Visit to Rumbek Hospital, Lakes State, South Sudan: 24-28th September 2013

Introduction: South Sudan is the newest country in the world, having gained official independence from the North on 9th July 2011 after 50 years of conflict or tenuous ceasefire. It has roughly 8.3 million inhabitants (2008 census data) and some of the worst health statistics in the world. Its maternal mortality rate stands at 2,054 / 100,000 and the under 5-mortality rate is 135/1000 compared with UK figures of 8.2 and 5 respectively. The purpose of our trip was to assess the viability and potential effectiveness of a health partnership between Dorset County Hospital (DCH), Dorchester, UK and Rumbek State Hospital. South Sudan was identified as a potential partner due to the obvious need in South Sudan but particularly due to the links already established between hospitals in the Wessex region and those in South Sudan. In addition, I was to provide two Lifeboxes and relevant training for the hospital, kindly donated by the Lifebox Foundation. I was fortunate enough to receive an IRC travel grant from the Association of Anaesthetists of Great Britain & Ireland for my return travel from Nairobi to Rumbek. Our flights to Nairobi were either self-funded or met through other funds. The Government of South Sudan was kind enough to provide free accommodation and food for our trip. Our initial plan had been to fly to Nairobi and catch a direct flight to Rumbek with ALS airlines. This would have avoided an inconvenient and time-costly stopover in South Sudan’s capital Juba while arranging onward transport to and from Rumbek, 250 miles away. Unfortunately this humanitarian airline ceased operating this route shortly before our arrival and we had no choice but to enter the country via Juba. South Sudan is a difficult place to travel around in. Most roads are impassable in the wet season (May-September) and scheduled internal airline services are unreliable. After 2 days in Juba, we finally boarded a flight to Rumbek, a journey of 1 hour. Despite assurances to the contrary, there was no one at the airport to meet us on our arrival. We hitched a lift with a World Food Programme vehicle and arrived at the hospital in the heat of mid-afternoon. After introductions to multiple members of staff who were not expecting us, we finally met someone who was! Rumbek Hospital: Rumbek Hospital is currently the largest institution providing care for the residents of Lakes State, and theoretically provides all of the WHO ‘essential’ services of a district healthcare facility. It has 120 beds, 4 consultants (Radiology, 2 x Obstetrics & Gynaecology, General Surgery), 6 medical officers & 1 dentist, 97 nurses including 14 midwives, 2 nurse anaesthetists, and 2 trainee anaesthetists.

The hospital currently provides multiple wards for the various medical specialities e.g. medicine, surgery, paediatrics, maternity, isolation (for TB & leprosy) and rehabilitation. It has a laboratory block, some X-ray & ultrasound facilities, two operating theatres (1 general & 1 obstetric) along with a minor ops room. It has a school of nursing, complete with classrooms and accommodation block. Virtually all buildings were in a poor state of repair and maintenance, particularly the wards and administration block. Apart from the maternity operating theatre most areas were dirty and dusty. There was only limited electricity (roughly 4 hours per day) as diesel for the generator was costly and in short supply. There were at least 5 non-functioning generators visible nearby the working one. They had either ceased working because of lack of maintenance, or a lack of available spare parts. Water supply is via borehole but most wards did not have running water anywhere, suffering from a lack of maintenance of the plumbing system. Only theatres and maternity had a functioning tap. There was universal dismay amongst the staff about the poor supply chain of drugs and equipment. This problem is complex but the end result is that there were very few reagents available for lab work, including an inability to X-match blood; an extreme shortage of basic drugs – e.g. there was no insulin; very limited antibiotics; and even quinine was in short supply. There are no drugs available for formal general anaesthesia, only ketamine. Spinal anaesthesia is possible, but inadvisable due to lack of equipment, lack of drugs and the perilous cardiovascular state that patients present with. There were three functioning oxygen concentrators: in maternity theatre - in the paediatric ward and in maternity. Oxygen cylinders were also available. The level of training of most staff was low (70% of the nurses are neither registered nor certified) with variable basic skills such as literacy. Morale was low mainly due to Government austerity measures where pay has been cut to 30% of the previous amount and even that is inconsistently paid (often one month in two). There is no payment for out of hours work so often staff not present when they are expected to be available and finding them causes delays e.g. some emergency LSCS have to be delayed until following morning and average “decision – incision time” is usually 2-3 hours. Theatres keep a logbook of cases but we did not see it during the visit. Maternity keeps a register of deliveries and paediatrics at least recorded monthly activity figures by diagnosis. Clinical record keeping is done on rough sheets and scraps of paper, and we were told that paper shortages are common.

Clinical areas and activity: Officially the hospital has 120 beds, but apart from paediatrics it was difficult to gauge true occupancy as many adult patients come and go from the ward throughout the day. Others sleep outside or on the floor in addition to the ‘true’ in-patients. Many relatives are generally present in the ward areas, as they provide the food, cleaning and laundry service for their patient. They are also expected to donate blood if needed, and to travel to town to buy the necessary drugs that have been prescribed if the hospital does not have them. Operating theatres: There are 3 theatres: one maternity, one general emergency and one for minor operations. Only the maternity theatre appeared in a reasonable state of repair and to be fit for purpose. It was clean and had a functioning operating table, operating light, oxygen concentrator, portable monitor (pulse & saturations), although the staff said that it had virtually no battery life and was therefore dependent on the electricity supply. The scrub area was poor but had running water. The staff complained about numerous problems with sterilising operating equipment due to autoclave problems. The surgical ward is essentially a mixed ward (both in terms of sex and cases) but with surprisingly few in-patients actually in beds on our visit. I saw 2 post-op inguinal hernia repairs (elective); 2 burns; 1 complex femoral fracture (there is no internal nor external fixation at Rumbek, only skin traction and plaster casts); 1 post-op laparotomy for abdominal abscess. The remainder of the 20 beds were unoccupied. Apparently they contain the ‘walking wounded’ having undergone principally incision & drainage of infected limb lesions, often from traffic accidents, fighting or sport (in that order!). During the day the wards are too hot, so they sit or lie outside under the nearest tree to take the breeze. The only operation I witnessed during my stay was emergency caesarean sections (invariably spontaneously breathing under ketamine). The only general surgeon was away on holiday and so no ‘general’ cases were done that week. They were very grateful for the Lifebox oximeter that would still work when the electricity supply failed. Lifebox use & training: I managed to deliver the Lifebox training materials on two occasions to two groups of mixed medical and nursing staff. This was well received and many questions were asked. We covered both tutorial 1 and 2 over a couple of hours switching from over to my laptop when the generator stopped working! I donated the two Lifeboxes to senior members of staff to whom I also gave further training on their care and maintenance. They intend to use one in theatres and the other one on the paediatric ward. We thought this would be beneficial as the medical staff could then target their very limited supplementary oxygen supply to the most critically ill children.

Summary: Rumbek hospital needs much help in all areas, in order for it to become a functional unit fit for purpose. Improvements need to be made across the board to the infrastructure; supply chain; organisation and clinical training to realise this goal. Since our return, we have signed a formal Memorandum of Understanding with the Government of South Sudan to both increase the capacity at Juba hospital in the short-term (through training visits being co-ordinated by some of the Medical Royal Colleges); and work with the Ministry of Health of South Sudan to develop a sustainable long-term plan for Rumbek hospital. Dr Mark Pulletz, Consultant in Anaesthesia & Intensive Care Dr Phil Wylie, Consultant Paediatrician Dorset County Hospital, Dorchester, UK November 2013 Our thanks go to: AAGBI for the travel grant received by M Pulletz Lifebox for the two Lifeboxes and training materials Ministry of Health of the Government of South Sudan for their help in arranging visas, flights, accommodation and food for our visit. The staff and patients at Rumbek Hospital Conflicts of Interest: None