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ORTHOPAEDIC HELP FOR SOUTH SUDAN – a North-South-South success story.

SOUTH SUDAN IS a young country, having been established as an independent state in 2011 after decades of conflict with the northern parts of the Sudan. Even within the borders of the new country, the official military is in conflict with many armed dissident groupings. Under such circumstances, the health care service becomes a major casualty. Some of the worst health indicators in the world occur in South Sudan, and in some areas the doctor-population ratio is 1: 500 000. The country of nine million has just three hospitals, and no specialist orthopaedic surgeons, not even in the capital city of Juba. It is in this dire situation that SMU (formerly known as Medunsa) became and remains involved.

This is how the involvement began. SMU had been part of several collaborations with Norwegian hospitals in the past, and then in 2012 a much larger collaboration – between Oslo University Hospital, the Haukeland University Hospital in Bergen, and the Juba Teaching Hospital – called on SMU to join them once again. The Norwegian partners had raised more than R1,5-million from the Norwegian funding agency, Fredskorpset. The request to SMU, considered by the Northern partners to be one of the best hospitals in Africa for the treatment of trauma, was that with this funding they train two South Sudan doctors to add a specialised orthopaedic focus to their existing general practitioner skills.

The Orthopaedics Department was happy to become involved, and began teaching a specially designed higher diploma course in orthopaedics. The thinking was that there must be a great need in other parts of Africa for this level of skill.

Thanks to the Fredskorpset funding, two South Sudan doctors, Morris Jakwot and Maker Wel, began their studies in February 2011, and completed the course their courses towards the end of 2013.

‘When the war ended,’ Dr Wel explained, ‘conditions changed dramatically. The streets of Juba, that had for so long stood empty of vehicles, suddenly were crowded with tens of thousands of cars. Pedestrians weren’t used to them. Trauma cases from road accidents resulted in at least twenty admissions a week. We had little idea how to treat them properly. We put them all in traction, a treatment that in most cases didn’t work. After only one year at SMU, it was as if my eyes were opened. When I went home for a short spell, I knew how to treat people with broken bones. Even the South Sudan Minister of Health came to see me. He had fractured his wrist.’

Dr Jakwot said: ‘It was as if, before, our hands were tied. Now I have even learned how to operate on trauma patients. This Higher Diploma in Orthopaedics has three main components: trauma, infection and paediatrics. I feel that we are being empowered. The situation back home needs us. Yes, of course, we will be very much in demand and always busy. But we are ready for that; and we are grateful to SMU for providing us with the extra expertise.’

Clearly, there is huge scope for the programme to expand, not only to assist South Sudan but other African countries as well. At the same time, it would draw SMU closer into the health challenges, however daunting, of some of South Africa’s neighbours.

‘That’s what the university’s vision is all about,’ says Marais. ‘To be a leading African institution that addresses the needs of rural communities through innovative ideas. It is certainly drawing the SMU into the medical realities of one of the most unstable places on the continent.’

Now there’s a sequel to this story.

IN December 2013, fighting broke out in South Sudan between rival political factions struggling for control of the world’s newest country. More than sixty people were killed in the streets of Juba in two days, and hundreds more were injured. The violence dragged on. A curfew was imposed. People hid in their houses. The injured were brought to the city’s only hospital, the Juba Training Hospital.

‘I was visiting my family in Canada,’ Dr Maker Wel explained. ‘I got a call from my hospital in Juba,’ he said. ‘They asked me to come and help. I went.’

What he found was a situation more chaotic than usual. There were only four functioning hospitals in the country, and one had been damaged in the fighting. Now in strife-torn Juba there were hundreds of people with bone fractures, some of them serious and needing surgery.

Already in Juba was a South Sudanese who had trained as an orthopaedic surgeon at Oslo University and who was domiciled in Norway. He had flown in to help out. When Wel arrived they tackled the crisis head-on.

‘We identified 148 fractures that needed serious attention,’ Wel recalled. ‘Most of them needed plaster of Paris casts, and a high percentage needed “plating” and “nailing” to repair the damage. We virtually lived in the theatre. We performed forty operations a week. Yes, the knowledge gained at SMU made a massive difference. I was saving limbs.’ Wel explained that many of their successes would have ended in amputations a few years previously.

The UL Trust’s Carina Marais said it had cost R1,5-million to bring Wel and Jakwot to South Africa and to provide them with the training required to prepare them for the postgraduate orthopaedic College diploma examinations.

‘It would be fantastic,’ she went on, ‘if we could interest South African funders to assist SMU to give practical voice to the vision of the university, which is to be an African university committed to addressing the particular needs of Africans, particularly those in under-developed and insecure situations. After all, South Africans can no longer think of their welfare in isolation from the fortunes of the continent as a whole.’

Now that the two South Sudan doctors have completed their specialised postgraduate orthopaedic training, attention has turned to the sort of basic equipment they will need to fully exercise their new skills.

The two most basic pieces of equipment are a traction table; the other is a c-arm x-ray image intensifier. The table is used in theatre to get the fractured bones into alignment before fixing together by nailing or plating. The c-arm is a diagnostics tool used to establish exact images of bone damage so that appropriate treatment can be administered. No such equipment exists anywhere in South Sudan.

It is difficult to imagine the level of medical deprivation that pertains in this small country situated in one of the most unstable regions of the continent – and of course in many other places in Africa as well. But what would be required to at least partially remedy the deprivation? The estimates are that the traction table would cost about R100 000, and R1,5-million would be needed for the c-arm x-ray image intensifier. There would obviously be additional costs for transport to South Sudan and installation there.

If this is the cost of helping SMU-trained orthopaedic doctors to avoid further amputations in that troubled country, it’s cheap at the price.

Ortho Africa

FREDSKORPSET (Norway)