Fútbol & Pool

If you had told me that when I came to South Sudan one of my main sources of entertainment would be either fútbol or pool I would have laughed at you. I would have imagined other ways I would spend my time. I am not sure what I thought I would be doing, but I had created a list of ideas of things I could do, and it did not include those two things.

I do love fútbol (what we Americans call Soccer, and the rest of the world shakes their heads and fists at us for not calling Football like they do). However, in the US I do watch fútbol from time to time but not to the extent I do here. I have watched a few games here and there over the past few years.

Here in WES fútbol is a big source of entertainment. I schedule certain plans around when there are fútbol matches. I have begun following the Primer League, which is very popular here. Now I am not the fan that so many of the people are here, but I certainly have begun following it more closely. My "teams" are Manchester United and Manchester City, thanks to one of my friends.

Now that the season is over, I am not sure what fútbol games we will watch but I am sure there will still be games we follow. During the season many of us would make plans to watch the games. Sometimes I watched a game with colleagues from the office. Other times I watched at my compound or the neighboring one. Most weekends I could be found, in the evenings, at the neighboring compound watching a game.

Fútbol is a source of entertainment and a source of joy for many people here in South Sudan, especially men. Many people I interact with have a team or teams they follow. We can jokingly tease each other about teams, or I witness debates about teams. Many people own different teams’ jerseys and you can buy them in the markets here. I have really enjoyed learning more about fútbol, but I still have more to learn.

Because I have been spending so much time at the neighboring compound (easily and safely accessed from the compound I live in) I have found many different activities there. Sometimes I just go there for dinner. Other nights I have gone there for karaoke or to go dancing. Now that I go there most nights (the food is good and I am tired of a rice, beans, and many of the other dishes available at my compound).

Since the kitchen there can take over an hour to prepare food it is good to find a way to pass the time. This has been playing pool. I haven't played pool since I was probably 16 or 17. I barely remember the rules. Sometimes I just make them up as I go. Plus, everyone from all the different countries here, has their own rules. I even taught one of my friends here how to play and now he beats me most games.

Sometimes my friends and I play, sometimes competitions start, and sometimes we just sit and watch other people play. Once in a while I will play by myself. I still stink at pool and feel like I don't have a good grasp on the skills it takes to play, but I don't care. It is fun to play regardless and it passes the time.

Some people are more serious about the game. There are a few pool players that seem to come in most nights and play. They have very specific rules that they play by and often I get very confused by all their rules. I am more interested in playing for fun. Sot that's what I do. Then I watch the more serious games.

I look forward to the days I watch pool or play and I look forward to the fútbol matches on TV. Last weekend the CMMB staff even played a friendly match of fútbol and the community came out and watched. All of this is a good way to pass the time and to try and make friends along the way. I am enjoying this very much. I may not play pool when I get back home, but I think I will keep following some of these fútbol teams.

 

The Things You Miss

Thankfully the one thing they seemed to have prepared me for before I left was to think about all of the things you would miss and the decide if you were willing to miss those things. One of the hardest parts of the decision to come to Africa was to decide if I was willing to miss certain things. I did a pros and con’s list. I made the decision to go but it didn’t mean those moments weren’t important.

The first thing and maybe the hardest event I was going to miss was my best friends bridal shower and bachelorette. Telling Ari that I was leaving was hard but she was so kind and so supportive. Even better she found a way to keep me included in her events. She and her friend Sarah (another member of the bridal party) made sure to include me in the festivities, including setting up video chats for both events. I am forever grateful for that.

Another big consideration (there were lots) was that I would miss ski season. Sounds silly, doesn’t it? But after over 15 years of not having ski boots and finally getting them the year before, mid-season, I was looking forward to skiing over the winter, and to a trip we had planned. Next year I will get a chance to ski so it was a sacrifice I was willing to make.

I missed events like birthdays and other celebrations. There were many things at home I wanted to attend. There are also the holidays that I missed, like Easter, but gratefully my family arranged a video call back with them so I could chat with people Then there was my birthday, which I had made a bunch of plans for and when I came here, I decided to forego that.

There are dozens of things I missed. Thankfully, with the current level of technology and the fact that I do have some WiFi access I am able to sometimes be there virtually. And in the grand scheme of things, giving up these mostly relatively small moments, to try and give back, is worth it. But sometimes it is hard.

And I miss other things. I miss hugs, real and genuine hugs. I miss spending time with friends, without the suspicion of other people over what I am doing. I miss my family and my dog. I miss the foods from home. I miss home in general.

But missing things isn’t necessarily a bad thing. It is a constant reminder of how much I have to be grateful for, and what I have to look forward to when I return. I have many blessings and am so very lucky in so many ways, so for that, missing things is a good thing.

I will be home soon enough. I will get to be with family and friends soon. I will go to all of my favorite places and see some of my favorite people. Until then I look at the photos I have scattered around my room and remember that I am trying to bring some of the wonderful things to the people here.

Maybe they won’t get it now, but I hope their future is one where they worry less about where their next meal is coming from and can plan parties and celebrations. They can worry about less life and death things.

The US is by no means perfect, but sometimes it is aggravating being here and seeing how much we have there and how ungrateful we often are for everything. But I miss that too. I can never live without the knowledge of what life is like here anymore. And when I go home, there will be things here I will miss too. 

 

Emotional Roller Coaster

South Sudan is a roller coaster of emotions for me. There are things I absolutely love, there is a lot of heartbreak, and then there are the things that make me angry and make me wonder why I am still trying to do work here. And I cycle through these emotions every day. I also find myself crying sometimes, whether it is the frustration, or sad. But then there are moments where I am laughing or relaxing and enjoying my time here a lot.

I wouldn't have made it over 5 months here if it wasn't for the things that make me happy here, but some days are just completely hard. I hear so many horrible stories from people here (but I think it is important to realize that some of these stories are not totally different than things in the US). The thing that separates these from the stories in the US is the sheer helplessness and prevalence of some of the tragedies here. I here so many domestic violence issues, traumatic stories, and other hard challenges.

This validates my work and why mental health care is needed here, but it also means that there is still a lot of work to be done. Things here move at their own pace. Despite the fact that I travel to Nzara every Friday, I am still in the office waiting for a ride because they forgot to get a vehicle for me. Meetings fail to accomplish what they were scheduled to do, and the reason is often hard to understand.

After months of witnessing these challenges, I still am unsure why certain things are such a struggle. The only thing I can identify as the main cause is that because this is the way things have been, this is the way that things will remain, until something is able to drastically force a change. With mental health care, baby steps seem to be the way to go. Subtle changes to make improvements over time and not trying to change things quickly. Maybe that is the key for even things like running a meeting.

There are the people who hate my presence here. Maybe that don't understand or like the work I am doing here. Maybe they think that I should be giving them things, like money. Maybe I am unwittingly doing things that upset them and don't realize it. The people here don't always tell you what is upsetting them, but will become mad and you won't know why. Some people don't want things to change, or don't believe in the work I am doing. Honestly, these people exist in the Western world too, so it is not fully unfamiliar to me.

But those moments when I am getting so frustrated or sad about being here and I want to just pack my bags up and fly home, are juxtapose with the moments where I see a patient experience relief in being able to share their story. Or maybe it is when I share a meal with one of the few friends I have here. It is when I run into some of the guys from the UN compound at the bar on Friday and we start joking around and relaxing after a long week.

Or when Sheila runs over to me on the dance floor and pulls me to come dance with her. Maybe it is the random act of kindness from Susan, who bought me a tailor-made dress. Or when the women from work invite me to their house to have lunch and dance. Perhaps it is listening to Dr. Maad speak passionately about mental health care, or another provider showing that they are actually interested in learning about the work I am doing and how they can incorporate it into their work.

Without these moments this work and this environment would be some of the harshest, most devastating ones to be in, where I would have never wanted to spend 6 months. While I know I will be happy to go home, when I fly back to the US, I hope it is those happy moments I hold onto most. I embrace the happy and try to remember them in those moments when I am over being here and missing home. I am still so lucky too. But that doesn't mean that there aren't hard moments or struggles for me too, they just look different. But I am getting through the hard times and enjoying the good moments too.

 

Calm In The Storm

As I start to write this I am down in Nzara for the night because I have to teach in the morning. I am staying at the doctor's quarters near the hospital compound. Not everyone in the house is a doctor, which is part of the reason I get to stay here. However, most of them are. Today it is all guys staying at the guest house.

The rooms that I have seen here are pretty bare bones and small. They have made some improvement since I was here last, which is to say that they now have flushing toilets in the bathroom. The first room I was put in doesn't though, so they move me to the other room that does have a flushing toilet. It also has a giant spider on the wall. Oh well that is part of the experience here.

I am restless here. I feel like I cannot settle in here. I feel like an acquired guest here, and I don't know if I should hide in my room or come out in the dining room and living room area. I opted for going outside first since no one is at the house yet. Dr. Maad shows up and gets me connected to the Wi-Fi. We end up going inside, hanging at the table, chatting and using the Wi-Fi.

I still can't help that I am feeling more and more restless so I end up going back outside. It is muggy out and the air inside is so still and hot I am struggling to feel at ease inside. Outside there is a storm brewing. Most evenings there are storms. I stand there in the light breeze and look out towards the hospital to where I can see the storm clouds rolling through the sky.

The storm comes in quicker than others. I have been outside at night before and watched as heat lightning lights up the skies for hours but the rain only comes 2-3 hours after the lightning starts. However, this storm rolls in quickly and it is a relief.

As most faster storms here start, this one starts with wind. Now this wind is fast but it is certainly not as strong as the winds I have felt elsewhere. It brings up the dusts and blows the trees and knocks things loose but it does not do some of the destruction that wind storms at home do. But the wind here blows (sometimes is does cause destruction but today things seem okay here).

I stand outside as the wind picks up and I embrace the wind and cool. All day the air has been still, humid, and hot. Now there is a little cool relief with the wind and incoming storm. However, the temperature is still in the high 80s so it is not that cool. Around me people have begun to run to get things like clothes off the clothes line, or to get what they need from another building before the storm really comes in. I simply stand there.

There is something about the wildness of the storm that calms me. I always feel calmer with a storm coming, and during the storms. It seems when the chaos of the storm is coming, that is when I stop feeling so restless and unable to sit still. Standing in the incoming storm I feel peace, even as the wind whips my hair around.

I love dancing in the rain. I feel free and open when I dance in the rain. It is one of the places I feel closest to the earth, to nature, and to God. Maybe it is just me, or maybe there is something to that. Here I am constantly amazed by the faith that exists, when every person here has suffered unimaginable traumas. But here faith is strong, and hope remains.

So, I stand and embrace the storm, letting the wind whip my hair and the rain pelt my face. And I am feeling calmer than before. The storm picks up and I decided to shelter a little farther away, on the veranda. Still, I love standing and watching the storm, listening to the loud smacks of rain on the tin roof, watching the lightning brighten the black sky and listen to the thunder crash.

Storms calm my wild soul, and I feel more connected to the world, and to the Earth with each storm. And as the weather cools Nzara a smidge and the storm slows its pace I feel more peace. I am able to relax, rest, and fine my soul just a little more ready for the next challenge to come my way.

Crickets and the Rain

 

I used to find the sound of crickets soothing and welcoming. I still do, but now when I wake up in the morning, I wonder how many crickets I will find inside my room and where in my room I will find them. I think I find anywhere from 5 to 8 typically in the morning. They sneak in through tiny cracks near the windows or the door. The management have done what they can to minimize the cracks, but still the crickets find their way in. Honestly it could be much worse. Now that rainy season is well underway the crickets have come out and they are everywhere.

I am grateful for many reasons, that I sleep under a net every night. It mostly keeps any intruding bug away from me. On occasion a small one manages to sneak in, but I feel so much better having it here. Strangely I wonder if I will miss it when I go back to the US. It makes my bed almost like a little fort, or small comfortable safe place to be. When I was a kid growing up, I loved to sleep in a tent in my living room, or go camping with my family, or build a fort in the middle of my Livingroom. Now sleeping under my mosquito net, I am transported back to those moments of sleeping in a fort or tent, but my bed here is much more comfortable than an air mattress or the floor.

There are little pockets of pure joy and relaxation that exist for me here. There is so much that happens every day. There are many challenges, but these moments of joy bring so much relief. Toto's Africa has been on repeat in my head, and sometimes in my room, since arriving in Africa. Now that rain season is more fully upon us it is in my brain even more. I have always been someone who enjoys rain and storms. I find so much enjoyment from watching the rain storms here and running around in the rain. Lying in bed at night and listening to the storms, or walking from the food stand in the dark right before the storm starts, is pure joy for me.

It is in those pockets of happiness and joy that I find the work I am doing more easily to be done. Without the good moments, those happy times, living here in South Sudan would be a very hard time. When the days get hard and the work and general life here gets overwhelming, I try to focus on those good moments. Lying in bed last night I was struggling, feeling very upset, and struggling not to feel overwhelmingly depressed and sad. But I listened to the crickets in my room and the storm outside and I found peace. Today is a new day to wake up and see what will come. The good and the bad and embrace it all and move forward.

Isolation

If you had told me that one of the hardest things about being a humanitarian worker was the number of meals, I would eat alone I wouldn't have believed you, but the reality is, that it is one of the things that is absolutely hard. I eat 85% of my meals alone. Sometimes I can go an entire week without sharing a meal with another person. It is lonely, but more than that, having a meal to share with someone at the end of a day is something I didn't realize was so therapeutic. There is no one to share the struggles, successes, and general highs and lows of the day with. Strange, but it is the truth. Humanitarian work can be incredibly isolating.

During the pandemic most of us experienced isolation and loneliness for one reason or another. This kind of isolation is different. At home I can pick up my phone and at least call one of my friends and talk about my day with them, and for the most part they will understand. Here there isn't someone I can call and tell them about my day, or what I am going through as a Khawaja doing Mental Health work in South Sudan, who will really understand what I am experiencing. That kind of isolation is hard.

It will get better, but that doesn't mean it is not hard. I have no regrets for coming and no regrets about staying here. But it is hard and that is okay.

 

Ambulance Ride

I have never ridden in an ambulance before. Not in the US. I have seen and been in the inside of one for educational and work reasons, but never actually gone in one when transporting a patient or as the patient myself. This week I got to experience what it is like to ride in an ambulance here in WES. No, I was not injured, hurt, or sick. I was the medical personnel going in the ambulance with a patient.

I think a month or two ago I wrote that I am not a maternity nurse. My work here in WES has me working closely with maternity a lot though. I am on a maternity unit at least 2 days a week. Some weeks I am there more often than others. It truly depends on what is going on. This week Yambio PHCC Maternity has been short staffed most of the week. I haven't been around much because I was busy preparing and launching the clinic. 

Later in the week, once things had calmed down, I was in the Yambio's Maternity unit. I am still limited about what I can do but I try to lend a hand doing whatever I am able. Sometimes that means hanging IVs and grabbing equipment for someone. Other times I stock supplies. Sometimes I talk and work with the patients. It all depends on what is going on within the unit when I am there.

However, just as the only midwife on duty was trying to conduct a delivery while I was out in the main ward area. A woman came in with a newborn small baby. She had delivered the baby at home and now the infant was having trouble breathing. There was a student on the unit with me who was able to translate basic information about the situation. I asked the student what the usual procedure was with a case like this, and the answer was that we refer them to the hospital for more advanced care.

I scrambled to find the referral forms, and fill out the paperwork. After I filled that out, I found the midwife in the delivery room doing the delivery and confirmed with her that the infant needed to be transferred. Now the problem was, who was going to go with the mother and infant. Staff has to go. A student could go but that is not ideal. So, it was up to me to go with them.

After several minutes of trying to locate the ambulance driver we got the ambulance over to the unit. There is an ambulance on site most of the time. However, you need to find the driver. We had tried to call his phone but he did not answer. I finally located him and he got everything set up. Unlike in the US when you go in an ambulance there is usually an EMT and Paramedic there is none of that here. There is not even equipment in the ambulance. Any that might have existed in there before had either been used or stolen. All that was there was a stretcher and bench. 

I had no equipment to take with me. The only bulb suction was being used for the delivery and if I took the only ambu-bag from the clinic they would have nothing if an infant was delivered who was not breathing. What do you do in a situation like this? I could take the equipment in case I needed it but what if the clinic had a delivery that needed it. Since the infant was still breathing, though poorly, we opted to leave the equipment behind and I prayed the whole way that this was the right decision.

We loaded the ambulance with the mother, her infant, and 3 other family members. Because it was so crowded in the back I road in the front of the ambulance. The driver was able to communicate with the family as we drove. I could hear the babies breathing most of the time, and while it did not improve it did not stop. This was probably the best-case scenario for this situation.

Now it is a very different experience riding in an ambulance in a country like South Sudan, than I imagine what it is like in America. I've already mentioned a few reasons why, but there are a lot other reasons. First is that this ambulance is much smaller than ones in the Western world. I was lucky enough to be riding in a "hard-top" one which features a regular vehicle cab and a covered truck bed with lights and siren. Other ones are driven by a motor bike with a steel wagon attached to the back and a soft fabric covering, hence being called "soft-tops".

As soon as we left the gate to the PHCC the driver hit the siren for the ambulance. There are no street signs, road markers, traffic lights, stop signs, or any other road signs here. There is not one specific side of the road people drive on, but rather there are tracks people stick to based on where there is more water or potholes or other issues. Most of the time people try to keep to the right side of the road like they do in the US, when there is other traffic, but it does get complicated here. So, as we drove through the main parts of Yambio the siren was going to alert people to get out of the road and out of the way.

I think I have mentioned before that there are no paved roads. The road between Yambio and Nzara, where we are taking the infant so they can go to the higher-level maternity unit at St. Theresa Hospital, is not paved but is considered "nice". This means there are no massive potholes or areas that are so flooded that they are not passable when it rains. They are still relatively smooth compared to most other roads here. Still, you better buckle up and be prepared for a rougher ride if you are used to smooth roads and American potholes because the ones here are much larger.

I am driven to Nzara at least once a week. Sometimes I am there 2 or 3 times a week. This week I have been there almost every day. On a good day, with good weather, no rain and good light, it takes at least 40 minutes to get there. Sometimes it can take an hour or more depending on rain, daylight, and other issues. We were fortunate because the rain that had come earlier in the day was light enough that the road wasn't too muddy or flooded. We made it to Nzara in about 30 minutes.

Nzara isn't really that far but let me try to explain further why it takes a little while to get there. There is usually only one good track to drive on for a 4 wheeled vehicle. Random speed bumps exist along the road, especially near villages or markets, to get people to slow down a little. We have to dodge some of the larger potholes that can have 6 inches of water in them. Your speed fluctuates from 20kmh to 90kmh depending on where you are and what you are avoiding in the road. Even if the road itself is straight, your driving will take you from one side of the road to the other and back again, depending once more, on what you are avoiding.

In the ambulance the same issues apply but this time we are trying to get there faster than when I am simply going for a regular day of work. I am listening and praying the entire time that the baby does not stop breathing. Sometimes I can hear them breathing and other times the road and drive is too loud, especially when the sirens are on. I have planned how to talk the family through mouth-to-mouth if I need to but luckily, we make it without needing to do this.

As soon as the ambulance arrives to the maternity unit I bring the mother, infant, and family inside the maternity unit. I find the charge midwife, explain the situation, and she takes over. They have more equipment since we are at the hospital. Still, they lack so much, but at least here they have a monitor for the baby, oxygen, and more tools to keep the baby alive. I head back to the ambulance once my role is over and we head back to Yambio, this time at a little slower pace.

I am grateful and pray that I never have to find out what it is like to be the patient or be with a loved one in an ambulance here. I am glad they exist and are available for the people here. Getting prompt care is hard but having this tool is very helpful. But the general helplessness of the situation like this one, I don't want to re-experience. But still, this is life here. Midwives, clinical officers, and nurses do this work every day here. Once more I am simply humbled by the way people are able to survive with so little.

Mental Health Clinic Opening!

Mental Health care in South Sudan is hard. I feel like I am starting from nowhere with no guidance on where to go most days. It has been hard over these last 3.5 months to create and execute a plan on how to tackle the mental health needs here. There are so many.

The first thing I had to come to terms with was the fact that I am not going to be able to help everyone, and realistically the scope of what I am able to do in the time that I am here is going to small. There is so much work to be done but no resource, or very few. And for the most part there is just me to do the work.

Sometimes it is hard to sit here and feel like I am doing work. Sometimes I feel like in the 3 months I have been here I haven't done any work. Sometimes I think I am throwing myself a pity party or something, because the work I am doing is frustrating in a way that work is not at home. I have never tried to build something out of virtually nothing at home, not something medical at any rate.

There are many logistical and random challenges that I come across in my work. Sometimes I see a patient and they think that mental health services will help them locate jobs or find money. I haven't quite figured out why they believe this but it happens more than I would like. I also have trouble getting people to follow up. I think not having access to regular healthcare and regular clinics means that people don't always understand the concept of following up. Another thing I am trying to figure out.

Generally, there are other challenges that I have to find creative or persistent ways around. There is often a lack of trust for the work I am doing. Part of this is because the work is new and that mental health is not fully understood. Part is due to the fact that I am white and not from this culture. Other challenges are the lack of resources and other mental health counterparts that I can work with.

I am virtually alone in many of the things I am doing. There are very few people that are trained in mental health care. I am probably the most skilled in psychiatric and mental health care for the entire state of WES. This makes it hard to find people I can problem-solve various issues with in real time. Sometimes I have to use best judgement and safe practice and go from there. 

The cases I talked about in my post before show how challenging some of the clients I am seeing are. Since I am alone in some of the work and since I am limited on services I can offer, sometimes I feel like I have not many ways of helping. But I try and listen, if nothing else, and teach self-care and coping skills. They are little things, but they are baby steps forward.

But this Month, as we start to celebrate Mental Health Month (All of May!), I am taking a huge step towards one of the goals I set myself when coming here and one huge step towards addressing mental health in South Sudan. On Wednesday May 10th 2023 "my" mental health clinic opened.

It has been months of hard work to coordinate, train, prep and start to facilitate the beginning of this clinic. It is located in a semi-temporary space in a newer building at St. Theresa's Hospital in Nzara. Together with Dr. Maad we have been working for weeks to put together the launch of the facility.

The opening of the clinic came with a ceremony in which the director general for the state, other important community members, different religious leaders, and other officials, like members of the military, showed up. There were a series of speeches. I even had to give one but I kept mine short.

Overall, it was a bizarre and exciting experience. Bizarre for me because I still have not gotten used to how the meetings run and ceremonies like this run here. I am still trying to understand of the formalities and the procedures that they use to run something like this. But of course, seeing something I worked so hard to start actual happen, was incredible!

There had been a series of false starts to this clinic. We had proposed and planned for the clinic opening for weeks and then had to keep postponing. Finally, we were able to settle on a date, plan, invite, and prepare the space for the opening.

Of course, on the day of the opening we arrived late but I was so excited to have several of my favorite staff members beside me. Plus, they are my friends. Veronica, my project manager, Norine, the head of HR, and Taban, the midwife I shadow maternity with, all came to be a part of the opening with me. It truly meant a lot. Sister Margaret and Sister Winnie were also there. I really like both of them and was so pleased to have them be a part of the day.

So, this was a huge success and a huge day for me. It is just the start and I really hope that the clinic manages to be successful. I told Dr. Maad that this clinic is "my baby" so after the ceremony Dr. Maad came up to me and said that he promises the hospital will be a good "foster parent" to "my baby." Over the next few weeks, I will transition the staff to run the clinic so that when I leave, they can do it on their own, and reach out to me when they need help.

While the clinic is starting off "small" by Western standards it is a huge step here. It is the first one in WES. It will run 1 day a week with outpatient services, but the hospital has 7 staff members trained as mental health staff, alongside their regular rolls. We are hoping it can grow from there, and during the opening ceremony we talked of plans for the future and how we hope to expand. The fact that this program and clinic have the support that they do is amazing.

While all of the work that I have been trying to do it hard and has caused me a lot of stress over the last months, finally taking this very significant step forward makes all of the work worth all of the stress and anxiety. The work won't stop. I have patients to see, more educations days to plan, and other projects still to go. But for a few moments we will celebrate this success.  

 

The Price of Being Female

It is not easy being a woman in South Sudan, which is probably why I write so much about the women here. Besides part of my position here is to focus on serving the women in South Sudan. Now before I write this, I want to say that not all the men in South Sudan are bad, but the culture and society here have created some pretty toxic situations for women here. Each of the stories I am going to share are just bits of situations or experiences that women have here.

Story 1: Betty

Betty is 12 years old. She comes in to the maternity unit on evening. No, she is not pregnant. She was raped. I won't go into the details much of that case. I picked up the case the next day.

I was rounding in maternity when I was directed to this patient. Alongside another midwife I interviewed the patient. She didn't want to discuss much of what happened to her. I kept trying to chat with her. It took her quite a while, and a lot of translation challenges, to open up.

She is feeling suicidal. She has a plan to take all her pills. I look over at the bed she was on, where several packages of different medications are laying, certainly enough to harm her, probably end her life.

By the time she is finished talking with us though, she is feeling slightly less suicidal. She has a reason to live. She has a dream and wants to go to school to be a midwife too. She has been watching, and listening to the midwives here and she likes what they are doing. Still, we have to be careful and take steps to make sure she is safe, like removing the medications from her bed, and having a responsible adult to give them to her.

After a little while and more talking throughout the day, more of the story comes out. Betty was raped by her friend of her family, someone who lives right next door to her. Now the family has already started the process to arrest him and press charges. We are told that his is in jail.

Over the next few days, the staff continue to assess how Betty is doing, and if she is physically and mentally ready for discharge. She is cleared and ready to go. We make plans to follow up a week later.

The week passes and she and the family never come back. We try to contact the family but have no luck. Unfortunately, without the medical and mental health follow up, the rape case will probably not get charged and the man has already been released from jail, so he will likely not face any more consequences.

This is not uncommon here. The way the system works for prosecuting rape cases is even more challenging and complicated than the one in the US. In other cases, the family will choose to handle it themselves. Sometimes this means "justice" in the form of them killing the rapist, other times it means that the family choses to do nothing.

In the end I have no closure and no idea what happened with Betty. I pray for her and hope things will get better. I hope she will have the chance to go after a career she wants. I hope she gets help for her trauma. She has my contact information and knows where she can get services. I will hope and pray for a safer and happier future for her.

Story 2: Miranda

Miranda has been married about 10 years. She had 3 children with her husband. Her youngest is not yet 1 year old. When Miranda got married, she was living near her family, but she and her husband chose to move to be closer to his husband's family. So, she is hundreds of miles from her own family.

After nearly 10 years together things are no longer good. They are worse than not good. Her husband regularly beats her. Her in-laws turn their attention to other things, and ignore what she tells them.

The beatings are coming more often. They are getting worse. She knows he is going to kill her one day. She has no way to stop him. She has tried to have his family intervene. They tell her these are just marital problems. Her family is far away.

She has no one to help her. The police won't do anything. Any money she gets from working she doesn't get to keep. She has limited resources. Her husband doesn't want her to leave him but he's not willing to change. She feels stuck in a no-win situation.

So, what does she do. Does she stay until he kills her? Does she try and run away and leave the kids behind? Does she try and take the kids? Divorce- even though he would refuse that option?

Story 3: Janelle

When Janelle was 14, she was still attending school. She had ambition and hopes to complete school and then to go on and advance herself and her education by going to college. She wanted to have a career where she could build a better future for herself and the life she wanted. But at 14 Janelle was forced into a marriage with an adult male.

Child marriages are technically illegal here in South Sudan. Technically, but the reality that each day girls under 18 become wives. Then they become mothers. Often there is little done to stop these marriages from happening. Women and girls are valued for what they can bring as a bride-price, or for their dowry. Some when a family needs money they can choose to marry of their daughters.

Many of the girls delivering babies on the maternity unit are married. Some of them to other teenage boys, but some to older men. It is not even shocking to my colleagues that 14- and 15-year-old girls are married and delivering babies here every day.

At 14 Janelle is married. She is "lucky" and is allowed to continue with her schooling. At 15 Janelle is pregnant and attending school. At 15 Janelle delivers twins. She is again "lucky" because she is allowed to return to school while still taking care of her children. She can continue her education when many other girls drop out as soon as they deliver a child.

At 17 Janelle finds herself pregnant again. At 17 she is almost done with school, still going to classes, and pregnant again. Close to exams she gives birth again. She takes a break from classes to care for her children, but is able to come back in time to take exams and complete school. Janelle has done what many girls cannot do. She completed her final year and has a high school level education

Janelle's story doesn't end there. She gets pregnant again. This time she is attending higher education. She is dedicated to finishing this education. She gives birth gain. She is still going to school.

By the time Janelle finishes her education and working she is in her late 20s and has 7 children. She still wants to advance her career, but she is taking care of her children and her family. She also is taking care of children her husband had with another wife. Janelle has dreams, but she also has priorities and limited options here.

Still, she is somewhat lucky because she has had a chance to work and earn an income. Not every 14-year-old child-bride gets this chance. But still we hope for a future where there are no child brides and girls are allowed to go choose a husband. When they want to get married, they can. They can finish their education and become real adults.

These are just 3 stories of 3 different females here in South Sudan. There are worse stories. There are better stories. There are some happy women here. There are some women with good lives and good relationships. But in my role here, and in my service to the community here, I listen to women share the hard stories. I hear the stories that are more common than the good relationships and happy lives. I hear the heartbreak. And I am trying to do my small part to try and help. There is still much work to do and more people that need to get involved.

 

Maslow

Since coming to South Sudan, I have been doing a lot of thinking about Maslow's hierarchy of needs. I assume most people who read this might not be familiar with Maslow's hierarchy of needs. Honestly, I am not sure why it is one of those things that has always stuck with me from school but it has. So, I have a picture of it above for reference. The idea of the pyramid is the bottom level is the basis on which life is founded (meaning our basic needs) and then from there each level of the pyramid builds on the other when the needs of the one below is met. So, the foundation or the bottom of the pyramid should be met so that the other levels can be achieved. That being said, when someone is easily able to meet the bottom parts of the pyramid, they are more easily able to move through the upper levels, and it can be more fluid in nature.

The basic levels are as follows: Physiological, safety, love and belonging, esteem, and then Self-actualization. Physiological includes things such as good air to breath, safe drinking water, shelter from the elements, food to eat, and clothing to protect and cover the body. This is just the very basic elements of survival. Then the next level is security needs which are things like personal safety, employment, security, access to resources, and healthcare access. From there the 3rd level includes friendship, levels of intimacy, family and a sense of belonging. The 4th level includes respect, rank and status, and recognition. The final level, the one that is hardest for people to reach, is self-actualization where the person becomes the most that they can possibly be.

In the US I find it easy to go between these different levels and to reach to the top of the pyramid. I have easy access to food, a home, a bed, clothing, a job, relative safety, friends and family. I have pretty good self-esteem and respect, and I am able to chase after my ambitions and dreams. In the US I think we find excuses often to be in the lower levels of the pyramid at times. Now I am not saying this is everyone in hard situations, but I think people pick things incorrectly at times that sometimes have them chasing the bottom levels of the pyramid. Others are in a position where things like medical debt and certain other situations make it very, very challenging to climb above the bottom two levels of the pyramid.

One example of people choosing to be a lower level of the pyramid are those that go to college and choose a career where they are unable to earn a decent living. I use this example because I was that person when I got my first degree. I wasn't able to live the life I wanted to with that degree, so I went back to college and got another career where I am better able to meet more needs and thrive better. This is not to belittle people for their choices but to reflect that in the US we have an abundance of options that are not available in many other areas of the developing world. I love that I am a nurse and I love what I do, but that being said, I chose to go back to college and get that degree partially because I knew I would be able to find a job and have options to earn a bigger pay. I certainly did not do nursing because it was an easy career.

Here in South Sudan, I am concerned mainly with the bottom 2-3. Most people here are only trying to fulfill the bottom level most days. The other levels are hard to reach for them. Safe drinking water is hard to find in many places. Here in Yambio the different NGOs have created boreholes so that people are able to pump safe drinking, cooking, and bathing water. Some areas of the country have large water tankers who bring water to them, such as in the capital city of Juba. But farther out, especially in the hard-to-reach areas and deep in the bush people drink water from streams, and rivers, and other unsafe bodies of water. All of this causes disease.

Many people in South Sudan struggle to have adequate food. This year is potentially going to be a year with the worst levels of poverty and lack of food for the entire country. That means many people will not have access to food and many children will be malnourished. Part of that is due to the fact that global warming is drastically impacting the climate here and the ability to cultivate crops (I will write more about this in the future). Even in areas where crops grow food can be hard to access for many reasons. Clothing here is often not new, but used clothing. People have only a few sets of clothing and are unable to afford more so continued washing of clothes is necessary. People cannot replace clothes that rip or are stained as easily because it would be too costly.

Access to healthcare and reproductive services is very limited. People have a dozen children or more due to both cultural norms and to the fact that they do not have access to reproductive education or birth control. Reproduction is a very challenging topic to discuss here because the entire topic is many layered and very much culturally sensitive, so I won't write more on that now. But even the access to safe places to deliver a baby and access to medical care during the pregnancy is very limited. So here in South Sudan people are struggling to even meet the needs at the very base of this pyramid.

Those that are able to meet the bottom level of the pyramid may advance to the second level. They may be able to find a job, though here finding jobs is very challenging. Once someone secures a job, they may be able to afford a house that has a security gate and fence around it. They might be able to shop at the market or in the stands, instead of relying on their own gardens for much of their food. From there maybe they can buy more land or even things like a smart phone or better clothing, or a second bed so the entire family does not share one bed. This is just the second level of the pyramid.

From there people may worry about love and friendship. Friendship is probably an easier thing to get here, though finding good friends and many is challenging. Because of the extreme levels of poverty some people turn to stealing to get their needs met which would make friendships challenging. Love is a lot harder to find here, owing to cultural obligations. Many people do not marry for love. Polygamy is also common here as well. Family connections are stronger here than elsewhere, so that is something good here. But with the tribalism that exists, those that come from other regions or tribes in the country may struggle to feel connection or make friends if they move outside their own villages, which many have to due to waring and poverty and employment.

The last 2 levels of the pyramid are hardest still for people here to reach. Yes, elsewhere they are hard to achieve, but in the context of South Sudan I think very few truly get to the 4th level of the pyramid and I think the 5th level is virtually impossible for most people. There is so much that people are unable to achieve and so many that can barely make it from the bottom level of the pyramid that reaching the top of the pyramid doesn't ever happen.

It is heartbreaking to see people struggling so much. A whole country where the basic physiological and safety needs are not met for most people is devastating to see. I don't think words or photos or stories ever fully do this matter justice. I cannot explain to someone who has not experienced and been in the community firsthand what it is really like. I truly never knew or understood until I was here.

Even for me, living here in South Sudan, my ability to access things is harder. I know I will have food, but sometimes getting food is a bit more challenging. Or finding drinking water or running water takes a little more time and consideration than it would in the Western World. My personal safety and security is always a consideration. Because I am a Westerner the community overall makes sure that I am more secure and more protected than those that are from here, but oddly that can be a double-edged sword. My safety needs are more often met, but building friendships and making connections is harder because I am also confined inside those safety measures. So, you meet the more basic needs first and worry about the other needs later.

Certainly, I am very fortunate though. Comparatively I have much less to worry about. I am living a much easier life than my colleagues and those in the community. I wish I could help them all out, but the realistic part is that I cannot. However, as a mental health provider, we discuss where people's priorities and needs are and what part of Maslow’s Hierarchy the person is struggling with, and therefore where we need to focus attention. Of course, I do not use the literal pyramid in discussions, but it guides my work. It guides lives and work everywhere, even if we do not know it. But for me, it is one of those things I often think about and consider during my time here in South Sudan.