In October and November 2019, I worked with Medecins Sans Frontieres (MSF) as an Anaesthesiologist in South Sudan.
South Sudan is an impoverished country of 12 million people that gained independence from Sudan in 2011 after 30 years of fighting. Peace didn’t last long and a civil war broke out in South Sudan between different ethnic groups in 2013 and has continued at various degrees of intensity since then. More than 400,000 people have been killed in this civil war and millions have been displaced. Development has been hindered by the decades of fighting despite the country having the third largest oil reserves in sub-Saharan Africa. It has the highest maternal mortality in the world (2000 per 100,000 births) and has the highest rate of malaria in Africa because much of the eastern part of the country along the White Nile is a swamp.
Medecins Sans Frontieres has multiple projects in the country. I spent six weeks in Aweil, in the northwest part of South Sudan, where MSF has been present for over 10 years. This was my fourth time working with MSF. My other three missions were in the Middle East; two in Iraq and one in Yemen.
MSF funds and operates the maternity and paediatric services in the local Government Hospital in Aweil and employs approximately 400 local staff and 30 expatriate staff including an Anaesthesiologist, General Surgeon, Obstetrician, and Paediatrician.
MSF is responsible for 200 in-patient beds, 2 operating rooms, a maternity centre, a paediatric emergency room, a feeding centre for malnourished and dehydrated children, and during my stay, they had to temporarily opened four large tents with 20 beds each; three for children with malaria and one for measles. The birth rate in South Sudan is high (4.9 births per woman) and 45% of the population is under 14 years of age. Paediatrics and obstetrics are the busiest services in the Hospital.
Although there is a road from Juba, the capital of South Sudan, to Aweil, it is poorly maintained and the trip takes four days in the rainy season which persisted until mid-November this year.
The road is not secure and is dangerous to travel on so the only practical way to get to Aweil is to get a World Food Program flight which lands on a red dirt runway just outside of town. Despite over 100,000 people living in the area, Aweil has no electricity and MSF powers the hospital and living compound with diesel generators.
More than half the local women choose to deliver in the MSF run Maternity Department while the rest have their babies at home. MSF trains and employs local midwives who do most of the deliveries in the hospital but there is always an expatriate Obstetrician available to deal with complicated cases. Despite having the facilities to do safe caesarian sections, only 3% of deliveries are by caesarian. There is a policy not to do surgical deliveries for fetal distress and caesarians are only done if the mother’s life is at risk. This policy prevents maternal deaths due to uterine rupture from previous caesarians. On average there was one or two caesarians a day and all were complicated in some way. There is a blood bank but there was seldom any blood available. Because of the high incidence of malaria many of the pregnant women were anemic and undertaking a caesarian section in a patient with a hemoglobin or 4-5 gm/dl was not uncommon.
Each day there was a long list of paediatric cases for surgery. Mainly short cases for burn dressings, abscess drainage, and fracture reduction, but there were also complicated cases such as gastroschisis, pyloric stenosis, imperforate anus, strangulated hernias, bowel obstructions, appendicitis, and abdominal trauma. Surgery was carried out in children as small as 2.5 to 3 kg.
Any Anaesthesiologist wanting to work in this project must be comfortable caring for complicated obstetrical patients and very small and sometimes very ill children. Because I was there at the end of the rainy season and much of the land was flooded, over 80% of children who were admitted to the hospital tested positive for malaria regardless of their primary medical problem.
The anesthetic resources (drugs and equipment) were good although one of the two ORs had a very basic anesthetic machine cobbled together with spare parts. The other room had a modern machine designed to function with an oxygen concentrator instead of high pressure medical gases. I had to revert back to my very early days of being an Anaesthesiologist because pentothal and ketamine were the only induction agents and one room only had halothane available as the anaesthetic gas. Neither of these agents are available in Canada any longer. There was no laboratory, only a glucometer and a HemoCue to measure Hb. There was no ICU capable of ventilating patients or running inotropes so it was difficult to manage the severely ill patients.
Despite the unresolved civil war, it was safe in Aweil and we were able to venture out and walk around the city and countryside. This was in contrast to my previous experience in the Middle East where expatriate staff were not permitted to leave the hospital or guesthouse due to security concerns. In Aweil we lived in tukuls (huts) inside a compound which had fans but no A/C. As with all MSF projects, the meals were prepared for us and there was a daily laundry and housekeeping service. And unlike the Middle East, there was cold beer. None of the expatriate staff became too ill while I was there, except two people who developed malaria despite taking appropriate prophylaxis.
People ask me what motivates me to work in these outreach projects. There is the obvious humanitarian reason of wanting to assist people who have no access to life saving medical care. I know that if I stepped aside here at home, some equally competent physician would take my place and patient care would not change. However, when I am working in places like South Sudan, I am treating patients who would not get adequate medical care and who would often die without my involvement and the presence of organizations like MSF.
I am also motivated by my love of travel and this work allows me the opportunity to visit places where no one else is permitted to go. I work with other organizations including Operation Smile, Accion en Medicos, and the Canadian Anesthesiologist’s Society International Education Foundation and my outreach work has allowed me to visit the Dominican Republic, Haiti, Ghana, Rwanda, Guatemala, Ethiopia, South Sudan, Iraq, India, Philippines, Yemen, and the West Bank of the Palestinian Authority.
These missions break up my year; I love to go away to somewhere new and to work in challenging circumstances and I love to come home again to the comforts of Victoria, my house, and our well staffed and equipped hospitals. I think I am more grateful for what I have and for the health care system I work in because I do this outreach work.
I also love meeting and working with people from all over the world. In Aweil I lived and worked with fabulous people from Ethiopia, Ivory Coast, Zimbabwe, Guinea, Nigeria, Cameroon, Uganda, Japan, Burkina Faso, France, Denmark, Sweden, Australia, and the United States.
Dr. Gordon Wood, Anaesthesiologist and Intensivist with Island Health, grew up in Victoria and attended the University of Victoria and UBC before going to Queen’s University for Medical School, finishing in 1982. I spent 3 years in New Zealand, first as an Intern then as a Family Doctor before coming back to Kingston to do a 4 year Anaesthesiology Residency. This was followed by a one year Critical Care Fellowship in London, Ontario. I was on staff at Queen’s University from 1991 to 1997 before accepting a Consultant position in ICU in London, UK from 1997 to 2000. In 2000 I returned to Victoria and have worked as an Anaesthesiologist and Intensivist since then. I have an active clinical research program in Victoria and am the Medical Director for Quality for Adult ICU in IH.
Dr. Wood shares his experience at Island Health in “We are Island Health” a video that takes a look at what matters most - at work and at home.