Five Days And Five Nights With Doctors Without Borders | KERA News

Five Days And Five Nights With Doctors Without Borders

May 25, 2016
Originally published on December 8, 2016 11:46 am

"Look!" says Stefania Poggi. "They've made inflatable rafts."

Two dozen boys are splashing in a massive, muddy pool surrounded by 30-foot-tall earthen banks. They're jumping on grain sacks that they've filled with plastic bottles to make them float.

Poggi manages the Doctors Without Borders operation in the largest refugee camp in South Sudan.

The 35-year-old Italian is standing on the banks of the drainage ditch, which was bulldozed through the middle of the camp to alleviate flooding.

She beams with delight at the kids' ingenuity. Then she snaps back into her role as a health care professional. It's probably a terrible idea that the kids are swimming in runoff from the camp, she says. "Could spread any kind of disease."

But there are worse risks for kids in South Sudan right now than a murky drainage pond. They could be child soldiers. They could be victims of rape. They could be dying of starvation or succumbing to a parasitic infection that would be easily treatable if the health care system hadn't collapsed.

The hospital Poggi runs in the southwest corner of the camp is packed with dozens of kids suffering from severe malnutrition, malaria, tuberculosis and diarrhea. The facility has only two doctors to oversee its 170 beds.

There was a hepatitis E outbreak recently, and the hospital has isolation tents for measles and cholera. So if some of the kids have turned a drainage ditch into a makeshift swimming pool, so be it. The Italian aid worker isn't too worried about the risk.

"It's good to get out [of the hospital] into the camp," Poggi says with a shrug, a slightly mischievous smile lingering on her face.

Strangers In Their Own Land

This camp where she has spent the past two months is officially known as the United Nations Protection of Civilians Site Bentiu. More than 120,000 South Sudanese have sought refuge inside this compound, which is just outside the ransacked town of Bentiu. The U.N. categorizes them as "displaced persons" rather than refugees because they haven't fled out of their own country.

From the outside, the camp looks like a post-apocalyptic prison. It stands on a dusty, arid plain and is ringed by bulldozed mounds of dirt topped with razor wire. Each wall is more than a mile long. U.N. peacekeepers man gun turrets along the earthen barricades.

In the rainy season, the camp turns into a giant mud pit. In the dry season, the temperature hits 115 degrees and it becomes an expanse of dust.

Residents aren't here because they want to be. They're coming because they're afraid they'll be killed if they don't. For the past 2 1/2 years, a brutal civil war has convulsed South Sudan. Late in 2013, the president and vice president, who are from rival ethnic groups, took up arms against each other. Both of their armies have been accused of rape, murder and torture.

"I saw people killed in front of me," says 26-year-old Tavitha Nyaluak, sitting in the darkness of her shelter in the camp. Her 2-year-old daughter is in her lap, curled against her breast. "There was a lot of fighting. We were scared away from our village and hid across the river." She arrived at the camp in June 2014. "I thank God that I came here. We could be killed if we stayed in the bush. Now I'm getting food for the children."

The Toll Of War

Before the war, South Sudan was one of the poorest countries in the world. Now it's even poorer. The fighting pushed the country deeper into crisis, destroying crops, homes and the nation's minimal infrastructure. Entire villages were burned to the ground. Hospitals were torched and patients massacred in their beds. Foreign medical teams and aid workers were forced to evacuate.

Originally the Bentiu camp was an ordinary U.N. base. As the war raged, people fled to the compound to escape the fighting. The peacekeepers kept extending the fortified perimeter farther out across the scrubland. The new residents kept building more huts from plastic sheeting, reeds and salvaged lumber.

Even before the civil war erupted, Doctors Without Borders had been working in Bentiu. The group moved into the camp soon after the town was looted and burned to the ground in 2014. Human rights groups accuse forces loyal to President Salva Kiir of carrying out a scorched-earth policy in areas dominated by rival ethnic groups. Bentiu is one such area. The 170-bed hospital erected by Doctors Without Borders is known universally in the camp as MSF, the abbreviation for the French name of the group, Medecins Sans Frontieres.

Today, the MSF facility is the only functioning hospital in this part of the country. Each ward is in a large white tent. In most wards, 20 beds line a center aisle. Particularly in the pediatric wards, entire families — mother, father, kids — sleep in the same hospital bed. The hospital is run by roughly three dozen foreign workers and 500 local staff. The South Sudanese workers are camp residents. The foreign aid workers come for various amounts of time: nurses and midwives for six months; doctors, for three or four months.

Making Rounds With Dr. Nav

One of the two doctors is Navpreet Sahsi, a 34-year-old emergency room physician from Toronto.

He's a big personality on the wards, where he's known as Dr. Nav. Kids rush up to greet him. The South Sudanese nurses gravitate toward him on his rounds. He jokes with a woman who just had twins that they're going to share the newborns. "One for you, one for me! Right?" He pantomimes snatching one of the babies like a football. Everyone laughs.

Dr. Nav is in the middle of his morning rounds, going to one of the isolation wards to check on a 35-year-old woman with a mysterious rash.

"When she came, we all were kind of scratching our heads," he says, pulling on a pair of latex gloves. "I've never seen a rash like this in my life."

The patient is covered head to toe in blisters. Some of the sores are open. Others have scabbed over. Blood and pus stain the sheet of her mattress.

"Her story is that she's from Leer and she escaped in May or June [2015]," he says. Leer is a small town about 70 miles south of Bentiu near the banks of the White Nile.

After Leer was ransacked by soldiers, the woman and a group of women and children hid in a swamp. They'd spend most days submerged like hippos, just their heads above water. At night they'd come out to search for food and a dry place to sleep. The next day they'd slip back into the swamp so the soldiers wouldn't be able to find them.

Dr. Nav is keeping her in an isolation ward — not because she's contagious but to give her some privacy and because he's worried her appearance might scare the other patients. He has given her a topical cream to soothe her skin. Despite not having a clear sense of what's causing the rash, he thinks it might respond to steroids.

He's also worried that an infection will take hold in her open wounds. "We don't live in a very clean environment. Flies are going in and out of her wounds, and we can't really do much to stop that except for encouraging her to use the mosquito net," he says. "But her risk of a secondary infection is quite high, which is why I just gave her antibiotics."

She's part of a steady stream of patients. Sometimes the sheer volume of patients can be overwhelming. Dr. Nav recalls doing rounds one time with a South Sudanese assistant. After checking the vital signs of an elderly woman in one of the beds, Nav declared that she was looking remarkably better than the day before. His assistant looked puzzled. "That woman yesterday died," Nav remembers the assistant saying. "This is a new one."

South Sudan is one of the most remote countries in Africa. It's slotted like a puzzle piece in the heart of the continent. All told, the civil war has forced more than 2 million South Sudanese from their homes. Hundreds of thousands have fled to neighboring countries: Ethiopia, Kenya, Uganda, the Democratic Republic of Congo, the Central African Republic, and even their former adversary, the Republic of Sudan.

But most of the displaced, like the woman with the full-body rash, remain inside the country.

Dr. Jiske Steensma: High Highs And Deep Lows

The other doctor at the hospital is Jiske Steensma, a pediatrician from the Netherlands. She is making rounds on a ward filled with malnourished children. One of them is a 3-year-old who weighs just 15 pounds and has malaria.

The child swings in and out of consciousness. Steensma at one point jams a needle all the way into the bone marrow of the girl's leg to start an IV. The little girl barely flinches.

Steensma says at first it was very hard to adjust from working in a hospital in Amsterdam to working here.

"Just getting used to the mortality, the children dying, every two to three nights being on call," Steensma says. "At first I had nightmares, just not feeling comfortable. But that lasted only the first week, I think."

Steensma sings in an a cappella group back in Holland. On the same ward as the malaria patient, Steensma sings in French with a girl who appears to be 8 or 9 years old. The child howls with laughter every time the doctor joins in.

A week after being admitted, the girl with severe malaria dies, despite repeated efforts by Steensma and the rest of the staff to revive her. The Dutch doctor at first curtly demands to know what happened and asks if the staff had done everything possible to save the child.

Her anger eventually subsides. Later she says it's really hard when a child dies, but she's coming to grips with the fact that she can't save everyone. And it's part of the reality here. "Now I can't imagine going back to work in Amsterdam to an academic hospital," says Steensma, who has been in South Sudan for two months. "I feel happy being here. It's hard work. It has really high highs and deep lows, but I'm happy to be here."

Malaria is one of the most widespread illnesses. Pneumonia and tuberculosis are also common. There are entire wards of malnourished children. There's a maternity ward and a tent for women and girls who have been raped.

When the war outside the camp's walls flares up, the hospital treats gunshot and stab wounds — a reminder that even though the camp itself is bleak, it's a safe haven compared with the chaos outside.

'We Sudanese Are Tired Now'

The hospital operates 24/7. As the sun goes down, mosquito nets are unfurled over beds. The lights in the wards are dimmed, but the tents still glow in the darkness.

Rebecca Nyarik, 29, has brought her 11-month-old son to the hospital. He's had a fever for several days that doesn't seem to be waning. Nyarik came to the camp two months ago to get away from a round of fighting that flared up in Leer, where she lived.

The irony is that the South Sudanese civil war — the fighting that she fled — on paper is officially over. Both sides signed a peace deal in August 2015. But sitting with her son asleep in her arms, Nyarik says there is no peace in South Sudan. Gunmen continue to terrorize many parts of the country. The night before Nyarik brought her son to the MSF hospital, government soldiers attacked a camp on a U.N. base in the neighboring Upper Nile state. That attack left 29 people dead, injured 140 and forced tens of thousands to flee their shelters. Among the dead were two South Sudanese employees of Doctors Without Borders.

"If this is peace, why do people still continue the war? I myself think there is no peace," Nyarik says, her anger barely contained. "If you have peace, then no fighting. I ask you why do Sudanese continue to die? Why?"

Nyarik says if she leaves the camp, she and her son could be killed by anybody – government soldiers, rebel soldiers, unaligned militias.

"I myself I can't go out [of the camp] until the peace is peace."

It's late, close to midnight. Most of the patients on the wards are asleep. At this time of night, calm settles over the hospital.

Nyarik shifts on the wooden bench and hoists her dozing infant farther up her chest.

"We Sudanese, we are tired now," she says.

Yet there is not much hope for peace in the near future. A March report from the U.N. Human Rights Office accused both sides in the conflict of gross violations of human rights, including the systematic rape of civilians. The report alleged that government soldiers and militias aligned with the president were the worst perpetrators.

"This is one of the most horrendous human rights situations in the world, with massive use of rape as an instrument of terror and weapon of war," U.N. High Commissioner for Human Rights Zeid Ra'ad Al Hussein said in a statement when the report was released in March. "Yet it has been more or less off the international radar."

The report found that some soldiers weren't actually paid but instead were given permission to take whatever they wanted, including sex from the villagers they conquered.

The U.N. said some of the gravest violations of human rights in South Sudan's civil war could constitute war crimes or crimes against humanity.

Rape As A Weapon

In conflicts like this, the MSF staff tries to take a stance that's fiercely neutral. To provide medical care in the midst of a war, they need access, they need to appear impartial, and they need to not antagonize gunmen who may decide to ransack their hospital.

So the MSF personnel won't talk about who is raping whom.

They simply care for the women and girls who have been assaulted.

Anissa Dickerson, an American midwife, has been working for the past six months on the maternity ward and on the ward next to it, the sexual violence ward.

It's Dickerson's second-to-last day before she heads home to Massachusetts.

She is part of a team that built up the sexual violence ward. They offer rape kits with drugs that could protect women from sexually transmitted diseases or unwanted pregnancy. "But we see mostly women who were raped two, three, sometimes six months ago," she says. "We see women who have walked three days to get here trying to get away from violence or leaving their village because there's no food available anymore." They provide counseling and referrals to other support groups in the camp.

On the maternity ward, Dickerson seems to delight in working with the premature babies. Her brown eyes light up and she flashes an impish smile when a former patient shows up at the neonatal intensive care unit. All the woman wants is to get her baby weighed, and she doesn't need to be in the neonatal intensive care unit for that. Dickerson humors her, laughs with her and reassures the young mother that her child is healthy. "We'll get your baby weighed and then maybe send you to pediatrics, OK?" she says.

When Dickerson talks about the sexual violence unit, however, her lightness evaporates.

"We've seen girls as young as 12 and women as old as their late 50s. So it happens — it happens to everyone," she says. "You know pregnant women and breast-feeding women used to be kind of a protected group. It wouldn't happen to them. But it happens to them as well. It's common to hear of women being raped by multiple men. Even pregnant women, you know, in front of children. They're very common stories that we hear over and over."

This is Dickerson's first mission with MSF. She quit her job as a midwife in western Massachusetts to come here because, as she puts it, "I believe that all women should have a safe place to deliver. That's really important to me. And unfortunately, in this country, most women don't. And that's why I want to work here."

But it's been a hard six months. "Hearing these [rape] cases every day — emotionally it's been difficult," she says.

"To some extent I've had to turn some emotion off to make it through this. You know it's hard to hear these stories and feel each one, and I don't think I would make it through six months of this, feeling the emotions of each of these stories. It makes me angry about what's happening. I think that eventually I'll deal with it but I haven't quite yet. It's frustrating. I'm here to do the medical side and we're doing that, but it's frustrating that I — that we — can't provide more than medical and psychological care to these survivors."

She says she's lost a lot of weight over the past six months. "I definitely have plans to eat a lot when I get home — lots of eating. Lots of sleeping."

Down the road, she hopes to sign up for another assignment with MSF, but possibly something different: "Yeah, something maybe outside of a camp would be nice."

To The Kids, He's A Rock Star Doc

Dr. Nav is at the bedside of an extremely thin, elderly woman with a nasty cough.

"How long has she been coughing like this?" Dr. Nav asks his assistant. The woman continues to cough as Dr. Nav examines her.

"Can you ask: Does anyone in her family have TB? Anyone in her house?"

This tent, like all the other wards here, is packed. People are sleeping under some of the beds.

The coughing woman finally says yes, her husband had tuberculosis.

"How long ago was that?" Dr. Nav asks.

The husband died of TB two years ago. Dr. Nav orders the woman to be moved to the "suspect" tuberculosis ward immediately. The hospital has another ward for confirmed TB cases.

TB can be difficult and time-consuming to diagnose. Sputum samples are sent by plane to Kenya. Diagnosis can be delayed not just by backlogs at the lab but by the flight schedule. Once a patient is diagnosed, treatment takes at least six months, sometimes years.

Many TB patients are also suffering from HIV, although Dr. Nav is careful never to say HIV or AIDS on the wards. He calls it "that immune-suppressive disease that we aren't going to mention."

There's a huge social stigma around HIV here; people who have it can become outcasts. The second problem Dr. Nav and his colleagues face is that this field hospital is not intended to be a long-term-care program. So they face a moral quandary. They could start people on powerful anti-AIDS drugs, but there's no mechanism to ensure that the patients can continue to get the drugs once MSF leaves. Someone with HIV who starts on these drugs is supposed to remain on them for life, long after MSF plans to pull out of here.

This is Dr. Nav's second mission with MSF. His first was two years ago in Yemen. The hospital was surrounded by heavy fighting and treated a lot of war casualties. It was so close to the conflict that Dr. Nav and the other foreign staff were eventually evacuated.

"Yemen was very different. It was also a mission with chronic stress but very different chronic stress," he says. "There was gun shooting and tank shooting and missile shooting all day every day, and there were some very close incidents. I came to peace with the idea that, you know, I might not make it out of that mission."

The stress in this hospital in South Sudan, he says, comes from the incredible volume of disease and health problems.

"I've been here long enough that I can often sort of see someone's mortality a couple of steps away," he says. "They might be still talking but I know that they are sick enough that in this context they'll probably continue to get sicker. And there's nothing I can do to stop that. At home that's really rare. That almost never happens."

In the pediatric ward at this field hospital, a 5-year-old girl drifts in and out of a malarial fever. Eventually, she succumbs. On the TB ward, an elderly man withers to the point that he appears to be just a skeleton draped in loose skin. He, too, slips away.

"We deal with a lot of death — a lot of death — much more than we're used to seeing at home by far," says Dr. Nav. "If a child dies at home in the emergency room, it's quite a significant tragedy. You share it with all of your co-workers and with the family, and it's something you really remember and have a lot of support for. Here a child dies almost every day."

Dr. Nav says part of why it's so difficult is that he knows what it's like to work in emergency rooms in Canada. He knows that with the right equipment and the right drugs, he could save a lot of these kids. But here that's not always the case.

"And it's really difficult when that happens time and time again over months — you know sometimes you question what real benefit you're providing to the community. And so yeah, the emotional toll is very high."

Exercise is one thing he tries to do to cope with the stress. He has set up a set of elastic straps in the sandbagged bunker to use as a makeshift workout machine. He sometimes does sit-ups and pushups for exercise, but it's nothing like being able to go for a long bike ride back in Canada.

For security reasons, the medical staff can't just go for a walk outside the compound. "You can definitely feel confined here," Dr. Nav says.

Late at night he binge-watches TV shows and movies he pre-loaded on his laptop. Breaking Bad is one of his favorites.

Dr. Nav at times gets frustrated. But even though some patients don't survive, many do. Kids recover. Parents recover. When an outbreak hits, patients turn to MSF. Outside the hospital, life for the 124,000 people in the camp can be bleak. People are crowded into a barren expanse of dirt and gravel. Women face a constant struggle to collect water and gather food to supplement the U.N. rations. Some residents say they worry about crime and won't let their children out after dark.

So the hospital tries to provide more than just medical relief. In one tent, staffers have set up a loudspeaker playing music in a waiting area. At times it looks like a disco with kids dancing under a green awning.

Among the kids, Dr. Nav is a rock star. They shake his hand. They yell the Nuer greeting, "MAL-LAY!" at him.

"Every time I walk up and down the aisle I'm greeted by 20 kids who want to shake my hand every single day," he says. "I mean there's lots of smiling, happy moments here. And we get to see a lot of people get better. We get to see them come back here happy and healthy and thankful. And so yeah there's a lot of joy in this place, too, for sure."

And sometimes, that's enough to keep him going.

Copyright 2017 NPR. To see more, visit http://www.npr.org/.

KELLY MCEVERS, HOST:

I'm Kelly McEvers, and this is EMBEDDED, an NPR podcast where we take a story from the news and go deep.

(SOUNDBITE OF MUSIC)

MCEVERS: Navpreet Sahsi is an ER doctor from Toronto. People call him Dr. Nav. A couple years ago, he went on his first mission for Medicins Sans Frontieres - MSF - also known as Doctors Without Borders. These are these incredible people who are, like, the first ones to get there when there's a war, earthquake or outbreak of Ebola or famine. Dr. Nav was posted at a hospital in Yemen, right on the front line of Yemen's civil war. One day, he was working in the emergency room.

NAVPREET SAHSI: I was rounding. I was doing my rounds - daily rounds - in the hospital and seeing patients. And while that was happening, there was sort of heavy fighting going on outside.

MCEVERS: And then this happened.

SAHSI: There was a really loud - really loud sort of boom. And I actually - my - sort of my initial thought was, whoa, something had just kind of hit, like, just outside us. What I didn't realize was that there actually was - all this glass had cracked just in the window that was not too far from me - I mean, 10, 15 feet to my right.

MCEVERS: A mortar had hit the hospital and broke that glass window.

SAHSI: When I looked behind me, there was smoke everywhere. And then, like, in those situations, everything kind of goes really slowly.

(SOUNDBITE OF MUSIC)

MCEVERS: Nav eventually gets himself together, runs to a safe room at the back of the hospital. He says MSF was not the target of this mortar. It was an accident. This is what's been happening to a lot of MSF hospitals, all around the world.

(SOUNDBITE OF NEWS MONTAGE)

UNIDENTIFIED WOMAN #1: Another Medicins Sans Frontieres hospital has been leveled by airstrikes.

ROBERT SIEGEL, BYLINE: Doctors Without Borders said that their hospital was partially destroyed by barrel bombs.

UNIDENTIFIED WOMAN #2: These deadly attacks appear to have been deliberate.

UNIDENTIFIED WOMAN #3: ...Says 27 people were killed in an airstrike.

UNIDENTIFIED WOMAN #4: That one killed at least 23 people.

MCEVERS: And when these attacks happen, sometimes, of course, the hospital has to close. And then all the people in these places - Afghanistan, Central African Republic, South Sudan, Syria - will now have no access to health care. They basically lose their lifeline. That's what happened at Nav's hospital in Yemen.

SAHSI: We got to a point where we thought that the risks and the benefits were not balancing out anymore, and we were taking too high of a risk.

MCEVERS: So they decided to leave. There were Yemeni doctors who stayed, but now all the people in this part of Yemen have been left without any help from MSF's highly trained international staff. Nav went home for a while, and then he signed up for another mission with MSF in South Sudan.

(SOUNDBITE OF MUSIC)

MCEVERS: What we wanted to do is get inside one of these hospitals and stay a while. We wanted to know what it's like to work there day after day. I mean, working in a hospital's hard enough, let alone in a place where you don't speak the language and a mortar might hit you. Who are these people who get bombed while they're doing their work, but keep coming back?

So we sign up for a week in an MSF hospital in South Sudan. That country's just come out of its own brutal civil war. We spend a lot of time with the people who work there, and we also spend a lot of time with one patient - one tiny, little patient whose case tells us a lot about why these people do the work they do.

(SOUNDBITE OF MUSIC)

MCEVERS: So the idea to do this story came from one of my favorite reporters at NPR, Jason Beaubien. He covers global health, and he is the one who arranged our trip to South Sudan with MSF. Here's Jason.

JASON BEAUBIEN, BYLINE: The place we decide to go is called Bentiu. It's a place that saw a lot of fighting during South Sudan's civil war, and now it has the largest refugee camp in the country. A hundred and twenty thousand people are crammed into this camp. It's basically a small city, and inside that camp is a 170-bed hospital that's basically a bunch of tents.

(BABY CRYING)

MCEVERS: So we go straight to the busiest tent in the hospital. It's the ward for malnourished children. There's 20 or so beds. Families are there with their kids. Some of the moms are actually sleeping under the kids' beds. The walls and ceilings are white plastic tarps that let in a lot of light. There are only two doctors in this entire hospital. Dr. Nav, who you heard at the beginning, and Dr. Jiske. Her full name is Jiske Steensma. She's a pediatrician from Holland. She's here on a six-month mission, as they say in MSF.

Hi, there.

JISKE STEENSMA: Hey.

MCEVERS: How are you?

STEENSMA: (Unintelligible).

MCEVERS: Good. Do you mind if I stand near you a little bit while you're doing rounds?

STEENSMA: Yeah, sure.

MCEVERS: That's OK? OK.

Back at home, Dr. Jiske - that's how they do it at MSF - they use their first names - works at a major research hospital in Amsterdam. When she's done in South Sudan, she's going on a fellowship in Cambridge. She says she's the kind of person who likes extremes. Her idea of a vacation is camping on glaciers.

(BABY CRYING)

MCEVERS: She's working in this ward for malnourished kids. She is clearly very good at this.

STEENSMA: She's slowly starting to improve. Yeah, this is really funny. Yeah. (Laughter).

(LAUGHTER)

MCEVERS: This is how Jiske communicates with these patients. She doesn't speak the local language, Nuer, but still, she tries to talk to the mothers and the siblings, so the patients will get to know her and maybe trust her.

UNIDENTIFIED WOMAN #5: (Singing in foreign language).

UNIDENTIFIED CHILD: (Laughter). (Foreign language spoken).

BEAUBIEN: Right in the middle of the ward where Dr. Jiske works is this baby. She's in a bed. She's naked except for a necklace of red and white beads, and then she has this feeding tube that's taped to her cheek. The hospital staff keeps wiping her down with wet cotton balls to try to pull down her fever. One of the hospital workers, Michael (ph), says she's unconscious. MSF has asked us for security reasons to only use the first names of their South Sudanese staff.

MICHAEL: This confusion has just happened today.

MCEVERS: Unconsciousness happened today.

BEAUBIEN: The baby's named Ngoni (ph). She's malnourished, and she has malaria and a respiratory problem. She wheezes whenever she breathes. Earlier that morning, there was a moment when she was getting cold and didn't have a clear pulse. They put her on an IV and stabilized her. Now she's not waking up.

MCEVERS: Is this the mother? Is this her mother?

UNIDENTIFIED MAN #1: Yeah, this is the mother.

MCEVERS: Could we talk to her? It's OK?

UNIDENTIFIED MAN #1: OK. Yeah. Yeah, it's OK.

MCEVERS: Yeah?

UNIDENTIFIED MAN #1: Yeah.

MCEVERS: So when did they come to the - to the camp?

UNIDENTIFIED MAN #1: (Foreign language spoken).

UNIDENTIFIED WOMAN #6: (Foreign language spoken).

UNIDENTIFIED MAN #1: They came May last year. Yeah. May last year - they came.

UNIDENTIFIED WOMAN #6: (Foreign language spoken).

BEAUBIEN: The baby and her mother and the rest of their family ran away from their home when the fighting started. In South Sudan, a lot of houses are made of mud and reed walls, and they have these thatched roofs. And a lot of them got torched in the war. People completely fled their villages. Many women were raped.

Tens of thousands of people were killed. So a lot of people in the refugee camp that surrounds this hospital are too afraid to go back home. This sick baby is the youngest in the family. She's one of three kids. The rest of her family comes and goes to her bedside throughout the day.

MCEVERS: Is this the first time the child has been in the hospital?

UNIDENTIFIED MAN #1: This is the first time the child's been in the hospital.

MCEVERS: What about her other children? Have they ever been sick?

UNIDENTIFIED MAN #1: (Foreign language spoken).

MCEVERS: She doesn't want to talk.

UNIDENTIFIED MAN #1: (Foreign language spoken).

MCEVERS: If she doesn't want to talk, it's OK.

UNIDENTIFIED MAN #1: Oh, no. When the child is severe like that, you know, the mother is purely disinterested so that maybe the child will not be survive whatever. That's why she is not willing to talk.

BEAUBIEN: He's basically saying the baby's mother is too overwhelmed to talk anymore right now, but she stays close to the bed. She's wearing a long, red dress that at one time was probably nice, but now it's been dulled by the dust of the refugee camp.

MCEVERS: Tell her we're sorry. We know it's difficult.

UNIDENTIFIED MAN #1: (Foreign language spoken).

BEAUBIEN: We move away from the mom and the other kids and stand at the foot of the sick child's bed.

MCEVERS: Is the temperature going - changing?

UNIDENTIFIED MAN #2: I keep temperature looking, so I hold up.

MCEVERS: He's taking the temperature now.

UNIDENTIFIED MAN #3: It's going up.

MCEVERS: It went back up. Yeah.

So Dr. Jiske is still doing her rounds in the ward for malnourished kids. Some of these kids are so small, they're getting weighed in what looks like a big plastic salad bowl with a scale attached. Eventually, Jiske comes back to the baby - Ngoni (ph). She was unconscious before, but now we realize she's awake.

We were watching this other patient, and she's awake. And that's great. (Laughter).

Jiske and I go talk to John (ph). He's the South Sudanese nurse who runs the intensive feeding ward for malnourished kids.

That's good. She looks tired, but she's awake, yeah?

JOHN: Yeah.

MCEVERS: That's good, no? Is the fever down?

JOHN: Fever before is down, and now it is up again.

MCEVERS: Again? Down, then up?

JOHN: Down, then up. And we continue to control fever again...

MCEVERS: Yeah.

JOHN: ...'Cause our main problem now is fever.

MCEVERS: She's awake - a little bit awake.

It's so clear how you can get really wrapped up into the drama of it really fast. The staff at this hospital has seen so much. They're used to these ups and downs. I am clearly new at this.

It's good. She's awake. Hello, she's awake. Yeah. This is good, right? It's very good. Yeah.

BEAUBIEN: It is kind of amazing, though, I mean, seeing these other kids that are watching. These are family members, and really, quite frankly, it's, you know, a question of whether they're going to have a cousin or a sibling later in life is in the balance right here, right now. You know, it's kind of amazing when you think about it. This kid would not be surviving if this hospital wasn't here right now.

MCEVERS: It's a roller coaster, even for Dr. Jiske. At one point later on, I see her just sit down, looking overwhelmed, and then just walk out of the tent for a minute. She does this sometimes, just takes a break, goes to her tent or goes and talks to one of the other MSF staffers. I mean, these people are doctors and nurses. They're pros, but still, this work has got to get to you. It's already gotten to us.

(SOUNDBITE OF MUSIC)

BEAUBIEN: Even when they're not doing rounds, the doctors here hardly ever stop working. They're on call every other night. They have a walkie-talkie blaring next to their heads, so it's hard to sleep. You may have to get up at any moment and run to the hospital. And it's always hot here - over 110 degrees most days. You're sweating constantly, and it feels impossible to drink enough water.

Also, you're not allowed out. The international staff spend most of their time inside the hospital compound. Remember; the refugee camp that surrounds this hospital - it's like a city. There's petty crime, and MSF doesn't want their people to just go out for a walk. You have to have some reason to go out of the hospital.

Everybody lives in tents, usually with a roommate. They share showers, pit toilets. And then there's the food - endless pots of lentils. One of the Canadians has started putting maple syrup on her lentils and insisting it makes them fabulous. So remember Dr. Nav, the doctor you heard about at the beginning of this story?

SAHSI: How's it going this morning with all that other stuff?

BEAUBIEN: Right now he's on one of the isolation wards at the hospital. Today he's doing the rounds of the adults. He's checking on a woman with this horrific rash that's covering her entire body.

SAHSI: How's the rash (unintelligible)?

UNIDENTIFIED MAN #2: (Foreign language spoken).

UNIDENTIFIED WOMAN #2: (Foreign language spoken).

BEAUBIEN: This woman just got to the refugee camp. Before that, she says, she was hiding out for ten months in a swamp. That's because soldiers came and destroyed her village. She says she would spend the daylight hours in the water with just her head above the surface, like a hippo, to avoid the gunmen who were murdering and attacking people in the surrounding countryside.

At night, she and some of the other women would climb out to dry land to sleep and to try to get something to eat. Now Dr. Nav says he's very worried that her wounds could get infected.

SAHSI: We don't live in a very clean environment. Flies are going in and out of her wounds. We can't really stop that, except for I encourage you to be in a mosquito net most of the time. But her risk of, like, getting a secondary infection is quite high, which is why we just gave her antibiotics.

BEAUBIEN: Antibiotics and a skin cream.

SAHSI: She should put it over any place that's, like, scabbed or painful or open. Just cover, cover, cover, cover. That'll protect it.

BEAUBIEN: Dr. Nav happens to have a lot of this skin cream, but there are shortages of a lot of other supplies. The roads to the hospital are either washed out or unsafe most of the year, so everything - even lab tests - has to get flown in and out by plane.

SAHSI: So, like, yeah - so we don't always have all the medicines that we - that we would like for all of the patients that we see. Although I would say that we have, like, a lot here. I'm very impressed with what we do have, but we never have everything, right? And then investigating-wise, we're limited in what we can investigate for, right? We only have a few lab tests.

BEAUBIEN: Nav is very clinical about all of his cases. A lot of these people have had it way worse than anything he's ever been through, even Yemen. Nav has been here in South Sudan for a while. He's about halfway through his mission. One way he deals with it is to try to laugh - ribbing the Scottish guy about his new haircut, joking about the broken air conditioner - but still, sometimes it's just really tough.

SAHSI: I mean, then there's, like, a cumulative, like, emotional wear, for sure. I mean, we - (unintelligible) - we deal with, I mean, a lot of death - right? - a lot of death - much more than we're used to seeing at home, by far. Here, a child dies almost every - it feels like almost every day. That one individual case might not be - you know, you might be able to deal with it and feel OK with it, but dealing with it every day, the - I mean, the constant drain of that definitely builds up.

MCEVERS: Later, Dr. Nav tells us about that mission in Yemen back in 2014. Turns out, when MSF decided to pull out all its international staff, they needed one person to stay to the end. And Nav volunteered to be that person. We asked him - why?

SAHSI: Personally, I was asking myself that, too. I said, wow, this is pretty - this is a pretty high-risk situation that's escalating. So do I want to leave? Should I leave? Should I go? I mean, I think, yeah, like, why aren't - and I didn't at that point. And I asked, well, why don't I want to go?

I think - like, I think in my own mind maybe I downplayed the risk a little bit, too, and maybe up-played the responsibility aspect of it because I - 'cause I felt like that was important. Like, it's a really hard job, but I think - I know I can do it. And so - and because I know I can do it and because I know the need is there, it's hard not to be involved in something like that when you know what's out there.

(SOUNDBITE OF MUSIC)

BEAUBIEN: So it's pretty clear why Nav wants to do this work. If he wasn't here, more people would die. But how do other people - the other doctors and medical staff - deal with all the misery without losing their minds? That's what we want to ask Jiske. And also, what about that tiny patient, Ngoni - the baby from the first day with malnutrition and malaria and that respiratory disease - the baby who woke up after being unconscious? We want to know what will happen to her.

(SOUNDBITE OF MUSIC)

MCEVERS: So I am back with Dr. Jiske in the ward for malnourished kids. Local staff have just called her to check on the baby, Ngoni. She was awake, but now things are bad again. The breathing's getting slower and slower.

She has a very low blood sugar. Very low - 18 - so her blood sugar's dropped way low. Dr. Jiske said, oh, [expletive]. She's moving fast.

Jiske tells a nurse to hold the baby's leg while she opens a package that contains a really thick needle.

STEENSMA: This goes into the bone.

MCEVERS: She has to push the needle into the baby's bone - it's a bone marrow IV. Because the baby's so limp and dehydrated, they couldn't get a vein in her wrist. They even tried to get one in her head. That's what they have to do with these kids. After this needle goes into the bone, Jiske does not look happy. The baby should have reacted, but she didn't. The baby does start getting the fluid she needs, and her breathing does even out.

So she's breathing, but slowly.

STEENSMA: Yeah, yeah. She's being quiet.

MCEVERS: Yeah. Her eyes open again?

STEENSMA: No.

MCEVERS: No.

STEENSMA: Not now - blood sugar too low. It's a sign of shock.

MCEVERS: She's a little bit better, but really, she's not. And it all just seems so unfair. This baby didn't do anything in South Sudan's civil war. She was born, and then she didn't get enough to eat, and now this.

It's going to be hard to not sit here all day. This baby was definitely going to die when she was putting in the IV - basically, when she was shoving a needle into this girl's leg bone - and the girl didn't react. I just can't seem to leave.

So I sit there for about a half an hour, and then this happens.

(ALARM BEEPING)

MCEVERS: She's opening her eyes.

UNIDENTIFIED WOMAN #3: Blinking.

MCEVERS: Oh.

The nurse is the baby is awake and asking for water, like, with words.

UNIDENTIFIED WOMAN #3: How old is she?

MCEVERS: Because it turns out she's not a baby.

UNIDENTIFIED WOMAN #4: She's three years.

MCEVERS: She's three years old. She's just so small - she only weighs 15 pounds - that this whole time I and a certified medical professional both thought she was a baby, which means her situation is probably even worse than I thought. But right now, she is drinking water, and she is crying, and that is good.

(BABY CRYING)

UNIDENTIFIED WOMAN #5: Look at that.

MCEVERS: All right. Complaining - this is good.

STEENSMA: Jiske's clearly affected by sick patients like this. You can see it in her face, smiling like crazy when things go right, all twisted up and worried when they don't. Jiske tells Kelly it was really hard when she first got to this hospital.

STEENSMA: I think that the beginning was the most intense. The - just getting used to the mortality, to the children dying, to every two or three nights, on call, big hospital - yeah, the whole environment. I remember at first I did have nightmares - the first week - just not really feeling comfortable here. But that lasted, you know, first week, I think. Actually thought last week, I don't want to leave here. I can't imagine going back to Amsterdam and being at work again in, you know, an academic hospital.

MCEVERS: Now you've crossed the line where you can't imagine.

STEENSMA: Yeah. Yeah. I feel happy being here. I mean, it's hard work. You've seen it. And it's really, really frustrating. It has really high highs and deep lows, but especially when the moms are appreciative of it, that's just really, really nice. You see the children - you know, they get their cheeks and smiles back, and their moms are happy. That's just wonderful. And so many of them get really, really better.

MCEVERS: Right.

STEENSMA: They don't die. Yeah, every other day or maybe every day, somebody does die, but we can - we can save so many. But, yeah, here sometimes you do think, OK, there's just not enough for these children. And sometimes if you die and you write down the cause of death, then sometimes I do think - born in South Sudan. So we're lucky, yeah.

MCEVERS: Is that why you do this work? - I ask. To remind yourself you're lucky?

STEENSMA: Yeah, maybe. Yeah, maybe. I do feel very lucky. Yeah.

MCEVERS: The next day is a Sunday. Jiske hasn't had a day off in a long time. She goes for a run, goes to the back of the compound and sings. She's in an a capella group back home. She Skypes with her friends. Her being off means Dr. Nav is the one who's on duty. I meet up with him in the intensive feeding ward, and he's asking the staff about Nenyoni (ph).

SAHSI: So what happened last night? Do you know?

UNIDENTIFIED MAN #4: Last night?

SAHSI: Yeah, with her. Any problems or anything you know about? Do we hand over?

UNIDENTIFIED MAN #4: Yeah (foreign language spoken).

SAHSI: If you feel her feet, they're, like, ice cold. Again, she's just, like, really shut down peripherally.

MCEVERS: Nav says it is not looking good.

SAHSI: She's still - I mean, the one good thing she's got some strength in her. She'll still kind of respond a little bit if you - you know, she'll kind of look at you if you kind of get her attention. Earlier, she was sitting up a little bit with mom but still very, very drowsy, you know.

MCEVERS: Yeah, she looks worse.

SAHSI: Yeah, she - even throughout the day she's gotten a little worse than she was this morning, so it's...

MCEVERS: Yeah.

SAHSI: Yeah, so it's unfortunate, yeah. But we still - you know, I never - we don't give up hope until...

MCEVERS: Sure.

SAHSI: ...There's no hope left.

MCEVERS: Yeah.

SAHSI: Yeah, so that's her.

MCEVERS: OK.

SAHSI: She's the sickest person in the ward - probably in the hospital right now. And let's just look at her medicines here 'cause we finished erythromycin clogs (ph). She finished her malaria medicines today. I'm going to give her some fluids more today. Can we do another ReSoMal today, another one?

MCEVERS: While all this is happening, Nenyoni's mother is sitting on the bed next to her. She's not talking to anyone. Her face is angry then blank then just really sad. The doctors say when a child starts to deteriorate in the hospital, the parents can't help but blame it on the hospital. Nav tells the staff to keep a close eye on the girl, and then he has to go deal with all the other patients in the hospital. He's the only doctor on duty.

A few hours later, someone comes to tell me an emergency has been called in the girls ward.

Dr. Nav got called to resuscitate the girl. And now I'm standing at the hospital door.

Nav walks by and just nods his head.

She died. She died.

(SOUNDBITE OF MUSIC)

MCEVERS: So I'm standing here at the entrance to the hospital because we don't want to, you know, bum-rush them during this moment. But it happened. She died. It's Sunday afternoon. I mean, it's not been looking good for a couple days, right, but it finally happened.

A little bit later, I talk to Dr. Nav. He says the girl died of severe malnutrition and severe malaria. When Dr. Jiske finds out the girl died, at first she's upset. She doesn't say it on tape, but she wants to know if there's anything else they could've done. Then later she tells me she's accepted it. She has to believe they did what they could. By the time I go back into the ward, there's another patient in Nenyoni's bed.

(SOUNDBITE OF MUSIC)

MCEVERS: I keep thinking about another thing Jiske told me - that the highs here are so high and the lows are so low, like, the smallest thing can be amazing after the worst thing happens. Life doesn't feel that way in Amsterdam. Every week, there's this thing the staff does for the kids at the hospital.

FRANK: (Singing) Clap your hands.

MCEVERS: A Dutch guy named Frank plays his guitar.

FRANK: (Singing) Clap your hands. If you're happy and you know it, then your face will surely show it. If you're happy and you know it clap your hands.

MCEVERS: But pretty soon, the women and the kids hijack Frank's sing-along and start singing South Sudanese songs. More people crowd around.

UNIDENTIFIED CROWD: (Singing in foreign language).

MCEVERS: And in that moment, it is so good. All the moms are into it. I'm laughing like an idiot the whole time.

And another one.

All the international staff is there. Nav's blowing up balloons. Everyone's dancing. There are a lot of people in this hospital who are still alive.

UNIDENTIFIED CROWD: (Singing in foreign language).

BEAUBIEN: A few months after we reported this story, soldiers approached the camp that surrounds this hospital. They lobbed a rocket-propelled grenade into the compound, fired a few shots. South Sudan's Civil War is at a lull, but attacks like this still sometimes happen. The MSF staff had to hide in a bunker for 15 minutes or so, and then they finally got the all clear. During that incident, a stray bullet hit a child inside the camp, and that child was treated at the MSF hospital.

UNIDENTIFIED CROWD: (Singing in foreign language).

(SOUNDBITE OF MUSIC)

MCEVERS: This story was reported by me, Kelly McEvers, Jason Beaubien and David Gilkey. You didn't hear David because he was too busy taking stunning photographs of the hospital and all the people we met there. You can see them at npr.org/southsudan. Do it. The story was produced by Rebecca Hersher and Chris Benderev and edited by Vikki Valentine and Sean Cole with help from Megan Cain (ph), Abby Wendle (ph) and Brent Bachman (ph). Digital production is by Alexander McCall, research help from Will Chase, production help from Ricky Nevetski (ph), Jess Chung (ph), Saxon Baird (ph) and Jacob Cruz (ph). Operations help from Angie Hamilton-Low (ph) and special thanks to Scott Carrier (ph). Original music in this podcast is by Colin Wambsgans. The show is executive produced by me, Chris Turpin and Anya Grundmann. Our project manager is Kasia Podbielski.

You can hear more NPR on your local public radio station on another show I host called All Things Considered. And here's some good news - there's a new season of Invisibilia coming soon. Listen to a preview at npr.org/podcasts. EMBEDDED will be back next week, where we will hear from a reporter who spent three months in the Arctic. Here she is looking for someone who went missing in the middle of a suicide crisis.

(SOUNDBITE OF ARCHIVED RECORDING)

UNIDENTIFIED WOMAN #7: Hey.

UNIDENTIFIED MAN #5: Hey.

UNIDENTIFIED WOMAN #6: Nothing from Julius (ph)?

UNIDENTIFIED MAN #5: Nothing.

UNIDENTIFIED WOMAN #6: No. I think I'm going to walk up to his house.

UNIDENTIFIED MAN #5: Yeah, try that.

UNIDENTIFIED WOMAN #6: I'm actually quite worried. Do you know where Julius Nielsen lives? Which house? No?

(SOUNDBITE OF KNOCKING)

UNIDENTIFIED WOMAN #6: So where is he?

(SOUNDBITE OF MUSIC)

MCEVERS: And, hey, I want to thank every person who has left a review of EMBEDDED in iTunes. It really does matter. Now we want more. Whether you like us or not, we want more reviews, and please, tell your friends about EMBEDDED on social media, on the front lawn, wherever. I'm Kelly McEvers. Thanks. Transcript provided by NPR, Copyright NPR.