February in Congo

Note:  This post was written 25/02/2013, but I could not connect to internet until today, 04 March.  Even now, I had to find an internet café to have a good enough connection.

I left Lyon for Paris on 21 January, 10 days after returning from South Sudan.  I arrived in Bumba on 28 January, where we are responding to a measles epidemy.  Case management started the same day I arrived at the local hospital and 16 health centers in the zone.  We are starting the first vaccinations today, 25 February (it takes some time to order and receive all the vaccines and logistics material necessary in this remote corner of the world) targeting 85 000 children between 6 months and 15 years old.  We may be vaccinating in 3 other zones with about the same target population in each zone.

Bumba is a small town situated on the Congo River, at the top of its course through the Democratic Republic of Congo.  I have been in country capitals the last few years, so it is refreshing to be in a small town again, although the choice of food and supplies is very limited.  Fortunately, in Congo, beer and bars - and churches (but this does not really affect me) - are rarely is short supply. 

We have taken over a small hotel with 12 rooms – with the last arrivals there will be 19 of us.  One of the big rooms serves us as an office.  The dining room is our pharmacy.  The commercial kiosks facing the street are our logistics store.  And the storeroom now houses the electrical generator.   We have arranged an indoor/outdoor kitchen and a covered outdoor dining room.  And as we have taken over the hotel, we have also taken over their 3 cleaners and 3 watchmen.

Most of our movements inside and outside of town are by chauffeur-driven motobikes.  As ot today, I have my own chauffeur – what class!  A lot of my time is spent changing US dollars for Congolese francs, and distributing both currencies for staff, purchases and rental contracts.  When not doing that, I am seeing the local authorities, revising our budget, recording the accounting, recruiting, and training.

I joined the emergency group in June, but this is really the first project opening I have done since then.  It is pretty exciting and very interesting.  Until now, I have been pretty much tied to the office.  But we just hired a cashier which should free me up to get out to the sites.  I am looking forward to seeing how a mass vaccination campaign works.

The organization of such a campaign is amazing.  First, we have to assess the gravity of the problem, start treating the cases, calculate the target population for vaccination, order the vaccines and other consumables, and find the freezers, icepacks, coolers, and refrigerators necessary to keep the vaccines at the correct temperature (some coming from our central supply in France).  There is also all the logistics material for the site circuits and the vehicles.  And then there is the personnel.  We have 3 supervision teams consisting of 1 nurse and 1 logistician each.  Each supervision team works with a circuit construction team of 1 carpenter and 1 laborer.  And each supervision team managers around 8 vaccination team a day during the 8 days of vaccination. For the vaccination teams, we are using staff provided by the local health center (each team consists of 14 people) so we don’t have to worry about recruiting these people, but we do pay them an incentive for their participation.  The vaccination kick-off was today.  It will be a very intense 8 days.

It is incredible the difference between here in Equator province and North Kivu, where I spent 2 missions (a total of 2 years and 9 months).  Equator is close to sea level, and as the name insinuates, on the equator.  Sun is up at 6:00am and down at 6:00pm all year round.   It is HOT – between 90° and 105° F each day.  If you read this blog regularly, you know that I am happy.  North Kivu is also on the Equator, but like Denver, it is very high, so it stays between 70 and 80° all year round (if there was peace in that district, it would be the perfect tourist spot, with animals and all – I would gladly take my retirement there.  But that is still not the case.)..  I can tell you that I suffered from the cold in France arriving in January.  I have spent 7 winters in central Africa.  I love this weather.

In Equator, this is the dry season.  That means it only rains 2 days a week rather than every day.  And when it rains, it pours.  In North Kivu, this is about the same.  For us that is good, because starting April the rainy season starts again and the roads (big word, because road means a dirt path – in some places less, where only the motorbikes can pass along a path or in a  creek) are impracticable.  If we have to vaccinate the other 3 zones, it must be very soon.

 I am once again in a country with a new language.   In the west of Congo, the language is Lingala (in the east it is Swahili).  Since I already have enough problems with written French, I doubt that I will be picking up a lot of Lingala.

Our MSF team is great.  By the time everyone arrives, we will have 15 international staff and 4 delocalised Congolese staff.  We have 12 local staff today (1 more to hire), the hotel staff, and godzillians of staff working for the Congolese ministry of health.

All in all, I am once again enjoying my new experiences.  EXCEL is still my best friend, for generating the payment frameworks, and creating automatic receipts.   And I still have contact with people from my previous missions, when I can.  The internet here is worse than terrible.  If I try 2 times a day, I am able to connect maybe 2 times a week, so contact is not great.  So please forgive me if I have not contacted you.  

Back to Congo (Hurray!)

I arrived in France on 9 January.  Winter.  Cold.  I have been in Africa for the last 7 winters, and I thought my balls were going to freeze and fall off (pardon my French)!  But I had a very good time!  I met up with a friend from the Netherlands while in Paris, and then I refound a great friend from Zanzibar while I was in Lyon (see below).

Now, I am going back to Congo !  And not too soon – this European winter weather is killing me.  Fortunately, it is the official time of “SALES” in France.  I found a winter coat for not too much money.

I received a call on Saturday telling me that the woman who was supposed to go to Congo for a measles epidemic could not get her visa, and so they wanted to send me.  Of course, I said yes, after about ½ second of reflection (okay, maybe not that much).

But this is not in the parts of Congo (Democratic Republic of Congo – DroC – Congo Kinshasa) that I know.  This in the province of Equateur – in the north west.  There are no security problems!  Well - no more that parts of Paris.  It is also in a district that MSF is not represented for the moment.  So we must start everything

MSF Belgium noticed that a measles epidemic has started in June 2012 in the neighbouring province.  They alerted MSF France (my section) in December that it might touch places that we did not know.  We sent out an exploration team and voila!  We found the need.

Measles means treating the cases found, especially less than 5 years old in which the disease can be most lethal.  It also means vaccination.  We have just decided to do both (it is complicated due to the politics of vaccination – I can’t go into that problem here).  So we will be working with the existing Congolese health organization for both treatment and vaccination.  But there is still a lot to do before we start the vaccination – it will be for 45000 and 90000 children.

Right now it is a small team – 8 people including me.  And I have already worked with half of them - and enjoyed it!  Since our section is new in the region, there is everything to do – how to get money (no banks where we are), what to pay people, hiring, how to bring in supplies and vaccines (probably charter a plane, because the only other way is by boat on the Congo river – loooooooong), and much more.  This will be my truly first start up mission since starting my contract with the Emergency Department in June.

I leave tomorrow at 5:30am from the hotel.  I arrive in the capital of Kinshasa tomorrow evening.  Then I take a flight on Thursday to the district capital of Mbandaka on Thursday.  Finally on Monday after, I take the flight to Bumba (I will rumba in Bumba!) directly on the Congo river, where I will be working.  Apparently the biggest difference with the North Kivu where I worked before it that it is in the lowlands (hotter) and it rains every evening (oh, well).

The other news it that my place is no longer empty!  While in Paris, I got a message from an old friend from Zanzibar from 7 years ago.  We have stayed in contact off and on.  He was living in Europe, and recently was aggressed where he was.  He no longer felt safe, and asked if I could help.  I had already offered my apartment to him and his wife a few years earlier.  (They have since parted ways for a couple of reasons, although they are still married and still see eacy other).  So he was able this time to come to visit.  And he will be staying now in my place for a while.  I feel a lot better with someone I trust in the place than when it is totally empty.

Once again, I must say that I have had much luck in my life.  Only problem – I must be awake at 4:30 in the morning!  Such sacrifices - hehehehe.

Again, to Cindy's mom (my most fidele blog follower) big hello. It was great to speak with you today.

Happy 2013

I am nearing the end of my time in South Sudan.  The guy I am replacing returns tomorrow afternoon, but there is no place available on departing flights until 9 January, so I will be leaving at that time.  I will fly into Paris for debriefings and to meet a Jamaican friend there for a day before returning to Lyon.  Then, I will head out again, although I am still not sure exactly when and where I will go.  I have been told that the break will be a short one.  Seeing how it will be very cold in France, this is ok.  Unless, of course, they send me to someplace even colder!

We had a wonderful holiday season here.  On the 24^th, I finished my work early and went home to make some Christmas breads – an Italian panettone and a German stollen, as well as a Linzer torte.  I had to start my panettone recipe 3 times before getting it right due to some ingredients problems.  Grhhhhh!  

 Having Christmas dinner outside under the mango trees in 90 degree weather is my idea of perfection.  The table was beautiful (thanks to the French contingent), and the wine was heavenly.  Almost everyone contributed to the cooking and we ate like kings.  We thought we might have too much food, but Christmas holiday is 3 days in South Sudan – 24-26 December – and we had no cook during that time.  So we finished everything by the end of the period. 

You might think we do nothing but party here.  Just to be clear, although we had no national staff in the office in Juba, our expatriate staff continued to work during this period, because our health centers operate 7 days a week / 24/24, and we need to support them.  The workload, however, was less than normal!

There were 15 of us in the house for Christmas dinner.  I am glad I planned large when buying small gifts while I was in France in November..  A couple of the other guys got together and did the same thing, buying small African crafts for everyone. It was a wonderful evening.

On New Year’s Eve we hosted a party at our house for the other sections of MSF.  This was also our housewarming party, since we moved into the house the new house the first week of December.  The organization was amazing, and we had a very good time, although there were a few pitiful faces the next morning!

I have enjoyed my 5 months in South Sudan.  I was originally slated to be here 2 months, but these things happen in MSF.  Tomorrow and the next day will be doing the handover with the financial controller, giving him back the work that I did during his absence.  Then I will be taking it a bit easy until my departure, since I am not sure how much time I will have before going out again.  I will miss a lot of the people here, both national staff as well as expatriates.  At least with the expatriates, I have a good chance of finding them somewhere else in the future.

Christmas and New Year's in Juba

I was supposed to leave South Sudan this Saturday, 15 December.  But as there is no pressing need for me elsewhere, and the South Sudan regular program Financial Coordinator is going on a break, I will be staying 3 more weeks to replace him.  I should now leave Juba around 5 January, probably with a week of break before heading out somewhere again.

So I will be spending another Christmas and New Year’s in the field.  I love that!  First, I hate cold weather.  My last 7 Christmases have been in Africa, and even the thought of a white Christmas sends chills up my spine.  It is also special to spend these holidays with co-workers from different backgrounds and cultures.  Each one adds his or her own flavour to the festivities.  

I am sure that we will eat well.  Our habitual cooking crew is a Georgian (the country, not the state), an Italian and me the Franco-American.  This team will certainly assure a wide and varied Christmas dinner.  The market near our house has nearly everything we could possibly need, and there are some large grocery stores which cater to the non-nationals for a price.

Planning ahead, I purchased small gifts in November when I was in Lyon, so everyone will have a Christmas present.  There should be around 12 of us.  We will probably do some kind of gift exchange as well.

I found some really cheesy fake Christmas trees in one of the larger expatriate stores here, but they are very expensive.  So I think we will improvise on the decorations.  “Deck the halls with boughs of holly, Falalalala, la la la la”!  Someday I am going to have to grow up.  But it will certainly not happen during the Christmas season.

Early December in South Sudan

The training in Dubai was very interesting.  We had sessions on the Middle East medias, the media in context of Middle East politics, some role playing excercises on interviews, and MSF activities in the region.  I would feel much more comfortable doing a media interview now.   The other participants in the course were very interesting people (both the students and the presenters), and this made for lively and informative participation. 

Dubai is an amazing city.  It is shiny and new, a very modern city and clean.  On the other hand, there are a few restrictions on personal freedoms in line with the Muslim religion - blockage of certain internet sites, and alcohol is only available in selected (and shielded) venues.   About 1/8th of the population are citizens.  The rest are migrant workers.

I returned just in time to see some last-minute changes to our 2013 budget proposition.  This was presented to the operations committee in Paris on 30 November.  No feedback yet, but it was a pretty solid proposition.

When I leave South Sudan I will be handing over to the Finance and the Human Resources persons for the regular programs in South Sudan.  This process already started, as they replaced me while I was in France and Dubai.  And during the next 2 weeks, I will be preparing a more formal, written handover. 

This past weekend, we moved into our new house.  It is wonderful, and it is good to have all of us together finally in the same house.  The house was originally built to be a hotel, so all 20 bedrooms have their own small balcony and bathroom.  With this many bedrooms - which in fact will often all be occupied - the perment members of the team will no longer need to share their rooms with people passing through.  These coordinators are usually here for at least a year, so having some private space is important.  The building has just been completed, and of course, there are some teething pains, (plumbing leaks,  electrical problems, etc.), but they are being sorted out with the owner, the construction crew and our logistics department.  Sunday, we began by arranging the kitchen and living space.  This is one big open space, so we can be cooking, watching TV, reading, or whatever all together.  At the end of the evening, we found a baby snake (about 4 inches) lounging among the television cables.  I quickly captured it and threw it outside.  We probably need to do something about the 1-inch gap under some of the doors.  And we are still in Africa, close to the Nile - lots of mosquitos in this place.

Although I still have a return ticket to France on 15 December, nothing is really sure.   I might stay to replace the financial coordinator who will be going on holidays until the beginning of January.  Or I might be going to some other hotspot in the world.  Whatever.  I am on a 1 year contract with the Emergencies Department, so they can send me wherever I'm needed.

Back from France, Preparing to leave.....

I returned from my break in France 10 days ago.  After a day of meetings and getting my second USA passport in Paris (so that we can obtain visas in one while I am travelling with another), I took the train to Lyon and had a short week there.  During that time I recovered my new 10-year French residence visa, although that task alone took me 2 complete afternoons and 250 euros (Vive la France).  Now I am good until 2022!  Other than that, I slept (a lot!), ate, drank, caught up with some acquaintances in Lyon, made some new acquaintances, and purchased a lot of very small Christmas gifts for the team, in case I am once again on mission at that time of the year (a very high probability).  During my return trip to Juba, I was in Nairobi for 1 day to do job interviews with 6 nurse practitioners, so that we could hire 3 of them to work with us in the Yida refugee camp in South Sudan.

In Juba, our pharmacy and logistics store is no longer available, which generated a search on how to rationalize our installations here.  Right now, we rent an office, 2 houses for the international staff and people on passage, plus the pharmacy/logistics store.  We found a beautiful solution – a new house large enough for the whole team and passage (20 bedrooms), a building for our pharmacy, and space for our logistics store.  This will really reduce the management of the coordination – 2 rental contracts to manage in place of 4, 2 teams of watchmen instead of  4,a smaller team of cleaners in the residence, better communication among the team, and less movements.  We should move in around 1 December, and it will change our lives.

Since my return, things have been busy.  There has been a lot of turnover in our coordination team, and that calls for a lot of meetings.  I have also been working on staffing for 2013 (the country has legislated a change from a 48-hour work week to a 40-hour work week), the budget for the upcoming year (we think the refugee camp will be there all year), briefing new arrivals, debriefing people leaving, and planning my handover of our emergency program to the regular South Sudan coordination.  I leave Friday to go to the camp, with a pretty large agenda of things to accomplish, coming back in the middle of the week.  Then the next weekend, I leave for a 3-day training session in Dubai on how to communicate with the press in northern Africa and the Middle East without getting into trouble.  That should be very interesting.  Then I concentrate on the handover until my departure on 15 December, maybe to Jordan to work with Syrian and Yemeni refugees.

More news concerning Yida

Here’s another article, and the link to the associated video, concerning the Yida refugee camp with which I am now working:

http://www.voanews.com/content/yida-south-sudan-refugee-camp-braces-for-new-arrivals/1521368.html

S. Sudan Refugee Camp Braces for New Arrivals

Michael Onyiego

October 05, 2012

YIDA, SOUTH SUDAN — Conditions at the Yida refugee camp in South Sudan have improved - after a wave of new arrivals, disease and death.  But as the rainy season ends, the camp is bracing for another wave of challenges that could overwhelm the humanitarian community.

Things are calmer now at the main hospital in South Sudan's Yida refugee camp.  The hospital is run by Doctors Without Borders (MSF).  Many beds in this makeshift tent hospital are still full, but according to MSF, the situation is finally manageable.
 
From mid-June through mid-July, a wave of disease hit the camps, sending mortality rates soaring.  This was coupled with a rush of new refugees, as many as 1,000 per day.   
Since then, the situation has improved.  At one of three Outreach Therapeutic Program centers, refugees come in for nutrition monitoring and evaluation.  Mothers receive special food rich in vitamins and nutrients to keep their children healthy.  The lines are still long, but MSF says the refugees are generally less malnourished.
 
"Now there is need," said Marie, a nurse with MSF in charge of this clinic.  "It's not so catastrophic like it was in July.  But it's very— it can change quickly.  If malaria comes, if cholera comes or if more people come, very quickly, it can be like in July."

The refugees at Yida come from the heart of Sudan's South Kordofan State.  Fighting broke out in June of last year between the government and the rebel SPLA-North, which was part of South Sudan's own rebel SPLA during the Sudanese civil war.
 
The camp now has more than 65,000 refugees who fled intense fighting and aerial bombardments by Sudanese warplanes.
 
New arrivals say fresh fighting will soon drive many more over the border into South Sudan.  Yusif al-Farik, 40, arrived with his daughter just days ago.  He says they left their home when Sudanese troops started shelling the area.

"They are just shooting randomly," said al-Farik.  "Maybe they are targeting an SPLA-North position.  But the shell doesn't hit that area, it hits the houses of the people there and wounds them."
 
The United Nations refugee agency (UNHCR) is now registering fewer than 200 new arrivals per day.  Officials say the rainy season cut off the roads from South Kordofan, preventing more from coming.
 
Those same rains have made it impossible to get food into the camps by road.  For the past few weeks, the World Food Program has been forced to deliver food by air.  The planes make six runs every day, dropping around 64 metric tons a day from the sky.
 
The drops have proved a critical lifeline for the refugees, and WFP says they should last until the end of the year.
 
But officials say the drops may need to be extended if more refugees arrive after the rainy season.  UNHCR says as many as 15,000 could come by the end of December.  If that happens, resources will be spread dangerously thin, and the Yida camp could face another crisis.

Other news here is that I now have 2 jobs – the human resources coordinator for the regular programs in the country came down with a very bad case of malaria, and had to be sent back home to recover.  So I am now finance and human resource coordinator for the emergency programs AND human resource coordinator for the regular programs.  That also means that my vacation was postponed by 2 weeks, so that his replacement will arrive before I leave for my 10 days in France.  That’s life in MSF!

Here is the latest press release from MSF concerning the refugee camp in South Sudan with which I am now working:

South Sudan: making progress in Yida Camp

Date Published: 18/09/2012 04:28
Médecins Sans Frontières/Doctors Without Borders' (MSF) work in Yida camp is proving effective. MSF has reduced the mortality rate in the camp, which is now the home of families seeking refuge from conflict and food insecurity in Sudan.
However, living conditions remain a concern, as does the high prevalence of disease. The main causes of mortality have not changed since early July when the situation reached a critical threshold. André Heller, MSF's head of mission in South Sudan, explains why.
Question: Are the conditions in Yida camp as bad as they were in July when the mortality rates were so high? 
André Heller: "No, we've made significant progress. Between mid-June and mid-July, the mortality rates were twice the emergency threshold levels. One month later, the mortality rate in the hospital was down from 25 percent to two percent. But most deaths are still among children under five. They're the most vulnerable ones.
Generally speaking, MSF's work has had a real impact on the refugees' health. We've brought the mortality rate right down. First of all, we see far more children than one month ago. We're seeing some 3,000 patients per week, who are hospitalised or treated as outpatients. We've multiplied our consultation sites so the children come earlier, before they fall seriously ill. And we give the malnourished ones adapted therapeutic foods."
Can we say that the situation is under control in Yida?
"Not completely. First of all because nearly half the children diagnosed with malnutrition need hospitalisation. We've had to hospitalise 81 children in the week of 27th August alone. Furthermore, the main causes of mortality haven’t changed. If we look at the number of inpatient and outpatient cases treated by MSF, we see that the main causes of mortality haven't changed, except for the number of malaria cases which have risen sharply.
We're right in the middle of the rainy season, when malaria peaks. So we must keep up the fight against malaria. Otherwise diarrhoea, water-borne infections and pulmonary infections remain the main causes of mortality. Of course we're increasing our efforts. And other partners are working on access to water and improved hygiene conditions. But there's still room for improvement in this regard."
How did MSF expand its assistance to the refugee population in Yida?
"MSF has increased the means deployed, mainly by increasing the number of hospital beds from 40 to 100 and expanding staff numbers. We've quadrupled our expatriate team: doctors, nurses, and water and sanitation experts too, because we're intervening in hygiene and sanitation facilities in the camp.
Concretely, the MSF team has scaled up the capacity for pumping and storing borehole water so that we're now able to provide 80,000 litres of clean and chlorinated water. We also distribute jerry cans, as we saw that the refugees' jerry cans were dirty and contaminated, potentially transmitting infections. And we build public latrines. There were nowhere near enough and the camp's population keeps expanding.
People pour in every day, fleeing Sudan's conflict and food insecurity. Up to 1,000 new arrivals settle in the camp every week. We don't have precise figures for Yida's population, but it's estimated at between 50,000 and 65,000 people."
What other difficulties do you face?
"Since the rainy season started in June, it has been very complicated bringing in material, medicines, food and so on. Supplies have to be flown in. MSF has a small plane that can transport 750kg of freight, but we have to use the United Nations' helicopters too, as everything has to be brought in to Yida.

The rainy season will last another two months. It means we'll have mud underfoot for a while yet. We'll need to monitor the refugee's health and continue efforts to improve their living conditions. We've achieved a first step: the mortality rate has been reduced. Now we have to maintain the momentum over the next few months because the refugees’ situation in Yida is still precarious."

Here is the video that goes along with the article: http://vimeo.com/49608837

I returned from the camp to Juba on Thursday after a week's stay.  I was there with our Human Resources contact from Paris for a few of those days, and we accomplished quite a few things.  Now I am working on the budget for the project through the end of the year, and will afterwards be making financial projections for 2013.   Unfortunately for the refugees, we think that the camp will still be necessary.

My trip back to France for a break may be pushed back a few days.  All of our South Sudan financial team is changing between this coming weekend and the middle of October.  So I will probably go back after helping the new Financial Controller for the regular program get settled into his job, and return at the same time that the Accounting Manager changes.  After meetings in Paris, I should have about 1 week in Lyon to relax before returning here for another month.  Then, the financial team here should be settled in, and I can hand over to someone else for the South Sudanese emergency programs.

News from Yida (and also from Syria)

Here is an interview by Al Jazeera with a surgeon from Médecins Sans Frontières just returning from a mission at the border of Syria:

      http://www.youtube.com/watch?v=kRidj-Qc8s8

I am now in the Yida refugee camp in South Sudan, close to the border of Sudan.  I am here to replace the field administrator who took a weekend break in the capital of Juba, and also to work on the budget revision, take some decisions in some personnel conflicts, and put some administrative procedures in place. 

It took me a few days to get here.  I was supposed to fly out of Juba on Wednesday, but that plane was cancelled.  Thursday the plane took off, and I got to Rumbeck, where we switched from the plane to a helicopter.  We got to Lere just as a big storm broke out.  The Lere passengers got off and the rain started immediately.  So we waited out the rain on the ground (which quickly became a swamp).  It was pretty funny, because a lot of schoolkids were returning home, and they took shelter with us in the helicopter until we couldn't fit any more in.  When the rain slowed to a sprinkle after about 40 minutes, the kids got out and we continued on to Bentiu, the capital of Unity State.  Here we were told that the weather was too bad between there and Yida, so we had to return to Rumbeck or spend the night in Bentiu and continue on the next day.  I spent a lovely night in the Bentiu Grand Hotel, which is not so grand, and barely a hotel, more like a set of 24 storage compartments fitted out with small beds and mosquito nets, although it is as expensive as f***.   I won't even explain the condition of the toilets and showers.  It is the only hotel in Bentiu so they can get away with it.  At least the food was good.  And they had Heineken!  After waiting 3 hours the next day at the Bentiu helipad for our helicopter to return, I finally arrived on dirt runway in Yida on Friday around 1:00pm  

The camp continues to grow, sometimes slowly and sometimes faster, depending on the situation in Sudan.  The various conflicts along the border (on both sides) continue, and we do not know what will happen in the coming weeks. 

After only a few weeks, we have over 900 children in our program for undernourished children.  This is alarming, especially because the UN is distributing food to the camp residents.  My interpretation is that the arriving refugees are in a very poor condition, and these are the children we are enrolling in our program. 

I just left 3 weeks ago, and our hospital continues to change quickly.  We have just increased the number of international staff nurses by 6 to help with the workload and to improve the quality of care that we provide to our patients.   We are adding another doctor and 3 nurse practitionners as well.  This is turning into a huge project.

The residence compound for our international and relocated national staff is much better, although everyone is still in tents.  They have added more outhouses (VERY important, especially since many of the international staff get diahrrea soon after arriving) and showers.  We just installed commercial satellite internet capability which should cut the cost of communications from the slow, expensive system we had before, and it means that the team can communicate with their family and friends in the rare moments when they are not working.

I go back to Juba on Thursday, if all goes well.

Here in South Sudan

I have now been in South Sudan for nearly a month.

Juba is one of the most expensive cities in the world.  As the capital of the world’s newest country (South Sudan, which gained it’s independence from Sudan, just had it’s first anniversary on 9 July 2012) it is a created capital situated on the Nile.  It has grown very quickly, and there is a huge international population here with all the diplomatic corps and non-governmental organizations (NGOs – like us) based here.  So there are a lot of good restaurants – Thai, Indian, Ethopian, Italian, etc – but they are VERY expensive.  The Dinkas, who are the majority of the population, are herders so there is meat, but everything else must come from neighboring countries such as Kenya, Tchad, and Congo-Kinshasa making those products expensive also.  Fortunately, the do make (and consume) their own beer.

South Sudan’s primary resource is oil.  Unfortunately, the country is land-locked.  The pipelines to a seaport run through Sudan, its old enemy.  For the moment, the pipeline has been shut down, while South Sudan and Sudan haggle over the price of passage through Sudan for this precious product.  So no money is coming into the country.

At the same time, there is still fighting in Sudan just north of the border of South Sudan’s Unity State.  That is why many Sudanese living in that region have fled south into South Sudan.  And this flight has increased recently.  The camp in Yida, where MSF is working, grew from 20,000 people in May to an estimated 65,000 people last week.  The host community of Yida is about 700 people. 

We have been cooperating with several other NGOs and UN agencies to provide some infrastructure to the refugees.  Our part in all of this, since November 2011, has been to operate an out-patient clinic and a hospital, serving both the local population and the refugees.  We have also done some distribution of non-food items and have recently set up 3 outposts distributed within the camp to treat malnourished children.  

Obviously, with the increase of the size of the camp and with people arriving in worse and worse shape, we have had to greatly expand our out-patient and hospital facilities (which are housed mainly in tents) and the staffing to take care of these people.  There are no sanitary facilities either.  People have been urinating and defecating in the areas around their homes.  With the hot, dry weather, this was not so bad, but the rainy season started about a month ago, and this practice now creates a serious health hazard.  We will be cooperating with some other organizations to build communal latrines (out-houses) in the camp.  Using standard numbers of 1 latrine per 20 people, this means a total need in the camp of over 3,000 latrines!  We have committed to build 200 over the next few weeks.

I mentioned the start of the rainy season.  This is one of the defining phenomenas of South Sudan.  Rainy season starts end of July – early August and lasts until sometime in November.  During this time huge areas are flooded and roads are no longer passable.  Already, to get people in and out of the Yida camp we must rely on airplanes and helicopters – our own and those of the U.N.  (The camp, which is V-shaped has a short dirt runway running up the middle of the V.) But during the rainy season, all freight also has to go by air.  And because the runway is very short and becomes dangerous when wet, we can only fly in helicopters or Cessnas (with a small payload) during this time.  Right now, this airfreight capacity is the biggest limiting factors to our work.

For example, we currently have 872 malnourished children in our therapeutic feeding program, and the number is growing every week.  Just to treat these children we need around 200 boxes of therapeutic foods per week, about 3 tons.  That alone is the capacity of freight we have using our own plane.  And within the next 2 weeks are receiving about 25 tons of medical supplies plus more tonnage in logistical items for the latrines, plus a tractor (used to pull the Toyota landcruisers out of the mud when necessary).  All of this must be moved to Yida from 2 or 3 other airports as quickly as possible.  Our logisticians are pulling their hair out right now to find airplanes, helicopters, intermediate storage, and people to assure arrival of everything.

I arrived in Juba on 5 August, and made my first trip to the Yida camp about a week later, for 4 days.  We have a residence compound, again in tents, for around 22 people plus visitors.  It is adjacent to the hospital.  They were just moving from the old site to the new when I was there.  It should be much better now – they had completely outgrown their capacity already, and soon they will be 30 people living there.  The hospital has grown from 2 tents to 9.  The workload is tremendous – people were getting tired and sick.  

But with the new facilities, and the increase of staffing, we are slowly coming out of the emergency phase.  Our people have better living conditions, the residence sanitary conditions have improved, and the hospital mortality rate has dropped.  All of this greatly helps the health and moral of the team.

I will be returning to the camp this week for about 8 days.  There is still plenty of work to do.  I should be returning to France sometime in the beginning of October for 10-14 days.  Besides taking a break, I will be picking up my renewed French residence visa (which has been waiting for me since the end of July – I hope) and obtaining a second passport (working with the emergency department, that will allow me to have one in Paris for them to get new visas in one while I am in the field with another).  I will also be debriefing with the department heads on my time in Mali and South Sudan.  As of now, it is unclear if I will be returning to South Sudan afterwards, or if I go elsewhere.  It depends on the evolution of the situation here, and the emergence of other needs somewhere else.  I love this life!

On my way

I fly out of Bamako Mali in a few hours, arriving in Juba South Sudan Monday morning.  I have enjoyed my time in Mali, and I am also looking forward to this new challenge.  I will again be the coordinator of finance and human resources for an emergency program, this time a refugee camp about 15km from the border with Sudan.  The camp grew from around 20,000 people end of May to around 55,000 people end of July!  The rainy season has started, and the families arriving now arrive in very bad shape.  I will be the only member of the coordination team associated purely with this emergency project at Yida.  I hope to spend about 50% of my time in the capital of Juba, and 50% of my time in the camp.  Here is the latest update on the situation from MSF:

MSF in South Sudan: update 2nd August 2012

New epidemiological data from two refugee camps in South Sudan show mortality and malnutrition rates soaring above emergency thresholds.
In Yida camp, which hosts the 55,000 refugees in Unity State, new MSF epidemiological data of mortality covering June and July shows four deaths per 10,000 people per day for children under five years old. This is double the emergency threshold and indicates an average of at least five children dying each day over this period, most from diarrhoea and severe infections.
The global mortality rate over this period is also double the emergency threshold, with two deaths per 10,000 people per day. The study, completed on July 27th, showed that 82 percent of refugee families had a family member fall ill over the previous two weeks.
In Batil camp in Upper Nile State, hosting around 34,000 refugees, preliminary results of another new MSF epidemiological survey completed on 31st July show the global malnutrition rate among children at 27.7 percent, and the rate of severe acute malnutrition at 10.1 percent, five times above the emergency threshold.
Even worse, 44 percent of children under two years old are malnourished, 18 percent of them with severe acute malnutrition. The study also shows a mortality rate for under-fives in the camp to be at 2.1 per 10,000 people per day over a four-month period, above the emergency threshold.
While the full break-down and analysis of data is still pending, the MSF team fears that the mortality rate in recent weeks is much higher.

MSF in South Sudan: update 30th July 2012

We now have 160 international staff responding to the crisis across the three camps in Maban County.
In Jamam camp, the health situation remains fragile but there have been signs of improvement. Healthcare provision has increased thanks to our mobile clinics and oral rehydration points. Improvements have also been made to sanitation and the water supply is no longer critical.
A 10-day stretch without heavy rain has meant no further flooding. However, the many pools of stagnant water have seen an increase in malaria cases. The relocation of people from Jamam to a new camp at Gendrassa has started, with around 500 people being transferred each day.
In Batil, we are seeing alarming rates of malnutrition. The estimated camp poplulation now stands at 34,099 and we now have more than 1,000 children enrolled in the feeding centre. We have airlifted 30 tonnes of high-energy biscuits and a further 100 tonnes of therapeutic food is on the way.
The population of Doro camp is now between 41,000 and 46,000. We are seeing more severely malnourished children being admitted to our clinic, and malaria cases are rising. However, provisional results suggest that overall and child mortality rates are around borderline emergency thresholds.
Yida camp - whose population is now estimated at 55,000 - is a health catastrophe. Hospital mortality remains very high due to the late arrival of many patients for specialised medical treatment. Children under five years of age are arriving in horrific conditions. They are in shock, with multiple morbidities including septicaemia, lower respiratory tract infections, malnutrition and bloody diarrhoea. 
All roads leading into the camp have been completely cut off and the condition of the airstrip prohibits all larger cargo flights into the camp.

Next stop: South Sudan

I will be leaving Mali sometime in the next 2 weeks, once my replacement arrives and we can do a handover, going to South Sudan.  Here is another MSF press release, this one concerning my new assignment:

South Sudan: health deteriorates in Yida camp

Date Published: 13/07/2012 03:29
Close to 500 people a day are crossing the border from Sudan and arriving at Yida camp in neighbouring South Sudan. The United Nations High Commission for Refugees (UNHCR) reports a total of 63,500 refugees in an already overcrowded camp originally intended for 15,000 people.

Having walked for days, and sometimes weeks, across the Nuba Mountains fleeing conflict and food insecurity in South Kordofan in neighbouring Sudan, the refugees arrive in extremely poor health.

Hospital mortality
“Most of our patients are in shock, and hospital mortality is going up as the camp’s population increases,” explains Dr Mego Terzian MSF emergency desk manager.
“Given the sheer number of patients, we have to focus our attention on those whose lives are at risk and children suffering from diarrhoea, severe infections and malnutrition.”
The majority of patients in the MSF-run hospital are children under five years old. The number of children admitted has doubled over the past month, increasing from 104 to 209.

Malnourishment

The percentage of malnourished children seen in consultations has also gone up and hospital mortality has more than doubled in a month from 7% to 15%, mainly due to diarrhoea and severe infections, including pneumonia. MSF teams are doing their utmost to help parents recognise the symptoms that call for a child to be brought to hospital as quickly as possible.
The number of people in Yida has more than tripled since April 2012. The rains have already started and the water and sanitation supply are simply insufficient. Despite the efforts of the organisations working in the camp, reception and living conditions for the 63,500 refugees are utterly inadequate.

Waterborne diseases

“The majority of consultations in MSF’s medical facilities are for waterborne diseases that could be contained if there were enough latrines and adequate access to drinking water,” explains André Heller-Perrache, MSF Head of Mission in South Sudan.
To respond to the ever-increasing needs, MSF, the main medical organisation in the camp, has stepped up its activities by increasing hospital capacity to 60 beds in three additional tents in the hospital. MSF is also reinforcing its team of already 80 people.

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MSF in South Sudan

MSF has been working in Yida in South Sudan's Unity State since November 2011. It runs a hospital in the refugee camp and a consultations service, as well as providing medical care at the camp registration point. In June, MSF vaccinated over 14,000 children under 15 against measles and continues to vaccinate children aged from six months to five years at the camp registration point. Other MSF teams provide assistance to Sudanese refugees in Upper Nile State.

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Mali: MSF maintains its presence in Timbuktu

This is a press release issued yesterday by MSF to Agence France-Presse, concerning the project on which I am working:

Date Published: 12/07/2012 10:15
A Médecins Sans Frontières/Doctors Without Borders (MSF) team is providing health care in Timbuktu despite the destabilising, ongoing violence in the north of the country which has displaced thousands in recent months.
Since the beginning of April, Timbuktu has been in the hands of Tuareg rebels and armed Islamist groups. The city is the scene of pillaging and has rapidly lost a large share of its population: two-thirds of its approximately 40,000 inhabitants have fled toward other regions of Mali, or to neighbouring countries.

Health centres pillaged

An armed rebellion took hold of northern Mali in early 2012, leading to the displacement of large groups of people. © Foura Sassou Madi/MSF

In the surrounding villages, some health centres have been pillaged. Since then, a latent tension has pervaded the city. Sporadic fighting has flared up among armed groups and, recently, sacred sites around the city have been destroyed.
“Bringing aid to this destabilised region is a challenge, but it’s also a necessity,” says Dr Mego Terzian, MSF Emergency Desk Manager.
“The instability impedes the access of humanitarians, and the north of Mali remains blocked to westerners. Nonetheless, because the situation remains volatile and could deteriorate at any time, we are maintaining our presence in Timbuktu’s hospital and in the surrounding villages.”
MSF is one of the few humanitarian organisations present in the region. Five expat volunteers along with the remaining local staff are providing medical care in the city hospital’s departments of paediatrics, medicine, gynaecology and, since mid-May, in the department of surgery.

Fuel shortages

Like the city's inhabitants, some of the medical personnel have fled, and those who remain are not paid regularly. Sporadic fuel shortages disrupt the supply of water and electricity, which in turn impedes the hospital’s operations.
Furthermore, the hospital lacks medicines. In two months, more than 300 patients have been admitted to the hospital and over 1,500 consultations have been performed by our teams.
In recent days, restrictions have been placed on vehicle movement within Timbuktu as well as movement out of the city. Nonetheless, MSF teams continue to provide medical care in Niafounké, Goundam, and Gourma-Rharous outside of the city, and limit medical referrals to the Timbuktu hospital.

Malnutrition

Over the past two months, more than 6,300 consultations have been performed. The primary diseases observed are respiratory infections, diarrhoea, and skin conditions, often related to a lack of water and poor sanitary conditions. 
MSF teams are also paying close attention to the nutritional situation since they have observed pockets of malnutrition in the region. Malnutrition is a chronic problem, and one that becomes more critical each year at the onset of the “hunger gap” – the lean period that falls between two harvests.
Nearly 800 malnourished children have already been treated by MSF. However, due to the security situation, which is having a detrimental effect on the economy, the nutritional crisis is in the region is likely to become worse.
MSF is also working in the country's south. Teams are providing nutritional treatment and pediatric care in five health centers and in the Koutiala hospital.

Bamako

Things are good in Bamako.

The budget for our project has been submitted and reviewed in Paris.  Most of the accounting has been entered, up through the 27 June.  I have developed my expense follow-up template.  Our employees are entered into the database, and they were paid for the month. We are getting the expatriates we need for the program.  And we have made a proposition for additional staffing to improve the medical care for our patients and are now negotiating with headquarters for the approval to hire them..

But the situation in northern Mali is still tense.  The Ansar Dine and the Mujao, the more extreme factions in the occupation of the north, have taken control from the Touaregs of all the main cities, including Gao and Timbuktu.  The Malian government, which is still in a transitory stage after the latest coup, is not in a good position now to try to recover the north.  The Ramadan fasting period starts in a couple of weeks, and we are watching to see if anything will happen before that.

Mali has been, until recently, a very touristic country, but with the current troubles this important source of income has dried up.  Hotels and restaurants which were thriving before are now closed.  This reduction in income, as well as the conflict and the instability in the government, are making it very hard on the population, both north and south.

The hospital in which we are working in Timbuktu is functioning, but we are currently not going out to our ambulatory sites because of the insecurity.  This hospital and two other health centers are running because we can provide the drugs necessary and can pay the staff, most of whom are no longer receiving salaries from the Malian health system.   Insecurity is rife.  Vehicles are frequently requisitioned, including one which was carrying one of our staff – he was left alone, but he lost all his luggage and papers which were in the car.  We are still able to move people and medical supplies, but only with extreme caution and careful planning.

Bamako is calm and very wet.  The rainy season has started, and it rains some nearly every day.  Last weekend it poured!  I spent my Sunday afternoon in the Mali National Museum.  It is in the national park, which is beautiful.  They have some interesting artefacts, including some incredible wooden carvings.  There is also a very interesting exhibition of Malian textiles.   

The park is old, so there are some big trees there, but apparently it was in ruins until recently.  It was restored in the last few years.  It is adjacent to the zoo, which is closed now for extensive renovation, to make a better living environment for its inhabitants.

Saturday, I took a long walk of about 3 hours round trip.  We are on one extremity of the city - I did not make it into the center.  But it was good.  I get a better feel of a place on foot than in a car.   It was a good experience, and I will be doing it again.   

Over the last couple of weeks I have been into town quite a bit, to set up flights, get visas, and take care of other business.  I am getting a better feel of the city.  Bamako straddles the Niger River, with 3 bridges linking the 2 sides.  There are a few big streets to get around, but the traffic in the center of town in incredible – cars, trucks, minibus taxis, motorbikes, pushcarts, horses, donkeys, and more.  We don’t drive here – as in most places where we work.  We use either the MSF cars and drivers, or taxis already qualified by the logistics group.  Moto-taxis are forbidden to us. Arghhhhh.

I went to a bar for a beer one evening this past week.  Like a lot of African bars, it is in a courtyard with an enclosed building, but most of the bar is roofed, open sections of the courtyard.  This set up is really agreeable.  I was sitting at the outside bar when the owner came in.  He is a great fellow.  He offered me a beer, and I think it surprised him when I afterwards offered him and his 2 employees something to drink.  We talked for a while.  And before I left he offered me 2 bronze statues, each about 3 inches high, a man and a woman.  I was really surprised.  He says he has thousands of them, but I was still touched by his gesture.  From what I have seen so far, this generosity is typical of the Malians.

Mali is known for its music.  It is a very vital part of the western Africa music scene.  This very bar I mentioned has live music 3-4 times a week.  I hope to go one evening soon.  But the music starts late, and I get up early.  I will have to find a way to have the experience without upsetting my work schedule.

A car just arrived from our regular program in the south, bringing back our chef de mission and assistant medical coordinator who were consulting with the team there last week.  I missed them – it is good to have them back.  And to my surprise, two of my old colleagues from previous projects arrived in the car also – a logistician from Congo-DRC and a doctor from Ivory Coast.  It is great to catch up with both of them again.  The logistician is going home on break, and the doctor is going for briefings in Paris.  I have two more former colleagues working in the regular programs here that I have not yet seen. 

The only frustrating part of my time here is that I cannot go to our project, because of a fear of kidnappings of whites$$$.  Working at a distance complicates things a lot.  But all in all, I am really pleased to be here.  I am happy that we can provide health care to the population of Timbuktu and the surrounding area, who would have no access to it if we were not there.  And I enjoy my life here in Bamako.   

For those of you following this blog, you probably remember that this is my first assignment in a 1-year contract with the Emergency Pool of Médecins Sans Frontières (Doctors Without Borders) – French section.  It is a whole new ballgame as compared to the “regular”, longer term projects in which I have worked.  I have now been here for a month, and will be here at least one more month.  Then, who knows?  Maybe more time here, maybe some other hotspot in the world.  All depends on the situation of the world.  And with the world as it is, I am pretty sure to have a job in the humanitarian field for a long time.