enough to go through the motions and attend church.  Faith must be accompanied by gratitude and obedience (James 2:17).  We look by faith to Christ as our righteousness, and He becomes for sin “the double cure; save me from its guilt and power” (Rock of Ages, Toplady).  It is a good word for us all.  Please pray that it will take root in the hearts of the people. 

26 March 2012 
Bill Deans has found a donor to get our solar power system replaced, and it is very timely.  Whatever the reason, over the last week or so, we have been completely dependent on the generator.  Even with a sun baking down at 120F, there is no power.  And now there is only spotty power even with the generator running.  For the past two days, there has been no power in the wards or tents.  I would like to think that I can get by without the power, but I find myself uprooted.  First of all, my morning routine is shot.  I usually get up early for Bible study, but with no light, that is impossible.  I have been turning on the generator a bit earlier than usual so that I can have some time, but I am such a creature of habit and I do not like having my routine altered.  Second, for the last two days, I have been gone during all the day light hours, so that means my only time in the tent is in the dark.  I am fairly disorganized anyway, but such hazards really disrupt me.  Third, darkness upsets everyone.  You would think Dinkas, who live much of their lives without power, would laugh at us, but the lack of power has upset them just as much as the kawajas.  How quickly we become dependent.
            It is a blessing that the help will come shortly after the need has become so acute.  The lack of power forces me to remember how many things I take for granted, and then like Jonah, bewail my fate when what I assume is mine is taken away.  And it makes me thankful for donors who give generously to keep our mission going.  God is our sustainer, but He usually uses men to do the work.  Thank you for your faithfulness towards us.

27 Mar 2012 
We had a bad case come to us today.  A woman, mid-thirties, who is pregnant (gravida 6 [6th pregnancy], para 5 [has given birth to 5 living children]) was beaten.  I would like for you to believe that is rare, but it is not.  Men often beat women here, usually for no good reason (I know, there is virtually never a good reason why a man would beat a woman, but I mean really poor excuses).  Men beating women is one of the things that has changed the way I manage STD’s (sexually transmitted diseases). I used to treat the woman when she came in with symptoms and then tell the woman to refuse to lie with her husband until he got treated, but when she did it, he would beat her. Now unless the woman is acutely ill, I do not treat the woman until the husband comes in as well.  Another horrible incident occurred New Years 2011.  A family found out a girl was pregnant outside marriage and beat her to death.  They did not mean to kill her, but they felt justified in beating her close to death.  Regularly if a girl does anything her brother considers “loose” he may beat her severely.  It still infuriates me to hear the stories, but I have gotten somewhat used to this type of behavior.  But I was not ready for this story. 
            Probably 90% (maybe more) of the homes (tukuls) in South Sudan are roofed with grasses.  The metal sheets last longer, but are much more expensive and do not insulate against the heat as well.  The negative of the grasses is that they last only about 3 years and then must be replaced.  Therefore every dry season there is a big market of buying and selling grasses.  This woman bought the grasses needed to repair or re-thatch her roof.  One of the payam administrators from her village (not Akot) came to her tukul and took one of the bundles of her grass, saying it was for taxes.  Since Bible times, tax-gathers have never been overly loved, but this collection did appear somewhat tainted.  After all, she was not there, there is no tax code in South Sudan, and it was hard to envision that this Zaccheus was gathering the bundle for Rumbek.  Therefore she reacted.  She came to the man wanting to know why he took her grass while she was not there.  I think most would agree that the question was legitimate, but he did not take it that way.  Instead of answering her question, he contacted the local SPLA leaders and had them beat her.  Her major complaint was pain.  She is early in her third trimester (last three months of pregnancy), but she had some pains that made the nurses fear she was going into labor and they have taken some appropriate measures. 
            Most people feel that if this woman went to the courts, there would not be any judgment against the man.  I compare this to the case of Mary Agum, where she elbowed out of the way a woman who had beaten her sister and was blocking her access to the hand pumps.  The girl came in two days later with signs of malaria and had a miscarriage and the courts were leaning towards a payment of cows for the couple, though everyone medical said the incident had nothing to do with her miscarriage.  “The first thing we do, let’s kill all the lawyers” (Shakespeare, Henry IV).  The quote is familiar, but the setting gives the quote a different slant than we usually think.  It is spoken by an anarchist, attempting to bring destroy the kingdom.  It is, in reality, a back-handed compliment.  Justice is important because it thwarts the designs of the evil one.  It is always imperfectly carried out, but it is right for us to work for justice.  There needs to be a day when officials cannot confiscate without fear and soldiers cannot and will not beat pregnant women at the beckoning of another. 

28 Mar 2012 
I got some good feedback from some patients previously mentioned in this journal.  I know that I leave you hanging often, and sometimes the reason is because I do not get follow up myself.  There was an 8 yo boy recently admitted with pyomyositis of the right calf.  He was in the hospital for several days and went home.  Today he came back walking close to normally and feeling good.  He has not had any fever or any significant pain in the leg. 
            The second patient was from earlier.  I never did get the patient in return, but there was a 2 yo old boy with what we thought was an amoebic infection under the liver, but he had responded clinically to meds instead of requiring surgery.  It was interesting because the parents had threatened to take the child home, probably meaning to the witch doctor.  The turnaround was slow, but the child showed improvement on the physical exam first, then began to eat, and finally started looking pretty good.  However, there is always a fear that once the antibiotics are removed, the illness will return.  But yesterday I saw the mother and she reported that the child was perfectly well, as though nothing had ever happened to him.  That was great news. 

29 March 2012 
Lacerations are common and generally not worth reporting, but I had an interesting one today.  A soldier was brought in following a motorcycle accident.  I do not know much about what happened (Dinkas are not generally very free with their reporting), but I smelled alcohol, so I felt it probably played a role in the accident.  His exam was basically unremarkable except for a laceration under the right eye, and I mean just under the eye.  It was a 3 cm laceration starting about 1.5 cm lateral to the orbit (outside the eyeball) and extending along the border of the lower lash for the same distance.  As I went to examine him, he resisted several times, so I decided to use Ketamine and Promethazine.  I soaked the wound in Betadine and numbed to the degree I could, but there is not much leeway with a laceration so close to the eye.  I also was limited by the suture material.  We have some Ethilon, the ideal suture material, but it is much larger than I would choose, given my preference.  With suture, the lower the number, the bigger the thread.  I would have preferred 6-0, but all we have is 2-0.  That would not be too bad except that the needle attached is about 3 cm long.  It would be analogous to using a butcher knife rather than a scalpel to open the skin in surgery.  I put two sutures in lateral to the eye, closing that part of the laceration and bringing the remaining skin closer.  There was a 2 mm lip of skin on the lashes, and I was seeking to grab it with my forceps and put a suture through it, but each time I tried, the patient would start thrashing around.  I gave more Ketamine, but he continued.  Finally I decided to leave it as it was and bandage his eye closed.  I put in some Tetracycline ophthalmic ointment.  I think he will have a scar, but I was afraid I would do more damage (potentially much more) if I persisted.

30 Mar 2012 
I had just made the announcement that anyone wanting assistance involving the use of hospital vehicles would have to pay for the mileage when Chief Sawat approached me about taking him to Rumbek.  Sawat Malual Arop is the executive chief of area.  His half-brother, Dut Malual Arop, is the paramount chief and in theory the one with the most power, but Dut has hypertension and diabetes, and he is not overly fond of follow-up appointments, so his health is not good and Sawat has moved into the power vacuum.  Sawat and I are cordial enough, but no one would mistake us for close friends.  I have to be politic around him, because he could make it more difficult for us to do our work if he chose.  Sawat apologized, but said that the reason for him needing to go was that the verdict for the case involving the death of his grandson would be read in Rumbek the next day.  I had already been to Rumbek this week and had no real need to return, but I wanted to come up with one so that I could accommodate Sawat without invalidating my word right away.  I told Sawat I would get back with him later that day.  I talked with Rose.  Though our stores were adequate, we had a lot of visitors coming over the next 5 weeks, so she would welcome the chance to get more staples.  I also checked out fuel status and found us close to empty.  Therefore I planned to take the pickup, take some barrels for fuel, and the three of us could ride to Rumbek.  I sent word to Sawat to that effect.  I then told Judy, because I knew there were some things she needed to get done in Rumbek.  Dr. Rossi overheard the conversation and said that he, also, needed to get some things done.  Deborah needed to go to transport some things for Maria.  Suddenly the truck was filling up.  
            We were an hour and a half later than planned for departure, but a fairly full truck emerged from our hospital.  Dr. Rossi was driving.  Judy and Sawat were up front and the rest of us were in the back.  We got to the market and Sawat instructed Rossi to pull over.  He had more guests, though he had not mentioned them.  He wanted me to clear out some of the things in the back, but I refused.  Had he let me know that there were many people, I may have been more cooperative, but I was fed up with the half truths I get so often.  So Sawat put another man in the front, about 10 men in the back, and then he took a different method of transportation. 
            I have ridden in the back before, and there has never been an overabundance of space, but I started really feeling like a Dinka in this trip.  I would be comfortable for while, but then I would need to move my leg or my arm, which meant Deborah or Rose needed to move as well.  I ended up sitting with my feet extended over the side.  A few bushes hit my feet, but fortunately nothing more substantial.  Rose was less fortunate.  She was in the middle.  My arm was around her, as were about 5 other men.  Another man put his hand on her neck and she erupted.  “No more men.  I cannot be touched by another man.”  But we made it without any real problems. 
            Actually we got a lot done.  The money transfer had gone through.  Fuel was down to 7 SSP/liter, so we saved about 800 SSP.  Judy needed to buy two tires to replace some that went flat and we were able to find good used tires for about a third of what she would have had to pay.  Judy also met with the head of water and sanitation, hoping against hope to get some pumps assigned to the women she had trained, but she was disappointed in that.  Rose had a lot to buy and we decided to move the truck to a different place to load the goods and keep a low profile, but that proved our undoing.  We got separated.  Judy, Deborah and I were on one track (our fruitless trip to the department of water and sanitation); Rossi, Rose, and Isaac Marial were marching to a different drummer.  We parked the truck where it had been and I know they found it, because it mysteriously filled up with goods.  But after putting the goods into some order, we went out again searching for toothpaste and other necessities.  We checked on Deborah’s phone, but it was still charging (she was the only one in our group with a phone).  We came back, but the second group was still missing.  I went to the fresh market area where I knew Rose did much of her shopping, but she was not there.  So we waited.  An hour later, we went back to get Deborah’s phone.  It was still not charged, but we took it anyway.  Rose did not have her phone, but Deborah tried Isaac.  No answer.  Finally we decided to pull out and try to find them.  They had returned to the old place and had been waiting for us for the same time.  It was a day destined for confusion and disappointment. 

31 March 2012 
When we pulled up to the market, we found that all the goods purchased had not been loaded.  Indeed, there was about as much to add as was already in the truck so that by the time the loading was complete, the goods were higher than the truck bed.  Then there were the people.  By returning to the usual port of exit, all attempts of leaving incognito were ruined and we ended up carrying just about as many people back as we had in coming, only this time Rose did get a seat in the front.  There was some shifting of the packages as we traveled and we stopped a couple of times to readjust so that no one fell off.  Dr. Rossi was sensitive to our lot and drove slowly.  All was going well, and it was actually a much more comfortable trip than in the morning.  I was enjoying watching the stars.  It felt like a hayride. 
But when we go to Thon-Aduel, Rossi made a mistake, though admittedly an understandable one.  A soldier came towards him with a gun, so Rossi stopped.  No one in his right mind looked at our truck and thought there was any room for additional passengers, but then we are not in the SPLA.  The soldier made Rossi take an additional three passengers.  That was bad enough, but it turns out that the soldiers were drunk.  I heard some arguments, but was unable to follow the course.  It turns out that one of the drunk soldiers was pinching and antagonizing some of the men.  Deborah got into the argument and the soldier threatened her, so intervened at that point.  We finally got to Atiaba, the point of exit of the soldiers, and I heard some more arguments.  I heard a couple of slaps, though I thought it was one of the soldiers slapping his subordinate for his behavior.  Turns out that they had slapped some of our men and they came around and wanted to abuse Deborah.  When my oblivion was lifted, I again intervened and the soldiers were let off so that we could conclude our trip.  But before we could arrive home, we dropped a tin of milk and soap (both of which were recovered, but somewhat abused for the drop).  It was a remarkable trip. 

Saturday, March 17, 2012

Journal Entries from Dr. Clarke

1 March 2012 
As we finished rounds today, the last patient was a 9 year old girl admitted the night before.  She looked ill.  In fact, she looked apprehensive, as though she sensed something bad pending.  I pointed out her apprehensive look to one of the students standing beside me.  A different student was examining her at the time.  But when I examined her, I was reassured.  She did not have fever.  Her heart rate was high, but not dramatically so.  She was alert and though she did not enjoy bending her neck, it was not as bad as other joint.  She really resisted me moving her joints (particularly elbows and knees), but there was no warmth or redness.  She had a big spleen. 
            I knew that she was quite ill, but I felt comfortable that this was malaria.  The question I had was whether to change her from ACT to Quinine, but we elected to continue the ACT as the fever was down.  Later this morning the patient became much sicker and started frothing at the mouth.  The nurses quickly put in a line and started the Quinine, but the child died before the Quinine was completed. 
            As I was writing this, Samuel Ireri came to me to tell me a second child died today.  This child also came in during the night.  She was a 15 month old child who came in with high fever.  The child did appear to be a bit cloudy, but what impressed me mostly about her on rounds was her low tone.  In biology there was a time when we would pith a frog, that is stick a needle up the spine, thus destroying the spinal cord.  You could then dissect a life frog and see the heart, lungs, and other vital organs working.  This child looked like a pithed frog.  There was little tone in the extremities.  Indeed, one of the neuromuscular disorders entered my mind, though she could sit up (or at least stay up once put in position).  At rounds she did not have fever.  She had been started on Quinine.  Though she did not have a big spleen, I thought malaria the most likely diagnosis and I did not alter her therapy.  When the nurses came back from lunch today, the child had died. 
            I realize that two deaths in a day do not constitute a wave, but it is discouraging in our small hospital.  I have been in hospitals when deaths seem to come like waves and it is disheartening.  Appropriately, there is a close examination to make sure we are not doing anything to cause the death or missing anything.  There is discouragement about the work.  Superstition sets in among the patients.  Today I saw a child with diarrhea and vomiting.  The child was not that ill, but the mother and older sibling also had the same thing, so for the family’s sake, I put them into the hospital.  When that second child died, the father took his family home.  Even more ominously, this could be the start of an epidemic of either meningococcus or a more virulent form of malaria.  We will be diligently looking. 

2 March 2012  
We have a five year old on the ward who came in with high fevers for three days, then started with vomiting and diarrhea the day before admission.  When she came to us, she had a low-grade fever, a distended abdomen, severe pain in the right lower quadrant (RLQ).  I felt this was fairly classic for typhoid fever.  Typhoid fever is caused by Salmonella typhi, a first cousin to the Salmonella that causes a lot of food poisoning.  It does cause vomiting and diarrhea, but typically there is high fever for 2-3 days prior to the onset of the gastrointestinal problems.  It can cause major problems, including rupture of the bowel, and the girl was sick when I put her into the hospital.  The drug of choice for Typhoid Fever used to be Chloramphenicol, and in my book, it is still the favored drug.  There are areas of the world where Chloramphenicol has been sold over the counter, and that includes South Sudan, but it is not a favorite.  People tend to prefer Penicillin here for injections.  For oral drugs, they tend to prefer Cipro.  Both of those drugs feature prominently in the GoSS supplied drugs and therefore tend to be found in the market place for sale.  My estimate is that Chloramphenicol is used much less often in that context and therefore organisms from the community should be less prone to resistance. 
            This morning on rounds she was fairly cheerful.  She did vomit once yesterday, but not again through the night and her diarrhea has slowed down.  On exam, the abdomen was less distended than before, the RLQ perhaps a bit less tender, but now I can feel the spleen.  Could this all be malaria?  The experts from America differ as to whether malaria causes any gastrointestinal problems.  Those who take care of malaria regularly are convinced that it does.  But I do not think the primary issue in this child is malaria, particularly with the response we have seen to the Chloramphenicol.  I think it very possible that it could be contributing to her illness and we did start her on ACT. 
            This girl is from Akot.  If we know anything about Typhoid Fever, it is its tendency to cause epidemics.  Episodic cases do occur, but this child could be the first case of an epidemic.  Our antennae will be up.  It gives us something else to be considering. 

3 March 2012 
My adventure today has tentacles reaching back several weeks.  We had a team from America coming, so we needed all the vehicles running their best.  We had been resuscitating and nursing along the battery in the new pickup (only five years old) and Lazarus’ battery was dead, so I decided to get a couple of new ones.  I went to the place where I generally get my parts and asked, but they do not sell batteries.  I have bought batteries in Rumbek before, but I thought these guys might have more insight as to where I should go.  Jovia is the receptionist at the parts place from Uganda and she has become a friend, so I asked her.  She pointed to a place relatively near, so I elected to buy my batteries there.  I do regret it.  I told him I needed batteries for LandCruisers.  All three of our vehicles are LandCruisers (two are pickups and the one I generally refer to as a LandCruiser we call the High Box).  LandCruisers are by far the most common vehicles in South Sudan because of the harsh conditions.  So when I told the proprietor the batteries were for LandCruisers, there was every reason to expect him to know what batteries a LandCruiser needs and whether his batteries meet the specifications.  Wrong.  He sold me a weak battery.  I explained again how it would be used and again he reassured me.  I got the batteries, the sulfuric acid, took them to Akot, filled and charged the batteries.  It was not enough.  We tried running them in the car for a bit, but they could not turn the engine over.  So I went back for an exchange.  That took some negotiating, but he exchanged one for the larger batter (N70 rather than N50), and I had to buy the second.  My dismay was compounded when these did not work either.  So now I am trying to figure out what to do and we are still using the old battery for now.  Generally once that battery has been started once, it will start the remainder of the day.  Yesterday I helped move some mudbricks and the pickup started just fine after the initial push start, so I anticipated the same thing today.
            Abraham Laat has been after me for several days to help his sister.  She, as everyone else lately, is a victim of the Agaar-Atuot violence because she lives on the frontier, the areas close to the other sub-tribe.  Her major issue is grasses.  The thatch that roofs the tukuls does not come from just anywhere.  We have tons of grass around us that looks similar, but that are not really the same.  The grasses used to re-roof the tukul often come from close to the lake or river.  The shaft is rather large (compared to our grasses at least) and there is a sturdiness about that grass that is not true of the weeds lining our paths and blocking our views when driving.  It costs about 10 pounds/bundle and a tukul usually needs 15-20 bundles, so re-roofing is serious.  But grasses are not as important as food for families.  Shelter comes before clothing but after food in the survival algorithm.  But I was committed and we bounced over mounds making a path to his sister’s tukul.  I parked the car at one side of the tukul, but Abraham directed me to the other side where the grasses were arranged.  I backed over some more rock hard fields and put the truck next to the stores.  We started loading the grasses with Abraham Laat up in the bed of the truck.  Soon we were over the sides and they got some limbs to stuff in the sides of the truck to hold the grasses in.  Soon we were well over the cab of the truck and I thought we were getting too high, too likely to fall, so I called it.  I jumped in to start the truck and got a slight groan.  The battery.  We were far away from anything approaching civilization and I did not have a phone.  I could foresee us walking back to Akot and then having to ride out in the LandCruiser to get the pickup going again.  I have push-started the car more often than I want to remember, but that is generally on fairly packed surfaces.  This was over a field.  But we had to do it.  Laat and his brother and all the women helped.  I was out beside the truck pulling/pushing.  We cleared some brush, moved forward and got some momentum, but not enough.  The engine coughed but did not start.  We had to try again.  We pushed several times without rolling at all.  We seemed past the obstacles, but we could not get going.  I looked in and the truck was still in 2nd gear where I had left it in my unsuccessful first attempt.  Back in neutral, we got the truck rolling and the engine came to life.  The worst case scenario had been averted. 
To keep the grasses in, we use ropes.  I put one around the posts, but fairly low, so the poles were sticking out the side, much like a shrimper lowering its nets.  I planned to come around again high, but Abraham thought going over the top more important.   I anticipated some problems.  We snaked our way to the tukul through some fairly tight squeezes, so I knew it would be difficult getting back out.  Twice in the first quarter of a mile, we had spillage from a tree limb catching a bundle or one of the posts hitting against a tree.  We decided to repack.  We had to keep the truck running, which is frustrating when fuel is 8 pounds/liter, but I dared not turn it off.  This time as the boys handed up the grasses, I roped in the poles at the tops to keep them from leaning outward.  And like a building built squarely, the pressures on the poles were not too great and poles stayed upright.  One bundle from the top spilled about half of its grasses, but we arrived intact.  One more down and one more lesson learned.

4 March 2012 
I come from a family of attorneys, and my father has a humorous story about a classmate badly misusing the legal term eminent domain, so I must be careful here.   Eminent domain is when the government takes over the property of an individual for the good of the community.  An old house on Main Street is condemned to allow the construction of a new courthouse.  In America, when that occurs, the individual has the right to demonstrate an equally effective way to meet the goal as an alternative (my father did that at his property and won) and the government must compensate the individual fairly.  I have complained in the past about the failure of eminent domain in the Dinka culture.  An individual decides he wants to extend his field into the road and he throws down a couple of sticks and declares the road closed.  I have thrown away many such locally imposed detours.  But yesterday I heard something from the other end of eminent domain abuse.  I was taking Deborah, one of the students working in the hospital with me, to her sister’s house in Rumbek.  As we turned down the street where she lives, a bulldozer was knocking down a mango tree.  We went some ways down the street and Deborah was excited.  “They did not knock down my sister’s house.”  This was another home owned by her sister and brother-in-law that they rented out.  What looked to be the new road came within a few feet of the house, a nice one by Dinka standards, but the house appeared to be spared.  Later, though, the sister informed us that the house would be destroyed so that they could widen the road.  They would lose the house and property, and there would be no compensation given.  “If they are fortunate, the government may give them some land outside the city, but nothing for the house,” Deborah informed me.  Nor will there be any insurance to help them.  I can imagine the protests that such an approach would generate in the US, but in South Sudan, it is just part of life.  I heard Deborah and her sister talking about the problem.  Though I made out few of the words, it was obvious that the sister had resigned herself to what was going to occur.  I often complain about government interference; I am for a smaller government, but I like the US form of eminent domain far more than the South Sudanese equivalent.  

5 March 2012 
Our first go at having Rumbek nursing students in our hospital tanked.   Shortly after their arrival I snuck them out of Akot, fearful that Malek might be the target of the malignant revenge of the Dinkas (see 28 February).  So I was pleased that CISP elected to continue the program even after the disastrous start.  Two more nurses, John Umbali and Kuotca Paulino came to spend a few weeks with us.  They are both from the Nuba mountain region.  Much information has come to the US about Darfur, but in fact, Khartoum has been guilty of similar abuses in various regions of the country all along.  The Nuba Mountains and South Kordofan are geographically located in northern Sudan, but the people are black.  Again, I have some difficulty distinguishing the Arabic black from the African blacks, but Khartoum obviously does not.  Throughout both Anyanya I and II, the wars of Khartoum against blacks of southern Sudan, the Nubians were also under attack.  Khartoum labeled the wars as jihad, religious wars against the infidels, but as the atrocities in Darfur suggest, the real explanation that fits the facts is attempted genocide.  The Khartoum government apparently hates sharing the country with blacks.  When the CPA (comprehensive peace agreement) was reached in Jan 2005, the Nuba Mountains were also to be allowed to vote on separation.  Instead, in the April 2010 elections, the governor of South Kordofan was selected by a large margin, but somehow Khartoum refused the man and sent Bashir’s handpicked crony instead, leading to unrest and eventual bombing of the civilian population.  I am unsure of the events in the Blue Nile region, but the referendum was again blocked and bombing and killings have followed.  Since the independence of South Sudan, it is as though Khartoum does not believe world opinion matters.  The little restraint the CPA engendered has evaporated and Khartoum is again bombing and committing all kinds of atrocities against its citizens in the Nuba Mountains and Blue Nile, though it usually goes unnoticed by the US.  The Upper Nile region of South Sudan is loaded with refugees who choose to face turmoil and possible starvation in refugee camps rather than the fears and potential for death from Khartoum’s military activities against her own citizens.  But these nursing students are committed.  They are from the Kauda region of Nuba Mountains, a place somewhat less affected than others parts of South Kordofan,  but still quite hostile.  Once they compete their education, they will return to Nuba and continue the struggle that so much of the world has ignored.  I am glad we can play a small role in assisting them. 

6 March 2012 
Robert Chekata visited us today.  He is from Mapuordit hospital.  I contacted Dr. Rosario, the head of that hospital, a few weeks ago about coordinating services for HIV/AIDS in our region.  Dr. Rosario has been in South Sudan close to 10 years and Mapuordit is arguably the best hospital in the Lakes State.  In the past, we have worked through Malteser for HIV, TB, and leprosy, but now Malteser is changing their emphasis (though continuing their work in South Sudan) and we need to either tackle this question alone or coordinate with someone else. 
            Robert told us the currently accepted incidence of HIV in the Lakes State is 3.7%.  That is still low compared to much of Africa (or even parts of South Sudan), but that is enough.  Given the level of promiscuity and the amount of denial, we will be inundated with AIDS within ten years, possibly five.  As we talked, Mary Agum said that Peter Mangar had been threatened by those in the community because they said he was lying when he told someone they were HIV positive.  Michael Marial said that a friend of his boasted that if a woman came to him telling him she was HIV (+) he would sleep with her anyway.  The wife of a man who died with AIDS refuses to get tested and now the man’s brother is sleeping with her to fulfill the role of kinsman redeemer. 
            I said I would like to get enough tests to screen all pregnant mothers and everyone coming for treatment for STD (sexually transmitted diseases).  The reason for screening pregnant women is that treatment with anti-retroviral therapy (ART) is proven effective in reducing the likelihood of the child becoming infected.  The reason for screening those with STD’s is twofold.  First, STD’s tend to run together.  Someone with one STD (say Gonorrhea) is more likely to have a second, including HIV.  The second reason is to drive home the point that sexual promiscuity puts you at risk for AIDS.  Currently we can treat most of the STD’s coming our way.  But unless I miss my bet (and I hope I do) HIV will soon become one of the most common STD’s in our area.  I shudder as I say this. 

7 March 2012 
Another baffling tragedy came in today.  It was baffling not from a patho-physiological stand point: I understood the medical issues.  It was baffling because it was beyond my comprehension of how it could occur.  A ten year old boy came to me today with pain and fever originating from his R eye.  He had been in too much pain to sleep the last two days.  Exam showed R orbit (eyeball) that was fairly hard.  The sclera (the white of the eyes) was blood red.  But most troubling, the pupil looked like pus.  He had endophthalmitis, an infection of the eyeball, a dangerous medical emergency. 
            As I got more history, I found out that the child of a friend, the younger cousin to this boy, shot him in the eye with a bow and arrow.  My friend told me that his son had the bow and arrow, but that other men told him to shoot at people.  That is like telling an obese man he can eat his way into fitness.  Of course the child started shooting everyone he saw and predictably tragedy occurred.  Had no one corrected the boy?  Had no one told my friend?  I find that hard to believe, but it may be so.  But what really baffled me was that this occurred two weeks ago.  He was seen on the day of the injury and treated appropriately and the mother was told to bring him back in 2 days.  Who knows what might have happened had they followed instructions.  Chances of the child losing vision in that eye still would have been high, but that prognosis was not as grim as it is now.  I watched the tears streaming down this mother’s face as she contemplated her son.  She is from Akot.  I have little doubt that this mother loves her child or is grieving for his loss of vision and possibly even worse, but I cannot conceive of taking such a casual interest in the child when it mattered. 
            I gave the child Ketamine and injected Ceftriaxone 12.5 mg indirectly into the orbit.  I also put him in the hospital.  The optic nerve is called the first cranial nerve (the first of twelve nerves coming directly out of the brain instead of going through the spinal cord) but now most experts say that is inaccurate.  It is not a nerve at all.  It is part of the brain itself.  And there is a danger of the infection spreading into the rest of the brain.  This is serious, made more so by two weeks of neglect.

8 March 2012
 Noncompliance is a general phenomenon in medicine.  Indeed, in the US, if a medication is given and half is taken the way the doctor prescribed, it is considered good compliance.  Over 25% is fair compliance.  Taking 80% of the drug is excellent compliance.  When I was in the Air Force, a pharmacist told me about taking a truck around base and collecting medications that had been given out but not completed.  There was no incentive or coercion, but the truck did not make it half way around the base before it was full and had to return to dump all the drugs before continuing.  But sometimes I think I had never seen a lack of cooperation with medical care until I got to South Sudan. 
            We have a 65 year old man who came to us with abdominal distension and diarrhea for 6 months.  He also had not urinated in two days.  Our nurses were appropriately concerned and put in a urinary catheter.  They got back a little urine and some blood.  We have treated the man for probable giardiasis with Flagyl, and his abdominal complaints are drastically reduced, and the urine output increased greatly after some IV fluids, but now is falling off again.  For several days now we have been supplying water and encouraging him to drink, but he says he is not thirsty and therefore he will not drink. 
            I had a seven year old in clinic today for cough and fear.  The cough has been chronic, so I suspect asthma and want him to take deep breaths and blow out hard to see if that will induce wheezing.  He looked me in the eye and steadfastly refused.  He complains of left upper quadrant pain in the abdomen, but will not take a deep breath, so if there is a moderately enlarged spleen, we will never know. 
            Overall, I have loved working here with the Dinkas, but I have never met a group more stubborn.  One patient was complaining of how concentrated her urine had gotten, but again refused to increase her water intake.  Routinely patients refuse to answer the questions I have asked but want to go into detail about how the worm in their kidney is eating through their diaphragm.  I see patients here going home after illnesses that would have killed them and I am encouraged, but sometimes I feel I would rather be a psychiatrist for lemmings than deal with Dinkas.
            Then I start thinking about my own disobedience.  God my Creator, designer, Father instructs me in what is for my good and I look Him in the eye and disobey.  “See, I have set before you today life and prosperity, and death and adversity, in that I command you today to love the Lord your God, to walk in His ways and to keep His commandments and His statutes and His judgments that you may live and multiply and that the Lord your God may bless you in the land where you are entering to possess it” (Deut 30:15-16).   Why do I so often choose poorly?  And why does God put up with my disobedience?   When I get so mad at Dinkas that I could spit, let me go to the mirror and remember God’s patience with me. 

9 March 2012 
We had an unusual case today.  A mother brought in her three week old girl with swelling behind the ear.  One look and it was obvious that it had to be drained: it looked like two headed boil that should have ruptured three days earlier, and there was a third spot right next to it over the mastoid process (the bone just behind the ear).  But the real question was the source.  The scalp was clean, so these were not just severe reactive nodes.  Mastoiditis is a type of bone infection, usually associated with chronic ear infections.   I did look in this child’s ear, and it was unremarkable.  I thought about TB.  Miliary TB is a severe kind of infection that the child can get from the mother, but usually the mother must be somewhat ill for that to happen.  This mother had a few complaints during her pregnancy, but nothing suggestive of severe disease.  Beside a child with miliary TB should be quite ill, but this child looks good except behind the left ear.  She is nursing well.  I gave a “whiff” of ketamine and then incised the lesion.  About 3 ml of pus were removed.  I probed down to the mastoid bone, and it felt a bit rough, though I cannot claim to have done that procedure often, particularly in 3 week olds.  I gave some Ceftriaxone and admitted the child.  This afternoon, the child looked good and was nursing well.  There was little drainage through the wick I placed within the lesion.  We will see what tomorrow brings. 

10 March 2012 
I need a two week vacation—from me.  The only problem is that I do not know how to leave me behind.  I have been in the foulest mood lately without any justification.  I know that I have been the recipient of amazing, unbelievable grace.  I am the adopted child of God, joint heir with my Lord.  I am in a place where I can see the significance of my work on a weekly if not daily basis.  If I had any sense of justice and fair play, I would never leave my knees.  Instead, I act more spoiled at times than any princess complaining the three boulders in her bed.  This little gadget does not work when I want it to.  That person did not thank me enough for what I did.  This group has the audacity to question my judgment on a medical matter; that Dinka wants to tell me how to drive.  Mortal offenses, everyone.  And then instead of laughing at my stupidity, ingratitude, orneriness, I sulk because I have demonstrated again how desperately I need a Savior.  I came back from Rumbek this evening and you would have thought my favorite dog died and my children denied any connection to me, whereas in truth it was a fairly unremarkable day.  I was just engaging in a little pity party.  I am so sick of doing the same thing over and again, but I see so little progress.  I am growing old without growing mature. 
            Sorry.  I hate to unload, but I had to talk with someone, and right now I am not speaking to me.

11 March 2012 
Tin-Machar Baptist Church used to be my favorite church in the area.  Since I have been here, I have sought to go to various churches around, to not be too strongly associated with any one church or denomination.  But I would find myself under the Lulu tree in Tin-Machar church every month and sometimes 2-3 times in a month.  However, there has been some conflict with the pastor, Abraham Maper and some strain in the relationship so I have been much less frequently this last year.  However, a couple of the young men from the church asked me this week to come back to their church.  I asked Abraham and he was for it, so that was my plan for Sunday.  Dr. Rossi and the girls decided to go back to the ECS church, and Judy was going to the Baptist church in Malual.  I was going to take the pickup, but the keys could not be located.  I suspected Dr. Rossi, but he says he had not had them for 2 days.  I remembered that Samuel Maker had them, but later I found he put them on my bedside table (without informing me, I say in my defense).  By the time I found them Judy and I had made plans to first go to Tin-Machar and afterwards to Malual so she could teach songs. 
            I seem to recall more people at Tin-Machar.  There were a few men and older boys, a few more women, and an abundance of children.  As usual, there were very few there before our arrival.  The increase after our arrival was about as speedy as usual, but just not as many as before.  I told the story about Simon the Pharisee having Jesus for dinner (Luke 7).  A harlot (I think Mary Magdalen) comes to Jesus, washing his feet with her tears and drying them with her hair.  She kissed his feet and anointed them with perfume.  Simon is indignant, thinking Jesus must not be a prophet if He cannot tell what kind of woman is touching Him.  So Jesus tells a brief parable.  Two men owed money: one 50 and the other 500 denarii.  Both were forgiven their debts.  Who is the more thankful?  Then Jesus contrasts Simon’s lack of hospitality to the harlot’s show of gratitude.  I believe Jesus would have us both remember and forget our sins.  Let us forget them rather than be weighed down with them.  God has removed our sin from us as far as the east is from the west (Ps 103:12-14, one of our readings).  But He would have us remember how much we owed Him so that we respond in gratitude toward God, forgiveness of our fellow man, service for the church and community. 
            After church, we drove to Malual.  A lot of Dinkas, particularly the boys, will ride anywhere a car is going and walk back just to have the pleasure of the ride.  We had a fairly full pickup heading to the Malual church.  We were expecting church to be over, but found that they were early in the service, so we joined them.  I glanced around and saw no one that appeared ready to preach, so I found some notes from an earlier presentation of the Prodigal Son, my favorite parable.  I might have used the same sermon if there was only one repeated hearer, but as there were many, I thought it better to deliver a different message.  One thing that did impress me was how many people were there despite the lack of a preacher.  I estimated the congregation to be twice the size of the one in Tin-Machar.  We sang and had sharing times, and then I was called upon to preach.  A young man from the congregation was called to translate, but he was not used to the American version of English and soon had to step aside in favor of Mary Agum.  I felt animated and it was a fun presentation.  Amazingly, however, the major lesson of the two parables is the same.  We get more review of the sins of the Prodigal; those of Mary Magdalene are self-evident.  We do have the great demonstration of grace where the father, instead of turning the dogs out on the Prodigal, runs to embrace him, calling for a robe, ring, sandals, and a feast.  But the real lesson is for Simon and the elder brother: we cannot forgive or love our brothers unless we remember the grace that has come our way.  God has forgiven me incredible sins, and I must in turn forgive others real offenses.  There is no evidence that either Simon or the elder brother learned that lesson.  I hope I have.

12 March 2012 
Jacob beckoned me from the doorway.  There was a tall woman standing beside him.  I had seen him with her a couple of days ago, scalpel in hand.  I thought at the time he would ask for my assistance, but he did not.  I try to keep a balance between being over-bearing and being irresponsible.  I want to give our staff some freedoms, partly because I do not want to be called on every patient, but I also want those who come to our clinic to receive good care every time they come.  It is a balance I am still trying to perfect. 
            The lady had suffered with swelling and pain in the tip of her right index finger for two weeks.  She attributes the swelling to an injection at the wrist she received in Adol, but I assured her that was very unlikely.  I am not sure I have an accurate view of what has occurred over those two weeks.  Dinkas are notorious for telling you what they want you to know and withholding the rest.  But she came back in a lot of pain.  She essentially did not sleep the night before. 
            What impressed me more than anything about her exam is that there was a dead smell coming from the finger tip, as though she had been working in dead fish all day.  The finger tip was swollen, very painful, and somewhat tense.  It had a mid-line incision at the tip, the very place Primary Surgery suggests avoiding because of the potential for nerve damage.  I assumed that was from Jacob.  I did a digital block and opened the finger parallel to the nail.  There was little bleeding and no pus.  I am afraid that much of the finger tip is dead.  I am convinced she had what we call a felon, which is basically pus trapped in the little compartments of the finger tip.  The major problem is the pressure can induce ischemia, insufficient blood delivery, or even infarction, death of tissue from lack of blood.  I cannot imagine the pain she must have endured these last two weeks, but I am afraid her bravery and Jacob’s confidence have not served her well.  I did pack the finger and leave it open and started her on Flagyl.  I hope that there is enough viable tissue there to not lose the finger tip. 

13 March 2012 
I admitted Piath today, a 14 month old girl child with a short history that did not fit.  While Rebecca was examining the child, I noted that the posterior fontanel was not closed.  Fontanels are the places where the skull is not completely joined in newborns.  They are important because of the rapidity of growth of the child’s brain, far faster than the skull can grow.   The posterior fontanel usually closes by 4 months, whereas the anterior may not close until 18 months.  The lack of closure of the posterior fontanel plus the wasted limbs, particularly the buttocks, spoke of a chronic, severe process.  She was somewhat sick today with fever, cough, vomiting and diarrhea, but I strongly suspected that this child had AIDS.  I noticed, however, that Mary Agum was remaining quiet during the examination.  On examination, I found severe thrush and crackles in the left lower lobe area.  I admitted the child to the hospital to test for HIV (mother and child) and started the child on Septrim and Nystatin. 
            After they left, Mary Agum opened up.  “I was trying to catch your eye.  Do you not remember this mother?”  I confessed that I did not.  Mary remembered her very well.  The husband died in 2010.  Mary was fairly certain that the mother had been tested before and found positive for HIV.  In an ideal world, the mother would have been tested and if (+), started on ART (anti-retrovirus therapy), thus substantially reducing the risk of transmission of HIV to the child, but South Sudan is far from an ideal world.  Instead, she started spreading malicious lies about Peter Mangar, the Dinka involved in testing for HIV in our clinic.  There were several men in the area who threatened Peter to stop the testing.  Peter told Mary and advised her not to translate when the discussion is about AIDS.
            Mary had reason to believe Peter.  In her own family, a brother-in-law was HIV positive.  Mary sought to persuade him to take ART’s so that he would have several more relatively healthy years with his family.  She also warned him about his own infectivity.  Instead of receiving the advice kindly, he and many of his extended family decided Mary was making all this up and sought to put a curse on her.   The fact that he died from the illness did nothing to persuade them that she was correct.
            When we speak of terminal cancer, we mean both incurable and the disease that will kill the person.  Sometimes I think we suffer from terminal stupidity.  “How many times can a man turn his head and pretend that he just doesn’t see?” (Blowing in the Wind, Bob Dylan).   Mary wants to keep quiet, but we cannot.  We must continue to at least try to warn them.  If they continue to ignore us, their blood is on their own heads. 

14 March 2012 
I have continued to meet with some of the pastors, teaching them from the Heidelberg Catechism.   The results are mixed.  Less than half of those who started have continued to come, but there have been some really good insights and confirmations from those who have stuck with it, and today that was even more the case.  We did not start propitiously.  I have been on time for every lesson until today.  Okay, I have been a few minutes late a couple of times, but I arrived before anyone else.  But today I was doing something in the hospital and then had to give a ride to a family who has been in the hospital for several days (the mother  8+ months pregnant, the child with severe croup), and then Rose wanted to do something along the way, meaning I then took her back to the hospital before arriving 25 minutes late.  And there were only two Dinkas.  But the discussion was very good, climaxing at Question 60: How are you right with God? Answer: Only by true faith in Jesus Christ. Even though my conscience accuses me of having grievously sinned against all God's commandments and of never having kept any of them, and even though I am still inclined toward all evil, nevertheless, without my deserving it at all, out of sheer grace, God grants and credits to me the perfect satisfaction, righteousness, and holiness of Christ, as if I had never sinned nor been a sinner, as if I had been as perfectly obedient as Christ was obedient for me.
All I need to do is to accept this gift of God with a believing heart. 
It is one of my favorites from the catechism, but what I loved was when we started talking about how God “grants and credits to me…”  I asked them, “How does Isaac Bol pay your salary?  How is it that Isaac has money in the bank in Rumbek?  Has Isaac done work to get money into that bank?  No.  Ann Rao credits the account.  They take money from her account and put it in the account for Isaac.”  In the same way, “God grants and credits to me the perfect satisfaction, righteousness, and holiness of Christ, as if I had never sinned nor been a sinner, as if I had been as perfectly obedient as Christ was obedient for me.”  I could watch as the truth swept over them.  It had to be earned by another and credited to me.  It is true.  I want the applause.  I want to think I have merited God’s favor, but I have not.  Yet if I “accept this gift of God with a believing heart” then God looks upon me “as if I had never sinned nor been a sinner, as if I had been as perfectly obedient as Christ was obedient for me.”  It is great news and it is great to see them grasping this truth in their hearts. 

15 March 2012 
The nurses admitted a 4 yo girl last night with a three day history of fever, painful swallowing, and some difficulty breathing.  When we came to her on rounds, she still looked rather sick.  Her fever was down (it had been 39C, 104F), and she was not struggling to breathe, but she was obviously uncomfortable and drooling slightly.  The left side of her face was swollen and she had large, very tender lymph nodes under her left jaw.  She did not want to open her mouth for examination (what four year old does), but with a tongue blade I got a good look at the pharynx.  Her soft palate was red, edematous, and shifted over towards the right.  She had a peri-tonsillar cellulitis versus abscess.  The look of the exam, the response to treatment, and the length of illness strongly suggested cellulitis rather than an abscess.  They are a spectrum: cellulitis is early and will respond completely to antibiotics, whereas an abscess is later in the process and will need to be drained. 
            We have not had great success with either.  We had an adult with the same problem.  We treated him with antibiotics and he improved.  He had an abscess in the nodes under the jaw that I drained.  After about a week of antibiotics, there was still some localized swelling and I thought probably an abscess.  I was planning on draining the abscess the next day, but the family took him elsewhere (I think Mapuordit) where he died.  The other case was a 6 yo boy who clearly had peri-tonsillar cellulitis and responded well, but for some reason the family still took him to the witch doctor and he died suddenly.  I still have no idea what he did to that child, and it still makes me mad.  I cautioned the parents that it would still be several more days before we knew if this child would need surgery, but warned them not to go to the witch doctor.  I am hoping that third time will be the charm for this illness.