Measuring in Inches

 

So I finally feel like I am starting to do some work here. It is tediously slow at times, however, and I find very hard to talk about what I am doing. Back home we measure things in what would be a big way, things that we could see and know that something has changer. Here progress comes in inches, rather than miles.

Fridays have become my favorite day, and one that I also come face-to-face with the realities of the world I inherit back in NY and what I am living in right now. On Fridays I travel to Nzara to meet with care team members there. I started coming down after the TOT training was completed and the plan is for me to come to the hospital every Friday to support the different health care workers and to start a real mental health program here, in the hope that it will be a full clinic when the time is right.

Dr. Maad, the head doctor here in Nzara, is young, hungry to improve the hospital he overseas, and eager to see his colleagues and fellow health care workers succeed and improve their care. I credit my ability to actually starting to really do some mental health care to him and his welcoming of me to his facility. We met my first week in South Sudan and quickly he is an ally in my work.

So on Fridays I get driven down to Nzara. I have yet to develop a rhythm with my visits but I think that is part of the work here. Some days I meet with Dr. Maad and other days I round to different units and write emails and notes for follow-up care. But each time I come down I face mental health cases and possible mental health cases and I get to round and see patients.

I have started to visit each of the main wards the house patients for longer than a "doctor's visit". I go to the inpatient medical adult unit and then to the inpatient medical pediatric unit. I also visit the maternity unit. Sometimes there are patients or family members one each unit who can use my help, or advice, and other times there aren't any known cases on all the units but a suspected case or two on one. 

The work fluctuates and flows. And sometimes I feel like I have been thrust against rocks with water crashing over me. There are times that it is not the patients who seem to need the mental health care, but rather the staff that seems to be struggling. Fortunately, my work here is not exclusively to work with patients so I am trying to also improve the mental health of those working in the hospital. 

I have the opportunity to train the CMMB staff who are humanitarian workers, which I try to do on Mondays during our morning meeting, and to help train and facilitate mental health discussions with different health care workers. I am attempting to start conversations with different groups and different people about what self-care is and how we practice and use coping skills. The process is slow and not everyone understands, but again, I am grateful that the conversation is starting.

This week I also saw my first patient independently. Since I do not have an actual client space to see patients in Yambio we utilized an ultrasound room in the maternity clinic at the PHCC. You make do with what you have. I evaluated the patient. There was certainly a language barrier but their family helped translate. I am not sure what he is suffering from. What I would give for diagnostic tools and US services right then, but alas I will make do, as best I can.

Since I work as an RN under the same scope, I work with at home I cannot formally diagnose like others do here. However, I did an assessment and did my best to advise how the family and patient could move forward to get the patient help. There is no formal outpatient clinic in Yambio. I would like there to be one as that would be where I would refer to but at least we are starting the assessments.

Another day this week I met with the psychiatric department at Yambio's State Hospital. Seems like if there was a psychiatric department, they would have services but the reality became clear when I got to the meeting. They are lacking pretty much everything, including funds. They have 2 volunteers that I trained in TOT and who have psychiatric training already but both are volunteers.

The hospital would like an inpatient unit but I feel that they need to have more outpatient services first. We also discussed doing more community training on mental health. Here in South Sudan when someone seems to suffer from mental illness, they may take the person to a traditional healer or to the church for prayer. While I won't discount that there are cases where this might help, we all agreed that we also need to educate the community, particularly those who are community leaders, when seeking the medical mental health facilities and care is more appropriate. This seems like one way I might be able to help them out.

I feel like my work is all over the place. Some days it involves more meetings, other days I am at the hospital, and sometimes I am sitting in a maternity ward. There is a variety to my work and I like that. I am glad more people are talking about the mental health here and that I am able to start doing more. These tiny progress markers are hard to overlook during my week, especially when I feel helpless, but I have to reflect and see that any progress is good.

They call me Khawaja

"Khawaja" is called out in the darkness as I walk with my friend back to my compound one night. I smile. This child’s voice is calling out after seeing me walk down the street. White person. But the voice doesn't sound scare. They sound excited. I smile and we continue on our way.

The children here in WES give me hope. Children are so resilient. I know that they have faced many hardships, and will face more to come. But through it all the children bring a sense of hope, of a future that can be better.

One of my favorite parts of my walks, especially my morning walk to work, is seeing the children. I often walk into work around the time that the children are going to school. I greet many and have chatted with a few. Khawaja is yelled so often and from different directions that I do not always know where it is coming from. I try to wave and identify whoever has called out for me, often the kids in the school room or courtyard that have spotted me walk by. Even weeks later they call out to me. I try and greet those that I can and say hi to those who want to chat.

However, my very favorite part of my morning walk is being greeted by 4 children who play outside the shelter their mother cooks food to sell from. These 4 kids run up and greet me each time I walk down the road. They offer me tentative handshakes and little bits of English that they know. One of the girls also likes to curtsey when she sees me.

There is another little boy, even younger than these four who loves to say hi. One day he got up the courage to come and shake my hand but then as soon as he did, he ran away crying. His mother has brought him up to say hi to me since then. He still cries if he touches me. He doesn't understand why my skin is white. But every day he happily waves to me and shouts hi as I walk by, but from the safety of his mother's side.

There are many wells in Yambio and as I walking near one, where several girls are filling up their water jugs, I see another child sitting inside an old water jug and a boy pulling the child around in it. They giggle and are happy. Such simple pleasures and simple ways to entertain themselves.

In Nzara I watch the kids play with a soccer ball as I walk back from the clinic. They are excited to play and energetic as they chase the ball. Soccer has its own rules here, amongst the children, rules I don't know, but it is fun to watch the kids play. Many don't wear shoes but they still chase the ball and play hard.

There are other little kids who have crafted cars out of boxes. They take wires and small sticks, then poking holes through bottle caps they fashion cars and trucks out of this pile of what was once trash. Groups of them will play with these newly created vehicles for hours. Their happy laughs abundant.

Outside my compound there is a woman who sells nuts and fruits. Her name is Brenda. She has 2 children. I have spent many hours sitting with them, the kids chatter with me, the girl pretends to be shy but the minute I leave her side she runs back to me. The kids play with my hair, show me their dance moves, and take turns steeling my phone to take photos with it. I get hugs and friendship and a sense of family here on the bench with them.

Another little boy has stolen a piece of my heart. He is the son of one of my friends and he is absolutely adorable. He calls me "sister", a term common here for white women here (referring to the nuns who used to be in this region). He is adorable and chatters, though he is wary of me. Listening to him laugh and play brings happiness. And watching his father care for him restores some more hope for the future of the children here.

One of the funniest experiences that happens to me, and other Khawaja, is when a very young child, often between the ages of 1 and 2 sees me or another white person for the first time. I will try and greet these children. Some will come up to me but others are scared of me. Some are interested in trying to understand why my skin is the wrong color and will approach me. Inevitably, though, they will cry. It is often funny and cute and makes the parents laugh.

My favorite time this happened was when I was inside the maternity clinic and someone had their young son with them. I saw him and waved but I was distracted and was not looking. He was originally standing by his mother but then he toddled over to me. When my co-worker alerted me to the little boys presence I crouched down next to him and held out my hand. The boy touched it and then started to cry. Rather than run away though, he curled into my side and hid his face. I tried to comfort him but it was clear I also scared him, but still he curled into me. His mother came and retrieved him after a minute. We all laughed. He was a really cute kid.

I've had quite a few kids react like this when I am at the clinic. One boy would cry any time he saw me rounding or walking around the clinic. I didn't even come near him but he was very scared of me. I am told by other volunteers that this is very normal. It just makes me chuckle.

The kids here manage to find joy with so little. They look out for each other. It is not uncommon to see children under the age of 5 taking care of each other or walking down the road together holding hands. The kids play together and have their own community. And the women in the village look after them. I hope for a brighter future for each of these kids, and that their happiness holds.

Facing Reality

Culture shock comes in waves I am starting to think. Being in Nzara at the beginning of the month was the start of my culture shock. In Yambio, while things are primitive in comparison to how things are in the US, there are many more luxuries, or at least access to things, than there are in Nzara. Housing in Nzara is more basic, more primitive and simplistic.

So walking around Nzara and seeing more of how people live there and I suspect, how people live in many regions of South Sudan, is a bit of a shock. Running water is virtually non-existent. People, mostly women and children, go to pumps and wells to get their water. Homes are brick or wood, and grass roofs. Doors are curtains. There is no electricity. Life seems basic here. Focus is on living and providing basic necessities of life. Children play with box cars they have made from old boxes, sticks, and bottle caps.

People live like this in Yambio too, but not to the extent they do in Nzara. In Nzara this seems almost exclusively how people live. In Yambio there seems to be a variety of homes and ways people live. Some with electricity through solar panels. Others more basic structures and homes. And there are a few that live in nicer places, but this too seems relatively rare.

It puts my living situation into a harsh reality. I joke that I live in luxury here, but the reality is that I do live in luxury here compared to most. I mostly have electricity. When it goes off it usually comes back within 5 minutes. I have drinking water, safe water, in my room. I have running water. I have my air conditioner. A bed I sleep in alone (instead of sharing one bed with my entire family).

I have reflected on this before but I keep reflecting. I am comfortable where I live. I am lucky. And sometimes I have to take a step back and be grateful and appreciative of all that I have, even here in South Sudan. That is not counting all that I have back in the US.

Then culture shock comes when I am in the maternity clinic during the week. I just watched a 16-year-old give birth. She is married already (at least the husband seems to be an age-mate of hers rather than a grown man), and this is her second child. No one blinks at this here. But I had to step out. I know this is considered normal here but I struggle with this.

Chances are this girl will not be able to do more than be a house-wife and mother. She most likely dropped out of school, won't return to school. She probably doesn’t have the option to go back, to improve her station in life, to have a job, to chase a dream she might have. And the children she births, particularly the girls, will have a greater chance of repeating the same things in their life, perpetuating this way of life.

No, I didn’t ask about her dreams, if she wanted to be married, or anything about her situation. Most of this is speculation, though based in the general normative that exist here. Many young girls and women are in similar situations. I was told by my age it would not be uncommon to be a grandmother. I haven’t even had a child yet. I was able to chase my own dreams, make my own choices, choose a path I wanted. I have chosen my life. How many women in the maternity unit can truly say that?

So, I spend the day struggling with the reality of this girl. I don’t know why her case bothered me so much. The delivery was routine, the baby fine, no complications on either side. But I struggle with it, and with the situation. I am bothered by the friends, some even younger than the mother, who come by and spend time with the girl, because I know that some will willingly choose this life and others will find themselves thrust into this life, regardless of choice.

But I think the biggest culture shock comes Friday when I am back in Nzara, rounding on their inpatient medical units there. I am there to assess and address a few cases and work with the newly trained mental health staff. I have been alerted that they have a few cases already to discuss, so I know when I get to Nzara there are patients for me to see. However, I also decide to round with all of the patients to see if there are missed cases or other issues.

I don’t have precise words to describe what the inside of a hospital ward looks like here, but the stark contrast to American wards is humbling and frustrating and emotional. Patients rely on a co-patient for much of their care. Co-patients help get medications for the patient, food, provide laundry, help patients up to the bathroom and to clean, bring sheets and clothes, and many other things.

If you don’t have a co-patient, well life gets infinity more complicated. There is no one to help you get supplies or food. You are on your own. Chances are if you are in the hospital like this you cannot do a lot on your own. Staffing is limited so the staff are unable to help with a lot of thing nurse’s aids or nurses would do in the US. It is almost unfathomable to truly understand how things run in the hospital without being there and seeing it.

On Friday I am down rounding and I am feel both humbled and shocked when I see more of the condition of the hospital. There is no privacy for patients. They are lined in beds in one large room, everything open. The doors and windows are open to the outside air which allows for fresh air, light, and a breeze. It also invites dust and bugs into the wards. There is little medical equipment. Supplies are used sparingly. Whole families will be sitting on a bed. Again, it is hard to really describe. Seeing it is the only real way the reality is shown.

But as I am rounding I discover that there are only 2 oxygen machines available on the unit. One can be hooked up to 2 patients as it has 2 ports. The other is a single patient use. There are 4 patients who need oxygen. How do you choose who gets oxygen and who does not? I believe they selected the most stable patient and took them off the oxygen. They did okay without it but would not have been able to sustain that way forever. Instead they get their oxygen back when one of the other patients who was using oxygen, dies.  

This patient was a child. I do not know the age but they were a young child. They came for respiratory issues. I had rounded on them earlier in the morning. They had been alert, crying, and struggling to breath, but I hadn’t known then, just how much worse things were going to get. We were rounding on the adult unit when we were called back to the pediatric ward.

The child had no respiratory output. The pulse was initially weak then gone. The family knew what was happening and were in distress. Immediately the staff was already working to try and save the child. But there is only so much to do. They initiate CPR and do what they can but there is not much they can do in this unit. There are small amounts of medications and interventions.

I feel helpless as I stand and watch. One of the women throws herself on the ground, calling out in prayer and yelling for help, for her prayers to be answered. Other women are crying. A few seem to just be numb. I cannot help any of them. I shew a few people away from windows and the door, as people try to watch what is happening. This is common here, but I want privacy for the family. Next to the bed where they are doing CPR is a mother holding her child who is also in respiratory distress, and I cannot help but wonder what she is thinking, as she rocks her child meer feet from the dying child.

All the staff interventions are unsuccessful. They declare time of death and allow the family to grieve. And we move on. The staff member I am shadowing was related to the patient who died but he doesn’t stop what he is doing. He goes right back to work. I try and encourage him to take a moment but he refuses. He wants to keep working. But I can see he is upset and bothered. It is subtle but it is there.

This worries me. Maybe he feels that if he stops working and takes a moment, he won’t be able to return to work. I am not sure and I don’t push the issue at that moment. I also wonder if death and dying is so normal, even when it is a child, that people do not feel as phased by it as I do. This patient wasn’t mine but I still struggle with the fact that they died. And I am worried that these experiences of death and dying are so routine, that the trauma is so normalize, across the society, that it is just accepted as normal.

Maybe this is something that bothers me a lot. I know I am an outsider looking in, but what I see sometimes, is concern for what has become normal. Even though there are laws to try and protect children from being forced into marriage before they are 18, it still happens and people look the other way, because it is the way things are done here. But to what end?

The trauma and death are so ingrained in society how do we address it? How do I talk to people about it? How do I start the conversation that children dying at the rate they do here is not normal, that life does not have to include all the trauma, war, and violence that the community has experienced. I don’t yet know how to start that conversation, how to address these issues.

The trauma concerns are huge in South Sudan. Everyone has had trauma. And the people know they have experienced trauma but, again, it seems almost accepted, and life goes on. They do not talk about it. They accept it. A few may discuss it here and there, but it is so casually talked about, can I make them realize it is not normal, and things can get better. The trauma does not have to continue. Generational trauma can be stopped. But where do we start?

I am struggling professionally this week. Finally, I am doing more mental health work. But that comes with opening up some very challenging topics and very emotional topics. I am feeling overwhelmed at times. But I have a plan for a few things, and now there are others trained to help me with my work.

I am humbled by the way people work here as well. Our hospitals back home typically overflow with supplies. Even during the worse parts of the pandemic, we had access to so much, even when we did not know it. Here, there is not even the appropriate oxygen mask for the patient who is not doing well with just a nasal cannula. But that is what they have so that is what they use.

How I want to pick up my computer and order off Amazon. How many supplies could I get? But there is no shipping supplies here. And that doesn’t stop the other problems, even with supplies, there is no way to sustain some of these things. I cannot buy endless supplies. What can I do? I stand there and watch during the rounds and feel helpless. Anything I do feels so inadequate. There is so much work to be done. Where do we start?

I guess as long as we start, that has to be enough. For now, at least. But that doesn’t stop my brain from struggling through the problems. This week brought me face to face with the reality of healthcare here. It also drives my resolve, that I am here to try and improve things here if I can. So I will work towards that. I pray I am able to help.

Meet the Azande King

Training for TOT for the mental health initiative ended Saturday afternoon. Many people headed back to their respective locations in WES that evening. I had one more night in Nzara. It was very much a lazy night.

On Sunday I got up early and went for a walk. I like walking through the village early in the morning. Mostly there are women and young children about in the morning. In Nzara people greet you when you walk down the different roads and paths much more than they do in Yambio. Often the kids run up when I am walking around and people call out. It is very nice.

I headed to the hospital, walking past some of the wards, and greeting people I met. I spent a while in the morning at the Doctor's Guesthouse chatting with Beverly. She is very much a mentor to me and a good friend and I appreciate having her here and being able to talk about challenges and successes with her.

We parted ways when she left for church and I headed back to the guesthouse I was staying at to gather my stuff so I was ready to be picked up when my ride arrived. After all my stuff was gathered, I sat in the sun in the courtyard for a while listening to the music coming from the church. The Zande mass was going on and the music is very beautiful to listen to.

Once my driver arrived, I piled all my bags in the car. Somehow, I returned to Yambio with more stuff than I left with but I never went shopping. I am not sure how these things happen. Though Bev did give me some fabric to take with me that I hope to get made into either a skirt or dress.

We picked up the MOH's from the Doctor's Guest house and they decided that they wanted to go to several markets on the way back to Yambio. We stopped at several along the way. All are much smaller than the one in Yambio. However, all were also not very busy and did not have as much stuff because people were still at church. Sundays are market days here, but most people come after masses conclude for the day.

We headed back to Yambio after concluding with the markets. Since Veronica (one of the PMs I work with) was also with us she showed us a very good restaurant in Yambio. Here we ate traditional South Sudanese dishes, in a traditional South Sudanese manner. All of the foods come out on one very large tray and we eat with our hands.

I got 4 small dishes, one with beans, one pasta-like dish, green, and another dish similar to greens. It was all served with pitas that you use to eat the food with in place of silverware. The food was excellent. I am getting more used to eating with my hands here but sometimes it throws me off because certain foods seem harder to eat with your hands. It can get messy as well but it is a great cultural experience.

After lunch I was dropped off to my apartment to prepare for the event of the afternoon. We were going to meet the Azande King! He is the king of the Zande tribe here in South Sudan. He has been king for 1 year. Because of the training I missed the celebration of the one-year anniversary but I was going to meet his so that was going to be better.

In South Sudan there are 2 kings. The Azande king is one and there is another tribal king in another region. I currently cannot remember what tribe he is from. However, South Sudan considers itself a democratic nation and is ruled by a president instead. I do not quite understand how all of this works but I do know that the kings do not rule over the president here.

So, I had to make sure I was presentable if I was going to meet with the King. Typically, I wear tank top style shirts here that are sports ones because of the heat. However, to meet the king this is not appropriate. Thankfully, I have my beautiful blue and yellow dress that I bought from Omelara back in Syracuse. This was the perfect outfit to wear as it was long enough and covered my arms enough to be acceptable. I also wore the headpiece with it to keep my hair covered and contained.

Our driver picked us up and we headed off to the King's place. He does not live in a palace like the monarchy does in the UK but rather we went to a compound on the outskirts of the town. It is secured and there are guards. We met with one of the royal family members. She is the niece of the king, as well as one of the women who attended training in Nzara with me.

We were greeted by several members of staff and warmly welcomed. We discussed protocol and how to greet the king when we did go in to see him. We were also shown several pieces of jewelry that were made by staff at the king's residence. They are traditional Zande jewelry, made from a special tree in the region and painted either brown or white. I purchased a necklace that had both brown and white seeds on it.

Meeting with the king was very interesting. We went into his sitting room. I was not sure who the king was at first as there were 3 men sitting in the room already. However, once I took my seat, I discovered that the king was very close to where I was sitting. He is actually a small man and seems very humble.

We introduced ourselves to him. When we did so we put our hands together like we were praying and made a little bow. He spoke to us for quite a while. He spoke in Zande and then his niece translated it into Arabic. I understood very little.  I was told he welcomes us to his Zande Kingdom and to get an honorary part of his Zande tribe. It is good to feel like a part of this community.

We took some photos together at the conclusion of the meeting and said our thanks. After meeting with the king, we went and met with one of the queens. She is very nice and was fun to speak with. We ate there at the compound as well. Then we met with one of the Zande princesses before leaving.

Once we left the king's compound we headed across the road to where there was a women's group meeting. I have wanted to meet with a women's group since learning they are very popular here. I think they are a great asset to the community and a good place for education for mental health care. It was nice to listen to some of their desires and conversations.

Overall, even though I had hoped for a more relaxed Sunday it was a very incredible experience. How many people get to say they have met a King and his royal family before?!

Training Time: Adjust Your Standards

Wow. So many emotions are racing through me this week. The 9^th marked 1 month of living in South Sudan. On a personal level it has been a month where I have learned a lot and have experienced a lot. On the professional side of things, I have faced much aggravation and challenges. I suppose I was warned of this but still I do not feel prepared.

On Monday I was planning on presenting but this was mis-communicated and I did not end up doing my mental health presentation at the office. Honestly, I was late as I had tried to get a ride to the office because I wanted to eat breakfast before coming to work. Of course, things didn’t go as planned so I was late after I walked to work due to not having a ride. So not presenting was okay.

Then I had expected to leave for Nzara for the start of our training on Monday and that we would start Tuesday Morning. So, the plan was to leave Monday. Of course, silly me expected this to remain the case. The Minister of Health for Mental Health Services in South Sudan, and the other facilitator were late to arrive and would not get to Yambio until Tuesday. I decided to try and go to the clinic instead but was told I was heading to see some people in another office just as soon as the car was ready. We never went so I stayed in the office reading for the day.

Tuesday, I arrived to the office with my stuff for the trip. I expected we would leave by 10am at the very latest. I don’t know what time we left but it was not on time. No shock. The Minister of Health for Mental Services (MOH) finally arrived and then we had to go and meet with the district governor. She then had to travel with us to the training in Nzara.

We arrived a little before lunch, maybe 1pm. There was a formal ceremony by the district governor while she opened the training officially. Apparently here training like this is almost a formal ceremony at the start of this. There are so many different aspects that we had to account for before it even started. And the disorganization that exists adds an extra layer to everything.

I think it was rather fortunate that Tuesday was a short day as we didn’t seem to have enough organization to be able to really start the education. It was scattered and did not make a lot of sense to me. We spent an hour discussing what were expectations, how to behave in a meeting, and what would happen if you did not follow the rules. Apparently this is a normal part of a training like this but I didn’t particularly think it was professional.

Wednesday training started in reality. Training is so much different here than it is in the US. I think I may have said it already but I think it is a point that bears the need to be repeated. Training is something that I have had to adjust my expectations around because of all the differences. There are times that it is still disorganized and a bit unprofessional but slowly things seemed to adjust and improve.

So, Wednesday we started off later than we were supposed to. If you haven’t noticed by now, things in South Sudan rarely start on time. I struggle with this, especially when things start an hour later than they were intended to  start. But they started off with prayers and well wishes for the training ahead. There are prayers throughout the day here. It is a part of the training process, along with making sure all of the participants are provided with food and drinks throughout the day.

The first day of training was on grief, stress, and depression. We talked through what each one of them was and the different categories for diagnosing them here. Apparently the criteria of who is able to diagnose someone with a disease or disorder is very different in South Sudan. As a registered nurse even I can diagnose mental health conditions. This was very new to me.

The second day we discussed epilepsy, suicide, substance abuse, and psychosis. Again, the focus was on how to diagnose them. Full days 3 and 4 were on how to treat each of these conditions. In total it is 5 days of training, with two tests, and certifications for the participants to engage in.

I taught a few of the different topics but since the MOH was the one who brought the presentations and the first time I saw them was when I got up to teach it was a bit weird to teach on the subjects. In the US, especially in New York, I would not have found it as strange but here there are so many cultural considerations and standards that are not what I would teach on that it was challenging.

Saturday training ended with a ceremony. I, along with another the MOH, District Governor, CMMB staff, and several others got up and spoke about the work and the importance of the training. We talked about next steps forward. We celebrated the end of the training with prayers, singing, and a large meal. There were group photos, and lots of chatting.

It was a moment to realize that one of the goals I set out to achieve when I left the US is started to come through. I will continue to support the 22 people that I helped to train while I am here. I hope to be able to travel to each of the sites to see how they are doing and what needs they have. I truly hope the training works well for them and they are able to use it, as I know the need is there.

In the end it is good that we did not use the material I created as I have different standards and expectations on things. Also, using the MOH material ensured that it was more fit for the cultural considerations here. The material is actually designed by the WHO, who I am shocked, considered Epilepsy and Intellectual Disability to be mental health disorders that mental health specialists should be treating. I understand the original rationale for this but it seems that the material may be outdated a bit.

I ended up learning some different things throughout the training. We discussed what drugs were called which names here in Western Equatoria State, how grieving was for different tribes, and some of the ways that the staff interact with people they suspect are mentally ill. It was good that I attended the training to learn some new things about the culture I am serving in.

There were several times when they have made fun of the Khawaja for the expectations white people have. I just sit there and listen. There are some times when I agree, because I thought some of the things that they were talking about, like there would be better access to internet for most people. So many people do not have any access to internet. There are other times that they make dun of white people and the technology that exists or does not exist here, without realizing that there are some of the same issues in the US with technology, that there are here.

Overall, the training was very good, once I adjusted my expectations. It is a combination of needing to adjust my standards and lowering them at times to meet the realities of some of the situations here. Other times I think that I will also need to challenge some of the expectations and standards of care to try and encourage improvements here for the staff. If they want to improve then some things need to change. But overall, I found the week to be a success. 
 

Life in Nzara

I arrived to Nzara on Tuesday. This is not my first time here. I have been to Nzara two other times. Both times were for short visits so this was the first time I am here for a longer period of time.

We traveled in a two-car convoy. It is still dry season so the trip to Nzara is quick and the road is not so bad this time or year. I took a video, though, to show what it is like to drive here. I am in Nzara for training (see my other blog post on this).

I have found Nzara beautiful and intriguing before and still do. It is so much smaller than Yambio. I hadn't gone to the market here but I know it is smaller than Yambio's. But Nzara means seeing Sarah, Martin, their kids, and Beverly.

After training ended Monday I met up with Beverly and Sarah. It is so good to see them. Sarah took me to the maternity unit. There I got to hold 3 tiny babies. I like getting to hold the babies. The unit here is bigger than the one at the PHC in Yambio but this is a part of the hospital here.

After round at the maternity unit Sarah walked with me back to the guest house where we are staying. On the way she introduced me to several children, a few of whom she delivered on previous missions here. Many kids ran up to us, a few curtsied, and most shook our hands.

At the guest house I settled into my room. Most of the guest house is roofed but not sealed from the outside world. The kitchen is open to the courtyard. The entire compound is gated and fenced in. Outside you can see the fútbol field and the Catholic Church.

Inside is the courtyard with 6 rooms off of it. Each is a room for different volunteers or staff. My room is pretty large. There is a full bed, cupboard for belongings, bedside table, and another table. I also have my own bathroom. There is running water. However, there is no electricity on Tuesday when I arrived. I have been warned it stops at 8pm anyways and usually starts again when the sun comes up (all solar powered). There is also no internet.

Food is left on the counter from lunch that day. There is chicken, rice, cabbage, and something else I do not know. There isn't a way to warm the food, unless you want to start a fire. We eat the food as it is. Sometimes it is warm. Other times it is room temperature. We make do either way. I enjoyed dinner with Sarah and her family that evening. There was plenty of chatting and laughter and it was so nice to share the meal with them.

After dinner I headed back to my room. Making the most of the lack of electricity and internet I decided I decided to read one of my e-books I had on my charged-up laptop. Since books took up too much room in my suitcases I had left all of mine in the US so e-books were all I had. However, it was amazing to just sit in bed and read for several hours.

I tried to sleep around 10pm. I definitely did not fall asleep then. In Yambio there is a lot of noise in the way of loud music, traffic, and noises in the form of a semi-city-like area. I am used to that now. Here, however, it is country. I should be used to it. And actually some of the noises reminded me of home in New York.

I lay in bed for several hours listening to the country around me. There are many animals that make noises that you can hear. There are the goats that make a lot of noise, and if you are not used to them they can sound like screaming. Then there are the roosters, though those are worse in the morning. What intrigued me most was the sound of the wild dogs howling for hours. They sound like cayotes, but they are African Wild Dogs (Think Africa by Toto, because I did).

You can also hear music at night. Sometimes it is a drum, and other times it is someone singing, or groups of people singing. You can also hear the people talking amongst themselves, calling out to others. Noises travel far here.

Of course, there is the sound of babies crying and children talking, normal sounds of households at night. And because fresh air is the only way to keep your room cool your windows are open, and most of the village homes only have curtains covering their windows. I have windows I could close but I love the fresh breezes blowing in the air.

I must have fallen asleep at some point and woke up around 4am to the sounds of the roosters. Roosters crow all the time here. There is one that must be close to our compound, and near-ish my room because he is very loud. They talk to each other too. So I lay in bed listening to the roosters.

Around 5am someone began sweeping near the compound, probably by the church. Sweeping is not as quiet as one might think it is. They use these long reeds or small branches gathered together and the sound they make on the dirt is not loud but it is noisy enough and distinctive. I lay in bed listening to it for a while.

At 6 the drumming started. I had not been warned of this but it was a very interesting noise to hear. There are drums and some sort of bell or loud clang that is made with the drumming. It happens 3 times every morning. When I asked Sarah about this later on she explained that it is the morning call to pray at the Catholic Church across the street.

Once I got myself ready I headed through the village to go to the hospital. The village is pretty quiet this time of day and there are just a few people about. The full moon was still up despite the fact that the sun was also up. I loved getting to walk through and look at some of the homes and ways that people live here. Some houses have large graves in their yards. It is common that family members are buried in the compound that their family lives in.

The hospital is a lot busier in the morning than the village. Many women are about, washing clothes, making breakfast, cleaning, and other things. Sometime I may talk about the conditions in the wards in the hospital but not in this post. I headed to Beverly’s apartment which is part of the doctor’s quarter on the other end of the hospital. We stayed and chatted for a while before heading to the main office, and the source of WiFi for my time here.

I stopped over to the office a few times a day just to do a few updates and to check in with family in the US and with my office in Yambio. Nothing exciting. I have to say it was actually pretty nice not having access to WiFi all the time. It gave me time to chat with Sarah and her family, read, and just relax and enjoy the world around me.

It is very peaceful here in Nzara. There is a lot less noise from vehicles and other such things, as there are in Yambio. It is relatively quiet and reminds me a lot of home in the US, with the roosters, and wild dogs at night. I am very relaxed here in Nzara. I am enjoying my time. But there is also a part of me that is looking forward to going back to my home in Yambio when the training is over.

First Impressions: Part 2

Garbage: There is garbage everywhere. I have been shocked to see how much people throw trash in the streets or just leave the trash behind. Inevitably you will find trash wherever you walk and wherever you go. Sure there are trash cans and certain places respect picking up trash more than others but still you will find trash everywhere. And its not that much of a shock when you realize there really isn't a garbage collection service. Much of the trash will end up in a pile to be burned anyways. It just collects certain places. Somehow it is both clean (well swept and tidy in many places) and dirty (piles of trash) in others. A bit of a contradiction.

Eating with your hands: No I do not mean foods like pizza or chicken wings, but full fledge meals are eaten with your hands. I will say that there are water buckets at most of the places I have eaten and sinks at others to wash hands before and after meals so at least when you eat with your hands it is cleaner. Depending on where I am I do not always have silverware. I went to a friend’s house for dinner (this will be another post) and we at with our hands and it was the most natural thing in the world, which I suppose it rather is. However, it has taken some getting used to.

Hospitals and Animals at the hospital: Hospitals here are so different than they are in the US. The hospital compound is one large field usually, with many different buildings scattered about. Depending, there may be fences around it or between some buildings but there are no large medical complexes like in the US. With the large fields and grasses that grow there, inevitably you will find an animal running around. At Nzara's hospital there are goats, lambs, and pigs often running around. There is a stray dog there as well. At the PHCC in Yambio there is often a horse in the compound. No one pays them any mind but it feels like a contradiction when you compare how clean and sterile hospitals are in the US to the rustic nature of the medical facilities here. It fits though.

Kindness: There is so much kindness here. If you have followed my other posts, I hope you have noticed that too but I sure have. People are happy to walk up to you and talk with you. People offer to help and often share what they can with me. If I am lost someone is sure to help me find my way. If it is not me then I see how members of the community work together and help out when they can. People seem genuinely invested in their community and therefore with each other to support each other. With the women this seems particularly true as well. There is a support and kindness between the women here that I have not seen so vividly as in the western world.

Prayers: America talks a big talk about their religious practices, whatever they may be, but here in South Sudan one can see the devotion and the reality of religious practice with the people in the community. I have blundered a few times when I am at a meeting and forget that meetings are inevitably opened and closed with prayers. We pray before each meal when I eat with others. There is no judgement to those who don't pray but it is common practice to pray often throughout the day. And it is not just Christians, as I witness many of the people in the community observing their Muslim traditions and attending the mosque.

Toilets: This is a fun one to talk about! Most places I have been have westernized bathrooms but every once in a while there is one that is not western in style, or it’s missing a part, or water. At the hospital in Nzara some of the more modern bathrooms still have the eastern style bathroom. This is the bathroom where the “toilet” is a hole in the ground with plumbing. It is very much a toilet with toilet features but there is no toilet bowl or seat. You squat and do your business and then flush. That was an interesting experience. I have peed many times in the woods and somehow this was bizarre experience. Other toilets have no water or no seat. You make do with whatever. At least there is almost always toilet paper.

I am sure I am missing some things that have stood out to me and other first impressions that I have had since coming here. There is just so much to take in. Maybe I will write another post or maybe some of those other impressions will come out just through this narrative I write in my updates on this blog.

 

Long Weekend Fun

This week feels like it flew by. I feel like I have been very busy. I am very happy about that. This weekend was good too. Friday, I had the day off because of the Pope's visit which meant an extra day of relaxing. I was a little worried I would be bored but I am finding ways to stay busy and active. This is helping a lot.

Friday morning, I went out for a walk. I got lost. I was trying to find the lake from the opposite direction I normally walk from. However, I took the wrong path and ended up in the middle of a family's compound. Not wanting to look overly lost I said hello and kept walking. I could see the lake in the distance but no clear path to it. So, I found another path that led back to the original road I was on and headed back towards the city center.

I try not to show if I am lost when I am walking. That seems to be a good way to not have people take advantage of me. I do talk to some of the locals when I am walking. Some ask me where I am from and ask me for things. Many people ask me for money. I am not giving them anything like that. I may start carrying candy or something like that for some of the kids I talk to but I haven't done anything like that yet.

Friday was very relaxing. I spent time in the courtyard at our compound. I sit at the benches under a very large mango tree and in the shade and with a good breeze it doesn't seem so warm. Also, when I am at the compound, I am able to wear shorts. When I leave the compound I have to wear long pants, a dress, or skirts. Often, I feel warmer in those so I love just relaxing in my shorts.

Taban came for several hours in the afternoon to hang out. He is sharing much about the history and culture here in Western Equatoria and in his own home state. This week there was a murder of over 20 people over cattle in his home state. This is an ongoing issue. These are just one form of traumatic events that people here experience.

Taban and I discuss this, and many other things. He is a wonderful source of information. He is very interested in learning things, and equally interested in sharing information with me. It is good to have someone to chat with openly. We also watched the pope's visit on TV.

After saying goodbye to Taban in the evening I met up with Sheila. Thursday night we went to a small stand to get ground nuts and chat with one of the local women who sells food right outside the compound. We spent time with her and her children, who are cute but shy to talk with me often.

On Friday night we stopped shortly to chat with them. Sheila and I walked to the market to get a chicken, sweet potato, and plantain from a local woman there. We brought the food back to the compound and at together on our veranda. The food was excellent.

After dinner we headed to UNMISS for Karaoke. Several people from the weekend before were there. I recognized a few and said hi. People sang for a while and it was a lot of fun. I have yet to get the desire to sing into the mic myself but it was funny to watch.

After people decided they were done with singing we walked inside to where they had dancing. It was so much fun. I danced with a few people but mostly we danced as a group. There are several very enthusiastic people who love dancing and if you sit too long, they will drag you out on the floor. We danced until almost 1AM.

Saturday, I got up and went on a walk again. This time I decided to walk the loop by the clinic and then walk towards the hospital. On the way back from my walk I passed the soccer field. I waved at one guy who I believe was my co-worker Jimmy but he was too far away to see clearly. I continued on for a while, walking around for about an hour.

After my walk I headed back to the compound. I usually make it back in time for breakfast and before the heat of the day gets to be too much. Shortly after breakfast I got a call from a colleague asking me how my weekend was going and if I needed anything. I am not sure if he or one of my other colleagues had told him I was out walking but it was funny but sweet that he cared to check in to see if I need anything. I think they are not used to the fact that I am relatively independent.

In the afternoon Sheila called me to come meet here at the clinic where she had a meeting so we could walk to the market together. We walked around the market for a while. Then Sheila got her hair done. This took several hours. During that time, I watched the community bustle around the market and walked a bit. We went to lunch at a local restaurant. I was also able to get fabric for several Kitenge Skirts. I need to take them to a tailor this week.

The afternoon was full of rest and relaxation. I joined some of the UN friend group that I have hung out with on weekends before. There were two new people that just arrived in the past week and so I got to chat with them. One of them is Spencer. He is from London and has lived in South Sudan for about 5 months, in Juba. We chatted a lot and that was nice. One of the guy’s Benewah, made grilled lamb, salad, and other very tasty food. He is an excellent chef.

We stayed out and chatted for a while together as a group. Sheila and I had plans to go out and go dancing. We headed to UNMISS. However, apparently at 8:30 at night it is too early to go dancing. We headed back to the apartments. I was tired so I ended up deciding to go to bed early. I wanted to dance but the minute I sat on my bed I was too tired to get back up.

Sunday, I woke early. Most days since coming to Yambio I get up early. I am a morning person anyways so I am okay with that. I decided to head out for a walk before 7am. When I got to the gate of the compound someone mentioned going to church to me. I have yet to make it to a Catholic mass here as I did not know where the church was. However, earlier in the week I thought I had figured out how to get there.

I walked beyond the clinic and down past the market. If you keep walking along the road you will make it to the church. I almost turned around thinking I got the wrong road when I finally saw the church. As I got closer, I found that people were not inside the church but in a large open pavilion in the back of the church.

There are at least 500 people inside the pavilion. As I approached the back on of my co-workers Julie greeted me. She must have seen me walking to the church and waited for me. I was late for church but she waited in the back for me. During one of the songs, we walked into the pavilion to find a seat. We ended up in a front pew next to a nun.

Church in South Sudan is not so different than Catholic masses in America. I had gone to the English service. This one takes place every Sunday at 7am. I think I was the only white person there, and as usual people watched me and made comments. It is a regular thing for me to experience here.

After the service I walked back to the compound. Shortly outside the church several young girls kept watching me and talking about me. They slowed their pace so I would catch up with them. I decided to say hi to them. They introduced themselves to me. They decided to walk with me.

 One of them asked me to take her home with me. Another said I could be her mother. All 3 were very interested in my skin color and hair. They made me laugh. They followed me almost to the compound but then turned to go to their home. It is a surreal experience, something like this. I am as interested in them as they are in me.

Now it is time for a lazy Sunday. I have done my laundry (all done by hand) and it is drying. I have to prep for my presentation tomorrow morning at the office and prepare for some of the other things for the week. Otherwise, I hope to spend time with some of my friends and just relax. It is warm and sunny and so nice outside.

 

Starting the Conversation

Monday morning I decide to walk to work. It is early and cool and I want to get to work before the morning meeting. I was told on Sunday that I would be presenting Monday. We had already had that tentatively planned but nothing had been finalized. Sunday I got word that I would be educating the CMMB staff on mental health. I planned on doing a series of short discussions on mental health, in different areas.

Monday I walked in and got to work extra early so after dropping off my bag I headed to a local vendor and grabbed some fresh “doughnuts.” I don’t know what they are actually called. They are a fried dough ball. But they are not sweet. They taste good though.

Monday morning is always the meeting first thing in the morning. This time I understood a little more about what was being discussed. I am slowly picking up on some things. Other things still confuse me. People also talk very fast at times and I cannot catch everything. I suppose it is the same for others as well.

After the meeting Monday I met with a few of my teammates to discuss my proposed project for the clinic in Nzara hospital. While parts of this were already planned and underway there were a few components that we needed to address further. I won’t get into too many details as realistically, even to me, they are relatively boring. The important bit was that the training is going to happen starting next Tuesday in Nzara.

After the meeting, and sensing my frustration with being in the office all the time, Veronica (a PM), suggested I head with Taban, a midwife, to the clinic to start observing and hopefully to find some people to work with. Taban and I walked the approximate quarter mile to the clinic.

 I spent the rest of the day shadowing and nearly fainted when I watched a delivery. That was a first for me. Even during my clinical rotations in the operating room and other times I have witnessed traumatic or graphic procedures I have never felt like fainting.

I blame it on the heat and the fact that I forgot to eat lunch that day. I excused myself from the delivery room and headed out to the main maternity ward. After sitting in a chair for a while and grabbing some water I started to feel better. One of the other clinicians (in training) chatted for me for a while with me, talking about deliveries he has attended. That distracted me.

I think Taban felt bad for me. When he walked out of the delivery room after taking care of the mother and the new baby he came to check on me. I told him what happened. I was also very clearly sweating a lot. It’s hot here. Everyday is in the high 90s. I assured him I was fine.

I spent the remainder of the day observing in the ward. I didn’t want to risk actually fainting. They have enough work to do without having to worry about me. That evening I caught a ride back to the compound and felt fine. I wanted to go back to the clinic. It was the first time I felt more at ease about work since coming here. Clinical settings are what I am used to, not offices.

Tuesday turned out to be a frustrating day. There was no work for me in the morning so I asked to go to the clinic. I was told I needed to stay at the office so I could go out and go to one of the Child-Friendly Safe spaces to see some children who have suffered trauma. We just had to wait on a vehicle to be available. Even when there was a vehicle we did not go. I could not go on my own because I didn’t know where it was.

I stayed in my office. I was also told there was a patient that the community was trying to get to come see me. One of my co-workers told me of her the week prior and wanted me to speak with her. However, she refused to come to the office. So I never saw her. I spent the day reading. I like to read but it is not why I am here.

My frustration with the lack of work that I am actually doing here now led to a new plan Wednesday. I come to the office in the mornings and see if there are meetings or other things going on, check for patients to see, and address any other needs that have been identified for me to work on. If there is no work at the office or no plans for me to go to one of the community centers to see patients I go to the clinic.

I want this. I can spend time in the maternity clinic. There I have been able to learn a lot about how things work here. I have learned a lot about the culture and about medical care. I am also learning a lot about mental health care, or lack of care. One thing I learned was that when a person attempts suicide the case must be investigated before that person receives medical care. This is certainly not how we do things in New York so it was very surprising to me.

On Wednesday I attended two more deliveries. Neither time did I feel like I was going to faint so that was good. I enjoy being in the maternity ward, trying to talk with the women, and seeing the babies. I am learning so much. I am also learning about some of the trauma and mental health struggles in the area. I hope the more time I spend there the more I will learn and the better I will be able to start talking with both staff and community about their mental health.

On Thursday I only spent an hour in the clinic at the end of the day. The morning was spent going to the Child-Friendly space. There I played with 3 small boys who are displaced with their mother and will hopefully go back to their country someday. I listened and talked with the man who runs that area. I will be doing more work there in the future.

We also attended a community meeting on Child Protection and Gender Based Violence. Both groups work together as their work often overlaps. It was very, very long meeting and meant I missed the second meeting I was supposed to go to. I hope to attend to that one Monday.

After my meeting finally ended I got back to the office to find that Sarah, Martin, and their kids have arrived in Yambio. Sarah is a Nurse Midwife who will be working at Nzara’s hospital. She is another volunteer. I met her in New York in December. She and her husband have been here 2 times before now. Martin does project management in Nzara.

This was my first-time meeting Martin and their two children. It is really nice to have more familiar, friendly faces from the US closer to me. We had lunch at the UN compound. We also had to do the rounds to some of the community leaders with them. After this we adventured to the market. The women loved seeing a white toddler. It was fun to watch. Then it was time to say goodbye to them. I should see them in Nzara next week.

My work certainly is not what I expected of it. And everything is moving slowly. But doing anything clinical and starting to see people open up and talk to me is a good thing. It is a slow process but we are starting conversations with locals and starting to make more plans and work towards more progress. I will keep pushing where I can and do what I can to work to try and do more.

Making Friends

I swear there is an art form to making friends. I have yet to learn how to do it as easily as I see others doing it. However, I am grateful that people are willing to make friends with this Khawaja (the term used here for white person- no idea how to spell it).

This weekend Sheila and Mike, both UNICEF employees temporarily in Yambio for a Covid Vaccine Campaign, took me under their wings and befriended me. Sheila was staying in the apartment next to mine. I have zero idea how we met but it must have been on the veranda between our rooms.

Anyways she invited me out with her and Mike Saturday night. So, Saturday night we headed to the adjoining UN compound and went dancing. All of the music is African Pop. The only American song was “Waka Waka” By Shakira.

We danced for hours. It was so much fun. Several people danced with me and tried to teach me how to dance like a real African woman. I failed miserably but I am going to keep going and keep trying. Mike and Sheila teased me about my poor dancing skills but we had fun. We walked back to the compound and made plans to hang out the following day.

Sunday was a lazier day. I got up early and headed out on a walk. I went to the market, but was there too early for anything to be open, and then to the lake near my work. I really enjoyed looking at the lake in the early morning light, but I didn’t hang out too long because there were many groups of guys but few women so I felt weird hanging there.

After my walk I headed back to the compound and just hung out for the hottest part of the day. It seems to be consistently around 98* and sunny. It doesn’t feel horrible but I also avoid moving around a lot outside during the hottest parts of the day.

Later in the day I am sitting on the veranda enjoying the afternoon sun and my music when Sheila comes out of her apartment. She invited me to a meeting with her and Mike about how the vaccine campaign is going. We walk to the PHCC. I didn’t know where it was by foot until then.

It was so interesting to sit there and listen to the different conversations, what things are going well and what things need improvement. It gave me a lot of insight into how things are done here and what might be some of the unanticipated challenges I may face in the future with my own work.

After the meeting we walked a bit, trying to go to the market but finding it closed, just through some of the streets. When we got back to the compound we headed to the restaurant in hopes of good food and music. We had decent food but no music. Mike decided to sing to us since there was no music. He likes karaoke. Sheila likes to dance.

I had a blast hanging out with them. Sheila is from Juba and Mike is from Ethiopia. Both are great teachers and enjoy talking about things, and answering the barrage of questions I always have. Mike and Sheila are both happy to share their culture with me. They are fun and make me laugh.

Monday night I didn’t see either of them when I headed to dinner at the cafeteria. However, just about the time I was finishing my food Mike walked in. He got his food and sat with me. We chatted, talked about work, and about his family. Eventually Sheila made her way in and got her food. We all hung out there for a while.

We walked outside the compound after dinner in hopes of some street maize (corn- but they call it maize here). We had no luck. The street was pretty quiet except some teenagers and young adults hanging out listening to the radio. Only two stands were still open.

None of us felt like going back inside to our apartments so we walked to the adjacent compound and went to the bar. It was a quiet night there but fun and relaxing. I met a few more people. Everyone is very friendly and fun. There is always lots of laughter, singing, and music with this group. I am very grateful to have met them.

Tuesday was our last night together, the three of us. Mike was headed back to Juba Wednesday. He was hesitant to hang out with us Tuesday night but we convinced him to grab a drink at UNMISS with us. We walk over and as usual with us it was fun and relaxing. There is so much laughter and happiness with these two.

Sadly on Wednesday morning I said goodbye to Mike. We had breakfast together, all three of us. Then we all had to get to work. But before we parted ways we exchanged numbers so we can keep in touch. Mike says he’ll be back and I hope that is true. I will also try and see him and Sheila in Juba when I go back there. Fortunately, Sheila is here for a few more days so I do still get to spend time with her.