A circus of pain and relief - kala azar in Somalia

Henrik Glette/MSF As we arrive, the twice a day distribution of the therapeutic nutrition product, Plumpy Nut, is in progress. It is a very happy scene. Children smile and laugh as the staff distributes the much awaited and thoroughly enjoyed meal. The disease they are suffering from is officially known as visceral leishmanianis. The parasite infects the immune system. Patients show fever, wasting, anaemia and an enlarged spleen. If untreated, it is fatal in almost 100 per cent of cases, within one to four months. An hour later the scene has changed dramatically. Medecins Sans Frontieres (MSF) has seen a substantial increase in the number of patients suffering from kala azar in its projects in Somalia. For the fortunate ones with access to treatment, relief is not all that awaits them. The health centre that is operated by MSF in Huddur, in south-west Somalia, is not like your average western hospital. We make our way towards the far end of the large compound, passing a grazing donkey and families doing their daily chores, on our way to observe what the staff describes as 'the eleven o'clock circus'. The venue is the kala azar ward of the health centre. Kala azar literally means 'black fever' in Hindi, and is an infectious disease caused by parasites transmitted by the bite of sand flies. As we arrive, the twice a day distribution of the therapeutic nutrition product, Plumpy Nut, is in progress. It is a very happy scene. Children smile and laugh as the staff distributes the much awaited and thoroughly enjoyed meal. The disease they are suffering from is officially known as visceral leishmanianis. The parasite infects the immune system. Patients show fever, wasting, anaemia and an enlarged spleen. If untreated, it is fatal in almost 100 per cent of cases, within one to four months. An hour later the scene has changed dramatically. Children are crying in anticipation of the pain they know is about to be inflicted upon them. Even Charlotte Jensen, the Norwegian nurse in charge of the ward, is twitching in visible discomfort, and says she never will get used to what is known as the 'eleven o'clock circus'. A circus it may be, but not one that would make anyone smile. The ward staff have prepared what seems like thousands of syringes. The children will now receive what is only one in a series of 28 injections in as many days. Each injection is very painful, and the ward is soon filled with the sore cries of children and quiet mumbling of comforting caretakers. Ancient treatment The injections are of SSG, Sodium stibogluconate, a treatment developed in the 1930s. The treatment is still effective in treating kala azar-patients in Somalia. In addition to being very painful, it is a problem that the treatment takes such a long time. Many of the patients have come a long way, and caretakers often stay with the children throughout the treatment period, having to leave their everyday life and responsibilities behind. The staff at the ward are very proud when they tell us that even now, in the middle of harvest, not a single patient has interrupted or stopped the treatment. "No defaulters in three months," they say with big smiles at the staff meeting we attend. It is clearly a sign of approval from the local population for MSF and the effectiveness of the treatment. Forgotten by the world In Somalia, every fourth child does not live to see their fifth birthday. The mortality rates are estimated to be among the worst in the world. Few exact data are available. There is little in terms of a health structures, and far more in terms of health needs. In a context like this - clearly an emergency, the four wheel drive car taking us to the health centre would normally be one of many dominating the area. All would normally carry the insignia of NGOs, the UN and others trying to help. In Somalia, the population is mostly left to itself. Few aid organisations have a real presence on the ground. Even MSF has to allow armed guards onto its premises for protection, not at all a normal procedure for the humanitarian organisation. "It is important to let the world know that not only are there enormous needs in Somalia," outgoing MSF Head of Mission David Michalski said. "It is also possible to work there and attend to those needs." Reaching out The area surrounding Huddur is an epicentre of kala azar. The next day we travel to one of the four health outposts that make up a vital part of MSF's efforts in the area. The small village of El Garas is a two hour drive from Huddur. Four cars travel in convoy to transport the team there, passing only the odd herd of camels being watched by young boys - and vacated termite hills, the very source of Kala azar. As the team arrive at the small health post, they are greeted by local nurse Ali. A few patients are sitting in the makeshift waiting room. Ali explains that during the harvest periods, the number of patients decreases, as the people have to ensure food for the coming dry period. The number of patients from this area is normally very high. Few of the patients have access to transport, and it is difficult for many parents to leave families and daily chores behind to accompany one dependant to the health centre for treatment. Henrik Glette/MSF Therefore, MSF has decided to open a satellite clinic in El Garas. With a possible capacity of up to 150 patients, it will open new possibilities of treatment for the population in the area. As to highlight the need, two young boys are lying flat out on the sandy floor of the waiting area of the health post. The brothers have been tested for malaria and found negative. Ali suspects they may be infected with kala azar, and wants them to come back to the health centre in Huddur with the team, where they may be tested and treated for the potentially deadly disease. The boys make it to the health centre, and the staff receive them. One of them has clearly not enjoyed the long, hot and dusty car ride, and is vomiting as soon as he gets out of the car. If the tests are positive, they will have to stay at the health centre for nearly a month. A month of painful injections every day at eleven o'clock. A month that will most likely save their lives.