The “nursery” is coming alive as some of the vegetables I planted in the deep red South Sudanese soil are sprouting.  Some seeds seem to be more receptive to the soil than others.  So far, as can be seen by the photo above, the lettuce is sprouting well.  There is hopeful notice of the cherry tomatoes starting to come up.

The routine involves watering morning and night, when the heat of the day isn’t so intense.  South Sudan is coming up to the hottest months (February and March) reaching up to 50 degrees Celsius which can be detrimental to the plants. These months are followed by a cooler rainy season which is when most farmers plant seeds.  This nursery is really an experiment to see which seeds will grow in this soil.  After this round, we’ll eliminate those plants that didn’t germinate properly and increase production of those that do by planting the seeds directly into the soil when the rainy season starts.

The garden is a-go, people.  Get out your shovels and prepare to swat the apple-sized locust because Oren is growing his veggies big!

It was hard to take photos in this market.  People, rightfully, were suspicious of my photo taking and refused.  After a few refusals and to avoid any possible hostilities, I decided to stop taking photos there.  Here are a few of what I could take.

Pictured above: Beans for sale presented on canvas bags -  most likely imported as is most food.  Notice that the ground is sandy and unpaved – there is basically no asphalt in this city except for a few places. 

Pictured above: The wall to wall display of packaged food items at one of the more expensive grocery stores and one where you can actually walk into the shop.  Fuel prices dictate the cost of these import items which are getting more expensive daily.

Pictured above: A woman vendor next to her basket of items.  She was kind enough to let me photograph her.

Pictured above: These stones are some sort of desiccant though I couldn’t get the a real answer on their purpose.  Pictured as well are some green vegetable called “greens” and, in the far right corner, some sweet potato. 

Pictured above: A typical open air vendor shop.  Eggs are unrefrigerated, oil is sectioned into cola bottles, tomatoes are stacked into purchasable units and everything is reduced to a single serving portion.  There is no economy of scale here from what I can tell.

BONUS PICTURE – Pictured above:  Just a guy with his scales who was considerate enough to let me take his photograph.  I don’t know what he was selling that required  a scale.

Only four percent of South Sudan is farmland. Some vegetables are imported and those that are local are still expensive due to the but the cost of fuel to bring them to the main cities.  In Wau, we get tomatoes, beans, onions, something generic called “greens” .  Currently for fruit, there are oranges with mangos and papaya coming in a few months.  None of these vegetables and fruit are of a decent quality but this is something all international NGO workers must deal with when living in a low resource country.

The first step is to acquire seeds that may or may not grow in hot African climates.  For some reason, I also brought some fertilizer with me.  The unlabeled bag on the left is filled with tomato seeds.

The garden space started off with burnt patches and a variety of broken CFL bulbs and plastic bottles scattered around.

After dissolving mud from my trip to Mapel, we planted seeds in egg cartons and left sprout.

We cleaned the area and turned the soil.  Even the security guard joined in on the fun.

This is the start of a real garden. I have never gardened in my life and especially not in Africa.  There are many questions:  Will the seeds grow in this soil? Will the bugs eat my plant to pieces?  Is it too dry for to grow these plants? 

Here is the final layout of the garden with the soil turned.  It will be a few weeks before we plant… 

What do you think?  Success or failure?  Can colder climate plants survive the harsh South Sudan environment?  Have you ever had a garden in Africa?  Write your thoughts and experiences in the comments.

There are no clinical notes in South Sudan nor any computer databases at the local level.  Health information is recorded in these books and the data from there is aggregated in weekly and monthly reports.Below is an example of an outpatient register book. Note that it is a badly formatted composite image.

There are also no doctors or nurses in the rural parts of Western Bhar el Ghazal.  Rural clinics are known as either Primary Health Care Centers (PHCC) or Primary Health Care Units (PHCU).  PHCCs, which can contain several hospital-like departments,  are bigger than PHCUs, which are usually a single clinical room.  Both are still small, understaffed, possibly run by generous and dedicated Community Health Workers (CHW) and a variety of other staff such as Traditional Birth Attendants (like a midwife but with much less formal training).

The field trip around Western Behr el Ghazal took myself, my Team Leader Patrick and Victoria, the Ministry of Health representative to Mbili, Kuajina, Mapel and, the following day, to Rocrocdong, Achongchong and Akorup to deliver register books and see the final stages of a new PHCU/PHCC being built.  The road was surprisingly flat but still dusty and unpaved.  We passed by burnt fields, giant kilns designed for curing bricks and many herds of cows and goats with intended use for the dowry system – none of which I photographed but there will be more trips and more photos to come.

Pictured above from left to right: Patrick, the HealthNet TPO Western Bhar el Ghazel team leader, Victoria from the state Ministry of Health and the Mbili Community Health Worker holding MOH Register Books.

Pictured above: A typical clinical room at a PHCC.

Pictured above from left to right: Patrick, the HealthNet TPO Western Bhar el Ghazel team leader, Victoria from the state Ministry of Health and the Kuajina Community Health Worker again holding MOH Register Books.

Pictured above from left to right: Mapel Community Health Worker, Victoria from the state Ministry of Health and the Patrick, the HealthNet TPO Western Bhar el Ghazel team leader holding MOH Register Books .  The bright South Sudanese sun over exposed this important picture.

Pictured above: HealthNet TPO staff with MOH and PHCU staff in front of the old Achongchong PHCU.  Notice that it is a very basic, one room house with a corrugated metal roof.

Pictured above: The newly built Achongchong building complex comprising of three separate buildings that will house many different clinical departments. This building replaces the corrugated roof clinic pictured above.  HealthNet TPO is the NGO responsible for the construction of this complex.

Pictured above: The newly constructed Arokup building where no health facility existed before.  As with Achonchong, HealthNet TPO is responsible for the construction of this site. The two health facilities are only a ten minute drive apart but for many who can only walk to see a health care worker, the distance is enormous, making this new clinic essential for maintaining the basic health services of the nearby community..

A composite image of a rural pharmacy dispensary in Wau County.

A destroyed church

A bicycle near some goats

A clinic waiting room

Rural South Sudanese kids near a well

My first look at South Sudan came from the opening area beyond the front gates of the airport.  The quick glimpse is exactly the Africa as I expected. Bathed by intense sunlight and 35 degree heat is a world that is a typically dusty orange-red with  one paved road, little corrugated-roof shanty houses and plenty of people just hanging around.  South Sudan is remarkably similar to my first experiences of Liberia with the exception of the lack of intense humidity. Of course, by the time I made it out of the airport, my typically amazing powers of observation were failing me due to intense exhaustion from the flight.

I didn’t sleep at all on the overnight flight to Nairobi from Amsterdam and with a six hour layover, I sweltered from the Nairobi heat at the airport.  Considering that I was still wearing long underwear to protect myself from the Nederland’s cold weather, I was the only one to blame for sweating like a monkey in heat and the incoherence that followed.

My time in Juba was short.  Security is high with recent car-jackings and security staff getting shot while on their shift so movement is still questionable.  I am still learning the rhythm of this country.  Like with everywhere that you travel, a city has a heart beat and a rhythm which defines what is acceptable and what is not.  For now, on my second day here, the rules are easy: don’t walk alone, don’t go out late at night, and make sure somebody knows where you are at all times but once you know the rules, you can have fun even in an insecure city.  The trauma from decades of war is obvious and the healing process will take a while but I can already feel that there is a warm kindness to the local people.

After a good 12 hour sleep, I got the flight from Juba to Wau – a one hour trip commercially hosted by the World Food Program.

Power in my guest house is limited so blogging will be difficult.  Taking photos is also a challenge as walking around alone is prohibited and I am still learning what is culturally acceptable and what isn’t..

This is my second day in South Sudan and it is already very interesting.  More to come…

On January 1st  2012, I will be moving to Wau,  South Sudan to work at HealthNet TPO as the Health Management Information Systems (HMIS) Advisor.  This is a new country with big dreams, a wide heart and some very big problems. 

This blog will be a composite of culture, life experiences, humour and, most importantly, the world of the international health NGO worker in a low-resource African public health setting.  This blog will also be a portal to the big problems health care workers deal with everyday in poorer countries and a vehicle for me to describe my everyday challenges as an expatriate epidemiologist.  Life will get tough but I am excited about the great unknown in front of me…

When given the opportunity, I can accomplish amazing things!

I have never had my own staff before or had so much control over a single project.  When given this opportunity, I found that I was accomplishing so much more than what I expected I could do.  Even with all the limitations of the people, the government and technology, I was still able to create something innovative and revolutionary.  I am extremely proud of what I managed to accomplish in such a short period of time.

Working with local people can be extremely rewarding.

As frustrating as the local people can be, with their ‘limited capacity’ as the expatriates referred to it, coming together and finding that perfect rhythm can be incredibly rewarding.  I eventually found that perfect working format that made everything click together and, at that point, working with the people was really a pleasure. 

Even in the harshest conditions, there are great people around you.

Working in Liberia is not easy.  From the people, to the local staff to the government, to the environment, everything around you seems to be on the attack.  But even through all that adversity, there are still great people around and I met many who were doing amazing work and accomplishing amazing things. 

As much as I want to help people, I like living in a world of convenience, character and technology.

There. I said it.  I don’t want to live without.  The first thing I did when I returned to France was to watch a 3D movie, which is not possible in Liberia and I thought to myself why would I miss out on all this great stuff! Life is too short to miss out on all the fun stuff that is going on.

I am so fortunate to be born in Canada and to be able to live there.

I have never felt the fortune of being born in the developed world until I finally left this comfort zone and moved to a post-conflict country.  I have never felt so blessed to be able to live in a safe, clean and organized country.  Sure Canada has it’s problems but they look so trivial compared to what I just came from. 

I can see where my future goes from here…

I learned a lot about my capabilities and what I want from my future.   I spent most of my life hunting for what would make me happy and this experience, more than any other I have had, has put me one step closer to that goal. I can see where my career should be taking me now.

So this will be my last post for now.  Who know what adventure lie before me but Africa is now part of my past and working there is no longer an option.   I will soon be back in Canada where the rest of my life begins…

Thanks for all the listening and feedback over the months.

Pictured above: sentinel site staff entering data by manually counting malaria cases from the ledger and entering clinical notes directly into laptop. 

In all countries, there is a need for health information.  Health Information Management Systems (HMIS) are struggling all over Africa and Liberia has been given the last chance to see the sentinel site project come to life.  It isn’t easy getting data from a developing country hospital but this has been my work.

I am back in Zwedru and I haven’t blogged in a month.  I was trying to blog daily but my work has put me in front of a computer tinkering with data and making presentations.  Since I last left you, I have had a meeting with USAID on the future of the sentinel sites, switched over to a new Country Director and had an emergency switching of a computer in Zwedru.  Now, I am back with some interesting details.  

Martha Tubman Hospital just came out with the first month of patient level data.  It was a bumpy road as a computer crash left a few days without data.  Also, I am using Dropbox to synchronize the remote hospital folder (with database in it) to my folder in my computer. To those who know Dropbox, it is a file syncing program but I am using it to get my data remotely from a hospital several hundred kilometres away.

For those interested, the staff are no longer tallying, which means that they are no longer counting the number of malaria cases.  Now, all the tallying will be done by the Sentinel Site staff through the paper hospital ledgers and, in parallel, a patient level database, using Epi Info, collects patient information by data entering each clinical note as it goes into the records room.

Now to the interesting part.  THE DATA…

I looked at three methods of collecting health data for the month of March:

1. By entering each record individually into the patient level database
2. By counting the number of malaria cases in the hospital paper ledgers
3. By counting the number of malaria cases which were tallied by the staff themselves.

The differences are quite big but here are some preliminary results:

The malaria rate for under 5 years old (number confirmed positive by lab results divided by all those who attended the hospital) was 56.4% for patient level database, 56.1% for hospital ledger and 45.1% for hospital staff tallying.

This means that between 45% to 56% of all hospital visits by children under five were for malaria.

The total malaria death rate (number who died of malaria divided by all those that confirmed positive for malaria in a lab test – also called the malaria case fatality rate) was 0.18%, 0.74% and 0.37% respectively.

This means that less that 1% of those who visited the hospital for malaria died from that disease. 

What is interesting about having patient level data is the ability to make pivot tables in your favourite spreadsheet program and tinker with the values.  Here we see what are the most common secondary diseases if someone already comes in with malaria (separated by age group):

As you can see, there were a total of 1375 visits which were diagnosed with malaria and 279 also had ARI (acute respiratory illness) while 27 also had an STD. 

It’s hard to say what you can do with this information right now.  Really, it is more important to get reliable data which is not easy.  Everything from improving the quality of records in the ledgers to renovating the records room is needed.  We’ll see what happens next month…

Pictured above: empty shelves where medicine should be. 

My time in Zwedru was nothing short of a rollercoaster.  By the end of the first day, I was exhausted.  The heat of the day, the fire of the fight and the struggle with the people had all taken a toll on my soul.  I was staying at the Save the Children residence and guest house (highly recommended) when I got a call from an unknown number which turned out to be a MENTOR employee who was working on a KAP survey (A KAP Survey is a Knowledge-Attitude-Practice survey where you go out to the villages and ask them questions about their knowledge and use of your health promotion campaign – in our case, it was about knowledge of malaria and use of mosquito nets). 

He and the rest of the team got caught in a bridge (which is actually just a bunch of logs above a big ditch in the road – see photo above).  He left the rest of the team and headed off by motorbike to Zwedru where he called me.  I then got my driver to go into the field and get them out.  That was at 10pm.  By morning, I hadn’t heard from either my driver or the other team so, with the wonderful help of the NGO called MERLIN, I headed off for a Search and Rescue mission!  Indiana, err, ONTARIO JONES TO THE RESCUE!

Here are some photos of the rescue team:

As we were driving through the deep dark bush, we saw the other cars returning.  Here’s what happened:

1. The KAP survey team got stuck.
2. The sent out a team member to get to Zwedru and get help
3. I got the call for help and sent my driver out to help them
4. My driver got stuck on another bridge.
5. Both teams slept the night in the bush
6. Morning arrives and I head out into the field
7. My driver gets out on his own, gets to the survey team and pulls them out.
8. I find them as they are driving to Zwedru

Then, one of the cars get stuck again.

But since we had three cars, the car was easily pulled out.

Ok.  So I really didn’t do anything.  I just drove out into the bush but the thrill of the search and rescue was pretty fantastic at the time. I have video footage but it is impossible for me to upload it with the current bandwidth that I have.  Ontario Jones was taking it easy this time.

..and that was that.  Back to Zwedru to work on the sentinel sites.  Just another day in Africa.