Feature story |

Kala Azar in Southern Sudan: "We Are Concerned About The Returnees"

Jane Boggini is a nurse from the U.S. who has completed more than 20 missions with Doctors Without Borders/Médecins Sans Frontières (MSF) since 1999. Boggini is currently working as the medical team leader of the MSF emergency response team responding to an outbreak of the neglected disease kala azar in Malakal, Upper Nile State, in Southern Sudan.

I was sent to southern Sudan in November to lead the MSF emergency medical team in responding to an outbreak of kala azar, a parasitic disease caused by the bite of a sandfly. Anyone can be affected by kala azar—children, adults, pregnant women, the elderly. Symptoms usually involve high fever lasting more than two weeks, weight loss, and general body weakness.

This year, the outbreak is particularly bad. We’ve seen almost eight times the number of cases as we did during the same time last year: 2,049 MSF-treated patients in 2010 versus 231 in 2009. The disease is prevalent in just a certain region of southern Sudan in what is called the kala azar belt. If you were to look at a map of southern Sudan, you’d see it’s a certain region mostly along the Nile River, where the acacia tree thrives. The sandfly hides in the bark of the acacia tree and the cracks in the black cotton soil, and is most active in the dark as it can’t stand the heat or exposure to light.  

We arrived in Malakal and began the emergency intervention by establishing some outreach clinics for treatment and also by supporting the kala azar ward in Malakal Hospital. The biggest challenge here is simply movement. The only way to reach Malakal is by air. We have to fly in all our drugs, all our equipment, bed nets, blankets. Then once on the ground in Malakal, it’s incredibly difficult to move around and reach the outlying areas.

We reach almost all our outreach clinics in rural areas by boat, on the Nile River. The countryside is beginning to dry out now after the rainy season and in the past two weeks, we were finally able to go by car to two clinics. There are really no roads, just dirt tracks. On top of this, we always have the problem of water. Yesterday, my outreach team drove more than five hours to go just 85 kilometers (52 miles) and when they were one kilometer (a little more than half a mile) away from the clinic they realized they couldn’t actually drive to the clinic. They had to walk through muddy water up to their knees that last kilometer in order to reach the clinic—carrying supplies over their heads!  There are always these little ‘surprises’ when we’re traveling.

In our clinics, the most affected people we are seeing are men. We think the majority of men are being bitten because they sit outside late at night, talking under the trees. Many young boys have also been affected because they’re out at night watching the cattle and goats. However, women and children can be bitten in their homes, as oftentimes they don’t have windows and its dark inside.

Now, we’re all very concerned about the returnees who are coming back to their villages in southern Sudan to vote in the referendum in January. Some of these people have been away from the region for a long time, some up to 20 years, and now they’re returning to kala azar-affected areas and have lost their acquired immunity to the disease. Their children have never been exposed to kala azar and do not know how to protect themselves. We expect to see our cases rise as these people return and start to live in the villages where the sandfly breeds. This won’t be an immediate increase—the incubation time for the sandfly can be four months before you begin to see symptoms, but over the coming months we expect to see an increase in patients.

The patients you tend to remember are the ones you’ve lost because you become very close to them as they struggle.  Sometimes people reach us too late and once past a certain point, there’s very little we can do. Without treatment, kala azar is almost 100 percent fatal. But there is more good news than bad—with treatment there is a 94 percent cure rate.

I’ve seen some heart-warming moments here in the hospital. One mother here is just a delightful woman; her children are here receiving treatment. There’s a young man here, Peter, with no family, no caretaker. He is just 16 and this mother has taken Peter into her family, cooking for him and helping to feed him. The other night I saw one of the fathers feeding his daughter next to Peter’s bed, and with one spoon he was feeding his daughter and with the other, he was feeding Peter. One of the nurses looked on with surprise and told me that they were of different tribal groups. It seems this sort of illness can bring all types together in times of need.