Longread: Semi-nomadic healthcare in South Sudan – First day in the cattle camps
MSF anthropologist Dale joins the healthcare promotion team in a remote region of South Sudan
8:30 a.m. South Sudan. Southeast of the country. Not far from Ethiopia.
We've been driving in the middle of the bush for two and a half hours. And when I say the middle of the bush, I mean it. There is no road and we are travelling at 5-6 km/h over an ocean of bumps and dry grass. The car’s body brushes against small trees that have spikes as long as my fingers. They look mean.
It's at least 40 degrees Celsius and there’s no air conditioning in this good old Land Cruiser. My colleagues and I are sweating. It's actually so hot that the grass naturally catches fire everywhere. Bushfires are routine. I can open the window for a few seconds to snatch a little air, but no longer. If I open it too long, there are I-don't-know-how-many ants who invite themselves I-don't-know-how on my legs. Gotta keep it closed.
Fortunately, the landscape is amazing; there are mountains spread all over vast yellow desert plains, great birds that soar, antelopes that frolic. In the end, time moves fast.
Cattle are key
We follow a GPS track left by my predecessors and drive towards the cattle camps. The camps are where semi-nomadic people in this region migrate during the dry season in search of green grass and water to graze their cows. Cattle are a pillar of life for these pastoral communities and I must explain (very) briefly why, so that you understand our medical activities.
First of all, whoever says “no cows” says “no food”, because cow milk is one of the primary sources of subsistence here.
Then, without cows, marriage is almost impossible, because dowries - which a man must pay to the family of his bride - are paid in cows.
If you say "no marriage" then often you also say "no children". But a man who has no children - and in particular no daughter - will not have hope that a man will marry her and thus return at least the number of cows that were given at his own marriage. It would be a broken cycle.
And for many people here, dying without descendants also means the end of your spirit.
So in addition to food and marriage, herds of cattle are thus at the core of social dynamics in this area of the country. They determine conflicts, peace, power, wealth and even health.
An absolute priority
Consequently, the survival of the herds is an absolute priority and that explains why people here walk for hours, days, under a blazing sun, in search of water and grass to feed them.
The places they travel to are arranged alongside large rivers or lakes able to withstand the dry season.
Although the decision to go to a particular camp also depends on other factors (alliances, security, health, personal preferences, etc.), the camps themselves are broadly the same from one year to another. You could draw them on a map, arranged largely around the payam (district) of Maruwa.
It is in Maruwa that we have set up a small primary healthcare unit and a maternity ward, and it is also where our “base camp” is located. Placed right in the middle of the village, we sleep in tents; increasing the feeling of being relatively close to the community.
In the mornings and evenings, I can see from my tent the busy water point 30 meters away. I can hear children playing, roosters crowing or youngsters fighting.
However, we’re in the middle of the dry season and Maruwa is very calm, almost empty. There are only young people looking for work, pregnant women or some elderly and young children. The rest live in the cattle camps.
So you're going to ask: what are you doing all day if there's no one left in Maruwa?
Good question. On the one hand, a team remains in the village to run the healthcare unit and the maternity ward, which is very useful for the vulnerable people who remain in the village, as well as patients who have returned from the camps specifically because they need care.
On the other hand, we get on the move. We try to follow the cattle herders and their families. We are working to set up a decentralized care system, integrated into the community and adapted to their priorities and realities. That means a group of people selected by the village chiefs and trained by us on the main killer diseases affecting children: diarrhoea, malaria and respiratory infections. We give them a stock of drugs, we inform the community and we follow up to see if it works.
This concept is not new. It is already used by quite a few other NGOs in various countries. However, our project is young and we are only at a pilot phase here.
It is the first dry season that we have experienced since the health centre has been operational and we do not yet have a solid knowledge of these cattle camps, nor of these communities.
Do these people migrate to the same place every year? Do they leave their village together, all at the same time? How do they know when to go from one cattle camp to another? How do they feed themselves? How do women give birth? How many children travel with them and what do families do when they get sick? Trying to understand all this is partly the job of my health promotion team and that's one of the reasons why we're out in the community today.
Personally, I just arrived and I’m having to learn all this fast. Today is my first outing in the bush in South Sudan. The team comprises a driver (Johan), a health promoter (Ernest) and a nursing team supervisor (John) who have experience of living in these same places in their younger days. Local knowledge, as we say.
Back on the road
Two and a half hours on the road, five litres of sweat, three mountains, twenty antelopes and two hundred ants later, the landscape changes. It gets greener. I don't see any houses yet but there is clearly a transition happening. Fewer mean trees, which are replaced by kinder, taller ones offering us nice shade.
Suddenly, I see small white shapes not far from us and John tells me “Do you see this herd? Do we talk to them?"
YES! Absolutely. I am so excited. We move forward. There are five teenagers with long spears, sticks, large gourds containing water or milk. And whips. And guns too, for the protection of the herds.
One of the young people has a piece of grass in his mouth and is looking at us serenely. The others smile at us. We wave, get out of the car and start talking. Well… my colleagues are talking, since I don't have a clue about the local language.
The young people explain to us that the majority of the leaders left the camp for a far-off place to hold peace talks with neighbouring tribes. We wish each other a safe journey and get on our way.
A few minutes later, as the greener landscape continues to emerge and there is more and more evidence of human life, I see something. A little house. Or it could be an agricultural hut? I’m not sure.
Made entirely of dried grass, it looks solid and neat. It could house two or three people at most. A small calf, silent, grazes on hay besides it.
The ochre colour of the cow is similar to the brownish grass the hut is made of. These buildings are impressive. I wonder how people construct them. How they resist strong wind.
There are six or seven more scattered around. They seem uninhabited.
Uninhabited? Really? Not a chance.
As if they were camouflaged in their small golden igloos, people start to appear as soon as we arrive. A few minutes and this place that seemed deserted almost becomes a village square. With a quick glance I count: thirteen children, five women and two men: one young, and one very old.
The older man wears many colourful necklaces and bracelets. He is shirtless, in shorts, and seated on a chair made of branches that have been carefully pruned, sanded, smoothed, lashed together with what resemble strong vines.
"This man is Allan, a very well-known traditional healer," Ernest tells me. I glance at the notes left by my predecessor and I see that she wrote next to his name: “very influential and experienced. Absolutely worth interviewing him”. I immediately start a conversation, of course with the help of my colleague who then translates everything.
This gentleman explains that he specializes in many things, including skin infections, fractures or even complicated deliveries, when the child is "stuck in the mother's womb".
He says he uses many local plants to treat various symptoms. Nevertheless, he is retired and teaches his knowledge to younger men, especially his son who has gone to graze the cows.
A sick child
Promptly he explains to us that their two-year-old child is sick and that he cannot treat him because, not only "he is of his own blood", but also because he does not have the capacity given his age. John, my colleague, is a nurse and examines the child. He has fever, swollen glands, vomiting and diarrhoea. He needs care.
John asks the family if they have met the community health worker whom we trained and gave medicine to. The mother replies “yes. But he's out of stock. There are too many sick children”. OK, noted. We are actually here to re-stock him. Finally, after giving the child the treatment that he needs, we leave in search of our local collaborator.
It proves a challenge. Cattle camps are vast, stretching for miles. I would need to write fifteen posts to fully describe them to you. The houses are scattered in clusters of five to 10, protected by these nasty trees which have been cut and positioned as fences to keep the cows safe at night.
While people seem to move with their villages of origin, they can mix up according to personal preferences, weather changes, power dynamics and so on. There is actually so much complexity to these population movements that finding our colleague is not as easy as I hoped.
People here move. A lot. One week in Logorgoroth, another in Kangen. One month in Ngazen, another in Logorichele. Between the names of all the villages, tribes and camps, I get a little lost, but I’m learning.
I am just following my colleagues at this point. We are now reaching the edge of a muddy river that’s around 15 metres wide. On the other side, there are about a dozen young men digging trenches so their cows can drink without getting bogged down. We get out of the car.
The house of our friend is on the other side of the river. John and I roll up our trousers while the rest of our team remains near the car. As we walk into the mud, water goes up to our thighs. Children on the other side laugh when they see me struggling. I laugh too as I set foot on dry land. It was all well worth it, although our guy isn't actually there; he is grazing his cows in the bush. We find his wife and are able to store some medications safely with her.
We continue the day like this, sailing from house to house, under a blazing sun. A discussion with five young mothers here, an interview with a hunter there. We find additional sick people whom we help with the means at our disposal but, unfortunately, we cannot treat everyone, we do not have the equipment of a full mobile clinic. As we talk to people about the services we are trying to put in place with the community health workers, we are offered glasses of fresh milk. Unfortunately, the day ends without us being able to meet a single one of our guys. That's fieldwork. Flexibility, adaptation and moving forward at the pace of the community are key.
In the car on the way back to the base, we are travelling more slowly, as we have an injured patient with us. The young woman has a broken leg which has got infected; she couldn’t do the three-hour walk to our clinic in Maruwa. She has a baby with her, which enlivens the journey. Joined by her brother, they chat with my colleagues throughout the journey. As they seem to be having fun and debating many topics, I wonder what they are talking about with so much energy. I learn that they are actually debating passionately about cattle, their colour, their importance. They mention a young guy who just married another woman with a dowry of 60 cows. They discuss the next camp they'll move to if the rain continues to fall. I would love to speak their language so I can learn more about their culture and their routine, understand more their challenges and their feelings.
As the group talks and the baby suckles its mother's breast despite the shaking of the vehicle, I see black, threatening clouds emerging on the horizon we’re heading toward. The wind picks up quickly. John pats me on the shoulder and tells me something that makes me put things in context. You know, that kind of simple but very thoughtful stuff. It contrasts with this nice moment in the car.
I share it to end this blog post, and perhaps to introduce the next one, leaving you thinking a little…
John looked at me from the back of the car and with a low voice in my ear said: “Dale, when it is windy, we say it may be going to rain. But if there is no rain, that means there will be war”…