Speaking of "universal health care"

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With barely a day to catch my breath, debrief, and plan the next leg of my trip, I was right back at Nairobi's Jomo Kenyatta International Airport, checking in on East African Airways, en route to Juba, the capital of South Sudan. "Safari njema" ("Have a good journey"), Samuel, the gregarious Merlin driver with a smile as big as all outdoors exclaimed as I made my way through the customs line...

Once inside the main cabin, it struck me -- I was the only Caucasian on the flight. It didn't make a difference to me (and I'd like to think that this indifference was shared by the other passengers), but it was the first time I had actually noticed it since having set foot on the continent. Surely, it wasn't the first of such situations on this trip, nor the last, but the first of such realizations...

Anyway, a few minutes later, as the plane was reaching its cruising altitude, we hit a small patch of turbulence and innocuously bounced for a bit. Fueled by what appeared to be utter trepidation, the gentleman sitting next to me who, might I add, was about 6 foot 5, 200 and some pounds, scars all across his face and looked as intimidating as I looked out of place, grabs my arm, while his body was gesticulating, tensing up and his complexion began to look more and more like mine! We eventually leveled of, at which point he promptly nodded at me in the international body language which implied a subtle apology on his part... "No worries" I responded, softly, and pretended that nothing happened... Our conversations remained limited for the remainder of the flight due to linguistic barriers; though as we landed, I heard a cavernous "Welcome!" from my large, not so intimidating (anymore) neighbor...
Then, all of a sud(a)n (pardon the terrible pun), I was walking through the immigration line at Juba International Airport... At last, I had arrived in Sudan!

Andrew, the logistics coordinator in Juba, found me right away (hmmm, I wonder how he picked me out of the crowd?!) and guided me through the convoluted airport procedures, walking me through each step needed to exit this madness. Finally, a few Sudanese pounds and passport stamps later, we were out, en route to the Merlin compound, which was barely a mile away.

Upon first impression, I thought... "This place is a dump!" One of the things that I've struggled with since I got to Africa is the people's utter disregard for responsible waste management, let alone recycling. I try never to revert to such gross (and often inaccurate) generalizations, but left and right it seems, people of all ages and backgrounds in East Africa don't think twice about throwing empty bottles and wrappers on the ground or out the window. "It's a cultural thing... Who am I to pass judgment!?" I keep telling myself - fair enough... But Juba seems especially bad - scratch that, terrible! The Environment Protection Agency would have a Field Day here! I'm actually surprised there are not more environmental NGO's in Juba. Judging by the logos found on so many land cruisers zipping around the city, it is clear that a number of humanitarian organizations have set up their logistics operations for South Sudan here in Juba, which provides the city with an interesting mix of people and, it appears, a distinct dichotomy between the aid workers and the local community. Admittedly, my ephemeral experience in Juba does not adequately qualify me as a knowledgeable source in the matter - just another meandering observation based on my vantage point as a passenger.

Once inside the Merlin compound, I met the team over lunch, went over the obligatory security and programmatic briefings, and discussed the schedule for the next few days. I would spend the weekend here in Juba then hit the road first thing on Monday morning to Nimule, one of our three field sites in South Sudan, where Merlin has taken over the operational management of the hospital since 2004.

Since there were a number of Merlin staff visiting the Juba office, the compound was actually full, which meant I would have to stay at the local hotel, located less than a 100 yards away - easy enough. The hotel was great - air conditioning, wireless access and a working TV in my room. Am I really in Sudan? I kept asking myself... Surely enough, it would be a different story once I'd get to the field... But for now, it was time for some much needed R&R! So Sunday, "the day of rest" consisted of sitting on the banks of the Nile river, kicking back, playing poker with the team, learning more about the local culture through several discussions with the local and regional staff... all while sipping on 'White Bulls' - South Sudan's first and only beer "celebrating peace and prosperity" - anything I can do to stimulate the local economy! It was a great day - both relaxing and instructional, despite losing to James in the end, having gone "all in" with a king high straight. He had an Ace high straight. So it goes...

The next day, I was off by mid-morning, en route to Nimule, which is located just a couple miles north of the Ugandan border, about 200 km away South of Juba, on what I was reassured to be secured roads. It would take anywhere between 4 to 6 hours based on the conditions of the roads. In this case, it was closer to 6 hours. Ecstatic to be getting out of the car, I got to the Merlin compound in Nimule, just as the sun was going down and the staff was wrapping up their work day.

I was greeted by Sergie, the Program Coordinator, who introduced me to the rest of the team, showed me around the place and outlined the next day's program. Each staff has his or her own "hut" which sits under several mango and guava trees - a sublime setting which, once again, makes you forget that you are in a region that has endured over twenty years of civil war! Worn out from the drive and nervously anticipating the next day's hospital visit, I tucked myself under my mosquito net and drifted off to sleep "under African skies."

One of the things I've highly enjoyed on this trip is not carrying a phone, blackberry, or watch for that matter. Somehow, I've managed to do without an alarm clock either... On this particular day, I woke up extra early, around 5:30 am, and took the opportunity to go for a sunrise walk around the village. It was a spectacular morning. I wondered around the main road as the sun was coming up in Nimule - a beautiful site - children on their morning commute to school, pastoralist farmers guiding their livestock and women gathering wood for the day, all greeted me with a familiar wave and ensuing smile. "Ho wa yu?" the local kids would repeatedly ask me... Fine, just fine!

Elizious, a clinical officer, who comes from just outside of Nimule, had kindly agreed to let me 'shadow' him for the day around the hospital so that I would get an idea of what a typical day consists of as well as gain tangible insight of how the hospital is operated. With all the hullaballoo going around in the States about the status and the effects of the economy coupled by the ongoing health care debate, I thought it would be a good way to contextualize the current situation by getting a first-hand look at the health care environment in South Sudan from a qualified health worker in an area that has not only felt the residual effects of a recessive economy, but that has also been warn-torn for almost 20 years. A little perspective would be refreshing.

Given his extensive knowledge, experience, and the respect he has gained by the community, Elizious proved to be the perfect person to follow around for a day. And he was such a great sport! I met him around 7:30 am at his house, which is conveniently located about 5 minutes away from the hospital and we walked over together. Aside from looking over the pediatric ward as well as giving highly sought out opinions to a number of other department attendants at the hospital, Elizious is the resident expert on trypanosomiasis, better known as "sleeping sickness," an awful parasitic disease that is transmitted by the tsetse fly and can go undetected for a while but is painfully fatal if not treated in time.

Considered a "neglected disease," sleeping sickness has become a serious problem in Sub-Saharan Africa, threatening millions of people in 36 African countries, according to the WHO. It’s especially bad in South Sudan. Elizious speaks emphatically about the illness and goes in details about the symptoms, the testing methodology as well as the treatment options. We go over this information inside his office and discuss the particular effects that this disease has had around the community in Nimule. He explains to me that many people have the disease but do not know about it until it's too late. Most just assume they have malaria, as the early symptoms are similar, but the complications ensue much faster and the victim's condition deteriorates at an exponential rate. In order to properly test for it, one has to perform a "lumbar puncture" which Elizious describes in details and which sounds excruciatingly painful! "Today is your lucky day," he tells me, as a patient was just about to undergo the dreadful "lumbar puncture" which meant that I would be able to witness the procedure first hand. "Oh, great... thank you Elizious," I reply, with a petrified look! Obviously, I was here to see as much as I could, but I wasn't sure I was ready to see this! Naturally, I obliged and halfheartedly welcomed this opportunity.

The particular patient undergoing the painful procedure was a soldier whose wife had earlier been diagnosed with the disease. This guy was the toughest person I have ever met! He walked right in, took his shirt off and didn't flinch once as the massive needle punctured his lower back and drew out the necessary fluid needed for the test. No words, no cries, no shouts, and no expressions... Once Elizious was done and patched him up, the soldier just got up, shook our hands and walked right out - incredible! I felt completely emasculated and exceedingly embarrassed thinking, in comparison, how much I cringe at the sight of a tiny needle anytime I get a minor injection!

The rest of the day was equally painful - in different ways. I spent the majority of the morning following Elizious as he made his rounds in the pediatric ward. Each bed was filled, it seemed, with sick children, the majority of whom were severely to extremely malnourished and suffered from several other complications, including high fever, vomiting and dehydration. Most signs pointed to malaria, which many of them did indeed have and were getting treated for. I tried to make them laugh as best I could and handed out the candy I had brought over with me - a tiny drop in what appeared to be a huge bucket of pain and misery.

In addition to the major neglect and destruction that the region has faced, so many people have been displaced from their homes as a result of the last two civil wars. In fact, it is estimated that more than 2.5 million people have been killed, and more than 5 million have become externally displaced while others, considered “refugees” have been internally displaced. Subsequently, a number of patients come to Nimule's hospital from all parts of the country, some even coming back from Uganda. I spoke to one particular woman whose husband had left her to become a soldier for the Sudan People’s Liberation Army (“SPLA”) and who had made the trek from over 150 km away walking for 3 days carrying her sick child in the blistering heat. She, like many others have come to the hospital in Nimule, since it is the only place where they can get free health care in the entire region. Some children, however, have been so severely affected by the effects of the war and the ensuing conflict that they have developed a debilitating fear of anyone who approaches them. One particular child was so severely malnourished that bones were sticking out of his ribcage and torso. Yet despite his obvious nutritional need, he refused to eat anything given to him by the nurse, since he had clearly been so badly abused in the past! Put simply, he was afraid of everyone, which in this country, I was told, is a psychological effect that has become prevalent.

I couldn't help but think... In this profession, we are told, over and over, to remain impartial, objective and not to try not to take into account the political, economic and social implications of war. As a humanitarian organization, specifically, as an emergency relief organization, our purpose is clear - to provide medical services and rebuild shattered health care systems in areas afflicted by natural disasters, conflict and the outbreak of diseases. However, in South Sudan, it is impossible not to take into account what the country has gone through - the horrendous effects of two debilitating wars, which many have described as some of the worst acts against humanity. Add high levels of drought, famine and dislocation, and that doesn't even begin to adequately describe Southern Sudan, which Adrian Gill calls "a rich petri dish for all the fungus and corruption of every conceivable form of apocalyptic, man made misery."

Now, just as the region was beginning to find a way to get out of this misery and focus on rebuilding itself, it is cursed with the uncertainty and instability that lurks over the next few years. Quite simply, the country is once again, on the verge of another potential civil war. The upcoming national elections of 2010 compounded by the referendum of 2011 on the future of South Sudan, both of which are in the backdrop of the Comprehensive Peace Agreement ("CPA") which was signed in 2005 make it all the more impossible to make any rational predictions and calculations regarding the future of South Sudan. Everything seems “provisional.” Fortunately, (if you can describe it as such), the tension in Darfur seems to have eased off a bit, which should hopefully shift some of the focus from the international community to South Sudan. Though, just a few days ago, it appears that the Lord's Resistance Army (“LRA”), the feared Ugandan sectarian guerilla army, known for committing merciless acts of violence, mutilation and blatant human rights abuse, has entered Darfur - as if they had not seen enough!

I spent a great deal of the day listening to Elizious explain the effects and implications of war in this fragile region - how he has dealt with it in the past and how he will most likely deal with it again in the future. He is such a courageous, dignified man - it's truly unbelievable! No wonder why he's so well respected by the community here. Having been educated and received degrees and diplomas from several countries, Elizious was offered many jobs around the world, and opportunities to escape all this misery. Yet he always came back, each time with an even cleaer sense of humanity. He's never once questioned his motives for wanting to stay here and give back to the community, what so many unjustly lack - basic health care.

I find it strange, funny, ironic, disgusting, sad that in the US we're currently arguing over whether or not we should implement a system whereby Americans would have access to a "universal health care." After spending a few days in Sudan, it's become clear to me how inaccurate this concept truly is. While we should undoubtedly be focusing on providing UNIVERSAL health care, we are merely bickering over the merits and viability of a system offering "national health privileges." Now don't get me wrong, I hope the bill does pass in the US and I fully support any and all efforts to expedite the process, but I think a little perspective is in order. I'll spare you with the statistics this time around, but know that we spend more in the western world on hair loss preventive medicine, anti-depressants and Viagra than what is spent tackling life-threatening diseases in the developing world. Yet with all these efforts and money being spent, it seems that the only thing we've actually become immuned to is our own complacency!

I try to stay away from the health care debate in the States, primarily because I'm not very well-versed on the varying complexities and the shifting political developments; but after spending a few days in Sudan, I find it difficult not to put it into a larger context. The future of South Sudan is indeed uncertain, just as is the stability of its political system. Just yesterday, President Obama issued a statement on his administration Sudan's Strategy:

"For years, the people of Sudan have faced enormous and unacceptable hardship...Conflict in the region has wrought more suffering, posing dangers beyond Sudan’s borders and blocking the potential of this important part of Africa. Sudan is now poised to fall further into chaos if swift action is not taken. Our conscience and our interests in peace and security call upon the United States and the international community to act with a sense of urgency and purpose. First, we must seek a definitive end to conflict, gross human rights abuses and genocide in Darfur. Second, the Comprehensive Peace Agreement between the North and South in Sudan must be implemented to create the possibility of long-term peace. These two goals must both be pursued simultaneously with urgency. Achieving them requires the commitment of the United States, as well as the active participation of international partners... Over the last several years, governments, non-governmental organizations, and individuals, and from around the world have taken action to address the situation in Sudan... Going forward, all of our efforts must be measured by the lives that are led by the people of Sudan. After so much suffering, they deserve a future that allows them to live with greater dignity, security, and opportunity. It will not be easy, and there are no simple answers to the extraordinary challenges that confront this part of the world. But now is the time for all of us to come together, and to make a strong and sustained effort on behalf of a better future for the people of Sudan."

I hope this message resonates. I hope that other state actors, NGO's, and international organizations understand and react accordingly to the gravity of the situation in South Sudan. Urgency is an understatement. Now, clearly I'm not an expert on the region, nor do I claim to have any palpable ideas on what to do to ensure that this marginalized country does not experience further suffering. Once again, I'm just an observing passenger, having been given the opportunity to see the effects of war, famine, drought, poverty, disaster, dislocation and other hardships on the dignified people of South Sudan - a brief snapshot of human suffering, which, in my case has become the barometer to understand what motivates me to work. I feel overwhelmed, somewhat lost, and most certainly weary... but in some strange way, it makes my appreciation clearer and my vision sharper.

I feel eternally grateful to have been given the chance to visit this incredible part of the world and to have had the opportunity to speak with such amazing people. I was told to go there, absorb, reflect, and record my experiences as ME, not as a humanitarian worker, not as a Merlin employee, but as me... I'm not sure exactly how I processed all this information, all these images and interactions, nor do I know that I will fully digest the impact that this trip has had on me, but I know one thing. I can confidently say that it has indeed changed my life. Alas, I have no "last word." The funny thing is the more I see, the more I travel and the older I get, it seems, the more I become less convinced of anything. People do change and situations do evolve...and all I can do is appreciate this evolution, learn from the past and accept the uncertainty that lies ahead. I refuse to let predetermined theories, societal norms and prejudices cloud my vision… I want each new conversation, interaction and revelation to help me formulate a clear appreciation.

Tonight, I am once again surrounded by western comfort and have a chance to get a full, uninterrupted night of sleep without sweating in a tiny mosquito net, yet sleep is the last thing on my mind. Admittedly, I AM exhausted, but I'm also restless, trying to cope with everything I've seen and understand just how much this trip has impacted me. I guess I'll never fully know and that's ok. Just as the sun is coming up here in East London, the day is getting on its way in Sudan. Elizious is making his rounds through the pediatric ward in Nimule's hospital. Business as usual it seems - You see, the reality is just that - the people of South Sudan know that they must remain realistic and know that they will most likely endure further suffering before things get any better. Their grounded resilience and compassionate cohesion have given them such strong sense of dignity - one that I will never fully be able to describe. There's a Sudanese proverb, which I was told, that sums it up quite well though: "if our feet leave the earth we no longer live in peace."


*Notes:
1) Additional photos
2) More info on Merlin's operations in Sudan

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Comments

[Diane Millikan]

You're a superior communicator
Alex, I have been extremely impressed--riveted--by your travel blogs. You are a wonderful, facile writer and clearly an insightful, empathetic, passionate person. Merlin is lucky to have you help us privileged Westerners better understand things from the ground--which is where, after all, it's all happening, all day, every day. I hope your re-entry to the US isn't too difficult; I know you'll be stunned by all that we have and take for granted (and now, thanks to your blogs, so am I). Diane

[naomi kebba]

great insight
Hi Alex, i must say you have captured the scene in South Sudan perfectly. Thanks for not sugar coating anything especially about the garbage disposal. It is frankly put and does not sound the least bit judgemental. I work in Nimule hospital as a doctor and u saw exactly what i see daily. It is depressing for the most part but what I also see is the love the people have for eachother and their homeland. One thing is for sure, life in S.Sudan will get better. I have seen changes in the short time I have been here that prove it. So u r one of the few who will have the real before and after picture- very soon. Stay tuned!