Darfur, Sudan: Diarrhoea watch key to identifying new health concerns
When you are trying to provide health care to huge numbers of people who have been driven from their homes and villages by conflict, one of the first resources you need is intelligence on their condition.
To help the clinics catch outbreaks there are home visitors or outreach workers. But to cross check the most critical trends, MSF has seven "grave watchers" in Kalma, who know every new burial. At the end of February, they noticed something.
"We saw many new funerals and graves", says the team leader, Omar Mohammed. "The people said it was diarrhoea. They were afraid it would spread."
The numbers had doubled to 72 deaths and when the figures were checked against those from outreach workers and the local community leaders - the sheikhs - they were clearly above internationally recognised medical emergency levels. The MSF primary health clinics in the camp have a huge caseload and their daily records were showing a shift, as well as the feeding centres with more needing extra rations - a common side effect of diarrhoea outbreaks.
In just one corner of the huge, 100,000 person camp, MSF had recently established a diarrhoea treatment centre. There had been a local outbreak because of water shortages, which had been picked up as a trend in the main clinic. The team tried a new tailored response; a specialised clinic where people with diarrhoea could get their re-hydration salts, be referred to a doctor if they had long-term problems and get a bar of soap to help fight transmission.
For serious symptoms, there was a donkey ambulance to get to the main health centre. All designed to speed up the treatment and improve the patient's experience of care. And all connected with health and hygiene discussions in the waiting room.
So, when the diarrhoea deaths went up across the camp, the treatment centre model was multiplied out to every area. Within five days, MSF was running four more centres and the diarrhoea figures began to drop away. But it is a constant battle of attrition says the project leader, Christine Nass, a paediatric nurse from Germany: "When latrines are not cleaned, when kids don't use them, when water is so limited, when people live so close to each other, it's very difficult to stop diarrhoea spreading."
Prevention is all part of the package in the centres. The outreach workers take informal classes with leading questions like: "How does diarrhoea harm your body? What happens if you lose too much water? How can you help your baby when it is sick like this?" Even the local sheikhs were persuaded that they should help by getting announcements in the mosques about the clinics.
There are real difficulties for the patients though. One of the struggles is to convince them that the oral re-hydration salts, which are the front line prescription for diarrhoea, must be taken to relieve the symptoms but will not stop them.
The body will usually do that by itself and drug treatment is held as the next line of defence if recovery is delayed. Christine is not surprised at the misunderstandings around the illness because she says her experience in a children's ward in Germany was that many doctors and nurses there did not know the best way to treat diarrhoea.
"They often gave strange mixtures for patients to drink and removed things from the diet. There is a tendency for people to think that you should "starve" the bug in the stomach. In fact it is very important to maintain the intake of nutrients and energy, which is otherwise drained away by diarrhoea."
The treatment centres in Kalma camp that Christine helped set up now have over 2,000 patients a day, some of them not very sick and probably coming for more soap. But in the war with diarrhoea, a small battle was won. And the grave watchers are pleased to be much less busy.