The Ramadan call to prayer filters into my consciousness. It's too early to get up, but only barely. This is a day in my life on mission in Wau, where we are establishing a new project, hopefully for only 3 months, to assess the situation and provide help to a population displaced by local fighting.
We leave at 7am today, and my alarm is set for 6. I submerge back to sleep after the call to prayer, and am startled awake by my alarm. It's still dark. 10 minutes later, after hitting snooze, it's still dark too. Sigh.
Members of the team progressively join the breakfast table, until we reach our 7am start time. The drivers have checked the cars and all our equipment was loaded the night before. We call our contact in the opposition forces (whose territory we are going into today) to confirm the security situation is calm. We get the green light, and head out. I hand the satellite phone to the project coordinator, confirming that he will be the one sending location updates at each town we reach. I'm going in the car with the HF radio, and I want to check if we can reach the neighboring projects by radio.
The sun is just coming above the trees and haze over Wau town as we roll out. It looks like it will be a beautifully clear day. We stop by a health center to see if a nurse that usually works in Ngesa is around. We couldn't contact him by phone, so we hoped the word had reached him that MSF is going to Ngesa today. He's not around, so we ask the watchman to let him know we stopped. We will make do with whomever we find in Ngesa.
The road is in good condition, with very few water puddles and almost no mud. We make good time, covering the 20+ kilometers in one hour. We roll over erosion channels and weave our way through holes. I reflect that these road conditions have become normal, even exceptionally good, in my recent experience. There is a piece of tarmac road that runs through the center of Wau town, but it's edges are slowly cracking away, so it's only about one lane wide. It's still used in two directions, just each car has one tire in the tarmac and one on the hard pack dirt.
We reach the abandoned health center to find no one waiting for us, but everything clean and open. As soon as we pull up, a woman bicyles up with her baby. She sits down on the nearest bench. Our first patient. We discuss set up with our new medical team leader, who has not been here before. We use a couple of 'patient flow' tricks that we learned from trial and error at other sites and this one in the past, and we redesign a system. We put the waiting area and first registration under a couple trees at the other end of the yard, then pass patients to another tree for vital signs. We have a rapid diagnostic test station in the hallway of another building, a bit out of the line since patients may go there after registration or after a doctor's consultation. The three rooms of a low building are perfect for our two consultation rooms and our dispensary. The shade from the vital signs tree makes a good waiting area for the pharmacy until about 11am. After that, we have to move the bench back every 10 min to keep it in the dwindling shade.
As we set up, people appear. By the time we have a registration table ready, there are 10 people waiting. We start registering before we are fully set up, building the infrastructure moments before our first patient hits each step. By the time the first patient finishes the consultation and goes to the drug dispensary for her medicine, there are 40 people waiting. We iron out the gaps, snags, and shortages, and local staff trickle in to start helping in their roles. A midwife shows up at the rapid diagnostic test station, and explains to me in either Arabic or Balanda (I can't recognize any words, so I can't be sure which one it is). The universal language of gestures let us communicate. She has been here before, she will do the RDTs. Great.
She immediately reorganizes her RDT area, and has everything under control. A cleaner has come with her, so I head to a hand wash station and explain to the cleaner (in gestures and one or two words of Arabic) that all patients need to wash their hands before vital signs.
We realize we have forgotten our scale, and quickly lament about the need for a global packing checklist. I have a logistics checklist, and medical has a drug checklist, but we found a sliver of a gap between the two. Our scale seems to have fallen in that gap. We hang a small 25-kg scale on the tree, and weigh the kids in a harness. The driver who is taking vital signs asks me how to read the scale, after he has registered 10 patients. At least he asked. I explain the hand of the scale, and counting the small tick marks. He gets the hang of it right away. It's funny to teach him to read a scale as he competently reads people's vital signs with a pulse oximeter that he attaches to each patient's finger. He's got O2 saturation down, but needs a refresher on weight.
I float around a bit, checking on the medical team leader, who is plugging gaps where ever he needs to. I ask if he wants to me relieve him so he can walk around, and we switch off in a couple of areas until the local nurse shows up and plugs the last gap in registration line. I check on the last few sanitation and hygiene items on my mental checklist, but the project coordinator has already seen to them. I settle into the pharmacy for drug dispensation, which is the area that is always backed up. I narrow my vision and dive in.
I've never worked in a medical context before MSF, so everything medical is new for me. I've learned to analyze bed occupancy rates, to ask for the percentage of positivity for rapid diagnostic tests, to speak in epidemiological weeks, to discuss morbidities and to do rapid nutritional screenings. I have never done mobile clinics before, so this mission is the first time I'm taking blood pressure, temperature, and weighing patients. I learned to get a blood sample and run a rapid diagnostic test for malaria. Just this week, I learned to dispense drugs.
And I love it.
Being in the drug dispensary at our mobile clinics is a whirlwind experience combining elements of being a short-order cook and a poker dealer. I have been neither of those things, but this is what I imagine. Dispensing is our biggest roadblock in patient flow, so the time pressure is always hanging over your head. But it is very important to have patients get the right drugs and to understand how to give the drugs. I work with the medical team leader, who speaks conversational Arabic, so he gives instructions to each patient. Rapidly, we take a translator from the local population ("Does anyone here speak English?") and have him tell patients when and how to take drugs. Mothers are walking away with 4 or 5 health cards and bags of drugs for their whole family. We brainstorm how to quality control our drug instructions... That's next on the list for improvement.
My time passes in a blur of pharmacy orders, selecting sachets of pre-prepared drugs in the right doses and quantities, and assembling bags of rarely-prescribed drugs for special prescriptions. I yell over the wall to the doctors who are in the other rooms whenever I have a question. "This 19 year old man is prescribed ACT 100mg 1x1x3. Shouldn't he get 2x1x3 instead?". "Can I give 1x3x5 Ibuprofen 200mg instead of 1x3x2 as prescribed?" "What's cloxacillin?" "We are out of mycodrin cream, or whatever this says here. We gave the last one away. What should I do?"
Registration of all waiting patients has finished by 12:45. Everyone who was waiting has been registered. That's a first, at this quantity. When mobile clinics are small and only 80 people come out, we have seen everyone. This time, we have two trees' shadows worth of people waiting. The end of the line trickles through vital signs. About this time, we see we are running low on RDTs for malaria. We have had a stunning number of malaria-positive patients. The medical team leader picks out the 65 remaining patients who need the test the most.
An hour later, all patients are registered and we pack up the registration areas. I'm still head-down in the pharmacy when I hear that we are out of RDTs. We make a call to Juba to ask for authorisation, and we get the green light to prescribe malaria drugs to all remaining patients with malaria symptoms.
At this point, 4 doctors are consulting the remaining patients, and the line for people waiting for drugs explodes. It's been at a constant 2-10 people waiting for a few hours, and now it stretches to 20. After checking all the cards, I see many patients with RDT results but without prescriptions from the doctors. They get shuffled to a new line to see the doctor again, and my line is back to a manageable 5. Then the wave of patients from the additional 2 doctors hits (we have had 2 doctors consulting all day). The line swells to 40. Time blurs.
I am dimly aware that the rest of the team is packing up. The local doctors come in to the pharmacy to start explaining drugs to patients. I prepare drugs orders in a blur. Our team goes to collect the prescription cards directly, and I don't leave the pharmacy. ATC, paracetamol, ibuprofen, amoxicillin. Pick, pack, cross off, "order up!". Next.
I'm out of bags! I'm out of adolescent ATC! Someone searches for resupply in our boxes, then it's the last card. Never mind, never mind! We made it, we are OK. The last adult ATC and paracetamol go out, and I take a deep breath. Wow.
I blink around at the 5 people inside the tiny room, and the deserted yard outside, with patients happily chatting and wandering away.
The team leader reminds me to pay the daily workers, and I leave the medical team to pack up the pharmacy. The drivers have already packed up everything else, and are starting to load the pickup.
I sit down with the project coordinator to make the list of all of our workers and the hours they work, then calculate their payment in a convoluted and bureaucratically-necessary process that takes a calculator and a meditative trance. One by one the workers come in, return their MSF ID that we have slapped on them throughout the day, and sign for their payment. There is a brief question about the cleaners who have cleaned the health center before we arrived, and we haggle out a solution.
As the drivers finish tying down the load, I grab a drink of water and a hand full of dates. We make contact, both via satellite phone and radio, for a final time here (we have been doing hourly check-ins), and hit the road. I find I am exhausted.
I let my thoughts wander on the way back, but remember that I need to sketch out a 3-month budget for the project. It's due tomorrow, so I should think on that. I run through our budget codes in my head and make notes on an estimated envelope for each line. Some are wild guesses. I'm glad for the admin who will clean up my conjecture and chicken scratch to make a real document.
We get home to find my assistant and a loader waiting for us, so the drivers hand over their keys, and the 10 questions from today's activities at the base are pressed upon me. I examine the construction in our compound (we are building a fuel store, watchman shelter and generator shelter). There are some electrical and plumbing problems with the house, so this is never ending.
I grab lunch/dinner, and we sit down to debrief the day and check in with the whole team. Some good ideas, solutions, questions and observations come up, and we plan next week's schedule, as well as strategy.
Time to hit email, but the internet connection isn't working. There is a land cruiser pickup outside that is waiting for a mechanical check to see if we would rent it, found by our sister project in Aweil. I check it without seeing the email, and call the log ref up in Aweil. We discuss supplies, movements between our project, the price of the car, and the decide to talk again on Monday. It's 7pm on Saturday, everything is stable for the weekend.
Having just eaten lunch at 5:30, we all agree to go out for a beer to get our minds off work and to change the scenery. As it starts to rain, we climb in the car and head to the hotel that we lived in for a couple weeks. A beer and some french fries are a nice closure to the day, and we stay out until our 9pm curfew. I check the internet connection, which is still flighty, and try to get an email off with a draft of next week's schedule.
Someone produces a bottle of Amarula, and we all take a night cap, but the party ends soon as we droop off to bed. Tomorrow is Sunday, and I swear the drivers to silence and stillness. I give out keys and bread money and instructions, and I hope to not hear from anyone until tomorrow afternoon.
Goodnight.
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