An observation
A Médecins Sans Frontières (MSF) health clinic located in a refugee
camp setting is a unique, self-contained health facility. Built in
a U-shape from semi-permanent tents, it measures 10 metres wide and
20 meters long. It is designed to be assembled quickly using
available trees and white plastic sheeting to make both its inside
and outside walls. The plastic walls are suspended on wooden poles.
The roof consists of metal sheeting. Cut-out slits in the plastic
walls suggest windows and doors. Plastic sheeting covering the
ground has to be cleaned every morning to rid the omnipresent red
earth that covers everything in the camp. The clinic’s main doors
are constructed from metal sheeting hung within a wooden frame and
bent nails serve as latches.
Open doors
Around the perimeter of the
clinic, drainage gutters have been dug to fend off the rainwater as
the rainy season is in full swing and lasts at least until mid May.
In fact, there are two rainy seasons in this country, which means
it will rain eight months out of twelve. To reduce security
concerns, the MSF team can only work in the camp from 9:00 until
16:30 each day. Because the clinic has no lockable doors, each
night the staff must pack up all the medication, supplies and forms
into boxes and place them in a nearby, secure metal container.
Every morning, all of the material must be carried back into the
clinic, unpacked and sorted for that day’s activities.
Starting the day
At 9:00 the team arrives in
the camp after an hour’s drive from the team base, picking up the
Burundian staff as they go along. First, Carole Mulachie, a French
nurse and the team’s medical leader, checks on the people staying
in the clinic’s inpatient unit. “Ça va?” she asks them when she
sees them. They nod, they are all right. The attending nurse tells
her that they’re doing fine, although one man will need to stay
another night. After these short medical rounds, the team,
consisting of international, Burundian and Rwandan staff, starts
each day with a quick meeting. Carole gives out staff assignments
for the day, making sure that all duties are covered and that the
staff rotates among the difficult tasks to keep motivation high and
teach them new skills. She decides who will conduct consultations,
who will run the pharmacy, the inpatient unit, the delivery room
and the prenatal consultations.
First triage
On her way to the main waiting
room, Carole stops by the clinic’s delivery room. A big smile
appears on her face when she sees the baby born during the night
and the baby born this morning. One woman is in labour now. She
proceeds to the main waiting room where all incoming patients
undergo triage, an initial screening by the medical staff that
determines which patients need help first. Two Burundian nurses
have divided the group of people in the main waiting room: children
on the right, adults on the left.
Fever and malnutrition
All of the children
will be checked for fever, a common sign of malaria and for
malnourishment. Carole and Zelda Goad, a nurse from the UK who will
soon succeed Carole as medical team leader determine which children
have fevers and move them to nearby benches where they wait to
receive a malaria test and medicine to bring down the fever. One
nurse dilutes paracetamol in warm water and spoonfeeds it to the
children with fever. The children gather where Egide Mdayisaba will
test them for malaria using a fast method that gives results within
15 minutes so that treatment, if needed, can start
immediately.
Paracheck
Swiftly pulling out what he needs,
including wrapped, sterilised instruments, from boxes on the table,
Egide first uses a small cloth with disinfectant to clean the
child’s finger. Then he takes a needle and quickly pricks the tip.
Using a special stick, he swipes the drop of blood and blots it in
a small round pad on the tester and adds six drops of reacting
agent. With the test done, he points the child to a bench on his
other side where he or she will wait for the test’s result. This
system makes it clear to everyone who has had the test and is
waiting, and who still needs to be tested.
Weighing
Children thought to be
malnourished, are sent to a special area to be weighed and
measured. One baby is carefully positioned in a black canvas bag,
its legs sticking out of two holes in the bottom. The bag’s long
black handle loops over a large hook attached to a scale hanging
from a wooden beam. Glancing at the scale, nurse Jean-Marie
Ndikumwami writes down the child’s weight on a card, frowning.
Quickly he takes out a special paper tape known as a MUAC tape,
designed to measure a child’s upper arm circumference.
Crying babies
Coloured bands on the tape
help the staff determine if a child is malnourished and if so, how
severely. This baby girl’s MUAC band falls within the orange
section of the tape signalling moderate malnutrition. He goes and
gets Carole to ask her advice. The orange tape could mean that the
child has to be transferred to the feeding centre outside of the
camp. The sound of crying babies forms a constant backdrop.
Wounds
As adults usually have a larger
variety of ailments, they are seen one by one by the MSF staff.
Once patients have had a medical consultation, those needing
medicine can pick it up for free at the clinic’s small pharmacy.
Those who need wound care wait outside of a special wound dressing
area where two nurses attend to wounds all day long. Many people
have open wounds that started as itchy skin conditions—related to
poor living conditions. When people scratch these itchy patches,
they can bleed and become infected. Homemade bandages made from
pieces of cloth often make things worse. Others have specific
medical problems that require regular dressing changes. The whole
day long, two nurses will bandage and dress wounds.
Sting
Emmanuelle Nahimana, a Burundian
nurse, is treating a 10-year-old boy with a large wound on his
shin. He has scratched his way through the top skin layer, and the
underlying pink dermis layer is now showing. Emmanuelle has to push
away his hands to keep him from scratching. While Emmanuelle cleans
the wound with antiseptic fluid, the boy pulls the men’s jacket
he’s wearing as a top, over his head, cringing as the fluid stings
him. Tears well up in his eyes. The nurse tilts his head: “It’s
over now, I’m going to put bandage on it now. But don’t scratch it
anymore, okay?”
Hit by a grenade
In one room, a Burundian
woman is clearly in severe pain. Her legs covered in blood, she’s
shivering and crying incessantly, she can hardly stay seated on her
chair. Quickly Carole and Zelda put her on a stretcher and bring
her to a separate room where she can be consoled and have her
wounds attended. Once the woman’s condition has stabilised, Prosper
Ndumuraro, assistant to MSF’s Head of Mission, sits down with her
to listen to her story. She tells Prosper how people barged into
her home in the middle of the night, stabbing her husband with
knives and machetes and throwing a grenade in the house. Then they
threw another grenade through her bedroom window, which hit
her.
Human cost of violence
Holding a knife to
her throat, they demanded money. She gave them whatever she could
find. Now her husband is dead. Her son was also hurt during the
attack but managed to escape. He is now being treated in the clinic
as well. Prosper fills in a trauma report, a tool MSF uses to make
sure this case of violence is logged so the patient has medical
proof of her injuries in case she wants to take legal action.
Recording such cases of violence is also crucial for MSF. These
stories reveal the human cost of violence and can be used to
support MSF’s advocacy efforts on behalf of these people and to
raise awareness about what they are living through.
Deadly malaria
Meanwhile, another nurse
tells Carole that a nine-year old girl has arrived in coma. The
girl has an advanced stage of malaria. Brought in too late, she
dies within 20 minutes. Carole shakes her head, sadly saying:
“Sometimes they wait too long. They don’t have transport or money
to come in, or they can’t leave because they have to work in the
field. Now, her mother got neighbours to help her, but it’s too
late.” One of the other nurses walks through the main waiting room
and other areas where people are waiting. In a loud voice he talks
to the groups about malaria, the disease’s telltale symptoms and
the right response when fever appears. It’s not even eleven
o’clock.
Second and third round
Patients coming to
the clinic who need to be monitored for a few days are brought to
the inpatient department. Ineke Swaans, the Dutch project
co-ordinator of the clinic, will transfer people requiring more
advanced care to a nearby hospital, using an MSF ambulance. All the
time, new people arrive in the waiting room and others move on for
treatment or leave the clinic. The waiting room remains full all
day, every day. In the next few hours, Carole and Zelda will repeat
their triage among the patients, determining who needs care most
urgently and who can wait. By the end of the day, approximately 350
patients will have been treated.
From January 2006 on, a fresh wave of refugees from Rwanda
entered northern Burundi, eventually numbering 20,000 people.
According to what people told the MSF team, their flight was linked
to the so-called gacaca courts in Rwanda. These local tribunals
have been set up to try perpetrators of the 1994 genocide in
Rwanda, in which Hutu militias killed 800,000 Tutsis and moderate
Hutus. The refugees reported all kinds of human rights violations.
Unlike a group of 10,000 refugees in 2005, these Rwandans were not
immediately repatriated, and an asylum procedure was started, in
part thanks to the MSF-Holland team’s efforts. MSF-Holland started
a project in several camps to help the Rwandan refugees, amongst
which the Musasa Camp described here, near the town of Ngozi. They
provided 90,000 consultations, including 12,000 for malaria
patients. The team assisted 470 deliveries. Following the decision
to repatriate the refugees, this project was closed in December
2006.
The story "A day in a refugee camp health clinic" was written in
April 2006.