refugee camp outbreak: a father, his sick daughter and the tiniest baby

by caitlin meredith

jamal’s baby granddaughter

Jamal  is the Blue Nile grampa I never had. He is a slight figure, even in his size 42 gumboots. He wears an Islamic cap and always comes early to work, perching on a chair to my right. While there are many younger men on my team, none compete with Jamal’s vigilance. Most mornings at the outreach worker meeting he pulls me aside at the end to tell me of people he’s concerned about from the village he visited the previous day. One day he told me about a man who was killing many goats in the village of Ayouk, scaring the other refugees. Last week he brought out a tiny scrap of paper with his Arabic-scripted note: there was a sick woman in Soda Amol who hadn’t been able to walk because of swollen legs for two days. He wanted me to go find her because thought she should come to the hospital. He was right – she needed urgent care.

In the past two weeks there has been a Hepatitis E outbreak in the Jamam camps where Jamal and I are both working and living – he as a refugee, me as the MSF epidemiologist.  More and more of our morning meetings have been focused on the epidemic.  After a couple of days of training to teach the outreach workers how to look for real jaundice, not just yellow eyes, they started reporting their findings.  I wasn’t surprised that Jamal was the first to produce a list of 17 names. Weary of outreach workers reporting of a condition that can be difficult to assess (especially in malaria-prone areas), I had the Expat outreach nurse Alison head to the village to find the cases and do a formal evaluation. Alison brought back 8 clinically jaundiced refugees in the Landcruiser so we could take blood samples at the hospital. The other 9 people were also jaundiced but not able to make the trip to the hospital. Jamal had identified our first Hepatitis E hotspot.

As the past week progressed Jamal’s daily reports were added to the growing list from other outreach workers and as we’ve mapped those cases and the others that have come to our clinics, the true picture of the epidemic has emerged. Unfortunately, it’s everywhere.

Within MSF we’re always hoping that our staff are immune to the many problems we know refugees and displaced people face. Mostly this is wishful thinking so we can get through our daily to-do list, not dwelling too much on the specific obstacles our staff must overcome just to show up to work every day. Within the outreach team there are single mothers with four children whose husbands stayed back in Blue Nile. I don’t ask who is taking care of their children while I’m asking them to count tents and ask sheiks in other villages how many deaths there were last Epi week. I’ve hoped that by giving them early and targeted education about Hepatitis E that they and their families might be protected from infection. Of course this is another example of wishful thinking.

Yesterday midmorning a pregnant woman named Khamisa was admitted to the hospital in a coma. Her family said she had had seizures at home very early and though she had been normal the night before – even playing with her children – she had not woken up that morning. The first thing the attending doctor noticed were her yellow eyes. Here in the maternity ward was our worst fear: the Hepatitis E outbreak would make late-term pregnant women very, very sick. Wherever there have been HEV outbreaks in similar settings, pregnant woman are the most affected group. Many die.

At lunchtime I went to the maternity ward to see this mama. It’s one thing to read about mortality rates, but the real learning comes by seeing first hand the challenges of managing complicated cases in this setting and the families behind the numbers.  As I read this woman’s chart I noticed that her last name was familiar: Jamal. A minute later I saw him at the maternity ward entrance and knew this must be a member of his family.  Khamisa, it turns out, is Jamal’s daughter.

Jamal had come to sit vigil with his wife, other daughter and Khamisa’s husband. There was not much to say beyond our salaam aleikums – by the looks on all of their faces it was clear that we didn’t have to explain how very sick Khamisa was. The only reason to share a smile was that there was still a fetal heartbeat. Despite Khamisa’s serious condition, her little one was somehow surviving.

After five hours of induced labor (Khamisa still in coma) the teeny tiniest little baby girl was born last night, wiggling her pink little fingers, blinking her eyes and pursing her impossibly perfect  lips around the syringe-ful of milk the midwives gave her grandma to feed her. She is the size of your smallest teddy bear. Jalal and Khamisa’s husband poked their heads into maternity to see the new baby, but it was hard to obscure the fact that in the bed behind, her mama was still struggling to survive. I left him and his family on the plastic waiting area chairs last night at 10:30pm. I’m sure he stayed the night.

Because of our fears that the outbreak would start claiming more and more of the pregnant women like Khamisa  in the camps, the medical team planned a jaundice screening for all the pregnant women in the camp. We call it Yellow Mama; it started today. Though the Expat midwife and infectious disease doctor planned the whole thing, the Epi outreach workers put on the actual show. They work as crowd controllers, registrars, tally takers, educators, and token distributors. I didn’t expect Jamal to be there this morning, but he was. He worked with the rest of the team to explain to pregnant mamas how the screening would work and where to go next. Two times he walked back to the hospital to check on Khamisa. There was no change.

Khamisa’s prognosis isn’t good. Like the other pregnant women that have landed at our hospital doorstep critically ill with Hepatitis E and the third trimester of their pregnancies, there’s not much that we can do. There’s no medicine that cures HEV and often by the time we see these patients it’s too late to reverse their deterioration. We can just hope that through this pregnant woman screening , outreach worker community education and improved water and sanitation conditions in the camps we can prevent more people from becoming sick.

But of course that won’t help Jamal. He’s still sitting outside maternity now, holding his newest granddaughter.