Rough Day

So yesterday the plan was to head down to the ECD center with some meds, mosquito nets, and registration forms to deworm the ECD kids.  That was the plan.  And deworm we did.  About 200 parents and kids showed up for the event.  

Unfortunately, the procedures for the actual registration and de-worming were a bit...ahem...underdeveloped.  And by underdeveloped I mean chaotic.  It started out simple enough.  Duncan and Jaffar gave a talk about malaria, how it is transmitted, and how people can protect themselves.  They gave a demonstration on how to put together and properly use one of the Long Lasting Insecticide Treated Nets.  Later we divided everybody up into about four or five groups and one or two of us manned each one with local translators (except for Judith who had to enlist the help of some of the students from her social marketing youth group).  We wrote down the name of each child and parent we treated, checked it against our ECD list, and gave each de-worming pills.  We gave the youngest children got a mosquito net.  Despite the disordered craziness, it was going great.  

That is until the nets and the meds meant for the ECD kids ran out.  Leaving a lot of very pissed off people wondering where their goodies were.  There were even people there from Ethiopia who had heard about the even through the vast informal network and had walked with kids all the way from Kuergen--about a six hour walk.  When we started to wrap up, most just begged for any of the goods.  It was terribly difficult to tell them that we only had enough drugs and nets for the young kids that attended the center.  Many though, were a bit more vociferous in demanding the nets and the meds.  It's entirely understandable, they walked from who knows where, waited for several hours, watched others get meds and nets, only to be denied at the end.  On the other hand it got a bit nasty as pleas turned into yelling in some cases.  I'm not sure who did it, but I definitely got whacked over the head with a stick or a piece of rope while I was kneeling in the other direction.  

As I mentioned previously, aid dependency is a very real problem and yesterday, thanks in part to some disorganization and poor planning, it reared its nasty side.  The trick of it all is to somehow continue to ensure that basic goods and services are in some way being produced and distributed, even as NGO's shift their programming away from relief aid towards development.  And avoid getting smacked in the process. 

The Drug Shortage Continues

Yesterday, we met again at the PHCC to discuss the complete shortage of drugs.  The supply of the critical drugs like Quinine is no worse today than it was yesterday (Still nearly at 0), but tensions over it have been steadily increasing.  The clinic staff is anxious over the clinic's condition.  And rightfully so.  They've also been working without salary for quite some time now.  Last year, when the same issue came to a breaking point, one of our staff was arrested by the local police for not suppling the clinic with drugs.

I'm afraid, that this is where things are headed again.  That is, unless we get the drugs here very soon.  One of the community health mobilizers, a 20 year veteran of the war, likened the situation to sending soldiers into battle with no bullets.  It reminded him of the time when he was given only two bullets for his rifle before a large engagement, fired them off within the first few minutes and had to run away.  That's not something you want your operation compared too.  Another second problem is lights.  If a patient comes in at night--too bad.  Without a generator to supply electricity, the staff have to work by flashlight or tell the patient to return in the morning.  SC had provided the clinic with a solar powered lamp, but it has gone missing in action--likely stolen and sold in some market somewhere.  

The problem is a complex one.  It begs the question--what are the roles and responsibilities of NGO's in post-conflict countries?  Especially those that have long existed as a humanitarian emergency that required the direct distribution of aid.  Duncan raised an interesting point, that when John Garang signed the CPA in 2005, it signaled the end to most organizations relief operations in Sudan.  Many have packed up and left, but others like SC are switching their programming from relief to development.  Aid dependence is a legacy of that time that will continue to affect life far after the end of the conflict.  And that's why this drug problem is becoming so acute.  The bureaucratic foul-ups and transport issues that have prevented the drug distribution aside (and I assure you there have been many), the current problem highlights the increasing divergence of community expectations and the responsibilities of organizations as they view themselves.  Community ownership of NGO programming and aid dependence are competing values--you can't have both.  At the same time, with an infant government of Southern Sudann (GoSS), public goods are in short supply and organizations cannot entirely abandon certain relief efforts wholesale.  Although that was not the intention of the drug shortage at the clinic, it has functioned as such.  One day the clinic had drugs, the next day it didn't.

And yet, what happens if a shipment of drugs is able to get through in the next month?  What happens after the rush on drugs a month later when the clinic is again empty?  You are back to square one--and that seems to have been the case during the period when our staff was arrested over the shortage a year ago and the situation today.  Who is to say that won't be the situation again a year from now?  Whose responsibility is it ultimately in the long run to keep drugs stocked at the clinic.

We talked about our two-pronged approach.  On the one hand, we are trying to get the drugs here.  Some are sitting somewhere in the region, but apparently there is no way to get them here given the weather.  The roads are flooded.  The other is where the idea of a Village Health Committee comes in.  Curative medicine is critical.  A person becomes sick with a life threatening disease and they need drugs and treatment to recover.  Otherwise they die. However, so many of the diseases here are preventable.  Not entirely, but with better sanitation facilities, knowledge of the spread of disease, and basic precautions the rates of infection will decrease.  If you can involve community stakeholders to become directly engaged in managing and solving these issues than you have a program that is sustainable.  When NGO's eventually leave,or the drug supply again runs out again, the region will be less likely to plummet back into a health disaster.  The problem is, thats a hard place to get to.  

The drug supply issue is threatening to undercut the VHC program.  Why should individuals help us mobilize others to spread awareness of a clinic's services if the community can't receive treatment there?  The short answer goes back to the importance of shifting attitudes towards accepting and using good health practices.  This would continue to reduce of the burden on the curative side of managing endemic health problems and makes for a better, self-sufficient society.  Yet this is something that is, at its core, an exercise dependent upon trust-building.  Without resolving the drug issue expediently, this trust is going to be in limited supply.    

Drugless in Pagak

Today, Duncan, Titus, Jaffar, and I went to the local Payam administrators to try to get them on board with the creation of the Village Health Committee.  They gave us a tentative go ahead and agreed to call all of the local Boma (village) chiefs together tomorrow so we can discuss the process of selecting a man and woman to represent each Boma in the committee.  We were, however, lectured at length about the lack of drugs at the Public Health Community Center (PHCC).  It seems that not only has there been a complete lack of drugs at the clinic, but also the staff have not been paid salary in some months.  The drug shortage is starting to reach a critical level and risks jeopardizing the programs we are working on.

Earlier, I went to the clinic with Jaffar to check up on a woman who was admitted yesterday with a severe case of cerebral malaria.  The problem is that the PHCC is at a total lack of drugs, including the quinine that is necessary to treat Malaria.  Cerebral malaria is what happens when malaria goes from bad to worse.  The parasite crosses the blood brain barrier and the infected individual will no longer respond to a strong dose of prophylaxis (which can only treat malaria while it is still in the bloodstream.  Without treatment it leads to coma and eventually death.  Despite the lack of quinine, someone in her family was able to buy a dose in the local market.

Jaffar and I went to the two small shops where drugs are sold to see if we could track down some quinine.  You need about four or five doses to make a decent recovery from such a severe case (Each dose contains six mini-doses that are administered intravenously).  Although the woman had received one, the chances are high that she would soon relapse into a severe case or, even worse, one that is quinine resistant.  The first chemist we went to was not only out of quinine, but also most antibiotics and other drugs that would be helpful in treating severe cases.  The second chemist had a small supply of quinine at about 60 Birr (about six bucks) a dose.  I really wanted to buy the woman a second dose, but with my Ethiopian currency supply dwindling, I came up about a dollar short.  Hopefully the woman's family can come up with enough cash for her to finish the treatment.

Malaria season is just kicking into high gear.  Last August, of the hundred or so cases at the clinic, seven people died.  This August, I am going to try to increase my ground time at the clinic and cover the Malaria season in video.

The other case was a young girl who was bitten by a snake.  Again, the lack of drugs means that she will not be able to receive the anti-venom she needs to make a reasonable recovery.  They started her on a course of antibiotics to prevent infection, but once necrosis sets in she will have to be sent to a better clinic, perhaps in Malakal (quite some distance from here).  

The drug situation is a tough one.  Even if we were to have a ready supply of drugs in Juba, like most other supplies, it is near impossible to get them up here.  A better solution would be to purchase them in Ethiopia and transport them overland by LandCruiser and quad bike.  Unfortunately, the government has a seemingly unofficial policy of "Ethiopian drugs are for the Ethiopians" and it is impossible to get a large quantity of drugs cleared by customs.  What needs to happen is a huge stock up of drugs at a central field depot where the clinics can make a long (but possible) LandCruiser trip to pick them up as needed.  Especially in anticipation of malaria season.  Unfortunately, given the realities on the ground and the difficulties of transport, the drug supply issue is one that will not be resolved anytime soon

Home Sweet Home...at Least for Another Seven Weeks

The town of Pagak is literally in the middle of nowhere.  To get here, you either need to hire a private plane, bum a ride on a cargo flight, or drive across Ethiopia to the border and hop on an ATV or a dirt bike for the rest of the way.  If you can manage to get here, Save the Children has a pretty permanent looking compound here right next to the dirt airstrip.

From the airstrip you walk down a dirt "road" that has been gutted with deep channels from our LandCruiser as it tries to avoid getting stuck in the mud.  You walk down said muddy path for about 30 seconds and knock on the corrugated tin sheet metal that forms the compound gate .  Eventually a guard will wander up, unlock the door and let you in.  

Inside, we have about 10 or so little buildings, tents, huts, or other forms of enclosed space to work out of or get away from the rain.  The largest is the Dining Hall (or Dining Hut).  Its a sweet wood and mud room covered with grass and topped off with a giant UNHCR tarp.  About once a month, some of the local staff re-muds the walls to fill in the cracks and crumbled exterior.  Outside are the two satellite dishes that provide communication with the outside world.  Provided there are no clouds or rain, that is.  Inside, we have our meals (Spaghetti, rice, and baked beans--everyday!) as well as a TV and dart board.  I've been hitting the darts pretty hard.  When the generator kicks off at noon, in the evening, and at night, there's not much else to do.  I've unwisely already long burned through my supply of books.  When the office gets too full of people, the overflow head into the dining hall and set up shop.

The office itself is actually pretty small--just a one room tukul.  But inside we have five desks, printers, and most importantly--wireless internet.  Although it becomes impossible to use once more than a few people are using it, its one of those things that you don't fully appreciate until the generator kicks off.  Because of the presence of the mighty internet, we usually are in the office until about 11 at night officially working on projects, or unofficially just messing around.

From the door of the office, you can take the network of rock paths (as the rain turns all of the mud into a deep deep soup) to either the kitchen or one of the several rooms in the compound.

Breakfast is usually pancakes or mandazi (fried bread--like an unsweetened donut) and always some hot tea with powdered milk.  Nyamone cooking up some pancakes:

There are two types of living quarters--brick rooms and tukuls.  I suppose three types--we also have two small two-man dome tents covered with tarps for overflow.  All of the rooms are arranged around the perimeter of the compound, which means that at night you can hear just about everything outside--blasting Teddy Afro music, local police on patrol, and people chatting away in their tukuls.  

The winner of the compound amenities game is the hot water.  That's right, hot water.  A while back, someone had the presence of mind to cut in half one of the many old oil drums that we have and use it to heat water throughout the day.

All you have to do is take your bucket walk over to the oil drum, scoop up some of the water, add some disinfectant to kill of all of the worms, bacteria, and all the other crap living in it and...bam! You've got yourself an instant shower my friend.

With all of the crazy moving around that I've been doing lately and the old luggage crisis at the beginning of my trip, I didn't realize until today that I've been here for over a month now.  I've started to settle in pretty well--hot water, mud, wandering goats and all.  Seven weeks to go!