"Do children die in England?"
The question came from one of the South Sudanese nursing assistants, but this was my first week and I didn't know names yet.
I realised the local staff were looking at me expectantly, to see how I would react. "The foreign female doctors sometimes cry the first time they see a child die," they informed me by way of explanation.
They were waiting to see if I was going to cry. I was not going to cry. Though I can't pretend it was normal either.
Do children die in England? Yes, they do. But so rarely and not like this, not with only me around.
I removed the oxygen mask and stepped back, so the mother could pick up her baby. She already knew, of course, but I still felt compelled to explain.
It's incredibly difficult to have the worst conversation imaginable, via a translator. The mother's face gave nothing away, I didn't know whether I was saying the right things.
I don’t think for a second that the pain of losing a child is less because it’s more common. The difference is here, it is not entirely unexpected
I would know the right things to say back home, how to carefully gauge how much or little information she wanted, how to modify my approach depending on her reaction. Over here, I hadn't worked it out yet.
“How can I blame you? It is God’s will.” Her resigned response was somehow even more heartbreaking than if she’d screamed or cried. I would have preferred her to shout at me.
“She has no questions,” the translator informed me. “There is nothing else she wants to say”.
Against the natural order of things
I wondered if it was the first baby this woman had lost.
South Sudan has some of the worst health outcomes in the world. According to the World Health Organisation, a child born here has almost a 10 percent chance of dying before their fifth birthday. Average life expectancy is in the 50s.
The reality behind these statistics means there are certain events that would be considered a rare tragedy back home but are part of life here.
Everyone grieves differently, I don’t want to generalise. Other mothers did scream and cry.
I don’t think for a second that the pain of losing a child is less because it’s more common. The difference is here, it is not entirely unexpected.
Not unthinkable that it could happen, not completely against the natural order of things.
Holding the spirit inside
There is a local belief in South Sudan that if someone is dying, you can prevent the spirit leaving the body by putting a hand over their eyes and mouth, keeping them closed, holding the spirit inside.
I didn’t know this when I first arrived. I learned it later, from the nursing assistants who grew up here, who are my translators and cultural interpreters.
Unfortunately, when called to a very sick child I need to do the exact opposite, opening the mouth wide and tipping back the head, to clear their airway and help them breathe.
This led to me having my hands slapped away by the mother on one occasion before I realised what the problem was.
From my point of view, a hand over the mouth risks smothering a child who is already struggling to breathe. Of course, there is no way I could expect the mother to understand my point of view.
If your child was dying in front of you and a foreign doctor appeared, speaking a language you didn't understand, then did something that made no sense to you, that you thought could harm your child, what would you do? I'd probably slap their hand away too.
Trying to resolve this difference of opinion quickly, via a translator, is not easy.
As I walked away from this mother, in the middle of the night, during my first shift on call covering the whole hospital, I felt guilty. Not because I couldn’t help her child - I’d done all I could given the circumstances.
I felt bad that I’d moved her hands away, that I’d failed to understand. I worried that next time one of her children is sick, she won’t bring them to us. I know there are many who don't.
My job at the hospital is to cover the Emergency Room and Intensive Care, meaning I am dealing with the very sickest patients. During my first weekend, I lost two babies and a small child. That is without mentioning the adults.
I realised later this was an unusually bad patch, not for any reason, just the normal ebb and flow of life and death in the hospital.
Almost anything can become normal, which is both comforting and terrifying
Nothing done differently could have changed it and it wouldn't always be like this, but those first few days did feel a bit like being repeatedly kicked in the head.
There are good shifts and bad shifts anywhere you work in the world, of course. Only here, everything is amplified.
I am writing this a month into my first assignment with MSF and it has all become normal very quickly. Almost anything can become normal, which is both comforting and terrifying.
I’ve had good shifts to balance out the bad ones and seen many more lives saved than lost.
With a lot of help from the extremely patient local staff, I am starting to understand more, communicate better. They have seen dozens of foreign doctors come and go, helping each of us through our first few difficult weeks.
Now when I’m called to the sick babies, I have the mother stand next to me with her hand over the eyes if she wants to, keeping the spirit inside, but I also quickly explain why I can't let her close the mouth.
This seems acceptable, most of the time. A compromise.