Life and death

"These regular reminders of life’s fragility, although startling, provide proper opportunity to reflect on things taken for granted."

Life and death are naturally intertwined throughout the world. Especially in hospitals where the birth of a new baby may be accompanied by the passing of another person’s loved one. It is perhaps life’s most influential and most basic system of checks and balances. This relationship is woven even closer here in South Sudan where each day might bring some of each.

Life — it can be loud and boisterous. One of my favorite cultural practices in Agok is the way in which people greet each other. Handshakes are an ever present social custom. In a given day one might shake 30 people’s hands as it is customary to shake the hand of every person in a room upon entering.

If your hand happens to be dirty or wet it is polite to offer another person your wrist to grasp. My favorite type of handshake is that between good friends or colleagues. This handshake is more of a clap between two people, which is followed by slapping the person’s shoulder and then clapping hands again.

This sequence might be repeated three times and during this clap/slap routine you ask your friend how their family, husband, and their day is going. Everyone seems to enjoy a secret handshake and this one happily appears on a daily basis.

Death, also, is greeted in its own way. In Agok the appearance of death is usually accompanied by loud grieving wails and sobbing by women who were the deceased’s mother, sister, wife, or friend. Other times, especially with mothers who lose a baby, grief appears quite differently. Many babies which are born preterm face many challenges: they may weigh less than a pound, have trouble eating and breathing on their own, and also must face the harsh conditions of their environment. Too often these tiny babies do not make it.

In our Neonatal Department nurse Johanna provides the best care possible, but when a baby is dying she will offer mothers to hold the baby for its last moments. Many mothers decline to hold their babies, and many babies are not even named until days after they go home. Perhaps a coping mechanism for mothers in a place where infant death rates are high.

A common question for patients upon admission is “How many babies have you had?” and “How many are still alive?” A couple months ago when a preterm baby born weighing 870 grams was finally sent home in good health it was cause for celebration, a speech or two, and applause from fellow patients.

These regular reminders of life’s fragility, although startling, provide proper opportunity to reflect on things taken for granted.

A repaired woman's renatal chart. © Mara Evans 

One afternoon I received a mother of twins who was transferred from a faraway clinic. She had gone into labor early in the morning and delivered her first baby without difficulty at home. While awaiting the second twin the mother and her caretaker suspected something was wrong and went to a small clinic near her home where she received a piece of paper referring her to our hospital. Although the distance was not especially far, travel can take a long time by shared transportation or foot.

Ten hours after she has given birth to the first twin, I am reading her referral note which states cord prolapse as the possible diagnosis. A cord prolapse is an emergency. This means the umbilical cord which supplies baby with oxygen has slipped outside of the mom’s body before the birth of the baby.

In this situation the cord usually becomes pinched and the pumping blood vessels that are keeping baby alive are no longer able to function. At home, a cord prolapse means rushing to the operating room in a matter of minutes for an emergency cesarean section. Even though this cord prolapse took place hours ago, when I look at the mother before me and see a cold thin white loop of cord I find my natural instinct is to anxiously check for a heartbeat and hope the baby is very near birth. But the baby is dead, and has been for a while.

The mother’s face is expressionless, probably because she already knows. The first twin carried along by the relatives, squirms under the baby warmer. I see a family member has tied off his umbilical cord with pieces of a plastic bag. The second twin is quietly cleaned and dried, and placed in an empty cardboard box for the family to carry back home.

Mothers who have lost one of their twins will sometimes be seen carrying a stick the size of a rolling pin, that is shaved free of bark and smoothed free of splinters. This stick is wrapped in a blanked and carried just like any other baby. The stick acts as a companion for the remaining twin so the baby doesn’t have to be alone. Most of the time births are causes for celebration.

The maternity ward. © Mara Evans

Family is indeed very important in South Sudan. Having family members may be the difference between life and death. Patients who require blood donation are usually required to find their own blood donors as it is rare for many blood transfusions to be available otherwise.

Blood donation is not well understood by the population, some believe men’s and women’s blood should not mix, or that donation from an older person will provide unwanted old blood to a young person. The most recent blood donation campaign offered donors a meal after donation, but it was learned many would rather have a red-colored beverage as they believe it helps restore their blood level.

I have also witnessed patients with severe anemia eating straight tomato paste as it is thought the thick red substance will directly improve their blood. Hemoglobin which is a component of blood, carries oxygen and can be used as a measurement of blood quality.

A normal hemoglobin level is about 12 g/dL. Recently a woman early in pregnancy walked into the hospital feeling weak, tired, and having some trouble breathing. Her hemoglobin was 2.9 g/dL. A request to her family members for blood donation was quickly sent out, but no donors arrived.

Two days she stayed in the maternity department, although she did not look well she was talking and walking with assistance. Still no blood was available and phone calls to other family members did not produce any donors. Blood donation is such a controversial subject here, many husbands won’t donate to their own wives. The third day without a blood donor, the woman slipped into unconsciousness, gasping before she passed away.

We are currently in the midst of a measles outbreak. This highly contagious disease is characterized by a sore throat, rash, runny nose, and swollen eyes.

Many patients will recover, but young children are most likely to be the victims. Measles is preventable with a vaccination. On days vaccines are available, many women will walk several hours carrying their babies through the heat, to have their children vaccinated.

Although some parts of the world may have forgotten what a miracle it is to be able to prevent these devastating childhood diseases, in Agok vaccinations are something to cherish as their benefits are seen on a daily basis. The hospital has tents that are for isolating these patients. The tents are platform tents made of concrete floors and tarpaulin walls and roof. The heat is thick and unmoving inside the tents. Still, there are times I hear a patient’s phone playing a single South Sudanese song on repeat for hours and the isolation tents take on a more festive mood for a while.

Even the most grueling tasks are improved with the right mood. Women are the traditional roofers in South Sudan. They gather the long grasses that are bundled and stacked in ascending tiers.

Roofers at Work. © Mara Evans

The work is hot, dangerous, and tedious, but the women who are repairing our roofs are often singing and laughing with each other. They scale the walls of the hut-like tukuls climbing high, upon ladders that have seen better days onto the steep peaks of the round roofs to arrange and spread the grasses evenly. The roofs work quite well at keeping the rain out, however, the bundles of dried grass are also attractive homes for birds, lizards and scorpions which have been known to make unwanted appearances inside. The roofs last for about three years before it’s once again time to start negotiations with the forewoman regarding a replacement.

Like many other people in the world: the nurses, midwives and doctors of MSF; the mothers of tiny babies; the sick and healing patients; the concerned family members; the women on the roof and the people of Agok will continue to contemplate the beginnings and endings of life. And under the roofs of each tukul and from inside the walls of the hospital, the sights and sounds of life and death continue on.