Dear friends in Hong Kong,
© Ben NG
I am doing fine in Cherrati in the Somalia area of Ethiopia. I have been here for almost two weeks and I think I have got used to the life here and everything is on track. Although I am responsible for the tuberculosis (TB) programme, taking care TB patients is only part of my work.
I wake up in the morning at 6 am and usually spend one hour reading quietly in my office. There is a regular meeting at 7:30 am everyday. After finishing my breakfast, I go to the clinic.
As the facilities and the medications here are very limited, I can only do the essentials most of the time, such as giving suitable antibiotics to control for infection and do some minor surgeries. Most of the patients in this environment just need a little bit of help because most of them are very young and they have a good potential to recover from acute illnesses. In fact, I have more satisfaction medically here than when I worked in Hong Kong.
I usually go back to my place at 2:30 pm and have my lunch alone there. (Others work and have lunch at a different time and I need to wait for the clinic to close in the afternoon to make sure that there are no urgent consultations.) I have my peaceful lunch in the bright hot afternoon and have a short sleep afterwards. It probably will be my best time of the day. In the evening after work, I have to do some paper work, have meetings and some readings. I normally go to bed around 11 pm.
Although life is a bit boring here, I have found another type of peace in return. Cherrati is a small town surrounded by a big river. The river will have crocodile during the rainy season and it is a few metres wide. But now it is just about 20cm deep and less then one metre wide. The sky is very blue with many birds flying, and there are hundreds of bright stars at night.
© Ben NG
There are quite a number of problems in carrying out the TB programme. At this moment, I have 110 TB patients registered in my clinic. A quarter of them are children. We have a laboratory and two laboratory assistants to do the sputum smear to diagnose TB. However, about 30% of the cases cannot be diagnosed by this method, including non-pulmonary TB such as TB lymph nodes and TB bone. Children are not suitable for this test because they do not have a good cough effort and it is difficult for them to produce good sputum samples. Hence the diagnosis is heavily dependent on clinical judgment.
Moreover, the number of our TB patients is increasing rapidly. We have about 20 new cases per month. At this moment, besides the two laboratory technicians for the TB sputum smear, we have one full time TB nurse and one TB social worker in the team. However, with the larger patient load, the lack of human resources will be more severe.
There is a problem of drought and famine in the Somali areas, especial in the rural part. MSF has done a small survey in Cherrati and the data shows that the adult mortality rate is 1% (the normal rate should be less than 0.5 %) and the mortality rate under 5 years old is 3 % (the normal rate is under 1%). This reflects the severity of the problem in this area. We have a nurse for outreach activities and she witnessed serious malnutrition among the people. Food delivery activities are going on in the area. For each of our TB patients, starting from last week, 10kg of wheat/bean has been given to them every week. (TB patients are selected because they need additional nutritional support) Everyone is waiting for the rain. The rainy season usually starts at the end of March but there is shortage of water in the area. People do not have enough water to grow vegetables or for their animals to drink. Once their animals die, people will have nothing to eat. The conditions are worse than before.
Here are some stories to share with you from the clinic:
"You are going to die"
I am the only doctor in the clinic (and probably the only doctor in the whole district) and hence I am in charge of both the emergency ward and all the in-patients. The clinic is actually a health centre with very limited equipment and medications and it provides 24-hour emergency services. Resources are so limited that we do not have any oxygen supply in the emergency room. As a doctor from a developed city, I am really surprised by the enormous number of patients (we have 200 out-patient consultations every day) together with the shortage of equipment and medications. We have many very ill patients coming to the clinic as there is no other health service in the surrounding 200km. Nonetheless, many patients come in a very late stage of their illness and are usually severely malnourished.
One evening, a 33-year-old man was admitted in the centre for difficultly breathing and shortness of breath. He was living in the bush. He had been ill for six months, could not work and could not tolerate solid food. He depended mainly on goat and camel milk for his survival. When I saw him, he was severely wasted and weighed only l8kg. My upper arm was bigger than his thigh. He was so weak that he could not stand or sit for the past three months. He developed a cough and high fever. I diagnosed that he had very severe pneumonia over the right lung and put him on medications. He was very anemic and could hardly talk. I was shocked by his conditions and I told his relatives, "He is going to die but we will try our best to help him." In Hong Kong, if I told the family that, they would challenge you and start to complain. However, the man's relatives here just replied, "We know his condition is very bad and if he dies, let him go and we are ready to accept it."
The man is still alive. He is getting much better and is able to talk and sit up in bed. However, everyday, I meet some other very ill patients and I have to repeat, "Your condition is very bad and you are going to die, but we will try our best to help you." I need to say that because they are so ill that under the very limited facilities here, they really have a high chance of dying. Fortunately, I have repeated the same wording almost 10 times but have only seen one patient die. If we had better facilities and the people here had better medical support, I would not need to say, "You are going to die" again.
"Congratulations! You have TB!"
A donkey car came to our clinic one evening, with a group of men who sent a 60-year-old man to us from a bush 100km away from the town centre. The man could hardly move and had difficultly breathing because of a huge swelling of his abdomen - as big as a pregnant lady with twins. He weighed only 42 kg and was very thin and wasted. He had a fever and cough for three months and could not tolerate food well. Clinically speaking, he had massive ascite (water accumulate in the abdomen).
We could do nothing in the centre because most of the cases of ascite are caused by cancer or heart problems. We could only treat him if it was due to TB.
I tried to drain the abdominal water for him and six litres of turbid water came out on the first day. He was greatly relieved and could walk and breathe better.
I had checked his sputum for TB but it turned out to be negative. But as I said, not all cases of TB, especially extra-pulmonary TB, can be diagnosed by this sputum test and it is difficult to diagnose extra-pulmonary TB with our primitive facilities. We should try to test for the ascite fluid too, but the laboratory cannot do it. Even if it can be tested, the yield is only 30%. That means for 10 positive cases, only 3 will appear to be positive in the examination.
In this way, we were not sure if this diagnosis of TB was true but we could see the response. Although a trial of TB treatment was not recommended to test for diagnosis, we had no other choice this time. We started to put him on anti-TB treatment after discussing with him.
It is almost a week since the treatment started. He still has an abdominal swelling but the amount of water seems not to be increasing and he is able to walk freely without breathing difficulty. If the swelling responses further to the treatment and one day fully subsides and he gets stronger, I will tell him, "Congratulations! You have TB but you are treated successfully!"
Keep in touch!
Dr. Ben NG started his first mission with MSF in January 2006 on a tuberculosis treatment and basic health care programme in Cherrati, Ethiopia. In the following sharing, he shares his feeling and what he encounters in this mission.