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.
An 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, called "hangars", 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.
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. "Ã?â?¡a 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.
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.
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.
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.
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.
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.
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.
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.
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.
The clinic described here is located in the Musasa camp in Burundi. Approximately 15,000 Rwandans who fled their country are now staying in the camp. In Musasa, MSF runs a health clinic where both Rwandans and Burundians from the area can receive needed medical care. MSF's team comprised of two international staff and 65 Burundian and Rwandan staff members see 350 &#– 600 patients per day.
Due to their hasty flight and the camp's rudimentary living conditions, respiratory tract infections are the most common ailment experienced by the Rwandans. The local population suffers most from malaria, a leading cause of death in Burundi.