Coping with disease and drought in Upper Nile

The small child lay motionless on a hospital bed in Malakal, a garrison town in central Sudan. Severely malnourished, the child had a high fever and a number of other unidentified medical complications. Medical staff said the child was suffering from Kala Azar - a severe parasitic infection transmitted by the female sand fly, which mainly lives in Acacia and Balamites woodland. Left untreated, it is fatal in 95 percent of the cases. "Most Kala Azar patients arrive in the hospital unable to walk and have other co-infections, such as TB or malaria, because the disease destroys the body's immune system," George Mbaluto, a nurse working for the medical charity MSF-Holland which runs the hospital, told IRIN. "They are usually severely malnourished and are often carried here by relatives," he added. The temperature in the intensive care unit was 48 degrees Celsius, as the heat of the dry season simmered over Malakal. It was so hot that before taking the child's temperature, the nurse had to dip her thermometer in a bowl of cold water to cool it down. According to the medical personnel at the hospital, the Kala Azar season in Upper Nile coincides with the dry season. It lasts from September-October until January-February. During this season there is also an increase in dust-induced pneumonia, as well as bloody diarrhoea. "The water-level of the River Nile is very low around this time of the year and people drink directly from the river, while they also use it to bathe and wash their clothes," Samuel Nyitwel, the supervisor of the hospital's in-patient department, told IRIN. Widespread in few countries According to the World Health Organization, there are 500,000 new cases of Kala Azar per year in 88 countries around the world. However, 90 percent of all the cases occur in only five countries: Bangladesh, Brazil, China, Nepal and Sudan. In Sudan, it is found in a belt that runs from Unity State, through Upper Nile, Blue Nile, Sennar, and Gedaref, up to Kassala in eastern Sudan. It is also found in some parts of Ethiopia, Kenya, Somalia and Eritrea. Mbaluto said new Kala Azar patients usually had to spend 30-45 days in the intensive care unit to stabilise the disease and treat complications. On average, Kala Azar patients remain in the hospital for one to three months before they are discharged. Most patients who receive treatment recover, but some die. Recently, a small girl died of co-infections in the hospital. Mbaluto said she had Kala Azar, TB and meningitis. Peter Garmaac Chol, a 37 year-old blind man from a village near the town of Ayod, showed up at the hospital in January suffering from Kala Azar. He travelled on his own for over two days, making his way to the hospital despite his lack of sight. Chol, who was 1.91 mt tall, but weighed only 53 kg, was discharged on 21 February, but he was still too weak to make the entire journey back to his village by himself. "We are trying to track down his relatives so that they can pick him up, but so far we have been unsuccessful," Mbaluto said. Other diseases widespread Diseases such as TB, malaria, diarrhoea, pneumonia and severe malnutrition, have also taken a heavy toll on the population of Upper Nile. During the last week of February, the Malakal hospital had 170 TB patients on treatment. "TB is endemic all year round and, as the first phase of the disease is highly infectious, new patients have to be isolated for up to 2 months," Moussa Hamadan, a national TB doctor, told IRIN. To complete the treatment, patients have to stay on combined TB drugs treatment for six to nine months. Those who live far away stay in the hospital during the entire time. Patients from nearby villages only stay in quarantine during the initial phase, then come to the hospital to get their medication every day. MSF is training medical staff from the Sudanese Ministry of Health to eventually take over the Kala Azar and TB programmes. However, it costs almost US $1000 to treat a TB patient, which is a substantial financial constraint for the ministry. Food shortages make matters worse Disease is rampant in Upper Nile, but lack of adequate food exacerbates matters. The region experienced very late rainfall during the last planting season and as a result, there was widespread crop failure. According to the UN Office for the Coordination of Humanitarian Affairs (OCHA), there was "strong evidence that there may be a region-wide food security crisis that will push the existing, highly food insecure population into an even more precarious situation", later. Around Malakal, the displacement of thousands of people from the nearby Shilluk Kingdom by attacks from government-allied militias in 2004 created further needs. An estimated 25,000 displaced Shilluk were still in Malakal town in February, while thousands of others had sought refuge in nearby towns. A report by the US-sponsored Civilian Protection Monitoring Team (CPMT) said residents who had remained in the villages had yet to recover from the devastating effects of the fighting. The region, the CPMT added, was facing severe food shortages as the planting season had been disrupted by the armed conflict. Adeng Anwour, team leader in Malakal for the Food and Agricultural Organization, told IRIN on 25 February that the price of sorghum on the local markets had gone up. While the supply had lowered, the demand had gone up because of the displaced people. "A 90-kg bag of sorghum is 10,000 Sudanese dinars [$40], but it was 6,000-7,000 Sudanese dinars [$24-$28] at the same time last year," he said. "It might go up to 15,000 Sudanese dinars [$60] in May, June and July." He added: "During average years, there is a food gap between May, when households' food stocks are running out, and July, when the early maize harvest comes in. This year people are already running out of food in February." Ger Tervoort, MSF project coordinator, told IRIN: "We are seeing a high number of severely malnourished patients, particularly among the children admitted to the paediatric hospital and among Kala Azar admissions, and we expect the admission rate to go up. "The number of new admissions in our Therapeutic Feeding Centre was stable at around 40 during December and January, but, since last week, the number has started to go up," he said on 24 February. Patients with families The hospital, at times, has to cope with the relatives of the patients as well. A Nuer man called Simon had arrived in the hospital from Galla Hill village, close to Nasir on the Ethiopian border, more than 200 km from Malakal. Severely malnourished, he was diagnosed with Kala Azar. However, Simon did not come alone. Outside the intensive care unit were his wife and his three children, sitting in the shade. "Having whole families here can be a real strain on our resources, but as they are a long way from home, we cannot deny them food," Mbaluto said. He added that there was also a medical reason for feeding the patient's caretakers. "In the past, we had cases where a patient's recovery got slowed down as he shared the hospital's food rations with his relatives." According to nurse Liane Behrens, however, the large number of people that were staying in and around the hospital for a prolonged period of time was an opportunity, rather than a constraint. "TB and Kala Azar patients and their care-takers, who stay here for months, are an ideal target for our health education programme," she told IRIN. "We try to avoid the social stigma that is associated with TB patients and teach them about HIV/AIDS, as well as preventive measures, such as the use of mosquito nets, the importance of washing hands and covering food." Future needs great The Upper Nile region only recently opened up to international organisations, following the signing of a comprehensive peace agreement between the Sudan government and the southern Sudan People's Liberation Movement/Army (SPLM/A). The agreement, signed in the Kenyan capital, Nairobi, on 9 January, officially ended 21 years of conflict between the government in Khartoum and the SLPM/A, which said it was fighting to emancipate the southerners. The region has very few clinics. Apart from the hospital in Malakal, MSF has opened three basic health care units along the Sobat River, which runs west from the Ethiopian border and reaches the Nile near Malakal. "We continue to try to improve the access to treatment and expand our mobile medical service in order to reach those most at risk," Tervoort said. "Already, we are seeing more cases of Kala Azar in the outreach centres in Ulang and Nasir [along the Sobat River] than we are seeing in the whole Kala Azar referral centre in Malakal." He added: "Our greatest problem, as well as for the Ministry of Health, is to find trained staff - nurses, general medical technicians, and doctors. University access for southerners had been extremely restricted, resulting in a very limited number of available doctors." A report by the UN Children's Fund, published in June 2004, estimated that there was only one doctor per 100,000 people in southern Sudan.