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.